WHAT'S NEW THIS WEEKEND: CDC MALARIA POSITIONS, PREDICTORS OF CHILD SURVIVAL, SIMPLIFIED ARV DELIVERY MODELS, USE OF LAY PERSONNEL FOR ROUTINE IMMUNIZATION

Friday, 12th of August 2011

‘Summary Points

‘Lessons from the smallpox, poliomyelitis, and measles eradication/elimination initiatives (in particular, the importance of starting laboratory, clinical, and field research early in the program and continuing research in parallel) should be incorporated into any malaria eradication initiative from the onset.

‘Vaccines are likely to be the lynchpin interventions of elimination/eradication programs, but ongoing research will be needed to improve formulations, delivery, and immunization schedules.

‘Surveillance will be critical throughout any elimination/eradication initiative, coupled with improved diagnostic methods to detect asymptomatic infections and low rates of transmission.

‘Because socio-cultural, religious, and local politics can impede eradication efforts, it is prudent to support research into improving ways to communicate effectively with local populations about the disease and the interventions to eradicate it.

‘A cross-cutting theme among the viral disease programs is that interrupting the last vestiges of transmission is particularly problematic and requires allocation of many resources including support for focused “last kilometre” research activities.’

Full text is at http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1000405

• ACCELERATING MEASLES CONTROL IN INDIA: OPPORTUNITY AND OBLIGATION TO ACT NOW 

T JACOB JOHN*AND PANNA CHOUDHURY􀁧

INDIAN PEDIATRICS 939 VOLUME 46

*Past President, Indian Academy of Pediatrics, and Co-Chair, NTAGI, 439 Civil Supplies Godown Lane, Kamalakshipuram,

Vellore, Tamil Nadu; and 􀁧President, Indian Academy of Pediatrics (IAP), and Chairman,

IAP Committee on Immunization, DII/M 2753 Netaji Nagar, New Delhi, India. pannachoudhury@gmail.com

E D I T O R I A L

 Two major milestones in the history of measles control have recently been achieved. Since November 2002, measles is no longer endemic in the Western Hemisphere(1) and the 2005 goal set by the World Health Assembly (WHA) to halve measles deaths worldwide (compared to 1999 levels) was achieved on time(2). The main intervention that led to these achievements was the tactical scaling-up of measles vaccination.

 In May 2005, the WHA welcomed the goal of reducing measles deaths by 90% by 2010 compared to 2000 levels, as part of the Global Immunization Vision and Strategy (GIVS)(3). This global goal was endorsed unanimously by the WHA in May, 2008. This editorial explores the potential impacts of measles control strategies on child survival in India and on the global goal of reduction in measles mortality.

MEASLES IN INDIA

Measles continues to be an important cause of childhood morbidity and mortality in many states in India. At a workshop convened jointly by Government of India (GoI), WHO, and UNICEF on measles, in May 2007, it was estimated that between 100,000 and 160,000 children die from measles in India each year and that over 90% of deaths occur in 10 states – Uttar Pradesh (UP), Bihar, Rajasthan, Madhya. Pradesh, Jharkhand, Assam, West Bengal, Andhra Pradesh (AP), Orissa and Gujarat (preliminary results from a workshop held at National Polio Surveillance Unit, New Delhi, May 2007). A recent (2006) vaccination coverage survey in India showed overall 71% coverage for measles vaccine (given during 9 to 12 months of age) (4).

Accepting 85% vaccine effectiveness for vaccination at 9 months, actual protection was offered to only 60% of annual birth cohorts (71% × 85% = 60%). In other words, 40% remained susceptible to measles. Coverage of measles vaccine was less than 50% in UP, Bihar, Assam and Nagaland and between 50% and 80% in 13 other states(4). Worldwide, of the estimated 26.2 million infants who missed receiving their first dose of measles vaccine by age 12 months through routine immunization services in 2006, 10.5 million were in India (5).

 Six states (AP, Gujarat, Karnataka, Kerala, Tamil Nadu, West Bengal) conduct measles surveillance through clinical and laboratory outbreak investigations. In these states, nearly 80% cases occur in children less than 10 years old (data available at National Polio Surveillance Project [NPSP], New Delhi). Even in the states with moderate routine immunization coverage, many under-five children with measles had not been given measles vaccine (e.g. West Bengal 72%, Karnataka 38%, Gujarat 35%). According to the Registrar General and Census Commissioner of India, UP, Bihar and Assam together had 114 million children under 15 years of age, in 2006(6). More than half of them had not received measles vaccine – providing fertile ground for continued intense transmission of measles virus.

 Studies in India have shown median case-fatality ratio (CFR) of 3.8% (range: 0% to 30%) among children with measles(7). UP had recorded measles CFR of 4.1% in 1996, through routine reporting(8).  Actually the present surveillance method tends to under-report measles deaths.  Given the formidable challenges of wide interregional disparities of immunization coverage, a huge unvaccinated child population and the large disease burden, can India reduce its enormous measles morbidity and mortality?

• ·         BILL GATES LOOKS AT THE LEGACY OF JAMES P. GRANT

 Writing in www.TheGatesNotes.com Bill Gates remembers the work of James P. Grant, executive director of UNICEF in the 1980s, in placing Universal Childhood Immunization on the world’s agenda.

For more on the work of Jim Grant, go to  http://www.unicef.org/publications/index_4402.html

 Jim Grant - UNICEF Visionary

Jim Grant's 'Child Survival Revolution'

Posted 02/16/2011

If ever anyone ever deserved the title “Miracle Worker” it would be Jim Grant, who as head of UNICEF for 15 years mobilized the global community to immunize millions of children. The story of Grant’s remarkable achievements is chronicled in an out-of-print book that Bill recently read.

I recently came across a book that tells the amazing story of Jim Grant, whose influence in making vaccines widely available in the developing world is credited with saving the lives of 25 million children.

Because of the work the foundation is doing on vaccine-preventable diseases, I’ve read quite a bit about the history of global immunization. But until I read Jim Grant—UNICEF Visionary (an out-of-print book available for free download), I didn’t appreciate what a remarkable visionary and results-driven leader he was. I talk more about the impact of Jim Grant’s contributions in the foundation’s annual letter.

Grant was executive director of UNICEF—the United Nations Children’s Fund—from 1980 to 1995. Prior to that time, UNICEF was already well regarded for its global work—begun in the aftermath of World War II—preventing epidemics and malnutrition among children. In 1965, for example, UNICEF was awarded the Nobel Peace Prize.

But when Grant became head of UNICEF, he saw an opportunity to address a problem that was not high on the priority list of world leaders or international development organizations. At the time, about 14 million children were dying every year of readily preventable illnesses such as measles, tetanus, whooping cough, pneumonia and diarrheal disease. Virtually all of the deaths were occurring in the developing world; Europe and North America had mostly conquered the diseases with low-cost means of prevention or cure developed in the first half of the 20th century.

Grant decided to focus UNICEF’s mission on halving child deaths in the developing world through a massive effort to introduce the same immunizations already available in developed countries, along with other highly-effective low-cost strategies, such as packets of oral rehydration salts for people suffering from diarrheal disease, educating women about the benefits of breast feeding, and monitoring the growth of children. Collectively, these efforts were known as UNICEF’s Child Survival and Development Revolution.

Although we still face many difficulties today getting vaccines to the people who need them, the challenges Grant faced were an order of magnitude greater. No organization had ever tried tackling a global health issue on such a large scale and there were many skeptics, including within UNICEF.

But as Peter Adamson, who worked closely with Grant, writes in one of the book’s chapters, “…who could not be struck by the sheer unforgiveableness of millions upon millions of children dying…when the means to prevent it were at hand.”

• BEST PRACTICES IN MALARIA BEDNET DISTRIBUTION

Best practices for an insecticide-treated bed net distribution programme in sub-Saharan eastern Africa

When initial bednet coverage is low, can anyone defend the step by step approach to raising it? Those who reject the mass campaign approach to quick gains in coverage are on the back foot.  

‘ [Bednet] distribution should employ a catch up/keep up programme strategy. The catch-up programme rapidly scales up coverage, while the keep-up programme maintains coverage levels.’

 Malaria Journal 2011, 10:157 doi:10.1186/1475-2875-10-157

Alexis R Sexton (arsexton@gmail.com)

Article URL http://www.malariajournal.com/content/10/1/157

This peer-reviewed article was published immediately upon acceptance. It can be downloaded, printed and distributed freely for any purposes (see copyright notice below).

Malaria Journal

© 2011 Sexton ; licensee BioMed Central Ltd.

This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Best practices for an insecticide-treated bed net distribution programme in sub-Saharan

eastern Africa

Alexis R Sexton1

1Graduate School of Public Health, College of Health and Human Services, San Diego State

University, 5500 Campanile Drive, San Diego, CA 92182-4162, USA, Tel 858-603-2946

arsexton@gmail.com

Abstract

Insecticide-treated bed nets are the preeminent malaria control means; though there is no consensus as to a best practice for large-scale insecticide-treated bed net distribution. In order to determine the paramount distribution method, this review assessed literature on recent insecticide treated bed net distribution programmes throughout sub-Saharan Eastern Africa. Inclusion criteria were that the study had taken place in sub-Saharan Eastern Africa, targeted malaria prevention and control, and occurred between 1996 and 2007. Forty-two studies were identified and reviewed. The results indicate that distribution frameworks varied greatly; and consequently so did outcomes of insecticide-treated bed net use. Studies revealed consistent inequities between urban and rural populations; which were most effectively alleviated through a free insecticide treated bed net delivery and distribution framework. However, cost sharing through subsidies was shown to increase programme sustainability, which may lead to more long-term coverage.

Thus, distribution should employ a catch up/keep up programme strategy. The catch-up programme rapidly scales up coverage, while the keep-up programme maintains coverage levels.

Future directions for malaria should include progress toward distribution of long-lasting insecticide-treated nets.

• THE POLIO ENDGAME

The view from WHO and BMGF.

Also at http://healthpolicyandreform.nejm.org/?p=14698&query=home

NEJM | June 15, 2011 | Topics: International, Public Health

Bruce Aylward, M.D., and Tadataka Yamada, M.D.

Infection with poliovirus can have devastating consequences, including paralysis and death. In 1988, a year when an estimated 350,000 or more children were paralyzed by polio, the World Health Assembly initiated a global effort to eradicate the infection once and for all. It was an audacious undertaking, given that the virus circulates largely undetected, requires laborious cell-culture techniques to confirm infection, and is tackled with vaccines that provide imperfect protection in the gut.

Cases of Poliomyelitis Caused by Wild Poliovirus Types 1 and 3, January 1–May 24, 2011.

Initially, the number of polio cases and countries with infections fell rapidly, particularly as financing and political support increased in the mid-1990s. The last case of paralytic poliomyelitis caused by the serotype 2 wild poliovirus was detected in 1999. The number of new polio cases caused by the two remaining wild serotypes had decreased by 99% between 1988 and 2005, but progress had stalled and there was a danger of failure when wild polio viruses were reintroduced into large areas of Africa and Asia. By the end of 2009, sustained investments in innovation had produced a new bivalent oral poliovirus vaccine (OPV)¹ and novel tactics for reaching children who had been missed consistently by vaccination campaigns. A new independent monitoring process was established for overseeing the program and guiding course corrections. Since January 2010, new polio cases have decreased by 95% in the world’s largest remaining reservoirs of indigenous virus in northern India and northern Nigeria; the number of cases caused by serotype 3 has fallen by 92% globally; and most countries where poliovirus had been reintroduced have again become polio-free (see map and interactive map).

Declines in the intensity of poliovirus transmission in India and Nigeria are key to interrupting wild poliovirus globally, since viruses originating in these countries have been responsible for all the recent importation-associated outbreaks in previously polio-free countries. Besides India and Nigeria, indigenous polioviruses now survive only in Pakistan and one part of Afghanistan, with just eight other countries currently responding to outbreaks caused by imported viruses. However, in three of these countries — Angola, Chad, and the Democratic Republic of Congo — transmission was reestablished (i.e., at least one imported virus continued to circulate for more than 12 months). All three countries then became secondary wild-poliovirus reservoirs, with onward spread to other previously polio-free countries. The logistic challenges of reaching more than 90% of young children in mass OPV immunization campaigns in countries with reestablished transmission are similar in scale to those faced in the remaining countries with endemic disease, where conflict, insecurity, and weak public services complicate eradication operations.

Although there is still much distance to cover to eradicate the remaining wild polioviruses, recent progress has generated new confidence in the eradication effort, and talk of the polio “endgame” has intensified. However, preventing new polio outbreaks in a “post-eradication era” will require more than biocontainment measures to prevent the reintroduction of wild virus from laboratory stocks or sites where inactivated (Salk) polio vaccine (IPV) is produced. Achieving a polio-free world will eventually require stopping routine immunization with OPV and eliminating vaccine-derived polioviruses (VDPVs), particularly circulating VDPVs, which are Sabin-strain viruses that have acquired both neurovirulence and the capacity to circulate.²

Of the three risks associated with OPV, the most frequently realized one is vaccine-associated paralytic poliomyelitis (VAPP). This risk will disappear with the cessation of use of OPV. Outbreaks caused by circulating VDPVs are rarer than VAPP cases, but new diagnostic tests have confirmed their regular emergence, particularly that of serotype 2 circulating VDPVs, which were found in eight of the nine countries reporting VDPV outbreaks between 2008 and 2010. The persistence of such an outbreak for more than 4 years in Nigeria highlights the importance of reducing the risk of VDPV outbreaks when OPV use ceases and of actively managing any persisting outbreaks.

The rarest risk associated with OPV use is chronic VDPV excretion by people with severe primary B-cell immune disorders. All but one of these chronic immunodeficiency-associated VDPVs to date have occurred in industrialized countries that no longer use OPV. However, people with such infections may excrete virulent virus for years and are themselves at risk for fatal disease (see Brief Report by DeVries et al. in this issue of the Journal, pages 2316–2323). Although industrialized countries now use IPV and will therefore no longer generate new immunodeficiency-associated VDPVs, additional strategies and tools are required to mitigate the associated risk. Ongoing studies in nine low- and low-middle-income countries should help to inform more robust surveillance and, if necessary, case-management strategies for chronic immunodeficiency-associated VDPVs in such settings.

Stopping routine immunization with OPV globally after wild poliovirus is eradicated will eliminate VAPP immediately and halt the generation of new circulating and immunodeficiency-associated VDPVs. The challenge will be to synchronize global cessation of OPV immunization and then manage the transition, potentially lasting several years, to the point where residual VDPVs have been eliminated. Five years ago, the tools for executing this endgame didn’t exist. Today, 12 monovalent OPVs, at least 1 for each serotype, are licensed, and a global stockpile is being built to facilitate a rapid response to any circulating VDPVs that persist after OPV immunization ceases.

It is important to decrease the risk of emergence and transmission of circulating VDPVs in low-income countries, as well as the transmission of any wild viruses introduced through breaks in laboratory containment. Low-cost solutions have been sought to facilitate routine immunization with IPV in such settings and thereby maintain some immunity to polio through at least the first 5 to 10 years after cessation of OPV administration, when risk would probably be highest. It now appears increasingly feasible to create an IPV administration schedule that costs no more than existing OPV schedules, through some combination of reducing the number of doses, delivering one fifth the amount of antigen per dose by intradermal administration, using adjuvants, and introducing seed strains (e.g., Sabin strains) that can be produced safely by low-cost manufacturers in developing countries.^3,4 To help address the problem of chronic shedding of immunodeficiency-associated VDPV and reduce the potential for emergence of resistance, there are at least two antiviral candidates in early stages of development. Given the potentially fatal outcome of chronic infection, the availability of such treatments should also facilitate screening of at-risk but asymptomatic people.

Of course, none of these tools is perfect. Using monovalent OPVs to combat residual circulating VDPVs incurs the small risk of generating a new circulating VDPV — a risk that could increase with time after OPV use ceases. Since IPV does not induce the same level of intestinal mucosal immunity as OPV, we don’t yet know how effective IPV would be in terminating transmission of a circulating VDPV in tropical settings. Even if an antiviral drug is successfully developed, viral resistance may be encountered in the treatment of chronic shedders of immunodeficiency-associated VDPVs. Further research is providing additional tools and strategies that may be necessary for managing the risks in the posteradication era. Already the availability of these new tools has allowed serious discussions to begin regarding replacing trivalent OPV with bivalent OPV in routine vaccination programs, to take advantage of the apparent eradication of wild poliovirus type 2 and eliminate the VDPV risks associated with continued routine use of live vaccines with a type 2 component.

Uncertainties about the risks associated with cessation of OPV use have contributed to arguments that continued OPV immunization might be a more prudent approach to the polio endgame. However, there is accumulating evidence that intelligent application of innovative tools and strategies has shifted the balance of risk so that sustaining routine OPV immunization after the eradication of wild-type virus would present a greater risk to society and cost much more⁵ than eventual cessation of OPV immunization as a critical step in eradicating all polio disease.

• ADDRESSING THE VACCINE CONFIDENCE GAP

Key messages

• Public concerns about vaccines are not merely about vaccine safety, but are also about vaccine policies and recommendations, vaccine costs, and new research findings.
• Public decision making related to vaccine acceptance is complex and is neither driven by scientific nor economic evidence alone, but is also driven by a mix of scientific, psychological, sociocultural, and political reasons, all of which need to be better understood.
• The internet and new forms of social media have not only allowed for rapid and ubiquitous sharing of information—and misinformation—but have also allowed new methods of self-organisation and empowerment of newly founded online communities that argue against or for vaccines.
• Although communication of positive, evidence-based information about the safety of specific vaccines and their benefit—risk ratios to the public is crucial, communication alone will not stop public distrust and dissent against vaccines.
• Levels of public trust in vaccines are highly variable and context specific. To sustain or restore confidence in vaccines, a thorough understanding is needed of the population's—or subpopulation's—specific vaccine concerns, historical experiences, religious or political affiliation, and socioeconomic status.
• Core principles to be followed by all health providers, experts, health authorities, policy makers, and politicians include: engagement with and listening to stakeholders, being transparent about decision making, and being honest and open about uncertainty and risks.

