Vaccines and Global Health: The Week in Review 29 November 2014

Vaccines and Global Health: The Week in Review is a weekly digest  summarizing news, events, announcements, peer-reviewed articles and research in the global vaccine ethics and policy space. Content is aggregated from key governmental, NGO, international organization and industry sources, key peer-reviewed journals, and other media channels. This summary proceeds from the broad base of themes and issues monitored by the Center for Vaccine Ethics & Policy in its work: it is not intended to be exhaustive in its coverage. You are viewing the blog version of our weekly digest, typically comprised of between 30 and 40 posts below all dated with the current issue date

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pdf version A pdf of the current issue is available here: Vaccines and Global Health_The Week in Review_29 November 2014

blog edition: comprised of the approx. 35+ entries posted below on this date.

Twitter:  Readers can also follow developments on twitter: @vaxethicspolicy.
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David R. Curry, MS
Executive Director
Center for Vaccine Ethics and Policy
a program of the
– Division of Medical Ethics, NYU Medical School
– The Wistar Institute Vaccine Center
– Children’s Hospital of Philadelphia Vaccine Education Center
Associate Faculty, Division of Medical Ethics, NYU Medical School

Editor’s Note:
We continue to lead this weekly digest with extensive coverage of polio and EVD – both designated as Public Health Emergencies of International Concern (PHEIC). Please note that Ebola/EVD content is threaded through this edition.

See Journal Watch [Nature, NEJM, PLoS Currents: Outbreaks, Science +) and Media Watch.

POLIO [to 29 November 2014]

POLIO [to 29 November 2014]
Public Health Emergency of International Concern (PHEIC)

GPEI Update: Polio this week – As of 26 November 2014
Global Polio Eradication Initiative
[Editor’s Excerpt and text bolding]
Full report: http://www.polioeradication.org/Dataandmonitoring/Poliothisweek.aspx
:: In response to the outbreak of circulating vaccine-derived poliovirus (cVDPV) in South Sudan, over 19,000 children were vaccinated last week in Bentiu Poc, where the two cases were reported. Outbreak response plans are in place to hold three rounds of supplementary immunization activities (SIAs) in high risk areas to stop transmission of the virus.
:: In the north of Madagascar, SIAs are planned for December in response to the outbreak of cVDPV. National Immunization Days are planned for January. The aim is to boost immunity across the country against all strains of poliovirus.
:: A planning meeting was held in Pakistan last week to develop a strategy for the low poliovirus transmission season, December 2014 to May 2015, using lessons learned from high risk areas. There is national consensus for the low season plan, including increased support from the Pakistan law enforcement and security services. The structure of the planned Emergency Operations Centre for polio eradication at the Federal and Provincial levels is being finalized.
:: For the first time ever, only 1 case of wild poliovirus has been reported in Africa in the last 4 months, despite the high season for polio transmission. The most recent case had onset of paralysis on 11 August in Somalia.
Afghanistan
:: One new wild poliovirus type 1 (WPV1) case was reported in the past week in Afghanistan in Kandahar district, with onset of paralysis on the 5 November. The total number of WPV1 cases for 2014 in Afghanistan is now 21.
Pakistan
:: Fourteen new wild poliovirus type 1 (WPV1) cases were reported in the past week. Five were from the Federally Administered Tribal Areas (FATA) (2 in Khyber Agency, 2 in South Waziristan Agency and 1 in Frontier Region Bannu); 3 from Balochistan province (1 in Quetta district, 1 in Killa Abdullah district and 1 in Khuzdar district, which has not previously been infected in 2014); 5 from Khyber Pakhtunkhwa province (4 from Peshawar district and 1 from Karak district, which has not reported cases so far in 2014); and 1 from Karachi Site town in Sindh province. The total number of WPV1 cases in Pakistan in 2014 is now 260, compared to 64 at this time last year. The most recent WPV1 case had onset of paralysis on 11 November, from Quetta district, Balochistan.
:: Immunization activities are continuing with particular focus on known high-risk areas, in particular newly opened previously inaccessible areas of FATA. At exit and entry points of conflict-affected areas that are still inaccessible during polio campaigns, 100 permanent vaccination points are being used to reach internally displaced families as they move in and out of the inaccessible area. Over 1 million people have been vaccinated in the past few months at transit points and in host communities, including over 850,000 children under 10 years old.
Horn of Africa
:: Following confirmation of two cases of circulating vaccine derived poliovirus type 2 (cVDPV2) in a refugee camp area of Unity state, South Sudan, outbreak response plans are in place to hold rounds of supplementary immunization activities (SIAs) in high risk areas. Over 19,000 children were vaccinated on 13 – 15 November in Bentiu Poc where the 2 cases were reported in September. The objective is to rapidly stop the cVDPV2 in the infected area, while further boosting immunity to type 1 wild poliovirus and to minimize the risk of renewed outbreaks following virus re-introduction from infected countries and areas.
West Africa
:: The Ebola crisis in western Africa is impacting on the implementation or polio eradication activities in Liberia, Guinea and Sierra Leone. Supplementary immunization activities in these countries have been postponed and the quality of acute flaccid paralysis surveillance has markedly decreased this year.
:: Even as polio programme staff across West Africa support efforts to control the Ebola outbreak affecting the region, efforts are being made in those countries not affected by Ebola to vaccinate children against polio.
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The Weekly Epidemiological Record (WER) for 28 November 2014, vol. 89, 48 (pp. 529–544) includes:
:: Performance of acute flaccid paralysis (AFP) surveillance and incidence of poliomyelitis, 2014 :: Review of the 2014 influenza season in the southern hemisphere
http://www.who.int/entity/wer/2014/wer8948.pdf?ua=1
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Polio Crisis Deepens in Pakistan, With New Cases and Killings
By DECLAN WALSH
New York Times
NOV. 26, 2014
LONDON — Pakistan’s polio crisis has reached new depths this year, health officials say, intensified by a deadly mix of ruthless militant violence, large-scale refugee displacement and political chaos that has cemented the country’s role as the central global incubator of a disease that other conflict-torn countries have managed to hold in check.

