Vaccines and Global Health: The Week in Review :: 23 February 2019

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

Nationwide measles and rubella immunization campaign reaches 11.6 million children in Yemen

Milestones :: Perspectives

Yemen
 
Nationwide measles and rubella immunization campaign reaches 11.6 million children in Yemen

21 February 2019 – In collaboration with local health authorities, WHO and UNICEF have concluded a nationwide measles and rubella vaccination campaign in Yemen reaching more than 11.6 million (90%) children aged 6 months–16 years across the country.

WHO, with the support of Saudi Arabia, United Arab Emirates, Kuwait and Gavi, the Vaccine Alliance, contributed to the campaign through the provision of vaccines, fuel, training, deployment of health workers and supervisors, as well as raising awareness among communities about ways to protect themselves against these diseases.

Dhamar, Mareb and Sana’a governorates have reported over 100% coverage due to a large number of internally displaced persons coming from other governorates. The campaign continued for an additional 3 days in districts where low coverage was reported.

Despite the challenging conditions, WHO teams and health workers were able to reach high-risk areas, IDP camps and marginalized communities with awareness-raising activities and vaccination.

The Guardian view on vaccination: a duty of public health

 

Milestones :: Perspectives
Vaccine “Hesitancy”
 

The Guardian
http://www.guardiannews.com/
Accessed 23 Feb 2019
Vaccines and immunisation

Opinion
The Guardian view on vaccination: a duty of public health
Editorial
The anti-vaxx movement arises from mistrust but threatens the physical health of society
Sun 17 Feb 2019
The latest World Health Organization report on measles epidemics shows that cases jumped by 50% last year. In one of the poorest and least connected countries in the world, Madagascar, nearly a thousand children are reported to have died after a measles outbreak in the countryside. The real figure is likely to be much higher, because of difficulties of reporting. An emergency programme of vaccination seems to have contained that epidemic for the moment but it is a reminder of how devastating the disease can be against unprepared populations. In the rich world, meanwhile, previously prepared populations are having their defences dismantled from the inside.

The discovery of ad campaigns against vaccination on Facebook that are carefully targeted at pregnant women is unusually worrying. It shows how the widespread availability of sophisticated advertising techniques is going to give considerable power to people who previously had no way of getting their message across to large numbers. In the most recent US campaigns against vaccination, 147 different advertisements have been used and some viewed more than 5m times. There is an arms race under way, whether we like it or not.

Facebook and YouTube/Google must take some responsibility for the consequences of their profit-seeking algorithms. Neither company should be profiting from an activity so detrimental to public health as anti-vaccination propaganda. Both ban tobacco advertising but permit propagandising against vaccination, even from people with a commercial interest in quack remedies. Yet the withholding of children from vaccination might be considered even more anti-social than tobacco smoking. The teenager who smokes puts their own body at risk more than that of anyone else, whereas the parent who refuses a child vaccination is unlikely to harm their own health at all: only that of their offspring. If this were just a decision to allow their own children to run a small risk, it might be defended. But it is not. Because of the way that herd immunity works, such parents are threatening other people’s children too, some of whom cannot for medical reasons be vaccinated.

In some western countries threatened by campaigns against vaccination there are rules in place to stop unvaccinated children from attending school. This protects communities and sends a powerful signal to the wider world, but it is a drastic step. It risks punishing children twice for their parents’ faults.

If parents trusted the state, the medical profession, or the gatekeepers of the media, this problem would not arise. The roots of the protests against vaccination lie for a large part in the inarticulate but powerful sense that modern life is dehumanising, and that powerful forces are conspiring to turn us into obedient robots and to squeeze out our humanity. When power is no longer trusted, it does not matter that it telling the truth. Yet the distrust of anti-vaxxer parents is a threat to everyone’s children and not just their own.

One step is obviously a campaign of public education by figures who are trusted by the target audience in the way that their friends on social media are. If public health campaigns were run with half the ruthless ingenuity displayed by betting companies, we might be better off. But not everything can be left to governments and large companies. Parents who care about their own children’s health must be prepared to take the argument to the playgrounds and on to social media as well.

