New England Journal of Medicine – January 8, 2015 Vol. 372 No. 2

New England Journal of Medicine
January 8, 2015 Vol. 372 No. 2

Original Article
Efficacy of a Tetravalent Dengue Vaccine in Children in Latin America
Luis Villar, M.D., Gustavo Horacio Dayan, M.D., José Luis Arredondo-García, M.D., Doris Maribel Rivera, M.D., Rivaldo Cunha, M.D., Carmen Deseda, M.D., Humberto Reynales, M.D., Maria Selma Costa, M.D., Javier Osvaldo Morales-Ramírez, M.D., Gabriel Carrasquilla, M.D., Luis Carlos Rey, M.D., Reynaldo Dietze, M.D., Kleber Luz, M.D., Enrique Rivas, M.D., Maria Consuelo Miranda Montoya, M.D., Margarita Cortés Supelano, M.D., Betzana Zambrano, M.D., Edith Langevin, M.Sc., Mark Boaz, Ph.D., Nadia Tornieporth, M.D., Melanie Saville, M.B., B.S., and Fernando Noriega, M.D. for the CYD15 Study Group
N Engl J Med 2015; 372:113-123 January 8, 2015 DOI: 10.1056/NEJMoa1411037
In light of the increasing rate of dengue infections throughout the world despite vector-control measures, several dengue vaccine candidates are in development.
In a phase 3 efficacy trial of a tetravalent dengue vaccine in five Latin American countries where dengue is endemic, we randomly assigned healthy children between the ages of 9 and 16 years in a 2:1 ratio to receive three injections of recombinant, live, attenuated, tetravalent dengue vaccine (CYD-TDV) or placebo at months 0, 6, and 12 under blinded conditions. The children were then followed for 25 months. The primary outcome was vaccine efficacy against symptomatic, virologically confirmed dengue (VCD), regardless of disease severity or serotype, occurring more than 28 days after the third injection.
A total of 20,869 healthy children received either vaccine or placebo. At baseline, 79.4% of an immunogenicity subgroup of 1944 children had seropositive status for one or more dengue serotypes. In the per-protocol population, there were 176 VCD cases (with 11,793 person-years at risk) in the vaccine group and 221 VCD cases (with 5809 person-years at risk) in the control group, for a vaccine efficacy of 60.8% (95% confidence interval [CI], 52.0 to 68.0). In the intention-to-treat population (those who received at least one injection), vaccine efficacy was 64.7% (95% CI, 58.7 to 69.8). Serotype-specific vaccine efficacy was 50.3% for serotype 1, 42.3% for serotype 2, 74.0% for serotype 3, and 77.7% for serotype 4. Among the severe VCD cases, 1 of 12 was in the vaccine group, for an intention-to-treat vaccine efficacy of 95.5%. Vaccine efficacy against hospitalization for dengue was 80.3%. The safety profile for the CYD-TDV vaccine was similar to that for placebo, with no marked difference in rates of adverse events.
The CYD-TDV dengue vaccine was efficacious against VCD and severe VCD and led to fewer hospitalizations for VCD in five Latin American countries where dengue is endemic. (Funded by Sanofi Pasteur; number, NCT01374516.)

Preventing Dengue — Is the Possibility Now a Reality?
Stephen J. Thomas, M.D.
N Engl J Med 2015; 372:172-173 January 8, 2015 DOI: 10.1056/NEJMe1413146
Dengue is a mosquito-borne flaviviral illness that is endemic in the tropics and subtropics. An estimated 390 million infections occur annually, of which 96 million have clinical manifestations.1 Although mortality is relatively lower than that for other tropical infectious diseases, the scale of human suffering and economic resources that are expended to control dengue makes it a major global public health problem.2 The factors driving transmission and infection persist without evidence of decline. For these reasons, the world needs a safe and effective dengue vaccine.

Infection with one of the four types of dengue virus (serotypes 1, 2, 3, and 4) may result in an asymptomatic infection, a mild nonspecific viral illness, classic dengue fever, or severe dengue manifested by plasma leakage, hemorrhagic tendencies, and possibly death. Patients with a second infection with a different serotype are at increased risk for severe disease. The mechanisms responsible for enhanced disease have not been completely elucidated. It is theorized the humoral and cellular convalescent immune profiles that are present after a first infection may not only fail to control a second infection with a different serotype but may also facilitate increased target-cell infection, viral replication, and generation of a so-called proinflammatory cytokine storm.3,4

The dengue-vaccine field is facing numerous challenges. First, a viable dengue vaccine must be capable of protecting against disease caused by any of the four serotypes, a process that has been burdened by the absence of a validated animal model of disease or a well-characterized human infection model. The incomplete understanding of dengue immunopathology introduces risk into clinical development programs. Finally, the reliance on neutralizing antibody assays, which are notorious for interassay variability and cross-reactivity among serotypes, to generate immunologic end-point data introduces error into data interpretation.5

After decades of attempts to develop a dengue vaccine, the results of a phase 3 efficacy trial that are now described in the Journal are a milestone. The vaccine candidate that is described by Villar et al.6 has been tested in three clinical end-point studies. In all the studies, three doses of vaccine or a control injection were administered at 0, 6, and 12 months, and all efficacy determinations were made at study month 25.

The first study was a phase 2b efficacy trial involving children between the ages of 4 and 11 years in a single center in Thailand. The trial did not meet the primary efficacy end point, with a per-protocol efficacy of 30.2%, and showed wide variation in serotype-specific efficacy: 55.6% for serotype 1, 9.2% for serotype 2, 75.3% for serotype 3, and 100% for serotype 4.7 The first phase 3 trial, which was conducted in five Asian countries and involved children between the ages of 2 and 14 years, showed a per-protocol efficacy of 56.5%, with a similar trend in serotype-specific efficacy: 50.0% for serotype 1, 35.0% for serotype 2, 78.4% for serotype 3, and 75.3% for serotype 4.8 The phase 3 trial by Villar et al., which was conducted in five Latin America countries and involved children between the ages of 9 and 16 years, had a per-protocol efficacy of 60.8%, with serotype-specific efficacies of 50.3%, 42.3%, 74.0%, and 77.7%, respectively. Additional end points included efficacy against hospitalization (80.3%) and against severe dengue (95.5%). In each of the three studies, the cohort was highly immune to at least one of the serotypes at baseline. In the phase 2b and 3 trials in Asia, average rates of seropositive status for one or more dengue serotypes were 69.5% and 67.5%, respectively; in the study by Villar et al., the average rate was 79.4%.

These studies have answered important questions with respect to the development of a dengue vaccine but have generated numerous others. Vaccine safety, immunogenicity, and efficacy were consistent across the phase 3 studies, with measures of performance similar to those in the phase 2b trial. There were no safety signals identified and no evidence of the hypothetical risk of administering a dengue vaccine to children with a mixture of seropositive and seronegative status who are living in an area in which dengue is endemic. However, it is not clear whether this favorable safety profile will be sustained through periods of waning immunity and successive dengue exposures remote from vaccination.
Vaccination of children with seropositive status produced high seroconversion rates and broad, potent neutralizing-antibody profiles. Despite such elicitation of antibody responses, why was there such disparity in efficacy across the dengue serotypes? Could too much preexisting immunity interfere with a serotype-specific vaccine response, leaving deficits in tetravalent efficacy? It is possible that the antibodies that were measured after vaccination were not all neutralizing but were a mixture of neutralizing and cross-reactive antibodies that were poorly functioning and potentially enhancing.9 If so, this could explain the discordance between the favorable serotype-specific serologic response to vaccination and the absence of corresponding serotype-specific efficacy.
Efficacy was higher in vaccine recipients with seropositive status than in those with seronegative status. Does the inferior efficacy in seronegative vaccine recipients preclude the usefulness of this vaccine for travelers or military personnel? If the vaccine is licensed and an immunization program is implemented, will this factor have an effect on its age-specific placement in the vaccination schedule?

The observed reduction in the severity of clinical disease and the prevention of hospitalization are encouraging. Although outpatient dengue has a substantial societal cost, dengue requiring hospitalization reflects morbidity.10 Is it possible that a vaccine candidate with a modest overall efficacy could be licensed and included in a national immunization program on the basis of its ability to reduce morbidity and other outcomes driving expenditures?

The efficacy trial by Villar et al. shows that we can protect populations from dengue disease and perhaps even reduce the proportion of patients with severe disease. Although the available results are not broadly generalizable across diverse populations, a foundation for additional studies has been laid. The global enrollment of more than 30,000 children in the phase 2b and 3 studies has assuaged fears focusing on the theoretical risk that dengue vaccination could predispose recipients to enhanced rates of severe disease. It remains to be seen whether licensure will be sought on the basis of these data and what effect this could have on future attempts to conduct efficacy trials with different candidate vaccines. For now, practitioners should remain optimistic that one day it will be possible to prevent dengue.

Pediatrics – January 2015, VOLUME 135 / ISSUE 1

January 2015, VOLUME 135 / ISSUE 1

Registry-Linked Electronic Influenza Vaccine Provider Reminders: A Cluster-Crossover Trial
Melissa S. Stockwell, MD, MPHa,b,c, Marina Catallozzi, MD, MSCEa,b,c, Stewin Camargo, MSa, Rajasekhar Ramakrishnan, EngScDa, Stephen Holleran, BAa, Sally E. Findley, PhDb, Rita Kukafka, DrPH, MAd,e, Annika M. Hofstetter, MD, PhD, MPHa,c, Nadira Fernandez, MDa, and
David K. Vawdrey, PhDc,d
Author Affiliations
Departments of aPediatrics,
bPopulation and Family Health,
dBiomedical Informatics, and
eSociomedical Sciences, Columbia University, New York, New York; and
cNewYork–Presbyterian Hospital, New York, New York
OBJECTIVE: To determine the impact of a vaccination reminder in an electronic health record supplemented with data from an immunization information system (IIS).
METHODS: A noninterruptive influenza vaccination reminder, based on a real-time query of hospital and city IIS, was used at 4 urban, academically affiliated clinics serving a low-income population. Using a randomized cluster-crossover design, each study site had “on” and “off” period during the fall and winter of 2011–2012. Influenza vaccination during a clinic visit was assessed for 6-month to 17-year-old patients. To assess sustainability, the reminder was active at all sites during the 2012–2013 season.
RESULTS: In the 2011–2012 season, 8481 unique non-up-to-date children had visits. Slightly more non–up-to-date children seen when the reminder was ‘on’ were vaccinated than when ‘off’ (76.2% vs 73.8%; P = .027). Effects were seen in the winter (67.9% vs 62.2%; P = .005), not fall (76.8% vs 76.5%). The reminder also increased documentation of the reason for vaccine non-administration (68.1% vs 41.5%; P < .0001). During the 2011–2012 season, the reminder displayed for 8630 unique visits, and clinicians interacted with it in 83.1% of cases where patients required vaccination. During the 2012–2013 season, it displayed for 22 248 unique visits; clinicians interacted with it in 84.8% of cases.
CONCLUSIONS: An IIS-linked influenza vaccination reminder increased vaccination later in the winter when fewer vaccine doses are usually given. Although the reminder did not require clinicians to interact with it, they frequently did; utilization did not wane over time.

PLoS Medicine (Accessed 10 January 2015)

PLoS Medicine
(Accessed 10 January 2015)

Randomized Controlled Trials in Environmental Health Research: Unethical or Underutilized?
Ryan W. Allen mail, Prabjit K. Barn, Bruce P. Lanphear
Summary Points
:: Efficacious environmental interventions are needed because environmental risks account for a large fraction of the global disease burden.
:: Randomized controlled trials have not been widely embraced by environmental health researchers and comprise less than 1% of research publications in the field.
:: Additional randomized controlled trials in environmental health would complement a strong tradition of observational research by creating new knowledge on exposure–health relationships, providing more definitive evidence of causality, identifying efficacious interventions to reduce or eliminate hazards, and countering the perception that environmental risks are evaluated with inadequate rigor.
:: Ethical issues—including clinical equipoise, the distribution of benefits and risks, and the relevance of the intervention and health outcome to the study population—must be carefully considered before conducting a randomized controlled trial of an environmental intervention.

PLoS Neglected Tropical Diseases (Accessed 10 January 2015)

PLoS Neglected Tropical Diseases
(Accessed 10 January 2015)

Research Article
Effectiveness of Routine BCG Vaccination on Buruli Ulcer Disease: A Case-Control Study in the Democratic Republic of Congo, Ghana and Togo
Richard Odame Phillips, Delphin Mavinga Phanzu, Marcus Beissner, Kossi Badziklou, Elysée Kalundieko Luzolo, Fred Stephen Sarfo, Wemboo Afiwa Halatoko, Yaw Amoako, Michael Frimpong, Abass Mohammed Kabiru, Ebekalisai Piten, Issaka Maman, Bawimodom Bidjada,
[ … ], Karl-Heinz Herbinger mail, [ view all ]
Published: January 08, 2015
DOI: 10.1371/journal.pntd.0003457
The only available vaccine that could be potentially beneficial against mycobacterial diseases contains live attenuated bovine tuberculosis bacillus (Mycobacterium bovis) also called Bacillus Calmette-Guérin (BCG). Even though the BCG vaccine is still widely used, results on its effectiveness in preventing mycobacterial diseases are partially contradictory, especially regarding Buruli Ulcer Disease (BUD). The aim of this case-control study is to evaluate the possible protective effect of BCG vaccination on BUD.
The present study was performed in three different countries and sites where BUD is endemic: in the Democratic Republic of the Congo, Ghana, and Togo from 2010 through 2013. The large study population was comprised of 401 cases with laboratory confirmed BUD and 826 controls, mostly family members or neighbors.
Principal Findings
After stratification by the three countries, two sexes and four age groups, no significant correlation was found between the presence of BCG scar and BUD status of individuals. Multivariate analysis has shown that the independent variables country (p = 0.31), sex (p = 0.24), age (p = 0.96), and presence of a BCG scar (p = 0.07) did not significantly influence the development of BUD category I or category II/III. Furthermore, the status of BCG vaccination was also not significantly related to duration of BUD or time to healing of lesions.
In our study, we did not observe significant evidence of a protective effect of routine BCG vaccination on the risk of developing either BUD or severe forms of BUD. Since accurate data on BCG strains used in these three countries were not available, no final conclusion can be drawn on the effectiveness of BCG strain in protecting against BUD. As has been suggested for tuberculosis and leprosy, well-designed prospective studies on different existing BCG vaccine strains are needed also for BUD.
Author Summary
After tuberculosis and leprosy, Buruli Ulcer Disease (BUD) is the third most common human mycobacterial disease. The only available vaccine that could be potentially beneficial against these diseases is BCG. Even though BCG vaccine is widely used, the results on its effectiveness are partially contradictory, probably since different BCG strains are used. The aim of this study was to evaluate the possible protective effect of BCG vaccines on BUD. The present study was performed in three different countries and sites where BUD is endemic: in the Democratic Republic of the Congo, Ghana, and Togo from 2010 through 2013. The large study population was comprised of 401 cases with laboratory confirmed BUD and 826 controls, mostly family members or neighbors. Considering the three countries, sex, and age, the analysis confirmed that the BCG vaccination did not significantly decrease the risk for developing BUD or for developing severe forms of BUD. Furthermore, the status of BCG vaccination was also not significantly related to duration of BUD or to time to healing of lesions. In our study, we could not find any evidence of a protective effect of routine BCG vaccination on BUD.

Strengthening Research Capacity—TDR’s Evolving Experience in Low- and Middle-Income Countries
Olumide A. T. Ogundahunsi mail, Mahnaz Vahedi, Edward M. Kamau, Garry Aslanyan, Robert F. Terry, Fabio Zicker, Pascal Launois
Published: January 08, 2015
DOI: 10.1371/journal.pntd.0003380
In the 1970s, very few international programmes provided support to strengthen tropical disease research capacity and most research for the diseases prevalent in low- and middle-income countries (LMICs) was done by scientists and institutions in advanced industrialised countries. Soon after inception in 1974, TDR established a research capacity strengthening (RCS) programme with a goal to train individuals and strengthen research capacity in disease-endemic countries so that they can find and implement appropriate solutions to their health problems [1], [2]. At that time, very little research addressed the burden of these diseases. For most of its existence, up to a third of TDR’s total resources were earmarked for strengthening research capacity in LMICs. In the past 20 years, other charities, foundations, health research councils, and development agencies have begun their own capacity strengthening programmes, so today, the concept is well accepted, although the means to achieve the end vary [3]–[5]. This paper presents a broad description from the TDR secretariat’s perspective on evolving approaches used to promote research capacity strengthening in LMICs. The paper is part of a special series commemorating TDR’s 40-year anniversary.

TDR has an intertwined approach: training support for individuals and collaborative research programmes for institutions [1], [2]. Research training requires adequate research facilities, which may need strengthening. Similarly, strengthening an institution so that it can fully participate in a research partnership often calls for supporting training facilities and staff. The specific needs and priorities that are funded by TDR have been identified by a capacity building steering committee and approved by the TDR Scientific and Technical Advisory Committee (STAC), which comprises 15 to 18 experts in a wide range of scientific disciplines who peer review the programme’s scientific and technical activities.

TDR’s placement within the United Nations system provides close collaboration with country offices of not only the World Health Organization but also of other co-sponsoring agencies UNICEF and UNDP, and with the World Bank. As a consequence, those who are supported by TDR often work closely with disease control programmes as well as other international organizations.

