The Benin experience: How computational modeling can assist major vaccine policy changes in low and middle income countries

Volume 33, Issue 25, Pages 2851-2954 (9 June 2015)


The Benin experience: How computational modeling can assist major vaccine policy changes in low and middle income countries
Pages 2858-2861
Bruce Y. Lee, Benjamin Schreiber, Angela R. Wateska, Diana L. Connor, Hamadou M. Dicko, Philippe Jaillard, Mercy Mvundura, Carol Levin, Mélanie Avella, Leila A. Haidari, Shawn T. Brown
While scientific studies can show the need for vaccine policy or operations changes, translating scientific findings to action is a complex process that needs to be executed appropriately for change to occur. Our Benin experience provided key steps and lessons learned to help computational modeling inform and lead to major policy change. The key steps are: engagement of Ministry of Health, identifying in-country “champions,” directed and efficient data collection, defining a finite set of realistic scenarios, making the study methodology transparent, presenting the results in a clear manner, and facilitating decision-making and advocacy. Generating scientific evidence is one component of policy change. Enabling change requires orchestration of a coordinated set of steps that heavily involve key stakeholders, earn their confidence, and provide them with relevant information. Our Benin EVM + CCEM + HERMES Process led to a decision to enact major changes and could serve as a template for similar approaches in other countries.

Parental reminder, recall and educational interventions to improve early childhood immunisation uptake: A systematic review and meta-analysis

Volume 33, Issue 25, Pages 2851-2954 (9 June 2015)


Parental reminder, recall and educational interventions to improve early childhood immunisation uptake: A systematic review and meta-analysis
Review Article
Pages 2862-2880
Hannah Harvey, Nadja Reissland, James Mason
Vaccination is one of the most effective ways of reducing childhood mortality. Despite global uptake of childhood vaccinations increasing, rates remain sub-optimal, meaning that vaccine-preventable diseases still pose a public health risk. A range of interventions to promote vaccine uptake have been developed, although this range has not specifically been reviewed in early childhood. We conducted a systematic review and meta-analysis of parental interventions to improve early childhood (0–5 years) vaccine uptake. Twenty-eight controlled studies contributed to six separate meta-analyses evaluating aspects of parental reminders and education. All interventions were to some extent effective, although findings were generally heterogeneous and random effects models were estimated.
Receiving both postal and telephone reminders was the most effective reminder-based intervention (RD = 0.1132; 95% CI = 0.033–0.193). Sub-group analyses suggested that educational interventions were more effective in low- and middle-income countries (RD = 0.13; 95% CI = 0.05–0.22) and when conducted through discussion (RD = 0.12; 95% CI = 0.02–0.21). Current evidence most supports the use of postal reminders as part of the standard management of childhood immunisations. Parents at high risk of non-compliance may benefit from recall strategies and/or discussion-based forums, however further research is needed to assess the appropriateness of these strategies.

The 23-valent pneumococcal polysaccharide vaccine is effective in elderly adults over 75 years old—Taiwan’s PPV vaccination program

Volume 33, Issue 25, Pages 2851-2954 (9 June 2015)


The 23-valent pneumococcal polysaccharide vaccine is effective in elderly adults over 75 years old—Taiwan’s PPV vaccination program
Original Research Article
Pages 2897-2902
Ying-Huang Tsai, Meng-Jer Hsieh, Chee-Jen Chang, Yu-Wen Wen, Han-Chung Hu, Yen-Nan Chao, Yhu-Chering Huang, Cheng-Ta Yang, Chung-Chi Huang
Pneumococcal infection is a serious cause of mortality and morbidity in the elderly. A nationwide pneumococcal polysaccharide vaccine (PPV) program for elderly adults aged 75 years and older was conducted in Taiwan in 2008. The efficacy of the PPV in this very elderly population was evaluated.
The data were analyzed using the Taiwan National Health Insurance Research Database (NHIRD), the cause-of-death registration database and the invasive pneumococcal disease (IPD) notification database of Taiwan’s Ministry of Health and Welfare. The efficacy of PPV administration in this very elderly population was evaluated using multivariate logistic regression after propensity score matching (PSM). The rates of IPD, death from IPD, pneumonia hospitalization, death from pneumonia, and all-cause mortality were compared for those who did and did not receive the PPV.
Among the 1078,955 eligible people, 318,257 (29.5%) received the PPV, and 760,698 (70.5%) were not vaccinated. Using PSM to adjust for confounding factors, including age, gender, influenza vaccination status, associated chronic diseases and health care utilization, those who received the PPV had significantly lower odds ratios (ORs) for IPD (OR = 0.24, 95% CI = 0.123–0.461, p < 0.001), death from IPD (OR = 0.09, 95% CI = 0.011–0.704, p < 0.022, p < 0.001), pneumonia hospitalization (OR = 0.40, 95% CI = 0.395–0.415, p < 0.001), death from pneumonia (OR = 0.07, 95% CI = 0.059–0.082, p < 0.001), and all-cause mortality (OR = 0.07, 95% CI = 0.069–0.072, p < 0.001) compared with those who were not vaccinated.
PPV vaccination in the previous year was associated with a 60% reduction in pneumonia hospitalization, a 76% reduction in IPD, and a greater than 90% reduction in death from pneumonia, IPD and all causes among people over 75 years old in Taiwan. Data from subsequent years in Taiwan and similar populations elsewhere are needed to evaluate the contribution of underlying variations in the mortality rate and the confounding effects of prior disease severity to these findings.

Review: Gavi HPV Programs: Application to Implementation

Vaccines — Open Access Journal
(Accessed 23 May 2015)

Review: Gavi HPV Programs: Application to Implementation
by Celina M. Hanson, Linda Eckert, Paul Bloem and Tania Cernuschi
Vaccines 2015, 3(2), 408-419; doi:10.3390/vaccines3020408 – published 20 May 2015
Developing countries disproportionately suffer from the burden of cervical cancer yet lack the resources to establish systematic screening programs that have resulted in significant reductions in morbidity and mortality in developed countries. Human Papillomavirus (HPV) vaccination provides an opportunity for primary prevention of cervical cancer in low-resource settings through vaccine provision by Gavi The Vaccine Alliance. In addition to the traditional national introduction, countries can apply for a demonstration program to help them make informed decisions for subsequent national introduction. This article summarizes information from approved Gavi HPV demonstration program proposals and preliminary implementation findings. After two rounds of applications, 23 countries have been approved targeting approximately 400,000 girls for vaccination. All countries are proposing primarily school-based strategies with mixed strategies to locate and vaccinate girls not enrolled in school. Experiences to date include: Reaching marginalized girls has been challenging; Strong coordination with the education sector is key and overall acceptance has been high. Initial coverage reports are encouraging but will have to be confirmed in population based coverage surveys that will take place later this year. Experiences from these countries are consistent with existing literature describing other HPV vaccine pilots in low-income settings.

Media/Policy Watch [to 23 May 2015]

Media/Policy Watch  [to 23 May 2015]
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.


Center for Global Development
Accessed 23 May 2015
Global Public Goods for Development: How Much and What For
Nancy Birdsall and Anna Diofasi
| 18 May 2015
Updated May 19, 2015
Global public goods (GPGs) provide benefits to people in both rich and poor countries. They play a crucial role in safeguarding the social, economic, and political progress of the past century. They are fundamental to managing global risks such as climate change, infectious diseases, and financial crises that can harm developing countries disproportionately; and in exploiting opportunities, such as new vaccines, that can benefit them especially. Yet very little is known about how much governments spend on GPGs that matter for developing countries. What scant publicly available information there is we have gathered here for an initial and provisional estimate. Our list is necessarily selective and conservative as none of the major institutions with a global mission – including the World Bank and WHO – report on the funds or programs they dedicate to global public goods, nor have they agreed on any standard definition of GPGs. Our compilation of spending on development-related global public goods in 2012 adds up to about $14 billion (Table 1 and Table 2), equivalent to a little over 10 percent of global spending on official development assistance that year…


Council on Foreign Relations
Accessed 23 May 2015
The Health of Nations: The WHO’s Moment of Truth
by Stewart M. Patrick and Guest Blogger for Stewart M. Patrick
The Ebola outbreak in West Africa underscored how vulnerable the world has become to infectious disease—and how vital it is to invest in global health security. Not since the H1N1 pandemic of 2009 had an epidemic garnered so much attention—and inspired so much fear—worldwide. But this window is closing fast. As Ebola has waned in West Africa, so has the political momentum for reforming the World Health Organization (WHO). The World Health Assembly (WHA), which opened Monday in Geneva, offers what may be the last chance to restore the badly tarnished credibility of the WHO and preserve its central role in pandemic preparedness and response…


The Economist
Accessed 23 May 2015
Development aid
It’s not what you spend
How to make aid to poor countries work better
May 23rd 2015 The Economist | 23 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…


The Guardian
Accessed 23 May 2015
Vaccine-free childcare ‘potentially catastrophic’, says industry group
Prospect of day care centres aimed at parents of unvaccinated children who are losing the childcare benefit condemned by Early Childhood Australia
21 May 2015
Moves by parents to open “vaccine-free” and “unvaccinated-friendly” day care centres in response to the federal government’s “no jab, no pay” policy have been described as “potentially catastrophic” by Early Childhood Australia, the peak advocacy body for early childcare.
In April the social services minister, Scott Morrison, announced that by next year, parents who refused to vaccinate their children on the grounds of being “conscientious objectors” would no longer receive the childcare benefit, childcare rebate and the family tax benefit part A end-of-year supplement.
The move has prompted some parents who do not vaccinate their children, and who will not be able to afford childcare as a result, to explore other options.
On social media, one woman has begun advertising the “Vaccine Free Family Day Care” centre on the page of an anti-vaccine group, which she says will open in Dromana, Victoria, start taking enrolments from 22 June, and charge $7 an hour for a minimum of eight hours a day…


New York Times
Accessed 23 May 2015
U.S. Bird Flu Causes Egg Shortage, Emergency Measures
OF LIFE OR DEATH For some companies, having an adequate supply of fertilized eggs can be a matter of life or death. Some vaccine makers, including Merck & Co Inc, maintain their own hen flocks to produce eggs used for incubating
May 23, 2015 – By REUTERS

Vaccines and Global Health: The Week in Review 16 May 2015

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

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

pdf version A pdf of the current issue is available here:  Vaccines and Global Health_The Week in Review_16 May 2015

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

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

David R. Curry, MS
Executive Director
Center for Vaccine Ethics and Policy
a program of the
– Division of Medical Ethics, NYU Medical School
– Children’s Hospital of Philadelphia Vaccine Education Center
Associate Faculty, Division of Medical Ethics, NYU Medical School

Nepal earthquake 2015 – Grade 3 emergency [to 16 May 2015]

Nepal earthquake 2015 – Grade 3 emergency
:: Health situation report No. 16pdf, 281kb 15 May 2015

:: Nepal ramps up disease surveillance after earthquakes 15 May 2015

:: Global Health Cluster
..Health Cluster 4Ws – 13 May 2015xlsx, 360kb
..Health Cluster Bulletin No. 2pdf, 2.26Mb 12 May 2015

:: WHO South-East Asia Region SEARO
.. Emergency preparedness pays off as Kathmandu hospitals respond to earthquakes  13 May 2015
.. Continuing care for tuberculosis, diabetes and heart patients in earthquake hit Nepal  10 May 2015

EBOLA/EVD [to 16 May 2015]

EBOLA/EVD [to 16 May 2015]
Public Health Emergency of International Concern (PHEIC); “Threat to international peace and security” (UN Security Council)

WHO: Ebola Situation Report – 13 May 2015
:: A total of 9 confirmed cases of Ebola virus disease (EVD) was reported in the week to 10 May: the lowest weekly total this year. Guinea reported a total of 7 cases, Sierra Leone reported 2. For the first time since the beginning of the outbreak in Sierra Leone, the country reported zero confirmed cases for more than 2 consecutive days in the week to 10 May. As at 12 May, Sierra Leone has reported 8 consecutive days without a confirmed case. The EVD outbreak in Liberia was declared over on 9 May, after 42 complete days elapsed since the burial of the last confirmed case. The country has now entered a 3-month period of heightened vigilance. WHO will maintain an enhanced presence in the country until the end of 2015, with a particular focus on areas that border Guinea and Sierra Leone….

:: There have been a total of 26,724 reported confirmed, probable, and suspected cases of EVD in Guinea, Liberia and Sierra Leone (figure 1, table 1), with 11,065 reported deaths (this total includes reported deaths among probable and suspected cases, although outcomes for many cases are unknown). A total of 7 new confirmed cases were reported in Guinea and 2 in Sierra Leone in the 7 days to 10 May. The outbreak in Liberia was declared over on 9 May…

Ebola Interim Assessment Panel 8 May 2015 [First Report]

Editor’s Note
Prepared in time for engagement during the upcoming World Health Assembly, the first report of the Ebola assessment panel is excerpted below. The panel will present its final report after visiting and consulting with the affected countries, currently set for June 2015.
The panel is chaired by Barbara Stocking, President of Murray Edwards College, University of Cambridge the United Kingdom and former chief executive of Oxfam GB; Professor Jean-Jacques Muyembe-Tamfun, Director-General of the National Institute for Biomedical Research, Democratic Republic of the Congo; Dr Faisal Shuaib, Head of the National Ebola Emergency Operations Center, Nigeria; Dr Carmencita Alberto-Banatin, independent consultant and advisor on health emergencies and disasters, Philippines; Professor Julio Frenk, Dean of the Faculty, Harvard T. H. Chan School of Public Health, Boston, Massachusetts; and Professor Ilona Kickbusch, Director of the Global Health Programme at the Graduate Institute of International and Development Studies, Geneva, Switzerland.

Ebola Interim Assessment Panel
Report by the Secretariat A68/25
Provisional agenda item 16.1
8 May 2015 :: 12 pages

[Selected Excerpts]
19. Now is the historic political moment for world leaders to give WHO new relevance and empower it to lead in global health. A strengthened, well-funded WHO can support all countries as they prepare to meet the challenges of increasing global interdependence and shared vulnerability. In response, the Secretariat needs to take serious steps to earn this leadership role in relation to outbreaks and emergency response and to regain the trust of the international community.

20. At present, WHO does not have the operational capacity or culture to deliver a full emergency public health response. A number of options have been suggested by different organizations and individuals: (i) a new agency should be established for health emergencies; (ii) the emergency part of the health response should be led by another United Nations agency; or (iii) investments should be made so that the operational capacity of WHO for emergency response is fully in place.

21. The panel recommends that the third option should be pursued with vigour. Establishing a new agency would take time to put in place and substantial new resources would be required to establish its basic administrative systems, and operational response capacity. A new agency would, in any case, have to rely on and coordinate with WHO for public health and technical resources, creating an unnecessary interface. Similarly, if another United Nations agency were expected to develop health operational capacity, it too would need to coordinate in depth with WHO, especially with respect to the International Health Regulations (2005). All this suggests that, as WHO already has the mandate to deliver on operational response, it would be a far more effective and efficient use of resources to make WHO fit for purpose. This will require the resources and political will of the Member States.

22. The Panel puts this recommendation to the Health Assembly now so that the overarching strategic direction is clear and that change can be driven forward quickly. If Member States agree to this strategic direction, then matters such as the Global Health Emergency Workforce and the proposed Contingency Fund can immediately move to implementation, so that the world is better placed to respond to significant public health emergencies.

23. A WHO that is capable of adequately responding to public health emergencies requires deep and substantial organizational change. The reaffirmation of WHO’s mandate in these emergencies should not be given lightly. This will require accountability and monitoring. Below we set out the key implications…

WHO Director-General addresses high-level meeting on Ebola R&D 11 May 2015

WHO Director-General addresses high-level meeting on Ebola R&D
Dr Margaret Chan, Director-General of the World Health Organization
Opening remarks at a WHO Ebola research and development forum
11 May 2015
Distinguished scientists, representatives of industry, colleagues in public health, ladies and gentlemen,

Good morning and a warm welcome to this high-level meeting. I thank you for your time and expertise.

The Ebola R&D effort has mobilised people, institutions and resources in ways never seen before. This is one positive outcome in an otherwise horrific human calamity.

New tools have been developed with unprecedented speed, though the window of opportunity for testing some is closing. On Saturday, WHO declared an end to the outbreak in Liberia. This is a monumental achievement in by far the worst outbreak since Ebola emerged in 1976.

Prior to the current outbreak, Ebola was considered a rare disease. Much about the disease and its causative agent was poorly understood. Your work has increased that understanding considerably. We are likely very close to having a vaccine that can protect against Ebola.

We have 4 rapid diagnostics to detect infection, and 2 of these are point-of-care. We have much more information about which therapeutic interventions may or may not work.
This is a contribution to scientific knowledge, but it is also a contribution to better preparedness. Thanks to your work, the world will be far better equipped to respond when the next Ebola outbreak inevitably occurs.

You have achieved something even bigger. What we see emerging, over a very short time, is a new model for the accelerated development, testing, and approval of new medical products during emergencies caused by any emerging or re-emerging infectious disease.

Your collaborative efforts prove that the traditional R&D model can be adapted, timeframes can be compressed, and partnerships that are otherwise unlikely can be formed.
The implications are huge. Many other serious diseases have no vaccines or therapeutic options, and some of these diseases have epidemic potential.

