PAHO: Eight in 10 adolescent girls in the Americas have access to HPV vaccine, following its introduction in Brazil
03/20/2014

PAHO said that following its introduction in Brazil last week, HPV vaccine is now available to more than 80% of adolescent girls in the Americas…

…PAHO/WHO estimates that 68,818 women in the Americas developed cervical cancer and 28,565 died from the disease in 2012. In Brazil, the National Cancer Institute estimates 15,000 new cases and 4,800 deaths each year.

This year, Brazil plans to vaccinate 5.2 million adolescent girls ages 11 to 13, or more than 20% of all girls in this age group in the Americas. In 2015, Brazil plans to expand the target group to girls 9 to 11, and starting in 2016 to 9-year-old girls. The vaccinations are being given at public and private schools and in the 36,000 vaccination centers of the national health system…

…PAHO supports Brazil’s decision to provide the HPV vaccine free of charge to adolescent girls as part of an integrated approach to prevention and control of cervical cancer. “The universal introduction of the HPV vaccine shows the commitment of Brazilian officials and health workers,” said Cuauhtémoc Ruiz, head of PAHO/WHO’s Expanded Immunization Program…

GAVI Watch [to 22 March 2014]
http://www.gavialliance.org/library/news/press-releases/
:: Norway raises the alarm on “silent killer” cervical cancer

Oslo seminar highlights critical role of human papillomavirus vaccine in fighting cervical cancer in developing countries
Excerpt
Oslo, 17 March 2014 – GAVI Alliance Deputy CEO Helen Evans joined a chorus of senior Norwegian politicians this week to help raise the alarm on the “silent killer” of women and girls in poor countries – cervical cancer.

Addressing the disease’s deadly burden at a seminar organised by the Norwegian Cancer Society and hosted by the conservative party, Ms Evans explained that the GAVI Alliance helps developing countries fund the introduction of the human papillomavirus (HPV) vaccine, protecting women and girls against the leading cause of cervical cancer.

“Cervical cancer is preventable – we have the technology,” said Ms Evans in her statement. More than a quarter of a million women die every year from cervical cancer, the overwhelming majority of them in developing countries.

“Cervical cancer is a silent killer as it touches women in the world’s poorest countries,” said Anne Lise Ryel, Secretary General of the Norwegian Cancer Society, “I don’t want it to be silent anymore.”…

Australian Vaccination-skeptics Network loses its charity status for fundraising over misinformation claims
ABC Australia | 17 March 2014
Updated Tue 18 Mar 2014, 8:07pm AEDT

The Australian Vaccination-skeptics Network has been stripped of its registered charity status because potential misinformation could impact on children’s health.
The controversial anti-immunisation group was last week forced to change its name from the Australian Vaccination Network because it was considered misleading.
The group actively campaigns against vaccinating children. Now New South Wales Fair Trading Minister Stuart Ayres has taken further action.

“We have requested that it surrender its authority to fundraise, which it has done, under the Charitable Fundraising Act,” he said. “An investigation has highlighted a number of potential concerns.”

The State Government said it gathered expert medical advice challenging the accuracy of the information provided by the group.

CDC/MMWR Watch [to 22 March 2014]
http://www.cdc.gov/mmwr/mmwr_wk.html

:: Meningococcal Disease Update – Media Statement
Tuesday, March 18, 2014, 12:00 PM
On Monday, March 10, a Drexel University student tragically died from serogroup B   meningococcal disease. CDC’s laboratory analysis shows that the strain in Princeton University’s serogroup B meningococcal disease outbreak matches the strain in the Drexel University case by “genetic fingerprinting.”

:: MMWR  March 21, 2014 / Vol. 63 / No. 11
– World TB Day — March 24, 2014
– Trends in Tuberculosis — United States, 2013
– Implementation of New TB Screening Requirements for U.S.-Bound Immigrants and  
Refugees — 2007–2014

Annals of Internal Medicine
18 March 2014, Vol. 160. No. 6
http://annals.org/issue.aspx

Ideas and Opinions | 18 March 2014
“Compassionate Use” for Public Health
Kristen A. Feemster, MD, MPH, MSHP; and Paul Offit, MD
Ann Intern Med. 2014;160(6):421-422-422. doi:10.7326/M13-2927
This article was published online first at www.annals.org on 24 December 2013.
http://annals.org/article.aspx?articleid=1794331

Initial text
Since 22 March 2013, 8 cases of confirmed Neisseria meningitidis serogroup B (MenB) meningitis have occurred among students and visitors at Princeton University. The only vaccine in production that protects against MenB is being distributed in response to the outbreak. This distribution is the first time the “compassionate use” mechanism has been granted to allow a group of healthy persons access to a nontherapeutic biological drug. The authors discuss the ethical implications of this decision.

BMC Health Services Research
(Accessed 22 March 2014)
http://www.biomedcentral.com/bmchealthservres/content

Research article  
The long walk to universal health coverage: patterns of inequities in the use of primary healthcare services in Enugu, Southeast Nigeria
Ijeoma L Okoronkwo, Obinna E Onwujekwe, Francis O Ani BMC Health Services Research 2014, 14:132 (21 March 2014)

Abstract | Provisional PDF
Background
Knowledge and understanding of health service usage are necessary for health resource allocation, planning and monitoring the achievement of universal coverage (UHC). There is limited information on patterns of utilization among adult users of primary health care (PHC) services. Lack of understanding of current and past utilization patterns of health services often hinders the improvement of future Primary Health Care (PHC) delivery in the remote areas of developing countries. This paper presents new knowledge on the patterns of utilization of PHC services among adults in Enugu metropolis southeast Nigeria.

Methods
A cross-sectional study was conducted in 15 PHC facilities of Enugu North Local Government Area (LGA) from June to July 2012. A total of 360 consenting adult users aged 18 years and above were consecutively recruited as they attended the health facilities. An interviewer-administered questionnaire was used to collect data from the respondents. A modified Likert scale questionnaire was used to analyze data on patterns of utilization. Utilization of PHC services was compared by gender, socio-economic status (SES) and level of education.

Results
Out of the 360 respondents, (46.9%) utilized PHC services regularly. The components of PHC mostly utilized by respondents were immunization with a mean score of 3.05, treatment of common ailments (2.99) and maternal and child health (2.64). The least poor SES group utilized PHC services the most while the very poor and poor SES groups used PHC services least. There were statistically significant relationships between utilization of PHC services and gender (p = 0.0084), level of education (p = 0.0366) and income (p = 0.0001).

Conclusions
Most adult users in this study did not utilize the health facilities regularly and there were gender, educational and SES inequities in the use of PHC services. These inequities will negate the achievement of universal health coverage with PHC services and should be remedied using appropriate interventions.

BMC Health Services Research
(Accessed 22 March 2014)
http://www.biomedcentral.com/bmchealthservres/content

Research article  
Community participation to design rural primary healthcare services
Jane Farmer, Amy Nimegeer BMC Health Services Research 2014, 14:130 (21 March 2014)

Abstract | Provisional PDF
Background
This paper explores how community participation can be used in designing rural primary healthcare services by describing a study of Scottish communities. Community participation is extolled in healthcare policy as useful in planning services and is understood as particularly relevant in rural settings, partly due to high social capital. Literature describes many community participation methods, but lacks discussion of outcomes relevant to health system reconfiguration. There is a spectrum of ideas in the literature on how to design services, from top-down standard models to contextual plans arising from population health planning that incorporates community participation. This paper addresses an evidence gap about the outcomes of using community participation in (re)designing rural community health services.

Methods
Community-based participatory action research was applied in four Scottish case study communities in 2008-10. Data were collected from four workshops held in each community (total 16) and attended by community members. Workshops were intended to produce hypothetical designs for future service provision. Themes, rankings and selections from workshops are presented.

Results
Community members identified consistent health priorities, including local practitioners, emergency triage, anticipatory care, wellbeing improvement and health volunteering. Communities designed different service models to address health priorities. One community did not design a service model and another replicated the current model despite initial enthusiasm for innovation.

Conclusions

Communities differ in their receptiveness to engaging in innovative service design, but some will create new models that fit in a given budget. Design diversity indicates that context influences local healthcare planning, suggesting community participation impacts on design outcomes, but standard service models maybe useful as part of the evidence in community participation discussions.

BMC Public Health
(Accessed 22 March 2014)
http://www.biomedcentral.com/bmcpublichealth/content

Study protocol  
Effectiveness of a smart phone app on improving immunization of children in rural Sichuan Province, China: study protocol for a paired cluster randomized controlled trial
Li Chen, Wei Wang, Xiaozhen Du, Xiuqin Rao, Michelle van Velthoven, Ruikan Yang, Lin Zhang, Jeanne Koepsell, Ye Li, Qiong Wu, Yanfeng Zhang BMC Public Health 2014, 14:262 (20 March 2014)

Abstract |
Background
Although good progress has been achieved in expanding immunization of children in China, disparities exist across different provinces. Information gaps both from the service supply and demand sides hinder timely vaccination of children in rural areas. The rapid development of mobile health technology (mHealth) provides unprecedented opportunities for improving health services and reaching underserved populations. However, there is a lack of literature that rigorously evaluates the impact of mHealth interventions on immunization coverage as well as the usability and feasibility of smart phone applications (apps). This study aims to assess the effectiveness of a smart phone-based app (Expanded Program on Immunization app, or EPI app) on improving the coverage of children’s immunization.

