British Medical Journal
13 September 2014(vol 349, issue 7974)
http://www.bmj.com/content/349/7974

Research
Government health insurance for people below poverty line in India: quasi-experimental evaluation of insurance and health outcomes
Neeraj Sood, associate professor123, Eran Bendavid, assistant professor45, Arnab Mukherji, associate professor6, Zachary Wagner, PhD student7, Somil Nagpal, senior health specialist8,
Patrick Mullen, senior health specialist8
Author affiliations
BMJ 2014; 349 doi: http://dx.doi.org/10.1136/bmj.g5114 (Published 11 September 2014) Cite this as: BMJ 2014;349:g5114
Abstract
Objectives To evaluate the effects of a government insurance program covering tertiary care for people below the poverty line in Karnataka, India, on out-of-pocket expenditures, hospital use, and mortality.
Design Geographic regression discontinuity study.
Setting 572 villages in Karnataka, India.
Participants 31 476 households (22 796 below poverty line and 8680 above poverty line) in 300 villages where the scheme was implemented and 28 633 households (21 767 below poverty line and 6866 above poverty line) in 272 neighboring matched villages ineligible for the scheme.
Intervention A government insurance program (Vajpayee Arogyashree scheme) that provided free tertiary care to households below the poverty line in about half of villages in Karnataka from February 2010 to August 2012.
Main outcome measure Out-of-pocket expenditures, hospital use, and mortality.
Results Among households below the poverty line, the mortality rate from conditions potentially responsive to services covered by the scheme (mostly cardiac conditions and cancer) was 0.32% in households eligible for the scheme compared with 0.90% among ineligible households just south of the eligibility border (difference of 0.58 percentage points, 95% confidence interval 0.40 to 0.75; P<0.001). We found no difference in mortality rates for households above the poverty line (households above the poverty line were not eligible for the scheme), with a mortality rate from conditions covered by the scheme of 0.56% in eligible villages compared with 0.55% in ineligible villages (difference of 0.01 percentage points, −0.03 to 0.03; P=0.95). Eligible households had significantly reduced out-of-pocket health expenditures for admissions to hospitals with tertiary care facilities likely to be covered by the scheme (64% reduction, 35% to 97%; P<0.001). There was no significant increase in use of covered services, although the point estimate of a 44.2% increase approached significance (−5.1% to 90.5%; P=0.059). Both reductions in out-of-pocket expenditures and potential increases in use might have contributed to the observed reductions in mortality.
Conclusions Insuring poor households for efficacious but costly and underused health services significantly improves population health in India.

Eurosurveillance
Volume 19, Issue 36, 11 September 2014
http://www.eurosurveillance.org/Public/Articles/Archives.aspx?PublicationId=11678

Editorials
Containing Ebola virus infection in West Africa
A J Kucharski, P Piot1
London School of Hygiene & Tropical Medicine, London, United Kingdom
Excerpt
Ebola virus disease (EVD) is leaving a mark deeper and wider than ever before. The current outbreak now spans five countries in West Africa – Guinea, Liberia, Nigeria, Senegal and Sierra Leone – with over 4,200 cases and 2,200 deaths reported to the World Health Organization (WHO) as of 6 September 2014 (Figure 1) [1]. Unfortunately, with many cases either not reported or yet to show symptoms, the true number of infections is likely to be considerably higher. The first countries affected were among the world’s poorest, areas where long periods of civil wars have battered health services and eroded public trust. As a result, the outbreak has spread to other countries, and continues to expand. What began as a local problem has turned into an international crisis

Globalization and Health
[Accessed 13 September 2014]
http://www.globalizationandhealth.com/

Research
Trade and investment liberalization and Asia’s noncommunicable disease epidemic – A synthesis of data and existing literature
Phillip I Baker, Adrian Kay and Helen L Walls
Author Affiliations
Globalization and Health 2014, 10:66 doi:10.1186/s12992-014-0066-8
Published: 12 September 2014
Abstract (provisional)
Background
Trade and investment liberalization (trade liberalization) can promote or harm health. Undoubtedly it has contributed, although unevenly, to Asia’s social and economic development over recent decades with resultant gains in life expectancy and living standards. In the absence of public health protections, however, it is also a significant upstream driver of non-communicable diseases (NCDs) including cardiovascular disease, cancer and diabetes through facilitating increased consumption of the `risk commodities” tobacco, alcohol and ultra-processed foods, and by constraining access to NCD medicines. In this paper we describe the NCD burden in Asian countries, trends in risk commodity consumption and the processes by which trade liberalization has occurred in the region and contributed to these trends. We further establish pressing questions for future research on strengthening regulatory capacity to address trade liberalization impacts on risk commodity consumption and health.
Methods
A semi-structured search of scholarly databases, institutional websites and internet sources for academic and grey literature. Data for descriptive statistics were sourced from Euromonitor International, the World Bank, the World Health Organization, and the World Trade Organization.
Results
Consumption of tobacco, alcohol and ultra-processed foods was prevalent in the region and increasing in many countries. We find that trade liberalization can facilitate increased trade in goods, services and investments in ways that can promote risk commodity consumption, as well as constrain the available resources and capacities of governments to enact policies and programmes to mitigate such consumption. Intellectual property provisions of trade agreements may also constrain access to NCD medicines. Successive layers of the evolving global and regional trade regimes including structural adjustment, multilateral trade agreements, and preferential trade agreements have enabled transnational corporations that manufacture, market and distribute risk commodities to increasingly penetrate and promote consumption in Asian markets.
Conclusions
Trade liberalization is a significant driver of the NCD epidemic in Asia. Increased participation in trade agreements requires countries to strengthen regulatory capacity to ensure adequate protections for public health. How best to achieve this through multilateral, regional and unilateral actions is a pressing question for ongoing research.

Health Affairs
September 2014; Volume 33, Issue 9
http://content.healthaffairs.org/content/current

Theme: Advancing Global Health Policy
Global Health Leaders Recommit To Reducing Child Deaths
Jessica Bylander
Health Aff September 2014 33:1503-1506; doi:10.1377/hlthaff.2014.0848

Innovation & Implementation
Accountable Care Around The World: A Framework To Guide Reform Strategies
Mark McClellan, James Kent, Stephen J. Beales, Samuel I.A. Cohen, Michael Macdonnell, Andrea Thoumi, Mariam Abdulmalik, and Ara Darzi
Health Aff September 2014 33:1507-1515; doi:10.1377/hlthaff.2014.0373

ANALYSIS & COMMENTARY:
Lessons From Eight Countries On Diffusing Innovation In Health Care
Oliver P. Keown, Greg Parston, Hannah Patel, Fiona Rennie, Fathy Saoud, Hanan Al Kuwari, and Ara Darzi
Health Aff September 2014 33:1516-1522; doi:10.1377/hlthaff.2014.0382

ANALYSIS & COMMENTARY:
Developing Public Policy To Advance The Use Of Big Data In Health Care
Axel Heitmueller, Sarah Henderson, Will Warburton, Ahmed Elmagarmid, Alex “Sandy” Pentland, and Ara Darzi
Health Aff September 2014 33:1523-1530; doi:10.1377/hlthaff.2014.0771

The Hidden Cost Of Low Prices: Limited Access To New Drugs In India
Ernst R. Berndt and Iain M. Cockburn
Health Aff September 2014 33:1567-1575; doi:10.1377/hlthaff.2013.1307

Improving Access To Malaria Medicine Through Private-Sector Subsidies In Seven African Countries
Sarah Tougher, Andrea G. Mann, ACTwatch Group, Yazoume Ye, Idrissa A. Kourgueni, Rebecca Thomson, John H. Amuasi, Ruilin Ren, Barbara A. Willey, Daniel Ansong, Katia Bruxvoort, Graciela Diap, Charles Festo, Boniface Johanes, Admirabilis Kalolella, Oumarou Mallam, Blessing Mberu, Salif Ndiaye, Samual Blay Nguah, Moctar Seydou, Mark Taylor, Marilyn Wamukoya, Fred Arnold, Kara Hanson, and Catherine Goodman
Health Aff September 2014 33:1576-1585; doi:10.1377/hlthaff.2014.0104

JAMA
September 10, 2014, Vol 312, No. 10
http://jama.jamanetwork.com/issue.aspx

Editorial | September 10, 2014
Open Access to Clinical Trials Data
Harlan M. Krumholz, MD, SM1; Eric D. Peterson, MD, MPH2,3
[+] Author Affiliations
JAMA. 2014;312(10):1002-1003. doi:10.1001/jama.2014.9647.
Excerpt
Well-conducted randomized clinical trials (RCTs) are the gold standard for evaluating the safety and efficacy of medical therapeutics. Yet most often, a single group of individuals who conducted the trial are the only ones who have access to the raw data, conduct the analysis, and publish the study results. This limited access does not typically allow others to replicate the trial findings. Given the time and expense required to conduct an RCT, it is often unlikely that others will independently repeat a similar experiment. Thus, the scientific community and the public often accept the results produced and published by the original research team without an opportunity for reanalysis. Increasingly, however, opinions and empirical data are challenging the assumption that the analysis of a clinical trial is straightforward and that analysis by any other group would obtain the same results.1- 3…

Medical News & Perspectives | September 10, 2014
Largest-Ever Outbreak of Ebola Virus Disease Thrusts Experimental Therapies, Vaccines Into Spotlight
Tracy Hampton, PhD
JAMA. 2014;312(10):987-989. doi:10.1001/jama.2014.11170.
As efforts to successfully contain the largest outbreak of Ebola virus disease in history prove elusive, the mounting number of cases and deaths has brought research to develop much-needed treatments and protective vaccines into the spotlight. Although the approval process for drugs and vaccines is typically slow and deliberate, the latest outbreak, declared by the World Health Organization (WHO) on August 8 as an international health emergency, has galvanized regulatory officials to consider proposals for providing as-yet unproven treatments under special emergency New Drug Applications.

The Lancet
Sep 13, 2014 Volume 384 Number 9947 p929 – 1070 e38
http://www.thelancet.com/journals/lancet/issue/current

Editorial
The silver bullet of resilience
The Lancet
The irony of September being US National Preparedness month was not lost as Médecins sans Frontières (MSF) made an uncharacteristic global call for rapid deployment of civil and military medical assets with expertise in biohazard containment to west Africa. With 42% of all reported Ebola infections occurring in the past month, and more than 2000 reported deaths, local health systems and international organisations were not prepared for the scale and speed of the current outbreak. MSF called for countries such as the UK and USA to deploy disaster response teams with medical and logistical experts for water and sanitation, building of mobile laboratories, isolation centres, hospitals, crematoriums, and the establishment of dedicated air bridges to move personnel and equipment between countries. On Sept 7, the US government announced that their military would be mobilised to set up isolation units and equipment, and provide security for public health workers.

Delayed international action has been largely blamed on the chronic underfunding and inability of WHO to mount an adequate initial response to manage the outbreak. This institutional failure begs first and foremost an urgent rethink of how the world responds to outbreaks, and with whom. The second equally important task is building resilience into health systems.

The notion of resilience is defined as the capacity to adapt and thrive in the face of challenge. For health organisations, this could mean creating more redundancy and organisational slack to respond efficiently to crises. For companies, it might mean rethinking the development pipeline of their products, delinked from profit, to contribute to a better prepared world. For countries and their partners, it means investing in weak health systems, building back the trust of communities, and examining the complex interactions between people and the environment. However, to earn the luxury of a much needed resilience debate for west Africa, countries and international organisations must heed the call to immediately deploy medical assets to contain the Ebola outbreak and offset further deaths.

Global, regional, and national levels of neonatal, infant, and under-5 mortality during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013
Haidong Wang, et al.
Summary
Background
Remarkable financial and political efforts have been focused on the reduction of child mortality during the past few decades. Timely measurements of levels and trends in under-5 mortality are important to assess progress towards the Millennium Development Goal 4 (MDG 4) target of reduction of child mortality by two thirds from 1990 to 2015, and to identify models of success.
Methods
We generated updated estimates of child mortality in early neonatal (age 0—6 days), late neonatal (7—28 days), postneonatal (29—364 days), childhood (1—4 years), and under-5 (0—4 years) age groups for 188 countries from 1970 to 2013, with more than 29 000 survey, census, vital registration, and sample registration datapoints. We used Gaussian process regression with adjustments for bias and non-sampling error to synthesise the data for under-5 mortality for each country, and a separate model to estimate mortality for more detailed age groups. We used explanatory mixed effects regression models to assess the association between under-5 mortality and income per person, maternal education, HIV child death rates, secular shifts, and other factors. To quantify the contribution of these different factors and birth numbers to the change in numbers of deaths in under-5 age groups from 1990 to 2013, we used Shapley decomposition. We used estimated rates of change between 2000 and 2013 to construct under-5 mortality rate scenarios out to 2030.
Findings
We estimated that 6•3 million (95% UI 6•0—6•6) children under-5 died in 2013, a 64% reduction from 17•6 million (17•1—18•1) in 1970. In 2013, child mortality rates ranged from 152•5 per 1000 livebirths (130•6—177•4) in Guinea-Bissau to 2•3 (1•8—2•9) per 1000 in Singapore. The annualised rates of change from 1990 to 2013 ranged from −6•8% to 0•1%. 99 of 188 countries, including 43 of 48 countries in sub-Saharan Africa, had faster decreases in child mortality during 2000—13 than during 1990—2000. In 2013, neonatal deaths accounted for 41•6% of under-5 deaths compared with 37•4% in 1990. Compared with 1990, in 2013, rising numbers of births, especially in sub-Saharan Africa, led to 1•4 million more child deaths, and rising income per person and maternal education led to 0•9 million and 2•2 million fewer deaths, respectively. Changes in secular trends led to 4•2 million fewer deaths. Unexplained factors accounted for only −1% of the change in child deaths. In 30 developing countries, decreases since 2000 have been faster than predicted attributable to income, education, and secular shift alone.
Interpretation
Only 27 developing countries are expected to achieve MDG 4. Decreases since 2000 in under-5 mortality rates are accelerating in many developing countries, especially in sub-Saharan Africa. The Millennium Declaration and increased development assistance for health might have been a factor in faster decreases in some developing countries. Without further accelerated progress, many countries in west and central Africa will still have high levels of under-5 mortality in 2030.
Funding
Bill & Melinda Gates Foundation, US Agency for International Development.

Global, regional, and national levels and causes of maternal mortality during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013
Nicholas J Kassebaum, et al
Summary
Background
The fifth Millennium Development Goal (MDG 5) established the goal of a 75% reduction in the maternal mortality ratio (MMR; number of maternal deaths per 100 000 livebirths) between 1990 and 2015. We aimed to measure levels and track trends in maternal mortality, the key causes contributing to maternal death, and timing of maternal death with respect to delivery.
Methods
We used robust statistical methods including the Cause of Death Ensemble model (CODEm) to analyse a database of data for 7065 site-years and estimate the number of maternal deaths from all causes in 188 countries between 1990 and 2013. We estimated the number of pregnancy-related deaths caused by HIV on the basis of a systematic review of the relative risk of dying during pregnancy for HIV-positive women compared with HIV-negative women. We also estimated the fraction of these deaths aggravated by pregnancy on the basis of a systematic review. To estimate the numbers of maternal deaths due to nine different causes, we identified 61 sources from a systematic review and 943 site-years of vital registration data. We also did a systematic review of reports about the timing of maternal death, identifying 142 sources to use in our analysis. We developed estimates for each country for 1990—2013 using Bayesian meta-regression. We estimated 95% uncertainty intervals (UIs) for all values.
Findings
292 982 (95% UI 261 017—327 792) maternal deaths occurred in 2013, compared with 376 034 (343 483—407 574) in 1990. The global annual rate of change in the MMR was −0•3% (—1•1 to 0•6) from 1990 to 2003, and −2•7% (—3•9 to −1•5) from 2003 to 2013, with evidence of continued acceleration. MMRs reduced consistently in south, east, and southeast Asia between 1990 and 2013, but maternal deaths increased in much of sub-Saharan Africa during the 1990s. 2070 (1290—2866) maternal deaths were related to HIV in 2013, 0•4% (0•2—0•6) of the global total. MMR was highest in the oldest age groups in both 1990 and 2013. In 2013, most deaths occurred intrapartum or postpartum. Causes varied by region and between 1990 and 2013. We recorded substantial variation in the MMR by country in 2013, from 956•8 (685•1—1262•8) in South Sudan to 2•4 (1•6—3•6) in Iceland.
Interpretation
Global rates of change suggest that only 16 countries will achieve the MDG 5 target by 2015. Accelerated reductions since the Millennium Declaration in 2000 coincide with increased development assistance for maternal, newborn, and child health. Setting of targets and associated interventions for after 2015 will need careful consideration of regions that are making slow progress, such as west and central Africa.
Funding
Bill & Melinda Gates Foundation.
Global, regional, and national incidence and mortality for HIV, tuberculosis, and malaria during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013
Christopher J L Murray, et al
Summary
Background
The Millennium Declaration in 2000 brought special global attention to HIV, tuberculosis, and malaria through the formulation of Millennium Development Goal (MDG) 6. The Global Burden of Disease 2013 study provides a consistent and comprehensive approach to disease estimation for between 1990 and 2013, and an opportunity to assess whether accelerated progress has occured since the Millennium Declaration.
Methods
To estimate incidence and mortality for HIV, we used the UNAIDS Spectrum model appropriately modified based on a systematic review of available studies of mortality with and without antiretroviral therapy (ART). For concentrated epidemics, we calibrated Spectrum models to fit vital registration data corrected for misclassification of HIV deaths. In generalised epidemics, we minimised a loss function to select epidemic curves most consistent with prevalence data and demographic data for all-cause mortality. We analysed counterfactual scenarios for HIV to assess years of life saved through prevention of mother-to-child transmission (PMTCT) and ART. For tuberculosis, we analysed vital registration and verbal autopsy data to estimate mortality using cause of death ensemble modelling. We analysed data for corrected case-notifications, expert opinions on the case-detection rate, prevalence surveys, and estimated cause-specific mortality using Bayesian meta-regression to generate consistent trends in all parameters. We analysed malaria mortality and incidence using an updated cause of death database, a systematic analysis of verbal autopsy validation studies for malaria, and recent studies (2010—13) of incidence, drug resistance, and coverage of insecticide-treated bednets.
Findings
Globally in 2013, there were 1•8 million new HIV infections (95% uncertainty interval 1•7 million to 2•1 million), 29•2 million prevalent HIV cases (28•1 to 31•7), and 1•3 million HIV deaths (1•3 to 1•5). At the peak of the epidemic in 2005, HIV caused 1•7 million deaths (1•6 million to 1•9 million). Concentrated epidemics in Latin America and eastern Europe are substantially smaller than previously estimated. Through interventions including PMTCT and ART, 19•1 million life-years (16•6 million to 21•5 million) have been saved, 70•3% (65•4 to 76•1) in developing countries. From 2000 to 2011, the ratio of development assistance for health for HIV to years of life saved through intervention was US$4498 in developing countries. Including in HIV-positive individuals, all-form tuberculosis incidence was 7•5 million (7•4 million to 7•7 million), prevalence was 11•9 million (11•6 million to 12•2 million), and number of deaths was 1•4 million (1•3 million to 1•5 million) in 2013. In the same year and in only individuals who were HIV-negative, all-form tuberculosis incidence was 7•1 million (6•9 million to 7•3 million), prevalence was 11•2 million (10•8 million to 11•6 million), and number of deaths was 1•3 million (1•2 million to 1•4 million). Annualised rates of change (ARC) for incidence, prevalence, and death became negative after 2000. Tuberculosis in HIV-negative individuals disproportionately occurs in men and boys (versus women and girls); 64•0% of cases (63•6 to 64•3) and 64•7% of deaths (60•8 to 70•3). Globally, malaria cases and deaths grew rapidly from 1990 reaching a peak of 232 million cases (143 million to 387 million) in 2003 and 1•2 million deaths (1•1 million to 1•4 million) in 2004. Since 2004, child deaths from malaria in sub-Saharan Africa have decreased by 31•5% (15•7 to 44•1). Outside of Africa, malaria mortality has been steadily decreasing since 1990.
Interpretation
Our estimates of the number of people living with HIV are 18•7% smaller than UNAIDS’s estimates in 2012. The number of people living with malaria is larger than estimated by WHO. The number of people living with HIV, tuberculosis, or malaria have all decreased since 2000. At the global level, upward trends for malaria and HIV deaths have been reversed and declines in tuberculosis deaths have accelerated. 101 countries (74 of which are developing) still have increasing HIV incidence. Substantial progress since the Millennium Declaration is an encouraging sign of the effect of global action.
Funding
Bill & Melinda Gates Foundation.

