Conflict and Health
http://www.conflictandhealth.com/
[Accessed 5 November 2016]

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Research
Community based system dynamic as an approach for understanding and acting on messy problems: a case study for global mental health intervention in Afghanistan
Jean-Francois Trani, Ellis Ballard, Parul Bakhshi and Peter Hovmand
Published on: 2 November 2016

Ethics & International Affairs
Fall 2016 (Issue 30.3)
https://www.ethicsandinternationalaffairs.org/2016/fall-2016-issue-30-3/

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ESSAYS
Climate Contributions and the Paris Agreement: Fairness and Equity in a Bottom-Up Architecture
Nicholas Chan
[Initial text]
Ethical questions of fairness, responsibility, and burden-sharing have always been central to the international politics of climate change and efforts to construct an effective intergovernmental response to this problem. The conclusion of the Paris Agreement last December, lauded by the media, governments, and civil society around the world, is the most recent such effort, following the collapse of negotiations six years prior at the 2009 Copenhagen conference. The shape and form of the Paris Agreement, however, represents a radically different governance structure to its predecessor, the Kyoto Protocol, reorienting the international regime toward a “bottom-up” structure, emphasizing national flexibility in order to ensure broader participation. In doing so, the Paris Agreement also provides a different answer to the question of what constitutes a fair and equitable response to climate change…

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Features
Self-Interest and the Distant Vulnerable
Luke Glanville | September 15, 2016
[Initial text]
What interests do states have in assisting and protecting vulnerable populations beyond their borders? Today, confronted as we are with civil wars, mass atrocities, and humanitarian catastrophes that have cost the lives of hundreds of thousands of civilians and generated the displacement of sixty million more, this question is as urgent as it has ever been. It is also one that is answered in a variety of ways.
Narrow interpretations of nationalism and realism tend to insist that states have no interests in assisting the distant vulnerable. A narrow nationalism claims that a state should never risk blood and treasure for the sake of vulnerable outsiders…

Globalization and Health
http://www.globalizationandhealth.com/
[Accessed 5 November 2016]

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Research
Assessment of the scope and practice of evaluation among medical donation programs
Alisa M. Jenny, Meng Li, Elizabeth Ashbourne, Myron Aldrink, Christine Funk and Andy Stergachis
Globalization and Health 2016 12:69
Published on: 4 November 2016
Abstract
Background
Medical donation programs for drugs, other medical products, training and other supportive services can improve access to essential medicines in low- and middle-income countries (LMICs) and provide emergency and disaster relief. The scope and extent to which medical donation programs evaluate their impact on recipients and health systems is not well documented.
Methods
We conducted a survey of the member organizations of the Partnership for Quality Medical Donations (PQMD), a global alliance of non-profit and corporate organizations, to identify evaluations conducted in conjunction with donation programs.
Results
Twenty-five out of the 36 PQMD organizations that were members at the time of the survey participated in the study, for a response rate of 69 %. PQMD members provided information on 34 of their major medical donation programs. Half of the donation programs reported conducting trainings as a part of their donation program. Twenty-six (76 %) programs reported that they conduct routine monitoring of their donation programs. Less than 30 % of donation programs were evaluated for their impact on health. Lack of technical staff and lack of funding were reported as key barriers to conducting impact evaluations.
Conclusions
Member organizations of PQMD provide a broad range of medical donations, targeting a wide range of public health issues and events. While some level of monitoring and evaluation was conducted in nearly 80 % of the donation programs, a program’s impact was infrequently evaluated. Opportunities exist to develop consistent metrics for medical donation programs, develop a common framework for impact evaluations, and advocate for data collection and analysis plans that collect meaningful metrics.

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Research
The challenge of bridging the gap between researchers and policy makers: experiences of a Health Policy Research Group in engaging policy makers to support evidence informed policy making in Nigeria
Benjamin Uzochukwu, Obinna Onwujekwe, Chinyere Mbachu, Chinenye Okwuosa, Enyi Etiaba, Monica E. Nyström and Lucy Gilson
Globalization and Health 2016 12:67
Published on: 4 November 2016
Abstract
Background
Getting research into policy and practice (GRIPP) is a process of going from research evidence to decisions and action. To integrate research findings into the policy making process and to communicate research findings to policymakers is a key challenge world-wide. This paper reports the experiences of a research group in a Nigerian university when seeking to ‘do’ GRIPP, and the important features and challenges of this process within the African context.
Methods
In-depth interviews were conducted with nine purposively selected policy makers in various organizations and six researchers from the universities and research institute in a Nigerian who had been involved in 15 selected joint studies/projects with Health Policy Research Group (HPRG). The interviews explored their understanding and experience of the methods and processes used by the HPRG to generate research questions and research results; their involvement in the process and whether the methods were perceived as effective in relation to influencing policy and practice and factors that influenced the uptake of research results.
Results
The results are represented in a model with the four GRIPP strategies found: i) stakeholders’ request for evidence to support the use of certain strategies or to scale up health interventions; ii) policymakers and stakeholders seeking evidence from researchers; iii) involving stakeholders in designing research objectives and throughout the research process; and iv) facilitating policy maker-researcher engagement in finding best ways of using research findings to influence policy and practice and to actively disseminate research findings to relevant stakeholders and policymakers.
The challenges to research utilization in health policy found were to address the capacity of policy makers to demand and to uptake research, the communication gap between researchers, donors and policymakers, the management of the political process of GRIPP, the lack of willingness of some policy makers to use research, the limited research funding and the resistance to change.
Conclusions
Country based Health Policy and Systems Research groups can influence domestic policy makers if appropriate strategies are employed. The model presented gives some direction to potential strategies for getting research into policy and practice in the health care sector in Nigeria and elsewhere.

