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Influenza epidemiology and immunization during pregnancy: Final report of a World Health Organization working group.
Vaccine. 2017 Oct 13; 35(43):5738-5750.From 2014 to 2017, the World Health Organization convened a working group to evaluate influenza disease burden and vaccine efficacy to inform estimates of maternal influenza immunization program impact. The group evaluated existing systematic reviews and relevant primary studies, and conducted four new systematic reviews. There was strong evidence that maternal influenza immunization prevented influenza illness in pregnant women and their infants, although data on severe illness prevention were lacking. The limited number of studies reporting influenza incidence in pregnant women and infants under six months had highly variable estimates and underrepresented low- and middle-income countries. The evidence that maternal influenza immunization reduces the risk of adverse birth outcomes was conflicting, and many observational studies were subject to substantial bias. The lack of scientific clarity regarding disease burden or magnitude of vaccine efficacy against severe illness poses challenges for robust estimation of the potential impact of maternal influenza immunization programs. Copyright (c) 2017 The Authors. Published by Elsevier Ltd.. All rights reserved.
Journal of Human Lactation. 2017 Feb; 33(1):140-148.BACKGROUND: Extended breastfeeding duration is common in India. Extended breastfeeding protects the infant from infectious disease and promotes child spacing. In the 1990s, the median breastfeeding duration in India was 24 months. Research aim: This study aimed to investigate the median duration of breastfeeding in India and to identify the factors associated with extended breastfeeding to 24 months as recommended by the World Health Organization. METHODS: This cross-sectional data analysis used nationally representative data from the 2011-2012 Indian Human Development Survey II. The outcome in this study was extended breastfeeding defined as breastfeeding to 24 months or more. Multivariate logistic regression was used to identify the factors associated with extended breastfeeding. RESULTS: The median duration of breastfeeding was 12 months; approximately 25% of women breastfed 24 months or more. Women were at greater odds of breastfeeding 24 months or more if the infant was a boy compared with a girl, if the women lived in a rural area compared with an urban area, if the women were married at a young age (< 17 vs. 20 years or older at marriage), and if the delivery was assisted by a friend or relative compared with a doctor. CONCLUSION: The median duration of breastfeeding has decreased by 50% from 1992-1993 to 2011-2012. The women who continue to breastfeed 24 months or more tend to be more traditional (i.e., living in rural areas, marrying young, and having family/friends as birth attendants). Further research to study the health effect of decreased breastfeeding duration is warranted.
Neglected chronic disease: The WHO framework on non-communicable diseases and implications for the global poor.
Global Public Health. 2017 Apr; 12(4):396-415.The current global framework on noncommunicable disease (NCD), as exemplified by the WHO Action Plan of 2012, neglects the needs of the global poor. The current framework is rooted in an outdated pseudo-evolutionary theory of epidemiologic transition, which weds NCDs to modernity, and relies on global aggregate data. It is oriented around a simplistic causal model of behavior, risk and disease, which implicitly locates ‘risk’ within individuals, conveniently drawing attention away from important global drivers of the NCD epidemic. In fact, the epidemiologic realities of the bottom billion reveal a burden of neglected chronic diseases that are associated with ‘alternative’ environmental and infectious risks that are largely structurally determined. In addition, the vertical orientation of the framework fails to centralize health systems and delivery issues that are essential to chronic disease prevention and treatment. A new framework oriented around a global health equity perspective would be able to correct some of the failures of the current model by bringing the needs of the global poor to the forefront, and centralizing health systems and delivery. In addition, core social science concepts such as Bordieu's habitus may be useful to re-conceptualizing strategies that may address both behavioral and structural determinants of health.
