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

.– Request an Email Summary: Vaccines and Global Health : The Week in Review is published as a single email summary, scheduled for release each Saturday evening before midnight (EDT in the U.S.). If you would like to receive the email version, please send your request to david.r.curry@centerforvaccineethicsandpolicy.org.
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– pdf version:  A pdf of the current issue is available here: Vaccines and Global Health_The Week in Review_20 December 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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– Links:  We endeavor to test each link as we incorporate it into any post, but recognize that some links may become “stale” as publications and websites reorganize content over time. We apologize in advance for any links that may not be operative. We believe the contextual information in a given post should allow retrieval, but please contact us as above for assistance if necessary.
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.Vaccines and Global Health: The Week in Review will resume publication on 3 January 2015 following a holiday break.
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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:
The Global Vaccine Action Plan (2011-2020) is the current, overarching framework integrating global immunization strategy, goals and indicators. The GVAP was the product of an extraordinary process – the Decade of Vaccines Collaboration – fueled by hundreds of volunteer experts from across international agencies, governments, INGOs, academia, industry and civil society.

The 2014 technical analysis and evaluation of performance against GVAP’s goals and indicators was recently completed by the GVAP Secretariat, which, in turn, supported an assessment and a set of action recommendations by the WHO SAGE Working Group on GVAP.

This work is captured in three key documents highlighted below, and will be considered by the WHO Executive Board at its January meeting. We recommend downloading and reading this documentation.

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EB136/25 – Global vaccine action plan: Report by the Secretariat
12 December 2014
WHO Executive Board – 136th session
26 January–3 February: Geneva
Meeting Documentation: http://apps.who.int/gb/e/e_eb136.html

…3. In accordance with the monitoring, evaluation and accountability process, the Strategic Advisory Group of Experts on immunization reviewed progress against each of the indicators for the goals and strategic objectives of the global vaccine action plan, based on data from 2013, and prepared the 2014 Assessment Report of the Global Vaccine Action Plan…

ANNEX
A SUMMARY OF THE 2014 ASSESSMENT REPORT OF THE GLOBAL VACCINE ACTION PLAN BY THE STRATEGIC ADVISORY GROUP OF EXPERTS ON IMMUNIZATION
1. The Global Vaccine Action Plan (GVAP) has two great ambitions, to make 2011–2020 the Decade of Vaccines:
:: To deliver vaccination to all – and through this: to end inequity in vaccination, eradicate polio globally, eliminate maternal and neonatal tetanus globally, and eliminate (guided by regional targets) measles and rubella.
:: To unleash vaccines’ vast future potential – because their impressive history is nothing in comparison to what they could yet achieve.
2. The Strategic Advisory Group of Experts on immunization noted that there has been success in introducing new vaccines, and positive achievements in numerous countries in several areas, including the establishment and strengthening of National Immunization Technical Advisory Groups. However, progress is far off-track. Five of the six goals set by the GVAP with deadlines at the end of 2014 or 2015 still require substantial progress to get the goals on track (poliovirus transmission interruption, maternal and neonatal tetanus, measles and rubella elimination, and DTP3 coverage targets). Indeed, most have seen very little progress. Some have been missed multiple times before.
3. To get the Action Plan back on track, the Strategic Advisory Group of Experts on immunization recommends that action focus particularly on addressing five priority problems. Each problem is major, but each can be tackled, with a reasonable expectation that doing so will improve progress considerably. Each problem is detailed in the full 2014 Assessment Report of the Global Vaccine Action Plan1 of the Strategic Advisory Group of Experts on immunization…

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SAGE GVAP Assessment Report 2014
English – http://www.who.int/immunization/global_vaccine_action_plan/en/
[Initial text from Conclusion]
The Global Vaccine Action Plan was established for very good reasons, to meet major and important needs. Progress towards its key targets is clearly far off-track. This should cause alarm bells to ring loudly. Vaccines are not being delivered equitably or reliably. Through vaccination, diseases such as tetanus and polio should have been consigned to history several years ago – previous targets for doing so have repeatedly been missed.

The five off-track targets are closely related. They are not separate, competing endeavours, but close cousins. The key to achieving all of them lies in strengthening immunization systems.

There are clear areas in which focused action can produce considerable improvement. This report has identified five that are particularly important. If these are acted upon, real progress can be made.

The Global Vaccine Action Plan sets important ambitions. If countries and their partners are to achieve these, dramatic change is needed. If they can do so, millions of deaths will be prevented.

This report’s recommendations need to be implemented with great urgency. The ‘Decade of Vaccines’ is one-third through, and the Global Vaccine Action Plan is an opportunity that should not be lost.

The SAGE, through its Global Vaccine Action Plan Working Group, will reexamine the situation annually.

This report has made 18 recommendations…

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GVAP Secretariat Report
The GVAP Secretariat Report is prepared jointly by the GVAP secretariat’s agencies (consisting of the Bill & Melinda Gates Foundation, GAVI Alliance secretariat, UNICEF, US National Institute of Allergy and Infectious Diseases and WHO). This detailed technical report is the basis used by SAGE to assess the progress made towards the achievement of GVAP Goals in its SAGE GVAP Assessment report.
GVAP Secretariat report 2014 -DRAFT-docx, 3.48Mb

POLIO [to 20 December 2014]
Public Health Emergency of International Concern (PHEIC)

GPEI Update: Polio this week – As of 17 December 2014
Global Polio Eradication Initiative
[Editor’s Excerpt and text bolding]
Full report: http://www.polioeradication.org/Dataandmonitoring/Poliothisweek.aspx
:: For the first time ever, no cases of wild poliovirus have been reported in Africa in the last 4 months. The most recent case had onset of paralysis on 11 August in Somalia.
:: In the north of Madagascar, supplementary immunization activities are currently underway in response to the outbreak of circulating vaccine-derived poliovirus type 1. National Immunization Days are planned for 19 – 23 January.
Selected country report content:
Afghanistan
:: One new wild poliovirus type 1 (WPV1) case was reported in the past week from Garmser district of Hilmand province, which had not previously reported a case in 2014. The case, which is the country’s most recent, had onset of paralysis on 17 November. The total number of WPV1 cases for 2014 in Afghanistan is now 25 compared to 11 at this time last year.
:: Given the growing wild poliovirus type 1 outbreak in neighbouring Pakistan, Afghanistan continues to conduct supplementary immunization activities (SIAs) to limit the spread of imported polioviruses and to tackle residual endemic transmission. Subnational Immunization Days (SNIDs) are planned in high risk areas of the south and east using monovalent oral polio vaccine (OPV) type 1 on 21 – 23 December, and 11 – 13 January using bivalent OPV.
Pakistan
:: Seven new wild poliovirus type 1 (WPV1) cases were reported in the past week. Four are from the Federally Administered Tribal Areas (FATA) 3 from Khyber Agency and 1 from South Waziristan); and 3 are from Khyber Pakhtunkhwa (KP) province (2 from Peshawar district and 1 from Swat). The total number of WPV1 cases in Pakistan in 2014 is now 283, compared to 75 at this time last year. The most recent WPV1 case had onset of paralysis on 25 November, from Peshawar, KP.
:: Immunization activities are continuing with particular focus on known high-risk areas, in previously inaccessible areas of FATA. At exit and entry points of conflict-affected areas 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 doses of vaccine have been used in the past few months to vaccinate people passing through transit points and in host communities, including over 850,000 children under 10 years old.
Horn of Africa
:: Following confirmation at the beginning of November of two cases of 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). Subnational Immunization Days are taking place on 16 – 19 December and 20 – 23 January. The objective is to rapidly stop the transmission of cVDPV2 in the infected area, while further boosting immunity to type 1 wild poliovirus and to minimize the risk of renewed outbreaks following wild poliovirus re-introduction from any 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.

Achieving the extraordinary: A world without polio
EurActiv
19/12/2014
Authors: Geeta Rao Gupta, Deputy Executive Director of UNICEF; John Hewko, General Secretary of Rotary International; Bruce Aylward, Assistant Director-General – Polio and Emergencies of the World Health Organisation (WHO).
[Full text, editor’s text bolding]

This year marks the sixteenth anniversary of the last reported case of polio in the European Region: a reminder of how far we have come in the fight against polio, and an opportunity to reignite international efforts in support of the very few countries that still have a distance to go.

Polio is a thing of the past across Europe, and indeed across most of the world now, thanks to the power of vaccination. Polio cases have fallen from 1,000 per day worldwide when the Global Polio Eradication Initiative was launched in 1988 to less than one per day so far in 2014. Yet, despite this success, it would be naïve to feel safe from the threat this virus poses to children everywhere. Critical action is needed by European leaders now to protect the world from this threat and realise the promise of global eradication.

Polio is a highly contagious disease which can spread across borders swiftly and silently, leaving in its wake legions of children maimed for life. Last year, in addition to the three countries where polio transmission has never halted (Afghanistan, Nigeria and Pakistan), there were also outbreaks in the Middle East, the Horn of Africa and Central Africa due to reinfection of areas that had long been polio free. This serves as a stark reminder that as long as polio continues to exist anywhere, it remains a threat everywhere.

Europe is no exception. Despite being declared polio-free in 2002, there are still dangerous vaccination coverage gaps in a number of countries, meaning the disease could make a come-back on this continent as well. In fact, if the global effort to eradicate polio slips, the disease will come roaring back all over the world. Within ten years, we could once again see more than 200,000 newly paralysed children – every single year. This could be a catastrophe that must be avoided at all costs.

Recognising this, on 5 May 2014, the director-general of the WHO declared the international spread of polio a Public Health Emergency of International Concern (PHEIC). This is now driving countries affected by the disease to redouble their efforts to eradicate polio within their borders. An increasing number of polio-free countries – such as Australia, China and India – are also taking extraordinary measures to protect themselves, by introducing national vaccination requirements for travellers arriving from infected countries.

That polio, once a leading cause of disability worldwide, can now be prevented and even eradicated through an extremely inexpensive, easily administered vaccine is one of the miracles of modern medicine. It is our collective responsibility to ensure that polio does not continue to paralyse even a single child, anywhere in the world.

UNICEF and Rotary International are driving and coordinating a significant commitment from civil society around the globe, and it is essential that these calls to action are heard by political leaders.

European governments have a particular interest in ensuring the heightened efforts towards eradication are realized, given their investments to date and the risk of re-infection. This can be achieved by rapidly mobilising the financial resources required to eradicate polio from the world; advocating with and assisting the leaders of infected countries in implementing the eradication strategies; maintaining high vaccination coverage across the continent to minimise the risk and consequences of outbreaks; and fully implementing vaccination recommendations for those travelling to polio-affected areas.

On this anniversary, we can reflect how close we are to success. It is the first anniversary since the entire Southeast Asia Region has been declared polio-free, long regarded the most technically-challenging place from where to eradicate polio. It is the first anniversary where Nigeria can be seen to be on the verge of becoming polio-free. It is the first anniversary during which every country worldwide has proven that with the right resources and political will, every child can be reached with the life-saving polio-vaccine.

But ending polio in these few remaining infected areas is not a challenge that can be resolved by any one country or organisation. Nor can it be left at the door of those countries where cases continue to be found. The responsibility lies at the feet of every one of us, as ending polio now will ensure the protection of children all around the world.

On this anniversary, let us intensify all of our efforts to eradicate this disease once and for all. Let us commit to achieving history, for all future generations to come.

EBOLA/EVD [to 20 December 2014]
Public Health Emergency of International Concern (PHEIC); “Threat to international peace and security” (UN Security Council)

Editor’s Note:
Our extensive coverage of Ebola/EVD activity continues – including detailed coverage of UNMEER and other INGO/agency activity now available at the end of this digest. Please also note that many of the organizations and journals we cover continue to publish important EVD content which is threaded throughout this edition.

WHO: Ebola response roadmap – Situation report 17 December 2014
Summary [Excerpt]
A total of 18,603 confirmed, probable, and suspected cases of Ebola virus disease (EVD) have been reported in five affected countries (Guinea, Liberia, Mali, Sierra Leone, and the United States of America) and three previously affected countries (Nigeria, Senegal and Spain) in the seven days to 14 December (week 50). There have been 6915 reported deaths (case definitions are provided in Annex 1).

Reported case incidence is fluctuating in Guinea and declining in Liberia. In Sierra Leone, there are signs the increase in incidence has slowed, and that incidence may no longer be increasing. The case fatality rate in the three intense-transmission countries among all cases for whom a definitive outcome is recorded is 70%. For those patients recorded as hospitalized, the case fatality rate is 60% in each of Guinea and Sierra Leone, and 58% in Liberia.

Interventions in the three most-affected countries continue to progress in line with the UN Mission for Ebola Emergency Response aim to isolate and treat 100% of EVD cases and bury safely and with dignity 100% of EVD-related fatal cases by 1 January, 2015. At a national level, there is now sufficient bed capacity in EVD treatment facilities to treat and isolate all reported EVD cases in each of the three countries, although the uneven distribution of beds and cases means serious shortfalls persist in some districts. At a national level, each country has sufficient capacity to bury all people known to have died from Ebola, although it is possible that in some areas capacity remains inadequate. Every district that has reported a case of EVD in the three intense-transmission countries has access to a laboratory within 24 hours from sample collection. All three countries report that more than 80% of registered contacts associated with known cases of EVD are being traced. Social mobilization continues to be an important component of the response to curb the spread of disease. Community engagement promotes burial practices that are safe and culturally acceptable, and the isolation and appropriate treatment of patients with clinical symptoms of EVD….
WHO Ebola R&D Effort – vaccines, therapies, diagnostics
18 December update
Since August, when the Ebola outbreak was declared a global public health emergency, WHO has convened a series of consultations and high-level meetings with key experts and stakeholders involved in the research, development, regulation and funding of potential medical solutions for Ebola. Based on concerted expert advice, the best evidence available, and ethical oversight, WHO has prioritized a number of products for further investigation through human testing. These products include two candidate vaccines, two antiviral drugs and convalescent whole blood and plasma. In addition, WHO is working on a number of emergency procedures with countries and other partners for assessment and fast-track development of adapted diagnostics, as well as joint reviews of vaccine clinical trial protocols.

VACCINES
Two vaccine candidates are currently being tested in humans – the cAd3-ZEBOV vaccine, developed by GlaxoSmithKline (GSK) in collaboration with the United States National Institutes for Health, and the rVSV-ZEBOV vaccine, developed by NewLink Genetics and Merck Vaccines USA, in collaboration with Health Canada. Both vaccines have shown to be safe and efficacious in animals and initial phase 1 trial results published in November reported that the GSK vaccine is safe. Further Phase 1 results are expected to emerge during December to January.
Phase I clinical trials of the cAd3-ZEBOV vaccine in healthy adults are nearing completion in the United Kingdom, United States, Mali and Switzerland. For the rVSV-ZEBOV vaccine, trials are well advanced or near completion in Canada, the United States, Gabon, Germany, and Switzerland. Trials in Kenya are due to begin this week. All trials are under the auspices of national research institutions in the countries where they are taking place.
Phase II clinical trials of the cdA3-ZEBOV vaccine are expected to begin in Cameroon, Ghana, Mali, Nigeria and Senegal in early 2015. These will test for safety and capacity to induce an immune response in larger numbers and in broader populations, including children. In order to accelerate ethical and regulatory approval of these trials, WHO convened ethics and regulatory experts from the five countries to meet in Geneva on 15-16 December, to agree on a joint review of the trial protocol presented by GSK, the company developing the vaccine. The outcome was provisional approval of the trials pending some minor adjustments to the protocol application requested by the countries concerned. Experts from Guinea, Liberia and Sierra Leone also participated in the meeting.
Phase III clinical trials are planned to start in the first quarter of 2015 in Guinea, Liberia and Sierra Leone to assess the extent to which the vaccines protect against EVD and to gauge the feasibility of full deployment.
Two other vaccines – one developed by Johnson & Johnson and the other by Novavax – are due to enter clinical trials in the coming weeks.
More about Vaccines

THERAPIES
Blood and blood products
Transfusion of whole blood and plasma from recovered Ebola patients has been prioritized for use as an investigational therapy. Convalescent whole blood donated by EVD recovered patients is currently being administered in Sierra Leone in a trial run by the government. A trial of convalescent plasma has begun in Liberia – under the auspices of ClinicalRM (a clinical research organization) with the US government and the Bill and Melinda Gates Foundation; and Guinea is planning to start a plasma trial in the next weeks through a partnership between its National Blood Transfusion Service, and institutes in Belgium, the UK and France, and MSF.
Assessments of national capacities for delivering safe blood products outside of clinical trial settings and plans for recovery and strengthening of national blood transfusion services in the three countries are expected to continue in the coming months.
Medicines
A number of pre-existing medicines already approved for treating non-Ebola diseases have been considered for re-purposing to treat Ebola because they have demonstrated efficacy against the virus in test tubes (in vitro). The advantage of considering re-purposing of drugs is that these are readily available, and their safety is known. So far only one of these has demonstrated sufficient activity in animals infected with EVD to warrant testing in clinical trials. This is favipiravir (Toyama, Japan), for which clinical trials have started in Gueckedou, Guinea. Trials are being run by Inserm, MSF and the Guinean government. In addition, one other re-purposed drug, amiodarone, has been used to treat patients in Sierra Leone, but it is not yet known if it has any benefit.
Other products that are still under development and are not yet approved for any disease are also being taken into small efficacy trials early in 2015. One of these is brincidofovir (Chimerix, USA) which was originally developed for treating cytomegalovirus but has activity against Ebola virus.
Others are medicines that were specifically developed for Ebola, including the monoclonal antibody cocktail ZMapp (Leafbio, USA) and small inhibitory ribonucleic acid (siRNA) (Tekmira, USA, Canada). All of these have been used compassionately in a few expatriated Ebola patients. While promising, these medicines are still under development and are not available in quantities adequate for large-scale clinical trials or deployment.
The scientific community is currently testing in monkeys a wide range of other drugs that have been proposed as potential therapies and will be taking the most promising into clinical trials.
More about Therapies

DIAGNOSTICS
In September, WHO introduced an emergency procedure under its Prequalification Programme for rapid assessment of Ebola diagnostics for UN procurement to affected countries. The first diagnostic was accepted in November. In the same month, WHO called on manufacturers to develop rapid and easy to use point-of-care diagnostics that are better suited for use in the affected countries, where health infrastructure and trained personnel are largely lacking. The call was followed by a consultation, on 12 December, where diagnostic experts joined WHO and the NGO FIND to plan for accelerated development, production and deployment of adapted and rapid Ebola tests.
As a result, two types of rapid diagnostics are expected to be ready for clinical trials in early 2015. The most promising type is a rapid, integrated nucleic acid PCR test, which is believed to be more effective in case finding. The other type is an antigen test that is easier to use but may be less reliable.
More about Diagnostics

Looking forward
WHO will continue to work with key stakeholders and partners on potential interventions to accelerate verification, development, testing and, if safety and efficacy are found, deployment of Ebola medical products. Mindful of the risks involved in compressing clinical trials and data gathering in short timeframes, WHO is also providing technical guidance to affected countries and is strongly advocating for patient safety and strict ethical oversight throughout the testing phases and potential deployment. In parallel, WHO is actively supporting community engagement activities in African countries where trials are already taking place.
At the same time, WHO has begun work with Ebola affected countries, development partners and financing institutions on recovery and building resilient health systems.