The Milbank Quarterly
A Multidisciplinary Journal of Population Health and Health Policy
June 2014 Volume 92, Issue 2 Pages 167–405
http://onlinelibrary.wiley.com/journal/10.1111/(ISSN)1468-0009/currentissue

Power and Persuasion in the Vaccine Debates: An Analysis of Political Efforts and Outcomes in the United States, 1998‐2012
DENISE F. LILLVIS1,2,*, ANNA KIRKLAND1 andANNA FRICK2
Article first published online: 9 SEP 2014
DOI: 10.1111/1468-0009.12075
Context
This article examines trends in state-level childhood vaccine policies in the United States from 1998 to 2012 and explains the trajectories for both vaccine-critical and proimmunization legislative efforts. Successful mobilization by vaccine critics during the height of the autism and thimerosal scares (roughly 1998 to 2003) yielded a few state-level expansions for the most permissive type of exemption from vaccine mandates for public school attendance, those based on personal beliefs. Vaccine-critical positions, however, have largely become discredited. How has vaccine critics’ ability to advance preferred policies and prevent the passage of unfavorable legislation changed over time?
Methods
We created a unique data set of childhood vaccine bills (n = 636), introduced from 1998 to 2012 across the 50 state legislatures, and coded them by type of effort (exemption, mandate, mercury ban, and information policies) and outcome. We then mapped out the trends in vaccine policies over time. In order to contextualize the trends we identified, we also reviewed numerous primary sources and conducted interviews with stakeholders.
Findings
In general, we found that vaccine critics’ legislative success has begun to wane. In only 20 bills in our data set were vaccine critics able to change policy in their preferred direction via the legislative process. Only 5 of those wins were significant (such as obtaining a new philosophical exemption to vaccine mandates), and the last of these was in 2007. Critics were more successful at preventing passage of proimmunization legislation, such as mandates for the human papillomavirus (HPV) vaccine.
Conclusions
Recent legislation in California, Oregon, and Washington that tightened philosophical exemptions by means of informational requirements suggests that vaccine politics may be entering another phase, one in which immunization supporters may be able to counter increasing opt-out rates, particularly in states with recent outbreaks and politicians favoring science-based policies.

Nature
Volume 513 Number 7517 pp143-272 11 September 2014
http://www.nature.com/nature/current_issue.html

Nature | Editorial
Ebola: time to act
Governments and research organizations must mobilize to end the West African outbreak.
09 September 2014

After disproportionate media attention on Ebola’s negligible risk to people in Western and Asian countries, the focus seems at last to be shifting towards how to stop the outbreak in West Africa. The grim reality is that medical organizations are struggling: the flood of new cases far outpaces available beds and treatment centres. Many of those who are ill are not receiving the basic health care that could keep them alive.

The tragedy is that we know how to stop Ebola. Well-informed communities can reduce the main routes of spread by avoiding unprotected home-based care of infected people and by modifying traditional burial practices. Infection-control measures protect health-care workers. Together with rapid identification and isolation of ill people, and tracing and monitoring of their contacts for 21 days (the maximum incubation period of the disease), such measures have stopped Ebola outbreaks in the past.
But the dysfunctional health-care infrastructure of the three countries at the centre of the outbreak — Guinea, Sierra Leone and Liberia, which are poor and struggling to emerge from years of war — is simply not up to the task. The nations need help, and urgently.

The international community must mobilize now. Aid is increasing, but most of those involved, from governments and the World Health Organization (WHO) to researchers, all initially underestimated the threat. This is perhaps because most past outbreaks have been small and relatively straightforward to control.

The WHO has a part to play, but contrary to a widespread assumption, it does not have the in-house capacity to send large teams into the field. The agency’s funding for outbreak responses has been slashed, and it has shifted focus to helping countries to reinforce their health systems so that they can respond better themselves. How the international community should best react to outbreaks, and what role the bureaucratic WHO should have, is a debate for after this outbreak is over. The pressing need now is to bring all available resources and talent to bear.

“The pressing need now is to bring all available resources and talent to bear.”

It is a sign of how desperate the situation has become that on 2 September, Joanne Liu, international president of medical group Médecins Sans Frontières (or Doctors Without Borders), called on countries to immediately deploy their military and civilian bio¬defence teams — units that have been developed to respond to bioterror attacks. The crucial priorities, she said, are to scale up isolation centres, deploy mobile diagnostic labs (see page 145), build a network of field hospitals and establish dedicated air links to shift staff and equipment to where they are needed. In short, a military-style response, with its associated strong chain of command, logistical capacities and speed.

The concept makes a lot of sense and is an approach that governments should consider adopting — or explain why, if they choose not to do so. US President Barack Obama indicated last weekend that he would deploy the US military to assist in the outbreak.

It cannot be repeated enough that public-health measures and good old-fashioned epidemiological tracking of the infected and their contacts will bring this outbreak to an end. The priority must be to scale these up, alongside establishing more Ebola treatment centres on the ground. For instance, Ebola’s high death rate could be slashed by better patient care, in particular by giving intravenous rehydration.

A highly effective Ebola vaccine would be a game-changer. A WHO-convened meeting on 4–5 September agreed on an unprecedented set of measures, including relaxing regulatory requirements so that experimental drugs and vaccines can be quickly tested under the difficult field conditions of this outbreak, and perhaps even widely deployed. The measures will, for example, permit expedited vaccine trials and informal clinical studies of drugs that could produce useful initial data within months.

Regulators and researchers should be applauded for their speed and pragmatism in exploring innovative methods for conducting trials during this outbreak. Crucially, all those who organize trials must be willing to standardize and share the data they collect to maximize their scientific and medical value, and to allow rapid decisions to be made on which products to prioritize.

West Africa’s outbreak illustrates the serious weaknesses in the international community’s ability to respond to outbreaks of emerging diseases, despite years of debate. It should also hammer home a truism for future planning — the costs of setting up infrastructure to ensure an early response are small compared with the huge social and economic costs of a large deadly disease outbreak.

Make diagnostic centres a priority for Ebola crisis
Bottlenecks in testing samples for Ebola leave patients stranded for days in isolation wards and raise fears of seeking treatment, says J. Daniel Kelly.

Nature Medicine
September 2014, Volume 20 No 9 pp967-1078
http://www.nature.com/nm/journal/v20/n9/index.html

Nature Medicine | Editorial
Ebola: a call to action
Nature Medicine 20, 967 (2014)
doi:10.1038/nm.3689
Published online
04 September 2014

The size, speed and potential reach of the 2014 Ebola virus outbreak in West Africa presents a wake-up call to the research and pharmaceutical communities—and to federal governments—of the continuing need to invest resources in the study and cure of emerging infectious diseases.

At the time of this writing, more than 2,200 people are estimated to have been infected by a new strain of Zaire ebolavirus in four West African nations, and more than 1,200 have died. Infection can cause fever, vomiting, diarrhea and internal and external hemorrhaging that can lead to death. Neighboring as well as non-neighboring countries are at risk because of porous borders and air travel of presymptomatic infected individuals, the latter having resulted in the spread of infection to Nigeria. And while the death rate—estimated at 55%—is lower than that of many previous Ebola outbreaks, the total number of cases exceeds all ebolavirus infections since 1976. We don’t know when the outbreak will end, or how far it will spread, but its control is expected to take months and may involve extraordinary measures.

Ebola virus first emerged in the Democratic Republic of the Congo (DRC) and in South Sudan in 1976 and reappeared in South Sudan in 1979, but it caused no further outbreaks until 1994. Since then, there have been several outbreaks in Africa, but none approached the magnitude of the current outbreak. The natural reservoir of the virus remains unclear, but it is suspected to be the fruit bat. However, Ebola virus also infects nonhuman primates, a species of antelope and porcupines, all of which could be sources of human transmission.

The unusually rapid and far-reaching spread of the virus during the current outbreak has been facilitated by insufficient treatment and containment facilities in West African nations that had no prior experience with Ebola; a distrust of Western medical practices; the stigma associated with infection, causing failure to seek early treatment; as well as the long asymptomatic incubation period of the virus (up to 21 days), which enables dissemination through travel.

Similar to the situation with severe acute respiratory syndrome (SARS), caused by the SARS coronavirus SARS-CoV and that killed more than 700 people in 29 countries during the 2003 epidemic, there is no approved vaccine or cure for Ebola virus infection. For both pathogens, vaccine development is hampered by the fact that the diseases are not endemic, resulting in a lack of identifiable at-risk populations in which to test vaccine candidates. Moreover, there have been no recorded cases of SARS since 2004, and the current Ebola outbreak began more than 2,000 miles from the previous Zaire ebolavirus outbreak in 2008–2009 in the DRC. These circumstances lessen the urgency in preparing for these threats.

What’s more, unlike with malaria, drugs or vaccines for SARS and Ebola cannot be tested in the setting of experimental human infection. Demonstrating their efficacy and safety is restricted to animal models, which themselves have limitations. For example, preclinical testing of treatments against ebolavirus is generally initiated within hours or a few days after infection, whereas in humans the virus may be first identified weeks after initial infection, and the viral load—and its sequelae—may or may not be comparable to those in animal models.

Financial challenges also slow development of vaccines and treatments for these infections. The market for drugs against SARS or Ebola is likely to be small and sporadic. Lacking market-driven forces, financial investment in their development is therefore dependent on governments of wealthy nations. However, the citizens of these nations may have limited exposure to the specific pathogens, and, as such, governments may not prioritize the development of drugs to fight them. For example, in 2012, around the time of the US ‘fiscal cliff’ scenario, the US Department of Defense (DoD), citing budget constraints, issued separate stop-work orders to Sarepta Therapeutics and Tekmira Pharmaceuticals on their programs aimed at developing morpholinos and RNAi therapeutics, respectively, against Ebola virus. The DoD ultimately reinstated Ebola research funding to Tekmira but not Sarepta.

In view of the unprecedented severity of the current Ebola outbreak, the World Health Organization (WHO) has stated that it would be ethical to use experimental medicines to combat the disease. Sarepta has said it would mobilize its stock of candidate drug, which was tested for safety in humans, if requested. The Tekmira drug might also be used in Ebola patients, although owing to concerns about cytokine-associated side effects, the US Food and Drug Administration placed a clinical hold—recently revised to a ‘partial hold’—on testing in healthy volunteers. Two Americans, a Spanish priest and three Liberian doctors infected with Ebola have received ZMapp, a cocktail of monoclonal antibodies produced by Mapp Biopharmaceutical that was shown to neutralize the virus in monkeys but had not been tested for safety in humans. But the supply of ZMapp is now exhausted, and the company estimates it will take several months before more is available. The WHO is also weighing the possibility of the use of serum from individuals who recovered from Ebola infection. And Canada has committed up to 1,000 doses of an experimental Ebola vaccine—VSV-EBOV—to the WHO. Other companies and governments also have drugs and vaccines in various stages of development.

These actions are laudable, but piecemeal. When this outbreak has run its course, what will become of these candidate drugs and vaccines? Which ones will be rigorously tested and stockpiled, and by which nations? Which countries will continue to invest in cures for Ebola, SARS and other emerging infectious diseases, such as Marburg hemorrhagic fever or the Middle East respiratory syndrome, once they cease to command global attention? Encouragingly, on 21 August the Wellcome Trust announced two initiatives: rapid funding for research proposals targeting the current and future Ebola outbreaks and a five-year £40 million commitment to fund research focusing on health challenges facing Africa, including emerging and endemic infections. The latter initiative, which takes a more long-term view, is a step in the right direction. The ability to survive the next outbreak requires continued investment by all nations in detection, prevention, containment, treatment and education. Anything less would be unethical.

New England Journal of Medicine
September 11, 2014 Vol. 371 No. 11
http://www.nejm.org/toc/nejm/medical-journal

Perspective
Lessons from a Public Health Emergency — Importation of Wild Poliovirus to Israel
Eran Kopel, M.D., M.P.H., Ehud Kaliner, M.D., M.P.H., and Itamar Grotto, M.D., Ph.D.
N Engl J Med 2014; 371:981-983September 11, 2014DOI: 10.1056/NEJMp1406250
Excerpt
Last year, Israel’s polio-free status was seriously challenged. On May 28, 2013, a sample obtained during routine supplementary environmental surveillance at a sewage-treatment plant in the South district tested positive for wild poliovirus type 1.1 Additional analyses retrospectively confirmed that the virus had already been present in February 2013 in samples from sewage-treatment plants near the capital of the South district. The virus found in these samples was closely related to polioviruses that have been circulating in polio-endemic Pakistan since 2012 and to the poliovirus that had been isolated from sewage samples in neighboring Egypt in December 2012.2
This public health emergency posed two major challenges for decision makers in Israel. The first one concerned the sustainability and interpretation of our supplementary environmental surveillance. Since the last poliomyelitis outbreak in Israel in 1988,1 the country has developed the capacity in our environmental laboratories to detect pathogens such as polioviruses in very low quantities within large volumes of sewage, and we have fully deployed this high-sensitivity detection on a national scale. This system routinely covered approximately 30 to 40% of the population in a representative fashion,2 and it was substantially intensified beginning in June 2013, shortly after the detection of the wild poliovirus importation. The number of sewage sites being sampled increased from a range of 8 to 10 per month to 80 per month at the height of the effort, to keep up with poliovirus activity.2 The coverage of the sampling was thereby expanded to include as much as 80% of Israel’s population, and the sampling frequency was increased from monthly to weekly.
This dramatically enhanced environmental surveillance, which has continued in 2014, has demonstrated the gradual clearance of the imported wild poliovirus since September 2013. Samples at all sampling sites outside the epicenter sites in southern Israel began testing negative quite rapidly, and later, the wild poliovirus gradually disappeared from the epicenter sites themselves — findings that indicated the fading out of human-to-human transmission of the virus and its excretion in feces. The latest surveillance data (from August 14, 2014) confirm the consistently negative results for all tested sites in Israel….

PLoS One
[Accessed 13 September 2014]
http://www.plosone.org/

Research Article
The Influence of Compositional and Contextual Factors on Non-Receipt of Basic Vaccines among Children of 12-23-Month Old in India: A Multilevel Analysis
Daouda Sissoko mail, Helen Trottier, Denis Malvy, Mira Johri
Published: September 11, 2014
DOI: 10.1371/journal.pone.0106528
Abstract
Background
Children unreached by vaccination are at higher risk of poor health outcomes and India accounts for nearly a quarter of unvaccinated children worldwide. The objective of this study was to investigate compositional and contextual determinants of non-receipt of childhood vaccines in India using multilevel modelling.
Methods and Findings
We studied characteristics of unvaccinated children using the District Level Health and Facility Survey 3, a nationally representative probability sample containing 65 617 children aged 12–23 months from 34 Indian states and territories. We developed four-level Bayesian binomial regression models to examine the determinants of non-vaccination. The analysis considered two outcomes: completely unvaccinated (CUV) children who had not received any of the eight vaccine doses recommended by India’s Universal Immunization Programme, and children who had not received any dose from routine immunisation services (no RI). The no RI category includes CUV children and those who received only polio doses administered via mass campaigns. Overall, 4.83% (95% CI: 4.62–5.06) of children were CUV while 12.01% (11.68–12.35) had received no RI. Individual compositional factors strongly associated with CUV were: non-receipt of tetanus immunisation for mothers during pregnancy (OR = 3.65 [95% CrI: 3.30–4.02]), poorest household wealth index (OR = 2.44 [1.81–3.22] no maternal schooling (OR = 2.43 [1.41–4.05]) and no paternal schooling (OR = 1.83 [1.30–2.48]). In rural settings, the influence of maternal illiteracy disappeared whereas the role of household wealth index was reinforced. Factors associated with no RI were similar to those for CUV, but effect sizes for individual compositional factors were generally larger. Low maternal education was the strongest risk factor associated with no RI in all models. All multilevel models found significant variability at community, district, and state levels net of compositional factors.
Conclusion
Non-vaccination in India is strongly related to compositional characteristics and is geographically distinct. Tailored strategies are required to overcome current barriers to immunisation.

Research Article
The Impact of Disability on the Lives of Children; Cross-Sectional Data Including 8,900 Children with Disabilities and 898,834 Children without Disabilities across 30 Countries
Hannah Kuper mail, Adrienne Monteath-van Dok, Kevin Wing, Lisa Danquah, Jenny Evans,
Maria Zuurmond, Jacqueline Gallinetti
Published: September 09, 2014
DOI: 10.1371/journal.pone.0107300
Abstract
Background
Children with disabilities are widely believed to be less likely to attend school or access health care, and more vulnerable to poverty. There is currently little large-scale or internationally comparable evidence to support these claims. The aim of this study was to investigate the impact of disability on the lives of children sponsored by Plan International across 30 countries.
Methods and Findings
We conducted a cross-sectional survey including 907,734 children aged 0–17 participating in the Plan International Sponsorship Programme across 30 countries in 2012. Parents/guardians were interviewed using standardised questionnaires including information on: age, sex, health, education, poverty, and water and sanitation facilities. Disability was assessed through a single question and information was collected on type of impairment. The dataset included 8,900 children with reported disabilities across 30 countries. The prevalence of disability ranged from 0.4%–3.0% and was higher in boys than girls in 22 of the 30 countries assessed – generally in the range of 1.3–1.4 fold higher. Children with disabilities were much less likely to attend formal education in comparison to children without disabilities in each of the 30 countries, with age-sex adjusted odds ratios exceeding 10 for nearly half of the countries. This relationship varied by impairment type. Among those attending school, children with disabilities were at a lower level of schooling for their age compared to children without disabilities. Children with disabilities were more likely to report experiencing a serious illness in the last 12 months, except in Niger. There was no clear relationship between disability and poverty.
Conclusions
Children with disabilities are at risk of not fulfilling their educational potential and are more vulnerable to serious illness. This exclusion is likely to have a long-term deleterious impact on their lives unless services are adapted to promote their inclusion.

