Vaccines and Global Health: The Week in Review :: 13 July 2019

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– 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

DRC – Ebola/Cholera/Polio/Measles

Milestones :: Perspectives :: Research

 

DRC – Ebola/Cholera/Polio/Measles

Disease Outbreak News (DONs}
Ebola virus disease – Democratic Republic of the Congo
11 July 2019
The outbreak of Ebola virus disease (EVD) in North Kivu and Ituri provinces, Democratic Republic of the Congo continues this past week with a similar transmission intensity to the previous week. While the number of new cases continues to ease in former hotspots, such as Butembo, Katwa and Mandima health zones, there has been an increase in cases in Beni, and a high incidence of cases continues in parts of Mabalako Health Zone. In addition to these re-emerging hotspots, there are a large number of people with confirmed and probable infections moving to other health zones, with the greatest number coming from Beni Health Zone. The movement of cases causes the outbreak to spread to new health zones and re-emerge in health zones with previously controlled infections. Overall, this underscores the importance of robust mechanisms for listing and following up contacts and understanding the motivations for peoples’ decisions to move…

 

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CDC Lab Research Shows Two Treatments Effective Against DRC Ebola Strain
Tuesday, July 9, 2019
New research by the Centers for Disease Control and Prevention (CDC) shows two investigational Ebola treatments being used in the ongoing outbreak in eastern Democratic Republic of the Congo (DRC) are effective in laboratory studies.

The treatments – the antiviral remdesivir and antibodies in the ZMapp treatmentblocked growth of the virus strain causing the outbreak in human cells in the laboratory. The research suggests these treatments hold promise for allowing patients to recover from the deadly illness. The research will be published Tuesday, July 9, in Lancet Infectious Diseases.

Importantly, the study also shows that the lab test most often used in DRC and neighboring countries to diagnose Ebola – which was developed during the 2014-2016 West Africa outbreak for use against a different strain of Ebola virus – appears to be accurate for the outbreak strain now circulating in DRC, which researchers are calling the Ituri strain. The Ituri strain and the strain that caused the West Africa outbreak are both strains of Ebola virus (formerly called Ebola Zaire).

“All of the treatments being tested in the current DRC outbreak were developed to fight Ebola viruses from previous outbreaks,” said Laura McMullan, Ph.D., CDC microbiologist and the paper’s lead author. “RNA viruses are always mutating – and because Ebola is an RNA virus it’s vitally important to make sure existing treatments work against the virus that’s making people sick now.”

How and Why This Research Was Done
Lacking samples from patients infected with the Ebola virus strain causing the current outbreak, CDC laboratory scientists reconstructed the Ituri strain of Ebola virus using reverse genetics in the CDC Biosafety Level 4 laboratory, under the highest level of biosecurity and safety. They based this work on virus sequence data generated from recent patient samples by the DRC National Institute of Biomedical Research (INRB) and the U.S. Army Medical Research Institute of Infectious Diseases (USAMRIID) and published in GenBank, an open-access database for pathogen sequences.

By having access to the virus strain, CDC laboratory experts can learn more about the Ituri strain and how it fits into the Ebola virus family tree, which may provide clues to finding additional promising treatments. The scientists will also be able to test new therapies as they are developed to see if they can effectively fight against the actual virus making people sick. They will also be able to compare it to future Ebola strains to explore how the virus changes over time.

“This work has benefits beyond the current study. Having access to this virus will allow us to explore whether other compounds or potential therapies affect the virus in the lab,” said Inger Damon, M.D., PhD, chief strategy officer for the CDC’s 2018 Ebola response and director of CDC’s Division of High-Consequence Pathogens and Pathology. “We hope the knowledge gained from this work can be translated into safe and effective therapies to help cure Ebola patients.”

Laboratory experts within CDC’s Viral Special Pathogens Branch have been testing compounds and antivirals since 2007 to look for potential treatments for viral hemorrhagic fevers – some of the world’s deadliest diseases, including Ebola and Marburg. In addition to assessing the effectiveness of remdesivir and the antibodies in the ZMapp cocktail against the Ituri strain, CDC researchers also encourage the future testing of the investigational vaccine being used in DRC and of other investigational therapies – such as mAb114 and Regeneron’s REGN-3EB against the current Ebola Ituri virus.

