Clinical Therapeutics
Volume 36, Issue 5, p613-816 May 2014
http://www.clinicaltherapeutics.com/current

Pneumococcal Vaccination in Europe: Schedule Adherence
Alain Gervaix, MD, Filippo Ansaldi, MD, António Brito-Avô, MD, Chiara Azzari, MD, Markus Knuf, PhD, Federico Martinón-Torres, PhD, David Tuerlinckx, MD, Myint Tin Tin Htar, MD, George A. Syrogiannopoulos, MD
Accepted: March 10, 2014; Published Online: April 16, 2014
DOI: http://dx.doi.org/10.1016/j.clinthera.2014.03.001
Abstract
Nonadherence to recommended pneumococcal conjugate vaccine (PCV) schedules may have implications for protection against pneumococcal disease. In this commentary, we have assessed adherence to the recommended dosing schedules (the completion of the primary PCV and booster series) in different European countries. We found that adherence with the PCV schedule was lower than that for diphtheria-tetanus-acellular pertussis (DTaP) and that higher adherence was observed in countries where PCV vaccination is recommended and funded. Adherence with the booster dose is often lower than that with the primary series completion, and it is often given after the recommended age. These data highlight the need to encourage timely vaccination of children with PCV, in line with local immunization schedules. There is no single solution to improve adherence; actions need to be tailored to the context of individual countries through initiatives at the national, regional, and local levels and should target different stakeholders.

Emerging Infectious Diseases
Volume 20, Number 6—June 2014
http://www.cdc.gov/ncidod/EID/index.htm

Commentaries
Unraveling the Mysteries of Middle East Respiratory Syndrome Coronavirus
PDF Version [PDF – 2.22 MB – 3 pages]
J. T. Watson et al.
Podcast – Unraveling the Mysteries of Middle East Respiratory Syndrome Coronavirus

International Journal of Infectious Diseases
Vol 23 Complete | June 2014 | Pages 1-108
http://www.ijidonline.com/current

Community Case Clusters of Middle East Respiratory Syndrome Coronavirus in Hafr Al-Batin, Kingdom of Saudi Arabia: A Descriptive Genomic study
Ziad A. Memish, Matthew Cotten, Simon J. Watson, Paul Kellam, Alimuddin Zumla, Rafat F. Alhakeem, Abdullah Assiri, Abdullah A. Al Rabeeah, Jaffar A. Al-Tawfiq
published online 02 April 2014.
Abstract
Summary
The Middle East respiratory syndrome coronavirus (MERS-CoV) was first described in September 2012 and to date 86 deaths from a total of 206 cases of MERS-CoV infection have been reported to the WHO. Camels have been implicated as the reservoir of MERS-CoV, but the exact source and mode of transmission for most patients remain unknown. During a 3 month period, June to August 2013, there were 12 positive MERS-CoV cases reported from the Hafr Al-Batin region district in the north east region of the Kingdom of Saudi Arabia. In addition to the different regional camel festivals in neighboring countries, Hafr Al-Batin has the biggest camel market in the entire Kingdom and hosts an annual camel festival. Thus, we conducted a detailed epidemiological, clinical and genomic study to ascertain common exposure and transmission patterns of all cases of MERS-CoV reported from Hafr Al-Batin. Analysis of previously reported genetic data indicated that at least two of the infected contacts could not have been directly infected from the index patient and alternate source should be considered. While camels appear as the likely source, other sources have not been ruled out. More detailed case control studies with detailed case histories, epidemiological information and genomic analysis are being conducted to delineate the missing pieces in the transmission dynamics of MERS-CoV outbreak.

Journal of Medical Microbiology
June 2014; 63 (Pt 6)
http://jmm.sgmjournals.org/content/current

Vaccine against tuberculosis: a view
Om Parkash
Author Affiliations
Scientist- E (Immunology), National JALMA Institute for Leprosy and Other Mycobacterial Diseases, Tajganj, Agra-282004, India
Excerpt
Tuberculosis (TB), a disease caused by Mycobacterium tuberculosis, continues to be a big health problem (WHO, 2013), particularly given the emergence of multidrug-resistant, extensively drug-resistant and totally drug-resistant strains of M. tuberculosis, which makes it more difficult to treat the infected individuals (Velayati et al., 2009; Falzon et al., 2011; Zignol et al., 2012). Moreover, the global epidemic of human immunodeficiency virus (HIV)/AIDS has added to the load of TB patients, further worsening the problem (Harries et al., 2010). According to a WHO report of 2013, TB afflicted about 8.6 million individuals and it caused death in more than 1.3 million cases in that year (WHO, 2013), indicating that it is a major scourge amongst infectious diseases. Chemotherapy of active TB saved the lives of many millions of patients, but extending it to chemoprophylaxis of latently infected subjects has not been implemented due to the excessive cost that would be involved. Hence, the availability of an effective vaccine could prove to be an affordable tool, with a major impact on the TB epidemic and thereby on the global elimination of the disease. Therefore, a search for the development of an effective vaccine has attracted a great deal of attention over the years. Thus far, Bacille Calmette–Guérin (BCG) remains the only licensed vaccine which has been used worldwide (Colditz et al., 1994; Zwerling et al., 2011). Its administration soon after birth can prevent severe forms of childhood TB. However, there is general agreement that BCG confers insufficient protection against TB in adolescents and adults. Currently, several candidate prophylactic vaccines have reached clinical trials (Kaufmann, 2013), but as yet, no new approved vaccine is available for immunoprophylactic use in the population. A major challenge for developing more efficacious vaccines against TB is the incomplete understanding of the mechanism of immunity and the mechanisms of immune evasion and subversion by M. tuberculosis….
…In conclusion, it is argued that despite inducing potent Th1 memory, anti-TB vaccines may not be protective against TB. This view is supported by the known inconsistent efficacy of BCG vaccination (Andersen & Doherty, 2005), the uncertainties regarding candidate vaccines (Kaufmann et al., 2010; Kaufmann, 2013) and the recent failure of a phase 2b TB vaccine trial in infants (Tameris et al., 2013). In all the foregoing approaches, generation of Th1-mediated protective immunity was the major aim to make the vaccines effective. What could be the remedy when Th1-mediated immunity fails? Probably, the answer may be sought by exploring alternative approaches, involving CD8+ T-cells, natural killer T-cells and γδ T-cells (Yoshikai, 2006; Barnes et al., 2009; Cooper, 2009) for generation of protective immunity by candidate vaccines. The reasons supporting this suggestion are that: (i) these cells are understood to contribute towards protection against M. tuberculosis; also, (ii) these cells do not require antigen presentation in association with MHC-II molecules. However, these still rely on antigen presentation in association with MHC-I or CD1, which could also be affected by M. tuberculosis (Baena & Porcelli, 2009). Regarding antibodies, there are several pieces of evidence indicating their contribution towards protection against TB (Achkar & Casadevall, 2013). However, their role in protecting against TB is controversial, as yet. Nevertheless, with vaccination, antibodies can be generated prior to infection, and for production of antibodies, processing and presentation of M. tuberculosis antigens are not required. Moreover, there is evidence that antibodies can affect downstream processing and presentation of antigens for generation of CMI. Therefore, the humoral response may help in preventing infection and is worth considering for developing an anti-TB vaccine. Thus, a combined approach, involving multiple antigens targeting multiple cells, deserves attention for further research for developing an anti-TB vaccine. Probably, such a formulation may lead to a better alternative anti-TB vaccine by providing a greater ability for the host to recognize a wider range of M. tuberculosis antigens.

Journal of the Pediatric Infectious Diseases Society (JPIDS)
Volume 3 Issue 2 June 2014
http://jpids.oxfordjournals.org/content/current

Meningococcal Disease: Epidemiology and Early Effects of Immunization Programs
Marco Aurelio P. Sáfadi, Eitan N. Berezin, and Luiza Helena F. Arlant
J Ped Infect Dis (2014) 3 (2): 91-93 doi:10.1093/jpids/piu027
Extract Full Text (HTML) Full Text (PDF)

Journal of Pediatrics
Vol 164 | No. 6 | June 2014 | Pages 1245-1504
http://www.jpeds.com/current

Antibody Persistence and Booster Response of a Quadrivalent Meningococcal Conjugate Vaccine in Adolescents
Roger Baxter, MD, Keith Reisinger, MD, Stanley L. Block, MD, Allen Izu, MS, Tatjana Odrljin, D, PhD, Peter Dull, MD
Objective: To evaluate the tolerability and immunogenicity of a booster dose of the quadrivalent meningococcal conjugate vaccine MenACWY-CRM (Menveo, Novartis Vaccines and Diagnostics, Siena, Italy)

The Lancet Global Health
Jun 2014 Volume 2 Number 6 e301 – 363
http://www.thelancet.com/journals/langlo/issue/current

Detention, denial, and death: migration hazards for refugee children
Mina Fazel, Unni Karunakara, Elizabeth A Newnham
Preview | Full Text | PDF
Organised violence, persecution, and community instability cause millions of children to flee their native countries every year. About 7•6 million people were newly displaced by conflict or persecution in 20121 (the highest number in a decade), of which approximately half were younger than 18 years. Regions prone to disaster and adversity often have disproportionately young populations, and thus larger numbers of children and adolescents are now moving across country borders, with or without their families.

The Lancet Global Health
Jun 2014 Volume 2 Number 6 e301 – 363
http://www.thelancet.com/journals/langlo/issue/current

Global causes of maternal death: a WHO systematic analysis
Dr Lale Say MD a, Doris Chou MD a, Alison Gemmill MPH a b, Özge Tunçalp MD a, Ann-Beth Moller MSc a, Jane Daniels PhD c, A Metin Gülmezoglu MD a, Marleen Temmerman MD a, Leontine Alkema PhD d
Summary
Background
Data for the causes of maternal deaths are needed to inform policies to improve maternal health. We developed and analysed global, regional, and subregional estimates of the causes of maternal death during 2003—09, with a novel method, updating the previous WHO systematic review.
Methods
We searched specialised and general bibliographic databases for articles published between between Jan 1, 2003, and Dec 31, 2012, for research data, with no language restrictions, and the WHO mortality database for vital registration data. On the basis of prespecified inclusion criteria, we analysed causes of maternal death from datasets. We aggregated country level estimates to report estimates of causes of death by Millennium Development Goal regions and worldwide, for main and subcauses of death categories with a Bayesian hierarchical model.
Findings
We identified 23 eligible studies (published 2003—12). We included 417 datasets from 115 countries comprising 60 799 deaths in the analysis. About 73% (1 771 000 of 2 443 000) of all maternal deaths between 2003 and 2009 were due to direct obstetric causes and deaths due to indirect causes accounted for 27•5% (672 000, 95% UI 19•7—37•5) of all deaths. Haemorrhage accounted for 27•1% (661 000, 19•9—36•2), hypertensive disorders 14•0% (343 000, 11•1—17•4), and sepsis 10•7% (261 000, 5•9—18•6) of maternal deaths. The rest of deaths were due to abortion (7•9% [193 000], 4•7—13•2), embolism (3•2% [78 000], 1•8—5•5), and all other direct causes of death (9•6% [235 000], 6•5—14•3). Regional estimates varied substantially.
Interpretation
Between 2003 and 2009, haemorrhage, hypertensive disorders, and sepsis were responsible for more than half of maternal deaths worldwide. More than a quarter of deaths were attributable to indirect causes. These analyses should inform the prioritisation of health policies, programmes, and funding to reduce maternal deaths at regional and global levels. Further efforts are needed to improve the availability and quality of data related to maternal mortality.
Funding
USAID, the US Fund for UNICEF through a grant from the Bill & Melinda Gates Foundation to CHERG, and The UNDP/UNFPA/UNICEF/WHO/The World Bank Special Programme of Research, Development, and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research.

The Lancet Infectious Diseases
Jun 2014 Volume 14 Number 6 p441 – 532
http://www.thelancet.com/journals/laninf/issue/current

Comment
In for the long haul: 20 years of malaria surveillance
Chris Drakeley, Jo Lines
Preview | Full Text | PDF
The past 20 years have seen many changes in malaria control. In most countries where malaria is endemic, first-line treatment has switched several times as drug resistance has developed, moving from chloroquine through to artemisinin-based combination therapies. In the past decade, thanks to increased funding through the Global Fund to Fight AIDS, Tuberculosis and Malaria, coverage of long-lasting insecticide-treated nets (LLINs) has massively expanded. These efforts have led to a substantial reduction in the incidence of malaria mortality,1 with a cumulative total of about 3•3 million deaths prevented since 2001, according to the 2013 World Malaria Report.

