Conflict and Health
[Accessed 4 April 2015]
http://www.conflictandhealth.com/

Research
Neuropsychiatric disorders among Syrian and Iraqi refugees in Jordan: a retrospective cohort study 2012–2013
Erica D McKenzie12, Paul Spiegel3, Adam Khalifa4 and Farrah J Mateen15*
* Corresponding author: Farrah J Mateen
Author Affiliations
Conflict and Health 2015, 9:10 doi:10.1186/s13031-015-0038-5
Published: 29 March 2015
Abstract (provisional)
Background
The burden of neuropsychiatric disorders in refugees is likely high, but little has been reported on the neuropsychiatric disorders that affect Syrian and Iraqi refugees in a country of first asylum. This analysis aimed to study the cost and burden of neuropsychiatric disorders among refugees from Syria and Iraq requiring exceptional, United Nations-funded care in a country of first asylum.
Methods
The United Nations High Commissioner for Refugees works with multi-disciplinary, in-country exceptional care committees to review refugees’ applications for emergency or exceptional medical care. Neuropsychiatric diagnoses among refugee applicants were identified through a retrospective review of applications to the Jordanian Exceptional Care Committee (2012–2013). Diagnoses were made using International Classification of Disease-10th edition codes rendered by treating physicians.
Results
Neuropsychiatric applications accounted for 11% (264/2526) of all Exceptional Care Committee applications, representing 223 refugees (40% female; median age 35 years; 57% Syrian, 36% Iraqi, 7% other countries of origin). Two-thirds of neuropsychiatric cases were for emergency care. The total amount requested for neuropsychiatric disorders was 925,674 USD. Syrian refugees were significantly more likely to request neurotrauma care than Iraqis (18/128 vs. 3/80, p = 0.03). The most expensive care per person was for brain tumor (7,905 USD), multiple sclerosis (7,502 USD), and nervous system trauma (6,466 USD), although stroke was the most frequent diagnosis. Schizophrenia was the most costly and frequent diagnosis among the psychiatric disorders (2,269 USD per person, 27,226 USD total).
Conclusions
Neuropsychiatric disorders, including those traditionally considered outside the purview of refugee health, are an important burden to health among Iraqi and Syrian refugees. Possible interventions could include stroke risk factor reduction and targeted medication donations for multiple sclerosis, epilepsy, and schizophrenia.

Emergency Medicine Journal
April 2015, Volume 32, Issue 4
http://emj.bmj.com/content/current

Editorial
A moral or an ethical issue?
Mary Dawood
Correspondence to Mary Dawood, Emergency Department, Imperial College NHS Trust, Praed St, Paddington, London W2 1NY, UK; Mary.dawood@imperial.nhs.uk
Accepted 6 October 2014
Published Online First 31 October 2014
[Extract]
Emergency care by its very nature is challenging where questions of ethics commonly arise. Issues such as crowding, access, urgency, sick patients and threat to life all combine to create uniquely fertile grounds for ethical dilemmas.1–4 Ethics in healthcare means doing the right thing for the patient, doing no harm, providing care and treatment that benefits the patient while at the same time respecting the patient’s autonomy and right to self-determination. Our sense of right and wrong and the duty of care we owe our patients are central to this.

Determining the right course of action in complex circumstances can be difficult and ethical decision making demands much more than a decision of what is right or wrong; it requires critical reflection. Beauchamp and Childress suggest that this reflection needs to guide what we ought to do in a specific situation by asking us to consider and reconsider ordinary actions, the rationales for those actions and the judgements we make.5

Such an ethical debate in clinical settings can be positive, instructive and can contribute to quality patient care, but moral issues that often arise simultaneously can muddy the waters. A person’s moral code is usually constant, but the ethical codes governing practice may be dependent on the context and setting and be at odds with moral feelings. In the great diversity that is healthcare and the limitations of our working environment it is often moral rather than ethical issues that give rise to angst and disequilibrium. The difference between ethics and morals is subtle, …

