Epidemics
Volume 16, In Progress (September 2016)
http://www.sciencedirect.com/science/journal/17554365

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Regular Articles
Using age-stratified incidence data to examine the transmission consequences of pertussis vaccination
Original Research Article
Pages 1-7
J.C. Blackwood, D.A.T. Cummings, S. Iamsirithaworn, P. Rohani
Abstract
Pertussis is a highly infectious respiratory disease that has been on the rise in many countries worldwide over the past several years. The drivers of this increase in pertussis incidence remain hotly debated, with a central and long-standing hypothesis that questions the ability of vaccines to eliminate pertussis transmission rather than simply modulate the severity of disease. In this paper, we present age-structured case notification data from all provinces of Thailand between 1981 and 2014, a period during which vaccine uptake rose substantially, permitting an evaluation of the transmission impacts of vaccination. Our analyses demonstrate decreases in incidence across all ages with increased vaccine uptake – an observation that is at odds with pertussis case notification data in a number of other countries. To explore whether these observations are consistent with a rise in herd immunity and a reduction in bacterial transmission, we analyze an age-structured model that incorporates contrasting hypotheses concerning the immunological and transmission consequences of vaccines. Our results lead us to conclude that the most parsimonious explanation for the combined reduction in incidence and the shift to older age groups in the Thailand data is vaccine-induced herd immunity.

Global Public Health
Volume 11, Issue 7-8, 2016
http://www.tandfonline.com/toc/rgph20/current
Special Issue: The trouble with ‘Categories’: Rethinking men who have sex with men, transgender and their equivalents in HIV prevention and health promotion

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Introduction
The trouble with ‘Categories’: Rethinking men who have sex with men, transgender and their equivalents in HIV prevention and health promotion
pages 819-823
Richard Parker, Peter Aggleton & Amaya G. Perez-Brumer
ABSTRACT
This double Special Issue of Global Public Health presents a collection of articles that seek more adequately to represent sexual and gender diversities and to begin to rethink the relationship to HIV prevention and health promotion – in both the resource rich nations of the global North, as well as in the more resource constrained nations of the global South. Reckoning with the reality that today the global response to HIV has failed to respond to the needs of gay, bisexual and other men who have sex with men, and transgender persons, we turn our attention to processes and practices of categorisation and classification, and the entanglement of the multiple social worlds that constitute our understanding of each of these categories and people within the categories. Jointly, these articles provide critical perspectives on how defining and redefining categories may impact the conceptual frameworks and empirical evidence that inform global understandings of HIV infection, those communities most vulnerable, and our collective response to the evolving HIV epidemic.

Globalization and Health
http://www.globalizationandhealth.com/
[Accessed 9 July 2016]

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Review
Why might regional vaccinology networks fail? The case of the Dutch-Nordic Consortium
Jan Hendriks and Stuart Blume
Globalization and Health 2016 12:38
Published on: 7 July 2016
Abstract
We analyzed an attempt to develop and clinically test a pneumococcal conjugate vaccine for the developing world, undertaken by public health institutions from the Netherlands, Sweden, Denmark, Norway and Finland: the Dutch Nordic Consortium (DNC), between 1990 and 2000. Our review shows that the premature termination of the project was due less to technological and scientific challenges and more to managerial challenges and institutional policies. Various impeding events, financial and managerial challenges gradually soured the initially enthusiastic collaborative spirit until near the end the consortium struggled to complete the minimum objectives of the project. By the end of 1998, a tetravalent prototype vaccine had been made that proved safe and immunogenic in Phase 1 trials in adults and toddlers in Finland. The planned next step, to test the vaccine in Asia in infants, did not meet approval by the local authorities in Vietnam nor later in the Philippines and the project eventually stopped.
The Dutch DNC member, the National Institute of Public Health and the Environment (RIVM) learned important lessons, which subsequently were applied in a following vaccine technology transfer project, resulting in the availability at affordable prices for the developing world of a conjugate vaccine against Haemophilus influenzae type b. We conclude that vaccine development in the public domain with technology transfer as its ultimate aim requires major front-end funding, committed leadership at the highest institutional level sustained for many years and a competent recipient-manufacturer, which needs to be involved at a very early stage of the development.
At the national level, RIVM’s policy to consolidate its national manufacturing task through securing a key global health position in support of a network of public vaccine manufacturers proved insufficiently supported by the relevant ministries of the Dutch government. Difficulties to keep up with high costs, high-risk innovative vaccine development and production in a public sector setting led to the gradual loss of production tasks and to the 2009 Government decision to privatize the vaccine production tasks of the Institute.

Intervention – Journal of Mental Health and Psychological Support in Conflict Affected Areas
July 2016 – Volume 14 – Issue 2 pp: 96-186
http://journals.lww.com/interventionjnl/pages/currenttoc.aspx

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Current affairs
Syria: the challenges of parenting in refugee situations of immediate displacement
El-Khani, Aala; Ulph, Fiona; Peters, Sarah;
Abstract
The way parents care for their children during displacement plays a key role in children’s emotional and behavioural outcomes. Yet, sparse literature exists regarding the parenting challenges faced by families fleeing conflict in transitional, pre-resettlement stages. This study, therefore, aimed to identify the parenting experiences of Syrian families living in refugee camps, focusing on understanding how their parenting had changed and the impact displacement had had on their parenting. Methods used included: interviews and focus groups discussions with 27 mothers living in refugee contexts, two interviews with professional aid workers, with the data analysed using thematic analysis. Data were structured in three themes; 1) environmental challenges; 2) child specific challenges; and 3) parent specific challenges. Results clearly showed that parents struggled physically and emotionally to support their children. Such challenges could be addressed by parenting interventions to reduce the trauma impact experienced by children.

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Being a refugee in Turkey and western Europe: how it affects mental health and psychosocial wellbeing
Anonymous
Abstract
In this personal reflection, the author is a Syrian refugee who describes his experiences as a psychosocial worker in Syria and with refugees in Turkey and Greece. He highlights how women and children lack safety in the camps. The second section discusses how he became a refugee himself. Due to his experiences in Syria, he now finds himself in a difficult situation in the Netherlands, the county where he applied for asylum and has received a permit, but his ‘cry for help’ remains unheard and unrecognised by the (health) workers in the asylum centre.

