BMC Infectious Diseases
http://www.biomedcentral.com/bmcinfectdis/content
(Accessed 5 November 2016)

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Research article
Prevalence and epidemiology of meningococcal carriage in Southern Ethiopia prior to implementation of MenAfriVac, a conjugate vaccine
Neisseria meningitidis colonizes humans and transmits mainly by asymptomatic carriage. We sought to determine the prevalence and epidemiology of meningococcal carriage in Ethiopia prio…
Guro K. Bårnes, Paul A. Kristiansen, Demissew Beyene, Bereket Workalemahu, Paulos Fissiha, Behailu Merdekios, Jon Bohlin, Marie-Pierre Préziosi, Abraham Aseffa and Dominique A. Caugant
BMC Infectious Diseases 2016 16:639
Published on: 4 November 2016

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Review
Alternative pre-approved and novel therapies for the treatment of anthrax
Bacillus anthracis, the causative agent of anthrax, is a spore forming and toxin producing rod-shaped bacterium that is classified as a category A bioterror agent. This pathogenic micr...
Breanne M. Head, Ethan Rubinstein and Adrienne F. A. Meyers
BMC Infectious Diseases 2016 16:621
Published on: 3 November 2016

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Research article
Using the 4 pillars™ practice transformation program to increase adult influenza vaccination and reduce missed opportunities in a randomized cluster trial
An evidence-based, step-by-step guide, the 4 Pillars™ Practice Transformation Program, was the foundation of an intervention to increase adult immunizations in primary care and was tested in a randomized contr…
Chyongchiou J. Lin, Mary Patricia Nowalk, Valory N. Pavlik, Anthony E. Brown, Song Zhang, Jonathan M. Raviotta, Krissy K. Moehling, Mary Hawk, Edmund M. Ricci, Donald B. Middleton, Suchita Patel, Jeannette E. South-Paul and Richard K. Zimmerman
BMC Infectious Diseases 2016 16:623
Published on: 3 November 2016

BMC Medical Ethics
http://www.biomedcentral.com/bmcmedethics/content
(Accessed 5 November 2016)

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Debate
Autonomy of the child in the South African context: is a 12 year old of sufficient maturity to consent to medical treatment?
Wandile Ganya, Sharon Kling and Keymanthri Moodley
Published on: 2 November 2016
Abstract
Background
A child is a developing person with evolving capacities that include autonomy, mental (decisional) capacity and capacity to assume responsibility. Hence, children are entitled to participatory (autonomy) rights in South Africa as observed in the Children’s Act 38 of 2005. According to section 129 of the Act a child may consent to his or her own medical treatment provided that he or she is over the age of 12 years and is of sufficient maturity and decisional capacity to understand the various implications of the treatment including the risks and benefits thereof. However, the Act does not provide a definition for what qualifies as ‘sufficient maturity’ nor does it stipulate how health professionals ought to assess the decisional capacity of a child. In addition, South Africa is a culturally diverse country. The Western liberal notion of autonomy may not necessarily find equal prominence in the mores of people with a different worldview. Hence we demonstrate a few salient comparisons between legal liberal moral theory and African communitarianism as pertinent to the autonomy of the child.
Discussion
Children are rights-holders by virtue of their humanity. Their dignity as individual human persons affords them the entitlement to human rights as contemplated under the Constitution of the Republic of South Africa. However, contrary to the traditional Western notion of individual autonomous persons African societies hold a communalistic notion of person hence there is less regard for individual autonomy and rights with more emphasis on the communal good and maintaining the continuity of relationships and interdependencies shared within a community. A child considered in this view is not regarded as a full person. This implies that decisions concerning the child, including consent to medical treatment are discussed and determined by the community to which the child belongs. Lastly, in this article, we draw on the notion of capacity for responsibility to produce a pragmatic definition of sufficient maturity.
Conclusion
It seems reasonable to suggest a move away from a general legal age of consent for medical treatment toward more individualised, context-specific approaches in determining the maturity of a child patient to consent to medical treatment. Perhaps, decision-making with respect to consent to the medical treatment of a child belonging to a traditional African community where the notion of a person is embedded in communitarianism ought to involve the child’s parents/guardians/caregivers where possible provided that the best interests of the child are awarded priority.

BMC Medicine

(Accessed 5 November 2016)

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Research article
The emerging threat of pre-extensively drug-resistant tuberculosis in West Africa: preparing for large-scale tuberculosis research and drug resistance surveillance
Drug-resistant tuberculosis (TB) is a global public health problem. Adequate management requires baseline drug-resistance prevalence data. In West Africa, due to a poor laboratory infrastructure and inadequate…
Florian Gehre, Jacob Otu, Lindsay Kendall, Audrey Forson, Awewura Kwara, Samuel Kudzawu, Aderemi O. Kehinde, Oludele Adebiyi, Kayode Salako, Ignatius Baldeh, Aisha Jallow, Mamadou Jallow, Anoumou Dagnra, Kodjo Dissé, Essosimna A. Kadanga, Emmanuel Oni Idigbe…
BMC Medicine 2016 14:160
Published on: 3 November 2016

Bulletin of the World Health Organization
Volume 94, Number 11, November 2016, 785-860
http://www.who.int/bulletin/volumes/94/11/en/

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EDITORIALS
Research on community-based health workers is needed to achieve the sustainable development goals
Dermot Maher & Giorgio Cometto
http://dx.doi.org/10.2471/BLT.16.185918

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Elimination of mother-to-child transmission of HIV and syphilis in Cuba and Thailand
Naoko Ishikawa, Lori Newman, Melanie Taylor, Shaffiq Essajee, Razia Pendse & Massimo Ghidinelli
http://dx.doi.org/10.2471/BLT.16.185033

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RESEARCH
Inequalities in full immunization coverage: trends in low- and middle-income countries
María Clara Restrepo-Méndez, Aluísio JD Barros, Kerry LM Wong, Hope L Johnson, George Pariyo, Giovanny VA França, Fernando C Wehrmeister & Cesar G Victora
http://dx.doi.org/10.2471/BLT.15.162172
Abstract
Objective
To investigate disparities in full immunization coverage across and within 86 low- and middle-income countries.
Methods
In May 2015, using data from the most recent Demographic and Health Surveys and Multiple Indicator Cluster Surveys, we investigated inequalities in full immunization coverage – i.e. one dose of bacille Calmette-Guérin vaccine, one dose of measles vaccine, three doses of vaccine against diphtheria, pertussis and tetanus and three doses of polio vaccine – in 86 low- or middle-income countries. We then investigated temporal trends in the level and inequality of such coverage in eight of the countries.
Findings
In each of the World Health Organization’s regions, it appeared that about 56–69% of eligible children in the low- and middle-income countries had received full immunization. However, within each region, the mean recorded level of such coverage varied greatly. In the African Region, for example, it varied from 11.4% in Chad to 90.3% in Rwanda. We detected pro-rich inequality in such coverage in 45 of the 83 countries for which the relevant data were available and pro-urban inequality in 35 of the 86 study countries. Among the countries in which we investigated coverage trends, Madagascar and Mozambique appeared to have made the greatest progress in improving levels of full immunization coverage over the last two decades, particularly among the poorest quintiles of their populations.
Conclusion
Most low- and middle-income countries are affected by pro-rich and pro-urban inequalities in full immunization coverage that are not apparent when only national mean values of such coverage are reported.

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Research
Hepatitis B immunization for indigenous adults, Australia
Andre Louis Wattiaux, J Kevin Yin, Frank Beard, Steve Wesselingh, Benjamin Cowie, James Ward & Kristine Macartney
http://dx.doi.org/10.2471/BLT.16.169524
Abstract
Objective
To quantify the disparity in incidence of hepatitis B between indigenous and non-indigenous people in Australia, and to estimate the potential impact of a hepatitis B immunization programme targeting non-immune indigenous adults.
Methods
Using national data on persons with newly acquired hepatitis B disease notified between 2005 and 2012, we estimated incident infection rates and rate ratios comparing indigenous and non-indigenous people, with adjustments for underreporting. The potential impact of a hepatitis B immunization programme targeting non-immune indigenous adults was projected using a Markov chain Monte Carlo simulation model.
Findings
Of the 54 522 persons with hepatitis B disease notified between 1 January 2005 and 31 December 2012, 1953 infections were newly acquired. Acute hepatitis B infection notification rates were significantly higher for indigenous than non-indigenous Australians. The rates per 100 000 population for all ages were 3.6 (156/4 368 511) and 1.1 (1797/168 449 302) for indigenous and non-indigenous people respectively. The rate ratio of age-standardized notifications was 4.0 (95% confidence interval: 3.7–4.3). If 50% of non-immune indigenous adults (20% of all indigenous adults) were vaccinated over a 10-year programme a projected 527–549 new cases of acute hepatitis B would be prevented.
Conclusion
There continues to be significant health inequity between indigenous and non-indigenous Australians in relation to vaccine-preventable hepatitis B disease. An immunization programme targeting indigenous Australian adults could have considerable impact in terms of cases of acute hepatitis B prevented, with a relatively low number needed to vaccinate to prevent each case.

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POLICY & PRACTICE
Dengue vaccine: local decisions, global consequences
Hugo López-Gatell, Celia M Alpuche-Aranda, José I Santos-Preciado & Mauricio Hernández-Ávila
http://dx.doi.org/10.2471/BLT.15.168765
Abstract
As new vaccines against diseases that are prevalent in low- and middle-income countries gradually become available, national health authorities are presented with new regulatory and policy challenges. The use of CYD-TDV – a chimeric tetravalent, live-attenuated dengue vaccine – was recently approved in five countries. Although promising for public health, this vaccine has only partial and heterogeneous efficacy and may have substantial adverse effects. In trials, children who were aged 2–5 years when first given CYD-TDV were seven times more likely to be hospitalized for dengue, in the third year post-vaccination, than their counterparts in the control group. As it has not been clarified whether this adverse effect is only a function of age or is determined by dengue serostatus, doubts have been cast over the long-term safety of this vaccine in seronegative individuals of any age. Any deployment of the vaccine, which should be very cautious and only considered after a rigorous evaluation of the vaccine’s risk–benefit ratio in explicit national and subnational scenarios, needs to be followed by a long-term assessment of the vaccine’s effects. Furthermore, any implementation of dengue vaccines must not weaken the political and financial support of preventive measures that can simultaneously limit the impacts of dengue and several other mosquito-borne pathogens.

Globalization and Health
http://www.globalizationandhealth.com/
[Accessed 5 November 2016]

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Research
Assessment of the scope and practice of evaluation among medical donation programs
Alisa M. Jenny, Meng Li, Elizabeth Ashbourne, Myron Aldrink, Christine Funk and Andy Stergachis
Globalization and Health 2016 12:69
Published on: 4 November 2016
Abstract
Background
Medical donation programs for drugs, other medical products, training and other supportive services can improve access to essential medicines in low- and middle-income countries (LMICs) and provide emergency and disaster relief. The scope and extent to which medical donation programs evaluate their impact on recipients and health systems is not well documented.
Methods
We conducted a survey of the member organizations of the Partnership for Quality Medical Donations (PQMD), a global alliance of non-profit and corporate organizations, to identify evaluations conducted in conjunction with donation programs.
Results
Twenty-five out of the 36 PQMD organizations that were members at the time of the survey participated in the study, for a response rate of 69 %. PQMD members provided information on 34 of their major medical donation programs. Half of the donation programs reported conducting trainings as a part of their donation program. Twenty-six (76 %) programs reported that they conduct routine monitoring of their donation programs. Less than 30 % of donation programs were evaluated for their impact on health. Lack of technical staff and lack of funding were reported as key barriers to conducting impact evaluations.
Conclusions
Member organizations of PQMD provide a broad range of medical donations, targeting a wide range of public health issues and events. While some level of monitoring and evaluation was conducted in nearly 80 % of the donation programs, a program’s impact was infrequently evaluated. Opportunities exist to develop consistent metrics for medical donation programs, develop a common framework for impact evaluations, and advocate for data collection and analysis plans that collect meaningful metrics.

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Research
The challenge of bridging the gap between researchers and policy makers: experiences of a Health Policy Research Group in engaging policy makers to support evidence informed policy making in Nigeria
Benjamin Uzochukwu, Obinna Onwujekwe, Chinyere Mbachu, Chinenye Okwuosa, Enyi Etiaba, Monica E. Nyström and Lucy Gilson
Globalization and Health 2016 12:67
Published on: 4 November 2016
Abstract
Background
Getting research into policy and practice (GRIPP) is a process of going from research evidence to decisions and action. To integrate research findings into the policy making process and to communicate research findings to policymakers is a key challenge world-wide. This paper reports the experiences of a research group in a Nigerian university when seeking to ‘do’ GRIPP, and the important features and challenges of this process within the African context.
Methods
In-depth interviews were conducted with nine purposively selected policy makers in various organizations and six researchers from the universities and research institute in a Nigerian who had been involved in 15 selected joint studies/projects with Health Policy Research Group (HPRG). The interviews explored their understanding and experience of the methods and processes used by the HPRG to generate research questions and research results; their involvement in the process and whether the methods were perceived as effective in relation to influencing policy and practice and factors that influenced the uptake of research results.
Results
The results are represented in a model with the four GRIPP strategies found: i) stakeholders’ request for evidence to support the use of certain strategies or to scale up health interventions; ii) policymakers and stakeholders seeking evidence from researchers; iii) involving stakeholders in designing research objectives and throughout the research process; and iv) facilitating policy maker-researcher engagement in finding best ways of using research findings to influence policy and practice and to actively disseminate research findings to relevant stakeholders and policymakers.
The challenges to research utilization in health policy found were to address the capacity of policy makers to demand and to uptake research, the communication gap between researchers, donors and policymakers, the management of the political process of GRIPP, the lack of willingness of some policy makers to use research, the limited research funding and the resistance to change.
Conclusions
Country based Health Policy and Systems Research groups can influence domestic policy makers if appropriate strategies are employed. The model presented gives some direction to potential strategies for getting research into policy and practice in the health care sector in Nigeria and elsewhere.

Infectious Diseases of Poverty
http://www.idpjournal.com/content
[Accessed 5 November 2016]
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Scoping Review
Alternatives to currently used antimalarial drugs: in search of a magic bullet
Malaria is a major cause of morbidity and mortality in many African countries and parts of Asia and South America. Novel approaches to combating the disease have emerged in recent years and several drug candid…
Akshaya Srikanth Bhagavathula, Asim Ahmed Elnour and Abdulla Shehab
Infectious Diseases of Poverty 2016 5:103
Published on: 4 November 2016

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Research Article
Assessment of the response to cholera outbreaks in two districts in Ghana
Despite recurring outbreaks of cholera in Ghana, very little has been reported on assessments of outbreak response activities undertaken in affected areas. This study assessed the response activities undertake...
Sally-Ann Ohene, Wisdom Klenyuie and Mark Sarpeh
Infectious Diseases of Poverty 2016 5:99
Published on: 2 November 2016

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Research Article
Tuberculosis care strategies and their economic consequences for patients: the missing link to end tuberculosis
While investment in the development of Tuberculosis (TB) treatment strategies is essential, it cannot be assumed that the strategies are affordable for TB patients living in countries with high economic constr…
Belete Getahun, Moges Wubie, Getiye Dejenu and Tsegahun Manyazewal
Infectious Diseases of Poverty 2016 5:93
Published on: 1 November 2016

JAMA
November 1, 2016, Vol 316, No. 17, Pages 1731-1838
http://jama.jamanetwork.com/issue.aspx

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Research Letter
Tdap Vaccination During Pregnancy and Microcephaly and Other Structural Birth Defects in Offspring
Malini DeSilva, MD, MPH; Gabriela Vazquez-Benitez, PhD; James D. Nordin, MD, MPH; et al.
JAMA. 2016;316(17):1823-1825. doi:10.1001/jama.2016.14432
This cohort study uses Vaccine Safety Datalink data to examine associations between maternal Tdap vaccination and structural birth defects in offspring.