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Original article
Moral experience and ethical challenges in an emergency department in Pakistan: emergency physicians’ perspectives
Waleed Zafar
Correspondence to Dr Waleed Zafar, Department of Emergency Medicine, Aga Khan University, Stadium Road, P.O. Box 3500, Karachi 74800, Pakistan; waleed.zafar@aku.edu
Received 6 June 2014
Revised 1 August 2014
Accepted 15 August 2014
Published Online First 18 September 2014
Abstract
Introduction
Emergency departments (ED) are often stressful environments posing unique ethical challenges—issues that primarily raise moral rather than clinical concerns—in patient care. Despite this, there are very few reports of what emergency physicians find ethically challenging in their everyday work. Emergency medicine (EM) is a relatively young but rapidly growing specialty that is gaining acceptance worldwide. The aim of this study was to explore the perspectives of EM residents and physicians regarding the common ethical challenges they face during patient care in one of only two academic EM departments in Pakistan. These challenges could then be addressed in residents’ training and departmental practice guidelines.
Methods
A qualitative research design was employed and in-depth interviews were conducted with ED physicians. Participants were encouraged to think of specific examples from their work, to highlight the particular ethical concerns raised and to describe in detail the process by which those concerns were addressed or left unresolved. Transcripts were analysed using grounded theory methods.
Results
Thirteen participants were interviewed and they described four key challenges: how to provide highest quality care with limited resources; how to be truthful to patients; what to do when it is not possible to provide or continue treatment to patients; and when (and when not) to offer life-sustaining treatments. Participants’ accounts provided important insights into how physicians tried to resolve these challenges in the ‘local moral world’ of an ED in Pakistan.
Conclusions
The study highlights the need for developing systematic and contextually appropriate mechanisms for resolving common ethical challenges in the EDs and for training residents in moral problem solving.

Health Policy and Planning
Volume 30 Issue 3 April 2015
http://heapol.oxfordjournals.org/content/current

An analysis of government immunization program expenditures in lower and lower middle income countries 2006–12
Alice Abou Nader1,*, Ciro de Quadros1, Claudio Politi2 and Michael McQuestion1
Author Affiliations
1Sabin Vaccine Institute, 2000 Pennsylvania Ave. Suite 7100, NW, Washington, DC 20006, USA 2World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland
Accepted December 31, 2013.
Abstract
Financing is becoming increasingly important as the cost of immunizing the world’s children continues to rise. By 2015, that cost will likely exceed US$60 per infant as new vaccines are introduced into national immunization programs. In 2006, 51 lower and lower middle income countries reported spending a mean US$12 per surviving infant on routine immunization. By 2012, the figure had risen to $20, a 67% increase. This study tests the hypothesis that lower and lower middle income countries will spend more on their routine immunization programs as their economies grow. A panel data regression approach is used. Expenditures reported by governments annually (2006–12) through the World Health Organization/UNICEF Joint Reporting Form are regressed on lagged annual per capita gross national income (GNI), controlling for prevailing mortality levels, immunization program performance, corruption control efforts, geographical region and correct reporting. Results show the expenditures increased with GNI. Expressed as an elasticity, the countries spent approximately $6.32 on immunization for every $100 in GNI increase from 2006 to 2012. Projecting forward and assuming continued annual GNI growth rates of 10.65%, countries could be spending $60 per infant by 2020 if national investment functions increase 4-fold. Given the political will, this result implies countries could fully finance their routine immunization programs without cutting funding for other programs.

Health Policy and Planning
Volume 30 Issue 3 April 2015
http://heapol.oxfordjournals.org/content/current