Infectious Diseases of Poverty
http://www.idpjournal.com/content
[Accessed 5 November 2016]
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Scoping Review
Alternatives to currently used antimalarial drugs: in search of a magic bullet
Malaria is a major cause of morbidity and mortality in many African countries and parts of Asia and South America. Novel approaches to combating the disease have emerged in recent years and several drug candid…
Akshaya Srikanth Bhagavathula, Asim Ahmed Elnour and Abdulla Shehab
Infectious Diseases of Poverty 2016 5:103
Published on: 4 November 2016

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Research Article
Assessment of the response to cholera outbreaks in two districts in Ghana
Despite recurring outbreaks of cholera in Ghana, very little has been reported on assessments of outbreak response activities undertaken in affected areas. This study assessed the response activities undertake...
Sally-Ann Ohene, Wisdom Klenyuie and Mark Sarpeh
Infectious Diseases of Poverty 2016 5:99
Published on: 2 November 2016

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Research Article
Tuberculosis care strategies and their economic consequences for patients: the missing link to end tuberculosis
While investment in the development of Tuberculosis (TB) treatment strategies is essential, it cannot be assumed that the strategies are affordable for TB patients living in countries with high economic constr…
Belete Getahun, Moges Wubie, Getiye Dejenu and Tsegahun Manyazewal
Infectious Diseases of Poverty 2016 5:93
Published on: 1 November 2016

Intervention – Journal of Mental Health and Psychological Support in Conflict Affected Areas
November 2016 – Volume 14 – Issue 3
http://journals.lww.com/interventionjnl/pages/currenttoc.aspx

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Special Section
Mainstreaming psychosocial approaches and principles in ‘other’ sectors
Introduction to Special section: mainstreaming psychosocial approaches and principles into ‘other’ sectors
Horn, Rebecca; Besselink, Djoen; Tankink, Marian

Articles
The integration of livelihood support and mental health and psychosocial wellbeing for populations who have been subject to severe stressors
Schininá, Guglielmo; Babcock, Elisabeth; Nadelman, Rachel; Walsh, James Sonam; Willhoite, Ann; Willman, Alys
Abstract
This article aims to promote the integration of mental health and psychosocial support into livelihood programmes, presenting existing research within behavioural economics, humanitarian and economic fields that support the need and effectiveness of such integration. It presents examples of mental health and psychosocial support integration into livelihood programmes put in place by a grass roots organisation in the USA and the largest development institution in the world, the World Bank Group, respectively. While these initiatives took place within organisational, socio-economic and political environments that significantly differ from those where most humanitarian programmes take place, a series of best practices, processes and approaches that could be considered within humanitarian settings are highlighted in the conclusions.

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Mainstreaming mental health and psychosocial support in camp coordination and camp management. The experience of the International Organization for Migration in the north east of Nigeria and South Sudan
Schininá, Guglielmo; Nunes, Nuno; Birot, Pauline; Giardinelli, Luana; Kios, Gladys
Abstract
This article examines the efforts of the International Organization for Migration to mainstream mental health and psychosocial considerations into camp coordination and camp management, through capacity building and provision of direct psychosocial support. It focusses on the activities carried out by the International Organization for Migration in South Sudan, in the Protection of Civilians Areas, and in the north east of Nigeria, with the aim to identify relevant challenges and best practices.

JAMA
November 1, 2016, Vol 316, No. 17, Pages 1731-1838
http://jama.jamanetwork.com/issue.aspx

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Research Letter
Tdap Vaccination During Pregnancy and Microcephaly and Other Structural Birth Defects in Offspring
Malini DeSilva, MD, MPH; Gabriela Vazquez-Benitez, PhD; James D. Nordin, MD, MPH; et al.
JAMA. 2016;316(17):1823-1825. doi:10.1001/jama.2016.14432
This cohort study uses Vaccine Safety Datalink data to examine associations between maternal Tdap vaccination and structural birth defects in offspring.
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Editorial
November 1, 2016
Mental Illness, Release From Prison, and Social Context
Jeffrey Swanson, PhD1
JAMA. 2016;316(17):1771-1772. doi:10.1001/jama.2016.12434
Zheng Chang, PhD; Paul Lichtenstein, PhD; Niklas Långström, MD; Henrik Larsson, PhD; Seena Fazel, MD
[Initial text]
Revolving in and out of prisons and jails is no way to recover from a devastating disease like schizophrenia—but that is the challenge facing too many people with serious mental illnesses. In addition to complex health needs that often include substance misuse and medical comorbidities, mentally ill individuals who reenter the community from prison are at risk for unemployment, homelessness, and criminal recidivism.1 What role does treatment with psychotropic medications have in improving outcomes for this population?…

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Original Investigation
November 1, 2016
Association Between Prescription of Major Psychotropic Medications and Violent Reoffending After Prison Release
JAMA. 2016;316(17):1798-1807. doi:10.1001/jama.2016.15380
Zheng Chang, PhD1,2; Paul Lichtenstein, PhD1; Niklas Långström, MD1,3; et al Henrik Larsson, PhD1,4; Seena Fazel, MD2
Author Affiliations
Key Points
Question
Is the use of psychotropic medications associated with a lower risk of reoffending for violent crime among released prisoners?
Findings
In this cohort study of 22 275 released prisoners, 3 classes of psychotropic medications (antipsychotics, psychostimulants, and medications used for addictive disorders) were associated with statistically significant hazard ratios (0.58, 0.62, and 0.48, respectively) of violent reoffending.
Meaning
Evidence-based provision of psychotropic medications to released prisoners was associated with lower risk of reoffending.

