The Lancet – Oct 25, 2014

The Lancet
Oct 25, 2014 Volume 384 Number 9953 p1477 – 1548
http://www.thelancet.com/journals/lancet/issue/current

Editorial
National armies for global health?
The Lancet
October, 2014, has seen unprecedented deployment of both US and British military personnel to support the efforts in west Africa against the Ebola crisis. Up to 4000 US troops could be deployed in Liberia as part of Operation United Assistance. The British Army commenced Operation Gritrock with the departure of a medical team on Oct 16 to Sierra Leone. “This unit has been the Vanguard medical regiment for the past 20 months which means we are on high readiness to deploy at short notice to anywhere in the world”, said Lieutenant Colonel Alison McCourt from 22 Field Hospital in Aldershot. This capacity to rapidly assemble highly trained personnel experienced in operating in extreme and dangerous conditions is just one factor that makes the military well suited to respond in such humanitarian crises, along with resources, expertise in logistics, transportation, and command and control.

Although countries like the UK and Australia contribute to humanitarian missions, by far the bulk of global support comes from the USA. Involvement of US military personnel in global health activities has increased substantially during the past decade, according to a report published on Oct 8 by the Center for Strategic and International Studies. The report, entitled Global Health Engagement: Sharpening a Key Tool for the Department of Defense, highlights the key role that the military health system could play in “the nation’s health, diplomacy and development goals”, but also criticises previous activities in global health engagement carried out by the US Department of Defense (DoD).

Much of this criticism focuses on the poor coordination of DoD efforts alongside other civilian agencies, which still provide the vast majority of humanitarian global aid. Before the Ebola effort, DoD spending on global health engagement was estimated at US$600 million, compared with $9 billion from civilian agencies. The report describes an ad-hoc short-term focus, and accuses the DoD’s global health efforts of poor appreciation of local cultural norms, little high-level oversight, and failure to properly assess effectiveness. However, the report acknowledges that since 2010, when a mandate for “promoting global health” was introduced into the US National Security Strategy, substantial developments have occurred in internal organisation, quality control, and inter-agency coordination. Specific examples include the formation of the new military position of DoD’s global health engagement coordinator and efforts to undertake extensive outreach to civilian agencies.

The DoD has also released a report which discusses the increasing demands on the DoD to provide humanitarian assistance as a consequence of climate change. The report 2014 Climate Change Adaptation Roadmap describes climate change as a “threat multiplier”, with the potential to exacerbate existing challenges to US national security. This is the first report from the DoD that acknowledges that climate change-related global extreme weather events are already creating unstable conditions that affect national security, creating demands for more frequent disaster relief because of hunger, poverty, conflict, and population displacement.
The stated aims of the DoD have moved from just protecting the health of US forces and US citizens from security threats to “partnering with other nations to achieve security cooperation and build partner capacity”. But this concept reflects the challenges posed by placing military personnel in sites of public health emergencies: the goals of deployments are in support of military strategy rather than as a purely humanitarian action. The use of the military for humanitarian operations is not militarily, politically, or legally neutral. Peacekeeping with combat troops has often proved to be a complicated arrangement and at times at odds with humanitarian needs and sometimes a precursor to hostility.

The 2007 UN Oslo Guidelines clearly state that military assets should only be used as a last resort in situations where “there is no comparable civilian alternative…to meet a critical humanitarian need”—a position reinforced by AJP-9, NATO’s doctrine on civil military cooperation. This situation is clearly the case with the Ebola epidemic, the scale and severity of which has outstripped the capacity of the humanitarian global health community. But should this involvement challenge the current position on military involvement in humanitarian catastrophes or prompt us to strengthen civilian global health systems?
As the DoD has recognised, the security of one nation’s citizens is inextricably linked to others through both global health and climate change. Therefore, the military seem set to play a greater part in global civilian health in the future. The question is what should this role look like in the 21st century?

Comment
Polio endgame management: focusing on performance with or without inactivated poliovirus vaccine
Kimberly M Thompson
Preview |
In The Lancet, Jacob John and colleagues1 report results from a randomised trial of 450 children from Vellore, India, aged 1–4 years that assessed the effects of giving a dose of inactivated poliovirus vaccine (IPV) to children previously immunised with five or more doses of oral poliovirus vaccine (OPV) at least 6 months before the study. The results confirm that an extra dose of IPV in this population increases serum antibodies.2 The study goes further to show that the IPV dose boosts individual intestinal immunity in OPV-vaccinated children, at least for a short period of time.

