The MMWR Weekly for May 11, 2012 / Vol. 61 / No. 18 includes:
– New Framework (GRADE) for Development of Evidence-Based Recommendations by the Advisory Committee on Immunization Practices

Twitter Watch [accessed 12 May 2012 – 16:46]
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.

EndPolioNow @EndPolioNow
Amazing photos from the @UNICEF polio vaccination campaigns in South Sudan http://www.unicef.org/photography/photo_infocus.php#UNI122548
2:16 PM – 12 May 12

IVAC at JHSPH @IVACtweets
Good wknd reading: Monitoring the Fight – blog on new estimates of global child mortality, & what they mean: http://bit.ly/JsChzX
9:00 AM – 12 May 12

Dagfinn Høybråten @Hoybraten
We are closer than ever to beating #polio, but the funding shortfall may undermine the progress against the disease. http://bit.ly/JHSJNP
Retweeted by GAVI Alliance
1:15 AM – 12 May 12

PATH @PATHtweets
Congratulations to Dr. F. Marc LaForce for winning the prestigious Sabin Gold Medal Award! http://ow.ly/aL11a
Retweeted by GAVI Alliance
5:46 PM – 7 May 12

UNICEF USA@unicefusa
The @UPS Dir. of Humanitarian Logistics blogs about how logistical expertise helps @UNICEF in times of crisis http://bit.ly/IUhGXu #SahelNOW
Retweeted by UNICEF
9:02 AM – 10 May 12

IVAC at JHSPH @IVACtweets
How do #globalhealth workers deliver diff #vaccines w/ consistency? Expert group talking primary containers http://bit.ly/JnBIG5
9:00 AM – 10 May 12

The Global Fund @globalfundnews
#GlobalFund forecasts $1.6b in available funds for 2012-2014 reflects strategic choices by board, renewed confidence http://bit.ly/IZJ2N2
3:56 AM – 10 May 12

Report: Ranking Vaccines: A Prioritization Framework – Phase I: Demonstration of Concept and a Software Blueprint
IOM

“As a number of diseases emerge or reemerge, thus stimulating new vaccine development opportunities to help prevent those diseases, it can be especially difficult for decision makers to know where to invest their limited resources. Therefore, it is increasingly important for decision makers to have the tools that can assist and inform their vaccine prioritization efforts. Ranking Vaccines: A Prioritization Framework describes a decision-support model and the blueprint of software called Strategic Multi-Attribute Ranking Tool for Vaccines, or SMART Vaccines, that should help decision makers prioritize new vaccines by accounting for demographic, economic, health, scientific, business, programmatic, social, policy and related factors. This study is being conducted in two phases. The first phase report which is being released describes a model—tested with three vaccine candidates—that can ultimately be used to prioritize new vaccines. Thus, this report describes a product that is purposefully midstream in development. In the next phase of this work, the committee will obtain feedback on the model from stakeholders to enhance SMART Vaccines. Moreover, the second phase of this study will test the model with three additional vaccines candidates.”

Read the Report >>

Report: Assembling the pharmaceutical R&D puzzle for needs in the developing world.
Pugatch Consilium – Meir Perez Pugatch, Rachel Chu & David Torstensson
May 2012

New report offers a blueprint to boost research and development (R&D) for diseases of the developing world

The IFPMA announced a new study was released “reviewing initiatives to encourage research and development (R&D) for diseases such as HIV, tuberculosis, malaria and neglected tropical diseases.” The report introduces “a blueprint based on six enabling factors that comprise: identification of gaps in the R&D process, mitigation of risk and cost of R&D, ability to translate research into clinical outcomes, sustainability of funding for specific disease areas, effective access to new medicines, and compatibility with different R&D mechanisms.” The report also provides a review of key mechanisms currently being discussed by global health policymakers which “delink the cost of R&D from the price of medicines, such as open databases, research grants, and advanced market commitments.”  The report’s authors conclude that multiple mechanisms are required to effectively address diverse R&D needs of the developing world. http://www.ifpma.org/fileadmin/content/News/2012/FINAL_-__IFPMA_Press_Release_-_R_D_in_developing_world_study_-_10_May_2012.pdf

Report: http://www.ifpma.org/fileadmin/content/Publication/2012/Assembling_the_RD_puzzle_FINAL.pdf

Journal of Infectious Diseases
Volume 205 Issue 11 June 1, 2012
http://www.journals.uchicago.edu/toc/jid/current

EDITORIAL COMMENTARIES
Biosecurity and Censorship: the H5N1 Influenza Controversy
Martin S. Hirsch

In this issue of The Journal of Infectious Diseases (JID), 3 short articles by leaders in influenza virus research and/or biosecurity discuss current controversies regarding experiments with bioengineered H5N1 influenza virus. Sander Herfst and colleagues, the creators of an H5N1 virus strain with increased …

PERSPECTIVES:
Sander Herfst, Albert D. M. E. Osterhaus, and Ron A. M. Fouchier
The Future of Research and Publication on Altered H5N1 Viruses
J Infect Dis. (2012) 205(11): 1628-1631 first published online March 27, 2012 doi:10.1093/infdis/jis257
a href=”http://jid.oxfordjournals.org/content/205/11/1628.abstract”>Abstract

PERSPECTIVES:
Nicole M. Bouvier
The Science of Security Versus the Security of Science
J Infect Dis. (2012) 205(11): 1632-1635 first published online March 27, 2012 doi:10.1093/infdis/jis256
Extract

PERSPECTIVES:
Michael T. Osterholm and David A. Relman
Creating a Mammalian-Transmissible A/H5N1 Influenza Virus: Social Contracts, Prudence, and Alternative Perspectives
J Infect Dis. (2012) 205(11): 1636-1638 first published online March 27, 2012 doi:10.1093/infdis/jis259
Extract

The Lancet  
May 12, 2012  Volume 379  Number 9828  p1763 – 1850  e50 – 51
http://www.thelancet.com/journals/lancet/issue/current

Comment
Re-engineering the European Union Clinical Trials Directive
MJH Kenter, AF Cohen

Preview
The European Union Clinical Trials Directive 2001/20/EC (EU CTD), which was introduced in 2004 for drug trials, aims to protect European citizens who take part in research, safeguard data quality, and harmonise the review of clinical trials. Unfortunately, the directive is based on an ill-defined, two-tier assessment system in which two review bodies—a national competent authority and a research ethics committee (REC)—both evaluate the same clinical trial application in every member state. The European Commission is currently considering a revision of the EU CTD, but this will simply build further on the current directive’s flawed foundations.

Nature  
Volume 485 Number 7397 pp147-272  10 May 2012
http://www.nature.com/nature/current_issue.html

Comment
Policy reform: Strengthen and stabilize the FDA
Daniel Carpenter
Nature 485, 169–170 (10 May 2012)
doi:10.1038/485169a
Published online  09 May 2012

The US Food and Drug Administration needs to be more independent, says Daniel Carpenter.
[No abstract]

New England Journal of Medicine
May 10, 2012  Vol. 366 No. 19
http://content.nejm.org/current.shtml

Perspective
Measles in the 21st Century
E. Kim Mulholland, M.D., Ulla Kou Griffiths, M.Sc., and Robin Biellik, Ph.D.
N Engl J Med 2012; 366:1755-1757May 10, 2012

This article has no abstract; the first 100 words appear below.
Barely 20 years ago, such a high proportion of childhood deaths globally was attributable to measles that the going estimate of more than 1 million measles-related deaths per year was almost certainly an underestimate. Pediatric wards in the developing world were filled with patients with measles and its complications, and measles continued to be a major cause of blindness globally. All this occurred despite the remarkable progress that had been achieved during the 1980s in bringing routine immunizations, including a single dose of measles vaccine, to the poorest countries of the world, culminating in the achievement of the global Universal . . .

PLoS One
[Accessed 12 May 2012]
http://www.plosone.org/article/browse.action;jsessionid=577FD8B9E1F322DAA533C413369CD6F3.ambra01?field=date

Understanding Disease Control: Influence of Epidemiological and Economic Factors
Katarzyna Oleś, Ewa Gudowska-Nowak, Adam Kleczkowski
PLoS ONE: Research Article, published 09 May 2012 10.1371/journal.pone.0036026

Abstract 
We present a model of disease transmission on a regular and small world network and compare different control options. Comparison is based on a total cost of epidemic, including cost of palliative treatment of ill individuals and preventive cost aimed at vaccination or culling of susceptible individuals. Disease is characterized by pre-symptomatic phase, which makes detection and control difficult. Three general strategies emerge: global preventive treatment, local treatment within a neighborhood of certain size and only palliative treatment with no prevention. While the choice between the strategies depends on a relative cost of palliative and preventive treatment, the details of the local strategy and, in particular, the size of the optimal treatment neighborhood depend on the epidemiological factors. The required extent of prevention is proportional to the size of the infection neighborhood, but depends on time till detection and time till treatment in a non-nonlinear (power) law. The optimal size of control neighborhood is also highly sensitive to the relative cost, particularly for inefficient detection and control application. These results have important consequences for design of prevention strategies aiming at emerging diseases for which parameters are not necessarily known in advance.

PLoS Medicine
(Accessed 12 May 2012)
http://www.plosmedicine.org/article/browse.action?field=date

Does Development Assistance for Health Really Displace Government Health Spending? Reassessing the Evidence
Rajaie Batniji, Eran Bendavid Essay, published 08 May 2012
doi:10.1371/journal.pmed.1001214

Summary Points
– At the core of the current aid debate is the question of whether development assistance for health provided to developing country governments increases health expenditures.