Research Article
Parents’ Knowledge, Risk Perception and Willingness to Allow Young Males to Receive Human Papillomavirus (HPV) Vaccines in Uganda
Wilson Winstons Muhwezi mail, Cecily Banura, Andrew Kampikaho Turiho, Florence Mirembe
Published: September 09, 2014
DOI: 10.1371/journal.pone.0106686
Abstract
The Ministry of Health in Uganda in collaboration with the Program for Appropriate Technology for Health (PATH) supported by Bill and Melinda Gates Foundation in 2008–2009 vaccinated approximately 10,000 girls with the bivalent humanpapilloma virus (HPV) vaccine. We assessed parent’s knowledge, risk perception and willingness to allow son(s) to receive HPV vaccines in future through a cross-sectional survey of secondary school boys aged 10–23 years in 4 districts. 377 questionnaires were distributed per district and 870 were used in analysis. Parents that had ever heard about cervical cancer and HPV vaccines; those who would allow daughter(s) to be given the vaccine and those who thought that HPV infection was associated with genital warts were more willing to allow son(s) to receive the HPV vaccine. Unwilling parents considered HPV vaccination of boys unimportant (p = 0.003), believed that only females should receive the vaccine (p = 0.006), thought their son(s) couldn’t contract HPV (p = 0.010), didn’t know about HPV sexual transmissibility (p = 0.002), knew that males could not acquire HPV (p = 0.000) and never believed that the HPV vaccines could protect against HPV (p = 0.000). Acceptance of HPV vaccination of daughters and likelihood of recommending HPV vaccines to son(s) of friends and relatives predicted parental willingness to allow sons to receive HPV vaccines. Probable HPV vaccination of boys is a viable complement to that of girls. Successfulness of HPV vaccination relies on parental acceptability and sustained sensitization about usefulness of HPV vaccines even for boys is vital.

Research Article
The Effect of Measles on Health-Related Quality of Life: A Patient-Based Survey
Dominic Thorrington mail, Mary Ramsay, Albert Jan van Hoek, W. John Edmunds, Roberto Vivancos, Antoaneta Bukasa,
Ken Eames
Published: September 09, 2014
DOI: 10.1371/journal.pone.0105153
Abstract
Background
Measles is a highly contagious and potentially fatal illness preventable through vaccination. Outbreaks in the UK and many other European countries have been increasing over recent years, with over 3,207 laboratory-confirmed cases reported by Public Health England from January 2012 to the end of June 2013. To aid rational decision making regarding measles control versus other use of healthcare resources, it is important to measure the severity of measles in units that are comparable to other diseases. The standard metric for this in the UK is the quality-adjust life year (QALY). To our knowledge, the impact of measles on health-related quality of life (HRQoL) in terms of QALYs has not been quantified.
Methods and Findings
Individuals with confirmed measles were sent questionnaires requesting information on the short-term impact of the illness on their HRQoL using the EuroQol EQ-5D-3L questionnaire. HRQoL was reported for the day the questionnaire was received, the worst day of infection and at follow-up three weeks later. 507 questionnaires were sent to individuals with confirmed measles with 203 returned (40%). The majority of respondents were not vaccinated. The mean time off work or school was 9.6 days. The mean duration of perceived illness was 13.8 days. The mean number of QALYs lost was 0.019 (equivalent to 6.9 days). The overall burden of disease in terms of QALYs lost in England based on the total number of confirmed cases in the twelve month period from 1st June 2012 was estimated to be 44.2 QALYs.
Conclusion
The short-term impact of measles infection on HRQoL is substantial, both at the level of the individual patient and in terms of the overall disease burden. This is the first attempt to quantify QALY-loss due to measles at a population level, and provides important parameters to guide future intervention and control measures.

Research Article
Costs and Cost-Effectiveness of 9-Valent Human Papillomavirus (HPV) Vaccination in Two East African Countries
Sorapop Kiatpongsan mail, Jane J. Kim
Published: September 08, 2014
DOI: 10.1371/journal.pone.0106836
Abstract
Background
Current prophylactic vaccines against human papillomavirus (HPV) target two of the most oncogenic types, HPV-16 and -18, which contribute to roughly 70% of cervical cancers worldwide. Second-generation HPV vaccines include a 9-valent vaccine, which targets five additional oncogenic HPV types (i.e., 31, 33, 45, 52, and 58) that contribute to another 15–30% of cervical cancer cases. The objective of this study was to determine a range of vaccine costs for which the 9-valent vaccine would be cost-effective in comparison to the current vaccines in two less developed countries (i.e., Kenya and Uganda).
Methods and Findings
The analysis was performed using a natural history disease simulation model of HPV and cervical cancer. The mathematical model simulates individual women from an early age and tracks health events and resource use as they transition through clinically-relevant health states over their lifetime. Epidemiological data on HPV prevalence and cancer incidence were used to adapt the model to Kenya and Uganda. Health benefit, or effectiveness, from HPV vaccination was measured in terms of life expectancy, and costs were measured in international dollars (I$). The incremental cost of the 9-valent vaccine included the added cost of the vaccine counterbalanced by costs averted from additional cancer cases prevented. All future costs and health benefits were discounted at an annual rate of 3% in the base case analysis. We conducted sensitivity analyses to investigate how infection with multiple HPV types, unidentifiable HPV types in cancer cases, and cross-protection against non-vaccine types could affect the potential cost range of the 9-valent vaccine. In the base case analysis in Kenya, we found that vaccination with the 9-valent vaccine was very cost-effective (i.e., had an incremental cost-effectiveness ratio below per-capita GDP), compared to the current vaccines provided the added cost of the 9-valent vaccine did not exceed I$9.7 per vaccinated girl. To be considered very cost-effective, the added cost per vaccinated girl could go up to I$5.2 and I$16.2 in the worst-case and best-case scenarios, respectively. At a willingness-to-pay threshold of three times per-capita GDP where the 9-valent vaccine would be considered cost-effective, the thresholds of added costs associated with the 9-valent vaccine were I$27.3, I$14.5 and I$45.3 per vaccinated girl for the base case, worst-case and best-case scenarios, respectively. In Uganda, vaccination with the 9-valent vaccine was very cost-effective when the added cost of the 9-valent vaccine did not exceed I$8.3 per vaccinated girl. To be considered very cost-effective, the added cost per vaccinated girl could go up to I$4.5 and I$13.7 in the worst-case and best-case scenarios, respectively. At a willingness-to-pay threshold of three times per-capita GDP, the thresholds of added costs associated with the 9-valent vaccine were I$23.4, I$12.6 and I$38.4 per vaccinated girl for the base case, worst-case and best-case scenarios, respectively.
Conclusions
This study provides a threshold range of incremental costs associated with the 9-valent HPV vaccine that would make it a cost-effective intervention in comparison to currently available HPV vaccines in Kenya and Uganda. These prices represent a 71% and 61% increase over the price offered to the GAVI Alliance ($5 per dose) for the currently available 2- and 4-valent vaccines in Kenya and Uganda, respectively. Despite evidence of cost-effectiveness, critical challenges around affordability and feasibility of HPV vaccination and other competing needs in low-resource settings such as Kenya and Uganda remain.

Science
12 September 2014 vol 345, issue 6202, pages 1209-1416
http://www.sciencemag.org/current.dtl

Editorial
Ebola’s perfect storm
Peter Piot
Peter Piot is director and professor of Global Health at the London School of Hygiene & Tropical Medicine, London, UK.
The devastating Ebola epidemic in West Africa is the result of a perfect storm: dysfunctional health services as the result of decades of war, low public trust in government and Western medicine, traditional beliefs and even denials about the cause or existence of the virus, and burial practices that involve contact with contagious Ebola-infected corpses. There are now five affected West African countries: Guinea, Liberia, Nigeria, Sierra Leone, and most recently, Senegal. Ebola has killed around 2000 and infected more than 3500, with over 40% of cases occurring within the past few weeks. The World Health Organization (WHO) predicts that 20,000 may become infected. This fast pace of Ebola’s spread is a grim reminder that epidemics are a global threat and that the only way to get this virus under control is through a rapid response at a massive global scale—much stronger than the current efforts.

In Depth
Infectious Disease
Ebola vaccines racing forward at record pace
Jon Cohen
Experimental Ebola vaccines started human tests last week and beginning in November may be rolled out to as many as 10,000 people in West Africa. The two vaccines being tested first must prove safe and capable of stimulating relevant immune responses in small trials taking place in four countries. No vaccine has ever moved more quickly into widespread use. Many issues remain on how to determine whether the vaccines actually protect people from Ebola. Because the vaccines are in short supply, they also will only be offered to health care workers and other first-line responders. One vaccine is being manufactured by a collaboration between the U.S. National Institute of Allergy and Infectious Diseases and GlaxoSmithKline, and the other is being made by NewLink Genetics.

In Depth
Interview
Ebola: ‘Wow, that is really tough’
Leslie Roberts
The news out of West Africa is grim. By early this week, Ebola cases had topped 4000 and deaths exceeded 2000, and the World Health Organization (WHO) had warned that thousands more should be expected in Liberia alone in the next few weeks. In an interview with Science on 4 September, WHO’s Bruce Aylward, an assistant director-general who is running operations as part of WHO’s new $600 million Ebola emergency plan, talked about why the international community has been slow to respond to the unprecedented epidemic and described the huge gap between the number of cases and the capacity in countries to deal with them. Governments are now keen to help, he says, but are having trouble mobilizing. Relief organizations are used to dealing with wars and natural disasters, not dangerous pathogens, and few have any experience in running the many treatment centers that are required. WHO’s just-released plan calls for stopping the outbreak in 6 to 9 months. That goal is still possible, Aylward says, but only if the international community takes immediate action.

Special Issue: Global Health
Perspectives
Putting women and girls at the center of development
Melinda French Gates
Science 12 September 2014: 1273-1275.

The state of global health in 2014
Jaime Sepúlveda and Christopher Murray
Science 12 September 2014: 1275-1278.

Getting essential health products to their end users: Subsidize, but how much?
Pascaline Dupas
Science 12 September 2014: 1279-1281.

Models of education in medicine, public health, and engineering
Patricia Garcia, Robert Armstrong, and Muhammad H. Zaman
Science 12 September 2014: 1281-1283.
Abstract
Prioritizing integrated mHealth strategies for universal health coverage
Garrett Mehl and Alain Labrique
Science 12 September 2014: 1284-1287.
Abstract
How to transform the practice of engineering to meet global health needs
Deb Niemeier, Harry Gombachika, and Rebecca Richards-Kortum
Science 12 September 2014: 1287-1290.

Strengthening the evidence base for health programming in humanitarian crises
A. Ager, G. Burnham, F. Checchi, M. Gayer, R. F. Grais, M. Henkens, M. B. F. Massaquoi,
R. Nandy, C. Navarro-Colorado, and P. Spiegel
Science 12 September 2014: 1290-1292.

Emerging, evolving, and established infectious diseases and interventions
M. Elizabeth Halloran and Ira M. Longini Jr.
Science 12 September 2014: 1292-1294.

Virus sharing, genetic sequencing, and global health security
Lawrence O. Gostin, Alexandra Phelan, Michael A. Stoto, John D. Kraemer, and K. Srinath Reddy
Science 12 September 2014: 1295-1296.

Monitoring parasite diversity for malaria elimination in sub-Saharan Africa
Anita Ghansah, Lucas Amenga-Etego, Alfred Amambua-Ngwa, Ben Andagalu, Tobias Apinjoh,
Marielle Bouyou-Akotet, Victoria Cornelius, Lemu Golassa, Voahangy Hanitriniaina ndrianaranjaka, Deus Ishengoma, Kimberly Johnson, Edwin Kamau, Oumou Maïga-Ascofaré, Dieudonne Mumba, Paulina Tindana, Antoinette Tshefu-Kitoto, Milijaona Randrianarivelojosia,
Yavo William, Dominic P. Kwiatkowski, and Abdoulaye A. Djimde
Science 12 September 2014: 1297-1298.

Antibiotic effectiveness: Balancing conservation against innovation
Ramanan Laxminarayan
Science 12 September 2014: 1299-1301.

Creating a global observatory for health R&D
Robert F. Terry, José F. Salm Jr., Claudia Nannei, and Christopher Dye

Vaccine
Volume 32, Issue 42, Pages 5371-5530 (22 September 2014)
http://www.sciencedirect.com/science/journal/0264410X/32/42

Obituary
Remembering Dr. Ciro de Quadros
Pages 5371-5374
Jon Kim Andrus
[No abstract]

Adjuvants for vaccines to drugs of abuse and addiction
Review Article
Pages 5382-5389
Carl R. Alving, Gary R. Matyas, Oscar Torres, Rashmi Jalah, Zoltan Beck
Abstract
Immunotherapeutic vaccines to drugs of abuse, including nicotine, cocaine, heroin, oxycodone, methamphetamine, and others are being developed. The theoretical basis of such vaccines is to induce antibodies that sequester the drug in the blood in the form of antibody-bound drug that cannot cross the blood brain barrier, thereby preventing psychoactive effects. Because the drugs are haptens a successful vaccine relies on development of appropriate hapten-protein carrier conjugates. However, because induction of high and prolonged levels of antibodies is required for an effective vaccine, and because injection of T-independent haptenic drugs of abuse does not induce memory recall responses, the role of adjuvants during immunization plays a critical role. As reviewed herein, preclinical studies often use strong adjuvants such as complete and incomplete Freund’s adjuvant and others that cannot be, or in the case of many newer adjuvants, have never been, employed in humans. Balanced against this, the only adjuvant that has been included in candidate vaccines in human clinical trials to nicotine and cocaine has been aluminum hydroxide gel. While aluminum salts have been widely utilized worldwide in numerous licensed vaccines, the experience with human responses to aluminum salt-adjuvanted vaccines to haptenic drugs of abuse has suggested that the immune responses are too weak to allow development of a successful vaccine. What is needed is an adjuvant or combination of adjuvants that are safe, potent, widely available, easily manufactured, and cost-effective. Based on our review of the field we recommend the following adjuvant combinations either for research or for product development for human use: aluminum salt with adsorbed monophosphoryl lipid A (MPLA); liposomes containing MPLA [L(MPLA)]; L(MPLA) adsorbed to aluminum salt; oil-in-water emulsion; or oil-in-water emulsion containing MPLA.

The Vaccine Safety Datalink: successes and challenges monitoring vaccine safety
Review Article
Pages 5390-5398
Michael M. McNeil, Julianne Gee, Eric S. Weintraub, Edward A. Belongia, Grace M. Lee, Jason M. Glanz, James D. Nordin, Nicola P. Klein, Roger Baxter, Allison L. Naleway, Lisa A. Jackson, Saad B. Omer, Steven J. Jacobsen, Frank DeStefano
Abstract
The Vaccine Safety Datalink (VSD) is a collaborative project between the Centers for Disease Control and Prevention (CDC) and 9 health care organizations. Established in 1990, VSD is a vital resource informing policy makers and the public about the safety of vaccines used in the United States. Large linked databases are used to identify and evaluate adverse events in over 9 million individuals annually. VSD generates rapid, important safety assessments for both routine vaccinations and emergency vaccination campaigns. VSD monitors safety of seasonal influenza vaccines in near-real time, and provided essential information on the safety of influenza A (H1N1) 2009 monovalent vaccine during the recent pandemic. VSD investigators have published important studies demonstrating that childhood vaccines are not associated with autism or other developmental disabilities. VSD prioritizes evaluation of new vaccines; searches for possible unusual health events after vaccination; monitors vaccine safety in pregnant women; and has pioneered development of biostatistical research methods.

Primary care providers human papillomavirus vaccine recommendations for the medically underserved: A pilot study in U.S. Federally Qualified Health Centers
Original Research Article
Pages 5432-5435
Katherine B. Roland, Vicki B. Benard, April Greek, Nikki A. Hawkins, Mona Saraiya
Abstract
Introduction
In the United States, Federally Qualified Health Centers (FQHCs) are safety-net clinics that provide cervical cancer screening and human papillomavirus (HPV) vaccination to medically underserved women, some of whom may be at risk for developing cervical cancer. National guidelines recommend against using screening test results or sexual history to determine vaccine eligibility. Documenting HPV vaccine recommendations and beliefs of primary care providers in FQHCs may aid in promoting evidence-based practices and prioritizing health interventions for vulnerable populations.
Methods
Between 2009 and 2010, we collected data from 98 primary care providers in 15 FQHC clinics in IL, USA using a cross-sectional survey. Questions assessed provider and practice characteristics, HPV vaccine recommendations, and provider’s belief about whether their screening and management procedures would change for women who were vaccinated.
Results
93% of providers recommended the HPV vaccine, most frequently for females aged 13–26 years (98%). Some providers reported sometimes to always using HPV test results (12%), Pap test results (7%), and number of sexual partners (33%) to determine vaccine eligibility. More than half of providers (55%) reported they will not change their screening and management practices for vaccinated females, yet believe vaccination will yield fewer abnormal Pap tests (71%) and referrals for colposcopy (74%).
Conclusion
Study providers routinely recommended the HPV vaccine for their patients. However, providers made fewer recommendations to vaccinate females ages 9–12 years (which includes the target age for vaccination) compared to older females, and used pre-vaccination assessments not recommended by U.S. guidelines, such as screening test results and number of sexual partners. In order to maximize the public health benefit of the HPV vaccine to prevent cervical cancer, adherence to guidelines is necessary, especially in settings that provide care to medically underserved women.

Economic evaluation of meningococcal serogroup B childhood vaccination in Ontario, Canada
Original Research Article
Pages 5436-5446
Hong Anh T. Tu, Shelley L. Deeks, Shaun K. Morris, Lisa Strifler, Natasha Crowcroft, Frances B. Jamieson, Jeffrey C. Kwong, Peter C. Coyte, Murray Krahn, Beate Sander
Abstract
Highlights
:: Neisseria meningitidis serotype B (MenB) causes invasive meningococcal disease.
:: Examined novel MenB vaccine (Bexsero®) approved in Europe, Canada and Australia.
:: Assessed cost-effectiveness of MenB infant vaccination program in Ontario, Canada.
:: Program is highly unlikely to be cost-effective in this low incidence setting.

Maternal determinants of timely vaccination coverage among infants in rural Bangladesh
Original Research Article
Pages 5514-5519
Lavanya Vasudevan, Alain B. Labrique, Sucheta Mehra, Lee Wu, Orin Levine, Danny Feikin, Rolf Klemm, Parul Christian, Keith P. West Jr.
Abstract
Highlights
:: Timely vaccination rates among infants in rural Bangladesh examined between 2001 and 2007.
:: 23,435 infants classified as vaccinated on time by 14 weeks of age with all vaccines or not.
:: Only 19% of infants included in study received timely vaccinations by 14 weeks of age.
:: Mothers’ receipt of antenatal care positively associated with timely vaccination status of infants.
:: Timely vaccination rates lower for infants perceived as small at birth by their mothers.

