Bulletin of the World Health Organization – Volume 94, Number 11, November 2016

Bulletin of the World Health Organization
Volume 94, Number 11, November 2016, 785-860
http://www.who.int/bulletin/volumes/94/11/en/

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EDITORIALS
Research on community-based health workers is needed to achieve the sustainable development goals
Dermot Maher & Giorgio Cometto
http://dx.doi.org/10.2471/BLT.16.185918

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Elimination of mother-to-child transmission of HIV and syphilis in Cuba and Thailand
Naoko Ishikawa, Lori Newman, Melanie Taylor, Shaffiq Essajee, Razia Pendse & Massimo Ghidinelli
http://dx.doi.org/10.2471/BLT.16.185033

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RESEARCH
Inequalities in full immunization coverage: trends in low- and middle-income countries
María Clara Restrepo-Méndez, Aluísio JD Barros, Kerry LM Wong, Hope L Johnson, George Pariyo, Giovanny VA França, Fernando C Wehrmeister & Cesar G Victora
http://dx.doi.org/10.2471/BLT.15.162172
Abstract
Objective
To investigate disparities in full immunization coverage across and within 86 low- and middle-income countries.
Methods
In May 2015, using data from the most recent Demographic and Health Surveys and Multiple Indicator Cluster Surveys, we investigated inequalities in full immunization coverage – i.e. one dose of bacille Calmette-Guérin vaccine, one dose of measles vaccine, three doses of vaccine against diphtheria, pertussis and tetanus and three doses of polio vaccine – in 86 low- or middle-income countries. We then investigated temporal trends in the level and inequality of such coverage in eight of the countries.
Findings
In each of the World Health Organization’s regions, it appeared that about 56–69% of eligible children in the low- and middle-income countries had received full immunization. However, within each region, the mean recorded level of such coverage varied greatly. In the African Region, for example, it varied from 11.4% in Chad to 90.3% in Rwanda. We detected pro-rich inequality in such coverage in 45 of the 83 countries for which the relevant data were available and pro-urban inequality in 35 of the 86 study countries. Among the countries in which we investigated coverage trends, Madagascar and Mozambique appeared to have made the greatest progress in improving levels of full immunization coverage over the last two decades, particularly among the poorest quintiles of their populations.
Conclusion
Most low- and middle-income countries are affected by pro-rich and pro-urban inequalities in full immunization coverage that are not apparent when only national mean values of such coverage are reported.

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Research
Hepatitis B immunization for indigenous adults, Australia
Andre Louis Wattiaux, J Kevin Yin, Frank Beard, Steve Wesselingh, Benjamin Cowie, James Ward & Kristine Macartney
http://dx.doi.org/10.2471/BLT.16.169524
Abstract
Objective
To quantify the disparity in incidence of hepatitis B between indigenous and non-indigenous people in Australia, and to estimate the potential impact of a hepatitis B immunization programme targeting non-immune indigenous adults.
Methods
Using national data on persons with newly acquired hepatitis B disease notified between 2005 and 2012, we estimated incident infection rates and rate ratios comparing indigenous and non-indigenous people, with adjustments for underreporting. The potential impact of a hepatitis B immunization programme targeting non-immune indigenous adults was projected using a Markov chain Monte Carlo simulation model.
Findings
Of the 54 522 persons with hepatitis B disease notified between 1 January 2005 and 31 December 2012, 1953 infections were newly acquired. Acute hepatitis B infection notification rates were significantly higher for indigenous than non-indigenous Australians. The rates per 100 000 population for all ages were 3.6 (156/4 368 511) and 1.1 (1797/168 449 302) for indigenous and non-indigenous people respectively. The rate ratio of age-standardized notifications was 4.0 (95% confidence interval: 3.7–4.3). If 50% of non-immune indigenous adults (20% of all indigenous adults) were vaccinated over a 10-year programme a projected 527–549 new cases of acute hepatitis B would be prevented.
Conclusion
There continues to be significant health inequity between indigenous and non-indigenous Australians in relation to vaccine-preventable hepatitis B disease. An immunization programme targeting indigenous Australian adults could have considerable impact in terms of cases of acute hepatitis B prevented, with a relatively low number needed to vaccinate to prevent each case.

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POLICY & PRACTICE
Dengue vaccine: local decisions, global consequences
Hugo López-Gatell, Celia M Alpuche-Aranda, José I Santos-Preciado & Mauricio Hernández-Ávila
http://dx.doi.org/10.2471/BLT.15.168765
Abstract
As new vaccines against diseases that are prevalent in low- and middle-income countries gradually become available, national health authorities are presented with new regulatory and policy challenges. The use of CYD-TDV – a chimeric tetravalent, live-attenuated dengue vaccine – was recently approved in five countries. Although promising for public health, this vaccine has only partial and heterogeneous efficacy and may have substantial adverse effects. In trials, children who were aged 2–5 years when first given CYD-TDV were seven times more likely to be hospitalized for dengue, in the third year post-vaccination, than their counterparts in the control group. As it has not been clarified whether this adverse effect is only a function of age or is determined by dengue serostatus, doubts have been cast over the long-term safety of this vaccine in seronegative individuals of any age. Any deployment of the vaccine, which should be very cautious and only considered after a rigorous evaluation of the vaccine’s risk–benefit ratio in explicit national and subnational scenarios, needs to be followed by a long-term assessment of the vaccine’s effects. Furthermore, any implementation of dengue vaccines must not weaken the political and financial support of preventive measures that can simultaneously limit the impacts of dengue and several other mosquito-borne pathogens.