The job now is to harness the lessons from Ebola to create a new R&D framework that can be used for any epidemic-prone disease, in any infectious disease emergency.
This is what you will be discussing over the next 2 days: an R&D preparedness plan with clear rules, well-defined platforms for information sharing, and agreed procedures to expedite development and clinical trials.

In emergencies, coordination is the first essential element. Timely and transparent information sharing is the second.

The more we know about what other partners have discovered or achieved, the better equipped we will be to make informed decisions and take the right next steps with the greatest possible speed.

In this sense, the R&D response to Ebola marks an historical, ground-breaking event. Public research institutes, private funders, civil society, countries, and industry have united, in unprecedented ways, to defend the world against a deadly and deeply dreaded disease.

Many of you present today were part of this army. I hope the world will recognize what your engagement means, also as a contribution to future preparedness.
I wish you every success over the coming 2 days and eagerly await the outcome of your discussions.

POLIO [to 16 May 2015]

POLIO [to 16 May 2015]
Public Health Emergency of International Concern (PHEIC)

GPEI Update: Polio this week – As of 13 May 2015
Global Polio Eradication Initiative
[Editor’s Excerpt and text bolding]
Full report:
:: Ministers of Health from around the world will meet in Geneva, Switzerland, next 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 latest semi-annual status report has been published and covers the period July to December 2014. The report provides an in-depth epidemiological and programmatic update for endemic, re-infected and high-risk countries.
:: Liberia and Sierra Leone have conducted polio and measles vaccination campaigns during the first week of 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]

WHO & Regionals [to 16 May 2015]

WHO & Regionals [to 16 May 2015]
:: Racing to combat an unprecedented meningitis outbreak in Niger
15 May 2015 — WHO and partners have sent an international expert team and negotiated provision of over half a million doses of vaccine to help Niger combat an unprecedented outbreak of meningococcal meningitis. This outbreak is the first large-scale meningitis outbreak caused by strain C to hit any country in Africa’s meningitis belt and has caused 5,855 suspected cases including 406 deaths.
Read the situation assessment
:: Sixty-eighth World Health Assembly
15 May 2015 — The Sixty-eighth session of the World Health Assembly takes place in Geneva 18–26 May 2015, as officials from 194 Member States begin their annual review of the activities of WHO and set new priorities for the future. The main functions of the World Health Assembly are to determine the policies of the Organization and review and approve the proposed programme budget. The Health Assembly is held every May in Geneva, Switzerland.
:: Global Alert and Response (GAR) – Disease Outbreak News (DONs)
.. Rapidly growing outbreak of meningococcal disease in Niger 15 May 2015
.. Human infection with avian influenza A(H7N9) virus – China 14 May 2015
.. Ebola virus disease – Italy 13 May 2015

:: The Weekly Epidemiological Record (WER) 15 May 2015, vol. 90, 20 (pp. 217–252) includes
.. Set of interviews
.. Epidemics timeline
.. Emerging and re-emerging infectious threats in the 21st century
.. Middle East respiratory syndrome coronavirus (MERS-CoV): current situation 3 years after the virus was first identified
.. Plague in Madagascar: overview of the 2014– 2015 epidemic season

:: Millennium Development Goals (MDGs) – Fact sheet N°290
Updated May 2015
Key facts
..Globally, the number of deaths of children under 5 years of age fell from 12.7 million in 1990 to 6.3 million in 2013.
..In developing countries, the percentage of underweight children under 5 years old dropped from 28% in 1990 to 17% in 2013.
..Globally, new HIV infections declined by 38% between 2001 and 2013.
..Existing cases of tuberculosis are declining, along with deaths among HIV-negative tuberculosis cases.
..In 2010, the world met the United Nations Millennium Development Goals target on access to safe drinking-water, as measured by the proxy indicator of access to improved drinking-water sources, but more needs to be done to achieve the sanitation target.

:: World Health Statistics 2015
World Health Statistics 2015 contains WHO’s annual compilation of health-related data for its 194 Member States, and includes a summary of the progress made towards achieving the health-related Millennium Development Goals (MDGs) and associated targets.
WHO presents World Health Statistics 2015 as an integral part of its ongoing efforts to provide enhanced access to comparable high-quality statistics on core measures of population health and national health systems.

:: WHO Regional Offices
WHO African Region AFRO
:: Renowned public health experts and leaders endorse a vision for an Africa Health Transformation Programme to enhance health in the African Region – 14 May 2015

WHO Region of the Americas PAHO
:: LGBT health sees progress and challenges 15 years after homosexuality ceased being considered a disease (05/15/2015)
:: PAHO/WHO urges more attention to blood pressure control (05/14/2015)
:: PAHO/WHO highlights need to train more nursing personnel (05/12/2015)
:: New studies show immunization remains a ‘best buy’ in the fight against vaccine-preventable diseases (05/11/2015)

WHO South-East Asia Region SEARO
:: Emergency preparedness pays off as Kathmandu hospitals respond to earthquakes
13 May 2015
:: Continuing care for tuberculosis, diabetes and heart patients in earthquake hit Nepal
10 May 2015

WHO European Region EURO
:: First confirmed Ebola case in Italy 14-05-2015
:: Better hospital care for children 11-05-2015
:: WHO/Europe supports translation of European Vaccine Action Plan into national immunization plans in Gavi-supported countries
A workshop to build capacity for comprehensive multi-year planning (cMYP) on immunization in countries eligible for support from the Global Alliance for Vaccines and Immunization (Gavi) took place on 27–29 April 2015 in Copenhagen, Denmark.
Continuation of GAVI support to countries is conditional on submission of updated cMYPs, which provide strategic guidance to national immunization programmes and stakeholders. WHO/Europe organized the workshop to help Armenia, Azerbaijan, Georgia, Kyrgyzstan, Republic of Moldova, Tajikistan, Ukraine and Uzbekistan identify critical aspects to be considered while developing their next cMYP, in line with revised WHO–United Nations Children’s Fund cMYP development guidelines and new costing and financing tool.
The process of updating cMYPs for the upcoming cycle (2016-2020) is also a vital time to translate the goals, objectives and proposed actions of the European Vaccine Action Plan 2015–2020 (EVAP) into national immunization plans.
Cross-border collaboration combined with tailored support to countries
Approximately 35 immunization programme managers and programme staff in charge of vaccine management and logistics, surveillance of vaccine-preventable diseases and immunization financing attended the workshop, along with WHO experts and representatives of partner agencies. Working together to improve planning of national immunization programmes allowed the participants to share experiences and best practices across national borders.
The workshop also provided WHO/Europe the opportunity to assess what technical assistance each country needs to finalize its cMYP. Based on this assessment, tailored support will be provided to countries at different stages of the planning process to ensure that development of cMYPs is aligned with national commitments and plans as laid out in the EVAP.

WHO Eastern Mediterranean Region EMRO
:: WHO to deliver additional medicines and medical supplies to Yemen
15 May 2015, Amman, Jordan — WHO is scaling up its provision of medicines and medical supplies to Yemen during the current humanitarian pause. Today, WHO is sending more than 20 tonnes of medicines and medical supplies to Hodeida, comprising international emergency health kits, trauma kits, surgical supply kits, emergency diarrhoeal disease kits, and water, sanitation and hygiene items for more than 120 000 beneficiaries. More than 300 000 people have been newly displaced in Yemen since March, and almost 8.6 million people are in need of health services around the country.
:: Morocco joins the International Agency for Research on Cancer 16 May 2015
:: Egypt: upsurge in H5N1 human and poultry cases but no change in transmission pattern of infection 15 May 2015
:: WHO–Kuwait partnership to help the people of Syria
15 May 2015

WHO Western Pacific Region
:: Four innovative Pacific projects receive WHO Healthy Islands Recognition
YANUCA ISLAND, 11 May 2015 – As part of the Eleventh Pacific Health Ministers Meeting, the World Health Organization (WHO) awarded four innovative projects in Commonwealth of the Northern Mariana Islands, Samoa, Tokelau and Vanuatu with the WHO Healthy Islands Recognition for the outstanding work by health and community leaders in the Pacific.

GAVI [to 16 May 2015]

GAVI [to 16 May 2015]

:: Qatar pledges support for Gavi to save children’s lives with vaccines
Funding will help Vaccine Alliance protect millions of children from infectious disease.
DOHA, 14 May 2015 – The Qatar Development Fund and Gavi, the Vaccine Alliance signed today a landmark Contribution Agreement, under which the State of Qatar agreed to make a multi-year financial pledge to help immunise children in the world’s poorest countries against vaccine-preventable diseases.
Under the agreement, Qatar committed to provide an initial US$ 10 million to Gavi to support immunisation programmes in the period between 2016 and 2020. The funding will be provided through the Qatar Development Fund and follows the announcement at the Gavi Pledging Conference, held in Berlin in January 2015, that Qatar intends to commit funding to the Vaccine Alliance…
…“The State of Qatar is committed to helping the international coalition save children’s lives and protect people’s health through cooperation with the Global Alliance for Vaccines and Immunization Organization by increasing access to immunisation in developing countries,” said Khalifa Al-Kuwari, General Director of Qatar Development Fund…

:: IFFIm awarded prize for ‘Innovation in Islamic Finance 2015’
12 May 2015
Third global award given for IFFIm’s November sukuk transaction.

European Medicines Agency Watch [to 16 May 2015]

European Medicines Agency Watch [to 16 May 2015]
:: Safety monitoring of medicines: EMA to screen medical literature for 400 active substance groups
New service will improve safety monitoring of medicines and simplify pharmacovigilance activities for companies

The European Medicines Agency (EMA) has published the list of active substances and a reference to the journals that will be covered by its new medical literature monitoring service. This service will start with a limited number of active substances on 1 July 2015 and will be fully rolled out in September 2015. A guide, a training video and a document detailing the inclusion and exclusion criteria to be used when screening the literature are also available on a dedicated webpage.

Medical literature is an important source of information on suspected adverse reactions reported on medicines. The European Union’s (EU) pharmacovigilance legislation has given EMA responsibility for the monitoring of selected medical literature for a defined list of active substances used in medicines and for entering identified reports of suspected adverse reactions in EudraVigilance, the EU adverse drug reaction collection and management system…

IOM: Scaling Program Investments for Young Children Globally: Evidence from Latin America and the Caribbean—Workshop in Brief

IOM: Scaling Program Investments for Young Children Globally: Evidence from Latin America and the Caribbean—Workshop in Brief
May 14, 2015
Authors: Amanda Pascavis, Rapporteur
Forum on Investing in Young Children Globally; Board on Children, Youth, and Families; Board on Global Health; Institute of Medicine; National Research Council
On November 11, 2014, the Forum on Investing in Young Children Globally of the Institute of Medicine and National Research Council, in partnership with Fundação Maria Cecilia Souto Vidigal (FMCSV) in São Paulo, Brazil, held a 1-day workshop. The purpose of this interactive public workshop was to highlight efforts made to scale program investments across health, education, nutrition, and social protection that aim to improve children’s developmental potential. Invited speakers and public participants explored four topics on scaling up program investments: evidence of impact for effective investments in young children; scalability of investments; sustainability of investments; and governance.
Presenters highlighted evidence on effective investments in programs and interventions in Latin America, including an account of their strengths and challenges. Speakers addressed scalability and sustainability of program investments and how to maintain quality at scale, with a focus on approaches in culturally and ethnically diverse contexts and issues of decentralization, local capacity, and information systems for monitoring and evaluation. Presentations and discussions included policy perspectives on scaling up programs. This brief summary of the workshop highlights the topics raised by panelists, moderators, and public participants, while also including possible directions for further discussion. It represents the viewpoints of individual session participants and should not be viewed as consensus conclusion or recommendations of the workshop as a whole. A full summary of the workshop will be available in summer 2015

Expanding Opportunities for the Next Generation, Early Childhood Development in the Middle East and North Africa – Directions in development; human development

Expanding Opportunities for the Next Generation, Early Childhood Development in the Middle East and North Africa – Directions in development; human development
World Bank Group
May 07, 2015 :: 343 pages
Authors: El-Kogali, Safaa El Tayeb; Krafft, Caroline Gould;
The report fills a critical research gap by providing the first comprehensive analysis of the state of early childhood development (ECD) in the Middle East and North Africa (MENA).

Early childhood is the most important stage of human development. In the Middle East and North Africa (MENA), there is little research and inadequate investment in this crucial stage of life. This book assesses the state of early childhood development (ECD) in MENA from before birth through age five, examining multiple dimensions of early development including health, nutrition, socio-emotional development, early learning, and early work. The book begins with a discussion of the importance of ECD as a critical foundation for later development, and also as a stage of life when inequality and social exclusion begin. ECD in MENA is set in a global context, and then countries within MENA are compared, with chapters on ECD in Algeria, Djibouti, Egypt, Iraq, Jordan, Lebanon, Libya, Morocco, Syria, Tunisia, West Bank and Gaza, and Yemen. As well as illustrating the state of ECD, the chapters assess risk and protective factors for early development and the extent of inequality in early childhood. A discussion of policies and programs that can enhance ECD illustrates how inequality and shortfalls in early development can be effectively addressed. This book will be of interest to anyone interested in the state of human development and inequality in MENA.

Contents Overview
The first chapter offers an overview of the evidence that the period from before birth to age five is the most important stage of human development. This period is especially crucial as deficits at this early stage tend to be irreversible and to perpetuate cycles of poverty and inequality. The many dimensions of healthy ECD, from proper healthcare and nutrition to early development activities, are identified along with the range of related indicators used to measure the state of ECD in the region.

Chapter 2 offers a comparison with other regions of the world, for a better understanding of the state of ECD in MENA,. The twelve countries of the region are also compared, to establish benchmarks and identify country-specific deficits in ECD. The chapter includes an analysis of the factors that influence ECD, as there is significant inequality of access to key development activities even in the region’s more developed countries.

Chapter 3 shows that economic growth alone will not address the many shortfalls in the region’s ECD. Targeted interventions are needed. The chapter provides a way forward with a number of approaches from around the world that have been implemented successfully and which would benefit children in MENA.

Country analyses:
:: Algeria which has achieved good immunization rates but has high rates of stunting due to malnutrition, and where a child’s social and economic background influences the chances of healthy development.
:: Djibouti where prenatal and delivery care is now almost universal but child mortality rates are still high and less than one third of children are fully immunized by the age of one.
:: Egypt where stunting is a major and persistent problem and disadvantaged children are the least likely to benefit from early schooling, although immunization rates have reached 92%.
:: Iraq where only half of children are receiving regular prenatal care, less than two-thirds are fully immunized and access to key development activities is closely related to social and economic background.
:: Jordan which has achieved near universal coverage for prenatal and neonatal care, and while rates for stunting are low there is large variation in nutrition status, with a child from the poorest segment of society seven times as likely to be stunted as a child from the richest.
:: Lebanon which has also achieved near universal coverage for prenatal and neonatal care but where only half of all children are fully immunized by age one and poorer children are more likely to be stunted.
:: Libya before the current crisis, where 87% of all children were fully immunized but only half had access to iodized salt, essential for cognitive development, and more than one fifth were stunted.
:: Morocco where 90% of children are fully immunized but almost one third are stunted and deaths in the first month and year of life are above regional averages, with the poorest children facing greater risk of death.
:: Syria before the current crisis, where 96% of births were assisted by a skilled attendant but only 78% of one-year-olds were fully immunized and over one quarter of all children were stunted.
:: Tunisia which has achieved near universal prenatal and delivery care and early mortality has fallen below regional averages, but children in rural areas have one third the chance of urban children to attend early education and 22% of children aged 5 are engaged in child labor.
:: West Bank and Gaza which has achieved near universal coverage for prenatal and delivery care but stunting remains a persistent problem and there are large differences in access to early care and education between advantaged and disadvantaged children.
:: Yemen before the current crisis where less than half of all births received prenatal care and children were more than twice as likely to die before their first birthday (7%) as they were to attend early childhood education (3%).

BMC Public Health (Accessed 16 May 2015)

BMC Public Health
(Accessed 16 May 2015)
Research article
Motives of Dutch persons aged 50 years and older to accept vaccination: a qualitative study
Renske Eilers, Paul Krabbe, Hester de Melker BMC Public Health 2015, 15:493 (16 May 2015)
Urban health indicators and indices: current status
Richard Rothenberg1*, Christine Stauber1, Scott Weaver1, Dajun Dai2, Amit Prasad3 and Megumi Kano3
Author Affiliations
BMC Public Health 2015, 15:494 doi:10.1186/s12889-015-1827-x
Published: 16 May 2015
Abstract (provisional)
Though numbers alone may be insufficient to capture the nuances of population health, they provide a common language of appraisal and furnish clear evidence of disparities and inequalities. Over the past 30 years, facilitated by high speed computing and electronics, considerable investment has been made in the collection and analysis of urban health indicators, environmental indicators, and methods for their amalgamation. Much of this work has been characterized by a perceived need for a standard set of indicators. We used publication databases (e.g. Medline) and web searches to identify compilations of health indicators and health metrics. We found 14 long-term large-area compilations of health indicators and determinants and seven compilations of environmental health indicators, comprising hundreds of metrics. Despite the plethora of indicators, these compilations have striking similarities in the domains from which the indicators are drawn—an unappreciated concordance among the major collections. Research with these databases and other sources has produced a small number of composite indices, and a number of methods for the amalgamation of indicators and the demonstration of disparities. These indices have been primarily used for large-area (nation, region, state) comparisons, with both developing and developed countries, often for purposes of ranking. Small area indices have been less explored, in part perhaps because of the vagaries of data availability, and because idiosyncratic local conditions require flexible approaches as opposed to a fixed format. One result has been advances in the ability to compare large areas, but with a concomitant deficiency in tools for public health workers to assess the status of local health and health disparities. Large area assessments are important, but the need for small area action requires a greater focus on local information and analysis, emphasizing method over prespecified content.

