BMC Public Health
(Accessed 27 September 2014)
http://www.biomedcentral.com/bmcpublichealth/content

Research article
Hepatitis B virus vaccination booster does not provide additional protection in adolescents: a cross-sectional school-based study
Yung-Chieh Chang, Jen-Hung Wang, Yu-Sheng Chen, Jun-Song Lin, Ching-Feng Cheng, Chia-Hsiang Chu BMC Public Health 2014, 14:991 (23 September 2014)
Abstract (provisional)
Background
Current consensus does not support the use of a universal booster of hepatitis B virus (HBV) vaccine because there is an anamnestic response in almost all children 15 years after universal infant HBV vaccination. We aimed to provide a booster strategy among adolescents as a result of their changes in lifestyle and sexual activity.
Methods
This study comprised a series of cross-sectional serological surveys of HBV markers in four age groups between 2004 and 2012. The seropositivity rates of hepatitis B surface antigen (HBsAg) and its reciprocal antibody (anti-HBs) for each age group were collected. There were two parts to this study; age-specific HBV seroepidemiology and subgroup analysis, including effects of different vaccine types, booster response for immunogenicity at 15 years of age, and longitudinal follow-up to identify possible additional protection by HBV booster.
Results
Within the study period, data on serum anti-HBs and HBsAg in a total of 6950 students from four age groups were collected. The overall anti-HBs and HBsAg seropositivity rates were 44.3% and 1.2%, respectively. The anti-HBs seropositivity rate in the plasma-derived subgroup was significantly higher in both 15- and 18-year age groups. Overall response rate in the double-seronegative recipients at 15 years of age was 92.5% at 6 weeks following one recombinant HBV booster dose. Among the 24 recipients showing anti-HBs seroconversion at 6 weeks after booster, seven subjects (29.2%) had lost their anti-HBs seropositivity again within 3 years. Increased seropositivity rates and titers of anti-HBs did not provide additional protective effects among subjects comprehensively vaccinated against HBV in infancy.
Conclusions
HBV booster strategy at 15 years of age was the main contributor to the unique age-related phenomenon of anti-HBs seropositivity rate and titer. No increase in HBsAg seropositivity rates within different age groups was observed. Vaccination with plasma-derived HBV vaccines in infancy provided higher anti-HBs seropositivity at 15-18 years of age. Overall booster response rate was 92.5% and indicated that intact immunogenicity persisted at least 15 years after primary HBV vaccination in infancy. Booster vaccination of HBV did not confer additional protection against HBsAg carriage in our study.

British Medical Journal
27 September 2014(vol 349, issue 7976)
http://www.bmj.com/content/349/7976

Editorials
Ebola in an unprepared Africa
BMJ 2014; 349 doi: http://dx.doi.org/10.1136/bmj.g5597 (Published 15 September 2014) Cite this as: BMJ 2014;349:g5597
Oyewale Tomori, professor of virology
Author affiliations
Governments of affected countries need help but must take the lead in protecting their citizens

The 2 year old boy who died in December 2013 in Gueckedou, Guinea, is considered the index case of the current outbreak of Ebola virus disease caused by the Zaire species.1 Up until 2014, the disease was limited to rural areas of east and central Africa,2 but it has now spread to Liberia, Sierra Leone, Nigeria, and Senegal. By 6 September 2014, 4293 cases and 2296 deaths had been reported in the current outbreak,3 which, by the time the outbreak is controlled, is likely to surpass the total number of cases and deaths reported for all 22 Ebola outbreaks that have occurred in Africa since 1976, when the disease was first described.3 The World Health Organization has declared the current outbreak an “out of control” public health emergency of international concern.4

One of the reasons for the unprecedented epidemic is that Ebola is spreading in three countries ranked among the poorest in the world. The 2014 Human Development Index ranks Liberia, Guinea, and Sierra Leone at 175, 179, and 183, respectively, of 187 countries.5 Whereas Liberia and Sierra Leone are recovering from civil wars, Guinea has been affected by chronic underdevelopment allowed and ignored by successive governments. Around a fifth of the citizens of these three countries live in extreme poverty.6 Health facilities and services are wholly inadequate. For example, Liberia has 0.1 physicians, 1.7 nurses and midwives, and eight hospital beds for every 10 000 people.7

To date, more than 240 healthcare workers have developed Ebola virus disease in Guinea, Liberia, Nigeria, and Sierra Leone and more than 120 have died.8 In addition to fragile health systems, several other contributory factors have compromised our ability to mount an adequate response. Poor disease surveillance and response systems make early detection and control of outbreaks inefficient and unreliable. In addition, unmanned borders artificially separate people of the same ethnic origin and cultural background into different nationalities, resulting in a high level of movement across borders and uncontrolled cross border movement of infected people. The death of healthcare workers has led to a shortage of workers to care for patients with other diseases and hospital closures. Ignorance and misconceptions about the virus’s mode of transmission and customary burial ceremonies complicate the situation further.

Governments of affected countries were initially in denial over the occurrence of the disease. Subsequently, they relinquished responsibility for the care of infected patients to overworked international non-governmental organisations and issued incoherent directives, such as the closure of markets and borders. The Ebola outbreak has now become so serious that health infrastructure is beginning to collapse and hospitals are closing. Without effective medical care patients are dying not only of Ebola but of malaria, diarrhoea, and other conditions. The medical charity Médecins Sans Frontières recently commented that it will take at least another six months to bring the epidemic under control.9 The organisation’s president and general director have described the international response to its repeated calls “for more hands-on assistance to control the epidemic and to provide the best possible care to patients” as “slow, derisory, [and] irresponsible.”10

What must be done to stop transmission and control the epidemic?
The current epidemic is beyond the capacity and capability of the affected nations. Ending the Ebola outbreak in west Africa and preventing a global calamity requires commitment and collaboration of national and international governments and agencies. The affected countries need urgent help with strengthening and sustaining basic infection control procedures to stop transmission of disease. These include daily tracking of people who come into contact with sick or dead people and monitoring them for the 21 day incubation period; documentation of historical and ongoing chains of virus transmission to ensure that accurate numbers of cases and deaths are recorded and to provide information on transmission of disease; identification of deaths in the community and ensuring safe burial practices; and improving specimen referral and strengthening laboratory diagnostic capacity. Healthcare workers must be educated on these practices to substantially reduce healthcare associated transmission.

National governments urgently need to communicate with the population to restore confidence and to ensure acceptance of healthcare services. They need to educate people on the community’s role in control of the disease and to enumerate government action and efforts in controlling the disease. They must show leadership and assume responsibility for the welfare of their citizens by prioritising the provision of adequate funds for procuring personal protective equipment and hospital supplies and paying salaries to healthcare workers. National professional groups—including medical associations, veterinarians, scientists, the media and non-governmental organisations—must make their expertise available for the service and welfare of their communities. International agencies and governments must also take decisive action, deploying the appropriate resources to contain the epidemic.

Eurosurveillance
Volume 19, Issue 38, 25 September 2014
http://www.eurosurveillance.org/Public/Articles/Archives.aspx?PublicationId=11678

News
The AIRSAN Project – Efficient, coherent EU level response to public health threats in air transport
A Milde-Busch, A Gilsdorf1
Department for Infectious Disease Epidemiology, Robert Koch Institute

The Ebola virus disease epidemic in West Africa since spring 2014 illustrates once again the need to be well prepared for cross-border public health threats. One challenge is to contain the spread of the disease by a coordinated international response which should entail sound cooperation between the public health and the aviation sector. The AIRSAN Project, funded by the European Commission, aims to ensure an efficient, coherent response at EU-level to public health threats in air transport. Project partners are public health authorities, airlines, airport managements and international organisations, e.g. the World Health Organization (WHO), the International Civil Aviation Organization (ICAO) and the International Air Transport Association (IATA).

The AIRSAN Project provides the AIRSAN website; an open-access website for dissemination of information for public health and civil aviation authorities, airlines and airports: http://www.airsan.eu/

The AIRSAN Project website also provides access to:
:: AIRSAN Guidance Documents: The AIRSAN Project develops guidance documents that focus on managing public health threats in air transport which will be made available on the AIRSAN website. As an interim result, the AIRSAN bibliography has been created and is available online. The bibliography makes public health action-orientated information in the aviation sector quickly accessible: http://www.airsan.eu/Resources/Bibliography/Search.aspx In the current Ebola outbreak situation the following example illustrates the benefit of the AIRSAN bibliography: a competent public health authority wants to know how to manage a flight-passenger with suspected Ebola virus disease at an airport. The keyword-search “Management of suspect or affected travellers (at-airport)” reveals 14 documents with information about the specific topic. In case the flight-passenger is confirmed with Ebola virus disease the keyword “Contact tracing” can be searched and results include documents like the Risk Assessment Guidelines for Infectious Diseases Transmitted on Aircraft (RAGIDA) [1] which gives specific advice on the definition of close contacts in cases of viral haemorrhagic fevers.

:: The AIRSAN Network: The AIRSAN Project brings together competent public health authorities, civil aviation authorities, airport management and airlines across EU Member States in form of a network. Interested authorities are invited to register here for the AIRSAN Network: http://www.airsan.eu/ContactUs/RegistertotheAirsanNetwork.aspx. Registered members can use the password-protected AIRSAN Communication Platform to exchange information, e.g. on airport exercises or developed information material and to discuss topics concerning public health in the aviation sector.

:: The AIRSAN Training Tool: The AIRSAN Project is developing a training tool that will support authorities and companies with the implementation of the AIRSAN Guidance Documents. The AIRSAN Training Tool will also be made available on the AIRSAN website.

In summary, the AIRSAN Project facilitates the implementation of the International Health Regulations (2005) [2] and the Decision 1082/2013 [3] in EU Member States.

References
1. European Centre for Disease Prevention and Control (ECDC): Risk assessment guidelines for diseases transmitted on aircraft. 2nd ed. Stockholm: ECDC; 2010.Available from: http://www.ecdc.europa.eu/en/publications/Publications/1012_GUI_RAGIDA_2.pdf.
2. World Health Organization (WHO). International Health Regulations (2005). Second edition. Reprinted 2008. Geneva: WHO; 2008. Available from: http://www.who.int/ihr/9789241596664/en/index.html
3. The European Parliament and of the Council of the European Union. Decision No 1082/2013/EU of the European Parliament and of the Council of 22 October 2013 on serious cross-border threats to health and repealing Decision No 2119/98/EC. Official Journal of the European Union. Luxembourg: Publications Office of the European Union. 5.11.2013:L 293. Available from: http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:2013:293:0001:0015:EN:PDF

Globalization and Health
[Accessed 27 September 2014]
http://www.globalizationandhealth.com/

Commentary
A call for a moratorium on the .health generic top-level domain: preventing the commercialization and exclusive control of online health information
Mackey TK, Eysenbach G, Liang BA, Kohler JC, Geissbuhler A and Attaran A Globalization and Health 2014, 10:62 (26 September 2014)
Abstract
In just a few weeks, the Internet could be expanded to include a new .health generic top-level domain name run by a for-profit company with virtually no public health credentials – unless the international community intervenes immediately. This matters to the future of global public health as the “Health Internet” has begun to emerge as the predominant source of health information for consumers and patients. Despite this increasing use and reliance on online health information that may have inadequate quality or reliability, the Internet Corporation for Assigned Names and Numbers (ICANN) recently announced it intends to move forward with an auction to award the exclusive, 10 year rights to the .health generic top-level domain name. This decision is being made over the protests of the World Medical Association, World Health Organization, and other stakeholders, who have called for a suspension or delay until key questions can be resolved. However, rather than engage in constructive dialogue with the public health community over its concerns, ICANN chose the International Chamber of Commerce—a business lobbying group for industries to adjudicate the .health concerns. This has resulted in a rejection of challenges filed by ICANN’s own independent watchdog and others, such that ICANN’s Board decided in June 2014 that there are “no noted objections to move forward” in auctioning the .health generic top-level domain name to the highest bidder before the end of the year. This follows ICANN’s award of several other health-related generic top-level domain names that have been unsuccessfully contested. In response, we call for an immediate moratorium/suspension of the ICANN award/auction process in order to provide the international public health community time to ensure the proper management and governance of health information online.

Debate
On the margins of aid orthodoxy: the Brazil-Mozambique collaboration to produce essential medicines in Africa
Russo G, de Oliveira L, Shankland A and Sitoe T Globalization and Health 2014, 10:70 (25 September 2014)
Abstract (provisional)
Background
On the back of its recent economic development and domestic success in the fight against HIV/AIDS, Brazil is helping the Government of Mozambique to set up a pharmaceutical factory as part of its South-South cooperation programme. Until recently, a consensus existed that pharmaceutical production in Africa was not viable or sustainable. This paper looks into practicalities and evolution of this collaboration to illustrate the characteristics of Brazilian development cooperation in health, with the aim of drawing lessons for the wider debate on aid and local production of pharmaceuticals in Africa.
Discussion
We show that the project process has been very long and complex, has involved multiple public and private partners, and cost in excess of USD34 million. There have also been setbacks in the process, and although production has already started, it is unclear whether all the project’s original objectives will be met.
Summary
The Brazil-Mozambique’s pharmaceutical factory experience illustrates positives as well as limitations of Brazil’s unorthodox approach to health development cooperation, highlighting its contribution to pushing the boundaries of the debate on local production of pharmaceuticals in resource-poor settings.

Health and Human Rights
Volume 16, Issue 2 December 2014
http://www.hhrjournal.org/
Papers in Press: Special Issue on Health Rights Litigation

Editorial
Promoting Equity in Health: What Role for Courts?
Alicia Ely Yamin

Health Research Policy and Systems
http://www.health-policy-systems.com/content
[Accessed 27 September 2014]

Editorial
Four centuries on from Bacon: progress in building health research systems to improve health systems?
Stephen R Hanney1* and Miguel A González-Block2
* Corresponding author: Stephen R Hanney
Author Affiliations
Health Research Policy and Systems 2014, 12:56 doi:10.1186/1478-4505-12-56
Published: 23 September 2014
Abstract
In 1627, Francis Bacon’s New Atlantis described a utopian society in which an embryonic research system contributed to meeting the needs of the society. In this editorial, we use some of the aspirations described in New Atlantis to provide a context within which to consider recent progress in building health research systems to improve health systems and population health. In particular, we reflect on efforts to build research capacity, link research to policy, identify the wider impacts made by the science, and generally build fully functioning research systems to address the needs identified.

