Bulletin of the World Health Organization
Volume 93, Number 6, June 2015, 361-436
http://www.who.int/bulletin/volumes/93/6/en/

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EDITORIALS
The Sendai framework: disaster risk reduction through a health lens
Amina Aitsi-Selmi & Virginia Murray
doi: 10.2471/BLT.15.157362

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Research
Identifying implementation bottlenecks for maternal and newborn health interventions in rural districts of the United Republic of Tanzania
Ulrika Baker, Stefan Peterson, Tanya Marchant, Godfrey Mbaruku, Silas Temu, Fatuma Manzi & Claudia Hanson
Abstract
Objective
To estimate effective coverage of maternal and newborn health interventions and to identify bottlenecks in their implementation in rural districts of the United Republic of Tanzania.
Methods
Cross-sectional data from households and health facilities in Tandahimba and Newala districts were used in the analysis. We adapted Tanahashi’s model to estimate intervention coverage in conditional stages and to identify implementation bottlenecks in access, health facility readiness and clinical practice. The interventions studied were syphilis and pre-eclampsia screening, partograph use, active management of the third stage of labour and postpartum care.
Findings
Effective coverage was low in both districts, ranging from only 3% for postpartum care in Tandahimba to 49% for active management of the third stage of labour in Newala. In Tandahimba, health facility readiness was the largest bottleneck for most interventions, whereas in Newala, it was access. Clinical practice was another large bottleneck for syphilis screening in both districts.
Conclusion
The poor effective coverage of maternal and newborn health interventions in rural districts of the United Republic of Tanzania reinforces the need to prioritize health service quality. Access to high-quality local data by decision-makers would assist planning and prioritization. The approach of estimating effective coverage and identifying bottlenecks described here could facilitate progress towards universal health coverage for any area of care and in any context.

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Policy & Practice
Applying the lessons of maternal mortality reduction to global emergency health
Emilie J Calvello, Alexander P Skog, Andrea G Tenner & Lee A Wallis
Over the last few decades, maternal health has been a major focus of the international community and this has resulted in a substantial decrease in maternal mortality globally. Although, compared with maternal illness, medical and surgical emergencies account for far more morbidity and mortality, there has been less focus on global efforts to improve comprehensive emergency systems. The thoughtful and specific application of the concepts used in the effort to decrease maternal mortality could lead to major improvements in global emergency health services. The so-called three-delay model that was developed for maternal mortality can be adapted to emergency service delivery. Adaptation of evaluation frameworks to include emergency sentinel conditions could allow effective monitoring of emergency facilities and further policy development. Future global emergency health efforts may benefit from incorporating strategies for the planning and evaluation of high-impact interventions.

Disasters
July 2015 Volume 39, Issue 3 Pages 407–609
http://onlinelibrary.wiley.com/doi/10.1111/disa.2015.39.issue-3/issuetoc

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Papers
Building disaster-resilient micro enterprises in the developing world
Sameer Prasad1, Hung-Chung Su2, Nezih Altay3 andJasmine Tata4
Article first published online: 29 DEC 2014
DOI: 10.1111/disa.12117
Abstract
Family-owned micro enterprises operating within the informal sector of most developing countries provide millions of citizens with a livelihood and are the economic backbone of many communities. Yet, the turbulence that emanates up or down respective supply chains following a disaster can cause these entities to fail. This study develops a model that recognises the relative weakness of micro enterprises to such disaster-related shocks. The model proposes that micro enterprises can moderate the effect of such shocks by creating resilience through cognitive preparation, continuous learning, and the generation of various forms of social capital (cognitive, relational, and structural). The propositions for the model are established through an extensive literature review, coupled with examples drawn from the documents of humanitarian agencies performing disaster relief work in India. This model also serves as a preliminary basis with which to derive metrics to set benchmarks or to assess the viability of a micro enterprise’s ability to survive disaster-related shocks.

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Papers
The impact of humanitarian context conditions and individual characteristics on aid worker retention
Valeska P. Korff1, Melinda Mills3, Liesbet Heyse4 and Rafael Wittek5
Article first published online: 9 JAN 2015
DOI: 10.1111/disa.12119
Abstract
High employee turnover rates constitute a major challenge to effective aid provision. This study examines how features of humanitarian work and aid workers’ individual characteristics affect retention within one humanitarian organisation, Médecins Sans Frontières (MSF) Holland. The study extends existing research by providing new theoretical explanations of employment opportunities and constraints and by engaging in the first large-scale quantitative analysis of aid worker retention. Using a database of field staff (N=1,955), a logistic regression is performed of the likelihood of reenlistment after a first mission. The findings demonstrate that only 40 per cent of employees reenlist for a second mission with MSF Holland, and that workplace location and security situation, age, and gender have no significant effect. Individuals are less likely to reenlist if they returned early from the first mission for a personal reason, are in a relationship, are medical doctors, or if they come from highly developed countries. The paper reflects on the findings in the light of policy.

IDRiM Journal
Vol 5, No 1 (2015) June 2015
http://idrimjournal.com/index.php/idrim/issue/view/13

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IDRiM Conference Special Issue Articles
Changing land use, disaster risk and adaptive responses in upland communities in Thailand
Malin Beckman, Junko Mochizuki, Sopon Naruchaikusol
Abstract
The Forensic Investigations of Disaster (FORIN) research approach was utilized to investigate the inter- relationships between land-use changes and adaptive capacity to climate risk in Northern Thailand, and how these are influenced by policy-related and economic activities at national, provincial and local levels. Scenario-based analysis indicated the necessity of community planning concerning future climate risk(s) and adaptive-capacity enhancement. The study highlighted numerous climate risks facing villagers, including flash floods, heavy rainfall, temperature extremes, and prolonged drought. The marginalized communities under study are located in National Park and Forest Reserve areas, and the limitations of their existing resources make them especially vulnerable to climate risk. In addition, recent land-use changes and increasing dependence on mono-culture crops planted on sloping land have rendered them more vulnerable to non-climate-based risks including pest outbreaks and market-price fluctuations. The study sees the need for further governmental support in the form of agricultural extension, community- based forest management, diversification and other livelihood strategies that would help to promote the resilience of these forest-dependent communities.

The Lancet
Jun 06, 2015 Volume 385 Number 9984 p2223-2322
http://www.thelancet.com/journals/lancet/issue/current

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Comment
An updated Ebola vaccine: immunogenic, but will it protect?
Andrea Marzi, Darryl Falzarano
Published Online: 24 March 2015
DOI: http://dx.doi.org/10.1016/S0140-6736(15)60613-4

The largest outbreak of Ebola virus ever recorded has been ongoing for about 16 months in west Africa. In the past week, Liberia, which had nearly reached the halfway point to being declared Ebola free, has reported a new case, and new Ebola infections continue to be confirmed in Sierra Leone and Guinea.1 With more than 24 000 cases and almost 10 000 fatalities,1 this outbreak is one of the biggest public health crises so far this century. When the outbreak was first confirmed in March, 2014, none of the experimental vaccine platforms with promising results in non-human primate studies2 had advanced beyond assessment in phase 1 clinical trials in human beings, let alone been approved for human use. But only a few months later, with the epidemic spreading and thousands of people infected in west Africa, the international community pulled together to accelerate phase 1 clinical trials in humans for vaccine platforms based on recombinant adenovirus (ClinicalTrials.gov numbers NCT02289027, NCT02368119, NCT02231866, NCT02354404, NCT02240875, NCT02267109) and vesicular stomatitis virus (NCT02287480, NCT02269423, NCT02296983, NCT02314923, NCT02280408, NCT02374385, NCT02283099).

The timely study by Feng-Cai Zhu and colleagues3 in The Lancet is the fourth report of a phase 1 trial in humans using either recombinant adenovirus-based or DNA-based vaccination strategies.4, 5, 6 The recombinant adenovirus type-5 vaccine platform has previously been tested by other investigators with a prototypic Ebola virus glycoprotein.2 The present study updated the vaccine vector to encode the glycoprotein from the 2014 west African Ebola virus isolate, making it the first Ebola vaccine report to use an immunogen that matches that of the currently circulating Ebola virus strain.