Who should be vaccinated against HPV? [boys AND girls?]

British Medical Journal
16 May 2015(vol 350, issue 8008)

Who should be vaccinated against HPV?
BMJ 2015; 350 doi: (Published 12 May 2015) Cite this as: BMJ 2015;350:h2244
Karen Canfell, director1

As richer countries consider vaccinating males, the focus for lower income countries should remain on cervical cancer prevention
Vaccination of girls against the human papillomavirus (HPV) has been implemented in most developed countries, driven by prevention of cervical cancer as a public health priority. Bivalent (Cervarix, GSK) and quadrivalent (Gardasil, Merck) vaccines protect against subsequent infection with oncogenic HPV16/18, and quadrivalent vaccine protects against HPV6/11, which cause anogenital warts. Although HPV vaccination effectively protects against external genital lesions and anal intraepithelial neoplasia in males, only a few jurisdictions have so far recommended universal vaccination of boys. These include Australia, Austria, two Canadian provinces, and the United States. In other countries, a cautious approach has been due, in part, to uncertainties around the population level impact and cost effectiveness of vaccination of boys.

In a linked article, Bogaards and colleagues (doi:10.1136/bmj.h2016) estimated the benefits to men of offering HPV vaccination to boys.1 They used a dynamic simulation and a bayesian synthesis to integrate the evidence on HPV related cancers in men. The analysis takes account of indirect protection from female vaccination: heterosexual men will benefit from reduced HPV circulation in females, so if coverage in girls is high the incremental benefit of vaccinating boys is driven by prevention of the residual burden of anal cancer in men who have sex with men.

The findings reinforce those of prior analyses that found that adding boys to established vaccination programmes in girls becomes less cost effective as female coverage increases.2 The cost effectiveness of vaccination of boys also depends on other local issues, especially vaccine type and vaccine and administration costs. A threshold total cost per vaccinated boy for cost effectiveness can be identified at any level of coverage in girls: such analyses can provide policy makers with the maximum rational vaccine price appropriate to the local environment. If vaccine coverage in girls is lower, however, the most effective use of resources is likely to involve increasing coverage in girls, if feasible.2 3

In some countries, vaccination of boys might not be cost effective, even at lower vaccine prices, due to higher administration costs.3 Recent developments towards reduced dose schedules could help. In 2013 the European Medical Agency recommended a two dose schedule for the bivalent vaccine in girls, in 2014 the United Kingdom switched to a two dose schedule, and the World Health Organization now recommends two doses for girls <15. Two dose schedules are the most cost effective option for girls provided protection lasts for ≥20 years4 and reduced dose schedules in boys are also likely to increase cost effectiveness if adequate efficacy is maintained.

Bogaards and colleagues highlight the importance of vaccination for prevention of anal cancer in men who have sex with men. In part due to uncertainties in natural history, the effectiveness of anal cancer screening is not established.5 Primary prevention with targeted vaccination of men who have sex with men is an attractive option and is potentially more cost effective than universal vaccination of boys. The US Advisory Committee on Immunization Practices already recommends vaccination of men who have sex with men up to the age of 26 years.6 Older men who have sex with men could also potentially benefit. The UK’s Joint Committee on Vaccination and Immunisation, as an interim position, recently stated that a programme to vaccinate men aged 16-40 who have sex with men with a quadrivalent vaccine should be considered, if cost effective.7 Lower coverage rates expected with targeted versus universal male vaccination are an important consideration, and the two approaches are not mutually exclusive.

Several other new developments should be factored in to future policy decisions. A recent study showed that the bivalent vaccine is effective in women aged ≥25 without a history of HPV disease.8 With a transition to primary HPV screening occurring in several countries, an interesting possibility to be evaluated involves “screen and vaccinate” strategies in older women—that is, offering HPV screening, followed by vaccination for HPV negative women with extended (or perhaps no) recall for this group. Secondly, a nonavalent vaccine (Gardasil9, Merck), which protects against an extra five HPV types,9 has recently been recommended for use in the US.6 In women, this will increase protection against cervical cancer in those who are fully vaccinated (from about 70% to about 90%)10 but as most HPV cancers in men are attributed to types included in current vaccines,1 tiered pricing structures for new generation vaccines based on differential incremental benefits (and thus differential cost effectiveness thresholds) in girls versus boys could be considered.

All these policy decisions must consider burden of disease, safety, effectiveness, acceptability, equity, and cost effectiveness. Although the focus in developed countries has now, appropriately, shifted to considering these issues for boys, men who have sex with men, and older women, broader efforts to prevent cervical cancer should remain the priority in low and middle income countries. Of the 610 000 cancers annually attributable to HPV worldwide, 87% are cancers of the cervix, and three quarters of these occur in countries with a low or medium human development index.11 Even if a substantial majority of young girls in such counties were vaccinated, hundreds of millions of older women would remain at risk—vaccination alone will not prevent an expected increase in cervical cancers in the next few decades, driven by population ageing. Here, the priority focus should be the development of integrated programmes for vaccinating young girls and screening older women. Based on experience in developed countries, this will also provide benefits for men through indirect vaccine protection.

Research, doi:10.1136/bmj.h2016

Direct benefit of vaccinating boys along with girls against oncogenic human papillomavirus: bayesian evidence synthesis
BMJ 2015; 350 doi: (Published 12 May 2015) Cite this as: BMJ 2015;350:h2016
Johannes A Bogaards, senior researcher12, Jacco Wallinga, senior researcher2, Ruud H Brakenhoff, professor3, Chris J L M Meijer, professor4, Johannes Berkhof, associate professor1
Author affiliations
To assess the reduction in the vaccine preventable burden of cancer in men if boys are vaccinated along with girls against oncogenic human papillomavirus (HPV).
Bayesian evidence synthesis approach used to evaluate the impact of vaccination against HPV types 16 and 18 on the burden of anal, penile, and oropharyngeal carcinomas among heterosexual men and men who have sex with men. The reduced transmission of vaccine-type HPV from vaccination of girls was assumed to lower the risk of HPV associated cancer in all men but not to affect the excess risk of HPV associated cancers among men who have sex with men.
General population in the Netherlands.
Inclusion of boys aged 12 into HPV vaccination programmes.
Main outcome measures
Quality adjusted life years (QALYs) and numbers needed to vaccinate.
Before HPV vaccination, 14.9 (95% credible interval 12.2 to 18.1) QALYs per thousand men were lost to vaccine preventable cancers associated with HPV in the Netherlands. This burden would be reduced by 37% (28% to 48%) if the vaccine uptake among girls remains at the current level of 60%. To prevent one additional case of cancer among men, 795 boys (660 to 987) would need to be vaccinated; with tumour specific numbers for anal, penile, and oropharyngeal cancer of 2162, 3486, and 1975, respectively. The burden of HPV related cancer in men would be reduced by 66% (53% to 805) if vaccine uptake among girls increases to 90%. In that case, 1735 boys (1240 to 2900) would need to be vaccinated to prevent an additional case; with tumour specific numbers for anal, penile, and oropharyngeal cancer of 2593, 29107, and 6484, respectively.
Men will benefit indirectly from vaccination of girls but remain at risk of cancers associated with HPV. The incremental benefit of vaccinating boys when vaccine uptake among girls is high is driven by the prevention of anal carcinomas, which underscores the relevance of HPV prevention efforts for men who have sex with men.

Human Vaccines & Immunotherapeutics – Volume 11, Issue 4, 2015

Human Vaccines & Immunotherapeutics (formerly Human Vaccines)
Volume 11, Issue 4, 2015

A review of economic evaluations of 13-valent pneumococcal conjugate vaccine (PCV13) in adults and the elderly
Open access
S Dirmesropiana, JG Wooda, CR MacIntyreab & AT Newalla*
pages 818-825
The 13-valent pneumococcal conjugated vaccine (PCV13) is already recommended for some adult groups and is being considered for wider use in many countries. In order to identify the strengths and limitations of the existing economic evaluation studies of PCV13 in adults and the elderly a literature review was conducted. The majority of the studies identified (9 out of 10) found that PCV13 was cost-effective in adults and/or the elderly. However, these results were based on assumptions that could not always be informed by robust evidence. Key uncertainties included the efficacy of PCV13 against non-invasive pneumonia and the herd immunity effect of childhood vaccination programs. Emerging trial evidence on PCV13 in adults from the Netherlands offers the ability to parameterize future economic evaluations with empirical efficacy data. However, it is important that these estimates are used thoughtfully when they are transferred to other settings

Cost-effectiveness analysis of a vaccination program for the prevention of herpes zoster and post-herpetic neuralgia in adults aged 50 and over in Germany
Open access
Emmanuelle Préauda*, Mathieu Uharta, Katharina Böhmb, Pamela Aidelsburgerb, Delphine Angerc, Florence Bianicc & Nathalie Largerona
pages 884-896
Herpes zoster (HZ; shingles) is a common viral disease that affects the nerves and surrounding skin causing a painful dermatomal rash and leading to debilitating complications such as, mainly, post-herpetic neuralgia (PHN). Currently, there is no effective treatment for HZ and PHN. The objective of this study was to assess the cost-effectiveness of a HZ vaccination program in Germany. An existing Markov Model was adapted to the German healthcare setting to compare a vaccination policy to no vaccination on a lifetime time-horizon, considering 2 scenarios: vaccinating people starting at the age of 50 or at the age of 60 years, from the perspective of the statutory health insurance (SHI) and the societal perspective. According to the perspective, vaccinating 20% of the 60+ German population resulted in 162,713 to 186,732 HZ and 31,657 to 35,793 PHN cases avoided. Corresponding incremental cost-effectiveness ratios (ICER) were 39,306 €/QALY from the SHI perspective and 37,417 €/QALY from a societal perspective. Results for the 50+ German population ranged from 336,468 to 394,575 HZ and from 48,637 to 56,087 PHN cases avoided from the societal perspective. Corresponding ICER were 39,782 €/QALY from a SHI perspective and 32,848 €/QALY from a societal perspective. Sensitivity analyses showed that results are mainly impacted by discount rates, utility values and use of alternative epidemiological data.The model indicated that a HZ vaccination policy in Germany leads to significant public health benefits and could be a cost-effective intervention. The results were robust and consistent with local and international existing literature.

Evaluation of a vaccination strategy by serosurveillance data: The case of varicella
Open access
Silvio Tafuri*, Maria Serena Gallonea, Maria Filomena Gallonea, Maria Giovanna Cappellia, Maria Chironnaa & Cinzia Germinarioa
pages 897-900
Serological studies have many important epidemiologic applications. They can be used to investigate acquisition of various infections in different populations, measure the induction of an immune response in the host, evaluate the persistence of antibody, identify appropriate target groups and the age for vaccination. Serological studies can also be used to determine the vaccine efficacy. Since 1995 a varicella vaccine is available and it has been recommended in several countries (e.g. USA, Australia, Canada, Costa Rica, Ecuador, etc.). Nevertheless few varicella seroprevalence studies in countries that adopted an URV are available. It is related to the relatively recent introduction of the vaccination and to the lack of structured and collaborative surveillance systems based on serosurvey at national or regional level. Varicella seroprevalence data collected before the introduction of vaccination strategies allowed to establish the age of vaccination (e.g., indicated the opportunity to offer the vaccine to Italian susceptible adolescents). In the post-vaccination era, seroprevalence data demonstrated vaccine as immunogenic and excluded an increase of the age of infection linked to the vaccination strategy. New seroprevalence studies should be performed to answer to open questions, such as the long-term immunity and the change of the herpes zoster epidemiological pattern related to the vaccine.

Vaccination attitudes and mobile readiness: A survey of expectant and new mothers
Open access
Katherine M Atkinsona, Robin Ducharmeab, Jacqueline Westeindea, Sarah E Wilsoncd, Shelley L Deekscd, Dante Pascalie & Kumanan Wilsonabef*
pages 1039-1045
Sub-optimal vaccination coverage and recent outbreaks of vaccine-preventable diseases serve as a reminder that vaccine hesitancy remains a concern. ImmunizeCA, a new smartphone app to help track immunizations, may address several reasons for not vaccinating. We conducted a study to describe demographic variables, attitudes, beliefs and information sources regarding pediatric vaccination in a sample of childbearing women who were willing to download an immunization app. We also sought to measure their current mobile usage behaviors and determine if there is an association between participant demographics, attitudes, beliefs and information sources regarding pediatric vaccination and mobile usage. We recruited participants using a combination of passive and active methods at a tertiary care hospital in Ottawa, Canada. We used surveys to collect demographic information, examine attitudes, behavior, and information sources regarding immunization and self-reported mobile phone usage. A total of 54 women participated. The majority had positive attitudes toward vaccination (96%) and intended to vaccinate their children (98%). Participants were interested in information on pediatric vaccination (94%), and found information from public health the most reliable and accessible (78%). Participants also trusted immunization information from their doctor or nurse and public health (83%) more than other sources. There was variability in participant use of mobile apps for other purposes. The median participant mobile readiness score was 3.2. We found no significant associations between participant age, behavior and attitudes regarding vaccination and mobile readiness scores. This is the first evaluation of mobile readiness for a smartphone app to track immunizations. Our findings suggest that there exists an opportunity to provide reliable information on vaccination through mobile devices to better inform the public, however predictors of individual engagement with these technologies merits further study.

International Health – May 2015

International Health
Volume 7 Issue 3 May 2015

Noma: neglected, forgotten and a human rights issue
M. Leila Sroura,*, Klaas W. Marckb and Denise Baratti-Mayerc
Author Affiliations
aHealth Frontiers, Bhan Tat Khao, Vientiane, Laos
bDutch Noma Foundation, De Pôlle 24, 9084BT Goutum, The Netherlands
cGESNOMA (Geneva Study Group on Noma), Service of Plastic and Reconstructive Surgery, Geneva University Hospitals, Geneva, Switzerland
Noma, an orofacial gangrene and opportunistic infection, affects primarily malnourished children living in extreme poverty. Neglected, forgotten, unknown by most health workers, noma results in death, disfigurement and disability of some of the world’s most vulnerable children. Noma is a biological indicator of multiple human rights violations, including the right to food. International support and national attention in countries with noma are lacking. The end of neglect of noma can lead to the elimination of this horrific childhood disease.

Patients struggle to access effective health care due to ongoing violence, distance, costs and health service performance in Afghanistan
Niamh Nic Carthaigha, Benoit De Gryseb, Abdul Sattar Esmatic, Barak Nizard, Catherine Van Overloope, Renzo Frickee, Jehan Bseisoa, Corinne Bakere, Tom Decroof and Mit Philipsa,*
Author Affiliations
aMédecins Sans Frontières–Operational Centre Brussels, Advocacy and Analysis Unit, Brussels
bMédecins Sans Frontières–Operational Centre Brussels, Afghanistan Mission, Kabul
cMinistry of Health–Afghanistan, Direction Ahmad Shah Baba District Hospital, Kabul, Afghanistan
dMinistry of Health–Afghanistan, Direction Boost Provincial Hospital, Helmand, Afghanistan
eMédecins Sans Frontières–Operational Centre Brussels, Operational Department, Brussels
fMédecins Sans Frontières–Operational Centre Brussels, Operational Research Unit, Brussels
The Afghan population suffers from a long standing armed conflict. We investigated patients’ experiences of their access to and use of the health services.
Data were collected in four clinics from different provinces. Mixed methods were applied. The questions focused on access obstacles during the current health problem and health seeking behaviour during a previous illness episode of a household member.
To access the health facilities 71.8% (545/759) of patients experienced obstacles. The combination of long distances, high costs and the conflict deprived people of life-saving healthcare. The closest public clinics were underused due to perceptions regarding their lack of availability or quality of staff, services or medicines. For one in five people, a lack of access to health care had resulted in death among family members or close friends within the last year.
Violence continues to affect daily life and access to healthcare in Afghanistan. Moreover, healthcare provision is not adequately geared to meet medical and emergency needs. Impartial healthcare tailored to the context will be vital to increase access to basic and life-saving healthcare.

