Health Research Policy and Systems
http://www.health-policy-systems.com/content
[Accessed 11 June 2016]

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Research
The role of researchers in disseminating evidence to public health practice settings: a cross-sectional study
Allese B. McVay, Katherine A. Stamatakis, Julie A. Jacobs, Rachel G. Tabak and Ross C. Brownson
Published on: 10 June 2016
Abstract
Background
Evidence-based public health interventions, which research has demonstrated offer the most promise for improving the population’s health, are not always utilized in practice settings. The extent to which dissemination from researchers to public health practice settings occurs is not widely understood. This study examines the extent to which public health researchers in the United States are disseminating their research findings to local and state public health departments.
Methods
In a 2012, nationwide study, an online questionnaire was administered to 266 researchers from the National Institutes of Health, the Centers for Disease Control and Prevention, and universities to determine dissemination practices. Logistic regression analyses were used to examine the association between dissemination to state and/or local health departments and respondent characteristics, facilitators, and barriers to dissemination.
Results
Slightly over half of the respondents (58%) disseminated their findings to local and/or state health departments. After adjusting for other respondent characteristics, respondents were more likely to disseminate their findings to health departments if they worked for a university Prevention Research Center or the Centers for Disease Control and Prevention, or received their degree more than 20 years ago. Those who had ever worked in a practice or policy setting, those who thought dissemination was important to their own research and/or to the work of their unit/department, and those who had expectations set by their employers and/or funding agencies were more likely to disseminate after adjusting for work place, graduate degree and/or fellowship in public health, and the year the highest academic degree was received.
Conclusions
There is still room for improvement in strengthening dissemination ties between researchers and public health practice settings, and decreasing the barriers researchers face during the dissemination process. Researchers could better utilize national programs or workshops, knowledge brokers, or opportunities provided through academic institutions to become more proficient in dissemination practices.

Human Vaccines & Immunotherapeutics (formerly Human Vaccines)
Volume 12, Issue 5, 2016
http://www.tandfonline.com/toc/khvi20/current

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Review
A review of clinical models for the evaluation of human TB vaccines
pages 1177-1187
Matthew K. O’Shea & Helen McShane
Open access
DOI:10.1080/21645515.2015.1134407
ABSTRACT
While much progress has been made in the fight against the scourge of tuberculosis (TB), we are still some way from reaching the ambitious targets of eliminating it as a global public health problem by the mid twenty-first century. A new and effective vaccine that protects against pulmonary TB disease will be an essential element of any control strategy. Over a dozen vaccines are currently in development, but recent efficacy trial data from one of the most advanced candidates have been disappointing. Limitations of current preclinical animal models exist, together with a lack of a complete understanding of host immunity to TB or robust correlates of disease risk and protection. Therefore, in the context of such obstacles, we discuss the lessons identified from recent efficacy trials, current concepts of biomarkers and correlates of protection, the potential of innovative clinical models such as human challenge and conducting trials in high-incidence settings to evaluate TB vaccines in humans, and the use of systems vaccinology and novel technologies including transcriptomics and metabolomics, that may facilitate their utility.

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Research Papers
Economic evaluation of pediatric influenza immunization program compared with other pediatric immunization programs: A systematic review
pages 1202-1216
Edward Gibson, Najida Begum, Birgir Sigmundsson, Alfred Sackeyfio, Judith Hackett & Sankarasubramanian Rajaram
Open access
DOI:10.1080/21645515.2015.1131369
ABSTRACT
This study compared the economic value of pediatric immunisation programmes for influenza to those for rotavirus (RV), meningococcal disease (MD), pneumococcal disease (PD), human papillomavirus (HPV), hepatitis B (Hep B), and varicella reported in recent (2000 onwards) cost-effectiveness (CE) studies identified in a systematic review of PubMed, health technology, and vaccination databases. The systematic review yielded 51 economic evaluation studies of pediatric immunisation — 10 (20%) for influenza and 41 (80%) for the other selected diseases. The quality of the eligible articles was assessed using Drummond’s checklist. Although inherent challenges and limitations exist when comparing economic evaluations of immunisation programmes, an overall comparison of the included studies demonstrated cost-effectiveness/cost saving for influenza from a European-Union-Five (EU5) and United States (US) perspective; point estimates for cost/quality-adjusted life-years (QALY) from dominance (cost-saving with more effect) to ≤45,444 were reported. The economic value of influenza programmes was comparable to the other vaccines of interest, with cost/QALY in general considerably lower than RV, Hep B, MD and PD. Independent of the perspective and type of analysis, the economic impact of a pediatric influenza immunisation program was influenced by vaccine efficacy, immunisation coverage, costs, and most significantly by herd immunity. This review suggests that pediatric influenza immunisation may offer a cost effective strategy when compared with HPV and varicella and possibly more value compared with other childhood vaccines (RV, Hep B, MD and PD.

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Economic evaluation of vaccines in Canada: A systematic review
pages 1257-1264
Ayman Chit, Jason K. H. Lee, Minsup Shim, Van Hai Nguyen, Paul Grootendorst, Jianhong Wu, Robert Van Exan & Joanne M. Langley
Open access
DOI:10.1080/21645515.2015.1137405
ABSTRACT
Background: Economic evaluations should form part of the basis for public health decision making on new vaccine programs. While Canada’s national immunization advisory committee does not systematically include economic evaluations in immunization decision making, there is increasing interest in adopting them. We therefore sought to examine the extent and quality of economic evaluations of vaccines in Canada.
Objective: We conducted a systematic review of economic evaluations of vaccines in Canada to determine and summarize: comprehensiveness across jurisdictions, studied vaccines, funding sources, study designs, research quality, and changes over time.
Methods: Searches in multiple databases were conducted using the terms “vaccine,” “economics” and “Canada.” Descriptive data from eligible manuscripts was abstracted and three authors independently evaluated manuscript quality using a 7-point Likert-type scale scoring tool based on criteria from the International Society for Pharmacoeconomics and Outcomes Research (ISPOR).
Results: 42/175 articles met the search criteria. Of these, Canada-wide studies were most common (25/42), while provincial studies largely focused on the three populous provinces of Ontario, Quebec and British Columbia. The most common funding source was industry (17/42), followed by government (7/42). 38 studies used mathematical models estimating expected economic benefit while 4 studies examined post-hoc data on established programs. Studies covered 10 diseases, with 28/42 addressing pediatric vaccines. Many studies considered cost-utility (22/42) and the majority of these studies reported favorable economic results (16/22). The mean quality score was 5.9/7 and was consistent over publication date, funding sources, and disease areas.
Conclusions: We observed diverse approaches to evaluate vaccine economics in Canada. Given the increased complexity of economic studies evaluating vaccines and the impact of results on public health practice, Canada needs improved, transparent and consistent processes to review and assess the findings of the economic evaluations of vaccines.

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Review
Knowledge, attitudes, beliefs and behaviors of general practitioners/family physicians toward their own vaccination: A systematic review
pages 1282-1292
Fanny Collange, Pierre Verger, Odile Launay & Céline Pulcini
DOI:10.1080/21645515.2015.1138024
ABSTRACT
Context: General practitioners and family physicians (GP/FPs) play a key role in the vaccination of the public in many countries and serve as role models for their patients through their own health behaviors. Objectives and Methods: a) To search for and document recommended/mandated vaccines for GP/FPs in high-income countries; b) To systematically search and review the literature on these physicians’ knowledge, attitudes, beliefs, and behaviors (KABB) toward their own vaccination with the recommended/mandated vaccines and the factors determining it. Results: a) The 14 countries included recommended or mandated as many as 12 vaccines; b) The systematic review identified 11 studies published in the last 10 y. All considered seasonal influenza vaccination but differed in the variables investigated. Discussion/Conclusions: This review highlights the need for further studies on this topic, including qualitative and interventional studies (based on behavior change theories). These should cover occupational vaccines and determinants known to be associated with vaccine hesitancy.

Infectious Diseases of Poverty
http://www.idpjournal.com/content
[Accessed 11 June 2016]

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Commentary
Malaria: Global progress 2000 – 2015 and future challenges
2015 was the target year for malaria goals set by the World Health Assembly and other international institutions to reduce malaria incidence and mortality. A review of progress indicates that malaria programme…
Richard E. Cibulskis, Pedro Alonso, John Aponte, Maru Aregawi, Amy Barrette, Laurent Bergeron, Cristin A. Fergus, Tessa Knox, Michael Lynch, Edith Patouillard, Silvia Schwarte, Saira Stewart and Ryan Williams
Infectious Diseases of Poverty 2016 5:61
Published on: 9 June 2016

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Research Article
Rapid assessment of knowledge, attitudes, practices, and risk perception related to the prevention and control of Ebola virus disease in three communities of Sierra Leone
Hai Jiang, Guo-Qing Shi, Wen-Xiao Tu, Can-Jun Zheng, Xue-Hui Lai, Xin-Xu Li, Qiang Wei, Mei Li, Li-Quan Deng, Xiang Huo, Ming-Quan Chen, Feng Xu, Long-Jie Ye, Xi-Chen Bai, Tong-Nian Chen, Shao-Hua Yin…
Infectious Diseases of Poverty 2016 5:53
Published on: 6 June 2016

The Lancet
Jun 11, 2016 Volume 387 Number 10036 p2351-2478 e29
http://www.thelancet.com/journals/lancet/issue/current
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Editorial
Dear Mr Ban Ki-moon
The Lancet
We have greatly admired your leadership as Secretary-General of the UN. Over your 10 years heading the world’s most important international organisation, you have played an exemplary part in strengthening the global health agenda—championing awareness of women’s and children’s health, global warming, and humanitarianism. But there is one issue that concerns us deeply.

In 2010, UN soldiers from Nepal were deployed to help after Haiti’s devastating earthquake and cholera contaminated sewage was discarded from their camp into the country’s major river. This triggered the largest cholera outbreak in the world, leaving more than 30 000 Haitians dead and more than 2 million affected.

6 years later a cholera epidemic still rages—14 000 new cases and 150 deaths are reported this year alone. The UN has yet to accept responsibility for introducing cholera into Haiti, despite two investigations establishing these facts.

We applaud the considerable work that the UN has done since 2010 to improve hygiene standards for peacekeepers and support immunisation campaigns. But we are distressed by reports that less than 20% of the funds pledged by the UN after the outbreak to eradicate cholera have been raised.

Calls for you to do more are intensifying. 2000 letters were sent to the UN by Haitians with stories of hardship. Diaspora leaders have urged the UN to install water and sanitation infrastructure to control cholera and to compensate victims. Failing to accept the UN’s responsibilities sets a poor example for the Haitian government to assume theirs, they say. Your own human rights advisers have implored you to respond. Instead, the UN continues to say it is immune from these claims.

It is disappointing that the UN’s silence has forced the matter into the US courts. The UN has enormous power to act. But its power to ignore is what prevails here.

We hope you can address this issue. Please endorse the facts. Please acknowledge the injustice. Please apologise for the indifference. Responsibility is not about vengeance, but about accountability from which needed reparation and reconciliation can flow. The UN has long emphasised the need for accountability—we urge you to make this a final act in your celebrated career as Secretary-General.

The Lancet
Jun 11, 2016 Volume 387 Number 10036 p2351-2478 e29
http://www.thelancet.com/journals/lancet/issue/current
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Articles
Global burden of diseases, injuries, and risk factors for young people’s health during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013
Ali H Mokdad, Mohammad Hossein Forouzanfar, Farah Daoud, Arwa A Mokdad, Charbel El Bcheraoui, Maziar Moradi-Lakeh, Hmwe Hmwe Kyu, Ryan M Barber, Joseph Wagner, Kelly Cercy, Hannah Kravitz, Megan Coggeshall, Adrienne Chew, Kevin F O’Rourke, Caitlyn Steiner, Marwa Tuffaha, Raghid Charara, Essam Abdullah Al-Ghamdi, Yaser Adi, Rima A Afifi, Hanan Alahmadi, Fadia AlBuhairan, Nicholas Allen, Mohammad AlMazroa, Abdulwahab A Al-Nehmi, Zulfa AlRayess, Monika Arora, Peter Azzopardi, Carmen Barroso, Mohammed Basulaiman, Zulfiqar A Bhutta, Chris Bonell, Cecilia Breinbauer, Louisa Degenhardt, Donna Denno, Jing Fang, Adesegun Fatusi, Andrea B Feigl, Ritsuko Kakuma, Nadim Karam, Elissa Kennedy, Tawfik A M Khoja, Fadi Maalouf, Carla Makhlouf Obermeyer, Amitabh Mattoo, Terry McGovern, Ziad A Memish, George A Mensah, Vikram Patel, Suzanne Petroni, Nicola Reavley, Diego Rios Zertuche, Mohammad Saeedi, John Santelli, Susan M Sawyer, Fred Ssewamala, Kikelomo Taiwo, Muhammad Tantawy, Russell M Viner, Jane Waldfogel, Maria Paola Zuñiga, Mohsen Naghavi, Haidong Wang, Theo Vos, Alan D Lopez, Abdullah A Al Rabeeah, George C Patton, Christopher J L Murray
Summary
Background
Young people’s health has emerged as a neglected yet pressing issue in global development. Changing patterns of young people’s health have the potential to undermine future population health as well as global economic development unless timely and effective strategies are put into place. We report the past, present, and anticipated burden of disease in young people aged 10–24 years from 1990 to 2013 using data on mortality, disability, injuries, and health risk factors.
Methods
The Global Burden of Disease Study 2013 (GBD 2013) includes annual assessments for 188 countries from 1990 to 2013, covering 306 diseases and injuries, 1233 sequelae, and 79 risk factors. We used the comparative risk assessment approach to assess how much of the burden of disease reported in a given year can be attributed to past exposure to a risk. We estimated attributable burden by comparing observed health outcomes with those that would have been observed if an alternative or counterfactual level of exposure had occurred in the past. We applied the same method to previous years to allow comparisons from 1990 to 2013. We cross-tabulated the quantiles of disability-adjusted life-years (DALYs) by quintiles of DALYs annual increase from 1990 to 2013 to show rates of DALYs increase by burden. We used the GBD 2013 hierarchy of causes that organises 306 diseases and injuries into four levels of classification. Level one distinguishes three broad categories: first, communicable, maternal, neonatal, and nutritional disorders; second, non-communicable diseases; and third, injuries. Level two has 21 mutually exclusive and collectively exhaustive categories, level three has 163 categories, and level four has 254 categories.
Findings
The leading causes of death in 2013 for young people aged 10–14 years were HIV/AIDS, road injuries, and drowning (25·2%), whereas transport injuries were the leading cause of death for ages 15–19 years (14·2%) and 20–24 years (15·6%). Maternal disorders were the highest cause of death for young women aged 20–24 years (17·1%) and the fourth highest for girls aged 15–19 years (11·5%) in 2013. Unsafe sex as a risk factor for DALYs increased from the 13th rank to the second for both sexes aged 15–19 years from 1990 to 2013. Alcohol misuse was the highest risk factor for DALYs (7·0% overall, 10·5% for males, and 2·7% for females) for young people aged 20–24 years, whereas drug use accounted for 2·7% (3·3% for males and 2·0% for females). The contribution of risk factors varied between and within countries. For example, for ages 20–24 years, drug use was highest in Qatar and accounted for 4·9% of DALYs, followed by 4·8% in the United Arab Emirates, whereas alcohol use was highest in Russia and accounted for 21·4%, followed by 21·0% in Belarus. Alcohol accounted for 9·0% (ranging from 4·2% in Hong Kong to 11·3% in Shandong) in China and 11·6% (ranging from 10·1% in Aguascalientes to 14·9% in Chihuahua) of DALYs in Mexico for young people aged 20–24 years. Alcohol and drug use in those aged 10–24 years had an annual rate of change of >1·0% from 1990 to 2013 and accounted for more than 3·1% of DALYs.
Interpretation
Our findings call for increased efforts to improve health and reduce the burden of disease and risks for diseases in later life in young people. Moreover, because of the large variations between countries in risks and burden, a global approach to improve health during this important period of life will fail unless the particularities of each country are taken into account. Finally, our results call for a strategy to overcome the financial and technical barriers to adequately capture young people’s health risk factors and their determinants in health information systems.
Funding
Bill & Melinda Gates Foundation.

