Vaccines and Global Health: The Week in Review 16 December 2017

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

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 pdf version A pdf of the current issue is available here: Vaccines and Global Health_The Week in Review_16 Dec 2017

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

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

Editor’s Note: We will resume publication on 6 January 2018 following the end-of-year holiday period.

Tokyo Declaration on Universal Health Coverage: All Together to Accelerate Progress towards UHC

Milestones :: Perspectives
Editor’s Note:
Universal Health Coverage [UHC] has become the nexus for much global health strategy and  governance focus in the larger context of Sustainable Development Goals/Agenda 2030 context. We present the full text of a joint statement underscoring UHC’s integrating role and a supporting press release below.

Tokyo Declaration on Universal Health Coverage: All Together to Accelerate Progress towards UHC
Statement December 14, 2017 – World Bank, WHO, UNICEF, JICA, UHC2030
Universal Health Coverage Forum 2017
[full text; editor’s text bolding]
We, the Co-Organizers of the Universal Health Coverage (UHC) Forum, reaffirm our commitment to accelerating progress towards UHC, and to achieving health for all people, whoever they are, wherever they live, by 2030.

We recognise the integrated and indivisible nature of the Sustainable Development Goals (SDGs), which balance the economic, social and environmental dimensions of sustainable development.

We reiterate the importance of target 3.8 of the SDGs, which seeks to provide all people with access to high-quality, integrated, “people-centred” health services. This must include promotive, preventive, curative, rehabilitative and palliative health services, as well as safe, effective, quality and affordable essential medicines and vaccines. We want to ensure that people do not suffer financial hardship when accessing services. We emphasize the importance of protecting all people from health risks such as outbreaks, and responding rapidly to outbreaks and crises.

We acknowledge that health is a human right and that UHC is essential to health for all and to human security. We adhere to the principle of Leaving No One Behind, which requires special effort to design and deliver health services informed by the voices and needs of people. This prioritizes the most vulnerable members of the world’s population — children and women — those affected by emergencies, refugees and migrants, and marginalized, stigmatized and minority populations, so often living in extremely difficult circumstances.

We affirm that UHC is both technically and financially feasible. UHC produces high returns across the life course and drives employment and inclusive economic growth. UHC is one of the cornerstones of the Sustainable Development Agenda and contributes to progress towards all SDGs. Without UHC, billions of people are at risk of losing the opportunity to live full and productive lives, and hundreds of millions risk impoverishment in their pursuit of health care. Millions of people live in countries and states considered to be fragile. Attaining UHC in these settings requires strong intersectoral collaboration.

We reaffirm and build on the G7 Ise-Shima Vision for Global Health, the TICAD VI Nairobi Declaration, which acknowledges the “UHC in Africa: A Framework for Action.” We also build on the G20 Berlin Declaration, which acknowledges the UHC2030 “Healthy systems for universal health coverage – a joint vision for healthy lives,” as well as other regional and international declarations. All of these stress the need to build and strengthen resilient and sustainable health systems and prepare for public health emergencies in an integrated way. In this context, we note the progress that has been made to reinforce preparedness and responses to public health emergencies, including formalization of coordination mechanisms among the World Health Organization (WHO) and other relevant United Nations (UN) partners, and funding mechanisms for emergencies like the WHO’s Contingency Fund for Emergencies (CFE) and the World Bank’s Pandemic Emergency Financing Facility (PEF).

We welcome the release of the 2017 UHC Global Monitoring Report. According to this report, much remains to be done to achieve UHC:  
   :: At least half of the world’s population still does not have access to quality essential services to protect and promote health. 
   :: 800 million people are spending at least 10 percent of their household budget on out-of-pocket health care expenses, and nearly 100 million people are being pushed into extreme poverty each year due to health care costs.

Concerned that progress towards UHC is too slow, despite the efforts made in each country, we call for greater commitment to accelerate progress towards UHC.

Strengthening global momentum towards UHC
:: By 2023, the midpoint towards 2030, the world needs to extend essential health coverage to 1 billion additional people and halve to 50 million the number of people being pushed into extreme poverty by health expenses.

:: We commit to monitoring progress towards UHC as part of the UN SDG review process by issuing global monitoring reports regularly, and reviewing key findings at the subsequent UHC Forum. We welcome the use of a uniform measurement methodology for UHC indicators in the 2017 Global Monitoring Report. We also emphasize the importance of strengthening the breadth and depth of data at the national and subnational levels, including disaggregated data, to inform evidence-based policymaking and to assess progress, as well as strengthening the capacity of local stakeholders to analyse and use data.

:: In response to the recommendations of the UN Secretary-General’s High-Level Commission on Health Employment and Economic Growth, and as articulated in the Dublin Declaration on Human Resources for Health, we call upon all relevant stakeholders to expand and transform investments in the health and social workforce for UHC, emphasizing the empowerment of women and youth employment.

:: To maintain a high level of political momentum on UHC, we welcome the 40th anniversary conference in 2018 of the Alma Ata Declaration, from the International Conference on Primary Health Care. We also welcome the decision to designate December 12 of each year as International UHC Day and support the UN high-level meeting on UHC in 2019. Furthermore, we will support stronger global leadership at high level of the UN system to promote UHC.

Accelerating country-led process towards UHC
:: We commit to jointly mobilizing political leadership around the world so that countries develop their own roadmaps towards UHC, with clearly indicated targets, indicators and specific plans. We support the increased alignment of efforts among all development partners through country-led, multi-stakeholder coordination platforms in line with the UHC2030 Global Compact principles. We also promote country-level engagement with diverse stakeholders from non-governmental and private sector partners to enhance shared ownership and accountability. We welcome the contribution of international initiatives such as the Tokyo Joint UHC Initiative, the UHC Partnership, Providing for Health Partnership, and the Global Financing Facility (GFF), which aim to strengthen country systems and platforms for UHC and preparedness in a collaborative manner.

   :: In pursuing UHC, we commit to targeted investments to prevent, detect and respond to disease outbreaks and other emergencies including surveillance systems in order to safeguard health security and international collaboration under the International Health Regulations (2005). In doing so, we will promote a focus on fragile and conflict-affected settings to ensure UHC financing in such settings. We also commit to investing in building a sound foundation for healthy societies with equitable access to social services such as water, sanitation, nutrition, housing, and education, and mainstreaming gender throughout policies and programmes.

: On financing for UHC, we support a strong dialogue between the Ministries of Health and Finance to mobilize and manage domestic resources to increase public funding and reduce out-of-pocket payments. It is also critical for countries to mobilise citizen and community platforms, strengthening their budgetary processes, tracking expenditures to achieve value and equity of health spending, and enhancing the efficiency of health expenditures.

: Effective and innovative financing tools offered by development partners, such as the GFF and World Bank’s IDA, also complement domestic resources. In this regard, we welcome IDA18’s strong policy commitment to the global health agenda, which was supported by Japan and other donors, and look forward to further mobilization of IDA funds to promote UHC. We also call for expanded financing and increased alignment to support UHC by all development partners, particularly multilateral development banks and Global Health Initiatives such as the Global Fund to Fight AIDS, Tuberculosis and Malaria (The Global Fund) and Gavi, the Vaccine Alliance, and foundations such as Bill and Melinda Gates Foundation. In order to further promote financing for UHC, we will explore holding a high-level dialogue with Health and Finance Ministries by 2019.

Innovation for UHC
:: We recognise that realising our ambition requires going beyond “business as usual,” and commit to developing and supporting strategies, policies and systems at the global and country level to harness and sustain the transformative potential of innovation. This commitment recognises the need for countries to articulate their local priorities for UHC and share best practices.

:: We also commit to improving access to medicines and vaccines through collaborative work and research and development, including during health emergencies building on platforms such as the Global Health Innovative Technology Fund (GHIT), the Coalition for Epidemic Preparedness and Innovations (CEPI) and the International AIDS Vaccine Initiative (IAVI). 

:: Accelerating progress towards UHC requires systematic learning from country experience through platforms such as UHC2030, increased focus on policy coherence, addressing implementation bottlenecks, and harnessing the potential of system innovations and effective and affordable technology in the health sector. We commit to stimulate learning on innovation for UHC by accelerating the generation and sharing of critical knowledge by building on and enhancing coordination of existing and future networks.

We look forward to future convenings and sharing the progress made towards UHC with the Global Community, in the context of the World Health Assembly, the High-Level Political Forum on Sustainable Development and the UN General Assembly, upcoming high-level UHC meetings such as the 2018 40th Anniversary of Alma Ata, and at the next UHC Forum. We extend our deep appreciation to the Government of Japan for its commitment to supporting the continuation of the UHC Fora in the future.

World Bank and WHO: Half the world lacks access to essential health services, 100 million still pushed into extreme poverty because of health expenses

Press release

World Bank and WHO: Half the world lacks access to essential health services, 100 million still pushed into extreme poverty because of health expenses
TOKYO, December 13, 2017 — At least half of the world’s population cannot obtain essential health services, according to a new report from the World Bank and the World Health Organization. And each year, large numbers of households are being pushed into poverty because they must pay for health care out of their own pockets…

The findings, released today in Tracking Universal Health Coverage: 2017 Global Monitoring Report, have been simultaneously published in Lancet Global Health….

“It is completely unacceptable that half the world still lacks coverage for the most essential health services,” said Dr. Tedros Adhanom Ghebreyesus, Director-General of the World Health Organization. “And it is unnecessary. A solution exists: universal health coverage (UHC) allows everyone to obtain the health services they need, when and where they need them, without facing financial hardship.”

“The report makes clear that if we are serious – not just about better health outcomes, but also about ending poverty – we must urgently scale up our efforts on universal health coverage,” said World Bank Group President Dr. Jim Yong Kim. “Investments in health, and more generally investments in people, are critical to build human capital and enable sustainable and inclusive economic growth. But the system is broken: we need a fundamental shift in the way we mobilize resources for health and human capital, especially at the country level. We are working on many fronts to help countries spend more and more effectively in people, and increase their progress towards universal health coverage.”…

The report is a key point of discussion at the global Universal Health Coverage Forum 2017, currently taking place in Tokyo, Japan. Convened by the Government of Japan, a leading supporter of UHC domestically and globally, the Forum is cosponsored by the Japan International Cooperation Agency (JICA), UHC2030, the leading global movement advocating for UHC, UNICEF, the World Bank, and WHO. Japanese Prime Minister Shinzo Abe, UN Secretary-General Antonio Guterres, World Bank President Kim, WHO Director-General Tedros and UNICEF Executive Director Anthony Lake will all be in attendance, in addition to heads of state and ministers from over 30 countries. ..

The Forum is the culmination of events in over 100 countries, which began on Dec. 12—Universal Health Coverage Day—to highlight the growing global momentum on UHC. It seeks to showcase the strong high-level political commitment to UHC at global and country levels, highlight the experiences of countries that have been pathfinders on UHC progress, and add to the knowledge base on how to strengthen health systems and effectively promote UHC…

“Without health care, how can children reach their full potential? And without a healthy, productive population, how can societies realize their aspirations?” said UNICEF Executive Director Anthony Lake. “Universal health coverage can help level the playing field for children today, in turn helping them break intergenerational cycles of poverty and poor health tomorrow.”

UNICEF: New funding will allow countries to secure sustainable vaccine supplies and reach children more quickly

UNICEF: New funding will allow countries to secure sustainable vaccine supplies and reach children more quickly

Initiative to support countries’ vaccine supply through bridge financing receives financial boost from the Bill and Melinda Gates Foundation

COPENHAGEN, 13 December 2017 – UNICEF announced today that funding for its Vaccine Independence Initiative (VII), a mechanism to help countries secure a sustainable supply of life-saving vaccines, has more than doubled in the past year, increasing from $15 million to $35 million.

The increase was made possible especially by a $15 million financial guarantee from the Bill & Melinda Gates Foundation, adding to a VII capital base that also includes recent contributions from Gavi, the Vaccine Alliance, and the United States Fund for UNICEF.

Over 60 low-income countries currently benefit from Gavi support to purchase life-saving vaccines. As countries’ economies grow and transition away from Gavi support, the VII gives them access to short-term bridge “loans” so that they can purchase vaccines while waiting for the release of national budget funds. In addition, it provides countries assistance to strengthen the planning and budgeting processes to manage their essential supplies procurement moving forward.

VII is one tool to help countries minimize vaccine stock-outs and ensure more children receive vaccines on time. Since 2016, it has helped provide an estimated 91 million doses to children in 23 countries faster than would have otherwise been possible.

