Vaccines and Global Health: The Week in Review 21 April 2018

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

Summary of the Meeting of the WHO Strategic Advisory Group of Experts on immunization, 17-18 April 2018

Milestones :: Perspectives

  
Summary of the Meeting of the WHO Strategic Advisory Group of Experts on immunization, 17-18 April 2018
The Strategic Advisory Group of Experts [SAGE] on Immunization1 met on 1718 April 2018. This full report will be published on 8 June 2018 in the Weekly Epidemiological Record.

Malaria Vaccine Implementation Programme
SAGE was informed on the progress made on the implementation of the recommendation
made by SAGE and the Malaria Policy Advisory Committee (MPAC) in October 2015 on pilot
studies for the RTS,S/AS01 malaria vaccine. SAGE was provided an overview of the Malaria
Vaccine Implementation Programme (MVIP) and given a status update of preparatory
activities in the three pilot countries (Ghana, Kenya, Malawi).

The pilots consist of three components: 1) Sub-national introduction of the malaria vaccine in areas with moderate to high malaria transmission led by country immunization
programmes; 2) Rigorous evaluation, supported by country-based research institutions, to
measure the programmatic feasibility of delivering RTS,S/AS01, the vaccine’s impact on
mortality (overall and sex-specific) and the vaccine’s safety in the context of routine
immunization, with an emphasis on meningitis and cerebral malaria; 3) the manufacturer-sponsored observational Phase 4 studies with hospital and active surveillance as part of the
vaccine’s Risk Management Plan agreed between the manufacturer and the European
Medicines Agency (EMA) taking place in a small sub-set of the pilot areas.

SAGE was reassured that uptake of the RTS,S/A01 vaccine, as well as use of other vaccines
and childhood health interventions will be monitored through countries’ routine data
monitoring systems; three consecutive cross-sectional household surveys will provide
representative community estimates of RTS,S/AS01 coverage, along with coverage
estimates for other vaccines, for recommended malaria prevention and control measures,
and for other childhood health interventions of interest. In addition, a qualitative research
study will explore and document any changes in health-seeking behaviours and on health
service provision that may occur upon RTS,S/AS01 introduction. SAGE re-emphasized the
importance of communication and community engagement to ensure acceptance and
understanding of the new vaccine in the context of other malaria control interventions.
Experience from other efforts related to strengthening the second year of life (2YL) platform
could prove useful.

SAGE was reassured that the evaluation has been sufficiently powered to assess whether
the safety signals (i.e., meningitis and cerebral malaria) and the imbalance in mortality
between males and females identified during the Phase 3 trial are causally related to
RTS,S/AS01 vaccination.

SAGE agreed on the importance of having a framework to clarify how data collected through
the MVIP might be used to answer identified questions and inform future policy
recommendations for vaccine use beyond the pilots. SAGE specifically recommended the
modelling inputs incorporate different scenarios and levels of uncertainty to enable
interpretation of the MVIP results in the context of real world settings.
1 See http://www.who.int/immunization/sage/en/index.html, accessed April 20April 2018

Polio eradication
SAGE acknowledged the ongoing efforts of the Global Polio Eradication Initiative (GPEI) and
the progress achieved towards wild polio virus (WPV) eradication. SAGE shared concern
over continuing WPV circulation in Pakistan and Afghanistan through the active corridors of
transmission, as manifested through the continued detection of WPV1 in environmental
samples during 2016 and 2017.

SAGE noted that the IPV supply is sufficient to introduce IPV in routine immunization
globally in 2018, but not to conduct catch up campaigns for cohorts that did not receive IPV
because of supply constraints. SAGE reviewed the available data on fractional IPV (fIPV) and
emphasized that two doses of fIPV are superior to one full IPV dose. SAGE agreed that IPV
should not be used routinely in outbreak response except in specific situations such as
where there is co-circulation of WPV1 and cVDPV2 and in these instances fIPV should be
used. In addition, SAGE recommended that instead of using term “fractional” for fIPV, GPEI
should think of other term such as “intradermal” to avoid impression that fIPV is substandard.
Studies to examine duration of immunity and protection following two doses of
fIPV are in progress.