– It has recently been suggested that development assistance for health to governments leads to a displacement of government spending, reinforcing skepticism about health aid.

– Here we examine a database of public financing for health from 1995 to 2006 and demonstrate that prior conclusions drawn from these data are unstable and driven by outliers.

– While government spending may be displaced by development assistance for health in some settings, the evidence is not robust and is highly variable across countries. We recommend

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_5 May 2012

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

Speech: Keynote address at the International Conference on Oman Health Vision 2050: Quality Care, Sustained Health
Dr Margaret Chan
Director-General of the World Health Organization
Muscat, Oman   30 April 2012

http://www.who.int/dg/speeches/2012/qualitycare_20120430/en/index.html

WHO Epidemiological Brief 23: European Region – Update on measles and rubella, regional and global polio outbreak status

Measles and rubella
Incomplete reporting makes it difficult to provide an accurate number of measles cases for 2012, thus far. The officially reported number of cases (4 463) is much lower than the actual number, with the Ukrainian Ministry of Health, for example, reporting nearly 8 000 cases on its web site. Romania continues to report the highest number of rubella cases in the Region, as it faces an ongoing outbreak.

Polio
The European Region has retained its polio-free status after a 2010 polio outbreak, but remains at risk of the poliovirus importation while polio is still endemic in countries like Afghanistan and Pakistan. A recent outbreak in China, which is no longer considered active, offers a sobering illustration of this risk.  Consequently, it is critical to maintain high quality AFP, enterovirus and environmental surveillance in the Region to ensure early detection of wild poliovirus importation.

http://www.euro.who.int/__data/assets/pdf_file/0008/163970/EpiBrief-Issue-23.pdf

The TuBerculosis Vaccine Initiative (TBVI) and Aeras announced a new memorandum of understanding “to enhance and strengthen collaborative efforts to advance the world’s most promising TB vaccine candidates.” Aeras is “a nonprofit global TB vaccine biotech based in the US and South Africa” and TBVI is “a pan-European TB vaccine research foundation based in the Netherlands.” The relationship “will address significant scientific opportunities and challenges described in Tuberculosis Vaccines: A Strategic Blueprint for the Next Decade” – a unified global strategy published last month in the journal Tuberculosis which provides a comprehensive approach for developing and introducing safe and effective TB vaccines over the next decade.” Jim Connolly, President and CEO of Aeras, said, “Without new TB vaccines, we cannot end this epidemic. TB vaccine development is particularly complex and costly, and to achieve our mission it is critical to bring together the best and brightest minds in the field. Aeras is looking forward to expanding our collaboration with TBVI, whose role has been pivotal in fueling the quality of research in Europe and the development of promising new vaccine candidates.” Dr. Jelle Thole, Director of TBVI, said, “Aeras has deep experience with preclinical and clinical evaluation of TB vaccine candidates and expertise in identifying promising vaccines. This provides important added value to our know-how. Together we are able to develop vaccines as cost-effectively and efficiently as possible, moving seamlessly from early laboratory research through clinical development to licensure, to deliver vaccines to communities that need their protection.”

http://www.aeras.org/newscenter/news-detail.php?id=1207

Event: Annual Albert B. Sabin Gold Medal Award Ceremony

The 19th annual Albert B. Sabin Gold Medal Award Ceremony will be held May 7, 2012 in Baltimore, Maryland. This year the award ceremony will honor Dr. F. Marc LaForce for his contributions to the development of a new vaccine for epidemic meningitis in Africa. The Gold Medal Award has been awarded annually since 1994 and is given to a distinguished member of the research community who has made extraordinary contributions in the field of vaccinology or a complementary field. Each recipient is a role model for young researchers, someone whose career has saved lives through the development and use of vaccines. The Medal is the highest scientific honor given by the Sabin Vaccine Institute and commemorates the legacy of the late Dr. Albert B. Sabin. This prestigious award is presented by the Sabin Vaccine Institute (Sabin) as part of the National Foundation for Infectious Diseases (NFID) annual conference in Baltimore, Maryland.

http://www.sabin.org/updates-events/events/gold-medal-awards

   PATH and the World Health Organization (WHO) were named winners of the 2012 Vaccine Industry Excellence Award for best vaccine partnership in recognition of the Meningitis Vaccine Project (MVP) that led to the introduction of a new meningitis A vaccine. Created in 2001, MVP developed MenAfriVac™, “a revolutionary vaccine that protects people against deadly meningitis A and could end a century of meningitis epidemics in sub-Saharan Africa. Since its introduction in 2010, more than 54 million Africans across six countries have received the vaccine. Not a single case of group A meningococcal meningitis has been reported among those vaccinated.” MVP, a partnership between PATH and WHO, is funded by the Bill & Melinda Gates Foundation and involves dozens of partner organizations working together across four continents. MVP “marks the first time a philanthropic foundation has joined with public- and private-sector organizations as well as nongovernmental organizations to create a vaccine that would not otherwise have been developed by the private sector.”

PATH’s Malaria Vaccine Initiative received an honorable mention in the same category for its public-private partnership with GSK Biologicals. That collaboration is supporting the development of RTS,S, a malaria vaccine candidate that could add a powerful, complementary tool for the control of malaria in Africa. The Malaria Vaccine Initiative was established at PATH in 1999 with the mission to accelerate the development of malaria vaccines and ensure their availability and accessibility in the developing world. The collaboration with GSK Biologicals began in 2001.

The Vaccine Industry Excellence Awards “are organized by Terrapinn and sponsored by Novartis Vaccines to recognize outstanding achievements by organizations and individuals in the vaccine industry. Nominees are judged on their strategic potential to the industry and potential to address unmet needs, among other criteria.” The awards were presented at the 12th World Vaccine Congress in Washington, DC, on April 11.

http://www.path.org/news/an120502-vie-award.php

The Weekly Epidemiological Record (WER) for 4 May 2012, vol. 87, 18 (pp 169–176) includes: Validation of maternal and neonatal tetanus elimination in Liberia, 2011.

http://www.who.int/entity/wer/2012/wer8718.pdf

The MMWR Weekly for May 4, 2012 / Vol. 61 / No. 17 includes:

– Imported Human Rabies in a U.S. Army Soldier — New York, 2011

– Comparison of Meningococcal Disease Surveillance Systems — United States, 2005–2008

– Notes from the Field: Identification of Vibrio cholerae Serogroup O1, Serotype Inaba, Biotype El Tor Strain — Haiti, March 2012
Extract
On October 20, 2010, an outbreak of cholera was confirmed in Haiti for the first time in more than a century. As of April 10, 2012, a total of 534,647 cases, 287,656 hospitalizations, and 7,091 deaths have been reported in Haiti as a result of the outbreak (1). The Vibrio cholerae strain that caused the Haiti epidemic has been characterized as toxigenic V. cholerae, serogroup O1, serotype Ogawa, biotype El Tor (2).

Recently, two V. cholerae isolates collected on March 12 and 13, 2012, in Anse Rouge, Artibonite Department, were characterized at the National Public Health Laboratory in Haiti as non-Ogawa serotypes. The isolates subsequently were confirmed by CDC to belong to the Inaba serotype. By molecular analyses (pulsed-field gel electrophoresis, multilocus variable number of tandem repeat analysis, and virulence gene sequencing [ctxB and tcpA]), these two isolates are indistinguishable from the currently circulating V. cholerae serotype Ogawa strain in Haiti. The molecular analyses conducted to date suggest that they arose from serotype switching, which is a commonly observed phenomenon in cholera epidemics, often driven by population immunity to the circulating serotype. Further characterization efforts are ongoing.  Finding these two isolates does not change current clinical management guidelines (3)…

…The two World Health Organization prequalified vaccines provide protection against the Ogawa and Inaba serotypes. In addition, the cholera rapid diagnostic tests detect all O1 serogroup infections, including Ogawa and Inaba serotypes.

This serotype conversion illustrates the increasing diversity of V. cholerae in Haiti (2) and emphasizes the importance of continued public health surveillance by the National Public Health Laboratory and CDC, which are partnering to establish a laboratory-enhanced sentinel surveillance system for a range of infectious diseases, including cholera and other diarrheal diseases. The system will provide data to determine the burden of diarrheal disease attributable to cholera and to help direct prevention efforts and programs to reduce morbidity and mortality from cholera in Haiti

Twitter Watch [accessed 5 May 2012 – 14:42]
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.

