Globalization and Health
http://www.globalizationandhealth.com/
[Accessed 21 November 2015]

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Research
‘They hear “Africa” and they think that there can’t be any good services’ – perceived context in cross-national learning: a qualitative study of the barriers to Reverse Innovation
Harris M, Weisberger E, Silver D and Macinko J Globalization and Health 2015, 11:45 (19 November 2015)

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Research
Rethinking health care commercialization: evidence from Malaysia
Nwagbara VC and Rasiah R Globalization and Health 2015, 11:44 (19 November 2015)
Abstract
Background
Against the backdrop of systemic inefficiency in the public health care system and the theoretical claims that markets result in performance and efficiency improvement, developing countries’ governments have been rapidly commercializing health care delivery. This paper seeks to determine whether commercialization through an expansion in private hospitals has led to performance improvements in public hospitals.
Methods
Inpatient utilization records of all public hospitals in Peninsular Malaysia over the period 2006–2010 were used in this study. These records were obtained from the Ministry of Health. The study relied on utilization ratios, bed occupancy rates (BOR), bed turnover rates (BTR) and average length of stay (ALOS). The data were analyzed using SPSS 22 Statistical Software and the Pabon Lasso technique.
Results
Over 60 % of public hospitals in Malaysia are inefficient and perform sub-optimally. Average BOR among the public hospitals was 56 % in 2006 and 61 % in 2010. There was excessive BTR of 65 and 73 times within the period. Overall, the ALOS was low, falling from 3.4 days in 2006 to 3.1 days in 2010.
Conclusions
This study demonstrates that commercialization has not led to performance improvements in the public health care sector in Malaysia. The evidence suggests that efforts to improve performance will require a focus directly on public hospitals.

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

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Safety and Immunogenicity of Human Serum Albumin-Free MMR Vaccine in US Children Aged 12–15 Months
Maurice A. Mufson, Clemente Diaz, Michael Leonardi, Christopher J. Harrison, Stanley Grogg,
Antonio Carbayo, Simon Carlo-Torres, Robert JeanFreau, Ana Quintero-Del-Rio, Gisele Bautista,
Michael Povey, Christopher Da Costa, Ouzama Nicholson, and Bruce L. Innis
J Ped Infect Dis (2015) 4 (4): 339-348 doi:10.1093/jpids/piu081
Free Full Text (HTML)
Abstract
Background
M-M-RTMII (MMRII; Merck & Co) is currently the only measles-mumps-rubella (MMR) vaccine licensed in the United States. Another licensed vaccine would reinforce MMR supply. This study assessed the immunogenicity of a candidate vaccine (PriorixTM, GlaxoSmithKline Vaccines [MMR-RIT]) when used as a first dose among eligible children in the United States.
Methods
In this exploratory Phase-2, multicenter, observer-blind study, 1220 healthy subjects aged 12–15 months were randomized (3:3:3:3) and received 1 dose of 1 of 3 MMR-RIT lots with differing mumps virus titers (MMR-RIT-1 [4.8 log10]; MMR-RIT-2 [4.1 log10]; MMR-RIT-3 [3.7 log10] CCID50) or MMRII co-administered with hepatitis A vaccine (HAV), varicella vaccine (VAR) and 7-valent pneumococcal conjugate vaccine (PCV7). Immune response to measles, mumps, and rubella viruses was evaluated at Day 42 post-vaccination. Incidence of solicited injection site, general, and serious adverse events was assessed.
Results
Seroresponse rates for MMR vaccine viral components in MMR-RIT lots were 98.3–99.2% (measles), 89.7–90.7% (mumps), and 97.5–98.8% (rubella), and for MMRII were 99.6%, 91.1%, and 100%, respectively. Immune responses to HAV, VAR, and PCV7 were similar when co-administered with any of the 3 MMR-RIT lots or MMRII. There were no apparent differences in solicited or serious adverse events among the 4 groups.
Conclusions
Immune responses were above threshold levels for projected protection against the 3 viruses from MMR-RIT lots with differing mumps virus titers. MMR-RIT had an acceptable safety profile when co-administered with HAV, VAR, and PCV7.
Clinical Trials Registration NCT00861744; etrack; 111870

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Efficacy of a Tetravalent Dengue Vaccine in Children in Latin America
Rana F. Hamdy
Author Affiliations
Division of Infectious Diseases, The Children’s Hospital of Philadelphia
Received July 9, 2015.
Accepted August 1, 2015.
Villar L, Dayan GH, Arredondo-Garcia JL, et al. Efficacy of a tetravalent dengue vaccine in children in Latin America. N Engl J Med 2015; 372:113–23.
Extract
Dengue is a mosquito-borne disease caused by 1 of 4 virus serotypes from the flavivirus genus present in tropical and subtropical regions. This study reports the results from a phase 3 randomized, blinded, placebo-controlled efficacy trial of a recombinant, live, attenuated, tetravalent dengue vaccine (CYD-TDV) involving healthy children ages 9 to 16 years in 5 Latin American countries.
The study, sponsored by Sanofi Pasteur, took place in 22 centers in Colombia, Brazil, Mexico, Puerto Rico, and Honduras from June 2011 to March 2012. The investigational vaccine consists of 4 recombinant dengue vaccine viruses, which were constructed by replacing the genes that encode the premembrane and envelope proteins of the yellow fever 17D vaccine virus with those from wild-type dengue viruses…

The Lancet
Nov 21, 2015 Volume 386 Number 10008 p2029-2116
http://www.thelancet.com/journals/lancet/issue/current

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Editorial
Violence against women and girls: how far have we come?
The Lancet
DOI: http://dx.doi.org/10.1016/S0140-6736(15)01029-6
Summary
A year ago, The Lancet published a Series on violence against women and girls ahead of the International Day for the Elimination of Violence against Women on Nov 25. The day marks the start of the 16 Days of Activism against Gender-Based Violence, which this year, for the first time, has prevention as its theme. This focus is encouraging. One in three women will experience physical and/or sexual violence in their lifetime but, as evidence in the Series showed, such violence is preventable. The authors found that community and group interventions involving men and women can shift entrenched social norms and attitudes to reduce the risk of violence against women and girls, but concerted efforts were needed for change

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Comment
Towards therapeutic vaccination against cervical precancer?
Mark Schiffman, Nicolas Wentzensen
Published Online: 16 September 2015
DOI: http://dx.doi.org/10.1016/S0140-6736(15)00240-8
Summary
In The Lancet, Cornelia Trimble and colleagues1 report the results of a double-blind, randomised controlled trial of therapeutic human papillomavirus (HPV) vaccination. Three doses of an intramuscular HPV-16 and HPV-18 plasmid vaccine significantly increased histological regression of cervical precancers caused by HPV types 16 and 18. At 36 weeks after the first dose, regression of cervical intraepithelial neoplasia 2/3 was 48·2% compared with a spontaneous rate in the placebo group of 30·0% (difference 18·2%, 95% CI 1·3–34·4).

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Safety, efficacy, and immunogenicity of VGX-3100, a therapeutic synthetic DNA vaccine targeting human papillomavirus 16 and 18 E6 and E7 proteins for cervical intraepithelial neoplasia 2/3: a randomised, double-blind, placebo-controlled phase 2b trial
Cornelia L Trimble, Matthew P Morrow, Kimberly A Kraynyak, Xuefei Shen, Michael Dallas, Jian Yan, Lance Edwards, R Lamar Parker, Lynette Denny, Mary Giffear, Ami Shah Brown, Kathleen Marcozzi-Pierce, Divya Shah, Anna M Slager, Albert J Sylvester, Amir Khan, Kate E Broderick, Robert J Juba, Timothy A Herring, Jean Boyer, Jessica Lee, Niranjan Y Sardesai, David B Weiner, Mark L Bagarazzi
Summary
Background
Despite preventive vaccines for oncogenic human papillomaviruses (HPVs), cervical intraepithelial neoplasia (CIN) is common, and current treatments are ablative and can lead to long-term reproductive morbidity. We assessed whether VGX-3100, synthetic plasmids targeting HPV-16 and HPV-18 E6 and E7 proteins, delivered by electroporation, would cause histopathological regression in women with CIN2/3.
Methods
Efficacy, safety, and immunogenicity of VGX-3100 were assessed in CIN2/3 associated with HPV-16 and HPV-18, in a randomised, double-blind, placebo-controlled phase 2b study. Patients from 36 academic and private gynaecology practices in seven countries were randomised (3:1) to receive 6 mg VGX-3100 or placebo (1 mL), given intramuscularly at 0, 4, and 12 weeks. Randomisation was stratified by age (<25 vs ≥25 years) and CIN2 versus CIN3 by computer-generated allocation sequence (block size 4). Funder and site personnel, participants, and pathologists were masked to treatment. The primary efficacy endpoint was regression to CIN1 or normal pathology 36 weeks after the first dose. Per-protocol and modified intention-to-treat analyses were based on patients receiving three doses without protocol violations, and on patients receiving at least one dose, respectively. The safety population included all patients who received at least one dose. The trial is registered at ClinicalTrials.gov (number NCT01304524) and EudraCT (number 2012-001334-33).
Findings
Between Oct 19, 2011, and July 30, 2013, 167 patients received either VGX-3100 (n=125) or placebo (n=42). In the per-protocol analysis 53 (49·5%) of 107 VGX-3100 recipients and 11 (30·6%) of 36 placebo recipients had histopathological regression (percentage point difference 19·0 [95% CI 1·4–36·6]; p=0·034). In the modified intention-to-treat analysis 55 (48·2%) of 114 VGX-3100 recipients and 12 (30·0%) of 40 placebo recipients had histopathological regression (percentage point difference 18·2 [95% CI 1·3–34·4]; p=0·034). Injection-site reactions occurred in most patients, but only erythema was significantly more common in the VGX-3100 group (98/125, 78·4%) than in the placebo group (24/42, 57·1%; percentage point difference 21·3 [95% CI 5·3–37·8]; p=0·007).
Interpretation
VGX-3100 is the first therapeutic vaccine to show efficacy against CIN2/3 associated with HPV-16 and HPV-18. VGX-3100 could present a non-surgical therapeutic option for CIN2/3, changing the treatment outlook for this common disease.
Funding
Inovio Pharmaceuticals.

New England Journal of Medicine
November 19, 2015 Vol. 373 No. 21
http://www.nejm.org/toc/nejm/medical-journal

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Editorials
Vaccine-Resistant Malaria
C.V. Plowe
[Free Full Text]
To ensure efficacy against wild poliovirus, Jonas Salk methodically classified circulating polio strains before choosing three to use in his inactivated vaccine.1 Several other successful vaccines against viruses and bacteria have likewise included immunogen variants that were selected through careful assessments of pathogen genetic diversity and strain-specific protective immunity.

In contrast, virtually all vaccines against the malaria parasite Plasmodium falciparum, including RTS,S/AS01, have been designed with the use of genetic sequences that are derived from a single, well-characterized reference strain thought to be of West African origin — 3D7. In light of the extreme diversity of malaria parasites, could this “freezer epidemiology” approach to vaccine development be one reason it has been so hard to make an effective malaria vaccine?

Phase 2 field trials of two malaria vaccines targeting highly polymorphic blood-stage antigens have shown strain-specific efficacy — that is, parasites that are genetically divergent from the strain used in the vaccine escaped its effect.2,3 However, field trials of RTS,S, which is based on the pre-erythrocytic P. falciparum circumsporozoite protein, showed no clear evidence of strain-specific efficacy.4,5 Circumsporozoite protein has polymorphism within two major T-cell epitopes, and although there is some variation in the immunodominant central repeat region, for decades it has been hoped that antibodies targeting a single dominant epitope based on the tetrapeptide repeat NANP would provide strain-transcending immunity. A molecular epidemiologic study showed no evidence of naturally acquired strain-specific immunity to different variants of circumsporozoite protein in African children,6 which added to the hope that RTS,S might not be threatened by “vaccine-resistant malaria.”7

These previous studies each examined malaria parasites in a few hundred children at a single African site and were constrained by the challenges of sequencing the long central repeat region of the circumsporozoite protein. Neafsey et al.8 now describe in the Journal how they used next-generation sequencing to measure strain-specific efficacy in a phase 3 trial of RTS,S/AS01 involving 15,000 children at 11 study sites across Africa. Parasite DNA was extracted from several thousand dried blood spots collected from children who were randomly assigned to receive the malaria vaccine or a control vaccine, and the efficacy of the vaccine against infection and clinical malaria with circumsporozoite protein identical to, or different from, the vaccine strain 3D7 was measured by means of a sieve analysis.9

The approach is straightforward: if vaccine-induced immunity is acting like a sieve that filters out parasites that are identical to the vaccine strain at immunologically important polymorphic amino acid positions, then less vaccine-type malaria should occur among vaccinated children, as compared with the control group. The large sample size was needed — vaccine-type parasites were in the minority at all study sites. Several predetermined analyses examining different variant components of circumsporozoite protein showed that, at least in older children, RTS,S/AS01 was indeed better at protecting against malaria caused by vaccine-type parasites. There was no such allele-specific efficacy in young infants, a group in which RTS,S efficacy was lower and in which there may have been different immune responses to both vaccination and malaria infection.

The effect of parasite genetic diversity on efficacy in older children was modest. Various measures of efficacy were approximately 10 to 15 percentage points lower when they were evaluated against non–vaccine-type parasites. This is a much smaller blow to efficacy than the more than 40-point deficit seen with a blood-stage vaccine.3

If we had a vaccine with 80% or 90% efficacy, we might be willing to accept a loss of this magnitude. But RTS,S/AS01 starts off with about 50 to 60% efficacy at best; the efficacy is lower in younger children, and it wanes over time. As this first malaria vaccine moves toward licensure, the results of this study should give pause to those considering whether, where, and when to deploy it. If RTS,S/AS01 is introduced into wide use, over time the loss of efficacy could be more profound than that seen during just a year of follow-up among children who are exposed to a large surrounding population of malaria parasites that are not under selection pressure from vaccine-induced immunity. The most prudent course may be to use RTS,S/AS01 in the specific populations that will benefit most, while redoubling efforts to improve this pioneering vaccine on the basis of new understanding provided by this study of the strain-specific basis of its partial efficacy.

The news is not all bad. The modest loss of efficacy against divergent parasites implies that RTS,S/AS01 offers some degree of cross-protection — vaccine escape is not complete. A multivalent version of RTS,S with carefully chosen circumsporozoite protein variants, possibly combined with additional antigens, might offer broader protection.10 The large set of molecular epidemiologic data on the prevalence of circumsporozoite protein variants across Africa that was generated for this study should provide the evidence needed to select a combination of strains for a more broadly efficacious, next-generation malaria vaccine.

