Cost Effectiveness and Resource Allocation
(Accessed 14 February 2015)
http://www.resource-allocation.com/

Research
Revisiting the cost-effectiveness of universal HPV-vaccination in Denmark accounting for all potentially vaccine preventable HPV-related diseases in males and females
Olsen J and Jørgensen TR Cost Effectiveness and Resource Allocation 2015, 13:4 (11 February 2015)
Abstract (provisional)
Objective
The purpose of this study was to assess the consequences of a national immunization program with HPV vaccine for both boys and girls in Denmark, including the prophylactic effects on all potentially vaccine preventable HPV-associated diseases in male and female.
Methods
The study focussed on the quadrivalent vaccine which protects against HPV type 6, 11, 16 and 18, and the vaccine’s protection against genital warts, cervical intraepithelial neoplasia, cervical cancer, anogenital cancer (anal, penile, vaginal and vulvar cancer) and head and neck cancer (oral cavity, oropharyngeal, hypopharyngeal and laryngeal cancer) were included in the analyses. In general, the analysis was performed in two phases. First, an agent-based transmission model that described the HPV transmission without and with HPV vaccination was applied. Second, an analysis of the incremental costs and effects was performed. The model did not include naturally-acquired immunity to HPV in the simulations.
Results
In the base case result (i.e. vaccination of girls only, 85% vaccination rate, private market price at ? 123 per dose ex. VAT) an ICER of 3583 ?/QALY (3-dose regime) is estimated when all HPV-related diseases are taken into account. Vaccination of girls & boys vs. vaccination of girls only an ICER of 28,031 ?/QALY (2-dose regime) and 41,636 ?/QALY (3-dose regime) is estimated.
Conclusions
Extension of the current HPV programme in Denmark to include boys and girls is a cost effective preventive intervention that would lead to a faster prevention of cancers, cancer precursors and genital warts in men and women.

Eurosurveillance
Volume 20, Issue 6, 12 February 2015
http://www.eurosurveillance.org/Public/Articles/Archives.aspx?PublicationId=11678

Surveillance and outbreak reports
Surveillance of infant pertussis in Sweden 1998–2012; severity of disease in relation to the national vaccination programme
by RM Carlsson, K von Segebaden, J Bergström , AM Kling, L Nilsson

Review articles
Timeliness of epidemiological outbreak investigations in peer-reviewed European publications, January 2003 to August 2013
by EC van de Venter, I Oliver, JM Stuart

Globalization and Health
[Accessed 14 February 2015]
http://www.globalizationandhealth.com/

Debate
Strengthening health systems in low-income countries by enhancing organizational capacities and improving institutions
Swanson RC, Atun R, Best A, Betigeri A, de Campos F, Chunharas S, Collins T, Currie G et al. Globalization and Health 2015, 11:5 (12 February 2015)

Research
Maternal mortality: a cross-sectional study in global health
Sajedinejad S, Majdzadeh R, Vedadhir AA, Tabatabaei MG and Mohammad K Globalization and Health 2015, 11:4 (12 February 2015)

Infectious Diseases of Poverty
[Accessed 14 February 2015]
http://www.idpjournal.com/content

Research Article
An ecohealth assessment of poultry production clusters (PPCs) for the livelihood and biosecurity improvement of small poultry producers in Asia
Libin Wang, Edi Basuno, Tuan Nguyen, Worapol Aengwanich, Nyak Ilham and Xiaoyun Li
Infectious Diseases of Poverty 2015, 4:6 doi:10.1186/2049-9957-4-6
Published: 9 February 2015
Abstract (provisional)
Background
Poultry production cluster (PPC) programs are key strategies in many Asian countries to engage small commercial poultry producers in high-value production chains and to control infectious poultry diseases. This study assessed the multiple impacts of PPCs through a transdisciplinary ecohealth approach in four Asian countries, and drew the implications for small producers to improve their livelihoods and reduce the risk of spreading infectious diseases in the poultry sector.
Methods
The data collection combined both quantitative and qualitative methods. It comprised: formal structured household survey questionnaires, measuring the biosecurity level of poultry farms with a biosecurity score card; and key informant interviews. Descriptive statistics were used to process the quantitative data and a content analysis was used to process the qualitative data.
Results
This research found that poultry farms in clusters do not necessarily have better economic performance than those outside PPCs. Many farmers in PPCs only consider them to be an advantage for expanding the scale of their poultry operations and improving household incomes, and they are less concerned about–and have limited capacities to–enhancing biosecurity and environmental management. We measured the biosecurity level of farms in PPCs through a 14-item checklist and found that biosecurity is generally very low across all sample sites. The increased flies, mosquitoes, rats, and smells in and around PPCs not only pollute the environment, but also cause social conflicts with the surrounding communities.
Conclusion
This research concluded that a poultry cluster, mainly driven by economic objectives, is not necessarily a superior model for the control of infectious diseases. The level of biosecurity in PPCs was found to be low. Given the intensity of poultry operations in PPCs (farms are densely packed into clusters), and the close proximity to residential areas of some PPCs, the risk of spreading infectious diseases, in fact, increases. Good management and collective action for implementing biosecurity measures are key for small producers in PPCs to address common challenges and pursue health-based animal production practices.

JAMA
February 10, 2015, Vol 313, No. 6
http://jama.jamanetwork.com/issue.aspx

Viewpoint | February 10, 2015
The 2014 Ebola Outbreak and Mental Health: Current Status and Recommended Response
FREE
James M. Shultz, MS, PhD1; Florence Baingana, MB, ChB, MMed (Psychiatry), MSc (HPPF)2; Yuval Neria, PhD3
Author Affiliations
JAMA. 2015;313(6):567-568. doi:10.1001/jama.2014.17934.

…CONCLUSIONS
Fear reactions are predictable and pervasive and may exacerbate disease spread in pandemic areas. Efforts to develop effective treatments and vaccines should be coupled with a response to help with efforts to control preventable viral transmission and support the psychological needs of the public overall as well as infected patients, family members, health care workers, and other responders. The West Africa pandemic provides insights into the psychological consequences associated with a “worst case scenario” event involving a highly virulent infectious disease. An effective response is essential both in West Africa to address the psychosocial needs associated with population-wide direct exposure to disease, death, and distress; and in the United States, to counterbalance fear-driven behaviors and policy making with prudent and effective preparedness for emerging infectious diseases.

The Lancet
Feb 14, 2015 Volume 385 Number 9968 p577-662 e7-e11
http://www.thelancet.com/journals/lancet/issue/current

Comment
Older people’s health in sub-Saharan Africa
Isabella A G Aboderin, John R Beard
Published Online: 05 November 2014
DOI: http://dx.doi.org/10.1016/S0140-6736(14)61602-0

Awareness is growing that the world’s population is rapidly ageing. Although much of the related policy debate is about the implications for high-income countries, attention is broadening to less developed settings.1 Middle-income country populations, in particular, are generally ageing at a much faster rate than was the case for today’s high-income countries, and the health of their older populations could be substantially worse.2 However, little consideration has been given to issues of old age in sub-Saharan Africa, which remains the world’s poorest and youngest region.3 Development and health agendas for that region, including those being discussed in relation to targets to succeed the Millennium Development Goals,4 understandably centre on how to increase the capacity of and opportunities for the region’s young people. Yet strong arguments exist for why the health of older people (aged 60 years and older) should not be overlooked. Not least is the substantial size of these populations—already double the number of older adults in northern Europe—which is expected to grow faster than anywhere else, increasing from 46 million in 2015 to 157 million by 2050.5 Furthermore, life expectancy at age 60 years in sub-Saharan Africa is 16 years for women and 14 years for men, suggesting that, for those who survive early life, a long old age is already a reality.2

However, perhaps the most important reason to consider the older population in present plans for increased human and economic wellbeing in sub-Saharan Africa is that, contrary to common assumptions, older Africans play roles that are crucial to achievement of this wellbeing. Within families, older people are often carers or guardians of younger kin. They directly shape younger generations’ access to health, education, and other capabilities, and thus their future human capital. The extent of older people’s caregiving is increasingly recognised in the context of HIV/AIDS—more than 60% of orphaned children in Namibia and Zimbabwe, for example, are looked after by their grandmothers.5 This care function is also important in everyday settings of poverty or labour-related parental absence—in the urban slums of Nairobi, Kenya, for instance, more than 30% of older women and 20% of older men (aged 60 years or older) care for one or more non-biological child (African Population and Health Research Center, Centre for Research on Ageing, University of Southampton, unpublished).

Beyond the family, older African people have key economic roles. In most sub-Saharan African countries, older people largely remain in the labour force,6 particularly in smallholder agriculture, which encompasses the bulk of food production and must be revitalised if nutrition security and sufficient job opportunities are to be ensured for younger generations. As a result of selective rural–urban outmigration, incapacity, or uninterest of younger adults in farming, older people constitute a substantial share of smallholders. In Kenya, for example, the average age of a farmer is estimated to be 60 years.7 Similarly, preliminary analyses of national survey data from Malawi and Kenya show close to 20% of decision makers on smallholder land use in both countries to be aged 60 years and older (African Population and Health Research Center, unpublished). The extent to which older African people can execute their social and economic functions effectively depends heavily on their physical and mental capacity.8, 9 Conversely, if their health deteriorates to a point at which they themselves need care, the responsibility is likely to fall on female younger kin, whose own health, and employment and education opportunities, can be affected.10 Impaired health in older age in sub-Saharan Africa thus affects not only older individuals, but families, communities, and prospects for development more broadly.

Yet older African people face a large morbidity and disability burden, particularly from chronic disease. Our preliminary analysis of 2010 Global Burden of Disease data identifies cardiovascular and circulatory disease, nutritional deficiencies, cirrhosis of the liver, and diabetes as major causes of disability-adjusted life years in sub-Saharan Africa’s older population. Moreover, representative surveys of older adults’ health show high rates of hypertension,11 musculoskeletal disease,12 visual impairment,13 functional limitations,9 and depression.14 Additionally, infectious diseases continue to affect older Africans, underscored by a substantial prevalence of HIV infection and its exacerbating effect on several non-communicable diseases.15 At the same time, evidence of heterogeneity in health and function within older populations and the importance of modifiable factors in shaping it underscore the importance of health-promoting interventions to enable successful ageing in the region.16 Yet a large proportion of, or even most, older Africans lack the requisite care—results of the WHO Study on Adult Health and Ageing11 in Ghana, for example, showed 96% of those with hypertension to have no adequate treatment for the disorder.

A crucial but often omitted perspective is a comparison with younger age groups. Illness and disability rates of older people substantially outstrip those of younger adults.17, 18 This contrasts starkly with findings from high-income countries that show older age to be an increasingly unreliable predictor of greater morbidity or impaired function.19 Yet, despite having worse health than younger age groups, older people in sub-Saharan Africa have been observed to use health services substantially less than younger people do.17, 18 This disparity points to possible age-based inequalities in access to health care that need attention in addition to the widely considered axes of inequities in health (ie, economic status, sex, ethnic origin, or rural or urban residence).

Barriers to health care faced by older African people include absence of an escort or high costs of transport to health providers, and private sector fees for medicines or treatment.18, 20 Older patients use commercial providers because of the unavailability, perceived poor quality, or age insensitivity of services in government facilities.18 These providers, in a bid to achieve the health Millennium Development Goals, typically remain focused on services for infectious diseases, children, and reproductive age adults.18, 20 The supply-side difficulties are exacerbated by important demand-side factors. Such obstacles include resource allocation norms within poor families, which can prioritise the needs of the young at the expense of the old, and older adults’ often little appreciation of the value of, or need for, management of asymptomatic chronic disease.18, 20

In view of the direct importance of older African people’s physical and mental health for the achievement of core development goals, their burden of ill health and likely inequitable access to necessary care provide compelling economic and social grounds for action. These needs should be incorporated into emergent frameworks for attainment of universal health coverage in sub-Saharan Africa in the form of a commitment to maintenance of health and function across the entire life course. Essential action on non-communicable diseases, in particular, will need to extend beyond a focus on prevention of early mortality from key diseases to include provision of chronic care for key non-fatal disorders that affect the function of older populations. However, such a commitment will need to be accompanied by concerted evidence generation if it is to be converted into practice. Such research will need to: better define health needs and care gaps for older Africans; identify feasible and effective models for adaptation of health systems in sub-Saharan Africa; and persuade decision makers to invest in these models.
Longitudinal studies such as the WHO Study on Adult Health and Ageing or 10/66 dementia research are starting to improve understanding of priority intervention needs in a small number of sub-Saharan African countries. However, further social and epidemiological investigations are needed in these and other national contexts. These studies will need to be complemented by assessments of effectiveness of the few existing health financing, human resource, essential medicine or technology, and service delivery approaches targeted at older people in sub-Saharan Africa, and by design and testing of new models.

Lastly, national evidence on possible age-based health inequities and economic effects of ill health in the older population is needed to help garner political will for action. Such information could be generated—as part of the called-for data revolution for the post-Millennium Development Goals agenda—through systematic expansions to sampling, data collection, or analysis protocols of routine surveys, such as Demographic and Health Surveys, regularly undertaken by countries in sub-Saharan Africa. The fact that developing-country governments have launched a joint Commission on Ageing in Developing Countries bodes well. This Commission should help promote the necessary research and operationalisation of emerging findings by policy makers and external drivers of health-system development in sub-Saharan Africa.
We declare no competing interests.
References
Bloom, DE, Börsch-Supan, A, McGee, P, and Seike, A. Population ageing: macro challenges and policy responses. in: JR Beard, S Biggs, DE Bloom, (Eds.) Global ageing: peril or promise?World Economic Forum, Geneva; 2012: 35–38
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WHO. Good health adds life to years. Global brief for World Health Day 2012. World Health Organization, Geneva; 2012
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UN Population Division. World population prospects: the 2012 revision. http://esa.un.org/unpd/wpp/index.htm. ((accessed Dec 20, 2013).)
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UN Economic Commission for Africa. Africa regional consultative meeting on the sustainable development goals. Outcome document. United Nations Economic Commission for Africa, Addis Ababa; 2013
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Olwande, J and Mathenge, M. Market participation among poor rural households in Kenya. Tegemeo Institute of Agricultural Policy and Development, Nairobi; 2011
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Skovdal, M, Campbell, C, Madanhire, C, Nyamukapa, C, and Gregson, S. Challenges faced by elderly guardians in sustaining the adherence to antiretroviral therapy in HIV-infected children in Zimbabwe. AIDS Care. 2011; 23: 957–964
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Payne, CF, Mkandawire, J, and Kohler, HP. Disability transitions and health expectancies among adults 45 years and older in Malawi: a cohort-based model. PLoS Med. 2013; 10: e1001435
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Aboderin I, Hoffman J. Care for dependent older people in sub-Saharan Africa: recognizing and addressing a “cultural lag”. 20th International Association of Gerontology and Geriatrics World Congress of Gerontology and Geriatrics; Seoul, South Korea; June 23–27, 2013.
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Lloyd-Sherlock, P, Beard, J, Minicuci, N, Ebrahim, S, and Chatterji, S. Hypertension among older adults in low and middle income countries: prevalence, awareness and control. Int J Epidemiol. 2014; 43: 116–128
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Clausen, T, Romøren, TI, Ferreira, M, Kristensen, P, Ingstad, B, and Holmboe-Ottensen, G. Chronic diseases and health inequalities in older persons in Botswana (southern Africa): a national survey. J Nutr Health Aging. 2005; 9: 455–461
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Bekibele, CO and Gureje, O. Self-reported visual impairment and impact on vision-related activities in an elderly Nigerian population: report from the Ibadan Study of Ageing. Ophthalmic Epidemiol. 2008; 15: 250–256
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Gureje, O, Kola, L, and Afolabi, E. Epidemiology of major depressive disorder in elderly Nigerians in the Ibadan Study of Ageing: a community-based survey. Lancet. 2007; 370: 957–964
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Mills, EJ, Barnighausen, T, and Negin, J. HIV and aging—preparing for the challenges ahead. N Engl J Med. 2012; 366: 1270–1273
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Gureje, O, Oladeji, BD, Abiona, T, and Chatterji, S. Profile and determinants of successful aging in the Ibadan Study of Ageing. J Am Geriatr Soc. 2014; 62: 836–842
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McIntyre, D. Health policy and older people in Africa. in: P Lloyd-Sherlock (Ed.) Living longer. Ageing, development and social protection. Zed Books, London; 2004: 160–183
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Aboderin, I and Kizito, P. Dimensions and determinants of health in old age in Kenya. National Coordinating Agency for Population and Development, Nairobi; 2010
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The Lancet
Feb 14, 2015 Volume 385 Number 9968 p577-662 e7-e11
http://www.thelancet.com/journals/lancet/issue/current