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WHO: Phase II clinical trial application for ChAd3 Ebola vaccine reviewed by national regulators
18 December 2014 – During a meeting convened by WHO on 15-16 December 2014, representatives from African national regulatory authorities and ethics committees reviewed an application for Phase II clinical trials of the chimpanzee adenovirus serotype-3 (ChAd3) Ebola vaccine.
The two-day review provided a forum for a thorough discussion on all aspects of the proposed trials. Reviewing countries requested additional documentation from the manufacturer of the vaccine, GlaxoSmithKline, before authorization of the trials. The submission of additional information, and subsequent review by the countries planning to host the trials, is expected to take place by the end of January. If these steps are completed to the satisfaction of the national authorities, Phase II trials are likely to begin in February.
Regulatory and ethics officials from the countries where the Phase II trials were being considered (Cameroon, Ghana, Mali, Nigeria and Senegal) were present, as well as from the countries most affected by the ongoing Ebola outbreak (Guinea, Liberia and Sierra Leone, as observers).
:: Announcement of meeting to review Phase II clinical trial application for ChAd3 Ebola vaccine
:: Summary of the meeting to review Phase II clinical trial application for ChAd3 Ebola vaccine pdf, 299kb.

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WHO and partners release manual on psychological first aid during Ebola outbreaks
In times of outbreaks, it is critical that helpers be equipped with the know-how to provide humane, supportive and practical help for people who are distressed, in ways that respect their dignity, culture and abilities.
Consequently, WHO and partners released their first facilitator’s manual, to provide helpers with a comprehensive orientation and materials for use when offering psychological first aid to people affected by an Ebola outbreak. More specifically, this facilitator’s manual includes:
– information on how to prepare for giving an orientation and tips for facilitators
– a full day orientation agenda and a step-by-step description of each module, including learning objectives, narrative and tips for the facilitator
– slides and instructions for group exercises and discussions
– annexes which provide supporting materials to print as handouts for participants.
This facilitator’s manual is to be used together with the guide Psychological first aid during Ebola virus disease outbreaks, launched September 2014.
:: Facilitation manual: Psychological first aid during Ebola disease outbreaks
:: Guide: Psychological first aid during Ebola virus disease outbreaks

European Medicines Agency Watch [to 20 December 2014]

:: Experimental Ebola treatments still at early stage of development
For robust scientific assessment more information on safety and efficacy needed
16/12/2014
At this point in time there is not enough evidence for any of the experimental therapies for Ebola Virus Disease to draw conclusions on their safety or efficacy when used in Ebola patients. This is the finding of an interim report published by the European Medicines Agency (EMA) that is continuing to review all Ebola treatments currently under development.
Any new information that becomes available will be added to the review to provide the best possible overview of data on medicinal treatments for Ebola.
“Treatments for patients infected with the Ebola virus are still in early stages of development,” notes Marco Cavaleri, Head of Anti-infectives and Vaccines at EMA. “We encourage developers to generate more information on the use of these medicines in the treatment of Ebola patients. We will review any new information as soon as it becomes available to support the response to this ongoing public health crisis.”
The EMA review was started by the Agency’s Committee for Medicinal Products for Human Use (CHMP) to support decision-making by health authorities. This first interim report includes information on seven experimental medicines intended for the treatment of people infected with the Ebola virus:
– BCX4430 (Biocryst);
– Brincidofovir (Chimerix);
– Favipiravir (Fujifilm Corporation/Toyama);
– TKM-100802 (Tekmira);
– AVI-7537 (Sarepta);
– ZMapp (Leafbio Inc.);
– Anti-Ebola F(ab’)2 (Fab’entech).
The amount of information available for the seven treatments is highly variable. For some compounds there is no data from use in human subjects available. A small number of treatments have been administered to patients in the current Ebola outbreak as compassionate use. Finally, there are also medicines included in this review that have already been studied in humans, albeit for the treatment of other viral diseases.
Vaccines to protect people against contracting the disease and treatments that do not directly target the Ebola virus have not been included in the review.
EMA’s role in the Ebola outbreak
The review of experimental Ebola treatments is part of EMA’s overall contribution to the global response to the Ebola outbreak in West Africa. The scale and complexity of this outbreak requires an unprecedented level of cooperation of the international health community. The Agency is working together with regulatory authorities around the world to support the World Health Organization and to advise on possible pathways for the development, evaluation and approval of medicines to fight Ebola.
– Assessment report for Article-5(3) procedure: Medicinal products under development for treatment of Ebola (16/12/2014)

CDC/MMWR Watch [to 20 December 2014]
http://www.cdc.gov/media/index.html

:: CDC Year in Review: “Mission: Critical” – Press Release – Monday, December 15, 2014

:: MMWR Weekly December 19, 2014 / Vol. 63 / No. 50
– Update: Influenza Activity — United States, September 28–December 6, 2014
– Update: Ebola Virus Disease Epidemic — West Africa, December 2014
– Challenges in Responding to the Ebola Epidemic — Four Rural Counties, Liberia, August–November 2014
– Support Services for Survivors of Ebola Virus Disease — Sierra Leone, 2014
– Reintegration of Ebola Survivors into Their Communities — Firestone District, Liberia, 2014
– Notes from the Field: Measles Transmission at a Domestic Terminal Gate in an International Airport — United States, January 2014

MSF/Médecins Sans Frontières [to 20 December 2014]

MSF Opens New Ebola Treatment Centers in Sierra Leone to Increase Access to Care
December 18, 2014
To increase access to care for Ebola patients in western Sierra Leone, which has been hit hard by the current outbreak, MSF has opened new treatment centers in Freetown and Magburaka.

Ebola: A Day in the Life of a Chlorine Sprayer
December 16, 2014
The team collecting victims of Ebola—both living and dead—from the community in Monrovia face a challenging task in the fight against Ebola.

Liberia: Ebola Outbreak Contained in Lofa County, MSF Hands Over Activities
December 15, 2014
The Ebola situation has improved in Lofa County and Doctors Without Borders/Médecins Sans Frontières (MSF) has decided to withdraw from the area. New actors have arrived to help and since October 30 there have been no more Ebola patients in the Ebola Management Center (EMC) in Foya. The success of MSF’s intervention in northern Liberia can be considered a model of response, benefitting from a comprehensive approach and constant community involvement.

WHO & Regionals [to 20 December 2014]

:: Global Alert and Response (GAR): Disease Outbreak News (DONs)
– Middle East respiratory syndrome coronavirus (MERS-CoV) – Saudi Arabia 17 December 2014
Between 20 November and 7 December 2014, the National IHR Focal Point for the Kingdom of Saudi Arabia (KSA) notified WHO of 11 additional cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection, including 4 deaths….
– West Nile virus – Brazil 15 December 2014
On 9 December 2014, the Ministry of Health of Brazil reported a case of West Nile Virus (WNV) in the state of Piauí (PI). This is the first detection of a human case of WNV infection in Brazil…

:: The Weekly Epidemiological Record (WER) 19 December 2014, vol. 89, 51/52 (pp. 577–588) includes:
.- Index of countries/areas
– Index, Volume 89, 2014, Nos. 1–52
– Revised guidance on meningitis outbreak response in sub-Saharan Africa
– Monthly report on dracunculiasis cases, January– October 2014

:: Syria Response Plan 2015 launched in Berlin
December 2014 — The Syria Response Plan 2015 incorporates, for the first time, the whole of Syria approach by bringing together humanitarian actors working inside Syria and in neighbouring countries under a single framework to increase the effectiveness of the response. Health partners are requesting a total of US$ 318 million, 182 million of which are for inside Syria.

:: Eight mobile health clinics to serve vulnerable populations in Iraq
December 2014 — These urgently needed clinics, procured by WHO and flown in by the World Food Programme from Amman, Jordan, will be immediately deployed to parts of Iraq and the Kurdistan Region of Iraq to help address the health needs of displaced populations residing in areas with limited access to health care services – in camps, informal settlements, and in urban and remote areas across the country.

:: Fact Sheet – Human papillomavirus (HPV) and cervical cancer 16 December 2014

:: GIN December 2014 pdf, 1.07Mb 19 December 2014
WHO Regional Offices
WHO African Region AFRO
:: How to save the lives of newborns in Africa 17 December 2014
Brazzaville, 17 December 2014 – According to a new WHO report, one third of all neonatal deaths occur in the African Region. Approximately three quarters of these deaths occur during the first week of life and almost half within the first 24 hours.
The first 28 days of life, called the neonatal period, is a very risky period for babies. For every newborn baby that dies, another 20 will face illness or disability from conditions such as birth injury, infection, the inability to breathe normally after birth, neonatal tetanus, congenital anomalies, and the complications of premature birth.
Too many babies are also being born to mothers who have not had adequate nutrition and antenatal care during pregnancy and who were not given skilled care during the birthing process. These mothers are at the greatest risk of dying during or after delivery – leaving newborns at an even greater risk of dying from inadequate care and suboptimal feeding practices.
According to statistics, quality care with simple, accessible, cost–effective interventions can prevent up to two thirds of all neonatal deaths. One method that has worked to reduce neonatal deaths in the African Region is kangaroo mother care (KMC). KMC is caring for preterm infants by carrying the baby skin-to-skin, usually by the mother…

WHO Region of the Americas PAHO
:: Number of babies born with HIV declined 78% in Latin America and the Caribbean, says new PAHO/WHO report (12/15/2014)

WHO South-East Asia Region SEARO
No new digest content identified.

WHO European Region EURO
:: Rehabilitation: key to an independent future for children with poliomyelitis in Tajikistan 18-12-2014
:: Mobile clinics in Ukraine to bring health services to people in need 15-12-2014

WHO Eastern Mediterranean Region EMRO
:: WHO and partners release manual on psychological first aid during Ebola outbreaks
15 December 2014

WHO Western Pacific Region
:: The Wantok Effect: Key populations and the HIV response in Papua New Guinea
PORT MORESBY, 18 December 2014 – Papua New Guinea has the highest HIV prevalence in the Pacific region, estimated at 0.8% in 2012. The nation is grappling with an HIV epidemic that is concentrated in marginalized and criminalized key populations including female sex workers and men who have sex with men (MSM). Stigma associated with HIV and advice from influential churches for people to rely on prayer rather than antiretroviral treatment (ART) to heal themselves further complicate the situation.
:: Ensuring a future that is free from measles and rubella 13 December 2014

GAVI Watch [to 20 December 2014]
http://www.gavialliance.org/library/news/press-releases/

:: US approves US$ 200 million for Gavi in fiscal year 2015 budget
Washington, DC, 17 December 2014 – Gavi, the Vaccine Alliance welcomed final approval of the fiscal year 2015 appropriations bill that includes US$ 200 million for Gavi. It is the largest single year contribution ever made to Gavi by the United States…
“Gavi is grateful for the unbending, bipartisan support to vaccinate children in the world’s poorest countries, especially in a challenging budget environment,” said Gavi CEO Dr. Seth Berkley. “We want to specifically thank House and Senate State and Foreign Operations subcommittee leaders Rep Kay Granger, Rep Nita Lowey, Sen. Patrick Leahy and Sen. Lindsey Graham. This support will help Gavi purchase and deliver vaccines that will protect tens of millions of vulnerable children in poor countries around the world.”…

:: Gavi announces appointment of new Board members
Geneva, 16 December 2014 – Gavi, the Vaccine Alliance has announced the appointment of 10 members to the Board. The appointments were confirmed at the Board meeting held in Geneva on the 10th and 11th of December 2014.
The appointments are as follows:
– David Sidwell, Senior Independent Director and Chair of the Risk Committee, UBS, as an Unaffiliated Board Member effective 1 January 2015 and until 31 December 2017
– Gunilla Carlsson, former Minister of International Development Cooperation, Sweden, as an Unaffiliated Board Member effective 1 January 2015 and until 31 December 2017
– Seif Seleman Rashid, Minister of Health and Social Welfare, Tanzania, as Board Member representing the developing country constituency effective 1 January 2015 and until 31 December 2017
– Khaga Raj Adhikari, Minister of Health and Population, Nepal, as Board Member representing the developing country constituency effective 1 January 2015 and until 31 December 2017
– Bahar Idriss Abu Garda, Minister of Health, Sudan as Board Member representing the developing country constituency effective 1 January 2015 and until 31 December 2017
– Mariam Diallo, Assistant Director for Health, Food Security and Human Development, Ministry of Foreign Affairs, France, as Board Member representing the France, Luxembourg, European Commission, and Germany donor constituency effective 1 January 2015 and until 31 December 2015
– Beate Stirø, Policy Director, Global Health Issues, Ministry of Foreign Affairs, Norway, as Board Member representing the Norway, Denmark, Netherlands, and Sweden donor constituency in the seat currently held by Anders Nordström of Sweden effective 1 January 2015 and until 31 December 2016
– Clare Walsh, First Assistant Secretary, Multilateral Development and Partnerships Division at the Department of Foreign Affairs and Trade, Australia, as Board Member representing the United States, Australia, Korea, and Japan donor constituency effective 1 January 2015 and until 30 June 2015
Nick Dyer, Director General for Policy and Global Programmes at the Department for International Development, United Kingdom, and Jan Paehler, Director General, Research – Public Health, European Commission, were elected to the Board to sit at the December 2014 meeting. In addition, eight new alternate Board members were appointed.

:: IFFIm rating action by Fitch follows France downgrade
Washington DC, 17 December 2014 — Fitch Ratings has downgraded the long-term credit rating of the International Finance Facility for Immunisation (IFFIm) from AA+ to AA with a stable outlook. The short-term foreign currency rating on IFFIm has been affirmed at F1+.
Fitch explained the decision as being linked to its rating action last week on France, which is the second largest financial contributor to IFFIm. More broadly, Fitch aligns its rating of IFFIm with the lower of that of the United Kingdom (AA+/stable) and France, IFFIm’s two largest donors.
“The IFFIm and Gavi Boards, donor countries and the World Bank continuously reiterate their full confidence in IFFIm’s mission and overall financial position, as well as the commitment of donor countries to fulfill their pledging obligations,” said René Karsenti, Chair of the IFFIm Board. “The downgrade is not expected to materially impact the amount of funds available to IFFIm and Gavi.”
IFFIm is currently rated AA by Fitch with stable outlook, Aa1 by Moody’s with a stable outlook and AA by S&P with a negative outlook.
More details on IFFIm’s financial position, including the latest rating agency publications, are available under IFFIm’s bond documentation page.

Sabin Vaccine Institute Watch [to 20 December 2014]
http://www.sabin.org/updates/pressreleases

:: Coalition against Typhoid Awarded Funding to Advance Surveillance of Typhoid and Paratyphoid
WASHINGTON, D.C. — December 16, 2014 — The Sabin Vaccine Institute, through the Coalition against Typhoid (CaT) Secretariat, announced today that it has received an award of approximately US$ 5 million from the Bill & Melinda Gates Foundation to support the establishment of an Asia regional enteric fever surveillance network. The network will enable the systematic collection of data in order to fill knowledge gaps on the impact of severe typhoid and paratyphoid — diseases collectively referred to as enteric fever.