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

Health Research Policy and Systems
http://www.health-policy-systems.com/content
[Accessed 13 September 2014]
Research
Advancing the application of systems thinking in health: analysing the contextual and social network factors influencing the use of sustainability indicators in a health system – a comparative study in Nepal and Somaliland
Karl Blanchet1*, Jennifer Palmer1, Raju Palanchowke2, Dorothy Boggs3, Ali Jama4 and Susan Girois5
Author Affiliations
1 International Centre for Evidence in Disability, London School of Hygiene and Tropical Medicine, Keppel St, Bloomsbury, London WC1E 7HT, UK
2 Handicap International, Narayan Gopal Chowk Sallaghari, PO Box 10179, Kathmandu, Nepal
3 Handicap International, 9 Rushworth Street, London SE1, UK
4 Disability Action Network, Hargeisa, Somaliland
5 Norfolk Community Services Board, 6401 Tidewater Dr, Norfolk, VA 23509, USA
Health Research Policy and Systems 2014, 12:46 doi:10.1186/1478-4505-12-46
Abstract
Background
Health systems strengthening is becoming a key component of development agendas for low-income countries worldwide. Systems thinking emphasizes the role of diverse stakeholders in designing solutions to system problems, including sustainability. The objective of this paper is to compare the definition and use of sustainability indicators developed through the Sustainability Analysis Process in two rehabilitation sectors, one in Nepal and one in Somaliland, and analyse the contextual factors (including the characteristics of system stakeholder networks) influencing the use of sustainability data.
Methods
Using the Sustainability Analysis Process, participants collectively clarified the boundaries of their respective systems, defined sustainability, and identified sustainability indicators. Baseline indicator data was gathered, where possible, and then researched again 2 years later. As part of the exercise, system stakeholder networks were mapped at baseline and at the 2-year follow-up. We compared stakeholder networks and interrelationships with baseline and 2-year progress toward self-defined sustainability goals. Using in-depth interviews and observations, additional contextual factors affecting the use of sustainability data were identified.
Results
Differences in the selection of sustainability indicators selected by local stakeholders from Nepal and Somaliland reflected differences in the governance and structure of the present rehabilitation system. At 2 years, differences in the structure of social networks were more marked. In Nepal, the system stakeholder network had become more dense and decentralized. Financial support by an international organization facilitated advancement toward self-identified sustainability goals. In Somaliland, the small, centralised stakeholder network suffered a critical rupture between the system’s two main information brokers due to competing priorities and withdrawal of international support to one of these. Progress toward self-defined sustainability was nil.
Conclusions
The structure of the rehabilitation system stakeholder network characteristics in Nepal and Somaliland evolved over time and helped understand the changing nature of relationships between actors and their capacity to work as a system rather than a sum of actors. Creating consensus on a common vision of sustainability requires additional system-level interventions such as identification of and support to stakeholders who promote systems thinking above individual interests.

Journal of Epidemiology & Community Health
2014;68:A59-A60 doi:10.1136/jech-2014-204726.127
PP31 Factors affecting variation in the uptake of HPV vaccine in secondary schools in the West Midlands
Oral Presentations
CM Chivu, A Clarke, G Hundt
Author Affiliations
Warwick Medical School, University of Warwick, Coventry, UK
Abstract
Background
In 2008, the health departments of the United Kingdom implemented routine and catch-up human papillomavirus (HPV) immunisation programme in schools to reduce the incidence of cervical cancer. European studies conducted from 2007 to 2012 showed inconsistent results on HPV vaccine uptake in relation to ethnicity and girls’ age. The aim of the study was to explore the views and experiences of students, teachers and health providers on the HPV vaccine to understand how mechanisms of delivery contributed to HPV vaccine uptake in a town in the West Midlands.
Methods
Data was collected through 47 semi-structured individual interviews with nine nurses, four school staff and 34 year 8 girls as well as through non-participant observations in 12 schools during the delivery of the first, the second and the third dose of HPV vaccine between February and September 2013. The school staff and the girls were sampled from four secondary schools that accepted to participate in the study. Thematic analysis was employed to identify major themes related to the school context of implementation of the HPV vaccine programme in secondary schools in the town of the study.
Results
Year 8 girls were aged 12–13 years. Some were Christian, Muslim and Hindu while others had no religion. The health professionals were nurse coordinators, school nurses, vaccinators, sexual health nurses and practice nurses. The school staff were teachers, support staff and head of year 8. Three main themes emerged from the analysis (1) school policy related to HPV vaccine, (2) the organisation of delivery of HPV vaccination programme in the schools before and on the day of vaccination, (3) promotion of HPV vaccine in schools. The findings showed that most of the schools have supported the delivery of the programme, but it has been more difficult for nurses to go to some of the faith schools in comparison to others. Chasing up the consent forms and communication with the parents have been the most challenging activities in the HPV vaccination administration, however they are essential for a high HPV vaccine uptake. The HPV vaccine was poorly promoted in the school environment because of tight curriculum for compulsory subjects and lack of adequate staff.
Conclusion
Implementation of a school-based HPV programme is resource intensive in terms of time as well as of school staff and staff nurse.

Technovation
Available online 5 September 2014
In Press, Corrected Proof
Policy-driven ecosystems for new vaccine development
Julia Fan Li, Elizabeth Garnsey1,
Abstract
This paper examines the relationship between biomedical policies and entrepreneurial R&D strategies. Public health programs have been unable to provide effective and affordable treatment of infectious diseases for the poor. While governments have become more open to private sector contributions to policy objectives, it is rare to find new ventures commercializing healthcare innovations for neglected diseases. Two case studies of entrepreneurial ventures, in the UK and China, provide evidence on how resource-constrained firms mobilize participants in policy-specific ecosystems to achieve their goals of new vaccine development for tuberculosis. Ecosystem analysis reveals how the innovators’ business models can align their strategies with national policy objectives.

International Journal for Parasitology
Available online 13 September 2014
In Press, Uncorrected Proof
Invited Review
Genome-based vaccine design: the promise for malaria and other infectious diseases
Denise L. Doolan, Simon H. Apte, Carla Proietti
DOI: 10.1016/j.ijpara.2014.07.010
Highlights
:: Vaccines against complex pathogens and chronic diseases have proved challenging.
:: Rational vaccine design exploiting advances in genomics and other ‘omics’ has great potential.
:: Malaria is an excellent model for genome-based vaccine design.
Abstract
Vaccines are one of the most effective interventions to improve public health, however, the generation of highly effective vaccines for many diseases has remained difficult. Three chronic diseases that characterise these difficulties include malaria, tuberculosis and HIV, and they alone account for half of the global infectious disease burden. The whole organism vaccine approach pioneered by Jenner in 1796 and refined by Pasteur in 1857 with the “isolate, inactive and inject” paradigm has proved highly successful for many viral and bacterial pathogens causing acute disease but has failed with respect to malaria, tuberculosis and HIV as well as many other diseases. A significant advance of the past decade has been the elucidation of the genomes, proteomes and transcriptomes of many pathogens. This information provides the foundation for new 21st Century approaches to identify target antigens for the development of vaccines, drugs and diagnostic tests. Innovative genome-based vaccine strategies have shown potential for a number of challenging pathogens, including malaria. We advocate that genome-based rational vaccine design will overcome the problem of poorly immunogenic, poorly protective vaccines that has plagued vaccine developers for many years.

Journal of Consumer Health On the Internet
Volume 18, Issue 3, 2014
Beta-Test Results for an HPV Information Web Site: GoHealthyGirls. org—Increasing HPV Vaccine Uptake in the United States
Randall Starlinga*, Jessica A. Nodulmana, Alberta S. Kongb, Cosette M. Wheelerc, David B. Bullerd & W. Gill Woodalla
DOI: 10.1080/15398285.2014.931771
pages 226-237
Abstract
A Web site, GoHealthyGirls, was developed to educate and inform parents and their adolescent daughters about human papillomavirus (HPV) and HPV vaccines. This article provides an overview of web site development and content followed by the results of a beta-test of the Web site. Sixty-three New Mexican parents of adolescent girls tested the site. Results indicated that GoHealthyGirls was a functioning and appealing Web site. During this brief educational intervention, findings suggest that the Web site has the potential to increase HPV vaccine uptake. This research supports the Internet as a valuable channel to disseminate health education and information to diverse populations.

New York Times
http://www.nytimes.com/
Accessed 13 September 2014
U.S. Scientists See Long Fight Against Ebola
By DENISE GRADY
SEPT. 12, 2014
The deadly Ebola outbreak sweeping across three countries in West Africa is likely to last 12 to 18 months more, much longer than anticipated, and could infect hundreds of thousands of people before it is brought under control, say scientists mapping its spread for the federal government.

“We hope we’re wrong,” said Bryan Lewis, an epidemiologist at the Virginia Bioinformatics Institute at Virginia Tech.

Both the time the model says it will take to control the epidemic and the number of cases it forecasts far exceed estimates by the World Health Organization, which said last month that it hoped to control the outbreak within nine months and predicted 20,000 total cases by that time. The organization is sticking by its estimates, a W.H.O. spokesman said Friday.

But researchers at various universities say that at the virus’s present rate of growth, there could easily be close to 20,000 cases in one month, not in nine. Some of the United States’ leading epidemiologists, with long experience in tracking diseases such as influenza, have been creating computer models of the Ebola epidemic at the request of the National Institutes of Health and the Defense Department….

EBOLA [to 6 September 2014]

Statement on the WHO Consultation on potential Ebola therapies and vaccines
5 September 2014 —
[Full text; Editor’s text bolding]
After 2 days of discussion on potential Ebola therapies and vaccines, more than 150 participants, representing the fields of research and clinical investigation, ethics, legal, regulatory, financing, and data collection, identified several therapeutic and vaccine interventions that should be the focus of priority clinical evaluation at this time.

Currently, none of these vaccines or therapies have been approved for human use to prevent or treat EVD. A number of candidate vaccines and therapies have been developed and tested in animal models and some have demonstrated promising results. In view of the urgency of these outbreaks, the international community is mobilizing to find ways to accelerate the evaluation and use of these compounds.

Safety in humans is also unknown, raising the possibility of adverse side effects when administered. Use of some of these products is demanding and requires intravenous administration and infrastructure, such as cold chain, and facilities able to offer a good and safe standard of care.

The experts determined:
:: There was consensus that the use of whole blood therapies and convalescent blood serums needs to be considered as a matter of priority.
:: Safety studies of the 2 most advanced vaccines identified – based on vesicular stomatitis virus (VSV-EBO) and chimpanzee adenovirus (ChAd-EBO) – are being initiated in the United States of America and will be started in Africa and Europe in mid-September. WHO will work with all the relevant stakeholders to accelerate their development and safe use in affected countries. If proven safe, a vaccine could be available in November 2014 for priority use in health-care workers.
:: In addition to blood therapies and candidate vaccines, the participants discussed the availability and evidence supporting the use of novel therapeutic drugs, including monoclonal antibodies, RNA-based drugs, and small antiviral molecules. They also considered the potential use of existing drugs approved for other diseases and conditions. Of the novel products discussed, some have shown great promise in monkey models and have been used in a few Ebola patients (although, in too few cases to permit any conclusion about efficacy).

Existing supplies of all experimental medicines are limited. While many efforts are underway to accelerate production, supplies will not be sufficient for several months to come. The prospects of having augmented supplies of vaccines rapidly look slightly better.

The participants cautioned that investigation of these interventions should not detract attention from the implementation of effective clinical care, rigorous infection prevention and control, careful contact tracing and follow-up, effective risk communication, and social mobilization, all of which are crucial for ending these outbreaks.

The recipients of experimental interventions, locations of studies, and study design should be based on the aim to learn as much as we can as fast as we can without compromising patient care or health worker safety, with active participation of local scientists, and proper consultation with communities.

This will require the following crucial elements:
:: Appropriate protocols must be rapidly developed for informed consent and safe use.
:: A mechanism for evaluating pre-clinical data should be put in place in order to recommend which interventions should be evaluated as a first priority.
A platform must be established for transparent, real-time collection and sharing of data.
A safety monitoring board needs to be established to evaluate the data from all interventions.

All of these will require continued ethical oversight.
.

WHO: Global Alert and Response (GAR) – Disease Outbreak News [to 6 September 2014]
http://www.who.int/csr/don/en/
:: Ebola virus disease outbreak – west Africa 4 September 2014

Meeting Video: UN Ebola Briefing
2 September 2014 :: 1:18
Deputy Secretary-General, Director-General of the World Health Organization (WHO); United Nations System Coordinator; MSF President; UNICEF ED, others.
http://webtv.un.org/watch/the-ebola-outbreak-in-west-africa-briefing-to-member-states/3763544442001

Additional WHO Content:
:: Ebola situation in Port Harcourt, Nigeria – 3 September 2014

:: Virological analysis: no link between Ebola outbreaks in west Africa and Democratic Republic of Congo – 2 September 2014
:: Ebola event management at points of entry: Interim guidance
WHO
September 2014 :: 11 pages:
WHO reference number: WHO/EVD/Guidance/PoE/14.1
pdf: Interim guidance: Ebola event management at points of entry
Overview
As the Ebola virus disease (EVD) continues to claim lives and put pressure on health systems in west Africa, its transmission across borders has prompted a need to manage suspected cases at Points of Entry (PoE).
The interim guidance document is intended for National Focal Points for the International Health Regulations (IHR)(2005)(1), PoE public health authorities, PoE operators, conveyance operators, crew members and other stakeholders involved in the management of Public health event.
The aim is to provide early detection of potentially infected persons; to assist in implementing WHO recommendations related to Ebola management; and to prevent the international spread of the disease while allowing PoE authorities to avoid unnecessary restrictions and delays.

:: Infection prevention and control guidance summary
Ebola guidance package

:: Infection prevention and control guidance for care of patients with Filovirus haemorrhagic fever
Infection prevention

:: Travel and transport risk assessment: Interim guidance for public health authorities and the transport sector

:: Toolkit for behavioural and social communication in outbreak response
Social mobilization

:: Ebola and Marburg virus disease epidemics: preparedness, alert, control, and evaluation
Preparedness and response

CDC/MMWR Watch [to 6 September 2014]
http://www.cdc.gov/mmwr/mmwr_wk.html
:: CDC warns Ebola epidemic in West Africa is outpacing current response – Press Release
9/2/2014, 4:50 PM
CDC Director Tom Frieden, M.D., M.P.H. reported on his visits last week to Guinea, Liberia and Sierra Leone and called for immediate steps across nations to accelerate response to the Ebola epidemic in West Africa.

POLIO [to 6 September 2014]

GPEI Update: Polio this week – As of 3 September 2014
Global Polio Eradication Initiative
Editor’s Excerpt and text bolding
Full report: http://www.polioeradication.org/Dataandmonitoring/Poliothisweek.aspx
:: Protecting west Africa: Even as polio programme staff across west Africa support efforts to control the Ebola outbreak affecting the region, preparations are going ahead for large scale multi-country vaccination campaigns in those countries not affected by Ebola, in mid-September.
:: In Nigeria, inactivated polio vaccine (IPV) has been used in early August during supplementary immunization activities in Borno and Yobe, reaching 0.6 million children. Further campaigns will integrate IPV, aiming to reach more than a million children by April 2015.
:: Polio vaccination activities have resumed in parts of Helmand Province in the Southern Region of Afghanistan for the first time in five months. Upcoming immunization campaigns in September will cover the entire province.
Pakistan
:: Two new circulating vaccine-derived poliovirus (cVDPV2) cases were reported in the past week. One was in the Lakki Marwat district with onset of paralysis on 8 May and the other in Bannu district, Khyber Pakhtunkhwa on 3 May. The country has reported 18 cases of cVDPV2 in 2014 and the most recent case had onset of paralysis on 27 May in FR Bannu, FATA.
West Africa
:: Even as polio programme staff across West Africa support efforts to control the Ebola outbreak affecting the region, preparations are going ahead for large scale multi-country vaccination campaigns in those countries not affected by Ebola, in mid-September.
:: A trivalent OPV campaign is planned for the entire region, in Mali on 19-22 September and in Benin, Burkina Faso, Cote d’Ivoire, Gambia, Ghana, Guinea-Bissau, Mauritania, Niger, Senegal and Togo on 20-23 September.

World Bank eyes up to $500 mln via immunisation sukuk -official
KUALA LUMPUR, Sep 3, 2014
(Reuters) – The World Bank plans to raise as much as $500 million worth of Islamic bonds, or sukuk, this year to help fund an immunisation programme, one of several initiatives from the multilateral body in the Islamic finance sector.
The World Bank, acting as treasurer of the International Finance Facility for Immunisation (IFFIm), would help issue the sukuk, said Michael Bennett, head of derivatives and structured finance at the World Bank’s treasury department.
IFFIm has previously raised money from retail investors in markets such as Australia and Japan through so-called “kangaroo” and “uridahsi” bonds. It could soon add sukuk to the lexicon of vaccine financing.
“Right now we’re thinking $300 million to $500 million, we are still talking to the market on what the right size should be,” said Bennett on the sidelines of an industry conference…

IVI Launches Children Public Health and Philanthropic Educational Program, ‘KiKi Program’
Media Release
2014.09.03
KiKi program centers around kids helping kids in developing countries
Excerpt
Seoul, September 3, 2014 — The International Vaccine Institute (IVI), an international organization based in Seoul, launched the ‘Kids Help Kids (KiKi) program—an educational philanthropic program centering around promoting public health practices such as hand washing, hygiene and immunization — organized by IVI and supported by the Ministry of Education (MoE) and Yanghyun Foundation…

Haiti launches cholera vaccination campaign
Effort targets 200,000 people in three departments considered at high risk

Port-au-Prince, Haiti, 2 September 2014 (PAHO/WHO) – Haiti launched a cholera vaccination campaign last week that seeks to reach 200,000 people in three departments. The campaign is being led by the Ministry of Health and Population (MSPP) with support from the United Nations and a coalition of strategic partners, including the Pan American Health Organization/World Health Organization (PAHO/WHO).

The campaign has financing from the U.N. Central Emergency Response Fund (CERF) and is using vaccines from a global stockpile created at the request of the 2011 World Health Assembly as a tool to help control cholera outbreaks worldwide. WHO serves as secretariat for the global stockpile, which is also supported by the International Federation of Red Cross and Red Crescent Societies, Doctors without Borders, and UNICEF.

Last week’s campaign was carried out in Artibonite (Gonaives and Ennery), Central (Lascahobas, Saut d’Eau, Savanette and Mirebalais), and West (Arcahaie) departments, which are considered high-risk zones. A second phase is planned for mid-September to deliver a second dose of the vaccine…

UNICEF Watch [to 6 September 2014]
http://www.unicef.org/media/media_71724.html

:: Ebola outbreak: UNICEF continues to rush critical supplies to protect health workers and families
GENEVA/DAKAR/FREETOWN/NEW YORK, 5 September 2014 – A cargo plane of UNICEF medical supplies including protective equipment and essential medicine has just landed in Sierra Leone, part of the children’s agency’s continued drive to tackle the Ebola outbreak in West Africa.

:: Amid ongoing conflict, Iraq successfully implements polio campaign supported by UNICEF and WHO
ERBIL / AMMAN, 1 September 2014 – A mass polio immunization campaign across Iraq earlier this month succeeded in reaching 3.75 out of the 4 million children under the age of 5, despite the ongoing violence sweeping much of the country.

Industry Watch [to 6 September 2014]
Selected media releases and other selected content from industry.
:: Sanofi Pasteur’s Dengue Vaccine Candidate Successfully Completes Final Landmark Phase III Clinical Efficacy Study in Latin America
September 3, 2014
– Second, large-scale phase III study successfully meets primary endpoint with overall vaccine efficacy of 60.8 percent and shows efficacy against each of the four dengue serotypes –
– Additional observation of the results shows a significant reduction of the risk of hospitalization by 80.3 percent confirming the potential public health impact of the vaccine –
– Initial safety data are consistent with the favorable safety profile documented in all previous studies (phase I, II, III) –

:: Johnson & Johnson Responds to Ebola Crisis With Commitment to Accelerate Vaccine Program in Collaboration With the US National Institutes of Health (NIH) and Provide Humanitarian Relief Aid
Sep 04, 2014
Johnson & Johnson (NYSE: JNJ) today announced it will fast-track the development of a promising new combination vaccine regimen against Ebola and broadly collaborate with its partners in global health to deliver immediate relief aid to address the current Ebola outbreak…

Reports/Research/Analysis/Commentary/Conferences/Meetings/Book Watch/Tenders
Vaccines and Global Health: The Week in Review has expanded its coverage of new reports, books, research and analysis published independent of the journal channel covered in Journal Watch below. Our interests span immunization and vaccines, as well as global public health, health governance, and associated themes. If you would like to suggest content to be included in this service, please contact David Curry at: david.r.curry@centerforvaccineethicsandpolicy.org

Video Commentary: Jon Andrus, Deputy Director of PAHO on Vaccination Development
BioMedox
1 September 2014
Discussion of costs, PAHO revolving fund, import taxes and vaccine price.

