The Lancet  
Aug 04, 2012  Volume 380  Number 9840  p447 – 536
http://www.thelancet.com/journals/lancet/issue/current

Editorial
Technologies for global health
The Lancet
Preview
“How good is a cure if only ten people can have it…or we haven’t got the money to train doctors to use it properly?” So asks Nadia Fall, director of a new production of The Doctor’s Dilemma, which revolves around rationing for a new treatment for tuberculosis. Access to beneficial health technology, including essential medicines and medical devices, for those most in need is a theme explored in this week’s issue in The Lancet and Imperial College London’s Commission on technologies for global health.

The Lancet Commissions
Technologies for global health
Peter Howitt, Ara Darzi, Guang-Zhong Yang, Hutan Ashrafian, Rifat Atun, James Barlow, Alex Blakemore, Anthony MJ Bull, Josip Car, Lesong Conteh, Graham S Cooke, Nathan Ford, Simon AJ Gregson, Karen Kerr, Dominic King, Myutan Kulendran, Robert A Malkin, Azeem Majeed, Stephen Matlin, Robert Merrifield, Hugh A Penfold, Steven D Reid, Peter C Smith, Molly M Stevens, Michael R Templeton, Charles Vincent, Elizabeth Wilson
Collaboration between The Lancet and Imperial College London, UK, has resulted in a new Commission, which examines how medical technology should best be used to improve health in low- and middle-income countries. The report concludes that in many cases, medical technology—almost exclusively developed in rich countries—is simply inappropriate for use in poorer nations.

Executive summary
According to hospital inventories, an estimated 40% of healthcare equipment in developing countries is out of service, compared with less than 1% in high-income countries. The inappropriate deployment of medical technologies from wealthy countries plays a major part in this high failure rate.

Instead of relying on hand-me-down technologies from wealthier countries, which can be costly, inappropriate for local conditions, and even dangerous, the authors urge a renewed effort towards developing what they call “frugal technologies”—cost-effective technologies that are developed specifically to cope in local conditions. Examples of frugal technologies which have been developed to meet local needs include: the Jaipur foot, a rubber prosthetic for people who have lost their leg and foot below the knee; PATH’s Uniject injection system, which allows once-only use of needles for injectable contraceptives; and the eRanger, a durable rural ambulance, based around a motorbike and stretcher sidecar (which can be modified to carry one or two people).

The report also advocates a wider understanding of what we mean by medical technologies, pointing out that technological improvement to sanitation and road conditions could also have a far-reaching impact on public health in many low- and middle-income countries. Furthermore, the authors argue that advances in technology need to be accompanied by innovation to have a significant effect on health—this includes the development of effective delivery mechanisms and novel approaches to financing.

The Imperial College London/ Lancet Commission

Nature Reviews Immunology
August 2012 Vol 12 No 8
http://www.nature.com/nri/journal/v12/n7/index.html

The immunological life cycle of tuberculosis
Joel D. Ernst
p581 | doi:10.1038/nri3259

Here, Joel Ernst proposes that there are distinct stages in the immune response to Mycobacterium tuberculosis that form an ‘immunological life cycle’. The description of this framework can help the understanding and study of immunity to tuberculosis in humans and animal models.

Immune responses to Mycobacterium tuberculosis are only partially effective; they drive the bacteria into a latent state, but rarely eliminate them. Unfortunately, the latent state of M. tuberculosis is reversible, and reactivation tuberculosis is the source of most transmission. Studies in animal models and in humans have not yet yielded a comprehensive picture of the mechanisms or correlates of immunity to M. tuberculosis infection, or of why immunity fails to eradicate the pathogen. This Review proposes that there are distinct stages in the immune response to M. tuberculosis that form an ‘immunological life cycle’. It is hoped that this thesis will provide a framework for investigation to understand immunity to M. tuberculosis and to guide tuberculosis vaccine discovery and development.

Nature Reviews Immunology
August 2012 Vol 12 No 8
http://www.nature.com/nri/journal/v12/n7/index.html

Recent progress in mucosal vaccine development: potential and limitations
Nils Lycke
p592 | doi:10.1038/nri3251

This Review summarizes the past, current and future directions for the development of mucosal vaccines, with a particular focus on the importance of the formulation, the route of administration and the choice of adjuvant for the induction of protective mucosal immunity.

Most pathogens access the body through the mucosal membranes. Therefore, effective vaccines that protect at these sites are much needed. However, despite early success with the live attenuated oral polio vaccine over 50 years ago, only a few new mucosal vaccines have been subsequently launched. This is partly due to problems with developing safe and effective mucosal adjuvants. In the past decade, however, the successful development of live attenuated mucosal vaccines against influenza virus and rotavirus infections has boosted interest in this field, and great expectations for new mucosal vaccines lie ahead. Here, I discuss the expanding knowledge and strategies used in the development of mucosal vaccines.

Nature Reviews Immunology
August 2012 Vol 12 No 8
http://www.nature.com/nri/journal/v12/n7/index.html

Opinion: Towards an HIV cure: a global scientific strategy
Steven G. Deeks1, Brigitte Autran, Ben Berkhout, Monsef Benkirane, Scott Cairns, Nicolas Chomont, Tae-Wook Chun, Melissa Churchill, Michele Di Mascio, Christine Katlama, Alain Lafeuillade, Alan Landay, Michael Lederman, Sharon R. Lewin, Frank Maldarelli, David Margolis, Martin Markowitz, Javier Martinez-Picado, James I. Mullins, John Mellors, Santiago Moreno, Una O’Doherty, Sarah Palmer, Marie-Capucine Penicaud, Matija Peterlin, Guido Poli, Jean-Pierre Routy, Christine Rouzioux, Guido Silvestri, Mario Stevenson, Amalio Telenti, Carine Van Lint, Eric Verdin, Ann Woolfrey, John Zaia & Françoise Barré-Sinoussi for The International AIDS Society Scientific Working Group on HIV Cure2

Abstract
Given the limitations of antiretroviral therapy and recent advances in our understanding of HIV persistence during effective treatment, there is a growing recognition that a cure for HIV infection is both needed and feasible. The International AIDS Society convened a group of international experts to develop a scientific strategy for research towards an HIV cure. Several priorities for basic, translational and clinical research were identified. This Opinion article summarizes the group’s recommended key goals for the international community.

New England Journal of Medicine
August 2, 2012  Vol. 367 No. 5
http://content.nejm.org/current.shtml

Antiretroviral Prophylaxis for HIV Prevention in Heterosexual Men and Women
J.M. Baeten and Others
Free Full Text
Abstract
Background
Antiretroviral preexposure prophylaxis is a promising approach for preventing human immunodeficiency virus type 1 (HIV-1) infection in heterosexual populations.
Full Text of Background…

Methods
We conducted a randomized trial of oral antiretroviral therapy for use as preexposure prophylaxis among HIV-1–serodiscordant heterosexual couples from Kenya and Uganda. The HIV-1–seronegative partner in each couple was randomly assigned to one of three study regimens — once-daily tenofovir (TDF), combination tenofovir–emtricitabine (TDF–FTC), or matching placebo — and followed monthly for up to 36 months. At enrollment, the HIV-1–seropositive partners were not eligible for antiretroviral therapy, according to national guidelines. All couples received standard HIV-1 treatment and prevention services.
Full Text of Methods…

Results
We enrolled 4758 couples, of whom 4747 were followed: 1584 randomly assigned to TDF, 1579 to TDF–FTC, and 1584 to placebo. For 62% of the couples followed, the HIV-1–seronegative partner was male. Among HIV-1–seropositive participants, the median CD4 count was 495 cells per cubic millimeter (interquartile range, 375 to 662). A total of 82 HIV-1 infections occurred in seronegative participants during the study, 17 in the TDF group (incidence, 0.65 per 100 person-years), 13 in the TDF–FTC group (incidence, 0.50 per 100 person-years), and 52 in the placebo group (incidence, 1.99 per 100 person-years), indicating a relative reduction of 67% in the incidence of HIV-1 with TDF (95% confidence interval [CI], 44 to 81; P<0.001) and of 75% with TDF–FTC (95% CI, 55 to 87; P<0.001). Protective effects of TDF–FTC and TDF alone against HIV-1 were not significantly different (P=0.23), and both study medications significantly reduced the HIV-1 incidence among both men and women. The rate of serious adverse events was similar across the study groups. Eight participants receiving active treatment were found to have been infected with HIV-1 at baseline, and among these eight, antiretroviral resistance developed in two during the study.

Conclusions
Oral TDF and TDF–FTC both protect against HIV-1 infection in heterosexual men and women. (Funded by the Bill and Melinda Gates Foundation; Partners PrEP ClinicalTrials.gov number, NCT00557245.)
Full Text of Discussion…

Preexposure Prophylaxis for HIV Infection among African Women
L. Van Damme and Others
Free Full Text

Antiretroviral Preexposure Prophylaxis for Heterosexual HIV Transmission in Botswana
M.C. Thigpen and Others
Free Full Text

Clinical Decisions
Editorial
Preexposure Prophylaxis for HIV — Where Do We Go from Here?
Myron S. Cohen, M.D., and Lindsey R. Baden, M.D.
N Engl J Med 2012; 367:459-461August 2, 2012

Pediatrics
August 2012, VOLUME 130 / ISSUE 2
http://pediatrics.aappublications.org/current.shtml

Articles
Vaccine-Type Human Papillomavirus and Evidence of Herd Protection After Vaccine Introduction
Jessica A. Kahn, Darron R. Brown, Lili Ding, Lea E. Widdice, Marcia L. Shew, Susan Glynn, and David I. Bernstein
Pediatrics 2012; 130:e249-e256

Abstract
OBJECTIVES: The aims of this study were to compare prevalence rates of human papillomavirus (HPV) in young women before and after HPV vaccine introduction to determine the following: (1) whether vaccine-type HPV infection decreased, (2) whether there was evidence of herd protection, and (3) whether there was evidence for type-replacement (increased prevalence of nonvaccine-type HPV).