In the study, 120 healthy Chinese individuals were randomly assigned to receive placebo (n=40), or a low dose (4 × 1010 viral particles; n=40) or high dose (1·6 × 1011 viral particles; n=40) of the recombinant adenovirus type-5 vaccine.3 In each group, roughly 60% of the participants had pre-existing neutralising antibody titres greater than 1:200 to adenovirus type-5. In a previous phase 1 trial based on a different recombinant adenovirus type-5-based Ebola vaccine vector with promising data in non-human primates, pre-existing adenovirus type-5 neutralising antibodies negatively affected the immune response to the vaccine (55% vs 100% response).2, 7 These data provided the basis for replacement of the adenovirus-type-5 vector with a chimpanzee adenovirus vector.5

The increased vaccine doses used in Zhu and colleagues’ study3 seem to partly circumvent pre-existing immunity to the vector, because participants in the high-dose group had a 100% response rate, with no resultant increase in adverse events. Glycoprotein-specific antibody titres significantly increased in the low-dose and high-dose vaccine groups at both day 14 (geometric mean titre 421·4 [95% CI 249·7–711·3] and 820·5 [598·9–1124·0], respectively) and day 28 (682·7 [424·3–1098·5] and 1305·7 [970·1–1757·2], respectively), with T-cell responses peaking at day 14 in both these groups (median 465·0 spot-forming cells [IQR 180·0–1202·5] and 765·0 cells [400·0–1460·0], respectively). The antigen-specific immunoglobulin-G responses in participants in the high-dose group with low pre-existing adenovirus type-5 immunity (≤1:200) resulted in geometric mean titres of 2231·8 (95% CI 1268·6–3926·2) at 4 weeks after vaccination, but titres decreased to 946·5 (705·4–1270·1) when the immunised individuals had pre-existing neutralising titres greater than 1:200. This finding is a major concern about this vaccine platform, because 80% of the target population in Africa are expected to have adenovirus type-5 neutralising antibody titres.8 Furthermore, findings from previous studies9, 10 in non-human primates suggest that with adenovirus-based vaccines, an Ebola virus glycoprotein-specific ELISA 90% effective concentration (the metric also used in the present study) titre of 3000 is required for protection, and this concentration was not reached in the present trial, particularly in participants with pre-existing adenovirus type-5 immunity. This recombinant adenovirus-based type-5 Ebola virus vaccine also elicits a similar T-cell response in humans to that shown with the chimpanzee adenovirus vector, peaking 14 days after vaccination.5

The glycoprotein from the present outbreak strain has 97% similarity to previously known Ebola virus vaccine isolates,11 and vaccines using the prototypic antigen are expected to protect against infection with the west African isolates. Data from preclinical animal studies will hopefully provide information about the importance of having a vaccine antigen that is identical to that of circulating viruses.

Because Zhu and colleagues’ report3 is preliminary, antibody responses have only been assessed up to day 28 after vaccination. Thus, the durability of a single-dose recombinant adenovirus type-5 vaccination is still unknown, and assessment of whether subsequent boosts will be necessary to maintain or establish sufficient long-term immunity will be important. 82 (68%) participants reported at least one solicited adverse reaction within 7 days of vaccination (19 in the placebo group vs 27 in the low-dose group vs 36 in the high-dose group). The only reported adverse event in all three groups was mild pain at the injection site (eight in the placebo group, 14 in the low-dose group, and 29 in the high-dose vaccine group),3 a minor side-effect, suggesting that administration of the high dose probably needed in Africa would be acceptable. However, follow-up was only for 28 days and no conclusion about long-term side-effects can be made.

This adenovirus type-5 Ebola vaccine vector is an example of how quickly existing vaccine platforms can be modified to incorporate a new virus strain, and moved, with minimum testing in animals, into trials in humans during a crisis situation. However, for this vector, efficacy testing in non-human primates to establish whether the high-dose vaccine would be effective against homologous and heterologous Ebola virus strains still needs to be done. The outstanding question remains as to whether DNA, recombinant adenovirus, or recombinant chimpanzee adenovirus vaccine platforms will be more effective than a recombinant vesicular stomatitis virus-based vaccine, which by contrast is fast acting and not affected by pre-existing vector immunity.12 Ultimately, the effectiveness of all these vaccines will only become clear when they proceed to phase 2 efficacy trials in outbreak regions.

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Articles
Safety and immunogenicity of a novel recombinant adenovirus type-5 vector-based Ebola vaccine in healthy adults in China: preliminary report of a randomised, double-blind, placebo-controlled, phase 1 trial
Feng-Cai Zhu, MSc, Li-Hua Hou, PhD, Jing-Xin Li, MSc, Shi-Po Wu, PhD, Prof Pei Liu, PhD, Gui-Rong Zhang, PhD, Yue-Mei Hu, BSc, Fan-Yue Meng, MSc, Jun-Jie Xu, PhD, Rong Tang, MSc, Jin-Long Zhang, PhD, Wen-Juan Wang, MSc, Lei Duan, MSc, Kai Chu, MSc, Qi Liang, MSc, Jia-Lei Hu, MSc, Li Luo, MSc, Tao Zhu, PhD, Jun-Zhi Wang, PhD, Dr Wei Chen, PhD
Published Online: 24 March 2015
DOI: http://dx.doi.org/10.1016/S0140-6736(15)60553-0
Summary
Background
Up to now, all tested Ebola virus vaccines have been based on the virus strain from the Zaire outbreak in 1976. We aimed to assess the safety and immunogenicity of a novel recombinant adenovirus type-5 vector-based Ebola vaccine expressing the glycoprotein of the 2014 epidemic strain.
Methods
We did this randomised, double-blind, placebo-controlled, phase 1 clinical trial at one site in Taizhou County, Jiangsu Province, China. Healthy adults (aged 18–60 years) were sequentially enrolled and randomly assigned (2:1), by computer-generated block randomisation (block size of six), to receive placebo, low-dose adenovirus type-5 vector-based Ebola vaccine, or high-dose vaccine. Randomisation was pre-stratified by dose group. All participants, investigators, and laboratory staff were masked to treatment allocation. The primary safety endpoint was occurrence of solicited adverse reactions within 7 days of vaccination. The primary immunogenicity endpoints were glycoprotein-specific antibody titres and T-cell responses at day 28 after the vaccination. Analysis was by intention to treat. The study is registered with ClinicalTrials.gov, number NCT02326194.
Findings
Between Dec 28, 2014, and Jan 9, 2015, 120 participants were enrolled and randomly assigned to receive placebo (n=40), low-dose vaccine (n=40), or high-dose vaccine. Participants were followed up for 28 days. Overall, 82 (68%) participants reported at least one solicited adverse reaction within 7 days of vaccination (n=19 in the placebo group vs n=27 in the low-dose group vs n=36 in the high-dose group; p=0·0002). The most common reaction was mild pain at the injection site, which was reported in eight (20%) participants in the placebo group, 14 (35%) participants in the low-dose group, and 29 (73%) participants in the high-dose vaccine group (p<0·0001). We recorded no statistical differences in other adverse reactions and laboratory tests across groups. Glycoprotein-specific antibody titres were significantly increased in participants in the low-dose and high-dose vaccine groups at both day 14 (geometric mean titre 421·4 [95% CI 249·7–711·3] and 820·5 [598·9–1124·0], respectively; p<0·0001) and day 28 (682·7 [424·3–1098·5] and 1305·7 [970·1–1757·2], respectively; p<0·0001). T-cell responses peaked at day 14 at a median of 465·0 spot-forming cells (IQR 180·0–1202·5) in participants in the low-dose group and 765·0 cells (400·0–1460·0) in those in the high-dose group. 21 (18%) participants had mild fever (n=9 in the placebo group, n=6 in the low-dose group, and n=6 in the high-dose group). No serious adverse events were recorded.
Interpretation
Our findings show that the high-dose vaccine is safe and robustly immunogenic. One shot of the high-dose vaccine could mount glycoprotein-specific humoral and T-cell response against Ebola virus in 14 days.
Funding
China National Science and Technology, Beijing Institute of Biotechnology, and Tianjin CanSino Biotechnology.

