The Lancet
Jul 09, 2016 Volume 388 Number 10040 p103-210 e1-e2
http://www.thelancet.com/journals/lancet/issue/current
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Editorial
Indigenous health: a worldwide focus
The Lancet
Summary
If you are a member of the Baka, an Indigenous tribe in Cameroon, you can expect to live until you are aged about 35 years, which is about 12 years less than for the non-Indigenous people there. In Greenland you would be better off, at 73 years, but nonetheless this figure is 9 years less than that for the Danish population. Such discrepancies are recognised, but now we have such data for all regions of the world.
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Comment
Addressing global health disparities among Indigenous peoples
Laurence J Kirmayer, Gregory Brass
Summary
In countries around the world, Indigenous peoples face great social disadvantages and poor health compared with the general population.1,2 In The Lancet, Ian Anderson and colleagues3 have documented significant disparities among 28 Indigenous populations from 23 countries compared with benchmark populations for several variables, including life expectancy at birth, maternal and infant mortality, and frequency of low birthweight and high birthweight infants. They also showed differences for Indigenous peoples in measures related to nutrition (eg, child malnutrition, childhood obesity, and adult obesity), and in key social indicators, including educational attainment and economic status.
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Polio vaccination: preparing for a change of routine
Edward P K Parker, Nicholas C Grassly
Summary
The Global Polio Eradication Initiative is on the brink of a major milestone. As of April, 2016, the serotype 2 component of oral poliovirus vaccine (OPV) will be removed from all immunisation activities worldwide. This transition, which is the first step in the synchronised withdrawal of all OPV serotypes, is essential to the polio endgame strategy. Although wild type 2 polioviruses have not caused a case of paralytic disease since 1999, vaccine viruses of this serotype have continued to cause rare cases of vaccine-associated paralytic poliomyelitis in OPV recipients or their close contacts,1 and sporadic emergences of circulating vaccine-derived polioviruses, wherein Sabin poliovirus strains mutate to regain neurovirulence.
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Articles
Indigenous and tribal peoples’ health (The Lancet–Lowitja Institute Global Collaboration): a population study
Ian Anderson, Bridget Robson, Michele Connolly, Fadwa Al-Yaman, Espen Bjertness, Alexandra King, Michael Tynan, Richard Madden, Abhay Bang, Carlos E A Coimbra Jr, Maria Amalia Pesantes, Hugo Amigo, Sergei Andronov, Blas Armien, Daniel Ayala Obando, Per Axelsson, Zaid Shakoor Bhatti, Zulfiqar Ahmed Bhutta, Peter Bjerregaard, Marius B Bjertness, Roberto Briceno-Leon, Ann Ragnhild Broderstad, Patricia Bustos, Virasakdi Chongsuvivatwong, Jiayou Chu, Deji, Jitendra Gouda, Rachakulla Harikumar, Thein Thein Htay, Aung Soe Htet, Chimaraoke Izugbara, Martina Kamaka, Malcolm King, Mallikharjuna Rao Kodavanti, Macarena Lara, Avula Laxmaiah, Claudia Lema, Ana María León Taborda, Tippawan Liabsuetrakul, Andrey Lobanov, Marita Melhus, Indrapal Meshram, J Jaime Miranda, Thet Thet Mu, Balkrishna Nagalla, Arlappa Nimmathota, Andrey Ivanovich Popov, Ana María Peñuela Poveda, Faujdar Ram, Hannah Reich, Ricardo V Santos, Aye Aye Sein, Chander Shekhar, Lhamo Y Sherpa, Peter Skold, Sofia Tano, Asahngwa Tanywe, Chidi Ugwu, Fabian Ugwu, Patama Vapattanawong, Xia Wan, James R Welch, Gonghuan Yang, Zhaoqing Yang, Leslie Yap
Summary
Background
International studies of the health of Indigenous and tribal peoples provide important public health insights. Reliable data are required for the development of policy and health services. Previous studies document poorer outcomes for Indigenous peoples compared with benchmark populations, but have been restricted in their coverage of countries or the range of health indicators. Our objective is to describe the health and social status of Indigenous and tribal peoples relative to benchmark populations from a sample of countries.