Abstract
Importance
Individuals released from prison have high rates of violent reoffending, and there is uncertainty about whether pharmacological treatments reduce reoffending risk.
Objective
To investigate the associations between major classes of psychotropic medications and violent reoffending.
Design, Setting, and Participants
This cohort study included all released prisoners in Sweden from July 1, 2005, to December 31, 2010, through linkage of population-based registers. Rates of violent reoffending during medicated periods were compared with rates during nonmedicated periods using within-individual analyses. Follow-up ended December 31, 2013.
Exposures Periods with or without dispensed prescription of psychotropic medications (antipsychotics, antidepressants, psychostimulants, drugs used in addictive disorders, and antiepileptic drugs) after prison release. Prison-based psychological treatments were investigated as a secondary exposure.
Main Outcomes and Measures
Violent crime after release from prison.
Results
The cohort included 22,275 released prisoners (mean [SD] age, 38 [13] years; 91.9% male). During follow-up (median, 4.6 years; interquartile range, 3.0-6.4 years), 4031 individuals (18.1%) had 5653 violent reoffenses. The within-individual hazard ratio (HR) associated with dispensed antipsychotics was 0.58 (95% CI, 0.39-0.88), based on 100 events in 1596 person-years during medicated periods and 1044 events in 11 026 person-years during nonmedicated periods, equating to a risk difference of 39.7 (95% CI, 11.3-57.7) fewer violent reoffenses per 1000 person-years. The within-individual HR associated with dispensed psychostimulants was 0.62 (95% CI, 0.40-0.98), based on 94 events in 1648 person-years during medicated periods and 513 events in 4553 person-years during nonmedicated periods, equating to a risk difference of 42.8 (95% CI, 2.2-67.6) fewer violent reoffenses per 1000 person-years. The within-individual HR associated with dispensed drugs for addictive disorders was 0.48 (95% CI, 0.23-0.97), based on 46 events in 1168 person-years during medicated periods and 1103 events in 15,725 person-years during nonmedicated periods, equating to a risk difference of 36.4 (95% CI, 2.1-54.0) fewer violent reoffenses per 1000 person-years. In contrast, antidepressants and antiepileptics were not significantly associated with violent reoffending rates (HR = 1.09 [95% CI, 0.83-1.43] and 1.14 [95% CI, 0.79-1.65], respectively). The most common prison-based program was psychological treatments for substance abuse, associated with an HR of 0.75 (95% CI, 0.63-0.89), which equated to a risk difference of 23.2 (95% CI, 10.3-34.1) fewer violent reoffenses per 1000 person-years.
Conclusions and Relevance
Among released prisoners in Sweden, rates of violent reoffending were lower during periods when individiduals were dispensed antipsychotics, psychostimulants, and drugs for addictive disorders, compared with periods in which they were not dispensed these medications. Further research is needed to understand the causal nature of this association.

Journal of Community Health
Volume 41, Issue 6, December 2016
http://link.springer.com/journal/10900/41/6/page/1
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Original Paper
Community Gardens for Refugee and Immigrant Communities as a Means of Health Promotion
Kari A. Hartwig, Meghan Mason

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Original Paper
Caregiving on the Hopi Reservation: Findings from the 2012 Hopi Survey of Cancer and Chronic Disease
Felina M. Cordova, Robin B. Harris…

Journal of Epidemiology & Community Health
November 2016, Volume 70, Issue 11
http://jech.bmj.com/content/current

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Research report
Socioeconomic inequalities in a 16-year longitudinal measurement of successful ageing
Almar A L Kok, Marja J Aartsen, Dorly J H Deeg, Martijn Huisman
J Epidemiol Community Health 2016;70:1106-1113 Published Online First: 17 May 2016 doi:10.1136/jech-2015-206938

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Research report
Education, material condition and physical functioning trajectories in middle-aged and older adults in Central and Eastern Europe: a cross-country comparison
Yaoyue Hu, Hynek Pikhart, Andrzej Pająk, Růžena Kubínová, Sofia Malyutina, Agnieszka Besala,
Anne Peasey, Michael Marmot, Martin Bobak
J Epidemiol Community Health 2016;70:1128-1135 Published Online First: 18 May 2016 doi:10.1136/jech-2015-206548

Journal of Health Care for the Poor and Underserved (JHCPU)
Volume 27, Number 4, November 2016
https://muse.jhu.edu/issue/35214

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Original Papers
How Should We Treat the Vulnerable?: Qualitative Study of Authoritative Ethics Documents
pp. 1656-1673
Ivana Zagorac
Abstract
The aim of this study is to explore what actual guidance is provided by authoritative ethics documents regarding the recognition and protection of the vulnerable. The documents included in this analysis are the Belmont Report, the Declaration of Helsinki, The Council for International Organizations of Medical Sciences (CIOMS) Guidelines, and the UNESCO Universal Declaration on Bioethics and Human Rights, including its supplementary report on vulnerability. A qualitative analysis of these documents was conducted in light of three questions: what is vulnerability, who are the vulnerable, and how should the vulnerable be protected? The results show significant differences among the documents regarding the first two questions. None of the documents provides any guidance on the third question (how to protect the vulnerable). These results suggest a great discrepancy between the acknowledged importance of the concept of vulnerability and a general understanding of the scope, content, and practical implications of vulnerability.

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Brief Communications
Pneumococcal Vaccination in Low-Income Latinos: An Unexpected Trend in Oregon Community Health Centers
pp. 1733-1744
John Heintzman, Steffani R. Bailey, Stuart Cowburn, Eve Dexter, Joseph Carroll, Miguel Marino
Abstract:
Background. In cross-sectional studies, Latino and Spanish-speaking U.S. residents age 65 and over are less likely to receive pneumococcal vaccination than non-Hispanic Whites.
Methods. We performed a time-to-event, cohort analysis, in 23 Oregon community health centers of low-income patients who turned 65 in the study period (2009–2013; n = 1,248). The outcome measure was receipt of PPSV-23 in the study period by race / ethnicity, preferred language, and insurance status.
Results. Insured Latino patients were more likely to receive PPSV-23 than insured non-Hispanic Whites (HR = 2.05, p < .001). Uninsured Latino seniors showed no difference from insured non-Hispanic Whites in PPSV-23 receipt (HR = 1.26, p = .381) unless they averaged fewer than one clinic visit yearly (HR = 1.80, p = .001).
Conclusions. Low-income Latino seniors in Oregon community health centers were immunized against pneumococcus more frequently than insured non-Hispanic Whites, although this finding was mitigated in Latinos without insurance. This finding needs further research in order to reduce adult immunization disparities in the society at large.

