Ebola: a game changer for vaccines, or a scare that will soon be forgotten?

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


Feature – Vaccines
Ebola: a game changer for vaccines, or a scare that will soon be forgotten?
BMJ 2015; 350 doi: http://dx.doi.org/10.1136/bmj.h1938 (Published 06 May 2015) Cite this as: BMJ 2015;350:h1938
Sophie Arie
Scientists say that it is only a matter of time before another neglected infectious disease causes a global public health emergency. So will the world now make these diseases a priority? Sophie Arie reports

In March 2014 the first case of a new outbreak of Ebola virus disease was confirmed in Guinea. After months of growing global panic that the virus was out of control and might rapidly spread worldwide, the World Health Organization agreed for the first time that, as part of the global response, it would support clinical trials of experimental Ebola drugs on the affected population.
Trials are rushed through at record speed

Treatments and vaccines developed in laboratories more than a decade earlier that had been mothballed for lack of commercial interest were put through human safety trials and small scale efficacy trials at record speed. Ethical issues were carefully tackled and trial protocols produced—again, at record speed—so that today, a year after that first case was reported, several large scale phase III clinical trials of vaccines and treatments for Ebola are under way in west Africa. A process that normally can take as long as 10 years was compressed into a year.
Yet, for more than 10 000 people who have died, this is still way too slow—and, because very few new Ebola cases are now occurring, it may also be too late to gather solid enough data to gain market approval for any of the experimental drugs in the pipeline.

So, how can the global community move even more quickly to develop drugs for potentially devastating infectious disease outbreaks in the future? Scientists are desperate to capitalise on progress made during the Ebola outbreak by focusing on developing drugs for more than 10 other neglected infectious diseases (see box 1) that, like Ebola, they say, have the potential to spread far further and more quickly today than in the past, in large part because of increased population density and cheap air travel.

The need to prepare and stockpile
“The way our society has changed, we have to be able to move within days and weeks now, not months or years,” said Jeremy Farrar, director of the Wellcome Trust, which has invested £10m (€13.6m; $15.2m) in the current trials. “We need a paradigm shift in thinking about how we develop and license these drugs.”

Farrar and many of the leading scientists involved in the Ebola response are calling for the global community not to wait until the next outbreak before reacting. Experimental treatments and vaccines for all of the long neglected outbreak pathogens must be fast tracked “in peace time,” he says, so that safety is affirmed, candidate drugs are manufactured and stockpiled, ethical issues are resolved, and protocols are put in place for clinical trials to begin within days or weeks of a future outbreak.

“Make them, have them ready in a stockpile, have everything ready to go,” said Adrian Hill, of the University of Oxford, who is the lead researcher in the trials of six different candidate vaccines and treatments in west Africa. “Then, when an outbreak comes, you move very quickly and nip it in the bud.”

The world must also develop a global mechanism (see box 2) for unlicensed drugs to be authorised for distribution to large numbers of people in emergencies, scientists have urged. During the Ebola outbreak a handful of infected Western health workers did not hesitate to try experimental treatments, but those drugs were not available in sufficient quantities or affordably enough for people in west Africa to try them.

Farrar, Hill, and an international group of scientists calling themselves the “B Team” outlined this vision in a document mainly about the Ebola response but also drawing wider conclusions, published in February.1

Funding and motivation
Funding, of course, is the major obstacle. The outbreak pathogens that the scientists believe are worth investing in have, until now, been far off the radar of the global drug companies. Candidate treatments and vaccines for Ebola were developed only because the United States considered the virus a potential weapon for bioterrorism.

Major drug companies have participated in the fast tracked trial process for Ebola largely because they have not had to pay for it (the Wellcome Trust and the US and UK governments have funded most of the trials) or because they have been guaranteed a certain number of sales. GAVI, the global alliance set up in 2000 to improve access to vaccines in the developing world, has created a unique “push” funding model for the Ebola outbreak, setting aside $300m (£196m; €266m) to cover production costs without knowing how many doses of vaccine this will buy.

“It’s the first time we’ve guaranteed funding for a vaccine that hasn’t yet completed development,” Aurelia Nguyen, director of policy and market shaping at GAVI, told The BMJ. GAVI is not, however, thinking of this as the way to approach all infectious disease outbreaks in the future, she said. Because of the level of global panic over the Ebola outbreak, “the global community wanted to produce and deliver whatever product is viable,” Nguyen explained. “So it’s not a normal commercial dynamic.”

Motivation is the other barrier. Hill noted that, rather than sidestepping any of the normal bureaucratic procedures for approving the Ebola trials, the relevant regulatory authorities—such as the Medicines and Healthcare Products Regulatory Agency and the research ethics committees in all of the countries involved, which review hundreds of trial protocols—put Ebola “on the top of the pile.” In this sense, he said, it is a question of people changing their priorities about which diseases to focus on.

But accelerating the process does not in any way compromise safety, Hill insisted. The University of Oxford is the “sponsor” that bears legal responsibility for most of the six Ebola trials Hill is leading and, if they result in harmful side effects or deaths, these trials are covered by the same indemnity policy that covers all clinical trials run by the university.

Hill believes that, where the moral arguments for finding vaccines for these 15 outbreak pathogens have failed, economic arguments should now motivate governments, foundations, and organisations such as the World Bank to invest in pre-empting the next Ebola-like outbreak.
“Ebola has cost many billions already,” said Hill. “It would cost £20m each to do for these 15 pathogens what we’ve just done [for Ebola] . . . £300m in all. That would be a bargain. Then, industry would provide what only it can provide, which is large scale manufacturing capacity.”
Farrar said, “There does seem to be the will to do this among the governments, drug companies, and scientists. I just hope that we don’t find that, once the Ebola scare has passed, it’s just back to business as usual and people forget or just have other priorities.”

The problem with a reactive response
Peter Hotez, director of the Sabin Vaccine Institute in the US, is somewhat less optimistic. Rather than seeing the unprecedented global collaboration on Ebola as a game changer for vaccine development, he said that it would be a “one-off.”

“The problem with the global response is that it is always going to be reactive. We’re still too myopic to look beyond the end of our nose,” Hotez told The BMJ. “We wait for catastrophe to emerge and then try to mobilise the pharmaceutical companies.”

The Sabin Vaccine Institute developed a candidate vaccine for severe acute respiratory syndrome (SARS) and has more recently done the same for Middle East respiratory syndrome (MERS) coronavirus. But, said Hotez, “So far there is no financial backer to take this to the next stage. Even now, the US government is not interested.” He said he believed that the key to moving more quickly in future is not to rely on the cooperation of the big drug companies at all.
Jennifer Cohn, medical director of the Médecins Sans Frontières access campaign, agrees. “We can no longer link research to the cost of a drug,” she said. “Resources for developing drugs should be delinked from profitability. Governments are going to have to pay, one way or another.”

Hotez, who was made a US science ambassador for the Obama administration in January, has opened discussions with Morocco and Saudi Arabia, which currently import most of the drugs that they need, to explore ways in which the US could support these countries developing their own drug industries. “Building vaccine development and production capacity [in these countries] could take 10 years,” he said. “But it has to be done. It’s like going to Mars.”

China, Indonesia, and several other countries in Asia have already begun to do this, added Hotez. But the next potentially devastating epidemic will emerge in the Middle East or in north Africa, he believes, because of the disruption caused by the Syria-Iraq conflict: “This is going to be the next wave, and once again the world will be taken by surprise.”

The animal rule
In the US the federal drug authority’s so called “animal rule” was introduced in 2002 amid concern over bioterrorism, to allow approval, in a health emergency, of the use of experimental drugs that have shown potential only in animal trials.2

The European Union has similar mechanisms, but other parts of the world—crucially, the developing countries where these diseases are most likely to break out—do not. Many developing countries rely on the World Health Organization’s recommendations on drugs; as a result of the Ebola crisis WHO is now developing its own “emergency use assessment and listing procedure”3 to ensure quality, safety, and performance standards for diagnostics, vaccines, and medicines procured by United Nations agencies. It also aims to give guidance on the use of unlicensed products to member countries in future public health emergencies of international concern.

But it is not clear whether populations in developing countries would be as eager as Westerners to try unlicensed treatments or diagnostics, however serious a health threat they face. As the Ebola outbreak has shown, some countries have a great mistrust of authorities and of Western backed health interventions.

Part of the reason for the rapid spread of Ebola in west Africa was a reluctance among many to seek medical assistance. Similarly, drug trials are facing deep mistrust from the population, and some reports say that potential participants have been too suspicious to participate.

Box 1: Similar threats
Scientists warn that some other neglected infectious disease pathogens have the potential now to pose a similar threat to Ebola:
:: Marburg virus disease
:: African sleeping sickness
:: Rift Valley fever
:: Lassa fever
:: Crimean-Congo haemorrhagic fever
:: Leishmaniasis (also known as kala azar)
::: Hendra and Nipah virus diseases
:: West Nile fever
:: Pandemic influenza
:: Middle East respiratory syndrome (MERS)
:: Hantavirus pulmonary syndrome
:: Chapare haemorrhagic fever

Box 2: Timeline—Ebola drugs currently being tested
14 April 2015: Phase III trials of candidate vaccine VSV-ZEBOV (NewLink Genetics, Canada, and Merck) began in Sierra Leone, involving 6000 health and frontline workers.4 5 6
March 2015: Phase II trials in Liberia showed two candidate vaccines—Cad3-EBOV (GSK) and VSV-ZEBOV (NewLink Genetics, Canada; Merck, USA)—to be safe,7 but planned phase III trials in Liberia were not viable because only one confirmed new case of Ebola has been reported there since February 19.
Phase II trials began in Sierra Leone for TKM-100802 (siRNA), a candidate treatment made by a Canadian firm, Tekmira.
February 2015: Preliminary data presented from a phase II trial of the influenza drug favipiravir (Fujifilm/Toyama), which began in Guinea in December 2014, were insufficient, so the trial continues.
Phase II trials began in Liberia for ZMapp (MappBio, USA), a cocktail of three monoclonal antibodies with excellent activity against Ebola virus in animal models.
Phase I trials for a recombinant protein candidate Ebola vaccine developed by Novavax began in Australia.
January 2015: Phase II trials of brincidofovir (Chimerix, USA), an antiviral used to treat cytomegalovirus (CMV) in Liberia, were halted after Chimerix pulled out owing to insufficient numbers of new Ebola cases.
Phase I trials of two other candidate vaccines, Ad26-EBOV and MVA-EBOV (Johnson and Johnson/Bavarian Nordic), began in several countries outside west Africa.
December 2014: Phase I trials of VSV-ZEBOV in Geneva, Switzerland, were delayed for a month after some people complained of joint pains. Trials of the drug in three other countries were successful, and the dose had been higher in Geneva so it was reduced.

01 Wellcome Trust, Center for Infectious Disease Research and Policy. Recommendations for accelerating the development of Ebola vaccines: report and analysis. February 2015. http://www.wellcome.ac.uk/stellent/groups/corporatesite/@policy_communications/documents/web_document/wtp058693.pdf.
02 US Food and Drug Administration. Approval of new drugs when human efficacy studies are not ethical or feasible. April 2014. http://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/CFRSearch.cfm?CFRPart=314&showFR=1&subpartNode=21:
03 World Health Organization. Public consultation on emergency use assessment and listing procedures for medical products during public health emergencies. http://www.who.int/medicines/news/public_consult_med_prods/en/.
04 World Health Organization. Ebola vaccines, therapies, and diagnostics: questions and answers. 17 March 2015. http://www.who.int/medicines/emp_ebola_q_as/en/.
05 European Centre for Disease Prevention and Control. Treatment and vaccine development. 3 April 2015. http://ecdc.europa.eu/en/healthtopics/ebola_marburg_fevers/Pages/treatment-vaccines.aspx#sthash.Kc7C2zDm.dpuf.
06 Merck. Phase III trial of the Merck and NewLink Genetics investigational Ebola vaccine initiated in Sierra Leone. 14 April 2015. http://www.mercknewsroom.com/news-release/ebola-newsroom/phase-iii-trial-merck-and-newlink-genetics-investigational-ebola-vaccine.
07 National Institutes of Health. Ebola test vaccines appear safe in phase 2 Liberian clinical trial. 26 March 2015. http://www.nih.gov/news/health/mar2015/niaid-26a.htm.

Immunogenicity of reduced dose priming schedules of serogroup C meningococcal conjugate vaccine followed by booster at 12 months in infants: open label randomised controlled trial

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


Immunogenicity of reduced dose priming schedules of serogroup C meningococcal conjugate vaccine followed by booster at 12 months in infants: open label randomised controlled trial
BMJ 2015; 350 doi: http://dx.doi.org/10.1136/bmj.h1554 (Published 01 April 2015) Cite this as: BMJ 2015;350:h1554
David Pace, consultant infectious disease paediatrician1, Ameneh Khatami, clinical lecturer2,
Jennifer McKenna, senior research nurse2, Danielle Campbell, research nurse2, Simon Attard-Montalto, consultant paediatrician1, Jacqueline Birks, senior medical statistician3, Merryn Voysey, senior trial statistician4, Catherine White, paediatric clinical research nurse5, Adam Finn, professor of paediatrics5, Emma Macloed, paediatric clinical research nurse6, Saul N Faust, professor of paediatric immunology and infectious diseases67, Alison Louise Kent, clinical research fellow8, Paul T Heath, professor/consultant paediatric infectious diseases8, Ray Borrow, consultant clinical scientist/professor of vaccine preventable diseases9, Matthew D Snape, consultant in vaccinology and general paediatrics2, Andrew J Pollard, professor of paediatric infection and immunity2
Author affiliations
Accepted 17 February 2015
To determine whether the immunogenicity of a single dose infant priming schedule of serogroup C meningococcal (MenC) conjugate vaccine is non-inferior to a two dose priming schedule when followed by a booster dose at age 12 months.
Design Phase IV open label randomised controlled trial carried out from July 2010 until August 2013
Four centres in the United Kingdom and one centre in Malta.
Healthy infants aged 6-12 weeks followed up until age 24 months.
Interventions In the priming phase of the trial 509 infants were randomised in a 10:10:7:4 ratio into four groups to receive either a single MenC-cross reacting material 197 (CRM) dose at 3 months; two doses of MenC-CRM at 3 and 4 months; a single MenC-polysaccharide-tetanus toxoid (TT) dose at 3 months; or no MenC doses, respectively. Haemophilus influenzae type b (Hib)-MenC-TT vaccine was administered to all infants at 12 months of age. All infants also received the nationally routinely recommended vaccines. Blood samples were taken at age 5, 12, 13, and 24 months.
Main outcome measure
MenC serum bactericidal antibody assay with rabbit complement (rSBA) one month after the Hib-MenC-TT vaccine. Non-inferiority was met if the lower 95% confidence limit of the difference in the mean log10 MenC rSBA between the single dose MenC-CRM and the two dose MenC-CRM groups was >−0.35.
The primary objective was met: after a Hib-MenC-TT booster dose at 12 months of age the MenC rSBA geometric mean titres induced in infants primed with a single MenC-CRM dose were not inferior to those induced in participants primed with two MenC-CRM doses in infancy (660 (95% confidence interval 498 to 876) v 295 (220 to 398)) with a corresponding difference in the mean log10 MenC rSBA of 0.35 (0.17 to 0.53) that showed superiority of the single over the two dose schedule). Exploration of differences between the priming schedules showed that one month after Hib-MenC-TT vaccination, MenC rSBA ≥1:8 was observed in >96% of participants previously primed with any of the MenC vaccine schedules in infancy and in 83% of those who were not vaccinated against MenC in infancy. The MenC rSBA geometric mean titres induced by the Hib-MenC-TT boost were significantly higher in children who were primed with one rather than two MenC-CRM doses in infancy. Only priming with MenC-TT, however, induced robust MenC bactericidal antibody after the Hib-MenC-TT booster that persisted until 24 months of age.
MenC vaccination programmes with two MenC infant priming doses could be reduced to a single priming dose without reducing post-boost antibody titres. When followed by a Hib-MenC-TT booster dose, infant priming with a single MenC-TT vaccine dose induces a more robust antibody response than one or two infant doses of MenC-CRM. Bactericidal antibody induced by a single Hib-MenC-TT conjugate vaccine dose at 12 months of age (that is, a toddler only schedule), without infant priming, is not well sustained at 24 months. Because of rapid waning of MenC antibody, programmes using toddler only schedules will still need to rely on herd protection to protect infants and young children.
Trial registration
Eudract No: 2009-016579-31; NCT01129518; study ID: 2008_06 (http://clinicaltrials.gov).

