Speech: WHO assessment of China’s national drug regulatory authority for vaccines
Dr Margaret Chan, Director-General of the World Health Organization
China’s regulatory system on food and drugs from a global perspective
Beijing, China
4 July 2014
Excerpt
Minister Zhang Yong, colleagues and friends, ladies and gentlemen,

Let me begin by extending my warm congratulations for a job well done. I have just announced that the China Food and Drug Administration’s regulatory system for vaccines has been assessed by WHO with outstanding results.

You have met established benchmarks that define international requirements for a functional vaccine regulatory system. The improvements made since the previous assessment are most encouraging. CFDA is well on its way towards meeting the highest international standards for a regulatory authority.

I just had a most productive meeting with Minister Zhang Yong. I am delighted to inform you that we signed a declaration of joint commitment. We will work together to make CFDA an advanced, internationally recognized regulator not just of vaccines, but also of medical products and food safety management.

Effective regulatory oversight of vaccines is especially important, as vaccines are used on a population-wide basis, and are usually given to healthy infants. High quality must be assured.
The results of the WHO assessment are good news for China, but also for the rest of the world. The demand for vaccines is increasing at a time when the number of countries producing vaccines is declining. China has the largest vaccine manufacturing capacity in the world.

With the latest seal of approval from WHO, this country is in a position to make high-quality vaccine supplies more abundant, predictable, and affordable. This capacity benefits all countries, but most especially in the developing world. It strengthens China’s long history of collaboration to improve health in Africa…

WHO: Global Alert and Response (GAR) – Disease Outbreak News [to 12 July 2014]
http://www.who.int/csr/don/en/

:: Ebola virus disease, West Africa – update 10 July 2014
Epidemiology and surveillance
The World Health Organization (WHO) continues to monitor the evolution of the Ebola virus disease (EVD) outbreak in Guinea, Liberia, and Sierra Leone. In Guinea, the current epidemic trend shows low activity of community viral transmission, with only 1 confirmed EVD case reported in the last 7 days. This trend is being closely monitored, particularly in communities that had resistance to recommended outbreak control measure. The epidemic trend in Liberia and Sierra Leone remains precarious with high numbers of new cases and deaths being reported. The current active foci of the EVD outbreak have been identified as Kailahun and Kenema in Sierra Leone and Lofa and Montserrado in Liberia. The respective Ministries of Health are working with WHO and its partners to step up containment measures.
Health sector response
As part of the effort to control this outbreak, Dr Keiji Fukuda, the Assistant Director-General for WHO’s Health Security cluster and Dr Benido Impouma, the Sub-regional Coordinator for the outbreak response visited Sierra Leone and Guinea from 7–10 July 2014. The WHO’s delegation engaged and had dialogue with high-level political and Government authorities aimed to enhance national leadership and commitment. The delegation also held discussions with the national coordination structures for EVD outbreak response, including partners, in order to strengthen coordination, communication, and inter-sectoral collaboration.
A Sub-regional Outbreak Coordination Centre for the response is being established in Conakry, Guinea. The centre will act as a control and coordination platform to consolidate and harmonize the technical support to West African countries and to assist in resource mobilization.
The Sub-regional Centre will be responsible for ensuring effective use and deployment of limited and scarce, but highly critical resources based on prioritization and agreed objectives. The organization and coordination of key support functions and field operations will move closer to outbreak areas, or hot spots.
In addition, the Sub-regional Centre will:
– Ensure sufficient technical and operational support and resources to sustain response activities in the field, facilitate the coordination of the Global Outbreak Alert and Response Network (GOARN) partners and networks, prepare public communications materials and activities, engage in contingency planning, risk assessments, and scaling of operations as required, and secure an environment that enables effective and successful field operations.
– Define operational periods to achieve agreed objectives and ensure the planning, coordination, and optimum use of limited resources, as well as continuity of action and management.
– Direct human and material resources to communications and social mobilization, investigation of alerts and new outbreaks, case finding and contact tracing, surveillance and data management, patient treatment and care, logistics, stockpiling, and movement of personal protective equipment to key locations.
– Provide technical guidance and resources, communications support, decision-making, and reporting for all field teams in the subregion.
WHO does not recommend any travel or trade restrictions be applied to Guinea, Liberia, or Sierra Leone based on the current information available for this event.
Disease update
New cases and deaths attributable to Ebola virus disease (EVD) continue to be reported by the Ministries of Health in the three West African countries of Guinea, Liberia, and Sierra Leone. Between 6 and 8 July 2014, 44 new cases of EVD, including 21 deaths, were reported from the three countries as follows: Guinea, 1 new case and 2 deaths; Liberia, 11 new cases with 4 deaths; and Sierra Leone 32 new cases and 15 deaths. These numbers include laboratory-confirmed, probable, and suspect cases and deaths of EVD.
As of 8 July 2014, the cumulative number of cases attributed to EVD in the three countries stands at 888, including 539 deaths. The distribution and classification of the cases are as follows: Guinea, 409 cases (296 confirmed, 96 probable, and 17 suspected) and 309 deaths (197 confirmed, 96 probable, and 16 suspected); Liberia, 142 cases (70 confirmed, 32 probable, and 40 suspected) and 88 deaths (44 confirmed, 28 probable, and 16 suspected); and Sierra Leone, 337 cases (298 confirmed, 34 probable, and 5 suspected) and 142 deaths (127 confirmed, 11 probable, and 4 suspected).

:: Middle East respiratory syndrome coronavirus (MERS-CoV) – update 4 July 2014
On 30 June and 1 July 2014, the National IHR Focal Point for Saudi Arabia reported an additional 3 laboratory-confirmed cases of infection with Middle East respiratory syndrome coronavirus (MERS-CoV), and a death in a previously reported case….
…WHO does not advise special screening at points of entry with regard to this event nor does it currently recommend the application of any travel or trade restrictions.

UNICEF Watch [to 12 July 2014]
http://www.unicef.org/media/media_71724.html
:: Misconceptions fuel Ebola outbreak in West Africa
GENEVA/DAKAR, Senegal, 11 July 2014 – As the Ebola-related death toll rises above 500 in West Africa, UNICEF and its partners are expanding their activities across the region to halt the spread of the disease by combating rumours, fears and misconceptions

POLIO [to 12 July 2014]

GPEI Update: Polio this week – As of 9 July 2014
Global Polio Eradication Initiative
Editor’s Excerpt and text bolding
Full report: http://www.polioeradication.org/Dataandmonitoring/Poliothisweek.aspx
:: Intense polio immunization activity is continuing in areas surrounding North Waziristan, Pakistan, to reach families who have not been able to access vaccination for two years. As displaced communities move into other parts of Pakistan and into Afghanistan, vaccination activities are taking place in host communities as well as at transit vaccination posts. Over 800,000 people have been vaccinated within Pakistan as part of these efforts, and over 35,000 in Afghanistan.
Afghanistan
:: In the provinces of Paktyka and Khost, efforts are under way to vaccinate children displaced from neighbouring North Waziristan in Pakistan. More than 35,000 displaced children under the age of 10 are reported to have received a dose of bivalent oral polio vaccine (bOPV). Health workers are also searching actively for cases of acute flaccid paralysis (AFP) among the displaced communities to ensure any polio transmission is rapidly detected.
Nigeria
:: One new case of wild poliovirus type 1 (WPV1) was reported in the past week, with onset of paralysis on 27 May in Kano state. This is the most recent case in the country, and brings Nigeria’s total case count for 2014 to five.
Pakistan
:: Two new wild poliovirus type 1 (WPV1) cases were reported in the past week, bringing the country’s total case count to 90. Both cases were from Khyber Agency of the Federally Administered Tribal Areas (FATA), and the most recent had onset of paralysis on 16 June.
:: In order to protect those displaced by the military action in North Waziristan, people of all ages are being vaccinated against polio at transit points within the country: over 357,000 to date. Immunization campaigns in parts of Khyber Pakhtunkhwa and FATA have vaccinated a further 500,000 children under the age of five.
Central Africa
:: Equatorial Guinea is vaccinating its entire population starting on 23 July Cameroon’s last Supplementary Immunization Activities took place starting 27 June. Activities synchronized between both countries are planned in September.
:: Outbreak response activities continue across the sub-region. Cameroon, the Central African Republic, the Democratic Republic of the Congo (DR Congo), Equatorial Guinea, Gabon and the Republic of Congo all have mass vaccination campaigns planned for July. DR Congo, Equatorial Guinea and Gabon are also planning to carry out campaigns in August.
:: Following detection in Brazil of WPV1 related to virus circulating in Equatorial Guinea, the latter is now on the list of “exporting countries”. Find out more about the temporary recommendations for these countries at: http://www.polioeradication.org/Infectedcountries/PolioEmergenc.aspx

Afghan Taliban bans polio vaccination teams from southern Helmand
Development marks attitude change of militants, who previously allowed medics into region but now suspect them of spying
Emma Graham-Harrison in Kabul
The Guardian, Tuesday 8 July 2014 08.00 EDT
Excerpt
The Taliban has banned polio vaccination teams from southern Helmand because it suspects them of spying for the government at a time of heavy clashes with government forces, the insurgent group said in a statement on its website.
The announcement is a worrying development, because although Taliban groups across the border in Pakistan have attacked and killed polio vaccinators for years, their Afghan counterparts have mostly supported, or at least tolerated, international efforts to wipe out the disease.
The last time polio vaccinators were blocked from part of Afghanistan, the insurgent group denied any role and said it supported efforts to stop the disease.
Afghanistan is one of just three countries, along with Pakistan and Nigeria, where polio is still endemic. There has been a rise in cases this year, with seven reported so far compared with just three for the same period of 2013, according to the Global Polio Eradication Initiative.
The group said Helmand has been off limits to vaccinators since February, but did not give a reason. The southern province has seen fierce fighting between insurgent and government forces in recent weeks, and the Taliban’s statement was the first indication it had chased out polio eradication teams.
“We have stopped vaccination in Helmand for the moment,” the Taliban said in a statement posted on its website this week. “The vaccinators were also collecting information about the Taliban and Taliban commanders, they were spying.”
The statement said they had asked UN officials for talks but received no response; the UN’s humanitarian arm declined to comment when asked about the ban…

The Weekly Epidemiological Record (WER) for
:: 11 July 2014, vol. 89, 28 (pp. 309–320)
– Human cases of influenza at the human– animal interface, 2013
:: 4 July 2014, vol. 89, 27 (pp. 297–308)
– Yellow fever in Africa and South America, 2013
– Monthly report on dracunculiasis cases, January– May 2014

WHO Europe: Four countries to benefit from Pandemic Influenza Preparedness (PIP) Framework 08-07-2014
8 July 2014
Excerpt
Armenia, Tajikistan, Turkmenistan and Uzbekistan will be the first countries in the WHO European Region to benefit from the PIP Framework, a unique partnership between industry, civil society and governments to improve pandemic preparedness and access to antiviral medicines and vaccines. Member States are responsible for sharing with WHO influenza viruses with pandemic potential through their national influenza centres, and industry’s responsibilities include making annual donations to the partnership contribution mechanism….

GAVI Watch [to 12 July 2014]
http://www.gavialliance.org/library/news/press-releases/

:: Dengue fever vaccine results published in Lancet
11 July 2014
Detailed results from the world’s first ever large-scale phase III clinical trial for a dengue
fever vaccine published in the journal the Lancet.

:: India to introduce four new vaccines
04 July 2014
Government of India’s decision to add new vaccines to Universal Immunization Programme
will save estimated 100,000 lives annually.

CDC/MMWR Watch [to 12 July 2014]
http://www.cdc.gov/mmwr/mmwr_wk.html

:: CDC Press Conference on laboratory quality and safety after recent lab incidents – Transcript
July 11, 2014

:: CDC Director to highlight steps being taken to improve laboratory quality and safety after recent lab incidents – Media Advisory
July 11, 2014

:: CDC Media Statement on Newly Discovered Smallpox Specimens – Media Statement
7/8/2014
MMWR – July 11, 2014 / Vol. 63 / No. 27
:: Interim CDC Guidance for Polio Vaccination for Travel to and from Countries Affected by Wild Poliovirus
Excerpt
…This report provides an update on CDC policy for polio vaccination of travelers for health protection. It also provides additional interim guidance for physicians whose U.S. resident patients will travel to or reside in affected countries for >4 weeks, to ensure those patients will have evidence of administration of polio vaccine (IPV or OPV) within 12 months of travel that might be required when they depart from countries with active poliovirus transmission. This interim guidance is to ensure compliance with WHO International Health Regulations temporary recommendations for countries designated as “polio-infected” to reduce the risk for exportation of WPV from those countries…

WHO:
:: World Health Statistics 2014
World Health Statistics 2014 contains WHO’s annual compilation of health-related data for its 194 Member States, and includes a summary of the progress made towards achieving the health-related Millennium Development Goals (MDGs) and associated targets.
This year, it also includes highlight summaries on the ongoing commitment to end preventable maternal deaths; on the need to act now to combat rising levels of childhood obesity; on recent trends.

