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

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– 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
– Children’s Hospital of Philadelphia Vaccine Education Center
Associate Faculty, Division of Medical Ethics, NYU Medical School

Sixty-eighth World Health Assembly [full documentation]

Editor’s Note:
The World Health Assembly concluded with a number high-level actions summarized in news releases as below. We focus below on action around immunization and include the full text of the WHA Global Vaccine Action Plan (GVAP) resolution. We note the aggressive call in the resolution for action on vaccine pricing transparency.

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Delegates discuss progress towards global immunization goals
25 May 2015 – Fifty-two speakers, including 46 delegates of Member States, one observer (Chinese Taipei), four civil society organizations and GAVI, the Vaccine Alliance took the floor during the discussion on the Global Vaccine Action Plan.

Delegates welcomed the GVAP assessment report, and commended the WHO Strategic Advisory Group of Experts (SAGE) on immunization on the recommendations in the report.

Delegates took note and expressed concern that the progress with the implementation of GVAP was patchy and slow and “far off-track” for achieving five out of six targets for 2014 and 2015.

WHO’s fundamental role in facilitating the implementation of the GVAP was acknowledged, stressing the important and leading role that WHO should play to:
:: Improve vaccine price transparency and build mechanisms that promote healthy and competitive vaccine markets, tackle the problems faced by middle income countries to secure sustainable supplies of vaccines at affordable prices, particularly for the newer vaccines.
:: Work to enhance awareness of the value of vaccines to increase acceptance of immunization and to mitigate the risks posed by misinformation leading to vaccine hesitancy and refusal.
:: Analyse the causes of vaccine stock out and develop tools to respond immediately to any supply shortfalls.
:: Regularly convene countries that remain off-track to assist with diagnosing the problems and finding solutions.
:: Support countries to improve the quality of data and to use data for informing decisions and for improving programme performance.
:: Expand the existing guidance for vaccination in humanitarian emergencies to also include guidance on sustaining routine immunization during periods of conflict and crisis, including outbreaks of disease, such as the current Ebola epidemic in west Africa.

Delegates acknowledged that countries and particularly national governments, play a leading role in making the needed investments in immunization. Governments are accountable for the progress as well as the monitoring of their own immunization programme performance.

The Health Assembly adopted a resolution tabled by Libya that specifically addresses the issue of access to sustainable supplies of affordable vaccines for low and middle income countries, including the promotion of vaccine price transparency, support for pooled procurement mechanisms and for increased capacity for the manufacture of vaccines of assured quality to foster competition for a healthy vaccine market.

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Note: List of Member States that made interventions during the GVAP discussion: Libya, Iceland, Panama, Chile, Australia, Brazil, Iran, Japan, Ethiopia, Morocco, Egypt, Republic of Korea, China, Ecuador, Pakistan, Lebanon, Brunei Darussalam, United Sates of America, Russians Federation, United Kingdom, Cape Verde, Thailand, Philippines, Tanzania, Nigeria, South Africa, Canada, Colombia, Bangladesh, Maldives, Jamaica, Bahamas, Bahrain, Saudi Arabia, Qatar, Malaysia, Argentina, Kuwait, Gabon, India, Venezuela, Latvia, Iraq, Senegal, Algeria, Greece

Note: List of civil society organizations that made interventions during the GVAP discussion: Save the Children, Médecins Sans Frontières, Medicus Mundi, International Pharmaceutical Federation

World Health Assembly addresses antimicrobial resistance, immunization gaps and malnutrition
25 May 2015
News release
Excerpt
…Immunization
The Assembly agreed a resolution to improve access to sustainable supplies of affordable vaccines – a key issue for low- and middle-income countries aiming to extend immunization to the entire population. In 2012, the Assembly endorsed the Global Vaccine Action Plan, a commitment to ensure that no one misses out on vital immunization by 2020. A report from WHO’s Strategic Advisory Group of Experts on immunization, warns, however, that progress towards the Action Plan’s targets is slow and patchy.

The resolution calls on WHO to coordinate efforts to address gaps in progress. It urges Member States to increase transparency around vaccine pricing and explore pooling the procurement of vaccines. It requests the WHO Secretariat to report on barriers that may undermine robust competition that can enable price reductions for new vaccines, and to address any other factors that might adversely affect the availability of vaccines. The resolution also highlighted that immunization is a highly cost-effective public health interventions, playing a major role in reducing child deaths and improving health. It recommends scaling up advocacy efforts to improve understanding of the value of vaccines and to allay fears leading to vaccine hesitancy.

Last week, on the margins of the Health Assembly, the Secretariat brought together high-level representatives of 34 countries with low immunization coverage to discuss challenges and explore solutions to overcome them…

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WHA Resolution – Global vaccine action plan   A68/73 26 May 2015
The Sixty-eighth World Health Assembly,
Having considered the report on the global vaccine action plan A68/30;

Emphasizing the importance of immunization as one of the most effective interventions in public health and access to immunization as a key step towards access to health and universal health coverage;

Acknowledging the progress made in global immunization and the commitment under the 2011–2020 Decade of Vaccines to achieve immunization goals and milestones;

Recalling resolutions WHA58.15 and WHA61.15 on the global immunization strategy, resolution WHA65.17 on the global vaccine action plan, resolution WHA61.21 on the global strategy and plan of action on public health, innovation and intellectual property, resolution WHA54.11 on the WHO medicines strategy and resolution WHA67.20 on regulatory system strengthening for medical products;

Noting with concern that globally immunization coverage has increased only marginally since the late 2000s; and that in 2013 more than 21 million children under one year of age did not complete the three-dose series of diphtheria-tetanus-pertussis (DTP) vaccine;

Recognizing that the availability of new vaccines against important causes of vaccine preventable diseases such as pneumonia, diarrhoea and cervical cancer can prevent leading causes of childhood and women’s death;

Acknowledging that successful national immunization programmes require sustainable political and financial support of Member States;

Appreciating the contributions of WHO, UNICEF, the Gavi Alliance, and all partners in their efforts to support the introduction of new vaccines in developing countries and strengthen immunization services;

Concerned that inequities between Member States are growing, inter alia, due to the increased financial burden of new vaccines and based upon those that are eligible or ineligible for financial and technical support from global partners;

Concerned that many low- and middle-income countries may not have the opportunity to access newer and improved vaccines, particularly because of the costs related to the procurement and introduction of these vaccines; and concerned at the increase of costs of overall immunization programmes because of increase in price of the WHO-recommended vaccines;

Recognizing that publicly available data on vaccine prices are scarce, and that the availability of price information is important for facilitating Member States’ efforts towards introduction of new vaccines;

Recalling many Member States’ interventions on the Health Assembly’s immunization agenda item each year, expressing concern over the unaffordable cost of new vaccines and appealing to the global community to support strategies that will reduce prices;

Recalling the WHO global framework for expanding access to essential drugs, and its four components: the rational selection and use of medicines, reliable health and supply systems, sustainable financing, and affordable prices;

Taking into account the importance of competition to reduce prices and the need to expand the number of manufacturers, particularly in developing countries, that can produce WHO-prequalified vaccines and create a competitive market;

Stressing the critical life-saving role of vaccines and immunization programmes and striving to make immunization available to all;

Noting with concern the global shortage of certain traditional routine vaccines, for example BCG vaccine and combined measles-rubella vaccine;

Acknowledging that shortages of vaccines are quite often an important cause of disruption of vaccination schedules and that therefore the establishment of effective and sustainable vaccine production, supply, procurement and delivery systems is essential to ensure access to all the necessary vaccines of assured quality at the right time;

Concerned that scepticism against vaccination is continuing to grow in society despite the proven efficacy and safety of modern vaccines, and that many children do not receive life-saving vaccines as a result of insufficient information to parents or health care workers or even of active anti-vaccination propaganda,

1. URGES Member States [And, where applicable, regional economic integration organizations]
(1) to allocate adequate financial and human resources for the introduction of vaccines into national immunization schedules and for sustaining strong immunization programmes in accordance with national priorities;

(2) to strengthen efforts, as and where appropriate, for pooling vaccine procurement volumes in regional and interregional or other groupings, as appropriate, that will increase affordability by leveraging economies of scale;

(3) to provide, where possible and available, timely vaccine price data to WHO for publication, with the goal of increasing affordability through improved price transparency, particularly for the new vaccines;

(4) to seek opportunities for establishing national and regional vaccine manufacturing capacity, in accordance with national priorities, that can produce to national regulatory standards, including WHO-prequalification;

(5) to create mechanisms to increase the availability of comparable information on government funding for vaccine development and work towards strategies that enhance public health benefit from government investments in vaccine development;

(6) to support the ongoing efforts of various partners coordinated by WHO to design and implement the strategies to address the vaccine and immunization gaps faced by the low- and middle-income countries that request assistance;

(7) to improve and sustain vaccine purchasing and delivery systems in order to promote the uninterrupted and affordable safe supply of all the necessary vaccines and their availability to all immunization service providers;

(8) to strengthen immunization advocacy and provide training to health professionals and information to the public regarding immunization issues to achieve a clear understanding of the benefits and risks of immunization;

2. REQUESTS the Director-General:
(1) to explore ways to mobilize funding to fully support collaborative efforts with international partners, donors, and vaccine manufacturers to support low- and middle-income countries in accessing affordable vaccines of assured quality in adequate supply;

(2) to continue developing and adequately managing publicly available vaccine price databases, like the WHO Vaccine Product, Price and Procurement project, working with Member States to increase availability of price information;

(3) to monitor vaccine prices through annual reporting of the global vaccine action plan;

(4) to provide technical support and facilitate financial resources for establishing pooled procurement mechanisms, where appropriate, for use by Member States;

(5) to strengthen the WHO prequalification programme and provide technical assistance to support developing countries in capacity building for research and development, technology transfer, and other upstream to downstream vaccine development and manufacturing strategies that foster proper competition for a healthy vaccine market;

(6) to report upon technical, procedural and legal barriers that may undermine robust competition that can enable price reductions for new vaccines, and address other factors that can adversely affect the availability of vaccines;

(7) to assist in mobilizing resources for countries that request assistance in the introduction of new vaccines in line with the global vaccine action plan and in accordance with national priorities;

(8) to continue to assist Member States to improve and sustain their vaccine delivery systems and to continue to provide technical support to Member States to strengthen the knowledge and skills of their health care professionals in vaccination programmes;

(9) to report back on progress in implementing this resolution to the Health Assembly through the Executive Board in the annual report on the global vaccine action plan.

WHA68 Side Meeting on Immunization
“Achieving the Global Vaccine Action Plan Objective for Routine Coverage: What can be done to get back on track?”
20 May 2015 ¦ Geneva – During the WHA68, a side meeting on immunization with delegates from Member States with DTP3 coverage below 80% was convened by WHO. The objectives were to discuss the challenges faced by countries to reach global vaccination targets for 2015 and explore solutions to overcome them. Lead agencies in the Decade of Vaccines Collaboration and other development partners were given the opportunity to reiterate their commitments to support countries to achieve this important goal.

The WHA side meeting was co-sponsored by Thailand, the Democratic Republic of Congo and the United States of America and was chaired by Dr Flavia Bustreo, Assistant Director General, Family, Women’s and Children’s Health. Dr Margaret Chan, the Director-General of WHO, was in attendance. Representatives of agencies comprising the Global Vaccine Action Plan (GVAP) Secretariat, namely Gavi, the Vaccine Alliance, UNICEF and the Bill & Melinda Gates Foundation were present, as well as representatives from Civil Society Organizations.

Member States highlighted critical operational needs and challenges to ensure wider vaccination and delivery on the ground to reach every last child especially those living in remote and inaccessible areas, the need to strengthen vaccine supply chains, the challenges posed by conflict, natural disasters and vaccine stock out and the importance of mechanisms to secure sustainable supplies of vaccines at affordable prices.

Dr Chan highlighted several areas that require attention, including the need to address vaccine hesitancy and refusal, improve communications to create greater awareness of the importance of immunization and the science behind vaccines, the need for collective actions and the importance of private public partnerships to come up with new funding mechanisms. She emphasized the need to build on the lessons learned from the polio eradication initiative.

Notable achievements have been made with the help of Gavi, the Vaccine Alliance to enhance access and the roll out of new vaccines. It was acknowledged that problems remain with reaching the “5th child”. UNICEF is working hand-in-hand with WHO and partners to address the issues impeding the achievement of high coverage and plays an important role in strengthening supply chains.

Dr Elias highlighted that a collective effort was required and encouraged each in the room, international agencies, development partners and national governments “to challenge ourselves to find new solutions to address the remaining barriers to universal access to immunization”.

“The fifth child is often part of undocumented migrant or urban populations or living in remote or insecure areas. Hence, the strategies to reach them cannot be a continuation of what we have done till now”
Dr Chris Elias, President of the Global Development Programme, the Bill & Melinda Gates Foundation

The Weekly Epidemiological Record (WER) 29 May 2015, vol. 90, 22 (pp. 261–280) includes:
…Monthly report on dracunculiasis cases, January– April 2015
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…Meeting of the Strategic Advisory Group of Experts on immunization, April 2015: conclusions and recommendations
[Meeting Report Sections and Editor’s Excerpts]

Report from the WHO Department of Immunization, Vaccines and Biologicals
The report focused on: the implementation of the Global Vaccine Action Plan (GVAP) and the related discussions during meetings of the WHO Governing Bodies at global and regional levels; the programmatic priorities to close the immunization gap; an update on implementation of selected SAGE recommendations; and agenda items on the horizon for future meetings.

The report stressed that reaching the GVAP goals is resource intensive (human and financial) and emphasized the urgent need for adequate investments and focus in order to increase routine immunization coverage which has been almost static, at global level, since 2009 and below the expected 90% coverage.

The report noted the current global short¬age of bacille Calmette–Guérin (BCG) vaccine and proposed interim solutions while stressing the need for the global community to pay more attention and take measures to avoid future shortages of other recommended vaccines.

SAGE took note of regional progress and commended the work carried out to advance regional vaccine action plans and promote activities to strengthen routine immunization.

SAGE stressed that additional disaggregation was needed in the analysis of the progress achieved on the ground, and in identifying bottlenecks for progress, and recommended that reports display disparities observed at subnational levels.

In view of weak infrastructure in some countries with a related inability to deliver vaccines, SAGE called for new politically supported initiatives to mobilize part¬ners and resources to apply technological know-how in fragile countries and find ways to build infrastructure in fragile systems. SAGE reaffirmed the need for solu¬tions that simplify operations on the ground, including delivery technologies such as compact pre-filled auto-disable injection technology. In this context SAGE also acknowledged the importance of the polio infrastruc-ture and noted how it had been critical in helping to deal with the Ebola situation, particularly in Nigeria.

SAGE stressed the importance of applying rigour and science in implementation programme design and eval¬uation of delivery of vaccines, in order to maximize the impact of current and future vaccines and delivery tech¬nologies.

SAGE also stressed the need to draw lessons from the Ebola epidemic regarding mobilization of communities as well as the encouragement of countries and partners to mobilize the private sector.

SAGE supported WHO’s plan to expand guidance beyond the current framework on the use of vaccines in humanitarian emergencies to include guidance on how to re-establish routine vaccination in those settings.

At the January 2015 WHO Executive Board meeting, Member States endorsed a resolution for pre-emptive development of vaccines against emerging infectious diseases such as Ebola virus disease. WHO was asked to provide leadership in supporting a prioritized research agenda. A framework for action in relation to vaccine development was proposed, which would include public health criteria, technical feasibility, regu¬latory pathways, and economic considerations. The issues will be reviewed by SAGE, the Product Develop¬ment for Vaccines Advisory Committee (PDVAC), the Expert Committee on Biological Standardization (ECBS) and other forums, with the aim of reaching an agree¬ment within a year.

A SAGE Working Group on Dengue Vaccine was established in March 2015.
Subject to the completion and conclusions of the vaccine assessment by the European Medicines Agency, it is planned that SAGE and the Malaria Programme Advi¬sory Committee will issue policy recommendations on the use of RTS,S malaria vaccine during a joint session in October 2015.
..1 See http://www.who.int/immunization/sage/en
..2 The complete set of presentations and background materials used for the SAGE meeting of 14-16 April 2015 together with the list of SAGE members and the summarized declarations of interests provided by SAGE members are available at http://www.who.int/immunization/sage/meetings/2015/april/en
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Report from Gavi, the Vaccine Alliance
Report of the Global Advisory Committee on Vaccine Safety (GACVS)
Report of the Product Development for Vaccines Advisory Committee (PDVAC)

Polio eradication
SAGE reviewed progress towards eradication of wild poliovirus (WPV) and elimination of persistent circulating vaccine-derived poliovirus type 2 (cVDPV2) as well as the plans, preparedness and timeline for with¬drawal of type 2 oral polio vaccine (OPV2).

