PLoS Currents: Outbreaks
http://currents.plos.org/outbreaks/
(Accessed 11 April 2015)

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Public Knowledge, Perception and Source of Information on Ebola Virus Disease – Lagos, Nigeria; September, 2014
April 8, 2015 • Research
Background: The first ever outbreak of Ebola virus disease (EVD) in Nigeria was declared in July, 2014. Level of public knowledge, perception and adequacy of information on EVD were unknown. We assessed the public preparedness level to adopt disease preventive behavior which is premised on appropriate knowledge, perception and adequate information.
Methods: We enrolled 5,322 respondents in a community-based cross-sectional study. We used interviewer-administered questionnaire to collect data on socio-demographic characteristics, EVD–related knowledge, perception and source of information. We performed univariate and bivariate data analysis using Epi-Info software setting p-value of 0.05 as cut-off for statistical significance.
Results: Mean age of respondents was 34 years (± 11.4 years), 52.3% were males. Forty one percent possessed satisfactory general knowledge; 44% and 43.1% possessed satisfactory knowledge on mode of spread and preventive measures, respectively. Residing in EVD cases districts, male respondents and possessing at least secondary education were positively associated with satisfactory general knowledge (p-value: 0.01, 0.001 and 0.000004, respectively). Seventy one percent perceived EVD as a public health problem while 61% believed they cannot contract the disease. Sixty two percent and 64% of respondents will not shake hands and hug a successfully treated EVD patient respectively. Only 2.2% of respondents practice good hand-washing practice. Television (68.8%) and radio (55.0%) are the most common sources of information on EVD.
Conclusions: Gaps in EVD-related knowledge and perception exist. Targeted public health messages to raise knowledge level, correct misconception and discourage stigmatization should be widely disseminated, with television and radio as media of choice.

PLoS Medicine
(Accessed 11 April 2015)
http://www.plosmedicine.org/

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Policy Forum
Improving Men’s Participation in Preventing Mother-to-Child Transmission of HIV as a Maternal, Neonatal, and Child Health Priority in South Africa
Wessel van den Berg, Kirsty Brittain, Gareth Mercer, Dean Peacock, Kathryn Stinson, Hanna Janson, Vuyiseka Dubula
Published: April 7, 2015
DOI: 10.1371/journal.pmed.1001811
Summary Points
– Involving male partners in programmes to prevent mother-to-child transmission of HIV may improve programme coverage and infant outcomes.
– Rates of male partner involvement remain low worldwide, and detailed guidelines to increase involvement are lacking in South Africa.
– We recommend that South African national and provincial guidelines and policies for preventing mother-to-child HIV transmission be adjusted to explicitly include a focus on increasing male partner involvement and that they include concrete descriptions of how to achieve this.
– We propose recommendations for improving male partner involvement at a policy, facility, and community level.
– Challenges to improving male partner involvement include the nature of relationships and family structures in South Africa and the capacity of health systems to implement recommendations.

PLoS Neglected Tropical Diseases
http://www.plosntds.org/
(Accessed 11 April 2015)

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Research Article
Community-Centered Responses to Ebola in Urban Liberia: The View from Below
Sharon Alane Abramowitz, Kristen E. McLean, Sarah Lindley McKune, Kevin Louis Bardosh, Mosoka Fallah, Josephine Monger, Kodjo Tehoungue, Patricia A. Omidian
Published: April 9, 2015
DOI: 10.1371/journal.pntd.0003706
Abstract
Background
The West African Ebola epidemic has demonstrated that the existing range of medical and epidemiological responses to emerging disease outbreaks is insufficient, especially in post-conflict contexts with exceedingly poor healthcare infrastructures. In this context, community-based responses have proven vital for containing Ebola virus disease (EVD) and shifting the epidemic curve. Despite a surge in interest in local innovations that effectively contained the epidemic, the mechanisms for community-based response remain unclear. This study provides baseline information on community-based epidemic control priorities and identifies innovative local strategies for containing EVD in Liberia.
Methodology/Principal Findings
This study was conducted in September 2014 in 15 communities in Monrovia and Montserrado County, Liberia – one of the epicenters of the Ebola outbreak. Findings from 15 focus group discussions with 386 community leaders identified strategies being undertaken and recommendations for what a community-based response to Ebola should look like under then-existing conditions. Data were collected on the following topics: prevention, surveillance, care-giving, community-based treatment and support, networks and hotlines, response teams, Ebola treatment units (ETUs) and hospitals, the management of corpses, quarantine and isolation, orphans, memorialization, and the need for community-based training and education. Findings have been presented as community-based strategies and recommendations for (1) prevention, (2) treatment and response, and (3) community sequelae and recovery. Several models for community-based management of the current Ebola outbreak were proposed. Additional findings indicate positive attitudes towards early Ebola survivors, and the need for community-based psychosocial support.
Conclusions/Significance
Local communities’ strategies and recommendations give insight into how urban Liberian communities contained the EVD outbreak while navigating the systemic failures of the initial state and international response. Communities in urban Liberia adapted to the epidemic using multiple coping strategies. In the absence of health, infrastructural and material supports, local people engaged in self-reliance in order to contain the epidemic at the micro-social level. These innovations were regarded as necessary, but as less desirable than a well-supported health-systems based response; and were seen as involving considerable individual, social, and public health costs, including heightened vulnerability to infection.
Author Summary
In this study the authors analyzed data from the 2014 Ebola outbreak in Monrovia and Montserrado County, Liberia. The data were collected for the purposes of program design and evaluation by the World Health Organization (WHO) and the Government of Liberia (GOL), in order to identify: (1) local knowledge about EVD, (2) local responses to the outbreak, and (3) community-based innovations to contain the virus. At the time of data collection, the international Ebola response had little insight into how much local Liberian communities knew about Ebola, and how communities managed the epidemic when they could not get access to care due to widespread hospital and clinic closures. Methods included 15 focus group discussions with community leaders from areas with active Ebola cases. Participants were asked about best practices and what they were currently doing to manage EVD in their respective communities, with the goal of developing conceptual models of local responses informed by local narratives. Findings reveal that communities responded to the outbreak in numerous ways that both supported and discouraged formal efforts to contain the spread of the disease. This research will inform global health policy for both this, and future, epidemic and pandemic responses.

PLoS One
[Accessed 11 April 2015]
http://www.plosone.org/

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Can Reproductive Health Voucher Programs Improve Quality of Postnatal Care? A Quasi-Experimental Evaluation of Kenya’s Safe Motherhood Voucher Scheme
Claire Watt, Timothy Abuya, Charlotte E. Warren, Francis Obare, Lucy Kanya, Ben Bellows Research Article | published 02 Apr 2015 | PLOS ONE 10.1371/journal.pone.0122828
Abstract
This study tests the group-level causal relationship between the expansion of Kenya’s Safe Motherhood voucher program and changes in quality of postnatal care (PNC) provided at voucher-contracted facilities. We compare facilities accredited since program inception in 2006 (phase I) and facilities accredited since 2010-2011 (phase II) relative to comparable non-voucher facilities. PNC quality is assessed using observed clinical content processes, as well as client-reported outcome measures. Two-tailed unpaired t-tests are used to identify differences in mean process quality scores and client-reported outcome measures, comparing changes between intervention and comparison groups at the 2010 and 2012 data collection periods. Difference-in-differences analysis is used to estimate the reproductive health (RH) voucher program’s causal effect on quality of care by exploiting group-level differences between voucher-accredited and non-accredited facilities in 2010 and 2012. Participation in the voucher scheme since 2006 significantly improves overall quality of postnatal care by 39% (p=0.02), where quality is defined as the observable processes or components of service provision that occur during a PNC consultation. Program participation since phase I is estimated to improve the quality of observed maternal postnatal care by 86% (p=0.02), with the largest quality improvements in counseling on family planning methods (IRR 5.0; p=0.01) and return to fertility (IRR 2.6; p=0.01). Despite improvements in maternal aspects of PNC, we find a high proportion of mothers who seek PNC are not being checked by any provider after delivery. Additional strategies will be necessary to standardize provision of packaged postnatal interventions to both mother and newborn. This study addresses an important gap in the existing RH literature by using a strong evaluation design to assess RH voucher program effectiveness on quality improvement.

PNAS – Proceedings of the National Academy of Sciences of the United States of America
http://www.pnas.org/content/early/
(Accessed 11 April 2015)

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Robust and sustained immune activation in human Ebola virus infection
Judith N. Mandla and Mark B. Feinbergb,1
Author Affiliations
Extract
Ebola viruses (EBOV) are zoonotic infectious agents that are highly pathogenic in humans, causing severe hemorrhagic fever with fatality rates of ∼50–70% (1). This genus of negative single-stranded RNA viruses consists of five known species that are part of the Filoviridae family. The current EBOV outbreak in western Africa began in March 2014 and has since resulted in >24,000 cases and >10,000 deaths (1). This 25th known EBOV outbreak is unprecedented in its magnitude, duration, and societal impact. Given the likelihood of future EBOV outbreaks, significant efforts are being devoted to develop vaccines that block EBOV transmission and novel therapeutic interventions to treat infected individuals (2, 3). Progress in these pursuits requires better understanding of what key elements of the immune response correlate with virus replication control and protection from disease. In PNAS, McElroy et al. report the results of their study of the cellular and humoral immune responses of four EBOV-infected people treated at Emory University (all of whom received experimental therapies) (4). Their data provide critical insight into aspects of the host response in humans to EBOV that have not previously been examined using contemporary immunologic methods, and provide the foundation for future studies, elucidating immune responses mediating effective virus control.

PNAS – Proceedings of the National Academy of Sciences of the United States of America
http://www.pnas.org/content/early/
(Accessed 11 April 2015)

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Effective and lesion-free cutaneous influenza vaccination
Ji Wang1, Bo Li1, and Mei X. Wu2
Author Affiliations
Significance
Skin is more potent than muscle for vaccination, but it is not yet a common site for immunization, in part owing to relatively high rates of pain and skin irritation and difficulty of administration. We resolve this dilemma by delivering vaccines into many micropores in the skin, which constrains vaccine-induced inflammation, leading to fast healing and lesion-free. Moreover, combination of microfractional vaccine delivery with nonablative fractional laser (NAFL), not only significantly augmented vaccine efficiency but also broadened cross-protection against homologous and heterologous influenza viral infections. Cross-protective immunity is pivotal for influenza vaccines because mismatches occur frequently between vaccine viral strains and circulating viruses. To the best of our knowledge, this represents the first strategy for lesion-free efficient cutaneous vaccination.

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Abstract
The current study details efficient lesion-free cutaneous vaccination via vaccine delivery into an array of micropores in the skin, instead of bolus injection at a single site. Such delivery effectively segregated vaccine-induced inflammation, resulting in rapid resolution of the inflammation, provided that distances between any two micropores were sufficient. When the inoculation site was treated by FDA-approved nonablative fractional laser (NAFL) before insertion of a PR8 model influenza vaccine-packaged, biodegradable microneedle array (MNs), mice displayed vigorous antigen-uptake, eliciting strong Th1-biased immunity. These animals were completely protected from homologous viral challenges, and fully or partially protected from heterologous H1N1 and H3N2 viral challenges, whereas mice receiving MNs alone suffered from severe illnesses or died of similar viral challenges. NAFL-mediated adjuvanicity was ascribed primarily to dsDNA and other “danger” signals released from laser-damaged skin cells. Thus, mice deficient in dsDNA-sensing pathway, but not Toll like receptor (TLR) or inflammasome pathways, showed poor responses to NAFL. Importantly, with this novel approach both mice and swine exhibited strong protective immunity without incurring any appreciable skin irritation, in sharp contrast to the overt skin irritation caused by intradermal injections. The effective lesion-free cutaneous vaccination merits further clinical studies.

