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The B.1.1.529 (Omicron) variant of SARS-CoV-2, the virus that causes COVID-19, was first clinically identified in the United States on December 1, 2021, and spread rapidly. By late December, it became the predominant strain, and by January 15, 2022, it represented 99.5% of sequenced specimens in the United States* (1). The Omicron variant has been shown to be more transmissible and less virulent than previously circulating variants (2,3). To better understand the severity of disease and health care utilization associated with the emergence of the Omicron variant in the United States, CDC examined data from three surveillance systems and a large health care database to assess multiple indicators across three high-COVID-19 transmission periods: December 1, 2020-February 28, 2021 (winter 2020-21); July 15-October 31, 2021 (SARS-CoV-2 B.1.617.2 [Delta] predominance); and December 19, 2021-January 15, 2022 (Omicron predominance). The highest daily 7-day moving average to date of cases (798,976 daily cases during January 9-15, 2022), emergency department (ED) visits (48,238), and admissions (21,586) were reported during the Omicron period, however, the highest daily 7-day moving average of deaths (1,854) was lower than during previous periods. During the Omicron period, a maximum of 20.6% of staffed inpatient beds were in use for COVID-19 patients, 3.4 and 7.2 percentage points higher than during the winter 2020-21 and Delta periods, respectively. However, intensive care unit (ICU) bed use did not increase to the same degree: 30.4% of staffed ICU beds were in use for COVID-19 patients during the Omicron period, 0.5 percentage points lower than during the winter 2020-21 period and 1.2 percentage points higher than during the Delta period. The ratio of peak ED visits to cases (event-to-case ratios) (87 per 1,000 cases), hospital admissions (27 per 1,000 cases), and deaths (nine per 1,000 cases [lagged by 3 weeks]) during the Omicron period were lower than those observed during the winter 2020-21 (92, 68, and 16 respectively) and Delta (167, 78, and 13, respectively) periods. Further, among hospitalized COVID-19 patients from 199 U.S. hospitals, the mean length of stay and percentages who were admitted to an ICU, received invasive mechanical ventilation (IMV), and died while in the hospital were lower during the Omicron period than during previous periods. COVID-19 disease severity appears to be lower during the Omicron period than during previous periods of high transmission, likely related to higher vaccination coverage

Comparisons of the utility and accuracy of methods for measuring social interactions relevant to disease transmission are rare. To increase the evidence base supporting specific methods to measure social interaction, we compared data from self-reported contact surveys and wearable proximity sensors from a cohort of schoolchildren in the Pittsburgh metropolitan area. Although the number and type of contacts recorded by each participant differed between the two methods, we found good correspondence between the two methods in aggregate measures of age-specific interactions. Fewer, but longer, contacts were reported in surveys, relative to the generally short proximal interactions captured by wearable sensors. When adjusted for expectations of proportionate mixing, though, the two methods produced highly similar, assortative age-mixing matrices. These aggregate mixing matrices, when used in simulation, resulted in similar estimates of risk of infection by age. While proximity sensors and survey methods may not be interchangeable for capturing individual contacts, they can generate highly correlated data on age-specific mixing patterns relevant to the dynamics of respiratory virus transmission.

Although non-Hispanic American Indian and Alaska Native (AI/AN) persons account for 0.7% of the U.S. population,* a recent analysis reported that 1.3% of coronavirus disease 2019 (COVID-19) cases reported to CDC with known race and ethnicity were among AI/AN persons (1). To assess the impact of COVID-19 among the AI/AN population, reports of laboratory-confirmed COVID-19 cases during January 22†-July 3, 2020 were analyzed. The analysis was limited to 23 states§ with >70% complete race/ethnicity information and five or more laboratory-confirmed COVID-19 cases among both AI/AN persons (alone or in combination with other races and ethnicities) and non-Hispanic white (white) persons. Among 424,899 COVID-19 cases reported by these states, 340,059 (80%) had complete race/ethnicity information; among these 340,059 cases, 9,072 (2.7%) occurred among AI/AN persons, and 138,960 (40.9%) among white persons. Among 340,059 cases with complete patient race/ethnicity data, the cumulative incidence among AI/AN persons in these 23 states was 594 per 100,000 AI/AN population (95% confidence interval [CI] = 203-1,740), compared with 169 per 100,000 white population (95% CI = 137-209) (rate ratio [RR] = 3.5; 95% CI = 1.2-10.1). AI/AN persons with COVID-19 were younger (median age = 40 years; interquartile range [IQR] = 26-56 years) than were white persons (median age = 51 years; IQR = 32-67 years). More complete case report data and timely, culturally responsive, and evidence-based public health efforts that leverage the strengths of AI/AN communities are needed to decrease COVID-19 transmission and improve patient outcomes.

CaliciNet China, a network of provincial, county, and city laboratories coordinated by the Chinese Centers for Disease Control and Prevention, was launched in October 2016 to monitor the epidemiology and genotype distribution of norovirus outbreaks in China. During October 2016–September 2018, a total of 556 norovirus outbreaks were reported, and positive fecal samples from 470 (84.5%) outbreaks were genotyped. Most of these outbreaks were associated with person-to-person transmission (95.1%), occurred in childcare centers or schools (78.2%), and were reported during November–March of each year (63.5%). During the 2-year study period, 81.2% of all norovirus outbreaks were typed as GII.2[P16]. In China, most norovirus outbreaks are reported by childcare centers or schools; GII.2[P16] is the predominant genotype. Ongoing surveillance by CaliciNet China will provide information about the evolving norovirus genotype distribution and outbreak characteristics important for the development of effective interventions, including vaccines.

Background Southern China is at risk for arborvirus disease transmission, including Zika virus and dengue. Patients often present to clinical care with non-specific acute febrile illnesses (AFI). To better describe the etiology of AFI, we implemented a two-year AFI surveillance project at five sentinel hospitals in Yunnan and Guangdong Provinces. Methods Between June 2017 and August 2019, we enrolled patients between 2 and 65 years of age presenting at one sentinel hospital in Mengla County, Yunnan, and four in Jiangmen City, Guangdong, with symptoms of AFI (acute onset of fever ≥ 37.5°C within the past 7 days) without respiratory symptoms or diarrhea. Demographic, epidemiologic, and clinical information was obtained and entered into a web-based AFI surveillance database. A custom TaqMan Array card (TAC) was used to test patients’ whole blood specimens for 27 different pathogens using real-time polymerase chain reaction assays. Results During the two-year project period, 836 patients were enrolled; 443 patients from Mengla County and 393 patients from Jiangmen City. The median age was 33 years [range: 2–65], and most were hospitalized [641, 77%]. Of 796 patients with valid TAC results, 341 (43%) were positive for at least one of the 10 unique pathogens detected. This included 205 (26%) patients positive for dengue virus, 60 (8%) for Orientia tsutsugamushi, and 42 (5%) for Coxiella burnetii. Ten patients (1%) in Jiangmen City tested positive for malaria, 8 of whom reported recent travel outside of China. TAC results were negative for 455 (57%) patients. None of the patients had a positive TAC detection for Zika virus. Conclusions The project detected variability in the etiology of AFI in Southern China and highlighted the importance of differential diagnosis. Dengue, O. tsutsugamushi, and C. burnetii were the most frequently identified pathogens among enrolled AFI patients. As a non-notifiable disease, the frequent detection of C. burnetii is noteworthy and warrants additional investigation. The project provided a framework for routine surveillance for persons presenting with AFI.

Background Hand, Foot, and Mouth Disease (HFMD) is most frequently caused by Enterovirus71 (EV-A71) or Coxsackie virus A16 (CV-A16), infants and young children are at greatest risk. Describing the epidemiology of HFMD can help develop and better target interventions, including the use of pediatric EV-A71 vaccination. Methods We obtained data from the national surveillance system for HFMD cases with onset dates from 2009 to 2015. We defined probable cases as patient with skin papular or vesicular rashes on the hands, feet, mouth, or buttocks and confirmed cases as patients with the above symptoms along with laboratory-based enterovirus detection. We generated overall and age-specific annual incidence rates and described the temporal variability and seasonality of HFMD in Qinghai Province. We identified spatial clustering of HFMD incidence at the county level using the Local Indicator of Spatial Associationand an alpha level of 0.05. Results During the study period, 14,480 HFMD probable or confirmed cases were reported in Qinghai Province. Of the 2158 (14.9%) with laboratory confirmation, 924 (42.6%) were caused by CV-A16 and 830 (38.2%) were caused by EV-A71. The majority (89%) of all case-patients were ≤ 5 years of age and male (61.5%). The overall mean annual HFMD incidence rate was 36.4 cases per 100,000 populations, while the incidence rate for children ≤5 years of age was 379.5 cases per 100,000. Case reports peaked during the months of May through July. HFMD was predominantly caused by EV-A71, except in 2010 and 2014 when CV-A16 was the predominant causative agent. High incidence rates of HFMD were clustered (Moran’s I = 0.59, P

Background Antimicrobial resistance (AMR) is a global healthcare problem, including in China where high rates of resistance to common bacterial infections have been documented. In 2016, the National Health and Family Planning Commission (NHFPC) in China established a comprehensive strategic plan to increase awareness about AMR through education programs. Methods We conducted an online survey to assess changes in public knowledge, awareness and practices related to AMR in China since 2016. The survey was administered using China’s national and provincial level 12320 Health Hotline Weibo (micro-blog site) and WeChat (text messaging service) social media accounts from April 12, 2019 to May 7, 2019. All persons ≥16 years of age able to read Chinese were eligible to participate. Results A total of 2773 respondents completed the survey. Of the 2633 respondents indicating recent use of antibiotics, 84% (2223) reported obtaining their course of antibiotics from a hospital or pharmacy, 9% (246) of respondents reported using antibiotics saved from a previous prescription or treatment course, and 42% (1115) of respondents reported that they had stopped taking antibiotics as soon as they started feeling better. Most respondents correctly indicated that antibiotics can effectively treat urinary tract infections (86% [2388]) and skin infections (76% [2119]), but many incorrectly indicated that antibiotics can also treat viral infections such as measles (32% [889]) or a cold or flu (26% [726]). Of all respondents, 95% (2634) had heard of ‘antibiotic resistance’. Almost half (47% [1315]) reported using antibiotics within the last 6 months. Conclusion While awareness of AMR was high in this survey of social media users in China, inappropriate antibiotic use remains common, including the believe that antibiotics can effectively treat viral infections. Multiple interventions targeting the correct use of antibiotics and information on the cause AMR are likely needed. The 12320 Health Hotline provides a platform for conducting routine surveys to monitor antibiotic use and knowledge about AMR.