Articles
A population-based, multifaceted strategy to implement antenatal corticosteroid treatment versus standard care for the reduction of neonatal mortality due to preterm birth in low-income and middle-income countries: the ACT cluster-randomised trial
Dr Fernando Althabe, MD, José M Belizán, MD, Elizabeth M McClure, PhD, Jennifer Hemingway-Foday, MPH, Mabel Berrueta, MD, Agustina Mazzoni, MD, Alvaro Ciganda, BIT, Prof Shivaprasad S Goudar, MD, Prof Bhalachandra S Kodkany, MD, Prof Niranjana S Mahantshetti, MD, Prof Sangappa M Dhaded, DM, Geetanjali M Katageri, MD, Prof Mrityunjay C Metgud, MD, Anjali M Joshi, BAMS, Prof Mrutyunjaya B Bellad, MD, Narayan V Honnungar, MBBS, Prof Richard J Derman, MD, Sarah Saleem, MBBS, Omrana Pasha, MD, Sumera Ali, MD, Farid Hasnain, PhD,
Prof Robert L Goldenberg, MD, Fabian Esamai, MBChB, Paul Nyongesa, MD, Silas Ayunga, MD, Edward A Liechty, MD, Ana L Garces, MD, Lester Figueroa, MD, Prof K Michael Hambidge, MD, Nancy F Krebs, MD, Prof Archana Patel, MD, Anjali Bhandarkar, MD, Manjushri Waikar, MD, Prof Patricia L Hibberd, MD, Prof Elwyn Chomba, MD, Prof Waldemar A Carlo, MD, Angel Mwiche, MD, Melody Chiwila, RN, Albert Manasyan, MD, Sayury Pineda, MD, Sreelatha Meleth, PhD, Vanessa Thorsten, MPH, Kristen Stolka, MPH, Dennis D Wallace, PhD, Marion Koso-Thomas, MD, Prof Alan H Jobe, MD, Prof Pierre M Buekens, MD
Published Online: 15 October 2014
DOI: http://dx.doi.org/10.1016/S0140-6736(14)61651-2
Summary
Background
Antenatal corticosteroids for pregnant women at risk of preterm birth are among the most effective hospital-based interventions to reduce neonatal mortality. We aimed to assess the feasibility, effectiveness, and safety of a multifaceted intervention designed to increase the use of antenatal corticosteroids at all levels of health care in low-income and middle-income countries.
Methods
In this 18-month, cluster-randomised trial, we randomly assigned (1:1) rural and semi-urban clusters within six countries (Argentina, Guatemala, India, Kenya, Pakistan, and Zambia) to standard care or a multifaceted intervention including components to improve identification of women at risk of preterm birth and to facilitate appropriate use of antenatal corticosteroids. The primary outcome was 28-day neonatal mortality among infants less than the 5th percentile for birthweight (a proxy for preterm birth) across the clusters. Use of antenatal corticosteroids and suspected maternal infection were additional main outcomes. This trial is registered with ClinicalTrials.gov, number NCT01084096.
Findings
The ACT trial took place between October, 2011, and March, 2014 (start dates varied by site). 51 intervention clusters with 47 394 livebirths (2520 [5%] less than 5th percentile for birthweight) and 50 control clusters with 50 743 livebirths (2258 [4%] less than 5th percentile) completed follow-up. 1052 (45%) of 2327 women in intervention clusters who delivered less-than-5th-percentile infants received antenatal corticosteroids, compared with 215 (10%) of 2062 in control clusters (p<0•0001). Among the less-than-5th-percentile infants, 28-day neonatal mortality was 225 per 1000 livebirths for the intervention group and 232 per 1000 livebirths for the control group (relative risk [RR] 0•96, 95% CI 0•87–1•06, p=0•65) and suspected maternal infection was reported in 236 (10%) of 2361 women in the intervention group and 133 (6%) of 2094 in the control group (odds ratio [OR] 1•67, 1•33–2•09, p<0•0001). Among the whole population, 28-day neonatal mortality was 27•4 per 1000 livebirths for the intervention group and 23•9 per 1000 livebirths for the control group (RR 1•12, 1•02–1•22, p=0•0127) and suspected maternal infection was reported in 1207 (3%) of 48 219 women in the intervention group and 867 (2%) of 51 523 in the control group (OR 1•45, 1•33–1•58, p<0•0001).
Interpretation
Despite increased use of antenatal corticosteroids in low-birthweight infants in the intervention groups, neonatal mortality did not decrease in this group, and increased in the population overall. For every 1000 women exposed to this strategy, an excess of 3•5 neonatal deaths occurred, and the risk of maternal infection seems to have been increased.
Funding
Eunice Kennedy Shriver National Institute of Child Health and Human Development.

The Lancet
Feb 14, 2015 Volume 385 Number 9968 p577-662 e7-e11
http://www.thelancet.com/journals/lancet/issue/current

Series
Subjective wellbeing, health, and ageing
Prof Andrew Steptoe, DPhil, Prof Angus Deaton, PhD, Prof Arthur A Stone, PhD
Published Online: 05 November 2014
DOI: http://dx.doi.org/10.1016/S0140-6736(13)61489-0
Summary
Subjective wellbeing and health are closely linked to age. Three aspects of subjective wellbeing can be distinguished—evaluative wellbeing (or life satisfaction), hedonic wellbeing (feelings of happiness, sadness, anger, stress, and pain), and eudemonic wellbeing (sense of purpose and meaning in life). We review recent advances in the specialty of psychological wellbeing, and present new analyses about the pattern of wellbeing across ages and the association between wellbeing and survival at older ages. The Gallup World Poll, a continuing survey in more than 160 countries, shows a U-shaped relation between evaluative wellbeing and age in high-income, English speaking countries, with the lowest levels of wellbeing in ages 45–54 years. But this pattern is not universal. For example, respondents from the former Soviet Union and eastern Europe show a large progressive reduction in wellbeing with age, respondents from Latin America also shows decreased wellbeing with age, whereas wellbeing in sub-Saharan Africa shows little change with age. The relation between physical health and subjective wellbeing is bidirectional. Older people with illnesses such as coronary heart disease, arthritis, and chronic lung disease show both increased levels of depressed mood and impaired hedonic and eudemonic wellbeing. Wellbeing might also have a protective role in health maintenance. In an analysis of the English Longitudinal Study of Ageing, we identify that eudemonic wellbeing is associated with increased survival; 29•3% of people in the lowest wellbeing quartile died during the average follow-up period of 8•5 years compared with 9•3% of those in the highest quartile. Associations were independent of age, sex, demographic factors, and baseline mental and physical health. We conclude that the wellbeing of elderly people is an important objective for both economic and health policy. Present psychological and economic theories do not adequately account for the variations in patterns of wellbeing with age across different parts of the world. The apparent association between wellbeing and survival is consistent with a protective role of high wellbeing, but alternative explanations cannot be ruled out at this stage.

.
Series
Macroeconomic implications of population ageing and selected policy responses
Prof David E Bloom, PhD, Somnath Chatterji, MD, Paul Kowal, PharmD, Peter Lloyd-Sherlock, PhD, Prof Martin McKee, DSc, Bernd Rechel, PhD, Larry Rosenberg, MPA, James P Smith, PhD
Published Online: 05 November 2014
DOI: http://dx.doi.org/10.1016/S0140-6736(14)61464-1
Summary
Between now and 2030, every country will experience population ageing—a trend that is both pronounced and historically unprecedented. Over the past six decades, countries of the world had experienced only a slight increase in the share of people aged 60 years and older, from 8% to 10%. But in the next four decades, this group is expected to rise to 22% of the total population—a jump from 800 million to 2 billion people. Evidence suggests that cohorts entering older age now are healthier than previous ones. However, progress has been very uneven, as indicated by the wide gaps in population health (measured by life expectancy) between the worst (Sierra Leone) and best (Japan) performing countries, now standing at a difference of 36 years for life expectancy at birth and 15 years for life expectancy at age 60 years. Population ageing poses challenges for countries’ economies, and the health of older populations is of concern. Older people have greater health and long-term care needs than younger people, leading to increased expenditure. They are also less likely to work if they are unhealthy, and could impose an economic burden on families and society. Like everyone else, older people need both physical and economic security, but the burden of providing these securities will be falling on a smaller portion of the population. Pension systems will be stressed and will need reassessment along with retirement policies. Health systems, which have not in the past been oriented toward the myriad health problems and long-term care needs of older people and have not sufficiently emphasised disease prevention, can respond in different ways to the new demographic reality and the associated changes in population health. Along with behavioural adaptations by individuals and businesses, the nature of such policy responses will establish whether population ageing will lead to major macroeconomic difficulties.

Nature
Volume 518 Number 7538 pp137-268 12 February 2015
http://www.nature.com/nature/current_issue.html

Nature | Editorial
Spot the difference
The US measles outbreak highlights why most states should reconsider their vaccination rules.
11 February 2015
Over the past decade, increasing numbers of US parents have chosen not to vaccinate their children against diseases such as whooping cough, mumps and measles. The consequence has been a periodic return of these historical scourges, in localized outbreaks of a few dozen to a few hundred people. These episodes often appear in local news reports, some of which warn that lower vaccination rates could result in a nationwide outbreak.

Reading the US news media over the past two weeks, you might conclude that that day has come. The current US measles outbreak, which began in December and was first reported in late January, has blown up into a national debate over the rights of parents to decide whether their children should be vaccinated. But by global standards, it is a tempest in a teapot: as of 6 February, measles had struck 121 people in 17 states and the District of Columbia.

Those numbers are unremarkable. Since October, a measles outbreak has affected more than 370 people in Germany; it saw almost 1,800 cases in 2013 and more than 1,600 in 2011. The Philippines had more than 50,000 cases in 2014. The United Kingdom had only 137 cases last year, but in both 2012 and 2013 it had close to 2,000 (see page 148).
In fact, even by US standards, the current outbreak is not unprecedented. Last year, a much larger outbreak was sparked by Amish missionaries returning from the Philippines to Ohio, where low vaccination rates among the community caused 383 cases.

Perhaps that incident stayed out of the national spotlight because it was an unusual set of circumstances that occurred in an isolated rural community. But the current outbreak centres on ‘the happiest place on Earth’ — Disneyland in southern California. At least 42 people seem to have been exposed to measles at the theme park, which receives an estimated 16 million visits a year.
Fortunately for the public’s health, attention around the outbreak has come down in favour of vaccination and against the myths about its dangers. Public opinion has turned against parents and physicians who are suspicious of vaccines. Two potential Republican presidential candidates, Governor Chris Christie of New Jersey and Senator Rand Paul of Kentucky, at first declared that parents should have the right to decide whether their children are vaccinated, and then had to clarify their positions in the face of harsh criticism.

Whether or not the theme park’s involvement in the episode contributed to the media coverage, Disneyland’s cherished place in US culture makes it ideal for an infectious-disease outbreak. It is popular with international tourists eager for a quintessential American experience, who as a group are less likely than US residents to be vaccinated. The park also hosts large numbers of infants less than one year old — younger than the age at which the first measles shot is generally given in the United States.

And Disneyland is at the epicentre of the US anti-vaccine movement. Although 94.7% of US children entering school at around age 5 are vaccinated against measles, in hundreds of California schools the percentage of vaccinated children falls well short of the 92% considered necessary to produce the ‘herd immunity’ that prevents transmission of the disease. The state’s public-health department reports that 2.54% of children entered school in 2014 with an exemption from vaccination based on personal belief.

The federal government has little say in who gets a measles shot — those rules are written by individual states. Most, like California, allow parents to send their children to school unvaccinated by claiming a religious or philosophical objection to the practice. But two — Mississippi and West Virginia — allow only medical exceptions. And that, many observers have argued, is why Mississippi, one of the poorest states in the union, has the highest percentage of 5-year-old children who have received vaccination for measles, mumps and rubella.

Last month, the Mississippi state legislature was considering a bill to allow the same types of personal-belief exemption that most other states allow. But on 3 February, a committee in the state’s House of Representatives killed the proposal. On 4 February, legislators in California said that they would introduce a bill to adopt the same strict rules as Mississippi. And several other states, including Maine, Minnesota and Oregon, are considering measures that would require parents to consult with a physician about vaccines before being granted an exemption.

That is a step in the right direction. Parents, of course, have the right to decide what is best for their children. But when it comes to vaccination, those decisions should be based on complete and accurate information about the risks and benefits.

PLoS Currents: Outbreaks
http://currents.plos.org/outbreaks/
(Accessed 14 February 2015)

Temporal Changes in Ebola Transmission in Sierra Leone and Implications for Control Requirements: a Real-time Modelling Study
February 10, 2015 • Research
Abstract
Background: Between August and November 2014, the incidence of Ebola virus disease (EVD) rose dramatically in several districts of Sierra Leone. As a result, the number of cases exceeded the capacity of Ebola holding and treatment centres. During December, additional beds were introduced, and incidence declined in many areas. We aimed to measure patterns of transmission in different regions, and evaluate whether bed capacity is now sufficient to meet future demand.

Methods: We used a mathematical model of EVD infection to estimate how the extent of transmission in the nine worst affected districts of Sierra Leone changed between 10th August 2014 and 18th January 2015. Using the model, we forecast the number of cases that could occur until the end of March 2015, and compared bed requirements with expected future capacity.

Results: We found that the reproduction number, R, defined as the average number of secondary cases generated by a typical infectious individual, declined between August and December in all districts. We estimated that R was near the crucial control threshold value of 1 in December. We further estimated that bed capacity has lagged behind demand between August and December for most districts, but as a consequence of the decline in transmission, control measures caught up with the epidemic in early 2015.

Conclusions: EVD incidence has exhibited substantial temporal and geographical variation in Sierra Leone, but our results suggest that the epidemic may have now peaked in Sierra Leone, and that current bed capacity appears to be sufficient to keep the epidemic under-control in most districts.

.
Estimating Drivers of Autochthonous Transmission of Chikungunya Virus in its Invasion of the Americas
February 10, 2015 • Research
Abstract
Background
Chikungunya is an emerging arbovirus that has caused explosive outbreaks in Africa and Asia for decades and invaded the Americas just over a year ago. During this ongoing invasion, it has spread to 45 countries where it has been transmitted autochthonously, infecting nearly 1.3 million people in total.
Methods
Here, we made use of weekly, country-level case reports to infer relationships between transmission and two putative climatic drivers: temperature and precipitation averaged across each country on a monthly basis. To do so, we used a TSIR model that enabled us to infer a parametric relationship between climatic drivers and transmission potential, and we applied a new method for incorporating a probabilistic description of the serial interval distribution into the TSIR framework.
Results
We found significant relationships between transmission and linear and quadratic terms for temperature and precipitation and a linear term for log incidence during the previous pathogen generation. The lattermost suggests that case numbers three to four weeks ago are largely predictive of current case numbers. This effect is quite nonlinear at the country level, however, due to an estimated mixing parameter of 0.74. Relationships between transmission and the climatic variables that we estimated were biologically plausible and in line with expectations.
Conclusions
Our analysis suggests that autochthonous transmission of Chikungunya in the Americas can be correlated successfully with putative climatic drivers, even at the coarse scale of countries and using long-term average climate data. Overall, this provides a preliminary suggestion that successfully forecasting the future trajectory of a Chikungunya outbreak and the receptivity of virgin areas may be possible. Our results also provide tentative estimates of timeframes and areas of greatest risk, and our extension of the TSIR model provides a novel tool for modeling vector-borne disease transmission.