METHODS: Young women 13 to 26 years of age who had had sexual contact were recruited from 2 primary care clinics in 2006–2007 for a prevaccination surveillance study (N = 368, none were vaccinated) and 2009–2010 for a postvaccination surveillance study (N = 409, 59% were vaccinated). Participants completed a questionnaire and were tested for cervicovaginal HPV DNA. HPV prevalence rates were compared in the pre- versus postsurveillance studies by using χ2 tests. Propensity score weighting was used to balance differences in covariates between the 2 surveillance studies.

RESULTS: The mean age was ∼19 years for both groups of participants and most were African American and non-Hispanic. After propensity score weighting, the prevalence rate for vaccine-type HPV decreased substantially (31.7%–13.4%, P < .0001). The decrease in vaccine-type HPV not only occurred among vaccinated (31.8%–9.9%, P < .0001) but also among unvaccinated (30.2%–15.4%, P < .0001) postsurveillance study participants. Nonvaccine-type HPV increased (60.7%–75.9%, P < .0001) for vaccinated postsurveillance study participants.

CONCLUSIONS: Four years after licensing of the quadrivalent HPV vaccine, there was a substantial decrease in vaccine-type HPV prevalence and evidence of herd protection in this community. The increase in nonvaccine-type HPV in vaccinated participants should be interpreted with caution but warrants further study.

Pediatrics
August 2012, VOLUME 130 / ISSUE 2
http://pediatrics.aappublications.org/current.shtml

Duration of Protection of Pentavalent Rotavirus Vaccination in Nicaragua
Manish Patel, Cristina Pedreira, Lucia Helena De Oliveira, Jazmina Umaña, Jacqueline Tate, Ben Lopman, Edmundo Sanchez, Martha Reyes, Juan Mercado, Alcides Gonzalez,Maria Celina Perez, Angel Balmaceda, Jon Andrus, and Umesh Parashar
Pediatrics 2012; 130:e365-e372

Abstract
OBJECTIVE: To evaluate the duration of protection of pentavaent rotavirus vaccine (RV5) against rotavirus hospitalizations in Nicaragua, a developing country in Central America.

METHODS: We conducted a case-control study at 4 hospitals from 2007 through 2010, including 1016 children hospitalized with laboratory-confirmed rotavirus diarrhea, 4930 controls with nonrotavirus diarrhea (ie, “test-negative”), and 5627 controls without diarrhea. All cases and controls were aged ≥6 months and born after August 2006. Outcomes included odds of antecedent vaccination between case-patients and controls, and effectiveness of vaccination (1 – adjusted odds ratio [OR] × 100). Duration of protection was assessed by comparing effectiveness among children aged <1 year compared with ≥1 year.

RESULTS: Indicators of socioeconomic conditions and nonrotavirus vaccination (oral polio vaccine and diphtheria/tetanus/pertussis/hepatitis A/hepatitis B) for test-negative controls were more comparable to the rotavirus case-patients than nondiarrhea controls. RV5 vaccination was associated with a significantly lower risk of rotavirus hospitalization by using test-negative controls (OR: 0.55; 95% confidence interval [CI]: 0.41–0.74) and nondiarrhea controls (OR: 0.30; 95% CI: 0.22–0.40). Risk of rotavirus hospitalization was twofold lower among RV5 vaccinated children aged <1 year (OR: 0.36; 95% CI: 0.22–0.57) compared with RV5 vaccinated children aged ≥1 year (OR: 0.70; 95% CI: 0.47–1.05).

CONCLUSIONS: RV5 provided good protection against severe rotavirus disease in Nicaragua during the first year of life, when most severe and fatal rotavirus disease in developing countries occurs. However, the decline in protection with age warrants monitoring of disease among older children and consideration of a booster dose evaluation at the end of infancy.

Pediatrics
August 2012, VOLUME 130 / ISSUE 2
http://pediatrics.aappublications.org/current.shtml

Special Articles
USPSTF Perspective on Evidence-Based Preventive Recommendations for Children
Bernadette Mazurek Melnyk, David C. Grossman, Roger Chou, Iris Mabry-Hernandez, Wanda Nicholson, Thomas G. DeWitt, Adelita G. Cantu, Glenn Flores, and for the US Preventive Services Task Force
Pediatrics 2012; 130:e399-e407

Abstract
The development and use of evidence-based recommendations for preventive care by primary care providers caring for children is an ongoing challenge. This issue is further complicated by the fact that a higher proportion of recommendations by the US Preventive Services Task Force (USPSTF) for pediatric preventive services in comparison with adult services have insufficient evidence to recommend for or against the service. One important root cause for this problem is the relative lack of high quality screening and counseling studies in pediatric primary care settings. The paucity of studies limits the development of additional evidence-based guidelines to enhance best practices for pediatric and adolescent conditions. In this article, we describe the following: (1) evidence-based primary care preventive services as a strategy for addressing important pediatric morbidities, (2) the process of making evidence-based screening recommendations by the USPSTF, (3) the current library of USPSTF recommendations for children and adolescents, and (4) factors influencing the use of USPSTF recommendations and other evidence-based guidelines by clinicians. Strategies to accelerate the implementation of evidence-based services and areas of need for future research to fill key gaps in evidence-based recommendations and guidelines are highlighted.

PLoS One
[Accessed 4 August 2012]
http://www.plosone.org/article/browse.action;jsessionid=577FD8B9E1F322DAA533C413369CD6F3.ambra01?field=date

Pandemic Influenza (A/H1N1) Vaccine Uptake among French Private General Practitioners: A Cross Sectional Study in 2010
Pierre Verger, Rémi Flicoteaux, Michael Schwarzinger, Luis Sagaon-Teyssier, Patrick Peretti-Watel, Odile Launay, Remy Sebbah, Jean-Paul Moatti
PLoS ONE: Research Article, published 03 Aug 2012 10.1371/journal.pone.0041837

Abstract 
Background
In July, 2009, French health authorities, like those in many other countries, decided to embark on a mass vaccination campaign against the pandemic A(H1N1) influenza. Private general practitioners (GPs) were not involved in this campaign. We studied GPs’ pandemic vaccine (pvaccine) uptake, quantified the relative contribution of its potential explanatory factors and studied whether their own vaccination choice was correlated with their recommendations to patients about pvaccination.

Methodology/Principal Findings
In this cross-sectional telephone survey, professional investigators interviewed an existing panel of randomly selected private GPs (N = 1431; response rate at inclusion in the panel: 36.8%; participation rate in the survey: 100%). The main outcome variable was GPs’ own pvaccine uptake. We used an averaging multi-model approach to quantify the relative contribution of factors associated with their vaccination. The pvaccine uptake rate was 61% (95%CI = 58.3–63.3). Four independent factors contributed the most to this rate (partial Nagelkerke’s R2): history of previous vaccination against seasonal influenza (14.5%), perception of risks and efficacy of the pvaccine (10.8%), opinions regarding the organization of the vaccination campaign (7.1%), and perception of the pandemic’s severity (5.2%). Overall, 71.3% (95%CI = 69.0–73.6) of the participants recommended pvaccination to young adults at risk and 40.1% (95%CI = 37.6–42.7) to other young adults. GPs’ own pvaccination was strongly predictive of their recommendation to both young adults at risk (OR = 9.6; 95%CI = 7.2–12.6) and those not at risk (OR = 8.5; 95%CI = 6.4–11.4).

Conclusions/Significance
These results suggest that around 60% of French private GPs followed French authorities’ recommendations about vaccination of health care professionals against the A(H1N1) influenza. They pinpoint priority levers for improving preparedness for future influenza pandemics. Besides encouraging GPs’ own uptake of regular vaccination against seasonal influenza, providing GPs with clear information about the risks and efficacy of any new pvaccine and involving them in the organization of any future vaccine campaign may improve their pvaccine uptake.

PLoS One
[Accessed 4 August 2012]
http://www.plosone.org/article/browse.action;jsessionid=577FD8B9E1F322DAA533C413369CD6F3.ambra01?field=date

An Assessment of the Screening Method to Evaluate Vaccine Effectiveness: The Case of 7-Valent Pneumococcal Conjugate Vaccine in the United States
Adam L. Cohen, Thomas Taylor, Monica M. Farley, William Schaffner, Lindsey J. Lesher, Kenneth A. Gershman, Nancy M. Bennett, Arthur Reingold, Ann Thomas, Joan Baumbach, Lee H. Harrison, Susan Petit, Bernard Beall, Elizabeth Zell, Matthew Moore PLoS ONE: Research Article, published 01 Aug 2012 10.1371/journal.pone.0041785

Abstract 
The screening method, which employs readily available data, is an inexpensive and quick means of estimating vaccine effectiveness (VE). We compared estimates of effectiveness of heptavalent pneumococcal conjugate vaccine (PCV7) against invasive pneumococcal disease (IPD) using the screening and case-control methods. Cases were children aged 19–35 months with pneumococcus isolated from normally sterile sites residing in Active Bacterial Core surveillance areas in the United States. Case-control VE was estimated for 2001–2004 by comparing the odds of vaccination among cases and community controls. Screening-method VE for 2001–2009 was estimated by comparing the proportion of cases vaccinated to National Immunization Survey-derived coverage among the general population. To evaluate the plausibility of screening-method VE findings, we estimated attack rates among vaccinated and unvaccinated persons. We identified 1,154 children with IPD. Annual population PCV7 coverage with ≥1 dose increased from 38% to 97%. Case-control VE for ≥1 dose was estimated as 75% against all-serotype IPD (annual range: 35–83%) and 91% for PCV7-type IPD (annual range: 65–100%). By the screening method, the overall VE was 86% for ≥1 dose (annual range: −240–70%) against all-serotype IPD and 94% (annual range: 62–97%) against PCV7-type IPD. As cases of PCV7-type IPD declined during 2001–2005, estimated attack rates for all-serotype IPD among vaccinated and unvaccinated individuals became less consistent than what would be expected with the estimated effectiveness of PCV7. The screening method yields estimates of VE that are highly dependent on the time period during which it is used and the choice of outcome. The method should be used cautiously to evaluate VE of PCVs.

