PLoS Medicine
http://www.plosmedicine.org/
(Accessed 20 June 2015)

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Policy Forum
Maximizing the Impact of Training Initiatives for Health Professionals in Low-Income Countries: Frameworks, Challenges, and Best Practices
Corrado Cancedda, Paul E. Farmer, Vanessa Kerry, Tej Nuthulaganti, Kirstin W. Scott, Eric Goosby, Agnes Binagwaho
June 16, 2015
DOI: 10.1371/journal.pmed.1001840
Summary Points
:: Historically, the impact of many health professional training initiatives in low-income countries has been limited by narrow focus on a small set of diseases, inefficient utilization of donor funding, inadequate scale up, insufficient emphasis on the acquisition of practical skills, poor alignment with local priorities, and lack of coordination.
:: Fortunately, several innovative training initiatives have emerged over the past five years in sub-Saharan Africa. This articles focuses on four initiatives funded by the United States government: the Medical Education Training Partnership Initiative (MEPI), the Nursing Training Partnership Initiative (NEPI), the Rwanda Human Resources for Health Program (HRH Program), and the Global Health Service Partnership (GHSP).
:: The best practices adopted by these initiatives are: alignment to local priorities, country ownership, competency-based training, institutional capacity building, and the establishment of long-lasting partnerships with international stakeholders,
:: Based on these best practices, we outline a framework for health professional training initiatives that can help better address the health workforce shortage in low-income countries.

PLoS Neglected Tropical Diseases
http://www.plosntds.org/
(Accessed 20 June 2015)

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Research Article
Acceptability and Willingness-to-Pay for a Hypothetical Ebola Virus Vaccine in Nigeria
Maduka Donatus Ughasoro, Dorothy Omono Esangbedo, Beckie Nnenna Tagbo, Ijeoma Chigozie Mejeha
Published: June 15, 2015
DOI: 10.1371/journal.pntd.0003838
Abstract
Background
Ebola virus disease is a highly virulent and transmissible disease. The largest recorded fatality from Ebola virus disease epidemic is ongoing in a few countries in West Africa, and this poses a health risk to the entire population of the world because arresting the transmission has been challenging. Vaccination is considered a key intervention that is capable of arresting further spread of the disease and preventing future outbreak. However, no vaccine has yet been approved for public use, although various recombinant vaccines are undergoing trials and approval for public use is imminent. Therefore, this study aimed to determine the acceptability of and willingness-to-pay for Ebola virus vaccine by the public.
Methods
The study was a community-based cross-sectional qualitative and quantitative interventional study conducted in two communities, each in two states in Nigeria. An interviewer-administered questionnaire was used to collect information on respondents’ knowledge of the Ebola virus, the ways to prevent the disease, and their preventive practices, as well as their acceptability of and willingness-to-pay for a hypothetical vaccine against Ebola virus disease. The association between acceptability of the vaccine and other independent variables were evaluated using multivariate regression analysis.
Results
Ebola virus disease was considered to be a very serious disease by 38.5% of the 582 respondents (224/582), prior to receiving health education on Ebola virus and its vaccine. Eighty percent (80%) accepted to be vaccinated with Ebola vaccine. However, among those that accepted to be vaccinated, most would only accept after observing the outcome on others who have received the vaccine. More than 87.5% was willing to pay for the vaccine, although 55.2% was of the opinion that the vaccine should be provided free of charge.
Conclusion
The level of acceptability of Ebola virus vaccine among respondents was impressive (though conditional), as well as their willingness to pay for it if the vaccine is not publicly funded. In order to achieve a high uptake of the vaccine, information and education on the vaccine should be extensively shared with the public prior to the introduction of the vaccine, and the vaccine should be provided free of charge by government.
Author Summary
Ebola virus disease (EVD) is highly virulent and transmissible. The transmission is mostly by direct contact with an infected person or indirectly through contact with material contaminated with the secretions or body fluids of an infected person. Currently there is no vaccine or drug for EVD. Maintaining good personal and environmental hygiene remains the only control strategy, and its implementation was a challenge in West Africa countries. Ebola virus vaccine (EVV) is being developed and may soon be deployed; thus a need to evaluate factors that can improve or discourage the uptake of the vaccine when it becomes approved for public administration. This study highlights the acceptability and willingness-to-pay for EVV. Majority of the respondents were willing to accept the vaccine and pay for it if it is not publicly funded. Of interest was that among those that accepted to be vaccinated, most would only accept to do so after they had observed the outcome on others that had received the vaccine. There is need for early dissemination of correct information and education on EVV to the populace so as to prevent any misinformation and misperception about the vaccine. This will improve universal coverage with the vaccine when deployed.

Vaccine
Volume 33, Issue 30, Pages 3435-3604 (9 July 2015)
http://www.sciencedirect.com/science/journal/0264410X/33/30
Vaccination against serogroup B Neisseria meningitidis: Perceptions and attitudes of parents
Original Research Article
Pages 3463-3470
Sandra Le Ngoc Tho, Florence Ader, Tristan Ferry, Daniel Floret, Maximilien Arnal, Simone Fargeas, Christian Chidiac, Florent Valour
Abstract
Background
A vaccine against serogroup B Neisseria meningitidis, major cause of bacterial meningitis in children and adults, has recently been developed. In a context of an increasing parental mistrust against vaccinations, understanding the reason for their choices is crucial in order to improve immunization coverage. Our study aimed at evaluating parental attitudes and perceptions towards serogroup B meningococcal invasive disease vaccination.
Methods
A prospective observational study was conducted in different French independent-practice medical offices (general practitioners and paediatricians) and nurseries between May 1 and December 31, 2013, using a questionnaire distributed in electronic and paper forms to parents having at least one child between the ages of 2 months and 16 years old.
Results
1270 parents were included, of whom 671 (52.8%) spontaneously stated to be in favour of this vaccination. Their choice was mainly justified by the severity of the disease (63.8%) and the desire to protect their child (51.7%). In multivariate analysis, the young age of parents (OR 0.949 per additional year; p < 10−3), the history of vaccination against serogroup C meningococcal invasive diseases (OR 6.755; p < 10−3), and the prior knowledge of the vaccine (OR 2.081; p = 0.001) were associated with vaccination acceptance. The main reasons for refusal were the lack of hindsight on this new vaccine (50.6%) and the fear of side effects (45.5%). After objective information on the disease and the vaccine, only 6.3% of the entire responding population would refuse to consider vaccination.
Conclusions
The spontaneous acceptance rate of vaccination against serogroup B meningococcal invasive disease is insufficient. However, after objective information by their physician or public health authorities, only a few parents would in the end be completely resistant.

Vaccine
Volume 33, Issue 30, Pages 3435-3604 (9 July 2015)
http://www.sciencedirect.com/science/journal/0264410X/33/30
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Evaluating the value proposition for improving vaccine thermostability to increase vaccine impact in low and middle-income countries
Original Research Article
Pages 3471-3479
Christopher L. Karp, Deborah Lans, José Esparza, Eleanore B. Edson, Katey E. Owen, Christopher B. Wilson, Penny M. Heaton, Orin S. Levine, Raja Rao
Abstract
The need to keep vaccines cold in the face of high ambient temperatures and unreliable access to electricity is a challenge that limits vaccine coverage in low and middle-income countries (LMICs). Greater vaccine thermostability is generally touted as the obvious solution. Despite conventional wisdom, comprehensive analysis of the value proposition for increasing vaccine thermostability has been lacking. Further, while significant investments have been made in increasing vaccine thermostability in recent years, no vaccine products have been commercialized as a result. We analyzed the value proposition for increasing vaccine thermostability, grounding the analysis in specific vaccine use cases (e.g., use in routine immunization [RI] programs, or in campaigns) and in the broader context of cold chain technology and country level supply chain system design. The results were often surprising. For example, cold chain costs actually represent a relatively small fraction of total vaccine delivery system costs. Further, there are critical, vaccine use case-specific temporal thresholds that need to be overcome for significant benefits to be reaped from increasing vaccine thermostability. We present a number of recommendations deriving from this analysis that suggest a rational path toward unlocking the value (maximizing coverage, minimizing total system costs) of increased vaccine thermostability, including: (1) the full range of thermostability of existing vaccines should be defined and included in their labels; (2) for new vaccines, thermostability goals should be addressed up-front at the level of the target product profile; (3) improving cold chain infrastructure and supply chain system design is likely to have the largest impact on total system costs and coverage in the short term—and will influence the degree of thermostability required in the future; (4) in the long term, there remains value in monitoring the emergence of disruptive technologies that could remove the entire RI portfolio out of the cold chain.

Vaccine
Volume 33, Issue 29, Pages 3263-3434 (26 June 2015)
http://www.sciencedirect.com/science/journal/0264410X/33/29

Conference report
Rotavirus landscape in Africa—Towards prevention and control: A report of the 8th African rotavirus symposium, Livingstone, Zambia
Pages 3263-3267
Cheryl Rudd, Jason Mwenda, Roma Chilengi

Vaccine
Volume 33, Issue 29, Pages 3263-3434 (26 June 2015)
http://www.sciencedirect.com/science/journal/0264410X/33/29

Protocol versus practice of supplementary immunization activity (SIA) for polio eradication in Pakistan
Page 3270
Ali Sibtain Farooq Sheikh
Highlights
:: Currently oral polio vaccine is made extensively available in Pakistan.
:: Children are getting more vaccine dose than required.
:: Subsequently risk of vaccine-derived poliovirus could increase many fold.
:: With all efforts towards polio eradication, other routine vaccinations get delayed.
:: Cross-referencing and tracking of vaccinated pool should be made more effective.

Vaccine
Volume 33, Issue 29, Pages 3263-3434 (26 June 2015)
http://www.sciencedirect.com/science/journal/0264410X/33/29

Exploring the presentation of HPV information online: A semantic network analysis of websites
Original Research Article
Pages 3354-3359
Jeanette B. Ruiz, George A. Barnett
Abstract
Context
Negative vaccination-related information online leads some to opt out of recommended vaccinations.
Objective
To determine how HPV vaccine information is presented online and what concepts co-occur.
Methods
A semantic network analysis of the words in first-page Google search results was conducted using three negative, three neutral, and three positive search terms for 10 base concepts such as HPV vaccine, and HPV immunizations. In total, 223 of the 300 websites retrieved met inclusion requirements. Website information was analyzed using network statistics to determine what words most frequently appear, which words co-occur, and the sentiment of the words.
Results
High levels of word interconnectivity were found suggesting a rich set of semantic links and a very integrated set of concepts. Limited number of words held centrality indicating limited concept prominence. This dense network signifies concepts that are well connected. Negative words were most prevalent and were associated with describing the HPV vaccine’s side-effects as well as the negative effects of HPV and cervical cancer. A smaller cluster focuses on reporting negative vaccine side-effects. Clustering shows the words women and girls closely located to the words sexually, virus, and infection.
Discussion
Information about the HPV vaccine online centered on a limited number of concepts. HPV vaccine benefits as well as the risks of HPV, including severity and susceptibility, were centrally presented. Word cluster results imply that HPV vaccine information for women and girls is discussed in more sexual terms than for men and boys.

Vaccine
Volume 33, Issue 29, Pages 3263-3434 (26 June 2015)
http://www.sciencedirect.com/science/journal/0264410X/33/29

Barriers to childhood immunisation: Findings from the Longitudinal Study of Australian Children
Original Research Article
Pages 3377-3383
Anna Pearce, Helen Marshall, Helen Bedford, John Lynch
Abstract
Objectives
To examine barriers to childhood immunisation experienced by parents in Australia.
Design
Cross-sectional analysis of secondary data.
Setting
Nationally representative Longitudinal Study of Australian Children (LSAC).
Participants
Five thousand one hundred seven infants aged 3–19 months in 2004.
Main outcome measure
Maternal report of immunisation status: incompletely or fully immunised.
Results
Overall, 9.3% (473) of infants were incompletely immunised; of these just 16% had mothers who disagreed with immunisation. Remaining analyses focussed on infants whose mother did not disagree with immunisation (N = 4994) (of whom 8% [398] were incompletely immunised).
Fifteen variables representing potential immunisation barriers and facilitators were available in LSAC; these were entered into a latent class model to identify distinct clusters (or ‘classes’) of barriers experienced by families. Five classes were identified: (1) ‘minimal barriers’, (2) ‘lone parent, mobile families with good support’, (3) ‘low social contact and service information; psychological distress’, (4) ‘larger families, not using formal childcare’, (5) ‘child health issues/concerns’. Compared to infants from families experiencing minimal barriers, all other barrier classes had a higher risk of incomplete immunisation. For example, the adjusted risk ratio (RR) for incomplete immunisation was 1.51 (95% confidence interval: 1.08–2.10) among those characterised by ‘low social contact and service information; psychological distress’, and 2.47 (1.87–3.25) among ‘larger families, not using formal childcare’.
Conclusions
Using the most recent data available for examining these issues in Australia, we found that the majority of incompletely immunised infants (in 2004) did not have a mother who disagreed with immunisation. Barriers to immunisation are heterogeneous, suggesting a need for tailored interventions

Vaccine
Volume 33, Issue 29, Pages 3263-3434 (26 June 2015)
http://www.sciencedirect.com/science/journal/0264410X/33/29

Field evaluation of measles vaccine effectiveness among children in the Democratic Republic of Congo
Original Research Article
Pages 3407-3414
Reena H. Doshi, Patrick Mukadi, Calixte Shidi, Audry Mulumba, Nicole A. Hoff, Sue Gerber, Emile Okitolonda-Wemakoy, Benoit Kebela Ilunga, Jean-Jacques Muyembe, Anne W. Rimoin
Abstract
Background
Large-scale measles outbreaks in areas with high administrative vaccine coverage rates suggest the need to re-evaluate measles prevention and control in the Democratic Republic of Congo (DRC). Monitoring of measles Vaccine Effectiveness (VE) is a useful measure of quality control in immunization programs. We estimated measles VE among children aged 12–59 months in the Democratic Republic of Congo (DRC) using laboratory surveillance data from 2010–2012.
Methods
We used the case-based surveillance system with laboratory confirmation to conduct a case-control study using the test negative design. Cases and controls were selected based on presence (n = 1044) or absence (n = 1335) of measles specific antibody IgM or epidemiologic linkage. Risk factors for measles were assessed using unconditional logistic regression, stratified by age.
Results
Among children 12–59 months, measles vaccination was protective against measles [aOR (95% C)], 0.20 (0.15–0.26) and estimated VE was 80% (95% CI 74–85%). Year of diagnosis, 2011: 6.02 (4.16–8.72) and 2012; 8.31 (5.57–12.40) was a risk factor for measles when compared to 2010. Compared to Kinshasa, children in Bas-Congo, Kasai-Oriental, Maniema and South Kivu provinces all had higher odds of developing measles. Measles VE was similar for children 12–23 months and 24–59 months (80% and 81% respectively).
Conclusions
Repeated occurrences of measles outbreaks and lower than expected VE estimates suggest the need to further evaluate measles vaccine efficacy and improve vaccine delivery strategies in DRC.

Vaccine
Volume 33, Issue 29, Pages 3263-3434 (26 June 2015)
http://www.sciencedirect.com/science/journal/0264410X/33/29

Outsourcing vaccine logistics to the private sector: The evidence and lessons learned from the Western Cape Province in South-Africa
Original Research Article
Pages 3429-3434
Patrick Lydon, Ticky Raubenheimer, Michelle Arnot-Krüger, Michel Zaffran
Abstract
With few exceptions, immunization supply chains in developing countries continue to face chronic difficulties in providing uninterrupted availability of potent vaccines up to service delivery levels, and in the most efficient manner possible. As these countries struggle to keep pace with an ever growing number of vaccines, more and more Ministries of Health are considering options of engaging the private sector to manage vaccine storage, handling and distribution on their behalf. Despite this emerging trend, there is limited evidence on the benefits or challenges of this option to improve public supply chain performance for national immunization programmes. To bridge this knowledge gap, this study aims to shed light on the value proposition of outsourcing by documenting the specific experience of the Western Cape Province of South Africa. The methodology for this review rested on conducting two key supply chain assessments which allowed juxtaposing the performance of the government managed segments of the vaccine supply chain against those managed by the private sector. In particular, measures of effective vaccine management best practice and temperature control in the cold chain were analysed. In addition, the costs of engaging the private sector were analysed to get a better understanding of the economics underpinning outsourcing vaccine logistics. The results from this analysis confirmed some of the theoretical benefits of outsourcing to the private sector. Yet, if the experience in the Western Cape can be deemed a successful one, there are several policy and practice implications that developing countries should be mindful of when considering engaging the private sector. While outsourcing can help improve the performance of the vaccine supply chain, it has the potential to do the reverse if done incorrectly. The findings and lessons learnt from the Western Cape experience can serve as a step towards understanding the role of the private sector in immunization supply chain and logistics systems for developing countries.

