Vaccine
Volume 35, Issue 19, Pages 2531-2612 (2 May 2017)
http://www.sciencedirect.com/science/journal/0264410X/35/19

Assessment of sex-specific differences in adverse events following immunization reporting in Ontario, 2012–15
Original Research Article
Pages 2600-2604
Tara Harris, Jyotsna Nair, Jill Fediurek, Shelley L. Deeks
Abstract
We assessed sex-specific trends within passive vaccine safety surveillance in Ontario, Canada. AEFIs reported following vaccines administered between 2012 and 2015 were included. There were 2466 AEFI reports; 66.2% were female. Annualized reporting rates were 5.9 and 3.1 per 100,000 population, for females and males respectively. The female:male reporting rate ratio (RRR) was 1.9. Sex-specific differences by age group were greatest in adults 18–64 years (RRR 6.3); whereas there were no differences in children

Value in Health
April 2017 Volume 20, Issue 4, p519-726
http://www.valueinhealthjournal.com/current

Patient-Reported Outcomes
Balancing the Optimal and the Feasible: A Practical Guide for Setting Up Patient Registries for the Collection of Real-World Data for Health Care Decision Making Based on Dutch Experiences
Saskia de Groot, Naomi van der Linden, Margreet G. Franken, Hedwig M. Blommestein, Brenda Leeneman, Ellen van Rooijen, J.J.M. (Koos) van der Hoeven, Michel W. Wouters, Hans M. Westgeest, Carin A. Uyl-de Groot
p627–636
Published online: April 6, 2016
Abstract
Objectives
The aim of this article was to provide practical guidance in setting up patient registries to facilitate real-world data collection for health care decision making.
Methods
This guidance was based on our experiences and involvement in setting up patient registries in oncology in the Netherlands. All aspects were structured according to 1) mission and goals (“the Why”), 2) stakeholders and funding (“the Who”), 3) type and content (“the What”), and 4) identification and recruitment of patients, data handling, and pharmacovigilance (“the How”).
Results
The mission of most patient registries is improving patient health by improving the quality of patient care; monitoring and evaluating patient care is often the primary goal (“the Why”). It is important to align the objectives of the registry and agree on a clear and functional governance structure with all stakeholders (“the Who”). There is often a trade off between reliability, validity, and specificity of data elements and feasibility of data collection (“the What”). Patient privacy should be carefully protected, and address (inter-)national and local regulations. Patient registries can reveal unique safety information, but it can be challenging to comply with pharmacovigilance guidelines (“the How”).
Conclusions
It is crucial to set up an efficient patient registry that serves its aims by collecting the right data of the right patient in the right way. It can be expected that patient registries will become the new standard alongside randomized controlled trials due to their unique value.

Value in Health                   
April 2017 Volume 20, Issue 4, p519-726
http://www.valueinhealthjournal.com/current

Methodology
Cost-Effectiveness Thresholds in Global Health: Taking a Multisectoral Perspective
Michelle Remme, Melisa Martinez-Alvarez, Anna Vassall
p699–704
Published online: January 3, 2017
Open Access
Abstract
Good health is a function of a range of biological, environmental, behavioral, and social factors. The consumption of quality health care services is therefore only a part of how good health is produced. Although few would argue with this, the economic framework used to allocate resources to optimize population health is applied in a way that constrains the analyst and the decision maker to health care services. This approach risks missing two critical issues: 1) multiple sectors contribute to health gain and 2) the goods and services produced by the health sector can have multiple benefits besides health. We illustrate how present cost-effectiveness thresholds could result in health losses, particularly when considering health-producing interventions in other sectors or public health interventions with multisectoral outcomes. We then propose a potentially more optimal second best approach, the so-called cofinancing approach, in which the health payer could redistribute part of its budget to other sectors, where specific nonhealth interventions achieved a health gain more efficiently than the health sector’s marginal productivity (opportunity cost). Likewise, other sectors would determine how much to contribute toward such an intervention, given the current marginal productivity of their budgets. Further research is certainly required to test and validate different measurement approaches and to assess the efficiency gains from cofinancing after deducting the transaction costs that would come with such cross-sectoral coordination.

From Google Scholar & other sources: Selected Journal Articles, Newsletters, Dissertations, Theses, Commentary

Public Health
Volume 148, July 2017, Pages 66–68
Short Communication
Zika, sexual transmission and prudent public health policy
K.M. Folkers, , A.L. Caplan, L.H. Igel
Highlights
:: There is significant debate about whether the Zika virus can be considered a sexually transmitted infection (STI).
:: Epidemiologically, Zika may not be an STI, but considering it one contributes to prudent public health policy.
:: Classifying Zika as an STI may increase access to testing, identify at risk partners, and educate the public on safer sex.

Birth Defects Research
Early View
Brief Report
Major Birth Defects after Vaccination Reported to the Vaccine Adverse Event Reporting System (VAERS), 1990 to 2014
PL Moro, J Cragan, P Lewis, L Sukumaran
DOI: 10.1002/bdra.2362
Abstract
Background
Major birth defects are important infant outcomes that have not been well studied in the postmarketing surveillance of vaccines given to pregnant women. We assessed the presence of major birth defects following vaccination in the Vaccine Adverse Event Reporting System (VAERS), a national spontaneous reporting system used to monitor the safety of vaccines in the United States.
Methods
We searched VAERS for reports of major birth defects during January 1, 1990, through December 31, 2014. We excluded birth defects from vaccines that had been studied in pregnancy registries or other epidemiological studies (e.g., human papilloma virus, varicella, measles/mumps/rubella, and anthrax vaccines). Birth defects were categorized into trimester of vaccination and classified based on the organs and/or systems affected. If several birth defects affecting different systems were described, we classified those as multiple body systems. Empirical Bayesian data mining was used to assess for disproportionate reporting.
Results
We identified 50 reports of major birth defects; in 28 reports, the vaccine was given during the first trimester; 25 were reports with single vaccines administered. Birth defects accounted for 0.03% of all reports received by VAERS during the study period and 3.2% of pregnancy reports; reported defects affected predominately the musculoskeletal (N = 10) or nervous (N = 10) systems. No unusual clusters or specific birth defects were identified.
Conclusion
This review of the VAERS database found that major birth defects were infrequently reported, with no particular condition reported disproportionally. Birth defects after routine maternal vaccination will continue to be monitored in VAERS for signals to prompt future studies. Birth Defects Research 00:000–000, 2017.

Media/Policy Watch
This watch section is intended to alert readers to substantive news, analysis and opinion from the general media and selected think tanks and similar organizations 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.

Forbes
http://www.forbes.com/
Accessed 15 April 2017
The March For Science May Be Flawed, But It’s More Than Worthy Of Your Support
Kavin Senapathy, Contributor
Apr 14, 2017
This march is representative of a fight that began long before President Trump—the one of the scientific method as an ever-standing touchstone of the truth versus exploitation of science to bolster alternative facts.

The Guardian
http://www.guardiannews.com/
Accessed 15 April 2017
Polio in Afghanistan: ‘Americans bomb our children daily, why would they care?’
Sune Engel Rasmussen
10 April 2017
After being denied access by the Taliban for 15 months, health workers this week resumed a vaccination campaign against polio in parts of Kunduz province in northern Afghanistan.

The Taliban block on polio vaccinations left an estimated 170,000 children without inoculation, endangering a campaign that has almost eradicated the disease in Afghanistan. Days before the Taliban allowed vaccinators access, a 14-month-old girl in the Afghan province of Kunduz was found to have been paralysed by polio.

Until it was blocked, leaving about 170,000 children in Kunduz province without inoculations, the scheme had almost eradicated the disabling viral disease in Afghanistan. But polio can spread quickly, with even a single case potentially enough to widen the disease’s footprint. When the girl in Kunduz’s Dasht-e-Archi district became the third child this year diagnosed with polio, Taliban commanders relented.

Local commanders have long been the main obstacle to polio vaccinators in Kunduz. Qari Bashir, the Taliban health chief in the province, had demanded construction of a clinic in Char Dara district to treat civilians and wounded fighters, on a par with clinics in government-held areas. But the WHO does not build trauma clinics.

Speaking to the Guardian, Bashir confirmed his demand for a clinic but said there were other concerns. Chief among them was a suspicion among villagers that polio teams could be infiltrated by spies.

Polio was a top issue in village council meetings, Bashir said. But while some locals argued he was obliged to allow vaccinations, others warned him not to trust foreign-run health teams, a scepticism Bashir shared.

“Every day, the Americans are bombing Afghan children. I don’t think this was so important to them,” he said…

Milestones :: Perspectives

Guinea: Battling a Large-Scale Measles Epidemic
April 06, 2017 – MSF Press Release
Less than a year after the official end of the Ebola outbreak, the Guinean health system continues to struggle.

NEW YORK/CONAKRY, GUINEA, APRIL 7, 2017—The international medical humanitarian organization Doctors without Borders/Médecins Sans Frontières (MSF), along with the Guinean Ministry of Health (MoH), is launching today a large-scale measles vaccination campaign in Conakry. Since the beginning of the year there have been 3,468 confirmed cases and 14 deaths dues to measles in Guinea, with most cases in the Conakry and Nzérékoré districts.

Routine vaccination in Guinea was drastically reduced during the 2014-2015 Ebola epidemic, both because most resources and attention were geared towards the management of Ebola and, mainly, due to fear. People stayed away from health facilities, and vaccination activities were suspended because of infection risks, leaving thousands of young children unprotected against easily preventable diseases. A nation-wide vaccination campaign was organized by authorities one year ago for children who had missed or never received their vaccines. Despite this catch-up effort, a measles epidemic was declared on February 8, 2017.

“The fact that a new epidemic occurs barely a year after a massive vaccination campaign is a worrying sign of the weakness of health care in Guinea,” said Ibrahim Diallo, MSF’s representative in Guinea. “Major problems remain in the health system, undermining its capacity to prevent and respond to outbreaks effectively and timely.”

After the devastating Ebola epidemic that killed over 11,000 people and severely affected the health systems of the three most affected countries—Guinea, Sierra Leone, and Liberia—the World Health Organization (WHO) and leading public health experts insisted on the importance of rebuilding responsive health systems in the three countries and equipping and supporting them to better manage similar or new health crises.

According to the United Nations (UN) body in charge of Ebola response, only 18 percent of the funds disbursed to support the countries during the Ebola outbreak were meant for recovery. International donor commitments to strengthen health systems has focused on improving disease surveillance to assure early detection and response to outbreaks, such as Ebola. However, today, faced with a large outbreak of measles, MSF in Conakry and Alima in Nzérokoré district are currently the only non-governmental organizations providing support to the MoH for the vaccination campaign in the worst affected districts. WHO and UNICEF have pledged support to other affected districts across the country, though it is still under discussion.

“If Ebola was a wake-up call, since then the world seems to have fallen back asleep,” said Dr. Mit Philips, MSF’s health policy analyst. “As shown by this measles outbreak, the concrete impact of the promises of funding, support and training made during and after the Ebola crisis still remain to be felt by ordinary Guineans. The country is still facing today the same problems that it was facing then, largely alone, in spite of the international public commitments to build better and more responsive health systems.”

To contain the measles epidemic, MSF and the MoH in Conakry is mobilizing 126 teams of 13 people, spread out across 164 vaccination sites in the city of three million people. All children from six months up to 10 years old will be vaccinated over the next nine days. MSF also supports 30 health centers in Conakry to care for children suffering from mild cases of measles, as well as a hospital referral center for severe cases.

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Socio-economic costs of Zika virus in Latin America and the Caribbean to reach $7-$18 billion over three years
The epidemic will have a long-term impact, disproportionately affecting the poorest and most vulnerable communities, and could contribute to widening inequalities in the region.

New York, 6 April 2017 – The socio-economic cost of the recent spread of the Zika virus in Latin America and the Caribbean will total an estimated US$7-18 billion between 2015 and 2017 according to an impact assessment launched today by the United Nations Development Programme (UNDP), in partnership with the International Federation of Red Cross and Red Crescent Societies (IFRC).

The new report, “A Socio-economic impact assessment of Zika virus in Latin America and the Caribbean: with a focus on Brazil, Colombia and Suriname” provides an up-to-date analysis of the socio-economic and human development implications of the epidemic.

With research on the Zika virus still on-going, there continues to be considerable uncertainty surrounding the spread and medical conditions associated with the virus. That said, the report clearly concludes that the Zika epidemic will have significant short and long-term impacts in the economic and socials spheres in the Americas.

