BMC Health Services Research
http://www.biomedcentral.com/bmchealthservres/content
(Accessed 12 September 2015)

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Research article
Maternal health care use among married women in Hossaina, Ethiopia
Zeleke Dutamo, Nega Assefa, Gudina Egata BMC Health Services Research 2015, 15:365 (10 September 2015)
Abstract
Background
Pregnancy and child birth are natural process of continuity of life. For many it is a normal process, for some it puts life at risk impending complications. Provision of skilled care for all women before, during, and after childbirth is a key in saving women’s life and ensuring delivery of healthy baby. Maternal health service drop-out through the course of pregnancy is widely claimed, yet by how much it is dropped is not known. The main aim of this study was to identify the use of maternal health service over the course of pregnancy and child birth in a comprehensive manner.
Methods
A community based cross-sectional quantitative study on 623 women supported by qualitative inquiry was conducted Hossaian town, South Ethiopia during January 1–31, 2014. A structured questionnaire was used to generate the quantitative data and 4 Focus Group Discussions (FGD) were carried out to support the finding. Multiple logistic regression was used to control the effect of confounding. Odds ratios with 95 % CI used to display the result of analysis. Data generated from the FGD was analyzed using thematic analysis.
Results
The study revealed that 87.6 % of women attended at least one antenatal care (ANC). Among 546 women who attended ANC, 61.3 % of the women made their first visit during second and third trimester of pregnancy and 49 % had less than four antenatal visits. The study also revealed that 62.6 % of deliveries were assisted by skilled attendants and 51.4 % of the women received at least one postnatal check-up. Parity, pregnancy intention and awareness on danger signs of pregnancy during pregnancy were significantly associated (p < 0.05) with ANC usage. Skilled delivery attendance was significantly associated with some socio-demographic, economic and obstetric factors. Average family monthly income, awareness on obstetric danger signs of pregnancy during recent pregnancy, and frequency of ANC were positive predictors of Postnatal Care (PNC) utilization.
Conclusions
Though use of maternal health care services is relatively higher, however, it is not adequate. Engaging women in their own reproductive health affairs, strengthening maternal health care, increasing community awareness about obstetric danger signs during pregnancy and child birth, and telling the benefit of family planning should be major targets for intervention.

BMC Medical Ethics
http://www.biomedcentral.com/bmcmedethics/content
(Accessed 12 September 2015)

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Debate
Informed consent in paediatric critical care research – a South African perspective
Brenda Morrow, Andrew Argent, Sharon Kling BMC Medical Ethics 2015, 16:62 (9 September 2015)
Abstract
Background
Medical care of critically ill and injured infants and children globally should be based on best research evidence to ensure safe, efficacious treatment. In South Africa and other low and middle-income countries, research is needed to optimise care and ensure rational, equitable allocation of scare paediatric critical care resources.
Ethical oversight is essential for safe, appropriate research conduct. Informed consent by the parent or legal guardian is usually required for child research participation, but obtaining consent may be challenging in paediatric critical care research. Local regulations may also impede important research if overly restrictive.
By narratively synthesising and contextualising the results of a comprehensive literature review, this paper describes ethical principles and regulations; potential barriers to obtaining prospective informed consent; and consent options in the context of paediatric critical care research in South Africa.
Discussion
Voluntary prospective informed consent from a parent or legal guardian is a statutory requirement for child research participation in South Africa. However, parents of critically ill or injured children might be incapable of or unwilling to provide the level of consent required to uphold the ethical principle of autonomy. In emergency care research it may not be practical to obtain consent when urgent action is required. Therapeutic misconceptions and sociocultural and language issues are also barriers to obtaining valid consent.
Alternative consent options for paediatric critical care research include a waiver or deferred consent for minimal risk and/or emergency research, whilst prospective informed consent is appropriate for randomised trials of novel therapies or devices.
Summary
We propose that parents or legal guardians of critically ill or injured children should only be approached to consent for their child’s participation in clinical research when it is ethically justifiable and in the best interests of both child participant and parent. Where appropriate, alternatives to prospective informed consent should be considered to ensure that important paediatric critical care research can be undertaken in South Africa, whilst being cognisant of research risk. This document could provide a basis for debate on consent options in paediatric critical care research and contribute to efforts to advocate for South African law reform.

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Debate
Obligations of low income countries in ensuring equity in global health financing
John Barugahare, Reidar Lie BMC Medical Ethics 2015, 16:59 (8 September 2015)
Abstract
Background
Despite common recognition of joint responsibility for global health by all countries particularly to ensure justice in global health, current discussions of countries’ obligations for global health largely ignore obligations of developing countries. This is especially the case with regards to obligations relating to health financing. Bearing in mind that it is not possible to achieve justice in global health without achieving equity in health financing at both domestic and global levels, our aim is to show how fulfilling the obligation we propose will make it easy to achieve equity in health financing at both domestic and international levels.
Discussion
Achieving equity in global health financing is a crucial step towards achieving justice in global health. Our general view is that current discussions on global health equity largely ignore obligations of Low Income Country (LIC) governments and we recommend that these obligations should be mainstreamed in current discussions. While we recognise that various obligations need to be fulfilled in order to ultimately achieve justice in global health, for lack of space we prioritise obligations for health financing. Basing on the evidence that in most LICs health is not given priority in annual budget allocations, we propose that LIC governments should bear an obligation to allocate a certain minimum percent of their annual domestic budget resources to health, while they await external resources to supplement domestic ones. We recommend and demonstrate a mechanism for coordinating this obligation so that if the resulting obligations are fulfilled by both LIC and HIC governments it will be easy to achieve equity in global health financing.
Summary
Although achieving justice in global health will depend on fulfilment of different categories of obligations, ensuring inter- and intra-country equity in health financing is pivotal. This can be achieved by requiring all LIC governments to allocate a certain optimal per cent of their domestic budget resources to health while they await external resources to top up in order to cover the whole cost of the minimum health opportunities for LIC citizens.

BMC Pregnancy and Childbirth
http://www.biomedcentral.com/bmcpregnancychildbirth/content
(Accessed 12 September 2015)

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Research article
Reasons for home delivery and use of traditional birth attendants in rural Zambia: a qualitative study
Cephas Sialubanje, Karlijn Massar, Davidson Hamer, Robert Ruiter BMC Pregnancy and Childbirth 2015, 15:216 (11 September 2015)
Abstract
Background
Despite the policy change stopping traditional birth attendants (TBAs) from conducting deliveries at home and encouraging all women to give birth at the clinic under skilled care, many women still give birth at home and TBAs are essential providers of obstetric care in rural Zambia. The main reasons for pregnant women’s preference for TBAs are not well understood. This qualitative study aimed to identify reasons motivating women to giving birth at home and seek the help of TBAs. This knowledge is important for the design of public health interventions focusing on promoting facility-based skilled birth attendance in Zambia.
Methods
We conducted ten focus group discussions (n = 100) with women of reproductive age (15–45 years) in five health centre catchment areas with the lowest institutional delivery rates in the district. In addition, a total of 30 in-depth interviews were conducted comprising 5 TBAs, 4 headmen, 4 husbands, 4 mothers, 4 neighbourhood health committee (NHC) members, 4 community health workers (CHWs) and 5 nurses. Perspectives on TBAs, the decision-making process regarding home delivery and use of TBAs, and reasons for preference of TBAs and their services were explored.
Results
Our findings show that women’s lack of decision- making autonomy regarding child birth, dependence on the husband and other family members for the final decision, and various physical and socioeconomic barriers including long distances, lack of money for transport and the requirement to bring baby clothes and food while staying at the clinic, prevented them from delivering at a clinic. In addition, socio-cultural norms regarding childbirth, negative attitude towards the quality of services provided at the clinic, made most women deliver at home. Moreover, most women had a positive attitude towards TBAs and perceived them to be respectful, skilled, friendly, trustworthy, and available when they needed them.
Conclusion
Our findings suggest a need to empower women with decision-making skills regarding childbirth and to lower barriers that prevent them from going to the health facility in time. There is also need to improve the quality of existing facility-based delivery services and to strengthen linkages between TBAs and the formal health system.

BMC Public Health
http://www.biomedcentral.com/bmcpublichealth/content
(Accessed 12 September 2015)

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Research article
Implementation of an HPV vaccination program in Eldoret, Kenya: results from a qualitative assessment by key stakeholders
Heleen Vermandere, Violet Naanyu, Olivier Degomme, Kristien Michielsen BMC Public Health 2015, 15:875 (10 September 2015)
Abstract
Background
Cervical cancer strikes hard in low-resource regions yet primary prevention is still rare. Pilot projects have however showed that Human Papillomavirus (HPV) vaccination programs can attain high uptake. Nevertheless, a study accompanying a vaccination demonstration project in Eldoret, Kenya, revealed less encouraging outcomes: uptake during an initial phase targeting ten schools (i.e., 4000 eligible girls), was low and more schools had to be included to reach the proposed number of 3000 vaccinated girls. The previously conducted study also revealed that many mothers had not received promotional information which had to reach them through schools: teachers were sensitized by health staff and asked to invite students and parents for HPV vaccination in the referral hospital. In this qualitative study, we investigate factors that hampered promotion and vaccine uptake.
Methods
Focus group discussions (FGD) with teachers (4) and fathers (3) were organized to assess awareness and attitudes towards the vaccination program, cervical cancer and the HPV vaccine, as well as a FGD with the vaccinators (1) to discuss the course of the program and potential improvements. Discussions were recorded, transcribed, translated, and analyzed using thematic analysis In addition, a meeting with the program coordinator was set up to reflect upon the program and the results of the FGD, and to formulate recommendations for future programs.
Results
Cervical cancer was poorly understood by fathers and teachers and mainly linked with nonconforming sexual behavior and modern lifestyle. Few had heard about the vaccination opportunity: feeling uncomfortable to discuss cervical cancer and not considering it as important had hampered information flow. Teachers requested more support from health staff to address unexpected questions from parents. Non-uptake was also the result of distrust towards new vaccines. Schools entering the program in the second phase reacted faster: they were better organized, e.g., in terms of transport, while the community was already more familiarized with the vaccine.
Conclusions
Close collaboration between teachers and health staff is crucial to obtain high HPV vaccine uptake among schoolgirls. Promotional messages should, besides providing correct information, tackle misbeliefs, address stigma and stress the priority to vaccinate all, regardless of lifestyle. Monitoring activities and continuous communication could allow for detection of rumors and unequal uptake in the community.

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Debate
Strategies to increase demand for maternal health services in resource-limited settings: challenges to be addressed
Khalifa Elmusharaf, Elaine Byrne, Diarmuid O’Donovan BMC Public Health 2015, 15:870 (8 September 2015)
Abstract
Background
Universal health access will not be achieved unless women are cared for in their own communities and are empowered to take decisions about their own health in a supportive environment. This will only be achieved by community-based demand side interventions for maternal health access. In this review article, we highlight three common strategies to increase demand-side barriers to maternal healthcare access and identify the main challenges that still need to be addressed for these strategies to be effective.
Discussion
Common demand side strategies can be grouped into three categories:(i) Financial incentives/subsidies; (ii) Enhancing patient transfer, and; (iii) Community involvement. The main challenges in assessing the effectiveness or efficacy of these interventions or strategies are the lack of quality evidence on their outcome and impact and interventions not integrated into existing health or community systems. However, what is highlighted in this review and overlooked in most of the published literature on this topic is the lack of knowledge about the context in which these strategies are to be implemented.
Summary
We suggest three challenges that need to be addressed to create a supportive environment in which these demand-side strategies can effectively improve access to maternal health services. These include: addressing decision-making norms, engaging in intergenerational dialogue, and designing contextually appropriate communication strategies.

British Medical Journal
28 August 2015 (vol 351, issue 8024)
http://www.bmj.com/content/351/8024

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Editorials
Europe’s refugee crisis: an urgent call for moral leadership
BMJ 2015; 351 doi: http://dx.doi.org/10.1136/bmj.h4833 (Published 09 September 2015) Cite this as: BMJ 2015;351:h4833
Kamran Abbasi, international editor, The BMJ,
Kiran Patel, consultant cardiologist, Heart of England NHS Trust,
Fiona Godlee, editor in chief, The BMJ
Offering asylum is a minimum standard of civilised society
Europe’s refugee crisis is the greatest test of humanity faced by the world’s rich countries this century. It isn’t a new crisis. Nor was it difficult for politicians to anticipate. Refugees have fled to Europe since at least the premature optimism of the Arab Spring in 2011. Today, optimism is replaced by desperation, a promise of freedom overshadowed by death. Western nations rushed to support the democratic principles of the Arab Spring yet are reluctant to address the root causes and the consequences, which include civil war and state brutality, most notably in Syria. Oil rich Arab States have played their part by allowing political oppression and conflict to flourish in their region. A funding crisis in UN organisations is affecting the humanitarian effort in the Middle East, driving refugees to Europe in greater numbers.1 Ignoring injustice and inequity in poorer countries and in areas of conflict has not prevented the consequences reaching the shores and borders of the rich world…

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Research
Effect of bivalent human papillomavirus vaccination on pregnancy outcomes: long term observational follow-up in the Costa Rica HPV Vaccine Trial
BMJ 2015; 351 doi: http://dx.doi.org/10.1136/bmj.h4358 (Published 07 September 2015) Cite this as: BMJ 2015;351:h4358
Orestis A Panagiotou, researcher1, Brian L Befano, senior programmer2, Paula Gonzalez, investigator34, Ana Cecilia Rodríguez, investigator3, Rolando Herrero, group head4, John T Schiller, senior investigator5, Aimée R Kreimer, investigator1, Mark Schiffman, senior investigator1, Allan Hildesheim, senior investigator1, Allen J Wilcox, senior investigator6, Sholom Wacholder, senior investigator1 on behalf of the Costa Rica HPV Vaccine Trial (CVT) Group (see end of manuscript for full list of investigators)
Abstract
Objective
To examine the effect of the bivalent human papillomavirus (HPV) vaccine on miscarriage.
Design
Observational long term follow-up of a randomized, double blinded trial combined with an independent unvaccinated population based cohort.
Setting S
ingle center study in Costa Rica.
Participants
7466 women in the trial and 2836 women in the unvaccinated cohort enrolled at the end of the randomized trial and in parallel with the observational trial component.
Intervention Women in the trial were assigned to receive three doses of bivalent HPV vaccine (n=3727) or the control hepatitis A vaccine (n=3739). Crossover bivalent HPV vaccination occurred in the hepatitis A vaccine arm at the end of the trial. Women in the unvaccinated cohort received (n=2836) no vaccination.
Main outcome measure
Risk of miscarriage, defined by the US Centers for Disease Control and Prevention as fetal loss within 20 weeks of gestation, in pregnancies exposed to bivalent HPV vaccination in less than 90 days and any time from vaccination compared with pregnancies exposed to hepatitis A vaccine and pregnancies in the unvaccinated cohort.
Results
Of 3394 pregnancies conceived at any time since bivalent HPV vaccination, 381 pregnancies were conceived less than 90 days from vaccination. Unexposed pregnancies comprised 2507 pregnancies conceived after hepatitis A vaccination and 720 conceived in the unvaccinated cohort. Miscarriages occurred in 451 (13.3%) of all exposed pregnancies, in 50 (13.1%) of the pregnancies conceived less than 90 days from bivalent HPV vaccination, and in 414 (12.8%) of the unexposed pregnancies, of which 316 (12.6%) were in the hepatitis A vaccine group and 98 (13.6%) in the unvaccinated cohort. The relative risk of miscarriage for pregnancies conceived less than 90 days from vaccination compared with all unexposed pregnancies was 1.02 (95% confidence interval 0.78 to 1.34, one sided P=0.436) in unadjusted analyses. Results were similar after adjusting for age at vaccination (relative risk 1.15, one sided P=0.17), age at conception (1.03, P=0.422), and calendar year (1.06, P=0.358), and in stratified analyses. Among pregnancies conceived at any time from bivalent HPV vaccination, exposure was not associated with an increased risk of miscarriage overall or in subgroups, except for miscarriages at weeks 13-20 of gestation (relative risk 1.35, 95% confidence interval 1.02 to 1.77, one sided P=0.017).
Conclusions
There is no evidence that bivalent HPV vaccination affects the risk of miscarriage for pregnancies conceived less than 90 days from vaccination. The increased risk estimate for miscarriages in a subgroup of pregnancies conceived any time after vaccination may be an artifact of a thorough set of sensitivity analyses, but since a genuine association cannot totally be ruled out, this signal should nevertheless be explored further in existing and future studies.
Trial registration
Clinicaltrials.gov NCT00128661 and NCT01086709.

Current Opinion in Infectious Diseases
October 2015 – Volume 28 – Issue 5 pp: v-vi,397-496
http://journals.lww.com/co-infectiousdiseases/pages/currenttoc.aspx

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A systems biology approach for diagnostic and vaccine antigen discovery in tropical infectious diseases
Liang, Li; Felgner, Philip L.
Abstract
Purpose of review:
There is a need for improved diagnosis and for more rapidly assessing the presence, prevalence, and spread of newly emerging or reemerging infectious diseases. An approach to the pathogen-detection strategy is based on analyzing host immune response to the infection. This review focuses on a protein microarray approach for this purpose.
Recent findings:
Here we take a protein microarray approach to profile the humoral immune response to numerous infectious agents, and to identify the complete antibody repertoire associated with each disease. The results of these studies lead to the identification of diagnostic markers and potential subunit vaccine candidates. These results from over 30 different organisms can also provide information about common trends in the humoral immune response.
Summary:
This review describes the implications of the findings for clinical practice or research. A systems biology approach to identify the antibody repertoire associated with infectious diseases challenge using protein microarray has become a powerful method in identifying diagnostic markers and potential subunit vaccine candidates, and moreover, in providing information on proteomic feature (functional and physically properties) of seroreactive and serodiagnostic antigens. Combining the detection of the pathogen with a comprehensive assessment of the host immune response will provide a new understanding of the correlations between specific causative agents, the host response, and the clinical manifestations of the disease.