The current DRC outbreak is the second-largest ever recorded and DRC’s tenth Ebola outbreak since 1976. To date, more than 2,400 people have become infected and more than 1,600 have died. Uganda also has reported three travel-associated deaths tied to a DRC Ebola patient. Armed conflicts and public mistrust in the area have complicated public health response efforts. Despite efforts from the DRC Ministry of Health and international health partners, including CDC, the current outbreak has continued for 10 months.

The research will be available on the Lancet Infectious Diseases websiteexternal icon at 6:30 p.m. EST Tuesday, July 9. For more information on Ebola and the current DRC outbreak, please visit www.cdc.gov/ebola.

 

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Press release
Vaccination to contain severe measles outbreak underway in the Democratic Republic of the Congo amidst Ebola and mass displacement
Campaign led by the Ministry of Health with support from UNICEF and MSF

ITURI, Democratic Republic of the Congo/DAKAR/GENEVA/NEW YORK, 11 July 2019 – Health workers are urgently rolling out a complex measles vaccination campaign targeting 67,000 children in Ituri, northeast Democratic Republic of the Congo (DRC), a region ravaged by armed conflict that is now also the hub of the second-deadliest Ebola outbreak on record.

At least 1,981 deaths due to measles have been reported across the DRC this year, over two-thirds of them among children below 5 years old. As of 23 June, nearly 115,000 cases of suspected measles had been reported, far more than the 65,000 recorded in all of 2018.
Ituri, one of the two provinces (the other is North Kivu) struck by Ebola since the outbreak began nearly a year ago, has recorded over 5,400 cases and 50 deaths.

“The combined threat of Ebola and measles for the thousands of families living in overcrowded and unsanitary displacement camps is unprecedented,” said UNICEF DRC Representative Edouard Beigbeder. “We have a small window to prevent a potentially massive loss of life.”

The first sites targeted for measles vaccinations are four displacement camps in Bunia, Ituri, that have seen a huge influx of families forcibly uprooted by fighting in recent weeks. The boundary of one camp, located alongside Bunia’s General Hospital, is less than 100 metres away from an Ebola treatment center. It is also less than 3 kilometres away from parts of Bunia that have seen 5 Ebola cases since the start of the outbreak, 2 of them in the past three weeks.

The Ebola outbreak means the measles vaccination campaign must incorporate extra measures to protect against infection and meticulous triage. Health workers will need to wear gowns to prevent contact with blood or other body fluids. Teams will include an additional health worker who will evaluate and refer suspected Ebola cases, check temperatures and oversee handwashing and other safety measures.

An additional layer of complexity is that some of the early symptoms of Ebola – fever, redness around the eyes, diarrhoea – are virtually indistinguishable from those of measles, malaria or cholera – all of which are prevalent, especially in severely congested displacement sites.

Up to 400,000 people are thought to be internally displaced across Ituri, the vast majority of them women and children. Many live in about 35 camps scattered throughout the province, in territory that is virtually inaccessible due to insecurity. Fighting among various armed groups has damaged or destroyed up to half the health facilities and schools in the province.

“The northeastern part of DRC is home to one of the worst humanitarian crises today. Whether it is from measles, Ebola, or the reality of living in a displacement camp, children are at grave risk. We must do everything we can to protect them,” Beigbeder said.

Measles campaigns are also being planned for Tchomia and Nyankunde health zones.

As of 8 July, there were 2,428 cases of Ebola, with 1,641 deaths. Almost 30 per cent of cases are among children.

Time to vaccinate against hesitancy

Featured Journal Content

 

Nature Medicine
Volume 25 Issue 7, July 2019
https://www.nature.com/nm/volumes/25/issues/7
Editorial | 03 July 2019
Time to vaccinate against hesitancy
Recent measles outbreaks worldwide highlight the urgency of tracking and countering vaccine hesitancy to ensure the continued success of immunization programs.

In 2012, the World Health Assembly endorsed the Global Vaccine Action Plan, whose goals included eliminating measles in at least five out of the six World Health Organization (WHO) regions by 2020. This goal seemed attainable, given the gains in measles vaccine coverage in low-income countries during the previous decade. And yet, in 2019, measles has surged worldwide. According to the World Health Organization (WHO), three times as many cases were reported in January through March of 2019 than during the same period in 2018. The United States, which had declared that locally transmitted measles was eliminated within its borders in 2000, has already reported the largest number of cases in any year since 1992 (https://www.cdc.gov/measles/cases-outbreaks.html).