:: Progress on the health-related Millennium Development Goals (MDGs)
Fact sheet N°290

:: Consolidated guidelines on HIV prevention, diagnosis, treatment and care for key populations
People most at risk of HIV are not getting the health services they need
The guidelines outline steps for countries to reduce new HIV infections and increase access to HIV testing, treatment and care for these five ‘key populations’*. They include a comprehensive range of clinical recommendations but, for these to be effective, WHO also recommends countries need to remove the legal and social barriers that prevent many people from accessing services.
For the first time, WHO strongly recommends men who have sex with men consider taking antiretroviral medicines as an additional method of preventing HIV infection (pre-exposure prophylaxis)** alongside the use of condoms. Rates of HIV infection among men who have sex with men remain high almost everywhere and new prevention options are urgently needed….

:: Member States commit to reduce preventable deaths from heart disease and stroke, cancer, diabetes and lung disease
11 July 2014

:: WHO targets elimination of TB in over 30 countries
3 July 2014

American Journal of Public Health
Volume 104, Issue 8 (August 2014)
http://ajph.aphapublications.org/toc/ajph/current

Sources of Racial/Ethnic Differences in Awareness of HIV Vaccine Trials
Michael P. Arnold, Michele Andrasik, Stewart Landers, Shelly Karuna, Matthew J. Mimiaga, Steven Wakefield, Kenneth Mayer, Susan Buchbinder, Beryl A. Koblin
American Journal of Public Health: August 2014, Vol. 104, No. 8: e112–e118.
Abstract
Objectives. We explored the relative effects of 2 awareness components—exposure and attention—on racial/ethnic differences in HIV vaccine trial awareness among men who have sex with men (MSM).
Methods. Surveys assessing awareness of and attitudes toward HIV vaccine trials were administered to 1723 MSM in 6 US cities. Proxy measures of exposure included use of HIV resources and other health care services, community involvement, income, and residence. Attention proxy measures included research attitudes, HIV susceptibility, and HIV message fatigue. Using logistic regression models, we assessed the extent to which these proxies accounted for racial/ethnic differences in vaccine trial awareness.
Results. White MSM reported significantly (P  < .01) higher rates of HIV vaccine trial awareness (22%) compared with Latino (17%), Black (13%) and “other” (13%) MSM. Venue-based exposure proxies and research-directed attitudinal attention proxies were significantly associated with awareness, but only accounted for the White-Latino disparity in awareness. No proxies accounted for the White-Black or White-“other” differentials in awareness.
Conclusions. Sources of disparities in awareness of HIV vaccine trials remain to be explained. Future trials seeking to promote diverse participation should explore additional exposure and attention mediators.

Adolescent Immunization Coverage and Implementation of New School Requirements in Michigan, 2010
Rachel C. Potter, Stefanie F. DeVita, Patricia A. Vranesich, Matthew L. Boulton
American Journal of Public Health: August 2014, Vol. 104, No. 8: 1526–1533.
Abstract
Objectives. We examined the effect of Michigan’s new school rules and vaccine coadministration on time to completion of all the school-required vaccine series, the individual adolescent vaccines newly required for sixth grade in 2010, and initiation of the human papillomavirus (HPV) vaccine series, which was recommended but not required for girls.
Methods. Data were derived from the Michigan Care Improvement Registry, a statewide Immunization Information System. We assessed the immunization status of Michigan children enrolled in sixth grade in 2009 or 2010. We used univariable and multivariable Cox regression models to identify significant associations between each factor and school completeness.
Results. Enrollment in sixth grade in 2010 and coadministration of adolescent vaccines at the first adolescent visit were significantly associated with completion of the vaccines required for Michigan’s sixth graders. Children enrolled in sixth grade in 2010 had higher coverage with the newly required adolescent vaccines by age 13 years than did sixth graders in 2009, but there was little difference in the rate of HPV vaccine initiation among girls.
Conclusions. Education and outreach efforts, particularly regarding the importance and benefits of coadministration of all recommended vaccines in adolescents, should be directed toward health care providers, parents, and adolescents.

BMC Infectious Diseases
(Accessed 12 July 2014)
http://www.biomedcentral.com/bmcinfectdis/content

Research article
Spatiotemporal characteristics of pandemic influenza
Lars Skog, Annika Linde, Helena Palmgren, Hans Hauska and Fredrik Elgh
Author Affiliations
BMC Infectious Diseases 2014, 14:378 doi:10.1186/1471-2334-14-378
Published: 9 July 2014
Abstract (provisional)
Background
Prediction of timing for the onset and peak of an influenza pandemic is of vital importance for preventive measures. In order to identify common spatiotemporal patterns and climate influences for pandemics in Sweden we have studied the propagation in space and time of A(H1N1)pdm09 (10,000 laboratory verified cases), the Asian Influenza 1957-1958 (275,000 cases of influenza-like illness (ILI), reported by local physicians) and the Russian Influenza 1889-1890 (32,600 ILI cases reported by physicians shortly after the end of the outbreak).
Methods
All cases were geocoded and analysed in space and time. Animated video sequences, showing weekly incidence per municipality and its geographically weighted mean (GWM), were created to depict and compare the spread of the pandemics. Daily data from 1957-1958 on temperature and precipitation from 39 weather stations were collected and analysed with the case data to examine possible climatological effects on the influenza dissemination.
Results
The epidemic period lasted 11 weeks for the Russian Influenza, 10 weeks for the Asian Influenza and 9 weeks for the A(H1N1)pdm09. The Russian Influenza arrived in Sweden during the winter and was immediately disseminated, while both the Asian Influenza and the A(H1N1)pdm09 arrived during the spring. They were seeded over the country during the summer, but did not peak until October-November. The weekly GWM of the incidence moved along a line from southwest to northeast for the Russian and Asian Influenza but northeast to southwest for the A(H1N1)pdm09. The local epidemic periods of the Asian Influenza were preceded by falling temperature in all but one of the locations analysed.
Conclusions
The power of spatiotemporal analysis and modeling for pandemic spread was clearly demonstrated. The epidemic period lasted approximately 10 weeks for all pandemics. None of the pandemics had its epidemic period before late autumn. The epidemic period of the Asian Influenza was preceded by falling temperatures. Climate influences on pandemic spread seem important and should be further investigated.

BMC Public Health
(Accessed 12 July 2014)
http://www.biomedcentral.com/bmcpublichealth/content

Research article
Performance of 21 HPV vaccination programs implemented in low and middle-income countries, 2009–2013
Joël Ladner1*, Marie-Hélène Besson2, Mariana Rodrigues2, Etienne Audureau3 and Joseph Saba2
Author Affiliations
1 Rouen University Hospital, Epidemiology and Public Health Department, Hôpital Charles Nicolle, 1, rue de Germont, 76 031 Rouen, France
2 Axios International, Paris, France
3 Hôpital Henri Mondor Hospital, Public Health, Assistance Publique Hôpitaux de Paris, Paris Est University, Créteil, France
Abstract
Background
Cervical cancer is the third most common cancer in women worldwide, with high incidence in lowest income countries. Vaccination against Human Papilloma Virus (HPV) may help to reduce the incidence of cervical cancer. The aim of the study was to analyze HPV vaccination programs performance implemented in low and middle-income countries.
Methods
The Gardasil Access Program provides HPV vaccine at no cost to help national institutions gain experience implementing HPV vaccination. Data on vaccine delivery model, number of girls vaccinated, number of girls completing the three-dose campaign, duration of vaccination program, community involvement and sensitization strategies were collected from each program upon completion. Vaccine Uptake Rate (VUR) and Vaccine Adherence between the first and third doses (VA) rate were calculated. Multivariate linear regressions analyses were fitted.
Results
Twenty-one programs were included in 14 low and middle-income countries. Managing institutions were non-governmental organizations (NGOs) (n = 8) or Ministries of Health (n = 13). Twelve programs were school-based, five were health clinic-based and four utilized a mixed model. A total of 217,786 girls received a full course of vaccination.
Mean VUR was 88.7% (SD = 10.5) and VA was 90.8% (SD = 7.3). The mean total number of girls vaccinated per program-month was 2,426.8 (SD = 2,826.6) in school model, 335.1 (SD = 202.5) in the health clinic and 544.7 (SD = 369.2) in the mixed models (p = 0.15). Community involvement in the follow-up of girls participating in the vaccination campaign was significantly associated with VUR. Multivariate analyses identified school-based (β = 13.35, p = 0.001) and health clinic (β = 13.51, p = 0.03) models, NGO management (β = 14.58, p < 10-3) and duration of program vaccination (β = -1.37, p = 0.03) as significant factors associated with VUR.
Conclusion
School and health clinic-based models appeared as predictive factors for vaccination coverage, as was management by an NGO; program duration could play a role in the program’s effectiveness. Results suggest that HPV vaccine campaigns tailored to meet the needs of communities can be effective. These results may be useful in the development of national HPV vaccination policies in low and middle-income countries.

British Medical Journal
28 June 2014(vol 348, issue 7964)
http://www.bmj.com/content/348/7964

Editorials
Making the World Health Assembly fit for the 21st century
Needs better quality of debate and use of technology
BMJ 2014; 348 doi: http://dx.doi.org/10.1136/bmj.g4079 (Published 18 June 2014) Cite this as: BMJ 2014;348:g4079
Ilona Kickbusch, professor1, Mathias Bonk, global health consultant2

Analysis
Global rules for global health: why we need an independent, impartial WHO
BMJ 2014; 348 doi: http://dx.doi.org/10.1136/bmj.g3841 (Published 18 June 2014) Cite this as: BMJ 2014;348:g3841
Devi Sridhar, senior lecturer12, J Frenk, dean3, L Gostin, professor4, S Moon, lecturer3
Devi Sridhar and colleagues argue that WHO’s unique political legitimacy makes it essential to achieving international action on global health and call for governments to re-establish guaranteed core funding.

Bulletin of the World Health Organization
Volume 92, Number 7, July 2014, 465-544
http://www.who.int/bulletin/volumes/92/7/en/

Success factors for reducing maternal and child mortality
Shyama Kuruvilla, Julian Schweitzer, David Bishai, Sadia Chowdhury, Daniele Caramani, Laura Frost, Rafael Cortez, Bernadette Daelmans, Andres de Francisco, Taghreed Adam, Robert Cohen, Y Natalia Alfonso, Jennifer Franz-Vasdeki, Seemeen Saadat, Beth Anne Pratt, Beatrice Eugster, Sarah Bandali, Pritha Venkatachalam, Rachael Hinton, John Murray, Sharon Arscott-Mills, Henrik Axelson, Blerta Maliqi, Intissar Sarker, Rama Lakshminarayanan, Troy Jacobs, Susan Jacks, Elizabeth Mason, Abdul Ghaffar, Nicholas Mays, Carole Presern, Flavia Bustreo & on behalf of the Success Factors for Women’s and Children’s Health study groups
Abstract
Reducing maternal and child mortality is a priority in the Millennium Development Goals (MDGs), and will likely remain so after 2015. Evidence exists on the investments, interventions and enabling policies required. Less is understood about why some countries achieve faster progress than other comparable countries. The Success Factors for Women’s and Children’s Health studies sought to address this knowledge gap using statistical and econometric analyses of data from 144 low- and middle-income countries (LMICs) over 20 years; Boolean, qualitative comparative analysis; a literature review; and country-specific reviews in 10 fast-track countries for MDGs 4 and 5a. There is no standard formula – fast-track countries deploy tailored strategies and adapt quickly to change. However, fast-track countries share some effective approaches in addressing three main areas to reduce maternal and child mortality. First, these countries engage multiple sectors to address crucial health determinants. Around half the reduction in child mortality in LMICs since 1990 is the result of health sector investments, the other half is attributed to investments made in sectors outside health. Second, these countries use strategies to mobilize partners across society, using timely, robust evidence for decision-making and accountability and a triple planning approach to consider immediate needs, long-term vision and adaptation to change. Third, the countries establish guiding principles that orient progress, align stakeholder action and achieve results over time. This evidence synthesis contributes to global learning on accelerating improvements in women’s and children’s health towards 2015 and beyond.