Also at
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)60678-8/fulltext

The Lancet, Early Online Publication, 9 June 2011

Addressing the vaccine confidence gap

Original Text

Dr Heidi J Larson PhD a , Prof Louis Z Cooper MD b, Juhani Eskola MD c, Prof Samuel L Katz MD d, Scott Ratzan MD e f

Summary

Vaccines—often lauded as one of the greatest public health interventions—are losing public confidence. Some vaccine experts have referred to this decline in confidence as a crisis. We discuss some of the characteristics of the changing global environment that are contributing to increased public questioning of vaccines, and outline some of the specific determinants of public trust. Public decision making related to vaccine acceptance is neither driven by scientific nor economic evidence alone, but is also driven by a mix of psychological, sociocultural, and political factors, all of which need to be understood and taken into account by policy and other decision makers. Public trust in vaccines is highly variable and building trust depends on understanding perceptions of vaccines and vaccine risks, historical experiences, religious or political affiliations, and socioeconomic status. Although provision of accurate, scientifically based evidence on the risk—benefit ratios of vaccines is crucial, it is not enough to redress the gap between current levels of public confidence in vaccines and levels of trust needed to ensure adequate and sustained vaccine coverage. We call for more research not just on individual determinants of public trust, but on what mix of factors are most likely to sustain public trust. The vaccine community demands rigorous evidence on vaccine efficacy and safety and technical and operational feasibility when introducing a new vaccine, but has been negligent in demanding equally rigorous research to understand the psychological, social, and political factors that affect public trust in vaccines.

This is the fifth in a Series of five papers about the new decade of vaccines

• SYPHILIS SCREENING IN PREGNANCY: A SYSTEMATIC REVIEW AND META-ANALYSIS

‘Interventions to improve the coverage and effect of screening programmes for antenatal syphilis could reduce the syphilis-attributable incidence of stillbirth and perinatal death by 50%. The resources required to roll out antenatal screening programmes would be a worthwhile investment for reduction of adverse pregnancy outcomes and improvement of neonatal and child survival.’

Best viewed at http://www.thelancet.com/journals/laninf/article/PIIS1473-3099(11)70104-9/fulltext

The Lancet Infectious Diseases, Early Online Publication, 16 June 2011

doi:10.1016/S1473-3099(11)70104-9 Cite or Link Using DOI

Effectiveness of interventions to improve screening for syphilis in pregnancy: a systematic review and meta-analysis

Original Text

Dr Sarah Hawkes PhD a , Nashaba Matin MRCP b, Nathalie Broutet PhD c, Prof Nicola Low MD d

Summary

Background

About 2·1 million pregnant women have active syphilis every year. Without screening and treatment, 69% of these women will have an adverse outcome of pregnancy. The objectives of this study were to review the literature systematically to determine the effectiveness of screening interventions to prevent congenital syphilis and other adverse pregnancy outcomes.

Methods

We searched four electronic databases and selected studies to examine evidence for effectiveness of interventions on three outcomes: increased uptake of syphilis testing, increased treatment rates, and reduction in adverse pregnancy outcomes. We used fixed effects meta-analysis to estimate pooled relative risks if no or little evidence of heterogeneity between trials existed.

Findings

Ten studies met the inclusion criteria, including two randomised trials. Only two studies aimed to encourage women to seek care earlier in pregnancy. Nine studies included decentralisation of screening and treatment. The effects of the interventions on uptake of testing for antenatal syphilis and receiving at least one dose of penicillin were variable and could not be combined statistically. Study interventions were associated with a reduction in perinatal death (pooled risk ratio [RR] from three studies 0·46, 95% CI 0·26—0·82) and stillbirth (pooled RR from three studies 0·42, 95% CI 0·19—0·93). The incidence of congenital syphilis was reduced in all four studies that measured this outcome with heterogeneous results.

Interpretation

Interventions to improve the coverage and effect of screening programmes for antenatal syphilis could reduce the syphilis-attributable incidence of stillbirth and perinatal death by 50%. The resources required to roll out antenatal screening programmes would be a worthwhile investment for reduction of adverse pregnancy outcomes and improvement of neonatal and child survival.

• DOES EXTERNAL AID LEAD TO SHIFTING OF GOVERNMENT EXPENDITURE?

'[A]id needs to be structured in a way that better aligns donors’ and recipient governments’ incentives, using innovative approaches such as performance-based aid financing. Differing donor and government priorities lead to donor funds partly replacing government resources, especially in poor countries.'


Does Funding From Donors Displace Government Spending For Health In Developing Countries? 1. Marwa Farag, 2. A.K. Nandakumar, 3. Stanley S. Wallack, 4. Gary Gaumer and 5. Dominic Hodgkin + Author Affiliations 1. Schneider Institutes for Health Policy, Heller School for Social Policy and Management, Brandeis University, in Waltham, Massachusetts 1. Marwa Farag (marwa@brandeis.edu)

Best viewed at http://content.healthaffairs.org/content/28/4/1045.long

 

Abstract The notable increases in funding from various donors for health over the past several years have made examining the effectiveness of aid all the more important. We examine the extent to which donor funding for health substitutes for—rather than complements—health financing by recipient governments. We find evidence of a strong substitution effect. The proportionate decrease in government spending associated with an increase in donor funding is largest in low-income countries. The results suggest that aid needs to be structured in a way that better aligns donors’ and recipient governments’ incentives, using innovative approaches such as performance-based aid financing. Differing donor and government priorities lead to donor funds partly replacing government resources, especially in poor countries.

'The number of women who die during pregnancy or childbirth has decreased by more than a third globally since 1990, . . . the overall downward trend is insufficient to achieve the Millennium Development Goal (MDG) of a 75% reduction in maternal mortality between 1990 and 2015.'

• ARE WE MAKING PROGRESS IN MATERNAL MORTALITY?

Anne  Paxton, Dr.P.H., and Tessa Wardlaw, Ph.D.

N Engl J Med 2011; 364:1990-1993May 26, 2011

Best viewed, with graphics, at http://www.nejm.org/doi/full/10.1056/NEJMp1012860?query=featured_home

The number of women who die during pregnancy or childbirth has decreased by more than a third globally since 1990, according to new estimates from the United Nations1 — from nearly 550,000 deaths in that year to roughly 350,000 in 2008. Yet progress has been uneven: while some countries have seen significant improvements, others have seen marked increases in maternal mortality. Furthermore, the overall downward trend is insufficient to achieve the Millennium Development Goal (MDG) of a 75% reduction in maternal mortality between 1990 and 2015 (see table Trends in Maternal Mortality Ratios, 1990–2008.). In the United States, where women's chances of surviving pregnancy and childbirth are far greater than in other parts of the world (see map Maternal Mortality Ratios, 2008., and interactive map, available with the full text of this article at NEJM.org) — the lifetime risk of pregnancy-related death for a U.S. woman is 1 in 2100, as compared with 1 in 31 for a woman in sub-Saharan Africa — maternal mortality actually increased during this period, according to United Nations estimates. Despite spending more money on health care than any other country, the United States has higher maternal mortality than many other developed countries. How do we interpret these data and conflicting impressions of progress and decline?

. . .

Where does all this leave us? Should we celebrate the global improvements in maternal mortality or chide ourselves for not being on target to meet the MDGs for maternal health? The overall picture is one of gradual but steady reduction in maternal deaths in most areas of the world — a global public health improvement that calls for cautious optimism. The attention that has been paid to the plight of women at risk of dying during pregnancy or childbirth and increased investments in health care systems, especially in basic and comprehensive emergency obstetrical care, have paid off. The dramatic improvements in China and gains in other Asian countries, which are associated with economic improvement, decreasing fertility rates, and strengthening of health systems, contrast with sharp increases in countries experiencing the chaos and destruction of war and HIV epidemics. The overall rate of decline in global maternal mortality, 2.3%, is lower than the 5.5% MDG target but is heartening nonetheless. We believe that continued focus on national and district-level planning to make pregnancy and delivery safer and to improve treatment of obstetrical complications, with particular attention to disadvantaged women, including those with HIV, will accelerate progress over the next decade.

Seven mistakes and potential solutions in epidemiology, including a call for a World Council of Epidemiology and Causality

Raj Bhopal

The electronic version of this article is the complete one and can be found online at:

http://www.ete-online.com/content/6/1/6

• DIARRHEAL DISEASE RISK IN RURAL BANGLADESH DECREASES AS TUBEWELL DENSITY INCREASES

‘Increasing the amount of drinking water available to households through increased density of tubewells contributed to lower reports of cholera and shigellosis events in rural Bangladesh.’

 Abstract below; provisional .pdf file with full text is accessible from

http://www.ij-healthgeographics.com/content/10/1/41/abstract

 Diarrheal disease risk in rural Bangladesh decreases as tubewell density increases: a zero-inflated and geographically weighted analysis

Margaret Carrel, Veronica Escamilla, Jane Messina, Sophia Giebultowicz, Jennifer Winston, Mohammad Yunus, P. KIM Streatfield and Michael Emch

International Journal of Health Geographics 2011, 10:41 doi:10.1186/1476-072X-10-41

Published: 15 June 2011

Abstract (provisional)

Background

This study investigates the impact of tubewell user density on cholera and shigellosis events in Matlab, Bangladesh between 2002 and 2004. Household-level demographic, health, and water infrastructure data were incorporated into a local geographic information systems (GIS) database. Geographically-weighted regression (GWR) models were constructed to identify spatial variation of relationships across the study area. Zero-inflated negative binomial regression models were run to simultaneously measure the likelihood of increased magnitude of disease events and the likelihood of zero cholera or shigellosis events. The aim of this study was to examine the effect of tubewell density on both the occurrence of diarrheal disease and the magnitude of diarrheal disease incidence.

Results

In Matlab, households with greater tubewell density were more likely to report zero cholera or shigellosis events. Results for both cholera and shigellosis GWR models suggest that tubewell density effects are spatially stationary and the use of non-spatial statistical methods is appropriate.

Conclusions

Increasing the amount of drinking water available to households through increased density of tubewells contributed to lower reports of cholera and shigellosis events in rural Bangladesh. Our findings demonstrate the importance of tubewell installation and access to groundwater in reducing diarrheal disease events in the developing world.

• Correspondence: Raj Bhopal raj.bhopal@ed.ac.uk

Author Affiliations

Public Health Sciences, Centre for Population Health Sciences, University of Edinburgh, Edinburgh, EH9 8AG, UK

 Emerging Themes in Epidemiology 2009, 6:6 doi:10.1186/1742-7622-6-6

 © 2009 Bhopal; licensee BioMed Central Ltd.

This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

• ·         SEVEN MISTAKES THAT EPIDEMIOLOGISTS MAKE

Abstract

All sciences make mistakes, and epidemiology is no exception. I have chosen 7 illustrative mistakes and derived 7 solutions to avoid them. The mistakes (Roman numerals denoting solutions) are:

1. Failing to provide the context and definitions of study populations. (I Describe the study population in detail)

2. Insufficient attention to evaluation of error. (II Don't pretend error does not exist.)

3. Not demonstrating comparisons are like-for-like. (III Start with detailed comparisons of groups.)

4. Either overstatement or understatement of the case for causality. (IV Never say this design cannot contribute to causality or imply causality is ensured by your design.)

5. Not providing both absolute and relative summary measures. (V Give numbers, rates and comparative measures, and adjust summary measures such as odds ratios appropriately.)

6. In intervention studies not demonstrating general health benefits. (VI Ensure general benefits (mortality/morbidity) before recommending application of cause-specific findings.)

7. Failure to utilise study data to benefit populations. (VII Establish a World Council on Epidemiology to help infer causality from associations and apply the work internationally.)

Analysis of these and other common mistakes is needed to benefit from the increasing discovery of associations that will be multiplying as data mining, linkage, and large-scale scale epidemiology become commonplace.

Introduction: epidemiological mistakes and solutions

All sciences and scientists make mistakes, and epidemiology and epidemiologists (including this writer) are no exception. Epidemiological mistakes may maim and kill, and sometimes the toll can be massive. The contemporary exemplar of this is hormone replacement therapy (HRT), used by millions of women in the hope of reducing cancer and heart disease [1,2]. Fortunately, the saving of life and health benefits arising from epidemiology, despite its mistakes, seem to outweigh the harm. The lives saved from epidemiological studies of tobacco, for example, possibly outweigh all our mistakes, and the information will save even more lives as tobacco control spreads globally, particularly in Asia[3]. This judgement, however, needs and deserves quantitative evaluation.

Mistakes in epidemiology are mostly simple, but they are often challenging, though only occasionally impossible, to avoid. Every study presents a dilemma on the balance between efficiency and accuracy. More generally, we have the puzzle of why mistakes continue to occur despite much guidance. Mistakes are rarely deliberate, and usually avoidable. I have chosen seven mistakes to illustrate how epidemiology goes wrong, and seven solutions are derived (these numbers were chosen to match the title of the presentation on which this paper is based - seven sins and seven commandments of epidemiology - which chimes with our wider culture on right and wrong). My chosen seven mistakes are a sample on which I have been reflecting [4], and against which I have personally battled, but there is scope for several papers of this kind. Phillipe Grandjean's paper on the seven deadly sins of environmental epidemiology covered human frailties, [5] so this one focuses on the scientific discipline, although the two perspectives overlap. Grandjean constructed his paper around the original sins (gluttony, sloth etc.) as shown in Table 1. The seven mistakes I have chosen illustrate some of the dilemmas facing all of us, and they focus us on principles. These mistakes call for better education and training. I have chosen one or two examples for illustration.

Table 1. Common vices in environmental epidemiology

Analysis

Mistake 1: Failing to provide the context and definitions of study populations

Textbooks tell us that epidemiology is a population science, though few discuss why [6], leading me to write a full chapter on the topic in my own textbook [6,7]. Populations differ by place, their characteristics and time. The results may not generalise easily between populations, within subgroups of the same population, or within the same population at different times. This applies particularly to the burden of disease and risk factors, but also to causal understanding. Thus, understanding the kind of population studied is essential. There is nothing more elementary in epidemiology but, nonetheless, this is possibly the commonest of the seven mistakes chosen for this paper.

The solution is:

(I) State the location and timing of fieldwork and describe the study population in detail, especially age, sex, socio-economic status and ethnic composition.

Rarely, the study location might be disguised to hide the identity of study participants, especially for rare, stigmatising conditions. If so, authors should use their discretion on the level of detail and, exceptionally, even hide the location. Authors need to justify the decision and inform the reader of why they took it. Otherwise, contextual detail must be given. Timing of fieldwork is essential for examining time trends as the date of publication is a sorry substitute. It is not enough to say the study was done in the USA or even New York, except when the work was indeed national and/or city-wide, respectively. Authors should be specific about the district of the city. Without the study population's details it is not possible to draw appropriate conclusions. This is obvious in relation to applied epidemiology used for health service/public health purposes. It also applies to causal research, where understanding the biological processes, presence of co-risk factors and competing risks of disease and death are so important to generalisation. An association may vary in its strength in different populations, reflecting the presence or absence of co-factors.

Examples

When answering specific questions, it is surprising how sparse the scientific literature is, and this applies particularly in low income countries as well as in relation to minority populations within the high income countries. As shown in table 2, in recent reviews my colleagues and I have found that information on time of fieldwork was present in every North American and European cardiovascular cohort study we examined, [8] but missing in a high proportion of studies on minorities and in West Africa [9-12]. By contrast, the cardiovascular cohort studies, particularly those in Europe, were lacking in information on the ethnic composition of the samples. Absence of such basics, especially as investigators move posts and are not always easy to contact, can undermine interpretation of individual publications and weaken both traditional and systematic reviews.

Table 2. Missing fieldwork dates and absence of information on ethnicity

Mistake 2: Insufficient attention to evaluation of error

Measurement is always imperfect in the empirical sciences, and especially in humans. The most fundamental error is mismeasurement, which is ubiquitous and often unavoidable. We have motivations to ignore error. We want a rapid, inexpensive and conclusive outcome. Seeking out and rectifying errors requires scarce time and resources, and funding (for pilot studies, for example) is not easy to obtain. We want (and need) publication. While acknowledging errors and limitations is good scholarship, openness can lead to rejection of manuscripts during review, particularly if errors could, in retrospect, have been avoided. Where publication is associated with direct financial rewards and prestige, the temptation to gloss over errors is strong. The solution arising is, again, a basic one, but one that needs reinforcement, for it is widely ignored.

Solution II: Don't act as if measurement error does not exist. If possible quantify it. If not, identify that as a limitation of the work. (Remember that lack of cross-cultural validity of measures may lead to serious errors.)

Examples

Our potential actions are to ignore errors, acknowledge them but do nothing, make qualitative adjustments in the interpretation - probably through qualifying words such as 'may', 'could', etc. (this is perhaps the commonest response) - or make quantitative adjustments to summary measures. Maldonado argues that making no quantitative adjustment equates to the assumption that the study's imperfections have no important impact on study results, which is mostly untrue. He demonstrates how to quantitatively adjust relative risk using error terms [13]. Such adjustments increase the uncertainty of the summary measures (widening confidence intervals). This makes conclusions more tentative, which is good science but potentially an obstacle to publication and implementation.

The need for cross-cultural validity of self report data is self evident but often ignored [14]. It is less obvious, and more controversial, that the interpretation of physical measures such as BMI, waist, birth weight, and fetal and childhood growth may differ across different populations, particularly by ethnic group [15]. The differential performance of clinical measures, such as the electrocardiogram, is reasonably well established, but has not led to any substantial programme of research to improve matters [16]. The cross-cultural, cross-national validity of biochemical measures, for example, the biological effect of a particular level of cholesterol, and normal values of glucose during the oral glucose tolerance test, has hardly been discussed.

Implementing this solution is a major challenge. The mistake is to ignore the problem.

Mistake 3: Not demonstrating comparisons are like-for-like, and the problem of confounding

Epidemiologists are fortunate that they study humans. This privilege comes at a price: the (relatively) easy route to causal knowledge through experimentation is largely barred for ethical reasons; the scientific principle of splitting a tissue specimen or a sample of cloned/inbred animals into a control or study group, permitting rigorous like-for-like comparisons, is rarely possible.

