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Immunity gaps caused by COVID-19-related disruptions highlight the importance of catch-up vaccination. Number of countries offering vaccines in second year of life (2YL) has increased, but use of 2YL for catch-up vaccination has been variable. We assessed pre-pandemic use of 2YL for catch-up vaccination in three countries (Pakistan, the Philippines, and South Africa), based on existence of a 2YL platform (demonstrated by offering second dose of measles-containing vaccine (MCV2) in 2YL), proportion of card availability, and geographical variety.We conducted a secondary data analysis of immunization data from Demographic and Health Surveys (DHS) in Pakistan (2017-2018), the Philippines (2017), and South Africa (2016). We conducted time-to-event analyses for pentavalent vaccine (diphtheria-tetanus-pertussis-Hepatitis B-Haemophilus influenzae type b [Hib]) and MCV and calculated use of 2YL and MCV visits for catch-up vaccination.Among 24-35-month-olds with documented dates, coverage of third dose of pentavalent vaccine increased in 2YL by 2%, 3%, and 1% in Pakistan, Philippines, and South Africa, respectively. MCV1 coverage increased in 2YL by 5% in Pakistan, 10% in the Philippines, and 3% in South Africa. In Pakistan, among 124 children eligible for catch-up vaccination of pentavalent vaccine at time of a documented MCV visit, 45% received a catch-up dose. In the Philippines, among 381 eligible children, 38% received a pentavalent dose during an MCV visit. In South Africa, 50 children were eligible for a pentavalent vaccine dose before their MCV1 visit, but only 20% received it; none with MCV2.Small to modest vaccine coverage improvements occurred in all three countries through catch-up vaccination in 2YL but many missed opportunities for vaccination continue to occur. Using the 2YL platform can increase coverage and close immunity gaps, but immunization programmes need to change policies, practices, and monitor catch-up vaccination to maximize the potential.

In 2020, the World Health Assembly endorsed the Immunization Agenda 2030, an ambitious global immunization strategy to reduce morbidity and mortality from vaccine-preventable diseases (1). This report updates a 2020 report (2) with global, regional,* and national vaccination coverage estimates and trends through 2021. Global estimates of coverage with 3 doses of diphtheria-tetanus-pertussis-containing vaccine (DTPcv3) decreased from an average of 86% during 2015-2019 to 83% in 2020 and 81% in 2021. Worldwide in 2021, 25.0 million infants (19% of the target population) were not vaccinated with DTPcv3, 2.1 million more than in 2020 and 5.9 million more than in 2019. In 2021, the number of infants who did not receive any DTPcv dose by age 12 months (18.2 million) was 37% higher than in 2019 (13.3 million). Coverage with the first dose of measles-containing vaccine (MCV1) decreased from an average of 85% during 2015-2019 to 84% in 2020 and 81% in 2021. These are the lowest coverage levels for DTPcv3 and MCV1 since 2008. ​Global coverage estimates were also lower in 2021 than in 2020 and 2019 for bacillus Calmette-Guérin vaccine (BCG) as well as for the completed series of Haemophilus influenzae type b vaccine (Hib), hepatitis B vaccine (HepB), polio vaccine (Pol), and rubella-containing vaccine (RCV). The COVID-19 pandemic has resulted in disruptions to routine immunization services worldwide. Full recovery to immunization programs will require context-specific strategies to address immunization gaps by catching up missed children, prioritizing essential health services, and strengthening immunization programs to prevent outbreaks (3).

The COVID-19 pandemic has contributed to the widespread disruption of immunization services, including the postponement of mass vaccination campaigns.In May 2020, the World Health Organization and partners started monitoring COVID-19-related disruptions to mass vaccination campaigns against cholera, measles, meningitis A, polio, tetanus-diphtheria, typhoid, and yellow fever through the Immunization Repository Campaign Delay Tracker. The authors reviewed the number and target population of reported preventive and outbreak response vaccination campaigns scheduled, postponed, canceled, and reinstated at 4 time points: May 2020, December 2020, May 2021, and December 2021.Mass vaccination campaigns across all vaccines were disrupted heavily by COVID-19. In May 2020, 105 of 183 (57%) campaigns were postponed or canceled in 57 countries because of COVID-19, with an estimated 796 million postponed or missed vaccine doses. Campaign resumption was observed beginning in July 2020. In December 2021, 77 of 472 (16%) campaigns in 54 countries, mainly in the African Region, were still postponed or canceled because of COVID-19, with about 382 million postponed or missed vaccine doses.There is likely a high risk of vaccine-preventable disease outbreaks across all regions because of an increased number of susceptible persons resulting from the large-scale mass vaccination campaign postponement caused by COVID-19.

Objectives In May 2018, a laboratory network for antimicrobial resistance (AMR) surveillance in Tamil Nadu, India, detected a cluster of Salmonella enterica serotype Typhi (S. Typhi) isolates resistant to ceftriaxone. We investigated to describe the epidemiology and identify risk factors for the outbreak. Methods We conducted unmatched case-control studies. We defined a case as illness (fever with abdominal pain, diarrhea or vomiting) in a person with blood culture-confirmed ceftriaxone-resistant S. Typhi isolated between January 1 and July 4, 2018 in Tiruchirappalli, Tamil Nadu. We interviewed cases using a semi-structured questionnaire to identify common exposures to food, water and places visited. Results We identified 7 cases (5 men) during March 25–June 8, 2018, median age 23 years (range: 12–42); all were hospitalized, none died. Eating at Restaurant A (odds ratio [OR]=22) and chicken gravy (OR=16) was associated with illness. Of the 10 workers at Restaurant A, stool culture from 8 did not detect S. Typhi; 2 did not consent to provide samples. Five water samples around the restaurant showed low or no residual chlorine content. Conclusions The investigation highlights the value of AMR surveillance in detecting emerging pathogens and the need for timely investigations, along with strengthening food safety.