Drivers of routine immunization coverage improvement in Africa: findings from district-level case studies
Anne LaFond1,*, Natasha Kanagat1, Robert Steinglass1, Rebecca Fields1, Jenny Sequeira1 and
Sangeeta Mookherji2
Author Affiliations
1John Snow Inc., 1616 Fort Myer Drive, 16th Floor, Arlington, VA 22209, USA and 2Department of Global Health, School of Public Health and Health Services, George Washington University 2175 K Street, Suite 200 Washington, DC 20037, USA
Accepted January 28, 2014.
Abstract
There is limited understanding of why routine immunization (RI) coverage improves in some settings in Africa and not in others. Using a grounded theory approach, we conducted in-depth case studies to understand pathways to coverage improvement by comparing immunization programme experience in 12 districts in three countries (Ethiopia, Cameroon and Ghana). Drawing on positive deviance or assets model techniques we compared the experience of districts where diphtheria–tetanus–pertussis (DTP3)/pentavalent3 (Penta3) coverage improved with districts where DTP3/Penta3 coverage remained unchanged (or steady) over the same period, focusing on basic readiness to deliver immunization services and drivers of coverage improvement. The results informed a model for immunization coverage improvement that emphasizes the dynamics of immunization systems at district level. In all districts, whether improving or steady, we found that a set of basic RI system resources were in place from 2006 to 2010 and did not observe major differences in infrastructure. We found that the differences in coverage trends were due to factors other than basic RI system capacity or service readiness. We identified six common drivers of RI coverage performance improvement—four direct drivers and two enabling drivers—that were present in well-performing districts and weaker or absent in steady coverage districts, and map the pathways from driver to improved supply, demand and coverage. Findings emphasize the critical role of implementation strategies and the need for locally skilled managers that are capable of tailoring strategies to specific settings and community needs. The case studies are unique in their focus on the positive drivers of change and the identification of pathways to coverage improvement, an approach that should be considered in future studies and routine assessments of district-level immunization system performance.

Health Policy and Planning
Volume 30 Issue 3 April 2015
http://heapol.oxfordjournals.org/content/current

Tackling the tensions in evaluating capacity strengthening for health research in low- and middle-income countries
Imelda Bates1,*, Alan Boyd2, Garry Aslanyan3 and Donald C Cole4
Author Affiliations
1Liverpool School of Tropical Medicine, Liverpool, UK, 2Manchester Business School, Booth St W, Manchester, Greater Manchester M15 6PB, UK, 3Tropical Disease Research, World Health Organization, 20, Avenue Appia, CH-1211 Geneva 27, Switzerland and 4Dalla Lana School of Public Health University of Toronto, 155 College St. Toronto, ON M5T3M7, Canada
Accepted February 13, 2014.
Abstract
Strengthening research capacity in low- and middle-income countries is one of the most effective ways of advancing their health and development but the complexity and heterogeneity of health research capacity strengthening (RCS) initiatives means it is difficult to evaluate their effectiveness. Our study aimed to enhance understanding about these difficulties and to make recommendations about how to make health RCS evaluations more effective. Through discussions and surveys of health RCS funders, including the ESSENCE on Health Research initiative, we identified themes that were important to health RCS funders and used these to guide a systematic analysis of their evaluation reports. Eighteen reports, produced between 2000 and 2013, representing 12 evaluations, were purposefully selected from 54 reports provided by the funders to provide maximum variety. Text from the reports was extracted independently by two authors against a pre-designed framework. Information about the health RCS approaches, tensions and suggested solutions was re-constructed into a narrative. Throughout the process contacts in the health RCS funder agencies were involved in helping us to validate and interpret our results. The focus of the health RCS evaluations ranged from individuals and institutions to national, regional and global levels. Our analysis identified tensions around how much stakeholders should participate in an evaluation, the appropriate balance between measuring and learning and between a focus on short-term processes vs longer-term impact and sustainability. Suggested solutions to these tensions included early and ongoing stakeholder engagement in planning and evaluating health RCS, modelling of impact pathways and rapid assimilation of lessons learned for continuous improvement of decision making and programming. The use of developmental approaches could improve health RCS evaluations by addressing common tensions and promoting sustainability. Sharing learning about how to do robust and useful health RCS evaluations should happen alongside, not after, health RCS efforts.