The closest practical alternatives in human epidemiology are randomised controlled trials, but even these have error. Even if like-for-like comparison is achieved by randomisation and blinding (both are needed), many factors including the selection of populations, may preclude causal inference to the target population, i.e. external validity. Only a small fraction of epidemiological questions are answerable using trials, either for ethical or resource- and time-related reasons. If comparing like-with-like is not possible, confounding is inevitable. The epidemiological mistake, however, is neither confounding nor failing to control for it - these are not fully in our hands. The mistake is not demonstrating whether comparisons are unlikely or likely to be like-for-like. Like mistakes 1 and 2 this one is also fundamental, and the solution is clear cut.

Solution III: Prepare a detailed, prior specification of the data to be collected in order to demonstrate the similarities and differences of comparison populations. Start the analysis with such detailed comparisons.

The paradox is that the first part of this solution is nearly always applied in trials (usually table 1), where it is not essential if the randomisation has worked, but is often missed out in other study designs, where it is imperative for data interpretation. The analysis must not proceed straight to comparisons of risk factor-disease outcome relationships. The strategy of controlling confounding within the (usually) multivariable analysis is not sufficient. The reason for this is that the variables entered are not comprehensive enough and that they are imprecisely measured and categorised. While the idea of residual confounding is known it is not taken seriously enough [17]. How often do authors conclude that the confounders cannot be controlled and that they have refrained from a multivariable analysis because causal conclusions cannot be drawn? That is a rare conclusion, but it should be a common one.

Example: alcohol

Behaviours are linked to other behaviours, social circumstances, age, sex and, of course, diseases. We might therefore assume that control of confounding is nigh impossible when we are looking for associations between single behaviours and disease outcomes. Instead of that, we find ourselves in almost endless controversies over repeated studies demonstrating a variety of associations that, in the paraphrased words of the late Petr Skrabanek, can be likened to punching a pillow, whereby the dimple so formed disappears, at which point we then punch it again, and again [18]. An example is the association between alcohol and cardiovascular diseases (CVD), which has been studied intensively for decades. Thousands of papers have resulted, many of them debating the evidence, which remains controversial. The study by Naimi et al. of the potential confounding factors using the 2003 Behavioural Risk Factor Surveillance System is illustrative [19]. This large telephone survey permitted examination of moderate drinkers (men 2 drinks, and women 1 drink, per day) and non-drinkers. The study showed that 27 out of 30 CVD-associated factors were significantly more prevalent in non-drinkers. Given imprecision in measurement of confounders, and the many other potential confounders not included in a telephone survey, is it not impossible to adjust for confounders in this and similar contexts? We need to confront such harsh realities. Implementing this solution will be a major advance in interpreting associations.

Mistake 4: Either overstatement or understatement of the case for causality based on associations

Overstatement of the case for causality is perennial, much discussed but not resolved. The problem is that causal reasoning is not suitable for an algorithm based approach. Counter-factual reasoning clarifies the underpinnings of causal reasoning in epidemiology, but it is theoretical [20-23]. The closest we come to the counterfactual ideal is trials, which are often not possible for ethical, financial or time-related reasons. Whenever possible, we should test out causal hypotheses using trials, but unless we envisage an age of unethical research, based on human experimentation, we will need to improve our conceptual frameworks for causal reasoning, particularly for non-trial epidemiology [20-23]. Causal frameworks in epidemiology, often founded on those of other disciplines, [4] have served us well and deserve to be improved through research rather than being subjected to the destabilising effects of attack and counter-attack. The interpretation of associations needs to be done with great rigour. In relation to mistake 7, and in my conclusion, I recommend that we set up a World Council in Epidemiology and Causality that compiles and evaluates evidence on associations.

Recently, a new problem has emerged: the understatement of the case for causality. Typically, the authors declare that a finding is not causal because the data come from a study of population statistics, or of cross-sectional, case-control or even cohort design. This arises from the too simplistic equating of study design with causal reasoning. As soon as epidemiologists postulate an association, never mind demonstrate that one exists, they are somewhere on the pathway of causal analysis. The key question is where we are on this path, surely the toughest one in epidemiology, and not one that can be evaded. It is made even tougher when trials and observational studies contradict each other. There are many good reasons why this contradiction happens, including the problem of confounding, insufficient study size (power) to demonstrate effects, the possibility that trials have not provided the duration and amount of exposure to the factor of interest to lead to an effect, the possibility that the exposure needs to be at a critical period of life that cannot be mimicked in a trial (for example, the first year), and, of course, that trials may be done in different kinds of populations to those studied in observational studies. The problem of causality is tough and deserves 7 solutions on its own, but I have chosen one.

Solution IV: Never say that a particular study design cannot contribute to causality or imply that causality is ensured by your design, but provide a judgement based on a theoretical perspective on causality and the world's empirical and theoretical literature.

Causal understanding may hold firm on the flimsiest of evidence (or even none that we recognise as epidemiology) and be demolished when it derives from large empirical data sets with strong designs (for example, cohorts), as in the example of HRT above [1,2]. A judgement that arises from the world's empirical and theoretical literature demands a discipline to avoid selective reading and rapid production of 'knowledge'. It demands a return to a chronological and thorough review as in a PhD, at least where causality is relevant. Ideas around causation are likely to be in commentaries and reviews, reports and theses, and introductory and discussion sections of empirical writings (not in the data in the results section). Such traditional reviews are surely more suited to in-depth causal thinking, while systematic reviews are better suited to quantifying effects, which is no more than the first step in the long path to declaring an association as causal.

Examples

In 1971 Herbst et al reported that their case-control study of adenocarcinoma of the vagina in young women showed an association with maternal use of stilbestrol [24]. The case group consisted of 8 girls born in New England hospitals between 1946 - 1951 and treated between 1966 - 1969. They selected 4 controls per case. The data on oestrogens given to mothers in the relevant pregnancy were as follows:

Cases: 7/8

Controls: 0/32

P < 0.00001 (chi squared)

Herbst et al's discussion of their findings was integrated in terms of epidemiology, biology and clinical medicine. Their understated but clear-cut conclusion was that "... the results of this study suggest it is unwise to administer stilbestrol to women early in pregnancy." They did not flinch from the challenge because the case group was so small and the power of the study was low. Equally, they did not hedge their bets by saying case-control studies do not produce causal evidence. Let us contrast this with a recent case-control study.

Ismail et al studied risk factors for myocardial infarction (MI) in Pakistan in a case-control study [25]. They highlighted 8 risk factors in the abstract. Of these, six had odds ratios (ORs) = 3 and one had an OR = 0.04 (95% CI: 0.01 - 0.35). They concluded:

"...While this study does not establish a cause-effect relation ... it raises the possibility that several of the associated factors may be modifiable risk factors ...". "Based on our findings, we suggest that stringent ...". They then listed six public health actions based on their risk factors. This claim that the study design does not permit a causal interpretation, while proceeding to interpret it as causal, is not good epidemiology. This kind of contradictory reasoning is common, as shown in the abstracts of the Society for Epidemiological Research (SER) Conference 2008; examples include abstract 77 and abstract 378 [26].

Each risk factor needs to be interpreted using an appropriate causal framework, and with reference to the full scientific literature and not just the study's data. Implementing this solution will be tough, as it requires deep scholarship that transcends the disciplines that underpin causal understanding, including biology, pathology, epidemiology, statistics, social science and philosophy. Authors may be pressured by editors, referees and their own institutions into these mistakes on causality, but they remain responsible for them, so need to resist external pressures.

Mistake 5: Not providing appropriate, and appropriately adjusted, absolute and relative measures

Accurate age- and sex-specific rates underpin virtually everything we value highly in epidemiology. Other data summaries distort the basic epidemiological reality of such rates. How much time do we spend looking at age- and sex-specific rates, the building blocks of epidemiology? How much do we reflect on the distortions of other forms of data presentation? By choosing one pathway to analysis - usually relative measures such as the relative risk and the odds ratio - we close off other options. As a minimum, however, in recognition of their different messages, we should give absolute and relative measures. Relative measures are particularly prone to distortion, and some, such as the odds ratio, have an inbuilt exaggeration of the association. When we use measures such as ORs we should ensure they are adjusted to give valid relative measures [7,27].

The solution is important for epidemiology:

Solution V. Give numbers, rates and comparative measures - rates hold primacy - and adjust the summary measure if appropriate.

Examples

I have emphasised the importance of absolute measures, especially for health needs assessment, for more than 20 years [28]. The data in table 3, showing how different priorities seem when examined from an absolute compared to relative risk perspective, continue to surprise both practitioners and researchers [28-30]. The topic remains controversial, especially in the health inequalities arena [31,32].

Table 3. Deaths and SMRs* in male immigrants from the indian sub continent (aged 20 and over; total deaths = 4,352)

The odds ratio is particularly prone to giving results that are interpreted very differently (and often wrongly) from the corresponding absolute measure and even the corresponding relative measure. One of many examples that has drawn critical comment, diverting from the main message of the paper, is the work of Barnes and Bero, reporting that there was a strong association between conclusions of review articles and authors' affiliations with the tobacco industry [33]. The published odds ratio was 88.4 (95% CI: 16.4 -476.5). The actual data were that 10 of 75 (13.3%) reviews by non-tobacco-affiliated authors concluded that passive smoking was not harmful to health. By contrast 29 of 31 (96.1%) reviews by tobacco-affiliated authors reached this conclusion. The result from the odds ratio is at odds with actual data, the prevalence ratio (7.3), and the absolute risk difference (82.8%). This odds ratio was misinterpreted in the BMJ as a risk ratio.

The question of what odds ratios measure in case-control studies has been reviewed recently, with the conclusion that there is insufficient attention to this issue [34]. My work with Katherine MacGilchrist and Robin Prescott has shown that about 50% of the reports of odds ratios in four major medical journals in the year 2000 were contrary to epidemiological guidance on their presentation and/or interpretation (unpublished).

Mistake 6: Making public health recommendations from intervention studies that show specific benefits but not do not demonstrate general health benefits

We live in a specialist's world. We have cardiologists and cardiovascular epidemiologists who want to control cardiovascular disorders. But there is no point if there is no net benefit, for example, if costs and side-effects balance or even outweigh the benefits. We really need, at least from a health and health care perspective, a life expectancy and health expectancy specialism to dominate the scene. Conclusions from research on specific outcomes draw important but still-limited conclusions, and these should be tested against the goal of general benefits. Of course, specific outcomes help in the causal endeavour, where contradictory results are particularly informative, raising questions about why a particular factor increases one disease or outcome, while decreasing another. The solution here is obvious but it has wide-ranging repercussions.

Solution VI. Ensure general benefits (e.g. mortality/morbidity) exceed the general costs before recommending a public health or clinical application of a study showing a specific benefit.

Examples

The benefits and costs of HRT in relation to post-menopausal symptoms (beneficial), and cardiovascular disease and cancer (not beneficial) are well known and were discussed earlier. Vitamin A at birth reduces mortality, at least in many Asian populations. However, it does not seem to produce the same benefits in Guinea-Bissau in Africa [35-37]. Even in India and Pakistan, the benefits are contested now, and it will not be beneficial in that setting for ever [35-37]. A recent study reported that reducing glycated haemoglobin to 6% in the elderly will improve control of diabetes, much desired by diabetes specialists, but increase mortality, an unfortunate and unexpected side-effect [38,39]. By contrast, Gaede et al reported a multifactorial intervention for people with diabetes that reduced non-fatal cardiovascular disease, progression to end-stage renal failure, and all cause mortality - perhaps an exemplary set of outcomes [40].

Following this solution would require larger trials, but in return the results would be more readily applicable in population settings. Where a trial can only demonstrate cause-specific benefits, the authors need to temper their public health-related conclusions, and consider the possibility of harmful effects that negate the benefits. Further, the net benefit of an intervention will be dependent on the mix of conditions in each population. To take a simple example, if an intervention reduces CHD but increases cancer, it will probably have net benefits in populations where CHD is common and cancer rare, but probably net harm where the opposite applies. In reality, trials will often not be powered to demonstrate general health benefits (except when these are claimed for the intervention), so information on harm may need to come from alternative sources, such as health monitoring data. Public health recommendations should be tentative until such data are available.

Mistake 7: Failure by investigators and local health systems to utilise study data correctly to benefit health - a need for a higher authority providing a unified voice

Interpreting data correctly is among the highest intellectual endeavours in science, perhaps on a par with generating worthwhile hypotheses. Making health care and public health recommendations from data extends this skill. People who combine these skills are rare. The first skill needs razor sharp thinking on the scientific aspects of data, the second, similar capacity in relation to politics, policy, leadership, management and clinical care and public health. We can fail to apply data in two main ways - misapplication arising from misinterpretation, and non-application because the information has been set aside, or not brought to attention, or ignored.

There is an ethical imperative to act where it is warranted. Academic epidemiologists are, however, under pressure to research and teach, not to serve, and service-based clinicians and public health staff are under pressure to deliver services. The two worlds have been parting ways for some time [41,42]. The solution here is organisational.

Solution VII

Epidemiology needs to provide partners who apply research, including politicians, doctors, and public health specialists, with a unified voice. Is it not time for a World Council in Epidemiology and Causality that provides authoritative statements on epidemiological evidence and makes recommendation on when and how epidemiological data on associations are ready for application? I return to this question in the conclusions.

Example

The need for a unified voice is shown by 'Causality: A Frank Statement to Cigarette Smokers', the 1954 advertisement in US newspapers by 14 tobacco companies and trade associations, recently reprinted in the Lancet [43]. Among the statements about the relationship between tobacco and lung cancer were these:

"... experiments on mice have given wide publicity to a theory ...".

"... eminent doctors and research scientists have publicly questioned the claimed significance of these experiments."

"Distinguished authorities point out: That there is no agreement among the authorities regarding what the cause is "

(and 5 more points are made in a similar vein).

There will always be dissenting voices, and controversy can be exploited easily unless there is an authoritative voice that is trusted and independent. Such a voice is required to help apply important causal evidence, even when there is national hesitancy. Witness, for example, the failure to apply the knowledge that infants should be placed on their backs to sleep, to halve the risk of sudden infant death syndrome. Many European countries failed to apply this, leading to the unnecessary deaths of thousands of infants in Europe alone [44].

Conclusion

There are numerous guidelines, published over some decades, on how to undertake and publish epidemiological research [45,46], available at the EQUATOR website http://www.equator-network.org/index.aspx?o=1032; accessed 14/8/08 webcite. These enjoy interesting acronyms such as CONSORT, STROBE, PRISMA, etc. Journals provide detailed guidance to authors and referees. Books summarise these for students. So why do we not apply the guidance? I think that our human frailties, the innate limitations of our science, insufficient education and training, and pressures of time and resources combine, making it hard to avoid the kind of fundamental mistakes illustrated in this paper. If so, the lessons are that:

1. we need to pay attention to the development of ethical and rigorous epidemiologists of high integrity [5,47] with high-level conceptual, theoretical and technical skills;

2. we make the innate limitations of our discipline more explicit;

3. we reorganise our scientific endeavour to make a collective, focused and more unified approach possible.

The seventh solution asks us to create a unified voice by pooling our intellectual resources, and creating a new global authority, to which I have given a provisional title. A World Council on Epidemiology and Causality could, however, dampen innovation. Alternatively, it could hasten advances, and counter the onslaught of undigested associations that bewilder us and will be multiplying as computerised data mining, data linkage, genetic epidemiology, and grand-scale epidemiology on millions of study participants become commonplace. (The analogy here is to do for associations and causality what the Cochrane collaboration, and the UK National Institute for Clinical Excellence, is doing for effectiveness of interventions.) Epidemiologists guard their academic freedom zealously and are mistrustful, sceptical people, particularly in relation to institutions. Nonetheless, to counter criticisms about false findings [18], advance epidemiology, and properly engage the public, we need to try out such a Council, learn from the experience and find workable, collaborative, global solutions to the kinds of problems illustrated here.

Competing interests

The author declares that they have no competing interests.

Authors' contributions

The author is solely responsible for this manuscript from conceptualisation to writing.

Acknowledgements

This manuscript develops a presentation at the 18th IEA World Congress of Epidemiology, Brazil 2008: Course on Epidemiologic Research and New Directions

Session Theme: Dilemmas and conundrums from epidemiologic research: have we learned the lessons?

Paper title: Conundrums and Dilemmas in Epidemiology: 7 sins and 7 commandments

I thank my colleagues Dr Charles Agyemang (a self-acknowledged epidemiological sinner like me) for helpful advice, and Professor Aziz Sheikh for detailed critical commentary on an earlier draft. I also thank several referees for helpful criticisms.

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32.  Harper S, Lynch J, Meersman SC, Breen N, Davis WW, Reichman ME: An Overview of Methods for Monitoring Social Disparities in Cancer with an Example Using Trends in Lung Cancer Incidence by Area-Socioeconomic Position and Race-Ethnicity, 1992-2004.

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36.  Sachdev HP: Neonatal vitamin A supplementation and infant survival in Asia.

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41.  Bhopal R: The context and role of the US school of public health: implications for the United Kingdom.

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WHAT’S NEW IN MALE CIRCUMCISION: ITEMS FROM WWW.CHILDSURVIVAL.NET

The three published RCTs on reduction of HIV acquisition through male circumcision laid the basis for the UN recommendations in favor of medical circumcision of males. More recent research (see below) points to a protective effect against HPV as well.

Remarkably, the growth of medical circumcision in African countries continues even as San Francisco prepares to vote on a blanket ban on pediatric circumcisions, with no religious exemptions.  Who is proceeding on data based decision making: the governments of Africa, or the intactivists of California?

• NEW ESTIMATES OF THE POPULATION IMPACT OF CIRCUMCISION INTERVENTIONS 

‘Communities, and especially women, may benefit much more from circumcision interventions than had previously been predicted, and these results provide an even greater imperative to increase scale-up of safe male circumcision services.’

Sex Transm Infect 2011;87:88-93; Volume 87, Issue 2

This article is best viewed at http://sti.bmj.com/content/87/2/88.long

Abstract

Background

Mathematical modelling has indicated that expansion of male circumcision services in high HIV prevalence settings can substantially reduce population-level HIV transmission. However, these projections need revision to incorporate new data on the effect of male circumcision on the risk of acquiring and transmitting HIV.