SAGE noted that the programme had made substantial progress since the previous SAGE meeting. No WPV case has been reported in the Middle East or Africa since April 2014 and August 2014, respectively. In polio-endemic countries there were definite improvements in the quality of supplementary immunization activities (SIAs), increasing access to children in conflict-affected areas of Pakistan, improvements in AFP surveillance and expansion of environmental surveillance…

…SAGE concluded that progress towards elimination of persistent cVDPV2 is on track. SAGE recommended that all countries and GPEI should plan firmly for April 2016 as the designated date for withdrawal of OPV2. SAGE will consider delaying OPV2 withdrawal only if the WG reports in October 2015 that the assessed risk of contin¬ued cVDPV2 transmission is high. SAGE requested the polio WG to continue monitoring progress towards cVDPV2 elimination and ensuring that remaining chal¬lenges are addressed including contingencies for vaccine supplies (IPV, bOPV and tOPV), registration of bOPV for routine use, surveillance sensitivity, and reaching inaccessible children. The Working Group will make a full report to SAGE in October 2015, when SAGE may reconfirm April 2016 as the definite date for OPV2 withdrawal.

SAGE endorsed the proposed approach to verification of compliance of poliovirus containment in essential facilities. Under the WHO Global Action Plan (GAP III), facilities planning to handle or store type 2 poliovirus are requested to implement containment measures and appropriately manage associated biorisks. National Regulatory Authorities for containment (NRAcs) are expected to certify facilities according to GAP III. Certification reports are submitted to Regional Certification Commissions (RCCs) for evaluation. In support of this process, RCCs, NRAcs or concerned facilities may request that WHO verify compliance of certified facili¬ties in keeping with GAP III. SAGE requested that the programme consider mechanisms to address the risks associated with research and therapeutic uses of live polioviruses.

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Administration of multiple injectable vaccines in a single visit
…SAGE supported the following Good Practice Statement on multiple vaccine injections in a single visit, recognizing that the country context is an important determinant of success and acceptability among caregivers and providers: National vaccination schedules recommending administration of multiple injections in the same visit are widely used and provide benefits insofar as they support timely and efficient vaccination of children. Where studies have evaluated the immunogenicity and safety of co-administered vaccines, these practices are encouraged based on the benefits they confer.

SAGE concluded that countries should not make modifications to recommended immunization schedules with the aim of preventing multiple injections during the same visit when such modifications are not evidence-based…

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Reducing pain and distress at the time of vaccination

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Sustainable access to vaccines in middle-income countries (MICs): report of the WHO-convened MIC Task Force
The MIC Task Force, a group of 9 immunization part¬ners, presented a proposed strategy for coordinated action to enhance sustainable access to vaccines in MICs. Over the past decade, access to vaccines in MICs has been much debated, fuelled by the fact that the majority of poor people are now in MICs and concern that this group of countries may be missing out on opportunities to introduce new vaccines, as donors focus on low-income countries. In view of this situation and at the request of SAGE, in June 2014 WHO convened the MIC Task Force to develop a coordinated strategy and plan of action.

A comprehensive review of MICs’ performance shows that they are far from attaining the GVAP targets. While 40 MICs are well supported by Gavi, 63 do not benefit from a unified international strategy for action. In these countries, vaccine-preventable disease burden and numbers of unvaccinated children are relatively low compared to the Gavi-supported MICs, but nonetheless substantial and unacceptable. Many of these countries have strong health systems and potential for rapid gains if key barriers are removed. The MIC strategy, aligned with the GVAP time frame (2016–2020), proposes a way forward for non-Gavi countries. Importantly, solutions and platforms set up as part of the strategy would also benefit countries that graduate from Gavi support over time, ensuring sustainability of current investments…

…SAGE acknowledged that the strategy represents a strong proposal for a coordinated and comprehensive approach to the MIC situation. SAGE concurred with the general direction of the strategy and valued the menu of options as an approach to tailoring activities to the individual needs of a heterogeneous group of countries. SAGE appreciated that the strategy builds upon lessons learnt and existing activities as the most efficient way to use resources and achieve impact.

SAGE called on partners to support implementation of the strategy and on countries to take advantage of the proposed solutions.

SAGE noted that prompt implementation of the MIC strategy is particularly important given the impending graduation of several large Gavi countries, which will require long-term solutions to be put in place…

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Ebola vaccines and vaccination
…In parallel with the vaccine trials, WHO and partners, including the 3 most affected countries, have established a framework to develop guidelines to support planning, implementing and monitoring vaccination once a vaccine becomes available for use, according to SAGE recommendations.

A proposed framework for making recommendations was presented, which aims to adopt a scenario-based approach, while also taking account of a number of programmatic, socio-cultural and other factors. Considerations guiding the use of the framework are: specific scenario relating to the epidemiology and the type of authorization for vaccine use; objectives for vaccination (primary – stopping transmission, secondary – individual protection); prioritization of target populations; and additional considerations which would inform SAGE’s recommendations. The framework would be adjusted based on evolution of the current epidemic, the type of regulatory or emergency use authorization given for a vaccine, and on the data that become avail¬able from the clinical trials.

In the discussion that followed, it was noted that the quality of the reported disease data had limitations and that the data on cultural and other factors that may have contributed to differences in the epidemic patterns were not fully captured in the national databases. However, there was confidence that the available data correctly reflected the epidemic patterns and the relative incidence of disease in different age groups.

SAGE members expressed concern about the likelihood that efficacy estimates may not be generated from the phase 3 trials, given the declining number of cases in all 3 countries and felt that the trials must also contribute additional data (including those related to programmatic aspects) that could inform recommendations. Noting WHO’s unique position to coordinate the development of Ebola vaccines, SAGE stressed the importance of transparent and prompt sharing of information on the trial protocols and data from the phase 3 clinical trials, and the need for a greater role for WHO in facilitating the sharing of information so that results between studies will generate the greatest benefit for policy decision-making.

SAGE supported the proposed framework for making recommendations, but asked that it be made explicit that the identification and prioritization of target populations for vaccination will be based on a thorough assessment of risks (from disease as well as from vaccination) and benefits. It was recognized that the final recommendations would be driven by the evolution of the current epidemic, the conditions laid down in the regulatory authorization for use of vaccines and social and cultural considerations.

SAGE recommended that the further development of the Emergency Use Assessment and Listing procedure being developed by WHO, which would allow use of a vaccine in the context of a Public Health Emergency of Inter¬national Concern, be done in close consultation with relevant regulatory authorities, including those of the affected countries.

SAGE again noted the probability that efficacy data for any of the Ebola vaccines may not be available by the end of the current outbreak, and therefore recom¬mended that future use of unproven Ebola vaccines should be in the context of studies that would generate safety and effectiveness data.

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Maternal vaccination during pregnancy
SAGE encouraged WHO to promote more implementation research to generate generalizable data on the best ways to integrate maternal immunization into routine antenatal care in low resource settings. SAGE also encouraged the Regional Office for the Americas to document the successful regional experience of deliver¬ing influenza vaccine to pregnant women.

It was considered unnecessary to establish a SAGE working group to review maternal influenza immunization at present, given that substantial data still being generated will not be available until late 2015–2016. SAGE emphasized the importance of the maternal immunization platform, in general, and called upon WHO to affirm its commitment to building the evidence base to strengthen vaccine delivery during pregnancy, as it has great potential for infection prevention in high-risk groups worldwide.

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Pertussis vaccination schedules

Nepal earthquake 2015 – Grade 3 emergency
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:: Health situation report No. 19 pdf, 317kb – 26 May 2015
KEY HIGHLIGHTS
:: The repeated earthquakes and aftershocks since 25 April 2015 have had a major public health consequences, with a total 1085 health facilities (402 completely and 683 partially) damaged.
:: A total of 2088 people have undergone major surgeries and 26,160 have received psychosocial support in the highly affected 14 districts.
:: Nepal’s Ministry of Health and Population (MOHP) identifies 429 patients in Bhaktapur, Kathmandu and Lalitpur who require longer term treatment support.
:: 42 Foreign Medical teams (FMTs) are operating in the country with a total 802 persons including 264 doctors and 236 nurses.
:: Currently there are over 100 beds available for patients requiring ongoing rehabilitation or nursing care within the Kathmandu valley.

:: Health Cluster Bulletin No. 4 pdf, 1.83Mb 27 May 2015
Situation update
Up to 26 May, just a little over a month after the first earthquake of 7.8 on the Richter scale struck Nepal on 25 April, followed by a 7.3 magnitude on 12 May and numerous aftershocks, the MoHP is reporting that there has been 8673 earthquake-related deaths and 21952 injuries. Of this amount, eight health workers and 10 FCHVs have lost their lives, 75 have been injured and two remain missing.
The Ministry of Health and Population’s (MoHP) Early Warning and Response System for epidemic-prone diseases (EWARS) show a generally stabilizing trend in numbers of outbreak prone diseases in the 14 severely affected districts. No major outbreaks have been reported to date…

EBOLA/EVD [to 30 May 2015]
Public Health Emergency of International Concern (PHEIC); “Threat to international peace and security” (UN Security Council)

WHO: Ebola Situation Report – 27 May 2015
[Excerpts]
SUMMARY
:: There were 12 confirmed cases of Ebola virus disease (EVD) reported in the week to 24 May: 9 from Guinea and 3 from Sierra Leone. A total of 5 districts (3 in Guinea, 2 in Sierra Leone) reported at least one confirmed case, compared with 6 districts the previous week. The west-Guinean prefecture of Forecariah reported the most cases of any one district, and continues to present the greatest challenge in terms of response, with multiple chains of transmission over a wide geographical area (4 sub-prefectures), and the continued occurrence of cases from unknown sources of infection.

COUNTRIES WITH WIDESPREAD AND INTENSE TRANSMISSION
:: There have been a total of 27,013 reported confirmed, probable, and suspected cases of EVD in Guinea, Liberia and Sierra Leone (figure 1, table 1), with 11,134 reported deaths (this total includes reported deaths among probable and suspected cases, although outcomes for many cases are unknown). A total of 9 new confirmed cases were reported in Guinea and 3 in Sierra Leone in the 7 days to 24 May. The outbreak in Liberia was declared over on 9 May.

POLIO [to 30 May 2015]
Public Health Emergency of International Concern (PHEIC)

GPEI Update: Polio this week – As of 27 May 2015
Global Polio Eradication Initiative
[Editor’s Excerpt and text bolding]
Full report: http://www.polioeradication.org/Dataandmonitoring/Poliothisweek.aspx
:: Ministers of Health from around the world adopted a landmark resolution to end polio once and for all at the World Health Assembly in Geneva last week. The discussions were informed by a status report prepared by the Global Polio Eradication Initiative. Draft 3rd report of the Committee A , WHO news release from 22 May 2015
:: Polio staff continue to offer support to the humanitarian response to the devastating earth quakes in Nepal. Read more.
:: The 11th IMB report was published last week, reporting on progress towards polio eradication and making recommendations
Selected excerpts from Country-specific Reports
Afghanistan
:: One new case of wild poliovirus type 1 (WPV1) has been reported in the past week in Gulestan district of Farah province. This most recent case had onset of paralysis on 5 May. The total number of WPV1 cases for 2015 is now 2, and remains 28 for 2014. Most of the cases from 2014 were linked with cross-border transmission from neighbouring Pakistan.
:: Environmental sampling in the country continues to find wild poliovirus (most recently in Hilmand). Such sampling is invaluable to improved surveillance for the virus.
:: Subnational Immunization Days (SNIDs) are planned from 14 – 16 June across the south and east using bivalent OPV. National Immunization Days are scheduled on 16 to 18 Augus
Pakistan
:: Two new environmental samples positive for WPV1 were reported this week from Quetta district of Balochistan and from Jacobabad district of Sindh.
:: Currently, the focus of the polio eradication programme in Pakistan is on known infected areas and on areas deemed to be high-risk but which have not reported polio cases.
:: Environmental surveillance indicates widespread circulation of polioviruses – WPV as well as VDPV – 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.

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WHO and UNICEF launch vaccination campaign to keep Iraq polio free
Baghdad | Erbil, 26 May 2015 – A mass polio vaccination campaign, aiming to target 5.7 million children under the age of 5, began in Iraq on 24 May. The campaign will be conducted in all governorates to maintain the country’s polio-free status. The last case of polio was reported on 7 April 2014; a 34-month-old girl from the Rasafa district of Baghdad.

Iraq’s response to combating polio aligns with a multi-country response plan developed following the outbreak of polio in Syria in 2013. Multiple vaccination rounds held in country since then have helped to protect Iraqi children from the paralysis caused by this incurable disease. Despite ongoing conflict, mass population displacement and a complex and unpredictable security situation, only 2 cases of polio were confirmed in Iraq during the regional outbreak in early 2014.

WHO Country Representative to Iraq Dr Syed Jaffar Hussain said, “Despite the civil unrest that engulfs over a third of the country, polio campaigns have continued to reach up to 90% of children through collaborative efforts with multiple line-ministries and local partners.” He paid tribute to polio vaccination team members and parents and appealed to the international community and partners for their continued financial and technical support over the next 12 months for an additional 4 nationwide vaccination campaigns.”Community efforts were well acknowledged by the Independent Monitoring Board for the Global Polio Eradication Initiative during their recent meeting. However, significant risks continue to exist and thus there is no room for complacency,” Dr Hussain added.

UNICEF Country Representative to Iraq Phillippe Heffinck added, “The polio effort in Iraq has been successful despite tremendous challenges. The collaboration and leadership of the Ministries of Health and strong collaboration with partners, such as WHO, have established community ownership for polio campaigns, and created a strong platform for rolling out strong routine immunization services. Both of these achievements are not only remarkable, but essential to keep Iraq polio free and improve the health of all Iraqi children.”…

WHO & Regionals [to 30 May 2015]
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Egypt: increase in H5N1 human and poultry cases but no change in transmission pattern of infection
May 2015 — The recent increase in the number of people affected by the avian influenza virus H5N1 in Egypt is not related to virus mutations but rather to more people becoming exposed to infected poultry. Since November 2014 to 30 April 2015, the period analysed by the international mission, a total of 165 cases, including 48 deaths were reported.

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WHO recommends 10 measurements for HIV
May 2015 — WHO released new guidelines recommending simplified indicators to measure the reach of HIV services, and the impact achieved at both the national and global levels.

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Global Alert and Response (GAR) – Disease Outbreak News (DONs)
30 May 2015 – Middle East respiratory syndrome coronavirus (MERS-CoV) – China
30 May 2015 – Middle East respiratory syndrome coronavirus (MERS-CoV) – Republic of Korea
28 May 2015 – Lassa Fever – United States of America
25 May 2015 – Middle East Respiratory Syndrome coronavirus (MERS-CoV) – Saudi Arabia
24 May 2015 – Middle East respiratory syndrome coronavirus (MERS-CoV) – United Arab Emirates

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:: WHO Regional Offices
WHO African Region AFRO
:: Cholera crisis in Tanzania improving despite high transmission risk
Kagunga, 26 May 2015 – The ongoing cholera outbreak in western Tanzania appears to be improving thanks to intensive national and international efforts, but the risk of transmission remains high due to limited access to shelter, toilets, water and essential medical care. As of 25 May, the total number of cases diagnosed and treated was 4408 and no deaths have been reported between 21-24 May.

WHO Region of the Americas PAHO
:: PAHO urges member countries to ratify new protocol on illicit tobacco (05/29/2015)

WHO South-East Asia Region SEARO
:: Stop illicit trade of tobacco products 29 May 2015

WHO European Region EURO
:: Final day of the World Health Assembly: highlights for the European Region 28-05-2015
:: World No Tobacco Day awards 2015 27-05-2015
:: Days 5 to 7 of the World Health Assembly: highlights for the European Region 27-05-2015

WHO Eastern Mediterranean Region EMRO
:: Urgent funding needed to prevent imminent closure of health care projects in Iraq
Cairo, 27 May 2015 – If urgently needed funds are not secured by the end of June 2015, more than 84% of health care projects serving populations in need in Iraq will be forced to close. If this happens, more than 3 million refugees, internally displaced persons and host communities will not have access to the treatment and care that these projects provide. WHO is coordinating the response of health cluster partners to optimize the use of available resources and calls on donors to provide financial support to prevent further avoidable death and additional suffering for millions of the most vulnerable people in Iraq.
:: WHO statement on the situation in Yemen by WHO Director-General Dr Margaret Chan
27 May 2015
:: WHO and UNICEF launch vaccination campaign to keep Iraq polio free 26 May 2015
:: WHO partners with MENTOR Initiative to control leishmaniasis in Aleppo and Deir ez-Zor  26 May 2015

WHO Western Pacific Region
No new digest content identified.