The number of new Pakistani polio cases this year hit 260 this week, four times as many as at the same point last year, making a mockery of promises by Prime Minister Nawaz Sharif and other politicians from across the spectrum to halt the galloping progress of the disease.

Even as domestic vaccination drives and extensive international aid have put huge numbers of anti-polio workers in the field, Pakistan’s militants have seen it as an opportunity to strike at symbols of authority, portraying the workers as agents in a sinister Western plot. On Wednesday, four more health workers were gunned down, bringing the death toll among anti-polio workers to 65 since the first targeted attack in December 2012.

The attackers, who struck in Quetta, the capital of Baluchistan Province, opened fire on the workers’ vehicle after demanding to know if they were involved in the anti-polio campaign. Television footage showed emergency workers carrying three other wounded workers from a van that contained abandoned slippers and blood-smeared iceboxes with polio vaccines.

The wounded, and three of the dead, were women, whose greater access to private households in conservative rural areas of Pakistan have put them in high demand as health workers.

The attackers escaped, and there was no claim of responsibility, although a Taliban splinter group said it had carried out a gun attack near Peshawar on Monday that wounded a polio worker and a student. Polio vaccinations are “dangerous to health and against Islam,” a spokesman for that group, Jamaat-e-Ahrar, said after the attack, echoing longstanding claims that Western countries are using immunization to sterilize Muslim children…

NIAID/GSK experimental Ebola vaccine appears safe, prompts immune response

NIH Watch [to 29 November 2014]
http://www.nih.gov/news/index.html

:: NIAID/GSK experimental Ebola vaccine appears safe, prompts immune response
Results from NIH Phase 1 clinical trial support accelerated development of candidate vaccine
November 28, 2014
An experimental vaccine to prevent Ebola virus disease was well-tolerated and produced immune system responses in all 20 healthy adults who received it in a phase 1 clinical trial conducted by researchers from the National Institutes of Health. The candidate vaccine, which was co-developed by the NIH’s National Institute of Allergy and Infectious Diseases (NIAID) and GlaxoSmithKline (GSK), was tested at the NIH Clinical Center in Bethesda, Maryland. The interim results are reported online in advance of print in the New England Journal of Medicine.

“The unprecedented scale of the current Ebola outbreak in West Africa has intensified efforts to develop safe and effective vaccines, which may play a role in bringing this epidemic to an end and undoubtedly will be critically important in preventing future large outbreaks,” said NIAID Director Anthony S. Fauci, M.D. “Based on these positive results from the first human trial of this candidate vaccine, we are continuing our accelerated plan for larger trials to determine if the vaccine is efficacious in preventing Ebola infection.”

The candidate NIAID/GSK Ebola vaccine was developed collaboratively by scientists at the NIAID Vaccine Research Center (VRC) and at Okairos, a biotechnology company acquired by GSK. It contains segments of Ebola virus genetic material from two virus species, Sudan and Zaire. The Ebola virus genetic material is delivered by a carrier virus (chimpanzee-derived adenovirus 3 or cAd 3) that causes a common cold in chimpanzees but causes no illness in humans. The candidate vaccine does not contain Ebola virus and cannot cause Ebola virus disease.

The trial enrolled volunteers between the ages of 18 and 50. Ten volunteers received an intramuscular injection of vaccine at a lower dose and 10 received the same vaccine at a higher dose. At two weeks and four weeks following vaccination, the researchers tested the volunteers’ blood to determine if anti-Ebola antibodies were generated. All 20 volunteers developed such antibodies within four weeks of receiving the vaccine. Antibody levels were higher in those who received the higher dose vaccine.

The investigators also analyzed the research participants’ blood to learn whether the vaccine prompted production of immune system cells called T cells. A recent study by VRC scientist Nancy J. Sullivan, Ph.D., and colleagues showed that non-human primates inoculated with the candidate NIAID/GSK vaccine developed both antibody and T-cell responses, and that these were sufficient to protect vaccinated animals from disease when they were later exposed to high levels of Ebola virus.