The Journal of Law, Medicine & Ethics
Spring 2015 Volume 43, Issue 1 Pages 6–166
http://onlinelibrary.wiley.com/doi/10.1111/jlme.2015.43.issue-1/issuetoc

Global Justice and Health Systems Research in Low- and Middle-Income Countries
Bridget Pratt1 and Adnan A. Hyder2
Article first published online: 2 APR 2015
DOI: 10.1111/jlme.12202
Abstract
Scholarship focusing on how international research can contribute to justice in global health has primarily explored requirements for the conduct of clinical trials. Yet health systems research in low- and middle-income countries (LMICs) has increasingly been identified as vital to the reduction of health disparities between and within countries. This paper expands an existing ethical framework based on the health capability paradigm – research for health justice – to externally-funded health systems research in LMICs. It argues that a specific form of health systems research in LMICs is required if the enterprise is to advance global health equity. “Research for health justice” requirements for priority setting, research capacity strengthening, and post-study benefits in health systems research are derived in light of the field’s distinctive characteristics. Specific obligations are established for external research actors, including governments, funders, sponsors, and investigators. How these framework requirements differ from those for international clinical research is discussed.

Nature
Volume 520 Number 7545 pp5-126 2 April 2015
http://www.nature.com/nature/current_issue.html

Articles
Global effects of land use on local terrestrial biodiversity
Tim Newbold, Lawrence N. Hudson, Samantha L. L. Hill, Sara Contu, Igor Lysenko + et al.
Analysis of a global data set of local biodiversity comparisons reveals an average 13.6% reduction in species richness and 10.7% reduction in abundance as a result of past human land use, and projections based on these data under a business-as-usual land-use scenario predict further substantial loss this century, unless strong mitigation efforts are undertaken to reverse the effects.

The Lancet
Apr 04, 2015 Volume 385 Number 9975 p1261-1364 e25-e37
http://www.thelancet.com/journals/lancet/issue/current

Editorial
China-Africa Health Collaboration
The Lancet
Summary
The 5th International Roundtable on China-Africa Health Collaboration: Contributing to Universal Health Coverage (UHC), Expanding Access to Essential Medicines, convened by Tsinghua University and the China Chamber of Commerce for Import and Export of Medicines and Health Products, took place in Beijing last week (March 26–28). The roundtable was attended by 350 Chinese, African, and international health delegates, including Chinese drug companies. The roundtable endorsed the Beijing Policy Recommendations 2015—calling for collaboration to reflect local country priorities, enhanced production and access to new health commodities, increased accountability, and investments in research, development, and health financing.

Comment
Achieving universal health coverage is a moral imperative
Carissa F Etienne
Published Online: 15 October 2014
Summary
In the past few decades, important policies and strategic initiatives in health and development have been embraced by Latin America, with the active participation and support of the Pan American Health Organization (PAHO), WHO, and other partners. As democratic processes in the region are consolidated, with increasing decentralisation and greater social inclusion in decision making, there is an increasingly large and structured social demand for equity in access to health care, consistent with the principles of the WHO Constitution of 1948: “the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being…”.

Towards universal health coverage: applying a gender lens
Michelle Bachelet
e25

Human-rights-based approaches to health in Latin America
Alicia Ely Yamin, Ariel Frisancho
e26

Health protection as a citizen’s right
Alicia Bárcena
e29

Latin America: priorities for universal health coverage
Jeanette Vega, Patricia Frenz
e31

Conditional cash transfers and health in Latin America
Simone Cecchini, Fábio Veras Soares
e32

The right to health: what model for Latin America?
Nila Heredia, Asa Cristina Laurell, Oscar Feo, José Noronha, Rafael González-Guzmán, Mauricio Torres-Tovar
e34

The Lancet
Apr 04, 2015 Volume 385 Number 9975 p1261-1364 e25-e37
http://www.thelancet.com/journals/lancet/issue/current

Articles
Effect of early neonatal vitamin A supplementation on mortality during infancy in Ghana (Neovita): a randomised, double-blind, placebo-controlled trial
Karen M Edmond, Sam Newton, Caitlin Shannon, Maureen O’Leary, Lisa Hurt, Gyan Thomas, Seeba Amenga-Etego, Charlotte Tawiah-Agyemang, Lu Gram, Chris N Hurt, Rajiv Bahl, Seth Owusu-Agyei, Betty R Kirkwood
1315