Bulletin of the World Health Organization
Volume 92, Number 7, July 2014, 465-544
http://www.who.int/bulletin/volumes/92/7/en/

Editorial
Making history: from a public health emergency to a polio-free world
R Bruce Aylward a
a. Polio Eradication Initiative, World Health Organization, avenue Appia 20, 1211 Geneva 27,
http://dx.doi.org/10.2471/BLT.14.142273

On 5 May 2014, the Director-General of the World Health Organization (WHO) declared the second-ever public health emergency of international concern. Polio is the emergency – a disease again posing a public health risk to countries around the world and requiring a coordinated international response.1

For some, this declaration seemed a paradox. Polio is nearly eradicated. The virus that once paralysed over 1000 children a day in more than 125 countries paralysed just over one child a day in eight countries in 2013. Two of the three countries that have never stopped polio – Afghanistan and Nigeria – overcame tremendous difficulties to achieve a greater than 50% reduction in cases in 2013 and have kept their case counts in the single digits so far in 2014.2 On 27 March 2014, India and the entire WHO South East Asia Region were certified polio-free , bringing to 80% the proportion of the world’s population that now lives in regions entirely free of indigenous wild polioviruses. It is also increasingly likely that two of the three strains of wild poliovirus have been wiped out. Type 2 virus was last detected in India in 1999 and the type 3 virus has not been detected anywhere in the world since a child in Nigeria was paralysed by the virus in November 2012. Overall, the world remains largely on track to achieve all four of the ambitious objectives set out in the Polio eradication and endgame strategic plan3 – the Global Polio Eradication Initiative’s strategy to end all polio, everywhere, by 2018.

However, this progress could still be undone. Although closer than ever to eradication in 2012, polio made a disturbing comeback in 2013. Both the number of children paralysed by the virus and the number of polio-infected countries nearly doubled.2 Much of the increase in cases was the result of the international spread of the virus into areas that had long been polio-free. In the first four months of 2014, during what is traditionally the low season for polio transmission, wild poliovirus had already spread internationally in three major epidemiologic zones, thousands of kilometres apart. In Central Asia, the virus spread from Pakistan to Afghanistan; in the Middle East, from the Syrian Arab Republic to Iraq;5 and in Central Africa, from Cameroon to Equatorial Guinea.

The Emergency Committee convened by WHO under the International Health Regulations concluded that, if left unchecked, this situation could result “in failure to eradicate globally one of the world’s most serious vaccine preventable diseases”.1 Further international spread with the onset of the high transmission season in June could potentially be disastrous, as the countries that had been exporting poliovirus have strong economic, political, geographic and/or cultural ties to a high number of fragile states and conflict-torn countries. Not only were such areas at highest risk of new importations, but their low routine immunization rates increased the likelihood of explosive polio outbreaks and even the re-establishment of transmission. This situation is compounded by the inability of some of these countries to mount an effective response against disease outbreaks.

Decisive and immediate action was needed to ensure that the global movement working to end polio once and for all did not suffer a setback from which it could be difficult, if not impossible, to recover. Failure would mean reverting to a strategy of only polio “control”, under which the world would soon have to accept more than 200 000 children again being paralysed every year.4 Ensuring that all residents and long-term visitors travelling from polio-infected countries (and especially from those countries that are actively exporting the virus) are vaccinated sufficiently in advance of departure boosts their own protection and helps protect children in other countries. The Temporary Recommendations on the vaccination of such travellers are designed to curb the spread of poliovirus from one country to another while intensified eradication activities continue globally.

At the 67th World Health Assembly in May 2014, delegates spoke of the need to ensure that the global community should do whatever is needed to deliver on the commitment made at the World Health Assembly 26 years ago to put a stop to polio forever. Today, as the world inches ever closer to a polio-free future, we are also learning the true costs and challenges of reaching all children with the most basic of health interventions. Overcoming those challenges, and addressing those costs, requires that we all step up our game. The global community is now using everything at its disposal in the fight to end polio. Full implementation of these new Temporary Recommendations can put a halt to the international spread of polio and, for only the second time in history, ensure that a devastating disease is eradicated.

References
WHO statement on the meeting of the International Health Regulations Emergency Committee concerning the international spread of wild poliovirus. Geneva: World Health Organization; 2014. Available from: http://www.who.int/mediacentre/news/statements/2014/polio-20140505/en/ [cited 2014 May 26].
The Global Polio Eradication Initiative. Polio this week [Internet]. Geneva: World Health Organization; 2014. Available from: http://www.polioeradication.org/dataandmonitoring/poliothisweek.aspx [cited 2014 May 26].
Polio eradication and endgame strategic plan 2013–2018. Geneva: World Health Organization; 2010. Available from: http://www.polioeradication.org/Resourcelibrary/Strategyandwork/Strategicplan.aspx [cited 2014 May 26].
Thompson KM, Tebbens RJ. Eradication versus control for poliomyelitis: an economic analysis. Lancet. 2007 Apr 21;369(9570):1363-71. http://dx.doi.org/10.1016/S0140-6736(07)60532-7 pmid: 17448822
The Global Polio Eradication Initiative. Middle East polio technical bulletin. Geneva: World Health Organization; 2014. http://www.polioeradication.org/Portals/0/Document/Aboutus/Governance/IMB/10IMBMeeting/10.1_10IMB.pdf [cited 2014 May 26].

Clinical Infectious Diseases (CID)
Volume 59 Issue 2 July 15, 2014
http://cid.oxfordjournals.org/content/current

Editor’s choice: Middle East Respiratory Syndrome Coronavirus: A Case-Control Study of Hospitalized Patients
Jaffar A. Al-Tawfiq, Kareem Hinedi, Jihad Ghandour, Hanan Khairalla, Samir Musleh, Alaa Ujayli,
and Ziad A. Memish
Clin Infect Dis. (2014) 59 (2): 160-165 doi:10.1093/cid/ciu226
Abstract
This case-control study of hospitalized patients compared underlying conditions, symptoms, signs, laboratory data, and radiographic presentations between Middle East respiratory syndrome coronavirus (MERS-CoV)–positive and –negative patients. Those with MERS-CoV were more likely to be overweight and to have diabetes mellitus, end-stage renal disease, tachypnea, and a normal white blood cell count on bivariate analysis.

Current Opinion in Infectious Diseases
August 2014 – Volume 27 – Issue 4 pp: v-vi,303-401
http://journals.lww.com/co-infectiousdiseases/pages/currenttoc.aspx

Immunizations following solid-organ transplantation
Kumar, Deepali
Abstract
Purpose of review
To highlight the latest evidence for the use of key vaccines that are recommended in organ transplant candidates and recipients.
Recent findings
Influenza vaccine is the best studied vaccine; factors affecting immunogenicity of this vaccine include time from transplant, use of mycophenolate mofetil and type of transplant. Newer formulations of influenza vaccine are available, but data for these are limited. Updated recommendations include giving conjugated pneumococcal vaccine to adult transplant candidates and recipients followed by the polysaccharide vaccine to increase serotype coverage. Human papillomavirus vaccine should also be given to transplant recipients, although the immunogenicity may be suboptimal. Quadrivalent meningococcal conjugate vaccine needs to be given in special circumstances such as to patients who are starting eculizumab therapy. Live vaccines in general are contraindicated, although increasing safety data are emerging for Varicella vaccine. Herpes Zoster vaccine may be offered prior to transplant, although the utility of this strategy regarding protection from shingles after transplant is not known. Newer vaccines such as inactivated zoster vaccine and vaccines for the prevention of cytomegalovirus are under study.
Summary
Immunization for organ transplant recipients is an important part of pretransplant evaluation and the long-term care of the transplant recipient.

Global Health Governance
[Accessed 12 July 2014]
http://blogs.shu.edu/ghg/category/complete-issues/summer-2013/

Analyzing Leadership in Global Health Governance
– June 16, 2014
Sophie Harman and Simon Rushton
Rhetoric around the need for more and better leadership is ubiquitous in contemporary global health governance, yet there has been little articulation of what type of leadership is required, who might play leadership roles, and in what fora leadership might be exercised. Global health governance has widely been seen as a policy space characterised by a multiplicity of (often competing) actors with no overall authority. Nonetheless, major accomplishments exist, and in some cases there are impressive levels of collective action to address particular health problems. We argue that leadership provides an important lens for understanding how goals are met in global health governance. Drawing on the existing literature on global health governance and leadership and agency in international relations, we set out in this paper a framework for analysing leadership in global health governance. Crucially, we argue, such a framework must be specific enough to be operationalised in terms of a program of research and at the same time broad enough to capture a wide variety of different sources, sites and forms of leadership – including the roles played by ‘hidden leaders’ who are seldom acknowledged in mainstream analyses of global health politics.

Institutional Readiness in Practice of Pandemic Response to an Emerging Infectious Disease
– June 16, 2014
Asif B. Farooq and Shannon E. Majowicz
This paper argues that emerging and re-emerging infectious diseases (EIDs) remain a threat-focused security issue as the relative success of recent international responses do not fully reflect our current readiness for EID outbreaks. Existing pandemic response plans have been tested only for either virulent or highly transmissible diseases. Therefore, global health institutions have not yet been tested for the worst-case scenario: a disease with high virulence and transmissibility. We categorize EIDs into four quartiles according to their virulence and transmissibility, identify five relevant factors, and use recent EID outbreaks to develop inferences for response capacity to a possible outbreak of highly virulent and transmissible EIDs. We conclude there may be significant shortcomings in the existing pandemic response capacity to EIDs, which could lead to a public health crisis.

Global Public Health
Volume 9, Issue 6, 2014
http://www.tandfonline.com/toc/rgph20/.Uq0DgeKy-F9#.U4onnCjDU1w

Sexual and reproductive health and rights in the post-2015 development agenda
Gita Sena*
DOI: 10.1080/17441692.2014.917197
pages 599-606
Abstract
Women’s health is currently shaped by the confluence of two important policy trends – the evolution of health system reform policies and from the early 1990s onwards, a strong articulation of a human rights-based approach to health that has emphasised laws and policies to advance gender equality and sexual and reproductive health and rights (SRHR). The drive for sexual and reproductive rights represents an inclusive trend towards human rights to health that goes beyond the right to health services, directing attention to girls’ and women’s rights to bodily autonomy, integrity and choice in relation to sexuality and reproduction. Such an expanded concept of the right to health is essential if laws, policies and programmes are to respect, protect and fulfil the health of girls and women. However, this expanded understanding has been ghettoised from the more mainstream debates on the right to health and was only partially included in the Millennium Development Goals. The paper argues in favour of a twofold approach in placing SRHR effectively in the context of the post-2015 development agenda: first, firmly ground it in an inclusive approach to the right to health; and second, drawing on two decades of national-level implementation, propose a forward-looking agenda focusing on quality, equality and accountability in policies and in programmes. This can build on good practice while addressing critical challenges central to the development framework itself.

Human Vaccines & Immunotherapeutics (formerly Human Vaccines)
September 2014 Volume 10, Issue 9
http://www.landesbioscience.com/journals/vaccines/toc/volume/10/issue/6/
Special focus: Vaccine acceptance

Commentary
Health care professionals and adolescent vaccination: A call for intervention research
Gregory D Zimet
http://dx.doi.org/10.4161/hv.28525
Abstract
In their recently published research study, Gargano et al. found that a physician’s recommendation and parental health beliefs had significant effects on adolescent vaccination rates and on parental intentions to vaccinate. This research replicates the findings of a number of human papillomavirus (HPV) vaccine-focused research studies, but explores new territory by focusing on all recommended adolescent vaccines: meningococcal-conjugate (MCV4), HPV, influenza, and tetanus, diphtheria, and acellular pertussis (Tdap) vaccines. Although Gargano et al.’s study is relatively small in scale and focuses on only one county in Georgia, their results are consistent with many other research reports, suggesting that their findings are robust and replicable. Most published intervention studies have targeted parents and young adults, with little focus on health care professionals. However, given the centrality of physician recommendation in adolescent vaccination, as shown by Gargano et al., it is clear that the time has come to develop and evaluate interventions that help physicians and other health care professionals to more effectively implement strong and routine recommendations for all adolescent platform vaccines.

Commentary
Influenza vaccination of healthcare personnel
Sabine Wicker and Georg Marckmann
http://dx.doi.org/10.4161/hv.28154
Abstract
The thought is terrifying—you are admitted to the hospital and you die of a nosocomial infection. What sounds like a horror scenario, happens every day in hospitals all over the world. Nosocomial influenza is associated with considerable morbidity and mortality among patients with underlying diseases (especially immunocompromised patients), the elderly, and neonates. Although vaccination of healthcare personnel (HCP) is the main measure for preventing nosocomial influenza and is consistently recommended by public-health authorities, vaccine uptake among HCP remains low.1

Review
What are the factors that contribute to parental vaccine-hesitancy and what can we do about it?
Sarah E Williams
http://dx.doi.org/10.4161/hv.28596
Abstract
Parental refusal or delay of childhood vaccines is increasing. Barriers to vaccination among this population have been described, yet less is known regarding motivating factors. Researchers are beginning to evaluate various approaches to address the concerns of “vaccine-hesitant” parents, but few studies have evaluated the effect of interventions on timely vaccine uptake. Several models for communicating with vaccine-hesitant parents have been reported for healthcare providers; however, the effectiveness and utility of these strategies has not been quantified. This article reviews the known barriers to vaccination reported by vaccine-hesitant parents and the current evidence on strategies to address parental vaccine hesitancy.