Health worker perceptions of integrating mobile phones into community case management of malaria in Saraya, Senegal
Demetri A. Blanasa,*, Youssoupha Ndiayeb, Matthew MacFarlanec, Isaac Mangab, Ammar Siddiquid, Olivia Veleze, Andrew S. Kanterf, Kim Nicholsg and Nils Hennigd
Author Affiliations
aHarlem Residency in Family Medicine, Institute for Family Health, New York, New York, 10029, USA
bHealth District of Saraya, Senegalese Ministry of Health, Saraya, Senegal
cCenter on Child Protection, Jakarta, Indonesia
dMount Sinai Global Health, Icahn School of Medicine at Mount Sinai, New York, New York, 10029, USA
eICF International, New York, New York, 10028, USA
fEarth Institute, Columbia University, New York, New York, 10027, USA
gAfrican Services Committee, New York, New York, 10027, USA
Although community case management of malaria increases access to life-saving care in isolated settings, it contends with many logistical challenges. Mobile phone health information technology may present an opportunity to address a number of these barriers.
Using the wireless adaptation of the technology acceptance model, this study assessed availability, ease of use, usefulness, and job relevance of mobile phones by health workers in Saraya, Senegal.
This study conducted seven key informant interviews with government health workers, and three focus groups and 76 surveys with lay health workers. Principal findings included that mobile phones are already widely available and used, and that participants valued using phones to address training, stock management, programme reporting, and transportation challenges.
By documenting widespread use of mobile phones and health worker perceptions of their most useful applications, this paper provides a framework for their integration into the community case management of malaria programme in Saraya, Senegal.

Can epidemiology inform global health and development targets?

Journal of Infectious Diseases
Volume 211 Issue 16 May 1, 2015

Can epidemiology inform global health and development targets?
Alan D Lopez
Author Affiliations
Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC, Australia
[Initial text]
In 2015, the global health and development community will collectively assess the progress of nations towards achieving the Millennium Development Goals (MDGs), an ambitious framework for human development based on broad principles of equity, solidarity and poverty reduction. Of the 12 goals established to measure social and economic progress, three (MDG4, MDG5 and MDG6) relate directly to health development; reduction of child mortality, reduction of maternal mortality; and progress against the global epidemics of HIV/AIDS, malaria and tuberculosis, respectively.1 There has been much debate about whether global goals with explicit targets are useful or not in stimulating action by countries and donors to improve health. Whereas broad development goals are likely to receive strong endorsement by countries, the addition of specific targets might well be unwelcome, particularly if they are perceived as being too ambitious. Worse, the global focus on targets for the MDGs has driven a culture of accountability with an almost singular focus on whether a country is likely to achieve the specified targets or not, to the detriment of other important measures of progress. The political imperative that countries have no doubt felt to accelerate progress with health development because of the existence of the MDGs is laudable, and real, but it has not necessarily been the ideal policy environment to do so, for five principal reasons.

First, recent global assessments have suggested that only about one-quarter of all countries, and less than one in five developing countries, will achieve MDGs 4 and 5, obscuring the very substantial progress in reducing child mortality, for example, that has occurred in sub-Saharan Africa, India and much of eastern Europe since 2000.2–4 In many countries, these accelerated declines have been due to the success of bold public policies, and financing, to scale-up and ensure delivery of bed nets …

The Lancet – May 16, 2015

The Lancet
May 16, 2015 Volume 385 Number 9981 p1917-2014 e47-e48

For every woman, every child, everywhere: a universal agenda for the health of women, children, and adolescents
Sarah Zeid, Flavia Bustreo, Maha Taysir Barakat, Peter Maurer, Kate Gilmore
Preventable mortality and morbidity among women, adolescents, and children are severe in humanitarian settings. Data from the Organisation for Economic Co-operation and Development on 50 fragile states show that 60% of preventable maternal deaths, 53% of deaths in children younger than 5 years, and 45% of neonatal deaths take place in fragile settings of conflict, displacement, and natural disasters.1–3 Worldwide, women and children are up to 14 times more likely than men to die in a disaster.4

World Report
Ebola vaccine trial in west Africa faces criticism
Miriam Shuchman
Published Online: 12 May 2015
WHO has come under fire for its running of the Ebola ring vaccine trial in Guinea, with critics highlighting inadequate care of participants and patients. Miriam Shuchman report

A Global Biomedical R&D Fund and Mechanism for Innovations of Public Health Importance

PLoS Medicine
(Accessed 16 May 2015)

A Global Biomedical R&D Fund and Mechanism for Innovations of Public Health Importance
Manica Balasegaram, Christian Bréchot, Jeremy Farrar, David Heymann, Nirmal Ganguly, Martin Khor, Yves Lévy, Precious Matsoso, Ren Minghui, Bernard Pécoul, Liu Peilong, Marcel Tanner, John-Arne Røttingen
Essay | published 11 May 2015 | PLOS Medicine 10.1371/journal.pmed.1001831
Summary Points
:: Anti-microbial resistance, emerging infectious diseases, and neglected diseases are all important public health concerns and priorities with serious market failures, deficits, and identified needs in biomedical innovation.
:: It is important to reconcile, rather than fragment, the needs of these three priority areas by considering an umbrella framework for specifically financing and coordinating research and development (R&D) that delivers innovation while securing patient access.
:: A sizeable, sustainably financed global R&D fund and mechanism that promotes coordination, collaboration, and utilization of new and innovative incentives should be set up to cover all three priority areas.

Prospects for Malaria Elimination in Mesoamerica and Hispaniola

PLoS Neglected Tropical Diseases
(Accessed 16 May 2015)

Prospects for Malaria Elimination in Mesoamerica and Hispaniola
Sócrates Herrera, Sergio Andrés Ochoa-Orozco, Iveth J. González, Lucrecia Peinado, Martha L. Quiñones, Myriam Arévalo-Herrera
Review | published 14 May 2015 | PLOS Neglected Tropical Diseases 10.1371/journal.pntd.0003700
Malaria remains endemic in 21 countries of the American continent with an estimated 427,000 cases per year. Approximately 10% of these occur in the Mesoamerican and Caribbean regions. During the last decade, malaria transmission in Mesoamerica showed a decrease of ~85%; whereas, in the Caribbean region, Hispaniola (comprising the Dominican Republic [DR] and Haiti) presented an overall rise in malaria transmission, primarily due to a steady increase in Haiti, while DR experienced a significant transmission decrease in this period.

The significant malaria reduction observed recently in the region prompted the launch of an initiative for Malaria Elimination in Mesoamerica and Hispaniola (EMMIE) with the active involvement of the National Malaria Control Programs (NMCPs) of nine countries, the Regional Coordination Mechanism (RCM) for Mesoamerica, and the Council of Health Ministries of Central America and Dominican Republic (COMISCA). The EMMIE initiative is supported by the Global Fund for Aids, Tuberculosis and Malaria (GFATM) with active participation of multiple partners including Ministries of Health, bilateral and multilateral agencies, as well as research centers. EMMIE’s main goal is to achieve elimination of malaria transmission in the region by 2020. Here we discuss the prospects, challenges, and research needs associated with this initiative that, if successful, could represent a paradigm for other malaria-affected regions.

“The One Who Chases You Away Does Not Tell You Go”: Silent Refusals and Complex Power Relations in Research Consent Processes in Coastal Kenya

PLoS One
[Accessed 16 May 2015]

Research Article
“The One Who Chases You Away Does Not Tell You Go”: Silent Refusals and Complex Power Relations in Research Consent Processes in Coastal Kenya
Dorcas M. Kamuya, Sally J. Theobald, Vicki Marsh, Michael Parker, Wenzel P. Geissler, Sassy C. Molyneux
Published: May 15, 2015
DOI: 10.1371/journal.pone.0126671
Consent processes have attracted significant research attention over the last decade, including in the global south. Although relevant studies suggest consent is a complex negotiated process involving multiple actors, most guidelines assume consent is a one-off encounter with a clear ‘yes’ or ‘no’ decision. In this paper we explore the concept of ‘silent refusals’, a situation where it is not clear whether potential participants want to join studies or those in studies want to withdraw from research, as they were not actively saying no. We draw on participant observation, in-depth interviews and group discussions conducted with a range of stakeholders in two large community based studies conducted by the KEMRI Wellcome Trust programme in coastal Kenya. We identified three broad inter-related rationales for silent refusals: 1) a strategy to avoid conflicts and safeguard relations within households, – for young women in particular—to appear to conform to the wishes of elders; 2) an approach to maintain friendly, appreciative and reciprocal relationships with fieldworkers, and the broader research programme; and 3) an effort to retain study benefits, either for individuals, whole households or wider communities. That refusals and underlying rationales were silent posed multiple dilemmas for fieldworkers, who are increasingly recognised to play a key interface role between researchers and communities in many settings. Silent refusals reflect and reinforce complex power relations embedded in decisions about research participation, with important implications for consent processes and broader research ethics practice. Fieldworkers need support to reflect upon and respond to the ethically charged environment they work in.

Science – 15 May 2015

15 May 2015 vol 348, issue 6236, pages 729-832
In Depth
Infectious Diseases
Ebola survivors fight back in plasma studies
Martin Enserink*
In the Guinean capital, Conakry, 90 people have so far been treated in a clinical trial that aims to seek whether plasma from Ebola survivors can help patients. Animal studies of similar therapies had yielded mixed results, and the findings of a small human study in 1995 were ambiguous. The study aims to recruit 130 patients, but enrollment has ground to a halt because the last Ebola patient in Conakry was discharged on 28 April. Results are expected later this year, but researchers acknowledge that they will be difficult to interpret because the study has no control arm.

Policy Forum
Public Health
Linking funds to actions for global health emergencies
C. J. Standley, E. M. Sorrell, S. Kornblet, A. Vaught, J. E. Fischer, R. Katz*
Author Affiliations
Department of Health Policy and Management, Milken Institute School of Public Health, George Washington University, Washington, DC 20052, USA.
The failings of the international community’s response to the Ebola virus disease outbreak in West Africa underscore the need for new mechanisms for governance and mobilization of resources for timely, coordinated responses to public health threats (1). Creating a global finance mechanism, ideally tied to existing global health frameworks, is a first step. The World Bank recently announced it would create a Pandemic Emergency Facility (PEF). The next necessary element is a trigger to release those funds to support rapid and effective responses during early phases of a public health event. With the World Health Assembly convening soon, we suggest how the World Health Organization’s (WHO’s) International Health Regulations (IHR) present such an initiator.

Cancer Immunotherapy
Neo approaches to cancer vaccines
Lélia Delamarre, Ira Mellman, Mahesh Yadav
Author Affiliations
Genentech, South San Francisco, CA 94080, USA.
The recent success of cancer immunotherapies is rapidly changing the face of both cancer care and cancer biology. The excitement has been driven by various antibodies that block so-called “immune checkpoints” to enhance antitumor immune responses (1). Although this approach has produced durable responses for patients across a variety of tumor types, it is also the case that only a minority of patients benefit from these agents. It seems likely that among patients who do not respond or respond poorly to immunotherapies, there will be individuals who lack preexisting antitumor T cell responses. In principle, this situation can be addressed with antitumor vaccines, a strategy that has yet to yield much success despite decades of effort. The recent finding that tumor-specific mutations (neoantigens) may drive potent antitumor responses has provided hope and prompted renewed interest in the field (2). On page 803 of this issue, Carreno et al. (3) report, in a first proof of concept study, that CD8 T cell responses to tumor neoantigens can be enhanced through vaccination in melanoma patients.

Immunogenicity of poliovirus vaccines in chronically malnourished infants: A randomized controlled trial in Pakistan

Volume 33, Issue 24, Pages 2735-2850 (4 June 2015)
Immunogenicity of poliovirus vaccines in chronically malnourished infants: A randomized controlled trial in Pakistan
Original Research Article
Pages 2757-2763
Ali Faisal Saleem, Ondrej Mach, Farheen Quadri, Asia Khan, Zaid Bhatti, Najeeb ur Rehman, Sohail Zaidi, William C. Weldon, Steven M. Oberste, Maha Salama, Roland W. Sutter, Anita K.M. Zaidi
Reaching high population immunity against polioviruses (PV) is essential to achieving global polio eradication. Efficacy of oral poliovirus vaccine (OPV) varies and is lower among children living in tropical areas with impoverished environments. Malnutrition found as a risk factor for lower serological protection against PV. We compared whether inactivated polio vaccine (IPV) can be used to rapidly close the immunity gap among chronically malnourished (stunted) infants in Pakistan who will not be eligible for the 14 week IPV dose in routine EPI schedule. A phase 3, multicenter 4-arm randomized controlled trial conducted at five Primary Health Care (PHC) centers in Karachi, Pakistan. Infants, 9–12 months were stratified by length for age Z score into chronically malnourished and normally nourished. Infants were randomized to receive one dose of either bivalent OPV (bOPV) alone or bOPV + IPV. Baseline seroprevalence of PV antibodies and serum immune response to study vaccine dose were assessed by neutralization assay. Vaccine PV shedding in stool was evaluated 7 days after a bOPV challenge dose. Sera and stool were analyzed from 852/928 (92%) enrolled children. At baseline, the seroprevalence was 85.6% (n = 386), 73.6% (n = 332), and 70.7% (n = 319) in malnourished children against PV types 1, 2 and 3 respectively; and 94.1% (n = 448), 87.0% (n = 441) and 83.6% (n = 397) in the normally nourished group (p < 0.05). Children had previously received 9–10 doses of bOPV (80%) or tOPV (20%). One dose of IPV + bOPV given to malnourished children increased their serological protection (PV1, n = 201, 97.6%; PV2, n = 198, 96.1% and PV3, n = 189, 91.7%) to parity with normally nourished children who had not received IPV (p = <0.001). Seroconversion and boosting for all three serotypes was significantly more frequent in children who received IPV + bOPV than in those with bOPV only (p < 0.001) in both strata. Shedding of polioviruses in stool did not differ between study groups and ranged from 2.4% (n = 5) to 7.1% (n = 15). In malnourished children the shedding was reduced after bOPV + IPV compared to bOPV only.
Chronically malnourished infants were more likely to be unprotected against polioviruses than normal infants. bOPV + IPV helped close the immunity gap better than bOPV alone.

An extended cost-effectiveness analysis of publicly financed HPV vaccination to prevent cervical cancer in China

Volume 33, Issue 24, Pages 2735-2850 (4 June 2015)
An extended cost-effectiveness analysis of publicly financed HPV vaccination to prevent cervical cancer in China
Original Research Article
Pages 2830-2841
Carol E. Levin, Monisha Sharma, Zachary Olson, Stéphane Verguet, Ju-Fang Shi, Shao-Ming Wang, You-Lin Qiao, Dean T. Jamison, Jane J. Kim
Cervical cancer screening and existing health insurance schemes in China fall short of reaching women with prevention and treatment services, especially in rural areas where the disease burden is greatest. We conducted an extended cost-effectiveness analysis (ECEA) to evaluate public financing of HPV vaccination to prevent cervical cancer, adding new dimensions to conventional cost-effectiveness analysis through an explicit inclusion of equity and impact on financial risk protection.
We synthesized available epidemiological, clinical, and economic data from China using an individual-based Monte Carlo simulation model of cervical cancer to estimate the distribution of deaths averted by income quintile, comparing vaccination plus screening against current practice. We also estimated reductions in cervical cancer incidence, net costs to the government (HPV vaccination costs minus cervical cancer treatment costs averted), and patient cost savings, as well as the incremental government health care costs per death averted.
HPV vaccination is cost-effective across all income groups when the cost is less than US $50 per vaccinated girl. Compared to screening alone, adding preadolescent HPV vaccination followed by cervical cancer screening in adulthood could reduce cancer by 44 percent across all income groups, while providing relatively higher financial protection to the poorest women. The absolute numbers of cervical cancer deaths averted and the financial risk protection from HPV vaccination are highest among women in the lowest quintile; women in the bottom income quintiles received higher benefits than those in the upper wealth quintiles. Patient cost savings represent a large proportion of poor women’s average per capita income, reaching 60 percent among women in the bottom income quintile and declining to 15 percent among women in the wealthiest quintile

Effect of multiple, simultaneous vaccines on polio seroresponse and associated health outcomes

Volume 33, Issue 24, Pages 2735-2850 (4 June 2015)
Effect of multiple, simultaneous vaccines on polio seroresponse and associated health outcomes
Original Research Article
Pages 2842-2848
Michael P. Broderick, M. Steven Oberste, Deborah Moore, Sandra Romero-Steiner, Christian J. Hansen, Dennis J. Faix
Administration of multiple simultaneous vaccines to infants, children, and military recruits is not uncommon. However, little research exists to examine associated serological and health effects, especially in adults.
We retrospectively examined 416 paired serum specimens from U.S. military subjects who had received the inactivated polio vaccine (IPV) alone or in combination with either 1 other vaccine (4 group). Each of the 2 groups was subdivided into 2 subgroups in which Tdap was present or absent.
The >4 group was associated with a higher proportion of polio seroconversions than the 4 subgroup that excluded Tdap showed no difference between them (p > 0.1). However, the >4 subgroup that included Tdap had significantly more seroconversions than either the 4 subgroup that excluded Tdap (p < 0.01). Overall, at least 98% of subjects were at or above the putative level of seroprotection both pre- and post-vaccination, yet at least 81% of subjects seroconverted. In an analysis of 400 of the subjects in which clinic in- and outpatient encounters were counted over the course of 1 year following vaccinations, there was no significant difference between the 2 groups (p > 0.1).
A combination of >4 vaccines including IPV appeared to have an immunopotentiation effect on polio seroconversion, and Tdap in particular was a strong candidate for an important role. The dose of IPV we studied in our subjects, who already had a high level of seroprotection, acted as a booster. In addition, there appear to be no negative health consequences from receiving few versus more multiple simultaneous vaccinations.