Shot@Life ‏ @ShotAtLife
What can you commit? We’re kicking-off the campaign with a goal to vaccinate 1,000 children by Mother’s Day. Will you help us? #vaccineswork
10:51 AM – 26 Apr 12

HarvardPublicHealth @HarvardHSPH
CDC reports cholera in Haiti has changed, a sign that it is becoming endemic http://ht.ly/aIECe #globalhealth
10:21 AM – 5 May 12

GAVI Alliance @GAVIAlliance
@MeaslesRubella provided indispensable funding 4 Nepal & Myanmar campaigns. But success also depends on vaccine heroes. http://ht.ly/aE0N0
3:35 AM – 5 May 12

Sandra Rotman Centre @srcglobal
“The challenge now is to stimulate public demand for vaccinations”: http://bit.ly/IyhbCu Southern Vaccine Advocacy Challenge
4:21 PM – 4 May 12

PAHO/WHO @pahowho
Top #PAHOWHO officials meet #Gates Foundation counterparts public health priorities http://bit.ly/IBtGw1
2:13 PM – 4 May 12

UofT Bioethics @utjcb
Anant Bhan, MHSc grad, has a new publication, “Clinical trial ethics in India: One step forward, two steps back”. http://bit.ly/IGgPJK
Retweeted by Sandra Rotman Centre
12:39 PM – 2 May 12

ECDC Eurovaccine @Eurovaccine
Helpful reading: 7 key reasons to immunise from @WHO_Europe http://bit.ly/JgkyKx #EuropeDoctorsMeet #immuniseEurope
5:07 AM – 4 May 12

ECDC @ECDC_EU
Public health experts, doctors & patients discuss role of doctors in childhood #vaccination, 4May w/ @CPME_Europa.Follow #EuropeDoctorsMeet
3:39 AM – 3 May 12

Report: Ethical and Scientific Issues in Studying the Safety of Approved Drugs

Institute of Medicine (IOM); 1 May 2012

Abstract
Prescription drugs are crucial for preventing and treating diseases and improving the public’s health, but they can also have unintended harmful effects. Often, their benefits and risks cannot be fully identified until after a drug has been used by a large, diverse group of patients over time. The passage of the Food and Drug Administration Act in 2007 provides the Food and Drug Administration (FDA) with additional postmarketing regulatory tools to better protect the health of the public, including the authority to require manufacturers to continue studying drugs that are being marketed. The FDA asked the IOM to evaluate the scientific and ethical aspects of conducting safety studies for approved drugs. The IOM recommends implementing a life cycle approach to drug safety oversight that could allow the FDA to better anticipate post-approval research needs and improve drug safety for all Americans.

Read the Report >>

Bulletin of the World Health Organization
Volume 90, Number 5, May 2012, 321-400
http://www.who.int/bulletin/volumes/90/5/en/index.html

Special theme: e-health
EDITORIALS
Establishing an evidence base for e-health: the proof is in the pudding
Najeeb Al-Shorbaji & Antoine Geissbuhler
Bulletin of the World Health Organization 2012;90:322-322A. doi: 10.2471/BLT.12.106146

Seven years have passed since the World Health Assembly adopted resolution WHA58.28 urging the World Health Organization and its Member States1 to endorse e-health as a way to strengthen health systems. In defining e-health as “the cost-effective and secure use of information and communication technologies in support of health and health-related fields”, the resolution offered a definition that was comprehensive and generic, yet specific enough for researchers wishing to evaluate the impact of e-health to know what to evaluate. Specifically, the resolution urged Member States to “mobilize multisectoral collaboration for determining evidence-based e-health standards and norms, to evaluate e-health activities, and to share the knowledge of cost-effective models, thus ensuring quality, safety and ethical standards and respect for the principles of confidentiality of information, privacy, equity and equality”.

This theme issue has three main objectives, as explained in a call for papers2 published in June 2011:

– to provide an authoritative, critical and independent overview of current knowledge about appropriate, trans-disciplinary methods and applications in e-health;

– to include contributors from developing countries, who seldom have the opportunity to publish in international journals;

– to strengthen the commitment of high-level decision-makers to address e-health interoperability issues and seek to widened the application of e-health.

Researchers, academicians and practitioners from all over the world responded to the call for papers with more than 90 submissions, 14 of which are published here.

Van Gemert-Pijnen et al.’s editorial3 makes a worthy point: e-health development must be holistic, evidence-based and people-centred; it must take into account how people live within their own environments and respond to stakeholders’ needs. In the research section that follows, Wootton et al.4 examine the characteristics of long-running telemedicine networks and conclude that “improved collaboration between networks could help attenuate the lack of resources […] and improve sustainability”. In a study of the health-related uses of information and communication technologies (ICT) in low- and middle-income countries, Lewis et al.5 find three leading purposes: to extend geographic access to health care, to improve data management, and to facilitate communication between patients and physicians outside the physician’s office. The authors highlight the need for more sustainable sources of funding, greater support for the adoption of new technologies, and better ways to evaluate impact. A review by Piette et al.6 of the published literature on e-health systems of three types – systems facilitating clinical practice, institutional systems and systems facilitating care at a distance – shows that e-health can improve clinical care in low- and middle-income countries, but that more research is needed on its economic benefits and impact on patient health.

In a revealing Perspective, Thirumurthy & Lester7 find evidence that mobile health (m-health) can enable behaviour change and improve health outcomes in resource-limited settings. Van Heerden et al.8 argue, in the same section, that the real challenge for the deployment of e-health lies in establishing country-level best practices that are both cost-effective and supported by rigorous research and evaluation. Policy-makers and funders must promote, legislate and fund programmes and interventions that integrate and build upon a common m-health framework. Kwankam9 identifies further challenges facing e-health: creating a platform for knowledge sharing; scaling up interventions; designing integrated e-health systems; conducting professional training on e-health; integrating e-health into the social and economic context, and building ICT into the health systems of the future.

Alkmim et al.,10 in a Lesson from the field, describe a telehealth network in Brazil and how in just five years there was a notable increase in the number of professionals trained in telehealth and in the number of electrocardiograms and teleconsultations performed through the network. The authors caution, however, that to succeed, a telehealth service needs to be collaborative, to meet the real needs of local health professionals, to employ a simple technology and to have at least some face-to-face components. According to Braa et al.11, data use workshops have strengthened the health management information systems by improving the quality of public health data in Zanzibar, United Republic of Tanzania. In Madagascar,12 Rajatonirina et al. found evidence of improved disease surveillance capacity despite resource constraints owing to an innovative sentinel system based on a short message service.

The factors promoting or inhibiting the implementation of e-health systems were the subject of a systematic review, by Mair et al.,13 that shows a growing research emphasis on “workability”, or the work that health professionals must undertake to make e-health systems function well in practice. The review also points to the need for more research on the impact of e-health services on everyday clinical practice.

This theme issue highlights what we have learnt from e-health projects throughout the world in terms of feasibility, acceptance and impact on processes. The recipe may seem familiar and replicable, but the proof is in the pudding, in the clear demonstration that e-health can result in economic benefits and improve health outcomes. Programme evaluators and implementers face the challenge of generating such evidence, a prerequisite for the widespread adoption of e-health.14

Health and Human Rights
Vol 13, No 2 (2011) December
http://hhrjournal.org/index.php/hhr
[Reviewed earlier]

Papers in Press  (Issue 14.1, June 2012)
Bridging international law and rights-based litigation: Mapping health-related rights through the development of the Global Health and Human Rights Database
Benjamin Mason Meier, Helena Nygren-Krug, Oscar A. Cabrera, Ana Ayala, Lawrence O. Gostin

Abstract
The O’Neill Institute for National and Global Health Law at Georgetown University, the World Health Organization, and the Lawyers Collective have come together to develop a searchable Global Health and Human Rights Database that maps the intersection of health and human rights in judgments, international and regional instruments, and national constitutions. Where states long remained unaccountable for violations of health-related human rights, litigation has arisen as a central mechanism in an expanding movement to create rights-based accountability. Facilitated by the incorporation of international human rights standards in national law, this judicial enforcement has supported the implementation of rights-based claims, giving meaning to states’ longstanding obligations to realize the highest attainable standard of health. Yet despite these advancements, there has been insufficient awareness of the international and domestic legal instruments enshrining health-related rights and little understanding of the scope and content of litigation upholding these rights. As this accountability movement evolves, the Global Health and Human Rights Database seeks to chart this burgeoning landscape of international instruments, national constitutions, and judgments for health-related rights. Employing international legal research to document and catalogue these three interconnected aspects of human rights for the public’s health, the Database’s categorization by human rights, health topics, and regional scope provides a comprehensive means of understanding health and human rights law. Through these categorizations, the Global Health and Human Rights Database serves as a basis for analogous legal reasoning across states to serve as precedents for future cases, for comparative legal analysis of similar health claims in different country contexts, and for empirical research to clarify the impact of human rights judgments on public health outcomes.

Human Vaccines & Immunotherapeutics (formerly Human Vaccines)
Volume 8, Issue 5  May 2012
http://www.landesbioscience.com/journals/vaccines/toc/volume/8/issue/5/

REVIEW
Lessons learned and applied: What the 20th century vaccine experience can teach us about vaccines in the 21st century
Corey Joseph Hebert, Corey Hall and La’ Nyia J. Odoms

Abstract    Open Access Article
Most vaccines available in the United States have been incorporated into vaccination schedules for infants and young children, age groups particularly at risk of contracting infectious diseases. High universal vaccination coverage is responsible for substantially reducing or nearly eliminating many of the diseases that once killed thousands of children each year in the US…

Human Vaccines & Immunotherapeutics (formerly Human Vaccines)
Volume 8, Issue 5  May 2012
http://www.landesbioscience.com/journals/vaccines/toc/volume/8/issue/5/

Research Papers
The human potential of a recombinant pandemic influenza vaccine produced in tobacco plants
Asne Jul-Larsen, Abdullah Madhun, Karl Brokstad, Emanuele Montomoli, Vidadi Yusibov and Rebecca Cox

Abstract   Open Access Article
Rapid production of influenza vaccine antigen is an important challenge when a new pandemic occurs. Production of recombinant antigens in plants is a quick, cost effective and up scalable new strategy for influenza vaccine production. In this study, we have characterized a recombinant influenza haemagglutinin antigen (HAC1) that was derived from the 2009 pandemic H1N1 virus and expressed in tobacco plants. Volunteers vaccinated with the 2009 pH1N1 oil-in-water adjuvanted vaccine provided serum and lymphocyte samples that were used to study the immunogenic properties of the HAC1 antigen in vitro. By 7 d post vaccination, the vaccine fulfilled the licensing criteria for antibody responses to the HA detected by haemagglutination inhibition and single radial hemolysis. By ELISA and ELISPOT analysis we showed that HAC1 was recognized by specific serum antibodies and antibody secreting cells, respectively. We conducted a kinetic analysis and found a peak of serum HAC1 spec antibody response between day 14 and 21 post vaccination by ELISA. We also detected elevated production of IL-2 and IFNγ and low frequencies of CD4+ T cells producing single or multiple Th1 cytokines after stimulating PBMCs (peripheral blood mononuclear cells) with the HAC1 antigen in vitro. This indicates that the antigen can interact with T cells, although confirming an effective adjuvant would be required to improve the T-cell stimulation of plant based vaccines. We conclude that the tobacco derived recombinant HAC1 antigen is a promising vaccine candidate recognized by both B- and T cells.