Effect of neonatal vitamin A supplementation on mortality in infants in Tanzania (Neovita): a randomised, double-blind, placebo-controlled trial
Honorati Masanja, Emily R Smith, Alfa Muhihi, Christina Briegleb, Salum Mshamu, Julia Ruben, Ramadhani Abdallah Noor, Polyna Khudyakov, Sachiyo Yoshida, Jose Martines, Rajiv Bahl, Wafaie W Fawzi, for the Neovita Tanzania Study Group
1324

Efficacy of early neonatal supplementation with vitamin A to reduce mortality in infancy in Haryana, India (Neovita): a randomised, double-blind, placebo-controlled trial
Sarmila Mazumder, Sunita Taneja, Kiran Bhatia, Sachiyo Yoshida, Jasmine Kaur, Brinda Dube, G S Toteja, Rajiv Bahl, Olivier Fontaine, Jose Martines, Nita Bhandari, for the Neovita India Study Group
1333

New England Journal of Medicine
April 2, 2015 Vol. 372 No. 14
http://www.nejm.org/toc/nejm/medical-journal

International Health Care Systems: Lessons from the East — China’s Rapidly Evolving Health Care System
D. Blumenthal and W. Hsiao
Free Full Text
At first glance, China might seem unlikely to offer useful health care lessons to many other countries. Its health system exists within a unique geopolitical context: a country of more than 1.3 billion people, occupying a huge, diverse landmass, living under authoritarian single-party rule, and making an extraordinarily rapid transition from a Third-World to a First-World economy.

But first impressions can be misleading. Since its birth in 1949, the People’s Republic of China has undertaken a series of remarkable health system experiments that are instructive at many levels. One of the most interesting lessons from the Chinese experience concerns the value of an institution that many countries take for granted: medical professionalism….

Pediatrics
April 2015, VOLUME 135 / ISSUE 4
http://pediatrics.aappublications.org/current.shtml

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Article
Government Health Care Spending and Child Mortality
Mahiben Maruthappu, MA, BM BCha, Ka Ying Bonnie Ng, BMedSci, MBChBa,b, Callum Williams, BAc,d, Rifat Atun, FRCP, MBA, FFPHa,e, and Thomas Zeltner, MD, LLMf,g
Author Affiliations
aImperial College London, London, United Kingdom;
bObstetrics and Gynaecology Department, Chelsea and Westminster Hospital, London, United Kingdom;
cThe Economist, London, United Kingdom;
dFaculty of History, University of Oxford, Oxford, United Kingdom;
eHarvard School of Public Health, Harvard University, Cambridge, Massachusetts;
fWorld Health Organization, Geneva, Switzerland; and
gUniversity of Bern, Bern, Switzerland.
Abstract
BACKGROUND: Government health care spending (GHS) is of increasing importance to child health. Our study determined the relationship between reductions in GHS and child mortality rates in high- and low-income countries.
METHODS: The authors used comparative country-level data for 176 countries covering the years 1981 to 2010, obtained from the World Bank and the Institute for Health Metrics and Evaluation. Multivariate regression analysis was used to determine the association between changes in GHS and child mortality, controlling for differences in infrastructure and demographics.
RESULTS: Data were available for 176 countries, equating to a population of ∼5.8 billion as of 2010. A 1% decrease in GHS was associated with a significant increase in 4 child mortality measures: neonatal (regression coefficient [R] 0.0899, P = .0001, 95% confidence interval [CI] 0.0440–0.1358), postneonatal (R = 0.1354, P = .0001, 95% CI 0.0678–0.2030), 1- to 5-year (R = 0.3501, P < .0001, 95% CI 0.2318–0.4685), and under 5-year (R = 0.5207, P < .0001, 95% CI 0.3168–0.7247) mortality rates. The effect was evident up to 5 years after the reduction in GHS (P < .0001). Compared with high-income countries, low-income countries experienced greater deteriorations of ∼1.31 times neonatal mortality, 2.81 times postneonatal mortality, 8.08 times 1- to 5-year child mortality, and 2.85 times under 5-year mortality.
CONCLUSIONS: Reductions in GHS are associated with significant increases in child mortality, with the largest increases occurring in low-income countries.

