BMC Public Health
(Accessed 15 December 2012)
http://www.biomedcentral.com/bmcpublichealth/content

Research article
Regional inequality and vaccine uptake: a multilevel analysis of the 2007 Welfare Monitoring Survey in Malawi
Dawit Shawel Abebe, Vibeke Oestreich Nielsen, Jon Erik Finnvold BMC Public Health 2012, 12:1075 (13 December 2012)

Abstract (provisional)
Background
A significant part of childhood mortality can be prevented given the existence of a well functioning health care system that can deliver vaccines to children during their first year of life. This study assesses immunization differentials between regions in Malawi, and attempts to relate regional disparities in immunization to factors on individual, household and village level.

Method
We used data from the 2007 Welfare Monitoring Survey which includes 18 251 children ages 10–60 months. Multilevel logistic regression models were applied for data analysis.

Results
Major differences in full vaccine coverage (children receiving all of the 9 recommended vaccines) were documented between the 27 official regions, called districts, of Malawi. The vaccine coverage among regions varied from 2 % to 74 % when all children 10 — 60 months old were included. Vaccine coverage was significantly higher for women that had their delivery attended by a midwife/nurse, or gave birth at a hospital or maternity clinic. Regions with a high percentage of deliveries attended by health personnel were also characterized by a higher coverage. Characteristics of health care utilization on the individual level could in part account for the observed regional variations in coverage.

Several factors related to socio-demographic characteristics of individuals and households were significantly correlated with coverage (child’s age, illiteracy, income, water and sanitary conditions), implying a lower coverage among the most vulnerable parts of the population. However, these factors could only to a minor extent account for the regional variation in coverage.

Conclusions
The persistent regional inequalities suggest that the low immunization coverage in Malawi is less likely to be a result of geographical clustering of social groups with difficult level-of living conditions. Although the mean vaccine coverage in Malawi is low, some regions have succeeded in reaching a relatively high proportion of their children. The relative success of some regions implies that there is a substantial potential for political intervention to improve vaccine coverage. One important negative implication of regional inequality is the presence of clusters with under-vaccinated children, leading to an increased vulnerability during outbreaks of vaccine-preventable diseases.

The complete article is available as a provisional PDF. The fully formatted PDF and HTML versions are in production.

The Lancet  
Dec 15, 2012  Volume 380  Number 9859  p2053 – 2260
http://www.thelancet.com/journals/lancet/issue/current

Comment
GBD 2010: understanding disease, injury, and risk
Richard Horton
Preview
Publication of the Global Burden of Disease Study 2010 (GBD 2010) is a landmark event for this journal and, we hope, for health. The collaboration of 486 scientists from 302 institutions in 50 countries has produced an important contribution to our understanding of present and future health priorities for countries and the global community.

From new estimates to better data
Margaret Chan
Preview
The Global Burden of Disease Study 2010 (GBD 2010) in The Lancet represents an unprecedented effort to improve global and regional estimates of levels and trends in the burden of disease. Accurate assessment of the global, regional, and country health situation and trends is critical for evidence-based decision making for public health. WHO therefore warmly welcomes GBD 2010, which was undertaken by the Institute for Health Metrics and Evaluation (IHME) with its partners and draws on the contributions of many scientists, including those who work in WHO programmes.

Data for better health—and to help end poverty
Jim Yong Kim
Preview
The World Bank Group welcomes the publication of the new Global Burden of Disease Study (GBD). The Bank commissioned the first GBD in 1990, and continues to make extensive use of this signal contribution to global health. Like its predecessors, the new, methodologically updated GBD 2010 marks a milestone in global health knowledge and our capacity for evidence-based action. It will once again set the terms of health policy, planning, and funding discussions for years to come.

GBD 2010: a multi-investigator collaboration for global comparative descriptive epidemiology
Christopher JL Murray, Majid Ezzati, Abraham D Flaxman, Stephen Lim, Rafael Lozano, Catherine Michaud, Mohsen Naghavi, Joshua A Salomon, Kenji Shibuya, Theo Vos, Alan D Lopez
Preview
The data, methods, and findings of the Global Burden of Disease Study 2010 (GBD 2010) are described in detail in The Lancet. This large collaboration is an evolution of a body of work that began with GBD 1990.1 The number of diseases, injuries, and risk factors evaluated and the geographical units of analysis have greatly expanded in the past 20 years, and change over time has been assessed. Nevertheless, GBD 2010 follows the basic principles of GBD 1990: trying to use all the relevant published and unpublished evidence; capturing fatal and non-fatal health outcomes with comparable metrics; and separating epidemiological assessment from advocacy concerns or entanglement of agendas.

GBD 2010: design, definitions, and metrics
Christopher JL Murray, Majid Ezzati, Abraham D Flaxman, Stephen Lim, Rafael Lozano, Catherine Michaud, Mohsen Naghavi, Joshua A Salomon, Kenji Shibuya, Theo Vos, Daniel Wikler, Alan D Lopez
Preview
The Global Burden of Diseases, Injuries, and Risk Factors (GBD) enterprise is a systematic, scientific effort to quantify the comparative magnitude of health loss due to diseases, injuries, and risk factors by age, sex, and geography for specific points in time. The GBD construct of the burden of disease is health loss, not income or productivity loss.1 For decision makers, health-sector leaders, researchers, and informed citizens, the GBD approach provides an opportunity to see the big picture, to compare diseases, injuries, and risk factors, and to understand in a given place, time, and age-sex group what are the most important contributors to health loss.

Articles
Age-specific and sex-specific mortality in 187 countries, 1970–2010: a systematic analysis for the Global Burden of Disease Study 2010
Haidong Wang, Laura Dwyer-Lindgren, Katherine T Lofgren, Julie Knoll Rajaratnam, Jacob R Marcus, Alison Levin-Rector, Carly E Levitz, Alan D Lopez, Christopher JL Murray
Summary
Background
Estimation of the number and rate of deaths by age and sex is a key first stage for calculation of the burden of disease in order to constrain estimates of cause-specific mortality and to measure premature mortality in populations. We aimed to estimate life tables and annual numbers of deaths for 187 countries from 1970 to 2010.

Methods
We estimated trends in under-5 mortality rate (children aged 0—4 years) and probability of adult death (15—59 years) for each country with all available data. Death registration data were available for more than 100 countries and we corrected for undercount with improved death distribution methods. We applied refined methods to survey data on sibling survival that correct for survivor, zero-sibling, and recall bias. We separately estimated mortality from natural disasters and wars. We generated final estimates of under-5 mortality and adult mortality from the data with Gaussian process regression. We used these results as input parameters in a relational model life table system. We developed a model to extrapolate mortality to 110 years of age. All death rates and numbers have been estimated with 95% uncertainty intervals (95% UIs).

Findings
From 1970 to 2010, global male life expectancy at birth increased from 56·4 years (95% UI 55·5—57·2) to 67·5 years (66·9—68·1) and global female life expectancy at birth increased from 61·2 years (60·2—62·0) to 73·3 years (72·8—73·8). Life expectancy at birth rose by 3—4 years every decade from 1970, apart from during the 1990s (increase in male life expectancy of 1·4 years and in female life expectancy of 1·6 years). Substantial reductions in mortality occurred in eastern and southern sub-Saharan Africa since 2004, coinciding with increased coverage of antiretroviral therapy and preventive measures against malaria. Sex-specific changes in life expectancy from 1970 to 2010 ranged from gains of 23—29 years in the Maldives and Bhutan to declines of 1—7 years in Belarus, Lesotho, Ukraine, and Zimbabwe. Globally, 52·8 million (95% UI 51·6—54·1 million) deaths occurred in 2010, which is about 13·5% more than occurred in 1990 (46·5 million [45·7—47·4 million]), and 21·9% more than occurred in 1970 (43·3 million [42·2—44·6 million]). Proportionally more deaths in 2010 occurred at age 70 years and older (42·8% in 2010 vs 33·1% in 1990), and 22·9% occurred at 80 years or older. Deaths in children younger than 5 years declined by almost 60% since 1970 (16·4 million [16·1—16·7 million] in 1970 vs 6·8 million [6·6—7·1 million] in 2010), especially at ages 1—59 months (10·8 million [10·4—11·1 million] in 1970 vs 4·0 million [3·8—4·2 million] in 2010). In all regions, including those most affected by HIV/AIDS, we noted increases in mean ages at death.

Interpretation
Despite global and regional health crises, global life expectancy has increased continuously and substantially in the past 40 years. Yet substantial heterogeneity exists across age groups, among countries, and over different decades. 179 of 187 countries have had increases in life expectancy after the slowdown in progress in the 1990s. Efforts should be directed to reduce mortality in low-income and middle-income countries. Potential underestimation of achievement of the Millennium Development Goal 4 might result from limitations of demographic data on child mortality for the most recent time period. Improvement of civil registration system worldwide is crucial for better tracking of global mortality.

Funding
Bill & Melinda Gates Foundation.

Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010
Rafael Lozano et al

Summary
Background
Reliable and timely information on the leading causes of death in populations, and how these are changing, is a crucial input into health policy debates. In the Global Burden of Diseases, Injuries, and Risk Factors Study 2010 (GBD 2010), we aimed to estimate annual deaths for the world and 21 regions between 1980 and 2010 for 235 causes, with uncertainty intervals (UIs), separately by age and sex.

Methods
We attempted to identify all available data on causes of death for 187 countries from 1980 to 2010 from vital registration, verbal autopsy, mortality surveillance, censuses, surveys, hospitals, police records, and mortuaries. We assessed data quality for completeness, diagnostic accuracy, missing data, stochastic variations, and probable causes of death. We applied six different modelling strategies to estimate cause-specific mortality trends depending on the strength of the data. For 133 causes and three special aggregates we used the Cause of Death Ensemble model (CODEm) approach, which uses four families of statistical models testing a large set of different models using different permutations of covariates. Model ensembles were developed from these component models. We assessed model performance with rigorous out-of-sample testing of prediction error and the validity of 95% UIs. For 13 causes with low observed numbers of deaths, we developed negative binomial models with plausible covariates. For 27 causes for which death is rare, we modelled the higher level cause in the cause hierarchy of the GBD 2010 and then allocated deaths across component causes proportionately, estimated from all available data in the database. For selected causes (African trypanosomiasis, congenital syphilis, whooping cough, measles, typhoid and parathyroid, leishmaniasis, acute hepatitis E, and HIV/AIDS), we used natural history models based on information on incidence, prevalence, and case-fatality. We separately estimated cause fractions by aetiology for diarrhoea, lower respiratory infections, and meningitis, as well as disaggregations by subcause for chronic kidney disease, maternal disorders, cirrhosis, and liver cancer. For deaths due to collective violence and natural disasters, we used mortality shock regressions. For every cause, we estimated 95% UIs that captured both parameter estimation uncertainty and uncertainty due to model specification where CODEm was used. We constrained cause-specific fractions within every age-sex group to sum to total mortality based on draws from the uncertainty distributions.

Findings
In 2010, there were 52·8 million deaths globally. At the most aggregate level, communicable, maternal, neonatal, and nutritional causes were 24·9% of deaths worldwide in 2010, down from 15·9 million (34·1%) of 46·5 million in 1990. This decrease was largely due to decreases in mortality from diarrhoeal disease (from 2·5 to 1·4 million), lower respiratory infections (from 3·4 to 2·8 million), neonatal disorders (from 3·1 to 2·2 million), measles (from 0·63 to 0·13 million), and tetanus (from 0·27 to 0·06 million). Deaths from HIV/AIDS increased from 0·30 million in 1990 to 1·5 million in 2010, reaching a peak of 1·7 million in 2006. Malaria mortality also rose by an estimated 19·9% since 1990 to 1·17 million deaths in 2010. Tuberculosis killed 1·2 million people in 2010. Deaths from non-communicable diseases rose by just under 8 million between 1990 and 2010, accounting for two of every three deaths (34·5 million) worldwide by 2010. 8 million people died from cancer in 2010, 38% more than two decades ago; of these, 1·5 million (19%) were from trachea, bronchus, and lung cancer. Ischaemic heart disease and stroke collectively killed 12·9 million people in 2010, or one in four deaths worldwide, compared with one in five in 1990; 1·3 million deaths were due to diabetes, twice as many as in 1990. The fraction of global deaths due to injuries (5·1 million deaths) was marginally higher in 2010 (9·6%) compared with two decades earlier (8·8%). This was driven by a 46% rise in deaths worldwide due to road traffic accidents (1·3 million in 2010) and a rise in deaths from falls. Ischaemic heart disease, stroke, chronic obstructive pulmonary disease (COPD), lower respiratory infections, lung cancer, and HIV/AIDS were the leading causes of death in 2010. Ischaemic heart disease, lower respiratory infections, stroke, diarrhoeal disease, malaria, and HIV/AIDS were the leading causes of years of life lost due to premature mortality (YLLs) in 2010, similar to what was estimated for 1990, except for HIV/AIDS and preterm birth complications. YLLs from lower respiratory infections and diarrhoea decreased by 45—54% since 1990; ischaemic heart disease and stroke YLLs increased by 17—28%. Regional variations in leading causes of death were substantial. Communicable, maternal, neonatal, and nutritional causes still accounted for 76% of premature mortality in sub-Saharan Africa in 2010. Age standardised death rates from some key disorders rose (HIV/AIDS, Alzheimer’s disease, diabetes mellitus, and chronic kidney disease in particular), but for most diseases, death rates fell in the past two decades; including major vascular diseases, COPD, most forms of cancer, liver cirrhosis, and maternal disorders. For other conditions, notably malaria, prostate cancer, and injuries, little change was noted.

Interpretation
Population growth, increased average age of the world’s population, and largely decreasing age-specific, sex-specific, and cause-specific death rates combine to drive a broad shift from communicable, maternal, neonatal, and nutritional causes towards non-communicable diseases. Nevertheless, communicable, maternal, neonatal, and nutritional causes remain the dominant causes of YLLs in sub-Saharan Africa. Overlaid on this general pattern of the epidemiological transition, marked regional variation exists in many causes, such as interpersonal violence, suicide, liver cancer, diabetes, cirrhosis, Chagas disease, African trypanosomiasis, melanoma, and others. Regional heterogeneity highlights the importance of sound epidemiological assessments of the causes of death on a regular basis.

Funding
Bill & Melinda Gates Foundation.