Vaccine hesitancy, defined as a delay in vaccination or a refusal to vaccinate in spite of vaccine availability, has played a major role in driving outbreaks in all regions. At the beginning of 2019, the WHO declared vaccine hesitancy one of the top ten threats to global health. Routine and supplemental immunizations are a cornerstone of preventive health and wellness, but are threatened by gaps in coverage. The ongoing measles outbreaks, although tragic, provide an opportunity for health authorities to rebuild and preserve trust in immunization programs by promoting the uptake of tools to measure vaccine hesitancy, thus better supporting health care providers as they engage with patients and field-test new messaging approaches in communities that have different reasons for delaying or refusing vaccines.

Measles vaccines are the poster child for successful vaccine design and potential disease control, but a mix of complacency, fear and challenges to vaccine access have stymied vaccine coverage efforts. Although there are now a number of published tools to measure attitudes toward vaccination, in an analysis of data collected from 2014 to 2016, only 30% of WHO member countries reported performing assessments of vaccine hesitancy in the previous 5 years (S. Lane, N. E. MacDonald, M. Marti and L. Dumolard, Vaccine 36, 3861–3867; 2018). In the future, it will be important for more countries to routinely measure vaccine hesitancy and dissect which distinct factors are contributing on per-country and even more localized bases, a strategy that might help better anticipate gaps in vaccine coverage.

In the same analysis, one of the top three cited reasons for vaccine hesitancy was concerns related to the safety and side effects of vaccines. The detrimental effects of anti-vaccine messaging have thus far proven challenging to overcome. Primary health care providers already have an important influence in the decision to vaccinate and are therefore well placed to discuss the monitoring systems that ensure vaccine safety. However, to communicate this message even more effectively, providers themselves must have a strong grasp of the principles underpinning vaccine development, scheduling and surveillance, because such an understanding has been shown to increase providers’ confidence in promoting immunization (Paterson, P. et al., Vaccine 34, 6700–6706; 2016). In addition, some public health researchers feel that if vaccine counseling were better reimbursed by insurance companies, more health care providers in countries with healthcare systems such as that in the United States might be motivated to take on the time commitment of having these dialogues.

More information is still needed about which approaches best convey the benefits of immunization and address the concerns of parents who delay or refuse vaccines. One study has found that common fear-based messages might actually backfire (B. Nyhan, J. Reifler, S. Richey and G. L. Freed, Pediatrics 133, e835–e842; 2014). In that study, parents randomly received one of four interventions designed to provide information about the safety of the measles–mumps–rubella vaccine or the risks of contracting these diseases. Those who were given images of children sick with measles, mumps or rubella were actually more likely to believe in the discredited link between vaccines and autism. New studies are needed to test the efficacy of more refined motivational or empathetic communication, with the caveat that there will be no one-size-fits-all strategy in light of the varied contextual factors that contribute to the lack of vaccine confidence. In addition to addressing the needs of caregivers, approaches designed to enhance preventive-care education of young adults, including those in college, could mitigate gaps in vaccine knowledge and confidence later in life. Social media has been rightly lambasted for its role in perpetuating irresponsible and dangerous beliefs about vaccine safety and efficacy, but attention has mostly focused on how to block the spread of spurious misinformation on online platforms. Immunization programs should also better leverage social media to respond to determinants of vaccine hesitancy in different communities.

If measles continues to circulate in the United States through the fall, the country is at danger of losing its elimination status. Importantly, the effects of vaccine hesitancy extend beyond measles vaccines. If elimination of measles, a relatively simple disease to control, cannot be achieved, the possibility of elimination of other vaccine-preventable diseases with more complex dynamics and variable vaccine efficacy seems less likely. Restricting allowable exemptions from vaccination for school-age children, although a welcome development in response to the outbreaks in regions of the United States, would provide only part of the solution. To be truly effective, immunization programs must improve both education and outreach by incorporating strategies to measure and respond to vaccine hesitancy. Unless this epidemic is used to galvanize these changes, the United States will be no better prepared to prevent the next outbreak.