Methods

Recent data on the effect of male circumcision during wound healing and the risk of HIV transmission to women were synthesised based on four trials of circumcision among adults and new observational data of HIV transmission rates in stable partnerships from men circumcised at younger ages. New estimates were generated for the impact of circumcision interventions in two mathematical models, representing the HIV epidemics in Zimbabwe and Kisumu, Kenya. The models did not capture the interaction between circumcision, HIV and other sexually transmitted infections.

Results

An increase in the risk of HIV acquisition and transmission during wound healing is unlikely to have a major impact of circumcision interventions. However, it was estimated that circumcision confers a 46% reduction in the rate of male-to-female HIV transmission. If this reduction begins 2 years after the procedure, the impact of circumcision is substantially enhanced and accelerated compared with previous projections with no such effect—increasing by 40% the infections averted by the intervention overall and doubling the number of infections averted among women.

• LESSONS LEARNED FROM THE FIRST YEAR OF MC IMPLEMENTATION IN NYANZA, KENYA

The authors reviewed health facilities for seven criteria for provision of male circumcision services:

1.       Room available for surgery (e.g., minor theater)
2.       Room available for recovery
3.       Trained and available staff
4.       Sterilization and infection control compliance
5.       HIV voluntary counseling and testing (VCT) and risk-reduction counseling
6.       STI syndromic diagnosis and treatment
7.       Provision and promotion of male and female condoms

Countries considering the promotion of male circumcision should consider doing likewise.

Best viewed at http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0018299

• MALE CIRCUMCISION IN EIGHT AFRICAN COUNTRIES 

EXCERPT FROM THE UN REPORT, 'AIDS AT 30: NATIONS AT THE CROSSROADS'

Medical circumcisions in eight African countries have risen to 350,000 per year from low baseline levels, according to this UN report. This, however, leaves millions of at risk males in eastern and southern Africa uncircumcised. Text below and at http://www.unaids.org/unaids_resources/aidsat30/aids-at-30.pdf page 66.

TEXT FROM UN REPORT:

'Over the past decade, a major tool for HIV prevention has emerged: voluntary medical male circumcision. To date, introduction of this breakthrough strategy has been slow, underscoring the need for urgent action to bring circumcision services to scale.

'At the time of the 2001 United Nations General Assembly Special Session, epidemiological patterns suggested that circumcised men might be less likely to become infected by HIV. However, no clinical trials had been performed that would provide definitive scientific evidence that medical circumcision of adult men reduced the odds of female-to-male sexual transmission.

'Beginning in 2005, a series of randomized controlled trials in sub-Saharan Africa found that circumcising adult men reduced their risk of infection by about 60%. These findings resulted in a major effort to introduce circumcision in settings with both high HIV prevalence and low levels of male circumcision. Male circumcision offers a partial reduction in HIV risk. Its main advantage is that, once performed, the risk reduction is life-long.

'The prevalence of circumcision varies considerably in sub-Saharan Africa. Although it is common in many areas, especially in West and Central Africa, most men are not circumcised in the Southern African countries most heavily affected by HIV. In nine countries in Southern Africa and four in Eastern Africa, less than 80% of adult men are circumcised. Outside Eastern and Southern Africa, only in the Central African Republic and Sudan are less than 80% of men circumcised.

• LOW RISK HPV AND MALE CIRCUMCISION IN YOUNG SOUTH AFRICAN MALES

‘This study shows a reduction in LR-HPV infection among circumcised men.’

Best read at http://www.ncbi.nlm.nih.gov/pubmed/21584275

• MALE CIRCUMCISION AND LOWER PREVALENCE OF HPV LESIONS IN KENYAN MEN

‘This study suggests that circumcision reduces the prevalence of HPV-associated flat lesions and may ultimately reduce male to female HPV transmission.’

Abstract below; full text, to subscribers, at http://onlinelibrary.wiley.com/doi/10.1002/ijc.26196/pdf

 International Journal of Cancer

Abstract

Human papillomavirus (HPV)-associated penile lesions in men may increase the risk of HPV transmission to their female partners. Risk factor data on HPV-associated penile lesions are needed from regions with a high burden of cervical cancer. Visual inspection of the penis was conducted using a colposcope at the 24-month visit among participants in a randomized controlled trial of male circumcision in Kenya, from May 2006 to October 2007. All photos were read independently by two observers for quality control.

Penile exfoliated cells sampled from the glans/coronal sulcus and the shaft were tested for HPV DNA using GP5+/6+ PCR and for HPV16, 18 and 31 viral loads using a real time PCR assay. Of 275 men, 151 were circumcised and 124 uncircumcised. The median age was 22 years.

Circumcised men had a lower prevalence of flat penile lesions (0.7%) versus uncircumcised (26.0%); adjusted odds ratio [OR]=0.02; 95% confidence interval [CI]: 0.003-0.1). Compared to men who were HPV-negative, men who were HPV DNA positive (OR=6.5; 95%CI: 2.4-17.5) or who had high HPV16/18/31 viral load (OR=5.2; 95%CI: 1.1-24.4) had higher odds of flat penile lesions. Among men with flat penile lesions, HPV56 (29.0%) and 16 (25.8%) were the most common types. Flat penile lesions are much more frequent in uncircumcised men, and associated with higher prevalence of HPV and higher viral loads. This study suggests that circumcision reduces the prevalence of HPV-associated flat lesions and may ultimately reduce male to female HPV transmission. © 2011 Wiley-Liss, Inc.

• EFFECT OF CIRCUMCISION OF HIV SERONEGATIVES ON HPV TRANSMISSION TO SERONEGATIVE WOMEN IN THE UGANDA
  • ·Bottom of Form

 ‘Our findings indicate that male circumcision should now be accepted as an efficacious intervention for reducing the prevalence and incidence of HPV infections in female partners. However, protection is only partial; the promotion of safe sex practices is also important.’

 Best viewed in full at

 http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)61967-8/fulltext

• CIRCUMCISION IN INDIA: TAKING THE ROAD LESS TRAVELED 

‘There is an immediate need to focus on circumcision as an important public health intervention at least coupled with the other preventive strategies like condom use, delayed sex onset, lesser number of partners, STDs management, HIV testing and counseling, and it can adequately reinforce our fight in preventing the HIV epidemic.’

Gude D. Circumcision in India: Taking the road less traveled. Indian J Public Health 54:228.

Full text: http://www.ijph.in/text.asp?2010/54/4/228/77268

• RISK COMPENSATION AMONG CIRCUMCISED MEN IN KENYA

‘The results of this study illustrate that MC does not necessarily lead to risk compensation, and that there are different behavior change outcomes.’

“When I Was Circumcised I Was Taught Certain Things”: Risk Compensation and Protective Sexual Behavior among Circumcised Men in Kisumu, Kenya

Best viewed at http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0012366

• ROLL-OUT OF ADULT CIRCUMCISION PRACTICES IN SOUTH AFRICA

As recently as 10 years ago, the Republic of South Africa had a president who denied the causal link between HIV and AIDS, and a health minister who promoted herbal remedies in preference to ARVs.

As Lissouba and colleagues show, things change.

Good reading. 

A Model for the Roll-Out of Comprehensive Adult Male Circumcision Services in African Low-Income Settings of High HIV Incidence: The ANRS 12126 Bophelo Pele Project

Best viewed at http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1000309

• RECOMMENDATIONS ON MALE CIRCUMCISION IN SOUTH AFRICA

This desk review of literature on male circumcision, also available at

http://www.malecircumcision.org/programs/documents/Review_MC_research_services_SA.pdf

comes from the first country in Africa to publish a randomized clinical trial on the impact of male circumcision on HIV acquisition in sexually active males. Given the progress of MC in neighboring countries, South Africa’s position is proof positive that ‘the first shall be last, and the last first.’

 Recommendations are at the foot of this Email.

 Country updates from other African countries are available online at

http://www.malecircumcision.org/programs/country_implementation_updates.html#progress_in_scaleup2

RECOMMENDATIONS

 The following recommendations from this review should be taken into consideration in

expanding, promoting and integrating MC into existing health services:

          Future expansion of circumcision services must be embedded within comprehensive HIV prevention programming, including informed consent, confidentiality, a stigma free environment, HIV counselling and testing and risk-reduction counselling.

         MC programmes should be designed to increase uptake of HCT and partner disclosure, as well as counselling to minimise MC in HIV positive men; priority should be placed on pairing MC roll-out with successful/innovative approaches such as home-based testing, integration of HCT with family planning clinics, male-oriented services).

          A plan for introduction of voluntary neonatal MC services within the provisions of the Children’s Act  of 2005 and integration of neonatal MC into existing maternal, women, neonatal and child health programmes must be drawn up.        

          MC must be delivered as part of a recommended minimum package which includes     counselling about risks and benefits of MC, counselling around risk reduction, HIV counselling and testing, couple counselling, condom promotion and provision, and STI management.

          A plan for reciprocal linking of traditional and medical MC is required. MC in traditional settings should include standards for infection control, pain management, and counselling on HIV prevention, sexual and reproductive health and rights of women and mechanisms to train traditional MC providers are urgently required. In addition, messaging around reduction of stigma and discrimination for males who opt for circumcision in clinical settings and before the age of traditional initiation is necessary.

          A forum be set up to ensure structured coordination and communication of activities and resources of donors and other stakeholders including policymakers, technical teams, private and public sector health providers.

         A culturally sensitive communications strategy for promoting acceptability and access to both adult and neonatal MMC and targeting both men and women for dissemination of consistent and correct packaging of messages around MC is critical.

         In order to address human resource challenges; service integration, task sharing, standardisation of methods and equipment, large scale training of health workers and integration of private health providers must be undertaken.

         The absence of existing mechanisms to monitor and evaluate the impact of the proposed national MC policy such as indicators for monitoring and evaluation, and quality assurance standards must be urgently addressed.

         Consideration should be given to the expansion of dedicated sexual and reproductive health services in SA, targeted at young men through schools and health facilities which could include MC as well as counselling on sexual health, substance abuse etc.

• TWO ON THE RESULTS OF THE LONDON PLEDGING CONFERENCE

1) GAVI PRESS RELEASE FROM THE LONDON PLEDGING CONFERENCE

GAVI Alliance poised to immunise more than 250 million children in developing countries by 2015 LONDON, 13 June 2011 – Major public and private donors achieved a milestone in global health today by committing funding to immunise more than 250 million of the world’s poorest children against life-threatening diseases by 2015 and prevent more than four million premature deaths. Donors committed US$ 4.3 billion at the first pledging conference held by the GAVI Alliance. This exceeds an initial target of $3.7 billion, enabling GAVI to reach more children faster than planned and to accelerate the introduction of new vaccines. A portion of the pledges are conditional upon GAVI raising additional funds from new donors in the future. Today’s pledges bring GAVI’s total available resources for the period 2011 to 2015 to $ 7.6 billion. The increased support is timely. GAVI recently reported a record 50 countries applied for vaccine funding during the Alliance’s latest application round – nearly double the previous record in 2007. This new support will allow GAVI to fully fund approved applications. “Today is an important moment in our collective commitment to protecting children in developing countries from disease,” said President of Liberia Ellen Johnson Sirleaf. “But every 20 seconds, a child still dies of a vaccine-preventable disease. There’s more work to be done.” The meeting convened prime ministers, ministers and high-level officials from donor and developing countries, leaders of UN Agencies, CEOs from private companies and senior civil society leaders to make commitments to support GAVI’s life-saving work. The meeting was hosted by the governments of the United Kingdom and Liberia and the Bill & Melinda Gates Foundation. Governments more than doubled their previous commitments and new donors will also give for the first time, including Japan and Brazil. GAVI’s largest corporate donor, “la Caixa” Foundation, extended its financial commitment and new donors Anglo American plc and Absolute Return for Kids (ARK) made their first pledges. Developing countries committed to maintain or increase the co-financing of their vaccine programmes and leverage the partnership to immunise their children. GAVI estimates that the total level of co-financing will triple to US$ 100 million by 2015. Vaccine manufacturers announced last week they will contribute by offering lower prices on a range of life-saving vaccines supported by GAVI, including a two-thirds reduction on the rotavirus vaccine, which combats the leading cause of diarrhea deaths. Co-financing and lower prices will enhance the sustainability of immunisation programmes. “GAVI was one of the very top performers in our root-and-branch review of the agencies that deliver British aid because it demonstrates tangible results. Britain will play its full part and our support to GAVI will help vaccinate over 80 million children and save 1.4 million lives. That’s one child vaccinated every two seconds for five years,” said David Cameron, UK Prime Minister. "For the first time in history, children in developing countries will receive the same vaccines against diarrhea and pneumonia as children in rich countries,” said Bill Gates, co-chair of the Bill & Melinda Gates Foundation. “Together we must do more to ensure that all children – no matter where they live – have equal access to life-saving vaccines.” Conference participants agreed that the momentum to reach more children with vaccines must be maintained and they encouraged GAVI to expand coverage of immunisation programmes and accelerate the introduction of new vaccines. It was also recognised that vaccine manufacturers should continue to deliver and expand on their promises to reduce vaccine prices and provide greater access, while the countries themselves should continue to meet their co-financing commitments. Participants also agreed to meet in two years time to review GAVI’s progress in immunisation and resource mobilisation. “Today was a vote of confidence for GAVI. But it was also a challenge to us: to keep delivering on our mission and to do even more. Nearly two million children die from vaccine-preventable diseases every year. The day will come when malaria and other killer diseases can be beaten with a simple shot in the arm. We must prepare for that day. Working with partners, GAVI will need to continue to raise the necessary resources to tackle all vaccine-preventable diseases,” said GAVI Alliance Board Chair Dagfinn Høybråten.

2) QUERY TO READERS

The London pledging meeting saw pledges to the GAVI Alliance of $4.3 billion. If you were on the GAVI Board, how would you propose  to spend the $600 million pledged today, over and above the $3.7 billion targeted primarily for pneumococcal and rotavirus vaccines? Reply to rdavis@africamail.com

WHAT’S NEW ON WWW.CHILDSURVIVAL.NET: THE 30^TH ANNIVERSARY OF AIDS

This month marks the thirtieth anniversary of the first detected case of AIDS. The UN has hosted a three day conference on the subject, with a report at http://www.unaids.org/unaids_resources/aidsat30/aids-at-30.pdf

• THE 30 YEARS’ WAR AGAINST AIDS

The Economist, Monday June 6th 2011

The 30 years war: Hard pounding is gradually bringing AIDS under control

‘[T]his is the sort of area where a single scientific breakthrough might, like the invention of AIDS-suppressing drugs and the discovery that those drugs could be used to break the chain of transmission, change everything.’

This article is best viewed at http://www.economist.com/node/18772276

• AIDS, 30 YEARS ON: A PODCAST FROM THE BBC WORLD SERVICE

Podcast,  http://www.bbc.co.uk/iplayer/console/p00gzd9c

• AIDS IN RETROSPECT: A PODCAST FROM THE ECONOMIST

A summary of three decades' experience, at http://www.economist.com/blogs/multimedia/2011/06/end-aids

• COVERAGE OF ANTIRETROVIRAL THERAPY AT THE END OF 2009 (WHO 2010 GUIDELINES, CD4<350)

Coverage of antiretroviral therapy at the end of 2009 (WHO 2010 Guidelines, CD4<350)

Burundi and Rwanda, neighboring countries at similar socio-economic levels. One is in the top quintile; the other, at the bottom.

Below, top and bottom quintiles; all quintiles and countries listed on page 45, AIDS AT 30, http://www.unaids.org/unaids_resources/aidsat30/aids-at-30.pdf

>80% COVERAGE

Botswana

Cambodia

Cuba

Guyana

Oman

Romania

Rwanda                  

0-20% COVERAGE

Burundi

Central African Republic

Colomiba

DRC

Djibouti

Egypt

Gambia

Iran

Kyrgyzstan

Latvia

Lebanon

Liberia

Madagascar

Maldives

Mongolia

Myanmar

Nepal

Pakistan

Republic of Moldova

Russian Federation

Sierra Leone

Somalia

Sri Lanka

Sudan

Tajikistan

Ukraine

• ANTIRETROVIRALS PROTECT PARTNERS FROM HIV

A randomized clinical trial in developed and developing countries has shown dramatic declines in HIV transmission among serodiscordant heterosexual couples when ARVs are started early in HIV seropositives.

'This breakthrough is a serious game changer and will set the prevention revolution forward,' according to Michel Sidibe, head of UNAIDS.

This update should be read in tandem with two others, 'HIV prevalence in Zimbabwe,' which calls for early inception of ARV treatment, and 'Provider Initiated HIV Testing.' According to the latter article, '‘The introduction of routine PITC using lay counsellors into health-care clinics in Lusaka, Zambia, dramatically increased the uptake and acceptability of HIV testing.’

Timely and early treatment cannot begin when at risk persons remain ignorant of their serostatus. Provider initiated HIV testing may have to supplement VCT if the proportion of those getting themselves tested is to rise.

National Institute of Allergy and Infectious Diseases (NIAID)
http://www.niaid.nih.gov

Treating HIV-infected People with Antiretrovirals Protects Partners from Infection

Findings Result from NIH-funded International Study

Men and women infected with HIV reduced the risk of transmitting the virus to their sexual partners by taking oral antiretroviral medicines when their immune systems were relatively healthy, according to findings from a large-scale clinical study sponsored by the National Institute of Allergy and Infectious Diseases (NIAID), part of the National Institutes of Health.

