BMC Infectious Diseases
(Accessed 6 December 2014)
http://www.biomedcentral.com/bmcinfectdis/content

Research article
Persistent low carriage of serogroup A Neisseria meningitidis two years after mass vaccination with the meningococcal conjugate vaccine, MenAfriVac
Paul A Kristiansen1*, Absatou Ky Ba2, Abdoul-Salam Ouédraogo3, Idrissa Sanou34, Rasmata Ouédraogo5, Lassana Sangaré4, Fabien Diomandé67, Denis Kandolo6, Inger Marie Saga1, Lara Misegades7, Thomas A Clark7, Marie-Pierre Préziosi89 and Dominique A Caugant110
Author Affiliations
BMC Infectious Diseases 2014, 14:663 doi:10.1186/s12879-014-0663-4
Published: 4 December 2014
Abstract (provisional)
Background
The conjugate vaccine against serogroup A Neisseria meningitidis (NmA), MenAfriVac, is currently being introduced throughout the African meningitis belt. In repeated multicentre cross-sectional studies in Burkina Faso we demonstrated a significant effect of vaccination on NmA carriage for one year following mass vaccination in 2010. A new multicentre carriage study was performed in October-November 2012, two years after MenAfriVac mass vaccination.
Methods
Oropharyngeal samples were collected and analysed for presence of N. meningitidis (Nm) from a representative selection of 1-29-year-olds in three districts in Burkina Faso using the same procedures as in previous years. Characterization of Nm isolates included serogrouping, multilocus sequence typing, and porA and fetA sequencing. A small sample of invasive isolates collected during the epidemic season of 2012 through the national surveillance system were also analysed.
Results
From a total of 4964 oropharyngeal samples, overall meningococcal carriage prevalence was 7.86%. NmA prevalence was 0.02% (1 carrier), significantly lower (OR, 0.05, 95% CI, P?=?0.005, 0.006-0.403) than pre-vaccination prevalence (0.39%). The single NmA isolate was sequence type (ST)-7, P1.20,9;F3-1, a clone last identified in Burkina Faso in 2003. Nm serogroup W (NmW) dominated with a carriage prevalence of 6.85%, representing 87.2% of the isolates. Of 161 NmW isolates characterized by molecular techniques, 94% belonged to the ST-11 clonal complex and 6% to the ST-175 complex. Nm serogroup X (NmX) was carried by 0.60% of the participants and ST-181 accounted for 97% of the NmX isolates. Carriage prevalence of serogroup Y and non-groupable Nm was 0.20% and 0.18%, respectively. Among the 20 isolates recovered from meningitis cases, NmW dominated (70%), followed by NmX (25%). ST-2859, the only ST with a serogroup A capsule found in Burkina Faso since 2004, was not found with another capsule, neither among carriage nor invasive isolates.
Conclusions
The significant reduction of NmA carriage still persisted two years following MenAfriVac vaccination, and no cases of NmA meningitis were recorded. High carriage prevalence of NmW ST-11 was consistent with the many cases of NmW meningitis in the epidemic season of 2012 and the high proportion of NmW ST-11 among the characterized invasive isolates.

Research article
Identifying an appropriate PCV for use in Senegal, recent insights concerning Streptococcus pneumoniae NP carriage and IPD in Dakar
Fatim Ba1, Abdoulaye Seck1, Mamadou Bâ2, Aliou Thiongane2, Moussa Fafa Cissé2, Khady Seck3, Madeleine Ndour4, Pascal Boisier5 and Benoit Garin16*
Author Affiliations
BMC Infectious Diseases 2014, 14:627 doi:10.1186/s12879-014-0627-8
Published: 4 December 2014
Abstract (provisional)
Background
Since 2000, the Global Alliance for Vaccines and Immunization (GAVI) and WHO have supported the introduction of the Pneumococcal Conjugate Vaccine (PCV) in the immunization programs of developing countries. The highest pneumococcal nasopharyngeal carriage rates have been reported (40-60%) in these countries, and the highest incidence and case fatality rates of pneumococcal infections have been demonstrated in Africa.
Methods
Studies concerning nasopharyngeal pneumococcal carriage and pneumococcal infection in children less than 5?years old were conducted in Dakar from 2007 to 2008. Serotype, antibiotic susceptibility and minimum inhibitory concentrations were determined. In addition, among 17 overall publications, 6 manuscripts of the Senegalese literature published from 1972 to 2013 were selected for data comparisons.
Results
Among the 264 children observed, 132 (50%) children generated a nasopharyngeal (NP) positive culture with Streptococcus pneumoniae. The five most prevalent serotypes, were 6B (9%), 19?F (9%), 23?F (7.6%), 14 (7.6%) and 6A (6.8%). Fifteen percent of the strains (20/132) showed reduced susceptibility to penicillin and 3% (4/132) showed reduced susceptibility to anti-pneumococcal fluoroquinolones. Among the 196 suspected pneumococcal infections, 62 (31.6%) Streptococcus pneumoniae were isolated. Serogroup 1 was the most prevalent serotype (21.3%), followed by 6B (14.9%), 23?F (14.9%) and 5 (8.5%). Vaccine coverage for PCV-7, PCV-10 and PCV-13, were 36.2% (17/47), 66% (31/47) and 70.2% (33/47) respectively. Reduced susceptibility to penicillin and anti-pneumococcal fluoroquinolones was 6.4% and 4.3%, respectively, and the overall lethality was 42.4% (14/33).
Conclusions
This study confirms a high rate of carriage and disease caused by Streptococcus pneumoniae serotypes contained within the current generation of pneumococcal conjugate vaccines and consistent with reports from other countries in sub-Saharan Africa prior to PCV introduction. Antimicrobial resistance in this small unselected sample confirms a low rate of antibiotic resistance. Case-fatality is high. Introduction of a high valency pneumococcal vaccine should be a priority for health planners with the establishment of an effective surveillance system to monitor post vaccine changes.

BMC Medical Ethics
(Accessed 6 December 2014)
http://www.biomedcentral.com/bmcmedethics/content

Research article
Ethical challenges in connection with the use of coercion: a focus group study of health care personnel in mental health care
Marit Helene Hem, Bert Molewijk and Reidar Pedersen
Author Affiliations
BMC Medical Ethics 2014, 15:82 doi:10.1186/1472-6939-15-82
Published: 4 December 2014
Abstract (provisional)
Background
In recent years, the attention on the use of coercion in mental health care has increased. The use of coercion is common and controversial, and involves many complex ethical challenges. The research question in this study was: What kind of ethical challenges related to the use of coercion do health care practitioners face in their daily clinical work?
Methods
We conducted seven focus group interviews in three mental health care institutions involving 65 multidisciplinary participants from different clinical fields. The interviews were recorded and transcribed verbatim. We analysed the material applying a ‘bricolage’ approach. Basic ethical principles for research ethics were followed. We received permission from the hospitals’ administrations and all health care professionals who participated in the focus group interviews.
Results
Health care practitioners describe ethical dilemmas they face concerning formal, informal and perceived coercion. They provide a complex picture. They have to handle various ethical challenges, not seldom concerning questions of life and death. In every situation, the dignity of the patient is at stake when coercion is considered as morally right, as well as when coercion is not the preferred intervention. The work of the mental health professional is a complicated “moral enterprise”.
The ethical challenges deserve to be identified and handled in a systematic way. This is important for developing the quality of health care, and it is relevant to the current focus on reducing the use of coercion and increasing patient participation. Precise knowledge about ethical challenges is necessary for those who want to develop ethics support in mental health care. Better communication skills among health care professionals and improved therapeutic relationships seem to be vital.