The rise and fall of malaria in a west African rural community, Dielmo, Senegal, from 1990 to 2012: a 22 year longitudinal study
Dr Jean-François Trape MD a, Adama Tall MD b, Cheikh Sokhna PhD a, Alioune Badara Ly MD c, Nafissatou Diagne PhD a, Ousmane Ndiath PhD a, Catherine Mazenot PhD a, Vincent Richard MD b, Abdoulaye Badiane BSc b, Fambaye Dieye-Ba BSc a, Joseph Faye BSc b, Gora Ndiaye a, Fatoumata Diene Sarr MD b, Clémentine Roucher PhD a, Charles Bouganali a, Hubert Bassène BSc a, Aissatou Touré-Baldé PhD d, Christian Roussilhon PhD d e, Ronald Perraut PhD d e, Prof André Spiegel MD b, Jean-Louis Sarthou PhD d, Prof Luiz Pereira da Silva e, Odile Mercereau-Puijalon PhD e, Pierre Druilhe MD e, Prof Christophe Rogier MD b f
Summary
Background
A better understanding of the effect of malaria control interventions on vector and parasite populations, acquired immunity, and burden of the disease is needed to guide strategies to eliminate malaria from highly endemic areas. We monitored and analysed the changes in malaria epidemiology in a village community in Senegal, west Africa, over 22 years.
Methods
Between 1990 and 2012, we did a prospective longitudinal study of the inhabitants of Dielmo, Senegal, to identify all episodes of fever and investigate the relation between malaria host, vector, and parasite. Our study included daily medical surveillance with systematic parasite detection in individuals with fever. We measured parasite prevalence four times a year with cross-sectional surveys. We monitored malaria transmission monthly with night collection of mosquitoes. Malaria treatment changed over the years, from quinine (1990—94), to chloroquine (1995—2003), amodiaquine plus sulfadoxine-pyrimethamine (2003—06), and finally artesunate plus amodiaquine (2006—12). Insecticide-treated nets (ITNs) were introduced in 2008.
Findings
We monitored 776 villagers aged 0—101 years for 2 378 150 person-days of follow-up. Entomological inoculation rate ranged from 142•5 infected bites per person per year in 1990 to 482•6 in 2000, and 7•6 in 2012. Parasite prevalence in children declined from 87% in 1990 to 0•3 % in 2012. In adults, it declined from 58% to 0•3%. We recorded 23 546 fever episodes during the study, including 8243 clinical attacks caused by Plasmodium falciparum, 290 by Plasmodium malariae, and 219 by Plasmodium ovale. Three deaths were directly attributable to malaria, and two to severe adverse events of antimalarial drugs. The incidence of malaria attacks ranged from 1•50 attacks per person-year in 1990 to 2•63 in 2000, and to only 0•046 in 2012. The greatest changes were associated with the replacement of chloroquine and the introduction of ITNs.
Interpretation
Malaria control policies combining prompt treatment of clinical attacks and deployment of ITNs can nearly eliminate parasite carriage and greatly reduce the burden of malaria in populations exposed to intense perennial malaria transmission. The choice of drugs seems crucial. Rapid decline of clinical immunity allows rapid detection and treatment of novel infections and thus has a key role in sustaining effectiveness of combining artemisinin-based combination therapy and ITNs despite increasing pyrethroid resistance.
Funding
Pasteur Institutes of Dakar and Paris, Institut de Recherche pour le Développement, and French Ministry of Cooperation.

The Pediatric Infectious Disease Journal
June 2014 – Volume 33 – Issue 6 pp: 549-673,e135-e161
http://journals.lww.com/pidj/pages/currenttoc.aspx

Safety and Immunogenicity of an Inactivated Quadrivalent Influenza Vaccine in Children 6 Months through 8 Years of Age
Greenberg, David P.; Robertson, Corwin A.; Landolfi, Victoria A.; More
Free Access Supplemental Author Material Abstract

Changes in Childhood Pneumonia and Infant Mortality Rates Following Introduction of the 13-valent Pneumococcal Conjugate Vaccine in Nicaragua
Becker-Dreps, Sylvia; Amaya, Erick; Liu, Lan; More
Free Access Abstract

Primary Immunization of Infants and Toddlers in Thailand with Japanese Encephalitis Chimeric Virus Vaccine in Comparison with SA14-14-2: A Randomized Study of Immunogenicity and…
Feroldi, Emmanuel; Pancharoen, Chitsanu; Kosalaraksa, Pope; More
Free Access Abstract

PLoS One
[Accessed 24 May 2014]
http://www.plosone.org/

Predominance of Norovirus and Sapovirus in Nicaragua after Implementation of Universal Rotavirus Vaccination
Filemón Bucardo, Yaoska Reyes, Lennart Svensson, Johan Nordgren
Research Article | published 21 May 2014 | PLOS ONE 10.1371/journal.pone.0098201
Abstract
Background
Despite significant reduction of rotavirus (RV) infections following implementation of RotaTeq vaccination in Nicaragua, a large burden of patients with diarrhea persists.
Methods
We conducted a community- and hospital-based study of the burden of RV, norovirus (NV) and sapovirus (SV) infections as cause of sporadic acute gastroenteritis (GE) among 330 children ≤ 5 years of age between September 2009 and October 2010 in two major cities of Nicaragua with a RotaTeq coverage rate of 95%.
Results
We found that NV, SV and RV infections altogether accounted for 45% of cases of GE. Notably, NV was found in 24% (79/330) of the children, followed by SV (17%, 57/330) and RV (8%, 25/330). The detection rate in the hospital setting was 27%, 15% and 14% for NV, SV and RV respectively, whereas in the community setting the detection rate of RV was < 1%. Among each of the investigated viruses one particular genogroup or genotype was dominant; GII.4 (82%) for NV, GI (46%) for SV and G1P[8] (64%) in RV. These variants were also found in higher proportions in the hospital setting compared to the community setting. The GII.4.2006 Minerva strain circulating globally since 2006 was the most common among genotyped NV in this study, with the GII.4-2010 New Orleans emerging in 2010.
Conclusions
This study shows that NV has become the leading viral cause of gastroenteritis at hospital and community settings in Nicaragua after implementation of RV vaccination.

PLoS Medicine
http://www.plosmedicine.org/
(Accessed 24 May 2014)

Ethical Alternatives to Experiments with Novel Potential Pandemic Pathogens
Marc Lipsitch Alison P. Galvani
Published: May 20, 2014
DOI: 10.1371/journal.pmed.1001646
Summary Points
:: “Gain of function” experiments involving the creation and manipulation of novel potential pandemic pathogens (PPPs) deserve ethical scrutiny regarding the acceptability of the risks of accidental or deliberate release and global spread.
:: The Nuremberg Code, a seminal statement of clinical research ethics, mandates that experiments that pose a risk to human life should be undertaken only if they provide humanitarian benefits that sufficiently offset the risks and if these benefits are unachievable by safer means.
:: A novel PPP research program of moderate size would pose substantial risks to human life, even optimistically assuming a low probability that a pandemic would ensue from a laboratory accident.
:: Alternative approaches would not only be safer but would also be more effective at improving surveillance and vaccine design, the two purported benefits of gain-of-function experiments to create novel, mammalian-transmissible influenza strains.
:: A rigorous, quantitative, impartial risk–benefit assessment should precede further novel PPP experimentation. In the case of influenza, we anticipate that such a risk assessment will show that the risks are unjustifiable. Given the risk of a global pandemic posed by such experiments, this risk assessment should be part of a broader international discussion involving multiple stakeholders and not dominated by those with an interest in performing or funding such research.

Science
23 May 2014 vol 344, issue 6186, pages 773-936
http://www.sciencemag.org/current.dtl

Introduction to Special Issue
The Science of Inequality: What the numbers tell us
Gilbert Chin, Elizabeth Culotta
Author Affiliations
Gilbert Chin is a senior editor for Science and Elizabeth Culotta is a deputy news editor for Science.

In 2011, the wrath of the 99% kindled Occupy movements around the world. The protests petered out, but in their wake an international conversation about inequality has arisen, with tens of thousands of speeches, articles, and blogs engaging everyone from President Barack Obama on down. Ideology and emotion drive much of the debate. But increasingly, the discussion is sustained by a tide of new data on the gulf between rich and poor.
This special issue uses these fresh waves of data to explore the origins, impact, and future of inequality around the world. Archaeological and ethnographic data are revealing how inequality got its start in our ancestors (see pp. 822 and 824). New surveys of emerging economies offer more reliable estimates of people’s incomes and how they change as countries develop (see p. 832). And in the past decade in developed capitalist nations, intensive effort and interdisciplinary collaborations have produced large data sets, including the compilation of a century of income data and two centuries of wealth data into the World Top Incomes Database (WTID) (see p. 826 and Piketty and Saez, p. 838).
It is only a slight exaggeration to liken the potential usefulness of this and other big data sets to the enormous benefits of the Human Genome Project. Researchers now have larger sample sizes and more parameters to work with, and they are also better able to detect patterns in the flood of data. Collecting data, organizing it, developing methods of analysis, extracting causal inferences, formulating hypotheses—all of this is the stuff of science and is more possible with economic data than ever before. Even physicists have jumped into the game, arguing that physical laws may help explain why inequality seems so intractable (see p. 828).
In the United States, the new information suggests a wide rift between top and bottom. Tax data from the WTID suggest that today the top 1% control nearly 20% of U.S. income, up from about 8% in the 1970s. But inequality is increasing within the 99%, too, as a consequence of a growing premium on college and postgraduate education: The fates of the tech-savvy worker at Google and the blue-collar employee at General Motors have been decoupled (see Autor, p. 843). According to surveys by the Census Bureau, in 2012 the richest 20% of Americans enjoyed more than 50% of the nation’s total income, up from 43% in 1967. The middle 20%—the actual middle class—received only about 14% of all income, and the poorest got a mere 3% (see p. 820).
Flip to a world map, and America’s inequality, despite reaching levels last seen in the Gilded Age, turns out to be far from extreme. Many nations, especially emerging economies, have even larger chasms between the super-rich and the poor. One widely used metric, the Gini coefficient, estimates inequality as an index between 0—at which point everyone has exactly equal incomes—to 1, in which a single person takes all the income and the rest get nothing. The U.S. Gini, at 0.40 in 2010, seems relatively high compared with, for example, Japan at 0.32. But South Africa is a sky-high 0.7.
Many assume that governments in emerging economies have chosen to favor growth even at the cost of inequality on the grounds that “a rising tide lifts all boats.” But evidence that this trade-off is necessary is sparse, and recent data show that policies to reduce inequality need not stymie growth (see Ravallion, p. 851).
What of those at the bottom? Research has established a base of knowledge about the harmful effects of disadvantageous circumstances on education and health. These influences can begin early in life, even prenatally (see Aizer and Currie, p. 856). But researchers are still exploring whether the stress of being low-ranked itself adds to the poor’s burden, causing illness and even early death (see p. 829). In addition, psychological mechanisms may spur a negative feedback loop in which poor individuals behave in ways that help keep them poor (see Haushofer and Fehr, p. 862).
Harsh as life can be for those at the bottom, the opportunity to move up the ladder can compensate. Newly available data from taxes and other records promise to yield insights into intergenerational mobility, in which children advance from their parents’ socioeconomic status. But so far, researchers have a relatively limited view of how and why people move into different social, as well as economic, classes (see p. 836 and http://scim.ag/sci_inequality; also see Corak, p. 812).
Few would deny that excessive inequality can be unhealthy for societies and economies, but the new data don’t pinpoint a desirable level. They do show that the forces that foster inequality—from the patchy distribution of resources among ancient hunter-gatherers to the sheer earning power of capital today—are many and potent. It is up to society to decide whether, and how, to restrain them (see p. 783).

[Selected articles from special issue]
Review
Income inequality in the developing world
Martin Ravallion
Author Affiliations
Department of Economics, Georgetown University, Washington, DC 20057, and National Bureau of Economic Research, Cambridge, MA 02138, USA.
Abstract
Should income inequality be of concern in developing countries? New data reveal less income inequality in the developing world than 30 years ago. However, this is due to falling inequality between countries. Average inequality within developing countries has been slowly rising, though staying fairly flat since 2000. As a rule, higher rates of growth in average incomes have not put upward pressure on inequality within countries. Growth has generally helped reduce the incidence of absolute poverty, but less so in more unequal countries. High inequality also threatens to stall future progress against poverty by attenuating growth prospects. Perceptions of rising absolute gaps in living standards between the rich and the poor in growing economies are also consistent with the evidence.

Review
On the psychology of poverty
Johannes Haushofer1,2,3,4,*, Ernst Fehr3,*
Author Affiliations
1Abdul Latif Jameel Poverty Action Lab, Massachusetts Institute of Technology, 30 Wadsworth Street, Cambridge, MA 02142, USA.
2Program in Economics, History, and Politics, Harvard University, Cambridge, MA 02138, USA.
3Department of Economics, University of Zürich, Blümlisalpstrasse 10, Zürich 8006, Switzerland.
4Department of Psychology and Woodrow Wilson School of Public and International Affairs, Princeton University, Princeton, NJ 08544, USA.
Abstract
Poverty remains one of the most pressing problems facing the world; the mechanisms through which poverty arises and perpetuates itself, however, are not well understood. Here, we examine the evidence for the hypothesis that poverty may have particular psychological consequences that can lead to economic behaviors that make it difficult to escape poverty. The evidence indicates that poverty causes stress and negative affective states which in turn may lead to short-sighted and risk-averse decision-making, possibly by limiting attention and favoring habitual behaviors at the expense of goal-directed ones. Together, these relationships may constitute a feedback loop that contributes to the perpetuation of poverty. We conclude by pointing toward specific gaps in our knowledge and outlining poverty alleviation programs that this mechanism suggests.