Background Monitoring hepatitis B surveillance data is important for evaluating progress towards global hepatitis B elimination goals. Accurate classification of acute and chronic hepatitis infections is essential for assessing program effectiveness. Methods We evaluated hepatitis B case-reporting at six hospitals in Fujian, Hainan and Gansu provinces in 2015 to assess the accuracy of case classification. We linked National Notifiable Disease Reporting System (NNDRS) HBV case-reports with hospital information systems and extracted information on age, gender, admission ward and viral hepatitis diagnosis from medical records. To assess accuracy, we compared NNDRS reported case-classifications with the national HBV case definitions. Multivariable logistic regression was used to identify factors associated with misclassification. Results Of the 1420 HBV cases reported to NNDRS, 23 (6.5%) of the 352 acute reports and 648 (60.7%) of the 1068 chronic reports were correctly classified. Of the remaining, 318 (22.4%) were misclassified and 431 (30.4%) could not be classified due to the lack of supporting information. Based on the multivariable analysis, HBV cases reported from Hainan (aOR = 1.8; 95% CI: 1.3–2.4) and Gansu (aOR = 12.7; 95% CI: 7.7–20.1) along with reports from grade 2 hospitals (aOR = 1.6; 95% CI:1.2–2.2) and those from non-HBV related departments (aOR = 5.3; 95% CI: 4.1–7.0) were independently associated with being ‘misclassified’ in NNDRS. Conclusions We identified discrepancies in the accuracy of HBV case-reporting in the project hospitals. Onsite training on the use of anti-HBc IgM testing as well as on HBV case definitions and reporting procedures are needed to accurately assess program effectiveness and ensure case-patients are referred to appropriate treatment and care. Routine surveillance evaluations such as this can be useful for improving data quality and monitoring program effectiveness.

Background Information on the etiology and age-specific burden of respiratory viral infections among school-aged children remains limited. Though school aged children are often recognized as driving the transmission of influenza as well as other respiratory viruses, little detailed information is available on the distribution of respiratory infections among children of different ages within this group. Factors other than age including gender and time spent in school may also be important in determining risk of infection but have been little studied in this age group. Methods We conducted a cohort study to determine the etiology of influenza like illness (ILI) among 2519 K–12 students during the 2012–13 influenza season. We obtained nasal swabs from students with ILI-related absences. Generalized linear mixed-effect regressions determined associations of outcomes, including ILI and laboratory-confirmed respiratory virus infection, with school grade and other covariates. Results Overall, 459 swabs were obtained from 552 ILI–related absences. Respiratory viruses were found in 292 (63.6%) samples. Influenza was found in 189 (41.2%) samples. With influenza B found in 134 (70.9%). Rates of influenza B were significantly higher in grades 1 (10.1, 95% CI 6.8–14.4%), 2 (9.7, 6.6–13.6%), 3 (9.3, 6.3–13.2%), and 4 (9.9, 6.8–13.8%) than in kindergarteners (3.2, 1.5–6.0%). After accounting for grade, sex and self-reported vaccination status, influenza B infection risk was lower among kindergarteners in half-day programs compared to kindergarteners in full-day programs (OR = 0.19; 95% CI 0.08–0.45). Conclusions ILI and influenza infection is concentrated in younger schoolchildren. Reduced infection by respiratory viruses is associated with a truncated school day for kindergarteners but this finding requires further investigation in other grades and populations.

Global spread of Zika virus in 2015 and 2016 highlighted the importance of surveillance to rapidly detect, report, and respond to emerging infections. We describe the lessons learned from the development and deployment of a web-based surveillance reporting system for Zika virus and other acute febrile illnesses (AFI) in Guangdong and Yunnan provinces, China. In less than 2 months, we customized the China Epidemiologic Dynamic Data Collection (EDDC) platform to collect, manage, and visualize data in close to real time. According to provincial and sentinel hospital staff requirements, the customized platform provided specific user authorization management, online/offline data collection, data quality control, and secure data transmission and protection and visualization tools. AFI case data and laboratory test results were entered through a web-based interface by hospital and provincial-level staff and saved on a China CDC server in Beijing. The dashboard visualized aggregate data by hospital, age, onset date, and laboratory test results. From June 2017 to December 2018, data from 768 patients with AFI were entered into the web-based surveillance system and visualized by hospital and provincial-level decision makers. Input from provincial and hospital staff was essential for developing the AFI case-reporting and feedback tools appropriate for specific settings and decision-making requirements. Web-based systems (eg, EDDC, data collection, and visualization tools that can be easily adapted to meet local surveillance needs) can help shorten time for system deployment, thereby strengthening global health security to rapidly detect and respond to emerging infections and outbreaks.

Previous research on respiratory infection transmission among university students has primarily focused on influenza. In this study, we explore potential transmission events for multiple respiratory pathogens in a social contact network of university students. University students residing in on-campus housing (n = 590) were followed for the development of influenza-like illness for 10-weeks during the 2012–13 influenza season. A contact network was built using weekly self-reported contacts, class schedules, and housing information. We considered a transmission event to have occurred if students were positive for the same pathogen and had a network connection within a 14-day period. Transmitters were individuals who had onset date prior to their infected social contact. Throat and nasal samples were analysed for multiple viruses by RT-PCR. Five viruses were involved in 18 transmission events (influenza A, parainfluenza virus 3, rhinovirus, coronavirus NL63, respiratory syncytial virus). Transmitters had higher numbers of co-infections (67%). Identified transmission events had contacts reported in small classes (33%), dormitory common areas (22%) and dormitory rooms (17%). These results suggest that targeting person-to-person interactions, through measures such as isolation and quarantine, could reduce transmission of respiratory infections on campus.

Mass gatherings create settings conducive to infectious disease transmission. Empirical data to model infectious disease transmission at mass gatherings are limited. Video-analysis technology could be used to generate data on social mixing patterns needed for simulating influenza transmission at mass gatherings. We analyzed short video recordings of persons attending the GameFest event at a university in Troy, New York, in April 2013 to demonstrate the feasibility of this approach. Attendees were identified and tracked during three randomly selected time periods using an object-tracking algorithm. Tracks were analyzed to calculate the number and duration of unique pairwise contacts. A contact occurred each time two attendees were within 2 m of each other. We built and tested an agent-based stochastic influenza simulation model assuming two scenarios of mixing patterns in a geospatially accurate representation of the event venue —one calibrated to the mean cumulative contact duration estimated from GameFest video recordings and the other using a uniform mixing pattern. We compared one-hour attack rates (i.e., becoming infected) generated from these two scenarios following the introduction of a single infectious seed. Across the video recordings, 278 attendees were identified and tracked, resulting in 1,247 unique pairwise contacts with a cumulative mean contact duration of 74.76 s (SD: 80.71). The one-hour simulated mean attack rates were 2.17 % (95 % CI:1.45 – 2.82) and 0.21 % (95 % CI: 0.14 – 0.28) in the calibrated and uniform mixing model scenarios, respectively. We simulated influenza transmission at the GameFest event using social mixing data objectively captured through video-analysis technology. Microlevel geospatially accurate simulations can be used to assess the layout of event venues on social mixing and disease transmission. Future work can expand on this demonstration project to larger spatial and temporal scenes in more diverse settings.

Monitoring hepatitis B surveillance data is important for evaluating progress towards global hepatitis B elimination goals. Accurate classification of acute and chronic hepatitis infections is essential for assessing program effectiveness. We evaluated hepatitis B case-reporting at six hospitals in Fujian, Hainan and Gansu provinces in 2015 to assess the accuracy of case classification. We linked National Notifiable Disease Reporting System (NNDRS) HBV case-reports with hospital information systems and extracted information on age, gender, admission ward and viral hepatitis diagnosis from medical records. To assess accuracy, we compared NNDRS reported case-classifications with the national HBV case definitions. Multivariable logistic regression was used to identify factors associated with misclassification. Of the 1420 HBV cases reported to NNDRS, 23 (6.5%) of the 352 acute reports and 648 (60.7%) of the 1068 chronic reports were correctly classified. Of the remaining, 318 (22.4%) were misclassified and 431 (30.4%) could not be classified due to the lack of supporting information. Based on the multivariable analysis, HBV cases reported from Hainan (aOR = 1.8; 95% CI: 1.3–2.4) and Gansu (aOR = 12.7; 95% CI: 7.7–20.1) along with reports from grade 2 hospitals (aOR = 1.6; 95% CI:1.2–2.2) and those from non-HBV related departments (aOR = 5.3; 95% CI: 4.1–7.0) were independently associated with being ‘misclassified’ in NNDRS. We identified discrepancies in the accuracy of HBV case-reporting in the project hospitals. Onsite training on the use of anti-HBc IgM testing as well as on HBV case definitions and reporting procedures are needed to accurately assess program effectiveness and ensure case-patients are referred to appropriate treatment and care. Routine surveillance evaluations such as this can be useful for improving data quality and monitoring program effectiveness.