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High-resolution Genomic Surveillance of 2014 Ebolavirus Using Shared Subclonal Variants
February 9, 2015 • Research
Abstract
Background: Viral outbreaks, such as the 2014 ebolavirus, can spread rapidly and have complex evolutionary dynamics, including coinfection and bulk transmission of multiple viral populations. Genomic surveillance can be hindered when the spread of the outbreak exceeds the evolutionary rate, in which case consensus approaches will have limited resolution. Deep sequencing of infected patients can identify genomic variants present in intrahost populations at subclonal frequencies (i.e. <50%). Shared subclonal variants (SSVs) can provide additional phylogenetic resolution and inform about disease transmission patterns.

Methods: We use metrics from population genetics to analyze data from the 2014 ebolavirus outbreak in Sierra Leone and identify phylogenetic signal arising from SSVs. We use methods derived from information theory to measure a lower bound on transmission bottleneck size.

Results and Conclusions: We identify several SSV that shed light on phylogenetic relationships not captured by consensus-based analyses. We find that transmission bottleneck size is larger than one founder population, yet significantly smaller than the intrahost effective population. Our results demonstrate the important role of shared subclonal variants in genomic surveillance.

PLoS Neglected Tropical Diseases
http://www.plosntds.org/
(Accessed 14 February 2015)

Viewpoints
The Newest “Omics”—Metagenomics and Metabolomics—Enter the Battle against the Neglected Tropical Diseases
Geoffrey A. Preidis ,
Affiliation: Section of Gastroenterology, Hepatology & Nutrition, Department of Pediatrics, Baylor College of Medicine and Texas Children’s Hospital, Houston, Texas, United States of America
Peter J. Hotez
Affiliations: National School of Tropical Medicine, Department of Pediatrics and Molecular Virology & Microbiology, Baylor College of Medicine, Houston, Texas, United States of America, Sabin Vaccine Institute and Texas Children’s Hospital Center for Vaccine Development, Houston, Texas, United States of America, James A. Baker III Institute for Public Policy, Rice University, Houston, Texas, United States of America, Department of Biology, Baylor University, Waco, Texas, United States of America
Published: February 12, 2015
DOI: 10.1371/journal.pntd.0003382

Introduction
The international Human Microbiome Project [1,2] trumpeted the coming of age of the field of metagenomics, the study of entire communities of microbes and their contributions to health and disease. Metagenomic analyses are most often undertaken by sequencing the bacterial 16S ribosomal RNA (rRNA) subunit or by whole metagenome shotgun sequencing, typically on a massively parallel pyrosequencing platform. These technologies have expanded the scope of traditional culture-dependent microbiological methods and have enhanced our understanding of the rich microbial communities that inhabit the intestine, skin, oral cavity, and genitourinary tract and how these commensal microbes interact with both pathogen and host.

In parallel, the field of metabolomics emerged as the systematic, nonbiased analysis of all low-molecular-weight small molecules, or metabolites, produced by a system in response to an environmental stimulus. Metabolites are secreted into body fluids by host and microbial cells, measured by mass spectrometry–based approaches, and aligned against libraries of known biochemicals. These techniques have been used to gain insights into mechanisms of pathogenesis and to identify new biomarkers of disease. Metabolomics also offers clues to the presence and function of microbes living deep within the small bowel that are difficult to sample directly and highlights the complex relationship between resident microbes, host metabolism, pharmacotherapeutic action, and relative health or disease.

Metagenomics and metabolomics are the two most rapidly advancing “omics” technologies and lie at either end of the “omics cascade” [3]; the former identifies the genetic potential of a community, whereas the latter reports the actual biology that produces a phenotype. These fields have enabled discoveries pertinent to a number of human conditions—namely, acute gastroenteritis, antibiotic-associated diarrhea, inflammatory bowel disease, irritable bowel syndrome, liver disease, undernutrition, and obesity—and have begun to shed new light on multiple aspects of the neglected tropical diseases. Moreover, there are exciting opportunities to now pair metagenomic and metabolomic data in order to gain new and unprecedented insights into the host–parasite relationship. Here, we explore the nascent metagenomic and metabolomic contributions to the diagnosis, pathogenesis, treatment, and prevention (including vector control) of neglected tropical diseases. We then look ahead to the full potential of the postgenomics era and consider how metagenomics and metabolomics could help in the control and elimination of these diseases…

Vaccine
Volume 33, Issue 10, Pages 1231-1298 (3 March 2015)
http://www.sciencedirect.com/science/journal/0264410X/33/10

Immunodeficiency-related vaccine-derived poliovirus (iVDPV) cases: A systematic review and implications for polio eradication
Review Article
Pages 1235-1242
Jean Guo, Sara Bolivar-Wagers, Nivedita Srinivas, Marisa Holubar, Yvonne Maldonado
Abstract
Background
Vaccine-derived polioviruses (VDPVs), strains of poliovirus mutated from the oral polio vaccine, pose a challenge to global polio eradication. Immunodeficiency-related vaccine-derived polioviruses (iVDPVs) are a type of VDPV which may serve as sources of poliovirus reintroduction after the eradication of wild-type poliovirus. This review is a comprehensive update of confirmed iVDPV cases published in the scientific literature from 1962 to 2012, and describes clinically relevant trends in reported iVDPV cases worldwide.
Methods
We conducted a systematic review of published iVDPV case reports from January 1960 to November 2012 from four databases. We included cases in which the patient had a primary immunodeficiency, and the vaccine virus isolated from the patient either met the sequencing definition of VDPV (>1% divergence for serotypes 1 and 3 and >0.6% for serotype 2) and/or was previously reported as an iVDPV by the World Health Organization.
Results
We identified 68 iVDPV cases in 49 manuscripts reported from 25 countries and the Palestinian territories. 62% of case patients were male, 78% presented clinically with acute flaccid paralysis, and 65% were iVDPV2. 57% of cases occurred in patients with predominantly antibody immunodeficiencies, and the overall all-cause mortality rate was greater than 60%. The median age at case detection was 1.4 years [IQR: 0.8, 4.5] and the median duration of shedding was 1.3 years [IQR: 0.7, 2.2]. We identified a poliovirus genome VP1 region mutation rate of 0.72% per year and a higher median percent divergence for iVDPV1 cases. More cases were reported from high income countries, which also had a larger age variation and different distribution of immunodeficiencies compared to upper and lower middle-income countries.
Conclusion
Our study describes the incidence and characteristics of global iVDPV cases reported in the literature in the past five decades. It also highlights the regional and economic disparities of reported iVDPV cases.

.

Vaccines — Open Access Journal
(Accessed 14 February 2015)
http://www.mdpi.com/journal/vaccines

Review: M2e-Based Universal Influenza A Vaccines
by Lei Deng, Ki Joon Cho, Walter Fiers and Xavier Saelens
Vaccines 2015, 3(1), 105-136; doi:10.3390/vaccines3010105 – published 13 February 2015
Abstract:
The successful isolation of a human influenza virus in 1933 was soon followed by the first attempts to develop an influenza vaccine. Nowadays, vaccination is still the most effective method to prevent human influenza disease. However, licensed influenza vaccines offer protection against antigenically matching viruses, and the composition of these vaccines needs to be updated nearly every year. Vaccines that target conserved epitopes of influenza viruses would in principle not require such updating and would probably have a considerable positive impact on global human health in case of a pandemic outbreak. The extracellular domain of Matrix 2 (M2e) protein is an evolutionarily conserved region in influenza A viruses and a promising epitope for designing a universal influenza vaccine. Here we review the seminal and recent studies that focused on M2e as a vaccine antigen. We address the mechanism of action and the clinical development of M2e-vaccines. Finally, we try to foresee how M2e-based vaccines could be implemented clinically in the future.

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

Journal of Family Planning & Reproductive Health Care
Online First
doi:10.1136/jfprhc-2014-100896
Article
Comparing risk behaviours of human papillomavirus-vaccinated and non-vaccinated women
Laura Sadler1, Stephen A Roberts2, Gail Hampal3, Dona McManus4, Debashis Mandal5, Loretta Brabin6
Author Affiliations
1Research Associate, Institute of Cancer Sciences, University of Manchester, Manchester, UK
2Senior Lecturer in Medical Statistics, Centre for Biostatistics, University of Manchester, Manchester, UK
3Sister, Department of Genitourinary Medicine, Warrington and Halton Hospitals NHS Foundation Trust, Cheshire, UK
4Departmental Manager, Department of Genitourinary Medicine, Warrington and Halton Hospitals NHS Foundation Trust, Cheshire, UK
5Consultant in Genitourinary Medicine, Department of Genitourinary Medicine, Warrington and Halton Hospitals NHS Foundation Trust, Cheshire, UK and Senior Lecturer, Faculty of Medical and Human Sciences, University of Manchester, Manchester, UK
6Reader in Women’s Health, Institute of Cancer Sciences, University of Manchester, Manchester, UK
Received 7 February 2014
Revised 5 November 2014
Accepted 1 December 2014
Published Online First 20 January 2015
Abstract
Background
Since September 2008, a national vaccine programme in the UK has offered routine human papillomavirus (HPV) vaccination to young women aged 12–13 years. A catch-up programme also offered HPV vaccination to women born after 1 September 1990.
Aim
To compare indicators of risk and preventive behaviours among young women attending genitourinary medicine (GUM) clinics who had, and had not, received at least one dose of HPV vaccine.
Methods
Clinical histories and HPV vaccination status were obtained from 363 participants eligible for HPV vaccination (Cervarix®) in the UK vaccination programme (born after 1 September 1990) attending GUM clinics in the North West of England. Using logistic regression, markers of sexual and non-sexual risk behaviours were compared between vaccinated and unvaccinated women.
Results
At least one dose of HPV vaccine had been received by 63.6% (n=231) of participants. Unvaccinated women demonstrated higher levels of risky behaviour than those who had undergone HPV vaccination. Unvaccinated women were significantly more likely to have had three or more partners in the last 6 months, attended the clinic with symptoms, not used a condom at first sexual intercourse, had anal intercourse with their last sexual contact, to have tested positive for Chlamydia trachomatis diagnosis at the clinic visit and to be a current smoker.
Conclusions
In the UK, where vaccine coverage is high, failure to initiate HPV vaccination amongst GUM attendees is a marker of high-risk behaviours. As a result, HPV vaccination status should be ascertained as part of an individual’s clinical history by sexual health services to ensure advice and counselling is provided to those at greatest risk of HPV-associated disease.

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Special Focus Newsletters
RotaFlash – February 9, 2015
– Significant reductions in rotavirus-related hospitalizations in Malawi
– Argentina and Tajikistan introduce rotavirus vaccines, bringing worldwide total to 75

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.

The Atlantic
http://www.theatlantic.com/magazine/
Accessed 14 February 2015

Vaccines Are Profitable, So What?
Bourree Lam Feb 10 2015, 7:50 AM ET
Yes, Big Pharma is making money from immunizations. But that doesn’t mean anyone should skip the shots.
…So while the vaccine industry is likely more profitable now than in the 1970s or 1980s, this is the result of global market forces, not a reason to skip a child’s vaccinations: Pharmaceutical companies need incentives to keep producing vaccines, because regardless of profits the economic and social benefits of vaccination are huge—in lives and the billions of dollars saved. A study released last year estimated that fully immunizing babies resulted in $10 saved for every dollar spent, about $69 billion total. “Vaccines are one of the most cost-effective interventions we have,” says Halsey.

In the U.S., a study looking at the benefits of vaccination between 1994 and 2013 estimated a net savings of $295 billion in direct costs and $1.38 trillion in total societal costs. Looking at the last 50 years of the vaccine market, it’s absurd to think profits could have ever been the sole motivation of vaccine production. In fact, 83 percent of Americans believe that the MMR vaccine is safe. Profits from vaccine production aren’t a valid argument against vaccinations—the most important question is whether vaccines are safe and effective, and the answer is unambiguously yes.

Why Is Germany So Calm About Its Measles Outbreak?
A bigger flare-up of the contagious disease has a different cause—and has prompted a much more placid reaction.
Adam Chandler Feb 9 2015, 5:28 PM E

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Foreign Affairs
http://www.foreignaffairs.com/
Accessed 14 February 2015

Good Thing Chris Christie Isn’t the Governor of Congo
Poor countries from India to Zambia are making huge gains against preventable killers like measles — just as rich countries are falling behind.
By Laurie Garrett February 9, 2015
…If the backlash against non-vaccinators continues to grow, Christie (and others like fellow presidential candidates Ben Carson, who insists illegal immigrants are responsible for measles, and Rand Paul, who has struggled to balance his libertarian views of free choice against support for public health) may realize they have made the wrong political gamble in playing with public health. A deep, emotional polarization already divides public health advocates and those who dream of global measles eradication versus parental-choice promoters who feel even scant hypothetical vaccine risks are too much burden for their babies to bear. This vaccine polarization has been vociferous and often angry for many years. It would be tragic not only for the children of America, but for the measles-fighting world as a whole, if efforts to achieve American herd immunity against the virus were stymied by U.S. political polarization. Measles infects both Democrats and Republicans, and the vaccine protects the children of conservatives and of liberals equally well…

.

The Huffington Post
http://www.huffingtonpost.com/
Accessed 14 February 2015

Don’t Politicize Vaccinations
6 February 2015
by Rosalynn Carter (former First Lady)
For more than four decades, I have joined with many others working to ensure the timely vaccination of children, and today I am saddened to see an outbreak of measles infecting more than 100 people in 14 states, many of them vulnerable infants. Our country has achieved the highest immunization rates in history and thankfully the vast majority of parents are choosing to vaccinate their children on time. Yet, some parents today are being swayed by misinformation that has caused them to delay or decline vaccinating their children, jeopardizing the health of many others. I want all people to know that immunizations are safe, and that they work…

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Los Angeles Times
The measles outbreaks that matter the most aren’t happening here
10 February 2015
By Andrea Gay
The measles outbreak linked to Disneyland has heightened public debate about the effect of anti-vaccination sentiment, and what can be characterized as a luxury of choice in the United States. Understandably, much of the dialogue is focused on whether to vaccinate kids. It’s critical to address these issues so we can dispel myths about immunization and reemphasize the important benefits of vaccines. But there is another conversation that we’re not having, one that is equally important to making sure measles outbreaks don’t happen in the United States: how to stop measles outside our borders….

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New Yorker
http://www.newyorker.com/
Accessed 14 February 2015

Comment February 16, 2015 Issue
Not Immune
By Margaret Talbot
Twenty-five years ago, when a doctor named Robert Ross was the deputy health commissioner of Philadelphia, a measles epidemic swept the country. Until this year’s outbreak, which started at Disneyland and has so far sickened more than a hundred people, the 1989-91 epidemic was the most alarming that the United States had seen since 1963, when the measles vaccine was introduced. Nationwide, there were more than fifty-five thousand cases and eleven thousand hospitalizations; a hundred and twenty-three people died. Most of those infected were unimmunized babies and toddlers, predominantly poor and minority kids living in cities…

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New York Times
http://www.nytimes.com/
Accessed 14 February 2015

Africa
Red Cross Faces Attacks at Ebola Victims’ Funerals
By PAM BELLUCK
FEB. 12, 2015
Red Cross volunteers helping to safely bury people who die of Ebola in Guinea have been attacked in recent days by people attending the funerals, complicating efforts to stop the spread of the disease.
The International Federation of Red Cross and Red Crescent Societies reported Thursday that since March, the organization’s burial teams in Guinea have been attacked verbally or physically 10 times a month on average. Most recently, on Sunday in Forécariah, two volunteers were beaten as they tried to carry out a safe burial…

The Opinion Pages | Editorial
Reform After the Ebola Debacle
By THE EDITORIAL BOARD
FEB. 10, 2015
The World Health Organization’s anemic performance in handling the Ebola outbreaks in West Africa may yield one positive outcome: sweeping, and long overdue, institutional reforms to improve its ability to respond more quickly to the next outbreak of a lethal infectious disease. Scrambling to answer growing criticism, the W.H.O.’s executive board recently endorsed changes to enhance the agency’s rapid response capabilities.