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The Lancet Commissions
Our future: a Lancet commission on adolescent health and wellbeing
George C Patton, Susan M Sawyer, John S Santelli, David A Ross, Rima Afifi, Nicholas B Allen, Monika Arora, Peter Azzopardi, Wendy Baldwin, Christopher Bonell, Ritsuko Kakuma, Elissa Kennedy, Jaqueline Mahon, Terry McGovern, Ali H Mokdad, Vikram Patel, Suzanne Petroni, Nicola Reavley, Kikelomo Taiwo, Jane Waldfogel, Dakshitha Wickremarathne, Carmen Barroso, Zulfiqar Bhutta, Adesegun O Fatusi, Amitabh Mattoo, Judith Diers, Jing Fang, Jane Ferguson, Frederick Ssewamala, Russell M Viner
Summary
Unprecedented global forces are shaping the health and wellbeing of the largest generation of 10 to 24 year olds in human history. Population mobility, global communications, economic development, and the sustainability of ecosystems are setting the future course for this generation and, in turn, humankind.1,2 At the same time, we have come to new understandings of adolescence as a critical phase in life for achieving human potential. Adolescence is characterised by dynamic brain development in which the interaction with the social environment shapes the capabilities an individual takes forward into adult life.

Nature
Volume 534 Number 7606 pp152-290 9 June 2016
http://www.nature.com/nature/current_issue.html

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Letters
The Brazilian Zika virus strain causes birth defects in experimental models
Fernanda R. Cugola, Isabella R. Fernandes, Fabiele B. Russo, Beatriz C. Freitas, João L. M. Dias
+ et al.
The Zika virus can cross the placenta and cause intrauterine growth restriction, including microcephaly, in the SJL strain of mice; the virus can also infect human brain organoids, inducing cell death by apoptosis and disrupting cortical layers.

Nature Medicine
June 2016, Volume 22 No 6 pp569-692
http://www.nature.com/nm/journal/v22/n5/index.html

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Opinion
Use the Bayh-Dole Act to lower drug prices for government healthcare programs – p576
Alfred B Engelberg & Aaron S Kesselheim
doi:10.1038/nm0616-576
As drug prices have increased, there is also greater pressure to find ways to ensure access to medicines. An existing provision of the Bayh-Dole Act could help to lower costs for qualifying drugs in federal programs such as Medicare and Medicaid.

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Article
Protection against malaria at 1 year and immune correlates following PfSPZ vaccination – pp614 – 623
Andrew S Ishizuka, Kirsten E Lyke, Adam DeZure, Andrea A Berry, Thomas L Richie, Floreliz H Mendoza, Mary E Enama, Ingelise J Gordon, Lee-Jah Chang, Uzma N Sarwar, Kathryn L Zephir, LaSonji A Holman, Eric R James, Peter F Billingsley, Anusha Gunasekera, Sumana Chakravarty, Anita Manoj, MingLin Li, Adam J Ruben, Tao Li, Abraham G Eappen, Richard E Stafford, Natasha K C, Tooba Murshedkar, Hope DeCederfelt, Sarah H Plummer, Cynthia S Hendel, Laura Novik, Pamela J M Costner, Jamie G Saunders, Matthew B Laurens, Christopher V Plowe, Barbara Flynn, William R Whalen, J P Todd, Jay Noor, Srinivas Rao, Kailan Sierra-Davidson, Geoffrey M Lynn, Judith E Epstein, Margaret A Kemp, Gary A Fahle, Sebastian A Mikolajczak, Matthew Fishbaugher, Brandon K Sack, Stefan H I Kappe, Silas A Davidson, Lindsey S Garver, Niklas K Björkström, Martha C Nason, Barney S Graham, Mario Roederer, B Kim Lee Sim, Stephen L Hoffman, Julie E Ledgerwood & Robert A Seder
doi:10.1038/nm.4110
Fifty-five percent of individuals vaccinated with an attenuated Plasmodium falciparum sporozoite vaccine remained without parasitemia after controlled human malaria infection one year later; immune correlate analysis in humans and non-human primates suggest a role for liver-resident T cells.

New England Journal of Medicine
June 9, 2016 Vol. 374 No. 23
http://www.nejm.org/toc/nejm/medical-journal

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Perspective
Saving Tiny Tim — Pediatrics and Childhood Poverty in the United States
Perri Klass, M.D.
N Engl J Med 2016; 374:2201-2205 June 9, 2016 DOI: 10.1056/NEJMp1603516
Free Full Text

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Perspective
The Hell of Syria’s Field Hospitals
Samer Attar, M.D.
N Engl J Med 2016; 374:2205-2207 June 9, 2016 DOI: 10.1056/NEJMp1603673
Free Full Text

PLOS Currents: Disasters
http://currents.plos.org/disasters/
[Accessed 11 June 2016]

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Brief Report
Needs of Internally Displaced Women and Children in Baghdad, Karbala, and Kirkuk, Iraq
June 10, 2016 ·
Background: The continuing conflict in Iraq has now created an estimated four million internally displaced persons (IDPs). The bulk of recently displaced persons are in Central Iraq, often in insecure and difficult situations.
Objective: To determine the health status and health needs of women and children, age 15 and under, among a sample of this IDP population in Kirkuk, Baghdad, and Karbala governorates.
Methods: Data were collected from the senior female in 1216 families which contained 3665 children living in 45 makeshift settlements.
Findings: The majority of IDPs were living in tents or religious centers. Repeated displacements were common. Kidnappings were reported by 5.2% of families, and 7.9% of families reported a death of a family member during or after displacement. Intentional violence accounted for 72.3% of deaths. Only a third of children in school at the time of displacement continued in school. On average, households had received assistance on 3.2 occasions since displacement, food being the most common form. Access to health services was difficult. Some form of transport was often required. Few women knew where to secure antenatal services and many did not know where childhood immunization services were available. During or after displacement 307 women had delivered or were currently pregnant. Complications of pregnancies were common, with a quarter reporting anemia, and 22.1% experiencing hemorrhage. Both communicable and non-communicable diseases (NCDs) were common in the women and children in the survey. Scabies, diarrhea and lice were common among children. Among women, hypertension accounted for 36.6% of NCDs and type 2 diabetes for 15.9%. Domestic violence directed against women was reported in 17.4% of families and against children in 26.6%
Interpretation: Women and children in IDP settlements of Central Iraq experience many vulnerabilities involving their health, education and their environment, in addition to living in physical danger. While some external assistance was received, much more is needed to meet the needs of a displaced population which is unlikely to return home soon.

PLoS Currents: Outbreaks
http://currents.plos.org/outbreaks/
(Accessed 11 June 2016)

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Research Article
FLIRT-ing with Zika: A Web Application to Predict the Movement of Infected Travelers Validated Against the Current Zika Virus Epidemic
June 10, 2016 ·
Introduction: Beginning in 2015, Zika virus rapidly spread throughout the Americas and has been linked to neurological and autoimmune diseases in adults and babies. Developing accurate tools to anticipate Zika spread is one of the first steps to mitigate further spread of the disease. When combined, air traffic data and network simulations can be used to create tools to predict where infectious disease may spread to and aid in the prevention of infectious diseases. Specific goals were to: 1) predict where travelers infected with the Zika Virus would arrive in the U.S.; and, 2) analyze and validate the open access web application’s (i.e., FLIRT) predictions using data collected after the prediction was made.
Method: FLIRT was built to predict the flow and likely destinations of infected travelers through the air travel network. FLIRT uses a database of flight schedules from over 800 airlines, and can display direct flight traffic and perform passenger simulations between selected airports. FLIRT was used to analyze flights departing from five selected airports in locations where sustained Zika Virus transmission was occurring. FLIRT’s predictions were validated against Zika cases arriving in the U.S. from selected airports during the selected time periods. Kendall’s τ and Generalized Linear Models were computed for all permutations of FLIRT and case data to test the accuracy of FLIRT’s predictions.
Results: FLIRT was found to be predictive of the final destinations of infected travelers in the U.S. from areas with ongoing transmission of Zika in the Americas from 01 February 2016 – 01 to April 2016, and 11 January 2016 to 11 March 2016 time periods. MIA-FLL, JFK-EWR-LGA, and IAH were top ranked at-risk metro areas, and Florida, Texas and New York were top ranked states at-risk for the future time period analyzed (11 March 2016 – 11 June 2016). For the 11 January 2016 to 11 March 2016 time period, the region-aggregated model indicated 7.24 (95% CI 6.85 – 7.62) imported Zika cases per 100,000 passengers, and the state-aggregated model suggested 11.33 (95% CI 10.80 – 11.90) imported Zika cases per 100,000 passengers.
Discussion: The results from 01 February 2016 to 01 April 2016 and 11 January 2016 to 11 March 2016 time periods support that modeling air travel and passenger movement can be a powerful tool in predicting where infectious diseases will spread next. As FLIRT was shown to significantly predict distribution of Zika Virus cases in the past, there should be heightened biosurveillance and educational campaigns to medical service providers and the general public in these states, especially in the large metropolitan areas.

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Radiological Characterization of Cerebral Phenotype in Newborn Microcephaly Cases from 2015 Outbreak in Brazil
June 8, 2016 · Research Article
Introduction: Brazil is facing, since October of 2015, an outbreak of microcephalic fetuses. This outbreak is correlated with the beginning of circulation of Zika virus (ZIKV) in the country. Although it is clear that the size of the head is diminished in these fetuses, the brain phenotype associated with these malformations is unknown.
Methods: We collected computed tomography images of the microcephaly cases from the region of Natal, Rio Grande do Norte, from September 2015 to February 2016.
Findings: The microcephalies derived from the current outbreak are associated with intracerebral calcifications, malformation of the ventricular system, migratory disorders in the telencephalon and, in a lower frequency, malformation of the cerebellum and brainstem.
Discussion: The characteristics described herein are not usually found in other types of microcephaly. We suggest that this work can be used as a guideline to identify microcephaly cases associated to the current outbreak.

PLoS Neglected Tropical Diseases
http://www.plosntds.org/

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Viewpoints
Dengue Vaccine: Considerations before Rollout in Colombia
Christian Julian Villabona-Arenas, Raquel Elvira Ocazionez Jimenez, Cinthy Lorena Jimenez Silva
Viewpoints | published 09 Jun 2016 | PLOS Neglected Tropical Diseases
http://dx.doi.org/10.1371/journal.pntd.0004653

PNAS – Proceedings of the National Academy of Sciences of the United States of America
http://www.pnas.org/content/early/
(Accessed 11 June 2016)

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Biological Sciences – Applied Biological Sciences:
Directed vaccination against pneumococcal disease
Yi Li, Andrew Hill, Marie Beitelshees, Shuai Shao, Jonathan F. Lovell, Bruce A. Davidson, Paul R. Knight III, Anders P. Hakansson, Blaine A. Pfeifer, and Charles H. Jones
PNAS 2016 ; published ahead of print June 6, 2016, doi:10.1073/pnas.1603007113

Significance
Pneumococcal disease represents a global health problem, especially for the young, the elderly, and the resource-limited. Disease progression begins with asymptomatic nasopharyngeal bacterial colonization before subsequent dissemination and disease (pneumonia, sepsis, and middle ear infection). Analysis of this transition from colonization to disease provided antigens that were tested in this study for directed vaccination against only the virulent subset of pneumococci. In so doing, a “smart” vaccine was sought that would address this disease broadly, effectively, and selectively.

Abstract
Immunization strategies against commensal bacterial pathogens have long focused on eradicating asymptomatic carriage as well as disease, resulting in changes in the colonizing microflora with unknown future consequences. Additionally, current vaccines are not easily adaptable to sequence diversity and immune evasion. Here, we present a “smart” vaccine that leverages our current understanding of disease transition from bacterial carriage to infection with the pneumococcus serving as a model organism. Using conserved surface proteins highly expressed during virulent transition, the vaccine mounts an immune response specifically against disease-causing bacterial populations without affecting carriage. Aided by a delivery technology capable of multivalent surface display, which can be adapted easily to a changing clinical picture, results include complete protection against the development of pneumonia and sepsis during animal challenge experiments with multiple, highly variable, and clinically relevant pneumococcal isolates. The approach thus offers a unique and dynamic treatment option readily adaptable to other commensal pathogens.

Social Science & Medicine
Volume 157, Pages 1-192 (May 2016)
http://www.sciencedirect.com/science/journal/02779536/156

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Commentary
What does India need to do to address childhood malnutrition at scale?
Pages 186-188
Zulfiqar A. Bhutta

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Improving household-level nutrition-specific and nutrition–sensitive conditions key to reducing child undernutrition in India
Pages 189-192
Daniel J. Corsi, Iván Mejía-Guevara, S.V. Subramanian

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Regular Articles
Risk factors for chronic undernutrition among children in India: Estimating relative importance, population attributable risk and fractions
Original Research Article
Pages 165-185
Daniel J. Corsi, Iván Mejía-Guevara, S.V. Subramanian
Highlights
:: Research on risk factors for child undernutrition has been single-factorial and downstream.
:: We assessed the relative and joint contribution of multiple factors for growth and development.
:: Maternal stature, education, household wealth, dietary diversity, and maternal BMI were the top 5 risk factors.
:: Together these five 5 factors accounted for more than 65% of the PAR for child undernutrition.
:: Strategies focused on social circumstances and direct investments in nutrition specific-programs are required.

Tropical Medicine & International Health
June 2016 Volume 21, Issue 6 Pages 691–817
http://onlinelibrary.wiley.com/doi/10.1111/tmi.2016.21.issue-6/issuetoc

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Ethical challenges in designing and conducting medicine quality surveys (pages 799–806)
Patricia Tabernero, Michael Parker, Raffaella Ravinetto, Souly Phanouvong, Shunmay Yeung, Freddy E. Kitutu, Phaik Yeong Cheah, Mayfong Mayxay, Philippe J. Guerin and Paul N. Newton
Version of Record online: 20 MAY 2016 | DOI: 10.1111/tmi.12707
Abstract
Objectives
In this paper we discuss the main ethical challenges related to the conduct of medicine quality surveys and make suggestions on how to address them.
Method
Most evidence-based information regarding medicine quality derives from surveys. However, existing research ethical guidelines do not provide specific guidance for medicine quality surveys. Hence, those conducting surveys are often left wondering how to judge what counts as best practice. A list of the main ethical challenges in the design and conduct of surveys is presented.
Results and conclusions
It is vital that the design and conduct of medicine quality surveys uphold moral and ethical obligations and analyse the ethical implications and consequences of such work. These aspects include the impact on the local availability of and access to medicines; the confidentiality and privacy of the surveyors and the surveyed; questions as to whether outlet staff personnel should be told they are part of a survey; the need of ethical and regulatory approvals; and how the findings should be disseminated. Medicine quality surveys should ideally be conducted in partnership with the relevant national Medicine Regulatory Authorities. An international, but contextually sensitive, model of good ethical practice for such surveys is needed.