WHO updates global guidance on medicines and diagnostic tests to address health challenges, prioritize highly effective therapeutics, and improve affordable access

Featured Journal Content

 

World Health Organization model list of essential medicines: 21st list – 2019
WHO/MVP/EMP/IAU/2019.06 : 60 pages
PDF: WHO-MVP-EMP-IAU-2019.06-eng.pdf (‎951.1Kb)‎
19.3 Vaccines [p.44]

News release
WHO updates global guidance on medicines and diagnostic tests to address health challenges, prioritize highly effective therapeutics, and improve affordable access
New essential medicines and diagnostics lists published today
9 July 2019 Geneva
WHO’s Essential Medicines List and List of Essential Diagnostics are core guidance documents that help countries prioritize critical health products that should be widely available and affordable throughout health systems.

Published today, the two lists focus on cancer and other global health challenges, with an emphasis on effective solutions, smart prioritization, and optimal access for patients.

“Around the world, more than 150 countries use WHO’s Essential Medicines List to guide decisions about which medicines represent the best value for money, based on evidence and health impact,” said WHO Director-General Dr Tedros Adhanom Ghebreyesus. “The inclusion in this list of some of the newest and most advanced cancer drugs is a strong statement that everyone deserves access to these life-saving medicines, not just those who can afford them.”

 

The Essential Medicines List (2019)
Cancer treatments: While several new cancer treatments have been marketed in recent years, only a few deliver sufficient therapeutic benefits to be considered essential. The 12 medicines WHO added to the new Medicines List for five cancer therapies are regarded as the best in terms of survival rates to treat melanoma, lung, prostate, multiple myeloma and leukemias cancers.

For example, two recently developed immunotherapies (nivolumab and pembrolizumab) have delivered up to 50% survival rates for advanced melanoma, a cancer that until recently was incurable.

Antibiotics: The Essential Medicines Committee strengthened advice on antibiotic use by updating the AWARE categories, which indicate which antibiotics to use for the most common and serious infections to achieve better treatment outcomes and reduce the risk of antimicrobial resistance.  The committee recommended that three new antibiotics for the treatment of multi-drug resistant infections be added as essential…

Bioethics International’s Good Pharma Scorecard Improved the Data-Sharing Practices of Large Pharmaceutical Companies

Featured Journal Content

 

Bioethics International’s Good Pharma Scorecard Improved the Data-Sharing Practices of Large Pharmaceutical Companies
NEW HAVEN, Conn., July 10, 2019 /PRNewswire/ — Bioethics International (BEI), a not-for-profit organization dedicated to raising the bar on ethics, trustworthiness and patient-centricity in the pharmaceutical industry, today announced the third publication of its Good Pharma Scorecard (GPS) in The BMJ. The GPS is an annual ranking of new drugs and the associated pharmaceutical companies on their ethics performance. This year’s rankings focus on clinical transparency and data-sharing practices in large pharmaceutical companies, specifically on trial registration, results reporting, publication and data-sharing practices.  BEI, in collaboration with Yale School of Medicine and Stanford Law School, developed new data sharing measures, which were informed by a multi-stakeholder advisory team.

Two companies, Novo Nordisk and Roche, tied for the top rank in overall trial transparency, each with scores of 100%. Novo Nordisk, Roche, Novartis and Janssen/Johnson & Johnson all achieved scores of 100% on the data-sharing measure.

In addition to measuring companies’ data-sharing practices, the study tested whether the GPS ranking tool could improve companies’ practices. BEI provided companies a 30-day window to amend their policies to meet the new data-sharing measure. At the end of the window, three companies improved their policies.  Additionally, since the first GPS published rankings in 2015, the industry’s overall median transparency scores have gone up year after year.

“A goal of the GPS is to help set ethics and social responsibility measures in the pharma industry and provide an independent tracking tool to both recognize best practices and catalyze reform, where needed, in companies,” said Jennifer E. Miller, Ph.D., founder of Bioethics International, assistant professor at the Yale School of Medicine and lead author on the paper.

