Vaccines and Global Health: The Week in Review_14 October 2017

Vaccines and Global Health: The Week in Review is a weekly digest  summarizing news, events, announcements, peer-reviewed articles and research in the global vaccine ethics and policy space. Content is aggregated from key governmental, NGO, international organization and industry sources, key peer-reviewed journals, and other media channels. This summary proceeds from the broad base of themes and issues monitored by the Center for Vaccine Ethics & Policy in its work: it is not intended to be exhaustive in its coverage. You are viewing the blog version of our weekly digest, typically comprised of between 30 and 40 posts below all dated with the current issue date

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

Milestones :: Perspectives

Milestones :: Perspectives
 
Meeting: SAGE Strategic Advisory Group of Experts on Immunization (SAGE)
17 – 19 October 2017
Executive Board Room, WHO Headquarters, Geneva, Switzerland
:: Draft agenda pdf, 110kb  As of 27 September 2017
:: Background documents
 
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Attack on vaccines sets back immunization efforts in eastern Syrian Arab Republic
13 October 2017 | GENEVA – The World Health Organization has received reports of an attack on medical facilities in eastern Syrian Arab Republic that has destroyed the only vaccines cold room in al-Mayadeen district, Deir Ezzor Governorate.

More than 100,000 doses of measles vaccines and 35,000 doses of polio vaccines were stored in these facilities, alongside equipment, syringes, and stocks for all vaccine-preventable childhood diseases.

If confirmed, this would set back the efforts of WHO and health partners to protect the children of Deir Ezzor from preventable childhood diseases, including polio. WHO and local partners have intensified efforts to respond to an outbreak of polio that has affected 48 children in the Syrian Arab Republic since March this year.

“WHO has made strenuous efforts in cooperation with health authorities to deliver vaccines to protect the children living in these areas from disease,” said Elizabeth Hoff, WHO Representative in the Syrian Arab Republic. “We unequivocally condemn these actions. Vaccines are not a legitimate target of war.”

“Until a new cold room is built and the required cold chain equipment — including solar fridges, cold boxes and vaccine carriers — are delivered, this will delay the implementation of routine immunization for vulnerable children in the area,” Hoff added.

WHO has supported 23 polio campaigns since the first outbreak in 2013 and helped to establish 1,148 sentinel sites across the country, of which more than 35% are in hard-to-reach and besieged areas, including al-Mayadeen in Deir Ezzor Govenorate.

The last polio vaccination campaign in Deir Ezzor reached 252,768 children aged 0-59 months.
 
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Experimental Ebola vaccines elicit year-long immune response
October 11, 2017 —
NIH reports final data from large clinical trial in West Africa.
Results from a large randomized, placebo-controlled clinical trial in Liberia show that two candidate Ebola vaccines pose no major safety concerns and can elicit immune responses by one month after initial vaccination that last for at least one year. The findings, published in the October 12 issue of the New England Journal of Medicine, are based on a study of 1,500 adults that began during the West Africa Ebola outbreak. The trial is being conducted by a U.S.-Liberia clinical research collaboration known as the Partnership for Research on Ebola Virus in Liberia (PREVAIL), established in 2014 in response to the request from the Liberian Minister of Health to the U.S. Secretary of Health and Human Services. The trial is sponsored by the National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health (NIH) and involves scientists and clinicians from Liberia and the United States.

“This clinical trial has yielded valuable information that is essential for the continued development of these two Ebola vaccine candidates and also demonstrates that well-designed, ethically sound clinical research can be conducted during an epidemic,” said NIAID Director Anthony S. Fauci, M.D. “A safe and effective vaccine would be a critically important addition to classical public health measures in controlling inevitable future Ebola outbreaks.”