Social Science & Medicine
Volume 113, In Progress (July 2014)

Valuing QALYs at the end of life
Original Research Article
Pages 5-14
Jose-Luis Pinto-Prades, Fernando-Ignacio Sánchez-Martínez, Belen Corbacho, Rachel Baker
Abstract
The possibility of weighting QALYs differently for different groups of patients has been a source of debate. Most recently, this debate has been extended to the relative value of QALYs at the end of life (EoL). The objective of this study is to provide evidence of societal preferences in relation to this topic. Three cross-sectional surveys were conducted amongst Spanish general population (n = 813). Survey 1 compared increases in life expectancy for EoL patients with health gains from temporary health problems. Survey 2 compared health gains for temporary health problems with quality of life gains at the EoL (palliative care). Survey 3 compared increases in life expectancy with quality of life gains, both for EoL patients. Preferences were elicited using Person Trade-Off (PTO) and Willingness to pay (WTP) techniques presenting two different durations of health benefit (6 and 18 months). Health benefits, measured in QALYs, were held constant in all comparisons.
In survey 1 mean WTP was higher for life extending treatments than for temporary health problems and the majority of respondents prioritised life extension over temporary health problems in response to the PTO questions. In survey 2 mean WTP was higher for palliative care than for temporary health problems and 83% prioritized palliative care (for both durations) in the PTO questions. In survey 3 WTP values were higher for palliative care than for life extending treatments and more than 60% prioritized palliative care in the PTO questions. Our results suggest that QALYs gained from EoL treatments have a higher social value than QALYs gained from treatments for temporary health problems. Further, we found that people attach greater weight to improvements in quality of life than to life extension at the end of life.

Social Science & Medicine
Volume 113, In Progress (July 2014)

Are public–private partnerships a healthy option? A systematic literature review
Original Research Article
Pages 110-119
Jens K. Roehrich, Michael A. Lewis, Gerard George
Abstract
Governments around the world, but especially in Europe, have increasingly used private sector involvement in developing, financing and providing public health infrastructure and service delivery through public–private partnerships (PPPs). Reasons for this uptake are manifold ranging from rising expenditures for refurbishing, maintaining and operating public assets, and increasing constraints on government budgets stifle, seeking innovation through private sector acumen and aiming for better risk management. Although PPPs have attracted practitioner and academic interest over the last two decades, there has been no attempt to integrate the general and health management literature to provide a holistic view of PPPs in healthcare delivery. This study analyzes over 1400 publications from a wide range of disciplines over a 20-year time period. We find that despite the scale and significance of the phenomenon, there is relatively limited conceptualization and in-depth empirical investigation. Based on bibliographic and content analyses, we synthesize formerly dispersed research perspectives into a comprehensive multi-dimensional framework of public-private partnerships. In so doing, we provide new directions for further research and practice.

Social Science & Medicine
Volume 112, Pages 1-88 (July 2014)
http://www.sciencedirect.com/science/journal/02779536/112

Attitudes to vaccination: A critical review
Review Article
Pages 1-11
Ohid Yaqub, Sophie Castle-Clarke, Nick Sevdalis, Joanna Chataway
Abstract
This paper provides a consolidated overview of public and healthcare professionals’ attitudes towards vaccination in Europe by bringing together for the first time evidence across various vaccines, countries and populations. The paper relies on an extensive review of empirical literature published in English after 2009, as well as an analysis of unpublished market research data from member companies of Vaccines Europe. Our synthesis suggests that hesitant attitudes to vaccination are prevalent and may be increasing since the influenza pandemic of 2009. We define hesitancy as an expression of concern or doubt about the value or safety of vaccination. This means that hesitant attitudes are not confined only to those who refuse vaccination or those who encourage others to refuse vaccination. For many people, vaccination attitudes are shaped not just by healthcare professionals but also by an array of other information sources, including online and social media sources. We find that healthcare professionals report increasing challenges to building a trustful relationship with patients, through which they might otherwise allay concerns and reassure hesitant patients. We also find a range of reasons for vaccination attitudes, only some of which can be characterised as being related to lack of awareness or misinformation. Reasons that relate to issues of mistrust are cited more commonly in the literature than reasons that relate to information deficit. The importance of trust in the institutions involved with vaccination is discussed in terms of implications for researchers and policy-makers; we suggest that rebuilding this trust is a multi-stakeholder problem requiring a coordinated strategy.

Vaccine
Volume 32, Issue 28, Pages 3469-3568 (12 June 2014)
http://www.sciencedirect.com/science/journal/0264410X/32/28

Social inequalities in vaccination uptake among children aged 0–59 months living in Madagascar: An analysis of Demographic and Health Survey data from 2008 to 2009
Original Research Article
Pages 3533-3539
S. Clouston, R. Kidman, T. Palermo
Abstract
Background
Socioeconomic inequalities in vaccination can reduce the ability and efficiency of global efforts to reduce the burden of disease. Vaccination is particularly critical because the poorest children are often at the greatest risk of contracting preventable infectious diseases, and unvaccinated children may be clustered geographically, jeopardizing herd immunity. Without herd immunity, these children are at even greater risk of contracting disease and social inequalities in associated morbidity and mortality are amplified.
Methods
Data on vaccination for children under five came from the most recent Demographic and Health Survey in Madagascar (2008–2009). Vaccination status was available for diptheria, pertussis, tetanus, hepatitis B, measles, tuberculosis, poliomyelitis, and H. influenza type-B. Multilevel logistic regression was used to analyze childhood vaccination by parental socioeconomic status while accounting for shared district, cluster, and household variation. Maps were created to serve as a roadmap for efforts to increase vaccination.
Findings
Geographic variation in vaccination rates was substantial. Districts that were less covered were near other districts with limited coverage. Most districts lacked herd immunity for diphtheria, pertussis, poliomyelitis and measles. Full herd immunity was reached in a small number of districts clustered near the capital. While within-district variation in coverage was substantial; parental education and wealth were independently associated with vaccination.
Interpretation
Socioeconomic inequalities in vaccination reduce herd immunity and perpetuate inequalities by allowing infectious diseases to disproportionately affect the most vulnerable populations. Findings indicated that most districts had low immunization coverage rates and unvaccinated children were geographically clustered. The result was inequalities in vaccination and reduced herd immunity. To further improve coverage, interventions must take a multilevel approach that focuses on both supply- and demand-side barriers to delivering vaccination to underserved regions, and to the poorest children in those regions.

Vaccine
Volume 32, Issue 27, Pages 3341-3468 (5 June 2014)
http://www.sciencedirect.com/science/journal/0264410X/32/27

Predictors of optional immunization uptake in an urban south Indian population
Original Research Article
Pages 3417-3423
Kalpana Manthiram, Emily A. Blood, Vasanthan Kuppuswamy, Yolanda Martins, Athi Narayan, Kelly Burmeister, K. Parvathy, Areej Hassan
Abstract
Background
In Tamil Nadu, India, bacille Calmette–Guérin, diphtheria–tetanus–pertussis, oral poliomyelitis, hepatitis B, and measles vaccines are part of the routine immunization schedule and are available free from government health centers. All other vaccines are optional and available in the private sector at a cost to families. This study assesses immunization rates of routine and optional vaccines and examines parental attitudes toward vaccines in Pallavapuram, Tamil Nadu.
Methods
The cluster sampling method was used to estimate immunization coverage. Seven children 18 to 36 months old were selected from 30 clusters for a total sample of 210 children. Demographics and vaccination data were collected from interviews and immunization records. Predictors of vaccination status were identified with logistic regression models. In addition, 21 parents participated in semi-structured interviews regarding their attitudes toward vaccination. Interviews were analyzed qualitatively for themes.
Results
Eighty one percent of children were fully immunized with routine vaccines. However, only 21% received all “major” optional vaccines, defined as 3 doses of Haemophilus influenzae type b vaccine, one dose of measles, mumps, rubella vaccine, and one dose of varicella zoster virus vaccine. Birth in a private hospital (OR 5.6, 95% CI 1.3 to 22.9, P < 0.01), higher income (P = 0.03), and maternal completion of high school (OR 6.4, 95% CI 1.5 to 27.6, P < 0.01) were significant predictors of receiving all major optional vaccines. Elucidated themes from interviews included (1) strong parental support for immunizations, (2) low concern for side effects, and (3) low uptake of optional vaccines due to high cost and lack of awareness.
Conclusions
Coverage of optional vaccines is low despite positive attitudes toward immunizations. Efforts to reduce cost and increase awareness of these vaccines particularly among low-income families or to include these vaccines in the routine schedule may increase uptake and reduce morbidity and mortality from vaccine-preventable diseases.

Vaccine
Volume 32, Issue 27, Pages 3341-3468 (5 June 2014)
http://www.sciencedirect.com/science/journal/0264410X/32/27

Decomposing socioeconomic inequality in child vaccination: Results from Ireland
Original Research Article
Pages 3438-3444
Edel Doherty, Brendan Walsh, Ciaran O’Neill
Abstract
Background
There is limited knowledge of the extent of or factors underlying inequalities in uptake of childhood vaccination in Ireland. This paper aims to measure and decompose socioeconomic inequalities in childhood vaccination in the Republic of Ireland.
Methods
The analysis was performed using data from the first wave of the Growing Up in Ireland survey, a nationally representative survey of the carers of over 11,000 nine-month old babies collected in 2008 and 2009. Multivariate analysis was conducted to explore the child and parental factors, including socioeconomic factors that were associated with non-vaccination of children. A concentration index was calculated to measure inequality in childhood vaccination. Subsequent decomposition analysis identified key factors underpinning observed inequalities.
Results
Overall the results confirm a strong socioeconomic gradient in childhood vaccination in the Republic of Ireland. Concentration indices of vaccination (CI = −0.19) show a substantial pro-rich gradient. Results from the decomposition analysis suggest that a substantial proportion of the inequality is explained by household level variables such as socioeconomic status, household structure, income and entitlement to publicly funded care (29.9%, 24% 30.6% and 12.9% respectively). Substantial differences are also observed between children of Irish mothers and immigrant mothers from developing countries.
Conclusions
Vaccination was less likely in lower than in higher income households. Access to publicly funded services was an important factor in explaining inequalities.

WHO South-East Asia Journal of Public Health
Volume 3, Issue 1, January-March 2014, 1-122
http://www.searo.who.int/publications/journals/seajph/issues/whoseajphv3n1/en/

Special Issue on Vector-borne diseases
Editorial
Vector-borne diseases in South-East Asia: burdens and key challenges to be addressed
pdf, 734kb
Page 2-4
Rajesh Bhatia, Leonard Ortega, A P Dash, Ahmed Jamsheed Mohamed

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

ASIAN JOURNAL OF MEDICAL SCIENCES
Oct-Dec 2014 | Vol 5 | Issue 4
[PDF] Knowledge, attitude and perceptions of mothers with children under five years of age about vaccination in Mangalore, India
Soundarya Mahalingam1, Abhijna Soori2, Pradhum Ram2, Basavaprabhu Achappa3, Mukta Chowta4, Deepak Madi3
1Associate Professor, Paediatrics, Kasturba Medical College, Mangalore, Affiliate to Manipal University, 2Final Year MBBS Student, Kasturba Medical College, Mangalore, Affiliate to Manipal University, 3Associate Professor, Internal Medicine, Kasturba Medical College, Mangalore, Affiliate to Manipal University, 4Additional Professor, Pharmacology, Kasturba Medical College, Mangalore, Affiliate to Manipal University
Abstract
Objective: Vaccination is a cost-effective intervention to prevent major illnesses that contribute to child mortality in the country. Increase in parental knowledge about vaccination will lead to increase in vaccination rates of children The main aim of our study was to assess the Knowledge (K), attitudes (A) and perceptions (KAP) of mothers with children under five years of age about vaccination. We also compared the KAP data between urban and rural setup.
Methodology: This cross sectional descriptive study was conducted on mothers attending the Urban Health Centre (in Mangalore city) and on mothers attending a Peripheral Health Centre (Bengre, outskirts of Mangalore) having children under five years of ageA semi structured pre validated questionnaire designed to assess the Knowledge, Attitudes and Perceptions about vaccination was administered to mothers attending the Urban Health Centre and on mothers attending a Peripheral Health Centre having children under five years of age.
Results: Among the study participants, 74 were from urban setup and 126 from rural set up. Around 8 (10.8%) from urban area and 78(61.9%) from rural area were illiterate. Mothers were the main decision makers regarding vaccination of the child in both urban and rural setup. The main source of information regarding vaccination differed among urban and rural setup, being the hospital and the anganwadi worker respectively. There was a statistically significant difference between urban and rural mothers when it was asked whether they knew why vaccination was important. A majority of the mothers both in the urban and rural areas believed that vaccines were safe. Among the urban mothers 90.5% and 62.7% of mother from rural were able to identify polio as a vaccine preventable disease. On a net analysis, 64(86.5%) mothers in the urban area and only 64 (50.8%) mothers in the rural area mothers found to have favourable knowledge, attitudes, perceptions and practices towards vaccination.
Conclusion: A significant number of mothers in rural areas were unaware about the vaccination and its implications. Even in the urban areas we found significant lacunae in the KAP of mothers towards childhood vaccination.