In 2014, Health Research Policy and Systems has continued to publish one-off papers and article collections covering a range of these issues in both high income countries and low- and middle-income countries. Analysis of these contributions, in the context of some earlier ones, is brought together to identify achievements, challenges and possible ways forward. We show how 2014 is likely to be a pivotal year in the development of ways to assess the impact of health research on policies, practice, health systems, population health, and economic benefits.

We demonstrate how the increasing focus on health research systems will contribute to realising the hopes expressed in the World Health Report, 2013, namely that all nations would take a systematic approach to evaluating the outputs and applications resulting from their research investment.

Journal of Community Health
Volume 39, Issue 5, October 2014
http://link.springer.com/journal/10900/39/4/page/1

Original Paper
Views on Human Papillomavirus Vaccination: A Mixed-Methods Study of Urban Youth
Melissa K. Miller, Joi Wickliffe, Sara Jahnke…

Original Paper
Parents’ Decisions About HPV Vaccine for Sons: The Importance of Protecting Sons’ Future Female Partners
Christine L. Schuler, Nancy S. DeSousa, Tamera Coyne-Beasley

Original Paper
Understanding HPV Vaccine Uptake Among Cambodian American Girls
Victoria M. Taylor, Nancy J. Burke, Linda K. Ko…

The Lancet
Sep 27, 2014 Volume 384 Number 9949 p1159 – 1236
http://www.thelancet.com/journals/lancet/issue/current

Editorials
Women, children, and adolescents: the post-2015 agenda
The Lancet
Preview |
As the global health community and government representatives gathered in New York this week to review progress towards the Millennium Development Goals (MDGs) and considered their successors the Sustainable Development Goals (SDGs), there is some good news to share and some not so good. Child mortality in under-5-year-olds worldwide has fallen from 12•7 million in 1990 to 6•3 million in 2013. Although the present rate of decrease is still not enough to meet MDG 4 (a reduction of under-5 child mortality by two thirds by the end of 2015), it is still remarkable progress.

Reducing the number of disaster refugees
The Lancet
Preview |
Natural disasters are inevitable but are the population displacements they cause also unavoidable? 22 million people were made refugees by natural disasters in 2013, according to a report released last week from the Internal Displacement Monitoring Centre and the Norwegian Refugee Council. This number is three-times higher than that for displacements caused by conflicts in 2013.

Series
Midwifery
Country experience with strengthening of health systems and deployment of midwives in countries with high maternal mortality
Wim Van Lerberghe, Zoe Matthews, Endang Achadi, Chiara Ancona, James Campbell, Amos Channon, Luc de Bernis, Vincent De Brouwere, Vincent Fauveau, Helga Fogstad, Marge Koblinsky, Jerker Liljestrand, Abdelhay Mechbal, Susan F Murray, Tung Rathavay, Helen Rehr, Fabienne Richard, Petra ten Hoope-Bender, Sabera Turkman

Improvement of maternal and newborn health through midwifery
Petra ten Hoope-Bender, Luc de Bernis, James Campbell, Soo Downe, Vincent Fauveau, Helga Fogstad, Caroline S E Homer, Holly Powell Kennedy, Zoe Matthews, Alison McFadden, Mary J Renfrew, Wim Van Lerberghe

The Lancet Global Health
Oct 2014 Volume 2 Number 10 e550 – 615
http://www.thelancet.com/journals/langlo/issue/current

Ebola: the missing link
Zoë Mullan a
“Liberia is facing a serious threat to its national existence.” So said the country’s Defence Minister, Brownie Samukai, earlier this month. For a nation that has only just seen the UN Refugee Agency withdraw after a 14-year civil war in which a quarter of a million people perished, Samukai’s words are chilling. Ebola virus entered the country from Guinea in the early part of 2014, and has since killed at least half of the 2218 people reported to have died in the west African outbreak as of Sept 7. After doing little more than spectate for almost 6 months, the world has now risen from the bleachers and set about some action.

The inadequacy of the international community’s initial response to this unusually fast-spreading urban outbreak has been lamented at length, as have WHO’s weakened capacity in the face of budget and staff cuts, and the lack of an emergency response fund and centralised global command and control structure to enable swift deployment of resources and trained personnel. However, at least we have now caught up with what is actually happening and have begun to monitor it. WHO’s regular situation reports have become a must-read and the agency’s prediction of an exponential increase in the number of new cases of Ebola virus disease in Liberia is proving tragically accurate. WHO’s Ebola Response Roadmap is a useful document and is hard to fault for its practical advice. Donor commitments are starting to arrive. But will data, directions, and donations be enough?

Respected voices such as those of Médecins Sans Frontières (MSF) and Ebolavirus co-discoverer Peter Piot have called for a military response to the coordination of supplies and the building of health centres, for UN peacekeeping forces to be deployed, and for individual Western governments to encourage and enable health workers to offer their assistance on the ground. In the case of Liberia, WHO has warned of the need for “non-conventional interventions”, whatever they may be. Amid scenes of men, women, and children prostrate outside treatment centres with no beds; of the exhaustion of national and international health workers alike; and in the face of what seems to be the infuriatingly ponderous nature of global health institutions, it is hard not to issue an empassioned plea for someone, somewhere to “do something”.

However, provision of military assistance or even well trained Western medical staff is not a panacea. The imagery conjured up by foreigners in biohazard suits or army camouflage can be powerfully negative, and even associated with the bringing of disease, rather than its banishment, as happened with cholera in Haiti. What is also vital in west Africa right now is the interface between the essential efforts of the international community and the needs of the populations affected: the entity that converts funds into care, information into understanding, and precautions into safety. In other words, the national governments of Liberia, Sierra Leone, and Guinea.

Some of the governments’ responses to the current crisis have been badly misjudged. Most notably, Liberia’s efforts to quarantine an affected community in West Point township in the capital Monrovia had disastrous consequences, with a heavy-handed security presence leading to the fatal shooting of a 15-year-old boy. Sierra Leone has threatened a 2-year gaol term on anyone found to be hiding a patient with Ebola virus disease. And, back in Liberia, President Ellen Johnson-Sirleaf’s declared 90-day state of emergency included “the suspensions of certain rights and privileges”, without stating what these were. None of these actions engenders the trust that is so crucial to the containment of the epidemic. Without trust, families will continue to hide sick loved ones, and health workers and mortuary staff will continue to be attacked.

Liberia, Sierra Leone, and Guinea are some of the poorest nations in the world, and two are still in the early stages of recovery from a devastating conflict. The international community must therefore do everything possible to assist with resources, staff, and logistics in the face of this humanitarian catastrophe. But what must not be forgotten is the responsibility of the national authorities to direct and communicate in a way that protects the human rights of those they have been elected to lead. The people of Liberia, and those of other affected countries, must be able to rely on the commitment, transparency, and cohesion of their own governments in times of national crisis.
Rethinking the development of Ebola treatments
Rajesh Gupta a
In response to the current outbreak, the international community has endorsed the clinical use of unregistered treatments for Ebola.1 Even with this accelerated pathway to in-human testing and use, radically novel approaches to drug development will be needed to improve the likelihood that a treatment is realised. Bypassing steps in development does not alter the probability of success, and historical patterns in drug development suggest that there is a slim probability of success with the current portfolio of potential Ebola treatments (all of which are were in preclinical development prior to the outbreak).

First, preclinical research in drug development can suffer from a lack of replicability, which contributes to high development failure rates.2 Second, if preclinical development is successful, the likelihood of successful regulatory approval of all investigational drugs reaching phase 1 is only 10•4%.3 Third, these patterns and low rates are based on therapeutic areas with: (a) robust preclinical and clinical data collected (often) over decades from hundreds to thousands of research and development activities spanning the globe, and (b) socially and politically acceptable clinical development programmes spanning large populations, mainly in resource-wealthy settings with strong clinical trial infrastructure. Ebola stands in stark contrast to such therapeutic areas; thus, one could expect that the likelihood of successful regulatory approval for an Ebola treatment would be lower than these estimates.

Repurposing (use of approved drugs for new indications) or repositioning (use of drugs whose development was not continued for new indications) of existing drugs has been put forward as a method to overcome some of these issues.4 Indeed, drug repositioning and repurposing could lead to higher rates of success, with lower costs of development, in a faster timeframe than de novo discovery approaches.5 However, these potential advantages are far from certain. Furthermore, drug repurposing/repositioning in and of itself does not remove the need for certain preclinical studies and clinical trials. Drugs still need to be validated and studied in the indications for which they are proposed.

In silico approaches might hold a key to overcoming some of these obstacles. Use of bioinformatics-based high-end computing to simulate drug—disease biological processes provides the ability to bypass time-consuming and costly in vitro and in vivo studies and increase the probability of success of clinical trials.6 For Ebola treatments, in silico approaches might offer two specific means to improve the current process and help address some of the critical preclinical and clinical concerns raised at the WHO meeting of international experts to discuss Ebola therapeutics on Sept 5.7 First, the number of preclinical compounds already containing clinical data for other therapeutic indications could be considerably increased. Although traditional repositioning methods using in vitro screening have led to initial discoveries for Ebola,8 computational screening could provide the needed efficiency to identify candidates more rapidly and accurately than de novo discovery methods. Second, virtual clinical trials could alleviate some of the logistical and ethical issues surrounding the clinical use of unregistered Ebola treatments, including the balance between generating safety data and the need to introduce treatments as soon as possible.9 This method would permit non-interventional assessments of pharmacokinetic-pharmacodynamic parameters and allow precise and efficient clinical trial design10 (the latter being particularly important because the epidemiology and infrequent emergence of Ebola often provides a narrow window of opportunity and limited population size to assess an intervention). There is at least one caveat, though. In silico approaches are dependent on drug and disease process data. Therapeutic Ebola research is heavily funded by the US government under the auspices of threats to national security,11 and international activities are limited to a few research groups. To allow for greater participation of researchers globally, real-time accessibility of crucial data is necessary.7

In silico methods are still in development and rapidly evolving, but have been successful in identifying potential candidates for various diseases and the risk of using such methods are very low. Their ability to affect, at scale, drug development processes, costs, and timelines is unknown but likely to be considerable given the private sector’s strong interest and investment in this area. Equally likely is that these approaches will be able to affect a wide range of diseases. Although these approaches are currently directed towards diseases with clear revenue streams (eg, inflammatory bowel disease and cancer), such approaches could be used for unprofitable diseases that affect the most underserved populations of the world.

The inequities already posed by a disease of poverty such as Ebola become further exacerbated when novel technologies are used first to explore diseases that are viable commercial opportunities. This does not have to be the pattern moving forward, and Ebola might provide the opportunity to apply new technological approaches to drug development (such as in silico methods) for traditional “market failure” diseases. If the global community is truly committed to rapidly developing a new drug for Ebola, multiple novel approaches, methods, and technologies will need to be used to beat the inherent hurdles of drug development.

1 Enserink M. Debate erupts on repurposed drugs for Ebola. Science 2014; 345: 718-719. PubMed
2 Begley C, Ellis LM. Drug development: raise standards for preclinical cancer research. Nature 2012; 483: 531-533. PubMed
3 Hay M, Thomas DW, Craighead JL, Economidies C, Rosenthal J. Clinical development success rates for investigational drugs. Nature Biotechnol 2014; 32: 40-51. PubMed
4 Editorial. New approaches for Ebola therapeutics. New York Times Aug 24, 2014.
5 Institute of Medicine. Drug repurposing and repositioning: workshop summary. Washington, DC: National Academies Press, 2014. http://www.iom.edu/Reports/2014/Drug-Repurposing-and-Repositioning.aspx. (accessed Sept 5, 2014).
6 Dudley JT, Deshpande T, Butte A. Exploiting drug-disease relationships for computational drug repositioning. Brief Bioinform 2011; 12: 303-311. PubMed
7 WHO. Statement on the WHO Consultation on potential Ebola therapies and vaccines. http://www.who.int/mediacentre/news/statements/2014/ebola-therapies-consultation/en/. (accessed Sept 8, 2014).
8 Johansen LM, Brannan JM, Delos SE, et al. FDA-approved selective estrogen receptor modulators inhibit Ebola virus infection. Sci Transl Med 2013; 190: 90ra79. PubMed
9 Arie S. Ebola: an opportunity for a clinical trial?. BMJ 2014; 349: g4997. PubMed
10 Holford N, Ma SC, Ploeger BA. Clinical trial simulation: a review. Clin Pharmacol Ther 2010; 88: 166-168. PubMed
11 Enserink M. Ebola drugs still stuck in lab. Science 2014; 345: 364-365. PubMed

The Lancet Infectious Diseases
Oct 2014 Volume 14 Number 10 p899 – 1022
http://www.thelancet.com/journals/laninf/issue/current

Safety and immunogenicity of a candidate tuberculosis vaccine MVA85A delivered by aerosol in BCG-vaccinated healthy adults: a phase 1, double-blind, randomised controlled trial
Iman Satti PhD a, Joel Meyer DM a Stephanie A Harris BSc a, Zita-Rose Manjaly Thomas MRCP a, Kristin Griffiths PhD a, Richard D Antrobus MBChB a, Rosalind Rowland BM a, Raquel Lopez Ramon RN a, Mary Smith RN a, Sharon Sheehan FRCPath a, Henry Bettinson FRCP b, Prof Helen McShane FRCP a
Summary
Background
Intradermal MVA85A, a candidate vaccine against tuberculosis, induces high amounts of Ag85A-specific CD4 T cells in adults who have already received the BCG vaccine, but aerosol delivery of this vaccine might offer immunological and logistical advantages. We did a phase 1 double-blind trial to compare the safety and immunogenicity of aerosol-administered and intradermally administered MVA85A
Methods
In this phase 1, double-blind, proof-of-concept trial, 24 eligible BCG-vaccinated healthy UK adults were randomly allocated (1:1) by sequentially numbered, sealed, opaque envelopes into two groups: aerosol MVA85A and intradermal saline placebo or intradermal MVA85A and aerosol saline placebo. Participants, the bronchoscopist, and immunologists were masked to treatment assignment. The primary outcome was safety, assessed by the frequency and severity of vaccine-related local and systemic adverse events. The secondary outcome was immunogenicity assessed with laboratory markers of cell-mediated immunity in blood and bronchoalveolar lavage samples. Safety and immunogenicity were assessed for 24 weeks after vaccination. Immunogenicity to both insert Ag85A and vector modified vaccinia virus Ankara (MVA) was assessed by ex-vivo interferon-γ ELISpot and serum ELISAs. Since all participants were randomised and vaccinated according to protocol, our analyses were per protocol. This trial is registered with ClinicalTrials.gov, number NCT01497769.
Findings
Both administration routes were well tolerated and immunogenic. Respiratory adverse events were rare and mild. Intradermal MVA85A was associated with expected mild local injection-site reactions. Systemic adverse events did not differ significantly between the two groups. Three participants in each group had no vaccine-related systemic adverse events; fatigue (11/24 [46%]) and headache (10/24 [42%]) were the most frequently reported symptoms. Ag85A-specific systemic responses were similar across groups. Ag85A-specific CD4 T cells were detected in bronchoalveolar lavage cells from both groups and responses were higher in the aerosol group than in the intradermal group. MVA-specific cellular responses were detected in both groups, whereas serum antibodies to MVA were only detectable after intradermal administration of the vaccine.
Interpretation
Further clinical trials assessing the aerosol route of vaccine delivery are merited for tuberculosis and other respiratory pathogens.
Funding
The Wellcome Trust and Oxford Radcliffe Hospitals Biomedical Research Centre.