The reforms call for well-trained public health workers to rush to the aid of beleaguered countries and an emergency fund to support their initial operations, among other advances. One big question, which can only be answered in practice, is whether the organization’s 194 member states will set aside their typical politicking on behalf of national self-interests and allow it to function as the global health leader it ought to be.

As of Feb. 6, Ebola had infected more than 22,000 people and killed more than 9,000 of them, mostly in the three West African nations of Guinea, Liberia and Sierra Leone, with a smattering of cases in other countries. The number of new cases of Ebola had been falling steadily in those three countries but recently ticked back up for the first time this year in all three, according to the W.H.O.’s latest weekly report. There were 124 new confirmed cases, up from 99 the week before.

That could be a momentary statistical aberration or a harbinger of worse to come as the rainy season makes it increasingly difficult to reach remote areas where the virus may still be lurking.

The agency’s lapses in confronting the Ebola outbreaks have been blamed, rightly, on poor leadership at its headquarters in Geneva and its regional office in Africa. Dr. Margaret Chan, the director general and a Hong Kong pediatrician who got her job thanks to pressure from the Chinese government, failed to respond quickly when Ebola first emerged in West Africa.

Only after a nongovernmental organization, Doctors Without Borders, repeatedly warned that the epidemic was out of control and the virus had spread to the populous neighboring country of Nigeria did Dr. Chan finally declare the outbreak a public health emergency of international concern.

The agency’s regional office in Africa was also slow to respond, partly because it was staffed by politically appointed people of little competence and partly because it feared that declaring a widespread emergency would tarnish the reputation and international trade of afflicted countries.

The resolution adopted by the W.H.O.’s executive board signals a heightened willingness to be more aggressive and could go a long way toward addressing these deficiencies. It calls for the agency to create a global cadre of public health workers trained to deal with a crisis, to establish a $100 million emergency fund that could be tapped quickly without waiting for donations from advanced nations to come dribbling in, and a commitment by the executive-director to ensure that regional staff members are selected for their expertise. The proposals are expected to be approved by the agency’s governing body, the World Health Assembly, in May.

In another promising sign of change, a highly regarded physician from Botswana was appointed last month as the new regional director for Africa. She promised to introduce competency tests for the staff and audits of job performance by outside consultants, among other changes.

But the long-term issue of adequate financing for the W.H.O. will remain. Budget cuts reduced the agency’s ability to monitor outbreaks even before Ebola arrived in West Africa. And the agency has not been given power to demand actions it thinks member nations should perform. With the epidemic appearing to ebb in West Africa, the danger remains that the drive for reform could lose steam as well

.The Opinion Pages | Op-Ed Contributor
What Would Jesus Do About Measles?
By PAUL A. OFFIT
FEB. 10, 2015
PHILADELPHIA — MEASLES is back. Last year, about 650 cases were reported in the United States — the largest outbreak in almost 20 years. This year, more than a hundred have already been reported.
Parents have chosen not to vaccinate their children because they can; 19 states have philosophical exemptions to vaccination, and 47 have religious exemptions. The other reason is that parents are not scared of the disease. But I’m scared. I lived through the 1991 Philadelphia measles epidemic….
…In the wake of the current epidemic, several states have proposed legislation modifying or eliminating philosophical exemptions to vaccination. No lawmaker, however, dares to touch religious exemptions. It’s political dynamite. But with an estimated 30,000 children in the United States unvaccinated for religious reasons, that is a dangerous mistake.
Parents shouldn’t be allowed to martyr their children — or in this case, those with whom their children have come in contact. Religious exemptions to vaccination are a contradiction in terms. In the good name of all religions, they should be eliminated.

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Wall Street Journal
http://online.wsj.com/home-page?_wsjregion=na,us&_homepage=/home/us
Accessed 14 February 2015

Measles Vaccine Debate Hits Home at California School
The measles outbreak and debate over vaccinations has hit close to home at Julian Charter School in California, where many parents have opted out of getting their children immunized.
02/11/15

Dan Henninger: Vaccines and Politicized Science
Jenny McCarthy knows the credibility of science is a house of cards.
02/11/15

U.S. Measles Cases for 2015 Rise 18.6% Over Past Week
The number of measles cases in the U.S. this year rose 18.6% over the past week, to 121 people in 17 states, federal health officials says.
02/09/15

Vaccines: Delays, Too, Pose Risks
While parents who don’t vaccinate their children have been the focus of the recent measles outbreak, experts say vaccine delayers compose a larger and growing group that may expose the most vulnerable population to vaccine-preventable diseases.
02/09/15

Doctors Work to Ease Vaccine Fears
Pediatricians face growing numbers of parents who question or reject vaccinations for their children. Now, public health experts are working on new ways to help these doctors hone their pitches to families.
02/09/15

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Washington Post
http://www.washingtonpost.com/
Accessed 14 February 2015

12 February 2015
The polio vaccine killed my father. But that’s not a reason to oppose vaccines.
Individual risk is a necessary part of public health.
By Nuria Sheehan
My father was one in 5 million. That’s the probability of getting polio after being in contact with someone who has received the oral polio vaccine. I got the vaccine as an infant. And somehow the weakened form of the virus within it managed to infect my father. He spent nine months in intensive care, eventually becoming entirely paralyzed except for one eyelid with which he agonizingly communicated with my mother. A year after I was born, he was dead….

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

.– Request an Email Summary: Vaccines and Global Health : The Week in Review is published as a single email summary, scheduled for release each Saturday evening before midnight (EDT in the U.S.). If you would like to receive the email version, please send your request to david.r.curry@centerforvaccineethicsandpolicy.org.

– pdf version:  A pdf of the current issue is available here: Vaccines and Global Health_The Week in Review_7 February 2015

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

– Twitter:  Readers can also follow developments on twitter: @vaxethicspolicy.
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– Links:  We endeavor to test each link as we incorporate it into any post, but recognize that some links may become “stale” as publications and websites reorganize content over time. We apologize in advance for any links that may not be operative. We believe the contextual information in a given post should allow retrieval, but please contact us as above for assistance if necessary.
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– 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

Editor’s Note:
A measles outbreak in the U.S. – traced to Disney Land park in California and now active in several U.S. states – has spawned a significant public debate about vaccines, hesitancy, parental responsibility, mandates, and the U.S. federal and state government’s role in assuring immunization against infectious diseases generally. This debate has generated assertions, refinements and retractions by politicians, pundits and public health officials over the last week. Please see Media Watch below to see a summary of this activity, which was still very active as we published this edition. Reactions to this activity has included statements of support for vaccines as a key preventive health measure, including the statement below by the American Osteopathic Association.

American Osteopathic Association Affirms Safety and Effectiveness of Vaccines
Feb 06, 2015
Amid continuing outbreaks of preventable illnesses, the American Osteopathic Association reiterated its support for CDC vaccination protocols and cited the importance of a fully vaccinated population on the public health of the nation….

EBOLA/EVD [to 7 February 2015]
Public Health Emergency of International Concern (PHEIC); “Threat to international peace and security” (UN Security Council)

WHO: Ebola Situation Report – 4 February 2015
[Excerpt; Editor’s text bolding]
SUMMARY
:: Weekly case incidence increased in all three countries for the first time this year. There were 124 new confirmed cases reported in the week to 1 February: 39 in Guinea, 5 in Liberia, and 80 in Sierra Leone.
:: Continued community resistance, increasing geographical spread in Guinea and widespread transmission in Sierra Leone, and a rise in incidence show that the EVD response still faces significant challenges.
:: As the wet season approaches, there is an urgent need to end the outbreak in as wide an area as possible, especially in remote areas that will become more difficult to access.
:: Guinea reported 39 new confirmed cases, compared with 30 the previous week. An unsafe burial that took place in early January in the eastern prefecture of Lola, on the border with Côte d’Ivoire, has so far resulted in an outbreak of 11 confirmed cases. A further confirmed case in the northern prefecture of Siguiri, on the border with Mali, also originated in Lola.
:: The north Guinean prefecture of Tougué, which also borders Mali, has reported its first 2 confirmed cases. Both cases originated in the western prefecture of Dubreka.
::: In light of the recent increase in cases in northern Guinea, cross-border meetings between Guinea, Mali, and Senegal are planned to strengthen coordination of surveillance. A rapid-response team has also arrived in the border area between Lola, Guinea, and Côte d’Ivoire to assess risk and strengthen surveillance.
:: A total of 80 new cases were reported in Sierra Leone in the week to 1 February, compared with 65 the previous week. The western districts of Port Loko and the capital Freetown are the worst-affected areas. Nine of 14 districts in the country reported at least 1 confirmed case, up from 7 districts in the previous week.
:: The target is for 100% of new cases to arise among registered contacts, so that each and every chain of transmission can be tracked and terminated. In Guinea in the week to 25 January, 14 of 26 (54%) new confirmed and probable cases in arose among registered contacts; in Liberia in the 9 days to 31 January, 7 of 7 (100%) new confirmed cases arose among registered contacts; and in Sierra Leone in the week to 18 January 26 of 121 (21%) confirmed cases arose among registered contacts.
:: The case fatality rate among hospitalized cases (calculated from all confirmed and probable hospitalized cases with a reported definitive outcome) is between 50% and 61% in the 3 intense-transmission countries.
:: A total of 822 confirmed health worker infections have been reported in the 3 intense-transmission countries; there have been 488 reported deaths.
:: A total of 10 of 34 prefectures in Guinea reported at least one security incident or other form of refusal to cooperate in the week to 1 February. No counties in Liberia and 3 districts in Sierra Leone reported at least one similar incident during the week to 27 January.

COUNTRIES WITH WIDESPREAD AND INTENSE TRANSMISSION
:: There have been almost 22 500 reported confirmed, probable, and suspected cases (Annex 1) of EVD in Guinea, Liberia and Sierra Leone (table 1), with almost 9000 reported deaths (outcomes for many cases are unknown). A total of 39 new confirmed cases were reported in Guinea, 5 in Liberia, and 80 in Sierra Leone in the 7 days to 1 February.
:: A stratified analysis of cumulative confirmed and probable cases indicates that the number of cases in males and females is similar (table 2). Compared with children (people aged 14 years and under), people aged 15 to 44 are approximately three times more likely to be affected. People aged 45 and over are almost four times more likely to be affected than are children.
:: A total of 822 confirmed health worker infections have been reported in the 3 intense-transmission countries; there have been 488 reported deaths (table 3)….

NIH Watch [to 7 February 2015]
http://www.nih.gov/news/index.html

:: Ebola Vaccine Trial Opens in Liberia
Study Led by Liberia-NIH Partnership Will Test Two Experimental Vaccines
Feb. 2, 2015
A large clinical trial to assess the safety and efficacy of two experimental vaccines to prevent Ebola virus infection is now open to volunteers in Liberia. The trial is being led by a recently formed Liberia-U.S. clinical research partnership and is sponsored by the National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health. The Partnership for Research on Ebola Vaccines in Liberia or PREVAIL, a Phase 2/3 study, is designed to enroll approximately 27,000 healthy men and women aged 18 years and older.

One vaccine candidate, cAd3-EBOZ, uses a chimpanzee-derived cold virus to deliver Ebola virus genetic material from the Zaire strain of virus causing the outbreak in Liberia. Published interim results from a Phase 1 trial of this vaccine, which was co-developed by NIAID scientists and GlaxoSmithKline, provided necessary safety information and showed that it prompted immune responses to the outer coat of Ebola virus. The other candidate, VSV-ZEBOV, employs vesicular stomatitis virus, an animal virus that primarily affects cattle, to carry an Ebola virus gene segment. The VSV-ZEBOV vaccine was developed by the Public Health Agency of Canada and licensed to NewLink Genetics Corporation through its wholly owned subsidiary BioProtection Systems Corporation. Phase 1 trial results of this vaccine also provided safety information and showed that it prompted immune responses to the outer coat of Ebola virus. These results have not yet been published but were made available to the regulatory bodies reviewing the study.

“The scale of the current Ebola outbreak in West Africa is unprecedented, and specific medical countermeasures are needed for this and future outbreaks,” said NIAID Director Anthony S. Fauci, M.D. “It is imperative that any potential countermeasures, including vaccines, be tested in a manner that conforms to the highest ethical and safety standards in clinical trials designed to provide a clear answer to the question of whether a candidate vaccine is safe and can prevent infection. This trial is designed to provide such answers.”

In addition to healthy adults in the general population, the trial will seek volunteers from groups at particular risk of Ebola infection, including health care workers, communities with ongoing transmission, contact tracers and members of burial teams. Social mobilization and community engagement activities began in Montserrado County, where the Liberian capital Monrovia is located, before the trial started and will continue in order to successfully recruit thousands of participants.

Participants will be assigned at random to one of three equal-sized groups. Volunteers in one group will receive a placebo (saline) injection, while the others will receive a single injection of either the cAd3-EBOZ vaccine or the VSV-ZEBOV vaccine. In addition to including a placebo group, the trial will be double-blinded, meaning that neither volunteers nor staff will know whether a vaccine or placebo was administered. A randomized, double-blind, placebo-controlled trial is considered the “gold standard” in clinical research. All participants will be advised on how to minimize the risk of becoming infected with Ebola virus and will be contacted by study staff about one week after the injection and then monthly for the duration of the study, which is currently expected to last about twelve months.

Given the current decline in the number of new Ebola cases in Liberia, study investigators anticipate the need for flexibility in the conduct and design of the trial to address the changing nature of the outbreak.

The co-leaders of the trial are Stephen B. Kennedy, M.D., MPH, secretary-general of the Liberia College of Physicians and Surgeons; Fatorma Baloy, Ph.D., director, Liberian Institute for Biomedical Research; and H. Clifford Lane, M.D., NIAID’s deputy director for clinical research and special projects. The pharmaceutical company GlaxoSmithKline (Research Triangle Park, North Carolina) will supply the cAd3-EBOZ investigational vaccine; Merck (Kenilworth, New Jersey) and NewLink Genetics, Inc. (Ames, Iowa) will supply the VSV-ZEBOV candidate. Additional information about the study is available at ClinicalTrials.gov using the identifier NCT02344407.

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Chimerix Focusing Efforts on CMV and Adenovirus Pivotal Trials
Brincidofovir Will Not Be Considered in Further Clinical Trials in Ebola Virus Disease
DURHAM, N.C., Jan. 30, 2015 (GLOBE NEWSWIRE) — Chimerix, Inc. (Nasdaq:CMRX), a biopharmaceutical company developing novel, oral antivirals in areas of high unmet medical need, today announced that after discussion with the U.S. Food and Drug Administration, the company is ceasing further participation in all current and future clinical studies of brincidofovir for Ebola Virus Disease (EVD), including the study announced in December in Liberia sponsored by investigators at the University of Oxford and the supportive Phase 2 study of brincidofovir for EVD, Study 205.

Over the last several weeks the number of new cases of confirmed Ebola Virus Disease in Liberia has decreased significantly, with only a handful of patients enrolled to date in the single-arm study of brincidofovir led by the University of Oxford and ISARIC (International Severe Acute Respiratory and Emerging Infection Consortium) with operational support from Médecins Sans Frontières (MSF).

The decision to cease further study of brincidofovir in individuals with Ebola Virus Disease does not impact the company’s continued focus on advancing brincidofovir in pivotal studies of CMV prevention in recipients of allogeneic hematopoietic transplant and for the treatment of adenovirus infection in immunocompromised patients.

“We were honored to be able to work with the researchers at University of Oxford and ISARIC together with MSF to initiate the first clinical trial of an investigational agent during an outbreak. The progress in controlling the Ebola outbreak in Liberia is to be commended,” said M. Michelle Berrey, MD, MPH, President and CEO of Chimerix. “Chimerix will continue to push forward with our development of brincidofovir for the prevention and treatment of serious viral infections in transplant recipients and other immunocompromised patients.”

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MSF/Médecins Sans Frontières [to 7 February 2015]
Selected Press Releases/Field News
Ebola Drug Trial in Liberia Halted
February 04, 2015
BRUSSELS/NEW YORK—A trial of the experimental Ebola drug brincidofovir in Liberia has officially ended due to a significant drop in the number of new Ebola cases and the drug manufacturer’s decision to withdraw from the trial, the international medical humanitarian organization Doctors Without Borders/Médecins Sans Frontières said Tuesday.

