Paratyphi A could have a large effect if Vi

Paratyphi A could have a large effect if Vi-polysaccharide-conjugate vaccines are introduced in Asia. The absence of the Vi-polysaccharide SCH772984 in Paratyphi A is the most important microbiological discrepancy between Paratyphi A and Typhi; vaccines based on Vi-polysaccharide do not provide any cross-serovar immunity. At present no vaccines specific to Paratyphi A are available. Conjugate vaccines using the O antigen as the main immunological component are under development. However, these vaccines are some way from being licensed and made available to use in endemic locations. Whether they will provide sufficient protective efficacy and herd immunity to be a cost-effective intervention for public health remains to be established. In the absence of improvements in sanitation, clean water, and systematic vaccination, antimicrobial therapy for acute infection is the only intervention that can contribute to control of community transmission. Available data suggest that infections with Typhi and Paratyphi A both respond equally well to antimicrobials when the bacteria are susceptible. Unfortunately, antimicrobial resistance in all invasive species is a growing threat, and Paratyphi A seems to have a greater propensity than does Typhi to develop resistance to antimicrobials. Multidrug resistance and intermediate susceptibility to ciprofloxacin is common in Paratyphi A, and full resistance to fluoroquinolones, azithromycin, and ceftriaxone is of increasing concern. The world is not prepared for the emergence of Paratyphi A. Although many lessons from research into Typhi are applicable to Paratyphi A, this neglected but emergent pathogen is a global health issue that needs the urgent attention of the enteric-fever research community. We declare that we have no competing interests. This work was funded by the Wellcome Trust of Great Britain. Stephen Baker is a Sir Henry Dale Fellow, jointly funded by the ().
Somalia is once again making headlines; this time for a polio outbreak in the capital and its surroundings. Despite the efforts of a widely lauded control programme that had been making steady progress in the past few years, this development should come as no surprise. Divided into three administrative regions—Puntland state in the northeast, Somaliland in the northwest, and south-central regions—the country is most widely known for its political instability and chronic health crises. Because of extended periods of conflict and instability, Somalia has become the quintessential fragile state. As a result of this prolonged fragility, existing health infrastructures have been destroyed and effective institutional investment in quality health services has been prevented. This breakdown of health service provision is a symptom of a dysfunctional health system, which is in turn characterised by poor infrastructure; an inability of governments to deliver services; an absence of equity, incoherent, or non-existent policies; a scarcity of actionable information; and poor management. These characteristics have meant that, in many regions of Somalia, health services are largely non-existent, exposing an already vulnerable population to a high disease burden and malnutrition. Seen in this context, sustained health efforts such as eradication of polio within the borders of Somalia cannot be reasonably expected to succeed in the long term. Although short-term emergency planning and well organised vertical programmes such as that of the polio eradication are essential, long-term success depends on a vibrant and functioning health system. However, research into health systems in fragile states has largely been overlooked, despite the important role such research would have in the improvement of health outcomes. Throughout the years of fragmentation and near total collapse, various efforts have been undertaken in a bid to reconstruct a functioning and dynamic health system. The recent Joint Health and Nutrition Programme (JHNP) is one such effort. Through explicit identification of health system strengthening as a primary goal, the programme has taken a step in the right direction. Importantly, the JHNP will be led by the Somali Health Authorities with UN partners playing a supporting part. To reach the stated goal of assurance of equitable, affordable, and effective health services to the population, the plans will focus on six main building blocks: (1) strengthening leadership and governance; (2) increasing health workforce quality and quantity; (3) delivering equitable health services through functioning health facilities; (4) developing a nationally financed and locally prioritised health financing system; (5) ensuring provision of appropriate and sufficient health products; and (6) establishing a comprehensive monitoring and evaluation system. Although these goals might be challenging for any government, they are especially ambitious within the context of Somalia. At present, in view of the scarcely existing health facilities with inadequate geographical reach, constrained supply, and insufficient staff capacity, overall access to health services remains poor. As a result, the programme intends to contract out service delivery to implement partners already present in the country. The emphasis will be on capacity building with the long-term goal being a gradual withdrawal of these partners as the government agencies shoulder greater responsibility.