Revista Panamericana de Salud Pública/Pan American Journal of Public Health (RPSP/PAJPH)
February 2015 Vol. 37, No. 2
http://www.paho.org/journal/index.php?option=com_content&view=article&id=151&Itemid=266&lang=en

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ARTÍCULOS DE INVESTIGACIÓN ORIGINAL / ORIGINAL RESEARCH ARTICLES
An adequacy evaluation of a maternal health intervention in rural Honduras: the impact of women [Evaluación de la suficiencia de una intervención de salud materna en un entorno rural de Honduras: repercusión de la participación de los hombres y el empoderamiento de las mujeres]
Peter R. Berti, Salim Sohani, Edith da Costa, Naomi Klaas, Luis Amendola, and Joel Duron

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TEMAS DE ACTUALIDAD / CURRENT TOPIC
Trends in research involving human beings in Brazil [Tendencias en la investigación con seres humanos en el Brasil]
Ricardo Eccard da Silva, Maria Rita Carvalho Novaes, Elza Martínez Pastor, Elena Barragan, and Angélica Amorim Amato

Science
10 April 2015 vol 348, issue 6231, pages 153-256
http://www.sciencemag.org/current.dtl

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Editorial
NIH research: Think globally
Anthony S. Fauci1, Francis S. Collins2,
1Anthony S. Fauci is director of the U.S. National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD.
2Francis S. Collins is director of the U.S. National Institutes of Health, Bethesda, MD.

The U.S. National Institutes of Health (NIH) has for more than 60 years supported research to improve the health and prolong the lives of people in the United States and around the world. Mean life expectancy worldwide has doubled to more than 70 years, due in large part to medical and public health interventions developed with NIH funding. Now, in the face of serious fiscal constraints, the idea has reemerged from some congressional leaders and disease constituency groups to more closely align NIH funding for disease research with disease burden in the United States. Although the nation must maintain robust research support for diseases that cause illness and death among large numbers of Americans, it would be unwise to deemphasize diseases that exact their largest toll elsewhere in the world. The United States has a vital interest in the health of people around the globe, rooted in an enduring tradition of humanitarian concern as well as in enlightened self-interest. Engagement in global health protects the nation’s citizens, enhances the economy, and advances U.S. interests abroad.

People from all walks of life understand and appreciate the moral imperative to alleviate human suffering, regardless of where it occurs. Polls show that Americans support efforts to improve health in developing countries, both for the sake of those individuals and for the sake of Americans exposed to infectious diseases that transcend national boundaries. The recent outbreak of Ebola virus disease in West Africa, which quickly found its way to the United States, is one more reminder of how global health challenges can become domestic. The concept of medical diplomacy—winning the hearts and minds of people in poor countries by exporting medical interventions, expertise, and personnel to improve their health—also resonates with many Americans, as does reducing instability in places where the United States has substantial economic and political interests.

The U.S. government, the largest funder of global health research and development, has played a central role in developing medical interventions that have saved countless lives in the world’s poorest countries. Smallpox has been eradicated, polio nearly eliminated, and important infectious diseases of childhood controlled with vaccines. An extraordinary 7.6 million AIDS deaths were averted in low- and middle-income countries between 2003 and 2013 by the development and distribution of antiretroviral drugs to treat HIV infection. Future products, including improved drugs for tuberculosis, treatments for parasitic diseases, vaccines for malaria, and new strategies to prevent and treat HIV infection could save millions more lives. Also, studying such complex diseases provides new insights that can advance how we diagnose, treat, and prevent other health challenges, including many commonly seen in the United States. For example, the treatment of hepatitis B virus infection has been revolutionized by antiviral drugs originally developed to treat HIV infection.

History shows that the tools of modern biology offer the opportunity to practically elimate major diseases that sap human health and exacerbate instability in areas where the United States has substantial interests. It is imperative that the nation sustain momentum and work with its global partners to deliver the fruits of global research to the people who need them most, both at home and abroad. Without such a commitment, we may miss opportunities to curtail or even eliminate important diseases such as AIDS and also risk the resurgence of major global health threats such as drug-resistant bacteria, tuberculosis, and malaria, for which new interventions are badly needed.

In 1940, President Franklin D. Roosevelt noted that “NIH speaks the universal language of humanitarianism… [it] has recognized no limitations imposed by international boundaries and has recognized no distinctions of race, of creed, or of color.” The NIH—and the United States—must continue to live by these words.

Tropical Medicine & International Health
May 2015 Volume 20, Issue 5 Pages 553–680
http://onlinelibrary.wiley.com/doi/10.1111/tmi.2015.20.issue-5/issuetoc
Original Article
Using multi-country household surveys to understand who provides reproductive and maternal health services in low- and middle-income countries: a critical appraisal of the Demographic and Health Surveys
K. Footman1,*, L. Benova1, C. Goodman2, D. Macleod1, C. A. Lynch1, L. Penn-Kekana1 and
O. M. R. Campbell1Article first published online: 5 MAR 2015
DOI: 10.1111/tmi.12471 You have full text access to this OnlineOpen article
Abstract
Objective
The Demographic and Health Surveys (DHS) are a vital data resource for cross-country comparative analyses. This study is part of a set of analyses assessing the types of providers being used for reproductive and maternal health care across 57 countries. Here, we examine some of the challenges encountered using DHS data for this purpose, present the provider classification we used, and provide recommendations to enable more detailed and accurate cross-country comparisons of healthcare provision.
Methods
We used the most recent DHS surveys between 2000 and 2012; 57 countries had data on family planning and delivery care providers and 47 countries had data on antenatal care. Every possible response option across the 57 countries was listed and categorised. We then developed a classification to group provider response options according to two key dimensions: clinical nature and profit motive.
Results
We classified the different types of maternal and reproductive healthcare providers, and the individuals providing care. Documented challenges encountered during this process were limitations inherent in household survey data based on respondents’ self-report; conflation of response options in the questionnaire or at the data processing stage; category errors of the place vs. professional for delivery; inability to determine whether care received at home is from the public or private sector; a large number of negligible response options; inconsistencies in coding and analysis of data sets; and the use of inconsistent headings.
Conclusions
To improve clarity, we recommend addressing issues such as conflation of response options, data on public vs. private provider, inconsistent coding and obtaining metadata. More systematic and standardised collection of data would aid international comparisons of progress towards improved financial protection, and allow us to better characterise the incentives and commercial nature of different providers.

Vaccine
Volume 33, Issue 19, Pages 2197-2296 (5 May 2015)
http://www.sciencedirect.com/science/journal/0264410X/33/19

Conference report
Vaccines, our shared responsibility
Pages 2197-2202
Sonia Pagliusi, Rishabh Jain, Rajinder Kumar Suri, the DCVMN Executive Committee Group
Abstract
The Developing Countries Vaccine Manufacturers’ Network (DCVMN) held its fifteenth annual meeting from October 27–29, 2014, New Delhi, India. The DCVMN, together with the co-organizing institution Panacea Biotec, welcomed over 240 delegates representing high-profile governmental and nongovernmental global health organizations from 36 countries.
Over the three-day meeting, attendees exchanged information about their efforts to achieve their shared goal of preventing death and disability from known and emerging infectious diseases.

Special praise was extended to all stakeholders involved in the success of polio eradication in South East Asia and highlighted challenges in vaccine supply for measles-rubella immunization over the coming decades. Innovative vaccines and vaccine delivery technologies indicated creative solutions for achieving global immunization goals.

Discussions were focused on three major themes including regulatory challenges for developing countries that may be overcome with better communication; global collaborations and partnerships for leveraging investments and enable uninterrupted supply of affordable and suitable vaccines; and leading innovation in vaccines difficult to develop, such as dengue, Chikungunya, typhoid-conjugated and EV71, and needle-free technologies that may speed up vaccine delivery. Moving further into the Decade of Vaccines, participants renewed their commitment to shared responsibility toward a world free of vaccine-preventable diseases.

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Cost–benefit of the introduction of new strategies for vaccination against pertussis in Spain: Cocooning and pregnant vaccination strategies
Original Research Article
Pages 2213-2220
María Isabel Fernández-Cano, Lluís Armadans Gil, Magda Campins Martí
Highlights
– The high incidence of pertussis in infants requires short-term preventive measures.
– Infant hospitalizations would decrease more with maternal vaccination than with cocoon strategy.
– The NNV to avoid a case would be more favorable for the pregnant vaccination approach.
– Benefit-to-cost ratio would be better for the pregnant vaccination.

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Accounting for personal and professional choices for pandemic influenza vaccination amongst English healthcare workers
Original Research Article
Pages 2267-2272
Afrodita Marcu, Helena Rubinstein, Susan Michie, Lucy Yardley

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Web-based intensive monitoring of adverse events following influenza vaccination in general practice
Original Research Article
Pages 2283-2288
Leontine van Balveren-Slingerland, Agnes Kant, Linda Härmark

Vaccine
Volume 33, Issue 18, Pages 2097-2196 (27 April 2015)
http://www.sciencedirect.com/science/journal/0264410X/33/18

Effectiveness and impact of rotavirus vaccines in Europe, 2006–2014
Review Article
Pages 2097-2107
Emilie Karafillakis, Sondus Hassounah, Christina Atchison
Highlights
– Seven European countries have implemented rotavirus vaccination at a national level.
– Vaccine effectiveness against rotavirus ranges from 68% to 98% in Europe.
– Reductions in rotavirus hospitalisations ranged from 65% to 84% in Europe.
– Our results confirm the public health benefit of rotavirus vaccination in Europe.
– Our results support the implementation of universal rotavirus vaccination in Europe.

Vaccine
Volume 33, Issue 18, Pages 2097-2196 (27 April 2015)
http://www.sciencedirect.com/science/journal/0264410X/33/18

Influenza vaccination during pregnancy: A systematic review of fetal death, spontaneous abortion, and congenital malformation safety outcomes
Review Article
Pages 2108-2117
M. McMillan, K. Porritt, D. Kralik, L. Costi, H. Marshall
Highlights
– This article presents the findings of a systematic review that includes analysis of critical adverse events including congenital malformation, fetal death, and spontaneous abortion.
– It provides a detailed analysis of individual study characteristics and argues that meta-analysis for these outcomes may not be appropriate due to clinical and methodological heterogeneity.
– The systematic review investigates 1st trimester immunisation for congenital malformation outcomes, raising crucial design issues for future research studies.
– Results did not indicate that maternal influenza vaccination is associated with an increased risk of fetal death, spontaneous abortion, or congenital malformations.
– The review includes previously unpublished data and definitions from four studies and detailed vaccine composition where known

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Influenza and pertussis vaccination coverage in pregnant women
Original Research Article
Pages 2125-2131
Jolien Laenen, Mathieu Roelants, Roland Devlieger, Corinne Vandermeulen
Highlights
– 42.8% of pregnant women had immunization records for flu and 39.2% for pertussis, 23.6% had documentation for both vaccines.
– The coverage increases to 62% for influenza and 46% for pertussis when oral communication was considered in addition.
– Obstetricians and GP are most influential in decision of pregnant women to vaccinate.
– Women with a low education and those of foreign origin are more vulnerable for non-vaccination.

Vaccine
Volume 33, Issue 18, Pages 2097-2196 (27 April 2015)
http://www.sciencedirect.com/science/journal/0264410X/33/18

Vaccine coverage estimation using a computerized vaccination registry with potential underreporting and a seroprevalence study
Original Research Article
Pages 2183-2188
Lina Pérez Breva, Javier Díez Domingo, Miguel Ángel Martínez Beneito, Joan Puig Barberà
Abstract
Objective
To develop a method to estimate vaccination coverage using both a computerized vaccine registry with an unknown underreporting rate and a seroprevalence study. A real example of a meningococcal C conjugate vaccine (MCCV) coverage estimation is studied to illustrate the proposed methodology.
Methods
We reviewed the Vaccine Information System of Valencia (Sistema de Información Vacunal, SIV) for the MCCV status of 1430 subjects aged 3–29 years as part of a seroprevalence study. When MCCV was not registered in SIV, subjects were classified into three groups (MCCV non-registered, no vaccination records and missing information) depending on the registry of other vaccines. A Bayesian model was developed to ascertain the percentage of MCCV-vaccinated subjects based on the meningococcal C seroprotection levels from the seroprevalence study.
Results
The seroprotection levels in subjects with no MCCV registered in SIV (358) were similar to those in subjects with MCCV registered (1072). This indicated a large proportion of vaccinated subjects with no MCCV registered. The estimated vaccine coverage was over 80% in all age groups, except >22 years, where it was 67.6% (95% CI: [54.0–80.4]), which corresponded to those aged over 13 years at the time of the catch-up campaign. An underreporting rate of 23.5–73.4%, depending on the age group, was estimated in those vaccinated in the 2002 catch-up campaign.
Conclusion
The Bayesian model allowed for a more realistic estimation of MCCV uptake. In this example, we quantified the underreporting of a vaccine registry, especially occurring during a catch-up campaign that occurred at the establishment of the registry.

