The Lancet
Jun 06, 2015 Volume 385 Number 9984 p2223-2322
http://www.thelancet.com/journals/lancet/issue/current

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Comment
An updated Ebola vaccine: immunogenic, but will it protect?
Andrea Marzi, Darryl Falzarano
Published Online: 24 March 2015
DOI: http://dx.doi.org/10.1016/S0140-6736(15)60613-4

The largest outbreak of Ebola virus ever recorded has been ongoing for about 16 months in west Africa. In the past week, Liberia, which had nearly reached the halfway point to being declared Ebola free, has reported a new case, and new Ebola infections continue to be confirmed in Sierra Leone and Guinea.1 With more than 24 000 cases and almost 10 000 fatalities,1 this outbreak is one of the biggest public health crises so far this century. When the outbreak was first confirmed in March, 2014, none of the experimental vaccine platforms with promising results in non-human primate studies2 had advanced beyond assessment in phase 1 clinical trials in human beings, let alone been approved for human use. But only a few months later, with the epidemic spreading and thousands of people infected in west Africa, the international community pulled together to accelerate phase 1 clinical trials in humans for vaccine platforms based on recombinant adenovirus (ClinicalTrials.gov numbers NCT02289027, NCT02368119, NCT02231866, NCT02354404, NCT02240875, NCT02267109) and vesicular stomatitis virus (NCT02287480, NCT02269423, NCT02296983, NCT02314923, NCT02280408, NCT02374385, NCT02283099).

The timely study by Feng-Cai Zhu and colleagues3 in The Lancet is the fourth report of a phase 1 trial in humans using either recombinant adenovirus-based or DNA-based vaccination strategies.4, 5, 6 The recombinant adenovirus type-5 vaccine platform has previously been tested by other investigators with a prototypic Ebola virus glycoprotein.2 The present study updated the vaccine vector to encode the glycoprotein from the 2014 west African Ebola virus isolate, making it the first Ebola vaccine report to use an immunogen that matches that of the currently circulating Ebola virus strain.

In the study, 120 healthy Chinese individuals were randomly assigned to receive placebo (n=40), or a low dose (4 × 1010 viral particles; n=40) or high dose (1·6 × 1011 viral particles; n=40) of the recombinant adenovirus type-5 vaccine.3 In each group, roughly 60% of the participants had pre-existing neutralising antibody titres greater than 1:200 to adenovirus type-5. In a previous phase 1 trial based on a different recombinant adenovirus type-5-based Ebola vaccine vector with promising data in non-human primates, pre-existing adenovirus type-5 neutralising antibodies negatively affected the immune response to the vaccine (55% vs 100% response).2, 7 These data provided the basis for replacement of the adenovirus-type-5 vector with a chimpanzee adenovirus vector.5

The increased vaccine doses used in Zhu and colleagues’ study3 seem to partly circumvent pre-existing immunity to the vector, because participants in the high-dose group had a 100% response rate, with no resultant increase in adverse events. Glycoprotein-specific antibody titres significantly increased in the low-dose and high-dose vaccine groups at both day 14 (geometric mean titre 421·4 [95% CI 249·7–711·3] and 820·5 [598·9–1124·0], respectively) and day 28 (682·7 [424·3–1098·5] and 1305·7 [970·1–1757·2], respectively), with T-cell responses peaking at day 14 in both these groups (median 465·0 spot-forming cells [IQR 180·0–1202·5] and 765·0 cells [400·0–1460·0], respectively). The antigen-specific immunoglobulin-G responses in participants in the high-dose group with low pre-existing adenovirus type-5 immunity (≤1:200) resulted in geometric mean titres of 2231·8 (95% CI 1268·6–3926·2) at 4 weeks after vaccination, but titres decreased to 946·5 (705·4–1270·1) when the immunised individuals had pre-existing neutralising titres greater than 1:200. This finding is a major concern about this vaccine platform, because 80% of the target population in Africa are expected to have adenovirus type-5 neutralising antibody titres.8 Furthermore, findings from previous studies9, 10 in non-human primates suggest that with adenovirus-based vaccines, an Ebola virus glycoprotein-specific ELISA 90% effective concentration (the metric also used in the present study) titre of 3000 is required for protection, and this concentration was not reached in the present trial, particularly in participants with pre-existing adenovirus type-5 immunity. This recombinant adenovirus-based type-5 Ebola virus vaccine also elicits a similar T-cell response in humans to that shown with the chimpanzee adenovirus vector, peaking 14 days after vaccination.5

The glycoprotein from the present outbreak strain has 97% similarity to previously known Ebola virus vaccine isolates,11 and vaccines using the prototypic antigen are expected to protect against infection with the west African isolates. Data from preclinical animal studies will hopefully provide information about the importance of having a vaccine antigen that is identical to that of circulating viruses.

Because Zhu and colleagues’ report3 is preliminary, antibody responses have only been assessed up to day 28 after vaccination. Thus, the durability of a single-dose recombinant adenovirus type-5 vaccination is still unknown, and assessment of whether subsequent boosts will be necessary to maintain or establish sufficient long-term immunity will be important. 82 (68%) participants reported at least one solicited adverse reaction within 7 days of vaccination (19 in the placebo group vs 27 in the low-dose group vs 36 in the high-dose group). The only reported adverse event in all three groups was mild pain at the injection site (eight in the placebo group, 14 in the low-dose group, and 29 in the high-dose vaccine group),3 a minor side-effect, suggesting that administration of the high dose probably needed in Africa would be acceptable. However, follow-up was only for 28 days and no conclusion about long-term side-effects can be made.

This adenovirus type-5 Ebola vaccine vector is an example of how quickly existing vaccine platforms can be modified to incorporate a new virus strain, and moved, with minimum testing in animals, into trials in humans during a crisis situation. However, for this vector, efficacy testing in non-human primates to establish whether the high-dose vaccine would be effective against homologous and heterologous Ebola virus strains still needs to be done. The outstanding question remains as to whether DNA, recombinant adenovirus, or recombinant chimpanzee adenovirus vaccine platforms will be more effective than a recombinant vesicular stomatitis virus-based vaccine, which by contrast is fast acting and not affected by pre-existing vector immunity.12 Ultimately, the effectiveness of all these vaccines will only become clear when they proceed to phase 2 efficacy trials in outbreak regions.

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Articles
Safety and immunogenicity of a novel recombinant adenovirus type-5 vector-based Ebola vaccine in healthy adults in China: preliminary report of a randomised, double-blind, placebo-controlled, phase 1 trial
Feng-Cai Zhu, MSc, Li-Hua Hou, PhD, Jing-Xin Li, MSc, Shi-Po Wu, PhD, Prof Pei Liu, PhD, Gui-Rong Zhang, PhD, Yue-Mei Hu, BSc, Fan-Yue Meng, MSc, Jun-Jie Xu, PhD, Rong Tang, MSc, Jin-Long Zhang, PhD, Wen-Juan Wang, MSc, Lei Duan, MSc, Kai Chu, MSc, Qi Liang, MSc, Jia-Lei Hu, MSc, Li Luo, MSc, Tao Zhu, PhD, Jun-Zhi Wang, PhD, Dr Wei Chen, PhD
Published Online: 24 March 2015
DOI: http://dx.doi.org/10.1016/S0140-6736(15)60553-0
Summary
Background
Up to now, all tested Ebola virus vaccines have been based on the virus strain from the Zaire outbreak in 1976. We aimed to assess the safety and immunogenicity of a novel recombinant adenovirus type-5 vector-based Ebola vaccine expressing the glycoprotein of the 2014 epidemic strain.
Methods
We did this randomised, double-blind, placebo-controlled, phase 1 clinical trial at one site in Taizhou County, Jiangsu Province, China. Healthy adults (aged 18–60 years) were sequentially enrolled and randomly assigned (2:1), by computer-generated block randomisation (block size of six), to receive placebo, low-dose adenovirus type-5 vector-based Ebola vaccine, or high-dose vaccine. Randomisation was pre-stratified by dose group. All participants, investigators, and laboratory staff were masked to treatment allocation. The primary safety endpoint was occurrence of solicited adverse reactions within 7 days of vaccination. The primary immunogenicity endpoints were glycoprotein-specific antibody titres and T-cell responses at day 28 after the vaccination. Analysis was by intention to treat. The study is registered with ClinicalTrials.gov, number NCT02326194.
Findings
Between Dec 28, 2014, and Jan 9, 2015, 120 participants were enrolled and randomly assigned to receive placebo (n=40), low-dose vaccine (n=40), or high-dose vaccine. Participants were followed up for 28 days. Overall, 82 (68%) participants reported at least one solicited adverse reaction within 7 days of vaccination (n=19 in the placebo group vs n=27 in the low-dose group vs n=36 in the high-dose group; p=0·0002). The most common reaction was mild pain at the injection site, which was reported in eight (20%) participants in the placebo group, 14 (35%) participants in the low-dose group, and 29 (73%) participants in the high-dose vaccine group (p<0·0001). We recorded no statistical differences in other adverse reactions and laboratory tests across groups. Glycoprotein-specific antibody titres were significantly increased in participants in the low-dose and high-dose vaccine groups at both day 14 (geometric mean titre 421·4 [95% CI 249·7–711·3] and 820·5 [598·9–1124·0], respectively; p<0·0001) and day 28 (682·7 [424·3–1098·5] and 1305·7 [970·1–1757·2], respectively; p<0·0001). T-cell responses peaked at day 14 at a median of 465·0 spot-forming cells (IQR 180·0–1202·5) in participants in the low-dose group and 765·0 cells (400·0–1460·0) in those in the high-dose group. 21 (18%) participants had mild fever (n=9 in the placebo group, n=6 in the low-dose group, and n=6 in the high-dose group). No serious adverse events were recorded.
Interpretation
Our findings show that the high-dose vaccine is safe and robustly immunogenic. One shot of the high-dose vaccine could mount glycoprotein-specific humoral and T-cell response against Ebola virus in 14 days.
Funding
China National Science and Technology, Beijing Institute of Biotechnology, and Tianjin CanSino Biotechnology.

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Comment
Ebola: the challenging road to recovery
Michael Edelstein, Philip Angelides, David L Heymann
Published Online: 08 February 2015
DOI: http://dx.doi.org/10.1016/S0140-6736(15)60203-3
The resurgence of polio in Syria in 2013 has shown how a breakdown in public health can lead to the re-emergence of previously well-controlled diseases.1 In 2014 and early 2015 Liberia, Guinea, and Sierra Leone have focused all resources on the Ebola response at the expense of other health programmes. Combined with losing a large proportion of the health-care workforce and the population’s reluctance to attend health-care facilities for fear of Ebola, this means the three countries are now at increased risk of other diseases that their health programmes usually target.

The Lancet Infectious Diseases
Jun 2015 Volume 15 Number 6 p615-746
http://www.thelancet.com/journals/laninf/issue/current

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Articles
Statistical power and validity of Ebola vaccine trials in Sierra Leone: a simulation study of trial design and analysis
Dr Steven E Bellan, PhD, Juliet R C Pulliam, PhD, Carl A B Pearson, PhD, David Champredon, MSc, Spencer J Fox, BS, Laura Skrip, MPH, Prof Alison P Galvani, PhD, Manoj Gambhir, PhD, Ben A Lopman, PhD, Prof Travis C Porco, PhD, Prof Lauren Ancel Meyers, PhD, Jonathan Dushoff, PhD
Published Online: 14 April 2015
DOI: http://dx.doi.org/10.1016/S1473-3099(15)70139-8
Summary
Background
Safe and effective vaccines could help to end the ongoing Ebola virus disease epidemic in parts of west Africa, and mitigate future outbreaks of the virus. We assess the statistical validity and power of randomised controlled trial (RCT) and stepped-wedge cluster trial (SWCT) designs in Sierra Leone, where the incidence of Ebola virus disease is spatiotemporally heterogeneous, and is decreasing rapidly.
Methods
We projected district-level Ebola virus disease incidence for the next 6 months, using a stochastic model fitted to data from Sierra Leone. We then simulated RCT and SWCT designs in trial populations comprising geographically distinct clusters at high risk, taking into account realistic logistical constraints, and both individual-level and cluster-level variations in risk. We assessed false-positive rates and power for parametric and non-parametric analyses of simulated trial data, across a range of vaccine efficacies and trial start dates.
Findings
For an SWCT, regional variation in Ebola virus disease incidence trends produced increased false-positive rates (up to 0·15 at α=0·05) under standard statistical models, but not when analysed by a permutation test, whereas analyses of RCTs remained statistically valid under all models. With the assumption of a 6-month trial starting on Feb 18, 2015, we estimate the power to detect a 90% effective vaccine to be between 49% and 89% for an RCT, and between 6% and 26% for an SWCT, depending on the Ebola virus disease incidence within the trial population. We estimate that a 1-month delay in trial initiation will reduce the power of the RCT by 20% and that of the SWCT by 49%.
Interpretation
Spatiotemporal variation in infection risk undermines the statistical power of the SWCT. This variation also undercuts the SWCT’s expected ethical advantages over the RCT, because an RCT, but not an SWCT, can prioritise vaccination of high-risk clusters.
Funding
US National Institutes of Health, US National Science Foundation, and Canadian Institutes of Health Research.

Maternal and Child Health Journal
Volume 19, Issue 6, June 2015
http://link.springer.com/journal/10995/19/6/page/1

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Commentary
New Dialogue for the Way Forward in Maternal Health: Addressing Market Inefficiencies
Katharine McCarthy, Saumya Ramarao, Hannah Taboada
Abstract
Despite notable progress in Millennium Development Goal (MDG) five, to reduce maternal deaths three-quarters by 2015, deaths due to treatable conditions during pregnancy and childbirth continue to concentrate in the developing world. Expanding access to three effective and low-cost maternal health drugs can reduce preventable maternal deaths, if available to all women. However, current failures in markets for maternal health drugs limit access to lifesaving medicines among those most in need. In effort to stimulate renewed action planning in the post-MDG era, we present three case examples from other global health initiatives to illustrate how market shaping strategies can scale-up access to essential maternal health drugs. Such strategies include: sharing intelligence among suppliers and users to better approximate and address unmet need for maternal health drugs, introducing innovative financial strategies to catalyze otherwise unattractive markets for drug manufacturers, and employing market segmentation to create a viable and sustainable market. By building on lessons learned from other market shaping interventions and capitalizing on opportunities for renewed action planning and partnership, the maternal health field can utilize market dynamics to better ensure sustainable and equitable distribution of essential maternal health drugs to all women, including the most marginalized

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Methodological Notes
Post-disaster Health Indicators for Pregnant and Postpartum Women and Infants
Marianne E. Zotti, Amy M. Williams, Etobssie Wako
Abstract
United States (U.S.) pregnant and postpartum (P/PP) women and their infants may be particularly vulnerable to effects from disasters. In an effort to guide post-disaster assessment and surveillance, we initiated a collaborative process with nationwide expert partners to identify post-disaster epidemiologic indicators for these at-risk groups. This 12 month process began with conversations with partners at two national conferences to identify critical topics for P/PP women and infants affected by disaster. Next we hosted teleconferences with a 23 member Indicator Development Working Group (IDWG) to review and prioritize the topics. We then divided the IDWG into three population subgroups (pregnant women, postpartum women, and infants) that conducted at least three teleconferences to discuss the proposed topics and identify/develop critical indicators, measures for each indicator, and relevant questions for each measure for their respective population subgroup. Lastly, we hosted a full IDWG teleconference to review and approve the indicators, measures, and questions. The final 25 indicators and measures with questions (available online) are organized by population subgroup: pregnant women (indicators = 9; measures = 24); postpartum women (indicators = 10; measures = 36); and infants (indicators = 6; measures = 30). We encourage our partners in disaster-affected areas to test these indicators and measures for relevancy and completeness. In post-disaster surveillance, we envision that users will not use all indicators and measures but will select ones appropriate for their setting. These proposed indicators and measures promote uniformity of measurement of disaster effects among U.S. P/PP women and their infants and assist public health practitioners to identify their post-disaster needs.

The Milbank Quarterly
A Multidisciplinary Journal of Population Health and Health Policy
June 2015 Volume 93, Issue 2 Pages 223–445
http://onlinelibrary.wiley.com/doi/10.1111/milq.2015.93.issue-2/issuetoc

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Review Article
Advocacy for Health Equity: A Synthesis Review
LINDEN FARRER*, CLAUDIA MARINETTI, YOLINE KUIPERS CAVACO andCAROLINE COSTONGS
Article first published online: 4 JUN 2015
DOI: 10.1111/1468-0009.12112
Abstract
Context
Health inequalities are systematic differences in health among social groups that are caused by unequal exposure to—and distributions of—the social determinants of health (SDH). They are persistent between and within countries despite action to reduce them. Advocacy is a means of promoting policies that improve health equity, but the literature on how to do so effectively is dispersed. The aim of this review is to synthesize the evidence in the academic and gray literature and to provide a body of knowledge for advocates to draw on to inform their efforts.
Methods
This article is a systematic review of the academic literature and a fixed-length systematic search of the gray literature. After applying our inclusion criteria, we analyzed our findings according to our predefined dimensions of advocacy for health equity. Last, we synthesized our findings and made a critical appraisal of the literature.
Findings
The policy world is complex, and scientific evidence is unlikely to be conclusive in making decisions. Timely qualitative, interdisciplinary, and mixed-methods research may be valuable in advocacy efforts. The potential impact of evidence can be increased by “packaging” it as part of knowledge transfer and translation. Increased contact between researchers and policymakers could improve the uptake of research in policy processes. Researchers can play a role in advocacy efforts, although health professionals and disadvantaged people, who have direct contact with or experience of hardship, can be particularly persuasive in advocacy efforts. Different types of advocacy messages can accompany evidence, but messages should be tailored to advocacy target. Several barriers hamper advocacy efforts. The most frequently cited in the academic literature are the current political and economic zeitgeist and related public opinion, which tend to blame disadvantaged people for their ill health, even though biomedical approaches to health and political short-termism also act as barriers. These barriers could be tackled through long-term actions to raise public awareness and understanding of the SDH and through training of health professionals in advocacy. Advocates need to take advantage of “windows of opportunity,” which open and close quickly, and demonstrate expertise and credibility.
Conclusions
This article brings together for the first time evidence from the academic and the gray literature and provides a building block for efforts to advocate for health equity. Evidence regarding many of the dimensions is scant, and additional research is merited, particularly concerning the applicability of findings outside the English-speaking world. Advocacy organizations have a central role in advocating for health equity, given the challenges bridging the worlds of civil society, research, and policy.