Methods/Design
This cluster randomized trial will take place in Xuanhan County, Sichuan Province, China. Functionalities of the app include the following: to make appointments automatically, record and update children’s immunization information, generate a list of children who missed their vaccination appointments, and send health education information to village doctors. After pairing, 36 villages will be randomly allocated to the intervention arm (n = 18) and control arm (n = 18). The village doctors in the intervention arm will use the app while the village doctors in the control arm will record and manage immunization in the usual way in their catchment areas. A household survey will be used at baseline and at endline (8 months of implementation). The primary outcome is full-dose coverage and the secondary outcome is immunization coverage of the five vaccines that are included in the national Expanded Program on Immunization program as well as Hib vaccine, Rotavirus vaccine and Pneumococcal conjugate vaccine. Multidimensional evaluation of the app will also be conducted to assess usability and feasibility.

Discussion
This study is the first to evaluate the effectiveness of a smart phone app for child immunization in rural China. This study will contribute to the knowledge about the usability and feasibility of a smart phone app for managing immunization in rural China and to similar populations in different settings.

Emerging Infectious Diseases
Volume 20, Number 4—April 2014
http://www.cdc.gov/ncidod/EID/index.htm

Synopsis
Distribution of Pandemic Influenza Vaccine and Reporting of Doses Administered, New York, New York, USA
Roopa Kalyanaraman Marcello1, Vikki Papadouka, Mark Misener, Edward Wake, Rebecca Mandell2, and Jane R. Zucker
Author affiliations: New York City Department of Health and Mental Hygiene, Queens, New York, USA (R.K. Marcello, V. Papadouka, M. Misener, E. Wake, R. Mandell, J.R. Zucker); Centers for Disease Control and Prevention, Atlanta, Georgia, USA (E. Wake, J.R. Zucker)
http://wwwnc.cdc.gov/eid/article/20/4/13-1114_article.htm

Abstract
In 2009, the New York City Department of Health and Mental Hygiene delivered influenza A(H1N1)pdm09 (pH1N1) vaccine to health care providers, who were required to report all administered doses to the Citywide Immunization Registry. Using data from this registry and a provider survey, we estimated the number of all pH1N1 vaccine doses administered. Of 2.8 million doses distributed during October 1, 2009–March 4, 2010, a total of 988,298 doses were administered and reported; another 172,289 doses were administered but not reported, for a total of 1,160,587 doses administered during this period. Reported doses represented an estimated 80%–85% of actual doses administered. Reporting by a wide range of provider types was feasible during a pandemic. Pediatric-care providers had the highest reporting rate (93%). Other private-care providers who routinely did not report vaccinations indicated that they had few, if any, problems, thereby suggesting that mandatory reporting of all vaccines would be feasible.

Emerging Infectious Diseases
Volume 20, Number 4—April 2014
http://www.cdc.gov/ncidod/EID/index.htm

Research
Efficiency of Points of Dispensing for Influenza A(H1N1)pdm09 Vaccination, Los Angeles County, California, USA, 2009
Shubhayu Saha , Brandon Dean, Steven Teutsch, Rebekah H. Borse, Martin I. Meltzer, DeeAnn Bagwell, Alonzo Plough, and Jonathan Fielding
Author affiliations: Centers for Disease Control and Prevention, Atlanta, Georgia, USA (S. Saha, R.H. Borse, M.I. Meltzer); Los Angeles County Department of Public Health, Los Angeles, California, USA (B. Dean, S. Teutsch, D. Bagwell, A. Plough, J. Fielding)
http://wwwnc.cdc.gov/eid/article/20/4/13-0725_article.htm

Abstract
During October 23–December 8, 2009, the Los Angeles County Department of Public Health used points of dispensing (PODs) to improve access to and increase the number of vaccinations against influenza A(H1N1)pdm09. We assessed the efficiency of these units and access to vaccines among ethnic groups. An average of 251 persons per hour (SE 65) were vaccinated at the PODs; a 10% increase in use of live-attenuated monovalent vaccines reduced that rate by 23 persons per hour (SE 7). Vaccination rates were highest for Asians (257/10,000 persons), followed by Hispanics (114/10,000), whites (75/100,000), and African Americans (37/10,000). Average distance traveled to a POD was highest for whites (6.6 miles; SD 6.5) and lowest for Hispanics (4.7 miles; SD ±5.3). Placing PODs in areas of high population density could be an effective strategy to reach large numbers of persons for mass vaccination, but additional PODs may be needed to improve coverage for specific populations.

Eurosurveillance
Volume 19, Issue 11, 20 March 2014
http://www.eurosurveillance.org/Public/Articles/Archives.aspx?PublicationId=11678

Editorials
Drug-resistance – a challenge for tuberculosis control in the European Union and European Economic Area

News
ECDC and WHO/Europe joint report on tuberculosis surveillance and monitoring in Europe

Global Public Health
Volume 9, Issue 3, 2014
http://www.tandfonline.com/toc/rgph20/current#.Uq0DgeKy-F9

Political commitment to tuberculosis control in Ghana
Joshua Amo-Adjei
pages 299-311
DOI:10.1080/17441692.2014.880500
Published online: 13 Feb 2014

Abstract
As part of expanding and sustaining tuberculosis (TB) control, the Stop TB Partnership of the World Health Organization initiative has called for strong political commitment to TB control, particularly in developing countries. Framing political commitment within the theoretical imperatives of the political economy of health, this study explores the existing and the expected dimensions of political commitment to TB control in Ghana. Semi-structured in-depth interviews were conducted with 29 purposively selected staff members of the Ghana Health Service and some political officeholders. In addition, the study analysed laws, policies and regulations relevant to TB control. Four dimensions of political commitment emerged from the interviews: provision of adequate resources (financial, human and infrastructural); political authorities’ participation in advocacy for TB; laws and policies’ promulgation and social protection interventions. Particularly in respect to financial resources, donors such as the Global Fund to Fight AIDS, Tuberculosis and Malaria presently give more than 60% of the working budget of the programme. The documentary review showed that laws, policies and regulations existed that were relevant to TB control, albeit they were not clearly linked.

The Lancet  
Mar 22, 2014  Volume 383  Number 9922  p1013 – 1098
http://www.thelancet.com/journals/lancet/issue/current

Editorial
A new brand for tuberculosis
The Lancet
Preview |
The Lancet received an interesting email last week—an invitation to participate in the research stage of a new Stop TB Partnership initiative to build a brand for tuberculosis from Siegel+Gale, a London-based branding agency who have been commissioned to undertake the work. The aim of the project is to develop an iconic and lasting identity for tuberculosis. The goal is to create a brand that will raise the profile of the disease, influence high-level decision makers, attract necessary resources, and amplify the voice of the tuberculosis community.

Comment
World TB Day 2014: finding the missing 3 million
Nick Herbert, Andrew George, Baroness Masham of Ilton, Virendra Sharma, Matt Oliver, Aaron Oxley, Mario Raviglione, Alimuddin I Zumla
Preview |
On April 23, 1993, WHO declared tuberculosis a global health emergency.1 Tuberculosis is now about to come of age as a global emergency—April, 2014 marks the 21st anniversary of that declaration. Arata Kochi, manager of WHO’s tuberculosis programme in 1993, aptly called the disease “a forgotten epidemic” and “humanity’s greatest killer”. Tuberculosis might no longer be humanity’s deadliest disease in terms of annual deaths but, 21 years after the declaration, it remains a serious and substantial threat to the health of people worldwide, causing 1·3 million unnecessary deaths every year.

Nature Immunology
April 2014, Volume 15 No 4 pp307-401
http://www.nature.com/ni/journal/v15/n4/index.html

Perspective
Vaccines that stimulate T cell immunity to HIV-1: the next step
Andrew J McMichael & Wayne C Koff
Affiliations
http://www.nature.com/ni/journal/v15/n4/abs/ni.2844.html

Abstract
The search for a vaccine against human immunodeficiency virus type 1 (HIV-1) has many hurdles to overcome. Ideally, the stimulation of both broadly neutralizing antibodies and cell-mediated immune responses remains the best option, but no candidate in clinical trials at present has elicited such antibodies, and efficacy trials have not demonstrated any benefit for vaccines designed to stimulate immune responses of CD8+ T cells. Findings obtained with the simian immunodeficiency virus (SIV) monkey model have provided new evidence that stimulating effective CD8+ T cell immunity could provide protection, and in this Perspective we explore the path forward for optimizing such responses in humans.

The Pediatric Infectious Disease Journal
April 2014 – Volume 33 – Issue 4  pp: 337-429,e87-e120
http://journals.lww.com/pidj/pages/currenttoc.aspx

Assessing the Evidence: Live Attenuated Influenza Vaccine in Children Younger than 2 Years. A Systematic Review
Prutsky, Gabriela J.; Domecq, Juan Pablo; Elraiyah, Tarig; More

Abstract
Background: Live attenuated influenza vaccine (LAIV) is effective in children but contraindicated in children <2 years of age.

Methods: We searched Medline, EMBASE, the Cochrane Library, Web of Science, Scopus, PsycInfo and CINAHL through February 2013 for existing systematic reviews, randomized controlled trials (RCTs) and observational studies (for safety). We included studies enrolling healthy children <2 years of age who received LAIV, compared with placebo or inactivated influenza vaccine (IIV). Data were extracted independently by 2 investigators. The relative risk (RR) was pooled across studies using the random effects model.