PREVAIL conducts collaborative biomedical research in accordance with best practices, to advance science, strengthen health policy and practice, and improve the health of people in Liberia and around the world. The partnership launched this first study, PREVAIL 1, in February 2015.  Originally designed to enroll 28,000 volunteers, the trial was scaled back to a Phase 2 study when the decline in new Ebola cases made it impossible to conduct a large efficacy study.
“In Liberia, we have demonstrated to the global community that rigorous scientific research can take place in a developing sub-Saharan African country when a mutually beneficial partnership is developed,” noted Dr. Bernice T. Dahn, Liberia’s Minister of Health. “The work of PREVAIL, ranging from the Ebola vaccine to the Ebola survivor studies, clearly manifest the prospects of such a sustainable partnership and clinical research platform.”

The co-leaders of the trial are Stephen B. Kennedy, M.D., M.P.H., senior research scientist at the University of Liberia-Pacific Institute for Research and Evaluation (UL-PIRE) Africa Center, an infectious disease research center; Fatorma Bolay, Ph.D., director, Public Health and Medical Research at the National Public Health Institute of Liberia; and H. Clifford Lane, M.D., NIAID’s clinical director…
 

An HIV Vaccine is Essential for Ending the HIV/AIDS Pandemic

JAMA
New Online – Published October 9, 2017. doi:10.1001/jama.2017.13505
Viewpoint
An HIV Vaccine is Essential for Ending the HIV/AIDS Pandemic
Anthony S. Fauci, MD1
Today, highly effective modalities of HIV treatment and prevention are available, and these essential tools, if properly implemented, could end the current HIV/AIDS pandemic. Yet, the pandemic continues.1

Most of the major infectious diseases affecting humans, such as smallpox, polio, and yellow fever, have required effective vaccines for their control and in some cases elimination, and so the question arises whether the HIV/AIDS pandemic can be effectively addressed without an HIV vaccine. The answer to that question is not straightforward, but needs to be addressed from both a theoretical and a practical standpoint. Theoretically, the HIV pandemic can be ended without an HIV vaccine. More than 30 highly effective anti-HIV drugs are currently available. When given in combinations of 3 or more, these medications can durably suppress the virus such that patients who are treated soon after infection and continue therapy throughout their lifetime can expect to have an almost-normal life expectancy.

Importantly, effective treatment can reduce the level of virus in a person with HIV so low that it is extremely unlikely that this person will transmit the virus to his or her uninfected sexual partner. This concept is referred to as “treatment as prevention.” Therefore, theoretically, if most or all of the people living with HIV in the world could be identified, accessed, and treated, it would be possible to stop all infections and end the epidemic. People who are uninfected, but whose behavior or life situation puts them at high risk of HIV infection, can take a single pill containing 2 anti-HIV drugs and decrease the likelihood of acquiring HIV infection. This approach—“preexposure prophylaxis” or PrEP—can lower the risk of acquiring HIV through sexual activity by more than 90%, or from injection drug use by more than 70% if the medications are taken consistently.2 Accordingly, if both of these treatment and prevention modalities were effectively implemented throughout the world, the HIV/AIDS pandemic would end.

However, from a practical standpoint, ending the HIV/AIDS pandemic without a vaccine is possible, although it is unlikely. Although an estimated 19.5 million of the estimated 36.7 million HIV-infected people globally are receiving anti-HIV therapy (an extraordinary accomplishment), more than 17 million people are not receiving therapy.1 This leaves a substantial treatment gap. These 17 million people can continue to infect others, allowing the pandemic to be sustained. In addition, although PrEP is highly effective in preventing acquisition of HIV among people at high risk of infection, only a very small percentage of these individuals are actually taking these medications. In the United States, it is estimated that only approximately 10% of people who could benefit from PrEP are actually receiving it,3 and this proportion is much smaller elsewhere in the world.1