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Articles
Psychosocial support among refugees of conflict in developing countries: a critical literature review
Alfadhli, Khalifah; Drury, John
Abstract
The aim of this paper is to examine the psychosocial needs and stressors among refugees of conflicts within developing countries, and their group based, social support mechanisms. Systematic literature searches of peer reviewed journal articles (n = 60 articles) were carried out using the following factors: type (refugee); cause (conflicts); location (developing countries). As refugees move towards a prolonged urban displacement phase, needs and stressors became different than those of the acute phase. While daily stressors affect far more people than posttraumatic stress disorder, many psychosocial support interventions focus only on the latter. Positive effects of social support on the mental health of displaced people have been established, while the process is not yet clear, group processes and identities appear to be important. The authors suggest, therefore, that a social identity approach can be applied to understand the emergence of a common refugee identity, and its role in empowerment through activating social support networks.

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Psychological interventions for children and young people affected by armed conflict or political violence: a systematic literature review
O’Sullivan, Clodagh; Bosqui, Tania; Shannon, Ciaran
Abstract
Youths exposed to armed conflict have a higher prevalence of mental health and psychosocial difficulties. Diverse interventions exist that aim to ameliorate the effect of armed conflict on the psychological and psychosocial wellbeing of conflict affected youths. However, the evidence base for the effectiveness of these interventions is limited. Using standard review methodology, this review aims to address the effectiveness of psychological interventions employed among this population. The search was performed across four databases and grey literature. Article quality was assessed using the Downs and Black Quality Checklist (1998). Where possible, studies were subjected to meta-analyses. The remaining studies were included in a narrative synthesis. Eight studies concerned non clinical populations, while nine concerned clinical populations. Review findings conclude that Group Trauma Focused–Cognitive Behavioural Therapy is effective for reducing symptoms of posttraumatic stress disorder, anxiety, depression and improving prosocial behaviour among clinical cohorts. The evidence does not suggest that interventions aimed at non clinical groups within this population are effective. Despite high quality studies, further robust trials are required to strengthen the evidence base, as a lack of replication has resulted in a limited evidence base to inform practice.

JAMA Pediatrics
July 2016, Vol 170, No. 7
http://archpedi.jamanetwork.com/issue.aspx

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Viewpoint
Real-Time Sharing of Zika Virus Data in an Interconnected World FREE
Esper G. Kallas, MD, PhD; David H. O’Connor, PhD

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Viewpoint
Leveraging Behavioral Insights to Promote Vaccine Acceptance: One Year After Disneyland
Alison M. Buttenheim, PhD, MBA; David A. Asch, MD, MBA
Extract
This Viewpoint discusses several approaches to increase vaccination acceptance in the United States 1 year after the measles outbreak that originated in Disneyland and has been attributed to parents who chose not to vaccinate their children.

An outbreak of measles originating in Disneyland in December 2014 that ultimately led to more than 100 cases has been attributed to parents who chose not to vaccinate their children. One year later, the United States remains vulnerable to outbreaks of vaccine-preventable diseases because parents continue to bypass the recommended childhood immunization schedule through exemptions from state-mandated immunizations at school entry. These personal choices affect everyone by weakening the herd immunity conferred by widespread vaccination…

Journal of Epidemiology & Community Health
July 2016, Volume 70, Issue 7
http://jech.bmj.com/content/current
Health inequalities
Trends in socioeconomic inequalities in self-assessed health in 17 European countries between 1990 and 2010
Yannan Hu, Frank J van Lenthe, Gerard J Borsboom, Caspar W N Looman, Matthias Bopp, Bo Burström, Dagmar Dzúrová, Ola Ekholm, Jurate Klumbiene, Eero Lahelma, Mall Leinsalu, Enrique Regidor, Paula Santana, Rianne de Gelder, Johan P Mackenbach
J Epidemiol Community Health 2016;70:644-652 Published Online First: 19 January 2016 doi:10.1136/jech-2015-206780
Abstract
Background Between the 1990s and 2000s, relative inequalities in all-cause mortality increased, whereas absolute inequalities decreased in many European countries. Whether similar trends can be observed for inequalities in other health outcomes is unknown. This paper aims to provide a comprehensive overview of trends in socioeconomic inequalities in self-assessed health (SAH) in Europe between 1990 and 2010.
Methods Data were obtained from nationally representative surveys from 17 European countries for the various years between 1990 and 2010. The age-standardised prevalence of less-than-good SAH was analysed by education and occupation among men and women aged 30–79 years. Socioeconomic inequalities were measured by means of absolute rate differences and relative rate ratios. Meta-analysis with random-effects models was used to examine the trends of inequalities.
Results We observed declining trends in the prevalence of less-than-good SAH in many countries, particularly in Southern and Eastern Europe and the Baltic states. In all countries, less-than-good SAH was more prevalent in lower educational and manual groups. For all countries together, absolute inequalities in SAH were mostly constant, whereas relative inequalities increased. Almost no country consistently experienced a significant decline in either absolute or relative inequalities.
Conclusions Trends in inequalities in SAH in Europe were generally less favourable than those found for inequalities in mortality, and there was generally no correspondence between the two when we compared the trends within countries. In order to develop policies or interventions that effectively reduce inequalities in SAH, a better understanding of the causes of these inequalities is needed.

Journal of Medical Ethics
July 2016, Volume 42, Issue 7
http://jme.bmj.com/content/current

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The concise argument
Medical involvement in torture today?
Kenneth Boyd
J Med Ethics 2016;42:411-412 doi:10.1136/medethics-2016-103737
[Extract]
In the ethics classroom, medical involvement in torture is often discussed in terms of what happens or has happened elsewhere, in some imagined country far away, under a military dictatorship for example, or historically in Nazi Germany or Stalin’s Russia. In these contexts, at a distance in space or time, the healthcare professional’s moral dilemma can be clearly demonstrated. On the one hand, any involvement whatever in the practice of torture, countenancing or condoning as well as participating, is forbidden, formally by the World Medical Association 1957 Declaration of Tokyo, but more generally by the professional duty to do no harm. On the other hand, the professional duty of care, and more generally human decency and compassion, forbids standing idly by when no other professional with comparable skills is available to relieve the suffering of victims of torture. In such circumstances, the health professional’s impulse to exercise their duty of care, albeit thereby implicitly countenancing or condoning torture, may be strengthened by the knowledge that to refuse may put their own life or that of a member of their family in danger. But then again, they may also be all too aware that in exercising their duty of care they may simply be ‘patching up’ the victims in order for them to be tortured again.
Ethics classroom discussion of medical involvement in torture can be a productive way of exercising moral imagination in seeking possible ways of resolving or ameliorating apparently intractable moral dilemmas. In discussing such moral dilemmas, moral imagination can a.lso be exercised, and may be enlarged, by trying to understand these dilemmas from the poi