Global Fund [to 20 December 2014]
http://www.theglobalfund.org/en/mediacenter/announcements/

Press releases
Global Fund Approves Emergency TB Funding for Syrian Refugees
18 December 2014
GENEVA – The Global Fund to Fight AIDS, Tuberculosis and Malaria has approved emergency funding to support the prevention, diagnosis and treatment of tuberculosis among Syrian refugees in Lebanon and Jordan.
The assistance, totaling US$3.3 million, comes from the Global Fund’s Emergency Fund, a special initiative designed to provide quick financing to fight HIV, TB and malaria in emergency situations. The Global Fund tapped the Emergency Fund for the first time in November to expand a mass-distribution campaign of mosquito nets in Liberia, a country severely hit by the Ebola outbreak.
The International Organization for Migration (IOM), which operates in Lebanon and Jordan, will be implementing the programs. The IOM is already providing active and early TB interventions among Syrian refugees, as well as TB drugs, equipment and awareness-raising…

Industry Watch [to 20 December 2014]

:: Baxter to Divest Vero Cell Vaccines Platform to Nanotherapeutics
December 15, 2014
DEERFIELD, Ill.–(BUSINESS WIRE)–Baxter International Inc. (NYSE:BAX) today announced that it has entered into a definitive agreement to sell its proprietary Vero cell technology and related assets, including its production facility in Bohumil, Czech Republic, to Nanotherapeutics, Inc. Financial details were not disclosed.
The Vero cell platform is an advanced, cell-based technology for vaccines production. The agreement with Nanotherapeutics includes all assets related to the platform, including vaccines for H5N1, H1N1 and seasonal influenza. The agreement also includes investigational vaccine programs for Ross River virus, Chikungunya disease and West Nile virus.
In recent weeks, the company has also completed the sale of its commercial vaccines business and related manufacturing facilities to Pfizer…

IOM: Ranking Vaccines Applications of a Prioritization Software Tool Phase III: Use Case Studies and Data Framework
December 19, 2014
Authors: Guruprasad Madhavan, Charles Phelps, Rino Rappuoli, Rose Marie Martinez, and Lonnie King, Editors; Committee on Identifying and Prioritizing New Preventive Vaccines for Development, Phase III; Board on Population Health and Public Health Practice; Board on Global Health; Institute of Medicine; National Research Council
Overview
At the request of the National Vaccine Program Office of the Department of Health and Human Services, the Institute of Medicine (IOM) initiated a sequence of projects in early 2011 to help provide guidance in prioritizing new vaccines for development. This effort has proceeded in three phases, each building upon the key objective of the U.S. National Vaccine Plan: “Develop a catalogue of priority vaccine targets of domestic and global health importance.” The result of this unique effort is the Strategic Multi-Attribute Ranking Tool for Vaccines—or SMART Vaccines—a novel software tool to facilitate stakeholder discussions and decisions on vaccine research and development priorities.
In the Phase III work, the IOM in partnership with the National Academy of Engineering enhanced SMART Vaccines—version 1.1 of the software can be downloaded for free from http://www.nap.edu/smartvaccines. The supporting report, Ranking Vaccines: Applications of a Prioritization Software Tool, describes: (1) the evaluation of the software in international user-based applications, (2) a general data framework for the software, and (3) the next steps that would increase the use and value of SMART Vaccines.
A blueprint for this computer-based guide was presented in the 2012 report Ranking Vaccines: A Prioritization Framework: Phase I. The 2013 Phase II report refined a beta version of the model developed in the Phase I report.
pdf of full report:
https://download.nap.edu/login.php?record_id=18763&page=http%3A%2F%2Fwww.nap.edu%2Fdownload.php%3Frecord_id%3D18763

American Journal of Public Health
Volume 105, Issue 1 (January 2015)
http://ajph.aphapublications.org/toc/ajph/current

Coupled Ethical–Epistemic Analysis of Public Health Research and Practice: Categorizing Variables to Improve Population Health and Equity
S. Vittal Katikireddi, MRCP, MFPH, PhD, and Sean A Valles, PhD
S. Vittal Katikireddi is with the Medical Research Council and the Chief Scientist Office Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK. Sean A. Valles is with Lyman Briggs College and the Department of Philosophy, Michigan State University, East Lansing.
Abstract
The categorization of variables can stigmatize populations, which is ethically problematic and threatens the central purpose of public health: to improve population health and reduce health inequities. How social variables (e.g., behavioral risks for HIV) are categorized can reinforce stigma and cause unintended harms to the populations practitioners and researchers strive to serve.
Although debates about the validity or ethical consequences of epidemiological variables are familiar for specific variables (e.g., ethnicity), these issues apply more widely.
We argue that these tensions and debates regarding epidemiological variables should be analyzed simultaneously as ethical and epistemic challenges. We describe a framework derived from the philosophy of science that may be usefully applied to public health, and we illustrate its application.

EDITORIAL The Moral Challenge of Ebola
Mark A. Rothstein
American Journal of Public Health: January 2015, Vol. 105, No. 1: 6–8.
Citation | Full Text | PDF (651 KB) | PDF Plus (653 KB)

Assessing the Expected Impact of Global Health Treaties: Evidence From 90 Quantitative Evaluations
Steven J. Hoffman, BHSc, MA, JD, and John-Arne Røttingen, MD, PhD, MSc, MPA
Steven J. Hoffman is with the Faculty of Law, University of Ottawa, Canada, and the Department of Global Health and Population, Harvard School of Public Health, Boston, MA. John-Arne Røttingen is with the Division of Infectious Disease Control, Norwegian Institute of Public Health, Oslo, Norway, and the Institute of Health and Society, University of Oslo, Norway.
Abstract
We assessed what impact can be expected from global health treaties on the basis of 90 quantitative evaluations of existing treaties on trade, finance, human rights, conflict, and the environment.
It appears treaties consistently succeed in shaping economic matters and consistently fail in achieving social progress. There are at least 3 differences between these domains that point to design characteristics that new global health treaties can incorporate to achieve positive impact: (1) incentives for those with power to act on them; (2) institutions designed to bring edicts into effect; and (3) interests advocating their negotiation, adoption, ratification, and domestic implementation.
Experimental and quasiexperimental evaluations of treaties would provide more information about what can be expected from this type of global intervention.

Cognitive Dissonance in the Early Thirties: The League of Nations Health Organization Confronts the Worldwide Economic Depression
Theodore M. Brown, Elizabeth Fee
American Journal of Public Health: January 2015, Vol. 105, No. 1: 65–65.
Citation | Full Text | PDF (163 KB) | PDF Plus (165 KB)

Human Papillomavirus Vaccination Among Young Adult Gay and Bisexual Men in the United States
Paul L. Reiter, PhD, Annie-Laurie McRee, DrPH, Mira L. Katz, PhD, and Electra D. Paskett, PhD
Paul L. Reiter and Electra D. Paskett are with the Division of Cancer Prevention and Control, College of Medicine and the Comprehensive Cancer Center, Ohio State University, Columbus. Annie-Laurie McRee and Mira L. Katz are with the Division of Health Behavior and Health Promotion, College of Public Health and the Comprehensive Cancer Center, Ohio State University.
Abstract
Objectives. We examined human papillomavirus (HPV) vaccination among gay and bisexual men, a population with high rates of HPV infection and HPV-related disease.
Methods. A national sample of gay and bisexual men aged 18 to 26 years (n = 428) completed online surveys in fall 2013. We identified correlates of HPV vaccination using multivariate logistic regression.
Results. Overall, 13% of participants had received any doses of the HPV vaccine. About 83% who had received a health care provider recommendation for vaccination were vaccinated, compared with only 5% without a recommendation (P < .001). Vaccination was lower among participants who perceived greater barriers to getting vaccinated (odds ratio [OR] = 0.46; 95% confidence interval [CI] = 0.27, 0.78). Vaccination was higher among participants with higher levels of worry about getting HPV-related disease (OR = 1.54; 95% CI =  1.05, 2.27) or perceived positive social norms of HPV vaccination (OR = 1.57; 95% CI =  1.02, 2.43).
Conclusions. HPV vaccine coverage is low among gay and bisexual men in the United States. Future efforts should focus on increasing provider recommendation for vaccination and should target other modifiable factors.

BMC Public Health
(Accessed 20 December 2014)
http://www.biomedcentral.com/bmcpublichealth/content

Research article
Knowledge and attitude of healthcare workers about middle east respiratory syndrome in multispecialty hospitals of qassim, Saudi Arabia
Muhammad Umair Khan, Shahjahan Shah, Akram Ahmad and Omotayo Fatokun
BMC Public Health 2014, 14:1281 doi:10.1186/1471-2458-14-1281
Published: 16 December 2014
Abstract (provisional)
Background
With the increase in prevalence of Middle East Respiratory Syndrome (MERS), healthcare workers (HCWs) are at risk of acquiring and subsequently transmitting this lethal virus. In view of this, HCWs were evaluated for their knowledge of and attitude towards MERS in Saudi Arabia.
Methods
A cross sectional study was performed in two hospitals of Qassim region in Saudi Arabia. A total of 280 healthcare workers were selected to participate in this study. Knowledge and attitude were assessed by using self-administered and pretested questionnaire. Descriptive statistics were carried out to express participants’ demographic information, mean knowledge score and mean attitude score of HCWs. Inferential statistics (Mann-Whitney U test and Kruskal Wallis tests, p < 0.05) were used to examine differences between study variables. Chi squares tests were used to assess the association between study variables and attitude questions. Spearman’s rho correlation was used to identify the association between the knowledge, attitude scores. Result: Participants demonstrated good knowledge and positive attitude towards MERS. The mean scores of knowledge and attitude were 9.45 +/- 1.69 (based on 13 knowledge questions) and 1.82 +/- 0.72 (based on 7 attitude questions). The correlation between knowledge and attitude was significant (correlation coefficient: 0.12; P <0.001). HCWs were less educated about the management (42.4%), source (66%) and consequences of MERS (67.3%), while a majority of them were well aware of the hallmark symptoms (96%), precautionary measures (96%) and hygiene issues (94%). Although the majority of respondents showed positive attitude towards the use of protective measures (1.52 +/- 0.84), their attitude was negative towards their active participation in infection control program (2.03 +/- 0.97). Gender and experience were significantly associated with knowledge and attitude (P < 0.05).
Conclusions
The findings of this study showed that healthcare workers in Qassim region of Saudi Arabia have good knowledge and positive attitude towards MERS. Yet there are areas where low knowledge and negative attitude of HCWs was observed. However, studies are required to assess the knowledge and attitude of HCWs at national level so that effective interventions could be designed as surveillance and infection control measures are critical to global public health.

Epidemiology and Infection
Volume 143 – Issue 02 – January 2015
http://journals.cambridge.org/action/displayIssue?jid=HYG&tab=currentissue

Pneumococcal infection
Appropriateness of administrative data for vaccine impact evaluation: the case of pneumonia hospitalizations and pneumococcal vaccine in Brazil
S. SGAMBATTIa1 c1, R. MINAMISAVAa2, E. T. AFONSOa1a3, C. M. TOSCANOa4, A. L. BIERRENBACHa4 and A. L. ANDRADEa4
a1 Department of Medicine, Pontifical Catholic University of Goiás, Goiânia, Goiás, Brazil
a2 Faculty of Nursing, Federal University of Goiás, Goiânia, Goiás, Brazil
a3 Department of Pediatrics, School of Medicine, Federal University of Goiás, Goiânia, Goiás, Brazil
a4 Department of Community Health, Federal University of Goiás, Goiânia, Goiás, Brazil
SUMMARY
Ten-valent pneumococcal conjugate vaccine (PCV10) was recently introduced into the Brazilian Immunization Programme. Secondary data are used as a measurement of community-acquired pneumonia (CAP) burden, but their completeness and reliability need to be ascertained. We performed probabilistic linkage between hospital primary data from active prospective population-based surveillance (APS) and hospital secondary data from the Hospital Information System administrative database of the National Unified Health System (SIH-SUS). Children aged 2–23 months hospitalized during January–December 2012 were identified. Incidence rates of hospitalized CAP were estimated. Agreement of case identification was measured by kappa index. A total of 1639 (26%) CAP cases were identified in APS and 1714 (35%) in SIH-SUS. Of these 3353 records, 1127 CAP cases were present in both databases. Kappa on CAP case identification was 0•72 (95% confidence interval 0•69–0•75). CAP hospitalization incidence using administrative (5285/100 000) and hospital (5054/100 000) primary data were similar (P = 0•184). Our findings suggest that administrative databases of hospitalizations are reliable sources to assess PCV10 impact in time-series analyses.

Eurosurveillance
Volume 19, Issue 50, 18 December 2014
http://www.eurosurveillance.org/Public/Articles/Archives.aspx?PublicationId=11678

Perspectives
Innovative applications of immunisation registration information systems: example of improved measles control in Taiwan
by DP Liu, ET Wang, YH Pan, SH Cheng
Immunisation registry systems have been shown to be important for finding pockets of under-immunised individuals and for increasing vaccination coverage. The National Immunisation Information System (NIIS) was established in 2003 in Taiwan. In this perspective, we present the construction of the NIIS and two innovative applications, which were implemented in 2009, which link the NIIS with other databases for better control of measles. Firstly, by linking the NIIS with hospital administrative records, we are able to follow up contacts of measles cases in a timely manner to provide the necessary prophylaxis, such as immunoglobulin or vaccines. Since 2009, there have been no measles outbreaks in hospitals in Taiwan. Secondly, by linking the NIIS with an immigration database, we are able to ensure that young citizens under the age of five years entering Taiwan from abroad become fully vaccinated. Since 2009, the measles-mumps-rubella vaccine coverage rate at two years of age has increased from 96% to 98%. We consider these applications of the NIIS to be effective mechanisms for improving the performance of infectious disease control in Taiwan. The experience gained could provide a valuable example for other countries.

Globalization and Health
[Accessed 20 December 2014]
http://www.globalizationandhealth.com/

Research
Involvement of low- and middle-income countries in randomized controlled trial publications in oncology
Wong JC, Fernandes KA, Amin S, Lwin Z and Krzyzanowska MK Globalization and Health 2014, 10:83 (13 December 2014)

Health Research Policy and Systems
http://www.health-policy-systems.com/content
[Accessed 20 December 2014]

Research
Needs assessment to strengthen capacity in water and sanitation research in Africa: experiences of the African SNOWS consortium
Paul R Hunter12*, Samira H Abdelrahman3, Prince Antwi-Agyei4, Esi Awuah4, Sandy Cairncross5, Eileen Chappell5, Anders Dalsgaard6, Jeroen HJ Ensink5, Natasha Potgieter7, Ingrid Mokgobu2, Edward W Muchiri8, Edgar Mulogo9, Mike van der Es1 and Samuel N Odai4
Author Affiliations
Health Research Policy and Systems 2014, 12:68 doi:10.1186/1478-4505-12-68
Published: 15 December 2014
Abstract
Background
Despite its contribution to global disease burden, diarrhoeal disease is still a relatively neglected area for research funding, especially in low-income country settings. The SNOWS consortium (Scientists Networked for Outcomes from Water and Sanitation) is funded by the Wellcome Trust under an initiative to build the necessary research skills in Africa. This paper focuses on the research training needs of the consortium as identified during the first three years of the project.
Methods
We reviewed the reports of two needs assessments. The first was a detailed needs assessment led by one northern partner, with follow-up visits which included reciprocal representation from the African universities. The second assessment, led by another northern partner, focused primarily on training needs. The reports from both needs assessments were read and stated needs were extracted and summarised.
Results
Key common issues identified in both assessments were supervisory skills, applications for external research funding, research management, and writing for publication in the peer-reviewed scientific literature. The bureaucratisation of university processes and inconsistencies through administration processes also caused problems. The lack of specialist laboratory equipment presented difficulties, particularly of inaccessibility through a lack of skilled staff for operation and maintenance, and of a budget provision for repairs and running costs. The lack of taught PhD modules and of research training methods also caused problems. Institutionally, there were often no mechanisms for identifying funding opportunities. On the other hand, grantees were often unable to understand or comply with the funders’ financial and reporting requirements and were not supported by their institution. Skills in staff recruitment, retention, and performance were poor, as were performance in proposal and paper writing. The requirements for ethical clearance were often not known and governance issues not understood, particularly those required by funders.
Conclusions
SNOWS believes that working with African universities to develop networks that support African-led research driven by the local context is an effective approach to develop and retain research skills needed to change policy and practice in water, sanitation, and hygiene in Africa.

JAMA
December 17, 2014, Vol 312, No. 23
http://jama.jamanetwork.com/issue.aspx

Viewpoint | December 17, 2014
Ebola Virus Disease and the Need for New Personal Protective Equipment
Michael B. Edmond, MD, MPH, MPA1; Daniel J. Diekema, MD, MS1; Eli N. Perencevich, MD, MS1,2
Author Affiliations
JAMA. 2014;312(23):2495-2496. doi:10.1001/jama.2014.15497.
[Initial text]
Preventing transmission of pathogens in the health care setting with the use of personal protective equipment (PPE) has been an area of longstanding debate in the infection prevention community. Recently, reports of nosocomial transmission of Ebola virus to 2 nurses from the same patient in Texas (despite their use of PPE) has generated great concern and presents new challenges, particularly because there is no postexposure prophylaxis or effective antiviral therapy for Ebola, and approximately half of the cases are fatal…

Viewpoint | December 17, 2014
Is the United States Prepared for Ebola?
Lawrence O. Gostin, JD, LLD1; James G. Hodge Jr, JD, LLM2; Scott Burris, JD3
Author Affiliations
JAMA. 2014;312(23):2497-2498. doi:10.1001/jama.2014.15041
[Concluding text]
Risk Reduction
Only by controlling Ebola in West Africa can lives be saved and the risks of international spread minimized. Domestically, Ebola prompts the recognition that preparedness depends on the core strength of health systems. Not enough has been done to support well-functioning health systems in West Africa, but the United States also needs to invest more in domestic health system capacity. After the country has spent more than a decade developing preparedness programs and laws, isolated Ebola cases reveal the vital need to build a stronger system for detecting and treating infectious diseases, evaluating and improving performance, and committing to the basic institutions and professionals charged with protecting the public’s health.