Vaccine
Volume 33, Issue 17, Pages 1999-2096 (21 April 2015)
http://www.sciencedirect.com/science/journal/0264410X/33/17

WHO consultation on clinical evaluation of vaccines, 17–18 July 2014, WHO Headquarters, Geneva, Switzerland
Pages 1999-2003
Ivana Knezevic, Vasee Moorthy, Rebecca Sheets
Abstract
A World Health Organization (WHO) consultation on guidelines for National Regulatory Authorities (NRAs) and vaccine manufacturers on clinical evaluation of vaccines was held from 17 to 18 July 2014, to review key scientific challenges that regulators have been facing since the establishment of the WHO Guidelines on Clinical Evaluation of Vaccines. The guidelines, adopted by the WHO Expert Committee on Biological Standardization (ECBS) in 2001, have served as the basis for setting or updating national requirements for the evaluation and licensing of a broad range of vaccines as well as for WHO vaccine prequalification. Regulators from Australia, Brazil, China, Canada, Germany, India, Republic of Korea, South Africa, United States of America and the United Kingdom were represented. The International Federation for Pharmaceutical Manufacturers’ Association (IFPMA) and the Developing Country Vaccine Manufacturers’ Network (DCVMN) provided industry representation.
The consultation concluded that the guidelines should be revised to address issues that were raised in the context of vaccines that were the subject of clinical development in the past decade. Although the current guidelines have served well over time, it was recognized that an update would further increase their utility and would help regulators, manufacturers, vaccine developers and academia to respond to the challenging questions regarding the safety, immunogenicity, efficacy and effectiveness of vaccines intended for global use. A summary of the main outcomes of the consultation and proposals for the next steps regarding the guidelines and beyond are provided in this report.

Vaccine
Volume 33, Issue 17, Pages 1999-2096 (21 April 2015)
http://www.sciencedirect.com/science/journal/0264410X/33/17

Implementation of pertussis immunization in health-care personnel
Original Research Article
Pages 2009-2014
Kathi Walther, Marie-Anne Burckhardt, Thomas Erb, Ulrich Heininger
Highlights
– Contact persons of newborns should receive pertussis vaccine to decrease transmission.
– We implemented this recommendation for health-care personnel with a campaign.
– Compliance with pertussis immunization was higher in newly hired staff.
– Mandatory appointments with occupational health service are needed for optimal coverage.

Vaccine
Volume 33, Issue 17, Pages 1999-2096 (21 April 2015)
http://www.sciencedirect.com/science/journal/0264410X/33/17

Alternative delivery of a thermostable inactivated polio vaccine
Original Research Article
Pages 2030-2037
Heleen Kraan, Ivo Ploemen, Gijsbert van de Wijdeven, Ivo Que, Clemens Löwik, Gideon Kersten, Jean-Pierre Amorij
Highlights
– Potential of Bioneedle technology for inactivated polio vaccine (IPV) was evaluated.
– IPV in Bioneedles is more resistant to elevated temperatures than liquid IPV.
– Comparable immunogenicity of IPV-Bioneedle and liquid IPV after booster vaccination.
– Similar kinetics at administration site for Bioneedle compared to liquid injection.
– LPS-derivate PagL is potent adjuvant for liquid IPV, not for IPV-Bioneedles

Original Research Article
Pages 2030-2037
Heleen Kraan, Ivo Ploemen, Gijsbert van de Wijdeven, Ivo Que, Clemens Löwik, Gideon Kersten, Jean-Pierre Amorij
Highlights
– Potential of Bioneedle technology for inactivated polio vaccine (IPV) was evaluated.
– IPV in Bioneedles is more resistant to elevated temperatures than liquid IPV.
– Comparable immunogenicity of IPV-Bioneedle and liquid IPV after booster vaccination.
– Similar kinetics at administration site for Bioneedle compared to liquid injection.
– LPS-derivate PagL is potent adjuvant for liquid IPV, not for IPV-Bioneedles

Vaccine
Volume 33, Issue 17, Pages 1999-2096 (21 April 2015)
http://www.sciencedirect.com/science/journal/0264410X/33/17

Accelerating measles elimination and strengthening routine immunization services in Guizhou Province, China, 2003–2009
Original Research Article
Pages 2050-2055
Shuyan Zuo, Lisa Cairns, Yvan Hutin, Xiaofeng Liang, Yibing Tong, Qing Zhu, Dayong Zhang, Lisa A. Lee, Peter Strebel, Linda Quick
Highlights
– Measles control over seven years in Guizhou Province comprised diverse strategies.
– Infant and primary-school-entry vaccination coverage of all antigens increased.
– Incidence of measles dropped.
– The strategies are a model for extension to other lesser-developed provinces.

Vaccine
Volume 33, Issue 17, Pages 1999-2096 (21 April 2015)
http://www.sciencedirect.com/science/journal/0264410X/33/17

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Accelerating measles elimination and strengthening routine immunization services in Guizhou Province, China, 2003–2009
Original Research Article
Pages 2050-2055
Shuyan Zuo, Lisa Cairns, Yvan Hutin, Xiaofeng Liang, Yibing Tong, Qing Zhu, Dayong Zhang, Lisa A. Lee, Peter Strebel, Linda Quick
Highlights
– Measles control over seven years in Guizhou Province comprised diverse strategies.
– Infant and primary-school-entry vaccination coverage of all antigens increased.
– Incidence of measles dropped.
– The strategies are a model for extension to other lesser-developed provinces.

Vaccine
Volume 33, Issue 17, Pages 1999-2096 (21 April 2015)
http://www.sciencedirect.com/science/journal/0264410X/33/17

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Pertussis in infants under one year old: Risk markers and vaccination status—A case-control study
Original Research Article
Pages 2073-2078
Chen Stein Zamir, Dana Bardugo Dahan, Hanna Shoob
Highlights
– Low birthweight and high birth order were found to be independent risk markers for pertussis in young infants.
– A third of reported pertussis cases in infants occurred under age 2 months (currently recommended for the 1st pertussis vaccine dose).
– Reported pertussis cases over age 2 months were more likely to be unvaccinated and to have delayed vaccinations.
– In 2-4-month-old infants, 1 dose of pertussis vaccine gave significant protection against pertussis overall and pertussis hospitalization.
– The pertussis vaccine effectiveness increased with the number of vaccine doses.

Vaccine
Volume 33, Issue 17, Pages 1999-2096 (21 April 2015)
http://www.sciencedirect.com/science/journal/0264410X/33/17

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Economic evaluation of typhoid vaccination in a prolonged typhoid outbreak setting: The case of Kasese district in Uganda
Original Research Article
Pages 2079-2085
Cristina Carias, Maroya Spalding Walters, Edward Wefula, Kashmira A. Date, David L. Swerdlow, Maya Vijayaraghavan, Eric Mintz
Abstract
Background
Vaccination has been increasingly promoted to help control epidemic and endemic typhoid fever in high-incidence areas. Despite growing recognition that typhoid incidence in some areas of sub-Saharan Africa is similar to high-incidence areas of Asia, no large-scale typhoid vaccination campaigns have been conducted there. We performed an economic evaluation of a hypothetical one-time, fixed-post typhoid vaccination campaign in Kasese, a rural district in Uganda where a large, multi-year outbreak of typhoid fever has been reported.
Methods
We used medical cost and epidemiological data retrieved on-site and campaign costs from previous fixed-post vaccination campaigns in Kasese to account for costs from a public sector health care delivery perspective. We calculated program costs and averted disability-adjusted life years (DALYs) and medical costs as a result of vaccination, to calculate the cost of the intervention per DALY and case averted.
Results
Over the 3 years of projected vaccine efficacy, a one-time vaccination campaign was estimated to avert 1768 (90%CI: 684–4431) typhoid fever cases per year and a total of 3868 (90%CI: 1353–9807) DALYs over the duration of the immunity conferred by the vaccine. The cost of the intervention per DALY averted was US$ 484 (90%CI: 18–1292) and per case averted US$ 341 (90%CI: 13–883).
Conclusion
We estimated the vaccination campaign in this setting to be highly cost-effective, according to WHO’s cost-effective guidelines. Results may be applicable to other African settings with similar high disease incidence estimates.

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.

Al Jazeera
http://america.aljazeera.com/search.html?q=vaccine
Accessed 11 April 2015
California bill to ban childhood vaccine exemptions advances
Senate health committee approves bill to require vaccinations, eliminating exemptions for personal or religious beliefs
April 9, 2015 2:52PM ET
California lawmakers on Wednesday advanced a bill that would require schoolchildren in the state to be vaccinated, amid impassioned pleas from doctors and parents, including the activist Robert Kennedy Jr.
Under the proposal, parents would no longer be able to send unvaccinated children to school with waivers for religious or personal beliefs. Exemptions would be available only for children with health problems.

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Council on Foreign Relations
http://www.cfr.org/
Accessed 11 April 2015
Expert Brief
Global Health Goal Hits and Misses
Laurie Garrett, Senior Fellow for Global Health
April 7, 2015
This year marks the wind down of one hugely ambitious fifteen-year global development plan and the launch of another even more far-reaching one. At the moment, the new United Nations initiative—the Sustainable Development Goals (SDGs)—looks deeply flawed, featuring an encyclopedic wish-list for costly global accomplishments envisioned for the coming fifteen years.
But its predecessor, the Millennium Development Goals (MDGs), also seemed impossibly aspirational, and only moderately achievable when ratified by the UN General Assembly in 2000. The MDGs, which set eight big goals, will reach their deadline for completion (or failure) this New Year’s Eve…

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Financial Times
http://www.ft.com/home/uk
April 8, 2015
UN envoy upbeat on progress against Ebola
An end to the Ebola epidemic in Liberia and Sierra Leone is…David Nabarro, the UN special envoy on Ebola, says he is “upbeat” about progress but…Liberia appears closest to ending its Ebola nightmare having not recorded a new case…Andrew Ward in London

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The Guardian
http://www.guardiannews.com/
Accessed 11 April 2015
Ebola: media ‘overlooked Africa’s role in combating crisis’
African Union says media downplayed Africans’ willingness and ability to deal with Ebola and focused instead on part played by international agencies
7 April 2015
Africa’s efforts to tackle the Ebola crisis have been largely overlooked even though Africans have taken the lead in providing frontline staff and shown themselves “better placed to fight infectious diseases in their continent than outsiders”, according to the African Union (AU).
Dr Olawale Maiyegun, director of social affairs at the AU commission, said that despite the fact that Africans had proved both willing and able to deal with Ebola, the focus had been on the work of international agencies and those with the greatest media clout.
“Unfortunately, Africans do not have the international voice of CNN, BBC and France 24, therefore much of our work is overlooked in the western media,” he said. “Most of the assistance provided by the international community is in the areas of finance and infrastructure. In the most critical human resources for health, Africans – including the affected countries – have had to take the lead.”…

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Wall Street Journal
http://online.wsj.com/home-page?_wsjregion=na,us&_homepage=/home/us
Accessed 11 April 2015
Business
Tekmira Approved to Continue Ebola Treatment Clinical Trials
FDA put trials on hold last year as it awaited additional information
By
Angela Chen
April 10, 2015 9:06 a.m. ET
Health Policy
Squabbles Over Testing Methods Hamper Search for Ebola Vaccine
Researchers at odds over most effective way to trial treatments
Thomas M. Burton
Updated April 9, 2015 4:42 p.m. ET
The Ebola virus outbreak in West Africa created a rare opportunity: New vaccines could be tested, and if they worked, serve as a firewall in future epidemics.
It now appears this chance is slipping away amid public health officials’ squabbles over the right way to test vaccines. As a consequence, there may never be a definitive answer about the vaccines’ effectiveness….

Washington Post
http://www.washingtonpost.com/
Accessed 11 April 2015
California vaccine bill sparks acidic debate, Nazi links
Judy Lin | AP | Health & Science | Apr 10, 2015
A California bill that would sharply limit vaccination waivers after a measles outbreak at Disneyland has generated such an acidic debate that the proposal’s author was under added security this week.

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_4 April 2015

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– 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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.
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

EBOLA/EVD [to 4 April 2015]
Public Health Emergency of International Concern (PHEIC); “Threat to international peace and security” (UN Security Council)

Ebola Situation Report – 1 April 2015
[Excerpts]
SUMMARY
:: A total of 82 new confirmed cases of Ebola virus disease (EVD) were reported in the week to 29 March, a slight increase compared with 79 cases the previous week. Case incidence in Guinea increased to 57, compared with 45 the previous week. This offset a fourth consecutive weekly fall in case incidence in Sierra Leone, which reported 25 confirmed cases. Liberia reported no confirmed cases over the same period.