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Asylum
Are healthcare professionals working in Australia’s immigration detention centres condoning torture?
David Isaacs
J Med Ethics 2016;42:413-415 Published Online First: 23 December 2015 doi:10.1136/medethics-2015-103066
Abstract
Australian immigration detention centres are in secluded locations, some on offshore islands, and are subject to extreme secrecy, comparable with ‘black sites’ elsewhere. There are parallels between healthcare professionals working in immigration detention centres and healthcare professionals involved with or complicit in torture. In both cases, healthcare professionals are conflicted between a duty of care to improve the health of patients and the interests of the government. While this duality of interests has been recognised previously, the full implications for healthcare professionals working in immigration detention have not been addressed. The Australian Government maintains that immigration detention is needed for security checks, but the average duration of immigration detention has increased from 10 weeks to 14 months, and detainees are not informed of the progress of their application for refugee status. Long-term immigration detention causes major mental health problems, is illegal in international law and arguably fulfils the recognised definition of torture. It is generally accepted that healthcare professionals should not participate in or condone torture. Australian healthcare professionals thus face a major ethical dilemma: patients in immigration detention have pressing mental and physical health needs, but providing healthcare might support or represent complicity in a practice that is unethical. Individual healthcare professionals need to decide whether or not to work in immigration detention centres. If they do so, they need to decide for how long and to what extent restrictive contracts and gagging laws will constrain them from advocating for closing detention centres.

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Commentary: The clinician and detention
Howard Goldenberg
J Med Ethics 2016;42:416-417 Published Online First: 28 January 2016 doi:10.1136/medethics-2016-103371

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Commentary: Torture, healthcare and Australian immigration detention
Ryan Essex
J Med Ethics 2016;42:418-419 Published Online First: 22 February 2016 doi:10.1136/medethics-2016-103387

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Paper: Is Australia engaged in torturing asylum seekers? A cautionary tale for Europe
John-Paul Sanggaran,
Deborah Zion
J Med Ethics 2016;42:420-423 Published Online First: 22 June 2016 doi:10.1136/medethics-2015-103326
Abstract
Australian immigration detention has been identified as perpetuating ongoing human rights violations. Concern has been heightened by the assessment of clinicians involved and by the United Nations that this treatment may in fact constitute torture. We discuss the allegations of torture within immigration detention, and the reasons why healthcare providers have an ethical duty to report them. Finally, we will discuss the protective power of ratifying the Optional Protocol to the Convention against Torture and other Cruel, Inhuman or Degrading Treatment or Punishment as a means of providing transparency and ethical guidance.

The Lancet
Jul 09, 2016 Volume 388 Number 10040 p103-210 e1-e2
http://www.thelancet.com/journals/lancet/issue/current

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Editorial
Indigenous health: a worldwide focus
The Lancet
Summary
If you are a member of the Baka, an Indigenous tribe in Cameroon, you can expect to live until you are aged about 35 years, which is about 12 years less than for the non-Indigenous people there. In Greenland you would be better off, at 73 years, but nonetheless this figure is 9 years less than that for the Danish population. Such discrepancies are recognised, but now we have such data for all regions of the world.

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Comment
Addressing global health disparities among Indigenous peoples
Laurence J Kirmayer, Gregory Brass
Summary
In countries around the world, Indigenous peoples face great social disadvantages and poor health compared with the general population.1,2 In The Lancet, Ian Anderson and colleagues3 have documented significant disparities among 28 Indigenous populations from 23 countries compared with benchmark populations for several variables, including life expectancy at birth, maternal and infant mortality, and frequency of low birthweight and high birthweight infants. They also showed differences for Indigenous peoples in measures related to nutrition (eg, child malnutrition, childhood obesity, and adult obesity), and in key social indicators, including educational attainment and economic status.

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Polio vaccination: preparing for a change of routine
Edward P K Parker, Nicholas C Grassly
Summary
The Global Polio Eradication Initiative is on the brink of a major milestone. As of April, 2016, the serotype 2 component of oral poliovirus vaccine (OPV) will be removed from all immunisation activities worldwide. This transition, which is the first step in the synchronised withdrawal of all OPV serotypes, is essential to the polio endgame strategy. Although wild type 2 polioviruses have not caused a case of paralytic disease since 1999, vaccine viruses of this serotype have continued to cause rare cases of vaccine-associated paralytic poliomyelitis in OPV recipients or their close contacts,1 and sporadic emergences of circulating vaccine-derived polioviruses, wherein Sabin poliovirus strains mutate to regain neurovirulence.