Tropical Medicine & International Health
June 2016 Volume 21, Issue 6 Pages 691–817
http://onlinelibrary.wiley.com/doi/10.1111/tmi.2016.21.issue-6/issuetoc

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Reviews
Tuberculosis and diabetes: current state and future perspectives (pages 694–702)
Damiano Pizzol, Francesco Di Gennaro, Kajal D. Chhaganlal, Claudia Fabrizio, Laura Monno, Giovanni Putoto and Annalisa Saracino
Version of Record online: 18 MAY 2016 | DOI: 10.1111/tmi.12704
Abstract
This review outlines the association between tuberculosis and diabetes, focusing on epidemiology, physiopathology, clinical aspects, diagnosis and treatment, and evaluates future perspectives, with particular attention to developing countries.

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Mortality risk and associated factors in HIV-exposed, uninfected children (pages 720–734)
Shino Arikawa, Nigel Rollins, Marie-Louise Newell and Renaud Becquet
Version of Record online: 19 APR 2016 | DOI: 10.1111/tmi.12695
Abstract
Objective
With increasing maternal antiretroviral treatment (ART), the number of children newly infected with HIV has declined. However, the possible increased mortality in the large number of HIV-exposed, uninfected (HEU) children may be of concern. We quantified mortality risks among HEU children and reviewed associated factors.
Methods
Systematic search of electronic databases (PubMed, Scopus). We included all studies reporting mortality of HEU children to age 60 months and associated factors. Relative risk of mortality between HEU and HIV-unexposed, uninfected (HUU) children was extracted where relevant. Inverse variance methods were used to adjust for study size. Random-effects models were fitted to obtain pooled estimates.
Results
A total of 14 studies were included in the meta-analysis and 13 in the review of associated factors. The pooled cumulative mortality in HEU children was 5.5% (95% CI: 4.0–7.2; I2 = 94%) at 12 months (11 studies) and 11.0% (95% CI: 7.6–15.0; I2 = 93%) at 24 months (four studies). The pooled risk ratios for the mortality in HEU children compared to HUU children in the same setting were 1.9 (95% CI: 0.9–3.8; I2 = 93%) at 12 months (four studies) and 2.4 (95% CI: 1.1–5.1; I2 = 93%) at 24 months (three studies).
Conclusion
Compared to HUU children, mortality risk in HEU children was about double at both age points, although the association was not statistically significant at 12 months. Interpretation of the pooled estimates is confounded by considerable heterogeneity between studies. Further research is needed to characterise the impact of maternal death and breastfeeding on the survival of HEU infants in the context of maternal ART, where current evidence is limited.

Vaccine
Volume 34, Issue 27, Pages 3007-3220 (8 June 2016)
http://www.sciencedirect.com/science/journal/0264410X/34/27

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Do we have enough evidence how seasonal influenza is transmitted and can be prevented in hospitals to implement a comprehensive policy?
Review Article
Pages 3014-3021
Roger E. Thomas
Abstract
Purpose
To identify if there is enough evidence at low risk-of-bias to prevent influenza transmission by vaccinating health-care workers (HCWs), patients and visitors; screening for laboratory-proven influenza all entering hospitals; screening asymptomatic individuals; identifying influenza supershedders; hand-washing and mask-wearing by HCWs, patients and visitors; and cleaning hospital rooms and equipment.
Principal Results
Vaccination reduces influenza episodes of vaccinated (4.81/100 HCW) compared to unvaccinated (7.54/100) HCWs/influenza season. A Cochrane review found for inactivated vaccines the Number Needed to Vaccinate (NNV) = 71 (95%CI 64%, 80%) for adults 18–60 (same age as HCWs) to prevent laboratory-proven influenza. There are no RCTs of screening HCWs, patients, visitors and influenza supershedders to prevent transmission. None of four RCTs of HCWs mask-wearing (two directly observed, two not) showed an effect because they were underpowered either due to small size or low circulation of influenza. Hospital rooms and equipment can effectively be cleaned of influenza by many chemicals and hydrogen peroxide vapor machines but the cleaning cycle needs shortening to increase the likelihood of adoption.
Major Conclusions
HCW vaccination is a partial solution with current vaccination levels. There are no RCTs of screening HCWs, patients and visitors demonstrating preventing influenza transmission. Only one study costed furloughing HCWs with influenza and no RCTs have identified benefits of isolating influenza supershedders. RCTs of directly- and electronically continuously-observed mask-wearing and hand-hygiene and RCTs of incentives for meticulous hygiene are required. RCTs of engineering solutions (external venting, frequent room air changes) are needed. A wide range of chemicals effectively cleans hospital rooms and equipment from influenza. Hydrogen peroxide vapor is effective against influenza and a wide range of bacterial pathogens with patient room changes, and clean areas cleaners do not clean but its cleaning cycle needs shortening to increase the likelihood of adoption of cleaning rooms vacated by influenza patients.

Vaccine
Volume 34, Issue 27, Pages 3007-3220 (8 June 2016)
http://www.sciencedirect.com/science/journal/0264410X/34/27

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Assessing the impact of vaccination programmes on burden of disease: Underlying complexities and statistical methods
Review Article
Pages 3022-3029
Nicole Mealing, Andrew Hayen, Anthony T. Newall
Abstract
It is important to assess the impact a vaccination programme has on the burden of disease after it is implemented. For example, this may reveal herd immunity effects or vaccine-induced shifts in the incidence of disease or in circulating strains or serotypes of the pathogen. In this article we summarise the key features of infectious diseases that need to be considered when trying to detect any changes in the burden of diseases at a population level as a result of vaccination efforts. We outline the challenges of using routine surveillance databases to monitor infectious diseases, such as the identification of diseased cases and the availability of vaccination status for cases. We highlight the complexities in modelling the underlying patterns in infectious disease rates (e.g. presence of autocorrelation) and discuss the main statistical methods that can be used to control for periodicity (e.g. seasonality) and autocorrelation when assessing the impact of vaccination programmes on burden of disease (e.g. cosinor terms, generalised additive models, autoregressive processes and moving averages). For some analyses, there may be multiple methods that can be used, but it is important for authors to justify the method chosen and discuss any limitations. We present a case study review of the statistical methods used in the literature to assess the rotavirus vaccination programme impact in Australia. The methods used varied and included generalised linear models and descriptive statistics. Not all studies accounted for autocorrelation and seasonality, which can have a major influence on results. We recommend that future analyses consider the strength and weakness of alternative statistical methods and justify their choice.

Vaccine
Volume 34, Issue 27, Pages 3007-3220 (8 June 2016)
http://www.sciencedirect.com/science/journal/0264410X/34/27

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Relationship status impacts primary reasons for interest in the HPV vaccine among young adult women
Original Research Article
Pages 3119-3124
Erika L. Thompson, Cheryl A. Vamos, William M. Sappenfield, Diane M. Straub, Ellen M. Daley
Abstract
Introduction
The HPV vaccine prevents HPV-related cancers and genital warts, which cause significant morbidity and mortality in the US. The vaccine is targeted toward 11–12 year old males and females, but is recommended for “catch-up” vaccination until age 26 for females. Young adult females (18–26 years) represent a unique group that may face distinct barriers to HPV vaccination, one of which is relationship status. The purpose of this study was to assess how relationship status impacts interest in HPV vaccination and primary reasons for non-vaccination among 18–26 year old young adult women.
Methods
The National Health Interview Survey 2010 was examined among unvaccinated females, 18–26 years (N = 1457). A survey-weighted logistic regression analysis with conversion to prevalence ratios assessed how interest in the HPV vaccine (yes/no) was influenced by relationship status (married, living with a partner, other, single) among young adult women. A Rao-Scott chi-square test examined differences between primary reasons for non-vaccination and relationship status among HPV vaccine uninterested women.
Results
Among unvaccinated women, 31.4% were interested in the HPV vaccine. Women who were living with a partner (PR = 1.45, 95%CI 1.06–1.90) and single (PR = 1.42, 95%CI 1.11–1.76) were significantly more likely than married women to be interested in the HPV vaccine, while controlling for socio-demographic and other known risk factors. Additionally, primary reasons for non-vaccination differed based on relationship status among uninterested women (p < 0.01). Women who were married were more likely to cite not needing the vaccine compared to never married women (p < 0.05).
Conclusion
Relationship status in young adulthood impacts HPV vaccine interest and decision-making among a national sample of women. Primary reasons for non-interest in the vaccine may be shaped by attitudes and knowledge about the HPV vaccine that differ by relationship status. Future research is needed to elucidate ways to overcome relationship status as a barrier to HPV vaccination.

Vaccine
Volume 34, Issue 27, Pages 3007-3220 (8 June 2016)
http://www.sciencedirect.com/science/journal/0264410X/34/27

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Cost-effectiveness of seasonal inactivated influenza vaccination among pregnant women
Original Research Article
Pages 3149-3155
Jing Xu, Fangjun Zhou, Carrie Reed, Sandra S. Chaves, Mark Messonnier, Inkyu K. Kim
Abstract
Objective
To evaluate the cost-effectiveness of seasonal inactivated influenza vaccination among pregnant women using data from three recent influenza seasons in the United States.
Design, setting, and participants
We developed a decision-analytic model following a cohort of 5.2 million pregnant women and their infants aged Main outcome measures
Total costs (direct and indirect), effects (QALY gains, averted case numbers), and incremental cost-effectiveness of seasonal inactivated influenza vaccination among pregnant women (cost per QALY gained).
Results
Using a recent benchmark of 52.2% vaccination coverage among pregnant women, we studied a hypothetical cohort of 2,753,015 vaccinated pregnant women. With an estimated vaccine effectiveness of 73% among pregnant women and 63% among infants Conclusions
Influenza vaccination for pregnant women can reduce morbidity from influenza in both pregnant women and their infants aged

Vaccine
Volume 34, Issue 27, Pages 3007-3220 (8 June 2016)
http://www.sciencedirect.com/science/journal/0264410X/34/27

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Commentary
Clinical trials: The mathematics of falling vaccine efficacy with rising disease incidence
Pages 3007-3009
M. Gabriela M. Gomes, Stephen B. Gordon, David G. Lalloo
Open Access
[Initial text]
Reports of unexplained discrepancies in the efficacy of vaccines, as estimated from randomised controlled trials in different parts of the world, are commonplace in the literature [1], [2], [3] and [4]. Moreover, there is a consistent trend for lower vaccine efficacy when measured in settings where the disease of interest has a higher incidence, leading to questions about the appropriateness of pooled estimates. Here, we examine the mathematical basis for such trends and propose a measure of efficacy that is valid across settings. The approach relies on fitting mechanistic models, which specify pathogen exposures and host responses, to global vaccine trial data stratified by local disease incidence. Such models enable the estimation of vaccine protection per exposure to the pathogen. A strategy to estimate per-exposure vaccine efficacy will enable more accurate estimates of vaccine efficacy across a range of disease incidence [5]…

Gynecologic Oncology
June 2016 Volume 141, Supplement 1,
Knowledge about the HPV vaccine among employees at a tertiary cancer center: Room for improvement
K.R. Dahlstrom, E.M. Sturgis, R.A. DePinho, E. Hawk, G. Baum, E. Tamez, R. Bello, L.D. Stevens, L.M. Ramondetta
Objectives: Despite the availability of several US Food and Drug Administration–approved vaccines that prevent human papillomavirus (HPV)–related cancers, vaccination rates for girls and boys in the United States remain low. The aim of this study was to determine the knowledge and attitudes of employees at a tertiary cancer center toward HPV vaccination.

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Resident physicians’ contribution to human papillomavirus vaccine uptake: Are residents offering the vaccine to eligible patients?
T. Zigras, H. Sauer, S. Kashani
Objectives: The goal of the study was to determine if resident physicians are vaccinating eligible patients with the human papillomavirus (HPV) vaccine. A comparison of the primary care specialties in the United States was undertaken to compare utilization of the vaccine, education during training, and foundation of knowledge. Family medicine, internal medicine, pediatrics, and obstetrics and gynecology were compared.

The Cochrane Library
First published: 2 June 2016
Influenza vaccination for healthcare workers who care for people aged 60 or older living in long‐term care institutions
RE Thomas, T Jefferson, TJ Lasserson
Abstract
Background
A systematic review found that 3% of working adults who had received influenza vaccine and 5% of those who were unvaccinated had laboratory-proven influenza per season; in healthcare workers (HCWs) these percentages were 5% and 8% respectively. Healthcare workers may transmit influenza to patients.
Objectives
To identify all randomised controlled trials (RCTs) and non-RCTs assessing the effects of vaccinating healthcare workers on the incidence of laboratory-proven influenza, pneumonia, death from pneumonia and admission to hospital for respiratory illness in those aged 60 years or older resident in long-term care institutions (LTCIs).
Search methods
We searched CENTRAL (2015, Issue 9), MEDLINE (1966 to October week 3, 2015), EMBASE (1974 to October 2015) and Web of Science (2006 to October 2015), but Biological Abstracts only from 1969 to March 2013 and Science Citation Index-Expanded from 1974 to March 2013 due to lack of institutional access in 2015.
Selection criteria
Randomised controlled trials (RCTs) and non-RCTs of influenza vaccination of healthcare workers caring for individuals aged 60 years or older in LTCIs and the incidence of laboratory-proven influenza and its complications (lower respiratory tract infection, or hospitalisation or death due to lower respiratory tract infection) in individuals aged 60 years or older in LTCIs.
Data collection and analysis
Two authors independently extracted data and assessed risk of bias. Effects on dichotomous outcomes were measured as risk differences (RDs) with 95% confidence intervals (CIs). We assessed the quality of evidence with GRADE.
Main results
We identified four cluster-RCTs and one cohort study (n = 12,742) of influenza vaccination for HCWs caring for individuals ≥ 60 years in LTCIs. Four cluster RCTs (5896 residents) provided outcome data that addressed the objectives of our review. The studies were comparable in their study populations, intervention and outcome measures. The studies did not report adverse events. The principal sources of bias in the studies related to attrition, lack of blinding, contamination in the control groups and low rates of vaccination coverage in the intervention arms, leading us to downgrade the quality of evidence for all outcomes due to serious risk of bias.
Offering influenza vaccination to HCWs based in long term care homes may have little or no effect on the number of residents who develop laboratory-proven influenza compared with those living in care homes where no vaccination is offered (RD 0 (95% CI -0.03 to 0.03), two studies with samples taken from 752 participants; low quality evidence). HCW vaccination probably leads to a reduction in lower respiratory tract infection in residents from 6% to 4% (RD -0.02 (95% CI -0.04 to 0.01), one study of 3400 people; moderate quality evidence). HCW vaccination programmes may have little or no effect on the number of residents admitted to hospital for respiratory illness (RD 0 (95% CI -0.02 to 0.02, one study of 1059 people; low quality evidence). We decided not to combine data on deaths from lower respiratory tract infection (two studies of 4459 people) or all cause deaths (four studies of 8468 people). The direction and size of difference in risk varied between the studies. We are uncertain as to the effect of vaccination on these outcomes due to the very low quality of evidence. Adjusted analyses, which took into account the cluster design, did not differ substantively from the pooled analysis with unadjusted data.

Authors’ conclusions
Our review findings have not identified conclusive evidence of benefit of HCW vaccination programmes on specific outcomes of laboratory-proven influenza, its complications (lower respiratory tract infection, hospitalisation or death due to lower respiratory tract illness), or all cause mortality in people over the age of 60 who live in care institutions. This review did not find information on co-interventions with healthcare worker vaccination: hand-washing, face masks, early detection of laboratory-proven influenza, quarantine, avoiding admissions, antivirals and asking healthcare workers with influenza or influenza-like illness (ILI) not to work. This review does not provide reasonable evidence to support the vaccination of healthcare workers to prevent influenza in those aged 60 years or older resident in LTCIs. High quality RCTs are required to avoid the risks of bias in methodology and conduct identified by this review and to test further these interventions in combination.