“Financing mechanisms such as the VII are an essential part of a vaccine supply financing toolkit to improve financial sustainability and ensure supplies are reaching children when they are most needed,” Shanelle Hall, UNICEF Deputy Executive Director for Field Results, explained. “We look forward to continuing our work supporting countries, together with the Foundation and other donors and partners. It is especially critical now, in light of many countries graduating from donor support, inequities in Middle Income Countries and the broader Sustainable Development Goals agenda.”…

Recent contributions to the VII have been key to support countries who are expanding their national budgets to purchase vaccines, such as Kenya and Chad. Additionally, the recently increased size of VII has allowed the new countries such as Uzbekistan, Cote d’Ivoire, and most recently Tajikistan to sign-up to the mechanism. More countries are in active discussions for new subscriptions. These efforts contribute to providing sustained immunization supplies to an increasing number of newborns in these countries.

New Michelson Prizes for Human Immunology and Vaccine Research launch

New Michelson Prizes for Human Immunology and Vaccine Research launch

The Michelson Medical Research Foundation and the Human Vaccines Project announce young investigator prizes to advance the development of future vaccines and therapies to defeat major global diseases
December 13, 2017, LOS ANGELES and NEW YORK – The Michelson Medical Research Foundation (MMRF) together with the Human Vaccines Project announced today the establishment of the Michelson Prizes for Human Immunology and Vaccine Research. The $20 million initiative, funded by the MMRF and administered by the Human Vaccines Project, aims to support young investigators applying innovative research concepts and disruptive technologies to significantly advance the development of future vaccines and therapies to defeat major global diseases.

A rigorous and competitive global search will be undertaken to identify the most innovative projects by young scientists across a broad spectrum of scientific fields. Two investigators under the age of 35 will each be awarded a $150,000 prize. To be considered, applicants need to show how they are going beyond conventional approaches in their field and clearly articulate how their contribution will make a lasting impact on human immunology and vaccine research.

“The Prizes give young scientists the freedom to think outside-of-the-box and explore disruptive technologies,” said Gary Michelson, MD, Founder of the Michelson Medical Research Foundation. “Our collaboration with the Human Vaccines Project in establishing the Michelson Prizes will help unravel the complexity of the human immune system to accelerate development of vaccines and therapies for some of the world’s most threatening diseases.”

While the Michelson Prizes are focused on research outcomes in the fields of human immunology and vaccinology, early career scientists across a wide array of disciplines, including clinical research, biomedicine, bioengineering, artificial intelligence/machine learning, and nanotechnology, are encouraged to apply. Proposals will be reviewed and winners selected by a distinguished committee of internationally recognized, independent scientists….

Dengue Vaccine – Dengvaxia Update

Dengue Vaccine – Dengvaxia Update
Editor’s Note:
We will continue to monitor and present major announcements and milestones around Dengvaxia as below. We have not identified any press releases from Sanofi Pasteur since its 30 November 2017 announcement:
Sanofi updates information on dengue vaccine
WHO advises Dengvaxia be used only in people previously infected with dengue
13 December 2017 – Following a consultation of the Global Advisory Committee on Vaccine Safety, the World Health Organization (WHO) finds that the dengue vaccine CYD-TDV, sold under the brand name Dengvaxia, prevents disease in the majority of vaccine recipients but it should not be administered to people who have not previously been infected with dengue virus.

This recommendation is based on new evidence communicated by the vaccine’s manufacturer (Sanofi Pasteur), indicating an increase in incidence of hospitalization and severe illness in vaccinated children never infected with dengue.

The WHO Global Advisory Committee on Vaccine Safety considered the company’s new results from clinical trial data analyses. Those studies indicate that increased risk of severe dengue disease in people who have never been infected affects about 15% of the vaccinated individuals. The magnitude of risk is in the order of about 4 out of every 1000 seronegative patients vaccinated who developed severe dengue disease during five years of observation. The risk of developing severe dengue disease in non-vaccinated individuals has been calculated as 1.7 per 1000 over the same period of observation. By contrast, for the 85% who have had dengue disease before immunization, there is a reduction of 4 cases of severe dengue per 1000 who are vaccinated.

The possibility of risk for seronegative people was raised by WHO and published in a position paper in July 2016: “…vaccination may be ineffective or may theoretically even increase the future risk of hospitalized or severe dengue illness in those who are seronegative at the time of first vaccination regardless of age.”[i] As this risk had at that time not been seen in the age groups for which the vaccine was licensed, WHO issued a conditional recommendation, emphasizing the use of the vaccine in populations having been previously infected with dengue virus.

To minimize illness for seronegative vaccinated people, WHO recommends enhancing measures that reduce exposure to dengue infection among populations where the vaccine has already been administered. For vaccine recipients who present with clinical symptoms compatible with dengue virus infection, access to medical care should be expedited to allow for proper evaluation, identification, and management of severe forms of the disease…
Former Philippine President Defends Controversial Dengue Programme
December 14, 2017 – By REUTERS (Reporting by Karen Lema; Editing by Robert Birsel)
MANILA — Former Philippine President Benigno Aquino defended on Thursday his decision to implement a controversial immunisation programme using a new dengue vaccine in 2016, saying it was justified with millions of people at risk of being infected by the virus.
The decision was made to help prevent a disease affecting up to 2.8 million people, Aquino told senators investigating the campaign after the company Sanofi said its Dengvaxia vaccine was to be strictly limited due to evidence it could worsen the disease in people who had not previously been exposed to the virus.
“I want to stress, before, during, and after my government decided to use Dengvaxia, nobody expressed their objection to the vaccine,” Aquino said.
Aquino approved the use of 3.5 billion pesos ($69 million) worth of government savings during his last few months in office to buy the Dengvaxia vaccine to be used for one million children in parts of the Philippines hard-hit by dengue.
“These types of drugs undergo years of development to ensure its efficacy, especially its safety,” Aquino said…
The current government of President Rodrigo Duterte stopped the immunisation programme on Dec. 1 after Sanofi issued the warning. About 830,000 children, aged 9 and older, have been inoculated with Dengvaxia.
Two Philippine congressional inquiries have begun and a criminal investigation has also been launched to determine how the danger to public health came about.
Senator Richard Gordon, chairman of the senate investigation panel, said approval and procurement for the programme went through with “unbelievable haste and phenomenal speed” given how quickly the Department of Health received funding for the campaign.
But Duterte said on Wednesday the previous government acted in good faith and that he was “not prepared to pass judgment”.
Philippines defied experts’ advice in pursuing dengue immunWecontinue to montior major annoucnements and milestones asation programme
Reuters | 10 December 2017
… Documents reviewed by Reuters that have not been disclosed until now, as well as interviews with local experts, show that key recommendations made by a Philippines Department of Health (DOH) advisory body of doctors and pharmacologists were not heeded before the program was rolled out to 830,000 children.
After Garin’s announcement, the Formulary Executive Council (FEC) of advisers urged caution over the vaccine because it said its safety and cost-effectiveness had not been established.
After twice meeting in January, the panel approved the state’s purchase of the vaccine on Feb 1, 2016 but recommended stringent conditions, minutes of all three meetings show.
“Based on the available scientific evidence presented to the Council, there is still a need to establish long-term safety, effectiveness and cost-effectiveness,” the FEC told Garin in a letter on that day. The letter was reviewed by Reuters.
The FEC said Dengvaxia should be introduced through small-scale pilot tests and phased implementation rather than across three regions in the country at the same time, and only after a detailed “baseline” study of the prevalence and strains of dengue in the targeted area, the FEC letter and minutes of the meetings said.
The experts also recommended that Dengvaxia be bought in small batches so the price could be negotiated down. An economic evaluation report commissioned by Garin’s own department had found the proposed cost of 1,000 pesos ($21.29) per dose was “not cost-effective” from a public payer perspective, the minutes from the meetings reveal.
For reasons that Reuters was unable to determine, these recommendations were ignored.

The DOH purchased 3 million doses of Dengvaxia in one lot, enough for the required three vaccinations for each child in the proposed immunization program and paid 1,000 pesos per dose, a copy of the purchase order reviewed by Reuters shows.
It did conduct a “limited baseline study” in late February and March 2016, but the survey looked at “common illnesses” rather than the prevalence of dengue, according to guidelines issued by Garin’s office at the time and reviewed by Reuters.
Garin, who was part of the government of former president Benigno Aquino and replaced when President Rodrigo Duterte took power in June, 2016, did not respond to requests for comment on why she ignored the local experts’ recommendations.
A physician, Garin has defended her conduct and a program that she said was “implemented in accordance with WHO guidance and recommendations”.
“I understand the concern,” she told Philippine TV station ABS-CBN on Friday. “Even us, we’re also very angry when we learned about Sanofi’s announcement about severe dengue. I‘m also a mother. My child was also vaccinated. I was also vaccinated.”
DOH spokesman Lyndon Lee Suy also did not respond to text messages or questions emailed to him.
Sanofi Philippines declined comment on the Philippines government decision. However, Dr. Su-Peing Ng, Global Medical Head of Sanofi Pasteur, told Reuters: “We communicated all known benefits and risks of the vaccine to the Philippines government.”…



Public Health Emergency of International Concern (PHEIC)
Polio this week as of 13 December 2017 [GPEI]
:: In Pakistan, the polio eradication programme and the routine immunization programme are working hand in hand to increase vaccination coverage in urban areas.
:: Pakistan and Afghanistan are implementing sub-national rounds during the second half of December; the rounds are synchronized to ensure that all the high risk mobile populations are efficiently reached with polio vaccine.
:: Summary of newly-reported viruses this week:
Afghanistan:  Two new WPV1 positive environmental samples reported, both collected from Nangarhar province.
Pakistan: One new case of wild poliovirus type 1 (WPV1) reported in Sindh province, Pakistan. This follows the advance notification of the case last week. Two new WPV1 positive environmental samples reported, one from Sindh province, and one from Balochistan province. Syria: Four new circulating vaccine derived poliovirus type 2 (cVDPV2) cases reported, all from Deir Ez-Zor governorate.

Editor’s Note:
It continues to be unclear why the weekly GPEI report on new cases at country level [above] does not capture cases in Syria [below].
Syria cVDPV2 outbreak situation report 26, 12 December 2017
Situation update 12 December 2017
:: Four new cases of circulating vaccine-derived poliovirus (cVDPV2) were reported this week. Three cases were reported from Mayadeen district, one case from Boukamal district, Deir Ez-Zor governorate. The most recent case (by date of onset) is 21 September 2017 from Boukamal district.
:: The total number of confirmed cVDPV2 cases is 74.
:: Global Polio Eradication Initiative (GPEI) partners continue to support the Syrian Ministry of Health with planning for the second phase of the outbreak response.
:: A new environmental surveillance laboratory has been successfully established in Damascus this week. WHO has led the training of surveillance officers and staff from the Ministry of Health and Ministry of Water Resources.


WHO Grade 3 Emergencies  [to 16 December 2017]
The Syrian Arab Republic
:: Saving the lives of Syrian mothers and children
13 December 2017, Damascus, Syrian Arab Republic — Through a donation from the Government of Spain, WHO is providing medicines to support health services in 7 governorates in the Syrian Arab Republic. WHO has provided anti-D immunoglobulin injections and other medicines, including anesthetics, to health facilities in 7 governorates in Syria through a generous donation from the Government of Spain. The grant provided sufficient medicines for more than 4500 treatments
:: Syria cVDPV2 outbreak situation report 26, 12 December 2017
[See Polio above for detail]

WHO Grade 2 Emergencies  [to 16 December 2017]
:: Bangladesh moves to protect Rohingya children from diphtheria 12 December 2017
[See joint announcement below]


Bangladesh moves to protect Rohingya children from diphtheria
COX’S BAZAR, Bangladesh, 12 December 2017 – The Government of Bangladesh, with the support of UNICEF, the World Health Organization and GAVI, the Vaccine Alliance, today launched  a vaccination campaign against diphtheria and other preventable diseases for all Rohingya children aged 6 weeks to 6 years living in 12 camps and temporary settlements near the Myanmar border.
Accelerated immunization will cover nearly 255 000 children in Ukhiya and Teknaf sub-districts in Cox’s Bazar, while the Government and health partners continue to increase support for diphtheria treatment and prevention….