Vaccines — Open Access Journal
(Accessed 20 June 2015)
http://www.mdpi.com/journal/vaccines

Review:
The Promise of Preventive Cancer Vaccines
by Pier-Luigi Lollini, Federica Cavallo, Patrizia Nanni and Elena Quaglino
Vaccines 2015, 3(2), 467-489; doi:10.3390/vaccines3020467 – published 17 June 2015
Abstract:
Years of unsuccessful attempts at fighting established tumors with vaccines have taught us all that they are only able to truly impact patient survival when used in a preventive setting, as would normally be the case for traditional vaccines against infectious diseases. While true primary cancer prevention is still but a long-term goal, secondary and tertiary prevention are already in the clinic and providing encouraging results. A combination of immunopreventive cancer strategies and recently approved checkpoint inhibitors is a further promise of forthcoming successful cancer disease control, but prevention will require a considerable reduction of currently reported toxicities. These considerations summed with the increased understanding of tumor antigens allow space for an optimistic view of the future.

Value in Health
June 2015 Volume 18, Issue 4, p355-548
http://www.valueinhealthjournal.com/current

Public Health Impact and Cost-Effectiveness of Hepatitis A Vaccination in the United States: A Disease Transmission Dynamic Modeling Approach
Praveen Dhankhar, PhD, Chizoba Nwankwo, PhD, Matthew Pillsbury, PhD, Andreas Lauschke, MsC, Michelle G. Goveia, MD, MPH, Camilo J. Acosta, MD, Elamin H. Elbasha, PhD
Open Access
DOI: http://dx.doi.org/10.1016/j.jval.2015.02.004
Abstract
Objective
To assess the population-level impact and cost-effectiveness of hepatitis A vaccination programs in the United States.
Methods
We developed an age-structured population model of hepatitis A transmission dynamics to evaluate two policies of administering a two-dose hepatitis A vaccine to children aged 12 to 18 months: 1) universal routine vaccination as recommended by the Advisory Committee on Immunization Practices in 2006 and 2) Advisory Committee on Immunization Practices’s previous regional policy of routine vaccination of children living in states with high hepatitis A incidence. Inputs were obtained from the published literature, public sources, and clinical trial data. The model was fitted to hepatitis A seroprevalence (National Health and Nutrition Examination Survey II and III) and reported incidence from the National Notifiable Diseases Surveillance System (1980–1995). We used a societal perspective and projected costs (in 2013 US $), quality-adjusted life-years, incremental cost-effectiveness ratio, and other outcomes over the period 2006 to 2106.
Results
On average, universal routine hepatitis A vaccination prevented 259,776 additional infections, 167,094 outpatient visits, 4781 hospitalizations, and 228 deaths annually. Compared with the regional vaccination policy, universal routine hepatitis A vaccination was cost saving. In scenario analysis, universal vaccination prevented 94,957 infections, 46,179 outpatient visits, 1286 hospitalizations, and 15 deaths annually and had an incremental cost-effectiveness ratio of $21,223/quality-adjusted life-year when herd protection was ignored.
Conclusions
Our model predicted that universal childhood hepatitis A vaccination led to significant reductions in hepatitis A mortality and morbidity. Consequently, universal vaccination was cost saving compared with a regional vaccination policy. Herd protection effects of hepatitis A vaccination programs had a significant impact on hepatitis A mortality, morbidity, and cost-effectiveness ratios.

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

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

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New York Times
http://www.nytimes.com/
Accessed 20 June 2015
North Korea Claims It Has Cure for MERS, Ebola and AIDS
Korea fights an outbreak of MERS that has killed two dozen people and sickened more than 160 since last month. There is no vaccine for the disease.
June 19, 2015 – By THE ASSOCIATED PRESS – World – Print Headline: “North Korea Claims It Has Cure for MERS, Ebola and AIDS”

Meningitis Vaccine Mandate for Seventh Graders in New York Passes
Legislature. Beginning in September 2016, the bill would require students entering seventh grade to have received the meningitis vaccine, with a booster shot to be given in the 12th grade. The United States Centers for Disease
June 19, 2015 – By ANEMONA HARTOCOLLIS – N.Y. / Region – Print Headline: “Meningitis Vaccine Mandate for Seventh Graders Passes”

Ebola Vaccines in Limbo Expose Need for More Speed in Trials
there are suddenly no cases for the trials,” said the World Health Organization’s (WHO) Marie-Paule Kieny. The Liberia Ebola vaccine trial, which had aimed to sign up more than 28,000 subjects, has had to stop enrolling after only
June 17, 2015 – By REUTERS – World – Print Headline: “Ebola Vaccines in Limbo Expose Need for More Speed in Trials”

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_13 June 2015

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

– Twitter:  Readers can also follow developments on twitter: @vaxethicspolicy.
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– Links:  We endeavor to test each link as we incorporate it into any post, but recognize that some links may become “stale” as publications and websites reorganize content over time. We apologize in advance for any links that may not be operative. We believe the contextual information in a given post should allow retrieval, but please contact us as above for assistance if necessary.
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David R. Curry, MS
Executive Director
Center for Vaccine Ethics and Policy
a program of the
– Division of Medical Ethics, NYU Medical School
– Children’s Hospital of Philadelphia Vaccine Education Center
Associate Faculty, Division of Medical Ethics, NYU Medical School

G7 Summit 7 and 8 June 2015
German G7 Presidency
https://www.g7germany.de/Webs/G7/EN/G7-Gipfel_en/g7summit_node.html

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Leadersʼ Declaration G7 Summit (PDF, 435KB, Barrier-free file)
08.06.2015
[Excerpts]
…
Health
The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being. We are therefore strongly committed to continuing our engagement in this field with a specific focus on strengthening health systems through bilateral programmes and multilateral structures.

Ebola
We commit to preventing future outbreaks from becoming epidemics by assisting countries to implement the World Health Organization’s International Health Regulations (IHR), including through Global Health Security Agenda and its common targets and other multilateral initiatives. In order to achieve this we will offer to assist at least 60 countries, including the countries of West Africa, over the next five years, building on countries’ expertise and existing partnerships. We encourage other development partners and countries to join this collective effort. In this framework, we will also be mindful of the healthcare needs of migrants and refugees.

The Ebola crisis has shown that the world needs to improve its capacity to prevent, protect against, detect, report and respond to public health emergencies. We are strongly committed to getting the Ebola cases down to zero. We also recognize the importance of supporting recovery for those countries most affected by the outbreak. We must draw lessons from this crisis. We acknowledge the work that is being done by the WHO and welcome the outcome agreed at the Special Session of the Executive Board on Ebola and the 68th World Health Assembly. We support the ongoing process to reform and strengthen the WHO’s capacity to prepare for and respond to complex health crises while reaffirming the central role of the WHO for international health security.

We welcome the initiative proposed by Germany, Ghana and Norway to the UN Secretary-General to draw up a comprehensive proposal for effective crisis management in the area of health and look forward to the report to be produced by the end of the year by the high-level panel established by the UN Secretary General. The Ebola outbreak has shown that the timely mobilization and disbursement of appropriate response capacities, both funding and human resources, is crucial. We welcome the ongoing development of mechanisms including by the WHO, the World Bank and the International Monetary Fund and call on all partners to strongly coordinate their work. We support the initiative taken by the World Bank to develop a Pandemic Emergency Facility. We encourage the G20 to advance this agenda. Simultaneously, we will coordinate to fight future epidemics and will set up or strengthen mechanisms for rapid deployment of multidisciplinary teams of experts coordinated through a common platform. We will implement those mechanisms in close cooperation with the WHO and national authorities of affected countries.

Antimicrobial Resistances
Antimicrobials play a crucial role for the current and future success of human and veterinary medicine. We fully support the recently adopted WHO Global Action Plan on Antimicrobial Resistance. We will develop or review and effectively implement our national action plans and support other countries as they develop their own national action plans.

We are strongly committed to the One Health approach, encompassing all areas – human, and animal health as well as agriculture and the environment. We will foster the prudent use of antibiotics and will engage in stimulating basic research, research on epidemiology, infection prevention and control, and the development of new antibiotics, alternative therapies, vaccines and rapid point-of-care diagnostics. We commit to taking into account the annex (Joint Efforts to Combat Antimicrobial Resistance) as we develop or review and share our national action plans.

Neglected Tropical Diseases
We commit ourselves to the fight against neglected tropical diseases (NTDs). We are convinced that research plays a vital role in the development and implementation of new means of tackling NTDs. We will work collaboratively with key partners, including the WHO Global Observatory on Health Research and Development. In this regard we will contribute to coordinating research and development (R&D) efforts and make our data available. We will build on efforts to map current R&D activities, which will help facilitate improved coordination in R&D and contribute to better addressing the issue of NTDs. We commit to supporting NTD-related research, focusing notably on areas of most urgent need. We acknowledge the role of the G7-Academies of Science in identifying such areas. In particular, we will stimulate both basic research on prevention, control and treatment and research focused on faster and targeted development of easily usable and affordable drugs, vaccines and point-of-care technologies.

As part of our health system strengthening efforts we will continue to advocate accessible, affordable, quality and essential health services for all. We support community based response mechanisms to distribute therapies and otherwise prevent, control and ultimately eliminate these diseases. We will invest in the prevention and control of NTDs in order to achieve 2020 elimination goals.

We are committed to ending preventable child deaths and improving maternal health worldwide, supporting the renewal of the Global Strategy for Women’s, Children’s and Adolescents’ Health and welcoming the establishment of the Global Financing Facility in support of “Every Woman, Every Child” and therefore welcome the success of the replenishment conference in Berlin for Gavi, the Global Vaccine Alliance, which has mobilized more than USD 7.5 billion to vaccinate an additional 300 million children by 2020. We fully support the ongoing work of the Global Fund to fight AIDS, Tuberculosis and Malaria and look forward to its successful replenishment in 2016 with the support of an enlarged group of donors….

MERS-CoV [to 13 June 2015]

Middle East respiratory syndrome coronavirus (MERS-CoV)
WHO Fact Sheet: 7 June 2015

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WHO recommends continuation of strong disease control measures to bring MERS-CoV outbreak in Republic of Korea to an end
13 June 2015 — A joint mission by WHO and the Republic of Korea’s Ministry of Health and Welfare to review the outbreak of Middle East respiratory syndrome coronavirus (MERS-CoV) in the Republic of Korea has recommended that continuing strengthening of contact tracing, monitoring and quarantine as well as expanded laboratory testing will prevent further spread of the virus….

High-level messages
Assessment
This outbreak in the Republic of Korea, which started with the introduction of MERS-CoV infection into the country by a single infected traveller, was amplified by infection in hospitals and movement of cases within and among hospitals.

A combination of older and new cases continues to be reported, but the epidemic curve shows that the number of new cases occurring each day appears to be declining. This decline has coincided with much stronger contact tracing, monitoring and quarantine, suggesting that disease control measures are working. These measures are greatly facilitated by expanded laboratory testing. However, several weeks will be required to confirm the impact of the measures and whether the outbreak is fully controlled.

Several factors appear to have contributed to the initial spread of this virus.
:: The appearance of MERS-CoV was unexpected and unfamiliar to most physicians
Infection prevention and control measures in hospitals were not optimal
:: Extremely crowded Emergency Rooms and multi-bed rooms contributed significantly to nosocomial infection in some hospitals.
:: The practice of seeking care at a number of medical facilities (“doctor shopping”) may have been a contributing factor
:: The custom of having many friends and family members accompanying or visiting patients may have contributed to secondary spread of infection among contacts.

The rapid increase in numbers of cases has led to much speculation as to whether there may be new contributing factors to transmission. It is too early to draw definitive conclusions at this time, but certain observations can be made:
:: There is no strong evidence at present to suggest that the virus has changed to make the virus more transmissible.
:: Thus far, the epidemiological pattern of this outbreak appears similar to hospital-associated MERS-CoV outbreaks that have occurred in the Middle East. However, this Mission has not been able to determine whether environmental contamination, inadequate ventilation, or other factors have had a role in transmission of the virus in this outbreak. There is a compelling need for further investigation.

While there is no evidence at present of ongoing community transmission of MERS-CoV in the Republic of Korea, continued monitoring for this possibility is critical. Because the outbreak has been large and complex and more cases can be anticipated, the Government should remain vigilant and continue intensified disease control, surveillance, and prevention measures until the outbreak is clearly over.

High Level Recommendations for Government
1. Infection prevention and control measures should immediately be strengthened in all health care facilities across the country.
2.All patients presenting with fever or respiratory symptoms should be asked about: contact with a MERS patient; visits to a healthcare facility where a MERS patient has been treated; and history of travel to the Middle East in the 14 days before symptom onset. Any patient with positive responses should be promptly reported to public health authorities and managed as a suspected case while the diagnosis is being confirmed.
3.Close contacts of MERS cases should not travel during the period when they are being monitored for the development of symptoms.
4.Strong consideration should be given to re-opening schools, as schools have not been linked to transmission of MERS-CoV in the Republic of Korea or elsewhere.
5.The most important steps needed to stop further cases involve continued implementation of basic public health measures by all health authorities. These include:
a.early and complete identification and investigation of all contacts
b.robust quarantine/isolation and monitoring of all contacts and suspected cases
c.full implementation of infection prevention and control measures; and
d.prevention of travel, especially internationally, of infected persons and contacts
6.Local governments must be fully engaged and mobilized in the national fight against this large and complex outbreak.
7.In parallel with disease prevention and control measures, steps should be taken to strengthen domestic and international confidence and trust. The most important actions involve improving risk communications. The Ministry of Health and Welfare should provide regularly updated information (in Korean and English) on the epidemiological situation, investigations, and disease control measures.
8.Additional staff (for “surge capacity”) are urgently required for the response and to provide relief for staff already working on the outbreak.
9.Selected hospitals should be designated for safe triage and assessment of suspected MERS cases. This will require trained personnel, facility management, and communication with the public.
10.Comprehensive research studies designed to close critical gaps in knowledge, including sero-epidemiological studies, should be completed and the results widely communicated as quickly as possible.
11.The Republic of Korea should ensure that it is able to optimally respond to future outbreaks. In particular, it should strengthen the medical facilities needed to deal with serious infectious diseases, including increased numbers of negative-pressure isolation rooms; consider how to reduce the practice of “doctor shopping”; train more infection prevention and control specialists, infectious disease experts, laboratory scientists, epidemiologists, and risk communication experts; and invest in strengthening public health capacities and leadership, including at Korea Centers for Disease Control and Prevention (KCDC).
Read the press release from the Regional Office for Western Pacific

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Global Alert and Response (GAR) – Disease outbreak news
Middle East respiratory syndrome coronavirus (MERS-CoV) – Republic of Korea  12 June 2015
Middle East Respiratory Syndrome coronavirus (MERS-CoV) – Saudi Arabia  11 June 2015
Middle East respiratory syndrome coronavirus (MERS-CoV) – United Arab Emirates 9 June 2015

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Preliminary data from sequencing of viruses in the Republic of Korea and the People’s Republic of China  9 June 2015

EBOLA/EVD [to 13 June 2015]
Public Health Emergency of International Concern (PHEIC); “Threat to international peace and security” (UN Security Council)

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WHO: Ebola Situation Report – 10 June 2015
[Excerpts]
SUMMARY
:: In recent weeks, the decline in case incidence and the contraction of the geographic area affected by Ebola virus disease (EVD) transmission that was apparent throughout April and early May has stalled. In total, 31 confirmed cases of EVD were reported in the week ending 7 June: 16 cases in Guinea and 15 in Sierra Leone. This is the second consecutive weekly increase in case incidence, and the highest weekly total number of cases reported from Sierra Leone since late March. In addition, cases were reported from a widening geographical area in Guinea and Sierra Leone, and the continued occurrence of cases that arise from unknown sources of infection highlights the challenges still faced in finding and eliminating every chain of transmission…

COUNTRIES WITH WIDESPREAD AND INTENSE TRANSMISSION
:: There have been a total of 27,237 reported confirmed, probable, and suspected cases of EVD in Guinea, Liberia and Sierra Leone (figure 1, table 1), with 11,158 reported deaths (this total includes reported deaths among probable and suspected cases, although outcomes for many cases are unknown). A total of 16 new confirmed cases were reported in Guinea and 15 in Sierra Leone in the 7 days to 7 June. The outbreak in Liberia was declared over on 9 May…

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IOM and CDC conduct Ebola Virus Disease outbreak assessment in Boke, Guinea
06/12/15
Guinea, one of the three hardest hit countries by the Ebola outbreak is still struggling to contain the virus spread. In mid-May, a new Ebola Virus Disease (EVD) outbreak was declared in Boké Prefecture, a region bordering Guinea Bissau.

In collaboration with Centre for Disease Control and Prevention – Atlanta (CDC), IOM has conducted an assessment in Boké Prefecture to assess the capacity of regional and local authorities to respond and further halt the spread of EVD.