Washington, D.C., World Bank, 2005.  p. (World Bank Working Paper No. 68)In recent years, Europe and Central Asia has experienced the world’s fastest growing HIV/AIDS epidemic. Yet, in the Western Balkan countries the HIV prevalence rate is under 0.1 percent, which ranks among the lowest. This may be due to a low level of infection among the population—or partly due to inadequate surveillance systems. All major contributing factors for the breakout of an HIV/AIDS epidemic are present in the Western Balkans. HIV/AIDS disproportionably affects youth (80 percent of HIV-infected people are 30 years old or younger). Most of the Western Balkan countries have very young populations, which have been affected by the process of social transition, wars, unemployment and other factors. Among youth, there is generalized use of drugs and sexual risk behavior. Therefore, the number of cases of HIV has been increasing, especially in Serbia, and the incidence of Hepatitis C has clearly increased, which suggests that sharing of infected needles is practiced by injecting drug users. Apart from human suffering, an HIV/AIDS epidemic can have a significant impact on costs of care for individuals, households, health services and society as a whole. This study has found weak public health systems and gaps in financing and institutional capacity necessary to implement evidence-based and cost-effective HIV/AIDS Strategies. Political commitment must increase for action to occur promptly. Prevention interventions are cost effective and, in the short term, affordable with own-country resources. Medium- and long-term interventions would require donor assistance. Longer-term interventions would aim at preventing poverty, exclusion and unemployment, for example, by empowering young people to participate in the regional and global labor market.
Characterizing the HIV/AIDS epidemic in the Middle East and North Africa: time for strategic action.
Washington, D.C., World Bank, 2010.  p. (World Bank Report No. 54889)This study is a continuation of the previous sector review, conducted in 2004. The 2008 review had two main objectives. This review is primarily an update on the situation. In its development strategy, Benin gave considerable importance to the health of its population. This effort is part of the long-term vision of the country. Improving health status, especially for the poor, is one of eight strategic directions for that vision. Similarly, on a more operational level, this objective is reflected in the current Growth Strategy for Poverty Reduction (GPRS 2007-2009). Benin is particularly committed towards the Millennium Development Goals, including 3 on the health sector. This review was also an opportunity to further analyze the constraints in the health system, consistent with the new strategy Health Nutrition and Population World Bank, Strategy adopted in 2007. But this exercise was not intended merely to be analytical. It also aimed to enrich the political dialogue between, on one hand, the actors in health and, secondly, the World Bank and other development partners. This effort relates more specifically to some themes such as governance, private sector involvement and alignment of partners' efforts (called technical and financial partners in Benin or PTFs). From this perspective, the journal is also a contribution to Benin's efforts to advance the IHP (International Health Partnership Plus). This initiative is now the main tool for implementing the Paris Declaration. In practice, the journal has sought to contribute to the consensus between the Ministry of Health and the donor group on the diagnosis of the health system and the changes needed to strengthen it. Several guidelines have emerged stronger from this discussion, particularly in the area of governance of the health system. Beyond the reinforcement of the various components of the health system, two fundamental principles should guide the transformation of this system: 1) A principle of corporate governance: through decentralization of the health system, health facilities must have their basic needs better taken into account (hence the need for bottom-up planning) and especially as more independent financially administrative; and 2) A principle of individual governance: health workers should be strongly encouraged to improve their performance (competence, productivity and compliance of patients). Given the limited success of measures to strengthen inspections and other controls "top-down, this incentive can only come from clients, either directly (i.e., bonuses based on cost recovery), or preferably indirectly with a mechanism for payment by results funded by the state and possibly partners.
Geneva, Switzerland, WHO, 2016.  p.Since the publication of the WHO Guidelines for the management of sexually transmitted infections in 2003, changes in the epidemiology of STIs and advancements in prevention, diagnosis and treatment necessitate changes in STI management. These guidelines provide updated treatment recommendations for common infections caused by C. trachomatis based on the most recent evidence; they form one of several modules of guidelines for specific STIs. It is strongly recommended that countries take updated global guidance into account as they establish standardized national protocols, adapting this guidance to the local epidemiological situation and antimicrobial susceptibility data. The objectives of these guidelines are: to provide evidence-based guidance on treatment of infection with C. trachomatis; and to support countries to update their national guidelines for treatment of chlamydial infection.
Geneva, Switzerland, WHO, 2016.  p.Since the publication of the WHO Guidelines for the management of sexually transmitted infections in 2003, changes in the epidemiology of STIs and advancements in prevention, diagnosis and treatment necessitate changes in STI management. These guidelines provide updated treatment recommendations for treatment of Treponema pallidum (syphilis) based on the most recent evidence. They form one of several modules of guidelines for specific STIs. It is strongly recommended that countries take updated global guidance into account as they establish standardized national protocols and adapt it to the local epidemiological situation and antimicrobial susceptibility data. The objectives of these guidelines are: to provide evidence-based guidance on treatment of infection with Treponema pallidum; and to support countries to update their national guidelines for treatment of Treponema pallidum.