Effect of a single inactivated poliovirus vaccine dose on intestinal immunity against poliovirus in children previously given oral vaccine: an open-label, randomised controlled trial
Jacob John MD a *, Sidhartha Giri MD a *, Arun S Karthikeyan MSc a, Miren Iturriza-Gomara PhD a b, Prof Jayaprakash Muliyil DrPH a, Prof Asha Abraham PhD a, Prof Nicholas C Grassly DPhil a c Prof Gagandeep Kang PhD a
Summary
Background
Intestinal immunity induced by oral poliovirus vaccine (OPV) is imperfect and wanes with time, permitting transmission of infection by immunised children. Inactivated poliovirus vaccine (IPV) does not induce an intestinal mucosal immune response, but could boost protection in children who are mucosally primed through previous exposure to OPV. We aimed to assess the effect of IPV on intestinal immunity in children previously vaccinated with OPV.
Methods
We did an open-label, randomised controlled trial in children aged 1—4 years from Chinnallapuram, Vellore, India, who were healthy, had not received IPV before, and had had their last dose of OPV at least 6 months before enrolment. Children were randomly assigned (1:1) to receive 0•5 mL IPV intramuscularly (containing 40, 8, and 32 D antigen units for serotypes 1, 2, and 3) or no vaccine. The randomisation sequence was computer generated with a blocked randomisation procedure with block sizes of ten by an independent statistician. The laboratory staff did blinded assessments. The primary outcome was the proportion of children shedding poliovirus 7 days after a challenge dose of serotype 1 and 3 bivalent OPV (bOPV). A second dose of bOPV was given to children in the no vaccine group to assess intestinal immunity resulting from the first dose. A per-protocol analysis was planned for all children who provided a stool sample at 7 days after bOPV challenge. This trial is registered with Clinical Trials Registry of India, number CTRI/2012/09/003005.
Findings
Between Aug 19, 2013, and Sept 13, 2013, 450 children were enrolled and randomly assigned into study groups. 225 children received IPV and 225 no vaccine. 222 children in the no vaccine group and 224 children in the IPV group had stool samples available for primary analysis 7 days after bOPV challenge. In the IPV group, 27 (12%) children shed serotype 1 poliovirus and 17 (8%) shed serotype 3 poliovirus compared with 43 (19%) and 57 (26%) in the no vaccine group (risk ratio 0•62, 95% CI 0•40—0•97, p=0•0375; 0•30, 0•18—0•49, p<0•0001). No adverse events were related to the study interventions.
Interpretation
The substantial boost in intestinal immunity conferred by a supplementary dose of IPV given to children younger than 5 years who had previously received OPV shows a potential role for this vaccine in immunisation activities to accelerate eradication and prevent outbreaks of poliomyelitis.
Funding

Bill & Melinda Gates Foundation.

Effectiveness of maternal pertussis vaccination in England: an observational study
Gayatri Amirthalingam MFPH a, Nick Andrews PhD b, Helen Campbell MSc a, Sonia Ribeiro BA a, Edna Kara MBBS a, Katherine Donegan PhD d, Norman K Fry PhD c, Prof Elizabeth Miller FRCPath a, Mary Ramsay FFPH a
Summary
Background
In October, 2012, a pertussis vaccination programme for pregnant women was introduced in response to an outbreak across England. We aimed to assess the vaccine effectiveness and the overall effect of the vaccine programme in preventing pertussis in infants.
Methods
We undertook an analysis of laboratory-confirmed cases and hospital admissions for pertussis in infants between Jan 1, 2008, and Sept 30, 2013, using data submitted to Public Health England as part of its enhanced surveillance of pertussis in England, to investigate the effect of the vaccination programme. We calculated vaccine effectiveness by comparing vaccination status for mothers in confirmed cases with estimates of vaccine coverage for the national population of pregnant women, based on data from the Clinical Practice Research Datalink.
Findings
The monthly total of confirmed cases peaked in October, 2012 (1565 cases), and subsequently fell across all age groups. For the first 9 months of 2013 compared with the same period in 2012, the greatest proportionate fall in confirmed cases (328 cases in 2012 vs 72 cases in 2013, −78%, 95% CI −72 to −83) and in hospitalisation admissions (440 admissions in 2012 vs 140 admissions in 2013, −68%, −61 to −74) occurred in infants younger than 3 months, although the incidence remained highest in this age group. Infants younger than 3 months were also the only age group in which there were fewer cases in 2013 than in 2011 (118 cases in 2011 vs 72 cases in 2013), before the resurgence. 26 684 women included in the Clinical Practice Research Datalink had a livebirth between Oct 1, 2012 and Sept 3, 2013; the average vaccine coverage before delivery based on this cohort was 64%. Vaccine effectiveness based on 82 confirmed cases in infants born from Oct 1, 2012, and younger than 3 months at onset was 91% (95% CI 84 to 95). Vaccine effectiveness was 90% (95% CI 82 to 95) when the analysis was restricted to cases in children younger than 2 months.
Interpretation
Our assessment of the programme of pertussis vaccination in pregnancy in England is consistent with high vaccine effectiveness. This effectiveness probably results from protection of infants by both passive antibodies and reduced maternal exposure, and will provide valuable information to international policy makers.
Funding
Public Health England.

Series
Homelessness
The health of homeless people in high-income countries: descriptive epidemiology, health consequences, and clinical and policy recommendations
Seena Fazel, John R Geddes, Margot Kushel

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Stephen W Hwang, Tom Burns