PLoS Medicine
http://www.plosmedicine.org/
(Accessed 21 November 2015)

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The First Use of the Global Oral Cholera Vaccine Emergency Stockpile: Lessons from South Sudan
Abdinasir Abubakar, Andrew S. Azman, John Rumunu, Iza Ciglenecki, Trina Helderman, Haley West, Justin Lessler, David A. Sack, Stephen Martin, William Perea, Dominique Legros, Francisco J. Luquero
Health in Action | published 17 Nov 2015 | PLOS Medicine
10.1371/journal.pmed.1001901
Summary Points
:: A global oral cholera vaccine (OCV) stockpile was established in 2013 to improve rapid access to the vaccine in outbreaks and emergencies in which cholera risk is high. The first deployment from the global OCV stockpile was to South Sudan in 2014 because of high cholera risk from massive population displacements within the civil war.
:: 256,700 doses of OCV were delivered, with high coverage, throughout the country as part of a comprehensive cholera prevention strategy by multiple agencies, some of which had little to no previous experience with this vaccine.
:: A cholera epidemic began during vaccination, and a basic comparison of epidemic curves in vaccinated and unvaccinated areas suggests little to no transmission occurred in vaccinated areas, though more in depth analysis is needed.
:: This deployment highlights the feasibility of effective deployments from the OCV stockpile and the importance of strong coordination between governmental and nongovernmental agencies in cholera prevention and control planning from the assessment of cholera risk to the deployment of the vaccines.
:: A larger global supply of OCV is urgently needed to cover those most in need. With limited vaccine availability now and likely in the upcoming years, more work is needed on deciding how to most efficiently use the vaccine, which may include alternative dosing regimens and targeting specific subpopulations.

PLoS One
http://www.plosone.org/
[Accessed 21 November 2015]

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Developing and Optimising the Use of Logic Models in Systematic Reviews: Exploring Practice and Good Practice in the Use of Programme Theory in Reviews
Dylan Kneale, James Thomas, Katherine Harris
Research Article | published 17 Nov 2015 | PLOS ONE
10.1371/journal.pone.0142187
Abstract
Background
Logic models are becoming an increasingly common feature of systematic reviews, as is the use of programme theory more generally in systematic reviewing. Logic models offer a framework to help reviewers to ‘think’ conceptually at various points during the review, and can be a useful tool in defining study inclusion and exclusion criteria, guiding the search strategy, identifying relevant outcomes, identifying mediating and moderating factors, and communicating review findings.
Methods and Findings
In this paper we critique the use of logic models in systematic reviews and protocols drawn from two databases representing reviews of health interventions and international development interventions. Programme theory featured only in a minority of the reviews and protocols included. Despite drawing from different disciplinary traditions, reviews and protocols from both sources shared several limitations in their use of logic models and theories of change, and these were used almost unanimously to solely depict pictorially the way in which the intervention worked. Logic models and theories of change were consequently rarely used to communicate the findings of the review.
Conclusions
Logic models have the potential to be an aid integral throughout the systematic reviewing process. The absence of good practice around their use and development may be one reason for the apparent limited utility of logic models in many existing systematic reviews. These concerns are addressed in the second half of this paper, where we offer a set of principles in the use of logic models and an example of how we constructed a logic model for a review of school-based asthma interventions.

Revista Panamericana de Salud Pública/Pan American Journal of Public Health (RPSP/PAJPH)
September 2015 Vol. 38, No. 3
http://www.paho.org/journal/

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SERIES ON EQUITY IN HEALTH AND SUSTAINABLE DEVELOPMENT
Social determinants and inequalities in tuberculosis incidence in Latin America and the Caribbean [Determinantes sociales y desigualdades en la incidencia de tuberculosis en América Latina y el Caribe]
César V. Munayco, Oscar J. Mújica, Francisco X. León, Mirtha del Granado, and Marcos A. Espinal

La ventaja epidemiológica de la orientación preferencial del control de la tuberculosis hacia los pobres [The epidemiological advantage of preferential targeting of tuberculosis control at the poor]
J. R. Andrews, S. Basu, D. W. Dowdy, and M. B. Murray

Science
20 November 2015 vol 350, issue 6263, pages 885-1000
http://www.sciencemag.org/current.dtl

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Feature
What does a disease deserve?
Jocelyn Kaiser
Since the early 1990s, Congress and the National Institutes of Health (NIH) have agreed to dedicate roughly 10% of the NIH budget to fighting HIV/AIDS. Now, however, that special arrangement is under fire. Health policy experts, lawmakers, and even NIH officials have wondered why, 2 decades after AIDS death rates began dropping dramatically in the United States, the disease still gets a lion’s share of NIH resources, or $3 billion this year. As questions have arisen about how HIV/AIDS research funds are spent, NIH has also resolved to refocus AIDS money on ending the epidemic. Some voice a broader critique: that NIH’s spending on a disease often doesn’t align with how much suffering it causes. They note that diseases imposing a relatively small burden on U.S. society, such as AIDS, can get a larger share of NIH funding than those that cause greater harm, such as heart disease. Recently, while responding to pointed questions from a member of Congress about the issue, NIH Director Francis Collins said the agency is ready to abandon the 10% set-aside. And next month officials are expected to release an agency-wide strategic plan that they say will address how disease burden should influence the allocation of research dollars.

Social Science & Medicine
Volume 144, Pages 1-148 (November 2015)
http://www.sciencedirect.com/science/journal/02779536/144

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Toward a multidimensional understanding of culture for health interventions
Original Research Article
Pages 79-87
Asad L. Asad, Tamara Kay
Abstract
Although a substantial literature examines the relationship between culture and health in myriad individual contexts, a lack of comparative data across settings has resulted in disparate and imprecise conceptualizations of the concept for scholars and practitioners alike. This article examines scholars and practitioners’ understandings of culture in relation to health interventions. Drawing on 169 interviews with officials from three different nongovernmental organizations working on health issues in multiple countries—Partners in Health, Oxfam America, and Sesame Workshop—we examine how these respondents’ interpretations of culture converge or diverge with recent developments in the study of the concept, as well as how these understandings influence health interventions at three different stages—design, implementation, and evaluation—of a project. Based on these analyses, a tripartite definition of culture is built—as knowledge, practice, and change—and these distinct conceptualizations are linked to the success or failure of a project at each stage of an intervention. In so doing, the study provides a descriptive and analytical starting point for scholars interested in understanding the theoretical and empirical relevance of culture for health interventions, and sets forth concrete recommendations for practitioners working to achieve robust improvements in health outcomes.

Social Science & Medicine
Volume 144, Pages 1-148 (November 2015)
http://www.sciencedirect.com/science/journal/02779536/144

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Toward a multidimensional understanding of culture for health interventions
Original Research Article
Pages 79-87
Asad L. Asad, Tamara Kay
Abstract
Although a substantial literature examines the relationship between culture and health in myriad individual contexts, a lack of comparative data across settings has resulted in disparate and imprecise conceptualizations of the concept for scholars and practitioners alike. This article examines scholars and practitioners’ understandings of culture in relation to health interventions. Drawing on 169 interviews with officials from three different nongovernmental organizations working on health issues in multiple countries—Partners in Health, Oxfam America, and Sesame Workshop—we examine how these respondents’ interpretations of culture converge or diverge with recent developments in the study of the concept, as well as how these understandings influence health interventions at three different stages—design, implementation, and evaluation—of a project. Based on these analyses, a tripartite definition of culture is built—as knowledge, practice, and change—and these distinct conceptualizations are linked to the success or failure of a project at each stage of an intervention. In so doing, the study provides a descriptive and analytical starting point for scholars interested in understanding the theoretical and empirical relevance of culture for health interventions, and sets forth concrete recommendations for practitioners working to achieve robust improvements in health outcomes.

Tropical Medicine & International Health
November 2015 Volume 20, Issue 11 Pages 1405–1589
http://onlinelibrary.wiley.com/doi/10.1111/tmi.2015.20.issue-11/issuetoc

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Improving survey data on pregnancy-related deaths in low-and middle-income countries: a validation study in Senegal (pages 1415–1423)
Stéphane Helleringer, Gilles Pison, Bruno Masquelier, Almamy Malick Kanté, Laetitia Douillot, Cheikh Tidiane Ndiaye, Géraldine Duthé, Cheikh Sokhna and Valérie Delaunay
Article first published online: 28 AUG 2015 | DOI: 10.1111/tmi.12583

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Reduction in symptomatic malaria prevalence through proactive community treatment in rural Senegal (pages 1438–1446)
Annē M. Linn, Youssoupha Ndiaye, Ian Hennessee, Seynabou Gaye, Patrick Linn, Karin Nordstrom and Matt McLaughlin
Article first published online: 7 AUG 2015 | DOI: 10.1111/tmi.12564

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Use of a bibliometric literature review to assess medical research capacity in post-conflict and developing countries: Somaliland 1991–2013 (pages 1507–1515)
Ross Boyce, Richard Rosch, Alexander Finlayson, Djibril Handuleh, Said Ahmed Walhad, Susannah Whitwell and Andy Leather
Article first published online: 14 SEP 2015 | DOI: 10.1111/tmi.12590

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Disease mapping for informing targeted health interventions: childhood pneumonia in Bohol, Philippines (pages 1525–1533)
Deborah S. K. Thomas, Peter Anthamatten, Elisabeth Dowling Root, Marilla Lucero, Hanna Nohynek, Veronica Tallo, Gail M. Williams, Eric A. F. Simões and the ARIVAC Consortium
Article first published online: 21 JUL 2015 | DOI: 10.1111/tmi.12561

Advanced Drug Delivery Reviews
Available online 17 November 2015

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In Press, Accepted Manuscript
Novel adjuvant formulations for delivery of anti-tuberculosis vaccine candidates
EM Agger
Abstract
There is an urgent need for a new and improved vaccine against tuberculosis for controlling this disease that continues to pose a global health threat. The current research strategy is to replace the present BCG vaccine or boost BCG-immunity with subunit vaccines such as viral vectored- or protein-based vaccines. The use of recombinant proteins holds a number of production advantages including ease of scalability, but requires an adjuvant inducing cell-mediated immune responses. A number of promising novel adjuvant formulations have recently been designed and show evidence of induction of cellular immune responses in humans. A common trait of effective TB adjuvants including those already in current clinical testing is a two-component approach combining a delivery system with an appropriate immunomodulator. This review summarises the status of current TB adjuvant research with a focus on the division of labor between delivery systems and immunomodulators.

Clinical Nursing Studies

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International Peer-reviewed and Open Access Journal for the Clinical Nursing Specialists
Vol 4, No 1 (2016)
Evaluation of specific antibody responses to selected malaria vaccine candidates in Zimbabwean children
A Marume, G. Nyandoro, I Mutingwende, M. Tshabalala, T. Gozho, N Paul, J. Gusha, E Zumbika, N. Midzi, Takafira Mduluza
Abstract
Introduction: There is high malaria related morbidity and mortality amongst infants and children in malaria endemic areas. An In-depth understanding of protective immunity correlates enables the long due necessary development of an effective malaria vaccine. This study aimed at evaluating antibody responses to apical membrane antigen 1 (AMA 1) that helps P falciparum entry into red blood cells, Glutamate rich protein (GLURP), an antigen expressed in the whole life cycle of the malaria causing pathogen, merozoite surface protein-1 (MSP 1) coding for a major antigen in the asexual stage of P falciparum and merozoite surface protein 3 (MSP 3), a polymorphic blood stage malaria antigen in Zimbabwean children living in malaria endemic areas.
Methods: We characterized humoral immune responses to malaria vaccine candidates in a two year longitudinal survey among 136 children (6-16 years) from Burma and Kariba in Zimbabwe. Blood samples were collected and analyzed for malaria parasites, plasma and antibody titers against malaria vaccine candidates [MSP1, MSP3, GLURP, AMA] by ELISA technique. The blood samples were also checked for potential confounders like anemia, bilharzia and HIV sero-status using the ELISA technique.
Results: Ig levels were significantly different (p < .0001) across the three time points, and against the different candidates (p < .0001). MSP3 had the highest (13,552.2) and GLURP the least (4,741.6) IgM titers. However, IgG, IgG1, IgG3 and IgG4 levels were highest against AMA compared to other vaccine candidates, [anti-MSP3 IgG3 (15.3) and anti-GLURP IgG4 (58.7)]. Anemia burden was about 44% at baseline with a threefold decrease (-16%) over the 12 month follow up.
Conclusions: This study highlights the need for robust evaluation of several malaria vaccine candidates in combination to understand correlates of protective immunity as suggested by the significant antibody levels against the four vaccine candidates. Longer follow up periods are needed to assess the impact of continuous malaria exposure on host immune responses. Multivalent malaria vaccine development offer a better chance towards an efficacious malaria vaccine compared to monovalent vaccine. Antibody levels against the four vaccine candidates were significant suggesting that an ideal malaria vaccine should target more than one antigen.

Infectious Agents and Cancer
December 2015, 10:41

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Cross-sectional study about primary health care professionals views on the inclusion of the vaccine against human papillomavirus in the vaccine schedules
M. Reyes Oliver Pérez, Victoria Bravo Violeta, Ana Vazquez del Campo, Cristina Ruiz, Ionia Yáñez Castaño, Laura P. Pérez Conde, Jesús S. Jiménez López
Abstract
Background
Although the inclusion of the HPV vaccine has been registered in Spain since 2007, vaccination rates are lower than expected. The patients wish to be vaccinated is heavily influenced by information they have received from many source. The Knowledge of primary health care professionals affects the information provided to patients and is fundamental in the decision making. The aim of this study is to assess the opinions of primary health care professionals on the vaccine against HPV and their knowledge about HPV infection and its links to with gynecological and oropharyngeal cancer.
Methods
Cross-sectional study. A 19-item survey was drawn up. It included questions on basic aspects of HPV infection and marketed vaccines, personal opinion about the inclusion in the immunization schedules and their level of prescription and recommendation to patients in their clinical practice. From October 2013 to December 2013, 607 surveys were distributed among 20 primary health centers affiliated to the University Hospital 12 de Octubre. The results were analyzed using SPSS statistical package.
Results
One hundred sixty four successfully completed surveys were obtained for analysis. 89 % of the professionals knew about the relationship between HPV infection and cervical cancer, 57.3 % did not know any of the serotypes against which vaccines are targeted; 40.4 % believed that there is insufficient data to support the commercialization of the vaccines. Of these, 65.7 % argue that there is no data of its long-term effectiveness, 13.4 % that there is no data as to its side effects, 13.4 % believed that the cost effectiveness is not worthwhile.
Conclusions
There is a strong controversy among health professionals regarding the marketing and inclusion of HPV vaccine in immunization schedules. However, the knowledge of the primary care health professionals on key aspects of infection and vaccine protection are insufficient. The training of professionals in vaccination, cervical pathology and HPV infection should be improved to provide objective information on the use as this vaccine for patients.

