Nature Medicine
December 2014, Volume 20 No 12 pp1355-1492
http://www.nature.com/nm/journal/v20/n12/index.html

Nature Medicine | Editorial
Principled compassion
oi:10.1038/nm.3772
Published online
04 December 2014
Abstract
Investigational drugs can save or extend lives, and seriously ill patients not able to take part in clinical trials should have access to such drugs whenever possible. In a climate of increased public pressure for this access—often termed compassionate use—five states in the US have passed so-called ‘right to try’ legislation. These laws are ill advised, as they are not likely to substantially increase access and have the potential to compromise the clinical trial system.

Nature Medicine | News
University travel bans and quarantines may impede Ebola response
Cassandra Willyard
doi:10.1038/nm1214-1359
Published online
04 December 2014

Travel to and from West Africa has become increasingly burdensome for researchers and health workers helping to curb the spread of an Ebola outbreak that has killed nearly 5,000 people in the past year. In October, US universities began banning campus-sponsored travel to Liberia, Sierra Leone and Guinea and began strongly discouraging travel to these countries for personal reasons, including volunteer work. As of 29 October, the guidelines set by the US Centers for Disease Control and Prevention advise health officials to monitor the condition of those arriving from Ebola-affected countries for 21 days—the maximum incubation period for the disease. But some institutions are also asking these individuals to stay away from campus during that time, regardless of their exposure to the virus. Although these policies are designed to prevent the spread of Ebola, they may also be hampering the response to the outbreak in West Africa.

“Universities in a time of crisis have historically been able to step up and provide not just research and other resources like that, but really personnel and expertise,” says Phuoc Le, a physician at the University of California, San Francisco (UCSF) who was headed to Liberia on 6 November to work with a nonprofit called Last Mile Health. Whereas UCSF is encouraging doctors and nurses to go to West Africa, Le adds, others are “putting up multiple barriers that are hard for individual faculty or staff to overcome.”

For example, as of early November, when this story went to press, Stanford University School of Medicine is prohibiting Stanford-related travel to the countries affected by Ebola and is adopting the 21-day rule, regardless of whether travelers are symptomatic or came into contact with infected individuals. Columbia University in New York has advised staff and students to avoid traveling to West Africa. Anyone wishing to make the trip must apply for an exception and sign a letter emphasizing that “evacuation of patients with Ebola symptoms may not be achievable.” Travelers must also submit an evacuation plan in case of emergency…

New England Journal of Medicine
December 4, 2014 Vol. 371 No. 23
http://www.nejm.org/toc/nejm/medical-journal

Online First
Perspective
Evaluating Ebola Therapies — The Case for RCTs
Edward Cox, M.D., M.P.H., Luciana Borio, M.D., and Robert Temple, M.D.
December 3, 2014
DOI: 10.1056/NEJMp1414145
The worst Ebola epidemic in history is ongoing. With the number of deaths from Ebola virus disease (EVD) already in the thousands and predicted to rise to tens of thousands,1 the situation is tragic. No treatments have yet been shown to be safe and effective in patients with EVD. Some candidate therapies have shown benefit in animal models of infection, and others have shown activity against certain Ebola strains in cell culture, but concerns have been raised about possible toxicity of some of these agents. There is an urgent need to identify therapies that are effective and safe, and well-designed clinical trials are the fastest and most reliable way to achieve that goal.

Studying investigational therapies for EVD presents scientific, practical, and ethical challenges. Not surprisingly, there has been substantial debate about the best and most appropriate study approaches.2,3 It is generally agreed that a trial with a concurrent control group, in which patients are randomly assigned to receive the test drug plus the best available supportive care (BASC) or to BASC alone, would be the most efficient and reliable way to evaluate the safety and effectiveness of candidate products. Some people in the health care community, however, have argued against such trials, urging instead use of a historical control — that is, making investigational drugs as widely available as their supply allows and then comparing mortality rates among treated patients with rates that would have been expected absent the drugs, on the basis of past experience with EVD. The desire to allow all patients access to investigational drugs is understandable, but there are strong reasons to doubt the ability of such “historically controlled” studies to distinguish effective therapies from ineffective ones.
Insofar as such studies cannot reliably identify effective treatments, their use could have tragic consequences. If historical comparisons falsely suggest a benefit or fail to detect modest but meaningful clinical effectiveness, the investigational drug might be erroneously adopted as effective or discarded as ineffective. Possible consequences include exposure of subsequent patients to harm or to lack of effect from the mistakenly adopted treatment and failure to use a drug with a real, though modest, ability to improve survival, as well as failure to further develop an intervention that provides meaningful benefit.
Historically controlled studies compare study outcomes with outcomes in an external group that is thought to be similar to the study participants. The challenge of such trials is identifying a pertinent historical experience. If the two groups are not similar, observed differences in results may be unrelated to the therapy, instead reflecting underlying differences between the groups or differences in supportive care.

Case fatality rates in past outbreaks of EVD have ranged from less than 50% to more than 80%,4 and even limited supportive care probably improves survival rates. Thus, the historical case fatality rates are irrelevant if current study patients receive better supportive care. Without clear knowledge of the mortality that would be expected with the study’s level of supportive care, a historically controlled study cannot determine whether a treatment has helped or harmed patients.5 In a randomized trial, by contrast, all patients would receive similar supportive care, so that the effect (or lack of effect) of the added treatment could be assessed. Moreover, such a trial could detect even a small but meaningful benefit that a historically controlled trial could not credibly identify.

Randomized, controlled trials (RCTs) with a BASC control group are a powerful tool for evaluating effects of an investigational therapy. Randomization ensures reasonable similarity of the test and control groups and protects against various imbalances and biases that could lead to erroneous conclusions. Properly designed RCTs that give reliable answers are critical to identifying urgently needed treatments for responding to the ongoing Ebola crisis and any future outbreaks.

The number of infected patients greatly exceeds the supply of certain investigational agents. Regardless of debates over trial design or ethics, when there are only limited supplies, most patients cannot receive specific antiviral therapy. RCTs for evaluating these agents will therefore not be depriving patients of treatment but will provide a pathway for identifying effective treatments as rapidly and reliably as possible. Even when sufficient supplies are available, RCTs will provide the definitive answer on effectiveness, in a generally quicker fashion than alternative trial designs.

When preclinical data suggest that a candidate treatment has a low likelihood of clinical effectiveness or may have substantial toxicity, RCTs including a BASC group are the most efficient and reliable way to identify benefits or harm. Given the accelerated development of Ebola drugs (which involves, for example, proceeding on the basis of only limited phase 1 data and little or no traditional phase 2 data) and preliminary data suggesting potential for adverse effects, such drugs need to be evaluated in RCTs with an appropriate control group so that any harm can be detected. Otherwise, it may not be possible to distinguish serious adverse drug effects from manifestations of EVD.

Some public health authorities are reluctant to support RCTs, which they see as traditional and slow trials.3 However, advances in trial design can and should be incorporated into Ebola RCTs. For example, such trials should include ongoing monitoring of results (e.g., group-sequential designs), adaptive elements, and other trial efficiencies to reduce the time required to identify an effective treatment, particularly a very effective treatment. If one investigational drug clearly shows benefit, trials should incorporate it into the new standard of care for all treatment groups thereafter. Then a regimen adding a different investigational therapy to the new standard of care could be compared with the new standard of care alone. If multiple investigational drugs are simultaneously available for clinical testing, an RCT could include more than one drug and a shared control group. Trials could be designed to assess effects on survival (recovery from disease) as the most important and measurable end point.