Results: We found 7 eligible randomized controlled trials and 2 observational studies. Randomized controlled trials included 6281 children and were at low to moderate risk of bias. LAIV reduced the incidence of influenza compared with placebo (relative risk = 0.36, 95% confidence interval: 0.23–0.58, P < 0.05) with a number needed to vaccinate of 17. LAIV increased the incidence of minor side effects (fever and rhinorrhea). LAIV had a similar effect in preventing influenza (relative risk = 0.76, 95% confidence interval: 0.45–1.30, P > 0.05) compared with inactivated influenza vaccine. There was an increase of hospitalization rate (post hoc analysis) and medical attended wheezing with LAIV.

Conclusions: LAIV is highly effective in children <2 years of age compared with placebo and is as effective to inactivated influenza vaccine. The safety profile of LAIV is reasonable although evidence is sparse. LAIV may be considered as an option in this age group particularly during seasons with vaccine shortage.

PLoS One
[Accessed 22 March 2014]
http://www.plosone.org/

Research Article
Prevention of HPV-Related Cancers in Norway: Cost-Effectiveness of Expanding the HPV Vaccination Program to Include Pre-Adolescent Boys
Emily A. Burger mail, Stephen Sy, Mari Nygård, Ivar S. Kristiansen, Jane J. Kim http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0089974

Abstract
Background
Increasingly, countries have introduced female vaccination against human papillomavirus (HPV), causally linked to several cancers and genital warts, but few have recommended vaccination of boys. Declining vaccine prices and strong evidence of vaccine impact on reducing HPV-related conditions in both women and men prompt countries to reevaluate whether HPV vaccination of boys is warranted.

Methods
A previously-published dynamic model of HPV transmission was empirically calibrated to Norway. Reductions in the incidence of HPV, including both direct and indirect benefits, were applied to a natural history model of cervical cancer, and to incidence-based models for other non-cervical HPV-related diseases. We calculated the health outcomes and costs of the different HPV-related conditions under a gender-neutral vaccination program compared to a female-only program.

Results
Vaccine price had a decisive impact on results. For example, assuming 71% coverage, high vaccine efficacy and a reasonable vaccine tender price of $75 per dose, we found vaccinating both girls and boys fell below a commonly cited cost-effectiveness threshold in Norway ($83,000/quality-adjusted life year (QALY) gained) when including vaccine benefit for all HPV-related diseases. However, at the current market price, including boys would not be considered ‘good value for money.’ For settings with a lower cost-effectiveness threshold ($30,000/QALY), it would not be considered cost-effective to expand the current program to include boys, unless the vaccine price was less than $36/dose. Increasing vaccination coverage to 90% among girls was more effective and less costly than the benefits achieved by vaccinating both genders with 71% coverage.

Conclusions
At the anticipated tender price, expanding the HPV vaccination program to boys may be cost-effective and may warrant a change in the current female-only vaccination policy in Norway. However, increasing coverage in girls is uniformly more effective and cost-effective than expanding vaccination coverage to boys and should be considered a priority.

PLoS One
[Accessed 22 March 2014]
http://www.plosone.org/

Research Article
Weight-Based Policy of Hepatitis B Vaccination in Very Low Birth Weight Infants in Taiwan: A Retrospective Cross-Sectional Study
Chien-Yi Chen, Huey-Ling Chen, Hung-Chieh Chou, Po-Nien Tsao, Wu-Shiun Hsieh, Mei-Hwei Chang mail
http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0092271

Abstract
Background
The current recommendation of giving the first dose of hepatitis B vaccine to very low birth weight (VLBW) infants at 30 days of chronologic age usually is not practical, because most VLBW infants are not medically stable at that age. We use an alternative body-weight-based protocol, and evaluate its efficacy in an endemic area under a universal immunization program.

Methods
The immunogenicity of the current hepatitis B vaccination strategy in 155 VLBW preterm infants was evaluated at age 2 to 13 years, with parental consent. All of the infants were born between 1995 and 2006, and received their first dose of hepatitis B vaccine when they reached 2,000–2,200 g, irrespective of chronological age. Hepatitis B immunoglobulin (HBIG) was given at birth to infants born to HBsAg(+)/HBeAg(+) mothers.

Results
All 155 of the recruited children were HBsAg and anti-HBc negative. The anti-HBs seropositivity rate (geometric mean titer) was 84.1% (146.5 mIU/mL) for children under 3 years, 73.5% (68.8 mIU/mL) for 4- to 7-year-olds, 27.7% (55.4 mIU/mL) for 8- to 11-year-olds and 20% (6.0 mIU/mL) for children ≥12 years of age. More than 90% of these children received the first vaccination after 30 days of age, half (51%) at 60 to 90 days, and 29 children (18.6%) after 90 days of age. Of the 26 infants born to HBsAg(+) mothers, 6/6 infants of HBeAg(+) mothers received HBIG at birth, and 12/20 infants of HBeAg(−) mothers received HBIG. None of the 26 infants became infected.

Conclusions
Delaying hepatitis B vaccinations in VLBW preterm infants until they reach a weight of 2,000 g, with the administration of HBIG at birth for infants of HBsAg(+) mothers provided adequate immunogenicity and protection in a highly endemic area. Weight-based policy of hepatitis B vaccination is an effective and practical alternative strategy for VLBW infants.

PLoS Neglected Tropical Diseases
February 2014
http://www.plosntds.org/article/browseIssue.action

Yellow Fever Outbreaks in Unvaccinated Populations, Brazil, 2008–2009
Alessandro Pecego Martins Romano, Zouraide Guerra Antunes Costa, Daniel Garkauskas Ramos, Maria Auxiliadora Andrade, Valéria de Sá Jayme, Marco Antônio Barreto de Almeida, Kátia Campomar Vettorello, Melissa Mascheretti, Brendan Flannery
Research Article | published 13 Mar 2014 | PLOS Neglected Tropical Diseases 10.1371/journal.pntd.0002740
http://www.plosntds.org/article/info%3Adoi%2F10.1371%2Fjournal.pntd.0002740

Abstract
Due to the risk of severe vaccine-associated adverse events, yellow fever vaccination in Brazil is only recommended in areas considered at risk for disease. From September 2008 through June 2009, two outbreaks of yellow fever in previously unvaccinated populations resulted in 21 confirmed cases with 9 deaths (case-fatality, 43%) in the southern state of Rio Grande do Sul and 28 cases with 11 deaths (39%) in Sao Paulo state. Epizootic deaths of non-human primates were reported before and during the outbreak. Over 5.5 million doses of yellow fever vaccine were administered in the two most affected states. Vaccine-associated adverse events were associated with six deaths due to acute viscerotropic disease (0.8 deaths per million doses administered) and 45 cases of acute neurotropic disease (5.6 per million doses administered). Yellow fever vaccine recommendations were revised to include areas in Brazil previously not considered at risk for yellow fever.

Author Summary
Yellow fever is a viral hemorrhagic disease transmitted by mosquitos, endemic in tropical regions of Africa and South America. Large urban outbreaks of yellow fever have been eliminated in the Americas, where most yellow fever cases result from human exposure to jungle or forested environments. Vaccination is effective but carries a risk of potentially fatal adverse events in a small number of vaccinees. In a large country such as Brazil, vaccination is recommended only in areas where there is a risk of exposure to yellow fever virus. We describe two outbreaks of yellow fever in areas without yellow fever vaccine recommendations. Numerous epizootics, or die-offs of non-human primates, were reported from areas with human cases. In response to the outbreaks and epizootic activity, over five million doses of vaccine were administered in previously unvaccinated populations, resulting in vaccine associated adverse events, six of which were fatal. The outbreaks resulted in expansion of areas with yellow fever vaccine recommendations, and highlight the need for safer yellow fever vaccines.

Pneumonia
Vol 3 (2014)
https://pneumonia.org.au/index.php/pneumonia/issue/current

ISPPD-9 Special Issue – The 9th International Symposium in Pneumococci and Pneumococcal Diseases
Hyderabad, India, 9-13 March 2014
Abstracts: ISPPD 2014 abstracts (PDF 3.9MB)

Vol 4 (2014)
Reflections on pneumonia in the tropics
Michael Alpers
Abstract
This review of pneumonia in the tropics is based on experience with respiratory infections in Papua New Guinea since the 1970s.  It discusses ideas, principles, historical aspects of pneumonia research and the need to work with the community.  In order to understand pneumonia in a tropical setting and evaluate new interventions it is essential to study the ecosystem of the causative infections, within the host and the community and between interacting microorganisms.  Vaccines are much-needed preventive tools, and for pneumonia in a highly endemic setting the prevention of severe and fatal disease takes priority over the prevention of infection.  In this setting mild infection plays an important role in preventing severe disease.  For achieving long-term sustainable outcomes, sometimes ‘less is more’.  A multipronged approach is required to control and prevent pneumonia, and in devising new ways of doing so.  This includes appropriate and accessible clinical care, a clean, smoke-free environment, good nutrition and a range of vaccines.  Also required are persistent advocacy from the global scientific community and strong engagement with and by the communities that bear the burden of disease.  Better health care must be pursued in conjunction with raising literacy rates and reducing poverty.