Common values in assessing health outcomes from disease and injury: disability weights measurement study for the Global Burden of Disease Study 2010
Joshua A Salomon et al

Summary
Background
Measurement of the global burden of disease with disability-adjusted life-years (DALYs) requires disability weights that quantify health losses for all non-fatal consequences of disease and injury. There has been extensive debate about a range of conceptual and methodological issues concerning the definition and measurement of these weights. Our primary objective was a comprehensive re-estimation of disability weights for the Global Burden of Disease Study 2010 through a large-scale empirical investigation in which judgments about health losses associated with many causes of disease and injury were elicited from the general public in diverse communities through a new, standardised approach.

Methods
We surveyed respondents in two ways: household surveys of adults aged 18 years or older (face-to-face interviews in Bangladesh, Indonesia, Peru, and Tanzania; telephone interviews in the USA) between Oct 28, 2009, and June 23, 2010; and an open-access web-based survey between July 26, 2010, and May 16, 2011. The surveys used paired comparison questions, in which respondents considered two hypothetical individuals with different, randomly selected health states and indicated which person they regarded as healthier. The web survey added questions about population health equivalence, which compared the overall health benefits of different life-saving or disease-prevention programmes. We analysed paired comparison responses with probit regression analysis on all 220 unique states in the study. We used results from the population health equivalence responses to anchor the results from the paired comparisons on the disability weight scale from 0 (implying no loss of health) to 1 (implying a health loss equivalent to death). Additionally, we compared new disability weights with those used in WHO’s most recent update of the Global Burden of Disease Study for 2004.

Findings
13 902 individuals participated in household surveys and 16 328 in the web survey. Analysis of paired comparison responses indicated a high degree of consistency across surveys: correlations between individual survey results and results from analysis of the pooled dataset were 0·9 or higher in all surveys except in Bangladesh (r=0·75). Most of the 220 disability weights were located on the mild end of the severity scale, with 58 (26%) having weights below 0·05. Five (11%) states had weights below 0·01, such as mild anaemia, mild hearing or vision loss, and secondary infertility. The health states with the highest disability weights were acute schizophrenia (0·76) and severe multiple sclerosis (0·71). We identified a broad pattern of agreement between the old and new weights (r=0·70), particularly in the moderate-to-severe range. However, in the mild range below 0·2, many states had significantly lower weights in our study than previously.

Interpretation
This study represents the most extensive empirical effort as yet to measure disability weights. By contrast with the popular hypothesis that disability assessments vary widely across samples with different cultural environments, we have reported strong evidence of highly consistent results.

Funding
Bill & Melinda Gates Foundation.

Healthy life expectancy for 187 countries, 1990–2010: a systematic analysis for the Global Burden Disease Study 2010
Joshua A Salomon, Haidong Wang, Michael K Freeman, Theo Vos, Abraham D Flaxman, Alan D Lopez, Christopher JL Murray

Summary
Background
Healthy life expectancy (HALE) summarises mortality and non-fatal outcomes in a single measure of average population health. It has been used to compare health between countries, or to measure changes over time. These comparisons can inform policy questions that depend on how morbidity changes as mortality decreases. We characterise current HALE and changes over the past two decades in 187 countries.

Methods
Using inputs from the Global Burden of Disease Study (GBD) 2010, we assessed HALE for 1990 and 2010. We calculated HALE with life table methods, incorporating estimates of average health over each age interval. Inputs from GBD 2010 included age-specific information for mortality rates and prevalence of 1160 sequelae, and disability weights associated with 220 distinct health states relating to these sequelae. We computed estimates of average overall health for each age group, adjusting for comorbidity with a Monte Carlo simulation method to capture how multiple morbidities can combine in an individual. We incorporated these estimates in the life table by the Sullivan method to produce HALE estimates for each population defined by sex, country, and year. We estimated the contributions of changes in child mortality, adult mortality, and disability to overall change in population health between 1990 and 2010.

Findings
In 2010, global male HALE at birth was 58·3 years (uncertainty interval 56·7—59·8) and global female HALE at birth was 61·8 years (60·1—63·4). HALE increased more slowly than did life expectancy over the past 20 years, with each 1-year increase in life expectancy at birth associated with a 0·8-year increase in HALE. Across countries in 2010, male HALE at birth ranged from 27·9 years (17·3—36·5) in Haiti, to 68·8 years (67·0—70·4) in Japan. Female HALE at birth ranged from 37·1 years (26·9—43·7) in Haiti, to 71·7 years (69·7—73·4) in Japan. Between 1990 and 2010, male HALE increased by 5 years or more in 42 countries compared with 37 countries for female HALE, while male HALE decreased in 21 countries and 11 for female HALE. Between countries and over time, life expectancy was strongly and positively related to number of years lost to disability. This relation was consistent between sexes, in cross-sectional and longitudinal analysis, and when assessed at birth, or at age 50 years. Changes in disability had small effects on changes in HALE compared with changes in mortality.

Interpretation
HALE differs substantially between countries. As life expectancy has increased, the number of healthy years lost to disability has also increased in most countries, consistent with the expansion of morbidity hypothesis, which has implications for health planning and health-care expenditure. Compared with substantial progress in reduction of mortality over the past two decades, relatively little progress has been made in reduction of the overall effect of non-fatal disease and injury on population health. HALE is an attractive indicator for monitoring health post-2015.

Funding
The Bill & Melinda Gates Foundation

Years lived with disability (YLDs) for 1160 sequelae of 289 diseases and injuries 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010
Theo Vos et al

Summary
Background
Non-fatal health outcomes from diseases and injuries are a crucial consideration in the promotion and monitoring of individual and population health. The Global Burden of Disease (GBD) studies done in 1990 and 2000 have been the only studies to quantify non-fatal health outcomes across an exhaustive set of disorders at the global and regional level. Neither effort quantified uncertainty in prevalence or years lived with disability (YLDs).

Methods
Of the 291 diseases and injuries in the GBD cause list, 289 cause disability. For 1160 sequelae of the 289 diseases and injuries, we undertook a systematic analysis of prevalence, incidence, remission, duration, and excess mortality. Sources included published studies, case notification, population-based cancer registries, other disease registries, antenatal clinic serosurveillance, hospital discharge data, ambulatory care data, household surveys, other surveys, and cohort studies. For most sequelae, we used a Bayesian meta-regression method, DisMod-MR, designed to address key limitations in descriptive epidemiological data, including missing data, inconsistency, and large methodological variation between data sources. For some disorders, we used natural history models, geospatial models, back-calculation models (models calculating incidence from population mortality rates and case fatality), or registration completeness models (models adjusting for incomplete registration with health-system access and other covariates). Disability weights for 220 unique health states were used to capture the severity of health loss. YLDs by cause at age, sex, country, and year levels were adjusted for comorbidity with simulation methods. We included uncertainty estimates at all stages of the analysis.

Findings
Global prevalence for all ages combined in 2010 across the 1160 sequelae ranged from fewer than one case per 1 million people to 350 000 cases per 1 million people. Prevalence and severity of health loss were weakly correlated (correlation coefficient −0·37). In 2010, there were 777 million YLDs from all causes, up from 583 million in 1990. The main contributors to global YLDs were mental and behavioural disorders, musculoskeletal disorders, and diabetes or endocrine diseases. The leading specific causes of YLDs were much the same in 2010 as they were in 1990: low back pain, major depressive disorder, iron-deficiency anaemia, neck pain, chronic obstructive pulmonary disease, anxiety disorders, migraine, diabetes, and falls. Age-specific prevalence of YLDs increased with age in all regions and has decreased slightly from 1990 to 2010. Regional patterns of the leading causes of YLDs were more similar compared with years of life lost due to premature mortality. Neglected tropical diseases, HIV/AIDS, tuberculosis, malaria, and anaemia were important causes of YLDs in sub-Saharan Africa.

Interpretation
Rates of YLDs per 100 000 people have remained largely constant over time but rise steadily with age. Population growth and ageing have increased YLD numbers and crude rates over the past two decades. Prevalences of the most common causes of YLDs, such as mental and behavioural disorders and musculoskeletal disorders, have not decreased. Health systems will need to address the needs of the rising numbers of individuals with a range of disorders that largely cause disability but not mortality. Quantification of the burden of non-fatal health outcomes will be crucial to understand how well health systems are responding to these challenges. Effective and affordable strategies to deal with this rising burden are an urgent priority for health systems in most parts of the world.

Funding
Bill & Melinda Gates Foundation.

Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010
Christopher J L Murray et al

Summary
Background
Measuring disease and injury burden in populations requires a composite metric that captures both premature mortality and the prevalence and severity of ill-health. The 1990 Global Burden of Disease study proposed disability-adjusted life years (DALYs) to measure disease burden. No comprehensive update of disease burden worldwide incorporating a systematic reassessment of disease and injury-specific epidemiology has been done since the 1990 study. We aimed to calculate disease burden worldwide and for 21 regions for 1990, 2005, and 2010 with methods to enable meaningful comparisons over time.

Methods
We calculated DALYs as the sum of years of life lost (YLLs) and years lived with disability (YLDs). DALYs were calculated for 291 causes, 20 age groups, both sexes, and for 187 countries, and aggregated to regional and global estimates of disease burden for three points in time with strictly comparable definitions and methods. YLLs were calculated from age-sex-country-time-specific estimates of mortality by cause, with death by standardised lost life expectancy at each age. YLDs were calculated as prevalence of 1160 disabling sequelae, by age, sex, and cause, and weighted by new disability weights for each health state. Neither YLLs nor YLDs were age-weighted or discounted. Uncertainty around cause-specific DALYs was calculated incorporating uncertainty in levels of all-cause mortality, cause-specific mortality, prevalence, and disability weights.

Findings
Global DALYs remained stable from 1990 (2·503 billion) to 2010 (2·490 billion). Crude DALYs per 1000 decreased by 23% (472 per 1000 to 361 per 1000). An important shift has occurred in DALY composition with the contribution of deaths and disability among children (younger than 5 years of age) declining from 41% of global DALYs in 1990 to 25% in 2010. YLLs typically account for about half of disease burden in more developed regions (high-income Asia Pacific, western Europe, high-income North America, and Australasia), rising to over 80% of DALYs in sub-Saharan Africa. In 1990, 47% of DALYs worldwide were from communicable, maternal, neonatal, and nutritional disorders, 43% from non-communicable diseases, and 10% from injuries. By 2010, this had shifted to 35%, 54%, and 11%, respectively. Ischaemic heart disease was the leading cause of DALYs worldwide in 2010 (up from fourth rank in 1990, increasing by 29%), followed by lower respiratory infections (top rank in 1990; 44% decline in DALYs), stroke (fifth in 1990; 19% increase), diarrhoeal diseases (second in 1990; 51% decrease), and HIV/AIDS (33rd in 1990; 351% increase). Major depressive disorder increased from 15th to 11th rank (37% increase) and road injury from 12th to 10th rank (34% increase). Substantial heterogeneity exists in rankings of leading causes of disease burden among regions.

Interpretation
Global disease burden has continued to shift away from communicable to non-communicable diseases and from premature death to years lived with disability. In sub-Saharan Africa, however, many communicable, maternal, neonatal, and nutritional disorders remain the dominant causes of disease burden. The rising burden from mental and behavioural disorders, musculoskeletal disorders, and diabetes will impose new challenges on health systems. Regional heterogeneity highlights the importance of understanding local burden of disease and setting goals and targets for the post-2015 agenda taking such patterns into account. Because of improved definitions, methods, and data, these results for 1990 and 2010 supersede all previously published Global Burden of Disease results.

Funding
Bill & Melinda Gates Foundation.

A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: a systematic analysis for the Global Burden of Disease Study 2010
Stephen S Lim et al

Summary
Background
Quantification of the disease burden caused by different risks informs prevention by providing an account of health loss different to that provided by a disease-by-disease analysis. No complete revision of global disease burden caused by risk factors has been done since a comparative risk assessment in 2000, and no previous analysis has assessed changes in burden attributable to risk factors over time.

Methods
We estimated deaths and disability-adjusted life years (DALYs; sum of years lived with disability [YLD] and years of life lost [YLL]) attributable to the independent effects of 67 risk factors and clusters of risk factors for 21 regions in 1990 and 2010. We estimated exposure distributions for each year, region, sex, and age group, and relative risks per unit of exposure by systematically reviewing and synthesising published and unpublished data. We used these estimates, together with estimates of cause-specific deaths and DALYs from the Global Burden of Disease Study 2010, to calculate the burden attributable to each risk factor exposure compared with the theoretical-minimum-risk exposure. We incorporated uncertainty in disease burden, relative risks, and exposures into our estimates of attributable burden.

Findings
In 2010, the three leading risk factors for global disease burden were high blood pressure (7·0% [95% uncertainty interval 6·2—7·7] of global DALYs), tobacco smoking including second-hand smoke (6·3% [5·5—7·0]), and alcohol use (5·5% [5·0—5·9]). In 1990, the leading risks were childhood underweight (7·9% [6·8—9·4]), household air pollution from solid fuels (HAP; 7·0% [5·6—8·3]), and tobacco smoking including second-hand smoke (6·1% [5·4—6·8]). Dietary risk factors and physical inactivity collectively accounted for 10·0% (95% UI 9·2—10·8) of global DALYs in 2010, with the most prominent dietary risks being diets low in fruits and those high in sodium. Several risks that primarily affect childhood communicable diseases, including unimproved water and sanitation and childhood micronutrient deficiencies, fell in rank between 1990 and 2010, with unimproved water and sanitation accounting for 0·9% (0·4—1·6) of global DALYs in 2010. However, in most of sub-Saharan Africa childhood underweight, HAP, and non-exclusive and discontinued breastfeeding were the leading risks in 2010, while HAP was the leading risk in south Asia. The leading risk factor in Eastern Europe, most of Latin America, and southern sub-Saharan Africa in 2010 was alcohol use; in most of Asia, North Africa and Middle East, and central Europe it was high blood pressure. Despite declines, tobacco smoking including second-hand smoke remained the leading risk in high-income north America and western Europe. High body-mass index has increased globally and it is the leading risk in Australasia and southern Latin America, and also ranks high in other high-income regions, North Africa and Middle East, and Oceania.

Interpretation
Worldwide, the contribution of different risk factors to disease burden has changed substantially, with a shift away from risks for communicable diseases in children towards those for non-communicable diseases in adults. These changes are related to the ageing population, decreased mortality among children younger than 5 years, changes in cause-of-death composition, and changes in risk factor exposures. New evidence has led to changes in the magnitude of key risks including unimproved water and sanitation, vitamin A and zinc deficiencies, and ambient particulate matter pollution. The extent to which the epidemiological shift has occurred and what the leading risks currently are varies greatly across regions. In much of sub-Saharan Africa, the leading risks are still those associated with poverty and those that affect children.