Regular reviews of TDR’s research capacity strengthening programmes have helped reorient the strategy as needed, shifting focus from institutional strengthening in the 1980s to human resources strengthening in the 1990s [1], as well as identifying the need to move to a more demand-driven model of national health research systems [4]. Over the years, TDR has continued to support multidisciplinary research, particularly to bring social science research and biomedical research together through different mechanisms [6], and has reinforced this effort through training in implementation research [7] and operations research [8]…


A Changing Model for Developing Health Products for Poverty-Related Infectious Diseases
Piero L. Olliaro, Annette C. Kuesel, John C. Reeder Historical Profiles and Perspectives | published 08 Jan 2015 | PLOS Neglected Tropical Diseases 10.1371/journal.pntd.0003379

Applied Research for Better Disease Prevention and Control
Johannes Sommerfeld, Andrew Ramsay, Franco Pagnoni, Robert F. Terry, Jamie A. Guth, John C. Reeder Historical Profiles and Perspectives | published 08 Jan 2015 | PLOS Neglected Tropical Diseases 10.1371/journal.pntd.0003378

What Have We Learned from 40 Years of Supporting Research and Capacity Building?
John C. Reeder, Jamie A. Guth Historical Profiles and Perspectives | published 08 Jan 2015 | PLOS Neglected Tropical Diseases 10.1371/journal.pntd.0003355

Shaping the Research Agenda
Edith Certain, Robert F. Terry, Fabio Zicker Historical Profiles and Perspectives | published 08 Jan 2015 | PLOS Neglected Tropical Diseases 10.1371/journal.pntd.0003350

Science – 9 January 2015 vol 347, issue 6218

9 January 2015 vol 347, issue 6218, pages 101-208

On the trail of contagion
Kai Kupferschmidt*
Tracing contacts is crucial for stopping an Ebola outbreak. Public health workers need to find every patient, identify everyone they have interacted with, and monitor them for symptoms during the 21-day incubation period. But tracing contacts is a difficult and often frustrating job. Science joined a team in Bong County in Liberia that tried to locate a woman who had been in contact with two Ebola patients before they died; she reportedly fled to a remote village. The tracing team made a harrowing and exhausting 9-hour trek through the jungle to find her—and came home empty-handed. Their quest highlights just how difficult it will be to end the West African Ebola epidemic.

Vaccine – Volume 33, Issue 3, Pages 403-486 (9 January 2015)

Volume 33, Issue 3, Pages 403-486 (9 January 2015)

Celebrating the ACIP at 50
Pages 403-404
Alan R. Hinman, Gregory A. Poland
[No abstract]

The history of the United States Advisory Committee on Immunization Practices (ACIP)
Pages 405-414
L. Reed Walton, Walter A. Orenstein, Larry K. Pickering
The United States Advisory Committee on Immunization Practices (ACIP) is a federal advisory committee that develops written recommendations for use of vaccines licensed by the Food and Drug Administration (FDA) for the U.S. civilian population. Vaccine development and disease outbreaks contributed to the need for a systematized, science-based, formal mechanism for establishing national immunization policy in this country. Formed in 1964, the ACIP was charged with this role. The committee has undergone significant changes in structure and operational activities during its 50-year history. The ACIP works closely with many liaison organizations to develop its immunization recommendations, which are harmonized among key professional medical societies. ACIP vaccine recommendations form two immunization schedules, which are updated annually: (1) the childhood and adolescent immunization schedule and (2) the adult immunization schedule. Today, once ACIP recommendations are adopted by the Director of the Centers for Disease Control and Prevention and the Secretary of the Department of Health and Human Services, these recommendations are published in Morbidity and Mortality Weekly Report (MMWR), become official policy, and are incorporated into the appropriate immunization schedule.

Vaccination against varicella as post-exposure prophylaxis in adults: A quantitative assessment
Original Research Article
Pages 446-450
Cécile Souty, Evelyne Boos, Clément Turbelin, Thierry Blanchon, Thomas Hanslik, Pierre-Yves Boëlle
Varicella can be severe in adults. When universal vaccination is not adopted, post-exposure prophylaxis has been recommended in adults with uncertain history of varicella to reduce the burden of the disease in adults, however its impact is not quantified.
We developed a Bayesian probabilistic framework to estimate the impact of post-exposure prophylaxis in adults. We hypothesized that post-exposure vaccination would be proposed only after varicella exposure in close relatives. Information regarding the nature of the culprit exposure was obtained from a sample of 221 adult varicella cases. The lifelong probability that adults aged 18 would be infected with varicella was determined using data from the French Sentinelles surveillance network. Estimates of post-exposure vaccination efficacy were then used to compute the number of cases and hospitalizations prevented in adults.
Familial exposure to varicella was reported by 81 adult cases out of 221. The probability of infection after exposure was 32%, so that six exposures on average were necessary to explain the observed cumulated lifetime incidence of varicella in non-immune 18 years old and over adults. Among the 35% of the 18 years old population with uncertain history of varicella, 11% would truly be non-immune. Post-exposure vaccination would prevent 26% of the cases (13 cases prevented per 100,000 adults per year) and 31% of the hospitalizations (0.2 hospitalizations prevented per 100,000 adults per year) if vaccination acceptance was 70%. An average of 16 adults would be vaccinated to avert one varicella case.
Post-exposure vaccination is associated with a substantial decrease in the burden of the disease in adults in a country where universal vaccination is not recommended. This quantitative information may help inform professionals to uphold the recommendation.

Does correcting myths about the flu vaccine work? An experimental evaluation of the effects of corrective information
Original Research Article
Pages 459-464
Brendan Nyhan, Jason Reifler
Seasonal influenza is responsible for thousands of deaths and billions of dollars of medical costs per year in the United States, but influenza vaccination coverage remains substantially below public health targets. One possible obstacle to greater immunization rates is the false belief that it is possible to contract the flu from the flu vaccine. A nationally representative survey experiment was conducted to assess the extent of this flu vaccine misperception. We find that a substantial portion of the public (43%) believes that the flu vaccine can give you the flu. We also evaluate how an intervention designed to address this concern affects belief in the myth, concerns about flu vaccine safety, and future intent to vaccinate. Corrective information adapted from the Centers for Disease Control and Prevention (CDC) website significantly reduced belief in the myth that the flu vaccine can give you the flu as well as concerns about its safety. However, the correction also significantly reduced intent to vaccinate among respondents with high levels of concern about vaccine side effects – a response that was not observed among those with low levels of concern. This result, which is consistent with previous research on misperceptions about the MMR vaccine, suggests that correcting myths about vaccines may not be an effective approach to promoting immunization.

Rotavirus vaccination compliance and completion in a Medicaid infant population
Original Research Article
Pages 479-486
Girishanthy Krishnarajah, Pamela Landsman-Blumberg, Elnara Eynullayeva
:: Rotavirus (RV) vaccination completion and compliance rates were assessed in the US.
:: Completion rates and compliance were better for 2-dose than the 3-dose RV vaccine.
:: DTaP vaccine was the greatest predictor of RV vaccination compliance.
:: Higher completion rates and compliance might offer protection against RV infection.

Vaccine – Volume 33, Issue 2, Pages 277-402 (3 January 2015)

Volume 33, Issue 2, Pages 277-402 (3 January 2015)

The need for a multi-disciplinary perspective on vaccine hesitancy and acceptance
Pages 277-279
Caroline M. Poland, Emily K. Brunson
[No abstract]

Factors associated with HPV awareness among mothers of low-income ethnic minority adolescent girls in Los Angeles
Original Research Article
Pages 289-293
Beth A. Glenn, Jennifer Tsui, Rita Singhal, Leah Sanchez, Narissa J. Nonzee, L. Cindy Chang, Victoria M. Taylor, Roshan Bastani
Among caregivers of adolescent girls, awareness of human papillomavirus (HPV) is strongly associated with vaccine uptake. Little is known, however, about the predictors of HPV awareness among low-income ethnic minority groups in the U.S. The purpose of this study is to understand demographic factors associated with HPV awareness among low-income, ethnic minority mothers in Los Angeles County. We conducted a cross-sectional study of caregivers of adolescent girls through the Los Angeles County Department of Public Health Office of Women’s Health’s hotline. The majority of the participants were foreign-born (88%), one quarter lacked a usual source of care, and one quarter lacked public or private health insurance for their daughter. We found that one in three participants had never heard of HPV or the vaccine. Mothers that were unaware of HPV were significantly more likely to conduct the interview in a language other than English and to lack health insurance for their daughters. HPV vaccine awareness was much lower in our caregiver sample (61%) than in a simultaneous national survey of caregivers (85%). The associations between lack of awareness and use of a language other than English, as well as lack of health insurance for their daughter indicate the need for HPV vaccine outreach efforts tailored to ethnic minority communities in the U.S.

Vaccine – Volume 33, Issue 1, Pages 1-276 (1 January 2015)

Volume 33, Issue 1, Pages 1-276 (1 January 2015)

Recommendations for strengthening NITAG policies in developed countries
Pages 1-2
G.W. Ricciardi, M. Toumi, G. Poland
Vaccination constitutes one of the most significant public health advancements protecting millions of people from infectious diseases worldwide and contributing to the socio-economic development of nations on a global scale. Preventative in nature, vaccines have been traditionally used with the aim of directly avoiding or reducing overall incidence, morbidity, and mortality in healthy individuals, proving vaccination is a highly cost-effective public health intervention [1]. Yet, time to effective populations’ access to new vaccines is heterogeneous and lengthy in developed countries, with an average of 6.4 years between European Marketing Authorization and effective populations’ access to new vaccines [2]. The delay in access is mainly driven by the time taken by National Immunization Technical Advisory Groups (NITAG) to issue vaccination recommendations guiding the executive policy-decisions [2]. Ricciardi et al. reported the heterogeneity in NITAG terms of reference and analytical decision frameworks that may contribute to the disparity in access to vaccination and immunization programs across developed countries [3]:
:: In a study of 13 countries, publicly available information on NITAGs’ policies and processes was very limited in most countries, but more documented in the UK, US and Germany.
:: The decision analysis frameworks that are critical for transparent, structured, reproducible and reliable decision-making, were available for a limited number of NITAGs with only two countries (Germany and the US) using a detailed and standardized methodology for reliable, robust, and reproducible assessments (the Grades of Recommendation, Assessment, Development and Evaluation – GRADE) [4], [5], [6] and [7].
:: The lack of transparency in NITAGs’ interaction with the general public and healthcare professionals deserves improvement. Few NITAGs published their meeting agendas and minutes and only the US had open meetings.

Development of a quality framework for models of cervical screening and its application to evaluations of the cost-effectiveness of HPV vaccination in developed countries
Review Article
Pages 34-51
Leonardo Simonella, Karen Canfell
HPV vaccination has now been introduced in most developed countries, but this has occurred in the context of established cervical cancer screening mechanisms which provide population-level protection against the most common HPV-related cancer. Therefore, estimating the cost-effectiveness of HPV vaccination to further reduce HPV-related disease depends in large part on the estimation of the effectiveness of the cervical screening ‘background’. The aim of this study was to systematically review and assess methods for simulating cervical screening in decision analytic models used for evaluation of HPV vaccination.
Existing quality frameworks for economic models were extended to develop a specific quality framework for models of cervical screening. This involved domains for model structure, parameterisation (data sources) and validation (consistency). A systematic review of economic evaluations of HPV vaccination was then conducted, and assessment of cervical screening model components was then performed via application of the new quality framework.
Generally, models took into account population-level cervical screening participation, but were inconsistent in their approach to modelling abnormal smear management, diagnostic evaluation and treatment of precancerous disease. There was also considerable variability in the accuracy of modelling clinical pathways and the scope of validation performed for screening-related outcomes, with focus directed towards cervical cancer targets. Only a few models comprehensively validated against observed pre-cancerous abnormalities.
Models of HPV vaccination in developed countries can be improved by further attention to the ‘background’ modelling of secondary protection via cervical screening. The quality framework developed for this review can be used to inform future HPV vaccination evaluations, including evaluations of the cost-effectiveness of male vaccination and next generation HPV vaccines, and to assess models used to evaluate new cervical screening technologies and recommendations.

Twenty-five years of the WHO vaccines prequalification programme (1987–2012): Lessons learned and future perspectives
Review Article
Pages 52-61
Nora Dellepiane, David Wood
The World Health Organization (WHO) vaccines prequalification programme was established in 1987. It is a service provided to United Nations procurement agencies to ensure that the vaccines supplied through these agencies are consistently safe and effective under conditions of use in national immunization programmes. This review describes the purpose and aims of the programme, its evolution during 25 years of existence, its added value, and its role in the context of the WHO strategy to ensure the global availability of vaccines of assured quality. The rationale for changes introduced during the implementation of the programme is provided. The paper also discusses the resources involved, both human and financial, its performance, strengths and weaknesses and steps taken to maximize its efficiency. This historical perspective is used to inform proposed future changes to the service.

What predicts postpartum pertussis booster vaccination? A controlled intervention trial
Original Research Article
Pages 228-236
Elizabeth Helen Hayles, Spring Chenoa Cooper, Nicholas Wood, John Sinn, S. Rachel Skinner
:: We immunised 70% of susceptible postpartum mothers, demonstrating that information, using either gain or loss-framing or standard factsheet, is effective at increasing uptake.
:: Perceived vaccine benefits, a vaccine recommendation and pre-existing vaccine intentions independently predicted pertussis vaccine uptake.
:: Postpartum pertussis booster vaccination can achieve high coverage (from 23% to 77%) when implemented in the hospital setting.

Vaccines — Open Access Journal (Accessed 10 January 2015)

Vaccines — Open Access Journal
(Accessed 10 January 2015)

The Potential Impact of Preventive HIV Vaccines in China: Results and Benefits of a Multi-Province Modeling Collaboration
by Thomas Harmon, Wei Guo, John Stover, Zunyou Wu, Joan Kaufman, Kammerle Schneider, Li Liu, Liao Feng and Bernard Schwartländer
Vaccines 2015, 3(1), 1-19; doi:10.3390/vaccines3010001 – published 5 January 2015
China’s commitment to implementing established and emerging HIV/AIDS prevention and control strategies has led to substantial gains in terms of access to antiretroviral treatment and prevention services, but the evolving and multifaceted HIV/AIDS epidemic in China highlights the challenges of maintaining that response. This study presents modeling results exploring the potential impact of HIV vaccines in the Chinese context at varying efficacy and coverage rates, while further exploring the potential implications of vaccination programs aimed at reaching populations at highest risk of HIV infection. A preventive HIV vaccine would add a powerful tool to China’s response, even if not 100% efficacious or available to the full population.

From Google Scholar+ [to 10 January 2015]

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

Journal of Women’s Health, Issues & Care
2014, 3:6
Issues Care 2014, 3:6
[PDF] Nuances in Inoculation: Protecting Positive Attitudes toward the HPV Vaccine & the Practice of Vaccinating Children
Norman C. H. Wong1* and Kylie J. Harrison2
This study examined the use of two different inoculation messages in conferring resistance to persuasive messages attacking vaccinations. A three-phase experiment involving 212 participants was conducted to determine if young women who held positive attitudes toward the HPV vaccine/practice of vaccinating children could be inoculated against messages attacking the HPV vaccine/practice of vaccinating children. Results found that inoculation treatments aimed at protecting positive attitudes toward the practice of vaccinations in general were as effective at thwarting attacks on the HPV vaccine as the use of inoculation treatments aimed directly at protecting positive attitudes about the HPV vaccine itself. In addition to traditional inoculation outcomes (e.g., attitudes, counterarguing), the results revealed that inoculation treatments also had an impact on other outcomes as well (e.g., perceived vaccine safety, behavioral intentions).
Journal of School Health
Vol 85 Issue 2
School Nurses’ Knowledge, Attitudes, Perceptions of Role as Opinion Leader, and Professional Practice Regarding Human Papillomavirus Vaccine for Youth
Brittany L. Rosen PhD, CHES Assistant Professor1,*, Patricia Goodson PhD Professor2, Bruce Thompson PhD Distinguished Professor3 andKelly L. Wilson PhD, CHES Associate Professor4
Article first published online: 7 JAN 2015
DOI: 10.1111/josh.12229
Because human papillomavirus (HPV) vaccine rates remain low, we evaluated US school nurses’ knowledge, attitudes, perceptions of their role as opinion leaders, and professional practice regarding HPV vaccine, and assessed whether knowledge, attitudes, and perceptions of being an opinion leader influenced their professional practice regarding the HPV vaccine.
We used a cross-sectional design by recruiting members from the National Association of School Nurses. All participants (N = 505) were e-mailed a survey designed for this study. Structural equation modeling (SEM) tested direct and indirect effects.
Overall, school nurses had knowledge about HPV and the vaccine, and positive attitudes toward the vaccine. They had less-than-enthusiastic perceptions of their role as opinion leaders regarding the vaccine and implemented few activities related to providing vaccine information. The model revealed a good fit (χ2 = 20.238 [df = 8, p < .01]), with knowledge directly related to attitudes, attitudes directly related to perceptions and practice, and perceptions directly affecting practice. In our model, perceptions functioned as a partial mediator.
To enhance school nurses’ practice regarding the HPV vaccine, focus should be on increasing positive attitudes toward the vaccine and strengthening perceptions of their role as opinion leaders
Materia Socio Medica
2014; 26(6): 382-384
doi: 10.5455/msm.2014.26.382-384
[PDF] The Impact of War on Vaccine Preventable Diseases
Zarema Obradovic, Snjezana Balta, Amina Obradovic, Salih Mesic.
Introduction: During the war in Bosnia and Herzegovina, which lasted from 1992-1995, the functioning of all sectors was disturbed, including the health sector. The priority of the heath sector was treatment and less attention was paid to prevention, and this applies also to the program of implementation of obligatory immunization, as one of the most important prevention measures. This program was conducted with difficulty and sometimes was completely interrupted because of the lack of necessary vaccines and the inability of adequate maintenance of the cold chain. It was difficult and sometimes completely impossible to bring children to vaccination. Because of these problems, a great number of children stayed unvaccinated so they suffered from vaccine-preventable diseases several years after the war.
Materials and methods: This is a retrospective epidemiological study. We analyzed data from January 1994 to July 2014 in Canton Sarajevo, and data about measles outbreak in 2014.
Results: In the period from January 1994 to July 2014, 3897 vaccine-preventable diseases were registered in Canton Sarajevo. Among them measles, rubella and mumps were the most frequent. In March 2014, measles outbreak was registered. Almost all cases are unvaccinated (99%) and 43% of all cases are connected with failure of vaccination during the war.
Conclusion: During the war, routine immunization program was disrupted in Bosnia and Herzegovina (also in Canton Sarajevo). The consequences are presented as vaccine preventable diseases cases.
Applied and Environmental Microbiology
January 2015, volume 81, issue 2
Environmental Surveillance of Poliovirus in Sewage Water around the Introduction Period of Inactivated Polio Vaccine in Japan
Tomofumi Nakamura1,2, Mitsuhiro Hamasaki2, Hideaki Yoshitomi2, Tetsuya Ishibashi2, Chiharu Yoshiyama2, Eriko Maeda2, Nobuyuki Sera2* and Hiromu Yoshida1
Environmental virus surveillance was conducted at two independent sewage plants from urban and rural areas in the northern prefecture of the Kyushu district, Japan, to trace the polioviruses (PVs) within communities. Consequently, 83 PVs were isolated over a 34-month period from April 2010 to January 2013. The frequency of PV isolation at the urban plant was 1.5-times higher than that at the rural plant. Molecular sequence analysis of the viral VP1 gene identified all three serotypes among the PV isolates the most prevalent serotype being type 2 (46%). Nearly all poliovirus isolates exhibited more than one nucleotide mutation from the Sabin vaccine strains. During this study, inactivated poliovirus vaccine (IPV) was introduced for routine immunization on September 1, 2012, replacing the live oral poliovirus vaccine (OPV). Interestingly, the frequency of PV isolation from sewage waters declined before OPV cessation at both sites. Our study highlights the importance of environmental surveillance to detect the excretion of PVs from an OPV-immunized population in a highly sensitive manner, during the OPV to IPV transition period.