Ebola—challenge and revival of theoretical epidemiology: Why Extrapolations from early phases of epidemics are problematic

May/June 2015 Volume 20, Issue 5 Pages C1–C1, 1–76

The Simply Complex
Ebola—challenge and revival of theoretical epidemiology: Why Extrapolations from early phases of epidemics are problematic
Peter Schuster*
Article first published online: 28 APR 2015
DOI: 10.1002/cplx.21694
[Initial text]
At the beginning of the second half of the 20th century, there was a widespread belief that science and in particular medicine had progressed so far that Nature could be brought under complete control. It seemed that healthcare and pharmacology were in the position to prevent or to cure almost all diseases. In the 1980s, for example, the pharmaceutical industry stopped the search for new antibiotic drugs that would be badly needed nowadays in the light of the universal capabilities of bacteria to develop resistance factors. At about the same time previously unknown or unnoticed virus transmitted infectious human diseases appeared: acquired immunodeficiency syndrome caused by human immunodeficiency virus (HIV), Ebola caused by Ebola virus (EBOV) and four related other strains of filoviridae, as well as severe acquired respiratory syndrome (SARS) brought about by SARS coronavirus. Caused by prions and not by a virus is been bovine spongiform encephalopathy (BSE). Nevertheless, it gave rise to an equally serious new epidemic. These and other cases as well as the consequences of the “antivaccination movement” [1, 2], for example, the recent reoccurrence of pertussis and measles, revived a need of reliable models in epidemiology. In particular, the recent Ebola epidemic starting in December 2013 in West Africa [3] initiated a new boom in theoretical work on infectious disease dynamics [4]. In PLoS Currents Outbreaks I counted 27 articles between the first publication on the recent Ebola epidemics on May 02, 2014 until March 09, 2015. In December 2014, researchers became aware that the predictions made 3 months earlier, in Fall 2014, apparently overstated the numbers of cases and deaths. A recent theoretical paper aims at an analysis of the prediction errors and provides suggestions how to make better forecasts [5]. In this essay, we shall be concerned with the predictive power of one frequently used model denoted as susceptible-exposed-infectious-removed (SEIR) model, and try to analyze typical general problems of predictions from early stages of exponentially growing systems to the final outcomes of the processes. In the focus are the model inherent limitations of reliabilities and not the lack of information or external problems like insufficient data or the uncertainty about the effectiveness of intervention strategies or countermeasures…

Access to healthcare for the most vulnerable migrants: a humanitarian crisis

Conflict and Health
[Accessed 9 May 2015]

Letter to Editor
Access to healthcare for the most vulnerable migrants: a humanitarian crisis
Kevin Pottie1*, Jorge Pedro Martin2, Stephen Cornish3, Linn Maria Biorklund4, Ivan Gayton5, Frank Doerner6 and Fabien Schneider3
Author Affiliations
Conflict and Health 2015, 9:16 doi:10.1186/s13031-015-0043-8
Published: 7 May 2015
Abstract (provisional)
A series of Médecins Sans Frontières projects over the past decade have consistently documented high rates of physical and sexual trauma, extortion and mental illness amidst severe healthcare, food, and housing limitations. Complex interventions were needed to begin to address illness and barriers to healthcare and to help restore dignity to the most vulnerable women, children and men. Promising interventions included mobile clinics, use of cultural mediators, coordination with migrant-friendly entities and NGOs and integrating advocacy programs and mental health care with medical services. Ongoing interventions, research and coordination are needed to address this neglected humanitarian crisis.

Breast milk and its impact on maturation of the neonatal immune system

Current Opinion in Infectious Diseases
June 2015 – Volume 28 – Issue 3 pp: v-v,199-282

Breast milk and its impact on maturation of the neonatal immune system
Turfkruyer, Mathilde; Verhasselt, Valerie
Purpose of review:
This article aims to review the evidence that breast milk can actively shape neonate gut immune system development toward a mature immune system capable of responding appropriately to encountered antigens.
Recent findings:
Recent findings in the adult have demonstrated the critical role of the interaction between diet, gut microbiota, gut epithelial cells and gut-associated lymphoid tissue in the development of immune responses. Here, we will review what is known in this field in the neonate, compare these data to those obtained in the adult and review how milk factors impact gut immune function in the short and long term.
We propose that the neonate immune system and maternal milk represent an entity necessary to ensure not only appropriate function in early life but also long term immune homeostasis.

Public health response to two incidents of confirmed MERS-CoV cases travelling on flights through London Heathrow Airport in 2014 – lessons learnt

Volume 20, Issue 18, 07 May 2015

Public health response to two incidents of confirmed MERS-CoV cases travelling on flights through London Heathrow Airport in 2014 – lessons learnt
F Parry-Ford1, N Boddington1, R Pebody1, N Phin1, on behalf of the Incident Management Team2
Centre for Infectious Disease Surveillance and Control, Public Health England, London, United Kingdom

In May 2014, Public Health England was alerted to two separate laboratory-confirmed cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection who transited through London Heathrow Airport while symptomatic on flights from Saudi Arabia to the United States of America. We present the rationale for the public health response to both incidents, and report results of contact tracing. Following a risk assessment, passengers seated two seats around the cases were prioritised for contact tracing and a proactive media approach was used to alert all passengers on the planes of their possible exposure in both incidents. In total, 64 United Kingdom (UK) residents were successfully contacted, 14 of whom were sat in the priority area two seats all around the case(s). Five passengers reported respiratory symptoms within 14 days of the flight, but all tested were negative for MERS-CoV. Details of non-UK residents were passed on to relevant World Health Organization International Health Regulation focal points for follow-up, and no further cases were reported back. Different approaches were used to manage contact tracing for each flight due to variations in the quality and timeliness of the passenger contact information provided by the airlines involved. No evidence of symptomatic onward transmission was found…

Medicines availability for non-communicable diseases: the case for standardized monitoring

Globalization and Health
[Accessed 9 May 2015]

Medicines availability for non-communicable diseases: the case for standardized monitoring
Jane Robertson12*, Cécile Macé1, Gilles Forte1, Kees de Joncheere1 and David Beran34
Author Affiliations
Globalization and Health 2015, 11:18 doi:10.1186/s12992-015-0105-0
Published: 7 May 2015
Abstract (provisional)
In response to the global burden of non-communicable diseases (NCDs), the World Health Organization (WHO) has developed a Global Action Plan that includes a voluntary medicines target of 80% availability and affordability of essential medicines for the prevention and treatment of diabetes, cardiovascular disease and respiratory disease both in public and private health facilities. Reliable measures of medicines availability are needed to track progress towards meeting this target. The results of three studies measuring the availability of medicines for hypertension and diabetes conducted in Tanzania in 2012–2013 were compared to assess the consistency of the results across the studies.
Availability was defined by observation of the medicine (no minimum quantity) on the day of the survey. The three studies involved 24, 107 and 1297 health facilities. Estimates of the availability of medicines for hypertension and diabetes were compared for medicines availability overall, by managing authority (government, mission/faith-based, private-for-profit), by facility level (hospital, health centre, dispensary) and by setting (urban, rural).
Comparisons of the availability of medicines were limited by differences in the definitions of the medicines and the classifications of the facilities surveyed. Metformin was variously reported as available in 33%, 39%, 46%, and 57% of facilities. Glibenclamide availability ranged from 19% to 52%. One study reported low levels of insulin availability (9-16% depending on insulin type) compared to 34% in a second study. Captopril (or angiotensin converting enzyme [ACE] inhibitor) availability ranged from 13% to 48%while availability of calcium channel blockers was 29% to 57% and beta-blockers 15% to 50%. Trends were similar across studies with lower availability in government compared to mission or private facilities, in dispensary and health centres compared to hospitals, and in rural compared to urban facilities.
All three studies showed suboptimal availability of NCD medicines, however the estimates of availability differed. Regular monitoring using reproducible methods and measuring key medicines must replace ad-hoc studies, small selected samples and differences in definitions. Low and middle-income countries need to implement monitoring and evaluation systems to track progress towards meeting the NCD medicines target and to inform country-level interventions to improve access to NCD medicines.

ACA Provisions Associated With Increase In Percentage Of Young Adult Women Initiating And Completing The HPV Vaccine

Health Affairs
May 2015; Volume 34, Issue 5

ACA Provisions Associated With Increase In Percentage Of Young Adult Women Initiating And Completing The HPV Vaccine
Brandy J. Lipton1,* and Sandra L. Decker2
Author Affiliations
1Brandy J. Lipton is a senior service fellow in the Office of Analysis and Epidemiology, National Center for Health Statistics, in Hyattsville, Maryland.
2Sandra L. Decker is a distinguished consultant in the Office of Analysis and Epidemiology, National Center for Health Statistics.
*Corresponding author
Affordable Care Act provisions implemented in 2010 required insurance plans to offer dependent coverage to people ages 19–25 and to provide targeted preventive services with zero cost sharing. These provisions both increased the percentage of young adults with any source of health insurance coverage and improved the generosity of coverage. We examined how these provisions affected use of the human papillomavirus (HPV) vaccine, which is among the most expensive of recommended vaccines, among young adult women. Using 2008–12 data from the National Health Interview Survey, we estimated that the 2010 policy implementation increased the likelihood of HPV vaccine initiation and completion by 7.7 and 5.8 percentage points, respectively, for women ages 19–25 relative to a control group of women age 18 or 26. These estimates translate to approximately 1.1 million young women initiating and 854,000 young women completing the vaccine series.

Innovations in communication technologies for measles supplemental immunization activities: lessons from Kenya measles vaccination campaign, November 2012

Health Policy and Planning
Volume 30 Issue 5 June 2015


Innovations in communication technologies for measles supplemental immunization activities: lessons from Kenya measles vaccination campaign, November 2012
William B Mbabazi1,*, Collins W Tabu2, Caleb Chemirmir3, James Kisia3, Nasra Ali3, Melissa G Corkum4 and Gene L Bartley5
Author Affiliations
1American Red Cross International Response and Programs, PO Box 41275-00100, Nairobi, Kenya, 2Division of Vaccines and Immunization, Ministry of Health, PO Box 30016, Nairobi, Kenya, 3Kenya Red Cross, PO Box 40712-00100, Nairobi, Kenya, 4UNICEF East and Southern African Regional Office, United Nations Complex, Gigiri, PO Box 44145-00100, Nairobi, Kenya and 5Bill and Melinda Gates Foundation, PO Box 45335-00100 Nairobi, Kenya
Accepted April 20, 2014.
To achieve a measles free world, effective communication must be part of all elimination plans. The choice of communication approaches must be evidence based, locally appropriate, interactive and community owned. In this article, we document the innovative approach of using house visits supported by a web-enabled mobile phone application to create a real-time platform for adaptive management of supplemental measles immunization days in Kenya.
One thousand nine hundred and fifty-two Red Cross volunteers were recruited, trained and deployed to conduct house-to-house canvassing in 11 urban districts of Kenya. Three days before the campaigns, volunteers conducted house visits with a uniform approach and package of messages. All house visits were documented using a web-enabled mobile phone application (episurveyor) that in real-time relayed information collected to all campaign management levels. During the campaigns, volunteers reported daily immunizations to their co-ordinators. Post-campaign house visits were also conducted within 4 days, to verify immunization of eligible children, assess information sources and detect adverse events following immunization.
Fifty-six per cent of the 164,643 households visited said that they had heard about the planned 2012 measles vaccination campaign 1–3 days before start dates. Twenty-five per cent of households were likely to miss the measles supplemental dose if they had not been reassured by the house visit. Pre- and post-campaign reasons for refusal showed that targeted communication reduced misconceptions, fear of injections and trust in herbal remedies. Daily reporting of immunizations using mobile phones informed changes in service delivery plans for better immunization coverage. House visits were more remembered (70%) as sources of information compared with traditional mass awareness channels like megaphones (41%) and radio (37%).
In high-density settlements, house-to-house visits are easy and more penetrative compared with traditional media approaches. Using mobile phones to document campaign processes and outputs provides real time evidence for service delivery planning to improve immunization coverage.

Determinants of HIV testing among Nigerian couples: a multilevel modelling approach

Health Policy and Planning
Volume 30 Issue 5 June 2015


Determinants of HIV testing among Nigerian couples: a multilevel modelling approach
Aurélia Lépine*, Fern Terris-Prestholt and Peter Vickerman
Author Affiliations
London School of Hygiene and Tropical Medicine, Global Health and Development Department, London, WC1H 9SH, UK
Accepted April 5, 2014.
In this article we analyse the determinants of HIV testing among Nigerian couples using Demographic and Health Survey data set (2008). This study is motivated by the fact that although there is a strong willingness from the Nigerian Government to examine new HIV preventions approaches such as Pre-Exposure Prophylaxis for HIV (PrEP) and Treatment as Prevention (TasP) for HIV serodiscordant couples, the implementation of such policies would require the HIV status of each partner in the couple to be known. This is far to be achieved in the Nigerian context since in Nigeria only 6% of couples know their HIV status. In order to identify potential policies that are needed to increase HIV testing uptake, we use a three-level random intercept logistic model to separately explore the determinants of knowing HIV status among female and male partners. The use of the multilevel modelling allows including the unobserved heterogeneity at the village and state level that may affect HIV testing behaviours. Our results indicate that education, wealth, stigma, HIV knowledge and perceived risk are predictors of HIV testing among both partners while routine provider initiated testing appears to be very effective to increase HIV testing among women. The introduction of financial incentives as well as an increase in routine testing and home-based testing may be needed for large scale increase in HIV testing prior to the implementation of new HIV prevention technologies among discordant couples.