“Aside from tangible losses to GDP and to economies heavily dependent on tourism, and the stresses on health care systems, the long-term consequences of the Zika virus can undermine decades of social development, hard-earned health gains and slow progress towards the Sustainable Development Goals”, said Jessica Faieta, UN Assistant Secretary-General and UNDP Director for Latin America and the Caribbean…

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Africa Centres for Diseases Control and Prevention launches new networks to fight health threats in Africa
Two new surveillance and laboratory networks will be built in all regions of Africa to accelerate outbreak detection, enhance disease intelligence and prevention, and combat antimicrobial resistance
Addis Ababa, 29 March 2017- African and international public health experts from governments, universities, and non-governmental organisations met from 27th to 29th March to coordinate prevention and response to disease threats in Africa through surveillance and laboratory networks. The recently launched Africa Centres for Disease Control and Prevention (Africa CDC) is committed to strengthening Africa’s disease intelligence, outbreak response, and prevention capacity through surveillance and laboratory networks. At the meeting, Africa CDC and partners established the Regional Integrated Surveillance and Laboratory Networks (Africa CDC RISLNET). These surveillance and laboratory networks will be established by Africa CDC’s five Regional Collaborating Centers (RCCs) in Egypt, Nigeria, Gabon, Zambia, and Kenya in collaboration with all available public health assets in their region, including universities, national public health institutes, private laboratories, centres of excellence, non-governmental organizations, and veterinary networks.

“This is the new spirit of practicing public health in Africa. We will be partnering effectively, collaborating closely, and using efficiently all public health assets in each region of Africa to improve detection and response,” said Dr. John Nkengasong, the Director of the Africa Centres of Disease Control and Prevention.

Africa CDC RISLNET will serve as the platform to implement Africa CDC’s 5 year strategic plan, which was endorsed by its Governing Board last week. Between 2017 and 2018, Africa CDC will support countries and regions to map existing surveillance and laboratory networks, including private laboratories.

Africa CDC is also committed to combating resistance to antibiotics, which are estimated to cause about 4 million deaths per year in Africa by 2050. To begin to address this severe threat, Africa CDC also launched the Antimicrobial Resistance Surveillance Network (Africa CDC AMRSNET). This new network will work closely with the World Health Organisation’s (WHO) Global Antimicrobial Resistance Surveillance Systems to strengthen capacity on the continent for surveillance, including through regional task-based and structured mentorship programmes.

Africa CDC will use proven models of medical education to build a community of practice to fight antimicrobial resistance, providing better care to more people where they live…

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Featured Journal Content

BMC Public Health
http://bmcpublichealth.biomedcentral.com/articles
(Accessed 8 April 2017)
Research article
Improving immunization in Afghanistan: results from a cross-sectional community-based survey to assess routine immunization coverage
Raveesha R. Mugali, Farooq Mansoor, Sardar Parwiz, Fazil Ahmad, Najibullah Safi, Ariel Higgins-Steele and Sherin Varkey
BMC Public Health 2017 17:290
Published on: 4 April 2017
Abstract
Background
Despite progress in recent years, Afghanistan is lagging behind in realizing the full potential of immunization. The country is still endemic for polio transmission and measles outbreaks continue to occur. In spite of significant reductions over the past decade, the mortality rate of children under 5 years of age continues to remain high at 91 per 1000 live births.
Methods
The study was a descriptive community-based cross sectional household survey. The survey aimed to estimate the levels of immunization coverage at national and province levels. Specific objectives are to: establish valid baseline information to monitor progress of the immunization program; identify reasons why children are not immunized; and make recommendations to enhance access and quality of immunization services in Afghanistan. The survey was carried out in all 34 provinces of the country, with a sample of 6125 mothers of children aged 12–23 months.
Results
Nationally, 51% of children participating in the survey received all doses of each antigen irrespective of the recommended date of immunization or recommended interval between doses. About 31% of children were found to be partially vaccinated. Reasons for partial vaccination included: place to vaccinate child too far (23%), not aware of the need of vaccination (17%), no faith in vaccination (16%), mother was too busy (15%), and fear of side effects (11%).
Conclusion
The innovative mechanism of contracting out delivery of primary health care services in Afghanistan, including immunization, to non-governmental organizations is showing some positive results in quickly increasing coverage of essential interventions, including routine immunization. Much ground still needs to be covered with proper planning and management of resources in order to improve the immunization coverage in Afghanistan and increase survival and health status of its children.

Emergencies

WHO Grade 3 Emergencies  [to 8 April 2017]
Iraq  –
Special health situation report from Mosulpdf, 646kb  1 April 2017

South Sudan  –
WHO supports new initiative to more easily allow people living in South Sudan’s rural communities to access health services
Juba, 3 April 2017 – The World Health Organization (WHO) is supporting the Republic of South Sudan’s Ministry of Health and partners to roll-out a new approach to community health service delivery called the Boma Health Initiative. Currently, only 40% of people in South Sudan are within reach of health facilities and have consistent access to primary health care services. The Boma Health Initiative seeks to provide sustainable delivery of essential health care and public health programmes at the community level.

The Syrian Arab Republic  –
WHO alarmed by use of highly toxic chemicals as weapons in Syria
5 April 2017 | GENEVA – WHO is alarmed by serious reports of the use of highly toxic chemicals in an attack in Khan Shaykhun, southern rural Idleb, Syria. According to Health Cluster partners on the ground treating the patients, at least 70 people have died and hundreds more have been affected. Doctors in Idleb are reporting that dozens of patients suffering from breathing difficulties and suffocation have been admitted to hospitals in the governorate for urgent medical attention, many of them women and children.

Nigeria – No new announcements identified
Yemen – No new announcements identified

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WHO Grade 2 Emergencies  [to 8 April 2017]
Cameroon  – No new announcements identified.
Central African Republic  – No new announcements identified.
Democratic Republic of the Congo – No new announcements identified.
Ethiopia – No new announcements identified.
Libya – No new announcements identified.
Myanmar – No new announcements identified.
Niger  – No new announcements identified.
Ukraine  – No new announcements identified.

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UN OCHA – L3 Emergencies
The UN and its humanitarian partners are currently responding to three ‘L3’ emergencies. This is the global humanitarian system’s classification for the response to the most severe, large-scale humanitarian crises. 
Iraq
:: Iraq: Mosul Humanitarian Response Situation Report No. 27 (27 March – 2 April 2017) [EN/KU]
:: Mosul Humanitarian Crisis, 4 April 2017

Syria  
:: 7 Apr 2017  Syrian Arab Republic: 2016 Humanitarian Dashboard, January – December 2016
:: 4 April 2017  Syria crisis: UN Humanitarian Chief welcomes donor pledges of $6 billion to help people in need in…
:: 4 Apr 2017  UN Humanitarian Chief –  Opening remarks at the ‘Humanitarian situation inside Syria: Needs, challenges and way forward” thematic session of the Brussels conference on Supporting the Future of Syria and the Region

Yemen –
:: 4 April 2017  Statement on behalf of the Humanitarian Country Team in Yemen, on the Critical Importance to Maintain Al Hudaydah Port Open [EN/AR]

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POLIO [to 8 April 2017]
Public Health Emergency of International Concern (PHEIC)

Polio this week as of 5 April 2017
:: Last week, the Technical Advisory Group Consultation on Polio Eradication in Pakistan convened in Islamabad, to review current epidemiology and strategies to eradicate remaining strains of transmission for the rest of the year. See ‘Pakistan’ section below for more.
 

Country Updates [Selected Excerpts]
New cases or environmental samples reported across the monitored country/region settings: Afghanistan, Pakistan, Nigeria, Lake Chad Basin. Guinea and West Africa, and Lao People’s Democratic Republic have been removed from the monitored geographies list.
:: No new activity reported

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Editor’s Note:
We will cluster these recent emergencies as below and continue to monitor the WHO webpages for updates and key developments.

Zika virus  [to 8 April 2017]
http://www.who.int/emergencies/zika-virus/en/
WHO: Study on the persistence of Zika virus in body fluids
April 2017 – Over the course of 2016, WHO along with the global research community quickly built evidence that Zika virus transmission through sex was not only possible, but more common than previously assumed. But many questions still remain unanswered.

MERS-CoV [to 8 April 2017]
http://www.who.int/emergencies/mers-cov/en/
Disease outbreak news
Middle East respiratory syndrome coronavirus (MERS-CoV) – Qatar   
4 April 2017
Middle East respiratory syndrome coronavirus (MERS-CoV) – Saudi Arabia
3 April 2017

Yellow Fever  [to 8 April 2017]
http://www.who.int/emergencies/yellow-fever/en/
Disease outbreak news
Yellow fever – Brazil  4 April 2017
Updates on yellow fever vaccination recommendations for international travellers related to the current situation in Brazil

EBOLA/EVD  [to 8 April 2017]
http://www.who.int/ebola/en/
[See CDC reports below]

WHO & Regional Offices [to 8 April 2017]

Highlights
World Health Day – 7 April 2017
Depression: let’s talk
7 April 2017 – Depression is the leading cause of ill health and disability worldwide. More than 300 million people are now living with depression, an increase of more than 18% between 2005 and 2015. WHO is leading a global campaign on depression for World Health Day 2017, with the goal of enabling more people with mental disorders to live healthy, productive lives.

World Health Day 2017 – High-level event on mental health and depression in the context of the 2030 Agenda for Sustainable Development
[Event Video: 2:25:58]
Depression affects people of all ages, from all walks of life, in all countries. Untreated depression can prevent people from working and participating in family and community life.
WHO’s “Depression: Let’s Talk” campaign seeks to promote a better understanding of depression, prevention and treatment mechanisms, and the underlying importance of talking about depression as a vital component for reducing stigmas and supporting recovery.

 
Reference Guide: Developing health financing strategy
April 2017 – A new guide published by WHO examines policy development for health financing, expanding on areas including revenue raising, pooling revenues, purchasing services, benefit design, and rationing mechanisms. Health financing is key to improving health system performance and progressing towards universal health coverage (UHC).

WHO alarmed by use of highly toxic chemicals as weapons in Syria
   April 2017 – WHO is alarmed by serious reports of the use of highly toxic chemicals in an attack in Khan Shaykhun, southern rural Idleb, Syria. According to Health Cluster partners on the ground treating the patients, at least 70 people have died and hundreds more have been affected.

Study on the persistence of Zika virus in body fluids
April 2017 – Over the course of 2016, WHO along with the global research community quickly built evidence that Zika virus transmission through sex was not only possible, but more common than previously assumed. But many questions still remain unanswered.

WHO calls for increased support for health aid in Syria and refugee-hosting neighbouring countries
April 2017 – In Syria, limited specialized medical staff, ambulances, equipment and medical supplies have led to growing numbers of deaths which could have been prevented. Large numbers of wounded Syrians continue to die or face permanent disabilities as a result of limited access to medical care

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Weekly Epidemiological Record, 7 April 2017, vol. 92, 14 (pp. 165–180)
Surveillance systems to track progress towards polio eradication worldwide, 2015–2016
Performance of acute flaccid paralysis (AFP) surveillance and incidence of poliomyelitis, 2017
Monthly report on dracunculiasis cases, January– December 2016

GIN March 2017  pdf, 1.77Mb   3 April 2017

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WHO Regional Offices
Selected Press Releases, Announcements
WHO African Region AFRO
No new digest content identified.

WHO Region of the Americas PAHO
:: Ismael Cala joins PAHO’s World Health Day Campaign (04/06/2017)
:: PAHO trains more than 100 journalists from the Americas on responsible coverage of suicide to prevent ‘suicide contagion’ (04/06/2017)

WHO South-East Asia Region SEARO
No new digest content identified.
 
WHO European Region EURO
:: Journalists in Tajikistan expand skills for reporting on tobacco 07-04-2017
:: Policy dialogue proposed during visit of Minister of Health of Latvia to WHO/Europe 07-04-2017
:: Greek Government hosts broad policy dialogue on public health reform 05-04-2017
:: Tackling mild depression: “iCBT was perfect for me.” 04-04-2017
:: Major health gains achieved through working together: 15 years of the South-eastern Europe Health Network and beyond 03-04-2017
: Examples of investing in health from the South-eastern Europe Health Network 03-04-2017

WHO Eastern Mediterranean Region EMRO
:: WHO alarmed by use of highly toxic chemicals as weapons in Syria  5 April 2017
:: WHO releases new guidance on malaria elimination  5 April 2017
:: WHO and Morocco sign Country Cooperation Strategy for 2017–2021  2 April 2017

WHO Western Pacific Region
No new digest content identified.