BMC Public Health
(Accessed 6 December 2014)
http://www.biomedcentral.com/bmcpublichealth/content

Research article
Stigmatizing attitudes towards people living with HIV/AIDS: validation of a measurement scale
Marianne Beaulieu, Alix Adrien, Louise Potvin and Clément Dassa
Author Affiliations
BMC Public Health 2014, 14:1246 doi:10.1186/1471-2458-14-1246
Published: 4 December 2014
Abstract (provisional)
Background
Although stigmatization has long been recognized as a major obstacle to HIV prevention. The lack of a valid and reliable measurement tool for stigmatization is a major gap in the research. This study aimed to: 1) develop a scale of stigmatizing attitudes towards people living with HIV (SAT-PLWHA-S) and 2) demonstrate its reliability and validity.
Methods
French and English-speaking experts (n = 21) from different professional communities (academics, practitioners) assessed the clarity and relevance of the proposed items. The psychometric properties of the SAT-PLWHA-S were assessed with a random digit dial population based telephone survey (n = 1,500) of respondents in Quebec, Canada. Analyses included exploratory and confirmatory factor analyses, correlations, multiple linear regressions, t-tests, hypothesis testing of factorial structure invariance, and Cronbach’s alpha.
Results
Confirmatory factor analysis (CFA) supported a 27-item structure with seven factors: 1) concerns about occasional encounters; 2) avoidance of personal contact; 3) responsibility and blame, 4) liberalism, 5) non-discrimination, 6) confidentiality of seropositive status, and 7) criminalization of HIV transmission. Cronbach’s alphas indicate satisfactory internal consistency. An assessment of concurrent validity using Pearson’s correlation and multiple linear regression shows that homophobia and HIV transmission knowledge are significant determinants of stigmatizing attitudes toward PLHIV. Discriminant validity (t-test) results suggest that the SAT-PLWHA-S can differentiate attitudes between different groups and indicates invariant factor structure across language.
Conclusions
The results of this study suggest that the SAT-PLWHA-S is a reliable and valid tool for measuring stigmatizing attitudes toward PLHIV and that it can contribute to a deeper understanding of HIV stigma.

Bulletin of the World Health Organization
Volume 92, Number 12, December 2014, 849-924
http://www.who.int/bulletin/volumes/92/12/en/

Health-system resilience: reflections on the Ebola crisis in western Africa
Marie-Paule Kieny a, David B Evans a, Gerard Schmets a & Sowmya Kadandale a
a. World Health Organization, avenue Appia 20, 1211 Geneva 27, Switzerland.
Bulletin of the World Health Organization 2014;92:850. doi: http://dx.doi.org/10.2471/BLT.14.149278
Disease outbreaks and catastrophes can affect countries at any time, causing substantial human suffering and deaths and economic losses. If health systems are ill-equipped to deal with such situations, the affected populations can be very vulnerable.1

The current Ebola virus disease outbreak in western Africa highlights how an epidemic can proliferate rapidly and pose huge problems in the absence of a strong health system capable of a rapid and integrated response. The outbreak began in Guinea in December 2013 but soon spread into neighbouring Liberia and Sierra Leone.2 In early August 2014, Ebola was declared an international public health emergency.2

At the time the outbreak began, the capacity of the health systems in Guinea, Liberia and Sierra Leone was limited. Several health-system functions that are generally considered essential were not performing well and this hampered the development of a suitable and timely response to the outbreak. There were inadequate numbers of qualified health workers.3 Infrastructure, logistics, health information, surveillance, governance and drug supply systems were weak. The organization and management of health services was sub-optimal. Government health expenditure was low whereas private expenditure – mostly in the form of direct out-of-pocket payments for health services – was relatively high.4

The last decade has seen increased external health-related aid to Guinea, Liberia and Sierra Leone. However, in the context of Millennium Development Goals 4, 5 and 6, most of this aid has been allocated to combat human immunodeficiency virus infection, malaria and tuberculosis, with much of the residual going to maternal and child health services. Therefore, relatively little external aid was left to support overall development of health systems.5 This lack of balanced investment in the health systems contributes to the challenges of controlling the current Ebola outbreak. Weak health systems cannot be resilient.6–8 A strong health system decreases a country’s vulnerability to health risks and ensures a high level of preparedness to mitigate the impact of any crises.

Frequently, the response by governments and external partners to a health crisis posed by a communicable disease, such as Ebola, is to focus solely on reducing transmission and the effect of the disease. However, such a response is insufficient. Febrile individuals need to be screened for Ebola – even if most of them have fevers caused by other infections – and those found to be negative for Ebola still need to be treated rather than simply turned away. Even in the worst-affected areas, women still need antenatal services, safe delivery and postnatal care. Many people will travel to seek care for unrelated conditions in areas that they perceive to be Ebola-free, putting enormous strain on the health system in so-called “non-Ebola” areas. Routine services need to be assured while dealing with the direct effects of an epidemic. Otherwise, more people may die – of unrelated causes – from a general breakdown of health services than as a direct result of the epidemic.

If this Ebola outbreak does not trigger substantial investments in health systems and adequate reforms in the worst-affected countries, pre-existing deficiencies in health systems will be exacerbated. The national governments, assisted by external partners, need to develop and implement strategies to make their health systems stronger and more resilient. Only then can they meet the essential health needs of their populations and develop strong disaster preparedness to address future emergencies. In the short-term, nongovernmental organizations, civil society and international organizations will have to bolster the national health systems, both to mitigate the direct consequences of the outbreak and to ensure that all essential health services are being delivered. However, this assistance should be carefully coordinated under the leadership of the national governments and follow development effectiveness principles. We expect health systems in the worst-affected areas to be left in a very weak state once the outbreak has ended. Hopefully, after the epidemic has ended, economic growth and government health spending will eventually rebound, with increased domestic investments in health systems. For the foreseeable future however, the negative economic impact on the affected countries9 means that substantial external financing will be needed to build stronger national and subnational health systems.
References

Systematic Review
Effectiveness of travel restrictions in the rapid containment of human influenza: a systematic review
Ana LP Mateus, Harmony E Otete, Charles R Beck, Gayle P Dolan & Jonathan S Nguyen-Van-Tam
Abstract
Objective
To assess the effectiveness of internal and international travel restrictions in the rapid containment of influenza.
Methods
We conducted a systematic review according to the requirements of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Health-care databases and grey literature were searched and screened for records published before May 2014. Data extraction and assessments of risk of bias were undertaken by two researchers independently. Results were synthesized in a narrative form.
Findings
The overall risk of bias in the 23 included studies was low to moderate. Internal travel restrictions and international border restrictions delayed the spread of influenza epidemics by one week and two months, respectively. International travel restrictions delayed the spread and peak of epidemics by periods varying between a few days and four months. Travel restrictions reduced the incidence of new cases by less than 3%. Impact was reduced when restrictions were implemented more than six weeks after the notification of epidemics or when the level of transmissibility was high. Travel restrictions would have minimal impact in urban centres with dense populations and travel networks. We found no evidence that travel restrictions would contain influenza within a defined geographical area.
Conclusion
Extensive travel restrictions may delay the dissemination of influenza but cannot prevent it. The evidence does not support travel restrictions as an isolated intervention for the rapid containment of influenza. Travel restrictions would make an extremely limited contribution to any policy for rapid containment of influenza at source during the first emergence of a pandemic virus.