Pediatrics
April 2015, VOLUME 135 / ISSUE 4
http://pediatrics.aappublications.org/current.shtml

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Article
Medical Providers’ Understanding of Sex Trafficking and Their Experience With At-Risk Patients
Megan E. Beck, BSa, Megan M. Lineer, BSa, Marlene Melzer-Lange, MDa,b, Pippa Simpson, PhDa,c, Melodee Nugent, MAa,c, and Angela Rabbitt, DOa,d
Author Affiliations
aDepartment of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin;
bDepartment of Emergency Medicine,
cDepartment of Pediatrics, and
dChild Advocacy and Protection Services, Children’s Hospital of Wisconsin, Milwaukee, Wisconsin
Abstract
BACKGROUND AND OBJECTIVES: Sex trafficking (ST) victims have unique medical and mental health needs and are often difficult to identify. Our objectives were to evaluate knowledge gaps and training needs of medical providers, to demonstrate the importance of provider training to meet the pediatric ST victim’s specific needs, and to highlight barriers to the identification of and response to victims.
METHODS: A survey was sent to providers in specialties that would be most likely to encounter victims of ST. Participants included physicians, nurses, physician assistants, social workers, and patient and family advocates at multiple hospitals and medical clinics in urban, suburban, and rural locations.
RESULTS: Of ∼500 survey recipients, 168 participants responded. In 2 clinical vignettes, 48% correctly classified a minor as an ST victim, and 42% correctly distinguished an ST victim from a child abuse victim. In all, 63% of respondents said that they had never received training on how to identify ST victims. Those with training were more likely to report ST as a major problem locally (P ≤ .001), to have encountered a victim in their practice (P ≤ .001), and to have greater confidence in their ability to identify victims (P ≤ .001). The greatest barriers to identification of victims reported were a lack of training (34%) and awareness (22%) of ST.
CONCLUSIONS: Health care providers demonstrate gaps in knowledge and awareness of ST, specifically of pediatric victims, that correlate with their limited experience and training. Training is crucial to improve identification of these victims and provide appropriate care for their specific needs.

PLoS One
[Accessed 4 April 2015]
http://www.plosone.org/

Research Article
Can Reproductive Health Voucher Programs Improve Quality of Postnatal Care? A Quasi-Experimental Evaluation of Kenya’s Safe Motherhood Voucher Scheme
Claire Watt, Timothy Abuya, Charlotte E. Warren, Francis Obare, Lucy Kanya, Ben Bellows
Published: April 2, 2015
DOI: 10.1371/journal.pone.0122828
Abstract
This study tests the group-level causal relationship between the expansion of Kenya’s Safe Motherhood voucher program and changes in quality of postnatal care (PNC) provided at voucher-contracted facilities. We compare facilities accredited since program inception in 2006 (phase I) and facilities accredited since 2010-2011 (phase II) relative to comparable non-voucher facilities. PNC quality is assessed using observed clinical content processes, as well as client-reported outcome measures. Two-tailed unpaired t-tests are used to identify differences in mean process quality scores and client-reported outcome measures, comparing changes between intervention and comparison groups at the 2010 and 2012 data collection periods. Difference-in-differences analysis is used to estimate the reproductive health (RH) voucher program’s causal effect on quality of care by exploiting group-level differences between voucher-accredited and non-accredited facilities in 2010 and 2012. Participation in the voucher scheme since 2006 significantly improves overall quality of postnatal care by 39% (p=0.02), where quality is defined as the observable processes or components of service provision that occur during a PNC consultation. Program participation since phase I is estimated to improve the quality of observed maternal postnatal care by 86% (p=0.02), with the largest quality improvements in counseling on family planning methods (IRR 5.0; p=0.01) and return to fertility (IRR 2.6; p=0.01). Despite improvements in maternal aspects of PNC, we find a high proportion of mothers who seek PNC are not being checked by any provider after delivery. Additional strategies will be necessary to standardize provision of packaged postnatal interventions to both mother and newborn. This study addresses an important gap in the existing RH literature by using a strong evaluation design to assess RH voucher program effectiveness on quality improvement.