Treatment outcomes of childhood tuberculous meningitis: a systematic review and meta-analysis
Silvia S Chiang, Faiz Ahmad Khan, Meredith B Milstein, Arielle W Tolman, Andrea Benedetti, Jeffrey R Starke, Mercedes C Becerra
Preview |
Despite treatment, childhood tuberculous meningitis has very poor outcomes. Poor prognosis and difficult early diagnosis emphasise the importance of preventive therapy for child contacts of patients with tuberculosis and low threshold for empirical treatment of tuberculous meningitis suspects. Implementation of consensus definitions, standardised reporting of data, and high-quality clinical trials are needed to clarify optimum therapy.

Assessment of herd immunity and cross-protection after a human papillomavirus vaccination programme in Australia: a repeat cross-sectional study
A/Prof Sepehr N Tabrizi PhD a b c d, Julia M L Brotherton BMed e f, Prof John M Kaldor PhD g, S Rachel Skinner PhD f, Bette Liu DPhil h, Deborah Bateson MBBS i, Kathleen McNamee MBBS j k, Maria Garefalakis MBBS l, Samuel Phillips BSc a d, Eleanor Cummins BSc a d, Michael Malloy PhD e, Prof Suzanne M Garland MD a b c d
Summary
Background
After the introduction of a quadrivalent human papillomavirus (HPV) vaccination programme in Australia in April, 2007, we measured the prevalence of vaccine-targeted and closely related HPV types with the aim of assessing direct protection, cross-protection, and herd immunity.
Methods
In this repeat cross-sectional study, we recruited women aged 18—24 years who attended Pap screening between October, 2005, and July, 2007, in three major metropolitan areas of Australia to form our prevaccine-implementation sample. For our postvaccine-implementation sample, we recruited women aged 18—24 years who attended Pap screening in the same three metropolitan areas from August, 2010, to November, 2012. We compared the crude prevalence of HPV genotypes in cervical specimens between the prevaccine and the postvaccine implementation groups, with vaccination status validated against the National HPV Vaccination Program Register. We estimated adjusted prevalence ratios using log linear regression. We estimated vaccine effectiveness both for vaccine-targeted HPV types (16, 18, 6, and 11) and non-vaccine but related HPV types (31, 33, and 45).
Findings
202 women were recruited into the prevaccine-implementation group, and 1058 were recruited into the postvaccine-implementation group. Crude prevalence of vaccine-targeted HPV genotypes was significantly lower in the postvaccine-implementation sample than in the prevaccine-implementation sample (58 [29%] of 202 vs 69 [7%] of 1058; p<0•0001). Compared with the prevaccine-implementation sample, adjusted prevalence ratios for vaccine-targeted HPV genotypes were 0•07 (95% CI 0•04—0•14; p<0•0001) in fully vaccinated women and 0•65 (0•43—0•96; p=0•03) in unvaccinated women, which suggests herd immunity. No significant declines were noted for non-vaccine-targeted HPV genotypes. However, within the postvaccine-implementation sample, adjusted vaccine effectiveness against vaccine-targeted HPV types for fully vaccinated women compared with unvaccinated women was 86% (95% CI 71—93), and was 58% (26—76) against non-vaccine-targeted but related genotypes (HPV 31, 33, and 45).
Interpretation
6 years after the initiation of the Australian HPV vaccination programme, we have detected a substantial fall in vaccine-targeted HPV genotypes in vaccinated women; a lower prevalence of vaccine-targeted types in unvaccinated women, suggesting herd immunity; and a possible indication of cross-protection against HPV types related to the vaccine-targeted types in vaccinated women.
Funding
Australian National Health and Medical Research Council and Cancer Council Victoria.

Series
Emerging respiratory tract infections
Surveillance for emerging respiratory viruses
Jaffar A Al-Tawfiq, Alimuddin Zumla, Philippe Gautret, Gregory C Gray, David S Hui, Abdullah A Al-Rabeeah, Ziad A Memish
Summary
Several new viral respiratory tract infectious diseases with epidemic potential that threaten global health security have emerged in the past 15 years. In 2003, WHO issued a worldwide alert for an unknown emerging illness, later named severe acute respiratory syndrome (SARS). The disease caused by a novel coronavirus (SARS-CoV) rapidly spread worldwide, causing more than 8000 cases and 800 deaths in more than 30 countries with a substantial economic impact. Since then, we have witnessed the emergence of several other viral respiratory pathogens including influenza viruses (avian influenza H5N1, H7N9, and H10N8; variant influenza A H3N2 virus), human adenovirus-14, and Middle East respiratory syndrome coronavirus (MERS-CoV).

Emerging respiratory tract infections
Emerging infectious diseases and pandemic potential: status quo and reducing risk of global spread
Brian McCloskey, Osman Dar, Alimuddin Zumla, David L Heymann
Preview |
Emerging infectious diseases are an important public health threat and infections with pandemic potential are a major global risk. Although much has been learned from previous events the evidence for mitigating actions is not definitive and pandemic preparedness remains a political and scientific challenge. A need exists to develop trust and effective meaningful collaboration between countries to help with rapid detection of potential pandemic infections and initiate public health actions. This collaboration should be within the framework of the International Health Regulations.

Medical Decision Making (MDM)
October 2014; 34 (7)
http://mdm.sagepub.com/content/current

Methods for Systematic Reviews of Health Economic Evaluations
A Systematic Review, Comparison, and Synthesis of Method Literature
Tim Mathes, Maren Walgenbach, Dr. Sunya-Lee Antoine, Dawid Pieper, Michaela Eikermann, Dr.
Institute for Research in Operative Medicine, Witten/Herdecke University, Cologne, Germany
Abstract
Introduction. The quality of systematic reviews of health economic evaluations (SR-HE) is often limited because of methodological shortcomings. One reason for this poor quality is that there are no established standards for the preparation of SR-HE. The objective of this study is to compare existing methods and suggest best practices for the preparation of SR-HE. Methods. To identify the relevant methodological literature on SR-HE, a systematic literature search was performed in Embase, Medline, the National Health System Economic Evaluation Database, the Health Technology Assessment Database, and the Cochrane methodology register, and webpages of international health technology assessment agencies were searched. The study selection was performed independently by 2 reviewers. Data were extracted by one reviewer and verified by a second reviewer. On the basis of the overlaps in the recommendations for the methods of SR-HE in the included papers, suggestions for best practices for the preparation of SR-HE were developed.
Results. Nineteen relevant publications were identified. The recommendations within them often differed. However, for most process steps there was some overlap between recommendations for the methods of preparation. The overlaps were taken as basis on which to develop suggestions for the following process steps of preparation: defining the research question, developing eligibility criteria, conducting a literature search, selecting studies, assessing the methodological study quality, assessing transferability, and synthesizing data.
Discussion. The differences in the proposed recommendations are not always explainable by the focus on certain evaluation types, target audiences, or integration in the decision process. Currently, there seem to be no standard methods for the preparation of SR-HE. The suggestions presented here can contribute to the harmonization of methods for the preparation of SR-HE.

Nature
Volume 513 Number 7519 pp459-580 25 September 2014
http://www.nature.com/nature/current_issue.html

Editorial
First response, revisited
The Ebola outbreak in West Africa has starkly exposed major gaps in plans to tackle emerging infectious diseases. Lessons must be learned.
23 September 2014
It is encouraging that the United States last week committed 3,000 military personnel and US$750 million to lend logistical support to civilian efforts to tackle the Ebola outbreak in West Africa. Civilian efforts also received a major, if belated, boost from United Nations intervention, with a Security Council resolution (see page 469).

Six months into the outbreak, this massive deployment of the US military and the combined resources of the UN is a damning indictment of the World Health Organization (WHO), the UN’s health arm charged with tackling outbreaks of potential international concern.

The international community has debated pandemic planning and outbreak response intensely over the past decade, following the SARS (severe acute respiratory syndrome) epidemic and the increased awareness of the threat of avian flu.

“Strengthening health-care systems everywhere will be the best defence against outbreaks.”
In 2005, the WHO member states agreed the International Health Regulations (IHR), designed to help the international community to respond better to outbreaks. And last year, the WHO adopted an Emergency Response Framework to guide its own actions.

These frameworks have failed miserably in this outbreak, and the WHO has been slow and, so far, ineffective. There has been some progress in disease surveillance, but the world is little better prepared to quickly stamp out a threatening outbreak than it was a decade ago.

Earlier this month, WHO director-general Margaret Chan told The New York Times: “We are not the first responder … the government has first priority to take care of their people and provide health care. WHO is a technical agency.” Fair enough, but if the WHO is not the first responder to an emergency such as this, then who is? The Ebola outbreak clearly demonstrates that response to such events cannot be left to the non-governmental organizations (NGOs) and governments of some of the poorest countries in the world.

The IHR states that countries must boost their surveillance and outbreak-response capacities, and that individual governments must foot the bill. The aspirations are correct: strengthening health-care systems everywhere will be the best defence against outbreaks of potential international concern. But the reality is that few poor countries have anything that resembles a working outbreak-response system.

Rich countries must make a greater effort to help poor countries to boost their health-care systems to defend against outbreaks, which would also contribute to the UN’s Millennium Development Goals of achieving reductions in child and maternal mortality and other causes of morbidity and mortality. The case is strong for a new global health fund to help build functioning health systems, on the scale of the multibillion-dollar Global Fund to Fight AIDS, Tuberculosis and Malaria.

But building better health-care systems will take time. One immediate step should be to create an international contingency fund. A 2011 independent review of the IHR called for the creation of a pot of at least $100 million that the WHO could immediately tap in the event of a public-health emergency. But that sensible proposal has been taken nowhere by the WHO’s member states. It should be resuscitated, and its size realistically estimated — $100 million is probably on the low side.

Also lacking is the capacity to quickly deploy medical supplies, emergency field hospitals, and people trained in the many aspects of outbreak response — from surveillance, epidemiology and virology to implementing public-health control measures, patient care and biosafety.

Rapid emergency response to outbreaks must inevitably be done on a case-by-case basis, drawing on the resources of individual country donors, the UN and NGOs. Flexible international plans and agreements should be put in place to allow this. A large reserve corps of appropriately trained staff should also be established. Lack of personnel has been the biggest bottleneck in the Ebola response.

In principle, the WHO should be the body best placed to oversee international response to outbreaks. It has a total budget of $4 billion for 2014 and 2015, less than many large Western hospitals, but it also spreads itself too thin by trying to do too much. The organization’s budget for outbreak response is just $110 million a year, and funding for preparedness and surveillance is just $140 million. Moreover, funds have dwindled and the organization has lost vital in-house expertise and talent for responding to outbreaks.

If member states want the WHO to be more active in outbreak response, they must fund it adequately. But the slow and bureaucratic WHO must also demonstrate that it is up to the task, and can spend its money wisely and act fast.

Nature Immunology
October 2014, Volume 15 No 10 pp895-996
http://www.nature.com/ni/journal/v15/n10/index.html

Commentary
Nonspecific effects of neonatal and infant vaccination: public-health, immunological and conceptual challenges
Peter Aaby, Tobias R Kollmann & Christine Stabell Benn
Affiliations
Corresponding author
Nature Immunology
15,895–899(2014) doi:10.1038/ni.2961
Published online
18 September 2014
Abstract
Vaccines can have nonspecific effects through their modulation of responses to infections not specifically targeted by the vaccine. However, lack of knowledge about the underlying immunological mechanisms and molecular cause-and-effect relationships prevent use of this potentially powerful early-life intervention to its greatest benefit. The World Health Organization has identified investigations into the molecular basis of nonspecific vaccine effects as a research priority.