Post-licensure deployment of oral cholera vaccines: a systematic review
Stephen Martin, Anna Lena Lopez, Anna Bellos, Jacqueline Deen, Mohammad Ali, Kathryn Alberti, Dang Duc Anh, Alejandro Costa, Rebecca F Grais, Dominique Legros, Francisco J Luquero, Megan B Ghai, William Perea & David A Sack
Abstract
Objective
To describe and analyse the characteristics of oral cholera vaccination campaigns; including location, target population, logistics, vaccine coverage and delivery costs.
Methods
We searched PubMed, the World Health Organization (WHO) website and the Cochrane database with no date or language restrictions. We contacted public health personnel, experts in the field and in ministries of health and did targeted web searches.
Findings
A total of 33 documents were included in the analysis. One country, Viet Nam, incorporates oral cholera vaccination into its public health programme and has administered approximately 10.9 million vaccine doses between 1997 and 2012. In addition, over 3 million doses of the two WHO pre-qualified oral cholera vaccines have been administered in more than 16 campaigns around the world between 1997 and 2014. These campaigns have either been pre-emptive or reactive and have taken place under diverse conditions, such as in refugee camps or natural disasters. Estimated two-dose coverage ranged from 46 to 88% of the target population. Approximate delivery cost per fully immunized person ranged from 0.11–3.99 United States dollars.
Conclusion
Experience with oral cholera vaccination campaigns continues to increase. Public health officials may draw on this experience and conduct oral cholera vaccination campaigns more frequently.

PERSPECTIVES
Defining disrespect and abuse of women in childbirth: a research, policy and rights agenda
Lynn P Freedman, Kate Ramsey, Timothy Abuya, Ben Bellows, Charity Ndwiga, Charlotte E Warren, Stephanie Kujawski, Wema Moyo, Margaret E Kruk & Godfrey Mbaruku
doi: 10.2471/BLT.14.137869

Dilemmas of evaluation: health research capacity initiatives
Donald C Cole, Garry Aslanyan, Alison Dunn, Alan Boyd & Imelda Bates
doi: 10.2471/BLT.14.141259

Conflict and Health
[Accessed 6 December 2014]
http://www.conflictandhealth.com/

Case study
Community health workers of Afghanistan: a qualitative study of a national program
Najafizada SA, Labonté R and Bourgeault IL Conflict and Health 2014, 8:26 (1 December 2014)

Case study
Treating drug-resistant tuberculosis in a low-intensity chronic conflict setting in India
Armstrong E, Das M, Mansoor H, Babu RB and Isaakidis P Conflict and Health 2014, 8:25 (1 December 2014)

Global Health Governance
[Accessed 6 December 2014]
http://blogs.shu.edu/ghg/category/complete-issues/summer-2013/

Determinants of Global Collective Action in Health: The Case of the UN Summit on Non-communicable Diseases
November 30, 2014
Chantal Blouin, Laurette Dube, Ebony Bertorelli and Monique Moreau
This article presents a case study of the policy process leading to the UN High-Level Meeting on non-communicable diseases (NCDs). The case study tests an analytical framework to understand the factors influencing successful global collective to address chronic diseases. Using this framework, we highlighted four factors explaining the weak outcome of this process. We observed a relatively weak mobilization and advocacy of civil society at the national and global level. Second, the financial context of that time, especially in industrial countries, has created the conditions where it is politically and fiscally difficult for donor countries to undertake financial commitments to support global actions. Thirdly, we observe that health actors have done an incorrect assessment as to where the policy process. Finally, we observed a certain lack of clarity on the rationale for global collective action; the key obstacle here is the economic case has not been sufficiently and visibly made to motivate and trigger policy change. After the Summit in the fall of 2011, the global health diplomacy around chronic diseases control and prevention continued. Future research should examine if the proposed analytical framework is a useful tool to analyze these further steps and to prepare for health diplomacy.

Plants, Patents and Biopiracy: The Globalization of Intellectual Property Rights and Traditional Medicine
– November 30, 2014
Suchita Shah
A controversial international debate has arisen between those who call for stronger intellectual property legislation to protect their scientific innovation, and those who claim ‘biopiracy’ of their traditional medical knowledge (TMK) under such legislation. This paper firstly presents and contextualises the debate, then argues that the difficulty in its resolution has been fuelled by three main factors: first, the lack of an integrated and comprehensive international rights-based system for TMK, which is mirrored in domestic legislation; second, attempts to redress perceived iniquities present legal, political and logistical problems to developing countries; third, when faced with these constraints, developing countries themselves may not act in the best interests of their TMK holders. The case of India, based on original fieldwork, illustrates these issues. Due to the complex nature of TMK and diverse positions on its protection, a broad international sui generis system of rights for TMK holders seems a distant prospect in reality. With a view to advancing the debate, this paper highlights local, national, regional and global initiatives to protect TMK holders, examining in particular the potential of four key processes – forum-shifting, linkages to public health, use of transnational networks and normative change in order to achieve incremental gains.

Health Economics, Policy and Law
Volume 10 – Special Issue 01 January 2015
http://journals.cambridge.org/action/displayIssue?jid=HEP&tab=currentissue
SPECIAL ISSUE: Global Financial Crisis, Health and Health Care

Overview
Financial impact of the GFC: health care spending across the OECD
David Morgana1 c1 and Roberto Astolfia2
a1 OECD Health Division, OECD, Paris, France
a2 Statistician/Economist, OECD, Paris, France
Abstract
Since the onset of the global financial crisis (GFC), health spending has slowed markedly or fallen in many OECD countries after years of continuous growth. However, health spending patterns across the 34 countries of the OECD have been affected to varying degrees. This article examines in more detail the observed downturn in health expenditure growth, analysing which countries and which sectors of health spending have been most affected. In addition, using more recent preliminary data for a subset of countries, this article tries to shed light on the prospects for health spending trends. Given that public sources account for around three-quarters of total spending on health on average across the OECD, and, in an overall context of managing public deficits, the article focuses on the specific areas of public spending that have been most affected. This study also tries to link the observed trends with some of the main policy measures and instruments put in place by countries. The investigation finds that while nearly all OECD countries have seen health spending growth decrease since 2009, there is wide variation as to the extent of the slowdown, with some countries outside of Europe continuing to see significant growth in health spending. While all sectors of spending appear to have been affected, initial analysis appears to show the greatest decreases has been experienced in pharmaceutical spending and in areas of public health and prevention.

Health Policy and Planning
Volume 29 Issue 8 December 2014
http://heapol.oxfordjournals.org/content/current

The emergence, growth and decline of political priority for newborn survival in Bolivia
Stephanie L Smith*
Author Affiliations
School of Public Administration, University of New Mexico, Albuquerque, NM 87131-0001, USA
Accepted September 16, 2013.
Abstract
Bolivia is expected to achieve United Nations Millennium Development Goal Four, reducing under-five child mortality by two-thirds between 2021 and 2025. However, progress on child mortality reduction masks a disproportionately slow decline in newborn deaths during the 2000s. Bolivia’s neonatal mortality problem emerged on the policy agenda in the mid-1990s and grew through 2004 in relationship to political commitments to international development goals and the support of a strong policy network. Network status declined later in the decade. This study draws upon a framework for analysing determinants of political priority for global health initiatives to understand the trajectory of newborn survival policy in Bolivia from the early 1990s. A process-tracing case study methodology is used, informed by interviews with 26 individuals with close knowledge of newborn survival policy in the country and extensive document analysis. The case of newborn survival in Bolivia highlights the significance of political commitments to international development goals, health policy network characteristics (cohesion, composition, status and key actor support) and political transitions and instability in shaping agenda status, especially decline—an understudied phenomenon considering the transitory nature of policy priorities. The study suggests that the sustainability of issue attention therefore become a focal point for health policy networks and analyses.