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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Center for Global Development
http://www.cgdev.org/
Press Release
Nancy Birdsall to Step Down as CGD President
November 16, 2015
The Center for Global Development today announced that Nancy Birdsall is to step down as president in 2016, once a successor is in place. Birdsall, CGD’s founding president, will stay with the Center as a senior fellow.
“This is an exciting moment for me and for CGD,” said Birdsall. “The Center, though still youthful and disruptive, is in fact a mature and established institution. And the key to CGD’s success has always been hard-wired into its culture: a value-driven ‘think and do’ approach based on top-grade research and practical ideas. That’s bigger than any one person. Knowing that makes me confident that this transition will inspire change along with continuity.”
Birdsall, a former executive vice president at the Inter-American Development Bank and head of the World Bank policy research department, co-founded the Center in 2001 to analyze how the policies and actions of rich country governments and international financial institutions affect people in the developing world…

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New York Times
http://www.nytimes.com/
Accessed 21 November 2015
Africa
Ebola Cases in 3 Family Members Confirmed in Liberia
By CLAIR MacDOUGALL and HELENE COOPERNOV. 20, 2015

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

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– pdf version:  A pdf of the current issue is available here:  Vaccines and Global Health_The Week in Review_14 November 2015

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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

ADVISORY GROUP OBSERVATIONS ON WHO’S CORE MANDATE, FUNDAMENTAL PRINCIPLES AND CRITICAL FUNCTIONS :: FIRST REPORT | EXECUTIVE SUMMARY | ADVANCE VERSION | NOVEMBER 6TH 2015 –
ADVISORY GROUP ON REFORM OF WHO’S WORK IN OUTBREAKS AND EMERGENCIES
[Editor’s text bolding]

1. The Advisory Group acknowledges that at all times WHO is committed to the “attainment by all peoples of the highest possible level of health”. Hence WHO’s responsibility to provide technical assistance and aid in emergencies. This is expressly set out in Article 2(d) of the Organization’s Constitution and has been recognized in numerous resolutions of the World Health Assembly.1
1WHA34.26, WHA46.6, WHA48.2, WHA58.1, WHA59.22 and WHA64.10.

2. To fulfil this mandate, WHO needs sufficient operational capability to lead and support preparation for and responses to disease outbreaks and humanitarian emergencies with health and humanitarian consequences. In these situations, WHO must exercise decisive leadership on the health aspects of the response, while supporting national authorities and operating as one partner alongside other international and local actors for health – each of whom have their own responsibilities and expertise in the different aspects of the work in outbreaks and emergencies.

3. WHO is expected to demonstrate that it is an independent and impartial institution that gives priority to the health and well-being of all people, especially those who are vulnerable. Article 37 of the WHO Constitution stipulates that in the “performance of their duties the Director-General and the staff shall not seek or receive instructions from any government or from any authority external to the Organization… Each Member of the Organization on its part undertakes to respect the exclusively international character of the Director-General and the staff and not to seek to influence them.” Independence and impartiality underpin WHO’s mandate and are expected of WHO staff at all levels. These fundamental principles should be made much more explicit both in all work undertaken throughout the Organization and in all its external communications.

4. The Advisory Group recommends the development of an overarching Framework for WHO’s activities in Outbreaks and Emergencies that will cover all phases of the emergency management cycle – preparedness, readiness, alert, response, recovery and prevention. The Framework should incorporate six critical functions that WHO must address when working on outbreaks and emergencies – (i) leadership for the health of all people; (ii) engagement with political leaders (when necessary, beyond the Minister for Health); (iii) capacity for coordination; (iv) scientific and technical expertise (backed by research and development); (v) information and communications; and (vi) offering services to people whose urgent needs are not being met by any other provider.

ADVISORY GROUP RECOMMENDATIONS FOR THE TRANSFORMATION OF WHO
5. WHO must quickly develop the capability to provide credible leadership and offer effective support for the collective efforts to ensure the health of all people facing outbreaks and emergencies. The establishment of this capability will require political commitment from WHO’s Member States, structural change within the Organization, an evolution of internal culture, a strengthening of relationships with external actors, and the application of new authorities, mechanisms, procedures and systems for accountability.

6. The Advisory Group recommends the immediate establishment of a centrally-managed, global Programme for Outbreaks and Emergencies Management. This Programme will be a separate, dedicated entity within the Organization. It will bring together all the units and functions across the country, regional and headquarter levels that work on disease outbreaks, on emergencies and on International Health Regulations core capacities related to surveillance, alert and response. Some Advisory Group members have emphasized that the Programme would address, among other things, events that may constitute a public health emergency of international concern and include the functions of the WHO International Health Regulations contact point.

7. The Programme should be headed by an Executive Director at the rank of Deputy Director-General who reports to the Director-General and the Global Policy Group. The Executive Director will be responsible and accountable for the centralized management of the budget and human resources of the Programme.

8. The Programme should include a dedicated Platform to support readiness and response operations in countries and in communities. Given the number of outbreaks and emergencies being addressed at any one time, it is anticipated the Platform will always be operational to varying degrees. When a risk assessment or a sudden-onset event indicates that significant action is needed, an Incident Manager may be appointed: in some instances by the Director-General (at the recommendation of the Executive Director); in other instances by the Executive Director. The Incident Manager will have the delegated authority to build support teams, access financing and procure necessary supplies. While reporting to the Executive Director, the Incident Manager will also work in close consultation with the relevant Country Representative and relevant Regional Director. Depending on the outbreak or emergency, the Country Representative may be appointed as the Incident Manager. The Platform should interface seamlessly and be interoperable with other similar Platforms established by national authorities, the UN system and partners.

9. The Programme will have the following key features:
a. A standing capacity to handle outbreak surveillance, risk assessment and management, planning, partnerships, information and communications, human resources, logistics, finance, quality assurance and monitoring;
b. Standardized procedures for operations, including pre-planned and tested procedures to ensure immediate responses to imminent crises;
c. Dedicated and tailored business processes and mechanisms for managing human resources, financing and information technology

10. To sustain these capabilities the Programme and Platform will require predictable “steady-state financing” as well as prompt access to a reliable contingency fund in case of need: this contingency fund should be replenished promptly once used. The Advisory Group will examine options for financing the Programme. Some Advisory Group members have highlighted the need for increased allocations to the core budget of the Organization so that the Programme can be adequately financed.

11. An external, independent oversight body should be established by the Director General to monitor the performance of the Programme and the Platform using benchmarks established for this purpose.

ADVISORY GROUP RECOMMENDATIONS FOR WHO’S STRATEGIC COLLABORATIONS
12. The central focus of WHO’s involvement in outbreaks and emergencies is to enable national authorities, local communities and other actors for health to be more effective and resilient. In these circumstances WHO has two responsibilities – firstly, enabling countries to deal with outbreaks and emergencies themselves and, secondly, leading and supporting other actors for health through the provision of strategic direction, reliable information, coordination and technical guidance.

13. The Advisory Group recommends that to enable countries to prepare and respond to outbreaks and emergencies, WHO should lead independent and comprehensive risk assessments. These will generally be undertaken jointly with the authorities of countries affected by outbreaks and emergencies, as well as with operational partners. Risk assessments will reach conclusions on the level of alert necessary, action to be triggered and means through which the risks are communicated to different audiences. In settings where the national authorities are not in a position to participate in comprehensive risk assessments, WHO would perform this function in collaboration with local-level, national and international actors in ways that reflect the best interests of all the affected communities.

14. The Advisory Group notes that in its work to lead and support other actors for health, WHO should operate within the existing humanitarian architecture – the Inter-Agency Standing Committee, including the Global Health Cluster. The Advisory Group recommends that WHO reaffirm its commitment to stronger and more visible leadership of the Health Cluster, and to consistent high-level engagement with the Inter-Agency Standing Committee. The Advisory Group proposes that WHO seeks to build stronger linkages with other humanitarian Clusters whose activities contribute to people’s health and well-being (e.g. water and sanitation, food, nutrition and protection). WHO should ensure that its Cluster activities are treated as part of its core mandate and have predictable funding. WHO should also establish partnership agreements with humanitarian and other partners to put in place a framework for cooperation and clarify the respective roles and responsibilities of the partners.

15. The Advisory Group considers that the Global Outbreak Alert and Response Network (GOARN) is another collaboration mechanism that needs to be strengthened. Training GOARN members in teams and involving them in joint risk assessments will help enhance their readiness to deploy. WHO should encourage long-term investments in GOARN so as to increase national, regional and global capabilities for risk assessment, management and communication in outbreaks, as well as preparedness and prevention – especially in relation to risks posed by unfamiliar and potentially dangerous pathogens.

ADVISORY GROUP RECOMMENDATIONS FOR IMMEDIATE ACTION
16. The Advisory Group recommends that the Director-General take immediate action to:
a. Reaffirm WHO’s commitment to strengthened leadership of the Global Health Cluster, and to more active engagement with the Inter-Agency Standing Committee;
b. Establish standby partnership agreements with humanitarian and other partners that can be activated under defined circumstances;
c. Restructure WHO to enable it to lead and support collective efforts in outbreaks and emergencies, with the establishment of the single Programme, its Platform for operation and centralization of the budget and of accountability for its work;
d. Redesign WHO’s human resources management system to establish systems that reflect the needs of the Programme and Platform and implement the changes immediately; and
e. Transform financial management processes so that there is no delay in accessing funds required for outbreaks and emergencies and implement the changes immediately.

17. The Advisory Group recommends that the Executive Director be engaged in the redesign of Human Resources and Financial Management Processes.

This is an advance version of the Executive Summary from the First Report of the Advisory Group on Reform of WHO’s Work in Outbreaks and Emergencies with Health and Humanitarian Consequences. The definitive version will be released with the First Report when it has been completed. Target Completion Date: November 16th 2015.

EBOLA/EVD [to 21 November 2015]
Public Health Emergency of International Concern (PHEIC); “Threat to international peace and security” (UN Security Council)

Ebola Situation Report – 11 November 2015
[Excerpt]
SUMMARY
:: On 7 November WHO declared that Ebola virus transmission had been stopped in Sierra Leone. The country has now entered a 90-day period of enhanced surveillance, which is scheduled to conclude on 5 February 2016. Both Liberia and Sierra Leone have now achieved objective 1 of the phase 3 response framework: to interrupt all remaining chains of Ebola virus transmission. Guinea reported no confirmed cases in the week to 8 November. A total of 4 cases have been reported from Guinea in the past 21 days, all of whom are members of the same family from the village of Kondeyah, in the subprefecture of Kaliah in Forecariah. All 69 contacts currently being followed in Guinea are located in Kaliah and are scheduled to complete their 21-day follow-up period on 21 November. However, 60 of the contacts are considered to be high risk, and one contact from Forecariah has been lost to follow up with the past 42 days. Therefore there remains a near-term risk of further cases among both registered and untraced contacts.

:: Robust surveillance measures are essential to ensure the rapid detection of any reintroduction or re-emergence of Ebola virus disease (EVD) in currently unaffected areas, and are central to the attainment of objective 2 of the phase 3 response framework: to manage and respond to the consequences of residual Ebola risks. To that end, Guinea, Liberia, and Sierra Leone have each put systems in place to enable members of the public to report any case of illness or death that they suspect may be related to EVD. In the week to 8 November, 24 634 such alerts were reported in Guinea, with alerts reported from all of the country’s 34 prefectures. Equivalent data are not currently available for Liberia. In Sierra Leone, 1690 alerts were reported from 12 of 14 districts in the week ending 25 October (the most recent week for which data are available).

:: As part of each country’s EVD surveillance strategy, blood samples or oral swabs should be collected from any individuals with clinical symptoms compatible with EVD, and from any dead person aged 5 years and above who died within 14 days of onset of symptoms and for whom cause of death has not been determined. In the week to 8, November 9 operational laboratories in Guinea tested a total of 633 new and repeat samples from 12 of the country’s 34 prefectures. 89% of all samples tested in Guinea were swabs collected from dead bodies. By contrast, 79% of the 653 new samples tested in Liberia over the same period were blood samples collected from live patients. In addition, all 15 counties in Liberia submitted samples for testing by the country’s 4 operational laboratories. 1294 new samples were collected from all 14 districts in Sierra Leone and tested by 9 operational laboratories. 77% of samples in Sierra Leone were swabs collected from dead bodies.

:: 470 deaths in the community were reported from Guinea in the week to 8 November. This represents approximately 20% of the 2248 deaths expected based on estimates of the population and a crude mortality rate of 11 deaths per 1000 people per year. All but 4 of the 470 reported deaths were buried safely. Equivalent data are not yet available for Liberia. In Sierra Leone, 1452 reports of community deaths were received through the alert system during the week ending 25 October (the most recent week for which data are available), representing approximately 70% of the 2075 deaths expected each week based on estimates of the population and a crude mortality rate of 17 deaths per 1000 people per year….

Measles [to 21 November 2015]

Measles vaccination has saved an estimated 17.1 million lives since 2000
But, 2015 global milestones and measles elimination goals are off track
WHO News release
12 November 2015 ¦ GENEVA – The number of measles-related deaths has decreased 79% from 546 800 at the beginning of the century to 114 900 in 2014. New data released by WHO for the Measles & Rubella Initiative, estimates that 17.1 million lives have been saved since 2000, largely due to increased vaccination coverage against this highly contagious viral disease. Measles vaccination has played a key role in reducing child mortality and in progress towards Millennium Development Goal 4.

However, the new data published in this week’s edition of the Centers for Disease Control and Prevention’s (CDC), “Morbidity and Mortality Weekly Report” and WHO’s “Weekly Epidemiological Record”, shows that overall progress towards increasing global immunization coverage has recently stagnated. While coverage with the first dose of the measles vaccine increased globally from 72% to 85% between 2000 and 2010, it has remained unchanged the past 4 years.

“We cannot afford to drop our guard,” says Dr Jean-Marie Okwo-Bele, Director of WHO’s Department of Immunization, Vaccines and Biologicals. “If children miss routine vaccination and are not reached by national immunization campaigns, we will not close the immunization gap.”

Based on current trends of measles vaccination coverage and incidence, the 2015 global milestones and measles elimination goals set by WHO’s Member States will not be achieved on time.

Although all countries include at least 1 dose of measles-containing vaccine in their routine vaccination schedule, only 122 (63%) have met the target of at least 90% of children vaccinated with a first dose. Additionally, only half of the world’s children are receiving the recommended second dose of the vaccine.

Success of immunization campaigns
In 2014, mass vaccination campaigns led by country governments with support from the Measles & Rubella Initiative and Gavi, the Vaccine Alliance, reached approximately 221 million children. Twenty-nine countries supplemented their routine vaccination programmes with mass immunization campaigns, helping to reduce measles incidence in 4 out of 6 WHO regions last year. Overall, since 2000, these campaigns have enabled 2 billion children to receive a supplemental dose of measles vaccine.

In the African Region, cases dropped from over 171 000 in 2013 to under 74 000 in 2014, likely due to campaigns in Democratic Republic of the Congo (DRC) and Nigeria. WHO’s Eastern Mediterranean, European and the South-East Asia regions also saw decreases in measles incidence in 2014.