New England Journal of Medicine
September 25, 2014 Vol. 371 No. 13
http://www.nejm.org/toc/nejm/medical-journal

Perspective
Ebola 2014 — New Challenges, New Global Response and Responsibility
Thomas R. Frieden, M.D., M.P.H., Inger Damon, M.D., Ph.D., Beth P. Bell, M.D., M.P.H., Thomas Kenyon, M.D., M.P.H., and Stuart Nichol, Ph.D.
N Engl J Med 2014; 371:1177-1180 September 25, 2014 DOI: 10.1056/NEJMp1409903
[Free full text]
Perspective
The International Ebola Emergency
Sylvie Briand, M.D., Eric Bertherat, M.D., Paul Cox, B.A., Pierre Formenty, M.P.H., Marie-Paule Kieny, Ph.D., Joel K. Myhre, M.A., Cathy Roth, M.B., B.Chir., Nahoko Shindo, Ph.D., and Christopher Dye, D.Phil.
N Engl J Med 2014; 371:1180-1183 September 25, 2014 DOI: 10.1056/NEJMp1409858
[Free full text]
Perspective
Ebola Virus Disease in West Africa — No Early End to the Outbreak
Margaret Chan, M.D.
N Engl J Med 2014; 371:1183-1185 September 25, 2014 DOI: 10.1056/NEJMp1409859
[Free full text]
Perspective
A Good Death — Ebola and Sacrifice
Josh Mugele, M.D., and Chad Priest, R.N., M.S.N., J.D.
N Engl J Med 2014; 371:1185-1187 September 25, 2014 DOI: 10.1056/NEJMp1410301
[Free full text]
Perspective
Interactive Perspective
Ebola Virus Disease — Current Knowledge
Rupa Kanapathipillai, M.B., B.S., M.P.H., D.T.M.&H.
N Engl J Med 2014; 371:e18 September 25, 2014 DOI: 10.1056/NEJMp1410741
[Free full text]

PLoS Medicine
(Accessed 27 September 2014)
http://www.plosmedicine.org/

Editorial
The PLOS “Monitoring Universal Health Coverage” Collection: Managing Expectations
The PLOS Medicine Editors mail
Published: September 22, 2014
DOI: 10.1371/journal.pmed.1001732
This week, PLOS Medicine publishes the PLOS Collection “Monitoring Universal Health Coverage” [1], launched on September 22nd at the Rockefeller Foundation as a side event of the United Nations General Assembly in New York City.

The high profile of the Collection launch is fitting for the topic that has emerged as a frontrunner of the post-2015 agenda and the concept of which has been integral to founding United Nations principles: Universal Health Coverage (UHC) is firmly based on the 1948 WHO constitution that declared health a fundamental human right and also on the Health for All agenda set by the Alma-Ata Declaration in 1978 [2].

The subject of several recent WHO World Reports and World Health Assembly resolutions [3]–[5], over the past few years, UHC has been the focus of much work and effort by the international community in order to turn the broad aims of UHC into an actionable framework. The PLOS Collection adds to the global conversation and consensus by providing the technical details and country-level experience of the implementation and of the monitoring and evaluation (M&E) of UHC.

According to the definition used in the PLOS Collection [6], UHC is the desired outcome of health system performance, whereby all people who need the full spectrum of health services (that is, promotion, prevention, treatment, rehabilitation, and palliation) receive them according to need, without resulting in financial hardship (including possible impoverishment caused by out-of-pocket payments) because of any associated health care costs.

Organized by WHO and the World Bank, and externally peer-reviewed by independent experts, the PLOS Collection explains and discusses these essential and interlinked components of UHC and includes an overview [6], five technical papers [7]–[11], and 13 country case studies (from Bangladesh [12], Brazil [13], Chile [14], China [15], Estonia [16], Ethiopia [17], Ghana [18], India [19], Singapore [20], South Africa [21], Tanzania [22], Thailand [23], and Tunisia [24]) on progress towards the M&E of UHC in each country written by national experts. The PLOS Collection includes a summary of each country case study with the full paper of each provided as supplementary information.

PLoS Neglected Tropical Diseases
(Accessed 27 September 2014)
http://www.plosntds.org/

Editorial
The NTDs and Vaccine Diplomacy in Latin America: Opportunities for United States Foreign Policy
Peter J. Hotez mail
Published: September 25, 2014
DOI: 10.1371/journal.pntd.0002922
Recently published prevalence estimates of neglected tropical diseases (NTDs) in five Latin American countries—Bolivia, Cuba, Ecuador, Nicaragua, and Venezuela—could suggest a new direction for United States foreign policy in the region.

Science
26 September 2014 vol 345, issue 6204, pages 1537-1652
http://www.sciencemag.org/current.dtl

Policy Forum
Infectious Disease
Implementing Pasteur’s vision for rabies elimination
Felix Lankester1,2,3,*, Katie Hampson3, Tiziana Lembo3, Guy Palmer1,2, Louise Taylor4, Sarah Cleaveland2,3
Author Affiliations
1Paul G. Allen School for Global Animal Health, Washington State University, Pullman, WA 99164, USA.
2School of Life Sciences and Bioengineering, Nelson Mandela African Institution of Science and Technology, Arusha, Tanzania.
3Boyd Orr Centre for Population and Ecosystem Health, Institute of Biodiversity, Animal Health and Comparative Medicine, University of Glasgow, Glasgow G12 8QQ, UK.
4Global Alliance for Rabies Control, Manhattan, KS 66502, USA.
It has been 129 years since Louis Pasteur’s experimental protocol saved the life of a child mauled by a rabid dog, despite incomplete understanding of the etiology or mechanisms by which the miracle cure worked (1). The disease has since been well understood, and highly effective vaccines are available, yet Pasteur’s vision for ridding the world of rabies has not been realized. Rabies remains a threat to half the world’s population and kills more than 69,000 people each year, most of them children (2). We discuss the basis for this neglect and present evidence supporting the feasibility of eliminating canine-mediated rabies and the required policy actions.

Vaccine
Volume 32, Issue 45, Pages 5889-6024 (14 October 2014)
http://www.sciencedirect.com/science/journal/0264410X/32/45

Health care professionals’ awareness of, knowledge about and attitude to influenza vaccination
Original Research Article
Pages 5957-5961
Thamir M. Alshammari, Lama S. AlFehaid, Joud K. AlFraih, Hisham S. Aljadhey
Highlights
:: We investigated the awareness, knowledge, and attitude of health care professionals (HCPs) towards influenza vaccination.
:: Only 38% of HCPs surveyed in Saudi Arabian hospitals is vaccinated against influenza.
:: The most common reasons given by HCPs for not getting vaccinated were: fear of contracting illness.
:: The most common barrier that prevented institutions providing the influenza vaccine was HCPs’ and patients’ concerns about safety of vaccine.
Almost 75% of HCPs surveyed in Saudi Arabia were not aware of the influenza immunization guidelines.

Vaccine
Volume 32, Issue 45, Pages 5889-6024 (14 October 2014)
http://www.sciencedirect.com/science/journal/0264410X/32/45

Qualitative evaluation of Rhode Island’s healthcare worker influenza vaccination regulations
Original Research Article
Pages 5962-5966
Megan C. Lindley, Donna Dube, Elizabeth J. Kalayil, Hanna Kim, Kristi Paiva, Patricia Raymond
Abstract
Objective
To evaluate Rhode Island’s revised vaccination regulations requiring healthcare workers (HCWs) to receive annual influenza vaccination or wear a mask during patient care when influenza is widespread.
Design
Semi-structured telephone interviews conducted in a random sample of healthcare facilities.
Setting
Rhode Island healthcare facilities covered by the HCW regulations, including hospitals, nursing homes, community health centers, nursing service agencies, and home nursing care providers.
Participants Staff responsible for collecting and/or reporting facility-level HCW influenza vaccination data to comply with Rhode Island HCW regulations.
Methods
Interviews were transcribed and individually coded by interviewers to identify themes; consensus on coding differences was reached through discussion. Common themes and illustrative quotes are presented.
Results
Many facilities perceived the revised regulations as extending their existing influenza vaccination policies and practices. Despite variations in implementation, nearly all facilities implemented policies that complied with the minimum requirements of the regulations. The primary barrier to implementing the HCW regulations was enforcement of masking among unvaccinated HCWs, which required timely tracking of vaccination status and additional time and effort by supervisors. Factors facilitating implementation included early and regular communication from the state health department and facilities’ ability to adapt existing influenza vaccination programs to incorporate provisions of the revised regulations.
Conclusions
Overall, facilities successfully implemented the revised HCW regulations during the 2012–2013 influenza season. Continued maintenance of the regulations is likely to reduce transmission of influenza and resulting morbidity and mortality in Rhode Island’s healthcare facilities.

Vaccine
Volume 32, Issue 44, Pages 5769-5888 (7 October 2014)
http://www.sciencedirect.com/science/journal/0264410X/32/44

Risk groups for yellow fever vaccine-associated viscerotropic disease (YEL-AVD)
Review Article
Pages 5769-5775
Stephen J. Seligman
Abstract
Although previously considered as the safest of the live virus vaccines, reports published since 2001 indicate that live yellow fever virus vaccine can cause a severe, often fatal, multisystemic illness, yellow fever vaccine-associated viscerotropic disease (YEL-AVD), that resembles the disease it was designed to prevent. This review was prompted by the availability of a listing of the cumulative cases of YEL-AVD, insights from a statistical method for analyzing risk factors and re-evaluation of previously published data. The purpose of this review is to identify and analyze risk groups based on gender, age, outcome and predisposing illnesses. Using a passive surveillance system in the US, the incidence was reported as 0.3 to 0.4 cases per 100,000. However, other estimates range from 0 to 12 per 100,000. Identified and potential risk groups for YEL-AVD include elderly males, women between the ages of 19 and 34, people with a variety of autoimmune diseases, individuals who have been thymectomized because of thymoma, and infants and children ≤11 years old. All but the last group are supported by statistical analysis. The confirmed risk groups account for 77% (49/64) of known cases and 76% (32/42) of the deaths. The overall case fatality rate is 66% (42/64) with a rate of 80% (12/15) in young women, in contrast to 50% (13/26) in men ≥56 years old. Recognition of YEL-AVD raises the possibility that similar reactions to live chimeric flavivirus vaccines that contain a yellow fever virus vaccine backbone could occur in susceptible individuals. Delineation of risk groups focuses the search for genetic mutations resulting in immune defects associated with a given risk group. Lastly, identification of risk groups encourages concentration on measures to decrease both the incidence and the severity of YEL-AVD.

Vaccine
Volume 32, Issue 44, Pages 5769-5888 (7 October 2014)
http://www.sciencedirect.com/science/journal/0264410X/32/44

Understanding vaccination resistance: Vaccine search term selection bias and the valence of retrieved information
Original Research Article
Pages 5776-5780
Jeanette B. Ruiz, Robert A. Bell
Abstract
Context
Dubious vaccination-related information on the Internet leads some parents to opt out of vaccinating their children.
Objectives
To determine if negative, neutral and positive search terms retrieve vaccination information that differs in valence and confirms searchers’ assumptions about vaccination.
Methods
A content analysis of first-page Google search results was conducted using three negative, three neutral, and three positive search terms for the concepts “vaccine,” “vaccination,” and “MMR”; 84 of the 90 websites retrieved met inclusion requirements. Two coders independently and reliably coded for the presence or absence of each of 15 myths about vaccination (e.g., “vaccines cause autism”), statements that countered these myths, and recommendations for or against vaccination. Data were analyzed using descriptive statistics.
Results
Across all websites, at least one myth was perpetuated on 16.7% of websites and at least one myth was countered on 64.3% of websites. The mean number of myths perpetuated on websites retrieved with negative, neutral, and positive search terms, respectively, was 1.93, 0.53, and 0.40. The mean number of myths countered on websites retrieved with negative, neutral, and positive search terms, respectively, was 3.0, 3.27, and 2.87. Explicit recommendations regarding vaccination were offered on 22.6% of websites. A recommendation against vaccination was more often made on websites retrieved with negative search terms (37.5% of recommendations) than on websites retrieved with neutral (12.5%) or positive (0%) search terms.
Conclusion
The concerned parent who seeks information about the risks of childhood immunizations will find more websites that perpetuate vaccine myths and recommend against vaccination than the parent who seeks information about the benefits of vaccination. This suggests that search term valence can lead to online information that supports concerned parents’ misconceptions about vaccines.

Vaccine
Volume 32, Issue 44, Pages 5769-5888 (7 October 2014)
http://www.sciencedirect.com/science/journal/0264410X/32/44

Comparing the cost-effectiveness of two- and three-dose schedules of human papillomavirus vaccination: A transmission-dynamic modelling study
Original Research Article
Pages 5845-5853
Jean-François Laprise, Mélanie Drolet, Marie-Claude Boily, Mark Jit, Chantal Sauvageau, Eduardo L. Franco, Philippe Lemieux-Mellouki, Talía Malagón, Marc Brisson
Highlights
:: 2-dose girls-only HPV vaccination is likely to be cost-effective if protection is at least 10 years.
:: A 3rd dose is unlikely to be cost-effective if 2-dose duration of protection is longer than 30 years.
:: Vaccinating boys is unlikely to be cost-effective unless the cost/dose is substantially reduced.

Bloomberg
http://www.bloomberg.com/

Ebola Shot Turned Down by WHO Is Best Hope as Virus Rages
By Makiko Kitamura and Shannon Pettypiece Sep 26, 2014 5:30 AM ET

The calls started coming in August to the office of GlaxoSmithKline Plc Chief Executive Officer Andrew Witty from the head of the World Health Organization, Margaret Chan. The Ebola outbreak was raging out of control and Chan needed the drugmaker’s vaccine as quickly as possible.

The sudden sense of urgency for an Ebola vaccine was an about face from a few months earlier when Glaxo contacted the WHO, asking whether its vaccine could help with the outbreak. At that time, the company was told the focus was on containment and the WHO didn’t have a policy for using vaccines in this type of situation. “We’ll get back to you” was the message, said Ripley Ballou, head of Glaxo’s Ebola vaccine program.

As those months passed and containment efforts failed, the epidemic spun out of control, claiming more lives than all past outbreaks combined. So far, more than 6,200 people have been infected and 2,900 have died, and the virus could sicken more than 1.4 million people by January under the worst-case scenario projected by the U.S. Centers for Disease Control and Prevention.