Geneva, Switzerland, WHO, 2016.  p.Since the publication of the WHO Guidelines for the management of sexually transmitted infections in 2003, changes in the epidemiology of STIs and advancements in prevention, diagnosis and treatment necessitate changes in STI management. There is an urgent need to update treatment recommendations for gonococcal infections to respond to changing antimicrobial resistance (AMR) patterns of N. gonorrhoeae. High-level resistance to previously recommended quinolones is widespread and decreased susceptibility to the extended-spectrum (third-generation) cephalosporins, another recommended first-line treatment in the 2003 guidelines, is increasing and several countries have reported treatment failures. These guidelines for the treatment of common infections caused by N. gonorrhoeae form one of several modules of guidelines for specific STIs. It is strongly recommended that countries take updated global guidance into account as they establish standardized national protocols, adapting this guidance to the local epidemiological situation and antimicrobial susceptibility data. The objectives of these guidelines are: to provide evidence-based guidance on treatment of infection with N. gonorrhoeae; and to support countries to update their national guidelines for treatment of gonococcal infection.
Zika virus infection: global update on epidemiology and potentially associated clinical manifestations.
Releve Epidemiologique Hebdomadaire. 2016 Feb 19; 91(7):73-81.Add to my documents.
[Geneva, Switzerland], WHO, 2016 Feb.  p.WHO has launched a global Strategic Response Framework and Joint Operations Plan to guide the international response to the spread of Zika virus infection and the neonatal malformations and neurological conditions associated with it. The strategy focuses on mobilizing and coordinating partners, experts and resources to help countries enhance surveillance of the Zika virus and disorders that could be linked to it, improve vector control, effectively communicate risks, guidance and protection measures, provide medical care to those affected and fast-track research and development of vaccines, diagnostics and therapeutics.
Population and Development Review. 2015 Sep 15; 41(3):507-532.Chronic noncommunicable diseases (NCDs) in low- and middle-income countries have recently provoked a surge of public interest. This article examines the policy literature-notably the archives and publications of the World Health Organization (WHO), which has dominated this field-to analyze the emergence and consolidation of this new agenda. Starting with programs to control cardiovascular disease in the 1970s, experts from Eastern and Western Europe had by the late 1980s consolidated a program for the prevention of NCD risk factors at the WHO. NCDs remained a relatively minor concern until the collaboration of World Bank health economists with WHO epidemiologists led to the Global Burden of Disease study that provided an “evidentiary breakthrough” for NCD activism by quantifying the extent of the problem. Soon after, WHO itself, facing severe criticism, underwent major reform. NCD advocacy contributed to revitalizing WHO's normative and coordinative functions. By leading a growing advocacy coalition, within which The Lancet played a key role, WHO established itself as a leading institution in this domain. However, ever-widening concern with NCDs has not yet led to major reallocation of funding in favor of NCD programs in the developing world.
Releve Epidemiologique Hebdomadaire / Section D'hygiene Du Secretariat De La Societe Des Nations. 2014 Oct 31; 89(44):493-9.Add to my documents.
Morbidity and Mortality Weekly Report. 2014 Jul 25; 63(29):634-637.Since 2008, the World Health Organization (WHO) has coordinated the Global Rotavirus Surveillance Network, a network of sentinel surveillance hospitals and laboratories that report to ministries of health (MoHs) and WHO clinical features and rotavirus testing data for children aged <5 years hospitalized with acute gastroenteritis. In 2013, WHO conducted a strategic review to assess surveillance network performance, provide recommendations for strengthening the network, and assess the network’s utility as a platform for other vaccine-preventable disease surveillance. The strategic review team determined that during 2011 and 2012, a total of 79 sites in 37 countries met reporting and testing inclusion criteria for data analysis. Of the 37 countries with sites meeting inclusion criteria, 13 (35%) had introduced rotavirus vaccine nationwide. All 79 sites included in the analysis were meeting 2008 network objectives of documenting presence of disease and describing disease epidemiology, and all countries were using the rotavirus surveillance data for vaccine introduction decisions, disease burden estimates, and advocacy; countries were in the process of assessing the use of this surveillance platform for other vaccine-preventable diseases. However, the review also indicated that the network would benefit from enhanced management, standardized data formats, linkage of clinical data with laboratory data, and additional resources to support network functions. In November 2013, WHO’s Strategic Advisory Group of Experts on Immunization (SAGE) endorsed the findings and recommendations made by the review team and noted potential opportunities for using the network as a platform for other vaccine-preventable disease surveillance. WHO will work to implement the recommendations to improve the network’s functions and to provide higher quality surveillance data for use in decisions related to vaccine introduction and vaccination program sustainability.