Measuring political commitment and opportunities to advance food and nutrition security: piloting a rapid assessment tool

Health Policy and Planning
Volume 30 Issue 5 June 2015


Measuring political commitment and opportunities to advance food and nutrition security: piloting a rapid assessment tool
Ashley M Fox1,*, Yarlini Balarajan2, Chloe Cheng3 and Michael R Reich4
Author Affiliations
1Department of Health Evidence and Policy, Mount Sinai School of Medicine, One Gustave L. Levy Place, New York, NY 10029, USA and 2Nutrition Section, Programme Division, United Nations Children’s Fund (UNICEF), Three United Nations Plaza, New York, NY 10017, USA, 3Department of Health Evidence and Policy, Mount Sinai School of Medicine, One Gustave L. Levy Place, New York, NY 10029, USA, 4Department of Global Health and Population, Harvard School of Public Health, 665 Huntington Avenue, Boston, MA 02115, USA
Accepted April 6, 2014.
Lack of political commitment has been identified as a primary reason for the low priority that food and nutrition interventions receive from national governments relative to the high disease burden caused by malnutrition. Researchers have identified a number of factors that contribute to food and nutrition’s ‘low-priority cycle’ on national policy agendas, but few tools exist to rapidly measure political commitment and identify opportunities to advance food and nutrition on the policy agenda. This article presents a theory-based rapid assessment approach to gauging countries’ level of political commitment to food and nutrition security and identifying opportunities to advance food and nutrition on the policy agenda. The rapid assessment tool was piloted among food and nutrition policymakers and planners in 10 low- and middle-income countries in April to June 2013. Food and nutrition commitment and policy opportunity scores were calculated for each country and strategies to advance food and nutrition on policy agendas were designed for each country. The article finds that, in a majority of countries, political leaders had verbally and symbolically committed to addressing food and nutrition, but adequate financial resources were not allocated to implement specific programmes. In addition, whereas the low cohesion of the policy community has been viewed a major underlying cause of the low-priority status of food and nutrition, the analysis finds that policy community cohesion and having a well thought-out policy alternative were present in most countries. This tool may be useful to policymakers and planners providing information that can be used to benchmark and/or evaluate advocacy efforts to advance reforms in the food and nutrition sector; furthermore, the results can help identify specific strategies that can be employed to move the food and nutrition agenda forward. This tool complements others that have been recently developed to measure national commitment to advancing food and nutrition security.

The cost of a knowledge silo: a systematic re-review of water, sanitation and hygiene interventions

Health Policy and Planning
Volume 30 Issue 5 June 2015


The cost of a knowledge silo: a systematic re-review of water, sanitation and hygiene interventions
Michael Loevinsohn1,*, Lyla Mehta1,2, Katie Cuming1, Alan Nicol1,4, Oliver Cumming3 and
Jeroen H J Ensink3
Author Affiliations
1Knowledge, Technology and Society Team, Institute of Development Studies, Library Road, Brighton BN1 9RE, UK, 2Noragric, Norwegian University of Life Sciences, P.O. Box 5003, NO-1432 Aas, Norway, 3Environmental Health Group, Department of Disease Control, Faculty of Infectious Tropical Disease, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT and 4Present address: CARE International in Uganda, Box 7280 Kampala, Uganda
Accepted April 5, 2014.
Divisions between communities, disciplinary and practice, impede understanding of how complex interventions in health and other sectors actually work and slow the development and spread of more effective ones. We test this hypothesis by re-reviewing a Cochrane-standard systematic review (SR) of water, sanitation and hygiene (WASH) interventions’ impact on child diarrhoea morbidity: can greater understanding of impacts and how they are achieved be gained when the same papers are reviewed jointly from health and development perspectives? Using realist review methods, researchers examined the 27 papers for evidence of other impact pathways operating than assumed in the papers and SR. Evidence relating to four questions was judged on a scale of likelihood. At the ‘more than possible’ or ‘likely’ level, 22% of interventions were judged to involve substantially more actions than the SR’s label indicated; 37% resulted in substantial additional impacts, beyond reduced diarrhoea morbidity; and unforeseen actions by individuals, households or communities substantially contributed to the impacts in 48% of studies. In 44%, it was judged that these additional impacts and actions would have substantially affected the intervention’s effect on diarrhoea morbidity. The prevalence of these impacts and actions might well be found greater in studies not so narrowly selected. We identify six impact pathways suggested by these studies that were not considered by the SR: these are tentative, given the limitations of the literature we reviewed, but may help stimulate wider review and primary evaluation efforts. This re-review offers a fuller understanding of the impacts of these interventions and how they are produced, pointing to several ways in which investments might enhance health and wellbeing. It suggests that some conclusions of the SR and earlier reviews should be reconsidered. Moreover, it contributes important experience to the continuing debate on appropriate methods to evaluate and synthesize evidence on complex interventions.

Monitoring the ability to deliver care in low- and middle-income countries: a systematic review of health facility assessment tools

Health Policy and Planning
Volume 30 Issue 5 June 2015


Monitoring the ability to deliver care in low- and middle-income countries: a systematic review of health facility assessment tools
Jason W Nickerson1,2,*, Orvill Adams3, Amir Attaran4,5, Janet Hatcher-Roberts6 and Peter Tugwell7
Author Affiliations
1Institute of Population Health, University of Ottawa, Ottawa, ON, Canada, 2Bruyère Research Institute, Ottawa, ON, Canada, 3Orvill Adams and Associates, Ottawa, ON, Canada, 4Faculty of Common Law, University of Ottawa, Ottawa, ON, Canada, 5Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada, 6Canadian Society for International Health, Ottawa, ON, Canada and 7Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
Accepted April 25, 2014.
Health facilities assessments are an essential instrument for health system strengthening in low- and middle-income countries. These assessments are used to conduct health facility censuses to assess the capacity of the health system to deliver health care and to identify gaps in the coverage of health services. Despite the valuable role of these assessments, there are currently no minimum standards or frameworks for these tools.
We used a structured keyword search of the MEDLINE, EMBASE and HealthStar databases and searched the websites of the World Health Organization, the World Bank and the International Health Facilities Assessment Network to locate all available health facilities assessment tools intended for use in low- and middle-income countries. We parsed the various assessment tools to identify similarities between them, which we catalogued into a framework comprising 41 assessment domains.
We identified 10 health facility assessment tools meeting our inclusion criteria, all of which were included in our analysis. We found substantial variation in the comprehensiveness of the included tools, with the assessments containing indicators in 13 to 33 (median: 25.5) of the 41 assessment domains included in our framework. None of the tools collected data on all 41 of the assessment domains we identified.
Not only do a large number of health facility assessment tools exist, but the data they collect and methods they employ are very different. This certainly limits the comparability of the data between different countries’ health systems and probably creates blind spots that impede efforts to strengthen those systems. Agreement is needed on the essential elements of health facility assessments to guide the development of specific indicators and for refining existing instruments.

Sexual violence in India: addressing gaps between policy and implementation

Health Policy and Planning
Volume 30 Issue 5 June 2015


Sexual violence in India: addressing gaps between policy and implementation
Prachi Sharma1, M K Unnikrishnan1 and Abhishek Sharma1,2,*
Author Affiliations
1Manipal College of Pharmaceutical Sciences, Manipal University, Madhav Nagar, Manipal 576104, Karnataka, India, 2Department of International Health, Boston University School of Public Health, 715 Albany Street, Boston, Massachusetts 02118, United States of America
Accepted February 6, 2014.
The savage Delhi rape of 16 December 2012 was instrumental in generating the Verma Report that framed policies for amending the Criminal Laws related to sexual violence, professionalizing forensic/medical examination of victims, and sensitizing the police, electorate and the educational sectors. Unfortunately, even after a year, the Indian Home Ministry has abysmally failed to implement most recommendations, even underutilizing budgetary allocations. This article addresses gaps in governance systems and offers solutions to the problem of sexual violence in India.

Substandard Vaccination Compliance and the 2015 Measles Outbreak

JAMA Pediatrics
May 2015, Vol 169, No. 5

Research Letter | May 2015
Substandard Vaccination Compliance and the 2015 Measles Outbreak
Maimuna S. Majumder, MPH1,2; Emily L. Cohn, MPH2; Sumiko R. Mekaru, DVM, PhD2; Jane E. Huston, MPH2; John S. Brownstein, PhD2,3
Author Affiliations
JAMA Pediatr. 2015;169(5):494-495. doi:10.1001/jamapediatrics.2015.0384.
The ongoing measles outbreak linked to the Disneyland Resort in Anaheim, California, shines a glaring spotlight on our nation’s growing antivaccination movement and the prevalence of vaccination-hesitant parents. Although the index case has not yet been identified, the outbreak likely started sometime between December 17 and 20, 2014.1,2 Rapid growth of cases across the United States indicates that a substantial percentage of the exposed population may be susceptible to infection due to lack of, or incomplete, vaccination. Herein, we attempt to analyze existing, publicly available outbreak data to assess the potential role of suboptimal vaccination coverage in the population.

Journal of Community Health – June 2015 [HPV Vaccination]

Journal of Community Health
Volume 40, Issue 3, June 2015

Latino Parents’ Perceptions of the HPV Vaccine for Sons and Daughters
Echo L. Warner, Djin Lai, Sara Carbajal-Salisbury, Luis Garza, Julia Bodson, Kathi Mooney,
Deanna Kepka
Latinas have the highest incidence of cervical cancer. Latino parents’ perceptions of the human papillomavirus (HPV) and willingness to have their sons and daughters vaccinated in Utah is largely unknown. Latino parents/guardians of children ages 11–17 years were recruited from two community organizations (N = 52) to participate in a mini-survey and focus group. Guided by the social ecological framework, a Latina facilitator conducted five focus groups that were recorded, transcribed and translated. Descriptive statistics were calculated from the mini-survey. Two members of the research team performed inductive content analysis of the focus group transcriptions separately. Discrepancies were discussed and resolved during bi-weekly meetings with group members who were present during the focus groups. Parents reported low HPV vaccine knowledge, high vaccine costs, and lack of strong provider recommendations as the main barriers to vaccine receipt. Language appropriate educational resources and consistent provider recommendations may enrich Latino parents’ perceptions about the HPV vaccine.

HPV Vaccination Completion and Compliance with Recommended Dosing Intervals Among Female and Male Adolescents in an Inner-City Community Health Center
Rula M. Wilson, Diane R. Brown, Dennis P. Carmody, Sushanna Fogarty
Human papillomavirus (HPV) vaccination continues to lag behind other adolescent vaccines, especially in areas with pervasive disparities in HPV-related cancers. The purpose of this study was to examine HPV vaccine completion and dosing intervals among low-income adolescents in urban areas. The study included electronic health record data on HPV vaccination for 872 adolescents who received at least one dose of the HPV vaccine. Only 28.4 % completed the 3-dose series. For the whole sample, HPV vaccine completion was higher for non-English speakers and among adolescents seen at Newark-South and East Orange sites. Completion was higher among non-English speaking female and Hispanic adolescents, females seen in Newark-South and East Orange sites, and insured Black adolescents. Completion was also dramatically lower among non-English speaking Black adolescents seen at Newark-North, Irvington, and Orange sites (12.5 %) compared to other Black adolescents (22.0–44.4 %). The mean dosing intervals were 5.5 months (SD = 4.6) between dose 1 and 2 and 10 months (SD = 6.1) between dose 1 and 3. Longer durations between vaccine doses were found among uninsured adolescents and those seen at Newark-North, Irvington, and Orange sites. Non-English speakers had longer duration between dose 1 and 3. Further, durations between dose 1 and 3 were dramatically longer among insured adolescents seen at Newark-North, Irvington, and Orange locations for the whole sample (M = 11.70; SD = 7.12) and among Hispanic adolescents (M = 13.45; SD = 8.54). Understanding how the study predictors facilitate or impede HPV vaccination is critical to reducing disparities in cervical and other HPV-related cancer, especially among Black, Hispanic, and low-income populations.

Differences in HPV Immunization Levels Among Young Adults in Various Regions of the United States
Mahbubur Rahman, Momin Islam, Abbey B. Berenson
HPV vaccine uptake in young adult women in the Southern US has been previously found to be the lowest in the country. In addition, geographic variation with regard to HPV vaccination among young adult men has not been investigated yet. The objective of this study was to use the most recent data to determine if inequality still exists. We used Behavioral Risk Factor Surveillance System 2012 data from 8 states (no data available from Midwest) to examine the geographic variations in weighted proportion of adults who initiated (≥1 dose) and completed (3 doses) the HPV vaccine among 3727 young adults (2014 women and 1713 men) 18–26 years old based on self-reported HPV vaccination and socio-demographic characteristics. The weighted vaccine initiation and completion rates among men were: 6.3 and 1.7 % overall, 8.5 and 2.2 % in the Northeast, 6.7 and 1.6 % in the West, and 4.9 and 1.4 % in the South (p = 0.184 and 0.774). The rates among women were: 40.4 % and 27.4, 58.7 and 45.6 %, 39.0 and 24.8 %, and 30.4 and 17.7 % in the respective regions (p < 0.001 for both). Adjusted multivariable logistic regression showed that women living in the South and West were less likely to initiate and complete the 3-dose HPV vaccine series when compared to those in the Northeast. Despite an increase in HPV vaccine uptake among young adult women in all regions, geographic disparity still exists. Moreover, young adult men had very low HPV vaccine initiation and completion rates throughout the US.

The Lancet – May 09, 2015

The Lancet
May 09, 2015 Volume 385 Number 9980 p1803-1916 e45-e46

Rural health inequities: data and decisions
The Lancet
DOI: http://dx.doi.org/10.1016/S0140-6736(15)60910-2
70% of the world’s 1.4 billion people who are extremely poor live in rural areas. A new report released on April 27 by the UN International Labour Organisation (ILO), Global evidence on inequities in rural health protection: new data on rural deficits in health coverage for 174 countries, presents the first global, regional, and national data on the extent and major causes of rural–urban inequities in coverage, and access to health care. 56% of rural residents worldwide are without legal health coverage (defined as protected by legislation or affiliation with a health insurance scheme)—compared with 22% of the urban population.

Keeping watch on women’s cancers
The Lancet
DOI: http://dx.doi.org/10.1016/S0140-6736(15)60911-4
Cancer is a perennial public health issue. With refined estimates of the global burden of disease (GBD), the picture of cancer has become clearer and has begun to yield crucial new details about where the challenges lie. According to the 2013 GBD study, the cancers that contribute to the most deaths are: lung (1•64 million), stomach (840 000), liver (820 000), colorectal (770 000), and breast (470 000). But other areas of concern emerge when aggregating across types of cancer, such as cancers that specifically affect women.

Global health security now
Richard Horton, Pamela Das
DOI: http://dx.doi.org/10.1016/S0140-6736(15)60909-6
The concept of security as an important dimension of health divides opinions. To invoke the idea of security risks giving permission to more authoritarian-minded governments to use health crises as justification for sometimes extreme curbs on liberty or the political, economic, and social rights of citizens. During the Ebola virus disease outbreak, photographs appeared in news media of police brutally attacking the public for breaching curfews. Invoking arguments of global health security might further encourage this kind of violent response.