The experimental NIAID/GSK vaccine did induce a T-cell response in many of the volunteers, including production of CD8 T cells, which may be an important part of immune protection against Ebola viruses. Four weeks after vaccination, CD8 T cells were detected in two volunteers who had received the lower dose vaccine and in seven of those who had received the higher dose.

“We know from previous studies in non-human primates that CD8 T cells played a crucial role in protecting animals that had been vaccinated with this NIAID/GSK vaccine and then exposed to otherwise lethal amounts of Ebola virus,” said Julie E. Ledgerwood, D.O., a VRC researcher and the trial’s principal investigator. “The size and quality of the CD8 T cell response we saw in this trial are similar to that observed in non-human primates vaccinated with the candidate vaccine.”

There were no serious adverse effects observed in any of the volunteers, although two people who received the higher dose vaccine did develop a briefly lasting fever within a day of vaccination…

Merck and NewLink Genetics Enter Into Licensing and Collaboration Agreement for Investigational Ebola Vaccine

Industry Watch [to 29 November 2014]
Selected media releases and other content from industry.

:: Merck and NewLink Genetics Enter Into Licensing and Collaboration Agreement for Investigational Ebola Vaccine
Clinical Development, Manufacturing Expertise, and Scale Critical to Success
November 24, 2014
WHITEHOUSE STATION, N.J. & AMES, IA–(BUSINESS WIRE)–Merck (NYSE:MRK), known as MSD outside the United States and Canada, and NewLink Genetics Corporation (NASDAQ:NLNK), announced today that they have entered into an exclusive worldwide license agreement to research, develop, manufacture, and distribute NewLink’s investigational rVSV-EBOV (Ebola) vaccine candidate.

The vaccine candidate, originally developed by the Public Health Agency of Canada (PHAC), is currently being evaluated in Phase I clinical trials. Pending the results of ongoing Phase I trials the U.S. National Institutes of Health (NIH) has announced plans to initiate, in early 2015, a large randomized, controlled Phase III study to evaluate the safety and efficacy of the rVSV-EBOV vaccine and another investigational Ebola vaccine co-developed by the National Institute of Allergy and Infectious Diseases (NIAID) and GlaxoSmithKline.

“Effective Ebola vaccines will be a critical component of comprehensive prevention and control measures for people at risk of Ebola virus infection and to stem future outbreaks globally,” said Dr. Julie Gerberding, president of Merck Vaccines. “Merck is committed to applying our vaccine expertise to address important global health needs and, through our collaboration with NewLink, we hope to advance the public health response to this urgent international health priority.”

According to Dr. Charles Link, chairman and chief executive officer of NewLink Genetics, “Merck’s vaccine development expertise, commercial leadership and history of successful strategic alliances make it an ideal partner to expedite the development of rVSV-EBOV and, if demonstrated to be efficacious and well-tolerated, to make it available to individuals and communities at risk of Ebola virus infection around the world.”

Under the terms of the agreement, Merck will be granted the exclusive rights to the rVSV-EBOV vaccine candidate as well as any follow-on products. The vaccine candidate is under an exclusive licensing arrangement with a wholly-owned subsidiary of NewLink Genetics. Under these license arrangements, the PHAC retains non-commercial rights pertaining to the vaccine candidate.

Phase I clinical trials of the rVSV-EBOV vaccine are now underway at the Walter Reed Army Institute of Research and the NIAID at the NIH. Additional Phase I studies are underway or planned to begin in the near future at clinical research centers in Switzerland, Germany, Kenya, and Gabon in a World Health Organization-coordinated effort, and in Canada by the Canadian Immunization Research Network.

“This vaccine is the result of years of hard work and innovation by Canadian scientists. We are pleased that this new alliance coupled with the clinical trials currently underway will further strengthen the possibility that the vaccine will make a difference in the global response to the Ebola outbreak,” said Canada’s Minister of Health, Rona Ambrose.

About rVSV Vaccine Platform
This vaccine platform is based on an attenuated strain of vesicular stomatitis virus that has been modified to express an Ebola virus protein that plays an essential role in establishing virus infection. The rVSV-EBOV vaccine was created by scientists at the Public Health Agency of Canada’s National Microbiology Laboratory. A significant portion of the funding for the further development of the vaccine came from the CBRN Research and Technology Initiative, a federal program led by Defence Research and Development Canada. In 2010, the PHAC signed a licensing arrangement with BioProtection Systems (BPS), a wholly-owned subsidiary of NewLink Genetics, as the sole licensee for these vaccines and the underlying technology. BPS has worked with the PHAC to produce clinical trial materials and to move this vaccine candidate into Phase I studies.