GAVI Watch [to 30 May 2015]
http://www.gavialliance.org/library/news/press-releases/
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:: Oman commits US$ 3 million to support childhood immunisation
28 May 2015
First time pledge will enable Gavi to reach children with life-saving vaccines.

Geneva, 28 May 2015 – The Government of the Sultanate of Oman today committed US$ 3 million to Gavi, the Vaccine Alliance – the first time Oman has provided funds to help Gavi reach children with vaccines in the world’s poorest countries.

“Oman is joining the global drive to protect children from potentially-fatal diseases,” said Dr Seth Berkley, Gavi CEO. “This new contribution will help us achieve our goal of supporting developing countries to immunise 300 million more children between 2016 and 2020, saving up to six million more lives.”

Oman’s contribution comes days after the World Health Assembly agreed on a resolution to improve access to sustainable supplies of affordable vaccines and highlighted the important role immunisation plays in reducing child deaths while also being a highly cost-effective public health intervention…

DoD Launches Review of Lab Procedures Involving Anthrax
WASHINGTON, May 29, 2015 – The Defense Department is launching a comprehensive review of its laboratory procedures, processes, and protocols associated with inactivating spore-forming anthrax…Deputy Defense Secretary Bob Work today ordered the review after consulting with Defense Secretary Ash Carter…

No Risk to the General Public
There is no known risk to the general public and an extremely low risk to lab workers from the department’s inadvertent shipments of inactivated samples containing small numbers of live anthrax to several laboratories, according to the release.

As of now, 24 laboratories in 11 states and two foreign countries are believed to have received suspect samples, the release said.

The department is working closely with the Centers for Disease Control and Prevention, who is leading the ongoing investigation pursuit to its statutory authorities, the release said.

Monitoring the Situation
The department will continue to monitor the situation and provide updates to the public, the release said.

In addition to the CDC review, Work ordered all DoD laboratories that have these materials to test all previously inactivated spore-forming anthrax in the inventory, the release said.

DoD also is advising labs that received inactive anthrax from the department to stop working with those samples until further instruction from the DoD and CDC…

CDC/MMWR/ACIP Watch [to 30 May 2015]
http://www.cdc.gov/media/index.html

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CDC investigating unintentional DoD shipment of anthrax
Media Statement
CDC is investigating the unintentional transfer of anthrax from the U.S. Department of Defense (DOD) to labs in multiple states and overseas. At this time we do not suspect any risk to the general public.

The CDC investigation was started after a request for technical consultation from a private commercial lab. The lab was working as part of a DOD effort to develop a new diagnostic test to identify biological threats. Although an inactivated agent was expected, the lab reported they were able to grow live Bacillus anthracis.

CDC is working in conjunction with DoD and other federal and state partners to conduct an investigation with all the labs that received samples from the DoD. The ongoing investigation includes determining if the labs also received other live samples, epidemiologic consultation, worker safety review, laboratory analysis, and handling of laboratory waste.

All samples involved in the investigation are being securely transferred to CDC or Laboratory Response Network (LRN) laboratories for further testing. CDC has sent officials from the CDC Federal Select Agent Program to the DOD labs to conduct onsite investigations.

Updates will continue to be provided as the investigation progresses.

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ACIP
:: February 2015 ACIP Minutes [2.16 MB, 72 pages]
.
:: Next ACIP Meeting – June 24-25, 2015
ACIP June 2015 Draft Meeting Agenda [2 pages]
Register for upcoming June ACIP meeting
(Wednesday – Thursday)
Deadline for registration:
– Non-US Citizens: June 3, 2015
– US Citizens: June 10, 2015

American Journal of Infection Control
June 2015 Volume 43, Issue 6, p547-662
http://www.ajicjournal.org/current

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What can we learn about the Ebola outbreak from tweets?
Michelle Odlum, Sunmoo Yoon
p563–571
Preview
Twitter can address the challenges of the current Ebola outbreak surveillance. The aims of this study are to demonstrate the use of Twitter as a real-time method of Ebola outbreak surveillance to monitor information spread, capture early epidemic detection, and examine content of public knowledge and attitudes.

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Healthcare worker influenza declination form program
Sherri L. LaVela, PhD, MPH, MBA, Jennifer N. Hill, MA, Bridget M. Smith, PhD, Charlesnika T. Evans, PhD, MPH, Barry Goldstein, MD, PhD, Richard Martinello, MD
Published Online: March 20, 2015
DOI: http://dx.doi.org/10.1016/j.ajic.2015.02.013
Highlights
:: The declination form program was compatible, flexible, easy to use, and supported by leadership.
:: Declination form program facilitators included complementary ongoing strategies and leadership engagement.
:: One-on-one attention and education at the time of vaccination led to health care worker accountability.
:: An influenza declination form program is of minimal cost, but it requires some dedicated staff and resources.
:: Vaccination rate improved from 53.5% to 77.4% pre- to postdeclination form program implementation.
Abstract
Background
Health care worker (HCW) vaccination rates have been low for many years (approximately 50%). Our goal was to implement an influenza declination form program (DFP) to assess feasibility, participation, HCW vaccination, and costs.
Methods
This was a prospective interventional pilot study using mixed methods to evaluate the DFP implementation processes and outcomes. We conducted a formative evaluation and interviews; data were transcribed and coded into themes. Secondary outcomes included self-reported HCW influenza vaccine uptake (pre-/postsurvey) and program costs; data were evaluated using descriptive and bivariate analyses.
Results
The DFP was compatible with ongoing strategies and unit culture. Barriers included multiple hospital shifts and competing demands. Facilitators included complementary ongoing strategies and leadership engagement. HCW vaccination rates were higher post- versus preimplementation (77.4% vs 53.5%, P =.01). To implement the DFP at site 1, using a mobile flu cart, 100% of declination forms were completed in 42.5 staff hours over <2 months. At site 2, using a vaccination table on all staff meeting days, 49% of forms were completed in 26.5 staff hours over 4.5 months. Average cost of staff time was $2,093 per site.
Conclusion
DFP implementation required limited resources and resulted in increased HCW influenza vaccine rates; this may have positive clinical implications for influenza infection control/prevention.
Increased reports of measles in a low endemic region during a rubella outbreak in adult populations
Takako Kurata, Daiki Kanbayashi, Hiroshi Nishimura, Jun Komano, Tetsuo Kase, Kazuo Takahashi
p653–655
Published online: April 1, 2015
Preview
In 2013, a rubella outbreak was observed in Japan, Romania, and Poland. The outbreak in Japan was accompanied by an increase of measles reports, especially from a region where measles is highly controlled. This was attributed to the adult populations affected by this rubella outbreak, similarity of clinical signs between rubella and measles, sufficiently small impact of measles outbreaks from neighboring nations, and elimination levels of measles endemicity. Current and future concerns for measles control are discussed.

American Journal of Preventive Medicine
June 2015 Volume 48, Issue 6, p647-770, e11-e30
http://www.ajpmonline.org/current

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Impact of Health Insurance Status on Vaccination Coverage Among Adult Populations
Peng-jun Lu, MD, PhD, Alissa O’Halloran, MSPH, Walter W. Williams, MD, MPH
Immunization Services Division, National Center for Immunization and Respiratory Diseases, CDC, Atlanta, Georgia
Published Online: April 15, 2015
DOI: http://dx.doi.org/10.1016/j.amepre.2014.12.008
Abstract
Introduction
Underinsurance is a barrier to vaccination among children. Information on vaccination among adults aged ≥18 years by insurance status is limited. This study assesses vaccination coverage among adults aged ≥18 years in the U.S. in 2012 by health insurance status and access to care characteristics.
Methods
The 2012 National Health Interview Survey data were analyzed in 2014 to estimate vaccination coverage among adults aged ≥18 years by health insurance status for seven routinely recommended vaccines.
Results
Influenza vaccination coverage among adults aged ≥18 years without or with health insurance was 14.4% versus 44.3%, respectively; pneumococcal vaccination coverage among adults aged 18–64 years with high-risk conditions was 9.8% versus 23.0%; tetanus and diphtheria toxoid (Td) coverage (age ≥18 years) was 53.2% versus 64.5%; tetanus, diphtheria, and acellular pertussis (Tdap) coverage (age ≥18 years) was 8.4% versus 15.7%; hepatitis A (HepA) coverage (age 18–49 years) was 16.6% versus 19.8%; hepatitis B (HepB) coverage (age 18–49 years) was 27.5% versus 38.0%; shingles coverage (age ≥60 years) was 6.1% versus 20.8%; and human papillomavirus (HPV) coverage (women aged 18–26 years) was 20.9% versus 39.8%. In addition, vaccination coverage differed by insurance type, whether respondents had a regular physician, and number of physician contacts.
Conclusions
Overall, vaccination coverage among adults aged ≥18 years is lower among uninsured populations. Implementation of effective strategies is needed to help improve vaccination coverage among adults aged ≥18 years, especially those without health insurance

American Journal of Public Health
Volume 105, Issue 6 (June 2015)
http://ajph.aphapublications.org/toc/ajph/current

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Long-Term Effectiveness of Accelerated Hepatitis B Vaccination Schedule in Drug Users
Dimpy P. Shah, Carolyn Z. Grimes, Anh T. Nguyen, Dejian Lai, Lu-Yu Hwang
American Journal of Public Health: June 2015, Vol. 105, No. 6: e36–e43.
ABSTRACT
Objectives. We demonstrated the effectiveness of an accelerated hepatitis B vaccination schedule in drug users.
Methods. We compared the long-term effectiveness of accelerated (0–1–2 months) and standard (0–1–6 months) hepatitis B vaccination schedules in preventing hepatitis B virus (HBV) infections and anti-hepatitis B (anti-HBs) antibody loss during 2-year follow-up in 707 drug users (HIV and HBV negative at enrollment and completed 3 vaccine doses) from February 2004 to October 2009.
Results. Drug users in the accelerated schedule group had significantly lower HBV infection rates, but had a similar rate of anti-HBs antibody loss compared with the standard schedule group over 2 years of follow-up. No chronic HBV infections were observed. Hepatitis C positivity at enrollment and age younger than 40 years were independent risk factors for HBV infection and antibody loss, respectively.
Conclusions. An accelerated vaccination schedule was more preferable than a standard vaccination schedule in preventing HBV infections in drug users. To overcome the disadvantages of a standard vaccination schedule, an accelerated vaccination schedule should be considered in drug users with low adherence. Our study should be repeated in different cohorts to validate our findings and establish the role of an accelerated schedule in hepatitis B vaccination guidelines for drug users.

BMC Health Services Research
http://www.biomedcentral.com/bmchealthservres/content
(Accessed 30 May 2015)

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Research article
Making health insurance pro-poor: evidence from a household panel in rural China
Mateusz Filipski, Yumei Zhang, Kevin Chen BMC Health Services Research 2015, 15:210 (29 May 2015)
Abstract
Background
In 2002, China launched the largest public health insurance scheme in the world, the New Cooperative Medical Scheme (NCMS). It is intended to enable rural populations to access health care services, and to curb medical impoverishment. Whether the scheme can reach its equity goals depends on how it is used, and by whom. Our goal is to shed light on whether and how income levels affect the ability of members to reap insurance benefits.
Methods
We exploit primary panel data consisting of a complete census (over 3500 individuals) in three villages in Puding County, Guizhou province, collected in 2004, 2006, 2009 and 2011. Data was collected during in-person interviews with household member(s). The data include yearly gross and net medical expenses for all individuals, and socio-economic information. We apply probit, ordinary least squares, and tobit multivariate regression analyses to the three waves in which NCMS was active (2006, 2009 and 2011). Explained variables include obtainment, levels and rates of NCMS reimbursement. Household income is the main explanatory variable, with household- and individual-level controls. We restrict samples to rule out self-selection, and exploit the 2009 NCMS reform to highlight equity-enhancing features of insurance.
Results
Prior to 2009 reforms, higher income in our sample was statistically significantly related to higher probability of obtaining reimbursement, as well as higher levels and rates of reimbursement. These relations all disappear after the reform, suggesting lower-income households were better able to reap insurance benefits after the scheme was reformed. Regression results suggest this is partly explained by reimbursement for chronic diseases.
Conclusions
The post-reform NCMS distributed benefits more equitably in our study area. Making health insurance pro-poor may require a focus on outpatient costs, credit constraints and chronic diseases, rather than catastrophic illnesses.

BMC Medical Ethics
http://www.biomedcentral.com/bmcmedethics/content
(Accessed 30 May 2015)

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Debate
Research partnerships between high and low-income countries: are international partnerships always a good thing?
John D Chetwood, Nimzing G Ladep, Simon D Taylor-Robinson BMC Medical Ethics 2015, 16:36 (28 May 2015)
Abstract
Background
International partnerships in research are receiving ever greater attention, given that technology has diminished the restriction of geographical barriers with the effects of globalisation becoming more evident, and populations increasingly more mobile.
Discussion
In this article, we examine the merits and risks of such collaboration even when strict universal ethical guidelines are maintained. There has been widespread examples of outcomes beneficial and detrimental for both high and low –income countries which are often initially unintended.
Summary
The authors feel that extreme care and forethought should be exercised by all involved parties, despite the fact that many implications from such international work can be extremely hard to predict. However ultimately the benefits gained by enhancing medical research and philanthropy are too extensive to be ignored

Globalization and Health
http://www.globalizationandhealth.com/
[Accessed 30 May 2015]

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Research
Tracking Global Fund HIV/AIDS resources used for sexual and reproductive health service integration: case study from Ethiopia
Mookherji S, Ski S and Huntington D Globalization and Health 2015, 11:21 (27 May 2015)
Abstract (provisional)
Objective/Background
The Global Fund to Fight AIDS, Tuberculosis & Malaria (GF) strives for high value for money, encouraging countries to integrate synergistic services and systems strengthening to maximize investments. The GF needs to show how, and how much, its grants support more than just HIV/AIDS, TB and malaria. Sexual and Reproductive Health (SRH) has been part of HIV/AIDS grants since 2007. Previous studies showed the GF PBF system does not allow resource tracking for SRH integration within HIV/AIDS grants. We present findings from a resource tracking case study using primary data collected at country level.
Methods
Ethiopia was the study site. We reviewed data from four HIV/AIDS grants from January 2009-June 2011 and categorized SDAs and activities as directly, indirectly, or not related to SRH integration. Data included: GF PBF data; financial, performance, in-depth interview and facility observation data from Ethiopia.
Results
All HIV/AIDS grants in Ethiopia support SRH integration activities (12-100%). Using activities within SDAs, expenditures directly supporting SRH integration increased from 25% to 66% for the largest HIV/AIDS grant, and from 21% to 34% for the smaller PMTCT-focused grant. Using SDAs to categorize expenditures underestimated direct investments in SRH integration; activity-based categorization is more accurate. The important finding is that primary data collection could not resolve the limitations in using GF GPR data for resource tracking. The remedy is to require existing activity-based budgets and expenditure reports as part of PBF reporting requirements, and make them available in the grant portfolio database. The GF should do this quickly, as it is a serious shortfall in the GF guiding principle of transparency.
Conclusions
Showing high value for money is important for maximizing impact and replenishments. The Global Fund should routinely track HIV/AIDs grant expenditures to disease control, service integration, and overall health systems strengthening. The current PBF system will not allow this. Real-time expenditure analysis could be achieved by integrating existing activity-based financial data into the routine PBF system. The GF’s New Funding Model and the 2012-2016 strategy present good opportunities for over-hauling the PBF system to improve transparency and allow the GF to monitor and maximize value for money.

Health Economics, Policy and Law
Volume 10 – Issue 03 – July 2015
http://journals.cambridge.org/action/displayIssue?jid=HEP&tab=currentissue

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The impact of Universal Health Coverage on health care consumption and risky behaviours: evidence from Thailand
Simone Ghislandi, Wanwiphang Manachotphong and Viviana M.E. Perego
Health Economics, Policy and Law / Volume 10 / Issue 03 / July 2015, pp 251 – 266
Abstract
Thailand is among the first non-OECD countries to have introduced a form of Universal Health Coverage (UHC). This policy represents a natural experiment to evaluate the effects of public health insurance on health behaviours. In this paper, we examine the impact of Thailand’s UHC programme on preventive activities, unhealthy or risky behaviours and health care consumption using data from the Thai Health and Welfare Survey. We use doubly robust estimators that combine propensity scores and linear regressions to estimate differences-in-differences (DD) and differences-in-DD models. Our results offer important insights. First, UHC increases individuals’ likelihood of having an annual check-up, especially among women. Regarding health care consumption, we observe that UHC increases hospital admissions by over 2% and increases outpatient visits by 13%. However, there is no evidence that UHC leads to an increase in unhealthy behaviours or a reduction of preventive efforts. In other words, we find no evidence of ex ante moral hazard. Overall, these findings suggest positive health impacts among the Thai population covered by UHC.