South Sudan implements the second round of Oral Cholera Vaccination to enhance outbreak response efforts in high risk locations
Juba, 14 December 2017:  Cholera in South Sudan remains an important public health problem which has affected 21 571 people and resulted in 462 deaths since the onset of the outbreak on 18 June 2016. This has been the longest and largest outbreak in magnitude and geographical extent, its impact exacerbated by the protracted crisis, insecurity, displacements and declining access to safe drinking water and sanitation. Access to improved sanitation facilities across South Sudan remains at less than 10% while access to safe drinking water from improved water sources is estimated at 60%.
As part of the ongoing cholera response, the Ministry of Health of South Sudan with support from WHO and partners has deployed cholera vaccines to complement traditional cholera response strategies in several high-risk populations and locations. From the 2,178,177 doses secured by WHO in 2017, a total of 1,133,579 doses have already been deployed with 879,239 doses used during the first round and 254,340 doses utilized in second round campaigns in 16 cholera-affected and high-risk populations countrywide.
“When used alongside other interventions for improving access to safe water and sanitation, oral cholera vaccines are very effective for cholera prevention and control, giving protection to those at risk, especially when the recommended two doses are administered,” emphasized Dr Pinyi, Director General for Preventive Services at the Ministry of Health of South Sudan.
The most recent consignment of 737,819 doses, requested by WHO from the Global Task Force on Cholera Control (GTFCC) stockpile was in Juba by 11 December, 2017. The vaccines have been deployed to areas and counties with pending second round vaccination campaigns and these include Kapoeta South, Kapoeta East, Tonj East, Aburoc and Malakal Town…

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. 
Syrian Arab Republic
:: 14 Dec 2017  Health Cluster Weekly Situation Report: Whole of Syria, Week 50 (8 – 15 December 2017)

:: 11 Dec 2017  Statement by the Humanitarian Coordinator for Yemen, Jamie McGoldrick, Calling on Parties to Facilitate Unimpeded Aid Delivery [EN/AR]
:: Yemen: Escalation of armed clashes and airstrikes in Sana’a City – Flash Update 2 | 7 December 2017

:: Iraq: Humanitarian Bulletin, November 2017 | Issued on 8 December

UN OCHA – Corporate Emergencies
When the USG/ERC declares a Corporate Emergency Response, all OCHA offices, branches and sections provide their full support to response activities both at HQ and in the field.
:: ISCG Situation Update: Rohingya Refugee Crisis, Cox’s Bazar – 14 December 2017

:: 12 Dec 2017  Ethiopia Humanitarian Bulletin Issue 42 | 27 Nov – 10 Dec 2017
…Ethiopia launched Comprehensive Refugee Response Framework in line with pledges made at Leaders’ Summit on Refugees in September 2016.
…30,000 refugees to benefit from employment opportunities under the “Ethiopian Jobs Compact”.
…Government to phase out encampment policy over 10 years and advance out-of-camp and local integration options.

:: Fact Sheet NE Nigeria: Bama, Bama LGA (as of 12 December 2017)
:: UN allocates $13.4 million to support 1 million people with life-saving aid in North-East Nigeria
(Abuja, 11 December 2017): The United Nations, through the Nigeria Humanitarian Fund, has allocated $13.4 million to help thousands of children, women and men in need of urgent humanitarian assistance in crisis-hit north-east Nigeria.
The humanitarian emergency in the northeastern Nigeria is one of the most severe in the world today, with 8.5 million people in need of life-saving aid in 2017 in the worst-affected states of Borno, Adamawa and Yobe.
The Nigeria Humanitarian Fund (NHF) allocation will help address this devastating situation by financing 24 projects in the sectors of protection, nutrition, water and sanitation, health, education, shelter and non-food items, rapid response and early recovery, targeting a total of 950,000 people…

WHO & Regional Offices [to 16 December 2017]

WHO & Regional Offices [to 16 December 2017]

Up to 650 000 people die of respiratory diseases linked to seasonal flu each year
14 December 2017 – Up to 650 000 deaths annually are associated with respiratory diseases from seasonal influenza, according to new estimates by the United States Centers for Disease Control and Prevention (US-CDC), WHO and global health partners.

Half the world lacks access to essential health services
13 December 2017 – At least half of the world’s population cannot obtain essential health services, according to a new report from the World Bank and WHO. And each year, large numbers of households are being pushed into poverty because they must pay for health care out of their own pockets. Currently, 800 million people spend at least 10% of their household budgets on health expenses for themselves, a sick child or other family member.
[See Milestones/Perspectives above for more detail]

New perspectives on global health spending for universal health coverage
December 2017 – WHO global health financing report summarizes the latest internationally comparable data on health spending in all WHO Member States between 2000 and 2015. For the first time the report uses the new international classification for health expenditures in the revised System of Health Accounts.


Fact Sheets
::  Avian and other zoonotic influenza   Updated December 2017
::  Influenza (Seasonal)  Updated November 2016
::  Universal health coverage (UHC)  December 2017

Weekly Epidemiological Record, 15 December 2017, vol. 92, 50 (pp. 761–780)
:: Review of global influenza activity, October 2016– October 2017
:: Monthly report on dracunculiasis cases, January-October 2017

WHO Regional Offices
Selected Press Releases, Announcements
WHO African Region AFRO
:: The Stop Transmission of Polio (STOP) program contributes to sustain Polio eradication in South Sudan  15 December 2017
:: South Sudan implements the second round of Oral Cholera Vaccination to enhance outbreak response efforts in high risk locations  15 December 2017
:: Amid protracted and widespread violence, WHO partners with National NGOs to improve immunization coverage and save the lives of women and children in South Sudan
Juba, 15 December 2017:  The World Health Organization (WHO) is expanding on its partners’ engagement mechanisms to address critical barriers in reaching vulnerable persons including women and children with life-saving interventions in besieged and hard-to-reach areas, where access and restrictions on movement severely hinder the ability of populations to get health services.
Since 2015, an estimated 456 000 people in south-eastern Upper Nile area have not been reached with life-saving health interventions leaving critical gaps and the derailment of vaccine preventable and communicable disease control achievements. Besides, surveillance indicators have remained very sub-optimal for vaccine preventable diseases.
To improve access and reduce family and community resistance to vaccination, WHO signed an agreement with Universal Network for Knowledge and Empowerment Agency (UNKEA), a national non-governmental organization operating in South Sudan to increase access to Expanded Programme on Immunization (EPI) services to achieve the overall goal of immunizing every child against vaccine preventable diseases in four counties of the south-eastern Upper Nile.
The four counties host over 342 482 persons at risk of meningitis, 86 763 exposed to deadly effects of measles and over 91 300 children not immunized with vaccine in the past two years, says Mr Kofi Boateng, the WHO EPI Officer…
:: Saving lives through streamlined emergency care  15 December 2017
:: WHO spearheads provision of mental health services in primary healthcare facilities  15 December 2017
:: South Sudan is getting closer to becoming free from Guinea-worm disease  14 December 2017
:: The Ministry of Health and World Health organization Conclude a 3-day advanced Infection Prevention Control (IPC)Follow Up training Workshop for County and Hospital IPC Focal Persons
14 December 2017
:: South Sudan adopts a new strategy to reduce deaths from cholera by 90 percent by 2030
14 December 2017
:: WHO reaffirms its support for initiatives and networks for harmonization and convergence of regulatory practices for Medicines in Africa  12 December 2017
:: WHO donates cholera kits to support the cholera outbreak response in the country  12 December 2017

WHO Region of the Americas PAHO
:: Regional movement for universal health launched (12/13/2017)
:: PAHO Director calls for building alliances to leave no one behind on the road to universal health (12/11/2017)

WHO South-East Asia Region SEARO
:: Bangladesh moves to protect Rohingya children from diphtheria
WHO European Region EURO
:: Greek health reform: opening of new primary health care units 14-12-2017
:: Financial hardship linked to inadequate health coverage policies 12-12-2017
:: Systems thinking helps England plan future health and care workforce 12-12-2017
:: Belarus and WHO Europe sign new collaborative agreement 11-12-2017

WHO Eastern Mediterranean Region EMRO
:: Universal Health Coverage Day: ensuring the right to health, leaving no one behind
13 December 2017
WHO Western Pacific Region
:: More action needed to achieve universal health coverage in Asia and the Pacific by global deadline  13 December 2017

MMWR News Synopsis for December 14, 2017

CDC/ACIP [to 16 December 2017]
MMWR News Synopsis for December 14, 2017
Health and Development at Age 19–24 Months of 19 Children Who Were Born with Microcephaly and Laboratory Evidence of Congenital Zika Virus Infection During the 2015 Zika Virus Outbreak — Brazil, 2017
Children with congenital Zika infection and microcephaly are now getting older and falling far behind their age-appropriate milestones, showing the need for long-term followup and support. These children will continue to require specialized care from many types of healthcare providers and their caregivers as they age. A new Centers for Disease Control and Prevention (CDC) investigation shows that children born with microcephaly (small head size for age) and evidence of congenital Zika virus infection face complex health and developmental challenges at ages 19-24 months, including an inability to sit independently, difficulties with sleeping and feeding, seizures, and hearing and vision problems. A majority of the 19 children in this investigation face challenges in multiple areas.

Large Outbreak of Neisseria meningitidis Serogroup C — Nigeria, December 2016–June 2017
Although the most recent meningococcal serogroup C outbreak in Nigeria is now fully controlled, improved surveillance and outbreak preparedness at all levels of the public health system are needed. Additionally, urgently expanding the availability of vaccines effective against multiple strains of the bacteria might help reduce the risk of outbreaks in Nigeria and other high-risk countries. From December 2016-June 2017, Nigeria experienced the largest global outbreak of meningitis caused by a new strain of the bacteria N. meningitidis serogroup C (NmC); 14,542 suspected cases and 1,166 deaths were reported. Nigeria, a country in the sub-Saharan “meningitis belt,” previously experienced large outbreaks caused by meningococcal A serogroup, which declined dramatically following the introduction in 2013 of meningococcal A vaccines. National and regional evaluations of the outbreak response outlined recommendations for improving meningitis outbreak prevention, timely detection, and response. Implementing these recommendations and expanding the availability of multivalent vaccines effective against non-A serogroups will reduce future meningitis outbreaks.

Introduction of Inactivated Poliovirus Vaccine and Elimination of Vaccine-Associated Paralytic Poliomyelitis — Beijing, China, 2014–2016
High population coverage with the sequential inactivated polio vaccine/oral poliovirus vaccine (IPV/OPV) schedule in Beijing resulted in the successful introduction of IPV in Beijing and the elimination of vaccine-associated paralytic poliomyelitis (VAPP). IPV Introduction using a sequential IPV/ OPV schedule in Beijing was associated with a good safety record, no occurrence of VAPP or other serious adverse events, and maintenance of >95 percent coverage with polio vaccines. Strong public health leadership, good operational planning, and secured resources and budget were critical to successful IPV introduction in Beijing, assuring public confidence in the safety of OPV, assuring the availability of 1-dose IPV access, and helping improve the current routine immunization system.



European Medicines Agency  [to 16 December 2017]
Meeting highlights from the Committee for Medicinal Products for Human Use (CHMP) 11-14 December 2017
Seven medicines recommended for approval, including an advanced therapy …

European Vaccine Initiative  [to 16 December 2017]
14 December 2017
ZIKAVAX Annual Meeting 2017
The first annual meeting of the EU-funded project ZIKAVAX took place on 7 December 2017 at CEA,…
FDA [to 16 December 2017]
December 15, 2017 –
Statement from FDA Commissioner Scott Gottlieb, M.D., on new FDA efforts to support more efficient development of targeted therapies
New website streamlines how FDA updates information used to help health care providers choose an appropriate treatment for a patient’s infection
Fondation Merieux  [to 16 December 2017]
December 12, 2017
REAOLAB presents the overview of phase 2 durig its 5th Steering Committee meeting held in Mali
The RESAOLAB project brought together the partners and networks members in Bamako for its 5th International Committee Meeting on 5 and 6 December 2017. This meeting was an opportunity to take stock of the achievements of phase 2 while reporting on the continuation of the program. A workshop dedicated to antimicrobial resistance, an increasing public health challenge, and a round table on the future of young researchers in West Africa, were also organized on this occasion.
GHIT Fund   [to 16 December 2017]
GHIT was set up in 2012 with the aim of developing new tools to tackle infectious diseases that devastate the world’s poorest people. Other funders include six Japanese pharmaceutical ·
Press Room   2017.12.11      
GHIT Fund’s Strategic Plan for 2018 to 2022: Accelerating Product Development and Product Delivery for its global health innovations

TOKYO, JAPAN (December 11, 2017)—The Global Health Innovative Technology Fund (GHIT) today announced its Strategic Plan targeting the next five years (FY2018-FY2022). Comprised of four pillars—i: Research & Development (R&D), ii: Partnership for Delivery, iii: Excellence through Good Governance, iv: Financial Strategies—GHIT will continue to accelerate global health R&D through an international partnership between Japan and countries overseas.
Since its inception in April 2013 as the world’s first global health R&D public-private partnership fund, GHIT has advanced the development of therapeutics, vaccines and diagnostics for infectious disease in low and middle income countries, by galvanizing Japan’s science and pharmaceutical capabilities. To date, GHIT has invested a total of US$115M in 68 global partnerships, and 7 clinical trials are currently underway…