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Ebola Drug Aids Some in a Study in West Africa
By SHERI FINK
New York Times
February 4, 2015
[Excerpt]
For the first time, a drug is showing promising signs of effectiveness in Ebola patients participating in a study. The medicine, which interferes with the virus’s ability to copy itself, seems to have halved mortality — to 15 percent, from 30 percent — in patients with low to moderate levels of Ebola in their blood, researchers have found. It had no effect in patients with more virus in their blood, who are more likely to die.

The drug, approved as an influenza treatment in Japan last year, was generally well tolerated.
“The results are encouraging in a certain phase of the disease,” Dr. Sakoba Keita, director of disease control for the Guinean Ministry of Health, said in a telephone interview. The drug is being tested in Guinea, one of the three West African countries most affected by the Ebola crisis.

The details of the early findings have not yet been announced, but they raise questions about which patients, if any, outside the study should be offered treatment with the drug, favipiravir. “These are very difficult, agonizing decisions,” said Susan Ellenberg, a professor of biostatistics at the University of Pennsylvania’s Perelman School of Medicine, who was not involved in the research. She cautioned that early results were sometimes not borne out.

The drug has been provided on an emergency basis to Ebola patients in European countries, but not in Africa. The Japanese maker of the drug announced in October that it had 20,000 courses of treatment in stock. The epidemic is now ebbing but is not over. The World Health Organization on Wednesday reported 124 new cases in Guinea, Sierra Leone and Liberia in the week that ended on Sunday, warning of an increased geographical spread in Guinea and a rise in new cases in all three countries for the first time this year.

Early reports of the interim results of the drug trial have created unanticipated complications, delaying the testing of at least one other therapy as researchers reconsidered plans and some doctors pressed to make favipiravir more widely available.

Researchers and health authorities have been quietly debating whether and when to release the preliminary results of the study. The dilemmas they face echo those from the early years of the AIDS epidemic. Because mortality was so high in a disease with no proven treatment, there was demand to provide experimental therapies to everyone.

The results for the drug favipiravir are based on an analysis of 69 patients older than 14 who have received it at two sites in Guinea since December. The survival rates of those with low to moderate levels of virus in their blood were significantly better than those of patients previously treated at a center run by Doctors Without Borders in Guéckédou, Guinea….

IMF [to 7 February 2015]
http://www.imf.org/external/news/default.aspx

IMF Establishes a Catastrophe Containment and Relief Trust to Enhance Support for Eligible Low Income Countries Hit by Public Health Disasters
Press Release No. 15/34
February 5, 2015
The Ebola epidemic in parts of West Africa is a humanitarian disaster that has drawn the attention of the international community to the threat posed by the rapid spread of life-threatening infectious diseases, both within and across international boundaries.

On February 4, 2015, the Executive Board of the International Monetary Fund (IMF) met to consider how the Fund could better support low-income countries hit by such public health disasters. This would take into account both the humanitarian case for providing such support and the wider international interest in supporting vigorous action to contain and halt a potential regional or global pandemic at the earliest possible stage.

To help meet these objectives, the Board approved the establishment of a new Catastrophe Containment and Relief (CCR) Trust, as a vehicle to provide exceptional support to countries confronting major natural disasters, including life-threatening, fast-spreading epidemics but also other types of catastrophic disasters, such as massive earthquakes. For eligible countries confronting epidemics that meet specified criteria, the IMF would use CCR trust fund resources to provide grants as a supplement to its conventional loan support. The grants would be used to pay off future debt service payments, thus reducing the country’s debt burden and freeing up resources to tackle relief and recovery challenges.

Subject to Board approval of requests from the individual countries, it is expected that the CCR trust would provide grants-for-debt relief of close to $100 million for the three countries affected by Ebola in West Africa –Liberia, Sierra Leone, and Guinea. These funds would come in addition to the $130 million of assistance provided in September 2014 and to a second round of new concessional loans amounting to about $160 million to be considered soon by the Executive Board.

At the conclusion of the Executive Board meeting on the CCR, IMF Managing Director Christine Lagarde stated: “I welcome the establishment of the Catastrophe Containment Relief Trust. It aims at enhancing our support to the countries in Africa hit by Ebola, as well as other low income countries that may be affected by public health disasters in the future. This is a strong example of the IMF demonstrating flexibility and innovation in responding to the needs of our global membership.”

Background
The primary tool through which the Fund supports low income countries confronting natural disasters is through the speedy provision of its interest-free loans to the affected countries, whether by expanding the amounts being provided under a pre-existing Fund financial program with the member or by disbursing funds under the Rapid Credit Facility (RCF).

In their November 2014 meeting in Brisbane, the G-20 called on the Bretton Woods Institutions to continue their strong support to countries severely affected by the Ebola outbreak through a combination of concessional loans, debt relief and grants, and asked the institutions to explore new, flexible mechanisms to address the economic effects of future comparable crises. The CCR Trust is the Fund’s response to that call. It replaces the Post-Catastrophe Debt Relief (PCDR) Trust established on June 25, 2010 in the wake of a massive earthquake in Haiti, and expands the circumstances under which the Fund can provide exceptional assistance to its low income members to include public health disasters.

Through the new instrument, the Fund is able to quickly and flexibly adjust its policies in the face of unexpected international developments, including pandemics, to serve the needs of its membership, especially the most vulnerable.

POLIO [to 7 February 2015]
Public Health Emergency of International Concern (PHEIC)

GPEI Update: Polio this week – As of 4 February 2014
Global Polio Eradication Initiative
[Editor’s Excerpt and text bolding]
Full report: http://www.polioeradication.org/Dataandmonitoring/Poliothisweek.aspx
:: Over 6 months have passed since the most recent case of wild poliovirus (WPV) type 1 had onset of paralysis in Nigeria. However, at least 12 months must pass without detection of WPV, in the presence of certification quality surveillance, before Nigeria would be considered as having stopped transmission of WPV. Polio-free certification of Nigeria (and the entire WHO African region) would follow only after 3 years with high quality surveillance have passed without identifying WPV. Intensified efforts are ongoing in the country not just to eradicate WPV, but also to urgently stop the circulating vaccine-derived poliovirus type 2 outbreak which continues to affect the country.
:: Ministers of Health, health leaders and experts from around the world convened in Geneva last week at WHO’s Executive Board meeting to set global public health policies. Participants were encouraged by progress towards a polio free world yet warned that as long as the disease remains anywhere, children everywhere are at risk. Read more

Selected country report content:
Nigeria
:: One new type 2 circulating vaccine-derived poliovirus (cVDPV2) case was reported this week in Gujba district of Yobe province (previously uninfected in 2014) with onset of paralysis on 3 November. The most recent case had onset of paralysis on 16 November in Barde district of Yobe state. The total number of cVDPV2 cases for 2014 in Nigeria is now 30.
National Immunization Days (NIDs) are taking place on 21 – 25 March using trivalent OPV.
Pakistan
:: Three new wild poliovirus type 1 (WPV1) cases were reported in the past week, all with onset of paralysis in 2015. One case was reported in Khyber Pakhtunkhwa (KP) province, in Nowshera district; one in the Federally Administered Tribal Areas (FATA), in South Waziristan; and one in Sindh province, in Kambar district. Each of these cases is the first in these districts for 2015. :: The total number of WPV1 cases in 2014 remains 305, and is now 6 for 2015. The most recent onset of paralysis was on 7 January, with one case in FATA and one in KP.
:: To urgently address the intense transmission affecting the country, the government has put in place emergency measures to take advantage of the current ‘low season’ for poliovirus transmission. A ‘low season plan’ has been established, based on lessons learned on accessing populations in insecure areas, engaging communities and fixing remaining operational challenges. Implementation is being overseen by Emergency Operations Centres at federal and provincial levels to ensure accountability for the quality of polio eradication operations. More.
:: The Technical Advisory Group (TAG) on polio eradication in Pakistan is meeting on 14 – 15 February to review the current epidemiological situation and the current status of the low transmission plan implementation.
West Africa
:: Even as polio programme staff across West Africa help to control the Ebola outbreak affecting the region, efforts are being made in those countries not affected by Ebola to vaccinate children against polio to create a buffer zone surrounding the affected countries. The Ebola crisis in western Africa continues to have an impact on the implementation of polio eradication activities in Liberia, Guinea and Sierra Leone. Supplementary immunization activities (SIAs) in these countries have been postponed and the quality of acute flaccid paralysis surveillance markedly decreased throughout 2014.

WHO & Regionals [to 7 February 2015]

:: 136th WHO Executive Board session
26 January–3 February 2015
Geneva, Switzerland
Documentation

:: Global Alert and Response (GAR): Disease Outbreak News (DONs)
– Middle East respiratory syndrome coronavirus (MERS-CoV) – Saudi Arabia 3 February 2015
– Human infection with avian influenza A(H7N9) virus – Canada 1 February 2015

:: The Weekly Epidemiological Record (WER) 6 February 2015, vol. 90, 6 (pp. 33–40)
Contents
33 Chagas disease in Latin America: an epidemiological update based on 2010 estimates
43 Monthly report on dracunculiasis cases, January– November 2014

:: GIN January 2015 pdf, 1.82Mb
30 January 2015

:: Cholera prevention measures reduce transmission in South Sudan
6 February 2015 — When violence erupted in South Sudan, tens of thousands of people fled the conflict and sought refuge in United Nations bases in the hopes of protection. As the rainy season approached it increased the risk of water-borne diseases, like cholera, and the potential for explosive outbreaks in congested camps. A timely decision to start cholera prevention and control measures, averted illness and death among the vulnerable camp inhabitants who had been at high-risk of the disease.

:: Preventing premature cancer deaths
4 February 2015 — Annually there are 14 million new cases of cancer and over 8 million people die from cancer, with 60% of deaths in Africa, Asia and Central and South America. WHO is working with countries to build solutions to reduce premature deaths from cancers through its global drive to prevent premature deaths from NCDs by 25% by 2025.
Read the commentary on cancer and tobacco
WHO Regional Offices

WHO African Region AFRO
No new digest content identified.

WHO Region of the Americas PAHO
:: PAHO/WHO says accessible, cost-effective measures can prevent premature cancer deaths (02/02/2015)

WHO South-East Asia Region SEARO
:: Beat cancer: Prevent, detect early 04 February 2015

WHO European Region EURO
:: WHO strengthens health operations in eastern Ukraine 06-02-2015
:: Influenza season underway in WHO European Region 04-02-2015

WHO Eastern Mediterranean Region EMRO
No new digest content identified.

WHO Western Pacific Region
No new digest content identified.

CDC/MMWR Watch [to 7 February 2015]
http://www.cdc.gov/media/index.html

:: MMWR Weekly, February 6, 2015 / Vol. 64 / No. 4
– Advisory Committee on Immunization Practices Recommended Immunization Schedule for Adults Aged 19 Years or Older — United States, 2015
– Advisory Committee on Immunization Practices Recommended Immunization Schedules for Persons Aged 0 Through 18 Years — United States, 2015
– Vaccination Coverage Among Adults, Excluding Influenza Vaccination — United States, 2013
– Update: Ebola Virus Disease Epidemic — West Africa, January 2015
– Outbreaks of Avian Influenza A (H5N2), (H5N8), and (H5N1) Among Birds — United States, December 2014–January 2015
– Announcements: Guidance Available for Implementing and Managing Contact Tracing for Ebola in Countries Without Ebola Outbreaks

BMGF – Gates Foundation Watch [to 7 February 2015]

Stanford launches major effort to expedite vaccine discovery with $50 million grant
Stanford Report, January 29, 2015
[Excerpt]
Stanford University today announced that it has received a grant from the Bill & Melinda Gates Foundation to accelerate efforts in vaccine development. The $50 million grant over 10 years will build on existing technology developed at Stanford and housed in the Human Immune Monitoring Core, and will establish the Stanford Human Systems Immunology Center. The center aims to better understand how the immune system can be harnessed to develop vaccines for the world’s most deadly infectious diseases….

PATH Watch [to 7 February 2015]
http://www.path.org/news/

:: Press release | February 06, 2015
PATH names Kathy Cahill as vice president for International Development
Public health expert to serve on executive leadership team and oversee PATH’s international presence

:: Announcement | February 01, 2015
PATH, partners team up to unlock lifesaving health innovation in India
Unique collaboration joins PATH, Unitus Seed Fund, Pfizer, and partners to increase access to health products and services, support Indian entrepreneurs, and improve health throughout India

:: Innovative health sector financing: the Vaccine Independence Initiative
30 January 2015
This week the UNICEF Board is considering expanding the Vaccine Independence Initiative (VII). This financing mechanism was launched almost 25 years ago in 1991 to decouple the procurement of vaccines from the payment for these vaccines by countries out of national budgets. We caught up with PATH’s chief strategy officer Amie Batson, who has an intimate connection with this program….Q: What is next for the VII? A: During its meeting this week, the UNICEF Board is considering expanding the VII ten-fold (from $10 million to $100 million) to cover prefinancing of vaccines as well as many health products like bednets treated with long-lasting insecticide and supplies needed for Ebola response. As countries graduate from Gavi and other donor support, there are increasing demands for mechanisms such as the VII that create greater financial flexibility.

Flu Care in Day Care: The Impact of Vaccination Requirements
A Report by the National Foundation for Infectious Diseases
January 2015 :: 10 pages
Overview
Despite the availability of safe and effective vaccines, tens of thousands of young children in the United States are hospitalized each year for influenza (flu). To protect as many young children as possible, New Jersey, Connecticut, and New York City have each implemented influenza vaccine requirements for children enrolled in licensed preschools, child care, or day care centers.* The National Foundation for Infectious Diseases (NFID), in collaboration with the Association of Immunization Managers (AIM), brought together key professionals from all three jurisdictions to discuss the challenges and key lessons learned in the planning and implementation of the regulations. These professionals were joined by immunization stakeholders, including members of the Childhood Influenza Immunization Coalition (CIIC). This report presents case studies from each jurisdiction along with an integrated set of lessons learned and key elements of successful programs (page 6) to help others considering implementing similar regulations.

American Journal of Tropical Medicine and Hygiene
February 2015; 92 (2)
http://www.ajtmh.org/content/current

Editorial
Perspectives on Ebola
Philip J. Rosenthal and Daniel G. Bausch
Am J Trop Med Hyg 2015 92:219-220; Published online January 12, 2015, doi:10.4269/ajtmh.14-0831
[Free Access]
An unprecedented epidemic of Ebola virus disease (EVD) unfolded in West Africa in 2014. The epidemic has been well described in the popular press and in regular reports from public health authorities. The medical literature has necessarily been slower in describing the epidemic, but comprehensive reports are now appearing, offering valuable accounts of the clinical features, epidemiology, and public health consequences of this terrifying disease. The American Society of Tropical Medicine and Hygiene (ASTMH) has been deeply involved with the EVD outbreak. Numerous ASTMH members have played major roles in addressing the epidemic, including clinicians and epidemiologists working at the front lines of the epidemic at great personal risk, public health authorities guiding control efforts in Africa and elsewhere, and drug and vaccine experts working to rush effective products to the field. The annual meeting of the ASTMH served as a forum for timely expert discussions on EVD, but also highlighted the political challenges of this particular crisis, as some experts were prevented from attending the ASTMH meeting as a result of ill-founded concerns about the consequences of their recent travel to West Africa. In this issue of the American Journal of Tropical Medicine and Hygiene (AJTMH) we offer a series of Perspectives from individuals active in addressing the EVD epidemic.