Emerging Infectious Diseases
Volume 21, Number 9—September 2015
http://wwwnc.cdc.gov/eid/

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THEME ISSUE – Emerging Infections Program
Emerging Infections Program—20 Years of Achievements and Future Prospects
Ruth Lynfield and William Schaffner
Excerpt
…This issue of Emerging Infectious Diseases marks the 20th anniversary of the EIP. Sponsored and organized by the Centers for Disease Control and Prevention (CDC), the EIP is a multifaceted collaboration of CDC with 10 state health departments and their academic partners, with the goal of conducting a portfolio of work that can be characterized as enhanced public health surveillance and applied research to detect, prevent, and control emerging infectious diseases. Collaboration derives from the Latin word “collaboratus,” meaning to labor together. The collaboration has been profound and successful, with marked commitment, creativity, and passion contributed by all participants…

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Monitoring Effect of Human Papillomavirus Vaccines in US Population, Emerging Infections Program, 2008–2012 PDF Version [PDF – 474 KB – 5 pages]
S. Hariri et al.
Summary
Methods for surveillance of cervical precancers and associated types were developed to monitor effect of HPV vaccination.

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Tracking Pertussis and Evaluating Control Measures through Enhanced Pertussis Surveillance, Emerging Infections Program, United States PDF Version [PDF – 541 KB – 6 pages]
T. H. Skoff et al.
Summary
This network can improve pertussis prevention and control and be a model for surveillance programs.

Health Affairs
September 2015; Volume 34, Issue 9
http://content.healthaffairs.org/content/current

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Issue Theme: Noncommunicable Diseases: The Growing Burden
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Achieving Effective Universal Health Coverage And Diagonal Approaches To Care For Chronic Illnesses
Felicia Marie Knaul1,*, Afsan Bhadelia2, Rifat Atun3 and Julio Frenk4
Author Affiliations
1Felicia Marie Knaul (fknaul@gmail.com) is director of the Miami Institute for the Americas and professor at the Miller School of Medicine, University of Miami, in Florida. At the time this research was conducted, she was director of the Harvard Global Equity Initiative, in Boston, Massachusetts.
2Afsan Bhadelia is a research associate at the Harvard Global Equity Initiative.
3Rifat Atun is a professor of global health systems in the Department of Global Health and Population at the Harvard School of Public Health.
4Julio Frenk is president of the University of Miami, in Florida. At the time this research was conducted, he was dean of the Harvard School of Public Health.
*Corresponding author
Abstract
Health systems in low- and middle-income countries were designed to provide episodic care for acute conditions. However, the burden of disease has shifted to be overwhelmingly dominated by chronic conditions and illnesses that require health systems to function in an integrated manner across a spectrum of disease stages from prevention to palliation. Low- and middle-income countries are also aiming to ensure health care access for all through universal health coverage. This article proposes a framework of effective universal health coverage intended to meet the challenge of chronic illnesses. It outlines strategies to strengthen health systems through a “diagonal approach.” We argue that the core challenge to health systems is chronicity of illness that requires ongoing and long-term health care. The example of breast cancer within the broader context of health system reform in Mexico is presented to illustrate effective universal health coverage along the chronic disease continuum and across health systems functions. The article concludes with recommendations to strengthen health systems in order to achieve effective universal health coverage.

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Cardiovascular Disease Screening By Community Health Workers Can Be Cost-Effective In Low-Resource Countries
Thomas Gaziano1,*, Shafika Abrahams-Gessel2, Sam Surka3, Stephen Sy4, Ankur Pandya5,
Catalina A. Denman6, Carlos Mendoza7, Thandi Puoane8 and Naomi S. Levitt9
Author Affiliations
1Thomas Gaziano (tgaziano@partners.org) is an assistant professor in the Cardiovascular Division of Brigham and Women’s Hospital, in Boston, Massachusetts.
2Shafika Abrahams-Gessel is a research manager at the Center for Health Decision Science in the Harvard T. H. Chan School of Public Health, in Boston.
3Sam Surka is a researcher in the Chronic Diseases Initiative for Africa at Old Groote Schuur Hospital, in Cape Town, South Africa.
4Stephen Sy is a programmer at the Center for Health Decision Science in the Harvard T. H. Chan School of Public Health.
5Ankur Pandya is an assistant professor of health policy and management at the Harvard T. H. Chan School of Public Health.
6Catalina A. Denman is a professor in the Centro de Estudios en Salud y Sociedad at El Colegio de Sonora, in Hermosillo, Mexico.
7Carlos Mendoza is a coinvestigator at the Instituto de Nutricion de Centro America y Panama, in Guatemala City, Guatemala.
8Thandi Puoane is a professor in the School of Public Health at the University of the Western Cape, in Bellville, South Africa.
9Naomi S. Levitt is director of the Division of Diabetes and the Chronic Diseases Initiative for Africa, both at Old Groote Schuur Hospital.
*Corresponding author
Abstract
In low-resource settings, a physician is not always available. We recently demonstrated that community health workers—instead of physicians or nurses—can efficiently screen adults for cardiovascular disease in South Africa, Mexico, and Guatemala. In this analysis we sought to determine the health and economic impacts of shifting this screening to community health workers equipped with either a paper-based or a mobile phone–based screening tool. We found that screening by community health workers was very cost-effective or even cost-saving in all three countries, compared to the usual clinic-based screening. The mobile application emerged as the most cost-effective strategy because it could save more lives than the paper tool at minimal extra cost. Our modeling indicated that screening by community health workers, combined with improved treatment rates, would increase the number of deaths averted from 15,000 to 110,000, compared to standard care. Policy makers should promote greater acceptance of community health workers by both national populations and health professionals and should increase their commitment to treating cardiovascular disease and making medications available.

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Overcoming Obstacles To Enable Access To Medicines For Noncommunicable Diseases In Poor Countries
Sandeep P. Kishore1,*, Kavitha Kolappa2, Jordan D. Jarvis3, Paul H. Park4, Rachel Belt5,
Thirukumaran Balasubramaniam6 and Rachel Kiddell-Monroe7
Author Affiliations
1Sandeep P. Kishore (sunny.kishore@gmail.com) is a fellow at Yale University, in New Haven, Connecticut, and president of the Young Professionals Chronic Disease Network, in Boston, Massachusetts.
2Kavitha Kolappa is a resident in psychiatry at Massachusetts General Hospital, in Boston, a and board member for the Young Professionals Chronic Disease Network.
3Jordan D. Jarvis is executive director of the Young Professionals Chronic Disease Network and a former postgraduate research fellow at the Harvard Global Equity Initiative, in Boston.
4Paul H. Park is director of noncommunicable diseases for Partners in Health—Rwanda and a member of Universities Allied for Essential Medicines, in Washington, D.C.
5Rachel Belt is a member of Universities Allied for Essential Medicines.
6Thirukumaran Balasubramaniam is a Geneva representative at Knowledge Ecology International, in Switzerland.
7Rachel Kiddell-Monroe is a special adviser for the Universities Allied for Essential Medicines, a board member for the Young Professionals Chronic Disease Network, and a member of the International Board for Médecins sans Frontières, in Geneva.
*Corresponding author
Abstract
The modern access-to-medicines movement grew largely out of the civil-society reaction to the HIV/AIDS pandemic three decades ago. While the movement was successful with regard to HIV/AIDS medications, the increasingly urgent challenge to address access to medicines for noncommunicable diseases has lagged behind—and, in some cases, has been forgotten. In this article we first ask what causes the access gap with respect to lifesaving essential noncommunicable disease medicines and then what can be done to close the gap. Using the example of the push for access to antiretrovirals for HIV/AIDS patients for comparison, we highlight the problems of inadequate global financing and procurement for noncommunicable disease medications, intellectual property barriers and concerns raised by the pharmaceutical industry, and challenges to building stronger civil-society organizations and a patient and humanitarian response from the bottom up to demand treatment. We provide targeted policy recommendations, specific to the public sector, the private sector, and civil society, with the goal of improving access to noncommunicable disease medications globally.

International Journal of Infectious Diseases
September 2015 Volume 38, In Progress
http://www.ijidonline.com/current

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Planning for the Next Global Pandemic
Allen G.P. Ross, Suzanne M. Crowe, Mark W. Tyndall
Corresponding Editor: Eskild Petersen, Aarhus, Denmark
DOI: http://dx.doi.org/10.1016/j.ijid.2015.07.016
Abstract
In order to mitigate human and financial losses as a result of future global pandemics, we must plan now. As the Ebola virus pandemic declines, we must reflect on how we have mismanaged this recent international crisis and how we can better prepare for the next global pandemic. Of great concern is the increasing frequency of pandemics occurring over the last few decades. Clearly, the window of opportunity to act is closing. This editorial discusses many issues including priority emerging and re-emerging infectious diseases; the challenges of meeting international health regulations; the strengthening of global health systems; global pandemic funding; and the One Health approach to future pandemic planning. We recommend that the global health community unites to urgently address these issues in order to avoid the next humanitarian crisis.

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Short Communications
Investigating the immunizing effect of the rubella epidemic in Japan, 2012-14
Hiroshi Nishiura, Ryo Kinoshita, Yuichiro Miyamatsu, Kenji Mizumoto
p16–18
Published online: July 13 2015

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Epidemiological features and trends of Ebola virus disease in West Africa
Ligui Wang, Guang Yang, Leili Jia, Zhenjun Li, Jing Xie, Peng Li, Shaofu Qiu, Rongzhang Hao, Zhihao Wu, Hui Ma, Hongbin Song
p52–53
Published online: July 24 2015

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Probable transmission chains of Middle East respiratory syndrome coronavirus and the multiple generations of secondary infection in South Korea
Shui Shan Lee, Ngai Sze Wong
p65–67

JAMA
September 8, 2015, Vol 314, No. 10
http://jama.jamanetwork.com/issue.aspx

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Editorial | September 8, 2015
Antenatal Iron Use in Malaria Endemic Settings: Evidence of Safety?
Parul Christian, DrPH, MSc1; Robert E. Black, MD, MPH2
Author Affiliations
JAMA. 2015;314(10):1003-1005. doi:10.1001/jama.2015.10032.
Extract
Anemia related to iron deficiency during pregnancy occurs in 19% of women worldwide and in 20% of women in sub-Saharan Africa.1 Findings from observational studies reveal a linear, inverse relationship between maternal anemia and risk of maternal mortality across the entire distribution of hemoglobin concentrations, although confounding may be an issue.2,3 Severe anemia in pregnancy may result in maternal death due to cardiac failure. The current World Health Organization (WHO) guideline is to provide 30 to 60 mg of elemental iron and 400 µg of folic acid daily throughout pregnancy. This recommendation is mainly based on the proven effects of supplementation in reducing maternal anemia, iron deficiency, and low birth weight.4 In addition, approximately 35 million pregnant women, nearly all of whom live in sub-Saharan Africa, are at risk of Plasmodium falciparum infection annually.5 Across Africa, the prevalence of infection among children aged 2 to 10 years has declined from 26% in 2000 to 14% in 2013.5 Still, in 2013, an estimated 437 000 malaria deaths occurred in children younger than 5 years, representing 83% of all deaths due to malaria in Africa.5

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Original Investigation | September 8, 2015
Effect of Daily Antenatal Iron Supplementation on Plasmodium Infection in Kenyan Women: A Randomized Clinical Trial
Martin N. Mwangi, PhD1,2; Johanna M. Roth, MSc1,3; Menno R. Smit, MD1; Laura Trijsburg, MSc1; Alice M. Mwangi, PhD4; Ayşe Y. Demir, MD, PhD5; Jos P. M. Wielders, PhD5; Petra F. Mens, PhD3; Jaco J. Verweij, PhD6; Sharon E. Cox, PhD7,8; Andrew M. Prentice, PhD, FMedSci7,8; Inge D. Brouwer, PhD9; Huub F. J. Savelkoul, PhD1; Pauline E. A. Andang’o, PhD2; Hans Verhoef, PhD1,7,8
Author Affiliations
JAMA. 2015;314(10):1009-1020. doi:10.1001/jama.2015.9496.
Abstract
Importance
Anemia affects most pregnant African women and is predominantly due to iron deficiency, but antenatal iron supplementation has uncertain health benefits and can increase the malaria burden.
Objective
To measure the effect of antenatal iron supplementation on maternal Plasmodium infection risk, maternal iron status, and neonatal outcomes.
Design, Setting, and Participants
Randomized placebo-controlled trial conducted October 2011 through April 2013 in a malaria endemic area among 470 rural Kenyan women aged 15 to 45 years with singleton pregnancies, gestational age of 13 to 23 weeks, and hemoglobin concentration of 9 g/dL or greater. All women received 5.7 mg iron/day through flour fortification during intervention, and usual intermittent preventive treatment against malaria was given.
Interventions Supervised daily supplementation with 60 mg of elemental iron (as ferrous fumarate, n = 237 women) or placebo (n = 233) from randomization until 1 month postpartum.
Main Outcomes and Measures
Primary outcome was maternal Plasmodium infection at birth. Predefined secondary outcomes were birth weight and gestational age at delivery, intrauterine growth, and maternal and infant iron status at 1 month after birth.
Results
Among the 470 participating women, 40 women (22 iron, 18 placebo) were lost to follow-up or excluded at birth; 12 mothers were lost to follow-up postpartum (5 iron, 7 placebo). At baseline, 190 of 318 women (59.7%) were iron-deficient. In intention-to-treat analysis, comparison of women who received iron vs placebo, respectively, yielded the following results at birth: Plasmodium infection risk: 50.9% vs 52.1% (crude difference, −1.2%, 95% CI, −11.8% to 9.5%; P = .83); birth weight: 3202 g vs 3053 g (crude difference, 150 g, 95% CI, 56 to 244; P = .002); birth-weight-for-gestational-age z score: 0.52 vs 0.31 (crude difference, 0.21, 95% CI, −0.11 to 0.52; P  = .20); and at 1 month after birth: maternal hemoglobin concentration: 12.89 g/dL vs 11.99 g/dL (crude difference, 0.90 g/dL, 95% CI, 0.61 to 1.19; P < .001); geometric mean maternal plasma ferritin concentration: 32.1 µg/L vs 14.4 µg/L (crude difference, 123.4%, 95% CI, 85.5% to 169.1%; P < .001); geometric mean neonatal plasma ferritin concentration: 163.0 µg/L vs 138.7 µg/L (crude difference, 17.5%, 95% CI, 2.4% to 34.8%; P = .02). Serious adverse events were reported for 9 and 12 women who received iron and placebo, respectively. There was no evidence that intervention effects on Plasmodium infection risk were modified by intermittent preventive treatment use.
Conclusions and Relevance
Among rural Kenyan women with singleton pregnancies, administration of daily iron supplementation, compared with administration of placebo, resulted in no significant differences in overall maternal Plasmodium infection risk. Iron supplementation led to increased birth weight.
Trial Registration clinicaltrials.gov Identifier: NCT01308112

The Lancet
Sep 12, 2015 Volume 386 Number 9998 p1013-1108
http://www.thelancet.com/journals/lancet/issue/current

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Comment
Diaspora engagement in humanitarian emergencies and beyond
Neeraja Nagarajan, Blair Smart, Joseph Nwadiuko
DOI: http://dx.doi.org/10.1016/S0140-6736(15)00071-9
Summary
Migration of health workers from low-income and middle-income countries (LMICs) to high-income countries continues unabated, with substantial effects on the development of health systems in LMICs.1–3 WHO estimates that an additional 4·3 million health-care workers are needed to meet global health-care needs, with acute shortages in LMICs.4 Yet almost 25% of physicians in high-income countries such as the USA, UK, Australia, and Canada are foreign-born and from the very LMICs that face shortages in health-care workforces.

Maternal and Child Health Journal
Volume 19, Issue 9, September 2015
http://link.springer.com/journal/10995/19/9/page/1

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Original Paper
Decentralizing Maternity Services to Increase Skilled Attendance at Birth and Antenatal Care Utilization in Rural Rwanda: A Prospective Cohort Study
Lisa M. Nathan, Quihu Shi, Kari Plewniak…

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Original Paper
Integrating Vitamin A Supplementation at 6 months into the Expanded Program of Immunization in Sierra Leone
Mary H. Hodges, Fatmata F. Sesay, Habib I. Kamara…

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Review Paper
Impact of Male Partner Antenatal Accompaniment on Perinatal Health Outcomes in Developing Countries: A Systematic Literature Review
Carolina Aguiar, Larissa Jennings

New England Journal of Medicine
September 10, 2015 Vol. 373 No. 11
http://www.nejm.org/toc/nejm/medical-journal

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Perspective
Creating a Global Health Risk Framework
Victor J. Dzau, M.D., and Judith Rodin, Ph.D.
N Engl J Med 2015; 373:991-993 September 10, 2015 DOI: 10.1056/NEJMp1509136

The Ebola outbreak in West Africa tragically illustrated the shortcomings of the global health system. Dysfunctional governance structures — within and among institutions and sectors — hindered response efforts. Financial and human resources were slow to arrive and insufficient,1 as they often are during humanitarian crises. Surveillance and other information systems were not up to the task. Health care personnel risked their lives to provide care, and many died. Local culture was not respected, and mistrust of the health system was rampant.2 Private industry had little incentive to proactively develop lifesaving products, and when it nevertheless did so, regulatory barriers and poor coordination hindered testing and deployment.3 The list goes on. As a result, the Ebola outbreak has had catastrophic health, economic, and social effects on Guinea, Liberia, Sierra Leone, and beyond.