Vaccine – 7 May 2015 :: Supplement – Expanding the Evidence Base to Inform Vaccine Introduction: Program Costing and Cost-effectiveness Analyses

Volume 33, Supplement 1, Pages A1-A254 (7 May 2015)

Supplement – Expanding the Evidence Base to Inform Vaccine Introduction: Program Costing and Cost-effectiveness Analyses
pp. A1-A254 (7 May 2015)
Perspectives on expanding the evidence base to inform vaccine introduction: Program costing and cost-effectiveness analyses
Jon Kim Andrusa, Damian G. Walkerb,

Over the past decade, the Pan American Health Organization’s (PAHO) ProVac Initiative has worked with countries to promote the development and use of evidence for immunization policymaking [1]. This supplement features examples of ProVac’s country-led research and other partner efforts in this area with an emphasis on analyses of cost-effectiveness, program costs and financial flows. The findings from these studies represent one important outcome of a broader objective to strengthen and institutionalize national capacity to generate, assess, interpret and use local data in the decision making process. Achieving this broader objective has always been a guiding principle of ProVac’s work [2].

Due to the success of ProVac, PAHO has received numerous requests for similar support from countries outside of the Americas Region. Therefore, in 2011, the ProVac International Working Group was formed with the aim of transferring the ProVac Initiative’s methods and tools to other WHO regions [3]. The International Working Group includes the Agence de Médicine Préventive (AMP), the United States’ Centers for Disease Control and Prevention (CDC), the Program for Appropriate Technologies in Health (PATH), PAHO, the Sabin Vaccine Institute, and World Health Organization headquarters and its regional offices for Africa (AFRO), Eastern Mediterranean (EMRO) and Europe (EURO). A total of 17 countries in these three regions received training from the International Working Group over a two year period resulting in nine cost-effectiveness studies [3].

The impact of ProVac’s mission to increase national capacity to make evidence-based immunization policy is difficult to quantify. However, cost-effectiveness analyses in this supplement demonstrate the quality of evidence a national team can produce for their own decision making use when given access to flexible tools and training. Nine studies were supported through the ProVac IWG platform and results from Albania, Croatia, Egypt, Georgia, Iran, Kenya, Senegal and Uganda are featured in this supplement [4], [5], [6], [7], [8], [9] and [10]. Another six studies featured in this supplement were from countries in the PAHO Region, including Argentina, Belize, Brazil, Honduras, Paraguay and Peru [11], [12], [13], [14], [15] and [16]. They were all led by national health professionals and stakeholders.

These analyses provide an important update to the cost-effectiveness literature on new vaccines from a diverse set of country contexts. With the exception of one cost-effectiveness analysis developed in a high-income country setting (Croatia) with no access to affordable vaccine prices, the findings from the cost-effectiveness research support the previously published evidence that pneumococcal conjugate, rotavirus and HPV vaccines represent good value for money, where disease burden is substantial and/or treatment costs are relatively high and the vaccines can be procured at an affordable price. All primary results from these analyses were subjected to sensitivity analyses to examine the robustness of the findings to changes in the values of key inputs and assumptions. For example, these analyses often considered vaccine price trends over time and other technical or programmatic uncertainties (i.e. booster doses, herd immunity and delivery strategies). Since many countries that received support from the ProVac IWG will graduate from Gavi subsidies in the coming years, these additional analyses were useful to explore the impact of price changes in the cost-effectiveness results. While the results are subject to uncertainty, the conclusions were stable.

The supplement also highlights a recent multi-country study on the costs and financing of routine immunization and new vaccines (EPIC) [17]. The EPIC study included six countries: Benin, Ghana, Honduras, Moldova, Uganda and Zambia. This work represents the first systematic evaluation of costs in countries with a baseline of routine immunization, while also estimating the incremental cost of new vaccines (pneumococcal and rotavirus) to the routine system [18].
The EPIC studies are unique in both the breadth and depth of the data collected from over 300 primary health care facilities across the six countries. An important outcome of this work was the development and use of a Common Approach to costing [17], as well as the creation of a community of practice around cost and financial analysis of immunization. The costing studies allow us to not only describe the range of total and unit costs of routine immunization (RI) [18], [19], [20] and [21], but also to evaluate more systematically the determinants of costs and productivity [22] and [23]. Finally, each country team undertook a financial mapping of the total resources available for routine immunization by source [24] and [25]. This work will be used to improve budgeting and planning of national immunization programs. The evidence will also be used to inform advocacy aimed at greater domestic resource mobilization.

Finally, leading researchers, decision makers and donors comment on the development and use of the data featured in this supplement from their perspective. The four commentaries highlight the following themes (1) the potential role of cost-effectiveness analysis in price negotiation; (2) the continued need for models and methodological approaches that can be adapted for use in low resource policy settings; and (3) the juxtaposition of supporting country-level decision making in the context of donor priority setting [26], [27], [28] and [29]. From Thailand’s Health Intervention and Technology Assessment Program’s (HITAP) perspective, cost-effectiveness data is critical in price negotiation for countries, like Thailand, that do not have access to donor subsidies or innovative financing mechanisms [26]. We see how the HITAP approach could easily be adapted in a context like Croatia, where PCV was found to be not cost-effective at the current assumed price of US$30-35 [8]. Decision support systems as a fundamental underpinning to making better choices with public monies are described from a decision scientist’s perspective in ‘The ProVac Initiative and evolving decision’support’ [27]. As we’ve seen with the implementation of ProVac, these systems require a long-term investment and commitment to building institutions that require and support an evidence-based approach.

We have only just begun with immunization programs but the lessons from the ProVac Initiative may serve to guide future work in promoting health technology assessment across the health sector. Lastly, Gavi and the immunization program manager from Honduras, a Gavi-graduating country, share perspectives on the increasing importance of priority-setting at country level for effective immunization policy and the support that Gavi-eligible countries may need today in order to enter into the near-term graduation from Gavi support [28] and [29]. All commentaries combined offer an insight into developing a forward thinking approach to the use of evidence for immunization decision making.

We hope the reader finds that this collection of articles provides useful insight into the work required to help countries strengthen their capacity to make evidence-based policy decisions. Accelerating national policy development on new vaccines adoption, together with rapid deployment of vaccines when appropriate, will contribute to saving more lives more quickly.

The studies published herein include but are not limited to work conducted by the Pan American Health Organization’s ProVac Initiative, the ProVac International Working Group and the EPIC study with financial support from the Bill and Melinda Gates Foundation (grant no. OPP50788). The views expressed in each article are those of the authors alone and do not necessarily reflect the official policy or position of the Bill and Melinda Gates Foundation or the Pan American Health Organization.

Impact of an Electronic Health Record (EHR) Reminder on Human Papillomavirus (HPV) Vaccine Initiation and Timely Completion

Journal of the American Board of Family Medicine ( JABFM )
May-June 2015; 28 (3)

Impact of an Electronic Health Record (EHR) Reminder on Human Papillomavirus (HPV) Vaccine Initiation and Timely Completion
Mack T. Ruffin IV, MD, MPH, Melissa A. Plegue, MA, Pamela G. Rockwell, DO, Alisa P. Young, MD, Divya A. Patel, PhD and Mark W. Yeazel, MD, MPH
Background: The initiation and timely completion of the human papillomavirus (HPV) vaccine in young women is critical. We compared the initiation and completion of the HPV vaccine among women in 2 community-based networks with electronic health records: 1 with a prompt and reminder system (prompted cohort) and 1 without (unprompted cohort).
Methods: Female patients aged 9 to 26 years seen between March 1, 2007, and January 25, 2010, were used as the retrospective cohort. Patient demographics and vaccination dates were extracted from the electronic health records.
Results: Patients eligible for the vaccine included 6019 from the prompted cohort and 9096 from the unprompted cohort. Mean age at initiation was 17.3 years in the prompted cohort and 18.1 years in the unprompted cohort. Significantly more (P < .001) patients initiated the vaccine in the prompted cohort (34.9%) compared with the unprompted cohort (21.5%). African Americans aged 9 to 18 years with ≥3 visits during the observation period were significantly more likely to initiate in the prompted cohort (P < .001). The prompted cohort was significantly more likely (P < .001) to complete the vaccine series in a timely manner compared with the unprompted cohort.
Conclusion: More patients aged 9 to 26 years initiated and achieved timely completion of the HPV vaccine series in clinics using an electronic health record system with prompts compared with clinics without prompts.

Philosophical Transactions of the Royal Society B: Biological Sciences: 19 June 2015 – Biological challenges to effective vaccines in the developing world

Philosophical Transactions of the Royal Society B: Biological Sciences:
19 June 2015; volume 370, issue 1671
Discussion meeting issue ‘Biological challenges to effective vaccines in the developing world’ organized and edited by Nicholas Grassly, Gagandeep Kang and Beate Kampmann

Biological challenges to effective vaccines in the developing world
Nicholas C. Grassly, Gagandeep Kang, Beate Kampmann
Phil. Trans. R. Soc. B 2015 370 20140138; DOI: 10.1098/rstb.2014.0138. Published 11 May 2015

Review article:
Searching for the human genetic factors standing in the way of universally effective vaccines
Alexander J. Mentzer, Daniel O’Connor, Andrew J. Pollard, Adrian V. S. Hill
Phil. Trans. R. Soc. B 2015 370 20140341; DOI: 10.1098/rstb.2014.0341. Published 11 May 2015

Research article:
Genomics of immune response to typhoid and cholera vaccines
Partha P. Majumder
Phil. Trans. R. Soc. B 2015 370 20140142; DOI: 10.1098/rstb.2014.0142. Published 11 May 2015

Research article:
The impact of maternal infection with Mycobacterium tuberculosis on the infant response to bacille Calmette–Guérin immunization
Patrice A. Mawa, Gyaviira Nkurunungi, Moses Egesa, Emily L. Webb, Steven G. Smith, Robert Kizindo, Mirriam Akello, Swaib A. Lule, Moses Muwanga, Hazel M. Dockrell, Stephen Cose, Alison M. Elliott
Phil. Trans. R. Soc. B 2015 370 20140137; DOI: 10.1098/rstb.2014.0137. Published 11 May 2015

Review article:
Malnutrition and vaccination in developing countries
Andrew J. Prendergast
Phil. Trans. R. Soc. B 2015 370 20140141; DOI: 10.1098/rstb.2014.0141. Published 11 May 2015

Review article:
Is infant immunization by breastfeeding possible?
Valerie Verhasselt
Phil. Trans. R. Soc. B 2015 370 20140139; DOI: 10.1098/rstb.2014.0139. Published 11 May 2015

Review article:
Exploring the role of environmental enteropathy in malnutrition, infant development and oral vaccine response
Allissia A. Gilmartin, William A. Petri
Phil. Trans. R. Soc. B 2015 370 20140143; DOI: 10.1098/rstb.2014.0143. Published 11 May 2015

Review article:
Potential for use of retinoic acid as an oral vaccine adjuvant
Mpala Mwanza-Lisulo, Paul Kelly
Phil. Trans. R. Soc. B 2015 370 20140145; DOI: 10.1098/rstb.2014.0145. Published 11 May 2015

Review article:
Probiotics, antibiotics and the immune responses to vaccines
Ira Praharaj, Sushil M. John, Rini Bandyopadhyay, Gagandeep Kang
Phil. Trans. R. Soc. B 2015 370 20140144; DOI: 10.1098/rstb.2014.0144. Published 11 May 2015

Review article:
Vaccinology in the era of high-throughput biology
Helder I. Nakaya, Bali Pulendran
Phil. Trans. R. Soc. B 2015 370 20140146; DOI: 10.1098/rstb.2014.0146. Published 11 May 2015

Opinion piece:
Systems vaccinology: a promise for the young and the poor
Nelly Amenyogbe, Ofer Levy, Tobias R. Kollmann
Phil. Trans. R. Soc. B 2015 370 20140340; DOI: 10.1098/rstb.2014.0340. Published 11 May 2015

Review article:
Factors influencing innate immunity and vaccine responses in infancy
Beate Kampmann, Christine E Jones
Phil. Trans. R. Soc. B 2015 370 20140148; DOI: 10.1098/rstb.2014.0148. Published 11 May 2015

Opinion piece:
Can immunological principles and cross-disciplinary science illuminate the path to vaccines for HIV and other global health challenges?
Christopher B. Wilson, Christopher L. Karp
Phil. Trans. R. Soc. B 2015 370 20140152; DOI: 10.1098/rstb.2014.0152. Published 11 May 2015

Review article:
Vaccines against enteric infections for the developing world
Cecil Czerkinsky, Jan Holmgren
Phil. Trans. R. Soc. B 2015 370 20150142; DOI: 10.1098/rstb.2015.0142. Published 11 May 2015

Review article:
Delivering vaccines to the people who need them most
Michèle Anne Barocchi, Rino Rappuoli
Phil. Trans. R. Soc. B 2015 370 20140150; DOI: 10.1098/rstb.2014.0150. Published 11 May 2015

Reproductive Health – Volume 12 Supplement 1 [2015] – True costs of maternal death

Reproductive Health
Volume 12 Supplement 1 [2015]
Special Supplement – True costs of maternal death
Edited by Jose Belizan and Suellen Miller
An accompanying blog can be found here.
Publication charges for this supplement were funded by Family Care International and the FXB Center for Health and Human Rights. The articles have been through the journal’s standard peer review process for supplements. The Supplement Editors declare that they have no competing interests.

Intergenerational impacts of maternal mortality: Qualitative findings from rural Malawi
Junior Bazile, Jonas Rigodon, Leslie Berman, Vanessa M Boulanger, Emily Maistrellis, Pilira Kausiwa, Alicia Yamin Reproductive Health 2015, 12(Suppl 1):S1 (6 May 2015)

Continuing with “…a heavy heart” – consequences of maternal death in rural Kenya
Rohini Pande, Sheila Ogwang, Robinson Karuga, Radha Rajan, Aslihan Kes, Frank O Odhiambo, Kayla Laserson, Kathleen Schaffer Reproductive Health 2015, 12(Suppl 1):S2 (6 May 2015)

The economic burden of maternal mortality on households: evidence from three sub-counties in rural western Kenya
Aslihan Kes, Sheila Ogwang, Rohini Pande, Zayid Douglas, Robinson Karuga, Frank O Odhiambo, Kayla Laserson, Kathleen Schaffer Reproductive Health 2015, 12(Suppl 1):S3 (6 May 2015)

Consequences of maternal mortality on infant and child survival: a 25-year longitudinal analysis in Butajira Ethiopia (1987-2011)
Corrina Moucheraud, Alemayehu Worku, Mitike Molla, Jocelyn E Finlay, Jennifer Leaning, Alicia Yamin Reproductive Health 2015, 12(Suppl 1):S4 (6 May 2015)

“Without a mother”: caregivers and community members’ views about the impacts of maternal mortality on families in KwaZulu-Natal, South Africa
Lucia Knight, Alicia Yamin Reproductive Health 2015, 12(Suppl 1):S5 (6 May 2015)

Impacts of maternal mortality on living children and families: A qualitative study from Butajira, Ethiopia
Mitike Molla, Israel Mitiku, Alemayehu Worku, Alicia Yamin Reproductive Health 2015, 12(Suppl 1):S6 (6 May 2015)

The impacts of maternal mortality and cause of death on children’s risk of dying in rural South Africa: evidence from a population based surveillance study (1992-2013)
Brian Houle, Samuel J Clark, Kathleen Kahn, Stephen Tollman, Alicia Yamin Reproductive Health 2015, 12

Media/Policy Watch [to 16 May 2015]

Media/Policy Watch
This section is intended to alert readers to substantive news, analysis and opinion from the general media on vaccines, immunization, global; public health and related themes. Media Watch is not intended to be exhaustive, but indicative of themes and issues CVEP is actively tracking. This section will grow from an initial base of newspapers, magazines and blog sources, and is segregated from Journal Watch above which scans the peer-reviewed journal ecology.

We acknowledge the Western/Northern bias in this initial selection of titles and invite suggestions for expanded coverage. We are conservative in our outlook in adding news sources which largely report on primary content we are already covering above. Many electronic media sources have tiered, fee-based subscription models for access. We will provide full-text where content is published without restriction, but most publications require registration and some subscription level.

The Guardian
Accessed 16 May 2015
Pay big pharma to solve antibiotics crisis, says UK government review
Jim O’Neill, economist appointed by David Cameron, says a global fund would incentivise drug firms to save millions of lives
14 May 2015
Pharmaceutical companies should be given cash incentives of up to $3bn to find and develop new antibiotics desperately needed to keep infections at bay, according to a UK government review. Jim O’Neill, the economist and former chair of Goldman Sachs Asset Management, asked to find solutions to the global antibiotic crisis, said at the launch of his report that a fund worth between $16bn and $37bn per decade would be enough to incentivise drug companies to turn their attentions to antibiotics.