RCTs will yield the safety and effectiveness data that are so desperately needed and will do so ethically, giving all patients in a study an equal opportunity to receive the often limited supply of investigational drugs. So far, investigational drugs have generally been used in the few patients treated in the United States or Europe. An RCT with sites in West Africa, the United States, and Europe could result in more equitable distribution, because random allocation provides a fair means of deciding who has access to limited quantities of an investigational drug.

Scientists at the National Institutes of Health, in collaboration with the Food and Drug Administration, the Biomedical Advanced Research and Development Authority, the Department of Defense, and clinicians caring for patients with EVD in the United States, are leading efforts to develop and implement such trials. They have developed a protocol for an RCT with a BASC control group that will use Bayesian analytic methods, allow for the study of more than one investigational drug using a shared control group, and permit incorporation of a therapy into the regimen for the standard-of-care group once it has been shown to be effective against Ebola. The trial will be initiated first in the United States, with an opportunity for subsequent expansion to affected countries in West Africa. Establishing such trials in those countries is likely to have additional beneficial effects, such as improving supportive care.

Conducting such trials in affected regions will be challenging. It is critical for public health leaders to articulate the rationale for conducting scientifically valid trials, to work closely with local health authorities, and to engage community leaders so that trials can be acceptable to the affected populations. Such efforts are essential if we are to correctly identify therapies that will benefit patients with EVD now and in the future.

Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.
This article was published on December 3, 2014, at NEJM.org.
Source Information
From the Center for Drug Evaluation and Research (E.C., R.T.) and the Office of the Commissioner (L.B.), Food and Drug Administration, Silver Spring, MD.

New England Journal of Medicine
December 4, 2014 Vol. 371 No. 23
http://www.nejm.org/toc/nejm/medical-journal

Original Article
Chimpanzee Adenovirus Vector Ebola Vaccine — Preliminary Report
Julie E. Ledgerwood, D.O., Adam D. DeZure, M.D., Daphne A. Stanley, M.S., Laura Novik, M.A., Mary E. Enama, M.A., Nina M. Berkowitz, M.P.H., Zonghui Hu, Ph.D., Gyan Joshi, M.S., Aurélie Ploquin, Ph.D., Sandra Sitar, M.S., Ingelise J. Gordon, R.N., Sarah A. Plummer, C.R.N.P., LaSonji A. Holman, F.N.P., Cynthia S. Hendel, C.R.N.P., Galina Yamshchikov, M.S., Francois Roman, M.D., Alfredo Nicosia, Ph.D., Stefano Colloca, Ph.D., Riccardo Cortese, M.D., Robert T. Bailer, Ph.D., Richard M. Schwartz, Ph.D., Mario Roederer, Ph.D., John R. Mascola, M.D., Richard A. Koup, M.D., Nancy J. Sullivan, Ph.D., Barney S. Graham, M.D., and the VRC 207 Study Team
November 26, 2014DOI: 10.1056/NEJMoa1410863
Abstract
Background
The unprecedented 2014 epidemic of Ebola virus disease (EVD) has prompted an international response to accelerate the availability of a preventive vaccine. A replication-defective recombinant chimpanzee adenovirus type 3–vectored ebolavirus vaccine (cAd3-EBO), encoding the glycoprotein from Zaire and Sudan species that offers protection in the nonhuman primate model, was rapidly advanced into phase 1 clinical evaluation.
Full Text of Background…
Methods
We conducted a phase 1, dose-escalation, open-label trial of cAd3-EBO. Twenty healthy adults, in sequentially enrolled groups of 10 each, received vaccination intramuscularly in doses of 2×1010 particle units or 2×1011 particle units. Primary and secondary end points related to safety and immunogenicity were assessed throughout the first 4 weeks after vaccination.
Full Text of Methods…
Results
In this small study, no safety concerns were identified; however, transient fever developed within 1 day after vaccination in two participants who had received the 2×1011 particle-unit dose. Glycoprotein-specific antibodies were induced in all 20 participants; the titers were of greater magnitude in the group that received the 2×1011 particle-unit dose than in the group that received the 2×1010 particle-unit dose (geometric mean titer against the Zaire antigen, 2037 vs. 331; P=0.001). Glycoprotein-specific T-cell responses were more frequent among those who received the 2×1011 particle-unit dose than among those who received the 2×1010 particle-unit dose, with a CD4 response in 10 of 10 participants versus 3 of 10 participants (P=0.004) and a CD8 response in 7 of 10 participants versus 2 of 10 participants (P=0.07).
Full Text of Results…
Conclusions
Reactogenicity and immune responses to cAd3-EBO vaccine were dose-dependent. At the 2×1011 particle-unit dose, glycoprotein Zaire–specific antibody responses were in the range reported to be associated with vaccine-induced protective immunity in challenge studies involving nonhuman primates. Clinical trials assessing cAd3-EBO are ongoing. (Funded by the Intramural Research Program of the National Institutes of Health; VRC 207 ClinicalTrials.gov number, NCT02231866.)

The Pediatric Infectious Disease Journal
December 2014 – Volume 33 – Issue 12 pp: 1211-1312,e316-e337
http://journals.lww.com/pidj/pages/currenttoc.aspx

Trends of Pneumococcal Meningitis in Children After Introduction of the 13-Valent Pneumococcal Conjugate Vaccine in France
Levy, Corinne MD; Varon, Emmanuelle MD; Picard, Capucine MD; Béchet, Stéphane MSc; Martinot, Alain MD; Bonacorsi, Stéphane MD; Cohen, Robert MD
Abstract
Background:
Streptococcus pneumoniae remains an important cause of bacterial meningitis in children younger than 2 years. Here, we analyzed data from an active surveillance network established 12 years ago by the Pediatric Infectious Disease Group and the Pediatric Clinical and Therapeutical Association to analyze the impact of pneumococcal conjugate vaccine (PCV7 implemented in 2002 and PCV13 in 2010) on pneumococcal meningitis (PM).
Methods:
Two hundred twenty-seven pediatric wards working with 168 microbiology departments throughout France were asked to report all cases of PM.
Results:
From 2001 to 2012, among 4808 bacterial meningitis cases, 1406 cases of PM (29.2%) were reported. After PCV13 implementation, from 2009 to 2012, the number of cases significantly decreased by 27.4% (P = 0.041, Cuzick trend test). For children younger than 2 years, the decrease was 28.2% (P = 0.039, Cuzick trend test). In the same period, the decrease was 66.7% in cases due to 6 additional PCV13 types, and the number of cases due to nonvaccine types remained stable. In 2012, the non-PCV13 serotype represented 67.6% of cases and were mainly represented by 12F (15%), 24F (15%), 22F (7%) and 15B/C (7%). For 88.6% of cases, initial antibiotic treatment was vancomycin with a third-generation cephalosporin. Overall mortality was 10.6%, most deaths (86.4%) occurred before day 15.
Conclusions:
Two years after the PCV13 implementation, we found an impact on PM cases particularly for children younger than 2 years.