Endorsed by the World Health Assembly in 2020, the Immunization Agenda 2030 (IA2030) strives to reduce morbidity and mortality from vaccine-preventable diseases across the life course (1). This report, which updates a previous report (2), presents global, regional,* and national vaccination coverage estimates and trends as of 2020. Changes are described in vaccination coverage and the numbers of unvaccinated and undervaccinated children as measured by receipt of the first and third doses of diphtheria, tetanus, and pertussis-containing vaccine (DTP) in 2020, when the COVID-19 pandemic began, compared with 2019. Global estimates of coverage with the third dose of DTP (DTP3) and a polio vaccine (Pol3) decreased from 86% in 2019 to 83% in 2020. Similarly, coverage with the first dose of measles-containing vaccine (MCV1) dropped from 86% in 2019 to 84% in 2020. The last year that coverage estimates were at 2020 levels was 2009 for DTP3 and 2014 for both MCV1 and Pol3. Worldwide, 22.7 million children (17% of the target population) were not vaccinated with DTP3 in 2020 compared with 19.0 million (14%) in 2019. Children who did not receive the first DTP dose (DTP1) by age 12 months (zero-dose children) accounted for 95% of the increased number. Among those who did not receive DTP3 in 2020, approximately 17.1 million (75%) were zero-dose children. Global coverage decreased in 2020 compared with 2019 estimates for the completed series of Haemophilus influenzae type b (Hib), hepatitis B vaccine (HepB), human papillomavirus vaccine (HPV), and rubella-containing vaccine (RCV). Full recovery from COVID-19-associated disruptions will require targeted, context-specific strategies to identify and catch up zero-dose and undervaccinated children, introduce interventions to minimize missed vaccinations, monitor coverage, and respond to program setbacks (3).

Gains in immunization coverage and delivery of primary health care service have stagnated in recent years. Remaining gaps in service coverage reflect multiple underlying reasons that may be amenable to improved health system design. Immunization systems and other primary health care services can be mutually supportive, for improved service delivery and for strengthening of Universal Health Coverage. Improvements require that dynamic and multi-faceted barriers and risks be addressed. These include workforce availability, quality data systems and use, leadership and management that is innovative, flexible, data driven and responsive to local needs. Concurrently, improvements in procurement, supply chain, logistics and delivery systems, and integrated monitoring of vaccine coverage and epidemiological disease surveillance with laboratory systems, and vaccine safety will be needed to support community engagement and drive prioritized actions and communication. Finally, political will and sustained resource commitment with transparent accountability mechanisms are required. The experience of the impact of COVID-19 pandemic on essential PHC services and the challenges of vaccine roll-out affords an opportunity to apply lessons learned in order to enhance vaccine services integrated with strong primary health care services and universal health coverage across the life course.

