Vaccines and Global Health: The Week in Review :: 30 June 2018

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

How to be ready for the next influenza pandemic

Milestones :: Perspectives

Lancet Infectious Diseases

Jul 2018 Volume 18 Number 7 p697-812  e183-e227
How to be ready for the next influenza pandemic
The Lancet Infectious Diseases
This year marks the 100th anniversary of the 1918 influenza pandemic, the worst acute infectious disease outbreak in modern history. The pandemic was caused by influenza virus H1N1 and emerged in the final stages of World War 1. It is estimated that between 20 million and 50 million people died during this pandemic, with a uniquely high mortality in young adults aged between 20 and 40 years. Low-income countries were hit particularly hard (17 million people are thought to have died in India alone) because of their poor health systems. Why the 1918 pandemic was so severe is still a matter of debate, but immunological factors and secondary bacterial infections were major contributors to the heavy death toll. Other influenza pandemics, albeit less severe, have then occurred in 1957, 1968, and 2009, so a new one appears inevitable at some point in the future. Thus, on the centenary of the 1918 pandemic, it is timely to ask ourselves whether the world would be prepared now for such an event.

The answer sadly is no: we do not know what virus will cause the next pandemic, there is no way to rapidly develop and deploy an effective vaccine against a pandemic virus, differences in quality of health systems hamper a prompt response, and surveillance data on influenza have major gaps. At the Massachusetts Medical Society’s annual meeting on April 27, American philanthropist Bill Gates presented a simulation by the Institute for Disease Modeling that found that a new influenza virus like the one that caused the 1918 pandemic would now most likely kill 30 million people within 6 months. Thus, an influenza pandemic represents a real threat that could only be managed with a rapid and effective response from both national governments and the international health community, something that was not seen for the most recent major oubreak of a deadly infectious disease, the emergence of Ebola virus disease in west Africa in 2014-16.

In order to improve the preparedness of the global health community to a pandemic, three areas are crucial: vaccination, surveillance, and building response capacity. As discussed in our May Editorial, the development of a universal influenza vaccine, the holy grail of influenza research, would enhance the capacity to protect people from infection. Gates’ announcement of a US$12 million donation to contribute to the development of such a vaccine is therefore welcome news. However, the development of an effective vaccine is expected to take at least 5–10 years.

Surveillance for influenza is of crucial importance but is also complex because it needs to cover two key populations: animals and humans. It is expected that the next pandemic influenza virus will originate from a spillover from birds, the natural reservoir of all influenza viruses, or pigs, in which avian and human viruses can coexist, thus favouring recombination. At the recent ECCMID meeting, Colin Russell presented the results of a study that mapped areas in the world at highest risk of spillover of avian and swine influenza virus into humans. Particularly ominous was the observation that surveillance for viruses circulating in birds and pigs in such areas is often very limited, so the rapid spread of an influenza virus of pandemic potential could easily go undetected. Equally patchy is the surveillance of human cases of influenza, which is essential to recognise unusual severity or incidence of cases which can be a prodrome for a pandemic. WHO has conducted monitoring through the Global Influenza Surveillance and Response System for over half a century, relying on collection and preliminary analysis of virus specimens from national influenza centres. Not all countries have such centres (for example, only 18 African countries have one) so the reporting of influenza cases remains suboptimum.

In case of an influenza pandemic, the capacity to respond promptly will play a key part because of airborne transmission. Antivirals and antibiotics to prevent secondary bacterial infections will be important, while awaiting development of an effective vaccine, but stockpiles of these are currently insufficient. Moreover, there is need to invest in strengthening health systems and microbiological capacities on the ground to enhance the rapid response to any outbreak.

Influenza is the infectious disease with a proven record of causing pandemics, so it is essential that it remains at the centre of efforts for pandemic preparedness. The next influenza pandemic will be a real test for the international health community. We should not find ourselves unprepared—to be so could cost millions of lives.