WHO: African regulators’ meeting looking to expedite approval of vaccines and therapies for Ebola

WHO: African regulators’ meeting looking to expedite approval of vaccines and therapies for Ebola
November 2014
pdf of slides: http://www.who.int/entity/immunization_standards/vaccine_regulation/avaref_meeting_recommendations_14nov2014.pdf?ua=1

Aiming to make potential Ebola therapies and vaccines available as quickly as possible, the ninth African Vaccine Regulatory Forum (AVAREF), was convened in Pretoria, South Africa, from 3-7 November. The first two days focused on a collaborative mechanism for fast tracking approvals for clinical trials and registration of these (Ebola) products in the affected countries.

The mechanism would cover:
:: Clear pathways and timelines for expedited ethical and regulatory review of clinical trial applications and approval of products;
:: Agreement on timelines and joint safety and efficacy assessments of the new products to fast-track national registration;
:: Endorsement of a panel of safety experts for expedited review of safety data of new products with relevant communication to National Regulatory Authorities (NRAs);
:: Technical assistance from the World Health Organization (WHO) to facilitate these processes.

Following are summary recommendations from this meeting as adapted from a WHO PowerPoint Presentation:

Recommendations: 9th Annual Meeting of the African Vaccine Regulatory Forum (AVAREF)
Pretoria, 3 to 7 November 2014
Background
:: The 9th annual meeting of the African Vaccine Regulatory Forum (AVAREF) was held in Pretoria South Africa, 3 to 7 November 2014
:: The meeting brought together NRAs, EC/IRB, in Africa, Manufacturers, developers, Research Institutions, US-FDA, EMA and BMGF and representatives of NRAs and ethics committees of 20 AVAREF countries
:: Participants reviewed progresses in development of vaccines and medicines for Ebola and other priority diseases

Recommendations to SPONSORS/Manufacturers
1. To immediately release the planned time line for submission of clinical trial applications indicating specific trial sites
2. To hold pre-submission meetings with each participating NRAs, EC and to attend
3. Manufacturers to attend the joint review sessions with their appropriate staff;
4. Manufacturers to file clinical trial applications through the focal persons identified by Heads of NRAs
5. To use the AVAREF clinical trials format for the submissions of clinical trial applications.
6. To include in their submissions all pertinent data that is available at the time of submission
7. To respond swiftly to any query from NRAs or EC/IRB

Recommendations to supporting regulatory authorities (EMA, USFDA, HC)
1. In collaboration with WHO, do everything in their power to share data relevant to clinical trials with the NRAs of participating countries
2. To provide expertise to support NRAs in the joint reviews when requested

Recommendations to WHO
1. To request Heads of regulatory Agencies to:
a) Identify and named senior regulators staff as the agency entry focal points for Ebola
b) Designate named reviewer(s) to participate in a joint review process with the mandate to take regulatory/ethics decisions (reviewers are empowered to take decisions during the joint review meeting).
2. To facilitate a joint review session of the clinical trial applications with a target date of 15 December 2014
3. To involve the NRAs of the Ebola affected countries in the joint review process
4. To provide expertise and develop briefing materials for ethics committees
5. To develop additional briefing materials on the vaccines, and novel clinical trial designs, to assist the national/regional reviews
6. To proactively play the needed broker role in facilitating the interaction between manufacturers and countries
7. Engage with heads of Institutions and research institutions and provide necessary support to countries to develop procedures for accelerated review of Ebola related research.
8. Ensure that ethics committees have the necessary support to follow up approved trials and research studies through site monitoring and having mechanisms to rapidly review amendments etc.

Recommendations to NRAs and EC/IRB
:: To prioritize assessment of clinical trial applications in parallel (regulatory/ethics) to minimize delays and to apply fast-track procedures’
:: To immediately release all national/regional provisions governing the area of clinical trials and highlight aspects favourable to fast track procedures
:: To accept to review all clinical trials submitted by manufacturers/sponsors

Other recommendations from the meeting
To NRAs and EC/IRB
:: To gradually strengthen Regional Harmonization of Technical processes and procedures
:: To emphasize on utilization of joint process implementation
:: To establish mechanisms for strengthening Transparency on processes/procedures and on country/regional performance (including adapting indicators for research ethics systems)
:: To interact actively with AMRH (EAC, SADC, WAHO, OCEAC, UEMOA)

Overall recommendations for the meeting To WHO
:: To support and strengthen collaborative mechanisms among NRAs and ethics committees including capacity building through regular trainings
:: To encourage multiplication of joint implementation of regulatory activities including joint reviews and joint inspections
:: To host and manage the AVAREF virtual community platform developed by Health Canada, the secretariat to implement the transition by end January 2015
:: WHO to provide specific guidelines for evaluation of clinical trial applications for vaccines against TB and HIV, build Capacity to efficiently address other anticipated products in the pipeline Issues to be considered by AVAREF
:: Bio-samples management and regulation at national, regional and global levels
:: WHO to support workshops on ethical issues in relation to bio-repositories

Acknowledgements
:: Recommendations drafted by Dr Nikiema with input from
:: Dr D. Akanmori, Dr V Ahonkhai, Dr A. Bellah, Dr R. Cushman, Dr L. Elmgren, Dr T. M. Lapnet, Dr D. Wood
:: Representatives of GSK, NEW LINK, J&J
:: Botswana, Burkina Faso, Central Africa Republic, Congo, Democratic Republic of Congo, Equatorial Guinea, Gambia, Ghana, Guinea, Kenya, Malawi, Mali, Mozambique, Niger, Nigeria, Senegal, South Africa, Tanzania, Uganda, Zambia and Zimbabwe.