The Joint United Nations Programme on HIV/AIDS (UNAIDS) has set an ambitious target to help end the HIV pandemic.1 Called “90-90-90,” the goal for 2020 is to have 90% of HIV-infected people throughout the world know their HIV status, 90% of people diagnosed with HIV receiving anti-HIV treatment, and 90% of people who receive treatment having their virus suppressed to undetectable levels. If successful, the result would be that an estimated 73% of all people in the world with HIV would have undetectable viral levels. Since suppressed viral levels result in a marked reduction in the risk of HIV transmission to other individuals, mathematical models suggest that achieving the 90-90-90 goal would reverse the kinetics and trajectory of global HIV disease such that it would no longer be of pandemic proportions. A recent study in rural Kenya and Uganda demonstrated that implementation of community-based testing and treatment resulted in increased HIV diagnosis, initiation of antiretroviral therapy and viral suppression, and the study communities reached the UNAIDS target within 2 years.4 In addition, some entire countries have been successful in reaching the goal of 73%, largely through the efforts of the President’s Emergency Plan for AIDS Relief and the Global Fund to Fight AIDS, Tuberculosis, and Malaria. However, the global figure for achieving this goal in all countries is just 44%.1 Also, modeling studies have suggested that in certain high-prevalence regions of the world, the geographic dispersion of the infected population, would make it extremely difficult to reach them effectively with HIV treatment.5

The question also arises whether it is economically feasible to end the HIV pandemic in the absence of a vaccine. In this regard, the resource requirements to achieve such a goal are continually increasing. The 19.5 million people currently receiving anti-HIV drugs must be maintained on these medications for the rest of their lives; at the same time, anti-HIV drugs need to be provided to the 17.2 million infected, but untreated people. Furthermore, the estimated 1.8 million people who are newly infected with HIV each year1 also need to be treated. In addition, the cost of providing PrEP and other prevention services to the millions of people who are at risk for HIV infection is substantial. In 2016, UNAIDS estimated that the total investments needed for an adequate treatment and prevention response for HIV in low- and middle-income countries between 2016 and 2030 would amount to approximately $350 billion.6 Against this backdrop, a recent Kaiser Family Foundation and UNAIDS study found that donor-government funding for HIV decreased by 7% in 2016, which represents the lowest funding level since 2010.7

Despite the remarkable gains in the treatment and prevention of HIV infection, development of an effective HIV vaccine will likely be necessary to achieve a durable end to the HIV pandemic. An important question is how effective that vaccine must be. One vaccine tested in a large vaccine trial8 in Thailand reduced the risk of infection by 31%, a figure inadequate to justify licensure of the vaccine. In contrast, other vaccines used in controlling or ending global outbreaks have been much more effective. For example, the measles, polio, and yellow fever vaccines are nearly 100% effective. Given the difficulty for the human immune system to mount a protective response against HIV, it is extremely unlikely that an HIV vaccine will be as effective as those other proven vaccines.

In fact, modeling studies have suggested that if current treatment and prevention efforts are continued and an HIV vaccine that is about 50% effective is developed and deployed, millions of additional new HIV infections could be averted, and the pandemic could slow substantially.9

Despite extraordinary advances in the treatment and prevention of HIV infection, it is theoretically possible to end the HIV epidemic by aggressively and effectively implementing these interventions, although from a practical standpoint this goal would be difficult to achieve. Therefore, development of a moderately effective vaccine together with optimal implementation of existing treatment and prevention modalities could end the current HIV pandemic. Recent advances in HIV vaccine research provide hope that at least a moderately effective vaccine can be developed. It is critical to continue to accelerate a robust research effort in that direction while aggressively scaling-up the implementation of current treatment and prevention tools. To do anything less would lead to failure, which for HIV is not an option.

Reference at title link above

 

Cholera

Cholera
 
World’s second largest oral cholera vaccination campaign kicks off at Rohingya camps in Bangladesh
COX’S BAZAR, Bangladesh, 10 October 2017 – A massive cholera immunization campaign started today near Cox’s Bazar, Bangladesh, to protect newly arrived Rohingya and host communities from the life-threatening diarrheal disease. 900 000 doses of the vaccine have been mobilized and are being delivered by more than 200 mobile vaccination teams, making it the second largest oral cholera vaccination campaign ever.

The campaign, which is led by the Ministry of Health and supported by the World Health Organization (WHO) and UNICEF, is being held in Ukhiya and Teknaf, where more than half a million people have arrived from across the border since August, joining vast numbers already residing in a series of settlements and camps.

The first round of the campaign will cover 650,000 people aged one year and older. The second round will commence on 31 October and will target 250,000 children between one and five years with an additional dose of the vaccine for added protection.