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CDC/ACIP [to 8 April 2017]
http://www.cdc.gov/media/index.html
Transcript
TUESDAY, APRIL 4, 2017
CDC Telebriefing: New Vital Signs Report – Zika Virus
New Vital Signs Report – Possible Zika virus infections in 44 U.S. states: What can healthcare providers do to help protect pregnant women and their babies?

Press Release
TUESDAY, APRIL 4, 2017
About 1 in 10 U.S. pregnant women with confirmed Zika infection had a fetus or baby with birth defects in 2016
Of the 250 pregnant women who had confirmed Zika infection in 2016, 24 – or about 1 in 10 of them – had a fetus or baby with Zika-related birth…

Press Release
MONDAY, APRIL 3, 2017
CDC Study Finds Flu Vaccine Saves Children’s Lives
   A new CDC study published today in Pediatrics is the first of its kind to show that flu vaccination significantly reduced a child’s risk of dying from influenza.

MMWR: https://www.cdc.gov/mmwr/index2017.html
MMWR Weekly April 7, 2017 / No. 13
[Excerpts]
:: HIV Services Provided by STD Programs in State and Local Health Departments — United States, 2013–2014
:: Surveillance Systems to Track Progress Toward Polio Eradication — Worldwide, 2015–2016
:: Vital Signs: Update on Zika Virus–Associated Birth Defects and Evaluation of All U.S. Infants with Congenital Zika Virus Exposure — U.S. Zika Pregnancy Registry, 2016
:: Announcement: Sexually Transmitted Diseases Awareness Month — April 2017

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::::::
 

Announcements
 
IVI   [to 8 April 2017]
http://www.ivi.int/
April 3,2017
Korean Ministry of Health and Welfare, International Vaccine Institute (IVI) sign agreement on vaccine development and delivery cooperation
– Agreement to collaborate on vaccine R&D projects, capacity-building, and information-exchange programs between IVI, universities, research institutes and industry
– IVI Director General Jerome Kim thanks Korea for its support of global health R&D and vows to increase IVI’s cooperation with Korea
SEOUL, KOREA – The Ministry of Health & Welfare of the Republic of Korea (MOH) and the International Vaccine Institute (IVI) signed a memorandum of understanding (MOU) on a collaboration to advance global public health, and to develop and deliver vaccines and related technologies for developing countries. Dr. Chung Chin-youb, Minister of Health & Welfare, visited the IVI headquarters at Seoul National University Research Park on April 3rd and exchanged the MOU with IVI Director General Dr. Jerome Kim, and discussed plans on mutual cooperation between Korea and the institute.

Established in 1997, IVI was the first international organization headquartered in Korea.  As IVI’s host country, Korea provides funding through its Official Development Assistance (ODA) to the institute for its vaccine research and operations. Up until recently, the institute was under the Ministry of Education. This MOU is a revision of the MOU signed in 2013 between the Ministry of Education and IVI, and includes newly added areas of support and expanded cooperation between IVI and MOH such as joint vaccine R&D projects and capacity-building initiatives.

Under the purview of MOH, IVI will continue to receive funding from the Korean government to support its operations as per the original host country agreement signed between IVI and Korea. The Ministry will also continue to support IVI’s vaccine research and development activities to help the institute fulfill its mission of making safe, effective and affordable vaccines available for global health.

Finally IVI and the Ministry agreed to actively support exchange and cooperation programs in Korea by collaborating more with Korean universities, research institutes and the life sciences industry.  Notably, IVI and the Korean Centers for Disease Control will partner to develop vaccines against norovirus and hepatitis A…
 
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NIH  [to 8 April 2017]
http://www.nih.gov/news-events/news-releases
April 5, 2017
Monoclonal antibody cures Marburg infection in monkeys
— NIH-funded groups preparing for next filovirus outbreak.
Scientists funded by the National Institutes of Health have found that an experimental treatment cured 100 percent of guinea pigs and rhesus monkeys in late stages of infection with lethal levels of Marburg and Ravn viruses, relatives of the Ebola virus. Although the Marburg and Ravn viruses are less familiar than Ebola virus, both can resemble Ebola in symptoms and outcomes in people, and both lack preventive and therapeutic countermeasures.

NIDA announces recipients of 2017 Avant-Garde Awards for HIV/AIDS research
April 5, 2017 — NIH awards highlight novel approaches to HIV prevention and treatment.
The National Institute on Drug Abuse (NIDA), part of the National Institutes of Health, today announced that three scientists have been selected to receive the 2017 Avant-Garde Award for HIV/AIDS Research. The winning proposals focus on a variety of novel approaches, including: improving HIV prevention through effective gene therapies; enhancing innate (natural) immunity against HIV and other related viruses; and developing new small-molecule drugs to treat HIV-1 infection.

The three scientists will each receive $500,000 per year for five years to support their research, subject to the availability of funds. NIDA’s tenth annual Avant-Garde Award competition is intended to stimulate high-impact research that may lead to groundbreaking opportunities for the prevention and treatment of HIV/AIDS in drug users.

“With nearly 37 million people living with HIV worldwide, it is essential that researchers continue to develop effective prevention and treatment strategies for those suffering from this devastating disease, including people with substance use disorders,” said NIDA Director Nora D. Volkow, M.D. “These scientists are pioneering exciting new approaches aimed at preventing and treating new cases of HIV and helping people at risk live longer, healthier lives.”

Awardees are listed below:
Michael Farzan, Ph.D., The Scripps Research Institute
Project: A safety switch for an effective HIV-1 vaccine
Dr. Farzan plans to use preclinical models to explore safe and effective gene therapies for the long-term prevention of HIV infection in high-risk populations, such as injection drug users. He will use an adeno-associated virus to deliver broadly neutralizing antibodies (bNAbs) or eCD4-Ig, proteins that prevent HIV-1 from infecting cells. His group will also explore safety switch mechanisms to control bNAbs and eCD4-Ig, thereby increasing safety during long-term exposure to these molecules.

Eric M. Poeschla, Ph.D., University of Colorado Denver
Project: Novel Approaches to Innate Immunity Against HIV-1 and Other Co-infection Viruses
Dr. Poeschla will use animal and human cells to explore the use of viral RNA-dependent RNA polymerase (RdRP) to enhance broad-spectrum (innate) immunity against various viruses, including HIV-1. Evidence suggests that this stable innate immune system activation does not trigger autoimmunity or inflammatory pathways. This approach may also protect against viruses that infect people with addiction.

Peter S. Kim, Ph.D., Stanford University
Project: Making the HIV-1 gp41 pocket amenable to small-molecule drug discovery
Dr. Kim’s group proposes a strategy that alters the HIV-1 gp41 region, thereby increasing structural rigidity in this region. This will enhance testing of new therapeutics that target the gp41 pocket to prevent HIV infection. Because the pocket is structurally similar across different HIV-1 strains, these therapeutics could treat patients, including people with substance use disorders, who are at higher risk of developing resistance to one or more classes of anti-HIV drugs…

International scientific teams find potential approach against parasites
April 3, 2017 — Research teams from the National Institutes of Health and abroad have identified the first inhibitor of an enzyme long thought to be a potential drug target for fighting disease-causing parasites and bacteria. The teams, led by NIH’s National Center for Advancing Translational Sciences (NCATS) and University of Tokyo scientists, sorted through more than 1 trillion small protein fragments called cyclic peptides to uncover two that could shut down the enzyme. The finding, reported April 3, 2017 in Nature Communications, could set the stage for the potential development of new types of antimicrobial drugs…

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Sabin Vaccine Institute  [to 8 April 2017]
http://www.sabin.org/updates/pressreleases
Tuesday, April 4, 2017
Public Health Experts Discuss Vaccines, Antibiotic Resistance and Surveillance at Conference on Typhoid and Other Invasive Salmonelloses
KAMPALA, UGANDA – April 4, 2017 – Today, the Sabin Vaccine Institute opened the 10th International Conference on Typhoid and Other Invasive Salmonelloses in Kampala, Uganda. Over the course of the three day conference, more than 300 experts from around the world have gathered to discuss new typhoid-related research, as well as how to turn this evidence into action in the fight against typhoid.

Typhoid fever, an illness caused by the bacteria Salmonella Typhi, kills an estimated 220,000 people, primarily children, each year. Currently available typhoid vaccines are underutilized in low- and middle-income countries, including many countries in Africa and Asia. Vaccines for other, nontyphoidal strains of Salmonella bacteria are not available. Typhoid is treated with antibiotics, but the recent rise of antibiotic-resistant typhoid and nontyphoidal Salmonella has increased the burden of treatment on health systems and families. There is an urgent need for new effective vaccines and policies to help prevent the disease and its transmission in communities. Preventing typhoid will minimize the need to treat this serious infection and will also reduce the danger of antibiotic resistance.

There has been significant progress in typhoid vaccine development. New typhoid conjugate vaccines offer important advantages over prior vaccines, including longer duration of protection, the ability to protect young children, and the potential for delivery with other vaccines in routine immunization of infants. Conjugate vaccines have the potential to dramatically reduce the burden of typhoid around the world and, consequently, help to prevent the occurrence of antibiotic resistance. The research shared at Sabin’s conference – the world’s only such meeting devoted to typhoid and other invasive salmonelloses – will inform discussions at the World Health Organization later this month, when experts gather to review recommendations on the use of typhoid vaccines…

“This conference comes at a pivotal moment for global action on typhoid,” said Bruce Gellin, president of Global Immunization at the Sabin Vaccine Institute. “…To have the greatest impact, we need to review the evidence for these vaccines and consider the vaccination programs in which they will be delivered. The discussions and debates over the next three days at this conference will help the researchers, policy makers and advocates meet the urgent need for prevention and control.”…

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AERAS  [to 8 April 2017]
http://www.aeras.org/pressreleases
Aeras Updates – Quarterly Newsletter
5 April 2017
:: Aeras celebrates World TB Day 2017
:: World TB Day Europe: Personal Stories and Focusing on AMR
:: Aeras Asia: Leveraging Social Media to Promote World TB Day Messages
:: Aeras Africa: Using World TB Day to Spark Discussion About TB R&D

 
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Global Fund [to 8 April 2017]
http://www.theglobalfund.org/en/news/?topic=&type=NEWS;&country=

News
Global Fund Welcomes Italy’s €140 million Contribution
07 April 2017
The Global Fund to Fight AIDS, Tuberculosis and Malaria welcomed a contribution of €140 million from the government of Italy for the three-year period beginning in 2017, a strong demonstration of Italy’s leadership in global health.

News
The Global Fund and Pink Ribbon Red Ribbon Partner to Prevent and Control Cervical Cancer
06 April 2017
Today, leaders of the Global Fund to Fight AIDS, Tuberculosis and Malaria and Pink Ribbon Red Ribbon signed an agreement to collaborate on programming to prevent cervical cancer. HIV positive women are up to five times more likely to develop cervical cancer, so routine screening and treatment is essential for this population. Screening and treatment for cervical pre-cancer is a cost-effective intervention, costing less than $25 per woman. Pink Ribbon Red Ribbon will work with countries to integrate cervical cancer programming into their HIV/AIDS grants from the Global Fund, building on efforts by national governments and the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR).