JAMA
May 26, 2015, Vol 313, No. 20
http://jama.jamanetwork.com/issue.aspx

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Principles and Challenges in Access to Experimental Medicines
Michael Rosenblatt, MD; Bruce Kuhlik, JD
Excerpt
Efforts by patients to obtain early access to experimental medicines have increased as novel therapies provide new evidence of their potential to treat or cure life-threatening diseases. As drug discovery efforts, particularly for cancer and orphan diseases, are increasingly based on molecular targets, success rates improve, generating further interest in early access to experimental drugs. Devising “expanded access programs” (EAPs), however, presents challenges.1,2 Fairness and ethical issues need to be addressed as do practical matters, such as efficient conduct of clinical trials, adequate drug supply, finances, and geography. The complexity of crafting EAPs is compounded by early, rapid, and broad communication by traditional and social media. This Viewpoint outlines general principles to help balance the competing interests of individuals facing life-threatening illness with practical concerns and broader societal interests in knowing which drugs do or do not work and making them generally available through expeditious regulatory approval…

The Lancet
May 30, 2015 Volume 385 Number 9983 p2121-2222
http://www.thelancet.com/journals/lancet/issue/current

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Comment
African health leaders: claiming the future
Agnes Binagwaho, Nigel Crisp
DOI: http://dx.doi.org/10.1016/S0140-6736(15)60934-5
Improving health in Africa is a team effort that involves many people from different backgrounds. The health gains made in recent years would not have been possible without the contribution of these people, national and global political will, and the support of development partners. All too often, however, the part played by Africans themselves has been overlooked or downplayed internationally in policy making and publications.

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Comment
Offline: An irreversible change in global health governance
Richard Horton
DOI: http://dx.doi.org/10.1016/S0140-6736(15)60997-7
“We should have reacted sooner”, was Angela Merkel’s conclusion in her address to the World Health Assembly last week. She was speaking about Ebola, and she gave a sharp and public rebuke to WHO for its diffident performance. WHO’s decentralised structure can be a powerful advantage, she said, but it “can also impede decision-making and hinder good functioning”. Still, despite its weaknesses, “WHO is the only international organisation that enjoys universal political legitimacy on global health matters.” It should be supported. Her assessment was backed by the Ebola Interim Assessment Panel, chaired by Barbara Stocking and whose first report was debated by WHO’s member states the next day. Stocking and her team, which included, among others, Ilona Kickbusch and Julio Frenk, listed their concerns with compelling clarity. They expressed surprise that it took WHO so long to recognise what it would take to bring Ebola transmission under control. Why did repeated early warnings from May to July, 2014, fail to trigger the declaration of a Public Health Emergency of International Concern before Aug 8, 2014, the date when an emergency was finally announced? Why was WHO unable “to engage in a high-level media response with greater command over the narrative”? Why did WHO fail to seek appropriate support from other UN agencies and humanitarian organisations? Why did WHO fail to ensure it had the operational capacity and culture to manage a public health emergency response? Donors were not spared: WHO “suffers from a lack of political and financial commitment by its Member States”. The Panel commented that “this [is] a defining moment for the work of WHO…’Business as usual’ or ‘more of the same’ is not an option.” Stocking concluded that, “Now is the historic political moment for world leaders to give WHO new relevance and empower it to lead in global health.”

Understandably, the Panel preferred to place responsibility on structures, not individuals. This is entirely correct. But structures are made up of individuals, and it is individuals who make decisions. There needs to be some serious soul-searching within the agency about who did what, when, and why it went wrong. The Lancet has felt resistance to these questions, in sometimes acutely hostile terms from WHO staff members. If WHO diagnoses the international response to Ebola as a collective failure and not as a failure of its own processes, procedures, and people, it risks sustaining the conditions that have led to this public health catastrophe for millions of west Africans. For example, it is surreal for WHO to say, as it did last week, that it has now heard what the world expects from the agency. Does this statement mean it was only when Ebola swept across west Africa that WHO woke up to an understanding of its global role? When WHO says that it will strengthen its command and control systems, does this statement mean that after six decades of experience in responding to health crises it needed Ebola to make the agency realise the importance of leadership? And can anyone take the statement that Ebola has accelerated reforms to the organisation seriously when the recent “WHO reform” programme is widely judged (internally and externally) to have delivered few tangible benefits to the agency’s work?

Debates about Ebola and WHO’s response (and future) certainly overwhelmed discussions in Geneva last week. But the most exciting moment was not in the Assembly Hall or Committees. Instead, it was in a small room in the Palais des Nations, and after hours too. For the first time in the history of WHO and its Assembly, a civil-society led forum was held to strengthen political accountability for global health—specifically, for women’s and children’s health. The White Ribbon Alliance, together with the Governments of Bangladesh and Sweden, convened the first Global Dialogue between Citizens and Governments. It was an historic moment. It built on National Citizen’s Hearings held in over 20 countries. Examples from Indonesia and Tanzania were presented with informed passion. Indonesian and Namibian Ministers of Health spoke. This Global Dialogue signalled the beginning of a very different World Health Assembly. What took place last week was an irreversible change in the governance of global health—one in which civil society assumed a legitimate place in shaping the future of health. While WHO reflected (sometimes painfully) on its role and purpose, civil society found its voice. Mark this moment.

The Lancet Global Health
Jun 2015 Volume 3 Number 6 e297-e340
http://www.thelancet.com/journals/langlo/issue/current

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Comment
Global access to surgical care: moving forward
Evan G Wong, Dan L Deckelbaum, Tarek Razek
Open Access
DOI: http://dx.doi.org/10.1016/S2214-109X(15)00004-2
Summary
Global surgical care is gaining ground on the public health platform. Throughout 2015–16, the World Bank is publishing the long-anticipated third edition of its Disease Control Priorities (DCP3). First published in 1993,1 these reports aim to systematically identify effective interventions to address the disease burden in low-income and middle-income countries. For the first time since its inception, the DCP now includes a distinct volume on the value of surgical care. Volume 1—Essential Surgery2—focuses on the benefits of surgical care, including its potential to substantially decrease mortality while being exceptionally cost-effective; the issues of access to life-saving surgery, perioperative safety, and the inclusion of surgery in universal health coverage are also specifically addressed.

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Comment
Health and sustainable development: a call for papers
Richard Horton, Zoë Mullan
Published Online: 30 April 2015
Open Access
DOI: http://dx.doi.org/10.1016/S2214-109X(15)00002-9
Summary
In just under 5 months’ time, the aspiration for the next 15 years of development efforts will be signed off at the UN General Assembly in New York, USA. These Sustainable Development Goals (SDGs) are already at an advanced stage of drafting—17 ambitious goals and 169 targets (panel), which have been criticised even by the UN General Secretary for being too voluminous.1 Amid this multitude of outcomes, those pertaining to health are reduced from three Millennium Development Goals to one SDG. What does this mean for global health research?

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Articles
Global access to surgical care: a modelling study
Blake C Alkire, MD*, Dr Nakul P Raykar, MD*, Mark G Shrime, MD, Thomas G Weiser, MD, Prof Stephen W Bickler, MD, John A Rose, MD, Cameron T Nutt, BA, Sarah L M Greenberg, MD, Meera Kotagal, MD, Johanna N Riesel, MD, Micaela Esquivel, MD, Tarsicio Uribe-Leitz, MD, George Molina, MD, Prof Nobhojit Roy, MD, John G Meara, MD, Prof Paul E Farmer, MD, *
Published Online: 26 April 2015
Open Access
DOI: http://dx.doi.org/10.1016/S2214-109X(15)70115-4
Summary
Background
More than 2 billion people are unable to receive surgical care based on operating theatre density alone. The vision of the Lancet Commission on Global Surgery is universal access to safe, affordable surgical and anaesthesia care when needed. We aimed to estimate the number of individuals worldwide without access to surgical services as defined by the Commission’s vision.
Methods
We modelled access to surgical services in 196 countries with respect to four dimensions: timeliness, surgical capacity, safety, and affordability. We built a chance tree for each country to model the probability of surgical access with respect to each dimension, and from this we constructed a statistical model to estimate the proportion of the population in each country that does not have access to surgical services. We accounted for uncertainty with one-way sensitivity analyses, multiple imputation for missing data, and probabilistic sensitivity analysis.
Findings
At least 4·8 billion people (95% posterior credible interval 4·6–5·0 [67%, 64–70]) of the world’s population do not have access to surgery. The proportion of the population without access varied widely when stratified by epidemiological region: greater than 95% of the population in south Asia and central, eastern, and western sub-Saharan Africa do not have access to care, whereas less than 5% of the population in Australasia, high-income North America, and western Europe lack access.
Interpretation
Most of the world’s population does not have access to surgical care, and access is inequitably distributed. The near absence of access in many low-income and middle-income countries represents a crisis, and as the global health community continues to support the advancement of universal health coverage, increasing access to surgical services will play a central role in ensuring health care for all.
Funding
None.

New England Journal of Medicine
May 28, 2015 Vol. 372 No. 22
http://www.nejm.org/toc/nejm/medical-journal

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Original Article
Efficacy of an Adjuvanted Herpes Zoster Subunit Vaccine in Older Adults
Himal Lal, M.D., Anthony L. Cunningham, M.B., B.S., M.D., Olivier Godeaux, M.D., Roman Chlibek, M.D., Ph.D., Javier Diez-Domingo, M.D., Ph.D., Shinn-Jang Hwang, M.D., Myron J. Levin, M.D., Janet E. McElhaney, M.D., Airi Poder, M.D., Joan Puig-Barberà, M.D., M.P.H., Ph.D., Timo Vesikari, M.D., Ph.D., Daisuke Watanabe, M.D., Ph.D., Lily Weckx, M.D., Ph.D., Toufik Zahaf, Ph.D., and Thomas C. Heineman, M.D., Ph.D. for the ZOE-50 Study Group
N Engl J Med 2015; 372:2087-2096 May 28, 2015 DOI: 10.1056/NEJMoa1501184
Abstract
Background
In previous phase 1–2 clinical trials involving older adults, a subunit vaccine containing varicella–zoster virus glycoprotein E and the AS01B adjuvant system (called HZ/su) had a clinically acceptable safety profile and elicited a robust immune response.
Methods
We conducted a randomized, placebo-controlled, phase 3 study in 18 countries to evaluate the efficacy and safety of HZ/su in older adults (≥50 years of age), stratified according to age group (50 to 59, 60 to 69, and ≥70 years). Participants received two intramuscular doses of the vaccine or placebo 2 months apart. The primary objective was to assess the efficacy of the vaccine, as compared with placebo, in reducing the risk of herpes zoster in older adults.
Results
A total of 15,411 participants who could be evaluated received either the vaccine (7698 participants) or placebo (7713 participants). During a mean follow-up of 3.2 years, herpes zoster was confirmed in 6 participants in the vaccine group and in 210 participants in the placebo group (incidence rate, 0.3 vs. 9.1 per 1000 person-years) in the modified vaccinated cohort. Overall vaccine efficacy against herpes zoster was 97.2% (95% confidence interval [CI], 93.7 to 99.0; P<0.001). Vaccine efficacy was between 96.6% and 97.9% for all age groups. Solicited reports of injection-site and systemic reactions within 7 days after vaccination were more frequent in the vaccine group. There were solicited or unsolicited reports of grade 3 symptoms in 17.0% of vaccine recipients and 3.2% of placebo recipients. The proportions of participants who had serious adverse events or potential immune-mediated diseases or who died were similar in the two groups.
Conclusions
The HZ/su vaccine significantly reduced the risk of herpes zoster in adults who were 50 years of age or older. Vaccine efficacy in adults who were 70 years of age or older was similar to that in the other two age groups. (Funded by GlaxoSmithKline Biologicals; ZOE-50 ClinicalTrials.gov number, NCT01165177.)

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Editorial
A New Vaccine to Prevent Herpes Zoster
Jeffrey I. Cohen, M.D.
N Engl J Med 2015; 372:2149-2150 May 28, 2015 DOI: 10.1056/NEJMe1505050

PLoS Currents: Outbreaks
http://currents.plos.org/outbreaks/
(Accessed 30 May 2015)

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Surveillance of Acute Respiratory Infections Using Community-Submitted Symptoms and Specimens for Molecular Diagnostic Testing
May 27, 2015 · Research
Participatory systems for surveillance of acute respiratory infection give real-time information about infections circulating in the community, yet to-date are limited to self-reported syndromic information only and lacking methods of linking symptom reports to infection types. We developed the GoViral platform to evaluate whether a cohort of lay volunteers could, and would find it useful to, contribute self-reported symptoms online and to compare specimen types for self-collected diagnostic information of sufficient quality for respiratory infection surveillance. Volunteers were recruited, given a kit (collection materials and customized instructions), instructed to report their symptoms weekly, and when sick with cold or flu-like symptoms, requested to collect specimens (saliva and nasal swab). We compared specimen types for respiratory virus detection sensitivity (via polymerase-chain-reaction) and ease of collection. Participants were surveyed to determine receptivity to participating when sick, to receiving information on the type of pathogen causing their infection and types circulating near them. Between December 1 2013 and March 1 2014, 295 participants enrolled in the study and received a kit. Of those who reported symptoms, half (71) collected and sent specimens for analysis. Participants submitted kits on average 2.30 days (95 CI: 1.65 to 2.96) after symptoms began. We found good concordance between nasal and saliva specimens for multiple pathogens, with few discrepancies. Individuals report that saliva collection is easiest and report that receiving information about what pathogen they, and those near them, have is valued and can shape public health behaviors. Community-submitted specimens can be used for the detection of acute respiratory infection with individuals showing receptivity for participating and interest in a real-time picture of respiratory pathogens near them.

PLoS Medicine
(Accessed 30 May 2015)
http://www.plosmedicine.org/

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Seasonal Influenza Vaccination for Children in Thailand: A Cost-Effectiveness Analysis
Aronrag Meeyai, Naiyana Praditsitthikorn, Surachai Kotirum, Wantanee Kulpeng, Weerasak Putthasri, Ben S. Cooper, Yot Teerawattananon
Research Article | published 26 May 2015 | PLOS Medicine 10.1371/journal.pmed.1001829
Abstract
Background
Seasonal influenza is a major cause of mortality worldwide. Routine immunization of children has the potential to reduce this mortality through both direct and indirect protection, but has not been adopted by any low- or middle-income countries. We developed a framework to evaluate the cost-effectiveness of influenza vaccination policies in developing countries and used it to consider annual vaccination of school- and preschool-aged children with either trivalent inactivated influenza vaccine (TIV) or trivalent live-attenuated influenza vaccine (LAIV) in Thailand. We also compared these approaches with a policy of expanding TIV coverage in the elderly.
Methods and Findings
We developed an age-structured model to evaluate the cost-effectiveness of eight vaccination policies parameterized using country-level data from Thailand. For policies using LAIV, we considered five different age groups of children to vaccinate. We adopted a Bayesian evidence-synthesis framework, expressing uncertainty in parameters through probability distributions derived by fitting the model to prospectively collected laboratory-confirmed influenza data from 2005-2009, by meta-analysis of clinical trial data, and by using prior probability distributions derived from literature review and elicitation of expert opinion. We performed sensitivity analyses using alternative assumptions about prior immunity, contact patterns between age groups, the proportion of infections that are symptomatic, cost per unit vaccine, and vaccine effectiveness. Vaccination of children with LAIV was found to be highly cost-effective, with incremental cost-effectiveness ratios between about 2,000 and 5,000 international dollars per disability-adjusted life year averted, and was consistently preferred to TIV-based policies. These findings were robust to extensive sensitivity analyses. The optimal age group to vaccinate with LAIV, however, was sensitive both to the willingness to pay for health benefits and to assumptions about contact patterns between age groups.
Conclusions
Vaccinating school-aged children with LAIV is likely to be cost-effective in Thailand in the short term, though the long-term consequences of such a policy cannot be reliably predicted given current knowledge of influenza epidemiology and immunology. Our work provides a coherent framework that can be used for similar analyses in other low- and middle-income countries.