As with other large disasters, the full toll of the EVD epidemic is difficult to fathom. The numbers are clear. As of the end of 2014, nearly 20,000 cases of EVD and 7,000 deaths have been reported to the World Health Organization (WHO). These numbers are likely underestimates caused by underreporting. Furthermore, although these numbers are much lower than those seen for our greatest tropical medicine challenges, the impact of the epidemic can easily be underappreciated. EVD is quite unique, even among severe infectious diseases, in causing massive disruption to societies, and in particular to the healthcare infrastructure. In affected areas of Africa, in addition to the huge direct toll of EVD, all aspects of healthcare have been torn apart. Management and control of the most important serious infectious diseases, including neonatal infections, human immunodeficiency virus (HIV) infection, tuberculosis, malaria, and other neglected diseases have been greatly disrupted. “Band-aid” solutions, such as widespread distribution of artemisinin-based combination therapies to decrease the incidence of non-Ebola febrile illnesses, have unknown efficacy, and may cause new problems, such as selection of drug resistance and loss of community confidence in the healthcare system. Outside of Africa, responses to the EVD epidemic have often been driven by fear, misguided estimates of risk, and political considerations.

Most often, we in the scientific community appropriately focus on the data—the numbers of cases, the epidemiologic characteristics, and the efficacies of new interventions. In this process we may lose sight of the fact that a crisis such as the EVD epidemic is inherently personal. People are getting infected, suffering, and dying. In the case of this epidemic, much more so than in most humanitarian disasters, many of the victims are the healthcare workers and scientists who have willingly put themselves in harm’s way to help alleviate the suffering of others. In this issue of the AJTMH we offer Perspectives focusing on the personal side of the epidemic, considering in particular the points of view of health workers as caregivers at risk, as patients, and as those working to improve our ability to manage and control this epidemic. Two perspectives, from Adaora Igonoh and Will Pooley, offer accounts from those who put themselves at personal risk caring for patients with EVD, and then contracted the disease themselves. Another, from Lewis Rubinson, offers an account of a potential Ebola virus exposure that led to complex consequences. Susan McClellan offers an account from one of the many non-African healthcare providers who eagerly put themselves at risk. Perspectives addressing an improved response to EVD include a discussion of how, despite some steps in the right direction, the public health community failed to best prepare for a potential hemorrhagic fever outbreak by Daniel Bausch, a consideration of rethinking discharge policy in seriously stressed EVD clinics by Tim O’Dempsey and others, and a comprehensive commentary on clinical preparedness for those providing EVD care from David Brett-Major and many others. Considering the political consequences of responses to the epidemic outside Africa, perspectives from groups led by Ramin Asgary and Piero Olliaro detail the consequences of the misguided effort of the State of Louisiana to protect public health by preventing attendance at the annual meeting of the ASTMH in New Orleans by anyone who had recently traveled to affected countries in West Africa.

The West African EVD epidemic is still unfolding. This enormous disaster is likely to have long-range consequences, with impacts on efforts to control all tropical diseases in addition to specific effects on viral hemorrhagic fever preparedness and far-reaching impacts on the affected countries. Regardless of the future overall course, the epidemic will remain deeply personal, with obvious consequences on affected patients and families, but also on health workers. We hope that the Perspectives in this issue of the AJTMH will help readers to appreciate the personal side of this epidemic, both as a major humanitarian disaster and as a formidable challenge for the international public health community.

Perspective Pieces
My Experience as an Ebola Patient
Adaora K. Igonoh
Am J Trop Med Hyg 2015 92:221-222; Published online December 22, 2014, doi:10.4269/ajtmh.14-0763
Full Text Full Text (PDF) OPEN ACCESS ARTICLE

Ebola: Perspectives from a Nurse and Patient
Will Pooley
Am J Trop Med Hyg 2015 92:223-224; Published online January 5, 2015, doi:10.4269/ajtmh.14-0762
Full Text Full Text (PDF) OPEN ACCESS ARTICLE

From Clinician to Suspect Case: My Experience After a Needle Stick in an Ebola Treatment Unit in Sierra Leone
Lewis Rubinson
Am J Trop Med Hyg 2015 92:225-226; Published online December 15, 2014, doi:10.4269/ajtmh.14-0769
Full Text Full Text (PDF) OPEN ACCESS ARTICLE

Ebola: My Head is Full of Stories
Susan L. F. McLellan
Am J Trop Med Hyg 2015 92:227-228; Published online December 22, 2014, doi:10.4269/ajtmh.14-0801
Full Text Full Text (PDF) OPEN ACCESS ARTICLE

The Year That Ebola Virus Took Over West Africa: Missed Opportunities for Prevention
Daniel G. Bausch
Am J Trop Med Hyg 2015 92:229-232; Published online January 5, 2015, doi:10.4269/ajtmh.14-0818
Full Text Full Text (PDF) OPEN ACCESS ARTICLE

Being Ready to Treat Ebola Virus Disease Patients
David M. Brett-Major, Shevin T. Jacob, Frederique A. Jacquerioz, George F. Risi, William A. Fischer II, Yasuyuki Kato, Catherine F. Houlihan, Ian Crozier, Henry Kyobe Bosa, James V. Lawler, Takuya Adachi, Sara K. Hurley, Louise E. Berry, John C. Carlson, Thomas. C. Button, Susan L. McLellan, Barbara J. Shea, Gary G. Kuniyoshi, Mauricio Ferri, Srinivas G. Murthy, Nicola Petrosillo, Francois Lamontagne, David T. Porembka, John S. Schieffelin, Lewis Rubinson, Tim O’Dempsey, Suzanne M. Donovan, Daniel G. Bausch, Robert A. Fowler, and Thomas E. Fletcher
Am J Trop Med Hyg 2015 92:233-237; Published online December 15, 2014, doi:10.4269/ajtmh.14-0746
Abstract Full Text Full Text (PDF) OPEN ACCESS ARTICLE

Rethinking the Discharge Policy for Ebola Convalescents in an Accelerating Epidemic
Tim O’Dempsey, S. Humarr Khan, and Daniel G. Bausch
Am J Trop Med Hyg 2015 92:238-239; Published online December 1, 2014, doi:10.4269/ajtmh.14-0719
Abstract Full Text Full Text (PDF) OPEN ACCESS ARTICLE

Ebola Policies That Hinder Epidemic Response by Limiting Scientific Discourse
Ramin Asgary, Julie A. Pavlin, Jonathan A. Ripp, Richard Reithinger, and Christina S. Polyak
Am J Trop Med Hyg 2015 92:240-241; Published online January 5, 2015, doi:10.4269/ajtmh.14-0803
Abstract Full Text Full Text (PDF) OPEN ACCESS ARTICLE

Out of (West) Africa—Who Lost in the End?
Piero Olliaro, Estrella Lasry, and Amanda Tiffany
Am J Trop Med Hyg 2015 92:242-243; Published online December 15, 2014, doi:10.4269/ajtmh.14-0753
Full Text Full Text (PDF) OPEN ACCESS ARTICLE

International Aid and Natural Disasters: A Pre- and Post-Earthquake Longitudinal Study of the Healthcare Infrastructure in Leogane, Haiti
Maxwell Kligerman, Michele Barry, David Walmer, and Eran Bendavid
Am J Trop Med Hyg 2015 92:448-453; Published online December 15, 2014, doi:10.4269/ajtmh.14-0379
Abstract Full Text Full Text (PDF) Supplementary File OPEN ACCESS ARTICLE

Annals of Internal Medicine
3 February 2015, Vol. 162. No. 3
http://annals.org/issue.aspx

Advisory Committee on Immunization Practices Recommended Immunization Schedule for Adults Aged 19 Years or Older: United States, 2015* FREE
David K. Kim, MD; Carolyn B. Bridges, MD; Kathleen H. Harriman, PhD, MPH, RN, on behalf of the Advisory Committee on Immunization Practices

Editorial
Adult Immunization 2015: Another Pearl of Pneumococcal Protection
Sandra Adamson Fryhofer, MD

Ideas and Opinions | 20 January 2015
Drug and Vaccine Access in the Ebola Epidemic: Advising Caution in Compassionate Use FREE
Andrew Hantel, MD; and Christopher Olusola Olopade, MD, MPH
[+] Article and Author Information
Ann Intern Med. 2015;162(2):141-142. doi:10.7326/M14-2002
This article was published online first at http://www.annals.org on 14 October 2014.

Ethical Guidance on the Use of Life-Sustaining Therapies for Patients With Ebola in Developed Countries ONLINE FIRST
Scott D. Halpern, MD, PhD; and Ezekiel J. Emanuel, MD, PhD
Article and Author Information
Ann Intern Med. Published online 30 December 2014 doi:10.7326/M14-2611
The authors discuss ethical issues in the provision of life-sustaining therapies, such as cardiopulmonary resuscitation and dialysis, to patients with Ebola being cared for in developed countries

BMC Health Services Research
http://www.biomedcentral.com/bmchealthservres/content
(Accessed 7 February 2015)

Research article
Streamlined research funding using short proposals and accelerated peer review: an observational study
Adrian G Barnett12*, Danielle L Herbert13, Megan Campbell12, Naomi Daly24, Jason A Roberts24, Alison Mudge24 and Nicholas Graves12
Author Affiliations
BMC Health Services Research 2015, 15:55 doi:10.1186/s12913-015-0721-7
Published: 7 February 2015
Abstract (provisional)
Background
Despite the widely recognised importance of sustainable health care systems, health services research remains generally underfunded in Australia. The Australian Centre for Health Services Innovation (AusHSI) is funding health services research in the state of Queensland. AusHSI has developed a streamlined protocol for applying and awarding funding using a short proposal and accelerated peer review.
Method
An observational study of proposals for four health services research funding rounds from May 2012 to November 2013. A short proposal of less than 1,200 words was submitted using a secure web-based portal. The primary outcome measures are: time spent preparing proposals; a simplified scoring of grant proposals (reject, revise or accept for interview) by a scientific review committee; and progressing from submission to funding outcomes within eight weeks. Proposals outside of health services research were deemed ineligible.
Results
There were 228 eligible proposals across 4 funding rounds: from 29% to 79% were shortlisted and 9% to 32% were accepted for interview. Success rates increased from 6% (in 2012) to 16% (in 2013) of eligible proposals. Applicants were notified of the outcomes within two weeks from the interview; which was a maximum of eight weeks after the submission deadline. Applicants spent 7 days on average preparing their proposal. Applicants with a ranking of reject or revise received written feedback and suggested improvements for their proposals, and resubmissions composed one third of the 2013 rounds.
Conclusions
The AusHSI funding scheme is a streamlined application process that has simplified the process of allocating health services research funding for both applicants and peer reviewers. The AusHSI process has minimised the time from submission to notification of funding outcomes.

BMC Infectious Diseases
http://www.biomedcentral.com/bmcinfectdis/content
(Accessed 7 February 2015)

Research article
Pertussis outbreak in university students and evaluation of acellular pertussis vaccine effectiveness in Japan
Megumi Hara, Mami Fukuoka, Katsuya Tashiro, Iwata Ozaki, Satoko Ohfuji, Kenji Okada, Takashi Nakano, Wakaba Fukushima, Yoshio Hirota BMC Infectious Diseases 2015, 15:45 (6 February 2015)

Research article
An effective strategy for influenza vaccination of healthcare workers in Australia: experience at a large health service without a mandatory policy
Kristina Heinrich-Morrison, Sue McLellan, Ursula McGinnes, Brendan Carroll, Kerrie Watson, Pauline Bass, Leon J Worth, Allen C Cheng BMC Infectious Diseases 2015, 15:42 (6 February 2015)

Research article
An outbreak following importation of wild poliovirus in Xinjiang Uyghur Autonomous Region, China, 2011
Hai-Bo Wang, Wen-Zhou Yu, Xin-Qi Wang, Fuerhati Wushouer, Jian-Ping Wang, Dong-Yan Wang, Fu-Qiang Cui, Jing-Shan Zheng, Ning Wen, Yi-Xin Ji, Chun-Xiang Fan, Hui-Ling Wang, Gui-Jun Ning, Guo-Hong Huang, Dong-Mei Yan, Qi-Ru Su, Da-Wei Liu, Guo-Ming Zhang, Kathleen H Reilly, Jing Ning, Jian-Ping Fu, Sha-Sha Mi, Hui-Ming Luo, Wei-Zhong Yang BMC Infectious Diseases 2015, 15:34 (31 January 2015)
Abstract | Provisional PDF | PubMed

BMC Public Health
(Accessed 7 February 2015)
http://www.biomedcentral.com/bmcpublichealth/content

Research article
The influence of partial public reimbursement on vaccination uptake in the older population: a cross-sectional study
Sheena M Mc Hugh1*, John Browne1, Ciaran O’Neill2 and Patricia M Kearney1
Author Affiliations
BMC Public Health 2015, 15:83 doi:10.1186/s12889-015-1356-7
Published: 5 February 2015
Abstract (provisional)
Background
Flu vaccination is recommended annually for high risk groups. However, in Ireland, free access to vaccination is not universal for those in high risk groups; the vaccine and consultation are only free for those with a medical card, a means tested scheme. Few private health insurance policies cover the cost of attendance for vaccination in general practice. The aim was to examine the influence of this reimbursement policy on vaccination coverage among older adults.
Methods
Cross-sectional wave 1 data from The Irish Longitudinal Study on Ageing (TILDA) were analysed (2009?2011). TILDA is a nationally representative prospective cohort study of adults aged ?50, sampled using multistage stratified clustered sampling. Self-reported entitlement to healthcare was categorised as 1) medical card only 2) private health insurance only, 3) both and 4) neither. The outcome was responses to `have you ever had a flu shot?. Multivariate logistic regression was used, adjusting for age and need.Results68.6% of those defined as clinically high-risk received the flu vaccination in the past (95% CI?=?67-71%). Those with a medical card were almost twice as likely to have been vaccinated, controlling for age and chronic illness (OR?=?1.9, 95% CI?=?1.5-2.5, p?=?<0.001).
Conclusions
Having a medical card increased the likelihood of being vaccinated, independent of age and need. The mismatch between vaccination guidelines and reimbursement policy is creating unequal access to recommended services among high risk groups.

British Medical Journal
07 February 2015(vol 350, issue 7994)
http://www.bmj.com/content/350/7994

Analysis
International donations to the Ebola virus outbreak: too little, too late?
BMJ 2015;350:h376 (Published 03 February 2015)
Karen Grépin examines the pledges made to the Ebola crisis, how much has actually reached affected countries, and the lessons to be learnt
…In this article, I examine the level and speed of the international donations to tackle the Ebola epidemic and how they aligned with evolving estimates of funds required to bring the epidemic under control. Understanding what has and has not worked well in the early phases of this crisis can help us learn from it and prepare for future humanitarian and public health emergencies. My analysis considers only international donations captured in the UN Office for the Coordination of Humanitarian Affairs’ (OCHA) financial tracking system (http://fts.unocha.org, box), which does not capture all resources that have been pledged to the outbreak…
Key messages
:: Pledges to the Ebola outbreak have reached at least $2.89bn
:: However, only about one third of these resources have been be disbursed to countries
:: Delays have occurred in requests for funding and translating pledges into paid contributions
:: New mechanisms to speed up disbursements could help in future crises

Clinical Infectious Diseases (CID)
Volume 60 Issue 4 February 15, 2015
http://cid.oxfordjournals.org/content/current

Editor’s choice: Durability of Antibody Response Against Hepatitis B Virus in Healthcare Workers Vaccinated as Adults
Naveen Gara, Adil Abdalla, Elenita Rivera, Xiongce Zhao, Jens M. Werner, T. Jake Liang, Jay H. Hoofnagle, Barbara Rehermann, and Marc G. Ghany
Clin Infect Dis. (2015) 60 (4): 505-513 doi:10.1093/cid/ciu867
Protective antibody levels persist long-term in a majority of healthcare workers after initial immunization. Those without protective levels have a rapid and robust response to a booster vaccine, suggesting that immunologic memory is long-lasting and booster vaccination is probably unnecessary.

Hepatitis A and B Immunity and Vaccination in Chronic Hepatitis B and C Patients in a Large United States Cohort
Emily Henkle, Mei Lu, Lora B. Rupp, Joseph A. Boscarino, Vinutha Vijayadeva, Mark A. Schmidt,
and Stuart C. Gordon for the Chronic Hepatitis Cohort Study (CHeCS) Investigators
Clin Infect Dis. (2015) 60 (4): 514-522 doi:10.1093/cid/ciu879
Abstract Full Text (HTML) Full Text (PDF)
Among Chronic Hepatitis Cohort Study patients, approximately 40% of chronic hepatitis B and C patients were potentially susceptible to hepatitis A or B. Clinicians should consider antibody testing and vaccination for this vulnerable population.