Global Fund [to 16 December 2017];&country=
Kenya and Global Fund Sign New Grants to Accelerate Response to Diseases
15 December 2017
The Global Fund and health partners in Kenya today signed six grant agreements to strengthen the response to HIV, tuberculosis and malaria. The grants aim to reach 1.3 million people with antiretroviral therapy by 2021, and drastically expand interventions to find more missing cases of TB, among other objectives.
Hilleman Laboratories   [to 16 December 2017]
12th October 2017
Hilleman Labs successfully completes Phase I/II Clinical Trial of its Heat Stable Rotavirus Vaccine (HSRV)
New Delhi: Making headway towards providing the developing nations an affordable and easy-to-use Heat Stable Rotavirus Vaccine (HSRV), Hilleman Laboratories, a joint-venture between Merck Sharp & Dohme (MSD) and the Wellcome Trust, today announced the successful completion of Phase I/II clinical trial of its oral vaccine against the deadly Rotavirus disease.
The study was conducted in partnership with the International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b)…
Human Vaccines Project   [to 16 December 2017]
Public Release: 13-Dec-2017
New Michelson Prizes for Human Immunology and Vaccine Research launch
The Michelson Medical Research Foundation and the Human Vaccines Project announce young investigator prizes to advance the development of future vaccines and therapies to defeat major global diseases
[See Milestones/Perspectives above for more detail]

IVAC  [to 16 December 2017]
Statement on Dengvaxia® issued by Global Dengue & Aedes-Transmitted Diseases Consortium (GDAC) with support from International Vaccine Access Center
JEE Alliance  [to 16 December 2017]
Strong health systems are essential for resilience and preparedness – time for synergy and joining up
Health security contributes to peace and security, democracy, economic and social stability as well as wellbeing. Strengthening health security is therefore an integral target of the SDGs…
MSF/Médecins Sans Frontières  [to 16 December 2017]
Press release
MSF: At Least 6,700 Rohingya Killed During Attacks in Myanmar
December 14, 2017
NEW YORK/AMSTERDAM/PARIS—At least 9,000 members of the ethnic Rohingya minority died—most of them from violence— in Rakhine state, Myanmar, between August 25 and September 24, according to surveys conducted in refugee settlement camps in Bangladesh and released today by the international medical humanitarian organization Doctors Without Borders/Médecins Sans Frontières (MSF).

Press release
Yemen: Diphtheria Spreads as War and Blockade Leave Health System in Tatters
December 12, 2017
Doctors Without Borders/Médecins Sans Frontières (MSF) is responding to a suspected outbreak of diphtheria in Yemen, where the disease has reemerged as the country’s health system is weakened by ongoing war and a blockade on essential goods.
PATH  [to 16 December 2017]
Press release | December 12, 2017
Launch of ‘Be Me. Be Happy!’: A campaign to increase transgender women’s access to HIV services in Vietnam

UNAIDS [to 16 December 2017]
15 December 2017 –
UNAIDS PCB discusses discrimination in health-care settings

14 December 2017 –
Closing the HIV resource gap in Nigeria with more domestic funding

13 December 2017 –
Key populations platform in Ukraine established

12 December 2017
41st meeting of the UNAIDS Programme Coordinating Board opens

UNICEF  [to 16 December 2017]
15 December 2017
World Bank and WHO: Half the world lacks access to essential health services, 100 million still pushed into extreme poverty because of health expenses
TOKYO, December 13, 2017 — At least half of the world’s population cannot obtain essential health services, according to a new report from the World Bank and the World Health Organization. And each year, large numbers of households are being pushed into poverty because they must pay for health care out of their own pockets.
[See Milestones/Perspectives above for more detail]

Three months after deadly hurricanes hit Caribbean islands, thousands of children still in need of assistance
PANAMA CITY, 13 December 2017 – Three months after two category-5 hurricanes – Irma and Maria – barreled through the Caribbean, causing widespread damage and loss of life, thousands of children remain in need of support across the region.

New funding will allow countries to secure sustainable vaccine supplies and reach children more quickly
COPENHAGEN, 13 December 2017 – UNICEF announced today that funding for its Vaccine Independence Initiative (VII), a mechanism to help countries secure a sustainable supply of life-saving vaccines, has more than doubled in the past year, increasing from $15 million to $35 million.
[See Milestones/Perspectives above for more detail]

Bangladesh moves to protect Rohingya children from diphtheria
COX’S BAZAR, Bangladesh, 12 December 2017 – The Government of Bangladesh, with the support of UNICEF, the World Health Organization and GAVI, the Vaccine Alliance, today launched  a vaccination campaign against diphtheria and other preventable diseases for all Rohingya children aged 6 weeks to 6 years living in 12 camps and temporary settlements near the Myanmar border.
[See Emergencies above for more detail]

Wellcome Trust  [to 16 December 2017]
News / Published: 12 December 2017
Wellcome’s charitable spend reaches record levels
Wellcome spent over £1.1 billion on science, research, innovation and public engagement in 2016-17, more than ever before and double what we spent a decade ago.
Explainer / Published: 11 December 2017
Sharing Clinical Trial Data: what it means for you
Wellcome is joining (CSDR), a data-sharing initiative involving academic research funders and pharmaceutical companies. Jen O’Callaghan, from our Open Research team, explains why and what it means for researchers.
As a global research foundation, we’re dedicated to ensuring that the outputs of the research we fund – including clinical trial data – can be accessed and used in ways that will advance medical science by building on previous findings and exploring new questions.
CSDR (opens in a new tab) is a website portal for listing and sharing clinical trial datasets. Initially established to provide a way in which researchers could access trial data from a consortium of 13 pharmaceutical companies, CSDR is now expanding to include data from academic-led trials….

IFPMA   [to 16 December 2017]
13 December 2017
10th annual G-FINDER report: Pharmaceutical industry R&D investment funding for negected diseases
Geneva, 13 December 2017: IFPMA, the international association representing the research-based biopharmaceutical companies, welcomes the 10th annual G-FINDER report[i] results that show industry contributed USD 497m to global R&D efforts, accounting for 16% of total global funding. The report notes that industry funding has reached new record highs for the last three years. Since 2008, reported industry investment has increased by nearly 50%. This firmly consolidates industry’s position as the 3rd largest funder of R&D for neglected diseases after the US NIH and the Bill and Melinda Gates Foundation…

Journal Watch

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:


Spatial clustering of measles vaccination coverage among children in sub-Saharan Africa

BMC Public Health
(Accessed 16 December 2017)

Research article
Spatial clustering of measles vaccination coverage among children in sub-Saharan Africa
Authors: Tenley K. Brownwright, Zan M. Dodson and Willem G. van Panhuis
Citation: BMC Public Health 2017 17:957
Published on: 15 December 2017
During the past two decades, vaccination programs have greatly reduced global morbidity and mortality due to measles, but recently this progress has stalled. Even in countries that report high vaccination coverage rates, transmission has continued, particularly in spatially clustered subpopulations with low vaccination coverage.
We examined the spatial heterogeneity of measles vaccination coverage among children aged 12–23 months in ten Sub-Saharan African countries. We used the Anselin Local Moran’s I to estimate clustering of vaccination coverage based on data from Demographic and Health Surveys conducted between 2008 and 2013. We also examined the role of sociodemographic factors to explain clustering of low vaccination.
We detected 477 spatial clusters with low vaccination coverage, many of which were located in countries with relatively high nationwide vaccination coverage rates such as Zambia and Malawi. We also found clusters in border areas with transient populations. Clustering of low vaccination coverage was related to low health education and limited access to healthcare.
Systematically monitoring clustered populations with low vaccination coverage can inform supplemental immunization activities and strengthen elimination programs. Metrics of spatial heterogeneity should be used routinely to determine the success of immunization programs and the risk of disease persistence.

Political drivers of epidemic response: foreign healthcare workers and the 2014 Ebola outbreak (pages 41–61)

January 2018  Volume 42, Issue 1  Pages 1–203

Political drivers of epidemic response: foreign healthcare workers and the 2014 Ebola outbreak (pages 41–61)
Daniel Nohrstedt and Erik Baekkeskov
Version of Record online: 25 APR 2017 | DOI: 10.1111/disa.12238
This study demonstrates that countries responded quite differently to calls for healthcare workers (HCWs) during the Ebola epidemic in West Africa in 2014. Using a new dataset on the scale and timing of national pledges and the deployment of HCWs to states experiencing outbreaks of the virus disease (principally, Guinea, Liberia, and Sierra Leone), it shows that few foreign nations deployed HCWs early, some made pledges but then fulfilled them slowly, and most sent no HCWs at all. To aid understanding of such national responses, the paper reviews five theoretical perspectives that offer potentially competing or complementary explanations of foreign government medical assistance for international public health emergencies. The study systematically validates that countries varied greatly in whether and when they addressed HCW deployment needs during the Ebola crisis of 2014, and offers suggestions for a theory-driven inquiry to elucidate the logics of foreign interventions in critical infectious disease epidemics.

Publicly available software tools for decision-makers during an emergent epidemic—Systematic evaluation of utility and usability

Volume 21, Pages 1-88 (December 2017)

Review Articles
Publicly available software tools for decision-makers during an emergent epidemic—Systematic evaluation of utility and usability
Review Article
Pages 1-12
David James Heslop, Abrar Ahmad Chughtai, Chau Minh Bui, C. Raina MacIntyre
Epidemics and emerging infectious diseases are becoming an increasing threat to global populations—challenging public health practitioners, decision makers and researchers to plan, prepare, identify and respond to outbreaks in near real-timeframes. The aim of this research is to evaluate the range of public domain and freely available software epidemic modelling tools. Twenty freely utilisable software tools underwent assessment of software usability, utility and key functionalities. Stochastic and agent based tools were found to be highly flexible, adaptable, had high utility and many features, but low usability. Deterministic tools were highly usable with average to good levels of utility.

The impact of current infection levels on the cost-benefit of vaccination

Volume 21, Pages 1-88 (December 2017)

Original Research Article
The impact of current infection levels on the cost-benefit of vaccination
Pages 56-62
Matt J. Keeling, Katherine A. Broadfoot, Samik Datta
When considering a new vaccine programme or modifying an existing one, economic cost-benefit analysis, underpinned by predictive epidemiological modelling, is a key component. This analysis is intimately linked to the willingness to pay for additional QALYs (quality-adjusted life-years) gained; currently in England and Wales a health programme is economically viable if the cost per QALY gained is less than £ 20,000, and models are often used to assess if a vaccine programme is likely to fall below this threshold cost. Before a programme begins, infection levels are generally high and therefore vaccination may be expected to have substantial effects and therefore will often be economically viable. However, once a programme is established, and infection rates are lower, it might be expected that a re-evaluation of the programme (using current incidence information) will show it to be less cost-effective. This is the scenario we examine here with analytical tools and simple ODE models. Surprisingly we show that in most cases the benefits from maintaining an existing vaccination programme are at least equal to those of starting the programme initially, and in the majority of scenarios the differences between the two are minimal. In practical terms, this is an extremely helpful finding, allowing us to assert that the action of immunising individuals does not de-value the vaccination programme.

The Global Fund’s paradigm of oversight, monitoring, and results in Mozambique

Globalization and Health
[Accessed 16 December 2017]

12 December 2017
The Global Fund’s paradigm of oversight, monitoring, and results in Mozambique
Authors: Ashley Warren, Roberto Cordon, Michaela Told, Don de Savigny, Ilona Kickbusch and Marcel Tanner
The Global Fund is one of the largest actors in global health. In 2015 the Global Fund was credited with disbursing close to 10 % of all development assistance for health. In 2011 it began a reform process in response to internal reviews following allegations of recipients’ misuse of funds. Reforms have focused on grant application processes thus far while the core structures and paradigm have remained intact. We report results of discussions with key stakeholders on the Global Fund, its paradigm of oversight, monitoring, and results in Mozambique.
We conducted 38 semi-structured in-depth interviews in Maputo, Mozambique and members of the Global Fund Board and Secretariat in Switzerland. In-country stakeholders were representatives from Global Fund country structures (eg. Principle Recipient), the Ministry of Health, health or development attachés bilateral and multilateral agencies, consultants, and the NGO coordinating body. Thematic coding revealed concerns about the combination of weak country oversight with stringent and cumbersome requirements for monitoring and evaluation linked to performance-based financing.
Analysis revealed that despite the changes associated with the New Funding Model, respondents in both Maputo and Geneva firmly believe challenges remain in Global Fund’s structure and paradigm. The lack of a country office has many negative downstream effects including reliance on in-country partners and ineffective coordination. Due to weak managerial and absorptive capacity, more oversight is required than is afforded by country team visits. In-country partners provide much needed support for Global Fund recipients, but roles, responsibilities, and accountability must be clearly defined for a successful long-term partnership. Furthermore, decision-makers in Geneva recognize in-country coordination as vital to successful implementation, and partners welcome increased Global Fund engagement.
To date, there are no institutional requirements for formalized coordination, and the Global Fund has no consistent representation in Mozambique’s in-country coordination groups. The Global Fund should adapt grant implementation and monitoring procedures to the specific local realities that would be illuminated by more formalized coordination.