PLoS Neglected Tropical Diseases
http://www.plosntds.org/
(Accessed 30 May 2015)

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Harnessing Case Isolation and Ring Vaccination to Control Ebola
Chad Wells, Dan Yamin, Martial L. Ndeffo-Mbah, Natasha Wenzel, Stephen G. Gaffney, Jeffrey P. Townsend, Lauren Ancel Meyers, Mosoka Fallah, Tolbert G. Nyenswah, Frederick L. Altice, Katherine E. Atkins, Alison P. Galvani
Research Article | published 29 May 2015 | PLOS Neglected Tropical Diseases 10.1371/journal.pntd.0003794
Abstract
As a devastating Ebola outbreak in West Africa continues, non-pharmaceutical control measures including contact tracing, quarantine, and case isolation are being implemented. In addition, public health agencies are scaling up efforts to test and deploy candidate vaccines. Given the experimental nature and limited initial supplies of vaccines, a mass vaccination campaign might not be feasible. However, ring vaccination of likely case contacts could provide an effective alternative in distributing the vaccine. To evaluate ring vaccination as a strategy for eliminating Ebola, we developed a pair approximation model of Ebola transmission, parameterized by confirmed incidence data from June 2014 to January 2015 in Liberia and Sierra Leone. Our results suggest that if a combined intervention of case isolation and ring vaccination had been initiated in the early fall of 2014, up to an additional 126 cases in Liberia and 560 cases in Sierra Leone could have been averted beyond case isolation alone. The marginal benefit of ring vaccination is predicted to be greatest in settings where there are more contacts per individual, greater clustering among individuals, when contact tracing has low efficacy or vaccination confers post-exposure protection. In such settings, ring vaccination can avert up to an additional 8% of Ebola cases. Accordingly, ring vaccination is predicted to offer a moderately beneficial supplement to ongoing non-pharmaceutical Ebola control efforts.
Author Summary
Public health efforts for controlling the 2014–2015 Ebola outbreak in West Africa have focused on contact tracing and isolation of symptomatic individuals. In addition, substantial resources have been committed to scaling up the production of experimental vaccines. Ring vaccination—the vaccination of the contacts of an infected individual—was successfully implemented to achieve smallpox eradication. Ring vaccination is particularly feasible and effective in settings where the supply of vaccines is limited and disease incidence is low. Using a disease transmission model, we evaluated the benefit of adding ring vaccination to case isolation in Liberia and Sierra Leone. We found that ring vaccination could have averted up to 126 cases in Liberia and 560 cases in Sierra Leone, thereby saving lives and intervention resources.

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Hepatitis B Vaccines and HPV Vaccines Have Been Hailed as Major Public Health Achievements in Preventing Cancer—Could a Schistosomiasis Vaccine be the Third?
Michael H. Hsieh, Julia M. L. Brotherton, Afzal A. Siddiqui
Editorial | published 28 May 2015 | PLOS Neglected Tropical Diseases 10.1371/journal.pntd.0003598

PLoS One
[Accessed 30 May 2015]
http://www.plosone.org/

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Cluster Survey Evaluation of a Measles Vaccination Campaign in Jharkhand, India, 2012
Heather M. Scobie, Arindam Ray, Satyabrata Routray, Anindya Bose, Sunil Bahl, Stephen Sosler, Kathleen Wannemuehler, Rakesh Kumar, Pradeep Haldar, Abhijeet Anand
Research Article | published 26 May 2015 | PLOS ONE 10.1371/journal.pone.0127105
Abstract
Introduction
India was the last country in the world to implement a two-dose strategy for measles-containing vaccine (MCV) in 2010. As part of measles second-dose introduction, phased measles vaccination campaigns were conducted during 2010–2013, targeting 131 million children 9 months to <10 years of age. We performed a post-campaign coverage survey to estimate measles vaccination coverage in Jharkhand state.
Methods
A multi-stage cluster survey was conducted 2 months after the phase 2 measles campaign occurred in 19 of 24 districts of Jharkhand during November 2011–March 2012. Vaccination status of children 9 months to <10 years of age was documented based on vaccination card or mother’s recall. Coverage estimates and 95% confidence intervals (95% CI) for 1,018 children were calculated using survey methods.
Results
In the Jharkhand phase 2 campaign, MCV coverage among children aged 9 months to <10 years was 61.0% (95% CI: 54.4–67.7%). Significant differences in coverage were observed between rural (65.0%; 95% CI: 56.8–73.2%) and urban areas (45.6%; 95% CI: 37.3–53.9%). Campaign awareness among mothers was low (51.5%), and the most commonly reported reason for non-vaccination was being unaware of the campaign (69.4%). At the end of the campaign, 53.7% (95% CI: 46.5–60.9%) of children 12 months to <10 years of age received ≥2 MCV doses, while a large proportion of children remained under-vaccinated (34.0%, 95% CI: 28.0–40.0%) or unvaccinated (12.3%, 95% CI: 9.3–16.2%).
Conclusions
Implementation of the national measles campaign was a significant achievement towards measles elimination in India. In Jharkhand, campaign performance was below the target coverage of ≥90% set by the Government of India, and challenges in disseminating campaign messages were identified. Efforts towards increasing two-dose MCV coverage are needed to achieve the recently adopted measles elimination goal in India and the South-East Asia region

Science
29 May 2015 vol 348, issue 6238, pages 941-1052
http://www.sciencemag.org/current.dtl

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Feature
Is measles next?
Leslie Roberts
Before the polio virus is even in the grave, a small cadre of disease fighters is itching to set the next global eradication target: measles. The case is compelling. Measles killed 145,000 children last year in poor countries and left many more blind, deaf, or disabled. A cheap and effective vaccine has long been on the shelves; numerous expert panels have deemed measles eradication feasible, although daunting—it is the most contagious virus on Earth. But the biggest obstacle to measles eradication is polio, which hasn’t disappeared as it was supposed to do in 2000. Skeptics question whether a measles initiative would fall down the same rabbit hole as did the polio effort, which has spent billions of dollars and nearly 3 decades chasing the last few cases, only to see them disappear around the corner. Maybe it is time, they say, to settle for keeping measles cases really low but not trying to get to zero…

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Feature
In Vietnam, an anatomy of a measles outbreak
Leslie Roberts
Routine immunization is one of the great public health success stories in Vietnam, where rates of vaccine-preventable diseases have plummeted. But the measles outbreak last year was another story, with 60,000 reported cases and nearly 150 deaths in children under age 2. Experts trace the epidemic to the public’s loss of faith in the government-led vaccination program, following reports of adverse events associated in time with another vaccine. Many parents stopped vaccinating their children, leaving them susceptible to measles. When the virus swept in from the north and hit Hanoi, it exploded. Panicked parents rushed their children to the hospital, which was quickly overburdened. With poor infection control, the hospital became a hub of measles transmission, and children who weren’t already infected caught the virus there.

Vaccines — Open Access Journal
(Accessed 30 May 2015)
http://www.mdpi.com/journal/vaccines

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Review: Emerging Vaccine Technologies
by Rebecca J. Loomis and Philip R. Johnson
Vaccines 2015, 3(2), 429-447; doi:10.3390/vaccines3020429 – published 26 May 2015
Abstract
Vaccination has proven to be an invaluable means of preventing infectious diseases by reducing both incidence of disease and mortality. However, vaccines have not been effectively developed for many diseases including HIV-1, hepatitis C virus (HCV), tuberculosis and malaria, among others. The emergence of new technologies with a growing understanding of host-pathogen interactions and immunity may lead to efficacious vaccines against pathogens, previously thought impossible.

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.

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The Economist
http://www.economist.com/
Accessed 30 May 2015
Development aid
It’s not what you spend
How to make aid to poor countries work better
May 23rd 2015 The Economist | 30 May 2015
FOR decades rich countries have sought to foster global development with aid. But all too often there is little to show for their spending, now over $135 billion a year and rising. Success depends on political will in recipient countries, says Erik Solheim of the Development Assistance Committee of the OECD, a club of mostly rich countries that includes the biggest donors. And that may well be lacking.

What donors will pay for may not be what recipients deem a priority. So poor countries’ governments say what they must to get cash, and often fail to keep their side of the deal. Aid to build schools may be used to give fat contracts to allies, and the schools left empty. Ambulances bought by donors may rust on the kerb, waiting for spare parts.
Now donors are trying a new approach: handing over aid only if outcomes improve. “Cash on delivery” sees donors and recipients set targets, for example to cut child mortality rates or increase the number of girls who finish school, and agree on how much will be paid if they are met. Conventional approaches still account for the lion’s share of international aid. But several countries, including Britain and Norway, and big private donors, including the Bill and Melinda Gates Foundation, are experimenting with cash-on-deliver…

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Forbes
http://www.forbes.com/
Accessed 30 May 2015
Can New Research Break The Anti-Vaccine Fever? Probably Not
Todd Essig, Contributor May 26, 2015
May has been a good month for health and well-being, at least for the science of preventing preventible illnesses. Here’s why: two new research studies appeared with powerful support for vaccines and two states made legislative progress towards ending so-called “philosophical exemptions” in which parents opt-out of vaccination programs on the basis of fear and misinformation. Unfortunately, the anti-vaccine fear-trepreneurs and celebrities, like Jenny McCarthy and Robert F. Kennedy Jr., have fomented a movement impervious to data.

Both of the new studies shift the risk-reward calculation even more towards the benefits vaccines provide, a calculation already so heavily dominated by reward it should not be a question for otherwise healthy individuals…

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New Yorker
http://www.newyorker.com/
Accessed 30 May 2015
News Desk
May 29, 2015
Vermont Says No to the Anti-Vaccine Movement
By Michael Specter
Just a year after Vermont became the first state to require labels for products made with genetically modified organisms, Governor Peter Shumlin on Thursday signed an equally controversial but very different kind of legislation: the state has now become the first to remove philosophical exemptions from its vaccination law.

The two issues are both emotional and highly contested. But Vermont’s decisions could hardly be less alike: the G.M.O. bill, which has enormous popular support, has been widely criticized by scientists—largely because no credible evidence exists suggesting that G.M.O.s are dangerous. The vaccine law, however, opposed by many people, is the strongest possible endorsement of the data that shows that vaccines are the world’s most effective public-health tool.

Perhaps because the debate over removing the philosophical exemption has been rancorous and long, the governor first opposed the legislation. More recently, he suggested that he was neutral. On Thursday, possibly sensing the political peril involved in siding with the anti-vaccine movement, Shumlin signed the bill without much publicity. Rather than hold a news conference, as he did when signing the G.M.O. legislation last year, he simply released a statement.

“Vaccines work and parents should get their kids vaccinated,” he said. “I know there are strong feelings on both sides of this issue. I wish the legislation passed three years ago had worked to sufficiently increase vaccination rates. However we’re not where we need to be to protect our kids from dangerous diseases, and I hope this legislation will have the effect of increasing vaccination rates.”

The previous legislation, which required parents to review educational materials before claiming the exemption, was an attempt to balance individual rights with the need to protect children from childhood diseases. Nobody has yet figured out how to do that. During the current debate, the Vermont State Health department reported that fewer than eighty-eight per cent of children entering the state’s kindergartens were fully vaccinated. Like most states, Vermont currently offers parents an exemption for medical conditions and one for religious beliefs. It has been one of about twenty states that allow for philosophical exemptions, and the majority of exemptions in Vermont have been for philosophical reasons.

Meanwhile, outbreaks of measles, like the one earlier this year at Disneyland, as well as other childhood diseases, have been increasingly difficult for politicians to ignore. Public-health experts say that ninety-five per cent of a student population needs to be vaccinated to provide adequate protection against measles, the world’s most contagious disease. Measles remains one of the world’s leading causes of death among children under five, according to the World Health Organization. In 2013, the disease killed nearly a hundred and fifty thousand people; before vaccines became available, millions died.

“There is something deep in the core of my being,’’ Representative Warren Kitzmiller, of Montpelier, said during the debate over the philosophical objection. “And it simply will not allow me to vote to remove a parent’s right to make this serious decision on what is in the best interest of their child.”

That is a reasonable position, and many people hold it. According to a 2014 Pew Research Center survey, only sixty-eight per cent of Americans believe that childhood vaccinations should be required. Among younger parents, the percentage who object is even higher.

Data and science are obviously not the only issues that matter in this debate. But it’s hard to see how all rights can be equal: if parents want their children to remain unprotected from vaccinations, perhaps they should have that right. But should those children then be allowed near other students, in public places like playgrounds, or anywhere else where they could infect people with weakened immune systems? By removing the philosophical objection, at least one state has begun to say no.

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New York Times
http://www.nytimes.com/
Accessed 30 May 2015
U.S. Military Orders Review as Anthrax Mishap Widens
By REUTERSMAY 30, 2015, 1:34 A.M. E.D.T.
WASHINGTON — The U.S. military said on Friday it discovered even more suspected shipments of live anthrax than previously thought, both in the United States and abroad, and ordered a sweeping review of practices meant to inactivate the bacteria…

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_23 May 2015

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

– Twitter:  Readers can also follow developments on twitter: @vaxethicspolicy.
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– Links:  We endeavor to test each link as we incorporate it into any post, but recognize that some links may become “stale” as publications and websites reorganize content over time. We apologize in advance for any links that may not be operative. We believe the contextual information in a given post should allow retrieval, but please contact us as above for assistance if necessary.
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– Support:  If you would like to join the growing list of individuals who support this service and its contribution to their roles in public health, clinical practice, government, IGOs/NGOs, research, industry and academia, please visit this page at The Wistar Institute, our co-founder and fiduciary, and follow the relevant steps . Thank you…

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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
– Children’s Hospital of Philadelphia Vaccine Education Center
Associate Faculty, Division of Medical Ethics, NYU Medical School

Editor’s Note:
The World Health Assembly continues through 26 May. Initial high-level actions are being reported on through press releases, including the three below on WHO’s emergency and response programme stemming from the Ebola crisis, polio, malaria, yellow fever, and the IHRs (International Health Regulations). Further below is a link to a draft resolution which we understand is still in discussion at WHA addressing issues around the GVAP (Global Vaccine Action Plan).

Sixty-eighth World Health Assembly [full documentation]

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WHO Director-General’s speech at the Sixty-eighth World Health Assembly
Dr Margaret Chan, Director-General of the World Health Organization
18 May 2015
[Closing text]
…Ladies and gentlemen,
The threats to health have multiplied, but so has our capacity to respond. For some reason, health brings out the very best in human creativity and determination.

We enter the post-2015 era blessed with a host of new initiatives, instruments, interventions, including new vaccines, and precise strategies with time-bound goals. The momentum behind the MDGs will continue. WHO has mature programmes, with strong track records of success, to guide this work.

Above all, our work is driven by a fierce commitment to equity, social justice, and the right to health. As the number of countries aiming for universal health coverage grows, we are in a position to change the mindset that poor people living in poor places will inevitably have poor health care. This is no longer true.

The Ebola outbreak shook this Organization to its core. As noted in the interim assessment report, this was a defining moment for the work of WHO and an historic political moment for world leaders to give WHO new relevance and empower it to lead in global health.

I urge you to make this happen. I will do my part.

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World Health Assembly gives WHO green light to reform emergency and response progamme
News release
23 May 2015 ¦ GENEVA – Delegates at the World Health Assembly made a series of decisions stemming from the 2014 Ebola virus disease outbreak. These give the WHO Secretariat the go-ahead to carry out structural reforms so it can prepare for and respond rapidly, flexibly and effectively to emergencies and disease outbreaks.

Preparing for and responding to emergencies
Delegates at the 68th World Health Assembly welcomed WHO’s commitment to deep reforms of its emergency work, in particular by setting out clear and effective command and control mechanisms across all 3 levels of the Organization – headquarters, regional and country offices.
At the same time, WHO will establish an emergency programme, which will be guided by an all-hazards health emergency approach, that emphasizes adaptability, flexibility and accountability, humanitarian principles, predictability, timeliness and country ownership.

WHO will set up a US$ 100-million contingency fund to provide financing for in-field operations for up to 3 months. The contingency fund will run initially as a two-year pilot and will then be evaluated.

Delegates appreciated the key coordination role played by WHO in its ongoing work to develop vaccines, diagnostics and drugs for Ebola virus disease. They noted the importance of being able to accelerate research and development activities to tackle health threats for which solutions do not currently exist. They also requested the Secretariat to continue and enhance WHO’s work in helping countries better prepare for emergencies by strengthening national health systems.

International Health Regulations (2005)
The Director-General was asked to set up a review committee under the International Health Regulations (2005) to:
:: assess the effectiveness of the International Health Regulations with regard to the prevention, preparedness and response to the Ebola outbreak
:: assess the status of implementation of recommendations from the previous Review Committee in 2011 and its impact on the Ebola outbreak
:: recommend steps to improve functioning, transparency, effectiveness and efficiency of the International Health Regulations and improve preparedness and response for future health emergencies.