“Recent development of the epidemic in the Prefecture of Boké at the border with GB increases the risk of introduction of Ebola into this unaffected country‏,” said Alexandre Robert, Ebola Regional Project Officer. “The analysis of EVD epidemiological data supports a correlation between cross-border mobility and sustained EVD transmission. A comprehensive intervention at the border is an essential component in the strategy to reduce EVD transmission.”…

…Boké prefecture is host to several important economic activities in the country; including mining, agriculture, and fisheries. The assessment team found monitoring of population mobility and cross-border movements for EVD infected travellers and contact cases will be a great challenge…

…The Prefecture and National Ebola response authorities have requested that IOM and CDC provide technical and material support in setting-up of health checkpoints on the roads around Kamsar. The team also recommended that other health checkpoints be set up at the main border point of entry.

“We have called for strengthening of social mobilization and enhancing capacity of Community Health Workers who are able to reach isolated communities,” said Mario Breton, team leader CDC Border Health team in Guinea…

…IOM will support the health screening at Points of Entry as part of the Health and Humanitarian Border Management framework in partnership with CDC Border Health team.
To this end, IOM will work with border officials, health facilities and related community health system located in border areas to strengthen their capacity to perform epidemiological surveillance, EVD case management, alert and referral systems in coordination with Points of Entry. Activities will start in June and the first expected outcome is the strengthening of the capacities of sea border officials to perform health screening of the fishermen who are transiting between Kamsar and several islands off of the coastal areas of this city…

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UNMEER [to 13 June 2015]
https://ebolaresponse.un.org/press-releases
Selected Press Releases
10 Jun 2015
Liberia still cautious one month into being declared free of Ebola transmission

08 Jun 2015
UNMEER Chief thanks President Mahama for ‘extraordinary leadership and solidarity’

Selected Statements
02 Jun 2015
:: Acting UNMEER SRSG Peter Graaff’s remarks to the General Assembly informal plenary on Ebola
:: Special Envoy David Nabarro’s remarks to the General Assembly informal plenary on Ebola
:: Secretary-General Ban Ki-moon’s remarks to the General Assembly informal plenary on Ebola

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WHO: Over 1.3 million under five children in Sierra Leone to be vaccinated against measles and polio
FREETOWN, 5 June 2015 – The year-long Ebola outbreak in Sierra Leone has had a negative impact on basic health services, especially maternal and child health, with opportunistic childhood diseases such as measles and polio continuing to challenge an already overstretched system.

So, while continuing to support the push to zero new Ebola cases, the Ministry of Health and Sanitation, in collaboration with UNICEF, WHO and other development partners, continues to work to restore basic health services – one of the Government’s priorities in the early recovery from the health emergency.

A major step forward starts today with the commencement of a six-day (5-10 June) nationwide mass measles and polio vaccination campaign for children under five years in all the districts in the country which should benefit more than 1.3 million children.

“While we laud the efforts of all the key stakeholders in this campaign and the fight against Ebola, we must not relent so as to lose focus on tackling other childhood diseases that are taking a toll on our children before they reach their fifth birthday,” said Dr Abubakarr Fofanah, Minister of Health and Sanitation.

Many children missed out on routine vaccination services due to the Ebola outbreak. Since 2014, measles outbreaks, mostly among under five children, have been reported in the country…

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Government of Canada strengthens Ebola preparedness for Canadians
Contract signed to manufacture ZMappTM to help protect Canadians
OTTAWA, June 10, 2015 /CNW/ – The Honourable Rona Ambrose, Minister of Health, and Canada’s Chief Public Health Officer, Dr. Gregory Taylor, today announced a $4.5 million USD contract between the Government of Canada and Mapp Biopharmaceutical, Inc. to manufacture a number of courses of ZMappTM monoclonal antibody (mAb) treatment for Ebola.
The ZMappTM treatment, developed by Mapp Biopharmaceutical, uses two mAbs discovered by scientists at the Public Health Agency of Canada’s National Microbiology Laboratory in Winnipeg and one mAb discovered by the U.S. Army Medical Research Institute of Infectious Diseases (USAMRIID). ZMappTM has been approved by the US Food and Drug Administration (FDA) for clinical trials in the United States and West Africa and has shown promise when used to treat infected individuals.
This contract with Mapp Biopharmaceutical secures Canada’s access to this Ebola treatment….

POLIO [to 13 June 2015]
Public Health Emergency of International Concern (PHEIC)

GPEI Update: Polio this week – As of 10 June 2015
Global Polio Eradication Initiative
[Editor’s Excerpt and text bolding]
Full report: http://www.polioeradication.org/Dataandmonitoring/Poliothisweek.aspx
:: This week, the “Written Declaration on EU Support and Funding for Polio Eradication” was signed by a majority of the members of the European Parliament. In total, 380 European Parliamentarians signed the Written Declaration, which calls for continued commitment to polio eradication by the European Commission. More [see below]
:: Expert groups in polio-infected areas are actively evaluating progress. Last week, the Technical Advisory Group for Afghanistan and Pakistan met to review latest epidemiology, while this week an international outbreak assessment is evaluating the situation in the Horn of Africa. Similar expert bodies will convene in other infected areas/countries over the coming months.

Selected excerpts from Country-specific Reports
Afghanistan
:: One new wild poliovirus type 1 (WPV1) case was reported in the past week, from Farah province, with onset of paralysis on 23 April. The total number of WPV1 cases for 2015 is three. This most recent case is from the same district of Farah (Gulestan district) as the last previous reported case (with onset of paralysis on 5 May).
:: While the bulk of cases in Afghanistan are linked with cross-border transmission with Pakistan, low-level endemic transmission persists in some areas. Focus must be on interrupting both this transmission and to prevent secondary spread as a result of cross-border transmission (i.e. local transmission).
:: The Technical Advisory Group last week identified that southern and eastern Afghanistan remain at particular risk to polio. The group identified reasons for missed children, which to a great extent are due to remaining operational challenges during campaign implementation. The meeting put forward key recommendations to urgently address these remaining gaps.
:: Subnational Immunization Days (SNIDs) are planned from 14 – 16 June across the south and east using bivalent OPV. National Immunization Days are scheduled on 16 to 18 August.
Pakistan
:: Two new environmental sample positive for WPV1 were reported this week, one from greater Karachi, Sindh, and the other from Jacobabad, Sindh, with collection dates on 11 and 5 May, respectively.
Horn of Africa
:: An international outbreak assessment is underway this week in the Horn of Africa, to examine the impact of the regional emergency outbreak response activities. The assessment will build on recommendations from the February Horn of Africa Technical Advisory Group, including the need to put in place additional and new measures to strengthen subnational surveillance sensitivity in key areas (notably south-central Somalia and Somali region, Ethiopia).

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WRITTEN DECLARATION submitted under Rule 136 of the Rules of Procedure on continued European Union support for polio eradication
EUROPEAN PARLIAMENT 9.3.2015 0008/2015 DC\1051044EN.doc PE550.890v01-00
1. The world is on the brink of one of its greatest public health achievements – the
eradication of poliomyelitis.
2. Childhood immunisation is one of the most cost-effective public health interventions available. Global polio eradication efforts have already generated net benefits of USD 27 billion and could save up to USD 50 billion in direct and indirect healthcare costs by 2035, not to mention the immeasurable alleviation of human suffering. Assets and infrastructures built to support the eradication effort are also currently being used in the response to the Ebola crisis.
3. Eradicating the last 1 % of polio cases is difficult and costly, yet achievable by 2018 thanks to global efforts. As proven by recent outbreaks, no country – including the EU Member States – will be safe until all countries are free of polio.
4. The Commission is therefore called upon to make a continued commitment to supporting
polio eradication as a priority in its future development actions, and to allocate appropriate levels of funding to polio vaccination campaigns and surveillance over the next four years.
5. This declaration, together with the names of the signatories, is forwarded to the Council and the Commission.

WHO & Regionals [to 13 June 2015]
WHO calls for increase in voluntary blood donors to save millions of lives
11 June 2015

Global Alert and Response (GAR) – Disease Outbreak News (DONs)
13 June 2015 – Middle East respiratory syndrome coronavirus (MERS-CoV) – Republic of Korea
13 June 2015 – Middle East Respiratory Syndrome coronavirus (MERS-CoV) – Saudi Arabia
5 June 2015 – Middle East respiratory syndrome coronavirus (MERS-CoV) – Republic of Korea
4 June 2015 – Middle East respiratory syndrome coronavirus (MERS-CoV) – Republic of Korea
4 June 2015 – Middle East Respiratory Syndrome coronavirus (MERS-CoV) – Saudi Arabia

The Weekly Epidemiological Record (WER) 12 June 2015, vol. 90, 24 (pp. 297–308) includes:
:: Progress towards measles elimination – South-East Asia Region, 2003–2013
:: Fact sheet on Middle East respiratory syndrome coronavirus

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:: WHO Regional Offices
WHO African Region AFRO
:: Niger now seeing a considerable decrease in meningitis cases
Niamey, 12 June 2015 – The situation of the meningitis epidemic in Niger, caused by Neisseria meningitidis serogroup C, has improved thanks to intensive efforts at the national and international levels. A significant reduction of cases is now being reported in all affected areas and two support centres in Niamey, the capital, were closed as no case has been recorded during the last week.
:: Experts to assess mental health impact of Ebola – 09 June 2015
:: Experts agree to develop robust blood transfusion services in Ebola affected and unaffected countries – 08 June 2015

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WHO Region of the Americas PAHO
:: New WHO and World Bank Group report shows that 400 million do not have access to essential health services (06/12/2015)
:: On World Blood Donor Day, PAHO/WHO thanks voluntary donors and encourages young people to donate (06/10/2015)
:: Caribbean leaders will discuss stepped-up action to tackle chronic diseases (06/08/2015)

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WHO South-East Asia Region SEARO
:: Medical Camp Kits replace primary health care facilities before onset of Nepal’s monsoon  01 June 2015

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WHO European Region EURO
:: Diphtheria detected in Spain 05-06-2015
:: Dramatic increase in Caesarean sections 01-06-2015

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WHO Eastern Mediterranean Region EMRO
:: Inequality has transformed surviving childhood into a global postcode lottery (commentary)  3 June 2015
:: Middle East respiratory syndrome coronavirus (MERS-CoV) in the Republic of Korea  2 June 2015

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WHO Western Pacific Region
:: The World Health Organization (WHO) and the Republic of Korea to carry out Joint Mission for the MERS-CoV Outbreak
MANILA, 5 June 2015 – In light of the recent outbreak of Middle East Respiratory Syndrome coronavirus (MERS-CoV), the World Health Organization and the Republic of Korea’s Ministry of Health and Welfare will conduct a joint mission to the Republic of Korea. The mission comes after close consultation between WHO and the Government.
:: Strategy for malaria elimination in the Greater Mekong Subregion (2015-2030)
5 June 2015
In close consultation with countries in the Greater Mekong Subregion, the WHO Regional Offices for the Western Pacific and South-East Asia have developed a malaria elimination strategy for the Subregion, where emerging antimalarial multidrug resistance, including resistance to artemisinin-based combination therapies, is threatening our recent gains. The elimination strategy is fully aligned with the Global technical strategy for malaria 2016-2030, which has just been endorsed by the World Health Assembly. The first subregional document that effectively operationalizes the global strategy, it is a prime example of partnership and collaboration, with six countries, WHO (two regions and headquarters) and multiple development partners joining forces to fight a common threat.

GAVI [to 13 June 2015]
http://www.gavialliance.org/library/news/press-releases/
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Gavi to step up engagement with countries preparing for transition from Vaccine Alliance support
11 June 2015
Board decisions will help increase sustainability of developing countries’ immunisation programmes.

Geneva, 11 June 2015 –The Board of Gavi, the Vaccine Alliance today approved a number of measures to support the implementation of the Alliance’s 2016 to 2020 strategy. These include an enhanced focus on coverage and equity, promoting sustainable immunisation programmes and supporting countries towards successful transition from Gavi funding.

“There is absolutely no reason why children should miss out on vaccination because of where they live,” said Dagfinn Høybråten, Chair of the Gavi Board. “Today’s decisions will help strengthen life-saving immunisation programmes in developing countries and ensure they can be sustained after Gavi support ends”

To increase the sustainability of immunisation programmes in developing countries as they transition out of Gavi support, the Gavi Board approved the following:

:: Changes to the way countries transition out of Gavi support. These include earlier preparation for the end of support with an increased focus on sustainability and, in specific circumstances, extending engagement with countries that have had a short period to prepare for the transition as a result of exceptionally rapid increases in income and therefore potentially coming to the end of Gavi support earlier than planned.

:: Alterations to Gavi’s country co-financing policy. Under the new policy, countries entering a preparatory transition phase will begin paying a percentage of the price of the vaccines they are using rather than the currently-used flat rate per dose. As with the existing policy, these countries’ contributions will increase on a yearly basis. The alterations will strengthen countries’ preparations for transitioning from Gavi support by creating more awareness around the financial implications of vaccine choices and supporting them to make more informed decisions on which vaccines to use.

:: Plans to allow countries who have transitioned from Gavi support to be included in UNICEF tenders on behalf of Gavi-supported countries for specific vaccines with the aim of continuing to provide them with access to prices similar to those Gavi pays for a five year period after they take on full self-financing of vaccines, giving them time to stabilise their budgets and further strengthen their systems. The decision is underpinned by an agreement between Gavi and the Pan-American Health Organization (PAHO) to work together to increase access to vaccines and sustainability of immunisation programmes for countries.

:: Provision of US$ 5 million in funding to UNICEF’s Vaccine Independence Initiative, a revolving fund which supports timely availability of short-term financing for countries to meet vaccine payment terms and is available to all low- and middle-income countries, including those who are not eligible for Gavi support.

The Board also approved:
:: A new Partners’ Engagement Framework (PEF), which recognises the critical need to work in new ways to achieve the goals of the Alliance’s 2016 to 2020 strategy. The PEF is designed to enable key Vaccine Alliance partners to better support developing countries’ immunisation programmes – including in key strategic areas such as data quality, demand promotion and supply chain strengthening.

:: A range of metrics to track delivery of Gavi’s 2016 to 2020 strategy, as part of the Vaccine Alliance’s commitment to impact, transparency and accountability.

:: The creation of an innovative funding mechanism to increase developing countries’ access to more efficient, reliable and innovative cold chain equipment. Inadequate cold chain equipment is a key bottleneck to reliably reaching all children with immunisation services. The new Cold Chain Equipment Optimisation Platform, which will be launched in 2016 with initial Gavi funding of US$ 50 million, offers market-shaping potential by consolidating demand from countries.

:: Support for two additional measles vaccination campaigns, one each in Ethiopia and the Democratic Republic of Congo. The support will enable these two countries to vaccinate a total of 26.5 million children against the deadly disease. At its next meeting, the Gavi Board will also consider a new strategy for the Vaccine Alliance’s engagement in tackling measles.

“The package of decisions taken today by the Gavi Board today leaves us well prepared to deliver on our 2016 to 2020 strategy,” said Gavi CEO Dr Seth Berkley. “Sustainability of immunisation programmes is vital to ensuring that children continue to receive life-saving vaccines and today’s decisions underpin Gavi’s commitment to sustainability.”

The Gavi Board approved the appointment of the following new members:
:: William Roedy, former Chairman and Chief Executive Officer of MTV Networks International, as an Unaffiliated Board Member.
:: Blair Exell, First Assistant Secretary of the Development Policy Division, Department of Foreign Affairs and Trade, as Board Member representing the Australia, Japan, Korea, and United States donor constituency.
:: Katherine Taylor, deputy assistant administrator for the Bureau for Global Health at USAID, as Board Member representing the Australia, Japan, Korea, and United States donor constituency.
:: Naveen Thacker, Director of Deep Children’s Hospital 9.4 and Research Centre in Gandhidham, in the Indian state of Gujarat, as Board Member representing the Civil Society Organisations.

The Gavi Board also approved the reappointment of the following Board members:
:: H.R.H. the Infanta Cristina of Spain, Director of International Programmes of “la Caixa” Foundation in charge of global health and development projects in the world’s most vulnerable countries, as an Unaffiliated Board Member.
:: Yifei Li, China chair for Man Group, as an Unaffiliated Board Member.

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IFFIm appoints Fatimatou Zahra Diop to its Board of Directors
10 June 2015
Economist from Senegal brings new insights on public-private partnerships

AMA Supports Tighter Limitations on Immunization Opt Outs
June 8, 2015
CHICAGO – Addressing the re-emergence of vaccine preventable diseases in the United States requires states to move toward barring non-medical exemptions to immunization mandates, according to new policy adopted by the nation’s physicians at the American Medical Association’s annual meeting. Under new policy, the AMA will seek more stringent state immunization requirements to allow exemptions only for medical reasons.

Immunization programs in the Unites States are credited with having controlled or eliminated the spread of epidemic diseases, including smallpox, measles, mumps, rubella, diphtheria and polio. Immunization requirements vary from state to state, but only two states bar non-medical exemptions based on personal beliefs.

“When people are immunized they also help prevent the spread of disease to others, said AMA Board Member Patrice A. Harris, M.D. “As evident from the recent measles outbreak at Disneyland, protecting community health in today’s mobile society requires that policymakers not permit individuals from opting out of immunization solely as a matter of personal preference or convenience.”