• HIV TREATMENT AS PREVENTION

Lancet editorial:

Last week any doubts around treatment as an approach to halt the spread of the HIV epidemic were allayed. An international study showed that antiretroviral treatment can prevent the sexual transmission of HIV among heterosexual couples in whom one partner is HIV-infected and the other is not. UNAIDS described the result as a “serious game changer” for HIV prevention. The phase 3 clinical trial, HPTN 052, was done by the HIV Prevention Trials Network and funded by the US National Institutes of Health. It was due to run until 2015, but compelling interim results led the international data and safety monitoring board to recommend the results be publicly released as soon as possible. Although the results are unsurprising given the extensive ecological data supporting the prevention benefi ts of treatment, this is the first large randomised trial to provide a true impact evaluation. The study showed a 96% reduction in risk of HIV transmission—the primary outcome. The trial began in 2005 and enrolled 1763 HIV serodiscordant couples across 13 sites in nine countries in Asia, Africa, and the USA. At enrolment, the HIVpositive partner was required to have a CD4 cell count between 350 and 550 cells per μL. The median CD4 count at enrolment was 436 cells per μL. This level is higher than WHO’s recommendation to start treatment, which is at 350 cells per μL or less. This diff erence is important because the HIV-positive individuals were asymptomatic, did not require treatment, and certainly would not have been eligible for treatment, according to most national guidelines. Couples were randomised so that the HIVpositive partner received antiretrovirals immediately, or delayed treatment until their CD4 counts fell below 250 cells per μL, or had an AIDS-related event such as pneumocystis pneumonia. Throughout the study both groups received the same amount of HIV-related care and counselling. Among the 877 couples in the delayed group, 27 HIV transmissions occurred compared with one transmission in the immediate group. This diff erence was highly statistically signifi cant (p<0•0001). Furthermore, the new infections were confi rmed as being genetically linked to the HIV-positive partners, though there were a cluster of unlinked cases, raising the issue of concurrency. The study also found a statistically signifi cant reduction in extrapulmonary tuberculosis with 17 cases in the delayed group versus three cases in the immediate group. Study participants and investigators have been informed of the results and all participants off ered the appropriate care. All study participants will be followed for at least 1 more year. Clearly, treating sooner rather than later results in both a clinical benefi t for the individual and has a potentially enormous public health benefi t in slowing the spread of infection. These results are likely to provide a new level of dialogue between physician and patient. Besides emphasising the benefit of medication adherence to the patient, clinicians could stress how it has the potential to benefit others alongside other altruistic practices such as condom use. Indeed, one of the most interesting observations was that most patients adhered to treatment and 95% had viral load suppressed at all times, which is a rare outcome for an HIV clinical trial. Treatment as prevention should decrease stigma and improve uptake of testing because there is more of an incentive for people to know their status with the reassurance of knowing that if treated early they are unlikely to infect others. Many interesting research questions now lie ahead. But most urgent will be the assessment of the practical impact of these fi ndings and their public health importance in generalised epidemics. Another immediate issue will be to refl ect these fi ndings in ongoing and future prevention trials. Certainly in discordant couples it will be unethical not to offer treatment to infected people. Findings now need to be translated into policy and action. Agencies such as President’s Emergency Plan For AIDS Relief and the Global Fund to Fight AIDS, Tuberculosis and Malaria need to reassess their prevention portfolios and consider diverting funds from programmes with poor evidence (such as behavioural change communication) to treatment for prevention. There is now an ethical imperative for guidelines to be revised to start treatment much earlier than recommended. But, with 6 million people on treatment and another 9 million needing treatment, how to fund and sustain such an endeavour with functioning health systems and a suffi cient workforce will be a huge challenge. One needs to take this data yet to be peer reviewed and published with caution. But if true, these findings present an opportunity to make a big difference in the epidemic over the next few years. ■ The Lancet

Editorial www.thelancet.com Vol 377 May 21, 2011 1719
For the National Institutes of Health news release on the HPTN 052 trial see
http://www.niaid.nih.gov/news/newsreleases/2011/Pages/HPTN052.aspx

 
For more on the HPTN 052 trial see

http://www.hptn.org/web%20documents/PressReleases/HPTN052PressRelease FINAL5_12_118am.pdf

• UNDER-FIVE MORTALITY FROM AIDS: REGIONAL TRENDS

‘[I]n 2009, HIV accounted for roughly 2.1% (1.2–3.0%) of under-5 deaths in low- and middle-income countries and 3.6% (2.0–5.0%) in sub-Saharan Africa. The percentage of under-5 deaths due to HIV has been falling in the last decade. . . .

‘The fall in under-5 deaths due to HIV has been driven by a combination of factors, including scale-up of prevention of mother-to-child transmission and treatment for pregnant women and children as well as a decrease in HIV prevalence among pregnant women.’

Best viewed at http://sti.bmj.com/content/86/Suppl_2/ii56.long

• THE HISTORY OF AIDS: HEROES AND VILLAINS

The history of AIDS : Heroes and villains

The story of AIDS involves many larger-than-life characters, good and bad

The Economist, Jun 2nd 2011 | from the print edition

http://www.economist.com/node/18772268

• THE END OF AIDS?

A video from The Economist, at http://www.economist.com/blogs/multimedia/2011/06/end-aids
with a retrospective look at 30 years of HIV/AIDS.

• TOWARDS AN IMPROVED INVESTMENT APPROACH FOR AN EFFECTIVE RESPONSE TO HIV/AIDS

 ‘Our framework incorporates major efficiency gains through community mobilisation, synergies between programme elements, and benefits of the extension of antiretroviral therapy for prevention of HIV transmission.. . .  Implementation of the new investment framework would avert 12·2 million new HIV infections and 7·4 million deaths from AIDS between 2011 and 2020 compared with continuation of present approaches, and result in 29·4 million life-years gained. The framework is cost effective at $1060 per life-year gained, and the additional investment proposed would be largely offset from savings in treatment costs alone.’

 The Lancet, Early Online Publication, 3 June 2011

Best viewed at http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)60702-2/fulltext

• HIV SURVEILLANCE, UNITED STATES – 1981—2008

'At the end of 2008, an estimated 1,178,350 persons aged ≥13 years in the United States were living with HIV infection, including 20.1% whose infections had not been diagnosed. HIV prevalence per 100,000 population was 1,819 among blacks or African Americans, 593 among Hispanics or Latinos, and 238 among whites. Nearly 50% of those living with HIV infection were men who have sex with men.’

The first medical publication on HIV was in the Morbidity and Mortality Weekly Report, 1981. This retrospective view is from the MMWR.

 Best viewed at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6021a2.htm?s_cid=mm6021a2_w

WHAT’S NEW BEFORE THE LONDON DONORS’ MEETING

In the run-up to the GAVI sponsored pledging meeting for new and underused vaccines, which starts on 13 June, I am highlighting, from the media and from the medical literature, five items on vaccine pricing. Among vaccines currently prequalified by WHO, those most likely to impact MDG 4 and MDG 5 are pneumococcal vaccine, rotavirus vaccine, and human papillomavirus vaccine.

All articles are at www.childsurvival.net

• TWO ON VACCINE PRICING

1)      UNICEF’s recent publication of vaccine prices paid to individual manufacturers, accessible at

http://www.unicef.org/supply/index_57476.html , is a step forward in transparency in vaccine procurement, and will assist other vaccine purchasers in doing price comparisons. Industrialized countries should bear in mind that ‘tiered pricing’ makes unit prices much lower for developing than for developed countries.

2)      FOR FIRST TIME, UNICEF REVEALS DIFFERENCES IN PRICES IT PAYS DRUG COMPANIES FOR VACCINES

By DONALD G. McNEIL Jr.

Published: New York Times, May 27, 2011

The United Nations Children’s Fund on Friday publicly listed for the first time the price it pays for vaccines.

The decision — which immediately revealed wide disparities in what vaccine makers charge — could lead to drastic cuts in prices for vaccines that save millions of children’s lives.

Unicef paid $747 million for vaccines last year, buying over two billion doses for 58 percent of the world’s children.

This Bloomberg News item on price cuts to GAVI and to 'graduating GAVI' countries. In terms of current GAVI expenditure, the cuts in the cost of pentavalent are most important. Will HPV, as well as pneumo and rotavirus vaccines, now become affordable to GAVI eligible and GAVI 'graduating' countries?

GlaxoSmithKline Plc (GSK) and Merck & Co. agreed to lower prices for vaccines to protect children against potentially deadly diarrhea, supporting an international effort to help least-developed nations fight diseases. The GAVI Alliance, set up by Microsoft Corp. (MSFT) founder Bill Gates to give the world’s poorest people better access to life- saving immunizations, also received commitments from India-based drugmakers Serum Institute of India Ltd. and Panacea Biotec Ltd. (PNCB) to cut the price of a key pediatric vaccine, it said today. The agreements will help the alliance prevent an extra 4 million deaths by 2015 by rolling out new vaccines to tackle the main killers of children: pneumonia and diarrhea. The Geneva- based group’s donors and partners are meeting in London next week as they seek $3.7 billion to expand immunization programs over the next five years.

• GAVI REACTION TO VACCINE PRICE CUTS

GAVI welcomes lower prices for life-saving vaccines

www.gavialliance.org

Manufacturer commitments will help GAVI vaccinate millions of children in least-developed countries

Geneva, 6 June 2011 – In the lead up to its first pledging conference on June 13, the GAVI Alliance announced today it has achieved commitments from two emerging market vaccine manufacturers to lower prices for the life-saving pentavalent vaccine, which protects against five deadly diseases. Developed country manufacturers have also offered price reductions on rotavirus and human papillomavirus, or HPV, vaccines.

• COST AND FINANCING ISSUES LIMIT ACCESS TO THE HPV VACCINE

‘Cervical cancer . . . is the leading cancer in women in half the countries of the world and mostly affects relatively young poor women. But the vaccine cost is too high. With the availability of cost-effective, safe vaccine, there is real hope for reducing the global burden of cervical cancer.’

• HPV VACCINATION FOR GHANA?

Copyright © Ghana Medical Association 2010

Is Routine Human Papillomavirus Vaccination an Option for Ghana?

A K Edwin

Text is at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2994148/?tool=pubmed

Summary

Cervical cancer remains an important public health problem in developing countries where over 80% of the global burden occurs annually but screening has been ineffective. In a polygamous country like Ghana with a high incidence of cervical cancer but no national screening program, the Human Papilloma Virus (HPV) vaccine presents a unique opportunity to reduce the burden of HPV infection and cervical cancer in Ghanaian women. The evidence so far indicates that the vaccines are safe and efficacious. Although routine HPV vaccination of girls raises several religious, political, socioeconomic and ethical challenges, the emphasis of this paper will be on addressing the ethical challenges using the principles of autonomy, beneficence, non-maleficence and justice as a framework. Parental autonomy can be preserved with judicious exemptions for those who decline the vaccine on religious and philosophical grounds. This promotes public health without trampling parental authority. Routine HPV vaccination confers several benefits to individuals and society by preventing HPV infection. Instead of causing harm; it reduces harm by preventing the development of about 70% of cervical cancers and removing the negative physical and psychological impact of a cervical cancer diagnosis. It also has the potential to reduce the disparities in cervical cancer rates and its cost effectiveness will ensure considerable cost savings in terms of the money spent on diagnosis and treatment. Consequently, the HPV vaccine is an important public health landmark and achievement in women's health that must be heralded, especially in developing countries where the bulk of the disease and death occur.

• VACCINES AGAINST CANCER: THE GAVI VIEW

While hep B vaccine is now given in almost all countries, HPV is given, to my knowledge, only in one African country.

Will the London pledging conference of 9 June find funds for HPV?

http://www.gavialliance.org/media_centre/statements/2010_02_04_uicc.php 

Increasing access to vaccines will reduce the global burden of cancer

The GAVI Alliance, the American Cancer Society, and LIVESTRONG® welcome the campaign Cancer can be prevented,  which the International Union Against Cancer (UICC) is launching on February 4, World Cancer Day. On this occasion, the UICC will also release a new report on cancer prevention with a specific focus on cancers caused by infections.

• PROJECTIONS OF GLOBAL HEALTH OUTCOMES FROM 2005 TO 2060 USING THE INTERNATIONAL FUTURES INTEGRATED FORECASTING MODEL

‘The base model projects that deaths from communicable diseases (CDs) will decline by 50%, whereas deaths from both non-communicable diseases (NCDs) and injuries will more than double. Considerable cross-national convergence in life expectancy will occur.’

Full text is at http://www.who.int/bulletin/online_first/10-083766.pdf

• DOES RECESSION REDUCE GLOBAL HEALTH AID? EVIDENCE FROM 15 HIGH-INCOME COUNTRIES, 1975–2007

‘Any important decrease in overall DAH following the current economic recession would have little historical precedent and claims of inevitability would be unjustifiable.’

Full text is at http://www.who.int/bulletin/volumes/89/4/10-080663/en/index.html

Objective To test the hypothesis that economic recessions lead to reduced global development assistance for health (DAH).

Methods Data obtained from the Creditor Reporting System of the Organisation for Economic Co-operation and Development (OECD) for 15 OECD countries were used to model the percentage change (relative difference) in commitments and disbursements for DAH as a function of three measures of economic recession: recessionary year (as a dummy variable with 0 for no recession and 1 for recession), percentage change in per capita gross domestic product and percentage point change in unemployment rate for recessionary cycles from 1975 through 2007. We looked for an association both during the concurrent recessionary year and one and two years later.

 Findings No statistically significant association was found in the short or long run between measures of economic recession and the amount of official DAH committed or disbursed.

 Conclusion Any important decrease in overall DAH following the current economic recession would have little historical precedent and claims of inevitability would be unjustifiable.

• ·         EFFECT OF DEEP TUBE WELL USE ON CHILDHOOD DIARRHOEA IN BANGLADESH

‘The introduction of deep tube wells to reduce arsenic in drinking water in rural Bangladesh had the additional benefit of lowering the incidence of diarrhoea among young children.’

‘A 1°C increase in temperature at 4 months lag resulted in a 2-fold increase of cholera cases, and an increase of 200 mm of rainfall at 2 months lag resulted in a 1.6-fold increase of cholera cases.’

Abstract below; full text online to subscribers of Am J Trop Med Hyg

• CLIMATE VARIABILITY AND THE OUTBREAKS OF CHOLERA IN ZANZIBAR, EAST AFRICA: A TIME SERIES ANALYSIS

Abstract.

Global cholera incidence is increasing, particularly in sub-Saharan Africa. We examined the impact of climate and ocean environmental variability on cholera outbreaks, and developed a forecasting model for outbreaks in Zanzibar. Routine cholera surveillance reports between 1997 and 2006 were correlated with remotely and locally sensed environmental data. A seasonal autoregressive integrated moving average (SARIMA) model determined the impact of climate and environmental variability on cholera. The SARIMA model shows temporal clustering of cholera. A 1°C increase in temperature at 4 months lag resulted in a 2-fold increase of cholera cases, and an increase of 200 mm of rainfall at 2 months lag resulted in a 1.6-fold increase of cholera cases. Temperature and rainfall interaction yielded a significantly positive association (P < 0.04) with cholera at a 1-month lag. These results may be applied to forecast cholera outbreaks, and guide public health resources in controlling cholera in Zanzibar.

 Full text is at http://www.who.int/bulletin/online_first/10-085530.pdf

 CIRCUMCISED HIV-INFECTED MEN AND HPV TRANSMISSION

 ‘Male circumcision is important for reduction of not only HIV infection but also HPV infection in HIV-negative men and their female partners. However, its efficacy in reducing HPV transmission seems restricted to HIV-negative men; thus, the results of increasing numbers of reports suggest the need for early circumcision to achieve maximum effectiveness in populations with a high incidence of HIV and cervical cancer. To achieve maximum reductions in HIV and HPV infections and their related diseases in women, both male circumcision and HPV vaccination of the population should be delivered before sexual debut.’

The Lancet Infectious Diseases, Early Online Publication, 12 April 2011

This comment by Guiliano and colleagues, text also at http://www.thelancet.com/journals/laninf/article/PIIS1473-3099(11)70038-X/fulltext
refers to a study by Tobian and colleagues, text and graphics available at
http://www.thelancet.com/journals/laninf/article/PIIS1473-3099(11)70038-X/fulltext

Acccess this item at http://www.childsurvival.net/?content=com_articles&artid=550

• TWO ON VACCINE PRICING

A)      VACCINE PRICING: THE UNICEF EXPERIENCE

One has to be cautious about generalizations. The world is moving from the ‘nickel and dime’ vaccines of the 1970s, when WHO created EPI, to a new ball game, where both increased transparency and the entry of new players in the game may serve to reduce the relative rigidities which have characterized pricing of some vaccines provided through the GAVI Alliance.

One has to wonder what will happen to prices in the polio posteradication era if UNICEF procures either IPV or hexavalent vaccine (pentavalent with IPV) on a large scale. Many believe that IPV is essential to stopping circulating vaccine derived poliovirus (cVDPV).

B) http://www.nytimes.com/2011/05/28/health/28vaccine.html?emc=tnt&tntemail1=y

Access this item at http://www.childsurvival.net/?content=com_articles&artid=557

• DECLINES IN HOUSEHOLD SMOKING AND IN OTITIS MEDIA, US

With No Tobacco Day on 31 May,  another item on tobacco and kids

 ‘This is the first study to quantify average annual decreases in paediatric encounters for OM over the past decade and a half. The observed steadily increasing trend in smoke-free households since the mid-1990s is the main explanatory factor whose influence cannot be excluded over this entire time period. The importance of smoke-free rules in homes to protect children from exposure to SHS has further significance, given the range of adverse effects that SHS exposure has on child health.’

 Article best viewed at http://tobaccocontrol.bmj.com/content/20/3/207.full

Access this item at http://www.childsurvival.net/?content=com_articles&artid=558

• ·         TRENDS IN SELECTIVE ABORTION OF GIRLS IN INDIA

The Lancet, Early Online Publication, 24 May 2011

Trends in selective abortions of girls in India: analysis of nationally representative birth histories from 1990 to 2005 and census data from 1991 to 2011

Prof Prabhat Jha DPhil a , Maya A Kesler MSc a, Prof Rajesh Kumar MD b, Prof Faujdar Ram PhD c, Usha Ram PhD a c, Lukasz Aleksandrowicz MSc a, Diego G Bassani PhD a, Shailaja Chandra IAS d, Jayant K Banthia PhD e

This article is best viewed at http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)60649-1/fulltext

Summary

Background

India's 2011 census revealed a growing imbalance between the numbers of girls and boys aged 0—6 years, which we postulate is due to increased prenatal sex determination with subsequent selective abortion of female fetuses. We aimed to establish the trends in sex ratio by birth order from 1990 to 2005 with three nationally representative surveys and to quantify the totals of selective abortions of girls with census cohort data.