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WHA reaches agreement on polio, International Health Regulations and strengthening surgical care
News release
22 May 2015 ¦ GENEVA – The World Health Assembly continued progress Friday, reaching agreements on polio eradication; further implementation of the International Health Regulations (2005); surgical care and medical products.

Polio
Delegates at the World Health Assembly today agreed on a resolution in which Member States recommit to stopping polio and to preparing for the phased withdrawal of oral polio vaccines.
The meeting noted that Polio eradication can only be achieved through global solidarity. Reviewing the latest global epidemiology and the impact of on-going efforts, delegates highlighted progress across Africa (which has not seen a case due to wild poliovirus since August 2014), and success in halting three large multi-country outbreaks in the Middle East, Horn of Africa and Central Africa. They also noted continuing efforts in Pakistan, and the strong progress being made, in close coordination with Gavi, the Vaccine Alliance, towards introduction of inactivated polio vaccine (IPV) and preparations for the phased withdrawal of oral polio vaccines.

International Health Regulations
Delegates endorsed the International Health Regulations Review Committee recommendation to extend the deadline to 2016 to all countries that need more time to implement the Regulations. The recommendation also emphasizes a dynamic, ongoing process of evaluation and improvement, and the value of independent assessment.

The recent Ebola outbreak has highlighted the importance of all countries having strong capacities to rapidly detect, respond to and prevent global public health threats such as disease outbreaks. The International Health Regulations (2005), oblige all Member States to have these capacities in place. Only one-third of all countries (64), however, reported that they had met the minimum requirements in 2014.

Speakers at today’s meeting recognized the important role WHO plays in providing expertise and guidance to help countries enhance surveillance systems and laboratory services, build early warning and alert systems, and train health workers so that they can deal with major public health threats. They expressed strong support for pairing well-resourced countries with other countries to help them to meet the IHR requirements.

Yellow fever
In 2013, WHO’s expert advisory group on immunization (SAGE) recommended that a single dose of yellow fever vaccine provides life-long immunity to the disease, making boosters unnecessary. Under the International Health Regulations (2005), vaccination may be required of any traveller leaving an area at risk of yellow fever transmission. The Regulations currently specify that travellers should renew immunization every ten years. Changes to the Regulations recognizing the adequacy of a single dose of the vaccine will come into force in June 2016.
Some countries may, however, wish to institute the changes immediately. Delegates agreed to inform WHO if their governments decide to apply these changes immediately, and accept the validity of yellow fever vaccination certificates as life-long. WHO will publish an updated list of these countries online to inform international travellers. The Secretariat has also agreed to establish a scientific advisory group to work with affected countries to maintain up-to-date analysis of areas at risk.

Surgical care
Delegates of the World Health Assembly agreed a resolution on strengthening emergency and essential surgical care and anaesthesia.

A wide range of conditions – from cancer and diabetes to obstructed labour and road traffic injuries – can be successfully treated by surgery. In many parts of the world, access to emergency and essential services is extremely limited, with low and middle income countries concentrating available surgical care in urban centres. As a result, maternal mortality rates remain high, minor surgical issues become lethal and treatable injuries can lead to death or disability.

This resolution will help countries adopt and implement policies which will integrate safe, quality and cost effective surgical care into the health system as a whole. It highlights the importance of both expanding access and improving the quality and safety of services; strengthening the surgical workforce; improving data collection, monitoring and evaluation; ensuring access to safe anaesthetics such as Ketamine; and fostering global collaboration and partnerships. The resolution also underscores the need to raise awareness of the issue and build political commitment

Substandard, spurious, falsely labelled, falsified and counterfeit medical products
Substandard, spurious, falsely labelled, falsified and counterfeit medical products continue to threaten health, not only because they do not provide the benefits they advertise, but because they also pose a serious health risk, and undermine the credibility of health systems. The World Health Assembly had set up a mechanism to raise awareness, gather evidence, implement policies and evaluate effectiveness of efforts to address this issue, and had planned to review the impact of that mechanism in 2016. Delegates today agreed to postpone this to 2017 – both to allow more time for the review itself and for implementation of new policies to tackle the problem.
World Health Assembly agrees Global Malaria Strategy and Programme Budget 2016-17

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GENEVA – WHO Member States today agreed a new global malaria strategy for 2016-2030 and approved the Organization’s proposed programme budget for 2016-2017.
News release
20 May 2015 ¦

Global Malaria Strategy
The strategy aims to reduce the global disease burden by 40% by 2020, and by at least 90% by 2030. It also aims to eliminate malaria in at least 35 new countries by 2030.
Between 2000 and 2013, the global malaria mortality rate dropped by 47%. A major expansion of the WHO-recommended core package of measures – vector control, chemoprevention, diagnostic testing and treatment – has proved both cost effective and efficient. Nevertheless, millions of people are still unable to access malaria prevention and treatment, and most cases and deaths continue to go unregistered and unreported. In 2013, malaria killed an estimated 584 000 people.
The new strategy aims to build on recent successes to radically reduce this figure. Developed in close consultation with endemic countries and partners, the strategy provides a comprehensive framework so countries can develop tailored programmes that will sustain and accelerate progress towards malaria elimination.
It comprises three key elements: ensuring universal access to malaria prevention, diagnosis and treatment; accelerating efforts towards elimination and attainment of malaria-free status; and strengthening malaria surveillance. It emphasises the importance of innovation and research, and the critical need for political commitment, sustainable financing, strong health systems, and collaboration across different sectors.

Programme Budget 2016-17
Member States also approved WHO’s proposed Programme Budget for 2016-17. The budget of US$ 4384.9 million includes a US$ 236 million increase over the 2014-15 programme budget requirement to meet the needs of countries; leverage the experience gained during the Ebola outbreak; address emerging priorities such as antimicrobial resistance, health and the environment, malaria and viral hepatitis; and implement resolutions passed by the Assembly and WHO’s Regional Committees. Additional funds will also be used to further strengthen transparency, improve risk management and enhance accountability.

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Draft Resolutions
A68/A/CONF./4 Rev.1
Global vaccine action plan
Draft resolution proposed by the delegations of Algeria, Egypt, Libya, Morocco, Nigeria, Pakistan, Qatar, Saudi Arabia, Thailand, Tunisia

Nepal earthquake 2015 – Grade 3 emergency
:: Health situation report No. 18 pdf, 296kb 22 May 2015
[Excerpt]
…The 14 highly affected districts were assessed for their status on carrying out routine immunization work. Most of the districts are in a position to resume routine immunization despite the severe damage in the physical infrastructure. The cold chain statuses in most of the districts are intact and vaccines are safe except in Sindhupalchok district. WHO in close coordination with Logistic Management Division and UNICEF is planning to avail generators to revitalize the cold chain system…

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:: Global Health Cluster
..Health Cluster 4Ws – 19 May 2015 xlsx, 380kb
..Health Cluster Bulletin No. 3 pdf, 3.15Mb 18 May 2015

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:: Nepal after the recent earthquakes: reconstruction and vaccine-preventable enteric diseases
By Lorenz von Seidlein
PLOS Blogs Posted: May 21, 2015
In the wake of the recent devastating earthquakes, PLOS Medicine Consulting Editor Lorenz von Seidlein visited Nepal to assess outbreak risks. Lorenz travelled with Anuj Bhattachan, International Vaccine Institute, Seoul, Korea and guidance from Deepak C. Bajracharya and Shyam Raj Upreti from the Group for Technical Assistance, Kathmandu, Nepal. The assessment was requested by the epidemiology and disease control division of the Ministry of Health of Nepal and facilitated by Stop Cholera. Here he reports on the damage he witnessed and considers the choice of administering vaccines pre-emptively versus reactively in response to an outbreak
:: Access to maternal and child health care in Nepal brings joy amid destruction
22 May 2015 Feature Story

::::::

WHO Grade 3 emergencies [listed at 23 May 2015]
:: Central African Republic
:: Democratic Republic of the Congo
:: Guinea
:: Iraq
:: Liberia
:: Malawi
:: Mali
:: Mozambique
:: Nepal
:: Niger
:: Nigeria
:: occupied Palestinian territory
:: Philippines
:: Sierra Leone
:: South Sudan
:: The Syrian Arab Republic
:: Ukraine
:: Vanuatu
:: Yemen

Grade 3: a single or multiple country event with substantial public health consequences that requires a substantial WCO response and/or substantial international WHO response. Organizational and/or external support required by the WCO is substantial. An Emergency Support Team, run out of the regional office, coordinates the provision of support to the WCO.

EBOLA/EVD [to 23 May 2015]
Public Health Emergency of International Concern (PHEIC); “Threat to international peace and security” (UN Security Council)

WHO: Ebola Situation Report – 20 May 2015
[Excerpts]
SUMMARY
:: The week to 17 May saw the highest weekly total of confirmed cases of Ebola virus disease (EVD) for over a month, with 35 cases reported from Guinea and Sierra Leone. This is a substantial increase compared with 9 cases reported the previous week. The geographical area of transmission has also expanded compared with recent weeks, with a total of 6 districts reporting cases (3 in Guinea, 3 in Sierra Leone), compared with 3 the previous week (2 in Guinea, 1 in Sierra Leone). Capacity for improved community engagement, case investigation, and targeted, active surveillance continues to be strengthened in areas of continuing transmission to ensure that remaining chains of transmission are detected, contained, and brought to an end…

COUNTRIES WITH WIDESPREAD AND INTENSE TRANSMISSION
:: There have been a total of 26,933 reported confirmed, probable, and suspected cases of EVD in Guinea, Liberia and Sierra Leone (figure 1, table 1), with 11,120 reported deaths (this total includes reported deaths among probable and suspected cases, although outcomes for many cases are unknown). A total of 27 new confirmed cases were reported in Guinea and 8 in Sierra Leone in the 7 days to 17 May. The outbreak in Liberia was declared over on 9 May…

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Health worker Ebola infections in Guinea, Liberia, and Sierra Leone
Preliminary report
WHO
Publication date: May 2015 :: 16 pages
Languages: English
WHO reference number: WHO/EVD/SDS/REPORT/2015.1
Pdf: http://apps.who.int/iris/bitstream/10665/171823/1/WHO_EVD_SDS_REPORT_2015.1_eng.pdf?ua=1
Overview
This preliminary report summarizes the impact of the Ebola epidemic on the health workforce of Guinea, Liberia and Sierra Leone. It investigates the determinants of infection and describes safe practices put in place to protect health workers during the epidemic. The report covers the period from 1 January 2014 to 31 March 2015 and is presents findings from the 815 confirmed and probable cases for whom individual case reports were available.

The Ebola epidemic has taken a heavy toll on the already scarce health workforce. Among the health workers for whom final outcome is known, two-thirds of those infected died. Preliminary analysis shows that, depending on their occupation in the health service, health workers are between 21 and 32 times more likely to be infected with Ebola than people in the general adult population. With higher risks of exposure in caring for others, health workers were disproportionately impacted and traumatised by Ebola.

Health worker infections can be prevented. WHO and partners have worked with ministries of health, partners, managers and health workers to put in place infection prevention control (IPC) and occupational health and safety (OHS) strategies and supplies to prevent health worker infections and improve patient safety. Health worker protection and support must be at the core of emergency response, preparedness and efforts to build a resilient health system. Cementing this lesson learnt into practice can be a lasting tribute to health workers.

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WHO: Stories from countries
:: Giving back after Ebola 22 May 2015
:: Ebola in Liberia: Frightened patients infected their carers 21 May 2015
:: Ebola diaries: Lessons in listening 19 May 2015
Red Cross Red Crescent Ebola responders among Florence Nightingale medal recipients
18 May 2015
World Bank Group Statement for the 68th World Health Assembly
BRIEF
May 19, 2015
Presented in discussion of item 16.1 and adoption of resolution pursuant to documents A68/24, A68/25, A68/26 and A68/27.
Tim Evans, Senior Director, Health, Nutrition and Population, World Bank Group

Hon’ble Chair and Excellencies
The World Bank Group welcomes the draft documents and discussions related to the Ebola virus outbreak and follow-up to the Special Session of the Executive Board on Ebola.

At the outset, the World Bank Group acknowledges and supports the leadership of the Governments, especially the Ministries of Health, of Guinea, Liberia and Sierra Leone in their fight to get to, and sustain zero cases of EVD — AND in their efforts to get their essential health services and economies back on track.

The World Bank Group acknowledges the untiring and selfless efforts of the health and development communities in these three countries, members of which have worked in very adverse circumstances and against tough odds to contain this epidemic.

The World Bank Group welcomes the update on the Ebola outbreak, and appreciates the frank assessment as well as the actionable recommendations of the Ebola Interim Assessment panel as presented in its First Report. The World Bank Group very strongly supports a strengthened and well-funded WHO, which can support all countries as they prepare to meet the challenges of increased global interdependence and shared vulnerability.

More specifically, the WBG acknowledges the important focus of the First Report on financing. The Report’s focus on the chronic under-financing of WHO arising from the Zero Economic Growth policy is critically important — we urge all member states to reconsider this policy that places at risk all of WHO’s core functions in the longer run.

The World Bank Group strongly supports the establishment of a Contingency Fund to support WHO’s emergency response capacity. The WBG sees this as one critical part of rebuilding the financing architecture for pandemic risk management. On its part, the World Bank Group working closely with WHO and other development partners and the private sector is developing a global Pandemic Emergency Financing Facility. The PEFF, upon receiving an agreed “trigger” or “signal” from WHO, will disburse resources of sufficient scale – swiftly – to priority needs. In this regard, the PEFF will complement the proposed WHO Contingency Fund by providing resources to countries and implementing agencies, including WHO, WFP, UNICEF and others, as well as NGOs, to finance containment activities in affected countries.

The World Bank Group also welcomes the plan for a Global Health Emergency Workforce to respond to acute or protracted risks and emergencies with health consequences, which is fully aligned with the White Coats initiative proposed by Chancellor Merkel. The proposed Pandemic Emergency Financing Facility will support the rapid deployment of medical and health personnel during outbreaks, and considers this to be a very critical component of a surge response.

As various processes – such as the UNSG High Level panel, WHO’s Ebola Interim Assessment Panel, the Institute of Medicine Pandemic review – move toward conclusions, it will be critical to agree how their recommendations for strengthened global risk management for pandemics can be financed swiftly and sustainably drawing on existing and new mechanisms. In this regard, the World Bank Group looks forward to organizing with WHO and other partners, in early September 2015, a high level consultation on “pandemic financing”, that aims to reach consensus on both an overall framework for financing and on the specific mechanisms that will fuel the recommendations for a renewed and revitalized pandemic preparedness and response capacity.

The Weekly Epidemiological Record (WER) 22 May 2015, vol. 90, 21 (pp. 253–260)
..Progress towards polio eradication worldwide, 2014–2015
..How Liberia reached zero cases of Ebola virus disease

POLIO [to 23 May 2015]
Public Health Emergency of International Concern (PHEIC)

GPEI Update: Polio this week – As of 20 May 2015
Global Polio Eradication Initiative
[Editor’s Excerpt and text bolding]
Full report: http://www.polioeradication.org/Dataandmonitoring/Poliothisweek.aspx
:: Ministers of Health from around the world are meeting in Geneva, Switzerland, this week for the annual World Health Assembly. The Ministers will discuss a number of topics related to public health, including polio eradication. The Global Polio Eradication Initiative has prepared a status report for delegates. The report and an accompanying resolution are expected to inform the discussions.
:: The 11th report of the Independent Monitoring Board has been published this week, reporting on progress towards polio eradication and making recommendations.
:: Polio staff continue to offer support to the humanitarian response to the devastating earth quakes in Nepal. Read more
:: Liberia and Sierra Leone have both conducted polio and measles vaccination campaigns during April and May. These are the first campaigns conducted in these countries since 2013 (due to the Ebola outbreak). Polio staff in these countries continue to assist in the Ebola outbreak response efforts
Selected excerpts from Country-specific Reports [No new polio cases reported]
Pakistan
:: One new case of wild poliovirus type 1 (WPV1) was reported this week, with onset of paralysis in Charsada district of Khyber Pakhtunkhwa. This most recent case had onset of paralysis on 20 April. The total number of WPV1 cases for 2015 is now 23 (and remains 306 for 2014).

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The Rocky Road to Zero
The Independent Monitoring Board of the Global Polio Eradication Initiative
Eleventh Report: May 2015 :: 24 pages
Pdf of Report: 11th report of the Independent Monitoring Board
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…CONCLUSIONS AND RECOMMENDATIONS
Over recent years, the IMB has witnessed the polio programme improving its system, and improving performance as a result. But further fundamental work of system redesign remains to be done.