The law and vaccine resistance

Milestones :: Perspectives

Science         
22 February 2019  Vol 363, Issue 6429
http://www.sciencemag.org/current.dtl

Editorial
The law and vaccine resistance
By Dorit Rubinstein Reiss
Science22 Feb 2019 : 795
Last week, the Centers for Disease Control and Prevention announced that more than 100 cases of measles, spanning 10 states, had been reported in the United States since the beginning of the year. This news came on the heels of the World Health Organization’s estimate of over 200,000 cases of measles in 2018. These numbers signal the reemergence of a preventable, deadly disease, attributed in significant part to vaccine hesitancy. Communities and nations must seriously consider leveraging the law to protect against the spread of this highly contagious disease.

In the United States, measles was deemed “eliminated” in 2000 because of vaccination success. Since then, its reemergence has been associated with a resistance to vaccination. This also reflects the fact that unvaccinated U.S. residents visit countries that have seen large measles outbreaks (such as Ukraine, the Philippines, and Israel), become infected, and bring the disease back home.

Outbreaks in the United States are still fewer than in, say, Europe because of unique U.S. policies and laws that maintain high vaccination coverage. All 50 states and the District of Columbia have laws requiring vaccinations for school and daycare attendance. School mandates have proven very effective: The stronger they are, the higher the vaccination rate, and the lower the risk of outbreaks. The Vaccines for Children Program is a broad federal initiative that funds vaccines for children whose families cannot otherwise afford them. There is, however, more that the United States can do. There are “hotspots” where vaccination rates are low, and these are where outbreaks appear. Recent measles outbreaks—including those in Washington state and New York—occurred when an unvaccinated individual, after visiting an area where measles is endemic, returned to a U.S. community with low vaccination rates and infected others (primarily unvaccinated children).

What can be done? States have extensive leeway to protect public health, and courts have consistently upheld strong school immunization mandates. Thus, states could tighten nonmedical exemptions (for example, by requiring consultation with a doctor) or remove these exemptions completely from school mandates. Valid medical exemptions are important, but it is less clear whether nonmedical exemptions are appropriate. Some scholars are concerned that eliminating nonmedical exemptions may generate resentment among parents and interfere with parental autonomy. Others—including professional medical associations—disagree, because mandates protect children, and a parent’s freedom to send an unvaccinated child to school places classmates at risk of dangerous diseases. There is a strong argument for removing nonmedical exemptions, and at the least, they should be hard to get, to further incentivize parents to vaccinate. In many states, however, getting an exemption is as easy as checking a box. States and localities could also require schools to provide their immunization rates to parents at the start of the school year.

Beyond school mandates, states can consider other legal tools that have not yet been used. States could implement workplace mandates for those working with vulnerable populations, such as health care workers, teachers in schools, and providers of daycare. States could impose tort liability (civil law damages for harm) when unexcused refusal to vaccinate leads to individuals becoming infected unnecessarily or worse, to a large outbreak. States could permit teenagers to consent to vaccinations without parental approval. And states could mandate vaccinations to enroll in institutions of higher education.

Vaccine hesitancy is a problem with many components. In handling it, societies should improve public understanding of vaccinations but also not hesitate to use the law to prevent deadly diseases from spreading.

DRC – Ebola

Milestones :: Perspectives

 DRC – Ebola

29: Situation report on the Ebola outbreak in North Kivu  19 February 2019

Situation Update

The Ebola virus disease (EVD) outbreak in North Kivu and Ituri provinces, Democratic Republic of the Congo, continues to prove challenging to contain as ongoing security incidents and pockets of community mistrust hamper response efforts. Following our last report on 12 February 2019, 24 new EVD cases have been reported, including 20 confirmed and four probable cases. The four probable cases were all deaths that occurred in November and December 2018 in Komanda Health Zone, with a clinical history consistent with EVD but without the opportunity to be tested…
…Case management

On 24 November 2018, MoH announced the launch of a randomized control trial (RCT) for Ebola therapeutics. The RCT is now enrolling and treating patients at ETC sites in Katwa, Beni and Butembo. This is ongoing, with all confirmed cases in ETCs receiving therapy under the compassionate use protocol, together with supportive care. To date, 66 patients have been enrolled in the RCT and 334 patients have received therapy under the compassion use protocol.