Pediatric Infectious Disease Journal
Post Acceptance: May 31, 2016
doi: 10.1097/INF.0000000000001241
Safety and Immunogenicity of MMR (R) II (Combination Measles-Mumps-Rubella Vaccine) in Clinical Trials of Healthy Children Conducted Between 1988 and 2009.
Kuter, Barbara J. PhD, MPH; Brown, Michelle BS; Wiedmann, Richard T. MS; Hartzel, Jonathan PhD; Musey, Luwy MD
Abstract
Background: M-M-R(R)II, a combination measles, mumps, and rubella vaccine, was licensed in the United States in 1978 based on data from several clinical trials that demonstrated that the safety and immunogenicity of the vaccine were comparable to the component monovalent vaccines and to the previous trivalent combination vaccine.
Methods: Safety and immunogenicity data from 23 postlicensure clinical trials conducted with M-M-R(R)II between 1988 and 2009 were summarized. A total of 12,901 children who received only a first dose, 920 children who received a first and second dose, and 400 children who received only a second dose were evaluated.
Results: The vaccine was generally well-tolerated among children who received a first and/or second dose of M-M-R(R)II. During the 28-42 day follow-up after dose 1 and dose 2, the median rate of temperatures >=102[degrees]F (oral equivalent) was 24.8% and 13.0% and the median rate of measles/rubella-like rash was 3.2% and 0.5%, respectively. The median rate of injection-site reactions during the first 5 days postdose 1 and postdose 2 was 17.3% and 42.7%, respectively.
The seroconversion rates (ELISA) after dose 1 were remarkably consistent from study to study between 1988 and 2009 (92.8-100% for measles, 97.7-100% for mumps, and 92.8-100% for rubella). A trend test showed that there was no change in the immunogenicity of the vaccine over the 21-year period.
Conclusions: The results of this analysis demonstrate that M-M-R(R)II is well-tolerated and immunogenic. The vaccine performed consistently over 21 years of evaluation in clinical trials.

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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Foreign Affairs
http://www.foreignaffairs.com/
Accessed 11 June 2016
Essay June 5, 2016
The Innovative Finance Revolution
Private Capital for the Public Good
By Georgia Levenson Keohane and Saadia Madsbjerg
…To help ensure that this money would be spent in the most cost-effective way, IFFIm partnered with Gavi, the Vaccine Alliance, a nonprofit that is funded in part by the Bill & Melinda Gates Foundation and that specializes in large-scale immunization programs and creative ways to fund them. IFFIm’s bond issues helped Gavi increase its annual budget from $227 million in 2006 to $1.5 billion in 2015 and expand programs such as a polio eradication initiative that has financed the development and testing of new vaccines and the stockpiling of proven ones in places such as the Democratic Republic of the Congo and India.

A 2011 evaluation of IFFIm conducted by the health-care consulting company HLSP (now part of Mott MacDonald) credited IFFIm with saving at least 2.75 million lives and improving the quality of millions more….

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New Yorker
http://www.newyorker.com/
Accessed 11 June 2016
June 10, 2016
The Mistrust of Science
By Atul Gawande
Science has never been more powerful, but it is under attack.
…Vaccine fears, for example, have persisted despite decades of research showing them to be unfounded. Some twenty-five years ago, a statistical analysis suggested a possible association between autism and thimerosal, a preservative used in vaccines to prevent bacterial contamination. The analysis turned out to be flawed, but fears took hold. Scientists then carried out hundreds of studies, and found no link. Still, fears persisted. Countries removed the preservative but experienced no reduction in autism—yet fears grew. A British study claimed a connection between the onset of autism in eight children and the timing of their vaccinations for measles, mumps, and rubella. That paper was retracted due to findings of fraud: the lead author had falsified and misrepresented the data on the children. Repeated efforts to confirm the findings were unsuccessful. Nonetheless, vaccine rates plunged, leading to outbreaks of measles and mumps that, last year, sickened tens of thousands of children across the U.S., Canada, and Europe, and resulted in deaths.

People are prone to resist scientific claims when they clash with intuitive beliefs. They don’t see measles or mumps around anymore. They do see children with autism. And they see a mom who says, “My child was perfectly fine until he got a vaccine and became autistic.”…

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New York Times
http://www.nytimes.com/
Accessed 11 June 2016
Africa
Fake Vaccination Papers Let Yellow Fever Spread in Angola
By REUTERS JUNE 10, 2016, 9:48 A.M. E.D.T.
LUANDA — The world’s worst yellow fever outbreak in decades took hold in an Angolan slum because its early victims were Eritrean migrants whose false vaccination papers sent doctors off on the wrong path for weeks, international health officials said.

The flare-up of the mosquito-borne disease has killed 325 people in Angola, spread as far as China – which has close commercial links with oil-rich Angola – and raised fears of the world running out of vaccine, but it might have been stopped in its tracks if it had been identified quickly in Luanda.

Since the outbreak was identified in January, 10.5 million Angolans – 40 percent of the population – have been vaccinated and the World Health Organization (WHO) plans to cover the rest of the war-scarred country by the end of the year.

But with a reported case this week of the disease jumping via a mosquito from one person to another in Kinshasa, a city of over 12 million in neighbouring Democratic Republic of Congo, there are concerns about global vaccine supplies running out.

Luanda WHO representative Hernando Agudelo said he and government experts thought they were dealing with a mystery disease when unexplained deaths first surfaced in Km 30, part of the capital’s sprawling Viana district, in mid-December.

“The first people that we found with this strange way of dying, this syndrome, they had vaccination cards,” Agudelo told Reuters. “The first meeting with the minister, we were analysing ‘What the hell is it?'”…

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Washington Post
http://www.washingtonpost.com/
Accessed 11 June 2016
Vaccine developer gets $7.5 million in government loans to expand in Montgomery
Novavax to add 850 new jobs while remaining in Gaithersburg, officials said.
Bill Turque | Local-Politics | Jun 8, 2016

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

.– Request an Email Summary: Vaccines and Global Health : The Week in Review is published as a single email summary, scheduled for release each Saturday evening before midnight (EDT in the U.S.). If you would like to receive the email version, please send your request to david.r.curry@centerforvaccineethicsandpolicy.org.

– pdf version:  A pdf of the current issue is available here:  Vaccines and Global Health_The Week in Review_4 June 2016

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

– Twitter:  Readers can also follow developments on twitter: @vaxethicspolicy.
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– Links:  We endeavor to test each link as we incorporate it into any post, but recognize that some links may become “stale” as publications and websites reorganize content over time. We apologize in advance for any links that may not be operative. We believe the contextual information in a given post should allow retrieval, but please contact us as above for assistance if necessary.

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David R. Curry, MS
Executive Director
Center for Vaccine Ethics and Policy

World Health Assembly – WHA69
Geneva 23-4 June 2016.
:: Main Documents

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Closing remarks at the Sixty-ninth World Health Assembly
Dr Margaret Chan, Director-General of the World Health Organization
Geneva, Switzerland
28 May 2016

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Sixty-ninth World Health Assembly closes
News release
28 MAY 2016 | GENEVA – The Sixty-ninth World Health Assembly closed today after approving new resolutions on WHO’s Framework for Engagement with Non-State Actors; the Sustainable Development Goals; the International Health Regulations; tobacco control; road traffic deaths and injuries; nutrition; HIV, hepatitis and STIs; mycetoma; research and development; access to medicines and integrated health services.

WHO Framework of Engagement with Non-State Actors
The World Health Assembly has adopted the WHO Framework of Engagement with Non-State Actors (FENSA), after more than 2 years of intergovernmental negotiations.

FENSA represents a major step in WHO’s governance reform. It provides the Organization with comprehensive policies and procedures on engaging with nongovernmental organizations, private sector entities, philanthropic foundations and academic institutions.

The Framework aims to strengthen WHO engagement with all stakeholders while protecting its work from conflicts of interest and undue influence from external actors, and is based on a standardized process of due diligence and risk assessment. FENSA also facilitates an enhanced level of transparency and accountability in WHO’s engagement with non-State actors, with information on these engagements publicly available online in the WHO Register of non-State actors.

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Sustainable Development Goals
Delegates agreed a comprehensive set of steps that lay the groundwork for pursuing the health-related Sustainable Development Goals (SDGs).

They agreed to prioritize universal health coverage, and to work with actors outside the health sector to address the social, economic and environmental causes of health problems, including antimicrobial resistance. They agreed to continue and expand efforts to address poor maternal and child health and infectious diseases in developing countries, and to put a greater focus on equity within and between countries, leaving no-one behind.

Delegates also asked WHO to take steps to ensure that the organization has the resources it needs at all levels to achieve the SDGs, to work with countries to strengthen their ability to monitor progress towards the goals, and to take the SDGs into consideration in developing the Organization’s budget and programme of work.

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International Health Regulations
The Health Assembly considered the report of the Review Committee on the Role of the International Health Regulations (IHR) (2005) in the Ebola Outbreak and Response. Delegates commended the Committee for its work. They called on WHO to develop a global implementation plan for the recommendations of the Committee, taking forward immediately those recommendations that are consistent with existing IHR (2005) practice and allowing for further discussion and consideration of the new approaches that are proposed.

The Review concluded that the escalation of the Ebola outbreak was not the fault of the IHR themselves. Instead, it identified a lack of implementation of the Regulations as contributing to the escalation. It also characterized the IHR as an invaluable international legal framework that provides the backbone for public health response.

Approaches proposed in the Committee’s report to strengthen implementation of the Regulations include the introduction of a new, intermediate level of public health alert and recognition of external assessment of country core capacities as a best practice.

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Tobacco control
In a move to further strengthen global tobacco control efforts, delegates decided to invite the WHO Framework Convention on Tobacco Control’s (WHO FCTC) Conference of the Parties (COP) to provide information on outcomes of this biennial event to future World Health Assembly meetings.

They also invited the COP to consider requesting the Assembly to provide a report for information on relevant tobacco-related activities to future meetings of the COP. The seventh session of the COP is being held on 7-12 November 2016, in New Delhi, India.

The WHO FCTC is the first treaty negotiated under WHO’s auspices. To date, it comprises 180 Parties and is one of the most rapidly and widely embraced treaties in UN history. It was developed in response to the globalization of the tobacco epidemic and is an evidence-based treaty that reaffirms the right of all people to the highest standard of health.

Delegates also decided to include a follow-up item on this issue at the Seventieth World Health Assembly.

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Road traffic deaths and injuries
To support countries’ efforts to reach the SDG target of reducing road traffic deaths and injuries by 50% by 2020, World Health Assembly delegates today adopted a resolution requesting Member States to accelerate implementation of the outcome document of the Second Global High-Level Conference on Road Safety 2011-2020 held in November 2015, (the Brasilia Declaration on Road Safety).

Road traffic crashes kill more than 1.2 million people annually and injure up to 50 million.

The resolution calls for national strategies and plans to address the needs of the most vulnerable people on the roads, including children, youth, older people and people with disabilities. It urges countries to rethink transport policies and to adopt more sustainable modes of transport, like walking, cycling and public transport.

It requests the WHO secretariat to continue facilitating development of voluntary global performance targets on risk factors and service delivery mechanisms. It also asks WHO to help countries implement policies and practices, including on trauma care and rehabilitation; and facilitate preparations for the Fourth United Nations Global Road Safety Week in May 2017.

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Nutrition
Delegates adopted 2 resolutions on nutrition. The first, drawn up in response to the recently launched UN Decade of Action on Nutrition from 2016 to 2025, urges countries to make concrete policy and financial commitments to improve people’s diets, and report back regularly on those policies and investments.

It calls on UN bodies to guide and implement national nutrition programmes and support monitoring and reporting mechanisms. It specifically requests that WHO and FAO work together to help countries develop, strengthen and implement their plans and maintain an open access database of commitments for public accountability.

The second welcomed WHO guidance on ending the inappropriate promotion of foods for infants and young children. The guidance clarifies that, in order to protect, promote and support breastfeeding, the marketing of “follow-up formula” and “growing-up milks”—targeted for consumption by babies aged 6 months to 3 years—should be regulated in just the same manner as infant formula for 0 to 6-month-olds is. This recommendation is in line with the International Code of Marketing of Breast-milk Substitutes adopted by the World Health Assembly in 1981. Milk that is marketed as a general family food is not covered by the guidance, since it is not marketed specifically for feeding of infants and young children.

In light of the poor nutritional quality of some food and beverages marketed to infants and young children, the WHO guidance also indicates that foods for infants and young children should be promoted only if they meet standards for composition, safety, quality and nutrient levels and are in-line with national dietary guidelines.

The guidance also lays out key principles of how health professionals should interact with companies that market complementary foods. It recommends that health professionals do not accept gifts or free samples from these companies. They should not distribute samples, coupons, or products to families nor allow the companies to provide education or market foods through their health facilities. The guidance also recommends that companies do not sponsor meetings of health professionals.

The resolution urges countries, health professionals, the food industry, and the media to implement the guidance. In the resolution, countries also requested support from WHO to implement the guidance and monitor and evaluate its impact on infant and young child nutrition. They asked WHO to work with other international organizations on promoting national implementation of the guidance, and to report back to the Assembly in 2018 and 2020.

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HIV, viral hepatitis and sexually transmitted infections
The World Health Assembly has adopted 3 global health sector strategies on: HIV, viral hepatitis and sexually transmitted infections (STIs) for the period 2016-2021. The integrated strategies highlight the critical role of Universal Health Coverage. Their targets are aligned with those laid out in the Sustainable Development Goals.

The strategies outline actions to be taken by countries and by the WHO secretariat. Each aims to accelerate and intensify the health sector response to further progress towards ending all 3 epidemics.

The HIV strategy aims to further accelerate the expansion of access to antiretroviral therapy to all people living with HIV as well as the further scale-up of prevention and testing to reach interim targets: since 2000, it has been estimated that as many as 7.8 million HIV-related deaths and 30 million new HIV infections have been averted. By 2020 the strategy aims to reduce global HIV-related deaths to below 500 000, to reduce new HIV infections to below 500 000 and to ensure zero new infections among infants.

The hepatitis strategy – the first of its kind – introduces the first-ever global targets for viral hepatitis. These include a 30% reduction in new cases of hepatitis B and C by 2020 and a 10% reduction in mortality. Key approaches will be to expand vaccination programmes for hepatitis A,B, and E; focus on preventing mother-to-child transmission of hepatitis B; improve injection, blood and surgical safety; “harm reduction” for people who inject drugs; and increase access to treatment for hepatitis B and C.

The STI strategy specifically emphasizes the need to scale up prevention, screening and surveillance, in particular for adolescents and other at-risk populations, as well as the need to control the spread and impact of drug resistance. Although diagnostic tests for STIs are widely used in high-income countries, in low- and middle-income countries, diagnostic tests are largely unavailable. Resistance of STIs – in particular gonorrhoea – to antibiotics has increased rapidly in recent years and has reduced treatment options. More than 1 million sexually transmitted infections (STIs) are acquired every day worldwide. Each year, there are an estimated 357 million new infections with 1 of 4 STIs: chlamydia, gonorrhoea, syphilis and trichomoniasis.

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Mycetoma
The Health Assembly adopted a resolution on mycetoma. Mycetoma is a chronic, progressively destructive inflammatory disease of the skin, subcutaneous and connective tissue, muscle and bone. It usually affects the foot but also can also affect other parts of the body.