Pediatrics
December 2014, VOLUME 134 / ISSUE 6
http://pediatrics.aappublications.org/current.shtml

Article
Sinusitis and Pneumonia Hospitalization After Introduction of Pneumococcal Conjugate Vaccine
Ann Lindstrand, MD, MPHa,b, Rutger Bennet, MD, PhDc, Ilias Galanis, MSca, Margareta Blennow, MD, PhDd,e, Lina Schollin Ask, MDd, Sofia Hultman Dennison, MDf, Malin Ryd Rinder, MD, PhDd, Margareta Eriksson, MD, PhDc, Birgitta Henriques-Normark, MD, PhDa,g,h, Åke Örtqvist, MD, PhDi,j, and Tobias Alfvén, MD, PhDb,d
Author Affiliations
aPublic Health Agency of Sweden, Solna, Sweden;
Departments of bPublic Health Sciences, Division of Global Health,
eClinical Sciences and Education, and
gMicrobiology, Tumor and Cell Biology, Karolinska Institutet, Stockholm, Sweden;
cAstrid Lindgren Children’s Hospital, and
hDepartment of Laboratory Medicine, Division of Clinical Microbiology, Karolinska University Hospital, Solna, Sweden;
dSachs’ Children and Youth Hospital, South General Hospital, Stockholm, Sweden;
fDepartment of Otorhinolaryngology, Karolinska University Hospital, Stockholm, Sweden;
iDepartment of Communicable Disease Control and Prevention, Stockholm County Council, Sweden; and
jDepartment of Medicine, Unit of Infectious Diseases, Karolinska Institutet, Karolinska, Solna, Sweden
Abstract
BACKGROUND AND OBJECTIVE:Streptococcus pneumoniae is a major cause of pneumonia and sinusitis. Pneumonia kills >1 million children annually, and sinusitis is a potentially serious pediatric disease that increases the risk of orbital and intracranial complications. Although pneumococcal conjugate vaccine (PCV) is effective against invasive pneumococcal disease, its effectiveness against pneumonia is less consistent, and its effect on sinusitis is not known. We compared hospitalization rates due to sinusitis, pneumonia, and empyema before and after sequential introduction of PCV7 and PCV13.
METHOD: All children 0 to <18 years old hospitalized for sinusitis, pneumonia, or empyema in Stockholm County, Sweden, from 2003 to 2012 were included in a population-based study of hospital registry data on hospitalizations due to sinusitis, pneumonia, or empyema. Trend analysis, incidence rates, and rate ratios (RRs) were calculated comparing July 2003 to June 2007 with July 2008 to June 2012, excluding the year of PCV7 introduction.
RESULTS: Hospitalizations for sinusitis decreased significantly in children aged 0 to <2 years, from 70 to 24 cases per 100 000 population (RR = 0.34, P < .001). Hospitalizations for pneumonia decreased significantly in children aged 0 to <2 years, from 450 to 366 per 100 000 population (RR = 0.81, P < .001) and in those aged 2 to <5 years from 250 to 212 per 100 000 population (RR = 0.85, P = .002). Hospitalization for empyema increased nonsignificantly. Trend analyses showed increasing hospitalization for pneumonia in children 0 to <2 years before intervention and confirmed a decrease in hospitalizations for sinusitis and pneumonia in children aged 0 to <5 years after intervention.
CONCLUSIONS: PCV7 and PCV13 vaccination led to a 66% lower risk of hospitalization for sinusitis and 19% lower risk of hospitalization for pneumonia in children aged 0 to <2 years, in a comparison of 4 years before and 4 years after vaccine introduction.

Article
Changes in Child Mortality Over Time Across the Wealth Gradient in Less-Developed Countries
Eran Bendavid, MD, MSa,b
Author Affiliations
aDivision of General Medical Disciplines, and
bCenter for Health Policy and the Center for Primary Care and Outcomes Research, Stanford University, Stanford, California
Abstract
BACKGROUND: It is unknown whether inequalities in under-5 mortality by wealth in low- and middle-income countries (LMICs) are growing or declining.
METHODS: All Demographic and Health Surveys conducted between 2002 and 2012 were used to measure under-5 mortality trends in 3 wealth tertiles. Two approaches were used to estimate changes in under-5 mortality: within-survey changes from all 54 countries, and between-survey changes for 29 countries with repeated survey waves. The principal outcome measures include annual decline in mortality, and the ratio of mortality between the poorest and least-poor wealth tertiles.
RESULTS: Mortality information in 85 surveys from 929 224 households and 1 267 167 women living in 54 countries was used. In the subset of 29 countries with repeat surveys, mortality declined annually by 4.36, 3.36, and 2.06 deaths per 1000 live births among the poorest, middle, and least-poor tertiles, respectively (P = .031 for difference). The mortality ratio declined from 1.68 to 1.48 during the study period (P = .006 for trend). In the complete set of 85 surveys, the mortality ratio declined in 64 surveys (from 2.11 to 1.55), and increased in 21 surveys (from 1.58 to 1.88). Multivariate analyses suggest that convergence was associated with good governance (P ≤ .03 for 4 governance indicators: government effectiveness, rule of law, regulatory quality, and control of corruption).
CONCLUSIONS: Overall, under-5 mortality in low- and middle-income countries has decreased faster among the poorest compared with the least poor between 1995 and 2012, but progress in some countries has lagged, especially with poor governance.

Article
Adolescent Vaccine Co-administration and Coverage in New York City: 2007–2013
Monica Sull, MPHa, Joanna Eavey, MSPHa,b, Vikki Papadouka, PhD, MPHa, Rebecca Mandell, MSa,c, Michael A. Hansen, MPHa,d, and Jane R. Zucker, MD, MSca,e
Author Affiliations
aBureau of Immunization, New York City Department of Health and Mental Hygiene, New York, New York;
bCenter for Health Statistics, Washington Department of Health,
cDepartment of Health Behavior and Health Education, University of Michigan, Ann Arbor, Michigan;
dAtlantic Management Center, Inc., Columbus, Ohio; and
eImmunization Services Division/National Center for Immunization and Respiratory Diseases/Centers for Disease Control & Prevention, Atlanta, Georgia
Abstract
OBJECTIVES: To investigate adolescent vaccination in New York City, we assessed tetanus, diphtheria, and acellular pertussis (Tdap), meningococcal conjugate (MCV4), and human papillomavirus (HPV) vaccine uptake, vaccine co-administration, and catch-up coverage over time.
METHODS: We analyzed data from the Citywide Immunization Registry, a population-based immunization information system, to measure vaccine uptake and co-administration, defined as a Tdap vaccination visit where MCV4 or HPV vaccine was co-administered, among 11-year-olds. Catch-up vaccinations were evaluated through 2013 for adolescents born 1996 to 2000, by birth cohort. HPV vaccination among boys included data from 2010 to 2013.
RESULTS: Adolescent vaccine administration was greatest during the back-to-school months of August to October and was highest for Tdap. Although MCV4 uptake improved over the study years, HPV vaccine uptake among girls stagnated; boys achieved similar uptake of HPV vaccine by 2012. By 2013, 65.4% had MCV4 co-administered with Tdap vaccine, whereas 28.4% of girls and 25.9% of boys had their first dose of HPV vaccine co-administered. By age 17, Tdap and MCV4 vaccination coverage increased to 97.5% and 92.8%, respectively, whereas ≥1-dose and 3-dose HPV vaccination coverage were, respectively, 77.5% and 53.1% for girls and 49.3% and 21.6% for boys. Age-specific vaccination coverage increased with each successive birth cohort (P < .001).
CONCLUSIONS: From 2007 to 2013, there were greater improvements in Tdap and MCV4 vaccination than HPV vaccination, for which co-administration with Tdap vaccine and coverage through adolescence remained lower. Parent and provider outreach efforts should promote timely HPV vaccination for all adolescents and vaccine co-administration.