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Articles
Indigenous and tribal peoples’ health (The Lancet–Lowitja Institute Global Collaboration): a population study
Ian Anderson, Bridget Robson, Michele Connolly, Fadwa Al-Yaman, Espen Bjertness, Alexandra King, Michael Tynan, Richard Madden, Abhay Bang, Carlos E A Coimbra Jr, Maria Amalia Pesantes, Hugo Amigo, Sergei Andronov, Blas Armien, Daniel Ayala Obando, Per Axelsson, Zaid Shakoor Bhatti, Zulfiqar Ahmed Bhutta, Peter Bjerregaard, Marius B Bjertness, Roberto Briceno-Leon, Ann Ragnhild Broderstad, Patricia Bustos, Virasakdi Chongsuvivatwong, Jiayou Chu, Deji, Jitendra Gouda, Rachakulla Harikumar, Thein Thein Htay, Aung Soe Htet, Chimaraoke Izugbara, Martina Kamaka, Malcolm King, Mallikharjuna Rao Kodavanti, Macarena Lara, Avula Laxmaiah, Claudia Lema, Ana María León Taborda, Tippawan Liabsuetrakul, Andrey Lobanov, Marita Melhus, Indrapal Meshram, J Jaime Miranda, Thet Thet Mu, Balkrishna Nagalla, Arlappa Nimmathota, Andrey Ivanovich Popov, Ana María Peñuela Poveda, Faujdar Ram, Hannah Reich, Ricardo V Santos, Aye Aye Sein, Chander Shekhar, Lhamo Y Sherpa, Peter Skold, Sofia Tano, Asahngwa Tanywe, Chidi Ugwu, Fabian Ugwu, Patama Vapattanawong, Xia Wan, James R Welch, Gonghuan Yang, Zhaoqing Yang, Leslie Yap
Summary
Background
International studies of the health of Indigenous and tribal peoples provide important public health insights. Reliable data are required for the development of policy and health services. Previous studies document poorer outcomes for Indigenous peoples compared with benchmark populations, but have been restricted in their coverage of countries or the range of health indicators. Our objective is to describe the health and social status of Indigenous and tribal peoples relative to benchmark populations from a sample of countries.
Methods
Collaborators with expertise in Indigenous health data systems were identified for each country. Data were obtained for population, life expectancy at birth, infant mortality, low and high birthweight, maternal mortality, nutritional status, educational attainment, and economic status. Data sources consisted of governmental data, data from non-governmental organisations such as UNICEF, and other research. Absolute and relative differences were calculated.
Findings
Our data (23 countries, 28 populations) provide evidence of poorer health and social outcomes for Indigenous peoples than for non-Indigenous populations. However, this is not uniformly the case, and the size of the rate difference varies. We document poorer outcomes for Indigenous populations for: life expectancy at birth for 16 of 18 populations with a difference greater than 1 year in 15 populations; infant mortality rate for 18 of 19 populations with a rate difference greater than one per 1000 livebirths in 16 populations; maternal mortality in ten populations; low birthweight with the rate difference greater than 2% in three populations; high birthweight with the rate difference greater than 2% in one population; child malnutrition for ten of 16 populations with a difference greater than 10% in five populations; child obesity for eight of 12 populations with a difference greater than 5% in four populations; adult obesity for seven of 13 populations with a difference greater than 10% in four populations; educational attainment for 26 of 27 populations with a difference greater than 1% in 24 populations; and economic status for 15 of 18 populations with a difference greater than 1% in 14 populations.
Interpretation
We systematically collated data across a broader sample of countries and indicators than done in previous studies. Taking into account the UN Sustainable Development Goals, we recommend that national governments develop targeted policy responses to Indigenous health, improving access to health services, and Indigenous data within national surveillance systems.
Funding
The Lowitja Institute.

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Humoral and intestinal immunity induced by new schedules of bivalent oral poliovirus vaccine and one or two doses of inactivated poliovirus vaccine in Latin American infants: an open-label randomised controlled trial
Edwin J Asturias, Ananda S Bandyopadhyay, Steve Self, Luis Rivera, Xavier Saez-Llorens, Eduardo Lopez, Mario Melgar, James T Gaensbauer, William C Weldon, M Steven Oberste, Bhavesh R Borate, Chris Gast, Ralf Clemens, Walter Orenstein, Miguel O’Ryan G, José Jimeno, Sue Ann Costa Clemens, Joel Ward, Ricardo Rüttimann, Latin American IPV001BMG Study Group
Summary
Background
Replacement of the trivalent oral poliovirus vaccine (tOPV) with bivalent types 1 and 3 oral poliovirus vaccine (bOPV) and global introduction of inactivated poliovirus vaccine (IPV) are major steps in the polio endgame strategy. In this study, we assessed humoral and intestinal immunity in Latin American infants after three doses of bOPV combined with zero, one, or two doses of IPV.
Methods
This open-label randomised controlled multicentre trial was part of a larger study. 6-week-old full-term infants due for their first polio vaccinations, who were healthy on physical examination, with no obvious medical conditions and no known chronic medical disorders, were enrolled from four investigational sites in Colombia, Dominican Republic, Guatemala, and Panama. The infants were randomly assigned by permuted block randomisation (through the use of a computer-generated list, block size 36) to nine groups, of which five will be discussed in this report. These five groups were randomly assigned 1:1:1:1 to four permutations of schedule: groups 1 and 2 (control groups) received bOPV at 6, 10, and 14 weeks; group 3 (also a control group, which did not count as a permutation) received tOPV at 6, 10, and 14 weeks; group 4 received bOPV plus one dose of IPV at 14 weeks; and group 5 received bOPV plus two doses of IPV at 14 and 36 weeks. Infants in all groups were challenged with monovalent type 2 vaccine (mOPV2) at 18 weeks (groups 1, 3, and 4) or 40 weeks (groups 2 and 5). The primary objective was to assess the superiority of bOPV–IPV schedules over bOPV alone, as assessed by the primary endpoints of humoral immunity (neutralising antibodies—ie, seroconversion) to all three serotypes and intestinal immunity (faecal viral shedding post-challenge) to serotype 2, analysed in the per-protocol population. Serious and medically important adverse events were monitored for up to 6 months after the study vaccination. This study is registered with ClinicalTrials.gov, number NCT01831050, and has been completed.
Findings
Between May 20, 2013, and Aug 15, 2013, 940 eligible infants were enrolled and randomly assigned to the five treatment groups (210 to group 1, 210 to group 2, 100 to group 3, 210 to group 4, and 210 to group 5). One infant in group 1 was not vaccinated because their parents withdrew consent after enrolment and randomisation, so 939 infants actually received the vaccinations. Three doses of bOPV or tOPV elicited type 1 and 3 seroconversion rates of at least 97·7%. Type 2 seroconversion occurred in 19 of 198 infants (9·6%, 95% CI 6·2–14·5) in the bOPV-only groups, 86 of 88 (97·7%, 92·1–99·4) in the tOPV-only group (p<0·0001 vs bOPV-only), and 156 of 194 (80·4%, 74·3–85·4) infants in the bOPV–one dose of IPV group (p<0·0001 vs bOPV-only). A further 20 of 193 (10%) infants in the latter group seroconverted 1 week after mOPV2 challenge, resulting in around 98% of infants being seropositive against type 2. After a bOPV–two IPV schedule, all 193 infants (100%, 98·0–100; p<0·0001 vs bOPV-only) seroconverted to type 2. IPV induced small but significant decreases in a composite serotype 2 viral shedding index after mOPV2 challenge. 21 serious adverse events were reported in 20 patients during the study, including two that were judged to be possibly related to the vaccines. Most of the serious adverse events (18 [86%] of 21) and 24 (80%) of the 30 important medical events reported were infections and infestations. No deaths occurred during the study.
Interpretation
bOPV provided humoral protection similar to tOPV against polio serotypes 1 and 3. After one or two IPV doses in addition to bOPV, 80% and 100% of infants seroconverted, respectively, and the vaccination induced a degree of intestinal immunity against type 2 poliovirus.
Funding
Bill & Melinda Gates Foundation.