The Antimicrobial Review (AMR) Committee proposals, he said, could “supercharge antibiotics discovery, potentially saving millions of lives for a fraction of the $100tn cost of inaction”. He estimated that globally, 10 million people could die every year from untreatable infections unless new antibiotics are discovered…

New Yorker
Accessed 16 May 2015
The Brighter Side of Rabies – The New Yorker
May 6, 2015 … Callaway and his team began with a vaccine form of the rabies virus that was missing the hook-making gene, rendering it unable to jump …


New York Times
Accessed 16 May 2015
Mexico Says Bacteria Contaminated Vaccine Blamed in 2 Deaths
Mexico’s public health system says a localized bacterial contamination appears to have been responsible for infant vaccine causing the deaths of two babies and the sickening of 31. The Mexican Institute for Social Security
May 13, 2015 –


Wall Street Journal,us&_homepage=/home/us
Accessed 16 May 2015
California Senate Approves School Vaccine Bill
Bill would prohibit parents from seeking exemptions because of religious or personal beliefs
Associated Press
May 14, 2015 2:53 p.m. ET
SACRAMENTO, Calif.—The state Senate has passed a bill aimed at increasing California’s school immunization rates…

Vaccines and Global Health: The Week in Review 9 May 2015

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

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

pdf version A pdf of the current issue is available here:  Vaccines and Global Health_The Week in Review_9 May 2015

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

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

David R. Curry, MS
Executive Director
Center for Vaccine Ethics and Policy
a program of the
– Division of Medical Ethics, NYU Medical School
– Children’s Hospital of Philadelphia Vaccine Education Center
Associate Faculty, Division of Medical Ethics, NYU Medical School

Nepal [to 9 May 2015]

Nepal [to 9 May 2015]

WHO committed to helping Nepal deliver health care to its citizens
7 May 2015 — More must be done to protect the health of Nepal’s people following the recent earthquake said Dr Poonam Khetrapal Singh, WHO Regional Director for South-East Asia, on a visit to Kathmandu today. High on her agenda are preparations to prevent disease outbreaks ahead of the oncoming rainy season, WHO’s commitment to support the country’s health system, and assistance for its heroic health workers as they recover from the disaster once the emergency phase has passed.
:: Nepali and international medical teams join forces to fill health care gaps in quake-ravaged Sindhupalchok
6 May 2015
:: Mobile health clinics help tackle post-earthquake mental health problems in Nepal
5 May 2015


Nepal earthquake: Emergency immunisation campaign for hundreds of thousands of children – UNICEF
KATHMANDU, Nepal, 4 May 2015 – More than half a million children are being targeted in an emergency vaccination drive in Nepal – as fears grow of measles outbreaks in the informal camps that have sprung up since the earthquake on 25 April.

The campaign was launched by the Nepalese Ministry of Health and Population, with support from UNICEF and the World Health Organisation.
Lack of shelter and sanitation are huge risk factors for disease – as the number of people who have fled their homes continues to grow, with many people now living next to their damaged houses.

According to figures available before the earthquake struck, around one in 10 children in Nepal is not vaccinated against measles.

“Measles is very contagious, and can potentially be deadly, and we fear it could spread very quickly in the often crowded conditions in the improvised camps where many children are living,” says UNICEF’s Representative in Nepal, Tomoo Hozumi.

“We have been working for decades to eliminate measles in Nepal. Unless we act now, there is a real risk of it re-emerging as a major threat for children – a setback for all of our collective efforts.”

In the first wave of the emergency response, teams are working to immunise children under the age of five in informal settlements in the three densely populated districts in Kathmandu Valley – Bhaktapur, Kathmandu and Lalitpur. The drive will continue in the coming weeks in the 12 districts worst-hit by the earthquake.

We are working with partners to take urgent practical steps to mobilise tens of thousands of vaccines, as well as the cold chain facilities needed to store them at the right temperature and keep them effective,” says Tomoo Hozumi…


Cholera vaccine stocks could save millions of refugees in Nepal
New Scientist
05 May 2015 by Debora MacKenzie
First the quake, now the disease. The earthquake in Nepal on 25 April drove 2.8 million people into tents with little clean water or sanitation. Infections like hepatitis and diarrhoea are now appearing, but the biggest fear is cholera. It hasn’t appeared yet, but it hits Nepal every rainy season. Those rains are due in June.

Yet, help is on the way. Nepal has an emergency vaccine to try to head off cholera, a first in such a natural disaster. This is because of a vaccine stockpile set up in response to the cholera that struck Haiti after an earthquake in 2010 – cholera carried there, ironically, by Nepalese peacekeepers.

It will be no panacea; cholera experts stress that supplying clean water and toilets, and isolating and treating any cases, are still essential. But Nepal also now has 18,000 doses of Shanchol, an oral vaccine made of dead cholera bacteria by Shantha Biotechnics of Hyderabad, India.

Full immunity requires two doses of vaccine, two weeks apart, so that is only enough for 9000 people – and it will be difficult to ensure people in camps get both doses. In a final hurdle, the vaccine must be refrigerated.

Vaccine stockpile
The WHO, other agencies and the Nepalese government will now assess where people are least likely to get clean water in coming weeks and where it will be possible to vaccinate people successfully, says Dominique Legros of the World Health Organization. Then more vaccine can be flown in from the WHO stockpile.

“We must not wait for outbreaks to start,” says Legros; it takes another week after the two doses for immunity to develop. Legros helped organise the first emergency use of the vaccine last year, in four camps of people displaced by fighting in South Sudan. “It really worked well.”

Researchers had discussed a vaccine stockpile before the Haitian epidemic. But in a cholera outbreak, many catch and spread the bacteria without getting sick, making it hard to tell who will still benefit from vaccine.

The WHO first recommended using vaccine during epidemics in 2010, after Haiti exploded. But when exactly to use vaccine in a pre-emptive strike was not clear, says Louise Ivers of Partners in Health, a health non-profit in Boston.

Long-lasting immunity?
And there was not much to use. The only oral vaccine approved by the WHO in 2010 was expensive and bulky. It approved Shanchol, which was cheaper and easier to use, in 2011, but there wasn’t much of either. Neither cause long-lasting immunity, so children in countries with cholera aren’t routinely vaccinated, meaning the market was small and not much was made.

In 2011, with the Haitian epidemic still raging, cholera researchers called for a vaccine stockpile partly to give manufacturers a bigger market. In 2012, to settle doubts about whether vaccination campaigns are possible during an epidemic, Ivers and colleagues vaccinated a rural community in Haiti. This year they reported that those people were subsequently 65 per cent less likely to get cholera.

In 2013, the WHO started the stockpile. “The Haiti epidemic was so huge it shook up the world of cholera experts,” says Ivers. “It was a big impetus to move forward with a vaccine stockpile.” “The epidemic in Haiti clearly had an impact,” says David Sack of Johns Hopkins University in Baltimore.

It now holds 2 million doses, and Gavi, the Geneva-based organisation that helps poor countries buy vaccines, plans to increase that to 20 million a year by 2018.
A cholera outbreak is a high probability in Nepal now, says Anuj Bhattachan of the International Vaccine Institute in Seoul, who is in Nepal. “The key mantra for us is not another Haiti situation,” with cholera spreading virtually unchecked, he says.

“If we mobilise cholera vaccination soon, along with sanitation, there will be immense immune protection.” The decision, he says, is now up to the Nepalese government.

EBOLA/EVD [to 9 May 2015]

EBOLA/EVD [to 9 May 2015]
Public Health Emergency of International Concern (PHEIC); “Threat to international peace and security” (UN Security Council)

WHO: Ebola Situation Report – 6 May 2015
:: A total of 18 confirmed cases of Ebola virus disease (EVD) was reported in the week to 3 May: Guinea and Sierra Leone each reported 9 cases. This is the lowest weekly total this year, and comes after a month-long period during which case incidence fluctuated between 30 and 37 confirmed cases per week. That both countries have each reported fewer than 10 cases is encouraging, but it is important to guard against complacency. Liberia has reported fewer than 10 cases per week since the start of January this year, but the outbreak will be declared to have ended only if no new cases are reported up to 9 May, which marks 42 complete days since the burial of the last confirmed case…

:: There have been a total of 26,593 reported confirmed, probable, and suspected cases of EVD in Guinea, Liberia and Sierra Leone (figure 1, table 1), with 11,005 reported deaths (outcomes for many cases are unknown). A total of 9 new confirmed cases were reported in Guinea, 0 in Liberia, and 9 in Sierra Leone in the 7 days to 3 May.

The Ebola outbreak in Liberia is over
WHO statement
9 May 2015
Today, 9 May 2015, WHO declares Liberia free of Ebola virus transmission. Forty-two days have passed since the last laboratory-confirmed case was buried on 28 March 2015. The outbreak of Ebola virus disease in Liberia is over.

Interruption of transmission is a monumental achievement for a country that reported the highest number of deaths in the largest, longest, and most complex outbreak since Ebola first emerged in 1976. At the peak of transmission, which occurred during August and September 2014, the country was reporting from 300 to 400 new cases every week.

During those 2 months, the capital city Monrovia was the setting for some of the most tragic scenes from West Africa’s outbreak: gates locked at overflowing treatment centres, patients dying on the hospital grounds, and bodies that were sometimes not collected for days.

Flights were cancelled. Fuel and food ran low. Schools, businesses, borders, markets, and most health facilities were closed. Fear and uncertainty about the future, for families, communities, and the country and its economy, dominated the national mood.

Though the capital city was hardest hit, every one of Liberia’s 15 counties eventually reported cases. At one point, virtually no treatment beds for Ebola patients were available anywhere in the country. With infectious cases and corpses remaining in homes and communities, almost guaranteeing further infections, some expressed concern that the virus might become endemic in Liberia, adding another – and especially severe – permanent threat to health.

It is a tribute to the government and people of Liberia that determination to defeat Ebola never wavered, courage never faltered. Doctors and nurses continued to treat patients, even when supplies of personal protective equipment and training in its safe use were inadequate. Altogether, 375 health workers were infected and 189 lost their lives.

Local volunteers, who worked in treatment centres, on burial teams, or as ambulance drivers, were driven by a sense of community responsibility and patriotic duty to end Ebola and bring hope back to the country’s people. As the number of cases grew exponentially, international assistance began to pour in. All these efforts helped push the number of cases down to zero.
Liberia’s last case was a woman in the greater Monrovia area who developed symptoms on 20 March and died on 27 March. The source of her infection remains under investigation. The 332 people who may have been exposed to the patient were identified and closely monitored. No one developed symptoms; all have been released from surveillance.

Health officials have maintained a high level of vigilance for new cases. During April, the country’s 5 dedicated Ebola laboratories tested around 300 samples every week. All test results were negative.

While WHO is confident that Liberia has interrupted transmission, outbreaks persist in neighbouring Guinea and Sierra Leone, creating a high risk that infected people may cross into Liberia over the region’s exceptionally porous borders.

The government is fully aware of the need to remain on high alert and has the experience, capacity, and support from international partners to do so. WHO will maintain an enhanced staff presence in Liberia until the end of the year as the response transitions from outbreak control, to vigilance for imported cases, to the recovery of essential health services.

Evolution of the outbreak
The start of the outbreak was deceptively slow. Health officials were on high alert for cases following WHO’s confirmation, on 23 March 2014, of the Ebola outbreak in Guinea. Liberia’s first 2 cases, in the northern county of Lofa near the border with Guinea, were confirmed on 30 March 2014.

On 7 April, 5 more cases were confirmed, 4 in Lofa and 1 in Monrovia. All 5 died. The situation then stabilized, with no new cases reported during April and most of May.

Further cases were detected in early June, mainly in Lofa county, but the trend did not look alarming, especially when compared with the situation elsewhere. At the end of June, Liberia reported 41 cases, compared with 390 in Guinea and 158 in Sierra Leone.

The impression of a calm situation turned out to be an illusion. The first additional cases in Monrovia were reported in mid-June. The city was ill-prepared to cope with the onslaught of infections that rapidly followed as the virus raced through hospitals, communities, and eventually entire neighbourhoods.

Case numbers that had multiplied quickly began to grow exponentially. On 6 August, President Ellen Johnson Sirleaf declared a three-month state of emergency and announced several strict measures aimed at getting cases down.

In mid-August, a WHO team of emergency experts estimated that Monrovia needed 1000 beds just to treat currently infected patients. Only 240 beds were available.

In September, WHO began construction of a new treatment centre, using teams of 100 construction workers labouring in round-the-clock shifts. On 21 September, the Island Clinic was formally handed over by WHO to Liberia’s Ministry of Health and Social Welfare. The clinic added 150 beds to Monrovia’s limited treatment capacity. However, within 24 hours after opening, the clinic was overflowing with patients, demonstrating the desperate need for more treatment beds.

WHO supported the construction of 2 additional Ebola treatment centres, augmenting Monrovia’s treatment capacity by another 400 beds. The remaining need was eventually met by multiple partners. The rapid increase in treatment capacity, especially in Monrovia, likely did much to turn the outbreak around.

The outbreak began to subside in late October, when more new cases were detected early and rapidly treated in isolation, and more safe and dignified burials were performed. Case-fatality rates dropped. As the number of survivors grew, public perceptions changed from viewing treatments centres as “death traps” to seeing them as places of hope. That altered perception, in turn, encouraged more patients to seek early treatment.

The incidence of new cases stabilized in mid-November, with daily reports showing only 10 to 20 new cases. During the early months of 2015, cases dwindled further, eventually allowing detection and investigation of the last remaining chains of transmission. From late March on, daily reports consistently showed zero cases.

Factors that contributed to success: big dreams
A number of factors contributed to the success of Liberia’s Ebola response.

The first decisive factor was the leadership shown by President Sirleaf, who regarded the disease as a threat to the nation’s “economic and social fabric” and made the response a priority for multiple branches of government. Her swift and sometimes tough decisions, frequent public communications, and presence at outbreak sites were expressions of this leadership.

As President Sirleaf famously stated in her memoir, “The size of your dreams must always exceed your current capacity to achieve them. If your dreams do not scare you, they are not big enough.”

Second, health officials and their partners were quick to recognize the importance of community engagement. Health teams understood that community leadership brings with it well-defined social structures, with clear lines of credible authority. Teams worked hard to win support from village chiefs, religious leaders, women’s associations, and youth groups.

One of the first signs that the outbreak might be turned around appeared in September 2014, when cases in Lofa county, Ebola’s initial epicentre, began to decline after a peak of more than 150 cases a week in mid-August. Epidemiologists would later link that decline to a package of interventions, with community engagement playing a critical role.

In Lofa, staff from the WHO country office moved from village to village, challenging chiefs and religious leaders to take charge of the response. Community task forces were formed to create house-to-house awareness, report suspected cases, call health teams for support, and conduct contact tracing.

See-through walls around the treatment centre replaced opaque ones, allowing families and friends to watch what was happening inside, thus dispelling many rumours. Calls for transportation to treatment facilities or for burial teams were answered quickly, building confidence that teams were there to help.

The effectiveness of this response, which was duplicated elsewhere, points to a third factor: generous support from the international community, including financial, logistical, and human resources. This support added more treatment beds, increased laboratory capacity, and augmented the number of contact tracing and burial teams. The deployment of self-sufficient foreign medical teams from several countries had a dramatic impact on the outbreak’s evolution.

Finally, strong coordination of the international and national response was essential for success. International support was slow to start, but abundant when it arrived. Innovations such as the Presidential Advisory Committee on Ebola and introduction of a incident management system helped ensure that resources and capacities were placed where needed.

Many of these lessons and experiences are reflected in WHO’s new response plan, which aims to identify all remaining cases in West Africa by June 2015.
WHO strategic response plan 2015: West Africa Ebola outbreak

Milestone Expected to Be Reached in Liberia’s Fight against Ebola, Senior Officials Tell Security Council
Speakers also Warn Against Complacency, Stress Continued Need for Support
5 May 2015
Security Council 7438th Meeting* (PM)
[Excerpts; Editor’s text bolding]
With Ebola nearly eradicated from Liberia, it was now critical to address factors that contributed to the epidemic’s spread in the country, particularly given the continued drawdown of peacekeepers, the Secretary-General’s Special Representative told the Security Council this afternoon.

“Ebola highlighted Liberia’s underlying fragility,” Karin Landgren, who is also Head of the United Nations Mission in Liberia (UNMIL), said in a briefing that also heard from Olof Skoog of Sweden, Chair of the Peacebuilding Commission and its country-specific configuration on Liberia, as well as the country’s Minister for Justice, Benedict Sannoh.

All three speakers spoke of the enormous milestone expected to be reached on 9 May, when, if no new case had been confirmed by then, the World Health Organization (WHO) was expected to declare Liberia Ebola-free “after almost 14 months spent under the cloud of Ebola”, as Ms. Landgren put it. At the same time, all three speakers warned against complacency and stressed the continued need for international support for the country.

Ms. Landgren introduced the Secretary-General’s latest bi-annual report on Liberia (document S/2015/275), which welcomed the eradication of the Ebola but said that the epidemic revealed the degree of distrust in the Government and the weakness of institutions in the country.

Liberians were angered, Ms. Landgren added, by the Government’s initial slow response and the rising cost of basic commodities, while the declaration of the state of emergency fuelled fears of misuse of power.

The report noted that, however, in line with the Secretary-General’s recommendations, UNMIL would continue its drawdown authorized through resolution 2215 (2015), reducing military personnel from 4,811 to 3,590 and its police from 1,795 to 1,515 by September 2015. June 2016 was set as the deadline for the Government to fully assume security responsibilities from the Mission…

…At the same time, she said that the Ebola epidemic showed that societal divisions existed and that reconciliation was a work in progress. Dialogue targeted to social exclusion and the crimes of the past was needed. In addition, more work was needed with neighbouring countries to promote regional stability…

She stressed that in all such areas, much would be at stake in 2017, when Liberia’s next presidential election was planned. In anticipation, she said, the political environment had become increasingly intense. The international community must consider how to frame its own support for the process and determine the proper peacekeeping presence that would sustain the country’s — and the Mission’s — successes and prevent a reversal.