Can the UNAIDS modes of transmission model be improved? A comparison of the original and revised model projections using data from a setting in west Africa.
AIDS. 2013 Oct 23; 27(16):2623-35.OBJECTIVE: The UNAIDS modes of transmission model (MoT) is a user-friendly model, developed to predict the distribution of new HIV infections among different subgroups. The model has been used in 29 countries to guide interventions. However, there is the risk that the simplifications inherent in the MoT produce misleading findings. Using input data from Nigeria, we compare projections from the MoT with those from a revised model that incorporates additional heterogeneity. METHODS: We revised the MoT to explicitly incorporate brothel and street-based sex-work, transactional sex, and HIV-discordant couples. Both models were parameterized using behavioural and epidemiological data from Cross River State, Nigeria. Model projections were compared, and the robustness of the revised model projections to different model assumptions, was investigated. RESULTS: The original MoT predicts 21% of new infections occur in most-at-risk-populations (MARPs), compared with 45% (40-75%, 95% Crl) once additional heterogeneity and updated parameterization is incorporated. Discordant couples, a subgroup previously not explicitly modelled, are predicted to contribute a third of new HIV infections. In addition, the new findings suggest that women engaging in transactional sex may be an important but previously less recognized risk group, with 16% of infections occurring in this subgroup. CONCLUSION: The MoT is an accessible model that can inform intervention priorities. However, the current model may be potentially misleading, with our comparisons in Nigeria suggesting that the model lacks resolution, making it challenging for the user to correctly interpret the nature of the epidemic. Our findings highlight the need for a formal review of the MoT.
Geneva, Switzerland, WHO, 2013.  p.The World Malaria Report 2013 summarizes information received from malaria-endemic countries and other sources, and updates the analyses presented in the 2012 report. It highlights the progress made towards global malaria targets set for 2015, and describes current challenges for global malaria control and elimination.
Sexually Transmitted Infections. 2010 Dec; 86 Suppl 2:ii93-9.BACKGROUND: Every 2 years, the Joint United Nations Programme on HIV/AIDS (UNAIDS) produces probabilistic estimates and projections of HIV prevalence rates for countries with generalised HIV/AIDS epidemics. To do this they use a simple epidemiological model and data from antenatal clinics and household surveys. The estimates are made using the Bayesian melding method, implemented by the incremental mixture importance sampling technique. This methodology is referred to as the 'estimation and projection package (EPP) model'. This has worked well for estimating and projecting prevalence in most countries. However, there has recently been an 'uptick' in prevalence in Uganda after a long sustained decline, which the EPP model does not predict. METHODS: To address this problem, a modification of the EPP model, called the 'r stochastic model' is proposed, in which the infection rate is allowed to vary randomly in time and is applied to the entire non-infected population. RESULTS: The resulting method yielded similar estimates of past prevalence to the EPP model for four countries and also similar median ('best') projections, but produced prediction intervals whose widths increased over time and that allowed for the possibility of an uptick after a decline. This seems more realistic given the recent Ugandan experience.