:: In addition to an increase in case incidence in Guinea, the geographic area of transmission also increased. A total of 7 Guinean prefectures reported at least one confirmed case in the week to 29 March, compared with 3 the previous week. Two of the 7 prefectures that reported a new confirmed case, Fria and Siguiri, did so for the first time in over 50 days. Siguiri, which borders Mali, is the first prefecture outside the western area of Guinea to report a confirmed case for over 30 days.

:: In Sierra Leone, cases were reported from 5 northern and western districts around and including the capital Freetown, which reported 10 new confirmed cases. The neighbouring districts of Bombali (1 case), Kambia (5 cases), Port Loko (6 cases) and Western Rural (3 cases) also reported cases.

:: Response indicators for Guinea present a mixed picture. Of 35 confirmed deaths from EVD in the week to 29 March, 15 (43%) were identified post-mortem in the community, compared with 10 of 37 (27%) the previous week. This increase may be attributable to improved access to communities in Forecariah prefecture. The proportion of confirmed cases that arose among registered contacts increased from 38% in the week to 15 March to 53% in week to 22 March. :: A total of 20 unsafe burials were reported in the week to 29 March, compared with 26 the previous week.

:: A 45-day state of health emergency has been declared in the Guinean prefectures of Forecariah, Coyah, Dubreka, Boffa, and Kindia. The capital, Conakry, will also be subject to emergency measures, which include the restriction of movement in areas of transmission, the temporary closure and quarantine of private hospitals and clinics where EVD cases have been detected, and limitation of burial participation to close relatives only. All corpses will be tested for EVD during the 45-day emergency period.

:: The last confirmed case in Liberia passed away on 27 March. Investigations are ongoing to establish the origin of infection. A total of 185 contacts associated with the case are being monitored twice a day. Heightened vigilance is being maintained throughout the country. In the week to 29 March, 278 laboratory samples were tested for EVD, with no confirmed cases.

:: In the week to 29 March, 67% of confirmed cases in Sierra Leone came from registered contacts, compared with 84% the previous week. There was one report of an unsafe burial over the same period. The proportion of confirmed deaths from EVD that were identified in the community increased slightly, from 7 of 56 (13%) in the previous week to 8 of 52 (15%) in the week to 29 March. Heightened surveillance is being maintained: over 100 suspected cases were reported in the week to 29 March, compared with 57 the previous week. The majority of suspected cases (52) were reported during the final 2 days of the 3-day stay-at-home.

:: There were 8 new health worker infections in the week to 29 March: 7 in Guinea, and 1 in Sierra Leone. This brings the total number of health worker infections reported across the three most-affected countries since the start of the outbreak to 861, with 495 deaths.

COUNTRIES WITH WIDESPREAD AND INTENSE TRANSMISSION
:: There have been a total of 25,178 reported confirmed, probable, and suspected cases of EVD in Guinea, Liberia and Sierra Leone (table 1), with over 10,000 reported deaths (outcomes for many cases are unknown). A total of 57 new confirmed cases were reported in Guinea, 0 in Liberia, and 25 in Sierra Leone in the 7 days to 29 March…
:: A total of 861 confirmed health worker infections have been reported in Guinea, Liberia, and Sierra Leone; there have been 495 reported deaths (table 5).

::::::

UNMEER [to 4 April 2015]
https://ebolaresponse.un.org/un-mission-ebola-emergency-response-unmeer
Press Releases
30 Mar 2015
UNMEER to align support behind “courageous” Ebola containment steps by Guinea

UN Mission Situation Reports
– 02 Apr 2015
– 01 Apr 2015
– 31 Mar 2015
– 30 Mar 2015
– 27 Mar 2015

2 April 2015
SG/A/1558
Secretary-General Appoints High-Level Panel on Global Response to Health Crises
Press Release
United Nations Secretary-General Ban Ki-moon today announced the appointment of a High-level Panel on the Global Response to Health Crises.

The Secretary-General has appointed Jakaya Mrisho Kikwete, President of the United Republic of Tanzania, as Chair. A full list of Panel members appears below. The Secretary-General has asked the Panel to make recommendations to strengthen national and international systems to prevent and manage future health crises, taking into account lessons learned from the response to the outbreak of Ebola virus disease.

In carrying out its work, the Panel will undertake a wide range of consultations, including with representatives from the affected countries and communities, the United Nations system, multilateral and bilateral financial institutions and regional development banks, non-governmental organizations, countries supporting the response effort, other Member States, health-care providers, academic and research institutions, the private sector and other experts. The Panel will be supported by a Resource Group of leading experts which is to provide advice to the Panel on technical and other issues.

The Panel will hold its first meeting in early May 2015 and is expected to submit its final report to the Secretary-General at the end of December 2015. The Secretary-General will make the report available to the General Assembly and undertake further action as appropriate.

Panel Members
– Jakaya Mrisho Kikwete (United Republic of Tanzania)
– Celso Amorim (Brazil)
– Micheline Calmy-Rey (Switzerland)
– Marty Natalegawa (Indonesia)
– Joy Phumaphi (Botswana)
– Rajiv Shah (United States)

[Full press release including bios here: http://www.un.org/press/en/2015/sga1558.doc.htm]

NIH Watch [to 4 April 2015]
http://www.nih.gov/news/health/apr2015/niaid-01.htm

:: Experimental Ebola vaccine safe, prompts immune response
Results from US government-sponsored phase 1 trial of VSV vaccine reported

An early-stage clinical trial of an experimental Ebola vaccine conducted at the National Institutes of Health and the Walter Reed Army Institute of Research (WRAIR) found that the vaccine, called VSV-ZEBOV, was safe and elicited robust antibody responses in all 40 of the healthy adults who received it. The most common side effects were injection site pain and transient fever that appeared and resolved within 12 to 36 hours after vaccination. A report describing preliminary results of the NIH-WRAIR study appears online today in The New England Journal of Medicine. The VSV-ZEBOV candidate is one of two experimental Ebola vaccines now being tested in the phase 2/3 PREVAIL clinical trial that is enrolling volunteers in Liberia.

“The ongoing Ebola ongoing outbreak in West Africa is unprecedented in scope and duration,” said Anthony S. Fauci, M.D., director of the National Institute of Allergy and Infectious Diseases (NIAID), part of NIH. “The outbreak is slowly coming under control, thanks to extraordinary and multi-faceted efforts in the affected nations. However, there still are no licensed specific therapies or vaccines for Ebola. Until a safe and effective vaccine is available, the world will continue to be under-prepared for the next Ebola outbreak.”

Scientists at the Public Health Agency of Canada developed the candidate vaccine. It was licensed to NewLink Genetics Corp. of Ames, Iowa, a company collaborating with Merck & Co. Inc., of Kenilworth, New Jersey, which is responsible for advancing this vaccine towards regulatory approval. The investigational vaccine is based on a genetically modified and attenuated vesicular stomatitis virus (VSV), a virus that mainly affects cattle. In the investigational vaccine, a gene for a VSV protein is replaced with a gene segment from a key protein in the Zaire species of Ebola virus. The vaccine does not contain the whole Ebola virus and therefore cannot infect vaccinated persons with Ebola.

The new report summarizes results of the first 52 volunteers enrolled in the study: 26 at the NIH Clinical Center in Bethesda, Maryland, and 26 at the WRAIR clinic in Silver Spring, Maryland. Six volunteers at each site received a placebo injection of saline solution, and the remaining 40 received the experimental vaccine at either one of two different dosages (2 x107 or 3 x106 in 20 volunteers at each site.) The NIH trial was led by NIAID investigators Richard T. Davey, Jr., M.D., and John H. Beigel, M.D., while Jason A. Regules, M.D., and Stephen J. Thomas, M.D., headed the trial at WRAIR.

The candidate vaccine’s ability to stimulate immune responses was assessed by sampling the volunteers’ blood at multiple time points following injection. (The blood sampling schedule differed between the two trial sites.) Of those volunteers tested at 14 days after injection, 93 percent (26 out of 28) of whose who had received vaccine developed antibodies against Zaire species of Ebola virus. Antibodies were detected in the remaining 14 volunteers who had received vaccine by 28 days after injection. Antibody responses were approximately three-fold greater in those who received the higher vaccine dose. This information was available to the designers of the PREVAIL trial and was used to guide the decision to use VSV-ZEBOV at the higher dosage level in that trial.

“The prompt, dose-dependent production of high levels of antibodies following a single injection and the overall favorable safety profile of this vaccine make VSV-ZEBOV a promising candidate that might be particularly useful in outbreak interventions,” said Dr. Davey.

The volunteers tolerated the vaccine well. Thirty percent (12 out of 40) of those who received the vaccine experienced mild or moderate fever; in all but one case, fever appeared and resolved within 24 hours of vaccination. The VSV-ZEBOV vaccine is made from live, weakened VSV and self-limiting fever following immunization with a live virus vaccine is not unexpected.

Some volunteers in a separate, Swiss study of this candidate vaccine reported experiencing arthritis that started in the second week after vaccination. Therefore, volunteers in the NIH-WRAIR study were specifically queried about new arthritis symptoms. No episodes of frank arthritis were reported by any volunteer.

More details about the NIH portion of this study are available at ClinicalTrials.gov using the identifier NCT02280408. Further details on the WRAIR portion are at ClinicalTrials.gov using the identifier NCT02269423.

CDC/MMWR/ACIP Watch [to 4 April 2015]
http://www.cdc.gov/media/index.html

:: Ebola in West Africa: The Importance of “Getting to Zero” – Press Release
FRIDAY, MARCH 27, 2015

:: Ebola: Getting to Zero – Digital Press Kit
FRIDAY, MARCH 27, 2015

:: MMWR Weekly April 3, 2015 / Vol. 64 / No. 12
– Ebola Virus Disease in a Humanitarian Aid Worker — New York City, October 2014

POLIO [to 4 April 2015]
Public Health Emergency of International Concern (PHEIC)

GPEI Update: Polio this week – As of 1 April 2015
Global Polio Eradication Initiative
[Editor’s Excerpt and text bolding]
Full report: http://www.polioeradication.org/Dataandmonitoring/Poliothisweek.aspx
:: Every day health workers around the world do heroic work on the frontlines to engage parents and provide children with polio vaccines. Read more about health workers in Pakistan.
:: April marks 60 years since Jonas Salk’s inactivated polio vaccine (IPV) was launched, enabling children to be protected against polio for the first time. Read more.
:: National Immunization Days are planned in Madagascar on 27 April to 1 May.
:: The GPEI is currently accepting applications from students and recent graduates interested in summer 2015 internships at the World Health Organization. More information is available here.

[Selected country-level report content]
Pakistan
:: Efforts are ongoing to strengthen the implementation of the ‘low season’ emergency operations plan.
:: Strong, functional Emergency Operations Centres (EOCs) are now operational both at the federal and provincial levels.
:: Strategies are focusing on clearly identifying reasons for missed children, and putting in place area-specific mechanisms to overcome area-specific challenges.
:: Independent monitoring is being strengthened and rolled out across wider geographic areas to provide a clearer assessment of quality and associated gaps.
:: Activities are focusing on known infected areas, but also areas deemed at high-risk but which have not reported polio cases. Environmental surveillance indicates widespread transmission of the virus, not just in known infected areas but also in areas without cases. Environmental surveillance is proving to be an instrumental supplemental surveillance tool enabling a clearer epidemiological picture.

WHO & Regionals [to 4 April 2015]
:: Conflict in Yemen kills and injures hundreds, places major strain on health system
1 April 2015, Sana’a, Yemen – An escalation in conflict and violence in Yemen has resulted in hundreds dead and thousands injured, and placed immense strain on health facilities and humanitarian health care providers…

…WHO, in support of Yemen’s Ministry of Public Health and Population, is working with the International Committee of the Red Cross, Médecins Sans Frontières (MSF France and Spain) and other partner organizations to ensure that patients receive the treatment they urgently need and that health facilities are provided with sufficient medicines and medical supplies.