Large-scale campaigns in 2014 included:
:: Bangladesh – more than 53.6 million children vaccinated
:: DRC – more than 18.5 million children vaccinated
:: Pakistan – more than 25 million children vaccinated
:: United Republic of Tanzania – more than 20.5 million children vaccinated
:: Yemen – more than 11.3 million children vaccinated
:: Viet Nam – more than 15.1 children vaccinated

“Last year, the Measles and Rubella Initiative supported campaigns in 29 high-risk countries to stop measles, including in Liberia where a serious outbreak occurred following the Ebola epidemic. Funding for many of the largest campaigns came from Gavi, the Vaccine Alliance. Gavi’s support for measles campaigns in large countries like DRC and Pakistan, and measles-rubella vaccine introduction through campaigns targeting children under 15 years of age, is providing a strong boost to measles control and elimination in those countries, ” says Dr Robert Linkins, Chief, Accelerated Disease Control and Surveillance Branch at the U.S. Centers for Disease Control and Prevention.

“Despite our success in these countries, globally over 100 000 children needlessly died from measles last year. That’s a tragedy which can be easily prevented if we intensify our measles surveillance and vaccination efforts,” Linkins concluded.

Measles outbreaks remain an issue
Measles outbreaks, which happen when there are gaps in vaccination programmes, continue to pose a serious challenge to meeting global targets. The Americas and Western Pacific regions saw increased numbers of cases in 2014, mostly due to large outbreaks in China, the Philippines, and Viet Nam. In other regions, although the overall number of cases fell, some individual countries still had large outbreaks, including Angola, Ethiopia, India, the Russian Federation and Somalia….

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MSF/Médecins Sans Frontières [to 21 November 2015]
http://www.doctorswithoutborders.org/news-stories/press/press-releases
Field news
Fighting Measles in DRC “Like Trying to Put out a Forest Fire Blindfolded”
November 12, 2015
A deadly measles epidemic continues to spread through Katanga province, in southern Democratic Republic of Congo (DRC), with devastating effects on the very young. For the past two months, Doctors Without Borders/Médecins Sans Frontières (MSF) doctor Marion Osterberger has been working in Ankoro hospital, which has become so overcrowded with patients that up to five children have had to share each bed.

POLIO [to 21 November 2015]
Public Health Emergency of International Concern (PHEIC)

GPEI Update: Polio this week as of 11 November 2015
http://www.polioeradication.org/Dataandmonitoring/Poliothisweek.aspx
:: Three years since no wild poliovirus type 3: the 10th of November is an opportunity to mark three years with no child paralysed by wild poliovirus type 3 (WPV3); a reminder of the role of surveillance in ensuring the world is polio free, and of innovations in driving the programme forward. For more, please click here.

:: Following its meeting in October, the Independent Monitoring Board (IMB) published its latest report evaluating the current status of polio eradication. The report is available here.

:: This week, the Emergency Committee of the International Health Regulations (IHR) is meeting by teleconference, to determine whether the current epidemiology continues to represent a public health emergency of international concern, and whether to maintain the temporary recommendations associated with it for a further three months. The Committee’s report is expected to be published by early next week.

:: The Global Commission for the Certification of Poliomyelitis Eradication (GCC) published an editorial in Science magazine, on the importance of ensuring global containment of type 2 polioviruses, following the group’s declaration in September that wild poliovirus type 2 has been globally eradicated. The containment of type 2 polioviruses is particularly critical, in the lead-up to the switch from trivalent OPV to bivalent OPV in April 2016. The editorial is available here.

[Selected elements from Country-level reports]
Afghanistan
:: Urgent efforts are underway to strengthen the implementation of the national emergency action plan in the country. Focus is on:
– Improving governance and coordination of partners through the National and Provincial Emergency Operations Centres
– Improving SIA quality by focusing resources on low-performing districts, and clearly identifying and targeting persistently missed children
– Maximising the impact of front-line health workers through more systematic vaccinator selection, training and supervision
– Ensuring closer cross-border coordination in border areas with Pakistan
– Further strengthening surveillance, including by expanding environmental surveillance activities
:: National Immunization Days (NIDs) took place on 1 – 3 November using trivalent oral polio vaccine (OPV). Mop up campaigns are planned in areas of Farah using inactivated polio vaccine (IPV) and bivalent OPV with dates to be confirmed, and Subnational Immunisation Days (SNIDs) are planned from 29 November to 1 December in the south and east of the country using bivalent OPV.
Pakistan
:: One new wild poliovirus type 1 (WPV1) case was reported in the past week, with onset of paralysis on 21 October. It is the most recent WPV1 case in the country, from Khyber in Federally Administered Tribal Areas (FATA). The total number of WPV1 cases for 2015 is 39.
September and October have historically been the months with the highest disease burden, as it is in the middle of the high transmission season. Epidemiologists are further evaluating data from this year, to more clearly ascertain current transmission patterns during this year’s high transmission season. This year, five WPV1 cases occurred during September and October, compared to 79 WPV1 cases in September/October 2014.
Lao People’s Democratic Republic
:: One new case of circulating vaccine-derived poliovirus type 1 (cVDPV1) was reported in the past week, in Bolikhanh district of Borkihamxay province, with onset of paralysis on 29 September. The total number of cVDPV1 cases in 2015 is three.
:: Emergency outbreak response is continuing in the country, with particular focus on three high-risk provinces. The first Subnational Immunization Days (SNIDs) using trivalent oral polio vaccine (OPV) is underway targeting an expanded age group of children under the age of fifteen in the three most high risk districts, and children under the age of ten elsewhere.
:: All three cases come from the same village. Efforts are underway to further strengthen surveillance activities in other parts of the country, to determine if other sources of transmission are occurring elsewhere in the country.
:: In neighbouring countries, notably Thailand and Vietnam, both surveillance and immunization activities have been stepped up, particularly in border areas.

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NOW IS THE TIME FOR PEAK PERFORMANCE
Independent Monitoring Board (IMB) of the Global Polio Eradication Initiative
Twelfth Report, October 2015 :: 32 pages
OVERVIEW
1.. The number of cases of polio that have occurred so far in 2015 is at its lowest point in history.

2. Since the last report of the Independent Monitoring Board (IMB), Nigeria has been removed from the list of polio endemic countries. Only two now remain: Pakistan and Afghanistan. No Wild Polio Virus (WPV) Type 3 has been reported anywhere in the world since November 2012, no WPV2 has arisen since 1999, and no WPV1 has been found in Africa since August 2014 in Somalia. These are major achievements.

3. The Global Polio Eradication Initiative (GPEI) has implemented changes to its structure and functioning following the management and governance review that reported in 2014. Decision-making, partnership working, overall leadership, financial transparency, and the cohesiveness of the programme have steadily improved since then but the level of coordination across partners
necessary to assure high within-country performance remains problematic.

4. The Polio Oversight Board (POB), at its meeting at the end of September 2015, after reviewing four end-of-transmission scenarios, concluded that the most likely outcome of the eradication programme is that polio transmission will be interrupted in 2016, and eradication
officially certified by 2019. This was given the status of a formal voting decision by the Board. This scenario has been costed by the Board’s Finance and Accountability Committee and requires $1.5 billion of funding on top of the budget already earmarked for eradication.

5. Should polio transmission not be interrupted by 2016, a further at least $800 million per year would be needed to deal with the consequences. This figure could easily be $1 billion per year.

KEY STEPS
6. The Polio Oversight Board’s decision to pick 2016 as the year in which transmission will be stopped is not merely a planning assumption. In effect, it sets a new deadline to follow the sequence of earlier missed deadlines that were set in the polio programme’s periodic strategic plans.

7. To create a realistic chance for this new timescale to be achieved, the following five measures are the minimum required:
:: High quality campaigns during the low season (the last before the deadline) in both Pakistan and Afghanistan;
:: Greatly strengthened resilience in areas of inaccessibility, and poor coverage, in Nigeria;
:: Massive cuts in the number of missed, and persistently missed, children in both endemic countries, Nigeria, and all other areas that are vulnerable because of low immunity levels;
:: Rigorous application, and careful targeting, of combined IPV/OPV in a more consistent way than hitherto in Pakistan and Afghanistan;
:: Major and rapid expansion of environmental surveillance throughout Pakistan and Afghanistan coupled with rigorous outbreak response action when positive samples are found.

8. The programme must be in no doubt that if it comes out of the forthcoming low season in Afghanistan and Pakistan with polio cases still occurring or with many positive environmental samples, then there will surely be further outbreaks of the polio virus.

MERS-CoV [to 21 November 2015]

Global Alert and Response (GAR) – Disease Outbreak News (DONs)
:: Middle East respiratory syndrome coronavirus (MERS-CoV) – Saudi Arabia
13 November 2015
Between 26 October and 1 November 2015, the National IHR Focal Point for the Kingdom of Saudi Arabia notified WHO of 7 additional cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection, including 1 death…

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IVI [to 21 November 2015]
http://www.ivi.org/web/www/home
MERS-CoV Vaccine Development Workshop in Riyadh, Saudi Arabia, Nov. 14-15, 2015
[undated]
IVI is co-organizer of a MERS-CoV vaccine development workshop with the Saudi Ministry of Health and King Abdulaziz City for Science and Technology from Nov. 14-15 in Riyadh, Saudi Arabia. The two-day international workshop will survey the work done so far on MERS-CoV vaccines and will bring together industry, academia, governments and research institutes to discuss coordinated approaches in MERS-CoV vaccine development. More information: http://saudigazette.com.sa/saudi-arabia/global-experts-to-address-coronavirus-conference
The workshop follows a MERS-CoV symposium organized by IVI and Shinil in Seoul, Korea on Sept. 10. IVI recently began an initiative to develop MERS-CoV vaccines with support from Samsung Medical Center.

WHO & Regionals [to 21 November 2015]

Iraq completes round one of oral cholera vaccination campaign
Baghdad, 12 November 2015 – This week, the Government of Iraq, with the support of WHO and UNICEF, completed the first round of the oral cholera vaccination campaign. The campaign has vaccinated 91% of the targeted population of 255 000 Syrian refugees and internally displaced Iraqis across 62 refugee and internally displaced persons camps in 13 governorates. The turnout was very high with no refusals or concerns raised regarding the vaccine. A second round will begin in December to administer a second dose to ensure protection against cholera for 5 years or more.

Oral cholera vaccination campaign
The OCV campaign was discussed and agreed by stakeholders in September 2015. This was followed by planning and training sessions for governorate-level managers of the Expanded Programme on Immunization in Baghdad on 26 and 27 October. On 28 October, training was provided to 1302 vaccinators and 651 social mobilizers in preparation for the first round of the mass vaccination campaign.

The Shanchol vaccine used in the campaign is a WHO prequalified vaccine. To achieve the required protection among high-risk groups, 2 doses of OCV Shanchol vaccine will be administered at an interval of 2 to 6 weeks.

The first round of the campaign, lasting 5 days, began on 31 October and the second round is due to take place in early December 2015. The administration of a second dose is needed to extend the duration of protection for 5 years or more. The vaccine is being administered to all persons over one year of age living in the target camps.

Cholera vaccination is an additional preventive measure that supplements but does not replace other traditional cholera control measures. “We need to intensify health promotion and education activities to help communities protect themselves and their families from cholera and other communicable diseases,” said acting WHO Representative Altaf Musani…

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Global Alert and Response (GAR) – Disease Outbreak News (DONs)
:: 13 November 2015 – Human infection with avian influenza A(H7N9) virus – China
:: 12 November 2015 – Dengue Fever – Egypt
:: 11 November 2015 – Zika virus infection – Suriname

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Weekly Epidemiological Record (WER) 13 November 2015, vol. 90, 46 (pp. 617–632)
Contents:
617 Global routine vaccination coverage, 2014
623 Progress towards regional measles elimination, worldwide, 2000–2014
632 WHO Strategic Advisory Group of Experts (SAGE) on immunization: request for nominations
WHO: Request for proposals: country review of the second-year-of-life visit and development of a field guide
11 November 2015
Information and submission of proposalspdf, 117kb
Deadline for application: 14 December 2015
:: WHO Regional Offices
WHO African Region AFRO
:: Health Ministers to discuss strategies and actions to tackle public health challenges in the African Region
Brazzaville, 12 November 2015 – Delegates from the 47 countries in the WHO African Region will meet in N’Djamena, Chad from 23-27 November 2015, for the annual session of the WHO Regional Committee. The week-long meeting is hosted by the Chadian government. The Regional Committee is the annual flagship meeting of ministers of health from the Region during which they discuss a range of strategies and actions to tackle public health challenges in the Region. As the highest decision-making body on health, its decisions have over the years contributed immensely towards improving the health and well-being of people
:: Measles vaccination has saved an estimated 17.1 million lives since 2000 – 11 November 2015
:: Affordable and effective vaccine brings Africa close to elimination of meningitis A – 10 November 2015

WHO Region of the Americas PAHO
:: Inequality is a major barrier to good health, according to new research published in Pan American Journal of Public Health (11/11/2015)

WHO South-East Asia Region SEARO
No new digest content identified.

WHO European Region EURO
:: Physical inactivity and diabetes 12-11-2015

WHO Eastern Mediterranean Region EMRO
:: Iraq completes round one of oral cholera vaccination campaign
Baghdad, 12 November 2015 – This week, the Government of Iraq, with the support of WHO and UNICEF, completed the first round of the oral cholera vaccination campaign. The campaign has vaccinated 91% of the targeted population of Syrian refugees and internally displaced Iraqis in camps around the country. The second round will begin in December to administer a second dose to ensure protection against cholera for 5 years or more… [See “Measles” above]
:: Join WHO Instagram campaign #YearsAhead and help combat ageism
November 2015
:: 4 million children in Sudan targeted with oral polio vaccine
8 November 2015

WHO Western Pacific Region
:: Pharmaceutical sector governance: critical to universal health coverage
Countries are being urged to invest in governance in their pharmaceutical sector, as an important building block of universal health coverage. WHO’s Good Governance for Medicines (GGM) programme is commemorating 10 years of operation with a consultation of Member States, partners and other stakeholders in WHO’s South-East Asian and Western Pacific Regions in Manila.

CDC/ACIP [to 21 November 2015]

Modifications to Enhanced Entry Airport Screening for Travelers from Sierra Leone to the United States
MONDAY, NOVEMBER 9, 2015
On November 10, 2015, the Centers for Disease Control and Prevention (CDC) and the Department of Homeland Security (DHS) will modify enhanced Ebola port-of-entry screening for travelers from Sierra Leone….
…Under the modified entry screening, travelers from Sierra Leone with no enhanced risk factors will receive a version of the CARE kit that includes information about Ebola, a thermometer, and contact information for state and local health departments. Travelers will be encouraged to watch their health for 21 days after leaving Sierra Leone and to contact their local health departments if they develop symptoms consistent with Ebola. Travelers from Sierra Leone will no longer need to be actively monitored by or be in daily contact with their health departments. We will continue to evaluate the need for continued screening of travelers from Sierra Leone at regular intervals in order to consider whether additional step-down measures may be warranted….