Methods
Collaborators with expertise in Indigenous health data systems were identified for each country. Data were obtained for population, life expectancy at birth, infant mortality, low and high birthweight, maternal mortality, nutritional status, educational attainment, and economic status. Data sources consisted of governmental data, data from non-governmental organisations such as UNICEF, and other research. Absolute and relative differences were calculated.
Findings
Our data (23 countries, 28 populations) provide evidence of poorer health and social outcomes for Indigenous peoples than for non-Indigenous populations. However, this is not uniformly the case, and the size of the rate difference varies. We document poorer outcomes for Indigenous populations for: life expectancy at birth for 16 of 18 populations with a difference greater than 1 year in 15 populations; infant mortality rate for 18 of 19 populations with a rate difference greater than one per 1000 livebirths in 16 populations; maternal mortality in ten populations; low birthweight with the rate difference greater than 2% in three populations; high birthweight with the rate difference greater than 2% in one population; child malnutrition for ten of 16 populations with a difference greater than 10% in five populations; child obesity for eight of 12 populations with a difference greater than 5% in four populations; adult obesity for seven of 13 populations with a difference greater than 10% in four populations; educational attainment for 26 of 27 populations with a difference greater than 1% in 24 populations; and economic status for 15 of 18 populations with a difference greater than 1% in 14 populations.
Interpretation
We systematically collated data across a broader sample of countries and indicators than done in previous studies. Taking into account the UN Sustainable Development Goals, we recommend that national governments develop targeted policy responses to Indigenous health, improving access to health services, and Indigenous data within national surveillance systems.
Funding
The Lowitja Institute.
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Humoral and intestinal immunity induced by new schedules of bivalent oral poliovirus vaccine and one or two doses of inactivated poliovirus vaccine in Latin American infants: an open-label randomised controlled trial
Edwin J Asturias, Ananda S Bandyopadhyay, Steve Self, Luis Rivera, Xavier Saez-Llorens, Eduardo Lopez, Mario Melgar, James T Gaensbauer, William C Weldon, M Steven Oberste, Bhavesh R Borate, Chris Gast, Ralf Clemens, Walter Orenstein, Miguel O’Ryan G, José Jimeno, Sue Ann Costa Clemens, Joel Ward, Ricardo Rüttimann, Latin American IPV001BMG Study Group
Summary
Background
Replacement of the trivalent oral poliovirus vaccine (tOPV) with bivalent types 1 and 3 oral poliovirus vaccine (bOPV) and global introduction of inactivated poliovirus vaccine (IPV) are major steps in the polio endgame strategy. In this study, we assessed humoral and intestinal immunity in Latin American infants after three doses of bOPV combined with zero, one, or two doses of IPV.
Methods
This open-label randomised controlled multicentre trial was part of a larger study. 6-week-old full-term infants due for their first polio vaccinations, who were healthy on physical examination, with no obvious medical conditions and no known chronic medical disorders, were enrolled from four investigational sites in Colombia, Dominican Republic, Guatemala, and Panama. The infants were randomly assigned by permuted block randomisation (through the use of a computer-generated list, block size 36) to nine groups, of which five will be discussed in this report. These five groups were randomly assigned 1:1:1:1 to four permutations of schedule: groups 1 and 2 (control groups) received bOPV at 6, 10, and 14 weeks; group 3 (also a control group, which did not count as a permutation) received tOPV at 6, 10, and 14 weeks; group 4 received bOPV plus one dose of IPV at 14 weeks; and group 5 received bOPV plus two doses of IPV at 14 and 36 weeks. Infants in all groups were challenged with monovalent type 2 vaccine (mOPV2) at 18 weeks (groups 1, 3, and 4) or 40 weeks (groups 2 and 5). The primary objective was to assess the superiority of bOPV–IPV schedules over bOPV alone, as assessed by the primary endpoints of humoral immunity (neutralising antibodies—ie, seroconversion) to all three serotypes and intestinal immunity (faecal viral shedding post-challenge) to serotype 2, analysed in the per-protocol population. Serious and medically important adverse events were monitored for up to 6 months after the study vaccination. This study is registered with ClinicalTrials.gov, number NCT01831050, and has been completed.