EBOLA/EVD [to 29 November 2014]

EBOLA/EVD [to 29 November 2014]
Public Health Emergency of International Concern (PHEIC); “Threat to international peace and security” (UN Security Council)

WHO: Ebola Virus Disease (EVD)
Situation report – ‘WHO Roadmap’
Editor’s Note: We do not find the regular weekly report posted. However, UNMEER reports that WHO, as of 23 November, projects a total of 15,935 cases have been confirmed in Guinea, Liberia, Mali, Sierra Leone, Spain and the United States and two previously affected countries of Nigeria and Senegal, with 5,689 reported deaths.

Bolstering UN support to the Ebola outbreak
24 November 2014 — Dr Margaret Chan, WHO Director-General, visited an Ebola treatment centre in Bamako, Mali. She met with President Ibrahim Boubacar Keïta, Prime Minister Moussa Mara, and other government leaders to discuss Mali’s ongoing Ebola outbreak response and ways UN organizations could increase their support. The support of the UN and other partners will enhance Mali’s capability to contain transmission from across the border, and respond robustly to any future importation.
Read the feature story

WHO: Ebola situation assessments
:: Mali confirms 2 new cases of Ebola virus disease
25 November 2014

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UNMEER [UN Mission for Ebola Emergency Response] @UNMEER #EbolaResponse
UNMEER’s website is aggregating and presenting content from various sources including its own External Situation Reports, press releases, statements and what it titles “developments.” We present a composite below from the week ending 29 November 2014.

UNMEER site: Press Releases
The world is on the side of those who are involved in this fight’ against Ebola – UN envoy
[Media release excerpt; Editor’s text bolding]
28 November 2014 – The top United Nations officials leading the fight against Ebola have made an appeal for people who possess skills that are “quite rare” to join the global effort, such as those who can provide patient care, undertake contact tracing and analyze how the outbreak is evolving in remote areas of the virus-affected countries, saying that “deploying more people to the districts is our highest priority.”
“These skills are quite rare in our world today because there are not thousands and thousands of people who are really experienced in Ebola and its management,” Dr. David Nabarro, UN Secretary-General Ban Ki-moon’s Special Envoy on Ebola, said in an interview with the Department of Public Information at the headquarters of the UN Mission for Ebola Emergency Response (UNMEER) in Accra, Ghana…
…Dr. Nabarro gave the interview together with UNMEER chief Anthony Banbury, in the lead-up to the 1 December target set by the mission, which aims to try to get 70 per cent of the cases isolated and treated, and 70 per cent of the deceased safely buried within 60 days from the beginning of October to 1 December.
According to the UN World Health Organization (WHO), a total of 15,935 cases have been confirmed in Guinea, Liberia, Mali, Sierra Leone, Spain and the United States and two previously affected countries of Nigeria and Senegal as of 23 November, with 5,689 reported deaths.
Both Dr. Nabarro and Mr. Banbury said progress so far has been uneven but that they were very pleased by what has been achieved in some parts of the affected countries.
“Tremendous progress has been achieved in some areas,” Mr. Banbury said. “That’s thanks to the hard work of the communities themselves but also very much the responders, the national and international responders.”
“Where we’ve been able to put the elements of the response in place, we’ve seen dramatic improvements in the situation,” he said. “So we’re very heartened by that. It shows the strategy works.”
“Unfortunately,” he went on to say, “We’ve not been able to put the elements of the response in place everywhere, and where it’s lacking, we see the significant or very bad situation in many of these communities, and that’s got to be the focus of our efforts going forward: spreading out our geographic response.”
Specifically, Dr. Nabarro said: “We’ve seen these incredible and promising results from Liberia. We’ve seen very good results from parts of Sierra Leone. But there are other parts of Sierra Leone and parts of Guinea where the numbers of cases continue to accelerate day by day.”…