[U.S.] Appeals Court: Infants, Preschoolers Must Get Flu Shot

Milestones :: Perspectives

[U.S.] Appeals Court: Infants, Preschoolers Must Get Flu Shot
By The Associated Press
June 28, 2018
NEW YORK — New York City’s requirement that infants and preschoolers in city-regulated child care or school-based programs must get yearly flu shots was upheld Thursday by the state’s highest court.
The Court of Appeals said that the city’s Department of Health had the authority to require the shots, a rule the city first enacted in 2013 during Mayor Michael Bloomberg’s administration.
A group of mothers filed a lawsuit in 2015, saying officials had overstepped their authority in requiring the annual vaccinations for children between the ages of 6 months and 5 years.
In its unanimous ruling, the court said the “promulgation of the flu vaccine falls squarely within the powers specifically delegated to the department.”
Health Commissioner Dr. Mary Bassett says the ruling is a “great win for New York City children.”
“Children who receive the influenza vaccine are less likely to get sick, less likely to need medical attention and less likely to die from influenza,” she said. “This decision will help us protect more than 150,000 children in City-regulated day cares and preschools across the city.”
The city said the mandate would go into effect immediately, and the more than 150,000 children in programs that are regulated by the city would be required to get the flu vaccine by December 31…


Public Health Emergency of International Concern (PHEIC)
Polio this week as of 26 June 2018 [GPEI]
:: The Republic of Korea becomes the first donor to support polio outbreak response in the Horn of Africa.
Summary of newly-reported viruses this week:
DRC : Three cVDPV cases type 2
Papua New Guinea: One  cVDPV case type 1
Somalia: One cVDPV case combining type 2 and type 3 and, two cVDPV cases type 3

Papua New Guinea confirms poliovirus outbreak, launches response
PORT MORESBY, 25 June 2018 – The National Department of Health of Papua New Guinea and the World Health Organization (WHO) today confirmed that the strain of poliovirus first detected in a child from Morobe Province in April is now circulating in the same community.
The one confirmed case is a 6-year-old boy with lower limb weakness, first detected on 28 April 2018. A vaccine-derived poliovirus type 1 (VDPV1) had been isolated as the cause of the paralysis on 21 May 2018.
On 22 June 2018, the United States Centers for Disease Control and Prevention confirmed that the same virus was also isolated from stool specimens of two healthy children from the same community. This means that the virus is circulating in the community—representing an outbreak of the virus.
“We are deeply concerned about this polio case in Papua New Guinea, and the fact that the virus is circulating,” said Pascoe Kase, Secretary of the National Department of Health (NDOH). “Our immediate priority is to respond and prevent more children from being infected.”…
Public health response
Outbreak response activities are ongoing in Morobe Province. Experts from the NDOH, Papua New Guinea’s Central Public Health Laboratory, Provincial Health Authorities, UNICEF and WHO have conducted field missions to undertake clinical investigation, house-to-house surveys, sample collection and contact tracing.
The team also collected stool specimens from family members of the patient and from the community. A “mop up” immunization campaign was done in the community targeting children under 15 years old. To date, 845 children from the Lufa Mountain Settlement have been vaccinated…


WHO Grade 3 Emergencies  [to 30 Jun 2018]
The Syrian Arab Republic
:: Syria crisis – SOUTHERN SYRIA UPDATE  Issue 1 – 26-28 June 2018
Iraq  – No new announcements identified
Nigeria  – No new announcements identified
South Sudan  – Webpage not responding at inquiry
Yemen  – No new announcements identified

WHO Grade 2 Emergencies  [to 30 Jun 2018]
[Several emergency pages were not available at inquiry]
:: Additional workforce added to Cox’s Bazar hospital to strengthen Rohingya refugee response
Cox’s Bazar, Bangladesh, 21 June 2018: To strengthen health services for Rohingya refugees and their host communities in Cox’s Bazar, additional health workforce has been added to the district hospital here, the only facility providing referral services to nearly 1.3 million vulnerable population at increased risk of diseases in the ongoing rainy season.
“The additional staff will help augment service delivery at the hospital as we seek to enhance capacities to treat acute watery diarrhoea cases, in addition to trauma and obstetric care,” said Dr Bardan Jung Rana, WHO Representative to Bangladesh.
With funding from the King Salman Humanitarian Aid and Relief Centre (KSrelief), 86 additional staff including 25 medical officers and 40 nurses, have been hired by the Ministry of Health and Family Welfare for the Sadar district hospital…

Cameroon  – No new announcements identified
Central African Republic  No new announcements identified.
Democratic Republic of the Congo  No new announcements identified
Ethiopia  No new announcements identified.
LibyaNo new announcements identified.
Niger  – No new announcements identified.
UkraineNo new announcements identified.

