The role of research in viral disease eradication and elimination programs: lessons for malaria eradication.

By examining the role research has played in eradication or regional elimination initiatives for three viral diseases--smallpox, poliomyelitis, and measles--we derive nine cross-cutting lessons applicable to malaria eradication. In these initiatives, some types of research commenced as the programs began and proceeded in parallel. Basic laboratory, clinical, and field research all contributed notably to progress made in the viral programs. For each program, vaccine was the lynchpin intervention, but as the programs progressed, research was required to improve vaccine formulations, delivery methods, and immunization schedules. Surveillance was fundamental to all three programs, whilst polio eradication also required improved diagnostic methods to identify asymptomatic infections. Molecular characterization of pathogen isolates strengthened surveillance and allowed insights into the geographic source of infections and their spread. Anthropologic, sociologic, and behavioural research were needed to address cultural and religious beliefs to expand community acceptance. The last phases of elimination and eradication became increasingly difficult, as a nil incidence was approached. Any eradication initiative for malaria must incorporate flexible research agendas that can adapt to changing epidemiologic contingencies and allow planning for posteradication scenarios.

Perspectives on the role of surveillance in eliminating rubella and congenital rubella syndrome in the Americas.

Effective management and coordination in regions currently lacking surveillance capacity will require significant increases in existing human resources to manage vitally needed expanded national surveillance systems. An adequate investment in human resources and infrastructure capacity is essential for ensuring surveillance functions well. This was the experience in the Americas, particularly with the recent elimination of rubella and congenital rubella syndrome. By taking this path, other benefits to the overall public health of the nations will occur. The purpose of this paper is to present perspectives on the role of surveillance in the elimination of rubella in the Americas and to share related perspectives on capacity development in developing countries. Hopefully, these perspectives will aid efforts to strengthen surveillance and advance rubella elimination in other regions of the world.

Overcoming perceptions of financial barriers to rotavirus vaccine introduction in Asia.

Despite a WHO recommendation in 2009, reaffirmed in 2013, that all countries should consider introducing rotavirus vaccines into their National Immunization Programs, as of June 2013 only 45 have done so. One major consideration appears to have been the costs of the vaccine to countries. Of concern, is that Asian countries have been slow to introduce rotavirus vaccines despite having robust data that could inform the decision-making process. Although decisions on new vaccine introduction are very complex and vary by country and region, economic evaluations are often pivotal once vaccine efficacy and safety has been established, and disease burden documented and communicated. Unfortunately, with private sector list prices of vaccines often used in economic evaluations, rather than a potential public health sector pricing structure, policy-makers may defer decisions on rotavirus vaccine introduction based on the belief that "the vaccine price is too high," even though this might be based on erroneous data. The Pan American Health Organization's Revolving Fund provides one example of how vaccine price can be made more competitive and transparent through a regional tendering process. Other mechanisms, such as tiered pricing and UNICEF procurement, also exist that could help Asian and other countries move forward more quickly with rotavirus vaccine introduction.

Experiences with smallpox eradication in Ethiopia.

The smallpox eradication campaign operated in Ethiopia from 1970 until 1977. During this time Ethiopia had only 84 hospitals, 64 health centres and fewer than 400 physicians in a country of 25 million people. In 1970 smallpox vaccination was relatively unknown in the country, and the government actually contested the fact that smallpox was present in the country. Most of the resources of the Ministry of Health were used for malaria eradication. Initial pessimism from the Ministry of Health and others was eventually overcome as the smallpox eradication campaign continued to pick up steam but many remained unenthusiastic. Ethiopia was the first country in the world to start its smallpox eradication campaign from day one with the strategy of "Surveillance and Containment". Establishing a surveillance system in a country with a limited health infrastructure was a daunting challenge. At the end of the first year of the programme in 1971, 26,000 cases of smallpox had been registered through the growing surveillance system. Throughout revolution of 1974 the smallpox campaign was the only UN program to operate in the country; in fact it expanded with the hire of many locals leading to a "nationalized" program. This development ushered in the most successful final phase of the program. As the program progressed cases were diminishing in most regions, however transmission continued in the Ogaden desert. Over the course of the campaign approximately 14.3 million US dollars was spent. Working conditions were extremely challenging and a variety of chiefs, guerrillas, landowners and governments had to be appeased. The programme was successful due to the dedicated national and international staff on the ground and by having the full support of the WHO HQ in Geneva.

Measles and rubella eradication in the Americas.

The challenge for regions embarking on measles elimination will be to maintain high population immunity with excellent vaccination coverage and high-quality surveillance. Meeting this challenge will be especially critical for dealing with importations of measles virus that will occur as long as the virus is circulating anywhere in the world. Implementation of measles elimination strategies will uncover the "hidden" disease burden of rubella and congenital rubella syndrome. As was the experience in countries of Latin America and the Caribbean (LAC), integrating the elimination of measles with the elimination of rubella will greatly enhance the capacity of countries to sustain progress in the reduction of measles mortality. Countries of LAC prioritized the routine national immunization program over short-term successes. While doing so, they have also encountered new opportunities to expand the benefits of disease control and elimination activities to other aspects of public health, most importantly towards improving health care for women and newborns and reducing inequities in health in the region's poorest communities. Implementation of similar strategies could lead to the global eradication of measles, rubella, and congenital rubella syndrome early this century, while strengthening routine immunization programs, and developing the capacity to introduce new and underutilized vaccines.

Strengthening surveillance: confronting infectious diseases in developing countries.

Effective management and coordination in regions currently lacking surveillance capacity will require significant increases in existing human resources to manage vitally needed expanded national systems. An adequate investment in human resources is essential for ensuring surveillance functions well. This was the experience in the Americas. By taking this path, other benefits to the overall public health of nations will occur. Monitoring deaths will help as an indicator for impending epidemics or other threats. Better equipped labs will detect antigen shifts in virus and circulating bacterial serotypes more rapidly and other earlier changes in patterns of transmission more efficiently. Any strategy must promote and galvanize the commitment of countries to excellence, equity, and access, above all.

From global to regional: the importance of pneumococcal disease in Latin America.

Latin America is estimated to have 3637 cases of meningitis, 14,548 cases of bacteremia, 192,761-318,238 cases of pneumonia, and about 5.6 million cases of otitis media annually. Pneumococcal conjugate vaccines (PCVs) have proven to be effective in preventing paediatric pneumococcal disease. Monitoring serotypes and anti-microbial resistance in Latin American children by collecting clinical and epidemiological data at regular intervals is essential. It is important to identify and support systems for surveillance of invasive pneumococcal disease based on population to demonstrate the impact of PCVs. Surveillance should include pneumococcal disease in adults to estimate the indirect effects of the vaccine.