SAGE reviewed the Post Certification Strategy (PCS). This is a high-level working document
which aims to guide Member States and stakeholders on the polio-essential functions
required to sustain a polio-free world after WPV eradication and dissolution of GPEI. The
PCS does not provide specific or detailed country level guidance. Its aim is to serve as a
roadmap to ensure that the oversight, infrastructure and funding is in place to 1) contain
polioviruses, 2) protect populations from polio, and 3) retain capacity to detect and respond
to any poliovirus event. SAGE endorsed the content and approach of the PCS and agreed to
submit it for discussion at the World Health Assembly in May 2018.

In order to align GAP III and SAGE recommendations on IPV schedules, SAGE reviewed
recommendations on IPV schedules in countries with Poliovirus-Essential Facilities (PEFs).
While the majority of the 29 countries hosting PEFs are located in Europe and North
America, and have introduced exclusive or sequential IPV schedules, some countries are
currently only using a single dose of IPV (together with bOPV) in their immunization
schedule.

SAGE endorsed the proposal to align the recommendations on future IPV schedule for
countries hosting PEFs storing or manipulating WPVs and/or Sabin/OPV and recommends
that those countries with PEFs using a single dose of IPV should adjust their IPV schedule,
coverage targets and geographical scope as soon as possible but no later than at the time of
all OPV cessation.

SAGE requested the program to explore the extent to which a legal instrument such as the
International Health Regulation (IHR) could be used to ensure compliance with poliovirus
containment requirements defined in GAP III and the Containment Certification Scheme.

Policy recommendations on the use of the first licensed dengue vaccine
[See separate announcement just below]

Measles and Rubella
SAGE noted the substantial progress in the reduction of global measles incidence and
mortality since 2000. However, concerns were expressed around resurgence of measles in
some areas, particularly in the European region, and the measles outbreak in Venezuela that
has put the elimination status of the American Region at risk.

SAGE reviewed preliminary modelled scenarios, designed to approach an investment case
(IC) for measles and rubella eradication. The investment case in development is planned as
part of the response to the GVAP 2017 resolution at the World Health Assembly (WHA) to
provide a report to the 73rd WHA in 2020 on the epidemiology, resource requirements, and
feasibility of measles and rubella eradication.

SAGE recommended that the Measles Rubella (MR) Working Group (WG) should revise the
key scenarios to include a baseline scenario that reflects current vaccination efforts and
disease in the countries and a separate mortality reduction scenario, besides the
“eradication as soon as possible” scenario. The MR WG was requested to develop additional
eradication scenarios with different timelines and with different levels of achievements (for
example, elimination in all but a few countries and including the costs of reaching
inaccessible pockets and hard-to-reach populations). SAGE also highlighted the importance
of the inclusion of total cost when a decision regarding a global eradication target is
considered, as well as the cost of elimination-standard surveillance. Furthermore, the IC
should consider including the contribution of measles and rubella eradication effort towards
the prevention of other vaccine preventable diseases. This IC model is currently under
review by IVIR-AC and a revised version will be presented to SAGE for recommendations.

SAGE also reviewed the guidance tool for endemic countries on prioritizing measles and
rubella control/elimination activities in order to increase population immunity, prevent
outbreaks and achieve elimination. The approach proposed four country categories that
take into consideration the disease epidemiology, population immunity and capacity to
carry out elimination strategies. Guidance was then provided within each category on how
to best prioritize the control or elimination interventions/activities. SAGE agreed with the
overall approach and highlighted the need to include sub-national and sub-groups within
countries when assessing and addressing immunity gaps and the importance of including
civil society organizations (CSOs) and community participation as important elements for
successful interventions.

Full Public Health Value Propositions for Vaccines (FPHVPs)
The remit of IVB includes accelerating development of vaccines against priority pathogens,
identified through its Product Development for Vaccines Advisory Committee (PDVAC), and
supporting countries with policy decisions to introduce vaccines once they become available.
In addition, many of the vaccines currently in development are expected to be targeted
towards specific populations, depending on the burden of disease and context-specific
epidemiology. In resource-poor settings, increasingly robust evidence will be needed to
justify the inclusion of new vaccines in the context of other disease interventions over and
above many other public health priorities. With this in mind, key stakeholders are
advocating that there is a need to broaden the evaluation of vaccine value beyond the
demonstration of individual, direct health benefits and related costs that support licensure
to the evaluation of broader economic, societal and indirect impacts of vaccination at a
population level. Consideration of these data and evidence requirements that inform policy
decisions, prior to undertaking phase III pivotal clinical studies, could help to prioritize the
vaccines that would have the greatest impact, and reduce delays between licensure and
introduction encountered by vaccines such as the RTS,S malaria vaccine.2