To date, WHO and partners have provided interagency emergency health kits for more than 80 000 beneficiaries, as well as blood bags, oxygen cylinders with regulators, and IV fluids. Urgently required medicines and other supplies that are available in the country are being procured locally. With the closure of all airports and ports to Yemen, WHO is coordinating with the World Food Programme and UN partners to explore alternative solutions for the provision of additional medicines and medical kits from its humanitarian hub in Dubai.

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:: The Weekly Epidemiological Record (WER) 3 April 2015, vol. 90, 14 (pp. 133–148) includes:
– Planning, requesting medicines and reporting for preventive chemotherapy
– UNICEF and WHO meet to strengthen reporting of anthelminthic treatment for preschool children

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:: GIN – March 2015 pdf, 1.87Mb 31 March 2015

.
:: WHO Regional Offices
WHO African Region AFRO
No new digest content identified.

WHO Region of the Americas PAHO
:: Experts Discuss Actions to Include Health in All Public Policies in the Countries of the Americas (03/30/2015)

WHO South-East Asia Region SEARO
:: Make food safety a priority: WHO 31 March 2015

WHO European Region EURO
:: Complex food chain increases food safety risks 31-03-2015

WHO Eastern Mediterranean Region EMRO
:: Conflict in Yemen kills and injures hundreds, places major strain on health system
1 April 2015, Sana’a, Yemen – An escalation in conflict and violence in Yemen has resulted in hundreds dead and thousands injured, and placed immense strain on health facilities and humanitarian health care providers

WHO Western Pacific Region
:: Ensuring food in the Region is safe from farm to plate
MANILA, 1 April 2015 – Diseases caused by unsafe food claim an estimated 2 million lives globally each year. The World Health Organization (WHO) in the Western Pacific Region marks World Health Day (7 April) this year by urging governments, the food industry and consumers to observe food safety to save lives and improve global health.

PATH [to 4 April 2015]
http://www.path.org/news/index.php

Announcement
April 01, 2015
Laos launches national Japanese encephalitis vaccination campaign
National launch signifies PATH’s decade-long work to bring a lifesaving vaccine to at-risk countries
Today, Laos launched a nationwide Japanese encephalitis (JE) campaign aimed at reaching 1.5 million children between the ages of one and 15 years. This national campaign, conducted with support from Gavi, the Vaccine Alliance, is the result of PATH’s longstanding efforts to protect millions of children from a devastating disease. After completing its national catch-up campaigns this year, the government of Laos is expected to fund and incorporate JE vaccination into its childhood routine immunization schedule, ensuring countrywide JE coverage for the first time in history…

The journey to vaccine scale up
With funding from the Bill & Melinda Gates Foundation, PATH and its partners have made tremendous progress in bringing global attention to a long-neglected disease. For more than a decade, PATH worked to identify and accelerate the delivery of an affordable JE vaccine. It began by identifying a safe, effective vaccine used in China for more than 20 years and collaborating with the manufacturer, Chengdu Institute of Biological Products (CDIBP); the World Health Organization (WHO), and ministries of health to conduct pivotal clinical trials to add to a growing collection of data on the vaccine. PATH also negotiated with CDIBP to secure an affordable public-sector price for the countries that needed it most.

In October 2013, a major milestone was reached—the WHO prequalification of CDIBP’s JE vaccine, a first for China—signaling its entrance into the global vaccine marketplace and allowing Gavi to provide financing for low-income countries struggling with JE control. PATH played a pivotal role in helping CDIBP meet the rigorous international standards of quality, safety, and efficacy required for WHO prequalification from providing technical support to assisting in the design and financing of a new manufacturing facility.

Countries forging ahead
In the spring of 2014, Laos moved forward to introduce JE immunization campaigns in two new provinces, with the goal of reaching 170,000 children in two weeks. These campaigns were conducted through an innovative partnership between Microsoft employees and PATH, allowing Laos to transport the vaccine from the Chinese manufacturer to the villages that needed them as well as provide health worker training to ensure successful vaccination campaigns. Now, by introducing a national JE vaccination program with additional funding provided by Gavi, Laos continues to demonstrate its commitment to eliminating JE.

The countrywide introduction of CDIBP’s JE vaccine in Laos is an incredibly proud moment for PATH and its partners, who have worked since 2003 to support countries in their quest to protect vulnerable children from this deadly disease. Together, their efforts have meant that more than 221 million kids across Southeast Asia in countries such as Nepal, Sri Lanka, Cambodia, and India have been reached by a vaccine once virtually unknown outside of China.

Cambodia is expected to conduct Gavi-funded, nationwide JE vaccination campaigns beginning in January 2016.

University Of Maryland School Of Medicine Plans To Launch Major New Global Health And Vaccine Institute; Building On Longstanding Worldwide Leadership In Malaria Research And Vaccine Development
New Centers/ Directors Announced as Part of New Institute
BALTIMORE, April 1, 2015 /PRNewswire-USNewswire/ — University of Maryland School of Medicine Dean E. Albert Reece, MD, PhD, MBA, announced today that the School of Medicine (UM SOM) plans to establish a major new Institute for Global Health (IGH), bringing together decades of UM SOM research, treatment and vaccine development around the world, and expanding the School’s platform as the premier, leading center for global health research, treatment and prevention. The new Institute will focus on vaccine development and malaria research, and will house the UM SOM’s reconfigured Center for Vaccine Development (CVD) as well as a newly-formed Center for Malaria Research (CMR).

The new Institute will assemble some of the most prominent scientists and researchers in the fields of malaria research and vaccine development. Myron Levine, MD, DTPH, the Simon and Bessie Grollman Distinguished Professor and Founding Director of the CVD, will serve as a senior advisor to the IGH, and will become the UM SOM’s Associate Dean for Global Health, Vaccinology and Infectious Diseases; Christopher Plowe, MD, MPH, Professor of Medicine, of Molecular Microbiology and Immunology, and of Epidemiology and Public Health, and Howard Hughes Medical Institute investigator at the UM SOM, will become the Founding Director of the IGH and the Director of the new CMR. Kathleen Neuzil, MD, MPH, newly-recruited physician-scientist, will become the Deputy Director of IGH and the Director of the CVD. Dr. Neuzil is now Professor of Medicine and Global Health at the University of Washington and is considered one of the world’s leaders in vaccinology. She directs worldwide vaccine access and delivery at PATH, an international nonprofit global health organization based in Seattle.

“This will truly be a landmark initiative for the School of Medicine,” said Dr. Reece, who is Vice President for Medical Affairs at the University of Maryland and John Z. and Akiko K. Bowers Distinguished Professor and Dean of the University of Maryland School of Medicine. “As a result of the tireless work of Dr. Levine, Dr. Plowe and others, we have continued to grow our global presence now in 35 countries around the world, including research and treatment facilities in Mali, Chile, Malawi and now emerging in Myanmar. This new Institute will enable us to leverage all of the tremendous work that has been done, and will have a powerful and lasting impact on global health.”…

Industry Watch [to 4 April 2015]
:: GSK to establish global vaccines R&D centre in the US
02 April 2015 Issued: London and Philadelphia, PA
New hub based in Rockville, MD expands GSK’s global vaccines R&D footprint
GSK announced today it is further strengthening and expanding its vaccines presence in the US by establishing a new global centre for vaccines research and development (R&D) in Rockville, Maryland. The site will become one of three global vaccines R&D centres for GSK, complementing the company’s existing global R&D centres in Rixensart, Belgium and in Siena, Italy, a site which GSK recently acquired from Novartis in March 2015.

The new US vaccines R&D centre will expand GSK’s efforts to discover and develop novel vaccines across a range of pressing public health threats, including those relevant to the US. It will consolidate vaccines R&D activities currently conducted at other GSK sites including in Philadelphia, PA and Cambridge, MA, into one centralised location. Key late stage development programmes, as well as vaccine discovery and new platform technology development will be led from Rockville…

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:: GSK statement on meningitis vaccination in the UK
29 March 2015 Issued: London
GSK is delighted to have reached an agreement with the UK’s Department of Health that will enable babies in the UK to receive its meningitis B vaccine through the NHS immunisation schedule.

We have moved rapidly to conclude negotiations since we acquired the vaccine from Novartis at the beginning of March.

We believe the agreement we have reached offers fair value for the NHS and allows a reasonable return for GSK to ensure that we can continue to invest in creating new treatments and vaccines.

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:: Pfizer to Cease Vaccine Sales Business in China
License not renewed for Prevenar, which protects toddlers against pneumococcal disease
By Laurie Burkitt
Wall Street Journal Updated April 2, 2015 12:03 p.m. ET
SHANGHAI—Pfizer Inc. is ceasing vaccine sales operations in China after the Chinese government failed to renew an import license for one of its products, a move that the company said will cause a shortage of the treatment in China.

Pfizer said in a statement Thursday that the license had expired for Prevenar, sold as Prevnar in the U.S. The vaccine protects toddlers against pneumococcal disease that can lead to pneumonia and other infections,. “Based on a careful assessment of this situation, we have decided to cease our Vaccines commercial operations in China at this time, effective immediately,” the statement said. The vaccine is Pfizer’s No. 2-selling franchise globally, behind the Lyrica pain drug.

The vaccine operations will close immediately, affecting 200 employees who work in the division, a statement from the company said, adding that “most colleagues will be impacted” by the closure. Pfizer, which has 9,000 employees in China, will help the affected employees find other positions within the company, the statement said.

The spokeswoman declined to disclose why the vaccine’s license wasn’t renewed. Regulators at China’s Food and Drug Administration weren’t immediately available for comment.

Global Fund [to 4 April 2015]
http://www.theglobalfund.org/en/mediacenter/newsreleases/

01 April 2015
Global Fund Affirms Commitment to Resilient Health Systems
GENEVA – Members of the Board of the Global Fund called for accelerated efforts to build resilient health systems that can contribute to ending AIDS, tuberculosis and malaria as epidemics.

At a Board meeting, several members stressed the need to support countries in strengthening health systems, at a national level and also at a community level, with the entire Global Fund partnership working together to achieve resilience and sustainability in health systems.

The German delegation pointed out the critical importance of making broader investments in health systems in order to address the health concerns of communities responding to HIV, TB and malaria.

Takeshi Osuga, Deputy Director General for International Cooperation and Global Issues in Japan’s Ministry of Foreign Affairs said that resilient health systems can galvanize action for many health challenges. By enacting policies that support universal health coverage, partners in global health can support efforts to transformative health systems.
There is broad recognition that the Ebola crisis in West Africa drew increased attention to the importance of health systems.

Prof. Onyebuchi Chukwu, former Minister of Health of Nigeria, spoke about how his country relied with great success on health systems that were built to respond to polio in combating Ebola. He also stressed the importance of community involvement and participation.

The Global Fund has been investing in health systems since its beginning, both in investments that are channelled through disease-specific grants as well as through grants that are solely on strengthening health systems.

Mark Dybul, Executive Director of the Global Fund, said more than a third of the Global Fund’s investments go to strengthening health systems in the countries and communities where programs treat, prevent and care for those affected by HIV, TB and malaria. Dr. Dybul said that health systems will be best sustained and strengthened where investments are firmly anchored within communities.

At its two-day meeting which closed today, the Board also approved a framework for financing co-infections and co-morbidities of HIV/AIDS, TB and malaria.
Dr. Nafsiah Mboi, completing a two-year term as Chair of the Board, said that the role of health systems in enabling communities to respond to their diverse and distinct health needs has never been more vital.

“The Global Fund is determined to play a robust role in strengthening health systems during the post-2015 development era,” Dr. Nafsiah Mboi said.

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Global Fund Board Selects New Chair and Vice-Chair
01 April 2015
GENEVA – The Board of the Global Fund to Fight AIDS, Tuberculosis and Malaria selected Norbert Hauser, a former Member of Parliament and international auditor from Germany, as its new Chair and also named Aida Kurtovic of Bosnia and Herzegovina as Vice-Chair. Both began serving a two-year term today.

Mr. Hauser, building upon a distinguished career in government and public service, previously served as interim Inspector General at the Global Fund in 2012-13 and as a member of the High-Level Panel that created a blueprint for reform at the Global Fund. Until 2011, he served as Vice President of Germany’s Supreme Audit Institution.

“In the changing landscape of global health, we are determined to build resilient health systems and expand our support to the people affected by the epidemics we fight,” said Mr. Hauser. “It is an honor to be able to serve the Global Fund, its Board and the people in need, working together with members of the Board of the Global Fund.”