With no approved Ebola medicines, and experimental treatments in short supply, a vaccine is now one of the best hopes for halting the virus’s spread before it becomes entrenched in the region. That puts pressure on the few drugmakers with a vaccine in development as they shift resources, delay other projects, and spend millions in a race to immunize patients. Glaxo and Johnson & Johnson are preparing thousands of doses of their experimental vaccines to test in Africa as early as January.

Traditional Measures
“It may be that without a vaccine we can’t really stop this epidemic,” Peter Piot, a co-discoverer of the Ebola virus in 1976 who is now the director of the London School of Hygiene and Tropical Medicine, said at a news conference in London this week.

When Glaxo contacted the WHO in March, the vaccine was seen as a “diversion of energy” at a time when it was believed the outbreak would be controlled with traditional measures, such as contact tracing and safe burials, that have helped contain every previous outbreak, said Marie-Paule Kieny, the WHO’s assistant director-general for health systems and innovation. At the end of March, there were about 100 cases of Ebola in Guinea, with early reports the virus was spreading to Liberia and Sierra Leone, according to the U.S. Centers for Disease Control and Prevention.

“We were in a situation where GSK had a vaccine which had been tested in animals, and that was it,” Kieny said in a telephone interview. “It was only then when the situation started to be quite worse, and people understood that we’re not going to make it, that the effort came to a higher level.”…

BBC
http://www.bbc.co.uk/

New York Times
http://www.nytimes.com/
Accessed 27 September 2014

The Opinion Pages | Op-Ed Columnist Nicolas Kristof
The Ebola Fiasco
SEPT. 24, 2014
The Ebola epidemic in West Africa is a tragedy. But, more than that, the response to it has been a gross failure.

It’s a classic case where early action could have saved lives and money. Yet the world dithered, and with Ebola cases in Liberia now doubling every two to three weeks, the latest worst-case estimate from the Centers for Disease Control and Prevention is that there could be 1.4 million cases in Liberia and Sierra Leone by late January…

…If the worst-case scenario comes to pass in West Africa, it may become endemic in the region and reach the West. Ebola is quite lethal but not particularly contagious, so it presumably wouldn’t cause an epidemic in countries with modern health systems. This entire tragedy is a failure of humanity.

As donor countries scramble to respond (which may cost $1 billion in the next six months, according to the United Nations, although nobody really knows), the risk is that they will raid pots of money intended for other vital purposes to assist the world’s needy. Jamie Drummond of the One campaign says he worries that governments may try to finance Ebola countermeasures with money that otherwise would buy childhood vaccines or ease emerging famines in Somalia and South Sudan.

Vaccines are a bargain. Since 1990, vaccines and other simple interventions (such as treatments for diarrhea) have saved nearly 100 million children’s lives, according to Unicef. Gavi, the Vaccine Alliance, is now in the middle of trying to raise an additional $7.5 billion to subsidize vaccinations of 300 million additional children around the world. On top of the $2 billion it has, Gavi says this would save 5 million to 6 million lives and produce economic benefits of $80 billion to $100 billion.

Such an investment should be a no-brainer. In the 21st century, we have the resources to fight more than one fire at a time.

“I am worried,” said Seth Berkley, the chief executive of Gavi. “You wouldn’t want to reduce immunizing children around the world to deal with an emergency even as severe as Ebola.”…

Editor’s Note:
It was a week of extraordinary and historic action in the Ebola outbreak context.

Key developments included:
:: continuing escalation of the outbreak across Liberia, Guinea and Sierra Leone (see WHO Ebola Roadmap Report 4 below),

:: proposed formation by the UN Secretary General of an unprecedented UN mission – UNMEER (UN Mission for Emergency Ebola Response) – reporting directly to the SG and charged with coordinating UN system, government, NGO and private sector response and (see “Identical Letters dated 17 September 2014..” below),

:: unprecedented action by the UN Security Council and the General Assembly on resolutions declaring the Ebola outbreak a “threat the international peace and security,” affirming formation of UNMEER, and issuing calls-to-action to focus new global resources and coordinate their deployment (see Security Council and General Assembly resolutions below),

:: major commitments of support to fight the outbreak from a number of countries, including a commitment by the U.S. of 3,000 military personnel and other forms of support (see White House Fact Sheet below),

:: release by UN OCHA of a composite analysis detailing needed resources to fight the outbreak – now scaled at about US$1 billion – complementing the WHO Ebola Roadmap issued earlier (see OCHA joint report summary below),

:: release by the World Bank of dire projections of the economic impact on Guinea, Liberia, and Sierra Leone (see report at The Economic Impact of the 2014 Ebola Epidemic: Short and Medium Term Estimates for Guinea, Liberia, and Sierra Leone)

:: implementation now underway in Sierra Leone of a three-day home “quarantine “ across the country to allow largely volunteer health worker teams to move house to house to educate about and assess potential new cases of Ebola (see UNICEF Watch below).

As we noted last week, the volume of coverage, comment and analysis driven by the Ebola outbreak is growing and is occurring across media sources well beyond those we actively monitor. We will strive to present a coherent digest of what is happening using official sources wherever possible, with a special focus on vaccines and other interventions now in development and various trials globally. Reading this issue you will encounter additional Ebola content throughout.

WHO
:: WHO: Ebola Response Roadmap Situation Report
18 September 2014
This is the fourth in a series of regular situation reports on the Ebola Response Roadmap1. The report contains a review of the epidemiological situation based on official information reported by ministries of health, and an assessment of the response measured against the core Roadmap indicators where available….
…Following the roadmap structure, country reports fall into three categories: those with widespread and intense transmission (Guinea, Liberia, and Sierra Leone); those with an initial case or cases, or with localized transmission (Nigeria, Senegal); and those countries that neighbour areas of active transmission (Benin, Burkina Faso, Côte d’Ivoire, Guinea-Bissau, Mali, Senegal). An overview of the situation in the Democratic Republic of the Congo, where a separate, unrelated outbreak of Ebola virus disease is occurring, is also provided…
The total number of probable, confirmed and suspected cases in the current outbreak of Ebola virus disease (Ebola) in West Africa was 5335, with 2622 deaths, as at the end of 14 September 2014…

:: WHO Director-General addresses UN Security Council on Ebola 18 September 2014
:: WHO welcomes Chinese contribution of mobile laboratory and health experts for Ebola response in west Africa 16 September 2014
:: WHO welcomes the extensive Ebola support from the United States of America 16 September 2014

Identical letters dated 17 September 2014 from the Secretary-General addressed to the President of the General Assembly and the President of the Security Council
A/69/389–S/2014/679
18 September 2014 :: 5 pages
Editor’s excerpts and text bolding

…In recognition of the rapidly evolving situation on the ground, including the rapid spread of Ebola virus disease, and following consultations with Dr. Margaret Chan and Dr. Nabarro, I have decided to establish a United Nations Mission. The Mission will harness the capabilities and competencies of all the relevant United Nations actors under a unified operational structure to reinforce unity of purpose, effective ground-level leadership and operational direction, in order to ensure a rapid, effective, efficient and coherent response to the crisis. The singular strategic objective and purpose of the Mission will be to work with others to stop the Ebola outbreak. To achieve this, the strategic priorities of the Mission will be to stop the spread of the disease, treat the infected, ensure essential services, preserve stability and prevent the spread to countries currently unaffected.

The Mission, through presences within the affected States, will provide needed field-level support to the Governments and peoples of West Africa as they respond to the crisis. The Mission will assist Member States and regional and sub-regional organizations, upon request, as well as other partners, including non-governmental organizations, in delivering their bilateral and multilateral assistance in a coordinated and coherent manner on the ground. In particular, the Mission will coordinate with the African Union, the Economic Community of West African States and the Mano River Union.

Under the joint initiative of the Director-General of WHO and myself, Dr. Nabarro will continue to represent the United Nations system and provide overarching strategic leadership, coordination and guidance, including through consultations with the Member States and other stakeholders participating in or contributing to the international efforts in response to Ebola virus disease. He will lead international efforts to mobilize and sustain the political will and strategic resources necessary to combat this crisis. I invite all Member States, other intergovernmental organizations, civil society and the private sector to join a broad international coalition at the earliest opportunity and to contribute decisively to the international response to the disease.

At the operational level, I intend to immediately establish a United Nations Mission for Ebola Emergency Response (UNMEER), to be headed by a Special Representative of the Secretary-General (Under-Secretary-General) whom I shall appoint following consultation with Dr. Chan and who will report directly to me. The Mission will build and maintain a regional operational platform, ensuring the rapid delivery of international assistance against the needs identified in the affected States, lead the response at the operational level and provide strategic direction to the United Nations system and other implementing partners on the ground. It will also work closely with all Governments and partners contributing to this effort….

…The Mission will bring together the range of United Nations actors and capabilities, as well as Governments, Member States, non-governmental organizations and other relevant stakeholders, in order to provide effective leadership, avoid unnecessary duplication and ensure the efficient prioritization of available assets and resources. The Mission will work closely with the national Ebola operational centres established by the Governments concerned, as well as with contributing Member States that are providing assistance within affected countries. The Mission will also engage closely with the private sector in order to ensure that the collective international community is drawing upon all possible assets to overcome the outbreak and its destructive secondary effects.

The Mission will be guided by six principles:
1.Reinforce government leadership;
2.Deliver rapid impact on the ground;
3.Closely coordinate and collaborate with actors outside the United Nations;
4.Tailor responses to particular needs in the different countries;
5.Reaffirm WHO lead on all health issues;
6.Identify benchmarks for transition post-emergency and ensure that actions strengthen systems.

Furthermore, the Mission will be responsible for catalysing a rapid and massive mobilization of international human, material, logistic and financial resources, under a single overarching framework, in pursuit of the objectives of the mandate and strategic priorities cited above. To achieve those strategic objectives, the Mission will focus on 12 mission-critical actions identified by the Senior United Nations System Coordinator, following consultations with major stakeholders, including the Governments of the affected countries, including:
1. Identification and tracing of people with Ebola virus disease;
2. Care for the infected and infection control;
3. Safe and dignified burial;
4. Medical care for responders;
5. Food security and nutrition;
6. Access to basic health services;
7. Cash incentives for health workers;
8. Economic protection and recovery;
9. Supplies of material and equipment;
10. Transportation and fuel;
11. Social mobilization;
12. Messaging.

…The Ebola situation has highlighted the need to determine if and how early identification systems need to be improved and how those systems can better translate into more timely action. I intend to consult with Dr. Chan on this issue in order to make recommendations to accelerate the global response in the future. Input from the affected Governments, Member States and other relevant stakeholders will be an essential part of this process….

…I count on the support of the Security Council, the General Assembly and all Member States in this vital endeavour. A more detailed report outlining the required resource requirements will be submitted for the approval and consideration of the Assembly. I also intend to establish a trust fund to mobilize the necessary voluntary contributions and other resources to further this task and to assist in funding the broader effort, including by addressing any gaps in the activities of United Nations system partners. I intend to make maximum use of the authority provided to me, including in the area of human resources, in order to promote the timely and effective response to the Ebola crisis.
No one country, no one organization has the resources to stem the tide of the Ebola crisis. Each Government is ultimately responsible for its own people.

The Governments and the people of West Africa have asked for our help. We must come together as one United Nations, and we call upon Member States to join us in answering their call….

UN Security Council :: Resolution 2177 (2014)
S/RES/2177 (2014)
Adopted by the Security Council at its 7268th meeting, on 18 September 2014
[Excerpt, primarily of action elements from resolution; Editor’s text bolding]

…“Recalling its primary responsibility for the maintenance of international peace and security,

“Expressing grave concern about the outbreak of the Ebola virus in, and its impact on, West Africa, in particular Liberia, Guinea and Sierra Leone, as well as Nigeria and beyond,

“Recognizing that the peacebuilding and development gains of the most affected countries concerned could be reversed in light of the Ebola outbreak and underlining that the outbreak is undermining the stability of the most affected countries concerned and, unless contained, may lead to further instances of civil unrest, social tensions and a deterioration of the political and security climate,

“Determining that the unprecedented extent of the Ebola outbreak in Africa constitutes a threat to international peace and security,

“Expressing concern about the particular impact of the Ebola outbreak on women,…

…“Emphasizing the key role of Member States, including through the Global Health Security Agenda where applicable, to provide adequate public health services to detect, prevent, respond to and mitigate outbreaks of major infectious diseases through sustainable, well-functioning and responsive public health mechanisms,

“Recalling the International Health Regulations (2005), which are contributing to global public health security by providing a framework for the coordination of the management of events that may constitute a public health emergency of international concern, and aim to improve the capacity of all countries to detect, assess, notify and respond to public health threats and underscoring the importance of WHO Member States abiding by these commitments,

“Underscoring that the control of outbreaks of major infectious diseases requires urgent action and greater national, regional and international collaboration and, in this regard, stressing the crucial and immediate need for a coordinated international response to the Ebola outbreak…

…1. Encourages the governments of Liberia, Sierra Leone and Guinea to accelerate the establishment of national mechanisms to provide for the rapid diagnosis and isolation of suspected cases of infection, treatment measures, effective medical services for responders, credible and transparent public education campaigns, and strengthened preventive and preparedness measures to detect, mitigate and respond to Ebola exposure, as well as to coordinate the rapid delivery and utilization of international assistance, including health workers and humanitarian relief supplies, as well as to coordinate their efforts to address the transnational dimension of the Ebola outbreak, including the management of their shared borders, and with the support of bilateral partners, multilateral organizations and the private sector;

2. Encourages the governments of Liberia, Sierra Leone and Guinea to continue efforts to resolve and mitigate the wider political, security, socioeconomic and humanitarian dimensions of the Ebola outbreak, as well as to provide sustainable, well-functioning and responsive public health mechanisms, emphasizes that responses to the Ebola outbreak should address the specific needs of women and stresses the importance of their full and effective engagement in the development of such responses;