A conceptual framework of pathways between immunisation and its proposed broader
economic and social benefits has been developed3, leading to publications on “Estimating
the full public health value of vaccination” and proposed methodology and measures to
quantify the economic elements.4, 5 This novel global health paradigm considers the
population impact of vaccination and encompasses measures of community benefits against
a range of outcomes, such as improvements in health inequity, financial risk protection,
reduction in long-term/on-going disability and a decrease in the development of antibiotic
resistance. IVB, under the auspices of PDVAC and IVIR-AC, is building on these efforts, to
develop an approach for describing the Full (i.e. articulating both the individual and
population benefits) Public Health Value Proposition for vaccines where there is a clear
public health need for, but a lack of investment in, developing vaccines for LMIC markets.
This FPHVP approach was presented to SAGE for information and discussion.

2 O’Brien K et al. Mind the gap: jumping from vaccine licensure to routine use The Lancet 387 1887-1889, 2016.
3 Jit M et al. The broader economic impact of vaccination: reviewing and appraising the strength of evidence. BMC Med. 2015 Sep 3;13:209.
4 Gessner BD et al. Estimating the full public health value of vaccination. Vaccine. 2017 Nov 1;35(46):6255-6263.
5 Wilder-Smith A et al. The public health value of vaccines beyond efficacy: methods, measures and outcomes. BMC Med. 2017 Jul 26;15(1):138.

Revised SAGE recommendation on use of dengue vaccine

Milestones :: Perspectives

Revised SAGE recommendation on use of dengue vaccine
19 April 2018
WHO published the recommendations of the Strategic Advisory Group of Experts on Immunization (SAGE) on the use of Dengvaxia® on 27 May 2016, and subsequently a WHO position paper on dengue vaccine on 29 July 2016.
 
Following the disclosure of new data on Dengvaxia® by its manufacturer, Sanofi Pasteur, on 29 November 2017 (as described in more detail below), WHO`s Global Advisory Committee on Vaccine Safety (GACVS) and the WHO Secretariat published interim statements on December 7, 20171, and December 22, 20172, respectively. WHO initiated a process engaging independent external experts to review the data in detail, and reconvened the SAGE working group on dengue vaccines. This process has led to revised recommendations from SAGE on 18 April 2018. An updated WHO position paper on dengue vaccine will be published in September 2018.
 
The purpose of this document is to supplement the WHO ”Question and Answer” document from December December 22, 20172.

Dengue is the most frequent and rapidly spreading mosquito-borne virus. The first dengue vaccine, CYD-TDV (Dengvaxia®) is currently licensed in twenty countries. The key findings from two large Phase 3 trials involving over 30,000 participants aged 2 to 16 years included:
:: Vaccine efficacy against virologically confirmed dengue, over a 25-month period from the first dose of a three-dose immunization regimen among 9-16 year olds was 65.6% and in this age-group, vaccination reduced severe dengue by 93% and dengue hospitalizations by 82%.
:: An increased risk of hospitalized dengue was seen in the 2 to 5-year age group in Year 3 of follow-up.
:: At the time of SAGE April 2016 meeting, this increased risk was not observed in those aged 9 years and above.

Because of the higher efficacy of the vaccine against dengue and the absence of an observed increased risk of hospitalized dengue observed in older children, licensure of the vaccine was sought in 2015 with an indication of 9 years and above. Mathematical modelling suggested that the public health benefits of vaccination could be maximized if dengue seropositivity in the age group targeted for vaccination was high.

WHO issued its position on the use of CYD-TDV in July 2016 based on recommendations provided by SAGE in April 2016, principally, that countries interested in introducing the vaccine consider its use only in those aged 9 years and above, and in areas with a seroprevalence of ≥70%, and not in areas below 50%. SAGE noted that the evidence of the absence of a safety issue in seronegative individuals aged 9 and above was based on the limited data set of 10%-20% of the trial population, and highlighted the urgent need to better describe the long-term benefit-risk ratio of CYD-TDV in seronegative individuals.