Media/Policy Watch [to 10 January 2015]

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.

Accessed 10 January 2015
‘Nigeria Is Paving The Way For A Polio-free Africa’
Forbes | 8 January 2015
“Nigeria is paving the way for a polio-free Africa,” according to John Vertefeuille, team lead for Nigeria at the Centers for Disease Control. With the World Health Organization reporting no cases of polio in Nigeria since July 24, 2014 and the last in Africa reported in August, Vertefeuille’s enthusiasm is well-founded…

Accessed 10 January 2015
IMF says preparing $150 mln in aid to three main Ebola-hit nations
Reuters | 9 January 2015
The International Monetary Fund is preparing $150 million in additional support to Liberia, Sierra Leone and Guinea, the countries at the heart of the Ebola epidemic, the Fund’s representative in Liberia told Reuters on Thursday.

Ebola/EVD: Additional Coverage [to 10 January 2015]

Ebola/EVD: Additional Coverage

UNMEER [UN Mission for Ebola Emergency Response] @UNMEER #EbolaResponse

Editor’s Note: UNMEER’s website is aggregating and presenting content from various sources including its own External Situation Reports, press releases, statements and other format.

We present a composite below from the week ending 10 January 2015. We also note that 1) a regular information category in these reports – human rights – has apparently eliminated as it no longer appears in any of these week’s updates, and 2) the content level of these reports has, in our view, become less informative and less coherent over the last several week cycles.


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.


:: 09 Jan 2015 UNMEER External Situation Report
Key Political and Economic Developments
1. Guinea is facing a fuel shortage which is impacting the Ebola response. The UNMEER Field Crisis Manager for Macenta reported that on 8 January the Guinea Red Cross was unable to transport a suspected case to the Ebola Treatment Centre (ETC) due to the fuel shortage. Reports indicate that local authorities have been working on to support the French Red Cross at the ETC. In addition the UNMEER Field Crisis Manager for N’zérékoré, Lola and Yomou has reported that fuel supplies are down to 5,000 liters (10 days of supply) at the Ebola Treatment Unit (ETU) and that radio stations which broadcast sensitization messages have not been working for 4 days.
Response Efforts and Health
5. The planned launch of the campaign “Zero Ebola in 60 days” (refer to Sitrep of 5 January) which was to be held in Forécariah prefecture, Guinea on 10 January has been put on hold due to the continuing resistance of the communities to EVD response in that area. According to WHO, on 6 January, there were 31 sub-prefectures in the country where EVD response efforts were facing community resistance.
Resource Mobilisation
9. The OCHA Ebola Virus Outbreak Overview of Needs and Requirements, now totaling USD 1.5 billion, has been funded for USD 1.16 billion, which is around 77% of the total ask.
10. The Ebola Response Multi-Partner Trust Fund currently has USD 134.9 million in commitments. In total USD 140 million has been pledged.
Essential Services
13. In addition to the procurement of 15,000 thermo-guns (refer to Sitrep of 6 January), UNICEF initiated procurement of sanitation and hygiene supplies (hand-washing buckets, sprayers, protective equipment for cleaning) to ensure that all 5,181 Liberian schools have the essential hygiene and hand-washing materials to promote safe learning environments and to be in compliance with the endorsed protocols upon reopening.


:: 8 Jan 2015 UNMEER External Situation Report
Key Political and Economic Developments
1. SRSG Ould Cheikh Ahmed continued his familiarization visit to Liberia on 7 January, and conducted a field mission to Robertsport and Sinje in Grand Cape Mount county, accompanied by Special Envoy David Nabarro, WHO Assistant Director-General Bruce Aylward and UNMEER Liberia’s ECM Peter Graaff. The delegation also included the Presidential Advisor on EVD and the Deputy Minister for Health in charge of the Incident Management System (IMS). In light of the recent flare-ups in EVD transmission in the county, and the risk of cross-border transmission along the frontier with Sierra Leone, the UNMEER leadership invited the county’s traditional and religious leaders, along with county health and security officials, for a series of meetings. The SRSG underlined the importance of national ownership to defeat the epidemic. He also emphasized the need to respect local communities and their values when implementing internationally-sponsored support activities, especially with regard to safe and dignified burials. He reiterated that coordinating activities at the district levels was essential. During the County Health Team meeting, the participants discussed the evolution of the epidemic in the county, as well as the emergency measures taken in response to the recent flare-up. Participants highlighted key challenges, including inadequate monitoring of cross-border traffic along the Sierra Leone frontier, ongoing traditional practices, secret burials, community pockets of denial and resistance, as well as lack of motivation among the response teams. The delegation also visited the recently opened Ebola Treatment Unit (ETU) in Sinje, before the SRSG is today in Sierra Leone.
2. On 7 January, the national trade unions in Guinea called off the general strike throughout the country, which had started on 6 January (refer to UNMEER Sitrep of 6 January), after reaching an agreement on salary increases with the Government.
Response Efforts and Health
3. To date, the UNICEF-led Family Tracing and Reunification (FTR) network in Sierra Leone has identified 14,766 children as being directly affected by the Ebola crisis (7,410 girls and 7,356 boys), with 7,938 children having lost one or both parents to EVD and 1,578 being unaccompanied or separated from their caregiver. The Ministry of Social Welfare, Gender and Children’s Affairs’ (MSWGCA) figures have jumped markedly from 24 – 31 December as child protection networks strengthened across the country.
Outreach and Education
13. Due to the persistent community resistance in 31 sub-prefectures in Guinea to EVD response efforts, WHO commissioned a number studies on this topic that will be collated as soon as possible.
Essential Services
14. Following reported cases of measles in Lofa county, Liberia, UNICEF supported periodic intensification of routine immunization against measles throughout the country. So far, the routine immunization has been completed in 8 counties, is underway in 4 and is about to begin in the last 3 counties (namely Maryland, Bong and River Gee). This is activity is being implemented in lieu of an immunization campaign, which is not recommended in the Ebola context and aims at rapidly reducing the number of unimmunized children against measles.


:: 07 Jan 2015 UNMEER External Situation Report
Key Political and Economic Developments
1. As part of a visit to the three most affected countries, President Ould Abdel Aziz of the Islamic Republic of Mauritania and current Chair of the African Union (AU), arrived in Guinea yesterday and met with President Condé. The President pledged USD 400,000 to help Guinea in its fight against EVD, and also announced that Air Mauritania would operate flights to Guinea. The Chair of the AU travelled to Liberia today.
2. Today, President Mahamadou Issoufou of Niger and President Boni Yayi of Benin are jointly visiting Guinea to demonstrate their support in the fight against EVD.
Response Efforts and Health
4. A Community Transit Centre (CTCom) was burnt down yesterday in Bossou, Lola prefecture, Guinea. The centre, which was still under construction, would have been one of the first functional CTCom in Guinea. This act of arson is likely to be due to the continuing resistance of the local community to EVD response efforts.
5. The Ministry of Education (MoE), UNICEF and education partners have been working together in preparation of the reopening of schools in Guinea. In this regard, UNICEF plans to reach 7,055 schools (56% of schools at all levels) and 1.4 million children (53% of all school children) with 16,000 school hygiene kits (containing buckets and soap). In addition, the Islamic Development Bank (IDB) confirmed its commitment to support the provision of Thermoflashes for schools in Guinea. An IDB consultant is scheduled to arrive in Conakry on 9 January to help implement this project.
Outreach and Education
18. UNICEF signed a partnership agreement with Search for Common Ground to support the Liberian Ministry of Education’s (MoE) Emergency Radio Education program in light of closed schools across the country. In collaboration with MoE’s radio content development team, Search for Common Ground will expand broadcast coverage across all 15 counties in Liberia, integrating targeted programs on peacebuilding and education to build resilience amongst listeners during times of crisis.


:: 06 Jan 2015 UNMEER External Situation Report
Key Political and Economic Developments
1. Following an impasse in the negotiations between the Government of Guinea and six national trade unions, including the public health workers union, on salary increases and other demands, the unions called for a general strike throughout the country as of today. Limited demonstrations and road closures have been observed in Conakry.
2. Following the announcement by the President of Sierra Leone on New Year’s day of his intention to reopen schools soon, the Governments of Liberia and Guinea similarly announced that schools would reopen. While Guinea did not provide a specific date, President Ellen Johnson Sirleaf provided 2 February as the target date.
9. In support of the Minister of Education’s school reopening plan in Liberia, UNICEF initiated procurement of infrared thermometers for every Liberian school (15,000 thermometers) to ensure effective health screening of all individuals upon entry to school campuses.
10. In Sierra Leone, UNICEF, in partnership with the National Ebola Response Centre (NERC), the Ministry of Health and Sanitation, and the Centre for Disease Control (CDC), continues the national scale up of trainings at all 1,188 Public Health Units (PHUs) in the country on Infection Prevention and Control (IPC) and the screening of suspected Ebola patients. As of 27 December, a total of 4,368 health personnel and 2,698 support staff including cleaners and security personnel have benefitted from IPC trainings.
11. Following the registration of 13,608 households in 9 chiefdoms within 29 Ebola affected communities in Kono District, Sierra Leone, which were identified as major EVD hotspots, WFP has begun the delivery of over 1,000 metric tons of assorted food commodities to quarantined communities. Food distributions will be undertaken by World Vision. In Waterloo, Western Area Rural, Sierra Leone, WFP and its cooperating partner CIDO are also continuing general food distributions to meet the needs of over 47,000 households where high EVD rates have been identified. Since mid-December over 25,000 households have received one month rations.


:: 05 Jan 2015 UNMEER External Situation Report
Key Political and Economic Developments
1. The New Head of UNMEER, SRSG Ismail Ould Cheikh Ahmed, assumed his functions on 3 January. In a joint townhall meeting with outgoing SRSG Banbury, SRSG Ould Cheikh Ahmed praised the achievements of all Ebola response partners, but also noted challenges ahead. He stressed that “this is a global crisis. We definitely have a difficult time ahead of us, but we can achieve our goal of zero cases,” said Ould Cheikh Ahmed. “This is within our reach, but we should not be complacent. We need to keep going until we don’t have even one case, because even one case is too many”. Together with the Special Envoy on Ebola, Dr. David Nabarro, SRSG Ould Cheikh Ahmed will be visiting Liberia, Sierra Leone this week and Guinea shortly after.
Response Efforts and Health
1. In Guinea, the National Coordinator briefed key response partners on 2 January on the launch of the campaign “Zero Ebola in 60 days”. Working groups have in recent days developed action plans for the campaign across the main lines of intervention: surveillance, case management, infection prevention and control, community engagement and social mobilization, safe burials and coordination. The first step of the campaign will involve the fielding of teams including experts from each line of action in six regions of the country for one or two weeks starting 6 January. The purpose of the missions will be for each team to assess the response efforts at the local level and develop with each prefecture the coordination of a local plan of action mirroring the national plan of action.
2. The total number of children registered as orphaned by EVD in Liberia is 4,128. All registered orphans are currently receiving follow-up and psychosocial support. More than 250 volunteer contact tracers trained and engaged by UNICEF are reporting cases of children orphaned or otherwise affected by EVD. UNICEF is working to ensure that children who have lost their parents due to EVD continue to receive care through a kinship arrangement, to prevent them from becoming institutionalized in an orphanage. To strengthen this, UNICEF provides onetime cash transfers to families that take the responsibility to care for orphaned children of relatives.
Outreach and Education
13. According to WHO, on 31 December, there were 25 sub-prefectures in Guinea where EVD response efforts were facing community resistance. These sub-prefectures are located in the prefectures adjacent to Conakry (Dubreka, Forécariah, Coyah and Kindia), in the Forest Region (Kissidougou, Guéckédou, Nzérékoré), in Upper Guinea (Dabola) and in Western Guinea (Télimélé and Labé).
14. On 1 January, a team of the Guinean Red Cross was assaulted by the local community in Kindia, Guinea resulting in one injured Red Cross volunteer and one vandalized vehicle. According to the IFRC, the team had travelled to Kindia to conduct a safe burial and to transfer suspected cases. The prefectural coordination solicited the support of the military which proceeded to arrest two persons suspected of taking part in the assault.

Vaccines and Global Health: The Week in Review 3 January 2015

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
pdf version A pdf of the current issue is available here: Vaccines and Global Health_The Week in Review_3 January 2015

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

Twitter:  Readers can also follow developments on twitter: @vaxethicspolicy.
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.
Support:  If you would like to join the growing list of individuals who support this service and its contribution to their roles in public health, clinical practice, government, IGOs/NGOs, research, industry and academia, please visit this page at The Wistar Institute, our co-founder and fiduciary, and follow the relevant steps . Thank you…

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

POLIO [to 3 January 2014]

POLIO [to 3 January 2014]
Public Health Emergency of International Concern (PHEIC)

GPEI Update: Polio this week – As of 24 December 2014
Global Polio Eradication Initiative
[Editor’s Excerpt and text bolding]
Full report:
:: The year ends with real – and fragile – progress: the longest stretch in history without wild poliovirus in Africa, large outbreaks stopped in the Middle East and the Horn of Africa, a certified polio-free South East Asia and no wild poliovirus type 3 for over 2 years. This will be the last weekly update of 2014.
:: Polio eradication efforts in 2015 will have five priorities: refining surveillance to catch any remaining virus, keeping Africa and the Middle East polio-free, providing a surge of support to Pakistan and Afghanistan, preparing for the withdrawal of oral polio vaccine type 2 and continuing to demonstrate and build on the differences that the polio programme makes to routine immunization programmes.

Selected country report content:
:: One new wild poliovirus type 1 (WPV1) case was reported in the past week in Afghanistan, in Spin Boldak, a district in Kandahar province. This most recent case had onset of paralysis on 26 November. The total number of WPV1 cases for 2014 in Afghanistan is now 26 compared to 11 at this time last year.
:: Subnational Immunization Days (SNIDs) took place in high risk areas of the south and east using monovalent oral polio vaccine (OPV) type 1 on 21 – 23 December. The next rounds are planned for 11 – 13 January using bivalent OPV.
:: Eight new wild poliovirus type 1 (WPV1) cases were reported in the past week. Four are from Balochistan, where districts of Nasirabad and Pishin are newly infected; 2 from Khyber Pakhtunkhwa (KP) province (Peshawar and newly-infected Kohat); 2 from Sindh (Sanghar and newly-infected Larakana). The total number of WPV1 cases in Pakistan in 2014 is now 291, compared to 77 at this time last year. The most recent WPV1 cases had onset of paralysis on 4 December, in Sindh and Balochistan.
:: 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.
West Africa
:: The Ebola crisis in western Africa continues to have an impact 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. The programme continues to monitor the situation with concern.
:: 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.
:: Subnational Immunization Days (SNIDs) are planned in Niger and tentatively for Mali in January.

Pakistan anti-polio drive halted
Zeenews | 22 December 2014
Islamabad: Pakistan’s anti-polio drive has been halted for security reasons in Khyber-Pakhtunkwa province where over 2.9 million children were expected to be administered the polio vaccine during the three-day campaign, media reported. Earlier Monday morning, the campaign was launched and over 8,000 teams were constituted to administer anti-polio drops to about 2.9 million children. Arrangements were also made to administer the vaccine to children at bus stops and railway stations. On Monday, two more polio cases were confirmed by the Polio Virology Laboratory (PVG) at the National Institute of Health in Islamabad.