Commentary
Impact of a physician recommendation
Paul M Darden and Robert M Jacobson http://dx.doi.org/10.4161/hv.29020

Research Paper
Attitude toward immunization and risk perception of measles, rubella, mumps, varicella, and pertussis in health care workers working in 6 hospitals of Florence, Italy 2011
Cristina Taddei, Vega Ceccherini, Giuditta Niccolai, Barbara Rita Porchia, Sara Boccalini, Miriam Levi, Emilia Tiscione, Maria Grazia Santini, Simonetta Baretti, Paolo Bonanni and Angela Bechini
http://dx.doi.org/10.4161/hv.29398

Research Paper
Knowledge, attitude, and uptake related to human papillomavirus vaccination among young women in Germany recruited via a social media site
Dietmar Walter, Patrick Schmich, Matthias Wetzstein, Deleré Yvonne, Ole Wichmann and Cornelius Remschmidt
http://dx.doi.org/10.4161/hv.29541

JAMA
July 9, 2014, Vol 312, No. 2
http://jama.jamanetwork.com/issue.aspx

Research Letter | July 9, 2014
Quadrivalent Human Papillomavirus Vaccine and the Risk of Venous Thromboembolism
Nikolai Madrid Scheller, MB1; Björn Pasternak, MD, PhD1; Henrik Svanström, MSc1; Anders Hviid, DrMedSci1
Author Affiliations
JAMA. 2014;312(2):187-188. doi:10.1001/jama.2014.2198.
A potential association between quadrivalent human papillomavirus (HPV) vaccination and venous thromboembolism (VTE) has been reported in 2 postlicensure safety studies.1,2 An analysis of the Vaccine Adverse Event Reporting System database found disproportionately high reporting of VTE following vaccination,1 and a study using the Vaccine Safety Datalink reported a doubling of VTE risk.2

Journal of Virology
August 2014, volume 88, issue 15
http://jvi.asm.org/content/current

Analysis of HLA A*02 Association with Vaccine Efficacy in the RV144 HIV-1 Vaccine Trial
Andrew J. Gartlanda, Sue Lia, John McNevina, Georgia D. Tomarasc, Raphael Gottardoa, Holly Janesa, Youyi Fonga, Daryl Morrisa, Daniel E. Geraghtyd, Gustavo H. Kijake, Paul T. Edlefsena, Nicole Frahma, Brendan B. Larsenf, Sodsai Tovanabutrae, Eric Sanders-Buellg, Allan C. deCampa, Craig A. Magareta, Hasan Ahmeda, Jodie P. Goodridgeh, Lennie Chenf, Philip Konopaf, Snehal Nariyaf, Julia N. Stoddardf, Kim Wongf, Hong Zhaof, Wenjie Dengf, Brandon S. Maustf, Meera Bosee, Shana Howelle, Adam Batese, Michelle Lazzaroe, Annemarie O’Sullivane,
Esther Leie, Andrea Bradfielde, Grace Ibitamunoe, Vatcharain Assawadarachaii, Robert J. O’Connelle, Mark S. deSouzai, Sorachai Nitayaphani, Supachai Rerks-Ngarmj, Merlin L. Robbe, John Sidneyk, Alessandro Settek, Susan Zolla-Paznerl, David Montefioric, M. Juliana McElratha, James I. Mullinsf, Jerome H. Kime, Peter B. Gilberta and Tomer Hertza,b
aVaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
bShraga Segal Department of Microbiology, Immunology and Genetics, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
cDuke Human Vaccine Institute, Duke University School of Medicine, Durham, North Carolina, USA
dClinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, Washington, USA
eU.S. Military HIV Research Program, Silver Spring, Maryland, USA
fDepartment of Microbiology, University of Washington, Seattle, Washington, USA
gHenry M. Jackson Foundation, Seattle, Washington, USA
hDepartment of Immunology, Oslo University Hospital, Oslo, Norway
iRoyal Thai Army Component, AFRIMS, Bangkok, Thailand
jThai Ministry of Public Health, Nonthaburi, Thailand
kLa Jolla Institute for Allergy and Immunology, La Jolla, California, USA
lDepartment of Pathology, New York University, New York, New York, USA
ABSTRACT
The RV144 HIV-1 vaccine trial demonstrated partial efficacy of 31% against HIV-1 infection. Studies into possible correlates of protection found that antibodies specific to the V1 and V2 (V1/V2) region of envelope correlated inversely with infection risk and that viruses isolated from trial participants contained genetic signatures of vaccine-induced pressure in the V1/V2 region. We explored the hypothesis that the genetic signatures in V1 and V2 could be partly attributed to selection by vaccine-primed T cells. We performed a T-cell-based sieve analysis of breakthrough viruses in the RV144 trial and found evidence of predicted HLA binding escape that was greater in vaccine versus placebo recipients. The predicted escape depended on class I HLA A*02- and A*11-restricted epitopes in the MN strain rgp120 vaccine immunogen. Though we hypothesized that this was indicative of postacquisition selection pressure, we also found that vaccine efficacy (VE) was greater in A*02-positive (A*02+) participants than in A*02− participants (VE = 54% versus 3%, P = 0.05). Vaccine efficacy against viruses with a lysine residue at site 169, important to antibody binding and implicated in vaccine-induced immune pressure, was also greater in A*02+ participants (VE = 74% versus 15%, P = 0.02). Additionally, a reanalysis of vaccine-induced immune responses that focused on those that were shown to correlate with infection risk suggested that the humoral responses may have differed in A*02+ participants. These exploratory and hypothesis-generating analyses indicate there may be an association between a class I HLA allele and vaccine efficacy, highlighting the importance of considering HLA alleles and host immune genetics in HIV vaccine trials.
IMPORTANCE
The RV144 trial was the first to show efficacy against HIV-1 infection. Subsequently, much effort has been directed toward understanding the mechanisms of protection. Here, we conducted a T-cell-based sieve analysis, which compared the genetic sequences of viruses isolated from infected vaccine and placebo recipients. Though we hypothesized that the observed sieve effect indicated postacquisition T-cell selection, we also found that vaccine efficacy was greater for participants who expressed HLA A*02, an allele implicated in the sieve analysis. Though HLA alleles have been associated with disease progression and viral load in HIV-1 infection, these data are the first to suggest the association of a class I HLA allele and vaccine efficacy. While these statistical analyses do not provide mechanistic evidence of protection in RV144, they generate testable hypotheses for the HIV vaccine community and they highlight the importance of assessing the impact of host immune genetics in vaccine-induced immunity and protection. (This study has been registered at ClinicalTrials.gov under registration no. NCT00223080.)

The Lancet
Jul 12, 2014 Volume 384 Number 9938 p103 – 206 e22 – 29
http://www.thelancet.com/journals/lancet/issue/current

NCD Countdown 2025: accountability for the 25 × 25 NCD mortality reduction target
Robert Beaglehole, Ruth Bonita, Majid Ezzati, George Alleyne, Katie Dain, Sandeep P Kishore, Richard Horton
Preview
In 2012, all countries committed to achieving a 25% reduction in premature mortality from non-communicable diseases (NCDs) by 2025 (the 25 × 25 target). In 2013, countries also agreed to a set of voluntary targets for risk factors and health systems.1 Unlike the Millennium Development Goals (MDGs), which were directed at low-income and middle-income countries, NCD targets are for all countries. Achieving targets for just six NCD risk factors (tobacco and alcohol use, salt intake, obesity, and raised blood pressure and glucose) will come close to achieving the global 25 × 25 target, especially if a more ambitious tobacco reduction target is adopted.

Use of contingency management incentives to improve completion of hepatitis B vaccination in people undergoing treatment for heroin dependence: a cluster randomised trial
Tim Weaver PhD a, Nicola Metrebian PhD b Jennifer Hellier MSc c, Prof Stephen Pilling PhD d, Vikki Charles MA b, Nicholas Little MSc d, Dilkushi Poovendran MSc a, Luke Mitcheson DClinPsy e, Frank Ryan D Psychol f, Owen Bowden-Jones FRCPsych g, John Dunn DM f, Anthony Glasper MRCPsych h, Emily Finch MD e, Prof John Strang MD b e
Summary
Background
Poor adherence to treatment diminishes its individual and public health benefit. Financial incentives, provided on the condition of treatment attendance, could address this problem. Injecting drug users are a high-risk group for hepatitis B virus (HBV) infection and transmission, but adherence to vaccination programmes is poor. We aimed to assess whether contingency management delivered in routine clinical practice increased the completion of HBV vaccination in individuals receiving opioid substitution therapy.
Methods
In our cluster randomised controlled trial, we enrolled participants at 12 National Health Service drug treatment services in the UK that provided opioid substitution therapy and nurse-led HBV vaccination with a super-accelerated schedule (vaccination days 0, 7, and 21). Clusters were randomly allocated 1:1:1 to provide vaccination without incentive (treatment as usual), with fixed value contingency management (three £10 vouchers), or escalating value contingency management (£5, £10, and £15 vouchers). Both contingency management schedules rewarded on-time attendance at appointments. The primary outcome was completion of clinically appropriate HBV vaccination within 28 days. We also did sensitivity analyses that examined vaccination completion with full adherence to appointment times and within a 3 month window. The trial is registered with Current Controlled Trials, number ISRCTN72794493.
Findings
Between March 16, 2011, and April 26, 2012, we enrolled 210 eligible participants. Compared with six (9%) of 67 participants treated as usual, 35 (45%) of 78 participants in the fixed value contingency management group met the primary outcome measure (odds ratio 12•1, 95% CI 3•7—39•9; p<0•0001), as did 32 (49%) of 65 participants in the escalating value contingency management group (14•0, 4•2—46•2; p<0•0001). These differences remained significant with sensitivity analyses.
Interpretation
Modest financial incentives delivered in routine clinical practice significantly improve adherence to, and completion of, HBV vaccination programmes in patients receiving opioid substitution therapy. Achievement of this improvement in routine clinical practice should now prompt actual implementation. Drug treatment providers should employ contingency management to promote adherence to vaccination programmes. The effectiveness of routine use of contingency management to achieve long-term behaviour change remains unknown.
Funding
National Institute for Health Research (RP-PG-0707-10149).

The Lancet
Jul 5, 2014 Volume 384 Number 9937 p1-102
Series
The Health of Americans
Challenges of infectious diseases in the USA
Dr Rima F Khabbaz MD a, Robin R Moseley MAT a, Riley J Steiner MPH b, Alexandra M Levitt PhD a, Beth P Bell MD c
Summary
In the USA, infectious diseases continue to exact a substantial toll on health and health-care resources. Endemic diseases such as chronic hepatitis, HIV, and other sexually transmitted infections affect millions of individuals and widen health disparities. Additional concerns include health-care-associated and foodborne infections—both of which have been targets of broad prevention efforts, with success in some areas, yet major challenges remain. Although substantial progress in reduction of the burden of vaccine-preventable diseases has been made, continued cases and outbreaks of these diseases persist, driven by various contributing factors. Worldwide, emerging and reemerging infections continue to challenge prevention and control strategies while the growing problem of antimicrobial resistance needs urgent action. An important priority for control of infectious disease is to ensure that scientific and technological advances in molecular diagnostics and bioinformatics are well integrated into public health. Broad and diverse partnerships across governments, health care, academia, and industry, and with the public, are essential to effectively reduce the burden of infectious diseases.

Viewpoint
Health security in 2014: building on preparedness knowledge for emerging health threats
Ali S Khan, Nicole Lurie
Preview
Ideas, information, and microbes are shared worldwide more easily than ever before. New infections, such as the novel influenza A H7N9 or Middle East respiratory syndrome coronavirus, pay little heed to political boundaries as they spread; nature pays little heed to destruction wrought by increasingly frequent natural disasters. Hospital-acquired infections are hard to prevent and contain, because the bacteria are developing resistance to the therapeutic advances of the 20th century. Indeed, threats come in ever-complicated combinations: a combined earthquake, tsunami, and radiation disaster; blackouts in skyscrapers that require new thinking about evacuations and medically fragile populations; or bombings that require as much psychological profiling as chemical profiling.

Global health and the US Centers for Disease Control and Prevention
Anne Schuchat, Jordan Tappero, John Blandford
Preview
Why is an article about global health included in a special issue on health in the USA? About half the produce that Americans consume is cultivated in other countries, 60 million Americans travel or work outside the USA, and most patients with measles and tuberculosis in the USA acquired their infection elsewhere. Emerging diseases, globalisation of foods and medicines, the rise in antimicrobial resistance, and the ease with which pathogens can be manipulated for good or harm increase each nation’s vulnerability and interdependence.