Mycetoma appears to mainly affect poor agricultural labourers and herdsmen. Due to its slow progression and painless nature, many patients come forward for treatment at an advanced stage of the disease when amputation is the only available treatment.

The global burden of mycetoma cannot be determined accurately due to lack of data. However, a 2013 systematic review of available data reported almost 9000 cases in 50 countries around the world.

The new resolution will help raise awareness of the disease. A wider recognition of the burden of mycetoma is expected to boost the development of control strategies and tools suitable for implementation in poor and remote areas where many of the cases occur.

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Access to medicines and vaccines
Delegates agreed a range of measures aimed at addressing the global shortage of medicines and vaccines, especially for children.

Delegates agreed to develop ways to forecast, avert and reduce shortages. These include notification systems, better ways of monitoring supply and demand, improving financial management of procurement systems to prevent funding shortfalls, and improving affordability through price negotiations and voluntary or compulsory licensing of high-priced medicines.

Access to medicines and vaccines is one of the cornerstones of universal health coverage, and is critical to the achievement of the health-related SDGs. Stock-outs and shortages have been increasing in severity in recent years in most parts of the world, including of antibiotics, anaesthetics, chemotherapy drugs and other essential medicines. Benzathine penicillin, an antibiotic used to treat congenital syphilis and rheumatic heart disease, has been in chronic short supply for several years.

The products most susceptible to shortages are those that are off-patent, difficult to formulate, have a short shelf-life, or are made by a small number of manufacturers. Low-volume markets, poor visibility of demand, and overly aggressive price reduction in procurement also contribute to shortages.

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Research and development
Delegates at the World Health Assembly agreed today to accelerate the development of the WHO Global Observatory on Health Research and Development in order to identify gaps in R&D, especially for diseases that disproportionately affect developing countries and attract little investment.

The observatory is a database of research and development projects. It is a key feature of WHO’s strategic R&D workplan, endorsed by the Assembly in 2013, to help achieve the development and delivery of health products for which market mechanisms fail to provide incentives. A demonstration version of the observatory was made available at the beginning of 2016, integrating available information on funding for health R&D, health products in the pipeline, clinical trials and research publications.

The workplan also includes 6 demonstration projects aimed at developing products. These include an initiative on R&D for visceral leishmaniasis; development of a vaccine against schistosomiasis; a single-dose cure for malaria; development of affordable biomarkers as diagnostics; open-source drug development for diseases of poverty and a multiplexed point-of-care test for acute febrile illness. Funding is urgently needed to develop both the observatory and the demonstration projects.

The delegates urged WHO’s Member States to increase funding for the observatory, and to strengthen their own national R&D observatories. They also requested WHO to expedite the development of the observatory, promote and advocate for sustainable financing for it, and to establish an expert advisory committee to identify R&D priorities based on analysis provided by the observatory and other sources.

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Integrated health services
The Health Assembly today adopted the WHO Framework on Integrated, People-Centred Health Services, which calls for a fundamental shift in the way health services are funded, managed and delivered.

Longer lifespans and the growing burden of long-term chronic conditions requiring complex interventions over many years are putting increasing pressure on health systems globally. Unless they are transformed, health systems will become increasingly fragmented, inefficient and unsustainable.

Integrated people-centred care means putting people and communities, not diseases, at the centre of health systems, and empowering people to take charge of their own health rather than being passive recipients of services. Evidence shows that health systems oriented around the needs of people and communities become more effective, cost less, improve health literacy and patient engagement, and are better prepared to respond to health crises.

Delegates requested WHO to develop indicators to track progress toward integrated people-centred health services.

WHA6 – GVAP [Global Vaccine Action Plan] Session
Overview from Dr JM Okwo-Bele
Director, Immunization, Vaccines and Biologicals (IVB) Department
WHO/Geneva

…Twenty five speakers, including 20 delegates from Member States, one observer (Chinese Taipei), three civil society organizations and Gavi, the Vaccine Alliance took the floor during the discussion on the Global Vaccine Action Plan (GVAP).

Delegates welcomed the GVAP assessment report on progress towards the achievement of global immunization goals and commended the WHO Strategic Advisory Group of Experts (SAGE) on immunization for their recommendations.

While delegates commented on the fact that the global vaccination targets remain off-track with gaps in immunization coverage, and slow progress in the elimination of maternal and neonatal tetanus (MNT), measles and rubella, they also noted that when countries and partners establish and enforce clear accountability systems, measure results and take corrective actions when results are not achieved, gaps in immunization can be closed.

Delegates acknowledged the first report to the Health Assembly on the newly adopted resolution on access to affordable vaccines. Access to sustainable supplies of affordable vaccines for low and middle income countries can be accelerated if partners and countries work together to ensure transparency in vaccine prices, develop pooled procurement mechanisms and increase the capacity of emerging manufactures to produce vaccines of assured quality to foster competition for a healthy vaccine market.

More specifically, delegates acknowledged the need for WHO to facilitate GVAP implementation and continue to play an important and leading role in:
:: Updating existing guidance for vaccination in humanitarian emergencies and providing further guidance on sustaining routine immunization in conflict areas and countries facing crisis, including outbreaks of diseases, such as the Zika, Ebola and Yellow Fever outbreaks;
:: Improving the management of the international emergency vaccines stockpiles;
:: Supporting countries to make evidence-based decisions on new vaccines introductions which is critical to ensure the efficient use of resources, sustainability and affordability of immunization programmes with high impact vaccines;
:: Supporting developing countries’ capacity to develop and produce vaccines to achieve affordable pricing;
:: Facilitating the provision of affordable lifesaving vaccines to countries currently facing humanitarian emergencies and to humanitarian organizations; and
:: Calling for an indicator that aligns with GVAP goals and objectives and helps track progress in immunization during the Sustainable Development Goals (SDG’s) period…

Zika virus [to 4 June 2016]
Public Health Emergency of International Concern (PHEIC)
http://www.who.int/emergencies/zika-virus/en/

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Zika situation report- 2 June 2016
Read the full situation report
Summary
:: As of 1 June 2016, 60 countries and territories report continuing mosquito-borne transmission (Fig. 1) of which:
….46 countries are experiencing a first outbreak of Zika virus since 2015, with no previous evidence of circulation, and with ongoing transmission by mosquitos (Table 1).
….14 countries reported evidence of Zika virus transmission between 2007 and 2014, with ongoing transmission.

:: In addition, four countries or territories have reported evidence of Zika virus transmission between 2007 and 2014, without ongoing transmission: Cook Islands, French Polynesia, ISLA DE PASCUA – Chile and YAP (Federated States of Micronesia).

:: Ten countries have reported evidence of person-to-person transmission of Zika virus, probably via a sexual route.

:: In the week to 1 June 2016, no new country reported on mosquito-borne or person-to-person Zika virus transmission.

:: As of 1 June 2016, microcephaly and other central nervous system (CNS) malformations potentially associated with Zika virus infection or suggestive of congenital infection have been reported by eleven countries or territories. Three of those reported microcephaly borne from mothers with a recent travel history to Brazil (Slovenia, United States of America) and Colombia (Spain), for one additional case the precise country of travel in Latin America is not determined.

:: Two cases of microcephaly and other neurological abnormalities are currently under verification in the Bolivarian Republic of Venezuela and Costa Rica.

:: In the context of Zika virus circulation, 13 countries and territories worldwide have reported an increased incidence of Guillain-Barré syndrome (GBS) and/or laboratory confirmation of a Zika virus infection among GBS cases.

:: Zika infection was diagnosed in a patient with a severe neurological condition (myelitis) in Guadeloupe.

:: Sequencing of the virus that causes the Zika outbreak in Cabo Verde showed that the virus is of the Asian lineage and the same as the one that circulates in Brazil. The precise implication of this finding is yet to be determined.

:: Based on research to date, there is scientific consensus that Zika virus is a cause of microcephaly and GBS.

:: The global Strategic Response Framework launched by the World Health Organization (WHO) in February 2016 encompasses surveillance, response activities and research. An interim report2 has been published on some of the key activities being undertaken jointly by WHO and international, regional and national partners in response to this public health emergency. A revised strategy for the period July 2016 to December 2017 is currently being developed with partners and will be published in mid-June.

:: WHO has developed new advice and information on diverse topics in the context of Zika virus. WHO’s latest information materials, news and resources to support corporate and programmatic risk communication, and community engagement are available online.

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Bulletin of the World Health Organization
2016;94:406-406A. doi: http://dx.doi.org/10.2471/BLT.16.176990
Editorials
Defining the syndrome associated with congenital Zika virus infection
Anthony Costello a, Tarun Dua b, Pablo Duran c, Metin Gülmezoglu d, Olufemi T Oladapo d, William Perea e, João Pires f, Pilar Ramon-Pardo g, Nigel Rollins a & Shekhar Saxena b
a. Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland.
b. Department of Mental Health and Substance Abuse, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland.
c. Center For Perinatology, Women and Reproductive Health, Pan American Health Organization/World Health Organization, Montevideo, Uruguay.
d. Department of Reproductive Health and Research, World Health Organization, Geneva, Switzerland.
e. Department of Pandemic and Epidemic Diseases, World Health Organization, Geneva, Switzerland.
f. Division of Communicable Diseases and Health Security, World Health Organization Regional Office for Europe, Copenhagen, Denmark.
g. Department of Communicable Diseases and Health Analysis, Pan American Health Organization/ World Health Organization, Washington, USA.
Correspondence to Tarun Dua (email: duat@who.int).

Zika virus infection in humans is usually mild or asymptomatic. However, some babies born to women infected with Zika virus have severe neurological sequelae. An unusual cluster of cases of congenital microcephaly and other neurological disorders in the WHO Region of the Americas, led to the declaration of a public health emergency of international concern by the World Health Organization (WHO) on 1 February 2016. By 5 May 2016, reports of newborns or fetuses with microcephaly or other malformations – presumably associated with Zika virus infection – have been described in the following countries and territories: Brazil (1271 cases); Cabo Verde (3 cases); Colombia (7 cases); French Polynesia (8 cases); Martinique (2 cases) and Panama (4 cases). Additional cases were also reported in Slovenia and the United States of America, in which the mothers had histories of travel to Brazil during their pregnancies.1

Zika virus is an intensely neurotropic virus that particularly targets neural progenitor cells but also – to a lesser extent – neuronal cells in all stages of maturity. Viral cerebritis can disrupt cerebral embryogenesis and result in microcephaly and other neurological abnormalities.2 Zika virus has been isolated from the brains and cerebrospinal fluid of neonates born with congenital microcephaly and identified in the placental tissue of mothers who had had clinical symptoms consistent with Zika virus infection during their pregnancies.3–5 The spatiotemporal association of cases of microcephaly with the Zika virus outbreak and the evidence emerging from case reports and epidemiologic studies, has led to a strong scientific consensus that Zika virus is implicated in congenital abnormalities.6,7

Existing evidence and unpublished data shared with WHO highlight the wider range of congenital abnormalities probably associated with the acquisition of Zika virus infection in utero. In addition to microcephaly, other manifestations include craniofacial disproportion, spasticity, seizures, irritability and brainstem dysfunction including feeding difficulties, ocular abnormalities and findings on neuroimaging such as calcifications, cortical disorders and ventriculomegaly.3–6,8–10 Similar to other infections acquired in utero, cases range in severity; some babies have been reported to have neurological abnormalities with a normal head circumference. Preliminary data from Colombia and Panama also suggest that the genitourinary, cardiac and digestive systems can be affected (Pilar Ramon-Pardo, unpublished data).

The range of abnormalities seen and the likely causal relationship with Zika virus infection suggest the presence of a new congenital syndrome. WHO has set in place a process for defining the spectrum of this syndrome. The process focuses on mapping and analysing the clinical manifestations encompassing the neurological, hearing, visual and other abnormalities, and neuroimaging findings. WHO will need good antenatal and postnatal histories and follow-up data, sound laboratory results, exclusion of other etiologies and analysis of imaging findings to properly delineate this syndrome. The scope of the syndrome will expand as further information and longer follow-up of affected children become available. The surveillance system that was established as part of the epidemic response to the outbreak initially called only for the reporting of microcephaly cases. This surveillance guidance has been expanded to include a spectrum of congenital malformations that could be associated with intrauterine Zika virus infection.11

Effective sharing of data is needed to define this syndrome. A few reports have described a wide range of abnormalities,3–6,8–10 but most data related to congenital manifestations of Zika infection remain unpublished. Global health organizations and research funders have committed to sharing data and results relevant to the Zika epidemic as openly as possible.12 Further analysis of data from cohorts of pregnant women with Zika virus infection are needed to understand all outcomes of Zika virus infection in pregnancy.

Thirty-seven countries and territories in the Region of the Americas now report mosquito-borne transmission of Zika virus and risk of sexual transmission. With such spread, it is possible that many thousands of infants will incur moderate to severe neurological disabilities. Therefore, routine surveillance systems and research protocols need to include a larger population than simply children with microcephaly. The health system response, including psychosocial services for women, babies and affected families will need to be fully resourced.

The Zika virus public health emergency is distinct because of its long-term health consequences and social impact. A coordinated approach to data sharing, surveillance and research is needed. WHO has thus started coordinating efforts to define the congenital Zika virus syndrome and issues an open invitation to all partners to join in this effort.
[References at links above]

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Zika Open [to 4 June 2016]
[Bulletin of the World Health Organization]
:: All papers available here
RESEARCH IN EMERGENCIES
Estimating the risk for microcephaly after Zika virus infection in Brazil
– Thomas Jaenisch, Kerstin Daniela Rosenberger, Carlos Brito, Oliver Brady, Patrícia Brasil, Ernesto Marques
Posted: 30 May 2016
http://dx.doi.org/10.2471/BLT.16.178608

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Guidance for health workers
:: Prevention of sexual transmission – 30 May 2016
:: Vector control operations framework – 30 May 2016

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Fact sheets
:: Zika virus – 2 June 2016

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CDC/ACIP [to 4 June 2016]
http://www.cdc.gov/media/index.html
TUESDAY, MAY 31, 2016
CDC releases interim guidance on Zika testing and interpretation of results
CDC published interim guidance for Zika virus antibody testing and interpretation of results. Because of the differences in recommended clinical management of Zika and dengue virus infections, and the risk…

EBOLA/EVD [to 4 June 2016]
“Threat to international peace and security” (UN Security Council)

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EBOLA VIRUS DISEASE – SITUATION REPORT 2 June 2016
Summary
:: The Public Health Emergency of International Concern (PHEIC) related to Ebola in West Africa was lifted on 29 March 2016. A total of 28 616 confirmed, probable and suspected cases have been reported in Guinea, Liberia and Sierra Leone, with 11 310 deaths.

:: In the latest cluster, seven confirmed and three probable cases of Ebola virus disease (EVD) were reported between 17 March and 6 April from the prefectures of N’Zerekore (nine cases) and Macenta (one case) in south-eastern Guinea. In addition, three confirmed cases were reported between 1 and 5 April from Monrovia in Liberia; these cases, the wife and two children of the Macenta case, travelled from Macenta to Monrovia.

:: The index case of this cluster (a 37-year-old female from Koropara sub-prefecture in N’Zerekore) had symptom onset on or around 15 February and died on 27 February without a confirmed diagnosis. The source of her infection is likely to have been due to exposure to infected body fluid from an Ebola survivor.

:: In Guinea, the last case tested negative for Ebola virus for the second time on 19 April. In Liberia, the last case tested negative for the second time on 28 April.

:: The 42-day (two incubation periods) countdown must elapse before the outbreak can be declared over in Liberia which is due to end on 9 June. Guinea declared an end to Ebola virus transmission on 1 June.