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Comment
Ebola: the challenging road to recovery
Michael Edelstein, Philip Angelides, David L Heymann
Published Online: 08 February 2015
DOI: http://dx.doi.org/10.1016/S0140-6736(15)60203-3
The resurgence of polio in Syria in 2013 has shown how a breakdown in public health can lead to the re-emergence of previously well-controlled diseases.1 In 2014 and early 2015 Liberia, Guinea, and Sierra Leone have focused all resources on the Ebola response at the expense of other health programmes. Combined with losing a large proportion of the health-care workforce and the population’s reluctance to attend health-care facilities for fear of Ebola, this means the three countries are now at increased risk of other diseases that their health programmes usually target.

The Lancet Infectious Diseases
Jun 2015 Volume 15 Number 6 p615-746
http://www.thelancet.com/journals/laninf/issue/current

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Articles
Statistical power and validity of Ebola vaccine trials in Sierra Leone: a simulation study of trial design and analysis
Dr Steven E Bellan, PhD, Juliet R C Pulliam, PhD, Carl A B Pearson, PhD, David Champredon, MSc, Spencer J Fox, BS, Laura Skrip, MPH, Prof Alison P Galvani, PhD, Manoj Gambhir, PhD, Ben A Lopman, PhD, Prof Travis C Porco, PhD, Prof Lauren Ancel Meyers, PhD, Jonathan Dushoff, PhD
Published Online: 14 April 2015
DOI: http://dx.doi.org/10.1016/S1473-3099(15)70139-8
Summary
Background
Safe and effective vaccines could help to end the ongoing Ebola virus disease epidemic in parts of west Africa, and mitigate future outbreaks of the virus. We assess the statistical validity and power of randomised controlled trial (RCT) and stepped-wedge cluster trial (SWCT) designs in Sierra Leone, where the incidence of Ebola virus disease is spatiotemporally heterogeneous, and is decreasing rapidly.
Methods
We projected district-level Ebola virus disease incidence for the next 6 months, using a stochastic model fitted to data from Sierra Leone. We then simulated RCT and SWCT designs in trial populations comprising geographically distinct clusters at high risk, taking into account realistic logistical constraints, and both individual-level and cluster-level variations in risk. We assessed false-positive rates and power for parametric and non-parametric analyses of simulated trial data, across a range of vaccine efficacies and trial start dates.
Findings
For an SWCT, regional variation in Ebola virus disease incidence trends produced increased false-positive rates (up to 0·15 at α=0·05) under standard statistical models, but not when analysed by a permutation test, whereas analyses of RCTs remained statistically valid under all models. With the assumption of a 6-month trial starting on Feb 18, 2015, we estimate the power to detect a 90% effective vaccine to be between 49% and 89% for an RCT, and between 6% and 26% for an SWCT, depending on the Ebola virus disease incidence within the trial population. We estimate that a 1-month delay in trial initiation will reduce the power of the RCT by 20% and that of the SWCT by 49%.
Interpretation
Spatiotemporal variation in infection risk undermines the statistical power of the SWCT. This variation also undercuts the SWCT’s expected ethical advantages over the RCT, because an RCT, but not an SWCT, can prioritise vaccination of high-risk clusters.
Funding
US National Institutes of Health, US National Science Foundation, and Canadian Institutes of Health Research.

Maternal and Child Health Journal
Volume 19, Issue 6, June 2015
http://link.springer.com/journal/10995/19/6/page/1

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Commentary
New Dialogue for the Way Forward in Maternal Health: Addressing Market Inefficiencies
Katharine McCarthy, Saumya Ramarao, Hannah Taboada
Abstract
Despite notable progress in Millennium Development Goal (MDG) five, to reduce maternal deaths three-quarters by 2015, deaths due to treatable conditions during pregnancy and childbirth continue to concentrate in the developing world. Expanding access to three effective and low-cost maternal health drugs can reduce preventable maternal deaths, if available to all women. However, current failures in markets for maternal health drugs limit access to lifesaving medicines among those most in need. In effort to stimulate renewed action planning in the post-MDG era, we present three case examples from other global health initiatives to illustrate how market shaping strategies can scale-up access to essential maternal health drugs. Such strategies include: sharing intelligence among suppliers and users to better approximate and address unmet need for maternal health drugs, introducing innovative financial strategies to catalyze otherwise unattractive markets for drug manufacturers, and employing market segmentation to create a viable and sustainable market. By building on lessons learned from other market shaping interventions and capitalizing on opportunities for renewed action planning and partnership, the maternal health field can utilize market dynamics to better ensure sustainable and equitable distribution of essential maternal health drugs to all women, including the most marginalized

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Methodological Notes
Post-disaster Health Indicators for Pregnant and Postpartum Women and Infants
Marianne E. Zotti, Amy M. Williams, Etobssie Wako
Abstract
United States (U.S.) pregnant and postpartum (P/PP) women and their infants may be particularly vulnerable to effects from disasters. In an effort to guide post-disaster assessment and surveillance, we initiated a collaborative process with nationwide expert partners to identify post-disaster epidemiologic indicators for these at-risk groups. This 12 month process began with conversations with partners at two national conferences to identify critical topics for P/PP women and infants affected by disaster. Next we hosted teleconferences with a 23 member Indicator Development Working Group (IDWG) to review and prioritize the topics. We then divided the IDWG into three population subgroups (pregnant women, postpartum women, and infants) that conducted at least three teleconferences to discuss the proposed topics and identify/develop critical indicators, measures for each indicator, and relevant questions for each measure for their respective population subgroup. Lastly, we hosted a full IDWG teleconference to review and approve the indicators, measures, and questions. The final 25 indicators and measures with questions (available online) are organized by population subgroup: pregnant women (indicators = 9; measures = 24); postpartum women (indicators = 10; measures = 36); and infants (indicators = 6; measures = 30). We encourage our partners in disaster-affected areas to test these indicators and measures for relevancy and completeness. In post-disaster surveillance, we envision that users will not use all indicators and measures but will select ones appropriate for their setting. These proposed indicators and measures promote uniformity of measurement of disaster effects among U.S. P/PP women and their infants and assist public health practitioners to identify their post-disaster needs.

The Milbank Quarterly
A Multidisciplinary Journal of Population Health and Health Policy
June 2015 Volume 93, Issue 2 Pages 223–445
http://onlinelibrary.wiley.com/doi/10.1111/milq.2015.93.issue-2/issuetoc

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Review Article
Advocacy for Health Equity: A Synthesis Review
LINDEN FARRER*, CLAUDIA MARINETTI, YOLINE KUIPERS CAVACO andCAROLINE COSTONGS
Article first published online: 4 JUN 2015
DOI: 10.1111/1468-0009.12112
Abstract
Context
Health inequalities are systematic differences in health among social groups that are caused by unequal exposure to—and distributions of—the social determinants of health (SDH). They are persistent between and within countries despite action to reduce them. Advocacy is a means of promoting policies that improve health equity, but the literature on how to do so effectively is dispersed. The aim of this review is to synthesize the evidence in the academic and gray literature and to provide a body of knowledge for advocates to draw on to inform their efforts.
Methods
This article is a systematic review of the academic literature and a fixed-length systematic search of the gray literature. After applying our inclusion criteria, we analyzed our findings according to our predefined dimensions of advocacy for health equity. Last, we synthesized our findings and made a critical appraisal of the literature.
Findings
The policy world is complex, and scientific evidence is unlikely to be conclusive in making decisions. Timely qualitative, interdisciplinary, and mixed-methods research may be valuable in advocacy efforts. The potential impact of evidence can be increased by “packaging” it as part of knowledge transfer and translation. Increased contact between researchers and policymakers could improve the uptake of research in policy processes. Researchers can play a role in advocacy efforts, although health professionals and disadvantaged people, who have direct contact with or experience of hardship, can be particularly persuasive in advocacy efforts. Different types of advocacy messages can accompany evidence, but messages should be tailored to advocacy target. Several barriers hamper advocacy efforts. The most frequently cited in the academic literature are the current political and economic zeitgeist and related public opinion, which tend to blame disadvantaged people for their ill health, even though biomedical approaches to health and political short-termism also act as barriers. These barriers could be tackled through long-term actions to raise public awareness and understanding of the SDH and through training of health professionals in advocacy. Advocates need to take advantage of “windows of opportunity,” which open and close quickly, and demonstrate expertise and credibility.
Conclusions
This article brings together for the first time evidence from the academic and the gray literature and provides a building block for efforts to advocate for health equity. Evidence regarding many of the dimensions is scant, and additional research is merited, particularly concerning the applicability of findings outside the English-speaking world. Advocacy organizations have a central role in advocating for health equity, given the challenges bridging the worlds of civil society, research, and policy.