New England Journal of Medicine
June 4, 2015 Vol. 372 No. 23
http://www.nejm.org/toc/nejm/medical-journal

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Perspective
International Health Care Systems
Brazil’s Family Health Strategy — Delivering Community-Based Primary Care in a Universal Health System
James Macinko, Ph.D., and Matthew J. Harris, M.B., B.S., D.Phil.
N Engl J Med 2015; 372:2177-218 1June 4, 2015 DOI: 10.1056/NEJMp1501140
[Initial text]
Brazil has made rapid progress toward universal coverage of its population through its national health system, the Sistema Único de Saúde (SUS). Since its emergence from dictatorship in 1985, Brazil — which has the world’s fifth-largest population and seventh-largest economy — has invested substantially in expanding access to health care for all citizens, a goal that is implicit in the Brazilian constitution and the principles guiding the national health system.1 The SUS comprises public and private health care institutions and providers, financed primarily through taxes with contributions from federal, state, and municipal budgets. Health care management is decentralized, and municipalities are responsible for most primary care services as well as some hospitals and other facilities. All publicly financed health services and most common medications are universally accessible and free of charge at the point of service for all citizens — even the 26% of the population enrolled in private health plans (see table)
An important innovation in the system has been the development, adaptation, and rapid scaling up of a community-based approach to providing primary health care…

Pediatrics
June 2015, VOLUME 135 / ISSUE 6
http://pediatrics.aappublications.org/current.shtml

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Article
Tdap Vaccine Effectiveness in Adolescents During the 2012 Washington State Pertussis Epidemic
Anna M. Acosta, MDa,b, Chas DeBolt, RN, MPHc, Azadeh Tasslimi, MPHc, Melissa Lewis, MPHd, Laurie K. Stewart, MSc, Lara K. Misegades, PhD, MSb, Nancy E. Messonnier, MDb, Thomas A. Clark, MD, MPHb, Stacey W. Martin, MSb, and Manisha Patel, MD, MSb
Author Affiliations
aEpidemic Intelligence Service, Scientific Education and Professional Development Program Office,
bMeningitis and Vaccine Preventable Disease Branch, Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, and
dBiostatistics Office, Division of Bacterial Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia; and
cCommunicable Disease Epidemiology, Washington State Department of Health, Shoreline, Washington
Abstract
BACKGROUND: Acellular pertussis vaccines replaced whole-cell vaccines for the 5-dose childhood vaccination series in 1997. A sixth dose of pertussis-containing vaccine, tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis, adsorbed (Tdap), was recommended in 2005 for adolescents and adults. Studies examining Tdap vaccine effectiveness (VE) among adolescents who have received all acellular vaccines are limited.
METHODS: To assess Tdap VE and duration of protection, we conducted a matched case-control study during the 2012 pertussis epidemic in Washington among adolescents born during 1993–2000. All pertussis cases reported from January 1 through June 30, 2012, in 7 counties were included; 3 controls were matched by primary provider clinic and birth year to each case. Vaccination histories were obtained through medical records, the state immunization registry, and parent interviews. Participants were classified by type of pertussis vaccine received on the basis of birth year: a mix of whole-cell and acellular vaccines (1993–1997) or all acellular vaccines (1998–2000). We used conditional logistic regression to calculate odds ratios comparing Tdap receipt between cases and controls.
RESULTS: Among adolescents who received all acellular vaccines (450 cases, 1246 controls), overall Tdap VE was 63.9% (95% confidence interval [CI]: 50% to 74%). VE within 1 year of vaccination was 73% (95% CI: 60% to 82%). At 2 to 4 years postvaccination, VE declined to 34% (95% CI: −0.03% to 58%).
CONCLUSIONS: Tdap protection wanes within 2 to 4 years. Lack of long-term protection after vaccination is likely contributing to increases in pertussis among adolescents

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Article
First Pertussis Vaccine Dose and Prevention of Infant Mortality
Tejpratap S.P. Tiwari, MDa, Andrew L. Baughman, PhD, MPHb, and Thomas A. Clark, MD, MPHa
Author Affiliations
aMeningitis and Bacterial Vaccine Preventable Diseases Branch, Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, and
bDivision of Global HIV/AIDS, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia
Abstract
BACKGROUND: American infants are at highest risk of severe pertussis and death. We investigated the role of ≥1 pertussis vaccinations in preventing pertussis-related deaths and risk markers for death among infants aged <42 days.
METHODS: We analyzed characteristics of fatal and nonfatal infant pertussis cases reported nationally during 1991–2008. Infants were categorized into 2 age groups on the basis of eligibility to receive a first pertussis vaccine dose at age 6 weeks; dose 1 was considered valid if given ≥14 days before illness onset. Multivariable logistic regression was used to estimate the effect of ≥1 pertussis vaccine doses on outcome and risk markers.
RESULTS: Pertussis-related deaths occurred among 258 of 45 404 cases. Fatal and nonfatal cases were confirmed by culture (54% vs 49%) and polymerase chain reaction (31% vs 27%). All deaths occurred before age 34 weeks at illness onset; 64% occurred before age 6 weeks. Among infants aged ≥42 days, receiving ≥1 doses of vaccine protected against death (adjusted odds ratio [aOR]: 0.28; 95% confidence interval [CI]: 0.11–0.74), hospitalization (aOR: 0.69; 95% CI: 0.63–0.77), and pneumonia (aOR: 0.80; 95% CI: 0.68–0.95). Risk was elevated for Hispanic ethnicity (aOR: 2.28; 95% CI: 1.36–3.83) and American Indian/Alaska Native race (aOR: 5.15; 95% CI: 2.37–11.2) and lower for recommended antibiotic treatment (aOR: 0.28; 95% CI: 0.16–0.47). Among infants aged <42 days, risk was elevated for Hispanic ethnicity and lower with recommended antibiotic use.
CONCLUSIONS: The first pertussis vaccine dose and antibiotic treatment protect against death, hospitalization, and pneumonia.

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Special Article
Strategies to Decrease Pertussis Transmission to Infants
Kevin Forsyth, MD, PhDa, Stanley Plotkin, MDb, Tina Tan, MDc, and Carl Heinz Wirsing von König, MDd
Author Affiliations
aDepartment of Paediatrics and Child Health, Flinders Medical Centre, Flinders University, Adelaide, Australia;
bDepartment of Pediatrics, University of Pennsylvania, Philadelphia, Pennsylvania;
cNorthwestern University, Feinberg School of Medicine, Chicago, Illinois; and
dLabor;Medizin Krefeld MVZ, Krefeld, Germany
Abstract
The Global Pertussis Initiative (GPI) is an expert scientific forum addressing the worldwide burden of pertussis, which remains a serious health issue, especially in infants. This age cohort is at risk for developing pertussis by transmission from those in close proximity. Risk is increased in infants aged 0 to 6 weeks, as they are too young to be vaccinated. Older infants are at risk when their vaccination schedules are incomplete. Infants also bear the greatest disease burden owing to their high risk for pertussis-related complications and death; therefore, protecting them is a high priority. Two vaccine strategies have been proposed to protect infants. The first involves vaccinating pregnant women, which directly protects through the passive transfer of pertussis antibodies. The second strategy, cocooning, involves vaccinating parents, caregivers, and other close contacts, which indirectly protects infants from transmission by preventing disease in those in close proximity. The goal of this review was to present and discuss evidence on these 2 strategies. Based on available data, the GPI recommends vaccination during pregnancy as the primary strategy, given its efficacy, safety, and logistic advantages over a cocoon approach. If vaccination during pregnancy is not feasible, then all individuals having close contact with infants <6 months old should be immunized consistent with local health authority guidelines. These efforts are anticipated to minimize pertussis transmission to vulnerable infants, although real-world effectiveness data are limited. Countries should educate lay and medical communities on pertussis and introduce robust surveillance practices while implementing these protective strategies.

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Commentary
Epidemic Pertussis and Acellular Pertussis Vaccine Failure in the 21st Century
James D. Cherry, MD, MSc
Author Affiliations
Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, California
[Initial text]
In this issue of Pediatrics Acosta et al1 present a tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis, adsorbed (Tdap) vaccine effectiveness study in adolescents in Washington State during the first 6 months of 2012. Their findings support the previous Tdap effectiveness data from Wisconsin.2 The duration of Tdap effectiveness is disappointing, particularly because case-control studies tend to inflate efficacy.3
In 4 recent publications (including 1 article in Pediatrics) I have discussed epidemic pertussis and why vaccines fail.4–7 Before discussing why Tdap vaccine effectiveness wanes so rapidly, it seems worthwhile to discuss how rapidly protection wanes after a natural infection in the pre-Tdap era and to take a realistic look at the resurgence of pertussis.
The resurgence of pertussis is often attributed to the switch from whole-cell pertussis vaccines to acellular products. However, the increase in reported pertussis began ∼14 years before the universal use of diphtheria-tetanus-acellular pertussis (DTaP) vaccines in childhood commenced. The 2 greatest contributors to the resurgence of pertussis are greater awareness and more sensitive diagnosis (the routine use …

PLoS Neglected Tropical Diseases
http://www.plosntds.org/
(Accessed 6 June 2015)

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What Factors Might Have Led to the Emergence of Ebola in West Africa?
Kathleen A. Alexander, Claire E. Sanderson, Madav Marathe, Bryan L. Lewis, Caitlin M. Rivers, effrey Shaman, John M. Drake, Eric Lofgren, Virginia M. Dato, Marisa C. Eisenberg, Stephen Eubank
Published: June 4, 2015
DOI: 10.1371/journal.pntd.0003652
Abstract
An Ebola outbreak of unprecedented scope emerged in West Africa in December 2013 and presently continues unabated in the countries of Guinea, Sierra Leone, and Liberia. Ebola is not new to Africa, and outbreaks have been confirmed as far back as 1976. The current West African Ebola outbreak is the largest ever recorded and differs dramatically from prior outbreaks in its duration, number of people affected, and geographic extent. The emergence of this deadly disease in West Africa invites many questions, foremost among these: why now, and why in West Africa? Here, we review the sociological, ecological, and environmental drivers that might have influenced the emergence of Ebola in this region of Africa and its spread throughout the region. Containment of the West African Ebola outbreak is the most pressing, immediate need. A comprehensive assessment of the drivers of Ebola emergence and sustained human-to-human transmission is also needed in order to prepare other countries for importation or emergence of this disease. Such assessment includes identification of country-level protocols and interagency policies for outbreak detection and rapid response, increased understanding of cultural and traditional risk factors within and between nations, delivery of culturally embedded public health education, and regional coordination and collaboration, particularly with governments and health ministries throughout Africa. Public health education is also urgently needed in countries outside of Africa in order to ensure that risk is properly understood and public concerns do not escalate unnecessarily. To prevent future outbreaks, coordinated, multiscale, early warning systems should be developed that make full use of these integrated assessments, partner with local communities in high-risk areas, and provide clearly defined response recommendations specific to the needs of each community.

PLoS Neglected Tropical Diseases
http://www.plosntds.org/
(Accessed 6 June 2015)

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Research Article
Updated Global Burden of Cholera in Endemic Countries
Mohammad Ali , Allyson R. Nelson, Anna Lena Lopez, David A. Sack
Published: June 4, 2015
DOI: 10.1371/journal.pntd.0003832
Abstract
Background
The global burden of cholera is largely unknown because the majority of cases are not reported. The low reporting can be attributed to limited capacity of epidemiological surveillance and laboratories, as well as social, political, and economic disincentives for reporting. We previously estimated 2.8 million cases and 91,000 deaths annually due to cholera in 51 endemic countries. A major limitation in our previous estimate was that the endemic and non-endemic countries were defined based on the countries’ reported cholera cases. We overcame the limitation with the use of a spatial modelling technique in defining endemic countries, and accordingly updated the estimates of the global burden of cholera.
Methods/Principal Findings
Countries were classified as cholera endemic, cholera non-endemic, or cholera-free based on whether a spatial regression model predicted an incidence rate over a certain threshold in at least three of five years (2008-2012). The at-risk populations were calculated for each country based on the percent of the country without sustainable access to improved sanitation facilities. Incidence rates from population-based published studies were used to calculate the estimated annual number of cases in endemic countries. The number of annual cholera deaths was calculated using inverse variance-weighted average case-fatality rate (CFRs) from literature-based CFR estimates. We found that approximately 1.3 billion people are at risk for cholera in endemic countries. An estimated 2.86 million cholera cases (uncertainty range: 1.3m-4.0m) occur annually in endemic countries. Among these cases, there are an estimated 95,000 deaths (uncertainty range: 21,000-143,000).
Conclusion/Significance
The global burden of cholera remains high. Sub-Saharan Africa accounts for the majority of this burden. Our findings can inform programmatic decision-making for cholera control.
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Author Summary
The global burden of cholera is largely unknown because the majority of cases are not reported. The low reporting can be attributed to limited capacity of epidemiological surveillance and laboratories, as well as social, political, and economic disincentives for reporting. We previously estimated 2.8 million cases and 91,000 deaths annually due to cholera in 51 endemic countries. A major limitation in our previous estimate was that the endemic and non-endemic countries were defined based on the countries’ reported cholera cases. If a country did not report cases even though the country had cholera, the country was classified as cholera free. This time we addressed this limitation by using a spatial modelling technique, which helped us define the cholera-endemic countries based on access to improved water and sanitation in the country as well as cholera incidence in neighboring countries. Our new estimate illustrates 2.9 million of cases and 95,000 deaths in 69 endemic countries, with the majority of the burden in Sub-Saharan Africa. The sustained high burden of cholera points to the necessity for integrated and improved control efforts, and these findings may help programmatic decision-making for controlling the disease in endemic countries.

PLoS Pathogens
http://journals.plos.org/plospathogens/
(Accessed 6 June 2015)
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Pearls
A 21st Century Perspective of Poliovirus Replication
Nicolas Lévêque, Bert L. Semler
Published: June 4, 2015
DOI: 10.1371/journal.ppat.1004825
Featured in PLOS Collections
Why Poliovirus Replication Has Been Studied for More Than 50 Years

Poliovirus is the etiologic agent of poliomyelitis, an acute flaccid paralysis affecting 1%–2% of infected patients and, on rare occasions, causing death by paralyzing muscles that control the throat or breathing. A striking feature of infection is lifelong disabilities that may affect survivors of the acute disease. Transmitted by the fecal—oral and oral—oral route, this virus (three serotypes) was one of the most feared pathogens in industrialized countries during the 20th century affecting hundreds of thousands of children every year, via outbreaks during warm summer months. Although there are highly effective vaccines to control poliomyelitis, it remains endemic in a few countries, from which spread and outbreaks continue to occur throughout the world. Since its discovery in 1908, poliovirus has been intensively studied to better understand and control this formidable pathogen. The history of poliovirus is not, however, limited to the fight against the disease. Poliovirus replication studies also have played important roles in the development of modern virology since poliovirologists and, more generally, picornavirologists have been pioneers in many domains of molecular virology. Poliovirus was, for example, the first animal RNA virus to have its complete genome sequence determined, the first RNA animal virus for which an infectious clone was constructed, and, along with the related rhinovirus, the first human virus that had its three-dimensional structure solved by X-ray crystallography. Indeed, the history of over half a century of poliovirus replication studies is marked by major discoveries, many of which are summarized here and illustrated in Fig 1…

Revista Panamericana de Salud Pública/Pan American Journal of Public Health (RPSP/PAJPH)
March 2015 Vol. 37, No.
http://www.paho.org/journal/index.php?option=com_content&view=article&id=158&Itemid=266&lang=en

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Prevalence of cholera risk factors between migrant Haitians and Dominicans in the Dominican Republic [Prevalencia de los factores de riesgo de cólera entre los inmigrantes haitianos y los dominicanos en la República Dominicana]
Andrea J. Lund, Hunter M. Keys, Stephanie Leventhal, Jennifer W. Foster, and Matthew C. Freeman

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Adequação da assistência pré-natal segundo as características maternas no Brasil [Adequacy of prenatal care according to maternal characteristics in Brazil]
Rosa Maria Soares Madeira Domingues, Elaine Fernandes Viellas, Marcos Augusto Bastos Dias, Jacqueline Alves Torres, Mariza Miranda Theme-Filha, Silvana Granado Nogueira da Gama e Maria do Carmo Leal

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A systematic review of nursing research priorities on health system and services in the Americas [Revisión sistemática de las prioridades de investigación de enfermería en sistemas y servicios de salud en la Región de las Américas]
Alessandra Bassalobre Garcia, Silvia Helena De Bortoli Cassiani,and Ludovic Reveiz

Tropical Medicine & International Health
July 2015 Volume 20, Issue 7 Pages 821–966
http://onlinelibrary.wiley.com/doi/10.1111/tmi.2015.20.issue-7/issuetoc

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Pneumococcal carriage in rural Gambia prior to the introduction of pneumococcal conjugate vaccine: a population-based survey (pages 871–879)
Effua Usuf, Henry Badji, Abdoulie Bojang, Sheikh Jarju, Usman Nurudeen Ikumapayi, Martin Antonio, Grant Mackenzie and Christian Bottomley
Article first published online: 6 APR 2015 | DOI: 10.1111/tmi.12505
Abstract
Objective
To evaluate pneumococcal colonisation before and after the introduction of pneumococcal conjugate vaccine (PCV) in eastern Gambia.
Methods
Population-based cross-sectional survey of pneumococcal carriage between May and August 2009 before the introduction of PCV into the Expanded Program on Immunization. Nasopharyngeal swabs were collected from all household members, but in selected households, only children aged 6–10 years were swabbed. This age group participated in an earlier trial of a nine-valent PCV between 2000 and 2004.
Results
The prevalence of nasopharyngeal pneumococcal carriage in 2933 individuals was 72.0% in underfives (N = 515), 41.6% in children aged 5–17 (N = 1508) and 13.0% in adults ≥18 (N = 910) years. The age-specific prevalence of serotypes included in PCV7, PCV10 and PCV13 was 24.7%, 26.6% and 46.8% among children <5 years of age; 8.5%, 9.2% and 17.7% among children 5–17 years; and 2.5%, 3.3% and 5.5% among adults ≥18 years. The most common serotypes were 6A (13.1%), 23F (7.6%), 3 (7.3%), 19F (7.1%) and 34 (4.6%). There was no difference in the overall carriage of pneumococci between vaccinated and unvaccinated children 8 years after the primary vaccination with three doses of PCV (48.3% vs. 41.1%).
Conclusion
Before the introduction of PCV, serotypes included in PCV13 accounted for about half the pneumococcal serotypes in nasopharyngeal carriage. Thus, the potential impact of PCV13 on pneumococcal disease in the Gambia is substantial.

Vaccine
Volume 33, Issue 28, Pages 3159-3262 (22 June 2015)
http://www.sciencedirect.com/science/journal/0264410X/33

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Vaccination errors reported to the Vaccine Adverse Event Reporting System, (VAERS) United States, 2000–2013
Original Research Article
Pages 3171-3178
Beth F. Hibbs, Pedro L. Moro, Paige Lewis, Elaine R. Miller, Tom T. Shimabukuro
Abstract
Importance
Vaccination errors are preventable events. Errors can have impacts including inadequate immunological protection, possible injury, cost, inconvenience, and reduced confidence in the healthcare delivery system.
Objectives
To describe vaccination error reports submitted to the Vaccine Adverse Event Reporting System (VAERS) and identify opportunities for prevention.
Methods
We conducted descriptive analyses using data from VAERS, the U.S. spontaneous surveillance system for adverse events following immunization. The VAERS database was searched from 2000 through 2013 for U.S. reports describing vaccination errors and reports were categorized into 11 error groups. We analyzed numbers and types of vaccination error reports, vaccines involved, reporting trends over time, and descriptions of errors for selected reports.
Results
We identified 20,585 vaccination error reports documenting 21,843 errors. Annual reports increased from 10 in 2000 to 4324 in 2013. The most common error group was “Inappropriate Schedule” (5947; 27%); human papillomavirus (quadrivalent) (1516) and rotavirus (880) vaccines were most frequently involved. “Storage and Dispensing” errors (4983; 23%) included mostly expired vaccine administered (2746) and incorrect storage of vaccine (2202). “Wrong Vaccine Administered” errors (3372; 15%) included mix-ups between vaccines with similar antigens such as varicella/herpes zoster (shingles), DTaP/Tdap, and pneumococcal conjugate/polysaccharide. For error reports with an adverse health event (5204; 25% of total), 92% were classified as non-serious. We also identified 936 vaccination error clusters (i.e., same error, multiple patients, in a common setting) involving over 6141 patients. The most common error in clusters was incorrect storage of vaccine (582 clusters and more than 1715 patients).
Conclusions
Vaccination error reports to VAERS have increased substantially. Contributing factors might include changes in reporting practices, increasing complexity of the immunization schedule, availability of products with similar sounding names or acronyms, and increased attention to storage and temperature lapses. Prevention strategies should be considered.