3. Expresses concern about the detrimental effect of the isolation of the affected countries as a result of trade and travel restrictions imposed on and to the affected countries;

4. Calls on Member States, including of the region, to lift general travel and border restrictions, imposed as a result of the Ebola outbreak, and that contribute to the further isolation of the affected countries and undermine their efforts to respond to the Ebola outbreak and also calls on airlines and shipping companies to maintain trade and transport links with the affected countries and the wider region;

5. Calls on Member States, especially of the region, to facilitate the delivery of assistance, including qualified, specialized and trained personnel and supplies, in response to the Ebola outbreak to the affected countries and, in this regard, expresses deep appreciation to the government of Ghana for allowing the resumption of the air shuttle of UNMIL from Monrovia to Accra, which will transport international health workers and other responders to areas affected by the Ebola outbreak in Liberia;

6. Calls on Member States, especially of the region, and all relevant actors providing assistance in response to the Ebola outbreak, to enhance efforts to communicate to the public, as well as to implement, the established safety and health protocols and preventive measures to mitigate against misinformation and undue alarm about the transmission and extent of the outbreak among and between individuals and communities and, in this regard, requests the Secretary-General to develop a strategic communication platform using existing United Nations System resources and facilities in the affected countries, as necessary and available, including to assist governments and other relevant partners;

7. Calls on Member States to provide urgent resources and assistance, including deployable medical capabilities such as field hospitals with qualified and sufficient expertise, staff and supplies, laboratory services, logistical, transport and construction support capabilities, airlift and other aviation support and aeromedical services and dedicated clinical services in Ebola Treatment Units and isolation units, to support the affected countries in intensifying preventive and response activities and strengthening national capacities in response to the Ebola outbreak and to allot adequate capacity to prevent future outbreaks;

8. Urges Member States, as well as bilateral partners and multilateral organizations, including the AU, ECOWAS, and European Union, to mobilize and provide immediately technical expertise and additional medical capacity, including for rapid diagnosis and training of health workers at the national and international level, to the affected countries, and those providing assistance to the affected countries, and to continue to exchange expertise, lessons learned and best practices, as well as to maximize synergies to respond effectively and immediately to the Ebola outbreak, to provide essential resources, supplies and coordinated assistance to the affected countries and implementing partners and calls on all relevant actors to cooperate closely with the Secretary-General on response assistance efforts;

9. Urges Member States to implement relevant Temporary Recommendations issued under the International Health Regulations (2005) regarding the 2014 Ebola Outbreak in West Africa, and lead the organization, coordination and implementation of national preparedness and response activities, including, where and when relevant, in collaboration with international development and humanitarian partners;

10. Commends the continued contribution and commitment of international health and humanitarian relief workers to respond urgently to the Ebola outbreak and calls on all relevant actors to put in place the necessary repatriation and financial arrangements, including medical evacuation capacities and treatment and transport provisions, to facilitate their immediate and unhindered deployment to the affected countries;

11. Requests the Secretary-General to help to ensure that all relevant United Nations System entities, including the WHO and UNHAS, in accordance with their respective mandates, accelerate their response to the Ebola outbreak, including by supporting the development and implementation of preparedness and operational plans and liaison and collaboration with governments of the region and those providing assistance;

12. Encourages the WHO to continue to strengthen its technical leadership and operational support to governments and partners, monitor Ebola transmission, assist in identifying existing response needs and partners to meet those needs to facilitate the availability of essential data and hasten the development and implementation of therapies and vaccines according to best clinical and ethical practices and also encourages Member States to provide all necessary support in this regard, including the sharing of data in accordance with applicable law;

13. Decides to remain seized of the matter.

.

Measures to contain and combat the recent Ebola outbreak in West Africa – Draft resolution submitted by the President of the General Assembly
Sixty-ninth session
Agenda item 125 of the provisional agenda* – Global health and foreign policy

The General Assembly,

Expressing grave concern at the recent Ebola outbreak in West Africa and its unprecedented nature and scope,

Expressing grave concern also at the rapid deterioration of the situation, in particular in Guinea, Liberia and Sierra Leone, and the threat that this poses to their post-conflict recovery,

Expressing deep concern about the potential reversal of the gains made by the affected countries in peacebuilding, political stability and the reconstruction of socioeconomic infrastructure in recent years,

Underscoring the urgent need to contain this public health crisis owing to its possible grave humanitarian, economic and social consequences,

Underlining its strong commitment to responding to this emergency in a timely, effective and coordinated manner,

Recognizing the central role being played by the World Health Organization in leading worldwide support for the courageous responses of countries whose people are affected by, and at risk of, Ebola,

Welcoming all national, regional and international efforts aimed at ending the crisis, and reaffirming the important role of regional and sub-regional organizations in this regard, in particular, the African Union and the Economic Community of West African States,

Expresses appreciation for the appointment by the Secretary-General of a United Nations System Senior Coordinator for Ebola Virus Disease and a Deputy Ebola Coordinator and Emergency Crisis Manager, in order to assist Governments in the region to address the Ebola outbreak,

Noting the adoption by the Security Council of resolution 2176 (2014)of 15 September 2014,

1. Welcomes the intention of the Secretary-General to establish the United Nations Mission for Ebola Emergency Response;1

2. Requests the Secretary-General to take such measures as may be necessary for the prompt execution of his intention and to submit a detailed report thereon for consideration by the General Assembly at its sixty-ninth session;

3. Calls upon all Member States, relevant United Nations bodies and the United Nations system to provide their full support to the United Nations Mission for Ebola Emergency Response.

.
1 See A/69/389-S/2014/679.

FACT SHEET: U.S. Response to the Ebola Epidemic in West Africa
The White House
September 16, 2014
Excerpt focused on opening language and commitment of military assets

As the President has stated, the Ebola epidemic in West Africa and the humanitarian crisis there is a top national security priority for the United States. In order to contain and combat it, we are partnering with the United Nations and other international partners to help the Governments of Guinea, Liberia, Sierra Leone, Nigeria, and Senegal respond just as we fortify our defenses at home. Every outbreak of Ebola over the past 40 years has been contained, and we are confident that this one can—and will be—as well.

Our strategy is predicated on four key goals:
:: Controlling the epidemic at its source in West Africa;
:: Mitigating second-order impacts, including blunting the economic, social, and political tolls in the region;
:: Engaging and coordinating with a broader global audience; and,
:: Fortifying global health security infrastructure in the region and beyond.

The United States has applied a whole-of-government response to the epidemic, which we launched shortly after the first cases were reported in March. As part of this, we have dedicated additional resources across the federal government to address the crisis, committing more than $175 million to date. We continue to work with Congress to provide additional resources through appropriations and reprogramming efforts in order to be responsive to evolving resource needs on the ground. Just as the outbreak has worsened, our response will be commensurate with the challenge.

New Resources to Confront a Growing Challenge
The United States will leverage the unique capabilities of the U.S. military and broader uniformed services to help bring the epidemic under control. These efforts will entail command and control, logistics expertise, training, and engineering support.
:: U.S. Africa Command will set up a Joint Force Command headquartered in Monrovia, Liberia, to provide regional command and control support to U.S. military activities and facilitate coordination with U.S. government and international relief efforts. A general from U.S. Army Africa, the Army component of U.S. Africa Command, will lead this effort, which will involve an estimated 3,000 U.S. forces.
:: U.S. Africa Command will establish a regional intermediate staging base (ISB) to facilitate and expedite the transportation of equipment, supplies and personnel. Of the U.S. forces taking part in this response, many will be stationed at the ISB.
:: Command engineers will build additional Ebola Treatment Units in affected areas, and the U.S. Government will help recruit and organize medical personnel to staff them.
:: Additionally, the Command will establish a site to train up to 500 health care providers per week, enabling healthcare workers to safely provide direct medical care to patients.
:: The United States Public Health Service Commissioned Corps is preparing to deploy 65 Commissioned Corps officers to Liberia to manage and staff a previously announced Department of Defense (DoD) hospital to care for healthcare workers who become ill. The deployment roster will consist of administrators, clinicians, and support staff…

Full text of fact sheet: http://www.whitehouse.gov/the-press-office/2014/09/16/fact-sheet-us-response-ebola-epidemic-west-africa

UN OCHA
EBOLA VIRUS DISEASE OUTBREAK – Overview of needs and requirements
Compiled by OCHA in collaboration with WHO, UN partner agencies and other key responders.
September 2014 :: 34 pages
SCOPE OF THE OVERVIEW
The overview of requirements covers primarily Guinea, Liberia and Sierra Leone, the three countries with intense transmission of the virus. The overview also provides information on countries with localized transmission of the virus, such as Senegal and Nigeria, or at risk of Ebola Virus Disease (EVD) transmission.
Building upon the WHO Ebola Roadmap and the activities and plans of all UN entities responding to the ebola crisis, this overview describes the collective requirements needed to defeat the ebola outbreak and to mitigate the immediate and longer term social, economic, development and security consequences in affected countries and the region.
These needs go beyond the sizeable medical requirements needed to treat, contain, and prevent the ebola outbreak, and include needs and requirements related to non-ebola medical service (i.e. reproductive healthcare and malaria and tuberculosis (TB) treatment); food availability; clean water; livelihoods, and logistics concerns related to travel and transport of goods and services within and outside the ebola affected areas.
The overview covers a period of six months, in line with the analysis that it will take 6-9 months overcome the outbreak according to the WHO Ebola Roadmap. As the outbreak is rapidly evolving, the needs and requirements contained in this overview will be updated and disseminated accordingly.

UNICEF Watch [to 20 September 2014]
http://www.unicef.org/media/media_71724.html

:: Sierra Leone launches three-day, door-to-door Ebola prevention campaign
UNICEF backs nationwide effort to reach every household with lifesaving information
FREETOWN, Sierra Leone, 18 September 2014 – An ambitious public information campaign aiming to reach every household in Sierra Leone with life-saving messages on Ebola will take place 19-2 September in a bid to reduce the spread of the disease with the help of community members. UNICEF has provided the Government-led campaign with technical and financial support, including information materials.
“We have been sending life-saving messages through radio, TV and print, but it’s not enough,” said Roeland Monasch, UNICEF Representative in Sierra Leone. “We need to take information to where people are.”
The Ose to Ose Ebola Tok initiative, which means ‘house-to-house talk’ in the Sierra Leonean local language, will see over 28,500 trained social mobilizers, youths and volunteers go to door-to-door to reach 1.5 million households and provide them with information on ways families can protect themselves against the Ebola virus disease and prevent its spread.
As Ebola continues to claim lives and ravage communities, reaching the largest number of people with vital advice, information and guidance on preventing Ebola, alongside the provision of adequate medical care, is critical.
“This is an opportunity to hear from families what they want to know about Ebola. If people don’t have access to the right information, we need to bring life-saving messages to them, where they live, at their doorsteps. The fight against Ebola needs to happen in every household, in every community and in every treatment centre,” said Monasch.

:: UNICEF appeals for $200 million for Ebola response in West Africa
GENEVA/DAKAR/NEW YORK, 16 September 2014 – UNICEF said today it needs over $200 million to respond to the Ebola outbreak that has claimed over 2,200 lives and ravaged communities across West Africa. This is part of a broader, six-month appeal for $979 million that governments and humanitarian agencies require to fight the disease.

:: Statement by UNICEF Executive Director Anthony Lake on announcement of support for Ebola prevention and treatment by the US Government
NEW YORK, 16 September 2014 – “This is great news for the millions of people in West Africa, particularly Liberia, threatened by Ebola. A rapidly escalating emergency like this requires a massive, urgent and global response.

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GAVI Watch [to 20 September 2014]
http://www.gavialliance.org/library/news/press-releases/

Gavi position statement on Ebola
Vaccine Alliance continues to provide support for health systems across the affected region
Geneva, 19 September 2014 – Gavi, the Vaccine Alliance is extremely concerned about the effect of the unfolding Ebola crisis on the people of West Africa. This public health emergency has exposed major weaknesses of health systems in the region, particularly since many of the affected countries are still recovering from recent conflicts.
Gavi has invested more than US$ 50 million to strengthen health systems for people in countries affected by the outbreak but the unfilled needs remain enormous. We will continue to provide support for health systems across the region with a long-term aim of building strong, resilient health infrastructures.
If countries request it, Gavi will try to respond to their situation by reprogramming current health and immunisation systems grants towards new health systems needs arising from the Ebola outbreak. Gavi will also play an active role in supporting countries in developing strong recovery plans for their health systems.
While Gavi is not structured to undertake emergency response operations, we are working with our Alliance partners in the affected areas to ensure that, wherever possible, children continue to receive vaccines — including pneumococcal, rotavirus and pentavalent — which protect against major killer diseases. Unfortunately, we do expect this crisis to have a negative impact on immunisation coverage in the affected countries

Joint WHO – UNICEF statement regarding deaths of children in Idlib, northern Syria
AMMAN/CAIRO, 17 September 2014 – “UNICEF and WHO have been shocked and saddened to learn of the deaths of at least 15 young children in Idlib, Syria. The deaths of the children occurred in areas where a measles immunization campaign had been under way.
Establishing the precise cause of the children’s deaths is vital. To that end, the WHO has deployed a team of experts to provide assistance to those carrying out the investigation in Idlib who will report back as soon as possible. WHO is also providing advice and protocols for the investigation of adverse events following immunization.
For as long as the facts remain unclear, the suspension of the immunization campaign in both Idlib and Deir Ezzour provinces is a wise step.
However, it is vital that immunization efforts against measles – a disease which is a leading killer of children worldwide – resume as soon as possible.
Measles is a particular threat to children who have been displaced from their homes and communities, and who are living in camps or other insanitary conditions….