Methods

We assessed sex ratios by birth order in 0·25 million births in three rounds of the nationally representative National Family Health Survey covering the period from 1990 to 2005. We estimated totals of selective abortion of girls by assessing the birth cohorts of children aged 0—6 years in the 1991, 2001, and 2011 censuses. Our main statistic was the conditional sex ratio of second-order births after a firstborn girl and we used 3-year rolling weighted averages to test for trends, with differences between trends compared by linear regression.

Findings

The conditional sex ratio for second-order births when the firstborn was a girl fell from 906 per 1000 boys (99% CI 798—1013) in 1990 to 836 (733—939) in 2005; an annual decline of 0·52% (p for trend=0·002). Declines were much greater in mothers with 10 or more years of education than in mothers with no education, and in wealthier households compared with poorer households. By contrast, we did not detect any significant declines in the sex ratio for second-order births if the firstborn was a boy, or for firstborns. Between the 2001 and 2011 censuses, more than twice the number of Indian districts (local administrative areas) showed declines in the child sex ratio as districts with no change or increases. After adjusting for excess mortality rates in girls, our estimates of number of selective abortions of girls rose from 0—2·0 million in the 1980s, to 1·2—4·1 million in the 1990s, and to 3·1—6·0 million in the 2000s. Each 1% decline in child sex ratio at ages 0—6 years implied 1·2—3·6 million more selective abortions of girls. Selective abortions of girls totalled about 4·2—12·1 million from 1980—2010, with a greater rate of increase in the 1990s than in the 2000s.

Access this item at http://www.childsurvival.net/?content=com_articles&artid=548

• ·         RAPID IMPLEMENTATION OF AN INTEGRATED LARGE-SCALE HIV COUNSELING AND TESTING, MALARIA, AND DIARRHEA PREVENTION CAMPAIGN IN RURAL KENYA

'Through integrated campaigns it is feasible efficiently to cover large proportions of eligible adults in rural underserved communities with multiple disease preventive services simultaneously achieving various national and international health development goals.'

This article is best read at http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0012435

Access this item at http://www.childsurvival.net/?content=com_articles&artid=553

Background

Integrated disease prevention in low resource settings can increase coverage, equity and efficiency in controlling high burden infectious diseases. A public-private partnership with the Ministry of Health, CDC, Vestergaard Frandsen and CHF International implemented a one-week integrated multi-disease prevention campaign.

Method

Residents of Lurambi, Western Kenya were eligible for participation. The aim was to offer services to at least 80 percent of those aged 15-49. 31 temporary sites in strategically dispersed locations offered: HIV counseling and testing, 60 male condoms, an insecticide treated bednet, a household water filter for women or an individual filter for men, and, for those testing positive, a 3 month supply of cotrimoxazole and referral for follow-up care and treatment.

Findings

Over 7 days, 47,311 people attended the campaign with a 96 percent uptake of the multi-disease preventive package. Of these, 99.7 percent were tested for HIV (87 percent in the target 15-49 age group); 80 percent had previously never tested. 4 percent of those tested were positives, 61 percent were women (5 percent of women and 3 percent of men), 6 percent had median CD4 counts of 541cell/ml (IQR; 356, 374). 386 certified counselors attended to an average 17 participants per day, consistent with recommended national figures for mass campaigns. Among women, HIV infection varied by age, and was more likely with an ended marriage (e.g. widowed vs. never married, OR 3.91; 95 percent VCI, 2.8705.34), and lack of occupation.

In men, quantitatively stronger relationships were found (e.g. widowed vs. never married, OR 7.0; 95 percent VI 3.5-13.9). always using condoms with a non-steady partners was more common among HIV infected women participants who knew their status compared to those who did not (OR 5.4, 95 percent CI, 2.3-128.).

Conclusion

Through integrated campaigns it is feasible to efficiently cover large proportions of eligible adults in rural underserved communities with multiple disease preventive services simultaneously achieving various national and international health development goals.

The way to go after 2015? Full text is  also at

http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1001031 

Summary Points

• A coalition of civil society organizations and academics are initiating a Joint Action and Learning Initiative on National and Global Responsibilities for Health (JALI) to research key conceptual questions involving health rights and responsibilities, with the goal of securing a global health agreement and supporting civil society mobilization around the human right to health.
• This agreement—such as a Framework Convention on Global Health—would inform post-Millennium Development Goal (MDG) global health commitments.
• Using broad partnerships and an inclusive consultation process, JALI seeks to clarify the health services to which everyone is entitled under the right to health, the national and global responsibilities for securing this right, and global governance structures that can realize these responsibilities and close major health inequities.
• Mutual benefits to countries in the Global South and North would come from a global health agreement that defines national and global health responsibilities.
• JALI aims to respond to growing demands for accountability, and to create the political space that could make a global health agreement possible.

The Joint Action and Learning Initiative: Towards a Global Agreement on National and Global Responsibilities for Health

Lawrence Gostin and colleagues discuss their work on the Joint Action and Learning Initiative on National and Global Responsibilities for Health (JALI), which aims to secure a global health agreement (such as a Framework Convention on Global Health) that would inform post-Millennium Development Goal global health commitments.

Top of Form

Lawrence O. Gostin^1*, Eric A. Friedman¹, Gorik Ooms², Thomas Gebauer³, Narendra Gupta⁴, Devi Sridhar⁵, Wang Chenguang⁶, John-Arne Røttingen⁷, David Sanders⁸

1 O'Neill Institute for National and Global Health Law, Georgetown University Law Center, Washington, D.C., United States of America, 2 Institute of Tropical Medicine, Antwerp, Belgium, 3 Medico International, Frankfurt, Germany, 4 Prayas, Chittorgarh, India, 5 Oxford University, Oxford, United Kingdom, 6 Tsinghua University Law School, Beijing, China, 7 Norwegian Knowledge Centre for the Health Services, Oslo, Norway and Institute of Health and Society, University of Oslo, Oslo, Norway, 8 School of Public Health, University of the Western Cape, Bellville, South Africa

Citation: Gostin LO, Friedman EA, Ooms G, Gebauer T, Gupta N, et al. (2011) The Joint Action and Learning Initiative: Towards a Global Agreement on National and Global Responsibilities for Health. PLoS Med 8(5): e1001031. doi:10.1371/journal.pmed.1001031

Published: May 10, 2011

Copyright: © 2011 Gostin et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Funding: No direct funding was received for this study.

Competing interests: Thomas Gebauer works for Medico International, a Germany-based nongovernmental organization. No other author declares a competing interest.

Abbreviations: JALI, Joint Action and Learning Initiative on National and Global Responsibilities for Health; MDG, Millennium Development Goal; NGO, nongovernmental organization; UN, United Nations; WHO, World Health Organization

* E-mail: gostin@law.georgetown.edu

Provenance: Not commissioned; externally peer reviewed.

Summary Points

• A coalition of civil society organizations and academics are initiating a Joint Action and Learning Initiative on National and Global Responsibilities for Health (JALI) to research key conceptual questions involving health rights and responsibilities, with the goal of securing a global health agreement and supporting civil society mobilization around the human right to health.
• This agreement—such as a Framework Convention on Global Health—would inform post-Millennium Development Goal (MDG) global health commitments.
• Using broad partnerships and an inclusive consultation process, JALI seeks to clarify the health services to which everyone is entitled under the right to health, the national and global responsibilities for securing this right, and global governance structures that can realize these responsibilities and close major health inequities.
• Mutual benefits to countries in the Global South and North would come from a global health agreement that defines national and global health responsibilities.
• JALI aims to respond to growing demands for accountability, and to create the political space that could make a global health agreement possible.

Introduction Top

A decade into the 21st century, billions of people have yet to benefit from the health advances of the 20th century. Life expectancy at birth in sub-Saharan Africa is 53 years [1]—only two years higher than in the United States a century ago [2], and 27 years lower than in high-income countries today [1]. The most basic human needs continue to elude the world's poorest people. In 2010, approximately 925 million people were suffering from chronic hunger [3], 884 million people lacked access to clean water, and 2.6 billion people were without access to proper sanitation facilities [4].

Such global health disparities will likely persist until there is fair and effective global governance for health—the organization of national and global norms, institutions, and processes that collectively shape the health of the world's population. Global governance for health goes beyond the health sector. It requires remediating the currently unfair and detrimental health impacts of international regimes (e.g., trade, intellectual property, and finance), and developing stable, responsive, democratic political institutions.

A coalition of civil society and academics, with a shared vision of the “right of everyone to the enjoyment of the highest attainable standard of physical and mental health” [5] (“right to health”), is therefore launching the Joint Action and Learning Initiative on National and Global Responsibilities for Health (JALI). JALI seeks to develop a post–Millennium Development Goal (MDG) framework for global health, one rooted in the right to health and aimed at securing universal health coverage for all people. We seek to clarify the health goods and services to which all people are entitled, national and global responsibilities to secure the health of the world's population, and governance structures required to realize these responsibilities. Our goal is a global agreement, such as a Framework Convention on Global Health, which sets priorities, clarifies national and international responsibilities, ensures accountability, and develops corresponding institutions, such as a Global Health Fund [6],[7].

Partnerships with Civil Society Organizations Top

JALI will draw inspiration from, and collaborate with, civil society movements, which are central to securing and ensuring adherence to a global health agreement. Such movements have spurred momentous transformations in health. Advocates changed the world's response to AIDS from one marked by discrimination to one focused on empowering marginalized people and scaling up HIV services. The Campaign to Ban Landmines drove a process that culminated in a treaty banning this indiscriminate weapon.

Civil society campaigns for the right to health, such as those through the People's Health Movement, are already underway [8]. Nongovernmental organizations (NGOs) from the South and North launched a Declaration of Solidarity for a Unified Movement for the Right to Health [9]. JALI is developing the partnerships required to undertake an inclusive process involving research, analysis, and extensive online and regional consultations to gain insight into and build consensus around answers to four foundational questions, and to stimulate coordinated action to reduce health inequities. This bottom-up, research-focused process will develop a detailed understanding of health rights and state obligations, clear targets and benchmarks for success, and effective monitoring and accountability mechanisms. These will add precision to and enhance the effectiveness of international human rights law, which could in turn enhance civil society efforts to hold their own governments to account. By drawing on the voices of civil society and disadvantaged communities, JALI could have the legitimacy and the political support to transform global governance for health.

Four Defining Questions in Global Health Top

The four defining questions, and preliminary directions on answers, are:

1. What are the services and goods guaranteed to every person under the human right to health?

The World Health Organization (WHO) has placed universal health coverage high on the global health agenda [10], defining three dimensions of coverage: 1) the proportion of the population served; 2) the level of services; and 3) the proportion of health costs covered by prepaid pooled funds [11]. WHO has defined universal coverage “as access to key promotive, preventive, curative and rehabilitative health interventions for all at an affordable cost” [12].

The human right to health, an international treaty obligation, provides critical insight into how states should work towards universal coverage (Figure 1). Core obligations offer benchmarks to assess progress towards universal coverage, such as non-discrimination, equitable distribution of health facilities, and essential services for all, including those addressing underlying determinants of health [13].

Figure 1. Universal health coverage and the right to health.

The pooled funds represent the total amount of funding that states have available to expand universal health coverage along three dimensions: 1) who is covered, and the proportion of population covered; 2) what services are covered; and 3) the extent to which the state covers the cost of these services. Under a right to health approach, this total level of funding will be derived from the maximum of available resources that states are required to dedicate to the right to health and other rights.

doi:10.1371/journal.pmed.1001031.g001

The core principle of equality requires states to prioritize covering 100% of their populations. Although 100% coverage of all health services will not be possible immediately, full coverage of “key” health interventions should be an initial benchmark towards universal coverage. The right to health framework militates against a narrow definition of “key” services. Rather, these should encompass WHO's health system building blocks (e.g., services, workforce, information, financing, and governance); essential vaccines, medicines, and technologies; and fundamental human needs (e.g., sanitation, nutritious food, potable water, safe housing, vector abatement, tobacco control, and healthy environments).

Critically, universal coverage should be re-conceptualized to encompass fundamental human needs given their major impact on health. Within this framework, specific services would be determined nationally through participatory processes [14].

The provision of each of these core entitlements—health systems, essential vaccines and medicines, and fundamental human needs—should represent only one significant step towards achieving the highest attainable standard of health. States, even wealthy ones, will need to continue to progress towards universal coverage. The right to health requires states to spend the “maximum of…available resources” towards progressively realizing health and other socioeconomic rights [5]. Thus, under international law, states have a duty “to move as expeditiously and effectively as possible towards” fully realizing the right to health [13].

2. What responsibilities do all states have for the health of their own populations?

The right to health places the primary responsibility on governments to ensure the health needs of all their inhabitants. National responsibility includes health sector funding, addressing the socioeconomic determinants of health, and good governance.

There is no universally agreed level of health sector funding adequate to meet the population's needs. African heads of state agreed to a benchmark of at least 15% of national budgets devoted to the health sector [15], and to allocating at least 10% of their national budgets for agricultural development [16]. Additionally, 32 African countries set a target, as an aspiration, to have public sector budget allocations for sanitation and hygiene programs reach at least 0.5% of gross domestic product [17].

These benchmarks set a minimum bar for national funding responsibilities, which extend beyond the health sector. National health responsibilities should comply with well-defined, measurable international standards, balanced against the flexibility necessary to respect national priorities, health profiles, and needs.

States also have a responsibility to govern well, derived from central human rights tenets such as participatory processes, transparent and accountable government, and non-discrimination and equality. Well-designed legal rules and institutional arrangements can facilitate honest administrations, openness, and accountability, along with meaningful civil society and community participation in decision-making. The law, moreover, should guarantee equality and non-discrimination on the basis of race, sex, religion, disability, and other statuses. Measures to enhance accountability to communities in India's National Rural Health Mission [18], and Brazilian policies to reduce health disparities [19], offer instructive lessons.

3. What duties do states owe to people beyond their borders in securing the right to health?

Resource-poor states lack capacity to ensure all of their people even core health goods and services, much less a fuller realization of the right to health. Countries in a position to assist are obliged to do so under principles of international law and global social justice. The Committee on Social, Economic and Cultural Rights has declared that cooperation towards realizing the right to health is “an obligation of all States,” particularly those “in a position to assist others” [13],[20]. All countries have mutual responsibilities towards ensuring the health of the world's most disadvantaged.

Beyond development assistance, coordination and coherence is required across sectors, as global health can be improved or harmed through state and international policies and rules that govern areas such as trade, intellectual property, health worker migration, international financing, and debt relief. These responsibilities extend to the exercise of state power and influence over multilateral institutions such as the World Bank, International Monetary Fund, and World Trade Organization.

International aspects of the right to health are ill-defined. With limited exceptions, such as the commitment of wealthy countries to spend 0.7% of gross national product on official development assistance, health and development commitments are framed collectively, vaguely, or not at all. Even when countries make commitments, they often fail to follow through. For example, only one month after countries at the 2010 United Nations (UN) MDG Summit committed to provide “adequate funding” for the Global Fund to Fight AIDS, Tuberculosis and Malaria, pledges at the replenishment conference fell billions of dollars short [21],[22]. The Summit called for accelerated development assistance for health, though the rate of increase in assistance dropped during the global recession [21],[23]. Budget shortfalls in the aftermath of the financial downturn further threaten assistance levels.

4. What kind of global governance for health is needed to ensure that all states live up to their mutual responsibilities?

Translating a shared understanding of national and global responsibilities into new realities requires effective and democratic global governance for health. Notwithstanding the Paris Declaration on Aid Effectiveness, global health faces challenges of weak leadership, poor coordination, underfunded priorities, and a lack of transparency, accountability, and enforcement [24].

Innovative global governance and enhanced funding would empower WHO to exercise effective leadership in the health sector and persuasive advocacy on agriculture, finance, and trade. Moreover, state policies (e.g., agricultural subsidies, intellectual property, and foreign affairs) can powerfully affect health in resource-poor countries. States, therefore, should adopt a “health-in-all-policies” approach where all ministries address the health impacts of their policies and programs. Effective governance must include active citizen participation to ensure transparency, collaboration, and accountability while maximizing creativity and resource mobilization by states, international organizations, businesses, and civil society.

Most importantly, the global health architecture must hold stakeholders accountable, with clear standards for success, monitoring progress, and enforcement—all of which have been lacking. Lack of sufficiently precise obligations and compliance mechanisms under the right to health hinders accountability, though promising approaches exist. Human rights bodies and UN special rapporteurs are adding clarity to state responsibilities under the right to health, which is required for meaningful accountability, as are constitutional court decisions in Argentina, India, and South Africa [25],[26].

Innovations in human rights law and practice hold potential for greater accountability. Regional right-to-health special rapporteurs could be established, enabling more effective national engagement. An empowered human rights sector could learn from international regimes with more vigorous adjudication and enforcement mechanisms, such as trade. Actions to ensure that social movements and voters are well-informed about their countries' commitments could strengthen political accountability.

The Global South, where most of the world's least healthy people reside, should lead in shaping global governance for health policies, where community priorities drive global action. New governance requires the full participation of, and support for, marginalized populations.

Towards a Hopeful Future for Global Health Top

Why would states agree to greater accountability when so many countries fail to adhere to existing commitments? We do not underestimate the gravity of the challenge, yet JALI offers possibilities for success. Social mobilization could ignite new possibilities, as the AIDS movement has done, unleashing the collective power of health advocates and empowered communities.

The framework of mutual responsibilities that emerges from JALI should prove attractive to both Southern and Northern governments, creating incentives to develop a far-reaching global health agreement. Mutual responsibilities come with mutual benefits. Southern countries will benefit from increased respect for their strategies, greater and more predictable funding from more coordinated and accountable development partners, reform of policies that harm health, such as those in trade and agriculture, and most importantly, better health for their populations. Countries in the North will benefit from increased confidence that development assistance is spent effectively and the prospect of reduced financing needs over time as host countries increase their own health spending and build sustainable health systems. All will benefit from lessons on shared health challenges, from the economic and educational gains that will come with improved global health, and from increased protection for their populations from global public health threats—and from mutual goodwill derived from participating in an historic venture to make unprecedented progress towards global health equity.