Background Timely and appropriate administration of post-exposure prophylaxis (PEP) is an essential component of human rabies prevention programs. We evaluated patient care at rabies clinics in a high-risk county in Hunan Province, China to inform strategies needed to achieve dog-mediated human rabies elimination by 2030. Methods We collected information on PEP, staff capacity, and service availability at the 17 rabies clinics in the high-risk county during onsite visits and key staff interviews. Additionally, we conducted observational assessments at five of these clinics, identified through purposive sampling to capture real-time information on patient care during a four-week period. Wound categories assigned by trained observers were considered accurate per national guidelines for comparison purposes. We used the kappa statistic and an alpha level of 0.05 to assess agreement between observers and clinic staff. Results In 2015, the 17 clinics provided PEP to 5,261 patients. Although rabies vaccines were available at all 17 clinics, rabies immune globulin (RIG) was only available at the single urban clinic in the county. During the assessment period in 2016, 196 patients sought care for possible rabies virus exposures. According to observers, 88 (44%) patients had category III wounds, 104 (53%) had category II wounds and 4 (2%) had category I wounds. Observers and PEP clinic staff agreed on approximately half of the assigned wound categories (kappa = 0.55, p-value< 0.001). Agreement for the urban county-level CDC clinic (kappa = 0.93, p-value, Author summary Members of the United Nations agreed on a goal of eliminating dog-mediated rabies by 2030. To achieve this goal, China and other endemic rabies countries will need to increase dog rabies vaccination coverage as well as ensure proper administration of rabies post-exposure prophylaxis (PEP) for patients with animal wounds. PEP includes wound washing, timely vaccination, and rabies immune globulin (RIG) according to the type and severity of patients’ wounds. The authors conducted an observational assessment of PEP clinics in a high-risk county in Hunan Province. Most patients at these clinics received PEP according to the national guidelines; however, certain patients received PEP, when not warranted, and others did not receive RIG, as recommended for severe animal wounds. Wound type categorization and corresponding use of PEP were most accurate at the single urban clinic and least accurate at the rural clinics in the project county. RIG was only available at the single urban clinic. These findings highlight the importance of improving the use of PEP and access to RIG, particularly in rural areas, and exploring the use of risk-based approaches for evaluating human rabies virus exposures. These steps can contribute to eliminating dog-mediated rabies in the project county as well as elsewhere in China.

Background Strong laboratory capacity is essential for detecting and responding to emerging and re-emerging global health threats. We conducted a quantitative laboratory assessment during 2014–2015 in two resource-limited provinces in southern China, Guangxi and Guizhou in order to guide strategies for strengthening core capacities as required by the International Health Regulations (IHR 2005). Methods We selected 28 public health and clinical laboratories from the provincial, prefecture and county levels through a quasi-random sampling approach. The 11-module World Health Organization (WHO) laboratory assessment tool was adapted to the local context in China. At each laboratory, modules were scored 0–100% through a combination of paper surveys, in-person interviews, and visual inspections. We defined module scores as strong (> = 85%), good (70–84%), weak (50–69%), and very weak (

We conducted a retrospective analysis of norovirus outbreaks reported to the National Public Health Emergency Event Surveillance System (PHEESS) in China from January 1, 2014 to December 31, 2017. We reviewed all acute gastroenteritis outbreaks (n = 692) submitted to PHEESS to identify the frequency, seasonality, geographic distribution, setting, and transmission mode of outbreaks due to norovirus. A total of 616 norovirus outbreaks resulting in 30,848 cases were reported. Among these outbreaks, 571 (93%) occurred in school settings including 239 (39%) in primary schools, 136 (22%) in childcare facilities, and 121 (20%) in secondary schools. The majority of outbreaks (63%) were due to person-to-person transmission, followed by multiple modes of transmission (11%), foodborne (5%) and waterborne (3%) transmission. These findings highlight the importance of improving hand hygiene and environmental disinfection in high-risk settings. Developing a standard and quantitative outbreak reporting structure could improve the usefulness of PHEESS for monitoring norovirus outbreaks.

ObjectiveThe WHO estimates that almost 40% of patients diagnosed with tuberculosis (TB) are not reported. We implemented this study to assess TB under-reporting and delayed treatment registration in nine counties in China.DesignA retrospective inventory study (record review).SettingCounties were selected using purposive sampling from nine provinces distributed across eastern, central and western regions of China in 2015.Primary and secondary outcome measuresUnder-reporting was calculated as the percentage of patients with TB not reported to TB Information Management System (TBIMS) within 6 months of diagnosis. Delayed registration was estimated as the percentage of reported cases initiating treatment 7 or more days after diagnosis. Multivariable logistic regression and an alpha level of 0.05 were used to examine factors associated with these outcomes.ResultsOf the 5606 patients with TB identified from project health facilities and social insurance systems, 1082 (19.3%) were not reported to TBIMS. Of the 4524 patients successfully reported, 1416 (31.3%) were not registered for treatment within 7 days of diagnosis. Children, TB pleurisy, patients diagnosed in the eastern and central regions and patients with a TB diagnosis recorded in either health facilities or social insurance system—but not both—were statistically more likely to be unreported. Delayed treatment registration was more likely for previously treated patients with TB, patients with negative or unknown sputum results and for patients diagnosed in the eastern region.ConclusionAlmost one in every five patients diagnosed with TB in this study was unknown to local or national TB control programmes. We recommend strengthening TB data management practices, particularly in the eastern and central regions, and developing specific guidelines for reporting paediatric TB and TB pleurisy. Patient education and follow-up by diagnosing facilities could improve timely treatment registration. Additional studies are needed to assess under-reporting elsewhere in China.

In 2015, China and other member states of the United Nations adopted the goal of eliminating dog-mediated rabies by 2030. China has made substantial progress in reducing dog-mediated human rabies since peaking with more than 3,300 reported cases in 2007. To further improve coordination and planning, the Chinese Center for Disease Control and Prevention, in collaboration with the United States Centers for Disease Control and Prevention, conducted a Stepwise Approach towards Rabies Elimination (SARE) assessment in March 2019. Assessment goals included outlining progress and identifying activities critical for eliminating dog-mediated rabies. Participants representing national, provincial and local human and animal health sectors in China used the SARE assessment tool to answer 115 questions about the current dog-mediated rabies control and prevention programs in China. The established surveillance system for human rabies cases and availability of post-exposure prophylaxis were identified as strengths. Low dog vaccination coverage and limited laboratory confirmation of rabid dogs were identified gaps, resulting in an overall score of 1.5 on a scale of 0 to 5. Participants outlined steps to increase cross-sectoral information sharing, improve surveillance for dog rabies, increase dog vaccination coverage, and increase laboratory capacity to diagnose rabies at the provincial level. All assessment participants committed to strengthening cross-sector collaboration using a One Health approach to achieve dog-mediated human rabies elimination by 2030., Author summary Rabies is an acute zoonosis with a mortality rate of almost 100% following the onset of symptoms. In China, the increased access to post-exposure prophylaxis has substantially reduced the number of human rabies deaths. However, rabies continues to circulate in many rural parts of the country, resulting in hundreds of rabid dog-related exposures and deaths each year. In 2015, member states of the United Nations adopted the goal of eliminating dog-mediated rabies by 2030. We conducted a Stepwise Approach towards Rabies Elimination (SARE) assessment to outline progress and identify steps needed to achieve the elimination goal in China. The assessment involved representatives from the national and 12 selected provincial-level human and animal health sectors. The 12 provinces were purposefully selected based on the current dog-mediated rabies burden, an interest in participating, and the ability to complete the SARE assessment tool. This cross-sector–or One Health—approach was useful for improving coordination and planning. In particular, the assessment identified opportunities to improve collaboration between sectors on laboratory diagnostic capacity, implementing mass dog vaccination campaigns and conducting epidemiologic investigations on dog-mediated rabies exposures. An integrated One Health strategy should be strengthened in China as well as in other countries aiming to eliminate dog-mediated rabies.

Background: Clostridioides difficile infection (CDI) is an important cause of morbidity and mortality among hospitalized patients. In China, however, hospital staff do not routinely test for CDI, leading to under-diagnosis and poor patient outcomes. Locally generated CDI data can help assess the magnitude of the problem and strengthen approaches for CDI prevention and control. Methods: We prospectively monitored hospital-onset hospital-associated (HOHA) CDI in four intensive care units (ICUs) from June 2013 to September 2014 in a large teaching hospital in China. We collected clinical information from all ICU patients with ≥ 3 episodes of diarrhea occurring within a 24-h period at least 48 h following admission (suspect case definition). Stool specimens were collected from all suspect cases of CDI and cultured for C. difficile. Polymerase chain reaction (PCR) was used to detect toxin genes from positive isolates; multi-locus sequence typing (MLST) was used for typing and identifying novel strains. We estimated the incidence rate as the number of HOHA CDI cases per 10,000 patient days; 95% confidence intervals were generated to assess rate differences between the four ICUs. Results: A total of 593 hospital-onset diarrhea patients met the suspect case definition during the study period. Of these, 47 patients (8%) were positive for C. difficile and toxin genes. The HOHA-CDI incidence rate was 14.1 cases per 10,000 patient days (95% CI: 10.5–18.6). Six patients with HOHA CDI died. ST54 (n = 14, 20%) was the most common type of HOHA-CDI strain circulating in the hospital during the study period and was linked to a temporal cluster (outbreak) involving two (NICU and GICU) of the four ICUs. Conclusion: HOHA-CDI occurs among ICU patients at this teaching hospital, supporting the importance of routine testing for CDI. Information on strain distribution can help detect CDI outbreaks. Detection of ST54 strain in a temporal cluster suggests possible gaps in infection control practices that should be investigated and addressed as needed.