Journal of Infectious Diseases
Volume 214 Issue 10 November 15, 2016
http://jid.oxfordjournals.org/content/current

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EDITORIAL COMMENTARIES
Challenges Remain for Influenza Vaccination of Children
J Infect Dis. (2016) 214 (10): 1470-1472 doi:10.1093/infdis/jiw384
Kathryn M. Edwards and Wendy A. Keitel
Extract
Over the past decades, multiple active surveillance and observational studies have demonstrated the major impact of influenza on children and underscored the need for effective vaccines [1–4]. Since 2009, annual influenza vaccination has been recommended for all children ≥6 months of age in the United States [5]. Extensive studies in children have been conducted over the years with both inactivated influenza vaccines (IIV) and live attenuated influenza vaccines (LAIV). Influenza hemagglutination inhibition (HAI) antibody responses are considered to be the gold standard for assessing IIV immunogenicity and serve as the basis for their licensure. Although achievement of HAI antibody titers of ≥40 (putative protective titer) was associated with a 50% reduction in the occurrence of influenza [6, 7], others have proposed that the protective HAI titer is much higher [8]. Furthermore, there can be variability in HAI assay results among laboratories [9]. Cell-mediated immune (CMI) responses have been less well characterized, and no CMI correlate of protection (COP) has been proposed.’

In this issue of The Journal of Infectious Diseases, Reber et al report detailed humoral and CMI responses in 50 children ages 9–14 years after receipt of the 2010–2011 seasonal IIV [10]. In the previous year, 38% of the participants had received influenza vaccine (10% received LAIV and 28% received IIV), and 32% had been immunized with monovalent 2009 pandemic influenza A(H1N1) vaccine. Which vaccine(s) the children had received previously was not noted in the article, and their impact on subsequent immune responses was not assessed because of small sample size. HAI antibody responses were assayed against influenza virus antigens included in both the 2009–2010 and 2010–2011 vaccines, as well as the …

Journal of Medical Ethics
November 2016, Volume 42, Issue 11
http://jme.bmj.com/content/current

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Brief report
Ethical issues and best practice in clinically based genomic research: Exeter Stakeholders Meeting Report
D Carrieri, C Bewshea, G Walker, T Ahmad, W Bowen, A Hall, S Kelly, on behalf of the 7th of October 2015 Exeter Stakeholders Meeting
J Med Ethics 2016;42:695-697 Published Online First: 27 September 2016 doi:10.1136/medethics-2016-103530
Abstract
Current guidelines on consenting individuals to participate in genomic research are diverse. This creates problems for participants and also for researchers, particularly for clinicians who provide both clinical care and research to their patients. A group of 14 stakeholders met on 7 October 2015 in Exeter to discuss the ethical issues and the best practice arising in clinically based genomic research, with particular emphasis on the issue of returning results to study participants/patients in light of research findings affecting research and clinical practices. The group was deliberately multidisciplinary to ensure that a diversity of views was represented. This report outlines the main ethical issues, areas of best practice and principles underlying ethical clinically based genomic research discussed during the meeting. The main point emerging from the discussion is that ethical principles, rather than being formulaic, should guide researchers/clinicians to identify who the main stakeholders are to consult with for a specific project and to incorporate their voices/views strategically throughout the lifecycle of each project. We believe that the mix of principles and practical guidelines outlined in this report can contribute to current debates on how to conduct ethical clinically based genomic research.

The Lancet
Nov 05, 2016 Volume 388 Number 10057 p2209-2322 e12
http://www.thelancet.com/journals/lancet/issue/current

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Editorial
After Bolam: what’s the future for patient consent?
The Lancet
Published: 05 November 2016
“Patients are now widely regarded as persons holding rights, rather than as the passive recipients of the care of the medical profession”, declared the UK Supreme Court in the case of Montgomery vs Lanarkshire Health Board in 2015, affirming the patient as a subject and not simply the object of medical care. Before Montgomery, whether doctors reasonably communicated risks to patients about potential procedures was judged by reference to a responsible body of medical opinion (Bolam test), in line with the paternalistic model of medicine. Since Montgomery, what makes a risk material for a doctor to tell their patient about are the circumstances, views, and values of the individual patient, rather than the opinion of the medical profession.

In response to this renewed emphasis on patients’ rights to self-determination, the Royal College of Surgeons has released new guidance to help surgeons and other health-care professionals to obtain and document consent. Recognising that it is not enough to simply substitute expert opinion with an exhaustive list of potential risks and benefits, the guidance advocates for “supported decision-making”, with a focus on tailoring discussions to individual patients.

Considerable practical challenges loom large, not least of which is time. The guidance states that to determine the content of discussions around risk, doctors should take time to get to know their patients. These discussions need to take place long enough before planned interventions so patients have enough time to reflect, and in particularly complex or potentially life changing scenarios might need to take place over several sessions.

To deal with the new time pressures that this approach will involve, the guidance recommends surgeons raise the issue with their hospital management. But surely, to enable real patient-centred decision making to take root, we must do more than simply tell already time-pressed doctors to find yet more time. Such changes will require cultural and administrative reform at the institutional level. If we want to support patient choice and autonomy, then we must empower our medical professionals with the resources they need to make it happen.

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Series
Maternal Health
Drivers of maternity care in high-income countries: can health systems support woman-centred care?
Dorothy Shaw, Jeanne-Marie Guise, Neel Shah, Kristina Gemzell-Danielsson, KS Joseph, Barbara Levy, Fontayne Wong, Susannah Woodd, Elliott K Main

Maternal Health
Next generation maternal health: external shocks and health-system innovations
Margaret E Kruk, Stephanie Kujawski, Cheryl A Moyer, Richard M Adanu, Kaosar Afsana, Jessica Cohen, Amanda Glassman, Alain Labrique, K Srinath Reddy, Gavin Yamey

Maternal Health
Quality maternity care for every woman, everywhere: a call to action
Marjorie Koblinsky, Cheryl A Moyer, Clara Calvert, James Campbell, Oona M R Campbell, Andrea B Feigl, Wendy J Graham, Laurel Hatt, Steve Hodgins, Zoe Matthews, Lori McDougall, Allisyn C Moran, Allyala K Nandakumar, Ana Langer
2307