This is also a moment of rare opportunity. The post-MDG global health framework is yet to be developed. Demand for accountability is growing. The right to health is increasingly motivating not only civil society, but also governments. The Pan American Health Organization passed a resolution on health and human rights [27], and the UN General Assembly explicitly recognized the right to clean water and sanitation [4]. Universal coverage, primary health care, and socioeconomic determinants are receiving renewed focus. Global health remains prominent on the international agenda, evidenced by the attention to global health and foreign policy and the upcoming UN high-level summit on non-communicable diseases.

In January 2011, WHO's Executive Board called on the Organization to assume a “more active and effective role” in “directing and coordinating” international health activities [28]. The agency initiated a reform process to strengthen its “central role in global health governance” [28],[29]. JALI supports WHO leadership, but also governance reforms extending beyond WHO, and even beyond the health sector, for a deeper understanding of the multiple forms of injustice that adversely affect health and development.

We invite readers to join JALI (http://www.section27.org.za/2010/11/23/j​ali) to develop widely shared understandings of national and global responsibilities for health to inform post-MDG commitments and create an innovative global agreement. It is time to define—and to meet—these responsibilities.

Author Contributions Top

Wrote the first draft: EAF LO. Contributed to writing the paper: LOG EAF GO TG NG DS WC J-AR DS. ICMJE criteria for authorship read and met: LOG EAF GO TG NG DS WC J-AR DS. Agree with the manuscript’s results and conclusions: LOG EAF GO TG NG DS WC J-AR DS.

References Top

1. World Health Organization (2010) World health statistics. Geneva: Available: http://www.who.int/whosis/whostat/EN_WHS​10_Part2.pdf. Accessed 22 September 2010.
2. Arias E (2010) United States life tables 2006. National Vital Statistics Reports 58: 1–40. Available: http://www.cdc.gov/nchs/data/nvsr/nvsr58​/nvsr58_21.pdf. Accessed 22 October 2010.
3. Food and Agricultural Organization (2010) 925 million in chronic hunger worldwide. Rome: Available: http://www.fao.org/news/story/en/item/45​210/icode/. Accessed 10 October 2010.
4. United Nations General Assembly (28 July 2010) The human right to water and sanitation: U.N. Doc. A/Res/64/292. New York: Available: http://www.un.org/en/ga/64/resolutions.s​html. Accessed 19 December 2010.
5. International Covenant on Economic, Social and Cultural Rights (1976) G.A. Res. 2200A (XXI), U.N. Doc. A/6316: Available: http://www1.umn.edu/humanrts/instree/b2e​sc.htm. Accessed 15 December 2010.
6. Gostin LO (2008) Meeting basic survival needs of the world's least healthy people: toward a Framework Convention on Global Health. Georgetown Law Journal 96: 331–392. Available: http://ssrn.com/abstract=1014082. Accessed 28 October 2010.
7. Cometto G, Ooms G, Starrs A, Zeitz P (2008) A global fund for the health MDGs? Lancet 373: 1500–1502. Find this article online
8. People's Health Movement (2010) PHM Right to Health and Health Care Campaign update January 2010. Available: http://www.phmovement.org/en/node/2769. Accessed 23 October 2010.
9. Partners In Health (2009) Declaration of solidarity for a unified movement for the right to health. Available: http://act.pih.org/page/s/declaration. Accessed 23 October 2010.

10.  World Health Assembly (2010) Primary health care, including health system strengthening: WHA62.12. Geneva: Available: http://apps.who.int/gb/ebwha/pdf_files/W​HA62-REC1/WHA62_REC1-en-P2.pdf. Accessed 15 December 2010.

11.  World Health Organization (2010) World health report: health systems financing: the path to universal coverage. Geneva: Available: http://www.who.int/whr/2010/en/index.htm​l. Accessed 15 December 2010.

12.  World Health Assembly (7 April 2005) Social health insurance: sustainable health financing, universal coverage and social health insurance: report by the Secretariat: A58/20: Available: http://apps.who.int/gb/ebwha/pdf_files/W​HA58/A58_20-en.pdf. Accessed 11 February 2011.

13.  United Nations Committee on Economic, Social and Cultural Rights (2000) General comment no. 14: the right to the highest attainable standard of health, E/C.12/2000. New York: Available: http://www.unhchr.ch/tbs/doc.nsf/%28symb​ol%29/E.C.12.2000.4.En. Accessed 9 September 2010.

14.  Frenk J, Gómez-Dantés O (2009) Ideas and ideals: ethical basis for health reform in Mexico. Lancet 373: 1406–1408. Find this article online

15.  Organization of African Unity (2001) Abuja declaration on HIV/AIDS, tuberculosis and other related infectious diseases. Abuja (Nigeria): Available: http://www.un.org/ga/aids/pdf/abuja_decl​aration.pdf. Accessed 1 September 2010.

16.  African Union Assembly (2003) Maputo declaration on agriculture and food security in Africa. Maputo (Mozambique): Available: http://www.africa-union.org/Official_doc​uments/Decisions_Declarations/Assembly%2​0final/Assembly%20%20DECLARATIONS%20%20-​%20Maputo%20-%20FINAL5%2008-08-03.pdf. Accessed 1 November 2010.

17.  Second African Conference on Sanitation and Hygiene (2008) eThekwini declaration. Durban (South Africa): Available: http://www.wsp.org/wsp/sites/wsp.org/fil​es/publications/eThekwiniAfricaSan.pdf. Accessed 1 November 2010.

18.  Ministry of Health and Family Welfare, Government of India (2010) National rural health mission. New Delhi: Available: http://mohfw.nic.in/nrhm.htm. Accessed 10 October 2010.

19.  Bhutta Z, Chopra M, Axelson H, Berman P, Boerma T, et al. (2010) Countdown to 2015 decade report (2000-10): taking stock of maternal, newborn, and child survival. Lancet 375: 2032–2044. Find this article online

20.  United Nations Committee on Economic, Social and Cultural Rights (1990) General comment no. 3: the nature of States' parties obligations, E/1991/23. New York: Available: http://www1.umn.edu/humanrts/gencomm/epc​omm3.htm. Accessed 14 February 2011.

21.  United Nations General Assembly (2010) Keeping the promise: united to achieve the Millennium Development Goals: A/65/L.1. New York: Available: http://www.un.org/en/mdg/summit2010/pdf/​mdg%20outcome%20document.pdf. Accessed 5 November 2010.

22.  McNeil D (6 October 2010) Global fight against AIDS falters as pledges fail to reach goal of $13 billion. New York Times: Available: http://www.nytimes.com/2010/10/06/world/​africa/06aids.html. Accessed 5 November 2010.

23.  Institute for Health Metrics and Evaluation, University of Washington (2010) Financing global health 2010: development assistance and country spending in economic uncertainty. Seattle: Institute for Health Metrics and Evaluation, University of Washington. Available: http://www.healthmetricsandevaluation.or​g/publications/policy-report/financing-g​lobal-health-2010-development-assistance​-and-country-spending-economic-uncertain​t. Accessed 9 February 2011.

24.  Gostin LO, Mok EA (2009) Grand challenges in global health governance. Br Med Bull 90: 7–18. Available: http://bmb.oxfordjournals.org/content/90​/1/7.full.pdfhtml. Accessed 9 September 2010.

25.  Hogerzeil HV, Samson M, Casanovas, Rahmani-Ocora L (2006) Is access to essential medicines as part of the fulfilment of the right to health enforceable through the courts? Lancet 368: 305–311. Available http://www.who.int/medicines/news/Lancet​_EssMedHumanRight.pdf. Accessed 22 February 2011.

26.  Gauri V, Brinks DM, editors. (2008) Courting social justice: judicial enforcement of social and economic rights in the developing world. New York: Cambridge University Press.

27.  Pan American Health Organization (29 September 2010) Resolution CD50.R8 health and human rights. 50th Directing Council, 62nd Session. Regional Committee. Available: http://www.un.org/disabilities/documents​/paho_mh_resolution.pdf. Accessed 9 February 2011.

28.  WHO Executive Board (2011) The future of financing for WHO. WHO Executive Board, 128th Session. EB128/INF.DOC./3. Available: http://apps.who.int/gb/ebwha/pdf_files/E​B128/B128_ID3-en.pdf. Accessed 9 February 2011.

29.  Sridhar D, Gostin LO (2011) Reforming the World Health Organization. JAMA. E-pub ahead of print 29 March 2011. doi:10.1001/jama.2011.418. Find this article online

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• MEASLES EDITION

I will not place on page 1 the measles updates (see next paragraph), but encourage you to click, on the red line, ‘measles edition.’  From the first page of the measles edition:

• ·         POLIO COMPARED TO MEASLES  
• ·         GLOBAL MEASLES UPDATE  
• ·         EQUALITY OF ACCESS FOR MEASLES VACCINATION/ AEROSOL MEASLES VACCINATION
• SEASONALITY AND THE PERSISTENCE AND INVASION OF MEASLES
  • ·         BAD PRACTICES IN MEASLES VACCINATION  
  • ·         FEASIBILITY OF MEASLES ERADICATION  
  • ·         MEASLES ERADICATION: 'NO' TO THE SKEPTICS
  • ·         LOW TITERS OF MEASLES ANTIBODY IN MOTHERS WHOSE INFANTS SUFFERED FROM MEASLES BEFORE ELIGIBLE AGE FOR VACCINATION

COCHRANE REVIEWS

I am placing on page 1, for your reading pleasure, each of the highly popular Cochrane reviews, none of them registering fewer than 95 visits so far this year. The review on ITN impact in pregnant women tops the league table, with 333 visits, followed by the reviews on hand washing impact and on vitamin A.

For those unfamiliar with the Cochrane reviews, consult http://www.cochrane.org/about-us/history/archie-cochrane

Good reading.

BD

AFTER 2015: POST-MDG RESPONSIBILITIES

The way to go after 2015? Full text is at

http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1001031

• A coalition of civil society organizations and academics are initiating a Joint Action and Learning Initiative on National and Global Responsibilities for Health (JALI) to research key conceptual questions involving health rights and responsibilities, with the goal of securing a global health agreement and supporting civil society mobilization around the human right to health.
• This agreement—such as a Framework Convention on Global Health—would inform post-Millennium Development Goal (MDG) global health commitments.
• Using broad partnerships and an inclusive consultation process, JALI seeks to clarify the health services to which everyone is entitled under the right to health, the national and global responsibilities for securing this right, and global governance structures that can realize these responsibilities and close major health inequities.
• Mutual benefits to countries in the Global South and North would come from a global health agreement that defines national and global health responsibilities.
• JALI aims to respond to growing demands for accountability, and to create the political space that could make a global health agreement possible.

• ·         GAME CHANGER IN HIV PREVENTION?

A randomized clinical trial in developed and developing countries has shown dramatic declines in HIV transmission among serodiscordant heterosexual couples when ARVs are started early in HIV seropositives.

'This breakthrough is a serious game changer and will set the prevention revolution forward,' according to Michel Sidibe, head of UNAIDS.

This update should be read in tandem with two others, 'HIV prevalence in Zimbabwe,' which calls for early inception of ARV treatment, and 'Provider Initiated HIV Testing.' According to the latter article, '‘The introduction of routine PITC using lay counsellors into health-care clinics in Lusaka, Zambia, dramatically increased the uptake and acceptability of HIV testing.’

Timely and early treatment cannot begin when at risk persons remain ignorant of their serostatus.

http://www.childsurvival.net/?content=com/articles&artid=534

• PREVENTION PROVIDER INITIATED HIV TESTING IN ZAMBIA

‘The introduction of routine PITC using lay counsellors into health-care clinics in Lusaka, Zambia, dramatically increased the uptake and acceptability of HIV testing.’ 

Full text, with figures, is at http://www.who.int/bulletin/volumes/89/5/10-084442.pdf

 Opt-out provider-initiated HIV testing and counselling in primary care outpatient clinics in Zambia

Stephanie M Topp,a Julien M Chipukuma,a Matimba M Chiko,b Chibesa S Wamulume,b Carolyn Bolton-Moorea & Stewart E Reida

Objective To increase case-finding of infection with human immunodeficiency virus (HIV) in Zambia and their referral to HIV care and treatment by supplementing existing client-initiated voluntary counselling and testing (VCT), the dominant mode of HIV testing in the country.

Methods Lay counsellors offered provider-initiated HIV testing and counselling (PITC) to all outpatients who attended primary clinics and did not know their HIV serostatus. Data on counselling and testing were collected in registers. Outcomes of interest included HIV testing coverage, the acceptability of testing, the proportion testing HIV-positive (HIV+), the proportion enrolling in HIV care and treatment and the time between testing and enrolment.

Findings After the addition of PITC to VCT, the number tested for HIV infection in the nine clinics was twice the number undergoing VCT alone. Over 30 months, 44 420 patients were counselled under PITC and 31 197 patients, 44% of them men, accepted testing. Of those tested, 21% (6572) were HIV+; 38% of these HIV+ patients (2515) enrolled in HIV care and treatment. The median time between testing and enrolment was 6 days. The acceptability of testing rose over time.

Conclusion The introduction of routine PITC using lay counsellors into health-care clinics in Lusaka, Zambia, dramatically increased the uptake and acceptability of HIV testing. Moreover, PITC was incorporated rapidly into primary care outpatient departments. Maximizing the number of patients who proceed to HIV care and treatment remains a challenge and warrants further research.’

http://www.childsurvival.net/?content=com_articles&artid=519

• ·         HIV PREVALENCE IN ZIMBABWE

HIV in Zimbabwe is disappearing like ‘snow in the desert’, in dramatic contrast to its neighbouring countries, mystifying epidemiologists, one of whom firmly believes the anomaly can be attributed to the country’s relatively high level of education.

. . . ‘Williams made a strong case to his colleagues in Cape Town for the introduction of ART immediately after testing positive as a powerful and long-term cost-effective prevention tool for both HIV and TB. . . .’

Full text also at http://www.samj.org.za/index.php/samj/article/viewFile/4672/3050

• ·         GOOD GOVERNANCE AND NEW VACCINE INTRODUCTION

 I found this article the same week that I read about Merck's donation of HPV vaccine to Rwanda, the first country in central Africa to introduce HPV on a nationwide scale. Rwanda was also the first country in central Africa to introduce pneumococcal vaccine. This is a hypothesis with legs.

 ‘[G]ood country-level governance is an imperative pre-requisite for the successful early introduction of new vaccines into poor African nations.’

Abstract below; full text, with figures, is at http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0013802

• DETERMINANTS  OF EXCLUSIVE BREAST FEEDING IN NIGERIA

‘The EBF rate in Nigeria is low and falls well short of the expected levels needed to achieve a substantial reduction in child mortality. Antenatal care was strongly associated with an increased rate of EBF.’

Best viewed at http://www.biomedcentral.com/1471-2393/11/2

Abstract Background Exclusive breast feeding (EBF) has important protective effects on the survival of infants and decreases risk for many early-life diseases. The purpose of this study was to assess the factors associated with EBF in Nigeria. Methods Data on 658 children less than 6 months of age were obtained from the Nigeria Demographic and Health Survey (NDHS) 2003.

The 2003 NDHS was a multi-stage cluster sample survey of 7864 households. EBF rates were examined against a set of individual, household and community level variables using a backward stepwise multilevel logistic regression method. Results The average EBF rate among infants younger than 6 months of age was 16.4% (95%CI: 12.6%-21.1%) but was only 7.1% in infants in their fifth month of age. After adjusting for potential confounders, multivariate analyses revealed that the odds of EBF were higher in rich (Adjusted Odds Ratios (AOR) = 1.15, CI = 0.28-6.69) and middle level (AOR = 2.45, CI = 1.06-5.68) households than poor households. Increasing infant age was associated with significantly less EBF (AOR = 0.65, 95%CI: 0.51-0.82). Mothers who had four or more antenatal visits were significantly more likely to engage in EBF (AOR = 2.70, 95%CI = 1.04-7.01). Female infants were more likely to be exclusively breastfed than male infants (AOR = 2.13, 95%CI = 1.03-4.39). Mothers who lived in the North Central geopolitical region were significantly more likely to exclusively breastfeed their babies than those mothers who lived in other geopolitical regions.

• TWO ON ROAD SAFETY
  
  

1) GLOBAL PLAN FOR THE DECADE OF ACTION FOR ROAD SAFETY

In six languages, at http://www.who.int/roadsafety/decade_of_action/plan/en/index.html

Country profiles, in alphabetical order, at http://www.who.int/violence_injury_prevention/road_safety_status/country_profiles/en/index.html

2) CHILDREN'S TRAFFIC EDUCATION, BANGLADESH

These 1998 documents give an interesting idea of how to attack the problem of death and injury from road traffic accidents.

By the way, do you know the word describing a Kigali motorcyclist without a helmet? Starts with a 'j.'

Scroll down to the end for the answer.

http://www.schoolsandhealth.org/Documents/Government%20of%20Bangladesh_Children%27s%20Traffic%20Education%20in%20Bangladesh.pdf

http://www.schoolsandhealth.org/Documents/Government%20of%20Bangladesh_Development%20of%20Road%20Safety%20Education%20Materials.pdf

From the Executive Summary

Research shows that human error plays a large part in road accidents, being a contributory factor in around 95 percent of accidents. Teaching safety skills to children can provide life long benefits to society. However, to develop safe road user behavior, children need to be taught skills rather than focus simply on rules, regulations and knowledge of traffic signs. By helping to develop positive, safe attitudes years as they become teenager and the adult road users.

Developing pedestrian safety is one of the main requirements of children’s traffic education in Bangladesh, especially in young children, as this will often be their primary mode of travel. The road crossing task is complex and requires a range of fundamental skills. . . .

Although immediate improvements in road user behavior are unlikely, many attitudes are developed early in life and road safety education should be seen as a longer term investment. The children of today are the adult road users of tomorrow.

What do you call a Kigali motorcyclist without a helmet? Jailbird!