Nature Reviews Immunology
July 2014 Vol 14 No 7
http://www.nature.com/nri/journal/v14/n7/index.html

From empiricism to rational design: a personal perspective of the evolution of vaccine development
Ennio De Gregorio & Rino Rappuoli
Abstract
Vaccination, which is the most effective medical intervention that has ever been introduced, originated from the observation that individuals who survived a plague or smallpox would not get the disease twice. To mimic the protective effects of natural infection, Jenner — and later Pasteur — inoculated individuals with attenuated or killed disease-causing agents. This empirical approach inspired a century of vaccine development and the effective prophylaxis of many infectious diseases. From the 1980s, several waves of new technologies have enabled the development of novel vaccines that would not have been possible using the empirical approach. The technological revolution in the field of vaccination is now continuing, and it is delivering novel and safer vaccines. In this Timeline article, we provide our views on the transition from empiricism to rational vaccine design.

Pediatrics
July 2014, VOLUME 134 / ISSUE 1
http://pediatrics.aappublications.org/current.shtml

Article
Impact of Vaccination on the Epidemiology of Varicella: 1995–2009
Roger Baxter, MDa, Trung N. Tran, MD, PhDb, Paula Ray, MPHa, Edwin Lewis, MPHa, Bruce Fireman, MAa, Steve Black, MDc, Henry R. Shinefield, MDd, Paul M. Coplan, ScD, MBAb, and
Patricia Saddier, MD, PhDb
Author Affiliations
a Kaiser Permanente Vaccine Study Center, Oakland, California;
b Department of Epidemiology, Merck Sharp & Dohme Corp, Whitehouse Station, New Jersey;
cCenter for Global Health, Cincinnati Children’s Hospital, Cincinnati, Ohio; and
d University of California San Francisco Medical Center, San Francisco, California
Abstract
BACKGROUND: When varicella vaccine was licensed in the United States in 1995, there were concerns that childhood vaccination might increase the number of adolescents susceptible to varicella and shift disease toward older age groups where it can be more severe.
METHODS: We conducted a series of 5 cross-sectional studies in 1994 to 1995 (prevaccine), 2000, 2003, 2006, and 2009 in Kaiser Permanente of Northern California to assess changes in varicella epidemiology in children and adolescents, as well as changes in varicella hospitalization in people of all ages. For each study, information on varicella history and varicella occurrence during the past year was obtained by telephone survey from a sample of ∼8000 members 5 to 19 years old; varicella hospitalization rates were calculated for the entire membership.
RESULTS: Between 1995 and 2009, the overall incidence of varicella in 5- to 19-year-olds decreased from 25.8 to 1.3 per 1000 person-years, a ∼90% to 95% decline in the various age categories (5–9, 10–14, and 15–19 years of age). The proportion of varicella-susceptible children and adolescents also decreased in all age groups, including in 15- to 19-year-olds (from 15.6% in 1995 to 7.6% in 2009). From 1994 to 2009, age-adjusted varicella hospitalization rates in the general member population decreased from 2.13 to 0.25 per 100 000, a ∼90% decline.
CONCLUSIONS: In the 15 years after the introduction of varicella vaccine, a major reduction in varicella incidence and hospitalization was observed with no evidence of a shift in the burden of varicella to older age groups.

Pediatrics
July 2014, VOLUME 134 / ISSUE 1
http://pediatrics.aappublications.org/current.shtml

Special Article
An Outbreak of Measles in an Undervaccinated Community
Pamala Gahr, MPHa, Aaron S. DeVries, MD, MPHa, Gregory Wallace, MD, MPHb, Claudia Miller, MPHa, Cynthia Kenyon, MPHa, Kristin Sweet, MPHa, Karen Martin, MPHa, Karen White, MPHa, Erica Bagstad, MPHc, Carol Hooker, MSc, Gretchen Krawczynski, MPHc, David Boxrud, MSa, Gongping Liu, PhDa, Patricia Stinchfield, MS, CPNPd, Julie LeBlanc, MPHd, Cynthia Hickman, MPHa, Lynn Bahta, RN, PHNa, Albert Barskey, MPHb, and Ruth Lynfield, MDa
Author Affiliations
aMinnesota Department of Health, St Paul, Minnesota;
bCenters for Disease Control and Prevention, Atlanta, Georgia;
cHennepin County Human Services and Public Health, Hopkins, Minnesota; and
dChildren’s Hospital and Clinics of Minnesota, St Paul, Minnesota
Abstract
Measles is readily spread to susceptible individuals, but is no longer endemic in the United States. In March 2011, measles was confirmed in a Minnesota child without travel abroad. This was the first identified case-patient of an outbreak. An investigation was initiated to determine the source, prevent transmission, and examine measles-mumps-rubella (MMR) vaccine coverage in the affected community. Investigation and response included case-patient follow-up, post-exposure prophylaxis, voluntary isolation and quarantine, and early MMR vaccine for non-immune shelter residents >6 months and <12 months of age. Vaccine coverage was assessed by using immunization information system records. Outreach to the affected community included education and support from public health, health care, and community and spiritual leaders. Twenty-one measles cases were identified. The median age was 12 months (range, 4 months to 51 years) and 14 (67%) were hospitalized (range of stay, 2–7 days). The source was a 30-month-old US-born child of Somali descent infected while visiting Kenya. Measles spread in several settings, and over 3000 individuals were exposed. Sixteen case-patients were unvaccinated; 9 of the 16 were age-eligible: 7 of the 9 had safety concerns and 6 were of Somali descent. MMR vaccine coverage among Somali children declined significantly from 2004 through 2010 starting at 91.1% in 2004 and reaching 54.0% in 2010 (χ2 for linear trend 553.79; P < .001). This was the largest measles outbreak in Minnesota in 20 years, and aggressive response likely prevented additional transmission. Measles outbreaks can occur if undervaccinated subpopulations exist. Misunderstandings about vaccine safety must be effectively addressed.

PLoS One
[Accessed 12 July 2014]
http://www.plosone.org/

Research Article
Safety and Immunogenicity of a Live Oral Recombinant Cholera Vaccine VA1.4: A Randomized, Placebo Controlled Trial in Healthy Adults in a Cholera Endemic Area in Kolkata, India
Suman Kanungo, Bandana Sen, Thandavarayan Ramamurthy, Dipika Sur, Byomkesh Manna, Gururaja P. Pazhani, Goutam Chowdhury, Puja Jhunjhunwala, Ranjan K. Nandy, Hemanta Koley, Mihir Kumar Bhattacharya, Sanjay Gupta, Gaurav Goel, Bindu Dey, Thungapathra M,
G. Balakrish Nair, Amit Ghosh, Dilip Mahalanabis mail
Abstract
Background
A live oral cholera vaccine VA 1.4 developed from a non-toxigenic Vibrio cholerae O1 El Tor strain using ctxB gene insertion was further developed into a clinical product following cGMP and was evaluated in a double-blind randomized placebo controlled parallel group two arm trial with allocation ratio of 1:1 for safety and immunogenicity in men and women aged 18–60 years from Kolkata, India.
Method
A lyophilized dose of 1.9×109 CFU (n = 44) or a placebo (n = 43) reconstituted with a diluent was administered within 5 minutes of drinking 100 ml of a buffer solution made of sodium bicarbonate and ascorbic acid and a second dose on day 14.
Result
The vaccine did not elicit any diarrhea related adverse events. Other adverse events were rare, mild and similar in two groups. One subject in the vaccine group excreted the vaccine strain on the second day after first dose. The proportion of participants who seroconverted (i.e. had 4-folds or higher rise in reciprocal titre) in the vaccine group were 65.9% (95% CI: 50.1%–79.5%) at both 7 days (i.e. after 1st dose) and 21 days (i.e. after 2nd dose). None of the placebo recipients seroconverted. Anti-cholera toxin antibody was detected in very few recipients of the vaccine.
Conclusion
This study demonstrates that VA 1.4 at a single dose of 1.9×109 is safe and immunogenic in adults from a cholera endemic region. No additional benefit after two doses was seen.
Trial Registration
Clinical Trials Registry-India, National Institute of Medical Statistics (Indian Council of Medical Research) CTRI/2012/04/002582

Science
11 July 2014 vol 345, issue 6193, pages 113-236
http://www.sciencemag.org/current.dtl

Special Issue – Strategies against HIV/AIDS
Perspective
A critical question for HIV vaccine development: Which antibodies to induce?
Susan Zolla-Pazner1,2
Author Affiliations
1New York Veterans Affairs Harbor Healthcare System, New York, NY 10010, USA.
2New York University School of Medicine, New York, NY 10016, USA.
Abstract
A vaccine against HIV-1 must prevent infection against genetically diverse virus strains. Two approaches are currently being pursued to elicit antibody-mediated protection: vaccines that induce potent and broadly reactive neutralizing antibodies (bnAbs) or vaccines that induce “conventional antibodies,” which are less potent and broadly neutralizing in comparison. Although bnAbs may provide the greatest level of protection, their structural and genetic characteristics make their elicitation through vaccination a major challenge. In contrast, conventional HIV-1 antibodies have been induced by vaccination and correlated with reduced HIV-1 infection in a phase III vaccine trial. Here, I present evidence that both approaches should be pursued with equal vigor.

Stability: International Journal of Security & Development
[accessed 12 July 2014]
http://www.stabilityjournal.org/articles

Peaceful Economies: Assessing the Role of the Private Sector in Conflict Prevention in Pakistan
Safwan A Khan, Vaqar Ahmed
7 Abstract
Pakistan today seems to be embroiled in a number of conflicts that have both domestic as well as international dimensions. Conflicts of course vary, ranging from household disputes to increasing crime resulting from disparities. However, at an aggregated level, conflicts have a societal connotation that reflects deep-rooted divisions within a society. On a macro-level, these conflicts suppress a country’s potential and inhibit future prosperity. Hence, investor confidence has declined in Pakistan as have market opportunities. The poor law and order situation in Karachi over the last few years, for example, has significantly affected the income of daily wage earners, while investors have taken a back seat. Moreover, entrepreneurial activity becomes even more difficult to pursue for those with less capital or access to financing.
With the rise in conflicts across the country coupled with a bleak economic situation, communities and businesses have suffered alike. Economic disparities often breed sustained conflicts. In this context, what is needed in Pakistan is an economic environment that engenders strategic peace. The two are complementing factors, and neglecting either can seriously undermine the effectiveness of measures taken for the other.
This research study, conducted by Sustainable Development Policy Institute (SDPI) in 2013, undertook an analysis of the private sector’s role in achieving sustainable peace in Pakistan. It is important to note that as far as sustainable peace is concerned, the private sector is just one of many actors. In that, Corporate Social Responsibility (CSR) initiatives by businesses can certainly play an important role. Their main contribution, however, can be to influence public policy in favor of strategic peace across the country. While approaches such as dispute resolution (formal and informal) and CSR are important in terms of conflict mitigation, long-term peace is contingent upon a just and equitable system of economic governance.

Tropical Medicine and Health
Vol. 42(2014) No. 2
https://www.jstage.jst.go.jp/browse/tmh/42/1/_contents

Current Trends of Immunization in Nigeria: Prospect and Challenges
Endurance A. Ophori, Musa Y. Tula, Azuka V. Azih, Rachel Okojie, Precious E. Ikpo
Released: July 12, 2014
Abstract
Immunization is aimed at the prevention of infectious diseases. In Nigeria, the National Programme on Immunization (NPI) suffers recurrent setbacks due to many factors including ethnicity and religious beliefs. Nigeria is made up of 36 states with its federal capital in Abuja. The country is divided into six geo-political zones; north central, north west, north east, south east, south west and south south. The population is unevenly distributed across the country. The average population density in 2006 was estimated at 150 people per square kilometres with Lagos, Anambra, Imo, Abia, and Akwa Ibom being the most densely populated states. Most of the densely populated states are found in the south east. Kano with an average density of 442 persons per square kilometre, is the most densely populated state in the northern part of the country. This study presents a review on the current immunization programme and the many challenges affecting its success in the eradication of childhood diseases in Nigeria.

Vaccine
Volume 32, Issue 34, Pages 4243-4364 (23 July 2014)
http://www.sciencedirect.com/science/journal/0264410X/32/34

Report of the Third European Expert Meeting on Rotavirus Vaccination: Progress in rotavirus universal mass vaccination in Europe
Pages 4243-4248
HI Huppertz, M Borte, V Schuster, C Giaquinto, T Vesikari

Recent progress and concerns regarding the Japanese immunization program: Addressing the “vaccine gap”
Review Article
Pages 4253-4258
Akihiko Saitoh, Nobuhiko Okabe
Abstract
Recent progress in the Japanese immunization program has partially closed the “vaccine gap,” i.e., the deficiencies in that program relative to immunization programs in other developed countries. During the last several years, seven new vaccines (12 new products, excluding influenza vaccines) have been introduced in Japan. Five of these new vaccines are produced outside Japan and four are now included as routine vaccines in the National Immunization Program, which is a new development in the licensing and financial support of imported vaccines. However, along with this progress, important concerns have arisen regarding the Japanese immunization program. A rubella epidemic among adults, in 2012–2013, resulted in more than 40 cases of congenital rubella syndrome as of March 2014. In addition, the temporary withdrawal of the active governmental recommendation for human papilloma virus vaccines, in 2013–2014, highlighted challenges in the current Japanese immunization system. Furthermore, some important vaccines – including vaccines for hepatitis B virus, mumps, varicella, and rotavirus – are still not included in the National Immunization Program and have been categorized as voluntary vaccines since their introduction. The possibility of their inclusion in the National Immunization Program remains a matter for discussion. We hope that future initiatives will further address the vaccine gap and protect Japanese children from vaccine-preventable diseases.