MMWR Weekly – November 13, 2015 / Volume (64) No. 44
:: Progress Toward Regional Measles Elimination — Worldwide, 2000–2014
:: Global Routine Vaccination Coverage, 2014
:: Notes from the Field: Meningococcal Disease Among Men Who Have Sex with Men — United States, January 2012–June 2015

IOM / International Organization for Migration [to 21 November 2015]
http://www.iom.int/press-room/press-releases

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IOM Begins Vaccination of US-Bound Refugees in Rwanda
11/13/15
Rwanda – IOM has begun the vaccination in Kigali, Rwanda of refugees due to be resettled in the United States. The vaccinations are part of a three-day IOM medical health assessment process for the United States Refugee Resettlement Program (USRAP).

The refugees will receive multiple vaccinations, depending on their age, before they arrive in the US. The goal is to provide cost-effective public health interventions, improve refugee health and limit the number of vaccinations the refugees will need after they arrive in the US.

In addition to Rwanda, the overseas vaccination scheme is being implemented by IOM with USRAP in Ethiopia, Uganda, Kenya, Thailand, Malaysia and Nepal. It will provide vaccinations to 56 per cent of US-bound refugees each year.

All refugees, regardless of age, will receive vaccinations for up to eight illnesses including measles, mumps, rubella, hepatitis B, haemophilus influenzae type b, diphtheria, tetanus and whooping cough. In eight weeks, IOM will make a trip to Gihembe to provide boosters for many of the vaccines administered this week.

Mothers at the Bon Samaritain clinic, where IOM conducts the health assessments, could be seen clutching their children’s Ministry of Health “Mother-Child Booklets”, in which their children’s vaccinations are logged.

They received the booklets as part of the expanded programme on immunization at the Gihembe refugee camp. IOM nurses will review these documents and add the previously administered vaccines to the medical documents required for travel to the US.

In Rwanda, IOM currently processes about 2,000 medical health assessments for US-bound refugees per year. Following vaccination, IOM will work with camp medical staff to identify any adverse reactions.

IOM Rwanda Chief of Mission Catherine Northing said: “As the refugees get ready for their new homes and new lives, the vaccines will help protect them while still in Rwanda and ensure that they are healthy on arrival in the US.”

PATH [to 21 November 2015]
http://www.path.org/news/index.php

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Press release | November 09, 2015
Scientists mark “stunning success” of vaccine in virtually ridding Africa of meningitis A
New research forecasts a resurgence of meningitis A epidemics in 15 years should immunization efforts stall
GENEVA and SEATTLE, 10 November 2015—Five years after the introduction of an affordable conjugate meningitis A vaccine, immunization has led to the control and near elimination of deadly meningitis A disease in the African “meningitis belt.” In 2013, only four laboratory-confirmed cases of meningitis A were reported by the 26 countries in the meningitis belt.

The findings are part of a special collection of 29 articles in the journal Clinical Infectious Diseases—with guest editors from Public Health England and the former Meningitis Vaccine Project, a partnership between the World Health Organization (WHO) and the international health nonprofit PATH—about the steps taken for the development, introduction, and evaluation of the PsA-TT conjugate meningitis A vaccine for Africa, better known as MenAfriVac®.

But scientists are now warning that unless countries within the belt incorporate the meningitis A vaccine in routine immunization schedules for infants, there is a risk that the disease could rebound in 15 years’ time. One of the journal studies found that a childhood vaccination strategy will be much cheaper than reacting to future epidemics with disruptive and costly case management and mass vaccination campaigns.

“We have nearly eliminated meningitis A epidemics from Africa, but the fact is the job is not yet done,” said Dr. Jean-Marie Okwo-Bele, Director of Immunization, Vaccines and Biologicals at WHO. “Our dramatic gains against meningitis A through mass vaccination campaigns will be jeopardized unless countries maintain a high level of protection by incorporating the meningitis A vaccine into their routine childhood immunization schedules.”…

UNICEF [to 21 November 2015]
http://www.unicef.org/media/media_78364.html

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A digital necklace and a wearable soap win ‘Wearables for Good’ Design Challenge with UNICEF, ARM and frog
HELSINKI/NEW YORK/LONDON, 12 November 2015 – A necklace that stores electronic health data to track child immunization and a wearable soap that helps limit the spread of infectious viruses by encouraging hand washing, have won the Wearables for Good challenge run by UNICEF, ARM and frog…

The winning designs, both led by joint Indian-US teams, will each receive a prize of $15,000 and incubation and mentoring from the partners.

Khushi Baby is a data-storing necklace that provides a two-year personal immunization record for children. It uses Near Field Communication (NFC) technology to send and receive information through a smartphone. Data is synced to the cloud and displayed on a dashboard accessible to health officials….

…Ruchit Nagar, representing the Khushi Baby team said: “Khushi Baby want to ensure that all infants have access to informed and timely health care by owning a copy of their medical history. The Khushi Baby system enables access to culturally appropriate wearable digital medical records, even in the most remote and isolated areas. We believe in tracking each child’s immunization to the last mile, and as a UNICEF Wearables for Good Challenge winner, we look to expand from monitoring the vaccination progress of 1,000 children in 100 villages to a larger beneficiary base in areas beyond India where our digital system can streamline access and delivery to health care. We also look forward to building our system to serve broader populations and medical applications, moving soon to a wider focus on a continuum of maternal and child health care. At its core, Khushi Baby functions as a key to connect those in need of services to a digitally integrated community.”…

Sabin Vaccine Institute [to 21 November 2015]
http://www.sabin.org/updates/pressreleases

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Dr. Regina Rabinovich Joins Sabin Vaccine Institute Board of Trustees
WASHINGTON, D.C. — November 10, 2015 — The Sabin Vaccine Institute (Sabin) today announced that Regina Rabinovich, M.D., M.P.H., has joined its Board of Trustees. Dr. Rabinovich is the ExxonMobil Malaria Scholar in Residence at the Harvard T.H. Chan School of Public Health and Global Health Institute. In addition, Dr. Rabinovich is chair of the Malaria Eradication Scientific Alliance at ISGlobal, University of Barcelona, where she also serves as director of the Malaria Elimination Initiative and senior advisor for the Chagas Initiative…

Fondation Merieux [to 21 November 2015]
http://www.fondation-merieux.org/news
Mission: Contribute to global health by strengthening local capacities of developing countries to reduce the impact of infectious diseases on vulnerable populations.

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3rd RESAOLAB International Steering Committee in Niamey
10 November 2015, Niamey (Niger)
:: Foundation Stone Laid for Building to House Niger’s Division of Health Laboratories
:: 2 initiatives to strengthen biomedical analysis laboratories and support epidemic surveillance: RESAOLAB and WARDS

Representatives of the ministries of health of 15 West African countries are convening with the director general of the West African Health Organisation (WAHO), Dr. Xavier Crespin, during the 3rd RESAOLAB* International Steering Committee and 1st regional workshop on laboratory capacity building for the project, WARDS (West African Regional Disease Surveillance). This joint meeting of two major initiatives for healthcare capacity building will cover the national and regional issues related to biomedical laboratories, the development of harmonized laboratory policies and the improvement of surveillance of epidemic-prone diseases…

BMGF – Gates Foundation [to 21 November 2015]
http://www.gatesfoundation.org/Media-Center/Press-Releases

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No Time to Lose: Fulfilling Our Family Planning Promise to 120 Million Women
SEATTLE (November 12, 2015) – More women and girls than ever before are able to access contraceptives and family planning services. But a new report finds that the global community risks falling short of its goal to reach an additional 120 million women and girls by 2020. In response, the Bill & Melinda Gates Foundation today announced that it will invest an additional $120 million dollars in family planning programs over the next three years – a 25% increase on its current family planning funding.

Trends in Maternal Mortality: 1990 to 2015
Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Fund
Publication date: November 2015 :: 12 pages
WHO reference number: WHO /RHR/15.23
Full report pdf, 5 MB :: Executive summary pdf, 1 MB

Millennium Development Goal (MDG) 5 Target 5A called for the reduction of maternal mortality ratio by three quarters between 1990 and 2015. It has been a challenge to assess the extent of progress due to the lack of reliable and accurate maternal mortality data – particularly in developing-country settings where maternal mortality is high. As part of ongoing efforts, the WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division updated estimates of maternal mortality for the years 1990, 1995, 2000, 2005 and 2015.

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Joint news release
Maternal deaths fell 44% since 1990 – UN
Report from WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division highlights progress

12 NOVEMBER 2015 ¦ GENEVA ¦ NEW YORK – Maternal mortality has fallen by 44% since 1990, United Nations agencies and the World Bank Group reported today.
Maternal deaths around the world dropped from about 532 000 in 1990 to an estimated 303 000 this year, according to the report, the last in a series that has looked at progress under the Millennium Development Goals (MDGs). This equates to an estimated global maternal mortality ratio (MMR) of 216 maternal deaths per 100 000 live births, down from 385 in 1990.

Maternal mortality is defined as the death of a woman during pregnancy, childbirth or within 6 weeks after birth.

“The MDGs triggered unprecedented efforts to reduce maternal mortality,” said Dr Flavia Bustreo, WHO Assistant Director-General, Family, Women’s and Children’s Health. “Over the past 25 years, a woman’s risk of dying from pregnancy-related causes has nearly halved. That’s real progress, although it is not enough. We know that we can virtually end these deaths by 2030 and this is what we are committing to work towards.”

Achieving that goal will require much more effort, according to Dr. Babatunde Osotimehin, the Executive Director of UNFPA, the United Nations Population Fund. “Many countries with high maternal death rates will make little progress, or will even fall behind, over the next 15 years if we don’t improve the current number of available midwives and other health workers with midwifery skills,” he said. “If we don’t make a big push now, in 2030 we’ll be faced, once again, with a missed target for reducing maternal deaths.”
The analyses contained in Trends in Maternal Mortality: 1990 to 2015 – Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division are being published simultaneously in the medical journal The Lancet.

Ensuring access to high-quality health services during pregnancy and child birth is helping to save lives. Essential health interventions include: practising good hygiene to reduce the risk of infection; injecting oxytocin immediately after childbirth to reduce the risk of severe bleeding; identifying and addressing potentially fatal conditions like pregnancy-induced hypertension; and ensuring access to sexual and reproductive health services and family planning for women.

Uneven gains
Despite global improvements, only 9 countries achieved the MDG 5 target of reducing the maternal mortality ratio by at least 75% between 1990 and 2015. Those countries are Bhutan, Cabo Verde, Cambodia, Iran, Lao People’s Democratic Republic, Maldives, Mongolia, Rwanda and Timor-Leste. Despite this important progress, the MMR in some of these countries remains higher than the global average.

“As we have seen with all of the health-related MDGs, health system strengthening needs to be supplemented with attention to other issues to reduce maternal deaths,” said UNICEF Deputy Executive Director, Geeta Rao Gupta. “The education of women and girls, in particular the most marginalized, is key to their survival and that of their children. Education provides them with the knowledge to challenge traditional practices that endanger them and their children.”

By the end of this year, about 99% of the world’s maternal deaths will have occurred in developing regions, with Sub-Saharan Africa alone accounting for 2 in 3 (66%) deaths. But that represents a major improvement: Sub-Saharan Africa saw nearly 45% decrease in MMR, from 987 to 546 per 100 000 live births between 1990 and 2015.

The greatest improvement of any region was recorded in Eastern Asia, where the maternal mortality ratio fell from approximately 95 to 27 per 100 000 live births (a reduction of 72%). In developed regions, maternal mortality fell 48% between 1990 and 2015, from 23 to 12 per 100 000 live births.

Working towards ending preventable maternal deaths
A new Global Strategy for Women’s, Children’s and Adolescents’ Health, launched by the UN Secretary General in September 2015, aims to help achieve the ambitious target of reducing maternal deaths to fewer than 70 per 100,000 live births globally, as included in the Sustainable Development Goals (SDGs). Reaching that goal will require more than tripling the pace of progress – from the 2.3% annual improvement in MMR that was recorded between 1990 and 2015 to 7.5% per year beginning next year.

The Global Strategy highlights the need to reinforce country leadership by mobilizing domestic and international resources for women’s, children’s and adolescents’ health. It will be important to strengthen health systems so they can provide good quality care in all settings, promote collaboration across sectors, and support individuals and communities to make informed decisions about their health and demand the quality care they need. The strategy emphasizes that special attention is imperative during humanitarian crises and in fragile settings, since maternal deaths tend to rise in these contexts.

“The SDG goal of ending maternal deaths by 2030 is ambitious and achievable provided we redouble our efforts,” said Dr Tim Evans, Senior Director of Health, Nutrition and Population at the World Bank Group. “The recently launched Global Financing Facility in Support of Every Woman Every Child, which focuses on smarter, scaled and sustainable financing, will help countries deliver essential health services to women and children.”

Need for better data
The 2015 maternal mortality estimates present the tremendous progress achieved towards the Millennium Development Goal 5 on maternal mortality reduction. They show a strong trend of reduction over the years. At the same time, we have seen more and better data coming from various countries, enhancing the accuracy of the absolute numbers reported.

Efforts to strengthen data and accountability especially over the past years have helped fuel this improvement. However, much more needs to be done to develop complete and accurate civil and vital registration systems that include births, deaths and causes of death.

Maternal death audits and reviews also need to be implemented to understand why, where and when women die and what can be done to prevent similar deaths. Since 2012, WHO, UNFPA and partners have developed Maternal Death Surveillance and Response for identification and timely notification of all maternal deaths, followed by review of their causes and the best methods of prevention. An increasing number of low- and middle-income countries are now implementing this approach.

NEW REPORT HIGHLIGHTS GAINS IN CHILD SURVIVAL, BUT THERE’S STILL WORK TO BE DONE TO ADDRESS LEADING KILLERS
International Vaccine Access Center (IVAC) at Johns Hopkins Bloomberg School of Public Health releases its 2015 Pneumonia and Diarrhea Progress Report: Sustainable Progress in the Post-2015 Era

Baltimore, MD, November 12, 2015: The 2015 Pneumonia and Diarrhea Progress Report: Sustainable Progress in the Post-2015 Era, released today on World Pneumonia Day by the International Vaccine Access Center (IVAC) at the Johns Hopkins Bloomberg School of Public Health, documents the progress of the 15 countries experiencing the greatest burden of pneumonia and diarrhea.