Human error seen in measles vaccination deaths in Syria: WHO
By Stephanie Nebehay
GENEVA Fri Sep 19, 2014 7:47am EDT
(Reuters) – A muscle relaxant appears to have been mixed mistakenly with measles vaccine, killing 15 children in Syria this week, the World Health Organization (WHO) said on Friday, calling it the biggest such tragedy in memory.
The WHO said it could not completely rule out sabotage, so the measles inoculation campaign remained suspended until the investigation was finished.
Fifteen children died after being vaccinated against measles in northern Syria, aid workers said on Wednesday, a tragedy likely to damage trust in health services in opposition-held areas.
The manufacturer, who has not been identified, shipped the vaccine in powder form with a diluent to a hub in Syria where it was stored and then sent to Deir al-Zor and Idlib provinces for the campaign to vaccinate tens of thousands of children that began on Monday, WHO spokesman Christian Lindmeier said.
“In the hub apparently, (from) what we know so far, the diluent was kept … together in the same refrigerator with a muscle relaxant. The relaxant is called Atracurium. This got mixed in some cases instead of the diluent with the vaccine powder,” Lindmeier told a news briefing in Geneva.
Pointing to human error, he said: “So the ones who packed it obviously put the wrong ampoules with the vaccine powder into the package. Then it gets shipped in the vaccine carriers to the facility, there it gets unpacked, mixed and then it has to be used within 6 hours.
“So both at the packing and at the unpacking there had to be gross negligence,” Lindmeier said.
The muscle relaxant, usually administered as an anesthetic for surgery, works according to weight, so all the children who died were under the age of two, he said. Older children survived after vomiting, diarrhea and anaphylactic shock.
Lindmeier said: “It seems very clear that it was not the manufacturer’s fault, not that the vaccine is contaminated, but it’s a fault on the ground, again not established whether it’s human error or deliberate, but the fault lies on the ground as per indications.”
It was not clear who was in charge of the refrigerator and investigations continue, he said. The WHO and UNICEF supported the campaign but were not directly involved due to insecurity and the “politically-charged” situation in the area, he added.
“There is still a slight possibility that it’s not only human error, but an intent, that has to be cleared up definitely before anything can continue,” he said.
More than 50,000 children in the two provinces received the vaccine before the campaign was suspended, he added.
Prior to Syria’s civil war, some 99 percent of children were vaccinated against measles, a highly contagious disease that can cause serious complications such as meningitis and pneumonia, becoming much deadlier in difficult conditions.
(Reporting by Stephanie Nebehay; Editing by Crispian Balmer)

GPEI Update: Polio this week – As of 17 September 2014
Global Polio Eradication Initiative
Editor’s Excerpt and text bolding
Full report: http://www.polioeradication.org/Dataandmonitoring/Poliothisweek.aspx
:: A synchronized regional mass polio vaccination campaign in central and western Africa is currently underway to vaccinate nearly 94 million children in 18 countries with oral polio vaccine (OPV).
:: In the Horn of Africa, current focus is on further strengthening microplans for upcoming outbreak response campaigns. Targeted approaches are being put in place and technical support has been deployed to the highest risk areas to ensure the best possible campaigns are implemented.
Pakistan
:: Seven new wild poliovirus type 1 (WPV-1) cases were reported in the past week. Of these, 4 are from the Federally Administered Tribal Areas (FATA) (1 from North Waziristan and 3 from Khyber Agency) and 2 from Khyber Pakhtunkhwa (1 from Tank and 1 from Bannu). The 7th case had onset in the previously-uninfected district of Quetta in Balochistan province. This brings the total number of polio cases in 2014 to 145 compared to 28 in 2013 by this date. The most recent onset of paralysis was on 30 August in FATA…
:: Immunization activities are continuing with particular focus on known high-risk areas, in particular the newly opened areas in Khyber Pakhtunkhwa. At exit and entry points, 182 permanent vaccination points are being used to reach internally displaced persons.

The Weekly Epidemiological Record (WER) 19 September 2014, vol. 89, 38 (pp. 409–420) includes:
:: Global programme to eliminate lymphatic filariasis: progress report, 2013
:: Children: reducing mortality
http://www.who.int/entity/wer/2014/wer8938.pdf?ua=1

CDC/MMWR Watch [to 20 September 2014]
http://www.cdc.gov/media/index.html

:: CDC Ebola Surge: 2014 – Fact Sheet
Tuesday, September 16, 2014
The 2014 Ebola outbreak is the largest in history and the first Ebola outbreak in West Africa. This outbreak is actually the first Ebola epidemic the world has ever known — affecting multiple countries in and around West Africa.

MMWR for September 19, 2014 / Vol. 63 / No. 37

:: Influenza Vaccination Coverage Among Health Care Personnel — United States, 2013–14 Influenza Season
Excerpt; Editor’s text bolding
The Advisory Committee on Immunization Practices recommends that all health care personnel (HCP) be vaccinated annually against influenza (1). Vaccination of HCP can reduce influenza-related morbidity and mortality among both HCP and their patients (1–4). To estimate influenza vaccination coverage among HCP during the 2013–14 season, CDC analyzed results of an opt-in Internet panel survey of 1,882 HCP conducted during April 1–16, 2014. Overall, 75.2% of participating HCP reported receiving an influenza vaccination during the 2013–14 season, similar to the 72.0% coverage among participating HCP reported in the 2012–13 season (5).
Coverage was highest among HCP working in hospitals (89.6%) and lowest among HCP working in long-term care (LTC) settings (63.0%). By occupation, coverage was highest among physicians (92.2%), nurses (90.5%), nurse practitioners and physician assistants (89.6%), pharmacists (85.7%), and “other clinical personnel” (87.4%) compared with assistants and aides (57.7%) and nonclinical personnel (e.g., administrators, clerical support workers, janitors, and food service workers) (68.6%).
HCP working in settings where vaccination was required had higher coverage (97.8%) compared with HCP working in settings where influenza vaccination was not required but promoted (72.4%) or settings where there was no requirement or promotion of vaccination (47.9%). Among HCP without an employer requirement for vaccination, coverage was higher for HCP working in settings where vaccination was offered on-site at no cost for 1 day (61.6%) or multiple days (80.4%) compared with HCP working in settings not offering free on-site vaccination (49.0%). Comprehensive vaccination strategies that include making vaccine available at no cost at the workplace along with active promotion of vaccination might be needed to increase vaccination coverage among HCP and minimize the risk for influenza to HCP and their patients…
:: Influenza Vaccination Performance Measurement Among Acute Care Hospital-Based Health Care Personnel — United States, 2013–14 Influenza Season
:: Influenza Vaccination Coverage Among Pregnant Women — United States, 2013–14 Influenza Season
:: Use of 13-Valent Pneumococcal Conjugate Vaccine and 23-Valent Pneumococcal Polysaccharide Vaccine Among Adults Aged ≥65 Years: Recommendations of the Advisory Committee on Immunization Practices (ACIP)
:: Announcement: Now Available Online: Final 2013–14 Influenza Vaccination Coverage Estimates for Selected Local Areas, States, and the United States

Nepal in “historic introduction of IPV”
ReliefWeb/ Report from UN Country Team in Nepal
18 September 2014
Excerpt
KATHMANDU, 18 September 2014 – In a landmark step to accelerate the global eradication of polio and help prevent a resurgence of the disease, Nepal is today introducing the Inactivated Polio Vaccine (IPV) into its routine immunization programme. Nepal has the distinction of being the first country in South Asia region to launch IPV as part of the global roll-out of the vaccine.
Until now, oral polio vaccine (OPV) has been the primary tool in the global polio eradication effort, reducing incidence of the disease by more than 99 percent worldwide thanks to its unique ability to stop person-to-person spread of the virus. Nepal, along with Bangladesh, Bhutan, Democratic People´s Republic of Korea, India, Indonesia, Maldives, Myanmar, Sri Lanka, Thailand and Timor-Leste, was declared polio free last March. Endemic polio has been successfully eliminated from all but three countries worldwide.
Nepal has made tremendous progress in improving the health and survival of children in the last 25 years. The under-5 mortality rate has significantly reduced from 147 per thousand live births in 1990 to 54 per thousand in 2011. Also, the coverage of immunization against polio has doubled to 90 percent in 2011 from 44 percent in 1984. Thanks to the tireless efforts of community members and the Female Community Health Volunteers together with the Government and its partners WHO, UNICEF, Rotary and GAVI, Nepal has been able to achieve near universal immunization coverage.
Despite this progress, experts caution that polio-free countries remain at risk of re-infection until the disease has been eradicated everywhere. New evidence now demonstrates that adding one dose of IPV at 14 weeks of age to OPV is even more effective than OPV alone at stopping the virus and protecting children. IPV and OPV evoke different immune responses and when used together, maximize immunity to polio virus.
IPV is being introduced in Nepal in order to quickly maximize childhood immunity to polio and maintain the country’s polio-free status. IPV has been proven an extremely safe and effective vaccine and has been used successfully in many developed countries for several decades. It is important to note that IPV is recommended in addition to the oral vaccine and does not replace the oral vaccine…

PATH receives award to develop novel vaccine against a leading bacterial cause of diarrhea
New award from the Wellcome Trust will support the clinical development of a vaccine against Shigella for children in the developing world
September 18, 2014
PATH is pleased to announce that we have received a Translation Fund award from the Wellcome Trust. The new award provides funding of more than US$4 million over 30 months, and it represents the first time that PATH has received this type of award from the United Kingdom-based agency. The award will support the clinical development of DB Fusion, a novel, serotype-independent vaccine candidate to prevent Shigella dysentery.
Since 2010, PATH has been working in partnership with Drs. Bill and Wendy Picking, who were researchers at Oklahoma State University (OSU), to develop a vaccine to prevent the short- and long-term negative effects of bacteria known as Shigella. Infection with Shigella causes bloody diarrhea and represents a major health threat to children living in poorer countries where access to clean water and appropriate hygiene and sanitation practices to prevent such diseases are lacking.
Unlike other Shigella vaccines currently under development, the approach used with this vaccine candidate, DB Fusion, targets proteins found on the surface of the bacteria to provide broad protection against all types of Shigella with one simple vaccine. The vaccine is intended for administration via a small needle that only goes into the skin’s outermost layer (known as intradermal immunization, a procedure long in use for other vaccines) and given in combination with a component that may enhance the vaccine’s effectiveness.
PATH and the Picking team have already completed preclinical research studies demonstrating the DB Fusion’s protection against several types of Shigella, and we are now collaborating on developing a process to manufacture the vaccine for clinical use. With the Wellcome Trust award, we plan to conduct early-stage clinical studies on the safety of the vaccine candidate in humans and, if warranted, a subsequent trial to show that it can protect humans against illness caused by Shigella.

Sabin Vaccine Institute Awarded Funding to Advance Therapeutic Vaccine Development for Chagas Disease
Excerpt
WASHINGTON, D.C. — September 16, 2014 — The Sabin Vaccine Institute (Sabin) announced that its product development partnership (Sabin PDP) received $2 million from the Global Health Innovative Technology Fund (GHIT Fund) to develop a new therapeutic vaccine formulation for Chagas disease. Baylor College of Medicine, Eisai Co., Ltd. (Eisai) and Aeras are partnering on this project with the Sabin PDP, based at the Sabin Vaccine Institute and Texas Children’s Hospital Center for Vaccine Development in Houston, Texas…

Pfizer Foundation Provides $2 Million In Grants To Support ‘Last-Mile’ Vaccine Coverage In Africa
Excerpt
NEW YORK– The Pfizer Foundation today announced $2 million in grant funding for pilot programs to improve immunization coverage in Africa. The programs will focus on ‘last-mile’ interventions to reach underserved populations living in Ethiopia, Malawi, Rwanda, Uganda and Zambia.
“These grants will work to support our global efforts to reach more patients with lifesaving and enhancing vaccines”
Grant recipients include UNICEF, Save the Children and International Rescue Committee. The grants will focus on building the capacity of health care systems within the five countries to ensure that efficient and sustainable vaccine supplies are available to reach children who need access to vaccines.
Interventions include mobile platforms for vaccinations, which provide health workers with mobile phones and solar-powered tablets to register children born in a clinic area and help track vaccination schedules in real time. Other interventions include short-message service (SMS) systems, which will be used to monitor vaccines and equipment to identify bottlenecks in the supply chain and prevent stock outs…

Investing in Global Health Systems: Sustaining Gains, Transforming Lives
IOM
September 16, 2014
Key Findings (PDF)
Report pdf: http://www.nap.edu/catalog.php?record_id=18940
Health and life expectancy in poor countries have improved rapidly over a short time, contributing to a more prosperous, stable, and productive world. The United States has been a part of this success and therefore has an interest in protecting the health gains of the past few decades. In addition, the recent Ebola outbreak in West Africa has drawn attention to the consequences of neglecting health systems development, as a strong health system allows for prompt response to pandemic threats and draws on the same skills and infrastructure that support routine health care. Vulnerabilities in this system pose financial, political, and health risks to developing countries and, in a larger sense, to the world.
An IOM study looked at how health systems improvements can lead to better health, reduce poverty, and make donor investment in health sustainable. The resulting report stresses the importance of the health system in making transformative investments that support health in developing countries, and outlines a broad donor strategy that can make effective use of the United States’ comparative advantage in science and technology to improve health for the world’s most vulnerable people.

Levels and trends in child mortality : estimates developed by the UN Inter-agency Group for child Mortality Estimation (IGME) – report 2014
Issued by World Bank as Working Paper 90587
pdf: http://www-wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2014/09/12/000470435_20140912082625/Rendered/PDF/905870WP0Box380ortality0report02014.pdf
Abstract
The under-five mortality rate is a key indicator of child well-being, including health and nutrition status. It is also a key indicator of the coverage of child survival interventions and, more broadly, of social and economic development. Millennium Development Goal 4 (MDG 4) calls for reducing the under-five mortality rate by two-thirds between 1990 and 2015. The world has made substantial progress, reducing the rate 49 percent, from 90 (89, 92) deaths per 1,000 live births in 1990 to 46 (44, 48) in 2013. Since 1990 almost 100 million children under age five roughly the current populations of the Philippines have been saved. The world is also reducing under-five mortality faster than at any other time during the past two decades. The global annual rate of reduction has steadily accelerated since 1990-1995 more than tripling from 1.2 percent to 4.0 percent in 2005-2013.