Cost Effectiveness and Resource Allocation
(Accessed 7 February 2015)
http://www.resource-allocation.com/

Research
Cost-effectiveness of using a social franchise network to increase uptake of oral rehydration salts and zinc for childhood diarrhea in rural Myanmar
Bishai D, Sachathep K, LeFevre A, Thant HNN, Zaw M, Aung T, McFarland W, Montagu D et al. Cost Effectiveness and Resource Allocation 2015, 13:3 (5 February 2015)
Abstract (provisional)
Introduction
This paper examines the cost-effectiveness of achieving increases in the use of oral rehydration solution and zinc supplementation in the management of acute diarrhea in children under 5 years through social franchising. The study uses cost and outcome data from an initiative by Population Services International (PSI) in 3 townships of Myanmar in 2010 to promote an ORS-Zinc product called ORASEL.
Background
The objective of this study was to determine the incremental cost-effectiveness of a strategy to promote ORS-Z use through private sector franchising compared to standard government and private sector practices.
Methods
Costing from a societal perspective included program, provider, and household costs for the 2010 calendar year. Program costs including ORASEL program launch, distribution, and administration costs were obtained through a retrospective review of financial records and key informant interviews with staff in the central Yangon office. Household out of pocket payments for diarrheal episodes were obtained from a household survey conducted in the study area and additional estimates of household income lost due to parental care-giving time for a sick child were estimated. Incremental cost-effectiveness relative to status quo conditions was calculated per child death and DALY averted in 2010. Health effects included deaths and DALYs averted; the former modeled based on coverage estimates from a household survey that were entered into the Lives Saved Tool (LiST). Uncertainty was modeled with Monte Carlo methods.
Findings
Based on the model, the promotional strategy would translate to 2.85 (SD 0.29) deaths averted in a community population of 1 million where there would be 81,000 children under 5 expecting 48,373 cases of diarrhea. The incremental cost effectiveness of the franchised approach to improving ORASEL coverage is estimated at a median $5,955 (IQR: $3437-$7589) per death averted and $214 (IQR: $127-$287) per discounted DALY averted.
Interpretation
Investing in developing a network of private sector providers and keeping them stocked with ORS-Z as is done in a social franchise can be a highly cost-effective in terms of dollars per DALY averted.

Eurosurveillance
Volume 20, Issue 5, 05 February 2015
http://www.eurosurveillance.org/Public/Articles/Archives.aspx?PublicationId=11678

Editorials
Influenza – the need to stay ahead of the virus
by S van der Werf, D Lévy-Bruhl

Rapid communications
Low effectiveness of seasonal influenza vaccine in preventing laboratory-confirmed influenza in primary care in the United Kingdom: 2014/15 mid–season results
by RG Pebody, F Warburton, J Ellis, N Andrews, C Thompson, B von Wissmann, HK Green, S Cottrell, J Johnston, S de Lusignan, C Moore, R Gunson, C Robertson, J McMenamin, M Zambon

Reduced cross-protection against influenza A(H3N2) subgroup 3C.2a and 3C.3a viruses among Finnish healthcare workers vaccinated with 2013/14 seasonal influenza vaccine
by A Haveri, N Ikonen, I Julkunen, A Kantele, VJ Anttila, E Ruotsalainen, H Nohynek, O Lyytikäinen, C Savolainen-Kopra

Research articles
Interim estimates of 2014/15 influenza vaccine effectiveness in preventing laboratory-confirmed influenza-related hospitalisation from the Serious Outcomes Surveillance Network of the Canadian Immunization Research Network, January 2015
by SA McNeil, MK Andrew, L Ye, F Haguinet, TF Hatchette, M ElSherif, J LeBlanc, A Ambrose, A McGeer, JE McElhaney, M Loeb, D MacKinnon-Cameron, R Sharma, G Dos Santos, V Shinde, on behalf of the Investigators of the Serious Outcomes Surveillance Network of the Canadian Immunization Research Network (CIRN)

Globalization and Health
[Accessed 7 February 2015]
http://www.globalizationandhealth.com/

Research
Reverse innovation: an opportunity for strengthening health systems
Anne W Snowdon12*, Harpreet Bassi12, Andrew D Scarffe12 and Alexander D Smith12
Author Affiliations
Globalization and Health 2015, $article.volume.volumeNumber:2 doi:10.1186/s12992-015-0088-x
Published: 7 February 2015
Abstract (provisional)
Background
Canada, when compared to other OECD countries, ranks poorly with respect to innovation and innovation adoption while struggling with increasing health system costs. As a result of its failure to innovate, the Canadian health system will struggle to meet the needs and demands of both current and future populations. The purpose of this initiative was to explore if a competition-based reverse innovation challenge could mobilize and stimulate current and future leaders to identify and lead potential reverse innovation projects that address health system challenges in Canada.
Methods
An open call for applications took place over a 4-month period. Applicants were enticed to submit to the competition with a $50,000 prize for the top submission to finance their project. Leaders from a wide cross-section of sectors collectively developed evaluation criteria and graded the submissions. The criteria evaluated: proof of concept, potential value, financial impact, feasibility, and scalability as well as the use of prize money and innovation team.
Results
The competition received 12 submissions from across Canada that identified potential reverse innovations from 18 unique geographical locations that were considered developing and/or emerging markets. The various submissions addressed health system challenges relating to education, mobile health, aboriginal health, immigrant health, seniors health and women?s health and wellness. Of the original 12 submissions, 5 finalists were chosen and publically profiled, and 1 was chosen to receive the top prize.
Conclusions
The results of this initiative demonstrate that a competition that is targeted to reverse innovation does have the potential to mobilize and stimulate leaders to identify reverse innovations that have the potential for system level impact. The competition also provided important insights into the capacity of Canadian students, health care providers, entrepreneurs, and innovators to propose and implement reverse innovation in the context of the Canadian health system.

Health Research Policy and Systems
http://www.health-policy-systems.com/content
[Accessed 7 February 2015]

Commentary
Informing the establishment of the WHO global observatory on health research and development: a call for papers
Taghreed Adam, John-Arne Røttingen, Marie-Paule Kieny Health Research Policy and Systems 2015

Infectious Diseases of Poverty
[Accessed 7 February 2015]
http://www.idpjournal.com/content

Research Article
Incidence of human rabies exposure and associated factors at the Gondar Health Center, Ethiopia: a three-year retrospective study
Meseret Yibrah, Debasu Damtie Infectious Diseases of Poverty 2015, 4:3 (2 February 2015)
Abstract | Provisional PDF | Editor’s summary
A three year retrospective study revealed a significant incidence of human rabies exposure in Ethiopia. This study also depicted being male and living in urban areas as a potential risk factor for human rabies exposure. Image: Canine rabies is a significant problem in Ethiopia.

Research Article
Assessment of research productivity of Arab countries in the field of infectious diseases using Web of Science database
Waleed M Sweileh, Samah W Al-Jabi, Alaeddin Abuzanat, Ansam F Sawalha, Adham S AbuTaha, Mustafa A Ghanim, Sa¿ed H Zyoud Infectious Diseases of Poverty 2015, 4:2 (2 February 2015)
Abstract | Provisional PDF | Editor’s summary
Arab countries, like other developing poor countries, suffer from various types of infectious diseases. Some of these diseases might be endemic or unique to the Arab countries. However, Arab countries are still lagging behind in research in the field of infectious diseases. More efforts and further financial support are needed to encourage research and publications in this field. Image: Dr. Adham Abu Taha doing microbiological testing for specimens at An-Najah National University.

Journal of Global Infectious Diseases (JGID)
January-March 2015 Volume 7 | Issue 1 Page Nos. 1-50
http://www.jgid.org/currentissue.asp?sabs=n

Editorial
State of Globe: Rabies: The lethality since antiquity!
Inder Maurya, Ketan Vagholkar, Bhavesh Patel, Mohsin Siddiqui, Shreshtha Tiwari, Premkumar Maurya
DOI:10.4103/0974-777X.150880

Journal of Medical Internet Research
Vol 17, No 2 (2015): February
http://www.jmir.org/2015/2

Knowledge, Attitudes, and Practices Regarding Avian Influenza A (H7N9) Among Mobile Phone Users: A Survey in Zhejiang Province, China
Hua Gu, Zhenggang Jiang, Bin Chen, Jueman (Mandy) Zhang, Zhengting Wang, Xinyi Wang, Jian Cai, Yongdi Chen, Dawei Zheng, Jianmin Jiang
JMIR mHealth uHealth 2015 (Feb 04); 3(1):e15

The Lancet
Feb 07, 2015 Volume 385 Number 9967 p481-576 e5-e6
http://www.thelancet.com/journals/lancet/issue/current

Editorial
Don’t forget health when you talk about human rights
The Lancet
Last week, Human Rights Watch (HRW) released World Report 2015, their 25th annual global review documenting human rights practices in more than 90 countries and territories in 2014. The content is based on a comprehensive investigation by HRW staff, together with in-country human rights activists. In his opening essay, HRW’s Executive Director, Kenneth Roth, writes, “The world has not seen this much tumult in a generation…it can seem as if the world is unravelling”. Indeed, this 656-page report is a grim read in a year marked by extensive conflict and extreme violence.

The Lancet Global Health
Feb 2015 Volume 3 Number 2 e62-e112
http://www.thelancet.com/journals/langlo/issue/current

Editorial
All about the money
Zoë Mullan
Open Access
DOI: http://dx.doi.org/10.1016/S2214-109X(15)70003-3
Summary
It’s finally 2015: a year by the end of which extreme poverty and hunger are to be eradicated, maternal and child mortality are to be drastically reduced, and the trajectory of the global incidence of HIV, tuberculosis, and malaria are to be reversed. Much has been written about where the Millennium Development Goals succeeded and failed as global targets, and what has changed in the world since 2000. Much work has also been done to establish what happens next. In his synthesis report on the post-2015 agenda released last month, UN Secretary-General Ban Ki-Moon summarised and annotated this work, ultimately backing the 17 goals proposed by the Open Working Group on Sustainable Development Goals as the basis for a truly transformative agenda.

Articles
Effect of self-collection of HPV DNA offered by community health workers at home visits on uptake of screening for cervical cancer (the EMA study): a population-based cluster-randomised trial
Dr Silvina Arrossi, PhD, Laura Thouyaret, BSc, Rolando Herrero, PhD, Alicia Campanera, MD, Adriana Magdaleno, BSc, Milca Cuberli, MSc, Paula Barletta, BSc, Rosa Laudi, MD, Liliana Orellana, PhD, the EMA Study team
EMA Study team members listed at end of reportOpen Access
DOI: http://dx.doi.org/10.1016/S2214-109X(14)70354-7
Open access funded by the Author(s)
Summary
Background
Control of cervical cancer in developing countries has been hampered by a failure to achieve high screening uptake. HPV DNA self-collection could increase screening coverage, but implementation of this technology is difficult in countries of middle and low income. We investigated whether offering HPV DNA self-collection during routine home visits by community health workers could increase cervical screening.
Methods
We did a population-based cluster-randomised trial in the province of Jujuy, Argentina, between July 1, 2012, and Dec 31, 2012. Community health workers were eligible for the study if they scored highly on a performance score, and women aged 30 years or older were eligible for enrolment by the community health worker. 200 community health workers were randomly allocated in a 1:1 ratio to either the intervention group (offered women the chance to self-collect a sample for cervical screening during a home visit) or the control group (advised women to attend a health clinic for cervical screening). The primary outcome was screening uptake, measured as the proportion of women having any HPV screening test within 6 months of the community health worker visit. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT02095561.
Findings
100 community health workers were randomly allocated to the intervention group and 100 were assigned to the control group; nine did not take part. 191 participating community health workers (94 in the intervention group and 97 in the control group) initially contacted 7650 women; of 3632 women contacted by community health workers in the intervention group, 3049 agreed to participate; of 4018 women contacted by community health workers in the control group, 2964 agreed to participate. 2618 (86%) of 3049 women in the intervention group had any HPV test within 6 months of the community health worker visit, compared with 599 (20%) of 2964 in the control group (risk ratio 4•02, 95% CI 3•44–4•71).
Interpretation
Offering self-collection of samples for HPV testing by community health workers during home visits resulted in a four-fold increase in screening uptake, showing that this strategy is effective to improve cervical screening coverage. This intervention reduces women’s barriers to screening and results in a substantial and rapid increase in coverage. Our findings suggest that HPV testing could be extended throughout Argentina and in other countries to increase cervical screening coverage.
Funding
Instituto Nacional del Cáncer (Argentina).

New England Journal of Medicine
February 5, 2015 Vol. 372 No. 6
http://www.nejm.org/toc/nejm/medical-journal

Editorial
Ebola in West Africa at One Year — From Ignorance to Fear to Roadblocks
Jeffrey M. Drazen, M.D., Edward W. Campion, M.D., Eric J. Rubin, M.D., Ph.D., Stephen Morrissey, Ph.D., and Lindsey R. Baden, M.D.
N Engl J Med 2015; 372:563-564 February 5, 2015 DOI: 10.1056/NEJMe1415398

It has been a year since the first case associated with the current Ebola virus outbreak in West Africa was identified and just over 8 months since we first started reporting on the outbreaks that stemmed from that patient in Guinea.1 Today’s posts at NEJM.org include an anniversary update on the fight against Ebola virus disease (EVD).2 It is painfully clear that the world’s initial handling of this dangerous outbreak was far from optimal, but we now appear to be making progress in the battle. This headway is evidenced by the observations that the rate of appearance of new cases is not as high as had been predicted by the World Health Organization or the U.S. Centers for Disease Control and Prevention in September 2014 and that outcomes may be improving at some Ebola treatment units.2,3

Patients in the hardest-hit areas are able to receive care at one of many Ebola treatment units that have been set up in West Africa. These units now offer hope for patients with EVD in places where 6 months ago there was little care available and little hope. The ongoing case finding and contact tracing are essential to preventing new outbreak clusters. Staffing the treatment units, tracing contacts, and providing basic health care services for the populations in the most severely affected areas, where the health care infrastructure has been devastated, are just a few of the tasks that must be performed if the battle against Ebola is to be won. If we don’t bring this outbreak to a halt now, it may again expand throughout the region and spread to other parts of the world. To deliver a victory, we need more volunteers who are willing to serve, to live in austere conditions, and to put themselves in harm’s way. All estimates indicate that the number of personnel needed far exceeds the current supply. We need to make it easier for those who want to help in the fight against Ebola to do so.

That brings us to academic medical centers in the United States. As the Ebola outbreak has burned its way deep into Guinea, Liberia, and Sierra Leone, in one of the worst acute public health crises in 50 years, our academic medical centers have sat largely on the sidelines. They have spent a fortune preparing their facilities and staff for the much-feared scenario of a local patient with possible Ebola virus infection. What has been lacking is leadership to help quell the crisis where it is actually happening. The problem is more than a lack of effective, positive leadership, as Rosenbaum reports4: the difficulties created by many academic medical centers for trainees and staff who want to go to West Africa to help control this outbreak are more akin to roadblocks. This response stands in contrast to that in the United Kingdom, where the Wellcome Trust has encouraged academic institutions to join the fight and has provided emergency funding for their research initiatives, and to that of the U.S. National Institute of Allergy and Infectious Diseases, which is offering extensions for grant renewals to people who have taken time to participate in Ebola mitigation efforts.

The medical centers that have helped pave the way for their personnel to fight Ebola deserve praise. The leaders of academic medical centers that have put roadblocks in the path of those wishing to serve need to rethink their priorities. They should be making it easier, not harder, for altruistic physicians, nurses, and other health care providers to help care for the sick and control the Ebola epidemic in West Africa. Our medical centers have immense resources and expertise; the countries wracked by Ebola have almost none. Something is wrong when some of the greatest health care centers in the world are not helping in the fight against this disastrously dangerous threat to human health. We ask the leaders of every medical center in the country to figure out how to make it possible for their staff, and even qualified trainees, to help on the ground in West Africa. And once the leaders have decided what to do, they need to tell their risk managers and their lawyers to make it work, rather than make decisions based on the worst-case scenarios and risks to their reputation, image, and market share painted by corporate advisors and legal staff. If in a year’s time this epidemic has not been controlled, we will have only ourselves to blame.