“We are encouraged by the efforts of some large companies to share patient-level trial data and a willingness to improve policies and practices, where needed. However, there is substantial room for improvement. Providing companies with a consistent, fair and achievable set of measures is important to encouraging and tracking further progress toward routine data sharing.”…

Emergencies

Emergencies

POLIO
Public Health Emergency of International Concern (PHEIC)
Polio this week as of 10 July 2019
:: A circulating vaccine-derived poliovirus type 2 (cVDPV2) has been confirmed in China. It is genetically linked to a VDPV2 isolated from an environmental sample from Xinjiang province, collected on 18 April 2018.  WHO is continuing to evaluate the situation and stands ready to support the ongoing investigation and risk assessment by national authorities.

Summary of new viruses this week:
:: Pakistan — nine wild poliovirus type 1 (WPV1) cases and 3 WPV1-positive environmental samples;
:: Angola —  one circulating vaccine-derived poliovirus  (cVDPV2) case;
:: China – one cVDPV2 case. See country sections below for more details.

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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 13 Jul 2019]

Democratic Republic of the Congo
:: 49: Situation report on the Ebola outbreak in North Kivu 9 July 2019
:: Disease Outbreak News (DONs} Ebola virus disease – Democratic Republic of the Congo
11 July 2019
[See DRC Ebola+ above for detail]

Yemen
:: Outbreak update – Cholera in Yemen, 30 June 2019
8 July 2019 – The Ministry of Public Health and Population of Yemen reported 21,865 suspected cases of cholera with 13 associated deaths during epidemiological week 26 (24 to 30 June) of 2019. Thirteen percent of cases were severe. The cumulative total number of suspected cholera cases from 1 January 2018 to 30 June 2019 is 823,221, with 1210 associated deaths (CFR 0.13%). Children under five represent 23.0% of total suspected cases during 2019. The outbreak has affected 22 of 23 governorates and 299 of 333 districts in Yemen…

Nigeria
:: Nigeria intensifies cross border immunization, with special focus on nomadic populations 
Kano, 8 July, 2019 – In renewed efforts to vaccinate children traversing in and out of Nigeria, the World Health Organization (WHO) is supporting the government in an initiative to improve supplemental and routine immunization activities in the North Western region, which has a significant nomadic population.
Nomadic pastoralists live beyond the reach of established health care programs that are designed to serve sedentary populations. As a result, these groups are often under-immunized and out of the reach of existing disease surveillance activities.
Speaking on the intervention, Mallam Gwanda Mairakuma of Maiadua local government in Niger Republic said that, “with this intensified commitment, vaccination activities have reduced the number of complications associated with Measles infection on our children”…

Mozambique floods – No new digest announcements identified
Myanmar – No new digest announcements identified
Somalia – No new digest announcements identified
South Sudan – No new digest announcements identified
Syrian Arab Republic – No new digest announcements identified

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WHO Grade 2 Emergencies [to 13 Jul 2019]

Libya
:: Medical aid accelerated as Libya crisis intensifies 6 July 2019

MERS-CoV
:: Worldwide reduction in MERS cases and deaths since 2016 8 July 2019
The World Health Organization and colleagues from the University of Oxford, Imperial College London and Institut Pasteur* have estimated that, since 2016, 1 465 cases of Middle East Respiratory syndrome coronavirus (MERS-CoV) and between 300 and 500 deaths may have been averted due to accelerated global efforts to detect infections early and reduce transmission.
In 2012, a novel virus that had not previously been seen in humans was identified for the first time in a resident from Saudi Arabia. The virus, now known as MERS-CoV, has, as of 31 May 2019, infected more than 2 442 people worldwide. MERS-CoV is a respiratory virus that can cause severe disease and has been fatal in approximately 35% of patients to date. MERS is zoonotic and people are infected from direct or indirect contact with dromedary camels. While the virus has demonstrated limited ability to transmit between people outside of hospitals, it has repeatedly caused large scale outbreaks in health care facilities with severe health, security and economic impacts, most notably in Saudi Arabia in 2014-2016 and the Republic of Korea in 2015. The outbreak in the Republic of Korea in 2015 involved 186 cases and 38 deaths, and had an estimated economic impact of US$12 billion.
In a research letter published in the journal Emerging Infectious Diseases on 8 July 2019, the researchers analyze case-based data on laboratory-confirmed MERS-CoV infections reported to WHO since 2012…