Putting science into practice for early child development
Anthony Lake, Margaret Chan
DOI: http://dx.doi.org/10.1016/S0140-6736(14)61680-9
The debate between nature and nurture as determinants of early child development is over. Today, we understand that the two are inextricably linked. The degree of their interdependence—and the impact of this interplay on the developing brains of children—is even greater than we previously imagined.1 This knowledge has tremendous implications for how we design and deliver early child development interventions…

Public Policy
Global health security: the wider lessons from the west African Ebola virus disease epidemic
Prof David L Heymann, MD, Lincoln Chen, MD, Prof Keizo Takemi, MA, Prof David P Fidler, BCL, Jordan W Tappero, MD, Mathew J Thomas, MPH, Thomas A Kenyon, MD, Thomas R Frieden, MD, Derek Yach, MBChB, Sania Nishtar, FRCP, Alex Kalache, Prof Piero L Olliaro, MD, Prof Peter Horby, MD, Els Torreele, PhD, Prof Lawrence O Gostin, JD, Margareth Ndomondo-Sigonda, MBA, Prof Daniel Carpenter, PhD, Simon Rushton, PhD, Louis Lillywhite, MSc, Prof Bhimsen Devkota, PhD, Prof Khalid Koser, PhD, Rob Yates, MBA ,Ranu S Dhillon, MD, Ravi P Rannan-Eliya, DPH
DOI: http://dx.doi.org/10.1016/S0140-6736(15)60858-3
The Ebola virus disease outbreak in West Africa was unprecedented in both its scale and impact. Out of this human calamity has come renewed attention to global health security—its definition, meaning, and the practical implications for programmes and policy. For example, how does a government begin to strengthen its core public health capacities, as demanded by the International Health Regulations? What counts as a global health security concern? In the context of the governance of global health, including WHO reform, it will be important to distil lessons learned from the Ebola outbreak. The Lancet invited a group of respected global health practitioners to reflect on these lessons, to explore the idea of global health security, and to offer suggestions for next steps. Their contributions describe some of the major threats to individual and collective human health, as well as the values and recommendations that should be considered to counteract such threats in the future. Many different perspectives are proposed. Their common goal is a more sustainable and resilient society for human health and wellbeing.

Public Policy
A retrospective and prospective analysis of the west African Ebola virus disease epidemic: robust national health systems at the foundation and an empowered WHO at the apex
Prof Lawrence O Gostin, JD, Eric A Friedman, JD
DOI: http://dx.doi.org/10.1016/S0140-6736(15)60644-4
The Ebola virus disease outbreak in west Africa is pivotal for the worldwide health system. Just as the depth of the crisis ultimately spurred an unprecedented response, the failures of leadership suggest the need for innovative reforms. Such reforms would transform the existing worldwide health system architecture into a purposeful, organised system with an empowered, highly capable WHO at its apex and enduring, equitable national health systems at its foundation. It would be designed not only to provide security against epidemic threats, but also to meet everyday health needs, thus realising the right to health. This retrospective and prospective analysis offers a template for these reforms, responding to the profound harms posed by fragile national health systems, delays in the international response, deficient resource mobilisation, ill defined responsibilities, and insufficient coordination. The scope of the reforms should address failures in the Ebola response, and entrenched weaknesses that enabled the epidemic to reach its heights.

What is a resilient health system? Lessons from Ebola
Margaret E Kruk, Michael Myers, S Tornorlah Varpilah, Bernice T Dahn
Ebola vaccines: keep the clinical trial protocols on the shelf and ready to roll out
David L Heymann, Guenael R Rodier, Michael J Ryan

The Effect of Different Graphical and Numerical Likelihood Formats on Perception of Likelihood and Choice

Medical Decision Making (MDM)
May 2015; 35 (4)

The Effect of Different Graphical and Numerical Likelihood Formats on Perception of Likelihood and Choice
Jurriaan P. Oudhoff, MD, PhD; Daniëlle R. M. Timmermans, PhD
EMGO Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands (JPO, DRMT)
Quantitative risk information plays an important role in decision making about health. This study focuses on commonly used numerical and graphical formats and examines their effect on perception of different likelihoods and choice preferences.
An experimental study was conducted with 192 participants, who evaluated 2 sets of 4 lotteries. Numerical formats to describe likelihood varied systematically between participants (X%, X-in-100, or 1-in-X). The effect of graphic formats (bar charts, icon charts) was assessed as a within-subjects factor. Dependent measures included perceived likelihood, choice preferences about participating in the lottery, and processing times.
Numerical likelihoods presented as 1-in-X were processed fastest and were perceived as conveying larger likelihoods than the X-in-100 and percentages formats (mean response times in seconds: 5.65 v. 7.31 and 6.50; mean rating on a 1–9 scale: 4.38 v. 3.30 and 3.31, respectively). The 1-in-X format also evoked a stronger willingness to participate in a lottery than the 2 other numerical formats. The effect of adding graphs on perceived likelihood was moderated by numerical aptitude. Graphs reduced ratings of perceived likelihood of participants with lower numeracy, while there was no overall effect for participants with higher numeracy. Conclusion.
Perception of likelihood differs significantly depending on the numerical format used. The 1-in-X format yields higher perceived likelihoods and it appears to be the easiest format to interpret. Graphs primarily affect perception of likelihood of people with lower numerical aptitude. These effects should be taken into account when discussing medical risks with patients.

PLoS Currents: Outbreaks (Accessed 9 May 2015)

PLoS Currents: Outbreaks
(Accessed 9 May 2015)

Assessing Measles Transmission in the United States Following a Large Outbreak in California
May 7, 2015 • Research
The recent increase in measles cases in California may raise questions regarding the continuing success of measles control. To determine whether the dynamics of measles is qualitatively different in comparison to previous years, we assess whether the 2014-2015 measles outbreak associated with an Anaheim theme park is consistent with subcriticality by calculating maximum-likelihood estimates for the effective reproduction number given this year’s outbreak, using the Galton-Watson branching process model. We find that the dynamics after the initial transmission event are consistent with prior transmission, but does not exclude the possibilty that the effective reproduction number has increased.

Epidemiological and Surveillance Response to Ebola Virus Disease Outbreak in Lofa County, Liberia (March-September, 2014); Lessons Learned
May 6, 2015 • Research
Ebola Virus Disease (EVD) outbreak was confirmed in Liberia on March 31st 2014. A response comprising of diverse expertise was mobilized and deployed to the country to contain transmission of Ebola and give relief to a people already impoverished from protracted civil war. This paper describes the epidemiological and surveillance response to the EVD outbreak in Lofa County in Liberia from March to September 2014. Five of the 6 districts of Lofa were affected. The most affected districts were Voinjama/Guardu Gbondi and Foya. By 26th September, 2014, a total of 619 cases, including 19.4% probable cases, 20.3% suspected cases and 44.2% confirmed cases were recorded by the Ebola Emergency Response Team (EERT) of Lofa County. Adults (20-50 years) were the most affected. Overall fatality rate was 53.3%. Twenty two (22) cases were reported among the Health Care Workers with a fatality rate of 81.8%. Seventy eight percent (78%) of the contacts successfully completed 21 days follow-up while 134 (6.15%) that developed signs and symptoms of EVD were referred to the ETU in Foya. The contributions of the weak health systems as well as socio-cultural factors in fueling the epidemic are highlighted. Importantly, the lessons learnt including the positive impact of multi-sectorial and multidisciplinary and coordinated response led by the government and community. Again, given that the spread of infectious disease can be considered a security threat every effort has to put in place to strengthen the health systems in developing countries including the International Health Regulation (IHR)’s core capacities.

Screening and Treating UN Peacekeepers to Prevent the Introduction of Artemisinin-Resistant Malaria into Africa

PLoS Medicine
(Accessed 9 May 2015)

Screening and Treating UN Peacekeepers to Prevent the Introduction of Artemisinin-Resistant Malaria into Africa
Stan Houston, Adam Houston
Published: May 5, 2015
DOI: 10.1371/journal.pmed.1001822
Summary Points
:: The Haitian cholera epidemic provides a tragic demonstration of the potential for United Nations peacekeepers to introduce serious disease into vulnerable populations.
:: Resistance to artemisinin derivatives, now the global standard therapy for falciparum malaria, has emerged and is spreading in Southeast Asia.
:: UN peacekeeping troops from Southeast Asia are frequently deployed in sub-Saharan Africa.
:: These circumstances entail a high risk of introducing artemisinin resistance into the populations most affected by malaria, with potentially disastrous consequences for malaria treatment and control in sub-Saharan Africa.
:: The UN has a responsibility to prevent such an outcome; selective predeployment screening and treatment of UN peacekeeping troops is feasible and urgently needed.
Introduction: The Precedent of Cholera in Haiti
In the aftermath of the massive earthquake that devastated Haiti in 2010, an ongoing epidemic of cholera introduced by United Nations peacekeepers has resulted in over 730,000 cases and over 8,700 deaths—the largest single-country cholera epidemic in nearly a century [1,2]. This disaster should serve as an urgent warning about the potential for introduction by UN troops of other serious infectious diseases into the vulnerable populations they were sent to protect. Indeed, the UN has recently agreed to avoid rotation of African troops to Haiti because of concern about the introduction of Ebola [3]. But the tragedy in Haiti pales in comparison to the scale of long-term impact on malaria morbidity, mortality, and control programs that would result from the introduction of artemisinin-resistance into sub-Saharan Africa, where 85% of the world’s falciparum malaria cases and over 90% of all malaria deaths now occur [4]. This threat demands urgent action, in particular on the part of the UN…

Millennium Development Goal Four and Child Health Inequities in Indonesia: A Systematic Review of the Literature

PLoS One
[Accessed 9 May 2015]

Millennium Development Goal Four and Child Health Inequities in Indonesia: A Systematic Review of the Literature
Julia Schröders, Stig Wall, Hari Kusnanto, Nawi Ng
Research Article | published 05 May 2015 | PLOS ONE 10.1371/journal.pone.0123629
Millennium Development Goal (MDG) 4 calls for reducing mortality of children under-five years by two-thirds by 2015. Indonesia is on track to officially meet the MDG 4 targets by 2015 but progress has been far from universal. It has been argued that national level statistics, on which MDG 4 relies, obscure persistent health inequities within the country. Particularly inequities in child health are a major global public health challenge both for achieving MDG 4 in 2015 and beyond. This review aims to map out the situation of MDG 4 with respect to disadvantaged populations in Indonesia applying the Social Determinants of Health (SDH) framework. The specific objectives are to answer: Who are the disadvantaged populations? Where do they live? And why and how is the inequitable distribution of health explained in terms of the SDH framework?
Methods and Findings
We retrieved studies through a systematic review of peer-reviewed and gray literature published in 1995-2014. The PRISMA-Equity 2012 statement was adapted to guide the methods of this review. The dependent variables were MDG 4-related indicators; the independent variable “disadvantaged populations” was defined by different categories of social differentiation using PROGRESS. Included texts were analyzed following the guidelines for deductive content analysis operationalized on the basis of the SDH framework. We identified 83 studies establishing evidence on more than 40 different determinants hindering an equitable distribution of child health in Indonesia. The most prominent determinants arise from the shortcomings within the rural health care system, the repercussions of food poverty coupled with low health literacy among parents, the impact of low household decision-making power of mothers, and the consequences of high persistent use of traditional birth attendants among ethnic minorities.
This review calls for enhanced understanding of the determinants and pathways that create, detain, and overcome inequities in child health in resource constraint settings like Indonesia and the promotion of actionable health policy recommendations and tailored investments.

Long-term measles-induced immunomodulation increases overall childhood infectious disease mortality

8 May 2015 vol 348, issue 6235, pages 605-728

Long-term measles-induced immunomodulation increases overall childhood infectious disease mortality
Michael J. Mina1,2,*, C. Jessica E. Metcalf1,3, Rik L. de Swart4, A. D. M. E. Osterhaus4, Bryan T. Grenfell1,3
Author Affiliations
1Department of Ecology and Evolutionary Biology, Princeton University, Princeton, NJ, USA.
2Medical Scientist Training Program, School of Medicine, Emory University, Atlanta, GA, USA.
3Fogarty International Center, National Institutes of Health, Bethesda, MD, USA.
4Department of Viroscience, Erasmus University Medical Center, Rotterdam, Netherlands.
Immunosuppression after measles is known to predispose people to opportunistic infections for a period of several weeks to months. Using population-level data, we show that measles has a more prolonged effect on host resistance, extending over 2 to 3 years. We find that nonmeasles infectious disease mortality in high-income countries is tightly coupled to measles incidence at this lag, in both the pre- and post-vaccine eras. We conclude that long-term immunologic sequelae of measles drive interannual fluctuations in nonmeasles deaths. This is consistent with recent experimental work that attributes the immunosuppressive effects of measles to depletion of B and T lymphocytes. Our data provide an explanation for the long-term benefits of measles vaccination in preventing all-cause infectious disease. By preventing measles-associated immune memory loss, vaccination protects polymicrobial herd immunity.

MATS: Global coverage estimates for 4CMenB, a novel multicomponent meningococcal B vaccine

Volume 33, Issue 23, Pages 2629-2734 (28 May 2015)


MATS: Global coverage estimates for 4CMenB, a novel multicomponent meningococcal B vaccine
Review Article
Pages 2629-2636
Duccio Medini, Maria Stella, James Wassil
Recently approved in the EU, US, Australia, and Canada, 4CMenB (Bexsero®, GSK Vaccines) is a multi-component meningococcal B (MenB) vaccine containing 3 surface exposed recombinant proteins (fHbp, NadA, and NHBA) and New Zealand strain outer membrane vesicles (NZ OMV) containing PorA 1.4. The accepted correlate of protection to assess response to MenB vaccines, the serum bactericidal assay with human complement, is impractical for large panels of strains with diverse antigenic profile and expression. Therefore, the Meningococcal Antigen Typing System (MATS) was developed to identify MenB strains with a high likelihood of being covered by 4CMenB. MATS is used to assess MenB strain coverage without requiring sera, an advantage for testing large panels of bacterial isolates. MATS provides an accurate, conservative estimate of 4CMenB coverage. In a public–private partnership, 10 reference laboratories around the world were established and standardized to facilitate the timely collection and analysis of regional data. MATS has global public health implications for informing local policy makers of the predicted effect of the implementation of the 4CMenB vaccine. Coverage estimates are similar to or better than other recently approved vaccines, ranging from 66% to 91%. The use of MATS in post-vaccine implementation surveillance could provide data regarding vaccine effectiveness in the field and duration of protection on a global scale that will aid in the development of vaccine booster schedules, if necessary. This MATS approach could potentially be applied rapidly to assess epidemiology of other bacterial pathogens and coverage by other protein-based vaccines.

Methods and challenges in measuring the impact of national pneumococcal and rotavirus vaccine introduction on morbidity and mortality in Malawi

Volume 33, Issue 23, Pages 2629-2734 (28 May 2015)


Methods and challenges in measuring the impact of national pneumococcal and rotavirus vaccine introduction on morbidity and mortality in Malawi
Original Research Article
Pages 2637-2645
Naor Bar-Zeev, Lester Kapanda, Carina King, James Beard, Tambosi Phiri, Hazzie Mvula, Amelia C. Crampin, Charles Mwansambo, Anthony Costello, Umesh Parashar, Jacqueline E. Tate, Jennifer R. Verani, Cynthia G. Whitney, Robert S. Heyderman, Nigel A. Cunliffe, Neil French, for the VacSurv Consortium
Pneumonia and gastroenteritis are leading causes of vaccine-preventable childhood morbidity and mortality. Malawi introduced pneumococcal conjugate and rotavirus vaccines to the immunisation programme in 2011 and 2012, respectively. Evaluating their effectiveness is vital to ensure optimal implementation and justify sustained investment.
A national evaluation platform was established to determine vaccine effectiveness and impact in Malawi. Impact and effectiveness against vaccine-type invasive pneumococcal disease, radiological pneumonia and rotavirus gastroenteritis are investigated using before-after incidence comparisons and case-control designs, respectively. Mortality is assessed using a prospective population cohort. Cost-effectiveness evaluation is nested within the case-control studies. We describe platform characteristics including strengths and weaknesses for conducting vaccine evaluations.
Integrating data from individual level and ecological methods across multiple sites provides comprehensive information for policymakers on programme impact and vaccine effectiveness including changes in serotype/genotype distribution over time. Challenges to robust vaccine evaluation in real-world conditions include: vaccination ascertainment; pre-existing rapid decline in mortality and pneumococcal disease in the context of non-vaccine interventions; and the maintenance of completeness and quality of reporting at scale and over time. In observational non-randomised designs ascertainment of vaccine status may be biased particularly in infants with fatal outcomes. In the context of multiple population level interventions targeting study endpoints attribution of reduced incidence to vaccine impact may be flawed. Providing evidence from several independent but complementary studies will provide the greatest confidence in assigning impact. Welcome declines in disease incidence and in child mortality make accrual of required sample sizes difficult, necessitating large studies to detect the relatively small but potentially significant contribution of vaccines to mortality prevention. Careful evaluation of vaccine effectiveness and impact in such settings is critical to sustaining support for vaccine programmes. Our evaluation platform covers a large population with a high prevalence of HIV and malnutrition and its findings will be relevant to other settings in sub-Saharan Africa.