Mr. Hauser began his career as a lawyer and prosecutor in Germany. He served in many government positions, including more than 20 years as a Member of the Council of the City of Bonn, and 15 years as District Mayor of the Borough of Bonn-Bad Godesberg. He also served as Chairman of the Panel of External Auditors of the United Nations and as External Auditor of the International Atomic Energy Agency, among other positions.

Mrs. Kurtovic served as a Board member of the Global Fund from 2012-2014, and has been involved with the Global Fund in numerous capacities, serving on Bosnia’s Country Coordinating Mechanism and on Board committees. She is Executive Director of Partnerships in Health, an organization in Sarajevo whose mission is assisting institutions to build capacity and achieve sustainable improvements in the quality of basic and essential health services, changing the lives of vulnerable populations. Partnerships in Health strongly focuses on the HIV testing, counseling and support to people living with HIV among other services.

“Like no other organization, the Global Fund has been able to mobilize, perform and deliver results in a very short period of time,” said Mrs. Kurtovic. “We have to sustain those gains and expand our support even more.”

The handover of Board leadership came at the close of a meeting of the Global Fund Board, as Dr. Nafsiah Mboi, former Minister of Health of Indonesia, completed a two-year term as Chair of the Board. Mireille Guigaz, former French Ambassador for the fight against HIV/AIDS and communicable diseases, completed a two-year term as Vice-Chair.
During that time, the Global Fund successfully engineered a significant change in its core business by launching a new approach to funding that is geared to increasing impact of programs in countries fighting HIV, TB and malaria.

European Medicines Agency Watch [to 4 April 2015]
http://www.ema.europa.eu/ema/

:: European Medicines Agency and Heads of Medicines Agencies consult on common network strategy to 2020
31/03/2015
Making a difference to human and animal health
The European Medicines Agency (EMA) and the Heads of Medicines Agencies (HMA) have released the ‘EU Medicines Agencies Network Strategy to 2020’, a draft common strategy to 2020 for the European medicines agencies network, for a three-month public consultation…

The need to further strengthen the collaboration between the members of the network and work together towards achieving agreed goals has become more urgent recently. Europe faces the global threat represented by antimicrobial resistance to human and animal health, and needs to be prepared for emerging epidemics, as reminded by the outbreak of Ebola Virus Disease in West Africa in March 2014. At the same time the healthcare needs of patients in Europe are changing. Advancements in science and medicine mean that new and more complex medicines are being developed, which may bring opportunities for personalised medicines and more treatments for rare diseases. Patients also require timely access to new, beneficial and safe medicines. The globalisation of the pharmaceutical industry means that greater collaboration with regulators beyond the European Union (EU) is essential to assure the supply of safe, effective and good quality medicines for humans and animals.

The joint strategy for the European medicines agencies network is based on a coordinated approach and a strengthened collaboration within the network over the next five years, to address the challenges and make the most of the opportunities to benefit human and animal health.

The network is unique in the global regulatory environment. It includes all national medicines regulatory authorities for both human and veterinary medicines from EU Member States and the European Economic Area (EEA), united in the Heads of Medicines Agencies (HMA), and the European Medicines Agency (EMA). By working closely together, the network can draw on the resources and expertise available across the EU, avoid duplication and share workloads.

The draft strategy focuses on areas where collaboration within the network can make a real difference to human and animal health in the European Union over the next five years. It builds on the EMA roadmap to 2015 and the HMA strategy document 2011-15.

The draft network strategy is arranged under four key themes focusing on:
– human health
– animal health and human health in relation to veterinary medicines
– optimising the operation of the network
– the global regulatory environment…

.
European Union Medicines Agencies Network Strategy to 2020 – Working together to improve health
EMA/MB/151414/2015 – draft: consultation open
Consultation end date 30/06/2015
Summary
This document outlines the high level strategy for the network for the next five years. It is presented, for the first time, as a single strategy for the entire network to reflect the need for a coordinated approach to address the multiple challenges and opportunities that face the network. Advances in science affect the nature of the products we regulate and the network must support new and innovative developments that contribute to public health.
Submission of comments template – EU Medicines Agencies Network Strategy to 2020 – Working together to improve health (31/03/2015)

American Journal of Infection Control
April 2015 Volume 43, Issue 4, p313-422
http://www.ajicjournal.org/current

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APIC 2015 opening plenary to feature thought-provoking panel discussion on Ebola: Music City Center in Nashville, TN, June 27-29, 2015
p313
The APIC 2015 Annual Conference, June 27-29 in Nashville, represents the most comprehensive infection prevention meeting in the world, complete with infection prevention experts, cutting-edge education, an exhibit hall showcasing the latest innovations, and vibrant networking events.

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Handling Europe’s first Ebola case: Internal hospital communication experience
Margarita Mosquera, MD, PhD, MPH, Victoria Melendez, PhD, Pello Latasa, MD, MPH
Published Online: February 24, 2015
Highlights
– Media communication plays an important role in a public health crisis to alarm or reassure the population.
– Internal hospital communication needs to be clear, science-based, and understandable.
– Health care workers are benchmarks for the rest of the population as a trusted source.
– Institutional communication preparedness reducing crisis response time will help social media and networks to convey reassuring coverage.
Abstract
Europe’s first Ebola virus disease (EVD) case was diagnosed in our hospital. There was an unjustified panic in the population because of an imbalance of credibility assigned to the media as opposed to scientific information. A reinforcement of hospital internal communication was needed to keep health care workers informed with up-to-date scientific EVD information. The proactive management of information flow to both internal and external actors is required to reduce unjustified fear within the public.

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Disinfecting personal protective equipment with pulsed xenon ultraviolet as a risk mitigation strategy for health care workers
Chetan Jinadatha, MD, MPH, Sarah Simmons, BS, MPH, Charles Dale, BA, Nagaraja Ganachari-Mallappa, PhD, Frank Charles Villamaria, MPH, Nicole Goulding, BS, Benjamin Tanner, PhD, Julie Stachowiak, PhD, Mark Stibich, MHS, PhD
Open Access
DOI: http://dx.doi.org/10.1016/j.ajic.2015.01.013
Highlights
– We determined the effectiveness of pulsed xenon ultraviolet against an Ebola surrogate virus on a dry inanimate surface.
– We determined the effectiveness of pulsed xenon ultraviolet against personal protective equipment material inoculated with an Ebola surrogate virus.
– We determined the level of ultraviolet exposure for a person wearing personal protective equipment.
– We described the distribution of germicidal light coverage on personal protective equipment.
Abstract
The doffing of personal protective equipment (PPE) after contamination with pathogens such as Ebola poses a risk to health care workers. Pulsed xenon ultraviolet (PX-UV) disinfection has been used to disinfect surfaces in hospital settings. This study examined the impact of PX-UV disinfection on an Ebola surrogate virus on glass carriers and PPE material to examine the potential benefits of using PX-UV to decontaminate PPE while worn, thereby reducing the pathogen load prior to doffing. Ultraviolet (UV) safety and coverage tests were also conducted. PX-UV exposure resulted in a significant reduction in viral load on glass carriers and PPE materials. Occupational Safety and Health Administration–defined UV exposure limits were not exceeded during PPE disinfection. Predoffing disinfection with PX-UV has potential as an additive measure to the doffing practice guidelines. The PX-UV disinfection should not be considered sterilization; all PPE should still be considered contaminated and doffed and disposed of according to established protocols.

American Journal of Preventive Medicine
April 2015 Volume 48, Issue 4, p365-490
http://www.ajpmonline.org/current

Medicare Claims Versus Beneficiary Self-Report for Influenza Vaccination Surveillance
Kimberly A. Lochner, ScD, Marc A. Wynne, MSPH, Gloria H. Wheatcroft, MPH, Chris M. Worrall, BS, Jeffrey A. Kelman, MD
Published Online: February 17, 2015
DOI: http://dx.doi.org/10.1016/j.amepre.2014.10.016
Abstract
Background
Although self-reported influenza vaccination status is routinely used in surveillance to estimate influenza vaccine coverage, Medicare data are becoming a promising resource for influenza surveillance to inform vaccination program management and planning.
Purpose
To evaluate the concordance between self-reported influenza vaccination and influenza vaccination claims among Medicare beneficiaries.
Methods
This study compared influenza vaccination based upon Medicare claims and self-report among a sample of Medicare beneficiaries (N=9,378) from the 2011 Medicare Current Beneficiary Survey, which was the most recent year of data at the time of analysis (summer 2013). Sensitivity, specificity, positive predictive value, and negative predictive value were calculated using self-reported data as the referent standard. Logistic regression was used to compute the marginal mean proportions for whether a Medicare influenza vaccination claim was present among beneficiaries who reported receiving the vaccination.
Results
Influenza vaccination was higher for self-report (69.4%) than Medicare claims (48.3%). For Medicare claims, sensitivity=67.5%, specificity=96.3%, positive predictive value=97.6%, and negative predictive value=56.7%. Among beneficiaries reporting receiving an influenza vaccination, the percentage of beneficiaries with a vaccination claim was lower for beneficiaries who were aged <65 years, male, non-Hispanic black or Hispanic, and had less than a college education.
Conclusions
The classification of influenza vaccination status for Medicare beneficiaries can differ based upon survey and claims. To improve Medicare claims–based surveillance studies, further research is needed to determine the sources of discordance in self-reported and Medicare claims data, specifically for sensitivity and negative predictive value.

American Journal of Preventive Medicine
April 2015 Volume 48, Issue 4, p365-490
http://www.ajpmonline.org/current

Impacting Delayed Pediatric Influenza Vaccination – A Randomized Controlled Trial of Text Message Reminders
Annika M. Hofstetter, MD, PhD, MPH, Celibell Y. Vargas, MD, Stewin Camargo, MS, Stephen Holleran, BA, David K. Vawdrey, PhD, Elyse Olshen Kharbanda, MD, MPH, Melissa S. Stockwell, D, MPH
This activity is available for CME credit. See page A3 for information.
DOI: http://dx.doi.org/10.1016/j.amepre.2014.10.023
Abstract
Background
Influenza vaccination coverage is low, especially among low-income populations. Most doses are generally administered early in the influenza season, yet sustained vaccination efforts are crucial for achieving optimal coverage. The impact of text message influenza vaccination reminders was recently demonstrated in a low-income population. Little is known about their effect on children with delayed influenza vaccination or the most effective message type.
Purpose
To determine the impact of educational plus interactive text message reminders on influenza vaccination of urban low-income children unvaccinated by late fall.
Design
Randomized controlled trial.
Setting/participants
Parents of 5,462 children aged 6 months–17 years from four academically affiliated pediatric clinics who were unvaccinated by mid-November 2011.
Intervention
Eligible parents were stratified by their child’s age and pediatric clinic site and randomized using a 1:1:1 allocation to educational plus interactive text message reminders, educational-only text message reminders, or usual care. Using an immunization registry-linked text messaging system, parents of intervention children received up to seven weekly text message reminders. One of the messages sent to parents in the educational plus interactive text message arm allowed selection of more information about influenza and influenza vaccination.
Main outcome measures
Influenza vaccination by March 31, 2012. Data were collected and analyzed between 2012 and 2014.
Results
Most children were publicly insured and Spanish speaking. Baseline demographics were similar between groups. More children of parents in the educational plus interactive text message arm were vaccinated (38.5%) versus those in the educational-only text message (35.3%; difference=3.3%, 95% CI=0.02%, 6.5%; relative risk ratio (RRR)=1.09, 95% CI=1.002, 1.19) and usual care (34.8%; difference=3.8%, 95% CI=0.6%, 7.0%; RRR=1.11, 95% CI=1.02-1.21) arms.
Conclusions
Text message reminders with embedded educational information and options for interactivity have a small positive effect on influenza vaccination of urban, low-income, minority children who remain unvaccinated by late fall.