EBOLA/EVD [to 3 January 2014]

EBOLA/EVD [to 3 January 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.
We note that the WHO Situation Report just below references the “100% goals” re-affirmed at the 60-day mark (see bolded text, second paragraph), but we have not encountered any update from UNMEER on performance against these goals.

WHO: Ebola response roadmap – Situation report 31 December 2014
Summary [Excerpt]
A total of 20,206 confirmed, probable, and suspected cases of Ebola virus disease (EVD) have been reported in four affected countries (Guinea, Liberia, Mali and Sierra Leone) and four previously affected countries (Nigeria, Senegal, Spain and the United States of America) in the seven days to 28 December (week 52). There have been 7,905 reported deaths (case definitions are provided in Annex 1). On 29 December, the United Kingdom reported its first confirmed EVD case. Reported case incidence has fluctuated between 70 and 160 confirmed cases in Guinea over the past 15 weeks. In Liberia, case incidence has mostly declined in the past six weeks. In Sierra Leone, there are signs that the increase in incidence has slowed, although the country’s west is now experiencing the most intense transmission of all the affected countries. The reported case fatality rate in the three intense-transmission countries among all cases for whom a definitive outcome is known is 71%.

Interventions in the three countries continue to progress in line with the UN Mission for Ebola Emergency Response aim to conduct 100% of burials safely and with dignity, and to isolate and treat 100% of EVD cases by 1 January, 2015. Every country has sufficient capacity to isolate patients, but the uneven geographical distribution of beds and cases means shortfalls persist in some districts. In the past month, the average number of beds per reported patient has grown from 6.6 to 13.9 in Liberia, and 1.4 to 3.6 in Sierra Leone. In Guinea, it has fallen slightly from 2.3 to 1.9 beds per patient, reflecting a small increase in probable and confirmed cases. Each country has sufficient capacity to bury all people known to have died from Ebola, yet the under-reporting of deaths is a persistent challenge. The number of trained safe burial teams has significantly grown in the past month – from 34 to 64 in Guinea, 56 to 89 in Liberia, and 50 to 101 in Sierra Leone. This is close to the capacity needed in each country. All three countries report that more than 90% of registered contacts associated with known cases of EVD are being traced, although the number of contacts traced per EVD case remains low in many districts. Social mobilization is a vital component of an effective response. Engaging communities promotes burial practices that are safe and culturally acceptable, and the isolation and appropriate treatment of patients with symptoms of EVD.

Stories from the Field
Sierra Leone: How Kailahun district kicked Ebola out
29 December 2014
Sierra Leone communities organize Ebola response
24 December 2014
Cured of Ebola, Rebecca returns to cure others
22 December 2014

UNMEER Watch [to 3 January 2014]
:: Ould Cheikh Ahmed Arrived in Accra to Officially Take Over as Head of UN Ebola Mission
03 Jan 2015

:: Outgoing UNMEER Chief: Zero Ebola Cases is “only acceptable outcome”
[Full text]
Accra, 2 January 2015 – Anthony Banbury, Head of the United Nations Mission for Ebola
Emergency Response (UNMEER), gave a final review of progress in the fight against Ebola today as he prepares to hand over the role to his successor, Ismail Ould Cheikh Ahmed of Mauritania on Saturday.
“It’s important to remember where we were when we started,” Banbury told journalists during a press conference in Accra. “At the time, there were predictions of up to 1.4 million cases of Ebola by the start of the year…Here we are in January and we have a total of around 20,000 cases instead of 1.4 million. That’s 1.4% of what was being projected as a possibility by credible scientists back in September.”
According to the latest World Health Organization report, there are 20,206 confirmed, probable or suspected cases of Ebola and 7,905 reported deaths.
“We are engaged in a big battle with this disease,” he said. “It’s an insidious, invasive disease that attacks people through acts of caring and kindness…It’s going to be extremely hard for us to bring it down to zero but that is what we will do. That is the only acceptable outcome.”
Returning from a final review mission in Guinea, Liberia and Sierra Leone, Banbury, who was
appointed in September, says there has been significant progress in the fight against Ebola over
the past 90 days. Banbury pointed, for instance, to the increased number of isolation beds in each country, which stands at two beds per patient in Guinea, 3.5 in Sierra Leone, and 14 in Liberia.
With support from UNMEER and other partners, the three countries now also have sufficient
capacity to isolate and treat 100 percent of confirmed Ebola patients and enough burial teams to ensure safe and dignified burials for 100 percent of all deaths due to Ebola.
Banbury, however, said several challenges remain, including the geographical dispersion of
Ebola. He also cited behavior change and community resistance as major obstacles in some areas despite massive interventions.
“It’s a bit like putting seatbelts in cars,” said Banbury. “If you have seatbelts in cars you can save a lot of lives, but only if people use those seatbelts.”
The key to success, according to Banbury, is to effectively engage with communities, and also to maintain vigilance and commitment as the number of cases continues to drop.
“It’s an obligation to set very ambitious targets so we can bring this crisis to an end as quickly as possible,” he said. “For the UN, it’s a very heavy responsibility. But it’s also a privilege to work with these communities and these people. We will succeed together.”
Banbury is succeeded by Ismail Ould Cheikh Ahmed of Mauritania, who will himself be visiting
the affected countries next week to reinforce UNMEER’s strategic priorities. Before his new
appointment, Ould Cheikh Ahmed was appointed Deputy Special Representative and Deputy
Head of the United Nations Support Mission in Libya (UNSMIL).

:: Secretary-General’s press encounter on Ebola (full transcript)
22 Dec 2014

UNICEF Watch [to 3 January 2014]
:: UNICEF Ebola response: 400+ survivors receive psycho-social support and kits to restart their lives
KENEMA, Sierra Leone, 24 December 2014 – More than 400 Ebola survivors have taken part in four separate survivor conferences over the past few days in the districts of Kailahun, Kenema and Bo, where they learned more about protecting their communities, were informed as to how their bodies defeated the disease, and received psycho-social support.

CDC/MMWR Watch [to 3 January 2014]
:: Ebola epidemic continues to spread, requiring intensified effort – Press Release
December 22, 2014
After more than a year of Ebola transmission in Guinea and more than 7 months of transmission in Liberia and Sierra Leone, there is still much to be done to stop the world’s first Ebola epidemic, CDC director Tom Frieden, M.D., M.P.H reported from his second visit to the three affected nations.
Dr. Frieden yesterday returned from West Africa, where he spoke with patients and staff; met with many of CDC’s 170 staff working in each of the countries; and met with the presidents, health ministers, and Ebola leadership of each country. He described the situation as both inspiring and sobering.
“It is inspiring to see how much better the response has become in the past two months, how much international commitment there is, and, most importantly, how hard people from each of the three countries are working to stop Ebola,” Dr. Frieden said. “But it is sobering that Ebola continues to spread rapidly in Sierra Leone and that in parts of Monrovia and Conakry Ebola is spreading unabated. Improvements in contact tracing are urgently needed.”
At a telebriefing held to discuss the results of his trip to Guinea, Liberia, and Sierra Leone, Dr. Frieden described progress in some areas but continued growth in Ebola cases in other areas. Lingering unmet needs throughout the region continue to challenge response efforts.
“In Liberia, the outbreak has slowed dramatically and at the moment the country has the upper hand against the virus, in part due to improvements in access to Ebola Treatment Units and Community Care Centers, safe burials, and community engagement,” Dr. Frieden said. “But the outbreak continues to surge in Sierra Leone, and there has been a troubling spread in Guinea’s capitol city. We’ve got a long way to go and this is no time to relax our grip on the response.”…

:: MMWR Weekly, January 2, 2014 / Vol. 63 / Nos. 51 & 52
– Perceptions of the Risk for Ebola and Health Facility Use Among Health Workers and Pregnant and Lactating Women — Kenema District, Sierra Leone, September 2014

MSF/Médecins Sans Frontières [to 3 January 2014]
:: A Mixed Welcome for Homecoming Ebola Survivors
December 31, 2014
Moses’s family has been hard hit by Ebola. Four of them were infected with the virus—his father and brother died, but Moses and his sister both survived. Moses was recently discharged from the Doctors Without Borders/Médecins Sans Frontières (MSF) Ebola management center in Bo, Sierra Leone, and made the journey back to his home village, accompanied by MSF health promoter Esmee de Jong.

:: Clinical Trial for Potential Ebola Treatment Starts in MSF Clinic in Guinea
December 29, 2014
A clinical trial for a possible treatment for Ebola started in Guinea on December 17. The trial is led by the French medical research institute INSERM and is taking place at the Doctors Without Borders/Médecins Sans Frontières (MSF) Ebola treatment center in Guéckédou, in the east of the country. Although every experimental treatment for Ebola patients offers hope, MSF remains prudent. There’s no guarantee that the drug will be effective and safe, and, even if it is, it will not mean the end of the epidemic which continues to spread in the three most affected countries of West Africa.
The trial aims to include as many Ebola-positive patients presenting at the MSF treatment center as possible. There will be no control group (group of patients who do not receive the treatment) in this study, as it is considered unethical to deny a group of patients the higher chance of survival that may come with the new treatment, especially given the high mortality rate of Ebola. Instead, the outcomes of the patients will be measured against those of MSF patients admitted earlier this year, before the trial began. The first conclusive results are not expected before the first trimester of 2015.
All new patients arriving at the MSF Ebola treatment center in Guéckédou are informed about the possibility of receiving the experimental treatment and can elect to participate in the study or not. Those who do not wish to be given the new treatment will receive the same supportive care as those who do, but without the administration of the trial drug.
The drug being used in Guéckédou is favipiravir, an antiviral drug produced by the Japanese company Toyama/FujiFilm. This drug has had good results against Ebola in animal studies and good safety results in humans when used as treatment for another viral infection. But, as the drug has never been studied in humans with Ebola, it is important to wait for the results of the trial before declaring favipiravir a treatment for the disease.
If favipiravir is shown to be safe and effective, it will be made accessible to Ebola patients in other Ebola treatment centers through advancing the trial to the next phase. This means that after approval from national authorities and independent ethics committees more Ebola-positive patients in West Africa will be started on the treatment.
A safe and effective treatment for Ebola will prevent many patients from dying, but it will not change the course of the epidemic. Interventions like early admission of patients in specialized centers, thorough and accurate contact tracing, tailored health promotion, and necessary hygiene and sanitation measures will continue to be the most important strategies in ending the outbreak. Research into other treatments including vaccines and new diagnostics will also remain important.

Press Release [Full text]
December 30, 2014
On the 28th December, the first Ebola patient treated in Africa with the experimental drug ZMAb has been discharged from the Ebola Treatment Centre run by EMERGENCY NGO in Goderich, Sierra Leone.
A.M., 72 years old, had been admitted 2 weeks ago in very critical conditions.
The ZMAb used for A. M. had been requested by the Ministry of Health of Sierra Leone to treat Dr. Victor Willoughby, a leading doctor in the country. Dr. Willoughby, unfortunately died as soon as the drug arrived in country.
The Ministry of Health asked EMERGENCY to give the ZMAb to A.M., wife and mother of two of the patients of Dr Willoughby, both died of Ebola few days before.
The high standard Ebola Treatment Centre run by EMERGENCY NGO is the only centre in Africa that has used ZMAb so far. It opened on 14th of December in collaboration with DFID, the Department for International Development of the British Government.

Save The Children [to 3 January 2014]
Save the Children’s Sierra Leone Ebola Center Discharges its 60th Survivor
December 24, 2014

Plan International [to 3 January 2014]
Children’s futures impacted due to Ebola school closures
29 December 2014:
Children in Ebola-stricken Liberia are playing, working or begging to fill their time while schools are closed, according to Plan International.
The virus has kept schools shut for more than five months, in a country which already suffered from limited learning facilities and trained teachers, as well as a high illiteracy rate.
New research from Plan shows that a cohort of children and youth will lose half a year or more of education, which is expected to affect their prospects in life, as well as dent their confidence and self-esteem.
The report, entitled Young Lives on Lockdown: The impact of Ebola on children and communities in Liberia, says that while teachers and older children are continuing to teach their children and sibling at home, the majority of parents are themselves uneducated and thus cannot give their children home schooling.
“Most parents cannot read or write so they cannot help their children at home, and at the same time they don’t let other people come to their houses to conduct lessons for them or let their children out for even 30 minutes,” said one community leader interviewed for the research.
Once schools do re-open, parents worry they will not have the money to pay their children’s fees. “Schools will reopen but there’s no money to put kids in school,” said another community leader, speaking to researchers…

European Vaccine Initiative Watch [to 3 January 2014]
Senior Project Manager position open at GAVI The Vaccine Alliance
24 December 2014
GAVI is currently looking for a Senior Project Manager, Ebola Vaccine.

WHO & Regionals [to 3 January 2014]

WHO & Regionals [to 3 January 2014]

WHO: 2014 in review: key health issues
Health headlines have recently been dominated by the Ebola outbreak in West Africa and humanitarian emergencies in many other countries. 2014 also saw major public health successes, and a clearer understanding of a number of public health threats. WHO produced reports on a range of critical health issues and provided new advice to help countries improve their people’s health. Here are a few highlights:
:: January – April
:: May – August
:: September – December

:: Global Alert and Response (GAR): Disease Outbreak News (DONs)
Ebola virus disease – United Kingdom 30 December 2014
On 29 December 2014, WHO was notified by the National IHR Focal Point for the United Kingdom of a laboratory-confirmed case of Ebola Virus Disease (EVD). This is the first EVD case to be detected on UK soil.
Human infection with avian influenza A(H7N9) virus – China 30 December 2014
Human infection with avian influenza A(H5N6) virus – China 28 December 2014
Middle East respiratory syndrome coronavirus (MERS-CoV) – Saudi Arabia 26 December 2014
Human infection with avian influenza A(H7N9) virus – China 24 December 2014

:: 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
WHO Regional Offices
WHO African Region AFRO
Press Releases
:: National health systems – Africa’s big public health challenge 22 December 2014
Feature Stories
:: Cured of Ebola, Rebecca returns to cure others – 24 December 2014
:: Liberia: Local students become active Ebola case finders – 22 December 2014

WHO Region of the Americas PAHO
:: PAHO year in review: 2014 public health highlights in the Americas
Washington, D.C., 24 December 2014 (PAHO/WHO) – The year 2014 was marked by progress as well as significant challenges for public health in the Americas. The region’s countries advanced toward goals including universal health coverage, expanded access to vaccination, and ensuring that fewer babies are born with HIV. They also confronted major new challenges, including the arrival and spread of the chikungunya virus and the need to prepare for the possible imported cases of Ebola…

WHO South-East Asia Region SEARO
:: Strengthening emergency preparedness, response capacities can save lives in mega disasters like tsunami 24 December 2014

WHO European Region EURO
:: First Ebola case detected on UK soil 02-01-2015
:: Avian influenza A(H5N8) continues to spread in poultry 23-12-2014

WHO Eastern Mediterranean Region EMRO
No new digest content identified.

WHO Western Pacific Region
:: 2014: Pacific year in review
2 January 2015 – The Pacific responded to a number of challenges in 2014, from outbreaks of vector-borne diseases to strengthening capacity to respond to public health threats such as Ebola. At the same time, work to combat the NCD crisis accelerated, through, for example, the launch of the Tobacco Free Pacific initiative and salt reduction activities. The Pacific voice was heard on the global stage at the World Health Assembly and the 3rd International Conference on Small Islands Developing States…

IVI and SK Chemicals Receive Funding to Advance Development of a New Typhoid Vaccine

IVI Watch [to 3 January 2014]

IVI and SK Chemicals Receive Funding to Advance Development of a New Typhoid Vaccine
IVI partnering with SK Chemicals on vaccine research and development
4.9 million USD grant from Gates Foundation to support typhoid vaccine early clinical trials

SEOUL, SOUTH KOREA – The International Vaccine Institute (IVI) announced today that grant funding of 4.9 million USD was received from the Bill & Melinda Gates Foundation to support clinical research and development of a new typhoid fever vaccine in collaboration with SK Chemicals. The grant is effective from December 2014 to September 2017…
…IVI developed a new typhoid vaccine based on conjugation of the bacterial Vi polysaccharide antigen, conjugated to diphtheria toxoid (DT). Compared with current typhoid vaccines, it has the potential to protect children below two years old and to provide protection against typhoid for a longer duration of time. SK Chemicals has gained extensive technology and expertise on conjugate vaccines from its experience with the pneumococcal conjugate vaccine. By combining this with the technology transferred from IVI, SK Chemicals has successfully established the manufacturing process for the typhoid vaccine at a commercial scale…
…The new grant will support early clinical trials for the typhoid conjugate vaccine. IVI will work with SK Chemicals in the development and conduct of clinical trials for vaccine licensure and eventually WHO prequalification…

Global Fund Appoints Mouhamadou Diagne as Inspector General

Global Fund Watch [to 3 January 2014]
Press releases
:: Global Fund Appoints Mouhamadou Diagne as Inspector General
22 December 2014
GENEVA – The Board of the Global Fund to Fight AIDS, Tuberculosis and Malaria appointed Mouhamadou Diagne, a distinguished auditor and financial supervisor, as Inspector General.
Mr. Diagne, a Certified Public Accountant, has 20 years of experience managing teams of auditors and financial analysts. With a strong background in international public accounting firms Deloitte, Andersen and Ernst & Young, Mr. Diagne currently serves as Director of Strategy and Operations in the World Bank Group’s Internal Audit…

IOM – Health Literacy Principles: Guidance for Making Information Understandable, Useful, and Navigable

Health Literacy Principles: Guidance for Making Information Understandable, Useful, and Navigable
IOM Discussion Paper
December 22, 2014
Kara L. Jacobson, Ruth M. Parker
Download PDF – 298 KB
Research documents that most people in the United States cannot understand or use the complex information needed for managing their health and effectively using health care services. We believe it is critical to take a health-literate approach to solving this problem, that is, to align system demands and complexities with individual skills and abilities. For the past two decades, we worked to advance research, teaching, and practices that systematically address improving health literacy. In this piece, we offer a synthesis of the principles we follow to create health information that is better aligned with the skills and abilities of those using that information. We then offer links to examples of materials where these principles guided the development and presentation of information.