::::::
 
FDA [to 8 April 2017]
http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/default.htm
April 07, 2017
FDA approves two hepatitis C drugs for pediatric patients

 What’s New for Biologics
:: February 8, 2017 Transcript – Identification and Characterization of the Infectious Disease Risks of Human Cells, Tissues, and Cellular and Tissue-based Products (PDF – 2.7MB)
Posted: 4/4/2017
:: February 9, 2017 Transcript – Identification and Characterization of the Infectious Disease Risks of Human Cells, Tissues, and Cellular and Tissue-based Products (PDF – 1.4MB)
Posted: 4/4/2017
 

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Wellcome Trust  [to 8 April 2017]
https://wellcome.ac.uk/news
News / Published: 7 April 2017
Public invited to help tackle antibiotic resistance
A new citizen science project, BashTheBug (opens in a new tab), has been launched to study antibiotic resistance in tuberculosis (TB).
On the Zooniverse website (opens in a new tab), volunteers are shown a series of small, circular wells each containing Mycobacterium tuberculosis, which causes TB, and a different dose of an antibiotic.
They are then asked to identify wells in which the bacteria have grown, helping the researchers to determine which antibiotics are effective at killing each specific strain of TB.
“Antibiotic resistance is a global threat, and accurately and rapidly diagnosing drug-resistant disease places a huge strain on hospital laboratories,” says Dr Philip Fowler, lead researcher on the BashTheBug project.
“Knowing which antibiotics are effective against a particular bacterial infection is crucial for effectively treating a patient, while also limiting the opportunity for the bug to develop antibiotic-resistance and then be passed onto other people.”
“Cultivating and examining TB plates is a time-consuming process, but by enlisting extra help online we hope to examine over 40 million images, something we could never do on our own…

 
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Industry Watch  [to 8 April 2017]
:: Takeda Completes Enrollment of More Than 20,000 Children and Adolescents in Global Phase 3 Trial of Dengue Vaccine Candidate
   Tetravalent Immunization against Dengue Efficacy Study (TIDES) trial evaluates the efficacy of two doses of vaccine candidate TAK-003, administered three months apart, to protect against all four strains of dengue virus, regardless of previous dengue exposure
   Study includes children and adolescents ages 4 through 16 years in eight dengue-endemic countries across Latin America and Asia
   Achieving enrollment demonstrates Takeda’s commitment to advancing global vaccine business and addressing unmet needs in dengue prevention
April 05, 2017 08:00 AM Eastern Daylight Time
OSAKA, Japan–(BUSINESS WIRE)–Takeda Pharmaceutical Company Limited today announced that it has completed enrollment of 20,100 children and adolescents ages 4 through 16 in its global, pivotal Phase 3 Tetravalent Immunization against Dengue Efficacy Study (TIDES) trial, a double-blind, randomized and placebo-controlled study designed to evaluate the efficacy, safety and immunogenicity of its live-attenuated tetravalent dengue vaccine candidate (TAK-003).1 Takeda initiated the TIDES trial, the largest vaccine clinical trial for Takeda to date, in September 2016 and completed enrollment in less than seven months.1 …
“The successful enrollment of more than 20,000 children and adolescents in this Phase 3 trial, across several continents, and on an ambitious timeline, while maintaining a clear focus on quality and subject safety, reflects Takeda’s prioritization of dengue and the substantial capabilities of our global organization,” said Rajeev Venkayya, MD, President of the Global Vaccine Business Unit at Takeda…

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
Volume 96, Issue 4, 2017
http://www.ajtmh.org/content/current

Perspective Pieces
Impacts on Global Health from Nursing Research
Authors: Kimberly Baltzell, Monica McLemore, Mona Shattell and Sally Rankin
https://doi.org/10.4269/ajtmh.16-0918
Infectious disease continues to adversely affect populations in low- and middle-income countries. Investments in solutions often focus on technology, yet health-care workers remain in short supply. Nurses are the largest cadre of health-care workers and are largely responsible for patient care around the world. In fact, it is estimated that nurses care for nine out of every 10 patients seen. Importantly, sound nursing science contributes to solutions that directly impact patient care, especially those that pertain to infectious disease. Here we share several examples of nursing science that are improving care delivery in three global health areas: human immunodeficiency virus testing and prevention strategies in Malawi, family planning in Kenya, and response to Ebola virus disease.

BMC Health Services Research
http://www.biomedcentral.com/bmchealthservres/content
(Accessed 8 April 2017)

Research article
A systematic review of strategies to increase access to health services among children in low and middle income countries
Tess Bright, Lambert Felix, Hannah Kuper and Sarah Polack
BMC Health Services Research 2017 17:252
Published on: 5 April 2017
Abstract
Background
Universal Health Coverage is widely endorsed as the pivotal goal in global health, however substantial barriers to accessing health services for children in low and middle-income countries (LMIC) exist. Failure to access healthcare is an important contributor to child mortality in these settings. Barriers to access have been widely studied, however effective interventions to overcome barriers and increase access to services for children are less well documented.
Methods
We conducted a systematic review of effectiveness of interventions aimed at increasing access to health services for children aged 5 years and below in LMIC. Four databases (EMBASE, Global Health, MEDLINE, and PSYCINFO) were searched in January 2016. Studies were included if they evaluated interventions that aimed to increase: health care utilisation; immunisation -uptake; and compliance with medication or referral. Randomised controlled trials and non-randomised controlled study designs were included in the review. A narrative approach was used to synthesise results.
Results
Fifty seven studies were included in the review. Approximately half of studies (49%) were conducted in sub-Saharan Africa. Most studies were randomised controlled trials (n = 44; 77%) with the remaining studies employing non-randomised designs. Very few studies were judged as high quality. Studies evaluated a diverse range of interventions and various outcomes. Supply side interventions included: delivery of services at or closer to home and service level improvements (eg. integration of services). Demand side interventions included: educational programmes, text messages, and financial or other incentives. Interventions that delivered services at or closer to home and text messages were in general associated with a significant improvement in relevant outcomes. A consistent pattern was not noted for the remaining studies.
Conclusions
This review fills a gap in the literature by providing evidence of the range and effectiveness of interventions that can be used to increase access for children aged ≤5 years in LMIC. It highlights some intervention areas that seem to show encouraging trends including text message reminders and delivery of services at or close to home. However, given the methodological limitations found in existing studies, the results of this review must be interpreted with caution.

BMC Infectious Diseases
http://www.biomedcentral.com/bmcinfectdis/content
(Accessed 8 April 2017)

Research article
Modelling the therapeutic dose range of single low dose primaquine to reduce malaria transmission through age-based dosing
Low-dose primaquine is a key candidate for use in malaria transmission reduction and elimination campaigns such as mass drug administration (MDA). Uncertainty about the therapeutic dose range (TDR) required fo…
Daniel Joseph Hayes, Clifford George Banda, Alexandra Chipasula-Teleka and Dianne Janette Terlouw
BMC Infectious Diseases 2017 17:254
Published on: 8 April 2017

Research article
Decline in hospitalization for genital warts in the Veneto region after an HPV vaccination program: an observational study
Human papillomavirus (HPV) is one of the most common sexually transmitted pathogens. This observational study was conducted to estimate the trend of hospitalization for genital warts (GWs) in the Veneto region…
Silvia Cocchio, Tatjana Baldovin, Chiara Bertoncello, Alessandra Buja, Patrizia Furlan, Mario Saia and Vincenzo Baldo
BMC Infectious Diseases 2017 17:249
Published on: 5 April 2017

BMC Medical Ethics
http://www.biomedcentral.com/bmcmedethics/content
(Accessed 8 April 2017)

Debate
A critique of the regulation of data science in healthcare research in the European Union
John M. M. Rumbold and Barbara K. Pierscionek
BMC Medical Ethics 2017 18:27
Published on: 8 April 2017
Abstract
The EU offers a suitable milieu for the comparison and harmonisation of healthcare across different languages, cultures, and jurisdictions (albeit with a supranational legal framework), which could provide improvements in healthcare standards across the bloc. There are specific ethico-legal issues with the use of data in healthcare research that mandate a different approach from other forms of research. The use of healthcare data over a long period of time is similar to the use of tissue in biobanks. There is a low risk to subjects but it is impossible to gain specific informed consent given the future possibilities for research. Large amounts of data on a subject present a finite risk of re-identification. Consequently, there is a balancing act between this risk and retaining sufficient utility of the data. Anonymising methods need to take into account the circumstances of data sharing to enable an appropriate balance in all cases. There are ethical and policy advantages to exceeding the legal requirements and thereby securing the social licence for research. This process would require the examination and comparison of data protection laws across the trading bloc to produce an ethico-legal framework compatible with the requirements of all member states. Seven EU jurisdictions are given consideration in this critique.

BMC Medical Ethics

(Accessed 8 April 2017)

Research article
The ECOUTER methodology for stakeholder engagement in translational research
Madeleine J. Murtagh, Joel T. Minion, Andrew Turner, Rebecca C. Wilson, Mwenza Blell, Cynthia Ochieng, Barnaby Murtagh, Stephanie Roberts, Oliver W. Butters and Paul R Burton
BMC Medical Ethics 2017 18:24
Published on: 4 April 2017

BMC Public Health
http://bmcpublichealth.biomedcentral.com/articles
(Accessed 8 April 2017)

Research article
Ethical issues in public health surveillance: a systematic qualitative review
Corinna Klingler, Diego Steven Silva, Christopher Schuermann, Andreas Alois Reis, Abha Saxena and Daniel Strech
BMC Public Health 2017 17:295
Published on: 4 April 2017
Abstract
Background
Public health surveillance is not ethically neutral and yet, ethics guidance and training for surveillance programmes is sparse. Development of ethics guidance should be based on comprehensive and transparently derived overviews of ethical issues and arguments. However, existing overviews on surveillance ethics are limited in scope and in how transparently they derived their results. Our objective was accordingly to provide an overview of ethical issues in public health surveillance; in addition, to list the arguments put forward with regards to arguably the most contested issue in surveillance, that is whether to obtain informed consent.

Methods

Ethical issues were defined based on principlism. We assumed an ethical issue to arise in surveillance when a relevant normative principle is not adequately considered or two principles come into conflict. We searched Pubmed and Google Books for relevant publications. We analysed and synthesized the data using qualitative content analysis.

Results

Our search strategy retrieved 525 references of which 83 were included in the analysis. We identified 86 distinct ethical issues arising in the different phases of the surveillance life-cycle. We further identified 20 distinct conditions that make it more or less justifiable to forego informed consent procedures.

Conclusions

This is the first systematic qualitative review of ethical issues in public health surveillance resulting in a comprehensive ethics matrix that can inform guidelines, reports, strategy papers, and educational material and raise awareness among practitioners.

BMC Public Health
http://bmcpublichealth.biomedcentral.com/articles
(Accessed 8 April 2017)

Research article
Improving immunization in Afghanistan: results from a cross-sectional community-based survey to assess routine immunization coverage
Raveesha R. Mugali, Farooq Mansoor, Sardar Parwiz, Fazil Ahmad, Najibullah Safi, Ariel Higgins-Steele and Sherin Varkey
BMC Public Health 2017 17:290
Published on: 4 April 2017
Abstract
Background
Despite progress in recent years, Afghanistan is lagging behind in realizing the full potential of immunization. The country is still endemic for polio transmission and measles outbreaks continue to occur. In spite of significant reductions over the past decade, the mortality rate of children under 5 years of age continues to remain high at 91 per 1000 live births.

Methods

The study was a descriptive community-based cross sectional household survey. The survey aimed to estimate the levels of immunization coverage at national and province levels. Specific objectives are to: establish valid baseline information to monitor progress of the immunization program; identify reasons why children are not immunized; and make recommendations to enhance access and quality of immunization services in Afghanistan. The survey was carried out in all 34 provinces of the country, with a sample of 6125 mothers of children aged 12–23 months.

Results

Nationally, 51% of children participating in the survey received all doses of each antigen irrespective of the recommended date of immunization or recommended interval between doses. About 31% of children were found to be partially vaccinated. Reasons for partial vaccination included: place to vaccinate child too far (23%), not aware of the need of vaccination (17%), no faith in vaccination (16%), mother was too busy (15%), and fear of side effects (11%).

Conclusion

The innovative mechanism of contracting out delivery of primary health care services in Afghanistan, including immunization, to non-governmental organizations is showing some positive results in quickly increasing coverage of essential interventions, including routine immunization. Much ground still needs to be covered with proper planning and management of resources in order to improve the immunization coverage in Afghanistan and increase survival and health status of its children.

Clinical Therapeutics
March 2017 Volume 39, Issue 3, p451-664
http://www.clinicaltherapeutics.com/issue/S0149-2918(17)X0003-9

Editorial
Current Insights in the Placebo and Nocebo Phenomena
Seetal Dodd, PhD
We have arranged a series of review and original research reports that are both up-to-date and timely. The articles are from leading researchers in different countries, and they provide insight into the range of ongoing research investigating the placebo and nocebo phenomena.