Journal of Epidemiology & Community Health
November 2016, Volume 70, Issue 11
http://jech.bmj.com/content/current

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Research report
Factors associated with influenza vaccine uptake during a universal vaccination programme of preschool children in England and Wales: a cohort study
Pia Hardelid, Greta Rait, Ruth Gilbert, Irene Petersen
J Epidemiol Community Health 2016;70:1082-1087 Published Online First: 13 May 2016 doi:10.1136/jech-2015-207014

Journal of Health Care for the Poor and Underserved (JHCPU)
Volume 27, Number 4, November 2016
https://muse.jhu.edu/issue/35214

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Original Papers
How Should We Treat the Vulnerable?: Qualitative Study of Authoritative Ethics Documents
pp. 1656-1673
Ivana Zagorac
Abstract
The aim of this study is to explore what actual guidance is provided by authoritative ethics documents regarding the recognition and protection of the vulnerable. The documents included in this analysis are the Belmont Report, the Declaration of Helsinki, The Council for International Organizations of Medical Sciences (CIOMS) Guidelines, and the UNESCO Universal Declaration on Bioethics and Human Rights, including its supplementary report on vulnerability. A qualitative analysis of these documents was conducted in light of three questions: what is vulnerability, who are the vulnerable, and how should the vulnerable be protected? The results show significant differences among the documents regarding the first two questions. None of the documents provides any guidance on the third question (how to protect the vulnerable). These results suggest a great discrepancy between the acknowledged importance of the concept of vulnerability and a general understanding of the scope, content, and practical implications of vulnerability.

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Brief Communications
Pneumococcal Vaccination in Low-Income Latinos: An Unexpected Trend in Oregon Community Health Centers
pp. 1733-1744
John Heintzman, Steffani R. Bailey, Stuart Cowburn, Eve Dexter, Joseph Carroll, Miguel Marino
Abstract:
Background. In cross-sectional studies, Latino and Spanish-speaking U.S. residents age 65 and over are less likely to receive pneumococcal vaccination than non-Hispanic Whites.
Methods. We performed a time-to-event, cohort analysis, in 23 Oregon community health centers of low-income patients who turned 65 in the study period (2009–2013; n = 1,248). The outcome measure was receipt of PPSV-23 in the study period by race / ethnicity, preferred language, and insurance status.
Results. Insured Latino patients were more likely to receive PPSV-23 than insured non-Hispanic Whites (HR = 2.05, p < .001). Uninsured Latino seniors showed no difference from insured non-Hispanic Whites in PPSV-23 receipt (HR = 1.26, p = .381) unless they averaged fewer than one clinic visit yearly (HR = 1.80, p = .001).
Conclusions. Low-income Latino seniors in Oregon community health centers were immunized against pneumococcus more frequently than insured non-Hispanic Whites, although this finding was mitigated in Latinos without insurance. This finding needs further research in order to reduce adult immunization disparities in the society at large.

Journal of Infectious Diseases
Volume 214 Issue 10 November 15, 2016
http://jid.oxfordjournals.org/content/current

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EDITORIAL COMMENTARIES
Challenges Remain for Influenza Vaccination of Children
J Infect Dis. (2016) 214 (10): 1470-1472 doi:10.1093/infdis/jiw384
Kathryn M. Edwards and Wendy A. Keitel
Extract
Over the past decades, multiple active surveillance and observational studies have demonstrated the major impact of influenza on children and underscored the need for effective vaccines [1–4]. Since 2009, annual influenza vaccination has been recommended for all children ≥6 months of age in the United States [5]. Extensive studies in children have been conducted over the years with both inactivated influenza vaccines (IIV) and live attenuated influenza vaccines (LAIV). Influenza hemagglutination inhibition (HAI) antibody responses are considered to be the gold standard for assessing IIV immunogenicity and serve as the basis for their licensure. Although achievement of HAI antibody titers of ≥40 (putative protective titer) was associated with a 50% reduction in the occurrence of influenza [6, 7], others have proposed that the protective HAI titer is much higher [8]. Furthermore, there can be variability in HAI assay results among laboratories [9]. Cell-mediated immune (CMI) responses have been less well characterized, and no CMI correlate of protection (COP) has been proposed.’

In this issue of The Journal of Infectious Diseases, Reber et al report detailed humoral and CMI responses in 50 children ages 9–14 years after receipt of the 2010–2011 seasonal IIV [10]. In the previous year, 38% of the participants had received influenza vaccine (10% received LAIV and 28% received IIV), and 32% had been immunized with monovalent 2009 pandemic influenza A(H1N1) vaccine. Which vaccine(s) the children had received previously was not noted in the article, and their impact on subsequent immune responses was not assessed because of small sample size. HAI antibody responses were assayed against influenza virus antigens included in both the 2009–2010 and 2010–2011 vaccines, as well as the …

Journal of Medical Ethics
November 2016, Volume 42, Issue 11
http://jme.bmj.com/content/current

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Brief report
Ethical issues and best practice in clinically based genomic research: Exeter Stakeholders Meeting Report
D Carrieri, C Bewshea, G Walker, T Ahmad, W Bowen, A Hall, S Kelly, on behalf of the 7th of October 2015 Exeter Stakeholders Meeting
J Med Ethics 2016;42:695-697 Published Online First: 27 September 2016 doi:10.1136/medethics-2016-103530
Abstract
Current guidelines on consenting individuals to participate in genomic research are diverse. This creates problems for participants and also for researchers, particularly for clinicians who provide both clinical care and research to their patients. A group of 14 stakeholders met on 7 October 2015 in Exeter to discuss the ethical issues and the best practice arising in clinically based genomic research, with particular emphasis on the issue of returning results to study participants/patients in light of research findings affecting research and clinical practices. The group was deliberately multidisciplinary to ensure that a diversity of views was represented. This report outlines the main ethical issues, areas of best practice and principles underlying ethical clinically based genomic research discussed during the meeting. The main point emerging from the discussion is that ethical principles, rather than being formulaic, should guide researchers/clinicians to identify who the main stakeholders are to consult with for a specific project and to incorporate their voices/views strategically throughout the lifecycle of each project. We believe that the mix of principles and practical guidelines outlined in this report can contribute to current debates on how to conduct ethical clinically based genomic research.

Journal of Medical Internet Research
Vol 18, No 11 (2016): November
http://www.jmir.org/2016/11

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Mobile Health (mhealth)
Can Mobile Phone Apps Influence People’s Health Behavior Change? An Evidence Review
J Med Internet Res 2016 (Nov 02); 18(11):e287
Jing Zhao, Becky Freeman, Mu Li
ABSTRACT
Background: Globally, mobile phones have achieved wide reach at an unprecedented rate, and mobile phone apps have become increasingly prevalent among users. The number of health-related apps that were published on the two leading platforms (iOS and Android) reached more than 100,000 in 2014. However, there is a lack of synthesized evidence regarding the effectiveness of mobile phone apps in changing people’s health-related behaviors. Objective: The aim was to examine the effectiveness of mobile phone apps in achieving health-related behavior change in a broader range of interventions and the quality of the reported studies. Methods: We conducted a comprehensive bibliographic search of articles on health behavior change using mobile phone apps in peer-reviewed journals published between January 1, 2010 and June 1, 2015. Databases searched included Medline, PreMedline, PsycINFO, Embase, Health Technology Assessment, Education Resource Information Center (ERIC), and Cumulative Index to Nursing and Allied Health Literature (CINAHL). Articles published in the Journal of Medical Internet Research during that same period were hand-searched on the journal’s website. Behavior change mechanisms were coded and analyzed. The quality of each included study was assessed by the Cochrane Risk of Bias Assessment Tool. Results: A total of 23 articles met the inclusion criteria, arranged under 11 themes according to their target behaviors. All studies were conducted in high-income countries. Of these, 17 studies reported statistically significant effects in the direction of targeted behavior change; 19 studies included in this analysis had a 65% or greater retention rate in the intervention group (range 60%-100%); 6 studies reported using behavior change theories with the theory of planned behavior being the most commonly used (in 3 studies). Self-monitoring was the most common behavior change technique applied (in 12 studies). The studies suggest that some features improve the effectiveness of apps, such as less time consumption, user-friendly design, real-time feedback, individualized elements, detailed information, and health professional involvement. All studies were assessed as having some risk of bias. Conclusions: Our results provide a snapshot of the current evidence of effectiveness for a range of health-related apps. Large sample, high-quality, adequately powered, randomized controlled trials are required. In light of the bias evident in the included studies, better reporting of health-related app interventions is also required. The widespread adoption of mobile phones highlights a significant opportunity to impact health behaviors globally, particularly in low- and middle-income countries.

Journal of Travel Medicine
Volume 24, Issue 1, July 2016
http://jtm.oxfordjournals.org/content/24/1

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Original Article
Pre-travel advice, attitudes and hepatitis A and B vaccination rates among travellers from seven countries
Anita E. Heywood, Hans Nothdurft, Dominique Tessier, Melissa Moodley, Lars Rombo, Cinzia Marano, Laurence De Moerlooze J Travel Med (2016) 24 (1): taw069 DOI: http://dx.doi.org/10.1093/jtm/taw069 First published online: 13 October 2016 (8 pages)
Abstract
Background: Knowledge about the travel-associated risks of hepatitis A and B, and the extent of pre-travel health-advice being sought may vary between countries.
Methods: An online survey was undertaken to assess the awareness, advice-seeking behaviour, rates of vaccination against hepatitis A and B and adherence rates in Australia, Finland, Germany, Norway, Sweden, the UK and Canada between August and October 2014. Individuals aged 18–65 years were screened for eligibility based on: travel to hepatitis A and B endemic countries within the past 3 years, awareness of hepatitis A, and/or combined hepatitis A&B vaccines; awareness of their self-reported vaccination status and if vaccinated, vaccination within the last 3 years. Awareness and receipt of the vaccines, sources of advice, reasons for non-vaccination, adherence to recommended doses and the value of immunization reminders were analysed.
Results: Of 27 386 screened travellers, 19 817 (72%) were aware of monovalent hepatitis A or combined A&B vaccines. Of these 13 857 (70%) had sought advice from a healthcare provider (HCP) regarding combined hepatitis A&B or monovalent hepatitis A vaccination, and 9328 (67%) were vaccinated. Of 5225 individuals eligible for the main survey (recently vaccinated = 3576; unvaccinated = 1649), 27% (841/3111) and 37% (174/465) of vaccinated travellers had adhered to the 3-dose combined hepatitis A&B or 2-dose monovalent hepatitis A vaccination schedules, respectively. Of travellers partially vaccinated against combined hepatitis A&B or hepatitis A, 84% and 61%, respectively, believed that they had received the recommended number of doses.
Conclusions: HCPs remain the main source of pre-travel health advice. The majority of travellers who received monovalent hepatitis A or combined hepatitis A&B vaccines did not complete the recommended course. These findings highlight the need for further training of HCPs and the provision of reminder services to improve traveller awareness and adherence to vaccination schedules

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Original Article
Refusal of recommended travel-related vaccines among U.S. international travellers in Global TravEpiNet
Sara M. Lammert, Sowmya R. Rao, Emily S. Jentes, Jessica K. Fairley, Stefanie Erskine, Allison T. Walker, Stefan H. Hagmann, Mark J. Sotir, Edward T. Ryan, Regina C. LaRocque J Travel Med (2016) 24 (1): taw075 DOI: http://dx.doi.org/10.1093/jtm/taw075 First published online: 30 October 2016 (7 pages)
Abstract
Background: International travellers are at risk of travel-related, vaccine-preventable diseases. More data are needed on the proportion of travellers who refuse vaccines during a pre-travel health consultation and their reasons for refusing vaccines.
Methods: We analyzed data on travellers seen for a pre-travel health consultation from July 2012 through June 2014 in the Global TravEpiNet (GTEN) consortium. Providers were required to indicate one of three reasons for a traveller refusing a recommended vaccine: (1) cost concerns, (2) safety concerns or (3) not concerned with the illness. We calculated refusal rates among travellers eligible for each vaccine based on CDC recommendations current at the time of travel. We used multivariable logistic regression models to examine the effect of individual variables on the likelihood of accepting all recommended vaccines.
Results: Of 24 478 travellers, 23 768 (97%) were eligible for at least one vaccine. Travellers were most frequently eligible for typhoid (N = 20 092), hepatitis A (N = 12 990) and influenza vaccines (N = 10 539). Of 23 768 eligible travellers, 6573 (25%) refused one or more recommended vaccine(s). Of those eligible, more than one-third refused the following vaccines: meningococcal: 2232 (44%) of 5029; rabies: 1155 (44%) of 2650; Japanese encephalitis: 761 (41%) of 1846; and influenza: 3527 (33%) of 10 539. The most common reason for declining vaccines was that the traveller was not concerned about the illness. In multivariable analysis, travellers visiting friends and relatives (VFR) in low or medium human development countries were less likely to accept all recommended vaccines, compared with non-VFR travellers (OR = 0.74 (0.59–0.95)).
Conclusions: Travellers who sought pre-travel health care refused recommended vaccines at varying rates. A lack of concern about the associated illness was the most commonly cited reason for all refused vaccines. Our data suggest more effective education about disease risk is needed for international travellers, even those who seek pre-travel advice.

The Lancet
Nov 05, 2016 Volume 388 Number 10057 p2209-2322 e12
http://www.thelancet.com/journals/lancet/issue/current

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Editorial
After Bolam: what’s the future for patient consent?
The Lancet
Published: 05 November 2016
“Patients are now widely regarded as persons holding rights, rather than as the passive recipients of the care of the medical profession”, declared the UK Supreme Court in the case of Montgomery vs Lanarkshire Health Board in 2015, affirming the patient as a subject and not simply the object of medical care. Before Montgomery, whether doctors reasonably communicated risks to patients about potential procedures was judged by reference to a responsible body of medical opinion (Bolam test), in line with the paternalistic model of medicine. Since Montgomery, what makes a risk material for a doctor to tell their patient about are the circumstances, views, and values of the individual patient, rather than the opinion of the medical profession.

In response to this renewed emphasis on patients’ rights to self-determination, the Royal College of Surgeons has released new guidance to help surgeons and other health-care professionals to obtain and document consent. Recognising that it is not enough to simply substitute expert opinion with an exhaustive list of potential risks and benefits, the guidance advocates for “supported decision-making”, with a focus on tailoring discussions to individual patients.

Considerable practical challenges loom large, not least of which is time. The guidance states that to determine the content of discussions around risk, doctors should take time to get to know their patients. These discussions need to take place long enough before planned interventions so patients have enough time to reflect, and in particularly complex or potentially life changing scenarios might need to take place over several sessions.

To deal with the new time pressures that this approach will involve, the guidance recommends surgeons raise the issue with their hospital management. But surely, to enable real patient-centred decision making to take root, we must do more than simply tell already time-pressed doctors to find yet more time. Such changes will require cultural and administrative reform at the institutional level. If we want to support patient choice and autonomy, then we must empower our medical professionals with the resources they need to make it happen.