Special Feature: The Lake Chad Basin: an overlooked crisis?

Humanitarian Exchange Magazine
Number 70   October 2017
Special Feature: The Lake Chad Basin: an overlooked crisis?
by Humanitarian Practice Network October 2017
The 70th edition of Humanitarian Exchange, co-edited with Joe Read, focuses on the humanitarian crisis in Nigeria and the Lake Chad Basin. The violence perpetrated by Boko Haram and the counter-insurgency campaign in Nigeria, Cameroon, Chad and Niger has created a humanitarian crisis affecting some 17 million people. Some 2.4 million have been displaced, the vast majority of them in north-eastern Nigeria. Many are living in desperate conditions, without access to sufficient food or clean water. The Nigerian government’s focus on defeating Boko Haram militarily, its reluctance to acknowledge the scale and gravity of the humanitarian crisis and the corresponding reticence of humanitarian leaders to challenge that position have combined to undermine the timeliness and effectiveness of the response…

[Reviewed earlier]

Support for research towards understanding the population health vulnerabilities to vector-borne diseases: increasing resilience under climate change conditions in Africa

Infectious Diseases of Poverty
[Accessed 16 December 2017]

12 December 2017
Support for research towards understanding the population health vulnerabilities to vector-borne diseases: increasing resilience under climate change conditions in Africa
Diseases transmitted to humans by vectors account for 17% of all infectious diseases and remain significant public health problems. Through the years, great strides have been taken towards combatting vector-borne diseases (VBDs), most notably through large scale and coordinated control programmes, which have contributed to the decline of the global mortality attributed to VBDs. However, with environmental changes, including climate change, the impact on VBDs is anticipated to be significant, in terms of VBD-related hazards, vulnerabilities and exposure. While there is growing awareness on the vulnerability of the African continent to VBDs in the context of climate change, there is still a paucity of research being undertaken in this area, and impeding the formulation of evidence-based health policy change.
Authors: Bernadette Ramirez

Addressing vulnerability, building resilience: community-based adaptation to vector-borne diseases in the context of global change

Infectious Diseases of Poverty
[Accessed 16 December 2017]

Scoping Review
11 December 2017
Addressing vulnerability, building resilience: community-based adaptation to vector-borne diseases in the context of global change
The threat of a rapidly changing planet – of coupled social, environmental and climatic change – pose new conceptual and practical challenges in responding to vector-borne diseases. These include non-linear and uncertain spatial-temporal change dynamics associated with climate, animals, land, water, food, settlement, conflict, ecology and human socio-cultural, economic and political-institutional systems. To date, research efforts have been dominated by disease modeling, which has provided limited practical advice to policymakers and practitioners in developing policies and programmes on the ground.
Authors: Kevin Louis Bardosh, Sadie Ryan, Kris Ebi, Susan Welburn and Burton Singer

Five Ethical Values to Guide Health System Reform

December 12, 2017, Vol 318, No. 22, Pages 2155-2265

The JAMA Forum
Five Ethical Values to Guide Health System Reform
Lawrence O. Gostin, JD
The US health system is so mired in politics, with positions hardened by rigid ideologies, that we can’t even seem to talk with one another civilly about difficult tradeoffs. If the polity could agree on core ethical values to guide discourse, we would make hard health system choices based on which values we prefer and why. Herein, I offer 5 critical values for health system reform—universal access, equitable access, affordable access (cost), quality, and choice—explain the tradeoffs, and provide reasons why certain values should take priority. There will be disagreement across the political spectrum, but alternative visions should be justified by reasoned argument.

Clinical Usage of the Adjuvanted Herpes Zoster Subunit Vaccine (HZ/su): Revaccination of Recipients of Live Attenuated Zoster Vaccine and Coadministration With a Seasonal Influenza Vaccine

Journal of Infectious Diseases
Volume 216, Issue 11   1 December 2017

Editor’s Choice
Clinical Usage of the Adjuvanted Herpes Zoster Subunit Vaccine (HZ/su): Revaccination of Recipients of Live Attenuated Zoster Vaccine and Coadministration With a Seasonal Influenza Vaccine
Michael N Oxman; Ruth Harbecke; David M Koelle
The Journal of Infectious Diseases, Volume 216, Issue 11, 12 December 2017, Pages 1329–1333,

Achieving sustainable solidarity development goals

The Lancet
Dec 16, 2017 Volume 390 Number 10113 p2605-2738  e51-e59

Achieving sustainable solidarity development goals
The Lancet
The meaning of social security varies nationally. In the USA, it might bring to mind the eponymous agency that administers social insurance providing benefits for retired individuals and those living with disability. In 1934, in the wake of the Great Depression when as many as 25% of Americans were unemployed, President Franklin D Roosevelt announced his plans to create a social security programme for the nation to “encourage a greater security for each individual who composes it”. He proclaimed: “This seeking for a greater measure of welfare and happiness does not indicate a change in values. It is rather a return to values lost in the course of our economic development and expansion…”

Thus, even early in the last century and beyond the European borders where the tradition of social welfare germinated, the role of government was acknowledged amid growing tensions between national economic development and the security of individuals—a discord that persists around the world with great heterogeneity because of the patchwork of policies and programmes in place to maintain standards of social protection.

The International Labour Organization (ILO), the UN agency that oversees labour standards and liaises with workers, unions, and governments, has endeavoured to formalise a framework to monitor the state of social protection systems around the world. In late November, the ILO released its most recent publication—World Social Protection Report 2017–19: Universal social protection to achieve the Sustainable Development Goals. It is a massive undertaking, using a “life-cycle” approach to quantify social protection, from benefits extended to children and families during maternity, unemployment, disability, to the health and the financing of these security schemes.

The work of the ILO is predicated on the foundation that social security is a right and these efforts are developed in accordance with the UN’s Sustainable Development Goals (SDGs). Specifically, the report focuses on SDG 1·3, the implementation of nationally appropriate social protection systems, including floors (or defined essential levels of security), as part of the main goal to end poverty in all its forms everywhere. The 2030 Agenda for Sustainable Development incorporates related social protection goals prioritising gender equality (SDG 5·4), decent work and economic growth (SDG 8·5), and universal health coverage (UHC; SDG 3·8).

But for all the positive movement in aligning national capacities with the SDGs, the report portrays the steep chasm between those who are secure and those who are not. By the most basic standards, only 45% of the world’s population are covered by at least one social benefit, leaving at least 4 billion people outside of the scope of protection, with Africa, Asia, and Arab States the farthest behind. Nearly 1·3 billion of those people are children. Notably, countries spend on average only 1·1% of GDP on social protection benefits for those younger than 14 years. This chronic underinvestment, left uncorrected, perpetuates staggering long-term inequities.

The report identifies UHC as a crucial piece of social protection, as the need for access to health care is independent of employment status and crosses the lifespan. It might be the most transformative of protections, but also the most fraught, from contracting programmes threatening health services in high-income countries to virtually non-existent long-term care access in low-income countries. Over half of the people in rural areas of the world lack any health coverage, compared with 22% of people in urban areas. Compounding rural–urban inequity is the shortage of health workers, estimated at 13·6 million. To improve access and to achieve UHC, an additional 10 million health workers will be needed. In meeting these care service needs, however, there is also great opportunity for job creation, reducing poverty, and improving conditions for health workers.

As countries navigate the challenging path to improving social protection and realising the SDGs, there is reason to return to the values that drive this work. Fittingly, International Human Solidarity Day is Dec 20, an observance that encourages governments to respect their commitments, promote poverty eradication, and celebrate unity in diversity. As there are many meanings for social security, there are many meanings for solidarity. It is not simply reciprocity or fostering prosocial interventions by government. It is cohesion. The sum will be greater than the parts. In creating a better world, sustainable development goals must also be solidarity development goals. Goals that can only be met by revisiting the fundamental values of promoting unity, harmony, and collective security—in solidarity.

Local, national, and regional viral haemorrhagic fever pandemic potential in Africa: a multistage analysis

The Lancet
Dec 16, 2017 Volume 390 Number 10113 p2605-2738  e51-e59

Local, national, and regional viral haemorrhagic fever pandemic potential in Africa: a multistage analysis
David M Pigott, Aniruddha Deshpande, Ian Letourneau, Chloe Morozoff, Robert C Reiner Jr, Moritz U G Kraemer, Shannon E Brent, Isaac I Bogoch, Kamran Khan, Molly H Biehl, Roy Burstein, Lucas Earl, Nancy Fullman, Jane P Messina, Adrian Q N Mylne, Catherine L Moyes, Freya M Shearer, Samir Bhatt, Oliver J Brady, Peter W Gething, Daniel J Weiss, Andrew J Tatem, Luke Caley, Tom De Groeve, Luca Vernaccini, Nick Golding, Peter Horby, Jens H Kuhn, Sandra J Laney, Edmond Ng, Peter Piot, Osman Sankoh, Christopher J L Murray, Simon I Hay
Open Access
Predicting when and where pathogens will emerge is difficult, yet, as shown by the recent Ebola and Zika epidemics, effective and timely responses are key. It is therefore crucial to transition from reactive to proactive responses for these pathogens. To better identify priorities for outbreak mitigation and prevention, we developed a cohesive framework combining disparate methods and data sources, and assessed subnational pandemic potential for four viral haemorrhagic fevers in Africa, Crimean–Congo haemorrhagic fever, Ebola virus disease, Lassa fever, and Marburg virus disease.
In this multistage analysis, we quantified three stages underlying the potential of widespread viral haemorrhagic fever epidemics. Environmental suitability maps were used to define stage 1, index-case potential, which assesses populations at risk of infection due to spillover from zoonotic hosts or vectors, identifying where index cases could present. Stage 2, outbreak potential, iterates upon an existing framework, the Index for Risk Management, to measure potential for secondary spread in people within specific communities. For stage 3, epidemic potential, we combined local and international scale connectivity assessments with stage 2 to evaluate possible spread of local outbreaks nationally, regionally, and internationally.
We found epidemic potential to vary within Africa, with regions where viral haemorrhagic fever outbreaks have previously occurred (eg, western Africa) and areas currently considered non-endemic (eg, Cameroon and Ethiopia) both ranking highly. Tracking transitions between stages showed how an index case can escalate into a widespread epidemic in the absence of intervention (eg, Nigeria and Guinea). Our analysis showed Chad, Somalia, and South Sudan to be highly susceptible to any outbreak at subnational levels.
Our analysis provides a unified assessment of potential epidemic trajectories, with the aim of allowing national and international agencies to pre-emptively evaluate needs and target resources. Within each country, our framework identifies at-risk subnational locations in which to improve surveillance, diagnostic capabilities, and health systems in parallel with the design of policies for optimal responses at each stage. In conjunction with pandemic preparedness activities, assessments such as ours can identify regions where needs and provisions do not align, and thus should be targeted for future strengthening and support.
Paul G Allen Family Foundation, Bill & Melinda Gates Foundation, Wellcome Trust, UK Department for International Development

Deploy vaccines to fight superbugs

Volume 552 Number 7684 pp147-278  14 December 2017

Deploy vaccines to fight superbugs
Immunizations combined with antibiotics could be our best shot at combating drug-resistant microbes, argue Rino Rappuoli, David E. Bloom and Steve Black.
[Initial text]
Bacteria, viruses, parasites and fungi that are resistant to drugs cause 700,000 deaths each year. By 2050, such ‘superbugs’, inured to treatments, could cause up to 10 million deaths annually and cost the global economy US$100 trillion12. If this happens, antimicrobial resistance (AMR) will be a bigger killer than cancer is now.
Antimicrobials alone won’t be able to mitigate the threat. The supply of naturally occurring antibiotics seems thin. And efforts to engineer new ones have floundered.
We think that vaccines could be a key way to stem the crisis. To launch a global strategic effort to prioritize their development, scientists, policymakers and key stakeholders need to see antibiotics and vaccines as complementary tools. Here we focus on antibiotic-resistant bacteria, for which the need for solutions is most urgent…

A Bivalent Meningococcal B Vaccine in Adolescents and Young Adults

New England Journal of Medicine
December 14, 2017  Vol. 377 No. 24

Original Article
A Bivalent Meningococcal B Vaccine in Adolescents and Young Adults
Lars Ostergaard, M.D., Ph.D., Timo Vesikari, M.D., Ph.D., Judith Absalon, M.D., M.P.H., Johannes Beeslaar, M.D., Brian J. Ward, M.D., C.M., Shelly Senders, M.D., Joseph J. Eiden, M.D., Ph.D., Kathrin U. Jansen, Ph.D., Annaliesa S. Anderson, Ph.D., Laura J. York, Ph.D., Thomas R. Jones, Ph.D., Shannon L. Harris, Ph.D., Robert O’Neill, Ph.D., David Radley, M.S., Roger Maansson, M.S., Jean-Louis Prégaldien, M.S., John Ginis, B.S., Nina B. Staerke, M.D., and John L. Perez, M.D., for the B1971009 and B1971016 Trial Investigators*
N Engl J Med 2017; 377:2349-2362 December 14, 2017
DOI: 10.1056/NEJMoa1614474
MenB-FHbp is a licensed meningococcal B vaccine targeting factor H–binding protein. Two phase 3 studies assessed the safety of the vaccine and its immunogenicity against diverse strains of group B meningococcus.