An Ebola transit (TC) centre was opened in Katwa in the last week.

…Implementation of ring vaccination protocol

As of 17 February 2019, a cumulative total of 80,989 people have been vaccinated since the start of the outbreak.

Vaccination of HCWs and FLsWS are underway in bordering areas of Uganda and South Sudan. Advanced preparations are ongoing in Rwanda.

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STRATEGIC RESPONSE PLAN FOR THE EBOLA VIRUS DISEASE OUTBREAK IN THE PROVINCES OF NORTH KIVU AND ITURI

February – July 2019

13 February 2019

[Excerpts’ full plan at title link qbove]]

Introduction

The tenth epidemic of Ebola virus disease (EVD) in the Democratic Republic of the Congo, affecting the provinces of North Kivu and Ituri, was declared by the Ministry of Health on 1 August 2018. The initial strategic response plan (SRP-1) covering the period up to in October 2018 and then the second strategic response plan (SRP-2) for the period from October 2018 to January 2019 facilitated deployment of the important resources of the Congolese Government and its partners.

Despite the complexity of this epidemic (dense and mobile population, insecurity, community resistance and risk of spread at the national and regional levels), the implementation of the interventions made it possible to significantly reduce the spread of the outbreak in the initial epicentres of Mangina / Mandima and Beni and stopped transmission in some secondary focal points like Tchomia, Masereka and Mutwanga.

Nevertheless, since the beginning of December a significant increase in the incidence of new cases has been observed particularly along the corridor towards the large urban center of Butembo (health zones of Butembo and Katwa) and beyond in the zone of Kayna health center located about 150 km from Goma. In addition, active outbreaks have emerged to the north, particularly in the health zones of Komanda and Oicha.

The third strategic response plan (SRP-3), which covers February through end July 2019, considers the salient points and recommendations made during the operational review of the implementation of the SRP-2 and other guidance based on lessons learned and risk analysis.

6.9 Vaccination of at-risk groups

Despite the context and challenges, as of January 27, 2019, in North Kivu and Ituri Provinces 695 rings (3 February) were defined in the community and 2 targeted geographical areas. A total of 73,298 contacts and contacts of contacts were listed. Of those vaccinated, 18,895 are contacts, 22,441 are health and front-line staff and 16,855 are children aged 1 to 18 years.

As the number of cases reported from unknown contacts remains high, efforts have been made to improve the identification of contacts and contact of contacts, particularly in all locations where the symptomatic case visited a high-risk health facility before being isolated or dying.

It is important to emphasize that the investigational vaccine will continue to be used according to WHO recommendations in compliance with Good Clinical Practice (GCP) and that sustained attention be paid to the quality of the processes, procedures and management of clinical trials data in accordance with international standards.

 

However, there is a shortage of national staff trained in GCP, low involvement of HZMTs and the community in the organization of vaccination and an increase in the number of ineligible people (pregnant women, breastfeeding women and infants).

Other measures to establish and continue to prevent the spread of transmission include:

:: Further improve the listing of the “satellites” of the rings (i.e. outside the place of residence of the case, these are all places that the symptomatic person visited before being isolated or dying) to identify and offer vaccination to all people at risk.

:: Organize vaccination teams performing “sweeping” operations to review how rings were defined for cases with onset of symptoms in the last 7 days and to verify if contacts at the place of residence and in the satellites have been fully enumerated and vaccinated.

::  Organize teams that primarily vaccinate all health personnel and front-line staff in priority-identified facilities because they have seen or treated a case of EVD within the previous 21 days.