Call to Action – HPV Vaccination as a Public Health Priority
NFID
August 2014
Experts gather to discuss importance of HPV vaccination
The recommendations in this document are based upon the proceedings of a May 2014 roundtable convened by the National Foundation for Infectious Diseases (NFID) and the Council of State and Territorial Epidemiologists (CSTE).
NFID and CSTE assembled subject matter experts, including representatives from relevant professional medical associations and organizations, consumer health organizations, and government agencies to discuss the long-term health impact of HPV and the important role of increased immunization…

The Influence of Global Environmental Change on Infectious Disease Dynamics – Workshop
IOM
September 3, 2014
The twentieth century witnessed an era of unprecedented, large-scale, anthropogenic changes to the natural environment. Understanding how environmental factors directly and indirectly affect the emergence and spread of infectious disease has assumed global importance for life on this planet. While the causal links between environmental change and disease emergence are complex, progress in understanding these links, as well as how their impacts may vary across space and time, will require transdisciplinary, transnational, collaborative research. This research may draw upon the expertise, tools, and approaches from a variety of disciplines.
The Forum on Microbial Threats hosted a public workshop on September 24 and 25, 2013, to explore the scientific and policy dimensions of the impacts of global environmental change on infectious disease dynamics. Participants examined and discussed the observed and likely influences of environmental factors, acting both individually and synergistically on infectious disease dynamics. A range of approaches to improve global readiness and capacity for surveillance, detection, and response to emerging microbial threats to plant, animal, and human health in the face of ongoing global environmental change was also discussed.
pdf: https://download.nap.edu/login.php?record_id=18800&page=%2Fdownload.php%3Frecord_id%3D18800

American Journal of Preventive Medicine
Volume 47, Issue 3, p233-374 September 2014
http://www.ajpmonline.org/current

A Systematic Review of Mandatory Influenza Vaccination in Healthcare Personnel
Samantha I. Pitts, MD, MPH, Nisa M. Maruthur, MD, MHS, Kathryn R. Millar, MPH, RN, Trish M. Perl, MD, MSc, Jodi Segal, MD, MPH
DOI: http://dx.doi.org/10.1016/j.amepre.2014.05.035
Abstract
Context
Influenza is a major cause of patient morbidity. Mandatory influenza vaccination of healthcare personnel (HCP) is increasingly common yet has uncertain clinical impact. This study systematically examines published evidence of the benefits and harm of influenza vaccine mandates.
Evidence acquisition
MEDLINE, Embase, the Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, Science Citation Index Expanded, and Conference Proceedings Citations Index were searched and analyzed in 2013. Studies must have assessed the effect of a requirement of influenza vaccination among HCP for continued employment or clinical practice. Studies were not limited by comparison group, outcome, language, or study design. Two reviewers independently abstracted data and assessed bias risk.
Evidence synthesis
Twelve observational studies were included in the study from 778 citations. Following implementation of a vaccine mandate, vaccination rates increased in all eight studies reporting this outcome, exceeding 94%. Three studies documented increased vaccination rates in hospitals with mandates compared to those without (p Conclusions
Evidence from observational studies suggests that a vaccine mandate increases vaccination rates, but evidence on clinical outcomes is lacking. Although challenging, large healthcare employers planning to implement a mandate should develop a strategy to evaluate HCP and patient outcomes. Further studies documenting the impact of HCP influenza vaccination on clinical outcomes would inform decisions on the use of mandatory vaccine policies in HCP.

American Journal of Tropical Medicine and Hygiene
September 2014; 91 (3)
http://www.ajtmh.org/content/current

Editorial
The Ability to Inoculate Purified Malaria Sporozoites Will Accelerate Vaccine and Drug Discovery
Michael F. Good*
Author Affiliations
Institute for Glycomics, Griffith University, Gold Coast, Queensland, Australia
The ability to infect a volunteer with malaria in a controlled and safe manner promises to be of enormous benefit to research programs aimed at developing malaria vaccines1 or novel antimalaria drugs.2 By challenging an individual in early-stage trials with a defined number of parasites of a specific laboratory strain in a controlled clinical environment, it is possible to derive more meaningful data and significantly reduce trial costs, thus facilitating product development. Research presented in this issue shows that it will now be possible for trial volunteers living in both malaria-endemic and non-endemic areas.3…

Current Strategic Thinking for the Development of a Trivalent Alphavirus Vaccine for Human Use
Daniel N. Wolfe*, D. Gray Heppner, Shea N. Gardner, Crystal Jaing, Lesley C. Dupuy, Connie S. Schmaljohn and Kevin Carlton
Author Affiliations
Chemical and Biological Technologies Department, Defense Threat Reduction Agency, Fort Belvoir, Virginia; TASC, Inc., Lorton, Virginia; Computations/Global Security, Lawrence Livermore National Laboratory, Livermore, California; Physical and Life Sciences Directorate, Lawrence Livermore National Laboratory, Livermore, California; US Army Medical Research Institute for Infectious Diseases, Fort Detrick, Maryland; Joint Vaccine Acquisition Program, Medical Countermeasure Systems, Joint Program Executive Office, Fort Detrick, Maryland
Abstract.
Vaccinations against the encephalitic alphaviruses (western, eastern, and Venezuelan equine encephalitis virus) are of significant interest to biological defense, public health, and agricultural communities alike. Although vaccines licensed for veterinary applications are used in the Western Hemisphere and attenuated or inactivated viruses have been used under Investigational New Drug status to protect at-risk personnel, there are currently no licensed vaccines for use in humans. Here, we will discuss the need for a trivalent vaccine that can protect humans against all three viruses, recent progress to such a vaccine, and a strategy to continue development to Food and Drug Administration licensure.

BMC Medical Ethics
(Accessed 6 September 2014)
http://www.biomedcentral.com/bmcmedethics/content

Debate
The social value of clinical research
Michelle GJL Habets, Johannes JM van Delden and Annelien L Bredenoord
Author Affiliations
BMC Medical Ethics 2014, 15:66 doi:10.1186/1472-6939-15-66
Published: 5 September 2014
Abstract (provisional)
Background
International documents on ethical conduct in clinical research have in common the principle that potential harms to research participants must be proportional to anticipated benefits. The anticipated benefits that can justify human research consist of direct benefits to the research participant, and societal benefits, also called social value. In first-in-human research, no direct benefits are expected and the benefit component of the risks-benefit assessment thus merely exists in social value. The concept social value is ambiguous by nature and is used in numerous ways in the research ethics literature. Because social value justifies involving human participants, especially in early human trials, this is problematic.
Discussion
Our analysis and interpretation of the concept social value has led to three proposals. First, as no direct benefits are expected for the research participants in first-in-human trials, we believe it is better to discuss a risk- value assessment instead of a risk – benefit assessment. This will also make explicit the necessity to have a clear and common use for the concept social value. Second, to avoid confusion we propose to limit the concept social value to the intervention tested. It is the expected improvement the intervention can bring to the wellbeing of (future) patients or society that is referred to when we speak about social value. For the sole purpose of gaining knowledge, we should not expose humans to potential harm; the ultimate justification of involving humans in research lies in the anticipated social value of the intervention. Third, at the moment only the validity of the clinical research proposal is a prerequisite for research to take place. We recommend making the anticipated social value a prerequisite as well.

BMC Public Health
(Accessed 6 September 2014)
http://www.biomedcentral.com/bmcpublichealth/content

Research article
Implementation of a universal rotavirus vaccination program: comparison of two delivery systems
Mitchell Zelman, Carolyn Sanford, Anne Neatby, Beth A Halperin, Donna MacDougall, Corinne Rowswell, Joanne M Langley and Scott A Halperin
Author Affiliations
BMC Public Health 2014, 14:908 doi:10.1186/1471-2458-14-908
Published: 2 September 2014
Abstract (provisional)
Background
Rotavirus vaccine is recommended for all infants in Canada. To evaluate the logistics of implementing a universal rotavirus vaccination program, we compared the effectiveness of program implementation in jurisdictions with either a physician-administered or public health nurse-administered program.
Methods
All infants born between October 1, 2010 and September 30, 2012 in Prince Edward Island and Nova Scotia’s Capital District Health Authority were eligible for the vaccination program. A universal rotavirus vaccination program was implemented and delivered in public health clinics in Prince Edward Island and in physicians’ offices in Nova Scotia.
Results
Engagement of vaccinators in delivery of the universal vaccination program was more successful in Prince Edward Island than in Nova Scotia. Vaccine coverage rates rose rapidly in Prince Edward Island, exceeding 90 % for both doses within 3 months and remaining at those levels over the two-year program. In contrast, coverage rates in Nova Scotia rose more slowly and never exceeded 40 % during the two years. Access to coverage data was more timely and accurate in Prince Edward Island than Nova Scotia.
Conclusion
A universal rotavirus vaccination program delivered through public health clinics achieved more rapid and higher levels of coverage than a program administered through physicians’ offices.

British Medical Journal
06 September 2014(vol 349, issue 7973)
http://www.bmj.com/content/349/7973

Editorials
The 2030 sustainable development goal for health
BMJ 2014; 349 doi: http://dx.doi.org/10.1136/bmj.g5295 (Published 26 August 2014) Cite this as: BMJ 2014;349:g5295
Gavin Yamey, evidence to policy initiative lead1, Rima Shretta, malaria elimination initiative deputy lead1, Fred Newton Binka, vice chancellor2
Author affiliations
Must balance bold aspiration with technical feasibility
Excerpt
In the year 2000, 193 countries adopted the millennium development goals (MDGs), a milestone in global development. The eight goals were simple to grasp, measurable, and time bound, ending in 2015. Goals 4, 5, and 6 focused on reducing child, maternal, and infectious disease mortality, respectively, raising health to the top of the global agenda and mobilising new health financing.1 Although the three health related goals are unlikely to be met, there has been substantial progress towards their achievement, particularly for infectious diseases.2
As the MDGs come to an end, a new set of sustainable development goals (SDGs) will be debated during the UN General Assembly that starts on 24 September 2014. These goals will have a 2030 end date. They could catalyse further transformations in global health.
An intergovernmental open working group is writing the new goals and has just published its first draft.3 Whereas the MDGs were “‘top-down goals’ formulated by policy elites,”4 the working group deserves credit for drafting the new goals using a bottom-up approach, based on wide ranging consultations. There is much to like in the draft: …

Bulletin of the World Health Organization
Volume 92, Number 9, September 2014, 621-696
http://www.who.int/bulletin/volumes/92/9/en/

Editorials
The 2014 Ebola outbreak: ethical use of unregistered interventions
Ruediger Krech a & Marie-Paule Kieny a
a. World Health Organization, avenue Appia 20, 1211 Geneva 27, Switzerland.
Bulletin of the World Health Organization 2014;92:622. doi: http://dx.doi.org/10.2471/BLT.14.145789
The large number of cases and wide geographical spread distinguish the current 2014 outbreak of Ebola virus disease in west Africa from all known earlier outbreaks.1 In the past, outbreaks of this disease have been stopped by identifying all cases, tracing all contacts and making sure that those caring for patients use correct protective gear at all times. However, the success of such methods depends on the presence of: (i) functional health systems; (ii) health workers who are trained, paid, willing to be deployed and adequately protected in a dangerous work environment; (iii) experts in public health with the skills needed to manage the tracing of people and monitor the evolution of the disease effectively; and (iv) people with solid skills in social engagement and development who are available to work with at-risk communities.2 Such systems and individuals were largely absent from the area where the current outbreak of Ebola virus disease is believed to have begun – a border area between three countries that all have fragile health systems and that are emerging from the traumas of civil war.
Encouragingly, research efforts over the past decade have led to the development, for the first time, of a range of potential treatments and vaccines that could support efforts to control Ebola virus disease. However, although some of these interventions have proven effective in animal models, none has completed clinical testing in humans – a step that is indispensable for the registration of any medical intervention as proven and safe. Why have there been no clinical trials, given that we have known the Ebola virus for 40 years? Why is there no effective registered vaccine or treatment available? At the onset of the current Ebola outbreak – despite some resources provided by the governments of Canada and the United States of America – substantial financial investment was still needed to evaluate and develop several interventions for the control and treatment of Ebola virus disease. Until now – as seen with several other neglected diseases – this disease has received little attention because it was affecting mostly poor people in poor countries.
The above shortcomings aggravate an ethical dilemma. If the treatments for Ebola virus disease that are currently under development could save lives – as the results of animal studies indicate – should they not be used immediately, since far too many people have already died? On the other hand, if there is a possibility that a treatment might cause substantial adverse effects in humans that have not been seen in animal testing, should it not be withheld?3
On 11 August 2014, the World Health Organization (WHO) convened a consultation to consider and assess the ethical implications of the potential use of unregistered interventions, such as drugs, vaccines and passive immunotherapy, in the current Ebola outbreak. The results of this consultation have been widely discussed in the media.4
In summary, the consultation’s panel of experts advised WHO that, in the particular circumstances of the current outbreak – and provided certain conditions are met – it would be ethical to offer unproven interventions – with as yet unknown efficacy and adverse effects – for the potential treatment or prevention of Ebola virus disease. One of the conditions that need to be met is that ethical principles must guide the provision of such interventions. For example, there must be transparency about all aspects of care, informed consent, freedom of choice, confidentiality, respect for the person, preservation of dignity, and involvement of the community.
To understand the safety and efficacy of these interventions, the panel of experts advised that – when and if any of the unregistered interventions is used to treat patients – there is a moral obligation to collect and share all of the data generated, including data arising from any treatment provided for compassionate use – i.e. the use of an unregistered drug outside of a clinical trial.5
What can we learn from this crisis? Robust health systems are key for controlling disease outbreaks. Let us make sure that development efforts are designed to strengthen health systems. Well trained and motivated health workers are indispensable. They should be paid and receive the support they need to carry out their duties. And, finally, increasing investment into research and development for the treatment, control and prevention of diseases that currently mostly affect poor people and poor countries should be a key priority for policy-makers worldwide. Let us not forget these lessons when the current Ebola outbreak no longer appears on the front pages of our newspapers.
References
Ebola virus disease update – west Africa [Disease Outbreak News, 13 August 2014]. Geneva: World Health Organization; 2014. Available from: http://who.int/csr/don/2014_08_13_ebola [cited 2014 Aug 15].
Key components of a well functioning health system. Geneva: World Health Organization; 2014. Available from: http://who.int/healthsystems/EN_HSSkeycomponents.pdf [cited 2014 Aug 15].
International ethical guidelines for biomedical research involving human subjects. Geneva: Council for International Organizations of Medical Sciences; 2002. Available from: http://www.cioms.ch/publications/layout_guide2002.pdf [cited 2014 Aug 15].
Ethical considerations for use of unregistered interventions for Ebola virus disease (EVD): summary of the panel discussion [WHO statement, 12 August 2014]. Geneva: World Health Organization; 2014. Available from: http://who.int/mediacentre/news/statements/2014/ebola-ethical-review-summary [cited 2014 Aug 15].
Ethical considerations for use of unregistered interventions for Ebola virus disease. Report of an advisory panel to WHO. Geneva: World Health Organization; 2014. Available from: http://www.who.int/csr/resources/publications/ebola/ethical-considerations/en/ [cited 2014 Aug 18].

Bulletin of the World Health Organization
Volume 92, Number 9, September 2014, 621-696
http://www.who.int/bulletin/volumes/92/9/en/

Perspectives
The Global Vaccine Safety Initiative: enhancing vaccine pharmacovigilance capacity at country level
Christine G Maure a, Alexander N Dodoo b, Jan Bonhoeffer c & Patrick LF Zuber a
a. Department of Essential Medicines and Health Products, World Health Organization, Avenue Appia 20, 1211 Geneva 27, Switzerland.
b. Centre for Tropical Clinical Pharmacology and Therapeutics, University of Ghana, Accra, Ghana.
c. Brighton Collaboration Foundation, Basel, Switzerland.
(Submitted: 19 March 2014 – Accepted: 21 March 2014 – Published online: 31 July 2014.)
Bulletin of the World Health Organization 2014;92:695-696. doi: http://dx.doi.org/10.2471/BLT.14.138875
Excerpt
“…The Decade of Vaccines, which was launched in 2010, aims to increase coordination within the vaccine community worldwide. The Global Vaccine Action Plan1 – the framework endorsed by the World Health Assembly for the Decade of Vaccines – includes a vaccine safety strategy, the Global Vaccine Safety Blueprint.2
The aim of the blueprint is to enhance the safety of vaccines through effective use of pharmacovigilance principles and methods. Its three strategic goals are: to assist LMICs to have at least minimal capacity for vaccine safety activities; to enhance capacity for vaccine safety assessment in countries that introduce newly developed vaccines, that introduce vaccines in settings with novel characteristics, or that manufacture and use prequalified vaccines; and to establish a global support structure for vaccine safety. The blueprint proposes eight complementary strategic objectives. Four of these objectives aim to improve the technical aspects of spontaneous reporting, active surveillance and risk communication; and to ensure the availability of harmonized methods and tools. The remaining four objectives promote the establishment of effective managerial principles to facilitate international collaboration and information exchange relating to vaccine safety monitoring. Implementing the blueprint is a task that requires coordinated participation of vaccine safety stakeholders worldwide. To that end, the World Health Organization (WHO) launched the Global Vaccine Safety Initiative in March 2012.
In its initial phase, the Global Vaccine Safety Initiative is attempting to build a global support structure by linking existing vaccine safety initiatives. Numerous projects are already addressing one or more of the blueprint’s strategic objectives. Some of the top priorities for the initiative are to identify such projects and engage their sponsors in collaboration, and to help disseminate their products and experiences. Therefore, a Global Vaccine Safety Initiative portfolio of activities has been assembled, where activities are prioritized based on their expected impact, geographical relevance, feasibility, usefulness and sustainability.3 For each activity, the portfolio recognizes the roles of initiators, managers and donors. All stakeholders in global pharmacovigilance can use this portfolio to help identify ongoing efforts, allow for better synergies, minimize duplications and enable resource mobilization…

Clinical Infectious Diseases (CID)
Volume 59 Issue 6 September 15, 2014
http://cid.oxfordjournals.org/content/current

Effectiveness of 7-Valent Pneumococcal Conjugate Vaccine Against Invasive Pneumococcal Disease in HIV-Infected and -Uninfected Children in South Africa: A Matched Case-Control Study
Cheryl Cohen, Claire von Mollendorf, Linda de Gouveia, Nireshni Naidoo, Susan Meiring, Vanessa Quan, Vusi Nokeri, Melony Fortuin-de Smit, Babatyi Malope-Kgokong, David Moore,
Gary Reubenson, Mamokgethi Moshe, Shabir A. Madhi, Brian Eley, Ute Hallbauer, Ranmini Kularatne, Laura Conklin, Katherine L. O’Brien, Elizabeth R. Zell, Keith Klugman, Cynthia G. Whitney, and Anne von Gottberg for the South African Invasive Pneumococcal Disease Case-Control Study Group
Clin Infect Dis. (2014) 59 (6): 808-818 doi:10.1093/cid/ciu431
Abstract
A 2 + 1 seven-valent pneumococcal conjugate vaccine schedule is effective against vaccine-serotype invasive pneumococcal disease (IPD) in HIV-uninfected children and HIV-exposed but -uninfected children and against all-serotype multidrug-resistant IPD in HIV-uninfected children.