Funding
Bill & Melinda Gates Foundation.

New England Journal of Medicine
December 13, 2012  Vol. 367 No. 24
http://content.nejm.org/current.shtml

Original Articles
A Phase 3 Trial of RTS,S/AS01 Malaria Vaccine in African Infants
The RTS,S Clinical Trials Partnership

Abstract
Background
The candidate malaria vaccine RTS,S/AS01 reduced episodes of both clinical and severe malaria in children 5 to 17 months of age by approximately 50% in an ongoing phase 3 trial. We studied infants 6 to 12 weeks of age recruited for the same trial.

Methods
We administered RTS,S/AS01 or a comparator vaccine to 6537 infants who were 6 to 12 weeks of age at the time of the first vaccination in conjunction with Expanded Program on Immunization (EPI) vaccines in a three-dose monthly schedule. Vaccine efficacy against the first or only episode of clinical malaria during the 12 months after vaccination, a coprimary end point, was analyzed with the use of Cox regression. Vaccine efficacy against all malaria episodes, vaccine efficacy against severe malaria, safety, and immunogenicity were also assessed.

Results
The incidence of the first or only episode of clinical malaria in the intention-to-treat population during the 14 months after the first dose of vaccine was 0.31 per person-year in the RTS,S/AS01 group and 0.40 per person-year in the control group, for a vaccine efficacy of 30.1% (95% confidence interval [CI], 23.6 to 36.1). Vaccine efficacy in the per-protocol population was 31.3% (97.5% CI, 23.6 to 38.3). Vaccine efficacy against severe malaria was 26.0% (95% CI, −7.4 to 48.6) in the intention-to-treat population and 36.6% (95% CI, 4.6 to 57.7) in the per-protocol population. Serious adverse events occurred with a similar frequency in the two study groups. One month after administration of the third dose of RTS,S/AS01, 99.7% of children were positive for anti-circumsporozoite antibodies, with a geometric mean titer of 209 EU per milliliter (95% CI, 197 to 222).

Conclusions
The RTS,S/AS01 vaccine coadministered with EPI vaccines provided modest protection against both clinical and severe malaria in young infants. (Funded by GlaxoSmithKline Biologicals and the PATH Malaria Vaccine Initiative; RTS,S ClinicalTrials.gov number, NCT00866619.)

Editorials
Malaria Vaccine Trials — Beyond Efficacy End Points
J.P. Daily

Extract [First 100 words]

PLoS Medicine
(Accessed 15 December 2012)
http://www.plosmedicine.org/article/browse.action?field=date

Progress toward Global Reduction in Under-Five Mortality: A Bootstrap Analysis of Uncertainty in Millennium Development Goal 4 Estimates
Leontine Alkema, Jin Rou
New Research Article, published 11 Dec 2012
doi:10.1371/journal.pmed.1001355

Abstract 
Background
Millennium Development Goal 4 calls for an annual rate of reduction (ARR) of the under-five mortality rate (U5MR) of 4.4% between 1990 and 2015. Progress is measured through the point estimates of the United Nations Inter-agency Group for Child Mortality Estimation (UN IGME). To facilitate evidence-based conclusions about progress toward the goal, we assessed the uncertainty in the estimates arising from sampling errors and biases in data series and the inferior quality of specific data series.

Methods and Findings
We implemented a bootstrap procedure to construct 90% uncertainty intervals (UIs) for the U5MR and ARR to complement the UN IGME estimates. We constructed the bounds for all countries without a generalized HIV epidemic, where a standard estimation approach is carried out (174 countries). In the bootstrap procedure, potential biases in levels and trends of data series of different source types were accounted for. There is considerable uncertainty about the U5MR, particularly for high mortality countries and in recent years. Among 86 countries with a U5MR of at least 40 deaths per 1,000 live births in 1990, the median width of the UI, relative to the U5MR level, was 19% for 1990 and 48% for 2011, with the increase in uncertainty due to more limited data availability. The median absolute width of the 90% UI for the ARR from 1990 to 2011 was 2.2%. Although the ARR point estimate for all high mortality countries was greater than zero, for eight of them uncertainty included the possibility of no improvement between 1990 and 2011. For 13 countries, it is deemed likely that the ARR from 1990 to 2011 exceeded 4.4%.

Conclusions
In light of the upcoming evaluation of Millennium Development Goal 4 in 2015, uncertainty assessments need to be taken into account to avoid unwarranted conclusions about countries’ progress based on limited data.

Editors’ Summary 
Background
In September 2000, world leaders adopted the United Nations Millennium Declaration, committing member states (countries) to a new global partnership to reduce extreme poverty and improve global health by setting out a series of time-bound targets with a deadline of 2015—the Millennium Development Goals (MDGs). There are eight MDGs and the fourth, MDG 4, focuses on reducing the number of deaths in children aged under five years by two-thirds from the 1990 level. Monitoring progress towards meeting all of the MDG targets is of vital importance to measure the effectiveness of interventions and to prioritize slow progress areas. MDG 4 has three specific indicators, and every year, the United Nations Inter-agency Group for Child Mortality Estimation (the UN IGME, which includes the key agencies the United Nations Children’s Fund, the World Health Organization, the World Bank, and the United Nations Population Division) produces and publishes estimates of child death rates for all countries.

Why Was This Study Done?
Many poorer countries do not have the infrastructure and the functioning vital registration systems in place to record the number of child deaths. Therefore, it is difficult to accurately assess levels and trends in the rate of child deaths because there is limited information (data) or because the data that exists may be inaccurate or of poor quality. In order to deal with this situation, analyzing trends in under-five child death rates (to show progress towards MDG 4) currently focuses on the “best” estimates from countries, a process that relies on “point” estimates. But this practice can lead to inaccurate results and comparisons. It is therefore important to identify a framework for calculating the uncertainty surrounding these estimates. In this study, the researchers use a statistical method to calculate plausible uncertainty intervals for the estimates of death rates in children aged under five years and the yearly reduction in those rates.

What Did the Researchers Do and Find?
The researchers used the publicly available information from the UN IGME 2012 database, which collates data from a variety of sources, and a statistical method called bootstrapping to construct uncertainty levels for 174 countries out of 195 countries for which the UN IGME published estimates in 2012. This new method improves current practice for estimating the extent of data errors, as it takes into account the structure and (potentially poor) quality of the data. The researchers used 90% as the uncertainty level and categorized countries according to the likelihood of meeting the MDG 4 target.

Using these methods, the researchers found that in countries with high child mortality rates (40 or more deaths per 1,000 children in 1990), there was a lot of uncertainty (wide uncertainty intervals) about the levels and trends of death rates in children aged under five years, especially more recently, because of the limited availability of data. Overall, in 2011 the median width of the uncertainty interval for the child death rate was 48% among the 86 countries with high death rates, compared to 19% in 1990. Using their new method, the researchers found that for eight countries, it is not clear whether any progress had been made in reducing child mortality, but for 13 countries, it is deemed likely that progress exceeded the MDG 4 target.

What Do These Findings Mean?
These findings suggest that new uncertainty assessments constructed by a statistical method called bootstrapping can provide more insights into countries’ progress in reducing child mortality and meeting the MDG 4 target. As demonstrated in this study, when data are limited, uncertainty intervals should to be taken into account when estimating progress towards MDG 4 in order to give more accurate assessments on a country’ progress, thus allowing for more realistic comparisons and conclusions.

Additional Information
Please access these websites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1​001355.

The UN website has more information about the Millennium Development Goals, including country-specific data

More information is available from UNICEF’s ChildInfo website about the UN IGME and child mortality

All UN IGME child mortality estimates and data are available via CME Info

Countdown to 2015 tracks coverage levels for health interventions proven to reduce child mortality and proposes new actions to reach MDG 4

PLoS Medicine
(Accessed 15 December 2012)
http://www.plosmedicine.org/article/browse.action?field=date

Preventing Pandemics Via International Development: A Systems Approach
Tiffany L. Bogich, Rumi Chunara, David Scales, Emily Chan, Laura C. Pinheiro, Aleksei A. Chmura, Dennis Carroll, Peter Daszak, John S. Brownstein
Policy Forum, published 11 Dec 2012
doi:10.1371/journal.pmed.1001354

Summary Points
The way in which public health programs are designed and funded has changed significantly; however, the trend toward establishing vertical, disease-specific global health programs may be at the cost of strengthening basic public health infrastructure and development in the long term.

In a review of nearly 400 public health events of international concern, we found that a breakdown or absence of public health infrastructure was the driving factor in the largest fraction of outbreaks (39.5%). No single other driving factor accounted for more than 10% of outbreaks.

The relative roles of emergency response versus long-term development strategies to mitigate infectious disease threats are being debated within bilateral and intergovernmental aid agencies.

We propose a systems approach within development agencies to address pandemic prevention at the intersection of people and their environment where the risk of disease emergence is highest. To achieve this goal, mainstream development funding, rather than emergency funding, is required.

Journal of Adolescent Health
Article in Press
http://www.jahonline.org/article/S1054-139X%2812%2900403-X/abstract

Factors Predicting Completion of the Human Papillomavirus Vaccine Series
Rachel Gold, Allison Naleway, Karen Riedlinger,
Received 16 May 2012; accepted 14 September 2012. published online 11 December 2012.
Corrected Proof

Abstract 
Purpose
This study identified factors associated with completion of the three dose quadrivalent human papillomavirus vaccine (HPV4) series by female adolescents.

Methods
Between February and September 2008, we prospectively surveyed 11- to 26-year-old female members of an integrated managed care organization shortly after their first HPV4 dose to identify factors that predicted series completion. We used regression analyses to assess whether self-reported experiences at the index visit, knowledge/attitudes about HPV and HPV4, and medical record data on adverse events, demographic characteristics, care-utilization frequency, and visit characteristics, were associated with vaccine series completion within one year of the first HPV4 dose.

Results
Of 899 survey respondents (27% of 3347 survey recipients), 786 (87%) maintained continuous enrollment in the health plan in the year following the first HPV4 dose. Fifty percent (n = 393) completed the vaccine series within that year. In multivariate analyses of survey respondents, only respondents’ ability to correctly identify the number of shots required for series completion was significantly associated with series completion. Reported bruising was associated with decreased likelihood of completion, and the clinician stating that future shots were required was associated with increased likelihood, but both were of borderline significance. Females ages 16–20 had the lowest series completion.

Conclusions

Improving HPV4 completion will require targeted efforts. Our results suggest that providers may help by stressing the need for additional doses of vaccine, and confirming that patients understand this information. Special attention should be given to females ages 16–20. Future randomized trials should assess the effect on vaccine completion of these simple, low-cost interventions.

Twitter Watch [accessed 15 December 2012 – 18:54]
Items of interest from a variety of twitter feeds associated with immunization, vaccines and global public health. This capture is highly selective and is by no means intended to be exhaustive.

CVEP @VaxEthicsPolicy
@MSF_USA @dndi_hq Center for Vaccine Ethics & Policy applauds the extraordinary #fatalneglect conference: compelling, alarming, energizing.
11:28 AM – 14 Dec 12

Doctors w/o Borders @MSF_USA
Thank you for following our #fatalneglect conference. See highlights from our discussion here: http://bit.ly/TZb0Lg  #globalhealth #ntds
#fatalneglect
By Doctors w/o Borders @MSF_USA
A two-day conference in New York City on delivering medical innovations for neglected patients and populations. Hosted by Doctors Without Borders/Médecins Sans Frontières (MSF) and the Drugs for…
10:26 AM – 14 Dec 12

PAHO/WHO @pahowho
Rt @TheLancet: The Lancet publishes largest ever study on global burden of disease. Freely available online http://ow.ly/g4ImF  #GBD2010”
6:43 AM – 14 Dec 12

PAHO/WHO @pahowho
Rt @WHO: 10 facts on the state of #globalhealth: the loss of health from all causes of illness and deaths worldwide http://goo.gl/xCQbU ”
5:31 AM – 14 Dec 12

WHO ‏@WHO
Global Health Observatory – free access to world’s largest and most comprehensive collection of up-to-date health data http://goo.gl/wwPuU 
3:52 AM – 14 Dec 12

The Global Fund @globalfundnews
Japan’s 2012 Contribution to the Global Fund is the Highest it Has Ever Made http://tinyurl.com/c3pcb8m 
3:29 AM – 14 Dec 12

M&R Initiative ‏@MeaslesRubella
Nepal: > 5.5 million children will be #immunized in 3rd phase of #measles & #rubella #vaccination drive starting today. http://bit.ly/12oRmvg 
11:35 PM – 13 Dec 12

M&R Initiative ‏@MeaslesRubella
#Pakistan: 20 children die with more 100 undergoing treatment after outbreak of #measles in rain-affected #Khanpur. http://bit.ly/Z4KO7c 
11:32 PM – 13 Dec 12

WHO @WHO
Only 34 countries produce high-quality data on causes of #death; WHO works closely w/ developing countries to improve health info systems
9:22 AM – 13 Dec 12

Editor’s Notes:

– Email Summary: Vaccines: The Week in Review is available as a weekly email summary: please send your request to david.r.curry@centerforvaccineethicsandpolicy.org.

– pdf version: A pdf of the current issues is available here: Vaccines_The Week in Review_8 December 2012

– Twitter: Readers can also follow developments on twitter: @vaxethicspolicy.

– Support: If you would like to join the growing list of individuals who support this service and its contribution to their roles in public health, clinical practice, government, IGOs/NGOs, research, industry and academia, please visit this page at The Wistar Institute, our co-founder and fiduciary. Thank you…

Media Release: Measles and polio vaccination campaign targets 2.5 million children in the Syrian Arab Republic

Excerpt
A vaccination campaign is under way in the Syrian Arab Republic to immunize children under 5 against polio and measles.

The campaign is being implemented by the Ministry of Health with support from the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF). In addition to the vaccines provided by the Ministry of Health, UNICEF procured 1.5 million doses of measles vaccine and WHO provided doses of infant paracetamol and multivitamin syrup. The Ministry of Health has increased its advocacy messages in the media to create awareness about the campaign throughout the country.

The total under-five population in the Syrian Arab Republic is almost 2.5 million children and the aim of the campaign is to reach every child, vaccinating all children below the age of five against polio and 2 million children against measles.