Journal of Health Care for the Poor and Underserved (JHCPU)
Volume 25, Number 2, May 2014
http://muse.jhu.edu/journals/journal_of_health_care_for_the_poor_and_underserved/toc/hpu.25.2.html
Cervical Cancer and HPV: Knowledge, Attitudes, Beliefs, and Behaviors among Women Living in Guatemala
Amy Petrocy, Mira L. Katz
Abstract:
This study was conducted to explore knowledge, attitudes, and beliefs about cervical cancer, cervical cancer screening, human papillomavirus (HPV), and acceptance of the HPV vaccine. A purposive sample of 40 women was interviewed during August 2012. Fisher’s exact test was used to evaluate differences among rural and urban women, and open-ended questions were coded independently by two individuals (Cohen’s kappa coefficient of 0.816). Among the 22 rural and 18 urban women, there was limited knowledge about cervical cancer, screening, HPV, and the HPV vaccine. Cervical cancer was described in language related to gender, science, severity, or associated with having children, a uterus, or menstruation. All rural and most urban participants were interested in the HPV vaccine for themselves and their daughters. Limited awareness and knowledge about cervical cancer and HPV was common among Guatemalan women, highlighting the need for additional information prior to developing cancer prevention educational materials and programs.

Fighting Cervical Cancer with Vaccines and Vinegar
Embassy of the United States of America in Gaborone, Botswana
[no issue date evident]
Excerpt
Gaborone, Botswana – Two years ago, Dr. Mmakgomo “Mimi” Raesima was put in charge of cervical cancer prevention at the Ministry of Health with the task of figuring out how to end its reign as the No. 1 cancer killer of women in Botswana.
This was no easy task given that cervical cancer accounts for more than a quarter of all cancer in Batswana women. Worldwide, about half a million women are diagnosed with cervical cancer every year and around 275,000 women die from the disease, 85% of whom live in low- and middle-income countries.
Undeterred by these challenges, Dr. Raesima has taken the reins and set into motion a new prevention and control strategy with some innovative and cost-effective techniques for fighting cervical cancer in Botswana, including two unlikely weapons: vaccines and vinegar.
With support from partners including the U.S. government, Dr. Raesima plans to scale-up “See and Treat” clinics where women are screened for cervical cancer, diagnosed and treated all in one visit. The clinics use a remarkably simple and low-cost acetic test – otherwise known as household vinegar – to screen for cancerous cells in women.
Meanwhile, plans are moving ahead to vaccinate young Batswana women against the human papillomavirus (HPV), the cause of cervical cancer. Last year, more than 2,000 girls between the ages of 9-11 were voluntarily vaccinated in a demonstration project in Molepolole schools. This year starting in March, the HPV vaccine was being offered in Kweneng East, Kweneng West and Selibe-Phikwe districts.
“Botswana is becoming a leader in the response to cervical cancer and that is exciting,” Dr. Raesima said in a recent interview.
Partnerships between the Government of Botswana and the United States through the President’s Emergency Plan for AIDS Relief (PEPFAR) and the Pink Ribbon Red Ribbon Initiative (PRRR) have helped to put the strategy into motion, Raesima said. “The reason that we are moving ahead so quickly is because of this support. It’s what’s driving our strategy.”…

Al Jazeera
http://www.aljazeera.com/Services/Search/?q=vaccine
Accessed 24 May 2014

Opinion
Pakistan’s polio puzzle
Why does Pakistan continue to suffer from polio, despite billions of dollars spent on eradication programmes?
Last updated: 23 May 2014 10:00
Samia Altaf
Dr Samia Altaf, a public health physician, was the 2007-08 Pakistan Scholar at the Woodrow Wilson Center in Washington, DC. She is the author of So Much Aid, So Little Development: Stories from Pakistan published by the Johns Hopkins University Press in 2011.

Excerpt
…Conventional wisdom now offers a convenient excuse for Pakistan’s failure to remove polio: Service-delivery challenges, such as the horrifying attacks on polio workers, and increased militancy and unrest throughout the country need to be addressed through the holy trinity of funding, technology and organisation. The situation has grown more challenging, but focusing attention on these new and immediate issues only helps to obscure the deeper underlying problem that has been present from the beginning.

What’s been missing in Pakistan for so many decades is an understanding of the big picture – which means, in part, acknowledging that funding, technology and organisation do not exist in a vacuum, but are applied in particular ways to particular contexts.

If increasing amounts of funding, steadily developing science and modified organisational plans have consistently failed, the only logical step is an analysis of the context. To use a medical analogy: There is pathology here, and increasing doses of the old medicine have not worked. Before upping the dose again or changing the prescription, the disease has to be diagnosed.
The best place to look is in the design and implementation strategy of the polio-eradication programmes to which all the funding, technology and organisation have been applied. Pakistan’s Polio Eradication Programme was designed three decades ago and has not changed since.

It is now outmoded and radically out of sync with the local context. It is rigidly structured and inflexible, unable to respond to challenges either in the field or at the policy level. Management responsibility has been divided between United Nations agencies, non-governmental organisations, and the government – yet there are still significant overlaps between the tasks of the provincial and central government. Thus these efforts are uncoordinated and no one is truly accountable.

Mistakes repeated
In the past few decades, repeated trials of the same programme have replicated the same mistakes at each step. Donors prioritise how much money is spent, rather than how effectively it is spent – and in any case, there are many donors, NGOs and other agencies competing over the same turf. Inadequately trained staff are hired only for intensive campaigns of a few days, and therefore – despite the best of intentions and despite the incredible courage that has become increasingly necessary for them – they are poorly informed and not invested in the programme’s overall success.
There is rarely any attempt to communicate effectively to the recipient population about the vaccinations. At best, printed brochures are distributed, but given that literacy rates are low in many of the at-risk communities (the literacy rate for women is barely above 50 percent in Punjab and is less than half that in Balochistan), these are largely useless.

The inability to even properly inform the population reflects a more disturbing problem: That polio eradication in Pakistan has consistently treated the recipients as little more than passive and recalcitrant targets. Their context has been brushed aside entirely, in a trend that is only growing worse. The dollars, the technology and the organisational changes are closely examined – but no one takes more than a glance at the men, women and children who are meant to benefit from them. There is, of course, no space for communities to have a say in the programmes themselves – no one has even thought to ask them the basic questions…

Economist
http://www.economist.com/
Accessed 24 May 2014

Polio – An unwelcome return
[Babbage – Science and Technology]
May 21st 2014

IN 1988 polio caused huge concern: the disease, which leaves one victim in every 200 paralysed, was prevalent in more than 125 countries which together counted 350,000 cases annually. A quarter of a century and 2.5 billion vaccinated children later, the virus looked close to extinction: just five countries reported new instances of polio in 2012. The World Health Organisation (WHO) declared that by 2018 it should be history, alongside smallpox, another once-feared killer. And in March of this year India, which five years ago accounted for nearly half of all cases, was declared polio-free.

Yet the prospect that the whole world will achieve the same feat is now slipping away. In a change of tune, the WHO earlier this month declared polio a “public health emergency of international concern”—something it has done only once before, with the pandemic flu in 2009. So far this year 77 polio cases have been reported, up from 33 in the same period of 2013, despite it being the disease’s low season. These are spread across eight countries: Pakistan, Afghanistan, Cameroon, Equatorial Guinea, Ethiopia, Iraq, Syria and Nigeria. Laboratory analyses of faecal samples show that three of the countries (Pakistan, Syria and Cameroon) have recently transmitted the virus to neighbours—particularly alarming for the WHO. Problems persist elsewhere too. Somalia had a case of polio as recently as December, and Israel has detected the virus in its sewage system.

Although children are more likely to catch polio, adults are helping to spread it. The WHO has asked all ten affected countries to encourage departing travellers to get vaccinated and told the three known to have exported it to refuse exit to anyone without a vaccination certificate. The fear is that the disease will spread to other politically unstable countries. The approach of the Asian monsoon season adds urgency: polio is transmitted more easily in humid conditions, and when already poor sanitations systems are overwhelmed.

Heidi Larson of the London School of Hygiene and Tropical Medicine puts the blame for fuelling the transmission of polio largely on Pakistan. It is the big backslider, accounting for the vast majority of cases (61 out of 77) this year, compared with just eight during the same period in 2013.

In recent years Pakistan has allowed some of its most lawless regions to become havens for the virus. Hardly any of the 290,000 children in the two Waziristans, for example, have been vaccinated since 2012—the year militant chieftains declared a ban on the work of vaccinators, most likely in retaliation for American drone strikes. The fact that the CIA is said to have used a fake vaccine campaing in the search for Osama Bin Laden has not helped the cause. (In response to a wave of deadly attacks on polio workers in the region, the American government said yesterday that the CIA has ended the use of vaccine programmes in its spying operations.) In addition, people in the region are exceptionally mobile, with large in- and outflows of jihadists, aid workers and refugees, all acting as possible couriers of the disease. Many of the strands found around the world, including in Israel and Afghanistan, originated in Pakistan.

Beyond the steps proposed by the WHO, more health diplomacy and intelligent security efforts could help curb polio’s spread by facilitating medical activities in conflict zones, says Dr Larson. But she admits that the Pakistani situation is far more complex than the one in northern Nigeria during the region’s polio-vaccination boycott in 2003-04, which Dr Larson helped to end as part of UNICEF’s negotiating team. Internal conflict and tribal loyalties in Pakistan are complicating matters.

It is critical to combat polio quickly, while its resurgence is still small. The downside of the disease becoming so rare—even with the increase in the number of cases this year, the disease’s occurrence has diminished by over 99% since 1988—is that people’s natural resistance has also been reduced. A failure to eradicate the disease could lead to as many as 200,000 new cases per year within the next decade, warns the Gates Foundation, which spends a lot of money to fight polio. This would put huge strain on medical budgets: a worldwide vaccination campaign, for instance, costs around $1 billion per year. But as Benjamin Neuman, a virologist at the University of Reading, points out, “you need to eradicate wars before you can eradicate polio.”

WHO: Fifth Meeting of the IHR Emergency Committee concerning MERS-CoV
WHO statement
14 May 2014
[Full text; Editor’s text bolding]

The fifth meeting of the Emergency Committee convened by the Director-General under the International Health Regulations (2005) concerning Middle East respiratory syndrome coronavirus (MERS-CoV) was held by teleconference on Tuesday, 13 May 2014, from 12:07 to 17:12 Geneva time (CEST).

In addition to Members of the Emergency Committee, three expert advisors participated in the informational session only1. These advisors did not participate in the formulation of advice to the Director-General.

Thirteen affected States Parties reporting cases of MERS-CoV or evidence of infection since December 2013, were also on the first part of the teleconference: Egypt, Greece, Jordan, Kuwait, Lebanon, Malaysia, Oman, Philippines, Qatar, Saudi Arabia, United Arab Emirates, United States of America, and Yemen.

The WHO Secretariat provided an update on and assessment of epidemiological and scientific developments, including a description of the recent increase in cases in communities and in hospitals, transmission patterns, and the main observations of a WHO mission to Saudi Arabia, conducted 28 April – 5 May 2014.

Affected countries gave information about recent events in their countries, including measures taken and their concerns about the current situation.

The Members of the Committee discussed the information provided. Based on current information, the Committee indicated that the seriousness of the situation had increased in terms of public health impact, but that there is no evidence of sustained human-to-human transmission. As a result of their deliberations, the Committee concluded that the conditions for a Public Health Emergency of International Concern (PHEIC) have not yet been met.

However, the Committee emphasized that its concern about the situation had significantly increased. Their concerns centred on the recent sharp rise in cases; systemic weaknesses in infection prevention and control, as well as gaps in critical information; and possible exportation of cases to especially vulnerable countries. The Committee strongly urged WHO and Member States to take immediate steps to:
:: improve national policies for infection prevention and control, and implement them in health-care facilities in all countries; this is most urgent for affected countries;
:: initiate and accelerate critical investigations, including case-control, serological, environmental, and animal studies, to better understand the epidemiology, especially risk factors and assess the effectiveness of control measures;
:: support countries that are particularly vulnerable, especially in sub-Saharan Africa, taking into account the regional challenges;
:: strengthen case and contact identification and management;
:: greatly enhance awareness and effective risk communication concerning MERS-CoV to the general public, health professionals, at-risk groups, and policy makers;
:: strengthen intersectoral collaboration and information sharing across ministries and with relevant international organizations, especially with the World Organization for Animal Health (OIE) and the Food and Agriculture Organization of the United Nations (FAO);
:: develop and disseminate advice regarding mass gatherings to prevent further spread of MERS-CoV;
:: share information in a timely manner with WHO, in accordance with the International Health Regulations (2005).

