BMC Infectious Diseases
http://www.biomedcentral.com/bmcinfectdis/content
(Accessed 11 July 2015)

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Research article
HBV immunization and vaccine coverage among hospitalized children in Cameroon, Central African Republic and Senegal: a cross-sectional study
Claudine Bekondi, Roberta Zanchi, Abdoulaye Seck, Benoit Garin, Tamara Giles-Vernick, Jean Gody, Petulla Bata, Angèle Pondy, Suzie Tetang, Mamadou Ba, Chantal Ekobo, Dominique Rousset, Jean-Marie Sire, Sarah Maylin, Loïc Chartier, Richard Njouom, Muriel Vray BMC Infectious Diseases 2015, 15:267 (12 July 2015)
Abstract
Background
Hepatitis B is a major health concern in Africa. The vaccine against hepatitis B virus (HBV) was introduced into the Expanded Programme on Immunization (EPI) of Cameroon and Senegal in 2005, and of CAR (Central African Republic) in 2008. A cross-sectional study was conducted to assess HBV immunization coverage following the vaccine’s introduction into the EPI and factors associated with having been vaccinated.
Methods
All hospitalized children, regardless of the reasons for their hospitalization, between 3 months and 6 years of age, for whom a blood test was scheduled during their stay and whose condition allowed for an additional 2 mL blood sample to be taken, and who provided the parent’s written consent were included. All children anti-HBs- and anti-HBc + were tested for HBsAg.
Vaccination coverage was assessed in three different ways: immunization card, maternal recall and serologic anti-HBs profile.
Results
1783 children were enrolled between April 2009 and May 2010. An immunization card was only available for 24 % of the children. The median age was 21 months.
Overall HBV immunization coverage based on immunization cards was 99 %, 49 % and 100 % in Cameroon, CAR and Senegal, respectively (p < 0,001). The immunization rate based on maternal recall was 91 %, 17 % and 88 % in Cameroon, CAR and Senegal, respectively (p < 0,001). According to serology (anti-HBs titer ≥ 10 mUI/mL and anti-HBc-), the coverage rate was 68 %, 13 % and 46 % in Cameroon, CAR and Senegal, respectively (p < 0,001). In Senegal and Cameroon, factors associated with having been vaccinated were: mother’s higher education (OR = 2.2; 95 % CI [1.5–3.2]), no malnutrition (OR = 1.6; 95 % CI [1.1–2.2]), access to flushing toilets (OR = 1.6; 95 % CI [1.1–2.3]), and < 24 months old (OR = 2.1; 95 % CI [1.3–3.4] between 12 and 23 months and OR = 2.7; 95 % CI [1.6–4.4] < 12 months). The prevalence of HBV-infected children (HBsAg+) were 0.7 %, 5.1 %, and 0.2 % in Cameroon, CAR and Senegal, respectively (p < 0.001).
Conclusions
Assessing immunization coverage based on immunization cards, maternal recall or administrative data could be usefully reinforced by epidemiological data combined with immunological profiles. Serology-based studies should be implemented regularly in African countries, as recommended by the WHO. Malnutrition, lack of maternal education and poverty are factors associated with vaccine non-compliance. The countries’ vaccination programs should actively address these problems.

BMC Public Health
http://www.biomedcentral.com/bmcpublichealth/content
(Accessed 11 July 2015)

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Research article
Vaccine coverage and determinants of incomplete vaccination in children aged 12–23 months in Dschang, West Region, Cameroon: a cross-sectional survey during a polio outbreak
Gianluca Russo, Alessandro Miglietta, Patrizio Pezzotti, Rodrigue Biguioh, Georges Bouting Mayaka, Martin Sobze, Paola Stefanelli, Vincenzo Vullo, Giovanni Rezza BMC Public Health 2015, 15:630 (10 July 2015)
Abstract
Background
Inadequate immunization coverage with increased risk of vaccine preventable diseases outbreaks remains a problem in Africa. Moreover, different factors contribute to incomplete vaccination status. This study was performed in Dschang (West Region, Cameroon), during the polio outbreak occurred in October 2013, in order to estimate the immunization coverage among children aged 12–23 months, to identify determinants for incomplete vaccination status and to assess the risk of poliovirus spread in the study population.
Methods
A cross-sectional household survey was conducted in November-December 2013, using the WHO two-stage sampling design. An interviewer-administered questionnaire was used to obtain information from consenting parents of children aged 12–23 months. Vaccination coverage was assessed by vaccination card and parents’ recall. Chi-square test and multilevel logistic regression model were used to identify the determinants of incomplete immunization status. Statistical significance was set at p < 0.05.
Results
Overall, 3248 households were visited and 502 children were enrolled. Complete immunization coverage was 85.9 % and 84.5 %, according to card plus parents’ recall and card only, respectively. All children had received at least one routine vaccination, the OPV-3 (Oral Polio Vaccine) coverage was >90 %, and 73.4 % children completed the recommended vaccinations before 1-year of age. In the final multilevel logistic regression model, factors significantly associated with incomplete immunization status were: retention of immunization card (AOR: 7.89; 95 % CI: 1.08–57.37), lower mothers’ utilization of antenatal care (ANC) services (AOR:1.25; 95 % CI: 1.07–63.75), being the ≥3 rd born child in the family (AOR: 425.4; 95 % CI: 9.6–18,808), younger mothers’ age (AOR: 49.55; 95 % CI: 1.59–1544), parents’ negative attitude towards immunization (AOR: 20.2; 95 % CI: 1.46–278.9), and poorer parents’ exposure to information on vaccination (AOR: 28.07; 95 % CI: 2.26–348.1). Longer distance from the vaccination centers was marginally significant (p = 0.05).
Conclusion
Vaccination coverage was high; however, 1 out of 7 children was partially vaccinated, and 1 out of 4 did not complete timely the recommended vaccinations. In order to improve the immunization coverage, it is necessary to strengthen ANC services, and to improve parents’ information and attitude towards immunization, targeting younger parents and families living far away from vaccination centers, using appropriate communication strategies. Finally, the estimated OPV-3 coverage is reassuring in relation to the ongoing polio outbreak.

British Medical Journal
11 July 2015(vol 351, issue 8016)
http://www.bmj.com/content/351/8016

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Performance of alternative strategies for primary cervical cancer screening in sub-Saharan Africa: systematic review and meta-analysis of diagnostic test accuracy studies
BMJ 2015; 351 :h3084 (Published 03 July 2015)
Open Access

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Evidence based community mobilization for dengue prevention in Nicaragua and Mexico (Camino Verde, the Green Way): cluster randomized controlled trial
BMJ 2015; 351 :h3267 (Published 08 July 2015)
Open Access

Epidemics
Volume 13, In Progress (December 2015)
http://www.sciencedirect.com/science/journal/17554365

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One versus two doses: What is the best use of vaccine in an influenza pandemic?
Original Research Article
Pages 17-27
Laura Matrajt, Tom Britton, M. Elizabeth Halloran, Ira M. Longini Jr.
Abstract
Avian influenza A (H7N9), emerged in China in April 2013, sparking fears of a new, highly pathogenic, influenza pandemic. In addition, avian influenza A (H5N1) continues to circulate and remains a threat. Currently, influenza H7N9 vaccines are being tested to be stockpiled along with H5N1 vaccines. These vaccines require two doses, 21 days apart, for maximal protection. We developed a mathematical model to evaluate two possible strategies for allocating limited vaccine supplies: a one-dose strategy, where a larger number of people are vaccinated with a single dose, or a two-dose strategy, where half as many people are vaccinated with two doses. We prove that there is a threshold in the level of protection obtained after the first dose, below which vaccinating with two doses results in a lower illness attack rate than with the one-dose strategy; but above the threshold, the one-dose strategy would be better. For reactive vaccination, we show that the optimal use of vaccine depends on several parameters, with the most important one being the level of protection obtained after the first dose. We describe how these vaccine dosing strategies can be integrated into effective pandemic control plans.