Effectiveness of human papillomavirus vaccine against incident and persistent infections among young girls: Results from a longitudinal Dutch cohort study

Volume 33, Issue 23, Pages 2629-2734 (28 May 2015)


Effectiveness of human papillomavirus vaccine against incident and persistent infections among young girls: Results from a longitudinal Dutch cohort study
Original Research Article
Pages 2678-2683
Madelief Mollers, Audrey J. King, Mirjam J. Knol, Mirte Scherpenisse, Chris J.L.M. Meijer, Fiona R.M. van der Klis, Hester E. de Melker
Because of the long interval between infection with high-risk human papillomavirus (hrHPV) and development of cervical cancer surrogate markers for cancer incidence are necessary to monitor vaccine effectiveness (VE). The aim of this study was to calculate VE of HPV16/18 vaccination by annually assessing incident and persistent infections among (un)vaccinated girls from the general Dutch population up to 3 years after vaccination.
In 2009, 1668 girls (54% vaccinated) aged 14–16 years were enrolled in a prospective cohort study. Annually, questionnaire data were obtained, and a vaginal swab was tested for type-specific HPV DNA with SPF10-LiPA. VE was estimated by a Poisson model comparing type-specific infection rates in (un)vaccinated girls.
The adjusted VE (95% CI) was 73% (49–86%) against incident infections with HPV16/18 and 72% (52–84%) against HPV16/18/31/45. VE against persistent HPV16/18 was 100% and 76% (−17 to 95%) against HPV16/18/31/45. This number was lower (36%) when girls who were positive for HPV16 and 18 at baseline were included in the analysis. The overall VE for hrHPV types combined was small. Although 96% of girls were HPV-naïve at baseline, the cumulative 36-month incidence for any HPV was 20%, indicating high sexual activity.
Vaccination is effective against incident and persistent infections with HPV16/18 and HPV16/18/31/45. Low VE against persistent HPV16/18 infection in girls positive at baseline indicates importance of vaccination before sexual debut.

Estimating the costs of the vaccine supply chain and service delivery for selected districts in Kenya and Tanzania

Volume 33, Issue 23, Pages 2629-2734 (28 May 2015)


Estimating the costs of the vaccine supply chain and service delivery for selected districts in Kenya and Tanzania
Original Research Article
Pages 2697-2703
Mercy Mvundura, Kristina Lorenson, Amos Chweya, Rosemary Kigadye, Kathryn Bartholomew, Mohammed Makame, T. Patrick Lennon, Steven Mwangi, Lydia Kirika, Peter Kamau, Abner Otieno, Peninah Murunga, Tom Omurwa, Lyimo Dafrossa, Debra Kristensen
Having data on the costs of the immunization system can provide decision-makers with information to benchmark the costs when evaluating the impact of new technologies or programmatic innovations. This paper estimated the supply chain and immunization service delivery costs and cost per dose in selected districts in Kenya and Tanzania. We also present operational data describing the supply chain and service delivery points (SDPs).
To estimate the supply chain costs, we collected resource-use data for the cold chain, distribution system, and health worker time and per diems paid. We also estimated the service delivery costs, which included the time cost of health workers to provide immunization services, and per diems and transport costs for outreach sessions. Data on the annual quantities of vaccines distributed to each facility, and the occurrence and duration of stockouts were collected from stock registers. These data were collected from the national store, 2 regional and 4 district stores, and 12 SDPs in each country for 2012. Cost per dose for the supply chain and immunization service delivery were estimated.
The average annual costs per dose at the SDPs were $0.34 (standard deviation (s.d.) $0.18) for Kenya when including only the vaccine supply chain costs, and $1.33 (s.d. $0.82) when including immunization service delivery costs. In Tanzania, these costs were $0.67 (s.d. $0.35) and $2.82 (s.d. $1.64), respectively. Both countries experienced vaccine stockouts in 2012, bacillus Calmette-Guérin vaccine being more likely to be stocked out in Kenya, and oral poliovirus vaccine in Tanzania. When stockouts happened, they usually lasted for at least one month.
Tanzania made investments in 2011 in preparation for planned vaccine introductions, and their supply chain cost per dose is expected to decline with the new vaccine introductions. Immunization service delivery costs are a significant portion of the total costs at the SDPs.

Accuracy of administrative claims data to identify dose specific rotavirus vaccination information: Implications for studies of vaccine safety

Volume 33, Issue 22, Pages 2517-2628 (21 May 2015)


Accuracy of administrative claims data to identify dose specific rotavirus vaccination information: Implications for studies of vaccine safety
Pages 2517-2520
Scott C. Quinlan, Stephan Lanes, Crystal N. Holick, T. Christopher Mast
The accuracy of vaccine administration information recorded in administrative claims databases is uncertain.
We conducted a retrospective cohort study using the HealthCore Integrated Research DatabaseSM among infants who received at least 1 RotaTeq® (RV5) dose during the first year of life between February 1, 2006 and November 30, 2012 and were enrolled in the health plan at birth. We reviewed medical records for a sample of infants to validate vaccine administration information.
We identified 169,560 infants who received at least 1 RV5 dose. Medical records were obtained for 85 infants, of which 74 (PPV1 87.1%; 95% CI 78.0–93.4%) had a corresponding first RV5 vaccination in the medical record with the same or similar administration date.
Administrative claims contained inaccuracies in dose number or administration date for 13% of RV5 first doses identified.

Accuracy of administrative claims data to identify dose specific rotavirus vaccination information: Implications for studies of vaccine safety

Volume 33, Issue 22, Pages 2517-2628 (21 May 2015)


Accuracy of administrative claims data to identify dose specific rotavirus vaccination information: Implications for studies of vaccine safety
Pages 2517-2520
Scott C. Quinlan, Stephan Lanes, Crystal N. Holick, T. Christopher Mast
The accuracy of vaccine administration information recorded in administrative claims databases is uncertain.
We conducted a retrospective cohort study using the HealthCore Integrated Research DatabaseSM among infants who received at least 1 RotaTeq® (RV5) dose during the first year of life between February 1, 2006 and November 30, 2012 and were enrolled in the health plan at birth. We reviewed medical records for a sample of infants to validate vaccine administration information.
We identified 169,560 infants who received at least 1 RV5 dose. Medical records were obtained for 85 infants, of which 74 (PPV1 87.1%; 95% CI 78.0–93.4%) had a corresponding first RV5 vaccination in the medical record with the same or similar administration date.
Administrative claims contained inaccuracies in dose number or administration date for 13% of RV5 first doses identified.

Nudges or mandates? The ethics of mandatory flu vaccination

Volume 33, Issue 22, Pages 2517-2628 (21 May 2015)


Nudges or mandates? The ethics of mandatory flu vaccination
Review Article
Pages 2530-2535
Alex Dubov, Connie Phung
According to the CDC report for the 2012–2013 influenza season, there was a modest increase in the vaccination coverage rate among healthcare workers from 67% in 2011–2012, to 72% in 2012–2013 to the current 75% coverage. This is still far from reaching the US National Healthy People 2020 goal of 90% hospitals vaccination rates. The reported increase in coverage is attributed to the growing number of healthcare facilities with vaccination requirements with average rates of 96.5%. However, a few other public health interventions stir so much controversy and debate as vaccination mandates. The opposition stems from the belief that a mandatory flu shot policy violates an individual right to refuse unwanted treatment. This article outlines the historic push to achieve higher vaccination rates among healthcare professionals and a number of ethical issues arising from attempts to implement vaccination mandates. It then turns to a review of cognitive biases relevant in the context of decisions about influenza vaccination (omission bias, ambiguity aversion, present bias etc.) The article suggests that a successful strategy for policy-makers and others hoping to increase vaccination rates is to design a “choice architecture” that influences behavior of healthcare professionals without foreclosing other options. Nudges incentivize vaccinations and help better align vaccination intentions with near-term actions.

Socioeconomic status and HIV vaccine preparedness studies in North America

Volume 33, Issue 22, Pages 2517-2628 (21 May 2015)


Socioeconomic status and HIV vaccine preparedness studies in North America
Review Article
Pages 2536-2545
Shayesta Dhalla, Gary Poole
Educational level, employment, and income are key components of socioeconomic status (SES). This article is a systematic review of SES variables in North American countries, and their relationship to willingness to participate (WTP) and retention in a hypothetical preventive phase 3 HIV vaccine trial and in actual HIV vaccine trials. Men who have sex with men (MSM) tended to have higher educational levels, be more employed, and had higher income levels than injection drug users (IDU) and women at heterosexual risk (WAHR). In large part, there was no relationship between educational level and WTP, as well as between educational level and retention. Similarly, there was no relationship between employment and WTP. In WAHR who were African-American, those employed were less likely than others to complete the study at 18 months. The exact occupations of participants analyzed have not been specified, and specification of these occupations may help determine whether enhanced retention (ER) strategies are required.

Immune overload: Parental attitudes toward combination and single antigen vaccines

Volume 33, Issue 22, Pages 2517-2628 (21 May 2015)


Immune overload: Parental attitudes toward combination and single antigen vaccines
Original Research Article
Pages 2546-2550
Ella Hulsey, Tami Bland
Parental concerns have led to a recent decline in immunization coverage, resulting in outbreaks of diseases that were once under control in the US. As the CDC vaccination schedule continues to increase in complexity, the number of required injections per office visit increases as well. Some parents perceive that there is trauma associated with the administration of multiple injections, and research shows that having multiple vaccines due in a single visit is associated with delays and lower immunization rates. Combination vaccines make vaccination more efficient by incorporating the antigens of several different diseases into a single injection, but many parents worry that they may overload the child’s developing immune system and leave him or her susceptible to secondary infections. This literature review synthesizes current evidence regarding the parental fear of vaccine-induced immune system overload and the fear of vaccine-associated trauma, in an attempt to understand the scope and nature of these fears. Despite the wealth of knowledge about each of these fears individually, it is still unknown which is of greater concern and how this affects parental decision-making.

Effect of media use on mothers’ vaccination of their children in sub-Saharan Africa

Volume 33, Issue 22, Pages 2517-2628 (21 May 2015)


Effect of media use on mothers’ vaccination of their children in sub-Saharan Africa
Original Research Article
Pages 2551-2557
Minsoo Jung, Leesa Lin, Kasisomayajula Viswanath
While several studies have examined the crucial role that parents’ vaccination behaviors play in reducing disease spread and severity among children, few have evaluated the connection between parents’ media use and their decision on whether or not to vaccinate their child, specifically in relation to the BCG (Bacillus Calmetter Guerin), DPT (Diptheria, Pertussis, Tetanus) polio, and measles vaccines. Media channels are a critical source of health information for parents, which is especially true in Sub-Saharan Africa, as there is often a dearth of local healthcare providers. The aim of this paper is to investigate the role that media use plays in a mothers’ choice to vaccinate their infant children in sub-Saharan Africa, specifically focusing on whether media use is associated with socioeconomic status (SES) and a mothers’ vaccination of their children. Cross-sectional data from the Demographic Health Surveys of 13 sub-Saharan countries (2004–2010) were pooled. A multivariate Poisson regression of 151,209 women was used to calculate adjusted relative ratios and 95% confidence intervals for the associations among SES, media use, and immunization. Education and wealth were found to be strongly and positively associated with vaccine-uptake behaviors. The effects of media use (radio and television) were found to be associated with the relationships between SES and vaccine uptake. However, it did not reduce the impact of SES on vaccination. These findings indicate that mass media may be an important tool for future efforts to reduce the health discrepancies between children from high- and low-socioeconomic backgrounds. Going forward, immunization strategies should include communication plans that will address and mitigate potential immunization disparities among parents of different SES backgrounds.

Changes in the prevalence of influenza-like illness and influenza vaccine uptake among Hajj pilgrims: A 10-year retrospective analysis of data

Volume 33, Issue 22, Pages 2517-2628 (21 May 2015)

Changes in the prevalence of influenza-like illness and influenza vaccine uptake among Hajj pilgrims: A 10-year retrospective analysis of data
Original Research Article
Pages 2562-2569
Mohammad Alfelali, Osamah Barasheed, Mohamed Tashani, Mohammad Irfan Azeem, Haitham El Bashir, Ziad A. Memish, Leon Heron, Gulam Khandaker, Robert Booy, Harunor Rashid, on behalf of the Hajj Research Team
Influenza is an important health hazard among Hajj pilgrims. For the last ten years, pilgrims are being recommended to take influenza vaccine before attending Hajj. Vaccination coverage has increased in recent years, but whether there has been any change in the prevalence of influenza-like illness (ILI) is not known. In this analysis, we examined the changes in the rate of ILI against seasonal influenza vaccine uptake among Hajj pilgrims over the last decade.
Data for this analysis is a synthesis of raw and published data from eleven Hajj seasons between 2005 and 214. For seven Hajj seasons the data were obtained from studies involving pilgrims of UK, Saudi Arabia and Australia; and for the remaining four Hajj seasons data were abstracted from published studies involving pilgrims from multiple countries. The data from both sources were synthesised to estimate the relative risk (RR) of acquisition of ILI in vaccinated versus unvaccinated pilgrims.
The pooled sample size of the included studies was 33,213 with most pilgrims being in the age band of 40–60 years (range: 0.5 to 95 years) and a male to female ratio of 1.6. The pilgrims originated, in order of frequency, from Iran, Australia, France, UK, Saudi Arabia, Indonesia, India, Algeria, Ivory Coast, Nigeria, Somalia, Turkey, Syria, Sierra Leone and USA. Except for one year (2008), data from individual years did not demonstrate a noticeable change in the rate of ILI against influenza vaccine coverage, however the combined data from all studies suggest that the prevalence of ILI decreased among Hajj pilgrims as the vaccine coverage increased over the last decade (RR 0.2, P < 0.01).
This analysis suggests that influenza vaccine might be beneficial for Hajj pilgrims. However, controlled trials aided by molecular diagnostic tools could confirm whether such an effect is real or ostensible.