New England Journal of Medicine
June 4, 2015 Vol. 372 No. 23
http://www.nejm.org/toc/nejm/medical-journal

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Perspective
International Health Care Systems
Brazil’s Family Health Strategy — Delivering Community-Based Primary Care in a Universal Health System
James Macinko, Ph.D., and Matthew J. Harris, M.B., B.S., D.Phil.
N Engl J Med 2015; 372:2177-218 1June 4, 2015 DOI: 10.1056/NEJMp1501140
[Initial text]
Brazil has made rapid progress toward universal coverage of its population through its national health system, the Sistema Único de Saúde (SUS). Since its emergence from dictatorship in 1985, Brazil — which has the world’s fifth-largest population and seventh-largest economy — has invested substantially in expanding access to health care for all citizens, a goal that is implicit in the Brazilian constitution and the principles guiding the national health system.1 The SUS comprises public and private health care institutions and providers, financed primarily through taxes with contributions from federal, state, and municipal budgets. Health care management is decentralized, and municipalities are responsible for most primary care services as well as some hospitals and other facilities. All publicly financed health services and most common medications are universally accessible and free of charge at the point of service for all citizens — even the 26% of the population enrolled in private health plans (see table)
An important innovation in the system has been the development, adaptation, and rapid scaling up of a community-based approach to providing primary health care…

Pediatrics
June 2015, VOLUME 135 / ISSUE 6
http://pediatrics.aappublications.org/current.shtml

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Article
Tdap Vaccine Effectiveness in Adolescents During the 2012 Washington State Pertussis Epidemic
Anna M. Acosta, MDa,b, Chas DeBolt, RN, MPHc, Azadeh Tasslimi, MPHc, Melissa Lewis, MPHd, Laurie K. Stewart, MSc, Lara K. Misegades, PhD, MSb, Nancy E. Messonnier, MDb, Thomas A. Clark, MD, MPHb, Stacey W. Martin, MSb, and Manisha Patel, MD, MSb
Author Affiliations
aEpidemic Intelligence Service, Scientific Education and Professional Development Program Office,
bMeningitis and Vaccine Preventable Disease Branch, Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, and
dBiostatistics Office, Division of Bacterial Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia; and
cCommunicable Disease Epidemiology, Washington State Department of Health, Shoreline, Washington
Abstract
BACKGROUND: Acellular pertussis vaccines replaced whole-cell vaccines for the 5-dose childhood vaccination series in 1997. A sixth dose of pertussis-containing vaccine, tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis, adsorbed (Tdap), was recommended in 2005 for adolescents and adults. Studies examining Tdap vaccine effectiveness (VE) among adolescents who have received all acellular vaccines are limited.
METHODS: To assess Tdap VE and duration of protection, we conducted a matched case-control study during the 2012 pertussis epidemic in Washington among adolescents born during 1993–2000. All pertussis cases reported from January 1 through June 30, 2012, in 7 counties were included; 3 controls were matched by primary provider clinic and birth year to each case. Vaccination histories were obtained through medical records, the state immunization registry, and parent interviews. Participants were classified by type of pertussis vaccine received on the basis of birth year: a mix of whole-cell and acellular vaccines (1993–1997) or all acellular vaccines (1998–2000). We used conditional logistic regression to calculate odds ratios comparing Tdap receipt between cases and controls.
RESULTS: Among adolescents who received all acellular vaccines (450 cases, 1246 controls), overall Tdap VE was 63.9% (95% confidence interval [CI]: 50% to 74%). VE within 1 year of vaccination was 73% (95% CI: 60% to 82%). At 2 to 4 years postvaccination, VE declined to 34% (95% CI: −0.03% to 58%).
CONCLUSIONS: Tdap protection wanes within 2 to 4 years. Lack of long-term protection after vaccination is likely contributing to increases in pertussis among adolescents

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Article
First Pertussis Vaccine Dose and Prevention of Infant Mortality
Tejpratap S.P. Tiwari, MDa, Andrew L. Baughman, PhD, MPHb, and Thomas A. Clark, MD, MPHa
Author Affiliations
aMeningitis and Bacterial Vaccine Preventable Diseases Branch, Division of Bacterial Diseases, National Center for Immunization and Respiratory Diseases, and
bDivision of Global HIV/AIDS, Center for Global Health, Centers for Disease Control and Prevention, Atlanta, Georgia
Abstract
BACKGROUND: American infants are at highest risk of severe pertussis and death. We investigated the role of ≥1 pertussis vaccinations in preventing pertussis-related deaths and risk markers for death among infants aged <42 days.
METHODS: We analyzed characteristics of fatal and nonfatal infant pertussis cases reported nationally during 1991–2008. Infants were categorized into 2 age groups on the basis of eligibility to receive a first pertussis vaccine dose at age 6 weeks; dose 1 was considered valid if given ≥14 days before illness onset. Multivariable logistic regression was used to estimate the effect of ≥1 pertussis vaccine doses on outcome and risk markers.
RESULTS: Pertussis-related deaths occurred among 258 of 45 404 cases. Fatal and nonfatal cases were confirmed by culture (54% vs 49%) and polymerase chain reaction (31% vs 27%). All deaths occurred before age 34 weeks at illness onset; 64% occurred before age 6 weeks. Among infants aged ≥42 days, receiving ≥1 doses of vaccine protected against death (adjusted odds ratio [aOR]: 0.28; 95% confidence interval [CI]: 0.11–0.74), hospitalization (aOR: 0.69; 95% CI: 0.63–0.77), and pneumonia (aOR: 0.80; 95% CI: 0.68–0.95). Risk was elevated for Hispanic ethnicity (aOR: 2.28; 95% CI: 1.36–3.83) and American Indian/Alaska Native race (aOR: 5.15; 95% CI: 2.37–11.2) and lower for recommended antibiotic treatment (aOR: 0.28; 95% CI: 0.16–0.47). Among infants aged <42 days, risk was elevated for Hispanic ethnicity and lower with recommended antibiotic use.
CONCLUSIONS: The first pertussis vaccine dose and antibiotic treatment protect against death, hospitalization, and pneumonia.

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Special Article
Strategies to Decrease Pertussis Transmission to Infants
Kevin Forsyth, MD, PhDa, Stanley Plotkin, MDb, Tina Tan, MDc, and Carl Heinz Wirsing von König, MDd
Author Affiliations
aDepartment of Paediatrics and Child Health, Flinders Medical Centre, Flinders University, Adelaide, Australia;
bDepartment of Pediatrics, University of Pennsylvania, Philadelphia, Pennsylvania;
cNorthwestern University, Feinberg School of Medicine, Chicago, Illinois; and
dLabor;Medizin Krefeld MVZ, Krefeld, Germany
Abstract
The Global Pertussis Initiative (GPI) is an expert scientific forum addressing the worldwide burden of pertussis, which remains a serious health issue, especially in infants. This age cohort is at risk for developing pertussis by transmission from those in close proximity. Risk is increased in infants aged 0 to 6 weeks, as they are too young to be vaccinated. Older infants are at risk when their vaccination schedules are incomplete. Infants also bear the greatest disease burden owing to their high risk for pertussis-related complications and death; therefore, protecting them is a high priority. Two vaccine strategies have been proposed to protect infants. The first involves vaccinating pregnant women, which directly protects through the passive transfer of pertussis antibodies. The second strategy, cocooning, involves vaccinating parents, caregivers, and other close contacts, which indirectly protects infants from transmission by preventing disease in those in close proximity. The goal of this review was to present and discuss evidence on these 2 strategies. Based on available data, the GPI recommends vaccination during pregnancy as the primary strategy, given its efficacy, safety, and logistic advantages over a cocoon approach. If vaccination during pregnancy is not feasible, then all individuals having close contact with infants <6 months old should be immunized consistent with local health authority guidelines. These efforts are anticipated to minimize pertussis transmission to vulnerable infants, although real-world effectiveness data are limited. Countries should educate lay and medical communities on pertussis and introduce robust surveillance practices while implementing these protective strategies.