Releve Epidemiologique Hebdomadaire. 2013 Jul 12; 88(28):285-96.This epidemiologic record discusses recent data about yellow fever outbreaks and cases in Africa and South America between 2011 and 2012. During this period, major outbreaks were reported in Sudan and Uganda while significant clusters of cases were reported in Cameroon, Chad and Cote d’Ivoire, necessitating an extended vaccination response. In addition, some isolated cases occurred in districts reporting high yellow fever vaccination coverage (Burkina Faso, Central African Republic, Togo), for which no vaccination response was undertaken. In South America, the World Health Organization American Region reported 32 cases (2011-2012), including 9 deaths, in Brazil, Ecuador, Plurinational State of Bolivia and Peru. As of 2012, most countries in the Caribbean and Latin America with enzootic areas had introduced the yellow fever vaccine into their national routine immunization schedules. The 2008 outbreaks in the Southern Cone expanded the area considered at risk to include northern Argentina and Paraguay. Building upon the yellow fever investment case strategy, which has reduced the frequency and size of disruptive outbreaks, the Yellow Fever Strategic Framework 2012-2020 prioritizes endemic countries according to their epidemic risk. This framework will enable WHO and partners to identify the populations’ high priority needs through a systematic approach so that limited resources can be allocated most effective to reduce the burden of yellow fever in Africa. Following a request from the countries, a form of yellow fever experts met in Panama to discuss how countries can make scientific evidence-based risk assessments and suggested that endemic countries should strive to enhance yellow fever surveillance systems.
Releve Epidemiologique Hebdomadaire. 2013 Jun 14; 88(24):241-2.In May 2013, eight total cases of wild poliovirus type 1 (WPV1) were isolated in Mogadishu and Bay Region, becoming the first polio cases reported in Somalia since March 2007. That same month, the Kenyan Ministry of Public Health and Sanitation confirmed a WPV1 case in an infant girl from the Dadaab refugee camps near the Somalia border. Genetic sequence analysis of WPV1 from both countries shows that they are closely related, with evidence of the virus’ single introduction into the region and subsequent local transmission. In Somalia and Kenya, rapid response polio supplementary immunization activities (SIA) were conducted. Preventive SIAs are being conducted in areas of Ethiopia and Yemen, and surveillance for acute flaccid paralysis (AFP) is being strengthened in all countries in the Horn of Africa.
Tropical Medicine and International Health. 2012 Jun; 17(6):760-6.OBJECTIVE: To review the activities, progress, achievements and challenges of the Zambia Ministry of Health tuberculosis (TB)/HIV collaborative activities over the past decade. METHODS: Analysis of Zambia Ministry of Health National TB and HIV programme documents and external independent programme review reports pertaining to 2000-2010. RESULTS: The number of people testing for HIV increased from 37 557 persons in 2003 to 1 327 995 persons in 2010 nationally. Those receiving anti-retroviral therapy (ART) increased from 143 in 2003 to 344 304 in 2010. The national HIV prevalence estimates declined from 14.3% in 2001 to 13.5% in 2009. The proportion of TB patients being tested for HIV increased from 22.6% in 2006 to 84% in 2010 and approximately 70% were HIV positive. The proportion of the HIV-infected TB patients who: (i) started on ART increased from 38% in 2006 to 50% in 2010; (ii) commenced co-trimoxazole preventive therapy (CPT) increased from 31% in 2006 to 70% in 2010; and (iii) were successfully treated increased to an average of 80% resulting in decline of deaths from 13% in 2006 to 9% in 2010. CONCLUSIONS: The scale-up of TB/HIV collaborative programme activities in Zambia has steadily increased over the past decade resulting in increased testing for TB and HIV, and anti-retroviral (ARV) rollout with improved treatment outcomes among TB patients co-infected with HIV. Getting service delivery points to adhere to WHO guidelines for collaborative TB/HIV activities remains problematic, especially those meant to reduce the burden of TB in people living with HIV/AIDS (PLWHA). (c) 2012 Blackwell Publishing Ltd.
Journal of the European Economic Association. 2012 Oct; 10(5):1025-1058.This paper estimates whether exports affect the incidence of HIV in Africa. This relationship has implications for HIV prevention policy as well as for the consequences of trade increases in Africa. I estimate this impact using two sources of data on HIV incidence, one generated based on UNAIDS estimates and the other based on observed HIV mortality. These data are combined with data on export value and volume. I find a fairly consistent positive relationship between exports and new HIV infections: doubling exports leads to a 10%-70% increase in new HIV infections. Consistent with theory, this relationship is larger in areas with higher baseline HIV prevalence. I interpret the result as suggesting that increased exports increase the movement of people (trucking), which increases sexual contacts. Consistent with this interpretation, the effect is larger for export growth than for income growth per se and is larger in areas with more extensive road networks.