Global Fund investments in human resources for health: innovation and missed opportunities for health systems strengthening
Diana Bowser1, Susan Powers Sparkes1, Andrew Mitchell1,2, Thomas J. Bossert1, Till Bärnighausen1, Gulin Gedik3 and Rifat Atun1,4,*
Author Affiliations
1Harvard School of Public Health, Boston, MA 02115, USA, 2Office of the U.S. Global AIDS Coordinator, Washington, DC, 20520, 3World Health Organization, 1211 Geneva 27, Switzerland and 4Imperial College Business School and Faculty of Medicine, London, SW7 2AZ, UK
Accepted September 16, 2013.
Abstract
Background
Since the early 2000s, there have been large increases in donor financing of human resources for health (HRH), yet few studies have examined their effects on health systems.
Objective To determine the scope and impact of investments in HRH by the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), the largest investor in HRH outside national governments.
Methods
We used mixed research methodology to analyse budget allocations and expenditures for HRH, including training, for 138 countries receiving money from the Global Fund during funding rounds 1–7. From these aggregate figures, we then identified 27 countries with the largest funding for human resources and training and examined all HRH-related performance indicators tracked in Global Fund grant reports. We used the results of these quantitative analyses to select six countries with substantial funding and varied characteristics—representing different regions and income levels for further in-depth study: Bangladesh (South and West Asia, low income), Ethiopia (Eastern Africa, low income), Honduras (Latin America, lower-middle income), Indonesia (South and West Asia, lower-middle income), Malawi (Southern Africa, low income) and Ukraine (Eastern Europe and Central Asia, upper-middle income). We used qualitative methods to gather information in each of the six countries through 159 interviews with key informants from 83 organizations. Using comparative case-study analysis, we examined Global Fund’s interactions with other donors, as well as its HRH support and co-ordination within national health systems.
Results
Around US$1.4 billion (23% of total US$5.1 billion) of grant funding was allocated to HRH by the 138 Global Fund recipient countries. In funding rounds 1–7, the six countries we studied in detail were awarded a total of 47 grants amounting to US$1.2 billion and HRH budgets of US$276 million, of which approximately half were invested in disease-focused in-service and short-term training activities. Countries employed a variety of mechanisms including salary top-ups, performance incentives, extra compensation and contracting of workers for part-time work, to pay health workers using Global Fund financing. Global Fund support for training and salary support was not co-ordinated with national strategic plans and there were major deficiencies in the data collected by the Global Fund to track HRH financing and to provide meaningful assessments of health system performance.
Conclusion
The narrow disease focus and lack of co-ordination with national governments call into question the efficiency of funding and sustainability of Global Fund investments in HRH and their effectiveness in strengthening recipient countries’ health systems. The lessons that emerge from this analysis can be used by both the Global Fund and other donors to improve co-ordination of investments and the effectiveness of programmes in recipient countries.

Aid for health in times of political unrest in Mali: does donors’ way of intervening allow protecting people’s health?
Elisabeth Paul1,*, Salif Samaké2, Issa Berthé2, Ini Huijts3, Hubert Balique4 and Bruno Dujardin5
Author Affiliations
1Université de Liège, Changement Social et Développement, and Research Group on the Implementation of the Agenda for Aid Effectiveness in the Health Sector (GRAP-PA Santé), Boulevard du Rectorat 7, Bât B31, bte 8, 4000 Liège, Belgium, 2Planning and Statistics Unit, Ministry of Health, BP232, Koulouba, Bamako, Mali, 3International Heath Expert, Bamako, Mali, 4Laboratoire de Santé Publique, Faculté de Médecine de Marseille 27, Bd Jean Moulin, 13385 Marseille CEDEX 05, France and 5Ecole de Santé Publique, Université Libre de Bruxelles, Campus Erasme, CP596, Route de Lennik 808, 1070 Bruxelles, Belgium
Accepted September 27, 2013.
Abstract
Mali has long been a leader in francophone Africa in developing systems aimed at improving aid effectiveness, especially in the health sector. But following the invasion of the Northern regions of the country by terrorist groups and a coup in March 2012, donors suspended official development assistance, except for support to NGOs and humanitarian assistance. They resumed aid after transfer of power to a civil government, but this was not done in a harmonized framework. This article describes and analyses how donors in the health sector reacted to the political unrest in Mali. It shows that despite its long sector-wide approach experience and international agreements to respect aid effectiveness principles, donors have not been able to intervene in view of safeguarding the investments of co-operation in the past decade, and of protecting the health system’s functioning. They reacted to the political unrest on a bilateral basis, stopped working with their ministerial partners, interrupted support to the health system which was still expected to serve populations’ needs and took months before organizing alternative and only partial solutions to resume aid to the health sector. The Malian example leads to a worrying conclusion: while protecting the health system’s achievements and functioning for the population should be a priority, and while harmonizing donors’ interventions seems the most appropriate way for that purpose, donors’ management practices do not allow for reacting adequately in times of unrest. The article concludes by a number of recommendations.

Health Research Policy and Systems

[Accessed 6 December 2014]

Review
A systematic review of Health Technology Assessment tools in sub-Saharan Africa: methodological issues and implications
Christine Kriza1*, Jill Hanass-Hancock2, Emmanuel Ankrah Odame3, Nicola Deghaye2, Rashid Aman4, Philip Wahlster1, Mayra Marin1, Nicodemus Gebe5, Willis Akhwale6, Isabelle Wachsmuth7 and Peter L Kolominsky-Rabas1
Author Affiliations
Health Research Policy and Systems 2014, 12:66 doi:10.1186/1478-4505-12-66
Published: 2 December 2014
Abstract
Background
Health technology assessment (HTA) is mostly used in the context of high- and middle-income countries. Many “resource-poor” settings, which have the greatest need for critical assessment of health technology, have a limited basis for making evidence-based choices. This can lead to inappropriate use of technologies, a problem that could be addressed by HTA that enables the efficient use of resources, which is especially crucial in such settings. There is a lack of clarity about which HTA tools should be used in these settings. This research aims to provide an overview of proposed HTA tools for “resource-poor” settings with a specific focus on sub-Saharan Africa (SSA).
Methodology
A systematic review was conducted using basic steps from the PRISMA guidelines. Studies that described HTA tools applicable for “resource-limited” settings were identified and critically appraised. Only papers published between 2003 and 2013 were included. The identified tools were assessed according to a checklist with methodological criteria.
Results
Six appropriate tools that are applicable in the SSA setting and cover methodological robustness and ease of use were included in the review. Several tools fulfil these criteria, such as the KNOW ESSENTIALS tool, Mini-HTA tool, and Multi-Criteria Decision Analysis but their application in the SSA context remains limited. The WHO CHOICE method is a standardized decision making tool for choosing interventions but is limited to their cost-effectiveness. Most evaluation of health technology in SSA focuses on priority setting. There is a lack of HTA tools that can be used for the systematic assessment of technology in the SSA context.
Conclusions
An appropriate HTA tool for “resource-constrained” settings, and especially SSA, should address all important criteria of decision making. By combining the two most promising tools, KNOW ESSENTIALS and Multi-Criteria Decision Analysis, appropriate analysis of evidence with a robust and flexible methodology could be applied for the SSA setting.