Vaccine
Volume 32, Issue 34, Pages 4243-4364 (23 July 2014)
http://www.sciencedirect.com/science/journal/0264410X/32/34

Are we there yet? Assessing achievement of vaccine-preventable disease goals in WHO’s Western Pacific Region
Review Article
Pages 4259-4266
Karen Hennessey, W. William Schluter, Xiaojun Wang, Liliane Boualam, Youngmee Jee, Jorge Mendoza-Aldana, Sigrun Roesel, Sergey Diorditsa, John Ehrenberg
Abstract
Accelerated disease control goals have long been appreciated for their role in galvanizing commitment and bringing a sense of urgency for disease prevention. WHO’s Western Pacific Region has 14 on-going communicable disease reduction goals including 1 targeting eradication, 10 targeting elimination, and 3 control initiatives. These goals cover mother-to-child transmission of HIV, congenital syphilis, tuberculosis, leprosy, five parasitic diseases and four vaccine-preventable diseases (VPD). The initiatives have distinct objectives, approaches, and means in which to measure achievement of the goals.
Given the long history and experience with VPD initiatives in the Western Pacific Region, this manuscript focuses on the Region’s following initiatives: (1) smallpox eradication, (2) polio eradication, (3) measles elimination, (4) maternal and neonatal tetanus elimination (MNTE), and (5) hepatitis B control.
There is good consistency across the Region’s VPD initiatives yet a pattern of more robust and representative data requirements, stricter evaluation criteria, and more formal evaluation bodies are linked to the intensity of the goal – with eradication being the peak. On the other end of this spectrum, the Regional hepatitis B control initiative has established efficient and low-cost approaches for measuring impact and evaluating if the goals have been met. Even within the confines of VPD initiatives there are some deviations in use of terminology and comparisons across other disease control initiatives in the Region are provided.

Vaccines — Open Access Journal
(Accessed 12 July 2014)
http://www.mdpi.com/journal/vaccines

Review
Peptide Vaccine: Progress and Challenges
Weidang Li 1, Medha D. Joshi 2, Smita Singhania 3, Kyle H. Ramsey 4 and Ashlesh K. Murthy 1
Authors’ affiliations
(This article belongs to the Special Issue Peptide Vaccine)
Abstract
Conventional vaccine strategies have been highly efficacious for several decades in reducing mortality and morbidity due to infectious diseases. The bane of conventional vaccines, such as those that include whole organisms or large proteins, appear to be the inclusion of unnecessary antigenic load that, not only contributes little to the protective immune response, but complicates the situation by inducing allergenic and/or reactogenic responses. Peptide vaccines are an attractive alternative strategy that relies on usage of short peptide fragments to engineer the induction of highly targeted immune responses, consequently avoiding allergenic and/or reactogenic sequences. Conversely, peptide vaccines used in isolation are often weakly immunogenic and require particulate carriers for delivery and adjuvanting. In this article, we discuss the specific advantages and considerations in targeted induction of immune responses by peptide vaccines and progresses in the development of such vaccines against various diseases. Additionally, we also discuss the development of particulate carrier strategies and the inherent challenges with regard to safety when combining such technologies with peptide vaccines.

From Google Scholar & other sources: Selected Journal Articles, Newsletters, Dissertations, Theses, Commentary

Conflict and Health
[Accessed 12 July 2014]
http://www.conflictandhealth.com/

Short report
Description of a large measles epidemic in Democratic Republic of Congo, 2010-2013
Mancini S, Coldiron ME, Ronsse A, Ilunga BK, Porten K and Grais RF Conflict and Health 2014, 8:9 (3 July 2014)
Abstract (provisional)
Background
Although measles mortality has declined dramatically in Sub-Saharan Africa, measles remains a major public health problem in countries like the Democratic Republic of Congo (DRC). Here, we describe the large measles epidemic that occurred in the Democratic Republic of Congo between 2010 and 2013 using data from the national surveillance system as well as vaccine coverage surveys to provide a snapshot of the epidemiology of measles in DRC.
Methods
Standardized national surveillance data were used to describe measles cases from 2010 to 2013. Attack rates and case fatality ratios were calculated and the temporal and spatial evolution of the epidemic described. Data on laboratory confirmation and vaccination coverage surveys as a part of routine program monitoring are also presented. Findings: Between week 1 of 2010 and week 45 of 2013, a total of 294,455 cases and 5,045 deaths were reported. The cumulative attack rate (AR) was 0.4%. The Case Fatality Ratio (CFR) was 1.7% among cases reported in health structures through national surveillance. A total of 186,178 cases (63%) were under 5 years old, representing an estimated AR of 1.4% in this age group. Following the first mass vaccination campaigns, weekly reported cases decreased by 21.5%. Results of post-vaccination campaign coverage surveys indicated sub-optimal (under 95%) vaccination coverage among children surveyed.
Conclusions
The data reported here highlight the need to seek additional means to reinforce routine immunization as well as ensure the timely implementation of Supplementary Immunization Activities to prevent large and repeated measles epidemics in DRC. Although reactive campaigns were conducted in response to the epidemic, strategies to ensure that children are vaccinated in the routine system remains the foundation of measles control.

PharmacoEconomics & Outcomes News
July 2014, Volume 706, Issue 1, p 12
Men B vaccine: cost perceived as strong barrier to prescribing
K Taylor
Excerpt
Vaccine cost is a significant barrier to Australian family physicians (FPs) recommending non-funded vaccines, such as meningococcal group B (Men B) vaccine.
This is one of the findings of a survey that examine knowledge, attitudes and immunisation practices in relation to invasive meningococcal disease (IMD) and the Men B vaccine among FPs in South Australia.
The analysis of data from 523 respondents showed that high vaccine cost and perceived low socioeconomic status of the patient were identified by many respondents (59% and 61%, respectively) as strong barriers to prescribing non-funded vaccines. Most respondents (63%) were aware that a Men B vaccine was under development, and 93% agreed that this vaccine should be government-funded. The Men B vaccine for children was given the highest mean rank to receive funding out of eight currently non-funded immunisation strategies. FPs with past IMD experience were more likely to give higher priority to funding Men B vaccine for children and adults…

Special Focus Newsletters
Dengue Vaccine Initiative 10 July 2014
Sanofi Pasteur Releases Phase 3 Trial Results of Dengue Vaccine Candidate
Today, July 10, Sanofi Pasteur published in The Lancet the results of the first of two Phase 3 clinical trials for its dengue vaccine candidate — a live attenuated tetravalent vaccine. The study is a randomized, observer-blind, placebo-controlled multicenter trial involving 10,275 children aged two to 14 in Indonesia, Malaysia, the Philippines, Thailand and Vietnam.
:: For DVI’s statement click here.

Forbes
http://www.forbes.com/
Accessed 12 July 2014

Vaccine Refusal Myths Drive Up Development Costs, Prices
David Kroll Contributor
3 July 2014

Africa’s Richest Man To Build 11 Health Centers in Nigeria To Combat Polio
Mfonobong Nsehe Contributor
3 July 2014
Africa’s wealthiest man Aliko Dangote has pledged to build 11 health centers in Kano, a large commercial state in Nigeria’s North-Western region, in an effort to ensure routine immunization and the general physical health of indigenes of the state. According to the Daily Post Nigeria, Dangote, who is the chairman of the Dangote Foundation, made the pledge during a video conference with Bill Gates, co-Chair of the Bill and Melinda Gates Foundation and Rabiu Musa Kwankwaso, Governor of Kano…

New York Times
http://www.nytimes.com/
Accessed 12 July 2014

The Price of Prevention: Vaccine Costs Are Soaring
ELISABETH ROSENTHAL
2 July 2014
…Vaccination prices have gone from single digits to sometimes triple digits in the last two decades, creating dilemmas for doctors and their patients as well as straining public health budgets

Media Note – Ebola: WHO to convene regional experts for comprehensive operational response
WHO
26 June 2014 | GENEVA
Excerpt
The emergence of an Ebola virus disease outbreak in West Africa in 2014 has become a challenge to the 3 countries involved, as the Governments of Guinea, Liberia and Sierra Leone work intensively with WHO and other partners to ramp up a series of measures to control the outbreak.

Since March 2014, more than 600 cases of Ebola and over 390 deaths have been reported in Guinea, Liberia and Sierra Leone. While the number of suspected, probable and confirmed cases and deaths changes rapidly, the outbreak is causing concern among health authorities because the deadly disease is being transmitted in communities and in health-care settings, and it has appeared in cities as well as rural and border areas. The disease, which causes severe haemorrhaging and can kill up to 90% of those infected, is spread by direct contact with the blood and body fluids of infected animals or people….

…Recognizing that a coordinated regional response is essential, WHO is convening the leading health authorities from the affected and nearby countries in Accra, Ghana on July 2–3, to agree on a comprehensive operational response to control the Ebola outbreak. A wide range of partners have been invited, and Ministries of Health of Guinea, Liberia, and Sierra Leone will report on their preventive and control measures, contact identification and tracing; case management; infection and prevention control; social mobilization; and situation reports.

The countries are working to bring supportive care to the ill, inform affected communities of recommended practices, trace contacts of infected patients, control infections in health care settings, and taking other measures to control the outbreak. Despite their progress in implementing preventive and control measures, health authorities still face challenges in curbing the spread of the outbreak, and will discuss these at the Accra meeting….

…The latest numbers, which change as cases are discovered, investigated, or discarded, are:
:: Guinea has reported some 396 cases and 280 deaths
:: Sierra Leone has 176 cases and 46 deaths
:: Liberia reports 63 cases and 41 deaths.

WHO: Global Alert and Response (GAR) – Disease Outbreak News [to 28 June 2014]
http://www.who.int/csr/don/en/

:: Human infection with avian influenza A(H7N9) virus – update 27 June 2014

:: Middle East respiratory syndrome coronavirus (MERS-CoV) – update 26 June 2014
Excerpt
…Globally, 707 laboratory-confirmed cases of infection with MERS-CoV, including at least 252
related deaths have officially been reported to WHO.
WHO advice
Based on the current situation and available information, WHO encourages all Member States to continue their surveillance for acute respiratory infections and to carefully review any unusual patterns.Infection prevention and control measures are critical to prevent the possible spread of MERS-CoV in health care facilities. It is not always possible to identify patients with MERS-
CoV early because like other respiratory infections, the early symptoms of MERS-CoV are non-specific. Therefore, health-care workers should always apply standard precautions consistently with all patients, regardless of their diagnosis. Droplet precautions should be added to the standard precautions when providing care to patients with symptoms of acute respiratory infection; contact precautions and eye protection should be added when caring for probable or confirmed cases of MERS-CoV infection; airborne precautions should be applied when performing aerosol generating procedures.

Until more is understood about MERS-CoV, people with diabetes, renal failure, chronic lung disease, and immunocompromised persons are considered to be at high risk of severe disease
from MERS‐CoV infection. Therefore, these people should avoid close contact with animals, particularly camels, when visiting farms, markets, or barn areas where the virus is known to be potentially circulating. General hygiene measures such as regular hand washing before and after touching animals and avoiding contact with sick animals, should be adhered to.

Food hygiene practices should be observed. People should avoid drinking raw camel milk or camel urine, or eating meat that has not been properly cooked.WHO does not advise special screening at points of entry with regard to this event nor does it currently recommend the application of any travel or trade restrictions.
:: Middle East respiratory syndrome coronavirus (MERS-CoV) – update 26 June 2014
:: Middle East respiratory syndrome coronavirus (MERS-CoV) – update 25 June 2014

:: Update on polio in central Africa 25 June 2014
[Full text; Editor’s text bolding]
On 17 March 2014, WHO elevated the risk assessment of international spread of polio from central Africa, particularly Cameroon, to very high. A new exportation event from Equatorial Guinea demonstrates that the risk of international spread from central Africa remains very high (http://www.who.int/csr/don/2014_03_17_polio/en/). On 18 June 2014, Brazil reported that wild poliovirus type 1 (WPV1) had been detected in a sewage sample collected in March 2014 at Viracopos International Airport in Sao Paolo state. Genetic sequencing indicates that this virus is most closely related to the virus that is circulating in Equatorial Guinea.