Findings
Between May 20, 2013, and Aug 15, 2013, 940 eligible infants were enrolled and randomly assigned to the five treatment groups (210 to group 1, 210 to group 2, 100 to group 3, 210 to group 4, and 210 to group 5). One infant in group 1 was not vaccinated because their parents withdrew consent after enrolment and randomisation, so 939 infants actually received the vaccinations. Three doses of bOPV or tOPV elicited type 1 and 3 seroconversion rates of at least 97·7%. Type 2 seroconversion occurred in 19 of 198 infants (9·6%, 95% CI 6·2–14·5) in the bOPV-only groups, 86 of 88 (97·7%, 92·1–99·4) in the tOPV-only group (p<0·0001 vs bOPV-only), and 156 of 194 (80·4%, 74·3–85·4) infants in the bOPV–one dose of IPV group (p<0·0001 vs bOPV-only). A further 20 of 193 (10%) infants in the latter group seroconverted 1 week after mOPV2 challenge, resulting in around 98% of infants being seropositive against type 2. After a bOPV–two IPV schedule, all 193 infants (100%, 98·0–100; p<0·0001 vs bOPV-only) seroconverted to type 2. IPV induced small but significant decreases in a composite serotype 2 viral shedding index after mOPV2 challenge. 21 serious adverse events were reported in 20 patients during the study, including two that were judged to be possibly related to the vaccines. Most of the serious adverse events (18 [86%] of 21) and 24 (80%) of the 30 important medical events reported were infections and infestations. No deaths occurred during the study.
Interpretation
bOPV provided humoral protection similar to tOPV against polio serotypes 1 and 3. After one or two IPV doses in addition to bOPV, 80% and 100% of infants seroconverted, respectively, and the vaccination induced a degree of intestinal immunity against type 2 poliovirus.
Funding
Bill & Melinda Gates Foundation.
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Review
The global response to HIV in men who have sex with men
Chris Beyrer, Stefan D Baral, Chris Collins, Eugene T Richardson, Patrick S Sullivan, Jorge Sanchez, Gift Trapence, Elly Katabira, Michel Kazatchkine, Owen Ryan, Andrea L Wirtz, Kenneth H Mayer
Summary
Gay, bisexual, and other men who have sex with men (MSM) continue to have disproportionately high burdens of HIV infection in countries of low, middle, and high income in 2016. 4 years after publication of a Lancet Series on MSM and HIV, progress on reducing HIV incidence, expanding sustained access to treatment, and realising human rights gains for MSM remains markedly uneven and fraught with challenges. Incidence densities in MSM are unacceptably high in countries as diverse as China, Kenya, Thailand, the UK, and the USA, with substantial disparities observed in specific communities of MSM including young and minority populations. Although some settings have achieved sufficient coverage of treatment, pre-exposure prophylaxis (PrEP), and human rights protections for sexual and gender minorities to change the trajectory of the HIV epidemic in MSM, these are exceptions. The roll-out of PrEP has been notably slow and coverage nowhere near what will be required for full use of this new preventive approach. Despite progress on issues such as marriage equality and decriminalisation of same-sex behaviour in some countries, there has been a marked increase in anti-gay legislation in many countries, including Nigeria, Russia, and The Gambia. The global epidemic of HIV in MSM is ongoing, and global efforts to address it remain insufficient. This must change if we are ever to truly achieve an AIDS-free generation.
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Viewpoint
Who’s been left behind? Why sustainable development goals fail the Arab world
Abbas El-Zein, Jocelyn DeJong, Philippe Fargues, Nisreen Salti, Adam Hanieh, Helen Lackner
Summary
A set of Sustainable Development Goals (SDGs) was adopted by the UN General Assembly in September, 2015. The Arab world, alongside other regions, has problems of poverty, poor health, and substantial environmental degradation—ie, the kind of problems that the SDGs aim to address.1–5 Evidence of persistent infectious disease in low-income and middle-income Arab countries exists, alongside increased prevalence of non-communicable diseases in all Arab countries,6,7 high out-of-pocket health expenditure,8 poor access to safe water, as well as violent conflict, persistent foreign interventions, and high levels of social and political fragmentation that result in weak health systems and diminished rights to health.
vaccines and global health :: ethics and policy 