“This is the second largest oral vaccination campaign in the world after Haiti in 2016,” says Edouard Beigbeder, UNICEF Representative in Bangladesh. “Cholera is a dangerous disease, especially among children living in cramped, unhygienic conditions. Prevention is essential.”

In the last week, at least 10,292 cases of diarrhoea have been reported and treated from across the settlements and camps. WHO has warned of the potential for an outbreak of cholera.

UNICEF and WHO are supporting the Ministry of Health with planning, distribution, volunteer orientation, operational costs and monitoring.

“Emergency vaccination saves lives. The risk of cholera is clear and present, and the need for decisive action apparent,” says Dr. N Paranietharan, WHO Representative to Bangladesh. “WHO is committed to mobilizing its full technical and operational capacity to support the Ministry and our partners to protect, promote and secure the health of this immensely vulnerable population.”

In Ukhiya 150 teams have been deployed to vaccinate the target population, while 55 teams have been deployed in Teknaf. Each team is comprised of five members.  Though vaccination can provide life-saving protection against cholera, it supplements but does not replace other traditional cholera control measures such as access to clean water, adequate sanitation and good hygiene.

To help meet present water, sanitation and hygiene needs, UNICEF is working to scale up its interventions and communication on safe practices, and is prepositioning critical supplies for case management. WHO is monitoring water quality and working with the Department of Public Health Engineering to increase local laboratory capacity, has raised an early warning, alert and response emergency surveillance system, and has prepositioned life-saving supplies to ensure a rapid response if and when an outbreak occurs. In addition, the WHO-led Health Sector has supported the Ministry set up diarrhea treatment centres among other response-oriented interventions.

 

Emergencies

Emergencies
 
POLIO
Public Health Emergency of International Concern (PHEIC)
Polio this week as of 4 October 2017 [GPEI]
:: Summary of newly-reported viruses this week:
Syria: one new circulating vaccine derived poliovirus 2 (cVDPV2) case reported, from Mayadeen district, Deir Ez-Zor governorate.  Two new cVDPV2 positives from healthy children, both from Mayadeen district. Afghanistan: two new wild poliovirus 1 (WPV1) positive environmental samples reported in Nangarhar province.
Pakistan: three new wild poliovirus 1 (WPV1) positive environmental samples reported in

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WHO Grade 3 Emergencies  [to 14 October 2017]
The Syrian Arab Republic
:: WHO responds to critical health needs of displaced populations in Al-Tabqa city, Ar-Raqqa Governorate  18 October 2017
:: Syria cVDPV2 outbreak situation report 17, 10 October 2017
 
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WHO Grade 2 Emergencies  [to 14 October 2017]
Myanmar
:: Situation Report 5 – 5 October 2017
 KEY HIGHLIGHTS
:: As of 5 October 2017, cumulative new arrivals in all sites of Ukiah, Tekna, Cox’s Bazar and Ramu was 515,000, of which 198 000 are in makeshift settlements, 225,000 in new spontaneous sites and 92,000 in host communities.
:: At the weekly health sector coordination meeting, the revised humanitarian response plan was shared, targeting 1.2 million people in need and the present requirement across sectors totalling USD 434 million. The health sector is targeting to reach these 1.2 million people in need with USD 48 million.
:: An oral cholera vaccine (OCV) campaign will be rolled out in two phases. 1st dose of OCV vaccination campaign is scheduled for 10-16 October, targeting 650 000 people (new arrival population and host communities) aged 1 year and above including pregnant women. 2 weeks after the first dose, the 2nd dose would be given to children under 5 years of age to be given.
:: Oral cholera vaccination campaign kicks off at Rohingya camps in Bangladesh
 [See Cholera above for more detail]

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UN OCHA – L3 Emergencies
The UN and its humanitarian partners are currently responding to three ‘L3’ emergencies. This is the global humanitarian system’s classification for the response to the most severe, large-scale humanitarian crises. 
Iraq
:: One year on from the start of the battle for Mosul, hundreds of thousands of civilians need…
(Baghdad, 12 October 2017) One year after the start of the military campaign to retake Mosul from the Islamic State of Iraq and the Levant (ISIL), 673,000 Muslawis are still displaced from their homes; 274,000 are living in 18 camps and emergency sites surrounding the city; 400,000 are staying with family, friends or in rented accommodation.