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Commentary
Epidemic Pertussis and Acellular Pertussis Vaccine Failure in the 21st Century
James D. Cherry, MD, MSc
Author Affiliations
Department of Pediatrics, David Geffen School of Medicine at UCLA, Los Angeles, California
[Initial text]
In this issue of Pediatrics Acosta et al1 present a tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis, adsorbed (Tdap) vaccine effectiveness study in adolescents in Washington State during the first 6 months of 2012. Their findings support the previous Tdap effectiveness data from Wisconsin.2 The duration of Tdap effectiveness is disappointing, particularly because case-control studies tend to inflate efficacy.3
In 4 recent publications (including 1 article in Pediatrics) I have discussed epidemic pertussis and why vaccines fail.4–7 Before discussing why Tdap vaccine effectiveness wanes so rapidly, it seems worthwhile to discuss how rapidly protection wanes after a natural infection in the pre-Tdap era and to take a realistic look at the resurgence of pertussis.
The resurgence of pertussis is often attributed to the switch from whole-cell pertussis vaccines to acellular products. However, the increase in reported pertussis began ∼14 years before the universal use of diphtheria-tetanus-acellular pertussis (DTaP) vaccines in childhood commenced. The 2 greatest contributors to the resurgence of pertussis are greater awareness and more sensitive diagnosis (the routine use …

PLOS Currents: Disasters
http://currents.plos.org/disasters/
[Accessed 6 June 2015]

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Supporting Rural Australian Communities after Disaster: the Warrumbungle Bushfire Support Coordination Service
June 1, 2015 · Research article

Aim: Natural disasters inflict significant trauma upon the individuals and communities in which they occur. In order to gain an understanding of the role of community-based disaster recovery support services in the post-disaster environment, we assessed the acceptability and perceived effectiveness of the Warrumbungle Bushfire Support Coordination Service (BSCS) implemented in response to the January 2013 bushfires in the Warrumbungle Shire, New South Wales, Australia.

Method: A mixed-methods approach was taken to explore the perspectives of former BSCS users and key stakeholders involved with the service. A survey was distributed to former services users (in both paper and online modalities) and included closed and open-ended questions. Semi-structured interviews were conducted with key stakeholders (face to face or via telephone).

Results: A total of 14 former BSCS users and six key stakeholders participated in the research. Almost half of the former service users had accessed the BSCS for more than six months. Regardless of the duration of their use of the service, most reported that the decision to use the service stemmed from the need for ‘help’. The majority of former service users were satisfied with the support provided by the BSCS and would recommend the service to others. Although most indicated that the BSCS informed them about where to get support, just over half were confident that they could access appropriate recovery services without the BSCS. Key themes arising from the former service use surveys were connectedness and support, whilst key themes in the interviews with key stakeholders were connectedness and the operation of the service. Both former service users and key stakeholders reported that the BSCS played an important role in facilitating community connectedness in the post-disaster period. Key stakeholders also identified challenges for the BSCS, including finding an appropriate agency and location to oversee the service and made suggestions about sustainability.

Conclusion: On the whole, the BSCS was perceived by former service users and key stakeholders as acceptable and effective. To develop a better understanding of the role of community-based disaster recovery support services, there is a need for more timely, rigorous and representative evaluation of disaster support services like the BSCS. Recommendations are made for the planning and development of future disaster support services. Key words: bushfires, natural disaster, Australia, disaster recovery support service, rural and remote, communities

PLoS Medicine
http://www.plosmedicine.org/
(Accessed 6 June 2015)
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Policy Forum
Assessing Development Assistance for Mental Health in Developing Countries: 2007–2013
Barnabas J. Gilbert, Vikram Patel, Paul E. Farmer, Chunling Lu
Published: June 2, 2015
DOI: 10.1371/journal.pmed.1001834
Summary Points
:: Mental disorders are a leading cause of the global burden of disease, and the provision of mental health services in developing countries remains very limited and far from equitable.
:: Using the Creditor Reporting System, we estimate the amounts and patterns of development assistance for global mental health (DAMH) between 2007 and 2013. This allows us to examine how well international donors have responded to calls by global mental health advocates to scale up evidence-based services.
:: Although DAMH did increase between 2007 and 2013, it remains low both in absolute terms and as a proportion of total development assistance for health (DAH). The average annual DAMH between 2007 and 2013 was US$133.57 million, and the proportion of DAH attributed to mental health is less than 1%.
:: Approximately 48% of total DAMH was for humanitarian assistance, education, and civil services. More annual DAMH was channelled into the nonpublic sector than the public sector.

Despite an expanding body of evidence suggesting that sustainable mental health care can be effectively integrated into existing health systems at relatively low cost, mental health has not received significant development assistance.

PLoS Neglected Tropical Diseases
http://www.plosntds.org/
(Accessed 6 June 2015)

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What Factors Might Have Led to the Emergence of Ebola in West Africa?
Kathleen A. Alexander, Claire E. Sanderson, Madav Marathe, Bryan L. Lewis, Caitlin M. Rivers, effrey Shaman, John M. Drake, Eric Lofgren, Virginia M. Dato, Marisa C. Eisenberg, Stephen Eubank
Published: June 4, 2015
DOI: 10.1371/journal.pntd.0003652
Abstract
An Ebola outbreak of unprecedented scope emerged in West Africa in December 2013 and presently continues unabated in the countries of Guinea, Sierra Leone, and Liberia. Ebola is not new to Africa, and outbreaks have been confirmed as far back as 1976. The current West African Ebola outbreak is the largest ever recorded and differs dramatically from prior outbreaks in its duration, number of people affected, and geographic extent. The emergence of this deadly disease in West Africa invites many questions, foremost among these: why now, and why in West Africa? Here, we review the sociological, ecological, and environmental drivers that might have influenced the emergence of Ebola in this region of Africa and its spread throughout the region. Containment of the West African Ebola outbreak is the most pressing, immediate need. A comprehensive assessment of the drivers of Ebola emergence and sustained human-to-human transmission is also needed in order to prepare other countries for importation or emergence of this disease. Such assessment includes identification of country-level protocols and interagency policies for outbreak detection and rapid response, increased understanding of cultural and traditional risk factors within and between nations, delivery of culturally embedded public health education, and regional coordination and collaboration, particularly with governments and health ministries throughout Africa. Public health education is also urgently needed in countries outside of Africa in order to ensure that risk is properly understood and public concerns do not escalate unnecessarily. To prevent future outbreaks, coordinated, multiscale, early warning systems should be developed that make full use of these integrated assessments, partner with local communities in high-risk areas, and provide clearly defined response recommendations specific to the needs of each community.