Clearly, a unifying framework for managing global public health events is needed. Although previous globally significant outbreaks, such as those of the human immunodeficiency virus, influenza, and the severe acute respiratory syndrome (SARS), highlighted many of these weaknesses, the political will needed to reform the global public health framework has failed. As a result, countless lives have been lost and billions of dollars in economic damage has been incurred. The situation urgently needs to be fixed, and that requires leadership from the highest levels. We can’t allow another epidemiologic crisis to become a full-fledged catastrophe. An independent, multinational Commission on a Global Health Risk Framework for the Future has been established to recommend a more effective global architecture for mitigating the threat of epidemic infectious diseases.4 The U.S. National Academy of Medicine (formerly the Institute of Medicine) is the secretariat for this commission.

The Global Health Risk Framework (GHRF) initiative will build on lessons from the current Ebola outbreak and other major outbreaks to develop a comprehensive framework for improving our response to future global public health threats. The Commission will rigorously analyze options for improving governance, finance, health system resilience, and research and development for global health security. To foster trust internationally with various levels of government, civil society, academia, and industry, the Commission intends to keep the framework from being influenced by politics or the interests of any one country or organization.

The 18 Commission members have expertise in global health governance; workforce mobilization; global financing, including reinsurance business, economics, and public–private partnerships; information management and disease surveillance; humanitarian and pandemic response; and research, development, acquisition, and distribution. Because preparing for and responding to outbreaks requires more than medical expertise, the Commission also includes lawyers, bankers, mining executives, and others. To ensure the group’s independence, the commissioners were screened for conflicts of interest, their evidence collection and analysis will be transparent, and their report will be rigorously peer reviewed.

An international oversight group will steer the initiative and determine the scope of the study, approve the Commission slate and the initiative processes, develop guidelines for the report review process, and assist with dissemination. The initiative also includes workstream planning groups that will oversee preparations for four public information-gathering workshops, involving experts to address governance for global health, financing for public health emergencies, resilient health systems, and research and development of medical products.

The governance-for-global-health workstream will begin with a review of the current responsibilities and constraints of countries, regional institutions, the World Health Organization (WHO), and other relevant United Nations (UN) agencies, as well as the International Health Regulations (IHR), and assessment of potential changes to international governance frameworks that would ensure a robust response capability regardless of the environmental contexts. Possible ways to reform or empower the WHO and the UN system to more effectively respond to public health emergencies — such as developing guidelines for roles of non–health-focused organizations, establishing mechanisms for mobilizing a global health workforce, developing strong regional networks that share information and coordinate responses, and creating national command centers — may also be considered.

The financing workstream will start with an examination of how global funding for response to pandemic threats can be set aside in advance or rapidly mobilized, where the money should come from, and how it should be spent. The workstream group will evaluate the role of the World Bank’s proposed Pandemic Emergency Financing Facility, which will coordinate international financial response to pandemics — in particular, how the facility might ensure rapid deployment and prompt remuneration of health workers and minimize transaction times on other expenses. Vital to this discussion will be the roles to be played by the private sector, especially the reinsurance industry, in pooling risk for global emergencies. The financing workshop will explore possible underwriting functions of banks, insurers, and investment houses and analyze how they could ease the financial shock of an epidemic and control the costs of response, including the cost of developing new drugs and vaccines. The financing of surveillance systems to comply with the IHR will also be considered.

In the workstream focused on resilient health systems, optimal approaches to achieving effective, resilient, and sustainable health systems in individual countries will be considered. Multiple components of health systems will be examined, including surveillance and health information systems; universal health coverage; workforce capacity; health systems infrastructure; community, regional, and global partner engagement; supply-chain coordination and management; and how these components are connected and coordinated to form a resilient health system. Other considerations include options for enhancing connections among the health sector, other sectors (such as agriculture, education, and commerce), and the community; strengthening syndromic surveillance systems to permit early reporting and response; enhancing education and training for health care workers, community leaders, and the public; and leveraging existing systems and resources to address surge needs and capabilities. These issues will be explored in the context of other efforts including the IHR, the Post-2015 Hyogo Framework for Disaster Risk Reduction, the Global Health Security Agenda, Health in All Policies initiatives, and the Sustainable Development Goals.

In the workstream for medical-product research and development, participating experts will examine issues surrounding ensuring global capacity for relevant research and development, acquisition, and dispensing of countermeasures and diagnostics. They may explore the need for a global plan to harmonize and strengthen regulatory systems, processes, and standards; models for public–private partnerships and nongovernmental organizations to support rapid research and development and complement and reinforce private-sector mechanisms; global financing models that provide incentives for research and development; frameworks for ethical and methodologic standards for product safety and efficacy; and investments in regulatory science and multiuse platforms to support rapid development and deployment.

In each workstream, expert participants will gather diverse perspectives on various policy options, which will be captured in written workshop summaries. The Commission will integrate the evidence from these workshops, synthesizing the expertise of more than 100 leaders in health and related areas. It will then develop a comprehensive set of recommendations based on the available evidence, with the ultimate aim of strengthening systems, reducing suffering, and saving lives. The Commission will also use information collected through expert consultations, literature reviews, and public input to propose a preparedness-and-response plan that will build on and be coordinated with other efforts in this area. This plan will be captured in a final report expected to be released by December 2015.

To be effective, the report will have to be positioned to encourage global health leaders to act on its recommendations. The International Oversight Group is working closely with decision makers to coordinate dissemination of the report. The plan is to feature the Commission’s work at major events of the UN, the World Health Assembly, and the G7 and G20 groups of countries, aiming for effect well beyond the health sphere. Ultimately, world leaders’ actions will determine international preparedness for future pandemics and medical disasters. This GHRF initiative should provide sound, evidence-based guidance for their decisions.

A world health crisis such as the Ebola outbreak should never happen again. If we prepare now, we can avoid devastation when the next outbreak occurs.

New England Journal of Medicine
September 10, 2015 Vol. 373 No. 11
http://www.nejm.org/toc/nejm/medical-journal

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Perspective
Combating Emerging Threats — Accelerating the Availability of Medical Therapies
Luciana Borio, M.D., Edward Cox, M.D., M.P.H., and Nicole Lurie, M.D., M.S.P.H.
N Engl J Med 2015; 373:993-995 September 10, 2015 DOI: 10.1056/NEJMp1508708

Life-threatening emerging or reemerging infectious diseases increasingly inspire demands for access to novel, often untested therapies. Recent concern about transmission of the Middle East respiratory syndrome coronavirus (MERS-CoV) in Asia underscores the need to rapidly evaluate investigational therapies during outbreaks, identify those that actually benefit patients, and protect against those that cause harm. Although a traditional sequence of studies in animals followed by phased clinical trials works well for many therapeutics, that process may be too slow during public health emergencies. We propose establishing a new paradigm for accelerating evaluation of investigational therapies during public health emergencies so that therapies shown to be safe and effective can reach patients as soon as possible.

The primary approach to containing outbreaks of emerging infectious diseases involves standard public health measures, such as identifying and isolating infected persons, tracing their contacts to detect secondary infections, and protecting contacts and health care workers from exposure. General supportive medical care for anyone who becomes infected is essential, in addition to use of any proven specific treatments. When such treatments are lacking, clinicians commonly try therapies on the basis of experience with other diseases (usually on the basis of a postulated mechanism of action) in the hope of improving outcomes. For example, during the 2003 epidemic of the severe acute respiratory syndrome (SARS), several small observational studies examined the use of interferon, ribavirin, steroids, and convalescent plasma.1 Unfortunately, the inability to implement properly designed trials precluded any clear demonstration of benefit, and some evaluations suggested possible harm.

During the 2009 H1N1 influenza pandemic, it was considered infeasible to establish a multisite clinical study for an investigational therapy during a public health emergency. Peramivir, an intravenously administered influenza antiviral drug under clinical development, was made available in the United States under Emergency Use Authorization (EUA) to treat certain hospitalized patients. Demand was brisk — nearly 1300 seriously ill patients received the drug.2 Unfortunately, no reliable data on effectiveness were derived from this use. Some analyses suggested that mortality was increased among patients receiving peramivir, although that finding could have represented channeling bias (if patients receiving peramivir were already “sicker” in ways that could not be readily measured). A subsequent randomized clinical trial did not demonstrate either benefit or increased mortality associated with peramivir in patients hospitalized with influenza.3 Demand for this investigational drug drove its use under EUA, but any imperative to get demonstrably effective products to people in need as quickly as possible was not fulfilled. This experience showed that a reasonable expectation of benefit doesn’t always pan out, data derived from uncontrolled use may not be interpretable, and use outside a properly designed clinical trial can delay product assessment.

In early August 2014, two Americans who became infected with Ebola virus in West Africa were evacuated to the United States for medical care. They received various interventions, including ZMapp, an investigational monoclonal antibody cocktail in early development, not previously tested in humans. Their survival from what had been considered a highly fatal disease was followed by widespread demand for access to early-stage investigational therapies for Ebola. A World Health Organization ethics panel opined that although it was ethical to offer interventions with as-yet-unknown efficacy and adverse effects as potential treatment or prevention, there was a moral imperative to determine as quickly as possible which therapies worked.4
The international medical research community rushed to conduct clinical trials of several investigational products, but trial infrastructure took some time to establish. Meanwhile, initial doses of investigational drugs, some of which existed in very limited quantities, were administered to a few patients outside a clinical trial through so-called compassionate use. In some countries, such use continued even after clinical trials were established, despite the knowledge that it could delay the gathering of high-quality evidence to identify beneficial drugs or prolong the use of harmful ones.

Moreover, substantial disagreement emerged about the types of clinical trial designs that were appropriate for rapidly evaluating unproven therapies. Some investigators argued that randomized, controlled studies comparing an investigational therapy with available supportive medical care would be unethical,5 even when a drug’s limited supply meant that some patients would receive it while others couldn’t; others argued that early randomized trials should take priority both ethically and scientifically. Several uncontrolled studies were implemented, but their design makes them unlikely to provide reliable efficacy data or adequately protect patients by detecting serious adverse effects.

In early 2015, the National Institutes of Health, in partnership with U.S. and West African academic institutions and health authorities in Liberia, Sierra Leone, and later, Guinea, implemented a common protocol in which multiple therapies, even those at very early stages of development, could be simultaneously evaluated against a shared control group in an adaptive randomized trial. In this design, the shared control group is initially given the best available supportive care until a drug is identified that improves outcomes. Once a drug is proven effective, it’s incorporated into the supportive care that all trial patients receive, and the study may continue in order to evaluate the added benefit of other investigational drugs.

The first drug being evaluated under this protocol, ZMapp, advanced more rapidly than usual to a clinical trial designed to assess both safety and efficacy (typically, efficacy trials occur much later in development). The study is very efficient because it includes frequent prespecified interim evaluations of the accruing data, employing Bayesian analytic techniques, to identify a winner or a harmful drug as early as possible. If proven effective, ZMapp will be incorporated in the control group against which other therapies are tested. This protocol is being used in both high- and low-resource settings, providing equity of access to the study drug.

The critical need for rapid availability of effective new therapies coupled with advances in product development, manufacturing, and clinical trial design create new opportunities for efficient, scientifically sound evaluation of investigational therapies during public health emergencies. The serious impact of these emergencies and the lack of effective therapies warrant moving forward with clinical testing as soon as possible. The Ebola experience indicates that the usual phased development approach can be accelerated and abridged on the basis of what’s known about the candidate product, the severity and acuteness of the disease, and the limited window of opportunity for study. In such emergency settings, it may be appropriate to accept greater-than-usual degrees of uncertainty and risk in order to move rapidly to clinical trials, with the goal of getting safe, effective therapies to patients sooner.

The common protocol launched during the Ebola epidemic could serve as a model for rapidly evaluating promising but unproven therapies in the current MERS-CoV outbreak and future epidemics. Such an approach would allow earlier clinical testing of investigational drugs to accelerate identification of safe, effective therapies and thereby make them available to patients sooner. To succeed, this model requires close cooperation among clinical researchers, product developers, and public health and regulatory authorities globally.

Public health leaders need to take action before the next new threatening infectious disease emerges. One high-priority action will be the development and prepositioning of scientifically sound and widely accepted protocols by global public health authorities, to have them ready for use at the onset of a deadly outbreak wherever it strikes. In addition, work is needed to augment global clinical trial infrastructure, streamline processes for careful ethical review of multisite international studies, and establish model agreements for managing data and addressing intellectual property issues. If we are to act on lessons learned, there is no time to waste in getting this work done.

PLoS Medicine
http://www.plosmedicine.org/
(Accessed 12 September 2015)

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Equity and Noncommunicable Disease Reduction under the Sustainable Development Goals
Harald Schmidt, Anne Barnhill
Essay | published 08 Sep 2015 | PLOS Medicine
10.1371/journal.pmed.1001872
Summary Points
:: Currently proposed Sustainable Development Goals (SDGs) include a timely call to significantly reduce the burden of noncommunicable diseases (NCDs).
:: Existing policy guidance highlights cost-effective interventions for NCDs, but focusing just on cost-effectiveness risks exacerbating socioeconomic and health inequalities rather than reducing them.
:: In implementing the SDGs, targets and interventions that benefit the worst off should be prioritized.
:: The United Nations should develop practical guidance to assist policy makers at the country level with incorporating equity considerations.

PLoS Neglected Tropical Diseases
http://www.plosntds.org/
(Accessed 12 September 2015)

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Financial and Economic Costs of the Elimination and Eradication of Onchocerciasis (River Blindness) in Africa
Young Eun Kim, Elisa Sicuri, Fabrizio Tediosi
Research Article | published 11 Sep 2015 | PLOS Neglected Tropical Diseases
10.1371/journal.pntd.0004056

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Antivenoms for Snakebite Envenoming: What Is in the Research Pipeline?
Emilie Alirol, Pauline Lechevalier, Federica Zamatto, François Chappuis, Gabriel Alcoba, Julien Potet
Viewpoints | published 10 Sep 2015 | PLOS Neglected Tropical Diseases
10.1371/journal.pntd.0003896

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An Estimation of Private Household Costs to Receive Free Oral Cholera Vaccine in Odisha, India
Vittal Mogasale, Shantanu K. Kar, Jong-Hoon Kim, Vijayalaxmi V. Mogasale, Anna S. Kerketta, Bikash Patnaik, Shyam Bandhu Rath, Mahesh K. Puri, Young Ae You, Hemant K. Khuntia, Brian Maskery, Thomas F. Wierzba, Binod Sah
Research Article | published 09 Sep 2015 | PLOS Neglected Tropical Diseases
10.1371/journal.pntd.0004072
Abstract
Background
Service provider costs for vaccine delivery have been well documented; however, vaccine recipients’ costs have drawn less attention. This research explores the private household out-of-pocket and opportunity costs incurred to receive free oral cholera vaccine during a mass vaccination campaign in rural Odisha, India.
Methods
Following a government-driven oral cholera mass vaccination campaign targeting population over one year of age, a questionnaire-based cross-sectional survey was conducted to estimate private household costs among vaccine recipients. The questionnaire captured travel costs as well as time and wage loss for self and accompanying persons. The productivity loss was estimated using three methods: self-reported, government defined minimum daily wages and gross domestic product per capita in Odisha.
Findings
On average, families were located 282.7 (SD = 254.5) meters from the nearest vaccination booths. Most family members either walked or bicycled to the vaccination sites and spent on average 26.5 minutes on travel and 15.7 minutes on waiting. Depending upon the methodology, the estimated productivity loss due to potential foregone income ranged from $0.15 to $0.29 per dose of cholera vaccine received. The private household cost of receiving oral cholera vaccine constituted 24.6% to 38.0% of overall vaccine delivery costs.
Interpretation
The private household costs resulting from productivity loss for receiving a free oral cholera vaccine is a substantial proportion of overall vaccine delivery cost and may influence vaccine uptake. Policy makers and program managers need to recognize the importance of private costs and consider how to balance programmatic delivery costs with private household costs to receive vaccines.
Author Summary
The price of vaccine and the costs of its delivery are two important economic measures considered by governments and various international organizations in their decisions on the use of a new vaccine. However, the costs to the vaccine recipients resulting from their travel, time and wage loss are hardly considered and rarely documented. Even if the vaccine is provided for free, the costs borne by vaccine recipients could be sufficient enough to be a hurdle for taking vaccine. We elucidate this less explored angle of “vaccine recipient cost” in the context of oral cholera vaccine mass campaign in Odisha, India. Our research shows that the potential loss of income for individuals for receiving oral cholera vaccine ranged from 25% to 38% of overall vaccine delivery costs. We believe our findings have global implications on future decisions and policy making on vaccine introduction in balancing programmatic delivery costs with private household costs to receive vaccines.