PLoS One
[Accessed 6 December 2014]
http://www.plosone.org/

Research Article
Quantifying the Impact of Expanded Age Group Campaigns for Polio Eradication
Bradley G. Wagner mail, Matthew R. Behrend, Daniel J. Klein, Alexander M. Upfill-Brown, Philip A. Eckhoff, Hao Hu
Published: December 01, 2014
DOI: 10.1371/journal.pone.0113538
Abstract
A priority of the Global Polio Eradication Initiative (GPEI) 2013–2018 strategic plan is to evaluate the potential impact on polio eradication resulting from expanding one or more Supplementary Immunization Activities (SIAs) to children beyond age five-years in polio endemic countries. It has been hypothesized that such expanded age group (EAG) campaigns could accelerate polio eradication by eliminating immunity gaps in older children that may have resulted from past periods of low vaccination coverage. Using an individual-based mathematical model, we quantified the impact of EAG campaigns in terms of probability of elimination, reduction in polio transmission and age stratified immunity levels. The model was specifically calibrated to seroprevalence data from a polio-endemic region: Zaria, Nigeria. We compared the impact of EAG campaigns, which depend only on age, to more targeted interventions which focus on reaching missed populations. We found that EAG campaigns would not significantly improve prospects for polio eradication; the probability of elimination increased by 8% (from 24% at baseline to 32%) when expanding three annual SIAs to 5–14 year old children and by 18% when expanding all six annual SIAs. In contrast, expanding only two of the annual SIAs to target hard-to-reach populations at modest vaccination coverage—representing less than one tenth of additional vaccinations required for the six SIA EAG scenario—increased the probability of elimination by 55%. Implementation of EAG campaigns in polio endemic regions would not improve prospects for eradication. In endemic areas, vaccination campaigns which do not target missed populations will not benefit polio eradication efforts.

PLoS One
[Accessed 6 December 2014]
http://www.plosone.org/
Research Article
What Are Fair Study Benefits in International Health Research? Consulting Community Members in Kenya
Maureen Njue, Francis Kombe, Salim Mwalukore, Sassy Molyneux, Vicki Marsh mail
Published: December 03, 2014
DOI: 10.1371/journal.pone.0113112
Abstract
Background
Planning study benefits and payments for participants in international health research in low- income settings can be a difficult and controversial process, with particular challenges in balancing risks of undue inducement and exploitation and understanding how researchers should take account of background inequities. At an international health research programme in Kenya, this study aimed to map local residents’ informed and reasoned views on the effects of different levels of study benefits and payments to inform local policy and wider debates in international research.
Methods and Findings
Using a relatively novel two-stage process community consultation approach, five participatory workshops involving 90 local residents from diverse constituencies were followed by 15 small group discussions, with components of information-sharing, deliberation and reflection to situate normative reasoning within debates. Framework Analysis drew inductively and deductively on voice- recorded discussions and field notes supported by Nvivo 10 software, and the international research ethics literature. Community members’ views on study benefits and payments were diverse, with complex contextual influences and interplay between risks of giving ‘too many’ and ‘too few’ benefits, including the role of cash. While recognising important risks for free choice, research relationships and community values in giving ‘too many’, the greatest concerns were risks of unfairness in giving ‘too few’ benefits, given difficulties in assessing indirect costs of participation and the serious consequences for families of underestimation, related to perceptions of researchers’ responsibilities.
Conclusions
Providing benefits and payments to participants in international research in low-income settings is an essential means by which researchers meet individual-level and structural forms of ethical responsibilities, but understanding how this can be achieved requires a careful account of social realities and local judgment. Concerns about undue inducement in low-income communities may often be misplaced; we argue that greater attention should be placed on avoiding unfairness, particularly for the most-poor.

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

Health in Action
Tracking Rural Health Facility Financial Data in Resource-Limited Settings: A Case Study from Rwanda
Chunling Lu mail, Sandy Tsai, John Ruhumuriza, Grace Umugiraneza, Solange Kandamutsa, Phillip P. Salvatore, Zibiao Zhang, Agnes Binagwaho, Fidele Ngabo
Published: December 02, 2014
DOI: 10.1371/journal.pmed.1001763
Summary Points
:: Tracking financial data for rural health facilities is difficult in low-income countries because of unstandardized accounting practices and the absence of effective health financial information tracking systems.
:: Poor-quality financial data hinders monitoring and evaluation of health facility performance.
:: We present a five-step procedure developed for gathering financial data from 21 health centers in two rural districts of Rwanda.
:: The five-step procedure generated financial data with internal consistency and a low percentage of reports of “missing” for in-kind support (donated goods and services). In-kind support (mainly medicine and equipment) accounted for a large proportion of the total expenditure of health centers.
:: We report challenges faced by the project and make suggestions for how Rwanda’s national web-based financial data collection system can be improved.
Knowledge gained from the Rwanda field experience may inform other low-income countries on how to establish an information system to track health facility financial data.

PLoS Neglected Tropical Diseases
http://www.plosntds.org/
(Accessed 6 December 2014)
Research Article
Comparative Effectiveness of Different Strategies of Oral Cholera Vaccination in Bangladesh: A Modeling Study
Dobromir T. Dimitrov, Christopher Troeger, M. Elizabeth Halloran, Ira M. Longini, Dennis L. Chao mail
Published: December 04, 2014
DOI: 10.1371/journal.pntd.000334
Abstract
Background
Killed, oral cholera vaccines have proven safe and effective, and several large-scale mass cholera vaccination efforts have demonstrated the feasibility of widespread deployment. This study uses a mathematical model of cholera transmission in Bangladesh to examine the effectiveness of potential vaccination strategies.
Methods & Findings
We developed an age-structured mathematical model of cholera transmission and calibrated it to reproduce the dynamics of cholera in Matlab, Bangladesh. We used the model to predict the effectiveness of different cholera vaccination strategies over a period of 20 years. We explored vaccination programs that targeted one of three increasingly focused age groups (the entire vaccine-eligible population of age one year and older, children of ages 1 to 14 years, or preschoolers of ages 1 to 4 years) and that could occur either as campaigns recurring every five years or as continuous ongoing vaccination efforts. Our modeling results suggest that vaccinating 70% of the population would avert 90% of cholera cases in the first year but that campaign and continuous vaccination strategies differ in effectiveness over 20 years. Maintaining 70% coverage of the population would be sufficient to prevent sustained transmission of endemic cholera in Matlab, while vaccinating periodically every five years is less effective. Selectively vaccinating children 1–14 years old would prevent the most cholera cases per vaccine administered in both campaign and continuous strategies.
Conclusions
We conclude that continuous mass vaccination would be more effective against endemic cholera than periodic campaigns. Vaccinating children averts more cases per dose than vaccinating all age groups, although vaccinating only children is unlikely to control endemic cholera in Bangladesh. Careful consideration must be made before generalizing these results to other regions.