PLoS One
[Accessed 4 August 2012]
http://www.plosone.org/article/browse.action;jsessionid=577FD8B9E1F322DAA533C413369CD6F3.ambra01?field=date

Were Equatorial Regions Less Affected by the 2009 Influenza Pandemic? The Brazilian Experience
Cynthia Schuck-Paim, Cécile Viboud, Lone Simonsen, Mark A. Miller, Fernanda E. A. Moura, Roberto M. Fernandes, Marcia L. Carvalho, Wladimir J. Alonso
PLoS ONE: Research Article, published 01 Aug 2012 10.1371/journal.pone.0041918

Abstract 
Although it is in the Tropics where nearly half of the world population lives and infectious disease burden is highest, little is known about the impact of influenza pandemics in this area. We investigated the mortality impact of the 2009 influenza pandemic relative to mortality rates from various outcomes in pre-pandemic years throughout a wide range of latitudes encompassing the entire tropical, and part of the subtropical, zone of the Southern Hemisphere (+5°N to −35°S) by focusing on a country with relatively uniform health care, disease surveillance, immunization and mitigation policies: Brazil. To this end, we analyzed laboratory-confirmed deaths and vital statistics mortality beyond pre-pandemic levels for each Brazilian state. Pneumonia, influenza and respiratory mortality were significantly higher during the pandemic, affecting predominantly adults aged 25 to 65 years. Overall, there were 2,273 and 2,787 additional P&I- and respiratory deaths during the pandemic, corresponding to a 5.2% and 2.7% increase, respectively, over average pre-pandemic annual mortality. However, there was a marked spatial structure in mortality that was independent of socio-demographic indicators and inversely related with income: mortality was progressively lower towards equatorial regions, where low or no difference from pre-pandemic mortality levels was identified. Additionally, the onset of pandemic-associated mortality was progressively delayed in equatorial states. Unexpectedly, there was no additional mortality from circulatory causes. Comparing disease burden reliably across regions is critical in those areas marked by competing health priorities and limited resources. Our results suggest, however, that tropical regions of the Southern Hemisphere may have been disproportionally less affected by the pandemic, and that climate may have played a key role in this regard. These findings have a direct bearing on global estimates of pandemic burden and the assessment of the role of immunological, socioeconomic and environmental drivers of the transmissibility and severity of this pandemic.

PLoS One
[Accessed 4 August 2012]
http://www.plosone.org/article/browse.action;jsessionid=577FD8B9E1F322DAA533C413369CD6F3.ambra01?field=date

Vaccination with Embryonic Stem Cells Protects against Lung Cancer: Is a Broad-Spectrum Prophylactic Vaccine against Cancer Possible?
Kavitha Yaddanapudi, Robert A. Mitchell, Kalyani Putty, Sharon Willer, Rajesh K. Sharma, Jun Yan, Haribabu Bodduluri, John W. Eaton
PLoS ONE: Research Article, published 31 Jul 2012 10.1371/journal.pone.0042289

Abstract 
The antigenic similarity between tumors and embryos has been appreciated for many years and reflects the expression of embryonic gene products by cancer cells and/or cancer-initiating stem cells. Taking advantage of this similarity, we have tested a prophylactic lung cancer vaccine composed of allogeneic murine embryonic stem cells (ESC). Naïve C57BL/6 mice were vaccinated with ESC along with a source of granulocyte macrophage-colony stimulating factor (GM-CSF) in order to provide immunostimulatory adjuvant activity. Vaccinated mice were protected against subsequent challenge with implantable Lewis lung carcinoma (LLC). ESC-induced anti-tumor immunity was not due to a non-specific “allo-response” as vaccination with allogeneic murine embryonic fibroblasts did not protect against tumor outgrowth. Vaccine efficacy was associated with robust tumor-reactive primary and memory CD8+ T effector responses, Th1 cytokine response, higher intratumoral CD8+ T effector/CD4+CD25+Foxp3+ T regulatory cell ratio, and reduced myeloid derived suppressor cells in the spleen. Prevention of tumorigenesis was found to require a CD8-mediated cytotoxic T lymphocyte (CTL) response because in vivo depletion of CD8+ T lymphocytes completely abrogated the protective effect of vaccination. Importantly, this vaccination strategy also suppressed the development of lung cancer induced by the combination of carcinogen administration and chronic pulmonary inflammation. Further refinement of this novel vaccine strategy and identification of shared ESC/tumor antigens may lead to immunotherapeutic options for lung cancer patients and, perhaps more importantly, could represent a first step toward the development of prophylactic cancer vaccines.

PLoS One
[Accessed 4 August 2012]
http://www.plosone.org/article/browse.action;jsessionid=577FD8B9E1F322DAA533C413369CD6F3.ambra01?field=date

Awareness and Attitude towards Human Papillomavirus (HPV) Vaccine among Medical Students in a Premier Medical School in India
Deeksha Pandey, Vidhi Vanya, Saurav Bhagat, Binu VS, Jyothi Shetty
PLoS ONE: Research Article, published 31 Jul 2012 10.1371/journal.pone.0040619

Abstract 
Background
As preventing cancer with the help of a vaccine is a comparatively new concept, awareness and education about it will have important implication in the implementation of this strategy.

Materials and Methods
Present explorative questionnaire based survey included 618 MBBS students for final analysis.

Results
Majority of participants (89.6%) were well aware of the preventable nature of cervical cancer. Most of them (89.2%) knew that necessary factor responsible for cervical cancer is infection with high risk HPV. Awareness regarding the availability of vaccine against cervical cancer was 75.6%. Females had a better awareness regarding availability of vaccine, target population for vaccination and about the catch up program. Overall acceptance of HPV vaccine among the population studied was 67.8%. Medical teaching had a definitive impact on the understanding of this important public health issue. Females seemed to be more ready to accept the vaccine and recommend it to others. For our study population the most common source of information was medical school teaching. Majority of participants agreed that the most important obstacle in implementation of HPV vaccination program in our country is inadequate information and 86.2% wanted to be educated by experts in this regard.

Conclusion
HPV vaccine for primary prevention of cervical cancer is a relatively new concept. Health professional will be able to play a pivotal role in popularizing this strategy.

Science        
3 August 2012 vol 337, issue 6094, pages 497-612
http://www.sciencemag.org/current.dtl

News Focus
Polio Campaign
The Polio Emergency
Leslie Roberts
Science 3 August 2012: 514-516.
Can a tough new taskmaster and ramped-up program finally push the global eradication initiative over the finish line?
Summary

Polio Campaign
Fighting Polio in Pakistan
Leslie Roberts
Science 3 August 2012: 517-521.
Pakistan’s 18-year struggle shows why it is so hard to eradicate polio from its last few strongholds.
Summary
Full Text
Podcast Interview

Polio Campaign
Closing a Deadly Refuge
Leslie Roberts
Science 3 August 2012: 520-521.
On 17 July in the town of Gadap in Karachi, Pakistan, two gunmen shot at two men who were participating in a national polio vaccination campaign—sadly, a not uncommon occurrence.
Summary

Science        
3 August 2012 vol 337, issue 6094, pages 497-612
http://www.sciencemag.org/current.dtl

Policy Forum
Research Ethics
Aligning Regulations and Ethics in Human Research
Rebecca Dresser

Government officials are revising the 1991 Common Rule regulations that govern most human research in the United States. They have already received public comments on a 2011 Advance Notice of Proposed Rulemaking (ANPRM) (1). The public will have another chance to comment when officials publish specific proposals. The revision effort’s overall goal is to remove unwarranted regulatory impediments to research while strengthening essential human subject protections. I offer three ideas for additions to the oversight system, each tied to one of the 1979 Belmont Report’s (2) three ethical principles governing human research.

Tropical Medicine & International Health
August 2012  Volume 17, Issue 8  Pages 935–1046, e1–e110
http://onlinelibrary.wiley.com/journal/10.1111/(ISSN)1365-3156/currentissue

Unsustainable funding of high-burden tuberculosis control programmes: who is responsible? (pages 1044–1046)
Verena Mauch, Rob Baltussen and Koos van der Velden
Article first published online: 12 JUN 2012 | DOI: 10.1111/j.1365-3156.2012.03023.x

Abstract [Free access]
The literature suggests that crowding-out effects of government funding for health happen in low-income countries with a high HIV burden. In a survey, we investigated the hypothesis that domestic funding for TB control has fallen in 11 low-income, high-TB-burden countries in the context of changes in gross domestic product (GDP), development assistance inflows and national health expenditures. We found that despite rises in GDP per capita between 2003 and 2009, health expenditure as per cent of GDP fell or stayed the same for the majority of these countries. Although TB control budgets increased for all 11 countries in absolute terms, 6 countries reduced government contribution to TB control. For health programmes to become sustainable in the long run, we suggest increases in donor funding for health to be accompanied by requirements to increase domestic funding for health. We thereby attribute responsibility to avoid crowding-out effects to donors and governments alike. Moreover, it is the responsibility of both to ensure essential items to be funded by government sources to avoid a collapse of programmes once aid is withdrawn.