Lifecourse Epidemiology and Molecular Pathological Epidemiology

American Journal of Preventive Medicine
January 2015 Volume 48, Issue 1, p1-120

Lifecourse Epidemiology and Molecular Pathological Epidemiology
Akihiro Nishi, MD, DrPH, Ichiro Kawachi, MD, PhD, Karestan C. Koenen, PhD, Kana Wu, MD, PhD, Reiko Nishihara, PhD, Shuji Ogino, MD, PhD
Lifecourse epidemiology studies long-term effects of social and environmental exposures on health and disease.1,2 A key challenge to the three models of lifecourse epidemiology is translating its empirical evidence into intervention planning, especially among populations where the critical social and environmental exposures happened in the past or when they represent difficult groups with which to intervene. In this article, molecular pathological epidemiology (MPE), which was first described in 2010, is reviewed.

Mitigation of infectious disease at school: targeted class closure vs school closure

BMC Infectious Diseases
(Accessed 3 January 2014)

Research article
Mitigation of infectious disease at school: targeted class closure vs school closure
Valerio Gemmetto, Alain Barrat and Ciro Cattuto
BMC Infectious Diseases 2014, 14:3841 doi:10.1186/s12879-014-0695-9
Published: 31 December 2014
Abstract (provisional)
School environments are thought to play an important role in the community spread of infectious diseases such as influenza because of the high mixing rates of school children. The closure of schools has therefore been proposed as an efficient mitigation strategy. Such measures come however with high associated social and economic costs, making alternative, less disruptive interventions highly desirable. The recent availability of high-resolution contact network data from school environments provides an opportunity to design models of micro-interventions and compare the outcomes of alternative mitigation measures.
Methods and results
We model mitigation measures that involve the targeted closure of school classes or grades based on readily available information such as the number of symptomatic infectious children in a class. We focus on the specific case of a primary school for which we have high-resolution data on the close-range interactions of children and teachers. We simulate the spread of an influenza-like illness in this population by using an SEIR model with asymptomatics, and compare the outcomes of different mitigation strategies. We find that targeted class closure affords strong mitigation effects: closing a class for a fixed period of time ? equal to the sum of the average infectious and latent durations ? whenever two infectious individuals are detected in that class decreases the attack rate by almost 70% and significantly decreases the probability of a severe outbreak. The closure of all classes of the same grade mitigates the spread almost as much as closing the whole school.
Our model of targeted class closure strategies based on readily available information on symptomatic subjects and on limited information on mixing patterns, such as the grade structure of the school, show that these strategies might be almost as effective as whole-school closure, at a much lower cost. This may inform public health policies for the management and mitigation of influenza-like outbreaks in the community.

BMJ: One promise fulfilled, much still to be done [clinical trials transparency]

British Medical Journal
03 January 2015(vol 350, issue 7989)

Editor’s Choice
One promise fulfilled, much still to be done
Fiona Godlee, editor in chief, The BMJ
This year, 2015, was the deadline for some pretty big promises. When these were made it must have seemed a long way off. In an article in the Lancet in 2004 I and others set 2015 as the date when there would be, we hoped, “health information for all” (Lancet 2004;364:295-300). More prominently, 2015 was the deadline for the United Nations’ millennium development goals. Now, with much achieved but of course still more to do, we are into the post-2015 development agenda.
But one important promise for 2015 has been fulfilled. The European Medicines Agency said that it would make publicly available the raw data from clinical trials of all newly approved drugs. And despite legal action from the drug industry (doi:10.1136/bmj.f1636) the agency has pushed ahead, and the new policy is in place. It will be a little while longer—until mid-2016—before it takes full effect. And the agency can still make restrictions and redactions to protect commercial confidentiality.
However, the fact remains that within two years the public and researchers will be able to read, in full, clinical study reports for all newly approved drugs, whether the trials were conducted by the industry or academia. This is an enormous achievement and something to celebrate…

Bulletin of the World Health Organization – January 2015

Bulletin of the World Health Organization
Volume 93, Number 1, January 2015, 1-64

The Ebola epidemic: a transformative moment for global health
Stephen B Kennedy a & Richard A Nisbett b
a. Liberia Post Graduate Medical Council, Corner of 12th Street and Russell Avenue, 2nd Floor Office Complex, Monrovia, 10001, Liberia.
b. Vanderbilt Institute of Global Health, Nashville, United States of America.
Bulletin of the World Health Organization 2015;93:2.
The devastating effects of the current epidemic of Ebola virus disease in western Africa have put the global health response in acute focus. The index case is believed to have been a 2-year-old child in Guéckédou, Guinea, who died in December 2013.1 By late February 2014, Guinea, Liberia and Sierra Leone were in the midst of a full-blown and complex global health emergency.2 The response by multilateral and humanitarian organizations has been laudable and – at times – heroic. Much of the worst affected region is recovering from civil conflicts. This region is characterized by weak systems of government and health-care delivery, high rates of illiteracy, poverty and distrust of the government and extreme population mobility across porous, artificial boundaries. A more coordinated, strategic and proactive response is urgently needed.

According to the World Health Organization (WHO), the outbreak had involved 17 145 probable, suspected or confirmed cases of Ebola virus disease and 6070 reported deaths, by 3 December 2014.3 The management of the outbreak has largely been taken out of the hands of the affected communities, even though such communities have cultural mechanisms and expertise to deal with various adversities. Local churches and community-based organizations, which have previously been involved in the response to health emergencies and conflicts, have been largely excluded. Although the worst-affected communities have been subject to quarantines and cordons sanitaires, the governments imposing these have often failed to provide adequate food and water to the people thus isolated. In addition, cordons sanitaires are hard to maintain when local police and military personnel are not trusted.

Although it is difficult to build trust and community support during an Ebola outbreak, the community-directed interventions developed by the WHO’s Special Programme for Training and Research in Tropical Diseases4 might usefully be implemented. The interventions are designed to prevent, treat and control infectious diseases of poverty by empowering and mobilizing communities and building effective cross-sectoral partnerships. To be effective in addressing salient transborder health issues, global health initiatives must focus on multilateral and cross-sectoral cooperation. Often, such cooperation must accommodate high levels of poverty and illiteracy and other substantive barriers to accessing formal health systems.

As we endeavour to combine biomedicine and social medicine to create a trans-disciplinary workforce for the Ebola frontline, we must ensure that our efforts are focused on the people, households and communities at risk. If we are to achieve any global health goals, we must empower the marginalized and voiceless. In the era of globalized supply chains and rapid transportation across very porous borders, it is in our self-interest to recognize our interdependence.
We also need a dose of humility and effective approaches at household, community, societal and global levels. At the household level, we need to promote family-centred interactions and interventions. Cultural practices such as embalming, burial and caregiving are family-based as well as community-based activities.

At community level, we need to re-emphasize the value of partnerships led by trusted community- and faith-based organizations. Even in the best of situations, most of the world’s resource-limited communities tend to be wary of government officials and other outsiders.

At societal level, we need approaches that engage, mobilize and energize non-state, non-political actors while coordinating the ministries involved in health, welfare, finance and education. Grassroots groups with a high reserve of trust can be successfully engaged and motivated to intervene in a manner that is culturally sensitive.

Finally, we need global approaches that will intensify the international response. The global health community should treat the Ebola outbreak as the complex humanitarian emergency that it is.

We admire, commend and thank the tireless and brave frontline workers responding to this tragic outbreak – they are genuine heroes and national treasures. However, without a more effective and robust emergency response – and years of intensive health systems strengthening –there will be many more serious epidemics of Ebola and other infectious diseases. Such epidemics threaten not just the world’s most resource-poor settings but also the entire global community.

Baize S, Pannetier D, Oestereich L, Rieger T, Koivogui L, Magassouba N, et al. Emergence of Zaire Ebola virus disease in Guinea. N Engl J Med. 2014;371(15):1418-25. 10.1056/NEJMoa1404505 pmid: 24738640
Chan M. Ebola virus disease in West Africa — no early end to the outbreak. N Engl J Med. 2014;371(13):1183-5. pmid: 25140856
Ebola response roadmap – situation report. 3 December 2014. Geneva: World Health Organization; 2014. Available from: [cited 2014 Dec 9].
CDI Study Group. Community-directed interventions for priority health problems in Africa: results of a multicountry study. Bull World Health Organ. 2010;88(7):509-18. pmid: 20616970

Expensive medicines: ensuring objective appraisal and equitable access
Suzanne R Hill a, Lisa Bero b, Geoff McColl a & Elizabeth Roughead c
a. University of Melbourne, Parkville, Melbourne, Victoria 3010, Australia.
b. Charles Perkins Centre, University of Sydney, Sydney, Australia.
c. University of South Adelaide, Adelaide, Australia.
Bulletin of the World Health Organization 2015;93:4.

Responses to donor proliferation in Ghana’s health sector: a qualitative case study
Sarah Wood Pallas, Justice Nonvignon, Moses Aikins & Jennifer Prah Ruger
To investigate how donors and government agencies responded to a proliferation of donors providing aid to Ghana’s health sector between 1995 and 2012.
We interviewed 39 key informants from donor agencies, central government and nongovernmental organizations in Accra. These respondents were purposively selected to provide local and international views from the three types of institutions. Data collected from the respondents were compared with relevant documentary materials – e.g. reports and media articles – collected during interviews and through online research.
Ghana’s response to donor proliferation included creation of a sector-wide approach, a shift to sector budget support, the institutionalization of a Health Sector Working Group and anticipation of donor withdrawal following the country’s change from low-income to lower-middle income status. Key themes included the importance of leadership and political support, the internalization of norms for harmonization, alignment and ownership, tension between the different methods used to improve aid effectiveness, and a shift to a unidirectional accountability paradigm for health-sector performance.
In 1995–2012, the country’s central government and donors responded to donor proliferation in health-sector aid by promoting harmonization and alignment. This response was motivated by Ghana’s need for foreign aid, constraints on the capacity of governmental human resources and inefficiencies created by donor proliferation. Although this decreased the government’s transaction costs, it also increased the donors’ coordination costs and reduced the government’s negotiation options. Harmonization and alignment measures may have prompted donors to return to stand-alone projects to increase accountability and identification with beneficial impacts of projects.

Neonatal cause-of-death estimates for the early and late neonatal periods for 194 countries: 2000–2013
Shefali Oza, Joy E Lawn, Daniel R Hogan, Colin Mathers & Simon N Cousens
To estimate cause-of-death distributions in the early (0–6 days of age) and late (7–27 days of age) neonatal periods, for 194 countries between 2000 and 2013.
For 65 countries with high-quality vital registration, we used each country’s observed early and late neonatal proportional cause distributions. For the remaining 129 countries, we used multinomial logistic models to estimate these distributions. For countries with low child mortality we used vital registration data as inputs and for countries with high child mortality we used neonatal cause-of-death distribution data from studies in similar settings. We applied cause-specific proportions to neonatal death estimates from the United Nations Inter-agency Group for Child Mortality Estimation, by country and year, to estimate cause-specific risks and numbers of deaths.
Over time, neonatal deaths decreased for most causes. Of the 2.8 million neonatal deaths in 2013, 0.99 million deaths (uncertainty range: 0.70–1.31) were estimated to be caused by preterm birth complications, 0.64 million (uncertainty range: 0.46–0.84) by intrapartum complications and 0.43 million (uncertainty range: 0.22–0.66) by sepsis and other severe infections. Preterm birth (40.8%) and intrapartum complications (27.0%) accounted for most early neonatal deaths while infections caused nearly half of late neonatal deaths. Preterm birth complications were the leading cause of death in all regions of the world.
The neonatal cause-of-death distribution differs between the early and late periods and varies with neonatal mortality rate level. To reduce neonatal deaths, effective interventions to address these causes must be incorporated into policy decisions.

Lessons from the Field
Informing evidence-based policies for ageing and health in Ghana
Islene Araujo de Carvalho, Julie Byles, Charles Aquah, George Amofah, Richard Biritwum, Ulysses Panisset, James Goodwin & John Beard
Ghana’s population is ageing. In 2011, the Government of Ghana requested technical support from the World Health Organization (WHO) to help revise national policies on ageing and health.
We applied WHO’s knowledge translation framework on ageing and health to assist evidence based policy-making in Ghana. First, we defined priority problems and health system responses by performing a country assessment of epidemiologic data, policy review, site visits and interviews of key informants. Second, we gathered evidence on effective health systems interventions in low- middle- and high-income countries. Third, key stakeholders were engaged in a policy dialogue. Fourth, policy briefs were developed and presented to the Ghana Health Services.
Local setting
Ghana has a well-structured health system that can adapt to meet the health care needs of older people.
Relevant changes
Six problems were selected as priorities, however after the policy dialogue, only five were agreed as priorities by the stakeholders. The key stakeholders drafted evidence-based policy recommendations that were used to develop policy briefs. The briefs were presented to the Ghana Health Service in 2014.
Lessons learnt
The framework can be used to build local capacity on evidence-informed policy-making. However, knowledge translation tools need further development to be used in low-income countries and in the field of ageing. The terms and language of the tools need to be adapted to local contexts. Evidence for health system interventions on ageing populations is very limited, particularly for low- and middle-income settings.

Measuring the incidence and prevalence of obstetric fistula: approaches, needs and recommendations
Özge Tunçalp a, Vandana Tripathi b, Evelyn Landry b, Cynthia K Stanton c & Saifuddin Ahmed c
a. Department of Reproductive Health and Research, World Health Organization, avenue Appia 20, 1211 Geneva 27, Switzerland.
b. Fistula Care Plus, EngenderHealth, New York, United States of America (USA).
c. Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA.
(Submitted: 09 June 2014 – Revised version received: 10 October 2014 – Accepted: 13 October 2014 – Published online: 01 December 2014.)
Bulletin of the World Health Organization 2015;93:60-62.

CChina’s role as a global health donor in Africa: what can we learn from studying under reported resource flows?

Globalization and Health
[Accessed 3 January 2014]

China’s role as a global health donor in Africa: what can we learn from studying under reported resource flows?
Karen A Grépin12*, Victoria Y Fan23, Gordon C Shen4 and Lucy Chen5
Author Affiliations
Globalization and Health 2014, 10:273 doi:10.1186/s12992-014-0084-6
Published: 30 December 2014
Abstract (provisional)
There is a growing recognition of China’s role as a global health donor, in particular in Africa, but there have been few systematic studies of the level, destination, trends, or composition of these development finance flows or a comparison of China’s engagement as a donor with that of more traditional global health donors.
Using newly released data from AidData on China’s development finance activities in Africa, developed to track under reported resource flows, we identified 255 health, population, water, and sanitation (HPWS) projects from 2000?2012, which we descriptively analyze by activity sector, recipient country, project type, and planned activity. We compare China’s activities to projects from traditional donors using data from the OECD?s Development Assistance Committee (DAC) Creditor Reporting System.
Since 2000, China increased the number of HPWS projects it supported in Africa and health has increased as a development priority for China. China’s contributions are large, ranking it among the top 10 bilateral global health donors to Africa. Over 50% of the HPWS projects target infrastructure, 40% target human resource development, and the provision of equipment and drugs is also common. Malaria is an important disease priority but HIV is not. We find little evidence that China targets health aid preferentially to natural resource rich countries.
China is an important global health donor to Africa but contrasts with traditional DAC donors through China’s focus on health system inputs and on malaria. Although better data are needed, particularly through more transparent aid data reporting across ministries and agencies, China’s approach to South-South cooperation represents an important and distinct source of financial assistance for health in Africa.

Health Research Policy and Systems [Accessed 3 January 2014]

Health Research Policy and Systems
[Accessed 3 January 2014]

Does health intervention research have real world policy and practice impacts: testing a new impact assessment tool
Gillian Cohen, Jacqueline Schroeder, Robyn Newson, Lesley King, Lucie Rychetnik, Andrew J Milat, Adrian E Bauman, Sally Redman and Simon Chapman
Health Research Policy and Systems 2015, 13:3 doi:10.1186/1478-4505-13-3
Published: 1 January 2015
Abstract (provisional)
There is a growing emphasis on the importance of research having demonstrable public benefit. Measurements of the impacts of research are therefore needed. We applied a modified impact assessment process that builds on best practice to 5 years (2003-2007) of intervention research funded by Australia’s National Health and Medical Research Council to determine if these studies had post-research real-world policy and practice impacts.
We used a mixed method sequential methodology whereby chief investigators of eligible intervention studies who completed two surveys and an interview were included in our final sample (n = 50), on which we conducted post-research impact assessments. Data from the surveys and interviews were triangulated with additional information obtained from documentary analysis to develop comprehensive case studies. These case studies were then summarized and the reported impacts were scored by an expert panel using criteria for four impact dimensions: corroboration; attribution, reach, and importance.
Nineteen (38%) of the cases in our final sample were found to have had policy and practice impacts, with an even distribution of high, medium, and low impact scores. While the tool facilitated a rigorous and explicit criterion-based assessment of post-research impacts, it was not always possible to obtain evidence using documentary analysis to corroborate the impacts reported in chief investigator interviews.
While policy and practice is ideally informed by reviews of evidence, some intervention research can and does have real world impacts that can be attributed to single studies. We recommend impact assessments apply explicit criteria to consider the corroboration, attribution, reach, and importance of reported impacts on policy and practice. Impact assessments should also allow sufficient time between impact data collection and completion of the original research and include mechanisms to obtain end-user input to corroborate claims and reduce biases that result from seeking information from researchers only.