:: Having contained the last Ebola virus outbreak in March 2016, Sierra Leone has maintained heightened surveillance with testing of all reported deaths and prompt investigation and testing of all suspected cases. The testing policy will be reviewed on the 30 June.

Risk assessment:
For the outbreak to be declared over, a 42-day countdown must pass after the last case tested negative for Ebola virus for the second time. This countdown is due to elapse on 31 May in Guinea and on 9 June in Liberia. Until then, active surveillance in Guinea and Liberia will continue. The performance indicators suggest that Guinea, Liberia and Sierra Leone still have variable capacity to prevent, detect (epidemiological and laboratory surveillance) and respond to new outbreaks (Table 1). The risk of additional outbreaks originating from exposure to infected survivor body fluids remains and requires sustained.

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End of Ebola transmission in Guinea
WHO AFRO news release
1 June 2016 | Brazzavile – Today WHO declares the end of Ebola virus transmission in the Republic of Guinea. Forty-two days have passed since the last person confirmed to have Ebola virus disease tested negative for the second time. Guinea now enters a 90-day period of heightened surveillance to ensure that any new cases are identified quickly before they can spread to other people.
Read the press release by WHO Regional Office for Africa

POLIO [to 4 June 2016]
Public Health Emergency of International Concern (PHEIC)

Polio this week as of 1 June 2016
:: Last week, health ministers from around the world met in Geneva for the annual World Health Assembly (WHA). Among other public health topics, delegates reviewed and discussed the latest global polio epidemiology and reaffirmed commitment to ending transmission in the remaining polio reservoirs. Read more

:: At the 42nd G7 Summit on 26-27 May 2016 in Ise-Shima, Japan, G7 Leaders reaffirmed their continued commitment to polio eradication in the Ise-Shima leaders’ statement. Read more

:: The report of the Strategic Advisory Group of Experts on immunization from their meeting in April 2016 has been published, including a discussion on progress made towards polio eradication.

Selected Country Levels Updates [excerpted]
No new cases identified in country reports.

Yellow Fever [to 4 June 2016]
http://www.who.int/emergencies/yellow-fever/en/

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Yellow Fever – Situation Report – 2 June 2016
Full Report:
http://apps.who.int/iris/bitstream/10665/208818/1/yellowfeversitrep_2Jun2016_eng.pdf?ua=1

Emergency Committee regarding yellow fever
Following the advice of the Emergency Committee (EC) convened on 19 May 2016, WHO Director-General decided that urban yellow fever outbreaks in Angola and DRC are serious public health events which warrant intensified national action and enhanced international support. The events do not at this time constitute a Public Health Emergency of International Concern (PHEIC).
Statement on the Emergency Committee meeting concerning yellow fever

Summary:
Angola: 2893 suspected cases
As of 1 June 2016, Angola has reported 2893 suspected cases of yellow fever with 325 deaths. Among those cases, 788 have been laboratory confirmed. Despite extensive vaccination campaigns in several provinces, circulation of the virus persists.

Cunene and Malanje provinces have reported, for the first time since the beginning of the outbreak, 5 autochthonous cases.

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Democratic Republic of The Congo: 52 laboratory confirmed cases
On 22 March 2016, the Ministry of Health of DRC confirmed cases of yellow fever in connection with Angola. The government officially declared the yellow fever outbreak on 23 April. As of 1 June, DRC has reported three probable cases and 52 laboratory confirmed cases: 44 of those are imported from Angola, reported in Kongo Central, Kinshasa and Kwango (formerly Bandundu) provinces, two are sylvatic cases in Northern provinces, and two other autochthonous cases in Ndjili (Kinshasa) and in Matadi (Kongo Central). The possibility of locally acquired infection is under investigation for at least four non-classified cases.

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Uganda: 68 suspect cases
In Uganda, the Ministry of Health notified yellow fever cases in Masaka district on 9 April 2016. As of 1 June, 68 suspected cases, of which three are probable and seven are laboratory confirmed, have been reported from three districts: Masaka, Rukungiri and Kalangala. According to sequencing results, those clusters are not epidemiologically linked to Angola.

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The risk of spread
The virus in Angola and DRC is largely concentrated in main cities; however there is a high risk of spread and local transmission to other provinces in both countries. There is also a high risk of potential spread to bordering countries especially those previously classified as low-risk for yellow fever disease (i.e. Namibia, Zambia) and where the population, travellers and foreign workers are not vaccinated against yellow fever.

Three countries have reported confirmed yellow fever cases imported from Angola: Democratic Republic of The Congo (DRC) (44 cases), Kenya (two cases) and People’s Republic of China (11 cases). This highlights the risk of international spread through nonimmunised travellers.

A further three countries have reported suspected cases of yellow fever: Republic of Congo (one case), Sao Tome and Principe (two cases) and Ethiopia (22 cases). Investigations are ongoing to identify the vaccination status of the cases and determine if they are linked with Angola.

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Risk assessment
The outbreak in Angola remains of high concern due to:
:: Persistent local transmission in Luanda despite the fact that approximately eight million people have been vaccinated.
:: Local transmission has been reported in ten highly populated provinces including Luanda. Luanda Norte, Cunene and Malenge are the provinces that most recently reported local yellow fever transmission.
:: The continued extension of the outbreak to new provinces and new districts.
:: High risk of spread to neighbouring countries. As the borders are porous with substantial crossborder social and economic activities, further transmission cannot be excluded. Viraemic travelling patients pose a risk for the establishment of local transmission especially in countries where adequate vectors and susceptible human populations are present.
:: Risk of establishment of local transmission in other provinces where no autochthonous cases are reported.
:: High index of suspicion of ongoing transmission in hard-to-reach areas like Cabinda.
:: Inadequate surveillance system capable of identifying new foci or areas of cases emerging.

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Disease Outbreak News (DONs)
:: 2 June 2016 – Yellow fever – Democratic Republic of the Congo

WHO & Regional Offices [to 4 June 2016]

Highlights
End of Ebola transmission in Guinea
June 2016 – It has been 42 days since the last person confirmed to have Ebola in the Republic of Guinea tested negative for the virus disease, for the second time. The Republic of Guinea now enters a 90-day period of heightened surveillance.

Landmark working group on health and human rights of women, children and adolescents
May 2016 – WHO and the Office of the United Nations High Commissioner for Human Rights (OHCHR) have announced the establishment of a high-level working group of global champions on health and human rights of women, children and adolescents.

Double burden of malnutrition
May 2016 – Addressing undernutrition along with overweight and obesity, or diet-related noncommunicable diseases, within individuals, households and populations will be key to achieving the Sustainable Development Goals. In low- and middle-income countries, roughly 5 million children die of undernutrition-related causes every year. These same populations are also experiencing a rise in childhood overweight and obesity – increasing 30% faster than high-income countries.

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Weekly Epidemiological Record (WER) 3 June 2016, vol. 91, 22 (pp. 285–296)
Contents
285 Epidemic focus: Influenza
287 Leishmaniasis in high-burden countries: an epidemiological update based on data reported in 2014

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Disease Outbreak News (DONs)
:: 3 June 2016 – Oropouche virus disease – Peru
:: 2 June 2016 – Yellow fever – Democratic Republic of the Congo

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DoV Secretariat – Call for 3 proposals pdf, 115kb
2 June 2016
Deadline for application: 23 June 2016

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GIN – May 2016 pdf, 3.05Mb
1 June 2016

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Fact sheets
:: Human papillomavirus (HPV) and cervical cancer – June 2016
:: Zika virus – 2 June 2016
:: Cardiovascular diseases (CVDs) – 1 June 2016
:: Yaws – 1 June 2016
:: Tobacco – 1 June 2016

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:: WHO Regional Offices
Selected Press Releases, Announcements
WHO African Region AFRO
:: End of Ebola transmission in Guinea
Brazzaville, 1 June 2016 – Today the World Health Organization (WHO) declares the end of Ebola virus transmission in the Republic of Guinea. Forty-two days have passed since the last person confirmed to have Ebola virus disease tested negative for the second time. Guinea now enters a 90-day period of heightened surveillance to ensure that any new cases are identified quickly before they can spread to other people. r
:: WHO Regional Director for Africa, Dr Matshidiso Moeti, calls on African countries to adopt plain packaging of tobacco products – 31 May 2016

WHO Region of the Americas PAHO
:: World No Tobacco Day, 31 May 2016: ‘Get ready for plain packaging’ (05/31/2016)

WHO South-East Asia Region SEARO
:: • Maldives and Sri Lanka eliminate lymphatic filariasis 03 June 2016

WHO European Region EURO
:: Can a mobile phone help you stop smoking? 03-06-2016
:: Closing of the World Health Assembly: WHO Framework for Engagement with Non-State Actors adopted 01-06-2016
:: Day 4 of the World Health Assembly: Two new strategies call for action on women’s and children’s health, ageing 01-06-2016
:: Day 3 of the World Health Assembly: New Health Emergencies Programme adopted 31-05-2016
:: Norway announces decision to send bill on plain packaging to Parliament 31-05-2016

WHO Eastern Mediterranean Region EMRO
:: WHO condemns attack on Benghazi Medical Center in Benghazi, Libya 30 May 2016

WHO Western Pacific Region
:: WHO urges the use and promotion of plain packaging to reduce tobacco-related harms
MANILA, 31 May 2016 – On World No Tobacco Day, the World Health Organization (WHO) in the Western Pacific continues its call for governments, civil society and other partners, to support the implementation and promotion of the use of plain packaging as a tobacco control measure. “Plain packaging is a good public health measure because it prevents tobacco companies from using packaging as an effective marketing tool,” said Dr Shin Young-soo, WHO Regional Director for the Western Pacific.

CDC/ACIP [to 4 June 2016]
http://www.cdc.gov/media/index.html

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TUESDAY, MAY 31, 2016
CDC releases interim guidance on Zika testing and interpretation of results
CDC published interim guidance for Zika virus antibody testing and interpretation of results. Because of the differences in recommended clinical management of Zika and dengue virus infections, and the risk…

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MMWR June 3, 2016 / Vol. 65 / No. 21
:: Human Rabies — Wyoming and Utah, 2015
:: Public Confidence in the Health Care System 1 Year After the Start of the Ebola Virus Disease Outbreak — Sierra Leone, July 2015
:: Interim Guidance for Interpretation of Zika Virus Antibody Test Results
:: Notes from the Field: Investigation of Hepatitis C Virus Transmission Associated with Injection Therapy for Chronic Pain — California, 2015

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June ACIP meeting
June 22-23, 2016
Deadline for registration:
:: Non-US Citizens: May 20, 2016
:: US Citizens: June 6, 2016
Registration is NOT required to watch the live meeting webcast or to listen via telephone.
Draft June 22-23, 2016 Meeting Agenda[2 pages]

Syria – UN REGULAR PRESS BRIEFING BY THE INFORMATION SERVICE
Geneva, 3 June 2016
The webcast for this briefing is available here: http://bit.ly/unog030616

[Excerpt; Editor’s text bolding]
…During the month of May, UNICEF had participated in seven humanitarian missions to besieged and hard-to-reach communities, and had delivered medicines and health supplies, vaccines, nutrition supplies, clothes, education and children’s recreational materials for 52,700 beneficiaries, including more than 40,000 children.

The access to children and communities living under siege has been far too limited. UNICEF and its partners had shown that when they could get access, they delivered life-saving assistance. In Madaya, after repeated access, there had been an improvement in the nutritional situation of children. Continuous access was needed to make a difference, and UNICEF was appealing to all parties to the conflict to grant unconditional and unimpeded access to all people in need.

In May, UNICEF with WHO and national partners had implemented the first nationwide routine immunization campaign for children since the beginning of the crisis over six years ago. Routine immunization in Syria had dropped from a 90 per cent pre-crisis level to less than 60 or even 40 per cent in some of the besieged and hard-to-reach areas. In the first phase of the campaign, 340,000 children had been reached in areas designated as besieged or hard-to-reach…

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UNICEF [to 4 June 2016]
http://www.unicef.org/media/media_89711.html
Selected Press Releases
Vaccination campaign at risk as fighting intensifies in Syria
Joint statement by Dr. Ala Alwan, WHO Regional Director, and Dr. Peter Salama, UNICEF Regional Director
AMMAN/CAIRO, 2 June 2016 – As fighting and violence escalate across Syria, we risk losing the opportunity to vaccinate and save the lives of more than one million children.

“For example, due to the sharp increase in attacks on health personnel and facilities in Idleb, the immunization campaign in the city has been temporarily halted amid fears to the safety of health workers and the local population.
“On 31 May, an ambulance centre in Idleb supported by the World Health Organization and UN partners was hit. As a result, two ambulances were destroyed and the nearby al-Watany hospital was forced to close down, leaving only the emergency room functioning. In one day alone, more than 50 civilians were reportedly killed, including several children. Another 250 people were injured.

“Similar reports were received from other areas in Syria, further jeopardizing the vaccination campaign. On 1 June, a UNICEF supported clinic in the city of Aleppo was hit, injuring over 40 people among them a pregnant woman who lost her baby. Earlier this week, a hospital in Haritan a town near Aleppo was damaged. On 23 May, a bombing hit the Jableh National hospital in Latakia reportedly killing over 40 patients and accompanying family members and one doctor and two nurses.

“Since the beginning of the year, there have been reports of attacks on 17 health care facilities across Syria. Only one third of hospitals currently function in the country.

“WHO and UNICEF appeal to all parties to the conflict to put an end to the violence across Syria so that health workers can resume the vaccination campaign in safety.

“Attacks on health facilities are increasing in frequency and scale. Such attacks are blatant violations of International Humanitarian Law. Health workers, patients and health facilities must be protected, and civilians allowed unrestricted access to urgently needed health services.”

UNAIDS [to 4 June 2016]
http://www.unaids.org/en/resources/presscentre/

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03 June 2016 |
Calling on innovators, implementers, investors, activists and leaders to Fast-Track ending the AIDS epidemic by 2030
UNAIDS Executive Director, Michel Sidibé, stresses the importance of a people-centred approach at up-coming United Nations General Assembly High-Level Meeting on Ending AIDS

NEW YORK/GENEVA, 3 June 2016—The AIDS epidemic has defined the global health agenda for an entire generation. The first AIDS-related deaths were diagnosed over 30 years ago and HIV rapidly became a global crisis. The epidemic threatened all countries and had the power to destabilize the most vulnerable nations. By 2000, AIDS had wiped out decades of development gains.

Today, many nations have taken great steps in getting ahead of the epidemic. South Africa, for example, has reduced the number of new HIV infections from 600 000 in 2000 to 340 000 in 2014. Life expectancy has risen in many of the most severely affected countries in sub-Saharan Africa as access to HIV prevention, testing and treatment has been scaled up. Worldwide, there are now more than 17 million people living with HIV accessing live-saving antiretroviral treatment.

But as world leaders grapple with a growing number of global concerns and threats, including massive displacement, climate change and an uncertain economic outlook—it would be a misstep to let up on the response to HIV. Here are three reasons why AIDS deserves continued attention and a Fast-Track approach:
:: To restore dignity, health and hope to the people left behind in the AIDS response.
:: To build robust and resilient societies ready to face future health crises
:: To serve as a beacon for what can be achieved through international solidarity and political will…

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30 May 2016
UNAIDS announces 2 million more people living with HIV on treatment in 2015, bringing new total to 17 million

Sabin Vaccine Institute [to 4 June 2016]
http://www.sabin.org/updates/ressreleases

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Thursday, June 2, 2016
Statement on G7 Summit from Dr. Peter Hotez
WASHINGTON, D.C. — On May 26-27, 2016, at the Group of 7 (G7) Summit, the leaders of Japan, the United States, the United Kingdom, Germany, Canada, Italy and France affirmed a commitment to neglected tropical diseases (NTDs).