Globalization and Health
http://www.globalizationandhealth.com/
[Accessed 11 July 2015]

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Short report
Psychosocial job characteristics, wealth, and culture: differential effects on mental health in the UK and Thailand
Yiengprugsawan V, Lazzarino AI, Steptoe A, Seubsman S and Sleigh AC Globalization and Health 2015, 11:31 (8 July 2015)
Abstract
Background
Most research on the influence of psychosocial job characteristics on health status has been conducted within affluent Western economies. This research addresses the same topic in a middle-income Southeast Asian country, enabling comparison with a Western benchmark.
Methods
We analysed and compared the Health Survey for England conducted in 2010 and the Thai Cohort Study data at 2005 baseline for workers aged 35–45 years. Multivariate logistic regression was used to assess relationships between psychosocial job characteristics and health, measured as Adjusted Odd Ratios (AOR), controlling for potential covariates in final analyses.
Results
In both UK and Thai working adults, psychological distress was associated with job insecurity (AOR 2.58 and 2.32, respectively), inadequate coping with job demands (AOR 2.57 and 2.42), and low support by employers (AOR 1.93 and 1.84). Job autonomy was associated with psychological distress in the UK samples (AOR 2.61) but no relationship was found among Thais after adjusting for covariates (AOR 0.99). Low job security, inability to cope with job demands, and low employer support were associated with psychological distress both among Thai and UK workers.
Conclusions
Job autonomy was an important part of a healthy work environment in Western cultures, but not in Thailand. This finding could reflect cultural differences with Thais less troubled by individualistic expression at work. Our study also highlights the implications for relevant workplace laws and regulations to minimise the adverse job effects. These public health strategies would promote mental health and wellbeing in the population.

Health Affairs
July 2015; Volume 34, Issue 7
http://content.healthaffairs.org/content/current
Focus: Medicaid’s Evolving Delivery Systems

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Health Aid Is Allocated Efficiently, But Not Optimally: Insights From A Review Of Cost-Effectiveness Studies
Eran Bendavid1,*, Andrew Duong2, Charlotte Sagan3 and Gillian Raikes4
Author Affiliations
1Eran Bendavid (ebd@stanford.edu) is an assistant professor in the Department of Medicine at Stanford University, in California.
2Andrew Duong is a research assistant in the Program of Human Biology at Stanford University.
3Charlotte Sagan is a research assistant in the School of Medicine at Stanford University.
4Gillian Raikes is a research assistant in the Program of Human Biology at Stanford University.
*Corresponding author
Abstract
Development assistance from high-income countries to the health sectors of low- and middle-income countries (health aid) is an important source of funding for health in low- and middle-income countries. However, the relationship between health aid and the expected health improvements from those expenditures—the cost-effectiveness of targeted interventions—remains unknown. We reviewed the literature for cost-effectiveness of interventions targeting five disease categories: HIV; malaria; tuberculosis; noncommunicable diseases; and maternal, newborn, and child health. We measured the alignment between health aid and cost-effectiveness, and we examined the possibility of better alignment by simulating health aid reallocation. The relationship between health aid and incremental cost-effectiveness ratios is negative and significant: More health aid is going to disease categories with more cost-effective interventions. Changing the allocation of health aid earmarked funding could lead to greater health gains even without expanding overall disbursements. The greatest improvements in the alignment would be achieved by reallocating some aid from HIV or maternal, newborn, and child health to malaria or TB. We conclude that health aid is generally aligned with cost-effectiveness considerations, but in some countries this alignment could be improved.

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Simulations Show Diagnostic Testing For Malaria In Young African Children Can Be Cost-Saving Or Cost-Effective
Victoria Phillips1,*, Joseph Njau2, Shang Li3 and Patrick Kachur4
Author Affiliations
1Victoria Phillips (vphil01@sph.emory.edu) is an associate professor in the Department of Health Policy and Management at the Rollins School of Public Health, Emory University, in Atlanta, Georgia.
2Joseph Njau is a prevention effectiveness fellow in the Global Immunization Division in the Center for Global Health, Centers for Disease Control and Prevention (CDC), in Atlanta.
3Shang Li is a health care analyst at Analysis Group, in New York City.
4Patrick Kachur is a medical epidemiologist and chief of the Malaria Branch, Division of Parasitic Disease and Malaria, Center for Global Health, CDC.
*Corresponding author
Abstract
Malaria imposes a substantial global disease burden. It disproportionately affects sub-Saharan Africans, particularly young children. In an effort to improve disease management, the World Health Organization (WHO) recommended in 2010 that countries test children younger than age five who present with suspected malaria fever to confirm the diagnosis instead of treating them presumptively with antimalarial drugs. Costs and concerns about the overall health impact of such diagnostic testing for malaria in children remain barriers to full implementation. Using data from national Malaria Indicator Surveys, we estimated two-stage microsimulation models for Angola, Tanzania, and Uganda to assess the policy’s cost-effectiveness. We found that diagnostic testing for malaria in children younger than five is cost-saving in Angola. In Tanzania and Uganda the cost per life-year gained is $5.54 and $94.28, respectively. The costs projected for Tanzania and Uganda are less than the WHO standard of $150 per life-year gained. Our results were robust under varying assumptions about cost, prevalence of malaria, and behavior, and they strongly suggest the pursuit of policies that facilitate full implementation of testing for malaria in children younger than five.

International Health
Volume 7 Issue 4 July 2015
http://inthealth.oxfordjournals.org/content/current

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EDITORIAL
Albinism in Africa: a medical and social emergency
Murray H. Brilliant
Extract
People with albinism (PWA) face a variety of medical and social problems, ranging from poor vision and skin cancer to murder for their body parts for witchcraft in East Africa, notably Tanzania. Albinism is an inherited disorder of melanin biosynthesis that results in a variable phenotype classified according to the mutation in one of several genes.
All forms of albinism are associated with problems of the visual system resulting in abnormalities of the retina, nystagmus, strabismus, foveal hypoplasia, abnormal crossing of the optic fibers, photophobia and reduced visual acuity.1 Oculocutaneous albinism (OCA) is a subgroup of recessive forms of albinism and characterized by a significant reduction or absence of melanin pigment in the eyes, skin and hair.2 Several genes are associated with OCA, although the most common forms are OCA1 and OCA2. OCA1 is caused by a reduction or complete lack of activity of the tyrosinase enzyme encoded by the TYR gene. OCA2 is caused by a reduction or complete lack of activity of the P protein—a chloride channel that helps regulate the pH of the melanosome organelle where tyrosinase is active.3,4 Although OCA2 is found in all populations, certain populations have a relatively high incidence. The worldwide incidence of OCA2 is 1 in 36 000, but it is especially common among individuals of African descent.5 The phenotype of sandy colored hair, chalky white skin and blue or hazel eyes is very distinctive in African populations (Figure 1). …

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Meningococcal meningitis: vaccination outbreak response and epidemiological changes in the African meningitis belt
Francisco Javier Carod Artal*
Author Affiliations
Neurology Department, Raigmore hospital, Old Perth road, Inverness, IV2 3UJ, UK and Universitat Internacional de Cataluya (UIC), Barcelona, Spain
*Corresponding author: Tel: +44 1463706229; E-mail: javier.carodartal@nhs.net
Received February 23, 2015.
Revision received March 25, 2015.
Accepted March 25, 2015.
Abstract
The main approach to controlling epidemics of meningococcal meningitis in the African meningitis belt has been reactive vaccination campaigns with serogroup A polysaccharide vaccine once the outbreak reached an incidence threshold. Early reactive vaccination is effective in reducing morbidity and mortality. A recent paper in International Health has shown that earlier reactive vaccination campaigns may be even more effective than increasing the coverage area of vaccination. Monovalent serogroup A conjugate vaccine programs have recently been launched to prevent transmission in endemic areas in the African meningitis belt. Conjugate vaccines can induce immunological memory and have impact on pharyngeal carriage. However, reactive vaccination still has a role to play taking into account the dynamic changes in the epidemiology of meningitis in this area.