Syrian Arab Republic
:: 13 Oct 2017  Growing concerns for Syrian civilians amid intense fighting in Al Raqqa and Deir ez-Zor

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UN OCHA – Corporate Emergencies
When the USG/ERC declares a Corporate Emergency Response, all OCHA offices, branches and sections provide their full support to response activities both at HQ and in the field.
Ethiopia
:: 13 Oct 2017  Ethiopia: Humanitarian Response Situation Report No.14 (August – September 2017)

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

EBOLA/EVD  [to 14 October 2017]
http://www.who.int/ebola/en/
Experimental Ebola vaccines elicit year-long immune response
October 11, 2017 — NIH reports final data from large clinical trial in West Africa.
[See Milestones/Perspectives above for more detail]

MERS-CoV [to 14 October 2017]
http://www.who.int/emergencies/mers-cov/en/
DONs
Middle East respiratory syndrome coronavirus (MERS-CoV) – Saudi Arabia
9 October 2017
Between 31 August and 26 September 2017, the national IHR focal point of Saudi Arabia reported nine additional cases of Middle East Respiratory Syndrome (MERS), including four deaths. In addition, four deaths from previously reported cases were reported…
 

WHO & Regional Offices [to 14 October 2017]

WHO & Regional Offices [to 14 October 2017]
 
WHO to establish commission on noncommunicable diseases
10 October 2017 – Dr Tedros Adhanom Ghebreyesus, the WHO’s Director-General, today announced the establishment of a new High-level global Commission on Noncommunicable Diseases (NCDs). The announcement came at the 64th Session of WHO’s Regional Committee for the Eastern Mediterranean being held in Islamabad, 9-12 October. The commission’s aim is to identify innovative ways to curb the world’s biggest causes of death and extend life expectancy for millions of people.
Read the statement

Sixty-eighth session of the Regional Committee for the Western Pacific
10 October 2017 — The WHO Regional Committee for the Western Pacific today opened its 68th session in Brisbane, Australia. The annual meeting brings together ministers of health and senior officials from 37 countries and areas to decide on issues that affect the health and well-being of the Region’s peoples.

Highlights
Investing in disaster prevention for a healthier world
October 2017 – The International Day for Disaster Reduction (IDDR) reminds us of the importance of putting health at the centre of action to prevent, prepare for, respond to and recover from emergencies and disasters. Millions of people are killed, injured or made sick each year by natural and manmade disasters.

Nepal tackles diabetic retinopathy
October 2017 – Diabetic retinopathy, which contributes to 2.6% of blindness in the world, can be a challenging disease for many countries to manage, because doing so involves two different parts of the health system, that which cares for patients with diabetes and that which cares for patients with vision loss. A lack of coordination can lead to people missing out on essential services, enduring long waits or traveling far from home to receive care.

Progressing the Sustainable Development Goals through Health in All Policies
October 2017 – WHO and the Government of South Australia have published the case study book on Health in All Policies (HiAP), which describes experiences from around the world in the context of the 2030 Sustainable Development Agenda.

WHO scales up response to plague in Madagascar
October 2017 – WHO is rapidly scaling up its response to an outbreak of plague that has spread to the capital and port towns, infecting more than 100 people in just a few weeks.