On 29 November 2017, Sanofi Pasteur announced the results of additional studies to better describe the benefit-risk in seronegative individuals. This was made possible through the use of a newly developed NS1-based antibody assay applied to blood samples taken 13 months after vaccination to retrospectively infer dengue serostatus at time of first vaccination.

The new analyses from the long-term safety follow-up indicated that:
:: Overall population level benefit of vaccination remains favorable, but the vaccine performs differently in seropositive versus seronegative individuals.
:: Vaccine efficacy (VE) against virologically confirmed symptomatic dengue was high among inferred baseline seropositive participants ≥9 years of age: 76% (95%CI: 63.9, to 84.0), but much lower among baseline seronegative participants: 38.8% (95%CI: –0.9 to 62.9%) in the first 25 months after the first dose of vaccine.
:: There is an increased risk of hospitalized and severe dengue in seronegative individuals starting about 30 months after the first dose.
:: In areas of 70% dengue seroprevalence, over a 5-year follow-up, for every 4 severe cases prevented in seropositive, there would be one excess severe case in seronegative per 1,000 vaccinees; for every 13 hospitalizations prevented in seropositive vaccinees, there would be 1 excess hospitalization in seronegative vaccinees per 1,000 vaccinees.

In light of the new evidence on the long-term safety issue in seronegative individuals, balanced against the documented efficacy and safety in seropositive individuals, SAGE carefully considered two strategies: population seroprevalence criteria versus pre-vaccination screening. SAGE weighed up the feasibility of population seroprevalence studies and individual pre-vaccination screening, heterogeneity of seroprevalence between and within countries, potential vaccine coverage rates, public confidence in national vaccination programmes, perceptions of ethical considerations with regard to population level benefit versus individual level risk, and communication issues.

SAGE acknowledged that currently both “population seroprevalence criteria” and “pre-vaccination screening” are programmatically difficult approaches for achieving high population protection from dengue.

Updated SAGE recommendations on the use of CYD-TDV (Dengvaxia®)
For countries considering vaccination as part of their dengue control program, a “pre-vaccination screening strategy” would be the preferred option, in which only dengue-seropositive persons are vaccinated.

Conventional serological testing for dengue virus IgG (e.g. dengue IgG ELISA) could be used to identify persons who have had previous dengue infections. Sensitivity and specificity of dengue IgG ELISA should be assessed in a local context, and will depend on the prevalence of other flaviviruses, and past use of flavivirus vaccines (such as Japanese encephalitis and yellow fever vaccines).

Currently available rapid diagnostic tests – despite their lower sensitivity and specificity to detect past dengue infection compared with conventional dengue IgG ELISA – could be considered in high transmission settings until better tests are available. In settings with high dengue transmission (high numbers of seropositives), a test with lower specificity might be acceptable.

The pre-test probability of an individual being seropositive will be higher in settings with high transmission. However, a pre-vaccination screening strategy may also be considered in low to moderate transmission settings. In settings with low transmission (high numbers of seronegatives) a test with high specificity is needed.

Given that no assay will be 100% specific, some truly seronegative individuals may be vaccinated due to a false positive test result. Furthermore, although the efficacy against dengue infections in seropositive individuals is high, it is still not complete. Hence, the limitations of CYD-TDV will need to be clearly communicated to populations offered vaccination.

There is a continued need to adhere to other disease preventive measures and to seek prompt medical care in the event of dengue-like symptoms, regardless of whether vaccinated or not. Vaccination should be considered as part of an integrated dengue prevention and control strategy together with well-executed and sustained vector control and the best evidence-based clinical care for all patients with dengue.

Decisions about implementing a “pre-vaccination screening” strategy with the currently available tests will require careful assessment at the country level, including consideration of the sensitivity and specificity of available tests and of local priorities, dengue epidemiology, country-specific dengue hospitalization rates, and affordability of both CYD-TDV and screening tests.

Age
Whether there are age-specific effects, independent of serostatus, is the subject of ongoing research. Currently, the vaccine should be used within the indicated age range, which is typically 9 to 45 years of age. The age to target for vaccination depends on the dengue transmission intensity in a given country, and will be lower in countries with high transmission, and higher in countries with low transmission. The optimal age group to be targeted is the age at which severe dengue disease incidence is highest, and this can be ascertained from national and subnational routine hospital surveillance data.

Schedule
In the absence of data on vaccine efficacy and safety with fewer than three doses, CYD-TDV is recommended as a three dose series given 6 months apart. Should a vaccine dose be delayed for any reason, it is not necessary to restart the course and the next dose in the series should be administered.