The word placebo has a Latin origin and a long history of use; however, the context in which the word is used has changed over time. Nocebo is a modern word that has been made up from the word placebo. In common usage, a placebo or nocebo effect occurs when an inert substance creates a beneficial or harmful effect in a person who takes it. The concept is also extended beyond the administration of inert substances.1 In a research setting, active placebos are pharmacologically active controls that are not considered to be effective for the index symptoms being treated. Active placebos have also been used in clinical settings, where an active agent has been given to a patient even though the pharmacologic action of the active agent is not known to be beneficial for treating the patient’s diagnosed condition, typically to meet a patient’s expectation that he or she will receive a treatment. Similarly, a nocebo response can occur with an inert or noninert substance as a worsening of the diagnosed condition or as treatment-emergent adverse effects. Moreover, when indication-appropriate active treatment is administered, the therapeutic effect may be a combination of the pharmacologic activity of the treating agent and a placebo effect, as demonstrated in an experiment of open and hidden analgesic administration using an infusion pump where pain relief was significantly reduced when the patients were unaware that an analgesic was being administered.2

It is also common usage to refer to all improvement in a placebo arm of a randomized clinical trial (RCT) as a placebo response and all worsening and adverse events as a nocebo response, even though fluctuation of symptoms occurs with the natural progression of many illnesses. It is often impossible to discern between a genuine placebo response and fluctuation in symptom severity that may have occurred without administering a placebo or between a nocebo response and highly prevalent physical ailments, such as headache or nausea. Consequently, the terms placebo and nocebo are used differently by different authors or even by the same authors when reporting different studies.

In placebo-controlled RCTs, a mean change in the primary outcome from baseline to treatment end point is commonly described as the placebo response. For researchers whose objectives is to demonstrate efficacy of treatment in the active arm of the RCT, it does not matter whether the change from baseline for individuals in the placebo arm of an RCT is a genuine placebo response driven by expectancy and the treatment environment or is attributable to fluctuations in illness severity that may occur during the illness. What matters to these researchers is that there is a statistically significant difference in outcome between participants in the placebo and active arms of the RCT. Alternatively, for researchers investigating the placebo phenomenon itself, experiments are tightly controlled to measure only the response to the placebo itself, typically, in healthy participants.

There is a need for considerable further research investigating the placebo and nocebo phenomena that will increase our scientific and theoretical knowledge about these phenomena and broaden our understanding of their clinical relevance. This requires researchers working in a broad range of fields.

In this issue of Clinical Therapeutics, experts in nocebo and placebo research contribute new insights into the mechanisms and characteristics of the phenomena. The article by Weimer et al3 reports an experiment on the placebo effects for treating nausea, investigating whether altering the levels of expectation of receiving an active agent when actually receiving a placebo can influence treatment outcomes. The article by by Bartels et al4 reports an experiment in which cognitive schemas with regard to memory and expectations are assessed as moderators of placebo and nocebo responses.

Also in this issue, Enck et al5 contribute a review article that describes a wealth of recent research into placebo and nocebo effects but highlights the gaps in current research. Two other review articles are contributed by researchers in Australia, Spain, and Portugal, one reviewing current knowledge regarding the scientific and theoretical basis of the nocebo and placebo phenomena6 and the other investigating the importance and effect of the nocebo and placebo phenomena in clinical research and clinical practice.7

This issue accurately represents the current understanding of the nocebo and placebo phenomena and the limitation in the current knowledge. Gaps still exist in the way placebo and nocebo are conceptualized. As suggested by Enck et al,5 gaps exist in our understanding of the basic science of the placebo response, especially outside placebo analgesia research. In addition, within clinical populations, identifying placebo and nocebo responders remains problematic. I hope that readers enjoy this issue and find it informative.

Clinical Therapeutics
March 2017 Volume 39, Issue 3, p451-664
http://www.clinicaltherapeutics.com/issue/S0149-2918(17)X0003-9

Reviews
Unsolved, Forgotten, and Ignored Features of the Placebo Response in Medicine
Paul Enck, Sibylle Klosterhalfen, Katja Weimer
p458–468
Published online: December 2, 2016

A Review of the Theoretical and Biological Understanding of the Nocebo and Placebo Phenomena
Seetal Dodd, Olivia M. Dean, João Vian, Michael Berk
p469–476
Published online: February 1, 2017

The Placebo and Nocebo Phenomena: Their Clinical Management and Impact on Treatment Outcomes
Victor Chavarria, João Vian, Círia Pereira, João Data-Franco, Brisa S. Fernandes, Michael Berk, Seetal Dodd
p477–486
Published online: February 22, 2017

Global Health Action
Volume 10, 2017 – Issue 1
http://www.tandfonline.com/toc/zgha20/10/1?nav=tocList

Review
The impact of the worldwide Millennium Development Goals campaign on maternal and under-five child mortality reduction: ‘Where did the worldwide campaign work most effectively?’
Seungman Cha
Article: 1267961
Published online: 07 Feb 2017

Rapid communication
The real-life number of neonatal doses of Bacille Calmette-Guérin vaccine in a 20-dose vial
Frederik Schaltz-Buchholzer, Hannah Nørtoft Frankel & Christine Stabell Benn
Article: 1267964
Published online: 27 Jan 2017

Review article
Who is a community health worker? – a systematic review of definitions
Abimbola Olaniran, Helen Smith, Regine Unkels, Sarah Bar-Zeev & Nynke van den Broek
Article: 1272223
Published online: 27 Jan 2017

Health Affairs
April 2017; Volume 36, Issue 4
http://content.healthaffairs.org/content/current
Issue Focus: Maternity Coverage, Children, Disability & More
Maternity & Children’s Coverage

State And Federal Coverage For Pregnant Immigrants: Prenatal Care Increased, No Change Detected For Infant Health
Laura R. Wherry, Rachel Fabi, Adam Schickedanz, and Brendan Saloner
Health Aff April 2017 36:607-615; doi:10.1377/hlthaff.2016.1198

Low-Income Children With Chronic Conditions Face Increased Costs If Shifted From CHIP To Marketplace Plans
Alon Peltz, Amy J. Davidoff, Cary P. Gross, and Marjorie S. Rosenthal
Health Aff April 2017 36:616-625; doi:10.1377/hlthaff.2016.1280

Global Health
Industry-Led Access-To-Medicines Initiatives In Low- And Middle-Income Countries: Strategies And Evidence
Peter C. Rockers, Veronika J. Wirtz, Chukwuemeka A. Umeh, Preethi M. Swamy, and Richard O. Laing
Health Aff April 2017 36:706-713; doi:10.1377/hlthaff.2016.1213
Abstract
Global biopharmaceutical companies are increasingly establishing access-to-medicines (AtM) initiatives in low- and middle-income countries. We reviewed the initiatives of twenty-one research-based global biopharmaceutical companies to assess their strategies for improving access and the quality of evidence on the impact of their initiatives. The number of operating initiatives increased from 17 in 2000 to 102 in 2015. Of the 120 different AtM initiatives identified, 48 percent used a medicine donation strategy, and 44 percent used a price reduction strategy. While companies have frequently claimed that their initiatives have had positive impacts, we found published evaluations for only seven initiatives, and nearly all of the evaluations were of low (62 percent) or very low (32 percent) quality. It is clear that the biopharmaceutical industry has increased its commitment to improving access to medicines in low- and middle-income countries. However, companies should do more to generate high-quality evidence on their initiatives, and the global health community should do more to assist the developing of evidence about the initiatives.

Infectious Diseases of Poverty
http://www.idpjournal.com/content
[Accessed 8 April 2017]

Scoping Review
The cross-cutting contribution of the end of neglected tropical diseases to the sustainable development goals
Mathieu Bangert, David H. Molyneux, Steve W. Lindsay, Christopher Fitzpatrick and Dirk Engels
Infectious Diseases of Poverty 2017 6:73
Published on: 4 April 2017
Abstract
The Sustainable Development Goals (SDGs) call for an integrated response, the kind that has defined Neglected Tropical Diseases (NTDs) efforts in the past decade.

NTD interventions have the greatest relevance for SDG3, the health goal, where the focus on equity, and its commitment to reaching people in need of health services, wherever they may live and whatever their circumstances, is fundamentally aligned with the target of Universal Health Coverage. NTD interventions, however, also affect and are affected by many of the other development areas covered under the 2030 Agenda. Strategies such as mass drug administration or the programmatic integration of NTD and WASH activities (SDG6) are driven by effective global partnerships (SDG17). Intervention against the NTDs can also have an impact on poverty (SDG1) and hunger (SDG2), can improve education (SDG4), work and economic growth (SDG8), thereby reducing inequalities (SDG10). The community-led distribution of donated medicines to more than 1 billion people reinforces women’s empowerment (SDG5), logistics infrastructure (SDG9) and non-discrimination against disability (SDG16). Interventions to curb mosquito-borne NTDs contribute to the goals of urban sustainability (SDG11) and resilience to climate change (SDG13), while the safe use of insecticides supports the goal of sustainable ecosystems (SDG15). Although indirectly, interventions to control water- and animal-related NTDs can facilitate the goals of small-scale fishing (SDG14) and sustainable hydroelectricity and biofuels (SDG7).

NTDs proliferate in less developed areas in countries across the income spectrum, areas where large numbers of people have little or no access to adequate health care, clean water, sanitation, housing, education, transport and information. This scoping review assesses how in this context, ending the epidemic of the NTDs can impact and improve our prospects of attaining the SDGs.

JAMA
April 4, 2017, Vol 317, No. 13, Pages 1291-1388
http://jama.jamanetwork.com/issue.aspx

The JAMA Forum
April 4, 2017
Vaccines and the Trump Administration
Joshua M. Sharfstein, MD1
JAMA. 2017;317(13):1305-1306. doi:10.1001/jama.2017.2311
Initial Text
Writing recently in the New York Times, infectious disease physician Peter Hotez warned: “It’s looking as if 2017 could become the year when the anti-vaccination movement gains ascendancy in the United States and we begin to see a reversal of several decades in steady public health gains. The first blow will be measles outbreaks in America.”

These fears have everything to do with the new administration in Washington, DC. During the campaign, Donald Trump met with discredited British physician Andrew Wakefield, who first alleged a connection between the measles, mumps, and rubella (MMR) vaccine and autism in a now-retracted Lancet article. Then, in a September 2015 primary debate, Trump himself suggested that vaccines cause autism. In January, Robert F. Kennedy Jr, known for his engagement with vaccine conspiracies, emerged from a meeting with the President-elect to claim that he will lead a new vaccine safety commission…

JAMA Pediatrics
April 1, 2017, Vol 171, No. 4, Pages 313-404
http://archpedi.jamanetwork.com/issue.aspx

Viewpoint
Implementing Public Health Goals for Human Immunodeficiency Virus Infection Through Law
Rhonda Gay Hartman, JD JAMA Pediatr. 2017;171(4):315-316. doi:10.1001/jamapediatrics.2016.4366
This Viewpoint discusses laws that favor confidential access to HIV testing and treatment for adolescents, as a way of achieving public health goals for HIV infection.

Viewpoint
Social Justice and the Provision of Health Care for Poor Children
Andrew D. Racine, MD, PhD
JAMA Pediatr. 2017;171(4):316-317. doi:10.1001/jamapediatrics.2016.4567
This Viewpoint asks whether the provision of health care to underserved children is an act of social justice.