Author Summary
Bangladesh has a high burden of cholera and may become the first country to use cholera vaccine on a large scale. Mass cholera vaccination may be hard to justify to international funding agencies because of the modest efficacy of existing vaccines and their limited duration of protection. However, mass cholera vaccination can induce high levels of indirect protection in a population, i.e., protecting even unvaccinated individuals by lowering cholera incidence, and a case for cost-effective cholera vaccination could be made. Mathematical modeling is one way to predict the magnitude of indirect protection conferred by a proposed vaccination program. Here, we predict the effectiveness of various mass cholera vaccination strategies in Bangladesh using a mathematical model. We found that maintaining high levels of vaccination coverage in children could be very effective in reducing the burden of cholera, and secondary transmission of cholera would virtually stop when 70% of the population is vaccinated. Mathematical modeling may play a key role in planning widespread cholera vaccination efforts in Bangladesh and other countries.

PLoS Pathogens
http://journals.plos.org/plospathogens/
(Accessed 6 December 2014)

Pearls
War and Infectious Diseases: Challenges of the Syrian Civil War
Sima L. Sharara, Souha S. Kanj mail
Published: November 13, 2014
DOI: 10.1371/journal.ppat.100443
Overview
Syria’s ongoing three-year civil war has displaced 6.5 million Syrians, left hundreds of thousands wounded or killed by violence, and created a vacuum in basic infrastructures that will reverberate throughout the region for years to come. Beyond such devastation, the civil war has introduced epidemics of infections that have spread through vulnerable populations in Syria and neighboring countries. In this article, we discuss the growing epidemics of poliomyelitis, measles, and cutaneous leishmaniasis in Syria and the region to examine the impact of conditions of war on the spread of infectious diseases in a public health emergency of global concern.

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

BMC Biology
http://www.biomedcentral.com/bmcbiol/content
Interview
Vaccines, emerging viruses, and how to avoid disaster
Rino Rappuoli
Author Affiliations
Novartis Vaccines, Siena 53100, Italy
BMC Biology 2014, 12:100 doi:10.1186/s12915-014-0100-6
29 November 2014
Abstract
Rino Rappuoli is a graduate of Siena University, where he also earned his PhD before moving to the Sclavo Research Center, the Italian vaccine institute, also in Siena. He then spent two years in the USA, mostly at Harvard with John Murphy and Alwin Pappenheimer working on a new diphtheria vaccine based on a non-toxic mutant of diphtheria toxin which has since become the basis for conjugate vaccines against haemophilus, meningococcus, and pneumococcal infections, before returning to the Sclavo Research Center where he developed an acellular vaccine based on a mutant pertussis toxin. With many achievements in vaccine development to his credit, he is now Global Head of Vaccines Research and Development for Novartis Vaccines in Siena, and has most recently pioneered reverse vaccinology, in which the genome of the pathogen is screened for candidate antigenic and immunogenic vaccine components. We spoke to him about the potential for outbreaks of the kind we are now seeing with Ebolavirus in West Africa, and what can be done to prevent them.

Q. Ebolavirus disease has been much in the news recently because of the horrendous outbreak in West Africa – but how many other rare, sporadic but severe infections are there that pose an equal threat?
Well, during the last few years, more or less with every 6 months to a year there has been a new outbreak of an emerging infection. Examples are the influenza viruses – for instance H1N1 in 2009, and H7N9 and H5N1 more recently [1] – the MERS rotavirus in Saudi Arabia [2], and Chikungunya virus in St Martin in 2013 [3], and of course now Ebola virus [4]. So there are many rare but potentially very dangerous diseases or emerging infections regularly breaking out. Ebola virus is by far the most lethal that we have now, but all of the others are very dangerous.

Q. I know that there are ’flu vaccines, but are there licensed vaccines for any of the others?
The answer is no – there are no vaccines for SARS, which emerged in 2003, there is no licensed vaccine for MERS, there is no licensed vaccine for Chikungunya, there is no licensed vaccine for Ebola – so for most of these diseases there are no vaccines, because they are too rare to justify the economic investment.

Q. Is that the only difficultly, or are there other difficulties in developing vaccines for these sorts of diseases? I realise it may be impossible to generalise.
Most of the time we do have the technologies to make these vaccines. I remember for example when SARS came in 2003/2004 we made a vaccine pretty quickly and brought it to the stage where it was ready to go to phase 1, but when we got to phase 1 the disease had gone away, there was no interest, no incentive to bring it even to phase 1, so we dropped it. For Ebola I think that the technology to make a vaccine has been there for many years, but nobody wanted to invest in it because there was no market, no demand.

Q. Do you think this is going to have to change in the light of what has happened with Ebola?
I hope that this humanitarian and health disaster is going to help us to become a little bit smarter in planning the future. I see these emerging infectious diseases as a constant threat. They pose a risk, just as in other areas we have a risk of earthquakes, we have a risk when we drive a car of car accidents, when we buy a house there is a risk of burning the house, and so on – and for all of those risks we prepare ahead of time. We have insurance for cars or we have insurance for houses and we build buildings that are earthquake-resistant. It looks as though the only place where we are not able to make investments ahead of time is health – we always have to wait for the disaster to happen and then we rush and usually with the vaccine we come too late and when the disease is no longer there then everyone forgets and we go from one disaster to another.

Q. How forward-thinking do we need to be? – How long does it actually take to develop a vaccine, generally?
For a normal commercial vaccine the time is between 10 and 15 years. Under very accelerated circumstances, like those we have now for Ebola, you can take advantage of previous studies that have been done and try to rush the development of the vaccine, but we do take risks with safety and efficacy when we accelerate so much, so I think we will be wise to develop those vaccines ahead of time.
Q. How much of a problem is viral mutation?
It depends on the virus, so for Ebola it is not a problem at all, for MERS it does not seem to be a problem, for SARS it does not seem to be a problem, for Chikungunya it does not seem to be a problem. For influenza it is a problem and for HIV it is a big problem, so it depends on the virus.

Q. What about the possibility, aired in the Press, that Ebola might become transmissible in an airborne form? Do you have any view on that possibility?
I believe that it is extremely unlikely. This virus has been there for a long time in the wild in Africa and it has never done it. It has had many opportunities to do it. I don’t think that a small exposure to mankind right now is going to do it and the preliminary data from the genetics and genomics of the virus show very good stability so I don’t think this is a risk in the short term.

So a little bit of good news. But you say one of these diseases pops out about every six months.