G7 nations pledged to drive research and development for NTDs and other conditions not adequately addressed by the market. From the G7 Ise-Shima Vision for Global Health, G7 nations will:
:: Implement policies to encourage the development of and access to medical products for those diseases.
:: Encourage G7 countries to support “push (e.g. support to cover R&D cost)” and “pull (e.g. making advance purchase and support creating markets/demands)” incentives, promote well-coordinated Public-Private Partnership to develop new vaccines, drugs and alternative therapies as exemplified by the Global Health Innovative Technology Fund (GHIT) and the Innovative Medicines Initiative (IMI).
:: Work to strengthen collaboration between research institutions, funding organizations and policy makers across G7 countries, building on the G7-process for mapping of R&D activities on NTDs and poverty-related diseases initiated in 2015 and now underway in 2016.

The Sabin Vaccine Institute applauds Japan, host of this year’s summit, for its ongoing leadership in the fight against NTDs, particularly in research and innovation for new tools to accelerate the fight against NTDs. Just days before the Summit, Japan announced its $130 million replenishment of the GHIT Fund, a global funding platform for research into new tools against HIV/AIDS, tuberculosis, malaria and NTDs.

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Statement of Dr. Peter Hotez, President of the Sabin Vaccine Institute and Director of its Product Development Partnership:
“I am pleased to see a renewed commitment from the G7 to address the scourge of NTDs. Creating market incentives for new tools against NTDs will help make it possible for interested scientists to engage in this research, and most importantly, will help get much needed new products into the hands of those who need them faster. Japan is leading by example with the GHIT Fund replenishment, and I hope to see the other member states step up to the challenge of NTD R&D in similar ways.

“More than 1.4 billion people around the world suffer from NTDs. The global effort to control and eliminate these diseases of poverty has treated more people than ever before with medication donated by pharmaceutical companies. But just half of people who require treatment receive it. Eliminating NTDs requires a two-pronged approach – investing in R&D for new vaccines, medications and diagnostics, while also scaling-up access to currently available treatments.

“We must ensure that communities are getting the care they need and that we will have new tools to finish the fight against NTDs. The estimated annual funding gap for NTD treatment is $220 million dollars – it’s a paltry amount in the G7 countries’ budgets. And, in fact, we are now seeing that NTDs are present in alarming numbers in impoverished communities in many nations, not just low-income countries. G7 leaders should increase their investment in NTD treatment to address this issue now as we pursue vaccines and other tools that may eventually eliminate these diseases for good.

“With regard to innovation, we are advancing and testing a new generation of ‘anti-poverty vaccines’ to combat the world’s most debilitating NTDs. These vaccine for helminth infections, Chagas disease, leishmaniasis, and other NTDs would not only improve global public health, but also help lift the bottom billion out of poverty.

“Sabin is asking the G7 to go beyond its current commitments by raising an additional annual investment of $220 million over the next five years to scale up access to treatments. We also encourage the G7 Health Ministers to expand upon the Heads of States’ declaration by proposing concrete, financially backed initiatives to tackle NTDs through both increased R&D and also access to currently existing treatments at their meeting in September.”

European Medicines Agency [to 4 June 2016]
http://www.ema.europa.eu/

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03/06/2016
Regulation of advanced therapy medicines
Report details concrete proposals to encourage development and authorisation of advanced therapy medicinal products (ATMPs) in the EU
The European Medicines Agency (EMA) today published a report from a multi-stakeholder expert meeting held on 27 May 2016 to explore possible ways to foster the development of ATMPs in Europe and expand patients’ access to these new treatments.

ATMPs comprise gene therapies, tissue engineered products and somatic cell therapies. These medicines have the potential to reshape the treatment of a wide range of conditions, particularly in disease areas where conventional approaches are inadequate. However, eight years since EU legislation on ATMPs entered into force in 2008, only five ATMPs are currently authorised. At the same time clinical trials investigating ATMPs appear to represent a fast-growing field of interest, underlining the need to better support innovation through a coherent and appropriate regulatory environment.

“We have organised this meeting with all relevant stakeholders to discuss concrete proposals on how we can nurture a regulatory environment that encourages development of ATMPs, safeguards public health and, ultimately, facilitates timely access for patients to much needed treatments,” said EMA’s Executive Director Guido Rasi in his opening address…

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01/06/2016
First statistics on PRIME are released
Four medicines in development are accepted under the scheme
The European Medicines Agency (EMA) has released today the outcome of the assessment of the first batch of applications received from medicine developers for its PRIME (PRIority MEdicines) scheme, a new initiative that aims to foster research on and development of medicines that have the potential to address an unmet medical need.

18 applications for PRIME were received as of 6 April 2016 and subsequently assessed by EMA’s Scientific Advice Working Party, Committee for Advanced therapies (CAT) and Committee for Medicinal Products for Human Use (CHMP). Four medicines have been accepted for PRIME.

EMA is making available detailed information on the applications that have been granted or denied access to PRIME, including statistics on the type of applicants, the therapeutic areas represented and the data supporting the applications…

FDA [to 4 June 2016]
http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/default.htm

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June 02, 2016
Statement from FDA Commissioner Robert Califf, M.D. on the release of the final individual patient expanded access form

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What’s New for Biologics
Influenza Virus Vaccine for the 2016-2017 Season
Posted: 6/3/2016

May 20, 2016 Clinical Review – Flucelvax Quadrivalent (PDF – 679KB)
Posted: 6/2/2016

Expanded Access
Posted: 6/2/2016

PATH [to 4 June 2016]
http://www.path.org/news/index.php

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Announcement | May 31, 2016
PATH welcomes Governor Gary Locke to its board of directors
PATH’s board of directors has voted to appoint former Washington State Governor Gary Locke to the board. Governor Locke’s years of experience in government and diplomacy will strengthen the board’s expertise in international relations, commerce, and organizational management…

NIH [to 4 June 2016]
http://www.nih.gov/news-events/news-releases

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June 1, 2016
Program will train first responders and hazardous waste workers on infectious disease safety
— A new training program will help approximately 35,000 first responders and workers, whose jobs may expose them to infectious diseases.

Journal Watch
Vaccines and Global Health: The Week in Review continues its weekly scanning of key peer-reviewed journals to identify and cite articles, commentary and editorials, books reviews and other content supporting our focus on vaccine ethics and policy. Journal Watch is not intended to be exhaustive, but indicative of themes and issues the Center is actively tracking. We selectively provide full text of some editorial and comment articles that are specifically relevant to our work. Successful access to some of the links provided may require subscription or other access arrangement unique to the publisher.

  If you would like to suggest other journal titles to include in this service, please contact David Curry at: david.r.curry@centerforvaccineethicsandpolicy.org

American Journal of Tropical Medicine and Hygiene
June 2016; 94 (6)
http://www.ajtmh.org/content/current

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Editorial
The Development of Small Animal Models for Zika Virus Vaccine Efficacy Testing and Pathological Assessment
Am J Trop Med Hyg 2016 94:1187-1188; Published online May 2, 2016, doi:10.4269/ajtmh.16-0277
Aaron C. Brault and Richard A. Bowen

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Long-Term Safety and Immunogenicity of a Tetravalent Live-Attenuated Dengue Vaccine and Evaluation of a Booster Dose Administered to Healthy Thai Children
Am J Trop Med Hyg 2016 94:1348-1358; Published online March 28, 2016, doi:10.4269/ajtmh.15-0659
Veerachai Watanaveeradej, Sriluck Simasathien, Mammen P. Mammen, Jr., Ananda Nisalak, Elodie Tournay, Phirangkul Kerdpanich, Rudiwilai Samakoses, Robert J. Putnak, Robert V. Gibbons, In-Kyu Yoon, Richard G. Jarman, Rafael De La Barrera, Philippe Moris, Kenneth H. Eckels, Stephen J. Thomas, and Bruce L. Innis
Abstract
We evaluated the safety and immunogenicity of two doses of a live-attenuated, tetravalent dengue virus vaccine (F17/Pre formulation) and a booster dose in a dengue endemic setting in two studies. Seven children (7- to 8-year-olds) were followed for 1 year after dose 2 and then given a booster dose (F17/Pre formulation), and followed for four more years (Child study). In the Infant study, 49 2-year-olds, vaccinated as infants, were followed for approximately 3.5 years after dose 2 and then given a booster dose (F17) and followed for one additional year. Two clinically notable events were observed, both in dengue vaccine recipients in the Infant study: 1 case of dengue approximately 2.7 years after dose 2 and 1 case of suspected dengue after booster vaccinations. The booster vaccinations had a favorable safety profile in terms of reactogenicity and adverse events reported during the 1-month follow-up periods. No vaccine-related serious adverse events were reported during the studies. Neutralizing antibodies against dengue viruses 1–4 waned during the 1–3 years before boosting, which elicited a short-lived booster response but did not provide a long-lived, multivalent antibody response in most subjects. Overall, this candidate vaccine did not elicit a durable humoral immune response

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Improving Capture of Vaccine History: Case Study from an Evaluation of 10-Valent Pneumococcal Conjugate Vaccine Introduction in Kenya
Am J Trop Med Hyg 2016 94:1400-1402; Published online May 2, 2016, doi:10.4269/ajtmh.15-0783
Aaron M. Harris, George Aol, Dominic Ouma, Godfrey Bigogo, Joel M. Montgomery, Cynthia G. Whitney, Robert F. Breiman, and Lindsay Kim
Abstract
With the accelerated introduction of new vaccines in low-income settings, understanding immunization program performance is critical. We sought to improve immunization history acquisition from Ministry of Health vaccination cards during a vaccine impact study of 10-valent pneumococcal conjugate vaccine on pneumococcal carriage among young children in Kenya in 2012 and 2013. We captured immunization history in a low proportion of study participants in 2012 using vaccination cards. To overcome this challenge, we implemented a household-based reminder system in 2013 using community health workers (CHWs), and increased the retrieval of vaccine cards from 62% in 2012 to 89% in 2013 (P < 0.001). The home-based reminder system using CHWs is an example of an approach that improved immunization history data quality in a resource-poor setting.

BMC Infectious Diseases
http://www.biomedcentral.com/bmcinfectdis/content
(Accessed 4 June 2016)

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Research article
Implementation of coordinated global serotype 2 oral poliovirus vaccine cessation: risks of inadvertent trivalent oral poliovirus vaccine use
Radboud J. Duintjer Tebbens, Lee M. Hampton and Kimberly M. Thompson
BMC Infectious Diseases 2016 16:237
Published on: 1 June 2016
Abstract
Background
The endgame for polio eradication includes coordinated global cessation of oral poliovirus vaccine (OPV), starting with the cessation of vaccine containing OPV serotype 2 (OPV2) by switching all trivalent OPV (tOPV) to bivalent OPV (bOPV). The logistics associated with this global switch represent a significant undertaking, with some possibility of inadvertent tOPV use after the switch.
Methods
We used a previously developed poliovirus transmission and OPV evolution model to explore the relationships between the extent of inadvertent tOPV use, the time after the switch of the inadvertent tOPV use and corresponding population immunity to serotype 2 poliovirus transmission, and the ability of the inadvertently introduced viruses to cause a serotype 2 circulating vaccine-derived poliovirus (cVDPV2) outbreak in a hypothetical population. We then estimated the minimum time until inadvertent tOPV use in a supplemental immunization activity (SIA) or in routine immunization (RI) can lead to a cVDPV2 outbreak in realistic populations with properties like those of northern India, northern Pakistan and Afghanistan, northern Nigeria, and Ukraine.
Results
At low levels of inadvertent tOPV use, the minimum time after the switch for the inadvertent use to cause a cVDPV2 outbreak decreases sharply with increasing proportions of children inadvertently receiving tOPV. The minimum times until inadvertent tOPV use in an SIA or in RI can lead to a cVDPV2 outbreak varies widely among populations, with higher basic reproduction numbers, lower tOPV-induced population immunity to serotype 2 poliovirus transmission prior to the switch, and a lower proportion of transmission occurring via the oropharyngeal route all resulting in shorter times. In populations with the lowest expected immunity to serotype 2 poliovirus transmission after the switch, inadvertent tOPV use in an SIA leads to a cVDPV2 outbreak if it occurs as soon as 9 months after the switch with 0.5 % of children aged 0–4 years inadvertently receiving tOPV, and as short as 6 months after the switch with 10–20 % of children aged 0–1 years inadvertently receiving tOPV. In the same populations, inadvertent tOPV use in RI leads to a cVDPV2 outbreak if 0.5 % of OPV RI doses given use tOPV instead of bOPV for at least 20 months after the switch, with the minimum length of use dropping to at least 9 months if inadvertent tOPV use occurs in 50 % of OPV RI doses.
Conclusions
Efforts to ensure timely and complete tOPV withdrawal at all levels, particularly from locations storing large amounts of tOPV, will help minimize risks associated with the tOPV-bOPV switch. Under-vaccinated populations with poor hygiene become at risk of a cVDPV2 outbreak in the event of inadvertent tOPV use the soonest after the tOPV-bOPV switch and therefore should represent priority areas to ensure tOPV withdrawal from all OPV stocks.

BMC Public Health
http://bmcpublichealth.biomedcentral.com/articles
(Accessed 4 June 2016)

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Research article
Greek health professionals’ perceptions of the HPV vaccine, state policy recommendations and their own role with regards to communication of relevant health information
Every year in Europe 60,000 women develop cervical cancer and 30,000 die from the disease. HPV vaccines are currently believed to constitute an important element of cervical cancer control strategy. Currently …
Christina Karamanidou and Kostas Dimopoulos
BMC Public Health 2016 16:467
Published on: 3 June 2016
Abstract
Background
Every year in Europe 60,000 women develop cervical cancer and 30,000 die from the disease. HPV vaccines are currently believed to constitute an important element of cervical cancer control strategy. Currently in Greece, the HPV vaccine is given on demand after prescription by a healthcare professional. Health care professionals’ role is key as they are in a position to discuss HPV vaccination with parents, adolescents and young women. This study is aiming to explore health care professionals’ perceptions of the HPV vaccine, state policy recommendations and their own role with regards to communication of relevant health information.
Methods
This was an in-depth, qualitative study, employing a stratified, purposeful sampling. Fifteen face-to-face, semi-structured interviews were conducted with health care professionals from a variety of disciplines: pediatrics, obstetrics and gynecology, infectious diseases, pharmacy, dermatology, general practice. Thematic qualitative analysis was used to analyze participants’ accounts.
Results
Five major themes were identified: health care professionals’ perceptions towards the HPV vaccine (recognition of importance, concerns about safety, effectiveness and impact of long-term use), animosity between medical specialties (territorial disputes among professional bodies, role advocacy, role limitations), health care professionals’ perceptions of the public’s attitudes (effects of cultural beliefs, health professionals’ attitudes, media and family), the role of the state (health policy issues, lack of guidance, unmet expectations) and their own role (provision of health information, sex education).
Conclusions
Health professionals’ concerns, lack of role definition and uniform information provision have led to territorial disputes among professional bodies and distrust among different medical specialties. Positive and negative judgements deriving from a multitude of sources have resulted in the confusion of the general public, as manifested by low vaccination rates. Due to the lack of clear regulation of vaccination prescription, administration and mode of delivery, factors such as lack of knowledge, cultural beliefs and personal attitudes have shaped the vaccination landscape. These factors have neither been explored nor addressed prior to the initiation of this public health effort and as such there is an evident less than efficient use of resources.