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Series
Maternal Health
Drivers of maternity care in high-income countries: can health systems support woman-centred care?
Dorothy Shaw, Jeanne-Marie Guise, Neel Shah, Kristina Gemzell-Danielsson, KS Joseph, Barbara Levy, Fontayne Wong, Susannah Woodd, Elliott K Main

Maternal Health
Next generation maternal health: external shocks and health-system innovations
Margaret E Kruk, Stephanie Kujawski, Cheryl A Moyer, Richard M Adanu, Kaosar Afsana, Jessica Cohen, Amanda Glassman, Alain Labrique, K Srinath Reddy, Gavin Yamey

Maternal Health
Quality maternity care for every woman, everywhere: a call to action
Marjorie Koblinsky, Cheryl A Moyer, Clara Calvert, James Campbell, Oona M R Campbell, Andrea B Feigl, Wendy J Graham, Laurel Hatt, Steve Hodgins, Zoe Matthews, Lori McDougall, Allisyn C Moran, Allyala K Nandakumar, Ana Langer
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Articles
Feasibility of achieving the 2025 WHO global tuberculosis targets in South Africa, China, and India: a combined analysis of 11 mathematical models
Rein M G J Houben, Nicolas A Menzies, Tom Sumner, Grace H Huynh, Nimalan Arinaminpathy, Jeremy D Goldhaber-Fiebert, Hsien-Ho Lin, Chieh-Yin Wu, Sandip Mandal, Surabhi Pandey, Sze-chuan Suen, Eran Bendavid, Andrew S Azman, David W Dowdy, Nicolas Bacaër, Allison S Rhines, Marcus W Feldman, Andreas Handel, Christopher C Whalen, Stewart T Chang, Bradley G Wagner, Philip A Eckhoff, James M Trauer, Justin T Denholm, Emma S McBryde, Ted Cohen, Joshua A Salomon, Carel Pretorius, Marek Lalli, Jeffrey W Eaton, Delia Boccia, Mehran Hosseini, Gabriela B Gomez, Suvanand Sahu, Colleen Daniels, Lucica Ditiu, Daniel P Chin, Lixia Wang, Vineet K Chadha, Kiran Rade, Puneet Dewan, Piotr Hippner, Salome Charalambous, Alison D Grant, Gavin Churchyard, Yogan Pillay, L David Mametja, Michael E Kimerling, Anna Vassall, Richard G White

Cost-effectiveness and resource implications of aggressive action on tuberculosis in China, India, and South Africa: a combined analysis of nine models
Nicolas A Menzies, Gabriela B Gomez, Fiammetta Bozzani, Susmita Chatterjee, Nicola Foster, Ines Garcia Baena, Yoko V Laurence, Sun Qiang, Andrew Siroka, Sedona Sweeney, Stéphane Verguet, Nimalan Arinaminpathy, Andrew S Azman, Eran Bendavid, Stewart T Chang, Ted Cohen, Justin T Denholm, David W Dowdy, Philip A Eckhoff, Jeremy D Goldhaber-Fiebert, Andreas Handel, Grace H Huynh, Marek Lalli, Hsien-Ho Lin, Sandip Mandal, Emma S McBryde, Surabhi Pandey, Joshua A Salomon, Sze-chuan Suen, Tom Sumner, James M Trauer, Bradley G Wagner, Christopher C Whalen, Chieh-Yin Wu, Delia Boccia, Vineet K Chadha, Salome Charalambous, Daniel P Chin, Gavin Churchyard, Colleen Daniels, Puneet Dewan, Lucica Ditiu, Jeffrey W Eaton, Alison D Grant, Piotr Hippner, Mehran Hosseini, David Mametja, Carel Pretorius, Yogan Pillay, Kiran Rade, Suvanand Sahu, Lixia Wang, Rein M G J Houben, Michael E Kimerling, Richard G White, Anna Vassall

Quality of basic maternal care functions in health facilities of five African countries: an analysis of national health system surveys
Margaret E Kruk, Hannah H Leslie, Stéphane Verguet, Godfrey M Mbaruku, Richard M K Adanu, Ana Langer

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Nov 2016 Volume 4 Number 11 e761-e871
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Effectiveness of one dose of oral cholera vaccine in response to an outbreak: a case-cohort study
Andrew S Azman, Lucy A Parker, John Rumunu, Fisseha Tadesse, Francesco Grandesso, Lul L Deng, Richard Laku Lino, Bior K Bior, Michael Lasuba, Anne-Laure Page, Lameck Ontweka, Augusto E Llosa, Sandra Cohuet, Lorenzo Pezzoli, Dossou Vincent Sodjinou, Abdinasir Abubakar, Amanda K Debes, Allan M Mpairwe, Joseph F Wamala, Christine Jamet, Justin Lessler, David A Sack, Marie-Laure Quilici, Iza Ciglenecki, Francisco J Luquero
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Summary
Background
Oral cholera vaccines represent a new effective tool to fight cholera and are licensed as two-dose regimens with 2–4 weeks between doses. Evidence from previous studies suggests that a single dose of oral cholera vaccine might provide substantial direct protection against cholera. During a cholera outbreak in May, 2015, in Juba, South Sudan, the Ministry of Health, Médecins Sans Frontières, and partners engaged in the first field deployment of a single dose of oral cholera vaccine to enhance the outbreak response. We did a vaccine effectiveness study in conjunction with this large public health intervention.
Methods
We did a case-cohort study, combining information on the vaccination status and disease outcomes from a random cohort recruited from throughout the city of Juba with that from all the cases detected. Eligible cases were those aged 1 year or older on the first day of the vaccination campaign who sought care for diarrhoea at all three cholera treatment centres and seven rehydration posts throughout Juba. Confirmed cases were suspected cases who tested positive to PCR for Vibrio cholerae O1. We estimated the short-term protection (direct and indirect) conferred by one dose of cholera vaccine (Shanchol, Shantha Biotechnics, Hyderabad, India).
Findings
Between Aug 9, 2015, and Sept 29, 2015, we enrolled 87 individuals with suspected cholera, and an 898-person cohort from throughout Juba. Of the 87 individuals with suspected cholera, 34 were classified as cholera positive, 52 as cholera negative, and one had indeterminate results. Of the 858 cohort members who completed a follow-up visit, none developed clinical cholera during follow-up. The unadjusted single-dose vaccine effectiveness was 80·2% (95% CI 61·5–100·0) and after adjusting for potential confounders was 87·3% (70·2–100·0).
Interpretation
One dose of Shanchol was effective in preventing medically attended cholera in this study. These results support the use of a single-dose strategy in outbreaks in similar epidemiological settings.
Funding
Médecins Sans Frontières.

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Comment
2016: the beginning of the end of rabies?
Bernadette Abela-Ridder, Lea Knopf, Stephen Martin, Louise Taylor, Gregorio Torres, Katinka De BaloghPublished: 27 September 2016
Open Access
DOI: http://dx.doi.org/10.1016/S2214-109X(16)30245-5
Sept 28 is the tenth annual World Rabies Day. It is a date that commemorates the anniversary of the 1895 death of Louis Pasteur, who developed the first human rabies vaccine. Modern effective vaccines, combined with other interventions, the necessary political will, and community awareness make the disease 100% preventable. Yet, an estimated 59 000 people still die from the disease every year.1 World Rabies Day is thus an uncomfortable reminder for the global health community of the ongoing neglect of this disease. The theme for 2016 is “Educate. Vaccinate. Eliminate”, a slogan that emphasises the pillars of rabies prevention and the vision to end human rabies deaths.

Rabies has no cure, and by the time of clinical onset it is invariably fatal. More than 95% of deaths occur in Africa and Asia, 80% of which are in people living in rural, underserved populations, most of whom are children.2 Community awareness about the power of preventing dog bites and of life-saving human post-exposure prophylaxis is key. 95–99% of human rabies cases are from dog bites, meaning that canine vaccination programmes are crucial if the transmission cycle is to be broken.3 Cross-sectoral solutions from stakeholders in both human and animal health systems are essential for the greatest benefits to be realised.

In December, 2015, WHO, the World Organisation for Animal Health (OIE), the Food and Agriculture Organization (FAO), and the Global Alliance for Rabies Control (GARC) endorsed a global framework to eliminate human deaths from dog-mediated disease by 2030.4 The decision was reinforced by the OIE in May this year.5 A business plan by the key organisations to quantify the costs of reaching zero rabies deaths across the world is under development.
Under our One Health Initiative, WHO, OIE, FAO, and GARC are working on concurrent campaigns to eliminate canine rabies through the vaccination of dogs, the treatment of all potential human rabies exposures with wound washing and post-exposure prophylaxis, and the improvement of education about rabies prevention where it is needed most. By prioritising rabies, our partnership also intends to leverage the global political will needed to eliminate the disease. Reaching zero rabies deaths would contribute towards fulfilling the Sustainable Development Goals, particularly goal 3·3, which targets an end to epidemics of neglected tropical diseases. The goal is ambitious but possible, as evidenced by the progress made in rabies campaigns around the world.4, 6 Such examples of successful multisectoral approaches serve as both a reference and motivation for future campaigns.

Countries will need improved access to high quality and optimally priced dog and human vaccines, as well as to rabies immunoglobulins. Insufficient national forecasting at present means that vaccine requests from countries to manufacturers can be left unfulfilled because of long lead times in production. In such instances, countries are forced to turn to suppliers without quality-assured vaccine. Improvements in supply will help to overcome these difficulties. To match the OIE-led dog rabies vaccine bank,7 WHO is therefore creating a human rabies vaccine stockpile, planned to be operation by the end of next year.

The opportunity of a potential GAVI investment into human rabies vaccine in 2018 has rallied partners and countries to build the evidence base to help inform the investment decision process. Investment from GAVI would be a game changer and substantially increase awareness about this disease and stimulate the necessary political will. With dog vaccination campaigns increasing in reach, the possibility of interrupting rabies transmission will become more tangible. This goal is helped by the availability of online resources such as the Blueprint for Rabies Prevention and Control,8 which offers practical information, expert advice, and case studies to support countries that want to eliminate rabies. FAO and GARC are assisting countries with practical tools for developing their rabies control strategies.9

World Rabies Day increases the awareness about this neglected and horrific disease. It will also make people aware of the realistic ambition of interrupting transmission in dogs and, in turn, the reality of one day eliminating dog-mediated rabies in people. We have all the tools to end this neglected zoonotic disease—what is required is a coordinated effort from all stakeholders at local, national, regional, and global levels to realise the vision of zero human deaths from dog-mediated rabies by 2030.
We declare no competing interests.

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Comment
New strategies for cholera control
Louise C Ivers
Open Access
DOI: http://dx.doi.org/10.1016/S2214-109X(16)30257-1
Cholera remains a serious global public health problem, disproportionately affecting poor individuals, causing illness and death for thousands of people each year. Cholera cases are on the rise, with 47% more cases reported to WHO in 2014 than in 2013.1 Innovative approaches to control the disease are urgently needed, and the study by Andrew Azman and colleagues in The Lancet Global Health2 contributes to growing evidence of the important part that oral cholera vaccine strategies have to play in this regard.

Cholera can have devastating consequences, especially in epidemic settings. Azman and colleagues’ study assesses the effectiveness of a single dose of bivalent whole-cell oral cholera vaccine on epidemic cholera in Juba, South Sudan. Typically, this oral cholera vaccine is given in two doses 14 days apart, and studies have shown its efficacy and effectiveness with this dosing schedule.3, 4, 5 However, the use of one dose of vaccine for an outbreak response would reduce costs and double the number of people that could be served, which is especially important considering the global shortage of vaccine that is expected to last for the next few years. Faced with an emerging epidemic of cholera in South Sudan, limited vaccine supply, and some evidence that a single dose of vaccine might give sufficient protection to thwart an epidemic, local public health officials and the non-governmental organisation Médecins Sans Frontières decided to proceed with a single-dose public health oral cholera vaccine campaign in Juba. Public health activities and a research study took place hand in hand.

The study found that the adjusted single-dose vaccine effectiveness was 87·3% (70·2–100·0) for reducing medically attended cholera for up to 2 months. This adds to existing evidence including a randomised study of a single-dose regimen from Bangladesh that found 40% direct effectiveness for reducing all cholera, and 63% direct effectiveness for reducing severely dehydrating cholera at 6 months.6 By contrast, Azman and colleagues used a case-cohort study design in an effort to measure both the direct and indirect protection offered by the vaccine (ie, herd protection), and measured effectiveness in a shorter period. This design makes the study particularly interesting and pertinent to dilemmas in the approach to cholera outbreak control. Debate continues between water, sanitation, and hygiene (WASH) purists, who believe that investments in cholera vaccination campaigns are a distraction from the goal of universal access to water and sanitation, and a more progressive public health community that advocates for a combined approach to cholera control including vaccination and evidence-based WASH interventions. In this context, a study that helps us to measure the herd protection of an oral cholera vaccine strategy is key to understanding the population-level effect and therefore the public health usefulness of oral cholera vaccine (beyond individual protection).

This study is also an excellent example of research in action. Resolving, as the researchers did, to be scientific in the context of rapid decision making and the often chaotic environment of an epidemic response is not straightforward. The context of the study means that the results are particularly useful for understanding the intervention as it might happen in the real world, outside of a formal research setting. More studies like this are needed for us to understand the right approaches for use of cholera vaccine.

Armed with the results of this study, public health officials and implementing organisations in areas where cholera occurs with some frequency should consider the option of using a single-dose vaccination campaign as part of an emergency outbreak response. This should be coupled with good monitoring and evaluation activities to continue to add to our knowledge on the issue.

Importantly, the usefulness of single-dose oral cholera vaccine in cholera-naive populations cannot be presumed on the basis of this study, and the authors acknowledge this fact. The impetus now exists, though, to study the approach in cholera-naive populations. Further questions also emerge that remain to be answered. How long does the protective effect of a single dose of this oral cholera vaccine last in cholera-experienced populations such as Juba? Does a single-dose pre-emptive campaign prevent epidemic outbreaks in susceptible groups such as displaced people? How well protected are subgroups such as young children? What complementary emergency WASH activities at household or community level should be combined with the single-dose approach to ensure durable control of cholera? Would a booster dose sometime after the initial outbreak response contribute to longer-term cholera control? To answer these pragmatic questions, we require continued investment in the global stockpile of cholera vaccine, forward-thinking health officials, and continued assessment of the vaccine’s use.

When the right to universal access to safe water and sanitation is realised, the world will be a better, healthier place—this is not doubted. However, if Haiti is any example, the struggle to execute on water and sanitation ideals is real. Those challenges are related both to the availability of funding, and the ability to deliver WASH interventions in sufficient quantity and quality to interrupt transmission of cholera as a matter of urgency. While the 2016 rainy season brings a surge in cholera cases in Haiti, this study offers one potential vaccination strategy to consider in outbreak responses going forward. We can only wonder what might have happened in Haiti if Azman and colleagues’ research had pre-dated the Haitian cholera outbreak—the largest ongoing cholera outbreak in the world, with more than 10 000 deaths so far.7, 8 Perhaps officials, public health experts, and vaccine manufacturers would have done innovative work together in the early days, and helped to avert a disaster.
I declare no competing interests.

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Comment
Putting numbers on the End TB Strategy—an impossible dream?
Olivia Oxlade, Dick Menzies
In 2015, WHO announced a plan to end tuberculosis by 2035 (their End TB Strategy) and set ambitious intermediate targets to reduce tuberculosis incidence by 50% and mortality by 75% by 2025.1 In The Lancet Global Health, two related papers by Rein Houben2 and Nicolas Menzies3 and their colleagues describe the results of a unique international collaboration between 11 different tuberculosis modelling groups, and public health officials from national tuberculosis programmes. They assessed the feasibility, costs, and epidemiological outcomes of country-specific interventions in India, China, and South Africa, and determined that these 10-year targets could be achievable only in South Africa with a combination of continuous isoniazid preventive therapy for individuals on antiretroviral therapy, expanded facility-based screening for symptoms of tuberculosis at health centres, and improved tuberculosis care. In China and India, important reductions could be achieved, but they fell short of the WHO targets.2 All models that considered costs projected the need for massive and sustained increases in government health spending, to more than three times current levels, although most judged that these interventions could be considered cost-effective. Interestingly, all predicted that patients’ costs would be substantially reduced with most interventions.