Human Vaccines & Immunotherapeutics (formerly Human Vaccines)
Volume 8, Issue 5  May 2012
http://www.landesbioscience.com/journals/vaccines/toc/volume/8/issue/5/

RECENTLY ACCEPTED AND COMING SOON
Commentaries
Cholera vaccine: New preventive tool for endemic countries
Ramesh Verma, Pardeep Khanna and Suraj Chawla

Abstract
Cholera is a major global public health problem and remains an important threat in almost every developing country, especially in areas where population overcrowding and poor sanitation are common, such as slums and refugee camps. Cholera is one of the most dreaded diseases in the world, in some cases leading to death within 24 h if left untreated. Without treatment, severe infection has a mortality rate of 30–50%. In 2007, WHO recorded 177,963 cholera cases and 4,031 deaths worldwide. However, the estimated actual burden of cholera is in the vicinity of 3 to 5 million cases and 100 000 to 130 000 deaths per year. The disease is endemic to parts of Africa, Asia, the Middle East and South America.1 Large outbreaks are common after natural disasters or in populations displaced by war, where there is inadequate sewage disposal and contaminated water. In India, during the 10-y period (1997–2006) studied, the states having the highest number of reported outbreaks were West Bengal, Orissa, Maharashtra and Kerala, which together accounted for 60% of all reported outbreaks. A review of cholera cases in India reported to WHO from 2003–2007 showed that the numbers were in the few thousands with a case fatality rate of < 1%. However, it is believed that the number of cholera cases and deaths occurring annually in India is much greater than the number reported. A literature review covering a four-year period from 2003 to 2006 found reported cholera outbreaks in 18 of the 35 States and Union Territories of India. Of these, 11 had cholera outbreaks reported for multiple years. Vietnam has produced a cheaper variant of killed whole-cell vaccine devoid of the B subunit. This vaccine contains both Vibrio cholerae O1 and O139, and provides 50 per cent protection for at least three years after vaccination. For endemic cholera, population-level immunity is relatively high, making control possible with relatively low vaccine coverage levels. This vaccine should be used in areas where cholera is endemic, particularly in those at risk of outbreaks, in conjunction with other prevention and control strategies.

JAMA   
May 2, 2012, Vol 307, No. 17, pp 1775-1877
http://jama.ama-assn.org/current.dtl

Original Contributions
Characteristics of Clinical Trials Registered in ClinicalTrials.gov, 2007-2010
Robert M. Califf, Deborah A. Zarin, Judith M. Kramer, Rachel E. Sherman, Laura H. Aberle, Asba Tasneem
JAMA. 2012;307(17):1838-1847.doi:10.1001/jama.2012.3424

Abstract
Context  Recent reports highlight gaps between guidelines-based treatment recommendations and evidence from clinical trials that supports those recommendations. Strengthened reporting requirements for studies registered with ClinicalTrials.gov enable a comprehensive evaluation of the national trials portfolio.

Objective  To examine fundamental characteristics of interventional clinical trials registered in the ClinicalTrials.gov database.

Methods  A data set comprising 96 346 clinical studies from ClinicalTrials.gov was downloaded on September 27, 2010, and entered into a relational database to analyze aggregate data. Interventional trials were identified and analyses were focused on 3 clinical specialties—cardiovascular, mental health, and oncology—that together encompass the largest number of disability-adjusted life-years lost in the United States.

Main Outcome  Measures Characteristics of registered clinical trials as reported data elements in the trial registry; how those characteristics have changed over time; differences in characteristics as a function of clinical specialty; and factors associated with use of randomization, blinding, and data monitoring committees (DMCs).

Results  The number of registered interventional clinical trials increased from 28 881 (October 2004–September 2007) to 40 970 (October 2007–September 2010), and the number of missing data elements has generally declined. Most interventional trials registered between 2007 and 2010 were small, with 62% enrolling 100 or fewer participants. Many clinical trials were single-center (66%; 24 788/37 520) and funded by organizations other than industry or the National Institutes of Health (NIH) (47%; 17 592/37 520). Heterogeneity in the reported methods by clinical specialty; sponsor type; and the reported use of DMCs, randomization, and blinding was evident. For example, reported use of DMCs was less common in industry-sponsored vs NIH-sponsored trials (adjusted odds ratio [OR], 0.11; 95% CI, 0.09-0.14), earlier-phase vs phase 3 trials (adjusted OR, 0.83; 95% CI, 0.76-0.91), and mental health trials vs those in the other 2 specialties. In similar comparisons, randomization and blinding were less frequently reported in earlier-phase, oncology, and device trials.

Conclusion  Clinical trials registered in ClinicalTrials.gov are dominated by small trials and contain significant heterogeneity in methodological approaches, including reported use of randomization, blinding, and DMCs.

Editorials
The Evolution of Trial Registries and Their Use to Assess the Clinical Trial Enterprise
Kay Dickersin, Drummond Rennie
JAMA. 2012;307(17):1861-1864.doi:10.1001/jama.2012.4230

Extract
The original purpose of registries of clinical trials was to reveal the existence of all trials, published or not, to investigators and systematic reviewers. Trials left unpublished because results were unfavorable to their sponsors, or simply because investigators never submitted them to journals for publication, could then be discovered, the trial investigators contacted, and the available trial evidence involving medical interventions could then be assessed. This would help eliminate publication bias, shown originally in the 1980s,1 demonstrated by Simes2 to affect the treatment of patients, and later revealed to be widespread by the expanding efforts of the Cochrane Collaboration. A seemingly arcane statistical point became a pressing clinical problem.

Although the 1997 US Food and Drug Administration Modernization Act (FDAMA)3 established a US-based trial registry, ClinicalTrials.gov, the mandated content was narrowly defined by law, and trial investigators, whether funded by commercial sponsors, government agencies, or academic institutions, …

Nature  
Volume 485 Number 7396 pp5-142  3 May 2012
http://www.nature.com/nature/current_issue.html

Advance Online Publication (AOP)
Letter
Experimental adaptation of an influenza H5 HA confers respiratory droplet transmission to a reassortant H5 HA/H1N1 virus in ferrets

Masaki Imai, Tokiko Watanabe, Masato Hatta, Subash C. Das, Makoto Ozawa, Kyoko Shinya, Gongxun Zhong, Anthony Hanson, Hiroaki Katsura, Shinji Watanabe, Chengjun Li, Eiryo Kawakami, Shinya Yamada, Maki Kiso, Yasuo Suzuki, Eileen A. Maher, Gabriele Neumann & Yoshihiro Kawaoka

Highly pathogenic avian H5N1 influenza A viruses occasionally infect humans, but currently do not transmit efficiently among humans. The viral haemagglutinin (HA) protein is a known host-range determinant as it mediates virus binding to host-specific cellular receptors1, 2, 3. Here we assess the molecular changes in HA that would allow a virus possessing subtype H5 HA to be transmissible among mammals. We identified a reassortant H5 HA/H1N1 virus—comprising H5 HA (from an H5N1 virus) with four mutations and the remaining seven gene segments from a 2009 pandemic H1N1 virus—that was capable of droplet transmission in a ferret model. The transmissible H5 reassortant virus preferentially recognized human-type receptors, replicated efficiently in ferrets, caused lung lesions and weight loss, but was not highly pathogenic and did not cause mortality. These results indicate that H5 HA can convert to an HA that supports efficient viral transmission in mammals; however, we do not know whether the four mutations in the H5 HA identified here would render a wholly avian H5N1 virus transmissible. The genetic origin of the remaining seven viral gene segments may also critically contribute to transmissibility in mammals. Nevertheless, as H5N1 viruses continue to evolve and infect humans, receptor-binding variants of H5N1 viruses with pandemic potential, including avian–human reassortant viruses as tested here, may emerge. Our findings emphasize the need to prepare for potential pandemics caused by influenza viruses possessing H5 HA, and will help individuals conducting surveillance in regions with circulating H5N1 viruses to recognize key residues that predict the pandemic potential of isolates, which will inform the development, production and distribution of effective countermeasures.

http://www.nature.com/nature/journal/vaop/ncurrent/full/nature10831.html

Nature Medicine
May 2012, Volume 18 No 5 pp631-834
http://www.nature.com/nm/journal/v18/n5/index.html

Opinion
The WHO must reform for its own health – p646
Tikki Pang & Laurie Garrett
doi:10.1038/nm0512-646

The World Health Organization (WHO) is facing an unprecedented crisis that threatens its position as the premier international health agency. To ensure its leading role, it must rethink its internal governance and revamp its financing mechanisms.