Lancet Global Health
Nov 2016 Volume 4 Number 11 e761-e871
http://www.thelancet.com/journals/langlo/issue/current
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Articles
Feasibility of achieving the 2025 WHO global tuberculosis targets in South Africa, China, and India: a combined analysis of 11 mathematical models
Rein M G J Houben, Nicolas A Menzies, Tom Sumner, Grace H Huynh, Nimalan Arinaminpathy, Jeremy D Goldhaber-Fiebert, Hsien-Ho Lin, Chieh-Yin Wu, Sandip Mandal, Surabhi Pandey, Sze-chuan Suen, Eran Bendavid, Andrew S Azman, David W Dowdy, Nicolas Bacaër, Allison S Rhines, Marcus W Feldman, Andreas Handel, Christopher C Whalen, Stewart T Chang, Bradley G Wagner, Philip A Eckhoff, James M Trauer, Justin T Denholm, Emma S McBryde, Ted Cohen, Joshua A Salomon, Carel Pretorius, Marek Lalli, Jeffrey W Eaton, Delia Boccia, Mehran Hosseini, Gabriela B Gomez, Suvanand Sahu, Colleen Daniels, Lucica Ditiu, Daniel P Chin, Lixia Wang, Vineet K Chadha, Kiran Rade, Puneet Dewan, Piotr Hippner, Salome Charalambous, Alison D Grant, Gavin Churchyard, Yogan Pillay, L David Mametja, Michael E Kimerling, Anna Vassall, Richard G White

Cost-effectiveness and resource implications of aggressive action on tuberculosis in China, India, and South Africa: a combined analysis of nine models
Nicolas A Menzies, Gabriela B Gomez, Fiammetta Bozzani, Susmita Chatterjee, Nicola Foster, Ines Garcia Baena, Yoko V Laurence, Sun Qiang, Andrew Siroka, Sedona Sweeney, Stéphane Verguet, Nimalan Arinaminpathy, Andrew S Azman, Eran Bendavid, Stewart T Chang, Ted Cohen, Justin T Denholm, David W Dowdy, Philip A Eckhoff, Jeremy D Goldhaber-Fiebert, Andreas Handel, Grace H Huynh, Marek Lalli, Hsien-Ho Lin, Sandip Mandal, Emma S McBryde, Surabhi Pandey, Joshua A Salomon, Sze-chuan Suen, Tom Sumner, James M Trauer, Bradley G Wagner, Christopher C Whalen, Chieh-Yin Wu, Delia Boccia, Vineet K Chadha, Salome Charalambous, Daniel P Chin, Gavin Churchyard, Colleen Daniels, Puneet Dewan, Lucica Ditiu, Jeffrey W Eaton, Alison D Grant, Piotr Hippner, Mehran Hosseini, David Mametja, Carel Pretorius, Yogan Pillay, Kiran Rade, Suvanand Sahu, Lixia Wang, Rein M G J Houben, Michael E Kimerling, Richard G White, Anna Vassall

Quality of basic maternal care functions in health facilities of five African countries: an analysis of national health system surveys
Margaret E Kruk, Hannah H Leslie, Stéphane Verguet, Godfrey M Mbaruku, Richard M K Adanu, Ana Langer

ancet Global Health
Nov 2016 Volume 4 Number 11 e761-e871
http://www.thelancet.com/journals/langlo/issue/current
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Effectiveness of one dose of oral cholera vaccine in response to an outbreak: a case-cohort study
Andrew S Azman, Lucy A Parker, John Rumunu, Fisseha Tadesse, Francesco Grandesso, Lul L Deng, Richard Laku Lino, Bior K Bior, Michael Lasuba, Anne-Laure Page, Lameck Ontweka, Augusto E Llosa, Sandra Cohuet, Lorenzo Pezzoli, Dossou Vincent Sodjinou, Abdinasir Abubakar, Amanda K Debes, Allan M Mpairwe, Joseph F Wamala, Christine Jamet, Justin Lessler, David A Sack, Marie-Laure Quilici, Iza Ciglenecki, Francisco J Luquero
e856
Summary
Background
Oral cholera vaccines represent a new effective tool to fight cholera and are licensed as two-dose regimens with 2–4 weeks between doses. Evidence from previous studies suggests that a single dose of oral cholera vaccine might provide substantial direct protection against cholera. During a cholera outbreak in May, 2015, in Juba, South Sudan, the Ministry of Health, Médecins Sans Frontières, and partners engaged in the first field deployment of a single dose of oral cholera vaccine to enhance the outbreak response. We did a vaccine effectiveness study in conjunction with this large public health intervention.
Methods
We did a case-cohort study, combining information on the vaccination status and disease outcomes from a random cohort recruited from throughout the city of Juba with that from all the cases detected. Eligible cases were those aged 1 year or older on the first day of the vaccination campaign who sought care for diarrhoea at all three cholera treatment centres and seven rehydration posts throughout Juba. Confirmed cases were suspected cases who tested positive to PCR for Vibrio cholerae O1. We estimated the short-term protection (direct and indirect) conferred by one dose of cholera vaccine (Shanchol, Shantha Biotechnics, Hyderabad, India).
Findings
Between Aug 9, 2015, and Sept 29, 2015, we enrolled 87 individuals with suspected cholera, and an 898-person cohort from throughout Juba. Of the 87 individuals with suspected cholera, 34 were classified as cholera positive, 52 as cholera negative, and one had indeterminate results. Of the 858 cohort members who completed a follow-up visit, none developed clinical cholera during follow-up. The unadjusted single-dose vaccine effectiveness was 80·2% (95% CI 61·5–100·0) and after adjusting for potential confounders was 87·3% (70·2–100·0).
Interpretation
One dose of Shanchol was effective in preventing medically attended cholera in this study. These results support the use of a single-dose strategy in outbreaks in similar epidemiological settings.
Funding
Médecins Sans Frontières.

Lancet Global Health
Nov 2016 Volume 4 Number 11 e761-e871
http://www.thelancet.com/journals/langlo/issue/current
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Comment
2016: the beginning of the end of rabies?
Bernadette Abela-Ridder, Lea Knopf, Stephen Martin, Louise Taylor, Gregorio Torres, Katinka De BaloghPublished: 27 September 2016
Open Access
DOI: http://dx.doi.org/10.1016/S2214-109X(16)30245-5
Sept 28 is the tenth annual World Rabies Day. It is a date that commemorates the anniversary of the 1895 death of Louis Pasteur, who developed the first human rabies vaccine. Modern effective vaccines, combined with other interventions, the necessary political will, and community awareness make the disease 100% preventable. Yet, an estimated 59 000 people still die from the disease every year.1 World Rabies Day is thus an uncomfortable reminder for the global health community of the ongoing neglect of this disease. The theme for 2016 is “Educate. Vaccinate. Eliminate”, a slogan that emphasises the pillars of rabies prevention and the vision to end human rabies deaths.