Although global progress has been made towards achieving the Millennium Development Goals and reducing child deaths, in 2015 a projected 5.9 million children around the world will die before reaching their fifth birthday. Of these 5.9 million deaths, pneumonia was responsible for 16% and diarrhea was responsible for 9%, making them two of the leading killers of children worldwide. This report highlights the need for sustained efforts to decrease the global burden of pneumonia and diarrhea, especially in the 15 highest burden countries.
Progress in countries is evaluated through “Global Action Plan for Prevention and Control of Pneumonia and Diarrhea (GAPPD) intervention scores” a calculated average of coverage levels for the vital pneumonia and diarrhea interventions outlined in the World Health Organization (WHO) and UNICEF’s integrated GAPPD for which data are available, including vaccination, exclusive breastfeeding, access to care, and use of antibiotics, oral rehydration solution, and zinc.

“This World Pneumonia Day, we celebrate the progress made in preventing pneumonia and reducing child deaths around the world. This year’s Pneumonia and Diarrhea Report highlights the need for sustainable progress as we move beyond 2015 toward achieving the Sustainable Development Goals. This means increasing equitable access to vaccines, diagnostic tools, and medication to prevent unnecessary pneumonia and diarrhea deaths,” said Kate O’Brien, Professor, Johns Hopkins Bloomberg School of Public Health and Executive Director of IVAC.

Vaccine introductions and scale ups, promotion of exclusive breastfeeding for the first six months of a child’s life, increasing access to appropriate pneumonia treatment, and ensuring sustainability for the post-2015 agenda are all required to put an end to these preventable diseases.
Key Findings from this year’s report:
:: Overall GAPPD scores in 2015 varied widely from a low of 20% (Somalia) to a high of 72% (Tanzania), with all 15 focus countries falling below the 86% target for the overall GAPPD score.
:: Rates of exclusive breastfeeding during a child’s first six months of life remain low. Currently, 12 of the 15 countries with the most child pneumonia and diarrhea deaths have exclusive breastfeeding rates that still fall short of the 50% GAPPD target for this protective intervention.
:: Currently, 3 of the 15 countries (Sudan, Bangladesh, and Tanzania) have met or exceeded the 90% GAPPD coverage target for Hib vaccination and several countries are relatively close to reaching the target, including Pakistan (73%), DRC (80%), Angola, (80%), Ethiopia (77%), and Afghanistan (75%). Still, many countries continue to have extremely low coverage, such as India (20%), Indonesia (21%), Somalia (42%), and Chad (46%).
:: Fifteen years after PCV’s first introduction in 2000, five of the highest burden countries (India, Indonesia, Chad, China, and Somalia) are still not using the vaccine in their routine immunization programs.
:: Of the 10 GAPPD interventions evaluated in this report, pneumonia and diarrhea treatment tend to have the lowest coverage rates; some countries are not reporting any data at all, creating blind spots on progress and program performance.
:: To meet the Strategic Development Goal 3.2 of ending preventable deaths of neonates and under-five children by the year 2030 and achieving high coverage of GAPPD interventions in places where the most children are dying of preventable causes is undoubtedly needed.

BMC Health Services Research
http://www.biomedcentral.com/bmchealthservres/content
(Accessed 21 November 2015)

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Research article
The cost of dialysis in low and middle-income countries: a systematic review
Lawrencia Mushi, Paul Marschall, Steffen Fleßa BMC Health Services Research 2015, 15:506 (12 November 2015)
Abstract
Background
The cost of dialysis in low and middle-Income countries has not been systematically reviewed. The objective of this article is to systematically review peer-reviewed articles on the cost of dialysis across low and middle-income countries.
Methods
PubMed and Embase databases were searched for the year 1998 to March 2013, and additional studies were added from Google Scholar search. An article was included if two reviewers agreed that it had reported cost of dialysis from low and middle-Income countries.
Results
The annual cost per patient for hemodialysis (HD) ranged from Int$ 3,424 to Int$ 42,785, and peritoneal dialysis (PD) ranged from Int$ 7,974 to Int$ 47,971. Direct medical cost especially drugs and consumables for HD and dialysis solutions and tubing for PD were the main cost drivers.
Conclusion
The number of studies on the economics of dialysis in low and middle-income countries is limited. Few papers indicate that dialysis is an expensive form of treatment for the population of these countries and that the poorer countries have an over-proportional burden to finance dialysis services. Further research is needed to determine the cost of dialysis based on a standard methodology grounded on existing economic guidelines and to address the question whether dialysis should be an element of the essential package of health in resource-poor countries. Used data should be as complete as possible. In case of missing data, proxies can be used. In case of developing countries, expert interviews are often used for estimating missing information

BMC Medical Ethics
http://www.biomedcentral.com/bmcmedethics/content
(Accessed 21 November 2015)

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Correspondence
Enhancing quality and integrity in biomedical research in Africa: an international call for greater focus, investment and standardisation in capacity strengthening for frontline staff
Francis Kombe, Participants of an International Workshop in Kenya on the Role of Frontline Staff in Biomedical Research, July 2014 BMC Medical Ethics 2015, 16:77 (13 November 2015)

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Debate
Informed consent instead of assent is appropriate in children from the age of twelve: Policy implications of new findings on children’s competence to consent to clinical research
Irma Hein, Martine De Vries, Pieter Troost, Gerben Meynen, Johannes Van Goudoever, Ramón Lindauer BMC Medical Ethics 2015, 16:76 (9 N
Abstract
Background
For many decades, the debate on children’s competence to give informed consent in medical settings concentrated on ethical and legal aspects, with little empirical underpinnings. Recently, data from empirical research became available to advance the discussion. It was shown that children’s competence to consent to clinical research could be accurately assessed by the modified MacArthur Competence Assessment Tool for Clinical Research. Age limits for children to be deemed competent to decide on research participation have been studied: generally children of 11.2 years and above were decision-making competent, while children of 9.6 years and younger were not. Age was pointed out to be the key determining factor in children’s competence. In this article we reflect on policy implications of these findings, considering legal, ethical, developmental and clinical perspectives.
Discussion
Although assessment of children’s competence has a normative character, ethics, law and clinical practice can benefit from research data. The findings may help to do justice to the capacities children possess and challenges they may face when deciding about treatment and research options. We discuss advantages and drawbacks of standardized competence assessment in children on a case-by-case basis compared to application of a fixed age limit, and conclude that a selective implementation of case-by-case competence assessment in specific populations is preferable. We recommend the implementation of age limits based on empirical evidence. Furthermore, we elaborate on a suitable model for informed consent involving children and parents that would do justice to developmental aspects of children and the specific characteristics of the parent-child dyad.
Summary
Previous research outcomes showed that children’s medical decision-making capacities could be operationalized into a standardized assessment instrument. Recommendations for policies include a dual consent procedure, including both child as well as parents, for children from the age of 12 until they reach majority. For children between 10 and 12 years of age, and in case of children older than 12 years in special research populations of mentally compromised patients, we suggest a case-by-case assessment of children’s competence to consent. Since such a dual consent procedure is fundamentally different from a procedure of parental permission and child assent, and would imply a considerable shift regarding some current legislations, practical implications are elaborated.

BMC Pregnancy and Childbirth
http://www.biomedcentral.com/bmcpregnancychildbirth/content
(Accessed 21 November 2015)

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Research article
Demand-side interventions for maternal care: evidence of more use, not better outcomes
Taylor Hurst, Katherine Semrau, Manasa Patna, Atul Gawande, Lisa Hirschhorn
BMC Pregnancy and Childbirth, 2015, 15:294 (11 November 2015)

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Research article
Fertility desires, family planning use and pregnancy experience: longitudinal examination of urban areas in three African countries
Ilene Speizer, Peter Lance
BMC Pregnancy and Childbirth 2015, 15:294 (11 November 2015)

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Research article
The triple threat of pregnancy, HIV infection and malaria: reported causes of maternal mortality in two nationwide health facility assessments in Mozambique, 2007 and 2012
Patricia Bailey, Emily Keyes, Allisyn Moran, Kavita Singh, Leonardo Chavane, Baltazar Chilundo BMC Pregnancy and Childbirth 2015, 15:293 (9 November 2015)

Clinical Infectious Diseases (CID)
Volume 61 Issue 11 December 1, 2015
http://cid.oxfordjournals.org/content/current

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Antibody Responses After Primary Immunization in Infants Born to Women Receiving a Pertussis-containing Vaccine During Pregnancy: Single Arm Observational Study With a Historical Comparator
Shamez N. Ladhani, Nick J. Andrews, Jo Southern, Christine E. Jones, Gayatri Amirthalingam, Pauline A. Waight, Anna England, Mary Matheson, Xilian Bai, Helen Findlow, Polly Burbidge,
Vasili Thalasselis, Bassam Hallis, David Goldblatt, Ray Borrow, Paul T. Heath, and Elizabeth Miller
Clin Infect Dis. (2015) 61 (11): 1637-1644 doi:10.1093/cid/civ695
Infants whose mothers received a pertussis-containing vaccine in pregnancy had high pre-immunization antibody concentrations, but responses to pertussis vaccine and CRM-conjugated vaccines were blunted after primary immunization.

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Editorial Commentary: The Effect of Tdap Vaccination of Pregnant Women on the Subsequent Antibody Responses of Their Infants
James D. Cherry
Clin Infect Dis. (2015) 61 (11): 1645-1647 doi:10.1093/cid/civ700

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Epidemiology and Risk Factors for Ebola Virus Disease in Sierra Leone—23 May 2014 to 31 January 2015
Patricia M. Dietz, Amara Jambai, Janusz T. Paweska, Zabulon Yoti, and Thomas G. Ksaizek
Clin Infect Dis. (2015) 61 (11): 1648-1654 doi:10.1093/cid/civ568
In Sierra Leone, 8056 persons had laboratory-confirmed Ebola virus disease between 23 May 2014 and 31 January 2015. Their median age was 28 years; 51.7% were female. Attending funerals and contact with sick persons were primary risk factors.

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Immunization Costs and Programmatic Barriers at an Urban HIV Clinic
Ellen F. Eaton, Andrzej Kulczycki, Michael Saag, Michael Mugavero, and James L. Raper
Clin Infect Dis. (2015) 61 (11): 1726-1731 doi:10.1093/cid/civ637
A cost analysis at an urban, university-affiliated human immunodeficiency virus clinic revealed that providing 3 common vaccines (Gardasil, Prevnar, and Zostavax) to eligible patients would lead to a net loss of more than $90 000 in the first year.

Eurosurveillance
Volume 20, Issue 45, 12 November 2015
http://www.eurosurveillance.org/Public/Articles/Archives.aspx?PublicationId=11678

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Editorial
Refugee crisis demands European Union-wide surveillance!
M Catchpole 1 , D Coulombier 1
1. European Centre for Disease Prevention and Control (ECDC), Stockholm, Sweden
The conflicts in the Middle-East and instability in Libya and some parts of Asia and Africa have resulted in a dramatic influx of refugees to the European Union (EU) in recent years. In the first nine months of 2015, more than 600,000 applications for asylum were filed in the EU [1]. With no prospect of change of the international context in the near future, it is likely that the influx of refugees into the EU will continue and may even increase in coming months.

We have witnessed numerous large displacements of populations in recent years and ‘Refugee health’ has become an area of concern for national and international, governmental and non-governmental organisations. Much has been learned from responding to these humanitarian crises.

Although refugees are facing a similar spectrum of non-communicable diseases to those experienced by the indigenous population of their countries of origin, trauma and injuries, sexual and reproductive health issues, violence and psychosocial disorders are among the most frequent health problems refugees encounter. Disruption of healthcare delivery systems in their countries of origin and limited access to healthcare during their journey result in the interruption of treatments often required for the control of chronic diseases [2].

Refugee populations entering the EU/European Economic Area (EEA), and particularly children, are at risk of exposure to infectious diseases in the same way as other EU residents, and in some cases may be more vulnerable because of the interruption of public health programmes, notably for immunisation, in their country of origin, as well as through various barriers to access healthcare such as language, culture etc. It is therefore important that they benefit from protection from infectious diseases, including those prevented through routine vaccinations. In addition, these refugees may be at specific risk for certain infectious diseases in relation to their country of origin, countries traversed during their migration, and the conditions they experienced during their mostly difficult journeys.

It is important to note that refugees should not be seen as representing a threat to Europeans regarding infectious diseases, but rather as being themselves vulnerable for such diseases. For example, poor living conditions and close contact in crowded shelters and refugee camps may increase the risk for the spread of lice and/or fleas, which in rare cases can carry diseases such as louse-borne diseases (relapsing fever due to Borrelia recurrentis, trench fever due to Bartonella quintana, epidemic typhus due to Rickettsia prowazekii), murine typhus and mites (scabies). In recent months, sporadic cases of louse-borne relapsing fever (LBRF) have been reported in Belgium, Finland, Germany and the Netherlands among migrants from Eritrea, Somalia and Sudan [3-5]. LBRF is a disease transmitted by body lice that caused major epidemics in the first half of the 20th century in Europe [6,7] and is known to have occurred occasionally among homeless people in recent years, without spreading to the general population [8]. Recent reports from Italy indicate that transmission of LBRF is likely to have occurred in shelters for refugees in the EU, resulting in the risk of cross-border spread as refugees are frequently moving to other countries [9,10]. Media are reporting outbreaks of scabies and diarrhoea, notably in Calais, France, in relation to poor housing and hygiene conditions [11].

Meningococcal disease outbreaks have been associated with overcrowding overall and in refugee settings. Contributing factors include sharing dormitories, poor hygiene, and limited access to medical care [12] and that meningococcal carriage rates have been shown to be higher in individuals in overcrowded settings. Most cases are acquired through exposure to asymptomatic carriers [13]. Meningococcal disease has usually been reported in children, but is still a leading cause of both meningitis and sepsis in adolescents, young adults and adults. In addition, overcrowding has been associated with increased transmission of measles, varicella and influenza.

As we are approaching winter, the travelling and living conditions for refugees in transit to Europe or in reception centres after their arrival is likely to deteriorate, with even more overcrowding in shelters with insufficient hygiene and therefore increased risk of transmission of communicable diseases. With the start of the influenza season, there is obviously a risk of increased influenza transmission.

Given the numbers and mobility of the refugee populations, the infectious disease risk can only be contained through a coordinated response at the EU level. That includes (i) raising awareness of the risks and types of infection that refugees may have been exposed to and may continue to be exposed to in reception centres, (ii) providing appropriate hygienic and medical countermeasures and (iii) ensuring ready access to medical diagnosis and treatment services. However, such a response will require that Europe has good information on the health situation of the refugees on the move in the EU.

Currently, the basic information that would allow a competent assessment of the situation is not available. The exact number of refugees is not known, and its assessment is hampered because refugees may avoid registration in fear of being sent back [14] and because they continue to move through different European countries. No comprehensive surveillance data is currently being gathered and only sporadic reports by organisations and institutions providing care for these populations are available.

Refugees are not currently a threat for Europe with respect to communicable diseases, but they are a priority group for communicable disease prevention and control efforts because they are more vulnerable.