American Journal of Tropical Medicine and Hygiene
April 2015; 92 (4)
http://www.ajtmh.org/content/current

Costs of Dengue to the Health System and Individuals in Colombia from 2010 to 2012
Raul Castro Rodriguez*, Katia Galera-Gelvez, Juan Guillermo López Yescas and Jorge A. Rueda-Gallardo
Author Affiliations
Department of Economics, Universidad de los Andes, Bogotá, Colombia; Sanofi Pasteur Latin America, Mexico DF, Mexico
Abstract.
Dengue fever (DF) is an important health issue in Colombia, but detailed information on economic costs to the healthcare system is lacking. Using information from official databases (2010–2012) and a face-to-face survey of 1,483 households with DF and dengue hemorrhagic fever (DHF) patients, we estimated the average cost per case. In 2010, the mean direct medical costs to the healthcare system per case of ambulatory DF, hospitalized DF, and DHF (in Colombian pesos converted to US dollars using the average exchange rate for 2012) were $52.8, $235.8, and $1,512.2, respectively. The mean direct non-medical costs to patients were greater ($29.7, $46.7, and $62.6, respectively) than the mean household direct medical costs ($13.3, $34.8, and $57.3, respectively). The average direct medical cost to the healthcare system of a case of ambulatory DF in 2010 was 57% of that in 2011. Our results highlight the high economic burden of the disease and could be useful for assigning limited health resources.

American Journal of Tropical Medicine and Hygiene
April 2015; 92 (4)
http://www.ajtmh.org/content/current
The “Performance of Rotavirus and Oral Polio Vaccines in Developing Countries” (PROVIDE) Study: Description of Methods of an Interventional Study Designed to Explore Complex Biologic Problems
Beth D. Kirkpatrick*, E. Ross Colgate, Josyf C. Mychaleckyj, Rashidul Haque, Dorothy M. Dickson, Marya P. Carmolli, Uma Nayak, Mami Taniuchi, Caitlin Naylor, Firdausi Qadri, Jennie Z. Ma, Masud Alam, Mary Claire Walsh, Sean A. Diehl, the PROVIDE Study Teams and William A. Petri Jr.
Author Affiliations
Department of Medicine and Vaccine Testing Center, The University of Vermont College of Medicine, Burlington, Vermont; Departments of Medicine, The University of Virginia, Charlottesville, Virginia; The icddr,b, Dhaka, Bangladesh
Abstract.
Oral vaccines appear less effective in children in the developing world. Proposed biologic reasons include concurrent enteric infections, malnutrition, breast milk interference, and environmental enteropathy (EE). Rigorous study design and careful data management are essential to begin to understand this complex problem while assuring research subject safety. Herein, we describe the methodology and lessons learned in the PROVIDE study (Dhaka, Bangladesh). A randomized clinical trial platform evaluated the efficacy of delayed-dose oral rotavirus vaccine as well as the benefit of an injectable polio vaccine replacing one dose of oral polio vaccine. This rigorous infrastructure supported the additional examination of hypotheses of vaccine underperformance. Primary and secondary efficacy and immunogenicity measures for rotavirus and polio vaccines were measured, as well as the impact of EE and additional exploratory variables. Methods for the enrollment and 2-year follow-up of a 700 child birth cohort are described, including core laboratory, safety, regulatory, and data management practices. Intense efforts to standardize clinical, laboratory, and data management procedures in a developing world setting provide clinical trials rigor to all outcomes. Although this study infrastructure requires extensive time and effort, it allows optimized safety and confidence in the validity of data gathered in complex, developing country settings.

BMC Health Services Research
http://www.biomedcentral.com/bmchealthservres/content
(Accessed 4 April 2015)

Research article
Can smartphones and tablets improve the management of childhood illness in Tanzania? A qualitative study from a primary health care worker’s perspective
Amani Flexson Shao123*, Clotilde Rambaud-Althaus12, Ndeniria Swai4, Judith Kahama-Maro4, Blaise Genton125, Valerie D’Acremont125 and Constanze Pfeiffer12
* Corresponding author: Amani F Shao shaotz@gmail.com
Author Affiliations
BMC Health Services Research 2015, 15:135 doi:10.1186/s12913-015-0805-4
Published: 2 April 2015
Abstract (provisional)
Background
The impact of the Integrated Management of Childhood Illness (IMCI) strategy has been less than anticipated because of poor uptake. Electronic algorithms have the potential to improve quality of health care in children. However, feasibility studies about the use of electronic protocols on mobile devices over time are limited. This study investigated constraining as well as facilitating factors that influence the uptake of a new electronic Algorithm for Management of Childhood Illness (ALMANACH) among primary health workers in Dar es Salaam, Tanzania. Methods
A qualitative approach was applied using in-depth interviews and focus group discussions with altogether 40 primary health care workers from 6 public primary health facilities in the three municipalities of Dar es Salaam, Tanzania. Health worker’s perceptions related to factors facilitating or constraining the uptake of the electronic ALMANACH were identified.
Results
In general, the ALMANACH was assessed positively. The majority of the respondents felt comfortable to use the devices and stated that patient’s trust was not affected. Most health workers said that the ALMANACH simplified their work, reduced antibiotic prescription and gave correct classification and treatment for common causes of childhood illnesses. Few HWs reported technical challenges using the devices and complained about having had difficulties in typing. Majority of the respondents stated that the devices increased the consultation duration compared to routine practice. In addition, health system barriers such as lack of staff, lack of medicine and lack of financial motivation were identified as key reasons for the low uptake of the devices.
Conclusions
The ALMANACH built on electronic devices was perceived to be a powerful and useful tool. However, health system challenges influenced the uptake of the devices in the selected health facilities.

BMC Health Services Research
http://www.biomedcentral.com/bmchealthservres/content
(Accessed 4 April 2015)

Research article
Cost of installing and operating an electronic clinical decision support system for maternal health care: case of Tanzania rural primary health centres
Happiness Pius Saronga14*, Maxwell Ayindenaba Dalaba24, Hengjin Dong3, Melkizedeck Leshabari1, Rainer Sauerborn4, Felix Sukums14, Antje Blank4, Jens Kaltschmidt4 and Svetla Loukanova4
Author Affiliations
BMC Health Services Research 2015, 15:132 doi:10.1186/s12913-015-0780-9
Published: 2 April 2015
Abstract (provisional)
Background
Poor quality of care is among the causes of high maternal and newborn disease burden in Tanzania. Potential reason for poor quality of care is the existence of a “know-do gap” where by health workers do not perform to the best of their knowledge. An electronic clinical decision support system (CDSS) for maternal health care was piloted in six rural primary health centers of Tanzania to improve performance of health workers by facilitating adherence to World Health Organization (WHO) guidelines and ultimately improve quality of maternal health care. This study aimed at assessing the cost of installing and operating the system in the health centers. Methods
This retrospective study was conducted in Lindi, Tanzania. Costs incurred by the project were analyzed using Ingredients approach. These costs broadly included vehicle, computers, furniture, facility, CDSS software, transport, personnel, training, supplies and communication. These were grouped into installation and operation cost; recurrent and capital cost; and fixed and variable cost. We assessed the CDSS in terms of its financial and economic cost implications. We also conducted a sensitivity analysis on the estimations.
Results
Total financial cost of CDSS intervention amounted to 185,927.78 USD. 77% of these costs were incurred in the installation phase and included all the activities in preparation for the actual operation of the system for client care. Generally, training made the largest share of costs (33% of total cost and more than half of the recurrent cost) followed by CDSS software- 32% of total cost. There was a difference of 31.4% between the economic and financial costs. 92.5% of economic costs were fixed costs consisting of inputs whose costs do not vary with the volume of activity within a given range. Economic cost per CDSS contact was 52.7 USD but sensitive to discount rate, asset useful life and input cost variations.
Conclusions
Our study presents financial and economic cost estimates of installing and operating an electronic CDSS for maternal health care in six rural health centres. From these findings one can understand exactly what goes into a similar investment and thus determine sorts of input modification needed to fit their context.

BMC Medical Ethics
http://www.biomedcentral.com/bmcmedethics/content
(Accessed 4 April 2015)

Debate
Journalists, district attorneys and researchers: why IRBs should Get in the middle
Anna H Chodos12* and Sei J Lee2
Author Affiliations
BMC Medical Ethics 2015, 16:19 doi:10.1186/s12910-015-0015-y
Published: 29 March 2015
Abstract (provisional)
Background
Federal regulations in the United States have shaped Institutional Review Boards (IRBs) to focus on protecting individual human subjects. Health services research studies focusing on healthcare institutions such as hospitals or clinics do not have individual human subjects. Since U.S. federal regulations are silent on what type of review, if any, these studies require, different IRBs may approach similar studies differently, resulting in undesirable variation in the review of studies focusing on healthcare institutions. Further, although these studies do not focus on individual human subjects, they may pose risks to participating institutions, as well as individuals who work at those institutions, if identifying information becomes public.
Discussion
Using two recent health services research studies conducted in the U.S. as examples, we discuss variations in the level of IRB oversight for studies focusing on institutions rather than individual human subjects. We highlight how lack of IRB guidance poses challenges for researchers who wish to both protect their subjects and work appropriately with the public, journalists or the legal system in the U.S. Competing interests include the public’s interest in transparency, the researcher’s interest in their science, and the research participants’ interests in confidentiality. Potential solutions that may help guide health services researchers to balance these competing interests include: 1) creating consensus guidelines and standard practices that address confidentiality risk to healthcare institutions and their employees; and 2) expanding the IRB role to conduct a streamlined review of health services research studies focusing on healthcare institutions to balance the competing interest of stakeholders on a case-by-case basis.
Summary
For health services research studies focusing on healthcare institutions, we outline the competing interests of researchers, healthcare institutions and the public. We propose solutions to decrease undesirable variations in the review of these studies.

British Medical Journal
04 April 2015(vol 350, issue 8002)
http://www.bmj.com/content/350/8002

Research
Avoidable waste of research related to inadequate methods in clinical trials
BMJ 2015; 350 doi: http://dx.doi.org/10.1136/bmj.h809 (Published 24 March 2015) Cite this as: BMJ 2015;350:h809
Youri Yordanov, physician and PhD student12, Agnes Dechartres, researcher134, Raphaël Porcher, associate professor134, Isabelle Boutron, professor1345, Douglas G Altman, professor and director6, Philippe Ravaud, professor and director13457
Author affiliations
Abstract
Objective
To assess the waste of research related to inadequate methods in trials included in Cochrane reviews and to examine to what extent this waste could be avoided. A secondary objective was to perform a simulation study to re-estimate this avoidable waste if all trials were adequately reported.
Design
Methodological review and simulation study.
Data sources
Trials included in the meta-analysis of the primary outcome of Cochrane reviews published between April 2012 and March 2013.
Data extraction and synthesis
We collected the risk of bias assessment made by the review authors for each trial. For a random sample of 200 trials with at least one domain at high risk of bias, we re-assessed risk of bias and identified all related methodological problems. For each problem, possible adjustments were proposed that were then validated by an expert panel also evaluating their feasibility (easy or not) and cost. Avoidable waste was defined as trials with at least one domain at high risk of bias for which easy adjustments with no or minor cost could change all domains to low risk. In the simulation study, after extrapolating our re-assessment of risk of bias to all trials, we considered each domain rated as unclear risk of bias as missing data and used multiple imputations to determine whether they were at high or low risk.
Results
Of 1286 trials from 205 meta-analyses, 556 (43%) had at least one domain at high risk of bias. Among the sample of 200 of these trials, 142 were confirmed as high risk; in these, we identified 25 types of methodological problem. Adjustments were possible in 136 trials (96%). Easy adjustments with no or minor cost could be applied in 71 trials (50%), resulting in 17 trials (12%) changing to low risk for all domains. So the avoidable waste represented 12% (95% CI 7% to 18%) of trials with at least one domain at high risk. After correcting for incomplete reporting, avoidable waste due to inadequate methods was estimated at 42% (95% CI 36% to 49%).
Conclusions
An important burden of wasted research is related to inadequate methods. This waste could be partly avoided by simple and inexpensive adjustments.