New AMA policy recommends that states have in place an established decision mechanism that involves qualified public health physicians to determine which vaccines will be mandatory for admission to schools and other public venues. States should only grant exemptions to these mandated vaccines for medical reasons.

In recognition that highly transmissible diseases could pose significant medical risks for vulnerable patients and the health care workforce, new AMA policy also states that physicians and other health professionals who have direct patient care responsibilities have an obligation to accept immunization unless there is a recognized medical reason.
The AMA also intends to support the dissemination of materials on vaccine efficacy to states as part of the effort to eliminate non-medical exemptions.

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American Medical Association – Policies
H-440.970 Religious Exemptions from Immunizations
‘Since religious/philosophic exemptions from immunizations endanger not only the health of the unvaccinated individual, but also the health of those in his or her group and the community at large, the AMA (1) encourages state medical associations to seek removal of such exemptions in statutes requiring mandatory immunizations; (2) encourages physicians and state and local medical associations to work with public health officials to inform religious groups and others who object to immunizations of the benefits of vaccinations and the risk to their own health and that of the general public if they refuse to accept them; and (3) encourages state and local medical associations to work with public health officials to develop contingency plans for controlling outbreaks in exempt populations and to intensify efforts to achieve high immunization rates in communities where groups having religious exemptions from immunizations reside. (CSA Rep. B, A-87; Reaffirmed: Sunset Report, I-97; Reaffirmed: CSAPH Rep. 3, A-07)

H-515.988 Repeal of Religious Exemptions in Child Abuse and Medical Practice Statutes
Our AMA (1) reaffirms existing policy supporting repeal of the religious exemption from state child abuse statutes; (2) recognizes that constitutional barriers may exist with regard to elimination of the religious exemption from state medical practice acts; and (3) encourages state medical associations that are aware of problems with respect to spiritual healing practitioners in their areas to investigate such situations and pursue all solutions, including legislation where appropriate, to address such matters. (BOT Rep. H, A-90; Reaffirmed: Sunset Report, I-00; Reaffirmed: CSAPH Rep. 1, A-10)

Global Fund [to 13 June 2015]

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News Release
New Approach on HIV Viral Load Testing
10 June 2015
GENEVA – Framework agreements will be established between the Global Fund and seven diagnostic manufacturers which aim to make the market for HIV viral load testing more transparent and competitive, driving cost reductions of up to one third.

The agreements should deliver net savings of at least US$30 million over three years to the Global Fund, and potentially much more.

Viral load testing is critical to providing appropriate treatment for HIV positive adults and also identifying infants who may be HIV positive. However, the price paid to conduct the tests has varied widely, sometimes reaching heights of US$85 per test.

The new agreements between the Global Fund and the seven manufacturers provide clarity on prices, aiming for an all-inclusive price as low as US$15, including equipment and other costs such as consumables, maintenance and shipping. It establishes benchmarks at which the Global Fund’s implementing partners can expect to purchase. These partners include government health departments, community health clinics and medical centres.

While pricing for new diagnostic equipment will be more transparent and reliable, the agreements also aim to expand the use of existing equipment, by providing better benchmark prices for maintenance and servicing.

The seven manufacturers are Abbott, Alere, bioMérieux, Cepheid, Hologic, QIAGEN and Roche. Each has been through a technical and commercial evaluation before being added to the panel of suppliers. The agreements initially last three years. Other public health funders and agencies will also be able to enter into agreements based on the benchmark prices negotiated…

USAID, World Bank, WHO, Countries and Partners Align on New Way Forward to Measure Impact of Country Health Programs
PRESS RELEASE
June 9, 2015
Global Health Leaders Unveil and Adopt Roadmap and 5-Point Call to Action

WASHINGTON, June 9, 2015—The U.S. Agency for International Development (USAID), World Bank Group, World Health Organization (WHO), and countries and partners are coming together today at the World Bank Group for a high-level summit, Measurement and Accountability for Results in Health, to examine and advance a common agenda for health measurement as we move into the post-2015 development era.

“Accurate and timely health data are the foundation to improving public health. Without reliable information to set priorities and measure results, countries and their development partners are working in the dark,” said Margaret Chan, Director-General of WHO. “Investing in measurement is an investment in health and countries that build and strengthen local capacity are better positioned to achieve greater long-term success and better health outcomes.”

Dozens of global health leaders from governments, multilaterals, academia, research institutions and civil society will endorse The Roadmap for Health Measurement and Accountability and a 5-Point Call to Action, which outline a shared strategic approach and priority actions and targets that countries and development partners can use to put effective health monitoring plans in place to strengthen health information systems.

“If we are going to ensure that people everywhere have access to quality health care, and that no one is impoverished paying for the health care they need, we need to invest in high-quality, timely, and accurate data and statistics so that countries can measure and monitor their progress,” said Jim Yong Kim, President of the World Bank Group. “Today’s investments in country health information systems will lead to a better tomorrow for billions of people.”
Supporting countries to achieve their health-related Sustainable Development Goals over the next 15 years and aligning partner and donors around common priorities are at the center of the Roadmap and 5-Point Call to Action.

“With the end of the Millennium Development Goals and advent of the Sustainable Development Goals, we are at a key moment to shape the future of international development—and that includes improving health,” said Alfonso Lenhardt, Acting Administrator of USAID. “Countries need to build and further strengthen their capacity in health so they can meet the growing demands for reliable and timely data required for effective measurement of health programs.”
The Roadmap outlines smart investments and proposes concrete actions and targets that countries can adopt to build local capacities, including strengthening basic measurement systems essential to successfully planning, managing and measuring their health programs. The 5-Point Call to Action provides concrete targets for increasing investments, strengthening institutional capacity, using data more effectively, sharing and standardizing data openly, and promoting accountability and transparency.

Panelists at the summit will represent a broad array of high-level global health leaders, country representatives and development partners, and will discuss issues related to building country capacity and demand for health data, including topics such as data revolution and the importance of country and global accountability.

The Roadmap and 5-Point Call to Action are available at: http://live.worldbank.org/measurement-and-accountability-for-results-in-health-summit. More information is available at: http://ma4health.hsaccess.org/home.

Tracking universal health coverage: First global monitoring report
Joint WHO/World Bank Group report
June 2015 :: 98 pages
ISBN 978 92 4 156497 7 (NLM classification: W 84)
Abstract
This report is the first of its kind to measure health service coverage and financial protection to assess countries’ progress towards universal health coverage.
It shows that at least 400 million people do not have access to one or more essential health services and 6% of people in low- and middle-income countries are tipped into or pushed further into extreme poverty because of health spending.

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Press Release
New WHO and World Bank Group Report Shows that 400 Million Do Not Have Access to Essential Health Services and 6% of Population Tipped into or Pushed Further into Extreme Poverty because of Health Spending
June 12, 2015
NEW YORK CITY, June 12, 2015—A World Health Organization and World Bank Group report launched today shows that 400 million people do not have access to essential health services and 6% of people in low- and middle-income countries are tipped into or pushed further into extreme poverty because of health spending.

“This report is a wakeup call: It shows that we’re a long way from achieving universal health coverage. We must expand access to health and protect the poorest from health expenses that are causing them severe financial hardship,” says Dr. Tim Evans, Senior Director of Health, Nutrition and Population at the World Bank Group…

…The report looked at global access to essential health services—including family planning, antenatal care, skilled birth attendance, child immunization, antiretroviral therapy, tuberculosis treatment, and access to clean water and sanitation—in 2013, and found that at least 400 million people lacked access to at least one of these services.

“The world’s most disadvantaged people are missing out on even the most basic services,” says Dr. Marie-Paule Kieny, Assistant Director-General, Health Systems and Innovation, at the World Health Organization. “A commitment to equity is at the heart of universal health coverage. Health policies and programmes should focus on providing quality health services for the poorest people, women and children, people living in rural areas and those from minority groups”.

The report also found that, across 37 countries, 6% of the population was tipped or pushed further into extreme poverty ($1.25/day) because they had to pay for health services out of their own pockets. When the study factored in a poverty measure of $2/day, 17% of people in these countries were impoverished, or further impoverished, by health expenses.

“These high levels of impoverishment, which happen when poor people have to pay out of pocket for their own emergency health care, pose a major threat to the goal of eliminating extreme poverty,” says Dr. Kaushik Basu, Senior Vice President and Chief Economist at the World Bank Group. “As we transition to a post-2015 development era, we must act on these findings, or the world’s poor risk being left behind.”

WHO and the World Bank Group recommend that countries pursuing universal health coverage should aim to achieve a minimum of 80% population coverage of essential health services, and that everyone everywhere should be protected from catastrophic and impoverishing health payments.

“As more countries make commitments to universal health coverage, one of the major challenges they face is how to track progress,” says Dr. Ties Boerma, Director of the Department of Health Statistics and Information Systems at the World Health Organization. “The report shows that it is possible to quantify universal health coverage and track progress towards its key goals, both in terms of health services and financial protection coverage.”

This is the first in a series of annual reports that WHO and the World Bank Group will produce on tracking progress towards UHC across countries…

BMC Health Services Research
http://www.biomedcentral.com/bmchealthservres/content
(Accessed 13 June 2015)

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Research article
Management practices to support donor transition: lessons from Avahan, the India AIDS Initiative
Sara Bennett1*, Daniela Rodriguez1, Sachiko Ozawa1, Kriti Singh2, Meghan Bohren1, Vibha Chhabra2 and Suneeta Singh2
Author Affiliations
BMC Health Services Research 2015, 15:232 doi:10.1186/s12913-015-0894-0
Published: 13 June 2015
Abstract
Background
During 2009-2012, Avahan, a large donor funded HIV/AIDS prevention program in India was transferred from donor support and operation to government. This transition of approximately 200 targeted interventions (TIs), occurred in three tranches in 2009, 2011 and 2012. This paper reports on the management practices pursued in support of a smooth transition of the program, and addresses the extent to which standard change management practices were employed, and were useful in supporting transition.
Results
We conducted structured surveys of a sample of 80 TIs from the 2011 and 2012 rounds of transition. One survey was administered directly before transition and the second survey 12 month after transition. These surveys assessed readiness for transition and practices post-transition. We also conducted 15 case studies of transitioning TIs from all three rounds, and re-visited 4 of these 1-3 years later.
Results
Considerable evolution in the nature of relationships between key actors was observed between transition rounds, moving from considerable mistrust and lack of collaboration in 2009 toward a shared vision of transition and mutually respectful relationships between Avahan and government in later transition rounds. Management practices also evolved with the gradual development of clear implementation plans, establishment of the post of “transition manager” at state and national levels, identified budgets to support transition, and a common minimum programme for transition. Staff engagement was important, and was carried out relatively effectively in later rounds. While the change management literature suggests short-term wins are important, this did not appear to be the case for Avahan, instead a difficult first round of transition seemed to signal the seriousness of intentions regarding transition.
Conclusions
In the Avahan case a number of management practices supported a smooth transition these included: an extended and sequenced time frame for transition; co-ownership and planning of transition by both donor and government; detailed transition planning and close attention to program alignment, capacity development and communication; engagement of staff in the transition process; engagement of multiple stakeholders post transition to promote program accountability and provide financial support; signaling by actors in charge of transition that they were committed to specified time frames.

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Research article
A concise, health service coverage index for monitoring progress towards universal health coverage
Anthony Leegwater1, Wendy Wong2 and Carlos Avila1*
BMC Health Services Research 2015, 15:230 doi:10.1186/s12913-015-0859-3
Published: 12 June 2015
Abstract (provisional)
Background There is a growing international commitment to universal health coverage (UHC), but limited means to determine progress towards that goal. We developed a practical index for capturing health service coverage – a critical dimension of UHC — that was more inclusive than previous methods. Methods Our data included publicly-available, indicators reflecting health service delivery, infrastructure, human resources, and health expenditures for 103 countries. We selected a set of internally-consistent indicators and performed principal component analysis. Multiple imputation was used to address missing values. We extracted and rotated four components related to health service coverage and developed a composite index for each country for 2009. Results Explaining cumulatively almost 80% of the total variance, the four extracted components were characterized as: 1) provision of services, 2) infrastructure and human resources, 3) immunization (provision of services), and 4) financial resources. The health service coverage index developed from these components demonstrated strong correlation with health outcome measures such as infant mortality and life expectancy, supporting its validity. Index values also appeared generally consistent with published reports and the regional distribution of health coverage. Conclusions Our approach moved beyond common indicators of service coverage focused on infectious diseases and maternal and child health, to include information on necessary health inputs. The resulting, balanced, composite index of health service coverage demonstrated promise as a metric, likely to discriminate coverage levels between countries and regions. An important number of service provision indicators were correlated, therefore a reduced set of services performed well as a proxy for the full set of available indicators. This parsimonious index is a start toward simplifying the task of policy-makers monitoring progress on a key domain of universal health coverage.

BMC Infectious Diseases
http://www.biomedcentral.com/bmcinfectdis/content
(Accessed 13 June 2015)

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Research article
Dramatic reduction in hepatitis B through school-based immunization without a routine infant program in a low endemicity region
Teegwendé Valérie Porgo1, Vladimir Gilca2*, Gaston De Serres2, Michèle Tremblay3 and Danuta Skowronski4
Author Affiliations
BMC Infectious Diseases 2015, 15:227 doi:10.1186/s12879-015-0979-8
Published: 12 June 2015
Abstract
Background
Hepatitis B (HB) prevention in the low-endemicity province of Quebec Canada, (population: ~8.2 million; birth cohort ~85,000/year), includes two decades of pre-adolescent school-based immunization, as well as catch-up immunization for those born since 1983 and pre-natal maternal HBsAg screening. To estimate the potential added benefit of routine infant HB immunization, notifiable disease reports were analyzed (1990–2013). Clinical and demographic information about cases was retrieved from standard questionnaires used by local public health units to investigate HB cases.
Methods
The Quebec provincial registry of notifiable diseases was used to identify confirmed HB cases reported between 1990 and 2013. Clinical and demographic information on cases was retrieved from the standard questionnaires used by local public health units to investigate reported HB cases.
Results
Between 1990–2013, acute-HB incidence per 100,000 population decreased by 97 % from 6.5 to 0.2. Compared to 1990, incidence fell from 0.6 to zero since 2010 among children ≤9 years of age (yoa), from 3.2 to zero since 2007 in those 10–19 yoa, and from 15 to zero in 2013 among adults 20–29 yoa, previously the age group of highest incidence (all p < 0.0001).
During the same period, the newly-reported chronic HB rate per 100,000 decreased by 66 % from 17.7 to 6.1 (p < 0.0001), with a reduction of 92 % (2.4 to 0.2;p < 0.001) in children ≤9 yoa and 83 % (7.2 to 1.2;p = 0.003) in those 10–19 yoa. The incidence of unspecified HB cases did not decrease significantly overall (5.9 vs. 5.4; p = 0.24), in children ≤ 9 yoa (0.3 vs. 0.2;p = 0.70) or 10–19 yoa (1.6 vs. 1.5;p = 0.45).
Overall, 91 % of cases ≤19 yoa were immigrants likely infected before arrival in Canada. Among those ≤9 yoa, there were 9 acute-HB case reports between 2005 and 2013, of whom 8 were not preventable by infant immunization.
Conclusions
Two decades of school-based immunization coupled with prenatal screening achieved striking reduction in disease burden in the low-endemicity province of Quebec, Canada. The oldest cohorts targeted by catch-up campaigns are now beyond the average age at childbirth so that neo-natal transmission and the potential incremental benefit of infant immunization will likely further diminish.

BMC Public Health
http://www.biomedcentral.com/bmcpublichealth/content
(Accessed 13 June 2015)

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Research article
Challenges and opportunities associated with neglected tropical disease and water, sanitation and hygiene intersectoral integration programs
E. Anna Johnston1*, Jordan Teague2 and Jay P. Graham1
Author Affiliations
BMC Public Health 2015, 15:547 doi:10.1186/s12889-015-1838-7
Published: 11 June 2015
Abstract
Background
Recent research has suggested that water, sanitation, and hygiene (WASH) interventions, in addition to mass drug administration (MDA), are necessary for controlling and eliminating many neglected tropical diseases (NTDs).
Objectives
This study investigated the integration of NTD and WASH programming in order to identify barriers to widespread integration and make recommendations about ideal conditions and best practices critical to future integrated programs.
Methods
Twenty-four in-depth, semi-structured interviews were conducted with key stakeholders in the global NTD and WASH sectors to identify barriers and ideal conditions in programmatic integration.
Results
The most frequently mentioned barriers to WASH and NTD integration included: 1) differing programmatic objectives in the two sectors, including different indicators and metrics; 2) a disproportionate focus on mass drug administration; 3) differences in the scale of funding; 4) siloed funding; and 5) a lack of coordination and information sharing between the two sectors. Participants also conveyed that a more holistic approach was needed if future integration efforts are to be scaled-up. The most commonly mentioned requisite conditions included: 1) education and advocacy; 2) development of joint indicators; 3) increased involvement at the ministerial level; 4) integrated strategy development; 5) creating task forces or committed partnerships; and 6) improved donor support.
Conclusions
Public health practitioners planning to integrate NTD and WASH programs can apply these results to create conditions for more effective programs and mitigate barriers to success. Donor agencies should consider funding more integration efforts to further test the proof of principle, and additional support from national and local governments is recommended if integration efforts are to succeed. Intersectoral efforts that include the development of shared indicators and objectives are needed to foster conditions conducive to expanding effective integration programs.