Publ
04 May 2012

Pediatrics
May 2012, VOLUME 129 / ISSUE 5
http://pediatrics.aappublications.org/current.shtml

Pediatrics Perspective
Inside Millennium Development Goal 4
Jonathan M. Spector
Pediatrics 2012; 129:805-808

Context and Extract
This Pediatrics Perspectives column traces the origins of the promises and commitments made to decrease global under-5 mortality. The disparities that exist worldwide are extraordinarily large, although significant progress has been made since the establishment of the Millennium Development Goals (MDGs). Dr Spector traces the origins and challenges of Goal 4 (of 8) that relate specifically to this issue. Although overall survival rates are improving, outcome gaps in under-5 mortality have widened between rich and poor nations. Clearly, the MDGs must be looked at as a large package. There are specific measurements for each goal, but success in 1 area influences the outcomes in the others. Our advocacy efforts should focus on improving the lives of the world’s poorest people broadly. World leaders have committed to achieving the MDGs by 2015. We all need to use our influence and personal resources to push the international community to succeed in eliminating extreme poverty and hunger everywhere, ultimately allowing for elimination of the growing health disparities among the affluent and poorest nations.
—Jay E. Berkelhamer, MD
Editor, Global Health Perspectives

The Millennium Development Goals (MDGs) have been dubbed the “world’s biggest promise.”1 At the turn of the 21st century, 189 (now 192) United Nations (UN) member states agreed to support the most comprehensive poverty reduction objectives ever established (Table 1).2,3 Child mortality is addressed through Goal 4: reduction of the global under-5 mortality rate (U5MR) by two-thirds between 1990 and 2015, equivalent to an annual drop rate of 4.3% (Table 2).4 In 1990, the U5MR was estimated at 84 of 1000 live births, and 11.9 million largely preventable child deaths took place. If MDG 4 could be achieved, 30 million children would be saved by 2015.2 Since their launch, the MDGs have been …

Pediatrics
May 2012, VOLUME 129 / ISSUE 5
http://pediatrics.aappublications.org/current.shtml

Articles
Measles-Containing Vaccines and Febrile Seizures in Children Age 4 to 6 Years
Nicola P. Klein, Edwin Lewis, Roger Baxter, Eric Weintraub, Jason Glanz, Allison Naleway, Lisa A. Jackson, James Nordin, Tracy Lieu, Edward A. Belongia, and Bruce Fireman
Pediatrics 2012; 129:809-814

Abstract
BACKGROUND: In the United States, children receive 2 doses of measles-mumps-rubella vaccine (MMR) and varicella vaccine (V), the first between ages 1 to 2 years and the second between ages 4 to 6 years. Among 1- to 2-year-olds, the risk of febrile seizures 7 to 10 days after MMRV is double that after separate MMR + V. Whether MMRV or MMR + V affects risk for febrile seizure risk among 4- to 6-year-olds has not been reported.

METHODS: Among 4- to 6-year-old Vaccine Safety Datalink members, we identified seizures in the emergency department and hospital from 2000 to 2008 and outpatient visits for fever from 2006 to 2008 during days 7 to 10 and 0 to 42 after MMRV and MMR + V. Incorporating medical record reviews, we assessed seizure risk after MMRV and MMR + V.

RESULTS: From 2006 through 2008, 86 750 children received MMRV; from 2000 through 2008, 67 438 received same-day MMR + V. Seizures were rare throughout days 0 to 42 without peaking during days 7 to 10. There was 1 febrile seizure 7 to 10 days after MMRV and 0 after MMR + V. Febrile seizure risk was 1 per 86 750 MMRV doses (95% confidence interval, 1 per 3 426 441, 1 per 15 570) and 0 per 67 438 MMR + V doses (1 per 18 282).

CONCLUSIONS: This study provides reassurance that MMRV and MMR + V were not associated with increased risk of febrile seizures among 4- to 6-year-olds. We can rule out with 95% confidence a risk greater than 1 febrile seizure per 15 500 MMRV doses and 1 per 18 000 MMR + V doses.

Pediatrics
May 2012, VOLUME 129 / ISSUE 5
http://pediatrics.aappublications.org/current.shtml

Commentaries
Why Do Pertussis Vaccines Fail?
James D. Cherry
Pediatrics 2012; 129:968-970

Extract
During the 2010 pertussis epidemic in California, there was considerable concern in the press and in public health communications about the possible contribution of vaccine failures to the problem.1,2.

…The first reason, and perhaps the most important one, is that our estimates of vaccine efficacy have been inflated because of case definition.3–11 At the time of the pediatric diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccine efficacy trials in the early 1990s, it was hoped that a universal case definition could be developed so that the results of the various trials could be compared. To this end, the World Health Organization (WHO) case definition was developed.3 The primary case definition required laboratory confirmation and ≥21 days of paroxysmal cough. I was a member of the WHO committee and disagreed with the primary case definition because it was clear at that time that this definition would eliminate a substantial number of cases and therefore inflate reported efficacy values.4–11 Nevertheless, the Center for Biologics Evaluation and Research of the Food and Drug Administration accepted this definition, and package inserts of the US-licensed DTaP vaccines reflect this. For example, Infanrix (containing 25 μg pertussis toxin [PT], 25 μg filamentous hemagglutinin [FHA], and 8 μg pertactin [PRN]) and Daptacel (containing 10 μg PT, 5 μg FHA, 5 μg fimbriae [FIM]-2/3, and 3 μg …

Pediatrics
May 2012, VOLUME 129 / ISSUE 5
http://pediatrics.aappublications.org/current.shtml

Pediatric Clinical Trial Registration and Trial Results: An Urgent Need for Improvement
Scott C. Denne
Pediatrics 2012; 129:e1320-e1321

Extract
Performing research studies in children to evaluate drugs and other therapies is critical to providing proper pediatric medical care. For too long, medication use in children has been limited to extrapolation from adult studies or off-label use for indications that have not been properly evaluated in children. It has been less than 20 years since practical measures have been put in place to ensure that the necessary research evaluating therapies is more consistently carried out in children. Prompted by the American Academy of Pediatrics and other pediatric organizations, the Food and Drug Administration (FDA) in 1997 and the National Institutes of Health (NIH) in 1998 initiated policies designed to increase the number of children in research studies, including drug trials.1,2 Along with subsequent legislation, including the Best Pharmaceuticals for Children Act (2002), and the Pediatric Research Equity Act (2007), the initiatives by the FDA and …

Science Translational Medicine
2 May 2012 vol 4, issue 132
http://stm.sciencemag.org/content/current

Commentary
Policy
Learning from Hackers: Open-Source Clinical Trials
Adam G. Dunn, Richard O. Day, Kenneth D. Mandl, and Enrico Coiera
2 May 2012: 132cm5

Abstract
Open sharing of clinical trial data has been proposed as a way to address the gap between the production of clinical evidence and the decision-making of physicians. A similar gap was addressed in the software industry by their open-source software movement. Here, we examine how the social and technical principles of the movement can guide the growth of an open-source clinical trial community.

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 April 2012

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

GAVI said that Ghana has become the first African country to introduce pneumococcal and rotavirus vaccines at the same time. In Ghana, these diseases, together, account for approximately 20% of the country’s under-five child mortality. Ghana’s First Lady H.E. Dr Ernestina Naadu Mills was joined by the country’s Minister of Health Hon. M Alban S. K. Bagbin, GAVI Alliance CEO Dr Seth Berkley, WHO Deputy Director General Dr Anarfi Asamoa-Baah, UNICEF Country Representative Dr Iyabode Olusanmi, and other international guests at a special ceremony in Accra, where the first doses of the vaccines were administered to children. Health Minister Hon. Alban S. K. Bagbin said, “Our children have been dying from these vaccine-preventable diseases for too long, but this moment begins a major fight back. With these vaccines, we want to, and we will, achieve MDG4, the two-thirds reduction of our child mortality by 2015.”

26 April 2012

http://www.gavialliance.org/library/news/press-releases/2012/ghana-rolls-out-vaccines-against-top-two-killers-of-children/

UNICEF Executive Director Anthony Lake, with partners in the renamed Measles and Rubella Initiative, launched “a new global strategy aimed at reducing measles deaths and congenital rubella syndrome to zero.” The announcement was accompanied by new data showing that accelerated efforts have resulted in a 74 per cent reduction in global measles mortality, from an estimated 535,000 deaths in 2000, to 139,000 in 2010. UNICEF noted that through increased routine immunization coverage and large-scale immunization campaigns, Africa made the most progress with an 85 per cent drop in measles deaths between 2000 and 2010. [see The Lancet – Online First content below in Journal Watch] The new strategy is focused on “…cutting global measles deaths by at least 95 per cent by 2015 compared with 2000 levels, and achieving measles and rubella elimination in at least five World Health Organization (WHO) regions by 2020. The strategy includes: high vaccination coverage; monitoring spread of disease using laboratory-backed surveillance; outbreak preparedness and response and measles case management; communication and community engagement; and research and development.”