Critical dynamics in population vaccinating behavior

PNAS – Proceedings of the National Academy of Sciences of the United States
of America
[Accessed 16 December 2017]

Biological Sciences – Ecology:
Critical dynamics in population vaccinating behavior
Demetri Pananos, Thomas M. Bury, Clara Wang, Justin Schonfeld, Sharada P. Mohanty, Brendan Nyhan, Marcel Salathé, and Chris T. Bauch
PNAS 2017 ; published ahead of print December 11, 2017, doi:10.1073/pnas.1704093114
Complex adaptive systems exhibit characteristic dynamics near tipping points such as critical slowing down (declining resilience to perturbations). We studied Twitter and Google search data about measles from California and the United States before and after the 2014–2015 Disneyland, California measles outbreak. We find critical slowing down starting a few years before the outbreak. However, population response to the outbreak causes resilience to increase afterward. A mathematical model of measles transmission and population vaccine sentiment predicts the same patterns. Crucially, critical slowing down begins long before a system actually reaches a tipping point. Thus, it may be possible to develop analytical tools to detect populations at heightened risk of a future episode of widespread vaccine refusal.
Vaccine refusal can lead to renewed outbreaks of previously eliminated diseases and even delay global eradication. Vaccinating decisions exemplify a complex, coupled system where vaccinating behavior and disease dynamics influence one another. Such systems often exhibit critical phenomena—special dynamics close to a tipping point leading to a new dynamical regime. For instance, critical slowing down (declining rate of recovery from small perturbations) may emerge as a tipping point is approached. Here, we collected and geocoded tweets about measles–mumps–rubella vaccine and classified their sentiment using machine-learning algorithms. We also extracted data on measles-related Google searches. We find critical slowing down in the data at the level of California and the United States in the years before and after the 2014–2015 Disneyland, California measles outbreak. Critical slowing down starts growing appreciably several years before the Disneyland outbreak as vaccine uptake declines and the population approaches the tipping point. However, due to the adaptive nature of coupled behavior–disease systems, the population responds to the outbreak by moving away from the tipping point, causing “critical speeding up” whereby resilience to perturbations increases. A mathematical model of measles transmission and vaccine sentiment predicts the same qualitative patterns in the neighborhood of a tipping point to greatly reduced vaccine uptake and large epidemics. These results support the hypothesis that population vaccinating behavior near the disease elimination threshold is a critical phenomenon. Developing new analytical tools to detect these patterns in digital social data might help us identify populations at heightened risk of widespread vaccine refusal.

Ethical review and qualitative research competence: Guidance for reviewers and applicants

Research Ethics
Volume 13, Issue 3-4, July-October 2017

Ethical review and qualitative research competence: Guidance for reviewers and applicants
Julie Mooney-Somers, Anna Olsen
First Published November 30, 2016; pp. 128–138
It is difficult to consider, describe or address the ethical issues particular to qualitative research without experience and understanding of the technicalities of qualitative methodologies. The Australian National Statement on the Ethical Conduct of Research Involving Humans charges researchers with a responsibility to demonstrate that they have the appropriate experience, qualifications and competence for their proposed research. Ethical review committees have the responsibility to judge claimed research competence. This article provides practical guidance to researchers and review committees on using formal qualifications and training, explicit claims of competence, and markers of in/competence to assess qualitative research competence.

Research with pregnant women: a call to action

Reproductive Health
[Accessed 16 December 2017]

Research with pregnant women: a call to action
Despite a global need for the use of medication during pregnancy, the medical research community lacks robust evidence for safety and efficacy of treatments and preventives often taken by pregnant women.
Authors: Margaret Olivia Little and Marisha N. Wickremsinhe
Citation: Reproductive Health 2017 14(Suppl 3):156
Published on: 14 December 2017

Protected to death: systematic exclusion of pregnant women from Ebola virus disease trials

Reproductive Health
[Accessed 16 December 2017]

Protected to death: systematic exclusion of pregnant women from Ebola virus disease trials
Authors: Melba F. Gomes, Vânia de la Fuente-Núñez, Abha Saxena and Annette C. Kuesel
Citation: Reproductive Health 2017 14(Suppl 3):172
Published on: 14 December 2017
For 30 years, women have sought equal opportunity to be included in trials so that drugs are equitably studied in women as well as men; regulatory guidelines have changed accordingly. Pregnant women, however, continue to be excluded from trials for non-obstetric conditions, though they have been included for trials of life-threatening diseases because prospects for maternal survival outweighed potential fetal risks. Ebola virus disease is a life-threatening infection without approved treatments or vaccines. Previous Ebola virus (EBOV) outbreak data showed 89–93% maternal and 100% fetal/neonatal mortality. Early in the 2013–2016 EBOV epidemic, an expert panel pointed to these high mortality rates and the need to prioritize and preferentially allocate unregistered interventions in favor of pregnant women (and children). Despite these recommendations and multiple ethics committee requests for their inclusion on grounds of justice, equity, and medical need, pregnant women were excluded from all drug and vaccine trials in the affected countries, either without justification or on grounds of potential fetal harm. An opportunity to offer pregnant women the same access to potentially life-saving interventions as others, and to obtain data to inform their future use, was lost. Once again, pregnant women were denied autonomy and their right to decide.
We recommend that, without clear justification for exclusion, pregnant women are included in clinical trials for EBOV and other life-threatening conditions, with lay language on risks and benefits in information documents, so that pregnant women can make their own decision to participate. Their automatic exclusion from trials for other conditions should be questioned.

Nubia’s mother: being pregnant in the time of experimental vaccines and therapeutics for Ebola

Reproductive Health
[Accessed 16 December 2017]

Nubia’s mother: being pregnant in the time of experimental vaccines and therapeutics for Ebola
Authors: Séverine Caluwaerts
Citation: Reproductive Health 2017 14(Suppl 3):157
Published on: 14 December 2017
During the 2014–2016 Ebola epidemic, Médecins Sans Frontières (MSF) treated Ebola-positive pregnant women in its Ebola Treatment Centers (ETCs). For pregnant women with confirmed Ebola virus disease, inclusion in clinical vaccine/drug/therapeutic trials was complicated. Despite their extremely high Ebola-related mortality in previous epidemics (89–93%) and a neonatal mortality of 100%, theoretical concerns about safety of vaccines and therapeutics in pregnancy were invoked, limiting pregnant women’s access to an experimental live attenuated vaccine and brincidofovir, an experimental antiviral. Favipiravir, another experimental antiviral, was made available to pregnant women only after extensive negotiations and under a ‘Monitored Emergency Use of Unregistered and Experimental Interventions’ (MEURI) protocol. This paper describes the case of a pregnant woman who presented to the ETCs near the end of the Ebola epidemic in Guinea. The pregnant patient was admitted with confirmed Ebola disease. She was previously denied access to potentially protective vaccination due to pregnancy, and access to experimental ZMapp was only possible through a randomized clinical trial (presenting a 50% chance of not receiving ZMapp). She received favipiravir, but died of Ebola-related complications. The infant, born in the ETC, tested positive for Ebola at birth. The infant received ZMapp (under MEURI access outside of the clinical trial), an experimental drug GS5734, and a buffy coat of an Ebola survivor, and survived. Though the infant did have access to experimental therapeutics within 24 h of birth, access to other experimental compounds for her mother was denied, raising serious ethical concerns.

Ethical considerations in developing an evidence base for pre-exposure prophylaxis in pregnant women

Reproductive Health
[Accessed 16 December 2017]

Ethical considerations in developing an evidence base for pre-exposure prophylaxis in pregnant women
Though many women in need of access to HIV preventive regimes are pregnant, there is a dearth of data to guide these care decisions. While oral pre-exposure prophylaxis (PrEP) has been shown to prevent HIV inf…
Authors: Kristen A. Sullivan and Anne D. Lyerly
Citation: Reproductive Health 2017 14(Suppl 3):171
Published on: 14 December 2017

Ethical challenges posed by clinical trials in preterm labor: a case study

Reproductive Health
[Accessed 16 December 2017]

Ethical challenges posed by clinical trials in preterm labor: a case study
This paper explores the ethical implications of a randomized double-blind clinical trial aimed to determine effectiveness and safety of an oxytocin receptor antagonist versus a betamimetic in the treatment of …
Authors: Sofía P. Salas
Citation: Reproductive Health 2017 14(Suppl 3):168
Published on: 14 December 2017

Enrolling pregnant women in research: ethical challenges encountered in Lao PDR (Laos)

Reproductive Health
[Accessed 16 December 2017]

Enrolling pregnant women in research: ethical challenges encountered in Lao PDR (Laos)
Laos has the highest maternal mortality ratio in mainland Southeast Asia but there has been little research conducted with pregnant women. We aim to discuss ethical challenges in enrolling pregnant women in re…
Authors: Vilada Chansamouth, Rose McGready, Danoy Chommanam, Soukanya Homsombath, Mayfong Mayxay and Paul N. Newton
Citation: Reproductive Health 2017 14(Suppl 3):167
Published on: 14 December 2017

The global forum on bioethics in research meeting, “ethics of research in pregnancy”: emerging consensus themes and outputs

Reproductive Health
[Accessed 16 December 2017]

The global forum on bioethics in research meeting, “ethics of research in pregnancy”: emerging consensus themes and outputs
Research during pregnancy is affected by multiple ethical challenges which have not received sufficient international attention and consideration from the bioethics, clinical, and policymaking communities work…
Authors: Adrienne Hunt, Natalie Banner and Katherine Littler
Citation: Reproductive Health 2017 14(Suppl 3):158
Published on: 14 December 2017

Durability and correlates of vaccine protection against Zika virus in rhesus monkeys

Science Translational Medicine
13 December 2017    Vol 9, Issue 420

Research Articles
Durability and correlates of vaccine protection against Zika virus in rhesus monkeys
By Peter Abbink, Rafael A. Larocca, Kittipos Visitsunthorn, Michael Boyd, Rafael A. De La Barrera, Gregory D. Gromowski, Marinela Kirilova, Rebecca Peterson, Zhenfeng Li, Ovini Nanayakkara, Ramya Nityanandam, Noe B. Mercado, Erica N. Borducchi, Abishek Chandrashekar, David Jetton, Shanell Mojta, Priya Gandhi, Jake LeSuer, Shreeya Khatiwada, Mark G. Lewis, Kayvon Modjarrad, Richard G. Jarman, Kenneth H. Eckels, Stephen J. Thomas, Nelson L. Michael, Dan H. Barouch
Science Translational Medicine13 Dec 2017 Full Access
Not all vaccines afford robust protection against ZIKV challenge in rhesus monkeys at 1 year after vaccination
Patience pays off
As an individual may not encounter the pathogen for years after they have been vaccinated, efficacious vaccines typically require induction of long-lasting immunity. Abbink and colleagues vaccinated nonhuman primates with one of several candidate Zika virus vaccines and then waited an entire year before conducting a viral challenge. These vaccines had all shown promising results in previous experiments with a more immediate challenge, but here, one vaccine faltered, likely due to waning antibodies. The researchers performed more experiments to suggest that circulating antibodies are mediating protection for these vaccines. These results are useful for Zika virus vaccine development and instructive for vaccine development in general.
An effective Zika virus (ZIKV) vaccine will require long-term durable protection. Several ZIKV vaccine candidates have demonstrated protective efficacy in nonhuman primates, but these studies have typically involved ZIKV challenge shortly after vaccination at peak immunity. We show that a single immunization with an adenovirus vector–based vaccine, as well as two immunizations with a purified inactivated virus vaccine, afforded robust protection against ZIKV challenge in rhesus monkeys at 1 year after vaccination. In contrast, two immunizations with an optimized DNA vaccine, which provided complete protection at peak immunity, resulted in reduced protective efficacy at 1 year that was associated with declining neutralizing antibody titers to subprotective levels. These data define a microneutralization log titer of 2.0 to 2.1 as the threshold required for durable protection against ZIKV challenge in this model. Moreover, our findings demonstrate that protection against ZIKV challenge in rhesus monkeys is possible for at least 1 year with a single-shot vaccine.