Climate for evidence informed health system policymaking in Cameroon and Uganda before and after the introduction of knowledge translation platforms: a structured review of governmental policy documents
Pierre Ongolo-Zogo, John N Lavis, Goran Tomson, Nelson K Sewankambo Health Research Policy and Systems 2015, 13:2 (1 January 2015)
Abstract (provisional)
There is a scarcity of empirical data on African country climates for evidence-informed health system policymaking (EIHSP) to backup the longstanding reputation that research evidence is not valued enough by health policymakers as an information input.
Herein, we assess whether and how changes have occurred in the climate for EIHSP before and after the establishment of two Knowledge Translation Platforms housed in government institutions in Cameroon and Uganda since 2006.
We merged content analysis techniques and policy sciences analytical frameworks to guide this structured review of governmental policy documents geared at achieving health Millennium Development Goals. We combined i) a quantitative exploration of the usage statistics of research-related words and constructs, citations of types of evidence, and budgets allocated to research-related activities; and (ii) an interpretive exploration using a deductive thematic analysis approach to uncover changes in the institutions, interests, ideas, and external factors displaying the country climate for EIHSP. Descriptive statistics compared quantitative data across countries during the periods 2001-2006 and 2007-2012.
We reviewed 54 documents, including 33 grants approved by global health initiatives. The usage statistics of research-related words and constructs showed an increase over time across countries. Varied forms of data, information, or research were instrumentally used to describe the burden and determinants of poverty and health conditions. The use of evidence syntheses to frame poverty and health problems, select strategies, or forecast the expected outcomes has remained sparse over time and across countries. The budgets for research increased over time from 28.496 to 95.467 million Euros (335%) in Cameroon and 38.064 to 58.884 million US dollars (155%) in Uganda, with most resources allocated to health sector performance monitoring and evaluation. The consistent naming of elements pertaining to the climate for EIHSP features the greater influence of external donors through policy transfer.
This structured review of governmental policy documents illustrates the nascent conducive climate for EIHSP in Cameroon and Uganda and the persistent undervalue of evidence syntheses. Global and national health stakeholders should raise the profile of evidence syntheses (e.g., systematic reviews) as an information input when shaping policies and programmes.

Equity and seeking treatment for young children with fever in Nigeria: a cross-sectional study in Cross River and Bauchi States

Infectious Diseases of Poverty
[Accessed 3 January 2014]

Research Article
Equity and seeking treatment for young children with fever in Nigeria: a cross-sectional study in Cross River and Bauchi States
Bikom Patrick Odu, Steven Mitchell, Hajara Isa, Iyam Ugot, Robbinson Yusuf, Anne Cockcroft and Neil Andersson
Infectious Diseases of Poverty 2015, 4:1 doi:10.1186/2049-9957-4-1
Published: 2 January 2015
Abstract (provisional)
Poor children have a higher risk of contracting malaria and may be less likely to receive effective treatment. Malaria is an important cause of morbidity and mortality in Nigerian children and many cases of childhood fever are due to malaria. This study examined socioeconomic factors related to taking children with fever for treatment in formal health facilities.
A household survey conducted in Bauchi and Cross River states of Nigeria asked parents where they sought treatment for their children aged 0-47 months with severe fever in the last month and collected information about household socio-economic status. Fieldworkers also recorded whether there was a health facility in the community. We used treatment of severe fever in a health facility to indicate likely effective treatment for malaria. Multivariate analysis in each state examined associations with treatment of childhood fever in a health facility.
43% weighted (%wt) of 10,862 children had severe fever in the last month in Cross River, and 45%wt of 11,053 children in Bauchi. Of these, less than half (31%wt Cross River, 44%wt Bauchi) were taken to a formal health facility for treatment. Children were more likely to be taken to a health facility if there was one in the community (OR 2.31 [95%CI 1.57-3.39] in Cross River, OR 1.33 [95%CI 1.0-1.7] in Bauchi). Children with fever lasting less than five days were less likely to be taken for treatment than those with more prolonged fever, regardless of whether there was such a facility in their community. Educated mothers were more likely to take children with fever to a formal health facility. In communities with a health facility in Cross River, children from less-poor households were more likely to go to the facility (OR 1.30; 95%CI 1.07-1.58).
There is inequity of access to effective malaria treatment for children with fever in the two states, even when there is a formal health facility in the community. Understanding the details of inequity of access in the two states could help the state governments to plan interventions to increase access equitably. Increasing geographic access to health facilities is needed but will not be enough.

Editorial: To hasten Ebola containment, mobilize survivors

International Journal of Epidemiology
Volume 43 Issue 6 December 2014

To hasten Ebola containment, mobilize survivors
Zena A Stein1,2, Jack Ume Tocco1,*, Joanne E Mantell1 and Raymond A Smith1
Author Affiliations
1HIV Center for Clinical and Behavioral Studies, Division of Gender, Sexuality and Health, New York State Psychiatric Institute and Columbia University, New York, NY, USA
2Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
The current Ebola outbreak is unique in its magnitude and its dispersion in dense, mobile populations. Physician and nurse responders face high mortality, and foreign aid in the form of medical supplies and staff continues to be unequal to the scope of the problem. Fear and loss have overwhelmed affected communities, already among the poorest in the world and still recovering from brutal civil wars. While the number of Ebola cases in Liberia appears to be on the decline, Ebola infections in Sierra Leone and Guinea continue to increase.1 That the response to the epidemic be swift and massive is a matter of life and an unknown number of deaths.

Survivors of Ebola infection are valuable resources still largely overlooked in the struggle to contain the epidemic. With a case recovery rate of around 30% at the present time for the current West African epidemic,2 survivors already number thousands. There are several reasons why Ebola survivors may be critical to controlling the epidemic.

First, and most importantly, the recovered have developed immunity to the current strain of Ebola and therefore are able to care for the sick with …

International Journal of Infectious Diseases – January 2015

International Journal of Infectious Diseases
January 2015 Volume 30, p1

Guidelines for treatment of patients with Ebola Virus Diseases are urgently needed
Eskild Petersen1, Boubacar Maiga2
1ProMED Moderator, Parasitic Diseases
2ProMED Moderator for Infectious Diseases, ProMED-FRA (Francophone Africa)
Open Access
The Ebola Virus Diseases, EVD, epidemic is still unfolding in West Africa with Guinea, Sierra Leone and Liberia most severely affected. This week it was estimated that there is at least 500 new cases every week and the total number of cases has passed 16,000, but there is probably a substantial underreporting of both cases and fatalities.1 There are some doubts about the mortality rate, but one recent case series reported a mortality of 72%.2

The outbreak is unprecedented in magnitude and few would have predicted that such an outbreak was possible. However, it seems clear that it is not due to a more pathogenic version of the Ebola virus and indeed low virus genetic diversity has been observed in person-to-person virus transmission.3, 4 Therefore, the current situation is most probable due to the poor status of the health care systems especially in Liberia and Sierra Leone, which has both recently suffered long civil wars, which have left the countries drained for educated health care staff and a dilapidated health infrastructure.

There is no approved, specific treatment of EVD. Several experimental anti-virals, immune-therapy5 and use of hyperimmune plasma from survivors have been proposed, but data from controlled clinical trials are lacking.6

After a slow start the international community including many Non Governmental Organizations, NGO’s, are managing treatment facilities in West Africa
But what are these treatment facilities offering?
Very little data has emerged. One published study reported a mortality of 72% but astonishingly the study contained no information of any treatment.2 Thus the question remains if the patients included in that study received any treatment at all. These patients were all from Sierra Leone and in contrast, nationals from industrialized countries are evacuated and treated in their home country and survived.7, 8 In particular, the case evacuated to Germany7 show very clearly that the treatment with classical tools used for patients in severe chock (bacterial septicemia, severe malaria) is expected to substantially reduce mortality. The patients received 30 liters of fluid intravenously over the first three days, had paralytic ileus and thus could not take oral fluid, had an fecal output of 14 liters over three days and severe hypokalemia. The same problems were seen in the two patients evacuated to the United States and one of these also had malaria.8

Is this a proper level of inpatient care in the Ebola treatment facilities or should we aim higher?
A mortality of 43% were reported in a case series of 80 patients with EVD from Guinea where 76% of the patients received intravenous fluid even though only 1 titer over 24 hours in average.9 If the difference in mortality between the report from Sierra Leone (72%)2 and Guinea (43%)9 are due to the use of intravenous fluid and even though one liter intravenous fluid seems very modest in view the need in the three expatriated cases7, 8, it seems that intravenous fluid replacement may significantly reduce mortality in the treatment centers perhaps by as much as 50%. This can be done in the conditions prevailing in West Africa using pulse, blood pressure, body weight and urine output as guidance and using simple point-of-care tests for measuring electrolytes, but require intravenous access, abundant fluid for intravenous administration and trained staff.

It is telling that the NGO’s have not published any treatment results and it is unclear if there is any control of treatment outcomes in EVD treatment facilities. Simply notifying confirmed cases and outcomes (fatal or not) and publishing weekly updates broken down to different NGO’s would allow quality control and allow adjustment of treatment algorithms adopting procedures identifying the highest survival rates. The difference in mortality between the two published case series2, 9 indicate that this is urgently needed.

We must to ensure that treatment is not palliation and that the so-called “Ebola hospitals” are hospitals and not hospices for untreated cases with the sole purpose of isolating cases from the community.

It is estimated in a study from Liberia, that only 25% of known Ebola patients had been admitted to an Ebola treatment facility as of August 14, 2014.10 The reasons for this low number are many, but a key point is probably that the chance of survival in these units does not differ significantly from patients staying at home.

The national governments in the affected countries does not have the resources nor the manpower to ensure the quality of the care provided by NGO’s and others. Thus the World Health Organization or others with the necessary resources should establish a notification system, to ensure that facilities are providing treatment and not only palliation and publish for instance weekly updates of survival figures broken down for each NGO to ensure quality control, transparency and optimization of treatment algorithms.

The German patient7 had septicemia and one of the American patients had malaria.8 Both diagnosis can lead to disseminated intravascular coagulation and will thus easily be confused with Ebola. If diagnostics are not available perhaps every patients in this highly endemic malaria area should receive a malaria treatment course and an infusion of a broad spectrum antibiotic, for instance ceftriaxone.

It is important to know if a patient is HIV positive as a low CD4 T cell count is expected to increase the risk of a fatal outcome, and thus treatment efficacy if at all possible should be stratified according to HIV status.

It is urgently needed to develop guidelines for treatment of EVD patients and to distinguish treatment from palliation and hospitals from hospices.

We suggest that the World Health Organization take the leadership and develop guidelines for treatment including:
1. Diagnosis of EVD
2. Principles for intravenous fluid replacement
3. Principles for measurement of electrolyte imbalance
4. Principles for correction of electrolyte imbalance
5. Diagnosis and treatment of concomitant malaria
6. When to administer antibiotics based on suspicion of septicemia
7. HIV testing.
8. Implement a reporting system for all EVD treatment facilities

These measures can all be implemented under the field conditions in West Africa, provided the staff are trained in high volume fluid replacement. Participating should be a prerequisite for receiving financial support from governments and receiving permission to manage EVD treatment facilities.
The staffing of the treatment facilities is a crucial issue and it can be speculated that the NGO’s does not have access to physicians and nurses with knowledge and experience in high volume fluid replacement and correction of electrolyte imbalance.
One solution could be twinning with hospitals in industrialized countries where these hospitals adopt an EVD treatment facility and ensure staffing and training. This of course would need support from the national health authorities. Such a program would ensure effective intravenous fluid replacement therapy were provided, most probably significantly reduce mortality, ensure confidence in the treatment facilities from the local population and thus increase the use of these facilities (earlier admission and higher proportion of cases treated, isolated and recovered).

Estimating influenza vaccine effectiveness using routine surveillance data among children aged 6–59 months for five consecutive influenza seasons
Wei-Ju Su, Ta-Chien Chan, Pei-Hung Chuang, Yu-Lun Liu, Ping-Ing Lee, Ming-Tsan Liu1, Jen-Hsiang Chuang2
1Tel.: +886 2 2653 1108; fax: +886 2 2785 3944.
2Tel.: +886 2 2391 8471; fax: +886 2 2391 8543.
Open Access
:: Multiyear studies are preferred for estimating robust influenza vaccine effectiveness over time.
:: An efficient way to evaluate the influenza vaccine effectiveness was used, through data linkage of two already established systems in the public health sector.
:: We applied both fixed-effects and random-effects meta-analysis of case–control studies to estimate the pooled vaccine effectiveness for children aged 6–59 months across five influenza seasons and considered the variation in antigenic match and epidemics year by year as the heterogeneity between studies.
We aimed to estimate the pooled vaccine effectiveness (VE) in children over five winters through data linkage of two existing surveillance systems.
Five test-negative case–control studies were conducted from November to February during the 2004/2005 to 2008/2009 seasons. Sentinel physicians from the Viral Surveillance Network enrolled children aged 6–59 months with influenza-like illness to collect throat swabs. Through linking with a nationwide vaccination registry, we measured the VE with a logistic regression model adjusting for age, gender, and week of symptom onset. Both fixed-effects and random-effects models were used in the meta-analysis.
Four thousand four hundred and ninety-four subjects were included. The proportion of influenza test-positive subjects across the five seasons was 11.5% (132/1151), 7.2% (41/572), 23.9% (189/791), 6.6% (75/1135), and 11.2% (95/845), respectively. The pooled VE was 62% (95% confidence interval (CI) 48–83%) in both meta-analysis models. By age category, VE was 51% (95% CI 23–68%) for those aged 6–23 months and 75% (95% CI 60–84%) for those aged 24–59 months.
Influenza vaccination provided measurable protection against laboratory-confirmed influenza among children aged 6–59 months despite variations in the vaccine match during the 2004/2005 to 2008/2009 influenza seasons in Taiwan.

The Lancet – Jan 03, 2015

The Lancet
Jan 03, 2015 Volume 385 Number 9962 p1-88 e1-e3

Ebola: worldwide dissemination risk and response priorities
Benjamin J Cowling, Hongjie Yu
Open Access
The scale of the current outbreak of Ebola virus disease in west Africa is staggering. Thousands of infections and deaths have been reported in recent months, and unless major changes occur in the situation, incidence of Ebola virus disease has been projected to continue to grow and cumulative incidence to exceed 20 000 by November.1 A humanitarian crisis that stretches far beyond the impact of Ebola virus infections is unfolding in Africa, devastating the health systems and economies in affected countries.2 In the present outbreak, most infections remain confined to west Africa, although four cases have been detected outside this region: three cases diagnosed in Dallas, USA (of which one infection was contracted in Liberia and two were associated with nosocomial transmission from the first case), and one case in Madrid, Spain, associated with nosocomial transmission (figuravergaee).

Among all reported cases in the 2014 outbreak to date, most infections have been contracted in three countries in west Africa: Guinea, Liberia, and Sierra Leone.

In The Lancet, Isaac Bogoch and colleagues3 report on the potential for international dissemination of Ebola virus disease. Their assessment of risk for different countries is an advance over previous work,4 which analysed flight networks and connectivity, but did not account for passenger flows and final destinations. Because of the assumptions of uniform risk across the population and constant prevalence of infection (whereas, in fact, risk within the population is not likely to be uniform and incidence is doubling every 15–30 days),1 the relative risks comparing different countries can be more valuable than the estimated absolute risks. Bogoch and colleagues report that the two countries at highest risk of receiving cases are Ghana and Senegal and, outside Africa, the risk for export to the UK or France combined was estimated to be about eight times higher than the risk for export to the USA (15•8 vs 2•0).3 In other words, for every case of Ebola virus disease exported to the USA, the authors predict that there will be roughly eight cases exported to the UK or France combined.

Bogoch and colleagues3 then studied the potential for exit and entry screening to reduce export of unidentified infections, concluding that exit screening would be a much more efficient approach than entry screening. We would like to add several points to this discussion. First, international support would be essential for implementation of exit screening in the three highly-affected resource-poor countries in west Africa. However, implementation of more stringent checks beyond what is already being done could be very challenging. The affected countries have many urgent priorities—resources including money, personnel, medical equipment, and supplies are urgently needed to expand capacity for detection, diagnosis, and treatment of patients with Ebola virus disease, and to implement isolation and contact tracing, which are currently the best available interventions to control the outbreak. Meanwhile, the outbreak is having a catastrophic effect on the local health-care systems, which were already fragile.2, 5 No announcements have been made yet about earmarked contributions from the international community to support exit screening.

Second, exit and entry screening might not have a substantial effect on export rates, because of the long incubation period of the disease (average 8–10 days, range 2–21 days),1 combined with rapid disease progression after onset, so that most exportations would be incubating infections missed at border screening points. Finally, a choice is posed between entry and exit screening in Bogoch and colleagues’ study,3 with exit screening shown to be more efficient than entry screening and the combination of entry and exit screening shown to have little incremental usefulness. However, some countries have implemented and will continue entry screening6, 7 for various reasons. Subject to entry screening already being implemented, exit screening from the affected countries might not have incremental utility, especially considering the other urgent priorities in the region. In addition to any entry or exit screening, vigilance within countries is essential for early detection of imported cases of Ebola virus disease.3

There are several important near-future research needs. Perhaps most urgent is a better understanding of the effectiveness of existing treatment options, including convalescent serum. In the medium term, it is hoped that new vaccines and drugs will be available quickly for human clinical trials and in exposed populations.8 The WHO Ebola Response team has neatly summarised the transmission dynamics and epidemiological characteristics including the reproductive number, incubation period, and case fatality risk in the current Ebola virus outbreak,1 but one important unknown is the proportion of infections that are asymptomatic or mildly symptomatic. If mild infections do occur and are infectious, disease control outside west Africa might be increasingly challenging. However, this scenario is thought to be unlikely.9 One particularly pressing need is for the reassessment of appropriate procedures for infection control, and the potential for the virus to spread via small particle aerosols10 in addition to via contact with infected patients or their bodily fluids. Infection of health-care personnel in west Africa is often attributed to the scarcity of appropriate protective equipment and supplies, or inadequate administrative controls.11, 12 However, the nosocomial cases in Dallas and Madrid have raised the concern that present protocols might not be sufficient to protect health-care personnel fully against infection, particularly if cases are managed in health-care facilities that are not fully prepared.