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Weekly Epidemiological Record, 13 October 2017, vol. 92, 41 (pp. 609–624)
:: Executive summary of the 9th meeting of the WHO working group RT-PCR for the detection and subtyping of influenza viruses
:: Executive summary of the 6th meeting of the WHO Expert Working Group of the GISRS for Surveillance of Antiviral Susceptibility
:: Continuing risk of meningitis due to Neisseria meningitidis serogroup C in Africa: revised recommendations from a WHO expert consultation
:: Progress towards eliminating onchocerciasis in the WHO Region of the Americas: elimination of transmission in the north-east focus of the Bolivarian Republic of Venezuela
 
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5 October 2017
GIN September 2017 pdf, 2.74Mb
 
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WHO Regional Offices
Selected Press Releases, Announcements
WHO African Region AFRO
:: With USAID’s support, WHO strengthens integrated diseases surveillance and response for timely and effective public health action in South Sudan  13 October 2017
:: WHO Regional Director for Africa begins official visit to Nigeria  11 October 2017
:: The World Mental Health Day commemorated in South Sudan  11 October 2017

WHO Region of the Americas PAHO
:: Eradicating hunger in Latin America and the Caribbean by 2030 is becoming increasingly unlikely (10/10/2017)

WHO South-East Asia Region SEARO
:: WHO, partners implement 900 000 dose oral cholera vaccination campaign in Cox’s Bazaar  10 Oct 2017

WHO European Region EURO
:: World Obesity Day: Understanding the social consequences of obesity 10-10-2017
:: “We’re doctors but we’re also human”: helping Syrian health workers handle severe stress 09-10-2017

WHO Eastern Mediterranean Region EMRO
:: 64th session of the Regional Committee for the Eastern Mediterranean concludes in Pakistan
12 October 2017, Islamabad, Pakistan – Members of WHO’s Regional Committee for the Eastern Mediterranean today concluded their 64th Session, endorsing a number of resolutions that will have a positive impact on the health of populations in countries of the Eastern Mediterranean Region.
Among the topics discussed were cancer, climate change, the health of adolescents and antimicrobial resistance…

WHO Western Pacific Region
:: Countries pledge to fund priority public health services; make medicines, the health workforce and food safer
BRISBANE, Australia, 12 October 2017 – Governments from across the Region today pledged to take action to ensure the safety of medicines and competence of health workers. They also agreed on frameworks for the financing of priority health services and for making food safer. Ministers and senior officials at the 68th session of the World Health Organization (WHO) Regional Committee for the Western Pacific also noted progress in areas of public health including: noncommunicable diseases, tobacco control, mental health, tuberculosis (TB), hepatitis, traditional medicine, and gender and health…
:: World Health Organization Director-General Dr Tedros appoints Cook Islands’ Elizabeth Iro as WHO’s Chief Nursing Officer
BRISBANE, Australia, 12 October 2017 – Director-General Dr Tedros Adhanom Ghebreyesus today appointed Ms Elizabeth Iro as the Chief Nursing Officer at the World Health Organization (WHO). Ms Iro is a registered nurse, and the Cook Islands’ current Secretary of Health. With this announcement, Dr Tedros fulfils a commitment he made during his transition to the Director-General role to appoint a nurse to his senior team. “I am thrilled to welcome Ms Iro to our team as WHO’s Chief Nursing Officer,” said Dr Tedros.
 

CDC/ACIP [to 14 October 2017]

CDC/ACIP [to 14 October 2017]
http://www.cdc.gov/media/index.html

MMWR News Synopsis for October 12, 2017
:: Vaccination Coverage Among Children in Kindergarten — United States, 2016–2017 School Year
Getting vaccines at the recommended ages protects children from serious vaccine-preventable diseases before they start school. For the 2016-2017 school year, vaccination coverage among kindergartners remained high. Immunization programs conduct annual kindergarten vaccination assessments to monitor school entry vaccination coverage. For the 2016-17 school year, vaccination coverage among kindergartners remained high and exemptions remained low. Based on the data:
:: Median vaccination coverage was 94.0 percent for two doses of measles, mumps, and rubella vaccine; 94.5 percent for the state-required number of doses of diphtheria, tetanus, and acellular pertussis vaccine; and 93.8 percent for two doses of varicella vaccine.
:: Median exemption level was 2.0 percent.
:: Median proportion of kindergartners under a grace period or provisional enrollment was 2.0 percent, the same as in 2015–16.
School assessment allows immunization programs to focus on schools with lower vaccination coverage and higher exemption levels, and encourages follow up with undervaccinated students to ensure kindergartners are protected from vaccine-preventable diseases.