Journal of Infectious Diseases
Volume 215, Issue 5  1 March 2017
http://jid.oxfordjournals.org/content/current

OBITUARY
Donald Ainslie (D. A.) Henderson, MD, MPH (1928–2016) Smallpox Eradication: Leadership and Legacy

Viruses
Development of a Global Respiratory Severity Score for Respiratory Syncytial Virus Infection in Infants
Mary T. Caserta; Xing Qiu; Brenda Tesini; Lu Wang; Amy Murphy

Effectiveness of Human Papillomavirus Vaccination on Prevalence of Vaccine Genotypes in Young Sexually Active Women in France
Isabelle Heard; Laura Tondeur; Laurence Arowas; Marie Demazoin; Michaël Falguières …

Journal of the Royal Society – Interface
01 April 2017; volume 14, issue 129
http://rsif.royalsocietypublishing.org/content/current
Life Sciences–Mathematics interface
Research article:

Exploring the high-resolution mapping of gender-disaggregated development indicators
C. Bosco, V. Alegana, T. Bird, C. Pezzulo, L. Bengtsson, A. Sorichetta, J. Steele, G. Hornby, C. Ruktanonchai, N. Ruktanonchai, E. Wetter, A. J. Tatem
J.R. Soc. Interface 2017 14 20160825; DOI: 10.1098/rsif.2016.0825. Published 5 April 2017
Open Access
Abstract
Improved understanding of geographical variation and inequity in health status, wealth and access to resources within countries is increasingly being recognized as central to meeting development goals. Development and health indicators assessed at national or subnational scale can often conceal important inequities, with the rural poor often least well represented. The ability to target limited resources is fundamental, especially in an international context where funding for health and development comes under pressure. This has recently prompted the exploration of the potential of spatial interpolation methods based on geolocated clusters from national household survey data for the high-resolution mapping of features such as population age structures, vaccination coverage and access to sanitation. It remains unclear, however, how predictable these different factors are across different settings, variables and between demographic groups. Here we test the accuracy of spatial interpolation methods in producing gender-disaggregated high-resolution maps of the rates of literacy, stunting and the use of modern contraceptive methods from a combination of geolocated demographic and health surveys cluster data and geospatial covariates. Bayesian geostatistical and machine learning modelling methods were tested across four low-income countries and varying gridded environmental and socio-economic covariate datasets to build 1×1 km spatial resolution maps with uncertainty estimates. Results show the potential of the approach in producing high-resolution maps of key gender-disaggregated socio-economic indicators, with explained variance through cross-validation being as high as 74–75% for female literacy in Nigeria and Kenya, and in the 50–70% range for many other variables. However, substantial variations by both country and variable were seen, with many variables showing poor mapping accuracies in the range of 2–30% explained variance using both geostatistical and machine learning approaches. The analyses offer a robust basis for the construction of timely maps with levels of detail that support geographically stratified decision-making and the monitoring of progress towards development goals. However, the great variability in results between countries and variables highlights the challenges in applying these interpolation methods universally across multiple countries, and the importance of validation and quantifying uncertainty if this is undertaken.

The Lancet
Apr 08, 2017 Volume 389 Number 10077 p1369-1490 e5
http://www.thelancet.com/journals/lancet/issue/current

Comment
Eliminating maternal and neonatal tetanus and closing the immunity gap
Craig Burgess, Francois Gasse, Robert Steinglass, Ahmadu Yakubu, Azhar Abid Raza, Kari Johansen
Summary
Although progress has been made in achieving maternal and neonatal tetanus elimination (MNTE), WHO’s Strategic Advisory Group of Experts on Immunization (SAGE) noted at its October, 2016, meeting that the 2015 goal for MNTE had been missed. Maternal and neonatal tetanus is still to be eliminated in 18 countries (Afghanistan, Angola, Central African Republic, Chad, DR Congo, Ethiopia, Guinea, Haiti, Kenya, Mali, Nigeria, Pakistan, Papua New Guinea, Philippines, Somalia, Sudan, South Sudan, and Yemen).

The Lancet
Apr 08, 2017 Volume 389 Number 10077 p1369-1490 e5
http://www.thelancet.com/journals/lancet/issue/current

Series
America: Equity and Equality in Health
Mass incarceration, public health, and widening inequality in the USA
Christopher Wildeman, Emily A Wang
Summary
In this Series paper, we examine how mass incarceration shapes inequality in health. The USA is the world leader in incarceration, which disproportionately affects black populations. Nearly one in three black men will ever be imprisoned, and nearly half of black women currently have a family member or extended family member who is in prison. However, until recently the public health implications of mass incarceration were unclear. Most research in this area has focused on the health of current and former inmates, with findings suggesting that incarceration could produce some short-term improvements in physical health during imprisonment but has profoundly harmful effects on physical and mental health after release. The emerging literature on the family and community effects of mass incarceration points to negative health impacts on the female partners and children of incarcerated men, and raises concerns that excessive incarceration could harm entire communities and thus might partly underlie health disparities both in the USA and between the USA and other developed countries. Research into interventions, policies, and practices that could mitigate the harms of incarceration and the post-incarceration period is urgently needed, particularly studies using rigorous experimental or quasi-experimental designs.

The Lancet
Apr 08, 2017 Volume 389 Number 10077 p1369-1490 e5
http://www.thelancet.com/journals/lancet/issue/current

America: Equity and Equality in Health
Population health in an era of rising income inequality: USA, 1980–2015
Jacob Bor, Gregory H Cohen, Sandro Galea
Summary
Income inequality in the USA has increased over the past four decades. Socioeconomic gaps in survival have also increased. Life expectancy has risen among middle-income and high-income Americans whereas it has stagnated among poor Americans and even declined in some demographic groups. Although the increase in income inequality since 1980 has been driven largely by soaring top incomes, the widening of survival inequalities has occurred lower in the distribution—ie, between the poor and upper-middle class. Growing survival gaps across income percentiles since 2001 reflect falling real incomes among poor Americans as well as an increasingly strong association between low income and poor health. Changes in individual risk factors such as smoking, obesity, and substance abuse play a part but do not fully explain the steeper gradient. Distal factors correlated with rising inequality including unequal access to technological innovations, increased geographical segregation by income, reduced economic mobility, mass incarceration, and increased exposure to the costs of medical care might have reduced access to salutary determinants of health among low-income Americans. Having missed out on decades of income growth and longevity gains, low-income Americans are increasingly left behind. Without interventions to decouple income and health, or to reduce inequalities in income, we might see the emergence of a 21st century health-poverty trap and the further widening and hardening of socioeconomic inequalities in health.

PLoS Medicine
http://www.plosmedicine.org/
(Accessed 8 April 2017)

Research Article
Demographic transition and the dynamics of measles in six provinces in China: A modeling study
Sheng Li, Chao Ma, Lixin Hao, Qiru Su, Zhijie An, Fubao Ma, Shuyun Xie, Aiqiang Xu, Yanyang Zhang, Zhengrong Ding, Hui Li, Lisa Cairns, Huaqing Wang, Huiming Luo, Ning Wang, Li Li, Matthew J. Ferrari
| published 04 Apr 2017 PLOS Medicine
http://dx.doi.org/10.1371/journal.pmed.1002255

PLoS Neglected Tropical Diseases
http://www.plosntds.org/
(Accessed 8 April 2017)

Research Article
Development of a glycoconjugate vaccine to prevent invasive Salmonella Typhimurium infections in sub-Saharan Africa
Scott M. Baliban, Mingjun Yang, Girish Ramachandran, Brittany Curtis, Surekha Shridhar, Rachel S. Laufer, Jin Y. Wang, John Van Druff, Ellen E. Higginson, Nicolas Hegerle, Kristen M. Varney, James E. Galen, Sharon M. Tennant, Andrew Lees, Alexander D. MacKerell Jr., Myron M. Levine, Raphael Simon
| published 07 Apr 2017 PLOS Neglected Tropical Diseases
http://dx.doi.org/10.1371/journal.pntd.0005493

PLoS One
http://www.plosone.org/
[Accessed 8 April 2017]

Research Article
Universal vaccine against respiratory syncytial virus A and B subtypes
Jeong-Yoon Lee, Jun Chang
Research Article | published 06 Apr 2017 PLOS ONE
http://dx.doi.org/10.1371/journal.pone.0175384

Decrease of invasive pneumococcal disease (IPD) in adults after introduction of pneumococcal 13-valent conjugate vaccine in Spain
Jordi Càmara, José María Marimón, Emilia Cercenado, Nieves Larrosa, María Dolores Quesada, Dionísia Fontanals, Meritxell Cubero, Emilio Pérez-Trallero, Asunción Fenoll, Josefina Liñares, Carmen Ardanuy
Research Article | published 06 Apr 2017 PLOS ONE
http://dx.doi.org/10.1371/journal.pone.0175224

Cost-effectiveness of dengue vaccination in Yucatán, Mexico using a dynamic dengue transmission model
Eunha Shim
Research Article | published 05 Apr 2017 PLOS ONE
http://dx.doi.org/10.1371/journal.pone.0175020

Public Health Ethics
Volume 10, Issue 1   April 2017
http://phe.oxfordjournals.org/content/current

Original Articles
Research Ethics Governance in Times of Ebola
Doris Schopper; Raffaella Ravinetto; Lisa Schwartz; Eunice Kamaara; Sunita Sheel …
Abstract
The Médecins Sans Frontières (MSF) ethics review board (ERB) has been solicited in an unprecedented way to provide advice and review research protocols in an ‘emergency’ mode during the recent Ebola epidemic. Twenty-seven Ebola-related study protocols were reviewed between March 2014 and August 2015, ranging from epidemiological research, to behavioural research, infectivity studies and clinical trials with investigational products at (very) early development stages. This article examines the MSF ERB’s experience addressing issues related to both the process of review and substantive ethical issues in this context. These topics include lack of policies regarding blood sample collection and use, and engaging communities regarding their storage and future use; exclusion of pregnant women from clinical and vaccine trials; and the difficulty of implementing timely and high-quality qualitative/anthropological research to consider potential upfront harms. Having noticed different standards across ethics committees (ECs), we propose that when multiple ethics reviews of clinical and vaccine trials are carried out during a public health emergency they should be accompanied by transparent communication between the ECs involved. The MSF ERB experience should trigger a broader discussion on the ‘optimal’ ethics review in an emergency outbreak and what enduring structural changes are needed to improve the ethics review process.

Science         
07 April 2017  Vol 356, Issue 6333
http://www.sciencemag.org/current.dtl

Books et al. – Reproducibility
On rigor and replication
Leonard P. Freedman
Rigor Mortis: How Sloppy Science Creates Worthless Cures, Crushes Hopes, and Wastes Billions Richard Harris Basic Books, 2017. 288 pp.
Summary
In Rigor Mortis: How Sloppy Science Creates Worthless Cures, Crushes Hopes, and Wastes Billions, a sensationalistic title belies a carefully crafted book about data reproducibility and scientific rigor in biomedical research. Although the book breaks no new ground, at a time when the so-called “irreproducibility crisis” has stoked passionate debate among scientists, bewil­dered the public, and even launched new disciplines (e.g., metaresearch), an accessible overview of the problem is most welcome.

Science
07 April 2017 Vol 356, Issue 6333
http://www.sciencemag.org/current.dtl

Policy Forum
Global Fund lessons for Sustainable Development Goals
By Jeffrey D. Sachs, Guido Schmidt-Traub
Science07 Apr 2017 : 32-33 Restricted Access
Summary
The Global Fund to Fight AIDS, Tuberculosis (TB), and Malaria (GF) was launched in 2001 in the context of the AIDS pandemic and the Millennium Development Goals (MDGs). Thanks in large part to key design principles (DPs), the GF public-private partnership has played a major role in advancing public health science and in scaling up and strengthening evidence-based public health efforts in developing countries. As world leaders prepare to advance international development finance at the July 2017 Group of 20 (G20) Summit, we suggest the GF as a template for funding research, development, and scale-up of interventions in both health and non-health areas of the Sustainable Development Goals (SDGs), which replaced MDGs in 2016.

Science
07 April 2017 Vol 356, Issue 6333
http://www.sciencemag.org/current.dtl

The applied value of public investments in biomedical research
By Danielle Li, Pierre Azoulay, Bhaven N. Sampat
Science07 Apr 2017 : 78-81 Full Access
For biomedical patents, basic research is just as valuable as applied research.
Patents from papers both basic and applied
Public funding for research depends on the idea that the resulting knowledge translates into socially valuable outcomes, such as medicines. Such linkages are easier to assert than to prove. Li et al. studied 27 years of grant-level funding by the U.S. National Institutes of Health. About 10% of grants are directly cited by patents, suggesting some technological application, and 30% of grants are cited in research articles that are then cited in patents. Five percent of grants result in papers cited by patents for successfully approved drugs, compared with less than 1% that are cited directly by such patents. These patterns hold regardless of whether the research is more basic or applied.
Abstract
Scientists and policy-makers have long argued that public investments in science have practical applications. Using data on patents linked to U.S. National Institutes of Health (NIH) grants over a 27-year period, we provide a large-scale accounting of linkages between public research investments and subsequent patenting. We find that about 10% of NIH grants generate a patent directly but 30% generate articles that are subsequently cited by patents. Although policy-makers often focus on direct patenting by academic scientists, the bulk of the effect of NIH research on patenting appears to be indirect. We also find no systematic relationship between the “basic” versus “applied” research focus of a grant and its propensity to be cited by a patent.