Editorial Commentary: Failing Our Patients by Suboptimally Treating Influenza Infections
Michael G. Ison1,2
Author Affiliations
1Division of Infectious Diseases
2Division of Organ Transplantation, Northwestern University Feinberg School of Medicine, Chicago, Illinois
(See the Major Article by Havers et al on pages 774–82.)

Influenza is an important cause of morbidity and mortality related to annual epidemics and intermittent pandemics of respiratory viral infections. Whereas most of the 25 million annual cases of influenza result in self-limited infections, influenza is responsible for an excess 31.4 million outpatient visits, 226 000 excess hospitalizations, and up to 48 614 excess deaths annually in the United States [1–5]. Risk factors for serious illness and death include age Antiviral therapy with one of the neuraminidase inhibitors (oseltamivir or zanamivir) is recommended for the treatment of patients who develop influenza infections [7, 8]. Prospective studies in ambulatory adults and children have demonstrated that the neuraminidase inhibitors are associated with shorter time to alleviation of illness and with reductions in severity of illness, duration of fever, time to return to normal activity, and quantity of shed virus [9]. Data also suggest that antiviral therapy is associated with reduction in the frequency of complications leading to antibiotic use, particularly bronchitis, compared with placebo in previously healthy adults [10–12]. In ambulatory adults and children, antiviral therapy is generally effective only if started within the first 48–72 hours after symptom onset [9, 13, 14]. Moreover, earlier initiation of oral oseltamivir therapy is associated with increased therapeutic effects [13].
Data also suggest that antiviral therapy may be associated with fewer hospitalizations, particularly in high-risk patient …

Epidemiology and Infection
Volume 142 – Issue 10 – October 2014
http://journals.cambridge.org/action/displayIssue?jid=HYG&tab=currentissue

Original Papers
Burden of Communicable Diseases in Europe Study
The disease burden of hepatitis B, influenza, measles and salmonellosis in Germany: first results of the Burden of Communicable Diseases in Europe Study
D. PLASSa1 c1, M.-J. J. MANGENa2, A. KRAEMERa1, P. PINHEIROa1, A. GILSDORFa3, G. KRAUSEa3a4, C. L. GIBBONSa5, A. VAN LIERa6, S. A. McDONALDa6, R. J. BROOKEa2, P. KRAMARZa7, A. CASSINIa7 and M. E. E. KRETZSCHMARa2a6
a1 Department of Public Health Medicine, School of Public Health, University of Bielefeld, Bielefeld, Germany
a2 University Medical Centre Utrecht (UMCU), Utrecht, The Netherlands
a3 Robert Koch Institute, Berlin, Germany
a4 Department for Epidemiology, Helmholtz Centre for Infection Research, Braunschweig, Germany
a5 Institute of Evolutionary Biology, University of Edinburgh, Edinburgh, Scotland, UK
a6 National Institute for Public Health and the Environment (RIVM), Centre for Infectious Disease Control, Bilthoven, The Netherlands
a7 European Centre for Disease Prevention and Control (ECDC), Stockholm, Sweden
SUMMARY
Setting priorities in the field of infectious diseases requires evidence-based and robust baseline estimates of disease burden. Therefore, the European Centre for Disease Prevention and Control initiated the Burden of Communicable Diseases in Europe (BCoDE) project. The project uses an incidence- and pathogen-based approach to measure the impact of both acute illness and sequelae of infectious diseases expressed in disability-adjusted life years (DALYs). This study presents first estimates of disease burden for four pathogens in Germany. The number of reported incident cases adjusted for underestimation served as model input. For the study period 2005–2007, the average disease burden was estimated at 33,116 DALYs/year for influenza virus, 19,115 DALYs/year for Salmonella spp., 8,708 DALYs/year for hepatitis B virus and 740 DALYs/year for measles virus. This methodology highlights the importance of sequelae, particularly for hepatitis B and salmonellosis, because if omitted, the burden would have been underestimated by 98% and 56%, respectively.

Eurosurveillance
Volume 19, Issue 35, 04 September 2014
http://www.eurosurveillance.org/Public/Articles/Archives.aspx?PublicationId=11678

Research articles
Association between temperature, humidity and ebolavirus disease outbreaks in Africa, 1976 to 2014
by S Ng, NE Basta, BJ Cowling

Measles virus spread initiated at international mass gatherings in Europe, 2011
by S Santibanez, K Prosenc, D Lohr, G Pfaff , O Jordan, A Mankertz

Is it reasonable to abandon obligatory vaccinations in Italy? A 2013 survey
by CP Pelullo, S Marino, AJ Valdes Abuadili, G Signoriello, F Attena

Globalization and Health
[Accessed 6 September 2014]
http://www.globalizationandhealth.com/

Research
Learning from developing countries in strengthening health systems: an evaluation of personal and professional impact among global health volunteers at Addis Ababa University’s Tikur Anbessa Specialized Hospital (Ethiopia)
Heidi Busse1*, Ephrem A Aboneh2 and Girma Tefera1
Author Affiliations
Globalization and Health 2014, 10:64 doi:10.1186/s12992-014-0064-x
Published: 5 September 2014
Abstract (provisional)
Background
The positive impact of global health activities by volunteers from the United States in low-and middle-income countries has been recognized. Most existing global health partnerships evaluate what knowledge, ideas, and activities the US institution transferred to the low- or middle-income country. However, what this fails to capture are what kinds of change happen to US-based partners due to engagement in global health partnerships, both at the individual and institutional levels. ?Reverse innovation? is the term that is used in global health literature to describe this type of impact. The objectives of this study were to identify what kinds of impact global partnerships have on health volunteers from developed countries, advance this emerging body of knowledge, and improve understanding of methods and indicators for assessing reverse innovation.
Methods
The study population consisted of 80 US, Canada, and South Africa-based health care professionals who volunteered at Tikur Anbessa Specialized Hospital in Ethiopia. Surveys were web-based and included multiple choice and open-ended questions to assess global health competencies. The data were analyzed using IBRM SPSS? version 21 for quantitative analysis; the open-ended responses were coded using constant comparative analysis to identify themes.
Results
Of the 80 volunteers, 63 responded (79 percent response rate). Fifty-two percent of the respondents were male, and over 60 percent were 40?years of age and older. Eighty-three percent reported they accomplished their trip objectives, 95 percent would participate in future activities and 96 percent would recommend participation to other colleagues. Eighty-nine percent reported personal impact and 73 percent reported change on their professional development. Previous global health experience, multiple prior trips, and the desire for career advancement were associated with positive impact on professional development.
Conclusion
Professionally and personally meaningful learning happens often during global health outreach. Understanding this impact has important policy, economic, and programmatic implications. With the aid of improved monitoring and evaluation frameworks, the simple act of attempting to measure ?reverse innovation? may represent a shift in how global health partnerships are perceived, drawing attention to the two-way learning and benefits that occur and improving effectiveness in global health partnership spending.

Health Policy and Planning
Volume 29 Issue 6 September 2014
http://heapol.oxfordjournals.org/content/current

Global health in foreign policy—and foreign policy in health? Evidence from the BRICS
Nicola F Watt1,*, Eduardo J Gomez2 and Martin McKee1
1European Centre on Health of Societies in Transition, London School of Hygiene and Tropical Medicine, 15-17, Tavistock Place, London WC1H 9SH, UK and 2King’s International Development Institute, King’s College London, Strand, London, WC2R 2LS, UK
Accepted July 19, 2013.
Abstract
Amidst the growing literature on global health, much has been written recently about the Brazil, Russia, India, China, South Africa (BRICS) countries and their involvement and potential impact in global health, particularly in relation to development assistance. Rather less has been said about countries’ motivations for involvement in global health negotiations, and there is a notable absence of evidence when their motivations are speculated on. This article uses an existing framework linking engagement in global health to foreign policy to explore differing levels of engagement by BRICS countries in the global health arena, with a particular focus on access to medicines. It concludes that countries’ differing and complex motivations reinforce the need for realistic, pragmatic approaches to global health debates and their analysis. It also underlines that these analyses should be informed by analysis from other areas of foreign policy.

Human Vaccines & Immunotherapeutics (formerly Human Vaccines)
September 2014 Volume 10, Issue 9
http://www.landesbioscience.com/journals/vaccines/toc/volume/10/issue/8/

Special focus: Vaccine acceptance

Commentary
Commentary for Human Vaccines and Immunotherapeutics: The big picture in addressing vaccine hesitancy
Julie Leask, Hal Willaby and Jessica Kaufman
Abstract
Public acceptance of vaccination has never been a given. Today there is a set of societal circumstances that may contribute to a growing parental hesitancy about vaccination. These include: increasingly ‘crowded’ vaccination schedules; lower prevalence of vaccine-preventable diseases; greater access to, and more rapid dissemination of, vaccine-critical messages via digital networks; hyper-vigilance of parents in relation to children and risk; and an increasingly consumerist orientation to healthcare.

Health care professionals and adolescent vaccination: A call for intervention research
Gregory D Zimet
Abstract
In their recently published research study, Gargano et al. found that a physician’s recommendation and parental health beliefs had significant effects on adolescent vaccination rates and on parental intentions to vaccinate. This research replicates the findings of a number of human papillomavirus (HPV) vaccine-focused research studies, but explores new territory by focusing on all recommended adolescent vaccines: meningococcal-conjugate (MCV4), HPV, influenza, and tetanus, diphtheria, and acellular pertussis (Tdap) vaccines. Although Gargano et al.’s study is relatively small in scale and focuses on only one county in Georgia, their results are consistent with many other research reports, suggesting that their findings are robust and replicable. Most published intervention studies have targeted parents and young adults, with little focus on health care professionals. However, given the centrality of physician recommendation in adolescent vaccination, as shown by Gargano et al., it is clear that the time has come to develop and evaluate interventions that help physicians and other health care professionals to more effectively implement strong and routine recommendations for all adolescent platform vaccines.

Commentary
Influenza vaccination of healthcare personnel
Sabine Wicker and Georg Marckmann
Abstract
The thought is terrifying—you are admitted to the hospital and you die of a nosocomial infection. What sounds like a horror scenario, happens every day in hospitals all over the world. Nosocomial influenza is associated with considerable morbidity and mortality among patients with underlying diseases (especially immunocompromised patients), the elderly, and neonates. Although vaccination of healthcare personnel (HCP) is the main measure for preventing nosocomial influenza and is consistently recommended by public-health authorities, vaccine uptake among HCP remains low.1

Review
What are the factors that contribute to parental vaccine-hesitancy and what can we do about it?
Sarah E Williams
Abstract
Parental refusal or delay of childhood vaccines is increasing. Barriers to vaccination among this population have been described, yet less is known regarding motivating factors. Researchers are beginning to evaluate various approaches to address the concerns of “vaccine-hesitant” parents, but few studies have evaluated the effect of interventions on timely vaccine uptake. Several models for communicating with vaccine-hesitant parents have been reported for healthcare providers; however, the effectiveness and utility of these strategies has not been quantified. This article reviews the known barriers to vaccination reported by vaccine-hesitant parents and the current evidence on strategies to address parental vaccine hesitancy.

Commentary
Impact of a physician recommendation
Paul M Darden and Robert M Jacobson
Abstract
HPV vaccination has failed to achieve uptake comparable to the other adolescent-specific vaccines. Gargano et al. conducted a survey of parents of adolescents in a single Georgia county and found uptake similar to national surveys. They also found among the most commonly cited reasons for receiving vaccines a recommendation from a health care provider and among the most commonly cited reasons for not getting any of the adolescent vaccines were concerns for adverse effects. Of note, they found that the recommendation for any one vaccine had a positive effect on the uptake of other vaccines. Their findings for the importance of provider recommendations matched finds from studies of adolescent vaccines, infant vaccines, and adult vaccines. This is despite flaws in their study including a very poor response rate (effectively 4.5%) of those surveyed and in their reporting including a lack of details of survey methods. Local surveys of vaccination have much to offer the national and local discussion about immunization delivery and how delivery should be optimized, but such surveys should use standardized approaches as well as pursue more comprehensive investigations at the local level to address the nuances national complex-cluster surveys cannot.

Research Paper
Attitude toward immunization and risk perception of measles, rubella, mumps, varicella, and pertussis in health care workers working in 6 hospitals of Florence, Italy 2011
Cristina Taddei, Vega Ceccherini, Giuditta Niccolai, Barbara Rita Porchia, Sara Boccalini, Miriam Levi, Emilia Tiscione, Maria Grazia Santini, Simonetta Baretti, Paolo Bonanni and Angela Bechini
Abstract
Background: Health care workers (HCWs) are at risk of infection and transmission of vaccine-preventable infectious diseases. In recent years cases of measles or varicella in health care workers were observed with increasing frequency. The aim of our study was to investigate attitude toward immunization and risk perception of measles, rubella, mumps, varicella, and pertussis in HCWs working in 6 hospitals of Florence (Italy).
Methods: A cross-sectional survey among the physicians, nurses, midwives, and nursing assistants working in selected departments was performed trough a self-administered, anonymous questionnaire. Overall, 600 questionnaires were sent and 436 HCWs’ completed forms were included into the study (Participation rate: 72.7%). Data were analyzed with STATA 11.0® and odds ratio (OR) were calculated in a multivariate analysis.
Results: Among all respondents 74.9% were females. The average age was nearly 43-years-old (42.9 – SD 8.95). The majority of participants (58.6%) were nurses, 21.3% physicians, 12.9% nursing assistants, and 7.2% were midwives. Among those HCWs reporting no history of disease, 52.8% (95% CI: 42.0–63.3%) declared to have been immunized for measles, 46.9% for rubella (95% CI: 39.0–54.9%), 21.6% for mumps (95% CI: 15.1–29.4%), 14.9% for varicella (95% CI: 7.4–25.7%), and 14.5% for pertussis (95% CI: 10.0–20.0%). When considering potentially susceptible HCWs (without history of disease or vaccination and without serological confirmation), less than a half of them feel at risk for the concerned diseases and only less than 30% would undergo immunization. One of the main reasons of the relatively low coverage was indeed lack of active offer of vaccines.
Conclusion: Attitudes toward immunization observed in this study are generally positive for preventing some infectious diseases (i.e., measles and rubella), but relatively poor for others (i.e., varicella). More information should be made available to HCWs on the benefits of vaccination and efforts to encourage vaccination uptake should be performed. Educational program on the risk of being infected working in a hospital should be implemented in order to increase the risk perception toward infectious diseases among HCWs.

Research Paper
Knowledge, attitude, and uptake related to human papillomavirus vaccination among young women in Germany recruited via a social media site
Cornelius Remschmidt, Dietmar Walter, Patrick Schmich, Matthias Wetzstein, Yvonne Deleré and Ole Wichmann
Abstract
Background: Many industrialized countries have introduced human papillomavirus (HPV) vaccination of young women, but vaccine uptake often remains suboptimal. This study aimed to investigate whether a social media site like Facebook is an appropriate tool to assess knowledge, attitude and uptake related to HPV vaccination in young women in Germany. Methods: Between December 2012 and January 2013 two different targeting strategies were implemented on Facebook, providing a link to an online questionnaire. Advertisements were displayed to female Facebook users aged 18–25 years living in Germany. During the simple targeting strategy, advertisements comprised health-related images along with various short titles and text messages. During the focused strategy, advertisements were targeted to users who in addition had certain fashion brands or pop stars listed on their profiles. The targeting strategies were compared with respect to participant characteristics. Univariate and multivariate analyses were used to identify factors associated with HPV vaccine uptake.
Results: A total of 1161 women participated. The two targeting strategies resulted in significant differences regarding educational status and migrant background. Overall, awareness of HPV was high, but only 53% received at least one vaccine dose. In multivariate analysis, HPV vaccine uptake was independently associated with a physician’s recommendation and trust in vaccine effectiveness. Concerns of adverse effects were negatively associated with vaccine uptake.
Discussion: Social network recruitment permits fast and convenient access to young people. Sample characteristics can be manipulated by adjusting targeting strategies. There is further need for promoting knowledge of HPV vaccination among young women. Physicians have a major role in the vaccination decision-making process of young women.

Review
Maternal immunization: Clinical experiences, challenges, and opportunities in vaccine acceptance
Michelle H Moniz and Richard H Beigi
Abstract
Maternal immunization holds tremendous promise to improve maternal and neonatal health for a number of infectious conditions. The unique susceptibilities of pregnant women to infectious conditions, as well as the ability of maternally-derived antibody to offer vital neonatal protection (via placental transfer), together have produced the recent increased attention on maternal immunization. The Advisory Committee on Immunization Practices (ACIP) currently recommends 2 immunizations for all pregnant women lacking contraindication, inactivated Influenza and tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap). Given ongoing research the number of vaccines recommended during pregnancy is likely to increase. Thus, achieving high vaccination coverage of pregnant women for all recommended immunizations is a key public health enterprise. This review will focus on the present state of vaccine acceptance in pregnancy, with attention to currently identified barriers and determinants of vaccine acceptance. Additionally, opportunities for improvement will be considered.

Research Paper
Vaccination against human papilloma virus infection in male adolescents: Knowledge, attitudes, and acceptability among parents in Italy
Aida Bianco, Claudia Pileggi, Francesca Iozzo, Carmelo Giuseppe Nobile and Maria Pavia
Abstract
Objectives: To elicit information about parents’ knowledge, attitudes, and acceptability towards HPV infection and vaccination of male adolescents in Italy; to identify subgroups of this population who exhibit poor knowledge about prevention of HPV infection and reveal negative attitudes towards HPV vaccination in relation to their male sons. Study design: Data were collected via self-administered anonymous questionnaire from 1021 parents of males aged 10 to 14 years who were recruited from a random sample of public secondary schools in the South of Italy. Results: Three-quarters (72.6%) reported that the vaccine is a preventive measure for HPV infection and 55.8% that condom use reduces the risk of HPV infection. A high education level, abundant sources of information about HPV infection received from physicians, and knowledge about HPV infection were factors significantly associated with high level of knowledge about preventive measures for HPV infection. 71% revealed their intentions to vaccinate their sons, and this intention was significantly associated with perceived benefits both for HPV vaccination for girls and for childhood recommended vaccinations as well as a need for additional information about HPV vaccination. 53.7% of the eligible parents reported that their daughters had been vaccinated against HPV. Conclusion: Results of the study suggest that the risk of acquiring HPV infection and HPV-related diseases is sorely underestimated. Knowledge on the benefits of adolescents’ HPV vaccination in cancer prevention in both sexes should be improved to maximize uptake of HPV vaccination.

Commentary
Social media targeting of health messages: A promising approach for research and practice
Cornelia Betsch
Abstract
In their contribution, Remschmidt and colleagues1 put forward an innovative approach for recruiting female, German study participants from diverse social and ethnical backgrounds to assess their knowledge, attitudes, and behaviors regarding HPV vaccination. The approach involves placing advertisements on the social media platform Facebook that specify tags for not only the sought after socio-demographic characteristics (age, gender) but also self-relevant aspects of the target group. These tags determine which Facebook users will see the ad. By sequentially adjusting the tags, the researchers were able to recruit different sub-populations, resulting in a final sample similar to a representative German sample for a particular age group.