PLoS Neglected Tropical Diseases
http://www.plosntds.org/
(Accessed 6 June 2015)

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Research Article
Updated Global Burden of Cholera in Endemic Countries
Mohammad Ali , Allyson R. Nelson, Anna Lena Lopez, David A. Sack
Published: June 4, 2015
DOI: 10.1371/journal.pntd.0003832
Abstract
Background
The global burden of cholera is largely unknown because the majority of cases are not reported. The low reporting can be attributed to limited capacity of epidemiological surveillance and laboratories, as well as social, political, and economic disincentives for reporting. We previously estimated 2.8 million cases and 91,000 deaths annually due to cholera in 51 endemic countries. A major limitation in our previous estimate was that the endemic and non-endemic countries were defined based on the countries’ reported cholera cases. We overcame the limitation with the use of a spatial modelling technique in defining endemic countries, and accordingly updated the estimates of the global burden of cholera.
Methods/Principal Findings
Countries were classified as cholera endemic, cholera non-endemic, or cholera-free based on whether a spatial regression model predicted an incidence rate over a certain threshold in at least three of five years (2008-2012). The at-risk populations were calculated for each country based on the percent of the country without sustainable access to improved sanitation facilities. Incidence rates from population-based published studies were used to calculate the estimated annual number of cases in endemic countries. The number of annual cholera deaths was calculated using inverse variance-weighted average case-fatality rate (CFRs) from literature-based CFR estimates. We found that approximately 1.3 billion people are at risk for cholera in endemic countries. An estimated 2.86 million cholera cases (uncertainty range: 1.3m-4.0m) occur annually in endemic countries. Among these cases, there are an estimated 95,000 deaths (uncertainty range: 21,000-143,000).
Conclusion/Significance
The global burden of cholera remains high. Sub-Saharan Africa accounts for the majority of this burden. Our findings can inform programmatic decision-making for cholera control.
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Author Summary
The global burden of cholera is largely unknown because the majority of cases are not reported. The low reporting can be attributed to limited capacity of epidemiological surveillance and laboratories, as well as social, political, and economic disincentives for reporting. We previously estimated 2.8 million cases and 91,000 deaths annually due to cholera in 51 endemic countries. A major limitation in our previous estimate was that the endemic and non-endemic countries were defined based on the countries’ reported cholera cases. If a country did not report cases even though the country had cholera, the country was classified as cholera free. This time we addressed this limitation by using a spatial modelling technique, which helped us define the cholera-endemic countries based on access to improved water and sanitation in the country as well as cholera incidence in neighboring countries. Our new estimate illustrates 2.9 million of cases and 95,000 deaths in 69 endemic countries, with the majority of the burden in Sub-Saharan Africa. The sustained high burden of cholera points to the necessity for integrated and improved control efforts, and these findings may help programmatic decision-making for controlling the disease in endemic countries.

PLoS One
[Accessed 6 June 2015]
http://www.plosone.org/

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Research Article
Coverage of Community-Based Management of Severe Acute Malnutrition Programmes in Twenty-One Countries, 2012-2013
Eleanor Rogers, Mark Myatt, Sophie Woodhead, Saul Guerrero, Jose Luis Alvarez
Published: June 4, 2015
DOI: 10.1371/journal.pone.0128666
Abstract
Objective
This paper reviews coverage data from programmes treating severe acute malnutrition (SAM) collected between July 2012 and June 2013.
Design
This is a descriptive study of coverage levels and barriers to coverage collected by coverage assessments of community-based SAM treatment programmes in 21 countries that were supported by the Coverage Monitoring Network. Data from 44 coverage assessments are reviewed.
Setting
These assessments analyse malnourished populations from 6 to 59 months old to understand the accessibility and coverage of services for treatment of acute malnutrition. The majority of assessments are from sub-Saharan Africa.
Results
Most of the programmes (33 of 44) failed to meet context-specific internationally agreed minimum standards for coverage. The mean level of estimated coverage achieved by the programmes in this analysis was 38.3%. The most frequently reported barriers to access were lack of awareness of malnutrition, lack of awareness of the programme, high opportunity costs, inter-programme interface problems, and previous rejection.
Conclusions
This study shows that coverage of CMAM is lower than previous analyses of early CTC programmes; therefore reducing programme impact. Barriers to access need to be addressed in order to start improving coverage by paying greater attention to certain activities such as community sensitisation. As barriers are interconnected focusing on specific activities, such as decentralising services to satellite sites, is likely to increase significantly utilisation of nutrition services. Programmes need to ensure that barriers are continuously monitored to ensure timely removal and increased coverage.

PLoS Pathogens
http://journals.plos.org/plospathogens/
(Accessed 6 June 2015)
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Pearls
A 21st Century Perspective of Poliovirus Replication
Nicolas Lévêque, Bert L. Semler
Published: June 4, 2015
DOI: 10.1371/journal.ppat.1004825
Featured in PLOS Collections
Why Poliovirus Replication Has Been Studied for More Than 50 Years

Poliovirus is the etiologic agent of poliomyelitis, an acute flaccid paralysis affecting 1%–2% of infected patients and, on rare occasions, causing death by paralyzing muscles that control the throat or breathing. A striking feature of infection is lifelong disabilities that may affect survivors of the acute disease. Transmitted by the fecal—oral and oral—oral route, this virus (three serotypes) was one of the most feared pathogens in industrialized countries during the 20th century affecting hundreds of thousands of children every year, via outbreaks during warm summer months. Although there are highly effective vaccines to control poliomyelitis, it remains endemic in a few countries, from which spread and outbreaks continue to occur throughout the world. Since its discovery in 1908, poliovirus has been intensively studied to better understand and control this formidable pathogen. The history of poliovirus is not, however, limited to the fight against the disease. Poliovirus replication studies also have played important roles in the development of modern virology since poliovirologists and, more generally, picornavirologists have been pioneers in many domains of molecular virology. Poliovirus was, for example, the first animal RNA virus to have its complete genome sequence determined, the first RNA animal virus for which an infectious clone was constructed, and, along with the related rhinovirus, the first human virus that had its three-dimensional structure solved by X-ray crystallography. Indeed, the history of over half a century of poliovirus replication studies is marked by major discoveries, many of which are summarized here and illustrated in Fig 1…

PNAS – Proceedings of the National Academy of Sciences of the United States of America
http://www.pnas.org/content/early/
(Accessed 6 June 2015)

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Financial competitiveness of organic agriculture on a global scale
David W. Crowdera,1 and John P. Reganoldb
Author Affiliations
Edited by M. S. Swaminathan, Centre for Research on Sustainable Agricultural and Rural Development, Madras, India, and approved May 1, 2015 (received for review December 10, 2014)
Significance
Some recognize organic agriculture as being important for future global food security, whereas others project it to become irrelevant. Although organic agriculture is rapidly growing, it currently occupies only 1% of global cropland. Whether organic agriculture can continue to expand will likely be determined by whether it is economically competitive with conventional agriculture. Accordingly, we analyzed the financial performance of organic and conventional agriculture from 40 y of studies covering 55 crops grown on five continents. We found that, in spite of lower yields, organic agriculture was significantly more profitable than conventional agriculture and has room to expand globally. Moreover, with its environmental benefits, organic agriculture can contribute a larger share in sustainably feeding the world.
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Abstract
To promote global food and ecosystem security, several innovative farming systems have been identified that better balance multiple sustainability goals. The most rapidly growing and contentious of these systems is organic agriculture. Whether organic agriculture can continue to expand will likely be determined by whether it is economically competitive with conventional agriculture. Here, we examined the financial performance of organic and conventional agriculture by conducting a meta-analysis of a global dataset spanning 55 crops grown on five continents. When organic premiums were not applied, benefit/cost ratios (−8 to −7%) and net present values (−27 to −23%) of organic agriculture were significantly lower than conventional agriculture. However, when actual premiums were applied, organic agriculture was significantly more profitable (22–35%) and had higher benefit/cost ratios (20–24%) than conventional agriculture. Although premiums were 29–32%, breakeven premiums necessary for organic profits to match conventional profits were only 5–7%, even with organic yields being 10–18% lower. Total costs were not significantly different, but labor costs were significantly higher (7–13%) with organic farming practices. Studies in our meta-analysis accounted for neither environmental costs (negative externalities) nor ecosystem services from good farming practices, which likely favor organic agriculture. With only 1% of the global agricultural land in organic production, our findings suggest that organic agriculture can continue to expand even if premiums decline. Furthermore, with their multiple sustainability benefits, organic farming systems can contribute a larger share in feeding the world.

Prehospital & Disaster Medicine
Volume 30 – Issue 03 – June 2015
https://journals.cambridge.org/action/displayIssue?jid=PDM&tab=currentissue

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Editorial
Disastrous Events and Political Failures
Jeffrey Levett
National School of Public Health, Department of Health Service Management, Athens, Greece
Abstract
Response to the Ebola crisis (ongoing event) has been less than efficient. It has been monitored less than adequately by the international community and has been coordinated poorly in the USA. The event is used as a platform to examine deficiencies in public health infrastructure, the limits of its political and financial support, and how political outcomes can be affected. The need to tease out the political determinants implicit in policy failure and disaster management is argued in this Editorial. Failures mentioned include in the Balkans and in Greece with ongoing austerity. Comments on the real heroes of Ebola on the ground in Africa and the need for a charismatic role for political leaders in public health are also included.