Four wild poliovirus type 1 (WPV1) cases have been reported in Equatorial Guinea in 2014. The index case – Equatorial Guinea’s first case to be reported since 1999 – had onset of paralysis on 28 January 2014; the country’s most recent case occurred on 3 April 2014. Genetic sequencing indicates these cases are linked to an ongoing WPV1 outbreak in Cameroon (Cameroon’s most recent case was on 31 January 2014). Equatorial Guinea is implementing outbreak response activities, with three National Immunization Days (NIDs) with bivalent oral polio vaccine (OPV) in April and May, and plans for further NIDs in July and August. NIDs are deemed essential to stop the outbreak as an estimated 40% of children are fully immunized against polio through the routine immunization programme in the country.

No one in Brazil has been paralyzed by the virus nor is there evidence of transmission within the population of that country. This importation event in Brazil demonstrates that all regions of the world continue to be at risk of exposure to wild poliovirus until polio eradication is completed globally. It is important that all countries, in particular those with frequent travel and contacts with polio-affected countries and areas, strengthen surveillance for polioviruses (especially through the detection and investigation of Acute Flaccid Paralysis or AFP cases) in order to rapidly detect any new virus importations and to facilitate a rapid response. Uniformly high routine immunization coverage should be maintained at the district level to minimize the consequences of any new virus introduction.
An analysis of immunity levels across central Africa found important immunity gaps in most countries in 2014, prompting the large-scale polio immunization campaigns that are ongoing in the area. In Gabon, a nationwide immunization campaign was held in June (with a further round planned for July), and in the Republic of Congo, a nationwide activity was conducted in May (another round is planned for June). Polio vaccination campaigns have been conducted where possible in the Central African Republic (May to June), with another round planned for accessible areas in July.

WHO note
There is no evidence to date that Brazil was re-infected by the poliovirus of Equatorial Guinea origin that was detected in a sewage sample collected in Sao Paolo State in March 2014; to date there has been no evidence of transmission of the virus in Brazil following this exposure.

Given Brazil’s high levels of population immunity, reflected in the high routine immunization coverage (>95%) and periodic vaccination campaigns, the lack of evidence so far of WPV1 transmission and the response being implemented, WHO assesses the risk of spread of this virus within or from Brazil as low.

WHO travel recommendations
WHO’s International Travel and Health recommends that all travellers to and from polio-affected areas be fully vaccinated against polio.

POLIO [to 28 June 2014]

GPEI Update: Polio this week – As of 25 June 2014
Global Polio Eradication Initiative
Editor’s Excerpt and text bolding
Full report: http://www.polioeradication.org/Dataandmonitoring/Poliothisweek.aspx
:: On 18 June, Brazil reported that wild poliovirus type 1 (WPV1) had been detected in a sewage sample collected in March 2014 at Viracopos International Airport in Sao Paolo state. Genetic sequencing indicates that this virus is most closely related to the virus that is circulating in Equatorial Guinea. No one in Brazil has been paralyzed by the virus nor is there evidence of transmission within the population of that country. This importation is a reminder of the importance of responding to the central Africa outbreak efficiently, of the critical need to vaccinate residents of Equatorial Guinea before international travel, and of the need for all countries to maintain high immunity against polio.
:: In the Bara sub-division of the Federally Administered Tribal Areas (FATA), Pakistan, a successful door-to-door polio vaccination campaign took place for the first time in five years reaching more than 42,000 children. The campaign – led by the FATA Secretariat and conducted by volunteers – was made possible by new financial support from the United Arab Emirates.
:: On 20 June, the Polio Oversight Board (POB) – made up of the heads of GPEI partners WHO, UNICEF, Rotary International and the US Centers for Disease Control and Prevention, and senior leadership from the Bill & Melinda Gates Foundation – met for the third time this year to examine progress against the Strategic Plan and review updates on GPEI management, financials and communications. Among other decisions, the POB endorsed additional activities to protect at-risk polio-free areas.
Nigeria
;: One new WPV1 case was reported in the past week from the previously uninfected Sumaila LGA, Kano state, with onset of paralysis on 17 May. The total number of WPV1 cases for 2014 is four.
:: Two new cVDPV2 cases were reported in the past week including one from Damboa LGA, Borno state with onset of paralysis on 2 May, and one from the previously uninfected Gwale LGA, Kano state with onset of paralysis on 10 May. The total number of cVDPV2 cases for 2014 is nine…
Pakistan
:: One new WPV1 case was reported in the past week from North Waziristan, Federally Administered Tribal Areas (FATA) with onset of paralysis on 28 May. The total number of WPV1 cases reported from Pakistan for 2014 is 83.
:: Six new cVDPV2 cases were reported in the past week including three cases from North Waziristan, FATA, and three cases from FR Bannu, FATA. The most recent cVDPV2 case had onset of paralysis on 27 May (from FR Bannu). The total number of cVDPV2 cases for 2014 is 16.
:: North Waziristan is the district with the largest number of children being paralyzed by poliovirus (both wild and cVDPV2) in the world. Immunization activities have been suspended by local leaders since June 2012. Immunizations in neighboring high-risk areas are being intensified, to further boost population immunity levels in those areas and prevent further spread of this outbreak. With thousands of people moving out of North Waziristan following the recent military operation against insurgents, the polio programme has been working with local government to identify displaced populations and reach them with the polio vaccine at either permanent transit points, or camps, or once they reach host communities.
:: According to the Technical Advisory Group (TAG) on Polio Eradication in Pakistan, convened in Islamabad from 2-3 June, the country is not in a position to interrupt transmission without radical change in reservoir areas including FATA, Peshawar, and Karachi. To put the program back on the path to polio eradication, the TAG recommended full political commitment and ownership, mobilization of national assets to facilitate access of vaccination teams, restoration of vaccination in FATA and addressing insecurity and chronic gaps in reservoirs and high risk areas. The TAG also recommended that all provinces integrate communications and social mobilization activities in their planning and operations.
Central Africa
:: One new WPV1 case was reported in the past week from Equatorial Guinea. The case is from the previously uninfected Mbini district in Litoral province and had onset of paralysis on 3 May.

Please see Polio eradication in Syria, The Lancet Infectious Diseases, in Journal Watch below.

Polio vaccine effort in Syria reaches 1.4 million children as volunteers brave violence
Washington Post | 22 June 2014
By Tik Root Ju
Excerpt
GAZIANTEP, Turkey — Despite grave danger, a campaign to combat the spread of polio in rebel-held Syria has been surprisingly successful, with volunteers inoculating about 1.4 million children since the beginning of the year.
The reemergence of polio in Syria in October alarmed health organizations, which feared that factors such as tainted water, dysfunctional sanitation systems and a mobile population could contribute to a broader, region-wide epidemic.
In response, a coalition of nonprofit organizations quickly recruited and deployed thousands of volunteers in the country’s embattled north, where they won the cooperation of rebel fighters and braved shelling and airstrikes to administer the vaccine to children under age 5. Four volunteers have been killed in the process, but there has not been a confirmed case of polio in Syria in nearly five months….

The Weekly Epidemiological Record (WER) for 27 June 2014, vol. 89, 26 (pp. 289–296) includes:
:: Index of countries/areas; Index, Volume 89, 2014, Nos. 1–26
:: Performance of acute flaccid paralysis (AFP) surveillance and incidence of poliomyelitis,
http://www.who.int/entity/wer/2014/wer8926.pdf?ua=1

Global Fund Watch [to 28 June 2014]
http://www.theglobalfund.org/en/mediacenter/announcements/

:: New Framework on Malaria Drugs to Save $100 Million
24 June 2014
Excerpt
GENEVA – In a major initiative that fundamentally changes how anti-malaria drugs are procured, the Global Fund is entering into new framework agreements with suppliers of artemisinin-based combination therapy (ACT) that are aimed at improving delivery and having a bigger impact, both in value for money and in lives saved.
Working closely with the UK’s Department for International Development, partners achieved a way to maximize transition funding for a private sector co-payment mechanism for ACTs, the driving factor in projected savings of over US$100 million through price reductions over two years. World Health Organization, the President’s Malaria Initiative, UNICEF, UNITAID and the Clinton Health Access Initiative all aligned their efforts in the process.
The agreement establishes framework contracts of two years with allocated and committed volumes of ACTs with a group of nine selected suppliers. In addition to the financial benefits, the framework will bring improvements in pipeline visibility, delivery performance and market sustainability, and also encourage local production…

Antimicrobial resistance: global report on surveillance 2014
WHO
April 2014 – 257 pages
ISBN: 978 92 4 156474 8
Overview
Antimicrobial resistance (AMR) threatens the effective prevention and treatment of an ever-increasing range of infections caused by bacteria, parasites, viruses and fungi. An increasing number of governments around the world are devoting efforts to a problem so serious that it threatens the achievements of modern medicine. A post-antibiotic era – in which common infections and minor injuries can kill – far from being an apocalyptic fantasy, is instead a very real possibility for the 21st Century.

This WHO report, produced in collaboration with Member States and other partners, provides for the first time, as accurate a picture as is presently possible of the magnitude of AMR and the current state of surveillance globally.

The report makes a clear case that resistance to common bacteria has reached alarming levels in many parts of the world and that in some settings, few, if any, of the available treatments options remain effective for common infections. Another important finding of the report is that surveillance of antibacterial resistance is neither coordinated nor harmonized and there are many gaps in information on bacteria of major public health importance.

Strengthening global AMR surveillance is critical as it is the basis for informing global strategies, monitoring the effectiveness of public health interventions and detecting new trends and threats. As WHO, along with partners across many sectors moves ahead in developing a global action plan to mitigate AMR, this report will serve as a baseline to measure future progress.

American Journal of Infection Control
Vol 42 | No. 7 | July 2014 | Pages 697-818
http://www.ajicjournal.org/current

Trends in racial/ethnic disparities in influenza vaccination coverage among adults during the 2007-08 through 2011-12 seasons
Peng-Jun Lu, MD, PhD, Alissa O’Halloran, MSPH, Leah Bryan, MPH, Erin D. Kennedy, DVM, MPH,
Helen Ding, MD, MSPH, Samuel B. Graitcer, MD, Tammy A. Santibanez, PhD, Ankita Meghani, MSPH, James A. Singleton, PhD
Abstract
Background
Annual influenza vaccination is recommended for all persons aged ≥6 months. The objective of this study was to assess trends in racial/ethnic disparities in influenza vaccination coverage among adults in the United States.
Methods
We analyzed data from the 2007-2012 National Health Interview Survey (NHIS) and Behavioral Risk Factor Surveillance System (BRFSS) using Kaplan-Meier survival analysis to assess influenza vaccination coverage by age, presence of medical conditions, and racial/ethnic groups during the 2007-08 through 2011-12 seasons.
Results
During the 2011-12 season, influenza vaccination coverage was significantly lower among non-Hispanic blacks and Hispanics compared with non-Hispanic whites among most of the adult subgroups, with smaller disparities observed for adults age 18-49 years compared with other age groups. Vaccination coverage for non-Hispanic white, non-Hispanic black, and Hispanic adults increased significantly from the 2007-08 through the 2011-12 season for most of the adult subgroups based on the NHIS (test for trend, P < .05). Coverage gaps between racial/ethnic minorities and non-Hispanic whites persisted at similar levels from the 2007-08 through the 2011-12 seasons, with similar results from the NHIS and BRFSS.
Conclusions
Influenza vaccination coverage among most racial/ethnic groups increased from the 2007-08 through the 2011-12 seasons, but substantial racial and ethnic disparities remained in most age groups. Targeted efforts are needed to improve coverage and reduce these disparities.

Baseline immunity to diphtheria and immunologic response after booster vaccination with reduced diphtheria and tetanus toxoid vaccine in Thai health care workers
Surasak Wiboonchutikul, MD, Weerawat Manosuthi, MD, Chariya Sangsajja, MD, Varaporn Thientong, RN, Sirirat Likanonsakul, MSc, Somkid Srisopha, BSc, Patamavadee Termvises, RN, Jitlada Rujitip, RN, Suda Loiusirirotchanakul, PhD, Pilaipan Puthavathana, PhD
Abstract
A prospective study to evaluate immune status against diphtheria and immunologic response after tetanus-diphtheria (Td) booster vaccination was conducted in 250 Thai health care workers (HCWs). A protective antibody was found in 89.2% of the HCWs (95% confidence interval [CI], 83.3%-91.5%) before receipt of the Td booster vaccination, compared with 97.2% (95% CI, 95.1%-99.3%) after receipt of the first dose of booster (P < .001). The mean antibody level against diphtheria increased from 0.39 IU/mL (95% CI, 0.35-0.44 IU/mL) before the Td booster vaccination to 1.20 IU/mL (95% CI, 1.12-1.29 IU/mL) after the vaccination (P < .001). Td booster vaccination should be considered for Thai HCWs to maintain immunity against diphtheria, which still circulates in Thailand.