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Results from a survey of national immunization programmes on home-based vaccination record practices in 2013
Stacy L. Younga, Marta Gacic-Dobob and David W. Brownc,*
Author Affiliations
aConsultant to the World Health Organization, Geneva, Switzerland
bWorld Health Organization, Geneva, Switzerland
cUnited Nations Children’s Fund, UNICEF House, 3 UN Plaza, New York, USA
*Corresponding author: Tel: +1 212 303 7988; E-mail: dbrown@unicef.org
Received December 1, 2014.
Revision received January 29, 2015.
Accepted February 10, 2015.
Abstract
Background
Data on home-based records (HBRs) practices within national immunization programmes are non-existent, making it difficult to determine whether current efforts of immunization programmes related to basic recording of immunization services are appropriately focused.
Methods
During January 2014, WHO and the United Nations Children’s Fund sent a one-page questionnaire to 195 countries to obtain information on HBRs including type of record used, number of records printed, whether records were provided free-of-charge or required by schools, whether there was a stock-out and the duration of any stock-outs that occurred, as well as the total expenditure for printing HBRs during 2013.
Results
A total of 140 countries returned a completed HBR questionnaire. Two countries were excluded from analysis because they did not use a HBR during 2013. HBR types varied across countries (vaccination only cards, 32/138 [23.1%]; vaccination plus growth monitoring records, 31/138 [22.4%]; child health books, 48/138 [34.7%]; combination of these, 27/138 [19.5%] countries). HBRs were provided free-of-charge in 124/138 (89.8%) respondent countries. HBRs were required for school entry in 62/138 (44.9%) countries. Nearly a quarter of countries reported HBR stock-outs during 2013. Computed printing cost per record was <US$0.50 in 53/77 (69%) of countries providing information.
Conclusions
These results provide a basis for national immunization programmes to develop, implement and monitor corrective activities to improve the availability and utilization of HBRs. Much work remains to improve forecasting where appropriate, to prevent HBR stock-outs, to identify and improve sustainable financing options and to explore viable market shaping opportunities.

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Hepatitis B vaccination of healthcare workers at the Princess Marina Hospital, Botswana
Tichaona Machiya, Rosemary J. Burnett, Lucy Fernandes, Guido François, Antoon De Schryver,
Marc van Sprundel, and M. Jeffrey Mphahlele
Int. Health (2015) 7 (4): 256-261 doi:10.1093/inthealth/ihu084

JAMA Pediatrics
July 2015, Vol 169, No. 7
http://archpedi.jamanetwork.com/issue.aspx

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Viewpoint
Time to Improve the Global Human Immunodeficiency Virus/AIDS Care Continuum for Adolescents: A Generation at Stake
Sarah M. Wood, MD, AAHIVS; Nadia Dowshen, MD, AAHIVS; Elizabeth Lowenthal, MD, MSCE, AAHIVS
Extract
This Viewpoint discusses the importance of improving care globally for adolescents with human immunodeficiency virus (HIV)/AIDS.
Pediatricians have an obligation to protect the health of children and adolescents. Human immunodeficiency virus (HIV)/AIDS remains the second leading cause of death for adolescents worldwide and the leading cause for adolescents in sub-Saharan Africa.1 Youth aged 15 to 24 years represent one-third of new infections.2 While AIDS-related mortality declined for adults and children from 2005 to 2012, there was a 50% increase in mortality among HIV-infected adolescents.2 For perinatally HIV-infected youth, worse outcomes largely reflect developmental struggles with treatment adherence they face as they enter adolescence. For adolescents with behaviorally acquired HIV, late diagnosis, poor linkage to and retention in care, low rates of antiretroviral therapy (ART) prescription, and inadequate treatment adherence all affect mortality.2 In the United States, nearly 60% of HIV-infected youth do not know they are infected.3 In sub-Saharan Africa, only 1 in 5 HIV-infected young women knows her status…

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International Child Health Competencies
Meaghann Shaw Weaver, MD, MPHc; Liza-Marie Johnson, MD, MSB, MPH
Extract
This Viewpoint reports that global health outreach partnerships with a bioethical foundation have the potential for immense societal benefit, personal growth, and professional enhancement for pediatric trainees.
Well-guided, sustainable global health outreach partnerships have the potential for immense societal benefit, personal growth, and professional enhancement for pediatric trainees. Yet, international pursuits lacking a bioethical foundation risk harming medically underserved populations and learners. Determining ethical competency in overseas training efforts rests on whether the pursuit is one of clinical skills practice or one of purposeful praxis (reflective experiential learning). Aristotle honored praxis as the highest form of knowledge, a practical knowledge; later philosophers used praxis to describe a shift from mindful reflection to social improvement. We define international child health praxis as a mentored, ethical approach that acknowledges system barriers, strives for solidarity with local stakeholders, and partners with them toward population wellness…

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Remembering the Benefits of Vaccination
Kristen A. Feemster, MD, MPH, MSHP
Extract
Between 2009 and 2012, 36 bills were introduced in 18 states to change vaccine exemption laws related to school-entry requirements. Of the 31 bills that sought to loosen requirements for obtaining an exemption, none passed.1 Fortunately, the clear evidence showing that easy exemption laws lead to higher exemption rates and higher exemption rates lead to outbreaks of vaccine-preventable diseases was well-heeded.2- 5 Further proof is now visible as we face the largest number of measles cases in the United States since the disease was declared eliminated in 2000, including a large ongoing outbreak associated with Disneyland that has affected more than 140 individuals.6 Most measles cases are among unvaccinated children whose parents refused the measles, mumps, and rubella vaccine because of philosophical or religious beliefs. Since January 2015, legislators in at least 8 states have introduced bills to tighten exemptions to mandatory school-entry vaccination policies.7 The reemergence of measles has raised a sense of urgency and voices in support of vaccination have become much louder…

Journal of Epidemiology & Community Health
August 2015, Volume 69, Issue 8
http://jech.bmj.com/content/current

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Editorial
Life course epidemiology: recognising the importance of adolescence
Russell M Viner, David Ross, Rebecca Hardy, Diana Kuh, Christine Power, Anne Johnson,
Kaye Wellings, Jim McCambridge, Tim J Cole, Yvonne Kelly, G David Batty
J Epidemiol Community Health 2015;69:719-720 Published Online First: 2 February 2015 doi:10.1136/jech-2014-20530
Extract
Life course epidemiology may be conceptualised as “the study of long term effects on later health or disease risk of physical or social exposures during gestation, childhood, adolescence, young adulthood and later adult life.”1 Adolescence, the period between childhood and adulthood defined by the WHO as 10–19 years, has an uneasy status in epidemiology. On the one hand, adolescents, who now number over 1.2 billion worldwide—around 20% of the global population—are highly visible in population-based studies. Young people’s behaviours have been an important subject of epidemiological inquiry, from tobacco and alcohol use to violence and sexual activity. Yet, concepts of adolescence as a discrete stage in the life course have been much less discussed within epidemiology. This is particularly so in studies of the developmental origins of adult health and disease, which have focused on the influence on adult health outcomes of exposures from the period of rapid physiological change in very early life. Similarly, investigators in the field of the social determinants of health and disease have concentrated their efforts on the effects of parenting and education in early childhood.