Public Health Ethics
Volume 7 Issue 1 April 2014
http://phe.oxfordjournals.org/content/current

Recruiting and Educating Participants for Enrollment in HIV-Vaccine Research: Ethical Implications of the Results of an Empirical Investigation
Sibusiso Sifunda*
HIV, AIDS, STIs & TB (HAST), Human Sciences Research Council, Pretoria, South Africa
Priscilla Reddy
Population Health, Health Systems & Innovation (PHHSI), Human Sciences Research Council, Cape Town, South Africa
Nasheen Naidoo
Health Promotion Research and Development Unit, Medical Research Council, Cape Town
Shamagonam James
Health Promotion Research and Development Unit, Medical Research Council, Cape Town
David Buchanan
+ Author Affiliations
School of Public Health and Health Sciences, University of Massachusetts at Amherst and Director of the Institute for Global Health
http://phe.oxfordjournals.org/content/7/1/78.abstract

Abstract
The study reports on the results of an empirical investigation of the education and recruitment processes used in HIV vaccine trials conducted in South Africa. Interviews were conducted with 21 key informants involved in HIV vaccine research in South Africa and three focus groups of community advisory board members. Data analysis identified seven major themes on the relationship between education and recruitment: the process of recruitment, the combined dual role of educators and recruiters, conflicts perceived by field staff, pressure to achieve recruitment targets, problems in achieving comprehension, accountability and education as capacity building. The results raise ethical concerns about the adequacy of current informed consent processes in these settings. The study findings bear directly on current debates about issues of exploitation and the scope of moral responsibilities of researchers and funding agencies to assure that HIV clinical prevention research is conducted

Public Health Ethics
Volume 7 Issue 1 April 2014
http://phe.oxfordjournals.org/content/current

Ethical Challenges in Implementation Research
Ruth Macklin*
Author Affiliations
Department of Epidemiology & Population Health, Albert Einstein College of Medicine
http://phe.oxfordjournals.org/content/7/1/86.abstract

Abstract
Implementation research is increasingly common in developing countries as a way of studying the introduction to the population of health interventions that have been proven to be effective elsewhere. Implementation studies are often conducted as cluster randomized trials, a design that raises ethical and conceptual questions different from those in conventional randomized controlled trials. It is often unclear who the subjects of the research are, informed consent may be difficult or impossible to obtain and controversy surrounds the use of comparison clusters that provide substandard care to the population where the research is carried out. An examination of protocols for this type of research reveals uncertainty on the part of researchers themselves about whom or what they are studying and from whom (if anyone) informed consent is required.

Risk Analysis
March 2014  Volume 34, Issue 3  Pages 399–598
http://onlinelibrary.wiley.com/doi/10.1111/risa.2014.34.issue-2/issuetoc

Original Research Article
Modeling Uncertainties in Workforce Disruptions from Influenza Pandemics Using Dynamic Input-Output Analysis
Amine El Haimar and Joost R. Santos*
Article first published online: 13 SEP 2013
DOI: 10.1111/risa.12113
http://onlinelibrary.wiley.com/doi/10.1111/risa.12113/abstract

Abstract
Influenza pandemic is a serious disaster that can pose significant disruptions to the workforce and associated economic sectors. This article examines the impact of influenza pandemic on workforce availability within an interdependent set of economic sectors. We introduce a simulation model based on the dynamic input-output model to capture the propagation of pandemic consequences through the National Capital Region (NCR). The analysis conducted in this article is based on the 2009 H1N1 pandemic data. Two metrics were used to assess the impacts of the influenza pandemic on the economic sectors: (i) inoperability, which measures the percentage gap between the as-planned output and the actual output of a sector, and (ii) economic loss, which quantifies the associated monetary value of the degraded output. The inoperability and economic loss metrics generate two different rankings of the critical economic sectors. Results show that most of the critical sectors in terms of inoperability are sectors that are related to hospitals and health-care providers. On the other hand, most of the sectors that are critically ranked in terms of economic loss are sectors with significant total production outputs in the NCR such as federal government agencies. Therefore, policy recommendations relating to potential mitigation and recovery strategies should take into account the balance between the inoperability and economic loss metrics.

Risk Analysis
March 2014  Volume 34, Issue 3  Pages 399–598
http://onlinelibrary.wiley.com/doi/10.1111/risa.2014.34.issue-2/issuetoc

Original Research Article
Understanding Public Perceptions of Benefits and Risks of Childhood Vaccinations in the United States
Geoboo Song*
Article first published online: 13 SEP 2013
DOI: 10.1111/risa.12114
http://onlinelibrary.wiley.com/doi/10.1111/risa.12114/abstract

Abstract
In the face of a growing public health concern accompanying the reemerging threat of preventable diseases, this research seeks mainly to explain variations in the perceived benefits and risks of vaccinations among the general public in the United States. As Mary Douglas and Aaron Wildavsky’s grid-group cultural theory of risk perception claims, the analytical results based upon original data from a nationwide Internet survey of 1,213 American adults conducted in 2010 suggest that individuals’ cultural predispositions contribute to the formation of their perceptions pertaining to vaccine benefits and risks at both societal and individual levels, in conjunction with other factors suggested by previous risk perception literature, such as perceived prevalence of diseases, trust, knowledge level, and demographic characteristics. Those with a strong hierarch orientation tend to envision greater benefits and lesser risks and conceive of a relatively high ratio of benefit to risk when compared to other cultural types. By contrast, those with a strong fatalist tendency are inclined to emphasize risks and downplay benefits while conceiving of a low vaccination benefit-risk ratio. Situated between hierarchs and fatalists, strong egalitarians are prone to perceive greater benefits, smaller risks, and a more positive benefit-risk ratio than strong individualists.

Vaccine
http://www.sciencedirect.com/science/journal/0264410X/32
Volume 32, Issue 18, Pages 2017-2134 (11 April 2014)

Editorial
Rabies: Underused vaccines, unnecessary deaths
Pages 2017-2019
Betty Dodet, David N. Durrheim, Helen Rees
No abstract

Development of a multivalent paediatric human vaccine for rabies virus in combination with Measles–Mumps–Rubella (MMR)
Pages 2020-2021
Anthony R. Fooks, Penelope Koraka, Rik L. de Swart, Charles E. Rupprecht, Albert D.M.E. Osterhaus
No abstract

Vaccine
http://www.sciencedirect.com/science/journal/0264410X/32
Volume 32, Issue 18, Pages 2017-2134 (11 April 2014)

Can the success of pneumococcal conjugate vaccines for the prevention of pneumococcal diseases in children be extrapolated to adults?
Review Article
Pages 2022-2026
Catherine Weil-Olivier, Jacques Gaillat

Abstract
Before conjugate pneumococcal vaccines (PCVs) were introduced it was estimated that Streptococcus pneumoniae caused 500,000 cases of pneumonia, 50,000 cases of bacteremia and 3000 cases of meningitis annually in the United States in both children and adults. After 10 years of routine use of the 7-valent pneumococcal conjugate vaccine (PCV7) the incidence of vaccine-type pneumococcal diseases (PDs) had significantly decreased in vaccinated children (direct effect) and unvaccinated subjects of all ages (indirect effect). Second generation, higher-valent PCVs, especially 13-valent (PCV13), routinely implemented since 2010, have reduced the incidence of PDs caused by the six additional non-PCV7 serotypes, in both vaccinated and unvaccinated subjects. The licence for this vaccine has recently been extended to include adults aged 18 to 49 in Europe. Although PCV13 has an indirect effect on IPD in adults, this will probably not achieve the same level of disease control in adults and the elderly (especially those at high risk) as that obtained in vaccinated children.

As highlighted in this paper, differences exist between children and adults for PD manifestations (incidence, morbidity and mortality) and serotypes isolated in nasopharyngeal carriage and diseases, so benefits from adult vaccination must be considered in this light. PCV13 induces an immune response in adults that is non-inferior for all serotypes common with the 23-valent plain polysaccharide vaccine that is currently recommended for adults and even superior for many serotypes. Although there is no evidence that this immune response translates to clinical efficacy in adults as seen in children, the results from a randomised trial in The Netherlands, expected in 2014, should provide the missing evidence. This evidence and efficient surveillance systems should provide the necessary data, essential for policy makers in their decisions on adult pneumococcal vaccination policies.

Vaccine
http://www.sciencedirect.com/science/journal/0264410X/32
Volume 32, Issue 18, Pages 2017-2134 (11 April 2014)

Community, parental and adolescent awareness and knowledge of meningococcal disease
Original Research Article
Pages 2042-2049
Bing Wang, Michelle Clarke, Hossein Haji Ali Afzali, Helen Marshall

Abstract
Objective
To assess knowledge of invasive meningococcal disease (IMD) and concern about the disease in the South Australian Community including adolescents, adults, parents and non-parents.

Methods
This cross-sectional study was conducted by face to face interviews in South Australia in 2012. Participants were scored on their knowledge and concern about IMD. Univariate and multivariate regression analyses were performed with the survey data weighted by age and gender in accordance with 2011 Census data.

Results
Of 5200 households randomly selected and stratified by metropolitan or rural location, 3055 participants were interviewed with a response rate of 60.3%. The majority were Australian born (74.2%, n = 2267) with 31.8% (n = 972) of those interviewed being parents, and 15.9% (n = 487) adolescents (15–24 years). Almost a quarter of participants (23.5%, n = 717) do not know what meningococcal disease is, with 9.1% (n = 278) believing incorrectly that IMD is a viral infection. 36.6% (n = 1114) had low overall knowledge of IMD. Adolescents (p < 0.050), non-Australian born (p < 0.001), low educational attainment (p = 0.019), low household income (p = 0.011), low/medium socio-economic status (p < 0.050) or living in a metropolitan area (p = 0.006) were more likely to have lower overall knowledge of IMD. Participants who were not parents (p < 0.001), male gender (p < 0.001), single (p < 0.001), highly educated (p = 0.022) or had high household income (p = 0.015), had lower concern about IMD.