Acceptability of human papillomavirus vaccine among parents of junior middle school students in Jinan, China

Volume 33, Issue 22, Pages 2517-2628 (21 May 2015)

Acceptability of human papillomavirus vaccine among parents of junior middle school students in Jinan, China
Original Research Article
Pages 2570-2576
Wei Wang, Yuanyuan Ma, Xia Wang, Huachun Zou, Fanghui Zhao, Shaoming Wang, Shaokai Zhang, Yong Zhao, Gifty Marley, Wei Ma
To determine the level of awareness on human papillomavirus (HPV) vaccine and acceptance of HPV vaccination among parents of junior middle school students.
A cross sectional survey employing cluster sampling was conducted in Jinan, Shandong Province of China in January of 2013.
A total of 400 parents of junior middle school students participated in the questionnaire survey, among whom 360 (90%) completed valid questionnaires. About 88 (22.63%) parents had ever heard of HPV. Only one in ten (10.2%) knew about HPV vaccine. Parents willing to accept HPV vaccination for children accounted for 40.8%. Factors associated willing to accept HPV vaccination for children among parents were: female parent (AOR: 0.38, 95%CI: 0.21–0.67), having ever heard of HPV vaccine (AOR: 2.38, 95%CI: 1.01–5.61), thinking HPV vaccination should commence before sexual debut(AOR: 2.16, 95%CI: 1.21–3.85), thinking HPV vaccination should commence before 12 years old (AOR: 2.76, 95%CI: 1.02–7.46) or 13–15 years old (AOR: 4.75, 95%CI: 1.79–12.61), concern about suffering from cervical cancer and/or genital warts (AOR: 2.43, 95%CI: 1.31–4.50). About 60% of parents were in favor of future HPV vaccination promoting in China believing that HPV vaccine could efficiently prevent cervical cancer, anal cancer or genital warts, 37.4% of parents with expectation of governmental subsidy and price regulation.
Parental awareness level of HPV vaccine and willingness to accept HPV vaccination for children was low. However, the general attitude of many participants toward future promoting of HPV vaccination in China was encouraging, particularly if certain expectations were met.

Home-based record prevalence among children aged 12–23 months from 180 demographic and health surveys

Volume 33, Issue 22, Pages 2517-2628 (21 May 2015)
Home-based record prevalence among children aged 12–23 months from 180 demographic and health surveys
Original Research Article
Pages 2584-2593
David W. Brown, Marta Gacic-Dobo
There is currently a re-focus at the global level on the importance of the home-based record within vaccination service delivery as an important information resource but there are few reports of ever and current home-based record prevalence across countries.
We considered all Demographic and Health Surveys (starting with DHS round 3) conducted between 1993 and 2013 for which a final dataset was available in the public domain at the time of the analysis. Ever and current prevalence of home-based records for recording vaccination was estimated for children aged 12–23 months at the time of the survey through a secondary analysis of data from 180 Demographic and Health Surveys conducted in 67 countries derived from questions asked of women aged 15–49 years for their children on home-based record availability and retention. Ever home-based record prevalence is the proportion of children aged 12–23 months who have ever received a home-based record. Current home-based record prevalence is the proportion of children aged 12–23 months for whom a home-based record was available for viewing by the surveyor at the time of the survey.
Estimated ever home-based record prevalence was ≥90% in 116 surveys from 52 countries and was <70% in 15 surveys from 7 countries. Estimated current home-based record prevalence was ≥80% in 31 surveys from 23 countries and was <50% in 51 surveys from 24 countries. Current home-based record prevalence was <80% as of the most recent survey during 2010–2013 for five (Bangladesh, Ethiopia, Nigeria, Indonesia and Pakistan) of the ten countries with the largest birth cohorts globally. Among 34 countries that conducted three or more DHS, we observed improvements in both ever and current home-based record prevalence of >10% points in six countries. Current home-based record prevalence increased >10% points in six countries where the ever prevalence was maintained at ≥90% across the period of observation. And, no meaningful change was observed in estimated ever and current home-based record prevalence in 11 countries, five of which maintained ever prevalence ≥90% across the period of observation. High home-based record loss rates were observed in many countries.
The results here show that despite improvements in the availability, utilization and retention of home-based records for recording vaccination history in some countries, opportunities remain to change the mind-set in many national immunization programmes around the importance of the home-based record, particularly in countries with large birth cohorts. Immunization programmes are encouraged to monitor ever and current home-based record prevalence. Nationally representative household surveys collecting information on immunization coverage should include ever and current home-based record prevalence in the standard survey reports and tables to better enable programme managers to identify problems and target corrective action.

Effect of Adverse Media Reports and Abeyance of Governmental Recommendation of Human Papillomavirus Vaccine in Japan

Obstetrics & Gynecology
May 2015 – Volume 125 – Issue 5

Effect of Adverse Media Reports and Abeyance of Governmental Recommendation of Human Papillomavirus Vaccine in Japan [368].
Tanaka, Yusuke MD; Enomoto, Takayuki MD, PhD; Kimura, Tadashi MD; Matsuo, Koji MD; Takata, Tomomi MD, PhD; Yagi, Asami
INTRODUCTION: Administration of the human papillomavirus (HPV) vaccine decreased dramatically in Japan after extensive news of the adverse vaccine events and suspension of the governmental recommendation for the vaccine. In this study, we investigated the knowledge and acceptance of vaccinated adolescents concerning cervical cancer, cancer screening, and the HPV vaccine. Furthermore, we analyzed whether and how much the news affected acceptance of the vaccination.
METHODS: This study was conducted as a part of Osaka Clinical resEArch of HPV vacciNe (OCEAN) study. A questionnaire was distributed to 2,777 study registrants.
RESULTS: The response rate was 38%. A recognition rate of the news of the vaccine’s adverse events was 80%; it was 68% for awareness of the government’s announcement of the suspension of its recommendation for the vaccine. Among those who had a chance to hear or see the negative news during their vaccination period, 46 (60%) continued vaccination while knowing of the news, 22 (29%) discontinued vaccination, and nine (11%) continued vaccination without an awareness of the news. Reports of the vaccine’s adverse events were the main reason for not continuing the vaccination series. Those who consulted doctors after hearing the adverse news were significantly more likely to continue their vaccinations than those who did not.
CONCLUSION: Our results should help in understanding the need of a strong promotion of vaccine use and cancer screening after future retraction of the recommendation suspension. This may apply for other countries with an unsatisfactory rate of HPV vaccination as a result of fears of adverse vaccine events.

Correlates of HPV vaccine uptake in school-based routine vaccination of preadolescent girls in Norway: A register-based study of 90,000 girls and their parents

Preventive Medicine
Available online 3 May 2015

Correlates of HPV vaccine uptake in school-based routine vaccination of preadolescent girls in Norway: A register-based study of 90,000 girls and their parents
Bo Terning Hansena, Suzanne Campbella, Emily Burgerb, Mari Nygårda,
To assess demographic, socioeconomic and behavioural correlates of HPV vaccination of preadolescent girls in a publicly funded, school-based vaccination programme.
Data for all Norwegian girls born 1997–1999, eligible for routine school-based HPV vaccination in 2009–2011 (n = 90,842), and their registered mother and father, were merged from national registries. Correlates of girl vaccination status were analysed by unadjusted and multivariable logistic regression.
In total, 78.2% of the girls received the first dose of the HPV vaccine, 74.6% received three doses, and 94.8% received the MMR vaccine. Correlates associated with initiation of HPV vaccination included parental age, income and education, maternal occupational status and cervical screening attendance, and girl receipt of the MMR vaccine. Rates of completion of HPV vaccination among initiators were high, and disparities in completion were negligible. Maternal and paternal correlates of daughter HPV vaccination status were similar.
Routine school-based vaccination generally provides equitable delivery, yet some disparities exist. Information campaigns designed to reach the sub-groups with relatively low vaccine uptake could reduce disparities. In none of the sub-groups investigated did uptake of the HPV vaccine approach that of the MMR vaccine, further demonstrating a general potential for improvement in HPV vaccine uptake.

Nursing Case Management, Peer Coaching, and Hepatitis A and B Vaccine Completion Among Homeless Men Recently Released on Parole: Randomized Clinical T

Nursing Research
May/June 2015 – Volume 64 – Issue 3 – p 177–189

Nursing Case Management, Peer Coaching, and Hepatitis A and B Vaccine Completion Among Homeless Men Recently Released on Parole: Randomized Clinical Trial
Nyamathi, Adeline; Salem, Benissa E.; Zhang, Sheldon; Farabee, David; Hall, Betsy; Khalilifard, Farinaz; Leake, Barbara
Background: Although hepatitis A virus (HAV) and hepatitis B virus (HBV) infections are vaccine-preventable diseases, few homeless parolees coming out of prisons and jails have received the hepatitis A and B vaccination series.
Objectives: The study focused on completion of the HAV and HBV vaccine series among homeless men on parole. The efficacy of three levels of peer coaching (PC) and nurse-delivered interventions was compared at 12-month follow-up: (a) intensive peer coaching and nurse case management (PC-NCM); (b) intensive PC intervention condition, with minimal nurse involvement; and (c) usual care (UC) intervention condition, which included minimal PC and nurse involvement. Furthermore, we assessed predictors of vaccine completion among this targeted sample.
Methods: A randomized control trial was conducted with 600 recently paroled men to assess the impact of the three intervention conditions (PC-NCM vs. PC vs. UC) on reducing drug use and recidivism; of these, 345 seronegative, vaccine-eligible subjects were included in this analysis of completion of the Twinrix HAV/HBV vaccine. Logistic regression was added to assess predictors of completion of the HAV/HBV vaccine series and chi-square analysis to compare completion rates across the three levels of intervention.
Results: Vaccine completion rate for the intervention conditions were 75.4% (PC-NCM), 71.8% (PC), and 71.9% (UC; p = .78). Predictors of vaccine noncompletion included being Asian and Pacific Islander, experiencing high levels of hostility, positive social support, reporting a history of injection drug use, being released early from California prisons, and being admitted for psychiatric illness. Predictors of vaccine series completion included reporting having six or more friends, recent cocaine use, and staying in drug treatment for at least 90 days.
Discussion: Findings allow greater understanding of factors affecting vaccination completion in order to design more effective programs among the high-risk population of men recently released from prison and on parole.

System Alignment for VaccinE Delivery (SAVED): Qualitative Interviews Inform a Technology-Based Intervention to Improve Influenza and Pneumococcal Vaccination Rates

Journal of Patient-Centered Research and Reviews
Volume 2, Issue 2 (2015)

System Alignment for VaccinE Delivery (SAVED): Qualitative Interviews Inform a Technology-Based Intervention to Improve Influenza and Pneumococcal Vaccination Rates
Sarah L. Cutrona, University of Massachusetts Medical SchoolFollow
Larry Garber, Meyers Primary Care Institute
Lloyd Fisher, University of Massachusetts Medical School
Peggy Preusse, Reliant Medical Group
Sarah L. Goff, Baystate Medical Center
Meera Sreedhara, Meyers Primary Care Institute
Madeline Jackson, Meyers Primary Care Institute
Devi Sundaresan, Reliant Medical Group
Kathleen M. Mazor, Meyers Primary Care Institute
Background/Aims: Influenza and pneumococcal vaccines are beneficial but underutilized. Patient interviews may help identify effective outreach strategies and increase vaccination rates.
Methods: We conducted in-depth qualitative interviews with a purposive sample of adults whose primary care physicians were part of a large multispecialty group practice in central Massachusetts. Interviews occurred between April and October 2014, with individuals who were not up to date on either influenza or pneumococcal vaccines. The goal of the interviews was to: (a) understand barriers to influenza and pneumococcal vaccination, and (b) inform development of provider educational materials and patient outreach materials.
Results: We interviewed 14 people, 57% under age 65 (8 out of 14); 64% female (9 out of 14) (additional interviews are in process). Major themes included trust, influence of family and friends, and impact of vaccination choice on others. Many participants trusted their doctor’s recommendations but did not trust vaccine safety and efficacy. In some cases, the safety of influenza vaccines was compared unfavorably with other vaccines because “they make it up fresh each year” as compared to a vaccine where “it has been given for years.” The majority of participants cited relationships of family, friends or coworkers as influencing their own vaccination decision. While some participants cited concern for others’ health as a reason to get vaccinated (“it’s not fair if you get sick and spread it to everybody else”), others voiced concerns that care-giving responsibilities could be compromised if the vaccine induced illness. Several participants had not previously heard of the pneumococcal vaccine. Preferred modes of information on vaccination included verbal and electronic; hard-copy handouts were preferred by slightly fewer patients. When asked about effective messaging, some responded unfavorably to message components perceived to be condescending or intrusive (“our records indicate that you haven’t yet gotten this vaccine”).
Discussion: We identified several potential barriers to vaccination for patients who were not up to date with influenza or pneumococcal vaccination. Based on these findings, we are developing patient messages that include references to protecting the health of friends and family but which minimize language implying that the sender has been monitoring vaccination behavior.

Media/Policy Watch [to 9 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.

UN struggles to stem new rise in Haiti cholera cases
8 May 2015
United Nations (United States) (AFP) – A deadly cholera epidemic in Haiti that experts say was introduced by UN peacekeepers from Nepal is on the rise, with hundreds of new cases registered weekly, a UN official said Thursday.
Pedro Medrano, the UN coordinator for Haiti’s cholera outbreak, said years of work to beat back the disease are in jeopardy as donors turn away from the emergency.
“Unfortunately because of lack of resources and of the rainy season, in the last six months we have moved from a thousand new cases a month to almost a thousand a week, ” Medrano told AFP in an interview.
The UN official predicts more than 50,000 new cases this year, up from 28,000 last year, the lowest level since the outbreak began in October 2010.
More than 8,800 people have died from cholera and 736,000 Haitians have been infected since the outbreak that expert studies have shown was brought to the island by Nepalese troops…


The Atlantic
Accessed 9 May 201
Bill Gates’s Quest to Determine Why Children Are Dying – The Atlantic
Olga Khazan
May 6, 2015
When it comes to child deaths, the world has made great strides in the past 25 years. “In 1990, one in ten children in the world died before age 5,” Bill and Melinda Gates write on their blog. But thanks to things like vaccines and better nutrition, “today, it’s one in 20.”
The death rate for children younger than one month has proven harder to budge. Newborns account for 44 percent of all childhood deaths, and health experts aren’t sure why. They know it might have something to do with prematurity, or infections, or complications during delivery. But they often don’t know exactly what happened right after a given birth that brought death just a few weeks later. Was the baby not dried off properly? Did the umbilical cord get infected?
In order to better understand the drivers of mortality for all children, on Wednesday, the Bill & Melinda Gates Foundation announced that it’s investing $75 million in a series of surveillance sites that will gather data “about how, where and why children are getting sick and dying,” according to the release. This Child Health and Mortality Prevention Surveillance Network, or CHAMPS, will be spread initially throughout six locations in Africa and South Asia. It will rely on field workers to take biopsies of children who have perished and on beefed-up laboratories that will perform medical testing…


Accessed 9 May 2015
What does the past tell us about the future? Possibilities for child survival in 2030
John McArthur | May 7, 2015
As the Millennium Development Goals approach their 2015 deadline, debates are in full swing about what might form appropriate targets for Sustainable Development Goals (SDG) to 2030 and beyond. At the intergovernmental level, there is active debate around setting a formal SDG target at perhaps 20 or 25 for 2030. Meanwhile Bill and Melinda Gates recently made a high-profile “bet” that global under-5 child mortality will drop from around 46 per 1,000 live births today to 23 by 2030.
In considering potential new goals, a first step is to adopt a clear set of terms. Trajectories usually extrapolate from recent trends. Projections imply assumptions about the future. Possibilities examine potential outcomes under a range of scenarios. Why care about such basic word choices? Simply put, because we need to ensure past trajectories don’t lead to flawed projections that limit our thinking regarding future possibilities…