• ·         AGAINST EUPHORIA

Those who believe that Africa is within shooting distance of malaria elimination may wish to reconsider their position after reading this article.

One should qualify this Ugandan article in several ways:

1)      Local insurgency in the area under consideration

2)      Hiccoughs with the GF over misappropriation of resources

3)      Autocratic gerontocracy at the national level

Unfortunately, these three factors are not peculiar to Uganda.

Good reading.

BD

Abstract from the American Journal of Tropical Medicine and Hygiene.  Full text available to subscribers

Continuing Intense Malaria Transmission in Northern Uganda

Carla Proietti, Davide D. Pettinato, Bernard N. Kanoi, Edward Ntege, Andrea Crisanti, Eleanor M. Riley, Thomas G. Egwang, Chris Drakeley*, AND Teun Bousema

Department of Immunology and Infection, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, United Kingdom; Microtest Matrices, Imperial College London, London, United Kingdom; Med Biotech Laboratories, Kampala, Uganda; Department of Experimental Medicine and Biochemical Science, University of Perugia, Perugia, Italy

Abstract.: Recent reports of reductions in malaria transmission in several African countries have resulted in optimism that malaria can be eliminated in parts of Africa where it is currently endemic. It is not known whether these trends are global or whether they are also present in areas where political instability has hindered effective malaria control. We determined malaria parasite carriage and age-dependent antibody responses to Plasmodium falciparum antigens in cross-sectional surveys in Apac, northern Uganda that was affected by political unrest. Under-five parasite prevalence was 55.8% (115/206) by microscopy and 71.9% (41/57) by polymerase chain reaction. Plasmodium ovale alone, or as a co-infection, was detected in 8.6% (12/139) and Plasmodium malariae in 4.3% (6/139) of the infections. Age seroprevalence curves gave no indication of recent changes in malaria transmission intensity. Malaria control remains a tremendous challenge in areas that have not benefited from large-scale interventions, illustrated here by the district of Apac.

• ·         PRINCIPLES OF EPIDEMIOLOGY

Epidemiology is the queen of the sciences. Here, Philip Brachman of CDC lays down the principles of epidemiology.

Best viewed at  http://www.ncbi.nlm.nih.gov/pubmed/21413284

Chapter 9

Epidemiology 

Philip S. Brachman.

General Concepts

Definitions

Epidemiology is the study of the determinants, occurrence, and distribution of health and disease in a defined population. Infection is the replication of organisms in host tissue, which may cause disease. A carrier is an individual with no overt disease who harbors infectious organisms. Dissemination is the spread of the organism in the environment.

Chain of Infection

There are three major links in disease occurrence: the etiologic agent, the method of transmission (by contact, by a common vehicle, or via air or a vector), and the host.

Epidemiologic Methods

Epidemiologic studies may be (1) descriptive, organizing data by time, place, and person; (2) analytic, incorporating a case-control or cohort study; or (3) experimental. Epidemiology utilizes an organized approach to problem solving by: (1) confirming the existence of an epidemic and verifying the diagnosis; (2) developing a case definition and collating data on cases; (3) analyzing data by time, place, and person; (4) developing a hypothesis; (5) conducting further studies if necessary; (6) developing and implementing control and prevention measures; (7) preparing and distributing a public report; and (8) evaluating control and preventive measures.

Introduction

This chapter reviews the general concepts of epidemiology, which is the study of the determinants, occurrence, distribution, and control of health and disease in a defined population. Epidemiology is a descriptive science and includes the determination of rates, that is, the quantification of disease occurrence within a specific population. The most commonly studied rate is the attack rate: the number of cases of the disease divided by the population among whom the cases have occurred. Epidemiology can accurately describe a disease and many factors concerning its occurrence before its cause is identified. For example, Snow described many aspects of the epidemiology of cholera in the late 1840s, fully 30 years before Koch described the bacillus and Semmelweis described puerperal fever in detail in 1861 and recommended appropriate control and prevention measures a number of years before the streptococcal agent was fully described. One goal of epidemiologic studies is to define the parameters of a disease, including risk factors, in order to develop the most effective measures for control. This chapter includes a discussion of the chain of infection, the three main epidemiologic methods, and how to investigate an epidemic.

• MALARIA RESEARCH IN AFRICA, 1948-2007

The majority of malaria RCT conducted in Africa report on drug treatment and prevention in children; there is need for more research done in pregnant women. Sources of funding, informed consent and trial quality were often poorly reported. Overall, clearer reporting of trials is needed.

Randomized controlled trials of malaria intervention trials in Africa, 1948 to 2007: a descriptive analysis

Malaria Journal 2011, 10:61doi:10.1186/1475-2875-10-61

The electronic version of this article is the complete one and can be found online at: http://www.malariajournal.com/content/10/1/61

• VACCINATION: RATTLING THE SUPPLY CHAIN

The introduction of new vaccines, combined with a push to expand immunization globally to reach every child, is straining vaccine supply chains to the limit. New thinking on the way vaccines are delivered is needed. Gary Humphreys reports. Text, with photos, best viewed at http://www.who.int/bulletin/volumes/89/5/11-030511.pdf The first decade of this century was perhaps the most productive in the history of vaccine development, seeing the release of a plethora of new life-saving vaccines for rotavirus diarrhoea, types of meningitis and pneumonia, and for human papillomavirus (HPV) infections that cause cervical cancer. “We are in a very different situation now compared to 10 years ago,” says Dr Osman Mansoor at the United Nations Children’s Fund (UNICEF) in New York. Mansoor, who is UNICEF’s senior health adviser for the Expanded Programme on Immunization and New Vaccines, notes that more vaccines are in the pipeline. In fact more than 80 vaccines are in the late stages of clinical testing, and 30 of them are designed to protect against major diseases including dengue and malaria. At the same time, the global vaccine market is booming: since 2000, global revenue from the sale of vaccines has almost tripled reaching more than US$ 17 billion by mid-2008. While most of this expansion is accounted for by sales of new and more costly vaccines in industrialized countries, more vaccines are also reaching developing countries due to the efforts of the GAVI Alliance (formerly the Global Alliance for Vaccines and Immunization), a public–private partnership established in 2000 to increase immunization in poor countries. The World Health Organization (WHO) and UNICEF estimate that just over 80% of the world’s children now have access to immunization, as measured by coverage of the third dose of DTP (diphtheria, tetanus and pertussis) vaccine, while an increasing number also have access to powerful new vaccines. “In the past, countries relied on a package of vaccines against six diseases,” says Project Optimize Coordinator Modibo Dicko, referring to WHO’s Expanded Programme on Immunization, which was launched in 1974. “Now some countries are doubling the number of vaccines they offer.” As encouraging as all this seems, the scaling up of immunization programmes and the introduction of new vaccines is putting an unprecedented strain on delivery systems that have not changed in decades.

Best read at http://www.who.int/bulletin/volumes/89/5/11-030511/en/index.html

• ECONOMIC VALUE OF DENGUE VACCINE IN THAILAND

‘A 50% efficacious vaccine was highly cost-effective [< 1x per capita gross domestic product (GDP) ($4,289)] up to a total vaccination cost of $60 and cost-effective [< 3x per capita GDP ($12,868)] up to a total vaccination cost of $200. When the total vaccine series was $1.50, many scenarios were cost saving.’

• From the authors’ conclusions: ‘As vaccine candidates get closer to licensure, now is the ideal time to further examine the economic value of a dengue vaccine.’

• ·         USE OF MASS MEDIA CAMPAIGNS TO CHANGE HEALTH BEHAVIOR

‘[M]ass media campaigns can produce positive changes or prevent negative changes in health-related behaviours across large populations.’

 Best read at http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(10)60809-4/fulltext

 Good reading. For those focusing on child survival, the relevant section is reproduced here.

 ‘Child survival

‘In many low-income countries, a substantial portion of premature mortality and associated morbidity occurs between birth and age 5 years. Major causes of poor child survival include inadequate treatment of dehydration resulting from diarrhoea, non-vaccination for preventable diseases, and failure to breastfeed exclusively and for sufficient time.71, 72 Each of these causes has been the target of mass media campaigns, with mixed evidence for success.

One review found four of six childhood vaccination programmes that used mass media achieved substantial improvements in vaccine use, and the effects were incremental with increasing exposure to the campaign.73, 74 One cost-effectiveness analysis in Bangladesh attributed increasing use of immunisation services to national campaign exposure.75 A later review of vaccination interventions found no additional examples of mass media campaigns alone.76 Rather, mass media was a strategy widely used in multicomponent vaccination campaigns worldwide, and substantial improvements in childhood vaccination were repeatedly recorded. As with other campaigns, effects cannot be specifically attributed to the mass media campaign component.77

• ·         THE BROAD STREET PUMP

Wikipedia article below; also at http://en.wikipedia.org/wiki/1854_Broad_Street_cholera_outbreak

See also ‘On the Mode of Communication of Cholera,’ by John Snow, available online at http://www.deltaomega.org/snowfin.pdf

• ·         PROVIDER INITIATED HIV TESTING, AN ALTERNATIVE TO CONVENTIONAL VCT

‘The introduction of routine PITC using lay counsellors into health-care clinics in Lusaka, Zambia, dramatically increased the uptake and acceptability of HIV testing.’ 

Full text, with figures, is at http://www.who.int/bulletin/volumes/89/5/10-084442.pdf

 Opt-out provider-initiated HIV testing and counselling in primary care outpatient clinics in Zambia

Stephanie M Topp,a Julien M Chipukuma,a Matimba M Chiko,b Chibesa S Wamulume,b Carolyn Bolton-Moorea & Stewart E Reida

Objective To increase case-finding of infection with human immunodeficiency virus (HIV) in Zambia and their referral to HIV care and treatment by supplementing existing client-initiated voluntary counselling and testing (VCT), the dominant mode of HIV testing in the country.

 Methods Lay counsellors offered provider-initiated HIV testing and counselling (PITC) to all outpatients who attended primary clinics and did not know their HIV serostatus. Data on counselling and testing were collected in registers. Outcomes of interest included HIV testing coverage, the acceptability of testing, the proportion testing HIV-positive (HIV+), the proportion enrolling in HIV care and treatment and the time between testing and enrolment.

 Findings After the addition of PITC to VCT, the number tested for HIV infection in the nine clinics was twice the number undergoing VCT alone. Over 30 months, 44 420 patients were counselled under PITC and 31 197 patients, 44% of them men, accepted testing. Of those tested, 21% (6572) were HIV+; 38% of these HIV+ patients (2515) enrolled in HIV care and treatment. The median time between testing and enrolment was 6 days. The acceptability of testing rose over time.

 Conclusion The introduction of routine PITC using lay counsellors into health-care clinics in Lusaka, Zambia, dramatically increased the uptake and acceptability of HIV testing. Moreover, PITC was incorporated rapidly into primary care outpatient departments. Maximizing the number of patients who proceed to HIV care and treatment remains a challenge and warrants further research.’

• ·         SCHISTOSOMIASIS ELIMINATION

This article, originally published in 2010, continues to generate editorial correspondence. The article and letters to the editor, with authors’ reply, are best viewed online at

http://www.thelancet.com/journals/laninf/article/PIIS1473-3099(10)70099-2/fulltext

This article, which originally appeared in 2010, has generated much correspondence to the editor. Article and correspondence are best viewed at http://www.thelancet.com/journals/laninf/article/PIIS1473-3099(10)70099-2/fulltextoutline goes here

The Lancet Infectious Diseases, Volume 10, Issue 10, Pages 733 - 736, October 2010

Schistosomiasis elimination: lessons from the past guide the future

Original Text

Dr Darren J Gray PhD a b c , Prof Donald P McManus DSc c, Prof Yuesheng Li MD c d, Prof Gail M Williams PhD b, Prof Robert Bergquist MD e, Prof Allen G Ross MD a

Summary

Schistosomiasis is a major neglected tropical disease, with more than 200 million people infected and close to 800 million at risk. The disease burden is estimated to exceed 70 million disability-adjusted life-years. The anthelmintic drug praziquantel is highly effective in killing adult schistosome worms, but it is unable to kill developing schistosomes and so does not prevent reinfection. As a result, current praziquantel-based control programmes in Asia and sub-Saharan Africa are not effective or sustainable in the long term. The control of neglected tropical diseases, including schistosomiasis, is a funding priority for several donor agencies, with over US$350 million committed until 2013. Here we put forward an argument that donor funds would be more effectively spent on the development of a multi-faceted, integrated control programme, which would have a greater and longer lasting effect on disease transmission than the current chemotherapy-based programmes. The development of a transmission-blocking vaccine is also of great importance. A multi-faceted integrated control programme that incorporates a vaccine, even if only partly effective, has the potential to eliminate schistosomiasis. This integrated-approach model has the potential to improve the health of a billion of the world's poorest people and its effect cannot be underestimated.

• ·         PLASMODIUM KNOWLESI MALARIA IN MALAYSIAN CHILDREN

‘P. knowlesi is the most common cause of childhood malaria in Kudat. Although infection is generally uncomplicated, anemia is common and thrombocytopenia universal. Transmission dynamics in this region require additional investigation.’

Another contribution from Emerging Infectious Diseases.

Best  read, with figures, at http://www.cdc.gov/eid/content/17/5/814.htm

• IMPACT OF VITAMIN A SUPPLEMENTATION

As the world moves towards 2015 and MDG4, how can we increase the coverage for routine vitamin A supplementation?

Amid the positive results, the absence of impact on measles mortality is notable. This means that strict adherence to the WHO guidelines for measles treatment, with vitamin A on Days 1 and 2 of treatment, is necessary to reduce the case fatality rate from measles.

‘Pooled results for preventive vitamin A supplementation showed that it reduced all-cause mortality by 25% [RR 0.75; 95 % CI 0.64-0.88] in children 6-59 months of age. Vitamin A supplementation also reduced diarrhea specific mortality by 30% [RR 0.70; 95 % CI 0.58-0.86] in children 6-59 months. This effect has been recommended for inclusion in the Lives Saved Tool.’ 

Best viewed at
http://jid.oxfordjournals.org/content/203/4/464.full?sid=0aa3a9d2-e733-465e-a8aa-3940870d3158

• LOW TITERS OF MEASLES ANTIBODY IN MOTHERS WHOSE INFANTS SUFFERED FROM MEASLES BEFORE ELIGIBLE AGE FOR MEASLES VACCINATION 

‘The mean measles neutralizing titer in 18 vaccinated mothers without natural boosting were significantly lower than that in 13 age-match women with the histories of clinical measles.’

Are these results unique to China? Probably not. What will happen to maternal antibody interference and to measles vaccine seroconversion among younger infant vaccinees if, in countries with declining measles incidence, there is no natural boosting?

Our floor ages for measles vaccination are largely based on studies from another era. Do they need a review, based on more recent evidence?

Full text is at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2874774/?tool=pubmed

• MASS CAMPAIGN BEDNET DISTRIBUTION IN MADAGASCAR

The phrase 'mass campaign' raises hackles among some advocates of integrated health services. But if you are trying rapidly to increase bednet coverage in malarious airways, is there any faster way to do so than through mass campaigns?

From the abstract: ‘Equity of campaign net ownership was evident. Post-campaign, the LLIN use target of 80% by children less than five years of age and a high level of LLIN use (69%) by pregnant women were attained. Targeted LLIN distribution further contributed to total population coverage (60%) through use of campaign nets by all age groups.’

From the text: ‘This study demonstrates the significant achievement of 80% insecticide-treated net use among children less than five years of age after an integrated campaign that distributed free LLINs to children less than five years of age in 59 districts of Madagascar. Although LLIN use by pregnant women (69%) did not achieve the 80% level, it still represents one of the highest reported use rates for this target group in sub-Saharan Africa.’

Full text, with figures, is at http://www.ajtmh.org/cgi/content/full/82/3/420

• TWO ON RABIES

With intradermal vaccination of rabies vaccine in fractionated doses, vaccination of high risk groups (here, rag pickers in Himachal Pradesh) is becoming more affordable.

Cross posted, with thanks, from www.technet21.org

http://www.technet21.org/index.php/forum/technet21/general-discussion/1906-225-rag-pickers-given-free-antirabies-vaccination.html

 Here are weblinks to the new WHO guidelines on rabies vaccination.

http://www.technet21.org/index.php/forum/technet21/general-discussion/2613-new-guidelines-for-anti-rabies-vaccination-prophylaxis-by-who-2010.html

• MORTALITY TRENDS IN A NIGERIAN TEACHING HOSPITAL OVER THREE DECADES

Death from infectious disease and trauma declined from 1,048 and 1,441 in the first decade (1977 – 1986) to 478 and 133 in the last decade respectively, while death from neoplasia increased from 112 in the first decade to 354 in the last decade of the study period.

 Full text is at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3035961/?tool=pubmed

• ·         CDC GRAND ROUNDS: THE OPPORTUNITY FOR AND CHALLENGES TO MALARIA ERADICATION

Note, in particular, the graphics showing changes over time in bednet utilization in countries which have measured this twice.

Can we do better than 60 percent bednet utilization rates? 

Best viewed at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6015a3.htm?s_cid=mm6015a3_w

• PMTCT IN KISUMU, KENYA

From the editors’ summary: 

What Do These Findings Mean?

Although these findings are limited by the single-arm design, they support the idea that giving breastfeeding women a triple-ARV regimen from late pregnancy to 6 months is a safe, feasible way to reduce MTCT in resource-limited settings. The HIV transmission rates in this study are comparable to those recorded in similar trials in other resource-limited settings and are lower than MTCT rates observed previously in Kisumu in a study in which no ARVs were used. Importantly, the KiBS mothers took most of the ARVs they were prescribed and most sped breastfeeding by 6 months as advised. 

Best viewed at http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1001015

• DOES IMPROVING MATERNAL KNOWLEDGE OF VACCINES IMPACT INFANT IMMUNIZATION RATES?

Aatekah Owais and colleagues, writing in BMC Public Health, point to a cheap, easy way to raise completion rates. This is the second article of its kind from Pakistan; see also CSU 115/2011, ‘Redesigned vaccination cards.’ Full text of this article is available online at http://www.biomedcentral.com/content/pdf/1471-2458-11-239.pdf