UNICEF said that under the new strategy, 63 countries currently not using rubella vaccines are encouraged to use their measles vaccination delivery system to introduce rubella vaccines into their national immunization schedule, protecting children against both diseases with one combined shot. Founded originally as the Measles Initiative in 2001, the new Measles and Rubella Initiative is led by the American Red Cross, the United Nations Foundation, the U.S. Centers for Disease Control and Prevention (CDC), UNICEF and WHO.

25 April 2012

http://www.unicef.org/immunization/index_62289.html

The WHO coverage of this announcement included links to the following content:

News

Measles mortality news release
24 April 2012

European countries must take action now to prevent continued measles outbreaks in 2012
2 December 2011

The Measles Initiative vaccinates one billion children in first decade
4 August 2011

Strategic plan

Global Measles and Rubella Strategic Plan 2012-2020
pdf, 1.39Mb

Press Conference Materials

April 2012

    World Immunization Week was implemented for the first time, involving over 180 countries and running 21-28 April 2012. The theme of the week —

Protect your world: Get vaccinated –  “aims to reinforce the importance of immunization and encourage people everywhere to vaccinate themselves and their children against serious diseases. It is also a time to recall that, in this rapidly globalizing world, disease outbreaks can affect communities everywhere.”

Additional coverage:

http://www.who.int/mediacentre/news/notes/2012/immunization_week_20120423/en/index.html

Statement: Director-General commemorates World Malaria Day
Dr Margaret Chan
Director-General of the World Health Organization
Statement on World Malaria Day
Oshakati, Namibia
25 April 2012
http://www.who.int/dg/speeches/2012/malariaday_20120425/en/index.html

Press release: UNICEF marks World Malaria Day
http://www.unicef.org/media/media_62293.html

Statement: NIH – World Malaria Day – April 25, 2012
B. F. (Lee) Hall, M.D., Ph.D., and Anthony S. Fauci, M.D.
National Institute of Allergy and Infectious Diseases
http://www.nih.gov/news/health/apr2012/niaid-24.htm

Media Release: PATH recognizes World Malaria Day 2012
Events in Seattle and Washington, DC, highlight progress toward ending malaria deaths
http://www.path.org/news/an120420-malaria-day.php

The Global Fund announced that “an innovative initiative…to put affordable and effective anti-malaria medicines in remote communities in Africa, is making rapid progress in Ghana, Kenya, Madagascar, Nigeria, Tanzania and Uganda.” The Affordable Medicines Facility for Malaria (AMFm), which is managed by the Global Fund, “allows people to buy life-saving malaria treatment in private stores and pharmacies for less than one U.S. dollar. Comparable malaria medicines outside the program cost up to ten to twenty times as much.” Dr. Olusoji Adeyi, who heads the AMFm initiative at the Global Fund in Geneva, said, “The innovation is working, bringing relief to millions who need quality anti-malaria medicines at affordable prices. The AMFm is a game-changer in financing access to malaria treatments.” AMFm is “making anti-malaria medicines, called artemisinin-based combination therapies (ACTs), available as widely and inexpensively as possible to those who need them. It allows people to obtain effective drugs without having to travel long distances to reach public health clinics. AMFm is also helping to drive out ineffective medicines off the market, making effective ACT treatment available and accessible to millions of people.”

http://www.theglobalfund.org/en/mediacenter/pressreleases/2012-04-25_Global_Fund-led_initiative_slashes_cost_of_anti-Malaria_medicines_in_many_African_countries/

GAVI said the “under the leadership of its Chair Dagfinn Høybråten, it is strengthening its governance structure by improving its gender balance and streamlining its executive committee composition.” GAVI had earlier announced the appointment of three new independent Board members, all of them women, “achieving the target it set for itself in 2010 of at least 40% representation for both genders. Eleven out of 26 Board members are now female.” In the current announcement, GAVI noted “the restructuring of the Board’s Executive Committee to simplify the process concerning commercially-sensitive decision making.” Mr Høybråten commented, “We believe our governance standards are world class and transparent, and we are always looking to improve and streamline our processes.” The restructuring involves the Board’s 12-member Executive Committee, which “is empowered to make time-sensitive decisions on behalf of the Board between scheduled Board meetings. Since 2008, one of these seats has been assigned to a representative of the vaccine manufacturing industry. Following a decision by vaccine manufacturers not to seek reappointment to the Executive Committee, the Executive Committee will contract to 11 members: the Board Chair, the Vice Chair, eight additional Board members, and the non-voting CEO.” Mr. Høybråten added, “This voluntary move by the Developing Countries Vaccines Manufacturers Network (DCVMN) and the industrialized countries vaccines manufacturers will simplify our discussions and decision making processes even further. Vaccine manufacturers continue to be an important partner in our Alliance and on the Board.” GAVI said that “under existing procedures, conflicted members and members with even a perceived conflict of interest must remove themselves from discussion and voting on sensitive items related to their respective constituencies.”

http://www.gavialliance.org/library/news/statements/2012/gavi-board-chair-announces-strengthened-governance-structure/

Twitter Watch [final access 28 April 2012 – 16:42]
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.

Mirta Roses Periago @mirtaroses
We arrived to the end of the 10th Vaccination Week in the Americas, but #health workers will continue to vaccinate every day of the year.
9:53 AM – 28 Apr 12

Sabin Vaccine Inst. @sabinvaccine
It is estimated that a child dies of a vaccine-preventable disease every 20 sec. What are we going to do about that? http://bit.ly/Jqh8Ht
4:02 PM – 27 Apr 12

WHO @WHO
Meet our new super heroes: VacciBoy and ImmuGirl http://goo.gl/VrwX2 #vaccineswork
8:18 AM – 27 Apr 12

Roll Back Malaria @RollBackMalaria
Ban Ki-moon says he has made #malaria “a priority for his second term as a UN Secretary General” in a #WMD video: http://bit.ly/HYUdCX
Retweeted by Malaria Consortium
6:07 PM – 26 Apr 12

UNICEF @UNICEF
Did you know that UNICEF supplies 2.5 billion doses of vaccines to 99 countries? That’s 58 per cent of the world’s children #vaccineswork infographic: http://ow.ly/i/AB1P
9:30 AM – 27 Apr 12

Seth Berkley @GAVISeth
My latest blog: “We have to extend the vaccine revolution to every child in every corner of our world” http://ind.pn/IeROX5 #vaccineswork
4:26 PM – 26 Apr 12

WHO @WHO
Keep your child’s school, kindergarten, caregivers updated on your child’s vaccination status http://goo.gl/pbcp1 #vaccineswork
3:11 PM – 26 Apr 12

Dagfinn Høybråten @Hoybraten
Read my latest blog “Why immunisation is an act of immeasurable love” #vaccineswork http://bit.ly/ziZ1h8
Retweeted by GAVI Alliance
2:26 PM – 26 Apr 12

UNICEF @UNICEF
8 mn ppl are walking today as a result of the effort to eradicate #polio. Most children in the world live in polio-free areas #vaccineswork
12:31 PM – 26 Apr 12

Seth Berkley @GAVISeth
Just honored to be one of 5 vaccinators to give first 5 courses of pneumo and Rota together in Ghana with first lady and MoH. #vaccineswork
9:34 AM – 26 Apr 12

UN Foundation @unfoundation
Let’s get ready to rumble! Today is the national launch of @shotatlife! Join this morning 9-12 to discuss #vaccineswork http://ow.ly/awXaQ
8:38 AM – 26 Apr 12

GAVI Alliance ‏ @GAVIAlliance
Today, #Ghana has become the 1st African country 2 introduce #pneumo and #rotavirus #vaccines at the same time! http://ht.ly/awVEg
8:38 AM – 26 Apr 12

Report: Facing the Reality of Drug-Resistant Tuberculosis: Challenges and Potential Solutions in India – Summary of a Joint Workshop by the Institute of Medicine, the Indian National Science Academy, and the Indian Council of Medical Research

An estimated 8.8 million people fell ill with tuberculosis (TB) in 2010 and 1.4 million died from the disease. Although antibiotics to treat TB were developed in the 1950s and are effective against a large percentage of TB cases, resistance to these antibiotics has emerged over the years, resulting in the growing spread of multi-drug resistant (MDR) TB. The IOM held a workshop April 18-19, 2011, in New Delhi, India, in collaboration with the Indian National Science Academy and the Indian Council of Medical Research, to highlight key challenges to controlling the spread of drug-resistant strains of TB in India and to discuss strategies for advancing and integrating local and international efforts to prevent and treat drug-resistant TB.

Read the Report >>

Report: The New Global Health Agenda – Universal Health Coverage
Council on Foreign Relations | April 2012

The field of global health is witnessing a shift in focus from disease-driven initiatives to projects aimed at increasing the sustainability and strengthening of health systems. A crucial component to this is universal health coverage (UHC), which seeks to address financing schemes for health, separate from efforts to provide both adequate numbers of health workers and structures for health-care delivery. …In The New Global Health Agenda: Universal Health Coverage, authors Oren Ahoobim, Daniel Altman, Laurie Garrett, Vicky Hausman, and Yanzhong Huang discuss this rise in support for universal health coverage and the financial benefits that may be reaped by implementing such schemes, and provide examples of models used to date by countries in establishing universal health coverage.

http://www.cfr.org/global-health/new-global-health-agenda/p27998

Foreign Affairs
May/June 2012  Volume 91, Number 3
http://www.foreignaffairs.com/

Essay
Developing Symptoms
Thomas J. Bollyky

The main health threat in developing states today is not plagues or parasites but illnesses such as cancer and diabetes, noncommunicable diseases long associated with the rich world. NCDs are striking poorer, younger populations, and this could debilitate states and the global economy. The best way for the West to help is by pushing for governance reform.