::  Modify the protocol for the use of the rVSV vaccine to include vaccination of pregnant women after the 1st trimester of pregnancy and vaccination of infants including new-borns, as recommended by the National Ethics Committee. Arrangements will be made for the follow-up of pregnant women who were vaccinated through the end of their pregnancies.

::  The supply of infrared thermometers and handwashing facilities, drinking water, soap and capacity building on hygiene behaviour in schools.

:: The construction of isolation rooms for suspected cases at school.

::  Providing specific documentation and protocol for the prevention, guidance and management of suspected cases at school to provide key messages on family-based Ebola prevention.

:: Strengthen the technical capacity of national PCB teams to be able to deploy an experimental vaccine for this epidemic and in the future and consider appropriate study options for the evaluation of other vaccines against GCPs

 

Emergencies

Emergencies
 
 
POLIO
Public Health Emergency of International Concern (PHEIC)
Polio this week as of 20 February 2019
:: On 19 February, the 20th IHR Emergency Committee including members, advisers, and invited Member States convened to discuss the status of international spread of poliovirus. The Committee unanimously agreed that the risk of polio spread continues to be a Public Health Emergency of International Concern (PHEIC) and proposed an extension of Temporary Recommendations for an additional three months. The recommendations come amid outbreak notification of cVDPV1 and cVDPV2 in Indonesia and Mozambique respectively. The official WHO Statement and the Temporary Recommendations will be issued shortly. [Full statement not yet posted]

:: The GPEI has developed the Global Polio Surveillance Action Plan 2018-2020, incorporating newer strategies and innovations to help endemic, outbreak and high-risk countries measure and enhance sensitivity of their surveillance systems. Read more here.

:: WHO is seeking input on draft guidance for managing human exposure to live polioviruses in facilities such as labs and vaccine plants. The document is open for public comment and WHO is particularly seeking feedback from national authorities for containment and others working in public health.
 
 
Summary of new viruses this week:
:: Afghanistan — one case of wild poliovirus type 1 (WPV1) and four WPV1-positive environmental samples;

:: Pakistan – two cases of WPV1 and four WPV1-positive environmental samples.

::::::
::::::
 
 
Editor’s Note:
WHO has posted a refreshed emergencies page which presents an updated listing of Grade 3,2,1 emergencies as below.

WHO Grade 3 Emergencies  [to 23 Feb 2019]
Democratic Republic of the Congo
:: :: 29: Situation report on the Ebola outbreak in North Kivu  19 February 2019
:: DONSEbola virus disease – Democratic Republic of the Congo   21 February 2019

Bangladesh – Rohingya crisis
:: Bi‐weekly Situation Report 3 – 14 February 2019
…Immunization
Vaccination at Registration Post: Three vaccination posts have been established in camp 7, camp 17 and 26 with the support of UNHCR to provide immunization service to newborn eligible for birth registration under family head count. The activity started in Teknaf in Sep 2018 and in Ukhia (camp 7 and 17) in Feb 2019. Immunization activities are offered for 5 days a week.
Health worker immunization: Two vaccinations post are providing immunization to health care workers on weekly basis to humanitarian workers in camps. To-date 1,753 Td doses have been administered to health workers.
VPD Surveillance: 3 AFP cases have been investigated in 2019 with result still pending. Out of 88 suspected measles cases in 2019, 53 patients (42%) have been investigated through Case Report Form.

South Sudan
::  WHO provides lifesaving health care services to displaced populations and host communities in 22 locations in South Sudan  18 February 2019

 

Myanmar – No new digest announcements identified  
Nigeria – No new digest announcements identified  
Somalia – No new digest announcements identified
Syrian Arab Republic – No new digest announcements identified  
Yemen – No new digest announcements identified

::::::