Rabies has no cure, and by the time of clinical onset it is invariably fatal. More than 95% of deaths occur in Africa and Asia, 80% of which are in people living in rural, underserved populations, most of whom are children.2 Community awareness about the power of preventing dog bites and of life-saving human post-exposure prophylaxis is key. 95–99% of human rabies cases are from dog bites, meaning that canine vaccination programmes are crucial if the transmission cycle is to be broken.3 Cross-sectoral solutions from stakeholders in both human and animal health systems are essential for the greatest benefits to be realised.

In December, 2015, WHO, the World Organisation for Animal Health (OIE), the Food and Agriculture Organization (FAO), and the Global Alliance for Rabies Control (GARC) endorsed a global framework to eliminate human deaths from dog-mediated disease by 2030.4 The decision was reinforced by the OIE in May this year.5 A business plan by the key organisations to quantify the costs of reaching zero rabies deaths across the world is under development.
Under our One Health Initiative, WHO, OIE, FAO, and GARC are working on concurrent campaigns to eliminate canine rabies through the vaccination of dogs, the treatment of all potential human rabies exposures with wound washing and post-exposure prophylaxis, and the improvement of education about rabies prevention where it is needed most. By prioritising rabies, our partnership also intends to leverage the global political will needed to eliminate the disease. Reaching zero rabies deaths would contribute towards fulfilling the Sustainable Development Goals, particularly goal 3·3, which targets an end to epidemics of neglected tropical diseases. The goal is ambitious but possible, as evidenced by the progress made in rabies campaigns around the world.4, 6 Such examples of successful multisectoral approaches serve as both a reference and motivation for future campaigns.

Countries will need improved access to high quality and optimally priced dog and human vaccines, as well as to rabies immunoglobulins. Insufficient national forecasting at present means that vaccine requests from countries to manufacturers can be left unfulfilled because of long lead times in production. In such instances, countries are forced to turn to suppliers without quality-assured vaccine. Improvements in supply will help to overcome these difficulties. To match the OIE-led dog rabies vaccine bank,7 WHO is therefore creating a human rabies vaccine stockpile, planned to be operation by the end of next year.

The opportunity of a potential GAVI investment into human rabies vaccine in 2018 has rallied partners and countries to build the evidence base to help inform the investment decision process. Investment from GAVI would be a game changer and substantially increase awareness about this disease and stimulate the necessary political will. With dog vaccination campaigns increasing in reach, the possibility of interrupting rabies transmission will become more tangible. This goal is helped by the availability of online resources such as the Blueprint for Rabies Prevention and Control,8 which offers practical information, expert advice, and case studies to support countries that want to eliminate rabies. FAO and GARC are assisting countries with practical tools for developing their rabies control strategies.9

World Rabies Day increases the awareness about this neglected and horrific disease. It will also make people aware of the realistic ambition of interrupting transmission in dogs and, in turn, the reality of one day eliminating dog-mediated rabies in people. We have all the tools to end this neglected zoonotic disease—what is required is a coordinated effort from all stakeholders at local, national, regional, and global levels to realise the vision of zero human deaths from dog-mediated rabies by 2030.
We declare no competing interests.

Lancet Global Health
Nov 2016 Volume 4 Number 11 e761-e871
http://www.thelancet.com/journals/langlo/issue/current
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Comment
New strategies for cholera control
Louise C Ivers
Open Access
DOI: http://dx.doi.org/10.1016/S2214-109X(16)30257-1
Cholera remains a serious global public health problem, disproportionately affecting poor individuals, causing illness and death for thousands of people each year. Cholera cases are on the rise, with 47% more cases reported to WHO in 2014 than in 2013.1 Innovative approaches to control the disease are urgently needed, and the study by Andrew Azman and colleagues in The Lancet Global Health2 contributes to growing evidence of the important part that oral cholera vaccine strategies have to play in this regard.

Cholera can have devastating consequences, especially in epidemic settings. Azman and colleagues’ study assesses the effectiveness of a single dose of bivalent whole-cell oral cholera vaccine on epidemic cholera in Juba, South Sudan. Typically, this oral cholera vaccine is given in two doses 14 days apart, and studies have shown its efficacy and effectiveness with this dosing schedule.3, 4, 5 However, the use of one dose of vaccine for an outbreak response would reduce costs and double the number of people that could be served, which is especially important considering the global shortage of vaccine that is expected to last for the next few years. Faced with an emerging epidemic of cholera in South Sudan, limited vaccine supply, and some evidence that a single dose of vaccine might give sufficient protection to thwart an epidemic, local public health officials and the non-governmental organisation Médecins Sans Frontières decided to proceed with a single-dose public health oral cholera vaccine campaign in Juba. Public health activities and a research study took place hand in hand.

The study found that the adjusted single-dose vaccine effectiveness was 87·3% (70·2–100·0) for reducing medically attended cholera for up to 2 months. This adds to existing evidence including a randomised study of a single-dose regimen from Bangladesh that found 40% direct effectiveness for reducing all cholera, and 63% direct effectiveness for reducing severely dehydrating cholera at 6 months.6 By contrast, Azman and colleagues used a case-cohort study design in an effort to measure both the direct and indirect protection offered by the vaccine (ie, herd protection), and measured effectiveness in a shorter period. This design makes the study particularly interesting and pertinent to dilemmas in the approach to cholera outbreak control. Debate continues between water, sanitation, and hygiene (WASH) purists, who believe that investments in cholera vaccination campaigns are a distraction from the goal of universal access to water and sanitation, and a more progressive public health community that advocates for a combined approach to cholera control including vaccination and evidence-based WASH interventions. In this context, a study that helps us to measure the herd protection of an oral cholera vaccine strategy is key to understanding the population-level effect and therefore the public health usefulness of oral cholera vaccine (beyond individual protection).

This study is also an excellent example of research in action. Resolving, as the researchers did, to be scientific in the context of rapid decision making and the often chaotic environment of an epidemic response is not straightforward. The context of the study means that the results are particularly useful for understanding the intervention as it might happen in the real world, outside of a formal research setting. More studies like this are needed for us to understand the right approaches for use of cholera vaccine.