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. 
:: Yemen: Al Hudaydah Update Situation Report No. 6, 27 June 2018

Syrian Arab Republic  – No new announcements identified.


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  – No new announcements identified.
Somalia   No new announcements identified.

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

EBOLA/EVD  [to 30 Jun 2018]
Ebola situation reports: Democratic Republic of the Congo
Case numbers can fluctuate on a daily basis due to many factors including enhanced surveillance, local laboratory capacity, possible communication delays caused by the challenge of accessing remote locations and constant reclassification of cases. Suspected cases with conclusively negative laboratory tests are systematically removed from the case counts.
Latest numbers as of 28 June 2018
:: Confirmed cases: 38
:: Probable cases: 15
:: Suspect cases: 2
:: Total cases: 55 (including 29 deaths)
2018 Ebola outbreak situation reports
Ebola Outbreak in DRC: 26 June 2018

MERS-CoV [to 30 Jun 2018]
No new announcements identified.
Yellow Fever  [to 30 Jun 2018]
No new announcements identified.
Zika virus  [to 30 Jun 2018]
No new announcements identified.

WHO & Regional Offices [to 30 Jun 2018]

WHO & Regional Offices [to 30 Jun 2018]

27 June 2018 – News Release, Geneva
WHO study shows drug could save thousands of women’s lives
A new formulation of a drug to prevent excessive bleeding following childbirth could save thousands of women’s lives in low- and lower-middle-income countries, according to a study led by the World Health Organization (WHO) in collaboration with MSD for Mothers and Ferring Pharmaceuticals.
Currently WHO recommends oxytocin as the first-choice drug for preventing excessive bleeding after childbirth. Oxytocin, however, must be stored and transported at 2–8 degrees Celsius, which is hard to do, in many countries, depriving many women of access to this lifesaving drug. When they can obtain it, the drug may be less effective because of heat exposure.
The study, published today in the New England Journal of Medicine, has shown an alternative drug – heat-stable carbetocin – to be as safe and effective as oxytocin in preventing postpartum haemorrhage. This new formulation of carbetocin does not require refrigeration and retains its efficacy for at least 3 years stored at 30 degrees celsius and 75% relative humidity…


Weekly Epidemiological Record, 29 June 2018, vol. 93, 26 (pp. 369–380)
Index of countries/areas
Index, Volume 93, 2018, Nos. 1–26

:: WHO Alliance for the Global Elimination of Trachoma by 2020: progress report on elimination of trachoma, 2017

WHO Regional Offices
Selected Press Releases, Announcements
WHO African Region AFRO
Selected Featured News
:: Bringing Ebola vaccine to remote communities in the Democratic Republic of Congo
27 June 2018
:: Government launches new Rotavirus vaccine to protect children in Uganda from diarrhea
26 June 2018
:: Adamawa state gets over 700,000 doses of oral cholera vaccines for emergency vaccination
25 June 2018

WHO Region of the Americas PAHO
:: PAHO Executive Committee concludes its 162nd session on advancing health in the Americas region (06/27/2018)
Issues that were advanced during the Committee include: action plans to ensure the health of women, children and adolescents; the prevention and treatment of cervical cancer; and the human resources required for universal health access and coverage.
WHO South-East Asia Region SEARO
No new announcements identified.
WHO European Region EURO
:: Primary health care: the bridge to universal health coverage in Greece 28-06-2018
:: Climate change increasingly affects small countries 25-06-2018

WHO Eastern Mediterranean Region EMRO
No new announcements identified.

WHO Western Pacific Region
:: Papua New Guinea confirms poliovirus outbreak, launches response  25 June 2018
[See Polio above for more detail]