BMC Research Notes
http://www.biomedcentral.com/bmcresnotes/content
(Accessed 13 June 2015)

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Research article
Level of immunization coverage and associated factors among children aged 12–23 months in Lay Armachiho District, North Gondar Zone, Northwest Ethiopia: a community based cross sectional study
Melkamu Beyene Kassahun1, Gashaw Andargie Biks2 and Alemayehu Shimeka Teferra3*
Author Affiliations
BMC Research Notes 2015, 8:239 doi:10.1186/s13104-015-1192-y
Published: 13 June 2015
Abstract
Background
Immunization against childhood disease is one of the most important public health interventions with cost effective means to preventing childhood morbidity, mortality and disability. However, complete immunization coverage remains low particularly in rural areas of Ethiopia. This study aimed to assess the level of immunization coverage and associated factors in Lay Armachiho District, North Gondar zone, Northwest Ethiopia. A community based cross-sectional study was conducted in March, 2014 among 751 pairs of mothers to children aged 12–23 months in Lay Armachiho District. A two stage sampling technique was employed. Logistic regression analysis was carried out to compute association between factors and immunization status of children. Backwards stepwise regression method was used and those variables significant at p value 0.05 were considered statistically significant.
Results
Seventy-six percent of the children were fully immunized during the study period. Dropout rate was 6.5% for BCG to measles, 2.7% for Penta1 to Penta3 and 4.5% for Pnemonia1 to Pnemonia3. The likelihood of children to be fully immunized among mothers who identified the number of sessions needed for vaccination were higher than those who did not [AOR = 2.8 (95% C1 = 1.89, 4.2)]. Full immunization status of children was higher among mothers who know the age at which the child become fully immunized than who did not know [AOR = 2.93 (95% CI = 2.02, 4.3)]. Taking tetanus toxoid immunization during pregnancy showed statistically significant association with full immunization of children [AOR 1.6 (95% CI = 1.06, 2.62)]. Urban children were more likely to be fully immunized than rural [AOR = 1.82 (95% CI = 1.15, 2.80)] and being male were more likely to be fully immunized than female [AOR = 1.80 (95% CI = 1.26, 2.6)].
Conclusion and recommendation
Vaccination coverage was low compared to the Millennium Development Goals target. It is important to increase and maintain the immunization level to the intended target. Efforts should be made to promote women‘s’ awareness on tetanus toxoid immunization, when the child should start vaccination, number of sessions needed to complete immunization, and when a child become complete vaccination to improve immunization coverage through health development army and health professionals working at antenatal care, postnatal care and immunization units.

Infectious Agents and Cancer
http://www.infectagentscancer.com/content
[Accessed 13 June 2015]

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Research Article
Vaccines against human papillomavirus in low and middle income countries: a review of safety, immunogenicity and efficacy
Miriam Nakalembe1*, Florence M. Mirembe1 and Cecily Banura2
Author Affiliations
Infectious Agents and Cancer 2015, 10:17 doi:10.1186/s13027-015-0012-2
Published: 12 June 2015
Abstract
Currently, there is limited data on the immunogenicity and efficacy of human papillomavirus vaccines in Low and Middle income countries (LMIC). The review aims to summarize the current status from published HPV vaccine safety, immunogenicity and efficacy studies in low and middle income countries (LMIC). Electronic databases (PubMed/MEDLINE and HINARI) were searched for peer reviewed English language articles on HPV vaccination in LMIC that have so far been published from 1st January 2006 up to 30th January 2015. Eligible studies were included if they had used the bivalent (bHPV) or quadrivalent HPV (qHPV) vaccines in a LMIC and investigated safety, immunogenicity and/or efficacy. The main findings were extracted and summarized. A total of fourteen HPV vaccine studies assessing safety, Immunogenicity and efficacy of the bivalent or quadrivalent vaccines in LMIC were included. There are only ten published clinical trials where a LMIC has participated. There was no published study so far that assessed efficacy of the HPV vaccines in Sub-Saharan Africa. From these studies, vaccine induced immune response was comparable to that from results of HICs for all age groups. Studies assessing HPV vaccine efficacy of the bivalent or quadrivalent vaccine within LMIC were largely missing. Only three studies were found where a LMIC was part of a multi center clinical trial. In all the studies, there were no vaccine related serious adverse events. The findings from the only study that investigated less than three doses of the bivalent HPV-16/18 vaccine suggest that even with less than three doses, antibody levels were still comparable with older women where efficacy has been proven. The few studies from LMIC in this review had comparable safety, Immunogenicity and efficacy profiles like in HIC. Overall, the LMIC of Africa where immune compromising/modulating situations are prevalent, there is need for long term immunogenicity as well as surveillance studies for long term clinical effectiveness after two and three dose regimens.

Journal of Infectious Diseases
Volume 212 Issue 1 July 1, 2015
http://jid.oxfordjournals.org/content/curren

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Editorial Commentaries
Stimulating Evidence for Pneumococcal Conjugate Vaccination Among HIV-Infected Adults
Nancy F. Crum-Cianflone1,2 and Mark R. Wallace3
Author Affiliations
1Infectious Disease Physician, Scripps Mercy Hospital
2Infectious Disease Division, Naval Medical Center San Diego, California
3Infectious Disease Physician, Skagit Valley Hospital, Mt Vernon, Washington
(See the major article by Glesby et al on pages 18–27.)
[Extract]
Streptococcus pneumoniae remains a formidable foe—it is the leading cause of bacterial pneumonia and an important cause of invasive disease. Adults infected with human immunodeficiency virus (HIV) are at particular risk for invasive pneumococcal disease (IPD), with an approximate 40-fold risk compared with the general population despite the advent of combination antiretroviral therapy (cART) [1–3]. Furthermore, up to 25% of HIV-infected persons develop recurrent disease, most commonly because of reinfection [4, 5]. The annual IPD incidence of 245 cases per 100 000 among HIV-positive adults in the developed world [2] points to the need for additional modalities to prevent this all too common infection.

The burden of pneumococcal disease among adults infected with HIV may be mitigated by several strategies including the use of effective cART, the avoidance of specific modifiable behaviors (eg, smoking, illicit drug use), prophylaxis against Pneumocystis carinii pneumonia (ie, trimethoprim-sulfamethoxazole), and annual influenza vaccination [1, 6, 7]. The most specific intervention to reduce IPD is the use of pneumococcal vaccination [6]. Two types of pneumococcal vaccines currently exist—a pneumococcal polysaccharide vaccine containing 23 serotypes (PPSV23) available since 1983, and pneumococcal conjugate vaccines (PCVs), available since 2000 as a 7-valent (PCV7) and since 2010 as a 13-valent (PCV13) formulation.

Given the risk of IPD among HIV-infected persons, vaccine advisory committees have recommended pneumococcal vaccinations since the 1980s [8]. Initially, guidelines advised a single dose of PPSV23 at HIV diagnosis, followed by revaccination at 5 years and then again at age 65 years (assuming ≥5 years had elapsed since last vaccine). Unfortunately, after PPSV23 anti-pneumococcal antibody levels rapidly decline [9], leaving HIV-infected patients at continued substantial risk for …

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Immunogenicity and Safety of 13-Valent Pneumococcal Conjugate Vaccine in HIV-Infected Adults Previously Vaccinated With Pneumococcal Polysaccharide Vaccine
Marshall J. Glesby1, Wendy Watson3, Cynthia Brinson4, Richard N. Greenberg5, Jacob P. alezari6, Daniel Skiest7, Vani Sundaraiyer8, Robert Natuk2, Alejandra Gurtman2, Daniel A. Scott2, Emilio A. Emini2, William C. Gruber2 and Beate Schmoele-Thoma9
Author Affiliations
1Weill Cornell Medical College, New York, New York
2Pfizer Inc, Pearl River, New York
3Pfizer Inc, Collegeville, Pennsylvania
4Central Texas Clinical Research, Austin
5University of Kentucky Medical Center, Lexington
6Quest Clinical Research, San Francisco, California
7Baystate Medical Center, Springfield, Massachusetts
8inVentiv Health Clinical, Princeton, New Jersey
9Pfizer GmbH, Berlin, Germany
Presented in part: 20th Conference on Retroviruses and Opportunistic Infections, Atlanta, Georgia, March 2013.
Abstract
Background.
Persons with human immunodeficiency virus (HIV) infection are at increased risk of pneumococcal disease. We evaluated the safety and immunogenicity of 13-valent pneumococcal conjugate vaccine (PCV13) in this population.
Methods.
HIV-infected persons ≥18 years of age who were previously vaccinated with ≥1 dose of 23-valent pneumococcal polysaccharide vaccine (PPSV23) and had CD4 cell counts ≥200 cells/mm3 and HIV viral loads <50 000 copies/mL were enrolled in this 3-dose PCV13 open-label study.
Results.
A total of 329 subjects received ≥1 dose, and 279 received 3 doses administered at 6-month intervals. Increases in anticapsular polysaccharide immunoglobulin G concentrations and opsonophagocytic antibody titers were demonstrated 1 month after each of the 3 doses of PCV13. Antibody levels were generally similar after each dose. The responses were similar whether subjects had previously received 1 or ≥2 doses of PPSV23. Pain at the injection-site was the most common local reaction. Severe injection site or systemic events were uncommon.
Conclusions.
Vaccination with PCV13 induces anticapsular immunoglobulin G and opsonophagocytic antibody responses in HIV-infected adults with prior PPSV23 vaccination and CD4 cell counts ≥200 cells/mm3. The observations support the use of PCV13 in this population.
Clinical Trials Registration. NCT00963235.

The Lancet
Jun 13, 2015 Volume 385 Number 9985 p2323-2432 e49-e50
http://www.thelancet.com/journals/lancet/issue/current

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Editorial
MERS—the latest threat to global health security
The Lancet
DOI: http://dx.doi.org/10.1016/S0140-6736(15)61088-1
The spread of Middle East respiratory syndrome (MERS) to South Korea, and now to China, is an important signal of the need for increased vigilance in global health security measures. As reported in Correspondence in this week’s issue, the rapid transmission of MERS in South Korea led to 12 laboratory-confirmed cases over a 2-week period in May, and many more cases since, with relatives, medical staff, and a fellow patient all contracting the disease, which started with one 68-year-old man who had travelled to the Middle East.

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Editorial
Iraq’s neglected health and humanitarian crisis
The Lancet
DOI: http://dx.doi.org/10.1016/S0140-6736(15)61089-3
“The situation is bad, really bad, and rapidly getting worse”, said WHO Director-General Margaret Chan in her keynote address to launch a new humanitarian response plan for Iraq last week. Iraq’s health and humanitarian crisis results from decades of war and occupation, most recently the takeover of territory by the Islamic State of Iraq and the Levant (ISIL) and the counter-insurgency launch by the government and its allied forces. Since January, 2014, 2·9 million people have fled their homes and presently 8·2 million people in Iraq require immediate humanitarian support.

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Correspondence
Favipiravir—a prophylactic treatment for Ebola contacts?
Michel Van Herp, Hilde Declerck, Tom Decroo
DOI: http://dx.doi.org/10.1016/S0140-6736(15)61095-9
Since the Ebola outbreak began in March, 2014, 25178 cases of Ebola have been reported.1 To control spread of Ebola in west African communities, vaccination campaigns have been proposed. However, the efficacy of candidate Ebola vaccines for primary prevention has not been proven.2 Furthermore, in communities in which Ebola transmission might be ongoing, an important question is: how will such a vaccination be perceived if a vaccinated person develops Ebola? Such a scenario is possible in people who contract Ebola virus before vaccination. If a person is infected with Ebola virus before vaccination, the vaccine might have a post-exposure prophylactic effect. However, how effective this prophylaxis might be is unknown.2 Moreover, if someone is infected more than 48 h before vaccination, the post-exposure prophylactic effect is likely to be insufficient, leading to possible development of Ebola after vaccination. This scenario is likely to result in serious issues relating to community trust and acceptance of an Ebola vaccine.3 How to exclude Ebola among people presenting with post-vaccination fever is also an issue.2

We make a case for the study of favipiravir (Toyama Chemical, Japan), administered as directly observed therapy for contacts of patients with Ebola. Favipiravir has increased benefit in patients with low Ebola viraemia compared with patients with high viraemia.4 As such, this drug could have a post-exposure prophylactic effect among recently infected contacts and a pre-exposure prophylactic effect among contacts exposed to, but not yet infected by, Ebola virus. Additionally, fever has not been reported as a side-effect of favipiravir (ClinicalTrials.gov, NCT02329054). Furthermore, oral administration of prophylactic favipiravir gives people the choice to interrupt treatment if wanted. Additional effects of prophylactic favipiravir might include increased openness of communities to use alert systems and to support contact tracing services (ie, contacts might be receptive to daily follow-up visits). Finally, to reduce incidence of malaria, prophylactic artesunate-amodiaquine could be administered to the contacts of patients with Ebola. One disadvantage of proposed favipiravir prophylaxis might be the need to exclude pregnant women. To mitigate this problem, pregnancy tests could be included as a routine part of the favipiravir prophylaxis package. Finally, prophylactic favipiravir could be field tested by measurement of incidence of Ebola among contacts of patients with Ebola before and after favipiravir is introduced.

We declare no competing interests.
References
1.WHO. Ebola Situation Report. http://apps.who.int/ebola/current-situation/ebola-situation-report-1-april-2015-0; April 1, 2015. ((accessed April 5, 2015).
2.Regules, JA, Beigel, JH, Paolino, KM et al. A recombinant vesicular stomatitis virus Ebola vaccine—preliminary report. N Engl J Med. 2015; DOI: http://dx.doi.org/10.1056/NEJMoa1414216 (published online April 1.)
3.Onishi, N and Fink, S. Vaccines face same mistrust that fed Ebola. New York Times (New York, USA). March 13, 2015; http://www.nytimes.com/2015/03/14/world/africa/ebola-vaccine-researchers-fight-to-overcome-public-skepticism-in-west-africa.html?_r=0. ((accessed April 5, 2015).)
4.Médecins Sans Frontières. Preliminary results of the JIKI clinical trial to test the efficacy of favipiravir in reducing mortality in individuals infected by Ebola virus in Guinea. http://www.msf.org/article/preliminary-results-jiki-clinical-trial-test-efficacy-favipiravir-reducing-mortality; Feb 24, 2015. ((accessed April 5, 2015).)

PLoS Medicine
http://www.plosmedicine.org/
(Accessed 13 June 2015)

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Essay
The Potential for Reducing the Number of Pneumococcal Conjugate Vaccine Doses While Sustaining Herd Immunity in High-Income Countries
Stefan Flasche, Albert Jan Van Hoek, David Goldblatt, W. John Edmunds, Katherine L. O’Brien, J. Anthony G. Scott, Elizabeth Miller
Published: June 9, 2015
DOI: 10.1371/journal.pmed.1001839
Summary Points
:: In high-income countries, pneumococcal conjugate vaccines induce strong herd protection that leads to near elimination of vaccine-type disease in vaccinated and unvaccinated alike.
:: In settings with minimal exposure to pneumococcal vaccine types, individual protection from pneumococcal conjugate vaccine (PCV) is rarely required, and the majority of disease episodes are prevented by controlling vaccine-type transmission.
:: Following the control of pneumococcal vaccine-type disease and colonisation through vaccination, a PCV schedule with a single priming and a booster dose may be sufficient to sustain that control at reduced costs and should be evaluated.