Conclusion
Large community knowledge gaps for IMD were observed, particularly amongst adolescents and adults with low educational attainment and low socio-economic status. Improving community knowledge of IMD could help ensure optimal uptake of a new meningococcal vaccine. Our study results can help guide development of community tailored immunisation education programs.

Vaccine
http://www.sciencedirect.com/science/journal/0264410X/32/17
Volume 32, Issue 17, Pages 1897-2016 (7 April 2014)

Educational interventions to increase HPV vaccination acceptance: A systematic review
Review Article
Pages 1901-1920
Linda Y. Fu, Lize-Anne Bonhomme, Spring Chenoa Cooper, Jill G. Joseph, Gregory D. Zimet

Abstract
Background
The Human papillomavirus (HPV) vaccine has been available for protection against HPV-associated cervical cancer and genital warts since 2006. Nonetheless, uptake has varied among countries and populations within countries. Studies have found that individuals’ knowledge and attitudes toward the vaccine are associated with immunization uptake. The purpose of the current review is to summarize and evaluate the evidence for educational interventions to increase HPV vaccination acceptance.

Methods
We searched the databases of PubMed and Web of Science for English-language articles describing educational interventions designed to improve HPV vaccination uptake, intention or attitude.

Results
We identified 33 studies of HPV vaccination educational interventions: 7 tested the effectiveness of interventions with parents, 8 with adolescents or young adults, and 18 compared the effectiveness of different message frames in an educational intervention among adolescents, young adults or their parents. Most studies involved populations with higher educational attainment and most interventions required participants to be literate. The minority of studies used the outcome of HPV vaccine uptake. Well-designed studies adequately powered to detect change in vaccine uptake were rare and generally did not demonstrate effectiveness of the tested intervention.

Conclusions
There is not strong evidence to recommend any specific educational intervention for wide-spread implementation. Future studies are required to determine the effectiveness of culturally-competent interventions reaching diverse populations.

Vaccine
http://www.sciencedirect.com/science/journal/0264410X/32/17
Volume 32, Issue 17, Pages 1897-2016 (7 April 2014)

HPV vaccination: Are we initiating too late?
Original Research Article
Pages 1939-1945
Annika M. Hofstetter, Melissa S. Stockwell, Noor Al-Husayni, Danielle Ompad, Karthik Natarajan, Susan L. Rosenthal, Karen Soren

Abstract
Background
Human papillomavirus (HPV) vaccination is recommended in early adolescence. While limited data suggest that patients frequently delay initiation of the three-dose series, age-based variability in initiation of HPV vaccination and its clinical relevance are not well described. Thus, this study aims to characterize HPV vaccination delay among adolescent and young adult females.

Methods
This retrospective cohort study examined age at HPV vaccination initiation and missed opportunities for receipt of the first vaccine dose (HPV1) among 11–26 year-old females (n = 22,900) receiving care at 16 urban academically-affiliated ambulatory care clinics between 2007 and 2011. Predictors of timely vaccination and post-licensure trends in age at HPV1 receipt were assessed using multivariable logistic regression and a generalized linear mixed model, respectively. Chlamydia trachomatis and Papanicolaou screening before HPV vaccination initiation, as markers of prior sexual experience and associated morbidity, were examined in a subcohort of subjects (n = 15,049).

Results
The proportion of 11–12 year-olds who initiated HPV vaccination increased over time (44.4% [2007] vs. 74.5% [2011], p < 0.01). Initiation rates also improved among 13–26 year-olds. Thus, the mean age at HPV1 receipt remained unchanged between 2007 and 2011 (16.0 ± 2.7 vs. 15.9 ± 4.0 years, p = 0.45). Spanish language was a positive predictor (AOR 1.62, 95% CI 1.05–2.48) of HPV vaccination initiation among 11–12 year-olds in 2011. The majority (70.8–76.4%) of unvaccinated subjects experienced missed vaccination opportunities. Of the subcohort, 36.9% underwent Chlamydia screening before HPV1 receipt (19.1% with ≥1 positive result). Of those with prior Papanicolaou screening (16.6%), 32.1% had ≥1 abnormal result.

Conclusions
These low-income, minority females frequently delayed initiation of HPV vaccination. Many had evidence of prior sexual experience and associated morbidity, placing them at risk of HPV-related complications. Promoting timely HPV vaccination and reducing missed vaccination opportunities are crucial.

Vaccine
http://www.sciencedirect.com/science/journal/0264410X/32/17
Volume 32, Issue 17, Pages 1897-2016 (7 April 2014)

Associations between race, sex and immune response variations to rubella vaccination in two independent cohorts
Original Research Article
Pages 1946-1953
Iana H. Haralambieva, Hannah M. Salk, Nathaniel D. Lambert, Inna G. Ovsyannikova, Richard B. Kennedy, Nathaniel D. Warner, V.Shane Pankratz, Gregory A. Poland

Abstract
Introduction
Immune response variations after vaccination are influenced by host genetic factors and demographic variables, such as race, ethnicity and sex. The latter have not been systematically studied in regard to live rubella vaccine, but are of interest for developing next generation vaccines for diverse populations, for predicting immune responses after vaccination, and for better understanding the variables that impact immune response.

Methods
We assessed associations between demographic variables, including race, ethnicity and sex, and rubella-specific neutralizing antibody levels and secreted cytokines (IFNγ, IL-6) in two independent cohorts (1994 subjects), using linear and linear mixed models approaches, and genetically defined racial and ethnic categorizations.

Results
Our replicated findings in two independent, large, racially diverse cohorts indicate that individuals of African descent have significantly higher rubella-specific neutralizing antibody levels compared to individuals of European descent and/or Hispanic ethnicity (p < 0.001).

Conclusion
Our study provides consistent evidence for racial/ethnic differences in humoral immune response following rubella vaccination.

Vaccine
http://www.sciencedirect.com/science/journal/0264410X/32/17
Volume 32, Issue 17, Pages 1897-2016 (7 April 2014)

Cost-effectiveness of childhood rotavirus vaccination in Germany
Original Research Article
Pages 1964-1974
Pamela Aidelsburger, Kristin Grabein, Katharina Böhm, Markus Dietl, Jürgen Wasem, Judith Koch, Bernhard Ultsch, Felix Weidemann, Ole Wichman

Abstract
Background
Rotavirus (RV) causes a highly contagious gastroenteritis especially in children under five years of age. Since 2006 two RV-vaccines are available in Europe (Rotarix® and RotaTeq®). To support informed decision-making within the German Standing Committee on Vaccination (STIKO) the cost-effectiveness of these two vaccines was evaluated for the German healthcare setting.

Methods
A Markov model was developed to evaluate the cost-effectiveness from the statutory health insurance (SHI) and from the societal perspective. RV-cases prevented, RV-associated hospitalizations avoided, and quality-adjusted life years (QALY) gained were considered as health outcomes. RV-incidences were calculated based on data from the national mandatory disease reporting system. RV-vaccine efficacy was determined as pooled estimates based on data from randomized controlled trials. Vaccine list prices and price catalogues were used for cost-assessment. Effects and costs were discounted with an annual discount rate of 3%.

Results
The base-case analysis (SHI-perspective) resulted in an incremental cost-effectiveness and cost-utility ratio for Rotarix® of € 184 per RV-case prevented, € 2457 per RV-associated hospitalization avoided, and € 116,973 per QALY gained. For RotaTeq®, the results were € 234 per RV-case prevented, € 2622 per RV-associated hospitalization avoided, and € 142,732 per QALY gained. Variation of various parameters in sensitivity analyses showed effects on the ICERs without changing the overall trend of base-case results. When applying base-case results to the 2012 birth cohort in Germany with 80% vaccination coverage, an estimated 206,000–242,000 RV-cases and 18,000 RV-associated hospitalizations can be prevented in this birth cohort over five years for an incremental cost of 44.5–48.2 million €.

Conclusion
Our analyses demonstrate that routine RV-vaccination could prevent a substantial number of RV-cases and hospitalizations in the German healthcare system, but the saved treatment costs are counteracted by costs for vaccination. However, with vaccine prices reduced by ∼62–66%, RV-vaccination could even become a cost-saving preventive measure.

Vaccine
http://www.sciencedirect.com/science/journal/0264410X/32/17
Volume 32, Issue 17, Pages 1897-2016 (7 April 2014)

Costs of vaccine delivery in the Gambia before and after, pentavalent and pneumococcal conjugate vaccine introductions
Original Research Article
Pages 1975-1981
E. Usuf, G. Mackenzie, Y. Lowe-Jallow, B. Boye, D. Atherly, C. Suraratdecha, U.K. Griffiths

Abstract
Background
The Gambia introduced seven-valent pneumococcal conjugate vaccine (PCV) in August 2009 and switched to 13-valent PCV in April 2011. In April 2009 monovalent hepatitis B and combined Diphtheria–Tetanus–Pertussis and Haemophilus influenzae type b vaccines were transitioned to a combined pentavalent vaccine. The current schedule offers three doses of PCV and pentavalent, and continues to give children monovalent hepatitis B vaccine at birth. We estimated the overall costs of the Gambian immunisation programme and the incremental costs of introducing pentavalent and the seven-valent PCV.