To analyse subnational inequality in diphtheria-tetanus-pertussis (DTP) immunization dropout in 24 African countries using administrative data on receipt of the first and third vaccine doses (DTP1 and DTP3, respectively) collected by the Joint Reporting Process of the World Health Organization and the United Nations Children's Fund.Districts in each country were grouped into quintiles according to the proportion of children who dropped out between DTP1 and DTP3 (i.e. the dropout rate). We used six summary measures to quantify inequalities in dropout rates between districts and compared rates with national dropout rates and DTP1 and DTP3 immunization coverage.The median dropout rate across countries was 2.4% in quintiles with the lowest rate and 14.6% in quintiles with the highest rate. In eight countries, the difference between the highest and lowest quintiles was 14.9 percentage points or more. In most countries, underperforming districts in the quintile with the highest rate tended to lag disproportionately behind the others. This divergence was not evident from looking only at national dropout rates. Countries with the largest inequalities in absolute subnational dropout rate tended to have lower estimated national DTP1 and DTP3 immunization coverage.There were marked inequalities in DTP immunization dropout rates between districts in most countries studied. Monitoring dropout at the subnational level could help guide immunization interventions that address inequalities in underserved areas, thereby improving overall DTP3 coverage. The quality of administrative data should be improved to ensure accurate and timely assessment of geographical inequalities in immunization.Analyser les inégalités régionales en matière de taux d'abandon du vaccin diphtérique-tétanique-coquelucheux (DTC) dans 24 pays de la région Afrique, en se fondant sur les données administratives relatives à l'injection de la première et de la troisième dose du vaccin (DTC1 et DTC3, respectivement) collectées dans le cadre du Rapport conjoint de notification de l'Organisation mondiale de la Santé et du Fonds des Nations Unies pour l'enfance.Dans chaque pays, les districts ont été regroupés en quintiles selon le pourcentage d'enfants ayant interrompu la vaccination entre DTC1 et DTC3 (taux d'abandon). Nous avons employé six mesures synthétiques afin de quantifier les inégalités en matière de taux d'abandon entre districts, puis nous avons comparé ces taux avec les taux d'abandon nationaux ainsi qu’avec la couverture vaccinale DTC1 et DTC3.Le taux d'abandon médian dans les différents pays s'élevait à 2,4% dans les quintiles affichant le taux le plus bas, et atteignait 14,6% dans les quintiles affichant le taux le plus haut. Dans huit pays, l'écart entre le quintile le plus haut et le quintile le plus bas était égal ou supérieur à 14,9 points de pourcentage. Dans la plupart des pays, les districts enregistrant les moins bonnes performances dans le quintile avec le taux le plus élevé étaient plus enclins à se laisser exagérément distancer par les autres. Une divergence qui passait inaperçue lorsqu'on ne tenait compte que des taux d'abandon nationaux. Les pays confrontés aux plus importantes inégalités en termes de taux d'abandon régional absolu étaient plus enclins, selon les estimations, à présenter une couverture vaccinale DTC1 et DTC3 moins élevée à l'échelle nationale.Dans la plupart des pays étudiés, nous avons constaté de fortes disparités entre districts concernant les taux d'abandon du vaccin DTC. Assurer un contrôle sur ces taux d'abandon au niveau régional pourrait orienter les campagnes de vaccination visant à réduire les inégalités dans les zones mal desservies, ce qui offrirait une meilleure couverture DTC3 globale. Enfin, la qualité des données administratives devrait être améliorée afin de fournir des évaluations précises et ponctuelles des variations géographiques en matière de vaccination.Analizar la desigualdad subnacional en el abandono de la inmunización contra la difteria, el tétanos y la tos ferina (DTP) en 24 países africanos utilizando datos administrativos sobre la recepción de la primera y la tercera dosis de la vacuna (DTP1 y DTP3, respectivamente) recogidos por el proceso de informes conjuntos de la Organización Mundial de la Salud y el Fondo de las Naciones Unidas para la Infancia.Los distritos de cada país se agruparon en quintiles según la proporción de niños que abandonaron la vacunación entre la DTP1 y la DTP3 (es decir, la tasa de abandono). Se utilizaron seis medidas de resumen para cuantificar las desigualdades en las tasas de abandono entre los distritos y se compararon estas tasas con las tasas nacionales de abandono y la cobertura de inmunización DTP1 y DTP3.La mediana de la tasa de abandono de la vacunación en todos los países fue del 2,4 % en los quintiles con la tasa más baja y del 14,6 % en los quintiles con la tasa más alta. En ocho países, la diferencia entre los quintiles más altos y más bajos era de 14,9 puntos porcentuales o más. En la mayoría de los países, los distritos con peores resultados en el quintil con la tasa más alta tendían a estar desproporcionadamente por detrás de los demás. Esta divergencia no era evidente si se observaban únicamente las tasas nacionales de abandono de la vacunación. Los países con las mayores desigualdades en la tasa absoluta de abandono de la vacunación subnacional tendían a tener una cobertura nacional estimada de inmunización DTP1 y DTP3 más baja.En la mayoría de los países estudiados hubo desigualdades claras en las tasas de abandono de la vacunación DTP entre los distritos. El seguimiento del abandono a nivel subnacional podría ayudar a orientar las intervenciones de inmunización que abordan las desigualdades en las zonas desatendidas, mejorando así la cobertura general de DTP3. La calidad de los datos administrativos debe mejorarse para garantizar una evaluación precisa y oportuna de las desigualdades geográficas en la inmunización.لتحليل حالة التفاوت دون الوطنية في التسرب من التحصين ضد الدفتيريا والتيتانوس والسعال الديكي (DTP) في 24 دولة أفريقية باستخدام البيانات الإدارية عند تلقي جرعتي التحصين الأولى والثالثة (DTP1 وDTP3 على التوالي)، والتي تم جمعها بواسطة عملية الإبلاغ المشتركة لمنظمة الصحة العالمية، ومنظمة الأمم المتحدة للطفولة.تم تجميع المناطق في كل دولة في مجموعات خمسية وفقًا لنسبة الأطفال الذين تسربوا بين الجرعتين DTP1 وDTP3 (أي معدل التسرب). استخدمنا ستة مقاييس موجزة لقياس حالات التفاوت في معدلات التسرب بين المناطق، وقمنا بمقارنة هذه المعدلات مع معدلات التسرب الوطنية وتغطية التحصين ضد الجرعتين DTP1 وDTP3.كان متوسط معدل التسرب عبر الدول 2.4% في المجموعات الخمسية ذات المعدل الأقل، و14.6% في المجموعات الخمسية ذات المعدل الأعلى. في ثماني دول، كان الفرق بين أعلى وأقل شريحتين 14.9 نقطة مئوية أو أكثر. في معظم الدول، كانت المناطق ذات الأداء الضعيف في المجموعة الخمسية ذات أعلى معدل، تميل إلى التدهور بشكل غير متناسب عن غيرها من المناطق. لم يكن هذا الاختلاف واضحًا من مجرد النظر فقط إلى معدلات التسرب الوطنية. تميل الدول التي لديها أكبر تفاوتات في معدل التسرب المطلق دون الوطني، إلى أن يكون لديها تغطية تحصين وطنية تقديرية أقل من الجرعتين DTP1 وDTP3.كانت هناك تفاوتات ملحوظة في معدلات التسرب من التحصين ضد الدفتيريا والتيتانوس والسعال الديكي بين المناطق في معظم الدول التي شملتها الدراسة. يمكن لمراقبة التسرب على المستوى دون الوطني أن تساعد في توجيه تدخلات التحصين التي تعالج التفاوتات في المناطق المحرومة، وبالتالي تحسين التغطية الشاملة للجرعة DTP3. يجب تحسين جودة البيانات الإدارية لضمان التقييم الدقيق وفي الوقت المناسب للتفاوتات في التحصين.使用世界卫生组织和联合国儿童基金会联合报告中收集的有关接种第一剂和第三剂疫苗（分别为 DTP1 和 DTP3）的管理数据，分析24个非洲国家关于白喉-破伤风-百日咳 (DTP) 免疫接种的地区不均问题。.根据要接种 DTP1 和 DTP3 却未完成全部接种的儿童比例（即辍接种率），将每个国家的地区按五分位置划分。我们使用六种综合测量方法来量化地区之间辍接种率的不均衡，并将其与国家辍接种率以及 DTP1 和 DTP3 免疫覆盖率进行比较。.各国的辍接种率中位数最低的五分之一为 2.4%，最高的五分之一为 14.6%。在八个国家中，最高和最低五分之一之间的差距为 14.9 个百分点或更多。在大多数国家，辍接种率最高的五分之一中，表现不佳的地区，远远落后于其他地区。仅从国家间的辍接种率来看，这种差异并不明显。地区辍接种率不均衡程度最大的国家，往往具有较低的预计国家 DTP1 和 DTP3 免疫覆盖率。.在大多数受调查的国家中，各地区之间 DTP 辍接种率存在明显不均。监测地区辍接种率，有助于对服务欠缺地区的不均衡问题进行免疫干预指导，从而提高 DTP3 的整体覆盖率。应提高管理数据的质量，以确保准确、及时地评估免疫接种方面的地域不均问题。.По коэффициентам выбытия проанализировать неравенство на субнациональном уровне в области охвата иммунизацией коклюшно-дифтерийно-столбнячной вакциной (КДС) в 24 африканских странах с использованием административных данных о получении первой и третьей доз вакцины (КДС-1 и КДС-3 соответственно), собранных в рамках Единого процесса отчетности Всемирной организации здравоохранения и Детского фонда Организации Объединенных Наций.Районы в каждой стране были сгруппированы по квинтилям согласно доле детей, выбывших между получением доз КДС-1 и КДС-3 (т. е. коэффициент выбытия). Мы использовали шесть сводных показателей для количественной оценки неравенства по коэффициентам выбытия между районами и сравнили коэффициенты с национальными коэффициентами выбытия и охватом иммунизацией КДС-1 и КДС-3.Для всех стран в квинтилях с наиболее низкими коэффициентами выбытия медианное значение выбытия составило 2,4%, в квинтилях с наиболее высокими коэффициентами выбытия — 14,6%. В восьми странах разница в показателях между квинтилями с наиболее высокими и наиболее низкими коэффициентами выбытия составила 14,9 процентного пункта или больше.. В большинстве стран отстающие районы в квинтилях с наиболее высокими коэффициентами выбытия имели тенденцию к непропорциональному отставанию по сравнению с другими районами. Это расхождение не было очевидным, если ориентироваться только на национальные коэффициенты выбытия. Страны с самым высоким уровнем неравенства по абсолютным коэффициентам выбытия на субнациональном уровне, как правило, имели более низкий оценочный уровень национального охвата иммунизацией КДС-1 и КДС-3.В большинстве изученных стран наблюдалось неравенство между районами в коэффициентах выбытия в период получения КДС-вакцины. Мониторинг выбытия на субнациональном уровне может помочь в проведении мероприятий по иммунизации, направленных на устранение неравенства в недостаточно обслуживаемых районах, тем самым улучшая общий охват иммунизацией КДС-3. Качество административных данных должно быть улучшено для обеспечения точной и своевременной оценки географического неравенства в области охвата иммунизацией.