Viewpoint | December 17, 2014
Ebola in the United States- EHRs as a Public Health Tool at the Point of Care
Kenneth D. Mandl, MD, MPH1,2
Author Affiliations
JAMA. 2014;312(23):2499-2500. doi:10.1001/jama.2014.15064.
[Concluding text]
ADDRESSING EBOLA AND HEALTH IT NOW
Not technical barriers but a pervasive socioadministrative-regulatory inertia slows progress in health IT. Simple actions taken now could advance health IT as the current Ebola epidemic unfolds but also deliver wider value. For example, diagnosis of streptococcal pharyngitis was substantially improved by integrating data about the local incidence of streptococcal disease and calculating disease risk based on prior probability of disease.8 Hundreds of thousands of antibiotic doses per year could potentially be avoided using these epidemiologically adjusted diagnostic models. Electronic health records are not yet capable of delivering those incidence data into a decision support system at the point of care, but the apps model readily allows data “mash-ups” and novel forms of decision support. To facilitate response to enterovirus D-68—a pathogen with a changing case definition now possibly including flaccid paralysis in rare cases9—a common apps interface to EHRs could enable rapid nationwide uptake of a triage and management app, one that could be updated as the epidemic and clinical picture evolves. Such technological feasibility would also be helpful when the next epidemic arrives. Potential next steps should include:
– Standardize on a programming interface between data and apps. The SMART platform specification, created under a $15 million federal investment, is a good place to start.
– Create the necessary apps functionality. Clinicians, informatics experts, and representatives from the CDC, the World Health Organization, the US Agency for International Development, and nongovernmental organizations could collaborate to design workflows and data displays to improve diagnosis and management apps that work for physicians providing care.
– Liberate data for contextualized diagnosis. Using the open.fda.gov initiative as a model, public health data resources could be identified and made available in computable formats so external data sources can be combined with EHR data to provide clinical and public health intelligence to treating physicians.
– Ready the point of care. Institutions with real-time data warehouses could adopt the SMART application programming interfaces and begin running apps. The largest EHR vendors, several of which have invested in SMART and SMART-inspired programming interfaces, could lead the way in responding to Ebola by upgrading as many installations as possible to support public health apps, as a first-use case.
With Ebola moving across the globe, this aggressively paced response may be achievable in a short time frame. Even if it takes more time, the steps outlined could rapidly transform current-stage HIT into a platform that may turn the point of care into a place for innovation, efficiency, and improved outcomes.

The Lancet
Dec 27, 2014 Volume 384 Number 9961 p2173-2266 e67-e69
http://www.thelancet.com/journals/lancet/issue/current

Editorial
Ebola: protection of health-care workers
The Lancet
DOI: http://dx.doi.org/10.1016/S0140-6736(14)62413-2
Summary
The Ebola outbreak in west Africa has taken a substantial toll on health-care workers in Guinea, Liberia, and Sierra Leone—not only doctors and nurses, but also other cadres including ambulance drivers, hospital cleaners, and burial team members. More than 600 of the nearly 17 000 cases of Ebola virus disease have been in health-care workers, more than half of them fatal. In today’s issue of The Lancet we pay tribute to several of the health workers who have lost their lives to the disease since the outbreak began a year ago.

Obituary
Remembering health workers who died from Ebola in 2014
Andrew Green
DOI: http://dx.doi.org/10.1016/S0140-6736(14)62417-X

Comment
HPV vaccination: for women of all ages?
Philip E Castle, Kathleen M Schmeler
Published Online: 01 September 2014
DOI: http://dx.doi.org/10.1016/S0140-6736(14)61230-7
Summary
The discovery of human papillomavirus (HPV) DNA in cervical cancer by Harald zur Hausen sparked 30 years of research that established that persistent cervical infection by certain HPV genotypes causes cervical cancer. This research has led to revolutionary technical advances for the prevention of cervical cancer: prophylactic HPV vaccination and sensitive molecular HPV testing for screening. These promising technologies can be used to complement or enhance established cervical cancer prevention programmes, and to provide robust solutions in low-resource settings without screening programmes.

Comment
Offline: Can Ebola be a route to nation-building?
Richard Horton
DOI: http://dx.doi.org/10.1016/S0140-6736(14)62387-4
Summary
At one of the first meetings of the UN Mission for Ebola Emergency Response, someone is reported to have said that if anyone present wanted to use Ebola as a reason to strengthen health systems they should leave the room. The Ebola response was about one goal and one goal only—getting to zero cases. How times have changed. Last week, WHO convened a High-Level Meeting on Building Resilient Systems for Health in Ebola-Affected Countries. What seems clear now is that Ebola in west Africa is not (only) about Ebola.

Articles
Efficacy, safety, and immunogenicity of the human papillomavirus 16/18 AS04-adjuvanted vaccine in women older than 25 years: 4-year interim follow-up of the phase 3, double-blind, randomised controlled VIVIANE study
S Rachel Skinner, PhD, Anne Szarewski, PhD, Prof Barbara Romanowski, MD, Prof Suzanne M arland, FRCPA, Prof Eduardo Lazcano-Ponce, PhD, Prof Jorge Salmerón, PhD, M Rowena Del Rosario-Raymundo, MD, Prof René H M Verheijen, MD, Swee Chong Quek, MBBCh, Daniel P da Silva, MD, Prof Henry Kitchener, MD, Kah Leng Fong, MRCOG, Céline Bouchard, FRCSC, Prof Deborah M Money, MD, Arunachalam Ilancheran, MD, Prof Margaret E Cruickshank, MD, Prof Myron J Levin, MD, Prof Archana Chatterjee, MD, Prof Jack T Stapleton, MD, Mark Martens, MD,
Wim Quint, PhD, Marie-Pierre David, MSc, Dorothée Meric, MSc, Karin Hardt, PhD, Dominique Descamps, MD, Brecht Geeraerts, PhD, Frank Struyf, MD, Gary Dubin, MD, for the VIVIANE tudy Group Dr Szarewski died in August, 2013
Published Online: 01 September 2014
DOI: http://dx.doi.org/10.1016/S0140-6736(14)60920-X
Summary
Background
Although adolescent girls are the main population for prophylactic human papillomavirus (HPV) vaccines, adult women who remain at risk of cervical cancer can also be vaccinated. We report data from the interim analysis of the ongoing VIVIANE study, the aim of which is to assess the efficacy, safety, and immunogenicity of the HPV 16/18 AS04-adjuvanted vaccine in adult women.
Methods
In this phase 3, multinational, double-blind, randomised controlled trial, we randomly assigned healthy women older than 25 years to the HPV 16/18 vaccine or control (1:1), via an internet-based system with an algorithm process that accounted for region, age stratum, baseline HPV DNA status, HPV 16/18 serostatus, and cytology. Enrolment was age-stratified, with about 45% of participants in each of the 26–35 and 36–45 years age strata and 10% in the 46 years and older stratum. Up to 15% of women in each age stratum could have a history of HPV infection or disease. The primary endpoint was vaccine efficacy against 6-month persistent infection or cervical intraepithelial neoplasia grade 1 or higher (CIN1+) associated with HPV 16/18. The primary analysis was done in the according-to-protocol cohort for efficacy, which consists of women who received all three vaccine or control doses, had negative or low-grade cytology at baseline, and had no history of HPV disease. Secondary analyses included vaccine efficacy against non-vaccine oncogenic HPV types. Mean follow-up time was 40•3 months. This study is registered with ClinicalTrials.gov, number NCT00294047.
Findings
The first participant was enrolled on Feb 16, 2006, and the last study visit for the present analysis took place on Dec 10, 2010; 5752 women were included in the total vaccinated cohort (n=2881 vaccine, n=2871 control), and 4505 in the according-to-protocol cohort for efficacy (n=2264 vaccine, n=2241 control). Vaccine efficacy against HPV 16/18-related 6-month persistent infection or CIN1+ was significant in all age groups combined (81•1%, 97•7% CI 52•1–94•0), in the 26–35 years age group (83•5%, 45•0–96•8), and in the 36–45 years age group (77•2%, 2•8–96•9); no cases were seen in women aged 46 years and older. Vaccine efficacy against atypical squamous cells of undetermined significance or greater associated with HPV 16/18 was also significant. We also noted significant cross-protective vaccine efficacy against 6-month persistent infection with HPV 31 (79•1%, 97•7% CI 27•6–95•9) and HPV 45 (76•9%, 18•5–95•6]) Serious adverse events occurred in 285 (10%) of 2881 women in the vaccine group and 267 (9%) of 2871 in the control group; five (<1%) and eight (<1%) of these events, respectively, were believed to be related to vaccination.
Interpretation
In women older than 25 years, the HPV 16/18 vaccine is efficacious against infections and cervical abnormalities associated with the vaccine types, as well as infections with the non-vaccine HPV types 31 and 45.

Viewpoint
Improving the assessment and attribution of effects of development assistance for health
Nour Ataya, MPH, Christoph Aluttis, MSc, Prof Antoine Flahault, PhD, Prof Rifat Atun, FRCP, Prof Andy Haines, FMedSci
Published Online: 25 June 2014
DOI: http://dx.doi.org/10.1016/S0140-6736(14)60791-1
Summary
Overseas development assistance for health (DAH) increased substantially from 2000, but has plateaued since 2010 because of the global economic crisis,1 with growing public demands for funders and beneficiary countries to show the effect of investments.2–5 When showing effect, donor agencies and countries need to address two challenges: first, accurate estimation of the effects of investments in different areas (eg, vaccines or health systems) on health outcomes; and second, attribution of the effects to specific investments.

The Milbank Quarterly
A Multidisciplinary Journal of Population Health and Health Policy
December 2014 Volume 92, Issue 4 Pages 633–840
http://onlinelibrary.wiley.com/journal/10.1111/(ISSN)1468-0009/currentissue

Editor-in-Chief
Ebola Fever and Global Health Responsibilities (pages 633–639)
HOWARD MARKEL
Article first published online: 10 DEC 2014 | DOI: 10.1111/1468-0009.12084
Abstract Full Article (HTML)

Op-Eds
The Strange Journey of Population Health (pages 640–643)
JOSHUA M. SHARFSTEIN
Article first published online: 10 DEC 2014 | DOI: 10.1111/1468-0009.12082
Abstract Full Article (HTML)

Ethical Allocation of Drugs and Vaccines in the West African Ebola Epidemic (pages 662–666)
LAWRENCE O. GOSTIN
Article first published online: 10 DEC 2014 | DOI: 10.1111/1468-0009.12089
Abstract Full Article (HTML)

Nature
Volume 516 Number 7531 pp287-444 18 December 2014
http://www.nature.com/nature/current_issue.html

Comment
Infectious disease: Mobilizing Ebola survivors to curb the epidemic
Joshua M. Epstein, Lauren M. Sauer, Julia Chelen, Erez Hatna, Jon Parker, Richard E. Rothman & Lewis Rubinson
17 December 2014
Scaling up the recruitment of individuals who have recovered from infection deserves urgent consideration, argue Joshua M. Epstein, Lauren M. Sauer and colleagues.
Multiple governments and non-governmental organizations have called on health-care personnel the world over to help control West Africa’s Ebola outbreak; these include Médecins Sans Frontières (MSF), the World Health Organization (WHO) and United Nations children’s charity UNICEF. But the demand for labour far exceeds the supply1. UN estimates, which may be low, suggest that approximately 5,000 international medical, training and support personnel are needed in the coming months.
While foreign assistance must continue, a nascent local strategy is a candidate for broad adoption. We call it MORE, for MObilization of REcovered individuals. The idea is simple: those who have recovered from Ebola could be engaged to reduce transmission, helping to bring the epidemic under control.
Examples of the approach can be seen in Sierra Leone, Guinea and Liberia. For instance, the UN is training survivors to support children who have had contact with infected individuals and are within Ebola’s 21-day incubation window (the time it takes to develop symptoms after being infected with the virus). MSF is similarly employing survivors to work in their Ebola treatment units in Guinea and Liberia.
There are uncertainties about the ultimate size of this cadre and, crucially, about the immunity of recovered responders to reinfection, both immediately and in the longer term (because immunity may wane). Nonetheless, the potential of MORE to shift the epidemic’s dynamics makes its consideration imperative…

New England Journal of Medicine
December 18, 2014 Vol. 371 No. 25
http://www.nejm.org/toc/nejm/medical-journal

Perspective
Panic, Paranoia, and Public Health — The AIDS Epidemic’s Lessons for Ebola
Gregg Gonsalves, B.S., and Peter Staley
N Engl J Med 2014; 371:2348-2349 December 18, 2014
DOI: 10.1056/NEJMp1413425
For those of us who lived through the early days of the U.S. AIDS epidemic, the current national panic over Ebola brings back some very bad memories. The toxic mix of scientific ignorance and paranoia on display in the reaction to the return of health care workers from the front lines of the fight against Ebola in West Africa, the amplification of these reactions by politicians and the media, and the fear-driven suspicion and shunning of whole classes of people are all reminiscent of the response to the emergence of AIDS in the 1980s…

Perspective
Evaluating Ebola Therapies — The Case for RCTs
Edward Cox, M.D., M.P.H., Luciana Borio, M.D., and Robert Temple, M.D.
N Engl J Med 2014; 371:2350-2351 December 18, 2014
DOI: 10.1056/NEJMp1414145

Brief Report
Clinical Care of Two Patients with Ebola Virus Disease in the United States
G. Marshall Lyon, M.D., M.M.Sc., Aneesh K. Mehta, M.D., Jay B. Varkey, M.D., Kent Brantly, M.D., Lance Plyler, M.D., Anita K. McElroy, M.D., Ph.D., Colleen S. Kraft, M.D., Jonathan S. Towner, Ph.D., Christina Spiropoulou, Ph.D., Ute Ströher, Ph.D., Timothy M. Uyeki, M.D., M.P.H., M.P.P., and Bruce S. Ribner, M.D., M.P.H. for the Emory Serious Communicable Diseases Unit
N Engl J Med 2014; 371:2402-2409
December 18, 2014
DOI: 10.1056/NEJMoa1409838
Abstract
West Africa is currently experiencing the largest outbreak of Ebola virus disease (EVD) in history. Two patients with EVD were transferred from Liberia to our hospital in the United States for ongoing care. Malaria had also been diagnosed in one patient, who was treated for it early in the course of EVD. The two patients had substantial intravascular volume depletion and marked electrolyte abnormalities. We undertook aggressive supportive measures of hydration (typically, 3 to 5 liters of intravenous fluids per day early in the course of care) and electrolyte correction. As the patients’ condition improved clinically, there was a concomitant decline in the amount of virus detected in plasma.

Editorial
Out of Africa — Caring for Patients with Ebola
Eric J. Rubin, M.D., Ph.D., and Lindsey R. Baden, M.D.
N Engl J Med 2014; 371:2430-2432 December 18, 2014
DOI: 10.1056/NEJMe1412744
[Final paragraph]
…The most important take-home message from these case reports is the importance of intensive fluid management and care. The case fatality rate in the current outbreak is approximately 70%.8 It is unlikely that the patient treated in Germany would have survived without modern, state-of-the-art care. But approximately 30% of patients are surviving with only the modest support that is available in treatment centers in West Africa. Another filovirus infection, Marburg hemorrhagic fever, was associated with a mortality rate of approximately 25% in Germany but approximately 80% in sub-Saharan Africa, further suggesting that optimal supportive care plays a crucial role in the overall outcome of these infections.9,10 Although this news is encouraging for patients with access to an intensive care unit, it is only more discouraging for those in areas where such infections are endemic and even basic care is often unavailable. It will be a tremendous challenge to bring to all patients the benefits of routine care, such as intravenous fluid and electrolyte support, as part of the response to this epidemic, but it must be done.

PLoS Currents: Outbreaks
http://currents.plos.org/outbreaks/
(Accessed 20 December 2014)

Ebola and Indirect Effects on Health Service Function in Sierra Leone
December 19, 2014 • Research
Background: The indirect effects of the Ebola epidemic on health service function may be significant but is not known. The aim of this study was to quantify to what extent admission rates and surgery has changed at health facilities providing such care in Sierra Leone during the time of the Ebola epidemic.
Methods: Weekly data on facility inpatient admissions and surgery from admission and surgical theatre register books were retrospectively retrieved during September and October. 21 Community Health Officers enrolled in a surgical task-shifting program personally visited the facilities. The study period was January 6 (week 2) to October 12, (week 41) 2014.
Results: Data was retrieved from 40 out of 55 facilities. A total of 62,257 admissions and 12,124 major surgeries were registered for the study period.
Total admissions in the week of the first Ebola case were 2,006, median 40 (IQR 20-76) compared to 883, median 12 (IQR 4-30) on the last week of the study. This equals a 70% drop in median number of admissions (p=0.005) between May and October. Total number of major surgeries fell from 342, median 6 (IQR 2-14) to 231, median 3 (IQR 0-6) in the same period, equal 50% reduction in median number of major surgeries (p=0.014).
Conclusions: Inpatient health services have been severely affected by the Ebola outbreak. The dramatic documented decline in facility inpatient admissions and major surgery is likely to be an underestimation. Reestablishing such care is urgent and must be a priority.

Estimation of MERS-Coronavirus Reproductive Number and Case Fatality Rate for the Spring 2014 Saudi Arabia Outbreak: Insights from Publicly Available Data
December 18, 2014 • Research
Background: The Middle East Respiratory Syndrome Coronavirus (MERS-CoV) was initially recognized as a source of severe respiratory illness and renal failure in 2012. Prior to 2014, MERS-CoV was mostly associated with sporadic cases of human illness, of presumed zoonotic origin, though chains of person-to-person transmission in the healthcare setting were reported. In spring 2014, large healthcare-associated outbreaks of MERS-CoV infection occurred in Jeddah and Riyadh, Kingdom of Saudi Arabia. To date the epidemiological information published by public health investigators in affected jurisdictions has been relatively limited. However, it is important that the global public health community have access to information on the basic epidemiological features of the outbreak to date, including the basic reproduction number (R0) and best estimates of case-fatality rates (CFR). We sought to address these gaps using a publicly available line listing of MERS-CoV cases.
Methods: R0 was estimated using the incidence decay with exponential adjustment (“IDEA”) method, while period-specific case fatality rates that incorporated non-attributed death data were estimated using Monte Carlo simulation.
Results: 707 cases were available for evaluation. 52% of cases were identified as primary, with the rest being secondary. IDEA model fits suggested a higher R0 in Jeddah (3.5-6.7) than in Riyadh (2.0-2.8); control parameters suggested more rapid reduction in transmission in the former city than the latter. The model accurately projected final size and end date of the Riyadh outbreak based on information available prior to the outbreak peak; for Jeddah, these projections were possible once the outbreak peaked. Overall case-fatality was 40%; depending on the timing of 171 deaths unlinked to case data, outbreak CFR could be higher, lower, or equivalent to pre-outbreak CFR.
Conclusions: Notwithstanding imperfect data, inferences about MERS-CoV epidemiology important for public health preparedness are possible using publicly available data sources. The R0 estimated in Riyadh appears similar to that seen for SARS-CoV, but CFR appears higher, and indirect evidence suggests control activities ended these outbreaks. These data suggest this disease should be regarded with equal or greater concern than the related SARS-CoV.