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Research article
Migrant integration policies and health inequalities in Europe
Research on socio-economic determinants of migrant health inequalities has produced a large body of evidence. There is lack of evidence on the influence of structural factors on lives of fragile groups…
Margherita Giannoni, Luisa Franzini and Giuliano Masiero
BMC Public Health 2016 16:463
Published on: 1 June 2016

Bulletin of the World Health Organization
Volume 94, Number 6, June 2016, 405-480
http://www.who.int/bulletin/volumes/94/6/en/

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EDITORIALS
Defining the syndrome associated with congenital Zika virus infection
Anthony Costello, Tarun Dua, Pablo Duran, Metin Gülmezoglu, Olufemi T Oladapo, William Perea, João Pires, Pilar Ramon-Pardo, Nigel Rollins & Shekhar Saxena
http://dx.doi.org/10.2471/BLT.16.176990

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Innovation for healthy ageing: a call for papers
Islene Araujo de Carvalho, Isabella Aboderin, Eri Arikawa-Hirasawa, Matteo Cesari, Yoshiaki Furukawa, Luis Miguel Gutierrez Robledo, John E Morley, Anne Margriet Pot, Jean-Yves Reginster, Greg Shaw, Naoko Tomita & John R Beard
http://dx.doi.org/10.2471/BLT.16.176743

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Charting a path to end the AIDS epidemic
Michel Sidibé
http://dx.doi.org/10.2471/BLT.16.176875

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Research
Recommendations for dealing with waste contaminated with Ebola virus: a Hazard Analysis of Critical Control Points approach
Kelly L Edmunds, Samira Abd Elrahman, Diana J Bell, Julii Brainard, Samir Dervisevic, Tsimbiri P Fedha, Roger Few, Guy Howard, Iain Lake, Peter Maes, Joseph Matofari, Harvey Minnigh, Ahmed A Mohamedani, Maggie Montgomery, Sarah Morter, Edward Muchiri, Lutendo S Mudau, Benedict M Mutua, Julius M Ndambuki, Katherine Pond, Mark D Sobsey, Mike van der Es, Mark Zeitoun & Paul R Hunter
Objective
To assess, within communities experiencing Ebola virus outbreaks, the risks associated with the disposal of human waste and to generate recommendations for mitigating such risks.
Methods
A team with expertise in the Hazard Analysis of Critical Control Points framework identified waste products from the care of individuals with Ebola virus disease and constructed, tested and confirmed flow diagrams showing the creation of such products. After listing potential hazards associated with each step in each flow diagram, the team conducted a hazard analysis, determined critical control points and made recommendations to mitigate the transmission risks at each control point.
Findings
The collection, transportation, cleaning and shared use of blood-soiled fomites and the shared use of latrines contaminated with blood or bloodied faeces appeared to be associated with particularly high levels of risk of Ebola virus transmission. More moderate levels of risk were associated with the collection and transportation of material contaminated with bodily fluids other than blood, shared use of latrines soiled with such fluids, the cleaning and shared use of fomites soiled with such fluids, and the contamination of the environment during the collection and transportation of blood-contaminated waste.
Conclusion
The risk of the waste-related transmission of Ebola virus could be reduced by the use of full personal protective equipment, appropriate hand hygiene and an appropriate disinfectant after careful cleaning. Use of the Hazard Analysis of Critical Control Points framework could facilitate rapid responses to outbreaks of emerging infectious disease.

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Research
Vaccination timing of low-birth-weight infants in rural Ghana: a population-based, prospective cohort study
Maureen O’Leary, Sara Thomas, Lisa Hurt, Sian Floyd, Caitlin Shannon, Sam Newton, Gyan Thomas, Seeba Amenga-Etego, Charlotte Tawiah-Agyemang, Lu Gram, Chris Hurt, Rajiv Bahl, Seth Owusu-Agyei, Betty Kirkwood & Karen Edmond
http://dx.doi.org/10.2471/BLT.15.159699
Objective
To investigate delays in first and third dose diphtheria–tetanus–pertussis (DTP1 and DTP3) vaccination in low-birth-weight infants in Ghana, and the associated determinants.
Methods
We used data from a large, population-based vitamin A trial in 2010–2013, with 22 955 enrolled infants. We measured vaccination rate and maternal and infant characteristics and compared three categories of low-birth-weight infants (2.0–2.4 kg; 1.5–1.9 kg; and < 1.5 kg) with infants weighing ≥ 2.5 kg. Poisson regression was used to calculate vaccination rate ratios for DTP1 at 10, 14 and 18 weeks after birth, and for DTP3 at 18, 22 and 24 weeks (equivalent to 1, 2 and 3 months after the respective vaccination due dates of 6 and 14 weeks).
Findings
Compared with non-low-birth-weight infants (n = 18 979), those with low birth weight (n = 3382) had an almost 40% lower DTP1 vaccination rate at age 10 weeks (adjusted rate ratio, aRR: 0.58; 95% confidence interval, CI: 0.43–0.77) and at age 18 weeks (aRR: 0.63; 95% CI: 0.50–0.80). Infants weighing 1.5–1.9 kg (n = 386) had vaccination rates approximately 25% lower than infants weighing ≥ 2.5 kg at these time points. Similar results were observed for DTP3. Lower maternal age, educational attainment and longer distance to the nearest health facility were associated with lower DTP1 and DTP3 vaccination rates.
Conclusion
Low-birth-weight infants are a high-risk group for delayed vaccination in Ghana. Efforts to improve the vaccination of these infants are warranted, alongside further research to understand the reasons for the delays.

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POLICY & PRACTICE
Priority-setting for achieving universal health coverage
Kalipso Chalkidou, Amanda Glassman, Robert Marten, Jeanette Vega, Yot Teerawattananon, Nattha Tritasavit, Martha Gyansa-Lutterodt, Andreas Seiter, Marie Paule Kieny, Karen Hofman & Anthony J Culyer
http://dx.doi.org/10.2471/BLT.15.155721
Abstract
Governments in low- and middle-income countries are legitimizing the implementation of universal health coverage (UHC), following a United Nation’s resolution on UHC in 2012 and its reinforcement in the sustainable development goals set in 2015. UHC will differ in each country depending on country contexts and needs, as well as demand and supply in health care. Therefore, fundamental issues such as objectives, users and cost–effectiveness of UHC have been raised by policy-makers and stakeholders. While priority-setting is done on a daily basis by health authorities – implicitly or explicitly – it has not been made clear how priority-setting for UHC should be conducted. We provide justification for explicit health priority-setting and guidance to countries on how to set priorities for UHC.

Conflict and Health
http://www.conflictandhealth.com/
[Accessed 4 June 2016]

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Debate
Syrian refugees in Lebanon: the search for universal health coverage
Karl Blanchet, Fouad M. Fouad and Tejendra Pherali
Published on: 1 June 2016
Abstract
The crisis in Syria has forced more than 4 million people to find refuge outside Syria. In Lebanon, in 2015, the refugee population represented 30 % of the total population. International health assistance has been provided to refugee populations in Lebanon. However, the current humanitarian system has also contributed to increase fragmentation of the Lebanese health system. Ensuring universal health coverage to vulnerable Lebanese, Syrian and Palestinian refugees will require in Lebanon to redistribute the key functions and responsibilities of the Ministry of Health and its partners to generate more coherence and efficiency.

Epidemiology and Infection
Volume 144 – Issue 09 – July 2016
http://journals.cambridge.org/action/displayIssue?jid=HYG&tab=currentissue

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Short Report
Arboviruses
Potential exposure to Zika virus for foreign tourists during the 2016 Carnival and Olympic Games in Rio de Janeiro, Brazil
M. N. BURATTINI, F. A. B. COUTINHO, L. F. LOPEZ, R. XIMENES, M. QUAM, A. WILDER-SMITH and E. MASSAD
DOI: http://dx.doi.org/10.1017/S0950268816000649, Published online: 04 April 2016
[No abstract]

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Original Papers
Polio
Effective case/infection ratio of poliomyelitis in vaccinated populations
G. BENCSKÓa1a2 and T. FERENCIa3 c1 id1
a1 Polymer Chemistry Research Group, Institute of Materials and Environmental Chemistry, Research Centre for Natural Sciences, Hungarian Academy of Sciences, Budapest, Hungary
a2 Institute of Chemistry, Eötvös Loránd University, Budapest, Hungary
a3 John von Neumann Faculty of Informatics, Physiological Controls Group, Óbuda University, Budapest, Hungary
SUMMARY
Recent polio outbreaks in Syria and Ukraine, and isolation of poliovirus from asymptomatic carriers in Israel have raised concerns that polio might endanger Europe. We devised a model to calculate the time needed to detect the first case should the disease be imported into Europe, taking the effect of vaccine coverage – both from inactivated and oral polio vaccines, also considering their differences – on the length of silent transmission into account by deriving an ‘effective’ case/infection ratio that is applicable for vaccinated populations. Using vaccine coverage data and the newly developed model, the relationship between this ratio and vaccine coverage is derived theoretically and is also numerically determined for European countries. This shows that unnoticed transmission is longer for countries with higher vaccine coverage and a higher proportion of IPV-vaccinated individuals among those vaccinated. Assuming borderline transmission (R = 1·1), the expected time to detect the first case is between 326 days and 512 days in different countries, with the number of infected individuals between 235 and 1439. Imperfect surveillance further increases these numbers, especially the number of infected until detection. While longer silent transmission does not increase the number of clinical diseases, it can make the application of traditional outbreak response methods more complicated, among others.

The European Journal of Public Health
Volume 26, Issue 3, 1 June 2016
http://eurpub.oxfordjournals.org/content/26/3?current-issue=y

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Viewpoint
Public health needs of migrants, refugees and asylum seekers in Europe, 2015: Infectious disease aspects
Jan C. Semenza, Paloma Carrillo-Santisteve, Herve Zeller, Andreas Sandgren, Marieke J. van der Werf, Ettore Severi, Lucia Pastore Celentano, Emma Wiltshire, Jonathan E. Suk, Irina Dinca, Teymur Noori, Piotr Kramarz
DOI: http://dx.doi.org/10.1093/eurpub/ckw023 372-373 First published online: 6 April 2016
Extract
In the first 10 months of 2015 the total number of asylum applications to the European Asylum Support Office (EASO) recorded by European Union (EU) countries exceeded the 1 million mark, an unprecedented level since the establishment of the EU. Syria has been the most common country of origin of asylum applications, followed by Afghanistan and Iraq.1 However, these figures do not take unregistered migrants into account: in the same time period, 500 000 undocumented border crossing detections were recorded on the EU’s external borders, according to Frontex.2 In the light of these developments, the European Centre for Disease Prevention and Control (ECDC) assessed the public health needs of migrants or individuals that are applying for asylum or refugee status, through: (i) interviews with 14 experts from Member States and Non-Governmental Organizations with first-hand experience working with migrant populations (7–11 August 2015); (ii) a non-systematic review of available evidence (peer-reviewed publications and relevant ECDC risk assessments); and (c) an expert meeting on the prevention of infectious diseases among newly arrived migrants in the EU and European Economic Area (EEA) (12–13 November 2015).3–5
Reception system for newly arrived migrants
A recurrent theme across all the expert consultations conducted by ECDC was the need to establish a reception system for newly arrived migrants. In primary reception centres, a health assessment should be carried out immediately upon arrival. Equipping these reception areas with primary care and public health services facilitates screening, vaccination and treatment (if required) of individuals free of charge. The organisers of reception areas should consider adequately stocking them with rapid tests (e.g. for malaria) and providing instant treatment and care to patients. Such rapid interventions are the best course of action to detect and prevent onwards spread of cases of infectious disease, through the identification and management of infectious diseases with potential for …

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Infectious Diseases
Detrimental effects of introducing partial compulsory vaccination: experimental evidence
Cornelia Betsch, Robert Böhm
DOI: http://dx.doi.org/10.1093/eurpub/ckv154 378-381 First published online: 21 August 2015
Abstract
Background: During outbreaks of vaccine-preventable diseases, compulsory vaccination is sometimes discussed as a last resort to counter vaccine refusal. Besides ethical arguments, however, empirical evidence on the consequences of making selected vaccinations compulsory is lacking. Such evidence is needed to make informed public health decisions. This study therefore assesses the effect of partial compulsory vaccination on the uptake of other voluntary vaccines.
Method: A total of 297 (N) participants took part in an online experiment that simulated two sequential vaccination decisions using an incentivized behavioural vaccination game. The game framework bases on epidemiological, psychological and game-theoretical models of vaccination. Participants were randomized to the compulsory vaccination intervention (n = 144) or voluntary vaccination control group (n = 153), which determined the decision architecture of the first of two decisions. The critical second decision was voluntary for all participants. We also assessed the level of anger, vaccination attitude and perceived severity of the two diseases.
Results: Compulsory vaccination increased the level of anger among individuals with a rather negative vaccination attitude, whereas voluntary vaccination did not. This led to a decrease in vaccination uptake by 39% in the second voluntary vaccination (reactance).
Conclusion: Making only selected vaccinations compulsory can have detrimental effects on the vaccination programme by decreasing the uptake of voluntary vaccinations. As this effect occurred especially for vaccine hesitant participants, the prevalence of vaccine hesitancy within a society will influence the damage of partial compulsory vaccination.

Eurosurveillance
Volume 21, Issue 22, 02 June 2016
http://www.eurosurveillance.org/Public/Articles/Archives.aspx?PublicationId=11678

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Research Articles
Public preferences for vaccination programmes during pandemics caused by pathogens transmitted through respiratory droplets – a discrete choice experiment in four European countries, 2013
by D Determann, IJ Korfage, A Fagerlin, EW Steyerberg, MC Bliemer, HA Voeten, JH Richardus, MS Lambooij, EW de Bekker-Grob
Abstract
This study aims to quantify and compare preferences of citizens from different European countries for vaccination programme characteristics during pandemics, caused by pathogens which are transmitted through respiratory droplets. Internet panel members, nationally representative based on age, sex, educational level and region, of four European Union Member States (Netherlands, Poland, Spain, and Sweden, n=2,068) completed an online discrete choice experiment. These countries, from different geographical areas of Europe, were chosen because of the availability of high-quality Internet panels and because of the cooperation between members of the project entitled Effective Communication in Outbreak Management: development of an evidence-based tool for Europe (ECOM). Data were analysed using panel latent class regression models. In the case of a severe pandemic scenario, vaccine effectiveness was the most important characteristic determining vaccination preference in all countries, followed by the body that advises on vaccination. In Sweden, the advice of family and/or friends and the advice of physicians strongly affected vaccine preferences, in contrast to Poland and Spain, where the advice of (international) health authorities was more decisive. Irrespective of pandemic scenario or vaccination programme characteristics, the predicted vaccination uptakes were lowest in Sweden, and highest in Poland. To increase vaccination uptake during future pandemics, the responsible authorities should align with other important stakeholders in the country and communicate in a coordinated manner.

Globalization and Health
http://www.globalizationandhealth.com/
[Accessed 4 June 2016]

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Review
Towards sustainable partnerships in global health: the case of the CRONICAS Centre of Excellence in Chronic Diseases in Peru
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J. Jaime Miranda, Antonio Bernabé-Ortiz, Francisco Diez-Canseco, Germán Málaga, María K. Cárdenas, Rodrigo M. Carrillo-Larco, María Lazo-Porras, Miguel Moscoso-Porras, M. Amalia Pesantes, Vilarmina Ponce, Ricardo Araya, David Beran, Peter Busse, Oscar Boggio, William Checkley, Patricia J. García…
Globalization and Health 2016 12:29
Published on: 2 June 2016