Due to escalations in the conflict, the national vaccination coverage for the first quarter of 2012 dropped from 95% to 80%, and it is expected to have dropped even further since then.    Challenges in implementing the national immunization programme include difficulties in maintaining the cold chain (leading to destroyed vaccines) and reaching children in areas where access is limited due to blocked roads and security issues. Many vaccination and supply vehicles have been damaged or affected, resulting in critical shortages of transportation for the vaccines.

An estimated 4000 health workers and volunteers are participating in the campaign taking place across 13 of the country’s 14 governorates from 26 November to 10 December. The governorate of Deir El Zor was not included in the campaign as the majority of its residents have relocated to other areas in the country.

Field staff working on the campaign have reported that some areas where children live are inaccessible due to the ongoing conflict. Othman Mohamed, field worker and supervisor of the Damascus field teams, said that despite restrictions in accessibility, the teams have so far managed to reach all children targeted to date. Eight mobile teams are responsible for vaccinations in Damascus, including one team dedicated to reaching internally displaced persons living in shelters. Mohamed reports that an average of 12 000 children are being vaccinated daily by the mobile teams, as well as in health centres and preschools in the city.

The Ministry of Health has requested assistance from WHO in delivering vaccines to heavily affected areas. WHO has distributed 650 000 vaccine doses to areas in Aleppo, Homs and Rural Damascus where the Ministry has restricted access.

Three days after the launch of the campaign, WHO visited two health centres and a medical point located in Adraa, Rural Damascus, an area hosting 200 000 internally displaced persons. WHO reported that despite health staff being overburdened with an extremely high workload, the campaign at the facilities was well managed and vaccines were available and well stored. Almost 500 children were visiting the facilities every day, including many who had not been previously vaccinated.

http://www.emro.who.int/media/news/vaccination-campaign-syria.html

UNICEF: Amid conflict and displacement, Syrian children receive lifesaving vaccinations  Mobile teams reach displaced children in shelters
DAMASCUS, 7 December 2012 – An emergency vaccination campaign is under way in Syria to protect young children against measles and polio, diseases that can spread rapidly – and sometimes with fatal results – in times of conflict and displacement.

The campaign – targeting 1.4 million children in all – has faced unusual challenges: With key roads blocked and fighting in many parts of the country, getting vital vaccine supplies to towns where they were needed has been both dangerous and difficult.

“The toughest job has been for the drivers who have had to collect supplies in Damascus and then deliver them, often by circuitous routes, to campaign workers across the country,” said Iman Bahnasi, Child Survival and Development specialist with UNICEF Syria. “But thanks to their determination and courage, all governorates have received the supplies they need.”

Data received from 11 of Syria’s 14 governorates show that since the campaign started on 26 November, more than 630,000 children aged under five have already received polio drops, while over 510,000 children aged 1 to 5 years have been vaccinated against measles.

Children over one year of age are also receiving a dose of Vitamin A, which contributes to reducing morbidity due to acute respiratory infections and diarrhoea…

http://www.unicef.org/media/media_66564.html

[Editor’s Note: The most recent SAGE meeting (Geneva, 6-8 November 2012) session titled  “Vaccination in humanitarian emergencies session” may be of interest to readers. The draft document discussed at the session is posted on the WHO SAGE site and available here:
Vaccination in acute emergencies: A framework for decision-making, 23 October 2012
pdf, 1.66Mb ]

GAVI: Alliance Partners Forum
5-7 December 2012, Dar es Salaam, Tanzania
More than 650 global health and government leaders exploring ways to accelerate Results, Innovation, Sustainability and Equity [RISE] in the field of immunisation.

This page – http://www.gavialliance.org/forum/ – provides a single, integrated source of content associated with the Forum. Please see Seth Berkley’s opening plenary excerpts just below and, further below, media releases issued by GAVI during the week.

Speech: GAVI Past, Present and Future – GAVI CEO Seth Berkley
Excerpts from GAVI

PAST
About the Baobab tree, the Forum’s symbol: “the baobab tree has a special significance in Africa. It’s revered. People gather under its branches to discuss important issues and talk to their ancestors. This Forum is a time for us to come together and discuss. We should start with our founders and the question is how are we doing. I think we are living up to their vision. As of 2014, every single GAVI country will be using the DTP3 vaccine. It is a routine vaccine and that is what we are trying to do.”

PRESENT
Rollout of pneumococcal vaccine: it‘s an extraordinary story that this vaccine (pneumococcal) was made available in developing countries about a year and a half after it became available in high-income countries. The ultimate goal would be simultaneous introduction in north and south. That’s what we want. Never again will a company have a life-saving vaccine and ask ‘when’ will it reach a developing country. The question should only be ‘how’.

On the heroic efforts of health workers in developing countries: health workers do whatever it takes to get the vaccines out there … camels, donkeys .. It’s heroic. It’s getting the vaccine into her hands so she can vaccinate and it’s going to lead to healthy children in school.”

FUTURE
The fully immunised child: WHO recommends that every child has 11 antigens: BCG, DTP3 (diphtheria-tetanus-pertussis), measles, polio, hepatitis B, Haemophilus influenzae type b, pneumococcal, rotavirus, rubella and human papillomavirus.

So should we be looking at DTP3 or the fully immunised child as an indicator of immunisation coverage? What we want is every child, everywhere protected by the full number of antigens.     Conceptually, this is where we want to go. If we want to do this, current estimates predict that by 2030, only 50 percent of children will be fully immunised. This is not good enough; we need to reset our aspirations.

Technology: we also need to use technology. Every village household has one cell phone in it and often two or more. Why is it that we are not looking at vaccine stock using GPS, so a flashing red light on an interactive map tells us immediately there is a stock problem in a local health clinic. This is not far fetched. This is what is happening in most of the world for supply chains. We just haven’t used it in immunisation.

Inconsistency in immunisation data: can we measure immunisation rates? Our numbers really aren’t very tight. We’re shooting in the dark against a target, because we don’t have the tools to really allow us to understand what is happening. This is a critical goal going forward.

Flowering of our effort: when we think about the field of immunisation, we’re back to the (baobab) tree. We need to bring together all the critical parts of immunisation, to become part of routine immunisation. Something extraordinary will happen, we will see the flowering of this effort, and we will see something extraordinary happen.

Watch the video of GAVI CEO, Seth Berkley presenting his visionary speech:
http://www.gavialliance.org/library/news/gavi-features/2012/past-present-future-plenary/

Media Releases during the week of the Alliance Partners’ Forum:
06 December 2012
More than 30 million girls to be immunised with HPV vaccines by 2020 with GAVI support
The GAVI Alliance plans to work with countries to prepare them for nationwide roll outs of the vaccine against the human papillomavirus (HPV), the leading cause of cervical cancer.

05 December 2012
Immunisation protecting 370 million additional children through successful global partnership
Progress is accelerating in the global effort to protect children from infectious diseases and spread the benefits of immunisation around the world.

04 December 2012
GAVI Board reappoints Dagfinn Høybråten as chair
The GAVI Alliance Board unanimously reappointed Dagfinn Høybråten to serve a second-year term as the GAVI Board Chair.

03 December 2012
100 millionth person receives lifesaving meningitis vaccine
A revolutionary meningitis vaccine will reach the 100 millionth person this week in a region of Africa that has been plagued by deadly epidemics for more than a century. The milestone will take place in northern Nigeria, part of Africa’s “meningitis belt’, where the country is conducting its second seasonal immunisation campaign against the disease

MSF at the GAVI Alliance “Partners’ Forum” Vaccination Conference, Tanzania, December 5–7, 2012

Three new issue briefs outlining Doctors Without Borders/Médecins Sans Frontières (MSF)’s main concerns regarding the need for adapted vaccines, the need to bring vaccine prices down, and the need to address vaccine supply problems can be accessed at: msfaccess.org/briefings.

http://dwb.org/press/release.cfm?id=6458&cat=press-release&source=ads120000r01

Speech: WHO -Director-General addresses reforms in WHO financing
Dr Margaret Chan, Director-General of the World Health Organization
Opening remarks at the Programme, Budget and Administrative Committee of the Executive Board, Second extraordinary meeting
Geneva, Switzerland
6 December 2012

http://www.who.int/dg/speeches/2012/reforms_20121206/en/index.html

The Global Fund to Fight AIDS, Tuberculosis and Malaria named Norbert Hauser as Interim Inspector General. The announcement described Mr. Hauser as “a highly-respected lawyer and international auditor who recently retired after a distinguished 35-year career in government and financial supervision” with “extensive experience supervising financial and legal matters, (who) served until 2011 as Vice President of Germany’s Supreme Audit Institution.  His reputation for independence, integrity and honesty is unsurpassed.” Simon Bland, Chair of the Global Fund Board, said, “We could not wish for a better person than Norbert Hauser to fill this interim role.  We are delighted that he is able to provide this support to the Global Fund at the current time.”

http://www.theglobalfund.org/en/mediacenter/newsreleases/2012-12-05_Global_Fund_Appoints_Norbert_Hauser_as_Interim_Inspector_General/

WHO – Call for nominations: SAGE Working Group on the Decade of Vaccines Global Vaccine Action Plan (GVAP)

Terms of reference
pdf, 99kb Proposals for nominations should be sent by email to sageexecsec@who.int with Curriculum Vitae, declaration of interests and indication of expertise and no later than Friday, 25 January 2013.

http://www.who.int/immunization/sage/working_group_decade_vaccines_action_plan_dec2012/en/index.html

WHO: Human Rights Day
10 December 2012

On 10 December 1948, the UN General Assembly adopted the Universal Declaration of Human Rights, which has become a universal standard for the promotion and protection of human rights worldwide. This year on 10 December, the international community celebrates Human Rights Day to mark the adoption of the Universal Declaration.

Related links
Human Rights Day web site

More on human rights and health

http://www.who.int/mediacentre/events/annual/human_rights_day/en/index.html

The MMWR Weekly for December 7, 2012 / Vol. 61 / No. 48 includes:
– Mumps Outbreak on a University Campus — California, 2011

– Update: Influenza Activity — United States, September 30–November 24, 2012

Update: Polio this week – As of 4 Dec 2012
Global Polio Eradication Initiative
http://www.polioeradication.org/Dataandmonitoring/Poliothisweek.aspx

[Editor’s Extract]
– The Regional Certification Commission of the Western Pacific met in Beijing, China, last week and confirmed the WHO Western Pacific Region’s polio-free certified status following China’s successful control of the outbreak last year in the Xinjiang Uyghur Autonomous Region. In a press release from 29 November, Dr. Shin Young-soo, WHO Regional Director for the Western Pacific, said “China’s all-out response to the polio outbreak is an inspiration to all countries in the Western Pacific to redouble efforts to have high-quality surveillance and immunization in place. It is encouraging to those places that still have polio that the right commitment, coordination and accountability

Afghanistan
– Two new WPV cases were reported in the past week (one WPV1 from Kandahar and one WPV1 from Uruzgan), bringing the total number of WPV cases for 2012 to 33. The most recent is a WPV1 with onset of paralysis on 9 November (from Khost).
– Additionally, two circulating vaccine-derived poliovirus type 2 (cVDPV2) cases were reported (from Kandahar). Genetic sequencing is ongoing to determine their origin, and to determine if they are linked to the cVDPV2 outbreak in neighbouring Pakistan (greater Quetta, Balochistan)…

Nigeria
– One new WPV case was reported in the past week (WPV1 from Nasarawa), bringing the total number of WPV cases for 2012 to 111. The WPV1 from Nasarawa is the most recent in the country and had onset of paralysis on 11 November.
– The new WPV1 case from Nasarawa occurred in the new district of Doma. The state had not reported a WPV case since June 2009, indicating continuation of localized WPV transmission in infected areas and polio-free Local Government Area (LGA)…

Pakistan
– No new WPV cases were reported in the past week. The most recently reported WPV case occurred in Federally Administered Tribal Areas (WPV1) with onset of paralysis on 10 November. The total number of WPV cases for 2012 remains 56.
– However, 3 new cVDPV2 cases were reported in the past week from Balochistan, bringing the total number of cVDPV2 cases to 10 (all from the greater Quetta area of Balochistan). Response vaccination activities are being planned for Killa Abdullah, Pishin and Quetta for second week of December…

Horn of Africa
– Efforts are continuing to stop an ongoing cVDPV2 outbreak in Kenya and parts of Somalia (in a Somali refugee camp in Dadaab, Kenya, and Kismayo, south-central Somalia).
– Immunizations of older age groups have taken place in Dadaab. In Somalia, campaigns have been conducted in border areas with Kenya and Ethiopia, and in some areas of central Somalia (access allowing).

– Across the region, OPV continues to be added to broader humanitarian response activities.

New tactics are being explored to further boost immunity levels in and around inaccessible areas of south-central Somalia. Potential activities include focusing on people in transit to/from inaccessible areas, using local negotiators to allow safe passage of vaccination teams to inaccessible areas, and immunizing populations bordering inaccessible areas…

Global Burden of Disease Launch
December 14, 2012
London

About the launch
On December 14, 2012 The Lancet together with the Institute for Health Metrics and Evaluation (IHME) will host an event to present the findings of the 2010 GBD study. The launch of the Global Burden of Diseases, Injuries, and Risk Factors Study 2010 results will feature discussion of comparable estimates of mortality, causes of death, years lived with disability (YLDs), and disability-adjusted life years (DALYs) for 291 conditions and 67 risk factors, for 21 regions and three time periods – 1990, 2005, and 2010. The results reveal substantial shifts in the burden of disease from children to younger adults, from premature mortality to morbidity and disability, from communicable, maternal, neonatal and nutritional conditions to noncommunicable diseases. Overlaid on these major shifts are important regional variations and the ongoing challenge in sub-Saharan Africa of conditions related to Millennium Development Goals 4, 5, and 6.