PLoS One
http://www.plosone.org/
[Accessed 12 September 2015]

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Research Article
Impact of Pneumococcal Conjugate Vaccine Administration in Pediatric Older Age Groups in Low and Middle Income Countries: A Systematic Review
Kimberly Bonner, Emily Welch, Kate Elder, Jennifer Cohn
Published: September 2, 2015
DOI: 10.1371/journal.pone.0135270
Abstract
Introduction
Pneumococcal conjugate vaccine (PCV) is included in the World Health Organization’s routine immunization schedule and is recommended by WHO for vaccination in high-risk children up to 60 months. However, many countries do not recommend vaccination in older age groups, nor have donors committed to supporting extended age group vaccination. To better inform decision-making, this systematic review examines the direct impact of extended age group vaccination in children over 12 months in low and middle income countries.
Methods
An a priori protocol was used. Using pre-specified terms, a search was conducted using PubMed, LILACS, Cochrane Infectious Diseases Group Specialized Register, Cochrane Central Register of Controlled Trials, CAB Abstracts, clinicaltrials.gov and the International Symposium on Pneumococci and Pneumococcal Diseases abstracts. The primary outcome was disease incidence, with antibody titers and nasopharyngeal carriage included as secondary outcomes.
Results
Eighteen studies reported on disease incidence, immune response, and nasopharyngeal carriage. PCV administered after 12 months of age led to significant declines in invasive pneumococcal disease. Immune response to vaccine type serotypes was significantly higher for those vaccinated at older ages than the unimmunized at the established 0.2ug/ml and 0.35ug/ml thresholds. Vaccination administered after one year of age significantly reduced VT carriage with odds ratios ranging from 0.213 to 0.69 over four years. A GRADE analysis indicated that the studies were of high quality.
Discussion
PCV administration in children over 12 months leads to significant protection. The direct impact of PCV administration, coupled with the large cohort of children missed in first year vaccination, indicates that countries should initiate or expand PCV immunization for extended age group vaccinations. Donors should support implementation of PCV as part of delayed or interrupted immunization for older children. For countries to effectively implement extended age vaccinations, access to affordably-priced PCV is critical.

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Influence of Pneumococcal Conjugate Vaccine on Acute Otitis Media with Severe Middle Ear Inflammation: A Retrospective Multicenter Study
Hirotoshi Sugino, Shigeru Tsumura, Masaru Kunimoto, Masuhiro Noda, Daisuke Chikuie, Chieko Noda, Mariko Yamashita, Hiroshi Watanabe, Hidemasa Ishii, Toru Tashiro, Kazuhiro Iwata, Takashi Kono, Kaoru Tsumura, Takahiro Sumiya, Sachio Takeno, Katsuhiro Hirakawa
Research Article | published 08 Sep 2015 | PLOS ONE
10.1371/journal.pone.0137546

PNAS – Proceedings of the National Academy of Sciences of the United States of America
http://www.pnas.org/content/early/
(Accessed 12 September 2015)

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Impact of human mobility on the emergence of dengue epidemics in Pakistan
Amy Wesolowskia,b, Taimur Qureshic, Maciej F. Bonid,e, Pål Roe Sundsøyc, Michael A. Johanssonb,f, Syed Basit Rasheedg, Kenth Engø-Monsenc, and Caroline O. Buckeea,b,1
Author Affiliations
Edited by Burton H. Singer, University of Florida, Gainesville, FL, and approved August 6, 2015 (received for review April 2, 2015)
Significance
Dengue virus has rapidly spread into new human populations due to human travel and changing suitability for the mosquito vector, causing severe febrile illness and significant mortality. Accurate predictive models identifying changing vulnerability to dengue outbreaks are necessary for epidemic preparedness and containment of the virus. Here we show that an epidemiological model of dengue transmission in travelers, based on mobility data from ∼40 million mobile phone subscribers and climatic information, predicts the geographic spread and timing of epidemics throughout the country. We generate fine-scale dynamic risk maps with direct application to dengue containment and epidemic preparedness.
Abstract
The recent emergence of dengue viruses into new susceptible human populations throughout Asia and the Middle East, driven in part by human travel on both local and global scales, represents a significant global health risk, particularly in areas with changing climatic suitability for the mosquito vector. In Pakistan, dengue has been endemic for decades in the southern port city of Karachi, but large epidemics in the northeast have emerged only since 2011. Pakistan is therefore representative of many countries on the verge of countrywide endemic dengue transmission, where prevention, surveillance, and preparedness are key priorities in previously dengue-free regions. We analyze spatially explicit dengue case data from a large outbreak in Pakistan in 2013 and compare the dynamics of the epidemic to an epidemiological model of dengue virus transmission based on climate and mobility data from ∼40 million mobile phone subscribers. We find that mobile phone-based mobility estimates predict the geographic spread and timing of epidemics in both recently epidemic and emerging locations. We combine transmission suitability maps with estimates of seasonal dengue virus importation to generate fine-scale dynamic risk maps with direct application to dengue containment and epidemic preparedness.

Preventive Medicine
Volume 78, Pages 1-122 (September 2015)
http://www.sciencedirect.com/science/journal/00917435/78

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HPV vaccine for teen boys: Dyadic analysis of parents’ and sons’ beliefs and willingness
Original Research Article
Pages 65-71
Jennifer L. Moss, Paul L. Reiter, Noel T. Brewer
Abstract
Objective
Parents and adolescents often decide together whether the child should receive human papillomavirus (HPV) vaccine. However, few studies have investigated the dyadic nature of beliefs that affect this process.
Method
Data came from the 2010 HPV Immunization in Sons (HIS) Study, a national sample of 412 parents and their adolescent sons. We conducted dyadic multivariate logistic regression to examine the relationships between parents’ and sons’ HPV vaccine beliefs and their willingness to have the son receive the vaccine.
Results
Less than half of parents and sons were willing to have the sons receive HPV vaccine (43% and 29%, respectively). Willing parents and sons anticipated greater regret if the son did not receive HPV vaccine but later contracted an HPV infection (parent odds ratio [OR] = 1.72, 95% confidence interval [CI] = 1.24–2.40; son OR = 1.51, 95% CI = 1.04–2.19) (both p < .05). Lower concerns about side effects, such as pain and fainting, were also associated with willingness.
Conclusion
Parents and sons were more willing to have the son receive HPV vaccine if they had higher anticipated regret about potential HPV infection and lower concerns about side effects. Communication campaigns may be able to target these beliefs to increase parents’ and sons’ willingness to seek HPV vaccination.

Social Science & Medicine
Volume 140, Pages 1-146 (September 2015)
http://www.sciencedirect.com/science/journal/02779536/140

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Paid maternity leave and childhood vaccination uptake: Longitudinal evidence from 20 low-and-middle-income countries
Original Research Article
Pages 104-117
Mohammad Hajizadeh, Jody Heymann, Erin Strumpf, Sam Harper, Arijit Nandi
Abstract
The availability of maternity leave might remove barriers to improved vaccination coverage by increasing the likelihood that parents are available to bring a child to the clinic for immunizations. Using information from 20 low-and-middle-income countries (LMICs) we estimated the effect of paid maternity leave policies on childhood vaccination uptake. We used birth history data collected via Demographic and Health Surveys (DHS) to assemble a multilevel panel of 258,769 live births in 20 countries from 2001 to 2008; these data were merged with longitudinal information on the number of full-time equivalent (FTE) weeks of paid maternity leave guaranteed by each country. We used Logistic regression models that included country and year fixed effects to estimate the impact of increases in FTE paid maternity leave policies in the prior year on the receipt of the following vaccines: Bacillus Calmette-Guérin (BCG) commonly given at birth, diphtheria, tetanus, and pertussis (DTP, 3 doses) commonly given in clinic visits and Polio (3 doses) given in clinic visits or as part of campaigns. We found that extending the duration of paid maternity leave had a positive effect on immunization rates for all three doses of the DTP vaccine; each additional FTE week of paid maternity leave increased DTP1, 2 and 3 coverage by 1.38 (95% CI = 1.18, 1.57), 1.62 (CI = 1.34, 1.91) and 2.17 (CI = 1.76, 2.58) percentage points, respectively. Estimates were robust to adjustment for birth characteristics, household-level covariates, attendance of skilled health personnel at birth and time-varying country-level covariates. We found no evidence for an effect of maternity leave on the probability of receiving vaccinations for BCG or Polio after adjustment for the above-mentioned covariates. Our findings were consistent with the hypothesis that more generous paid leave policies have the potential to improve DTP immunization coverage. Further work is needed to understand the health effects of paid leave policies in LMICs.

From Google Scholar & other sources: Selected Journal Articles, Newsletters, Dissertations, Theses, Commentary

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Parasitology
FirstView Article
Special Issue Research Article
Pertussis immunity and epidemiology: mode and duration of vaccine-induced immunity
F. M. G. MAGPANTAYa1, M. DOMENECH DE CELLÈSa1, P. ROHANIa1a2a3 and A. A. KINGa1a2a3a4 c1
a1 Department of Ecology and Evolutionary Biology, University of Michigan, Ann Arbor, MI 48109, USA
a2 Center for the Study of Complex Systems, University of Michigan, Ann Arbor, MI 48109, USA
a3 Fogarty International Center, National Institutes of Health, Bethesda, MD 20892, USA
a4 Department of Mathematics, University of Michigan, Ann Arbor, MI 48109, USA
SUMMARY
The resurgence of pertussis in some countries that maintain high vaccination coverage has drawn attention to gaps in our understanding of the epidemiological effects of pertussis vaccines. In particular, major questions surround the nature, degree and durability of vaccine protection. To address these questions, we used mechanistic transmission models to examine regional time series incidence data from Italy in the period immediately following the introduction of acellular pertussis (aP) vaccine. Our results concur with recent animal-challenge experiments wherein infections in aP-vaccinated individuals proved as transmissible as those in naive individuals but much less symptomatic. On the other hand, the data provide evidence for vaccine-driven reduction in susceptibility, which we quantify via a synthetic measure of vaccine impact. As to the precise nature of vaccine failure, the data do not allow us to distinguish between leakiness and waning of vaccine immunity, or some combination of these. Across the range of well-supported models, the nature and duration of vaccine protection, the age profile of incidence and the range of projected epidemiological futures differ substantially, underscoring the importance of the remaining unknowns. We identify key data gaps: sources of data that can supply the information needed to eliminate these remaining uncertainties.
Thesis
Factors Associated with Willingness to the Human Papillomavirus (HPV) Vaccine Adoption among Unmarried Women in Taiwan
TI Liu –
2015-07-23
Abstract
Cervical cancer is both the ten most common cause of cancer and the three most common cause of death from cancer in women. Cervical cancer is mainly caused by the virus called Human Papillomavirus (HPV). The virus spread through sexual contact. Treatment of cervical cancer not only affects the health of the patience herself but also put great financial and mental burden on the members in the family. The medical expenditure on cervical cancer is quite high. The early stage cervical cancer it is a high cure rate cancer. The main policy of government to prevent the cervical cancer now is by promoting female citizens to do Papanicolaou test (Pap smear) regularly and to take the HPV vaccine. However, Pap smear now is facing a difficulty to raise the screen rate, and Pap smear result sometimes has false result or human error in it and cause the delay of best treatment time. Therefore, prevention of Human Papillomavirus (HPV) by vaccine is far more important.

Considering the importance of taking HPV vaccine to prevent the cervical cancer, this study does sampling from the latest research: Family and Fertility (2008, 10th), Population of Health and Research Center, Health Promotion Administration, Ministry of Health and Welfare. This study use STATA to do the regression analysis by Probit model and Marginal effect. Dependent variables are the willingness of unmarried women to take the HPV vaccine and the willingness of married women to encourage the age 9-26 unmarried female family member to take HPV vaccine. Independent variables are social-economic status, health status, health behavior, health knowledge, and the frequency of using knowledge communication channels. The purpose of this study is to analysis the factors that influence the willingness of unmarried women to take HPV vaccine and also analysis the factors that influence the willingness of married women to encourage the age 9-26 unmarried female family member to take HPV vaccine.

The result of this study shows a high correlation: the willingness of unmarried women to take HPV vaccine is highly related to the education status of interviewee, the family’s economic status of interviewee, BMI of interviewee, and if the interviewee ever heard of Human Papillomavirus (HPV) vaccine. Furthermore, the factors that influence the willingness of married women to encourage the age 9-26 unmarried female family member to take HPV vaccine are closely related to the family’s economic status, the inhabited area of the married woman lived before 12 years old, the smoking habit of married woman, and if the married woman ever heard of Human Papillomavirus ( HPV). The empirical result of this study could be a reference for the government when drafting the health care and medical service strategy, and also this result could be a basis for promoting HPV vaccine by the department concerned.
Expert Review of Vaccines
Efficacy and effectiveness of live attenuated influenza vaccine in school-age children
Kathleen Coelingh*a, Ifedapo Rosemary Olajideb, Peter MacDonalda & Ram Yogevc
DOI:10.1586/14760584.2015.1078732
Published online: 07 Sep 2015
Abstract
Evidence of high efficacy of live attenuated influenza vaccine (LAIV) from randomized controlled trials is strong for children 2–6 years of age, but fewer data exist for older school-age children. We reviewed the published data on efficacy and effectiveness of LAIV in children ≥5 years. QUOSA (Elsevier database) was searched for articles published from January 1990 to June 2014 that included ‘FluMist’, ‘LAIV’, ‘CAIV’, ‘cold adapted influenza vaccine’, ‘live attenuated influenza vaccine’, ‘live attenuated cold adapted’ or ‘flu mist’. Studies evaluated included randomized controlled trials, effectiveness and indirect protection studies. This review demonstrates that LAIV has considerable efficacy and effectiveness in school-age children.

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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Brookings
http://www.brookings.edu/
Accessed 12 September 2015
The promise and pitfalls of partnerships in tackling extreme poverty around the world
Homi Kharas | September 10, 2015
Yesterday, Erik Solheim, chairman of the OECD’s Development Assistance Committee, summarized the moral case for international development cooperation by paraphrasing Abraham Lincoln’s remark that “If slavery is not wrong, then nothing is wrong.” Solheim, in a modernized version, challenged the audience to ask “If the presence of extreme poverty in the world today is not wrong, then what is?” This provided the backdrop to a discussion of how to implement the sustainable development goals and, in particular, the first goal on ending extreme poverty.

The venue was Brookings, where I was moderating a discussion and Solheim was launching the OECD’s 2015 Development Cooperation Report. In discussing the report’s findings, Solheim highlighted the significant potential for partnerships as coalitions for action. He underlined the progress that partnerships have already made, citing 7 million lives saved as a result of just one vaccination and immunization partnership.

Partnerships are an intriguing new tool for driving progress in the developing world. They are a hybrid between unilateralism and multilateralism. In today’s world, no actor, even one as large and powerful as the United States, can be successful if acting on its own…

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_5 September 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 5 September 2015]
Public Health Emergency of International Concern (PHEIC); “Threat to international peace and security” (UN Security Council)

Ebola Situation Report – 2 September 2015
[Excerpts]
SUMMARY
:: There were 3 confirmed cases of Ebola virus disease (EVD) reported in the week to 30 August: 2 in Guinea and 1 in Sierra Leone. The case in Sierra Leone is the first in the country for over 2 weeks. Overall case incidence has remained stable at 3 confirmed cases per week for 5 consecutive weeks…

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Ebola transmission in Liberia over. Nation enters 90-day intensive surveillance period
WHO statement
3 September 2015
Today, 3 September 2015, WHO declares Liberia free of Ebola virus transmission in the human population. Forty-two days have passed since the second negative test on 22 July 2015 of the last laboratory-confirmed case. Liberia now enters a 90-day period of heightened surveillance…

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Guinea Ring Vaccination trial extended to Sierra Leone to vaccinate contacts of new Ebola case
Freetown, Sierra Leone – 31 August 2015: Detection of a new case of Ebola virus disease in Kambia, Sierra Leone after the country had marked almost three weeks of zero cases has set in motion the first ‘ring vaccination’ use of the experimental Ebola vaccine in Sierra Leone.

A team of experts in ring vaccination has travelled from Conakry, Guinea to join a large WHO and Ministry of Health team already in the district where the new case has been reported. The source of the Ebola virus transmission is being investigated and all the people who may have been in contact with the infected person are being traced.

“Although no-one wanted to see more cases of Ebola virus disease in Sierra Leone, we kept all our teams on alert and ready to respond and close down any new transmission” said Dr Anders Nordstrom, WHO Representative in Sierra Leone.

Heightened surveillance for Ebola virus disease in Sierra Leone includes swabbing all people who have died at home and testing those swabs for Ebola virus. On Saturday, 29th August, a swab taken from a woman who died aged around 60, in the village of Sella, Tonko Limba, Kambia district, tested positive for Ebola virus.

Members of the team currently conducting the ring vaccination trial in Guinea, drove from Conakry in Guinea to Kambia, Sierra Leone on Sunday to begin work.
The Guinea team were met in Kambia by another team from Freetown, who had been trained and prepared last week by WHO in order to be ready should there be any new Ebola virus infections in Sierra Leone.

The Guinea ring vaccination trial is a Phase III efficacy trial of the VSV-EBOV vaccine (Merck, Sharp & Dohme) which is being conducted by WHO and partners*. Interim results published last July show that this vaccine is highly effective against Ebola. The ‘ring vaccination’ strategy involves vaccinating all contacts -the people known to have come into contact with a person confirmed to have been infected with Ebola (a ‘case’) – and contacts of contacts.

Following publication of those results, the Sierra Leone government requested that the trial be extended to Sierra Leone. The WHO Sierra Leone country office immediately sent a team to Guinea to organize this, ensuring that all the correct procedures and protocols are followed. WHO and partners then trained 18 Sierra Leonean health care workers on implementation of the study protocol.

“The training was done to ensure teams are ready to rapidly perform ring vaccination should there be new confirmed cases of Ebola in Sierra Leone,” said Dr Margaret Lamunu, WHO technical co-ordinator of the Ebola response in Sierra Leone, who is managing the extension of the ring vaccination trial in Sierra Leone.