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Review
The global response to HIV in men who have sex with men
Chris Beyrer, Stefan D Baral, Chris Collins, Eugene T Richardson, Patrick S Sullivan, Jorge Sanchez, Gift Trapence, Elly Katabira, Michel Kazatchkine, Owen Ryan, Andrea L Wirtz, Kenneth H Mayer
Summary
Gay, bisexual, and other men who have sex with men (MSM) continue to have disproportionately high burdens of HIV infection in countries of low, middle, and high income in 2016. 4 years after publication of a Lancet Series on MSM and HIV, progress on reducing HIV incidence, expanding sustained access to treatment, and realising human rights gains for MSM remains markedly uneven and fraught with challenges. Incidence densities in MSM are unacceptably high in countries as diverse as China, Kenya, Thailand, the UK, and the USA, with substantial disparities observed in specific communities of MSM including young and minority populations. Although some settings have achieved sufficient coverage of treatment, pre-exposure prophylaxis (PrEP), and human rights protections for sexual and gender minorities to change the trajectory of the HIV epidemic in MSM, these are exceptions. The roll-out of PrEP has been notably slow and coverage nowhere near what will be required for full use of this new preventive approach. Despite progress on issues such as marriage equality and decriminalisation of same-sex behaviour in some countries, there has been a marked increase in anti-gay legislation in many countries, including Nigeria, Russia, and The Gambia. The global epidemic of HIV in MSM is ongoing, and global efforts to address it remain insufficient. This must change if we are ever to truly achieve an AIDS-free generation.

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Viewpoint
Who’s been left behind? Why sustainable development goals fail the Arab world
Abbas El-Zein, Jocelyn DeJong, Philippe Fargues, Nisreen Salti, Adam Hanieh, Helen Lackner
Summary
A set of Sustainable Development Goals (SDGs) was adopted by the UN General Assembly in September, 2015. The Arab world, alongside other regions, has problems of poverty, poor health, and substantial environmental degradation—ie, the kind of problems that the SDGs aim to address.1–5 Evidence of persistent infectious disease in low-income and middle-income Arab countries exists, alongside increased prevalence of non-communicable diseases in all Arab countries,6,7 high out-of-pocket health expenditure,8 poor access to safe water, as well as violent conflict, persistent foreign interventions, and high levels of social and political fragmentation that result in weak health systems and diminished rights to health.

The Lancet Infectious Diseases
Jul 2016 Volume 16 Number 7 p753-866 e108-e138
http://www.thelancet.com/journals/laninf/issue/current

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Editorial
Yellow fever: the consequences of neglect
The Lancet Infectious Diseases
Summary
Yellow fever is a vector-borne viral disease endemic to Africa and Americas that represented a major challenge for public health until the early 1930s, when a vaccine was developed. Mass immunisation campaigns have greatly reduced its incidence and now yellow fever is mainly reported in small outbreaks in tropical forests where it is maintained through a sylvatic cycle involving monkeys as a natural reservoir. Yet, it was known that an urban outbreak of yellow fever in a large city in the tropics would present challenges for control because such setting combines many and diverse risk factors for the disease, such as high population density, frail public-health infrastructures, and high density of mosquitoes.

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Articles
Testing the hypothesis that treatment can eliminate HIV: a nationwide, population-based study of the Danish HIV epidemic in men who have sex with men
Justin T Okano, Danielle Robbins, Laurence Palk, Jan Gerstoft, Niels Obel, Sally Blower

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Prevalence and burden of HCV co-infection in people living with HIV: a global systematic review and meta-analysis
Lucy Platt, Philippa Easterbrook, Erin Gower, Bethan McDonald, Keith Sabin, Catherine McGowan, Irini Yanny, Homie Razavi, Peter Vickerman

Lancet Global Health
Jul 2016 Volume 4 Number 7 e427-e501
http://www.thelancet.com/journals/langlo/issue/current
Editorial
The right(s) approach to Zika
The Lancet Global Health
Summary
The Zika virus epidemic is spreading: 63 countries are now reporting transmission, over 1500 cases of related microcephaly or CNS malformations have been confirmed this year, and knowledge on the disease is advancing slowly. Adding to the tension around Zika, at the epicentre of the outbreak, Brazil is bracing for a large-scale mass gathering: the Olympic and Paralympic Games 2016 in Rio de Janeiro. Conflicting opinions on the need to postpone or cancel the Games have been expressed, but during the 69th World Health Assembly last month, the WHO issued clear public health advice on the matter: the Games will not significantly change the international spread of the virus and travellers can reduce their risk of contracting the disease by following simple prevention measures such as avoiding mosquito bites with repellents and adequate clothing, practising safe sex, staying in air-conditioned housing, and avoiding areas with poor water and sanitation.

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Comment
Global disparities in HPV vaccination
Ophira Ginsburg
Summary
Cervical cancer is the fourth most common cancer in women globally, but remains the second most common cancer (after breast cancer) in many low-income and middle-income countries, and is still more common than breast cancer in sub-Saharan Africa.1 Most new cervical cancer cases (85%) and deaths (88%) occur in low-income and middle-income countries, where health systems are often fragmented or fragile, and where most have not yet implemented effective national cervical cancer screening programmes.