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Estimates of pertussis vaccine effectiveness in United States air force pediatric dependents
Original Research Article
Pages 3228-3233
Greg Wolff, Michael Bell, James Escobar, Stefani Ruiz
Abstract
Background
Pertussis vaccination compliance is critical for reduction in the prevalence of disease; however, the current acellular pertussis vaccine may not provide sufficient protection from infection. This study examined acellular pertussis vaccine effectiveness (VE) for Air Force dependents less than 12 years of age.
Methods
We conducted a case-control study among Air Force pediatric dependents from 2011 to 2013, comparing cases with positive pertussis test results to controls who received the same lab tests with a negative result. Our study population was categorized by age group and vaccination status based on the Centers for Disease Control and Prevention recommended pertussis vaccination schedule. VE was calculated with respect to vaccination status and pertussis lab results.
Results
We compared 27 pertussis laboratory positive cases with 974 pertussis laboratory negative controls, 2 months to <12 years old. Comparing completely vaccinated to non-vaccinated patients, the overall VE was 78.3% (95% confidence interval (CI): 48.6, 90.8; p < 0.001). VE was highest among those 15 months to <6 years old: 97.6% (95% CI: 78.5, 99.7; p < 0.001). Children 6 to <12 years old had the lowest VE: 48.5% (95% CI: −74.0, 84.7; p = 0.28). Comparing partially vaccinated patients to nonvaccinated patients yielded 64.2% (95% CI: −7.2, 88.1; p = 0.06) overall VE.
Conclusions
Acellular pertussis vaccination was effective at preventing laboratory confirmed pertussis among our Air Force pediatric dependent population, with highest protection among completely vaccinated, young children. Older children received the lowest amount of protection. Partial vaccination had near significant protection. Our overall calculated pertussis VE corroborates other pertussis VE studies looking at similar age groups.

Vaccine
Volume 33, Issue 27, Pages 3065-3158 (17 June 2015)
http://www.sciencedirect.com/science/journal/0264410X/33/27

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Cost-effectiveness of norovirus vaccination in children in Peru
Original Research Article
Pages 3084-3091
Andrew J. Mirelman, Sarah Blythe Ballard, Mayuko Saito, Margaret N. Kosek, Robert H. Gilman
Abstract
Background
With candidate norovirus (NV) vaccines in a rapid phase of development, assessment of the potential economic value of vaccine implementation will be necessary to aid health officials in vaccine implementation decisions. To date, no evaluations have been performed to evaluate the benefit of adopting NV vaccines for use in the childhood immunization programs of low- and middle-income countries.
Methods
We used a Markov decision model to evaluate the cost-effectiveness of adding a two-dose NV vaccine to Peru’s routine childhood immunization schedule using two recent estimates of NV incidence, one for a peri-urban region and one for a jungle region of the country.
Results
Using the peri-urban NV incidence estimate, the annual cost of vaccination would be $13.0 million, offset by $2.6 million in treatment savings. Overall, this would result in 473 total DALYs averted; 526,245 diarrhea cases averted;153,735 outpatient visits averted; and 414 hospitalizations averted between birth and the fifth year of life. The incremental cost-effectiveness ratio would be $21,415 per DALY averted; $19.86 per diarrhea case; $68.23 per outpatient visit; and $26,298 per hospitalization. Using the higher jungle NV incidence rates provided a lower cost per DALY of $10,135. The incremental cost per DALY with per-urban NV incidence is greater than three times the 2012 GDP per capita of Peru but the estimate drops below this threshold using the incidence from the jungle setting. In addition to the impact of incidence, sensitivity analysis showed that vaccine price and efficacy play a strong role in determining the level of cost-effectiveness.
Conclusions
The introduction of a NV vaccine would prevent many healthcare outcomes in the Peru and potentially be cost-effective in scenarios with high NV incidence. The vaccine cost-effectiveness model could also be applied to the evaluation of NV vaccine cost-effectiveness in other countries. In resource-poor settings, where NV incidence rates are expected to be higher.

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Influenza vaccination coverage of Vaccine for Children (VFC)-entitled versus privately insured children, United States, 2011–2013
Original Research Article
Pages 3114-3121
Anup Srivastav, Yusheng Zhai, Tammy A. Santibanez, Katherine E. Kahn, Philip J. Smith, James A. Singleton
Abstract
Background
The Vaccines for Children (VFC) program provides vaccines at no cost to children who are Medicaid-eligible, uninsured, American Indian or Alaska Native (AI/AN), or underinsured and vaccinated at Federally Qualified Health Centers or Rural Health Clinics. The objective of this study was to compare influenza vaccination coverage of VFC-entitled to privately insured children in the United States, nationally, by state, and by selected socio-demographic variables.
Methods
Data from the National Immunization Survey-Flu (NIS-Flu) surveys were analyzed for the 2011–2012 and 2012–2013 influenza seasons for households with children 6 months–17 years. VFC-entitlement and private insurance status were defined based upon questions asked of the parent during the telephone interview. Influenza vaccination coverage estimates of children VFC-entitled versus privately insured were compared by t-tests, both nationally and within state, and within selected socio-demographic variables.
Results
For both seasons studied, influenza coverage for VFC-entitled children did not significantly differ from coverage for privately insured children (2011–2012: 52.0% ± 1.9% versus 50.7% ± 1.2%; 2012–2013: 56.0% ± 1.6% versus 57.2% ± 1.2%). Among VFC-entitled children, uninsured children had lower coverage (2011–2012: 38.9% ± 4.7%; 2012–2013: 44.8% ± 3.5%) than Medicaid-eligible (2011–2012: 55.2% ± 2.1%; 2012–2013: 58.6% ± 1.9%) and AI/AN children (2011–2012: 54.4% ± 11.3%; 2012–2013: 54.6% ± 7.0%). Significant differences in vaccination coverage among VFC-entitled and privately insured children were observed within some subgroups of race/ethnicity, income, age, region, and living in a metropolitan statistical area principle city.
Conclusions
Although finding few differences in influenza vaccination coverage among VFC-entitled versus privately insured children was encouraging, nearly half of all children were not vaccinated for influenza and coverage was particularly low among uninsured children. Additional public health interventions are needed to ensure that more children are vaccinated such as a strong recommendation from health care providers, utilization of immunization information systems, provider reminders, standing orders, and community-based interventions such as educational activities and expanded access to vaccination services.

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Burden of invasive pneumococcal disease (IPD) in Sri-Lanka: Deriving a reasonable measure for vaccine introduction decision making
Original Research Article
Pages 3122-3128
S. Kularatna, P.R. Wijesinghe, M.R.N. Abeysinghe, K. Karunaratne, L. Ekanayake
Abstract
Purpose
The lack of evidence on the disease burden has been an obstacle for decision-making on introducing pneumococcal vaccines in Sri-Lanka. Hence, the purpose of this study is to determine the incidence of invasive pneumococcal disease among children under five-years of age in Sri-Lanka’s Colombo district.
Methods
In a community-based study, using a sample of 2310 children, we identified syndromes associated with pneumococcal disease (pneumonia, meningitis, sepsis). The estimates of annual cumulative incidence of invasive pneumococcal disease were derived by having applied proportions of laboratory confirmed invasive pneumococcal disease among all-cause syndromes associated with pneumococcal infection obtained from the hospital-based invasive bacterial disease sentinel surveillance and findings of the community-based study to population parameters of the district. The estimates of invasive pneumococcal pneumonia and sepsis based on low-sensitive, culture confirmation were adjusted by a correction factor.
Results
The annual cumulative incidence of all-cause clinical syndromes associated with pneumococcal disease (pneumonia, meningitis, sepsis) were 1.3, 0.52, 0.39 per 100 children, respectively. The estimate of adjusted, invasive pneumococcal disease cumulative incidence was 206.3 per 100,000 while estimates of pneumococcal pneumonia, meningitis and sepsis cumulative incidence were 147.9, 13.2 and 45.2 per 100,000 under-five children.
Conclusion
Reasonable estimates of invasive pneumococcal disease could be derived by using incidence of clinical syndromes associated with pneumococcal disease obtained from population-based studies and proportion of pneumococcal infection among all-cause clinical syndromes associated with pneumococcal disease generated from hospital-based sentinel surveillance. These estimates may help informed decision-making on introduction of pneumococcal conjugated vaccine.

Vaccine
Volume 33, Issue 26, Pages 2955-3064 (12 June 2015)
http://www.sciencedirect.com/science/journal/0264410X/33/26

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Poliovirus immunity in newly resettled adult refugees in Idaho, United States of America
Pages 2968-2970
Clay Roscoe, Ryan Gilles, Alex J. Reed, Matt Messerschmidt, Rebecca Kinney
Abstract
Background
In the United States, vaccines have eliminated wild poliovirus (WPV) infection, though resettling refugees may lack immunity and importation of WPV remains a concern.
Methods
A cross-sectional survey was performed to determine the prevalence of poliovirus immunity in adult refugees resettling in Boise, Idaho, U.S.A.; immunity was evaluated using two definitions: serotypes 1, 2 and 3 positive, or serotypes 1 and 3 positive.
Results
This survey evaluated 795 adult refugees between August 2010 and November 2012. Poliovirus immunity in adults >18 years was 55.3% for serotypes 1, 2 and 3 combined, and 60% for serotypes 1 and 3 only.
Conclusion
This study demonstrated a WPV immunity rate of <60% in a recently resettled adult refugee population in the United States, reinforcing the need to ensure poliovirus immunity in all newly arrived adult refugees, either by expanding pre-departure immunization or by screening for immunity at resettlement and vaccinating when indicated.

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Determinants of maternal immunization in developing countries
Original Research Article
Pages 2971-2977
Jayani Pathirana, Jerome Nkambule, Steven Black
Abstract
Background
Maternal immunization is an effective intervention to protect newborns and young infants from infections when their immune response is immature. Tetanus toxoid vaccination of pregnant women is the most widely implemented maternal vaccine in developing countries where neonatal mortality is the highest. We identified barriers to maternal tetanus vaccination in developing African and Asian countries to identify means of improving maternal immunization platforms in these countries.
Method
We categorized barriers into health system, health care provider and patient barriers to maternal tetanus immunization and conducted a literature review on each category. Due to limited literature from Africa, we conducted a pilot survey of health care providers in Malawi on barriers they experience in immunizing pregnant women.
Results
The major barriers of the health system are due to inadequate financial and human resources which translate to inadequate vaccination services delivery and logistics management. Health care providers are limited by poor attendance of Antenatal Care and inadequate knowledge on vaccinating pregnant women. Patient barriers are due to lack of education and knowledge on pregnancy immunization and socioeconomic factors such as low income and high parity.
Conclusion
There are several factors that affect maternal tetanus immunization. Increasing knowledge in health care providers and patients, increasing antenatal care attendance and outreach activities will aid the uptake of maternal immunization. Health system barriers are more difficult to address requiring an improvement of overall immunization services. Further analyses of maternal immunization specific barriers and the means of addressing them are required to strengthen the existing program and provide a more efficient delivery system for additional maternal vaccines.

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Vaccines4Kids: Assessing the impact of text message reminders on immunization rates in infants
Original Research Article
Pages 2984-2989
Victoria Niederhauser, Melissa Johnson, Abbas S. Tavakoli
Abstract
The purpose of this study was to examine the effect text messages (TM) immunization reminders have on immunization rates in the first 7 months of life. This randomized-control trial enrolled 57 parent/infant dyads and had a 74% completion rate (43) at the end of the study period. The study was approved by Committee on Human Subjects at the University of Hawaii Institutional Board Review. All participants completed a demographics form and a Barriers to Immunization Survey (SHOTS survey) at the start and end of the study. Parents received TM at 4, 7, 12, 15, 20, & 23 weeks of child’s age. The intervention group received immunization reminders and the control group received healthy baby messages. In the overall mixed model, between enrollment and 7 months of age, the barriers to immunizations decreased for all parents significantly. There were no significant differences in immunization rates between groups at 7 months of age. Positive responses from regarding TM interventions show this is a promising intervention, but further research is required regarding how to address behavior change and motivation for health prevention behaviors with TM.

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Deaths averted by influenza vaccination in the U.S. during the seasons 2005/06 through 2013/14
Original Research Article
Pages 3003-3009
Ivo M. Foppa, Po-Yung Cheng, Sue B. Reynolds, David K. Shay, Cristina Carias, Joseph S. Bresee, Inkyu K. Kim, Manoj Gambhir, Alicia M. Fry
Abstract
Background
Excess mortality due to seasonal influenza is substantial, yet quantitative estimates of the benefit of annual vaccination programs on influenza-associated mortality are lacking.
Methods
We estimated the numbers of deaths averted by vaccination in four age groups (0.5 to 4, 5 to 19, 20 to 64 and ≥65 yrs.) for the nine influenza seasons from 2005/6 through 2013/14. These estimates were obtained using a Monte Carlo approach applied to weekly U.S. age group-specific estimates of influenza-associated excess mortality, monthly vaccination coverage estimates and summary seasonal influenza vaccine effectiveness estimates to obtain estimates of the number of deaths averted by vaccination. The estimates are conservative as they do not include indirect vaccination effects.
Results
From August, 2005 through June, 2014, we estimated that 40,127 (95% confidence interval [CI] 25,694 to 59,210) deaths were averted by influenza vaccination. We found that of all studied seasons the most deaths were averted by influenza vaccination during the 2012/13 season (9398; 95% CI 2,386 to 19,897) and the fewest during the 2009/10 pandemic (222; 95% CI 79 to 347). Of all influenza-associated deaths averted, 88.9% (95% CI 83 to 92.5%) were in people ≥65 yrs. old.
Conclusions
The estimated number of deaths averted by the US annual influenza vaccination program is considerable, especially among elderly adults and even when vaccine effectiveness is modest, such as in the 2012/13 season. As indirect effects (“herd immunity”) of vaccination are ignored, these estimates represent lower bound estimates and are thus conservative given valid excess mortality estimates

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Special Section on Aeras Meeting Reports on Tuberculosis Vaccine Development; Edited by Stefan H.E. Kaufmann
Aeras-sponsored meeting reports: Aerosol TB vaccines, whole mycobacteria cell TB vaccines, and prevention of sustained Mycobacterium tuberculosis infection
Pages 3035-3037
Stefan H.E. Kaufmann

Vaccine
Volume 33, Supplement 2, 8 June 2015, Pages B29–B33
http://www.sciencedirect.com/science/journal/0264410X/33/supp/S2

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Supplement: Enhancing Vaccine Immunity and Value
An update of the progress and future needs of research and policies for enhancing vaccine value, based on the symposium organised by Novartis

Introduction to the supplement
Pages B1-B2
Rino Rappuoli
Abstract
In July of 2014, a symposium entitled “Enhancing Vaccine Immunity and Value” was held in Siena, Italy. The focus of the symposium was on how to best meet the challenge of developing and implementing vaccines for future disease targets. Vaccination has been responsible for averting estimated 3 billion cases of disease and more than 500 million lives to date through the prevention of infectious diseases. This has largely been responsible for dramatic increases in life span in developed countries. However, with the demographics of the world’s population are changing, with many adults now surviving into their 80s, we now face the challenge of protecting the aging and other underserved populations not only against infectious diseases but also against cancer and other chronic conditions that occur in older adults. To face this challenge, we must harness new technologies derived from recent advances in the fields of immunology, structural biology, synthetic biology and genomics that promise a revolution in the vaccine field. Specifically, vaccine adjuvants have the potential to harness the immune system to provide protection against new types of diseases, improve protection in young children and expand this protection to adults and the elderly. However, in order to succeed, we need to overcome the non-technical challenges that could limit the implementation of innovative vaccines, including controversies regarding the safety of adjuvants, increasing regulatory complexity, the inadequate methods used to assess the value of novel vaccines, and the resulting industry alienation from future investment. In this supplement, we have assembled manuscripts from lectures and discussions of the symposium last July that addressed two related questions: how to improve vaccine efficacy using breakthrough technologies and how to capture the full potential of novel vaccines.

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Valuing vaccines: Deficiencies and remedies
Review Article
Pages B29-B33
David E. Bloom
Abstract
Current evaluation models for the value of vaccines typically account for a small subset of the full social and economic benefits of vaccination. Health investments yield positive economic benefits via several channels at the household, community, and national levels. Underestimating, or worse, not considering these benefits can lead to ill-founded recommendations regarding the introduction of vaccines into immunization programs. The clear and strong links between health and wealth suggest the need to redesign valuation frameworks for vaccination so that the full costs may be properly weighed against the full benefits of vaccines.

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Bridging the gap: Need for a data repository to support vaccine prioritization efforts
Review Article
Pages B34-B39
Guruprasad Madhavan, Charles Phelps, Kinpritma Sangha, Scott Levin, Rino Rappuoli

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_30 May 2015

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

– 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.
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David R. Curry, MS
Executive Director
Center for Vaccine Ethics and Policy
a program of the
– Division of Medical Ethics, NYU Medical School
– Children’s Hospital of Philadelphia Vaccine Education Center
Associate Faculty, Division of Medical Ethics, NYU Medical School

Sixty-eighth World Health Assembly [full documentation]

Editor’s Note:
The World Health Assembly concluded with a number high-level actions summarized in news releases as below. We focus below on action around immunization and include the full text of the WHA Global Vaccine Action Plan (GVAP) resolution. We note the aggressive call in the resolution for action on vaccine pricing transparency.

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Delegates discuss progress towards global immunization goals
25 May 2015 – Fifty-two speakers, including 46 delegates of Member States, one observer (Chinese Taipei), four civil society organizations and GAVI, the Vaccine Alliance took the floor during the discussion on the Global Vaccine Action Plan.

Delegates welcomed the GVAP assessment report, and commended the WHO Strategic Advisory Group of Experts (SAGE) on immunization on the recommendations in the report.

Delegates took note and expressed concern that the progress with the implementation of GVAP was patchy and slow and “far off-track” for achieving five out of six targets for 2014 and 2015.