American Journal of Public Health
Volume 104, Issue S4 (September 2014)
http://ajph.aphapublications.org/toc/ajph/current

Ahead of Print.
Nonmedical Exemptions From School Immunization Requirements: A Systematic Review
Eileen Wang, Jessica Clymer, BA, BSN, Cecilia Davis-Hayes, BA, and Alison Buttenheim, PhD, MBA
Abstract
We summarized studies describing the prevalence of, trends in, and correlates of nonmedical exemptions from school vaccination mandates and the association of these policies with the incidence of vaccine-preventable disease.
We searched 4 electronic databases for empirical studies published from 1997 to 2013 to capture exemption dynamics and qualitatively abstracted and synthesized the results. Findings from 42 studies suggest that exemption rates are increasing and occur in clusters; most exemptors questioned vaccine safety, although some exempted out of convenience. Easier state-level exemption procedures increase exemption rates and both individual and community disease risk.
State laws influence exemption rates, but policy implementation, exemptors’ vaccination status, and underlying mechanisms of geographical clustering need to be examined further to tailor specific interventions.

BMC Public Health
(Accessed 20 September 2014)
http://www.biomedcentral.com/bmcpublichealth/content

Research article
Factors influencing adolescent girls’ decision in initiation for human papillomavirus vaccination: a cross-sectional study in Hong Kong
Albert Lee, Mandy Ho, Calvin Ka Cheung, Vera Mei Keung BMC Public Health 2014, 14:925 (8 September 2014)
Abstract (provisional)
Background
Cervical cancer is one of the common cancers among women worldwide. Despite HPV vaccination being one of the effective preventive measures, it is not included in government vaccination programme in Hong Kong. This study aimed to assess the knowledge of and attitude towards cervical cancer prevention among Chinese adolescent girls in Hong Kong, and to identify factors influencing the initiation of HPV vaccination.
Methods
This was a cross-sectional study conducted in Hong Kong during the period of October 2010 to November 2010. A self-administered questionnaire was used, with 1,416 girls from 8 secondary schools completing the questionnaire. Knowledge scores were composited and initiation of HPV vaccination was staged based on stage of change. Analyses were conducted to identify the association of initiation of HPV vaccination with participant’s personal and family factors as well as their knowledge and attitude towards cervical cancer prevention.
Results
The uptake rate of HPV vaccination was low (7%) with 58% respondents in pre-contemplation and contemplation stage. The survey identified a significant gap in knowledge on cervical cancer prevention. The main channels of information were from media and very few from schools or parents. However, 70% expressed their wishes to have more information on cancer prevention, and 78% stated that they were willing to change their lifestyles if they knew the ways of prevention. Multivariate analysis identified three independent significant factors for initiation of vaccination (action and intention): perceived cancer as terrifying disease, school should provide more information on cancer prevention, and comments from relatives and friends having received the vaccine. The cost of vaccination and socio-economic background were not found to be significant.
Conclusions
Public education on cervical cancer needs to be well penetrated into the community for more sharing among friends and relatives. School as setting to provide source of information would facilitate uptake rate of HPV vaccine as students have expressed their wishes that school should provide more information on prevention of cancer. School and community education on cancer prevention would help adolescents to have better understanding of the seriousness of cancer.

Clinical Infectious Diseases (CID)
Volume 59 Issue 7 October 1, 2014
http://cid.oxfordjournals.org/content/current

Editor’s choice: Vaccination Against Zoster Remains Effective in Older Adults Who Later Undergo Chemotherapy
Hung Fu Tseng, Sara Tartof, Rafael Harpaz, Yi Luo, Lina S. Sy, Rulin C. Hetcher, and Steven J. Jacobsen
Clin Infect Dis. (2014) 59 (7): 913-919 doi:10.1093/cid/ciu498
Abstract
Persons treated with chemotherapy who are at high risk of herpes zoster and its sequelae received substantial protection through zoster vaccination, providing an additional rationale for offering zoster vaccine to adults for whom it is indicated, before vaccination becomes contraindicated.

Editor’s choice: Editorial Commentary: Zoster Vaccine in Immunocompromised Patients: Time to Reconsider Current Recommendations
Michael N. Oxman and Kenneth E. Schmader
Clin Infect Dis. (2014) 59 (7): 920-922 doi:10.1093/cid/ciu501

Editorial Commentary: A Shigella Vaccine Against Prevalent Serotypes
Lillian L. Van de Verg1 and Malabi M. Venkatesan2
Author Affiliations
1Vaccine Development Global Program, PATH, Washington, District of Columbia
2Bacterial Diseases Branch, Walter Reed Army Institute of Research, Silver Spring, Maryland
Invited Commentary to article by Livio et al “Shigella Isolates from the Global Enteric Multicenter Study (GEMS) Inform Vaccine Development”.
(See the Major Article by Livio et al on pages 933–41.)
Dysentery due to Shigella is a severe, intensely inflammatory infection that disproportionately affects the very young in less developed parts of the world where there is little to no access to clean water and sanitation. Mortality due to shigellosis has decreased significantly in the last 2 to 3 decades, arguably due, in large part, to the virtual disappearance of major epidemics of S. dysenteriae 1. However, the incidence of diarrheal disease due to other shigellae has remained high. Worldwide, Shigella is estimated to cause 80–120 million episodes of diarrhea and more than 100 000 deaths annually, mostly in children aged <5 years [1].
The recently published Global Enteric Multicenter Study (GEMS) is a large-scale survey of the incidence and causative agents of moderate to severe diarrheal disease in young children aged 0–59 months who reside in low-income parts of 7 countries in Africa and South Asia [2]. In children aged 0–11 months, rotavirus and enterotoxigenic Escherichia coli were often the leading agents of moderate to severe diarrhea. In children aged 12–59 months, Shigella became the lead agent overall. Children who are subjected to repeated bouts of diarrheal diseases such as shigellosis are susceptible to faltering in physical growth and cognitive development

Dramatic Decline of Respiratory Illness Among US Military Recruits After the Renewed Use of Adenovirus Vaccines
Jennifer M. Radin, Anthony W. Hawksworth, Patrick J. Blair, Dennis J. Faix, Rema Raman,
Kevin L. Russell, and Gregory C. Gray
Clin Infect Dis. (2014) 59 (7): 962-968 doi:10.1093/cid/ciu507
Abstract
Following resumption of adenovirus vaccination in late 2011, 100-fold declines in adenovirus disease burden were seen among US military recruits at 8 training sites. Simultaneous decline of non-vaccine-associated adenovirus types was also found.

Shigella Isolates From the Global Enteric Multicenter Study Inform Vaccine Development
Sofie Livio, Nancy A. Strockbine, Sandra Panchalingam, Sharon M. Tennant, Eileen M. Barry, Mark E. Marohn, Martin Antonio, Anowar Hossain, Inacio Mandomando, John B. Ochieng, Joseph O. Oundo, Shahida Qureshi, Thandavarayan Ramamurthy, Boubou Tamboura, Richard A. Adegbola, Mohammed Jahangir Hossain, Debasish Saha, Sunil Sen, Abu Syed Golam aruque, Pedro L. Alonso, Robert F. Breiman, Anita K. M. Zaidi, Dipika Sur, Samba O. Sow, Lynette Y. Berkeley, Ciara E. O’Reilly, Eric D. Mintz, Kousick Biswas, Dani Cohen, Tamer H. Farag, Dilruba Nasrin, Yukun Wu, William C. Blackwelder, Karen L. Kotloff, James P. Nataro, and Myron M. Levine
Clin Infect Dis. (2014) 59 (7): 933-941 doi:10.1093/cid/ciu468
Free Full Text (HTML)
Shigella case isolates from the Global Enteric Multicenter Study were serotyped to guide vaccine development. A quadrivalent vaccine that includes O antigens from S. sonnei, S. flexneri 2a, S. flexneri 3a, and S. flexneri 6 should provide broad protection.

Cost Effectiveness and Resource Allocation
(Accessed 20 September 2014)
http://www.resource-allocation.com/

Research
Modelling the cost-effectiveness of a new infant vaccine to prevent tuberculosis disease in children in South Africa
Liezl Channing and Edina Sinanovic*
Health Economics Unit, School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, Anzio Road, Observatory, 7925 Cape Town, South Africa
Abstract
Background
Tuberculosis remains the leading cause of death in South Africa. A number of potential new TB vaccine candidates have been identified and are currently in clinical trials. One such candidate is MVA85A. This study aimed to estimate the cost-effectiveness of adding the MVA85A vaccine as a booster to the BCG vaccine in children from the perspective of the South African government.
Methods
The cost-effectiveness was assessed by employing Decision Analytic Modelling, through the use of a Markov model. The model compared the existing strategy of BCG vaccination to a new strategy in which infants receive BCG and a booster vaccine, MVA85A, at 4 months of age. The costs and outcomes of the two strategies are estimated through modelling the vaccination of a hypothetical cohort of newborns and following them from birth through to 10 years of age, employing 6-monthly cycles.
Results
The results of the cost-effectiveness analysis indicate that the MVA85A strategy is both more costly and more effective – there are fewer TB cases and deaths from TB than BCG alone. The South African government would need to spend an additional USD 1,105 for every additional TB case averted and USD 284,017 for every additional TB death averted. The threshold analysis shows that, if the efficacy of the MVA85A vaccine was 41.3% (instead of the current efficacy of 17.3%), the two strategies would have the same cost but more cases of TB and more deaths from TB would be prevented by adding the MVA85A vaccine to the BCG vaccine. In this case, the government should consider the MVA85A strategy.
Conclusions
At the current level of efficacy, the MVA85A vaccine is neither effective nor cost-effective and, therefore, not a good use of limited resources. Nevertheless, this study contributes to developing a standardized Markov model, which could be used, in the future, to estimate the potential cost-effectiveness of new TB vaccines compared to the BCG vaccine, in children between the ages of 0–10 years. It also provides an indicative threshold of vaccine efficacy, which could guide future development.

The European Journal of Public Health
Volume 24 Issue 5 October 2014
http://eurpub.oxfordjournals.org/content/current

Editorial
The health of migrants and ethnic minorities in Europe: where do we go from here?
Oliver Razum1 and Karien Stronks2
Author Affiliations
1 Department of Epidemiology & International Public Health, School of Public Health, Bielefeld University, 33501 Bielefeld, Germany
2 Department of Public Health, Academic Medical Center, University of Amsterdam, 1100 DD Amsterdam, The Netherlands
Abstract
Between 0.4 (Slovakia) and 15.3% (Estonia) of the European population were born in a non-EU-27 (European Union-27) country,1 and this proportion is increasing in most member states. Given that migrants and ethnic minorities do not always have equal access to health services, their rights to health and health care are important public health topics. To improve the basis for further research and advocacy, these issues were discussed at the fifth EUPHA European Conference on Migrant and Minority Ethnic Health in Granada, Spain, in April 2014 (more details of the conference, including the programme and the volume of abstracts, can be found at http://www.eupha-migranthealthconference.com/).
Some of the lessons learned
The health of migrants and ethnic minorities should not be approached from a paternalistic perspective and with a focus only on deficits. On a population level, migrants (and also some ethnic minority groups) are comparatively healthier—especially with regard to non-communicable diseases such as cancer.2 Migrants and ethnic minorities are of course also exposed to health risks, such as limited accessibility to health care, …

Roma health is global ill health
Róza Ádány1,2,3
Author Affiliations
1 Department of Preventive Medicine, Faculty of Public Health, University of Debrecen, Debrecen, Hungary
2 MTA-DE Public Health Research Group of the Hungarian Academy of Sciences, University of Debrecen, Debrecen, Hungary
3 WHO Collaborating Centre on Vulnerability and Health, Faculty of Public Health, University of Debrecen, Debrecen, Hungary
Abstract
The accompanying paper by Kühlbrandt et al.1 begins to fill the void of quantitative data on access to health insurance coverage by Roma in Central Eastern European (CEE) countries. Survey data from 12 CEE countries clearly show that Roma, Europe’s largest ethnic minority, comprising up to 12% of the population of some of these countries, are significantly less likely to have health insurance than non-Roma in all countries except Slovakia and Serbia. The share of Roma without coverage reaches almost 30% in Bosnia–Herzegovina, over 40% in Bulgaria and Romania and 59.7% and 67.7% in Moldova and Albania, respectively. Throughout the region, Roma face poverty, poor access to education, high levels of unemployment and social exclusion. All of these might be expected to impact adversely on their health. Yet, …

The right of access to health care for undocumented migrants: a revision of comparative analysis in the European context
Amets Suess, Isabel Ruiz Pérez, Ainhoa Ruiz Azarola, and Joan Carles March Cerdà
Eur J Public Health (2014) 24 (5): 712-720 doi:10.1093/eurpub/cku036
Abstract

JAMA
September 17, 2014, Vol 312, No. 11
http://jama.jamanetwork.com/issue.aspx

Viewpoint | September 17, 2014
The Ebola Epidemic – A Global Health Emergency
Lawrence O. Gostin, JD1; Daniel Lucey, MD, MPH2; Alexandra Phelan, LLM, BBiomedSc/LLB1
Author Affiliations
JAMA. 2014;312(11):1095-1096. doi:10.1001/jama.2014.11176.
Excerpt
On August 8, the World Health Organization (WHO) Director-General Margaret Chan declared the West Africa Ebola crisis a “public health emergency of international concern,”1 triggering powers under the 2005 International Health Regulations (IHR). The IHR requires countries to develop national preparedness capacities, including the duty to report internationally significant events, conduct surveillance, and exercise public health powers, while balancing human rights and international trade. Until last year, the director-general had declared only one such emergency—influenza AH1N1 (in 2009). Earlier this year, she declared poliomyelitis a public health emergency of international concern and now again for Ebola, signaling perhaps a new era of potential WHO leadership in global health security…