*Partners in the Guinea Ebola vaccine trial
The Guinea Ebola vaccine trial is the coordinated effort of many international agencies. WHO is the regulatory sponsor of the study, which is implemented by the Ministry of Health of Guinea, WHO, Médecins sans Frontières (MSF), EPICENTRE and the Norwegian Institute of Public Health. In Sierra Leone, the trial is being implemented by the Ministry of Health and WHO with the Guinea Ebola vaccine trial team.

The trial is funded by WHO, with support from the Wellcome Trust, the United Kingdom Department for International Development, the Norwegian Ministry of Foreign Affairs to the Norwegian Institute of Public Health through the Research Council of Norway, the Canadian Government through the Public Health Agency of Canada, Canadian Institutes of Health Research, International Development Research Centre and Department of Foreign Affairs, Trade and Development and MSF.
The trial team includes experts from The University of Bern, the University of Florida, the London School of Hygiene and Tropical Medicine, Public Health England, the European Mobile Laboratories among others.

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Sierra Leone village in quarantine after Ebola death
BBC 4 September 2015
Nearly 1,000 people in Sierra Leone have been put under quarantine following the death of a 67-year-old woman who tested positive for Ebola

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WHO Director-General addresses Institute of Medicine Ebola workshop
1 September 2015

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WHO: Ebola features map update
August 2015 — This interactive timeline highlights the events of the Ebola outbreak in West Africa. The timeline links to stories of the people who responded, the people who survived and the communities who stood up and faced this disease.

POLIO [to 5 September 2015]
Public Health Emergency of International Concern (PHEIC)

GPEI Update: Polio this week – As of 2 September 2015
Global Polio Eradication Initiative
[Editor’s Excerpt and text bolding]
Full report: http://www.polioeradication.org/Dataandmonitoring/Poliothisweek.aspx
:: In Ukraine, a circulating vaccine-derived poliovirus type 1 (cVDPV1) outbreak has been confirmed. Two cases have been confirmed, with dates of onset of paralysis of 30 June and 7 July. The genetic similarity between the cases indicates active transmission of cVDPV1. Both are from the Zakarpatskaya oblast, in south-western Ukraine, bordering Romania, Hungary, Slovakia and Poland. Ukraine had been at particular risk of emergence of a cVDPV, due to inadequate vaccination coverage. In 2014, only 50% of children were fully immunized against polio and other vaccine-preventable diseases. Discussions are currently ongoing with national health authorities to plan and implement an urgent outbreak response. More [see full text below]
Pakistan
:: Three new environmental samples positive for WPV1 were reported this week: in DI Khan, Khyber Pakhtunkhwa (KP), collected on 4 August; in Sukkur, Sindh, collected on 10 August; and in Khi Gulshan-e-Iqbal, Sindh, collected on 12 August.
:: Environmental surveillance allows detection of continuing circulation of polioviruses, not just in known infected areas but also in areas without confirmed polio cases. Environmental surveillance continues to be a very helpful supplemental surveillance tool enabling the programme to increase the overall sensitivity of surveillance for polioviruses.

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Circulating vaccine-derived poliovirus confirmed in Ukraine
Emergency outbreak response being planned
Tuesday, September 01, 2015
In Ukraine, 2 cases of circulating vaccine-derived poliovirus type 1 (cVDPV1) have been confirmed, with dates of onset of paralysis of 30 June and 7 July 2015. The genetic similarity between the cases indicates active transmission of cVDPV1. Both are from the Zakarpatskaya oblast, in south-western Ukraine, bordering Romania, Hungary, Slovakia and Poland. One child was 4 years old and the other 10 months old at the time of onset of paralysis.

Ukraine had been at particular risk of emergence of a cVDPV, due to inadequate vaccination coverage. In 2014, only 50% of children were fully immunized against polio and other vaccine-preventable diseases.

Discussions are currently ongoing with national health authorities to plan and implement an urgent outbreak response. An outbreak response of internationally-agreed standard, as adopted by the World Health Assembly in May 2015, requires a minimum of three large-scale supplementary immunization activities with an appropriate oral polio vaccine, to begin within two weeks of confirmation of the outbreak and covering a target population of 2 million children aged less than five years, and the public declaration of the outbreak as a national public health emergency.

Circulating VDPVs are rare but well-documented strains of poliovirus that can emerge in some populations which are inadequately immunized. A robust outbreak response can rapidly stop such events. The emergence of cVDPV strains underscores the importance of maintaining high levels of routine vaccination coverage.

It is important that all countries, in particular those with frequent travel and contacts with polio-affected countries and areas, strengthen surveillance for AFP cases in order to rapidly detect any new virus importation or emergence and to facilitate a rapid response. Countries should also maintain uniformly high routine immunization coverage at the district level to minimize the consequences of any new virus introduction.

WHO’s International Travel and Health recommends that all travelers to polio-affected areas be fully vaccinated against polio. Residents (and visitors for more than 4 weeks) from infected areas should receive an additional dose of OPV or inactivated polio vaccine (IPV) within 4 weeks to 12 months of travel.

MERS-CoV [to 5 September 2015]
Global Alert and Response (GAR) – Disease Outbreak News (DONs)
:: 2 September 2015 – Middle East Respiratory Syndrome coronavirus (MERS-CoV) – Saudi Arabia
:: 1 September 2015 – Middle East Respiratory Syndrome coronavirus (MERS-CoV) – Jordan

WHO: Middle East respiratory syndrome (MERS) and the Hajj
September 2015 — The International Health Regulations (2005) Emergency Committee regarding the Middle East respiratory syndrome (MERS) noted that progress to control the virus is not yet sufficient and until this is achieved, the world will remain at significant risk for further outbreaks. The current outbreak is also occurring near the start of the Hajj and many pilgrims will return to countries with weak surveillance and health systems.

WHO: Considerations for mass gathering events and Middle East respiratory syndrome coronavirus (MERS – CoV)
September 2015 — In anticipation of the Hajj, which will start shortly, this interim guidance document presents organizers of international mass gatherings with proposed steps to improve public health preparedness to prevent, contain, and mitigate the impact of Middle East respiratory syndrome coronavirus (MERS-CoV).

WHO & Regionals [to 5 September 2015]

Population movement is a challenge for refugees and migrants as well as for the receiving population
02-09-2015
Statement by Dr Zsuzsanna Jakab, WHO Regional Director for Europe
The large influx of refugees and migrants to countries of the WHO European Region, which has escalated in the past few months, calls for an urgent response to their health needs. Actions are needed between and within countries as well as among sectors….

Refugees and migrants are not a homogeneous group, and we must ensure that our care systems respond to their diverse needs. This is particularly relevant for refugees and migrants who are exposed to violence, including gender-based violence, sexual violence and forced prostitution. It is also relevant for sexual reproductive health and rights, mother and child health, diabetes, cardiovascular diseases, mental health, emergency care and protection against vaccine-preventable diseases.

A good response to the challenges of people on the move requires health system preparedness and capacity, including robust epidemiological data and migration intelligence, careful planning, training and, above all, adherence to the principles of equity and solidarity and to human rights and dignity.

High-quality care for refugee and migrant groups cannot be addressed by health systems alone. Social determinants of health cut across sectors such as education, employment, social security and housing. All these sectors have a considerable impact on the health of refugees and migrants.

Health issues related to population movement have been on the WHO agenda for many years, especially in the European Region. We must ensure that our health systems are adequately prepared to provide aid to refugees and migrants while at the same time protecting the health of the resident population. This requires cooperation among the countries of origin, transit and destination.

The WHO Regional Office for Europe is providing technical and on-site assistance to affected countries, with assessment of and support to their capacity to address the health needs of refugees and migrants. In addition, the Regional Office is providing policy advice on contingency planning, training of health personnel and delivery of emergency kits, each covering the needs of a population of 10 000 for 3 months.

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World Hepatitis Summit harnesses global momentum to eliminate viral hepatitis
WHO News release
2 September 2015 ¦ GLASGOW – Participants at the first-ever World Hepatitis Summit will urge countries to develop national programmes that can ultimately eliminate viral hepatitis as a problem of public health concern.

“We know how to prevent viral hepatitis, we have a safe and effective vaccine for hepatitis B, and we now have medicines that can cure people with hepatitis C and control hepatitis B infection,” said Dr Gottfried Hirnschall, Director of the WHO’s Global Hepatitis Programme. “Yet access to diagnosis and treatment is still lacking or inaccessible in many parts of the world. This summit is a wake-up call to build momentum to prevent, diagnose, treat – and eventually eliminate viral hepatitis as a public health problem.”

Around 400 million people are currently living with viral hepatitis, and the disease claims an estimated 1.45 million lives each year, making it one of the world’s leading causes of death. Hepatitis B and C together cause approximately 80% of all liver cancer deaths, yet most people living with chronic viral hepatitis are unaware of their infection.

The summit, co-sponsored by WHO and the World Hepatitis Alliance, and hosted in Glasgow by the Scottish Government this week, is the first high-level global meeting to focus specifically on hepatitis, attracting delegates from more than 60 countries. The aim is to help countries enhance action to prevent viral hepatitis infection and ensure that people who are infected are diagnosed and offered treatment…

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The Weekly Epidemiological Record (WER) 4 September 2015, vol. 90, 36 (pp. 461–476) includes:
…Global leprosy update, 2014: need for early case detection
…Seasonal influenza vaccine composition for tropical and subtropical countries: WHO Expert group meeting, 23–24 April 2015

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GIN August 2015 pdf, 1.32Mb
4 September 2015

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WHO Fact Sheets:
Immunization coverage
Fact sheet N°378
Updated September 2015
Key facts
:: Immunization prevents illness, disability and death from vaccine-preventable diseases including cervical cancer, diphtheria, hepatitis B, measles, mumps, pertussis (whooping cough), pneumonia, polio, rotavirus diarrhoea, rubella and tetanus.
:: Global vaccination coverage is generally holding steady.
:: Uptake of new and underused vaccines is increasing.
:: Immunization currently averts an estimated 2 to 3 million deaths every year.
:: But an estimated 18.7 million infants worldwide are still missing out on basic vaccines.

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:: WHO Regional Offices
WHO African Region AFRO
:: Ebola transmission in Liberia over. Nation enters 90-day intensive surveillance period
3 September 2015
:: Message of Dr Matshidiso Moeti, WHO Regional Director for Africa, on the occasion of Women’s Health Day 2015
On 4 September 2015 we commemorate Women’s Health Day in the African Region under the theme: “Women’s Health in the Context of Humanitarian Emergencies”.
This year’s theme is especially pertinent in the African Region as it continues to be challenged by a multitude of humanitarian crises, notably: religious, political, and ethnic conflicts, natural disasters, and large-scale outbreaks and epidemics.
These crises frequently cause injuries, deaths, population displacements, destruction of health facilities and disruption of health care services. Statistics show that women are the most impacted or affected in the majority of these situations…

WHO Region of the Americas PAHO
:: PAHO, OAS and ECLAC call on countries of the Americas to support convention to protect the rights of older adults (09/03/2015)
:: Countries of the Americas explore mechanisms to improve access to strategic and high-cost medicines (09/02/2015)
:: Ultra-processed foods are driving the obesity epidemic in Latin America, says new PAHO/WHO report (09/01/2015)

WHO South-East Asia Region SEARO
:: Ministers from South-East Asia meet in Dili to set health priorities
01 September 2015

WHO European Region EURO
:: Population movement is a challenge for refugees and migrants as well as for the receiving population 02-09-2015
:: Circulating vaccine-derived poliovirus type 1 confirmed in Ukraine 01-09-2015

WHO Eastern Mediterranean Region EMRO
:: WHO establishes mobile nutrition clinics in Aden, Lahj and Hadramout [Yemen]
Sana’a, 31 August 2015 — WHO and the Field Medical Foundation have set up mobile nutrition clinics to diagnose and treat children between 6 months and 5 years in Aden, Lahj and Hadramout. Ongoing conflict, disruption of health services and lack of safe water have worsened the general nutritional status of children and the population in Yemen. The clinics will operate for 5 months targeting around 23 000 children, in addition to providing services for mothers and pregnant women…

WHO Western Pacific Region
No new digest content identified

CDC/MMWR/ACIP Watch [to 5 September 2015]
http://www.cdc.gov/media/index.html

Liberia Travel Alert Revised from Level 2 to Level 1: “Practice Usual Precautions”
Effective Sept. 3, 2015, CDC has downgraded the travel notice for Ebola in Liberia to a Watch Level 1, which means CDC recommends U.S. residents practice usual precautions when traveling to Liberia. Travel notices are designed to inform travelers and clinicians about current health issues related to specific destinations.
September 2, 2015, marks 42 days (two 21-day incubation periods) after the release of the last survivor of Ebola from a Liberian Ebola treatment unit (ETU). On Sept. 3, the World Health Organization declared that Liberia was free of Ebola virus transmission. There is a very low risk of Ebola transmission in Liberia and a very low risk of Ebola importation. Although the risk of Ebola is low, travelers should, as usual, avoid contact with sick people, animals, undercooked meat, bush meat, dead bodies, blood and body fluids.
CDC is closely monitoring the situation and will update information and advice for travelers as needed.

MMWR September 4, 2015 / Vol. 64 / No. 34
:: Intervals Between PCV13 and PPSV23 Vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP)
:: Licensure of a Diphtheria and Tetanus Toxoids and Acellular Pertussis Adsorbed and Inactivated Poliovirus Vaccine and Guidance for Use as a Booster Dose
:: Announcements: Recommendations Regarding Interventions to Increase Appropriate Vaccination — Community Preventive Services Task Force

DCVMN Members committed to boost global access to high-quality vaccines
31 August 2015
Geneva  – DCVMN Member companies have reached an understanding to cooperate in an effort to increase and maintain the number of WHO prequalified vaccines available for international procurement, and to achieve a more sustainable and secure supply of priority vaccines, as identified by global health agencies such as WHO, UNICEF and Gavi, the Vaccine Alliance. All corporate members are invited to join the effort.

The agreements highlight the principles of Global Access to ensure the development, manufacture and delivery of vaccines available and accessible in terms of quality, quantity and affordability to people in need in the developing world. For that purpose DCVNM members committed to Global Access to vaccines through a Memorandum of Understanding – between DCVMN and Member Companies – that provides a mechanism through which they can work together at both a strategic level and a specific project level.

DCVMN Member Companies share the common goal of protecting people from infectious diseases, by accelerating access to affordable high-quality vaccines: “Our focus is twofold: high-quality vaccines for all people and dialogue with stakeholders, to assist manufacturers in getting the knowledge, tools and skills required to attain and maintain WHO prequalification status giving access to priority vaccines”, emphasized Mahendra Suhardono, President of the Network.

DCVMN Member companies [1] that committed to Global Access to Vaccines through a signed MOU to date include:
Arabio Co.
Beijing Minhai Biotechnology Co. Ltd
Bharat Biotech International Ltd
Bio Farma PT
Biological E Ltd
Bio-Manguinhos Fiocruz
BioNet-Asia Co. Ltd
Biovac Institute
BravoVax Co. Ltd
Butantan Institute
Cadila Biopharmaceuticals
Changchun BCHT Biotechnology Co.
China National Biotec Group Company Ltd
EuBiologics Co. Ltd
Finlay Instituto
Fundacao Ataulpho De Paiva
Incepta Vaccine Ltd
Laboratorios de Biologicos y Reactivos de Mexico S.A de C.V
LG Life Sciences
Liaoning ChengDa Biotechnology Co. Ltd (CDBIO)
Medigen Vaccinology Corporation
Panacea Biotec Ltd
Pasteur Institute of Iran
Polyvac
Razi Vacccine & Serum Research Institute
Serum Institute of India Ltd (Poonawalla Group)
Sinergium Biotech
Sk Chemicals
Thai Red Cross Society- Queen Saovabha Memorial Institute
The National Insitute of Infectious Diseases and Vaccinology (NIIDV)
The Institute of Medical Biology, Chinese Academy of Medical Sciences (IMBCAMS)
Tiantian Bio
Vabiotech
Vacsera
VINS Bioproducts Ltd
Walvax Biotechnology Co. Ltd
Xiamen Innovax Biotech Co. Ltd

IVI [to 5 September 2015]
http://www.ivi.org/web/www/home

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IVI Initiates MERS Vaccine Research and Development
:: IVI to launch MERS vaccine development project with donation from Samsung
:: Institute to host International MERS Symposium on September 10, convening leading scientists and experts in public health, infectious diseases and vaccine development

The International Vaccine Institute (IVI) will embark on vaccine research initiatives on Middle East Respiratory Syndrome (MERS), a viral respiratory illness caused by the Middle East Respiratory Syndrome Coronavirus (MERS-CoV).

First detected in 2012 in Saudi Arabia, MERS-CoV has been reported in several countries, causing 1,478 cases and 516 deaths globally. It was responsible for a recent outbreak in South Korea with 185 cases and 36 deaths reported. Relatively little is known about the disease and researchers are still trying to understand MERS-CoV. There is currently no vaccine or antiretroviral treatment for MERS-CoV infection.

The Institute will launch a project to accelerate the research and development of MERS vaccines. Samsung Medical Center announced on September 2 that it would donate 41 billion Korean won (34 million USD) over five years to IVI to develop MERS vaccines. The funding will be used to identify the most promising vaccines currently ready for testing and to begin human studies as quickly and safely as possible. IVI is in the process of discussion and partnering with groups that have data suggesting protection in animal models and anticipates = an initial set of collaborators to be assembled shortly.