WHO’s fundamental role in facilitating the implementation of the GVAP was acknowledged, stressing the important and leading role that WHO should play to:
:: Improve vaccine price transparency and build mechanisms that promote healthy and competitive vaccine markets, tackle the problems faced by middle income countries to secure sustainable supplies of vaccines at affordable prices, particularly for the newer vaccines.
:: Work to enhance awareness of the value of vaccines to increase acceptance of immunization and to mitigate the risks posed by misinformation leading to vaccine hesitancy and refusal.
:: Analyse the causes of vaccine stock out and develop tools to respond immediately to any supply shortfalls.
:: Regularly convene countries that remain off-track to assist with diagnosing the problems and finding solutions.
:: Support countries to improve the quality of data and to use data for informing decisions and for improving programme performance.
:: Expand the existing guidance for vaccination in humanitarian emergencies to also include guidance on sustaining routine immunization during periods of conflict and crisis, including outbreaks of disease, such as the current Ebola epidemic in west Africa.

Delegates acknowledged that countries and particularly national governments, play a leading role in making the needed investments in immunization. Governments are accountable for the progress as well as the monitoring of their own immunization programme performance.

The Health Assembly adopted a resolution tabled by Libya that specifically addresses the issue of access to sustainable supplies of affordable vaccines for low and middle income countries, including the promotion of vaccine price transparency, support for pooled procurement mechanisms and for increased capacity for the manufacture of vaccines of assured quality to foster competition for a healthy vaccine market.

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Note: List of Member States that made interventions during the GVAP discussion: Libya, Iceland, Panama, Chile, Australia, Brazil, Iran, Japan, Ethiopia, Morocco, Egypt, Republic of Korea, China, Ecuador, Pakistan, Lebanon, Brunei Darussalam, United Sates of America, Russians Federation, United Kingdom, Cape Verde, Thailand, Philippines, Tanzania, Nigeria, South Africa, Canada, Colombia, Bangladesh, Maldives, Jamaica, Bahamas, Bahrain, Saudi Arabia, Qatar, Malaysia, Argentina, Kuwait, Gabon, India, Venezuela, Latvia, Iraq, Senegal, Algeria, Greece

Note: List of civil society organizations that made interventions during the GVAP discussion: Save the Children, Médecins Sans Frontières, Medicus Mundi, International Pharmaceutical Federation

World Health Assembly addresses antimicrobial resistance, immunization gaps and malnutrition
25 May 2015
News release
Excerpt
…Immunization
The Assembly agreed a resolution to improve access to sustainable supplies of affordable vaccines – a key issue for low- and middle-income countries aiming to extend immunization to the entire population. In 2012, the Assembly endorsed the Global Vaccine Action Plan, a commitment to ensure that no one misses out on vital immunization by 2020. A report from WHO’s Strategic Advisory Group of Experts on immunization, warns, however, that progress towards the Action Plan’s targets is slow and patchy.

The resolution calls on WHO to coordinate efforts to address gaps in progress. It urges Member States to increase transparency around vaccine pricing and explore pooling the procurement of vaccines. It requests the WHO Secretariat to report on barriers that may undermine robust competition that can enable price reductions for new vaccines, and to address any other factors that might adversely affect the availability of vaccines. The resolution also highlighted that immunization is a highly cost-effective public health interventions, playing a major role in reducing child deaths and improving health. It recommends scaling up advocacy efforts to improve understanding of the value of vaccines and to allay fears leading to vaccine hesitancy.

Last week, on the margins of the Health Assembly, the Secretariat brought together high-level representatives of 34 countries with low immunization coverage to discuss challenges and explore solutions to overcome them…

::::::

WHA Resolution – Global vaccine action plan   A68/73 26 May 2015
The Sixty-eighth World Health Assembly,
Having considered the report on the global vaccine action plan A68/30;

Emphasizing the importance of immunization as one of the most effective interventions in public health and access to immunization as a key step towards access to health and universal health coverage;

Acknowledging the progress made in global immunization and the commitment under the 2011–2020 Decade of Vaccines to achieve immunization goals and milestones;

Recalling resolutions WHA58.15 and WHA61.15 on the global immunization strategy, resolution WHA65.17 on the global vaccine action plan, resolution WHA61.21 on the global strategy and plan of action on public health, innovation and intellectual property, resolution WHA54.11 on the WHO medicines strategy and resolution WHA67.20 on regulatory system strengthening for medical products;

Noting with concern that globally immunization coverage has increased only marginally since the late 2000s; and that in 2013 more than 21 million children under one year of age did not complete the three-dose series of diphtheria-tetanus-pertussis (DTP) vaccine;

Recognizing that the availability of new vaccines against important causes of vaccine preventable diseases such as pneumonia, diarrhoea and cervical cancer can prevent leading causes of childhood and women’s death;

Acknowledging that successful national immunization programmes require sustainable political and financial support of Member States;

Appreciating the contributions of WHO, UNICEF, the Gavi Alliance, and all partners in their efforts to support the introduction of new vaccines in developing countries and strengthen immunization services;

Concerned that inequities between Member States are growing, inter alia, due to the increased financial burden of new vaccines and based upon those that are eligible or ineligible for financial and technical support from global partners;

Concerned that many low- and middle-income countries may not have the opportunity to access newer and improved vaccines, particularly because of the costs related to the procurement and introduction of these vaccines; and concerned at the increase of costs of overall immunization programmes because of increase in price of the WHO-recommended vaccines;

Recognizing that publicly available data on vaccine prices are scarce, and that the availability of price information is important for facilitating Member States’ efforts towards introduction of new vaccines;

Recalling many Member States’ interventions on the Health Assembly’s immunization agenda item each year, expressing concern over the unaffordable cost of new vaccines and appealing to the global community to support strategies that will reduce prices;

Recalling the WHO global framework for expanding access to essential drugs, and its four components: the rational selection and use of medicines, reliable health and supply systems, sustainable financing, and affordable prices;

Taking into account the importance of competition to reduce prices and the need to expand the number of manufacturers, particularly in developing countries, that can produce WHO-prequalified vaccines and create a competitive market;

Stressing the critical life-saving role of vaccines and immunization programmes and striving to make immunization available to all;

Noting with concern the global shortage of certain traditional routine vaccines, for example BCG vaccine and combined measles-rubella vaccine;

Acknowledging that shortages of vaccines are quite often an important cause of disruption of vaccination schedules and that therefore the establishment of effective and sustainable vaccine production, supply, procurement and delivery systems is essential to ensure access to all the necessary vaccines of assured quality at the right time;

Concerned that scepticism against vaccination is continuing to grow in society despite the proven efficacy and safety of modern vaccines, and that many children do not receive life-saving vaccines as a result of insufficient information to parents or health care workers or even of active anti-vaccination propaganda,

1. URGES Member States [And, where applicable, regional economic integration organizations]
(1) to allocate adequate financial and human resources for the introduction of vaccines into national immunization schedules and for sustaining strong immunization programmes in accordance with national priorities;

(2) to strengthen efforts, as and where appropriate, for pooling vaccine procurement volumes in regional and interregional or other groupings, as appropriate, that will increase affordability by leveraging economies of scale;

(3) to provide, where possible and available, timely vaccine price data to WHO for publication, with the goal of increasing affordability through improved price transparency, particularly for the new vaccines;

(4) to seek opportunities for establishing national and regional vaccine manufacturing capacity, in accordance with national priorities, that can produce to national regulatory standards, including WHO-prequalification;

(5) to create mechanisms to increase the availability of comparable information on government funding for vaccine development and work towards strategies that enhance public health benefit from government investments in vaccine development;

(6) to support the ongoing efforts of various partners coordinated by WHO to design and implement the strategies to address the vaccine and immunization gaps faced by the low- and middle-income countries that request assistance;

(7) to improve and sustain vaccine purchasing and delivery systems in order to promote the uninterrupted and affordable safe supply of all the necessary vaccines and their availability to all immunization service providers;

(8) to strengthen immunization advocacy and provide training to health professionals and information to the public regarding immunization issues to achieve a clear understanding of the benefits and risks of immunization;

2. REQUESTS the Director-General:
(1) to explore ways to mobilize funding to fully support collaborative efforts with international partners, donors, and vaccine manufacturers to support low- and middle-income countries in accessing affordable vaccines of assured quality in adequate supply;

(2) to continue developing and adequately managing publicly available vaccine price databases, like the WHO Vaccine Product, Price and Procurement project, working with Member States to increase availability of price information;

(3) to monitor vaccine prices through annual reporting of the global vaccine action plan;

(4) to provide technical support and facilitate financial resources for establishing pooled procurement mechanisms, where appropriate, for use by Member States;

(5) to strengthen the WHO prequalification programme and provide technical assistance to support developing countries in capacity building for research and development, technology transfer, and other upstream to downstream vaccine development and manufacturing strategies that foster proper competition for a healthy vaccine market;

(6) to report upon technical, procedural and legal barriers that may undermine robust competition that can enable price reductions for new vaccines, and address other factors that can adversely affect the availability of vaccines;

(7) to assist in mobilizing resources for countries that request assistance in the introduction of new vaccines in line with the global vaccine action plan and in accordance with national priorities;

(8) to continue to assist Member States to improve and sustain their vaccine delivery systems and to continue to provide technical support to Member States to strengthen the knowledge and skills of their health care professionals in vaccination programmes;

(9) to report back on progress in implementing this resolution to the Health Assembly through the Executive Board in the annual report on the global vaccine action plan.

WHA68 Side Meeting on Immunization
“Achieving the Global Vaccine Action Plan Objective for Routine Coverage: What can be done to get back on track?”
20 May 2015 ¦ Geneva – During the WHA68, a side meeting on immunization with delegates from Member States with DTP3 coverage below 80% was convened by WHO. The objectives were to discuss the challenges faced by countries to reach global vaccination targets for 2015 and explore solutions to overcome them. Lead agencies in the Decade of Vaccines Collaboration and other development partners were given the opportunity to reiterate their commitments to support countries to achieve this important goal.

The WHA side meeting was co-sponsored by Thailand, the Democratic Republic of Congo and the United States of America and was chaired by Dr Flavia Bustreo, Assistant Director General, Family, Women’s and Children’s Health. Dr Margaret Chan, the Director-General of WHO, was in attendance. Representatives of agencies comprising the Global Vaccine Action Plan (GVAP) Secretariat, namely Gavi, the Vaccine Alliance, UNICEF and the Bill & Melinda Gates Foundation were present, as well as representatives from Civil Society Organizations.

Member States highlighted critical operational needs and challenges to ensure wider vaccination and delivery on the ground to reach every last child especially those living in remote and inaccessible areas, the need to strengthen vaccine supply chains, the challenges posed by conflict, natural disasters and vaccine stock out and the importance of mechanisms to secure sustainable supplies of vaccines at affordable prices.

Dr Chan highlighted several areas that require attention, including the need to address vaccine hesitancy and refusal, improve communications to create greater awareness of the importance of immunization and the science behind vaccines, the need for collective actions and the importance of private public partnerships to come up with new funding mechanisms. She emphasized the need to build on the lessons learned from the polio eradication initiative.

Notable achievements have been made with the help of Gavi, the Vaccine Alliance to enhance access and the roll out of new vaccines. It was acknowledged that problems remain with reaching the “5th child”. UNICEF is working hand-in-hand with WHO and partners to address the issues impeding the achievement of high coverage and plays an important role in strengthening supply chains.

Dr Elias highlighted that a collective effort was required and encouraged each in the room, international agencies, development partners and national governments “to challenge ourselves to find new solutions to address the remaining barriers to universal access to immunization”.

“The fifth child is often part of undocumented migrant or urban populations or living in remote or insecure areas. Hence, the strategies to reach them cannot be a continuation of what we have done till now”
Dr Chris Elias, President of the Global Development Programme, the Bill & Melinda Gates Foundation

The Weekly Epidemiological Record (WER) 29 May 2015, vol. 90, 22 (pp. 261–280) includes:
…Monthly report on dracunculiasis cases, January– April 2015
.
…Meeting of the Strategic Advisory Group of Experts on immunization, April 2015: conclusions and recommendations
[Meeting Report Sections and Editor’s Excerpts]

Report from the WHO Department of Immunization, Vaccines and Biologicals
The report focused on: the implementation of the Global Vaccine Action Plan (GVAP) and the related discussions during meetings of the WHO Governing Bodies at global and regional levels; the programmatic priorities to close the immunization gap; an update on implementation of selected SAGE recommendations; and agenda items on the horizon for future meetings.

The report stressed that reaching the GVAP goals is resource intensive (human and financial) and emphasized the urgent need for adequate investments and focus in order to increase routine immunization coverage which has been almost static, at global level, since 2009 and below the expected 90% coverage.

The report noted the current global short¬age of bacille Calmette–Guérin (BCG) vaccine and proposed interim solutions while stressing the need for the global community to pay more attention and take measures to avoid future shortages of other recommended vaccines.

SAGE took note of regional progress and commended the work carried out to advance regional vaccine action plans and promote activities to strengthen routine immunization.

SAGE stressed that additional disaggregation was needed in the analysis of the progress achieved on the ground, and in identifying bottlenecks for progress, and recommended that reports display disparities observed at subnational levels.

In view of weak infrastructure in some countries with a related inability to deliver vaccines, SAGE called for new politically supported initiatives to mobilize part¬ners and resources to apply technological know-how in fragile countries and find ways to build infrastructure in fragile systems. SAGE reaffirmed the need for solu¬tions that simplify operations on the ground, including delivery technologies such as compact pre-filled auto-disable injection technology. In this context SAGE also acknowledged the importance of the polio infrastruc-ture and noted how it had been critical in helping to deal with the Ebola situation, particularly in Nigeria.

SAGE stressed the importance of applying rigour and science in implementation programme design and eval¬uation of delivery of vaccines, in order to maximize the impact of current and future vaccines and delivery tech¬nologies.

SAGE also stressed the need to draw lessons from the Ebola epidemic regarding mobilization of communities as well as the encouragement of countries and partners to mobilize the private sector.

SAGE supported WHO’s plan to expand guidance beyond the current framework on the use of vaccines in humanitarian emergencies to include guidance on how to re-establish routine vaccination in those settings.

At the January 2015 WHO Executive Board meeting, Member States endorsed a resolution for pre-emptive development of vaccines against emerging infectious diseases such as Ebola virus disease. WHO was asked to provide leadership in supporting a prioritized research agenda. A framework for action in relation to vaccine development was proposed, which would include public health criteria, technical feasibility, regu¬latory pathways, and economic considerations. The issues will be reviewed by SAGE, the Product Develop¬ment for Vaccines Advisory Committee (PDVAC), the Expert Committee on Biological Standardization (ECBS) and other forums, with the aim of reaching an agree¬ment within a year.

A SAGE Working Group on Dengue Vaccine was established in March 2015.
Subject to the completion and conclusions of the vaccine assessment by the European Medicines Agency, it is planned that SAGE and the Malaria Programme Advi¬sory Committee will issue policy recommendations on the use of RTS,S malaria vaccine during a joint session in October 2015.
..1 See http://www.who.int/immunization/sage/en
..2 The complete set of presentations and background materials used for the SAGE meeting of 14-16 April 2015 together with the list of SAGE members and the summarized declarations of interests provided by SAGE members are available at http://www.who.int/immunization/sage/meetings/2015/april/en
.
Report from Gavi, the Vaccine Alliance
Report of the Global Advisory Committee on Vaccine Safety (GACVS)
Report of the Product Development for Vaccines Advisory Committee (PDVAC)

Polio eradication
SAGE reviewed progress towards eradication of wild poliovirus (WPV) and elimination of persistent circulating vaccine-derived poliovirus type 2 (cVDPV2) as well as the plans, preparedness and timeline for with¬drawal of type 2 oral polio vaccine (OPV2).

SAGE noted that the programme had made substantial progress since the previous SAGE meeting. No WPV case has been reported in the Middle East or Africa since April 2014 and August 2014, respectively. In polio-endemic countries there were definite improvements in the quality of supplementary immunization activities (SIAs), increasing access to children in conflict-affected areas of Pakistan, improvements in AFP surveillance and expansion of environmental surveillance…

…SAGE concluded that progress towards elimination of persistent cVDPV2 is on track. SAGE recommended that all countries and GPEI should plan firmly for April 2016 as the designated date for withdrawal of OPV2. SAGE will consider delaying OPV2 withdrawal only if the WG reports in October 2015 that the assessed risk of contin¬ued cVDPV2 transmission is high. SAGE requested the polio WG to continue monitoring progress towards cVDPV2 elimination and ensuring that remaining chal¬lenges are addressed including contingencies for vaccine supplies (IPV, bOPV and tOPV), registration of bOPV for routine use, surveillance sensitivity, and reaching inaccessible children. The Working Group will make a full report to SAGE in October 2015, when SAGE may reconfirm April 2016 as the definite date for OPV2 withdrawal.

SAGE endorsed the proposed approach to verification of compliance of poliovirus containment in essential facilities. Under the WHO Global Action Plan (GAP III), facilities planning to handle or store type 2 poliovirus are requested to implement containment measures and appropriately manage associated biorisks. National Regulatory Authorities for containment (NRAcs) are expected to certify facilities according to GAP III. Certification reports are submitted to Regional Certification Commissions (RCCs) for evaluation. In support of this process, RCCs, NRAcs or concerned facilities may request that WHO verify compliance of certified facili¬ties in keeping with GAP III. SAGE requested that the programme consider mechanisms to address the risks associated with research and therapeutic uses of live polioviruses.

.
Administration of multiple injectable vaccines in a single visit
…SAGE supported the following Good Practice Statement on multiple vaccine injections in a single visit, recognizing that the country context is an important determinant of success and acceptability among caregivers and providers: National vaccination schedules recommending administration of multiple injections in the same visit are widely used and provide benefits insofar as they support timely and efficient vaccination of children. Where studies have evaluated the immunogenicity and safety of co-administered vaccines, these practices are encouraged based on the benefits they confer.

SAGE concluded that countries should not make modifications to recommended immunization schedules with the aim of preventing multiple injections during the same visit when such modifications are not evidence-based…

.
Reducing pain and distress at the time of vaccination

.
Sustainable access to vaccines in middle-income countries (MICs): report of the WHO-convened MIC Task Force
The MIC Task Force, a group of 9 immunization part¬ners, presented a proposed strategy for coordinated action to enhance sustainable access to vaccines in MICs. Over the past decade, access to vaccines in MICs has been much debated, fuelled by the fact that the majority of poor people are now in MICs and concern that this group of countries may be missing out on opportunities to introduce new vaccines, as donors focus on low-income countries. In view of this situation and at the request of SAGE, in June 2014 WHO convened the MIC Task Force to develop a coordinated strategy and plan of action.

A comprehensive review of MICs’ performance shows that they are far from attaining the GVAP targets. While 40 MICs are well supported by Gavi, 63 do not benefit from a unified international strategy for action. In these countries, vaccine-preventable disease burden and numbers of unvaccinated children are relatively low compared to the Gavi-supported MICs, but nonetheless substantial and unacceptable. Many of these countries have strong health systems and potential for rapid gains if key barriers are removed. The MIC strategy, aligned with the GVAP time frame (2016–2020), proposes a way forward for non-Gavi countries. Importantly, solutions and platforms set up as part of the strategy would also benefit countries that graduate from Gavi support over time, ensuring sustainability of current investments…

…SAGE acknowledged that the strategy represents a strong proposal for a coordinated and comprehensive approach to the MIC situation. SAGE concurred with the general direction of the strategy and valued the menu of options as an approach to tailoring activities to the individual needs of a heterogeneous group of countries. SAGE appreciated that the strategy builds upon lessons learnt and existing activities as the most efficient way to use resources and achieve impact.