Ebola: December 1 target for response may not be met in some areas of West Africa, UN reports
25 November 2014 – The United Nations World Health Organization (WHO) said today that while Ebola response targets for December 1 in West Africa may be reached in many places, they may not be met in some areas, and confirmed two new cases in Mali amid ramped up efforts to reduce the likelihood that additional cases will be imported from neighbouring Guinea….
In response to a question at the UN press briefing in Geneva, WHO Spokesman Tarik Jasarevic said the December 1 targets for treatment and burials and set by his organization in its response to Ebola would likely be reached in many places, but not in others.
UNMEER head Anthony Banbury had said in media interviews that the mission is already exceeding its 1 December targets in some areas, but that it is almost certain the targets will not be reached in all areas.
The targets are the so-called “70-70-60 plan” which aims to try to get 70 per cent of the cases isolated and treated, and 70 per cent of the deceased safely buried within 60 days from the beginning of October to 1 December…
UNMEER External Situation Reports
UNMEER External Situation Reports are issued daily (excepting Saturday) with content organized under these headings:
– Highlights
– Key Political and Economic Developments
– Human Rights
– Response Efforts and Health
– Logistics
– Outreach and Education
– Resource Mobilisation
– Essential Services
– Upcoming Events
The “Week in Review” will present highly-selected elements of interest from these reports. The full daily report is available as a pdf using the link provided by the report date.

28 November 2014 | UNMEER External Situation Report
Key Points
:: The first human trial of an experimental vaccine has produced promising results.
:: Some traditional leaders in Liberia remain reluctant to participate in response efforts.
:: A total of 15,935 confirmed, probable, and suspected cases of Ebola Virus Disease (EVD) have been reported in 8 countries. There have been 5,689 reported deaths.
Key Political and Economic Developments
1. WHO needs reform to prevent a recurrence of crises such as West Africa’s Ebola outbreak, former Australian Prime Minister Kevin Rudd said on 27 November. Rudd is leading a two-year study to suggest ways to improve the effectiveness of the UN system and other global bodies, which are often deadlocked by disagreements between states or hamstrung by their internal bureaucracy. Rudd said he was seeking practical recommendations to improve the system’s effectiveness, adding he thought WHO suffered from a “systemic problem” in the way power was shared between its central organization and regional branches. “If you do not want this sort of thing to repeat itself then a substantive reform would lie in sufficiently empowering WHO globally to act globally on threats to global public health,” Rudd said in Geneva after briefing diplomats.
Response Efforts and Health
4. On Tuesday 25 November a national consultation took place in Monrovia about the payment of wages to EVD response workers. The meeting was co-chaired by UNDP and the Ministry of Health and Social Welfare. The main challenge that emerged from the meeting was the absence of any centralised government list of response workers. County visits will be held in the coming days, with the goal of gathering all the information needed to develop a centralized, national database of response workers. A similar consultation was held in Guinea on 26 November, and there it was also agreed that a database of response workers would be set up so all payments can be tracked.
6. UNICEF, along with county health teams, key partners and local communities, is setting up 15 Community Care Centers (CCCs) in EVD hotspots in Liberia. In these CCCs patients can be safely isolated and rapidly treated close to the community. First of its kind, the newly-opened Jene Wonde Rapid Response Center includes triage to separate patients based on the severity of their symptoms, medication to control the symptoms and infection prevention measures such as a strict separation of spaces, personal protective equipment, safe waste disposal and hygiene and sanitation supplies.
Resource Mobilisation
15. The OCHA Ebola Virus Outbreak Overview of Needs and Requirements, now totaling US$ 1.5 billion, has been funded for $ 860 million, which is around 57 percent of the total ask.
16. The Ebola Response Multi-Partner Trust Fund currently has US$ 71.9 million in commitments. In total $ 121 million has been pledged.

27 November 2014 | UNMEER External Situation Report
Key Political and Economic Developments
1. Guinean president Alpha Condé said on Wednesday the use of force could be justified in battling the EVD outbreak in his country. “There are still people who think Ebola is fiction,” Condé told a press conference. “We have an agenda which is to finish with Ebola as soon as possible and in Guinea this is possible,” he added. “If people don’t want to be treated we will use force because we won’t allow the illness to spread despite all our efforts.” The spread of EVD in Guinea has been accompanied by fear and paranoia among some villagers who feel the government and the international community cannot be trusted.
2. The outbreak in Sierra Leone, which has been surging in recent weeks, may have reached its peak and could be on the verge of slowing down, Sierra Leone’s information minister said Wednesday. Speaking on the nearing completion of two British-built treatment centers, minister Alpha Kanu said: “We believe that now that those treatment centers are ready, the transmission of new cases will start reducing. We are at the plateau of the curve and very soon we will have a downward trend, once we have somewhere to take people.” The minister also pleaded for the US to assist in Sierra Leone, and announced that the country would repeat its shutdown of September, when people across the country had to remain at home while medical teams went door to door.
Human Rights
4. In Sierra Leone, UNDP funded and advised the Office of National Security in rolling out new Standard Operational Procedures (SOPs) for 2,000 security forces working at checkpoints and quarantined neighborhoods across the country. Military and police are being trained on how to respect human rights and communicate with courtesy, and have committed to engaging with community leaders in all checkpoints and quarantined areas. The SOPs were developed in close consultation with the Sierra Leone armed forces, police, Ministry of Health and Human Rights Commission. The government of Sierra Leone is using quarantines and checkpoints to halt the spread of EVD, but the methods used have led to tensions between security forces and civilians.
Response Efforts and Health
7. WHO reported Wednesday that Guinea isolates more than 70% of all reported cases of EVD, and has more than 80% of required safe burial teams. Progress has apparently been slower in parts of Liberia and Sierra Leone, although continuing challenges in data collection and analysis preclude firm conclusions across the board. On those countries, WHO reports that the goal of isolating 70% of patients has regrettably not yet been reached in either, although data on isolation is up to 3 weeks out of date. Every EVD-affected district in the three intense-transmission countries has access to a laboratory for case confirmation within 24 hours. WHO also reported that in all three countries more than 80% of contacts associated with known EVD cases are traced, though the low mean number of contacts per case suggests that contact tracing is still a challenge in areas of intense transmission.
8. South Korea announced an agreement with Britain to evacuate South Korean medical workers who may get infected with EVD while working at a British-run ETU in Sierra Leone. Seoul will send 10 medical workers next month to work at the new ETU in Goderich, outside Freetown. Under the agreement, an EU-operated plane will fly any infected South Korean medical worker to an EU hospital for treatment, as if they were an EU citizen. Australia has a similar agreement with Britain.