“We are extremely grateful to Samsung for their very generous contribution,” said Dr. Jerome Kim, IVI’s Director General, “Thanks to Samsung, we will be able to harness the best resources and capabilities in Korea and internationally to develop new, safe and effective MERS vaccines.”…

Global Fund [to 5 September 2015]
http://www.theglobalfund.org/en/mediacenter/newsreleases/

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Partnership Forum Discusses Strategy for New Era
03 September 2015
BUENOS AIRES – Partners in global health began discussions today aimed at shaping a new strategy for the Global Fund partnership to accelerate the end of AIDS, tuberculosis and malaria as epidemics and to build resilient and sustainable systems for health.

The Partnership Forum brought together more than 110 participants from communities affected by the diseases, civil society, nongovernmental organizations, governments, technical partners and the private sector to a two-day gathering to influence the development of the Global Fund’s new strategy

Dr. J. Donald Millar, 81, Dies; Led C.D.C. Mission That Helped Eradicate Smallpox
New York Times, SEPT. 3, 2015
By MARGALIT FOX
Dr. J. Donald Millar, a physician and former public-health official whose work helped eradicate smallpox in Africa and with it, the world, died on Sunday at his home in Murrayville, Ga. He was 81. The apparent cause was kidney failure, his wife, Joan, said.

A retired assistant surgeon general of the United States Public Health Service, Dr. Millar (pronounced mil-LAHR) was long associated with what is now the Centers for Disease Control and Prevention. He was the first director of its global smallpox eradication program, a position he held from 1966 to 1970.

Dr. Millar was later a director of the National Institute for Occupational Safety and Health.

The last case of smallpox in the United States occurred in 1949, but when Dr. Millar assumed his post, the disease remained an urgent international health concern: From 1880 to 1980, it killed a half-billion people worldwide.

The C.D.C. (known in the late 1960s as the National Communicable Disease Center) began its overseas eradication campaign in West and Central Africa. From the center’s offices in Atlanta, Dr. Millar oversaw the training, deployment and support of dozens of health workers in some 20 countries there. Many, like Sierra Leone, Guinea, Niger and Togo, then had some of the highest rates of smallpox in the world.

Operating under the aegis of the World Health Organization, Dr. Millar’s program focused on locations, like marketplaces and festival sites, where inhabitants of remote rural settlements came together in large numbers. There, local workers trained by his staff gave smallpox vaccinations to as many people as possible.

Eventually, some 4,000 Africans were trained to administer the vaccine. By 1969, The New York Times reported, Dr. Millar’s program had vaccinated 100 million people in the region.

“This was considered to be the most difficult area of the world, because of communications and transportation and so forth,” Dr. William H. Foege, a former director of the C.D.C. who in the 1960s worked under Dr. Millar in Nigeria, said on Thursday. “The objective was to stop smallpox within five years, and the goal was actually reached in three and a half years.”

The Africa program became a model for smallpox eradication campaigns in other countries, among them India, Pakistan, Bangladesh, Afghanistan and Brazil…

Post-2015 Summit to chart a new era for sustainable development
United Nations Department of Economic and Social Affairs
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25 Aug 2015 – More than 150 world leaders are expected to attend the UN Sustainable Development Summit from September 25-27 at UN headquarters in New York to formally adopt an ambitious new sustainable development agenda. Secretary-General Ban Ki-moon has said that the summit “will chart a new era of sustainable development in which poverty will be eradicated, prosperity shared and the core drivers of climate change tackled”.

The Summit will be the climax of a negotiating process that has spanned more than two years, involved all 193 member states of the United Nations and has featured the unprecedented participation of major groups of society and other stakeholders. On 2 August 2015, Member States reached agreement on the outcome document for the summit with the title ‘Transforming our world: the 2030 Agenda for Sustainable Development’, which includes 17 new sustainable development goals.

The Secretary-General said that this agreement, to be formally adopted at the summit, “encompasses a universal, transformative and integrated agenda that heralds an historic turning point for our world. This is the people’s agenda, a plan of action for ending poverty in all its dimensions, irreversibly, everywhere and leaving no one behind. It seeks to ensure peace and prosperity and forge partnerships with people and planet at the core. The integrated, interlinked and indivisible 17 sustainable development goals are the people’s goals and demonstrate the scale, universality and ambition of this new agenda.”

Six interactive dialogues
The Summit will feature six interactive dialogues with the following themes: Ending poverty and hunger; Tackling inequalities, empowering women and girls and leaving no one behind; Fostering sustainable economic growth, transformation and promoting sustainable consumption and production; Protecting our planet and combatting climate change; Building effective, accountable and inclusive institutions to achieve sustainable development; Delivering on a revitalised Global Partnership.

It is envisaged that each dialogue will address the three dimensions of sustainable development. There will also be scope to address in each dialogue issues such as gender equality and the empowerment of women and girls, prioritising the needs of all vulnerable groups including children, older persons, persons with disabilities, indigenous peoples and migrants and ensuring implementation at all levels.

Core Elements of the new sustainable development agenda
The new sustainable development agenda to be adopted in September highlights poverty eradication as the overarching goal of the new agenda and has at its core the integration of the economic, social and environmental dimensions of sustainable development. The emerging agenda is unique in that it calls for action by all countries, poor, rich and middle-income.

Member States pledge that as they embark on this collective journey, no one will be left behind. The “five Ps” — people, planet, prosperity, peace and partnership — capture the broad scope of the agenda.

The 17 goals and 169 targets aim at tackling key systemic barriers to sustainable development such as inequality, unsustainable consumption and production patterns, inadequate infrastructure and lack of decent jobs.

The means of implementation outlined in the outcome document match its ambitious goals and focus on finance, technology and capacity development. In addition to a stand-alone goal on the means of implementation for the new agenda, specific means are tailored to each of the goals.

Member States stressed that the desired transformations will require a departure from “business as usual” and that intensified international cooperation on many fronts will be needed. The agenda calls for a revitalized, global partnership for sustainable development, including for multi-stakeholder partnerships. It also calls for increased capacity-building and better data and statistics to measure sustainable development.

An effective follow-up and review architecture — a core element of the outcome document — will be critical to support the implementation of the new agenda. The High Level Political Forum on Sustainable Development, set up after the Rio+20 Conference, will serve as the apex for follow-up and review and will thus play a central role. The General Assembly, the Economic and Social Council and specialized agencies will also be engaged in reviewing progress in specific areas.

Based on the outcome document, the agenda will include a Technology Facilitation Mechanism to support the new goals, based on multi-stakeholder collaboration between Member States, civil society, business, the scientific community and the United Nations system of agencies. The Mechanism, which was agreed at the Addis Conference in July, will have an inter-agency task team, a forum on science, technology and innovation and an online platform for collaboration.

American Journal of Tropical Medicine and Hygiene
September 2015; 93 (3)
http://www.ajtmh.org/content/current

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Perspective Piece
Ebola Virus Disease: Rapid Diagnosis and Timely Case Reporting are Critical to the Early Response for Outbreak Control
Lola V. Stamm
Am J Trop Med Hyg 2015 93:438-440; Published online July 14, 2015, doi:10.4269/ajtmh.15-0229

Articles
A Phase II, Randomized, Safety and Immunogenicity Trial of a Re-Derived, Live-Attenuated Dengue Virus Vaccine in Healthy Children and Adults Living in Puerto Rico
Kristen Bauer, Ines O. Esquilin, Alberto Santiago Cornier, Stephen J. Thomas, Ana I. Quintero del Rio, Jorge Bertran-Pasarell, Javier O. Morales Ramirez, Clemente Diaz, Simon Carlo, Kenneth H. Eckels, Elodie Tournay, Jean-Francois Toussaint, Rafael De La Barrera, Stefan Fernandez, Arthur Lyons, Wellington Sun, and Bruce L. Innis
Am J Trop Med Hyg 2015 93:441-453; Published online July 14, 2015, doi:10.4269/ajtmh.14-0625
OPEN ACCESS ARTICLE
Abstract
This was a double-blind, randomized, controlled, phase II clinical trial, two dose study of re-derived, live-attenuated, tetravalent dengue virus (TDEN) vaccine (two formulations) or placebo in subjects 1–50 years of age. Among the 636 subjects enrolled, 331 (52%) were primed, that is, baseline seropositive to at least one dengue virus (DENV) type. Baseline seropositivity prevalence increased with age (10% [< 2 years], 26% [2–4 years], 60% [5–20 years], and 93% [21–50 years]). Safety profiles of TDEN vaccines were similar to placebo regardless of priming status. No vaccine-related serious adverse events (SAEs) were reported. Among unprimed subjects, immunogenicity (geometric mean antibody titers [GMT] and seropositivity rates) for each DENV increased substantially in both TDEN vaccine groups with at least 74.6% seropositive for four DENV types. The TDEN vaccine candidate showed an acceptable safety and immunogenicity profile in children and adults ranging from 1 to 50 years of age, regardless of priming status. ClinicalTrials.gov: NCT00468858.

Safety and Immunogenicity of a Dengue Virus Serotype-1 Purified-Inactivated Vaccine: Results of a Phase 1 Clinical Trial
Luis Javier Martinez, Leyi Lin, Jason M. Blaylock, Arthur G. Lyons, Kristen M. Bauer, Rafael De La Barrera, Monika Simmons, Richard G. Jarman, Jeffrey R. Currier, Heather Friberg, Janine R. Danko, Nimfa C. Teneza-Mora, J. Robert Putnak, Kenneth H. Eckels, and Stephen J. Thomas
Am J Trop Med Hyg 2015 93:454-460; Published online July 6, 2015, doi:10.4269/ajtmh.14-0819
OPEN ACCESS ARTICLE

A Randomized, Placebo-Controlled Trial Evaluating Safety and Immunogenicity of the Killed, Bivalent, Whole-Cell Oral Cholera Vaccine in Ethiopia
Sachin N. Desai, Zenebe Akalu, Samuel Teshome, Mekonnen Teferi, Lawrence Yamuah,
Jae Seung Yang, Jemal Hussein, Ju Yeong Park, Mi Seon Jang, Chalachew Mesganaw, Hawult Taye, Demissew Beyene, Ahmed Bedru, Ajit Pal Singh, Thomas F. Wierzba, and Abraham Aseffa
Am J Trop Med Hyg 2015 93:527-533; Published online June 15, 2015, doi:10.4269/ajtmh.14-
OPEN ACCESS ARTICLE
Abstract.
Killed whole-cell oral cholera vaccine (OCV) has been a key component of a comprehensive package including water and sanitation measures for recent cholera epidemics. The vaccine, given in a two-dose regimen, has been evaluated in a large number of human volunteers in India, Vietnam, and Bangladesh, where it has demonstrated safety, immunogenicity, and clinical efficacy. We conducted a double-blind randomized placebo-controlled trial in Ethiopia, where we evaluated the safety and immunogenicity of the vaccine in 216 healthy adults and children. OCV was found to be safe and elicited a robust immunological response against Vibrio cholerae O1, with 81% adults and 77% children demonstrating seroconversion 14 days after the second dose of vaccine. This is the first study to evaluate safety and immunogenicity of the vaccine in a population outside Asia using a placebo-controlled, double-blind, randomized study design.

Multinational Disease Surveillance Programs: Promoting Global Information Exchange for Infectious Diseases
Aiden K. Varan, Robson Bruniera-Oliveira, Christopher R. Peter, Maureen Fonseca-Ford, and Stephen H. Waterman
Am J Trop Med Hyg 2015 93:668-671; Published online June 1, 2015, doi:10.4269/ajtmh.15-0097
Abstract.
Cross-border surveillance for emerging diseases such as Ebola and other infectious diseases requires effective international collaboration. We surveyed representatives from 12 multinational disease surveillance programs between January 2013 and April 2014. Our survey identified programmatic similarities despite variation in health priorities, geography, and socioeconomic context, providing a contemporary perspective on infectious disease surveillance networks.

Annals of Internal Medicine
1 September 2015, Vol. 163. No. 5
http://annals.org/issue.aspx

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Original Research | 1 September 2015
Pragmatic Randomized Trials Without Standard Informed Consent?: A National Survey
Rahul K. Nayak, BSE; David Wendler, PhD; Franklin G. Miller, PhD; and Scott Y.H. Kim, MD, PhD
Ann Intern Med. 2015;163(5):356-364. doi:10.7326/M15-0817
Abstract
Background: Significant debate surrounds the issue of whether written consent is necessary for pragmatic randomized, controlled trials (RCTs) with low risk.
Objective: To assess the U.S. public’s views on alternatives to written consent for low-risk pragmatic RCTs.
Design: National experimental survey (2 × 2 factorial design) examining support for written consent versus general notification or verbal consent in 2 research scenarios.
Setting: Web-based survey conducted in December 2014.
Participants: 2130 U.S. adults sampled from a nationally representative, probability-based online panel (response rate, 64.0%).
Measurements: Respondent’s recommendation to an ethics review board and personal preference as a potential participant on how to obtain consent or notification in the 2 research scenarios.
Results: Most respondents in each of the 4 groups (range, 60.3% to 71.5%) recommended written informed consent, and personal preferences were generally in accord with that advice. Most (78.9%) believed that the pragmatic RCTs did not pose additional risks, but 62.5% of these respondents would still recommend written consent. In contrast, a substantial minority in all groups (28.5% to 39.7%) recommended the alternative option (general notification or verbal consent) over written consent.
Limitation: Framing effects could have affected respondents’ attitudes, and nonrespondents may have differed in levels of trust toward research or health care institutions.
Conclusion: Most of the public favored written informed consent over the most widely advocated alternatives for low-risk pragmatic RCTs; however, a substantial minority favored general notification or verbal consent.
Primary Funding Source: Time-sharing Experiments for the Social Sciences and Intramural Research Program of the National Institutes of Health Clinical Center.

BMC Health Services Research
http://www.biomedcentral.com/bmchealthservres/content
(Accessed 5 September 2015)

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Technical advance
African vaccination week as a vehicle for integrated health service delivery
Richard Mihigo, Blanche Anya, Joseph Okeibunor, Samuel Ajibola, Collins Boakye-Agyemang, Linda Muzenda, Flavienne Issembe, Deo Nshimirimana
BMC Health Services Rese
Abstract
Background
African Vaccination Week (AVW) is an initiative of the Member States of the African Region aimed at promoting vaccination and ensuring equity and access to its benefits. The initiative has proven to be particularly effective in reaching populations with limited access to regular health services as well as providing an opportunity to integrate other interventions with immunization services.
Methods
Using data available from the countries within the African Region, the effectiveness of AVW in creating awareness on vaccination as well as providing platform for integrated delivery of other interventions with immunization in the African Region were explored during the 2013 and 2014 campaigns of the AVW.
Results
Countries that participated in the two campaigns of AVW have integrated other interventions with immunization during the AVW. The most common integrated intervention is vitamin A supplementation, followed by deworming. However, other interventions integrated, include public health educational activities, supplementation with vitamins and minerals, provision of other health services as well as introduction of new interventions. In 2013, more than 7,500,000 doses of different vaccine antigens were delivered in17 countries. Vitamin A administered to children under 5 years and women in post-partum in 13 countries with 31,500,000 tablets distributed. Polio eradication campaigns reaching young children in ten countries with 36,711,984 doses of oral polio vaccines (OPV) was the third most common intervention added onto the AVW activities. Over 21,190,000 deworming tablets were distributed to children <5 years and pregnant women in 9 countries. With respect to nutritional interventions, 6,377,222 children were screened for malnutrition in 3 countries while 3,814,680 water, sanitation and hygiene kits were distributed in 3 countries. In 2014, these results were even higher as many more countries integrated multiple interventions in the AVW.
Conclusion
Integration of other interventions with immunization during AVW, in the African Region is common and has shown potentials for improving immunization coverage, as this dedicated period is used both for catch-up campaigns and periodic intensified routine immunization. While its impact may call for further examination, it is a potential platform for integrated delivery of health interventions to people with limited access to regular health service.

BMC Public Health
http://www.biomedcentral.com/bmcpublichealth/content
(Accessed 5 September 2015)

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Research article
Addressing issues of vaccination literacy and psychological empowerment in the measles-mumps-rubella (MMR) vaccination decision-making: a qualitative study
Marta Fadda, Miriam Depping, Peter Schulz
BMC Public Health 2015, 15:836 (2 September 2015)
Abstract
Background
Whether or not to vaccinate one’s child is one of the first health-related decisions parents have to make after their child’s birth. For the past 20 years, the share of parents choosing not to immunize their children has increased in many countries, for various reasons. Among these, rumors affirming that vaccinations contain dangerous chemicals or might trigger severe chronic diseases have negatively affected parental attitudes towards pediatric immunizations, particularly the vaccination against measles, mumps and rubella (MMR), raising a number of public health concerns. The primary aim of this qualitative study is to understand what drives parents’ decision, giving special attention to vaccination literacy and psychological empowerment in such a context.
Methods
Twenty individual semi-structured interviews were conducted in the Canton of Ticino (Switzerland) between January and June 2014. Participants were either mothers or fathers of children less than 1 year old living in Switzerland. An inductive thematic analysis was performed to identify the main themes with regard to vaccination literacy and psychological empowerment in the MMR vaccination decision-making.
Results
Parents’ reports yielded four main themes: (a) the paradox of the free choice, referring to the misinterpretation of current vaccination policies; (b) giving up the power, pointing at the outcomes of a low perceived competence; (c) a far-reaching decision, reflecting the importance attributed to the MMR choice and the different levels of impact the decision can have; (d) the demand for shared-decision making, referring to the parental needs in relation to the child’s healthcare provider.
Conclusion
Understanding what drives parents’ management of their children’s immunization schedule in terms of vaccination literacy and psychological empowerment can help health professionals to communicate more effectively with parents in order to facilitate an informed decision, and stakeholders to design tailored health education programs and materials. This can ultimately help increase the coverage of the MMR vaccination.