Details of the event
This free one-day event is open to the public and will feature five panel sessions with the opportunity for open discussion of key findings and implications. The event will occur from 9:00am to 5:30pm at the Royal Society 6-9 Carlton House Terrace, London SW1Y 5AG, with coffee and tea available at 8:30am, and a reception following at the same location, from 5:30pm to 7:00pm. No registration is required.
If you are unable to attend the event, a live webcast of each session can be viewed by clicking on the link. Choose which sessions you would like to attend from the preliminary agenda below. Full agenda available here.

http://www.thelancet.com/themed/global-burden-of-disease

Conference: 2012 Science of Eliminating Health Disparities Summit
December 17 to Wednesday, December 19, 2012
Gaylord National Resort and Convention Center
201 Waterfront Street, National Harbor, MD 20745

The U.S. Department of Health and Human Services (HHS) under the leadership of the National Institutes of Health (NIH) through the National Institute on Minority Health and Health Disparities (NIMHD), in partnership with:

   HHS agencies and offices: Food and Drug Administration, Agency for Healthcare Quality and Research, Centers for Disease Control and Prevention, Health Resources and Services Administration, Substance Abuse and Mental Health Services Administration; Indian Health Service, Centers for Medicare and Medicaid Services, Administration for Children and Families, Office of the Assistant Secretary for Health, Office of Minority Health, Office of the Surgeon General, Office of Global Affairs, and

   Other federal agencies: The Environmental Protection Agency, the U.S. Departments of State, Defense, Agriculture, Housing and Urban Development, Transportation, Veterans Affairs, Education, Labor, and Justice, and their many grantees, constituents, and partners in the public and private sector. The 2012 Science of Eliminating Health Disparities Summit is the leading scientific gathering on health disparities. Thousands of participants will attend approximately 100 sessions to exchange new knowledge, and learn about progress, successes, challenges, and opportunities in implementing innovative research. Sessions will also feature practice and policy interventions to inform health disparities science, and highlight the power and impact of multi-sector partnerships in tackling the social, behavioral, environmental, economic, and biological factors that cause health disparities. The theme is Building a Healthier Society: Integrating Science, Practice, and Policy. http://www.nimhd.nih.gov/summit_site/ http://www.nih.gov/news/health/dec2012/nimhd-07.htm

American Journal of Public Health
Volume 103, Issue 1 (January 2013)
http://ajph.aphapublications.org/toc/ajph/current

Health Care Provider Recommendation, Human Papillomavirus Vaccination, and Race/Ethnicity in the US National Immunization Survey
Kelly R. Ylitalo, Hedwig Lee, Neil K. Mehta
American Journal of Public Health: January 2013, Vol. 103, No. 1: 164–169.

Abstract
Objectives. Human papillomavirus (HPV) is a common sexually transmitted infection in the United States, yet HPV vaccination rates remain relatively low. We examined racial/ethnic differences in the prevalence of health care provider recommendations for HPV vaccination and the association between recommendation and vaccination.

Methods. We used the 2009 National Immunization Survey–Teen, a nationally representative cross-section of female adolescents aged 13 to 17 years, to assess provider-verified HPV vaccination (≥ 1 dose) and participant-reported health care provider recommendation for the HPV vaccine.

Results. More than half (56.9%) of female adolescents received a recommendation for the HPV vaccine, and adolescents with a recommendation were almost 5 times as likely to receive a vaccine (odds ratio = 4.81; 95% confidence interval = 4.01, 5.77) as those without a recommendation. Racial/ethnic minorities were less likely to receive a recommendation, but the association between recommendation and vaccination appeared strong for all racial/ethnic groups.

Conclusions. Provider recommendations were strongly associated with HPV vaccination. Racial/ethnic minorities and non-Hispanic Whites were equally likely to obtain an HPV vaccine after receiving a recommendation. Vaccine education efforts should target health care providers to increase recommendations, particularly among racial/ethnic minority populations.

BMC Public Health
(Accessed 8 December 2012)
http://www.biomedcentral.com/bmcpublichealth/content

Research article
Childhood immunization rates in rural Intibuca, Honduras: An analysis of a local database tool and community health center records for assessing and improving vaccine coverage
Yuan He, Alan Zarychta, Joseph B Ranz, Mary Carroll, Lori M Singleton, Paria M Wilson, Elizabeth P Schlaudecker BMC Public Health 2012, 12:1056 (7 December 2012)

Abstract (provisional)
Background
Vaccines are highly effective at preventing infectious diseases in children, and prevention is especially important in resource-limited countries where treatment is difficult to access. In Honduras, the World Health Organization (WHO) reports very high immunization rates in children. To determine whether or not these estimates accurately depict the immunization coverage in non-urban regions of the country, we compared the WHO data to immunization rates obtained from a local database tool and community health center records in rural Intibuca, Honduras.

Methods
We used data from two sources to comprehensively evaluate immunization rates in the area: 1) census data from a local database and 2) immunization data collected at health centers. We compared these rates using logistic regression, and we compared them to publicly available WHO-reported estimates using confidence interval inclusion.

Results
We found that mean immunization rates for each vaccine were high (range 84.4 to 98.8 percent), but rates recorded at the health centers were significantly higher than those reported from the census data (p<=0.001). Combining the results from both databases, the mean rates of four out of five vaccines were less than WHO-reported rates (p<0.05). Overall immunization rates were significantly different between townships (p=0.03). The rates by individual vaccine were similar across townships (p>0.05), except for diphtheria/tetanus/pertussis vaccine (p=0.02) and oral polio vaccine (p<0.01).

Conclusions
Immunization rates in Honduras are high across data sources, though most of the rates recorded in rural Honduras were less than WHO-reported rates. Despite geographical difficulties and barriers to access, the local database and Honduran community health workers have developed a thorough system for ensuring that children receive their immunizations on time. The successful integration of community health workers and a database within the Honduran decentralized health system may serve as a model for other immunization programs in resource-limited countries where health care is less accessible.

The complete article is available as a provisional PDF. The fully formatted PDF and HTML versions are in production.

BMC Public Health
(Accessed 8 December 2012)
http://www.biomedcentral.com/bmcpublichealth/content

Study protocol
The efficacy and safety of a nicotine conjugate vaccine (NicVAX(R)) or placebo co-administered with varenicline (Champix(R)) for smoking cessation: study protocol of a phase IIb, double blind, randomized, placebo controlled trial
Philippe Hoogsteder, Daniel Kotz, Wolfgang Viechtbauer, Ruth Brauer, Paul Kessler, Matthew Kalnik, Raafat Fahim, Paul van Spiegel, Onno van Schayck BMC Public Health 2012, 12:1052 (6 December 2012)

Abstract (provisional)
Background
A potential new treatment in smoking cessation and relapse prevention is nicotine vaccination which is based on active immunization against the nicotine molecule. This immunization will elicit the immune system to produce nicotine-specific antibodies that sequester nicotine in the blood stream, after inhaling tobacco products. The resulting antibody-antigen is too large to cross the blood–brain barrier and is therefore postulated to attenuate the rewarding effect of nicotine by preventing the latter from reaching its receptors in the brain and causing the release of dopamine. The aim of this paper is to describe the design of a phase IIb, multi-center, double blind, randomized, placebo controlled trial to assess the efficacy of the nicotine vaccine NicVAX(R) co-administered with varenicline (Champix(R)) and intensive counseling as an aid in smoking cessation and relapse prevention.

Methods
Two centers will include a total of 600 smokers who are motivated to quit smoking. At week -2 these smokers will be randomized, in a 1:1 ratio, to either 6 injections of NicVAX(R) or placebo, both co-administered with 12-weeks of varenicline treatment, starting at week 0. The target quit day will be set after 7 days of varenicline treatment at week 1. Smokers will be followed up for 54 weeks. The primary outcome is defined as biochemically validated prolonged smoking abstinence from week 9 to 52. Secondary outcomes include safety, immunogenicity, smoking abstinence from week 37 to 52, abstinence from week 9 to 24, abstinence in the subset of subjects with the highest antibody response, and lapse/relapse rate.

Discussion
This is the first study to assess the efficacy of a nicotine conjugate vaccine in combination with an evidence-based smoking cessation pharmacotherapy (varenicline) to quit smoking. Although NicVAX(R) is primarily designed as an aid to smoking cessation, our study is designed to explore its potential to maintain abstinence and prevent relapse. The results of this trial will give a unique insight in the potential of nicotine vaccination for relapse prevention.

ClinicalTrials.gov (NCT00995033)

The complete article is available as a provisional PDF. The fully formatted PDF and HTML versions are in production.

Eurosurveillance
Volume 17, Issue 49, 06 December 2012
http://www.eurosurveillance.org/Public/Articles/Archives.aspx?PublicationId=11678

Surveillance and outbreak reports
Use of a geographic information system to map cases of measles in real-time during an outbreak in Dublin, Ireland, 2011
by G Fitzpatrick, M Ward, O Ennis, H Johnson, S Cotter, MJ Carr, B O’Riordan, A Waters, J Hassan, J Connell, W Hall, A Clarke, H Murphy, M Fitzgerald

Abstract
In 2011, there was a large measles outbreak in Dublin. Nationally 285 cases were notified to the end of December 2011, and 250 (88%) were located in the Dublin region. After the first case was notified in week 6, numbers gradually increased, with 25 notified in June and a peak of 53 cases in August. Following public health intervention including a measles-mumps-rubella (MMR) vaccination campaign, no cases were reported in the Dublin region in December 2011. Most cases (82%) were children aged between 6 months and 14 years, and 46 cases (18%) were under 12 months-old. This is the first outbreak in Dublin to utilise a geographic information system for plotting measles cases on a digital map in real time. This approach, in combination with the analysis of case notifications, assisted the department of public health in demonstrating the extent of the outbreak. The digital mapping documented the evolution of two distinct clusters of 87 (35%) cases. These measles cases were infected with genotype D4-Manchester recently associated with large outbreaks across Europe. The two clusters occurred in socio-economically disadvantaged areas and were attributable to inadequate measles vaccination coverage due in part to the interruption of a school-based MMR2 vaccination programme.

Health Policy and Planning
Volume 27 Issue 8   December 2012
http://heapol.oxfordjournals.org/content/current

Original Articles
Editor’s Choice: An analysis of GAVI, the Global Fund and World Bank support for human resources for health in developing countries
Marko Vujicic, Stephanie E Weber, Irina A Nikolic, Rifat Atun, and Ranjana Kumar
Health Policy Plan. (2012) 27(8): 649-657 doi:10.1093/heapol/czs012

Abstract
Shortages, geographic imbalances and poor performance of health workers pose major challenges for improving health service delivery in developing countries. In response, multilateral agencies have increasingly recognized the need to invest in human resources for health (HRH) to assist countries in achieving their health system goals. In this paper we analyse the HRH-related activities of three agencies: the Global Alliance for Vaccines and Immunisation (GAVI); the Global Fund for Aids, Tuberculosis, and Malaria (the Global Fund); and the World Bank. First, we reviewed the type of HRH-related activities that are eligible for financing within each agency. Second, we reviewed the HRH-related activities that each agency is actually financing. Third, we reviewed the literature to understand the impact that GAVI, Global Fund and World Bank investments in HRH have had on the health workforce in developing countries. Our analysis found that by far the most common activity supported across all agencies is short-term, in-service training. There is relatively little investment in expanding pre-service training capacity, despite large health worker shortages in developing countries. We also found that the majority of GAVI and the Global Fund grants finance health worker remuneration, largely through supplemental allowances, with little information available on how payment rates are determined, how the potential negative consequences are mitigated, and how payments are to be sustained at the end of the grant period. Based on the analysis, we argue there is an opportunity for improved co-ordination between the three agencies at the country level in supporting HRH-related activities. Existing initiatives, such as the International Health Partnership and the Health Systems Funding Platform, could present viable and timely vehicles for the three agencies to implement this improved co-ordination.

Free full-text: http://heapol.oxfordjournals.org/content/27/8/649.full

Human Vaccines & Immunotherapeutics(formerly Human Vaccines)
Volume 8, Issue 12  December 2012
http://www.landesbioscience.com/journals/vaccines/toc/volume/8/issue/11/

Acceptance and rejection of influenza vaccination by pregnant women in southern Iran: Physicians’ role and barriers
Behnam Honarvar, Neda Odoomi, Mojtaba Mahmoodi, Golnar Kashkoli, Fatemeh Khavandegaran, Kamran Bagheri Lankarani and Mohsen Moghadami

Abstract:
Objective: Vaccination provides the most effective protection against maternal, fetal and neonatal complications of influenza infection. This study aimed to determine the uptake rate of influenza vaccination including 2009 pandemic H1N1 influenza and seasonal influenza vaccination and the reasons for acceptance or rejection among pregnant women.

Method: This questionnaire based study was conducted at obstetrics and maternity hospitals affiliated with Shiraz University of Medical Sciences, Shiraz, Iran. Pregnant women were interviewed individually and privately. SPSS was used for data analysis.

Result: Mean age of the 416 pregnant women enrolled in this study was 27.06 ± 5.27 y. Only 25 (6%) of 397 women had history of vaccination. Of 383 (92.06%) pregnant women who had rejected vaccination, 116 (30.28%) declared that they lacked information about influenza vaccination and 44 (11.48%) felt that they did not need vaccination. Concerns about the safety of influenza vaccination were reported by only 2 women (0.52%). Of the 25 (6%) pregnant women who were vaccinated against influenza, 15 (60%) accepted because of advice they received from persons other than physicians, 5 (20%) believed that influenza vaccination is necessary for everyone, and 3 (12%) accepted because of a history of frequent influenza virus infections in previous years.

Conclusion: Most of the unvaccinated and vaccinated pregnant women lacked sufficient knowledge about influenza. Education of pregnant women about influenza vaccination and encouragement from physicians may have a remarkable effect on turning poor compliance into high flu vaccination uptake among pregnant women.

Human Vaccines & Immunotherapeutics(formerly Human Vaccines)
Volume 8, Issue 12  December 2012
http://www.landesbioscience.com/journals/vaccines/toc/volume/8/issue/11/

COMMENTARIES
Meningococcal vaccine: A new vaccine to combat meningococcal disease in India
Ramesh Verma and Pardeep Khanna
http://dx.doi.org/10.4161/hv.21666

Abstract:
Meningococcal meningitis is caused by Neisseria meningitidis, a gram-negative, aerobic, encapsulated diplococcus. Meningococci are divided into numerous serogroups based on the composition of their capsular polysaccharide (Ps) antigens. At least 13 serogroups have been described: A, B, C, D, 29E, H, I, K, L, W-135, X, Y and Z. Out of these 13, six (A, B, C, W135, X and Y) can cause epidemics. The incubation period averages 3–4 d (range 1–10 d), which is the period of communicability. Bacteria can be found for 2–4 d in the nose and pharynx, and for up to 24 h after starting antibiotics. N. meningitidis is a leading cause of meningitis worldwide and a significant public health problem and dreaded disease in most countries. Morbidity and mortality rates from the disease remain high. Apart from epidemics, at least 1.2 million cases of bacterial meningitis are estimated to occur every year, 135,000 of which are fatal – of these, ~500,000 and ~50,000 respectively are caused by meningococci. Many outbreaks of meningococcal meningitis have been documented, with major outbreaks mainly seen in large cities of northern, western and eastern India like New Delhi, Mumbai, Kolkata and northeastern states. In 2011, 245 people died in India, the vast majority (179) in West Bengal, while 467 and 341 people in 2009 and 2010 respectively died of this disease. The meningococcal conjugate vaccines (MCV) are preferred for reasons of immunogenicity and persistence of immunity but are unavailable in India. Only the quadrivalent and bivalent meningococcal Ps vaccines (MPV) are available in India. The quadrivalent MPV is preferred for Haj pilgrims, international travelers and students in that it provides protection against emerging W-135 and Y disease in these areas. A single-dose 0.5mL injection is recommended.