Vaccine
http://www.sciencedirect.com/science/journal/0264410X
Volume 30, Issue 38  p. 5585-5698 (17 August 2012)
The impact of making vaccines thermostable in Niger’s vaccine supply chain

Original Research Article
Pages 5637-5643
Bruce Y. Lee, Brigid E. Cakouros, Tina-Marie Assi, Diana L. Connor, Joel Welling, Souleymane Kone, Ali Djibo, Angela R. Wateska, Lionel Pierre, Shawn T. Brown

Abstract
Objective
Determine the effects on the vaccine cold chain of making different types of World Health Organization (WHO) Expanded Program on Immunizations (EPI) vaccines thermostable.

Methods
Utilizing a detailed computational, discrete-event simulation model of the Niger vaccine supply chain, we simulated the impact of making different combinations of the six current EPI vaccines thermostable.

Findings
Making any EPI vaccine thermostable relieved existing supply chain bottlenecks (especially at the lowest levels), increased vaccine availability of all EPI vaccines, and decreased cold storage and transport capacity utilization. By far, the most substantial impact came from making the pentavalent vaccine thermostable, increasing its own vaccine availability from 87% to 97% and the vaccine availabilities of all other remaining non-thermostable EPI vaccines to over 93%. By contrast, making each of the other vaccines thermostable had considerably less effect on the remaining vaccines, failing to increase the vaccine availabilities of other vaccines to more than 89%. Making tetanus toxoid vaccine along with the pentavalent thermostable further increased the vaccine availability of all EPI vaccines by at least 1–2%.

Conclusion
Our study shows the potential benefits of making any of Niger’s EPI vaccines thermostable and therefore supports further development of thermostable vaccines. Eliminating the need for refrigerators and freezers should not necessarily be the only benefit and goal of vaccine thermostability. Rather, making even a single vaccine (or some subset of the vaccines) thermostable could free up significant cold storage space for other vaccines, and thereby help alleviate supply chain bottlenecks that occur throughout the world.

Financial Times
http://www.ft.com
Accessed 4 August 2012

Infectious diseases: Innovation can still be a matter of life or death
Financial Times | 31 July 2012
By Andrew Jack

If necessity is the mother of invention, self-interest is the father. The influenza pandemic of 2009 – which first caught the public eye in Mexico – triggered a surge in research, investment and health preparations in the west to tackle the latest manifestation of an ancient scourge. Richer governments invested billions of dollars in purchasing vaccines and drugs, in the process stimulating fresh activity by companies into new technologies in a field long neglected by lack of interest and money.

http://www.ft.com/cms/s/0/1a688bac-d276-11e1-abe7-00144feabdc0.html#axzz22doJwClN

Twitter Watch [accessed 4 August 2012 – 18:42]
Items of interest from a variety of twitter feeds associated with immunization, vaccines and global public health. This capture is highly selective and is by no means intended to be exhaustive.

Arthur Caplan @ArthurCaplan
Editorial: Continue ban on risky flu research | http://StarTribune.com http://www.startribune.com/opinion/editorials/164947126.html
11:12 AM – 4 Aug 12

CDCgov@CDCgov
@CDCgov has staff in Uganda investigating the #ebola outbreak including lab & epi experts. http://go.usa.gov/Gj7
8:20 AM – 4 Aug 12

World Bank @WorldBank
Visualize #globaldev data with free data mapping tools. http://bit.ly/PjreZi #opendata
3:44 AM – 4 Aug 12

ACP ‏@ACPinternists
Communicating Risk-Benefit of #Vaccination to Patients: free recorded webinar http://bit.ly/xA9X0B from American College of Physicians
8:55 AM – 3 Aug 12

Amanda Glassman ‏@glassmanamanda
Global health policy summit – high-level but none of the usual names http://j.mp/N1Ee9Q
2:56 PM – 2 Aug 12

PATH @PATHtweets
We welcome Dr. Ponni Subbiah, the new program leader for PATH’s drug development program,  @OneWorldHealth. http://ow.ly/cFAKd
12:27 PM – 2 Aug 12

UNICEF @UNICEF
Via @GdnDevelopment #Yemen to vaccinate all children against diarrhoea rotavirus, plus UNICEF comment http://uni.cf/OLlF9L #Promise4Children
11:52 AM – 2 Aug 12

Editor’s Notes:

– Email Summary: Vaccines: The Week in Review is available as a weekly email summary: please send your request to david.r.curry@centerforvaccineethicsandpolicy.org.

– pdf version: A pdf of the current issues is available here: Vaccines_The Week in Review_28 July 2012

– Twitter: Readers can also follow developments on twitter: @vaxethicspolicy.

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

World Hepatitis Day 2012: 28 July 2012
“The campaign focuses on raising awareness of the different forms of hepatitis: what they are and how they are transmitted; who is at risk; and the various methods of prevention and treatment. Despite its staggering toll on health, hepatitis remains a group of diseases that are largely unknown, undiagnosed and untreated.

Technical resources
– Prevention and control of viral hepatitis infection: framework for global action

– Hepatitis A, B, C, and E fact sheets

– Position paper on hepatitis A vaccines
pdf, 1.24Mb

– Position paper on hepatitis B vaccines
pdf, 830kb

– Guidance on prevention of viral hepatitis B and C among people who inject drugs

http://www.who.int/csr/disease/hepatitis/world_hepatitis_day/en/index.html

The XIXth International AIDS Conference held in Washington DC, USA 22–27 July 2012 concluded. Conference web site  Key speeches given at the conference or at satellite events included:

Speech: Changing the global health architecture
Dr Margaret Chan
Director-General of the World Health Organization
Statement at the WHO satellite symposium on strategic use of antiretrovirals:
bringing HIV prevention and treatment together
International AIDS Conference
Washington DC, USA
22 July 2012
http://www.who.int/dg/speeches/2012/global_health_architecture_20120722/en/index.html

Speech: Towards the elimination of new HIV infections among children
Dr Margaret Chan
Director-General of the World Health Organization
Opening remarks at the UNICEF high-level meeting on innovations for elimination of new HIV infections among children
International AIDS Conference
Washington DC, USA
22 July 2012
http://www.who.int/dg/speeches/2012/aids_pmtct_20120722/en/index.html

Speech: From scientific advances to public health implementation
Anthony S. Fauci, M.D., director of the National Institute of Allergy and Infectious Diseases (NIAID) at the National Institutes of Health
At AIDS 2012, Fauci delivers opening plenary on ending the HIV/AIDS pandemic
http://www.nih.gov/news/health/jul2012/niaid-23.htm

Speech: World Bank Group President Jim Yong Kim Remarks at the Opening Plenary of the International AIDS Conference 2012
World Bank Group President Jim Yong Kim
Opening Plenary, International AIDS Conference 2012
Washington, DC, United States
July 22, 2012
As Prepared for Delivery
http://www.worldbank.org/en/news/2012/07/22/world-bank-group-president-jim-yong-kim-remarks-at-the-opening-plenary-international-aids-conference-2012

The Korea National Institute of Health and the International Vaccine Institute (IVI) announced a memorandum of understanding to “expedite research and development of vaccines for public use.” According to the MOU, the two organizations “will boost research cooperation in vaccine development, and strengthen and expand cooperation in diverse fields of interest, including:

– Development of vaccines against emerging or re-emerging infectious diseases with a public health purpose;

– Molecular epidemiological studies for vaccine development; and

– Sharing information and resources in the field of emerging and re-emerging infectious diseases.

The two organizations “expect strengthened cooperation between the two sides will generate synergistic effect in the field of vaccine R&D, and thus enable them to emerge as global centers of research, including in the development of next-generation vaccines.”

IVI Director-General Dr. Christian Loucq added, “IVI is very pleased to collaborate with KNIH on vaccine research projects and training initiatives, which will mutually benefit the two organizations as well as Korea’s vaccine R&D. More importantly, this collaboration will ultimately contribute to improving the health and well-being of people in Korea and worldwide.”

http://www.ivi.org/web/www/07_01?p_p_id=EXT_BBS&p_p_lifecycle=0&p_p_state=normal&p_p_mode=view&_EXT_BBS_struts_action=%2Fext%2Fbbs%2Fview_message&_EXT_BBS_messageId=278

The Global Fund “welcomed an announcement by Spain’s Ministry of Foreign Relations and Cooperation that it will contribute €10 million (around US$12.1 million) to the Global Fund, a resumption of funding that signals Spain’s deep commitment to disease prevention and treatment.” The decision is expected to be confirmed by the Board of Spain’s Fund for the Promotion of Development on 30 July. Spain ranks as the 9th largest donor to the Global Fund based on its cumulative contributions. In addition to contributing financially, Spain “participates in the development of policies and strategies to fight the three diseases through its representation on the Global Fund’s Board.”

http://www.theglobalfund.org/en/mediacenter/newsreleases/2012-07-25_Global_Fund_Recognizes_Signal_of_Deep_Commitment_by_Spain/

The Decade of Vaccines (DoV) Collaboration announced that its Leadership Council organizations “are now focusing on the points made in the resolution passed by WHA on the GVAP.” These include “working to help countries and regions apply the GVAP vision, creating strategies to develop immunization components of national health plans and allocating adequate human and financial resources to achieve immunization goals and monitor progress made.” The DoV Collaboration Secretariat “is beginning to transition key areas to the Leadership Council organizations as part of the GVAP implementation planning process for the coming decade. The DoV Collaboration Secretariat will wrap up their work as originally planned by December 31, 2012.” Current areas of work include defining a Monitoring and Accountability Framework which involves “…a group of experts working to further refine and define the GVAP indicators that will be monitored, as well as a framework and process to evaluate progress at national, regional and global levels.”