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Articles
Global estimates of human papillomavirus vaccination coverage by region and income level: a pooled analysis
Laia Bruni, Mireia Diaz, Leslie Barrionuevo-Rosas, Rolando Herrero, Freddie Bray, F Xavier Bosch, Silvia de Sanjosé, Xavier Castellsagué
Summary
Background
Since 2006, many countries have implemented publicly funded human papillomavirus (HPV) immunisation programmes. However, global estimates of the extent and impact of vaccine coverage are still unavailable. We aimed to quantify worldwide cumulative coverage of publicly funded HPV immunisation programmes up to 2014, and the potential impact on future cervical cancer cases and deaths.
Methods
Between Nov 1 and Dec 22, 2014, we systematically reviewed PubMed, Scopus, and official websites to identify HPV immunisation programmes worldwide, and retrieved age-specific HPV vaccination coverage rates up to October, 2014. To estimate the coverage and number of vaccinated women, retrieved coverage rates were converted into birth-cohort-specific rates, with an imputation algorithm to impute missing data, and applied to global population estimates and cervical cancer projections by country and income level.
Findings
From June, 2006, to October, 2014, 64 countries nationally, four countries subnationally, and 12 overseas territories had implemented HPV immunisation programmes. An estimated 118 million women had been targeted through these programmes, but only 1% were from low-income or lower-middle-income countries. 47 million women (95% CI 39–55 million) received the full course of vaccine, representing a total population coverage of 1·4% (95% CI 1·1–1·6), and 59 million women (48–71 million) had received at least one dose, representing a total population coverage of 1·7% (1·4–2·1). In more developed regions, 33·6% (95% CI 25·9–41·7) of females aged 10–20 years received the full course of vaccine, compared with only 2·7% (1·8–3·6) of females in less developed regions. The impact of the vaccine will be higher in upper-middle-income countries (178,192 averted cases by age 75 years) than in high-income countries (165,033 averted cases), despite the lower number of vaccinated women (13·3 million vs 32·2 million).
Interpretation
Many women from high-income and upper-middle-income countries have been vaccinated against HPV. However, populations with the highest incidence and mortality of disease remain largely unprotected. Rapid roll-out of the vaccine in low-income and middle-income countries might be the only feasible way to narrow present inequalities in cervical cancer burden and prevention.
Funding
PATH, Instituto de Salud Carlos III, and Agència de Gestió d’Ajuts Universitaris i de Recerca (AGAUR)
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Daily co-trimoxazole prophylaxis to prevent mortality in children with complicated severe acute malnutrition: a multicentre, double-blind, randomised placebo-controlled trial
James A Berkley, Moses Ngari, Johnstone Thitiri, Laura Mwalekwa, Molline Timbwa, Fauzat Hamid, Rehema Ali, Jimmy Shangala, Neema Mturi, Kelsey D J Jones, Hassan Alphan, Beatrice Mutai, Victor Bandika, Twahir Hemed, Ken Awuondo, Susan Morpeth, Samuel Kariuki, Gregory Fegan

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Estimating the most efficient allocation of interventions to achieve reductions in Plasmodium falciparum malaria burden and transmission in Africa: a modelling study
Patrick G T Walker, Jamie T Griffin, Neil M Ferguson, Azra C Ghani
e474

Nature Medicine
July 2016, Volume 22 No 7 pp693-705
http://www.nature.com/nm/journal/v22/n6/index.html

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Commentary
A roadmap for MERS-CoV research and product development: report from a World Health Organization consultation – pp701 – 705
Kayvon Modjarrad, Vasee S Moorthy, Peter Ben Embarek, Maria Van Kerkhove, Jerome Kim & Marie-Paule Kieny
doi:10.1038/nm.4131
As part of the World Health Organization (WHO) R&D Blueprint initiative, leading stakeholders on Middle East respiratory syndrome coronavirus (MERS-CoV) convened to agree on strategic public-health goals and global priority research activities that are needed to combat MERS-CoV.

New England Journal of Medicine
July 7, 2016 Vol. 375 No. 1
http://www.nejm.org/toc/nejm/medical-journal

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Perspective
Zika and the Risk of Microcephaly
M.A. Johansson, L. Mier-y-Teran-Romero, J. Reefhuis, S.M. Gilboa, and S.L. Hills

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Review Article
The Changing Face of Clinical Trials: Adaptive Designs for Clinical Trials
D.L. Bhatt and C. Mehta
Investigators use adaptive trial designs to alter basic features of an ongoing trial. This approach obtains the most information possible in an unbiased way while putting the fewest patients at risk. In this review, the authors discuss selected issues in adaptive design.

Pediatrics
July 2016, VOLUME 138 / ISSUE 1
http://pediatrics.aappublications.org/content/138/1?current-issue=y

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Review Articles
Interventions to Improve HPV Vaccine Uptake: A Systematic Review
Emily B. Walling, Nicole Benzoni, Jarrod Dornfeld, Rusha Bhandari, Bryan A. Sisk, Jane Garbutt, Graham Colditz
Pediatrics Jul 2016, 138 (1) e20153863; DOI: 10.1542/peds.2015-3863

PLOS Currents: Disasters
http://currents.plos.org/disasters/
[Accessed 9 July 2016]

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Research Article
Codified Hashtags for Weather Warning on Twitter: an Italian Case Study
July 5, 2016 ·
Introduction: During emergencies increasing numbers of messages are shared through social media platforms becoming a primary source of information for lay people and emergency managers. For Twitter codified hashtagging is emerging as a practical way to coordinate messages during emergencies and quickly identify relevant information. This paper considers a case study on the use of codified hashtags concerning weather warning in Italy in three different regions.
Methods: From November 3rd to December 2nd 2014, tweets identified by the 3 codified hashtags #allertameteoTOS, #allertameteoLIG and #allertameteoPIE were retrieved, collecting a total of 35,558 tweets published by 7361 unique tweets authors, with the aim to assess if codified hashtags could represent an effective way to align formal and informal sources of information during weather related emergencies. An auxiliary R-package was built to lead the analytics used in this study. Authors performed a manual coding of users, hashtags and content of messages of all Twitter data considered.
Results: Content analysis showed that tweets were overwhelmingly related to situational updates, with a high percentage containing geo-location information. Communication patterns of different user types were discussed for the three contexts. In accordance with previous studies, individuals showed an active participation primarily functioning as information hub during the emergency.
Discussion: In the proposed cases codified hashtags have proven to be an effective tool to convey useful information on Twitter by formal and informal sources. Where institutions supported the use of the predefined hashtag in communication activities, like in Tuscany, messages were very focused, with more than 90% of tweets being situational updates. In this perspective, use of codified hashtags may potentially improve the performance of systems for automatic information retrieval and processing during disasters.