This project showed the potential value of two innovative collaborations toward achieving global tuberculosis control. First, this investigation was accomplished simultaneously by several different modelling groups and investigators from a total of ten different countries—in itself a major achievement! The modelling groups worked independently, using their preferred modelling approaches, but with similar parameters and assumptions. Readers will usually want to know if the findings are unchanged when key assumptions are varied in sensitivity analyses, and if results are similar in studies published separately by different groups. We think readers should be sceptical, given the grand scale of assumptions made by the investigators of these two studies. In these Articles,2, 3 results from 11 models are presented together—a sort of uber-sensitivity analysis. The results are quite consistent and provide a coherent message, which we find reassuring. The second innovation was the partnership of these modelling teams with personnel from national tuberculosis programmes, who were responsible for the selection of interventions and helping to estimate their expected effects. This should make the results more applicable and realistic for the countries selected, while also enhancing knowledge translation.

For most health-care professionals, infectious-disease modelling is something of a black box. One can see the input assumptions (ie, what goes in) and the outputs (ie, what comes out), but what happens in between seems close to magic. Given their complexity, to understand any one of the models used in these studies is difficult; to understand the strengths and limitations of all 11 models might be beyond the capacity of most (if not all) readers. So, we must therefore accept a little magic, and rely on a careful review of what goes in, to decide if what comes out is credible. And the assumed inputs are a major limitation of these studies, for although the involvement of national tuberculosis programme officials in selecting interventions and targets was a strength, the actual population-level effect, and costs, of the interventions are unknown.
For example, active case finding through chest radiography was the cornerstone of tuberculosis control for decades in high-income countries,4 and interest in active case finding has been revived recently.5 However, scant published evidence of its effect on outcomes, transmission, or its cost-effectiveness is available,6 and therefore mass screening is not recommended by WHO.6 The true costs of these interventions, when applied at national scale, are also unknown.
Estimations of costs extrapolated from small projects might not be accurate for national-level interventions. For example, the finding that scaling up use of the Xpert RIF/MTB assay might simply reflect better information, since the actual costs for national expansion in South Africa have been carefully measured,7 by contrast with the estimated costs for the other interventions. Even feasibility is uncertain, particularly for population-level interventions such as mass chest radiography and isoniazid preventive therapy in South Africa, or partnerships with the rapidly evolving private sector in India.

Overall, however, we feel the investigators used all currently available information, and did a careful and thorough analysis of innovative approaches for global tuberculosis control. Although further research is required to better understand the epidemiological effects and the enormous health-system expenditures that will be needed to implement these interventions on a large scale, this requirement should not obscure two important messages from these studies. First, the consistent finding of substantial savings for patients is a reminder that reducing the tuberculosis burden is all about reducing the burden on patients. And second, that perhaps the goal of ending tuberculosis is not such an impossible dream.

We declare no competing interests.

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Nov 2016 Volume 4 Number 11 e761-e871
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Editorial
Disease, conflict, and the challenge of elimination in the Americas
The Lancet Global Health
Good news from the Americas illuminated the global health scene in September. As the Ministers of Health from the western hemisphere gathered in Washington, DC, USA, for PAHO’s 55th Directing Council, a series of announcements confirmed the New World’s role as a pioneer of sorts in disease prevention and control. Repeating the pattern that began with smallpox in 1971, polio in 1994, and rubella in 2015, the region of the Americas was declared the first in the world to be free of endemic measles on Sept 27. This feat was achieved through 14 years of unrelenting efforts to reach the farthest pockets of unvaccinated populations and document the end of transmission of a virus that still caused over 110 000 deaths worldwide in 2014, mostly in children under 5 years of age. It is a laudable achievement and a testament to the success of yearly national immunisation campaigns and efforts to educate the populations of the region on the innocuity and efficacy of vaccines. The confidence in this essential global health tool in the countries of the Americas is highlighted in a recent article published in EBioMedicine, which shows that countries of the region reported low levels of scepticism on the dimensions surveyed, including the importance of vaccination and the safety and effectiveness of vaccines. The fact that other countries or regions do not show the same confidence, and the related impact on vaccination coverage, underscore the fragility of the elimination status and the importance of persistently promoting the value of vaccines at the global level.

Achievements such as these educate us on the feasibility of reaching elimination goals. They perhaps also provide additional thrust for efforts towards harder to reach, more uncertain milestones. The Ministers of Health concluded their gathering at PAHO with a set of agreements on the prevention, control, and elimination of diseases in the Americas, including a plan of action for malaria elimination with ambitious goals for the next 4 years. Elimination, if reached, would be a first step in a major global health quest: the eradication of malaria, a disease that currently threatens half of the world’s population, and in 2015 killed almost 500 000 people worldwide. Perhaps the Americas can show us once again how it is done.

While the region celebrated the elimination of one scourge, another—namely the devastating 52-year civil war in Colombia—was also on the brink of history. Over the years, and within the confines of Colombia’s borders, the conflict has touched on many issues that are now at the forefront of global health and development. Rapid urbanisation, fuelled in large part by the displacement of millions fleeing violence, led to the creation of slums and all their related health issues. Those who stayed in conflict zones, many of them of indigenous and African descent, were left in a health services vacuum and now suffer the consequences, on maternal and child health in particular, and in terms of inequalities. A historic peace agreement between the Colombian Government and the Revolutionary Armed Forces of Colombia (FARC) was signed in Cartagena on Sept 26. Yet on Oct 2, the Colombian people narrowly rejected this agreement in a national referendum, sending back to the negotiation table a document considered by some as too lenient towards the FARC.

So the promise of stronger social cohesion and human rights is not to be delivered just yet in Colombia, but the implications of the peace process and their potential impact on health must not be overlooked. Nobody denies the radical impact peace could have on these populations, and the now defunct agreement, negotiated with the active participation of women’s and minority groups in a process deemed by some as a model, had the consideration of health and inequalities threaded throughout its terms. So wherever the process goes in Colombia from this point forward, that experience and the point reached on the way to peace remain a much needed sign of hope in a world where violence is on the rise. War and violence, or the absence thereof, are now integral building blocks of the development agenda since their inclusion in SDG16. In Colombia and elsewhere, peace—just like health—is a delicate balancing act that requires constant work, but we must remain convinced that it is attainable.

The Lancet Infectious Diseases
Nov 2016 Volume 16 Number 11 p1203-1304 e241-e275
http://www.thelancet.com/journals/laninf/issue/current

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Articles
Potential for Zika virus introduction and transmission in resource-limited countries in Africa and the Asia-Pacific region: a modelling study
Isaac I Bogoch, Oliver J Brady, Moritz U G Kraemer, Matthew German, Maria I Creatore, Shannon Brent, Alexander G Watts, Simon I Hay, Manisha A Kulkarni, John S Brownstein, Kamran Khan

The number of privately treated tuberculosis cases in India: an estimation from drug sales data
Nimalan Arinaminpathy, Deepak Batra, Sunil Khaparde, Thongsuanmung Vualnam, Nilesh Maheshwari, Lokesh Sharma, Sreenivas A Nair, Puneet Dewan

Use of standardised patients to assess antibiotic dispensing for tuberculosis by pharmacies in urban India: a cross-sectional study
Srinath Satyanarayana, Ada Kwan, Benjamin Daniels, Ramnath Subbaraman, Andrew McDowell, Sofi Bergkvist, Ranendra K Das, Veena Das, Jishnu Das, Madhukar Pai
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The cascade of care in diagnosis and treatment of latent tuberculosis infection: a systematic review and meta-analysis
Hannah Alsdurf, Philip C Hill, Alberto Matteelli, Haileyesus Getahun, Dick Menzies

Personal View
Affordable HIV drug-resistance testing for monitoring of antiretroviral therapy in sub-Saharan Africa
Seth C Inzaule, Pascale Ondoa, Trevor Peter, Peter N Mugyenyi, Wendy S Stevens, Tobias F Rinke de Wit, Raph L Hamers

Medical Decision Making (MDM)
November 2016; 36 (8)
http://mdm.sagepub.com/content/current

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Original Articles
Quantitative Framework for Retrospective Assessment of Interim Decisions in Clinical Trials
Roger Stanev
Med Decis Making November 2016 36: 999-1010, first published on June 27, 2016 doi:10.1177/0272989X16655346
Abstract
This article presents a quantitative way of modeling the interim decisions of clinical trials. While statistical approaches tend to focus on the epistemic aspects of statistical monitoring rules, often overlooking ethical considerations, ethical approaches tend to neglect the key epistemic dimension. The proposal is a second-order decision-analytic framework. The framework provides means for retrospective assessment of interim decisions based on a clear and consistent set of criteria that combines both ethical and epistemic considerations. The framework is broadly Bayesian and addresses a fundamental question behind many concerns about clinical trials: What does it take for an interim decision (e.g., whether to stop the trial or continue) to be a good decision? Simulations illustrating the modeling of interim decisions counterfactually are provided.

New England Journal of Medicine
November 3, 2016 Vol. 375 No. 18
http://www.nejm.org/toc/nejm/medical-journal

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Original Article
Benefits and Risks of Antiretroviral Therapy for Perinatal HIV Prevention
Mary G. Fowler, M.D., M.P.H., Min Qin, Ph.D., Susan A. Fiscus, Ph.D., Judith S. Currier, M.D., Patricia M. Flynn, M.D., Tsungai Chipato, M.B., Ch.B., M.C.E., James McIntyre, F.R.C.O.G., Devasena Gnanashanmugam, M.D., George K. Siberry, M.D., M.P.H., Anne S. Coletti, M.S., Taha E. Taha, M.D., Ph.D., Karin L. Klingman, M.D., Francis E. Martinson, M.B., Ch.B., Ph.D., Maxensia Owor, M.B., Ch.B., M.P.H., Avy Violari, M.D., Dhayendre Moodley, Ph.D., Gerhard B. Theron, M.D., Ramesh Bhosale, M.D., Raziya Bobat, M.B., Ch.B., M.D., Benjamin H. Chi, M.D., Renate Strehlau, M.B., Ch.B., Pendo Mlay, M.D., Amy J. Loftis, B.S., Renee Browning, R.N., M.S.N., Terence Fenton, Ed.D., Lynette Purdue, Pharm.D., Michael Basar, B.A., David E. Shapiro, Ph.D., and Lynne M. Mofenson, M.D., for the IMPAACT 1077BF/1077FF PROMISE Study Team*
N Engl J Med 2016; 375:1726-1737 November 3, 2016 DOI: 10.1056/NEJMoa1511691
Abstract
Background
Randomized-trial data on the risks and benefits of antiretroviral therapy (ART) as compared with zidovudine and single-dose nevirapine to prevent transmission of the human immunodeficiency virus (HIV) in HIV-infected pregnant women with high CD4 counts are lacking.
Full Text of Background…
Methods
We randomly assigned HIV-infected women at 14 or more weeks of gestation with CD4 counts of at least 350 cells per cubic millimeter to zidovudine and single-dose nevirapine plus a 1-to-2-week postpartum “tail” of tenofovir and emtricitabine (zidovudine alone); zidovudine, lamivudine, and lopinavir–ritonavir (zidovudine-based ART); or tenofovir, emtricitabine, and lopinavir–ritonavir (tenofovir-based ART). The primary outcomes were HIV transmission at 1 week of age in the infant and maternal and infant safety.
Full Text of Methods…
Results
The median CD4 count was 530 cells per cubic millimeter among 3490 primarily black African HIV-infected women enrolled at a median of 26 weeks of gestation (interquartile range, 21 to 30). The rate of transmission was significantly lower with ART than with zidovudine alone (0.5% in the combined ART groups vs. 1.8%; difference, −1.3 percentage points; repeated confidence interval, −2.1 to −0.4). However, the rate of maternal grade 2 to 4 adverse events was significantly higher with zidovudine-based ART than with zidovudine alone (21.1% vs. 17.3%, P=0.008), and the rate of grade 2 to 4 abnormal blood chemical values was higher with tenofovir-based ART than with zidovudine alone (2.9% vs. 0.8%, P=0.03). Adverse events did not differ significantly between the ART groups (P>0.99). A birth weight of less than 2500 g was more frequent with zidovudine-based ART than with zidovudine alone (23.0% vs. 12.0%, P<0.001) and was more frequent with tenofovir-based ART than with zidovudine alone (16.9% vs. 8.9%, P=0.004); preterm delivery before 37 weeks was more frequent with zidovudine-based ART than with zidovudine alone (20.5% vs. 13.1%, P<0.001). Tenofovir-based ART was associated with higher rates than zidovudine-based ART of very preterm delivery before 34 weeks (6.0% vs. 2.6%, P=0.04) and early infant death (4.4% vs. 0.6%, P=0.001), but there were no significant differences between tenofovir-based ART and zidovudine alone (P=0.10 and P=0.43). The rate of HIV-free survival was highest among infants whose mothers received zidovudine-based ART.
Full Text of Results…
Conclusions
Antenatal ART resulted in significantly lower rates of early HIV transmission than zidovudine alone but a higher risk of adverse maternal and neonatal outcomes. (Funded by the National Institutes of Health; PROMISE ClinicalTrials.gov numbers, NCT01061151 and NCT01253538.)

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Editorial
First-in-Human Clinical Trials — What We Can Learn from Tragic Failures
Sergio Bonini, M.D., and Guido Rasi, M.D.
N Engl J Med 2016; 375:1788-1789 November 3, 2016 DOI: 10.1056/NEJMe1609006
This article has no abstract; the first 100 words appear below.
On January 10, 2016, a healthy volunteer who had received 50 mg per day of a fatty acid amide hydrolase (FAAH) inhibitor for 5 days as part of a first-in-human phase 1 clinical trial was admitted to Rennes University Hospital with neurologic and gait disturbances. After a dramatic worsening of neurologic symptoms, the participant died on January 17. Another 5 participants who received the same drug dose for 6 days were subsequently admitted to the hospital, 4 of them with similar neurologic symptoms. In this issue of the Journal, Kerbrat et al.1 report the clinical and imaging findings of the…