Health Policy and Planning
http://heapol.oxfordjournals.org/content/current

Supplement: Policy making for new vaccines in low- and middle-income countries
Volume 27 suppl 2 May 2012
Guest Editors: Sandra Mounier-Jack and Helen Burchett

Commentary
Pauline Paterson and Heidi J Larson
The role of publics in the introduction of new vaccines
Health Policy Plan. (2012) 27(suppl 2): ii77-ii79 doi:10.1093/heapol/czs038
Extract
KEY MESSAGES
– The ‘public’ in public engagement could be a variety of stakeholders.
– Engaging with the public builds trust and helps to identify concerns that need to be addressed.
– There is a need for more research on the impact of different public engagement strategies on vaccination programmes to improve their effectiveness.
– The importance of listening to and engaging publics in the design and implementation of immunization policies and programmes has been well established (Waisbord 2004; Cooper et al. 2008; Obregon 2009; Larson et al. 2010; Larson et al. 2011). There are a number of examples of the costs (financial and social) of not involving publics early, the most acute being the boycott of polio vaccination in five states in Northern Nigeria in 2003 (Yahya 2007).
– Several papers in this special issue highlight potential roles of publics in the introduction of new vaccines, mostly at the level of implementation, but some point to the importance of bringing the role of citizen voices earlier into the decision-making process—i.e. not just as players to implement decisions made by central authorities, but to be a part of decision-making processes (Wonodi et al. 2012).
– The ‘public’ in public engagement could be a variety of stakeholders; such as individuals, parents, policy-makers (Mantel and Wang 2012), researchers and clinicians (Burchett et al. 2012), immunization programme managers (Brooks and Ba-Nguz 2012; Gordon et al. 2012), ‘global/regional bodies’ (Makinen et al. 2012), advocacy groups, or influential individuals (Makinen et al. 2012), such as religious leaders (Wonodi et al. 2012). …

Editorial
Carsten Mantel and Susan A Wang
The privilege and responsibility of having choices: decision-making for new vaccines in developing countries
Health Policy Plan. (2012) 27(suppl 2): ii1-ii4 doi:10.1093/heapol/czs041

Extract
Decisions to introduce new vaccines into national immunization programmes have become a highly complex endeavour. When the Expanded Programme on Immunization (EPI) was established in 1974 through a World Health Assembly resolution to build on the success of the global smallpox eradication programme and to ensure that all children in all countries benefit from life-saving vaccines, the first six diseases targeted by EPI were diphtheria, pertussis, tetanus, polio, measles and tuberculosis (WHO 1974). Today, thanks to scientific advancements and renewed global interest in immunization, more than a dozen1 antigens have been made available through public health services in developing countries, with increasingly reduced time delay compared with introduction in industrialized countries. Country decision-makers can select vaccines from a portfolio of options. This is a privilege and a serious responsibility requiring due consideration, as any decision to select one vaccine will need to be taken in light of the opportunity costs of not investing in another vaccine or another (health) intervention. Moreover, country decision-makers do not form their decisions in a vacuum; the number of immunization stakeholders in both the public and the private sectors has vastly increased and those stakeholders are equipped with varying levels of knowledge and expertise and may have vested interests.

The multitude of factors influencing country decisions to introduce new vaccines, and the process for making these decisions is becoming increasingly important. These factors and processes are briefly outlined and discussed below.

 Sources of information and the decision-making process
One of the main and undisputed sources of information for decision making on new vaccine introduction in developing countries is the World Health Organization (WHO) global recommendations and policy guidelines, such as the vaccine position papers. These position papers are based on a thorough and graded review of available evidence by an independent Strategic Advisory Group of Experts in immunization (SAGE) and they

Original articles
H E D Burchett, S Mounier-Jack, U K Griffiths, R Biellik, P Ongolo-Zogo, E Chavez, H Sarma, J Uddin, M Konate, Y Kitaw, M Molla, S Wakasiaka, L Gilson, and A Mills
New vaccine adoption: qualitative study of national decision-making processes in seven low- and middle-income countries
Health Policy Plan. (2012) 27(suppl 2): ii5-ii16 doi:10.1093/heapol/czs035
W Scott Gordon, Andrew Jones, and John Wecker

Abstract
As more new and improved vaccines become available, decisions on which to adopt into routine programmes become more frequent and complex. This qualitative study aimed to explore processes of national decision-making around new vaccine adoption and to understand the factors affecting these decisions.

Ninety-five key informant interviews were conducted in seven low- and middle-income countries: Bangladesh, Cameroon, Ethiopia, Guatemala, Kenya, Mali and South Africa. Framework analysis was used to explore issues both within and between countries.

The underlying driver for adoption decisions in GAVI-eligible countries was the desire to seize GAVI windows of opportunity for funding. By contrast, in South Africa and Guatemala, non-GAVI-eligible countries, the decision-making process was more rooted in internal and political dynamics.

Decisions to adopt new vaccines are, by nature, political. The main drivers influencing decisions were the availability of funding, political prioritization of vaccination or the vaccine-preventable disease and the burden of disease. Other factors, such as financial sustainability and feasibility of introduction, were not as influential. Although GAVI procedures have established more formality in decision-making, they did not always result in consideration of all relevant factors. As familiarity with GAVI procedures increased, questioning by decision-makers about whether a country should apply for funding appeared to have diminished.

This is one of the first studies to empirically investigate national processes of new vaccine adoption decision-making using rigorous methods. Our findings show that previous decision-making frameworks (developed to guide or study national decision-making) bore little resemblance to real-life decisions, which were dominated by domestic politics. Understanding the realities of vaccine policy decision-making is critical for developing strategies to encourage improved evidence-informed decision-making about new vaccine adoptions. The potential for international initiatives to encourage evidence-informed decision-making should be realised, not assumed.

Introducing multiple vaccines in low- and lower-middle-income countries: issues, opportunities and challenges
Health Policy Plan. (2012) 27(suppl 2): ii17-ii26 doi:10.1093/heapol/czs040
C B Wonodi, L Privor-Dumm, M Aina, A M Pate, R Reis, P Gadhoke, and O S Levine

Using social network analysis to examine the decision-making process on new vaccine introduction in Nigeria
Health Policy Plan. (2012) 27(suppl 2): ii27-ii38 doi:10.1093/heapol/czs037
Marty Makinen, Miloud Kaddar, Vivikka Molldrem, and Lara Wilson

Abstract
Objectives Lower-middle-income countries (LMICs) are lagging behind both high-income and low-income countries in new vaccine adoption. Our study involved the following objectives: (1) understand the decision-making processes of LMICs on new vaccine adoption, (2) identify the factors influencing LMIC decisions, (3) obtain the views of vaccine manufacturers about LMIC markets for new vaccines, and (4) make recommendations concerning how to speed up and improve decision making, including proposing mechanisms for implementation of the recommendations.

Methods Collect and analyse qualitative data from participants in decision making in 15 case study countries [12 LMICs and three upper-middle-income countries (UMICs)] and multinational and developing country vaccine manufacturers.

Findings Interviews of actors in decision making indicate that the aspects deemed most important for adoption are: World Health Organization (WHO) recommendations, the existence of local epidemiological data and a set of factors comprising affordability, cost-effectiveness and overall cost of the new vaccine for the programme. National Immunization Technical Advisory Groups (NITAG) have a key role in advising decision-makers, although their resources and capacity vary. Country decision-makers and manufacturers both see advantages in pooled procurement mechanisms for vaccine purchasing. Recommendations for countries and the international community involve assisting with making epidemiological data and vaccine market information accessible to countries, building and reinforcing related analysis capacity, and assisting with purchasing mechanisms and practices such as pooled procurement.

New vaccine adoption in lower-middle-income countries
Health Policy Plan. (2012) 27(suppl 2): ii39-ii49 doi:10.1093/heapol/czs036
Alan Brooks and Antoinette Ba-Nguz
Country planning for health interventions under development: lessons from the malaria vaccine decision-making framework and implications for other new interventions
Health Policy Plan. (2012) 27(suppl 2): ii50-ii61 doi:10.1093/heapol/czs039

Review
H E D Burchett, S Mounier-Jack, U K Griffiths, and A J Mills
National decision-making on adopting new vaccines: a systematic review
Health Policy Plan. (2012) 27(suppl 2): ii62-ii76 doi:10.1093/heapol/czr049

Abstract
In recent years numerous new vaccines have been developed, offering potential reductions in the morbidity and mortality caused by a range of diseases. This has led to increased interest in decision-making about the adoption of new vaccines into national immunization programmes. This paper aims to systematically review the literature on national decision-making around the adoption of new vaccines.

A thematic framework was developed inductively through analysis of the vaccine adoption decision-making frameworks included in the review. This thematic framework was then applied to the remaining studies included in the review.

In total, 85 articles were included in the review: 39 articles describing examples of vaccine adoption decision-making, 26 presenting vaccine decision-making frameworks, 21 empirical articles of decision-making relating to vaccine adoption and 19 theoretical essays.

An analysis of vaccine adoption decision-making frameworks identified nine broad categories of criteria: the importance of the health problem; vaccine characteristics; immunization programme considerations; acceptability; accessibility, equity and ethics; financial/economic issues; impact; alternative interventions and the decision-making process.