PLoS Medicine
(Accessed 20 December 2014)
http://www.plosmedicine.org/

Policy Forum
World Health Organization Guidelines for Management of Acute Stress, PTSD, and Bereavement: Key Challenges on the Road Ahead
Wietse A. Tol mail, Corrado Barbui, Jonathan Bisson, Judith Cohen, Zeinab Hijazi, Lynne Jones, Joop T. V. M. de Jong, Nicola Magrini, Olayinka Omigbodun, Soraya Seedat, Derrick Silove, Renato Souza, Athula Sumathipala, [ … ], Mark van Ommeren , [ view all ]
Published: December 16, 2014
DOI: 10.1371/journal.pmed.1001769
Summary Points
:: The implementation of new WHO mental health guidelines for conditions and disorders specifically related to stress is likely to face obstacles, particularly in low- and middle-income countries.
:: Formulation of evidence-based guidelines is complicated by limited knowledge regarding (a) the effectiveness of commonly implemented interventions, (b) the effectiveness of established evidence-based interventions when used in situations of ongoing adversity, and (c) the effectiveness of widely used cultural practices in LMICs. The application of the guidelines requires improved knowledge on how to reduce potentially harmful practices that are widely applied.
:: The implementation of recommendations regarding psychotherapeutic interventions will require an approach that balances (a) strengthening the availability and capacity of specialists to train and supervise and (b) shifting to the delivery of psychotherapy by non-specialists.
:: The strengthening of evidence for managing these conditions will require collaborative efforts by researchers and practitioners in a manner that is mindful of local sociocultural and health system realities.

PLoS One
[Accessed 20 December 2014]
http://www.plosone.org/

Research Article
The Relationship between Influenza Vaccination Habits and Location of Vaccination
Lori Uscher-Pines mail, Andrew Mulcahy, Jurgen Maurer, Katherine Harris
Published: December 09, 2014
DOI: 10.1371/journal.pone.0114863
Abstract
Objectives
Although use of non-medical settings for vaccination such as retail pharmacies has grown in recent years, little is known about how various settings are used by individuals with different vaccination habits. We aimed to assess the relationship between repeated, annual influenza vaccination and location of vaccination.
Study Design: We conducted a cross-sectional survey of 4,040 adults in 2010.
Methods: We fielded a nationally representative survey using an online research panel operated by Knowledge Networks. The completion rate among sampled panelists was 73%.
Results: 39% of adults reported that they have never received a seasonal influenza vaccination. Compared to those who were usually or always vaccinated from year to year, those who sometimes or rarely received influenza vaccinations were significantly more likely to be vaccinated in a medical setting in 2009–2010.
Conclusions: Results indicate that while medical settings are the dominant location for vaccination overall, they play an especially critical role in serving adults who do not regularly receive vaccinations. By exploring vaccination habits, we can more appropriately choose among interventions designed to encourage the initiation vs. maintenance of desired behaviors.

PNAS – Proceedings of the National Academy of Sciences of the United States of America
(Accessed 20 December 2014)
http://www.pnas.org/content/early/

Economic optimization of a global strategy to address the pandemic threat
Jamison Pikea,b, Tiffany Bogichb,c,d, Sarah Elwoodb, David C. Finnoffa, and Peter Daszakb,1
Author Affiliations
Edited by Robert M. May, University of Oxford, Oxford, United Kingdom, and approved November 17, 2014 (received for review July 4, 2014)
Significance
Emerging pandemics are increasing in frequency, threatening global health and economic growth. Global strategies to thwart pandemics can be classed as adaptive (reducing impact after a disease emerges) or mitigation (reducing the causes of pandemics). Our economic analysis shows that the optimal time to implement a globally coordinated adaptive policy is within 27 y and that given geopolitical challenges around pandemic control, these should be implemented urgently. Furthermore, we find that mitigation policies, those aimed at reducing the likelihood of an emerging disease originating, are more cost effective, saving between $344.0 billion and $360.8 billion over the next 100 y if implemented today.
Abstract
Emerging pandemics threaten global health and economies and are increasing in frequency. Globally coordinated strategies to combat pandemics, similar to current strategies that address climate change, are largely adaptive, in that they attempt to reduce the impact of a pathogen after it has emerged. However, like climate change, mitigation strategies have been developed that include programs to reduce the underlying drivers of pandemics, particularly animal-to-human disease transmission. Here, we use real options economic modeling of current globally coordinated adaptation strategies for pandemic prevention. We show that they would be optimally implemented within 27 y to reduce the annual rise of emerging infectious disease events by 50% at an estimated one-time cost of approximately $343.7 billion. We then analyze World Bank data on multilateral “One Health” pandemic mitigation programs. We find that, because most pandemics have animal origins, mitigation is a more cost-effective policy than business-as-usual adaptation programs, saving between $344.0.7 billion and $360.3 billion over the next 100 y if implemented today. We conclude that globally coordinated pandemic prevention policies need to be enacted urgently to be optimally effective and that strategies to mitigate pandemics by reducing the impact of their underlying drivers are likely to be more effective than business as usual.

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

Vaccine
Available online 15 December 2014
Evaluation of invalid vaccine doses in 31 countries of the WHO African Region
Manas K. Akmatova, b, Elizabeth Kimani-Muragec, Frank Pesslerb, Carlos A. Guzmand, Gérard Krausea, e, Lothar Kreienbrockf, Rafael T. Mikolajczyka, e
Highlights
:: A systematic evaluation of invalid vaccinations, i.e. vaccinations administered earlier than recommended or with too short intervals between vaccine doses, in countries of the WHO African Region has not been performed yet.
:: We found that in most African countries a relevant proportion of vaccines were administered at ages or intervals not compliant with established recommendations.
:: Invalid vaccinations were partly associated with individual and with community associated factors.
:: Community contextual factors should be considered when planning immunisation services.
Abstract
We examined (a) the fraction of and extent to which vaccinations were administered earlier than recommended (age-invalid) or with too short intervals between vaccine doses (interval-invalid) in countries of the World Health Organisation (WHO) African Region and (b) individual- and community-level factors associated with invalid vaccinations using multilevel techniques. Data from the Demographic and Health Surveys conducted in the last 10 years in 31 countries were used. Information about childhood vaccinations was based on vaccination records (n = 134,442). Invalid vaccinations (diphtheria, tetanus, pertussis [DTP1, DTP3] and measles-containing vaccine (MCV)) were defined using the WHO criteria. The median percentages of invalid DTP1, DTP3 and MCV vaccinations across all countries were 12.1% (interquartile range, 9.4–15.2%), 5.7% (5.0–7.6%), and 15.5% (10.0–18.1%), respectively. Of the invalid DTP1 vaccinations, 7.4% and 5.5% were administered at child’s age of less than one and two weeks, respectively. In 12 countries, the proportion of invalid DTP3 vaccinations administered with an interval of less than two weeks before the preceding dose varied between 30% and 50%. In 13 countries, the proportion of MCV doses administered at child’s age of less than six months varied between 20% and 45%. Community-level variables explained part of the variation in invalid vaccinations. Invalid vaccinations are common in African countries. Timing of childhood vaccinations should be improved to ensure an optimal protection against vaccine-preventable infections and to avoid unnecessary wastage in these economically deprived countries.
Journal of Hospital Infection
Available online 16 December 2014
Sociocognitive predictors of the intention of healthcare workers to receive the influenza vaccine in Belgian, Dutch and German hospital settings
B.A. Lehmanna, R.A.C. Ruitera, D. van Damb, S. Wickerc, G. Koka
Abstract
Background
Influenza vaccination of healthcare workers (HCWs) is recommended to prevent the transmission of influenza to vulnerable patients. Nevertheless, vaccination coverage rates of HCWs in European countries have been low.
Aim
To investigate the relative and combined strength of sociocognitive variables, from past research, theory and a qualitative study, in explaining the motivation of HCWs to receive the influenza vaccine.
Methods
An anonymous, online questionnaire was distributed among HCWs in hospital settings in Belgium, Germany and the Netherlands between February and April 2013.
Findings
Attitude and past vaccination uptake explained a considerable amount of variance in the intention of HCWs to receive the influenza vaccine. Moreover, low perceived social norms, omission bias, low moral norms, being older, having no patient contact, and being Belgian or Dutch (compared with German) increased the probability of having no intention to receive the influenza vaccine compared with being undecided about vaccination. High intention to receive the influenza vaccine was shown to be more likely than being undecided about vaccination when HCWs had high perceived susceptibility of contracting influenza, low naturalistic views, and lower motivation to receive the vaccine solely for self-protection.
Conclusion
Country-specific interventions and a focus on different sociocognitive variables depending on the intention/lack of intention of HCWs to receive the influenza vaccine may be beneficial to promote vaccination uptake.

Media/Policy Watch

Council on Foreign Relations
http://www.cfr.org/
Accessed 20 December 2014
Op-Ed
A New Direction for Global Health
by Thomas J. Bollyky, Thomas E. Donilon, Mitchell E. Daniels Jr. December 15, 2014
Dramatic changes in urbanization, global trade, and consumer markets – which occurred over decades in wealthy countries – are happening at a faster rate, and at a much larger scale, in still-poor countries. These trends have brought substantial health benefits, but have given rise to significant challenges as well.

Forbes
http://www.forbes.com/
Accessed 20 December 2014
MedidataVoice: Fighting Viral Epidemics: The Long Road To A Dengue Vaccine
Dec 18, 2014
Guest post by Kasia Hein-Peters, VP, Head of Marketing Dengue Vaccine, at Sanofi Pasteur.
Dengue is currently the most common vector-borne virus disease and puts nearly half of the world at risk of this disease. Even though people living in Europe or the U.S. may not be familiar with it (and more […]
NHL Mumps Outbreak: What’s Up With The Vaccine?
Tara Haelle, Contributor Dec 16, 2014
The number of NHL hockey players diagnosed with the mumps may rise to 14 soon, depending on the test results that come back for Pittsburgh Penguins forward Beau Bennett. Though his symptoms could be the flu or another illness, a positive mumps result would make him the second Penguin to […]
The Ebola Treatment You Haven’t Heard Of
David Kroll, Contributor
Pharmaceuticals and biotechnology-derived products have attracted the greatest public and professional interest in treating victims of Ebola virus disease. But a privately-held, small company with a treatment for shock and multi-organ failure may be the dark horse victor in the race to stop the West African outbreak. LB1148 from San Diego-based Leading BioSciences is starting Phase 2 clinical trials that build on 12 years of NIH-funded research to address an underappreciated, common denominator in shock and organ failure, including shock caused by Ebola infection.

The Guardian
http://www.guardiannews.com/
Accessed 20 December 2014
NHS Ebola staff ‘insulted’ by UK travel ban
Volunteers’ anger at restrictions imposed on their return home from west Africa
Tracy McVeigh
Saturday 20 December 2014
As the latest of the six British-built Ebola treatment centres in west Africa admitted its first three patients this weekend, some of the volunteer NHS staff working there over Christmas said they felt insulted by a draconian ramping up of the protocols they have been told they will have to follow when they return to the UK.
Public Health England (PHE) has told the NHS personnel it is increasing restrictions on their movements when they return from the frontline of Ebola-infection, banning them from travelling on public transport for longer than an hour and increasing from two to three the number of weeks before they can return to work.
For Dr John Wright, a clinical epidemiologist from Bradford working at the clinic at Moyamba, Sierra Leone, which opened on Friday, it was a slap in the face for him and his colleagues.
“It’s a return to the ecology of fear that they insisted they were going to steer clear of,” he said. “No travel, no shared accommodation, no clinical work, a fever parole officer to report to daily. Why not issue us with plague masks and bells?…

Reuters
http://www.reuters.com/
Accessed 20 December 2014
China approves experimental Ebola vaccine for clinical trials
SHANGHAI Thu Dec 18, 2014 6:06am EST
(Reuters) – China has approved a domestically developed experimental Ebola vaccine for clinical trials, the official Xinhua news agency said on Thursday, citing the People’s Liberation Army logistics unit.
Scientists around the world are racing to develop Ebola vaccines after the world’s worst outbreak of the virus, which has killed more than 6,000 people in West Africa this year.
The Chinese vaccine is being developed by the Academy of Military Medical Sciences, Xinhua said, a military research unit which is also involved in developing a drug to treat the disease.
“This follows American and Canadian vaccines to become the third Ebola vaccine to enter clinical trials,” the official Chinese state news agency said.
The news agency did not say when the trials would start, but other media said it would be this month.
British drugmaker GlaxoSmithKline PLC is one of the front runners in developing an Ebola vaccine along with a vaccine being developed by Merck and NewLink. Both are in clinical trials, while other experimental vaccines are expected to start clinical trials next year.
A big trial in Liberia, involving up to 30,000 participants, will test single shots of GSK’s vaccine, the rival one from NewLink and Merck, and a placebo.
Chinese biotechnology firm Tianjin CanSino Biotechnology Inc is also involved in developing the vaccine, Xinhua said.

Ebola/EVD: Additional Coverage [to 20 December 2014]

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 20 December 2014.

News
UNMEER confident that Conakry Warehouse fire will not hinder Ebola response (18 December 2014)

Ebola: UN Secretary-General will visit West Africa to ‘show solidarity with those affected’
17 December 2014 Secretary-General Ban Ki-moon announced he will leave today for the countries hardest hit by the Ebola outbreak “to show my solidarity with those affected and urge even greater global action” to fight the epidemic, which two United Nations food agencies said could push the number of people facing food insecurity to more than one million by next spring.

Ebola: UN says health workers in Sierra Leone to receive hazard pay using mobile money
16 December 2014 Response workers battling the Ebola outbreak in West Africa will receive “hazard pay” for the first time in Sierra Leone using mobile money because “unless there is a certain element of incentives, or danger pay, it’s very difficult to attract and retain people,” the United Nations Development Programme (UNDP) announced today.

Ebola: UN forum urges debt relief for hard-hit countries, as search for faster diagnostics gets underway
15 December 2014 The United Nations Economic Commission for Africa (ECA) today recommended that creditors should seriously consider debt cancellation for the countries worst-hit by the Ebola epidemic in West Africa, and also projected that even if those most affected were to register zero economic growth, the impact on Africa as a continent would be minimal.
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.

19 December 2014 |
Key Political and Economic Developments
1. UN Secretary-General Ban Ki-moon arrived in Ghana yesterday, the first stop on his visit to West Africa. He met with Ghanaian president John Dramani Mahama to discuss the EVD response, which is being directed from the UNMEER headquarters in Accra. He was briefed on the response and UNMEER’s work by Tony Banbury, the head of UNMEER, and the UNMEER senior leadership. Today the Secretary-General will visit Liberia and Sierra Leone.
2. A warehouse with supplies for the EVD operation caught fire yesterday morning in Conakry, at the main humanitarian logistics base located at the city’s airport. No casualties were reported. The fire in the warehouse, mainly containing pharmaceutical supplies and laboratory materials, was discovered when the workers arrived in the morning. The warehouse is used by Médecins sans Frontières (MSF), the World Health Organization (WHO), UNICEF, the Red Cross, the World Food Programme (WFP) and the Pharmacie Centrale de Guinée to store supplies for the EVD emergency response under the umbrella of UNMEER. The exact amount of property and material damaged as a result of the fire is not yet known. Firefighters of the airport and of the city of Conakry, who immediately intervened, extinguished the fire. An investigation is ongoing. “This is a regrettable loss, but no one was hurt and we will move quickly together with our partners to replace the lost supplies”, SRSG Banbury said. “We certainly won’t be deterred in our fight against Ebola.”
Response Efforts and Health
4. According to WHO, a number of healthcare workers have tested EVD positive in the main health centre in Kérouané, Guinea. The affected personnel includes the centre’s director, a midwife, 2 nurses and an ambulance driver. The patients have been transferred to the Donka ETC in Conakry, and contacts are being identified and followed up. Following the spread of this news, a security incident occurred on 17 December when members of the local community including groups of youths threatened to ransack the EVD transit centre in Kérouané. The prefectural coordination appealed for calm and instructed responders from WHO, African Union and ECOWAS/ West African Health Organization to suspend their activities and remain in their hotel. The authorities also dispatched a police unit. As a result of these measures, the threats of violence were not carried out.
6. China has approved a domestically developed experimental EVD vaccine for clinical trials. The Chinese vaccine is being developed by the Academy of Military Medical Sciences, a military research unit which is also involved in developing a drug to treat the disease. It has been reported that the trials would start this month.
Resource Mobilisation
12. The OCHA Ebola Virus Outbreak Overview of Needs and Requirements, now totaling US$ 1.5 billion, has been funded for $ 1.04 billion, which is around 69 percent of the total ask.
13. The Ebola Response Multi-Partner Trust Fund currently has US$ 129.8 million in commitments. In total $ 140 million has been pledged.