Infectious Diseases of Poverty
[Accessed 6 December 2014]
http://www.idpjournal.com/content

Research Article
An integrative approach to enhancing small-scale poultry slaughterhouses by addressing regulations and food safety in northern -Thailand
Suwit Chotinun, Suvichai Rojanasthien, Fred Unger, Manat Suwan, Pakpoom Tadee and Prapas Patchanee
Author Affiliations
Infectious Diseases of Poverty 2014, 3:46 doi:10.1186/2049-9957-3-46
Published: 5 December 2014
Abstract (provisional)
Background
In Asian countries, small-scale rural poultry meat production can face challenges due to food safety policies that limit economic growth and hinder improvement of sanitation and disease prevention. In this study, an integrative, participatory research approach was used to elucidate the sanitation and disease prevention practices in small-scale poultry slaughterhouses in rural northern Thailand.
Methods
Initial steps included the identification of key stakeholders associated with the meat production chain, development of a research framework, and design of a methodology based on stakeholder consultations. The framework and methodology combine issues in five major areas: (1) public health, (2) socioeconomics, (3) policy, (4) veterinary medicine, and (5) communities and the environment. Methods used include questionnaires, direct observation, focus groups, and in-depth interviews. In addition, a microbiological risk assessment approach was employed to detect Salmonella contamination in meat processing facilities. The microbial risk assessment was combined with stakeholder perceptions to provide an overview of the existing situation, as well as to identify opportunities for upgrading slaughterhouses in order to more effectively address matters of food safety, processing, and government licensing.
Results
The conceptual framework developed elucidated the complex factors limiting small-scale slaughterhouse improvement including a lack of appropriate enabling policies and an apparent absence of feasible interventions for improvement. Unhygienic slaughterhouse management was reflected in the incidence of Salmonella contamination in both the meat and the surrounding environment.
Conclusion
There is potential for the use of an integrative approach to address critical problems at the interface of rural development and public health. The findings of this study could serve as a model for transdisciplinary studies and interventions related to other similar complex challenges.

International Health
Volume 6 Issue 4 December 2014
http://inthealth.oxfordjournals.org/content/6/3.toc

Addressing the global health burden of sickle cell disease
Peter J. Carey*
Author Affiliations
Royal Victoria Infirmary, Newcastle upon Tyne, NE1 4LP, UK
Received April 1, 2014.
Revision received June 13, 2014.
Accepted June 16, 2014.
Abstract
A review of the clinical manifestations of sickle cell disease (SCD), available therapeutic interventions and a necessarily limited assessment of progress with their implementation in Nigeria (the country with the largest number of affected individuals worldwide) was recently published in this journal. Despite a disappointing dearth of targeted therapy for a condition whose molecular basis has been well understood for half a century, there is a wealth of evidence-based supportive interventions, including antibiotic and vaccination prophylaxis against early bacteraemic mortality, childhood stroke risk prevention, patient and population education and screening and community care provision that are simple and inexpensive to implement. There is a real opportunity for international collaboration to drive an improvement in healthcare provision for this condition.

Time is (still) of the essence: quantifying the impact of emergency meningitis vaccination response in Katsina State, Nigeria
Matthew J. Ferraria, Florence Fermonb, Fabienne Nackersc, Augusto Llosac, Claire Magonec and
Rebecca F. Graisc,*
Author Affiliations
aCenter for Infectious Disease Dynamics, Department of Biology, Pennsylvania State University, University Park, PA 16802 USA
bEpicentre, Paris, France
cMédecins Sans Frontières, Paris, France
Received March 19, 2014.
Revision received July 28, 2014.
Accepted July 29, 2014.
Abstract
Background
In 2009, a large meningitis A epidemic affected a broad region of northern Nigeria and southern Niger, resulting in more than 75 000 cases and 4000 deaths. In collaboration with state and federal agencies, Médecins Sans Frontières (MSF) intervened with a large-scale vaccination campaign using polysaccharide vaccine. Here the authors analyze the impact (cases averted) of the vaccination response as a function of the timing and coverage achieved.
Methods
Phenomenological epidemic models were fitted to replicate meningitis surveillance data from the Nigerian Ministry of Health/WHO surveillance system and from reinforced surveillance conducted by MSF in both vaccinated and unvaccinated areas using a dynamic, state–space framework to account for under-reporting of cases.
Results
The overall impact of the vaccination campaigns (reduction in meningitis cases) in Katsina State, northern Nigeria, ranged from 4% to 12%. At the local level, vaccination reduced cases by as much as 50% when campaigns were conducted early in the epidemic.
Conclusions
Reactive vaccination with polysaccharide vaccine during meningitis outbreaks can significantly reduce the case burden when conducted early and comprehensively. Introduction of the conjugate MenAfriVac vaccine has reduced rates of disease caused by serogroup A Neisseria meningitidis in the region. Despite this, reactive campaigns with polysaccharide vaccine remain a necessary and important tool for meningitis outbreak response.

Perceptions of foreign health aid in East Africa: an exploratory baseline study
Shannon L. Lövgrena,1, Trisa B. Tarob and Heather L. Wipflib,*
Author Affiliations
aDivision of Global Health/IHCAR, Department of Public Health Science, Karolinska Institutet, Widerströmsa Huset, Tomtebodavägen 18A, 171 76 Stockholm, Sweden
bUSC Institute of Global Health, University of Southern California, Suite #318K, Los Angeles, CA 90032, USA
Received December 13, 2013.
Revision received March 6, 2014.
Accepted March 12, 2014.
Abstract
Background
There is insufficient literature on the perceptions of aid recipients with respect to foreign health aid administration and impact. This study sought to identify perceptions of foreign health aid among individuals, health care workers (HCWs), and policymakers in three East African countries: Kenya, Uganda, and Ethiopia. Each country receives substantial foreign aid and shares regional proximity.
Methods
A qualitative exploratory study design was adopted and 81 questionnaires were administered to individuals, HCWs and policymakers. Questionnaires ascertained perceptions of foreign aid, health aid and the USA. Responses were compared between groups and across countries.
Results
Perceptions of how much foreign aid a community receives varied between individuals (‘a little’), HCWs (‘some’) and policymakers (‘a lot’). Respondents were positive towards the USA irrespective of the level of aid they perceived came from the USA. Opinions regarding the impact of aid varied by country and by profession. Aid priorities were similar among all countries and participants, with health care, education and economic development among the primary sectors reported.
Conclusions
More research is needed on perceptions of aid recipients. The findings of this pilot study highlight the need for inclusion of these stakeholders in order to better inform decisions regarding foreign aid.

International Journal of Sustainable Development & World Ecology
Volume 21, Issue 6, 2014
http://www.tandfonline.com/toc/tsdw20/current#.VIORRslLDg2

Bioenergy as a means to social and economic development in Guinea-Bissau: a proposal for a biodiesel production and use program
Manoela Silveira Dos Santos, Tito Francisco Ianda & Antonio Domingos Padula
pages 495-502
DOI:10.1080/13504509.2014.972479
Published online: 01 Dec 2014
Abstract
Given that agro-industrial activity is widely seen as a means of promoting development and the production of bioenergy has come to be considered a means of both fostering socioeconomic development and reducing greenhouse gas emissions, the production of biodiesel would appear to be a means of promoting development in developing countries. The situation of Guinea-Bissau suggests the country may benefit from a biodiesel production program. Thus, this paper uses Brazil’s experience with biodiesel as a basis for proposing a framework for a Biodiesel Program in Guinea-Bissau. The proposed framework includes the following elements related to public policy, regulations, organizations and mechanisms: (i) introduction of biodiesel through the creation and implementation of laws and regulations; (ii) an Inter-ministerial Executive Committee to plan, coordinate and manage the program; (iii) promotion, incentives and support for agricultural and agro-industrial production by providing tax benefits for specific links of the chain, creating incentive programs for different oilseeds and establishing programs that support family farming; and (iv) the creation and installation of representative bodies for the stakeholders involved in the chain, such as small farmers cooperatives, national association of biodiesel producers, R&D and rural extension programs.