Attitudes about adult vaccines and reminder/recall in a safety net population

Volume 35, Issue 52  Pages 7213–7346 (19 December 2017)

Attitudes about adult vaccines and reminder/recall in a safety net population
Original research article
Pages 7292–7296
Karen Albright, Laura P. Hurley, Steven Lockhart, Dennis Gurfinkel, … Allison Kempe
Little is known about adult patients’ attitudes toward vaccination and preferences for reminder/recall. The objective of this study was to determine patient perspectives on adult vaccines generally; attitudes about Tdap, pneumococcal polysaccharide (PPSV-23), and seasonal influenza vaccines specifically; and preferences for adult reminder/recall delivery. Twelve focus groups were conducted with 68 patients in a safety net health system. The sample was stratified by preferred language (English or Spanish), age (18–64 or 65+), and health status (with or without chronic conditions). Participants expressed positive attitudes toward vaccines generally, but had little knowledge of specific vaccines other than influenza, about which they expressed concerns. Although none reported previous experience receiving reminder/recall notices for adult vaccines, all were in favor of receiving them. These results suggest potential patient interest in greater adoption of evidence-based methods to improve immunization rates, and highlight the need for improved communication between providers and patients about adult vaccines.

Beneficiary characteristics and vaccinations in the end-stage renal disease Medicare beneficiary population, an analysis of claims data 2006–2015

Volume 35, Issue 52  Pages 7213–7346 (19 December 2017)

Beneficiary characteristics and vaccinations in the end-stage renal disease Medicare beneficiary population, an analysis of claims data 2006–2015
Original research article
Pages 7302–7308
Angela K. Shen, Jeffrey A. Kelman, Rob Warnock, Weiwei Zhang, … Bruce G. Gellin

Adjuvant Probiotics and the Intestinal Microbiome: Enhancing Vaccines and Immunotherapy Outcomes

Vaccines — Open Access Journal
(Accessed 16 December 2017)

Open Access  Review
Adjuvant Probiotics and the Intestinal Microbiome: Enhancing Vaccines and Immunotherapy Outcomes
by Luis Vitetta, Emma Tali Saltzman, Michael Thomsen, Tessa Nikov and Sean Hall
Vaccines 2017, 5(4), 50; doi:10.3390/vaccines5040050 – 11 December 2017
Immune defence against pathogenic agents comprises the basic premise for the administration of vaccines. Vaccinations have hence prevented millions of infectious illnesses, hospitalizations and mortality. Acquired immunity comprises antibody and cell mediated responses and is characterized by its specificity and memory. Along a similar congruent yet diverse mode of disease prevention, the human host has negotiated from in utero and at birth with the intestinal commensal bacterial cohort to maintain local homeostasis in order to achieve immunological tolerance in the new born. The advent of the Human Microbiome Project has redefined an appreciation of the interactions between the host and bacteria in the intestines from one of a collection of toxic waste to one of a symbiotic existence. Probiotics comprise bacterial genera thought to provide a health benefit to the host. The intestinal microbiota has profound effects on local and extra-intestinal end organ physiology. As such, we further posit that the adjuvant administration of dedicated probiotic formulations can encourage the intestinal commensal cohort to beneficially participate in the intestinal microbiome-intestinal epithelia-innate-cell mediated immunity axes and cell mediated cellular immunity with vaccines aimed at preventing infectious diseases whilst conserving immunological tolerance. The strength of evidence for the positive effect of probiotic administration on acquired immune responses has come from various studies with viral and bacterial vaccines. We posit that the introduction early of probiotics may provide significant beneficial immune outcomes in neonates prior to commencing a vaccination schedule or in elderly adults prior to the administration of vaccinations against influenza viruses

ISPOR Code of Ethics 2017 (4th Edition)

Value in Health                   
December 2017 Volume 20, Issue 10, p1227-1440

ISPOR Code of Ethics 2017 (4th Edition)
Jessica Santos, Francis Palumbo, Elizabeth Molsen-David, Richard J. Willke, Louise Binder, Michael Drummond, Anita Ho, William D. Marder, Louise Parmenter, Gurmit Sandhu, Asrul A. Shafie, David Thompson
Published online: December 1, 2017

As the leading health economics and outcomes research (HEOR) professional society, ISPOR has a responsibility to establish a uniform, harmonized international code for ethical conduct. ISPOR has updated its 2008 Code of Ethics to reflect the current research environment. This code addresses what is acceptable and unacceptable in research, from inception to the dissemination of its results.
There are nine chapters: 1 – Introduction; 2 – Ethical Principles respect, beneficence and justice with reference to a non-exhaustive compilation of international, regional, and country-specific guidelines and standards; 3 – Scope HEOR definitions and how HEOR and the Code relate to other research fields; 4 – Research Design Considerations primary and secondary data related issues, e.g., participant recruitment, population and research setting, sample size/site selection, incentive/honorarium, administration databases, registration of retrospective observational studies and modeling studies; 5 – Data Considerations privacy and data protection, combining, verification and transparency of research data, scientific misconduct, etc.; 6 – Sponsorship and Relationships with Others (roles of researchers, sponsors, key opinion leaders and advisory board members, research participants and institutional review boards (IRBs) / independent ethics committees (IECs) approval and responsibilities); 7 – Patient Centricity and Patient Engagement new addition, with explanation and guidance; 8 – Publication and Dissemination; and 9 – Conclusion and Limitations.

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

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

Health Policy and Planning
Published: 11 December 2017
Social costs of illicit financial flows in low- and middle-income countries: the case of infant vaccination coverage
Bienvenido Ortega Jesús Sanjuán Antonio Casquero
The liberalization of capital flows is generally associated with prospects of higher growth. However, in developing countries, opening the capital account may also facilitate the flow of capital out of the country through illicit financial flows (IFFs). Given that IFFs drain the scarce public resources available to finance the provision of public goods and services, the extent of illicit capital flows from developing countries is serious cause for concern. In this context, as a first step in analysing the social costs of IFFs in developing countries, this article studied the relationship between IFFs and infant immunization coverage rates. Data for 56 low- and middle-income countries for the period 2002–13 were used in the empirical analysis. The main result was that the relative level of IFFs to total trade negatively impacted vaccination coverage but only in the case of countries with very high levels of perceived corruption. In this case, the total effect of an annual 1 p.p. increase in the ratio of IFFs to total trade was to reduce the level of vaccination coverage rates over the coming years by 0.19 p.p. Given that there was an annual average of 18 million infants in this cluster of 25 countries, this result suggests that at least 34 000 children may not receive this basic health care intervention in the future as a consequence of this increase in IFFs in any particular year.

2017, 6(4), 65;
Differences of Rotavirus Vaccine Effectiveness by Country: Likely Causes and Contributing Factors
U Desselberger
Rotaviruses are a major cause of acute gastroenteritis in infants and young children worldwide and in many other mammalian and avian host species. Since 2006, two live-attenuated rotavirus vaccines, Rotarix® and RotaTeq®, have been licensed in >100 countries and are applied as part of extended program of vaccination (EPI) schemes of childhood vaccinations. Whereas the vaccines have been highly effective in high-income countries, they were shown to be considerably less potent in low- and middle-income countries. Rotavirus-associated disease was still the cause of death in >200,000 children of <5 years of age worldwide in 2013, and the mortality is concentrated in countries of sub-Saharan Africa and S.E. Asia. Various factors that have been identified or suggested as being involved in the differences of rotavirus vaccine effectiveness are reviewed here. Recognition of these factors will help to achieve gradual worldwide improvement of rotavirus vaccine effectiveness.

Public Health
05 Dec 2017, 154:102-109
Self-reported influenza vaccination rates and attitudes towards vaccination among health care workers: results of a survey in a German university hospital.
MH Hagemeister, NK Stock, T Ludwig, P Heuschmann…
The objective of this survey was to analyse vaccination rates and attitudes towards vaccination among health care workers (HCWs). The period prevalence of self-reported acute respiratory infections in the influenza season 2014/2015 was examined.A cross-sectional study was conducted among HCWs of a German university hospital using an anonymised questionnaire. Recruitment was performed by providing all medical and nursing staff a paper questionnaire with an invitation to participate.Descriptive aggregated data were generated from digitalised questionnaires for all variables. Differences in categorical variables were analysed by Chi-squared test. Textual data were analysed by an iterative process based on the grounded theory by Glaser and Strauss.The response rate was 31% (677/2186). Probable influenza was described by 9% (64/677) of the participants. The overall self-reported vaccination rate was 55% (366/666). Self-reported vaccination rate was higher in physicians (172/239, 72%) than in nursing staff (188/418, 45%). HCWs in paediatrics (103/148, 70%) more likely received vaccines than HCWs in surgery (31/84, 37%). Most vaccinations were provided by medical staff on the wards (164/368, 45%). Self-reported lost work-time due to adverse events after vaccination was low (6/336, 2%). Eight categories for vaccine refusal were identified, whereof doubts about effectiveness and indication of the vaccine was most frequently mentioned (72/202, 36%).Efforts to promote vaccination should focus on nursing staff and should provide scientific evidence on effectiveness, adverse effects, and the benefits of health care workers’ vaccination for patients. Administering vaccines at the workplace proved to be a successful strategy in our setting. Studies are needed to assess the frequency of influenza causing disease in HCWs.

Medical Decision Making : an International Journal of the Society for Medical Decision Making
DOI: 10.1177/0272989X17704858
Effects of Anti-Versus Pro-Vaccine Narratives on Responses by Recipients Varying in Numeracy: A Cross-sectional Survey-Based Experiment.
W de Bruin Bruine, A Wallin, AM Parker, J Strough…
To inform their health decisions, patients may seek narratives describing other patients’ evaluations of their treatment experiences. Narratives can provide anti-treatment or pro-treatment evaluative meaning that low-numerate patients may especially struggle to derive from statistical information. Here, we examined whether anti-vaccine (v. pro-vaccine) narratives had relatively stronger effects on the perceived informativeness and judged vaccination probabilities reported among recipients with lower (v. higher) numeracy. Participants ( n=1,113) from a nationally representative US internet panel were randomly assigned to an anti-vaccine or pro-vaccine narrative, as presented by a patient discussing a personal experience, a physician discussing a patient’s experience, or a physician discussing the experiences of 50 patients. Anti-vaccine narratives described flu experiences of patients who got the flu after getting vaccinated; pro-vaccine narratives described flu experiences of patients who got the flu after not getting vaccinated. Participants indicated their probability of getting vaccinated and rated the informativeness of the narratives. Participants with lower numeracy generally perceived narratives as more informative. By comparison, participants with higher numeracy rated especially anti-vaccine narratives as less informative. Anti-vaccine narratives reduced the judged vaccination probabilities as compared with pro-vaccine narratives, especially among participants with lower numeracy. Mediation analyses suggested that low-numerate individuals’ vaccination probabilities were reduced by anti-vaccine narratives-and, to a lesser extent, boosted by pro-vaccine narratives-because they perceived narratives to be more informative. These findings were similar for narratives provided by patients and physicians. Patients with lower numeracy may rely more on narrative information when making their decisions. These findings have implications for the development of health communications and decision aids.

Media/Policy Watch

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.
The Atlantic
Accessed 16 December 2017
40 Years Later, Some Survivors of the First Ebola Outbreak Are Still Immune
The antibodies in their blood might hold the key to future vaccines.
Ed Yong, Dec 14, 2017

New Yorker
Accessed 16 December 2017
A Reporter at Large
December 18 & 25, 2017 Issue
Ophelia Dahl’s National Health Service
Partners in Health wants to rebuild entire countries’ medical systems, and bring health care to some of the poorest people on earth.
By Ariel Levy
New York Times
Accessed 16 December 2017
Former Philippine President Defends Controversial Dengue Programme
By REUTERSDEC. 14, 2017, 6:45 A.M. E.S.T
Washington Post
Accessed 16 December 2017
Diphtheria deaths in Indonesia spark immunization campaign
Niniek Karmini | AP · · Dec 11, 2017

AKARTA, Indonesia — Indonesia is immunizing millions of children and teenagers against diphtheria after the disease killed 38 people, mostly children, since January.

