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investments to support countries with greatest burden of viral hepatitis All heavily burdened countries to have fully funded elimination plans by 2019 Recognition of need to focus on high burden countries and support for national policy development (All) Funding for national elimination plans Creation of fiscal space for new programmes with costed investment programmes Adopt domestic innovative finance tools where appropriate Support national policy makers in their activity (WHO, UNITAID, NGOs) Provide international support for financing measures (UNITAID, GFATM, bilaterial donors) Prevention Ensure all WHO elimination targets addressed in plans Address operational challenges in delivery of birth dose HBV vaccine Ensure provision of harm reduction services and engage with marginalised group (e.g. prisoners, PWIDs). Ensure clear public health messages to encourage testing and treatment Support countries to decriminalise injecting drug use and ensure equitable access to services for all (NGOs, WHO, civil society) Ensure appropriate funding for HBV vaccine, including birth dose (GAVI, WHO) Support R&D into HCV vaccine development (Research funders and pharma) Testing and Models of Care Focus on substantially scaling up testing for HBV and HCV Create and evaluate simplified care pathways relevant to local setting, integrating with existing services. Promote task sharing and decentralisation of care through capacity building, training and removal of Support operational research into simplified pathways (Research funders, UNITAID) requirements for specialised prescribing Diagnostics Ensure testing is integrated into the wider healthcare system, rather than centralised facilties Ensure access to quality diagnostics through Essential Diagnostic List and prequalification (WHO, funders) Support implementation science for models of care and R&D into novel diagnostics suitable for decentralised settings. (Research funders, FIND, industry) Access to treatment Ensure all Essential Medicines for viral hepatitis are included in national programmes, with an emphasis on pan-genotypic regimens Apply comprehensive policy approach to promoting access, including compulsory licensing Ensure all essential medicines are pre-qualified and either available through voluntary licensing or Medicines Patent Pool (WHO, NGOs, civil society, funders) Support shared procurement mechanisms for treatment (PAHO) Monitor Progress National plans need clearly defined, measurable objectives Develop new indices of national progress Progress of individual countries needs to be closely monitored towards elimination goals (Polaris, WHO, Creation of Elimination Index) Develop greater capacity for advocacy in high burden regions (all) Viral hepatitis is one of the leading causes of death in the world. 96% of those deaths are due to hepatitis B and C, which are the focus of this commission. Unlike many other major diseases, the tools exist to eliminate viral hepatitis. A highly effective vaccine is available to prevent hepatitis B, and a revolution in HCV treat...

EARLY 2 MILLION CHILDREN die annually from diarrheal disease. 1 A recent metaanalysis concluded that handwashing promotion interventions decrease diarrhea by a mean of 47%. 2 The authors estimate that such interventions could prevent 1 million child deaths per year. 2 However, the systematic meta-analysis and the studies it included summarized the reduction in diarrheal rates among all children or all family members. But all family members are not at equal risk of death from diarrhea. Children younger than 5 years are at much higher risk of death from diarrhea than older children and adults, 1 and infants (younger than 1 year) are at the highest risk of death. Verbal autopsy studies from Egypt, 3 Pakistan, 4 Bangladesh, 5 and Ethiopia 6 report that 43% to 78% of deaths from diarrhea among children younger than 5 years occur in the first year of life.Infants cannot wash their own hands and therefore cannot interrupt the transfer of pathogens between their hands and their mouth. Infants might benefit from a lower rate of diarrheal pathogen transmission from parents and siblings who wash their hands more

Summaryobjectives To evaluate the effectiveness of point of use water treatment with flocculent-disinfectant on reducing diarrhoea and the additional benefit of promoting hand washing with soap.methods The study was conducted in squatter settlements of Karachi, Pakistan, where diarrhoea is a leading cause of childhood death. Interventions were randomly assigned to 47 neighbourhoods. Households in 10 neighbourhoods received diluted bleach and a water vessel; nine neighbourhoods received soap and were encouraged to wash hands; nine neighbourhoods received flocculent-disinfectant water treatment and a water vessel; 10 neighbourhoods received disinfectant-disinfectant water treatment and soap and were encouraged to wash hands; and nine neighbourhoods were followed as controls. Field workers visited households at least once a week from April to December 2003 to promote use of the interventions and to collect data on diarrhoea.results Study participants in control neighbourhoods had diarrhoea on 5.2% of days. Compared to controls, participants living in intervention neighbourhoods had a lower prevalence of diarrhoea: 55% (95% CI 17%, 80%) lower in bleach and water vessel neighbourhoods, 51% (95% CI 12%, 76%) lower in hand washing promotion with soap neighbourhoods, 64% lower (95% CI 29%, 90%) in disinfectant-disinfectant neighbourhoods, and 55% (95% CI 18%, 80%) lower in disinfectantdisinfectant plus hand washing with soap neighbourhoods.conclusions With an intense community-based intervention and supplies provided free of cost, each of the home-based interventions significantly reduced diarrhoea. There was no benefit by combining hand washing promotion with water treatment.

SummaryIn December 1994 in a private hospital in Quetta, Pakistan, 3 health-workers contracted Crimean-Congo haemorrhagic fever (CCHF) after surgery on a bleeding patient who later died. We conducted a retrospective study to determine transmission risks among contacts. Fifty contacts gave blood for antibody tests and answered questions about exposure. Two of four people exposed percutaneously and one of five with cutaneous exposure contracted CCHF. The person with cutaneous exposure was a surgeon who tore his glove during surgery and noted blood on his hand but no cut. There were no anti-CCHF antibodies or CCHF cases among persons whose skin came into contact with body fluids other than blood (0/4), who had skin-to-skin contact (0/16) with patients or were physically close to them (0/21). Three index case relatives reported that although 10 family members had cutaneous exposure, none developed CCHF. The family refused blood tests. CCHF transmission in resource-constrained settings can be limited by focusing on avoiding health worker contact with blood.