Booster
There are currently no data on the use of booster doses. Additional studies to determine the utility of a booster dose and its best timing are under way. Accordingly, there is no current recommendation for a booster dose.

Research priorities
Development of a highly sensitive and specific rapid diagnostic test to determine serostatus, and assessment of simplified immunization schedules and booster needs should be prioritized.

Global Fund Joins Movement to Halve Malaria by 2023

Milestones :: Perspectives

Global Fund Joins Movement to Halve Malaria by 2023
LONDON, 18 April 2018
– The Global Fund to Fight AIDS, Tuberculosis and Malaria joined leaders at the Malaria Summit London 2018 to call for reducing malaria by one half across the Commonwealth in the coming five years. Collective action aims to prevent 350 million cases of malaria and save 650,000 lives, predominately children and pregnant women who are most at risk.

The Global Fund acts as a catalyst for mobilizing resources, and through co-financing mechanisms has leveraged US$355 million of donor funding to generate US$2 billion in domestic public funding in 46 countries affected by malaria.

“To defeat an infectious disease like malaria you have to hit it hard – and you have to keep hitting it until it’s gone,” said Peter Sands, Executive Director of the Global Fund. “There are compelling, hard-nosed economic reasons for ridding the world of malaria. We risk a resurgence, and we can’t let that happen.”

Since 2000, extraordinary progress has been made in the fight against malaria, with sharp reductions in malaria cases and deaths. But those declines have stalled and even reversed in some regions, while global investments have plateaued. Malaria still kills about 450,000 people a year – including a young child every two minutes – and there is a risk of resurgence as mosquitoes become more resistant to insecticides and malaria parasites become resistant to the current first-line treatments.

The Malaria Summit was co-hosted by the governments of the UK, Swaziland and Rwanda as part of the Commonwealth Heads of Government Meeting, and convened by the Bill & Melinda Gates Foundation and the RBM Partnership to End Malaria, to galvanize more funding.
The Global Fund is increasingly using co-financing mechanisms to ensure that donor contributions to fight malaria are matched by domestic investment.

The Bill & Melinda Gates Foundation announced it will extend its investments in malaria by an additional US$1 billion (£700 million) through 2023 to fund research and development efforts and to reduce the burden of the disease.

The UK Government re-affirmed its commitment to spend £500 million a year on malaria to 2020-21, and announced a further £100 million commitment to the Global Fund to match new contributions from private donors pound for pound. The Bill & Melinda Gates Foundation pledged £50 million in matching funds, and the Global Fund committed to raising another £50 million among the private sector.

Uganda committed to establishing a dedicated malaria fund – the Presidential Malaria Fund Uganda – to help mobilize additional resources of US$785 million by 2020 to accelerate national progress against malaria.

Emergencies

Emergencies

 
POLIO
Public Health Emergency of International Concern (PHEIC)
Polio this week as of 17 April 2018 [GPEI]
Summary of newly-reported viruses this week:
Pakistan: Two new wild poliovirus type 1 (WPV1)  positive environmental samples have been reported, one in Sindh province, and one in Balochistan province.
Kenya:  Notification of a circulating vaccine-derived poliovirus type 2 (cVPDV2) detected from an environmental sample has been confirmed, linked to the cVDPV2 confirmed from Somalia in March. No cases of paralysis associated with this virus have been detected in either country.

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Yemen

UNICEF – Military action on and around water infrastructure jeopardizes efforts to prevent another outbreak of cholera in Yemen
AMMAN, 17 April 2018 – “Yemen continues to be one of the world’s most water-scarce countries. Access to drinking water is extremely costly for the most vulnerable people: 8.6 million children in Yemen don’t have sufficient access to water, sanitation and hygiene services.

“Since 2015, the escalation of conflict has only exacerbated this already dire situation, with attacks and military action on and around water infrastructure cutting off even more people from access to safe drinking water.

“Earlier this week, the Al-Hamazat water system in the Sehar district in Sa’ada governorate was completely destroyed in an attack that left 7,500 people, including internally displaced families, without water. During the attack, the nearby solar energy system which provides power to the water system was also severely damaged. The same water system came under attack and was destroyed in 2015. UNICEF rebuilt it in 2017.