More at: http://www.dovcollaboration.org/dov-collaboration-updates/july-2012-dov-collaboration-update/

UN Appointment: Secretary-General Appoints Michel Kazatchkine as Special Envoy for HIV/AIDS in Eastern Europe and Central Asia (20 July 2012)
SG/A/1361-AIDS/181

The International Federation of Pharmaceutical Manufacturers & Associations (IFPMA) called for “broad-based cooperation to fight online sales of counterfeit medicines around the world.”  23 July 2012

Media Release:
http://www.ifpma.org/fileadmin/content/News/2012/FINAL_press_release_-_Fight_against_counterfeiting_-_IFPMA_PhRMA_EFPIA_JPMA_23_JULY_2012.pdf

Statement:
http://www.ifpma.org/fileadmin/content/News/2012/FINAL_Joint_Industry_Internet_Statement.pdf

   The Weekly Epidemiological Record (WER) for 27 July 2012, vol. 87, 30 (pp 277–288) includes: Health conditions for travellers to Saudi Arabia for the pilgrimage to Mecca (Hajj); Global Advisory Committee on Vaccine Safety, June 2012

http://www.who.int/entity/wer/2012/wer8730.pdf

The MMWR Weekly for July 27, 2012 / Vol. 61 / No. 29 includes:

– World Hepatitis Day — July 28, 2012

– Progress Toward Prevention and Control of Hepatitis C Virus Infection — Egypt, 2001–2012

– Notes from the Field: Outbreak of Influenza A (H3N2) Virus Among Persons and Swine at a County Fair — Indiana, July 2012

British Medical Journal
28 July 2012 (Vol 345, Issue 7867)
http://www.bmj.com/content/345/7867

Feature
Global Health
Paying the poor
Using cash incentives to encourage healthy behaviour among poor communities is being hailed as a new silver bullet in global health. Megan Tan and Gavin Yamey investigate why this popular idea went so badly wrong in Guatemala

Extract
The Economist calls it “the world’s favourite new anti-poverty device.”1 Global health donors, development agencies, and governments in developing countries praise it as a way of empowering women and investing in community development. A remarkably simple idea that took root in the late 1990s—offering poor mothers cash incentives to enrol their families in health and education programmes—is now being used in over 40 developing countries, from Mexico to Burkina Faso, Cambodia to Yemen.

Although each country’s incentive programme has its own characteristics, the basic idea is the same: impoverished mothers are paid a regular cash stipend in exchange for meeting certain predetermined conditions, or “coresponsibilities” as they are often called in Latin America. Typically, these conditions include attending regular medical check-ups and ensuring that children go to school. In most countries, parents must also attend educational seminars on topics such as nutrition, hygiene, and money management.       Advocates believe that that these cash rewards, known as “conditional cash transfers,” will get transformed over the long run into improved maternal and child health and economic development.

But against this backdrop of intense fervour for cash rewards, a series of missteps and crises led Guatemala to recently suspend its conditional cash transfer programme, called Mi Familia Progresa (My Family Makes Progress) or MIFAPRO. The suspension takes the shine off the reputation of cash transfers as a silver bullet and serves as a cautionary tale for donors and developing countries that are currently planning similar programmes.

High hopes
Although the World Bank classifies Guatemala as a middle income country, over half the population lives in poverty. The country’s …

Cost Effectiveness and Resource Allocation
(Accessed 28 July 2012)
http://www.resource-allocation.com/

Research
Planning influenza vaccination programs: a cost benefit model
Ian G Duncan, Michael S Taitel, Junjie Zhang and Heather S Kirkham
Cost Effectiveness and Resource Allocation 2012, 10:10 doi:10.1186/1478-7547-10-10
Published: 26 July 2012

Abstract (provisional)
Background
Although annual influenza vaccination could decrease the significant economic and humanistic burden of influenza in the United States, immunization rates are below recommended levels, and concerns remain whether immunization programs can be cost beneficial. The research objective was to compare cost benefit of various immunization strategies from employer, employee, and societal perspectives.

Methods
An actuarial model was developed based on the published literature to estimate the costs and benefits of influenza immunization programs. Useful features of the model included customization by population age and risk-level, potential pandemic risk, and projection year. Various immunization strategies were modelled for an average U.S. population of 15,000 persons vaccinated in pharmacies or doctor’s office during the 2011/12 season. The primary outcome measure reported net cost savings per vaccinated (PV) from the perspective of various stakeholders.

Results
Given a typical U.S. population, an influenza immunization program will be cost beneficial for employers when more than 37% of individuals receive vaccine in non-traditional settings such as pharmacies. The baseline scenario, where 50% of persons would be vaccinated in non-traditional settings, estimated net savings of $6 PV. Programs that limited to pharmacy setting ($31 PV) or targeted persons with high-risk comorbidities ($83 PV) or seniors ($107 PV) were found to increase cost benefit. Sensitivity analysis confirmed the scenario-based findings.

Conclusions
Both universal and targeted vaccination programs can be cost beneficial. Proper planning with cost models can help employers and policy makers develop strategies to improve the impact of immunization programs.

The complete article is available as a provisional PDF. The fully formatted PDF and HTML versions are in production.

Emerging Infectious Diseases
Volume 18, Number 8—August 2012
http://www.cdc.gov/ncidod/EID/index.htm

Synopses
Vaccination of Health Care Workers to Protect Patients at Increased Risk for Acute Respiratory Disease
PDF Version [PDF – 291 KB – 10 pages]
G. P. Dolan et al.

Evidence is limited but sufficient to sustain current vaccination recommendations.

Health Policy and Planning
Volume 27 Issue 5  August 2012
http://heapol.oxfordjournals.org/content/current

Original articles
Avian and pandemic human influenza policy in South-East Asia: the interface between economic and public health imperatives
Health Policy Plan. (2012) 27(5): 374-383 doi:10.1093/heapol/czr056
Petcharat Pongcharoensuk, Wiku Adisasmito, Le Minh Sat, Pornpit Silkavute, Lilis Muchlisoh, Pham Cong Hoat, and Richard Coker

Abstract
The aim of this study was to analyse the contemporary policies regarding avian and human pandemic influenza control in three South-East Asia countries: Thailand, Indonesia and Vietnam. An analysis of poultry vaccination policy was used to explore the broader policy of influenza A H5N1 control in the region. The policy of antiviral stockpiling with oseltamivir, a scarce regional resource, was used to explore human pandemic influenza preparedness policy. Several policy analysis theories were applied to analyse the debate on the use of vaccination for poultry and stockpiling of antiviral drugs in each country case study. We conducted a comparative analysis across emergent themes.

The study found that whilst Indonesia and Vietnam introduced poultry vaccination programmes, Thailand rejected this policy approach. By contrast, all three countries adopted similar strategic policies for antiviral stockpiling in preparation. In relation to highly pathogenic avian influenza, economic imperatives are of critical importance. Whilst Thailand’s poultry industry is large and principally an export economy, Vietnam’s and Indonesia’s are for domestic consumption. The introduction of a poultry vaccination policy in Thailand would have threatened its potential to trade and had a major impact on its economy. Powerful domestic stakeholders in Vietnam and Indonesia, by contrast, were concerned less about international trade and more about maintaining a healthy domestic poultry population. Evidence on vaccination was drawn upon differently depending upon strategic economic positioning either to support or oppose the policy.

With influenza A H5N1 endemic in some countries of the region, these policy differences raise questions around regional coherence of policies and the pursuit of an agreed overarching goal, be that eradication or mitigation. Moreover, whilst economic imperatives have been critically important in guiding policy formulation in the agriculture sector, questions arise regarding whether agriculture sectoral policy is coherent with public health sectoral policy across the region.

JAMA   
July 25, 2012, Vol 308, No. 4
http://jama.ama-assn.org/current.dtl
This issue of JAMA is largely themed to HIV/AIDS including editorials, research and clinical practice topics.

Viewpoint |
Toward an AIDS-Free Generation
Anthony S. Fauci, MD; Gregory K. Folkers, MS, MPH
JAMA. 2012;308(4):343-344. doi:10.1001/jama.2012.8142

Extract
… The prospect of an HIV cure remains challenging.7 Despite the considerable success of antiretroviral therapy in reducing viremia and improving patient health, it has not been possible to cure an individual of HIV infection—ie, to induce permanent remission in the absence of therapy. Over the past 3 years, an accelerated research effort has been undertaken to elucidate the exact mechanisms of HIV persistence and to develop interventions to eliminate or permanently suppress recalcitrant HIV reservoirs.  The effects of a cure would substantially benefit the individual, obviating the need for lifelong daily therapy. In addition, society would benefit because of the reduction in treatment costs and rates of HIV transmission.

The availability of combination antiretroviral therapy for prevention as well as treatment, advances in preexposure prophylaxis with oral or mucosally delivered antiretroviral medications to reduce an individual’s risk of acquiring HIV infection, together with scaling up medical male circumcision, services for pregnant HIV-infected women, condom provision, and other proven prevention tools suggest that controlling and ultimately ending the global HIV/AIDS pandemic is possible. Achieving this goal, however, will require implementing a multifaceted global effort to expand testing, treatment, and prevention programs, as well as meet the scientific challenges of developing an HIV vaccine and possibly a cure. Realization of success will require a global commitment of resources involving additional donor countries, strengthening health care systems overall, and fostering greater ownership by host countries of HIV/AIDS effort, including investing more in the health of their people. With collective and resolute action now and a steadfast commitment for years to come, an AIDS-free generation is indeed within reach.

The Lancet Infectious Disease
Aug 2012  Volume 12  Number 8  p577 – 646
http://www.thelancet.com/journals/laninf/issue/current

Editorial
Cambodian outbreak tests International Health Regulations
The Lancet Infectious Diseases
Preview
The news that emerged from Cambodia in the first week of July of an unknown fatal illness that had killed at least 60 children in the previous 3 months, and the subsequent interagency response, shows how the International Health Regulations (IHRs) can work in practice. The event also serves as a timely reminder of the progress that still needs to be made to implement the IHR provisions in all WHO member states.