The Lancet
Online First
Articles
Feasibility and effectiveness of oral cholera vaccine in an urban endemic setting in Bangladesh: a cluster randomised open-label trial
Dr Firdausi Qadri, PhD, Mohammad Ali, PhD, Fahima Chowdhury, MPH, Ashraful Islam Khan, PhD, Amit Saha, MMed, Iqbal Ansary Khan, MSc, Yasmin A Begum, PhD, Taufiqur R Bhuiyan, PhD, Mohiul Islam Chowdhury, MPH, Md Jasim Uddin, PhD, Jahangir A M Khan, PhD, Atique Iqbal Chowdhury, MSc, Anisur Rahman, MSc, Shah Alam Siddique, MPH, Muhammad Asaduzzaman, MBBS, Afroza Akter, MBBS, Arifuzzaman Khan, MBBS, Young Ae You, MS, Ashraf Uddin Siddik, MSS, Nirod Chandra Saha, MSc, Alamgir Kabir, MSc, Baizid Khoorshid Riaz, MBBS, Shwapon Kumar Biswas, MPH, Farzana Begum, MPH, Leanne Unicomb, PhD, Prof Stephen P Luby, MD, Prof Alejandro Cravioto, PhD, Prof John D Clemens, MD
Published Online: 08 July 2015
DOI: http://dx.doi.org/10.1016/S0140-6736(15)61140-0
Summary
Background
Cholera is endemic in Bangladesh with epidemics occurring each year. The decision to use a cheap oral killed whole-cell cholera vaccine to control the disease depends on the feasibility and effectiveness of vaccination when delivered in a public health setting. We therefore assessed the feasibility and protective effect of delivering such a vaccine through routine government services in urban Bangladesh and evaluated the benefit of adding behavioural interventions to encourage safe drinking water and hand washing to vaccination in this setting.
Methods
We did this cluster-randomised open-label trial in Dhaka, Bangladesh. We randomly assigned 90 clusters (1:1:1) to vaccination only, vaccination and behavioural change, or no intervention. The primary outcome was overall protective effectiveness, assessed as the risk of severely dehydrating cholera during 2 years after vaccination for all individuals present at time of the second dose. This study is registered with ClinicalTrials.gov, number NCT01339845.
Findings
Of 268 896 people present at baseline, we analysed 267 270: 94 675 assigned to vaccination only, 92 539 assigned to vaccination and behavioural change, and 80 056 assigned to non-intervention. Vaccine coverage was 65% in the vaccination only group and 66% in the vaccination and behavioural change group. Overall protective effectiveness was 37% (95% CI lower bound 18%; p=0·002) in the vaccination group and 45% (95% CI lower bound 24%; p=0·001) in the vaccination and behavioural change group. We recorded no vaccine-related serious adverse events.
Interpretation
Our findings provide the first indication of the effect of delivering an oral killed whole-cell cholera vaccine to poor urban populations with endemic cholera using routine government services and will help policy makers to formulate vaccination strategies to reduce the burden of severely dehydrating cholera in such populations.
Funding
Bill & Melinda Gates Foundation.

The Lancet
Jul 11, 2015 Volume 386 Number 9989 p103-218
http://www.thelancet.com/journals/lancet/issue/current

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Editorial
A plan to protect the world—and save WHO
The Lancet
DOI: http://dx.doi.org/10.1016/S0140-6736(15)61225-9
Summary
“WHO must reestablish its pre-eminence as the guardian of global public health.” These words resonate throughout the final report of the Ebola Interim Assessment Panel, requested by WHO’s Executive Board, chaired by Dame Barbara Stocking, and published this week. The findings of the panel present a devastating critique of WHO and the chronic inaction of its member states, which together created the conditions for an Ebola virus disease outbreak of unprecedented ferocity and human tragedy. The Stocking Report, as it will come to be known, sets out in agonising detail how the entire global health system fatally let down the people of west Africa.

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Editorial
Cuba: defeating AIDS and advancing global health
The Lancet
DOI: http://dx.doi.org/10.1016/S0140-6736(15)61227-2
Summary
On June 30, Cuba became the world’s first country to eliminate mother-to-child transmission of HIV. As WHO Director-General Margaret Chan noted, this achievement is a “major victory” and “an important step towards having an AIDS-free generation”.

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Comment
The Global Financing Facility: country investments for every woman, adolescent, and child
Hailemariam Desalegn, Erna Solberg, Jim Yong Kim
DOI: http://dx.doi.org/10.1016/S0140-6736(15)61224-7
Summary
On July 13–16, 2015, leaders from around the globe will meet in Addis Ababa, Ethiopia, for the Third International Financing for Development Conference. The promise of this conference is in both finding new resources for development and doing development differently. We are setting a course of bold action for sustainable results to achieve a world in which every woman, child, and adolescent thrives and realises her full potential. The launch of the Global Financing Facility (GFF) at the conference in Addis Ababa will be an essential pillar to support this goal.

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Articles
Social network targeting to maximise population behaviour change: a cluster randomised controlled trial
David A Kim, BSc, Alison R Hwong, BSc, Derek Stafford, BSc, D Alex Hughes, BSc, Prof A James O’Malley, PhD, Prof James H Fowler, PhD, Prof Nicholas A Christakis, MD
Published Online: 04 May 2015
DOI: http://dx.doi.org/10.1016/S0140-6736(15)60095-2
Summary
Background
Information and behaviour can spread through interpersonal ties. By targeting influential individuals, health interventions that harness the distributive properties of social networks could be made more effective and efficient than those that do not. Our aim was to assess which targeting methods produce the greatest cascades or spillover effects and hence maximise population-level behaviour change.
Methods
In this cluster randomised trial, participants were recruited from villages of the Department of Lempira, Honduras. We blocked villages on the basis of network size, socioeconomic status, and baseline rates of water purification, for delivery of two public health interventions: chlorine for water purification and multivitamins for micronutrient deficiencies. We then randomised villages, separately for each intervention, to one of three targeting methods, introducing the interventions to 5% samples composed of either: randomly selected villagers (n=9 villages for each intervention); villagers with the most social ties (n=9); or nominated friends of random villagers (n=9; the last strategy exploiting the so-called friendship paradox of social networks). Participants and data collectors were not aware of the targeting methods. Primary endpoints were the proportions of available products redeemed by the entire population under each targeting method. This trial is registered with ClinicalTrials.gov, number NCT01672580.
Findings
Between Aug 4, and Aug 14, 2012, 32 villages in rural Honduras (25–541 participants each; total study population of 5773) received public health interventions. For each intervention, nine villages (each with 1–20 initial target individuals) were randomised, using a blocked design, to each of the three targeting methods. In nomination-targeted villages, 951 (74·3%) of 1280 available multivitamin tickets were redeemed compared with 940 (66·2%) of 1420 in randomly targeted villages and 744 (61·0%) of 1220 in indegree-targeted villages. All pairwise differences in redemption rates were significant (p<0·01) after correction for multiple comparisons. Targeting nominated friends increased adoption of the nutritional intervention by 12·2% compared with random targeting (95% CI 6·9–17·9). Targeting the most highly connected individuals, by contrast, produced no greater adoption of either intervention, compared with random targeting.
Interpretation
Introduction of a health intervention to the nominated friends of random individuals can enhance that intervention’s diffusion by exploiting intrinsic properties of human social networks. This method has the additional advantage of scalability because it can be implemented without mapping the network. Deployment of certain types of health interventions via network targeting, without increasing the number of individuals targeted or the resources used, could enhance the adoption and efficiency of those interventions, thereby improving population health.
Funding
National Institutes of Health, The Bill & Melinda Gates Foundation, Star Family Foundation, and the Canadian Institutes of Health Research.