The scale of the current influx of refugees is inevitably putting pressure on public health systems in frontline receiving countries. Protecting the health of this vulnerable group is complicated further by the potential occurrence of communicable diseases that have not been commonly or widely seen within Europe, creating challenges in terms of recognition and case management. It is vital to ensure that public health authorities have the right information to target resources and provide appropriate measures.

Given these challenges, the European Centre for Disease Prevention and Control (ECDC) will continue to work with its partners in Europe, including public health authorities in the Member States and the European Commission, to strengthen the evidence base guiding prevention and control measures and adding to the current evidence which pinpoint adequate hygiene conditions and vaccination services as the most immediate needs. Strengthening and coordinating surveillance will require continuing efforts to improve the quantity and quality of surveillance data collected through a EU-wide surveillance scheme. It will allow to ensure that interventions aimed at improving health of the refugees are relevant, proportionate, appropriately targeted and coordinated.
[References available at title link]

Globalization and Health
http://www.globalizationandhealth.com/
[Accessed 21 November 2015]

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Commentary
Mitigation of non-communicable diseases in developing countries with community health workers
Mishra SR, Neupane D, Preen D, Kallestrup P and Perry HB Globalization and Health 2015, 11:43 (10 November 2015)
Abstract
Non-communicable diseases (NCDs) are rapidly becoming priorities in developing countries. While developed countries are more prepared in terms of skilled human resources for NCD management, developing the required human resources is still a challenge in developing countries. In this context, mobilizing community health workers (CHWs) for control of NCDs seems promising. With proper training, supervision and logistical support, CHWs can participate in the detection and treatment of hypertension, diabetes, and other priority chronic diseases. Furthermore, advice and support that CHWs can provide about diet, physical activity, and other healthy lifestyle habits (such as avoidance of smoking and excessive alcohol intake) have the potential for contributing importantly to NCD programs. This paper explores the possibility of involving CHWs in developing countries for addressing NCDs.

International Health
Volume 7 Issue 6 November 2015
http://inthealth.oxfordjournals.org/content/current

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When free healthcare is not free. Corruption and mistrust in Sierra Leone’s primary healthcare system immediately prior to the Ebola outbreak
Pieternella Pieterse and Tom Lodge
Int. Health (2015) 7 (6): 400-404 doi:10.1093/inthealth/ihv024
Abstract
Introduction
Sierra Leone is one of three countries recently affected by Ebola. In debates surrounding the circumstances that contributed to the initial failure to contain the outbreak, the word ‘trust’ is often used: In December 2014, WHO director Margret Chan used ‘lack of trust in governments’; The Lancet’s Editor-in-Chief, wrote how Ebola has exposed the ‘… breakdown of trust between communities and their governments.’ This article explores the lack of trust in public healthcare providers in Sierra Leone, predating the Ebola outbreak, apparently linked to widespread petty corruption in primary healthcare facilities. It compares four NGO-supported accountability interventions targeting Sierra Leone’s primary health sector.
Methods
Field research was conducted in Kailahun, Kono and Tonkolili Districts, based on interviews with health workers and focus group discussions with primary healthcare users.
Results
Field research showed that in most clinics, women and children entitled to free care routinely paid for health services.
Conclusions
A lack of accountability in Sierra Leone’s health sector appears pervasive at all levels. Petty corruption is rife. Understaffing leads to charging for free care in order to pay clinic-based ‘volunteers’ who function as vaccinators, health workers and birth attendants. Accountability interventions were found to have little impact on healthworker (mis)behaviour.

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Prevalence of pneumonia and associated factors among indigenous children in Brazil: results from the First National Survey of Indigenous People’s Health and Nutrition
Andrey M. Cardoso, Bernardo L. Horta, Ricardo V. Santos, Ana L. Escobar, James R. Welch,
and Carlos E. A. Coimbra, Jr.
Int. Health (2015) 7 (6): 412-419 doi:10.1093/inthealth/ihv023

The Lancet
Nov 14, 2015 Volume 386 Number 10007 p1917-2028 e36-e44
http://www.thelancet.com/journals/lancet/issue/current

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Comment
HPV vaccination for victims of childhood sexual abuse
Suzanne M Garland, Asvini K Subasinghe, Yasmin L Jayasinghe, John D Wark, Anna-Barbara Moscicki, Albert Singer, Xavier Bosch, Karen Cusack, Margaret Stanley
DOI: http://dx.doi.org/10.1016/S0140-6736(15)00757-6

Health authorities around the world, including WHO, recommend starting cervical screening at age 25 years or older, thus excluding young women from population screening.1 This guidance was developed on the basis of numerous investigations documenting high rates of human papillomavirus infection in the general population of young women, with very low rates of cervical cancer.2 Although human papillomavirus infection is common, occurring shortly after sexual debut, it is largely transient and asymptomatic. Cervical cancer has decreased greatly owing to cervical cytology screening for and treatment of precursor lesions.3 However, the data from cervical cytology screening are from birth cohorts whose age of sexual debut was 5–10 years later than that of the present generation. An earlier age of sexual debut creates a wider gap between initial contact with human papillomavirus and the present recommendations for age of onset for screening.4 This generational change in sexual behaviour has the potential to increase the population risk for cervical cancer, an outcome that can be offset by human papillomavirus vaccination before sexual debut.

Less than 2% of women worldwide receive human papillomavirus vaccination, despite vaccines being licenced in 129 countries, with 64 countries having such vaccines in their national immunisation programmes.5 Few countries achieve wide vaccine coverage, although even in those with low coverage—such as the USA—the prevalence of vaccine-targeted human papillomavirus genotypes is low. Although delayed screening will not pose a risk to the vast majority of women, it could lead to otherwise preventable cervical cancers among high-risk women younger than 25 years of age in countries with poor vaccine coverage. Young women who have experienced childhood sexual abuse might fall into this category.

According to WHO, childhood sexual abuse is defined as the involvement in sexual activity of a child under the age of 18 years who did not give informed consent or is not developmentally prepared.6 The global prevalence of childhood sexual abuse is estimated to be 8–31% for girls and 3–17% for boys.7 According to a review published in 2004, parents were the perpetrators of about 45% of cases of childhood sexual abuse in the USA, and other relatives were responsible for 19%.8 Additionally, perpetrators can be trusted authority figures in society such as priests and teachers.8 Consequently, survivors of such abuse are often hesitant to report such incidents because of shame and fear of retribution. Thus, the incidence and prevalence of childhood sexual abuse is almost certainly underestimated.

Results of a study in Australia9 suggest unwanted sexual experiences with genital contact in adolescence increase the risk of cervical cancer. Moreover, early onset of sexual activity is a strong risk factor for cervical cancer. This effect could be due to the greater risk of prolonged carriage of high-risk human papillomavirus as a result of earlier genital contact in these young women, or a specific vulnerability of the cervical epithelium during a critical developmental period. Globally, around 5–10% of girls and 1–5% of boys are exposed to penetrative childhood sexual abuse.10 Preliminary data from questionnaires from 398 women aged 16–25 years in Victoria, Australia, who had experienced childhood sexual abuse showed that penile–genital contact at the time of the abuse was common (32%)—the mean age at time of abuse was 12 years.11 Certainly, cervical or vaginal trauma resulting from forced intercourse places these women at high risk of infection. In addition, the epithelial vulnerability of immature cervixes could accelerate human papillomavirus acquisition and persistent human papillomavirus carriage.12
People who have experienced childhood sexual abuse are more likely to engage in risky behaviours associated with cervical cancer, such as an increased number of sexual partners, sex work, and cigarette smoking.13 Drug and alcohol use and depression are also more common in victims of childhood sexual abuse.14 Most childhood sexual abuse (70%) occurs at a mean age of 10–11 years, which is younger than the age at which human papillomavirus vaccinations are administered.15 Early virus exposure thus reduces later human papillomavirus vaccine efficacy. Hence, it would be intuitive to administer human papillomavirus vaccine as soon as childhood sexual abuse is reported because of the risk of ongoing exposures due to maladaptive coping, including potential disengagement with mainstream education and health services.

We believe that male and female victims of childhood sexual abuse should not only be screened for sexually transmitted infections (and offered appropriate treatment), but also be offered human papillomavirus vaccination. Moreover, although cervical cancer screening from age 25 years is appropriate for the general female population, policy makers should consider options for screening from 18 years when clinicians are concerned about individual risk. Early human papillomavirus vaccination, and cervical screening for women younger than 25 years who have experienced childhood sexual abuse, should help to reduce the burden of human papillomavirus-related disease in this high-risk population.

Women treated for cervical cancer are at increased risk of developing human papillomavirus-related anogenital cancers16 and need lifelong surveillance.17
[References at title link]

SMG has received research funding from Merck, GlaxoSmithKline, and bioCSL; non-financial support from Merck; and speaking fees from Merck Sharp & Dohme and Sanofi Pasteur MSD. YLJ has received the Novartis Scholarship from the Royal Australasian College of Physicians. AS has received personal fees from IBC Medical Services. XB has received research funding and personal fees from Merck Sharp & Dohme, GlaxoSmithKline, Sanofi Pasteur MSD, and Qiagen; and personal fees from Roche Molecular Systems. MS has received personal fees from GlaxoSmithKline Biologicals, MSD Merck, and Sanofi Pasteur MSD. A-BM has received personal fees from Merck. AKS, JDW, and KC declare no competing interests.

The Lancet Commissions
The Rockefeller Foundation–Lancet Commission on planetary health
Safeguarding human health in the Anthropocene epoch: report of The Rockefeller Foundation–Lancet Commission on planetary health
Sarah Whitmee, Andy Haines, Chris Beyrer, Frederick Boltz, Anthony G Capon, Braulio Ferreira de Souza Dias, Alex Ezeh, Howard Frumkin, Peng Gong, Peter Head, Richard Horton, Georgina M Mace, Robert Marten, Samuel S Myers, Sania Nishtar, Steven A Osofsky, Subhrendu K Pattanayak, Montira J Pongsiri, Cristina Romanelli, Agnes Soucat, Jeanette Vega, Derek Yach
Summary
Far-reaching changes to the structure and function of the Earth’s natural systems represent a growing threat to human health. And yet, global health has mainly improved as these changes have gathered pace. What is the explanation? As a Commission, we are deeply concerned that the explanation is straightforward and sobering: we have been mortgaging the health of future generations to realise economic and development gains in the present. By unsustainably exploiting nature’s resources, human civilisation has flourished but now risks substantial health effects from the degradation of nature’s life support systems in the future.

Medical Decision Making (MDM)
November 2015; 35 (8)
http://mdm.sagepub.com/content/current

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Presenting Numeric Information with Percentages and Descriptive Risk Labels
A Randomized Trial
Aleksandr Sinayev, MA, Ellen Peters, PhD, Martin Tusler, MA, Liana Fraenkel, MD, MPH
Ohio State University, Columbus, OH (AS, EP, MT)
Yale School of Medicine, New Haven, CT (LF)
Abstract
Background.
Previous research demonstrated that providing (v. not providing) numeric information about the adverse effects (AEs) of medications increased comprehension and willingness to use medication but left open the question about which numeric format is best. The objective was to determine which of 4 tested formats (percentage, frequency, percentage + risk label, frequency + risk label) maximizes comprehension and willingness to use medication across age and numeracy levels.
Methods.
In a cross-sectional internet survey (N = 368; American Life Panel, 15 May 2008 to 18 June 2008), respondents were presented with a hypothetical prescription medication for high cholesterol. AE likelihoods were described using 1 of 4 tested formats. Main outcome measures were risk comprehension (ability to identify AE likelihood from a table) and willingness to use the medication (7-point scale; not likely = 0, very likely = 6).
Results.
The percentage + risk label format resulted in the highest comprehension and willingness to use the medication compared with the other 3 formats (mean comprehension in percentage + risk label format = 95% v. mean across the other 3 formats = 81%; mean willingness = 3.3 v. 2.95, respectively). Comprehension differences between percentage and frequency formats were smaller among the less numerate. Willingness to use medication depended less on age and numeracy when labels were used. Generalizability is limited by the use of a sample that was older, more educated, and better off financially than national averages.
Conclusions.
Providing numeric AE-likelihood information in a percentage format with risk labels is likely to increase risk comprehension and willingness to use a medication compared with other numeric formats.

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Preferences for Vaccination: Does Health Literacy Make a Difference?
Jorien Veldwijk, Iris van der Heide, Jany Rademakers, A. Jantine Schuit, G. Ardine de Wit,
Ellen Uiters, and Mattijs S. Lambooij
Med Decis Making November 2015 35: 948-958, first published on September 3, 2015 doi:10.1177/0272989X15597225
Abstract
Purpose.
The purpose of this study is to examine to what extent health literacy is associated with parental preferences concerning childhood vaccination.
Methods.
A cross-sectional study was conducted among 467 Dutch parents of newborns aged 6 weeks (response rate of 37%). A self-reported questionnaire was used to measure health literacy by means of Chew’s Set of Brief Screening Questions, as well as parental preferences for rotavirus vaccination by means of a discrete choice experiment. Five rotavirus-related characteristics were included (i.e., vaccine effectiveness, frequency of severe side effects, location of vaccination, protection duration, and out-of-pocket costs). Panel latent class models were conducted, and health literacy and educational level were added to the class probability model to determine the association between health literacy and study outcomes.
Results.
Lower educated and lower health literate respondents considered protection duration to be more important and vaccine effectiveness and frequency of severe side effects to be less important compared with higher educated and higher health literate respondents. While all respondents were willing to vaccinate against rotavirus when the vaccine was offered as part of the National Immunization Program, only lower educated and lower health literate parents were willing to vaccinate when the vaccine was offered on the free market.
Conclusion:
Health literacy is associated with parents’ preferences for rotavirus vaccination. Whether differences in vaccination decisions are actually due to varying preferences or might be better explained by varying levels of understanding should be further investigated. To contribute to more accurate interpretation of study results, it may be advisable that researchers measure and report health literacy when they study vaccination decision behavior.

PharmacoEconomics
Volume 33, Issue 11, November 2015
http://link.springer.com/journal/40273/33/10/page/1

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Systematic Review
Assessing the Economics of Dengue: Results from a Systematic Review of the Literature and Expert Survey
Dagna Constenla, Cristina Garcia, Noah Lefcourt
Abstract
Background
The economics of dengue is complex and multifaceted.
Objectives
We performed a systematic review of the literature to provide a critical overview of the issues related to dengue economics research and to form a background with which to address the question of cost.
Methods
Three literature databases were searched [PubMed, Embase and Latin American and Caribbean Health Sciences Literature (LILACS)], covering a period from 1980 to 2013, to identify papers meeting preset inclusion criteria. Studies were reviewed for methodological quality on the basis of a quality checklist developed for this purpose. An expert survey was designed to identify priority areas in dengue economics research and to identify gaps between the methodology and actual practice. Survey responses were combined with the literature review findings to determine stakeholder priorities in dengue economics research.
Results
The review identified over 700 papers. Forty-two of these papers met the selection criteria. The studies that were reviewed presented results from 32 dengue-endemic countries, underscoring the importance of dengue as a global public health problem. Cost analyses were the most common, with 21 papers, followed by nine cost-effectiveness analyses and seven cost-of-illness studies, indicating a relatively strong mix of methodologies. Dengue annual overall costs (in 2010 values) ranged from US$13.5 million (in Nicaragua) to $56 million (in Malaysia), showing cost variations across countries. Little consistency exists in the way costs were estimated and dengue interventions evaluated, making generalizations around costs difficult.
Conclusions
The current evidence suggests that dengue costs are substantial because of the cost of hospital care and lost earnings. Further research in this area will broaden our understanding of the true economic impact of dengue.