The Lancet Infectious Disease
Aug 2012  Volume 12  Number 8  p577 – 646
http://www.thelancet.com/journals/laninf/issue/current

Comment
Vaccines targeting serogroup B meningococci
Muhamed-Kheir Taha, Ala Eddine Deghm
Preview
In The Lancet Infectious Diseases, Peter Richmond and colleagues1 report results of a phase 2 trial of a bivalent vaccine for Neisseria meningitidis containing two variants of lipoprotein 2086, a surface-exposed and immunogenic factor H binding protein. This protein is conserved in N meningitidis and is polymorphic, with a high number of variants that are classified into two families (A and B).2 Lipoprotein 2086 induces bactericidal antibodies against strains of different phenotypes.3 Cross-immune reactivity occurs for proteins encoded by alleles of the same family but not of different families.

Articles
Safety, immunogenicity, and tolerability of meningococcal serogroup B bivalent recombinant lipoprotein 2086 vaccine in healthy adolescents: a randomised, single-blind, placebo-controlled, phase 2 trial
Peter C Richmond, Helen S Marshall, Michael D Nissen, Qin Jiang, Kathrin U Jansen, Maria Garcés-Sánchez, Federico Martinón-Torres, Johannes Beeslaar, Leszek Szenborn, Jacek Wysocki, Joseph Eiden, Shannon L Harris, Thomas R Jones, John L Perez, on behalf of the 2001 Study Investigators

Summary
Background
Neisseria meningitidis serogroup B is a major cause of invasive meningococcal disease, but a broadly protective vaccine is not currently licensed. A bivalent recombinant factor H-binding protein vaccine (recombinant lipoprotein 2086) has been developed to provide broad coverage against diverse invasive meningococcus serogroup B strains. Our aim was to test the immune response of this vaccine.

Methods
This randomised, placebo-controlled trial enrolled healthy adolescents from 25 sites in Australia, Poland, and Spain. Exclusion criteria were previous invasive meningococcal disease or serogroup B vaccination, previous adverse reaction or known hypersensitivity to the vaccine, any significant comorbidities, and immunosuppressive therapy or receipt of blood products in the past 6 months. Participants were randomly assigned with a computerised block randomisation scheme to receive ascending doses of vaccine (60, 120, or 200 μg) or placebo at 0, 2, and 6 months. Principal investigators, participants and their guardians, and laboratory personnel were masked to the allocation; dispensing staff were not. Immunogenicity was measured by serum bactericidal assays using human complement (hSBA) against eight diverse meningococcus serogroup B strains. The co-primary endpoints were seroconversion for the two indicator strains (PMB1745 and PMB17) analysed by the Clopper-Pearson method. Local and systemic reactions and adverse events were recorded. The study is registered at ClinicalTrials.gov, number NCT00808028.

Findings
539 participants were enrolled and 511 received all three study vaccinations—116 in the placebo group, 21 in the 60 μg group, 191 in the 120 μg group, and 183 in the 200 μg group. The proportion of participants responding with an hSBA titre equal to or greater than the lower limit of quantitation of the hSBA assays (reciprocal titres of 7 to 18, depending on test strain) was similar for the two largest doses and ranged from 75·6 to 100·0% for the 120 μg dose and 67·9 to 99·0% for the 200 μg dose. Seroconversion for the PMB1745 reference strain was 17 of 19 (89·5%) participants for the 60 μg dose, 103 of 111 (92·8%) participants for the 120 μg dose, 94 of 100 (94·0%) participants for the 200 μg dose, and four of 73 (5·5%) participants for placebo. For the PMB17 reference strain seroconversion was 17 of 21 (81·0%) participants for the 60 μg dose, 97 of 112 (86·6%) participants for the 120 μg dose, 89 of 105 (84·8%) participants for the 200 μg dose, and one of 79 (1·3%) participants for placebo. The hSBA response was robust as shown by the high proportion of responders at hSBA titres up to 16. Mild-to-moderate injection site pain was the most common local reaction (50 occurrences with the 60 μg dose, 437 with the 120 μg dose, 464 with the 200 μg dose, and 54 with placebo). Systemic events, including fatigue and headache, were generally mild to moderate. Overall, adverse events were reported by 18 participants (81·8%) in the 60 μg group, 77 (38·9%) in the 120 μg group, 92 (47·2%) in the 200 μg group, and 54 (44·6%) in the placebo group. Fevers were rare and generally mild (one in the 60 μg group, 24 in the 120 μg group, 35 in the 200 μg group, and five in the placebo group; range, 0—6·3% after each dose). Incidence and severity of fever did not increase with subsequent vaccine dose within groups. One related serious adverse event that resolved without sequelae occurred after the third dose (200 μg).

Interpretation
The bivalent recombinant lipoprotein 2086 vaccine is immunogenic and induces robust hSBA activity against diverse invasive meningococcus serogroup B disease strains and the vaccine is well tolerated. Recombinant lipoprotein 2086 vaccine is a promising candidate for broad protection against invasive meningococcus serogroup B disease.

Funding
Wyeth, Pfizer.

The Lancet Infectious Disease
Aug 2012  Volume 12  Number 8  p577 – 646
http://www.thelancet.com/journals/laninf/issue/current

Comment
Male vaccination against human papillomavirus
David M Salisbury

Preview
If high enough coverage for vaccination against human papillomavirus (HPV) can be achieved in girls and women, boys and men should be protected from infection. Hence, routine vaccination of male adolescents might not be cost effective. At present, only Austria and the USA have recommended routine vaccination against HPV in boys and men as well as in girls and women. No reports of the coverage among male recipients seem to be available for Austria, and the US recommendation is only newly made. The consequences of such programmes, therefore, cannot be assessed.

Review
Population-wide vaccination against human papillomavirus in adolescent boys: Australia as a case study
Melina Georgousakis, Sanjay Jayasinghe, Julia Brotherton, Nicole Gilroy, Clayton Chiu, Kristine Macartney

Summary
Female-only vaccination programmes for human papillomavirus (HPV) have been introduced in many countries aimed at the prevention of cervical cancer in women. One HPV vaccine is registered for male vaccination, but boys, men, or both, are not yet included in nationally funded HPV vaccination programmes. In this Review we discuss the different considerations relevant to the introduction of population-wide HPV vaccination of boys in Australia, which was the first country to publicly fund HPV vaccination of girls. Several factors need to be taken into account during decision making around the introduction of population-based vaccination programmes, such as local disease burden, vaccine efficacy, vaccine safety, and cost-effectiveness. Social and ethical factors are also important. Although evidence for men is increasing in these areas, uncertainties need to be kept in mind. The features discussed in this Review are likely to be applicable, with caveats, to policy making in other developed countries.

PLoS One
[Accessed 28 July 2012]
http://www.plosone.org/article/browse.action;jsessionid=577FD8B9E1F322DAA533C413369CD6F3.ambra01?field=date

Personal Decision-Making Criteria Related to Seasonal and Pandemic A(H1N1) Influenza-Vaccination Acceptance among French Healthcare Workers
Lila Bouadma, François Barbier, Lucie Biard, Marina Esposito-Farèse, Bertrand Le Corre, Annick Macrez, Laurence Salomon, Christine Bonnal, Caroline Zanker, Christophe Najem, Bruno Mourvillier, Jean Christophe Lucet, Bernard Régnier, Michel Wolff, Florence Tubach, for the INFLUENCE-A Study Group
PLoS ONE: Research Article, published 27 Jul 2012 10.1371/journal.pone.0038646

Abstract 
Background
Influenza-vaccination rates among healthcare workers (HCW) remain low worldwide, even during the 2009 A(H1N1) pandemic. In France, this vaccination is free but administered on a voluntary basis. We investigated the factors influencing HCW influenza vaccination.

Methods
In June–July 2010, HCW from wards of five French hospitals completed a cross-sectional survey. A multifaceted campaign aimed at improving vaccination coverage in this hospital group was conducted before and during the 2009 pandemic. Using an anonymous self-administered questionnaire, we assessed the relationships between seasonal (SIV) and pandemic (PIV) influenza vaccinations, and sociodemographic and professional characteristics, previous and current vaccination statuses, and 33 statements investigating 10 sociocognitive domains. The sociocognitive domains describing HCWs’ SIV and PIV profiles were analyzed using the classification-and-regression–tree method.

Results
Of the HCWs responding to our survey, 1480 were paramedical and 401 were medical with 2009 vaccination rates of 30% and 58% for SIV and 21% and 71% for PIV, respectively (p<0.0001 for both SIV and PIV vaccinations). Older age, prior SIV, working in emergency departments or intensive care units, being a medical HCW and the hospital they worked in were associated with both vaccinations; while work shift was associated only with PIV. Sociocognitive domains associated with both vaccinations were self-perception of benefits and health motivation for all HCW. For medical HCW, being a role model was an additional domain associated with SIV and PIV.

Conclusions
Both vaccination rates remained low. Vaccination mainly depended on self-determined factors and for medical HCW, being a role model.

PLoS One
[Accessed 28 July 2012]
http://www.plosone.org/article/browse.action;jsessionid=577FD8B9E1F322DAA533C413369CD6F3.ambra01?field=date

Research Questions and Priorities for Tuberculosis: A Survey of Published Systematic Reviews and Meta-Analyses
Ioana Nicolau, Daphne Ling, Lulu Tian, Christian Lienhardt, Madhukar Pai
PLoS ONE: Research Article, published 27 Jul 2012 10.1371/journal.pone.0042479

Abstract 
Background
Systematic reviews are increasingly informing policies in tuberculosis (TB) care and control. They may also be a source of questions for future research. As part of the process of developing the International Roadmap for TB Research, we did a systematic review of published systematic reviews on TB, to identify research priorities that are most frequently suggested in reviews.

