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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.

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 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.

Haemophilus influenzae type b (Hib) is a leading cause of bacterial meningitis and pneumonia and can be prevented by Hib vaccine. We conducted a vaccine impact evaluation to support continued use of Hib vaccine in Morocco following introduction in 2007.Bacterial meningitis surveillance data from 2004 to 2009 were obtained from 11 sentinel hospitals located in eight provinces and one prefecture in Morocco to examine Hi meningitis reporting for cases aged5 years. We defined the years of 2004-2006 as the pre-vaccine period and 2008-2009 as the post-vaccine period and compared the mean annual number of confirmed Hi meningitis cases for these time periods using a Chi-square test. We calculated the minimum incidence of Hi meningitis during the evaluation period in Grand Casa Prefecture, where the catchment population could be estimated.From 2004 to 2009, 1844 suspected meningitis case-patients aged5 years were reported; 354 (19.2%) were confirmed with bacterial meningitis, including 105 (29.7%) Hi cases. The mean annual number of confirmed Hi meningitis cases decreased by 75%, from 24 in the pre-vaccine period to 6 during the post-vaccine period (p0.001). Assuming Hi cases with unknown age were5 years of age, the estimated minimum incidence of confirmed Hi meningitis in Grand Casa Prefecture decreased by 93%, from 15 cases per 100,000 children in the pre-vaccine period to 1 case per 100,000 children in the post-vaccine period.Hib vaccine introduction likely significantly reduced the occurrence of Hi meningitis among children aged5 years at the 11 sentinel hospitals included in this evaluation in Morocco, suggesting that continued use of Hib vaccine in Morocco would be beneficial.

OBJECTIVE: Despite increases in routine vaccination coverage during the past three decades, the percent of children completing the recommended vaccination schedule remains below expected targets in many low and middle income countries. In 2008, the World Health Organization Strategic Advisory Group of Experts on Immunization requested more information on the reasons that children were under-vaccinated (receiving at least one but not all recommended vaccinations) or not vaccinated in order to develop effective strategies and interventions to reach these children. METHODS: A systematic review of the peer-reviewed literature published from 1999 to 2009 was conducted to aggregate information on reasons and factors related to the under-vaccination and non-vaccination of children. A standardized form was used to abstract information from relevant articles identified from eight different medical, behavioural and social science literature databases. FINDINGS: Among 202 relevant articles, we abstracted 838 reasons associated with under-vaccination; 379 (45%) were related to immunization systems, 220 (26%) to family characteristics, 181 (22%) to parental attitudes and knowledge, and 58 (7%) to limitations in immunization-related communication and information. Of the 19 reasons abstracted from 11 identified articles describing the non-vaccinated child, 6 (32%) were related to immunization systems, 8 (42%) to parental attitudes and knowledge, 4 (21%) to family characteristics, and 1 (5%) to communication and information. CONCLUSIONS: Multiple reasons for under-vaccination and non-vaccination were identified, indicating that a multi-faceted approach is needed to reach under-vaccinated and unvaccinated children. Immunization system issues can be addressed through improving outreach services, vaccine supply, and health worker training; however, under-vaccination and non-vaccination linked to parental attitudes and knowledge are more difficult to address and likely require local interventions.