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The Lancet Commissions
Defeating AIDS—advancing global health
Prof Peter Piot, PhD, Salim S Abdool Karim, PhD, Robert Hecht, PhD, Helena Legido-Quigley, PhD, Kent Buse, PhD, John Stover, MA, Stephen Resch, PhD, Theresa Ryckman, BA, Sigrun Møgedal, MD, Mark Dybul, MD, Eric Goosby, MD, Charlotte Watts, PhD, Nduku Kilonzo, PhD, Joanne McManus, Michel Sidibé, MSc on behalf of the UNAIDS–Lancet Commission – Listed at end of paper
Published Online: 24 June 2015
DOI: http://dx.doi.org/10.1016/S0140-6736(15)60658-4
Summary
After more than a decade of major achievements, the AIDS response is at a crucial juncture, both in terms of its immediate trajectory and its sustainability, as well as its place in the new global health and development agendas. In May, 2013, the UNAIDS–Lancet Commission—a diverse group of experts in HIV, health, and development, young people, people living with HIV and affected communities, activists, and political leaders—was established to investigate how the AIDS response could evolve in a new era of sustainable development.

PLoS Medicine
http://www.plosmedicine.org/
(Accessed 11 July 2015)

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Risk of Adverse Pregnancy Outcomes among Women Practicing Poor Sanitation in Rural India: A Population-Based Prospective Cohort Study
Bijaya K. Padhi, Kelly K. Baker, Ambarish Dutta, Oliver Cumming, Matthew C. Freeman, Radhanatha Satpathy, Bhabani S. Das, Pinaki Panigrahi
Research Article | published 07 Jul 2015 | PLOS Medicine 10.1371/journal.pmed.1001851
Abstract
Background
The importance of maternal sanitation behaviour during pregnancy for birth outcomes remains unclear. Poor sanitation practices can promote infection and induce stress during pregnancy and may contribute to adverse pregnancy outcomes (APOs). We aimed to assess whether poor sanitation practices were associated with increased risk of APOs such as preterm birth and low birth weight in a population-based study in rural India.
Methods and Findings
A prospective cohort of pregnant women (n = 670) in their first trimester of pregnancy was enrolled and followed until birth. Socio-demographic, clinical, and anthropometric factors, along with access to toilets and sanitation practices, were recorded at enrolment (12th week of gestation). A trained community health volunteer conducted home visits to ensure retention in the study and learn about study outcomes during the course of pregnancy. Unadjusted odds ratios (ORs) and adjusted odds ratios (AORs) and 95% confidence intervals for APOs were estimated by logistic regression models. Of the 667 women who were retained at the end of the study, 58.2% practiced open defecation and 25.7% experienced APOs, including 130 (19.4%) preterm births, 95 (14.2%) births with low birth weight, 11 (1.7%) spontaneous abortions, and six (0.9%) stillbirths. Unadjusted ORs for APOs (OR: 2.53; 95% CI: 1.72–3.71), preterm birth (OR: 2.36; 95% CI: 1.54–3.62), and low birth weight (OR: 2.00; 95% CI: 1.24–3.23) were found to be significantly associated with open defecation practices. After adjustment for potential confounders such as maternal socio-demographic and clinical factors, open defecation was still significantly associated with increased odds of APOs (AOR: 2.38; 95% CI: 1.49–3.80) and preterm birth (AOR: 2.22; 95% CI: 1.29–3.79) but not low birth weight (AOR: 1.61; 95% CI: 0.94–2.73). The association between APOs and open defecation was independent of poverty and caste. Even though we accounted for several key confounding factors in our estimates, the possibility of residual confounding should not be ruled out. We did not identify specific exposure pathways that led to the outcomes.
Conclusions
This study provides the first evidence, to our knowledge, that poor sanitation is associated with a higher risk of APOs. Additional studies are required to elucidate the socio-behavioural and/or biological basis of this association so that appropriate targeted interventions might be designed to support improved birth outcomes in vulnerable populations. While it is intuitive to expect that caste and poverty are associated with poor sanitation practice driving APOs, and we cannot rule out additional confounders, our results demonstrate that the association of poor sanitation practices (open defecation) with these outcomes is independent of poverty. Our results support the need to assess the mechanisms, both biological and behavioural, by which limited access to improved sanitation leads to APOs.

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Editors’ Summary
Background
Pregnancy is usually a happy time for women and their families. But, for some women, pregnancy ends unhappily. Some women lose their baby during early pregnancy (spontaneous abortion or miscarriage) or during late pregnancy (stillbirth). Others have their baby earlier than expected (preterm birth) or have a baby with low birth weight, two outcomes that adversely affect the baby’s survival and long-term health. The burden of adverse pregnancy outcomes (low birth weight, preterm birth, stillbirth, and spontaneous abortion) is substantial across the world but is particularly high in resource-limited settings. More than 60% of all preterm births take place in Asia and sub-Saharan Africa, and in India alone nearly 13 million babies (47% of all births) had a low birth weight in 2010. Many risk factors for adverse pregnancy outcomes have been identified, including infection, diabetes, poor antenatal care, and other socio-economic factors, but a clear causal mechanism for adverse pregnancy outcomes has not been established.
Why Was This Study Done?
One potential risk factor for adverse pregnancy outcomes, particularly in resource-limited settings, is poor sanitation—the inadequate provision of facilities and services for the safe disposal of human urine and feces. The WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation estimates that, globally, 1.1 billion people defecate in the open, a practice that can expose individuals to contact with human feces containing infectious organisms and that can contaminate food and water. Poor sanitation might contribute to adverse pregnancy outcomes by promoting infection or by causing stress during pregnancy. Women might, for example, limit their intake of food and water to avoid having to use inadequate toilet facilities, thereby adversely affecting the health of their unborn child. Here, the researchers assess whether poor sanitation practices are associated with an increased risk of adverse pregnancy outcomes by undertaking a population-based prospective study in two rural areas of Odisha state, India. Odisha has a high infant death rate (57 deaths per 1,000 live births), only 18.2% of households have access to an improved latrine (a facility such as a flush toilet that hygienically prevents human contact with human excreta), and 75% of households practice open defecation.
What Did the Researchers Do and Find?
For their study, the researchers enrolled 670 women during the first trimester of their pregnancy. They recorded socio-demographic data (for example, age, level of education, and household assets), clinical data, weight and height, and toilet access and sanitation practices for each woman at enrollment and followed them through pregnancy until birth. Nearly two-thirds of the women practiced open defecation, and a quarter experienced an adverse pregnancy outcome, most commonly a preterm birth and/or having a baby with low birth weight. After adjustment for potential confounding factors (factors that might affect outcomes, such as socio-demographic characteristics), open defecation was significantly associated with adverse pregnancy outcomes (all four adverse outcomes considered together) and with preterm birth, but not with low birth weight (a significant association is one that is unlikely to have happened by chance). Specifically, the adjusted odds ratios (an indicator of the strength of association between an exposure and an outcome; an odds ratio of more than one indicates that an exposure increases the risk of an outcome) of adverse pregnancy outcomes and preterm birth among women practicing open defecation compared with women with access to a latrine were 2.38 and 2.22, respectively. Notably, these associations were independent of poverty, caste, and religion.
What Do These Findings Mean?
These findings indicate that, among women in Odisha, defecation in the open (poor sanitation) during pregnancy is associated with a higher risk of any adverse pregnancy outcome and of preterm birth than the use of a latrine. Counterintuitively, these findings also suggest that the association between open defecation and adverse pregnancy outcomes is not explained by poverty. Although the researchers adjusted for numerous confounding factors in their analysis, the women who defecated in the open may have shared some other unknown characteristic (residual confounding) that was actually responsible for their increased risk of an adverse pregnancy outcome. Further studies are now needed to determine the socio-behavioral and/or biological basis of the association between poor sanitation and adverse pregnancy outcomes. Appropriate public health interventions can then be designed to reduce the burden of adverse pregnancy outcomes among women living in settings where there is limited access to adequate sanitation.