Pediatrics
November 2016, VOLUME 138 / ISSUE
http://pediatrics.aappublications.org/content/138/5?current-issue=y
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Articles
School-Located Influenza Vaccinations: A Randomized Trial
Peter G. Szilagyi, Stanley Schaffer, Cynthia M. Rand, Phyllis Vincelli, Ashley Eagan, Nicolas P.N. Goldstein, A. Dirk Hightower, Mary Younge, Aaron Blumkin, Christina S. Albertin, Byung-Kwang Yoo, Sharon G. Humiston
Pediatrics Nov 2016, 138 (5) e20161746; DOI: 10.1542/peds.2016-1746
Abstract
OBJECTIVE: Assess impact of offering school-located influenza vaccination (SLIV) clinics using both Web-based and paper consent upon overall influenza vaccination rates among elementary school children.
METHODS: We conducted a cluster-randomized trial (stratified by suburban/urban districts) in upstate New York in 2014–2015. We randomized 44 elementary schools, selected similar pairs of schools within districts, and allocated schools to SLIV versus usual care (control). Parents of children at SLIV schools were sent information and vaccination consent forms via e-mail, backpack fliers, or both (depending on school preferences) regarding school vaccine clinics. Health department nurses conducted vaccine clinics and billed insurers. For all children registered at SLIV/control schools, we compared receipt of influenza vaccination anywhere (primary outcome).
RESULTS: The 44 schools served 19 776 eligible children in 2014–2015. Children in SLIV schools had higher influenza vaccination rates than children in control schools county-wide (54.1% vs 47.4%, P < .001) and in suburban (61.9% vs 53.6%, P < .001) and urban schools (43.9% vs 39.2%; P < .001). Multivariate analyses (controlling for age, grade, vaccination in previous season) confirmed bivariate findings. Among parents who consented for SLIV, nearly half of those notified by backpack fliers and four-fifths of those notified by e-mail consented online. In suburban districts, SLIV did not substitute for primary care influenza vaccination. In urban schools, some substitution occurred. CONCLUSIONS: SLIV raised seasonal influenza vaccination rates county-wide and in both suburban and urban settings. SLIV did not substitute for primary care vaccinations in suburban settings where pediatricians often preorder influenza vaccine but did substitute somewhat in urban settings. Articles Complementary and Alternative Medicine and Influenza Vaccine Uptake in US Children William K. Bleser, Bilikisu Reni Elewonibi, Patricia Y. Miranda, Rhonda BeLue Pediatrics Nov 2016, 138 (5) e20154664; DOI: 10.1542/peds.2015-4664 Quality Reports Achieving High Adolescent HPV Vaccination Coverage Anna-Lisa M. Farmar, Kathryn Love-Osborne, Katherine Chichester, Kristin Breslin, Kristi Bronkan, Simon J. Hambidge Pediatrics Nov 2016, 138 (5) e20152653; DOI: 10.1542/peds.2015-2653 Abstract BACKGROUND AND OBJECTIVE: Despite national recommendations for adolescent human papillomavirus (HPV) vaccination, rates have lagged behind those of other adolescent vaccines. We implemented interventions and examined rates of vaccination coverage in a large, urban, safety net health care system to understand whether our tactics for achieving high rates of adolescent vaccination were successful. METHODS: Denver Health is an integrated urban safety net health system serving >17 000 adolescents annually. The process for achieving high vaccination rates in our health system includes “bundling” of vaccines, offering vaccines at every visit, and standard orders. Data from vaccine registry and utilization statistics were used to determine vaccination rates in adolescents aged 13 to 17 years from 2004 to 2014, and these findings were compared with state and national rates for 2013. Regression analysis was used to identify characteristics associated with vaccination.
RESULTS: In 2013 (N=11,463), HPV coverage of ≥1 dose was 89.8% (female subjects) and 89.3% (male subjects), compared with national rates of 57.3% and 34.6%. Rates of HPV coverage (≥3 doses) were 66.0% for female subjects and 52.5% for male subjects, versus 37.6% and 13.9% nationally. For both sexes, tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis, adsorbed, vaccine coverage was 95.9% (86.0% nationally), and meningococcal conjugate vaccine coverage was 93.5% (77.8% nationally). Female subjects, Hispanic subjects, non-English speakers, and teenagers <200% below the federal poverty level were more likely to have received 3 doses of HPV.
CONCLUSIONS: Through low-cost, system-wide standard procedures, Denver Health achieved adolescent vaccination rates well above national coverage rates. Avoiding missed opportunities for vaccination and normalizing the HPV vaccine were key procedures that contributed to high coverage rates.
.
Articles
Complementary and Alternative Medicine and Influenza Vaccine Uptake in US Children
William K. Bleser, Bilikisu Reni Elewonibi, Patricia Y. Miranda, Rhonda BeLue
Pediatrics Nov 2016, 138 (5) e20154664; DOI: 10.1542/peds.2015-4664
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Quality Reports
Achieving High Adolescent HPV Vaccination Coverage
Anna-Lisa M. Farmar, Kathryn Love-Osborne, Katherine Chichester, Kristin Breslin, Kristi Bronkan, Simon J. Hambidge
Pediatrics Nov 2016, 138 (5) e20152653; DOI: 10.1542/peds.2015-2653
Abstract
BACKGROUND AND OBJECTIVE: Despite national recommendations for adolescent human papillomavirus (HPV) vaccination, rates have lagged behind those of other adolescent vaccines. We implemented interventions and examined rates of vaccination coverage in a large, urban, safety net health care system to understand whether our tactics for achieving high rates of adolescent vaccination were successful.
METHODS: Denver Health is an integrated urban safety net health system serving >17 000 adolescents annually. The process for achieving high vaccination rates in our health system includes “bundling” of vaccines, offering vaccines at every visit, and standard orders. Data from vaccine registry and utilization statistics were used to determine vaccination rates in adolescents aged 13 to 17 years from 2004 to 2014, and these findings were compared with state and national rates for 2013. Regression analysis was used to identify characteristics associated with vaccination.
RESULTS: In 2013 (N=11,463), HPV coverage of ≥1 dose was 89.8% (female subjects) and 89.3% (male subjects), compared with national rates of 57.3% and 34.6%. Rates of HPV coverage (≥3 doses) were 66.0% for female subjects and 52.5% for male subjects, versus 37.6% and 13.9% nationally. For both sexes, tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis, adsorbed, vaccine coverage was 95.9% (86.0% nationally), and meningococcal conjugate vaccine coverage was 93.5% (77.8% nationally). Female subjects, Hispanic subjects, non-English speakers, and teenagers <200% below the federal poverty level were more likely to have received 3 doses of HPV.
CONCLUSIONS: Through low-cost, system-wide standard procedures, Denver Health achieved adolescent vaccination rates well above national coverage rates. Avoiding missed opportunities for vaccination and normalizing the HPV vaccine were key procedures that contributed to high coverage rates.

PLoS Currents: Outbreaks
http://currents.plos.org/outbreaks/
[Accessed 5 November 2016]

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The Ebola Crisis and the Corresponding Public Behavior: A System Dynamics Approach
November 3, 2016 · Research Article
Background: The interaction of several sociocultural and environmental factors during an epidemic crisis leads to behavioral responses that consequently make the crisis control a complex problem.
Methods: The system dynamics approach has been adopted to study the relationships between spread of disease, public attention, situational awareness, and community’s response to the Ebola epidemic.
Results: In developing different simulation models to capture the trend of death and incidence data from the World Health Organization for the Ebola outbreak, the final model has the best fit to the historical trends. Results demonstrate that the increase of quarantining rate over time due to increase in situational awareness and performing safe burials had a significant impact on the control of epidemic. However, public attention did not play a significant role.
Conclusion: The best fit to historical data are achieved when behavioral factors specific to West Africa like studying the Situational Awareness and Public Attention are included in the model. However, by ignoring the sociocultural factors, the model is not able to represent the reality; therefore, in the case of any epidemics, it is necessary that all the parties and community members find the most significant behavioral factors that can curb the epidemic.

PLoS Medicine
http://www.plosmedicine.org/
(Accessed 5 November 2016)

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Perspective
Improving the Pipeline for Developing and Testing Pharmacological Treatments in Pregnancy
Lucy C. Chappell, Anna L. David
Perspective | published 01 Nov 2016 PLOS Medicine
http://dx.doi.org/10.1371/journal.pmed.1002161

Research Article
Pregnancy-Associated Changes in Pharmacokinetics: A Systematic Review
Gali Pariente, Tom Leibson, Alexandra Carls, Thomasin Adams-Webber, Shinya Ito, Gideon Koren
published 01 Nov 2016 PLOS Medicine
http://dx.doi.org/10.1371/journal.pmed.1002160

PLoS Neglected Tropical Diseases
http://www.plosntds.org/

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Research Article
Containing Ebola at the Source with Ring Vaccination
Stefano Merler, Marco Ajelli, Laura Fumanelli, Stefano Parlamento, Ana Pastore y Piontti, Natalie E. Dean, Giovanni Putoto, Dante Carraro, Ira M. Longini Jr., M. Elizabeth Halloran, Alessandro Vespignani
| published 02 Nov 2016 PLOS Neglected Tropical Diseases
http://dx.doi.org/10.1371/journal.pntd.0005093
Abstract
Interim results from the Guinea Ebola ring vaccination trial suggest high efficacy of the rVSV-ZEBOV vaccine. These findings open the door to the use of ring vaccination strategies in which the contacts and contacts of contacts of each index case are promptly vaccinated to contain future Ebola virus disease outbreaks. To provide a numerical estimate of the effectiveness of ring vaccination strategies we introduce a spatially explicit agent-based model to simulate Ebola outbreaks in the Pujehun district, Sierra Leone, structurally similar to previous modelling approaches. We find that ring vaccination can successfully contain an outbreak for values of the effective reproduction number up to 1.6. Through an extensive sensitivity analysis of parameters characterising the readiness and capacity of the health care system, we identify interventions that, alongside ring vaccination, could increase the likelihood of containment. In particular, shortening the time from symptoms onset to hospitalisation to 2–3 days on average through improved contact tracing procedures, adding a 2km spatial component to the vaccination ring, and decreasing human mobility by quarantining affected areas might contribute increase our ability to contain outbreaks with effective reproduction number up to 2.6. These results have implications for future control of Ebola and other emerging infectious disease threats.
Author Summary
When the 2014–15 Ebola outbreak in West Africa began, no licensed vaccines for the disease were available. The rVSV-ZEBOV vaccine was developed during the course of the epidemic and underwent a clinical trial demonstrating 100% efficacy when vaccinating contacts and contacts of contacts of confirmed Ebola cases (an approach called ring vaccination). However, the trial did not provide any understanding on whether this vaccination strategy can be effective in containing future Ebola virus disease outbreaks. Through a modelling study on a region of Sierra Leone, we provide numerical estimates for the effectiveness of ring vaccination: we show that outbreaks with moderate transmission potential, with no more than 1.6 secondary cases generated by an index case on average, can be successfully contained; more extensive vaccination(e.g., including spatial rings around index cases) and reinforcement of the healthcare system would increase the likelihood of containment even if the virus were more transmissible than in the past. Our results provide implications for control plans of possible future Ebola outbreaks.

PLoS One
http://www.plosone.org/
[Accessed 5 November 2016]

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Research Article
Cost-Effectiveness Analysis of Hepatitis B Vaccination Strategies to Prevent Perinatal Transmission in North Korea: Selective Vaccination vs. Universal Vaccination
Donghoon Lee, Sang Min Park
Research Article | published 01 Nov 2016 PLOS ONE
http://dx.doi.org/10.1371/journal.pone.0165879
Abstract
Background
To tackle the high prevalence of Hepatitis B virus (HBV) infection in North Korea, it is essential that birth doses of HBV vaccines should be administered within 24 hours of birth. As the country fails to provide a Timely Birth Dose (TBD) of HBV vaccine, the efforts of reducing the high prevalence of HBV have been significantly hampered.
Methods
To examine the cost-effectiveness of vaccination strategies to prevent perinatal transmission of HBV in North Korea, we established a decision tree with a Markov model consisting of selective, universal, and the country’s current vaccination program against HBV. The cost-effectiveness analysis was performed from societal and payer’s perspectives and evaluated by Disability Adjusted Life Year (DALY).
Results
The results suggest that introducing the universal vaccination would prevent 1,866 cases of perinatal infections per 100,000 of the birth cohort of 2013. Furthermore, 900 cases of perinatal infections per 100,000 could be additionally averted if switching to the selective vaccination. The current vaccination is a dominated strategy both from the societal and payer’s perspective. The Incremental Cost-Effectiveness Ratio (ICER) between universal and selective vaccination is $267 from the societal perspective and is reported as $273 from the payer’s perspective.
Conclusion
Based on the assumption that the 2012 Gross Domestic Product (GDP) per capita in North Korea, $582.6 was set for cost-effectiveness criteria, the result of this study indicates that selective vaccination may be a highly cost-effective strategy compared to universal vaccination.

PNAS – Proceedings of the National Academy of Sciences of the United States of America
http://www.pnas.org/content/early/
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Biological Sciences – Population Biology:
Vaccination strategies against respiratory syncytial virus
Dan Yamin, Forrest K. Jones, John P. DeVincenzo, Shai Gertler, Oren Kobiler, Jeffrey P. ownsend, and Alison P. Galvani
PNAS 2016 ; published ahead of print October 31, 2016, doi:10.1073/pnas.1522597113
Significance
The WHO estimates that respiratory syncytial virus (RSV) vaccination will be available in the next 5–10 y. To evaluate the population effectiveness of an RSV vaccination program in the United States, we developed a transmission model that integrates data on daily infectious viral load and behavior changes while symptomatic. Our model simulations demonstrate that vaccinating children younger than 5 y of age will be the most efficient and effective way to prevent RSV infection in both children and older adults, a result that is robust across the US states considered. Accordingly, the population burden of RSV would be most effectively reduced if current vaccine candidates were to focus on children.
Abstract
Respiratory syncytial virus (RSV) is the most common cause of US infant hospitalization. Additionally, RSV is responsible for 10,000 deaths annually among the elderly across the United States, and accounts for nearly as many hospitalizations as influenza. Currently, several RSV vaccine candidates are under development to target different age groups. To evaluate the potential effectiveness of age-specific vaccination strategies in averting RSV incidence, we developed a transmission model that integrates data on daily infectious viral load and changes of behavior associated with RSV symptoms. Calibrating to RSV weekly incidence rates in Texas, California, Colorado, and Pennsylvania, we show that in all states considered, an infected child under 5 y of age is more than twice as likely as a person over 50 y of age to transmit the virus. Geographic variability in the effectiveness of a vaccination program across states arises from interplay between seasonality patterns, population demography, vaccination uptake, and vaccine mechanism of action. Regardless of these variabilities, our analysis showed that allocating vaccine to children under 5 y of age would be the most efficient strategy per dose to avert RSV in both children and adults. Furthermore, due to substantial indirect protection, the targeting of children is even predicted to reduce RSV in the elderly more than directly vaccinating the elderly themselves. Our results can help inform ongoing clinical trials and future recommendations on RSV vaccination.

PNAS – Proceedings of the National Academy of Sciences of the United States of America
http://www.pnas.org/content/early/

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Commentary:
Timing and periodicity of influenza epidemics
Ottar N. Bjørnstad and Cecile Viboud
PNAS 2016 ; published ahead of print November 3, 2016, doi:10.1073/pnas.1616052113
[Extract]
Although the annual cycle of summers and winters is a long-resolved mystery of astronomy, the annual antipodal waxing and waning of influenza epidemics is still an unresolved question in epidemiology. In 1981, R. E. Hope-Simpson, an astute British physician who maintained and analyzed detailed records of his patients and their diseases for more than three decades, observed that “Influenza outbreaks are globally ubiquitous and epidemics move smoothly to and fro across the surface of the earth almost every year in a sinuous curve that runs parallel with the ‘midsummer’ curve of vertical solar radiation…” (1). In PNAS Deyle et al. (2) combine convergent cross-mapping with empirical dynamic modeling to elucidate the nonlinear roles of absolute humidity and temperature in explaining influenza’s “sinuous curve that runs parallel with the ‘midsummer’” across the globe (1).

Understanding interepidemic intervals and timing of outbreaks has been a focus of mathematical epidemiologists for more than 50 y (3, 4). Acute immunizing infections have internal cyclic clockworks determined by the overcompensatory predator/prey-like interaction that results from slow susceptible recruitment, through births and loss of immunity, and rapid susceptible depletion from transmission during epidemics. The internal clock depends on traits of both the pathogen and the host and determines the frequency of oscillations we expect to see in the presence of random perturbations to the disease dynamics (3). The “flu” is a recurrent menace—and sometime scourge—caused by cocirculating strains of influenza A and B viruses, which at the strain-aggregate level can be modeled using the “susceptible-infected-recovered-(re)suceptible” compartmental model (5). For influenza, the internal interepidemic period is usually in the 10- to 16-mo range depending on the infectious period and transmissibility (the basic reproductive ratio, R0) of each strain (Fig. 1A). The prediction is that, in the absence of extrinsic forcing, the flu peak would …

Science
04 November 2016 Vol 354, Issue 6312
http://www.sciencemag.org/current.dtl

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In Depth
Controversial HIV vaccine strategy gets a second chance
By Jon Cohen
Science04 Nov 2016 : 535 Restricted Access
Modest success in Thailand inspires South Africa trial
Summary
A two-pronged HIV vaccine strategy that delivered lackluster results in a trial in Thailand 7 years ago will get another chance in South Africa. Last week, researchers injected the first of what they hope will be 5400 participants in the $130 million study, which should show once and for all whether the combination actually works. But some researchers say the trial amounts to a waste of money. In the Thai study, the vaccine combination reduced the risk of HIV infection by only 31.2%, and the study failed to show a mechanism that explained this modest benefit, critics say. Backers of the new trial counter that there’s enough evidence to give it another try and argue that even a modestly efficacious vaccine would help South Africa, which has more than 6 million HIV-infected people.