BMJ Open
2015, Volume 5, Issue 9
http://bmjopen.bmj.com/content/current

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Geospatial patterns of human papillomavirus vaccine uptake in Minnesota
Erik J Nelson1, John Hughes2, J Michael Oakes3, James S Pankow3, Shalini L Kulasingam3
BMJ Open 2015;5:e008617 doi:10.1136/bmjopen-2015-008617
Abstract
Objectives To identify factors associated with human papillomavirus (HPV) vaccination and to determine the geographic distribution of vaccine uptake while accounting for spatial autocorrelation.
Design This study is cross-sectional in design using data collected via the Internet from the Survey of Minnesotans About Screening and HPV study.
Setting and participants The sample consists of 760 individuals aged 18–30 years nested within 99 ZIP codes surrounding the downtown area of Minneapolis, Minnesota.
Results In all, 46.2% of participants had received≥1 dose of HPV vaccine (67.7% of women and 13.0% of men). Prevalence of HPV vaccination was found to exhibit strong spatial dependence ( ) across ZIP codes. Accounting for spatial dependence, age (OR=0.76, 95% CI 0.70 to 0.83) and male gender (OR=0.04, 95% CI 0.03 to 0.07) were negatively associated with vaccination, while liberal political preferences (OR=4.31, 95% CI 2.32 to 8.01), and college education (OR=2.58, 95% CI 1.14 to 5.83) were found to be positively associated with HPV vaccination.
Conclusions Strong spatial dependence and heterogeneity of HPV vaccination prevalence were found across ZIP codes, indicating that spatial statistical models are needed to accurately identify and estimate factors associated with vaccine uptake across geographic units. This study also underscores the need for more detailed data collected at local levels (eg, ZIP code), as patterns of HPV vaccine receipt were found to differ significantly from aggregated state and national patterns. Future work is needed to further pinpoint areas with the greatest disparities in HPV vaccination and how to then access these populations to improve vaccine uptake.
Strengths and limitations of this study
This is the first study to identify factors associated with human papillomavirus (HPV) vaccination at the ZIP code level using statistical models that account for spatial dependence.
Study strengths include the large representative sample of 18–30-year olds in Minneapolis, Minnesota, adjustment for factors known to be associated with HPV vaccination, and the use of robust spatial statistical models.
This study reveals a gap between local estimation of HPV vaccination and estimates from large national surveillance programmes.
Potential limitations include the reliance on self-reported data collected via the Internet, selection bias and the absence of information regarding study participants’ age at vaccination and income.

Bulletin of the World Health Organization
Volume 93, Number 9, September 2015, 589-664
http://www.who.int/bulletin/volumes/93/9/en/

EDITORIALS
Maximizing the impact of community-based practitioners in the quest for universal health coverage
James Campbell, Kesetebirhan Admasu, Agnes Soucat & Sheila Tlou
doi: 10.2471/BLT.15.162198
Monitoring inequality: an emerging priority for health post-2015
Ahmad Reza Hosseinpoor, Nicole Bergen & Veronica Magar
doi: 10.2471/BLT.15.162081

Research
Cost–effectiveness of community-based practitioner programmes in Ethiopia, Indonesia and Kenya
Barbara McPake, Ijeoma Edoka, Sophie Witter, Karina Kielmann, Miriam Taegtmeyer, Marjolein Dieleman, Kelsey Vaughan, Elvis Gama, Maryse Kok, Daniel Datiko, Lillian Otiso, Rukhsana Ahmed, Neil Squires, Chutima Suraratdecha & Giorgio Cometto
Abstract
Objective
To assess the cost–effectiveness of community-based practitioner programmes in Ethiopia, Indonesia and Kenya.
Methods
Incremental cost–effectiveness ratios for the three programmes were estimated from a government perspective. Cost data were collected for 2012. Life years gained were estimated based on coverage of reproductive, maternal, neonatal and child health services. For Ethiopia and Kenya, estimates of coverage before and after the implementation of the programme were obtained from empirical studies. For Indonesia, coverage of health service interventions was estimated from routine data. We used the Lives Saved Tool to estimate the number of lives saved from changes in reproductive, maternal, neonatal and child health-service coverage. Gross domestic product per capita was used as the reference willingness-to-pay threshold value.
Findings
The estimated incremental cost per life year gained was 82 international dollars ($)in Kenya, $999 in Ethiopia and $3396 in Indonesia. The results were most sensitive to uncertainty in the estimates of life-years gained. Based on the results of probabilistic sensitivity analysis, there was greater than 80% certainty that each programme was cost-effective.
Conclusion
Community-based approaches are likely to be cost-effective for delivery of some essential health interventions where community-based practitioners operate within an integrated team supported by the health system. Community-based practitioners may be most appropriate in rural poor communities that have limited access to more qualified health professionals. Further research is required to understand which programmatic design features are critical to effectiveness.

Systematic Reviews
Data collection tools for maternal and child health in humanitarian emergencies: a systematic review
Thidar Pyone, Fiona Dickinson, Robbie Kerr, Cynthia Boschi-Pinto, Matthews Mathai & Nynke van den Broek
Abstract
Objective
To describe tools used for the assessment of maternal and child health issues in humanitarian emergency settings.
Methods
We systematically searched MEDLINE, Web of Knowledge and POPLINE databases for studies published between January 2000 and June 2014. We also searched the websites of organizations active in humanitarian emergencies. We included studies reporting the development or use of data collection tools concerning the health of women and children in humanitarian emergencies. We used narrative synthesis to summarize the studies.
Findings
We identified 100 studies: 80 reported on conflict situations and 20 followed natural disasters. Most studies (76/100) focused on the health status of the affected population while 24 focused on the availability and coverage of health services. Of 17 different data collection tools identified, 14 focused on sexual and reproductive health, nine concerned maternal, newborn and child health and four were used to collect information on sexual or gender-based violence. Sixty-nine studies were done for monitoring and evaluation purposes, 18 for advocacy, seven for operational research and six for needs assessment.
Conclusion
Practical and effective means of data collection are needed to inform life-saving actions in humanitarian emergencies. There are a wide variety of tools available, not all of which have been used in the field. A simplified, standardized tool should be developed for assessment of health issues in the early stages of humanitarian emergencies. A cluster approach is recommended, in partnership with operational researchers and humanitarian agencies, coordinated by the World Health Organization.

Achieving universal health coverage
Joseph Wong
doi: 10.2471/BLT.14.149070

Clinical Infectious Diseases (CID)
Volume 61 Issue 7 October 1, 2015
http://cid.oxfordjournals.org/content/current

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Study of Ebola Virus Disease Survivors in Guinea
Adnan I. Qureshi, Morad Chughtai, Tokpagnan Oscar Loua, Jean Pe Kolie, Hadja Fatou Sikhe Camara, Muhammad Fawad Ishfaq, Cheikh Tidane N’Dour, and Kezely Beavogui
Clin Infect Dis. (2015) 61 (7): 1035-1042 doi:10.1093/cid/civ453
This survey study is an effort to recognize symptoms experienced by Ebola virus disease survivors. Subjects reported symptoms including arthralgia, anorexia, and pain at various bodily sites and overall functional recovery

Editor’s choice: Mortality Associated With Seasonal and Pandemic Influenza Among Pregnant and Nonpregnant Women of Childbearing Age in a High-HIV-Prevalence Setting—South Africa, 1999–2009
Stefano Tempia, Sibongile Walaza, Adam L. Cohen, Claire von Mollendorf, Jocelyn Moyes, Johanna M. McAnerney, and Cheryl Cohen
Clin Infect Dis. (2015) 61 (7): 1063-1070 doi:10.1093/cid/civ448
Among South African women of childbearing age, the majority of seasonal influenza–associated deaths occurred among human immunodeficiency virus-infected individuals. Pregnant women experienced about a 3-fold increased risk of death associated with seasonal and A(H1N1)pdm09 influenza infection compared with nonpregnant women.

Globalization and Health
http://www.globalizationandhealth.com/
[Accessed 5 September 2015]

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Research
Introducing payment for performance in the health sector of Tanzania- the policy process
Chimhutu V, Tjomsland M, Songstad NG, Mrisho M and Moland KM Globalization and Health 2015, 11:38 (2 September 2015)
Abstract
Background
Prompted by the need to achieve progress in health outcomes, payment for performance (P4P) schemes are becoming popular policy options in the health systems in many low income countries. This paper describes the policy process behind the introduction of a payment for performance scheme in the health sector of Tanzania illuminating in particular the interests of and roles played by the Government of Norway, the Government of Tanzania and the other development partners.
Methods
The study employed a qualitative research design using in-depth interviews (IDIs), observations and document reviews. Thirteen IDIs with key-informants representing the views of ten donor agencies and government departments influential in the process of introducing the P4P scheme in Tanzania were conducted in Dar es Salaam, Tanzania and Oslo, Norway. Data was collected on the main trends and thematic priorities in development aid policy, countries and actors perceived to be proponents and opponents to the P4P scheme, and P4P agenda setting in Tanzania.
Results
The initial introduction of P4P in the health sector of Tanzania was controversial. The actors involved including the bilateral donors in the Health Basket Fund, the World Bank, the Tanzanian Government and high level politicians outside the Health Basket Fund fought for their values and interests and formed alliances that shifted in the course of the process. The process was characterized by high political pressure, conflicts, changing alliances, and, as it evolved, consensus building.
Conclusion
The P4P policy process was highly political with external actors playing a significant role in influencing the agenda in Tanzania, leaving less space for the Government of Tanzania to provide leadership in the process. Norway in particular, took a leading role in setting the agenda. The process of introducing P4P became long and frustrating causing mistrust among partners in the Health Basket Fund.

Journal of Infectious Diseases
Volume 212 Issue 7 October 1, 2015
http://jid.oxfordjournals.org/content/current

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Safety and Immunogenicity of a Live Attenuated Tetravalent Dengue Vaccine Candidate in Flavivirus-Naive Adults: A Randomized, Double-Blinded Phase 1 Clinical Trial
Sarah L. George, Mimi A. Wong, Tina J. T. Dube, Karen L. Boroughs, Janae L. Stovall, Betty E. Luy, Aurelia A. Haller, Jorge E. Osorio, Linda M. Eggemeyer, Sharon Irby-Moore, Sharon E. Frey, Claire Y.-H. Huang, and Dan T. Stinchcomb
J Infect Dis. (2015) 212 (7): 1032-1041 doi:10.1093/infdis/jiv179
Abstract
Background. Dengue viruses (DENVs) infect >300 million people annually, causing 96 million cases of dengue disease and 22 000 deaths [1]. A safe vaccine that protects against DENV disease is a global health priority [2].
Methods. We enrolled 72 flavivirus-naive healthy adults in a phase 1 double-blinded, randomized, placebo-controlled dose-escalation trial (low and high dose) of a live attenuated recombinant tetravalent dengue vaccine candidate (TDV) given in 2 doses 90 days apart. Volunteers were followed for safety, vaccine component viremia, and development of neutralizing antibodies to the 4 DENV serotypes.
Results. The majority of adverse events were mild, with no vaccine-related serious adverse events. Vaccinees reported injection site pain (52% vs 17%) and erythema (73% vs 25%) more frequently than placebo recipients. Low levels of TDV-serotype 2 (TDV-2), TDV-3, and TDV-4 viremia were observed after the first but not second administration of vaccine. Overall seroconversion rates and geometric mean neutralization titers after 2 doses were 84.2% and 54.1, respectively, for DENV serotype 1 (DENV-1); 92.1% and 292.8, respectively, for DENV-2; 86.8% and 32.3, respectively, for DENV-3; and 71.1% and 15.0, respectively, for DENV-4. More than 90.0% of high-dose recipients had trivalent or broader responses.
Conclusions. TDV was generally well tolerated, induced trivalent or broader neutralizing antibodies to DENV in most flavivirus-naive vaccinees, and is undergoing further development.
Clinical Trials Registration. NCT01110551.

The Lancet Infectious Diseases
Sep 2015 Volume 15 Number 9 p987-1114
http://www.thelancet.com/journals/laninf/issue/current

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Articles
Effect of the Ebola-virus-disease epidemic on malaria case management in Guinea, 2014: a cross-sectional survey of health facilities
Published Online: 23 June 2015
DOI: http://dx.doi.org/10.1016/S1473-3099(15)00061-4
Dr Mateusz M Plucinski, PhD, Timothée Guilavogui, MD, Sidibe Sidikiba, MD, Nouman Diakité, MD, Souleymane Diakité, MD, Mohamed Dioubaté, MS, Ibrahima Bah, MS, Ian Hennessee, MPH, Jessica K Butts, MPH, Eric S Halsey, MD, Peter D McElroy, PhD, S Patrick Kachur, MD, Jamila Aboulhab, MD, Richard James, MD, Moussa Keita, MD
Summary
Background
The ongoing west Africa Ebola-virus-disease epidemic has disrupted the entire health-care system in affected countries. Because of the overlap of symptoms of Ebola virus disease and malaria, the care delivery of malaria is particularly sensitive to the indirect effects of the current Ebola-virus-disease epidemic. We therefore characterise malaria case management in the context of the Ebola-virus-disease epidemic and document the effect of the Ebola-virus-disease epidemic on malaria case management.
Methods
We did a cross-sectional survey of public health facilities in Guinea in December, 2014. We selected the four prefectures most affected by Ebola virus disease and selected four randomly from prefectures without any reported cases of the disease. 60 health facilities were sampled in Ebola-affected and 60 in Ebola-unaffected prefectures. Study teams abstracted malaria case management indicators from registers for January to November for 2013 and 2014 and interviewed health-care workers. Nationwide weekly surveillance data for suspect malaria cases reported between 2011 and 2014 were analysed independently. Data for malaria indicators in 2014 were compared with previous years.
Findings
We noted substantial reductions in all-cause outpatient visits (by 23 103 [11%] of 214 899), cases of fever (by 20249 [15%] of 131 330), and patients treated with oral (by 22 655 [24%] of 94 785) and injectable (by 5219 [30%] of 17 684) antimalarial drugs in surveyed health facilities. In Ebola-affected prefectures, 73 of 98 interviewed community health workers were operational (74%, 95% CI 65–83) and 35 of 73 were actively treating malaria cases (48%, 36–60) compared with 106 of 112 (95%, 89–98) and 102 of 106 (96%, 91–99), respectively, in Ebola-unaffected prefectures. Nationwide, the Ebola-virus-disease epidemic was estimated to have resulted in 74 000 (71 000–77 000) fewer malaria cases seen at health facilities in 2014.
Interpretation
The reduction in the delivery of malaria care because of the Ebola-virus-disease epidemic threatens malaria control in Guinea. Untreated and inappropriately treated malaria cases lead to excess malaria mortality and more fever cases in the community, impeding the Ebola-virus-disease response.
Funding
Global Fund to Fight AIDS, Tuberculosis and Malaria, and President’s Malaria Initiative.

Clinical features of patients isolated for suspected Ebola virus disease at Connaught Hospital, Freetown, Sierra Leone: a retrospective cohort study
Marta Lado, Naomi F Walker, Peter Baker, Shamil Haroon, Colin S Brown, Daniel Youkee, Neil Studd, Quaanan Kessete, Rishma Maini, Tom Boyles, Eva Hanciles, Alie Wurie, Thaim B Kamara, Oliver Johnson, Andrew J M Leather

Clinical features and viral kinetics in a rapidly cured patient with Ebola virus disease: a case report
Manuel Schibler, Pauline Vetter, Pascal Cherpillod, Tom J Petty, Samuel Cordey, Gaël Vieille, Sabine Yerly, Claire-Anne Siegrist, Kaveh Samii, Julie-Anne Dayer, Mylène Docquier, Evgeny M Zdobnov, Andrew J H Simpson, Paul S C Rees, Felix Baez Sarria, Yvan Gasche, François Chappuis, Anne Iten, Didier Pittet, Jérôme Pugin, Laurent Kaiser
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Articles
High titre neutralising antibodies to influenza after oral tablet immunisation: a phase 1, randomised, placebo-controlled trial
David Liebowitz, MD, Jonathan D Lindbloom, BA, Jennifer R Brandl, BS, Shaily J Garg, BS, Dr Sean N Tucker, PhD
DOI: http://dx.doi.org/10.1016/S1473-3099(15)00266-2
Summary
Background
Most influenza vaccines are manufactured in eggs, and the inactivated virus is purified for injection. For a seasonal influenza product, manufacturing, distribution, and perhaps even vaccine coverage, would be greatly improved with an oral tablet alternative made in cell culture. We aimed to assess the safety and immunogenicity of an oral tablet vaccine against influenza A H1N1 in healthy adults.
Methods
At a single site, we did a randomised, double-blind, placebo-controlled trial of a monovalent influenza A H1N1 vaccine to establish the safety and immunogenicity of a recombinant, non-replicating, adenovirus vector expressing haemagglutinin and double-stranded RNA adjuvant delivered orally by tablets. Participants had to have an initial haemagglutination inhibition titre of at most 1/20, be aged between 18 and 49 years, and be in good health. We randomly assigned (1:1) participants to receive either a single oral dose of vaccine or placebo. Randomisation was done by computer-generated assignment, and study drug was distributed with concealed identity to the masked staff by an unmasked pharmacist. Investigative site staff, people directly involved with immunological assays or the assessment of clinical safety, and participants were masked to treatment assignments. Solicited symptoms of reactogenicity were assessed, and all safety assessments were reported through the active phase of the study (day 28). Immunogenicity was assessed by haemagglutination inhibition titres, the percentage of participants that seroconverted, microneutralisation titres, and the number of antibody secreting cells. Descriptive statistics were used for continuous variables and t-tests or Fisher’s exact tests were used to compare treatment groups. The study is registered at ClinicalTrials.gov, number NCT01688297.
Findings
24 participants were enrolled in the study at WCCT Global between Dec 2, 2013, and April 15, 2014. Adverse events were mild in nature, and occurred with similar frequency in vaccine (four events) and placebo recipients (four events). After immunisation, 11 (92%) of 12 vaccine-treated participants had a four-fold increase in haemagglutination inhibition titres (group geometric mean fold rise of 7·7) and microneutralisation titres (group geometric mean fold rise of 29). No participants in the placebo group had a four-fold increase in haemagglutination inhibition titres (group geometric mean fold rise of 1·1) or microneutralisation titres (group geometric mean fold rise of 1·0). Neutralising antibody responses to influenza were not hindered by pre-existing immunity to the vector.
Interpretation
An oral recombinant adenovirus vaccine to influenza was well tolerated and can elicit neutralising antibody responses to influenza virus in human beings. These data are a step forward in making oral influenza vaccination possible.
Funding
Vaxart Inc.