Methods
Twenty health facilities out of a total of 56 were surveyed. Data collected included number of vaccine doses delivered, staff time spent on vaccine delivery, distance travelled to collect vaccines, and cold chain expansion due to new vaccine introduction. National level data were collected from key informant interviews. Annualised costs were calculated in 2009 US$.

Results
With a PCV price of US$7 per dose, the incremental costs of introducing PCV was US$1.6 million, equivalent to US$25 per fully immunised child, with systems costs accounting for US$1.90. The switch to pentavalent vaccine resulted in cost savings of US$0.45 per fully immunised child. Total annual costs increased by 45% after the introduction of the new vaccines, amounting to US$ 3.0 million, or US$45 per fully immunised child.

Conclusion
Vaccine prices were the most important determinant of total incremental costs and cold chain expansion the biggest cost component of systems costs.

Vaccine
http://www.sciencedirect.com/science/journal/0264410X/32/17
Volume 32, Issue 17, Pages 1897-2016 (7 April 2014)

School-based vaccination of young US males: Impact of health beliefs on intent and first dose acceptance
Original Research Article
Pages 1982-1987
Vaughn I. Rickert, Beth A. Auslander, Dena S. Cox, Susan L. Rosenthal, Jeffrey A. Rickert, Richard Rupp, Gregory D. Zimet

Abstract
Little is known about adolescent males and their parents with respect to intent and first dose uptake of the human papillomavirus (HPV) vaccine outside of primary care settings. The purpose of this study was to evaluate potential predictors of parental intent to vaccinate (study was conducted in November 2010–December 2012) and of first dose uptake of HPV vaccine among a sample of young adolescent males, 11–15 years of age, who received care at a school-based health center (SBHC). We also examined intent as a potential mediator of the relationships between predictors (health beliefs and perceived spousal agreement) and vaccination. Slightly more than half (n = 135 of 249) of parents reported an intention to vaccinate and 28% (n = 69) of males received their first dose of the HPV vaccine. Two of three health beliefs were significantly associated with both intention and uptake as was perceived spousal agreement. We found intention to vaccinate was a partial meditator between the perceived benefits of HPV vaccine and first dose acceptance. We also determined that intent was a strong mediator between both general immunization benefits and perceived spousal agreement and first dose uptake. While vaccine uptake was lower than expected, particularly considering that many barriers to vaccine initiation were eliminated because of the SBHC setting, this rate is higher than in traditional settings. After controlling for intent, only perceived benefits of the HPV vaccine remained a significant predictor of first dose acceptance.

Value in Health                  
Vol 17 | No. 2 | March 2014 | Pages 141-306
http://www.valueinhealthjournal.com/current

A Questionnaire to Assess the Relevance and Credibility of Observational Studies to Inform Health Care Decision Making: An ISPOR-AMCP-NPC Good Practice Task Force Report  
Marc L. Berger, Bradley C. Martin, Don Husereau, Karen Worley, et al.
Abstract 
Evidence-based health care decisions are best informed by comparisons of all relevant interventions used to treat conditions in specific patient populations. Observational studies are being performed to help fill evidence gaps. Widespread adoption of evidence from observational studies, however, has been limited because of various factors, including the lack of consensus regarding accepted principles for their evaluation and interpretation. Two task forces were formed to develop questionnaires to assist decision makers in evaluating observational studies, with one Task Force addressing retrospective research and the other Task Force addressing prospective research. The intent was to promote a structured approach to reduce the potential for subjective interpretation of evidence and drive consistency in decision making. Separately developed questionnaires were combined into a single questionnaire consisting of 33 items. These were divided into two domains: relevance and credibility. Relevance addresses the extent to which findings, if accurate, apply to the setting of interest to the decision maker. Credibility addresses the extent to which the study findings accurately answer the study question. The questionnaire provides a guide for assessing the degree of confidence that should be placed from observational studies and promotes awareness of the subtleties involved in evaluating those.

Questionnaire to Assess Relevance and Credibility of Modeling Studies for Informing Health Care Decision Making: An ISPOR-AMCP-NPC Good Practice Task Force Report
J. Jaime Caro, David M. Eddy, Hong Kan, Cheryl Kaltz, et al.
Abstract 
The evaluation of the cost and health implications of agreeing to cover a new health technology is best accomplished using a model that mathematically combines inputs from various sources, together with assumptions about how these fit together and what might happen in reality. This need to make assumptions, the complexity of the resulting framework, the technical knowledge required, as well as funding by interested parties have led many decision makers to distrust the results of models. To assist stakeholders reviewing a model’s report, questions pertaining to the credibility of a model were developed. Because credibility is insufficient, questions regarding relevance of the model results were also created. The questions are formulated such that they are readily answered and they are supplemented by helper questions that provide additional detail. Some responses indicate strongly that a model should not be used for decision making: these trigger a “fatal flaw” indicator. It is hoped that the use of this questionnaire, along with the three others in the series, will help disseminate what to look for in comparative effectiveness evidence, improve practices by researchers supplying these data, and ultimately facilitate their use by health care decision makers.

The path of malaria vaccine development: challenges and perspectives
C Arama, M Troye‐Blomberg – Journal of Internal Medicine, 2014
Abstract
Malaria is a life-threatening disease caused by parasites of the Plasmodium genus. In many parts of the world, the parasites have developed resistance to a number of anti-malarial agents. Key interventions to control malaria include prompt and effective treatment with artemisinin-based combination therapies, use of insecticidal nets by individuals at risk and active research into malaria vaccines. Protection against malaria through vaccination was demonstrated more than 30 years ago when individuals were vaccinated via repeated bites by Plasmodium falciparum-infected and irradiated but still metabolically active mosquitoes. However, vaccination with high doses of irradiated sporozoites injected into humans has long been considered impractical. Yet, following recent success using whole-organism vaccines, the approach has received renewed interest; it was recently reported that repeated injections of irradiated sporozoites increased protection in 80 vaccinated individuals. Other approaches include subunit malaria vaccines, such as the current leading candidate RTS,S (consisting of fusion between a portion of the P. falciparum-derived circumsporozoite protein and the hepatitis B surface antigen), which has been demonstrated to induce reasonably good protection. Although results have been encouraging, the level of protection is generally considered to be too low to achieve eradication of malaria. There is great interest in developing new and better formulations and stable delivery systems to improve immunogenicity. In this review we will discuss recent strategies to develop efficient malaria vaccines.

Combining multiple healthcare databases for post‐marketing drug and vaccine safety surveillance: why and how?
G Trifirò, PM Coloma, PR Rijnbeek, S Romio… – Journal of Internal Medicine, 2014
Abstract
A growing number of international initiatives (e.g. EU-ADR, Sentinel, OMOP, PROTECT and VAESCO) are based on the combined use of multiple healthcare databases for the conduct of active surveillance studies in the area of drug and vaccine safety. The motivation behind combining multiple healthcare databases is the earlier detection and validation, and hence earlier management, of potential safety issues. Overall, the combination of multiple healthcare databases increases statistical sample size and heterogeneity of exposure for post-marketing drug and vaccine safety surveillance, despite posing several technical challenges. Healthcare databases generally differ by underlying healthcare systems, type of information collected, drug/vaccine and medical event coding systems and language. Therefore, harmonization of medical data extraction through homogeneous coding algorithms across highly different databases is necessary. Although no standard procedure is currently available to achieve this, several approaches have been developed in recent projects. Another main challenge involves choosing the work models for data management and analyses while respecting country-specific regulations in terms of data privacy and anonymization. Dedicated software (e.g. Jerboa) has been produced to deal with privacy issues by sharing only anonymized and aggregated data using a common data model. Finally, storage and safe access to the data from different databases requires the development of a proper remote research environment. The aim of this review is to provide a summary of the potential, disadvantages, methodological issues and possible solutions concerning the conduct of post-marketing multi-database drug and vaccine safety studies, as demonstrated by several international initiatives.

A Randomized Controlled Trial of Clinician-Led Tactile Stimulation to Reduce Pain During Vaccination in Infants
A Taddio, T Ho, C Vyas, S Thivakaran, A Jamal… – Clinical Pediatrics, 2014
Abstract
Background. Clinician-led tactile stimulation (rubbing the skin adjacent to the injection site or applying pressure) has been demonstrated to reduce pain in children and adults undergoing vaccination. Objective. To evaluate the analgesic effectiveness of clinician-led tactile stimulation in infants undergoing vaccination. Methods. This was a partially blinded randomized controlled trial that included infants undergoing vaccination in a private clinic in Toronto. Infants were randomly allocated to tactile stimulation or no tactile stimulation immediately prior to, during, and after vaccination. The primary outcome was infant pain, assessed using a validated observational measure, the Modified Behavioral Pain Scale (MBPS; range = 0-10). Results. Altogether, 121 infants participated (n = 62 tactile stimulation; n = 59 control); demographics did not differ (P > .05) between groups. MBPS scores did not differ between groups: mean = 7.2 (standard deviation = 2.4) versus 7.6 (1.9); P = .245. Conclusion. Tactile stimulation cannot be recommended as a strategy to reduce vaccination pain in infants because of insufficient evidence of a benefit.

Forbes
http://www.forbes.com/
Accessed 22 March 2014

A Doctor’s Take On The Anti-Vaccine Movement
Today, there are safe and effective vaccines to prevent many types of diseases. Yet a growing number of parents choose not to vaccinate their children, resulting in long-term disability and unnecessary deaths. read »
Robert Pearl, M.D., Contributor

Washington Post
http://www.washingtonpost.com/
Accessed 22 March 2014

Obituaries
Albert Z. Kapikian, prominent National Institutes of Health virologist, dies at 83
Dr. Kapikian led advances in the understanding of the norovirus and the rotavirus.