26 November 2014 | UNMEER External Situation Report
Key Political and Economic Developments
1. Burial workers in the Sierra Leonean city of Kenema have dumped bodies in public after going on strike. The workers reportedly left 15 bodies abandoned at the city’s main hospital, including two at the main entrance. The workers have now been sacked for treating the corpses in a “very, very inhumane” way, an official said.
2. On 24 November, the Liberian finance minister announced a recovery package to tackle the wider impact of EVD in Liberia. The package includes US$ 60 million for the restoration of essential health services, $ 30 million for education, and $ 35 million for food security.
Response Efforts and Health
5. Traditional practices remain a significant obstacle in countering the epidemic, especially in relation to burial practices. UNMEER Field Crisis Managers (FCMs) in Liberia reported several instances of non-compliance related to burial permits, as well as violent reactions towards burial teams. Despite the intensification of social awareness campaigns in Bomi and Grand Capemount counties, contact tracing and reporting remain problematic.
Essential Services
15. At a meeting of the Food Crises Prevention and Management Network (PREGEC), held in Dakar from 18 to 20 November 2014, a special session was dedicated to the impact of EVD on food and nutrition security. FAO, WFP, UNICEF and partners presented a study of the three most affected countries, which showed a decrease of agricultural production and demand, disruption of the functioning of markets, a deterioration of livelihoods, a decline in the purchasing power of households, and a risk of degradation of the nutrition situation due to more difficult access to food and basic social services.

25 November 2014 | UNMEER External Situation Report
Key Political and Economic Developments
1. UNMEER SRSG Anthony Banbury has stated in an interview with Newsweek that the mission is already exceeding its 1 December targets in some areas. He added, though, that it is almost certain the targets will not be reached in all areas. The target was to have 70 percent of patients under treatment and 70 percent of victims buried safely. That target has been achieved in some areas, Banbury said, citing progress in Liberia. But he added that the mission will almost certainly fall short in other areas. In both those cases, the mission will adjust to what the circumstances are on the ground. Of greatest concern are rural parts of Sierra Leone, as well as Makeni in the centre and Port Loko in the northwest. Additional efforts by the international community remain needed.
2. Mali has confirmed a new case of EVD, bringing the number of confirmed cases in the country to eight. The patient has been placed in a treatment center. Six of Mali’s eight patients have died. The other confirmed case has also been isolated and is receiving treatment. Officials are monitoring 271 people in a bid to contain the disease.
Human Rights
5. According to WHO, in Kourémalé (Siguiri prefecture, Guinea), a village on the Guinea-Mali border, members of the local community have threatened teams of contact tracers who arrived to follow up on recent EVD cases traced to the unsafe burial of the local imam who died of EVD in late October. Whereas the Mali side of the border today has a functioning isolation/treatment centre, active surveillance in place and no community resistance, there is no such center on the Guinean side. The latter also has only limited surveillance and is experiencing serious community resistance.
6. According to OHCHR, people in Koropara sub-prefecture (Nzérékoré prefecture) threatened to chase away the sub-prefect and health workers after three patients were transferred to Guéckédou ETC and died thereafter. Families of the victims accuse the local authorities of selling their relatives to the Red Cross. Lack of feedback related to the fate of patients at the ETC is one the causes. Red Cross teams in Nzérékoré said they would not operate in Koropara until a sustainable solution is found for security reasons.
Response Efforts and Health
7. The government of Liberia has completed acquisition of a plot of land to be used as a national cemetery. This is a critical step towards a safe burials system that doesn’t require the highly unpopular practice of cremation. A survey showed that throughout October, most of the bodies handled by burial teams came from ETUs (85%). 14.7% came from communities and 0.3% were found abandoned. The survey also indicated that secret burials are on the decline.
8. In Guinea, EVD is spreading in the north up to the border with Mali, an area with no functioning EVD treatment centres or transit centres. The prefecture of Siguiri has seen a resurgence of cases, many of which are related to the unsafe burial at the end of October of a local imam infected with EVD. There is also active transmission in the areas of Kankan and Kouroussa. Meanwhile, the newly opened 40-bed Ebola Treatment Centre (ETC) in Macenta, Guinea, had already surpassed its capacity, with 22 confirmed cases and 19 suspected cases. The ETC in Guéckédou has also had to turn away patients in recent days due to capacity constraints.
9. UNMEER Guinea reports that community reticence in many areas remains the main obstacle to contact tracing. Reticence is often due to communities being disappointed with the EVD response, for instance because of lacking ambulance services or support to the families (often due to logistic and funding shortcomings). In addition, national contact tracing staff is often not paid or paid very little which creates a lack of incentive.
Logistics
14. The first inter-agency airlift, supported by the Logistics Emergency Team and facilitated by the Logistics Cluster, from Germany’s Cologne Bonn airport to Monrovia is set to depart tomorrow. The flight will transport over 560m3 of cargo (including two vehicles) on behalf of eight organisations.