Summary Background The COVID-19 pandemic and efforts to reduce SARS-CoV-2 transmission substantially affected health services worldwide. To better understand the impact of the pandemic on childhood routine immunisation, we estimated disruptions in vaccine coverage associated with the pandemic in 2020, globally and by Global Burden of Disease (GBD) super-region. Methods For this analysis we used a two-step hierarchical random spline modelling approach to estimate global and regional disruptions to routine immunisation using administrative data and reports from electronic immunisation systems, with mobility data as a model input. Paired with estimates of vaccine coverage expected in the absence of COVID-19, which were derived from vaccine coverage models from GBD 2020, Release 1 (GBD 2020 R1), we estimated the number of children who missed routinely delivered doses of the third-dose diphtheria-tetanus-pertussis (DTP3) vaccine and first-dose measles-containing vaccine (MCV1) in 2020. Findings Globally, in 2020, estimated vaccine coverage was 76·7% (95% uncertainty interval 74·3–78·6) for DTP3 and 78·9% (74·8–81·9) for MCV1, representing relative reductions of 7·7% (6·0–10·1) for DTP3 and 7·9% (5·2–11·7) for MCV1, compared to expected doses delivered in the absence of the COVID-19 pandemic. From January to December, 2020, we estimated that 30·0 million (27·6–33·1) children missed doses of DTP3 and 27·2 million (23·4–32·5) children missed MCV1 doses. Compared to expected gaps in coverage for eligible children in 2020, these estimates represented an additional 8·5 million (6·5–11·6) children not routinely vaccinated with DTP3 and an additional 8·9 million (5·7–13·7) children not routinely vaccinated with MCV1 attributable to the COVID-19 pandemic. Globally, monthly disruptions were highest in April, 2020, across all GBD super-regions, with 4·6 million (4·0–5·4) children missing doses of DTP3 and 4·4 million (3·7–5·2) children missing doses of MCV1. Every GBD super-region saw reductions in vaccine coverage in March and April, with the most severe annual impacts in north Africa and the Middle East, south Asia, and Latin America and the Caribbean. We estimated the lowest annual reductions in vaccine delivery in sub-Saharan Africa, where disruptions remained minimal throughout the year. For some super-regions, including southeast Asia, east Asia, and Oceania for both DTP3 and MCV1, the high-income super-region for DTP3, and south Asia for MCV1, estimates suggest that monthly doses were delivered at or above expected levels during the second half of 2020. Interpretation Routine immunisation services faced stark challenges in 2020, with the COVID-19 pandemic causing the most widespread and largest global disruption in recent history. Although the latest coverage trajectories point towards recovery in some regions, a combination of lagging catch-up immunisation services, continued SARS-CoV-2 transmission, and persistent gaps in vaccine coverage before the pandemic still left millions of children under-vaccinated or unvaccinated against preventable diseases at the end of 2020, and these gaps are likely to extend throughout 2021. Strengthening routine immunisation data systems and efforts to target resources and outreach will be essential to minimise the risk of vaccine-preventable disease outbreaks, reach children who missed routine vaccine doses during the pandemic, and accelerate progress towards higher and more equitable vaccination coverage over the next decade. Funding Bill & Melinda Gates Foundation.

In 2010, the World Health Assembly (WHA) set the following three milestones for measles control to be achieved by 2015: 1) increase routine coverage with the first dose of measles-containing vaccine (MCV1) among children aged 1 year to ≥90% at the national level and to ≥80% in every district, 2) reduce global annual measles incidence to

'Zero-dose' refers to a person who does not receive a single dose of any vaccine in the routine national immunization schedule, while 'missed dose' refers to a person who does not complete the schedule. These peopleremain vulnerable to vaccine-preventable diseases, and are often already disadvantaged due to poverty, conflict, and lack of access to basic health services. Globally, more 22.7 million children are estimated to be zero- or missed-dose, of which an estimated 3.1 million (∼14 %) reside in Nigeria.We conducted a scoping review tosynthesize recent literature on risk factors and interventions for zero- and missed-dosechildren in Nigeria. Our search identified 127 papers, including research into risk factors only (n = 66); interventions only (n = 34); both risk factors and interventions (n = 18); and publications that made recommendations only (n = 9). The most frequently reported factors influencing childhood vaccine uptake were maternal factors (n = 77), particularly maternal education (n = 22) and access to ante- and perinatal care (n = 19); heterogeneity between different types of communities - including location, region, wealth, religion, population composition, and other challenges (n = 50); access to vaccination, i.e., proximity of facilities with vaccines and vaccinators (n = 37); and awareness about immunization - including safety, efficacy, importance, and schedules (n = 18).Literature assessing implementation of interventions was more scattered, and heavily skewed towards vaccination campaigns and polio eradication efforts. Major evidence gaps exist in how to deliver effective and sustainable routine childhood immunization. Overall, further work is needed to operationalise the learnings from these studies, e.g. through applying findings to Nigeria's next review of vaccination plans, and using this summary as a basis for further investigation and specific recommendations on effective interventions.

In May 2018, a laboratory network for antimicrobial resistance (AMR) surveillance in Tamil Nadu, India, detected a cluster ofWe conducted unmatched case-control studies. We defined a case as illness (fever with abdominal pain, diarrhea or vomiting) in a person with blood culture-confirmed ceftriaxone-resistantWe identified 7 cases (5 men) during March 25-June 8, 2018, median age 23 years (range: 12-42); all were hospitalized, none died. Eating at Restaurant A (odds ratio [OR]=22) and chicken gravy (OR=16) was associated with illness. Of the 10 workers at Restaurant A, stool culture from 8 did not detectThe investigation highlights the value of AMR surveillance in detecting emerging pathogens and the need for timely investigations, along with strengthening food safety.