Background The prevalence, symptom course, and shedding in persons infected with the 4 most common human coronaviruses (HCoV)-229E, HKU1, NL63, and OC43 are poorly described. Objectives We estimate their prevalence and associated symptoms among college students identified via a social network study design. Patients/methods We collected 1-3 samples (n = 250 specimens) from 176 participants between October 2012 and January 17, 2013: participants with acute respiratory infection (ARI; cough and body aches or chills or fever/feverishness) and their social contacts. Virus was detected using RT-PCR. Results 30.4% (76/250) of specimens tested positive for any virus tested, and 4.8% (12/250) were positive for 2 or more viruses. Human coronaviruses (HCoVs [22.0%; 55/250]), rhinovirus (7.6%; 19/250), and influenza A (6.4%; 16/250) were most prevalent. Symptoms changed significantly over time among ARI participants with HCoV: the prevalence of cough and chills decreased over 6 days (P = .04, and P = .01, respectively), while runny nose increased over the same period (P = .02). HCoV-NL63 was the most frequent virus detected 6 days following symptom onset (8.9%), followed by rhinovirus (6.7%). Conclusions During a 3-month period covering a single season, HCoVs were common, even among social contacts without respiratory symptoms; specific symptoms may change over the course of HCoV-associated illness and were similar to symptoms from influenza and rhinovirus.

Background Pregnant women are at higher risk for complications from influenza infection. Nevertheless, seasonal influenza vaccination among pregnant women in China is low. A better understanding of perceptions of pregnant women and their physicians, and factors influencing decisions about receiving seasonal influenza vaccine could be used to develop effective strategies for improving seasonal influenza vaccine uptake during pregnancy. Methods We recruited pregnant women from 9 hospitals located in 5 cities across China to participate in focus group interviews. Obstetricians from the same hospitals were recruited for one on one in-depth interviews. We collected information about perceptions of barriers and motivating factors for utilizing seasonal influenza vaccine during pregnancy. We systematically analyzed the information using qualitative methods. Results We conducted 18 focus groups with 108 pregnant women and interviewed 18 obstetricians. Awareness about the use of influenza vaccine during pregnancy was minimal in both subject groups. None of the pregnant women had received influenza vaccine during pregnancy and none of the obstetricians had recommended influenza vaccine for their patients. Both groups noted insufficient knowledge about influenza infection and benefits of the vaccine, concerns about vaccine safety, and lack of local data related to vaccine use in Chinese pregnant women. Obstetricians cited the lack of a national policy as a major barrier to recommending seasonal influenza vaccine to pregnant women. Pregnant women cited not receiving a recommendation for vaccination from healthcare workers as an additional barrier. Conclusion Our findings highlight the immediate need to increase awareness and knowledge about the risks of influenza infection and the benefits and safety of seasonal influenza vaccination among both pregnant women and obstetricians in China. Obstetricians interviewed stated that the development and implementation of a national policy prioritizing pregnant women for seasonal influenza vaccination would facilitate their willingness to recommend seasonal influenza vaccine to pregnant women.

ObjectiveFrom January 29 through February 5, 2013, a school district outside metropolitan Denver, Colorado, was closed because of absenteeism related to influenza-like illness (ILI) among students and staff. We evaluated the consequences and acceptability of the closure among affected households.MethodsWe conducted a household survey regarding parent or guardian employment and income interruptions, alternative child care arrangements, interruption of noneducational school services, ILI symptoms, student re-congregation, and communication preferences during the closure.ResultsOf the 35 (31%) of 113 households surveyed, the majority (28 [80%]) reported that the closure was not challenging. Seven (20%) households reported challenges: 5 (14%) reported that 1 or more adults missed work, 3 (9%) reported lost pay, and 1 (3%) reported challenges because of missed subsidized school meals. The majority (22 [63%]) of households reported that a hypothetical 1-month closure would not represent a problem; 6 of 8 households that did anticipate challenges reported that all adults worked outside the home. The majority (58%) of students visited at least 1 outside venue during the closure.ConclusionsA brief school closure did not pose a major problem for the majority of the affected households surveyed. School and public health officials should consider the needs of families in which all adults work outside the home when creating school closure contingency plans. (Disaster Med Public Health Preparedness. 2015;9:4-8)

Mass gatherings create environments conducive to the transmission of infectious diseases. Thousands of mass gatherings are held annually in the United States; however, information on the frequency and characteristics of respiratory disease outbreaks and on the use of nonpharmaceutical interventions at these gatherings is scarce. We administered an online assessment to the 50 state health departments and 31 large local health departments in the United States to gather information about mass gathering-related respiratory disease outbreaks occurring between 2009 and 2014. The assessment also captured information on the use of nonpharmaceutical interventions to slow disease transmission in these settings. We downloaded respondent data into a SAS dataset for descriptive analyses. We received responses from 43 (53%) of the 81 health jurisdictions. Among these, 8 reported 18 mass gathering outbreaks. More than half (n = 11) of the outbreaks involved zoonotic transmission of influenza A (H3N2v) at county and state fairs. Other outbreaks occurred at camps (influenza A (H1N1)pdm09 [n = 2] and A (H3) [n = 1]), religious gatherings (influenza A (H1N1)pdm09 [n = 1] and unspecified respiratory virus [n = 1]), at a conference (influenza A (H1N1)pdm09), and a sporting event (influenza A). Outbreaks ranged from 5 to 150 reported cases. Of the 43 respondents, 9 jurisdictions used nonpharmaceutical interventions to slow or prevent disease transmission. Although respiratory disease outbreaks with a large number of cases occur at many types of mass gatherings, our assessment suggests that such outbreaks may be uncommon, even during the 2009 influenza A (H1N1) pandemic, which partially explains the reported, but limited, use of nonpharmaceutical interventions. More research on the characteristics of mass gatherings with respiratory disease outbreaks and effectiveness of nonpharmaceutical interventions would likely be beneficial for decision makers at state and local health departments when responding to future outbreaks and pandemics.

Introduction School closures, while an effective measure against the spread of disease during a pandemic, may carry unintended social and economic consequences for students and families. We evaluated these costs and consequences following a 4-day school closure in Mississippi's Harrison County School District (HCSD). Methods In a survey of all households with students enrolled in HCSD, we collected information on difficulties related to the school closure, including interruption of employment and pay, loss of access to subsidized school meals, and arrangement of alternative childcare. We analyzed this information in the context of certain demographic characteristics of the survey respondents and households, such as race, level of education, and income. We also estimated the average number of lost work days and documented the childcare alternatives chosen by households affected by the school closure. Results We received 2,229 (28.4%) completed surveys from an estimated 7,851 households eligible to participate. About half (1,082 [48.5%]) of the households experienced at least some difficulty during the closure, primarily in three areas: uncertainty about duration of the closure, lost income, and the effort of arranging alternate childcare. Adults working outside the home, particularly the major wage earner in the household, were more likely to suffer lost income while schools were closed, an effect mitigated by paid leave benefits. Difficulty arranging childcare was reported most frequently by respondents with lower levels of education and households with younger children. Beyond the top three concerns expressed by households in HCSD, the survey also shed light on the issue of food insecurity when subsidized school meals are not available. Reported by 17.9% of households participating in the subsidized school lunch program, difficulty providing meals during the closure was associated with higher numbers of dependent children, selection of "other" as the race of the household respondent, and lower levels of education. Conclusion To help prevent undue financial hardship in families of school children, public health authorities and school administrators should provide recommendations for childcare alternatives and paid leave or remote work options during prolonged school closures, particularly to households in which all adults work outside of the home.

Background China has a substantial tuberculosis (TB) disease burden and an aging population. Seniors have a higher risk of developing TB disease compared to younger age groups. Active case finding (ACF) could help identify seniors with TB disease. Methods From March to June 2017, we included ACF during annual physical check-ups for persons aged ≥ 65 years in Bayi, Sichuan Province. Seniors with clinical TB symptoms (i.e., cough lasting ≥ 2 weeks and/or hemoptysis) or one or more risk factors (e.g., previous TB disease, diabetes, and heavy alcohol consumption) were offered chest x-rays. We used acid-Fast Bacilli smear and solid culture laboratory testing for TB confirmation. We calculated the yield (i.e., cases identified among seniors screened) and cost per new each TB case detected. Focus group-interviews were conducted with health care workers and seniors to evaluate project acceptability. Participation rates and acceptability were used to assess feasibility. Results Of the 2,393 seniors residing in Bayi, 2,049 (85.6%) were enrolled in the pilot project. Of these seniors, 794 (38.7%) presented with at least one TB risk factor and 74 (3.6%) had symptoms consistent with active TB disease. Three seniors (0.2%)–each presenting with at least one risk factor—were diagnosed with active TB. The project yielded 146 TB cases per 100,000 seniors screened; the cost per case detected was $4,897. Most workers supported ACF if additional resources and staff could be provided. Seniors appreciated the convenience of this integrated health service approach. Conclusions Although the yield was lower than expected, ACF appeared feasible in Bayi. Targeting seniors with at least one known TB risk factor could help detect previously unidentified TB cases. However, similar projects in communities with a higher TB prevalence are needed to further evaluate the yield and required resources prior to implementation on a larger scale. Findings from our pilot project should be combined with data from these future ACF projects to improve TB screening criteria.