REDD+ comes with money, not with development: an analysis of post-pilot project scenarios from the community forestry of Nepal Himalaya
Dilli Prasad Poudel
pages 552-562
DOI:10.1080/13504509.2014.970242
Published online: 21 Nov 2014
Abstract
Reducing emissions from deforestation and forest degradation (REDD+) attracts poor nations to keep their forest standing only to sequester carbon through monetary incentives. However, in countries like Nepal where forest is an integral part of social practices, communities need to keep using forests for making a living. Based on household survey, field interview, personal observation, and broad review of forestry legislations, this paper scrutinizes villagers’ experiences of changes in forest management after implementation of a REDD+ pilot project in nine Community Forestry Users Groups (CFUGs) of Nepal. Since REDD+ was not initiated by local communities but tacitly implemented by international NGOs, most villagers lacked knowledge about it and the associated benefits from the pilot project, thus fewer villagers were found to be motivated to participate in the pilot project. Consequently, it delinked villagers from their forest by implicitly tightening uses rules, which resulted in constraints to fetch forest products. In addition, REDD+ benefits were distributed to some poor households but not to all, which resulted to an antagonistic sentiment in the villages. Thus, a rigorous assessment of conditions and framework of REDD+ and an involvement of local community from the start without compromising in the uses of forest products is of the utmost importance before considering the REDD+ framework as an alternative or as similar to CFUG in Nepal. Alternatively, REDD+ can be a part or a development project under the CFUG’s framework, which could be socially as well as legally acceptable on the present situation.

JAMA Pediatrics
December 2014, Vol 168, No. 12
http://archpedi.jamanetwork.com/issue.aspx

Viewpoint | December 2014
Ebola Virus Disease and Children – What Pediatric Health Care Professionals Need to Know FREE
Georgina Peacock, MD, MPH1; Timothy M. Uyeki, MD, MPH, MPP1; Sonja A. Rasmussen, MD, MS1
[+] Author Affiliations
JAMA Pediatr. 2014;168(12):1087-1088. doi:10.1001/jamapediatrics.2014.2835.

…WHAT IS KNOWN ABOUT EVD IN CHILDREN?
Transmission of Ebolavirus to Children
Because EVD outbreaks have typically occurred in low-resource settings, detailed information about pediatric cases has not been systematically collected. Based on available data, children and adolescents often comprise a small percentage of EVD cases. For example, in an outbreak in Zaire in 1995 in which more than half of the population was younger than 18 years, only 9% of the 315 EVD cases were younger than 18 years.5 Similarly, 147 of 823 (18%) reported EVD cases reported from the current outbreak in Guinea were children,6 and 13.8% of cases from 4 affected countries were younger than 15 years.4 Investigators have suggested that the low number of pediatric EVD cases may be owing to cultural practices in which children are kept away from sick family members, resulting in reduced ebolavirus transmission.4

Manifestations of EVD in Children
A unique challenge facing pediatricians is being able to distinguish EVD signs and symptoms from features of much more common pediatric infectious diseases. Typically, children may present with nonspecific signs and symptoms of EVD similar to those in adults, which initially include fever, headache, myalgia, abdominal pain, and weakness, followed several days later by vomiting, diarrhea, and, less commonly, unexplained bleeding or bruising. However, data are very limited. This highlights the key issue of eliciting a history of exposure to Zaire ebolavirus including a travel history and especially any recent direct contact with the blood or bodily fluids of a person who was sick or died from suspected or confirmed Zaire ebolavirus infection.

In the 2000-2001 Sudanebolavirus outbreak in Uganda, all children with laboratory-confirmed EVD were febrile, while only 16% had hemorrhage.7 Respiratory (eg, cough and dyspnea) and gastrointestinal symptoms were common among children, while central nervous system signs were rare.7

The overall case-fatality proportion in the current outbreak is estimated at 70.8%, including 73.4% in children younger than 15 years, 66.1% for those aged 15 to 44 years, and 80.4% for those older than 44 years.4 However, in the Sudanebolavirus outbreak in Uganda during 2000-2001, children younger than 5 years were reported to be at increased risk for illness and death.6 The authors hypothesized that this was owing to more prolonged contact with ill caregivers (in this outbreak, young uninfected children were often admitted to EVD treatment unit isolation wards with their ill parents because of the reluctance of other adults to care for them).7

Given the impact of this EVD outbreak on the health care infrastructure in the most severely affected countries, the health of children is likely to be seriously impacted because of challenges to providing routine care (eg, immunizations and hospitalizations for common illnesses) in affected countries.

Considerations for the Pediatric Health Care Professional
Pediatric health care professionals should have a high index of suspicion for EVD if the child has compatible signs and symptoms and a history of travel from an affected country within the past 21 days. It is essential that health care professionals take a detailed travel history. Malaria, measles, typhoid fever, and other infectious diseases are also endemic in West Africa and should be included in the differential diagnosis of a febrile pediatric traveler from West Africa. Information on high- and low-risk exposures and case definitions for the United States are available at http://www.cdc.gov/vhf/ebola/hcp/case-definition.html. If EVD is suspected, appropriate infection-control precautions (eg, standard, droplet, and contact) should be implemented immediately and the state health department should be promptly notified. The CDC developed an algorithm to evaluate travelers returning from areas with cases of EVD (http://www.cdc.gov/vhf/ebola/pdf/ebola-algorithm.pdf). Laboratory specimens should be processed according to CDC guidance (http://www.cdc.gov/vhf/ebola/pdf/ebola-lab-guidance.pdf).

CONCLUSIONS
Health care professionals, including those who care for children, should be familiar with the clinical features of EVD and should inquire about recent travel to affected West African countries when assessing patients with compatible illness. Prompt implementation of recommended infection-control measures and appropriate reporting to state health departments are essential to prevent further transmission. Based on previous outbreaks and limited data from the current epidemic to date, children may be at lower risk for EVD than adults. Therefore, health care professionals should also consider other common infectious diseases prevalent in West Africa when evaluating ill children from this region, while maintaining a high level of suspicion for EVD.

Journal of International Development
November 2014 Volume 26, Issue 8 Pages 1097–1196
http://onlinelibrary.wiley.com/doi/10.1002/jid.v26.8/issuetoc
Special Issue: Policy Arena: Papers from DSA Conference, University of Birmingham, November 2013

Research Article
HOW IS DISASTER AID ALLOCATED WITHIN POOR COMMUNITIES? RISK SHARING AND SOCIAL HIERARCHY
Yoshito Takasaki*
Article first published online: 7 JAN 2014
DOI: 10.1002/jid.2985
Abstract
How disaster aid is allocated within poor communities is little understood. Using original post-disaster survey data in rural Fiji that capture household-level traditional kin status, cyclone damage and aid allocations over post-disaster phases, this paper demonstrates that allocations are driven by informal risk-sharing institutions and social hierarchies. On one hand, in response to a disaster with moderate severity, private risk sharing can strongly make up limited aid, making targeting aid on damage appear weak as a result. On the other hand, local elites can dominate not only aid allocation for given damage but also the targeting on damage.

SA Conference 2013 Special Issue
THE SHORT- AND LONG-TERM EFFECTS OF DEVELOPMENT PROJECTS: EVIDENCE FROM ETHIOPIA
Ivica Petrikova*
Article first published online: 5 NOV 2014
DOI: 10.1002/jid.3035
Abstract
This paper examines the short-term and long-term impact of development projects on recipients’ wellbeing in Ethiopia. Specifically, it compares the effects of five types of development projects—unconditional and conditional direct transfers, agricultural and social-infrastructure knowledge transfers, and credit projects—on children’s nutrition and on household consumption and income levels. The main finding is that knowledge transfers have the largest positive impact on children’s nutritional status and household consumption, in both the short and the long term. The impact of direct transfers on children’s health is also positive but less significant, whereas the effect of credit projects is here undetectable.