In 2010, the World Health Assembly (WHA) set the following three milestones for measles control to be achieved by 2015: 1) increase routine coverage with the first dose of measles-containing vaccine (MCV1) among children aged 1 year to ≥90% at the national level and to ≥80% in every district, 2) reduce global annual measles incidence to less than five cases per 1 million population, and 3) reduce global measles mortality by 95% from the 2000 estimate* (1). In 2012, WHA endorsed the Global Vaccine Action Plan,† with the objective of eliminating measles§ in five of the six World Health Organization (WHO) regions by 2020. This report updates a previous report (2) and describes progress toward WHA milestones and regional measles elimination during 2000-2018. During 2000-2018, estimated MCV1 coverage increased globally from 72% to 86%; annual reported measles incidence decreased 66%, from 145 to 49 cases per 1 million population; and annual estimated measles deaths decreased 73%, from 535,600 to 142,300. During 2000-2018, measles vaccination averted an estimated 23.2 million deaths. However, the number of measles cases in 2018 increased 167% globally compared with 2016, and estimated global measles mortality has increased since 2017. To continue progress toward the regional measles elimination targets, resource commitments are needed to strengthen routine immunization systems, close historical immunity gaps, and improve surveillance. To achieve measles elimination, all communities and countries need coordinated efforts aiming to reach ≥95% coverage with 2 doses of measles vaccine (3).

ObjectivesDespite significant progress in childhood vaccination coverage globally, substantial inequality remains. Remote rural populations are recognised as a priority group for immunisation service equity. We aimed to link facility and individual data to examine the relationship between distance to services and immunisation coverage empirically, specifically using a rural population.Design and settingRetrospective cross-sectional analysis of facility data from the 2013–2014 Malawi Service Provision Assessment and individual data from the 2015–2016 Malawi Demographic and Health Survey, linking children to facilities within a 5 km radius. We examined associations between proximity to health facilities and vaccination receipt via bivariate comparisons and logistic regression models.Participants2740 children aged 12–23 months living in rural areas.Outcome measuresImmunisation coverage for the six vaccines included in the Malawi Expanded Programme on Immunization schedule for children under 1 year at time of study, as well as two composite vaccination indicators (receipt of basic vaccines and receipt of all recommended vaccines), zero-dose pentavalent coverage, and pentavalent dropout.Findings72% (706/977) of facilities offered childhood vaccination services. Among children in rural areas, 61% were proximal to (within 5 km of) a vaccine-providing facility. Proximity to a vaccine-providing health facility was associated with increased likelihood of having received the rotavirus vaccine (93% vs 88%, p=0.004) and measles vaccine (93% vs 89%, p=0.01) in bivariate tests. In adjusted comparisons, how close a child was to a health facility remained meaningfully associated with how likely they were to have received rotavirus vaccine (adjusted OR (AOR) 1.63, 95% CI 1.13 to 2.33) and measles vaccine (AOR 1.62, 95% CI 1.11 to 2.37).ConclusionProximity to health facilities was significantly associated with likelihood of receipt for some, but not all, vaccines. Our findings reiterate the vulnerability of children residing far from static vaccination services; efforts that specifically target remote rural populations living far from health facilities are warranted to ensure equitable vaccination coverage.

Background: Acute diarrheal disease (ADD) outbreaks frequently occur in the Gangetic plains of Uttar Pradesh, India. In August 2017, Muzaffarpur village, Uttar Pradesh, reported an ADD outbreak. Objectives: Outbreak investigation was conducted to find out the epidemiology and to identify the risk factors. Methods: A 1:1 area-matched case–control study was conducted. Suspected ADD case was defined as ≥3 loose stools or vomiting within 24 h in a Muzaffarpur resident between August 7 and September 9, 2017. A control was defined as an absence of loose stools and vomiting in a resident between August 7 and September 9, 2017. A matched odds ratio (mOR) with 95% confidence intervals (CIs) was calculated. Drinking water was assessed to test for the presence of any contamination. Stool specimens were tested for Vibrio cholerae, and water samples were also tested for any fecal contamination and residual chlorine. Results: Among 70 cases (female = 60%; median age = 12 years, range = 3 months–70 years), two cases died and 35 cases were hospitalized. Area–A in Muzaffarpur had the highest attack rate (8%). The index case washed soiled clothes at well – A1 1 week before other cases occurred. Among 67 case–control pairs, water consumption from well–A1 (mOR: 43.00; 95% CI: 2.60–709.88) and not washing hands with soap (mOR: 2.87; 95% CI: 1.28–6.42) were associated with illness. All seven stool specimens tested negative for V. cholerae. All six water samples, including one from well–A1, tested positive for fecal contamination with

Background: Acute diarrheal disease (ADD) accounts for 12 million cases and 1216 deaths annually in India. On July 13, 2016, an ADD outbreak was reported from Sawargaon village from Nagpur district, Maharashtra. Objective: The outbreak was investigated to describe the epidemiology and suggest control and preventive measures. Methods: A case was defined as a person experiencing at least one loose stool in Sawargaon village between July 9, 2016, and July 31, 2016. We searched for cases by enhanced passive surveillance. We collected stool samples for bacterial culture and tested water from multiple water sources for fecal coliforms. We also reviewed sanitary practices and rainfall data. Results: A total of 889 cases were identified, with 51% female, 280 hospitalizations (31%), and two deaths. The median age was 27 years (range 6 months to 90 years). Cases started on July 9, a week after heavy rains. District authorities started chlorination of water sources on July 13 and cases declined soon after. Two of nine stool samples tested positive for Vibrio cholera O1 serogroup. Of the 18 water samples collected, 16 (88%) samples from multiple sources, including wells, hand pumps, and taps, were positive for fecal coliforms. Of 1,885 households in the village, 450 (24%) households had no toilets and open defecation was commonly observed in the nearby river bed. Conclusions: This ADD outbreak was likely associated with drinking contaminated groundwater, which probably occurred after heavy rainfall in an area of open defecation. We recommended providing chlorinated drinking water, promoting safe sanitation practices, including building more public and private toilets, and enhancing diagnostic laboratory capacity.