The earthquake that struck Haiti in January 2010 caused 1.5 million people to be displaced to temporary camps. The Haitian Ministry of Public Health and Population and global immunization partners developed a plan to deliver vaccines to those residing in these camps. A strategy was needed to determine whether the immunization targets set for the campaign were achieved.Following the vaccination campaign, staff from the Ministry of Public Health and Population interviewed convenience samples of households - in specific predetermined locations in each of the camps - regarding receipt of the emergency vaccinations. A camp was targeted for "mop-up vaccination" - i.e. repeat mass vaccination - if more than 25% of the children aged 9 months to 7 years in the sample were found not to have received the emergency vaccinations.Rapid monitoring was implemented in camps located in the Port-au-Prince metropolitan area. Camps that housed more than 5000 people were monitored first.By the end of March 2010, 72 (23%) of the 310 vaccinated camps had been monitored. Although 32 (44%) of the monitored camps were targeted for mop-up vaccination, only six of them had received such repeat mass vaccination when checked several weeks after monitoring.Rapid monitoring was only marginally beneficial in achieving immunization targets in the temporary camps in Port-au-Prince. More research is needed to evaluate the utility of conventional rapid monitoring, as well as other strategies, during post-disaster vaccination campaigns that involve mobile populations, particularly when there is little capacity to conduct repeat mass vaccination.Le séisme qui a frappé Haïti en janvier 2010 a causé le déplacement de 1,5 million de personnes dans des camps temporaires. Le ministère de la Santé publique et de la Population d'Haïti et les partenaires mondiaux de vaccination ont élaboré un plan pour fournir des vaccins aux personnes qui résident dans ces camps. Une stratégie a été nécessaire pour déterminer si les objectifs de vaccination définis pour la campagne ont été atteints.Après la campagne de vaccination, le personnel du ministère de la Santé publique et de la Population a interrogé un échantillon représentatif de ménages – dans des lieux prédéterminés spécifiques dans chacun des camps – en ce qui concernait la réception des vaccinations d'urgence. Un camp faisait l'objet d'une «campagne de vaccination de ratissage» – c'est-à-dire une vaccination de masse répétée – si plus de 25% des enfants âgés de 9 mois à 7 ans dans l'échantillon n'avaient pas reçu les vaccinations d'urgence.Le suivi rapide a été mis en œuvre dans les camps situés dans la zone métropolitaine de Port-au-Prince. Les camps accueillant plus de 5 000 personnes étaient surveillés en premier.À la fin du mois de mars 2010, 72 (23,2%) des 310 camps vaccinés avaient été surveillés. Bien que 32 (44%) des camps surveillés aient fait l'objet d'une campagne de ratissage, seulement 6 d'entre eux avaient bénéficié d'une telle vaccination de masse répétée lors du contrôle effectué plusieurs semaines après le suivi.Le suivi rapide n'a été que peu bénéfique dans la réalisation des objectifs de vaccination dans les camps temporaires de Port-au-Prince. Il est nécessaire d'effectuer plus de recherches pour évaluer l'utilité du suivi rapide traditionnel, ainsi que de mettre en place d'autres stratégies, pendant les campagnes de vaccination post-catastrophe, qui impliquent des populations mobiles, en particulier lorsqu'il y a peu de capacité pour mener à bien des vaccinations de masse répétées.El terremoto que asoló Haití en enero de 2010 provocó el desplazamiento de 1,5 millones de personas a campamentos provisionales. El Ministro de Sanidad Pública y Población haitiano y las partes implicadas internacionales desarrollaron un plan para el reparto de vacunas entre los residentes de los campamentos. Fue necesario desarrollar una estrategia a fin de determinar si se habían logrado los objetivos de inmunización de la campaña.Siguiendo la campaña de vacunación, el personal del Ministerio de Salud Pública y Población entrevistó muestras por conveniencia de hogares en emplazamientos predeterminados específicos de cada uno de los campamentos sobre la recepción de las vacunas de emergencia. Se seleccionaron los campamentos en los que más del 25 % de los niños con edades comprendidas entre 9 meses y 7 años de la muestra no habían recibido las vacunas de emergencia para una inmunización «de barrido», esto es, una vacunación masiva repetida.La vigilancia rápida se puso en marcha en campamentos situados en la zona metropolitana de Port-au-Prince. En primer lugar se supervisaron los campamentos que acogían a más de 5000 personas.A finales de marzo de 2012 se habían vigilado 72 (23,2 %) de los 310 campamentos vacunados. Aunque se habían seleccionado 32 (44 %) de los campamentos supervisados para la inmunización «de barrido», solo seis de ellos habían recibido la vacunación masiva cuando se efectuó un control varias semanas tras la supervisión.La supervisión rápida únicamente ofreció ventajas marginales en la consecución de los objetivos de inmunización en los campamentos temporales de Port-au-Prince. Es necesario llevar a cabo más investigaciones para evaluar la utilidad de la vigilancia rápida tradicional y otras estrategias durante las campañas de vacunación tras desastres en los que se vean involucradas poblaciones móviles, en particular, en los casos en los que haya poca capacidad para efectuar inmunizaciones masivas repetidas.أدى الزلزال الذي ضرب هايتي في كانون الثاني/يناير 2010 إلى تشريد حوالي 1.5 مليون شخص في مخيمات مؤقتة. وقامت وزارة الصحة العمومية والسكان في هايتي وشركاء التمنيع العالميين بوضع خطة لإيتاء اللقاحات لسكان هذه المخيمات. وتطلب الأمر استراتيجية لتحديد ما إذا كانت أهداف التمنيع الموضوعة للحملة قد تحققت.عقب حملة التطعيم، قام فريق من وزارة الصحة العمومية والسكان بعقد مقابلات مع عينات ملاءمة من الأسر المعيشية – في مواقع معينة محددة سلفاً في كل مخيم – فيما يتعلق بتلقي تطعيمات الطوارئ. وكان يتم استهداف المخيم من أجل "تطعيم الاجتثاث" - أي التطعيم الجماعي المتكرر – إذا تبين عدم تلقي أكثر من 25 % من الأطفال الذين تتراوح أعمارهم من 9 أشهر إلى 7 سنوات في العينة تطعيمات الطوارئ.تم تنفيذ الرصد السريع في المخيمات الواقعة في المنطقة الحضرية في بورت أو برينس. وتم رصد المخيمات التي ضمت أكثر من 5000 شخص أولاً.بحلول نهاية آذار/ مارس 2010، تم رصد 72 (23.2 %) مخيماً من بين 310 مخيماً خضعت للتطعيم. وعلى الرغم من استهداف 32 (44 %) مخيماً من المخيمات التي خضعت للرصد من أجل تطعيم الاجتثاث، لم يتلق سوى ستة مخيمات منها التطعيم الجماعي المتكرر عند فحصها بعد الرصد بعدة أسابيع.كان الرصد السريع مفيداً فقط بشكل هامشي في تحقيق أهداف التمنيع في المخيمات المؤقتة في بورت أو برينس. ويجب إجراء مزيد من البحث لتقييم فائدة الرصد السريع التقليدي، بالإضافة إلى غيره من الاستراتيجيات، أثناء حملات التطعيم بعد الكوارث التي تشتمل على سكان متنقلين، ولاسيما عند انخفاض القدرة على إجراء تطعيم جماعي متكرر.2010 年1 月海地遭受地震灾害，造成1500 万人栖身于临时营地。海地公共卫生与人口部以及全球免疫合作伙伴制定计划向这些营地的居住者发放疫苗。确定是否实现了为该计划设定的免疫目标需要一项策略。在疫苗接种活动之后，公共卫生和人口部的工作人员对方便抽样的样本家庭（在每个营地特定的的预先确定位置）进行了访谈，了解接受紧急接种疫苗的相关情况。如果在样本中发现在9 个月到7 岁大的儿童中超过25%的儿童没有接受紧急疫苗接种，就要对营地进行“扫荡式免疫接种”，即重复大规模疫苗接种。对位于太子港市区的难民营实施快速监测。首先对拥有超过 5000 人的营地进行监测。到2010 年3 月底，310 个接过种的营地有72（23.2%）个经过了监测。尽管有32（44%）个被监测的营地要进行扫荡式免疫接种，其中只有六个营地在监测后数周进行检查时接受了这样的重复大规模疫苗接种。在实现太子港临时营地免疫目标方面，快速监测收效不大。对于涉及流动人口的灾后疫苗接种活动，尤其是在没有能力进行重复大规模疫苗接种的时候，需要更多的研究来评估这种活动中传统快速监测以及其他策略的效用。В результате землетрясения на Гаити в январе 2010 года 1,5 миллиона человек было размещено в лагерях временного проживания. Министерство здравоохранения и населения Гаити и глобальные партнеры в области иммунизации разработали план по доставке вакцин пострадавшим, размещенным в этих лагерях. Необходимо было выработать стратегию, которая позволила бы определить, достигнуты ли были цели иммунизации, поставленные перед этой кампанией.После кампании по вакцинации сотрудниками Министерства здравоохранения и населения проводился опрос нерепрезентативных выборок домохозяйств – в конкретных, предварительно установленных местах в каждом лагере – о прохождении экстренной вакцинации. "Подчищающая вакцинация" – т.е. повторная массовая вакцинация – планировалась в лагерях, где обнаруживалось, что более 25% детей в возрасте от 9 месяцев до 7 лет в выборке не проходили экстренную вакцинацию.Оперативный мониторинг осуществлялся в лагерях, расположенных в окрестностях Порт-о-Пренса. Сначала проводился мониторинг лагерей, вмещавших более 5 000 человек.К концу марта 2010 года был проведен мониторинг 72 (23,2%) из 310 лагерей, прошедших вакцинацию. Несмотря на то, что 32 (44%) проверенных лагеря были определены на получение подчищающей вакцинации, только шесть из них прошли подобную повторную массовую вакцинацию, что выяснилось при проверке, проведенной несколько недель спустя после мониторинга.Оперативный мониторинг принес лишь незначительную выгоду в достижении целей по проведению вакцинации на территории лагерей временного проживания в городе Порт-о-Пренс. Необходимо провести дополнительные исследования для оценки целесообразности традиционного оперативного мониторинга и других стратегий, использующихся для кампаний по проведению вакцинации в период после стихийных бедствий среди мобильных групп населения, особенно в случае ограниченных возможностей по проведению повторных массовых вакцинаций.