PLoS Neglected Tropical Diseases
http://www.plosntds.org/
[Accessed 9 July 2016]

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Research Article
Mapping the Risk of Snakebite in Sri Lanka – A National Survey with Geospatial Analysis
Dileepa Senajith Ediriweera, Anuradhani Kasturiratne, Arunasalam Pathmeswaran, Nipul Kithsiri Gunawardena, Buddhika Asiri Wijayawickrama, Shaluka Francis Jayamanne, Geoffrey Kennedy Isbister, Andrew Dawson, Emanuele Giorgi, Peter John Diggle, David Griffith Lalloo, Hithanadura Janaka de Silva
| published 08 Jul 2016 | PLOS Neglected Tropical Diseases
http://dx.doi.org/10.1371/journal.pntd.0004813
Author Summary
Snakebite is a neglected tropical disease which mainly affects the rural poor in tropical countries. There is little reliable data on snakebite, which makes it difficult to estimate the true disease burden. Hospital statistics underestimate numbers of snakebites because a significant proportion of victims in tropical countries seek traditional treatments. On the other hand, time limited or localized surveys may be inaccurate as they may underestimate or overestimate numbers depending on when and where they are performed. To get a truer picture of the situation in Sri Lanka, where snakebites are an important cause of hospital admission, we undertook an island-wide community survey to determine the number of bites, envenomings and deaths due to snakebite in the previous 12 months. We found that there were more than 80,000 bites, 30,000 envenomings and 400 deaths due to snakebite, much more than claimed by official statistics. There was variation in numbers of bites and envenomings in different parts of the country and, using the data from our survey, we were able develop snakebite risk maps to identify snakebite hotspots and cold spots in the country. These maps would be useful for healthcare decision makers to allocate resources to manage snakebite in the country. We used free and open source software and replicable methods, which we believe can be adopted to other regions where snakebite is a public health problem.

PLoS Neglected Tropical Diseases
http://www.plosntds.org/
[Accessed 9 July 2016]

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Viewpoints
What Is Next for NTDs in the Era of the Sustainable Development Goals?
James Smith, Emma Michelle Taylor
| published 07 Jul 2016 | PLOS Neglected Tropical Diseases
http://dx.doi.org/10.1371/journal.pntd.0004719
…Conclusion: From Invisibility to Ubiquity
We are now firmly in the post-MDG era, but are still feeling our way into the Brave New World of the SDGs. The NTD lobby has been extraordinarily effective in building momentum and ultimately achieving recognition for NTDs within the new SDGs. This success is somewhat tempered by the sheer array of new goals, related targets, and uncertainty about how resources and commitments will map onto them.

The fight now is for traction within the emerging SDG Framework, and this requires a different focus. There is a need to shift from the limited number and international perspective of the MDGs to the much larger number of goals that need to be taken up and acted upon by a huge number of national governments. There is an opportunity here for NTDs to be leveraged throughout the SDGs; focusing on NTDs can assist nation states in grappling with the large array of new goals and targets. National governments must be—and can be—convinced of the crosscutting nature of NTD programmes and the benefits of mainstreaming NTD interventions, securing indicators and, thus, funding. There is a lot of hard work ahead, however.

There is a certain irony here that the previously “invisible” NTDs have gained prominence through their ubiquity within the SDGs, and this prominence is due in no small measure to the work of the NTD lobby thus far. Within the narrower rubric of the MDGs, the lower profile of NTDs was somewhat obscured until concerted efforts were made to underline how NTDs underpinned and interacted with the other goals and the very fabric of poverty itself. There is great value in NTDs being named in target 3.3, but there is still a challenge regarding relevance given the large number of other goals and targets, which may slice funding commitments rather more thinly than was the case with the MDGs. However, the ubiquity of NTDs in relation to the broader SDG agenda can come to the fore in relation to a greater number of goals and targets, especially those for which strong arguments can be made that NTDs may severely hamper progress: for example, goal 1 (end poverty) or goal 2 (end hunger), or where focusing on NTDs can drive progress towards specific targets, for example, 6.1 (achieve universal and equitable access to safe drinking water), 6.2 (achieve access to adequate and equitable sanitation and hygiene for all), and 3.8 (achieve UHC). From this perspective, an investment in NTDs becomes an investment in the broader sustainable development agenda [8,16].

Underlying and implicit in this is the ultimate aim of UHC. Here NTDs can act as both a focal point and a tracer indicator. Perhaps the newfound prominence and enduring ubiquity of NTDs is the mechanism to raise the prominence of the need for ubiquitous health coverage. If NTDs can become a mechanism to drive UHC, there may well be profound implications for the direction the NTD community choose to take next in their advocacy and action. There are a great many potential synergies to be built on, but also a great amount of coordination to be undertaken. Moreover, there is a risk to be managed as the NTD lobby looks to reconcile the WHO’s 2020 goals for the NTD Roadmap with the 2030 timeframe of the SDGs [18].

PLoS Pathogens
http://journals.plos.org/plospathogens/
(Accessed 9 July 2016)

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Research Article
Preventing Vaccine-Derived Poliovirus Emergence during the Polio Endgame
Margarita Pons-Salort, Cara C. Burns, Hil Lyons, Isobel M. Blake, Hamid Jafari, M. Steven Oberste, Olen M. Kew, Nicholas C. Grassly
| published 06 Jul 2016 | PLOS Pathogens
http://dx.doi.org/10.1371/journal.ppat.1005728
Abstract
Reversion and spread of vaccine-derived poliovirus (VDPV) to cause outbreaks of poliomyelitis is a rare outcome resulting from immunisation with the live-attenuated oral poliovirus vaccines (OPVs). Global withdrawal of all three OPV serotypes is therefore a key objective of the polio endgame strategic plan, starting with serotype 2 (OPV2) in April 2016. Supplementary immunisation activities (SIAs) with trivalent OPV (tOPV) in advance of this date could mitigate the risks of OPV2 withdrawal by increasing serotype-2 immunity, but may also create new serotype-2 VDPV (VDPV2). Here, we examine the risk factors for VDPV2 emergence and implications for the strategy of tOPV SIAs prior to OPV2 withdrawal. We first developed mathematical models of VDPV2 emergence and spread. We found that in settings with low routine immunisation coverage, the implementation of a single SIA increases the risk of VDPV2 emergence. If routine coverage is 20%, at least 3 SIAs are needed to bring that risk close to zero, and if SIA coverage is low or there are persistently “missed” groups, the risk remains high despite the implementation of multiple SIAs. We then analysed data from Nigeria on the 29 VDPV2 emergences that occurred during 2004−2014. Districts reporting the first case of poliomyelitis associated with a VDPV2 emergence were compared to districts with no VDPV2 emergence in the same 6-month period using conditional logistic regression. In agreement with the model results, the odds of VDPV2 emergence decreased with higher routine immunisation coverage (odds ratio 0.67 for a 10% absolute increase in coverage [95% confidence interval 0.55−0.82]). We also found that the probability of a VDPV2 emergence resulting in poliomyelitis in >1 child was significantly higher in districts with low serotype-2 population immunity. Our results support a strategy of focused tOPV SIAs before OPV2 withdrawal in areas at risk of VDPV2 emergence and in sufficient number to raise population immunity above the threshold permitting VDPV2 circulation. A failure to implement this risk-based approach could mean these SIAs actually increase the risk of VDPV2 emergence and spread.