Afghanistan – No new digest announcements identified
Bangladesh – Rakhine conflict – No new digest announcements identified
Cameroon – No new digest announcements identified
Central African Republic – No new digest announcements identified
Cyclone Idai – No new digest announcements identified
Ethiopia – No new digest announcements identified
Iran floods 2019 – No new digest announcements identified
Iraq – No new digest announcements identified
Malawi floods – No new digest announcements identified
Niger – No new digest announcements identified
occupied Palestinian territory – No new digest announcements identified
Sudan – No new digest announcements identified
Ukraine – No new digest announcements identified
Zimbabwe – No new digest announcements identified

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WHO Grade 1 Emergencies [to 13 Jul 2019]

Angola – No new digest announcements identified
Chad – No new digest announcements identified
Djibouti – No new digest announcements identified
Indonesia – Sulawesi earthquake 2018 – No new digest announcements identified
Kenya – No new digest announcements identified
Mali – No new digest announcements identified
Namibia – viral hepatitis – No new digest announcements identified
Tanzania – No new digest announcements identified

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UN OCHA – L3 Emergencies
The UN and its humanitarian partners are currently responding to three ‘L3’ emergencies. This is the global humanitarian system’s classification for the response to the most severe, large-scale humanitarian crises. 
Syrian Arab Republic
:: Syrian Arab Republic: Recent Developments in Northwestern Syria Situation Report No. 7 – as of 12 July 2019
HIGHLIGHTS
:: …Humanitarian response is ongoing with hundreds of thousands of people receiving critical assistance essential for their survival. Violence in areas directly affected by conflict is driving displacement into denselypopulated areas, putting a strain on service delivery for humanitarian actors. A joint assessment is currently being finalized that will provide an overview of needs in the most affected areas.
:: Civilian infrastructure, including humanitarian facilities, continues to be damaged or destroyed in the violence. In the last two weeks, at least four medical facilities have been impacted by the violence, with several other unconfirmed reports, as well as a water station serving over 80,000 people, and several schools, IDP settlements, markets and bakeries.

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.
Editor’s Note:
Ebola in the DRC has bene added as a OCHA “Corporate Emergency” this week:
CYCLONE IDAI and Kenneth
:: Southern Africa: Cyclones Idai and Kenneth Snapshot, as of 10 July 2019.

EBOLA OUTBREAK IN THE DRC – No new digest announcements identified

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WHO & Regional Offices [to 13 Jul 2019]

WHO & Regional Offices [to 13 Jul 2019]
WHO updates global guidance on medicines and diagnostic tests to address health challenges, prioritize highly effective therapeutics, and improve affordable access
New essential medicines and diagnostics lists published today
9 July 2019 News release Geneva
[See Milestones above for detail]

 

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Calls for consultants / proposals
8 July 2019
Consultancy – Support for WHO’s work on advancing vaccine development and vaccination against yellow fever, Zika, and dengue
Deadline for applications: 25 July 2019

 

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Weekly Epidemiological Record, 12 July 2019, vol. 94, 28 (pp. 309–316)
:: Global Advisory Committee on Vaccine Safety, 5–6 June 2019

 

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WHO Regional Offices
Selected Press Releases, Announcements
WHO African Region AFRO
:: Marginalised and mistrustful: listening to people who have few reasons to trust outsiders [DRC] 13 July 2019
:: Uganda Village joins forces to Fight Ebola 11 July 2019

WHO Region of the Americas PAHO
:: PAHO/WHO urges northern hemisphere countries to prepare for heatwaves  (07/12/2019)
:: CDB, PAHO launch “Stronger Together” campaign, raising awareness about mental health and psychosocial support in disasters (07/10/2019)

WHO South-East Asia Region SEARO
:: Sri Lanka eliminates measles SEAR/PR/1712
New Delhi, 9 July 2019: The World Health Organization today announced Sri Lanka has eliminated measles, interrupting transmission of the indigenous virus that causes the killer childhood disease.
“Sri Lanka’s achievement comes at a time when globally measles cases are increasing. The country’s success demonstrates its commitment, and the determination of its health workforce and parents to protect children against measles,” said Dr Poonam Khetrapal Singh, Regional Director WHO South-East Asia, congratulating the island nation…

WHO European Region EURO
– No new digest announcements identified

WHO Eastern Mediterranean Region EMRO
– No new digest announcements identified

WHO Western Pacific Region
– No new digest announcements identified