The impact of the new WHO antiretroviral treatment guidelines on HIV epidemic dynamics and cost in South Africa.
PloS One. 2011; 6(7):e21919.BACKGROUND: Since November 2009, WHO recommends that adults infected with HIV should initiate antiretroviral therapy (ART) at CD4+ cell counts of =350 cells/microl rather than =200 cells/microl. South Africa decided to adopt this strategy for pregnant and TB co-infected patients only. We estimated the impact of fully adopting the new WHO guidelines on HIV epidemic dynamics and associated costs. METHODS AND FINDING: We used an established model of the transmission and control of HIV in specified sexual networks and healthcare settings. We quantified the model to represent Hlabisa subdistrict, KwaZulu-Natal, South Africa. We predicted the HIV epidemic dynamics, number on ART and program costs under the new guidelines relative to treating patients at =200 cells/microl for the next 30 years. During the first five years, the new WHO treatment guidelines require about 7% extra annual investments, whereas 28% more patients receive treatment. Furthermore, there will be a more profound impact on HIV incidence, leading to relatively less annual costs after seven years. The resulting cumulative net costs reach a break-even point after on average 16 years. CONCLUSIONS: Our study strengthens the WHO recommendation of starting ART at =350 cells/microl for all HIV-infected patients. Apart from the benefits associated with many life-years saved, a modest frontloading appears to lead to net savings within a limited time-horizon. This finding is robust to alternative assumptions and foreseeable changes in ART prices and effectiveness. Therefore, South Africa should aim at rapidly expanding its healthcare infrastructure to fully embrace the new WHO guidelines.
Bulletin of the World Health Organization. 2010 Mar; 88(3):232-4.Add to my documents.
How Brazil outpaced the United States when it came to AIDS: the politics of civic infiltration, reputation, and strategic internationalization.
Journal of Health Politics, Policy and Law. 2011 Apr; 36(2):317-52.Using a temporal approach dividing the reform process into two periods, this article explains how both Brazil and the United States were slow to respond to AIDS. However, Brazil eventually outpaced the United States in its response due to international rather than democratic pressures. Since the early 1990s, Brazil's success has been attributed to "strategic internationalization": the concomitant acceptance and rejection of global pressure for institutional change and antiretroviral treatment, respectively. The formation of tripartite partnerships among donors, AIDS officials, and nongovernmental organizations has allowed Brazil to avoid foreign aid dependency, while generating ongoing incentives for influential AIDS officials to incessantly pressure Congress for additional funding. Given the heightened international media attention, concern about Brazil's reputation has contributed to a high level of political commitment. By contrast, the United States' more isolationist relationship with the international community, its focus on leading the global financing of AIDS efforts, and the absence of tripartite partnerships have prevented political leaders from adequately responding to the ongoing urban AIDS crisis. Thus, Brazil shows that strategically working with the international health community for domestic rather than international influence is vital for a sustained and effective response to AIDS.
Geneva, Switzerland, UNAIDS, 2011 Aug.  p. (UNAIDS/ JC2112E)This report shows that these global commitments will be achieved only if the unique needs of young women and men are acknowledged, and their human rights fulfilled, respected, and protected. In order to reduce new HIV infections among young people, achieve the broader equity goals set out in the MDGs, and begin to reverse the overall HIV epidemic, HIV prevention and treatment efforts must be tailored to the specific needs of young people.
Measles outbreaks and progress towards meeting measles pre-elimination goals: WHO African Region, 2009-2010. Flambees de rougeole et progres accomplis en vue d'atteindre les objectifs de preelimination de la rougeole: Region africaine de l'OMS, 2009-2010.
Releve Epidemiologique Hebdomadaire. 2011 Apr 1; 86(14):129-36.This report summarizes the progress made during 2009-2010 towards meeting the pre-elimination goals after a historically low incidence of measles cases was reported in 2008. In addition, it provides information on measles outbreaks occurring during the same period which highlights the urgent need for renewed political will from governments and their partners to ensure that national multiyear vaccination plans, budgetary line-items and financial commitments exist for routine immunization services and measles-control activities. To assist countries in resonding to measles outbreaks, WHO guidelines were published in 2009.