Social Science & Medicine
Volume 177, Pages 1-288 (March 2017)
http://www.sciencedirect.com/science/journal/02779536/177

Barriers to accessing adequate maternal care in Central and Eastern European countries: A systematic literature review
Original Research Article
Pages 1-8
Elina Miteniece, Milena Pavlova, Bernd Rechel, Wim Groot
Abstract
Maternal health outcomes in Central and Eastern Europe (CEE) compare unfavorable with those in Western Europe, despite macro-indicators that suggest well-designed maternal care systems. However, macro-indicators at the system level only capture capacity, funding and utilization of care and not the actual allocation of financial and human resources, the quality of care and access to it. It is these latter which are problematic in the CEE region. In this study service-related indicators of access to maternal care in CEE are examined. These include availability, appropriateness, affordability, approachability and acceptability of maternal care.
This study uses a qualitative systematic literature review, analyzing information of peer-reviewed articles published since 2004. Other inclusion criteria included language, setting and publication purpose. The included articles were analyzed using a framework analysis technique and quality was assessed using standardized evaluation checklists.
Results indicate improvements in maternal care. However, availability of care is limited by outdated equipment and training curricula, and the lack of professionals and pharmaceuticals. Geographical distance to healthcare institutions, inappropriate communication of providers and waiting times are the main approachability barriers. Some mothers are unaware of the importance of care or are discouraged to utilize healthcare services because of cultural aspects. Finally, a major barrier in accessing maternal care in the CEE is the inability to pay for it.
Our findings indicate that major gaps in evidence exist and that more representative and better quality data should be collected. Governments in CEE countries need to establish a reliable system for measuring and monitoring a suitable set of indicators, as well as deal with the general social and economic problem of informality. Medical curricula in the CEE region need to be overhauled and there should be a focus on improving the allocation of medical staff and institutions as well as protecting vulnerable population groups to ensure universal access to care.

Social Science & Medicine
Volume 177, Pages 1-288 (March 2017)
http://www.sciencedirect.com/science/journal/02779536/177

Adapting public policy theory for public health research: A framework to understand the development of national policies on global health
Original Research Article
Pages 69-77
Catherine M. Jones, Carole Clavier, Louise Potvin
Abstract
National policies on global health appear as one way that actors from health, development and foreign affairs sectors in a country coordinate state action on global health. Next to a burgeoning literature in which international relations and global governance theories are employed to understand global health policy and global health diplomacy at the international level, little is known about policy processes for global health at the national scale. We propose a framework of the policy process to understand how such policies are developed, and we identify challenges for public health researchers integrating conceptual tools from political science. We developed the framework using a two-step process: 1) reviewing literature to establish criteria for selecting a theoretical framework fit for this purpose, and 2) adapting Real-Dato’s synthesis framework to integrate a cognitive approach to public policy within a constructivist perspective. Our framework identifies multiple contexts as part of the policy process, focuses on situations where actors work together to make national policy on global health, considers these interactive situations as spaces for observing external influences on policy change and proposes policy design as the output of the process. We suggest that this framework makes three contributions to the conceptualisation of national policy on global health as a research object. First, it emphasizes collective action over decisions of individual policy actors. Second, it conceptualises the policy process as organised interactive spaces for collaboration rather than as stages of a policy cycle. Third, national decision-making spaces are opportunities for transferring ideas and knowledge from different sectors and settings, and represent opportunities to identify international influences on a country’s global health policy. We discuss two sets of challenges for public health researchers using interdisciplinary approaches in policy research.

Social Science & Medicine
Volume 177, Pages 1-288 (March 2017)
http://www.sciencedirect.com/science/journal/02779536/177

Impact of health financing policies in Cambodia: A 20 year experience
Original Research Article
Pages 118-126
Tim Ensor, Chhim Chhun, Ton Kimsun, Barbara McPake, Ijeoma Edoka
Abstract
Improving financial access to services is an essential part of extending universal health coverage in low resource settings. In Cambodia, high out of pocket spending and low levels of utilisation have impeded the expansion of coverage and improvement in health outcomes. For twenty years a series of health financing policies have focused on mitigating costs to increase access particularly by vulnerable groups. Demand side financing policies including health equity funds, vouchers and community health insurance have been complemented by supply side measures to improve service delivery incentives through contracting.
Multiple rounds of the Cambodia Socio-Economic Survey are used to investigate the impact of financing policies on health service utilisation and out of pocket payments both over time using commune panel data from 1997 to 2011 and across groups using individual data from 2004 and 2009. Policy combinations including areas with multiple interventions were examined against controls using difference-in-difference and panel estimation.
Widespread roll-out of financing policies combined with user charge formalisation has led to a general reduction in health spending by the poor. Equity funds are associated with a reduction in out of pocket payments although the effect of donor schemes is larger than those financed by government. Vouchers, which are aimed only at reproductive health services, has a more modest impact that is enhanced when combined with other schemes. At the aggregate level changes are less pronounced although there is evidence that policies take a number of years to have substantial effect.
Health financing policies and the supportive systems that they require provide a foundation for more radical extension of coverage already envisaged by a proposed social insurance system. A policy challenge is how disparate mechanisms can be integrated to ensure that vulnerable groups remain protected.

Tropical Medicine & International Health
April 2017 Volume 22, Issue 4 Pages 371–512
http://onlinelibrary.wiley.com/doi/10.1111/tmi.2017.22.issue-4/issuetoc

Original Research Papers
Determining the effective coverage of maternal and child health services in Kenya, using demographic and health survey data sets: tracking progress towards universal health coverage (pages 442–453)
Peter K. Nguhiu, Edwine W. Barasa and Jane Chuma
Version of Record online: 7 FEB 2017 | DOI: 10.1111/tmi.12841

Vaccine
Volume 35, Issue 18, Pages 2279-2530 (25 April 2017)
http://www.sciencedirect.com/science/journal/0264410X/35/18

Conference report
Report of the WHO technical consultation on the effect of maternal influenza and influenza vaccination on the developing fetus: Montreal, Canada, September 30–October 1, 2015
Pages 2279-2287
Deshayne B. Fell, Zulfiqar A. Bhutta, Jennifer A. Hutcheon, Ruth A. Karron, Marian Knight, Michael S. Kramer, Arnold S. Monto, Geeta K. Swamy, Justin R. Ortiz, David A. Savitz
Abstract
In 2012, the World Health Organization (WHO) released a position paper on influenza vaccination recommending that pregnant women have the highest priority for seasonal vaccination in countries where the initiation or expansion of influenza immunization programs is under consideration. Although the primary goal of the WHO recommendation is to prevent influenza illness in pregnant women, the potential benefits of maternal immunization in protecting young infants are also recognized. The extent to which maternal influenza vaccination may prevent adverse birth outcomes such as preterm birth or small-for-gestational-age birth, however, is unclear as available studies are in disagreement.
To inform WHO about the empirical evidence relating to possible benefits of influenza vaccination on birth outcomes, a consultation of experts was held in Montreal, Canada, September 30–October 1, 2015. Presentations and discussions covered a broad range of issues, including influenza virus infection during pregnancy and its effect on the health of the mother and the fetus, possible biological mechanisms for adverse birth outcomes following maternal influenza illness, evidence on birth outcomes following influenza illness during pregnancy, evidence from both observational studies and randomized controlled trials on birth outcomes following influenza vaccination of pregnant women, and methodological issues. This report provides an overview of the presentations, discussions and conclusions.

Vaccine
Volume 35, Issue 18, Pages 2279-2530 (25 April 2017)
http://www.sciencedirect.com/science/journal/0264410X/35/18

Commentaries
Informing pneumococcal conjugate vaccine policy in middle-income countries: The case of Malaysia
Pages 2288-2290
Serena Tricarico, Hannah C. McNeil, Michael G. Head, David W. Cleary, Stuart C. Clarke, on behalf of MYCarriage

Consensus statement from 17 relevant Japanese academic societies on the promotion of the human papillomavirus vaccine
Pages 2291-2292
Satoshi Iwata, Kenji Okada, Kei Kawana, Expert Council on Promotion of Vaccination

Rabies: Still a silent killer targeting the poor
Pages 2293-2294
Henry Wilde, Siriporn Ghai, Thiravat Hemachudha

Short communications
Cognitive testing to evaluate revisions to the Vaccine Adverse Event Reporting System (VAERS) reporting form
Pages 2295-2297
Tiffany A. Suragh, Elaine R. Miller, Beth F. Hibbs, Scott K. Winiecki, Craig Zinderman, Tom T. Shimabukuro

Measuring maternal Tdap and influenza vaccination rates: Comparison of two population-based methods
Pages 2298-2302
Ruth Koepke, Stephanie L. Schauer, Jeffrey P. Davis

Vaccine
Volume 35, Issue 18, Pages 2279-2530 (25 April 2017)
http://www.sciencedirect.com/science/journal/0264410X/35/18

Reviews
Lower vaccine uptake amongst older individuals living alone: A systematic review and meta-analysis of social determinants of vaccine uptake
Review Article
Pages 2315-2328
Anu Jain, A.J. van Hoek, Delia Boccia, Sara L. Thomas
Abstract
Introduction
Vaccination is a key intervention to reduce infectious disease mortality and morbidity amongst older individuals. Identifying social factors for vaccine uptake enables targeted interventions to reduce health inequalities.
Objective
To systematically appraise and quantify social factors associated with vaccine uptake amongst individuals aged ≥60 years from Europe.
Methods
We searched Medline and Embase from inception to 24/02/2016. The association of vaccine uptake was examined for social factors relevant at an individual level, to provide insight into individuals’ environment and enable development of targeted interventions by healthcare providers to deliver equitable healthcare. Factors included: living alone, marital status, education, income, vaccination costs, area-level deprivation, social class, urban versus rural residence, immigration status and religion. Between-study heterogeneity for each factor was identified using I2-statistics and Q-statistics, and investigated by stratification and meta-regression analysis. Meta-analysis was conducted, when appropriate, using fixed- or random-effects models.
Results
From 11,754 titles, 35 eligible studies were identified (uptake of: seasonal influenza vaccine (SIV) only (n = 27) or including pneumococcal vaccine (PV) (n = 5); herpes zoster vaccine (n = 1); pandemic influenza vaccine (n = 1); PV only (n = 1)). Higher SIV uptake was reported for individuals not living alone (summary odds ratios (OR) = 1.39 (95% confidence interval (CI): 1.16–1.68). Lower SIV uptake was observed in immigrants and in more deprived areas: summary OR = 0.57 (95%CI: 0.47–0.68) and risk ratio = 0.93 (95%CI: 0.92–0.94) respectively. Higher SIV uptake was associated with higher income (OR = 1.26 (95%CI: 1.08–1.47)) and higher education (OR = 1.05 (95%CI: 1–1.11)) in adequately adjusted studies. Between-study heterogeneity did not appear to result from variation in categorisation of social factors, but for education was partly explained by varying vaccination costs (meta-regression analysis p = <0.0001); individuals with higher education had higher vaccine uptake in countries without free vaccination.
Conclusions
Quantification of associations between social factors and lower vaccine uptake, and notably living alone (an overlooked factor in vaccination programmes), should enable health professionals target specific social groups to tackle vaccine-related inequalities.

Vaccine
Volume 35, Issue 18, Pages 2279-2530 (25 April 2017)
http://www.sciencedirect.com/science/journal/0264410X/35/18

Off-label use of vaccines
Review Article
Pages 2329-2337
Pieter Neels, James Southern, Jon Abramson, Philippe Duclos, Joachim Hombach, Melanie Marti, Alanna Fitzgerald-Husek, Jacqueline Fournier-Caruana, Germaine Hanquet
Abstract
This article reviews the off-label recommendations and use of vaccines, and focuses on the differences between the labelled instructions on how to use the vaccine as approved by the regulatory authorities (or “label”1), and the recommendations for use issued by public health advisory bodies at national and international levels. Differences between public health recommendations and the product label regarding the vaccine use can lead to confusion at the level of vaccinators and vaccinees and possibly result in lower compliance with national vaccination schedules. In particular, in many countries, the label may contain regulatory restrictions and warnings against vaccination of specific population groups (e.g. pregnant women) due to a lack of evidence of safety from controlled trials at the time of initial licensure of the vaccine, while public health authorities may recommend the same vaccine for that group, based on additional post-marketing data and benefit risk analyses.
We provide an overview of the different responsibilities between regulatory authorities and public health advisory bodies, and the rationale for off-label use2 of vaccines, the challenges involved based on the impact of off-label use in real-life. We propose to reduce off-label use of vaccines by requiring the manufacturer to regularly adapt the label as much as possible to the public health needs as supported by new evidence. This would require manufacturers to collect and report post-marketing data, communicate them to all stakeholders and regulators to extrapolate existing evidence (when acceptable) to other groups or to other brands of a vaccine (class effect3). Regulatory authorities have a key role to play by requesting additional post-marketing data, e.g. in specific target groups. When public health recommendations for vaccine use that are outside labelled indications are considered necessary, good communication between regulatory bodies, public health authorities, companies and health care providers or vaccinators is crucial. Recommendations as well as labels and label changes should be evidence-based. The rationale for the discrepancy and the recommended off-label use of a vaccine should be communicated to providers.