The United States Should Take a Proactive Stance on Polio Eradication Legacy Planning
By Nellie Bristol
May 6, 2015
The U.S. government is a staunch supporter of the ongoing global effort to eradicate polio. It has contributed more than $2 billion to the cause, providing invaluable resources for vaccine purchases, communications, and social mobilization. The U.S. Centers for Disease Control and Prevention and the U.S. Agency for International Development have provided funding and technical assistance for everything from program to disease surveillance and response to laboratory strengthening. While eradication remains elusive—with Pakistan now producing the bulk of the disease—solid support from the United States has helped the Global Polio Eradication Initiative reduce the number of reported polio cases worldwide by more than 99 percent. Given its significant support for the polio program and the potential for polio resources to contribute to other global health priorities, the U.S. government should actively champion polio “legacy planning” over the next several years.
Download PDF file of “The United States Should Take a Proactive Stance on Polio Eradication Legacy Planning”


Accessed 9 May 2015
Will Sanofi’s Big Bet On Vaccines Pull It Out Of Its Diabetes Slump?
Arlene Weintraub Contributor
1 May 2015
…Sanofi flipped the standard model of production, choosing to invest in manufacturing capacity long before anyone could say for certain the vaccine would succeed. Michael Watson, vice president of global immunization policy at Sanofi, says the company chose that route so it could get the vaccines to the countries that needed it the most right out of the gate. “Historically it has taken five to 10 years to get vaccines out to lower-income countries,” Watson said in a phone interview shortly after the World Vaccine Conference, held in early April in Washington, D.C., where he was a featured speaker. “What we said with dengue is that we would go ahead and invest in [production] right up front. So we took a risk.”
After more than 20 years of stops and starts, and an estimated $1.5 billion in R&D costs, Sanofi is now preparing to apply for approval for the vaccine in several countries. During a conference call with analysts after the first-quarter results were released, Sanofi’s vaccines chief, Olivier Charmeil, said he expects the first licenses to be granted in Asia and Latin America in the second half of 2015.
Sanofi has several other vaccines in the pipeline, including a late-stage combination shot for children that protects against six diseases. But the company is constantly fighting headwinds in the market that Watson refers to as the “Five A’s” of vaccine development: access, awareness, acceptance, availability, and activation.
In developing countries, access to standard vaccines like polio and diphtheria-tetanus-pertussis (DTP) has been one of the biggest challenges, Watson says, but not because vaccines are unaffordable. “Most children don’t get polio or DTP [vaccines], which cost 12 and 19 cents respectively,” Watson says. “So while some of the newer vaccines were quite expensive to begin with, actually bringing those prices down hasn’t solved the access problem to those one in five children who are not getting anything.”
To combat the access problem, Sanofi is pilot testing research programs in Mexico, Romania, and the African country of Gabon aimed at understanding why coverage gaps are occurring and then developing plans to address the issues. Last year, Watson says, the Mexican government took what it learned from the research and developed a plan to expand access to the flu vaccine. Vaccination rates have risen 60% there in the last year, he says.
As for access to the dengue vaccine, that’s where the flipped production model comes into play, Watson says. The company’s goal is to make the vaccine available in large quantities in the countries where the disease is endemic. He expects Sanofi will still see a significant return on its investment—just not in the same way vaccines makers did in the past. “Rather than taking the old-fashioned route, which was to start with a smaller volume of higher-priced vaccines, we’re going for much higher volume initially,” Watson says. “It’s a much bigger risk, but for everybody’s benefit, we need to do it.”


New York Times
Accessed 9 May 2015
Liberia, Ravaged by Ebola, Faces a Future Without It
MAY 8, 2015
After Nearly Claiming His Life, Ebola Lurked in a Doctor’s Eye
Before he contracted Ebola, Dr. Ian Crozier had two blue eyes. After he was told he was cured of the disease, his left eye turned green. Credit Emory Eye Center
ATLANTA — When Dr. Ian Crozier was released from Emory University Hospital in October after a long, brutal fight with Ebola that nearly ended his life, his medical team thought he was cured. But less than two months later, he was back at the hospital with fading sight, intense pain and soaring pressure in his left eye.
Test results were chilling: The inside of Dr. Crozier’s eye was teeming with Ebola….
Tracing the Ebola Outbreak, Scientists Hunt a Silent Epidemic
By SHERI FINK- MAY 5, 2015
Scientists are using blood samples collected throughout the Ebola outbreak to map the virus’s spread from country to country by tracking tiny mutations in its gene sequences.
The picture is not yet complete, but intriguing discoveries have been made. Virus mutations first detected in Sierra Leone last spring were found later in Liberia and Mali, and scientists are examining whether this resulted from the chance movements of people across borders.
While some scientists think it is unlikely that the mutations made a difference in how the virus functioned, others are looking at whether this version of the virus had properties that made it more capable of causing infection…
Review: Paul Offit’s ‘Bad Faith’ Explores Casualties of Doctrine
MAY 4, 2015


US News & World Report
Vaccines: Why There Is Really No Debate At All
As states continue to clarify laws about exemptions, here’s what we must remember.
By Elaine Cox, M.D. May 4, 2015


Washington Post
Accessed 9 May 2015
A horrifying reminder of what life without vaccines was really like [polio]
By Ana Swanson May 4
Making polio history
The Post’s View
By Editorial Board May 3
PAKISTAN NOW stands as the main barrier to the global elimination of wild poliovirus. In two other countries where it is endemic, things are going well: There hasn’t been a case in Nigeria in nine months, and there has been only one in Afghanistan so far this year. Outbreaks last year in Syria, Iraq and other parts of Africa have been contained. Consider the progress: In 1988, there were more than 125 countries where polio was endemic. But now, all eyes are on Pakistan as the high season approaches for transmission of the virus. Plans are in place for the fight, methods are known, good intentions declared. Now a nation often weakened by its own internal chaos must deliver.

The poliovirus is highly contagious, largely strikes children under 5 years old and can cause permanent paralysis. The oral vaccine is effective if it can be given to enough children to prevent and interrupt transmission.

Last year, Pakistan recorded 306 cases, which was the highest in 15 years and 85 percent of all those in the entire world. A review of the program in October declared, “Pakistan’s polio programme is a disaster.” The review found inadequate political backing, poor public health programs and little engagement at the local level. “Something big has to change in Pakistan,” the review concluded. Then, Pakistan began this year with a terrible surge of attacks on vaccination teams in what looked like a new campaign by Taliban militants. Violence is a major disruption to the vaccination effort, tearing a hole in the prevention net and allowing the virus to spread.

For two years, children in North and South Waziristan could not be vaccinated because local leaders suspended the campaigns. Then a military operation in the North Waziristan and Khyber tribal areas in the last six months of 2014 displaced nearly a million people. The movement created risks of the virus spreading, but it also opened up a window of opportunity to vaccinate children who had been inaccessible. Outbreaks occur even in more stable areas in Pakistan, where there are clusters of unvaccinated children.

ortunately, research shows that parents have a high degree of acceptance of the need for oral polio vaccines, although suspicion and distrust still linger in some places.
Pakistan is rallying. There have been only 22 cases so far this year, compared with almost 60 at this time last year. Violence has abated, at least in the past month. Emergency operations centers, an important innovation to help monitor the virus, have been set up. Experts also applaud another recent tactic, the recruitment of female volunteers to work on vaccination in their own communities with approval from local religious and tribal leaders. This approach seems to be making headway in previously inaccessible areas. Pakistan’s political leadership also has vowed a renewed campaign.

In the end, the only metric that really counts with polio is getting to zero. The world has never been closer. Pakistan could do much to push this disease into the history books.

Vaccines and Global Health: The Week in Review 2 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 david.r.curry@centerforvaccineethicsandpolicy.org.

pdf version A pdf of the current issue is available here:  Vaccines and Global Health_The Week in Review_2 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.
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David R. Curry, MS
Executive Director
Center for Vaccine Ethics and Policy
a program of the
– Division of Medical Ethics, NYU Medical School
– The Wistar Institute Vaccine Center
– Children’s Hospital of Philadelphia Vaccine Education Center
Associate Faculty, Division of Medical Ethics, NYU Medical School

EBOLA/EVD [to 2 May 2015]

EBOLA/EVD [to 2 May 2015]
Public Health Emergency of International Concern (PHEIC); “Threat to international peace and security” (UN Security Council)

WHO: Ebola Situation Report – 29 April 2015
:: A total of 33 confirmed cases of Ebola virus disease (EVD) was reported in the week to 26 April. Two areas, Forecariah in Guinea and Kambia in Sierra Leone, accounted for 25 (76%) of all confirmed cases reported. Improved community engagement in these areas is required to ensure that all remaining chains of transmission can be tracked and ultimately brought to an end…

:: There have been a total of 26,277 reported confirmed, probable, and suspected cases of EVD in Guinea, Liberia and Sierra Leone (figure 1, table 1), with 10,884 reported deaths (outcomes for many cases are unknown). A total of 22 new confirmed cases were reported in Guinea, 0 in Liberia, and 11 in Sierra Leone in the 7 days to 26 April…

WHO strategic response plan 2015: West Africa Ebola outbreak

WHO strategic response plan 2015: West Africa Ebola outbreak
ISBN 978 92 4 150869 8 :: 27 pages
pdf: Ebola response strategic plan 2015
The outbreak of the Ebola virus disease in West Africa is unprecedented in its scale, severity, and complexity. Guinea, Liberia and Sierra Leone are still affected by this outbreak, and are struggling to control the epidemic against a backdrop of extreme poverty, weak health systems and social customs that make breaking human-to-human transmission difficult. While encouraging progress has been made, there is still a considerable effort required to stop all chains of transmission in the affected countries, prevent the spread of the disease to neighbouring countries and to safely re-activate life-saving essential health services.

Strategic objectives for WHO
1. Stop transmission of the Ebola virus in affected countries
2. Prevent new outbreaks of the Ebola virus in new areas and countries
3. Safely reactivate essential health services and increase resilience
4. Fast-track Ebola research and development
5. Coordinate national and international Ebola response

The next step in the response is crucial: to build on the progress and lessons to date, especially on the critical role of communities. A critical step will be to limit the spread of the virus to the coastal areas of the three high-transmission countries before the onset of the rainy season in April–May 2015. The priority is to identify and isolate all new cases by the end of May, and to confirm that they have come from known transmission chains and contact lists….

In collaboration with our partners, WHO is determined to support the affected countries to reach zero cases of Ebola virus disease in West Africa and to facilitate the early recovery of the health sector. The successful strategies and lessons already learned in the fight against this devastating disease underpin the pragmatic approach and practical activities encompassed in this new strategic plan for 2015. Getting to zero cases through rigorous surveillance and extensive and thorough case finding, case investigation and management, and contact tracing can only be achieved with the vigilance and close collaboration of our partners and the governments of the most-affected nations. Most importantly, at the district and community levels we need to anticipate and pre-empt resistance, demanding new ways of working and behavioural adaptations of service providers.
The response efforts must continue in earnest because, without the elimination of Ebola, the planned reactivation of essential services disrupted by the epidemic and the future recovery of the countries’ fragile economies and service infrastructures cannot successfully begin. WHO is working with its partners to make sure a positive legacy remains after this crisis; a legacy that encompasses strengthened health systems and a resilience and preparedness.

WHO convenes Meeting for the Assisted Review of the Janssen Ebola Zaire Vaccine Clinical Trials Application by Representatives of Ethics Committee and National Regulatory Authority of Sierra Leone in Accra Ghana

WHO convenes Meeting for the Assisted Review of the Janssen Ebola Zaire Vaccine Clinical Trials Application by Representatives of Ethics Committee and National Regulatory Authority of Sierra Leone in Accra Ghana
Accra, 27 April 2015 – Despite signs of the Ebola Virus Disease (EVD) epidemic abating in West Africa, efforts continue to find an effective vaccine that can fight the virus both now and for future generations. As the race for an Ebola vaccine continues, experts gathered in Ghana from 8-10 April 2015 to review the clinical trial application for the Janssen Ebola Zaire Vaccine that will take place in Sierra Leone.

The meeting aimed to review the scientific and ethical aspects of the proposed vaccine trial in Sierra Leone to evaluate the immune response, identify any side effects and determine its effectiveness.

The meeting facilitated by WHO under the platform of the African Vaccine Regulatory Forum (AVAREF) was attended by 60 expert representatives of the Ethics Committee and the Pharmacy Board of Sierra Leone with support from Ghana’s Food and Drug Authority (GFDA), Health Canada, the European Medicines Agency, the Medicines and Healthcare Products Regulatory Agency (MHRA) United Kingdom, and the United States Food and Drug Administration (US FDA). This meeting provided a forum for a thorough discussion on all scientific and ethical aspects of the proposed phase III clinical trial.

The meeting comes at a time when, despite the number of cases reducing, the goal of zero cases has not been reached. As at 15 April, the outbreak, which has persisted for more than a year, has infected 25,826 people and resulted in 10,704 deaths, according to WHO. There still remains a need to develop a vaccine capable of protecting the population in this epidemic and any future ones

The importance of collaborative partnerships in this regard is critical. WHO Coordinator of Regulatory System Strengthening, Director of Essential Medicines and Health Products (EMP) Department, Mr. Michael Ward explains the partnership with AVAREF, “WHO plays a key enabling role in supporting the AVAREF network, so that it may fulfil its potential in accelerating the availability of preventative vaccines and other important therapies for the people of Africa.”

The meeting concluded with a signed agreement by Sierra Leone and Crucell Holland B.V., study sponsor and one of the Janssen Pharmaceutical Companies of Johnson & Johnson noting that further documentation and timelines are required before a final regulatory decision could be provided. AVAREF Chair Dr Beno Yakubu said, “Under the platform of AVAREF, this meeting is an indication of the due diligence taken by the pharmaceutical companies and partners to jointly ensure that the clinical trial process is of the highest ethical and scientific standards to ensure the safety of the volunteers and patients who will ultimately receive the vaccine.”

The meeting was co-chaired by Health Canada (Dr Lindsay Elmgren, Director, Centre for Biologics Evaluation), Ghana National Regulation Authority (NRA) CEO (Mr Hudu Mogtari) and the AVAREF Chair Dr Beno Yakubu).

About the vaccine regimen:
The Ebola vaccine regimen in development at the Janssen Pharmaceutical Companies of Johnson & Johnson, which was discovered in a collaborative research program with the National Institutes of Health, uses a prime-boost combination of two components that are based on AdVac® technology from Crucell Holland B.V., one of the Janssen Pharmaceutical Companies, and the MVA-BN® technology from Bavarian Nordic. The company is collaborating with numerous partners, including London School of Hygiene and Tropical Medicine and Inserm, to accelerate the development of the vaccine regimen. Evaluation of the vaccine regimen commenced with Phase I clinical trial at the Oxford Vaccine Group in December 2014 and this has been followed by Phase 1 studies in the United States (US) and Africa (Kenya, Uganda, Tanzania).