PLoS Neglected Tropical Diseases
http://www.plosntds.org/
(Accessed 11 July 2015)

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Elimination of Onchocerciasis from Mexico
Mario A. Rodríguez-Pérez, Nadia A. Fernández-Santos, María E. Orozco-Algarra, José A. Rodríguez-Atanacio, Alfredo Domínguez-Vázquez, Kristel B. Rodríguez-Morales, Olga Real-Najarro, Francisco G. Prado-Velasco, Eddie W. Cupp, Frank O. Richards, Hassan K. Hassan, Jesús F. González-Roldán, Pablo A. Kuri-Morales, Thomas R. Unnasch
Research Article | published 10 Jul 2015 | PLOS Neglected Tropical Diseases 10.1371/journal.pntd.0003922

PNAS – Proceedings of the National Academy of Sciences of the United States of America
http://www.pnas.org/content/early/
(Accessed 11 July 2015)

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Perspective: Redesigning photosynthesis to sustainably meet global food and bioenergy demand
Donald R. Ort, Sabeeha S. Merchant, Jean Alric, Alice Barkan, Robert E. Blankenship, Ralph Bock, Roberta Croce, Maureen R. Hanson, Julian M. Hibberd, Stephen P. Long, Thomas A. Moore, James Moroney, Krishna K. Niyogi, Martin A. J. Parry, Pamela P. Peralta-Yahya, Roger C. Prince, Kevin E. Redding, Martin H. Spalding, Klaas J. van Wijk, Wim F. J. Vermaas, Susanne von Caemmerer, Andreas P. M. Weber, Todd O. Yeates, Joshua S. Yuan, and Xin Guang Zhu
PNAS 2015 ; published ahead of print June 29, 2015, doi:10.1073/pnas.1424031112
Abstract
The world’s crop productivity is stagnating whereas population growth, rising affluence, and mandates for biofuels put increasing demands on agriculture. Meanwhile, demand for increasing cropland competes with equally crucial global sustainability and environmental protection needs. Addressing this looming agricultural crisis will be one of our greatest scientific challenges in the coming decades, and success will require substantial improvements at many levels. We assert that increasing the efficiency and productivity of photosynthesis in crop plants will be essential if this grand challenge is to be met. Here, we explore an array of prospective redesigns of plant systems at various scales, all aimed at increasing crop yields through improved photosynthetic efficiency and performance. Prospects range from straightforward alterations, already supported by preliminary evidence of feasibility, to substantial redesigns that are currently only conceptual, but that may be enabled by new developments in synthetic biology. Although some proposed redesigns are certain to face obstacles that will require alternate routes, the efforts should lead to new discoveries and technical advances with important impacts on the global problem of crop productivity and bioenergy production.

Public Health Ethics
Volume 8 Issue 2 July 2015
http://phe.oxfordjournals.org/content/current
Special Symposium: Migrant Health

Health of Migrants: Approaches from a Public Health Ethics Perspective
Verina Wild, Deborah Zion, and Richard Ashcroft
Extract
‘How do we know when it is dawn? When we have enough light to recognise, in the face of the stranger, that of our sister.’ 1
In 2013, a number of 230 million international migrants was estimated, of which 51.2 million people were forcibly displaced (UNHCR, 2014; United Nations, 2014). The majority of these refugees reside in the global South, in countries that have difficulties providing health care to their own citizens. However, in countries with functioning health care systems, there are also hundreds of thousands of people who are seeking refuge for example from brutal wars in the Middle East, and in the Horn of Africa. Additionally, an unknown number of undocumented migrants or temporary workers are on the move.

Despite the fact that Europe, the USA and Australia have considerably more resources to support health care (among other social and economic benefits) than other reception countries such as Pakistan and Iran, there is little consensus between or within countries about an acceptable standard of health care for different migrant groups, such as undocumented migrants, asylum seekers, refugees and temporary workers. There is also considerable disagreement about how this health care might be accessed, or the philosophical and human rights positions that underpin discussions concerning access and delivery.

In this edition of Public Health Ethics, we seek to address these concerns. Our conversation began in 2013 at an international symposium at the Brocher Foundation in Switzerland, in which a group of scholars, and experts from non-governmental organizations and international organizations from five continents explored ethical issues related to different migrant groups and health. We focussed particularly on undocumented migrants, asylum seekers and refugees as some of those who can be rendered most vulnerable. The papers published here trace the arc of philosophical debates and practical …

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Global Justice, Cosmopolitan Duties and Duties to Compatriots: The Case of Healthcare
Gillian Brock
Public Health Ethics (2015) 8 (2): 110-120 doi:10.1093/phe/phu039

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A Global Public Goods Approach to the Health of Migrants
Heather Widdows and Herjeet Marway
Public Health Ethics (2015) 8 (2): 121-129 doi:10.1093/phe/phv013

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Irregular Migrant Access to Care: Mapping Public Policy Rationales
Mark A. Hall and Jacob Perrin
Public Health Ethics (2015) 8 (2): 130-138 doi:10.1093/phe/phv016

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On Taking Responsibility for Undocumented Migrants
James Dwyer
Public Health Ethics (2015) 8 (2): 139-147 doi:10.1093/phe/phv005

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The Right to Health: Why It Should Apply to Immigrants
Patricia Illingworth and Wendy E. Parmet
Public Health Ethics (2015) 8 (2): 148-161 doi:10.1093/phe/phv007

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Universal Access to Health Care for Migrants: Applying Cosmopolitanism to the Domestic Realm
Verina Wild
Public Health Ethics (2015) 8 (2): 162-172 doi:10.1093/phe/phv014

Science
3 July 2015 vol 349, issue 6243, pages 1-112
http://www.sciencemag.org/current.dtl

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Policy Forum
Oceans
Managing mining of the deep seabed
L. M. Wedding, S. M. Reiter, C. R. Smith, K. M. Gjerde, J. N. Kittinger, A. M. Friedlander, S. D. Gaines, M. R. Clark, A. M. Thurnherr, S. M. Hardy, and L. B. Crowder
Science 10 July 2015: 144-145.
Contracts are being granted, but protections are lagging
Summary
Interest in mining the deep seabed is not new; however, recent technological advances and increasing global demand for metals and rare-earth elements may make it economically viable in the near future (1). Since 2001, the International Seabed Authority (ISA) has granted 26 contracts (18 in the last 4 years) to explore for minerals on the deep seabed, encompassing ∼1 million km2 in the Pacific, Atlantic, and Indian Oceans in areas beyond national jurisdiction (2). However, as fragile habitat structures and extremely slow recovery rates leave diverse deep-sea communities vulnerable to physical disturbances such as those caused by mining (3), the current regulatory framework could be improved. We offer recommendations to support the application of a precautionary approach when the ISA meets later this July.