Methodology/Principal Findings
We searched EMBASE, MEDLINE, Web of Science, and the Cochrane Library for systematic reviews and meta-analyses on any aspect of TB published between 2005 and 2010. One reviewer extracted data and a second reviewer independently extracted data from a random subset of included studies. In total, 137 systematic reviews, with 141 research questions, were included in this review. We used the UK Health Research Classification System (HRCS) to help us classify the research questions and priorities. The three most common research topics were in the area of detection, screening and diagnosis of TB (32.6%), development and evaluation of treatments and therapeutic interventions (23.4%), and TB aetiology and risk factors (19.9%). The research priorities determined were mainly focused on the discovery and evaluation of bacteriological TB tests and drug-resistant TB tests and immunological tests. Other important topics of future research were genetic susceptibility linked to TB and disease determinants attributed to HIV/TB. Evaluation of drug treatments for TB, drug-resistant TB and HIV/TB were also frequently proposed research topics.

Conclusions
Systematic reviews are a good source of key research priorities. Findings from our survey have informed the development of the International Roadmap for TB Research by the TB Research Movement.

PLoS One
[Accessed 28 July 2012]
http://www.plosone.org/article/browse.action;jsessionid=577FD8B9E1F322DAA533C413369CD6F3.ambra01?field=date

Improving Community Coverage of Oral Cholera Mass Vaccination Campaigns: Lessons Learned in Zanzibar
Christian Schaetti, Said M. Ali, Claire-Lise Chaignat, Ahmed M. Khatib, Raymond Hutubessy, Mitchell G. Weiss
PLoS ONE: Research Article, published 23 Jul 2012 10.1371/journal.pone.0041527

Abstract 
Background
Recent research in two cholera-endemic communities of Zanzibar has shown that a majority (~94%) of the adult population was willing to receive free oral cholera vaccines (OCVs). Since OCV uptake in the 2009 campaign reached only ~50% in these communities, an evaluation of social and cultural factors and of barriers was conducted to understand this difference for future cholera control planning.

Methodology/Principal Findings
A random sample of 367 adult peri-urban and rural community residents (46.6% immunized vs. 53.4% unimmunized) was studied with a semi-structured interview that inquired about social and cultural features of cholera depicted in a vignette and barriers to OCV uptake. Symptoms (rectal pain, loose skin only in rural community) and perceived causes (uncovered food, contact with contaminated water) specific for severe diarrhea were associated with uptake. Purchasing drugs from pharmacies to stop diarrhea and vomiting was negatively associated with uptake. Increasing household size, age and previous enteric illness episode were positively related to uptake, the latter only at the rural site. The most prominent barrier to uptake was competing obligations or priorities (reported by 74.5%, identified as most important barrier by 49.5%). Next most prominent barriers were lacking information about the campaign (29.6%, 12.2%), sickness (14.3%, 13.3%) and fear of possible vaccine side effects (15.3%, 5.6%). The majority of unvaccinated respondents requested repetition of the vaccination with free OCVs.

Conclusions/Significance
Factors associated with uptake indicated a positive impact of the vaccination campaign and of sensitization activities on vaccine acceptance behavior. Unlike communities opposed to cholera control or settings where public confidence in vaccines is lacking, identified barriers to uptake indicated a good campaign implementation and trust in the health system. Despite prospects and demand for repeating the vaccination, local decision-makers should reconsider how careful logistical arrangements may improve community coverage and thus effectiveness of vaccination campaigns.

PLoS One
[Accessed 28 July 2012]
http://www.plosone.org/article/browse.action;jsessionid=577FD8B9E1F322DAA533C413369CD6F3.ambra01?field=date

Epidemiologic and Economic Burden of Influenza in the Outpatient Setting: A Prospective Study in a Subtropical Area of China
Ru-ning Guo, Hui-zhen Zheng, Li-qun Huang, Yong Zhou, Xin Zhang, Chan-kun Liang, Jin-yan Lin, Jian-feng He, Jin-qing Zhang
PLoS ONE: Research Article, published 20 Jul 2012 10.1371/journal.pone.0041403

Abstract 
Objectives
To understand the incidence of outpatient influenza cases in a subtropical area of China and the associated economic burden on patients’ families.

Methods
A hospital-based prospective study was conducted in Zhuhai City during 2008–2009. All outpatient influenza-like illness (ILI) cases were identified in 28 sentinel hospitals. A representative sample of throat swabs from ILI cases were collected for virus isolation using Madin-Darby canine kidney cells. The incidence of outpatient influenza cases in Zhuhai was estimated on the basis of the number of influenza patients detected by the sentinel sites. A telephone survey on the direct costs associated with illness was conducted as a follow-up.

Results
The incidence of influenza was estimated to be 4.1 per 1,000 population in 2008 and 19.2 per 1,000 population in 2009. Children aged <5 years were the most-affected population, suffering from influenza at the highest rates (34.3 per 1,000 population in 2008 and 95.3 per 1,000 population in 2009). A high incidence of 29.2–40.9 per 1000 population was also seen in young people aged 5–24 years in 2009. ILI activity and influenza virus isolations adopted a consistent seasonal pattern, with a summer peak in July 2008 and the longest epidemic period lasting from July–December 2009. The medical costs per episode of influenza among urban patients were higher than those for rural patients. A total of $1.1 million in direct economic losses were estimated to be associated with outpatient influenza during 2008–2009 in Zhuhai community.

Conclusions
Influenza attacks children aged <5 years in greater proportions than children in other age groups. Seasonal influenza 2008 and Pandemic influenza A (H1N1) 2009 had different epidemiological and etiological characteristics. Direct costs (mostly medical costs) impose an enormous burden on the patient family. Vaccination strategies for high-risk groups need to be further strengthened.

PNAS – Proceedings of the National Academy of Sciences of the United States
of America
(Accessed 28 July 2012)
http://www.pnas.org/content/early/recent

Agriculture Development and Nutrition Security Special Feature – Introduction
Laurette Dubé, Prabhu Pingali, and Patrick Webb
2012 ; published ahead of print July 23, 2012, doi:10.1073/pnas.0912951109
http://www.pnas.org/content/early/2012/07/20/0912951109.abstract

Abstract
This special feature calls for forward thinking around paths of convergence for agriculture, health, and wealth. Such convergence aims for a richer integration of smallholder farmers into national and global agricultural and food systems, health systems, value chains, and markets. The articles identify analytical innovation, where disciplines intersect, and cross-sectoral action where single, linear, and siloed approaches have traditionally dominated. The issues addressed are framed by three main themes: (i) lessons related to agricultural and food market growth since the 1960s; (ii) experiences related to the integration of smallholder agriculture into national and global business agendas; and (iii) insights into convergence-building institutional design and policy, including a review of complexity science methods that can inform such processes. In this introductory article, we first discuss the perspectives generated for more impactful policy and action when these three themes converge. We then push thematic boundaries to elaborate a roadmap for a broader, solution-oriented, and transdisciplinary approach to science, policies, and actions. As the global urban population crosses the 50% mark, both smallholder and nonsmallholder agriculture are keys in forging rural–urban links, where both farm and nonfarm activities contribute to sustainable nutrition security. The roadmaps would harness the power of business to reduce hunger and poverty for millions of families, contribute to a better alignment between human biology and modern lifestyles, and stem the spread of noncommunicable chronic diseases.

Science        
27 July 2012 vol 337, issue 6093, pages 381-496
http://www.sciencemag.org/current.dtl

Policy Forum
Intellectual Property
Challenges to India’s Pharmaceutical Patent Laws
Bhaven N. Sampat, Kenneth C. Shadlen, and Tahir M. Amin
Science 27 July 2012: 414-415.
Published online 5 July 2012 [DOI:10.1126/science.1224892]

The Indian Supreme Court will soon hear final arguments in a challenge by the pharmaceutical company Novartis against the Indian Patent Office’s (IPO) rejection of a patent for the leukemia drug Glivec. We discuss key issues, particularly the patentability of new compounds versus variants of existing compounds, and how the outcome of the case might affect patent terms and access to drugs in the developing world.

Vaccine
http://www.sciencedirect.com/science/journal/0264410X
Volume 30, Issue 37 pp. 5449-5584 (10 August 2012)

Risk factors for low vaccination coverage among Roma children in disadvantaged settlements in Belgrade, Serbia
Original Research Article
Pages 5459-5463
Kristefer Stojanovski, Gerry McWeeney, Nedret Emiroglu, Piroska Ostlin, Theadora Koller, Lucianne Licari, Dorit Nitzan Kaluski

Abstract
Background
Full vaccination coverage for children under 59 months of age in Serbia is over 90%. This study assesses vaccination coverage and examines its association with birth registration among Roma children who resided in disadvantaged settlements in Belgrade, Serbia.

Methods
The First Roma Health and Nutrition Survey in Belgrade settlements, 2009, was conducted among households of 468 Roma children between the ages of 6–59 months. The 2005 WHO Immunization Coverage Cluster Survey sampling methodology was employed. Vaccinations were recorded using children’s vaccination cards and through verification steps carried out in the Primary Health Care Centers. For those who had health records the information on vaccination was recorded.

Results
About 88% of children had vaccination cards. The mean rate of age appropriate full immunization was 16% for OPV and DTP and 14.3% for MMR. Multivariate analyses indicated that children whose births were registered with the civil authorities were more likely to have their vaccination cards [OR = 6.1, CI (2.5, 15.0)] and to have their full, age appropriate, series vaccinations for DTP, OPV, MMR and HepB [OR = 3.8, CI (1.5, 10.0), OR = 3.2, CI (1.5, 6.6), OR = 4.8, CI (1.1, 21.0), OR = 5.4, CI (1.4, 21.6), respectively].

Conclusions
The immunization coverage among Roma children in settlements is far below the WHO/UNICEF MDG4 target in achieving prevention and control of vaccine preventable diseases. It demonstrates the need to include “invisible” populations into the health systems in continuous, integrated, comprehensive, accessible and sensitive modes.