The quality of the empirical studies was varied. Although some of the issues included in the frameworks were similar to those considered in the studies, there were also some notable differences. On the whole, the frameworks were more comprehensive than the studies, including a greater range of criteria.

The existing literature provides a good foundation for further research into vaccine adoption decision-making. The current review, in pulling together what is already known and by identifying strengths, weaknesses and gaps in the existing evidence base, aims to encourage a more focused and rigorous approach to the topic in future. This could help to identify the most appropriate ways to develop vaccine adoption decision-making, so as to improve decisions and, ultimately, health outcomes

International Journal of Infectious Diseases
Volume 16, Issue 6 pp. e413-e468 (June 2012)
http://www.sciencedirect.com/science/journal/12019712

Original Reports
Comparison of attitudes about polio, polio immunization, and barriers to polio eradication between primary health center physicians and private pediatricians in India
Original Research Article
Pages e417-e423
Naveen Thacker, Panna Choudhury, Lisa M. Gargano, Paul S. Weiss, Karen Pazol, Sunil Bahl, Hamid S. Jafari, Manisha Arora, A.P. Dubey, Vipin M. Vashishtha, Rohit Agarwal, Amod Kumar, Walter A. Orenstein, Saad B. Omer, James M. Hughes

Summary
Objectives
The objectives of this study were to compare attitudes and perceptions of primary health center (PHC) physicians and pediatricians in Uttar Pradesh and Bihar toward polio disease, immunization, and eradication, and to identify barriers to polio eradication.

Methods
PHC physicians from blocks with at least one confirmed polio case during January 2006 to June 2009 were selected for an in-person survey. Pediatricians were members of the Indian Academy of Pediatrics and were selected from a national directory of members for telephone or mail survey.

Results
A higher percentage of PHC physicians than pediatricians reported that an unvaccinated child was susceptible to polio (82.1% vs. 63.0%, p < 0.0001) and that polio disease was severe in a child aged 1–5 years (77.7% vs. 62.2%, p < 0.0001). PHC physicians and pediatricians expressed confidence in the protectiveness and safety of oral polio vaccine and cited parents’ lack of awareness of the importance of polio eradication as an important barrier to eradication. Strengthening routine immunization efforts was reported as the leading intervention required to eradicate polio.

Conclusions
PHC physicians and pediatricians support and have confidence in the success of polio eradication efforts. These findings will be useful for policy-makers involved in the planning of eradication strategies. Providers and parents need to maintain confidence in polio vaccination if polio is to be eradicated.

JAMA   
April 25, 2012, Vol 307, No. 16, pp 1669-1766
http://jama.ama-assn.org/current.dtl

Original Contributions
Effect of a Text Messaging Intervention on Influenza Vaccination in an Urban, Low-Income Pediatric and Adolescent Population: A Randomized Controlled Trial
Melissa S. Stockwell, Elyse Olshen Kharbanda, Raquel Andres Martinez, Celibell Y. Vargas, David K. Vawdrey, Stewin Camargo
JAMA. 2012;307(16):1702-1708.doi:10.1001/jama.2012.502

Abstract
Context Influenza infection results in substantial costs, morbidity, and mortality. Vaccination against influenza is particularly important in children and adolescents who are a significant source of transmission to other high-risk populations, yet pediatric and adolescent vaccine coverage remains low. Traditional vaccine reminders have had a limited effect on low-income populations; however, text messaging is a novel, scalable approach to promote influenza vaccination.

Objective To evaluate targeted text message reminders for low-income, urban parents to promote receipt of influenza vaccination among children and adolescents.

Design, Setting, and Participants Randomized controlled trial of 9213 children and adolescents aged 6 months to 18 years receiving care at 4 community-based clinics in the United States during the 2010-2011 influenza season. Of the 9213 children and adolescents, 7574 had not received influenza vaccine prior to the intervention start date and were included in the primary analysis.

Intervention Parents of children assigned to the intervention received up to 5 weekly immunization registry–linked text messages providing educational information and instructions regarding Saturday clinics. Both the intervention and usual care groups received the usual care, an automated telephone reminder, and access to informational flyers posted at the study sites.

Main Outcome Measures Receipt of an influenza vaccine dose recorded in the immunization registry via an electronic health record by March 31, 2011. Receipt was secondarily assessed at an earlier fall review date prior to typical widespread influenza activity.

Results Study children and adolescents were primarily minority, 88% were publicly insured, and 58% were from Spanish-speaking families. As of March 31, 2011, a higher proportion of children and adolescents in the intervention group (43.6%; n = 1653) compared with the usual care group (39.9%; n = 1509) had received influenza vaccine (difference, 3.7% [95% CI, 1.5%-5.9%]; relative rate ratio [RRR], 1.09 [95% CI, 1.04-1.15]; P = .001). At the fall review date, 27.1% (n = 1026) of the intervention group compared with 22.8% (n = 864) of the usual care group had received influenza vaccine (difference, 4.3% [95% CI, 2.3%-6.3%]; RRR, 1.19 [95% CI, 1.10-1.28]; P < .001).

Conclusions Among children and adolescents in a low-income, urban population, a text messaging intervention compared with usual care was associated with an increased rate of influenza vaccination. However, the overall influenza vaccination rate remained low.

Trial Registration clinicaltrials.gov Identifier: NCT01146912

JAMA   
April 25, 2012, Vol 307, No. 16, pp 1669-1766
http://jama.ama-assn.org/current.dtl

Editorials
Text Messaging: A New Tool for Improving Preventive Services
Peter G. Szilagyi, William G. Adams
JAMA. 2012;307(16):1748-1749.doi:10.1001/jama.2012.524

Extract
Prevention of influenza disease through vaccination is a public health challenge. Influenza disease causes substantial morbidity and mortality in children, adolescents, and adults; vaccination is the best method to prevent this disease. In light of the increasing understanding of the burden of influenza among children and adolescents and its spread from children to adults, the Advisory Committee on Immunization Practices expanded its influenza vaccination recommendations in 2008 to include all children and adolescents between 6 months and 18 years of age.1 More than 65 million children and adolescents should be vaccinated annually, usually within a short timeframe of several months when the vaccine is available. While influenza vaccination coverage nationwide has increased, it remains low—only about half of all children and adolescents are vaccinated.

In the United States, primary care practices bear the major burden of vaccinating children and adolescents, and because most do not have health care visits …

Journal of Infectious Diseases
Volume 205 Issue 10 May 15, 2012
http://www.journals.uchicago.edu/toc/jid/current

Viruses
Nicholas C. Grassly, Hamid Jafari, Sunil Bahl, Raman Sethi, Jagadish M. Deshpande, Chris Wolff, Roland W. Sutter, and R. Bruce Aylward
Waning Intestinal Immunity After Vaccination With Oral Poliovirus Vaccines in India
J Infect Dis. (2012) 205(10): 1554-1561 doi:10.1093/infdis/jis241

Abstract
Background The eradication of wild-type polioviruses in areas with efficient fecal-oral transmission relies on intestinal mucosal immunity induced by oral poliovirus vaccine (OPV). Mucosal immunity is thought to wane over time but the rate of loss of protection has not been examined.

Methods We examined the degree and duration of intestinal mucosal immunity in India by measuring the prevalence of vaccine poliovirus in stool samples collected 4–28 days after a “challenge” dose of OPV among 47 574 children with acute flaccid paralysis reported during 2005–2009.

Results Previous vaccination with OPV was protective against excretion of vaccine poliovirus after challenge, but the odds of excretion increased significantly with the time since the child was last exposed to an immunization activity (odds ratio, 1.39 [95% confidence interval .99–1.97], 2.04 [1.28–3.25], and 1.31 [1.00–1.70] comparing ≥6 months with 1 month ago for serotypes 1, 2, and 3, respectively). Vaccine administered during the high season for enterovirus infections (April–September) was significantly less likely to result in excretion, especially in northern states (odds ratio, 0.57 [95% confidence interval, .50–.65], 0.58 [.41–.81], and 0.48 [.40–.57] for serotypes 1, 2, and 3).

Conclusions Infection with OPV (vaccine “take”) is highly seasonal in India and results in intestinal mucosal immunity that appears to wane significantly within a year of vaccination.

Journal of Infectious Diseases
Volume 205 Issue 10 May 15, 2012
http://www.journals.uchicago.edu/toc/jid/current

Bacteria
Peter C. Wroe, Jonathan A. Finkelstein, G. Thomas Ray, Jeffrey A. Linder, Kristen M. Johnson, Sheryl Rifas-Shiman, Matthew R. Moore, and Susan S. Huang
Aging Population and Future Burden of Pneumococcal Pneumonia in the United States
J Infect Dis. (2012) 205(10): 1589-1592 doi:10.1093/infdis/jis240

Abstract
Pneumococcal pneumonia is concentrated among the elderly. Using a decision analytic model, we projected the future incidence of pneumococcal pneumonia and associated healthcare utilization and costs accounting for an aging US population. Between 2004 and 2040, as the population increases by 38%, pneumococcal pneumonia hospitalizations will increase by 96% (from 401 000 to 790 000), because population growth is fastest in older age groups experiencing the highest rates of pneumococcal disease. Absent intervention, the total cost of pneumococcal pneumonia will increase by $2.5 billion annually, and the demand for healthcare services for pneumococcal pneumonia, especially inpatient capacity, will double in coming decades.