Background: Of 1115 measles outbreaks during 2015 in India, 61,255 suspected measles cases were reported. In 2016, a measles outbreak was reported at East and West Jaintia Hills districts in Meghalaya State, India. Objectives: The outbreak was investigated to describe the epidemiology, estimate vaccination coverage and vaccine effectiveness (VE), determine risk factors for the disease, and recommend control and prevention measures. Methods: A measles case was defined as new-onset fever with maculopapular rash occurring between May 1, 2016, and January 21, 2017, in a resident of East and West Jaintia Hills. Cases were identified by active and passive surveillance. Serum and urine samples were collected from cases with laboratory diagnosis for confirmation. A retrospective cohort study was conducted to estimate vaccination coverage, VE, and risk factors for the disease. Results: We identified 382 cases (51% female). The attack rate was 24% with three deaths. The case fatality rate was

Background: The SARS-CoV-2 pandemic has revealed the vulnerability of immunization systems worldwide, although the scale of these disruptions has not been described at a global level. Methods: This report synthesized data representing 169 countries and territories. Data sources included administered vaccine dose data from January-December 2019 and 2020, WHO Regional office reports, and the WHO-led pulse survey administered in April and June 2020. Results were expressed as frequencies and proportions of respondents or reporting countries. Vaccine doses administered data were weighted by the population of surviving infants per country. Findings: A decline in the number of DTP3 and MCV1 doses administered in the first half of 2020 was noted. The nadir was observed in April 2020, when 35% fewer DTP3 doses were administered globally, ranging from 10% in Africa to 58% in South East Asia. Recovery of vaccinations began by June 2020 and continued into late 2020. WHO regional offices reported significant disruption to routine vaccination sessions in April 2020, related to interrupted vaccination demand, and supply, including reduced availability of the health workforce. Pulse survey analysis revealed that 69% of countries experienced disruption in outreach services compared to 44% countries with disrupted fixed-post immunization services. Interpretation: The marked magnitude and global scale of immunization disruption evokes the dangers of vaccine-preventable disease outbreaks in the future. Trends indicating partial resumption of services highlight the urgent need for ongoing assessment of recovery, catch-up vaccination strategy implementation for vulnerable populations, and ensuring vaccine coverage equity and health system resilience. Funding: World Health Organization and U.S. Agency for International Development (USAID). Conflict of Interest: We declare no competing interests.

Background: The COVID-19 pandemic has contributed to a widespread disruption of immunization services, including the suspension of mass vaccination campaigns. Methods: In May 2020, the World Health Organization (WHO) and partners established an Immunization Repository Campaign Delay Tracker to document the COVID-19 related disruptions to preventive and outbreak response vaccination campaigns worldwide of nine vaccines. Data were collected from disease specific initiatives that provided programme information to WHO Headquarters and reported through the Polio Information System (POLIS). Using these data, the authors reviewed the number of vaccination campaigns that were scheduled, postponed, cancelled and reinstated at three timepoints: May 2020, December 2020 and May 2021. Findings: The results indicate that mass vaccination campaigns across all vaccines were disrupted heavily by COVID-19. In May 2020, 105 of 183 (57%) campaigns were postponed or cancelled in 57 countries due to COVID-19, which resulted in an estimated 796 million postponed or missed vaccine doses. Campaign resumption was observed beginning in July 2020. By May 2021, 56% (72 of 128) postponed campaigns had been reinstated after an initial postponement due to COVID-19. However, 79 campaigns in 53 countries were still postponed or cancelled due to COVID-19, which resulted in an estimated 390 million postponed or missed vaccine doses. Interpretation: Our findings suggest a high risk of an increased number of persons susceptible to vaccine-preventable diseases during the pandemic due to mass vaccination campaign postponement. Implementing safe, aggressive and innovative catch-up vaccination strategies is needed to prevent sizeable vaccine-preventable disease outbreaks resulting from these accumulated immunity gaps. Funding Information: This study is not supported by any funder. Declaration of Interests: We declare no competing interests.

Endorsed by the World Health Assembly in 2020, the Immunization Agenda 2030 strives to reduce morbidity and mortality from vaccine-preventable diseases across the life course (1). This report, which updates previous reports (2), presents global, regional,* and national vaccination coverage estimates and trends as of 2019 and describes the number of surviving infants who did not receive the first dose of diphtheria and tetanus toxoids and pertussis-containing vaccine (DTP1) during the first year of life (i.e., zero-dose children), which serves as a proxy for children with poor access to immunization and other health services. Global estimates of coverage with the third dose of DTP (DTP3), the first dose of measles-containing vaccine (MCV1), and the third dose of polio vaccine (Pol3) ranged from 84% to 86% during 2010-2019. Worldwide, 19.7 million children (15%) were not vaccinated with DTP3 in 2019, 13.8 million (70%) of whom were zero-dose children. During 2010-2019, the number of zero-dose children increased in the African, Americas, and Western Pacific regions. Global coverage with the second MCV dose (MCV2) increased from 42% in 2010 to 71% in 2019. During 2010-2019, global coverage with underused vaccines increased for the completed series of rotavirus vaccine (rota), pneumococcal conjugate vaccine (PCV), rubella-containing vaccine (RCV), Haemophilus influenzae type b vaccine (Hib), hepatitis B vaccine (HepB), and human papillomavirus vaccine (HPV). Achieving universal coverage with all recommended vaccines will require tailored, context-specific strategies to reach communities with substantial proportions of zero-dose and incompletely vaccinated children, particularly those in remote rural, urban poor, and conflict-affected communities (3).

Background Cutaneous anthrax in humans is associated with exposure to infected animals or animal products and has a case fatality rate of up to 20% if untreated. During May to June 2015, an outbreak of cutaneous anthrax was reported in Koraput district of Odisha, India, an area endemic for anthrax. We investigated the outbreak to identify risk factors and recommend control measures. Method We defined a cutaneous anthrax case as skin lesions (e.g., papule, vesicle or eschar) in a person residing in Koraput district with illness onset between February 1 and July 15, 2015. We established active surveillance through a house to house survey to ascertain additional cases and conducted a 1:2 unmatched case control study to identify modifiable risk factors. In case control study, we included cases with illness onset between May 1 and July 15, 2015. We defined controls as neighbours of case without skin lesions since last 3 months. Ulcer exudates and rolled over swabs from wounds were processed in Gram stain in the Koraput district headquarter hospital laboratory. Result We identified 81 cases (89% male; median age 38 years [range 5–75 years]) including 3 deaths (case fatality rate = 4%). Among 37 cases and 74 controls, illness was significantly associated with eating meat of ill cattle (OR: 14.5, 95% CI: 1.4–85.7) and with close handling of carcasses of ill animals such as burying, skinning, or chopping (OR: 342, 95% CI: 40.5–1901.8). Among 20 wound specimens collected, seven showed spore-forming, gram positive bacilli, with bamboo stick appearance suggestive of Bacillus anthracis. Conclusion Our investigation revealed significant associations between eating and handling of ill animals and presence of anthrax-like organisms in lesions. We immediately initiated livestock vaccination in the area, educated the community on safe handling practices and recommended continued regular anthrax animal vaccinations to prevent future outbreaks.