Tropical Medicine & International Health
November 2016 Volume 21, Issue 11 Pages 1347–1488, E1–E1
http://onlinelibrary.wiley.com/doi/10.1111/tmi.2016.21.issue-11/issuetoc

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Original Research Papers
Rotavirus vaccines contribute towards universal health coverage in a mixed public–private healthcare system (pages 1458–1467)
Tharani Loganathan, Mark Jit, Raymond Hutubessy, Chiu-Wan Ng, Way-Seah Lee and Stéphane Verguet
Version of Record online: 24 AUG 2016 | DOI: 10.1111/tmi.12766
Abstract
Objectives
To evaluate rotavirus vaccination in Malaysia from the household’s perspective. The extended cost-effectiveness analysis (ECEA) framework quantifies the broader value of universal vaccination starting with non-health benefits such as financial risk protection and equity. These dimensions better enable decision-makers to evaluate policy on the public finance of health programmes.
Methods
The incidence, health service utilisation and household expenditure related to rotavirus gastroenteritis according to national income quintiles were obtained from local data sources. Multiple birth cohorts were distributed into income quintiles and followed from birth over the first five years of life in a multicohort, static model.
Results
We found that the rich pay more out of pocket (OOP) than the poor, as the rich use more expensive private care. OOP payments among the poorest although small are high as a proportion of household income. Rotavirus vaccination results in substantial reduction in rotavirus episodes and expenditure and provides financial risk protection to all income groups. Poverty reduction benefits are concentrated amongst the poorest two income quintiles.
Conclusion
We propose that universal vaccination complements health financing reforms in strengthening Universal Health Coverage (UHC). ECEA provides an important tool to understand the implications of vaccination for UHC, beyond traditional considerations of economic efficiency.

Travel Medicine and Infectious Diseases
September-October, 2016 Volume 14, Issue 5
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Editorials
Hajj 2016: Required vaccinations, crowd control, novel wearable tech and the Zika threat
Qanta A. Ahmed, Ziad A. Memish
Vol. 14, Issue 5, p429–432
Published online: September 20, 2016
Article Outline [initial text]
Today 1,323,520 Muslims arrived in Saudi Arabia joining millions more Muslims from around the world to perform Hajj. As physician experts in Hajj medicine who have also performed the Hajj pilgrimage and attended pilgrim-patients both during Hajj at the Hajj sites we welcome the arrival of novel wearable technology introduced by Saudi Arabia to safeguard the Hajj pilgrim during what is one of the world’s largest mass gatherings [1].

Like all mass gatherings, physical hazards are a risk and among them one of the most dangerous is stampede that unfortunately impacted Hajj 2015 on a causeway on route to the Three Pillars in the Mina area of the Holy Sites [2]. Looking at the modern history of the Hajj, stampedes have indeed occurred sporadically though the 2015 events marked the end of years free of mass stampedes following significant reengineering of crowd management. Certainly this calamity is at the forefront of Hajj planners’ priorities with some interesting solutions already being piloted, but as every year basic precautions -cough etiquette, facemask use, hand hygiene and careful food hygiene remain paramount [[3], [4]].

Routine vaccination is not only recommended but is required- Hajj visa applications being accepted contingent upon on full sets of immunizations as is standard. Like every year, the three key vaccine requirements for visa issuing include yellow fever vaccination for all travellers arriving from countries or areas at risk of yellow fever given at least 10 days prior to arrival, quadrivalent (ACYW135) meningococcal vaccine; both polysaccharide and conjugated vaccines are valid with attention to differing duration of protection [5] issued no more than 3 years and no less than 10 days before arrival in Saudi Arabia and proof of receipt of a dose of oral polio vaccine (OPV) or inactivated poliovirus vaccine (IPV), within the previous 12 months and at least 6 weeks prior to departure for travellers arriving from polio-endemic countries which have never interrupted indigenous virus transmission. In addition, the Ministry of Health of Saudi Arabia continues to recommend that international pilgrims be vaccinated against seasonal influenza with most recently available vaccines particularly those at increased risk of severe influenza diseases including pregnant women, children aged over 5 years, the elderly, and individuals with pre-existing health conditions such as asthma, chronic heart or lung diseases and HIV/AIDS infection [[5], [6], [7]]…

Vaccine
Volume 34, Issue 48, Pages 5819-5990 (21 November 2016)
http://www.sciencedirect.com/science/journal/0264410X/34/48
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Original Research Article
Manufacturing costs of HPV vaccines for developing countries
Pages 5984-5989
Chaevia Clendinen, Yapei Zhang, Rebecca N. Warburton, Donald W. Light
Abstract
Background
Nearly all of the 500,000 new cases of cervical cancer and 270,000 deaths occur in middle or lower income countries. Yet the two most prevalent HPV vaccines are unaffordable to most. Even prices to Gavi, the Vaccine Alliance, are unaffordable to graduating countries, once they lose Gavi subsidies. Merck and Glaxosmithkline (GSK) claim their prices to Gavi equal their manufacturing costs; but these costs remain undisclosed. We undertook this investigation to estimate those costs.
Methods
Searches in published and commercial literature for information about the manufacturing of these vaccines. Interviews with experts in vaccine manufacturing.
Findings
This detailed sensitivity analysis, based on the best available evidence, finds that after a first set of batches for affluent markets, manufacturing costs of Gardasil for developing countries range between $0.48 and $0.59 a dose, a fraction of its alleged costs of $4.50. Because volume of Cervarix is low, its per unit costs are much higher, though at comparable volumes, its costs would be similar.
Interpretation
Given the recovery of fixed and annual costs from sales in affluent markets, Merck’s break-even price to Gavi could be $0.50–$0.60, not $4.50. These savings could support Gavi programs to strengthen delivery and increase coverage. Outside Gavi, prices to lower- and middle-income countries, with profit, could also be lowered and made available to millions more adolescents at risk. These estimates and their policy implications deserve further discussion.

Vaccine
Volume 34, Issue 48, Pages 5819-5990 (21 November 2016)
http://www.sciencedirect.com/science/journal/0264410X/34/48
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Original Research Article
Rabies pre-exposure prophylaxis elicits long-lasting immunity in humans
Original Research Article
Pages 5959-5967
Karen L. Mansfield, Nick Andrews, Hooman Goharriz, Trudy Goddard, Lorraine M. McElhinney, Kevin E. Brown, Anthony R. Fooks
Abstract
Despite the availability of safe and effective human vaccines, rabies remains a global threat, with an estimated 60,000 human deaths annually attributed to rabies. Pre-exposure prophylaxis against rabies infection is recommended for travelers to countries where rabies is endemic, and also for those with a higher risk of exposure. In this study, the rabies-specific neutralising antibody responses in a cohort of rabies-vaccinated recipients over a period of twenty years have been assessed. In particular, the antibody response to primary vaccinations and boosters, and the waning of antibody post primary vaccination and post booster were investigated. The significance of gender, age at vaccination, vaccine manufacturer and vaccination intervals were also evaluated. These data confirm that rabies vaccination can elicit a neutralising antibody response that can remain at detectable levels for a number of years, without additional booster vaccinations. The antibody response following both primary vaccination and booster was significantly influenced by the gender of the subject (p = 0.002 and 0.03 respectively), with supportive data that suggests an effect by the make of vaccine administered following primary vaccination, with significantly higher VNA titres observed for one vaccine manufactured prior to 2006 (p < 0.001) in a small subset of recipients (n = 5). Additionally, the decay rate was demonstrated through the overall decline in antibody titre for all individuals, which was a 37% and 27% reduction per 2-fold change in time following primary and booster vaccination respectively. Individuals within older age groups demonstrated a significantly faster decline in antibody titre following the primary vaccination course (p = 0.012). Rate of decline in antibody titre was also significantly influenced by the vaccine make following primary course (p < 0.001). The assessment of neutralising antibody titre decline has also provided an insight into the most appropriate timing for booster administration, and enabled the prediction of long term titres from post-vaccination antibody titres.

Vaccine
Volume 34, Issue 48, Pages 5819-5990 (21 November 2016)
http://www.sciencedirect.com/science/journal/0264410X/34/48
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Original Research Article
Measuring polio immunity to plan immunization activities
Pages 5946-5952
Arend Voorman, Hil M. Lyons
Abstract
The Global Polio Eradication Initiative is closer than ever to achieving a polio-free world. Immunization activities must still be carried out in non-endemic countries to maintain population immunity at levels which will stop poliovirus from spreading if it is re-introduced from still-infected areas. In areas where there is no active transmission of poliovirus, programs must rely on surrogate indicators of population immunity to determine the appropriate immunization activities, typically caregiver-reported vaccination history obtained from non-polio acute flaccid paralysis patients identified through polio surveillance. We used regression models to examine the relationship between polio vaccination campaigns and caregiver-reported polio vaccination history. We find that in many countries, vaccination campaigns have a surprisingly weak impact on these commonly used indicators. We conclude that alternative criteria and data, such as routine immunization indicators from vaccination records or household surveys, should be considered for planning polio vaccination campaigns, and that validation of such surrogate indicators is necessary if they are to be used as the basis for program planning and risk assessment. We recommend that the GPEI and similar organizations consider or continue devoting additional resources to rigorously study population immunity and campaign effectiveness in at-risk countries.

Vaccine
Volume 34, Issue 48, Pages 5819-5990 (21 November 2016)
http://www.sciencedirect.com/science/journal/0264410X/34/48
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Original Research Article
Rotavirus, vaccine failure or diagnostic error?
Pages 5912-5915
Monica Lopez-Lacort, Susana Collado, Ana Díez-Gandía, Javier Díez-Domingo
Abstract
Immunochromatography (ICG) is highly used in clinical settings for rotavirus (RV) diagnosis. The specificity of the tests differs by brand type and is not 100%, therefore its use when the prevalence of the disease is low (i.e. in vaccinated children) may result in a proportion of false positive diagnoses.
In some areas, vaccine effectiveness studies or surveillance is done using ICG. Our objective was to estimate the validity of ICG test in vaccinated children, and estimate the number of false positive results in the Valencian Region of Spain, where all RV infections are diagnosed using ICG and are not confirmed by PCR.
Population based registries were used to identify all results from the RV antigen tests performed between January 2008 and June 2012 in children under 37 months. Hospitalization and vaccination status of the patients were obtained by linking different databases through a unique identification number. The Positive Predictive Value of the ICG test depending on the vaccination status of the child, hospitalization and the rotavirus season was estimated by a Bayesian model of latent classes.
Of the 48,833 tests with valid results, 9429 were done in vaccinated children, and of those 3963 (42%) during the rotavirus season. The prevalence of positive results in vaccinated varied from 2.9 to 21.4% of the tests depending on the hospitalization and seasonality. The estimated PPV also varied from 27.1 to 84.6% when stratified by these two parameters. Globally it is calculated that approximately 267 out of the 520 (51.3%) positives in vaccinated children were false positive tests.
The large percentage of false positives, due to an excessive number of tests in vaccinated and out of the RV season, if interpreted as vaccine failures, can cause a loss of confidence in the vaccine and lower the estimates of vaccine effectiveness.

Vaccine
Volume 34, Issue 48, Pages 5819-5990 (21 November 2016)
http://www.sciencedirect.com/science/journal/0264410X/34/48
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Original Research Article
Knowledge, attitudes, and practices of healthcare providers in the country of Georgia regarding influenza vaccinations for pregnant women
Pages 5907-5911
Mariam Dvalishvili, Darejan Mesxishvili, Maia Butsashvili, George Kamkamidze, Deborah McFarland, Robert A. Bednarczyk
Abstract
Objective
To document knowledge, attitudes, and practices of Georgian obstetrician-gynecologists concerning influenza infection and vaccination during pregnancy.
Methods
We conducted a cross-sectional study of obstetrician-gynecologists in 8 cities in the country of Georgian, from June to July, 2015, using an anonymous, self-administered, written survey. Collected data included demographics; knowledge, attitudes, and practices related to influenza vaccination during pregnancy; perceptions of influenza infection in pregnancy; perceived barriers to influenza vaccination during pregnancy; and willingness to receive education about influenza infection and vaccination during pregnancy.
Results
A total of 278 obstetrician-gynecologists completed surveys. Most physicians perceived influenza to be a serious infectious disease (88%) and that pregnant women are more susceptible to it than the general population. Only 43% of physicians reported recommending influenza vaccination during pregnancy; 18% reported vaccinating any pregnant patients during the last influenza season. Most (75%) physicians reported a perception that there is insufficient evidence supporting influenza vaccination during pregnancy. Most (93%) were receptive to receiving additional education on maternal vaccination.
Conclusions
Georgian physicians are hesitant to vaccinate pregnant women, but are receptive to education about maternal vaccination. Future educational outreach to Georgian physicians could reduce concerns about maternal vaccination, potentially increasing influenza vaccination among pregnant Georgian women.

Vaccine
Volume 34, Issue 48, Pages 5819-5990 (21 November 2016)
http://www.sciencedirect.com/science/journal/0264410X/34/48
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Review Article
Meningococcal disease in the Asia-Pacific region: Findings and recommendations from the Global Meningococcal Initiative
Pages 5855-5862
Ray Borrow, Jin-Soo Lee, Julio A. Vázquez, Godwin Enwere, Muhamed-Kheir Taha, Hajime Kamiya, Hwang Min Kim, Dae Sun Jo, the Global Meningococcal Initiative
Abstract
The Global Meningococcal Initiative (GMI) is a global expert group that includes scientists, clinicians, and public health officials with a wide range of specialties. The purpose of the Initiative is to promote the global prevention of meningococcal disease (MD) through education, research, and cooperation. The first Asia-Pacific regional meeting was held in November 2014. The GMI reviewed the epidemiology of MD, surveillance, and prevention strategies, and outbreak control practices from participating countries in the Asia-Pacific region. Although, in general, MD is underreported in this region, serogroup A disease is most prominent in low-income countries such as India and the Philippines, while Taiwan, Japan, and Korea reported disease from serogroups C, W, and Y. China has a mixed epidemiology of serogroups A, B, C, and W.
Perspectives from countries outside of the region were also provided to provide insight into lessons learnt. Based on the available data and meeting discussions, a number of challenges and data gaps were identified and, as a consequence, several recommendations were formulated: strengthen surveillance; improve diagnosis, typing and case reporting; standardize case definitions; develop guidelines for outbreak management; and promote awareness of MD among healthcare professionals, public health officials, and the general public.