Introduction In March, 2006, oral rotavirus vaccine was added to Brazil's infant immunization schedule with recommended upper age limits for initiating (by age 14 weeks) and completing (by age 24 weeks) the two-dose series to minimize age-specific risk of intussusception following rotavirus vaccination. Several years after introduction, estimated coverage with rotavirus vaccine (83%) was lower compared to coverage for other recommended childhood immunizations (≥94%). Methods We analyzed data from Brazil's national immunization program on uptake of oral rotavirus vaccine by geographic region and compared administrative coverage estimates for first and second doses of oral rotavirus vaccine (Rota1 and Rota2) with first and second doses of diphtheria-tetanus-pertussis-Haemophilus influenzae type b vaccine (DTP-Hib1 and DTP-Hib2). For 27 Brazilian cities, we compared differences between estimated rotavirus and DTP-Hib coverage in 2010 with delayed receipt of DTP-Hib vaccine among a cohort of children surveyed before rotavirus introduction. Results In 2010, infant vaccination coverage was 99.0% for DTP-Hib1 versus 95.2% for Rota1 (3.8% difference), and 98.4% for DTP-Hib2 versus 83.0% for Rota2 (15.4% difference), with substantial regional variation. Differences between DTP-Hib and rotavirus vaccination coverage in Brazilian cities correlated with delay in DTP-Hib vaccination among children surveyed. Age restrictions for initiating and completing the rotavirus vaccination series likely contributed to lower coverage with rotavirus vaccine in Brazil. Conclusion To maximize benefits of rotavirus vaccination, strategies are needed to improve timeliness of routine immunizations; monitoring rotavirus vaccine uptake and intussusception risk is needed to guide further recommendations for rotavirus vaccination.

Background Because mass gatherings create environments conducive for infectious disease transmission, public health officials may recommend postponing or canceling large gatherings during a moderate or severe pandemic. Despite these recommendations, limited empirical information exists on the frequency and characteristics of mass gathering-related respiratory disease outbreaks occurring in the United States. Methods We conducted a systematic literature review to identify articles about mass gathering-related respiratory disease outbreaks occurring in the United States from 2005 to 2014. A standard form was used to abstract information from relevant articles identified from six medical, behavioral and social science literature databases. We also analyzed data from the National Outbreaks Reporting System (NORS), maintained by the Centers for Disease Control and Prevention since 2009, to estimate the frequency of mass gathering-related respiratory disease outbreaks reported to the system. Results We identified 21 published articles describing 72 mass gathering-related respiratory disease outbreaks. Of these 72, 40 (56%) were associated with agriculture fairs and Influenza A H3N2v following probable swine exposure, and 25 (35%) with youth summer camps and pandemic Influenza A H1N1. Outbreaks of measles (n = 1) and mumps (n = 2) were linked to the international importation of disease. Between 2009 and 2013, 1,114 outbreaks were reported to NORS, including 96 respiratory disease outbreaks due to Legionella. None of these legionellosis outbreaks was linked to a mass gathering according to available data. Conclusion Mass gathering-related respiratory disease outbreaks may be uncommon in the United States, but have been reported from fairs (zoonotic transmission) as well as at camps where participants have close social contact in communal housing. International importation can also be a contributing factor. NORS collects information on certain respiratory diseases and could serve as a platform to monitor mass gathering-related respiratory outbreaks in the future.

BACKGROUND School closure is one of the primary measures considered during severe influenza pandemics and other emergencies. However, prolonged school closures may cause unintended adverse consequences to schools, students, and their families. A better understanding of these consequences will inform prepandemic planning, and help public health and education authorities in making informed decisions when considering school closures. METHODS We conducted a household survey and interviewed school officials following an 8-day long closure of a school district in rural Illinois. We described household responses regarding difficulties of school closure, and summarized main themes from school official interviews. RESULTS A total of 208 (27%) household surveys were completed and returned. This school closure caused difficulties to 36 (17%) households; uncertain duration of closure, childcare arrangements, and lost pay were the most often reported difficulties. Having 1 adult in the household losing pay and household income below $25,000 were significantly associated with overall difficulty during this school closure. Concern about student health and safety was the most frequent theme in school administrator interviews. CONCLUSIONS Whereas the majority of responding households did not report difficulties during this school closure, households with 1 adult losing pay during the closure reported incurring additional expenses for childcare.

A reactive school closure following high influenza-like illness-related student absenteeism in a Kentucky school district did not influence reported influenza-like illness transmission in student households., Background. School closures are an important mitigation strategy during influenza pandemic: if implemented early in a local outbreak, they can slow the disease spread in the surrounding community. During seasonal influenza epidemics, school closures may occur reactively, after the disease is already widespread in the community. Such reactive closures are often too late to reduce influenza transmission. However, they can provide data to determine under which circumstances they might be effective in reducing influenza-like illness (ILI) transmission. Methods. We conducted a household survey in a school district in Kentucky. District A closed after high student absenteeism due to influenza-like illness (ILI), whereas adjacent Districts B and C remained open. We collected data on self-reported ILI among household members in these 3 districts 2 weeks before the District A closure, during closure, and 2 weeks after reopening, and we evaluated economic and social consequences of school closure on student households in District A. The difference-in-differences method was applied to compare changes in ILI rates from before to after closure between districts. Results. Estimated average daily ILI rate decreased less in District A than in District B or C for the entire sample and when stratified by age groups (0–5 years old, 6–18 years old, and above 18 years old). Twenty-five percent of District A households reported ≥1 closure-related economic or social difficulty. Conclusions. Closing schools after a widespread ILI activity in District A did not reduce ILI transmission but caused difficulties for some households.

Background Social networks are increasingly recognized as important points of intervention, yet relatively few intervention studies of respiratory infection transmission have utilized a network design. Here we describe the design, methods, and social network structure of a randomized intervention for isolating respiratory infection cases in a university setting over a 10-week period. Methodology/principal findings 590 students in six residence halls enrolled in the eX-FLU study during a chain-referral recruitment process from September 2012–January 2013. Of these, 262 joined as “seed” participants, who nominated their social contacts to join the study, of which 328 “nominees” enrolled. Participants were cluster-randomized by 117 residence halls. Participants were asked to respond to weekly surveys on health behaviors, social interactions, and influenza-like illness (ILI) symptoms. Participants were randomized to either a 3-Day dorm room isolation intervention or a control group (no isolation) upon illness onset. ILI cases reported on their isolation behavior during illness and provided throat and nasal swab specimens at onset, day-three, and day-six of illness. A subsample of individuals (N = 103) participated in a sub-study using a novel smartphone application, iEpi, which collected sensor and contextually-dependent survey data on social interactions. Within the social network, participants were significantly positively assortative by intervention group, enrollment type, residence hall, iEpi participation, age, gender, race, and alcohol use (all P Conclusions/significance We identified a feasible study design for testing the impact of isolation from social networks in a university setting. These data provide an unparalleled opportunity to address questions about isolation and infection transmission, as well as insights into social networks and behaviors among college-aged students. Several important lessons were learned over the course of this project, including feasible isolation durations, the need for extensive organizational efforts, as well as the need for specialized programmers and server space for managing survey and smartphone data.

Background Persons with primary immunodeficiency disorders (PIDD) who receive oral poliovirus vaccine (OPV) or are household contacts of OPV recipients are at risk of excreting immunodeficiency-associated vaccine-derived polioviruses (iVDPVs). iVDPVs can be transmitted and cause paralytic polio. The objective of this study was to determine the feasibility of identifying infants and young children with PIDD in Bangladesh, and among those identified, to estimate the proportion excreting iVDPVs. Methods Patients admitted at 5 referral and teaching hospitals from the hospital catchment area were screened for PIDD using a standardized clinical case definition. PIDD was confirmed using results of testing for age-specific quantitative immunoglobulins (QIGs) levels. Stool specimens were collected according to WHO guidelines from children with confirmed PIDD. Results During February–July 2009, 13 patients were identified who met the clinical case definition for PIDD; their median age was 1.4 years (range: 2 months to 10 years). Six (46%) of the patients had age-specific QIG results that confirmed PIDD. Stool specimens from four patients tested negative for polio vaccine viruses. All four had received OPV between 50 and 264 days prior to study recruitment. Conclusion Identifying children with PIDD at referral and teaching hospitals in Bangladesh is feasible, but a larger number of patients is needed to estimate the risk for iVDPV excretion. The national polio eradication program should expand surveillance for PIDD case-patients and regularly test persons with PIDD for poliovirus excretion. These efforts will be essential for developing effective prevention and control strategies following OPV cessation, especially for densely populated and tropical countries like Bangladesh where even a minimal iVDPV risk could have significant public health consequences.