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Research Article
Efficacy of Handwashing with Soap and Nail Clipping on Intestinal Parasitic Infections in School-Aged Children: A Factorial Cluster Randomized Controlled Trial
Mahmud Abdulkader Mahmud, Mark Spigt, Afework Mulugeta Bezabih, Ignacio Lopez Pavon, Geert-Jan Dinant, Roman Blanco Velasco
Published: June 9, 2015
DOI: 10.1371/journal.pmed.1001837
Abstract
Background
Intestinal parasitic infections are highly endemic among school-aged children in resource-limited settings. To lower their impact, preventive measures should be implemented that are sustainable with available resources. The aim of this study was to assess the impact of handwashing with soap and nail clipping on the prevention of intestinal parasite reinfections.
Methods and Findings
In this trial, 367 parasite-negative school-aged children (aged 6–15 y) were randomly assigned to receive both, one or the other, or neither of the interventions in a 2 × 2 factorial design. Assignment sequence was concealed. After 6 mo of follow-up, stool samples were examined using direct, concentration, and Kato-Katz methods. Hemoglobin levels were determined using a HemoCue spectrometer. The primary study outcomes were prevalence of intestinal parasite reinfection and infection intensity. The secondary outcome was anemia prevalence. Analysis was by intention to treat. Main effects were adjusted for sex, age, drinking water source, latrine use, pre-treatment parasites, handwashing with soap and nail clipping at baseline, and the other factor in the additive model. Fourteen percent (95% CI: 9% to 19%) of the children in the handwashing with soap intervention group were reinfected versus 29% (95% CI: 22% to 36%) in the groups with no handwashing with soap (adjusted odds ratio [AOR] 0.32, 95% CI: 0.17 to 0.62). Similarly, 17% (95% CI: 12% to 22%) of the children in the nail clipping intervention group were reinfected versus 26% (95% CI: 20% to 32%) in the groups with no nail clipping (AOR 0.51, 95% CI: 0.27 to 0.95). Likewise, following the intervention, 13% (95% CI: 8% to 18%) of the children in the handwashing group were anemic versus 23% (95% CI: 17% to 29%) in the groups with no handwashing with soap (AOR 0.39, 95% CI: 0.20 to 0.78). The prevalence of anemia did not differ significantly between children in the nail clipping group and those in the groups with no nail clipping (AOR 0.53, 95% CI: 0.27 to 1.04). The intensive follow-up and monitoring during this study made it such that the assessment of the observed intervention benefits was under rather ideal circumstances, and hence the study could possibly overestimate the effects when compared to usual conditions.
Conclusions
Handwashing with soap at key times and weekly nail clipping significantly decreased intestinal parasite reinfection rates. Furthermore, the handwashing intervention significantly reduced anemia prevalence in children. The next essential step should be implementing pragmatic studies and developing more effective approaches to promote and implement handwashing with soap and nail clipping at larger scales.

Editors’ Summary
Background
Intestinal parasitic infections are common human infections, particularly in resource-limited countries, where personal hygiene and access to clean water and sanitation (disposal of human feces and urine) is often poor. Worldwide, more than a billion people are infected with soil-transmitted helminths—roundworms, tapeworms, and other parasitic worms that live in the human intestine (gut). And millions of people are infected with protozoan (single-celled) intestinal parasites that cause diseases such as amebiasis and giardiasis. Both helminths and protozoan parasites are mainly spread by the fecal-oral route. Infected individuals excrete helminth eggs and protozoan parasites in their feces, and in regions where people regularly defecate in the open, the soil and water supplies become contaminated with parasites. People then ingest the parasites by eating raw, unwashed vegetables, by not washing their hands after handling contaminated soil, or by drinking contaminated water. Mild infections with helminths rarely have symptoms, but severe infections can cause abdominal pain, diarrhea, and malnutrition. Protozoan parasites also cause diarrhea. Importantly, among children, who are particularly susceptible to parasitic infections, intestinal parasite infections may slow growth, affect school performance, and cause anemia.
Why Was This Study Done?
Intestinal worm and protozoan infections can be treated with anthelmintic drugs and antibiotics, respectively. However, reinfection is often rapid, and, particularly in resource-limited countries, additional preventative measures are needed that do not rely on drugs (parasites can become drug-resistant) and that are sustainable with available resources. Given that intestinal parasitic infections usually spread through the fecal-oral route, the promotion of handwashing with soap and regular fingernail clipping might be one way to reduce intestinal parasite infection rates in low-income settings. Handwashing prevents other types of infection, and both unwashed hands and dirty, untrimmed nails are associated with high rates of parasite infection. Here, the researchers investigate whether handwashing with soap and nail clipping reduce intestinal reinfection rates by undertaking a factorial cluster randomized controlled trial (a study that compares outcomes in groups of people chosen at random to receive different combinations of two or more interventions) among school-aged children in northern Ethiopia.
What Did the Researchers Do and Find?
The researchers assigned 367 parasite-negative school-aged children to receive a handwashing intervention, a nail clipping intervention, both interventions, or neither intervention for six months. For the handwashing intervention, fieldworkers visited each intervention household weekly, provided soap, encouraged all the household members to wash their hands with water and soap at key times, such as before meals and after defecation, and checked on the household’s use of soap. For the nail clipping intervention, the fieldworkers clipped the nails of children in the intervention households every week. After six months, parasite reinfection (primary outcome) and anemia (secondary outcome) in the participants were assessed by examining stool samples for parasites and by measuring hemoglobin levels, respectively. After adjustment for factors likely to affect reinfection such as latrine use and drinking water source, 14% of the children in the handwashing with soap groups (handwashing alone and handwashing plus nail clipping) were reinfected with parasites compared to 29% of the children in the no handwashing groups (nail clipping only or neither intervention). Similarly, 17% of the children in the nail clipping groups were reinfected compared to 26% in the no nail clipping groups. Finally, handwashing (but not nail clipping) significantly reduced the rate of anemia among the children.
What Do These Findings Mean?
These findings show that handwashing with soap at key times decreased intestinal parasite reinfection rates by 68% and that weekly nail clipping reduced reinfection rates by 49% among school-aged Ethiopian children. Thus, these findings support the promotion of proper handwashing and weekly nail clipping as a public health measure to reduce parasite reinfection rates in resource-limited regions. However, although both interventions were “efficacious” under trial conditions that included intensive monitoring and follow-up, handwashing and nail clipping may not be “effective” interventions. That is, they may not work as well under real-life conditions. Moreover, because long-established personal hygiene and sanitation practices may be hard to change, large-scale implementation of these interventions might be expensive. The researchers call, therefore, for pragmatic studies to be undertaken to investigate the performance of these interventions under real-life conditions and for the development of effective approaches for widespread promotion of handwashing with soap and nail clipping.

PLoS Neglected Tropical Diseases
http://www.plosntds.org/
(Accessed 13 June 2015)

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The Complexity of a Dengue Vaccine: A Review of the Human Antibody Response
Jacky Flipse, Jolanda M. Smit
Review | published 11 Jun 2015 | PLOS Neglected Tropical Diseases 10.1371/journal.pntd.0003749

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The Case for Improved Diagnostic Tools to Control Ebola Virus Disease in West Africa and How to Get There
Arlene C. Chua, Jane Cunningham, Francis Moussy, Mark D. Perkins, Pierre Formenty
Policy Platform | published 11 Jun 2015 | PLOS Neglected Tropical Diseases 10.1371/journal.pntd.0003734

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Research Article
Prioritising Infectious Disease Mapping
David M. Pigott, Rosalind E. Hows, Antoinette Wiebe, Katherine E. Battle, Nick Golding, Peter W. Gething, Scott F. Dowell, Tamer H. Farag, Andres J. Garcia, Ann M. Kimball, L. Kendall Krause, Craig H. Smith, Simon J. Brooker, [ … ],Simon I. Hay
Published: June 10, 2015
DOI: 10.1371/journal.pntd.0003756
Abstract
Background
Increasing volumes of data and computational capacity afford unprecedented opportunities to scale up infectious disease (ID) mapping for public health uses. Whilst a large number of IDs show global spatial variation, comprehensive knowledge of these geographic patterns is poor. Here we use an objective method to prioritise mapping efforts to begin to address the large deficit in global disease maps currently available.
Methodology/Principal Findings
Automation of ID mapping requires bespoke methodological adjustments tailored to the epidemiological characteristics of different types of diseases. Diseases were therefore grouped into 33 clusters based upon taxonomic divisions and shared epidemiological characteristics. Disability-adjusted life years, derived from the Global Burden of Disease 2013 study, were used as a globally consistent metric of disease burden. A review of global health stakeholders, existing literature and national health priorities was undertaken to assess relative interest in the diseases. The clusters were ranked by combining both metrics, which identified 44 diseases of main concern within 15 principle clusters. Whilst malaria, HIV and tuberculosis were the highest priority due to their considerable burden, the high priority clusters were dominated by neglected tropical diseases and vector-borne parasites.
Conclusions/Significance
A quantitative, easily-updated and flexible framework for prioritising diseases is presented here. The study identifies a possible future strategy for those diseases where significant knowledge gaps remain, as well as recognising those where global mapping programs have already made significant progress. For many conditions, potential shared epidemiological information has yet to be exploited.
Author Summary
Maps have long been used to not only visualise, but also to inform infectious disease control efforts, identify and predict areas of greatest risk of specific diseases, and better understand the epidemiology of disease over various spatial scales. In spite of the utilities of such outputs, globally comprehensive maps have been produced for only a handful of infectious diseases. Due to limited resources, it is necessary to define a framework to prioritise which diseases to consider mapping globally. This paper outlines a framework which compares each disease’s global burden with its associated interest from the policy community in a data-driven manner which can be used to determine the relative priority of each condition. Malaria, HIV and TB are, unsurprisingly, ranked highest due to their considerable health burden, while the other priority diseases are dominated by neglected tropical diseases and vector-borne diseases. For some conditions, global mapping efforts are already in place, however, for many neglected conditions there still remains a need for high resolution spatial surveys.

PLoS One
[Accessed 13 June 2015]
http://www.plosone.org/

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Research Article
Can Economic Analysis Contribute to Disease Elimination and Eradication? A Systematic Review
Elisa Sicuri, David B. Evans, Fabrizio Tediosi
Published: June 12, 2015
DOI: 10.1371/journal.pone.0130603
Abstract
Background
Infectious diseases elimination and eradication have become important areas of focus for global health and countries. Due to the substantial up-front investments required to eliminate and eradicate, and the overall shortage of resources for health, economic analysis can inform decision making on whether elimination/eradication makes economic sense and on the costs and benefits of alternative strategies. In order to draw lessons for current and future initiatives, we review the economic literature that has addressed questions related to the elimination and eradication of infectious diseases focusing on: why, how and for whom?
Methods
A systematic review was performed by searching economic literature (cost-benefit, cost-effectiveness and economic impact analyses) on elimination/eradication of infectious diseases published from 1980 to 2013 from three large bibliographic databases: one general (SCOPUS), one bio-medical (MEDLINE/PUBMED) and one economic (IDEAS/REPEC).
Results
A total of 690 non-duplicate papers were identified from which only 43 met the inclusion criteria. In addition, only one paper focusing on equity issues, the “for whom?” question, was found. The literature relating to “why?” is the largest, much of it focusing on how much it would cost. A more limited literature estimates the benefits in terms of impact on economic growth with mixed results. The question of how to eradicate or eliminate was informed by an economic literature highlighting that there will be opportunities for individuals and countries to free-ride and that forms of incentives and/or disincentives will be needed. This requires government involvement at country level and global coordination. While there is little doubt that eliminating infectious diseases will eventually improve equity, it will only happen if active steps to promote equity are followed on the path to elimination and eradication.
Conclusion
The largest part of the literature has focused on costs and economic benefits of elimination/eradication. To a lesser extent, challenges associated with achieving elimination/eradication and ensuring equity have also been explored. Although elimination and eradication are, for some diseases, good investments compared with control, countries’ incentives to eliminate do not always align with the global good and the most efficient elimination strategies may not prioritize the poorest populations. For any infectious disease, policy-makers will need to consider realigning contrasting incentives between the individual countries and the global community and to assure that the process towards elimination/eradication considers equity.

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Research Article
Mass Media and the Contagion of Fear: The Case of Ebola in America
Sherry Towers, Shehzad Afzal, Gilbert Bernal, Nadya Bliss, Shala Brown, Baltazar Espinoza, Jasmine Jackson, Julia Judson-Garcia, Maryam Khan, Michael Lin, Robert Mamada, Victor M. Moreno, Fereshteh Nazari, [ … ], Carlos Castillo-Chavez
Published: June 11, 2015
DOI: 10.1371/journal.pone.0129179
Abstract
Background
In the weeks following the first imported case of Ebola in the U. S. on September 29, 2014, coverage of the very limited outbreak dominated the news media, in a manner quite disproportionate to the actual threat to national public health; by the end of October, 2014, there were only four laboratory confirmed cases of Ebola in the entire nation. Public interest in these events was high, as reflected in the millions of Ebola-related Internet searches and tweets performed in the month following the first confirmed case. Use of trending Internet searches and tweets has been proposed in the past for real-time prediction of outbreaks (a field referred to as “digital epidemiology”), but accounting for the biases of public panic has been problematic. In the case of the limited U. S. Ebola outbreak, we know that the Ebola-related searches and tweets originating the U. S. during the outbreak were due only to public interest or panic, providing an unprecedented means to determine how these dynamics affect such data, and how news media may be driving these trends.
Methodology
We examine daily Ebola-related Internet search and Twitter data in the U. S. during the six week period ending Oct 31, 2014. TV news coverage data were obtained from the daily number of Ebola-related news videos appearing on two major news networks. We fit the parameters of a mathematical contagion model to the data to determine if the news coverage was a significant factor in the temporal patterns in Ebola-related Internet and Twitter data.
Conclusions
We find significant evidence of contagion, with each Ebola-related news video inspiring tens of thousands of Ebola-related tweets and Internet searches. Between 65% to 76% of the variance in all samples is described by the news media contagion model.

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Vaccination Coverage and Compliance with Three Recommended Schedules of 10-Valent Pneumococcal Conjugate Vaccine during the First Year of Its Introduction in Brazil: A Cross-Sectional Study
Fabricia Oliveira Saraiva, Ruth Minamisava, Maria Aparecida da Silva Vieira, Ana Luiza Bierrenbach, Ana Lucia Andrade
Research Article | published 10 Jun 2015 | PLOS ONE 10.1371/journal.pone.0128656.

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Understanding Public Perceptions of the HPV Vaccination Based on Online Comments to Canadian News Articles
Yael Feinberg, Jennifer A. Pereira, Susan Quach, Jeffrey C. Kwong, Natasha S. Crowcroft, Sarah E. Wilson, Maryse Guay, Yang Lei, Shelley L. Deeks, Public Health Agency of Canada/Canadian Institutes of Health Research Influenza Research Network (PCIRN) Program Delivery and Evaluation Group
Research Article | published 08 Jun 2015 | PLOS ONE 10.1371/journal.pone.0129587

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

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

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Forbes
http://www.forbes.com/
Accessed 13 June 2015
Vaccine Kicked Rotavirus To The Curb In A Few Short Years
Within six years of the introduction of the rotavirus vaccine, hospitalizations for the diarrheal illness had dropped by 94% and hospitalizations for overall gastrointestinal illnesses were cut in half. Those are the findings of CDC-funded research published in JAMA today. The first vaccine, RotaTeq by Merck, was introduced in 2006, followed […]
Tara Haelle, Contributor Jun 09, 2015

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New York Times
http://www.nytimes.com/
Accessed 13 June 2015
A Chinese Ebola Drug Raises Hopes, and Rancor
Chinese government issued a directive last summer that helped inspire the production not only of MIL77 but also of an Ebola vaccine, which is in human safety studies; rapid Ebola diagnostic tests; and copies of antiviral drugs made
June 12, 2015 – By SHERI FINK – World – Print Headline: “A Chinese Ebola Drug Raises Hopes, and Rancor ”
New Bird Flu Cases Slow, Focus Turns to Preventing Repeat
By THE ASSOCIATED PRESSJUNE 12, 2015, 12:44 P.M. E.D.T.
DES MOINES, Iowa — No new bird flu cases have been reported in nearly a week on commercial farms in Minnesota and Iowa, giving government officials, scientists and farmers hope that the worst U.S. outbreak of the bird flu is, though not over, winding down.
As such, farms are focused on disposing of the poultry carcasses, disinfecting barns and preparing to restock their flocks. Meanwhile, laboratories continue to intensely study the virus in hopes of developing an effective vaccine, determining how it evaded biosecurity measures and establishing what can be done to prevent a repeat.
Here are some questions and answers about the bird flu:
WHERE DOES THE OUTBREAK STAND?
The frequency of new cases has slowed as temperatures in the Midwest rise — up to 90 degrees in Iowa and 70s and 80s in Minnesota. It follows scientists’ predictions that temperatures in the 70s and above would neutralize the H5N2 virus so it would no longer infect birds…

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Washington Post
http://www.washingtonpost.com/
Accessed 13 June 2015
California lawmakers pass vaccine bill amid emotional debate
California lawmakers on Tuesday approved a hotly contested bill that would impose one of the strictest vaccination laws in the country, after five hours of highly emotional testimony that brought hundreds of opponents to the Capitol.
SB277 is intended to boost vaccination rates after a measles outbreak at Disneyland that sickened more than 100 in the U.S. and Mexico. It has prompted the most contentious legislative debate of the year with thousands of opponents taking to social media and legislative hearings to protest the legislation.
The Assembly Health Committee approved the legislation 12-6 Tuesday evening with one lawmaker abstaining, sending it to the full Assembly for its final legislative hurdle.
If the bill becomes law, California would join Mississippi and West Virginia as the only states with such strict requirements…
…The bill, sponsored by Democratic Sens. Richard Pan of Sacramento and Ben Allen of Santa Monica, would only allow children with serious health problems to opt out of school-mandated vaccinations. School-age children who remain unvaccinated would need to be home-schooled…
Julia Horowitz | AP | Health & Science | Jun 9, 2015
Experts: California vaccine bill would increase immunization
A hotly contested California bill to impose one of the strictest vaccination laws in the nation would boost immunization rates by changing parents’ behavior, according to immunologists and people who have researched the impact of such requirements.
Julia Horowitz | AP | Health & Science | Jun 9, 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_6 June 2015

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

– Twitter:  Readers can also follow developments on twitter: @vaxethicspolicy.
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– Links:  We endeavor to test each link as we incorporate it into any post, but recognize that some links may become “stale” as publications and websites reorganize content over time. We apologize in advance for any links that may not be operative. We believe the contextual information in a given post should allow retrieval, but please contact us as above for assistance if necessary.
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David R. Curry, MS
Executive Director
Center for Vaccine Ethics and Policy
a program of the
– Division of Medical Ethics, NYU Medical School
– Children’s Hospital of Philadelphia Vaccine Education Center
Associate Faculty, Division of Medical Ethics, NYU Medical School

EBOLA/EVD [to 6 June 2015]
Public Health Emergency of International Concern (PHEIC); “Threat to international peace and security” (UN Security Council) .
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WHO: Ebola Situation Report – 3 June 2015 [Excerpts] SUMMARY :: Since the week ending 10 May, when a 10-month low of 9 cases of Ebola virus disease (EVD) were reported from 2 prefectures of Guinea and 1 district of Sierra Leone, both the intensity and geographical area of EVD transmission have increased. In the week ending 31 May, a total of 25 confirmed cases were reported from 4 prefectures of Guinea and 3 districts of Sierra Leone. Several cases in both Guinea and Sierra Leone arose from unknown sources of infection in areas that have not reported confirmed cases for several weeks, indicating that chains of transmission continue to go undetected. Rigorous contact tracing, active case finding, and infection prevention and control must be maintained at current intensive levels in order to uncover and break every chain of transmission. However, the onset of the rainy season will make field operations more difficult from now onwards. COUNTRIES WITH WIDESPREAD AND INTENSE TRANSMISSION :: There have been a total of 27 145 reported confirmed, probable, and suspected cases of EVD in Guinea, Liberia and Sierra Leone (figure 1, table 1), with 11 147 reported deaths (this total includes reported deaths among probable and suspected cases, although outcomes for many cases are unknown). A total of 13 new confirmed cases were reported in Guinea and 12 in Sierra Leone in the 7 days to 31 May. The outbreak in Liberia was declared over on 9 May.