Q. Do you expect that we’ll be continuing to see emerging infections we haven’t seen before?
Oh yes, I believe that in six months we will have a new emerging disease. Hopefully the Ebola outbreak will be under control. It will not be in the news and there will be other news about another emerging infection and we will rush into the new one, and instead of doing that I think it would be nice to be able to plan ahead of time. I think we have technologies today by which we could prepare multiple vaccine platforms that could be tested for safety and efficacy against multiple diseases and where you could plug in an antigen from a new emerging infection quickly. We already effectively have this for influenza virus, for which as the virus mutates each year we just plug in the most prevalent haemagglutinin variants to the existing vaccine platform. If the regulatory authorities could approve platforms suitable for use against other pathogens – thus already of proven safety and efficacy – we could have a way of being as ready as possible for unexpected events.
The Lancet Respiratory Medicine
Online First
Comment
Paediatric influenza vaccination: time to better protect high-risk groups?
Harish Nair, Marc-Alain Widdowson
4 December 2014
Preview
Paediatric influenza vaccination: time to better protect high-risk groups?
Influenza is an important contributor to severe acute lower respiratory infection (ALRI). It is estimated to cause 20 million cases of influenza-associated ALRI per year worldwide, including 1 million severe ALRI cases, and 28 000—111 500 deaths in children younger than 5 years, mostly in the first 2 years of life… In many countries with few resources, children are very rarely vaccinated against influenza, and antivirals are usually unavailable. Moreover, children could be more susceptible to well documented sequelae of influenza infection, especially Streptococcus pneumoniae. Unfortunately, pneumococcal vaccine has been introduced in only 40 of the Gavi-eligible countries, and even where introduced, the coverage remains poor.

Identification of children at risk of influenza-related complications in primary and ambulatory care: a systematic review and meta-analysis
Peter J Gill DPhil a b, Helen F Ashdown MRCGP a, Dr Kay Wang DPhil a, Prof Carl Heneghan DPhil a, Nia W Roberts MSc Econ c, Prof Anthony Harnden FRCGP a, Susan Mallett DPhil a
Summary
Background
Interventions to prevent influenza-related complications are recommended for individuals at the greatest risk of serious clinical deterioration. However, guidelines are based on consensus opinion rather than evidence, and do not specify risk factors in children. We aimed to provide an evidence-based definition of children who are most at risk of such complications.
Methods
In this systematic review, we searched the Medline and Medline In Process, Embase, Science Citation Index, and CINAHL databases for studies published between inception and April 3, 2013. We included studies that reported data for underlying disorders and complications in children presenting in primary or ambulatory care with influenza or influenza-like illness. We requested unpublished data from investigators of studies that had obtained, but not published, relevant data. We analysed data with univariable meta-analysis and individual patient data multivariable meta-analysis methods. The primary outcome was admission to hospital as a proxy for complications of influenza or influenza-like illness.
Findings
We included 28 articles that reported data from 27 studies (14 086 children). Strong risk factors for hospital admission were neurological disorders (univariable odds ratio [OR] 4• 62, 95% CI 2•82—7•55), prematurity (4•33, 2•47—7•58), sickle cell disease (3•46, 1•63—7•37), immunosuppression (2•39, 1•24—4•61), diabetes (2•34, 1•20—4•58), and age younger than 2 years (2•51, 1•71—3•69). However, reactive airways disease including asthma (1•36, 0•82—2•26) and obesity (0•99, 0•61—1•62) were not found to be risk factors. On the basis of individual patient data multivariable analysis (1612 children, four studies), the risk of hospital admission was higher in children with more than one risk factor than in children with just one risk factor, when age younger than 2 years was included as a risk factor (92 [74%] of 124 vs 428 [52%] of 817; difference 22%, 95% CI 13—30%, p<0•0001).
Interpretation
We identified prematurity as a new strong risk factor for influenza-related complications in children. Our findings also support the inclusion of neurological disorders, sickle cell disease, immunosuppression, diabetes, and age younger than 2 years as risk factors in existing guidelines. Interventions to prevent influenza-related complications should be prioritised in these groups, but should also be considered for other children, especially those with more than one risk factor or severe underlying comorbidities.
Funding
UK National Institute for Health Research.

Media/Policy Watch
This section is intended to alert readers to substantive news, analysis and opinion from the general media on vaccines, immunization, global; public health and related themes. Media Watch is not intended to be exhaustive, but indicative of themes and issues CVEP is actively tracking. This section will grow from an initial base of newspapers, magazines and blog sources, and is segregated from Journal Watch above which scans the peer-reviewed journal ecology.
We acknowledge the Western/Northern bias in this initial selection of titles and invite suggestions for expanded coverage. We are conservative in our outlook in adding news sources which largely report on primary content we are already covering above. Many electronic media sources have tiered, fee-based subscription models for access. We will provide full-text where content is published without restriction, but most publications require registration and some subscription level.

AP (Associated Press)
http://hosted.ap.org/dynamic/fronts/HOME?SITE=AP
Accessed 6 December 2014 Dec 5, 1:22 PM EST
Sierra Leone seeing 80-100 new Ebola cases daily
By EDITH M. LEDERER
Associated Press UNITED NATIONS (AP) — Sierra Leone said Friday that between 80 and 100 new cases of Ebola are being reported every day and the country now hardest-hit by the deadly virus desperately needs over 1,000 beds to treat victims.
Sierra Leone’s Finance Minister Kaifalah Marah painted a grim picture to the U.N. Economic and Social Council Friday of the challenges facing his West African nation which failed to meet a World Health Organization interim goal of isolating 70 percent of Ebola patients and safely burying 70 percent of victims by Dec. 1…

Council on Foreign Relations
http://www.cfr.org/
Accessed 6 December 2014
Transcript
DC Event: Launch of the CFR-Sponsored Independent Task Force Report on the Emerging Global Health Crisis of Noncommunicable Diseases
with Mitchell E. Daniels Jr., Thomas E. Donilon, Thomas J. Bollyky, Massimo F. T. Calabresi December 5, 2014
Experts discuss the newly published Council on Foreign Relations (CFR)-sponsored Independent Task Force on Noncommunicable Diseases, which assesses the NCD crisis in developing countries and recommends a practical, scalable strategy for intervention.

New York Times
http://www.nytimes.com/
Accessed 6 December 2014
Chronic Diseases Are Killing More in Poorer Countries
4 December 2014
Chronic diseases like cancer and heart disease are rising fast in low- and middle-income countries, striking far younger populations than in rich countries and causing much worse outcomes, according to a new report. Deaths from chronic diseases have risen by more than 50 percent in low- and middle-income countries over the past two decades, according to the report (The Emerging Global Health Crisis), by the Council on Foreign Relations. The increase is part of a shift in global mortality patterns in which infectious diseases, such as malaria and tuberculosis, have declined substantially and are no longer the leading cause of death in the developing world.

Wall Street Journal
http://online.wsj.com/home-page?_wsjregion=na,us&_homepage=/home/us
Accessed 6 December 2014
Haider Javed Warraich: The Measles Outbreak Coming Near You
Parents who won’t vaccinate their children are reviving once-dead diseases. Will a vaccine mandate be needed?

Washington Post
http://www.washingtonpost.com/
Accessed 6 December 2014
U.S. designates 35 hospitals to treat Ebola patients
President Obama says the fight against Ebola in West Africa “is not even close to being over.”
Lena H. Sun | Health & Science | December 2, 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 6 December 2014.

UNMEER site: Press Releases & Statement
:: UN employs ‘district-by district’ approach in fight against Ebola (1 December 2014)

:: Remarks by David Nabarro, Special Envoy of the Secretary-General on Ebola, to mark the first 60 days of UNMEER, Freetown, Sierra Leone (1 December 2014)

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.