Pediatrics
February 2015, VOLUME 135 / ISSUE 2
http://pediatrics.aappublications.org/current.shtml

Article
Safety of Measles-Containing Vaccines in 1-Year-Old Children
Nicola P. Klein, MD, PhDa, Edwin Lewis, MPHa, Bruce Fireman, MAa, Simon J. Hambidge, MD, hDb, Allison Naleway, PhDc, Jennifer C. Nelson, PhDd, Edward A. Belongia, MDe, W. Katherine Yih, PhD, MPHf, James D. Nordin, MD, MPHg, Rulin C. Hechter, MD, PhDh, Eric Weintraub, MPHi, and Roger Baxter, MDa
Author Affiliations
aKaiser Permanente Vaccine Study Center, Oakland, California;
bKaiser Permanente Colorado Institute for Health Research, Denver and Department of Ambulatory Care Services, Denver Health, Denver, Colorado;
cThe Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon;
dGroup Health Cooperative and the University of Washington, Seattle, Washington;
eCenter for Clinical Epidemiology & Population Health, Marshfield Clinic Research Foundation, Marshfield, Wisconsin;
fHarvard Pilgrim Health Care Institute, Boston, Massachusetts;
gHealthPartners Research Foundation, Minneapolis, Minnesota;
hResearch and Evaluation, Kaiser Permanente Southern California, Pasadena, California; and
iImmunization Safety Office, Centers for Disease Control and Prevention, Atlanta, Georgia
Abstract
BACKGROUND AND OBJECTIVES: All measles-containing vaccines are associated with several types of adverse events, including seizure, fever, and immune thrombocytopenia purpura (ITP). Because the measles-mumps-rubella-varicella (MMRV) vaccine compared with the separate measles-mumps-rubella (MMR) and varicella (MMR + V) vaccine increases a toddler’s risk for febrile seizures, we investigated whether MMRV is riskier than MMR + V and whether either vaccine elevates the risk for additional safety outcomes.
METHODS: Study children were aged 12 to 23 months in the Vaccine Safety Datalink from 2000 to 2012. Nine study outcomes were investigated: 7 main outcomes (anaphylaxis, ITP, ataxia, arthritis, meningitis/encephalitis, acute disseminated encephalomyelitis, and Kawasaki disease), seizure, and fever. Comparing MMRV with MMR + V, relative risk was estimated by using stratified exact binomial tests. Secondary analyses examined post-MMRV or MMR + V risk versus comparison intervals; risk and comparison intervals were then contrasted for MMRV versus MMR+V.
RESULTS: We evaluated 123 200 MMRV and 584 987 MMR + V doses. Comparing MMRV with MMR + V, risks for the 7 main outcomes were not significantly different. Several outcomes had few or zero postvaccination events. Comparing risk versus comparison intervals, ITP risk was higher after MMRV (odds ratio [OR]: 11.3 [95% confidence interval (CI): 1.9 to 68.2]) and MMR + V (OR: 10 [95% CI: 4.5 to 22.5]) and ataxia risk was lower after both vaccines (MMRV OR: 0.8 [95% CI: 0.5 to 1]; MMR + V OR: 0.8 [95% CI: 0.7 to 0.9]). Compared with MMR + V, MMRV increased risk of seizure and fever 7 to 10 days after vaccination.
CONCLUSIONS: This study did not identify any new safety concerns comparing MMRV with MMR + V or after either the MMRV or the MMR + V vaccine. This study provides reassurance that these outcomes are unlikely after either vaccine.

.
Article
Variation in Rotavirus Vaccine Coverage by Provider Location and Subsequent Disease Burden
Leila C. Sahni, MPHa, Jacqueline E. Tate, PhDb, Daniel C. Payne, PhD, MSPHb, Umesh D. Parashar, MBBS, MPHb, and Julie A. Boom, MDa,c
Author Affiliations
aImmunization Project, Texas Children’s Hospital, Houston, Texas;
bDivision of Viral Diseases, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia; and
cDepartment of Pediatrics, Baylor College of Medicine, Houston, Texas
Abstract
BACKGROUND: Rotavirus vaccines were introduced in the United States in 2006. Full-series coverage is lower than for other vaccines, and disease continues to occur. We examined variation in vaccine coverage among provider locations and correlated coverage with the detection of rotavirus in children who sought treatment of severe acute gastroenteritis (AGE).
METHODS: Vaccine records of children enrolled in an AGE surveillance program were obtained and children were grouped by the location that administered each child’s 2-month vaccines. Cases were children with laboratory-confirmed rotavirus AGE; controls were children with rotavirus-negative AGE or acute respiratory infection. Location-level coverage was calculated using ≥1 dose rotavirus vaccine coverage among controls and classified as low (<40%), medium (≥40% to <80%), or high (≥80%). Rotavirus detection rates among patients with AGE were calculated by vaccine coverage category.
RESULTS: Of controls, 80.4% (n = 1123 of 1396) received ≥1 dose of rotavirus vaccine from 68 locations. Four (5.9%) locations, including a NICU, were low coverage, 22 (32.3%) were medium coverage, and 42 (61.8%) were high coverage. In low-coverage locations, 31.4% of patients with AGE were rotavirus-positive compared with 13.1% and 9.6% in medium- and high-coverage locations, respectively. Patients with AGE from low-coverage locations had 3.3 (95% confidence interval 2.4–4.4) times the detection rate of rotavirus than patients with AGE from high vaccine coverage locations.
CONCLUSIONS: We observed the highest detection of rotavirus disease among locations with low rotavirus vaccine coverage, suggesting that ongoing disease transmission is related to failure to vaccinate. Educational efforts focusing on timely rotavirus vaccine administration to age-eligible infants are needed.

.
Article
Geographic Clusters in Underimmunization and Vaccine Refusal
Tracy A. Lieu, MD, MPHa, G. Thomas Ray, MBAa, Nicola P. Klein, MD, PhDa,b, Cindy Chung, MDc, and Martin Kulldorff, PhDd
Author Affiliations
aDivision of Research, Kaiser Permanente Northern California, Oakland, California;
bVaccine Study Center, Kaiser Permanente, Oakland, California;
cDepartment of Pediatrics, San Rafael Medical Center, Kaiser Permanente Northern California, San Rafael, California; and
dDepartment of Population Medicine, Harvard Pilgrim Health Care and Harvard Medical School, Boston, Massachusetts
Abstract
BACKGROUND AND OBJECTIVE: Parental refusal and delay of childhood vaccines has increased in recent years and is believed to cluster in some communities. Such clusters could pose public health risks and barriers to achieving immunization quality benchmarks. Our aims were to (1) describe geographic clusters of underimmunization and vaccine refusal, (2) compare clusters of underimmunization with different vaccines, and (3) evaluate whether vaccine refusal clusters may pose barriers to achieving high immunization rates.
METHODS: We analyzed electronic health records among children born between 2000 and 2011 with membership in Kaiser Permanente Northern California. The study population included 154 424 children in 13 counties with continuous membership from birth to 36 months of age. We used spatial scan statistics to identify clusters of underimmunization (having missed 1 or more vaccines by 36 months of age) and vaccine refusal (based on International Classification of Diseases, Ninth Revision, Clinical Modification codes).
RESULTS: We identified 5 statistically significant clusters of underimmunization among children who turned 36 months old during 2010–2012. The underimmunization rate within clusters ranged from 18% to 23%, and the rate outside them was 11%. Children in the most statistically significant cluster had 1.58 (P < .001) times the rate of underimmunization as others. Underimmunization with measles, mumps, rubella vaccine and varicella vaccines clustered in similar geographic areas. Vaccine refusal also clustered, with rates of 5.5% to 13.5% within clusters, compared with 2.6% outside them.
CONCLUSIONS: Underimmunization and vaccine refusal cluster geographically. Spatial scan statistics may be a useful tool to identify locations with challenges to achieving high immunization rates, which deserve focused intervention.

.
Review Article
Duration of Pertussis Immunity After DTaP Immunization: A Meta-analysis
Ashleigh McGirr, MPH and David N. Fisman, MD, MPH, FRCPC
Author Affiliations
Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
Abstract
BACKGROUND AND OBJECTIVES: Pertussis incidence is increasing, possibly due to the introduction of acellular vaccines, which may have decreased the durability of immune response. We sought to evaluate and compare the duration of protective immunity conferred by a childhood immunization series with 3 or 5 doses of diphtheria-tetanus-acellular pertussis (DTaP).
METHODS: We searched Medline and Embase for articles published before October 10, 2013. Included studies contained a measure of long-term immunity to pertussis after 3 or 5 doses of DTaP. Twelve articles were eligible for inclusion; 11 of these were included in the meta-analysis. We assessed study quality and used meta-regression models to evaluate the relationship between the odds of pertussis and time since last dose of DTaP and to estimate the probability of vaccine failure through time.
RESULTS: We found no significant difference between the annual odds of pertussis for the 3- versus 5-dose DTaP regimens. For every additional year after the last dose of DTaP, the odds of pertussis increased by 1.33 times (95% confidence interval: 1.23–1.43). Assuming 85% vaccine efficacy, we estimated that 10% of children vaccinated with DTaP would be immune to pertussis 8.5 years after the last dose. Limitations included the statistical model extrapolated from data and the different study designs included, most of which were observational study designs.
CONCLUSIONS: Although acellular pertussis vaccines are considered safer, the adoption of these vaccines may necessitate earlier booster vaccination and repeated boosting strategies to achieve necessary “herd effects” to control the spread of pertussis.

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Quality Report
Quality Improvement Initiative to Increase Influenza Vaccination in Pediatric Cancer Patients
Jason L. Freedman, MD, MSCEa, Anne F. Reilly, MD, MPHa,b, Stephanie C. Powell, MSNc, and
L. Charles Bailey, MD, PhDa,b
Author Affiliations
aDivision of Oncology, and
cDepartment of Nursing, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania; and
bDepartment of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
Abstract
BACKGROUND: Pediatric patients with cancer face more severe complications of influenza than healthy children. Although Centers for Disease Control and Prevention guidelines recommend yearly vaccination in these patients, in our large academic center, <60% of oncology patients receiving chemotherapy were immunized at baseline. Our objective was to increase this rate through a multifaceted quality improvement initiative.
METHODS: Eligible patients were >6 months old, within 1 year of receiving chemotherapy, >100 days from stem cell transplant, and had ≥1 outpatient oncology visit between September 1, 2012, and March 31, 2013. Five interventions were instituted concomitantly: (1) family education: influenza/vaccine handouts were provided to families in clinic waiting rooms; (2) health informatics: daily lists of outpatients due for immunization were generated from the electronic medical record and sent automatically to triage staff and nurses; (3) outpatient clinic: patients due for vaccination were given colored wristbands during triage to alert providers; (4) inpatient: vaccine order was built into admission order set; and (5) provider education: staff education was provided at conferences on screening of patients, vaccine ordering, and documentation of refusals/contraindications.
RESULTS: The complete influenza immunization rate increased by 20.1% to 64.5%, and the proportion of patients receiving ≥1 dose of vaccination increased by 22.9% to 77.7%. Similar changes were noted across all cancer types, with highest rates of immunization in leukemia/lymphoma patients (86.8%) and lowest in patients after stem cell transplant (66.7%).
CONCLUSIONS: Technology, education, and multidisciplinary clinical process changes increased influenza vaccination rates. Ongoing efforts are targeting subgroups with lowest rates of immunization.

PLoS Currents: Outbreaks
http://currents.plos.org/outbreaks/
(Accessed 7 February 2015)

Measles Vaccination Coverage Survey in Moba, Katanga, Democratic Republic of Congo, 2013: Need to Adapt Routine and Mass Vaccination Campaigns to Reach the Unreached
February 2, 2015 • Research
Julita Gil Cuesta, Narcisse Mukembe, Palle Valentiner-Branth, Pawel Stefanoff, Annick Lenglet
The Democratic Republic of Congo (DRC) has committed to eliminate measles by 2020. In 2013, in response to a large outbreak, Médecins Sans Frontières conducted a mass vaccination campaign (MVC) in Moba, Katanga, DRC. We estimated the measles vaccination coverage for the MVC, the Expanded Programme on Immunization routine measles vaccination (EPI) and assessed reasons for non-vaccination.
We conducted a household-based survey among caretakers of children aged 6 months-15 years in Moba from November to December 2013. We used a two-stage-cluster-sampling, where clusters were allocated proportionally to village size and households were randomly selected from each cluster. The questionnaire included demographic variables, vaccination status (card or oral history) during MVC and EPI and reasons for non-vaccination. We estimated the coverage by gender, age and the reasons for non-vaccination and calculated 95% confidence intervals (95% CI).
We recruited 4,768 children living in 1,684 households. The MVC coverage by vaccination card and oral history was 87% (95% CI 84-90) and 66% (95% CI 61-70) if documented by card. The EPI coverage was 76% (95% CI 72-81) and 3% (95% CI 1-4) respectively. The MVC coverage was significantly higher among children previously vaccinated during EPI 91% (95% CI 88-93), compared to 74% (95% CI 66-80) among those not previously vaccinated. Six percent (n=317) of children were never vaccinated. The main reason for non-vaccination was family absence 68% (95% CI 58-78).
The MVC and EPI measles coverage was insufficient to prevent the recurrence of outbreaks in Moba. Lack of EPI vaccination and lack of accessibility by road were associated with lower MVC coverage. We recommend intensified social mobilization and extended EPI and MVCs to increase the coverage of absent residents and unreached children. Routine and MVCs need to be adapted accordingly to improve coverage in hard-to-reach populations in DRC.
Conclusions
We estimated 87% coverage of the MVC in response to the measles outbreak in Moba territory. This coverage may be insufficient to prevent future outbreaks. Lack of a EPI vaccination and lack of accessibility by road were associated with lower MVC campaign coverage. Absence during the MVC and EPI vaccination were the main reasons for non-vaccination. On the basis of these conclusions, we recommend more accessible vaccination sites for each village in order to improve vaccination coverage during EPI and MVCs. We recommend improved social mobilization of the population through extended vaccination time in less accessible villages and to give notice well ahead of vaccination days. Campaign staff must emphasise children and their parents the importance of keeping the vaccination cards. EPI and MVCs need to be adapted accordingly to face these logistical and communication barriers. Hence, the vaccination of hard-to-reach children can contribute to meet the goal of measles elimination in DRC and similar settings.

PLoS Medicine
(Accessed 7 February 2015)
http://www.plosmedicine.org/

Enabling Dynamic Partnerships through Joint Degrees between Low- and High-Income Countries for Capacity Development in Global Health Research: Experience from the Karolinska Institutet/Makerere University Partnership
Nelson Sewankambo, James K. Tumwine, Göran Tomson, Celestino Obua, Freddie Bwanga, Peter Waiswa, Elly Katabira, Hannah Akuffo, Kristina Persson, Stefan Peterson
Health in Action | published 03 Feb 2015 | PLOS Medicine 10.1371/journal.pmed.1001784
Summary Points
:: Partnerships between universities in high- and low-income countries have the potential to increase research capacity in both settings.
:: We describe a partnership between the Karolinska Institutet in Sweden and Makerere University in Uganda that includes a joint PhD degree program and sharing of scientific ideas and resources.
:: Ten years of financial support from the Swedish International Development Cooperation Agency has enabled 44 graduated PhD students and more than 500 peer-reviewed articles, the majority with a Ugandan as first author.
:: The collaborative research environment is addressing Ugandan health and health system priorities, in several cases resulting in policy and practice reforms.
:: Even though all Ugandan PhD graduates have remained in the country and 13 have embarked on postdoc training, remaining institutional challenges include developing functioning research groups, grant writing, network building at Makerere, and continued funding on both sides of the partnership.