18 December 2014 |
Key Political and Economic Developments
1. UN Secretary-General Ban Ki-moon today will start his visit to the African countries affected by the EVD outbreak, to express his support and advocate for continued international assistance until the epidemic ends. He will start his tour in Accra, Ghana, where UNMEER’s headquarters are located. He will be joined by Margaret Chan, Director-General of the World Health Organization, David Nabarro, his special envoy on Ebola, and Tony Banbury, head of UNMEER, on visits to Sierra Leone, Guinea, Liberia and Mali. “I want to see the response for myself, and show my solidarity with those affected and urge even greater global action,” Ban said before leaving New York. “The Ebola response strategy is working, and we are beginning to see improvements,” he added. “But now is not the time to ease up on our efforts. As long as there is one case of Ebola, the risk remains.”
Response Efforts and Health
3. EVD transmission remains intense in Sierra Leone, with 327 new confirmed cases reported in the week to 14 December. Transmission is most intense and persistent in the western and northern districts of the country. The capital, Freetown, accounted for 125 of all new confirmed cases. Response partners and the government of Sierra Leone have implemented the Western Area Surge, an operation to intensify efforts to curb the disease in the western parts of the country. The response targets Freetown and neighbouring areas to break chains of transmission, and increase the number of beds to ensure patients with clinical symptoms of EVD are isolated and receive appropriate treatment..
Outreach and Education
14. This week, 11,501 households across 15 counties in Liberia were reached through door-to-door visits with EVD prevention and home protection messages. 17,966 women, 13,660 men and 11,112 children were engaged through 221 meetings and group discussions. 410 people across the country participated in 13 training workshops on community engagement. Social mobilizers also interacted with 692 community leaders and elders through community dialogues.
Essential Services
15. The number of people facing food insecurity due to the EVD epidemic in Guinea, Liberia, and Sierra Leone could top 1 million by March 2015 unless access to food is drastically improved and measures are put in place to safeguard crop and livestock production, the UN Food and Agriculture Organization (FAO) and the World Food Programme (WFP) warned Wednesday. Already, the EVD epidemic has seriously affected food supply chains in West Africa, leaving 500,000 people without enough to eat. Food security has deteriorated due to crop losses and the disruption of production and supply chains. In addition, the outbreak has hurt the overall economies in the three countries, leaving them with less money to pay for necessary food imports. FAO and WFP urged donors to jump-start agriculture in the region by funding necessary products including seeds, fertilizers and farming technology. They also recommended that people should be given cash or vouchers to stimulate markets.
17. The first US$ 2 million tranche from the Ebola Multi Partner Trust Fund has been received by UNICEF for a project aimed at supporting the wellbeing and protection of EVD affected children in Liberia. The $ 4 million project, implemented in partnership with the Ministry of Health and Social Welfare, is meant to support appropriate alternative care, social protection, social mobilization and social safety nets for EVD-affected children in Liberia.

17 December 2014 |
Key Political and Economic Developments
1. President Ernest Bai Koroma of Sierra Leone announced that government officials will begin a house-to-house search on Wednesday for sick people in the Western Area, which includes Freetown. It was not clear, however, if people had to stay in their homes and, if so, for how long. The Sierra Leonean government has periodically restricted movements into and out of hot spots in order to slow the disease’s spread. Freetown and its surrounding areas currently account for more than half of the country’s new infections.
2. The director of the United States Centres for Disease Control and Prevention (CDC), Dr. Thomas Frieden, visited Guinea on 15 December. Dr. Frieden met, among others, with the coordinator of the National Ebola Response Cell, Dr. Sakoba Keita and participated in the national response coordination meeting. Dr. Frieden, Dr. Sakoba and a delegation including the United States Ambassador took part in a visit to the ETC in Macenta, where they attended a ceremony awarding a certificate to two survivors of EVD.
3. Britain said on Tuesday it would not be seeking US military assistance to fight EVD in Sierra Leone, where it expects to see “enormous change” by the end of January following a surge in response measures. The head of the British taskforce, Donal Brown, said he expected a breakthrough within four to six weeks. “The pieces are in place to fight the disease, which weren’t here a month ago. So I think you will see enormous change in the next few weeks,” Brown said Tuesday. While Britain is discussing how the US government might provide more foreign health workers and assist in the building of additional laboratories for EVD testing, Brown said there was no need for US military support in Sierra Leone. The UK is calling for additional resources from the World Health Organization to boost case surveillance for rural areas.
Outreach and Education
16. UNMEER’s FCM covering Nzérékoré, Guinea, was informed about instances of resistance in different parts of the prefecture where the local community has resorted to hiding persons suspected of having EVD or has outright refused to refer them to the nearest ETC in Nzérékoré. Villages such as Kaya and Tilepulo have refused any EVD response activity. In the district of Wessoah, youth groups have reportedly decided to prevent any EVD-related activities by community agents or the Guinean Red Cross. In response, UNMEER has proposed a meeting to be held this week with the prefectural coordination and UNICEF to plan a sensitization campaign to be funded by UNICEF, with highly regarded community members such as elders, teachers and other civil servants who will in turn disseminate EVD prevention and response messages at the local level. This campaign is to be followed by a sensitization mission led by the prefect in communities displaying resistance.

16 December 2014 |
Key Political and Economic Developments
1. Liberia will hold delayed senatorial elections on December 20, the National Election Commission said on Sunday, a day after the Supreme Court ruled the vote should go ahead despite the EVD outbreak. The court had suspended campaigning for the vote last month, while it considered a petition from a group that included some former government officials and political party representatives. The group had warned that electioneering risked spreading the virus.
2. WHO Assistant Director-General Bruce Aylward has stated that the failure of Sierra Leone’s strategy for fighting EVD may be down to a missing ingredient: a big shock that could change people’s behavior and prevent further infection, such as what happened in Monrovia in August when the disease had a big flare-up there. “Every new place that gets infected goes through that same terrible learning curve where a lot of people have to die … before those behaviors start to change,” Aylward said. Sierra Leone’s Health Minister Abu Bakarr Fofanah said the government was considering banning some unsafe practices. He recognized however that it would be difficult to police such a law. Fofanah noted that some areas of eastern Sierra Leone that were hit hardest early in the epidemic — around the towns of Kenema and Kailahun — have seen a massive reduction in case numbers as people change behavior. “The areas that are now doing badly are the areas that were affected last. They are still on the learning curve.”
3. The UN Security Council on Monday extended the mandate of the UN Mission in Liberia (UNMIL) for another nine months until September 30, 2015. The mission will continue to provide, among other tasks, humanitarian assistance and electoral support, as well as human rights promotion and protection. The council recognized that the EVD outbreak in Liberia has slowed the efforts of the government to advance certain governance and national reform priorities, and emphasized the need for continued progress on constitutional and institutional reforms, especially of the rule of law and security sectors and the national reconciliation processes.
4. The UN Economic Commission for Africa has asked for more debt cancellations for the three countries hardest hit by EVD. The commission said Monday that it is crucial that the current health crisis not be a catalyst for financial distress in Sierra Leone, Guinea and Liberia. Carlos Lopez, the executive secretary of the commission, appealed on Monday for loan forgiveness.
Response Efforts and Health
7. Liberia has begun treating EVD patients with serum therapy – a treatment made from the blood of recovered survivors. If a person has successfully fought off EVD infection, they will have antibodies in their blood that can attack the virus. Doctors can then take a sample of their blood and turn it into a serum – by removing the red blood cells but keeping the antibodies – which can be used to treat other patients. Patients treated in the UK and the US have already received this type of treatment. The treatment is being given by doctors at the ELWA Hospital in Monrovia.
9. A pilot project in Guinea spearheaded by the NERC with support from experts from Columbia University, on collection and transmission of contact tracing information via mobile phones, is being conducted in Conakry, Dubreka and Coyah prefectures. To date, a training of trainers has been provided to 27 supervisors and 130 community agents working in these 3 prefectures. The pilot will test whether the data collected via mobile transmission corresponds to the data collected via the current paper-based system. If the pilot phase is successful, the NERC is to decide whether to roll out this solution in the country’s 33 prefectures.

15 December 2014 |
Response Efforts and Health
4. The Sierra Leonean National Ebola Response Centre (NERC), with UNMEER support, will for the first time pay hazard payments to Ebola Response Workers (ERWs) using mobile money. This marks an important shift from cash payments to an electronic solution that improves the overall efficiency, timeliness and security of payments for the ERWs. The transition to electronic payments will bolster the effectiveness of fiscal operations through efficient receipts and payments, as well as the security of transactions targeting the ERWs. It will help to eliminate wastes and leakages and ensure a strong transaction audit trail. This cycle of hazard payments will be made from December 15, 2014 to December 19, 2014 through a consortium of private sector partners, namely Airtel, Africell, and Splash Money.
5. UNICEF in Liberia, together with the NGO IntraHealth and the Liberian health ministry, are piloting mHERO – an SMS-based tool that can be used on basic mobile phones. mHERO stands for Mobile Health Worker Electronic Response and Outreach. It will allow the ministry to instantly send critical information to health workers’ mobile phones during the outbreak and in the future. The pilot will start with 430 health workers in Grand Gedeh, Grand Cape Mount and Margibi counties.
Outreach and Education
16. In Kindia prefecture, Guinea, the Minister of Youth and Youth Employment launched a training of trainers funded by UNICEF which is intended to reach 15,000 young people. They will then convey the key messages of prevention and the fight against EVD in all sub-prefectures, in order to promote behavior change and help lift community resistance.

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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David R. Curry, MS
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Center for Vaccine Ethics and Policy
a program of the
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Associate Faculty, Division of Medical Ethics, NYU Medical School

POLIO [to 13 December 2014]
Public Health Emergency of International Concern (PHEIC)

GPEI Update: Polio this week – As of 10 December 2014
Global Polio Eradication Initiative
[Editor’s Excerpt and text bolding]
Full report: http://www.polioeradication.org/Dataandmonitoring/Poliothisweek.aspx
:: This week, donors, partners and stakeholders of the GPEI convened at the Global Polio Partners Group (PPG) meeting in Geneva to discuss the current status of the global effort and priorities for 2015 and beyond. Discussions also focused on polio legacy planning, strengthening routine immunization, the status of IPV introduction into OPV-using countries, and preparations for the trivalent to bivalent oral polio vaccine switch.
:: In the north of Madagascar, supplementary immunization activities are planned for 15 – 19 December in response to the outbreak of circulating vaccine-derived poliovirus type 1. National Immunization Days are planned for 19 – 23 January. The aim is to boost immunity across the country against all strains of poliovirus using trivalent oral polio vaccine.
:: For the first time ever, only 1 case of wild poliovirus has been reported in Africa in the last 4 months. The case had onset of paralysis on 11 August in Somalia.

Selected country report content:
Afghanistan
:: One new wild poliovirus type 1 (WPV1) case was reported in the past week in Afghanistan, in Spin Boldak, a district bordering Balochistan, Pakistan, in Kandahar province, which had not previously reported a case in 2014. The most recent case had onset of paralysis on 5 November in Kandahar district. The total number of WPV1 cases for 2014 in Afghanistan is now 24 compared to 11 at this time last year.
:: Given the growing wild poliovirus type 1 outbreak in neighbouring Pakistan, Afghanistan continues to conduct supplementary immunization activities (SIAs) to limit the spread of imported polioviruses and to tackle residual endemic transmission. In addition to SIAs using oral polio vaccine (OPV) two special activities were conducted in mid-November using Inactivated Polio Vaccine (IPV) in several high risk districts of the Southern and the Eastern Regions. Subnational Immunization Days (SNIDs) are planned in high risk areas of the south and east using monovalent oral polio vaccine (OPV) on 21 – 23 December, and 11 – 13 January using bivalent OPV.
Nigeria
:: Over 4 months has passed since the last case of WPV1 was reported in Nigeria.
:: One new type 2 circulating vaccine-derived poliovirus (cVDPV2) case was reported from Ajingi district of Kano state in the past week, with onset of paralysis on 2 November. The total number of cVDPV2 cases for 2014 in Nigeria is now 28.
Pakistan
:: Eight new wild poliovirus type 1 (WPV1) cases were reported in the past week. One is from Balochistan province in Killa Abdullah district (across the border from Spin Boldak, Afghanistan); 6 are from the Federally Administered Tribal Areas (FATA) (4 from Khyber Agency, 1 from South Waziristan and 1 from Frontier Region Bannu); and 1 from Nowshera district, in Khyber Pakhtunkhwa (KP) province. The total number of WPV1 cases in Pakistan in 2014 is now 276, compared to 74 at this time last year. The most recent WPV1 case had onset of paralysis on 22 November, from Frontier Region Bannu, FATA.
:: Immunization activities are continuing with particular focus on known high-risk areas, in previously inaccessible areas of FATA. At exit and entry points of conflict-affected areas 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 doses of vaccine have been used in the past few months to vaccinate people passing through transit points and in host communities, including over 850,000 children under 10 years old.
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.

New York Times
http://www.nytimes.com/
Accessed 13 December 2014
Anti-Polio Worker Slain in Pakistan
By SALMAN MASOOD
DEC. 9, 2014
ISLAMABAD, Pakistan — A pair of unidentified gunmen killed a polio vaccinator in central Pakistan on Tuesday in yet another assault on workers who are part of a government effort to curb the disease.

Pakistan is struggling to contain the spread of polio as militant violence and a chaotic political environment hobble the campaign’s progress. At least 268 new cases of polio have been reported in the country this year.

Despite the government’s repeated vows to protect health workers, the attacks continue. Taliban militants have targeted workers across the country, accusing them of being spies for Western countries.

The latest shooting took place about 9 a.m. in Faisalabad, an industrial city in Punjab Province, on the second day of a three-day national vaccination campaign.

Two men on a motorbike opened fire on a health worker, Muhammad Sarfraz, in the Peoples Colony neighborhood, officials said. Mr. Sarfraz, 40, was a schoolteacher who had volunteered for the campaign.

“The attackers shot six bullets in his body and managed to escape,” said Ali Waseem, a senior police official. A female worker with Mr. Sarfraz was unharmed.

Officials suspended the campaign in Faisalabad district.

Jundullah, a Taliban splinter group, claimed responsibility. Ahmed Marwat, a Jundullah spokesman, was quoted by local news media as saying that anti-polio workers would be targeted throughout Pakistan.

But police officials in Faisalabad speculated that the attack could have been a result of personal enmity. Mr. Sarfraz had been attacked twice this year, the officials said.

Waqar Gillani contributed reporting from Lahore, Pakistan.

WHO: Ebola response roadmap – Situation report 10 December 2014
Summary [Excerpt]
A total of 17 942 confirmed, probable, and suspected cases of Ebola virus disease (EVD) have been reported in five affected countries (Guinea, Liberia, Mali, Sierra Leone, and the United States of America) and three previously affected countries (Nigeria, Senegal and Spain) up to the end of 7 December. There have been 6388 reported deaths. Reported case incidence is slightly increasing in Guinea (103 confirmed and probable cases reported in the week to 7 December), declining in Liberia (29 new confirmed cases in the 3 days to 3 December), and may still be increasing in Sierra Leone (397 new confirmed cases in the week to 7 December). The case fatality rate across the three most-affected countries in all reported cases with a recorded definitive outcome is 76%; in hospitalized patients the case fatality rate is 61%.

Response activities in the three intense-transmission countries continue to progress in line with the UNMEER aim to isolate and treat 100% of EVD cases and safely bury 100% of EVD-related deaths by 1 January. At a national level, there is now sufficient bed capacity in EVD treatment facilities to treat and isolate all reported EVD cases in each of the three intense-transmission countries, although the uneven distribution of beds and cases means there are serious shortfalls in some areas. Similarly, each country has sufficient and widespread capacity to bury all reported EVD-related deaths; however, because not all EVD-related deaths are reported, and many reported burials are of non-EVD-related deaths, it is possible that some areas still have insufficient burial capacity. Every district that has reported a case of EVD in the three intense-transmission countries has access to a laboratory within 24 hours from sample collection. All three countries report that more than 80% of registered contacts associated with known cases of EVD are being traced, although contact tracing is still a challenge in areas of intense transmission and in areas of community resistance. Rapidly increasing capacity for case finding and contact tracing in areas with low and moderate levels of transmission will be necessary to end local chains of transmission….

Gavi commits to purchasing Ebola vaccine for affected countries
Vaccine Alliance ready to begin procurement as soon as WHO recommends a vaccine for use

Geneva, 11 December 2014 – Plans to purchase millions of doses of an Ebola vaccine to support large-scale vaccination efforts were today agreed by the board of Gavi, the Vaccine Alliance. Today’s decision means that Gavi will be ready to act as soon as a safe, effective vaccine is recommended for use by the World Health Organization.
The Gavi Board endorsed plans that could see up to US$ 300 million committed to procure the vaccines, to be used to immunise at risk populations in affected countries. Up to an additional US$ 90 million could be used to support countries to introduce the vaccines and to rebuild devastated health systems and restore immunisation services for all vaccines in Ebola-affected countries.

Join forces
To meet the funding requirements of the approved Ebola initiative, Gavi will use a combination of existing and new sources of funds and join forces with initiatives that have already pledged funding to address the Ebola crisis.
Although there is currently no approved Ebola vaccine, two manufacturers have candidates undergoing human trials, with more manufacturers due to begin human trials with their candidate vaccines shortly. The Gavi Board’s decision to support the preparations for procuring Ebola vaccines while still awaiting a WHO recommendation was taken in light of the seriousness of the situation and the risks associated with delays in making a vaccine available.