Based on the Committee’s advice, and information currently available, the Director-General accepted the Committee’s assessment. She thanked the Committee for its work.

The WHO Secretariat will continue to provide regular updates to the Committee Members and Advisors. In view of the Committee’s concerns, the Emergency Committee will be reconvened in June 2014 or earlier if circumstances require.

.
CDC/MMWR Watch [to 17 May 2014]
http://www.cdc.gov/mmwr/mmwr_wk.html
:: CDC Transcript: Second case of Middle East Respiratory Syndrome Coronavirus infection (MERS) in the United States – Transcript
Monday, May 12, 2014, 5:00 PM
Transcipt of the telebriefing detailing a second imported case of Middle East Respiratory Syndrome (MERS) which was confirmed late night on May 11 in a traveler to the United States. This patient is a healthcare worker who resides and works in Saudi Arabia.
:: CDC announces second imported case of Middle East Respiratory Syndrome (MERS) in the United States – Press Release
Monday, May 12, 2014, 5:00 PM
A second imported case of Middle East Respiratory Syndrome (MERS) was confirmed late night on May 11 in a traveler to the United States. This patient is a healthcare worker who resides and works in Saudi Arabia.

MMWR, May 16, 2014 / Vol. 63 / No. 19
:: First Confirmed Cases of Middle East Respiratory Syndrome Coronavirus (MERS-CoV) Infection in the United States, Updated Information on the Epidemiology of MERS-CoV Infection, and Guidance for the Public, Clinicians, and Public Health Authorities — May 2014

WHO Europe: Middle East respiratory syndrome coronavirus (MERS-CoV) update: cases reported in the Netherlands, and implications for the European Region
16 May 2014
Excerpt
…Situation in the European Region
In the European Region, since April 2012, in total 12 laboratory-confirmed cases have been reported by France, Germany, Greece, Italy, the Netherlands and the United Kingdom. With the exception of three cases who were close contacts of laboratory-confirmed cases in France and the United Kingdom, all the other cases have been returning travellers or residents of countries of the Middle East. The most recent cases were reported by Greece (1 case reported to WHO on 18 April 2014) and by the Netherlands (2 cases reported to WHO on 14 and 15 May 2014). The Greek case is a Greek citizen living in Saudi Arabia who came to Greece on holiday and was diagnosed in Athens on arrival. The two cases in the Netherlands were returning travellers from countries of the Middle East. Extensive tracing of contacts of these cases has been conducted or is under way to ensure that any new cases are detected in a timely fashion….

WHO: Global Alert and Response (GAR) – Disease Outbreak News [to 17 May 2014]
http://www.who.int/csr/don/en/
:: Middle East respiratory syndrome coronavirus (MERS-CoV) – update 15 May 2014
:: Human infection with avian influenza A(H7N9) virus – update 15 May 2014
:: Ebola virus disease, West Africa – update 15 May 2014
:: Ebola virus disease, West Africa – update 12 May 2014

Polio [to 17 May 2014]

GPEI Update: Polio this week – As of 14 May 2014
Global Polio Eradication Initiative
Full report: http://www.polioeradication.org/Dataandmonitoring/Poliothisweek.aspx
[Editor’s extract and bolded text]
:: The 67th World Health Assembly, the world’s highest health policy setting body, is set to meet from 19-24 May. The report of the polio eradication programme to the Assembly is available here.
:: A case of polio due to wild poliovirus type 1 (WPV1) was reported this week from the Nigerian state of Yobe with onset of paralysis on 19 April. This is the first case in this state since July 2013. Genetic sequencing is ongoing to determine the origin of the virus.
Nigeria
:: A case of polio due to wild poliovirus type 1 (WPV1) was reported this week from the Nigerian state of Yobe with onset of paralysis on 19 April. This is the first case in this state since July 2013. Genetic sequencing is ongoing to determine the origin of the virus. The total number of WPV1 cases for 2014 is three
Pakistan
:: Two new WPV1 cases were reported in the past week (one from North Waziristan, Federally Administered Tribal Areas – FATA – and one from Gadap, greater Karachi), bringing the total number of WPV1 cases for 2014 to 61. The most recent WPV1 case had onset of paralysis on 20 April (from North Waziristan).

Pakistan: Polio vaccine a must for exit travelers
Associated Press
May 13, 2014 12:35 PM
ISLAMABAD (AP) — Pakistan will require all travelers leaving the country to obtain a polio vaccination from June 1, 2014, the health ministry said Tuesday.
A statement from the ministry said the restrictions comply with a decision by the World Health Organization advising travelers of all ages to be vaccinated by next month.
It says all provinces have been provided necessary guidance and material to set up special counters at hospitals and airports for polio vaccination and certification.
The ministry spokesman Sajid Shah says pregnant women traveling abroad are not exempted from the restrictions and the vaccination is not injurious for them…

The Lancet
Volume 383, Issue 9930, Pages 1697 – 1698, 17 May 2014
doi:10.1016/S0140-6736(14)60751-0

Beyond expectations: 40 years of EPI
Margaret Chan
[Full text]
The Expanded Programme on Immunization (EPI) was established by the World Health Assembly in 1974 at a time of great optimism for public health. The imminent certification for the eradication of smallpox was taken as proof of the power of vaccines, delivered in well-managed programmes, to permanently improve the world.1

When EPI was established, only about 5% of the world’s children were protected from six diseases (polio, diphtheria, tuberculosis, pertussis, measles, and tetanus) targeted by four vaccines. Today, that figure is 83%, with some low-income countries reaching 99% immunisation coverage.2 The number of public health vaccines being used for universal protection has more than doubled since 1974. Almost all countries include vaccines against hepatitis B and Haemophilus influenzae type b in addition to the original six diseases, and quality-assured vaccines are used in 97% of all countries.3 Today, WHO estimates that immunisation programmes save the lives of 2•5 million people each year and protect many millions more from illness and disability.4 With the certification of WHO’s South-East Asia Region as polio-free, 80% of the world’s population now lives in a country where polio has been eradicated.5

What accounts for this success? Does EPI offer lessons of broader relevance as the world prepares for the post-2015 era? EPI had some advantages from the outset. The prevention of childhood deaths has great public and political appeal, and that helped create momentum within individual countries and the international community to support immunisation programmes. Vaccines are scheduled interventions that can be delivered even in the absence of well functioning health systems, and even in places where capacities are weak and skilled health workers are scarce. The costs of the initial six EPI antigens against polio, diphtheria, tuberculosis, pertussis, measles, and tetanus were low.

But EPI’s success must be attributed to more than these advantages. During the past four decades, EPI has encouraged new models of international cooperation, found new sources of funding, and stimulated innovation in technology and the operational performance of national immunisation programmes.3 EPI has also pioneered improvements in surveillance and monitoring as a contribution to accountability for results.3 Fundamental public health capacities have also been strengthened; as just one example, there are nearly 700 laboratories, in 164 countries, accredited by WHO to undertake laboratory-based surveillance for measles and other vaccine-preventable epidemic-prone diseases.6

The establishment of the GAVI Alliance in 2000 helped launch the most innovative EPI decade to date.7 Since the start of this century, WHO, UNICEF, and the GAVI Alliance have worked to change the dynamics of the market for public health vaccines, making supplies more plentiful, predictable, and affordable.8 Collaboration with the pharmaceutical industry also intensified, leading not only to new vaccines against the world’s biggest childhood diseases, but also to new product designs and formulations that simplified safe administration in resource-constrained settings.9

A commitment to fairness has always been a driving force for the expansion of immunisation coverage and the introduction of new products. GAVI, with support from WHO, UNICEF, and others, has increased equitable access through rapid introduction of the newer and more expensive vaccines into the routine immunisation programmes of low-income countries. In 1997, for example, only 29 countries, mostly wealthy, used Haemophilus influenzae type b (Hib) vaccines in their national programmes, but by 2014 that number had increased to about 190 countries, including nearly all low-income countries. Financial sustainability for national immunisation programmes, however, remains a concern in several countries.

For public health, the previous century was an era of treatment that relied on technology-driven medicine to combat infectious diseases. With chronic non-communicable diseases now responsible for most deaths worldwide,10 the 21st century must be an era of prevention. Immunisation programmes—a prime model for prevention—have dealt with the problems of poor procurement policies, weak supply chains, infrequent supportive supervision, insufficient planning, and inadequate engagement of community leaders.3 Any goals set for health in the post-2015 era will need to address similar problems.

In this the Decade of Vaccines, EPI and its community of partners are focused on the estimated 22 million children who are still not reached by immunisation programmes.11 In doing so, they are guided by the Global Vaccine Action Plan, which aims to extend the full benefits of immunisation to all people.12, 13 Beyond the eradication of polio and the elimination of measles, rubella, and tetanus, the framework calls for all countries to reach 90% national immunisation coverage and 80% coverage in every district, with provision of essential vaccines, including vaccines against pneumococcal disease and rotavirus diarrhoea. Doing so will avert an estimated 24—26 million deaths by 2020, improving the world beyond EPI’s initial expectations.12

I see many signs that this desire to aim ever higher, with ambitious yet feasible goals, such as exceeding the Millennium Development Goal for reducing childhood mortality, eliminating a number of the neglected tropical diseases, and reducing tuberculosis deaths by 75%, will characterise the post-2015 era for public health. The future of global health can benefit from the pioneering work done by EPI in many respects—for example, finding new ways to secure and increase funding, fostering cooperation between multiple partners to work together with shared yet flexible strategies, stimulating industry innovation, and promoting country ownership through the streamlining of programmatic demands. Above all, EPI carved out pathways and strategies to achieve universal access to immunisation services. This legacy provides guidance for reforms that move health systems towards universal coverage, another worthy ambition for the future.

I am Director-General of WHO. I declare that I have no competing interests.
References
1 Okwo-Bele JM, Cherian T. The expanded programme on immunization: a lasting legacy of smallpox eradication. Vaccine 2011; 29 (suppl 4): D74-D79. PubMed
2 WHO. WHO/UNICEF coverage estimates for 1980—2012. Geneva: World Health Organization, 2012. http://www.who.int/immunization/monitoring_surveillance/data/coverage_estimates_series.xls. (accessed May 5, 2014).
3 WHO. Global vaccine action plan: monitoring, evaluation and accountability. Secretariat Annual Report 2013. Geneva: World Health Organization, 2013. http://www.who.int/immunization/global_vaccine_action_plan/GVAP_secretariat_report_2013.pdf?ua=1. (accessed May 5, 2014).
4 Duclos P, Okwo-Bele JM, Gacic-Dobo M, Cherian T. Global immunization: status, progress, challenges and future. BMC Int Health Hum Rights 2009; 9 (suppl 1): S2. PubMed
5 WHO. Media release: WHO South-East Asia Region certified polio-free. http://www.searo.who.int/mediacentre/releases/2014/pr1569/en/. (accessed May 5, 2014).
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a World Health Organization, 1211 Geneva 27, Switzerland

IAVI Statement: Together, We Can Achieve a World Without AIDS
World AIDS Vaccine Day – 18 May 2014
Full text
Do you remember the world before HIV/AIDS? Where will you be when the shadow of this disease is finally gone?

We have seen major advances in preventing and treating HIV/AIDS – but millions of people are still becoming infected and dying. In East and Southern Africa, 10.5 million children have lost one or both parents to HIV/AIDS. As the number-one killer of women of reproductive age, this epidemic takes an enormous human toll on individuals, families and communities, and an enormous economic toll in terms of healthcare costs and lost productivity.

For every three people put on treatment, four others contract HIV. And even if sufficient funding materializes to maximize access and adherence to existing treatment and prevention approaches, “best case” estimates are that low- and middle-income countries will still see more than half a million new infections a year come 2050.

Adding and successfully implementing a vaccine with 60-percent efficacy could reduce new HIV infections by 25 percent in its first decade and by almost half in 25 years, averting up to 22 million infections, according to modelling by IAVI, AVAC and Futures Institute.

Science is closing in on an AIDS vaccine. Researchers daily learn more about how HIV changes in the body and varies by geography; what the potential targets are on this highly elusive and mutating virus; how antibodies and our own T-cells could help prevent and even clear HIV infection; and how different vectors might be used to make a future vaccine more effective and longer-lasting. Studies are being prepared to build on the landmark RV144 vaccine trial; other exciting breakthroughs are advancing development of second-generation vaccines with even higher, longer-lasting and broader efficacy, and many new candidates are entering early development.

A vaccine will be transformative for so many people, cutting through barriers of stigma and gender inequity that stand between many individuals and the power to protect their own health. Yet global spending on AIDS vaccine research and development has been flat in recent years, despite the promising scientific advances. Sustained commitment will be critical to translating today’s and tomorrow’s promising science into a rich pipeline of vaccine candidates with the best chance of success.

This World AIDS Vaccine Day, we stand proudly beside our many partners and supporters, and together reaffirm our commitment to finding a vaccine that will help rid the world of HIV/AIDS.