PLoS One
[Accessed 4 April 2015]
http://www.plosone.org/

Research Article
Determinants of Performance of Health Systems Concerning Maternal and Child Health: A Global Approach
Carlos Eduardo Pinzón-Flórez, Julián Alfredo Fernández-Niño, Myriam Ruiz-Rodríguez, Álvaro J. Idrovo, Abel Armando Arredondo López
Published: March 30, 2015
DOI: 10.1371/journal.pone.0120747
Abstract
Aims
To assess the association of social determinants on the performance of health systems around the world.
Methods
A transnational ecological study was conducted with an observation level focused on the country. In order to research on the strength of the association between the annual maternal and child mortality in 154 countries and social determinants: corruption, democratization, income inequality and cultural fragmentation, we used a mixed linear regression model for repeated measures with random intercepts and a conglomerate-based geographical analysis, between 2000 and 2010.
Results
Health determinants with a significant association on child mortality(<1year): higher access to water (βa Quartile 4(Q4) vs Quartile 1(Q1) = -6,14; 95%CI: -11,63 to -0,73), sanitation systems, (Q4 vs Q1 = -25,58; 95%CI: -31,91 to -19,25), % measles vaccination coverage (Q4 vs Q1 = -7.35; 95%CI: -10,18 to -4,52), % of births attended by a healthcare professional (Q4 vs Q1 = -7,91; 95%CI: -11,36 to -4,52) and a % of the total health expenditure (Q3 vs Q1 = -2,85; 95%CI: -4,93 to -0,7). Ethnic fragmentation (Q4 vs Q1 = 9,93; 95%CI: -0.03 to 19.89) had a marginal effect. For child mortality<5 years, an association was found for these variables and democratization (not free vs free = 11,23; 95%CI: -0,82 to 23,29), out-of-pocket expenditure (Q1 vs Q4 = 17,71; 95%CI: 5,86 to 29,56). For MMR (Maternal mortality ratio), % of access to water for all the quartiles, % of access to sanitation systems, (Q3 vs Q1 = -171,15; 95%CI: -281,29 to -61), birth attention by a healthcare professional (Q4 vs Q1 = -231,23; 95%CI: -349,32 to -113,15), and having corrupt government (Q3 vs Q1 = 83,05; 95%CI: 33,10 to 133).
Conclusions
Improving access to water and sanitation systems, decreasing corruption in the health sector must become priorities in health systems. The ethno-linguistic cultural fragmentation and the detriment of democracy turn out to be two factors related to health results.

Science
3 April 2015 vol 348, issue 6230, pages 1-150
http://www.sciencemag.org/current.dtl
Special Issue
Cancer Immunology and Immunotherapy

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Infectious Diseases
As Ebola wanes, trials jockey for patients
Kai Kupferschmidt
The Ebola epidemic in West Africa has caused enormous suffering, but scientists also see it as a chance to test experimental therapies that could save lives in the future. With declining case numbers, however, it is becoming less likely that all the drug tests will reach a conclusion. Now, scientists are debating whether some trials should be stopped so that tests of more promising therapies that have only now become available have a better chance of reaching a conclusion. An expert panel at the World Health Organization has given ZMapp and TKM-Ebola highest priority but in a recent meeting did not call for ongoing studies of favipiravir and convalescent blood to be stopped. The experts did convince a group of Italian doctors to test ZMapp instead of the heart drug amiodarone and criticized an interferon trial that has now started in Guinea.