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

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– Email Summary: Vaccines and Global health : The Week in Review is published as a single email summary, scheduled for release each Saturday eveningbefore midnight (EDT in the U.S.). If you would like to receive the email version, please send your request to david.r.curry@centerforvaccineethicsandpolicy.org.
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– pdf version:  A pdf of the current issues is available here: Vaccines and Global Health_The Week in Review_15 Mar 2014

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– Links:  We endeavor to test each link as we incorporate it into any post, but recognize that some links may become “stale” as publications and websites reorganize content over time. We apologize in advance for any links that may not be operative. We believe the contextual information in a given post should allow retrieval, but please contact us as above for assistance if necessary.
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David R. Curry, MS
Executive Director
Center for Vaccine Ethics and Policy
a program of the
– Division of Medical Ethics, NYU Medical School
– The Wistar Institute Vaccine Center
– Children’s Hospital of Philadelphia Vaccine Education Center
Associate Faculty, Division of Medical Ethics, NYU Medical School

Novel Vaccine Trial Design Aims to Answer Key Tuberculosis Questions and Enhance Vaccine Development Strategy
Prevention of infection study underway in South Africa

Excerpt from Media Release
ROCKVILLE, MD, USA & CAPE TOWN, ZA, March 11, 2014 – Aeras today announced the initiation of the first randomized, controlled tuberculosis (TB) vaccine trial designed to study prevention of Mycobacterium tuberculosis (Mtb) infection by vaccination. The Phase II study of the TB vaccine candidate, H4+IC31 (AERAS-404), will evaluate its safety, immunogenicity, and ability to prevent infection by Mtb, the bacterium that causes TB. The trial, which will be conducted in South Africa, will also evaluate BCG revaccination.

This novel trial design establishes a potential new paradigm in TB vaccine development. Clinical development of TB vaccines is hampered by the lack of biologic correlates of protection and lack of validated preclinical models, which could provide evidence of likely efficacy in early stages of development. The prevention of infection trial design enables a smaller, faster proof of concept to help in deciding on advancement into large-scale disease-prevention trials. While a TB vaccine would not need to prevent infection with Mtb to prevent TB disease, prevention of infection with Mtb would be an important marker of biologic impact.

“For the first time in a TB vaccine trial, we will be testing for infection by Mtb, rather than waiting to measure the occurrence of clinical disease, which is more expensive and requires much larger studies,” said Thomas G. Evans, MD, Aeras President and CEO. “This will enable us to obtain results much more quickly and with fewer subjects, and the data we generate will ensure that the entire field of TB vaccine R&D progresses in a more informed and streamlined way.”…
Full text of media release: http://www.aeras.org/pressreleases/novel-vaccine-trial-design-aims-to-answer-key-tuberculosis-questions-and-en#.UyTTyYUWNdc

GPEI Update: Polio this week – As of 12 March 2014
Global Polio Eradication Initiative
Full report: http://www.polioeradication.org/Dataandmonitoring/Poliothisweek.aspx
[Editor’s extract and bolded text]
:: In Cameroon, two new wild poliovirus type 1 (WPV1) cases are reported this week, from 2014. The new cases confirm continued transmission of this strain and geographic expansion of infected areas following detection of four cases in October.
:: Newsweek Pakistan published an in-depth interview with Dr Hamid Jafari, WHO, about the current situation of polio eradication in Pakistan. The interview can be accessed here.

Pakistan
:: Three new WPV1 cases were reported in the past week, all from Federally Administered Tribal Areas (FATA – two from North Waziristan and one from South Waziristan). The total number of cases for 2014 is now 27. The total number of cases for 2013 remains 93. The most recent case had onset of paralysis on 15 February 2014 (one of the two WPV1s reported this week from North Waziristan).

Central Africa
:: In Cameroon, two new WPV1 cases were reported in the past week, with onset of paralysis on 6 and 25 January 2014, confirming continued WPV1 transmission and geographic expansion of infected areas following detection of four cases in October.
:: Genetic sequencing suggests prolonged undetected circulation.
:: Since confirmation of the outbreak in October, three nationwide campaigns have been conducted, and a fourth is currently underway. However, quality varies greatly by region, and serious gaps remain. As many as 40% of children remain under-immunized (with 30% having received zero doses).
:: The confirmation of new cases has resulted in planning additional emergency outbreak response activities, including converting a subnational immunization campaign to a full nationwide activity in April 2014, and implementing nationwide campaigns in May and June 2014. Critical to success will be to ensure substantial improvement in the quality campaigns that reach all children multiple times with OPV. Equally important will be efforts to rapidly improve the quality of surveillance so that the full extent of the outbreak can be determined and tracked.

2 killed in latest attack on Pakistan polio workers
Agence France Presse
Published — Tuesday 11 March 2014
PESHAWAR, Pakistan: Two policemen guarding a polio vaccination team in northwest Pakistan were shot dead by armed men on Tuesday, police said, the latest setback to efforts to eradicate the crippling disease.
Militant strikes and threats of violence have badly hampered a campaign to stamp out polio in Pakistan, which along with Nigeria and Afghanistan are the only countries where the disease remains endemic.
Tuesday’s attack took place in the village of Gandi Umar Khan, about 20 km west of the nearest city of Dera Ismail Khan, on the second day of an innoculation drive, senior police official Sadiq Baluch said.
Nisar Khan Marwat, another police officer, confirmed the attack, adding: “Two police officials were accompanying two local polio workers when four gunmen riding on two motorbikes shot at them.”…

Roadside bomb kills 3 polio vaccinators in Afghanistan
ANS
Kabul, March 11: A roadside bomb planted by militants struck a vehicle, killing three polio vaccinators in Afghanistan Tuesday, an official said.
“The vaccinators were going to a village in Sangin district (in Helmand province) at midday today to give polio drops to children when their car ran over a mine. As a result, all three were killed,” Omar Zawak, spokesman of the Helmand provincial government, told Xinhua…

Pakistan to pay parents in new polio vaccination drive
Parents in Khyber Pakhtunkhwa province to get 1,000 rupees for each child who completes vaccinations after Peshawar declared largest reservoir of endemic polio
Jon Boone in Peshawar
theguardian.com, Monday 10 March 2014 08.45 EDT
Parents in one of Pakistan‘s most troubled provinces are to be paid to vaccinate their children against polio, the crippling disease the world is tantalisingly close to eradicating.

It is hoped some 2 million children from some of the most disadvantaged areas of Khyber Pakhtunkhwa (KP), the north-western province wracked by Taliban violence, will benefit from the scheme.

Parents will be entitled to claim 1,000 rupees (almost £6) for each newborn child who completes a 15-month programme of vaccinations that will protect them against a number of diseases including measles, hepatitis and polio.

It is the first time the country has resorted to monetary incentives, which are rarely used around the world.

Public health officials battling childhood diseases face immense challenges in KP, where militant attacks are a daily routine, poverty is entrenched and many people are deeply suspicious of programmes enthusiastically backed by western powers.

“It has to be a good amount of money to be attractive, even in the very poorest districts of the province,” said Janbaz Afridi, deputy director of the province’s expanded programme on immunisation. “If it is a success we will extend it to every child in the province.”…

The Weekly Epidemiological Report (WER) for 14 March 2014, vol. 89, 11 (pp. 105–116) includes:
:: Antigenic and genetic characteristics of zoonotic influenza viruses and development of candidate vaccine viruses for pandemic preparedness
:: Monthly report on dracunculiasis cases, January 2014
http://www.who.int/entity/wer/2014/wer8911.pdf?ua=1

WHO: Global Alert and Response (GAR) – Disease Outbreak News

http://www.who.int/csr/don/2013_03_12/en/index.html
:: Middle East respiratory syndrome coronavirus (MERS-CoV) – update 12 March 2014
:: Human infection with avian influenza A(H7N9) virus – update 11 March 2014
:: Human infection with avian influenza A(H7N9) virus – update 11 March 2014
:: Middle East respiratory syndrome coronavirus (MERS-CoV) – update 11 March 2014

Industry Watch  [to 15 March 2014]
Selected media releases and other selected content from industry.

3/12/14 6:37am EDT
Pfizer Presents Detailed Results From Landmark Community-Acquired Pneumonia Immunization Trial In Adults (CAPiTA) Evaluating Efficacy Of Prevenar 13*
Study Findings, Presented at ISPPD, Demonstrate that Prevenar 13 Can Prevent Vaccine-Type Community-Acquired Pneumonia
Pfizer Inc. (NYSE:PFE) today presented detailed results of the Community-Acquired Pneumonia Immunization Trial in Adults (CAPiTA), the landmark study of approximately 85,000 subjects, demonstrating that Prevenar 13* (pneumococcal polysaccharide conjugate vaccine [13-valent, adsorbed]) prevented a first episode of vaccine-type community-acquired pneumonia (CAP) in adults 65 years of age and older, the study’s primary objective. This trial is the first in adults to clearly demonstrate a significant reduction in vaccine-type pneumococcal CAP, and importantly, non-bacteremic/non-invasive vaccine-type pneumococcal CAP. Results were presented during the late-breaker session at the 9th International Symposium on Pneumococci and Pneumococcal Diseases (ISPPD) in Hyderabad, India, on March 12, 2014…

Comment: GAVI Moves on Better Data Verification
Center for Global Development | 11 March 20143/11/14
Victoria Fan  This is a joint post with Kate McQueston.