WHO: Sixty-seventh World Health Assembly
The Sixty-seventh session of the World Health Assembly (WHA) takes place in Geneva during 19–24 May 2014. The WHA is the supreme decision-making body of WHO. It is attended by delegations from all WHO Member States and focuses on a specific health agenda prepared by the Executive Board. The main functions of the WHA are to determine the policies of the Organization, appoint the Director-General, supervise financial policies, and review and approve the proposed programme budget. The Health Assembly is held annually in Geneva, Switzerland.
:: WHA67 pre-session documentation planning profile, March-May 2014
:: Provisional agenda
:: Journal: Preliminary number – 9 May 2014
:: All documentation

WHO: World Health Statistics 2014 – Large gains in life expectancy
News release
Excerpt
15 May 2014 | GENEVA – People everywhere are living longer, according to the “World Health Statistics 2014” published today by WHO. Based on global averages, a girl who was born in 2012 can expect to live to around 73 years, and a boy to the age of 68. This is six years longer than the average global life expectancy for a child born in 1990.
WHO’s annual statistics report shows that low-income countries have made the greatest progress, with an average increase in life expectancy by 9 years from 1990 to 2012. The top six countries where life expectancy increased the most were Liberia which saw a 20-year increase (from 42 years in 1990 to 62 years in 2012) followed by Ethiopia (from 45 to 64 years), Maldives (58 to 77 years), Cambodia (54 to 72 years), Timor-Leste (50 to 66 years) and Rwanda (48 to 65 years).
“An important reason why global life expectancy has improved so much is that fewer children are dying before their fifth birthday,” says Dr Margaret Chan, WHO Director-General. “But there is still a major rich-poor divide: people in high-income countries continue to have a much better chance of living longer than people in low-income countries.”
: World Health Statistics 2014

Statement: Sabin Vaccine Institute: A rare spotlight for a neglected disease
May 13, 2014
Regarding New York Times May 11, 2014 Front Page Article

Schistosomiasis, a parasitic disease transmitted by freshwater snails, infects more than 200 million people worldwide, causing horrific symptoms, especially in girls and women. Schistosomiasis is the second deadliest parasitic disease after malaria, killing an estimated 300,000 people annually, and has been linked as a co-factor in the spread of HIV/AIDS in sub-Saharan Africa and the incidence of bladder cancer.

Despite its prevalence among the world’s poor, schistosomiasis has been largely neglected as a major disease by global media and policymakers. Yesterday, the New York Times featured a front-page profile of efforts to control and eliminate schistosomiasis as part of an examination of the links between the disease and HIV/AIDS.

In response to the article, Ambassador Michael W. Marine, CEO of Sabin Vaccine Institute, today issued the following statement:

“We applaud the New York Times for giving schistosomiasis the front page spotlight it deserves in ‘A Simple Theory, and a Proposal, on H.I.V. in Africa,’ by Donald G. McNeil Jr. Greater attention for the disease’s devastating social and economic impact on individuals and entire communities, and increased examination of its cross-cutting impact – particularly its role in increasing the risk of diseases such as HIV in girls and women – are crucial.

Currently, global partners are racing to meet the World Health Organization’s 2020 goal of controlling schistosomiasis by advancing commitments made in the landmark 2012 London Declaration on NTDs. To meet this deadline and sustain advances already made, we must all take urgent measures, such as expanding mass drug administration programs that treat and protect against schistosomiasis and other NTDs with safe medicines donated by pharmaceutical companies. Innovative partnerships that reach across development sectors and capitalize on cost-effective integration opportunities also will drive success.

Yet, we remain convinced that ultimately the world needs a schistosomiasis vaccine that can offer the promise of protection to millions of people worldwide and help achieve elimination of the disease. Under the leadership of Peter Hotez, MD, we are developing such an intervention through the Sabin Product Development Partnership’s Schistosomiasis Vaccine Initiative, a joint venture with the Texas Children’s Hospital and the Baylor College of Medicine in Houston.

Our schistosomiasis vaccine will soon enter Phase 1 clinical trials, to be carried out at Baylor’s Vaccine and Treatment Evaluation Unit (VTEU), funded by the National Institutes of Health. Our schistosomiasis research and development endeavors would not be possible without generous support from Mr. and Mrs. Morton Hyman, the Blavatnik Family Foundation, the Michelson Medical Research Foundation and Texas Children’s Hospital.

We are thankful for the New York Times’ comprehensive feature on schistosomiasis and hope that it energizes the NTD movement to drive momentum forward and overcome remaining challenges.”

The American Journal of Bioethics
Volume 14, Issue 6, 2014
http://www.tandfonline.com/toc/uajb20/current

Patient and Citizen Participation in Health: The Need for Improved Ethical Support
Laura Williamson
pages 4-16
DOI: 10.1080/15265161.2014.900139
Published online: 08 May 2014
Abstract
Patient and citizen participation is now regarded as central to the promotion of sustainable health and health care. Involvement efforts create and encounter many diverse ethical challenges that have the potential to enhance or undermine their success. This article examines different expressions of patient and citizen participation and the support health ethics offers. It is contended that despite its prominence and the link between patient empowerment and autonomy, traditional bioethics is insufficient to guide participation efforts. In addition, the turn to a “social paradigm” of ethics in examinations of biotechnologies and public health does not provide an account of values that is commensurable with the pervasive autonomy paradigm. This exacerbates rather than eases tensions for patients and citizens endeavoring to engage with health. Citizen and patient participation must have a significant influence on the way we do health ethics if its potential is to be fulfilled.

BMC Public Health
(Accessed 17 May 2014)
http://www.biomedcentral.com/bmcpublichealth/content

Research article
Expanded program of immunization coverage and associated factors among children age 12 – 23 months in Arba Minch town and ZuriaDistrict, Southern Ethiopia, 2013
Worku Animaw, Wondimagegn Taye, Behailu Merdekios, Marilign Tilahun and Gistane Ayele
Abstract (provisional)
Background
Immunization averts an estimated 2 to 3 million deaths every year globally. In Ethiopia only quarter of children are fully immunized; the rest are remained at risk for vaccine-preventable mortality. To increase the immunization, its coverage and predictors has to be identified. This study has measured immunization coverage and identified the predictors.
Methods
Cross-sectional community based study has been conducted within 630 age 12-23 months children in 15 districts of Arba Minch town and Arba Minch Zuria district, Southern Ethiopia in March 2013. Census was done to identify eligible children. The 2005 world health organization expanded program of immunization cluster sampling method has been used. Data were collected using semi-structured pretested Amharic version questionnaire by interviewing index children’s mothers/caretakers, copying from vaccine card and observing BCG vaccine scar. Data were processed using SPSS version 16. Associations between dependent and independent variables has been assessed and presented using three consecutive logistic regression models. Result: Nearly three fourth (73.2%) of children in Arba Minch Town and Arba Minch Zuria district were fully immunized. The rest 20.3% were partially immunized and 6.5% received no vaccine. Mother education, mothers’ perception to accessibility of vaccines, mothers’ knowledge to vaccine schedule of their site, place of delivery and living altitude were independent predictors of children immunization status.
Conclusion
Expanded program of immunization (EPI) coverage at Arba Minch town and Arba Minch Zuria district is better than the national immunization coverage but still below the goal. Educating mother, promoting institution delivery could help to maintain and enhance current immunization coverage. More emphasis should be given to the highland areas of the area.

BMC Public Health
(Accessed 17 May 2014)
http://www.biomedcentral.com/bmcpublichealth/content

Research article
Parents’ preferences for vaccinating daughters against human papillomavirus in the Netherlands: a discrete choice experiment
Robine Hofman, Esther W de Bekker-Grob, Hein Raat, Theo JM Helmerhorst, Marjolein van Ballegooijen and Ida J Korfage
Abstract (provisional)
Background
To generate knowledge about potential improvements to human papillomavirus (HPV) vaccination information and organization strategies, we assessed how aspects of HPV vaccination are associated with parents’ preferences for their daughters’ uptake, and which trade-offs parents are willing to make between these aspects.
Methods
A discrete choice experiment (DCE) was conducted among parents with a daughter aged 10-12 years. Panel mixed logit regression models were used to determine parents’ preferences for vaccination. Trade-offs were quantified between four vaccination programme aspects: degree of protection against cervical cancer, duration of protection, risk of serious side-effects, and age of vaccination.
Results
Total response rate was 302/983 (31%). All aspects influenced respondents’ preferences for HPV vaccination (p < 0.05). Respondents preferred vaccination at age 14 years instead of at a younger age. Respondents were willing to trade-off 11% of the degree of protection to obtain life-time protection instead of 25 years. To obtain a vaccination with a risk of serious side-effects of 1/750,000 instead of 1/150,000, respondents were willing to trade-off 21%.
Conclusions
Uptake may rise if the age ranges for free HPV vaccinations are broadened. Based on the trade-offs parents were willing to make, we conclude that uptake would increase if new evidence indicated outcomes are better than are currently understood, particularly for degree and duration of protection.

BMC Public Health
(Accessed 17 May 2014)
http://www.biomedcentral.com/bmcpublichealth/content

Research article
Knowledge, attitudes, beliefs and behaviours of older adults about pneumococcal immunization, a Public Health Agency of Canada / Canadian Institutes of Health Research Influenza Research Network (PCIRN) investigation
Amy Schneeberg, Julie A Bettinger, Shelly McNeil, Brian J Ward, Marc Dionne, Curtis Cooper, Brenda Coleman, Mark Loeb, Ethan Rubinstein, Janet McElhaney, David W Scheifele and Scott A Halperin
Abstract (provisional)
Background
Fewer Canadian seniors are vaccinated against pneumococcal disease than receive the influenza vaccine annually. Improved understanding of factors influencing pneumococcal vaccination among older adults is needed to improve vaccine uptake.
Methods
A self-administered survey measuring knowledge, attitudes, beliefs and behaviours about pneumococcal vaccination was administered to a cohort of seniors participating in a clinical trial of seasonal influenza vaccines at eight centers across Canada. Eligible participants were ambulatory adults 65?years of age or older, in good health or with stable health conditions, previously given influenza vaccine. The primary outcome was self-reported receipt of pneumococcal vaccination. Multi-variable logistic regression was used to determine factors significantly associated with pneumococcal vaccine receipt.
Results
A total of 863 participants completed questionnaires (response rate 92%); 58% indicated they had received the pneumococcal vaccine. Being offered the vaccine by a health care provider had the strongest relationship with vaccine receipt (AOR 23.4 (95% CI 13.4-40.7)). Other variables that remained significantly associated with vaccine receipt in the multivariable model included having heard of the vaccine (AOR 10.1(95% CI 4.7-21.7)), and strongly agreeing that it is important for adults?>?65 to be vaccinated against pneumococcus (AOR 3.3 (95% CI 1.2-9.2)). Participants who were?<?70?years of age were less likely to be vaccinated.
Conclusions
These results indicate healthcare recommendation significantly influenced vaccine uptake in this population of older adults. Measures to encourage healthcare providers to offer the vaccine may help increase coverage.

Cost Effectiveness and Resource Allocation
(Accessed 17 May 2014)
http://www.resource-allocation.com/

Research
Multi-criteria decision analysis of breast cancer control in low- and middle- income countries: development of a rating tool for policy makers
Kristie Venhorst, Sten G Zelle, Noor Tromp and Jeremy A Lauer
Abstract (provisional)
Background
The objective of this study was to develop a rating tool for policy makers to prioritize breast cancer interventions in low- and middle- income countries (LMICs), based on a simple multi-criteria decision analysis (MCDA) approach. The definition and identification of criteria play a key role in MCDA, and our rating tool could be used as part of a broader priority setting exercise in a local setting. This tool may contribute to a more transparent priority-setting process and fairer decision-making in future breast cancer policy development.
Methods
First, an expert panel (n = 5) discussed key considerations for tool development. A literature review followed to inventory all relevant criteria and construct an initial set of criteria. A Delphi study was then performed and questionnaires used to discuss a final list of criteria with clear definitions and potential scoring scales. For this Delphi study, multiple breast cancer policy and priority-setting experts from different LMICs were selected and invited by the World Health Organization. Fifteen international experts participated in all three Delphi rounds to assess and evaluate each criterion.
Results
This study resulted in a preliminary rating tool for assessing breast cancer interventions in LMICs. The tool consists of 10 carefully crafted criteria (effectiveness, quality of the evidence, magnitude of individual health impact, acceptability, cost-effectiveness, technical complexity, affordability, safety, geographical coverage, and accessibility), with clear definitions and potential scoring scales.
Conclusions
This study describes the development of a rating tool to assess breast cancer interventions in LMICs. Our tool can offer supporting knowledge for the use or development of rating tools as part of a broader (MCDA based) priority setting exercise in local settings. Further steps for improving the tool are proposed and should lead to its useful adoption in LMICs.