POLIO [to 2 May 2015]

POLIO [to 2 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: http://www.polioeradication.org/Dataandmonitoring/Poliothisweek.aspx
:: Our thoughts are with the people of Nepal, where the polio infrastructure is closely involved in relief operations. Polio staff are often among the first to respond in emergencies by utilizing their local knowledge and strong systems to plan, monitor and implement the response.
:: Following a year since the last detection of wild poliovirus in the environment, Israel has been moved from the International Health Regulations (IHR) list of countries infected with poliovirus to the list of countries no longer infected but vulnerable to the international spread of polio. The Emergency Committee of the IHR met on 24 April for the fifth time to discuss the temporary recommendations and a report will be released shortly. More.
Selected excerpts from Country-specific Reports
:: One new WPV1 case was reported in this week in Peshawar district of Khyber Pakhtunkhwa Province. This most recent case had onset of paralysis on 29 March. The total number of WPV1 cases for 2015 is now 22 (and remains 306 for 2014)
:: Efforts are ongoing to strengthen the implementation of the ‘low season’ emergency operations plan. Strong, functional Emergency Operations Centres (EOCs) are now operational both at the federal and provincial levels. Strategies are focusing on clearly identifying reasons for missed children, and putting in place area-specific mechanisms to overcome area-specific challenges. Independent monitoring is being strengthened and rolled out across wider geographic areas to provide a clearer assessment of quality and associated gaps.
:: Activities are focusing on known infected areas, but also areas deemed at high-risk but which have not reported polio cases. Environmental surveillance indicates widespread transmission of polioviruses, not just in known infected areas but also in areas without cases. Environmental surveillance is proving to be an instrumental supplemental surveillance tool enabling a clearer epidemiological picture.

GAVI [to 2 May 2015]

GAVI [to 2 May 2015]
28 April 2015
More than two million Congolese children per year to be protected against polio
Democratic Republic of Congo to introduce Inactivated Polio Vaccine with Gavi and partners’ support.

Kinshasa, 28 April 2015 – More than two million children in the Democratic Republic of Congo will benefit from Inactivated Polio Vaccine (IPV) every year as the country celebrates African Vaccination Week by introducing the vaccine into its routine immunisation schedule…

…The first doses of the vaccine will be delivered this month in four provinces (Bandundu, Bas Congo, Equateur and Kinshasa),a further four provinces (Kasaï Occidental, Kasaï Oriental, Katanga and Maniema) will introduce the vaccine in May and children in the final three provinces (North and South Kivu, Province Orientale) will receive the vaccine in June.

“As long as a child somewhere is not protected against this crippling disease, every child is at risk,” said Anuradha Gupta, deputy CEO of Gavi, the Vaccine Alliance. “Gavi fully supports the government in its efforts to strengthen its immunisation system as high routine coverage establishes a strong base for population immunity to prevent polio outbreaks and builds a sustainable platform for the introduction of IPV and other lifesaving vaccines. Immunisation is not just about protecting children against a disease, it is about unlocking the productivity potential of individuals, communities and countries.”

Strong routine immunisation systems are critical to reach polio elimination targets and prevent thousands of cases of disease and death. The Democratic Republic of Congo, with support from its partners, has improved its routine immunisation coverage and seen the percentage of children receiving DTP3 (three doses of diphtheria, tetanus, pertussis) rise from 25% in 1999 to 72% in 2013. However, geographical challenges as well as conflicts and insecurity have resulted in large differences between provinces.

DRC has been polio-free since the end of 2011 but for many years it was among the most affected countries worldwide. The year before DRC was declared polio-free, 93 cases were recorded. The challenge now for the Congolese health system and other partners is to make sure that polio does not return, and increase routine immunisation coverage against other diseases…

:: Statement – Gavi’s relationship with India
Clarification from Gavi, the Vaccine Alliance
Geneva, 30 April 2015 – Following a recent newspaper report regarding the relationship between Gavi, the Vaccine Alliance and India, Gavi would like to clarify the following points:
An article published recently in an Indian newspaper stated that Gavi was withdrawing funding from India, thereby jeopardising the Government of India’s ongoing efforts to improve immunisation coverage. That is not the case.

Gavi remains a committed partner of India and we will continue to support the country in its endeavours to immunise more of its children against life-threatening diseases.
Thanks to its growing economy, India is projected to reach the threshold of US$ 1,580 Gross National Income per capita which means it has entered what is known as the ‘graduation’ phase in relation to Gavi support.

Over the next five years, Gavi and India will work together towards financing the introductions of some new vaccines and assuring that these will ultimately have budget provisions within the Government of India budget so that children in India continue to have access to vaccines for generations to come.

Gavi applauds the excellent work by the Government of India to improve immunisation coverage under Mission Indradhanush and its work to protect the lives of children living in 201 of the most at risk districts in the country.

Gavi’s work with India
Gavi currently supports pentavalent vaccine which offers protection against five diseases (diphtheria-tetanus-pertussis (DTP), hepatitis B, and Haemophilius influenzae type b) as well as providing funding to help India to strengthen its health systems.

Between 2000 and 2015, Gavi has disbursed more than US$ 240 million to help India to immunse its children against life-threatening diseases. Additionally, Gavi has committed $107 million to support health systems strengthening in India, which is likely to play a role in the success of Mission Indradhanush, over the next five years

WHO & Regionals [to 2 May 2015]

WHO & Regionals [to 2 May 2015]
:: Nepal’s Ministry of Health puts a hold on foreign medical teams
The Nepalese Ministry of Health has asked that any foreign medical teams ready to deploy to Nepal should please refrain from doing so. While the Ministry has expressed gratitude for all offers of assistance, they have advised that the need for foreign medical teams has already been met. Teams en route without a designated duty station will due to this be asked to turn away. All foreign medical teams on stand-by to assist Nepal’s earthquake response should register with WHO and keep updated on the situation through WHO’s homepage and the virtual On-site Operations Coordination Centre (OSSOC) website.

:: WHO mobilizes funds for long-term spinal cord treatment after Nepal earthquake
2 May 2015 — Among the estimated 14,000 injuries incurred as a result of the April 25 earthquake, which measured 7.8 on the Richter scale and has so far resulted in 6200 recorded fatalities, approximately 1 in 3 (or around 4700) will require follow-up rehabilitation treatment. Of this number, approximately 12% have damage to their spinal cord.

:: Sixty-eighth World Health Assembly – 18–26 May 2015

:: Sierra Leone wraps up four-day health and vaccination campaign 1 May 2015
…WHO worked in close collaboration with the Sierra Leone government and partners, to plan and supervise the recent Maternal and Child Health Week national campaign. The campaign aimed to reach more than 1.5 million children under the age of 5, with life-saving immunizations. In addition, children’s nutritional levels were measured, deworming tablets were administered and HIV testing was available for pregnant women and their partners…

:: Americas region is declared the world’s first to eliminate rubella
April 2015– The Americas region has become the first in the world to be declared free of endemic transmission of rubella, a contagious viral disease that can cause multiple birth defects as well as fetal death when contracted by women during pregnancy.

:: Global Alert and Response (GAR) – Disease Outbreak News (DONs)
Middle East Respiratory Syndrome coronavirus (MERS-CoV) – Saudi Arabia 29 April 2015
Meningococcal disease – Niger 29 April 2015

:: WHO Regional Offices
WHO African Region AFRO
:: A new entity to accelerate the elimination of neglected tropical diseases in Africa
Johannesburg, 30 April 2015 – The World Health Organization is stepping up efforts to accelerate the elimination of neglected tropical diseases (NTD) in the African Region. Health experts, donors, development partners and affected countries have reached a consensus on the main components of the framework for establishing a new NTD entity. This entity will support and guide affected countries in the African region to accelerate the implementation of actions required to eliminate NTDs by 2020.
The WHO Regional Director for Africa, Dr Matshidiso Moeti in her opening remarks underscored the need for a strong entity that will provide high quality technical support, and strengthen capacity of Member States to eliminate NTDs. Dr Moeti said, “The new NTD entity needs to be cost efficient, cross-cutting with other NTD interventions and with a stronger link with stakeholders and actors in order to achieve the set targets in 2020.”
The WHO African Region faces a huge burden of neglected tropical diseases which affects millions of people who are impoverished. The region carries half of the global burden of NTDs. The move to establish a new entity arises from the current global and regional commitment from donors, pharmaceutical companies, countries and other partners to accelerate the elimination of NTDs.
The new NTD entity will also facilitate the smooth transition of technical support to affected countries as the African Programme for Onchocerciasis Control (APOC) closes on 31 December, 2015. APOC was established in 1995 to tackle river blindness. Over the past 20 years, the work of APOC has made commendable progress in tackling river blindness (Onchocerciasis) in most affected communities. The new entity focuses on the five diseases (elephantiasis, river blindness, trachoma, bilharzia and intestinal worms) that can be treated with mass drug administration. Its operations will build on the experience gained in recent years in tackling NTDs.
In her concluding comments, Dr Moeti thanked APOC for its contribution to tackling river blindness and expressed profound gratitude to Member States, donors, communities, non-governmental development organizations and the many WHO staff that contributed significantly to this achievement. The Regional Director promised to “follow up the NTD agenda and ensure that the new entity achieves the expected results by 2020.”

:: 1 in 5 children in Africa do not have access to life-saving vaccines – 28 April 2015
:: Humanitarian crisis in the Central African Republic: lack of funding threatens the free-access to healthcare –

WHO Region of the Americas PAHO
:: Americas region is declared the world’s first to eliminate rubella (04/29/2015)
:: La Fundación Chespirito se unió a la OPS/OMS para celebrar la Semana de Vacunación en las Américas (04/28/2015)
:: 13th annual Vaccination Week in the Americas kicks off in Ecuador (04/26/2015)

WHO South-East Asia Region SEARO
:: WHO works with partners to prevent diarrhoeal diseases SEAR/PR/1597 30 April 2015
:: WHO, health partners striving to treat quake survivors in Nepal’s remote regions SEAR/PR/1596 29 April 2015
:: WHO coordinating the health response to Nepal earthquake; working to prevent spread of disease 29 April 2015
:: WHO sending in more medical supplies and assisting the arrival of foreign medical team support for earthquake-ravaged Nepal 27 April 2015

WHO European Region EURO
:: At least one in three Europeans can be exposed to asbestos at work and in the environment 30-04-2015
:: Air pollution costs European economies US$ 1.6 trillion a year in diseases and deaths, new WHO study says 28-04-2015
:: From the migration front line: interview with Lampedusa doctor 27-04-2015

WHO Eastern Mediterranean Region EMRO
:: WHO report finds systems to combat antibiotic resistance lacking 29 April 2015
:: The future of nursing and midwifery in the Region 29 April 2015
:: Closing the immunization gap in Afghanistan 26 April 2015

WHO Western Pacific Region
:: Protect your community: Get vaccinated
2015 – An estimated 1.5 million children worldwide die each year of diseases that can be readily prevented by vaccines. On World Immunization Week (24 April – 3 May), the World Health Organization (WHO) in the Western Pacific Region underscores the importance of immunization as a shared responsibility and a vital component in protecting communities.

IVI Watch [to 2 May 2015]

IVI Watch [to 2 May 2015]
:: IVI joins forces with Kia Motors, Korea, Malawi, and WHO to conduct emergency vaccination in flood-hit areas in Malawi
– Southern region in Malawi hit by cholera outbreak due to recent massive flooding.
– International efforts ongoing to stem the potentially explosive deadly outbreak among other post-flood relief measures.
– IVI teams up with Kia Motors, South Korea’s Ministry of Foreign Affairs, Malawi’s Ministry of Health, and the World Health Organization to vaccinate 160,000 people against cholera in Nsanje District.
Seoul, Korea – The International Vaccine Institute (IVI), in collaboration with Kia Motors, the Ministry of Foreign Affairs of the Republic of Korea (MOFA), Malawi’s Ministry of Health, and the World Health Organization (WHO) conducted an emergency cholera vaccination campaign in Nsanje District in southern Malawi in response to concerns over a rapidly spreading cholera outbreak. The campaign, which targeted vaccinating 160,000 people, was launched on March 31, 2015.

The floods that hit Nsanje District in January this year have killed 176 people and displaced more than 200,000 people. Malawian President Peter Mutharika declared it a national crisis and urged the international community to provide assistance. Amid the situation, an increasing number of cholera cases have been reported in camps for internally displaced persons and surrounding areas. A total of 329 cases have been confirmed since the outbreak began in February, with half of all cases reported in two weeks through April 10.

In the wake of mounting concerns over a potentially explosive outbreak that could kill and sicken thousands as seen in Haiti in 2010 and South Sudan in 2013, IVI, Malawi’s Ministry of Health, and WHO have worked together to rapidly deploy the oral cholera vaccine as an emergency measure to control the outbreak and prevent its further spread.

Since 2013, Kia Motors has been supporting IVI on a survey of areas considered to be at high risk for cholera in Malawi and on preparations for a pilot cholera vaccination demonstration project. However, when the floods struck and a cholera outbreak emerged in southern Malawi in early 2015, Kia Motors responded to the crisis by supporting the procurement of vaccines needed for the emergency vaccination. In addition, the Korean Ministry of Foreign Affairs has quickly responded to the humanitarian crisis by providing emergency funding to IVI for the vaccination.

“We are thrilled to have the opportunity to provide help in a small way to flood-affected people in a disaster situation through the cholera vaccination project in Malawi,” Chang Muk Choi, the head of CSR Management Team at Kia Motors Corporation said, “Going forward, Kia will redouble efforts to become a company that helps meet the need of our society.”

The emergency vaccination campaign uses an oral cholera vaccine that was developed by IVI through an international product development partnership with collaborators from Korea, India, Sweden, Vietnam and the United States. The vaccine, Shanchol, (manufactured by Shantha Biotechnics, part of the Sanofi Group) was approved by WHO for global use in 2011. The vaccine is given in two doses and protects against cholera for up to five years…

UNICEF [to 2 May 2015]

UNICEF [to 2 May 2015]
:: One week after Nepal earthquake UNICEF warns of disease risk for children
KATHMANDU, 2 May 2015 – One week on from the earthquake in Nepal, UNICEF says the health and wellbeing of children affected by the disaster are hanging in the balance – as many have been left homeless, in deep shock and with no access to basic care. With the monsoon season only a few weeks away, children will be at heightened risk of diseases like cholera and diarrhoeal infections, as well as being more vulnerable to the threat of landslides and floods.

:: Life-saving UNICEF supplies reach Nepal to help 1.7 million children severely affected by earthquake
KATHMANDU, Nepal / NEW YORK, 30 April 2015 – Over the past 48 hours, UNICEF has delivered 29 metric tonnes of humanitarian supplies to Nepal including tents and tarpaulins, water purification tablets, first aid and hygiene kits, as part of ongoing efforts to reach at least 1.7 million children living in areas hardest hit by the earthquake. Over the coming days, UNICEF is planning additional aid items to arrive in Kathmandu.

:: UNICEF delivers lifesaving supplies to Aden as Yemen runs out of medicine, equipment
SANA’A, Yemen/AMMAN, Jordan, 28 April 2015 – A UNICEF shipment of urgent medical supplies reached Yemen today and will benefit more than 500,000 people, mostly women and children, for the next three months.

Sabin Vaccine Institute Watch [to 2 May 2015]

Sabin Vaccine Institute Watch [to 2 May 2015]
9th International Conference on Typhoid, Invasive NTS Disease Held in Bali, Indonesia
BALI, INDONESIA — May 1, 2015 —The Coalition against Typhoid (CaT), in collaboration with Bio Farma, began the 9th International Conference on Typhoid and Invasive NTS Disease in Bali, Indonesia, with more than 200 public health experts from around the world in attendance. Over the next three days, they will discuss strategies to combat typhoid and invasive non-typhoidal salmonella (iNTS) disease. Experts will present their research on disease burdens, the cost effectiveness of intervention strategies and global policy recommendations for invasive salmonelloses.