Armed with the results of this study, public health officials and implementing organisations in areas where cholera occurs with some frequency should consider the option of using a single-dose vaccination campaign as part of an emergency outbreak response. This should be coupled with good monitoring and evaluation activities to continue to add to our knowledge on the issue.

Importantly, the usefulness of single-dose oral cholera vaccine in cholera-naive populations cannot be presumed on the basis of this study, and the authors acknowledge this fact. The impetus now exists, though, to study the approach in cholera-naive populations. Further questions also emerge that remain to be answered. How long does the protective effect of a single dose of this oral cholera vaccine last in cholera-experienced populations such as Juba? Does a single-dose pre-emptive campaign prevent epidemic outbreaks in susceptible groups such as displaced people? How well protected are subgroups such as young children? What complementary emergency WASH activities at household or community level should be combined with the single-dose approach to ensure durable control of cholera? Would a booster dose sometime after the initial outbreak response contribute to longer-term cholera control? To answer these pragmatic questions, we require continued investment in the global stockpile of cholera vaccine, forward-thinking health officials, and continued assessment of the vaccine’s use.

When the right to universal access to safe water and sanitation is realised, the world will be a better, healthier place—this is not doubted. However, if Haiti is any example, the struggle to execute on water and sanitation ideals is real. Those challenges are related both to the availability of funding, and the ability to deliver WASH interventions in sufficient quantity and quality to interrupt transmission of cholera as a matter of urgency. While the 2016 rainy season brings a surge in cholera cases in Haiti, this study offers one potential vaccination strategy to consider in outbreak responses going forward. We can only wonder what might have happened in Haiti if Azman and colleagues’ research had pre-dated the Haitian cholera outbreak—the largest ongoing cholera outbreak in the world, with more than 10 000 deaths so far.7, 8 Perhaps officials, public health experts, and vaccine manufacturers would have done innovative work together in the early days, and helped to avert a disaster.
I declare no competing interests.

Lancet Global Health
Nov 2016 Volume 4 Number 11 e761-e871
http://www.thelancet.com/journals/langlo/issue/current
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Comment
Putting numbers on the End TB Strategy—an impossible dream?
Olivia Oxlade, Dick Menzies
In 2015, WHO announced a plan to end tuberculosis by 2035 (their End TB Strategy) and set ambitious intermediate targets to reduce tuberculosis incidence by 50% and mortality by 75% by 2025.1 In The Lancet Global Health, two related papers by Rein Houben2 and Nicolas Menzies3 and their colleagues describe the results of a unique international collaboration between 11 different tuberculosis modelling groups, and public health officials from national tuberculosis programmes. They assessed the feasibility, costs, and epidemiological outcomes of country-specific interventions in India, China, and South Africa, and determined that these 10-year targets could be achievable only in South Africa with a combination of continuous isoniazid preventive therapy for individuals on antiretroviral therapy, expanded facility-based screening for symptoms of tuberculosis at health centres, and improved tuberculosis care. In China and India, important reductions could be achieved, but they fell short of the WHO targets.2 All models that considered costs projected the need for massive and sustained increases in government health spending, to more than three times current levels, although most judged that these interventions could be considered cost-effective. Interestingly, all predicted that patients’ costs would be substantially reduced with most interventions.

This project showed the potential value of two innovative collaborations toward achieving global tuberculosis control. First, this investigation was accomplished simultaneously by several different modelling groups and investigators from a total of ten different countries—in itself a major achievement! The modelling groups worked independently, using their preferred modelling approaches, but with similar parameters and assumptions. Readers will usually want to know if the findings are unchanged when key assumptions are varied in sensitivity analyses, and if results are similar in studies published separately by different groups. We think readers should be sceptical, given the grand scale of assumptions made by the investigators of these two studies. In these Articles,2, 3 results from 11 models are presented together—a sort of uber-sensitivity analysis. The results are quite consistent and provide a coherent message, which we find reassuring. The second innovation was the partnership of these modelling teams with personnel from national tuberculosis programmes, who were responsible for the selection of interventions and helping to estimate their expected effects. This should make the results more applicable and realistic for the countries selected, while also enhancing knowledge translation.

For most health-care professionals, infectious-disease modelling is something of a black box. One can see the input assumptions (ie, what goes in) and the outputs (ie, what comes out), but what happens in between seems close to magic. Given their complexity, to understand any one of the models used in these studies is difficult; to understand the strengths and limitations of all 11 models might be beyond the capacity of most (if not all) readers. So, we must therefore accept a little magic, and rely on a careful review of what goes in, to decide if what comes out is credible. And the assumed inputs are a major limitation of these studies, for although the involvement of national tuberculosis programme officials in selecting interventions and targets was a strength, the actual population-level effect, and costs, of the interventions are unknown.
For example, active case finding through chest radiography was the cornerstone of tuberculosis control for decades in high-income countries,4 and interest in active case finding has been revived recently.5 However, scant published evidence of its effect on outcomes, transmission, or its cost-effectiveness is available,6 and therefore mass screening is not recommended by WHO.6 The true costs of these interventions, when applied at national scale, are also unknown.
Estimations of costs extrapolated from small projects might not be accurate for national-level interventions. For example, the finding that scaling up use of the Xpert RIF/MTB assay might simply reflect better information, since the actual costs for national expansion in South Africa have been carefully measured,7 by contrast with the estimated costs for the other interventions. Even feasibility is uncertain, particularly for population-level interventions such as mass chest radiography and isoniazid preventive therapy in South Africa, or partnerships with the rapidly evolving private sector in India.

Overall, however, we feel the investigators used all currently available information, and did a careful and thorough analysis of innovative approaches for global tuberculosis control. Although further research is required to better understand the epidemiological effects and the enormous health-system expenditures that will be needed to implement these interventions on a large scale, this requirement should not obscure two important messages from these studies. First, the consistent finding of substantial savings for patients is a reminder that reducing the tuberculosis burden is all about reducing the burden on patients. And second, that perhaps the goal of ending tuberculosis is not such an impossible dream.

We declare no competing interests.