Vaccine
http://www.sciencedirect.com/science/journal/0264410X
Volume 30, Issue 37 pp. 5449-5584 (10 August 2012)

Impact of postpartum information about pertussis booster to parents in a university maternity hospital
Original Research Article
Pages 5472-5481
Bertrand Leboucher, Loïc Sentilhes, Fatma Abbou, Estelle Henry, Emmanuel Grimprel, Philippe Descam

Abstract
Parent-to-infant transmission of pertussis remains an issue in France. Although adult booster vaccination was introduced in 2004 as part of a cocooning strategy targeted primarily to parents of young infants, vaccination coverage in this population has remained low. The aim of this study was to evaluate the impact on vaccination coverage, over two consecutive years, of a protocol in which information about the pertussis booster and a prescription for pertussis vaccine were given to parents upon discharge from a French university maternity hospital. A questionnaire was administered to mothers two months after delivery, during two 3-month periods in 2008 and 2009. Participation rates were 67% (first period) and 76.3% (second period). Information about pertussis was delivered mainly by paediatricians and midwives and was considered clear and pertinent in more than 95% of cases. In 2009, 69% of mothers and 63% of fathers who received a prescription for pertussis vaccine before discharge from the maternity declared being vaccinated, with no difference as compared to 2008. Vaccination was done by a general practitioner (95.9%) and mostly in the first month after birth (81%). Postpartum information about pertussis was successfully implemented and well understood by parents in the maternity hospital and should contribute towards increasing pertussis vaccination coverage in parents of young children.

Vaccine
http://www.sciencedirect.com/science/journal/0264410X
Volume 30, Issue 37 pp. 5449-5584 (10 August 2012)

Reduction of HPV infections through vaccination among at-risk urban adolescents
Original Research Article
Pages 5496-5499
Teresa Cummings, Gregory D. Zimet, Darron Brown, Wanzhu Tu, Ziyi Yang, J. Dennis Fortenberry, Marcia L. Shew

Abstract
Introduction
Human papillomavirus (HPV) vaccine trials have demonstrated high efficacy in preventing HPV infections and HPV related disease in females ages 16–26. However, there is no source data to demonstrate the impact of the vaccine in other populations who may be at higher risk for HPV related disease. This study examines the impact of HPV vaccination on subsequent HPV detection and sexual behaviors among urban adolescents in a clinical setting.

Methods
A cohort of adolescent women, ages 14–17, were recruited prospectively and matched to historical controls to assess the impact of HPV vaccination. All women completed the same questionnaire and face-to-face interview that assessed sexual behaviors; all provided a clinician or self-collected vaginal swab that was used to test for sexually transmitted infections, including HPV. Logistic regression models, incorporating random pair effects, were used to assess the impact of the HPV vaccine on HPV detection and sexual behaviors between the two groups.

Results
Each woman recruited (N = 75) was matched to 2 historical controls (HC); most of the recruited women (89.3%) had received one or more doses of the HPV vaccine. At enrollment, detection of quadrivalent vaccine types (HPV 6, 11, 16 and 18) was significantly less in the recruited group (5.3%) as compared to the HC (24%): OR = 5.6 (CI = 1.9, 16.5), p = 0.002. Adolescent women in the HC had a 9.5 times greater odds of HPV infection when the analysis was adjusted to compare those who had 2 or more vaccine doses to their matched controls. The only behavioral difference found was that the recruited women used condoms more frequently.

Conclusion
This study demonstrates that HPV vaccination was associated with fewer vaccine-type HPV infections despite incomplete vaccination and high risk sexual behaviors. These data also suggest that sexual behaviors were not altered because of the vaccine.

Vaccine
http://www.sciencedirect.com/science/journal/0264410X
Volume 30, Issue 37 pp. 5449-5584 (10 August 2012)

Potential impact of parental Tdap immunization on infant pertussis hospitalizations
Original Research Article
Pages 5527-5532
Timothy R. Peters, Gretchen C. Banks, Beverly M. Snively, Katherine A. Poehling

Abstract
We estimated the potential impact of parental Tdap immunization before delivery, at delivery and at the 2-week newborn visit on U.S. infant pertussis hospitalizations. We used published data for pertussis hospitalization rates among U.S. infants aged 0–4 months, the Tdap vaccine efficacy in adults, and the proportion of infants with pertussis <6 months of age in which either parent was the source (16–40% from mothers and 16–20% from fathers). Immunizing parents before pregnancy or ≥2 weeks prior to delivery should reduce pertussis hospitalizations among infants 0–4 months by 2694–9314 if both parents are vaccinated, and by 1347–6909 if only mothers are vaccinated. Greater reductions in pertussis hospitalizations would be achieved if parents are immunized ≥2 weeks prior to delivery than after delivery or the 2-week newborn visit. Although immunizing parents prior to pregnancy or delivery is best, immunizing parents in the postpartum period should provide protection to that newborn and to infants of subsequent pregnancies.

Vaccine
http://www.sciencedirect.com/science/journal/0264410X
Volume 30, Issue 37 pp. 5449-5584 (10 August 2012)

High HPV vaccination uptake rates for adolescent girls after regional governmental funding in Shiki City, Japan
Original Research Article
Pages 5547-5550
Y. Hayashi, Y. Shimizu, S. Netsu, S. Hanley, R. Konno

Abstract
Background
In Japan, the bivalent HPV vaccine was approved in October, 2009 and became available as a non-routine vaccine from December, 2009. While routine vaccinations are free, the cost and responsibility for non-routine vaccinations are left to the individual. In exceptional circumstances regional governments fund non-routine vaccinations. This was the case in Shiki City, Saitama Prefecture, where a high uptake rate for individual (non-school based) HPV vaccination was obtained.

Materials
On January 20, 2010, the mayor of Shiki City announced to the media his decision to vaccinate adolescent girls in Shiki City against HPV. A project team for HPV vaccination was set up in the city’s Health Promotion Center. To gain mutual consent for HPV vaccination, senior health professionals, city officials, the head of the board of education, school principals and health-care teachers met several times. The cohort to be vaccinated was 1254 girls aged 12–15 years. Individual notifications were mailed to each girl on April 23, 2010, along with information about the HPV vaccine.

Conclusions
As of April 10th, 2011, the uptake rate for girls aged 15 years old was 90.7% for the 1st dose. The vaccine registry is managed by the health care system of the city. The success of the HPV vaccination program and high uptake rates in Shiki City is a good model for the nationwide HPV vaccination program that started in February, 2011.

Vaccine
http://www.sciencedirect.com/science/journal/0264410X
Volume 30, Issue 37 pp. 5449-5584 (10 August 2012)

An economic evaluation of the use of Japanese encephalitis vaccine in the expanded program of immunization of Guizhou province, China
Original Research Article
Pages 5569-5577
Zundong Yin, Garrett R. Beeler Asay, Li Zhang, Yixing Li, Shuyan Zuo, Yvan J. Hutin, Guijun Ning, Hardeep S. Sandhu, Lisa Cairns, Huiming Luo, Guizhou JE Study Group

Abstract
Background
Historically, China’s Japanese encephalitis vaccination program was a mix of household purchase of vaccine and government provision of vaccine in some endemic provinces. In 2006, Guizhou, a highly endemic province in South West China, integrated JE vaccine into the provincial Expanded Program on Immunization (EPI); later, in 2007 China fully integrated 28 provinces into the national EPI, including Guizhou, allowing for vaccine and syringe costs to be paid at the national level. We conducted a retrospective economic analysis of JE integration into EPI in Guizhou province.

Methods
We modeled two theoretical cohorts of 100,000 persons for 65 years; one using JE live-attenuated vaccine in EPI (first dose: 95% coverage and 94.5% efficacy; second dose: 85% coverage and 98% efficacy) and one not. We assumed 60% sensitivity of surveillance for reported JE rates, 25% case fatality, 30% chronic disability and 3% discounting. We reviewed acute care medical records and interviewed a sample of survivors to estimate direct and indirect costs of illness. We reviewed the EPI offices expenditures in 2009 to estimate the average Guizhou program cost per vaccine dose.

Results
Use of JE vaccine in EPI for 100,000 persons would cost 434,898 US$ each year (46% of total cost due to vaccine) and prevent 406 JE cases, 102 deaths, and 122 chronic disabilities (4554 DALYs). If we ignore future cost savings and only use EPI program cost, the program would cost 95.5 US$/DALY, less than China Gross Domestic Product per capita in 2009 (3741 US$). From a cost–benefit perspective taking into account future savings, use of JE vaccine in EPI for a 100,000-person cohort would lead to savings of 1,591,975 US$ for the health system and 11,570,989 US$ from the societal perspective.

Conclusions
In Guizhou, China, use of JE vaccine in EPI is a cost effective investment. Furthermore, it would lead to savings for the health system and society.

Wall Street Journal
http://online.wsj.com/home-page

OPINION
July 24, 2012, 6:57 p.m. ET
How to Eradicate Polio Once and for All
Only three endemic countries remain—Pakistan, Afghanistan and Nigeria. But they pose special problems.
BY JAY WINSTEN AND EMILY SERAZIN

Extract
Earlier this year, the World Health Organization removed India from the list of polio-endemic countries, a victory that involved 2.4 million volunteers administering vaccine to nearly 172 million children. Only three endemic countries remain—Pakistan, Afghanistan, and Nigeria—and a massive 24-year global effort to eradicate the disease forever is now within striking distance of its goal. However, there is still a very real danger that the entire campaign could come undone if obstacles to vaccination stall further progress and enable the disease to escape its current confines.

An intensive effort is underway to prevent any further spread of the virus while …

http://online.wsj.com/article/SB10000872396390444025204577546562570306028.html?mod=dist_smartbrief