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Original Research
Humanitarian Assistance and Accountability: What Are We Really Talking About?
Y.S. Andrew Tana1 c1 and Johan von Schreeba2
a1 Yong Loo Lin School of Medicine, National University of Singapore, Singapore
a2 Centre for Research on Health Care in Disasters, Health Systems and Policy, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
Abstract
Background In the past two decades, there has been a worldwide increase in the number of disasters, as well as the number of people affected, along with the number of foreign medical teams (FMTs) deployed to provide assistance. However, in the wake of the 2010 Haiti earthquake, multiple reports and anecdotes questioned the actual, positive contribution of such FMTs and even the intentions behind these aid efforts. This brought on a renewed interest in the humanitarian community towards accountability. Between 2000 and 2012, the number of “Quality and Accountability” initiatives and instruments more than tripled from 42 to 147. Yet, to date, there is no single accepted definition of accountability in the humanitarian context.
Aim The aim of this report was to explore and assess how accountability in the humanitarian context is used and/or defined in the literature.
Methods The electronic database PubMed and a predefined list of grey literature comprising 46 organizations were searched for articles that discussed or provided a definition of accountability in the humanitarian context. The definitions found in these articles were analyzed qualitatively using a framework analysis method based on principles of grounded theory as well as using a summative content analysis method.
Results A total of 85 articles were reviewed in-depth. Fifteen organizations had formal definitions of accountability or explained what it meant to them. Accountability was generally seen in two paradigms: as a “process” or as a “goal.” A total of 16 different concepts were identified amongst the definitions. Accountability to aid recipients had four main themes: empowering aid recipients, being in an optimal position to do the greatest good, meeting expectations, and being liable. The concepts of “enforcement/enforceability” under the last theme of “being liable” received the least mention.
Conclusion The concept of accountability is defined poorly in many humanitarian organizations. Humanitarian providers often refer to different concepts when talking about accountability in general. The lack of a common understanding is contributed by the semantic and practical complexities of the term. The lack of emphasis on “enforcement/enforceability” is noteworthy. Other aspects of accountability, such as its “measurability” and by whom, similarly lack a common understanding and community-wide consensus. To what extent these vague definitions of accountability affect agencies’ work in the field remains to be documented.

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Comprehensive Review
Child Debriefing: A Review of the Evidence Base
Betty Pfefferbauma1 c1, Anne K. Jacobsa1, Pascal Nitiémaa1 and George S. Everly Jr.a2a3
a1 Terrorism and Disaster Center, Department of Psychiatry and Behavioral Sciences, College of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma USA
a2 Department of Psychiatry and Behavioral Sciences, Johns Hopkins School of Medicine, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland USA
a3 Department of Psychology, Loyola University Maryland, Baltimore, Maryland USA
Abstract
Introduction
Debriefing, a controversial crisis intervention delivered in the early aftermath of a disaster, has not been well evaluated for use with children and adolescents. This report constitutes a review of the child debriefing evidence base.
Methods
A systematic search of selected bibliographic databases (EBM Reviews, EMBASE, ERIC, Medline, Ovid, PILOTS, PubMed, and PsycINFO) was conducted in the spring of 2014 using search terms related to psychological debriefing. The search was limited to English language sources and studies of youth, aged 0 to 18 years. No time limit was placed on date of publication. The search yielded 713 references. Titles and abstracts were reviewed to select publications describing scientific studies and clinical reports. Reference sections of these publications, and of other literature known to the authors that was not generated by the search, were used to locate additional materials. Review of these materials generated 187 publications for more thorough examination; this assessment yielded a total of 91 references on debriefing in children and adolescents. Only 15 publications on debriefing in children and adolescents described empirical studies. Due to a lack of statistical analysis of effectiveness data with youth, and some articles describing the same study, only seven empirical studies described in nine papers were identified for analysis for this review. These studies were evaluated using criteria for assessment of methodological rigor in debriefing studies.
Results
Children and adolescents included in the seven empirical debriefing studies were survivors of motor-vehicle accidents, a maritime disaster, hostage taking, war, or peer suicides. The nine papers describing the seven studies were characterized by inconsistency in describing the interventions and populations and by a lack of information on intervention fidelity. Few of the studies used randomized design or blinded assessment. The results described in the reviewed studies were mixed in regard to debriefing’s effect on posttraumatic stress, depression, anxiety, and other outcomes. Even in studies in which debriefing appeared promising, the research was compromised by potentially confounding interventions.
Conclusion
The results highlight the small empirical evidence base for drawing conclusions about the use of debriefing with children and adolescents, and they call for further dialogue regarding challenges in evaluating debriefing and other crisis interventions in children.

Revista Panamericana de Salud Pública/Pan American Journal of Public Health (RPSP/PAJPH)
March 2015 Vol. 37, No.
http://www.paho.org/journal/index.php?option=com_content&view=article&id=158&Itemid=266&lang=en

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Prevalence of cholera risk factors between migrant Haitians and Dominicans in the Dominican Republic [Prevalencia de los factores de riesgo de cólera entre los inmigrantes haitianos y los dominicanos en la República Dominicana]
Andrea J. Lund, Hunter M. Keys, Stephanie Leventhal, Jennifer W. Foster, and Matthew C. Freeman

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Adequação da assistência pré-natal segundo as características maternas no Brasil [Adequacy of prenatal care according to maternal characteristics in Brazil]
Rosa Maria Soares Madeira Domingues, Elaine Fernandes Viellas, Marcos Augusto Bastos Dias, Jacqueline Alves Torres, Mariza Miranda Theme-Filha, Silvana Granado Nogueira da Gama e Maria do Carmo Leal

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A systematic review of nursing research priorities on health system and services in the Americas [Revisión sistemática de las prioridades de investigación de enfermería en sistemas y servicios de salud en la Región de las Américas]
Alessandra Bassalobre Garcia, Silvia Helena De Bortoli Cassiani,and Ludovic Reveiz

Tropical Medicine & International Health
July 2015 Volume 20, Issue 7 Pages 821–966
http://onlinelibrary.wiley.com/doi/10.1111/tmi.2015.20.issue-7/issuetoc

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Systematic Reviews
Utilization of maternal health services among adolescent women in Bangladesh: A scoping review of the literature (pages 822–829)
A. S. M. Shahabuddin, Thérèse Delvaux, Saloua Abouchadi, Malabika Sarker and Vincent De Brouwere
Article first published online: 27 MAR 2015 | DOI: 10.1111/tmi.1250
Abstract
Objective
To understand the health-seeking behaviour of adolescent women in Bangladesh with respect to the use of maternal health services.
Methods
Literature review of seven electronic databases: PubMed, ISI Web of Knowledge, PsycINFO, Embase, CINAHL, POPLINE and Global Health. Studies published in English between 1990 and 2013 which describe Bangladeshi adolescent women’s healthcare-seeking behaviour during pregnancy, delivery and post-partum were included.
Results
Twelve studies were included in this review. 11 used quantitative methods and one used a mixed-methods approach. All studies included married adolescent women only. Women with lower educational levels are less likely to seek skilled maternal health services than those with higher levels of education. Use of maternal health services is also less common among rural married adolescent women than women in urban areas. Being part of the richest bands of wealth, having had previous experiences of childbirth and higher women’s autonomy positively influence the use of skilled maternal health services among married adolescent women in Bangladesh. Antenatal care is a key predictor of the use of skilled birth attendants for delivery and post-natal care.
Conclusion
Maternal health-related programmes should be designed targeting rural and uneducated married adolescent women in Bangladesh. More qualitative investigations are required to broaden our understanding on maternal health-seeking behaviour of both married and unmarried adolescent women.