Introduction Since 1977, vaccinations to protect against tuberculosis, diphtheria, tetanus, pertussis, polio, and measles (and rubella since 2009) have been offered to children in Haiti through the routine immunization program. From April to July 2009, a national vaccination coverage survey was conducted to assess the success of the routine immunization program at reaching children in Haiti. Methods A multi-stage cluster survey was conducted using a modified WHO method for household sampling. A standardized questionnaire was administered to collect vaccination histories, demographic information, and reasons for under-vaccination of children aged 12–23 months. A child who received the eight recommended routine vaccinations was considered fully vaccinated. The routine vaccination schedule was used to define valid doses and estimate the percentage of children vaccinated on time. Results Among 1345 children surveyed, 40.4% (95% CI: 36.6–44.2) of the 840 children with vaccination cards had received all eight recommended vaccinations. Coverage was highest for the Bacille Calmette–Guerin vaccine (87.3%), the first doses of the diphtheria–tetanus–pertussis vaccine (92.0%), and oral poliovirus vaccine (93.4%) and lowest for measles vaccine (46.9%). Timely vaccination rates were lower. Assuming similar coverage for the 505 children without cards, coverage with the complete vaccination series among all surveyed children 31.9%. Reasons for under-vaccination included not having enough time to reach the vaccination location (24.8%), having a child who was ill (13.8%), and not knowing when, or forgetting, to go for vaccination (12.8%). Conclusions and recommendations Coverage for early-infant vaccines was high; however, most children did not complete the full vaccination series, and many children received vaccinations later than recommended. Efforts to improve the immunization program should include increasing the frequency of outreach services, training for vaccination staff to minimize missed opportunities, and better communicating the timing of vaccinations to encourage caregivers to bring their children for vaccinations at the recommended age. Efforts to promote the benefits of vaccination and card retention are also needed.

In the United States, influenza season typically begins in October or November, peaks in February, and tapers off in April. During the winter holiday break, from the end of December to the beginning of January, changes in social mixing patterns, healthcare-seeking behaviors, and surveillance reporting could affect influenza-like illness (ILI) rates. We compared predicted with observed weekly ILI to examine trends around the winter break period. We examined weekly rates of ILI by region in the United States from influenza season 2003-2004 to 2012-2013. We compared observed and predicted ILI rates from week 44 to week 8 of each influenza season using the auto-regressive integrated moving average (ARIMA) method. Of 1,530 region, week, and year combinations, 64 observed ILI rates were significantly higher than predicted by the model. Of these, 21 occurred during the typical winter holiday break period (weeks 51-52); 12 occurred during influenza season 2012-2013. There were 46 observed ILI rates that were significantly lower than predicted. Of these, 16 occurred after the typical holiday break during week 1, eight of which occurred during season 2012-2013. Of 90 (10 HHS regions x 9 seasons) predictions during the peak week, 78 predicted ILI rates were lower than observed. Out of 73 predictions for the post-peak week, 62 ILI rates were higher than observed. There were 53 out of 73 models that had lower peak and higher post-peak predicted ILI rates than were actually observed. While most regions had ILI rates higher than predicted during winter holiday break and lower than predicted after the break during the 2012-2013 season, overall there was not a consistent relationship between observed and predicted ILI around the winter holiday break during the other influenza seasons.

Background Streptococcus pneumoniae (Sp) is a leading cause of bacterial pneumonia, meningitis, and sepsis and a major source of morbidity and mortality worldwide. Invasive pneumococcal disease (IPD) is defined as isolation of Sp from a normally sterile site, including blood or cerebrospinal fluid. The aim of this study is to describe outcomes as well as clinical and epidemiological characteristics of hospitalized IPD case patients in central China. Methods We conducted surveillance for IPD among children and adults from April 5, 2010 to September 30, 2012, in four major hospitals in Jingzhou City, Hubei Province. We collected demographic, clinical, and outcome data for all enrolled hospitalized patients with severe acute respiratory infection (SARI) or meningitis, and collected blood, urine, and cerebrospinal fluid (CSF) for laboratory testing for Sp infections. Collected data were entered into Epidata software and imported into SPSS for analysis. Results We enrolled 22,375 patients, including 22,202 (99%) with SARI and 173 (1%) with meningitis. One hundred and eighteen (118, 3%) with either SARI or meningitis were Sp positive, 32 (0.8%) from blood/CSF culture, and 87 (5%) from urine antigen testing. Of those 118 patients, 57% were aged ≥65 years and nearly 100% received antibiotics during hospitalization. None were previously vaccinated with 7-valent pneumococcal conjugate vaccine (PCV 7), 23-valent pneumococcal polysaccharide vaccine, or seasonal influenza vaccine. The main serotypes identified were 14, 12, 3, 1, 19F, 4, 5, 9V, 15 and 18C, corresponding to serotype coverage rates of 42%, 63%, and 77% for PCV7, PCV10, and PCV13, respectively. Conclusions Further work is needed to expand access to pneumococcal vaccination in China, both among children and potentially among the elderly, and inappropriate use of antibiotics is a widespread and serious problem in China.

PROBLEM: Poliovirus transmission remained a public health challenge in western Uttar Pradesh, India in late 2005 and early 2006. In 2006, the India Expert Advisory Group for Polio Eradication concluded that, given the peak incidence of polio among children 6 to 12 months of age, a targeted birth dose of oral polio vaccine may be necessary to interrupt intense poliovirus transmission in high risk areas. APPROACH: The Government of Uttar Pradesh, the National Polio Surveillance Project and the United Nations Children's Fund (UNICEF) implemented a pilot birth-dose project aimed at identifying and vaccinating all newborns with a dose of oral polio vaccine within 72 hours of birth in an effort to evaluate operational feasibility and potential impact on population immunity. LOCAL SETTING: The project was piloted in Moradabad district: zone 7 in Moradabad City (urban setting), Kunderki block (rural setting) and in select birthing hospitals. RELEVANT CHANGES: Between July 2006 and February 2007, 9740 newborns were identified, of which 6369 (65%) were vaccinated by project personnel within 72 hours of birth. Project coverage (for total newborns vaccinated) ranged from 39% (in zone 7) to 76% (in Kunderki block) of the estimated number of newborns vaccinated during previous supplemental immunization activities. LESSONS LEARNED: Birth-dose coverage among newborns was lower than expected. Expansion costs were estimated to be high, with marginal impact. The project, however, provided opportunities to strengthen newborn tracking systems which have increased the number of newborns and young infants vaccinated during supplemental immunization activities and enrolled in routine programmes.

Endemic Burkitt's lymphoma (eBL) has been linked to Epstein-Barr virus and holoendemic Plasmodium falciparum malaria. These co-infections, however, are insufficient to explain the non-random occurrence of Endemic Burkitt's lymphoma within Equatorial Africa. To explore whether this distribution could be explained by household characteristics and family environment, we conducted a case-control study using 41 hospitalized incident endemic Burkitt's lymphoma cases and 91 healthy controls identified through a population-based multistage cluster-sampling scheme in Nyanza Province, Kenya. In a multivariate analysis, odds ratios associated with having one, two, and three or more younger siblings compared with none were 0.28 (90% CI: 0.09, 0.83), 0.59 (90% CI: 0.16, 2.23) and 0.15 (90% CI: 0.03, 0.67) respectively, suggesting that children with endemic Burkitt's lymphoma were more likely than controls to be last-born. Children with endemic Burkitt's lymphoma were also more likely to live in non-monogamous families (OR=3.12, 90% CI:1.19, 8.17) and to have at least one deceased parent (OR=3.38, 90% CI: 1.18, 9.64). Household characteristics, especially sibship relationships, may contribute to endemic Burkitt's lymphoma and therefore warrant further study.

In the course of its work at the grassroots - during disasters (both natural and man-made) in the most backward districts amongst hilly areas as well as tribal areas etc. VHAI has come across children in a range of difficult circumstances. Through this arose the need to enhance the focus on children in our work. However to begin with it is essential to document and understand their situation. We have done this through a comprehensive report entitled: "Seen but not heard: Indias marginalised neglected and vulnerable children." Seen but not heard is as much a report about Indias forgotten children as it is a commentary by these children about the world that adults have bequeathed to them. A world that neglects them tramples on their vulnerability and pushes them to the fringes and very often over the edge. A unique feature of this report is that childrens views share space with adult analysis very much in the spirit of participation enshrined in the UN Convention on the Rights of the Child. (excerpt)

School closures implemented pre-emptively, before the peak of influenza activity, are an effective mitigation strategy to slow disease transmission during influenza pandemic. Prolonged school closures may impose unintended economic and social costs to students families. To better understand this unintended impact, we conducted household surveys in five different regions of the United States following school closures implemented for various reasons. One of the primary challenges for families during unplanned school closures is making emergency childcare arrangements. While the most frequently childcare is provided by a non-working household member, this option is not available for families where all adults are employed full-time. Although disruption of subsidized school lunch program did not appear as a difficulty for the majority of eligible families during these school closures, more research might be needed on closures that last longer than 7 days.

Swimmer’s itch (cercarial dermatitis) affects people engaged in open-water activities. We report incidence and risk factors for a US lake. Water exposures and swimmer’s itch experience were reported daily for riparian household residents and guests at Douglas Lake, Michigan, in July 2000. Incidence of swimmer’s itch was 6.8 episodes per 100 water exposure days. Positive risks were (1) exposures in shallow water and in areas with onshore winds and (2) more days of lake use in July. Further epidemiological studies will help public health agencies address this bothersome problem at recreational lakes.