SAGE called on partners to support implementation of the strategy and on countries to take advantage of the proposed solutions.

SAGE noted that prompt implementation of the MIC strategy is particularly important given the impending graduation of several large Gavi countries, which will require long-term solutions to be put in place…

.
Ebola vaccines and vaccination
…In parallel with the vaccine trials, WHO and partners, including the 3 most affected countries, have established a framework to develop guidelines to support planning, implementing and monitoring vaccination once a vaccine becomes available for use, according to SAGE recommendations.

A proposed framework for making recommendations was presented, which aims to adopt a scenario-based approach, while also taking account of a number of programmatic, socio-cultural and other factors. Considerations guiding the use of the framework are: specific scenario relating to the epidemiology and the type of authorization for vaccine use; objectives for vaccination (primary – stopping transmission, secondary – individual protection); prioritization of target populations; and additional considerations which would inform SAGE’s recommendations. The framework would be adjusted based on evolution of the current epidemic, the type of regulatory or emergency use authorization given for a vaccine, and on the data that become avail¬able from the clinical trials.

In the discussion that followed, it was noted that the quality of the reported disease data had limitations and that the data on cultural and other factors that may have contributed to differences in the epidemic patterns were not fully captured in the national databases. However, there was confidence that the available data correctly reflected the epidemic patterns and the relative incidence of disease in different age groups.

SAGE members expressed concern about the likelihood that efficacy estimates may not be generated from the phase 3 trials, given the declining number of cases in all 3 countries and felt that the trials must also contribute additional data (including those related to programmatic aspects) that could inform recommendations. Noting WHO’s unique position to coordinate the development of Ebola vaccines, SAGE stressed the importance of transparent and prompt sharing of information on the trial protocols and data from the phase 3 clinical trials, and the need for a greater role for WHO in facilitating the sharing of information so that results between studies will generate the greatest benefit for policy decision-making.

SAGE supported the proposed framework for making recommendations, but asked that it be made explicit that the identification and prioritization of target populations for vaccination will be based on a thorough assessment of risks (from disease as well as from vaccination) and benefits. It was recognized that the final recommendations would be driven by the evolution of the current epidemic, the conditions laid down in the regulatory authorization for use of vaccines and social and cultural considerations.

SAGE recommended that the further development of the Emergency Use Assessment and Listing procedure being developed by WHO, which would allow use of a vaccine in the context of a Public Health Emergency of Inter¬national Concern, be done in close consultation with relevant regulatory authorities, including those of the affected countries.

SAGE again noted the probability that efficacy data for any of the Ebola vaccines may not be available by the end of the current outbreak, and therefore recom¬mended that future use of unproven Ebola vaccines should be in the context of studies that would generate safety and effectiveness data.

.
Maternal vaccination during pregnancy
SAGE encouraged WHO to promote more implementation research to generate generalizable data on the best ways to integrate maternal immunization into routine antenatal care in low resource settings. SAGE also encouraged the Regional Office for the Americas to document the successful regional experience of deliver¬ing influenza vaccine to pregnant women.

It was considered unnecessary to establish a SAGE working group to review maternal influenza immunization at present, given that substantial data still being generated will not be available until late 2015–2016. SAGE emphasized the importance of the maternal immunization platform, in general, and called upon WHO to affirm its commitment to building the evidence base to strengthen vaccine delivery during pregnancy, as it has great potential for infection prevention in high-risk groups worldwide.

.
Pertussis vaccination schedules

Nepal earthquake 2015 – Grade 3 emergency
.
:: Health situation report No. 19 pdf, 317kb – 26 May 2015
KEY HIGHLIGHTS
:: The repeated earthquakes and aftershocks since 25 April 2015 have had a major public health consequences, with a total 1085 health facilities (402 completely and 683 partially) damaged.
:: A total of 2088 people have undergone major surgeries and 26,160 have received psychosocial support in the highly affected 14 districts.
:: Nepal’s Ministry of Health and Population (MOHP) identifies 429 patients in Bhaktapur, Kathmandu and Lalitpur who require longer term treatment support.
:: 42 Foreign Medical teams (FMTs) are operating in the country with a total 802 persons including 264 doctors and 236 nurses.
:: Currently there are over 100 beds available for patients requiring ongoing rehabilitation or nursing care within the Kathmandu valley.

:: Health Cluster Bulletin No. 4 pdf, 1.83Mb 27 May 2015
Situation update
Up to 26 May, just a little over a month after the first earthquake of 7.8 on the Richter scale struck Nepal on 25 April, followed by a 7.3 magnitude on 12 May and numerous aftershocks, the MoHP is reporting that there has been 8673 earthquake-related deaths and 21952 injuries. Of this amount, eight health workers and 10 FCHVs have lost their lives, 75 have been injured and two remain missing.
The Ministry of Health and Population’s (MoHP) Early Warning and Response System for epidemic-prone diseases (EWARS) show a generally stabilizing trend in numbers of outbreak prone diseases in the 14 severely affected districts. No major outbreaks have been reported to date…

EBOLA/EVD [to 30 May 2015]
Public Health Emergency of International Concern (PHEIC); “Threat to international peace and security” (UN Security Council)

WHO: Ebola Situation Report – 27 May 2015
[Excerpts]
SUMMARY
:: There were 12 confirmed cases of Ebola virus disease (EVD) reported in the week to 24 May: 9 from Guinea and 3 from Sierra Leone. A total of 5 districts (3 in Guinea, 2 in Sierra Leone) reported at least one confirmed case, compared with 6 districts the previous week. The west-Guinean prefecture of Forecariah reported the most cases of any one district, and continues to present the greatest challenge in terms of response, with multiple chains of transmission over a wide geographical area (4 sub-prefectures), and the continued occurrence of cases from unknown sources of infection.

COUNTRIES WITH WIDESPREAD AND INTENSE TRANSMISSION
:: There have been a total of 27,013 reported confirmed, probable, and suspected cases of EVD in Guinea, Liberia and Sierra Leone (figure 1, table 1), with 11,134 reported deaths (this total includes reported deaths among probable and suspected cases, although outcomes for many cases are unknown). A total of 9 new confirmed cases were reported in Guinea and 3 in Sierra Leone in the 7 days to 24 May. The outbreak in Liberia was declared over on 9 May.

POLIO [to 30 May 2015]
Public Health Emergency of International Concern (PHEIC)

GPEI Update: Polio this week – As of 27 May 2015
Global Polio Eradication Initiative
[Editor’s Excerpt and text bolding]
Full report: http://www.polioeradication.org/Dataandmonitoring/Poliothisweek.aspx
:: Ministers of Health from around the world adopted a landmark resolution to end polio once and for all at the World Health Assembly in Geneva last week. The discussions were informed by a status report prepared by the Global Polio Eradication Initiative. Draft 3rd report of the Committee A , WHO news release from 22 May 2015
:: Polio staff continue to offer support to the humanitarian response to the devastating earth quakes in Nepal. Read more.
:: The 11th IMB report was published last week, reporting on progress towards polio eradication and making recommendations
Selected excerpts from Country-specific Reports
Afghanistan
:: One new case of wild poliovirus type 1 (WPV1) has been reported in the past week in Gulestan district of Farah province. This most recent case had onset of paralysis on 5 May. The total number of WPV1 cases for 2015 is now 2, and remains 28 for 2014. Most of the cases from 2014 were linked with cross-border transmission from neighbouring Pakistan.
:: Environmental sampling in the country continues to find wild poliovirus (most recently in Hilmand). Such sampling is invaluable to improved surveillance for the virus.
:: Subnational Immunization Days (SNIDs) are planned from 14 – 16 June across the south and east using bivalent OPV. National Immunization Days are scheduled on 16 to 18 Augus
Pakistan
:: Two new environmental samples positive for WPV1 were reported this week from Quetta district of Balochistan and from Jacobabad district of Sindh.
:: Currently, the focus of the polio eradication programme in Pakistan is on known infected areas and on areas deemed to be high-risk but which have not reported polio cases.
:: Environmental surveillance indicates widespread circulation of polioviruses – WPV as well as VDPV – not just in known infected areas but also in areas without cases. Environmental surveillance is proving to be an instrumental supplemental surveillance tool enabling a clearer epidemiological picture.

.
WHO and UNICEF launch vaccination campaign to keep Iraq polio free
Baghdad | Erbil, 26 May 2015 – A mass polio vaccination campaign, aiming to target 5.7 million children under the age of 5, began in Iraq on 24 May. The campaign will be conducted in all governorates to maintain the country’s polio-free status. The last case of polio was reported on 7 April 2014; a 34-month-old girl from the Rasafa district of Baghdad.

Iraq’s response to combating polio aligns with a multi-country response plan developed following the outbreak of polio in Syria in 2013. Multiple vaccination rounds held in country since then have helped to protect Iraqi children from the paralysis caused by this incurable disease. Despite ongoing conflict, mass population displacement and a complex and unpredictable security situation, only 2 cases of polio were confirmed in Iraq during the regional outbreak in early 2014.

WHO Country Representative to Iraq Dr Syed Jaffar Hussain said, “Despite the civil unrest that engulfs over a third of the country, polio campaigns have continued to reach up to 90% of children through collaborative efforts with multiple line-ministries and local partners.” He paid tribute to polio vaccination team members and parents and appealed to the international community and partners for their continued financial and technical support over the next 12 months for an additional 4 nationwide vaccination campaigns.”Community efforts were well acknowledged by the Independent Monitoring Board for the Global Polio Eradication Initiative during their recent meeting. However, significant risks continue to exist and thus there is no room for complacency,” Dr Hussain added.

UNICEF Country Representative to Iraq Phillippe Heffinck added, “The polio effort in Iraq has been successful despite tremendous challenges. The collaboration and leadership of the Ministries of Health and strong collaboration with partners, such as WHO, have established community ownership for polio campaigns, and created a strong platform for rolling out strong routine immunization services. Both of these achievements are not only remarkable, but essential to keep Iraq polio free and improve the health of all Iraqi children.”…

WHO & Regionals [to 30 May 2015]
.
Egypt: increase in H5N1 human and poultry cases but no change in transmission pattern of infection
May 2015 — The recent increase in the number of people affected by the avian influenza virus H5N1 in Egypt is not related to virus mutations but rather to more people becoming exposed to infected poultry. Since November 2014 to 30 April 2015, the period analysed by the international mission, a total of 165 cases, including 48 deaths were reported.

.
WHO recommends 10 measurements for HIV
May 2015 — WHO released new guidelines recommending simplified indicators to measure the reach of HIV services, and the impact achieved at both the national and global levels.

.
Global Alert and Response (GAR) – Disease Outbreak News (DONs)
30 May 2015 – Middle East respiratory syndrome coronavirus (MERS-CoV) – China
30 May 2015 – Middle East respiratory syndrome coronavirus (MERS-CoV) – Republic of Korea
28 May 2015 – Lassa Fever – United States of America
25 May 2015 – Middle East Respiratory Syndrome coronavirus (MERS-CoV) – Saudi Arabia
24 May 2015 – Middle East respiratory syndrome coronavirus (MERS-CoV) – United Arab Emirates

.
:: WHO Regional Offices
WHO African Region AFRO
:: Cholera crisis in Tanzania improving despite high transmission risk
Kagunga, 26 May 2015 – The ongoing cholera outbreak in western Tanzania appears to be improving thanks to intensive national and international efforts, but the risk of transmission remains high due to limited access to shelter, toilets, water and essential medical care. As of 25 May, the total number of cases diagnosed and treated was 4408 and no deaths have been reported between 21-24 May.

WHO Region of the Americas PAHO
:: PAHO urges member countries to ratify new protocol on illicit tobacco (05/29/2015)

WHO South-East Asia Region SEARO
:: Stop illicit trade of tobacco products 29 May 2015

WHO European Region EURO
:: Final day of the World Health Assembly: highlights for the European Region 28-05-2015
:: World No Tobacco Day awards 2015 27-05-2015
:: Days 5 to 7 of the World Health Assembly: highlights for the European Region 27-05-2015

WHO Eastern Mediterranean Region EMRO
:: Urgent funding needed to prevent imminent closure of health care projects in Iraq
Cairo, 27 May 2015 – If urgently needed funds are not secured by the end of June 2015, more than 84% of health care projects serving populations in need in Iraq will be forced to close. If this happens, more than 3 million refugees, internally displaced persons and host communities will not have access to the treatment and care that these projects provide. WHO is coordinating the response of health cluster partners to optimize the use of available resources and calls on donors to provide financial support to prevent further avoidable death and additional suffering for millions of the most vulnerable people in Iraq.
:: WHO statement on the situation in Yemen by WHO Director-General Dr Margaret Chan
27 May 2015
:: WHO and UNICEF launch vaccination campaign to keep Iraq polio free 26 May 2015
:: WHO partners with MENTOR Initiative to control leishmaniasis in Aleppo and Deir ez-Zor  26 May 2015

WHO Western Pacific Region
No new digest content identified.

GAVI Watch [to 30 May 2015]
http://www.gavialliance.org/library/news/press-releases/
.
:: Oman commits US$ 3 million to support childhood immunisation
28 May 2015
First time pledge will enable Gavi to reach children with life-saving vaccines.

Geneva, 28 May 2015 – The Government of the Sultanate of Oman today committed US$ 3 million to Gavi, the Vaccine Alliance – the first time Oman has provided funds to help Gavi reach children with vaccines in the world’s poorest countries.

“Oman is joining the global drive to protect children from potentially-fatal diseases,” said Dr Seth Berkley, Gavi CEO. “This new contribution will help us achieve our goal of supporting developing countries to immunise 300 million more children between 2016 and 2020, saving up to six million more lives.”

Oman’s contribution comes days after the World Health Assembly agreed on a resolution to improve access to sustainable supplies of affordable vaccines and highlighted the important role immunisation plays in reducing child deaths while also being a highly cost-effective public health intervention…

DoD Launches Review of Lab Procedures Involving Anthrax
WASHINGTON, May 29, 2015 – The Defense Department is launching a comprehensive review of its laboratory procedures, processes, and protocols associated with inactivating spore-forming anthrax…Deputy Defense Secretary Bob Work today ordered the review after consulting with Defense Secretary Ash Carter…

No Risk to the General Public
There is no known risk to the general public and an extremely low risk to lab workers from the department’s inadvertent shipments of inactivated samples containing small numbers of live anthrax to several laboratories, according to the release.

As of now, 24 laboratories in 11 states and two foreign countries are believed to have received suspect samples, the release said.

The department is working closely with the Centers for Disease Control and Prevention, who is leading the ongoing investigation pursuit to its statutory authorities, the release said.

Monitoring the Situation
The department will continue to monitor the situation and provide updates to the public, the release said.

In addition to the CDC review, Work ordered all DoD laboratories that have these materials to test all previously inactivated spore-forming anthrax in the inventory, the release said.

DoD also is advising labs that received inactive anthrax from the department to stop working with those samples until further instruction from the DoD and CDC…

CDC/MMWR/ACIP Watch [to 30 May 2015]
http://www.cdc.gov/media/index.html

.
CDC investigating unintentional DoD shipment of anthrax
Media Statement
CDC is investigating the unintentional transfer of anthrax from the U.S. Department of Defense (DOD) to labs in multiple states and overseas. At this time we do not suspect any risk to the general public.

The CDC investigation was started after a request for technical consultation from a private commercial lab. The lab was working as part of a DOD effort to develop a new diagnostic test to identify biological threats. Although an inactivated agent was expected, the lab reported they were able to grow live Bacillus anthracis.

CDC is working in conjunction with DoD and other federal and state partners to conduct an investigation with all the labs that received samples from the DoD. The ongoing investigation includes determining if the labs also received other live samples, epidemiologic consultation, worker safety review, laboratory analysis, and handling of laboratory waste.

All samples involved in the investigation are being securely transferred to CDC or Laboratory Response Network (LRN) laboratories for further testing. CDC has sent officials from the CDC Federal Select Agent Program to the DOD labs to conduct onsite investigations.

Updates will continue to be provided as the investigation progresses.

.

ACIP
:: February 2015 ACIP Minutes [2.16 MB, 72 pages]
.
:: Next ACIP Meeting – June 24-25, 2015
ACIP June 2015 Draft Meeting Agenda [2 pages]
Register for upcoming June ACIP meeting
(Wednesday – Thursday)
Deadline for registration:
– Non-US Citizens: June 3, 2015
– US Citizens: June 10, 2015

American Journal of Infection Control
June 2015 Volume 43, Issue 6, p547-662
http://www.ajicjournal.org/current

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What can we learn about the Ebola outbreak from tweets?
Michelle Odlum, Sunmoo Yoon
p563–571
Preview
Twitter can address the challenges of the current Ebola outbreak surveillance. The aims of this study are to demonstrate the use of Twitter as a real-time method of Ebola outbreak surveillance to monitor information spread, capture early epidemic detection, and examine content of public knowledge and attitudes.

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Healthcare worker influenza declination form program
Sherri L. LaVela, PhD, MPH, MBA, Jennifer N. Hill, MA, Bridget M. Smith, PhD, Charlesnika T. Evans, PhD, MPH, Barry Goldstein, MD, PhD, Richard Martinello, MD
Published Online: March 20, 2015
DOI: http://dx.doi.org/10.1016/j.ajic.2015.02.013
Highlights
:: The declination form program was compatible, flexible, easy to use, and supported by leadership.
:: Declination form program facilitators included complementary ongoing strategies and leadership engagement.
:: One-on-one attention and education at the time of vaccination led to health care worker accountability.
:: An influenza declination form program is of minimal cost, but it requires some dedicated staff and resources.
:: Vaccination rate improved from 53.5% to 77.4% pre- to postdeclination form program implementation.
Abstract
Background
Health care worker (HCW) vaccination rates have been low for many years (approximately 50%). Our goal was to implement an influenza declination form program (DFP) to assess feasibility, participation, HCW vaccination, and costs.
Methods
This was a prospective interventional pilot study using mixed methods to evaluate the DFP implementation processes and outcomes. We conducted a formative evaluation and interviews; data were transcribed and coded into themes. Secondary outcomes included self-reported HCW influenza vaccine uptake (pre-/postsurvey) and program costs; data were evaluated using descriptive and bivariate analyses.
Results
The DFP was compatible with ongoing strategies and unit culture. Barriers included multiple hospital shifts and competing demands. Facilitators included complementary ongoing strategies and leadership engagement. HCW vaccination rates were higher post- versus preimplementation (77.4% vs 53.5%, P =.01). To implement the DFP at site 1, using a mobile flu cart, 100% of declination forms were completed in 42.5 staff hours over <2 months. At site 2, using a vaccination table on all staff meeting days, 49% of forms were completed in 26.5 staff hours over 4.5 months. Average cost of staff time was $2,093 per site.
Conclusion
DFP implementation required limited resources and resulted in increased HCW influenza vaccine rates; this may have positive clinical implications for influenza infection control/prevention.
Increased reports of measles in a low endemic region during a rubella outbreak in adult populations
Takako Kurata, Daiki Kanbayashi, Hiroshi Nishimura, Jun Komano, Tetsuo Kase, Kazuo Takahashi
p653–655
Published online: April 1, 2015
Preview
In 2013, a rubella outbreak was observed in Japan, Romania, and Poland. The outbreak in Japan was accompanied by an increase of measles reports, especially from a region where measles is highly controlled. This was attributed to the adult populations affected by this rubella outbreak, similarity of clinical signs between rubella and measles, sufficiently small impact of measles outbreaks from neighboring nations, and elimination levels of measles endemicity. Current and future concerns for measles control are discussed.

