The Lancet Infectious Diseases
Jun 2016 Volume 16 Number 6 p619-752 e82-e107
http://www.thelancet.com/journals/laninf/issue/current

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Comment
Mandating influenza vaccine for Hajj pilgrims
Mohammad Alfelali, Amani S Alqahtani, Osamah Barasheed, Robert Booy, Harunor Rashid
DOI: http://dx.doi.org/10.1016/S1473-3099(16)30064-0
The risk of acquisition and transmission of respiratory tract infections including influenza is considerably enhanced among attendees of the Hajj pilgrimage.1 Influenza vaccine has been recommended by the Saudi Ministry of Health since 2005 for all pilgrims, particularly for those at increased risk of severe disease.2 The Saudi Ministry of Health is now seriously considering mandating influenza vaccine for all pilgrims,3 and the Saudi Thoracic Society has already urged consideration of a “strict vaccination strategy” for Hajj and Umrah visitors.

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Articles
Effect of the introduction of pneumococcal conjugate vaccination on invasive pneumococcal disease in The Gambia: a population-based surveillance study
Grant A Mackenzie, Philip C Hill, David J Jeffries, Ilias Hossain, Uchendu Uchendu, David Ameh, Malick Ndiaye, Oyedeji Adeyemi, Jayani Pathirana, Yekini Olatunji, Bade Abatan, Bilquees S Muhammad, Augustin E Fombah, Debasish Saha, Ian Plumb, Aliu Akano, Bernard Ebruke, Readon C Ideh, Bankole Kuti, Peter Githua, Emmanuel Olutunde, Ogochukwu Ofordile, Edward Green, Effua Usuf, Henry Badji, Usman N A Ikumapayi, Ahmad Manjang, Rasheed Salaudeen, E David Nsekpong, Sheikh Jarju, Martin Antonio, Sana Sambou, Lamin Ceesay, Yamundow Lowe-Jallow, Momodou Jasseh, Kim Mulholland, Maria Knoll, Orin S Levine, Stephen R Howie, Richard A Adegbola, Brian M Greenwood, Tumani Corrah
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Open Access
Summary
Background
Little information is available about the effect of pneumococcal conjugate vaccines (PCVs) in low-income countries. We measured the effect of these vaccines on invasive pneumococcal disease in The Gambia where the 7-valent vaccine (PCV7) was introduced in August, 2009, followed by the 13-valent vaccine (PCV13) in May, 2011.
Methods
We conducted population-based surveillance for invasive pneumococcal disease in individuals aged 2 months and older who were residents of the Basse Health and Demographic Surveillance System (BHDSS) in the Upper River Region, The Gambia, using standardised criteria to identify and investigate patients. Surveillance was done between May, 2008, and December, 2014. We compared the incidence of invasive pneumococcal disease between baseline (May 12, 2008–May 11, 2010) and after the introduction of PCV13 (Jan 1, 2013–Dec 31, 2014), adjusting for changes in case ascertainment over time.
Findings
We investigated 14 650 patients, in whom we identified 320 cases of invasive pneumococcal disease. Compared with baseline, after the introduction of the PCV programme, the incidence of invasive pneumococcal disease decreased by 55% (95% CI 30–71) in the 2–23 months age group, from 253 to 113 per 100 000 population. This decrease was due to an 82% (95% CI 64–91) reduction in serotypes covered by the PCV13 vaccine. In the 2–4 years age group, the incidence of invasive pneumococcal disease decreased by 56% (95% CI 25–75), from 113 to 49 cases per 100 000, with a 68% (95% CI 39–83) reduction in PCV13 serotypes. The incidence of non-PCV13 serotypes in children aged 2–59 months increased by 47% (−21 to 275) from 28 to 41 per 100 000, with a broad range of serotypes. The incidence of non-pneumococcal bacteraemia varied little over time.
Interpretation
The Gambian PCV programme reduced the incidence of invasive pneumococcal disease in children aged 2–59 months by around 55%. Further surveillance is needed to ascertain the maximum effect of the vaccine in the 2–4 years and older age groups, and to monitor serotype replacement. Low-income and middle-income countries that introduce PCV13 can expect substantial reductions in invasive pneumococcal disease.
Funding
GAVI’s Pneumococcal vaccines Accelerated Development and Introduction Plan (PneumoADIP), Bill & Melinda Gates Foundation, and the UK Medical Research Council.