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Psychological interventions for Common Mental Disorders for People Living With HIV in Low- and Middle-Income Countries: systematic review (pages 830–839)
Dixon Chibanda, Frances M. Cowan, Jessica L. Healy, Melanie Abas and Crick Lund
Article first published online: 20 MAR 2015 | DOI: 10.1111/tmi.12500

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Pneumococcal carriage in rural Gambia prior to the introduction of pneumococcal conjugate vaccine: a population-based survey (pages 871–879)
Effua Usuf, Henry Badji, Abdoulie Bojang, Sheikh Jarju, Usman Nurudeen Ikumapayi, Martin Antonio, Grant Mackenzie and Christian Bottomley
Article first published online: 6 APR 2015 | DOI: 10.1111/tmi.12505
Abstract
Objective
To evaluate pneumococcal colonisation before and after the introduction of pneumococcal conjugate vaccine (PCV) in eastern Gambia.
Methods
Population-based cross-sectional survey of pneumococcal carriage between May and August 2009 before the introduction of PCV into the Expanded Program on Immunization. Nasopharyngeal swabs were collected from all household members, but in selected households, only children aged 6–10 years were swabbed. This age group participated in an earlier trial of a nine-valent PCV between 2000 and 2004.
Results
The prevalence of nasopharyngeal pneumococcal carriage in 2933 individuals was 72.0% in underfives (N = 515), 41.6% in children aged 5–17 (N = 1508) and 13.0% in adults ≥18 (N = 910) years. The age-specific prevalence of serotypes included in PCV7, PCV10 and PCV13 was 24.7%, 26.6% and 46.8% among children <5 years of age; 8.5%, 9.2% and 17.7% among children 5–17 years; and 2.5%, 3.3% and 5.5% among adults ≥18 years. The most common serotypes were 6A (13.1%), 23F (7.6%), 3 (7.3%), 19F (7.1%) and 34 (4.6%). There was no difference in the overall carriage of pneumococci between vaccinated and unvaccinated children 8 years after the primary vaccination with three doses of PCV (48.3% vs. 41.1%).
Conclusion
Before the introduction of PCV, serotypes included in PCV13 accounted for about half the pneumococcal serotypes in nasopharyngeal carriage. Thus, the potential impact of PCV13 on pneumococcal disease in the Gambia is substantial.

Media/Policy Watch  [to 6 June 2015]
This section is intended to alert readers to substantive news, analysis and opinion from the general media on vaccines, immunization, global; public health and related themes. Media Watch is not intended to be exhaustive, but indicative of themes and issues CVEP is actively tracking. This section will grow from an initial base of newspapers, magazines and blog sources, and is segregated from Journal Watch above which scans the peer-reviewed journal ecology.

We acknowledge the Western/Northern bias in this initial selection of titles and invite suggestions for expanded coverage. We are conservative in our outlook in adding news sources which largely report on primary content we are already covering above. Many electronic media sources have tiered, fee-based subscription models for access. We will provide full-text where content is published without restriction, but most publications require registration and some subscription level.

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Center for Global Development
http://www.cgdev.org/
Accessed 6 June 2015
New Rules for Public Payers and Pharma in Emerging Economies?
6/3/15
Amanda Glassman
This week, emerging economy governments and multinational pharmaceutical executives announced they have agreed to a new way of working together, which should ensure people in those countries get the medicines they need at affordable prices. I’m glad to see this new framework for better priority-setting become a reality. Agreed to in April in Vietnam, it will allow public healthcare payers, the pharma industry and patients benefit from a more transparent process for deciding what drugs are made available to those who rely on strained public health care systems. While I have some questions and reservations about the agreement, at least it begins to address a chronic problem in global public health…

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Forbes
http://www.forbes.com/
Accessed 6 June 2015
Bill Gates, Dr. Paul Farmer And African Tycoon Strive Masiyiwa On Combating Future Epidemics
Billionaire Bill Gates, renowned doctor Paul Farmer and Zimbabwe’s richest man Strive Masiyiwa discussed how to combat future epidemics during the Forbes 400 Summit on Philanthropy.
Keren Blankfeld, Forbes Staff Jun 05, 2015

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The Guardian
http://www.guardiannews.com/
Accessed 6 June 2015
Children continue to die from vaccine-preventable diseases. We can stop that
Amy Belisle
4 June 2015
An unprecedented outbreak of chicken pox and whooping cough in Maine likely stems from a breakdown of herd immunity

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New York Times
http://www.nytimes.com/
Accessed 6 June 2015
Movie Review
Review: ‘Every Last Child,’ a Front-Line View of the Polio Crisis in Pakistan
New York Times | 2 June 2015
“Every Last Child,” a compelling documentary by Tom Roberts, gives a street-level view of the polio crisis in Pakistan, where that crippling virus remains endemic. While a program by the World Health Organization goes door to door administering oral vaccinations to infants, Pakistani Taliban militants have killed dozens of health workers since 2012.

The film spends time with an adult victim of polio and with a father whose infant son must be fitted for leg braces. And it follows Gulnaz Sherazi, a health worker who lost her niece and sister-in-law to Taliban attacks but continues to serve. These wrenching stories humanize the stakes of a health initiative that found itself and its employees at risk from a toxic mix of politics, propaganda and terrorism.

Once thought to be on the verge of global eradication, polio continues to threaten pockets of Pakistan: Peshawar in the north and the Waziristan tribal areas, and spreading south to Karachi. And the Pakistan polio strain has turned up in Afghanistan, Egypt, Syria, even China.

The Taliban’s brutal violence stuns Elias Durry, in charge of the W.H.O. program in Pakistan. “It’s a public health campaign,” he says. “It’s not supposed to be a war.” But that’s what the vaccination project has become, with an implacable enemy and a resentful populace…

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Wall Street Journal
http://online.wsj.com/home-page?_wsjregion=na,us&_homepage=/home/us
Accessed 6 June 2015
Ebola’s Long Shadow – West Africa Struggles to Rebuild Its Ravaged Health-Care System
By Betsy McKay 5 June 2015

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Washington Post
http://www.washingtonpost.com/
Accessed 6 June 2015
The Post’s View
Cholera’s fresh attack in Haiti
As donor dollars have dried up, the impoverished Caribbean nation faces a surge in the disease.
Editorial Board | Opinions | Jun 4, 2015
By Editorial Board June 4

THE FIGHT against the cholera epidemic in Haiti, by far the world’s worst in recent years, has been a hard slog. Still, the number of new cases had fallen precipitously, to just 1,000 per month for much of 2014 from an average in 2011 of nearly 30,000 per month.

But a recent spike — to about 1,000 new cases per week — is a grim reminder of how much is left to do to eradicate an illness that was virtually unknown in Haiti until U.N. peacekeepers from Nepal introduced it in 2010.

The surge in new cases also casts an unflattering spotlight on international donors, whose focus has gradually shifted elsewhere since the deadly 2010 earthquake killed at least 160,000 people .

It’s impossible to know whether flagging contributions reflect donor fatigue or the fact that relatively few cholera victims end up dying (less than 1 percent), thanks to quicker recognition and treatment in many parts of the country. Still, tighter money means longer odds for tackling the disease over the long term.

A plan to eliminate cholera in Haiti by 2022, devised in coordination with the Port-au-Prince government, was pegged to cost $2.2 billion. But of the $1.7 billion sought to execute the first five years of the plan, from 2013 to 2018, only 17 percent — about $286 million — has been raised and spent so far.

That means that blueprints to improve and replace portions of Haiti’s glaringly inadequate water and sanitation infrastructure are not being implemented. In the absence of those upgrades, more Haitians will continue to succumb to cholera, a diarrheal illness caused by consuming contaminated food and water.

Vaccinations have been a major focus of international health organizations combating cholera in Haiti. Yet in a country of more than 10 million people, fewer than 400,000 Haitians have received the cholera vaccine despite the efforts of organizations such as Partners in Health, which has vaccinated thousands of people in rural areas, and a Haitian group called GHESKIO, which has done similar work in the slums of Port-au-Prince. Supplies of the vaccine, which was not in wide demand before the Haitian outbreak, remain limited.

The United Nations has done extensive and admirable work in Haiti, including on public health, but it maintains it is immune from legal liability for the cholera epidemic. This is despite the consensus of health experts that U.N. peacekeepers introduced the disease into the country. In January, a federal judge in New York sided with the United Nations .
Nonetheless, it has a moral obligation to do more, including pressing donors to fund the plan to eradicate the disease. There is no mystery about how cholera is transmitted or about the means to eradicate it. Only money is lacking.