Children in school uniforms and toddlers clinging to their parents received shots at a high school in Indonesia’s capital, Jakarta, on the first day of the campaign Monday.

Diphtheria is a bacterial disease that can cause breathing difficulties, heart failure and paralysis. It was more or less eradicated in Indonesia in the 1990s but health officials say it has re-emerged in the past four years because immunization rates have dropped, partly reflecting fears about vaccines.

The first stage of the $112 million campaign aims to vaccinate 8 million people under the age of 19 in Jakarta and the populous provinces of Banten and West Java.

The outbreak is “likely due to some people refusing immunization which causes their children’s antibodies and resistance to be low,” Health Minister Nila Moeloek said after visiting a hospital where more than more than 30 diphtheria patients were being treated…

Fifteen Years Isn’t That Long: The SDGs and Holistic Development

Think Tanks et al

Center for Global Development
Accessed 16 December 2017
Fifteen Years Isn’t That Long: The SDGs and Holistic Development
Blog Post  12/15/17
Charles Kenny
Do the fifteen year targets of the SDGs stand in the way of their vision of integration and sustainability? If you wanted to achieve long term development progress, you’d probably focus on technology change, learning and innovation in policies, and improving institutional functioning. If you wanted to improve outcomes in fifteen years, you’d probably focus on throwing money at technical solutions. The problems with the second approach include that we don’t have the money, and the technical solutions won’t necessarily work best over the long term.

Vaccines and Global Health: The Week in Review 9 Dec 2017

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

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

 pdf version A pdf of the current issue is available here: Vaccines and Global Health_The Week in Review_9 Dec 2017

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

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

Support this knowledge-sharing service: Your financial support helps us cover our costs and to address a current shortfall in our annual operating budget. Click here to donate and thank you in advance for your contribution.

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

Milestones :: Perspectives

Milestones :: Perspectives
Editor’s Note:
WHO published a new Fact Sheet titled “Human rights and health” which we present below [full text]. In reading it, our perspective that full, life-course immunization is and should be the core of “health as a human right” was strengthened.
WHO Fact Sheet – Human rights and health
December 2017
Key facts
:: The WHO Constitution (1946) envisages “…the highest attainable standard of health as a fundamental right of every human being.”
:: Understanding health as a human right creates a legal obligation on states to ensure access to timely, acceptable, and affordable health care of appropriate quality as well as to providing for the underlying determinants of health, such as safe and potable water, sanitation, food, housing, health-related information and education, and gender equality.
:: A States’ obligation to support the right to health – including through the allocation of “maximum available resources” to progressively realise this goal – is reviewed through various international human rights mechanisms, such as the Universal Periodic Review, or the Committee on Economic, Social and Cultural Rights. In many cases, the right to health has been adopted into domestic law or Constitutional law.
:: A rights-based approach to health requires that health policy and programmes must prioritize the needs of those furthest behind first towards greater equity, a principle that has been echoed in the recently adopted 2030 Agenda for Sustainable Development and Universal Health Coverage. (1)
:: The right to health must be enjoyed without discrimination on the grounds of race, age, ethnicity or any other status. Non-discrimination and equality requires states to take steps to redress any discriminatory law, practice or policy.
:: Another feature of rights-based approaches is meaningful participation. Participation means ensuring that national stakeholders – including non-state actors such as non-governmental organizations – are meaningfully involved in all phases of programming: assessment, analysis, planning, implementation, monitoring and evaluation.

“The right to the highest attainable standard of health” implies a clear set of legal obligations on states to ensure appropriate conditions for the enjoyment of health for all people without discrimination.

The right to health is one of a set of internationally agreed human rights standards, and is inseparable or ‘indivisible’ from these other rights. This means achieving the right to health is both central to, and dependent upon, the realisation of other human rights, to food, housing, work, education, information, and participation.

The right to health, as with other rights, includes both freedoms and entitlements:
:: Freedoms include the right to control one’s health and body (for example, sexual and reproductive rights) and to be free from interference (for example, free from torture and non-consensual medical treatment and experimentation).
:: Entitlements include the right to a system of health protection that gives everyone an equal opportunity to enjoy the highest attainable level of health.

Focus on disadvantaged populations
Disadvantage and marginalization serve to exclude certain populations in societies from enjoying good health. Three of the world’s most fatal communicable diseases – malaria, HIV/AIDS and tuberculosis – disproportionately affect the world’s poorest populations, and in many cases are compounded and exacerbated by other inequalities and inequities including gender, age, sexual orientation or gender identity and migration status. Conversely the burden of non-communicable diseases – often perceived as affecting high-income countries – is increasing disproportionately among lower-income countries and populations, and is largely associated with lifestyle and behaviour factors as well as environmental determinants, such as safe housing, water and sanitation that are inextricably linked to human rights.

A focus on disadvantage also reveals evidence of those who are exposed to greater rates of ill-health and face significant obstacles to accessing quality and affordable healthcare, including indigenous populations. While data collection systems are often ill-equipped to capture data on these groups, reports show that these populations have higher mortality and morbidity rates, due to noncommunicable diseases such as cancer, cardiovascular diseases, and chronic respiratory disease. These populations may also be the subject of laws and policies that further compound their marginalization and make it harder for them to access healthcare prevention, treatment, rehabilitation and care services.

Violations of human rights in health
Violations or lack of attention to human rights can have serious health consequences. Overt or implicit discrimination in the delivery of health services – both within the health workforce and between health workers and service users – acts as a powerful barrier to health services, and contributes to poor quality care.

Mental ill-health often leads to a denial of dignity and autonomy, including forced treatment or institutionalization, and disregard of individual legal capacity to make decisions. Paradoxically, mental health is still given inadequate attention in public health, in spite of the high levels of violence, poverty and social exclusion that contribute to worse mental and physical health outcomes for people with mental health disorders.

Violations of human rights not only contribute to and exacerbate poor health, but for many, including people with disabilities, indigenous populations, women living with HIV, sex workers, people who use drugs, transgender and intersex people, the health care setting presents a risk of heightened exposure to human rights abuses – including coercive or forced treatment and procedures.

Human rights-based approaches
A human rights-based approach to health provides a set of clear principles for setting and evaluating health policy and service delivery, targeting discriminatory practices and unjust power relations that are at the heart of inequitable health outcomes.

In pursuing a rights-based approach, health policy, strategies and programmes should be designed explicitly to improve the enjoyment of all people to the right to health, with a focus on the furthest behind first. The core principles and standards of a rights-based approach are detailed below.

Core principles of human rights
States and other duty-bearers are answerable for the observance of human rights. However, there is also a growing movement recognising the importance of other non-state actors such as businesses in the respect and protection of human rights. (2)

Equality and non-discrimination
The principle of non-discrimination seeks ‘…to guarantee that human rights are exercised without discrimination of any kind based on race, colour, sex, language, religion, political, or other opinion, national or social origin, property, birth or other status such as disability, age, marital and family status, sexual orientation and gender identity, health status, place of residence, economic and social situation’.

Any discrimination, for example in access to health care, as well as in means and entitlements for achieving this access, is prohibited on the basis of race, colour, sex, language, religion, political or other opinion, national or social origin, property, birth, physical or mental disability, health status (including HIV/AIDS), sexual orientation ,and civil, political, social or other status, which has the intention or effect of impairing the equal enjoyment or exercise of the right to health.

The principle of non-discrimination and equality requires WHO to address discrimination in guidance, policies, and practices, such as relating to the distribution and provision of resources and health services. Non-discrimination and equality are key measures required to address the social determinants affecting the enjoyment of the right to health. Functioning national health information systems and availability of disaggregated data are essential to be able to identify the most vulnerable groups and diverse needs.

Participation requires ensuring that all concerned stakeholders including non-state actors have ownership and control over development processes in all phases of the programming cycle: assessment, analysis, planning, implementation, monitoring, and evaluation. Participation goes well beyond consultation or a technical addition to project design; it should include explicit strategies to empower citizens, especially the most marginalized, so that their expectations are recognised by the State.

Participation is important to accountability as it provides “…checks and balances which do not allow unitary leadership to exercise power in an arbitrary manner”.

Universal, indivisible and interdependent
Human rights are universal and inalienable. They apply equally, to all people, everywhere, without distinction. Human Rights standards – to food, health, education, to be free from torture, inhuman or degrading treatment – are also interrelated. The improvement of one right facilitates advancement of the others. Likewise, the deprivation of one right adversely affects the others.

Core elements of a right to health
Progressive realization using maximum available resources
No matter what level of resources they have at their disposal, progressive realisation requires that governments take immediate steps within their means towards the fulfilment of these rights. Regardless of resource capacity, the elimination of discrimination and improvements in the legal and juridical systems must be acted upon with immediate effect.

States should not allow the existing protection of economic, social, and cultural rights to deteriorate unless there are strong justifications for a retrogressive measure. For example, introducing school fees in secondary education which had formerly been free of charge would constitute a deliberate retrogressive measure. To justify it, a State would have to demonstrate that it adopted the measure only after carefully considering all the options, assessing the impact and fully using its maximum available resources.

Core components of the right to health
The right to health (Article 12) was defined in General Comment 14 of the Committee on Economic, Social and Cultural Rights – a committee of Independent Experts, responsible for overseeing adherence to the Covenant. (4) The right includes the following core components:

Refers to the need for a sufficient quantity of functioning public health and health care facilities, goods and services, as well as programmes for all. Availability can be measured through the analysis of disaggregated data to different and multiple stratifiers including by age, sex, location and socio-economic status and qualitative surveys to understand coverage gaps and health workforce coverage

Requires that health facilities, goods, and services must be accessible to everyone. Accessibility has four overlapping dimensions:
:: non-discrimination
:: physical accessibility
:: economical accessibility (affordability)
:: information accessibility.

Assessing accessibility may require analysis of barriers – physical financial or otherwise – that exist, and how they may affect the most vulnerable, and call for the establishment or application of clear norms and standards in both law and policy to address these barriers, as well as robust monitoring systems of health-related information and whether this information is reaching all populations.

Relates to respect for medical ethics, culturally appropriate, and sensitivity to gender. Acceptability requires that health facilities, goods, services and programmes are people-centred and cater for the specific needs of diverse population groups and in accordance with international standards of medical ethics for confidentiality and informed consent.

Facilities, goods, and services must be scientifically and medically approved. Quality is a key component of Universal Health Coverage, and includes the experience as well as the perception of health care. Quality health services should be:
:: Safe – avoiding injuries to people for whom the care is intended;
:: Effective – providing evidence-based healthcare services to those who need them;
:: People-centred – providing care that responds to individual preferences, needs and values;
:: Timely – reducing waiting times and sometimes harmful delays.
:: Equitable – providing care that does not vary in quality on account of gender, ethnicity, geographic location, and socio-economic status;
:: Integrated – providing care that makes available the full range of health services throughout the life course;
:: Efficient – maximizing the benefit of available resources and avoiding waste

WHO response
WHO has made a commitment to mainstream human rights into healthcare programmes and policies on national and regional levels by looking at underlying determinants of health as part of a comprehensive approach to health and human rights.

In addition, WHO has been actively strengthening its role in providing technical, intellectual, and political leadership on the right to health including:
:: strengthening the capacity of WHO and its Member States to integrate a human rights-based approach to health;
:: advancing the right to health in international law and international development processes; and
:: advocating for health-related human rights, including the right to health.

Addressing the needs and rights of individuals at different stages across the life course requires taking a comprehensive approach within the broader context of promoting human rights, gender equality, and equity.

As such, WHO promotes a concise and unifying framework that builds on existing approaches in gender, equity, and human rights to generate more accurate and robust solutions to health inequities. The integrated nature of the framework is an opportunity to build on foundational strengths and complementarities between these approaches to create a cohesive and efficient approach to promote health and well-being for all.


  1. Transforming our World: The 2030 Agenda for Sustainable Development.
    UN General Assembly. 2015. 21 October. UN Doc. A/RES/70/1.
  2. General comment No. 20: Non-discrimination in economic, social and cultural rights
    Committee on Economic, Social and Cultural Rights. 2009.
  3. Guiding principles for business and human rights, Implementing the United Nations “Protect, Respect and Remedy” Framework
    Office of the high Commissioner for Human Rights, Geneva, 2011.

CESCR General Comment No. 14: The Right to the Highest Attainable Standard of Health (Art. 12)
CESCR (Committee on Economic, Social, and Cultural Rights). 2000. ). 11 August. Doc. E/C.12/2000/4.