“At the same time, armed groups have launched military attacks from sites close to water points.

“Access to clean water is especially critical to prevent waterborne diseases from spreading further in the war-torn country. Last year, Yemen had the biggest outbreak of cholera/acute watery diarrhea in the world and the likelihood of another outbreak looms if access to water continues to be jeopardized.

“UNICEF is calling on all parties to the conflict wherever they are in Yemen and those who have influence over them to protect basic civilian infrastructure. In line with international humanitarian law, all parties to the conflict should immediately stop attacks on civilians and civilian infrastructure and any military activities near or from these facilities including schools, hospitals, water facilities and keep children out of harm’s way.”

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WHO Grade 3 Emergencies  [to 21 April 2018]

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WHO Grade 2 Emergencies  [to 21 April 2018]
Democratic Republic of the Congo
:: 5 April 2018 Reanalysing the humanitarian context to better redefine priorities for action [FR]
— The crisis in the Democratic Republic of the Congo affect more than 13.1 million people, specally affected areas are Tanganyika, Kasai region, Kivus and Ituri. WHO national experts from the Health Emergency Management Team (WHE) and other Country Office clusters (epidemiologists, logisticians, internal and external communications, data managers, finance and travel services etc.), and international experts deployed in the Democratic Republic of the Congo gathered together to review WHO emergency operations in the county…

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UN OCHA – L3 Emergencies
The UN and its humanitarian partners are currently responding to three ‘L3’ emergencies. This is the global humanitarian system’s classification for the response to the most severe, large-scale humanitarian crises. 
Syrian Arab Republic
:: Syrian Arab Republic: The Humanitarian Crisis in Syria as of 15 April 2018 [EN/AR] 18 Apr 2018
KEY MESSAGES
…As humanitarian needs remain staggering in terms of their scale, severity and complexity, no amount of humanitarian assistance and protection services can offset the lack of a political solution.
…Against this backdrop, the overall conditions for safe, dignified, voluntary and sustainable returns are not yet in place in Syria, with the need for a coherent response to the needs of IDPs and returnees based on humanitarian and protection principles paramount…

DRC 
::  Democratic Republic of the Congo: CERF allocations overview 2017-2018 (as of 12 April 2018…

Yemen  
:: Yemen Humanitarian Update Covering 10 – 16 April 2018 | Issue 11
 
 
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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.
Ethiopia 
:: Ethiopia: Conflict Displacement Situation Report #3 (17 April 2018)
 
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Editor’s Note:
We will cluster these recent emergencies as below and continue to monitor the WHO webpages for updates and key developments.

MERS-CoV [to 21 April 2018]
http://www.who.int/emergencies/mers-cov/en/
Maps and epicurves
:: Epicurve of confirmed global cases of MERS-CoV   png, 213kb  20 April 2018
:: Global map of countries with confirmed cases of MERS-CoV  gif, 2.42Mb  20 April 2018
 

WHO & Regional Offices [to 21 April 2018]

WHO & Regional Offices [to 21 April 2018]

Latest News
Vaccine hesitancy in the Federation of Bosnia and Herzegovina
19 April 2018
Immunization rates in the Federation of Bosnia and Herzegovina are as low as 40% in some areas and continuing to decline, increasing the risk of large disease outbreaks. But, no one knows precisely why.
Growing vaccine hesitancy, misinformation in social media, lack of trust in the health system, a shortage of health workers and supply issues are all suspected reasons for low coverage rates. However, these are mostly assumptions with little evidence.

Highlights
Revised SAGE recommendation on use of dengue vaccine
April 2018 – Dengue is the most frequent and rapidly spreading mosquito-borne virus. The first dengue vaccine, CYD-TDV (Dengvaxia®) is currently licensed in 20 countries. The key findings from 2 large Phase 3 trials involving over 30,000 participants.
[See Milestones above for detail]

Urgent action needed to tackle the double burden of malnutrition
April 2018 – Under nutrition, obesity and diet-related noncommunicable diseases are leading to catastrophic costs to individuals, to communities and to national healthcare systems in Africa. According to experts nutritional status, a critical component of a person’s health and wellbeing, must be recognized as a key building block towards achieving Universal Health Coverage and the Sustainable Development Goals by 2030.