Bulletin of the World Health Organization
Volume 93, Number 4, April 2015, 209-284
http://www.who.int/bulletin/volumes/93/4/en/

Editorials
Lack of toilets and safe water in health-care facilities
Jamie Bartram a, Ryan Cronk a, Maggie Montgomery b, Bruce Gordon b, Maria Neira b, Edward Kelley c & Yael Velleman d
a. Water Institute and Department of Environmental Sciences and Engineering, University of North Carolina, Chapel Hill, North Carolina, 27599, United States of America.
b. Department of Public Health, Environmental and Social Determinants of Health, World Health Organization, Geneva, Switzerland.
c. Department of Service Delivery and Safety, World Health Organization, Geneva, Switzerland.
d. WaterAid, London, England.
Bulletin of the World Health Organization 2015;93:210. doi: http://dx.doi.org/10.2471/BLT.15.154609
[Initial text]
In March 2015, the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) released a report1 on the status of water and sanitation in health-care facilities from 54 low- and middle-income countries. Data representing 66 000 health facilities show that water was not readily available in about 40%.1 Over a third of facilities lacked soap for hand washing and a fifth lacked toilets. In many countries, in facilities where water is available, there is no guarantee that it is safe for consumption.2
This is a major embarrassment for the health sector: health facilities serve as foci for infection and patients seeking treatment fall ill and may die, for the lack of the most basic requirements for good hygiene – safe, reliable water supplies and adequate sanitation…

Bulletin of the World Health Organization
Volume 93, Number 4, April 2015, 209-284
http://www.who.int/bulletin/volumes/93/4/en/

WHO’s first global health treaty: 10 years in force
Haik Nikogosian a & Vera Luiza da Costa e Silva a
a. World Health Organization, Avenue Appia 20, 1211 Geneva 27, Switzerland.
Bulletin of the World Health Organization 2015;93:211. doi: http://dx.doi.org/10.2471/BLT.15.154823
[Initial text]
It is 10 years since the World Health Organization (WHO) Framework Convention on Tobacco Control entered into force.1 This binding treaty, the first to be negotiated under the auspices of WHO, is widely recognized as a major milestone in global health.
Although challenges in fully implementing the treaty remain, it has been successful as a novel public health instrument. It has been ratified by 180 Parties – representing 90% of the global population – making it one of the most rapidly embraced treaties in the United Nations system…

Bulletin of the World Health Organization
Volume 93, Number 4, April 2015, 209-284
http://www.who.int/bulletin/volumes/93/4/en/

Data-driven methods for imputing national-level incidence in global burden of disease studies
Scott A McDonald, Brecht Devleesschauwer, Niko Speybroeck, Niel Hens, Nicolas Praet, Paul R Torgerson, Arie H Havelaar, Felicia Wu, Marlène Tremblay, Ermias W Amene & Dörte Döpfer
Abstract
Objective
To develop transparent and reproducible methods for imputing missing data on disease incidence at national-level for the year 2005.
Methods
We compared several models for imputing missing country-level incidence rates for two foodborne diseases – congenital toxoplasmosis and aflatoxin-related hepatocellular carcinoma. Missing values were assumed to be missing at random. Predictor variables were selected using least absolute shrinkage and selection operator regression. We compared the predictive performance of naive extrapolation approaches and Bayesian random and mixed-effects regression models. Leave-one-out cross-validation was used to evaluate model accuracy.
Findings
The predictive accuracy of the Bayesian mixed-effects models was significantly better than that of the naive extrapolation method for one of the two disease models. However, Bayesian mixed-effects models produced wider prediction intervals for both data sets.
Conclusion
Several approaches are available for imputing missing data at national level. Strengths of a hierarchical regression approach for this type of task are the ability to derive estimates from other similar countries, transparency, computational efficiency and ease of interpretation. The inclusion of informative covariates may improve model performance, but results should be appraised carefully.

Bulletin of the World Health Organization
Volume 93, Number 4, April 2015, 209-284
http://www.who.int/bulletin/volumes/93/4/en/
The Global Drug Facility as an intervention in the market for tuberculosis drugs
Nimalan Arinaminpathy, Thierry Cordier-Lassalle, Kaspars Lunte & Christopher Dye
Abstract
Objective
To investigate funding for the Global Drug Facility since 2001 and to analyse the facility’s influence on the price of high-quality tuberculosis drugs.
Methods
Data on the price of tuberculosis drugs were obtained from the Global Drug Facility for 2001 to 2012 and, for the private sector in 15 countries, from IMS Health for 2002 to 2012. Data on funding of the facility were also collected.
Findings
Quality-assured tuberculosis drugs supplied by the Global Drug Facility were generally priced lower than drugs purchased in the private sector. In 2012, just three manufacturers accounted for 29.9 million United Stated dollars (US$) of US$ 44.5 million by value of first-line drugs supplied. The Global Fund to Fight AIDS, Tuberculosis and Malaria provided 73% (US$ 32.5 million of US$ 44.5 million) and 89% (US$ 57.8 million of US $65.2 million) of funds for first- and second-line drugs, respectively. Between 2010 and 2012, the facility’s market share of second-line tuberculosis drugs increased from 26.1% to 42.9%, while prices decreased by as much as 24% (from US$ 1231 to US$ 939). Conversely, the facility’s market share of first-line drugs fell from 37.2% to 19.2% during this time, while prices increased from US$ 9.53 to US$ 10.2.
Conclusion
The price of tuberculosis drugs supplied through the facility was generally less than that on the private market. However, to realize its full potential and meet the needs of more tuberculosis patients, the facility requires more diverse and stable public funding and greater flexibility to participate in the private market.

Bulletin of the World Health Organization
Volume 93, Number 4, April 2015, 209-284
http://www.who.int/bulletin/volumes/93/4/en/

SYSTEMATIC REVIEWS
Inequities in postnatal care in low- and middle-income countries: a systematic review and meta-analysis
Étienne V Langlois, Malgorzata Miszkurka, Maria Victoria Zunzunegui, Abdul Ghaffar, Daniela Ziegler & Igor Karp
Abstract
Objective
To assess the socioeconomic, geographical and demographic inequities in the use of postnatal health-care services in low- and middle-income countries.
Methods
We searched Medline, Embase and Cochrane Central databases and grey literature for experimental, quasi-experimental and observational studies that had been conducted in low- and middle-income countries. We summarized the relevant studies qualitatively and performed meta-analyses of the use of postnatal care services according to selected indicators of socioeconomic status and residence in an urban or rural setting.
Findings
A total of 36 studies were included in the narrative synthesis and 10 of them were used for the meta-analyses. Compared with women in the lowest quintile of socioeconomic status, the pooled odds ratios for use of postnatal care by women in the second, third, fourth and fifth quintiles were: 1.14 (95% confidence interval, CI : 0.96–1.34), 1.32 (95% CI: 1.12–1.55), 1.60 (95% CI: 1.30–1.98) and 2.27 (95% CI: 1.75–2.93) respectively. Compared to women living in rural settings, the pooled odds ratio for the use of postnatal care by women living in urban settings was 1.36 (95% CI: 1.01–1.81). A qualitative assessment of the relevant published data also indicated that use of postnatal care services increased with increasing level of education.
Conclusion
In low- and middle-income countries, use of postnatal care services remains highly inequitable and varies markedly with socioeconomic status and between urban and rural residents.

Health Policy and Planning
Volume 30 Issue 3 April 2015
http://heapol.oxfordjournals.org/content/current

An analysis of government immunization program expenditures in lower and lower middle income countries 2006–12
Alice Abou Nader1,*, Ciro de Quadros1, Claudio Politi2 and Michael McQuestion1
Author Affiliations
1Sabin Vaccine Institute, 2000 Pennsylvania Ave. Suite 7100, NW, Washington, DC 20006, USA 2World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland
Accepted December 31, 2013.
Abstract
Financing is becoming increasingly important as the cost of immunizing the world’s children continues to rise. By 2015, that cost will likely exceed US$60 per infant as new vaccines are introduced into national immunization programs. In 2006, 51 lower and lower middle income countries reported spending a mean US$12 per surviving infant on routine immunization. By 2012, the figure had risen to $20, a 67% increase. This study tests the hypothesis that lower and lower middle income countries will spend more on their routine immunization programs as their economies grow. A panel data regression approach is used. Expenditures reported by governments annually (2006–12) through the World Health Organization/UNICEF Joint Reporting Form are regressed on lagged annual per capita gross national income (GNI), controlling for prevailing mortality levels, immunization program performance, corruption control efforts, geographical region and correct reporting. Results show the expenditures increased with GNI. Expressed as an elasticity, the countries spent approximately $6.32 on immunization for every $100 in GNI increase from 2006 to 2012. Projecting forward and assuming continued annual GNI growth rates of 10.65%, countries could be spending $60 per infant by 2020 if national investment functions increase 4-fold. Given the political will, this result implies countries could fully finance their routine immunization programs without cutting funding for other programs.

Health Policy and Planning
Volume 30 Issue 3 April 2015
http://heapol.oxfordjournals.org/content/current

Drivers of routine immunization coverage improvement in Africa: findings from district-level case studies
Anne LaFond1,*, Natasha Kanagat1, Robert Steinglass1, Rebecca Fields1, Jenny Sequeira1 and
Sangeeta Mookherji2
Author Affiliations
1John Snow Inc., 1616 Fort Myer Drive, 16th Floor, Arlington, VA 22209, USA and 2Department of Global Health, School of Public Health and Health Services, George Washington University 2175 K Street, Suite 200 Washington, DC 20037, USA
Accepted January 28, 2014.
Abstract
There is limited understanding of why routine immunization (RI) coverage improves in some settings in Africa and not in others. Using a grounded theory approach, we conducted in-depth case studies to understand pathways to coverage improvement by comparing immunization programme experience in 12 districts in three countries (Ethiopia, Cameroon and Ghana). Drawing on positive deviance or assets model techniques we compared the experience of districts where diphtheria–tetanus–pertussis (DTP3)/pentavalent3 (Penta3) coverage improved with districts where DTP3/Penta3 coverage remained unchanged (or steady) over the same period, focusing on basic readiness to deliver immunization services and drivers of coverage improvement. The results informed a model for immunization coverage improvement that emphasizes the dynamics of immunization systems at district level. In all districts, whether improving or steady, we found that a set of basic RI system resources were in place from 2006 to 2010 and did not observe major differences in infrastructure. We found that the differences in coverage trends were due to factors other than basic RI system capacity or service readiness. We identified six common drivers of RI coverage performance improvement—four direct drivers and two enabling drivers—that were present in well-performing districts and weaker or absent in steady coverage districts, and map the pathways from driver to improved supply, demand and coverage. Findings emphasize the critical role of implementation strategies and the need for locally skilled managers that are capable of tailoring strategies to specific settings and community needs. The case studies are unique in their focus on the positive drivers of change and the identification of pathways to coverage improvement, an approach that should be considered in future studies and routine assessments of district-level immunization system performance.

Health Policy and Planning
Volume 30 Issue 3 April 2015
http://heapol.oxfordjournals.org/content/current

Tackling the tensions in evaluating capacity strengthening for health research in low- and middle-income countries
Imelda Bates1,*, Alan Boyd2, Garry Aslanyan3 and Donald C Cole4
Author Affiliations
1Liverpool School of Tropical Medicine, Liverpool, UK, 2Manchester Business School, Booth St W, Manchester, Greater Manchester M15 6PB, UK, 3Tropical Disease Research, World Health Organization, 20, Avenue Appia, CH-1211 Geneva 27, Switzerland and 4Dalla Lana School of Public Health University of Toronto, 155 College St. Toronto, ON M5T3M7, Canada
Accepted February 13, 2014.
Abstract
Strengthening research capacity in low- and middle-income countries is one of the most effective ways of advancing their health and development but the complexity and heterogeneity of health research capacity strengthening (RCS) initiatives means it is difficult to evaluate their effectiveness. Our study aimed to enhance understanding about these difficulties and to make recommendations about how to make health RCS evaluations more effective. Through discussions and surveys of health RCS funders, including the ESSENCE on Health Research initiative, we identified themes that were important to health RCS funders and used these to guide a systematic analysis of their evaluation reports. Eighteen reports, produced between 2000 and 2013, representing 12 evaluations, were purposefully selected from 54 reports provided by the funders to provide maximum variety. Text from the reports was extracted independently by two authors against a pre-designed framework. Information about the health RCS approaches, tensions and suggested solutions was re-constructed into a narrative. Throughout the process contacts in the health RCS funder agencies were involved in helping us to validate and interpret our results. The focus of the health RCS evaluations ranged from individuals and institutions to national, regional and global levels. Our analysis identified tensions around how much stakeholders should participate in an evaluation, the appropriate balance between measuring and learning and between a focus on short-term processes vs longer-term impact and sustainability. Suggested solutions to these tensions included early and ongoing stakeholder engagement in planning and evaluating health RCS, modelling of impact pathways and rapid assimilation of lessons learned for continuous improvement of decision making and programming. The use of developmental approaches could improve health RCS evaluations by addressing common tensions and promoting sustainability. Sharing learning about how to do robust and useful health RCS evaluations should happen alongside, not after, health RCS efforts.