Globalization and Health
[Accessed 17 May 2014]
http://www.globalizationandhealth.com/

Research
Patient factors to target for elimination of mother-to-child transmission of HIV
Coceka N Mnyani, Adonia Simango, Joshua Murphy, Matthew Chersich and James A McIntyre
Abstract (provisional)
Background
There is great impetus to achieve elimination of mother-to-child transmission of HIV (eMTCT) by 2015, and part of this is to identify factors to target to achieve the goal. This study thus identified key patient factors for MTCT in a high HIV prevalence setting in Johannesburg, South Africa. Between November 2011 and May 2012, we conducted a case-control study among HIV-infected women with HIV-infected (cases) and uninfected (controls) infants diagnosed around six weeks of age as part of routine, early infant diagnosis. Mothers and infants were identified through registers in six healthcare facilities that provide antenatal, postpartum and HIV care. Structured interviews were conducted with a focus on history of HIV infection, antenatal, intrapartum and immediate postpartum management of the mother-infant pair. Patient-related risk factors for MTCT were identified.
Results
A total of 77 women with HIV-infected infants and 154 with -uninfected infants were interviewed. Among HIV-infected cases, 13.0% of the women knew their HIV status prior to conception, and 83.1% reported their pregnancies as unplanned. Antenatal antiretroviral coverage was high in the control group – only 1/154 (0.7%) reported receiving no prophylaxis or treatment compared with 17/74 (22.9%) of cases. In multivariate analysis, key patient-related risks for HIV transmission were: unknown HIV status prior to conception (adjusted odds ratio [AOR] = 6.6; 95%CI = 2.4 – 18.4; p < 0.001); accessing antenatal care after 20 weeks gestation (AOR = 4.3; 95%CI = 2.0 – 9.3; p < 0.001); less than 12 years of formal education (AOR = 3.4; 95%CI = 1.6 – 7.5; p = 0.002); and unplanned pregnancy (AOR = 2.7; 95%CI = 1.2 to 6.3; p = 0.022). Mean age at first HIV test was 6.6 weeks (SD = 3.5) for infants who were diagnosed as HIV-infected, and the mean age at antiretroviral treatment initiation was 10.8 weeks (SD = 4.4). HIV-uninfected infants were diagnosed at a mean age of 6.0 weeks (SD = 0.2).
Conclusions
Undiagnosed maternal HIV infection prior to conception, unplanned pregnancies, delays in accessing antenatal care, and low levels of education were the most significant patient risk factors associated with MTCT. While the emphasis has been on increasing availability and coverage of efficacious antiretroviral regimens, and strengthening health systems within eMTCT initiatives, there is a need to also address patient-related factors if we are to achieve eMTCT goals.

Research
Translation, cultural adaptation and field-testing of the Thinking Healthy Program for Vietnam
Jane Fisher, Hau Nguyen, Priya Mannava, Ha Tran, Thao Dam, Huong Tran, Thach Tran, Kelly Durrant, Atif Rahman and Stanley Luchters
Abstract (provisional)
Background
Depression and anxiety are prevalent among women in low- and lower-middle income countries who are pregnant or recently delivered. There is promising evidence that culturally-adapted, evidence-informed, perinatal psycho-educational programs implemented in local communities are effective in reducing mental health problems. The Thinking Healthy Program (THP) has proved effective in Pakistan. The aims were to adapt the THP for rural Vietnam; establish the program’s comprehensibility, acceptability and salience for universal use, and investigate whether administration to small groups of women might be of equivalent effectiveness to administration in home visits to individual women.
Methods
The THP Handbook and Calendar were made available in English by the program developers and translated into Vietnamese. Cultural adaptation and field-testing were undertaken using WHO guidance. Field-testing of the four sessions of THP Module One was undertaken in weekly sessions with a small group in a rural commune and evaluated using baseline, process and endline surveys.
Results
The adapted Vietnamese version of the Thinking Healthy Program (THP-V) was found to be understandable, meaningful and relevant to pregnant women, and commune health centre and Women’s Union representatives in a rural district. It was delivered effectively by trained local facilitators. Role-play, brainstorming and small-group discussions to find shared solutions to common problems were appraised as helpful learning opportunities.
Conclusions
The THP-V is safe and comprehensible, acceptable and salient to pregnant women without mental health problems in rural Vietnam. Delivery in facilitated small groups provided valued opportunities for role-play rehearsal and shared problem solving. Local observers found the content and approach highly relevant to local needs and endorsed the approach as a mental health promotion strategy with potential for integration into local universal maternal and child health services. These preliminary data indicate that the impact of the THP-V should be tested in its complete form in a large scale trial.

Infectious Agents and Cancer
http://www.infectagentscancer.com/content
[Accessed 17 May 2014]

Review
Human papillomavirus genotypes in cervical cancer and vaccination challenges in Zimbabwe
Nyasha Chin¿ombe, Natasha L Sebata, Vurayai Ruhanya and Hilda T Matarira
Abstract (provisional)
Cervical cancer is one of the major causes of morbidity and mortality in women in Zimbabwe. This is mainly due to the high prevalence of high-risk human papillomavirus (HPV) genotypes in the population. So far, few studies have been done that showed the presence of high-risk genital HPV genotypes such as 16, 18, 31, 33, 52, 58 and 70 in Zimbabwean women with cervical cancer. The prevalence of HPV DNA in women with cervical cancer has been shown to range from 63% to 98%. The high-risk HPV 16, 18, 31, 33 and 58 were the most common genotypes in all the studies. The introduction of the new HPV vaccines, HPV2 and HPV4, which protect against HPV genotypes 16 and 18 into Zimbabwe is likely to go a long way in reducing deaths due to cervical cancer. However, there are few challenges to the introduction of the vaccines. The target population for HPV vaccination is at the moment not well-defined. The other challenge is that the current HPV vaccines confer only type-specific (HPV 16 and 18) immunity leaving a small proportion of Zimbabwean women unprotected against other high-risk HPV genotypes such as 31, 33 and 58. Future HPV vaccines such as the nanovalent vaccine will be more useful to Zimbabwe as they will protect women against more genotypes.

The Lancet
May 17, 2014 Volume 383 Number 9930 p1693 – 1780
http://www.thelancet.com/journals/lancet/issue/current

Comment
Mandatory polio vaccination for travellers: protecting global public health
Paul D Rutter, Liam J Donaldson
Full Text
The goal of following smallpox eradication with another programme to eliminate a disease from the planet was too compelling to resist and, in 1988, the World Health Assembly set its sights on polio.1 26 years later, the dream is not yet a reality. On May 5, 2014, WHO issued strong recommendations that Pakistan, Syria, and Cameroon should ensure that their residents and long-term visitors have up-to-date vaccination against polio before they travel internationally, and that each individual is issued with an International Certificate of Vaccination or Prophylaxis as proof of this.

Beyond expectations: 40 years of EPI
Margaret Chan

Use of vaccines as probes to define disease burden
Dr Daniel R Feikin MD a b, Prof J Anthony G Scott c d, Bradford D Gessner MD e
Summary
Vaccine probe studies have emerged in the past 15 years as a useful way to characterise disease. By contrast, traditional studies of vaccines focus on defining the vaccine effectiveness or efficacy. The underlying basis for the vaccine probe approach is that the difference in disease burden between vaccinated and unvaccinated individuals can be ascribed to the vaccine-specific pathogen. Vaccine probe studies can increase understanding of a vaccine’s public health value. For instance, even when a vaccine has a seemingly low efficacy, a high baseline disease incidence can lead to a large vaccine-preventable disease burden and thus that population-based vaccine introduction would be justified. So far, vaccines have been used as probes to characterise disease syndromes caused by Haemophilus influenzae type b, pneumococcus, rotavirus, and early infant influenza. However, vaccine probe studies have enormous potential and could be used more widely in epidemiology, for example, to define the vaccine-preventable burden of malaria, typhoid, paediatric influenza, and dengue, and to identify causal interactions between different pathogens.

New England Journal of Medicine
May 15, 2014 Vol. 370 No. 20
http://www.nejm.org/toc/nejm/medical-journal

Perspective
Treating Hepatitis C in Lower-Income Countries
Channa R. Jayasekera, M.D., Michele Barry, M.D., Lewis R. Roberts, M.B., Ch.B., Ph.D., and Mindie H. Nguyen, M.D.
N Engl J Med 2014; 370:1869-1871May 15, 2014DOI: 10.1056/NEJMp1400160
Excerpt
With costs that may exceed $90,000 per course, effective new hepatitis C treatments seem beyond the reach of low- and middle-income countries. But the global rollout of HIV treatment teaches us that it’s possible to make these agents broadly available and affordable.

Editorial
Advancing the Treatment for Chagas’ Disease
Pedro Albajar-Viñas, M.D., Ph.D., and João Carlos P. Dias, M.D.
N Engl J Med 2014; 370:1942-1943May 15, 2014DOI: 10.1056/NEJMe1403689
Excerpt
It is estimated that 8 million people are infected with Trypanosoma cruzi worldwide, with the majority of cases occurring in the Latin American countries in which the parasite is endemic. However, cases of Chagas’ disease have been increasingly detected in the United States, Canada, many European countries, and some Western Pacific countries, owing primarily to an increase in population movements between Latin America and other continents. Moreover, some countries in which the parasite is not endemic have higher estimated numbers of cases than many endemic countries in Latin America (e.g., >300,000 cases in the United States and >50,000 in Spain). . . .

PLoS One
[Accessed 17 May 2014]
http://www.plosone.org/

A Randomized Trial of an Early Measles Vaccine at 4½ Months of Age in Guinea-Bissau: Sex-Differential Immunological Effects
Kristoffer Jarlov Jensen, Mia Søndergaard, Andreas Andersen, Erliyani Sartono, Cesario Martins, May-Lill Garly, Jesper Eugen-Olsen, Henrik Ullum, Maria Yazdanbakhsh, Peter Aaby, Christine Stabell Benn, Christian Erikstrup
Research Article | published 16 May 2014 | PLOS ONE 10.1371/journal.pone.0097536
Abstract
Background
After measles vaccine (MV), all-cause mortality is reduced more than can be explained by the prevention of measles, especially in females.
Objective
We aimed to study the biological mechanisms underlying the observed non-specific and sex-differential effects of MV on mortality.
Methods
Within a large randomised trial of MV at 4.5 months of age blood samples were obtained before and six weeks after randomisation to early MV or no early MV. We measured concentrations of cytokines and soluble receptors from plasma (interleukin-1 receptor agonist (IL-1Ra), IL-6, IL-8, IL-10, tumor necrosis factor (TNF)-α, monocyte chemoattractant protein (MCP)-1, soluble urokinase-type plasminogen activator receptor), and secreted cytokines (interferon-γ, TNF-α, IL-5, IL-10, IL-13, IL-17) after in vitro challenge with innate agonists and recall antigens. We analysed the effect of MV in multiple imputation regression, overall and stratified by sex. The majority of the infants had previously been enrolled in a randomised trial of neonatal vitamin A. Post hoc we explored the potential effect modification by neonatal vitamin A.
Results
Overall, MV versus no MV was associated with higher plasma MCP-1 levels, but the effect was only significant among females. Additionally, MV was associated with increased plasma IL-1Ra. MV had significantly positive effects on plasma IL-1Ra and IL-8 levels in females, but not in males. These effects were strongest in vitamin A supplemented infants. Vitamin A shifted the effect of MV in a pro-inflammatory direction.
Conclusions
In this explorative study we found indications of sex-differential effects of MV on several of the plasma biomarkers investigated; in particular MV increased levels in females, most strongly in vitamin A recipients. The findings support that sex and micronutrient supplementation should be taken into account when analysing vaccine effects.
Trial Registration
clinicaltrials.gov number NCT 00168545

The Effects of School Closures on Influenza Outbreaks and Pandemics: Systematic Review of Simulation Studies
Charlotte Jackson, Punam Mangtani, Jeremy Hawker, Babatunde Olowokure, Emilia Vynnycky Research Article | published 15 May 2014 | PLOS ONE 10.1371/journal.pone.0097297

Women Have a Preference for Their Male Partner to Be HPV Vaccinated
Diane Medved Harper, Natalie Marya Alexander, Debra Ann Ahern, Johanna Claire Comes, Melissa Smith Smith, Melinda Ann Heutinck, Sandra Martin Handley
Research Article | published 14 May 2014 | PLOS ONE 10.1371/journal.pone.0097119

Vaccine
Volume 32, Issue 26, Pages 3115-3340 (30 May 2014)
http://www.sciencedirect.com/science/journal/0264410X/32

Consultation on dengue vaccines: Progress in understanding protection, 26–28 June 2013, Rockville, Maryland
Conference Report
Pages 3115-3121
M. Cristina Cassetti, Scott B. Halstead
Abstract
There is an unmet need for a dengue vaccine to further prevent the spread of this disease and contain the growing pandemic. To this end several vaccine companies and academic groups are actively pursuing the development of a tetravalent vaccine to prevent dengue. In the last few years progress has been made in this area, including the first results of a vaccine efficacy trial and improved understanding of the immune responses to the infection. Despite this progress, development of dengue vaccines faces important challenges including the need for a vaccine that induces balanced immune responses against all dengue strains and an incomplete understanding of the mechanism(s) of protection against infection and disease. This is a summary of a Consultation on dengue vaccines held in June 26–28, 2013 by the National Institute of Allergy and Infectious Diseases (part of the US National Institutes of Health) and the Dengue Vaccine Initiative (part of the International Vaccine Institute). The primary goal of this consultation was to review the progress in dengue vaccine development, evaluate the known mechanism of protection of dengue vaccines and discuss avenues for future research.