American Journal of Preventive Medicine
June 2015 Volume 48, Issue 6, p647-770, e11-e30
http://www.ajpmonline.org/current

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Impact of Health Insurance Status on Vaccination Coverage Among Adult Populations
Peng-jun Lu, MD, PhD, Alissa O’Halloran, MSPH, Walter W. Williams, MD, MPH
Immunization Services Division, National Center for Immunization and Respiratory Diseases, CDC, Atlanta, Georgia
Published Online: April 15, 2015
DOI: http://dx.doi.org/10.1016/j.amepre.2014.12.008
Abstract
Introduction
Underinsurance is a barrier to vaccination among children. Information on vaccination among adults aged ≥18 years by insurance status is limited. This study assesses vaccination coverage among adults aged ≥18 years in the U.S. in 2012 by health insurance status and access to care characteristics.
Methods
The 2012 National Health Interview Survey data were analyzed in 2014 to estimate vaccination coverage among adults aged ≥18 years by health insurance status for seven routinely recommended vaccines.
Results
Influenza vaccination coverage among adults aged ≥18 years without or with health insurance was 14.4% versus 44.3%, respectively; pneumococcal vaccination coverage among adults aged 18–64 years with high-risk conditions was 9.8% versus 23.0%; tetanus and diphtheria toxoid (Td) coverage (age ≥18 years) was 53.2% versus 64.5%; tetanus, diphtheria, and acellular pertussis (Tdap) coverage (age ≥18 years) was 8.4% versus 15.7%; hepatitis A (HepA) coverage (age 18–49 years) was 16.6% versus 19.8%; hepatitis B (HepB) coverage (age 18–49 years) was 27.5% versus 38.0%; shingles coverage (age ≥60 years) was 6.1% versus 20.8%; and human papillomavirus (HPV) coverage (women aged 18–26 years) was 20.9% versus 39.8%. In addition, vaccination coverage differed by insurance type, whether respondents had a regular physician, and number of physician contacts.
Conclusions
Overall, vaccination coverage among adults aged ≥18 years is lower among uninsured populations. Implementation of effective strategies is needed to help improve vaccination coverage among adults aged ≥18 years, especially those without health insurance

American Journal of Public Health
Volume 105, Issue 6 (June 2015)
http://ajph.aphapublications.org/toc/ajph/current

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Long-Term Effectiveness of Accelerated Hepatitis B Vaccination Schedule in Drug Users
Dimpy P. Shah, Carolyn Z. Grimes, Anh T. Nguyen, Dejian Lai, Lu-Yu Hwang
American Journal of Public Health: June 2015, Vol. 105, No. 6: e36–e43.
ABSTRACT
Objectives. We demonstrated the effectiveness of an accelerated hepatitis B vaccination schedule in drug users.
Methods. We compared the long-term effectiveness of accelerated (0–1–2 months) and standard (0–1–6 months) hepatitis B vaccination schedules in preventing hepatitis B virus (HBV) infections and anti-hepatitis B (anti-HBs) antibody loss during 2-year follow-up in 707 drug users (HIV and HBV negative at enrollment and completed 3 vaccine doses) from February 2004 to October 2009.
Results. Drug users in the accelerated schedule group had significantly lower HBV infection rates, but had a similar rate of anti-HBs antibody loss compared with the standard schedule group over 2 years of follow-up. No chronic HBV infections were observed. Hepatitis C positivity at enrollment and age younger than 40 years were independent risk factors for HBV infection and antibody loss, respectively.
Conclusions. An accelerated vaccination schedule was more preferable than a standard vaccination schedule in preventing HBV infections in drug users. To overcome the disadvantages of a standard vaccination schedule, an accelerated vaccination schedule should be considered in drug users with low adherence. Our study should be repeated in different cohorts to validate our findings and establish the role of an accelerated schedule in hepatitis B vaccination guidelines for drug users.

BMC Health Services Research
http://www.biomedcentral.com/bmchealthservres/content
(Accessed 30 May 2015)

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Research article
Making health insurance pro-poor: evidence from a household panel in rural China
Mateusz Filipski, Yumei Zhang, Kevin Chen BMC Health Services Research 2015, 15:210 (29 May 2015)
Abstract
Background
In 2002, China launched the largest public health insurance scheme in the world, the New Cooperative Medical Scheme (NCMS). It is intended to enable rural populations to access health care services, and to curb medical impoverishment. Whether the scheme can reach its equity goals depends on how it is used, and by whom. Our goal is to shed light on whether and how income levels affect the ability of members to reap insurance benefits.
Methods
We exploit primary panel data consisting of a complete census (over 3500 individuals) in three villages in Puding County, Guizhou province, collected in 2004, 2006, 2009 and 2011. Data was collected during in-person interviews with household member(s). The data include yearly gross and net medical expenses for all individuals, and socio-economic information. We apply probit, ordinary least squares, and tobit multivariate regression analyses to the three waves in which NCMS was active (2006, 2009 and 2011). Explained variables include obtainment, levels and rates of NCMS reimbursement. Household income is the main explanatory variable, with household- and individual-level controls. We restrict samples to rule out self-selection, and exploit the 2009 NCMS reform to highlight equity-enhancing features of insurance.
Results
Prior to 2009 reforms, higher income in our sample was statistically significantly related to higher probability of obtaining reimbursement, as well as higher levels and rates of reimbursement. These relations all disappear after the reform, suggesting lower-income households were better able to reap insurance benefits after the scheme was reformed. Regression results suggest this is partly explained by reimbursement for chronic diseases.
Conclusions
The post-reform NCMS distributed benefits more equitably in our study area. Making health insurance pro-poor may require a focus on outpatient costs, credit constraints and chronic diseases, rather than catastrophic illnesses.

BMC Medical Ethics
http://www.biomedcentral.com/bmcmedethics/content
(Accessed 30 May 2015)

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Debate
Research partnerships between high and low-income countries: are international partnerships always a good thing?
John D Chetwood, Nimzing G Ladep, Simon D Taylor-Robinson BMC Medical Ethics 2015, 16:36 (28 May 2015)
Abstract
Background
International partnerships in research are receiving ever greater attention, given that technology has diminished the restriction of geographical barriers with the effects of globalisation becoming more evident, and populations increasingly more mobile.
Discussion
In this article, we examine the merits and risks of such collaboration even when strict universal ethical guidelines are maintained. There has been widespread examples of outcomes beneficial and detrimental for both high and low –income countries which are often initially unintended.
Summary
The authors feel that extreme care and forethought should be exercised by all involved parties, despite the fact that many implications from such international work can be extremely hard to predict. However ultimately the benefits gained by enhancing medical research and philanthropy are too extensive to be ignored

Globalization and Health
http://www.globalizationandhealth.com/
[Accessed 30 May 2015]

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Research
Tracking Global Fund HIV/AIDS resources used for sexual and reproductive health service integration: case study from Ethiopia
Mookherji S, Ski S and Huntington D Globalization and Health 2015, 11:21 (27 May 2015)
Abstract (provisional)
Objective/Background
The Global Fund to Fight AIDS, Tuberculosis & Malaria (GF) strives for high value for money, encouraging countries to integrate synergistic services and systems strengthening to maximize investments. The GF needs to show how, and how much, its grants support more than just HIV/AIDS, TB and malaria. Sexual and Reproductive Health (SRH) has been part of HIV/AIDS grants since 2007. Previous studies showed the GF PBF system does not allow resource tracking for SRH integration within HIV/AIDS grants. We present findings from a resource tracking case study using primary data collected at country level.
Methods
Ethiopia was the study site. We reviewed data from four HIV/AIDS grants from January 2009-June 2011 and categorized SDAs and activities as directly, indirectly, or not related to SRH integration. Data included: GF PBF data; financial, performance, in-depth interview and facility observation data from Ethiopia.
Results
All HIV/AIDS grants in Ethiopia support SRH integration activities (12-100%). Using activities within SDAs, expenditures directly supporting SRH integration increased from 25% to 66% for the largest HIV/AIDS grant, and from 21% to 34% for the smaller PMTCT-focused grant. Using SDAs to categorize expenditures underestimated direct investments in SRH integration; activity-based categorization is more accurate. The important finding is that primary data collection could not resolve the limitations in using GF GPR data for resource tracking. The remedy is to require existing activity-based budgets and expenditure reports as part of PBF reporting requirements, and make them available in the grant portfolio database. The GF should do this quickly, as it is a serious shortfall in the GF guiding principle of transparency.
Conclusions
Showing high value for money is important for maximizing impact and replenishments. The Global Fund should routinely track HIV/AIDs grant expenditures to disease control, service integration, and overall health systems strengthening. The current PBF system will not allow this. Real-time expenditure analysis could be achieved by integrating existing activity-based financial data into the routine PBF system. The GF’s New Funding Model and the 2012-2016 strategy present good opportunities for over-hauling the PBF system to improve transparency and allow the GF to monitor and maximize value for money.

Health Economics, Policy and Law
Volume 10 – Issue 03 – July 2015
http://journals.cambridge.org/action/displayIssue?jid=HEP&tab=currentissue

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The impact of Universal Health Coverage on health care consumption and risky behaviours: evidence from Thailand
Simone Ghislandi, Wanwiphang Manachotphong and Viviana M.E. Perego
Health Economics, Policy and Law / Volume 10 / Issue 03 / July 2015, pp 251 – 266
Abstract
Thailand is among the first non-OECD countries to have introduced a form of Universal Health Coverage (UHC). This policy represents a natural experiment to evaluate the effects of public health insurance on health behaviours. In this paper, we examine the impact of Thailand’s UHC programme on preventive activities, unhealthy or risky behaviours and health care consumption using data from the Thai Health and Welfare Survey. We use doubly robust estimators that combine propensity scores and linear regressions to estimate differences-in-differences (DD) and differences-in-DD models. Our results offer important insights. First, UHC increases individuals’ likelihood of having an annual check-up, especially among women. Regarding health care consumption, we observe that UHC increases hospital admissions by over 2% and increases outpatient visits by 13%. However, there is no evidence that UHC leads to an increase in unhealthy behaviours or a reduction of preventive efforts. In other words, we find no evidence of ex ante moral hazard. Overall, these findings suggest positive health impacts among the Thai population covered by UHC.

JAMA
May 26, 2015, Vol 313, No. 20
http://jama.jamanetwork.com/issue.aspx

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Principles and Challenges in Access to Experimental Medicines
Michael Rosenblatt, MD; Bruce Kuhlik, JD
Excerpt
Efforts by patients to obtain early access to experimental medicines have increased as novel therapies provide new evidence of their potential to treat or cure life-threatening diseases. As drug discovery efforts, particularly for cancer and orphan diseases, are increasingly based on molecular targets, success rates improve, generating further interest in early access to experimental drugs. Devising “expanded access programs” (EAPs), however, presents challenges.1,2 Fairness and ethical issues need to be addressed as do practical matters, such as efficient conduct of clinical trials, adequate drug supply, finances, and geography. The complexity of crafting EAPs is compounded by early, rapid, and broad communication by traditional and social media. This Viewpoint outlines general principles to help balance the competing interests of individuals facing life-threatening illness with practical concerns and broader societal interests in knowing which drugs do or do not work and making them generally available through expeditious regulatory approval…

The Lancet
May 30, 2015 Volume 385 Number 9983 p2121-2222
http://www.thelancet.com/journals/lancet/issue/current

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Comment
African health leaders: claiming the future
Agnes Binagwaho, Nigel Crisp
DOI: http://dx.doi.org/10.1016/S0140-6736(15)60934-5
Improving health in Africa is a team effort that involves many people from different backgrounds. The health gains made in recent years would not have been possible without the contribution of these people, national and global political will, and the support of development partners. All too often, however, the part played by Africans themselves has been overlooked or downplayed internationally in policy making and publications.

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Comment
Offline: An irreversible change in global health governance
Richard Horton
DOI: http://dx.doi.org/10.1016/S0140-6736(15)60997-7
“We should have reacted sooner”, was Angela Merkel’s conclusion in her address to the World Health Assembly last week. She was speaking about Ebola, and she gave a sharp and public rebuke to WHO for its diffident performance. WHO’s decentralised structure can be a powerful advantage, she said, but it “can also impede decision-making and hinder good functioning”. Still, despite its weaknesses, “WHO is the only international organisation that enjoys universal political legitimacy on global health matters.” It should be supported. Her assessment was backed by the Ebola Interim Assessment Panel, chaired by Barbara Stocking and whose first report was debated by WHO’s member states the next day. Stocking and her team, which included, among others, Ilona Kickbusch and Julio Frenk, listed their concerns with compelling clarity. They expressed surprise that it took WHO so long to recognise what it would take to bring Ebola transmission under control. Why did repeated early warnings from May to July, 2014, fail to trigger the declaration of a Public Health Emergency of International Concern before Aug 8, 2014, the date when an emergency was finally announced? Why was WHO unable “to engage in a high-level media response with greater command over the narrative”? Why did WHO fail to seek appropriate support from other UN agencies and humanitarian organisations? Why did WHO fail to ensure it had the operational capacity and culture to manage a public health emergency response? Donors were not spared: WHO “suffers from a lack of political and financial commitment by its Member States”. The Panel commented that “this [is] a defining moment for the work of WHO…’Business as usual’ or ‘more of the same’ is not an option.” Stocking concluded that, “Now is the historic political moment for world leaders to give WHO new relevance and empower it to lead in global health.”

Understandably, the Panel preferred to place responsibility on structures, not individuals. This is entirely correct. But structures are made up of individuals, and it is individuals who make decisions. There needs to be some serious soul-searching within the agency about who did what, when, and why it went wrong. The Lancet has felt resistance to these questions, in sometimes acutely hostile terms from WHO staff members. If WHO diagnoses the international response to Ebola as a collective failure and not as a failure of its own processes, procedures, and people, it risks sustaining the conditions that have led to this public health catastrophe for millions of west Africans. For example, it is surreal for WHO to say, as it did last week, that it has now heard what the world expects from the agency. Does this statement mean it was only when Ebola swept across west Africa that WHO woke up to an understanding of its global role? When WHO says that it will strengthen its command and control systems, does this statement mean that after six decades of experience in responding to health crises it needed Ebola to make the agency realise the importance of leadership? And can anyone take the statement that Ebola has accelerated reforms to the organisation seriously when the recent “WHO reform” programme is widely judged (internally and externally) to have delivered few tangible benefits to the agency’s work?

Debates about Ebola and WHO’s response (and future) certainly overwhelmed discussions in Geneva last week. But the most exciting moment was not in the Assembly Hall or Committees. Instead, it was in a small room in the Palais des Nations, and after hours too. For the first time in the history of WHO and its Assembly, a civil-society led forum was held to strengthen political accountability for global health—specifically, for women’s and children’s health. The White Ribbon Alliance, together with the Governments of Bangladesh and Sweden, convened the first Global Dialogue between Citizens and Governments. It was an historic moment. It built on National Citizen’s Hearings held in over 20 countries. Examples from Indonesia and Tanzania were presented with informed passion. Indonesian and Namibian Ministers of Health spoke. This Global Dialogue signalled the beginning of a very different World Health Assembly. What took place last week was an irreversible change in the governance of global health—one in which civil society assumed a legitimate place in shaping the future of health. While WHO reflected (sometimes painfully) on its role and purpose, civil society found its voice. Mark this moment.

The Lancet Global Health
Jun 2015 Volume 3 Number 6 e297-e340
http://www.thelancet.com/journals/langlo/issue/current

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Comment
Global access to surgical care: moving forward
Evan G Wong, Dan L Deckelbaum, Tarek Razek
Open Access
DOI: http://dx.doi.org/10.1016/S2214-109X(15)00004-2
Summary
Global surgical care is gaining ground on the public health platform. Throughout 2015–16, the World Bank is publishing the long-anticipated third edition of its Disease Control Priorities (DCP3). First published in 1993,1 these reports aim to systematically identify effective interventions to address the disease burden in low-income and middle-income countries. For the first time since its inception, the DCP now includes a distinct volume on the value of surgical care. Volume 1—Essential Surgery2—focuses on the benefits of surgical care, including its potential to substantially decrease mortality while being exceptionally cost-effective; the issues of access to life-saving surgery, perioperative safety, and the inclusion of surgery in universal health coverage are also specifically addressed.

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Comment
Health and sustainable development: a call for papers
Richard Horton, Zoë Mullan
Published Online: 30 April 2015
Open Access
DOI: http://dx.doi.org/10.1016/S2214-109X(15)00002-9
Summary
In just under 5 months’ time, the aspiration for the next 15 years of development efforts will be signed off at the UN General Assembly in New York, USA. These Sustainable Development Goals (SDGs) are already at an advanced stage of drafting—17 ambitious goals and 169 targets (panel), which have been criticised even by the UN General Secretary for being too voluminous.1 Amid this multitude of outcomes, those pertaining to health are reduced from three Millennium Development Goals to one SDG. What does this mean for global health research?

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Articles
Global access to surgical care: a modelling study
Blake C Alkire, MD*, Dr Nakul P Raykar, MD*, Mark G Shrime, MD, Thomas G Weiser, MD, Prof Stephen W Bickler, MD, John A Rose, MD, Cameron T Nutt, BA, Sarah L M Greenberg, MD, Meera Kotagal, MD, Johanna N Riesel, MD, Micaela Esquivel, MD, Tarsicio Uribe-Leitz, MD, George Molina, MD, Prof Nobhojit Roy, MD, John G Meara, MD, Prof Paul E Farmer, MD, *
Published Online: 26 April 2015
Open Access
DOI: http://dx.doi.org/10.1016/S2214-109X(15)70115-4
Summary
Background
More than 2 billion people are unable to receive surgical care based on operating theatre density alone. The vision of the Lancet Commission on Global Surgery is universal access to safe, affordable surgical and anaesthesia care when needed. We aimed to estimate the number of individuals worldwide without access to surgical services as defined by the Commission’s vision.
Methods
We modelled access to surgical services in 196 countries with respect to four dimensions: timeliness, surgical capacity, safety, and affordability. We built a chance tree for each country to model the probability of surgical access with respect to each dimension, and from this we constructed a statistical model to estimate the proportion of the population in each country that does not have access to surgical services. We accounted for uncertainty with one-way sensitivity analyses, multiple imputation for missing data, and probabilistic sensitivity analysis.
Findings
At least 4·8 billion people (95% posterior credible interval 4·6–5·0 [67%, 64–70]) of the world’s population do not have access to surgery. The proportion of the population without access varied widely when stratified by epidemiological region: greater than 95% of the population in south Asia and central, eastern, and western sub-Saharan Africa do not have access to care, whereas less than 5% of the population in Australasia, high-income North America, and western Europe lack access.
Interpretation
Most of the world’s population does not have access to surgical care, and access is inequitably distributed. The near absence of access in many low-income and middle-income countries represents a crisis, and as the global health community continues to support the advancement of universal health coverage, increasing access to surgical services will play a central role in ensuring health care for all.
Funding
None.