Vaccine
Volume 34, Issue 48, Pages 5819-5990 (21 November 2016)
http://www.sciencedirect.com/science/journal/0264410X/34/48
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Brief report
Parental experiences with vaccine information statements: Implications for timing, delivery, and parent-provider immunization communication
Pages 5840-5844
Paula M. Frew, Yunmi Chung, Allison Kennedy Fisher, Jay Schamel, Michelle M. Basket
Abstract
Objective
We examined Vaccine Information Statements (VIS) dissemination practices and parental use and perceptions.
Methods
We conducted a national online panel survey of 2603 US parents of children aged Results
Most parents received a VIS (77.2%; [95% CI: 74.5–79.7%]), 59.7% [56.6–62.7%] before vaccination but 14.5% [12.5–16.8%] reported receiving it after their child’s immunization; 15.1% [13.0–17.6%] were unsure of receipt status or timing; another 10.7% [9.0–12.6%] reported non-receipt of a VIS. Less than half who received a VIS before vaccination completed it before vaccination (46.2% [42.4, 50.0%]), but most who read at least some found the information useful (95.7% [93.8–97.0%]). Parents who delayed or refused at least one recommended non-influenza vaccine reported fewer opportunities to ask providers VIS questions.
Conclusions
Most parents report receiving VIS before vaccination as per federal guidelines. Continued effort is needed to enhance VIS distribution practice and parent-provider VIS content communication.

Vaccine
Volume 34, Issue 48, Pages 5819-5990 (21 November 2016)
http://www.sciencedirect.com/science/journal/0264410X/34/48
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WHO Report
Investing in life saving vaccines to guarantee life of future generations in Africa
Pages 5827-5832
R.M. Mihigo, J.C. Okeibunor, H. O’Malley, B. Masresha, P. Mkanda, F. Zawaira
Abstract
The World Health Organization’s Regional Offices for Africa and for the Eastern Mediterranean in conjunction with the African Union and the Government of Ethiopia hosted a ministerial conference on immunization in Africa from 24 to 25 February 2016 in Addis Ababa, Ethiopia under the theme “towards universal immunization coverage as a cornerstone for health and development in Africa”. The conference brought together African leaders – including health and finance ministers, and parliamentarians thus creating a powerful platform for governments to demonstrate their commitment to advancing universal access to immunization on the continent in line with the Global Vaccine Action Plan. The event also brought together advocates, technical experts, policymakers, partner agencies, donors and journalists to examine how best to drive forward immunization across Africa, ensuring every child has access to the vaccines they need. Key points highlighted throughout conference were: universal access to immunization is at the forefront of enabling Africa to reach its full potential – by improving health, driving economic growth and empowering future generations; it is one of the most cost-effective solutions in global health, with clear benefits for health and development; and immunization brings economic benefits too, reducing health care costs and increasing productivity. At the close of the conference, 46 African countries signed a historic ministerial declaration on “Universal Access to Immunization as a Cornerstone for Health and Development in Africa” signaling fierce determination among African leaders to secure the health and prosperity of their societies through immunization.

Vaccine
Volume 34, Issue 48, Pages 5819-5990 (21 November 2016)
http://www.sciencedirect.com/science/journal/0264410X/34/48

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Conference report
Pertussis: Biology, epidemiology and prevention
Pages 5819-5826
Mitra Saadatian-Elahi, Stanley Plotkin, Kingston H.G. Mills, Scott A. Halperin, Peter B. McIntyre, Valentina Picot, Jacques Louis, David R. Johnson
Abstract
Despite long-standing vaccination programs, substantial increases in reported cases of pertussis have been described in several countries during the last 5 years. Cases among very young infants who are at greatest risk of pertussis-related hospitalizations and mortality are the most alarming. Multiple hypotheses including but not limited to the availability of more sensitive diagnostic tests, greater awareness, and waning vaccine-induced immunity over time have been posited for the current challenges with pertussis. The conference “Pertussis: biology, epidemiology and prevention” held in Annecy-France (November 11–13, 2015) brought together experts and interested individuals to examine these issues and to formulate recommendations for optimal use of current vaccines, with a particular focus on strategies to minimize severe morbidity and mortality among infants during the first months of life. The expert panel concluded that improving vaccination strategies with current vaccines and development of new highly immunogenic and efficacious pertussis vaccines that have acceptable adverse event profiles are currently the two main areas of investigation for the control of pertussis. Some possible pathways forward to address these main challenges are discussed in this report.

Vaccines — Open Access Journal
http://www.mdpi.com/journal/vaccines
(Accessed 5 November 2016)

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Targeting Immune Regulatory Networks to Counteract Immune Suppression in Cancer
Vaccines 2016, 4(4), 38; doi:10.3390/vaccines4040038 (registering DOI) – 4 November 2016
by Chiara Camisaschi, Viviana Vallacchi, Elisabetta Vergani, Marcella Tazzari, Simona Ferro, Alessandra Tuccitto, Olga Kuchuk, Eriomina Shahaj, Roberta Sulsenti, Chiara Castelli, Monica Rodolfo, Licia Rivoltini and Veronica Huber
Abstract
The onset of cancer is unavoidably accompanied by suppression of antitumor immunity. This occurs through mechanisms ranging from the progressive accumulation of regulatory immune cells associated with chronic immune stimulation and inflammation, to the expression of immunosuppressive molecules. Some of them are being successfully exploited as therapeutic targets, with impressive clinical results achieved in patients, as in the case of immune checkpoint inhibitors. To limit immune attack, tumor cells exploit specific pathways to render the tumor microenvironment hostile for antitumor effector cells. Local acidification might, in fact, anergize activated T cells and facilitate the accumulation of immune suppressive cells. Moreover, the release of extracellular vesicles by tumor cells can condition distant immune sites contributing to the onset of systemic immune suppression. Understanding which mechanisms may be prevalent in specific cancers or disease stages, and identifying possible strategies to counterbalance would majorly contribute to improving clinical efficacy of cancer immunotherapy. Here, we intend to highlight these mechanisms, how they could be targeted and the tools that might be available in the near future to achieve this goal.

Journal of Preventive Medicine and Hygiene
Vol 57, No 3 (2016)
http://www.jpmh.org/index.php/jpmh/issue/view/2016573
Article
History and evolution of influenza control through vaccination: from the first monovalent vaccine to universal vaccines
Ilaria Barberis, Puja Myles, Steven Ault, Nicola Luigi Bragazzi, Mariano Martini
Abstract
Influenza is a highly infectious airborne disease with an important epidemiological and societal burden; annual epidemics and pandemics have occurred since ancient times, causing tens of millions of deaths. A hundred years after this virus was first isolated, influenza vaccines now ensure effective protection, and the preparations used display good safety and tolerability profiles.
Innovative tools, such as recombinant technologies and intra-dermal devices, are currently being investigated in order to elicit good immunity even in the event of unforeseen changes in the virus due to drift and antigenic shift or the co-circulation different viral strains.
The recurring mutations of influenza strains has prompted the recent introduction of a quadrivalent inactivated vaccine. In the near future, scientific research will strive to produce a long-lasting universal vaccine containing an antigen that is not subject to genetic modifications, and surveillance systems will be implemented in order to exactly predict circulating strains.

Media/Policy Watch
This watch section is intended to alert readers to substantive news, analysis and opinion from the general media and selected think tanks and similar organizations on vaccines, immunization, global public health and related themes. Media Watch is not intended to be exhaustive, but indicative of themes and issues CVEP is actively tracking. This section will grow from an initial base of newspapers, magazines and blog sources, and is segregated from Journal Watch above which scans the peer-reviewed journal ecology.

We acknowledge the Western/Northern bias in this initial selection of titles and invite suggestions for expanded coverage. We are conservative in our outlook in adding news sources which largely report on primary content we are already covering above. Many electronic media sources have tiered, fee-based subscription models for access. We will provide full-text where content is published without restriction, but most publications require registration and some subscription level.

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BBC
http://www.bbc.co.uk/
Accessed 5 November 2016
UK forms global infection response team
1 November 2016
The UK has created a specialist team of health experts who can be deployed anywhere around the world within 48 hours if a disease outbreak strikes.

The aim is to stamp out infections like Ebola before they spread far and wide.
The scientists, academics and clinicians will be funded by £20m from the government over five years.

When not responding to an immediate emergency, the rapid response team will assess future disease threats and train colleagues from home and abroad.

Public Health Minister Nicola Blackwood said the Ebola crisis highlighted the need for such a team.
“Ebola shook the world and brave experts from the UK led the global response in Sierra Leone. The ability to deploy emergency support to investigate and respond to disease outbreaks within 48 hours will save lives, prevent further outbreaks and cement the UK’s position as a leader in global health security.”

Public Health England will run the project with the London School of Hygiene and Tropical Medicine…

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Forbes
http://www.forbes.com/
Accessed 5 November 2016

Is It Fair To Reward Medicaid Patients For Receiving Flu Shots?
Peter Ubel, Contributor

Big Pharma Has Broken Its Social Contract: How To Restore Fairness In Drug Pricing
Kenneth L. Davis, Contributor
The pharmaceutical industry must restore the social contract governing its business practices and lower drug prices so Americans can better afford medication.

Why The Approach To Drug Pricing Has To Change Now
1 November 2016
By Joseph Jimenez, CEO of Novartis
As CEO of one of the world’s largest pharmaceutical companies, I believe that we need a new perspective on drug pricing: As an industry, we must shift to a model that focuses on value and outcomes delivered, both to patients and to health systems.

New Measles Study Shows Why Anti-Vaccination Thinking Is Deadly
30 October 2016
New research on fatal measles complications shows how the failure to vaccinate not only endangers the patient, but also everyone else susceptible to the disease. Subacute sclerosing panencephalitis (SSPE) is a neurological disorder that can develop years after someone has measles, and it is fatal 100% of the time. Previously it was thought rare at about one in 100,000 post-measles cases. But recent research in Germany shows that it occurs in one in 1,700 children infected with measles before they turned five, and a new study finds the incidence can be as many as one in 600 for infants who contract measles before they’re vaccinated. The findings were presented at IDWeek 2016, the annual meeting of the Infectious Diseases Society of America…

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Fortune
http://fortune.com/
Accessed 5 November 2016
Here’s What We Could Be Doing to Stop Pandemics Like Zika and Ebola
1 November 2016
…A boiling pot of global conditions, like ubiquitous travel and the growing populations of developing cities, have led to an outbreak of pandemics like Ebola, Zika, SARs, and even the flu over the past decade.

But while the global health industry and national governments and regulators have made a lot of progress, there’s still much more that these groups can do together to better plan, fund, and organize the battle against emerging pandemics, said a group of experts at Fortune’s Brainstorm Health conference in San Diego, Calif. on Tuesday night.
Once an outbreak occurs, the response is all about speed, said Bruce Gellin, director of the U.S. National Vaccine Program Office.

GSK’s CEO Explains How Big Pharma Can Help the Poor and Still Make Money
2 November 2016
Capitalism and doing good don’t have to be mutually exclusive.
Big pharma has been a persistent villain in the public’s consciousness over the past year in the wake of exorbitant drug price hikes, including on ancient medications. But drug makers don’t necessarily have to conform to some Monopoly man caricature to be successful, according to the chief executive of pharma giant

Outgoing GSK chief Sir Andrew Witty laid out a straightforward manifesto to drug pricing, especially when it comes to vaccines, at Fortune’s Brainstorm Health conference on Wednesday. His message: Pharma can do good while still turning a profit.

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New York Times
http://www.nytimes.com/
Accessed 5 November 2016
Colombia is Hit Hard by Zika, but Not by Microcephaly
By DONALD G. McNEIL Jr. and JULIA SYMMES COBB OCT. 31, 2016
BARRANQUILLA, Colombia — This tropical city on the Caribbean coast may hold the answer to one of the deeper mysteries of the Zika epidemic: Why has the world’s second-largest outbreak, after Brazil’s, produced so few birth defects?

In Brazil, more than 2,000 babies have been born with microcephaly, abnormally small heads and brain damage caused by the Zika virus. In Colombia, officials had predicted there might be as many as 700 such babies by the end of this year. There have been merely 47.
The gap has been seen all over the Americas. According to the World Health Organization, the United States has 28 cases — almost all linked to women infected elsewhere. Guatemala has 15, and Martinique has 12.

Had the rest of the Americas been as affected as northeastern Brazil, a tidal wave of microcephaly would be washing over the region. Most experts say that will not happen, but they are at a loss as to why…

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Washington Post
http://www.washingtonpost.com/
Accessed 5 November 2016
Washington state polio-like cases linked to rare syndrome
Eight of nine children hospitalized in Washington state for a polio-like illness have a rare syndrome that causes varying degrees of limb weakness, state health officials confirmed on Friday.
Lisa Baumann | AP | National | Nov 4, 2016

Think Tanks et al

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Council on Foreign Relations
http://www.cfr.org/
Accessed 5 November 2016
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Health and U.S. Foreign Policy in the Age of Miracles
3 November 2016
Thomas J. Bollyky, Senior Fellow for Global Health, Economics, and Development, and Eric Goosby, UN Special Envoy on Tuberculosis and Former U.S. Global AIDS Coordinator

…Global deaths from malaria and tuberculosis (TB) declined 48 percent and 47 percent, respectively, over this period. Maternal mortality dropped 43 percent. Deaths for children under five have halved, which means nineteen thousand fewer of these children die each day. More than ten million people with HIV/AIDS in sub-Saharan Africa are on lifesaving antiretroviral treatment, up from just one hundred thousand in 2003.

U.S. leadership and investment helped spur this progress. The U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) program, created in 2003, remains the largest financial commitment of any country to global health or the treatment of a specific disease. The United States is the biggest funder of GAVI, the global vaccine alliance, as well as the Global Fund to Fight AIDS, Tuberculosis, and Malaria, which immunize and treat millions of people each year. The United States also provides the most aid to fight neglected tropical diseases and poor maternal and child health. These investments have been consistently bipartisan, and their returns are, quite literally, measured in reduced human suffering and longer lives around the globe.

Can this age of miracles endure? Yes, but only with continued U.S. leadership and investment amid some challenging headwinds. The next president should build on the recent efforts to harness the positive synergies between global health and U.S. foreign policy…

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

.– Request an Email Summary: Vaccines and Global Health : The Week in Review is published as a single email summary, scheduled for release each Saturday evening before midnight (EDT in the U.S.). If you would like to receive the email version, please send your request to david.r.curry@centerforvaccineethicsandpolicy.org.

– pdf version:  A pdf of the current issue is available here: vaccines-and-global-health_the-week-in-review_29-october-2016-docx

– blog edition: comprised of the approx. 35+ entries posted below.

– Twitter:  Readers can also follow developments on twitter: @vaxethicspolicy.
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– Links:  We endeavor to test each link as we incorporate it into any post, but recognize that some links may become “stale” as publications and websites reorganize content over time. We apologize in advance for any links that may not be operative. We believe the contextual information in a given post should allow retrieval, but please contact us as above for assistance if necessary.

Support this knowledge-sharing service: Your financial support helps us cover our costs and to address a current shortfall in our annual operating budget. Click here to donate and thank you in advance for your contribution.

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

Milestones

Editor’s Note:
We provide the full text of the preliminary report of the WHO SAGE meeting just concluded. The full meeting report will be published in the WHO Weekly Epidemiological Record on 2 December 2016. The meeting documents — including presentations and background readings — can be found at http://www.who.int/immunization/sage/meetings/2016/October/en/

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Summary of the October 2016 meeting of the Strategic Advisory Group of Experts on immunization (SAGE)
The Strategic Advisory Group of Experts (SAGE) on immunization1 met on 18-20 October 2016 in Geneva, Switzerland.
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Global Vaccine Action Plan: 2016 mid-term review of progress and recommendations
At the mid-term of the Decade of Vaccines (DoV), SAGE reviewed the progress made towards the achievement of the Global Vaccine Action Plan (GVAP) goals. SAGE assessment was based on the report prepared by the DoV secretariat on progress against each of the GVAP indicators2; including a section on “Sustainable financing and supply for immunization” to detail the activities initiated in response to the WHA resolution on access to affordable vaccines3 adopted in 2014, progress reports from the regions4 and from priority countries5.