The Lancet  
Dec 08, 2012   Volume 380  Number 9858  p1967 – 2052
http://www.thelancet.com/journals/lancet/issue/current

Health Policy
Innovative financing for health: what is truly innovative?
Rifat Atun, Felicia Marie Knaul, Yoko Akachi, Julio Frenk

Preview
Development assistance for health has increased every year between 2000 and 2010, particularly for HIV/AIDS, tuberculosis, and malaria, to reach US$26·66 billion in 2010. The continued global economic crisis means that increased external financing from traditional donors is unlikely in the near term. Hence, new funding has to be sought from innovative financing sources to sustain the gains made in global health, to achieve the health Millennium Development Goals, and to address the emerging burden from non-communicable diseases.

The Lancet  
Dec 08, 2012   Volume 380  Number 9858  p1967 – 2052
http://www.thelancet.com/journals/lancet/issue/current

Offline: The struggle for leadership
Richard Horton

Excerpt
Shortly after the UN General Assembly concluded its September meeting, the Director-General of WHO, Margaret Chan, wrote to, among others, heads of UN agencies, the World Bank, USAID, GAVI, and the Gates Foundation—Anthony Lake, Michel Sidibé, Babatunde Osotimehin, Jim Kim, Rajiv Shah, Seth Berkley, and Chris Elias. Her message was candid: “You will recall that we discussed what we can do to step up our collective action and collaboration to accelerate progress on the health MDGs before the 2015 deadline. There was agreement on the following points: the urgent need to stop competition and fragmentation among global health agencies, and improving harmonisation and alignment at the country level with a focus on results.” Her note went on to make specific recommendations for revitalising the International Health Partnership (IHP+). But her general intention was clear: a sharp warning to colleagues for pursuing agendas that were more about their own interests than the needs of countries. She was expressing the frustration of someone who sees the global health architecture as failing those it is supposed to defend and protect. She knows that the competition for influence and authority between WHO, UNICEF, UNAIDS, UNFPA, the World Bank, the Gates Foundation, and other Global Health Initiatives is leading her and other leaders to overpromise and underdeliver.

Two weeks after Dr Chan sent her email, Michel Sidibé replied (during the annual University College London/Lancet Lecture). Sidibé began by recalling the fear that AIDS once instilled in nations. That sense of crisis created an utterly new social compact between countries. In 2000, there were few signs of real or lasting success in the battle against AIDS. Now 8 million people have access to antiretrovirals and there is “a serious belief in ending the epidemic”. But Sidibé also offered a warning. None of these achievements are sustainable if the global community continues to work in the same way. There is not only a financial crisis afflicting countries. There is also an “ethical crisis…a crisis of trust”. If there is no trust between countries it is impossible to inspire global solidarity around any notion of justice. Sidibé argued that global health was at a “moment of transition”. It was moving away from a disease-centred to a people-centred vision of development. Yet just as this transition was upon us, “multilateralism is more and more in crisis”. Perhaps the ideal of achieving global consensus has passed forever. The world is multipolar. The idea of one central authority of knowledge or power is no longer credible.    China and India are already strong voices. Africa is rising. Governance mechanisms are slowly giving space to these emerging nations. In this “new world”, five key issues will demand our attention. First, the architecture of global health, although changing, is still “not good enough”. Second, better ways have to be devised to engage new actors, especially new country voices. Third, despite billions of dollars of aid pouring into countries, delivery systems for health have to be rethought. Fourth, technology will be a much bigger determinant of success. Finally, none of this manifesto can be delivered without applying principles of human rights to health…

The Milbank Quarterly
A Multidisciplinary Journal of Population Health and Health Policy
December 2012  Volume 90, Issue 4  Pages 631–807
http://onlinelibrary.wiley.com/doi/10.1111/milq.2012.90.issue-4/issuetoc

Original Articles
The Use of Cost-Effectiveness Analysis for Pediatric Immunization in Developing Countries (pages 762–790)
CINDY LOW GAUVREAU, WENDY J. UNGAR, JILLIAN CLARE KÖHLER and STANLEY ZLOTKIN
Article first published online: 6 DEC 2012 | DOI: 10.1111/j.1468-0009.2012.00682.x

Context: Developing countries face critical choices for introducing needed, effective, but expensive new vaccines, especially given the accelerated need to decrease the mortality of children under age five and the increased immunization resources available from international donors. Cost-effectiveness analysis (CEA) is a tool that decision makers can use for efficiently allocating expanding resources. Its use in developing countries, however, lags behind that in industrialized countries.

Methods: We explored how CEA could be made more relevant to immunization policymaking in developing countries by identifying the limitations for using CEA in developing countries and the impact of donor funding on the CEA estimation. We conducted a comprehensive literature search using formal search protocols and hand searching indexed and gray literature sources. We then systematically summarized the application of CEA in industrialized and developing countries through thematic analysis, focusing on pediatric immunization and methodological and contextual issues relevant to developing countries.

Findings: Industrialized and developing countries use CEA differently. The use of the Disability-Adjusted Life Year (DALY) outcome measure and an alternative generalized cost-effectiveness analysis approach is restricted to developing countries. In pediatric CEAs, the paucity of evaluations and the lack of attention to overcoming the methodological limitations pertinent to children’s cognitive and development distinctiveness, such as discounting and preference characterization, means that pediatric interventions may be systematically understudied and undervalued. The ability to generate high-quality CEA evidence in child health is further threatened by an inadequate consideration of the impact of donor funding (such as GAVI immunization funding) on measurement uncertainty and the determination of opportunity cost.

Conclusions:  Greater attention to pediatric interventions and donor funding in the conduct of CEA could lead to better policies and thus more worthwhile and good-value programs to benefit children’s health in developing countries.

Nature Medicine
December 2012, Volume 18 No 12 pp1717-1857
http://www.nature.com/nm/journal/v18/n12/index.html

Nature Medicine | Editorial
Lessons from vaccine history
Nature Medicine
18, 1717 (2012)
doi:10.1038/nm.3039
Published online 06 December 2012

In spite of years of effort, we still lack highly efficacious vaccines against HIV, tuberculosis, malaria and numerous other widespread pathogens. Two recent setbacks in vaccine trials suggest that it’s time to rethink how new vaccines are developed and to investigate what can be learned from the existing armament of childhood vaccines.

In November, a phase 3 trial of the malaria vaccine RTS,S/AS01 in African infants showed only 31% protection against clinical malaria compared with a control nonmalaria vaccine (N. Engl. J. Med. doi:10.1056/NEJMoa1208394). The results were disappointing to many, given the initial clinical experience with RTS,S.

In 1997, in a trial of 22 adults, one formulation of RTS,S protected six out of seven individuals from infection, whereas two other formulations of the same antigen did not. Subsequent phase 2 trials of two different formulations of RTS,S in young children also showed protective efficacy. And in early results of the phase 3 trial reported in 2011, the vaccine was 55.8% efficacious at protecting against a first episode of clinical malaria in young children aged 5 to 17 months at trial enrollment in the first 12 months after vaccination. The new results show that in infants aged 6 to 12 weeks at enrollment, which is a population at high risk of developing severe malaria, the protective efficacy of RTS,S/AS01 is substantially lower (see News story page 1723).

Similarly disappointing were the recent results of a phase 2b trial of a vaccine candidate against dengue fever, which is caused by four serotypes of dengue virus (Lancet 380, 1559–1567, 2012). Although the vaccine showed 30% overall efficacy against infection, protection was limited to three of the four serotypes of dengue, and the vaccine did not confer protection against the most prevalent serotype (serotype 2) in the region where the trial was conducted. As antibodies to one serotype have been associated with enhancement of disease after infection with another serotype, the lack of complete protection could increase the risk of developing severe disease, although this was not observed in the trial.

Still, some remain optimistic about both the malaria and the dengue vaccine candidates, arguing that modest protection may be better than none, particularly in view of the hundreds of millions of individuals who are infected with these pathogens each year. But the suboptimal results of these trials are emblematic of the problems with vaccine development in general—we don’t even understand how effective vaccines work, making it very difficult to identify the reasons why new candidates fail. The dengue vaccine induced an antibody response against serotype 2, yet did not protect against it. And in the initial trial of RTS,S in adults, all three formulations induced similar antibody and T cell responses, but only one formulation was protective against malaria. The fact that we don’t know what kind and what quality of immune response is necessary to prevent infection greatly challenges attempts to rationally approach vaccine design.

We do, in theory, have a starting point to try to better understand the mechanisms of vaccine efficacy. In the US, within the first six years of life, children receive ten different vaccines that provide protection against 14 different viral and bacterial diseases. All but one are delivered intramuscularly. Several contain attenuated or inactivated viruses, whereas others are composed of bacterial sugars, virus-like particles or purified proteins. Some contain aluminum-based adjuvants, some do not. In spite of their differences, when primarily injected into an arm or a leg, they all succeed in inducing protective immunity against an array of pathogens that target different tissues and use different strategies of immune evasion. If there is strength in numbers, surely there are commonalities to the induction of protection by these distinct vaccines that can be understood and applied to the development of future vaccines.

The trouble is that there are limited information and data from the original trials of approved childhood vaccines and no investment—and therefore no incentive—to analyze anew the protection that they confer in humans. Nevertheless, there is impetus to rationally develop vaccines: systems biology approaches have identified molecular signatures of the immune responses to influenza and yellow fever vaccines, albeit not correlates of the protection the vaccines confer. Preclinical studies of new adjuvants have provided fresh insight into their stimulatory effects on innate immune cells, although the key pathways by which they induce protective immunity remain unclear. And improved tools exist to predict T and B cell receptor epitopes and their immunogenicity, although the present accuracy of these methods is not sufficient for routine application. Moreover, as the recent experiences with the dengue and malaria vaccines show, predicting immunogenicity is not equivalent to predicting protection.    Therefore, it is incumbent on the vaccine field to increase investment into identifying the mechanisms of protection of successful vaccines in humans in order to fine-tune the application of these new tools to contribute to future vaccine success.

Different pathogens have different degrees of antigenicity, mutation rates and mechanisms to subvert protective immunity. Yet even the wiliest infection might be blocked if the right magnitude, breadth and potency of immune response were rapidly recruited upon initial infection. Understanding what those parameters should be, whether they are common to all infectious agents and how they can be induced by a vaccine will require both empirical and rational design, as well as a systematic approach to understanding the past to help guide the future.

Nature Medicine
December 2012, Volume 18 No 12 pp1717-1857
http://www.nature.com/nm/journal/v18/n12/index.html

Opinion
Global health needs to fill the innovation gap – p1735
Trevor Mundel
doi:10.1038/nm1212-1735

In recent years, the pharmaceutical industry has struggled to deliver new therapies, especially for diseases that affect the most vulnerable in developing countries. The global health community can fill this vacuum by catalyzing innovative partnerships across academia, government and the private sector, fostering a more rigorous environment for scientific decision making and creating the tools and infrastructure to conduct effective translational research.

PLoS One
[Accessed 8 December 2012]
http://www.plosone.org/article/browse.action;jsessionid=577FD8B9E1F322DAA533C413369CD6F3.ambra01?field=date

Willingness to Participate in HIV Vaccine Trials among Men Who Have Sex with Men in Chennai and Mumbai, India: A Social Ecological Approach
Venkatesan Chakrapani, Peter A. Newman, Neeti Singhal, Jhalak Jerajani, Murali Shunmugam
PLoS ONE: Research Article, published 04 Dec 2012 10.1371/journal.pone.0051080

Abstract 
Background
Recruitment of low- and middle-income country volunteers from most-at-risk populations in HIV vaccine trials is essential to vaccine development. In India, men who have sex with men (MSM) are at disproportionately high risk for HIV infection and an important population for trial recruitment. Investigations of willingness to participate (WTP) in HIV vaccine trials have focused predominantly on individual-level determinants. We explored multi-level factors associated with WTP among MSM in India.

Methods
We conducted 12 focus groups (n = 68) with low socioeconomic MSM in Chennai and Mumbai, and 14 key informant interviews with MSM community leaders and service providers. Focus groups/interviews were recorded, transcribed and translated into English. Two bilingual investigators conducted thematic analysis using line-by-line coding and a constant comparative method, with member-checking by community representatives.

Results
Factors associated with WTP were evidenced across the social ecology of MSM–social-structural: poverty, HIV-, sexual- and gender non-conformity stigma, institutionalized discrimination and government sponsorship of trials; community-level: endorsement by MSM community leaders and organizations, and fear of within-group discrimination; interpersonal: anticipated family discord, partner rejection, having financially-dependent family members and disclosure of same-sex sexuality; and individual-level: HIV vaccine trial knowledge and misconceptions, safety concerns, altruism and preventive misconception.

Conclusion
Pervasive familial, community and social-structural factors characteristic of the Indian sociocultural context may complicate individual-focused approaches to WTP and thereby constrain the effectiveness of interventions to support recruitment and retention in HIV vaccine trials. Interventions to reduce stigma and discrimination against MSM and people living with HIV, capacity-building of MSM community organizations and transparent communications tailored to the knowledge and educational level of local communities may support meaningful engagement of MSM in HIV vaccine trials. Vigilance in providing fair but not excessive compensation and healthcare benefits and in mitigating preventive misconception are warranted to support ethical conduct of trials among MSM in India.