New England Journal of Medicine
May 28, 2015 Vol. 372 No. 22
http://www.nejm.org/toc/nejm/medical-journal

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Original Article
Efficacy of an Adjuvanted Herpes Zoster Subunit Vaccine in Older Adults
Himal Lal, M.D., Anthony L. Cunningham, M.B., B.S., M.D., Olivier Godeaux, M.D., Roman Chlibek, M.D., Ph.D., Javier Diez-Domingo, M.D., Ph.D., Shinn-Jang Hwang, M.D., Myron J. Levin, M.D., Janet E. McElhaney, M.D., Airi Poder, M.D., Joan Puig-Barberà, M.D., M.P.H., Ph.D., Timo Vesikari, M.D., Ph.D., Daisuke Watanabe, M.D., Ph.D., Lily Weckx, M.D., Ph.D., Toufik Zahaf, Ph.D., and Thomas C. Heineman, M.D., Ph.D. for the ZOE-50 Study Group
N Engl J Med 2015; 372:2087-2096 May 28, 2015 DOI: 10.1056/NEJMoa1501184
Abstract
Background
In previous phase 1–2 clinical trials involving older adults, a subunit vaccine containing varicella–zoster virus glycoprotein E and the AS01B adjuvant system (called HZ/su) had a clinically acceptable safety profile and elicited a robust immune response.
Methods
We conducted a randomized, placebo-controlled, phase 3 study in 18 countries to evaluate the efficacy and safety of HZ/su in older adults (≥50 years of age), stratified according to age group (50 to 59, 60 to 69, and ≥70 years). Participants received two intramuscular doses of the vaccine or placebo 2 months apart. The primary objective was to assess the efficacy of the vaccine, as compared with placebo, in reducing the risk of herpes zoster in older adults.
Results
A total of 15,411 participants who could be evaluated received either the vaccine (7698 participants) or placebo (7713 participants). During a mean follow-up of 3.2 years, herpes zoster was confirmed in 6 participants in the vaccine group and in 210 participants in the placebo group (incidence rate, 0.3 vs. 9.1 per 1000 person-years) in the modified vaccinated cohort. Overall vaccine efficacy against herpes zoster was 97.2% (95% confidence interval [CI], 93.7 to 99.0; P<0.001). Vaccine efficacy was between 96.6% and 97.9% for all age groups. Solicited reports of injection-site and systemic reactions within 7 days after vaccination were more frequent in the vaccine group. There were solicited or unsolicited reports of grade 3 symptoms in 17.0% of vaccine recipients and 3.2% of placebo recipients. The proportions of participants who had serious adverse events or potential immune-mediated diseases or who died were similar in the two groups.
Conclusions
The HZ/su vaccine significantly reduced the risk of herpes zoster in adults who were 50 years of age or older. Vaccine efficacy in adults who were 70 years of age or older was similar to that in the other two age groups. (Funded by GlaxoSmithKline Biologicals; ZOE-50 ClinicalTrials.gov number, NCT01165177.)

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Editorial
A New Vaccine to Prevent Herpes Zoster
Jeffrey I. Cohen, M.D.
N Engl J Med 2015; 372:2149-2150 May 28, 2015 DOI: 10.1056/NEJMe1505050

PLoS Currents: Outbreaks
http://currents.plos.org/outbreaks/
(Accessed 30 May 2015)

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Surveillance of Acute Respiratory Infections Using Community-Submitted Symptoms and Specimens for Molecular Diagnostic Testing
May 27, 2015 · Research
Participatory systems for surveillance of acute respiratory infection give real-time information about infections circulating in the community, yet to-date are limited to self-reported syndromic information only and lacking methods of linking symptom reports to infection types. We developed the GoViral platform to evaluate whether a cohort of lay volunteers could, and would find it useful to, contribute self-reported symptoms online and to compare specimen types for self-collected diagnostic information of sufficient quality for respiratory infection surveillance. Volunteers were recruited, given a kit (collection materials and customized instructions), instructed to report their symptoms weekly, and when sick with cold or flu-like symptoms, requested to collect specimens (saliva and nasal swab). We compared specimen types for respiratory virus detection sensitivity (via polymerase-chain-reaction) and ease of collection. Participants were surveyed to determine receptivity to participating when sick, to receiving information on the type of pathogen causing their infection and types circulating near them. Between December 1 2013 and March 1 2014, 295 participants enrolled in the study and received a kit. Of those who reported symptoms, half (71) collected and sent specimens for analysis. Participants submitted kits on average 2.30 days (95 CI: 1.65 to 2.96) after symptoms began. We found good concordance between nasal and saliva specimens for multiple pathogens, with few discrepancies. Individuals report that saliva collection is easiest and report that receiving information about what pathogen they, and those near them, have is valued and can shape public health behaviors. Community-submitted specimens can be used for the detection of acute respiratory infection with individuals showing receptivity for participating and interest in a real-time picture of respiratory pathogens near them.

PLoS Medicine
(Accessed 30 May 2015)
http://www.plosmedicine.org/

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Seasonal Influenza Vaccination for Children in Thailand: A Cost-Effectiveness Analysis
Aronrag Meeyai, Naiyana Praditsitthikorn, Surachai Kotirum, Wantanee Kulpeng, Weerasak Putthasri, Ben S. Cooper, Yot Teerawattananon
Research Article | published 26 May 2015 | PLOS Medicine 10.1371/journal.pmed.1001829
Abstract
Background
Seasonal influenza is a major cause of mortality worldwide. Routine immunization of children has the potential to reduce this mortality through both direct and indirect protection, but has not been adopted by any low- or middle-income countries. We developed a framework to evaluate the cost-effectiveness of influenza vaccination policies in developing countries and used it to consider annual vaccination of school- and preschool-aged children with either trivalent inactivated influenza vaccine (TIV) or trivalent live-attenuated influenza vaccine (LAIV) in Thailand. We also compared these approaches with a policy of expanding TIV coverage in the elderly.
Methods and Findings
We developed an age-structured model to evaluate the cost-effectiveness of eight vaccination policies parameterized using country-level data from Thailand. For policies using LAIV, we considered five different age groups of children to vaccinate. We adopted a Bayesian evidence-synthesis framework, expressing uncertainty in parameters through probability distributions derived by fitting the model to prospectively collected laboratory-confirmed influenza data from 2005-2009, by meta-analysis of clinical trial data, and by using prior probability distributions derived from literature review and elicitation of expert opinion. We performed sensitivity analyses using alternative assumptions about prior immunity, contact patterns between age groups, the proportion of infections that are symptomatic, cost per unit vaccine, and vaccine effectiveness. Vaccination of children with LAIV was found to be highly cost-effective, with incremental cost-effectiveness ratios between about 2,000 and 5,000 international dollars per disability-adjusted life year averted, and was consistently preferred to TIV-based policies. These findings were robust to extensive sensitivity analyses. The optimal age group to vaccinate with LAIV, however, was sensitive both to the willingness to pay for health benefits and to assumptions about contact patterns between age groups.
Conclusions
Vaccinating school-aged children with LAIV is likely to be cost-effective in Thailand in the short term, though the long-term consequences of such a policy cannot be reliably predicted given current knowledge of influenza epidemiology and immunology. Our work provides a coherent framework that can be used for similar analyses in other low- and middle-income countries.

PLoS Neglected Tropical Diseases
http://www.plosntds.org/
(Accessed 30 May 2015)

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Harnessing Case Isolation and Ring Vaccination to Control Ebola
Chad Wells, Dan Yamin, Martial L. Ndeffo-Mbah, Natasha Wenzel, Stephen G. Gaffney, Jeffrey P. Townsend, Lauren Ancel Meyers, Mosoka Fallah, Tolbert G. Nyenswah, Frederick L. Altice, Katherine E. Atkins, Alison P. Galvani
Research Article | published 29 May 2015 | PLOS Neglected Tropical Diseases 10.1371/journal.pntd.0003794
Abstract
As a devastating Ebola outbreak in West Africa continues, non-pharmaceutical control measures including contact tracing, quarantine, and case isolation are being implemented. In addition, public health agencies are scaling up efforts to test and deploy candidate vaccines. Given the experimental nature and limited initial supplies of vaccines, a mass vaccination campaign might not be feasible. However, ring vaccination of likely case contacts could provide an effective alternative in distributing the vaccine. To evaluate ring vaccination as a strategy for eliminating Ebola, we developed a pair approximation model of Ebola transmission, parameterized by confirmed incidence data from June 2014 to January 2015 in Liberia and Sierra Leone. Our results suggest that if a combined intervention of case isolation and ring vaccination had been initiated in the early fall of 2014, up to an additional 126 cases in Liberia and 560 cases in Sierra Leone could have been averted beyond case isolation alone. The marginal benefit of ring vaccination is predicted to be greatest in settings where there are more contacts per individual, greater clustering among individuals, when contact tracing has low efficacy or vaccination confers post-exposure protection. In such settings, ring vaccination can avert up to an additional 8% of Ebola cases. Accordingly, ring vaccination is predicted to offer a moderately beneficial supplement to ongoing non-pharmaceutical Ebola control efforts.
Author Summary
Public health efforts for controlling the 2014–2015 Ebola outbreak in West Africa have focused on contact tracing and isolation of symptomatic individuals. In addition, substantial resources have been committed to scaling up the production of experimental vaccines. Ring vaccination—the vaccination of the contacts of an infected individual—was successfully implemented to achieve smallpox eradication. Ring vaccination is particularly feasible and effective in settings where the supply of vaccines is limited and disease incidence is low. Using a disease transmission model, we evaluated the benefit of adding ring vaccination to case isolation in Liberia and Sierra Leone. We found that ring vaccination could have averted up to 126 cases in Liberia and 560 cases in Sierra Leone, thereby saving lives and intervention resources.

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Hepatitis B Vaccines and HPV Vaccines Have Been Hailed as Major Public Health Achievements in Preventing Cancer—Could a Schistosomiasis Vaccine be the Third?
Michael H. Hsieh, Julia M. L. Brotherton, Afzal A. Siddiqui
Editorial | published 28 May 2015 | PLOS Neglected Tropical Diseases 10.1371/journal.pntd.0003598

PLoS One
[Accessed 30 May 2015]
http://www.plosone.org/

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Cluster Survey Evaluation of a Measles Vaccination Campaign in Jharkhand, India, 2012
Heather M. Scobie, Arindam Ray, Satyabrata Routray, Anindya Bose, Sunil Bahl, Stephen Sosler, Kathleen Wannemuehler, Rakesh Kumar, Pradeep Haldar, Abhijeet Anand
Research Article | published 26 May 2015 | PLOS ONE 10.1371/journal.pone.0127105
Abstract
Introduction
India was the last country in the world to implement a two-dose strategy for measles-containing vaccine (MCV) in 2010. As part of measles second-dose introduction, phased measles vaccination campaigns were conducted during 2010–2013, targeting 131 million children 9 months to <10 years of age. We performed a post-campaign coverage survey to estimate measles vaccination coverage in Jharkhand state.
Methods
A multi-stage cluster survey was conducted 2 months after the phase 2 measles campaign occurred in 19 of 24 districts of Jharkhand during November 2011–March 2012. Vaccination status of children 9 months to <10 years of age was documented based on vaccination card or mother’s recall. Coverage estimates and 95% confidence intervals (95% CI) for 1,018 children were calculated using survey methods.
Results
In the Jharkhand phase 2 campaign, MCV coverage among children aged 9 months to <10 years was 61.0% (95% CI: 54.4–67.7%). Significant differences in coverage were observed between rural (65.0%; 95% CI: 56.8–73.2%) and urban areas (45.6%; 95% CI: 37.3–53.9%). Campaign awareness among mothers was low (51.5%), and the most commonly reported reason for non-vaccination was being unaware of the campaign (69.4%). At the end of the campaign, 53.7% (95% CI: 46.5–60.9%) of children 12 months to <10 years of age received ≥2 MCV doses, while a large proportion of children remained under-vaccinated (34.0%, 95% CI: 28.0–40.0%) or unvaccinated (12.3%, 95% CI: 9.3–16.2%).
Conclusions
Implementation of the national measles campaign was a significant achievement towards measles elimination in India. In Jharkhand, campaign performance was below the target coverage of ≥90% set by the Government of India, and challenges in disseminating campaign messages were identified. Efforts towards increasing two-dose MCV coverage are needed to achieve the recently adopted measles elimination goal in India and the South-East Asia region

Science
29 May 2015 vol 348, issue 6238, pages 941-1052
http://www.sciencemag.org/current.dtl

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Feature
Is measles next?
Leslie Roberts
Before the polio virus is even in the grave, a small cadre of disease fighters is itching to set the next global eradication target: measles. The case is compelling. Measles killed 145,000 children last year in poor countries and left many more blind, deaf, or disabled. A cheap and effective vaccine has long been on the shelves; numerous expert panels have deemed measles eradication feasible, although daunting—it is the most contagious virus on Earth. But the biggest obstacle to measles eradication is polio, which hasn’t disappeared as it was supposed to do in 2000. Skeptics question whether a measles initiative would fall down the same rabbit hole as did the polio effort, which has spent billions of dollars and nearly 3 decades chasing the last few cases, only to see them disappear around the corner. Maybe it is time, they say, to settle for keeping measles cases really low but not trying to get to zero…

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Feature
In Vietnam, an anatomy of a measles outbreak
Leslie Roberts
Routine immunization is one of the great public health success stories in Vietnam, where rates of vaccine-preventable diseases have plummeted. But the measles outbreak last year was another story, with 60,000 reported cases and nearly 150 deaths in children under age 2. Experts trace the epidemic to the public’s loss of faith in the government-led vaccination program, following reports of adverse events associated in time with another vaccine. Many parents stopped vaccinating their children, leaving them susceptible to measles. When the virus swept in from the north and hit Hanoi, it exploded. Panicked parents rushed their children to the hospital, which was quickly overburdened. With poor infection control, the hospital became a hub of measles transmission, and children who weren’t already infected caught the virus there.

Vaccines — Open Access Journal
(Accessed 30 May 2015)
http://www.mdpi.com/journal/vaccines

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Review: Emerging Vaccine Technologies
by Rebecca J. Loomis and Philip R. Johnson
Vaccines 2015, 3(2), 429-447; doi:10.3390/vaccines3020429 – published 26 May 2015
Abstract
Vaccination has proven to be an invaluable means of preventing infectious diseases by reducing both incidence of disease and mortality. However, vaccines have not been effectively developed for many diseases including HIV-1, hepatitis C virus (HCV), tuberculosis and malaria, among others. The emergence of new technologies with a growing understanding of host-pathogen interactions and immunity may lead to efficacious vaccines against pathogens, previously thought impossible.

Media/Policy Watch
This section is intended to alert readers to substantive news, analysis and opinion from the general media 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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The Economist
http://www.economist.com/
Accessed 30 May 2015
Development aid
It’s not what you spend
How to make aid to poor countries work better
May 23rd 2015 The Economist | 30 May 2015
FOR decades rich countries have sought to foster global development with aid. But all too often there is little to show for their spending, now over $135 billion a year and rising. Success depends on political will in recipient countries, says Erik Solheim of the Development Assistance Committee of the OECD, a club of mostly rich countries that includes the biggest donors. And that may well be lacking.

What donors will pay for may not be what recipients deem a priority. So poor countries’ governments say what they must to get cash, and often fail to keep their side of the deal. Aid to build schools may be used to give fat contracts to allies, and the schools left empty. Ambulances bought by donors may rust on the kerb, waiting for spare parts.
Now donors are trying a new approach: handing over aid only if outcomes improve. “Cash on delivery” sees donors and recipients set targets, for example to cut child mortality rates or increase the number of girls who finish school, and agree on how much will be paid if they are met. Conventional approaches still account for the lion’s share of international aid. But several countries, including Britain and Norway, and big private donors, including the Bill and Melinda Gates Foundation, are experimenting with cash-on-deliver…

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Forbes
http://www.forbes.com/
Accessed 30 May 2015
Can New Research Break The Anti-Vaccine Fever? Probably Not
Todd Essig, Contributor May 26, 2015
May has been a good month for health and well-being, at least for the science of preventing preventible illnesses. Here’s why: two new research studies appeared with powerful support for vaccines and two states made legislative progress towards ending so-called “philosophical exemptions” in which parents opt-out of vaccination programs on the basis of fear and misinformation. Unfortunately, the anti-vaccine fear-trepreneurs and celebrities, like Jenny McCarthy and Robert F. Kennedy Jr., have fomented a movement impervious to data.

Both of the new studies shift the risk-reward calculation even more towards the benefits vaccines provide, a calculation already so heavily dominated by reward it should not be a question for otherwise healthy individuals…

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New Yorker
http://www.newyorker.com/
Accessed 30 May 2015
News Desk
May 29, 2015
Vermont Says No to the Anti-Vaccine Movement
By Michael Specter
Just a year after Vermont became the first state to require labels for products made with genetically modified organisms, Governor Peter Shumlin on Thursday signed an equally controversial but very different kind of legislation: the state has now become the first to remove philosophical exemptions from its vaccination law.

The two issues are both emotional and highly contested. But Vermont’s decisions could hardly be less alike: the G.M.O. bill, which has enormous popular support, has been widely criticized by scientists—largely because no credible evidence exists suggesting that G.M.O.s are dangerous. The vaccine law, however, opposed by many people, is the strongest possible endorsement of the data that shows that vaccines are the world’s most effective public-health tool.

Perhaps because the debate over removing the philosophical exemption has been rancorous and long, the governor first opposed the legislation. More recently, he suggested that he was neutral. On Thursday, possibly sensing the political peril involved in siding with the anti-vaccine movement, Shumlin signed the bill without much publicity. Rather than hold a news conference, as he did when signing the G.M.O. legislation last year, he simply released a statement.

“Vaccines work and parents should get their kids vaccinated,” he said. “I know there are strong feelings on both sides of this issue. I wish the legislation passed three years ago had worked to sufficiently increase vaccination rates. However we’re not where we need to be to protect our kids from dangerous diseases, and I hope this legislation will have the effect of increasing vaccination rates.”

The previous legislation, which required parents to review educational materials before claiming the exemption, was an attempt to balance individual rights with the need to protect children from childhood diseases. Nobody has yet figured out how to do that. During the current debate, the Vermont State Health department reported that fewer than eighty-eight per cent of children entering the state’s kindergartens were fully vaccinated. Like most states, Vermont currently offers parents an exemption for medical conditions and one for religious beliefs. It has been one of about twenty states that allow for philosophical exemptions, and the majority of exemptions in Vermont have been for philosophical reasons.

Meanwhile, outbreaks of measles, like the one earlier this year at Disneyland, as well as other childhood diseases, have been increasingly difficult for politicians to ignore. Public-health experts say that ninety-five per cent of a student population needs to be vaccinated to provide adequate protection against measles, the world’s most contagious disease. Measles remains one of the world’s leading causes of death among children under five, according to the World Health Organization. In 2013, the disease killed nearly a hundred and fifty thousand people; before vaccines became available, millions died.

“There is something deep in the core of my being,’’ Representative Warren Kitzmiller, of Montpelier, said during the debate over the philosophical objection. “And it simply will not allow me to vote to remove a parent’s right to make this serious decision on what is in the best interest of their child.”