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Policy Forum
Vaccine Testing
Ebola and beyond
Marc Lipsitch1,*, Nir Eyal2, M. Elizabeth Halloran3,4, Miguel A. Hernán5, Ira M. Longini6,
Eli N. Perencevich7,8, Rebecca F. Grais9,*
Author Affiliations
1Center for Communicable Disease Dynamics and Departments of Epidemiology and Immunology and Infectious Diseases, Harvard T. H. Chan School of Public Health, Boston, MA 02115, USA.
2Department of Global Health and Population, Harvard T. H. Chan School of Public Health and Center for Bioethics, Harvard Medical School, Boston, MA, USA.
3Center for Inference and Dynamics of Infectious Diseases, Vaccine and Infectious Disease Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA.
4Department of Biostatistics, University of Washington, Seattle, WA 98105, USA.
5Center for Communicable Disease Dynamics and Departments of Epidemiology and Biostatistics, Harvard T. H. Chan School of Public Health, and Harvard-MIT Division of Health Sciences and Technology, Boston, MA, USA.
6Center for Inference and Dynamics of Infectious Diseases, Department of Biostatistics, College of Public Health and Health Professions, and College of Medicine, University of Florida, Gainesville, FL, USA.
7Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA.
8Center for Comprehensive Access and Delivery Research and Evaluation, Iowa Veterans Affairs Health Care System, Iowa City, IA, USA.
9Epicentre, Paris, France.
Many epidemic-prone infectious diseases present challenges that the current West African Ebola outbreak brings into sharp relief. Specifically, the urgency to evaluate vaccines, initially limited vaccine supplies, and large and unpredictable spatial and temporal fluctuations in incidence have presented huge logistical, ethical, and statistical challenges to trial design.

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Report
Mutation rate and genotype variation of Ebola virus from Mali case sequences
T. Hoenen1,*, D. Safronetz1,*, A. Groseth1,*, K. R. Wollenberg2,*, O. A. Koita3, B. Diarra3,
I. S. Fall4, F. C. Haidara5, F. Diallo5, M. Sanogo3, Y. S. Sarro3, A. Kone3, A. C. G. Togo3, A. Traore5, M. Kodio5, A. Dosseh6, K. Rosenke1, E. de Wit1, F. Feldmann7, H. Ebihara1, V. J. Munster1, K. C. Zoon8, H. Feldmann1, S. Sow5,
Author Affiliations
1Laboratory of Virology, Division of Intramural Research, National Institute of Allergy and Infectious Diseases (NIAID), National Institutes of Health (NIH), Hamilton, MT 59840, USA.
2Bioinformatics and Computational Biosciences Branch, NIAID, NIH, Bethesda, MD 20892, USA.
3Center of Research and Training for HIV and Tuberculosis, University of Science, Technique and Technologies of Bamako, Mali.
4World Health Organization Office, Bamako, Mali.
5Centre des Operations d’Urgence, Centre pour le Développement des Vaccins (CVD-Mali), Centre National d’Appui à la lutte contre la Maladie, Ministère de la Sante et de l’Hygiène Publique, Bamako, Mali.
6World Health Organization Inter-Country Support Team, Ouagadougou, Burkina Faso.
7Rocky Mountain Veterinary Branch, Division of Intramural Research, NIAID, NIH, Hamilton, MT 59840, USA.
8Office of the Scientific Director, NIAID, NIH, Bethesda, MD 20895, USA.
Abstract
Editor’s Summary
The occurrence of Ebola virus (EBOV) in West Africa during 2013–2015 is unprecedented. Early reports suggested that in this outbreak EBOV is mutating twice as fast as previously observed, which indicates the potential for changes in transmissibility and virulence and could render current molecular diagnostics and countermeasures ineffective. We have determined additional full-length sequences from two clusters of imported EBOV infections into Mali, and we show that the nucleotide substitution rate (9.6 × 10–4 substitutions per site per year) is consistent with rates observed in Central African outbreaks. In addition, overall variation among all genotypes observed remains low. Thus, our data indicate that EBOV is not undergoing rapid evolution in humans during the current outbreak. This finding has important implications for outbreak response and public health decisions and should alleviate several previously raised concerns.