Research Paper
Factors Associated with Maternal Influenza Immunization Decision-Making: Evidence of Immunization History and Message Framing Effects
Paula M Frew, Lauren E Owens, Diane S Saint-Victor, Samantha Benedict, Siyu Zhang and Saad B Omer
Abstract
Objective
We examined pregnant women’s intention to obtain the seasonal influenza vaccine via a randomized controlled study examining the effects of immunization history, message exposure, and sociodemographic correlates.
Methods
Pregnant women ages 18–50 participated in a randomized message framing study from September 2011 through May 2012. Venue-based sampling was used to recruit racial and ethnic minority women throughout Atlanta, Georgia. Key outcomes were evaluated using bivariate and multivariate analyses.
Results
History of influenza immunization was positively associated with intent to immunize during pregnancy [OR = 2.31, 90%CI: (1.06, 5.00)]. Significant correlates of intention to immunize included perceived susceptibility to influenza during pregnancy [OR = 3.8, 90% CI: (1.75, 8.36)] and vaccine efficacy [OR = 10.53, 90% CI: (4.34, 25.50)]. Single message exposure did not influence a woman’s intent to vaccinate.
Conclusions
Prior immunization, perceived flu susceptibility and perceived vaccine effectiveness promoted immunization intent among this population of pregnant minority women. Vaccine efficacy and disease susceptibility are critical to promoting immunization among women with no history of seasonal influenza immunization, while those who received the vaccine are likely to do so again. These findings provide evidence for the promotion of repeated exposure to vaccine messages emphasizing vaccine efficacy, normative support, and susceptibility to influenza.

Research Paper
Parental concern about vaccine safety in Canadian children partially immunized at age two: A multivariable model including system level factors
Donald Schopflocher, Wendy Vaudry and Shannon MacDonald
Abstract
Children who begin but do not fully complete the recommended series of childhood vaccines by two years of age are a much larger group than those who receive no vaccines. While parents who refuse all vaccines typically express concern about vaccine safety, it is critical to determine what influences parents of ‘partially’ immunized children. This case-control study examined whether parental concern about vaccine safety was responsible for partial immunization, and whether other personal or system-level factors played an important role. A random sample of parents of partially and completely immunized two year old children were selected from a Canadian regional immunization registry and completed a postal survey assessing various personal and system-level factors. Unadjusted odds ratios (OR) and adjusted ORs (aOR) were calculated with logistic regression. While vaccine safety concern was associated with partial immunization (OR 7.338, 95% CI 4.138- 13.012), other variables were more strongly associated and reduced the strength of the relationship between concern and partial immunization in multivariable analysis (aOR 2.829, 95% CI 1.151 – 6.957). Other important factors included perceived disease susceptibility and severity (aOR 4.629, 95% CI 2.017 – 10.625), residential mobility (aOR 3.908, 95% CI 2.075 – 7.358), daycare use (aOR 0.310, 95% CI 0.144 – 0.671), number of needles administered at each visit (aOR 7.734, 95% CI 2.598 – 23.025) and access to a regular physician (aOR 0.219, 95% CI 0.057 – 0.846). While concern about vaccine safety may be addressed through educational strategies, this study suggests that additional program and policy-level strategies may positively impact immunization uptake.

Commentary
Protecting a New Generation against HPV: Are We Willing to be Bold?
Richard Crosby, Lindsay Stradtman and Robin Vanderpool
Abstract
Despite the advent of a novel human papillomavirus (HPV) vaccine to prevent associated cancers, HPV vaccination rates in the United States (US) remain well below national goals. Two recent reports by the Centers for Disease Control and Prevention (CDC) and the President’s Cancer Panel (PCP) have identified missed clinical opportunities as an intervention point for increasing HPV vaccination rates, including the provision of immunization in alternative venues by varying healthcare providers. In this paper, we specifically comment on the idea of offering HPV vaccination in emergency departments (ED) by emergency medicine (EM) physicians as posited by Hill and Okugo (2014), identifying both strengths and limitations to this strategy. We also offer ideas for additional research, suggest provider and healthcare systems changes, and discuss needed policy changes to improve HPV vaccination rates in the US.

Commentary
Comprehensive Efforts to Increase Healthcare Personnel Immunization
Samuel B Graitcer, David Kim and Megan Lindley
Abstract
Vaccination of healthcare personnel (HCP) is an important component of worker and patient safety, yet vaccination rates are lagging. The findings from Taddei et al.’s study of healthcare personnel immunization attitudes and practices in Florence, Italy provides further data of the importance of routine assessment of and recommendations for vaccines for HCP in order to improve coverage.
Does Intention to Recommend HPV Vaccines Impact HPV Vaccination Rates?
Maria Middleton, Alexander Fiks, Sarah Winters, Sara Kinsman, Jessica Kahn and Kristen Feemster
Abstract
Despite recommendations for routine vaccination, HPV vaccination rates among adolescent females have remained low. The objective of this prospective cohort study was to determine whether clinician intention to recommend HPV vaccines predicts HPV vaccine series initiation among previously unvaccinated 11 to 18 year-old girls (N=18,083) who were seen by a pediatric clinician (N=105) from a large primary care network within three years of vaccine introduction. We used multivariable logistic regression with generalized estimating equations, Cox Regression and standardized survival curves to measure the association between clinician intention and time to and rate of first HPV vaccine receipt among eligible females. All models adjusted for patient age, race / ethnicity, payor category, visit type, and practice location. Eighty-five percent of eligible 11 to 12 year-old and 95% of 13 to 18 year-old girls were seen by a provider reporting high intention to recommend HPV vaccines. However, only 30% of the cohort initiated the HPV vaccine series and the mean number of days from first eligible visit to series initiation was 190 (95% C.I. 184.2, 195.4). After adjusting for covariates, high clinician intention was modestly associated with girls’ likelihood of HPV vaccine series initiation (OR 1.36; 95 % C.I. 1.07, 1.71) and time to first HPV vaccination (HR 1.22; 95% 1.06, 1.40). Despite high intention to vaccinate among this cohort of pediatric clinicians, overall vaccination rates for adolescent girls remained low. These findings support ongoing efforts to develop effective strategies to translate clinician intention into timely HPV vaccine receipt.

Commentary
Making evidence-based selections of influenza vaccines
Billy-Clyde Childress, Joshua D Montney and Elise A Albro
Abstract
Years ago, intramuscular influenza vaccines were the only option for those who wanted to arm themselves against the flu. Today there are alternatives, including intradermal injections and intranasal sprays. In order to select the right influenza vaccine for their patients, pharmacists, and other healthcare professionals must have a basic understanding of the immune system. Influenza vaccines elicit different levels of immune response involving innate and adaptive immunity, which are critical to fighting infection. For the 2013–2014 flu season, there were 13 different formulations of influenza vaccines on the market with vast differences in indications, contraindications, and effectiveness. The CDC does not recommend one vaccine over another, but recommends that all patients be vaccinated against the flu. Preventing the spread of influenza is no simple task; however, the most recent evidence on influenza vaccines and sufficient knowledge of the immune system will allow pharmacists and other healthcare providers to better advocate for vaccines, determine which are most appropriate, and ensure their proper administration.

International Journal of Infectious Diseases
Vol 26 Complete | September 2014 | Pages 1-172
http://www.ijidonline.com/current

Immunogenicity and safety of a quadrivalent meningococcal polysaccharide CRM conjugate vaccine in infants and toddlers
Miguel Tregnaghi, Pio Lopez, Daniel Stamboulian, Gabriela Graña, Tatjana Odrljin, Lisa Bedell, Peter M. Dull
Received 20 December 2013; received in revised form 7 March 2014; accepted 27 March 2014. published online 30 June 2014.
Corresponding Editor: Eskild Petersen, Aarhus, Denmark
Summary
Objectives
This phase III study assessed the safety and immunogenicity of MenACWY-CRM, a quadrivalent meningococcal conjugate vaccine, administered with routine vaccines starting at 2 months of age.
Methods
Healthy infants received MenACWY-CRM in a two- or three-dose primary infant series plus a single toddler dose. In addition, a two-dose toddler catch-up series was evaluated. Immune responses to MenACWY-CRM were assessed for serum bactericidal activity with human complement (hSBA). Reactogenicity and safety results were collected systematically.
Results
After a full infant/toddler series or two-dose toddler catch-up series, MenACWY-CRM elicited immune responses against the four serogroups in 94–100% of subjects. Noninferiority of the two- versus three-dose MenACWY-CRM infant dosing regimen was established for geometric mean titers for all serogroups. Following the three-dose infant primary series, 89–98% of subjects achieved an hSBA ≥8 across all serogroups. Immune responses to concomitant routine vaccines given with MenACWY-CRM were noninferior to responses to routine vaccines alone, except for pertactin after the two-dose infant series. Noninferiority criteria were met for all concomitant antigens after the three-dose infant series.
Conclusions
MenACWY-CRM vaccination regimens in infants and toddlers were immunogenic and well tolerated. No clinically meaningful effects of concomitant administration with routine infant and toddler vaccines were observed.

International Journal of Infectious Diseases
Vol 26 Complete | September 2014 | Pages 1-172
http://www.ijidonline.com/current

An outbreak of adult measles by nosocomial transmission in a high vaccination coverage community
Fen-juan Wang, Xiang-jue Sun, Fu-liang Wang, Long-fang Jiang, Er-ping Xu, Jian-feng Guo
Received 3 March 2014; received in revised form 4 May 2014; accepted 6 May 2014. published online 07 July 2014.
Corresponding Editor: Eskild Petersen, Aarhus, Denmark
Abstract
Highlights
:: With the implementation of hastened measles elimination strategies, the susceptible populations now have moved to the infants under 8 months who are too young to receive the MCV vaccination and the adults over 20 year old.
:: Hospital exposure 1∼2 weeks before infected with measles was the main cause of the community-based measles outbreak, there is a link between them.
:: Controlling nosocomial infections is a vital link in propagation of measles prevention and control.
Summary
Objectives
The aims of this study were to determine the mechanism of an outbreak of measles in adults and to provide scientific measures for putting forward a measles elimination program.
Methods
We performed a cross-sectional investigation during the measles outbreak to identify a possible communication link.
Results
From November 1, 2011 to January 26, 2012, the town reported 11 cases of measles in total. The case study identified an obvious propagation chain, which showed ordered and intimate exposure between cases.
Conclusions
Hospital exposure 1–2 weeks before infection with measles was the main cause of the measles outbreak. We must be fully aware of the possibility of nosocomial infection in an outbreak of measles; controlling nosocomial infections is a vital step in the prevention and control of the propagation of measles.

Journal of Immigrant and Minority Health
Volume 16, Issue 5, October 2014
http://link.springer.com/journal/10903/16/4/page/1

Screening and Vaccines in an Urban Primary Care Practice: A Retrospective Chart Review
Barbara Waldorf, Christopher Gill, Sondra S. Crosby
Abstract
In the United States, 38.5 million people are foreign-born, one in three arriving since 2000. Health issues include high rates of hepatitis B, human immunodeficiency virus infection, parasitic infections, and M. tuberculosis. We sought to determine rates of provider adherence to accepted national guidelines for immigrant and refugee health screening and vaccines done at the primary care clinics at Boston Medical Center. Randomized, retrospective chart review of foreign born patients in the primary care clinics. We found low screening and immunization rates that do not conform to CDC/ACIP guidelines. Only 43 % of immigrant patients had tuberculosis screening, 36 % were screened for HIV and hepatitis B, and 33 % received tetanus vaccinations. Organizational changes incorporating multi-disciplinary approaches such as creative use of nursing staff, protocols, standing orders, EMR reminders, and web based educational tools can contribute to better outcomes by identifying patients and improving utilization of guidelines.

New England Journal of Medicine
August 28, 2014 Vol. 371 No. 9
http://www.nejm.org/toc/nejm/medical-journal

Original Article
Influenza Vaccination of Pregnant Women and Protection of Their Infants
Shabir A. Madhi, M.D., Ph.D., Clare L. Cutland, M.D., Locadiah Kuwanda, M.Sc., Adriana Weinberg, M.D., Andrea Hugo, M.D., Stephanie Jones, M.D., Peter V. Adrian, Ph.D., Nadia van Niekerk, B.Tech., Florette Treurnicht, Ph.D., Justin R. Ortiz, M.D., Marietjie Venter, Ph.D., Avy Violari, M.D., Kathleen M. Neuzil, M.D., Eric A.F. Simões, M.D., Keith P. Klugman, M.D., Ph.D., and Marta C. Nunes, Ph.D. for the Maternal Flu Trial (Matflu) Team
N Engl J Med 2014; 371:918-931September 4, 2014DOI: 10.1056/NEJMoa1401480
Background
There are limited data on the efficacy of vaccination against confirmed influenza in pregnant women with and those without human immunodeficiency virus (HIV) infection and protection of their infants.
Methods
We conducted two double-blind, randomized, placebo-controlled trials of trivalent inactivated influenza vaccine (IIV3) in South Africa during 2011 in pregnant women infected with HIV and during 2011 and 2012 in pregnant women who were not infected. The immunogenicity, safety, and efficacy of IIV3 in pregnant women and their infants were evaluated until 24 weeks after birth. Immune responses were measured with a hemagglutination inhibition (HAI) assay, and influenza was diagnosed by means of reverse-transcriptase–polymerase-chain-reaction (RT-PCR) assays of respiratory samples.
Results
The study cohorts included 2116 pregnant women who were not infected with HIV and 194 pregnant women who were infected with HIV. At 1 month after vaccination, seroconversion rates and the proportion of participants with HAI titers of 1:40 or more were higher among IIV3 recipients than among placebo recipients in both cohorts. Newborns of IIV3 recipients also had higher HAI titers than newborns of placebo recipients. The attack rate for RT-PCR–confirmed influenza among both HIV-uninfected placebo recipients and their infants was 3.6%. The attack rates among HIV-uninfected IIV3 recipients and their infants were 1.8% and 1.9%, respectively, and the respective vaccine-efficacy rates were 50.4% (95% confidence interval [CI], 14.5 to 71.2) and 48.8% (95% CI, 11.6 to 70.4). Among HIV-infected women, the attack rate for placebo recipients was 17.0% and the rate for IIV3 recipients was 7.0%; the vaccine-efficacy rate for these IIV3 recipients was 57.7% (95% CI, 0.2 to 82.1).
Conclusions
Influenza vaccine was immunogenic in HIV-uninfected and HIV-infected pregnant women and provided partial protection against confirmed influenza in both groups of women and in infants who were not exposed to HIV. (Funded by the Bill and Melinda Gates Foundation and others; ClinicalTrials.gov numbers, NCT01306669 and NCT01306682.)

Pediatrics
September 2014, VOLUME 134 / ISSUE 3
http://pediatrics.aappublications.org/current.shtml

Article
Long-term Study of a Quadrivalent Human Papillomavirus Vaccine
Daron Ferris, MDa, Rudiwilai Samakoses, MDb, Stan L. Block, MDc, Eduardo Lazcano-Ponce, Dd,
Jaime Alberto Restrepo, MDe, Keith S. Reisinger, MD, MPHf, Jesper Mehlsen, MDg, Archana Chatterjee, MD, PhDh, Ole-Erik Iversen, MDi, Heather L. Sings, PhDj, Qiong Shou, PhDj, Timothy A. Sausser, BSj, and Alfred Saah, MDj
Author Affiliations
aDepartment of Obstetrics and Gynecology, Georgia Regents University, Augusta, Georgia;
bDepartment of Pediatrics, Phramongkutklao Hospital, Bangkok, Thailand;
cKentucky Pediatric and Adult Research, Inc, Bardstown, Kentucky;
dCenter for Research in Population Health, National Institute of Public Health, Cuernavaca Morelos, Mexico;
eClinical Research Center, Medellín, Colombia;
fPrimary Physicians Research, Pittsburgh, Pennsylvania;
gCoordinating Research Centre, Frederiksberg Hospital, Frederiksberg, Denmark;
hDepartment of Pediatrics, University of South Dakota Sanford School of Medicine, Sanford Children’s Specialty Clinics, Sioux Falls, South Dakota;
iDepartment of Obstetrics and Gynecology, Haukeland University Hospital, Bergen, Norway; and
jMerck & Co., Inc, Whitehouse Station, New Jersey
Abstract
BACKGROUND: We present a long-term safety, immunogenicity, and effectiveness study of a quadrivalent human papillomavirus (HPV4) vaccine.
METHODS: Sexually naive boys and girls aged 9 to 15 years (N = 1781) were assigned (2:1) to receive HPV4 vaccine or saline placebo at day 1 and months 2 and 6. At month 30, the placebo group (n = 482) received HPV4 vaccine following the same regimen and both cohorts were followed through month 96. Subjects ≥16 years were eligible for effectiveness evaluations. The primary objective was to evaluate the long-term anti-HPV6/11/16/18 serological levels. The secondary objective was to estimate vaccine effectiveness against HPV6/11/16/18-related persistent infection or disease.
RESULTS: For each of the HPV4 vaccine types, vaccination-induced anti-HPV response persisted through month 96. Among 429 subjects who received HPV4 vaccine at a mean age of 12, none developed HPV6/11/16/18-related disease or persistent infection of ≥12 months’ duration. Acquisition of new sexual partners (among those ≥16 years) was ∼1 per year. Subjects receiving HPV4 vaccine at month 30 (mean age 15 years) had a similar baseline rate of seropositivity to ≥1 of the 4 HPV types to those vaccinated at day 1 (mean age 12 years; 1.9% [9 of 474] vs 1.7% [20 of 1157]); however, 4 of the 9 subjects vaccinated at the later age were seropositive to 3 vaccine types, indicating previous HPV exposure. No new significant serious adverse events were observed for 8 years postvaccination in both genders.
CONCLUSIONS: When administered to adolescents, the HPV4 vaccine demonstrated durability in clinically effective protection and sustained antibody titers over 8 years.