Critical importance
“The Ebola outbreak reminds us of the critical importance of vaccines in fighting infectious diseases,” said Gavi CEO Dr Seth Berkley. “The Board’s decision underlines Gavi’s commitment to support the people of the Ebola-affected countries by ensuring that they will have access to a WHO-recommended vaccine as soon as one is approved and available from manufacturers.”

Noting the seriousness of the epidemic and the devastating consequences for people and communities, the Gavi Board approved plans that could see:
:: Up to US$ 300 million spent procuring up to 12 million courses of WHO recommended Ebola vaccines
:: Up to US$ 45 million to help countries roll out the vaccine, including critical activities such as health worker training, social mobilisation, surveillance and, if required, improvements to cold storage facilities
:: Up to US$ 45 million to assist with the recovery of health systems and immunisation services for all vaccines in the countries affected by the outbreak
The Ebola outbreak, and its tragic effect on countries where we have been working for years, has tested Gavi’s ability to respond quickly to an urgent need and I am proud of the decision taken by the Board today.

Stockpiles
In addition to supporting the use of Ebola vaccines to control the current epidemic, Gavi funding could also be used to create stockpiles of first- and second-generation Ebola vaccines which countries can access rapidly in future outbreaks. Gavi already funds similar stockpiles for yellow fever, meningitis A and oral cholera vaccines.

“Gavi has a responsibility to those in need,” said Gavi Board Chair Dagfinn Høybråten. “The Ebola outbreak, and its tragic effect on countries where we have been working for years, has tested Gavi’s ability to respond quickly to an urgent need and I am proud of the decision taken by the Board today. We are making determined efforts to ensure that people living in Ebola-affected countries are protected as soon as possible and do not have to face another terrible outbreak in the future.”
Oversight
To maintain effective oversight of Gavi’s Ebola activities, the Board requested a schedule of regular updates through the Executive Committee and other governance mechanisms.

The Gavi Board’s decision was based on recommendations drawn up following three months of intensive collaboration between the Gavi Secretariat, Ebola-affected countries, the African Development Bank, WHO, UNICEF, the US Centers for Disease Control and Prevention, the World Bank, vaccine manufacturers, civil society organisations including Médecins Sans Frontières, and donors.

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WHO welcomes Gavi support for Ebola candidate vaccines
11 December 2014, Geneva – The World Health Organization (WHO) welcomes the commitment by Gavi, the Vaccine Alliance to support the procurement of vaccines as soon as WHO recommends one for use.

“This is yet another example of the rapid mobilization from partners and stakeholders to respond to the Ebola outbreak with innovative products. If the vaccines currently being tested live up to their promise of safety and efficacy, this will be the fastest vaccine development and roll-out in history”, said Dr Marie-Paule Kieny, WHO Assistant Director-General of Health Systems and Innovation.

WHO has been spearheading efforts to galvanize the research and development of vaccines that could be used to curb the outbreaks. Accelerated efforts are underway to evaluate a number of Ebola candidate vaccines with preliminary results anticipated in early 2015. Effective strategies for vaccination may be to prioritize those greatest at risk of contracting Ebola; for example, frontline workers and close contacts of people proven to be infected with the virus.

The Gavi announcement follows the high level meeting convened by WHO, the African Development Bank, the West African Health Organization and the World Bank on Building Resilient Health Systems in Ebola-affected countries in Geneva with the aim of laying the foundation for stronger health systems in the medium- to long-term.

[U.S.] Secretary Burwell issues declaration under PREP Act to support development of Ebola vaccines
Important step in effort to develop Ebola vaccines to combat current, future outbreaks
December 9, 2014
[Full text; Editor’s text bolding]
Health and Human Services Secretary Sylvia M. Burwell today announced a declaration under the Public Readiness and Emergency Preparedness (PREP) Act to facilitate the development and availability of experimental Ebola vaccines. This declaration is intended to assist in the global community’s effort to help combat the current epidemic in West Africa and help prevent future outbreaks there.

The declaration provides immunity under United States law against legal claims related to the manufacturing, testing, development, distribution, and administration of three vaccines for Ebola virus disease. It does not, generally, provide immunity for a claim brought in a court outside the United States.

For many years, the U.S. has encouraged vaccine development by managing liability and compensation, starting with the National Childhood Vaccine Injury Act of 1986. The PREP Act was designed to facilitate the development of medical countermeasures to respond to urgent public health needs, including the development of critical vaccines like those to prevent the spread of Ebola. This U.S. declaration under the PREP act is part of a global dialogue to address these issues in the U.S., and other countries where the vaccine is being developed, manufactured and potentially used.

“My strong hope in issuing this PREP Act declaration in the United States is that other nations will also enact appropriate liability protection and compensation legislation,” said Secretary Burwell. “As a global community, we must ensure that legitimate concerns about liability do not hold back the possibility of developing an Ebola vaccine, an essential strategy in our global response to the Ebola epidemic in West Africa.”

The PREP Act declaration is expected to strengthen the incentive to conduct research and spur development, manufacturing, and the potential use of the vaccines in large scale vaccination campaigns in West Africa. The PREP Act declaration provides legal protection under U.S. law for three vaccine candidates:
:: the GlaxoSmithKline’s Recombinant Replication Deficient Chimpanzee Adenovirus Type 3-Vectored Ebola Zaire Vaccine known as ChAd3-EBO-Z;
:: the BPSC1001 vaccine, known as rVSV-ZEBOV-GP, made by BioProtection Services Corporation, a subsidiary of Newlink Genetics; and
:: the Ad26.ZEBOV/MVA-BN-Filo vaccine manufactured by Janssen Corporation, subsidiary of Johnson & Johnson/Bavarian Nordic.
Similar PREP Act declarations have been issued, revised or renewed 14 times since the Act was signed in 2005. Past declarations have covered vaccines used in H5N1 pandemic influenza clinical trials in 2008, products related to the H1N1 influenza pandemic in 2009, and the development and manufacturing of antitoxins to treat botulism in 2008.

For more information about the PREP Act, visit http://www.phe.gov/preparedness/legal/prepact/pages/default.aspx.

Vaccinations with VSV-ZEBOV have been suspended and will resume in early 2015
Press release by University Hospitals of Geneva (HUG)
Geneva, 11 December 2014
Since 10 November 2014, a total of 59 volunteers have been included in the clinical trial of the experimental VSV-ZEBOV Ebola vaccine at the University Hospitals of Geneva (HUG). All of these volunteers are in good health and are being monitored regularly by the team in charge of the study.

Initial results show that the vaccination is very well tolerated. In the hours and days following the injection, some volunteers had some fever or muscle pain; these reactions were expected and participants were informed about them during the medical consultation which took place before their inclusion in the study.

Close monitoring of the volunteers by the VSV-ZEBOV Geneva study team has allowed the identification of four cases of mild joint pain (in the hands and feet), 10 to 15 days after receiving the injection. These symptoms were not part of the expected side effects and were not included in the prior information given to volunteers, since this vaccine is being tested on humans for the first time.

As a precautionary measure, the study team has declared a pause in the injections. No injections will take place next week. This pause is beginning one week earlier than an already
scheduled pause in the vaccination series. The available time will serve to gather more information and exchange it with the other teams that are testing the same experimental vaccine. Several investigations have been launched to ensure that the symptoms which have been identified are benign and transient. In the context of clinical trials the safety of volunteers is always a priority.
The onset of joint pain after infection or vaccination is very common. This happens, for instance, in one out of five vaccinations against rubella. This is a well-documented phenomenon which does not worry specialists. However, it deserves to be carefully studied in order to update the information which is provided to the volunteers. The temporary interruption of a clinical trial is a standard precautionary measure in such cases.
The VSV-ZEBOV Geneva study team is constantly exchanging information with teams conducting similar studies in the United States, Canada, Germany and Gabon. Up to now, these teams have not observed inflammatory symptoms among their volunteers. In Geneva, vaccinations will resume on 5 January 2015, with maximum 15 volunteers per week in order to ensure optimal monitoring conditions.

Pdf: http://www.hug-ge.ch//sites/interhug/files/actualites/ebola/news_vaccin_ebola_11_12_2014.pdf

The Lancet Infectious Diseases
Online First
Correspondence
Dose regimen of favipiravir for Ebola virus disease
France Mentré, Anne-Marie Taburet, Jeremie Guedj, Xavier Anglaret, Sakoba Keïta,
Xavier de Lamballerie, Denis Malvy
Published Online: 27 November 2014
DOI: http://dx.doi.org/10.1016/S1473-3099(14)71047-3
Full Text
Although several antivirals have shown efficacy against Ebola virus infection in vitro or in animal models, none of them have been yet assessed in human beings with Ebola virus disease.

Potential drug candidates include favipiravir,1 a nucleotide analogue approved for novel or re-emerging influenza in Japan. This year, results of two independent studies in mice infected with Ebola virus showed that the initiation of 150 mg/kg favipiravir twice a day within 6 days of infection induced rapid virus clearance, reduced biochemical parameters of disease severity, and led to 100% survival.2, 3 Moreover, favipiravir had a good safety profile in thousands of patients worldwide, is immediately available, and can be used orally, leading the French drug safety agency (ANSM) to approve the compassionate use of favipiravir in patients with Ebola virus disease. Here we explain the approach we used to propose a dose regimen in a forthcoming trial in Guinea that is assessing survival in adults with Ebola virus disease who receive favipiravir.

First we used the dose regimen used to successfully treat mice to estimate target plasma favipiravir concentrations for human patients. Using data provided by the manufacturer, we showed that, in mice, 150 mg/kg every 12 h led to mean daily minimal concentrations (Cmin, 12 h post-dosing) of 5 μg/mL, average concentrations (Cave, defined by the area under the concentration curve from 0 h to 24 h divided by 24 h) of 58 μg/mL, a half-life of 1•8 h, and maximal concentrations (Cmax) of 200 μg/mL. Since 10% of favipiravir is bound to plasma proteins in mice, unbound average (Cave_u) was therefore targeted to 52 μg/mL, and minimum concentrations (Cmin_u) to 4•5 μg/mL. Of note, 52 μg/mL is higher than the 99% inhibitory concentration with Zaire ebolavirus Mayinga 1976 strain (estimated to be 29 μg/mL).3 Plasma protein binding in human beings was 54%; therefore, plasma Cmin and Cave were targeted to 10 μg/mL and 113 μg/mL, respectively.

Second, we used the pharmacokinetic model developed by the manufacturer in human beings with the parameter values estimated in US healthy volunteers to assess a dose regimen that could achieve these targeted concentrations. Simulations were done with various maintenance doses of 1000 mg, 1200 mg, and 1800 mg twice a day and led to median Cave at a steady state of 66•8 μg/mL (90% prediction interval 57•2–76•5), 83•3 μg/mL (72•2–95•3), and 134•4 μg/mL (115•9–152•0), respectively. Although the dose of 1200 mg twice a day gave a slightly lower Cave than targeted, it minimised the chance of relapse (Cmin of 57 μg/mL) and remained in the range of exposures previously assessed in human beings with good tolerance.

Since viral spread has to be blocked as soon and as strongly as possible after appearance of first symptoms, we assessed several loading dose strategies on day 1 to rapidly achieve high levels of exposure. In view of the short half-life of favipiravir, a dose of 2400 mg twice a day led to a low median Cmin of 4•3 μg/mL (90% prediction interval 0•6–15•6). Rather, concentrations achieved with a regimen of 2400 mg, 2400 mg, and 1200 mg every 8 h allowed us to achieve a Cmin at 8 h of 9•8 μg/mL (2•9–23•5) and a Cmin at 16 h of 45•2 μg/mL (12•9–85•1).

To summarise, we describe the method used to propose a relevant dose regimen of favipiravir to be assessed in patients with Ebola virus disease, in a context where trials are urgently needed. Our approach combined data on favipiravir efficacy against Ebola virus in vitro and in vivo with data provided by the manufacturer on favipiravir pharmacokinetics in uninfected mice and human beings. On the basis of these elements, we will assess favipiravir in adults with a loading dose of 2400 mg, 2400 mg, and 1200 mg every 8 h on day 1, and a maintenance dose of 1200 mg twice a day afterwards. Of note, this dose regimen is 50% greater than the one in the phase 3 trials of favipiravir for influenza in the USA (1800 mg twice a day on day 1, 800 mg twice a day on day 2–5). To reduce the chance of relapse in Ebola virus disease, we decided to give the treatment for 10 days, which corresponds to the time needed for an effective antibody response.4

Although modelling is a valuable method to optimise the search of a dosing regimen, it is not a substitute for clinical data. Tolerance, virological, and pharmacokinetic data will be obtained during the trial to help to refine the dose regimen.

We declare no competing interests. We thank Toyama Chemical for sharing with us detailed data on favipiravir pharmacokinetics. We also thank Caroline Semaille and Nathalie Morgensztejn from the French National Agency for the Safety of Medicine and Health Products for helpful discussions, and the REACTing network of Aviesan for scientific support.

References
Furuta, Y, Gowen, BB, Takahashi, K, Shiraki, K, Smee, DF, and Barnard, DL. Favipiravir (T-705), a novel viral RNA polymerase inhibitor. Antiviral Res. 2013; 100: 446–454 View in Article
Smither, SJ, Eastaugh, LS, Steward, JA, Nelson, M, Lenk, RP, and Lever, MS. Post-exposure efficacy of oral T-705 (favipiravir) against inhalational Ebola virus infection in a mouse model. Antiviral Res. 2014; 104: 153–155 View in Article
Oestereich, L, Lüdtke, A, Wurr, S, Rieger, T, Muñoz-Fontela, C, and Günther, S. Successful treatment of advanced Ebola virus infection with T-705 (favipiravir) in a small animal model. Antiviral Res. 2014; 105: 17–21 View in Article
Ksiazek, T, Rollin, P, Williams, A et al. Clinical virology of Ebola hemorrhagic fever (EHF): virus, virus antigen, and IgG and IgM antibody findings among EHF patients in Kikwit, Democratic Republic of the Congo, 1995. J Infect Dis. 1999; 179: S177–S187 View in Article

CDC/MMWR Watch [to 13 December 2014]
http://www.cdc.gov/media/index.html

:: Supporting West African Ebola Survivors – Press Release – Friday, December 12, 2014
The case fatality rate in West Africa’s ongoing Ebola epidemic – estimates range from 60 percent to 70 percent of those hospitalized – hides a hopeful statistic: the fact that many Ebola patients survive. There now are thousands of Ebola survivors.
In this epidemic as in past Ebola outbreaks, survivors often face stigma, income loss, and both grief and survivor guilt over the loss of family and friends. Many if not all of their possessions have been destroyed to prevent disease transmission. In some cases, families have been reluctant to accept orphaned children.
Two reports in the December 12 early release issue of CDC’s Morbidity and Mortality Weekly Report (MMWR) detail programs in Liberia and Sierra Leone to help Ebola survivors reintegrate with their communities and resume their lives. As survivors are thought to have some protective immunity to the strain of Ebola that sickened them, many survivors now work as caregivers for other Ebola patients.
“Nothing says more about the resilience of the human spirit than Ebola survivors who become role models for their communities,” said CDC Director Tom Frieden, M.D., M.P.H. “They show others that Ebola can be defeated and provide care, support, and inspiration for others stricken by this terrible disease.”

:: MMWR Early Release December 12, 2014 / Vol. 63 / Early Release
– Support Services for Survivors of Ebola Virus Disease — Sierra Leone, 2014
– Reintegration of Ebola Survivors into Their Communities — Firestone District, Liberia, 2014

:: MMWR Weekly, December 12, 2014 / Vol. 63 / No. 49
– Estimated Influenza Illnesses and Hospitalizations Averted by Vaccination — United States, 2013–14 Influenza Season
– Global Invasive Bacterial Vaccine-Preventable Diseases Surveillance — 2008–2014
– Airport Exit and Entry Screening for Ebola — August–November 10, 2014
– Ebola Virus Disease in Health Care Workers — Sierra Leone, 2014
– Rapid Assessment of Ebola Infection Prevention and Control Needs — Six Districts, Sierra Leone, October 2014
– Clinical Inquiries Regarding Ebola Virus Disease Received by CDC — United States, July 9–November 15, 2014

US$35 million grant from King Abdallah of Saudi Arabia to fight Ebola in West Africa
Press Release by Islamic Development Bank
Thursday, 11 December 2014

The Custodian of the Two Holy Mosques, Saudi Arabia’s King Abdallah bin Abdulaziz al-Saud has extended a grant of US$35 million to help fight Ebola in West Africa.
In a statement to the media on this occasion, Dr. Ahmed Mohamed Ali, President of the Islamic Development Bank (IDB) said that the Ebola fighting programme, initiated by the Custodian of the Two Holy Mosques and implemented by IDB, comprises the following elements:
1- Providing schools with thermal sensors and medical examination equipment designed to diagnose the disease, thereby facilitating its treatment and preventing its spread. The equipment will allow governments to open schools for the current academic year. Pupils will be examined at entry to ensure they have not contracted the disease, thus reassuring parents about the safety of their children at school.
2- Providing thermal sensors and medical examination equipment at airports, railway stations and bus stations to diagnose the disease and ensure early treatment.
3- Establishing a specialized treatment centre in each of the three endemic countries, Sierra Leone, Guinea and Liberia, designed to serve suspected cases in schools, hospitals and public transport, and wherever contamination is likely to occur in crowded conditions. Suspected cases will be received in these centres for further medical tests before they are referred for specialized treatment if necessary.
4- Establishing a specialized treatment centre in Mali where Ebola appears to have broken out but is not widespread. The centre will help the country’s health authorities cope with potential epidemics in the future.
The IDB President emphasized that the kind donation made by the Custodian of the Two Holy Mosques will further boost the Islamic world efforts in supporting the international fight against Ebola. He added that the equipment financed by this donation will speed up the opening of schools in the countries concerned, reinforce the institutional and health infrastructure to fight the current epidemic and any potential epidemics in the future, Allah forbids, thus saving thousands of lives and ensuring the safety of those at risk of contamination…

New York Times
DEC. 11, 2014
The Opinion Pages
The Path to Zero Ebola Cases
By JIM YONG KIM
| Op-Ed Contributor
MONROVIA, Liberia — In my career as a medical doctor and global health policy maker, I have been in the middle of monumental struggles, including fights to make treatment accessible in the developing world for those living with H.I.V./AIDS as well as multi-drug resistant tuberculosis. But the Ebola epidemic is the worst I’ve ever seen.