Mumps, a vaccine-preventable disease, cause inflammation of salivary glands and may cause severe complications, such as encephalitis, meningitis, deafness, and orchitis/oophoritis. In India, mumps vaccine is not included in the universal immunization program and during 2009 to 2014, 72 outbreaks with greater than 1500 cases were reported. In August 2016, a suspected mumps outbreak was reported in Jaisalmer block, Rajasthan. We investigated to confirm the etiology, describe the epidemiology, and recommend prevention and control measures. We defined a case as swelling in the parotid region in a Jaisalmer block resident between 23 June 2016 and 10 September 2016. We searched for cases in health facilities and house-to-house in affected villages and hamlets. We tested blood samples of cases for mumps immunoglobulin M (IgM) enzyme-linked immunosorbent assay (ELISA). We found 162 cases (60% males) with a median age of 9.4 years (range: 7 month-38 years) and 65 (40%) were females. Symptoms included fever (70%) and bilateral swelling in neck (65%). None of them were vaccinated against mumps. Most (84%) cases were school-going children (3-16 years old). The overall attack rate was 2%. Village A, with two hamlets, had the highest attack rate (hamlet 1 = 13% and hamlet 2 = 12%). School A of village A, hamlet 1, which accommodated 200 children in two classrooms, had an attack rate of 55%. Of 18 blood samples from cases, 11 tested positive for mumps IgM ELISA. This was a confirmed mumps outbreak in Jaisalmer block that disproportionately affected school-going children. We recommended continued surveillance, 5-day absence from school, and vaccination.

The US Food Safety Modernization Act (FSMA) gives food safety regulators increased authority to require implementation of safety measures to reduce the contamination of produce. To evaluate the future impact of FSMA on food safety, a better understanding is needed regarding outbreaks attributed to the consumption of raw produce. Data reported to the US Centers for Disease Control and Prevention's Foodborne Disease Outbreak Surveillance System during 1998–2013 were analysed. During 1998–2013, there were 972 raw produce outbreaks reported resulting in 34 674 outbreak-associated illnesses, 2315 hospitalisations, and 72 deaths. Overall, the total number of foodborne outbreaks reported decreased by 38% during the study period and the number of raw produce outbreaks decreased 19% during the same period; however, the percentage of outbreaks attributed to raw produce among outbreaks with a food reported increased from 8% during 1998–2001 to 16% during 2010–2013. Raw produce outbreaks were most commonly attributed to vegetable row crops (38% of outbreaks), fruits (35%) and seeded vegetables (11%). The most common aetiologic agents identified were norovirus (54% of outbreaks), Salmonella enterica (21%) and Shiga toxin-producing Escherichia coli (10%). Food-handling errors were reported in 39% of outbreaks. The proportion of all foodborne outbreaks attributable to raw produce has been increasing. Evaluation of safety measures to address the contamination on farms, during processing and food preparation, should take into account the trends occurring before FSMA implementation.

Background. To monitor immunization-system strengthening in the Polio Eradication Endgame Strategic Plan 2013–2018 (PEESP), the Global Polio Eradication Initiative identified 1 indicator: 10% annual improvement in third dose of diphtheria- tetanus-pertussis–containing vaccine (DTP3) coverage in polio high-risk districts of 10 polio focus countries. Methods. A multiagency team, including staff from the African Region, developed a comprehensive list of outcome and process indicators measuring various aspects of the performance of an immunization system. Results. The development and implementation of the dashboard to assess immunization system performance allowed national program managers to monitor the key immunization indicators and stratify by high-risk and non–high-risk districts. Discussion. Although only a single outcome indicator goal (at least 10% annual increase in DTP3 coverage achieved in 80% of high-risk districts) initially existed in the endgame strategy, we successfully added additional outcome indicators (eg, decreasing the number of DTP3-unvaccinated children) as well as program process indicators focusing on cold chain, stock availability, and vaccination sessions to better describe progress on the pathway to raising immunization coverage. Conclusion. When measuring progress toward improving immunization systems, it is helpful to use a comprehensive approach that allows for measuring multiple dimensions of the system.

Background Measles incidence and mortality rates have significantly decreased since vaccine introduction. Despite this progress, however, there has been a global resurgence of measles. To understand the current global epidemiology, we analyzed measles surveillance data. Methods We analyzed data on measles cases from 2013–2018 reported to the World Health Organization. Univariate analysis was undertaken based on age, vaccination history, onset year, World Health Organization region, and World Bank income status for the country where the case was reported, and a surrogate indicator of the historical strength of the country’s immunization program. Annual incidence and a 2013–2018 mean country incidence per million were calculated. Results From 2013 through 2018, there were 899 800 reported measles cases, of which 57% occurred unvaccinated or undervaccinated persons, with an unknown vaccination history in another 30%. Lower-middle-income countries accounted for 66% of cases, 23% occurred in persons ≥15 years of age. In countries with stronger historical vaccination programs and higher country income, case patients had higher median ages. Conclusions Although most measles case patients are

Introduction Immunization programs in developing countries increasingly face challenges to ensure equitable delivery of services within cities where rapid urban growth can result in informal settlements, poor living conditions, and heterogeneous populations. A number of strategies have been utilized in developing countries to ensure high community demand and equitable availability of urban immunization services; however, a synthesis of the literature on these strategies has not previously been undertaken. Methods We reviewed articles published in English in peer-reviewed journals between 1990 and 2013 that assessed interventions for improving routine immunization coverage in urban areas in low- and middle-income countries. We categorized the intervention in each study into one of three groups: (1) interventions aiming to increase utilization of immunization services; (2) interventions aiming to improve availability of immunization services by healthcare providers, or (3) combined availability and utilization interventions. We summarized the main quantitative outcomes from each study and effective practices from each intervention category. Results Fifteen studies were identified; 87% from the African, Eastern Mediterranean and Southeast Asian regions of the World Health Organization (WHO). Six studies were randomized controlled trials, eight were pre- and post-intervention evaluations, and one was a cross-sectional study. Four described interventions designed to improve availability of routine immunization services, six studies described interventions that aimed to increase utilization, and five studies aiming to improve both availability and utilization of services. All studies reported positive change in their primary outcome indicator, although seven different primary outcomes indicators were used across studies. Studies varied considerably with respect to the type of intervention assessed, study design, and length of intervention assessment. Conclusion Few studies have assessed interventions designed explicitly for the unique challenges facing immunization programs in urban areas. Further research on sustainability, scalability, and cost-effectiveness of interventions is needed to fill this gap.