That is a reasonable position, and many people hold it. According to a 2014 Pew Research Center survey, only sixty-eight per cent of Americans believe that childhood vaccinations should be required. Among younger parents, the percentage who object is even higher.

Data and science are obviously not the only issues that matter in this debate. But it’s hard to see how all rights can be equal: if parents want their children to remain unprotected from vaccinations, perhaps they should have that right. But should those children then be allowed near other students, in public places like playgrounds, or anywhere else where they could infect people with weakened immune systems? By removing the philosophical objection, at least one state has begun to say no.

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New York Times
http://www.nytimes.com/
Accessed 30 May 2015
U.S. Military Orders Review as Anthrax Mishap Widens
By REUTERSMAY 30, 2015, 1:34 A.M. E.D.T.
WASHINGTON — The U.S. military said on Friday it discovered even more suspected shipments of live anthrax than previously thought, both in the United States and abroad, and ordered a sweeping review of practices meant to inactivate the bacteria…

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_23 May 2015

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

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

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David R. Curry, MS
Executive Director
Center for Vaccine Ethics and Policy
a program of the
– Division of Medical Ethics, NYU Medical School
– Children’s Hospital of Philadelphia Vaccine Education Center
Associate Faculty, Division of Medical Ethics, NYU Medical School

Editor’s Note:
The World Health Assembly continues through 26 May. Initial high-level actions are being reported on through press releases, including the three below on WHO’s emergency and response programme stemming from the Ebola crisis, polio, malaria, yellow fever, and the IHRs (International Health Regulations). Further below is a link to a draft resolution which we understand is still in discussion at WHA addressing issues around the GVAP (Global Vaccine Action Plan).

Sixty-eighth World Health Assembly [full documentation]

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WHO Director-General’s speech at the Sixty-eighth World Health Assembly
Dr Margaret Chan, Director-General of the World Health Organization
18 May 2015
[Closing text]
…Ladies and gentlemen,
The threats to health have multiplied, but so has our capacity to respond. For some reason, health brings out the very best in human creativity and determination.

We enter the post-2015 era blessed with a host of new initiatives, instruments, interventions, including new vaccines, and precise strategies with time-bound goals. The momentum behind the MDGs will continue. WHO has mature programmes, with strong track records of success, to guide this work.

Above all, our work is driven by a fierce commitment to equity, social justice, and the right to health. As the number of countries aiming for universal health coverage grows, we are in a position to change the mindset that poor people living in poor places will inevitably have poor health care. This is no longer true.

The Ebola outbreak shook this Organization to its core. As noted in the interim assessment report, this was a defining moment for the work of WHO and an historic political moment for world leaders to give WHO new relevance and empower it to lead in global health.

I urge you to make this happen. I will do my part.

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World Health Assembly gives WHO green light to reform emergency and response progamme
News release
23 May 2015 ¦ GENEVA – Delegates at the World Health Assembly made a series of decisions stemming from the 2014 Ebola virus disease outbreak. These give the WHO Secretariat the go-ahead to carry out structural reforms so it can prepare for and respond rapidly, flexibly and effectively to emergencies and disease outbreaks.

Preparing for and responding to emergencies
Delegates at the 68th World Health Assembly welcomed WHO’s commitment to deep reforms of its emergency work, in particular by setting out clear and effective command and control mechanisms across all 3 levels of the Organization – headquarters, regional and country offices.
At the same time, WHO will establish an emergency programme, which will be guided by an all-hazards health emergency approach, that emphasizes adaptability, flexibility and accountability, humanitarian principles, predictability, timeliness and country ownership.

WHO will set up a US$ 100-million contingency fund to provide financing for in-field operations for up to 3 months. The contingency fund will run initially as a two-year pilot and will then be evaluated.

Delegates appreciated the key coordination role played by WHO in its ongoing work to develop vaccines, diagnostics and drugs for Ebola virus disease. They noted the importance of being able to accelerate research and development activities to tackle health threats for which solutions do not currently exist. They also requested the Secretariat to continue and enhance WHO’s work in helping countries better prepare for emergencies by strengthening national health systems.

International Health Regulations (2005)
The Director-General was asked to set up a review committee under the International Health Regulations (2005) to:
:: assess the effectiveness of the International Health Regulations with regard to the prevention, preparedness and response to the Ebola outbreak
:: assess the status of implementation of recommendations from the previous Review Committee in 2011 and its impact on the Ebola outbreak
:: recommend steps to improve functioning, transparency, effectiveness and efficiency of the International Health Regulations and improve preparedness and response for future health emergencies.

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WHA reaches agreement on polio, International Health Regulations and strengthening surgical care
News release
22 May 2015 ¦ GENEVA – The World Health Assembly continued progress Friday, reaching agreements on polio eradication; further implementation of the International Health Regulations (2005); surgical care and medical products.

Polio
Delegates at the World Health Assembly today agreed on a resolution in which Member States recommit to stopping polio and to preparing for the phased withdrawal of oral polio vaccines.
The meeting noted that Polio eradication can only be achieved through global solidarity. Reviewing the latest global epidemiology and the impact of on-going efforts, delegates highlighted progress across Africa (which has not seen a case due to wild poliovirus since August 2014), and success in halting three large multi-country outbreaks in the Middle East, Horn of Africa and Central Africa. They also noted continuing efforts in Pakistan, and the strong progress being made, in close coordination with Gavi, the Vaccine Alliance, towards introduction of inactivated polio vaccine (IPV) and preparations for the phased withdrawal of oral polio vaccines.

International Health Regulations
Delegates endorsed the International Health Regulations Review Committee recommendation to extend the deadline to 2016 to all countries that need more time to implement the Regulations. The recommendation also emphasizes a dynamic, ongoing process of evaluation and improvement, and the value of independent assessment.

The recent Ebola outbreak has highlighted the importance of all countries having strong capacities to rapidly detect, respond to and prevent global public health threats such as disease outbreaks. The International Health Regulations (2005), oblige all Member States to have these capacities in place. Only one-third of all countries (64), however, reported that they had met the minimum requirements in 2014.

Speakers at today’s meeting recognized the important role WHO plays in providing expertise and guidance to help countries enhance surveillance systems and laboratory services, build early warning and alert systems, and train health workers so that they can deal with major public health threats. They expressed strong support for pairing well-resourced countries with other countries to help them to meet the IHR requirements.

Yellow fever
In 2013, WHO’s expert advisory group on immunization (SAGE) recommended that a single dose of yellow fever vaccine provides life-long immunity to the disease, making boosters unnecessary. Under the International Health Regulations (2005), vaccination may be required of any traveller leaving an area at risk of yellow fever transmission. The Regulations currently specify that travellers should renew immunization every ten years. Changes to the Regulations recognizing the adequacy of a single dose of the vaccine will come into force in June 2016.
Some countries may, however, wish to institute the changes immediately. Delegates agreed to inform WHO if their governments decide to apply these changes immediately, and accept the validity of yellow fever vaccination certificates as life-long. WHO will publish an updated list of these countries online to inform international travellers. The Secretariat has also agreed to establish a scientific advisory group to work with affected countries to maintain up-to-date analysis of areas at risk.

Surgical care
Delegates of the World Health Assembly agreed a resolution on strengthening emergency and essential surgical care and anaesthesia.

A wide range of conditions – from cancer and diabetes to obstructed labour and road traffic injuries – can be successfully treated by surgery. In many parts of the world, access to emergency and essential services is extremely limited, with low and middle income countries concentrating available surgical care in urban centres. As a result, maternal mortality rates remain high, minor surgical issues become lethal and treatable injuries can lead to death or disability.

This resolution will help countries adopt and implement policies which will integrate safe, quality and cost effective surgical care into the health system as a whole. It highlights the importance of both expanding access and improving the quality and safety of services; strengthening the surgical workforce; improving data collection, monitoring and evaluation; ensuring access to safe anaesthetics such as Ketamine; and fostering global collaboration and partnerships. The resolution also underscores the need to raise awareness of the issue and build political commitment

Substandard, spurious, falsely labelled, falsified and counterfeit medical products
Substandard, spurious, falsely labelled, falsified and counterfeit medical products continue to threaten health, not only because they do not provide the benefits they advertise, but because they also pose a serious health risk, and undermine the credibility of health systems. The World Health Assembly had set up a mechanism to raise awareness, gather evidence, implement policies and evaluate effectiveness of efforts to address this issue, and had planned to review the impact of that mechanism in 2016. Delegates today agreed to postpone this to 2017 – both to allow more time for the review itself and for implementation of new policies to tackle the problem.
World Health Assembly agrees Global Malaria Strategy and Programme Budget 2016-17

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GENEVA – WHO Member States today agreed a new global malaria strategy for 2016-2030 and approved the Organization’s proposed programme budget for 2016-2017.
News release
20 May 2015 ¦

Global Malaria Strategy
The strategy aims to reduce the global disease burden by 40% by 2020, and by at least 90% by 2030. It also aims to eliminate malaria in at least 35 new countries by 2030.
Between 2000 and 2013, the global malaria mortality rate dropped by 47%. A major expansion of the WHO-recommended core package of measures – vector control, chemoprevention, diagnostic testing and treatment – has proved both cost effective and efficient. Nevertheless, millions of people are still unable to access malaria prevention and treatment, and most cases and deaths continue to go unregistered and unreported. In 2013, malaria killed an estimated 584 000 people.
The new strategy aims to build on recent successes to radically reduce this figure. Developed in close consultation with endemic countries and partners, the strategy provides a comprehensive framework so countries can develop tailored programmes that will sustain and accelerate progress towards malaria elimination.
It comprises three key elements: ensuring universal access to malaria prevention, diagnosis and treatment; accelerating efforts towards elimination and attainment of malaria-free status; and strengthening malaria surveillance. It emphasises the importance of innovation and research, and the critical need for political commitment, sustainable financing, strong health systems, and collaboration across different sectors.

Programme Budget 2016-17
Member States also approved WHO’s proposed Programme Budget for 2016-17. The budget of US$ 4384.9 million includes a US$ 236 million increase over the 2014-15 programme budget requirement to meet the needs of countries; leverage the experience gained during the Ebola outbreak; address emerging priorities such as antimicrobial resistance, health and the environment, malaria and viral hepatitis; and implement resolutions passed by the Assembly and WHO’s Regional Committees. Additional funds will also be used to further strengthen transparency, improve risk management and enhance accountability.

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Draft Resolutions
A68/A/CONF./4 Rev.1
Global vaccine action plan
Draft resolution proposed by the delegations of Algeria, Egypt, Libya, Morocco, Nigeria, Pakistan, Qatar, Saudi Arabia, Thailand, Tunisia

Nepal earthquake 2015 – Grade 3 emergency
:: Health situation report No. 18 pdf, 296kb 22 May 2015
[Excerpt]
…The 14 highly affected districts were assessed for their status on carrying out routine immunization work. Most of the districts are in a position to resume routine immunization despite the severe damage in the physical infrastructure. The cold chain statuses in most of the districts are intact and vaccines are safe except in Sindhupalchok district. WHO in close coordination with Logistic Management Division and UNICEF is planning to avail generators to revitalize the cold chain system…

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:: Global Health Cluster
..Health Cluster 4Ws – 19 May 2015 xlsx, 380kb
..Health Cluster Bulletin No. 3 pdf, 3.15Mb 18 May 2015

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:: Nepal after the recent earthquakes: reconstruction and vaccine-preventable enteric diseases
By Lorenz von Seidlein
PLOS Blogs Posted: May 21, 2015
In the wake of the recent devastating earthquakes, PLOS Medicine Consulting Editor Lorenz von Seidlein visited Nepal to assess outbreak risks. Lorenz travelled with Anuj Bhattachan, International Vaccine Institute, Seoul, Korea and guidance from Deepak C. Bajracharya and Shyam Raj Upreti from the Group for Technical Assistance, Kathmandu, Nepal. The assessment was requested by the epidemiology and disease control division of the Ministry of Health of Nepal and facilitated by Stop Cholera. Here he reports on the damage he witnessed and considers the choice of administering vaccines pre-emptively versus reactively in response to an outbreak
:: Access to maternal and child health care in Nepal brings joy amid destruction
22 May 2015 Feature Story

::::::

WHO Grade 3 emergencies [listed at 23 May 2015]
:: Central African Republic
:: Democratic Republic of the Congo
:: Guinea
:: Iraq
:: Liberia
:: Malawi
:: Mali
:: Mozambique
:: Nepal
:: Niger
:: Nigeria
:: occupied Palestinian territory
:: Philippines
:: Sierra Leone
:: South Sudan
:: The Syrian Arab Republic
:: Ukraine
:: Vanuatu
:: Yemen

Grade 3: a single or multiple country event with substantial public health consequences that requires a substantial WCO response and/or substantial international WHO response. Organizational and/or external support required by the WCO is substantial. An Emergency Support Team, run out of the regional office, coordinates the provision of support to the WCO.

EBOLA/EVD [to 23 May 2015]
Public Health Emergency of International Concern (PHEIC); “Threat to international peace and security” (UN Security Council)

WHO: Ebola Situation Report – 20 May 2015
[Excerpts]
SUMMARY
:: The week to 17 May saw the highest weekly total of confirmed cases of Ebola virus disease (EVD) for over a month, with 35 cases reported from Guinea and Sierra Leone. This is a substantial increase compared with 9 cases reported the previous week. The geographical area of transmission has also expanded compared with recent weeks, with a total of 6 districts reporting cases (3 in Guinea, 3 in Sierra Leone), compared with 3 the previous week (2 in Guinea, 1 in Sierra Leone). Capacity for improved community engagement, case investigation, and targeted, active surveillance continues to be strengthened in areas of continuing transmission to ensure that remaining chains of transmission are detected, contained, and brought to an end…

COUNTRIES WITH WIDESPREAD AND INTENSE TRANSMISSION
:: There have been a total of 26,933 reported confirmed, probable, and suspected cases of EVD in Guinea, Liberia and Sierra Leone (figure 1, table 1), with 11,120 reported deaths (this total includes reported deaths among probable and suspected cases, although outcomes for many cases are unknown). A total of 27 new confirmed cases were reported in Guinea and 8 in Sierra Leone in the 7 days to 17 May. The outbreak in Liberia was declared over on 9 May…

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Health worker Ebola infections in Guinea, Liberia, and Sierra Leone
Preliminary report
WHO
Publication date: May 2015 :: 16 pages
Languages: English
WHO reference number: WHO/EVD/SDS/REPORT/2015.1
Pdf: http://apps.who.int/iris/bitstream/10665/171823/1/WHO_EVD_SDS_REPORT_2015.1_eng.pdf?ua=1
Overview
This preliminary report summarizes the impact of the Ebola epidemic on the health workforce of Guinea, Liberia and Sierra Leone. It investigates the determinants of infection and describes safe practices put in place to protect health workers during the epidemic. The report covers the period from 1 January 2014 to 31 March 2015 and is presents findings from the 815 confirmed and probable cases for whom individual case reports were available.

The Ebola epidemic has taken a heavy toll on the already scarce health workforce. Among the health workers for whom final outcome is known, two-thirds of those infected died. Preliminary analysis shows that, depending on their occupation in the health service, health workers are between 21 and 32 times more likely to be infected with Ebola than people in the general adult population. With higher risks of exposure in caring for others, health workers were disproportionately impacted and traumatised by Ebola.

Health worker infections can be prevented. WHO and partners have worked with ministries of health, partners, managers and health workers to put in place infection prevention control (IPC) and occupational health and safety (OHS) strategies and supplies to prevent health worker infections and improve patient safety. Health worker protection and support must be at the core of emergency response, preparedness and efforts to build a resilient health system. Cementing this lesson learnt into practice can be a lasting tribute to health workers.

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WHO: Stories from countries
:: Giving back after Ebola 22 May 2015
:: Ebola in Liberia: Frightened patients infected their carers 21 May 2015
:: Ebola diaries: Lessons in listening 19 May 2015
Red Cross Red Crescent Ebola responders among Florence Nightingale medal recipients
18 May 2015
World Bank Group Statement for the 68th World Health Assembly
BRIEF
May 19, 2015
Presented in discussion of item 16.1 and adoption of resolution pursuant to documents A68/24, A68/25, A68/26 and A68/27.
Tim Evans, Senior Director, Health, Nutrition and Population, World Bank Group

Hon’ble Chair and Excellencies
The World Bank Group welcomes the draft documents and discussions related to the Ebola virus outbreak and follow-up to the Special Session of the Executive Board on Ebola.

At the outset, the World Bank Group acknowledges and supports the leadership of the Governments, especially the Ministries of Health, of Guinea, Liberia and Sierra Leone in their fight to get to, and sustain zero cases of EVD — AND in their efforts to get their essential health services and economies back on track.

The World Bank Group acknowledges the untiring and selfless efforts of the health and development communities in these three countries, members of which have worked in very adverse circumstances and against tough odds to contain this epidemic.

The World Bank Group welcomes the update on the Ebola outbreak, and appreciates the frank assessment as well as the actionable recommendations of the Ebola Interim Assessment panel as presented in its First Report. The World Bank Group very strongly supports a strengthened and well-funded WHO, which can support all countries as they prepare to meet the challenges of increased global interdependence and shared vulnerability.

More specifically, the WBG acknowledges the important focus of the First Report on financing. The Report’s focus on the chronic under-financing of WHO arising from the Zero Economic Growth policy is critically important — we urge all member states to reconsider this policy that places at risk all of WHO’s core functions in the longer run.

The World Bank Group strongly supports the establishment of a Contingency Fund to support WHO’s emergency response capacity. The WBG sees this as one critical part of rebuilding the financing architecture for pandemic risk management. On its part, the World Bank Group working closely with WHO and other development partners and the private sector is developing a global Pandemic Emergency Financing Facility. The PEFF, upon receiving an agreed “trigger” or “signal” from WHO, will disburse resources of sufficient scale – swiftly – to priority needs. In this regard, the PEFF will complement the proposed WHO Contingency Fund by providing resources to countries and implementing agencies, including WHO, WFP, UNICEF and others, as well as NGOs, to finance containment activities in affected countries.

The World Bank Group also welcomes the plan for a Global Health Emergency Workforce to respond to acute or protracted risks and emergencies with health consequences, which is fully aligned with the White Coats initiative proposed by Chancellor Merkel. The proposed Pandemic Emergency Financing Facility will support the rapid deployment of medical and health personnel during outbreaks, and considers this to be a very critical component of a surge response.

As various processes – such as the UNSG High Level panel, WHO’s Ebola Interim Assessment Panel, the Institute of Medicine Pandemic review – move toward conclusions, it will be critical to agree how their recommendations for strengthened global risk management for pandemics can be financed swiftly and sustainably drawing on existing and new mechanisms. In this regard, the World Bank Group looks forward to organizing with WHO and other partners, in early September 2015, a high level consultation on “pandemic financing”, that aims to reach consensus on both an overall framework for financing and on the specific mechanisms that will fuel the recommendations for a renewed and revitalized pandemic preparedness and response capacity.

The Weekly Epidemiological Record (WER) 22 May 2015, vol. 90, 21 (pp. 253–260)
..Progress towards polio eradication worldwide, 2014–2015
..How Liberia reached zero cases of Ebola virus disease