Vaccine
Volume 32, Issue 26, Pages 3115-3340 (30 May 2014)
http://www.sciencedirect.com/science/journal/0264410X/32

Safety of influenza vaccination during pregnancy: A review of subsequent maternal obstetric events and findings from two recent cohort studies
Review Article
Pages 3122-3127
Allison L. Naleway, Stephanie A. Irving, Michelle L. Henninger, De-Kun Li, Pat Shifflett, Sarah Ball, Jennifer L. Williams, Janet Cragan, Julianne Gee, Mark G. Thompson, for the Vaccine Safety Datalink and Pregnancy and Influenza Project
Abstract
Pregnant women and their infants are vulnerable to severe disease and secondary complications from influenza infection. For this reason, annual influenza vaccination is recommended for all pregnant women in the United States. Women frequently cite concerns about vaccine safety as a barrier to vaccination. This review describes the safety of inactivated influenza vaccination during pregnancy with a focus on maternal obstetric events, including hypertensive disorders, gestational diabetes, and chorioamnionitis. Included in the review are new findings from two studies which examined the safety of seasonal inactivated influenza vaccination during pregnancy. The first study enrolled 641 pregnant women during the 2010–2011 season and prospectively followed them until delivery or pregnancy termination. The second study enrolled 1616 pregnant women during the 2010–2011 influenza season, and followed the women and their infants for six months after delivery. No associations between inactivated influenza vaccination and gestational diabetes, gestational hypertension, preeclampsia/eclampsia, or chorioamnionitis were observed in either cohort. When considered as a whole, these studies should further reassure women and clinicians that influenza vaccination during pregnancy is safe for mothers.

Vaccine
Volume 32, Issue 26, Pages 3115-3340 (30 May 2014)
http://www.sciencedirect.com/science/journal/0264410X/32

Vaccine preventable disease incidence as a complement to vaccine efficacy for setting vaccine policy
Review Article
Pages 3133-3138
Bradford D. Gessner, Daniel R. Feikin
Abstract
Traditionally, vaccines have been evaluated in clinical trials that establish vaccine efficacy (VE) against etiology-confirmed disease outcomes, a measure important for licensure. Yet, VE does not reflect a vaccine’s public health impact because it does not account for relative disease incidence. An additional measure that more directly establishes a vaccine’s public health value is the vaccine preventable disease incidence (VPDI), which is the incidence of disease preventable by vaccine in a given context. We describe how VE and VPDI can vary, sometimes in inverse directions, across disease outcomes and vaccinated populations. We provide examples of how VPDI can be used to reveal the relative public health impact of vaccines in developing countries, which can be masked by focus on VE alone. We recommend that VPDI be incorporated along with VE into the analytic plans of vaccine trials, as well as decisions by funders, ministries of health, and regulatory authorities.

Vaccine
Volume 32, Issue 26, Pages 3115-3340 (30 May 2014)
http://www.sciencedirect.com/science/journal/0264410X/32

Anaphylaxis after vaccination of children: Review of literature and recommendations for vaccination in child and school health services in Belgium
Review Article
Pages 3147-3154
Anouk Vanlander, Karel Hoppenbrouwers
Abstract
Background
Concerns about the very small, but real risk of anaphylaxis after vaccination, has given rise to specific questions about the safe administration of vaccines to children and adolescents in the context of preventive settings (i.e. well baby clinics and school health services). As a support to preventive health professionals a guideline based on scientific evidence and supported by professional consensus was developed in Belgium.
Methods
First, a draft of guideline was written based on a review of international literature. Second, through several rounds of consultation professional consensus about the document was obtained across the Belgian communities and professional groups, and in a final version endorsed by the Belgian Superior Health Council in July 2012.
Results
In a literature overview information is given about the definition of anaphylaxis, allergens in vaccines potentially causing anaphylaxis, published incidence rates of anaphylaxis after vaccination, and strategies for first-aid management of anaphylaxis. The Belgian guideline on the prevention of anaphylaxis after vaccination includes recommendations on prevaccination risk assessment, the content of the emergency kit, measures to be taken after vaccination, differential diagnosis and first-aid management of anaphylaxis.
Conclusion
The guideline, summarized as a flowchart for the prevention and first-aid management of anaphylaxis, is considered as the actual state of the art in Belgium for vaccination of children and youngsters in preventive health services, and may inspire governmental bodies and/or professional groups in other countries to adopt similar recommendations.

Vaccine
Volume 32, Issue 26, Pages 3115-3340 (30 May 2014)
http://www.sciencedirect.com/science/journal/0264410X/32

Therapeutic vaccines for tuberculosis—A systematic review
Review Article
Pages 3162-3168
Matthias I. Gröschel, Satria A. Prabowo, Père-Joan Cardona, John L. Stanford, Tjip S van der Werf
Abstract
For eradication of tuberculosis (TB) by 2050, the declared aim of the Stop TB Partnership, novel treatment strategies are indispensable. The emerging epidemic of multi-drug resistant (MDR) TB has fuelled the debate about TB vaccines, as increasing numbers of patients can no longer be cured by pharmacotherapy. Of several proposed modalities, TB vaccines administered in therapeutic manner represents a promising alternative, despite the controversial history due to the occurrence of exacerbated immune response. A modified concept of immunotherapy is required in order to justify further exploration. In this paper we systematically reviewed the most advanced therapeutic vaccines for TB. We address the rationale of immunotherapeutic vaccination combined with optimized pharmacotherapy in active TB. We summarize preclinical and patient data regarding the five most advanced therapeutic vaccines currently in the pipeline. Of the five products that have been tested in animal models and in humans during active or latent TB, the quality of the published clinical reports of two of these products justify further studies in patients with active TB. This systematic review fuels further clinical evaluation eventually including head-to-head comparative studies.

Vaccine
Volume 32, Issue 26, Pages 3115-3340 (30 May 2014)
http://www.sciencedirect.com/science/journal/0264410X/32

Formal training in vaccine safety to address parental concerns not routinely conducted in U.S. pediatric residency programs
Original Research Article
Pages 3175-3178
S. Elizabeth Williams, Rebecca Swan
Abstract
Objective
To determine if U.S. pediatric residency programs provide formal training in vaccine safety to address parental vaccine concerns.
Methods
An electronic survey was mailed to all members of the Association of Pediatric Program Directors (APPD) to assess (1) if U.S. pediatric residency programs were providing formal vaccine safety training, (2) the content and format of the training if provided, and (3) interest in a training module for programs without training. Two follow-up surveys were mailed at 2 week intervals. Responses to the survey were collected at 4 weeks following the last mailing and analyzed. Logistic regression was used to assess the impact of program size on the likelihood of vaccine safety training. Pearson’s chi square was used to compare programs with and without formal vaccine safety training in 5 U.S. regions.
Results
The survey was sent to 199 APPD members; 92 completed the survey (response rate 46.2%). Thirty-eight respondents (41%) had formal training in vaccine safety for pediatric residents at their programs; 54 (59%) did not. Of those that did not, the majority (81.5%) were interested in formal vaccine safety training for their residents. Of all respondents, 78% agreed that training in vaccine safety was a high priority for resident education. Thirty-five percent of all respondents agreed that local parental attitudes about vaccines influenced the likelihood of formal vaccine safety training.
Conclusion
Most pediatric residency programs surveyed do not include formal training on vaccine safety; yet, such training is supported by pediatric residency program directors as a priority for pediatric residents.

Vaccine
Volume 32, Issue 26, Pages 3115-3340 (30 May 2014)
http://www.sciencedirect.com/science/journal/0264410X/32

Planning for human papillomavirus (HPV) vaccination in sub-Saharan Africa: A modeling-based approach
Original Research Article
Pages 3316-3322
J. Kathleen Tracy, Nicholas H. Schluterman, Christina Greene, Samba O. Sow, Holly D. Gaff
Abstract
Background
Human papillomavirus (HPV) vaccines have the potential to reduce cervical cancer incidence and mortality, particularly in the parts of the developing world that bear the greatest burden of disease. This research sought to predict the impact and cost-effectiveness of an HPV vaccination program in an example low-resource country with a high burden of cervical cancer: Mali, West Africa.
Methods
Novel compartmental mathematical models projected the impact of adolescent HPV vaccination in urban and rural areas of Mali. The models accounted for two high-risk vaccine-types: HPV 16 and 18. We then attached comprehensive real cost and cost-effectiveness estimates.
Results
Our models predict that HPV vaccination in Mali will reduce cervical cancer burden by a factor roughly equal to vaccine coverage. A point vaccination program was simulated in a cohort of 333,146 urban and 588,982 rural Malian women, age 10–14. Vaccination of 50% of girls reduced the peak prevalence of HPV 16/18 to 5.0% in the urban setting and 9.6% in the rural setting, down from 11.7% and 22.0%, respectively, with no vaccination. The 50% vaccination scenario averted 1145 cervical cancer deaths in the urban group and 2742 in the rural group. The cost per discounted life-year saved in this scenario was 1030 US dollars (urban) and 725 dollars (rural). The cost per life-year saved was higher at 90% coverage, but was still in the range of a “cost-effective” public health intervention.
Conclusions
This research yielded the most comprehensive real cost estimates of HPV vaccination yet published for sub-Saharan Africa. Our models indicate that HPV vaccination in Mali will be cost-effective when introduced. To maximize the benefit using limited resources, vaccination programs may begin with a target coverage of about 50%. We anticipate that costs of reaching late adopters after the First Vaccinated Wave of vaccination will be higher, but worthwhile.

Vaccine
Volume 32, Issue 26, Pages 3115-3340 (30 May 2014)
http://www.sciencedirect.com/science/journal/0264410X/32

Vaccine perception among acceptors and non-acceptors in Sokoto State, Nigeria
Original Research Article
Pages 3323-3327
Bola Murele, Rui Vaz, Alex Gasasira, Pascal Mkanda, Tesfaye Erbeto, Joseph Okeibunor
Abstract
Vaccine perceptions among acceptors and non-acceptors of childhood vaccination were explored. Seventy-two care givers, among them, acceptors and non-acceptors were interviewed in-depth with an interview guide that assessed vaccine acceptance, social and personality factors, and health belief model (HBM) categories in relation to oral polio vaccine (perceived susceptibility, severity, cost barriers, general barriers, benefits, knowledge, and engagement in preventative health behaviours). Community leaders were purposively selected while parents were selected on the basis of availability while ensuring the different attitude to vaccines was covered. Results showed that the HBM framework was found to be appropriate for identifying and distinguishing vaccine acceptors and non-acceptors. In addition, the HBM categories of benefits and susceptibility were found to influence oral polio vaccine acceptance. Second, the opinion of family members about the oral polio vaccine moderated the relationship between number of social ties and vaccine acceptance. Further, oral polio vaccine acceptance was related to outbreaks of paralysis of any sort, but not aggregate scores of other preventative health behaviours. Implications of this study include the investigation of vaccine acceptance in a high risk population. Research was done to investigate vaccine acceptance.

Vaccine
Volume 32, Issue 26, Pages 3115-3340 (30 May 2014)
http://www.sciencedirect.com/science/journal/0264410X/32

Toward more specific and transparent research and development costs: The case of seasonal influenza vaccines
Original Research Article
Pages 3336-3340
Ayman Chit, Jayson Parker, Scott A. Halperin, Manny Papadimitropoulos, Murray Krahn, Paul Grootendorst
Abstract
Background
The ability to calculate the development costs for specific medicines and vaccines is important to inform investments in innovation. Unfortunately, the literature is predominated by non-reproducible studies only measuring aggregate level drug research and development (R&D) costs. We describe methodology that improves the transparency and reproducibility of primary indication expected R&D expenditures.
Methods
We used publically accessible clinical trial data to investigate the fate of all seasonal influenza vaccine candidates that entered clinical development post year 2000. We calculated development times and probabilities of success for these candidates through the various phases of clinical development. Clinical trial cost data obtained from university based clinical researchers were used to estimate the costs of each phase of development. The cost of preclinical development was estimated using published literature.
Results
A vaccine candidate entering pre-clinical development in 2011 would be expected to achieve licensure in 2022; all costs are reported in 2022 Canadian dollars (CAD). After applying a 9% cost of capital, the capitalized total R&D expenditure amounts to $474.88 million CAD.
Conclusion
Clinical development costs for vaccines and drugs can be estimated with increased specificity and transparency using public sources of data. The robustness of these estimates will only increase over time due to public disclosure incentives first introduced in the late 1990s. However, preclinical development costs remain difficult to estimate from public data.