Mr. Skoog, in his briefing… stressed the importance of a regional approach to recovery from the Ebola crisis and to cementing stability in West Africa. Relevant initiatives towards that end deserved greater international support. The priority for the Commission was to safeguard and strengthen all gains made in the country as UNMIL drew down, with the transition well-coordinated with Ebola recovery efforts…
:: Twenty-ninth progress report of the Secretary-General on the United Nations Mission in Liberia
United Nations Security Council
23 April 2015

CDC/MMWR/ACIP Watch [to 9 May 2015]
:: Liberia Travel Alert Revised from Level 3 to Level 2: “Practice Enhanced Precautions” – Media Statement
MONDAY, MAY 4, 2015

POLIO [to 9 May 2015]

POLIO [to 9 May 2015]
Public Health Emergency of International Concern (PHEIC)

GPEI Update: Polio this week – As of 29 April 2015
Global Polio Eradication Initiative
[Editor’s Excerpt and text bolding]
Full report:
:: Polio spread remains public health emergency: The WHO Director-General has accepted the assessment of the 5th meeting of the Emergency Committee under the International Health Regulations (2005) (IHR) that the spread of polio still constitutes a public health emergency of international concern and recommended the extension of revised Temporary Recommendations.
:: Global Polio Eradication Initiative (GPEI) report to upcoming World Health Assembly (WHA) now available: The report and an accompanying resolution are expected to inform discussions at the WHA, 18-26 May in Geneva, Switzerland.
:: Latest semi-annual status report covers second half of 2014: details on the situation in endemic, re-infected and high-risk countries.
:: Independent Monitoring Board (IMB) meeting: the IMB met last week in Abu Dhabi, United Arab Emirates, to review the current status of the global polio eradication effort and is expected to publish its report here over the coming weeks.
Selected excerpts from Country-specific Reports [No new polio cases reported]

Statement on the 5th IHR Emergency Committee meeting regarding the international spread of wild poliovirus
WHO statement
5 May 2015
[Initial text; Editor’s text bolding]
The fifth meeting of the Emergency Committee under the International Health Regulations (2005) (IHR) regarding the international spread of wild poliovirus in 2014 – 15 was convened via teleconference by the Director-General on 24 April 2015. The following IHR States Parties submitted an update on the implementation of the Temporary Recommendations since the Committee last met on 17 February 2015: Afghanistan and Pakistan.

The Committee noted that after nearly one year since the declaration that the international spread of polio constituted a Public Health Emergency of International Concern (PHEIC), strong progress has been made by countries in response to the Temporary Recommendations issued by the Director-General, and that this was a commendable achievement. No cases of wild poliovirus have been reported in Africa for eight months; in 2015, Pakistan and Afghanistan have reported less than half the number of cases that were reported during the same period in 2014; there has been no exportation from Pakistan since October 2014; and the number of persistently missed and inaccessible children is declining in Pakistan. The number of inaccessible children has declined from an estimated 300,000 to 50,000 in Federally Administered Tribal Areas. Pakistan continued to implement the Temporary Recommendations; since November, an average of 370,000 international travellers per month were vaccinated pre-departure at health facilities and points of exit.

The Committee noted, however, that the international spread of wild poliovirus has continued with three new documented exportations from Afghanistan into neighbouring Pakistan which occurred in late 2014. The poliovirus isolates found in the three cases in Pakistan were more closely related to strains recently circulating in Afghanistan than to those currently found in Pakistan. While two of these virus strains circulated in bordering areas of Afghanistan following recent exportation from Pakistan (September 2014), the third virus was related to a strain that had circulated only in Afghanistan for a period of more than one year, thus demonstrating the strongest evidence of exportation into Pakistan of a strain of poliovirus that has established transmission in Afghanistan.

The Committee agreed that Pakistan and Afghanistan formed a single epidemiological block with frequent cross-border population movement, which accounts for the ebb and flow of poliovirus in both directions. Much stronger coordination and quality of cross-border vaccination and surveillance activities will be essential to reduce the risk of this international spread. In addition, both countries must achieve interruption of poliovirus transmission simultaneously in order to prevent such international spread from repeatedly setting back progress in both countries.

In Pakistan, a reduction of cases occurred during the low season and the performance of the eradication program has improved. Nevertheless, 21 of 22 reported cases in 2015 to date (or 95% of global cases in 2015) were reported from Pakistan, and the key factors that contribute to international spread of wild poliovirus from Pakistan, although improving, have not changed sufficiently since the fourth meeting of the Emergency Committee on 17 February. The risk of new exportations from Pakistan remains with the ongoing transmission in the country during the low transmission season, nearly 50,000 children still inaccessible in infected areas of the Federally Administered Tribal Areas and the imminent high transmission season that commences in May. In Afghanistan, the number of cases reported has declined and cross-border transit vaccination activities have been strengthened, particularly in the Southeast Region. However, areas with chronically missed or inaccessible populations remain in parts of Southern and Eastern Regions.

Despite the commendable progress, the implications of the continued risk of international spread from Pakistan and Afghanistan remain of concern. This is a critical stage for global polio eradication during which the hard-earned gains can be quickly lost given fragility of progress and continued disruption of immunization systems in settings of conflict and complex humanitarian emergencies.

Although the risk of new international spread from other infected Member States appears to have declined, the possibility of international spread still remains a global threat worsened by expansion of conflict-affected areas, particularly in the Middle East and Central Africa. Countries affected by conflict are vulnerable to outbreaks of polio that can be difficult to detect and are very challenging and costly to control.

The Committee unanimously agreed that the spread of polio still constitutes a PHEIC and recommended the extension of the Temporary Recommendations, as revised, for a further three months…

May 2015 :: 50 pages
Objective 1: Poliovirus detection and interruption
:: Endemic countries: Strong progress has been made in Nigeria towards eradicating the disease, but polio cases are on the rise in Pakistan, affecting Afghanistan.
:: Outbreaks: In the Horn of Africa and central Africa, outbreaks appear close to being stopped. The response is strong in the Middle East, despite ongoing security challenges.
:: Wild poliovirus type 3 (WPV3): November marked two years since the most recent case of WPV3 and onset of paralysis in Nigeria. With no reported cases of wild poliovirus type 2 (WPV2) since 1999, potentially just one of the three strains of wild poliovirus remains.
:: PHEIC: In May 2014, WHO Director-General declared the international spread of wild poliovirus a “public health emergency of international concern” (PHEIC) and issued Temporary Recommendations under the International Health Regulations (2005) to minimize the risk of further global spread. Countries’ implementation of the recommendations varied in the second half of 2014.

Objective 2: Immunization systems strengthening and OPV withdrawal
:: The Strategic Advisory Group of Experts on immunization (SAGE) concludes global preparations are on track to switch from trivalent oral polio vaccine (OPV) to bivalent OPV in April 2016.
:: The SAGE notes progress achieved with regard to inactivated polio vaccine (IPV) introduction worldwide.
:: Efforts intensify in 10 priority countries (with the bulk of Global Polio Eradication Initiative infrastructure) to use the infrastructure in support of routine immunization systems strengthening.

Objective 3: Containment and certification
:: Certification: The WHO South-East Asia Region was certified polio-free on 27 March 2014; certification of the conclusive global eradication of WPV2 is on track for 2015.
:: Containment: In 2014, the Global Action Plan (GAP) to minimize post-eradication poliovirus facility-associated risks (GAPIII) was updated and aligned with Polio Eradication & Endgame Strategic Plan timelines, particularly with regard to the phased removal of OPVs.

Objective 4: Legacy planning
:: A draft Global Legacy Framework is under development by a legacy planning working
group, following outcomes from a Boston Consultancy Group evaluation. The draft plan was approved by the Polio Oversight Board. Legacy planning is to be guided by national priorities at the country level, with strong linkages to global priorities. Planning missions were conducted in the Democratic Republic of the Congo and Nepal. A practical example of legacy in action is support to the Ebola outbreak in west Africa.

WHO & Regionals [to 9 May 2015]

WHO & Regionals [to 9 May 2015]
:: Sixty-eighth World Health Assembly – 18–26 May 2015

:: Improving access to lifesaving medicines for hepatitis C, drug-resistant TB and cancers
8 May 2015 — WHO today published the new edition of its Model List of Essential Medicines which includes ground-breaking new treatments for hepatitis C, a variety of cancers (including breast cancer and leukaemia) and multi-drug resistant tuberculosis (TB), among others. The move opens the way to improve access to innovative medicines that show clear clinical benefits and could have enormous public health impact globally.
Press release on the new edition of the Essential Medicines list

:: WHO issues best practices for naming new human infectious diseases
May 2015 — WHO today called on scientists, national authorities and the media to follow best practices in naming new human infectious diseases to minimize unnecessary negative effects on nations, economies and people

:: A commitment to improve global health information
May 2015 — WHO and the Institute of Health Metrics and Evaluation (IHME) signed a Memorandum of Understanding defining areas where they will work together to improve the quality and use of global health estimates to measure the world’s health challenges.
Stories from countries
Nepali and international medical teams join forces to fill health care gaps in quake-ravaged Sindhupalchok
6 May 2015
“Sin Tax” expands health coverage in the Philippines
6 May 2015
Syrian Arab Republic builds capacity for mental health care during conflict
5 May 2015
Mobile health clinics help tackle post-earthquake mental health problems in Nepal
5 May 2015
Sierra Leone: Helping health workers protect patients with clean hands
4 May 2015
:: The Weekly Epidemiological Record (WER) 8 May 2015, vol. 90, 19 (pp. 201–216) includes:
..Dracunculiasis eradication: global surveillance summary, 2014
..Monthly report on dracunculiasis cases, January– February 2015

:: Global Alert and Response (GAR) – Disease Outbreak News (DONs)
..8 May 2015 – Middle East Respiratory Syndrome coronavirus (MERS-CoV) – Iran
..8 May 2015 – Middle East Respiratory Syndrome coronavirus (MERS-CoV) – Saudi Arabia

:: Global Immunization Meeting: “Protect, Innovate, Accelerate”
23-25 June 2015, Sitges/Barcelona, Spain.
Agenda pdf, 499kb
:: WHO Regional Offices
WHO African Region AFRO
:: WHO calls Experts’ Meeting to promote responsible use of antimicrobials and combat antimicrobial resistance in the African Region
Brazzaville, 8 May 2015 – The African Region is facing an increasing risk of antimicrobial resistance (AMR) that threatens the effective prevention and treatment of an ever-increasing range of infections caused by bacteria, parasites, viruses and fungi. AMR and its spread will compromise health security in the Region as many standard medical treatments will fail or turn into high-risk procedures causing prolonged illnesses, high health care expenditures, and greater risks of death.
:: African Public Health Leaders Unite to End Preventable Deaths and Improve Health of Women, Children and Adolescents by 2030 – 06 May 2015

WHO Region of the Americas PAHO
:: Ten key actions by PAHO member countries that led to elimination of rubella (05/04/2015)

WHO South-East Asia Region SEARO
:: WHO committed to helping Nepal deliver health care to its citizens, says WHO South-East Asia Regional Director 07 May 2015
:: WHO setting up Gorkha field office to extend health-care reach in Nepal 03 May 2015

WHO European Region EURO
:: Health financing course on universal health coverage another success 05-05-2015

WHO Eastern Mediterranean Region EMRO
:: WHO pushes health diplomacy agenda forward in fourth high-level seminar in Cairo
Cairo, 2 May 2015 – The WHO Regional Office held the fourth seminar on health diplomacy in Cairo, Egypt, from 2 to 4 May 2015. Senior officials from ministries of health and foreign affairs, ministers and permanent missions at the United Nations in Geneva, ambassadors, heads of parliamentary health committees and public health institutes attended the meeting and discussed priority issues, such as: noncommunicable diseases; the post-2015 development agenda; health security; and crises and humanitarian response.
:: Syrian Arab Republic builds capacity for mental health care during conflict May 2015
:: WHO/UNHCR issue new guide on mental health in humanitarian emergencies 5 May 2015

WHO Western Pacific Region
No new digest content identified.

BMGF (Gates Foundation) [to 9 May 2015]

BMGF (Gates Foundation) [to 9 May 2015]

:: The Bill & Melinda Gates Foundation to Fund Disease Surveillance Network in Africa and Asia to Prevent Childhood Mortality and Help Prepare for the Next Epidemic
SEATTLE (May 6, 2015) – At its Global Partners Forum, the Bill & Melinda Gates Foundation will announce the Child Health and Mortality Prevention Surveillance Network (CHAMPS), a network of disease surveillance sites in developing countries. These sites will help gather better data, faster, about how, where and why children are getting sick and dying. This data will help the global health community get the right interventions to the right children in the right place to save lives. The network will also be invaluable in providing capacity and training in the event of an epidemic, such as Ebola or SARS. The Gates Foundation plans an initial commitment of up to $75 million on the effort.

“The world needs better, more timely public health data not only to prepare for the next epidemic, but to save children’s lives now,” said Bill Gates, co-chair of the Bill & Melinda Gates Foundation. “Over the past 15 years, deaths of children in developing countries have been dramatically reduced, but to continue that trend for the next 15 years, we need more definitive data about where and why children are dying. This will also better position us to respond to other diseases that may turn into an epidemic.”

This network of disease surveillance sites in areas with high childhood mortality rates in Sub Saharan Africa and South Asia will offer a long-term approach to information management, laboratory infrastructure and workforce capacity – vital resources in geographies lacking sufficient public health infrastructure. This network could be repurposed quickly in the event of an epidemic, as in Nigeria where the national polio program’s Emergency Operations Center was mobilized to fight Ebola.

A lead partner in the effort will be the Emory Global Health Institute, which houses the International Association of National Public Health Institutes (IANPHI), and the Centers for Disease Control and Prevention (CDC) will provide technical assistance with laboratory infrastructure. Each site will have trained staff and technology capabilities.

“We are excited by and committed to this extraordinary opportunity to make a major contribution to children’s health,” said Dr. Jeffrey Koplan, vice president for Global Health at Emory University.

“A disease threat anywhere is a threat everywhere,” said CDC Director Tom Frieden, M.D., M.P.H. “Strong networks such as CHAMPS will help us find, stop, and prevent outbreaks and will not only save children in Africa and Asia, but will help to make the world a safer, healthier place for everyone.”

CHAMPS is a minimum twenty-year project to gather more accurate data about how, where and why children are dying in developing countries. It will help ensure that the right vaccines and treatments are delivered to the people who need them most and that the global health community invests in crucial new drugs and health tools.

The announcement will be made at the Bill & Melinda Gates Foundation’s Global Partners Forum held in Seattle. The forum is a one-time event taking place in a milestone year for global health and development. Research and development, delivery, and advocacy partners are meeting to exchange perspectives on major global health challenges facing the world over the next 15 years. The event is expected to draw more than 1000 attendees including partners, high-level representatives from governments and organizations across the globe.

IVI Watch [to 9 May 2015]

IVI Watch [to 9 May 2015]

:: Successful pilot launch of Vaccine Adverse Events Management System (VAEIMS) in Sri Lanka
In 2013, IVI built the infrastructure for a WHO-conceptualized project, the Vaccine Adverse Events Information Management System (VAEIMS), to efficiently and effectively transfer Adverse Events Following Immunization (AEFI) data from periphery health care locals to a central database. The software, which will facilitate the transfer of data for public health action, was successfully adapted in Sri Lanka. Sri Lanka served as the first launching site to test the beta-version of the software. To learn more please visit:

European Medicines Agency Watch [to 9 May 2015]

European Medicines Agency Watch [to 9 May 2015]

:: EMA tightens rules on ‘revolving door’ for committee members and experts
Intention to take up job in pharma industry will trigger immediate halt of involvement in medicines evaluation
The European Medicines Agency (EMA) has updated its rules on declarations of interests for scientific committee members and experts. The updates further strengthen EMA’s policy by restricting involvement of experts in the scientific assessment of medicines if they plan to take up a job in the pharmaceutical industry. The updates also include a revised guide on how to complete the Agency’s declaration of interest form…

DCVMN / PhRMA / EFPIA / IFPMA / BIO Watch [to 9 May 2015]

DCVMN / PhRMA / EFPIA / IFPMA / BIO Watch [to 9 May 2015]

:: Research-based pharmaceutical companies are contributing to emergency aid efforts for Nepal
04 May 2015
… The global research-based pharmaceutical industry represented by the IFPMA is providing significant funds to relief organisations following the major earthquake. The total cash value of the first emergency responses provided so far by IFPMA members already amounts to over $1.1 million, and most of the companies and their foundations have also donated medicines and other medical supplies.

So far eighteen research-based pharmaceutical companies and national associations have already provided donations to charities (for emergency aid as well as helping meet the immediate needs of shelter, water, food, hygiene and sanitation). In addition, these companies are donating over $5.6 million of medicines (including antibiotics, anti-infective creams, anti-inflammatories, and analgesics) and other healthcare products (such as emergency medical kits, band-aids, fluids for cleaning wounds, etc.) to organizations on the ground. The first shipments have already reached Nepal and others are to follow.