5 December 2014 | UNMEER External Situation Report
Key Political and Economic Developments
2. The government of Guinea-Bissau announced on 4 December that it would reopen the country’s official border crossings with Guinea within 5 days. Guinea-Bissau had closed the border in August 2014 in an effort to prevent cross-border transmission of EVD. Surveillance measures will be strengthened along the border. The recent summit of Heads of State of the Economic Community of West African States (ECOWAS) held in Ghana had recommended the reopening of borders with the most affected countries to accelerate response efforts and avoid stigmatization of their populations.
3. The United Nations Mission in Liberia (UNMIL) on Thursday said that a member of its military personnel had tested positive for EVD. The patient is receiving treatment at an Ebola Treatment Unit in Monrovia. In line with WHO protocols, the medical team of UNMIL has immediately conducted robust contact tracing to ensure that all those who came into contact with the individual while he was symptomatic have been assessed and quarantined. All areas where the individual is known to have been while symptomatic have been decontaminated.
4. A ceremony scheduled on 4 December for Guinea’s Prime Minister to lay the first stone of a new ETC in Matoto commune in Conakry, was cancelled when groups of local youth ransacked the premises. They were reportedly protesting against the establishment of the ETC, arguing that it would lead to a spike in EVD cases in their community. Government officials, diplomats and representatives of non-governmental organizations were forced to leave the site of the planned ceremony due to the tensions.
Response Efforts and Health
7. 17,256 confirmed, probable, and suspected cases of EVD have been reported in the three most affected countries, where there have been 6,113 reported deaths.
Resource Mobilisation
11. The OCHA Ebola Virus Outbreak Overview of Needs and Requirements, now totaling US$ 1.5 billion, has been funded for $ 993 million, which is around 66 percent of the total ask.
Essential Services
15. The EVD crisis is destroying livelihoods, according to a newly released UNDP socioeconomic study. The study shows disproportionate numbers of economically active people are getting infected. In Sierra Leone, for instance, 65% of the sick were in the 15-49 age group. As caregivers, women are especially vulnerable. They represent up to 74% of the people who get infected in some areas of Guinea. Because women are often responsible for growing and trading food in all three countries, these sectors are also particularly impacted. 97% of respondents in a recent survey reported reduced incomes from farming, petty trading and service delivery. Employment in the informal sector and in education is especially affected in all three countries. The report calls for boosting informal and formal loan schemes and microfinance; investments in the next planting season; promotion of value chains in export-oriented primary commodities; and continuing to build skills among the workforce.
16. As schools remain closed, two million children in Sierra Leone are affected. The Emergency Radio Education Programme (EREP) continues to broadcast daily lessons through 41 radio stations nationwide. Some 47% of 2,489 surveyed households have children listening. The Ministry of Education and UNICEF are working to increase listenership through community outreach. UNICEF is in the process of procuring 50,000 solar powered radios for the most vulnerable households.

4 December 2014 | UNMEER External Situation Report
Key Political and Economic Developments
1. Europe must send more medical staff to West Africa to help rebuild local health systems and tackle the outbreak of EVD, EU Ebola coordinator Christos Stylianides has said, adding that he was in touch with European capitals on additional assistance to counter the disease in Guinea, Liberia, Sierra Leone, and Mali. At European level the mobilisation is “satisfactory but we must not relax our efforts” he indicated. Sweden has already announced that it will send 42 healthcare workers, while Greece is readying its first team. The EU’s medical evacuation system is “fully operational” with four planes on standby in Luxembourg and the US, and nine countries ready to treat repatriated staff. Mr. Stylianides is due to present an EVD action plan in December. Brussels is counting on more help;
2. MSF expressed concern on Tuesday about what it called a slow and uneven international response that portends further setbacks. MSF president Dr. Joanne Liu acknowledged an outpouring of financial and construction help from abroad in the past few months, but added that most of the work on tracking, isolating and treating patients, burying the dead and raising awareness to minimize contagion had fallen to the three countries at the heart of the outbreak: Guinea, Liberia and Sierra Leone. “It is extremely disappointing that states with biological disaster response capacities have chosen not to utilize them,” Dr. Liu said. “How is it that the international community has left the
Response Efforts and Health
8. The WFP-led Emergency Telecommunications Cluster is equipping rapid response teams in Sierra Leone with tools such as satellite phones and portable internet to ensure efficient and effective communication even in the remotest of areas. These teams of 15-20 people include a burial team, medical professionals and contact tracers amongst others, and are managed by the government of Sierra Leone.
Resource Mobilisation
13. Guinea, Liberia and Sierra Leone will each receive US$ 500,000 to help curb the impact of EVD on food security and on the livelihoods of people in rural areas. The $ 1.5 million grant from the Africa Solidarity Trust Fund will be used in support of FAO’s recently launched Regional Response Programme to tackle agriculture and food security issues related to the EVD outbreak in West Africa.
Outreach and Education
18. UNDP in Sierra Leone, working with local NGO One Family People, has completed the first stage of a sensitization campaign for people living with disability, having reached out to 10,000 women, men and children. Thanks to the campaign, people who are deaf, blind or physically impaired received messages in braille, sign language and pictures on how to protect themselves and others.

3 December 2014 | UNMEER External Situation Report
Key Political and Economic Developments
2. The World Bank said Tuesday that EVD is costing the three most affected countries more than US$ 2 billion, as the virus causes their economies to slow down or shrink. The bank sharply revised down its 2014 and 2015 economic growth estimates for Sierra Leone and Guinea, but said the outlook for Liberia was improving slightly. For 2015, it now forecasts Sierra Leone’s economy will shrink 2.0%, down from a 7.7% growth forecast in October and 8.9% before the crisis. Guinea will shrink 0.2% versus October’s estimate of 2% growth and a pre-outbreak forecast of 4.3%. In Liberia, where there are signs of progress and increasing economic activity, the bank increased its 2015 GDP growth estimate to 3.0%, up from 1.0% in October, but still less than half the pre-crisis estimate of 6.8%.
3. With more than half of its population already under lockdown, Sierra Leone has now quarantined a sixth district. Tonkolili, in the centre of the country, was added to the growing list of districts which no one is allowed to leave or enter without special dispensation, in an effort to combat the outbreak. The northern districts of Port Loko and Bombali were closed off indefinitely in September, along with the southern district of Moyamba – effectively sealing in more than one million people. With the eastern districts of Kenema and Kailahun also under quarantine, more than half of the population of six million, in six of the nation’s 14 districts, now finds itself unable to move freely. Tonkolili is expected to end its quarantine on December 15, according to health ministry officials.
Response Efforts and Health
5. Community resistance, denial and resorting to traditional healers remain prevalent in Gbarpolu and Grand Cape Mount counties, Liberia. The high mortality rates in the remote communities affected by the EVD flare ups (e.g. 17 deaths vs 2 survivors as last reported by the Glensyasu community), combined with limited outreach in hard to reach places, contribute to maintaining a worrying trend in the two counties.
10. UNICEF has provided EVD prevention (hygiene and sanitation) supplies and infection control training to wardens and staff of 14 prisons housing juvenile offenders across Liberia.
Logistics
12. The WFP-led Emergency Telecommunications Cluster is providing technical support to the International Rescue Committee (IRC) to programme 400 mobile phones to be used for data collection by health workers in Bo, Sierra Leone. Internet equipment provided by standby partners Emergency and Ericsson Response will be sent to the International Humanitarian Partnership camp in Port Loko, to provide 80 organisations with internet access by the end of this week.