BJC has received research funding from MedImmune and Sanofi Pasteur, and consults for Crucell. HY declares no competing interests. We thank Ren Xiang, Michael Ni, and Charles Yiu for technical assistance with the figure.

Assessment of the potential for international dissemination of Ebola virus via commercial air travel during the 2014 west African outbreak
Isaac I Bogoch, MD, Maria I Creatore, PhD, Martin S Cetron, MD, John S Brownstein, PhD, Nicki Pesik, MD, Jennifer Miniota, MSc, Theresa Tam, MD, Wei Hu, MSA, Adriano Nicolucci, MSA, Saad Ahmed, BSc, James W Yoon, MISt, Isha Berry, Prof Simon I Hay, DSc, Aranka Anema, PhD, Andrew J Tatem, PhD, Derek MacFadden, MD, Matthew German, MSc, Dr Kamran Khan, Open Access
Open access funded by Wellcome Trust
The WHO declared the 2014 west African Ebola epidemic a public health emergency of international concern in view of its potential for further international spread. Decision makers worldwide are in need of empirical data to inform and implement emergency response measures. Our aim was to assess the potential for Ebola virus to spread across international borders via commercial air travel and assess the relative efficiency of exit versus entry screening of travellers at commercial airports.
We analysed International Air Transport Association data for worldwide flight schedules between Sept 1, 2014, and Dec 31, 2014, and historic traveller flight itinerary data from 2013 to describe expected global population movements via commercial air travel out of Guinea, Liberia, and Sierra Leone. Coupled with Ebola virus surveillance data, we modelled the expected number of internationally exported Ebola virus infections, the potential effect of air travel restrictions, and the efficiency of airport-based traveller screening at international ports of entry and exit. We deemed individuals initiating travel from any domestic or international airport within these three countries to have possible exposure to Ebola virus. We deemed all other travellers to have no significant risk of exposure to Ebola virus.
Based on epidemic conditions and international flight restrictions to and from Guinea, Liberia, and Sierra Leone as of Sept 1, 2014 (reductions in passenger seats by 51% for Liberia, 66% for Guinea, and 85% for Sierra Leone), our model projects 2•8 travellers infected with Ebola virus departing the above three countries via commercial flights, on average, every month. 91 547 (64%) of all air travellers departing Guinea, Liberia, and Sierra Leone had expected destinations in low-income and lower-middle-income countries. Screening international travellers departing three airports would enable health assessments of all travellers at highest risk of exposure to Ebola virus infection.
Decision makers must carefully balance the potential harms from travel restrictions imposed on countries that have Ebola virus activity against any potential reductions in risk from Ebola virus importations. Exit screening of travellers at airports in Guinea, Liberia, and Sierra Leone would be the most efficient frontier at which to assess the health status of travellers at risk of Ebola virus exposure, however, this intervention might require international support to implement effectively.
Canadian Institutes of Health Research.

HIV and sex workers
Global epidemiology of HIV among female sex workers: influence of structural determinants
Kate Shannon, Steffanie A Strathdee, Shira M Goldenberg, Putu Duff, Peninah Mwangi, Maia Rusakova, Sushena Reza-Paul, Joseph Lau, Kathleen Deering, Michael R Pickles, Marie-Claude Boily
HIV and sex workers
Combination HIV prevention for female sex workers: what is the evidence?
Linda-Gail Bekker, Leigh Johnson, Frances Cowan, Cheryl Overs, Donela Besada, Sharon Hillier, Willard Cates

Funding AIDS programmes in the era of shared responsibility: an analysis of domestic spending in 12 low-income and middle-income countries

The Lancet Global Health
Jan 2015 Volume 3 Number 1 e1-e61

Funding AIDS programmes in the era of shared responsibility: an analysis of domestic spending in 12 low-income and middle-income countries
Stephen Resch, Theresa Ryckman, Robert Hecht

New England Journal of Medicine – January 1, 2015

New England Journal of Medicine
January 1, 2015 Vol. 372 No. 1

Communicating Uncertainty — Ebola, Public Health, and the Scientific Process
L. Rosenbaum

Interactive Perspective
International Health Care Systems — Selected Measures
N Engl J Med 2015; 372:e1January 1, 2015DOI: 10.1056/NEJMp1413937
An interactive graphic presents characteristics of selected health care systems from around the world, as well as health outcomes achieved in each country covered in the Perspective series on International Health Care Systems.

Clinical Presentation of Patients with Ebola Virus Disease in Conakry, Guinea
E.I. Bah and Others

International Health Care Systems
S. Morrissey, D. Blumenthal, R. Osborn, G.D. Curfman, and D. Malina

Efficacy of Neonatal HBV Vaccination on Liver Cancer and Other Liver Diseases over 30-Year Follow-up of the Qidong Hepatitis B Intervention Study: A Cluster Randomized Controlled Trial

PLoS Medicine
(Accessed 3 January 2014)

Policy Forum
Efficacy of Neonatal HBV Vaccination on Liver Cancer and Other Liver Diseases over 30-Year Follow-up of the Qidong Hepatitis B Intervention Study: A Cluster Randomized Controlled Trial
Chunfeng Qu, Taoyang Chen, Chunsun Fan, Qimin Zhan, Yuting Wang, Jianhua Lu, Ling-ling Lu, Zhengping Ni, Fei Huang, Hongyu Yao, Jian Zhu, Jian Fan, Yuanrong Zhu, Zhiyuan Wu, Guoting Liu, Wenhong Gao, Mengya Zang, Dongmei Wang, Min Dai, Chu Chieh Hsia, Yawei Zhang, Zongtang Sun
Research Article | published 30 Dec 2014 | PLOS Medicine 10.1371/journal.pmed.1001774

PLoS One [Accessed 3 January 2014]

PLoS One
[Accessed 3 January 2014]

Research Article
Costs of Eliminating Malaria and the Impact of the Global Fund in 34 Countries
Brittany Zelman mail, Anthony Kiszewski, Chris Cotter, Jenny Liu
Published: December 31, 2014
DOI: 10.1371/journal.pone.0115714
International financing for malaria increased more than 18-fold between 2000 and 2011; the largest source came from The Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund). Countries have made substantial progress, but achieving elimination requires sustained finances to interrupt transmission and prevent reintroduction. Since 2011, global financing for malaria has declined, fueling concerns that further progress will be impeded, especially for current malaria-eliminating countries that may face resurgent malaria if programs are disrupted.
This study aims to 1) assess past total and Global Fund funding to the 34 current malaria-eliminating countries, and 2) estimate their future funding needs to achieve malaria elimination and prevent reintroduction through 2030.
Historical funding is assessed against trends in country-level malaria annual parasite incidences (APIs) and income per capita. Following Kizewski et al. (2007), program costs to eliminate malaria and prevent reintroduction through 2030 are estimated using a deterministic model. The cost parameters are tailored to a package of interventions aimed at malaria elimination and prevention of reintroduction.
The majority of Global Fund-supported countries experiencing increases in total funding from 2005 to 2010 coincided with reductions in malaria APIs and also overall GNI per capita average annual growth. The total amount of projected funding needed for the current malaria-eliminating countries to achieve elimination and prevent reintroduction through 2030 is approximately US$8.5 billion, or about $1.84 per person at risk per year (PPY) (ranging from $2.51 PPY in 2014 to $1.43 PPY in 2030).
Although external donor funding, particularly from the Global Fund, has been key for many malaria-eliminating countries, sustained and sufficient financing is critical for furthering global malaria elimination. Projected cost estimates for elimination provide policymakers with an indication of the level of financial resources that should be mobilized to achieve malaria elimination goals.

Vaccinating Sons against HPV: Results from a U.S. National Survey of Parents
Jaime L. Taylor, Greg D. Zimet, Kelly L. Donahue, Andreia B. Alexander, Marcia L. Shew, Nathan W. Stupiansky
Research Article | published 26 Dec 2014 | PLOS ONE 10.1371/journal.pone.0115154

Responding to Vaccine Safety Signals during Pandemic Influenza: A Modeling Study
Judith C. Maro, Dennis G. Fryback, Tracy A. Lieu, Grace M. Lee, David B. Martin
Research Article | published 23 Dec 2014 | PLOS ONE 10.1371/journal.pone.0115553

Vaccine (12 December 2014)

Volume 32, Issue 52, Pages 7033-7184 (12 December 2014)

Introducing cholera vaccination in Asia, Africa and Haiti: A meeting report
Pages 487-492
Robert H. Hall, David A. Sack
Orally-administered cholera vaccine (OCV) has been increasingly examined as an additional tool to intervene against endemic and epidemic cholera. In 2013, short- and long-term field experience with OCV under nine distinctive field settings was reported from India, Bangladesh, Vietnam, Guinea, Haiti, and Thailand. Lead investigators from each of these projects presented their findings at a symposium chaired by Drs. David A. Sack and Robert H. Hall at the Vaccines for Enteric Diseases (VED) Conference in Bangkok on November 7, 2013. The objective of the symposium was to describe the unique features of each setting and project, share field experience of implementing cholera vaccination, discuss results, and identify constraints to the wider use of OCV. The VED provided a forum where >200 attendees engaged with this exciting and potentially decisive new development in the cholera field.

Safety of quadrivalent human papillomavirus vaccine (Gardasil®) in pregnancy: Adverse events among non-manufacturer reports in the Vaccine Adverse Event Reporting System, 2006–2013
Original Research Article
Pages 519-522
Pedro L. Moro, Yenlik Zheteyeva, Paige Lewis, Jing Shi, Xin Yue, Oidda I. Museru, Karen Broder
In 2006, quadrivalent human papillomavirus (HPV4; Gardasil, Merck & Co., Inc.) vaccine was licensed in the US for use in females aged 9–26 years. HPV4 is not recommended during pregnancy; however, inadvertent administration during pregnancy may occur.
To evaluate and summarize reports to the Vaccine Adverse Event Reporting System (VAERS) in pregnant women who received HPV4 vaccine and assess for potentially concerning adverse events among non-manufacturer reports.
We searched the VAERS database for non-manufacturer reports of adverse events (AEs) in pregnant women who received HPV4 vaccine from 6/1/2006 to 12/31/2013. We conducted clinical review of reports and available medical records.
We found 147 reports after HPV4 vaccine administered to pregnant women. The most frequent pregnancy-specific AE was spontaneous abortion in 15 (10.2%) reports, followed by elective terminations in 6 (4.1%). Maternal fever was the most frequent non-pregnancy-specific AE in 3 reports. Two reports of major birth defects were received. No maternal deaths were noted. One hundred-three (70.1%) reports did not describe an AE.
This review of VAERS non-manufacturer reports following vaccination with HPV4 in pregnancy did not find any unexpected patterns in maternal or fetal outcomes.

From Google Scholar [to 3 January 2015]

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

Contemporary Clinical Trials
Available online 29 December 2014
Hepatitis C vaccine clinical trials among people who use drugs: potential for participation and involvement in recruitment
April M. Younga, b, Dustin B. Stephensc, Hanan A. Khaleela, Jennifer R. Havensb, c
Candidate prophylactic HCV vaccines are approaching phase III clinical trial readiness, yet little is known about the potential for participation among target groups or innovative ways to promote enrollment within ‘hard-to-reach’ populations. This study describes HCV vaccine trial participation willingness among a high-risk sample of people who use drugs and their willingness to assist researchers by promoting the trial among peers. Willingness to participate in and encourage peers’ participation in an HCV vaccine trial was assessed among injection and non-injection drug users enrolled in a cohort study in Kentucky using interviewer-administered questionnaires (n = 165 and 415, respectively, with willingness to participate assessed among HCV-seronegative participants only). Generalized linear mixed models were used to determine correlates to being “very likely” to participate or encourage participation in a trial. Most reported being likely to participate or encourage participation in a vaccine trial (63% and 87%, respectively). Men were significantly less likely to report willingness to encourage others’ participation, while willingness to encourage was higher among HCV-seropositive participants. Unemployment, lesser education, receipt of financial support from more peers, and nonmedical prescription drug use were positively associated with willingness to participate, as were heroin and methamphetamine use. Differential enrollment in HCV vaccine clinical trials by socioeconomic status may occur, underscoring ethical considerations and need for avoiding coercion. Notably, the data suggest that a peer-driven approach to promoting trial participation among people who use drugs could be feasible in this population and that HCV-seropositive individuals and women could be especially instrumental in these efforts.
Phil. Transactions of The Royal Society B
369: 20130426.
After 2015: infectious diseases in a new era of health and development
Christopher Dye
Running over timescales that span decades or centuries, the epidemiological transition provides the central narrative of global health. In this transition, a
reduction in mortality is followed by a reduction in fertility, creating larger, older populations in which the main causes of illness and death are no longer
acute infections of children but chronic diseases of adults. Since the year 2000, the Millennium Development Goals (MDGs) have provided a framework for
accelerating the decline of infectious diseases, backed by a massive injection of foreign investment to low-income countries. Despite the successes of the
MDGs era, the inhabitants of low-income countries still suffer an enormous burden of disease owing to diarrhoea, pneumonia, HIV/AIDS, tuberculosis,
malaria and other pathogens. Adding to the predictable burden of endemic disease, the threat of pandemics is ever-present and global. With a view to the
future, this review spotlights five aspects of the fight against infection beyond 2015, when the MDGs will be replaced by a new set of goals for poverty reduction and sustainable development. These aspects are: exploiting the biological links between infectious and non-infectious diseases; controlling infections among the new urban majority; enhancing the response to international health threats; expanding childhood immunization programmes to prevent acute and chronic diseases in adults; and working towards universal health coverage.
PLos One
Research Article
Pharmacokinetic Correlates of the Effects of a Heroin Vaccine on Heroin Self-Administration in Rats
Michael D. Raleigh mail, Paul R. Pentel, Mark G. LeSage
Published: December 23, 2014
DOI: 10.1371/journal.pone.0115696
The purpose of this study was to evaluate the effects of a morphine-conjugate vaccine (M-KLH) on the acquisition, maintenance, and reinstatement of heroin self-administration (HSA) in rats, and on heroin and metabolite distribution during heroin administration that approximated the self-administered dosing rate. Vaccination with M-KLH blocked heroin-primed reinstatement of heroin responding. Vaccination also decreased HSA at low heroin unit doses but produced a compensatory increase in heroin self-administration at high unit doses. Vaccination shifted the heroin dose-response curve to the right, indicating reduced heroin potency, and behavioral economic demand curve analysis further confirmed this effect. In a separate experiment heroin was administered at rates simulating heroin exposure during HSA. Heroin and its active metabolites, 6-acetylmorphine (6-AM) and morphine, were retained in plasma and metabolite concentrations were reduced in brain in vaccinated rats compared to controls. Reductions in 6-AM concentrations in brain after vaccination were consistent with the changes in HSA rates accompanying vaccination. These data provide evidence that 6-AM is the principal mediator of heroin reinforcement, and the principal target of the M-KLH vaccine, in this model. While heroin vaccines may have potential as therapies for heroin addiction, high antibody to drug ratios appear to be important for obtaining maximal efficacy.

Media/Policy Watch [to 3 January 2015]

Media/Policy Watch

Accessed 3 January 2014
Ebola outbreak: Liberia lifts curfew for New Year’s Eve
1 December 2014
Liberia has lifted a curfew imposed to curb Ebola in an effort to let church-goers attend New Year’s Eve services, a government official has said.
Worshippers should avoid over-crowding and touching to prevent contagion, the deputy information minister said.
Health agencies did not comment directly on the one-night suspension, but warned against complacency.
Liberia’s government had hoped for an Ebola-free Christmas, but the disease has continued to claim lives.
The virus has killed nearly 8,000 people, mostly in Sierra Leone, Liberia and Guinea, where it was first identified in March.
‘Great concern’
Liberia’s President Ellen Johnson-Sirleaf had ordered the lifting of the curfew so that the traditional New Year’s Eve services could be held, Isaac Jackson, the deputy information minister, told the BBC…

Accessed 3 January 2014
Are Placebos Ethical In Ebola Trials?
As more potential treatments for Ebola become available, there is increasing debate about the best clinical trial design to show benefit. There are as many viewpoints as there are ethicists and writers, about what is an appropriate strategy. Last month’s Advancing Ethical Research meeting, sponsored by Public Responsibility in Medicine and […]
Judy Stone, Contributor Dec 30, 2014

The Guardian
Accessed 3 January 2014
British Ebola nurse in critical condition, hospital says
Lisa O’Carroll and agencies
Saturday 3 January 2015 12.23 EST
Pauline Cafferkey’s condition deteriorates as another person with symptoms of disease after travel to west Africa is tested
The condition of the British nurse diagnosed with Ebola has deteriorated and is now critical, the Royal Free hospital in north London has said.
Pauline Cafferkey, a Scottish public health nurse who had been volunteering in Sierra Leone, was diagnosed with the virus after returning to Glasgow via Casablanca in Morocco…

New York Times
Accessed 3 January 2014
How Ebola Roared Back
DEC. 29, 2014
For a fleeting moment last spring, the epidemic sweeping West Africa might have been stopped. But the opportunity to control the virus, which has now caused more than 7,800 deaths, was lost….