At the midpoint of the GVAP, SAGE remains very concerned that progress toward the goals to eradicate polio, eliminate measles and rubella, eliminate maternal and neonatal tetanus, and increase equitable access to lifesaving vaccines is too slow.

Global immunization coverage has increased by only 1% since 2010. In 2015, 68 countries fell short of the target to achieve at least 90% national coverage with the third dose of diphtheria-tetanus-pertussis vaccine. Twenty-six of these countries reported no change and 25 reported a net decrease in coverage since 2010.

However, SAGE sees many reasons for hope. Sixteen countries, including some of the countries with the highest numbers of un- or under-vaccinated children, have made measurable progress since 2010. Research and development efforts are accelerating the discovery and testing of an expanded portfolio of vaccine candidates and platform delivery technologies.

SAGE reaffirmed that immunization is one of the world’s most effective and cost-effective tools against both the threat of emerging diseases and anti-microbial resistance and has a powerful impact on social and economic development. Finally, SAGE made several important recommendations to countries, immunization partners and the DoV secretariat.

Among those recommendations, SAGE recommends that countries demonstrate stronger leadership and governance of national immunization systems by: 2

a) Ensuring ministers at all levels are strong immunization advocates within their countries and regions, conveying the high return on investment, the urgency and the value of investing more in immunization programmes as an integral part of government-supported Universal Health Coverage packages.
b) Governments are encouraged to enact laws that guarantee access to immunization, establish National Immunization Technical Advisory Groups or equivalent groups, ensure that sufficient budgets are allocated to immunization each year and create mechanisms to monitor and efficiently manage funds at all levels (including those from the private sector).
c) National leaders must take courageous decisions to initiate necessary upgrades to systems, protocols, and policies that will ensure high immunization coverage that is sustained. Such upgrades might require redesigning supply chains, information systems and procurement policies, and reassessing roles and responsibilities in case the government decides to implement the decentralization of the health system.
d) National immunization programme managers should report each year to their National Immunization Technical Advisory Group or equivalent groups on progress made, lessons learnt and remaining challenges toward implementing National Immunization Plans and show how these plans are aligned to Regional and Global Vaccine Action Plan goals.

SAGE recommends that countries secure necessary investments to sustain immunization during polio and Gavi transitions.
a) All countries should mitigate any risk to sustaining effective immunization programmes when polio funding decreases. All Member States with substantial numbers of staff and resources issued from the Global Polio Eradication Initiative are requested to describe, in their polio transition plan, how they propose to maintain and fund critical immunization, laboratory and surveillance activities that are currently supported with polio funding and staff.
b) In all countries transitioning from Gavi support, all national and global immunization partners must advocate strongly and persistently for increased domestic financing to sustain immunization gains over time.

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Yellow fever
Recent outbreaks of yellow fever in Central Africa highlighted the need to revisit and expand the control strategy as well as the vaccine supply, and the need for vaccine supply surge capacity. Therefore, WHO has initiated the development of a new global strategy to Eliminate Yellow Fever Epidemics (EYE strategy) globally by 2026. There are 3 strategic objectives: protect at risk populations, prevent international spread, and rapidly contain outbreaks. The Strategy outlines four key activities: continued access to affordable vaccines through a sustainable vaccine market; political commitment at global, regional and country levels; robust governance and strong partnerships; and research to support better tools and practices. New aspects of the strategy from previous efforts include the revised country risk category, the aim to protect specific risk populations, the need to address the urban risk, and the establishment of a revolving emergency vaccine stockpile. Following establishment of the EYE strategy, WHO and partners will develop an implementation plan.

SAGE confirmed the need for new strategic thinking and supported the general approach of the EYE strategy. SAGE emphasized the importance to link the EYE strategy to existing programmes/initiatives, e.g. measles-rubella strategy, integrated disease surveillance, and also vector control. It was noted that EYE can serve as a driver to raise awareness and preparedness in urban settings for other outbreak prone diseases.
Considering the global spread of Aedes mosquitos, rapid urbanization, and increased international travel, it is critical to have surge capacity in the event of an outbreak. SAGE previously reviewed the evidence for the minimum effective dose (also called fractional dose) in June 2016 in the context of the outbreak in Central Africa and supported its use in this type of situation. The minimum effective dose, administered as a fraction of the volume of the normal dose, should induce a protective immune response equivalent to a full dose. SAGE was updated on the evidence for minimum effective dose, for which most evidence is limited to one of the yellow fever vaccine products. Available studies suggest that a reduced volume dose was equivalent to the standard dose with respect to all measured immunological and virological parameters as long as the dose contained at least 3000 International Units.

SAGE was also updated on the experience of the minimum effective dose campaign in Kinshasa in August 2016. Logistically and operationally, the use of a minimum effective dose was shown to be feasible and a promising approach to protect at-risk populations that would otherwise be left unprotected.

Based on the available evidence, SAGE reaffirmed that a minimum effective dose can be used as part of an exceptional response in a time when there is a large outbreak and a shortage of vaccine.

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Measles and rubella elimination
SAGE reviewed the findings and the recommendations outlined in the mid-term review of the Measles and Rubella Strategic Plan 2012-2022. SAGE commended the MTR team on their work and endorsed the report and its recommendations.

SAGE stressed the critical role of high quality measles and rubella case-based surveillance for achieving the goals of the measles and rubella strategic plans and that countries should move towards weekly reporting to regions. SAGE stressed the importance of achieving and maintaining high population immunity in order to achieve the regional and global measles and rubella goals.

SAGE recommended that a routine second dose of measles containing vaccine (MCV) should be added to national immunization schedules in all countries regardless of MCV1 coverage. In countries meeting the criteria for rubella containing vaccine introduction into national immunization programmes6 , measles and rubella containing vaccines (MRCV) should be used in place of single-antigen MCV.

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Maternal and neonatal tetanus elimination (MNTE) and broader tetanus prevention
SAGE noted that while there was progress with MNTE, the goal to achieve global elimination by 2015 was missed once again. The failure to achieve this goal is a reminder of the persisting health inequities and the inability of some countries to provide basic health services to the most marginalized and vulnerable populations.

Countries yet to achieve MNTE should establish/update and implement their operational plans to achieve the required action within the timelines stated in the report from the Working Group on MNTE and broader tetanus prevention. Achievement of MNTE by 2020 is feasible with timely availability of financial resources and compact single-dose pre-filled auto-disable injection devices (CPAD) to reach the most marginalized populations.

UNICEF, UNFPA (United Nations Populations Fund) and WHO should work with countries to generate and sustain political interest in the continuing elimination of MNT to guard against complacency once a country has been declared to have eliminated the disease.

All immunization programmes should review and adjust their routine immunization schedules to ensure tetanus protection over the life course (3 priming doses in infancy and 3 booster doses in childhood/adolescence). All countries should also scale up and sustain the coverage of clean delivery and improve clean cord care practices. The 3 booster doses schedule intended to achieve protection throughout adulthood (reproductive age for women), and probably providing lifelong protection should preferably be given during the second year of life, between 4-7 years of age, and between 9-15 years of age.

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Hepatitis B vaccination
SAGE reemphasized the importance of introduction of the birth dose and urged all countries to introduce universal birth dose without further delays.

All infants should receive their first dose of hepatitis B vaccine as soon as possible after birth, preferably within 24 hours. However, if this is not feasible the birth dose will still be beneficial in preventing perinatal transmission if given within 7 days, although somewhat less than if given within 24 hours. After 7 days, a late birth dose is effective in preventing horizontal transmission and therefore remains beneficial. Therefore, SAGE recommends that all infants receive the birth dose during the first contact with health facilities any time up to the time of the first primary dose.

Schedules and strategies for human papillomavirus immunization
Noting the high effectiveness and safety of the human papillomavirus (HPV) vaccine, SAGE recommends that it is promptly introduced for adolescent girls as part of a coordinated and comprehensive strategy to prevent cervical cancer and other diseases caused by HPV. The 5

immunization of multiple cohorts of girls aged 9–14 years is recommended when the vaccine is first introduced. If resources are available, the age range could be expanded up to 18 years.
SAGE also discussed polio eradication. It was updated on the tOPV to bOPV switch and the progress with polio eradication and started an initial discussion on post eradication.

The full meeting report will be published in the WHO Weekly Epidemiological Record on 2 December 2016. The meeting documents — including presentations and background readings — can be found at http://www.who.int/immunization/sage/meetings/2016/October/en/

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References
1 http://www.who.int/imunization/sage/en/index.html
2 http://www.who.int/entity/immunization/global_vaccine_action_plan/gvap_secretariat_report_2016.pdf?ua=1
3 http://apps.who.int/gb/ebwha/pdf_files/WHA68-REC1/A68_R1_REC1-en.pdf
4 http://www.who.int/entity/immunization/global_vaccine_action_plan/2_Regional_reports_annex_GVAP_secretariat_report_2016.pdf?ua=1
5
http://www.who.int/entity/immunization/global_vaccine_action_plan/3_Country_reports_annex_GVAP_secretariat_report_2016.pdf?ua=1
6 Rubella Vaccines: WHO Position Paper. WER No. 29, 2011, 86, Pp. 301–316.

ZikaPLAN: 25 Research Organizations Unite to Fight Zika Virus and Build Long-term Outbreak Response Capacity in Latin America
RECIFE, Brazil, October 25, 2016 /PRNewswire/ — 25 leading research and public health organizations from Latin America, North America, Africa, Asia, and Europe gathered in Recife for the launch of ZikaPLAN (Zika Preparedness Latin American Network). This global initiative, created in response to a Horizon 2020 funding call by the European Commission’s Directorate-General Research and Innovation, has been formed to address the Zika virus outbreak and the many research and public health challenges it poses. The initiative takes a comprehensive approach to tackle the Zika threat by:
:: addressing the knowledge gaps and needs in the current Zika outbreak to better understand the disease, prevent its spread and educate the affected populations,
:: building a sustainable response capacity in Latin America for Zika and other emerging infectious diseases (EID).

The impact of the Zika outbreak took scientists and public health authorities by surprise and hit the most vulnerable populations the hardest. The severity of the outbreak and mutation of the virus have generated numerous research questions. To take effective measures, health authorities need to know the severity of the disease and its impact on public health, what interventions will work to prevent and stop its spread, and how best to manage and treat those who have been infected. This unprecedented Zika outbreak has also highlighted the need to build local capacities: in some of the regions where the virus struck there was not the necessary research infrastructure to understand the threat and take action quickly.

To bridge these gaps, research organizations in the ZikaPLAN consortium will look at Zika’s connection with congenital syndromes and neurological complications, and the pathogenesis of severe cases, through a series of clinical studies. They will explore non-vector and vector transmission and risk factors for geographic spread, measure the burden of disease and investigate how the virus has evolved, comparing current and historic strains. ZikaPLAN will look at novel personal preventive measures, innovation in diagnostics and modelling of vector control and vaccine strategies to inform policy decisions. The social sciences will also play a role in ZikaPLAN, which aims to determine the best communication strategies to keep the affected communities informed.

ZikaPLAN will work closely with two other European Union-funded consortia, ZIKAction and ZikAlliance, to establish a Latin American and Caribbean network. This network will address the broader issue of building local capacity in Latin America to prepare for and rapidly launch a large-scale research response to emerging infectious disease threats. ZikaPLAN will contribute to developing an inter-epidemic research plan, policy recommendations, training, research networks and dissemination strategies that are designed to permanently strengthen local capacities, beyond the four years of the project. The three consortia will set up common bodies for the global management of scientific programs, communication, and ethical, regulatory and legal issues.

ZikaPLAN is receiving a €11.5 million grant from the European Union’s Horizon 2020 research and innovation program, under grant agreement number 734584.

Emergencies

WHO Grade 3 Emergencies [to 29 October 2016]
Iraq
:: WHO and partners gear up to safeguard lives of displaced persons fleeing Mosul
26 October 2016 — The World Health Organization, together with national health authorities and health cluster partners, have accelerated preparedness and response measures for internally displaced persons from Mosul by prepositioning 46 mobile medical clinics, 45 mobile health teams and 26 ambulances in a number of prioritized areas around the country. Life-saving medicines and supplies for more than 350 000 beneficiaries have also been prepositioned, including chronic disease medicines, diarrhoeal disease medicines, and trauma and surgical supplies. Additional essential medicines are being delivered from WHO’s logistics hub in Dubai, and are also being procured locally.

Nigeria -No new announcements identified.
South Sudan – No new announcements identified.
The Syrian Arab Republic – No new announcements identified.
Yemen – No new announcements identified.

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WHO Grade 2 Emergencies [to 29 October 2016]
Cameroon – No new announcements identified.
Central African Republic – No new announcements identified.
Democratic Republic of the Congo – No new announcements identified.
Ethiopia – No new announcements identified.
Libya – No new announcements identified.
Myanmar – No new announcements identified.
Niger – No new announcements identified.
Ukraine – No new announcements identified.

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Editor’s Note:
While the WHO Emergency webpages above do not capture the announcements below, we add them here for continuity in understanding emergency contexts.
WHO Eastern Mediterranean Region EMRO
:: WHO releases emergency funds to support cholera response in Yemen
27 October 2016 – WHO has released approximately US$ 1 million from its internal emergency funds to support the ongoing response to the cholera outbreak in Yemen. Since the outbreak was announced by the Ministry of Public Health and Population on 6 October, a total of 1184 suspected cases of cholera, including 6 deaths, have been reported. More than 7.6 million people are currently living in areas affected by the outbreak, and more than 3 million internally displaced persons are especially vulnerable.

: WHO expands the system for detection, alert, and containment of potential epidemics in light of Mosul humanitarian response – 26 October 2016
Baghdad, 26 October 2016 – In coordination with the Iraqi Federal Ministry of Health and Ministry of Health of Kurdistan Regional Government, WHO conducted 3 consecutive training sessions from 28 September to 6 October 2016 in Erbil and Suleimaniyah in the Kurdistan region.
The training focused on the early warning alert and response network system (EWARNS) and was targeted at staff from the new health facilities established to respond to the health needs of newly displaced populations in formal and emergency settlements, and hosting communities.
“We have to monitor communicable diseases trends, patterns and vigilance,” said Altaf Musani, WHO Representative to Iraq. “EWARNS will be the tool to measure these trends and help to detect early epidemics in displaced population areas to support the federal and regional ministries of health and health cluster partners with effective epidemic-prone disease prevention and control measures,” he added.
This series of trainings marked the entry of new 43 health facilities to the network in Iraq to scale up the number of reporting sites to over 180. 24 health staff from Ninewa Directorate of Health received comprehensive training on EWARNS reporting and are ready for deployment to the new health facilities to resume related EWARNS functions…

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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 –
:: Iraq: Mosul Humanitarian Response Situation Report #3 (23-25 October 2016)
Highlights
…Over 10,500 people are currently displaced and in need of humanitarian assistance. Partners are providing emergency assistance in camps and host communities. The majority of displaced people are sheltering in host communities.
…Population movements are fluctuating as the front lines move, including people returning to their homes following improved security conditions in the immediate area.
…Assessments have recorded a significant number of female-headed households, raising concerns around the detention or capture of men and boys.
…Almost 14,500 people have received emergency assistance within 24 hours of areas newly-retaken from ISIL becoming accessible to humanitarian partners since the start of military operations.

Syria
:: 28 Oct 2016 Turkey | Syria: Flash Update – Developments in Eastern Aleppo (as of 27 October 2016) [EN/AR]
:: 26 October 2016 Under-Secretary-General for Humanitarian Affairs and Emergency Relief Coordinator Stephen O’Brien Statement to the Security Council on Syria, 26 October 2016

Yemen
– No new announcements identified.