Public Health Ethics
Volume 5 Issue 3 November 2012
http://phe.oxfordjournals.org/content/current

Editorial
Risk, Risk Groups and Population Health
Marcel Verweij and Angus Dawson
Public Health Ethics (2012) 5(3): 213-215 doi:10.1093/phe/phs032

Excerpt
A central issue in public health is whether preventive activities are best aimed at groups held to be at high risk or at the population as a whole. Such a decision is often an issue in discussions about policies relating to vaccinations, health promotion, infectious disease control as well as protection from risks relating to toxic agents or radiation, etc. There are a number of interesting conceptual issues that can be explored such as what we mean by risk, how we define a ‘risk group’, and how subgroups relate to each other and to a larger population. For example, how do we determine what level of risk is sufficient for calling some subpopulation a ‘high-risk’ group? Suppose we can identify a group of children who run a risk of developing complications from varicella that is 10 times higher than the average, but it is also possible to identify even smaller subgroups that run a 50- or even 100-fold risk of developing severe complications if infected? Which group is ‘high risk’? How do we decide what our priorities ought to be? Judgements in this case would be influenced, perhaps, by what the options are for preventive care. Clearly, the identification of risk groups is just as much a normative judgement as decision making about the content of any policies relating to a high-risk group. This suggests that policy decisions are, and ought, to be not only dependent on which strategy is most efficient or cost-effective, but equally require consideration of ethical issues relating to justice, equity and solidarity.

Twenty years ago, Rose (1992) published his book The Strategy of Preventive Medicine, offering an in-depth exploration of these issues in relation to public health. Rose argued that in many cases a population strategy, focused on reducing average risk within the whole…

Public Health Ethics
Volume 5 Issue 3 November 2012
http://phe.oxfordjournals.org/content/current

Original Articles
Conceptualizing a Human Right to Prevention in Global HIV/AIDS Policy
Public Health Ethics (2012) 5(3): 263-282 doi:10.1093/phe/phs034
Benjamin Mason Meier, Kristen Nichole Brugh, and Yasmin Halima

Abstract
Given current constraints on universal treatment campaigns, recent advances in public health prevention initiatives have revitalized efforts to stem the tide of HIV transmission. Yet, despite a growing imperative for prevention—supported by the promise of behavioral, structural and biomedical approaches to lower the incidence of HIV—human rights frameworks remain limited in addressing collective prevention policy through global health governance. Assessing the evolution of rights-based approaches to global HIV/AIDS policy, this review finds that human rights have shifted from collective public health to individual treatment access. While the advent of the HIV/AIDS pandemic gave meaning to rights in framing global health policy, the application of rights in treatment access litigation came at the expense of public health prevention efforts. Where the human rights framework remains limited to individual rights enforced against a state duty bearer, such rights have faced constrained application in framing population-level policy to realize the public good of HIV prevention. Concluding that human rights frameworks must be developed to reflect the complementarity of individual treatment and collective prevention, this article conceptualizes collective rights to public health, structuring collective combination prevention to alleviate limitations on individual rights frameworks and frame rights-based global HIV/AIDS policy to assure research expansion, prevention access and health system integration.

Public Health Ethics
Volume 5 Issue 3 November 2012
http://phe.oxfordjournals.org/content/current

Prioritizing Vaccine Access for Vulnerable but Stigmatized Groups
Public Health Ethics (2012) 5(3): 283-295 doi:10.1093/phe/phs010
Chris Kaposy and Natalie Bandrauk

Abstract
This article discusses the prioritization of scarce and in-demand influenza vaccines during a pandemic. The mass vaccination campaign in Canada against H1N1 influenza in 2009 illustrated that some groups considered vulnerable may also be stigmatized. In 2009, prisoners and people with severe obesity were given priority of H1N1 vaccination in some Canadian jurisdictions. Assigning priority for vaccination to such groups may be socially unpopular. This article examines a number of possible arguments that might motivate opposition to prioritizing stigmatized groups. We find these arguments flawed. They rely on a suspect ‘social worth’ rationale for the prioritization of scarce resources. Furthermore, human rights concerns support the prioritization of vulnerable but stigmatized groups for vaccination during a pandemic. We also argue that it is necessary to prioritize vulnerable but stigmatized groups to promote the common good in its various forms. The article concludes with an analysis of an objection that no vulnerable groups—stigmatized or otherwise—should be given priority for influenza vaccination in a pandemic. We argue that the objection is based on a confusion.

Science        
7 December 2012 vol 338, issue 6112, pages 1249-1384
http://www.sciencemag.org/current.dtl

News & Analysis – Avian Influenza
Proposed H5N1 Research Reviews Raise Concerns
David Malakoff

Researchers are giving a mixed reception to a draft U.S. government plan to do more stringent funding reviews of certain kinds of H5N1 avian influenza research—and perhaps even require some studies to be kept secret. The proposal, presented last week at a meeting of the National Science Advisory Board for Biosecurity, is the latest fallout from the controversy surrounding two studies in which scientists engineered the H5N1 virus and led to a voluntary moratorium on such potentially risky “gain-of-function” studies. The new proposal seeks to help biosecurity experts for funding agencies identify problematic experiments before they begin.

The effect of falsely balanced reporting of the autism–vaccine controversy on vaccine safety perceptions and behavioral intentions

G Dixon, C Clarke – Health Education Research, 2012

Abstract Controversy surrounding an autism–vaccine link has elicited considerable news
media attention. Despite being widely discredited, research suggests that journalists report
this controversy by presenting claims both for and against a link in a relatively ‘balanced’ …

Reuters
http://www.reuters.com/
Accessed 8 December 2012

Yellow fever outbreak kills 164 in Sudan’s Darfur: WHO
KHARTOUM | Mon Dec 3, 2012 10:11am EST

(Reuters) – Yellow fever has killed 164 people over the last three months in Sudan’s Darfur, the World Health Organization (WHO) said on Monday, an arid region the size of Spain where fighting and banditry makes access particularly difficult.

Healthcare is provided almost entirely by aid agencies in parts of Darfur, where rebels took up arms in 2003 complaining of neglect by the central government hundreds of miles away in Khartoum.

The latest outbreak of mosquito-borne yellow fever has been concentrated in central Darfur, the WHO and Sudan’s health ministry said in a joint statement.

“Between 2 September and 29 November, the total number of suspected yellow fever cases has reached 677, including 164 deaths,” the statement said.

Nearly half the yellow fever cases were in people between the ages of 15 and 30, it said, and about a quarter were children aged five to 15.

There is no effective treatment for the hemorrhagic fever, but there is a vaccine. The WHO said last month that some 3.6 million people would be vaccinated in affected areas of Darfur.

Monday’s statement said more than half of the targeted population had been vaccinated by November 30.

http://www.reuters.com/article/2012/12/03/us-sudan-fever-darfur-idUSBRE8B20PD20121203

Twitter Watch [accessed 8 December 2012 – 17:21]
Items of interest from a variety of twitter feeds associated with immunization, vaccines and global public health. This capture is highly selective and is by no means intended to be exhaustive.

GAVI Alliance ‏@GAVIAlliance
The “best ever” #GAVIPartners closed after 3 days of discussion about Results, Innovation, Sustainability & Equity. http://ht.ly/fVIUz 
2:53 AM – 8 Dec 12

PAHO/WHO ‏@pahowho
Bolivia, Haiti, Honduras & Nicaragua honored by @gavialliance for their achievements in #immunization #gavipartners http://new.paho.org/hq/index.php?option=com_content&view=article&id=7859%3Agavi-honors-four-paho-member-countries-for-their-immunization-achievements&catid=1443%3Anews-front-page-items&lang=en&Itemid=1926 …
3:13 PM – 7 Dec 12

UNICEF ‏@UNICEF
As leaders talk at #GAVIpartners, #Tanzania introduces new vaccines for #pneumonia and #diarrhoea http://uni.cf/VCF4zq  #Promise4Children
2:05 PM – 7 Dec 12

GAVI Alliance ‏@GAVIAlliance
The 5th #GAVIPartners Forum is officially over. Here’s what the leading voices in global immunisation were saying: http://ht.ly/fVbnd 
1:23 PM – 7 Dec 12

Doctors w/o Borders ‏@MSF_USA
“There’s no reason children should still be dying of vaccine-preventable diseases.” http://bit.ly/QNpWws 
11:15 AM – 7 Dec 12

The Global Fund ‏@globalfundnews
Video: the Global Fund’s 2012 end-year results. #progress #thebigpush http://bit.ly/SA2VeT 
3:25 AM – 6 Dec 12

Editor’s Notes:

– Email Summary: Vaccines: The Week in Review is available as a weekly email summary: please send your request to david.r.curry@centerforvaccineethicsandpolicy.org.

– pdf version: A pdf of the current issues is available here: Vaccines_The Week in Review_1 December 2012

– Twitter: Readers can also follow developments on twitter: @vaxethicspolicy.

– Support: If you would like to join the growing list of individuals who support this service and its contribution to their roles in public health, clinical practice, government, IGOs/NGOs, research, industry and academia, please visit this page at The Wistar Institute, our co-founder and fiduciary. Thank you…

WHO: 1 December 2012 – World AIDS Day 2012: Getting to Zero
Getting to Zero: Zero new HIV infections. Zero deaths from AIDS-related illness. Zero discrimination is the theme of World AIDS Day 2012. Given the spread of the epidemic today, getting to zero may sound difficult but significant progress is underway.
In 2011, 2.5 million people were newly infected with HIV. An estimated 1.7 million people died. That is 700,000 fewer new infections worldwide than ten years ago, and 600,000 fewer deaths than in 2005…
http://www.who.int/hiv/events/2012/world_aids_day/en/index.html

.
PEPFAR Blueprint: Creating an AIDS-Free Generation
U.S. Secretary of State Hillary Rodham Clinton unveiled the new PEPFAR Blueprint to correspond to this year’s World AIDS Day on December 1. The document’s vision statement notes:  Scientific advances and their successful implementation have brought the world to a tipping point in the fight against AIDS. The United States believes that by making smart investments based on sound science, and a shared global responsibility, we can save millions of lives and achieve an AIDS-free generation.
http://www.pepfar.gov/documents/organization/201386.pdf

 
NIH Statement: World AIDS Day 2012
December 1, 2012
Anthony S. Fauci, M.D., Director, National Institute of Allergy and Infectious Diseases; Jack Whitescarver, Ph.D., Director, NIH Office of AIDS Research; Francis S. Collins, M.D., Ph.D., NIH Director

Extract
The International AIDS Conference in Washington, D.C., this past summer energized HIV/AIDS researchers and focused on the potential benefits of broadly implementing scientifically proven HIV prevention and treatment tools. On World AIDS Day, the National Institutes of Health joins with our global partners to maintain this momentum toward a world without AIDS. As the world’s leading funder of HIV/AIDS research, NIH is vigorously pursuing promising research in therapeutics, prevention (including efforts to develop a vaccine), and work toward a cure, while also studying how best to deliver these interventions to people who need them.

NIH-funded researchers have contributed to the development of the more than 30 antiretroviral drugs and drug combinations currently available, which have saved millions of lives. Additionally, NIH partners with pharmaceutical companies to identify optimal treatment regimens. We continue to pursue the development of new antiretroviral drugs that are longer acting, simpler to use, and less toxic than currently available therapies.

NIH also supports studies on how to improve HIV treatment outcomes and how to manage and reduce the incidence of diseases and complications associated with long-term HIV disease and antiretroviral therapy…
http://www.nih.gov/news/health/nov2012/niaid-29.htm

Media Release: China and Global Fund Signal Strong Partnership
30 November 2012

Extract
China and the Global Fund to Fight AIDS, Tuberculosis and Malaria marked a new stage in their partnership today by drawing senior leaders together with health workers and civil society partners to celebrate the achievements and identify the challenges of joint action to prevent and treat HIV and AIDS.

On the occasion of World AIDS Day, Premier Wen Jiabao led the special gathering inside the headquarters of the central government in downtown Beijing and welcomed Gabriel Jaramillo, General Manager of the Global Fund, as a special guest.

“China and the Global Fund have been cooperating well in the fight against HIV and AIDS,” said Premier Wen. He pledged that China do more to fight the spread of AIDS, both by working with international organizations and by investing in anti-AIDS efforts within China.

Mr. Jaramillo praised China’s leadership in fighting HIV, as the country assumes a more prominent role in global health efforts. He cited China’s generosity and its willingness to help other countries, as well as its growing commitment to domestic initiatives, as an example for all nations to follow.

http://www.theglobalfund.org/en/mediacenter/newsreleases/2012-11-30_China_and_Global_Fund_Signal_Strong_Partnership/

WHO Europe: Recommendation to Resume BCG vaccination programme against tuberculosis in Romania
30 November 2012

Extract
“A joint mission of WHO/Europe and the European Centre for Disease Prevention and Control (ECDC) to Romania has recommended immediate resumption of bacille Calmette–Guérin (BCG) vaccination against tuberculosis (TB) in the country.

“The Ministry of Health temporarily suspended BCG vaccination on 22 November as a precautionary measure, following increased reports of enlarged lymph nodes in children after administration of the vaccine produced by the State Serum Institute (SSI) of Denmark.

“The BCG vaccination programme will resume with additional elements, taking account of the mission’s findings. These include:
– strengthening the risk management plan, including guidelines for vaccine administration, follow-up and treatment of adverse events;
– reinforcing close monitoring of adverse events to detect them early and enable rapid and appropriate action; and
– developing a communication plan for health care workers and the public.

In the last decade, BCG vaccination has halved the number of TB cases in children under 14 years in Romania. For every million children aged under 5 years with BCG vaccination, over 350 severe TB cases are avoided…

http://www.euro.who.int/en/what-we-do/health-topics/disease-prevention/vaccines-and-immunization/news/news/2012/11/who-and-ecdc-recommend-immediate-resumption-of-bcg-vaccination-programme-against-tuberculosis-in-romania

Report: Polio’s Last Stand 
Independent Monitoring Board of the Global Polio Eradication Initiative
November 2012

The full report is available as a 50-page pdf here: http://www.polioeradication.org/Portals/0/Document/Aboutus/Governance/IMB/7IMBMeeting/7IMB_Report_EN.pdf

[Editor’s Note: We present the final section of the report titled “Conclusions and Recommendations” in full text below. We draw reader attention to the first recommendation (our bolding which suggests that “the International Health Regulations Expert Review Committee urgently issue a standing recommendation by May 2013 that will introduce pre-travel vaccination or vaccination checks in Afghanistan, Nigeria and Pakistan until national transmission is stopped. No country should allow a citizen from any endemic polio state to cross their border without a valid vaccination certificate.”