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Video: Ebola Briefing – General Assembly, Informal meeting of the plenary 2 June 2015 Fifth informal meeting of the plenary to hear a briefing by the Secretary-General of the United Nations, concerning the public health crisis emanating from the Ebola virus outbreak. Mr. Peter Graaff, Acting Special Representative and Head of the United Nations Mission for Ebola Emergency Response (UNMEER), and Mr. David Nabarro, Special Envoy of the Secretary-General on Ebola, will deliver statements http://webtv.un.org/watch/ebola-briefing-general-assembly-informal-meeting-of-the-plenary/4271433354001#full-text WHO:

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An unprecedented response to an unprecedented outbreak 4 June 2015 — Since notifying the world of the Ebola outbreak in West Africa on 23 March 2014, WHO has, in partnership with the international health community, mobilized its largest ever outbreak response. WHO’s public health expertise, linkages with government and technical networks are unparalleled. This enables collaboration across multiple UN agencies, mobilization of foreign medical teams, deployment of specialized laboratories, training, delivery of millions of sets of personal protective equipment, and rapid development of vaccines, treatments, and diagnostics. Read more on WHO’s achievements

POLIO [to 6 June 2015]
Public Health Emergency of International Concern (PHEIC)

GPEI Update: Polio this week – As of 3 June 2015
Global Polio Eradication Initiative
[Editor’s Excerpt and text bolding]
Full report: http://www.polioeradication.org/Dataandmonitoring/Poliothisweek.aspx
:: This week, the Technical Advisory Groups of Afghanistan and Pakistan are meeting to evaluate progress on polio eradication efforts in recent months and to plan for the upcoming polio high transmission season.
:: As the poliovirus is more and more geographically limited, surveillance becomes increasingly important for ensuring that it cannot spread unchecked. Read more about polio surveillance and laboratories.
:: Polio staff continue to offer support to the humanitarian response to the devastating earth quakes in Nepal. Read more.

Selected excerpts from Country-specific Reports
Afghanistan
:: Environmental sampling in the country continues to find wild poliovirus (most recently in Hilmand). Such sampling is invaluable to improved surveillance for the virus.
:: Subnational Immunization Days (SNIDs) are planned from 14 – 16 June across the south and east using bivalent OPV. National Immunization Days are scheduled on 16 to 18 Augus
Pakistan
:: One new case of wild poliovirus type 1 (WPV1) was reported this week in North Waziristan district in the Federally Administered Tribal Areas. This most recent case had onset of paralysis on 6 May. The total number of WPV1 cases for 2015 is now 24 (and remains 306 for 2014).
:: One new environmental sample positive for WPV1 was reported this week from Peshawar district, Khyber Pakhtunkhwa.
:: Environmental surveillance indicates widespread circulation of polioviruses – WPV as well as VDPV – not just in known infected areas but also in areas without cases. Environmental surveillance is proving to be an instrumental supplemental surveillance tool enabling a clearer epidemiological picture.
:: Currently, the focus of the polio eradication programme in Pakistan is on known infected areas and on areas deemed to be high-risk but which have not reported polio cases.

WHO & Regionals [to 6 June 2015]
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Liberia tackles measles as Ebola comes to an end
2 June 2015
As Liberia emerges from the devastating Ebola epidemic, it has been battling the worst measles outbreak in years. The Ebola outbreak led to the collapse of most health services in Liberia, including routine vaccinations. The Liberian government moved swiftly to organize a countrywide vaccination campaign with the help of WHO and partners.
Read more about the vaccination campaign

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WHO and the Republic of Korea to carry out joint mission for the MERS-CoV outbreak
5 June 2015 — The pressing objective of this joint mission is to gain information and review the situation in the Republic of Korea including the epidemiological pattern, the characteristic of the virus and clinical features. The team will also assess the public health response efforts and provide recommendations for response measures going forward.

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Middle East respiratory syndrome coronavirus in the Republic of Korea: situation assessment
June 2015 — The outbreak of Middle East respiratory syndrome coronavirus (MERS-CoV) in the Republic of Korea continues to evolve. WHO is in close contact with the country’s government and Ministry of Health, and is receiving information as soon as facts are confirmed.

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Global Alert and Response (GAR) – Disease Outbreak News (DONs)
6 June 2015 – Middle East respiratory syndrome coronavirus (MERS-CoV) – Republic of Korea
6 June 2015 – Middle East Respiratory Syndrome coronavirus (MERS-CoV) – Saudi Arabia
5 June 2015 – Middle East respiratory syndrome coronavirus (MERS-CoV) – Republic of Korea
4 June 2015 – Middle East respiratory syndrome coronavirus (MERS-CoV) – Republic of Korea
4 June 2015 – Middle East Respiratory Syndrome coronavirus (MERS-CoV) – Saudi Arabia

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The Weekly Epidemiological Record (WER) 5 June 2015, vol. 90, 23 (pp. 281–296) includes
…Review of the 2014–2015 influenza season in the northern hemisphere

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:: WHO Regional Offices
WHO African Region AFRO
:: Dr Moeti applauds Zambia for reducing illnesses and deaths of mothers and children
Lusaka, 04 June 2015 – The WHO Regional Director for Africa, Dr Matshidiso Moeti has applauded the Zambian government for progress made in reducing deaths and illnesses amongst women and children under five years old.
:: WHO strengthens capacities of national blood transfusion systems in Ebola-affected countries – 02 June 2015

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WHO Region of the Americas PAHO
:: PAHO/WHO urges measles and rubella vaccination for travelers to the 2015 Americas Cup (06/04/2015)

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WHO South-East Asia Region SEARO
:: Medical Camp Kits replace primary health care facilities before onset of Nepal’s monsoon  01 June 2015

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WHO European Region EURO
:: Diphtheria detected in Spain 05-06-2015
:: Dramatic increase in Caesarean sections 01-06-2015

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WHO Eastern Mediterranean Region EMRO
:: Inequality has transformed surviving childhood into a global postcode lottery (commentary)  3 June 2015
:: Middle East respiratory syndrome coronavirus (MERS-CoV) in the Republic of Korea  2 June 2015

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WHO Western Pacific Region
:: The World Health Organization (WHO) and the Republic of Korea to carry out Joint Mission for the MERS-CoV Outbreak
MANILA, 5 June 2015 – In light of the recent outbreak of Middle East Respiratory Syndrome coronavirus (MERS-CoV), the World Health Organization and the Republic of Korea’s Ministry of Health and Welfare will conduct a joint mission to the Republic of Korea. The mission comes after close consultation between WHO and the Government.

:: Strategy for malaria elimination in the Greater Mekong Subregion (2015-2030)
5 June 2015
In close consultation with countries in the Greater Mekong Subregion, the WHO Regional Offices for the Western Pacific and South-East Asia have developed a malaria elimination strategy for the Subregion, where emerging antimalarial multidrug resistance, including resistance to artemisinin-based combination therapies, is threatening our recent gains. The elimination strategy is fully aligned with the Global technical strategy for malaria 2016-2030, which has just been endorsed by the World Health Assembly. The first subregional document that effectively operationalizes the global strategy, it is a prime example of partnership and collaboration, with six countries, WHO (two regions and headquarters) and multiple development partners joining forces to fight a common threat.

Sabin Vaccine Institute Watch [to 6 June 2015]
http://www.sabin.org/updates/pressreleases

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Phase 1 Clinical Trial of Sm-TSP-2 Schistosomiasis Vaccine Begins
WASHINGTON, D.C. — June 3, 2015 — The Sabin Vaccine Institute Product Development Partnership (Sabin PDP) today released an update on a Phase 1 clinical trial of its vaccine candidate to prevent intestinal schistosomiasis, Sm-TSP-2/Alhydrogel®. Schistosomiasis is one of the most pervasive neglected tropical diseases (NTDs) affecting the world’s poorest communities. The Sabin PDP is based at the Sabin Vaccine Institute and Texas Children’s Hospital Center for Vaccine Development at Baylor College of Medicine (BCM) in Houston, Texas.

New formulation of HIV treatment to save more children’s lives — UNICEF and UNAIDS
Tiny pellets make antiretroviral medicines more palatable for children
Joint press release
NEW YORK/GENEVA, 5 June 2015—Children affected by HIV and AIDS will benefit from the decision by the United States Food and Drug Administration to grant approval to a new antiretroviral formulation that can be mixed with food to make it easier for children living with HIV to take the life-saving medicines, UNAIDS and UNICEF said today.

“Treatment innovations such as this that replace unpleasant and bad tasting medicines are a real breakthrough, accelerating access to treatment for children and keeping our youngest healthy,” said Michel Sidibé, Executive Director of UNAIDS. “It is unacceptable that only 24% of children living with HIV have access to antiretroviral medicines.”

The oral pellets, manufactured by Indian generic medicines manufacturer CIPLA, contain an antiretroviral formulation of lopinavir and ritonavir that can be mixed into a child’s food. The treatment is heat stable and more palatable than medicines currently available, making it particularly suitable for treating very young children.

“This new formulation is a step in the right direction towards saving more lives of children living with HIV,” said Craig McClure, UNICEF’s Chief of HIV and AIDS and Associate Director, Programmes. “We expect it to greatly improve treatment access for many more children and support UNICEF’s equity focused programming aimed at reaching the most disadvantaged children throughout the world.”

HIV infection progresses rapidly in children and, in highly impacted countries, is a major contributor to child morbidity and mortality. Without treatment, one in three children who become infected with HIV will die before their first birthday. Half will die before their second birthday.

Early initiation of antiretroviral treatment in children as recommended by the World Health Organization substantially reduces the risk of death. Many countries have not been able to fully implement the WHO recommendation because of the challenge of not having a more appropriate, heat stable and palatable paediatric formulation of lopinavir/ritonavir used as part of the treatment options for children under 3 years of age.

Despite global efforts to accelerate access to HIV paediatric care and treatment, fewer than 800 000 of the 3.2 million children living with HIV worldwide had access to antiretroviral medicines in 2013.

Application of uniform quality management principles in European medicines agencies.
05/06/2015 13:26 | Presidency of the Council of the EU

On 2-3 June 2015 the meeting of the Heads of Medicines Agencies (HMA) Working Group of Quality Managers (WGQM) took place in Riga, Latvia. The agenda of the meeting included implementation and ensuring of the uniform quality management principles in European medicines agencies.

Meeting participants – the quality managers of national medicines agencies in the European Economic Area countries and representatives of the European Commission and the European Medicines Agency – discussed the following issues: implementation of guidelines on conflict of interest mitigation, ensuring risk management approach in national medicines agencies and results of benchmarking (comparison of one entity (business or other organisation) to other entities and learning from the results of this comparison). The future activities for the next assessment cycle were also planned. The quality managers of European medicines agencies exchanged examples of best practices in quality management, which is a significant contribution to further operational improvement of medicines agencies. Ms Caitriona Fisher, the Manager of Chief Executive’s Office and Quality Manager of the Health Products Regulatory Authority of Ireland, was re-elected as the Head of the Working Group for the next three-year period.

WGQM is the working group established by HMA whose main task is to support the quality management of the European Medicines regulatory framework system for public and animal health. The WGQM meetings are held every six months by the medicines agency of the current Presidency of the Council of the European Union.
More information on WGQM is available here: http://www.hma.eu/wgqm.html

BMGF (Gates Foundation) [to 6 June 2015]
http://www.gatesfoundation.org/Media-Center/Press-Releases

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The Bill & Melinda Gates Foundation announces new $776 million investment in nutrition to tackle child mortality and help all women and children survive and thrive
Melinda Gates makes announcement in Brussels during European Development Days

BRUSSELS, BELGIUM (June 3, 2015, 12:30pm CET) – Melinda Gates today urged European leaders to make the health and nutrition of women and children a top priority, and announced that the Bill & Melinda Gates Foundation will more than double its investments in nutrition to $776 million over the next six years as part of a new commitment to nutrition. The co-chair of the Bill & Melinda Gates Foundation made the announcement at the European Development Days (EDD), Europe’s leading forum on development and international cooperation organized by the European Commission.

“Malnutrition is the underlying cause of nearly half of all under-5 child deaths,” said Gates. “Yet for too long the world has underinvested in nutrition. Today we see an opportunity to change that. Along with the Gates Foundation, many European donors are now prioritizing nutrition, which we believe will be one of the fundamental solutions to help cut child mortality in half by 2030.”

The announcement unlocks $180 million in additional matched funding from the UK’s Department for International Development who had committed to match 1:2 any pledge additional to those made at the Nutrition for Growth summit in 2013…

The Gates Foundation’s new approach to nutrition will:
:: Reach women and children with solutions proven to improve nutrition, such as breastfeeding and food fortification, and expand research into innovative new approaches.
:: Help women and adolescent girls before they become pregnant, improving the likelihood they’ll have a safe pregnancy and a healthy, well-nourished child.
:: Improve food systems (in conjunction with the agriculture sector) to help ensure people have better access to safe, nutritious and affordable food year-round.
:: Catalyze a data revolution in nutrition to strengthen the evidence-base for action, inform decisions and track progress toward goals and commitments.
:: Focus work in India, Ethiopia, Nigeria, Bangladesh, Burkina Faso, where there is both a high burden of malnutrition and a significant opportunity to affect positive change…

USAID Announces Groundbreaking Online Training for Global Health Workforce
June 1, 2015
Today, the U.S. Agency for International Development and partners from the public and private sector announced a new comprehensive online library of resources for training health workers across the globe. This is the first-ever resource that will be freely available and accessible through internet-enabled mobile devices. The online library, called ORB, has the potential to support 100,000 frontline health workers by 2017 who are delivering services to more than 10 million women and children around the world.

Connecting Global Priorities: Biodiversity and Human Health
A State of Knowledge Review
World Health Organization and Secretariat of the Convention on Biological Diversity, 2015.
ISBN: 9789241508537 :: 364 pages

Overview
Healthy communities rely on well-functioning ecosystems. They provide clean air, fresh water, medicines and food security. They also limit disease and stabilize the climate. But biodiversity loss is happening at unprecedented rates, impacting human health worldwide, according to a new state of knowledge review of the Convention on Biological Diversity (CBD) and WHO.

American Journal of Tropical Medicine and Hygiene
June 2015; 92 (6)
http://www.ajtmh.org/content/current

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The Post-2015 Development Agenda: Keeping Our Focus on the Worst Off
Daniel Sharp and Joseph Millum*
Author Affiliations
Clinical Center Department of Bioethics, National Institutes of Health, Bethesda, Maryland; Fogarty International Center, National Institutes of Health, Bethesda, Maryland
Abstract
Non-communicable diseases now account for the majority of the global burden of disease and an international campaign has emerged to raise their priority on the post-2015 development agenda. We argue, to the contrary, that there remain strong reasons to prioritize maternal and child health. Policy-makers ought to assign highest priority to the health conditions that afflict the worst off. In virtue of how little healthy life they have had, children who die young are among the globally worst off. Moreover, many interventions to deal with the conditions that cause mortality in the young are low-cost and provide great benefits to their recipients. Consistent with the original Millennium Development Goals, the international community should continue to prioritize reductions in communicable diseases, neonatal conditions, and maternal health despite the shifts in the global burden of disease.