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Articles
The global burden of dengue: an analysis from the Global Burden of Disease Study 2013
Jeffrey D Stanaway, Donald S Shepard, Eduardo A Undurraga, Yara A Halasa, Luc E Coffeng, Oliver J Brady, Simon I Hay, Neeraj Bedi, Isabela M Bensenor, Carlos A Castañeda-Orjuela, Ting-Wu Chuang, Katherine B Gibney, Ziad A Memish, Anwar Rafay, Kingsley N Ukwaja, Naohiro Yonemoto, Christopher J L Murray
Summary
Background
Dengue is the most common arbovirus infection globally, but its burden is poorly quantified. We estimated dengue mortality, incidence, and burden for the Global Burden of Disease Study 2013.
Methods
We modelled mortality from vital registration, verbal autopsy, and surveillance data using the Cause of Death Ensemble Modelling tool. We modelled incidence from officially reported cases, and adjusted our raw estimates for under-reporting based on published estimates of expansion factors. In total, we had 1780 country-years of mortality data from 130 countries, 1636 country-years of dengue case reports from 76 countries, and expansion factor estimates for 14 countries.
Findings
We estimated an average of 9221 dengue deaths per year between 1990 and 2013, increasing from a low of 8277 (95% uncertainty estimate 5353–10 649) in 1992, to a peak of 11 302 (6790–13 722) in 2010. This yielded a total of 576 900 (330 000–701 200) years of life lost to premature mortality attributable to dengue in 2013. The incidence of dengue increased greatly between 1990 and 2013, with the number of cases more than doubling every decade, from 8·3 million (3·3 million–17·2 million) apparent cases in 1990, to 58·4 million (23·6 million–121·9 million) apparent cases in 2013. When accounting for disability from moderate and severe acute dengue, and post-dengue chronic fatigue, 566 000 (186 000–1 415 000) years lived with disability were attributable to dengue in 2013. Considering fatal and non-fatal outcomes together, dengue was responsible for 1·14 million (0·73 million–1·98 million) disability-adjusted life-years in 2013.
Interpretation
Although lower than other estimates, our results offer more evidence that the true symptomatic incidence of dengue probably falls within the commonly cited range of 50 million to 100 million cases per year. Our mortality estimates are lower than those presented elsewhere and should be considered in light of the totality of evidence suggesting that dengue mortality might, in fact, be substantially higher.
Funding
Bill & Melinda Gates Foundation.

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Review
HIV-exposed, uninfected infants: new global challenges in the era of paediatric HIV elimination
Ceri Evans, MBBCh, Christine E Jones, PhD, Dr Andrew J Prendergast, DPhil
Published Online: 31 March 2016
DOI: http://dx.doi.org/10.1016/S1473-3099(16)00055-4
Summary
The number of infants infected with HIV is declining with the rise in interventions for the elimination of paediatric HIV infection, but the number of uninfected infants exposed to HIV through their HIV-infected mothers is increasing. Interest in the health outcomes of HIV-exposed, uninfected infants has grown in the past decade, with several studies suggesting that these infants have increased mortality rates, increased infectious morbidity, and impaired growth compared with HIV-unexposed infants. However, heterogeneous results might reflect the inherent challenges in studies of HIV-exposed, uninfected infants, which need large populations with appropriate, contemporaneous comparison groups and repeated HIV testing throughout the period of breastfeeding. We review the effects of HIV exposure on mortality, morbidity, and growth, discuss the immunological abnormalities identified so far, and provide an overview of interventions that could be effective in this susceptible population. As the number of infants infected with HIV declines, the health needs of HIV-exposed, uninfected infants should be prioritised further, to ensure that post-2015 Sustainable Development Goals are achieved.