Pediatrics
September 2015, VOLUME 136 / ISSUE 3
http://pediatrics.aappublications.org/current.shtml

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Article
Coadministration of a 9-Valent Human Papillomavirus Vaccine With Meningococcal and Tdap Vaccines
Andrea Schilling, MDa, Mercedes Macias Parra, MDb, Maricruz Gutierrez, MDc, Jaime Restrepo, MDd, Santiago Ucros, MDe, Teobaldo Herrera, MDf, Eli Engel, MDg, Luis Huicho, MDh, Marcia Shew, MDi, Roger Maansson, MSj, Nicole Caldwell, BSj, Alain Luxembourg, MD, PhDj, and Ajoke Sobanjo ter Meulen, MDj
Author Affiliations
aFacultad de Medicina Clinica Alemana-Universidad del Desarrollo, Santiago, Chile;
bInstituto Nacional de Pediatría, Mexico City, Mexico;
cHospital del Niño Poblano, Puebla, Mexico;
dFundacion Centro de Investigacion Clinica CIC, Medellín, Colombia;
eCentro de Investigaciones en Salud, Fundacion Santa Fe de Bogotá, Bogotá, Colombia;
fInsituto de Investigación Nutricional anexo Huáscar, Lima, Perú;
gBayview Research Group, Valley Village, California;
hInstituto Nacional de Salud del Niño, Lima, Perú;
iIndiana University School of Medicine/Department of Pediatrics, Indianapolis, Indiana; and
jMerck & Co., Inc., Kenilworth, New Jersey

Abstract
BACKGROUND: This study in 11- to 15-year-old boys and girls compared the immunogenicity and safety of GARDASIL 9 (9-valent human papillomavirus [9vHPV] vaccine) administered either concomitantly or nonconcomitantly with 2 vaccines routinely administered in this age group (Menactra [MCV4; Neisseria meningitidis serotypes A/C/Y/W-135] or Adacel [Tdap; diphtheria/tetanus/acellular pertussis]).
METHODS: Participants received 9vHPV vaccine at day 1 and months 2 and 6; the concomitant group (n = 621) received MCV4/Tdap concomitantly with 9vHPV vaccine at day 1; the nonconcomitant group (n = 620) received MCV4/Tdap at month 1. Antibodies to HPV-, MCV4-, and Tdap-relevant antigens were determined. Injection-site and systemic adverse events (AEs) were monitored for 15 days after any vaccination; serious AEs were monitored throughout the study.
RESULTS: The geometric mean titers for all HPV types in 9vHPV vaccine 4 weeks after dose 3, proportion of subjects with a fourfold rise or greater in titers for 4 N meningitidis serotypes 4 weeks after injection with MCV4, proportion of subjects with antibody titers to diphtheria and tetanus ≥0.1 IU/mL, and geometric mean titers for pertussis antigens 4 weeks after injection with Tdap were all noninferior in the concomitant group compared with the nonconcomitant group. Injection-site swelling occurred more frequently in the concomitant group. There were no vaccine-related serious AEs.
CONCLUSIONS: Concomitant administration of 9vHPV vaccine with MCV4/Tdap was generally well tolerated and did not interfere with the antibody response to any of these vaccines. This strategy would minimize the number of visits required to deliver each vaccine individually.

PLoS Currents: Outbreaks
http://currents.plos.org/outbreaks/
(Accessed 5 September 2015)

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The Tortoise and the Hare: Guinea Worm, Polio and the Race to Eradication
August 31, 2015 · Commentary
Introduction: The eradication of a human infectious disease is a major challenge and, if achieved, represents a enormous achievement. This article explores the long and difficult journey towards eradication for polio and guinea worm.
Methods: The authors reviewed the programmatic approaches taken in the eradication strategies for these two diseases and the unique socio-political contexts in which these strategies are couched. The epidemiology of the last 15 years is compared and contrasted. The specific challenges for both programs are outlined and some key elements for success are highlighted.
Discussion: The success of these eradication programs is contingent upon many factors. Nothing is assured, and progress remains fragile and vulnerable to setbacks. Security must be ensured in guinea worm transmission areas in Africa and polio transmission areas in Pakistan and Afghanistan. Technical solutions alone cannot guarantee eradication. National leadership and continued international focus and support are necessary, today more than ever. The legacy of success would be extraordinary. It would reverberate to future generations in the same way that the eradication of smallpox does for this generation.

PLoS One
http://www.plosone.org/
[Accessed 5 September 2015]

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Assessing Community Based Improved Maternal Neonatal Child Survival (IMNCS) Program in Rural Bangladesh
Mahfuzar Rahman, Fatema Tuz Jhohura, Sabuj Kanti Mistry, Tridib Roy Chowdhury, Tanveen Ishaque, Rasheduzzaman Shah, Kaosar Afsana
Research Article | published 04 Sep 2015 | PLOS ONE
10.1371/journal.pone.0136898

Research Stakeholders’ Views on Benefits and Challenges for Public Health Research Data Sharing in Kenya: The Importance of Trust and Social Relations
Irene Jao, Francis Kombe, Salim Mwalukore, Susan Bull, Michael Parker, Dorcas Kamuya, Sassy Molyneux, Vicki Marsh
Research Article | published 02 Sep 2015 | PLOS ONE
10.1371/journal.pone.0135545

Impact of Pneumococcal Conjugate Vaccine Administration in Pediatric Older Age Groups in Low and Middle Income Countries: A Systematic Review
Kimberly Bonner, Emily Welch, Kate Elder, Jennifer Cohn
Research Article | published 02 Sep 2015 | PLOS ONE
10.1371/journal.pone.0135270

Human Papillomavirus (HPV) Vaccination and Adolescent Girls’ Knowledge and Sexuality in Western Uganda: A Comparative Cross-Sectional Study
Andrew Kampikaho Turiho, Wilson Winston Muhwezi, Elialilia Sarikiaeli Okello, Nazarius Mbona Tumwesigye, Cecil Banura, Anne Ruhweza Katahoire
Research Article | published 01 Sep 2015 | PLOS ONE
10.1371/journal.pone.0137094

Science
4 September 2015 vol 349, issue 6252, pages 1021-1136
http://www.sciencemag.org/current.dtl

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Food Security
Global agricultural research network is overhauled again
Dennis Normile
A key guardian of global food security is looking shaky. Funding for the Consultative Group on International Agricultural Research (CGIAR), the world’s premier group of agricultural research centers, is sagging in the global economic downturn. Its flagship backer—the World Bank—threatened to pull the plug on its contributions. And now CGIAR is about to undergo internal convulsions: It’s reorganizing for the second time in just 5 years. Backers say the move will give CGIAR a more coherent strategy and make the most of available funding. Critics argue that greater effort should go into securing stable funding and prioritizing research.

Policy Forum
Sustainability
Sustainable development agenda: 2030
William Colglazier
Author Affiliations
Visiting Scientist and Senior Scholar, Center for Science Diplomacy, American Association for the Advancement of Science, Washington, DC 20005, USA.
On 25 to 27 September, United Nations member states will formally adopt the Sustainable Development Goals (SDGs) as key elements of the post-2015 development agenda (1), successors to the eight Millennium Development Goals (MDGs) that focused attention from 2000 to 2015. The final 2030 agenda text for adoption proposes 17 SDGs with 169 targets, to be supplemented in 2016 with numerous indicators. All of the text emphasizing science, technology, and innovation (STI) is most welcome but achieving desired outcomes by 2030 will require deep understanding of how to maximize the contributions of STI. Having had the privilege of addressing this topic to the UN High-Level Political Forum (HLPF) that will oversee the SDG effort, I discuss areas that I believe are essential to success. I focus on three issues: (i) using the Global Sustainable Development Report (GSDR) process to bridge SDGs and scientific communities, (ii) choosing targets, indicators, and roadmaps related to STI, and (iii) the imperative of building knowledge-based societies.

Review
Why infectious disease research needs community ecology
Pieter T. J. Johnson1,*, Jacobus C. de Roode2, Andy Fenton3
Author Affiliations
1Ecology and Evolutionary Biology, University of Colorado, Boulder, CO 80309, USA.
2Department of Biology, Emory University, Atlanta, GA 30322, USA.
3Institute of Integrative Biology, University of Liverpool, Liverpool L69 7ZB, UK.
Abstract
BACKGROUND
Despite ongoing advances in biomedicine, infectious diseases remain a major threat to human health, economic sustainability, and wildlife conservation. This is in part a result of the challenges of controlling widespread or persistent infections that involve multiple hosts, vectors, and parasite species. Moreover, many contemporary disease threats involve interactions that manifest across nested scales of biological organization, from disease progression at the within-host level to emergence and spread at the regional level. For many such infections, complete eradication is unlikely to be successful, but a broader understanding of the community in which host-parasite interactions are embedded will facilitate more effective management. Recent advances in community ecology, including findings from traits-based approaches and metacommunity theory, offer the tools and concepts to address the complexities arising from multispecies, multiscale disease threats.
ADVANCES
Community ecology aims to identify the factors that govern the structure, assembly, and dynamics of ecological communities. We describe how analytical and conceptual approaches from this discipline can be used to address fundamental challenges in disease research, such as (i) managing the ecological complexity of multihost-multiparasite assemblages; (ii) identifying the drivers of heterogeneities among individuals, species, and regions; and (iii) quantifying how processes link across multiple scales of biological organization to drive disease dynamics. We show how a community ecology framework can help to determine whether infection is best controlled through “defensive” approaches that reduce host suitability or through “offensive” approaches that dampen parasite spread. Examples of defensive approaches are the strategic use of wildlife diversity to reduce host and vector transmission, and taking advantage of antagonism between symbionts to suppress within-host growth and pathology. Offensive approaches include the targeted control of superspreading hosts and the reduction of human-wildlife contact rates to mitigate spillover. By identifying the importance of parasite dispersal and establishment, a community ecology framework can offer additional insights about the scale at which disease should be controlled.
OUTLOOK
Ongoing technological advances are rapidly overcoming previous barriers in data quality and quantity for complex, multispecies systems. The emerging synthesis of “disease community ecology” offers the tools and concepts necessary to interpret these data and use that understanding to inform the development of more effective disease control strategies in humans and wildlife. Looking forward, we emphasize the increasing importance of tight integration among surveillance, community ecology analyses, and public health implementation. Building from the rich legacy of whole-system manipulations in community ecology, we further highlight the value of large-scale experiments for understanding host-pathogen interactions and designing effective control measures. Through this blending of data, theory, and analytical approaches, we can understand how interactions between parasites within hosts, hosts within populations, and host species within ecological communities combine to drive disease dynamics, thereby providing new ways to manage emerging infections.

Vaccine
Volume 33, Issue 38, Pages 4737-5026 (11 September 2015)
http://www.sciencedirect.com/science/journal/0264410X/33/38

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Methodological challenges in measuring vaccine effectiveness using population cohorts in low resource settings
Review Article
Pages 4748-4755
C. King, J. Beard, A.C. Crampin, A. Costello, C. Mwansambo, N.A. Cunliffe, R.S. Heyderman, N. French, N. Bar-Zeev, for the VacSurv Consortium
Abstract
Post-licensure real world evaluation of vaccine implementation is important for establishing evidence of vaccine effectiveness (VE) and programme impact, including indirect effects. Large cohort studies offer an important epidemiological approach for evaluating VE, but have inherent methodological challenges.
Since March 2012, we have conducted an open prospective cohort study in two sites in rural Malawi to evaluate the post-introduction effectiveness of 13-valent pneumococcal conjugate vaccine (PCV13) against all-cause post-neonatal infant mortality and monovalent rotavirus vaccine (RV1) against diarrhoea-related post-neonatal infant mortality. Our study sites cover a population of 500,000, with a baseline post-neonatal infant mortality of 25 per 1000 live births.
We conducted a methodological review of cohort studies for vaccine effectiveness in a developing country setting, applied to our study context. Based on published literature, we outline key considerations when defining the denominator (study population), exposure (vaccination status) and outcome ascertainment (mortality and cause of death) of such studies. We assess various definitions in these three domains, in terms of their impact on power, effect size and potential biases and their direction, using our cohort study for illustration. Based on this iterative process, we discuss the pros and cons of our final per-protocol analysis plan. Since no single set of definitions or analytical approach accounts for all possible biases, we propose sensitivity analyses to interrogate our assumptions and methodological decisions.
In the poorest regions of the world where routine vital birth and death surveillance are frequently unavailable and the burden of disease and death is greatest We conclude that provided the balance between definitions and their overall assumed impact on estimated VE are acknowledged, such large scale real-world cohort studies can provide crucial information to policymakers by providing robust and compelling evidence of total benefits of newly introduced vaccines on reducing child mortality.

Vaccine
Volume 33, Issue 38, Pages 4737-5026 (11 September 2015)
http://www.sciencedirect.com/science/journal/0264410X/33/38

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Functional immune responses to twelve serotypes after immunization with a 23-valent pneumococcal polysaccharide vaccine in older adults
Original Research Article
Pages 4770-4775
Jong Gyun Ahn, Han Wool Kim, Hee Jung Choi, Jin Hwa Lee, Kyung-Hyo Kim
Abstract
Background
The 23-valent pneumococcal polysaccharide vaccine (PPSV23) was introduced as part of the national immunization program for the elderly (≥65 years of age) in Korea on 2013. To evaluate immune responses in this population, serotype-specific anti-pneumococcal antibodies were studied with opsonophagocytic assay (OPA).
Methods
Pneumococcal vaccine-naïve participants ≥65 years of age were enrolled. They were divided into two groups according to their age: 30 in (65–74 years) and 32 in group (≥75 years). The functional antibody response was determined by multiplexed OPA (MOPA) for 12 serotypes (1, 3, 4, 5, 6B, 7F, 9V, 14, 18C, 19A, 19F, and 23F) before and 4 weeks after vaccination with PPSV23.
Results
Geometric mean titers (GMTs) to all tested serotypes significantly increased in both groups after vaccination compared to those before vaccination. There were no significant differences in either the fold rise (post-vaccination to pre-vaccination) or the percentage of participants with a ≥4-fold increase in OPA titers between two groups for any of the 12 serotypes. Following vaccination, GMT for serotype 9V was higher in group 1 than in group 2 (P = 0.011).
Conclusions
PPSV23 induces functional immune response for 12 vaccine serotypes in both age groups. Further analysis is needed for the remaining 11 serotypes in the PPSV23, in order to develop a better understanding of the immune responses induced by PPV23 in older adults.

Vaccine
Volume 33, Issue 38, Pages 4737-5026 (11 September 2015)
http://www.sciencedirect.com/science/journal/0264410X/33/38

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Peru-15 (Choleragarde®), a live attenuated oral cholera vaccine, is safe and immunogenic in human immunodeficiency virus (HIV)-seropositive adults in Thailand
Original Research Article
Pages 4820-4826
W. Ratanasuwan, Y.H. Kim, B.K. Sah, S. Suwanagool, D.R. Kim, A. Anekthananon, A.L. Lopez, W. Techasathit, S.L. Grahek, J.D. Clemens, T.F. Wierzba
Abstract
Background
Many areas with endemic and epidemic cholera report significant levels of HIV transmission. According to the World Health Organization (WHO), over 95% of reported cholera cases occur in Africa, which also accounts for nearly 70% of people living with HIV/AIDS globally. Peru-15, a promising single dose live attenuated oral cholera vaccine (LA-OCV), was previously found to be safe and immunogenic in cholera endemic areas. However, no data on the vaccine’s safety among HIV-seropositive adults had been collected.
Methods
This study was a double-blinded, individually randomized, placebo-controlled trial enrolling HIV-seropositive adults, 18–45 years of age, conducted in Bangkok, Thailand, to assess the safety of Peru-15 in a HIV-seropositive cohort.
Results
32 HIV infected subjects were randomized to receive either a single oral dose of the Peru-15 vaccine with a buffer or a placebo (buffer only). No serious adverse events were reported during the follow-up period in either group. The geometric mean fold (GMF) rise in V. cholerae O1 El Tor specific antibody titers between baseline and 7 days after dosing was 32.0 (p < 0.001) in the vaccine group compared to 1.6 (p < 0.14) in the placebo group. Among the 16 vaccinees,14 vaccinees (87.5%) had seroconversion compared to 1 of 16 placebo recipients (6.3%). V. cholerae was isolated from the stool of one vaccinee, and found to be genetically identical to the Peru-15 vaccine strain. There were no significant changes in HIV viral load or CD4 T-cell counts between vaccine and placebo groups.
Conclusion
Peru-15 was shown to be safe and immunogenic in HIV-seropositive Thai adults.