PLoS Neglected Tropical Diseases
http://www.plosntds.org/
(Accessed 21 November 2015)

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Generating Evidence to Improve the Response to Neglected Diseases: How Operational Research in a Médecins Sans Frontières Buruli Ulcer Treatment Programme Informed International Management Guidance
Daniel P. O’Brien, Nathan Ford, Marco Vitoria, Kingsley Asiedu, Alexandra Calmy, Philipp Du Cros, Eric Comte, Vanessa Christinet
Viewpoints | published 12 Nov 2015 | PLOS Neglected Tropical Diseases
10.1371/journal.pntd.0004075

Public Health Ethics
Volume 8 Issue 3 November 2015
http://phe.oxfordjournals.org/content/current

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Special Symposium: Antimicrobial Resistance
The Ethical Significance of Antimicrobial Resistance
Jasper Littmann, Institute of Experimental Medicine, Christian-Albrechts University Kiel
A. M. Viens, Author Affiliations
Southampton Law School, University of Southampton
Abstract
In this paper, we provide a state-of-the-art overview of the ethical challenges that arise in the context of antimicrobial resistance (AMR), which includes an introduction to the contributions to the symposium in this issue. We begin by discussing why AMR is a distinct ethical issue, and should not be viewed purely as a technical or medical problem. In the second section, we expand on some of these arguments and argue that AMR presents us with a broad range of ethical problems that must be addressed as part of a successful policy response to emerging drug resistance. In the third section, we discuss how some of these ethical challenges should be addressed, and we argue that this requires contributions from citizens, ethicists, policy makers, practitioners and industry. We conclude with an overview of steps that should be taken in moving forward and addressing the ethical problems of AMR.

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Ebola and Learning Lessons from Moral Failures: Who Cares about Ethics?
Maxwell J. Smith, University of Toronto; Ross E. G. Upshur, University of Toronto
Abstract
The exercise of identifying lessons in the aftermath of a major public health emergency is of immense importance for the improvement of global public health emergency preparedness and response. Despite the persistence of the Ebola Virus Disease (EVD) outbreak in West Africa, it seems that the Ebola ‘lessons learned’ exercise is now in full swing. On our assessment, a significant shortcoming plagues recent articulations of lessons learned, particularly among those emerging from organizational reflections. In this article we argue that, despite not being recognized as such, the vast majority of lessons proffered in this literature should be understood as ethical lessons stemming from moral failures, and that any improvements in future global public health emergency preparedness and response are in large part dependent on acknowledging this fact and adjusting priorities, policies and practices accordingly such that they align with values that better ensure these moral failures are not repeated and that new moral failures do not arise. We cannot continue to fiddle at the margins without critically reflecting on our repeated moral failings and committing ourselves to a set of values that engenders an approach to global public health emergencies that embodies a sense of solidarity and global justice.

Vaccine
Volume 33, Issue 46, Pages 6135-6370 (17 November 2015)
http://www.sciencedirect.com/science/journal/0264410X/33/46
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Editorial
Answering the call for educating the new generation of vaccinologists – A new European Erasmus+ Joint Master degree in vaccinology
Pages 6135-6136
Stéphane Paul, Nicolas Rochereau, Paz Martinez, Thomas Stratmann, Peter Delputte, Christine Delprat, Gregory A. Poland
[No abstract]

Vaccine
Volume 33, Issue 46, Pages 6135-6370 (17 November 2015)
http://www.sciencedirect.com/science/journal/0264410X/33/46
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Conference report
Workshop report: Malaria vaccine development in Europe–preparing for the future
Pages 6137-6144
Nicola K. Viebig, Flavia D’Alessio, Simon J. Draper, B. Kim Lee Sim, Benjamin Mordmüller, Paul W. Bowyer, Adrian J.F. Luty, Stefan Jungbluth, Chetan E. Chitnis, Adrian V.S. Hill, Peter Kremsner, Alister G. Craig, Clemens H.M. Kocken, Odile Leroy
Abstract
The deployment of a safe and effective malaria vaccine will be an important tool for the control of malaria and the reduction in malaria deaths. With the launch of the 2030 Malaria Vaccine Technology Roadmap, the malaria community has updated the goals and priorities for the development of such a vaccine and is now paving the way for a second phase of malaria vaccine development. During a workshop in Brussels in November 2014, hosted by the European Vaccine Initiative, key players from the European, North American and African malaria vaccine community discussed European strategies for future malaria vaccine development in the global context. The recommendations of the European malaria community should guide researchers, policy makers and funders of global health research and development in fulfilling the ambitious goals set in the updated Malaria Vaccine Technology Roadmap.

Vaccine
Volume 33, Issue 46, Pages 6135-6370 (17 November 2015)
http://www.sciencedirect.com/science/journal/0264410X/33/46
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Post-marketing surveillance of adverse events following immunization with inactivated quadrivalent and trivalent influenza vaccine in health care providers in Western Australia
Pages 6149-6151
Annette K. Regan, Lauren Tracey, Robyn Gibbs
Abstract
In 2015, inactivated quadrivalent influenza vaccine (QIV) was first introduced into the Australian market. A routine vaccine safety surveillance system in Western Australia was used to conduct post-licensure surveillance of adverse events following immunization with inactivated QIV and trivalent influenza vaccines (TIV) in a sample of 1685 healthcare providers (HCPs). A similar percentage of HCPs who received QIV reported having any reaction seven days post-vaccination as HCPs who received TIV (13.6 vs. 12.8%, respectively; p = 0.66). However, a slightly higher percentage of HCPs who received QIV reported pain or swelling at the injection site as compared to HCPs who received TIV (6.9% vs. 4.2%, respectively; p = 0.02). No serious vaccine-associated adverse events were detected during follow-up of either vaccine. Acknowledging the study limitations, the results of this post-marketing surveillance support the safety of QIV, suggesting there is little difference in the reactogenicity of QIV as compared to TIV.

Vaccine
Volume 33, Issue 46, Pages 6135-6370 (17 November 2015)
http://www.sciencedirect.com/science/journal/0264410X/33/46
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Systematic review of economic evaluations of vaccination programs in mainland China: Are they sufficient to inform decision making?
Review Article
Pages 6164-6172
Xiong-Fei Pan, Ulla K. Griffiths, Mark Pennington, Hongjie Yu, Mark Jit
Abstract
The purpose of the study was to systematically review economic evaluations of vaccine programs conducted in mainland China. We searched for economic evaluations of vaccination in China published prior to August 3, 2015 in eight English-language and three Chinese-language databases. Each article was appraised against the 19-item Consensus on Health Economic Criteria list (CHEC-list). We found 23 papers evaluating vaccines against hepatitis B (8 articles), Streptococcus pneumoniae (5 articles), human papillomavirus (3 articles), Japanese encephalitis (2 articles), rotavirus (2 articles), hepatitis A (1 article), Enterovirus 71 (1 article) and influenza (1 article). Studies conformed to a mean of 12 (range: 6–18) items in the CHEC-list criteria. Five of six Chinese-language articles conformed to fewer than half of the 19 criteria items. The main criteria that studies failed to conform to included: inappropriate measurement (20 articles) and valuation (18 articles) of treatment and/or vaccination costs, no discussion about distributional implications (18 articles), missing major health outcomes (14 articles), no discussion about generalizability to other contexts (14 articles), and inadequate sensitivity analysis (13 articles). In addition, ten studies did not include major cost components of vaccination programs, and nine did not report outcomes in terms of life years even in cases where QALYs or DALYs were calculated. Only 13 studies adopted a societal perspective for analysis. All studies concluded that the appraised vaccination programs were cost-effective except for one evaluation of universal 7-valent pneumococcal conjugate vaccine (PCV-7) in children. However, three of the five studies on PCV-7 showed poor overall quality, and the number of studies on vaccines other than hepatitis B vaccine and PCV-7 was limited. In conclusion, major methodological flaws and reporting problems exist in current economic evaluations of vaccination programs in China. Local guidelines for good practice and reporting, institutional mechanisms and education may help to improve the overall quality of these evaluations.

Vaccine
Volume 33, Issue 46, Pages 6135-6370 (17 November 2015)
http://www.sciencedirect.com/science/journal/0264410X/33/46
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Invasive disease potential of pneumococci before and after the 13-valent pneumococcal conjugate vaccine implementation in children
Original Research Article
Pages 6178-6185
Emmanuelle Varon, Robert Cohen, Stéphane Béchet, Catherine Doit, Corinne Levy
Abstract
Background
Changes in serotype distribution have been induced after pneumococcal conjugate vaccines (PCV) implementation, and non-vaccine serotypes are now circulating. Among these latter serotypes, we aimed to distinguish those with high invasive disease potential before (2008–2009) and after PCV13 implementation (2012–2013).
Methods
Invasive pneumococcal disease (IPD) serotypes isolated from children 6 to 24 months were compared with nasopharyngeal-colonizing serotypes in healthy children. To assess the invasive potential of a given serotype, odds ratios (ORs) were calculated. For each serotype, OR >1 indicated increased probability of association with IPD and OR <1 decreased probability.
Results
In 2008/2009 and 2012/2013, 355 pneumococci were isolated from 1212 healthy children and from 569 IPD, including 166 meningitis, 114 pneumonia, and 289 other IPDs. In period 1, serotypes 7F, 3, 1, 24F, and 19A showed highly significant invasive disease potential whereas in period 2, only serotype 24F was associated with a significant high OR (6.6 [95% CI 2.6; 16.2]). Of note, for serotype 12F, OR could not be calculated because of no carrier recorded, however, if there had been a single 12F carrier, the OR would be among the highest, in period 2, 15.7 [95% 3.4; 73.0]). Only two serotypes appeared negatively associated with IPD, 11A and 23B in the period 2 as compared with nine in period 1. In the second period, pneumococcal penicillin non-susceptible isolates were mostly represented by serotypes 19A, 15A, 19F, 35B and 24F both in carriers and IPD. Only one strain was resistant to penicillin with MIC = 4 μg/ml (serotype 19A) during the first period.
Conclusion
In children <2 years old, compared to the previous period, the number of serotypes having a high disease potential decreased after PCV13 implementation, only two non-vaccine serotypes, 24F and 12F, had high invasive disease potential.

Vaccine
Volume 33, Issue 46, Pages 6135-6370 (17 November 2015)
http://www.sciencedirect.com/science/journal/0264410X/33/46
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The epidemiology of measles in Tianjin, China, 2005–2014
Original Research Article
Pages 6186-6191
Xiexiu Wang, Matthew L. Boulton, JoLynn P. Montgomery, Bradley Carlson, Ying Zhang, Brenda Gillespie, Abram L. Wagner, Yaxing Ding, Xiaoyan Luo, Tian Hong
Abstract
Background
Measles incidence in China has declined over the last decade and elimination is targeted by 2020. Despite increases in routine immunization services and supplementary immunization activities (SIAs), periodic outbreaks continue to occur. In this paper, we examine measles epidemiology during 2005–2014 in Tianjin, China.
Methods
Measles case data were extracted from a web-based communicable disease surveillance system. We examined the socio-demographic characteristics of measles case patients, including age, sex, urbanicity, residency status, and vaccination history. Demographic characteristics of cases were compared with the general population.
Results
From January 1, 2005 to December 31, 2014, 12,466 measles cases in Tianjin were reported. Among the cases, 7179 (57.6%) were male and 5287 (42.4%) were female. Over time, more cases occurred in adults, and for the 2711 cases in 2014, the majority were either infants <1 year (558, 20.58%) or adults ≥20 years (2043, 75.36%). Municipal-wide SIAs in Tianjin occurred in 2008 and 2010 with reduction in measles cases the following year for both (189 cases in 2009, and 37 cases in 2011). The number of cases rebounded to pre-SIA levels or higher within 1–3 years following each SIA: 1990 cases in 2010 and 2711 cases in 2014. Vaccination status was reported as “none” or “unknown” for 84% of all reported measles cases.
Conclusions
Despite the general decline in cases, measles outbreaks continue to occur. Although the SIAs reduce numbers in their immediate aftermath, case counts rebound 1–3 years after the intervention. Continued monitoring of cases through disease surveillance activities accompanied by targeted immunization activities, including to adults, can help ensure progress toward elimination.

Vaccine
Volume 33, Issue 46, Pages 6135-6370 (17 November 2015)
http://www.sciencedirect.com/science/journal/0264410X/33/46
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Response thresholds for epidemic meningitis in sub-Saharan Africa following the introduction of MenAfriVac
Original Research Article
Pages 6212-6217
Caroline L. Trotter, Laurence Cibrelus, Katya Fernandez, Clément Lingani, Olivier Ronveaux, James M. Stuart
Abstract
Background
Since 2010, countries in the African meningitis belt have been introducing a new serogroup A meningococcal conjugate vaccine (MenAfriVac®) through mass campaigns. With the subsequent decline in meningitis due to Neisseria meningitidis serogroup A (NmA) and relative increase in meningitis due to other serogroups, mainly N. meningitidis serogroup W (NmW), the World Health Organisation (WHO) initiated a review of the incidence thresholds that guide response to meningitis epidemics in the African meningitis belt.
Methods
Meningitis surveillance data from African meningitis belt countries from 2002 to 2013 were used to construct a single NmW dataset. The performance of different weekly attack rates, used as thresholds to initiate vaccination response, on preventing further cases was estimated. The cumulative seasonal attack rate used to define an epidemic was also varied.
Results
Considerable variation in effect at different thresholds was observed. In predicting epidemics defined as a seasonal cumulative incidence of 100/105 population, an epidemic threshold of 10 cases/105 population/week performed well. Based on this same epidemic threshold, with a 6 week interval between crossing the epidemic threshold and population protection from a meningococcal vaccination campaign, an estimated 17 cases per event would be prevented by vaccination. Lowering the threshold increased the number of cases per event potentially prevented, as did shortening the response interval. If the interval was shortened to 4 weeks at the threshold of 10/105, the number of cases prevented would increase to 54 per event.
Conclusions
Accelerating time to vaccination could prevent more cases per event than lowering the threshold. Once the meningitis epidemic threshold is crossed, it is of critical importance that vaccination campaigns, where appropriate, are initiated rapidly.