BMC Infectious Diseases
Accessed 28 June 2014
http://www.biomedcentral.com/bmcinfectdis/content

Research article
Is expanding HPV vaccination programs to include school-aged boys likely to be value-for-money: a cost-utility analysis in a country with an existing school-girl program
Amber L Pearson, Giorgi Kvizhinadze, Nick Wilson, Megan Smith, Karen Canfell and Tony Blakely
Author Affiliations
BMC Infectious Diseases 2014, 14:351 doi:10.1186/1471-2334-14-351
Published: 26 June 2014
Abstract (provisional)
Background
Similar to many developed countries, vaccination against human papillomavirus (HPV) is provided only to girls in New Zealand and coverage is relatively low (47% in school-aged girls for dose 3). Some jurisdictions have already extended HPV vaccination to school-aged boys. Thus, exploration of the cost-utility of adding boys’ vaccination is relevant. We modeled the incremental health gain and costs for extending the current girls-only program to boys, intensifying the current girls-only program to achieve 73% coverage, and extension of the intensive program to boys.
Methods
A Markov macro-simulation model, which accounted for herd immunity, was developed for an annual cohort of 12-year-olds in 2011 and included the future health states of: cervical cancer, pre-cancer (CIN I to III), genital warts, and three other HPV-related cancers. In each state, health sector costs, including additional health costs from extra life, and quality-adjusted life-years (QALYs) were accumulated. The model included New Zealand data on cancer incidence and survival, and other cause mortality (all by sex, age, ethnicity and deprivation).
Results
At an assumed local willingness-to-pay threshold of US$29,600, vaccination of 12-year-old boys to achieve the current coverage for girls would not be cost-effective, at US$61,400/QALY gained (95% UI $29,700 to $112,000; OECD purchasing power parities) compared to the current girls-only program, with an assumed vaccine cost of US$59 (NZ$113). This was dominated though by the intensified girls-only program; US$17,400/QALY gained (95% UI: dominant to $46,100). Adding boys to this intensified program was also not cost-effective; US$128,000/QALY gained, 95% UI: $61,900 to $247,000).
Vaccination of boys was not found to be cost-effective, even for additional scenarios with very low vaccine or program administration costs – only when combined vaccine and administration costs were NZ$125 or lower per dose was vaccination of boys cost-effective.
Conclusions
These results suggest that adding boys to the girls-only HPV vaccination program in New Zealand is highly unlikely to be cost-effective. In order for vaccination of males to become cost-effective in New Zealand, vaccine would need to be supplied at very low prices and administration costs would need to be minimised.

Research article
Migration intensity has no effect on peak HIV prevalence: an ecological study
Chris Kenyon, Robert Colebunders, Helene Voeten and Mark Lurie
Author Affiliations
BMC Infectious Diseases 2014, 14:350 doi:10.1186/1471-2334-14-350
Published: 24 June 2014
Abstract (provisional)
Background
Correctly identifying the determinants of generalized HIV epidemics is crucial to bringing down ongoing high HIV incidence in these countries. High rates of migration are believed to be an important determinant of HIV prevalence. This study has two aims. Firstly, it evaluates the ecological association between levels of internal and international migration and national peak HIV prevalence using thirteen variables from a variety of sources to capture various aspects of internal and international migration intensity. Secondly, it examines the relationship between circular migration and HIV at an individual and population-level in South Africa.
Methods
Linear regression was used to analyze the association between the various measures of migration intensity and peak national HIV prevalence for 141 countries and HIV prevalence by province and ethnic group in South Africa.
Results
No evidence of a positive ecological association between national migration intensity and HIV prevalence was found. This remained the case when the analyses were limited to the countries of sub-Saharan Africa. On the whole, countries with generalized HIV epidemics had lower rates of internal and external migration. Likewise, no association was found between migration and HIV positivity at an individual or group-level in South Africa.
Conclusion
These results do not support the thesis that migration measured at the country level plays a significant role in determining peak HIV prevalence.

BMC Medical Ethics
(Accessed 28 June 2014)
http://www.biomedcentral.com/bmcmedethics/content

Research article
Linking international clinical research with stateless populations to justice in global health
Bridget Pratt, Deborah Zion, Khin Maung Lwin, Phaik Yeong Cheah, Francois Nosten and Bebe Loff
Author Affiliations
BMC Medical Ethics 2014, 15:49 doi:10.1186/1472-6939-15-49
Published: 26 June 2014
Abstract (provisional)
Background
In response to calls to expand the scope of research ethics to address justice in global health, recent scholarship has sought to clarify how external research actors from high-income countries might discharge their obligation to reduce health disparities between and within countries. An ethical framework–‘research for health justice’–was derived from a theory of justice (the health capability paradigm) and specifies how international clinical research might contribute to improved health and research capacity in host communities. This paper examines whether and how external funders, sponsors, and researchers can fulfill their obligations under the framework.
Methods
Case study research was undertaken on the Shoklo Malaria Research Unit’s (SMRU) vivax malaria treatment trial, which was performed on the Thai-Myanmar border with Karen and Myanmar refugees and migrants. We conducted nineteen in-depth interviews with trial stakeholders, including investigators, trial participants, community advisory board members, and funder representatives; directly observed at trial sites over a five-week period; and collected trial-related documents for analysis.
Results
The vivax malaria treatment trial drew attention to contextual features that, when present, rendered the ‘research for health justice’ framework’s guidance partially incomplete. These insights allowed us to extend the framework to consider external research actors’ obligations to stateless populations. Data analysis then showed that framework requirements are largely fulfilled in relation to the vivax malaria treatment trial by Wellcome Trust (funder), Oxford University (sponsor), and investigators. At the same time, they demonstrate that it may be difficult for long-term collaborations to shift the focus of their research agendas in accordance with the changing burden of illness in their host communities and to build the independent research capacity of host populations when working with refugees and migrants. Obstructive factors included the research funding environment and staff turnover due to resettlement or migration.
Conclusions
Our findings demonstrate that obligations for selecting research targets, research capacity strengthening, and post-trial benefits that link clinical trials to justice in global health can be upheld by external research actors from high-income countries when working with stateless populations in LMICs. However, meeting certain framework requirements for long-term collaborations may not be entirely feasible.

Globalization and Health
[Accessed 28 June 2014]
http://www.globalizationandhealth.com/

Research
Commentary
Accelerating learning for pro-poor health markets
Sara Bennett, Gina Lagomarsino, Jeff Knezovich and Henry Lucas
Author Affiliations
Globalization and Health 2014, 10:54 doi:10.1186/1744-8603-10-54
Published: 24 June 2014
Abstract (provisional)
Background
Given the rapid evolution of health markets, learning is key to promoting the identification and uptake of health market policies and practices that better serve the needs of the poor. However there are significant challenges to learning about health markets. We discuss the different forms that learning takes, from the development of codified scientific knowledge, through to experience-based learning, all in relationship to health markets.
Discussion
Notable challenges to learning in health markets include the difficulty of acquiring data from private health care providers, designing evaluations that capture the complex dynamics present within health markets and developing communities of practice that encompass the diverse actors present within health markets, and building trust and mutual understanding across these groups.
The paper proposes experimentation with country-specific market data platforms that can integrate relevant evidence from different data sources, and simultaneously exploring strategies to secure better information on private providers and health markets. Possible approaches to adapting evaluation designs so that they are better able to take account of different and changing contexts as well as producing real time findings are discussed. Finally capturing informal knowledge about health markets is key. Communities of practice that bridge different health market actors can help to share such experience-based knowledge and in so doing, may help to formalize it. More geographically-focused communities of practice are needed, and such communities may be supported by innovation brokers and/or be built around member-based organizations.
Summary
Strategic investments in and support to learning about health markets can address some of the challenges experienced to-date, and accelerate learning that supports health markets that serve the poor.

Private sector, for-profit health providers in low and middle income countries: can they reach the poor at scale?
Elizabeth Tung and Sara Bennett
Author Affiliations
Globalization and Health 2014, 10:52 doi:10.1186/1744-8603-10-52
Published: 24 June 2014
Abstract (provisional)
Background
The bottom of the pyramid concept suggests that profit can be made in providing goods and services to poor people, when high volume is combined with low margins. To-date there has been very limited empirical evidence from the health sector concerning the scope and potential for such bottom of the pyramid models. This paper analyzes private for-profit (PFP) providers currently offering services to the poor on a large scale, and assesses the future prospects of bottom of the pyramid models in health.
Methods
We searched published and grey literature and databases to identify PFP companies that provided more than 40,000 outpatient visits per year, or who covered 15% or more of a particular type of service in their country. For each included provider, we searched for additional information on location, target market, business model and performance, including quality of care.
Results
Only 10 large scale PFP providers were identified. The majority of these were in South Asia and most provided specialized services such as eye care. The characteristics of the business models of these firms were found to be similar to non-profit providers studied by other analysts (such as Bhattacharya 2010). They pursued social rather than traditional marketing, partnerships with government, low cost/high volume services and cross-subsidization between different market segments. There was a lack of reliable data concerning these providers.
Conclusions
There is very limited evidence to support the notion that large scale bottom of the pyramid models in health offer good prospects for extending services to the poor in the future. In order to be successful PFP providers often require partnerships with government or support from social health insurance schemes. Nonetheless, more reliable and independent data on such schemes is needed.

JAMA
June 25, 2014, Vol 311, No. 24
http://jama.jamanetwork.com/issue.aspx

Viewpoint | June 25, 2014
Healthy People 2020: A Report Card on the Health of the Nation
Howard K. Koh, MD, MPH1; Carter R. Blakey, BS1; Allison Y. Roper, LICSW1
Author Affiliations
JAMA. 2014;311(24):2475-2476. doi:10.1001/jama.2014.6446.
Excerpt
For 4 decades, Healthy People has represented the United States’ vision for a healthier future. Each decade, it serves as a public health road map and compass for the nation by establishing a broad set of overarching health goals while specifying actions to improve length and quality of life. For the current decade, this comprehensive national health promotion and disease prevention agenda encompasses more than a thousand specific objectives organized into 42 topic areas.
To focus particular attention on the leading causes of preventable death and illness, Healthy People 2020 features Leading Health Indicators. This subset of 26 indicators from 12 topic areas offers high-priority targets for which concerted action could lead to major improvements for public health. This article reviews newly available Leading Health Indicators’ data for the first third of the decade, thereby offering a timely snapshot of the nation’s progress toward better health
:: (eTable in the Supplement).
[From Healthy People 2020 Leading Health Indicators: Progress Update]
Leading Health Topic and Indicator
Clinical Preventive Services
:: IID-8 Children receiving the recommended doses of DTaP, polio, MMR, Hib, hepatitis B, varicella and PCV vaccines (percent, aged 19–35 months)
– Baseline: (2009) – 44.3%
– Most Recent: (2011) – 68.5%
– Target: – 80.0%

Journal of Medical Ethics
July 2014, Volume 40, Issue 7
http://jme.bmj.com/content/current

The concise argument
Why is informed consent important?
Rebecca Roache, Associate Editor
Decision-making is a prominent theme in this edition of the Journal of Medical Ethics. Our feature article examines the relationship between trust and informed consent. Informed consent is, of course, central to the decision-making process in medicine. In addition, several articles consider decision-making in medicine from a variety of angles.

Clinical ethics
Paper
Overriding parents’ medical decisions for their children: a systematic review of normative literature
Rosalind J McDougall, Lauren Notini
Author Affiliations
Centre for Health and Society, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
Abstract
This paper reviews the ethical literature on conflicts between health professionals and parents about medical decision-making for children. We present the results of a systematic review which addressed the question ‘when health professionals and parents disagree about the appropriate course of medical treatment for a child, under what circumstances is the health professional ethically justified in overriding the parents’ wishes?’ We identified nine different ethical frameworks that were put forward by their authors as applicable across various ages and clinical scenarios. Each of these frameworks centred on a different key moral concept including harm, constrained parental autonomy, best interests, medically reasonable alternatives, responsible thinking and rationality.

Theoretical ethics
Paper
Islam and the four principles of medical ethics
Yassar Mustafa
Author Affiliations
Queen Elizabeth Hospital, Birmingham, West Midlands, UK
Abstract
The principles underpinning Islam’s ethical framework applied to routine clinical scenarios remain insufficiently understood by many clinicians, thereby unfortunately permitting the delivery of culturally insensitive healthcare. This paper summarises the foundations of the Islamic ethical theory, elucidating the principles and methodology employed by the Muslim jurist in deriving rulings in the field of medical ethics. The four-principles approach, as espoused by Beauchamp and Childress, is also interpreted through the prism of Islamic ethical theory. Each of the four principles (beneficence, non-maleficence, justice and autonomy) is investigated in turn, looking in particular at the extent to which each is rooted in the Islamic paradigm. This will provide an important insight into Islamic medical ethics, enabling the clinician to have a better informed discussion with the Muslim patient. It will also allow for a higher degree of concordance in consultations and consequently optimise culturally sensitive healthcare delivery.