Lancet Global Health
Nov 2016 Volume 4 Number 11 e761-e871
http://www.thelancet.com/journals/langlo/issue/current

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Editorial
Disease, conflict, and the challenge of elimination in the Americas
The Lancet Global Health
Good news from the Americas illuminated the global health scene in September. As the Ministers of Health from the western hemisphere gathered in Washington, DC, USA, for PAHO’s 55th Directing Council, a series of announcements confirmed the New World’s role as a pioneer of sorts in disease prevention and control. Repeating the pattern that began with smallpox in 1971, polio in 1994, and rubella in 2015, the region of the Americas was declared the first in the world to be free of endemic measles on Sept 27. This feat was achieved through 14 years of unrelenting efforts to reach the farthest pockets of unvaccinated populations and document the end of transmission of a virus that still caused over 110 000 deaths worldwide in 2014, mostly in children under 5 years of age. It is a laudable achievement and a testament to the success of yearly national immunisation campaigns and efforts to educate the populations of the region on the innocuity and efficacy of vaccines. The confidence in this essential global health tool in the countries of the Americas is highlighted in a recent article published in EBioMedicine, which shows that countries of the region reported low levels of scepticism on the dimensions surveyed, including the importance of vaccination and the safety and effectiveness of vaccines. The fact that other countries or regions do not show the same confidence, and the related impact on vaccination coverage, underscore the fragility of the elimination status and the importance of persistently promoting the value of vaccines at the global level.

Achievements such as these educate us on the feasibility of reaching elimination goals. They perhaps also provide additional thrust for efforts towards harder to reach, more uncertain milestones. The Ministers of Health concluded their gathering at PAHO with a set of agreements on the prevention, control, and elimination of diseases in the Americas, including a plan of action for malaria elimination with ambitious goals for the next 4 years. Elimination, if reached, would be a first step in a major global health quest: the eradication of malaria, a disease that currently threatens half of the world’s population, and in 2015 killed almost 500 000 people worldwide. Perhaps the Americas can show us once again how it is done.

While the region celebrated the elimination of one scourge, another—namely the devastating 52-year civil war in Colombia—was also on the brink of history. Over the years, and within the confines of Colombia’s borders, the conflict has touched on many issues that are now at the forefront of global health and development. Rapid urbanisation, fuelled in large part by the displacement of millions fleeing violence, led to the creation of slums and all their related health issues. Those who stayed in conflict zones, many of them of indigenous and African descent, were left in a health services vacuum and now suffer the consequences, on maternal and child health in particular, and in terms of inequalities. A historic peace agreement between the Colombian Government and the Revolutionary Armed Forces of Colombia (FARC) was signed in Cartagena on Sept 26. Yet on Oct 2, the Colombian people narrowly rejected this agreement in a national referendum, sending back to the negotiation table a document considered by some as too lenient towards the FARC.

So the promise of stronger social cohesion and human rights is not to be delivered just yet in Colombia, but the implications of the peace process and their potential impact on health must not be overlooked. Nobody denies the radical impact peace could have on these populations, and the now defunct agreement, negotiated with the active participation of women’s and minority groups in a process deemed by some as a model, had the consideration of health and inequalities threaded throughout its terms. So wherever the process goes in Colombia from this point forward, that experience and the point reached on the way to peace remain a much needed sign of hope in a world where violence is on the rise. War and violence, or the absence thereof, are now integral building blocks of the development agenda since their inclusion in SDG16. In Colombia and elsewhere, peace—just like health—is a delicate balancing act that requires constant work, but we must remain convinced that it is attainable.

The Lancet Infectious Diseases
Nov 2016 Volume 16 Number 11 p1203-1304 e241-e275
http://www.thelancet.com/journals/laninf/issue/current

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Articles
Potential for Zika virus introduction and transmission in resource-limited countries in Africa and the Asia-Pacific region: a modelling study
Isaac I Bogoch, Oliver J Brady, Moritz U G Kraemer, Matthew German, Maria I Creatore, Shannon Brent, Alexander G Watts, Simon I Hay, Manisha A Kulkarni, John S Brownstein, Kamran Khan

The number of privately treated tuberculosis cases in India: an estimation from drug sales data
Nimalan Arinaminpathy, Deepak Batra, Sunil Khaparde, Thongsuanmung Vualnam, Nilesh Maheshwari, Lokesh Sharma, Sreenivas A Nair, Puneet Dewan

Use of standardised patients to assess antibiotic dispensing for tuberculosis by pharmacies in urban India: a cross-sectional study
Srinath Satyanarayana, Ada Kwan, Benjamin Daniels, Ramnath Subbaraman, Andrew McDowell, Sofi Bergkvist, Ranendra K Das, Veena Das, Jishnu Das, Madhukar Pai
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The cascade of care in diagnosis and treatment of latent tuberculosis infection: a systematic review and meta-analysis
Hannah Alsdurf, Philip C Hill, Alberto Matteelli, Haileyesus Getahun, Dick Menzies

Personal View
Affordable HIV drug-resistance testing for monitoring of antiretroviral therapy in sub-Saharan Africa
Seth C Inzaule, Pascale Ondoa, Trevor Peter, Peter N Mugyenyi, Wendy S Stevens, Tobias F Rinke de Wit, Raph L Hamers

Medical Decision Making (MDM)
November 2016; 36 (8)
http://mdm.sagepub.com/content/current

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Original Articles
Quantitative Framework for Retrospective Assessment of Interim Decisions in Clinical Trials
Roger Stanev
Med Decis Making November 2016 36: 999-1010, first published on June 27, 2016 doi:10.1177/0272989X16655346
Abstract
This article presents a quantitative way of modeling the interim decisions of clinical trials. While statistical approaches tend to focus on the epistemic aspects of statistical monitoring rules, often overlooking ethical considerations, ethical approaches tend to neglect the key epistemic dimension. The proposal is a second-order decision-analytic framework. The framework provides means for retrospective assessment of interim decisions based on a clear and consistent set of criteria that combines both ethical and epistemic considerations. The framework is broadly Bayesian and addresses a fundamental question behind many concerns about clinical trials: What does it take for an interim decision (e.g., whether to stop the trial or continue) to be a good decision? Simulations illustrating the modeling of interim decisions counterfactually are provided.