To ensure that the assistance provided is appropriate and coordinated, IFPMA members are partnering with a range of expert medical and disaster relief organizations: American Red Cross, AmeriCares, British Red Cross, CARE International, Corps Mondial de Secours (CMS), Direct Relief International, Deutschland Hilft, Doctors of the World, Handicap International, Heart to Heart International, International Health Partners, International Medical Corps, Japan Platform, MAP International, Project Hope, Red Cross, Save the Children, Secouristes Sans Frontières, Swiss Red Cross, UN World Food Programme, UNICEF…

American Journal of Tropical Medicine and Hygiene – May 2015

American Journal of Tropical Medicine and Hygiene
May 2015; 92 (5)

Malaria Control: Tortoises and Hares
Steven R. Meshnick*
Author Affiliations
Department of Epidemiology, University of North Carolina Gillings School of Global Public Health, Chapel Hill, North Carolina
How long will it take to effectively control and then eliminate malaria in sub-Saharan Africa? Is it a sprint to the finish line or a crawl? Will the tortoise or hare win the malaria race?

Malaria Transmission, Infection, and Disease at Three Sites with Varied Transmission Intensity in Uganda: Implications for Malaria Control
Moses R. Kamya, Emmanuel Arinaitwe, Humphrey Wanzira, Agaba Katureebe, Chris Barusya,
Simon P. Kigozi, Maxwell Kilama, Andrew J. Tatem, Philip J. Rosenthal, Chris Drakeley, Steve W. Lindsay, Sarah G. Staedke, David L. Smith, Bryan Greenhouse, and Grant Dorsey
Am J Trop Med Hyg 2015 92:903-912; Published online March 16, 2015, doi:10.4269/ajtmh.14-0312
The intensification of control interventions has led to marked reductions in malaria burden in some settings, but not others. To provide a comprehensive description of malaria epidemiology in Uganda, we conducted surveillance studies over 24 months in 100 houses randomly selected from each of three subcounties: Walukuba (peri-urban), Kihihi (rural), and Nagongera (rural). Annual entomological inoculation rate (aEIR) was estimated from monthly Centers for Disease Control and Prevention (CDC) light trap mosquito collections. Children aged 0.5–10 years were provided long-lasting insecticidal nets (LLINs) and followed for measures of parasite prevalence, anemia and malaria incidence. Estimates of aEIR were 2.8, 32.0, and 310 infectious bites per year, and estimates of parasite prevalence 7.4%, 9.3%, and 28.7% for Walukuba, Kihihi, and Nagongera, respectively. Over the 2-year study, malaria incidence per person-years decreased in Walukuba (0.51 versus 0.31, P = 0.001) and increased in Kihihi (0.97 versus 1.93, P < 0.001) and Nagongera (2.33 versus 3.30, P < 0.001). Of 2,582 episodes of malaria, only 8 (0.3%) met criteria for severe disease. The prevalence of anemia was low and not associated with transmission intensity. In our cohorts, where LLINs and prompt effective treatment were provided, the risk of complicated malaria and anemia was extremely low. However, malaria incidence was high and increased over time at the two rural sites, suggesting improved community-wide coverage of LLIN and additional malaria control interventions are needed in Uganda.

Rotavirus Seasonal Distribution and Prevalence Before and After the Introduction of Rotavirus Vaccine in a Peri-Urban Community of Lima, Peru
Millie R. Chang, Grace Velapatiño, Miguel Campos, Elsa Chea-Woo, Nelly Baiocchi, Thomas G. Cleary and Theresa J. Ochoa*
Author Affiliations
Universidad Peruana Cayetano Heredia, Lima, Peru; Instituto de Medicina Tropical, Universidad Peruana Cayetano Heredia, Lima, Peru; Department of Mathematics, Universidad Peruana Cayetano Heredia, Lima, Peru; Department of Pediatrics, Universidad Peruana Cayetano Heredia, Lima, Peru; Center for Infectious Diseases, University of Texas School of Public Health, Houston, Texas
We evaluated the monthly distribution of rotavirus diarrhea in a cohort of children 12–24 months of age followed as part of a diarrhea clinical trial in a peri-urban community of Lima. We observed a peak of rotavirus diarrhea in the winter months and a decrease in rotavirus prevalence after the introduction of the rotavirus vaccine in Peru.

Measles at Disneyland, a Problem for All Ages

Annals of Internal Medicine
5 May 2015, Vol. 162. No. 9

Ideas and Opinions | 5 May 2015
Measles at Disneyland, a Problem for All Ages
Neal A. Halsey, MD; and Daniel A. Salmon, PhD, MPH
Article and Author Information
Ann Intern Med. 2015;162(9):655-656. doi:10.7326/M15-0447
Although great progress has been made in global control, measles has recently rebounded in many countries. Eradication is possible but will take time, ramped-up efforts to ensure that eligible U.S. children are vaccinated, and greater international collaboration.

BMC Medical Ethics (Accessed 9 May 2015)

BMC Medical Ethics
(Accessed 9 May 2015)

Research article
Ethics-sensitivity of the Ghana national integrated strategic response plan for pandemic influenza
Amos Laar1* and Debra DeBruin2
Author Affiliations
BMC Medical Ethics 2015, 16:30 doi:10.1186/s12910-015-0025-9
Published: 7 May 2015
Abstract (provisional)
Many commentators call for a more ethical approach to planning for influenza pandemics. In the developed world, some pandemic preparedness plans have already been examined from an ethical viewpoint. This paper assesses the attention given to ethics issues by the Ghana National Integrated Strategic Plan for Pandemic Influenza (NISPPI).
We critically analyzed the Ghana NISPPI’s sensitivity to ethics issues to determine how well it reflects ethical commitments and principles identified in our review of global pandemic preparedness literature, existing pandemic plans, and relevant ethics frameworks.
This paper reveals that important ethical issues have not been addressed in the Ghana NISPPI. Several important ethical issues are unanticipated, unacknowledged, and unplanned for. These include guidelines on allocation of scarce resources, the duties of healthcare workers, ethics-sensitive operational guidelines/protocols, and compensation programs. The NISPPI also pays scant attention to use of vaccines and antivirals, border issues and cooperation with neighboring countries, justification for delineated actions, and outbreak simulations. Feedback and communication plans are nebulous, while leadership, coordination, and budgeting are quite detailed. With respect to presentation, the NISPPI’s text is organized around five thematic areas. While each area implicates ethical issues, NISPPI treatment of these areas consistently fails to address them.
Our analysis reveals a lack of consideration of ethics by the NISPPI. We contend that, while the plan’s content and fundamental assumptions provide support for implementation of the delineated public health actions, its consideration of ethical issues is poor. Deficiencies include a failure to incorporate guidelines that ensure fair distribution of scarce resources and a lack of justification for delineated procedures. Until these deficiencies are recognized and addressed, Ghana runs the risk of rolling out unjust and ethically indefensible actions with real negative effects in the event of a pandemic. Soliciting inputs from the public and consultation with ethicists during the next revision of the NISPPI will be useful in addressing these issues.

Research article
Clinical trialist perspectives on the ethics of adaptive clinical trials: a mixed-methods analysis
Laurie J Legocki, William J Meurer, Shirley Frederiksen, Roger J Lewis, Valerie L Durkalski, Donald A Berry, William G Barsan, Michael D Fetters BMC Medical Ethics 2015, 16:27 (3 May 2015)

Early vaccine availability represents an important public health advance for the control of pandemic influenza

BMC Research Notes
(Accessed 9 May 2015)

Research article
Early vaccine availability represents an important public health advance for the control of pandemic influenza
Amy L Greer BMC Research Notes 2015, 8:191 (8 May 2015)
Abstract (provisional)
Traditional processes for the production of pandemic influenza vaccines are not capable of producing a vaccine that could be deployed sooner than 5–6 months after strain identification. Plant-based vaccine technologies are of public health interest because they represent an opportunity to begin vaccinating earlier.
We used an age- and risk- structured disease transmission model for Canada to evaluate the potential impact of a plant-produced vaccine available for rapid deployment (within 1–3 months) compared to an egg-based vaccine timeline.
We found that in the case of a mildly transmissible virus (R0 = 1.3), depending on the amount of plant-based vaccine produced per week, severe clinical outcomes could be decreased by 60–100 % if vaccine was available within 3 months of strain identification. However, in the case of a highly transmissible virus (R0 = 2.0), a delay of 3 months does not change clinical outcomes regardless of the level of weekly vaccine availability. If transmissibility is high, the only strategy that can impact clinical outcomes occurs if vaccine production is high and available within 2 months.
Pandemic influenza vaccines produced by plants, change the timeline of pandemic vaccine availability in a way that could significantly mitigate the impact of the next influenza pandemic.

Towards a better epidemic ][Ebola]

British Medical Journal
09 May 2015(vol 350, issue 8007)


Editor’s Choice
Towards a better epidemic
BMJ 2015; 350 doi: (Published 07 May 2015) Cite this as: BMJ 2015;350:h2419
Tony Delamothe, deputy editor, The BMJ

The consensus seems to be that no one had a particularly good Ebola epidemic, with the exception of the charity Médecins Sans Frontières (MSF). This begs the question of who makes these judgment calls, and what was the last “good” epidemic you can remember?

The World Health Organization got it in the neck for delivering too little, too late, and its own report last week joined in the criticisms, listing lessons learnt and actions planned (doi:10.1136/bmj.h2144). MSF thought the problems went wider than WHO. The international response had been a “global coalition of inaction,” its report concluded (doi:10.1136/bmj.h1619). “For the Ebola outbreak to spiral this far out of control required many institutions to fail,” said its director. MSF also noted that the affected countries hadn’t always made the right choices—not easy for some of the poorest countries on earth.

In The BMJ Christian Gericke continues the generally critical line, saying that the epidemic attracted medical ethics commentators “like bees to a honey pot” (doi:10.1136/bmj.h2105). Were they of any use? He thinks that the short term use of experimental drugs (and their complex ethical challenges) attracted far more attention than it deserved and distracted from the urgent business of controlling the epidemic. He quotes approvingly the bioethicist Udo Schüklenk’s criticism of WHO’s recommendation to provide access to experimental drugs as “pointless grandstanding in the face of a pandemic that requires a public health response.”

In her feature this week Sophie Arie considers WHO’s support of clinical trials for experimental drugs as a bottle half full rather than empty (doi:10.1136/bmj.h1938). A year after the first case of Ebola virus disease was reported, several phase II and III trials of vaccines and other treatments are under way—“a process that normally can take as long as 10 years was compressed into a year.”

At least a dozen other neglected infectious disease pathogens have the potential to pose a similar threat to Ebola, and Arie describes how an international group of scientists has argued for fast tracking experimental vaccines and treatments for these, so that they’re available at the beginning of a disease outbreak. Such long range thinking comes as a welcome alternative to the attention deficit that usually afflicts the disasterazzi, as they flit from one trouble spot to the next…


Editorial – Ebola and ethics: autopsy of a failure

British Medical Journal
09 May 2015(vol 350, issue 8007)


Ebola and ethics: autopsy of a failure
BMJ 2015; 350 doi: (Published 23 April 2015) Cite this as: BMJ 2015;350:h2105
Christian A Gericke, chief executive and director of research
Author affiliations
Thousands died while we argued over the wrong questions
The current epidemic of Ebola virus disease has attracted medical ethics commentators like bees to a honey pot. No previous infectious disease epidemic has elicited such a flurry of articles on the ethical challenges associated with infection control and treatment in such a short time. Has this been of any use?

The ethical questions raised by various authors broadly fall into three categories. The first relates to questions of individual medical ethics, in particular surrounding the compassionate use of experimental drugs and vaccines. The second concerns allocation of resources to these experimental treatments versus infection control. And the third centres on how resources should be spent in the long term—on building a public health and clinical infrastructure that can cope in an epidemic instead of propping up a weak infrastructure during a humanitarian crisis.
The tension between these moral challenges can be grouped along two axes: individual versus public health, and short term versus long term (Download figure)

The short term use of experimental drugs such as ZMapp, first used in a few repatriated health workers from high income countries, attracted far more public attention than it deserved. It generated a series of ethical questions that are hard to answer and distracted from the real, practical, and urgent business of controlling the wider Ebola epidemic. Commentators argued about whether randomised trials were required in the heat of the epidemic, the level of personal risk that might be acceptable for recipients, who should receive these drugs, how to ensure informed consent, and whether health professionals should get preferential treatment, among other things.

The inappropriate focus on experimental treatments for individuals diverted attention away from infection control and other measures that would benefit everyone. In August 2014, Médecins Sans Frontières (MSF) was the first to point out that the international response to the epidemic was “dangerously inadequate.”1 International collective action came too late, and too little was done.2 MSF called for support in the form of laboratory staff, healthcare workers to provide supportive care, and portable equipment to isolate patients.1

Only a few writers have commented on the ethical aspects of a misguided international effort. Bioethicist Udo Schüklenk characterised the humanitarian intervention as a theatrical farce. He described the aid organisations as “a mixed bunch of Christian missionaries busily trying to get their hands on the last available experimental agents while on private medical jets out of west Africa.”3 He also criticised WHO’s recommendations to provide access to experimental drugs as “pointless grandstanding in the face of a pandemic that requires a public health response.”3 David Heymann, an infectious disease epidemiologist, prioritised stopping the outbreak using intensified patient isolation, contact tracing, and community empowerment flanked by properly conducted clinical trials of treatments such as survivor serum.4

In November 2014, Annette Rid and Ezekiel Emanuel published a viewpoint that rightly stressed the need to prioritise strengthening of health systems over experimental treatments because the treatments are unlikely to have a noticeable effect on the epidemic, even if effective.5 Jacob and colleagues wanted effort directed at patient outcomes instead.6 These arguments show why a clear distinction is needed between short and long term responses, and between the needs of individuals versus the wider public health. Where Rid and Emanuel think big picture and long term, Jacob and colleagues think about the needs of individuals, in the short term. Both are important, and they should not compete.

What went wrong?
In my view, the expert meeting on experimental drugs and vaccines convened by WHO in August 20147 not only sidetracked relief efforts but led medical ethicists from all over the world sheepishly down the wrong path. The moral challenges surrounding the compassionate use of experimental drugs and vaccines are complex. Heated debate arose, and the wider public health perspective was lost in the noise. The misguided WHO expert panel and relief effort was picked up by some medical ethicists.3 5 8 However, their insights came too late to change the course of events or the public debate.

What can we learn from this failure? Governments, international organisations, and donor agencies need to take a wider perspective and a longer term view on health system preparedness when it comes to effective prevention of epidemics, including Ebola.

Once an epidemic occurs, rapid deployment of proved methods of infection control should take precedence over experimental treatments. In the wake of the 2009 H1N1 influenza pandemic a WHO review committee recommended the creation of a $100m (£67m; €93m) contingency fund to allow rapid responses to future pandemic threats. This recommendation was ignored, which partly explains the delayed and fractured response to the Ebola epidemic.9

A renewed focus on developing more effective drugs and vaccines against neglected tropical diseases is another important long term measure that should happen now, between epidemics.10

The World Bank estimates that the two year socioeconomic effect of the current Ebola epidemic could reach $32.6bn.11 If only a fraction of this amount had been spent on health system preparedness before the current epidemic, early case identification and containment, contact tracing, and supportive care for the few people affected in the first wave of the disease would have been possible. Many of the more than 10,000 deaths reported by 17 April 2015 might have been prevented.12 Finally, the benefits of a well prepared health system would extend to many other diseases, including HIV/AIDS, tuberculosis, and malaria.

Medical ethics can provide useful insights for decision making in epidemics, provided that you ask the right questions.

01 Médecins Sans Frontières. International response to west Africa Ebola epidemic dangerously inadequate. MSF, 2014.
02 Ebola: a failure of international collective action. Lancet2014;384:637. CrossRefMedline
03 Schuklenk U. Bioethics and the Ebola outbreak in west Africa. Dev World ioeth2014;14(3):ii-iii.
04 Heymann DL. Ebola: learn from the past. Nature2014;514:299-300. CrossRefMedlineWeb of Science
05 Rid A, Emanuel EJ. Ethical considerations of experimental interventions in the Ebola outbreak. Lancet2014;384:1896-99. CrossRefMedline
06 Jacob ST, Crozier I, Schieffelin JS, Colebunders R. Priorities for Ebola virus disease response in west Africa. Lancet2014;384:1843.
07 WHO. Ethical considerations for use of unregistered interventions for Ebola virus disease. Report of an advisory panel to WHO. WHO, 2014.
08 Dawson AJ. Ebola: what it tells us about medical ethics. J Med Ethics2015;41:107-10.
Abstract/FREE Full Text
09 Gostin LO. Ebola: towards an international health systems fund. Lancet2014;384:e49-51.
10 Oprea L, Braunack-Mayer A, Gericke CA. Ethical issues in funding research and development of drugs for neglected tropical diseases. J Med Ethics2009;35:310-4.
Abstract/FREE Full Text
11 World Bank. The economic impact of the 2014 Ebola epidemic: short and medium term estimates for west Africa. World Bank, 2014.
12 WHO. Ebola situation report—17 April 2015. WHO, 2015.