The Lancet
Dec 06, 2014 Volume 384 Number 9959 p1999 – 2082 e62
http://www.thelancet.com/journals/lancet/issue/current

Editorial
Changing attitudes to child disability in Africa
The Lancet
It is a punishment from God, witchcraft, the fault of the mother, reincarnation. These are all frequently stated causes for disability in children in Africa. Such false beliefs are deeply rooted in tradition and culture. In truth, most children with disabilities in Africa have been disabled by the sad predicaments that continue to haunt the continent: war, poverty, and inadequate access to health care. A new report released this week by the African Child Policy Forum draws attention to the challenges facing children with disabilities in Africa…

The Lancet Global Health
Dec 2014 Volume 2 Number 12 e672 – 736
http://www.thelancet.com/journals/langlo/issue/current

Comment
Prevention of neonatal pneumonia and sepsis via maternal immunisation
Amy Sarah Ginsburg, Ajoke Sobanjo-ter Meulen, Keith P Klugman
Preview |
Pneumonia is the leading killer of children younger than 5 years, and the greatest risk of mortality from pneumonia in childhood is in the neonatal period.1 Substantial reductions in childhood pneumonia deaths have been hindered by a lack of progress in addressing neonatal mortality. Deaths in the neonatal period constitute 41•6% of the 6•3 million children who die annually before their fifth birthday.2 In 2010, there were an estimated 1•7 million cases of neonatal sepsis and 510 000 cases of neonatal pneumonia.

Comment
Political economy analysis for nutrition policy
Michael R Reich, Yarlini Balarajan
Preview |
The past decade has seen increasing global policy attention to nutrition. Concrete steps have been taken to construct a global governance architecture for nutrition and also to mobilise resources for action.1 Efficacious, low-cost interventions exist,2 and there is greater consensus around technical issues, including the role of nutrition-specific and nutrition-sensitive interventions in addressing malnutrition in different settings.3 The economic argument to invest in nutrition is well developed, supported by cost-benefit analyses and studies that quantify the cost to scale up interventions.

Article
Annual rates of decline in child, maternal, HIV, and tuberculosis mortality across 109 countries of low and middle income from 1990 to 2013: an assessment of the feasibility of post-2015 goals
Dr Stéphane Verguet PhD a, Prof Ole Frithjof Norheim PhD b, Zachary D Olson MA a, Gavin Yamey MD c, Prof Dean T Jamison PhD c
Summary
Background
Measuring a country’s health performance has focused mostly on estimating levels of mortality. An alternative is to measure rates of decline in mortality, which are more sensitive to changes in health policy than are mortality levels. Historical rates of decline in mortality can also help test the feasibility of future health goals (eg, post-2015). We aimed to assess the annual rates of decline in under-5, maternal, tuberculosis, and HIV mortality over the past two decades for 109 low-income and middle-income countries.
Methods
For the period 1990—2013, we estimated annual rates of decline in under-5 mortality (deaths per 1000 livebirths), the maternal mortality ratio (deaths per 100 000 livebirths), and tuberculosis and HIV mortality (deaths per 100 000 population per year) using published data from UNICEF and WHO. For every 5-year interval (eg, 1990—95), we defined performance as the size of the annual rate of decline for every mortality indicator. Subsequently, we tested the feasibility of post-2015 goals by estimating the year by which countries would achieve 2030 targets proposed by The Lancet’s Commission on Investing in Health (ie, 20 deaths per 1000 for under-5 mortality, 94 deaths per 100 000 for maternal mortality, four deaths per 100 000 for tuberculosis mortality, and eight deaths per 100 000 for HIV mortality) at observed country and aspirational best-performer (90th percentile) rates.
Findings
From 2005 to 2013, the mean annual rate of decline in under-5 mortality was 4•3% (95% uncertainty interval [UI] 3•9—4•6), for maternal mortality it was 3•3% (2•5—4•1), for tuberculosis mortality 4•1% (2•8—5•4), and for HIV mortality 2•2% (0•1—4•3); aspirational best-performer rates per year were 7•1% (6•8—7•5), 6•3% (5•5—7•1), 12•8% (11•5—14•1), and 15•3% (13•2—17•4), respectively. The top two country performers were Macedonia and South Africa for under-5 mortality, Belarus and Bulgaria for maternal mortality, Uzbekistan and Macedonia for tuberculosis mortality, and Namibia and Rwanda for HIV mortality. At aspirational rates of decline, The Lancet’s Commission on Investing in Health target for under-5 mortality would be achieved by 50—64% of countries, 35—41% of countries would achieve the 2030 target for maternal mortality, 74—90% of countries would meet the goal for tuberculosis mortality, and 66—82% of countries would achieve the target for HIV mortality.
Interpretation
Historical rates of decline can help define realistic targets for Sustainable Development Goals. The gap between targets and projected achievement based on recent trends suggests that countries and the international community must seek further acceleration of progress in mortality.
Funding
Bill & Melinda Gates Foundation, NORAD.

Tuberculosis in pregnancy: an estimate of the global burden of disease
Jordan Sugarman BSc a, Charlotte Colvin PhD b, Allisyn C Moran PhD b, Dr Olivia Oxlade PhD a
Summary
Background
The estimated number of maternal deaths in 2013 worldwide was 289 000, a 45% reduction from 1990. Non-obstetric causes such as infectious diseases including tuberculosis now account for 28% of maternal deaths. In 2013, 3•3 million cases of tuberculosis were estimated to occur in women globally. During pregnancy, tuberculosis is associated with poor outcomes, including increased mortality in both the neonate and the pregnant woman. The aim of our study was to estimate the burden of tuberculosis disease among pregnant women, and to describe how maternal care services could be used as a platform to improve case detection.
Methods
We used publicly accessible country-level estimates of the total population, distribution of the total population by age and sex, crude birth rate, estimated prevalence of active tuberculosis, and case notification data by age and sex to estimate the number of pregnant women with active tuberculosis for 217 countries. We then used indicators of health system access and tuberculosis diagnostic test performance obtained from published literature to determine how many of these cases could ultimately be detected.
Findings
We estimated that 216 500 (95% uncertainty range 192 100—247 000) active tuberculosis cases existed in pregnant women globally in 2011. The greatest burdens were in the WHO African region with 89 400 cases and the WHO South East Asian region with 67 500 cases in pregnant women. Chest radiography or Xpert RIF/MTB, delivered through maternal care services, were estimated to detect as many as 114 100 and 120 300 tuberculosis cases, respectively.
Interpretation
The burden of tuberculosis disease in pregnant women is substantial. Maternal care services could provide an important platform for tuberculosis detection, treatment initiation, and subsequent follow-up.
Funding
United States Agency for International Development.

The Lancet Infectious Diseases
Dec 2014 Volume 14 Number 12 p1163 – 1292
http://www.thelancet.com/journals/laninf/issue/current

Editorial
Rationality and coordination for Ebola outbreak in west Africa
The Lancet Infectious Diseases
According to WHO, as of Oct 31, 2014, 13 540 people have been diagnosed with Ebola virus disease in eight countries—including 4951 deaths. Transmission remains persistent and widespread in Guinea (1667 cases, 1018 deaths), Liberia (6535 cases, 2413 deaths), and Sierra Leone (5338 cases, 1510 deaths). Dedicated doctors, nurses, and other health-care workers have made great efforts to contain the epidemic. WHO reports that 450 of these health-care workers have developed the disease and more than 230 have died. WHO has attributed these cases to the shortage and improper use of personal protective equipment, and lack of trained medical personnel.