24 November 2014 | UNMEER External Situation Report
Key Political and Economic Developments
4. On the occasion of the opening of the Kakata ETU, local counterparts emphasized to UNMEER that the EVD response has entered into the second phase, which they described as “hunting the virus”. The officials also mentioned the need to expedite the payment for EVD health workers, as key government personnel are taking jobs with NGOs. Case denial at the family level for fear of quarantine and stigma reportedly also remains present in several communities.
Outreach and Education
16. Following the death in Bamako of an imam from Guinea, UNDP and UNICEF have helped organize a gathering of 35 muslim leaders and local officials in Kankan, Eastern Guinea, where they were trained on how to protect themselves and vowed to encourage people to join the fight against EVD.
17. The NGO International SOS has released a mobile app designed to help share its medical and travel information on EVD. The free app is available on iOS and Android devices. It provides online, instant access to key sections from International SOS’ dedicated EVD website, including maps of the affected areas and the latest updates on the outbreak.
Essential Services
18. EVD has crippled the provision of treatment and care to people living with HIV/AIDS in Liberia, according to health workers and patients. There are an estimated 30,000 people living with HIV in Liberia, according to UNAIDS. Before the EVD outbreak, more than 70 per cent of them had access treatment via 144 HIV/AIDS care centers across the country. But now, due to a shortage of health workers and fear about EVD transmission, more than 60 per cent of these facilities have closed. The National AIDS Control Program (NACP) is now going door to door in Montserrado county to deliver antiretroviral drugs each week or else refer people to mobile treatment centers to fill prescriptions.

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UNDP: Ebola Virus Disease (EVD) Outbreak and Price Dynamics in Guinea, Liberia and Sierra Leone
Ebola, through its impact on prices, is reducing people’s purchasing power and is increasing their vulnerability
UNDP Africa Policy Note, Vol. 1, No. 4, 9 November 2014 12 pages
…Stemming the tide of EVD on future prices is doable. Some of the strategic interventions to achieve this include:
:: In Guinea, Liberia and Sierra Leone, price shocks increase the vulnerability of the poor and
the marginalized communities, especially rural areas experiencing the outbreak. This calls for
a well-targeted social protection for people and communities heavily affected by price hikes.
:: The closure of borders reduces the supply of imported commodities that could compensate
for the shortfall in domestic production. Countries should desist from closing their borders to
avert the inflationary impact of such actions on the epicentre countries.
:: The Governments of these three countries should strategically support local farmers to
prepare for the next planting season to avoid food shortages in 2015 and beyond. This
includes the provision of improved seedlings, fertilizers and finances. It is also important to
address all impediments that make locally produced rice more expensive than imported rice.
:: The ministries of finance and central banks of these countries should effectively coordinate
fiscal and monetary policies to ensure that exchange rates and domestic borrowing do not
distort the price system.
:: Given that EVD affected the planting seasons of these countries, the international
community should scale up support for the provision of food and related items to cushion the
effect of food shortages and the associated price hikes.

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World Bank [to 29 November 2014]
http://www.worldbank.org/en/news/all
World Bank Group to support Cote d’Ivoire’s Health Systems Strengthening and Ebola Preparedness
WASHINGTON, November 25, 2014- The World Bank Group’s Board of Executive Directors today approved a $US70 million International Development Association (IDA)* credit to help Cote d’Ivoire improve deployment and quality of health services in selected regions, with a focus on maternal, newborn and child health and nutrition services.Today’s financing will support the Health Systems Strengthening and Ebola Preparedness project and part of the funds ($10.0 million) is aimed at promoting Cote d’Ivoire’s pro-active measures to prevent the spread of Ebola.Recent political and social crises have taken a heavy toll on the country’s health system. During 2002-2010, most of the health centers were closed in the central and northern part of the country (over 52% of health centers nationally), and only Non-Governmental Organization (NGO) facilities remained open…