WHO Grade 2 Emergencies  [to 23 Feb 2019]
Brazil (in Portugese) – No new digest announcements identified
Cameroon  – No new digest announcements identified
Central African Republic  – No new digest announcements identified
Ethiopia – No new digest announcements identified
Hurricane Irma and Maria in the Caribbean – No new digest announcements identified
Iraq – No new digest announcements identified
Libya – No new digest announcements identified
MERS-CoV – No new digest announcements identified
Niger – No new digest announcements identified
occupied Palestinian territory  – No new digest announcements identified
Sao Tome and Principe Necrotizing Cellulitis (2017) – No new digest announcements identified
Sudan – No new digest announcements identified
Ukraine – No new digest announcements identified
Zimbabwe – No new digest announcements identified

::::::

WHO Grade 1 Emergencies  [to 23 Feb 2019]
Afghanistan
Chad
Indonesia – Sulawesi earthquake 2018
Kenya
Lao People’s Democratic Republic
Mali
Namibia – viral hepatitis
Peru
Philippines – Tyhpoon Mangkhut
Tanzania

 
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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   
:: Humanitarian Update Syrian Arab Republic – Issue 01 | 19 February 2019

  FIGURES
. People in need of humanitarian assistance 13M
. People in acute need of humanitarian assistance 5.2M
. Internally displaced people (as of August) 6.2M
. Returnees (January – December 2018) 1.4 M
. People in need in UN-declared hardto-reach areas 1.1M
HRP 2018 FUNDING
. 3.36 billion requested (US$)
. 64.9% funded

Yemen – No new digest announcements identified

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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 Humanitarian Bulletin Issue #3 | 04-17 February 2019

HIGHLIGHTS
. Over 45,000 IDPs in need of urgent humanitarian assistance in Central Gondar.
. The level of humanitarian needs in 2019 expected to remain similar to 2018.
. UNHCR notes spontaneous movement of South Sudanese refugees in Ethiopia.

Somalia  – No new digest announcements identified

 

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

EBOLA/EVD  [to 23 Feb 2019]
http://www.who.int/ebola/en/
:: 29: Situation report on the Ebola outbreak in North Kivu  19 February 2019
:: DONS – Ebola virus disease – Democratic Republic of the Congo   21 February 2019
 
 
MERS-CoV [to 23 Feb 2019]
http://who.int/emergencies/mers-cov/en/
– No new digest announcements identified.
 
 
Yellow Fever  [to 23 Feb 2019]
http://www.who.int/csr/disease/yellowfev/en/
– No new digest announcements identified.
 
 
Zika virus  [to 23 Feb 2019]
http://www.who.int/csr/disease/zika/en/
– No new digest announcements identified.

WHO & Regional Offices [to 23 Feb 2019]

WHO & Regional Offices [to 23 Feb 2019]

21 February 2019
Nationwide measles and rubella immunization campaign reaches 11.6 million children in Yemen

20 February 2019
News Release
Countries are spending more on health, but people are still paying too much out of their own pockets

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Weekly Epidemiological Record, 22 February 2019, vol. 94, 08 (pp. 85–104)
:: Pneumococcal conjugate vaccines in infants and children under 5 years of age: WHO position paper – February 2019

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WHO Regional Offices
Selected Press Releases, Announcements
WHO African Region AFRO
:: Kenya now eliminates maternal and neonatal tetanus  22 February 2019
:: Zambian Government commits to ending cholera by 2025   22 February 2019
:: Community informants yield results in surveillance for suspected polio in hard-to-reach areas
22 February 2019
:: WHO and Uganda Red Cross society sign agreement to strengthen Ebola screening at Points of Entry between Uganda and DRC  21 February 2019
:: New Minister of Health recommits government to end Hepatitis E Outbreak  20 February 2019
 
 
WHO Region of the Americas PAHO
– No new digest announcements identified.
 
 
WHO South-East Asia Region SEARO
– No new digest announcements identified.
 
 
WHO European Region EURO
:: Summits give citizens a voice in creating sustainable health policy 22-02-2019
 
 
WHO Eastern Mediterranean Region EMRO
:: Improving access to health care in Yemen  19 February 2019
 
 
WHO Western Pacific Region
– No new digest announcements identified.