Stability: International Journal of Security & Development
http://www.stabilityjournal.org/articles
[accessed 11 July 2015]

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Research Article
Containing Ebola: A Test for Post-Conflict Security Sector Reform in Sierra Leone
Cathy Haenlein, Ashlee Godwin
Abstract
Ebola has provided the greatest test of the Sierra Leonean security sector – and, in turn, of the UK-led reforms of the past ten-to-fifteen years. The performance of the country’s security forces at the height of the crisis suggests that there are sound structures in place; however, Ebola has shown that the Government of Sierra Leone’s national security architecture still lacks maturity in responding to such a scenario.
Drawing on first-hand interviews with advisers on the ground, this article explores the Sierra Leone government’s response to the Ebola crisis and the performance of the security sector so far, within the wider context of UK-led security-sector reform (SSR) since the end of the civil war. In doing so, it highlights a number of lessons to have emerged from the crisis, exploring what these reveal about the nature of the reforms implemented since the end of the country’s civil war. In turn, it explores what these suggest for future SSR, which continues to be a core component of the UK’s approach to development and overseas capacity-building.
DOI: http://doi.org/10.5334/sta.gb

The Sentinel

Human Rights Action :: Humanitarian Response :: Health ::
Holistic Development :: Sustainable Resilience
__________________________________________________
Week ending 4 July 2015

This weekly digest is intended to aggregate and distill key content from a broad spectrum of practice domains and organization types including key agencies/IGOs, NGOs, governments, academic and research institutions, consortia and collaborations, foundations, and commercial organizations. We also monitor a spectrum of peer-reviewed journals and general media channels. The Sentinel’s geographic scope is global/regional but selected country-level content is included. We recognize that this spectrum/scope yields an indicative and not an exhaustive product. Comments and suggestions should be directed to:

David R. Curry
Editor &
Founding Managing Director
GE2P2 – Center for Governance, Evidence, Ethics, Policy, Practice
david.r.curry@ge2p2center.net

pdf version: The Sentinel_ week ending 4 July 2015

blog edition: comprised of the 35+ entries to be posted below on 6 July 2015

earlier pdf editions archived here

Ethical Principles of Health Care in Times of Armed Conflict and Other Emergencies
June 2015
Within the framework of the Health Care in Danger project, the World Medical Association (WMA), the International Committee of Military Medicine (ICMM), the International Council of Nurses (ICN) and the International Pharmaceutical Federation (FIP) were consulted by the ICRC with the aim of these organizations agreeing on a common denominator of ethical principles of health care applicable in times of armed conflict and other emergencies. The following document, which is the result of these consultations, is without prejudice to existing policy documents adopted by these organizations.

Civilian and military health-care organizations share the common goal of improving the safety of their personnel and other health assets and the delivery of impartial and efficient health care in armed conflicts and other emergencies,

Referring to the principles of humanity, whereby human suffering shall be prevented and alleviated wherever it may be found and impartiality, whereby health care shall be provided with no discrimination;

Bearing in mind the standards of international humanitarian law, in particular the 1949 Geneva Conventions and their 1977 Additional Protocols, and of international human rights law, specifically the Universal Declaration of Human Rights (1948) and the International Covenants on Civil and Political Rights and on Economic, Social and Cultural Rights (1966);

Considering the principles of professional ethics adopted by health-care professional associations, including the WMA Regulations in Times of Armed Conflict and Other Situations of Violence;

Endorse the following ethical principles of health care:

GENERAL PRINCIPLES
1. Ethical principles of health care do not change in times of armed conflict and other emergencies and are the same as the ethical principles of health care in times of peace.

2. Health-care personnel shall at all times act in accordance with relevant international and national law, ethical principles of health care and their conscience. In providing the best available care, they shall take into consideration the equitable use of resources.

3. The primary task of health-care personnel is to preserve human physical and mental health and to alleviate suffering. They shall provide the necessary care with humanity, while respecting the dignity of the person concerned, with no discrimination of any kind, whether in times of peace or of armed conflict or other emergencies.

4. Privileges and facilities afforded to health-care personnel in times of armed conflict and other emergencies are never to be used for purposes other than for health-care needs.

5. No matter what arguments may be put forward, health-care personnel never accept acts of torture or any other form of cruel, inhuman or degrading treatment under any circumstances, including armed conflict or other emergencies. They must never be present at and may never take part in such acts.

RELATIONS WITH PATIENTS
6. Health-care personnel act in the best interest of their patients and whenever possible with their explicit consent. If, in performing their professional duties, they have conflicting loyalties, their primary obligation, in terms of their ethical principles, is to their patients.

7. In armed conflict or other emergencies, health-care personnel are required to render immediate attention and requisite care to the best of their ability. No distinction is made between patients, except in respect of decisions based upon clinical need and available resources.

8. Health-care personnel respect patients’ right to confidentiality. It is ethical for health-care personnel to disclose confidential information only with the patient’s consent or when there is a real and imminent threat of harm to the patient or to others

9. Health-care personnel make their best efforts to ensure respect for the privacy of the wounded, sick and deceased, including avoiding the use of health care for the wounded and sick, whether civilian or military, for publicity or political purposes.

PROTECTION OF HEALTH-CARE PERSONNEL
10. Health-care personnel, as well as health-care facilities and medical transports, whether military or civilian, must be respected by all. They are protected while performing their duties and the safest possible working environment shall be provided to them.

11. Safe access by health-care personnel to patients, health-care facilities and equipment shall not be unduly impeded, nor shall patients’ access to health-care facilities and health-care personnel be unduly impeded.

12. In fulfilling their duties and where they have the legal right, health-care personnel are identified by internationally recognized symbols such as the Red Cross, Red Crescent or Red Crystal as a visible manifestation of their protection under applicable international law.

13. Health-care personnel shall never be punished for executing their duties in compliance with legal and ethical norms.

FINAL
14. By endorsing these ethical principles of health care, the signatory organizations commit themselves to work for the promotion and implementation thereof wherever possible, including by appropriate dissemination amongst their members.

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Press Release
Common ethical principles of health care in conflict and other emergencies
30 June 2015
The World Medical Association (WMA), the International Committee of Military Medicine (ICMM), the International Council of Nurses (ICN), and the International Pharmaceutical Federation (FIP), representing more than 30 million people from both the military and civilian realms, have adopted the “Ethical Principles of Health Care in Times of Armed Conflict and Other Emergencies”, a first-of-its-kind code of ethics that provides a common core for these major international health care organizations.
This document marks an important step towards the protection of health care, with the signatory’s organizations showing a cohesive front against all forms of disrespect of ethical principles affecting the access to and the delivery of health care in armed conflict and other emergencies.

Common code to protect health care workers from violence
Consistent information gathered by the ICRC through the Health Care in Danger initiative shows that, in armed conflict and other emergencies, health–care personnel are often coerced to act against health-care ethics, or are victims of threats and subjected to deprivation of liberty for acting in accordance with the ethical principles of their profession.
Within the framework of the HCiD project, WMA, ICMM, ICN and FIP were consulted by the ICRC with the aim of these organizations agreeing on a common denominator of ethical principles of health care applicable in times of armed conflict and other emergencies. The document is the result of these consultations.
With the adoption of the Ethical Principles of Health Care in Times of Armed Conflict and Other Emergencies, the five organizations reinstate the importance of respect of ethical principles of health care for the full implementation of International Humanitarian Law and the protection of health care.
The code enumerates the principles guiding the relationship between patients and health-care workers, and contemplates issues such as discrimination, abuse of privileges, confidentiality, and torture. The principles underlying this relationship apply in times of armed conflict and other emergencies, thereby facilitating the oft-arduous application of ethics in wartime. In this sense, these ethical principles of health care constitute a significant negotiation tool for health-care personnel (in and beyond the humanitarian domain) with the authorities and other relevant actors.

About
The International Pharmaceutical Federation is the global federation of national associations of pharmacists and pharmaceutical scientists, and is a non-governmental organisation in official relations with the World Health Organization. With 132 member organisations FIP represents more than three million experts in medicines, supporting the responsible use of medicines around the world.
The World Medical Association is the global federation of National Medical Associations representing the millions of physicians worldwide. Acting on behalf of patients and physicians, the WMA endeavors to achieve the highest possible standards of medical care, ethics, education and health-related human rights for all people.
The ICMM is an International and Intergovernmental organization created in 1921 whose primary mission is to maintain and strengthen the bonds of cooperation and knowledge between the Armed Forces Medical Services of all Member States.
The International Council of Nurses is a federation of more than 130 national nurses associations representing the millions of nurses worldwide. Operated by nurses and leading nursing internationally, ICN works to ensure quality nursing care for all and sound health
policies globally.