The IMB emphasizes that recent gains should be applauded, but should not be a source of triumphalism. There will be some temptation to coast; to think that it is now just a matter of time. The rocky road to eradication does not allow for coasting.

The IMB has made a series of recommendations intended to catalyse the further changes that are required. No crystal ball can now tell when polio will be eradicated. No crystal ball is required to know that polio will not be eradicated until the system is perfectly designed to so.

Speed in improving the system is key. Without the discipline of fast implementation, the polio virus will still be circulating more than a year from now – in short, the programme will have granted the polio virus permission to keep on paralyzing children for more than another whole year after the last failed deadline of ending transmission. It will be the polio virus celebrating, not the programme.

AFGHANISTAN
1.The IMB recommends that Afghanistan’s Minister of Health appoints a very senior official with the skills and credibility to lead the programme day-to-day on the Minister’s behalf.

2.The IMB recommends that programme officials from the Southern and Eastern regions of Afghanistan visit the Emergency Operations Centres of Pakistan at once, and return with lessons that can be appropriately applied in Afghanistan with urgency.

NIGERIA
3.The IMB recommends that the new President of Nigeria makes a clear public declaration that polio cannot yet be considered gone from Nigeria, and sets out and leads a plan to achieve polio-free certification in 2017.

PAKISTAN
4.The IMB recommends that Pakistan’s National Task Force meets at least monthly until polio transmission is stopped, to oversee strict implementation of the National Emergency Action Plan. The National Task Force should particularly ensure that a monthly meeting of each Chief Secretary with their Deputy Commissioners goes ahead without exception, and with full attendance, to tightly oversee implementation of the National Emergency Action Plan in each province.

5.The IMB recommends that Pakistan’s National Task Force, within the next four weeks, resolves the issues that are resulting in front-line workers not being properly paid, to stall any further deterioration in morale amongst this crucial group, which could be fatal to the programme.

OUTBREAKS
6.The IMB recommends that the Polio Oversight Board explicitly re-affirm that the programme’s planning – in and beyond the endemic countries – should be based on what is needed to achieve eradication, not limited by what funds are available, and that more funding should be sought in the event of a shortfall. The IMB further recommends that the Polio Partners Group formally endorse this approach, and actively seek to mobilise further funds that may be required. The work of the Financial Accountability Committee is critical in ensuring that finances are well-managed, and that donors have the appropriate information and assurances.

THE NEED TO HARNESS THE POWER OF PEOPLE
7.The IMB recommends that the GPEI partner agencies convene an urgent meeting to i) leave no stone unturned in urgently recruiting more top-notch staff into the polio-infected and highest-risk countries, cutting through red-tape as needed to achieve this, ii) explicitly analyse whether the best people are currently in the places where they are needed the most.

SURVEILLANCE FIT FOR THE PRESENT AND FUTURE
8.The IMB recommends that the program should expedite activity to improve surveillance, aiming to reach global-certification standard by the end of 2015. Any uncertainty about what global-certification standard now constitutes (particularly the role of environmental surveillance) should be clarified with input from the Global Certification Commission.

SIMPLE DROPS OF VACCINE
9.The IMB recommends that in the endemic and priority countries, vaccine wastage be urgently reduced to 15% as an absolute maximum in every subnational area, starting by full implementation of the programme’s standard operating procedure for reporting on vaccine utilization and stock balance.

VACCINE-DERIVED POLIO VIRUS: A POTENTIAL SHOW-STOPPER
10.The IMB recommends that the Prime Minister of Pakistan and the President of Nigeria each receive a monthly briefing on stopping circulating vaccine-derived polio virus in their countries, to ensure that neither country stands in the way of the planned global withdrawal of trivalent oral polio vaccine.

PERSISTENTLY MISSED CHILDREN
11.The IMB recommends that an urgent global polio summit is convened on the subject of the persistently missed child, charged with the task of producing a plan that will cut the number of such children by 50% within six months.

PERFORMANCE: MOVING FROM THE ORDINARY TO THE EXTRAORDINARY
12.The IMB recommends that the GPEI makes funds immediately available to appoint a company with an established track record in process redesign and quality improvement. This company should deploy staff to work in each of the Emergency Operations Centres and at global programme management level. The IMB asks that this recommendation is implemented urgently with the company selected by 1st July 2015, teams in place by 1st August 2015 and initial improvement results posted by the time of the IMB’s next meeting, in October 2015.

WHO Regionals [to 23 May 2015]

WHO African Region AFRO
:: Dr Moeti urges intensified actions to address heart diseases in children 19 May 2015
:: Burundian crisis triggers emerging humanitarian emergency in Tanzania – 19 May 2015

WHO Region of the Americas PAHO
:: PAHO/WHO honors Nicaragua, Uruguay and four tobacco control advocates with the 2015 World No Tobacco Day awards 05/22/2015

WHO South-East Asia Region SEARO
:: Access to maternal and child health care in Nepal brings joy amid destruction [undated]

WHO European Region EURO
:: Day 4 of the World Health Assembly: highlights for the European Region 22-05-2015
:: Moving environment and health forwards 22-05-2015
:: Day 3 of the World Health Assembly: highlights for the European Region 21-05-2015
:: Day 2 of the World Health Assembly: highlights for the European Region 20-05-2015

WHO Eastern Mediterranean Region EMRO
:: WHO Regional Director calls for respect and safety for health care workers and facilities 21 May 2015
:: WHO delivers additional medicines and medical supplies to Yemen 18 May 2015

WHO Western Pacific Region
No new digest content identified.

UNAIDS calls for sustained commitment to develop an effective HIV vaccine

GENEVA, 18 May 2015—On HIV Vaccine Awareness Day, UNAIDS is calling for a renewed global commitment to finding an effective HIV vaccine.

“A vaccine would be a major step towards ending the AIDS epidemic,” said UNAIDS Executive Director Michel Sidibé. “There have been encouraging recent scientific advances that give us hope for the future development of an HIV vaccine.”

UNAIDS is committed to leaving nobody behind in the HIV response. A major advantage of vaccines is that they promote equity and can be used effectively in all communities and settings, including those where many other health services can be harder to deliver.

Studies show that an HIV vaccine is possible. The RV144 vaccine trial in 2009 lowered the rate of HIV infection by 31%. There is much hope that ongoing research will build on this trial and deliver results. Newer vaccine candidates, as well as neutralizing antibodies, are also being studied.

Vaccines have eradicated smallpox, and polio is close to eradication. Vaccines have also effectively controlled diphtheria, pertussis, tetanus, mumps, measles and rubella, among other infectious diseases.

However, in 2013, HIV vaccine research and development saw the largest decline in investment since 2008. In order to transform promising concepts into an effective and accessible vaccine increased and sustained funding will be critical.

GAVI Watch [to 23 May 2015]
http://www.gavialliance.org/library/news/press-releases/
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:: The Arab League supports Gavi efforts on immunisation and saving children’s lives with vaccines
Support will enhance advocacy efforts across Arab League countries
Geneva, 19 May 2015 – The Arab League has agreed to collaborate with Gavi, the Vaccine Alliance on advocating for children in the world’s poorest countries to be immunised against vaccine-preventable diseases, as part of a Memorandum of Understanding (MoU) signed between the two organisations.
The agreement – the first between the Arab League and Gavi – will support the Alliance’s 2016-2020 strategic goals. Both organisations will advocate through the education sector – parents, teachers and pupils – and society as a whole for the improvement of women and children’s health by scaling up immunisation coverage…

New US poll shows most parents (83%) want their teens and young adults to be vaccinated against meningococcal disease

PHILADELPHIA, May 19, 2015 /PRNewswire/ — GlaxoSmithKline (@GSKUS) today announced the results of an online consumer poll, conducted by Harris Poll on behalf of GSK, of US parents with children ages 16 to 21 years, and young people of the same age range, gauging the knowledge of and attitudes related to meningococcal disease*.

Results from this new, national poll serve as a reminder to parents and high school/college-aged individuals to talk to a healthcare professional to learn if meningococcal disease vaccination is right for them, and determine how to get up to date on vaccinations this summer. US adolescents/young adults are at greater risk for contracting meningococcal disease due to increased likelihood of being in community settings that foster close contact with people (e.g., residence halls, military and other camps).

Key findings of the Harris online poll include:
:: The majority of parents (83%) report wanting their children to be vaccinated against all vaccine-preventable serogroups of bacteria that cause meningococcal disease. The five serogroups of bacteria that cause the overwhelming majority of cases in the US are A, B, C, W-135 and Y.
:: Less than half of parents say they have talked to their child about how the disease is spread (42%) or its early symptoms (38%).
:: Less than half of young people (49%) know that meningococcal disease can lead to serious health complications, which may include hospitalization, hearing loss or amputation.
:: Only about one third of young people (35%) correctly identified college students as a high risk group for the disease. Only 22% know that it is possible to die within 24 hours of early symptoms.
:: Of those parents whose child has been vaccinated against meningococcal disease, 88% don’t know which serogroups of bacteria their child is vaccinated against…

Annals of Internal Medicine
19 May 2015, Vol. 162. No. 10
http://annals.org/issue.aspx

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Original Research | 19 May 2015
IMPROVING PATIENT CARE
Attitudes Toward Risk and Informed Consent for Research on Medical Practices: A Cross-sectional Survey
Mildred K. Cho, PhD; David Magnus, PhD; Melissa Constantine, PhD, MPAff; Sandra Soo-Jin Lee, PhD; Maureen Kelley, PhD; Stephanie Alessi, JD; Diane Korngiebel, DPhil; Cyan James, PhD; Ellen Kuwana, MS; Thomas H. Gallagher, MD; Douglas Diekema, MD, MPH; Alexander M. Capron, LLB; Steven Joffe, MD, MPH; and Benjamin S. Wilfond, MD
Abstract
Background: The U.S. Office for Human Research Protections has proposed that end points of randomized trials comparing the effectiveness of standard medical practices are risks of research that would require disclosure and written informed consent, but data are lacking on the views of potential participants.
Objective: To assess attitudes of U.S. adults about risks and preferences for notification and consent for research on medical practices.
Design: Cross-sectional survey conducted in August 2014.
Setting: Web-based questionnaire.
Patients: 1095 U.S. adults sampled from an online panel (n = 805) and an online convenience river sample (n = 290).
Measurements: Attitudes toward risk, informed consent, and willingness to participate in 3 research scenarios involving medical record review and randomization of usual medical practices.
Results: 97% of respondents agreed that health systems should evaluate standard treatments. Most wanted to be asked for permission to participate in each of 3 scenarios (range, 75.2% to 80.4%), even if it involved only medical record review, but most would accept nonwritten (oral) permission or general notification if obtaining written permission would make the research too difficult to conduct (range, 70.2% to 82.7%). Most perceived additional risk from each scenario (range, 64.0% to 81.6%).
Limitation: Use of hypothetical scenarios and a nonprobability sample that was not fully representative of the U.S. population.
Conclusion: Most respondents preferred to be asked for permission to participate in observational and randomized research evaluating usual medical practices, but they are willing to accept less elaborate approaches than written consent if research would otherwise be impracticable. These attitudes are not aligned with proposed regulatory guidance.
Primary Funding Source: National Center for Advancing Translational Sciences at the National Institutes of Health.

BMC Health Services Research
http://www.biomedcentral.com/bmchealthservres/content
(Accessed 23 May 2015)

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Research article
Does a voucher program improve reproductive health service delivery and access in Kenya?
Rebecca Njuki, Timothy Abuya, James Kimani, Lucy Kanya, Allan Korongo, Collins Mukanya, Piet Bracke, Ben Bellows, Charlotte Warren BMC Health Services Research 2015, 15:206 (23 May 2015)
Abstract (provisional)
Background
Current assessments on Output-Based Aid (OBA) programs have paid limited attention to the experiences and perceptions of the healthcare providers and facility managers. This study examines the knowledge, attitudes, and experiences of healthcare providers and facility managers in the Kenya reproductive health output-based approach voucher program.
Methods
A total of 69 in-depth interviews with healthcare providers and facility managers in 30 voucher accredited facilities were conducted. The study hypothesized that a voucher program would be associated with improvements in reproductive health service provision. Data were transcribed and analyzed by adopting a thematic framework analysis approach. A combination of inductive and deductive analysis was conducted based on previous research and project documents. Results
Facility managers and providers viewed the RH-OBA program as a feasible system for increasing service utilization and improving quality of care. Perceived benefits of the program included stimulation of competition between facilities and capital investment in most facilities. Awareness of family planning (FP) and gender-based violence (GBV) recovery services voucher, however, remained lower than the maternal health voucher service. Relations between the voucher management agency and accredited facilities as well as existing health systems challenges affect program functions.
Conclusions
Public and private sector healthcare providers and facility managers perceive value in the voucher program as a healthcare financing model. They recognize that it has the potential to significantly increase demand for reproductive health services, improve quality of care and reduce inequities in the use of reproductive health services. To improve program functioning going forward, there is need to ensure the benefit package and criteria for beneficiary identification are well understood and that the public facilities are permitted greater autonomy to utilize revenue generated from the voucher program.

Emerging Infectious Diseases
Volume 21, Number 6—June 2015
http://wwwnc.cdc.gov/eid/

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Research
Cost-effectiveness of Chlamydia Vaccination Programs for Young Women
Kwame Owusu-Edusei , Harrell W. Chesson, Thomas L. Gift, Robert C. Brunham, and Gail Bolan
Author affiliations: Centers for Disease Control and Prevention, Atlanta, Georgia, USA (K. Owusu-Edusei Jr, H.W. Chesson, T.L. Gift, G. Bolan); University of British Columbia, Vancouver, British Columbia, Canada (R.C. Brunham)
Abstract
We explored potential cost-effectiveness of a chlamydia vaccine for young women in the United States by using a compartmental heterosexual transmission model. We tracked health outcomes (acute infections and sequelae measured in quality-adjusted life-years [QALYs]) and determined incremental cost-effectiveness ratios (ICERs) over a 50-year analytic horizon. We assessed vaccination of 14-year-old girls and catch-up vaccination for 15–24-year-old women in the context of an existing chlamydia screening program and assumed 2 prevaccination prevalences of 3.2% by main analysis and 3.7% by additional analysis. Estimated ICERs of vaccinating 14-year-old girls were $35,300/QALY by main analysis and $16,200/QALY by additional analysis compared with only screening. Catch-up vaccination for 15–24-year-old women resulted in estimated ICERs of $53,200/QALY by main analysis and $26,300/QALY by additional analysis. The ICER was most sensitive to prevaccination prevalence for women, followed by cost of vaccination, duration of vaccine-conferred immunity, and vaccine efficacy. Our results suggest that a successful chlamydia vaccine could be cost-effective.

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Ebola Risk Perception in Germany, 2014 PDF Version [PDF – 1.14 MB – 7 pages]
N. Rübsamen et al.
Knowledge about actual risks was poor, creating the potential for inappropriate behavior changes.

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Research
Oral Cholera Vaccine Coverage, Barriers to Vaccination, and Adverse Events following Vaccination, Haiti, 2013 1
Rania A. Tohme , Jeannot François, Kathleen Wannemuehler, Preetha Iyengar, Amber Dismer, Paul Adrien, Terri B. Hyde, Barbara J. Marston, Kashmira Date, Eric D. Mintz, and Mark A. Katz
Author affiliations: Centers for Disease Control and Prevention, Atlanta, Georgia, USA (R.A. Tohme, K. Wannemuehler, P. Iyengar, A. Dismer, T.B. Hyde, B.J. Marston, K. Date, E. Mintz); Ministry of Public Health and Population, Port-au-Prince, Haiti (J. Francois, P. Adrien); Centers for Disease Control and Prevention, Port-au-Prince (M.A. Katz)
Abstract
In 2013, the first government-led oral cholera vaccination (OCV) campaign in Haiti was implemented in Petite Anse and Cerca Carvajal. To evaluate vaccination coverage, barriers to vaccination, and adverse events following vaccination, we conducted a cluster survey. We enrolled 1,121 persons from Petite Anse and 809 persons from Cerca Carvajal, categorized by 3 age groups (1–4, 5–14, >15 years). Two-dose OCV coverage was 62.5% in Petite Anse and 76.8% in Cerca Carvajal. Two-dose coverage was lowest among persons >15 years of age. In Cerca Carvajal, coverage was significantly lower for male than female respondents (69% vs. 85%; p<0.001). No major adverse events were reported. The main reason for nonvaccination was absence during the campaign. Vaccination coverage after this campaign was acceptable and comparable to that resulting from campaigns implemented by nongovernmental organizations. Future campaigns should be tailored to reach adults who are not available during daytime hours.