Excerpt
Data quality and rigorous measurement is important for any funder using performance-based or results-based aid. Poorly measured or self-reported data are often subject to major biases. Indeed, recent CGD research by Justin Sandefur and Amanda Glassman found a clear increase in over-reporting of DTP3 vaccination after GAVI introduced a now defunct pay-for-performance program (its immunization services support program) in the early 2000s.  Thus, strengthening systems to verify data is important and increasingly feasible; recent experience from the World Bank’s HRITF suggests that independent verification of data isn’t overly expensive.

So we’re encouraged by the GAVI Alliance’s new application guidelines, which outline strengthened requirements for data verification of the immunization outcomes used for performance payments as part of its Health System Strengthening (HSS) support. Per the new guidelines, countries must meet both performance goals and “checks and balances for data verification based on WHO/UNICEF estimates, independent assessments of the quality of administrative data, and periodic household surveys.”…

The American Journal of Bioethics
Volume 14, Issue 3, 2014
http://www.tandfonline.com/toc/uajb20/current

The Ethics of Advertising for Health Care Services
Yael Schenkera, Robert M. Arnolda & Alex John Londonb
pages 34-43
Published online: 04 Mar 2014
DOI:10.1080/15265161.2013.879943
http://www.tandfonline.com/doi/abs/10.1080/15265161.2013.879943#.UyTmTYUWNdc

Abstract
Advertising by health care institutions has increased steadily in recent years. While direct-to-consumer prescription drug advertising is subject to unique oversight by the Federal Drug Administration, advertisements for health care services are regulated by the Federal Trade Commission and treated no differently from advertisements for consumer goods. In this article, we argue that decisions about pursuing health care services are distinguished by informational asymmetries, high stakes, and patient vulnerabilities, grounding fiduciary responsibilities on the part of health care providers and health care institutions. Using examples, we illustrate how common advertising techniques may mislead patients and compromise fiduciary relationships, thereby posing ethical risks to patients, providers, health care institutions, and society. We conclude by proposing that these risks justify new standards for advertising when considered as part of the moral obligation of health care institutions and suggest that mechanisms currently in place to regulate advertising for prescription pharmaceuticals should be applied to advertising for health care services more broadly.

American Journal of Public Health
Volume 104, Issue 4 (April 2014)
http://ajph.aphapublications.org/toc/ajph/current

Cumulative Risk of Guillain–Barré Syndrome Among Vaccinated and Unvaccinated Populations During the 2009 H1N1 Influenza Pandemic
Claudia Vellozzi, MD, MPH, Shahed Iqbal, PhD, MBBS, MPH, Brock Stewart, PhD, Jerome Tokars, MD, MPH, and Frank DeStefano, MD, MPH
Claudia Vellozzi, Shahed Iqbal, Brock Stewart, and Frank DeStefano are with the Immunization Safety Office, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA. Jerome Tokars is with the Influenza Division, National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention.
http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2013.301651

Abstract
Objectives. We sought to assess risk of Guillain–Barré syndrome (GBS) among influenza A (H1N1) 2009 monovalent (pH1N1) vaccinated and unvaccinated populations at the end of the 2009 pandemic.

Methods. We applied GBS surveillance data from a US population catchment area of 45 million from October 15, 2009, through May 31, 2010. GBS cases meeting Brighton Collaboration criteria were included. We calculated the incidence density ratio (IDR) among pH1N1 vaccinated and unvaccinated populations. We also estimated cumulative GBS risk using life table analysis. Additionally, we used vaccine coverage data and census population estimates to calculate denominators.

Results. There were 392 GBS cases; 64 (16%) occurred after pH1N1vaccination. The vaccinated population had lower average risk (IDR = 0.83, 95% confidence interval = 0.63, 1.08) and lower cumulative risk (6.6 vs 9.2 cases per million persons, P = .012) of GBS.

Conclusions. Our findings suggest that at the end of the influenza season cumulative GBS risk was less among the pH1N1vaccinated than the unvaccinated population, suggesting the benefit of vaccination as it relates to GBS. The observed potential protective effect on GBS attributed to vaccination warrants further study

Developing World Bioethics
April 2014   Volume 14, Issue 1  Pages ii–ii, 1–57
http://onlinelibrary.wiley.com/doi/10.1111/dewb.2014.14.issue-1/issuetoc

ARTICLE
Impact of Three Years Training on Operations Capacities of Research Ethics Committees in Nigeria
Morenike Oluwatoyin Folayan, Aisha Adaranijo, Florita Durueke, Ademola Ajuwon, Adebayo Adejumo, Oliver Ezechi, Kola Oyedeji and Olayide Akanni
Article first published online: 24 SEP 2012
DOI: 10.1111/j.1471-8847.2012.00340.x
http://onlinelibrary.wiley.com/doi/10.1111/j.1471-8847.2012.00340.x/abstract

Abstract
This paper describes a three-year project designed to build the capacity of members of research ethics committees to perform their roles and responsibilities efficiently and effectively. The project participants were made up of a cross-section of the membership of 13 Research Ethics Committees (RECs) functioning in Nigeria. They received training to develop their capacity to evaluate research protocols, monitor trial implementation, provide constructive input to trial staff, and assess the trial’s success in promoting community engagement in the research.

Following the training, technical assistance was provided to participants on an ongoing basis and the project’s impacts were assessed quantitatively and qualitatively. Results indicate that sustained investment in capacity building efforts (including training, ongoing technical assistance, and the provision of multiple tools) improved the participants’ knowledge of both the ethical principles relevant to biomedical research and how effective REC should function. Such investment was also shown to have a positive impact on the knowledge levels of other RECs members (those who did not receive training) and the overall operations of the RECs to which the participants belonged. Building the capacity of REC members to fulfill their roles effectively requires sustained effort and investment and pays off by enabling RECs to fulfill their essential mission of ensuring that trials are conducted safely and ethically.

Developing World Bioethics
April 2014   Volume 14, Issue 1  Pages ii–ii, 1–57
http://onlinelibrary.wiley.com/doi/10.1111/dewb.2014.14.issue-1/issuetoc

ARTICLE
The Ethics of Engaged Presence: A Framework for Health Professionals in Humanitarian Assistance and Development Work
Matthew R. Hunt, Lisa Schwartz, Christina Sinding and Laurie Elit
Article first published online: 21 DEC 2012
DOI: 10.1111/dewb.12013
http://onlinelibrary.wiley.com/doi/10.1111/dewb.12013/abstract

Abstract
In this article, we present an ethics framework for health practice in humanitarian and development work: the ethics of engaged presence. The ethics of engaged presence framework aims to articulate in a systematic fashion approaches and orientations that support the engagement of expatriate health care professionals in ways that align with diverse obligations and responsibilities, and promote respectful and effective action and relationships. Drawn from a range of sources, the framework provides a vocabulary and narrative structure for examining the moral dimensions of providing development or humanitarian health assistance to individuals and communities, and working with and alongside local and international actors. The elements also help minimize or avoid certain miscalculations and harms. Emphasis is placed on the shared humanity of those who provide and those who receive assistance, acknowledgement of limits and risks related to the contributions of expatriate health care professionals, and the importance of providing skillful and relevant assistance. These elements articulate a moral posture for expatriate health care professionals that contributes to orienting the practice of clinicians in ways that reflect respect, humility, and solidarity. Health care professionals whose understanding and actions are consistent with the ethics of engaged presence will be oriented toward introspection and reflective practice and toward developing, sustaining and promoting collaborative partnerships.

Globalization and Health
[Accessed 15 March 2014]
http://www.globalizationandhealth.com/

Research
Local production of pharmaceuticals in Africa and access to essential medicines: ‘urban bias’ in access to imported medicines in Tanzania and its policy implications
Phares GM Mujinja, Maureen Mackintosh, Mary Justin-Temu and Marc Wuyts
Author Affiliations
Globalization and Health 2014, 10:12  doi:10.1186/1744-8603-10-12
Published: 10 March 2014
http://www.globalizationandhealth.com/content/10/1/12/abstract

Abstract (provisional)
Background
International policy towards access to essential medicines in Africa has focused until recently on international procurement of large volumes of medicines, mainly from Indian manufacturers, and their import and distribution. This emphasis is now being challenged by renewed policy interest in the potential benefits of local pharmaceutical production and supply. However, there is a shortage of evidence on the role of locally produced medicines in African markets, and on potential benefits of local production for access to medicines. This article contributes to filling that gap.

Methods
This article uses WHO/HAI data from Tanzania for 2006 and 2009 on prices and sources of a set of tracer essential medicines. It employs innovative graphical methods of analysis alongside conventional statistical testing.

Results
Medicines produced in Tanzania were equally likely to be found in rural and in urban areas. Imported medicines, especially those imported from countries other than Kenya (mainly from India) displayed ‘urban bias’: that is, they were significantly more likely to be available in urban than in rural areas. This finding holds across the range of sample medicines studied, and cannot be explained by price differences alone. While different private distribution networks for essential medicines may provide part of the explanation, this cannot explain why the urban bias in availability of imported medicines is also found in the public sector.

Conclusions
The findings suggest that enhanced local production may improve rural access to medicines. The potential benefits of local production and scope for their improvement are an important field for further research, and indicate a key policy area in which economic development and health care objectives may reinforce each other.