BMJ Open
2015, Volume 5, Issue 6
http://bmjopen.bmj.com/content/current

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Research
Association of pneumococcal conjugate vaccination with rates of ventilation tube insertion in Denmark: population-based register study
Christina Groth, Reimar W Thomsen, Therese Ovesen
Abstract
Objective To examine if the introduction of pneumococcal conjugate vaccine (PCV) in Denmark was associated with a decrease in the rate of ventilation tube (VT) insertions performed by office-based practising ear, nose and throat (ENT) specialists.
Design Population-based register study based on prospectively collected data.
Setting Central Denmark Region. Data on VT insertions performed by any office-based practising ENT specialist in the region were collected from the National Health Service Registry.
Participants
All children below the age of 2 years with a first-time VT insertion from 2001 through 2011.
Main outcome measures Age-stratified and gender-stratified standardised incidence rates of first-time VT insertion, and incidence rate ratio for PCV period 2008–2011 compared with pre-PCV period 2001–2007.
Results The annual incidence rate of first-time VT insertion in small children increased steadily from 64/1000 person-years in 2001 to 100/1000 person-years in 2011. The incidence rate ratio was 1.27 (95% CI 1.24 to 1.30) in the PCV period compared with the pre-PCV period.
Conclusions The introduction of PCV into the Danish childhood immunisation programme in 2007 was not associated with a subsequent decrease in the rate of VT insertions among children below the age of 2 years. Instead, the rate continued to rise, as before the introduction of PCV.
Trial registration number Danish Data Protection Agency: 2007-58-0010.

Bulletin of the World Health Organization
Volume 93, Number 6, June 2015, 361-436
http://www.who.int/bulletin/volumes/93/6/en/

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EDITORIALS
The Sendai framework: disaster risk reduction through a health lens
Amina Aitsi-Selmi & Virginia Murray
doi: 10.2471/BLT.15.157362

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Research
Identifying implementation bottlenecks for maternal and newborn health interventions in rural districts of the United Republic of Tanzania
Ulrika Baker, Stefan Peterson, Tanya Marchant, Godfrey Mbaruku, Silas Temu, Fatuma Manzi & Claudia Hanson
Abstract
Objective
To estimate effective coverage of maternal and newborn health interventions and to identify bottlenecks in their implementation in rural districts of the United Republic of Tanzania.
Methods
Cross-sectional data from households and health facilities in Tandahimba and Newala districts were used in the analysis. We adapted Tanahashi’s model to estimate intervention coverage in conditional stages and to identify implementation bottlenecks in access, health facility readiness and clinical practice. The interventions studied were syphilis and pre-eclampsia screening, partograph use, active management of the third stage of labour and postpartum care.
Findings
Effective coverage was low in both districts, ranging from only 3% for postpartum care in Tandahimba to 49% for active management of the third stage of labour in Newala. In Tandahimba, health facility readiness was the largest bottleneck for most interventions, whereas in Newala, it was access. Clinical practice was another large bottleneck for syphilis screening in both districts.
Conclusion
The poor effective coverage of maternal and newborn health interventions in rural districts of the United Republic of Tanzania reinforces the need to prioritize health service quality. Access to high-quality local data by decision-makers would assist planning and prioritization. The approach of estimating effective coverage and identifying bottlenecks described here could facilitate progress towards universal health coverage for any area of care and in any context.

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Policy & Practice
Applying the lessons of maternal mortality reduction to global emergency health
Emilie J Calvello, Alexander P Skog, Andrea G Tenner & Lee A Wallis
Over the last few decades, maternal health has been a major focus of the international community and this has resulted in a substantial decrease in maternal mortality globally. Although, compared with maternal illness, medical and surgical emergencies account for far more morbidity and mortality, there has been less focus on global efforts to improve comprehensive emergency systems. The thoughtful and specific application of the concepts used in the effort to decrease maternal mortality could lead to major improvements in global emergency health services. The so-called three-delay model that was developed for maternal mortality can be adapted to emergency service delivery. Adaptation of evaluation frameworks to include emergency sentinel conditions could allow effective monitoring of emergency facilities and further policy development. Future global emergency health efforts may benefit from incorporating strategies for the planning and evaluation of high-impact interventions.

Clinical Therapeutics
May 2015 Volume 37, Issue 5, p925-1146
http://www.clinicaltherapeutics.com/current

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Recent Developments and Future Directions of Pneumococcal Vaccine Recommendations
Katherine M. Tromp, PharmD, Marcus W. Campbell, PharmD, Alejandro Vazquez, PharmD LECOM, Bradenton, Florida
Accepted: March 31, 2015; Published Online: April 23, 2015
DOI: http://dx.doi.org/10.1016/j.clinthera.2015.03.025
Abstract
Purpose
The goal of this article was to review the key clinical trials that resulted in the recent recommendation from the Advisory Committee on Immunization Practices (ACIP) to vaccinate all adults aged ≥65 years with the 13-valent pneumococcal polysaccharide conjugate vaccine (PCV13) in addition to the previously recommended 23-valent pneumococcal polysaccharide vaccine (PPSV23).
Methods
Pertinent articles were identified through searches of EMBASE and MEDLINE by using the terms pneumococcal polysaccharide conjugate vaccine, pneumococcal vaccine, and PCV13. Searches were limited to articles published between January 1, 2013, and January 31, 2015, and were limited to clinical trials. Resources from the Centers for Disease Control and Prevention’s ACIP recommendations and cited references were also reviewed.
Findings
Recent clinical trials have focused on the order of administration of PPSV23 and PCV13, comparisons in immunogenicity of PPSV23 and PCV13, and efficacy of PCV13 in adults aged ≥65 years. Immunogenicity trials have shown that PCV13 elicits an equal or greater immune response than PPSV23 for most of the serotypes that both vaccines share. The evidence suggests that PCV13 should be administered before PPSV23 when possible. Most recently, clinical data demonstrated the efficacy of PCV13 in adults aged ≥65 years.
Implications
Recent randomized clinical trials and disease trends have prompted the ACIP to recommend that all adults aged ≥65 years receive a single dose of PCV13. This is in addition to the previous recommended single dose of PPSV23 in the same population. The ACIP and the Centers for Disease Control and Prevention plan to monitor disease trends and clinical data to determine if this recommendation will need to be changed in the future.

The Lancet
Jun 06, 2015 Volume 385 Number 9984 p2223-2322
http://www.thelancet.com/journals/lancet/issue/current

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Comment
An updated Ebola vaccine: immunogenic, but will it protect?
Andrea Marzi, Darryl Falzarano
Published Online: 24 March 2015
DOI: http://dx.doi.org/10.1016/S0140-6736(15)60613-4

The largest outbreak of Ebola virus ever recorded has been ongoing for about 16 months in west Africa. In the past week, Liberia, which had nearly reached the halfway point to being declared Ebola free, has reported a new case, and new Ebola infections continue to be confirmed in Sierra Leone and Guinea.1 With more than 24 000 cases and almost 10 000 fatalities,1 this outbreak is one of the biggest public health crises so far this century. When the outbreak was first confirmed in March, 2014, none of the experimental vaccine platforms with promising results in non-human primate studies2 had advanced beyond assessment in phase 1 clinical trials in human beings, let alone been approved for human use. But only a few months later, with the epidemic spreading and thousands of people infected in west Africa, the international community pulled together to accelerate phase 1 clinical trials in humans for vaccine platforms based on recombinant adenovirus (ClinicalTrials.gov numbers NCT02289027, NCT02368119, NCT02231866, NCT02354404, NCT02240875, NCT02267109) and vesicular stomatitis virus (NCT02287480, NCT02269423, NCT02296983, NCT02314923, NCT02280408, NCT02374385, NCT02283099).

The timely study by Feng-Cai Zhu and colleagues3 in The Lancet is the fourth report of a phase 1 trial in humans using either recombinant adenovirus-based or DNA-based vaccination strategies.4, 5, 6 The recombinant adenovirus type-5 vaccine platform has previously been tested by other investigators with a prototypic Ebola virus glycoprotein.2 The present study updated the vaccine vector to encode the glycoprotein from the 2014 west African Ebola virus isolate, making it the first Ebola vaccine report to use an immunogen that matches that of the currently circulating Ebola virus strain.

In the study, 120 healthy Chinese individuals were randomly assigned to receive placebo (n=40), or a low dose (4 × 1010 viral particles; n=40) or high dose (1·6 × 1011 viral particles; n=40) of the recombinant adenovirus type-5 vaccine.3 In each group, roughly 60% of the participants had pre-existing neutralising antibody titres greater than 1:200 to adenovirus type-5. In a previous phase 1 trial based on a different recombinant adenovirus type-5-based Ebola vaccine vector with promising data in non-human primates, pre-existing adenovirus type-5 neutralising antibodies negatively affected the immune response to the vaccine (55% vs 100% response).2, 7 These data provided the basis for replacement of the adenovirus-type-5 vector with a chimpanzee adenovirus vector.5

The increased vaccine doses used in Zhu and colleagues’ study3 seem to partly circumvent pre-existing immunity to the vector, because participants in the high-dose group had a 100% response rate, with no resultant increase in adverse events. Glycoprotein-specific antibody titres significantly increased in the low-dose and high-dose vaccine groups at both day 14 (geometric mean titre 421·4 [95% CI 249·7–711·3] and 820·5 [598·9–1124·0], respectively) and day 28 (682·7 [424·3–1098·5] and 1305·7 [970·1–1757·2], respectively), with T-cell responses peaking at day 14 in both these groups (median 465·0 spot-forming cells [IQR 180·0–1202·5] and 765·0 cells [400·0–1460·0], respectively). The antigen-specific immunoglobulin-G responses in participants in the high-dose group with low pre-existing adenovirus type-5 immunity (≤1:200) resulted in geometric mean titres of 2231·8 (95% CI 1268·6–3926·2) at 4 weeks after vaccination, but titres decreased to 946·5 (705·4–1270·1) when the immunised individuals had pre-existing neutralising titres greater than 1:200. This finding is a major concern about this vaccine platform, because 80% of the target population in Africa are expected to have adenovirus type-5 neutralising antibody titres.8 Furthermore, findings from previous studies9, 10 in non-human primates suggest that with adenovirus-based vaccines, an Ebola virus glycoprotein-specific ELISA 90% effective concentration (the metric also used in the present study) titre of 3000 is required for protection, and this concentration was not reached in the present trial, particularly in participants with pre-existing adenovirus type-5 immunity. This recombinant adenovirus-based type-5 Ebola virus vaccine also elicits a similar T-cell response in humans to that shown with the chimpanzee adenovirus vector, peaking 14 days after vaccination.5

The glycoprotein from the present outbreak strain has 97% similarity to previously known Ebola virus vaccine isolates,11 and vaccines using the prototypic antigen are expected to protect against infection with the west African isolates. Data from preclinical animal studies will hopefully provide information about the importance of having a vaccine antigen that is identical to that of circulating viruses.

Because Zhu and colleagues’ report3 is preliminary, antibody responses have only been assessed up to day 28 after vaccination. Thus, the durability of a single-dose recombinant adenovirus type-5 vaccination is still unknown, and assessment of whether subsequent boosts will be necessary to maintain or establish sufficient long-term immunity will be important. 82 (68%) participants reported at least one solicited adverse reaction within 7 days of vaccination (19 in the placebo group vs 27 in the low-dose group vs 36 in the high-dose group). The only reported adverse event in all three groups was mild pain at the injection site (eight in the placebo group, 14 in the low-dose group, and 29 in the high-dose vaccine group),3 a minor side-effect, suggesting that administration of the high dose probably needed in Africa would be acceptable. However, follow-up was only for 28 days and no conclusion about long-term side-effects can be made.

This adenovirus type-5 Ebola vaccine vector is an example of how quickly existing vaccine platforms can be modified to incorporate a new virus strain, and moved, with minimum testing in animals, into trials in humans during a crisis situation. However, for this vector, efficacy testing in non-human primates to establish whether the high-dose vaccine would be effective against homologous and heterologous Ebola virus strains still needs to be done. The outstanding question remains as to whether DNA, recombinant adenovirus, or recombinant chimpanzee adenovirus vaccine platforms will be more effective than a recombinant vesicular stomatitis virus-based vaccine, which by contrast is fast acting and not affected by pre-existing vector immunity.12 Ultimately, the effectiveness of all these vaccines will only become clear when they proceed to phase 2 efficacy trials in outbreak regions.

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Articles
Safety and immunogenicity of a novel recombinant adenovirus type-5 vector-based Ebola vaccine in healthy adults in China: preliminary report of a randomised, double-blind, placebo-controlled, phase 1 trial
Feng-Cai Zhu, MSc, Li-Hua Hou, PhD, Jing-Xin Li, MSc, Shi-Po Wu, PhD, Prof Pei Liu, PhD, Gui-Rong Zhang, PhD, Yue-Mei Hu, BSc, Fan-Yue Meng, MSc, Jun-Jie Xu, PhD, Rong Tang, MSc, Jin-Long Zhang, PhD, Wen-Juan Wang, MSc, Lei Duan, MSc, Kai Chu, MSc, Qi Liang, MSc, Jia-Lei Hu, MSc, Li Luo, MSc, Tao Zhu, PhD, Jun-Zhi Wang, PhD, Dr Wei Chen, PhD
Published Online: 24 March 2015
DOI: http://dx.doi.org/10.1016/S0140-6736(15)60553-0
Summary
Background
Up to now, all tested Ebola virus vaccines have been based on the virus strain from the Zaire outbreak in 1976. We aimed to assess the safety and immunogenicity of a novel recombinant adenovirus type-5 vector-based Ebola vaccine expressing the glycoprotein of the 2014 epidemic strain.
Methods
We did this randomised, double-blind, placebo-controlled, phase 1 clinical trial at one site in Taizhou County, Jiangsu Province, China. Healthy adults (aged 18–60 years) were sequentially enrolled and randomly assigned (2:1), by computer-generated block randomisation (block size of six), to receive placebo, low-dose adenovirus type-5 vector-based Ebola vaccine, or high-dose vaccine. Randomisation was pre-stratified by dose group. All participants, investigators, and laboratory staff were masked to treatment allocation. The primary safety endpoint was occurrence of solicited adverse reactions within 7 days of vaccination. The primary immunogenicity endpoints were glycoprotein-specific antibody titres and T-cell responses at day 28 after the vaccination. Analysis was by intention to treat. The study is registered with ClinicalTrials.gov, number NCT02326194.
Findings
Between Dec 28, 2014, and Jan 9, 2015, 120 participants were enrolled and randomly assigned to receive placebo (n=40), low-dose vaccine (n=40), or high-dose vaccine. Participants were followed up for 28 days. Overall, 82 (68%) participants reported at least one solicited adverse reaction within 7 days of vaccination (n=19 in the placebo group vs n=27 in the low-dose group vs n=36 in the high-dose group; p=0·0002). The most common reaction was mild pain at the injection site, which was reported in eight (20%) participants in the placebo group, 14 (35%) participants in the low-dose group, and 29 (73%) participants in the high-dose vaccine group (p<0·0001). We recorded no statistical differences in other adverse reactions and laboratory tests across groups. Glycoprotein-specific antibody titres were significantly increased in participants in the low-dose and high-dose vaccine groups at both day 14 (geometric mean titre 421·4 [95% CI 249·7–711·3] and 820·5 [598·9–1124·0], respectively; p<0·0001) and day 28 (682·7 [424·3–1098·5] and 1305·7 [970·1–1757·2], respectively; p<0·0001). T-cell responses peaked at day 14 at a median of 465·0 spot-forming cells (IQR 180·0–1202·5) in participants in the low-dose group and 765·0 cells (400·0–1460·0) in those in the high-dose group. 21 (18%) participants had mild fever (n=9 in the placebo group, n=6 in the low-dose group, and n=6 in the high-dose group). No serious adverse events were recorded.
Interpretation
Our findings show that the high-dose vaccine is safe and robustly immunogenic. One shot of the high-dose vaccine could mount glycoprotein-specific humoral and T-cell response against Ebola virus in 14 days.
Funding
China National Science and Technology, Beijing Institute of Biotechnology, and Tianjin CanSino Biotechnology.

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Comment
Ebola: the challenging road to recovery
Michael Edelstein, Philip Angelides, David L Heymann
Published Online: 08 February 2015
DOI: http://dx.doi.org/10.1016/S0140-6736(15)60203-3
The resurgence of polio in Syria in 2013 has shown how a breakdown in public health can lead to the re-emergence of previously well-controlled diseases.1 In 2014 and early 2015 Liberia, Guinea, and Sierra Leone have focused all resources on the Ebola response at the expense of other health programmes. Combined with losing a large proportion of the health-care workforce and the population’s reluctance to attend health-care facilities for fear of Ebola, this means the three countries are now at increased risk of other diseases that their health programmes usually target.