Wall Street Journal,us&_homepage=/home/us
Accessed 3 January 2014
Africa News
After Slow Ebola Response, WHO Seeks to Avoid Repeat
Health Body to Consider Rapid-Response Teams, Other Changes
By Betsy McKay in Atlanta and Peter Wonacott in Freetown, Sierra Leone
The tepid initial response to West Africa’s Ebola outbreak exposed holes in the global health system so gaping it has prompted the World Health Organization to consider steps to prevent a repeat, including emergency-response teams and a fund for public-health crises…

Ebola/EVD: Additional Coverage [to 3 January 2015]

Ebola/EVD: Additional Coverage

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 3 January 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.

:: 02 Jan 2015 UNMEER External Situation Report
Key Political and Economic Developments
1. SRSG Banbury concluded his farewell visit to the three most affected countries in Sierra Leone from 30 to 31 December. He travelled to Bombali District, where he met with members of the District Ebola Response Center and visited three Ebola Treatment Units as well asa Community Care Center. He also met with President Ernest Bai Koroma in Freetown to commend him for his leadership and engagement on the Ebola crisis. . The President thanked UNMEER for the support provided to date, noting its positive impact on the ground. He expressed his hope that Sierra Leone, with the support of the international community, will be able to fully contain the Ebola outbreak by mid-2015 and pursue the economic agenda that had been set.
2. In his New Year’s Day Address, President Ernest Bai Koroma called on the country to begin a week of fasting and prayers to end the Ebola outbreak. The President urged people not to touch the sick or corpses and not to disobey quarantine orders. The President also indicated that schools, which have been closed since July due to the outbreak, would reopen soon.
Resource Mobilisation
11. The OCHA Ebola Virus Outbreak Overview of Needs and Requirements, now totaling USD 1.5 billion, has been funded for USD 1.1 billion, which is around 74% of the total ask.
12. The Ebola Response Multi-Partner Trust

:: 31 Dec 2014 UNMEER External Situation Report
Key Political and Economic Developments
1. On 29 December, the Prime Minister of Guinea visited the construction site of the new centre for epidemiological research and microbiology funded by the Russian aluminum company Rusal in Kindia. The centre will become part of the Institut Pasteur de Guinée which has secured funding from the Institut Pasteur in France and the French Government to enhance its capacity for surveillance, detection and prevention of infectious diseases in Guinea and the sub-region.
2. On 30 December, three national trade unions in Guinea issued a statement requesting that the government decrease the retail price of gasoline and fuel to reflect the drop in the price of oil in the global market. They have also urged the government to honour its pledges concerning the revised pay scale of civil servants and retirees. This request comes at a time when six other trade unions have threatened to launch
Response Efforts and Health
5. To support the Government of Sierra Leone’s response to the EVD outbreak, the World Bank and UNFPA have designed a joint project to reinforce and scale-up contact tracing, so as to strengthen the existing surveillance system.
7. In Liberia, WHO has identified the growing need for more disaggregated epidemiological data on children affected by the Ebola crisis for cross-cluster planning. Other vulnerable groups (patients, affected families, the elderly and the disabled) should also be considered.
Outreach and Education
16. In Guinea, the prefect of Lola prefecture conducted a sensitization mission in the village of Thuo on 30 December to address community resistance. Thuo has seen a flare-up of EVD cases in the past ten days and 2 new suspected cases were transferred today to the ETC in Nzérékoré. Members of the local community have reportedly threatened EVD response partners who have mostly left the area due to the tensions. The return of response partners is pending the outcome of the prefect’s mission. Save the Children has begun identifying 40 children in Thuo who have lost one or both parents to EVD with the aim of providing protection, but they will only deploy after a lifting of community resistance in Thuo.
17. Similarly, on 29 December, the prefectural coordination in Nzérékoré prefecture, Guinea, deployed a sensitization mission to the resistant communities of Banzou North and Zeremouda. The mission faced difficulties in engaging in dialogue with the members of the local community in both areas. UNMEER’s FCM covering Nzérékoré is following up to ascertain the reasons for resistance in these specific communities.
Essential Services
19. In Sierra Leone, the World Bank and UNFPA have developed a joint project to support the Government of Sierra Leone to establish appropriate arrangements to revitalize Reproductive, Maternal, Adolescent and Newborn Health (RMANH) services in the context of Ebola.
20. In Liberia, the Ministry of Health with support from UNFPA is conducting fistula prevention awareness in two counties (Margibi and Grand Bassa). UNFPA also hired a local NGO (Liberia Prevention Maternal Mortality) to conduct Maternal and Newborn Health (MNH) needs assessments in 20 health facilities in four Counties (Montserrado, Cape Mount, Margibi and Grand Bassa).

:: 30 Dec 2014 UNMEER External Situation Report
Key Political and Economic Developments
2. The Minister of Health of Guinea is continuing his sensitization and oversight mission in EVD affected prefectures. On 27 December, the minister took part in the prefectural coordination meeting in Nzérékoré, attended by the main response partners. The prefectural coordinator gave a briefing on the current situation, highlighting challenges including persistent resistance in communities in Sadou, Banzou North, Baya and Zenemouda; insufficient supply of thermo flash thermometers; lack of equipment and electricity; lack of an office for the prefectural coordination; and weak coordination among response partners. Concerning local resistance, the minister advised that partners must enable community members to take ownership of the sensitization process to engage their respective communities. Concerning the Community Watch Committees (CWCs), response partners briefed the minister that a number have been established but their members have not yet received training and are not operational. The minister stressed that partners involved with the CWCs had to work faster and he warned that alternative measures would be taken in case partners could not deliver on the operationalization of CWCs. He also encouraged response partners to better integrate their activities under the umbrella of the prefectural coordination and to increase their actions in the field where flare-ups and resistance are persistent.
Response Efforts and Health
4. UNDP has made additional incentive payments to 758 health personnel working in four ETUs in Guinea, ensuring their continued engagement in saving patients. The agency was requested by Guinea’s National Coordination Unit against Ebola to complete existing salaries with incentive pays for the French Red Cross, Doctors without Borders and Alima, three Non-Governmental Organizations (NGOs) operating ETUs in Donka, Macenta, Kissidougou and Nzérékoré. Together with UNMEER and the World Bank, UNDP assisted the Ministry of Health in harmonizing incentives, and ensured that US$ 220,000 were deposited in local banks.

:: 29 Dec 2014 UNMEER External Situation Report
– A field hospital donated by Israel will be established as an Ebola Treatment Unit (ETU) in Dubreka, Guinea.
– UNICEF joined partners in engaging the population of the quarantined and neighboring villages of Lonfaye town and Yekepa town, Liberia, following two separate outbreaks there.
– In response to measles cases in Lofa county, Liberia, the UNICEF-supported periodic intensification of routine immunization, or PIRI, is ongoing across all of the 15 counties.
Response Efforts and Health
3. On 26 December, the National Ebola Response Coordinator informed UNMEER that a field hospital donated by Israel would be established as an ETU in Dubreka, Guinea. He added that the target opening date was 15 January. This ETU and the one in Coyah will help relieve the caseload on the ETU in Conakry (Donka) coming from prefectures adjacent to the capital.
4. According to recent data from the Liberian health ministry, there have been at least 1,042 confirmed cases of children with EVD in the country. The number of children identified by name and location as orphaned by EVD is 4,115. All of the children identified are currently receiving follow-up and psychosocial support. Over 250 volunteer contact tracers, trained and engaged by UNICEF, are now reporting cases of children orphaned or otherwise affected by EVD. UNICEF is working to ensure that children who have lost their parents due to EVD continue to receive care through a kinship arrangement. That way children may be from becoming institutionalized, for example in an orphanage.
Essential Services
15. West Africa’s fight to contain EVD has hampered the campaign against malaria, which is a fully preventable and treatable disease. In Guéckédou, Guinea, doctors have had to stop pricking fingers to do blood tests for malaria. Bernard Nahlen, deputy director of the US President’s Malaria Initiative, said Guinea’s 40% drop in reported malaria cases this year is likely because people are too scared to go to health facilities and are not getting treated for malaria. Nets for Life Africa, a New York-based charity that provides insecticide-treated mosquito nets, said some 15,000 Guineans died from malaria last year.
16. In response to measles cases in Lofa county, Liberia, the UNICEF-supported periodic intensification of routine immunization, or PIRI, is ongoing across all 15 counties. The goal is to rapidly reduce the number of unimmunized children against measles. This intensification comes in lieu of an immunization campaign, which is not recommended in the EVD context. Vaccinators are being trained simultaneously across the country on infection prevention and control measures, supervision during PIRI and on how to conduct outreach sessions in remote areas. In addition, UNICEF provided basic infection control kits, including infrared thermometers, to 500 health facilities providing immunization services in Liberia.

:: 26 Dec 2014 UNMEER External Situation Report
Key Political and Economic Developments
1. Sierra Leone has declared a lockdown of at least three days in the north of the country to try to contain an EVD flare-up there. Response workers will go door to door to look for suspected cases of EVD. Shops, markets and travel services will be shut down. Sierra Leone had already banned many public Christmas celebrations. Alie Kamara, resident minister for the Northern Region, indicated that “muslims and christians are not allowed to hold services in mosques and churches throughout the lockdown, except for christians on Christmas day”. No unauthorized vehicles will be allowed to operate, except those officially assigned to EVD-related assignments. The lockdown is scheduled to last for at least three days, but this could be extended if deemed necessary.
10. The Liberian health ministry has received permission from the World Bank to release funds for the payment of workers’ salaries to the counties. Unfortunately the pre-Christmas deadline was missed, but the plan to pay all workers in the counties through banks and off-site payments is being completed by the government. UNDP will support the teams financially and logistically to execute the payments, which are planned over several days and are expected to begin through the holiday period. Separately, funds that had been provided to banks in time were not paid to contact tracers and active case finders by the 23rd, due to banks’ liquidity issues. There were demonstrations at the health ministry as a result.
11. UNDP has received a request to pay more than 400 workers in Montserrado, Liberia, including staff of the newly established IMS for the county. UNDP, as a provider of last resort, will seek to ensure that all other avenues for payment have been exhausted before committing to these payments.
Essential Services
21. From 10-16 December, as part of the Integrated Management of Acute Malnutrition (IMAM), a total of 18,885 children under 5 were screened at the community level in 64 out of 149 chiefdoms (389 communities) in Sierra Leone. 506 were referred for treatment at the Peripheral Health Units that provide nutrition treatment services.

:: 24 Dec 2014 UNMEER External Situation Report
Key Political and Economic Developments
1. The director of the US Centers for Disease Control and Prevention (CDC), Dr. Tom Frieden, said on Monday that even though the number of cases in West Africa has not reached worst-case scenario predictions, the world remains at risk until it drops to zero. “I’m hopeful about stopping the epidemic, but I remain realistic that this is going to be a long, hard fight”, he said. On his recent visit to Liberia, Guinea and Sierra Leone, Dr. Frieden said he had seen “real momentum and real progress” in combating the virus. “I am hopeful that we are going to see continued progress. The challenge is not to let up, not to be complacent and to really double down”. Asked about the CDC’s report in September that in certain scenarios, EVD cases could reach 550,000 by January, Frieden replied: “The projections we released a few months ago showed what could happen if nothing more were done – in fact an enormous amount has been done.”
2. Peter Piot, a leading researcher who helped to discover EVD, has also said that the EVD crisis is likely to last until the end of 2015, warning that vaccines would take time to develop. Professor Piot was one of the scientists who discovered EVD in 1976 and is now director of the London School of Hygiene and Tropical Medicine. He said that even though the outbreak has peaked in Liberia and was likely to peak in Sierra Leone in the next few weeks, the epidemic could have a “very long tail and a bumpy tail”. Piot stated: “We need to be ready for a long effort, a sustained effort for probably the rest of 2015.” But he added that he was impressed by the progress that he had seen on a recent visit to Sierra Leone: “Treatment units have now been established across the country. You don’t see any longer the scenes where people are dying in the streets”.
Response Efforts and Health
5. A Nigerian peacekeeper diagnosed with EVD, who had been evacuated to the Netherlands for treatment, has recovered and has returned to the UN mission in Liberia. The peacekeeper will resume duties while undergoing monitoring and psychological counseling. The man arrived in the Netherlands earlier this month. The Netherlands has followed Germany, France and Switzerland in taking on EVD patients at the request of the World Health Organization.

:: 23 Dec 2014 UNMEER External Situation Report
Key Political and Economic Developments
1. The United Nations must learn lessons from the EVD crisis and begin preparing now for the next outbreak of a deadly disease, Secretary-General Ban Ki-moon said in New York after returning from a visit to West Africa. “We must learn the lessons of Ebola, which go well beyond strengthening public health systems”, Ban stated. “The international community needs better early warning and rapid response.” The UN chief said he will launch a serious effort to “explore what more we can do to stay ahead of the next outbreak of disease — a test that is sure to come.” Ban also called for recovery efforts to be stepped up in West Africa in order to rebuild shattered economies, get children back in school and begin caring for EVD orphans.
2. Sierra Leone is withdrawing its troops from Somalia after the African Union blocked the West African country from rotating its soldiers over fears for EVD. Sierra Leone sent 850 troops to Somalia in 2013 for a 12-month deployment to fight jihadist terrorist group al-Shabab. Their rotation was delayed after a group of 800 soldiers, who were waiting to replace their comrades in Somalia, were quarantined after one of the soldiers was tested positive for EVD. In August, Somalia’s President Hassan Sheikh Mohamud said no new troops from Sierra Leone will be deployed to his country after calls by activists and a campaign on social media by Somalis calling for a halt to the deployment.

:: 22 Dec 2014 UNMEER External Situation Report
Key Political and Economic Developments
1. United Nations Secretary-General Ban Ki-moon made a three-day tour of the region on Friday and Saturday, visiting Liberia, Sierra Leone, Guinea, Mali and Ghana. He met with the leaders of those countries as well as with survivors of Ebola Virus Disease (EVD), healthcare workers and UN staff. In Liberia, the SG participated in an Incident Management System (IMS) meeting with EVD response partners, where he discussed current trends and the next steps in the response. He warned against complacency at what remains a critical time. The Secretary-General also visited several treatment facilities. On his visits he was accompanied by the Director General of WHO, Dr. Margaret Chan, the UN Special Envoy on Ebola, Dr. David Nabarro, and the Head of UNMEER, Anthony Banbury.
2. In Guinea, Secretary-General Ban Ki-moon warned about rising EVD infection rates in the south-east of the country. While infection rates in Liberia, one of the nations hardest hit by the outbreak, have been slowing, other areas have registered an uptick in the rate of the disease’s progress. Infection rates in south-eastern Guinea, the region where the deadliest outbreak in history began a year ago, have also failed to decline substantially. Solid cross border collaboration is necessary to prevent a resurgence of the epidemic, Ban said in Conakry. The Secretary-General also warned of the serious socio-economic consequences the outbreak is likely to have in the affected countries. “While our immediate priority is to stop the spread of the disease, it is not too early to start thinking about recovery,” Ban said. “We must scale up our efforts to restore basic social services, strengthen health services, support economic activity and build up the countries’ resilience.”
3. In Sierra Leone, Ban Ki-moon met Rebecca Johnson, a Sierra Leonean nurse who caught the virus but survived. She recounted how she fell gravely ill, recovered and is now back treating EVD patients. Ban said he was moved by Johnson’s story, especially that she still faced a stigma as a survivor. “There should be no discrimination for those who have been working or helping with Ebola. Those people are giving all of themselves,” Ban said. He also made it clear that UNMEER is intended to be a short term mission: “My intention is not to keep UNMEER longer than one year. If that isn’t the case, people will regard it as a failure”.
Response Efforts and Health
6. Last week, in support of quarantined households in the Western Area of Sierra Leone, UNICEF has distributed 2,580 jerry cans, together with a 21-day supply of aqua tabs. To date, UNICEF has provided around 6,648 quarantined households with 23,720 jerry cans and 254,643 aqua tabs, benefiting 40,164 people in quarantined households and communities. Supplies have been distributed through WFP packages. UNICEF also delivered a total of 184,000 litres of safe water to two 100-bed EVD treatment centers, while setup work is ongoing in two new 24-bed Community Care Centers (CCCs) in the Western area. UNICEF, with its partners, has also ensured that 12 newly constructed CCCs were fully stocked with Water, Sanitation and Hygiene (WASH) packages.
7. In Sierra Leone, UNDP has supported the payment of hazard pay entitlements for 16,000 EVD workers in five days, through a mobile cash transfer system. With concurrent support to the government of Sierra Leone by UNDP, the World Bank and the African Development Bank, policy and guidelines are being drafted to streamline the system.
Outreach and Education
15. Last week, 8,220 households in Liberia were reached through door-to-door campaigns with EVD prevention messages as well as through 167 meetings and group discussions, reaching 13,787 women, 11,142 men and 8,912 children across all counties. 675 community leaders and elders were engaged.
16. In the first week of December, 1,414 social mobilizers were trained by UNICEF in Sierra Leone. 48% were women and 44% were less than 25 years old. Participants were trained on topics including infection prevention and control, home protection, safe burial practices, and quarantined households. 370 religious leaders and 65 paramount chiefs were sensitized to support social mobilization activities in 8 districts. Social mobilizers engaged by partners reached 5,867 households to disseminate key messages and sensitize the community.