Conclusions
With just weeks remaining, the Programme is certain to fail in its main 2010-2012 Strategic Plan target of interrupting polio transmission globally by the end of 2012. The impact of this failure has been mitigated by a final strategic plan phase of high achievement: India and Angola polio-free for over a year; DR Congo close behind; numbers of cases in Afghanistan, Chad and Pakistan down on last year; globally the number of polio cases at their lowest level in history. Only Nigeria has clouded the picture but there are encouraging signs here with strong new policies in place and actions in train. The IMB is heartened that global and country programmes have acted on its guidance set out in five reports.

To all appearances the polio virus is making its last stand, in 0.2% of the world’s land surface.

The uninformed observer might conclude that it had no chance of survival. But those who have targeted the polio viruses for three decades to make it extinct know what a formidable foe it is. It survives for reasons that are well known. The polio virus finds friends amongst missed children, badly managed campaigns, weak data, ill-informed parents, poor political and public health leadership and resistance in adopting best practice.

There is one ingredient, a magic formula for transformation, that is still missing in the affected countries – absolute ownership. Ownership means parents demanding the vaccine, making it their mission to protect their children. Ownership means local leaders grasping the challenge of wiping polio from their area. Ownership means a critical mass in the population believing that their children can, must and will be protected through the eradication of polio. Most of all ownership is about national pride: a country determined to be a vibrant, respected 21st century nation, not one that is looked down on because it remains tainted by a disease that almost everywhere else in the world survives only in the memory of grandparents.

A new strategic plan is being prepared. It needs to be very different to its predecessors. It needs to be built on a foundation of knowledge and understanding about what the remaining barriers to polio eradication are – not just the technical elements, but the ever-important, ever-challenging ‘human factors’ too. It needs to be rigorous in establishing the case for why polio must and can be eradicated, and how this will be achieved. It needs to be deeply compelling, to draw in everybody in the world who can help the Programme to overcome polio’s last stand.

Recommendations
This report makes ten recommendations:

    1. We recommend that the International Health Regulations Expert Review Committee urgently issue a standing recommendation by May 2013 that will introduce pre-travel vaccination or vaccination checks in Afghanistan, Nigeria and Pakistan until national transmission is stopped. No country should allow a citizen from any endemic polio state to cross their border without a valid vaccination certificate.

2. We recommend that within the next fortnight, programme leaders in Afghanistan, Nigeria, Pakistan and Chad discuss their country’s plan and best practice elsewhere to write, with their partners, a list of no more than five priority goals that they will achieve by the end of April 2013, circulate these goals to all programme staff, and maintain the focus and pace necessary to achieve them.

3. We recommend that an analysis be urgently commissioned to examine the relationship

between the frequency and quality of vaccination campaigns, to guide programmatic decisions about the optimum interval between campaigns.

4. We recommend that every endemic country district-level task force (or equivalent) should be constituted to include a parent, representing parents of the district.

5. We recommend that every opportunity be taken to ‘pair’ other health and neighbourhood benefits with the polio vaccine.

6. The IMB requests a report on vaccine supply at each of its future meetings.

7. We recommend that the Programme accelerate planning to set out how the learning from polio eradication can be captured rigorously and comprehensively, overseen and funded with minimal distraction to current work.

8. We recommend that an intensive ‘Polio Watch’ be established in the countries at highest risk of a polio outbreak. We further recommend that the responsible WHO Regional Offices should issue within the next month an action plan for strengthening vaccination coverage and surveillance in these areas.

9. We recommend that India plans for a simulation exercise to test the readiness of its emergency response plans. We recommend that the exercise should begin, on an unannounced date in mid-2013, by selecting a sample of districts at random and carrying out real-time simulation-based scrutiny of their emergency response capability

10. We recommend that a continual live audiovisual feed should be broadcast online from the Nigerian Emergency Operations Centre, with a facility for the world’s polio experts and the IMB to observe and provide input at any time.

Update: Polio this week – As of 27 Nov 2012
Global Polio Eradication Initiative
http://www.polioeradication.org/Dataandmonitoring/Poliothisweek.aspx

[Editor’s Extract]
– The Independent Monitoring Board (IMB) has published the report of its end-October meeting. Entitled ‘Polio’s Last Stand’, the report highlights that polio is ‘more tightly confined than ever’ and that the global eradication effort is ‘enjoying an unprecedented level of priority and commitment’. While the report notes that the programme ‘will now clearly not achieve its goal of stopping all transmission by end-2012’, the IMB points out that despite this, prospects for success ‘are more positive than ever’. [http://www.polioeradication.org/Portals/0/Document/Aboutus/Governance/IMB/7IMBMeeting/7IMB_Report_EN.pdf
– The Kano State Government, the Bill & Melinda Gates Foundation and the Dangote Foundation – funded by Nigerian business magnate Alhaji Aliko Dangote – launched this week a collaboration to improve routine immunization and primary health care in Kano, with a goal of reaching 80% coverage with basic vaccines by 2015. Kano has one of the lowest routine immunization coverage rates in Nigeria, with less than 40% of children vaccinated.

Afghanistan
– One new WPV case was reported in the past week (one WPV1 from Khost), bringing the total number of WPV cases for 2012 to 31. It is the most recent case in the country and had onset of paralysis on 9 November.
– Khost province is on the country’s eastern border with Pakistan. Though Khost is not an endemic area, a case was reported in September as well. Both cases are linked to virus circulating in Quetta, capital of Balochistan province in Pakistan.
– The Independent Monitoring Board has stated that Afghanistan has made progress, but too slowly, and that too many children in southern Afghanistan are missed not just due to insecurity but also due to remaining managerial challenges. As with each of the three endemic countries, the IMB recommends ‘absolute ownership’ by leaders at all levels…

Nigeria
– Six new WPV cases were reported in the past week (five WPV1s from Katsina and one WPV1 from Borno), bringing the total number of WPV cases for 2012 to 110. A WPV1 from Katsina is the most recent in the country and had onset of paralysis on 4 November.
– Katsina has now had 32 cases, and represents nearly one-third of all of Nigeria’s cases this year. The state has the most intense transmission of wild poliovirus in the world at the moment, accounting for more than 15% of all polio cases globally this year.
– The new case in Borno is the first since August. Insecurity in Borno continues to complicate operations, and the state’s proximity to Chad is cause for concern. Historically, polio from Borno has spread east into Chad and from there onwards…

Pakistan
– Two new WPV cases were reported in the past week (WPV1s from Khyber Pakhtunkhwa – KP, and Federally Administered Tribal Areas – FATA), bringing the total number of WPV cases for 2012 to 56. The WPV1 from FATA is the most recent case in the country and had onset of paralysis on 10 November.
– Additionally, two new cVDPV2 cases were reported in the past week, bringing the total number of cVDPV2 cases to seven (all from the greater Quetta area of Balochistan)…

PATH announced the appointment of Amie Batson to the newly created position of chief strategy officer. Ms. Batson is currently senior deputy assistant administrator for global health with the US Agency for International Development (USAID) in Washington, DC. Her 20-year career in global health includes positions with the World Bank, the World Health Organization, and UNICEF. Ms. Batson will have responsibility for helping guide PATH’s strategy, strengthening its partnerships and business relationships in the global health community, and contributing to PATH’s advocacy and policy priorities. She will join PATH in mid-April 2013 and report to Steve Davis, PATH’s president and CEO. http://www.prnewswire.com/news-releases/path-names-amie-batson-as-chief-strategy-officer-181192571.html

The Weekly Epidemiological Record (WER) for 30 November 2012, vol. 87, 47 (pp. 477–492) includes:
– Outbreak news: Yellow fever, Sudan – update
– Transmission assessment surveys in the Global Programme to Eliminate Lymphatic Filariasis: WHO position statement
– Validation of maternal and neonatal tetanus elimination in Timor-Leste, 2012

http://www.who.int/entity/wer/2012/wer8748.pdf

BMC Public Health
(Accessed 1 December 2012)
http://www.biomedcentral.com/bmcpublichealth/content

Research article
French women’s knowledge of and attitudes towards cervical cancer prevention and the acceptability of HPV vaccination among those with 14 — 18 year old daughters: a quantitative-qualitative study
Julie Haesebaert, Delphine Lutringer-Magnin, Julie Kalecinski, Giovanna Barone, Anne-Carole Jacquard, Véronique Régnier, Yann Leocmach, Philippe Vanhems, Franck Chauvin, Christine Lasset BMC Public Health 2012, 12:1034 (27 November 2012)

Abstract (provisional)
Background
In France, it is recommended that girls and women aged 14–23 are vaccinated against the human papillomavirus (HPV). However, French women’s knowledge of and attitude towards the vaccine has been little studied.

Methods
Thirty-nine general practitioners, representative of those working in the large Rhone-Alpes region, offered a self-administered questionnaire on cervical cancer (CC) prevention to all 18–65 year-old women who came for consultation during June and July 2008. In addition, semi-structured interviews were undertaken with a sample of those who had daughters aged 14–18.

Results
Of the 1,478 women who completed the questionnaire, only 16.9% mentioned HPV as the cause of CC, even though 76.2% knew of the vaccine. 210 women had daughters aged 14–18, and 32 were interviewed. Compared with the wider group, more of these women were aware of the HPV vaccine (91.4%). 44.8% knew the target population and 17.1% the recommended ages for vaccination. 54.3% favoured HPV vaccination; 37.2% were undecided and only 0.9% were opposed. The main barrier to acceptance was the recency of the vaccine’s introduction and concern about possible side effects (54.9%); 14.1% preferred to rely on their GP’s decision. Factors associated with acceptance of the HPV vaccine were having previously vaccinated a child against pneumococcus (OR=3.28 [1.32-8.11]) and knowing the target population for HPV vaccination (OR=2.12 [1.15-3.90]). Knowing the recommended frequency of Papanicolaou smear testing (Pap test) screening was associated with lower acceptance (OR=0.32 [0.13-0.82]).

Conclusions
Few mothers are opposed to HPV vaccination. Factors associated with acceptability were knowledge about the vaccine, acceptance of other vaccines and, unexpectedly, lack of knowledge about the recommended frequency of Pap testing. On multivariate analysis, compliance with recommendations for Pap test screening and socioeconomic factors had no effect on views about HPV vaccination. Given that concern about possible side effects is the major barrier to wider acceptance of the HPV vaccine in France, GPs have a key role in providing information.

The complete article is available as a provisional PDF. The fully formatted PDF and HTML versions are in production.

British Medical Journal
01 December 2012 (Vol 345, Issue 7885)
http://www.bmj.com/content/345/7885

Head to Head
Should India launch a national immunisation programme against rotavirus? Yes
BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e7818 (Published 30 November 2012)
Cite this as: BMJ 2012;345:e7818
Johnie Rose, senior instructor 1; Umesh D Parashar, medical epidemiologist2

Extract
India is considering including rotavirus vaccine in its national childhood immunisation programme. Johnie Rose and Umesh Parashar support the move, but Jacob Puliyel and Joseph Mathew (doi:10.1136/bmj.e7832) question the evidence used to support vaccination

The World Health Organization recommends inclusion of rotavirus vaccination of infants into all national immunisation programmes, with a strong recommendation for introduction of vaccine in countries like India where diarrhoeal deaths account for ≥10% of child mortality.1    The health burden of rotavirus in India is well established. WHO estimated that 98 621 Indian children died from rotavirus gastroenteritis in 2008, representing about one third of deaths from diarrhoeal disease and 4% of all child deaths in India.2 More recent data from the Million Death  Study, a nationally representative survey of 1.1 million Indian households, estimated that the virus causes 113 000 deaths a year.3 Both of these figures are conservative compared with an estimate of 147 000 annual rotavirus deaths obtained by directly extrapolating rates of laboratory confirmed rotavirus mortality from a contemporary community based birth cohort study in India.4

Non-fatal rotavirus gastroenteritis results in around 880 000 hospital admissions and 1.26 million …

Head to Head
Should India launch a national immunisation programme against rotavirus? No
BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e7832 (Published 30 November 2012)
Jacob M Puliyel, consultant paediatrician1,
Joseph L Mathew, associate professor2

Extract
India is considering including rotavirus vaccine in its national childhood immunisation programme. Johnie Rose and Umesh Parashar (doi:10.1136/bmj.e7818) support the move, but Jacob Puliyel and Joseph Mathew question the evidence used to support vaccination

The programme to immunise all the world’s children with the rotavirus vaccine is based on mistaken assumptions. Careful evaluation of available evidence does not support the launch of the programme in India. It will divert funds from more life saving interventions and could cause harm.

Inappropriate extrapolations
The World Health Organization recommended universal rotavirus vaccination well before regional evidence of its effectiveness was collected. This is a distortion of the standard procedure whereby recommendations are made based on local evidence. The distortion came about in two stages. In 2007, the WHO committee looking at rotavirus vaccination for developing countries decided that efficacy data from one population can be extrapolated to other populations that are in an “equivalent child mortality strata.”1 This presumes that the prevalent virus strains are the same in different regions with similar socioeconomic status and mortality rates. There is no scientific evidence to support this assumption. Following this in 2009, using data from Malawi (one of the poorest regions in the world),2 Nicaragua, and a handful of developed countries, WHO recommended rotavirus vaccine for all regions of the world.3

Rationale

According to the GAVI Alliance, which funds vaccination for children in poor countries, rotavirus…

Bulletin of the World Health Organization
Volume 90, Number 12, December 2012, 869-944
http://www.who.int/bulletin/volumes/90/12/en/index.html

EDITORIALS
A framework convention on global health: a catalyst for justice
Michel Sidibé & Kent Buse
doi: 10.2471/BLT.12.114371
Article [HTML]

Bulletin of the World Health Organization
Volume 90, Number 12, December 2012, 869-944
http://www.who.int/bulletin/volumes/90/12/en/index.html

PERSPECTIVES
Cost–effectiveness analysis of pandemic influenza preparedness: what’s missing?
Tom L Drake, Zaid Chalabi & Richard Coker
doi: 10.2471/BLT.12.109025
Article [HTML]

Conclusion
The evidence base for the cost–effectiveness of pandemic influenza preparedness policy options is small but growing rapidly. Modelling methods vary considerably between studies and the literature is limited in scope. To contribute to improving quality and consistency in this emerging study area, we recommend: (i) greater focus on low-resource settings; (ii) inclusion of non-pharmaceutical interventions; (iii) incorporation of health system capacity; and (iv) more robust analysis and presentation of pandemic event uncertainty. So, what’s missing from pandemic influenza preparedness cost–effectiveness analysis? Answer: poor countries, non-pharmaceutical interventions, health system capacity and pandemic uncertainty.