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Peter Maurer on ethical principles of health care in conflict
30 June 2015
Speech given by Peter Maurer, President of the ICRC, at the launch of the “Ethical Principles of Health Care in Times of Armed Conflict and Other Emergencies.”
[Excerpts]

Dear colleagues, Dear friends,
The nature of humanitarian work often has me deliver speeches with words of warning and caution, and with descriptions of the particularly distressing situations in which victims of violence find themselves. I am glad to deviate from such patterns today, at the launch of our “Ethical principles of health care in times of armed conflict and other emergencies”.

Agreeing on these principles is indeed a substantive achievement and I would like to thank the World Medical Association (WMA), the International Committee of Military Medicine (ICMM), the International Council of Nurses (ICN) and the International Pharmaceutical Federation (FIP) for their participation and commitment to this process under the auspices of the ICRC.

The ethical principles we are launching today are a ground-breaking document because now, for the first time, our global associations have a common and concise set of shared principles. They will apply to more than 30 million professionals, civilian and military, who may face ethical dilemmas in times of armed conflict and other emergencies…

…This set of principles is a great achievement and demonstrates the capacity of a single sector to produce far-reaching ethical standards. The process through which we achieved this result is a perfect example of what I like to describe as principled pragmatism – where professional experience meets normative frameworks.

The endorsement of the ethical principles also demonstrates the outstanding commitment of health care professionals to preserve the integrity of health care staff and their resolve to lead without waiting for a governmental process – while it is critically relevant, it may take some more years to materialize.

Indeed, professional ethics transcend borders and political interests. The principles can therefore be seen as an articulation by individuals and civil society of what is acceptable and what is unacceptable behavior. Our common purpose today is to discuss how we are going to disseminate these rules and give them more leverage with different stakeholders.

We hope that you will use your own power, influence and your different networks to encourage the establishment of robust national legislations and accountability mechanisms…
Peter Maurer, President of the ICRC

Progress on Sanitation and Drinking Water: 2015 Update and MDG Assessment
UNICEF and WHO
June 2015
ISBN: 978-92-4-150329-7 :: 90 pages
PDF: http://www.unicef.org/publications/index_82419.html#
Abstract
Looking back on 25 years of water, sanitation and hygiene monitoring, this report provides a comprehensive assessment of progress since 1990. The Millennium Development Goal target for drinking water was achieved in 2010, but, in 2015, 663 million people still lack improved drinking water sources. The world has missed the sanitation target by almost 700 million people, with 2.4 billion still lacking improved sanitation facilities and 946 million practicing open defecation.

Introduction [excerpts]
In 2000 the Member States of the United Nations signed the Millennium Declaration, which later gave rise to the Millennium Development Goals (MDGs). Goal 7, to ensure environmental sustainability, included a target that challenged the global community to halve, by 2015, the proportion of people without sustainable access to safe drinking water and basic sanitation. The WHO/UNICEF Joint Monitoring Program for Water Supply and Sanitation (JMP), which began monitoring the sector in 1990, has provided regular estimates of progress towards the MDG targets, tracking changes over the 25 years to 2015.

In 1990, global coverage of the use of improved drinking water sources and sanitation facilities stood at 76 per cent and 54 per cent, with respective MDG targets of 88 per cent and 77 per cent by 2015. The challenges were huge, as the global figures hid vast disparities in coverage between countries, many of which were battling poverty, instability and rapid population growth.

The JMP has monitored the changes in national, regional and global coverage, establishing a large and robust database and presenting analysis not only of the indicators detailed in the original framework for the MDGs, but also many other parameters. The analysis has helped shed light on the nature of progress and the extent to which the ambition and vision of the MDGs have been achieved. It has also helped to identify future priorities to be addressed in the post-2015 Sustainable Development Goals.

Despite significant progress in water and sanitation, much still remains to be done. This report shows how the world has changed since 1990. It provides an assessment of progress towards the MDG target, and insight into the remaining challenges….

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Joint press release
UNICEF, WHO: Lack of sanitation for 2.4 billion people undermining health improvements
Final MDG progress report on water and sanitation released

NEW YORK/GENEVA, 30 June 2015 – Lack of progress on sanitation threatens to undermine the child survival and health benefits from gains in access to safe drinking water, warn WHO and UNICEF in a report tracking access to drinking water and sanitation against the Millennium Development Goals.

The Joint Monitoring Programme report, Progress on Sanitation and Drinking Water: 2015 Update and MDG Assessment, says worldwide, 1 in 3 people, or 2.4 billion, are still without sanitation facilities – including 946 million people who defecate in the open.

“What the data really show is the need to focus on inequalities as the only way to achieve sustainable progress,” said Sanjay Wijesekera, head of UNICEF’s global water, sanitation and hygiene programmes. “The global model so far has been that the wealthiest move ahead first, and only when they have access do the poorest start catching up. If we are to reach universal access to sanitation by 2030, we need to ensure the poorest start making progress right away.”

Access to improved drinking water sources has been a major achievement for countries and the international community. With some 2.6 billion people having gained access since 1990, 91 per cent of the global population now have improved drinking water – and the number is still growing. In sub-Saharan Africa, for example, 427 million people have gained access – an average of 47,000 people per day every day for 25 years.

The child survival gains have been substantial. Today, fewer than 1,000 children under five die each day from diarrhoea caused by inadequate water, sanitation and hygiene, compared to over 2,000 15 years ago.

On the other hand, the progress on sanitation has been hampered by inadequate investments in behaviour change campaigns, lack of affordable products for the poor, and social norms which accept or even encourage open defecation. Although some 2.1 billion people have gained access to improved sanitation since 1990, the world has missed the MDG target by nearly 700 million people. Today, only 68 per cent of the world’s population uses an improved sanitation facility – 9 percentage points below the MDG target of 77 per cent.

“Until everyone has access to adequate sanitation facilities, the quality of water supplies will be undermined and too many people will continue to die from waterborne and water-related diseases,” said Dr Maria Neira, Director of the WHO Department of Public Health, Environmental and Social Determinants of Health.

Access to adequate water, sanitation and hygiene is critical in the prevention and care of 16 of the 17 ‘neglected tropical diseases’ (NTDs), including trachoma, soil-transmitted helminths (intestinal worms) and schistosomiasis. NTDs affect more than 1.5 billion people in 149 countries, causing blindness, disfigurement, permanent disability and death.

The practice of open defecation is also linked to a higher risk of stunting – or chronic malnutrition – which affects 161 million children worldwide, leaving them with irreversible physical and cognitive damage.

“To benefit human health it is vital to further accelerate progress on sanitation, particularly in rural and underserved areas,” added Dr Neira.

Rural areas are home to 7 out of 10 people without access to improved sanitation and 9 out of 10 people who defecate in the open.

Plans for the new Sustainable Development Goals to be set by the United Nations General Assembly in September 2015 include a target to eliminate open defecation by 2030. This would require a doubling of current rates of reduction, especially in South Asia and sub-Saharan Africa, WHO and UNICEF say.

WHO and UNICEF say it is vitally important to learn from the uneven progress of the 1990-2015 period to ensure that the SDGs close the inequality gaps and achieve universal access to water and sanitation. To do so, the world needs:
:: Disaggregated data to be able to pinpoint the populations and areas which are outliers from the national averages;
:: A robust and intentional focus on the hardest to reach, particularly the poor in rural areas;
:: Innovative technologies and approaches to bring sustainable sanitation solutions to poor communities at affordable prices;
:: Increased attention to improving hygiene in homes, schools and health care facilities.