Article
Missed Opportunities for HPV Vaccination in Adolescent Girls: A Qualitative Study
Rebecca B. Perkins, MD, MSca, Jack A. Clark, PhDb,c, Gauri Apte, MB, BS, MPHc, Jessica L. Vercruysse, MAa, Justen J. Sumner, MD, MPHa, Constance L. Wall-Haas, DNP, PPCNP-BCd,
Anna W. Rosenquist, MDe, and Natalie Pierre-Joseph, MD, MPHa
Author Affiliations
aBoston University School of Medicine, Boston, Massachusetts;
bEdith Nourse Rogers Memorial Veterans Hospital–Bedford, Bedford, Massachusetts;
cBoston University School of Public Health, Boston, Massachusetts;
dHarvard Vanguard Medical Associates, Chelsmford, Massachusetts; and
eHarvard Vanguard Medical Associates, Burlington, Massachusetts
Abstract
OBJECTIVE: The goal of this study was to identify the rationale by parents/guardians and providers for delaying or administering human papillomavirus (HPV) vaccination to girls.
METHODS: Qualitative interviews were conducted with parents/guardians accompanying their vaccine-eligible 11- to 17-year-old daughters to medical visits. Interviews were conducted in 1 public clinic and 3 private practice settings to ascertain why girls did or did not receive HPV vaccination. Questions probed vaccine decision-making from the point of view of parents/guardians and providers.
RESULTS: A total of 124 parents/guardians and 37 providers participated. The most common reasons parents reported for not vaccinating their daughters was the lack of a physician recommendation (44%). Both parents and providers believed that HPV vaccination provided important health benefits, but the timing of vaccination with relation to sexual activity was an important theme related to vaccine delay. Providers with lower self-reported vaccination rates delayed vaccine recommendations in girls perceived to be at low risk for sexual activity, and several parents reported that their providers suggested or supported delaying vaccination until their daughters were older. However, parents/guardians and providers agreed that predicting the timing of sexual debut was extremely difficult. In contrast, providers with high vaccination rates presented HPV vaccination as a routine vaccine with proven safety to prevent cancer, and parents responded positively to these messages.
CONCLUSIONS: Although most parents and providers believe that HPV vaccination is important, missed opportunities result from assumptions about the timing of vaccination relative to sexual activity. Routinely recommending HPV vaccination as cancer prevention to be coadministered with other vaccines at age 11 years can improve vaccination rates

Article
Vaccine Message Framing and Parents’ Intent to Immunize Their Infants for MMR
Kristin S. Hendrix, PhDa,b, S. Maria E. Finnell, MD, MSa,b,c, Gregory D. Zimet, PhDa, Lynne A. Sturm, PhDa, Kathleen A. Lane, MSd, and Stephen M. Downs, MD, MSa,b
Author Affiliations
aDepartments of Pediatrics, and
dBiostatistics, Indiana University School of Medicine, Indianapolis, Indiana;
bRegenstrief Institute, Inc, Indianapolis, Indiana; and
cRyan White Center for Pediatric Infectious Disease, Riley Hospital for Children, Indianapolis, Indiana
Abstract
BACKGROUND AND OBJECTIVE: Emphasizing societal benefits of vaccines has been linked to increased vaccination intentions in adults. It is unclear if this pattern holds for parents deciding whether to vaccinate their children. The objective was to determine whether emphasizing the benefits of measles-mumps-rubella (MMR) vaccination directly to the vaccine recipient or to society differentially impacts parents’ vaccine intentions for their infants.
METHODS: In a national online survey, parents (N = 802) of infants RESULTS: Compared with the VIS-only group (mean intention = 86.3), parents reported increased vaccine intentions for their infants when receiving additional information emphasizing the MMR vaccine’s benefits either directly to the child (mean intention = 91.6, P = .01) or to both the child and society (mean intention = 90.8, P = .03). Emphasizing the MMR vaccine’s benefits only to society did not increase intentions (mean intention = 86.4, P = .97).
CONCLUSIONS: We did not see increases in parents’ MMR vaccine intentions for their infants when societal benefits were emphasized without mention of benefits directly to the child. This finding suggests that providers should emphasize benefits directly to the child. Mentioning societal benefits seems to neither add value to, nor interfere with, information highlighting benefits directly to the child.

Article
Impact of a Pertussis Epidemic on Infant Vaccination in Washington State
Elizabeth R. Wolf, MD, MPHa,b, Douglas Opel, MD, MPHa,b, M. Patricia DeHart, ScDc,
Jodi Warren, BSNd, and Ali Rowhani-Rahbar, MD, MPH, PhDe
Author Affiliations
aSeattle Children’s Research Institute, Seattle, Washington;
Departments of bPediatrics, and
eEpidemiology, University of Washington, Seattle, Washington;
cWashington State Department of Health, Olympia, Washington; and
dWashington State Immunization Information System, Seattle, Washington
Abstract
BACKGROUND AND OBJECTIVES: Washington State experienced a pertussis epidemic from October 2011 to December 2012. There was wide variation in incidence by county. The objectives of this study were to determine how the pertussis epidemic affected infant vaccination in Washington State and whether the incidence in counties modified this effect.
METHODS: We conducted an ecologic before–after study to compare the proportion of infants up to date (UTD) with a pertussis-containing vaccine at time points before (September 30, 2011), during (September 30, 2012), and after (September 30, 2013) the epidemic. Children aged 3 to 8 months enrolled in the Washington State Immunization Information System with documented county of residence were included. UTD status was determined as ≥1, ≥2, or ≥3 doses of a pertussis-containing vaccine at ages 3, 5, and 7 months, respectively. Generalized linear models with extension to the binomial family and clustered robust standard errors were used to examine differences in the proportion of UTD infants between preepidemic and either epidemic or postepidemic points. The potential modifying effect of pertussis incidence by county was examined.
RESULTS: We found no significant difference in statewide UTD status with a pertussis-containing vaccine between preepidemic and either epidemic (absolute difference 2.1%; 95% confidence interval, −1.6 to 5.9) or postepidemic (absolute difference 0.2%; 95% confidence interval, −4.0 to 4.5) time points. There was no significant modification by county pertussis incidence. There was wide variation in the absolute difference in UTD status across counties.
CONCLUSIONS: A statewide pertussis epidemic does not appear to have significantly changed the proportion of infants who were UTD with a pertussis-containing vaccine.

Commentary
Pertussis Resurgence and Vaccine Uptake: Implications for Reducing Vaccine Hesitancy
Jessica E. Atwell, MPHa,b and Daniel A. Salmon, PhD, MPHa,b,c,d
Author Affiliations
aGlobal Disease Epidemiology and Control,
cHealth, Behavior, and Society,
bDepartment of International Health, and
dInstitute for Vaccine Safety, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
Previously controlled vaccine preventable diseases (VPDs) are in resurgence.1,2 To date, there have been 477 confirmed measles cases in the United States in 2014, the most in 18 years.3 In 2013 there were ∼25 000 pertussis cases in the United States. Vaccine refusal has been associated with outbreaks of invasive Haemophilus influenzae type b disease,4 varicella,5 pneumococcal disease,6 measles,7 and pertussis.8–12
Even while national and statewide immunization coverage remain high, rates of parents who refuse vaccines via nonmedical exemptions (NMEs) to school immunization requirements have been increasing.13,14 Furthermore, NMEs cluster geographically,9,10 leading to critical reductions in herd immunity and a perfect storm for sustained transmission, outbreaks, and increased risk of VPDs to both unvaccinated and vaccinated individuals.7,9,10,15,16
Beyond active refusal, many parents are delaying vaccines and using “alternative immunization schedules” to spread out the number of vaccines given per visit or in infancy.17 Seventy-seven percent of parents of young children report concerns about vaccines, such as the number of vaccines or doses given simultaneously or before age two, what ingredients are contained in vaccines, or if there are associations with adverse outcomes such as autism and other chronic diseases.18 Some have gone so far as to identify a “vaccine crisis in confidence…”19–21

PLoS Medicine
(Accessed 6 September 2014)
http://www.plosmedicine.org/

Oral Cholera Vaccine Development and Use in Vietnam
Dang Duc Anh, Anna Lena Lopez mail, Hung Thi Mai Tran, Nguyen Van Cuong, Vu Dinh Thiem,
Mohammad Ali, Jacqueline L. Deen, Lorenz von Seidlein, David A. Sack
Published: September 02, 2014
DOI: 10.1371/journal.pmed.1001712
Summary Points
:: Vietnam is the first and only country in the world to regularly use oral cholera vaccines (OCVs) in their cholera control program.
:: From 1998 to 2012, more than 10.9 million doses of the locally produced OCV were deployed in the country through its public health system.
:: We present an overview of cholera epidemiology in Vietnam and the development and deployment of the OCV.
:: Since 1997, the number of cholera cases in Vietnam has declined, in association with increased OCV use as well as improvements in socioeconomic and water and sanitation conditions. It is not possible to establish the relative contributions of each of these to the reduction in cholera rates.
:: Hue, the only province to use OCVs consistently every year, has not reported any cholera case since 2003.
:: As WHO organizes a stockpile of OCV for use in emergencies and recommends the use of OCVs together with traditional means of control, the experience in Vietnam will be helpful to other at-risk countries as they look towards adopting the vaccine in their cholera control programs.

Cholera: A Continuing Public Health Threat
The emergence of cholera in Haiti highlighted the difficulties in containing cholera outbreaks with only safe water, sanitation, hygiene, and appropriate case management. In less developed settings where cholera occurs, these basic needs are often not met or are rapidly overwhelmed during man-made or natural disasters. Prior to the Haitian outbreak, countries in Africa and Asia had borne most of the cholera burden, with an estimated 1.4 billion people at risk, 2.8 million cases, and 100,000 to 200,000 deaths occurring annually [1],[2]; however, because of difficulties in surveillance and differences in reporting systems, only 245,393 cases with 3,034 deaths were reported to the World Health Organization (WHO) in 2012 [1]. This figure does not include the large number of acute watery diarrhoea cases reported in Asia, of which a significant proportion is caused by Vibrio cholerae. As cholera continues to be a global public health problem, in 2011, the World Health Assembly called for an integrated and comprehensive approach to cholera control, including oral cholera vaccines (OCVs) [3].
OCVs have been available for more than 20 years, but public health use has been limited. Vietnam is the first and currently the only country in the world to use killed OCVs routinely in its public health program. This article describes the cholera problem in Vietnam and how an oral cholera vaccine was developed and used as a component of a public health strategy against the disease…

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

International Health
Volume 6, Issue 3 Pp. 160-161.
Vaccination in humanitarian crises: satisficing should no longer suffice
Rebecca F. Graisa, and Aitana Juan-Ginera,b
Author Affiliations
aEpicentre, 8 rue Saint Sabin, Paris 75011, France
bInternational Vaccination Working Group, Médecins Sans Frontières, Paris, France
Received May 22, 2014.
Revision received July 9, 2014.
Accepted July 9, 2014. doi: 10.1093/inthealth/ihu051
Abstract
There are more possible vaccination interventions to mitigate the adverse health consequences of populations in crises than ever before, but recent reviews suggest delivering these vaccines has been fraught with difficulty. The decision to implement vaccination interventions in crises remains, more often than not, an exercise in satisficing. The sparse credible epidemiologic and effectiveness data in populations affected by crises contributes greatly to decision-making difficulty, as do the limits of vaccine presentations, formulations and storage. Political considerations and lack of decision-making guidance contribute further. Moving forward requires sound effectiveness studies to help ensure that decision-making is based to the degree possible on substance.

Journal of Medical Internet Research
2014;16(9):e198)
Original Paper
Estimation of Geographic Variation in Human Papillomavirus Vaccine Uptake in Men and Women: An Online Survey Using Facebook Recruitment
Erik J Nelson1, MPH, PhD; John Hughes2, PhD; J Michael Oakes1, PhD; James S Pankow1, MPH, PhD; Shalini L Kulasingam1, PhD
1School of Public Health, Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, MN, United States
2School of Public Health, Division of Biostatistics, University of Minnesota, Minneapolis, MN, United States
ABSTRACT
Background: Federally funded surveys of human papillomavirus (HPV) vaccine uptake are important for pinpointing geographically based health disparities. Although national and state level data are available, local (ie, county and postal code level) data are not due to small sample sizes, confidentiality concerns, and cost. Local level HPV vaccine uptake data may be feasible to obtain by targeting specific geographic areas through social media advertising and recruitment strategies, in combination with online surveys.
Objective: Our goal was to use Facebook-based recruitment and online surveys to estimate local variation in HPV vaccine uptake among young men and women in Minnesota.
Methods: From November 2012 to January 2013, men and women were recruited via a targeted Facebook advertisement campaign to complete an online survey about HPV vaccination practices. The Facebook advertisements were targeted to recruit men and women by location (25 mile radius of Minneapolis, Minnesota, United States), age (18-30 years), and language (English).
Results: Of the 2079 men and women who responded to the Facebook advertisements and visited the study website, 1003 (48.2%) enrolled in the study and completed the survey. The average advertising cost per completed survey was US $1.36. Among those who reported their postal code, 90.6% (881/972) of the participants lived within the previously defined geographic study area. Receipt of 1 dose or more of HPV vaccine was reported by 65.6% women (351/535), and 13.0% (45/347) of men. These results differ from previously reported Minnesota state level estimates (53.8% for young women and 20.8% for young men) and from national estimates (34.5% for women and 2.3% for men).
Conclusions: This study shows that recruiting a representative sample of young men and women based on county and postal code location to complete a survey on HPV vaccination uptake via the Internet is a cost-effective and feasible strategy. This study also highlights the need for local estimates to assess the variation in HPV vaccine uptake, as these estimates differ considerably from those obtained using survey data that are aggregated to the state or federal level.

British Journal of Cancer
(2 September 2014) | doi:10.1038/bjc.2014.479
Reduction of low-and high-grade cervical abnormalities associated with high uptake of the HPV bivalent vaccine in Scotland
K G J Pollock, K Kavanagh, A Potts, J Love, K Cuschieri, H Cubie, C Robertson, M Cruickshank, T J Palmer, S Nicoll and M Donaghy
Abstract
Background:
In Scotland, a national HPV immunisation programme began in 2008 for 12- to 13-year olds, with a catch-up campaign from 2008 to 2011 for those under the age of 18. To monitor the impact of HPV immunisation on cervical disease at the population level, a programme of national surveillance was established.
Methods:
We analysed colposcopy data from a cohort of women born between 1988 and 1992 who entered the Scottish Cervical Screening Programme (SCSP) and were aged 20–21 in 2008–2012.
Results:
By linking datasets from the SCSP and colposcopy services, we observed a significant reduction in diagnoses of cervical intraepithelial neoplasia 1 (CIN 1; RR 0.71, 95% CI 0.58 to 0.87; P=0.0008), CIN 2 (RR 0.5, 95% CI 0.4 to 0.63; P<0.0001) and CIN 3 (RR 0.45, 95% CI 0.35 to 0.58; P<0.0001) for women who received three doses of vaccine compared with unvaccinated women.
Conclusions:
To our knowledge, this is one of the first studies to show a reduction of low- and high-grade CIN associated with high uptake of the HPV bivalent vaccine at the population level. These data are very encouraging for countries that have achieved high HPV vaccine uptake.

New York Times
http://www.nytimes.com/
Accessed 6 September 2014

Cuts at W.H.O. Hurt Response to Ebola Crisis
SHERI FINK
3 September 2014

With treatment centers overflowing, and alarmingly little being done to stop Ebola from sweeping through West African villages and towns, Dr. Joanne Liu, the president of Doctors Without Borders, knew that the epidemic had spun out of control.

The only person she could think of with the authority to intensify the global effort was Dr. Margaret Chan, the director general of the World Health Organization, which has a long history of fighting outbreaks. If the W.H.O., the main United Nations health agency, could not quickly muster an army of experts and health workers to combat an outbreak overtaking some of the world’s poorest countries, then what entity in the world would do it?

“I wish I could do that,” Dr. Chan said when the two met at the W.H.O.’s headquarters in Geneva this summer, months after the outbreak burgeoned in a Guinean rain forest and spilled into packed capital cities. The W.H.O. simply did not have the staffing or ability to flood the Ebola zone with help, said Dr. Chan, who recounted the conversation. It was a fantasy, she argued, to think of the W.H.O. as a first responder ready to lead the fight against deadly outbreaks around the world.

The Ebola epidemic has exposed gaping holes in the ability to tackle outbreaks in an increasingly interconnected world, where diseases can quickly spread from remote villages to cities housing millions of people.

The W.H.O., the United Nations agency assigned in its constitution to direct international health efforts, tackle epidemics and help in emergencies, has been badly weakened by budget cuts in recent years, hobbling its ability to respond in parts of the world that need it most. Its outbreak and emergency response units have been slashed, veterans who led previous fights against Ebola and other diseases have left, and scores of positions have been eliminated — precisely the kind of people and efforts that might have helped blunt the outbreak in West Africa before it ballooned into the worst Ebola epidemic ever recorded…

Washington Post
http://www.washingtonpost.com/
Accessed 6 September 2014

What’s missing in the Ebola fight in West Africa: Jim Yong Kim and Paul Farmer
By Jim Yong Kim and Paul Farmer August 31
Jim Yong Kim is president of the World Bank. Paul Farmer is the Kolokotrones University professor at Harvard University. Farmer and Kim, who are infectious disease physicians, co-founded the nonprofit organization Partners in Health.

If the Ebola epidemic devastating the countries of Guinea, Liberia and Sierra Leone had instead struck Washington, New York or Boston, there is no doubt that the health systems in place could contain and then eliminate the disease.

Hospitals would isolate suspected cases. Health workers would be outfitted with proper protective clothing and equipment. Doctors and nurses would administer effective supportive care, including comprehensive management of dehydration, impaired kidney and liver function, bleeding disorders and electrolyte disturbance. Labs would dispose of hazardous materials properly. And a public health command center would both direct the response and communicate clearly to the public about the outbreak.
Ebola is spread by direct physical contact with infected bodily fluids, making it less transmissible than an airborne disease such as tuberculosis. A functioning health system can stop Ebola transmission and, we believe, save the lives of a majority of those who are afflicted.

So why isn’t this happening in West Africa, where more than 1,500 people have already died?

As international groups pull staff from the three countries, airlines suspend commercial flights and neighboring countries close their borders, some have argued that it will be next to impossible to contain the outbreak — that public health systems are too weak, the cost of providing effective care too high and health workers too scarce.

But Ebola has been stopped in every other outbreak to date, and it can be stopped in West Africa, too. The crisis we are watching unfold derives less from the virus itself and more from deadly and misinformed biases that have led to a disastrously inadequate response to the outbreak.

These biases, tragically, live on, despite evidence that disproves them again and again.

Just 15 years ago, Western experts said confidently that there was little that rich countries could do to stop the global AIDS crisis, which was killing millions of people in Africa and elsewhere.

Today, thanks to leadership and advocacy from President George W. Bush, a bipartisan coalition of members in Congress, courageous faith-based organizations and U.S. government researchers such as Tony Fauci and Mark Dybul, more than 10 million Africans are getting life-saving treatment.

The take-no-action argument has been used over the years as an excuse not to mount an effort to control drug-resistant tuberculosis, malaria and many other diseases that afflict primarily the poor.

But the reality is this: The Ebola crisis today is a reflection of long-standing and growing inequalities of access to basic health care. Guinea, Liberia and Sierra Leone do not have the staff, stuff and systems required to halt the outbreak on their own. According to its ministry of health, before the outbreak Liberia had just 50 doctors working in public health facilities serving a population of 4.3 million.

To halt this epidemic, we need an emergency response that is equal to the challenge. We need international organizations and wealthy countries that possess the required resources and knowledge to step forward and partner with West African governments to mount a serious, coordinated response as laid out in the World Health Organization’s Ebola response roadmap.

Many are dying needlessly. Historically, in the absence of effective care, common acute infections have been characterized by high mortality rates. What’s happening with Ebola in Africa has been no different.

A 1967 outbreak in Germany and Yugoslavia of Marburg hemorrhagic fever — a disease similar to Ebola — had a 23 percent fatality rate. Compare that with an 86 percent rate for cases across sub-Saharan Africa in the years since. The difference is that Germany and Yugoslavia had functioning health systems and the resources to treat patients effectively. The West African countries coping with Ebola today have neither.

With a strong public health response led by the United Nations, the World Health Organization, the United States, Britain, France and other wealthy nations, the virus could be contained and the fatality rate — which, based on the most conservative estimates, exceeds 50 percent in the present outbreak — would drop dramatically, perhaps to below 20 percent.

We are at a dangerous moment in these three West African countries, all fragile states that have had strong economic growth in recent years after decades of wars and poor governance. It would be scandalous to let this crisis escalate further when we have the knowledge, tools and resources to stop it. Tens of thousands of lives, the future of the region and hard-won economic and health gains for millions hang in the balance.