More than 11 months into the crisis, thousands of people are dead and more than 17,000 have been infected. The virus kills quickly, spreads fear even faster, alters human relationships, devastates economies and threatens to cruelly extinguish hope in three fragile countries that were on the rebound after years of misery. No other modern epidemic has been so destructive so fast.

Recently, the regional response to the Ebola epidemic has been extremely effective in slowing its spread. Presidents Alpha Condé of Guinea, Ellen Johnson Sirleaf of Liberia and Ernest Bai Koroma of Sierra Leone have shown strong resolve and determined political will in battling the virus. I recently spent two days in those countries and saw first-hand that the situation today is far better than it was a month ago because of national and international efforts.

But we are not yet on the path to end the epidemic. These three countries and the world must now shift the focus of their strategy with one goal in mind: zero Ebola cases. While each country faces different challenges in reaching this destination, there are common principles that can guide them. Here are five steps the world must take together.

First, we must find the resources required, no matter the cost, to get to zero cases as soon as possible. Any delay will dramatically increase the price in terms of both lives and money. For Senegal, the cost to treat one patient and track all of his contacts was more than $1 million. For Nigeria, one infected person led to 19 other cases, and more than 19,000 contacts traced by over 800 health care workers at a cost of more than $13 million. In Guinea, Liberia and Sierra Leone, there are not one or 10 active transmission lines, but hundreds. Defeating Ebola now will cost billions — but it will spare the rest of the world from the spread of the virus, save lives in the countries, save money over the long term, and help the countries rebuild their economies.

Second, it is time to multiply the number of trained people to hunt down the virus. Responders must track each contact of an infected person. Done right, this strategy will eventually extinguish all transmission lines, ending the epidemic. The focus of this vital activity must be on the intensity, quality and reach of tracking activities deep into the community. The communities need to be engaged, empowered and true partners in the drive to zero. It will also begin these countries’ recovery process by providing work for potentially thousands of local people, and teach skills that are much needed to build effective community health care systems.

Third, response coordination and support mechanisms must move down to the district level, with teams capable of collecting and analyzing data to further drive the intervention, as well as to scale up diagnostics and triage capabilities. We must especially focus on one particular piece of data: The percentage of new cases not on previous contact lists. In other words, did trackers previously identify the people who are newly infected as contacts of other cases, or do the new cases represent unidentified transmission lines? This will tell us whether we’re winning or losing. Right now, in all three countries, we have only partial data on this particular indicator.

Fourth, national response strategies must be nimble and adapt to local conditions, rather than be bound by prior commitments. Liberia, for instance, has had the most recent success in the fight against the virus and has seen a dramatic drop in reported cases. When I was in Liberia, they counted 150 active cases — the lowest number in several months. Now there is an opportunity to aggressively set in motion a contact tracing program to stop the lines of transmission, one by one until it’s over.

Finally, we must empower the strong leaders in the region who head the response to extinguish the virus wherever it exists. On the ground, there are talented national staff who have been tested on the frontline. There are also international partners: the United States and the United Kingdom, other countries, the United Nations, and international nongovernmental organizations, which have deployed massive resources in support of national efforts. Together, they have stood fast and slowed down this horrific epidemic. We must now give them the freedom and resources to end it.

We have no choice but to beat Ebola. I return from West Africa admiring the leaders and the international responders. But we must also acknowledge that we have underestimated Ebola in the past and it’s possible we could do so again.

We must not forget we have one goal only: zero cases.
Jim Yong Kim, a physician, anthropologist and former president of Dartmouth College, is president of the World Bank Group.

WHO & Regionals [to 13 December 2014]
:: The Weekly Epidemiological Record (WER) 12 December 2014, , vol. 89, 50 (pp. 561–576) includes:
– Meeting of the Strategic Advisory Group of Experts on immunization, October 2014 – conclusions and recommendations

:: World Malaria Report 2014
WHO, 2014 :: 242 pages ISBN: 978 92 4 156483 0
Overview
The World Malaria Report 2014 summarizes information received from malaria-endemic countries and other sources, and updates the analyses presented in the 2013 report.
The World Malaria Report is WHO’s flagship malaria publication, released each year in December. It assesses global and regional malaria trends, highlights progress towards global targets, and describes opportunities and challenges in controlling and eliminating the disease. Most of the data presented in this report is for 2013.

:: New study highlights need to scale up violence prevention efforts globally
10 December 2014 — The “Global status report on violence prevention 2014” reveals that 475 000 people were murdered in 2012, and homicide is the third leading cause of death globally for males aged 15–44 years, highlighting the urgent need for more decisive action to prevent violence.

WHO Regional Offices
WHO African Region AFRO
:: Democratic Republic of the Congo: The country that knows how to beat Ebola
In DRC there was long experience with Ebola – this was the seventh outbreak of the disease here. The country had the knowledge and the people needed to stop an outbreak – plus strong technical assistance and support from WHO.
:: Liberia: Sharing his experience fighting Ebola – 09 December 2014

WHO Region of the Americas PAHO
:: First-ever Universal Health Coverage Day urges “Health for all – everywhere” (12/12/2014)
:: Developing countries in Latin America and the Caribbean have world’s highest homicide rates (12/10/2014)
:: PAHO/WHO provides training in risk communication for possible Ebola introduction (12/09/2014)

WHO South-East Asia Region SEARO
:: WHO targets implementation of new guidelines for indoor air quality 11 December 2014
:: Address at the Ebola Preparedness Partners Meeting 5 December 2014, SEARO, New Delhi
Dr Poonam Khetrapal Singh, WHO Regional Director for South-East Asia

WHO European Region EURO
[website unreachable]

WHO Eastern Mediterranean Region EMRO
:: WHO delivers six tonnes of medicines to west Harasta in Syria
8 December 2014 – As part of an UN inter-agency convoy, WHO, in collaboration with the Syrian Arab Red Crescent (SARC), has delivered 6 tonnes of medicines and other items to west Harasta in Syria for a population of 2200 families. Since the beginning of the crisis, WHO has supported local health authorities, SARC and nongovernmental organization partners with the provision of medicines and medical equipment, including surgical supplies for over 12.5 million people across the country. It was the first time that medical support has reached west Harasta since October 2011.
:: Government of Saudi Arabia provides support for purpose-built mobile medical clinics in Erbil, Iraq 11 December 2014
:: Afghanistan’s midwifery report highlights need for still greater investment 10 December 2014
:: Vaccinators, health educators and volunteers in Aden: working enthusiastically with vulnerable groups 8 December 2014

UNICEF Watch [to 13 December 2014]

:: With 15 million children caught up in major conflicts, UNICEF declares 2014 a devastating year for children
NEW YORK/GENEVA, 8 December 2014 – The year 2014 has been one of horror, fear and despair for millions of children, as worsening conflicts across the world saw them exposed to extreme violence and its consequences, forcibly recruited and deliberately targeted by warring groups, UNICEF said today. Yet many crises no longer capture the world’s attention, warned the children’s agency.

GAVI Watch [to 13 December 2014]
http://www.gavialliance.org/library/news/press-releases/

:: Gavi commits to purchasing Ebola vaccine for affected countries [see Ebola coverage above]

:: Dr Flavia Bustreo appointed Vice Chair of Gavi Board
11 December 2014
WHO Assistant Director-General will also chair the Board’s Governance Committee
Geneva, 11 December 2014 – Gavi, the Vaccine Alliance has today appointed World Health Organization Assistant Director-General for Family, Women’s and Children’s Health Dr Flavia Bustreo as the new Vice Chair of its Board.
Dr Bustreo has been a Gavi Board member since 2010 and will take up the position of Vice Chair on the January 1st 2015. As part of her responsibilities as Vice Chair of the Board, Dr Bustreo will also be the Chair of the Board’s Governance Committee and Vice Chair of the Executive Committee.
“I am very humbled by the Board’s decision, which is I believe is a reflection of the value of WHO’s critical role and contribution to the Alliance,” said Dr Bustreo. “I am also delighted that my appointment coincides with Human Rights Day and at a time when Gavi is embarking on its new strategy for 2016-2020, given that Gavi is such a critical instrument to saving and improving the lives of women and children and increasing equitable use of vaccines in lower income countries “
Dr Bustreo succeeds UNICEF Deputy Executive director Dr Geeta Rao Gupta who has served as Vice Chair since 2011.
“I am grateful to Geeta Rao Gupta for her strong support and counsel during a period of remarkable expansion of Gavi’s programmes,” said Gavi Board Chair Dagfinn Høybråten. “Geeta Rao Gupta was, along with Flavia Bustreo, a leading advocate in support of crucial board decisions including the approval of support for human papillomavirus vaccine and measles-rubella vaccine.”
“Flavia Bustreo’s appointment comes at an important moment for Gavi as we seek to secure funds for immunisation programmes between 2016 and 2020. We have a great deal of work to do if we are to reach every child with lifesaving vaccines and the knowledge and experience that Flavia will bring to her new role will help us address the challenges we face,” added Mr Høybråten.
Dr Bustreo has served as the WHO Assistant Director-General for Family, Women’s and Children’s Health since 2010. Her responsibilities include the oversight of WHO’s work on immunisation, reproductive, maternal, newborn, child and adolescent health, social and environmental determinants of health, gender, equity and human rights and ageing.

Sabin Vaccine Institute Watch [to 13 December 2014]
http://www.sabin.org/updates/pressreleases

Axel Hoos, MD, PhD, Appointed as Interim Chairman of the Sabin Board of Trustees
WASHINGTON, D.C. — December 10, 2014 — The Sabin Vaccine Institute (Sabin) today announced that its Board of Trustees unanimously appointed Axel Hoos, MD, PhD, to serve as the interim Chairman of the Board. Building upon the past successes of late Chairman Morton P. Hyman, Dr. Hoos will be instrumental to providing continuity to the institute and to Sabin’s efforts in launching new programs, clinical trials and advocacy campaigns around the world.

Global Fund Watch [to 13 December 2014]
Press releases

:: 11 December 2014 – New Approach on Buying HIV Drugs Will Save $100 Million
GENEVA – The Global Fund to Fight AIDS, Tuberculosis and Malaria is putting into place a new agreement for purchasing HIV medication that will save close to US$100 million over two years, money that can be reinvested in lifesaving drugs and programs all over the world.
By using a Pooled Procurement Mechanism, the agreement means lower prices, swifter delivery and more predictable and sustainable long-term supply – delivering on the goals of the Global Fund’s Market Shaping Strategy.
It also yields greater transparency, reducing risks and expenses for countries that implement programs treating people with HIV. The new approach will also deliver better HIV medication options for children.
The improvements were achieved by bundling the purchase of, high volume drugs with lower volume ones which are sometimes more difficult to obtain. Negotiators also focused on improved shelf life and active pharmaceutical ingredient security.
The Global Fund is entering agreements with eight suppliers, with three of them as long-term strategic partnerships…

:: 10 December 2014 – Côte d’Ivoire Launches Giveaway of 13 Million Nets to Fight Malaria

:: 09 December 2014 – UNAIDS and Global Fund Sign Cooperation Agreement
GENEVA – UNAIDS and the Global Fund to Fight AIDS, Tuberculosis and Malaria signaled their strong partnership with a renewed cooperation agreement to help countries achieve Fast-Track targets to end the AIDS epidemic as a global health threat by 2030.
At the core of the agreement is an improved way of collaborating that strengthens coordination mechanisms, and information-sharing at all levels and mutual accountability.
The UNAIDS Fast-Track approach emphasizes the need to focus on the countries, cities and communities most affected by HIV and recommends that resources be concentrated on the areas with the greatest impact. The new agreement will focus on maximizing support to countries and optimizing investments and impact at country level…

Industry Watch [to 13 December 2014]

:: Sanofi Pasteur Announces FDA Approval of Fluzone® Intradermal Quadrivalent (Influenza Vaccine) for Adults
– The first and only four-strain influenza vaccine option administered intradermally –
– Helps protect adults 18 through 64 years of age against an additional influenza B strain
SWIFTWATER, Pa., Dec. 12, 2014 /PRNewswire/ — Sanofi Pasteur, the vaccines division of Sanofi (EURONEXT: SAN and NYSE: SNY), today announced that the U.S. Food and Drug Administration (FDA) has approved the supplemental biologics license application (sBLA) for Fluzone Intradermal Quadrivalent vaccine. Fluzone Intradermal vaccine, which has been available in trivalent formulation for three years, is now available in a quadrivalent formulation to help protect against four strains of influenza virus. Fluzone Intradermal Quadrivalent vaccine is indicated for adults 18 through 64 years of age for active immunization for the prevention of influenza (“the flu”) caused by influenza A subtype viruses and type B viruses contained in the vaccine.
“Influenza B is a common cause of influenza-related morbidity and mortality across all age groups,” said David P. Greenberg, M.D., Vice President, Scientific & Medical Affairs, and Chief Medical Officer, Sanofi Pasteur US. “Fluzone Intradermal Quadrivalent vaccine will offer another influenza vaccination option for health care providers and their adult patients with broad coverage against influenza viruses that may be predominant, coupled with the efficiency of using the intradermal microinjection system.”…

:: FDA Approves Merck’s HPV Vaccine, GARDASIL®9, to Prevent Cancers and Other Diseases Caused by Nine HPV types – Including Types that Cause About 90% of Cervical Cancer Cases
GARDASIL 9 includes the greatest number of HPV types in any available HPV vaccine
December 11, 2014 05:30 PM Eastern Standard Time
KENILWORTH, N.J.–(BUSINESS WIRE)–Merck (NYSE:MRK), known as MSD outside the United States and Canada, announced today that the U.S. Food and Drug Administration (FDA) approved GARDASIL®9 (Human Papillomavirus 9-valent Vaccine, Recombinant), Merck’s 9-valent human papillomavirus (HPV) vaccine, for use in girls and young women 9 to 26 years of age for the prevention of cervical, vulvar, vaginal, and anal cancers caused by HPV types 16, 18, 31, 33, 45, 52 and 58, pre-cancerous or dysplastic lesions caused by HPV types 6, 11, 16, 18, 31, 33, 45, 52, and 58, and genital warts caused by HPV types 6 and 11. GARDASIL 9 is also approved for use in boys 9 to 15 years of age for the prevention of anal cancer caused by HPV types 16, 18, 31, 33, 45, 52 and 58, precancerous or dysplastic lesions caused by HPV types 6, 11, 16, 18, 31, 33, 45, 52 and 58, and genital warts caused by HPV types 6 and 11. GARDASIL 9 is contraindicated in individuals with hypersensitivity, including severe allergic reactions to yeast, or after a previous dose of GARDASIL 9 or GARDASIL® [Human Papillomavirus Quadrivalent (Types 6, 11, 16, and 18) Vaccine, Recombinant].
“With GARDASIL 9, the medical and public health community now has the potential to help prevent 90 percent of cervical cancers caused by HPV,” said Dr. Julie Gerberding, president, Merck Vaccines. “This is an extraordinary opportunity to even further reduce the burden of HPV-related diseases and cancers in males and females.”…

:: Merck Announces Appointment of Dr. Julie Gerberding as Executive Vice President for Strategic Communications, Global Public Policy and Population Health
December 10, 2014 09:30 AM Eastern Standard Time
KENILWORTH, N.J.–(BUSINESS WIRE)–Merck (NYSE:MRK), known as MSD outside the United States and Canada, today announced the appointment of Dr. Julie Gerberding, 59, as executive vice president for strategic communications, global public policy and population health, effective Dec. 15. In this newly created Executive Committee position, Gerberding, who most recently served as president of Merck Vaccines, will be responsible for Merck’s global public policy, corporate responsibility and communications functions, as well as the Merck Foundation and the Merck for Mothers program. Gerberding will also lead new partnership initiatives that accelerate Merck’s ability to contribute to improved population health, a measure of impact that is increasingly valued by governments and other global health organizations.
“Julie has been instrumental in making Merck’s vaccines more accessible and affordable, particularly in emerging markets and many of the world’s most resource-limited countries,” said Kenneth C. Frazier, chairman and chief executive officer, Merck. “Julie’s leadership of our vaccines business and her exceptional track record in both the public and private sectors make her ideally suited to lead these areas and to advance our engagement with organizations around the world that, like Merck, are working to advance population health.”
Gerberding joined Merck as president of Merck Vaccines in January 2010. Since then, Merck’s vaccines are reaching more people than ever, and Merck became the global leader in the vaccine market based on sales. In addition, the Sanofi Pasteur MSD joint venture in Europe, Merck’s European vaccine business for which Gerberding is the Board co-chair, has improved in both population reach and financial performance. She also helped lead the successful launch in India of the Merck Wellcome Trust non-profit joint venture for vaccine development, the MSD Wellcome Trust Hilleman Laboratories.
Prior to joining Merck, Gerberding served as director of the U.S. Centers for Disease Control and Prevention (CDC) from 2002-2009 and before that served as director of the Division of Healthcare Quality Promotion. Before joining the CDC, Gerberding was a tenured faculty member in Infectious Diseases at the University of California at San Francisco (UCSF). She continues as an Adjunct Associate Clinical Professor of Medicine at UCSF…