2 December 2014 | UNMEER External Situation Report
Key Political and Economic Developments
2. In his press conference, the SRSG also reported on performance against the targets the UN had set for 1 December: 70 per cent of burials being done safely and 70 per cent of new cases isolated in a treatment facility. He indicated that those targets have been exceeded in most cases. In the case of safe burials, those targets are exceeded in all three countries. The other target – 70 per cent of new cases being isolated – is being exceeded in two of the three countries, in Liberia and Guinea. And it is being exceeded in many places in Sierra Leone – but some areas remain in serious crisis, and there, targets are not yet being met. Those areas are the focus of UNMEER’s efforts now. Nonetheless, the 70/70 target in 60 days was set so the crisis could be turned around, and that has been achieved.
3. Despite the positive news, the SRSG also emphasized that there was still a long way to go. Special Envoy David Nabarro said the disease was slowing down in some districts and increasing in others. He cautioned that the distribution changes from week to week, and the situation can worsen unexpectedly. EVD remains a very complex, multidimensional crisis, and additional efforts remain needed. The strategy that has been designed to get it under control has proven to work, SRSG Banbury said – putting people in treatment facilities, ensuring safe burials, contact tracing and social mobilization. But it needs to be present everywhere, and it need to be supported with logistics, with payments to response workers, with the information management needed for these activities.
4. The SRSG stressed that to achieve the goal of zero cases, the response needs to be present everywhere. As numbers get lower, more and more emphasis needs to be on contact tracing, on surveillance, and on rapid response capabilities. UNMEER and its partners are looking at putting in place a district-by-district strategy for 62 districts in the three countries, with interventions in every district that are appropriate to the circumstances there. That will be the focus for the next 60 days. SRSG Banbury expressed his confidence that 60 days from now the three countries will be in a much better condition than they are now, though that will still require a lot of hard work. There remains a lot to be done to get to zero cases, but the global EVD response is on the right track.
Response Efforts and Health
9. The Global Fund to Fight AIDS, Tuberculosis and Malaria has agreed to contribute € 500,000 to bolster UNDP’s support to the Malian Ministry of Health. The funds will be used to strengthen preventive measures in health facilities; train and pay health staff, and purchase protective gear.
Essential Services
19. Beyla prefecture in Guinea has 45 community agents working as contact tracers in EVD affected areas. Out of these 45 personnel, only 13 staff members received their salaries in November. The 32 others have not been paid for more than a month. UNMEER’s FCM has followed up with the prefectoral Ebola response coordinator on this payments issue, and has requested the coordinator to bring this to the attention of the National Ebola Response Cell.
20. In Montserrado, where Monrovia is located, UNDP and the Liberian Ministry of Health have set up a task force to increase communication within communities around denial, stigma, safe burials and hiding of sick people. The group will dispel widely held fears that no one comes back from ETUs, and help locate contacts, secret burials and households hiding sick people.

1 December 2014 | UNMEER External Situation Report
Response Efforts and Health
7. On Thursday 27 November, the UNMEER ECM in Liberia hosted the first NGO partnership meeting, to seek inputs from a broad range of implementing partners. Building county level capacity to decentralize policy discussions and coordination was deemed of high importance. Partners agreed that UNMEER has a central role in this regard. In addition, partners agreed to rationalize ad hoc coordination and create specific task groups to address issues such as CCC strategy and funding imbalances. The NGO partnership meeting will be held on a bi-weekly basis.
Outreach and Education
20. According to UNICEF, women in Samana sub-prefecture (Beyla prefecture), an area where there has been community resistance to EVD response, abandoned plans to march in protest against the presence of EVD responders after a sensitization by women leaders via rural radio. Also in Beyla, an agreement was reached for the establishment of a rapid response team within the prefectural communication commission. This cell plans advocacy activities to overcome community resistance.
21. In Liberia’s Grand Geddeh county, WHO, UNICEF, IRC and other partners conducted community engagement activities in Zwedru together with the county health team. The main aim was to have an interactive and informative session with community members and to share health information on EVD. More than 200 EVD posters were distributed. Teams also brought the emergency hotline telephone numbers to the attention of the communities.
Essential Services
22. UNICEF formed a partnership with Africa Humanitarian Action this week to expand the coverage of essential health services to 14 primary healthcare facilities in Montserrado County, Liberia, serving 158,181 people, including 26,890 children under five and 7,909 pregnant women. The provision of lifesaving medical and nutritional supplies is key in enabling access to lifesaving interventions.
World Bank [to 6 December 2014]
http://www.worldbank.org/en/news/all
:: Transcript of Press Conference with World Bank Group President Jim Yong Kim and President of Sierra Leone Ernest Bai Koroma December 3, 2014

:: Remarks by World Bank Group President Jim Yong Kim in Press Conference with President of Guinea Alpha Condé December 3, 2014

:: Transcript of Press Conference with World Bank Group President Jim Yong Kim and President of Liberia Ellen Johnson Sirleaf December 2, 2014

:: Ebola: New World Bank Group Report Shows Growth Shrinking, Economic Impact Worsening in Guinea, Liberia, and Sierra Leone
December 2, 2014
WASHINGTON, December 2, 2014 – The Ebola epidemic continues to cripple the economies of Guinea, Liberia, and Sierra Leone, and is projected to result in negative or contracting growth in these countries next year as they work to eradicate the virus, according to an Ebola Economic Impact Update released today by the World Bank Group. The report comes as World Bank Group President Jim Yong Kim begins a two-day visit to West Africa to assess the epidemic’s impact and discuss with governments and international agencies what steps need to be taken to reach the goal of zero cases as soon as possible.

This report updates the World Bank Group’s October 8 analysis of the economic effects of the Ebola crisis on the three hardest-hit countries. GDP growth estimates for 2014 have been revised sharply downward since pre-crisis estimates to 2.2 percent for Liberia (versus 5.9 percent pre-crisis and 2.5 percent in October); and 4.0 percent for Sierra Leone (versus 11.3 percent pre-crisis and 8.0 percent in October); and 0.5 percent for Guinea (versus 4.5 percent pre-crisis and 2.4 percent in October). All three countries had been growing rapidly in recent years and into the first half of 2014.

In addition, the World Bank Group is now projecting negative growth for 2015 of -0.2% in Guinea (down from pre-crisis estimates of 4.3 percent and 2.0 percent in October) and -2.0% in Sierra Leone (down from 8.9 percent and 7.7 percent in October). In Liberia, where there are signs of progress in containing the epidemic and some increasing economic activity, the updated 2015 growth estimate is 3.0 percent, an increase from 1.0 percent in October but still less than half the pre-crisis estimate of 6.8 percent. These latest projections imply forgone income across the three countries in 2014–15 totaling more than $2 billion.

“This report reinforces why zero Ebola cases must be our goal. While there are signs of progress, as long as the epidemic continues, the human and economic impact will only grow more devastating,” said Jim Yong Kim, President of the World Bank Group. “As we accelerate the immediate health response, the international community must also do everything we can to help the affected countries back on the road to economic recovery and development.”…