Health-care workers returning from west Africa, who have put their lives at risk to help others, have been quarantined in several US states, such as New York and New Jersey; more recently, Illinois has started imposing the same measures. Quarantine measures in the USA were put in place after Craig Spencer returned from Guinea and travelled around New York City before he fell ill. A further development was the decision by Louisiana health officials to ban anyone who travelled from Ebola-affected parts of west Africa, and hence Ebola researchers were told not to come to the American Society of Tropical Medicine and Hygiene meeting held recently in New Orleans…

Article
Dynamics and control of Ebola virus transmission in Montserrado, Liberia: a mathematical modelling analysis
Joseph A Lewnard BA a b †, Martial L Ndeffo Mbah PhD a b †, Jorge A Alfaro-Murillo PhD a b, Prof Frederick L Altice MD a c, Luke Bawo MPH d, Tolbert G Nyenswah MPH d, Prof Alison P Galvani PhD a b
Summary
Background
A substantial scale-up in public health response is needed to control the unprecedented Ebola virus disease (EVD) epidemic in west Africa. Current international commitments seek to expand intervention capacity in three areas: new EVD treatment centres, case ascertainment through contact tracing, and household protective kit allocation. We aimed to assess how these interventions could be applied individually and in combination to avert future EVD cases and deaths.
Methods
We developed a transmission model of Ebola virus that we fitted to reported EVD cases and deaths in Montserrado County, Liberia. We used this model to assess the effectiveness of expanding EVD treatment centres, increasing case ascertainment, and allocating protective kits for controlling the outbreak in Montserrado. We varied the efficacy of protective kits from 10% to 50%. We compared intervention initiation on Oct 15, 2014, Oct 31, 2014, and Nov 15, 2014. The status quo intervention was defined in terms of case ascertainment and capacity of EVD treatment centres on Sept 23, 2014, and all behaviour and contact patterns relevant to transmission as they were occurring at that time. The primary outcome measure was the expected number of cases averted by Dec 15, 2014.
Findings
We estimated the basic reproductive number for EVD in Montserrado to be 2•49 (95% CI 2•38—2•60). We expect that allocating 4800 additional beds at EVD treatment centres and increasing case ascertainment five-fold in November, 2014, can avert 77 312 (95% CI 68 400—85 870) cases of EVD relative to the status quo by Dec 15, 2014. Complementing these measures with protective kit allocation raises the expectation as high as 97 940 (90 096—105 606) EVD cases. If deployed by Oct 15, 2014, equivalent interventions would have been expected to avert 137 432 (129 736—145 874) cases of EVD. If delayed to Nov 15, 2014, we expect the interventions will at best avert 53 957 (46 963—60 490) EVD cases.
Interpretation
The number of beds at EVD treatment centres needed to effectively control EVD in Montserrado substantially exceeds the 1700 pledged by the USA to west Africa. Accelerated case ascertainment is needed to maximise effectiveness of expanding the capacity of EVD treatment centres. Distributing protective kits can further augment prevention of EVD, but it is not an adequate stand-alone measure for controlling the outbreak. Our findings highlight the rapidly closing window of opportunity for controlling the outbreak and averting a catastrophic toll of EVD cases and deaths.
Funding
US National Institutes of Health.

Pediatrics
December 2014, VOLUME 134 / ISSUE 6
http://pediatrics.aappublications.org/current.shtml

Article
Changes in Child Mortality Over Time Across the Wealth Gradient in Less-Developed Countries
Eran Bendavid, MD, MSa,b
Author Affiliations
aDivision of General Medical Disciplines, and
bCenter for Health Policy and the Center for Primary Care and Outcomes Research, Stanford University, Stanford, California
Abstract
BACKGROUND: It is unknown whether inequalities in under-5 mortality by wealth in low- and middle-income countries (LMICs) are growing or declining.
METHODS: All Demographic and Health Surveys conducted between 2002 and 2012 were used to measure under-5 mortality trends in 3 wealth tertiles. Two approaches were used to estimate changes in under-5 mortality: within-survey changes from all 54 countries, and between-survey changes for 29 countries with repeated survey waves. The principal outcome measures include annual decline in mortality, and the ratio of mortality between the poorest and least-poor wealth tertiles.
RESULTS: Mortality information in 85 surveys from 929 224 households and 1 267 167 women living in 54 countries was used. In the subset of 29 countries with repeat surveys, mortality declined annually by 4.36, 3.36, and 2.06 deaths per 1000 live births among the poorest, middle, and least-poor tertiles, respectively (P = .031 for difference). The mortality ratio declined from 1.68 to 1.48 during the study period (P = .006 for trend). In the complete set of 85 surveys, the mortality ratio declined in 64 surveys (from 2.11 to 1.55), and increased in 21 surveys (from 1.58 to 1.88). Multivariate analyses suggest that convergence was associated with good governance (P ≤ .03 for 4 governance indicators: government effectiveness, rule of law, regulatory quality, and control of corruption).
CONCLUSIONS: Overall, under-5 mortality in low- and middle-income countries has decreased faster among the poorest compared with the least poor between 1995 and 2012, but progress in some countries has lagged, especially with poor governance.

PLoS One
[Accessed 6 December 2014]
http://www.plosone.org/
Research Article
What Are Fair Study Benefits in International Health Research? Consulting Community Members in Kenya
Maureen Njue, Francis Kombe, Salim Mwalukore, Sassy Molyneux, Vicki Marsh mail
Published: December 03, 2014
DOI: 10.1371/journal.pone.0113112
Abstract
Background
Planning study benefits and payments for participants in international health research in low- income settings can be a difficult and controversial process, with particular challenges in balancing risks of undue inducement and exploitation and understanding how researchers should take account of background inequities. At an international health research programme in Kenya, this study aimed to map local residents’ informed and reasoned views on the effects of different levels of study benefits and payments to inform local policy and wider debates in international research.
Methods and Findings
Using a relatively novel two-stage process community consultation approach, five participatory workshops involving 90 local residents from diverse constituencies were followed by 15 small group discussions, with components of information-sharing, deliberation and reflection to situate normative reasoning within debates. Framework Analysis drew inductively and deductively on voice- recorded discussions and field notes supported by Nvivo 10 software, and the international research ethics literature. Community members’ views on study benefits and payments were diverse, with complex contextual influences and interplay between risks of giving ‘too many’ and ‘too few’ benefits, including the role of cash. While recognising important risks for free choice, research relationships and community values in giving ‘too many’, the greatest concerns were risks of unfairness in giving ‘too few’ benefits, given difficulties in assessing indirect costs of participation and the serious consequences for families of underestimation, related to perceptions of researchers’ responsibilities.
Conclusions
Providing benefits and payments to participants in international research in low-income settings is an essential means by which researchers meet individual-level and structural forms of ethical responsibilities, but understanding how this can be achieved requires a careful account of social realities and local judgment. Concerns about undue inducement in low-income communities may often be misplaced; we argue that greater attention should be placed on avoiding unfairness, particularly for the most-poor.

PLOS Currents: Disasters
[Accessed 6 December 2014]
http://currents.plos.org/disasters/

Variables Associated with Effects on Morbidity in Older Adults Following Disasters
December 5, 2014 • Research article
Introduction: Older adults are vulnerable to disproportionately higher morbidity following disasters. Reasons for this vulnerability are multifaceted and vary by disaster type as well as patient comorbidities. Efforts to mitigate this increased morbidity require identification of at-risk older adults who can be targeted for intervention.

Methods: A PubMed search was performed using the search terms “geriatric, disaster” and “morbidity, disaster” to identify published articles that reported variables associated with increased morbidity of older adults during and after disasters. A review of article titles and abstracts was then conducted to identify those articles that contained evidence-based variables that render older adults vulnerable to poor health outcomes during disasters.

Results: A total of 233 studies was initially identified. After applying exclusion criteria, nine studies were chosen for the comprehensive review. Based on the synthesis of the literature, factors were identified that were repeatedly associated with morbidity and mortality among older adults during and shortly after disasters.

Conclusion: Older adults, especially those with multiple co-morbidities, are at risk of increased morbidity after disasters and catastrophic events. Factors such as the need for prescription medications, low social support, visual and hearing impairment, impaired mobility, and poor economic status are associated with an increased risk of morbidity.