The European Journal of Public Health
Volume 25, Issue 3, 01 June 2015
http://eurpub.oxfordjournals.org/content/25/3

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Vaccination coverage for measles, mumps and rubella in anthroposophical schools in Gelderland, The Netherlands
Judith H.E. Klomp , Alies van Lier , Wilhelmina L.M. Ruijs Eur J Public Health (2015) 25 (3): 501-505 DOI: http://dx.doi.org/10.1093/eurpub/cku178 First published online: 18 November 2014 (5 pages)
Abstract
Background: Social clustering of unvaccinated children in anthroposophical schools occurs, as inferred from various measles outbreaks that can be traced to these schools. However, accurate vaccination coverage data of anthroposophical schools are not widely available.
Methods:
In 2012, we performed a survey to estimate the vaccination coverage in three different grades of 11 anthroposophical schools in Gelderland, The Netherlands. We also gauged the opinion on childhood vaccination of the parents and compared these with the results of a national survey. In 2014, we were also able to obtain the registered total vaccination coverage per school from the national vaccination register to compare this with our survey data.
Results:
The self-reported MMR vaccination coverage (2012) in the three grades of the schools in our study was 83% (range 45–100% per school). The registered total vaccination coverage (2014) was 78% (range 59–88% per school). The 95% confidence intervals of the two different vaccination coverages overlap for all schools. The parents in this study were less convinced about the beneficial effect of vaccinations and more worried about the possible side effects of vaccination compared with parents in general.
Conclusion:
Despite high overall vaccination coverage, the WHO goal to eliminate measles and rubella will not easily be achieved when social clustering of unvaccinated children in anthroposophical schools remains.

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Low measles vaccination coverage among medical residents in Marseille, France: reasons for non-vaccination, March 2013
Teija Korhonen , Ariane Neveu , Alexis Armengaud , Caroline Six , Kostas Danis , Philippe Malfait
DOI: http://dx.doi.org/10.1093/eurpub/cku254 512-517 First published online: 12 February 2015
Abstract
Background:
During 2008–12, France and Europe experienced large measles outbreaks, involving also healthcare workers (HCW). We aimed to estimate the vaccination coverage (VC) of measles among medical residents of the University of Aix/Marseille, in South-Eastern France.
Methods:
In March 2013, we conducted a cross-sectional study among all medical residents of the Medical Faculty of Aix/Marseille. We used a self-administered questionnaire to collect information on self-reported VC and reasons for vaccination and non-vaccination. We compared proportions, using the chi-squared test and prevalence ratios (PRs) with 95% confidence intervals (95% CIs).
Results:
Of 1152 eligible residents, 703 (61%) participated in the study and 95 (14%; 95% CI: 12–17%) reported having had measles in the past. Of all participants, 613 (93%; 95% CI: 91–95%) reported having been vaccinated against measles and 389 (76%; 95% CI: 73–80%) received two doses. Only 268 (38%) reported having visited an occupational health physician. Vaccinated individuals were more likely to report easy access to vaccination as the main motivation for measles vaccination, compared with unvaccinated residents (435; 71% and 21; 45%; P < 0.001, respectively).
Conclusions:
VC among the medical residents of the University of Aix/Marseille was well below the recommended 95% coverage for two doses of measles vaccination. The majority of the study participants had not visited an occupational health doctor. Lack of easy access seems to represent major barriers to measles vaccination. We recommend that the student union, occupational health services and hospitals co-operate and address these problems in order to improve VC in this group.

Eurosurveillance
Volume 20, Issue 20, 21 May 2015
http://www.eurosurveillance.org/Public/Articles/Archives.aspx?PublicationId=11678

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Rapid communications
Genome sequence analysis of Ebola virus in clinical samples from three British healthcare workers, August 2014 to March 2015
by A Bell, K Lewandowski, R Myers, D Wooldridge, E Aarons, A Simpson, R Vipond, M Jacobs, S Gharbia, M Zambon
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Post-vaccine measles in a child with concomitant influenza, Sicily, Italy, March 2015
by F Tramuto, P Dones, C D’Angelo, N Casuccio, F Vitale

Journal of Global Infectious Diseases (JGID)
April-June 2015 Volume 7 | Issue 2 Page Nos. 53-94
http://www.jgid.org/currentissue.asp?sabs=n

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State of the globe: Ebola outbreak in the western world: Are we really ready?
Miguel Reina-Ortiz1, Ismael Hoare1, Vinita Sharma2, Ricardo Izurieta1
1 Department of Global Health, College of Public Health, University of South Florida, Florida, USA
2 Department of Community and Family Health, College of Public Health, University of South Florida, Florida, USA
Excerpt
…In summary, if we are to prevent an Ebola outbreak to ever occur in the Western World, we would need to consider the additional following steps: Educate the population to avoid overflowing of healthcare services, but at the same time to recognize early symptoms properly; implement triage units or sentinel posts closer to the most vulnerable populations (if and when needed); care for the uninsured; educate and train healthcare workers; establish sterilizing units directly under the command of Health Departments; and recruit and train staff and volunteers. We deem the prospects of an Ebola outbreak to occur in the US and the Western World still very low; however, we believe it is important to address the weaknesses in our healthcare systems to be better prepared for such a challenge should it occur.

Journal of Health Care for the Poor and Underserved (JHCPU)
Volume 26, Number 2, May 2015 Supplement
https://muse.jhu.edu/journals/journal_of_health_care_for_the_poor_and_underserved/toc/hpu.26.2A.html
SUPPLEMENT FOCUS: Shining the Light on Asian American, Native Hawaiian, and Pacific Islander Health

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Introduction: Shining the Light on Asian American, Native Hawaiian, and Pacific Islander Health
Winston Tseng, Simona C. Kwon
Author’s Note: In liieu of an abstract, here is a brief excerpt of the content:
The United States’s diverse Asian American and Native Hawaiian and Pacific Islander (AA and NHPI) populations have grown faster than those of any other racial/ethnic group over the past three decades.* , Out of the shadows and into the light, the health and health care issues faced by our AA and NHPI communities across the U.S., its territories, and freely associated states matter more and more to the vitality and future of the nation.

In 2015, we mark the 30th anniversary of the Heckler Report, the seminal Report of the Secretary’s Task Force on Black and Minority Health documenting national health inequities by race and ethnicity, which led to the establishment of the Office of Minority Health by Congress in 1986. Notably, the report concluded that Asian/Pacific Islanders in aggregrate were healthier than any other racial group in the U.S. In this supplement, Ponce and colleagues– Ko Chin and Caballero* present a community perspective on the leadership of Assistant Secretary for Health, Dr. Howard Koh, and his work in shepherding new national health equity initiatives, including the Patient Protection and Affordable Care Act of 2010, the reauthorization of the Office of Minority Health (OMH), the creation of the first national U.S. Department of Health and Human Services (HHS) Plan for Asian American, Native Hawaiian, and Pacific Islander Health, and the new HHS data standards for race, ethnicity, sex, primary language, and disability status from Section 4302 of the Affordable Care Act (ACA)., In addition, the National Standards for Culturally and Linguistically Appropriate Service in Health and Health Care were updated in 2013 to provide a comprehensive framework of health and health care organizations for the delivery of culturally respectful and linguistically responsive care and services to all. We honor the heroes and transformative ideas that have worked to advance AA and NHPI health equity.

Asian American and NHPI advocates, researchers, and community leaders have also made tremendous strides in building local and regional community coalitions to document health disparities and advance health equity on behalf of our diverse communities over the past decades., In this supplement, Trinh-Shevrin and colleagues
Authors across the articles by Huang, Islam, is to focus on addressing NHPI health conditions and health care services. This work ahead of us must start with recognizing the effects of structural racism, federal policies, and U.S. occupation on NHPI health, if it is to address racial justice and restore the agency and civil rights of NHPI indigenous communities across Hawaii, the Pacific Islands, and the continental U.S.

The health equity goals of the HHS Action Plan to Reduce Racial and Ethnic Health Disparities, National Stakeholder Strategy for Achieving Health Equity and Healthy People 2020 offer an opportunity for strengthening public-private partnerships between government and communities to document further the structural health inequities disfavoring AA and NHPI populations., The new HHS data standards that examine granular ethnicity and primary languages, as they are implemented across national surveys (e.g., National Health and Nutrition Examination Survey, National Health Interview Survey, Behavioral Risk Factors Surveillance System, Youth Risk Behavioral Surveillance System) and administrative health data systems (e.g., Medicare, Medicaid, Medical Expenditure Panel Survey, Physician Quality Reporting Initiative, and Uniform Data System) and reported through Healthy People 2020 and other public health dissemination venues, will allow us to track and monitor many key health issues facing AA and NHPI populations for the first time at a national level.

The National Stakeholder Strategy for Achieving Health Equity defines health equity as the “attainment of the highest level of health for all people. Achieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and health care disparities.”24[page 9] The definition of disparities by HHS and the Healthy People program has changed over time; initially the term disparities was understood as denoting disparities by race and ethnicity and focused on health behaviors and conditions. The conception of disparities in Healthy People 2020 is much broader today and includes health disparities by race and ethnicity, gender, sexual orientation, disability status, and geography as well as an examination of other…

Journal of the Pediatric Infectious Diseases Society (JPIDS)
Volume 4 Issue 2 June 2015
http://jpids.oxfordjournals.org/content/current

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Vaccine Exemptions: When Do Individual Rights Trump Societal Good?
Paul A. Offit
Author Affiliations
The Children’s Hospital of Philadelphia
Abramson Research Building
Philadelphia, Pennsylvania
Excerpt
To the Editors—This year’s measles epidemic is different.
Last year, in 2014, about 650 people in the United States suffered measles, an outbreak larger than any in 20 years. Neither the press nor the public took much notice.
This year, as of February 17, 2015, more than 140 people have been infected with measles in 17 states. Now, the media and the public have surely taken notice. For about 2 weeks, articles appeared daily in every major newspaper and segments aired on every national television program. ABC, NBC, CBS, CNN, FOX, as well as the New York Times, Washington Post, and Wall Street Journal covered the 2015 measles outbreak in the manner of a national emergency. Why the difference? One possibility is that, at the current rate, this year’s outbreak will be twice as large as last year’s. But the more likely difference is where these outbreaks occurred. Last year’s outbreak centered on an insular Amish community in Ohio; this year’s epicenter was Disneyland—a shared space, a commons. Disneyland, “the happiest place on earth,”…

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Challenges in the Surveillance of Invasive Pneumococcal Disease in the Postvaccination Era
Kattia Camacho-Badilla1, Luiza H. Falleiros-Arlant2, José Brea3 and María L. Avila-Aguero1
Author Affiliations
1Pediatric Infectious Diseases Service, Hospital Nacional de Niños, “Dr. Carlos Sáenz Herrera”, San José, Costa Rica
2Pediatrics, Facultade de Medicina da Universidade de Santos, Sao Paulo, Brazil
3Pediatrics, Centro Universitario Médico del Este, Santo Domingo, Dominican Republic
Accepted April 6, 2015.
Excerpt
Worldwide, meningitis and pneumonia are the leading cause of morbidity and mortality in children. Invasive pneumococcal disease (IPD) is the leading cause of vaccine-preventable deaths, accounting for 11% of deaths in children <5 years globally in the pre-pneumococcal conjugate vaccine (PCV) era [1], and it causes significant disease burden in Latin America (LA) and the Caribbean.

According to data published by the Pan American Health Organization (PAHO) in July 2014, 25 countries from LA and the Caribbean have introduced PCVs in their immunization schedules. Bolivia is the latest country that has introduced the 13-PCV in their national immunization program. The First Latin American Meeting of Pneumococcus: Epidemiology and Impact of Pneumococcal Conjugate Vaccines was held in San José, Costa Rica in August 2014 given the importance of analyzing the data of the post-PCVs era and its impact since their introduction in different countries…

The Lancet
May 23, 2015 Volume 385 Number 9982 p2015-2120
http://www.thelancet.com/journals/lancet/issue/current

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Editorial
Strengthening clinical research in children and young people
The Lancet
DOI: http://dx.doi.org/10.1016/S0140-6736(15)60974-6
Summary
“The time has come to protect children and young people through research not from research”, said Bobbie Farsides, Professor of Bioethics at Brighton and Sussex Medical School and Chair of the Working Party for the Nuffield Council on Bioethics, which published its report Children and clinical research: ethical issues on May 14. “It will always be easier to say ‘no’ to research with children on the grounds that it’s too difficult, but we should challenge the idea that it is acceptable to continue to offer health care to children without seeking to improve the evidence base for many of the treatments provided”, added Farsides. [Download the report]

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Articles
Socioeconomic inequalities in adolescent health 2002–2010: a time-series analysis of 34 countries participating in the Health Behaviour in School-aged Children study
Dr Frank J Elgar, PhD, Timo-Kolja Pförtner, PhD, Irene Moor, MSc, Bart De Clercq, MSc, Gonneke W J M Stevens, PhD, Candace Currie, PhD
Published Online
DOI: http://dx.doi.org/10.1016/S0140-6736(14)61460-4
Summary
Background
Information about trends in adolescent health inequalities is scarce, especially at an international level. We examined secular trends in socioeconomic inequality in five domains of adolescent health and the association of socioeconomic inequality with national wealth and income inequality.
Methods
We undertook a time-series analysis of data from the Health Behaviour in School-aged Children study, in which cross-sectional surveys were done in 34 North American and European countries in 2002, 2006, and 2010 (pooled n 492 788). We used individual data for socioeconomic status (Health Behaviour in School-aged Children Family Affluence Scale) and health (days of physical activity per week, body-mass index Z score [zBMI], frequency of psychological and physical symptoms on 0–5 scale, and life satisfaction scored 0–10 on the Cantril ladder) to examine trends in health and socioeconomic inequalities in health. We also investigated whether international differences in health and health inequalities were associated with per person income and income inequality.
Findings
From 2002 to 2010, average levels of physical activity (3·90 to 4·08 days per week; p<0·0001), body mass (zBMI −0·08 to 0·03; p<0·0001), and physical symptoms (3·06 to 3·20, p<0·0001), and life satisfaction (7·58 to 7·61; p=0·0034) slightly increased. Inequalities between socioeconomic groups increased in physical activity (−0·79 to −0·83 days per week difference between most and least affluent groups; p=0·0008), zBMI (0·15 to 0·18; p<0·0001), and psychological (0·58 to 0·67; p=0·0360) and physical (0·21 to 0·26; p=0·0018) symptoms. Only in life satisfaction did health inequality fall during this period (−0·98 to −0·95; p=0·0198). Internationally, the higher the per person income, the better and more equal health was in terms of physical activity (0·06 days per SD increase in income; p<0·0001), psychological symptoms (−0·09; p<0·0001), and life satisfaction (0·08; p<0·0001). However, higher income inequality uniquely related to fewer days of physical activity (−0·05 days; p=0·0295), higher zBMI (0·06; p<0·0001), more psychological (0·18; p<0·0001) and physical (0·16; p<0·0001) symptoms, and larger health inequalities between socioeconomic groups in psychological (0·13; p=0·0080) and physical (0·07; p=0·0022) symptoms, and life satisfaction (−0·10; p=0·0092).
Interpretation
Socioeconomic inequality has increased in many domains of adolescent health. These trends coincide with unequal distribution of income between rich and poor people. Widening gaps in adolescent health could predict future inequalities in adult health and need urgent policy action.
Funding
Canadian Institutes of Health Research.

Science
22 May 2015 vol 348, issue 6237, pages 833-940
http://www.sciencemag.org/current.dtl

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Report
Encouraging sanitation investment in the developing world: A cluster-randomized trial
Raymond Guiteras1, James Levinsohn2, Ahmed Mushfiq Mobarak2,*
Author Affiliations
1Department of Economics, University of Maryland, College Park, MD 20742, USA.
2School of Management, Yale University, New Haven, CT 06520, USA.
Abstract
Poor sanitation contributes to morbidity and mortality in the developing world, but there is disagreement on what policies can increase sanitation coverage. To measure the effects of alternative policies on investment in hygienic latrines, we assigned 380 communities in rural Bangladesh to different marketing treatments—community motivation and information; subsidies; a supply-side market access intervention; and a control—in a cluster-randomized trial. Community motivation alone did not increase hygienic latrine ownership (+1.6 percentage points, P = 0.43), nor did the supply-side intervention (+0.3 percentage points, P = 0.90). Subsidies to the majority of the landless poor increased ownership among subsidized households (+22.0 percentage points, P < 0.001) and their unsubsidized neighbors (+8.5 percentage points, P = 0.001), which suggests that investment decisions are interlinked across neighbors. Subsidies also reduced open defecation by 14 percentage points (P < 0.001).