Vaccine
Volume 35, Issue 18, Pages 2279-2530 (25 April 2017)
http://www.sciencedirect.com/science/journal/0264410X/35/18

Regular papers
Predictors of influenza vaccination in the U.S. among children 9–13 years of age
Original Research Article
Pages 2338-2342
Teresa M. Imburgia, Kristin S. Hendrix, Kelly L. Donahue, Lynne A. Sturm, Gregory D. Zimet
Abstract
Background and objectives
U.S. estimates of seasonal influenza (flu) vaccine uptake in 2014–2015 were 62% for 5–12 year olds, dropping to 47% for 13–17 year olds. The Healthy People 2020 goal for these age groups is 80%. It is important to understand factors associated with influenza vaccination, especially for those ages where rates begin to decline. The objective of this study was to identify factors associated with influenza vaccination acceptance in 9–13 year old children.
Methods
An online U.S. survey of mothers of children aged 9–13 assessed children’s influenza vaccine uptake in the previous season, healthcare utilization, sociodemographics, and vaccine attitudes. Multivariable logistic regression identified independent predictors of influenza vaccine status.
Results
There were 2363 respondents (Mean age = 38 years old). Referent children were 57% female and 66% non-minority race/ethnicity with a mean age of 10.6 years. By maternal report, 59% of children had received an influenza vaccine in the previous season. Predictors of influenza vaccine uptake included a recommendation or strong recommendation from a health care provider, seeing a health care provider in the past year, positive attitudes regarding the influenza vaccine, and being a minority race. Child gender, age, insurance coverage, and whether the child had a regular healthcare provider were not associated with influenza vaccine uptake (p = n.s.).
Conclusions
This sample reported overall rates of influenza vaccine uptake similar to national surveillance data, but still lower than national goals. Provider recommendations along with health attitudes and seeing a health care provider were associated with vaccine uptake. Promising interventions may include more directive physician messaging for influenza vaccine uptake in youth, encouraging more regular well-child visits during the adolescent years, and promoting influenza vaccination at alternative sites.

Vaccine
Volume 35, Issue 18, Pages 2279-2530 (25 April 2017)
http://www.sciencedirect.com/science/journal/0264410X/35/18

Moving the needle on nursing staff influenza vaccination in long-term care: Results of an evidence-based intervention
Original Research Article
Pages 2390-2395
Cori L. Ofstead, Miriam R. Amelang, Harry P. Wetzler, Litjen Tan
Abstract
Purpose
Influenza vaccination rates among healthcare providers (HCPs) in long-term care facilities (LTCFs) are commonly below the Healthy People 2020 goal of 90%. This study was conducted to develop and evaluate an intervention program designed to increase influenza uptake among HCPs in LTCFs.
Methods
This study was conducted in four Midwestern LTCFs. Baseline interviews, surveys, and administrative data analysis were performed following the 2013–2014 influenza season. Interventions implemented during the 2014–2015 season were based on the health belief and ecological models and included goal-setting worksheets, policy development, educational programs, kick-off events, incentives, a vaccination tracking roster, and facility-wide communication about vaccine uptake among HCPs. Outcomes were evaluated in 2015.
Results
At baseline, 50% of 726 nursing staff employed during the 2013–2014 influenza season had documented receipt of influenza vaccine (Site A: 34%; Site B: 5%; Site C: 75%; Site D: 62%), and 31% of 347 survey respondents reported absenteeism due to respiratory illness. At follow-up, 85% of HCPs had documented receipt of influenza vaccine (p < 0.01) and 19% of 323 survey respondents reported absenteeism due to respiratory illness (p < 0.01). Vaccination rates among respondents’ family members increased from 31% at baseline to 44% post-intervention (p < 0.01). Reasons for declining vaccination did not change following exposure to educational programs, but HCPs were more likely to recommend vaccination to others after program implementation.
Conclusions
Vaccination rates among long-term care HCPs and their family members increased significantly and HCP absenteeism decreased after the implementation of multifaceted interventions based on an ecological model. The findings suggest that major increases in HCP vaccination can be achieved in LTCFs. More research is needed to evaluate the impact of increased HCP vaccination on the health and productivity of LTCF employees, their family members, and residents.

Vaccine
Volume 35, Issue 18, Pages 2279-2530 (25 April 2017)
http://www.sciencedirect.com/science/journal/0264410X/35/18

Country-level predictors of vaccination coverage and inequalities in Gavi-supported countries
Original Research Article
Pages 2479-2488
Catherine Arsenault, Mira Johri, Arijit Nandi, José M. Mendoza Rodríguez, Peter M. Hansen, Sam Harper
Abstract
Background
Important inequalities in childhood vaccination coverage persist between countries and population groups. Understanding why some countries achieve higher and more equitable levels of coverage is crucial to redress these inequalities. In this study, we explored the country-level determinants of (1) coverage of the third dose of diphtheria-tetanus-pertussis- (DTP3) containing vaccine and (2) within-country inequalities in DTP3 coverage in 45 countries supported by Gavi, the Vaccine Alliance.
Methods
We used data from the most recent Demographic and Health Surveys (DHS) conducted between 2005 and 2014. We measured national DTP3 coverage and the slope index of inequality in DTP3 coverage with respect to household wealth, maternal education, and multidimensional poverty. We collated data on country health systems, health financing, governance and geographic and sociocultural contexts from published sources. We used meta-regressions to assess the relationship between these country-level factors and variations in DTP3 coverage and inequalities. To validate our findings, we repeated these analyses for coverage with measles-containing vaccine (MCV).
Results
We found considerable heterogeneity in DTP3 coverage and in the magnitude of inequalities across countries. Results for MCV were consistent with those from DTP3. Political stability, gender equality and smaller land surface were important predictors of higher and more equitable levels of DTP3 coverage. Inequalities in DTP3 coverage were also lower in countries receiving more external resources for health, with lower rates of out-of-pocket spending and with higher national coverage. Greater government spending on heath and lower linguistic fractionalization were also consistent with better vaccination outcomes.
Conclusion
Improving vaccination coverage and reducing inequalities requires that policies and programs address critical social determinants of health including geographic and social exclusion, gender inequality and the availability of financial protection for health. Further research should investigate the mechanisms contributing to these associations.

Vaccine
Volume 35, Issue 18, Pages 2279-2530 (25 April 2017)
http://www.sciencedirect.com/science/journal/0264410X/35/18

Knowledge, attitudes, beliefs, and behaviors of university students, faculty, and staff during a meningococcal serogroup B outbreak vaccination program
Original Research Article
Pages 2520-2530
D.M. MacDougall, J.M. Langley, L. Li, L. Ye, D. MacKinnon-Cameron, K.A. Top, S.A. McNeil, B.A. Halperin, A. Swain, J.A. Bettinger, E. Dubé, G. De Serres, S.A. Halperin, for the Canadian Immunization Research Network
Abstract
Objectives
During an outbreak of invasive meningococcal B disease on a university campus, we explored the knowledge, attitudes, beliefs, and behaviors of members of the university community in relation to the disease, the vaccine, and the vaccination program.
Design
All students, faculty and staff were invited by email to participate in a 71-item online survey, which was administered after completion of the mass clinics for the first and second doses of a meningococcal B vaccination program.
Results
A total of 404 individuals responded to the survey; 75.7% were students. Knowledge about meningococcal disease and vaccine was generally high; more than 70% correct responses were received on each knowledge question except for one question about the different meningococcal serogroups. Gender (female) and higher knowledge scores were significantly associated with either being immunized or intending to be immunized (p < 0.05). Positive attitudes about immunization, concern about meningococccal infection, a sense of community responsibility, and trust in public health advice also correlated with being vaccinated or intending to be vaccinated (p < 0.05).

Media/Policy Watch
This watch section is intended to alert readers to substantive news, analysis and opinion from the general media and selected think tanks and similar organizations 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.

BBC
http://www.bbc.co.uk/
Accessed 8 April 2017
Vaccine credited with HPV virus reduction in Scotland
Published Date 5 Apr 2017

Nigeria meningitis: Vaccine cost cripples response to outbreak
3 April 2017
Nigeria does not have enough vaccine doses to deal with a deadly meningitis outbreak because they are too expensive, a senior official has said.
Each vaccine dose costs $50, and only 500,000 doses are currently available, Dr Chikuwe Ihekuwazu, head of Nigeria’s Centre for Disease Control said.
The outbreak which is said to be spreading rapidly has already killed more than 300 people.
It is the worst to hit Nigeria since 2009 when it killed 156 people…

Forbes
http://www.forbes.com/
Accessed 8 April 2017
UNICEF USA How To Close The Immunization Gap? Summon The Spirit Of Jim Grant
Adam Fifield, UNICEF USA
6 April 2017
How can we close the immunization gap? Two decades after the death of UNICEF’s visionary leader, the solution may be: “What would Jim Grant do?”

Doctors Should Be Talking To Teens And Parents About MenB Vaccination
Tara Haelle, Contributor
6 April 2017
A group of mothers whose teens died from meningococcal disease want other parents to know how to prevent it.

The Guardian
http://www.guardiannews.com/
Accessed 8 April 2017
Unvaccinated children would be barred from childcare in NSW under new proposals
Labor opposition leader Luke Foley says legislation intends to stop specialist anti-vaccination childcare centres being set up
Australian Associated Press
Saturday 1 April 2017 22.19 EDT Last modified on Sunday 2 April 2017 00.27 EDT
Parents who oppose vaccinations on conscientious grounds won’t allowed to enrol their children at New South Wales childcare centres under legislation to be introduced by the state opposition.
The state’s Labor leader, Luke Foley, announced the policy on Sunday and said the legislation, set to be introduced this week, would plug the loophole which had allowed specialist anti-vaccination childcare centres to be set up.
The changes won’t affect children who can’t be vaccinated for medical reasons, such as a specialised cancer treatment.
“We need to be encouraging vaccinations not discouraging them,” Foley said in a statement. “Vaccinations are the only way to protect against serious diseases like polio, mumps, whooping cough, meningococcal, diphtheria and tetanus.”…

New York Times
http://www.nytimes.com/
Accessed 8 April 2017
Meningitis Epidemic Kills 336 Children in Nigeria
A statement Tuesday says most victims are between 5 and 14. Some 500,000 doses of vaccine have arrived in Zamfara, where the disease surfaced. But officials say 2 million doses are needed and
April 04, 2017

DOJ: For Decade, Sanofi Vaccine Unit Overcharged VA on Meds
The vaccines unit of French pharmaceutical company Sanofi SA will pay a $19.9 million fine for overcharging the U.S. Department of Veterans Affairs for two products between 2002 and 2011.
By law, drug manufacturers cannot charge the VA more than a maximum level called the Federal Ceiling Price for drugs.
The Justice Department said Monday that Sanofi Pasteur notified the VA that it had incorrectly calculated the price for some medicines from 2007 to 2011, and thereby overcharged the VA.
An investigation by the VA’s Office of Inspector General then determined the overcharges dated back to 2002.
Sanofi Pasteur, based in Swiftwater, Pennsylvania, also agreed not to seek reimbursement for sales where it undercharged the VA.
The government did not identify the products involved.
April 03, 2017 – By THE ASSOCIATED PRESS

Washington Post
http://www.washingtonpost.com/
Accessed 8 April 2017
Africa
Massive measles vaccination campaign launches in Guinea
By Associated Press April 7
DAKAR, Senegal — Doctors Without Borders says it is launching a massive measles vaccination campaign with Guinea’s government after at least 14 deaths and more than 3,400 cases were confirmed so far this year.
The aid group said Friday that thousands of people were left unprotected in 2014 and 2015 when the Ebola outbreak swept through the West African nation. Vaccination activities were reduced because of infection risks, and frightened families stayed away from health facilities.
A measles epidemic was declared in February despite a vaccination campaign a year ago…