BACKGROUND Persons with primary immune deficiency disorders (PIDD) who receive oral poliovirus vaccine (OPV) may transmit immunodeficiency-associated vaccine-derived polioviruses (iVDPVs) and cause paralytic polio. The objective of this study was to identify children with PIDD in Bangladesh, and estimate the proportion with chronic poliovirus excretion. METHODS Patients admitted at 5 teaching hospitals were screened for PIDD according to standardized clinical case definitions. PIDD was confirmed by age-specific quantitative immunoglobulin levels. Stool specimens were collected from patients with confirmed PIDD. RESULTS From February 2011 through January 2013, approximately 96 000 children were screened, and 53 patients were identified who met the clinical case definition for PIDD. Thirteen patients (24%) had age-specific quantitative immunoglobulins results that confirmed PIDD. Of these, 9 (69%) received OPV 3-106 months before stool specimen collection. Among 11 patients, stool specimens from 1 patient tested positive for polioviruses 34 months after OPV ingestion. However, the poliovirus isolate was not available for genetic sequencing, and a subsequent stool specimen 45 days later was negative. CONCLUSIONS The risk of chronic poliovirus excretion among children with PIDD in Bangladesh seems to be low. The national polio eradication program should incorporate strategies for screening for poliovirus excretion among patients with PIDD.

Background Current approaches for estimating social mixing patterns and infectious disease transmission at mass gatherings have been limited by various constraints, including low participation rates for volunteer-based research projects and challenges in quantifying spatially and temporally accurate person-to-person interactions. We developed a proof-of-concept project to assess the use of automated video analysis for estimating contact rates of attendees of the GameFest 2013 event at Rensselaer Polytechnic Institute (RPI) in Troy, New York. Methods Video tracking and analysis algorithms were used to estimate the number and duration of contacts for 5 attendees during a 3-minute clip from the RPI video. Attendees were considered to have a contact event if the distance between them and another person was ≤1 meter. Contact duration was estimated in seconds. We also simulated 50 attendees assuming random mixing using a geo-spatially accurate representation of the same GameFest location. Results The 5 attendees had an overall median of 2 contact events during the 3-minute video clip (range: 0–6). Contact events varied from less than 5 seconds to the full duration of the 3-minute clip. The random mixing simulation was visualized and presented as a contrasting example. Conclusion We were able to estimate the number and duration of contacts for 5 GameFest attendees from a 3-minute video clip that can be compared to a random mixing simulation model at the same location. The next phase will involve scaling the system for simultaneous analysis of mixing patterns from hours-long videos and comparing our results with other approaches for collecting contact data from mass gathering attendees.

INTRODUCTION: We describe characteristics of unplanned school closures (USCs) in the United States over two consecutive academic years during a non-pandemic period to provide context for implementation of school closures during a pandemic. METHODS: From August 1, 2011 through June 30, 2013, daily systematic internet searches were conducted for publicly announced USCs lasting ≥1 day. The reason for closure and the closure dates were recorded. Information on school characteristics was obtained from the National Center for Education Statistics. RESULTS: During the two-year study period, 20,723 USCs were identified affecting 27,066,426 students. Common causes of closure included weather (79%), natural disasters (14%), and problems with school buildings or utilities (4%). Only 771 (4%) USCs lasted ≥4 school days. Illness was the cause of 212 (1%) USCs; of these, 126 (59%) were related to respiratory illnesses and showed seasonal variation with peaks in February 2012 and January 2013. CONCLUSIONS: USCs are common events resulting in missed school days for millions of students. Illness causes few USCs compared with weather and natural disasters. Few communities have experience with prolonged closures for illness. Language: en

High rates of absences from influenza-like-illness (ILI) resulted in closure of a Kentucky school district for 4-days during the 2012-2013 influenza season. We calculated average daily rates of household ILI as recalled in paper surveys by parents for the weeks before, during, and after the closure. Average daily rates of ILI in the district that closed were not significantly reduced when compared with rates in 2 surrounding school districts that did not close.

Schools are known to play a significant role in the spread of influenza. High vaccination coverage can reduce infectious disease spread within schools and the wider community through vaccine-induced immunity in vaccinated individuals and through the indirect effects afforded by herd immunity. In general, herd immunity is greatest when vaccination coverage is highest, but clusters of unvaccinated individuals can reduce herd immunity. Here, we empirically assess the extent of such clustering by measuring whether vaccinated individuals are randomly distributed or demonstrate positive assortativity across a United States high school contact network. Using computational models based on these empirical measurements, we further assess the impact of assortativity on influenza disease dynamics. We found that the contact network was positively assortative with respect to influenza vaccination: unvaccinated individuals tended to be in contact more often with other unvaccinated individuals than with vaccinated individuals, and these effects were most pronounced when we analyzed contact data collected over multiple days. Of note, unvaccinated males contributed substantially more than unvaccinated females towards the measured positive vaccination assortativity. Influenza simulation models using a positively assortative network resulted in larger average outbreak size, and outbreaks were more likely, compared to an otherwise identical network where vaccinated individuals were not clustered. These findings highlight the importance of understanding and addressing heterogeneities in seasonal influenza vaccine uptake for prevention of large, protracted school-based outbreaks of influenza, in addition to continued efforts to increase overall vaccine coverage.

Estimates of contact among children, used for infectious disease transmission models and understanding social patterns, historically rely on self-report logs. Recently, wireless sensor technology has enabled objective measurement of proximal contact and comparison of data from the two methods. These are mostly small-scale studies, and knowledge gaps remain in understanding contact and mixing patterns and also in the advantages and disadvantages of data collection methods. We collected contact data from a middle school, with 7th and 8th grades, for one day using self-report contact logs and wireless sensors. The data were linked for students with unique initials, gender, and grade within the school. This paper presents the results of a comparison of two approaches to characterize school contact networks, wireless proximity sensors and self-report logs. Accounting for incomplete capture and lack of participation, we estimate that "sensor-detectable", proximal contacts longer than 20 seconds during lunch and class-time occurred at 2 fold higher frequency than "self-reportable" talk/touch contacts. Overall, 55% of estimated talk-touch contacts were also sensor-detectable whereas only 15% of estimated sensor-detectable contacts were also talk-touch. Contacts detected by sensors and also in self-report logs had longer mean duration than contacts detected only by sensors (6.3 vs 2.4 minutes). During both lunch and class-time, sensor-detectable contacts demonstrated substantially less gender and grade assortativity than talk-touch contacts. Hallway contacts, which were ascertainable only by proximity sensors, were characterized by extremely high degree and short duration. We conclude that the use of wireless sensors and self-report logs provide complementary insight on in-school mixing patterns and contact frequency.

Students attending schools play an important role in the transmission of influenza. In this study, we present a social network analysis of contacts among 1,828 students in eight different schools in urban and suburban areas in and near Pittsburgh, Pennsylvania, United States of America, including elementary, elementary-middle, middle, and high schools. We collected social contact information of students who wore wireless sensor devices that regularly recorded other devices if they are within a distance of 3 meters. We analyzed these networks to identify patterns of proximal student interactions in different classes and grades, to describe community structure within the schools, and to assess the impact of the physical environment of schools on proximal contacts. In the elementary and middle schools, we observed a high number of intra-grade and intra-classroom contacts and a relatively low number of inter-grade contacts. However, in high schools, contact networks were well connected and mixed across grades. High modularity of lower grades suggests that assumptions of homogeneous mixing in epidemic models may be inappropriate; whereas lower modularity in high schools suggests that homogenous mixing assumptions may be more acceptable in these settings. The results suggest that interventions targeting subsets of classrooms may work better in elementary schools than high schools. Our work presents quantitative measures of age-specific, school-based contacts that can be used as the basis for constructing models of the transmission of infections in schools.

BACKGROUND A national campaign was conducted in Haiti in 2007-2008 to vaccinate all children and adolescents aged 1-19 years with measles-rubella vaccine in support of achieving the Region of the Americas' 2010 goal of eliminating rubella and congenital rubella syndrome (CRS). Measles-rubella vaccine was introduced into the country's routine childhood immunization schedule after the campaign. METHODS A nationwide, stratified, multistage cluster sample survey of 20859 children was conducted to assess coverage using house-to-house interviews. RESULTS Estimated national coverage with measles-rubella vaccine was 79.2% (95% confidence interval, 77.6%-80.7%), ranging from 90.2% in Nord-Ouest Department to 70.0% in Cite Soleil Metropolitan Area. National coverage was lower for children aged 1-5 years (76.7%) than for those aged 6-19 years (80.3%) (P< .001) but similar in rural departments (79.4%) and metropolitan areas (78.6%; P = .61). The reasons most frequently cited for nonparticipation in the campaign were that the child was ill or unavailable (18.6%), did not know vaccinations were important (13.8%), did not know when to go or forgot to go (13.3%), and did not have enough time (12.3%). CONCLUSIONS The measles-rubella vaccination campaign was critical for raising rubella immunity levels in children and adolescents in Haiti. To remain free of rubella transmission and CRS, Haiti must also achieve and sustain high routine measles-rubella vaccination coverage and maintain high-quality integrated measles-rubella and CRS surveillance, including laboratory-based confirmation for reported rash illnesses. If routine measles-rubella vaccination coverage is suboptimal or if gaps in coverage are identified, additional mass campaigns with measles-rubella vaccine will be necessary.

BACKGROUND The Region of the Americas eliminated measles in 2002 through high first-dose routine measles vaccine coverage and vaccination campaigns every 4-6 years; a second routine dose at school entry was added in some countries. The impact of this second routine dose on measles elimination was evaluated. METHODS Data on socioeconomic factors, demographic characteristics, vaccination coverage, and the estimated proportion of children (