WHO continues to serve communities affected by PNG quake
April 2018 – Fifty days after a 7.5 magnitude earthquake hit Papua New Guinea (PNG), limited delivery of essential health services has resumed in earthquake-affected provinces. However, thousands remain vulnerable to health threats as they continue to live in crowded temporary settlements with inadequate access to clean water and medical services.

New hepatitis data highlight need for urgent global response
April 2017 – New WHO data reveal that an estimated 325 million people worldwide are living with chronic hepatitis B virus (HBV) or hepatitis C virus (HCV) infection. The WHO Global hepatitis report, 2017 shows the majority of these people lack access to life-saving testing and treatment.
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Weekly Epidemiological Record, 20 April 2018, vol. 93, 16 (pp. 201–220)
Rabies vaccines: WHO position paper – April 2018
WHO Strategic Advisory Group of Experts (SAGE) on immunization: request for nominations

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WHO Regional Offices
Selected Press Releases, Announcements
WHO African Region AFRO
Selected Featured News
:: WHO supports South Sudan to strengthen health promotion strategic actions  19 April 2018
:: Botswana Excels in the 2018 National Measles Laboratory Review For Accreditation  18 April 2018
:: New data from Africa allays fears of bowel obstruction from rotavirus vaccine  18 April 2018
:: Malawi administers Oral Cholera Vaccine to over 500,000 people in Lilongwe Urban  17 April 2018

WHO Region of the Americas PAHO
:: 70 million people to be vaccinated as part of Vaccination Week in the Americas (04/19/2018)
 
WHO European Region EURO
:: WHO delivers 185 tonnes of medical supplies to improve access to health services in northern Syria 20-04-2018
:: Evidence shows banning asbestos has no negative economic impact 19-04-2018
:: Day 3 of high-level meeting Health Systems Respond to NCDs: opportunities and challenges for accelerated response 19-04-2018
:: Day 2 of high-level meeting Health Systems Respond to NCDs: Learning from good examples and real-time problem solving in policy labs 18-04-2018
:: Day 1 of high-level meeting Health Systems Respond to NCDs: focus on equity and people centredness 17-04-2018

WHO Eastern Mediterranean Region EMRO
:: WHO scales up support to mitigate child malnutrition in Yemen
18 April 2018 – As the conflict in Yemen continues unabated, the situation worsens, with more than 1.8 million children under the age of 5 acutely malnourished, including 500 000 children suffering from severe acute malnutrition, requiring immediate admission into therapeutic nutrition programmes. Responding to rising malnutrition rates in Yemen, WHO is providing life-saving treatment for children with severe acute malnutrition and medical complications, supporting 47 centres, with 3 more planned in 2018, to cope with the rising needs for malnutrition treatment services.
:: Addressing emergency care in Afghanistan  18 April 2018
:: Health worker shot in the leg during Gaza demonstrations  April 2018

WHO Western Pacific Region
:: 50 days on, WHO continues to serve communities affected by PNG quake
PORT MORESBY, 16 April 2018 – Fifty days after a 7.5 magnitude earthquake hit Papua New Guinea (PNG), limited delivery of essential health services has resumed in earthquake-affected provinces. However, thousands remain vulnerable to health threats as they continue to live in crowded temporary settlements with inadequate access to clean water and medical services. More than 500 000 were affected by the earthquake that struck on 26 February.

MMWR News Synopsis for April 19, 2018 Recommendations of the Advisory Committee on Immunization Practices for Use of a Hepatitis B Vaccine with a Novel Adjuvant

CDC/ACIP [to 21 April 2018]

http://www.cdc.gov/media/index.html
https://www.cdc.gov/vaccines/acip/index.html

MMWR News Synopsis for April 19, 2018
Recommendations of the Advisory Committee on Immunization Practices for Use of a Hepatitis B Vaccine with a Novel Adjuvant
On February 21, 2018, the Advisory Committee on Immunization Practices (ACIP) recommended the use of HEPLISAV-B (HepB-CpG) vaccine, a 2-dose series hepatitis B vaccine for use in people 18 years of age or over. Hepatitis B vaccination is the primary means of preventing infections and complications caused by hepatitis B virus. Prior to making this recommendation, the ACIP Hepatitis Vaccines Work Group conducted a systematic review of the existing evidence to determine that the benefits of protection with two doses administered over one month make the HEPLISAV-B (HepB-CpG) vaccine an important option for prevention of hepatitis B in at-risk persons.