Author Summary
Global, coordinated withdrawal of serotype-2 OPV (OPV2) is planned for April 2016 and will mark a major milestone for the Global Polio Eradication Initiative (GPEI). Because OPV2 withdrawal will leave cohorts of young children susceptible to serotype-2 poliovirus, minimising the risk of new serotype-2 vaccine-derived poliovirus (VDPV2) emergences before and after OPV2 withdrawal is crucial to avoid large outbreaks. Supplementary immunisation activities (SIAs) with trivalent OPV (tOPV) could raise serotype-2 immunity in advance of OPV2 withdrawal, but may also create new VDPV2. To guide the GPEI strategy we examined the risks and benefits of implementing tOPV SIAs using mathematical models and analysis of data on the 29 independent VDPV2 emergences in Nigeria during 2004–2014. We found that in settings with low routine immunisation coverage, the implementation of a small number of tOPV SIAs could in fact increase the probability of VDPV2 emergence. This probability is greater if SIA coverage is poor or if there are persistently unvaccinated groups within the population. A strategy of tOPV SIA in sufficient number and with high coverage to achieve high population immunity in geographically-focused, at-risk areas is needed to reduce the global risk of VDPV2 emergence after OPV2 withdrawal.

PNAS – Proceedings of the National Academy of Sciences of the United States of America
http://www.pnas.org/content/early/
(Accessed 9 July 2016)

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Biological Sciences – Ecology:
Large scale, synchronous variability of marine fish populations driven by commercial exploitation
Kenneth T. Frank, Brian Petrie, William C. Leggett,and Daniel G. Boyce
PNAS 2016 ; published ahead of print July 5, 2016, doi:10.1073/pnas.1602325113
Significance
Large-scale synchronous variation in the abundance of marine fish populations has generally been viewed as a response to coupled atmosphere–ocean forcing. The possibility that commercial exploitation could contribute significantly to these variations has been largely dismissed. We demonstrate, using data from 22 Atlantic cod stocks distributed across the North Atlantic, that fishing pressure can cause synchronous changes in stock abundance at spatial and temporal scales comparable to those attributed to climate forcing. We conclude that an understanding of the underlying causes of the large-scale, often synchronous variability of exploited marine fish populations and their underlying food chains will require greater acceptance of the potential importance of exploitation than has been evident to date.
Abstract
Synchronous variations in the abundance of geographically distinct marine fish populations are known to occur across spatial scales on the order of 1,000 km and greater. The prevailing assumption is that this large-scale coherent variability is a response to coupled atmosphere–ocean dynamics, commonly represented by climate indexes, such as the Atlantic Multidecadal Oscillation and North Atlantic Oscillation. On the other hand, it has been suggested that exploitation might contribute to this coherent variability. This possibility has been generally ignored or dismissed on the grounds that exploitation is unlikely to operate synchronously at such large spatial scales. Our analysis of adult fishing mortality and spawning stock biomass of 22 North Atlantic cod (Gadus morhua) stocks revealed that both the temporal and spatial scales in fishing mortality and spawning stock biomass were equivalent to those of the climate drivers. From these results, we conclude that greater consideration must be given to the potential of exploitation as a driving force behind broad, coherent variability of heavily exploited fish species.

Risk Management and Healthcare Policy
Volume 9, 2016
https://www.dovepress.com/risk-management-and-healthcare-policy-archive56
[Accessed 9 July 2016]

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Review
Multimorbidity in chronic disease: impact on health care resources and costs
McPhail SM
Risk Management and Healthcare Policy 2016, 9:143-156
Published Date: 5 July 2016
Abstract:
Effective and resource-efficient long-term management of multimorbidity is one of the greatest health-related challenges facing patients, health professionals, and society more broadly. The purpose of this review was to provide a synthesis of literature examining multimorbidity and resource utilization, including implications for cost-effectiveness estimates and resource allocation decision making. In summary, previous literature has reported substantially greater, near exponential, increases in health care costs and resource utilization when additional chronic comorbid conditions are present. Increased health care costs have been linked to elevated rates of primary care and specialist physician occasions of service, medication use, emergency department presentations, and hospital admissions (both frequency of admissions and bed days occupied). There is currently a paucity of cost-effectiveness information for chronic disease interventions originating from patient samples with multimorbidity. The scarcity of robust economic evaluations in the field represents a considerable challenge for resource allocation decision making intended to reduce the burden of multimorbidity in resource-constrained health care systems. Nonetheless, the few cost-effectiveness studies that are available provide valuable insight into the potential positive and cost-effective impact that interventions may have among patients with multiple comorbidities. These studies also highlight some of the pragmatic and methodological challenges underlying the conduct of economic evaluations among people who may have advanced age, frailty, and disadvantageous socioeconomic circumstances, and where long-term follow-up may be required to directly observe sustained and measurable health and quality of life benefits. Research in the field has indicated that the impact of multimorbidity on health care costs and resources will likely differ across health systems, regions, disease combinations, and person-specific factors (including social disadvantage and age), which represent important considerations for health service planning. Important priorities for research include economic evaluations of interventions, services, or health system approaches that can remediate the burden of multimorbidity in safe and cost-effective ways.

Science
08 July 2016 Vol 353, Issue 6295
http://www.sciencemag.org/current.dtl

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In Depth
Panel slams plan for human research rules
By David Malakoff
Science08 Jul 2016 : 106-107
National Academies report urges creation of new national commission on ethical studies.
Summary
In a development certain to fuel a long-running controversy, a prominent science advisory panel is calling on the U.S. government to abandon a nearly finished update to rules on protecting human research participants. It should wait until a new high-level commission, created by Congress and the president, to recommend improvements and then start over, the panel says. The recommendation, made 29 June by a committee of the National Academies of Sciences, Engineering, and Medicine that is examining ways to reduce the regulatory burden on academic scientists, is the political equivalent of stepping in front of a speeding car in a bid to prevent a disastrous wreck. It’s not clear, however, whether the panel will succeed in stopping the regulatory express—or just get run over. Both the Obama administration, which has been pushing to complete the new rules this year, and key lawmakers in Congress would need to back the halt—and so far they’ve been silent. Still, many researchers and university groups are thrilled with the panel’s recommendation, noting that they have repeatedly objected to some of the proposed rule changes as unworkable—with little apparent impact.