Mumps, a vaccine-preventable disease, cause inflammation of salivary glands and may cause severe complications, such as encephalitis, meningitis, deafness, and orchitis/oophoritis. In India, mumps vaccine is not included in the universal immunization program and during 2009 to 2014, 72 outbreaks with greater than 1500 cases were reported. In August 2016, a suspected mumps outbreak was reported in Jaisalmer block, Rajasthan. We investigated to confirm the etiology, describe the epidemiology, and recommend prevention and control measures. We defined a case as swelling in the parotid region in a Jaisalmer block resident between 23 June 2016 and 10 September 2016. We searched for cases in health facilities and house-to-house in affected villages and hamlets. We tested blood samples of cases for mumps immunoglobulin M (IgM) enzyme-linked immunosorbent assay (ELISA). We found 162 cases (60% males) with a median age of 9.4 years (range: 7 month-38 years) and 65 (40%) were females. Symptoms included fever (70%) and bilateral swelling in neck (65%). None of them were vaccinated against mumps. Most (84%) cases were school-going children (3–16 years old). The overall attack rate was 2%. Village A, with two hamlets, had the highest attack rate (hamlet 1 = 13% and hamlet 2 = 12%). School A of village A, hamlet 1, which accommodated 200 children in two classrooms, had an attack rate of 55%. Of 18 blood samples from cases, 11 tested positive for mumps IgM ELISA. This was a confirmed mumps outbreak in Jaisalmer block that disproportionately affected school-going children. We recommended continued surveillance, 5-day absence from school, and vaccination.

ObjectivesTorrential rainfall and flooding from September 2-6, 2014 submerged >350 villages in Jammu and Kashmir state. We conducted rapid needs assessment in capital Srinagar from 27 September to 1 October to assess population health and safety needs.MethodsBased on Community Assessment for Public Health Emergency Response (CASPER) methodology, we selected 7 households each from 30 census blocks using 2-stage cluster sampling. We collected information on demographics, needs, and illnesses using structured questionnaire.ResultsOf the 210 households surveyed, an estimated 57% (CI: 41%-73%) reported significant damage, 50% (CI: 36%-63%) were evacuated, and 16% (CI: 10%-22%) reported injuries. Households lacked electricity (22%; CI: 8.8%-36%), tap water (13%; CI: 5%-21%), working toilets (11%; CI: 4%-19%), and adequate food supply (14%; CI: 8%-20%). Moreover, 55% (CI: 45%-64%) of households reported cough, cold, fever, rashes, or diarrhea; 68% (CI: 59%-77%) experienced agitation, anxiety, depression, or nightmares since the flooding. Of the households with a member on medicines for non-communicable diseases, 40% did not have a week’s supply. Restoring basic essentials (30%; CI: 22%-37%) and repairing houses (30%; CI: 19%-40%) were the most urgent needs expressed.ConclusionsFloods damaged >1/2 of households in Srinagar, disrupting basic essentials, and causing mental trauma. These findings helped authorities prioritize assistance with psychological symptoms and availability of prescription medicines. (Disaster Med Public Health Preparedness. 2019;13:133–137)

SUMMARYWe compared the impact of a commercial chlorination product (brand name Air RahMat) in stored drinking water to traditional boiling practices in Indonesia. We conducted a baseline survey of all households with children Escherichia coli concentration in stored water, and determined diarrhoea prevalence among children E. coli in stored water treated with Air RahMat than boiling (risk ratio (RR) 0·75, 95% confidence interval (CI) 0·56–1·00). The risk of diarrhoea in children E. coli concentrations of 1–1000 MPN/100 ml (RR 1·54, 95% CI 1·04–2·28) or >1000 MPN/100 ml (RR 1·86, 95% CI 1·09–3·19) in stored water than in households without detectable E. coli. Although results suggested that Air RahMat water treatment was associated with lower E. coli contamination and diarrhoeal rates among children

During September to October, 2006, state and local health departments and the Centers for Disease Control and Prevention investigated a large, multistate outbreak of Escherichia coli O157:H7 infections. Case patients were interviewed regarding specific foods consumed and other possible exposures. E. coli O157:H7 strains isolated from human and food specimens were subtyped using pulsed-field gel electrophoresis and multiple-locus variable-number tandem repeat analyses (MLVA). Two hundred twenty-five cases (191 confirmed and 34 probable) were identified in 27 states; 116 (56%) case patients were hospitalized, 39 (19%) developed hemolytic uremic syndrome, and 5 (2%) died. Among 176 case patients from whom E. coli O157:H7 with the outbreak genotype (MLVA outbreak strain) was isolated and who provided details regarding spinach exposure, 161 (91%) reported fresh spinach consumption during the 10 days before illness began. Among 116 patients who provided spinach brand information, 106 (91%) consumed bagged brand A. E. coli O157:H7 strains were isolated from 13 bags of brand A spinach collected from patients' homes; isolates from 12 bags had the same MLVA pattern. Comprehensive epidemiologic and laboratory investigations associated this large multistate outbreak of E. coli O157:H7 infections with consumption of fresh bagged spinach. MLVA, as a supplement to pulsed-field gel electrophoresis genotyping of case patient isolates, was important to discern outbreak-related cases. This outbreak resulted in enhanced federal and industry guidance to improve the safety of leafy green vegetables and launched an independent collaborative approach to produce safety research in 2007.

SUMMARYUS public health laboratories began reportingEscherichia coliO157 isolates to CDC in 1996. We describe temporal and geographical patterns of isolates reported from 1996 to 2011 and demographics of persons whose specimens yielded isolates. We calculated annualE. coliO157 isolation rates/100 000 persons by patient's state of residence, county of residence, age, and sex using census data. The average annual isolation rate was 0·84. The average isolation rate in northern states (1·52) was higher than in southern states (0·43). Counties with ⩾76% rural population had a lower isolation rate (0·67) than counties with ⩽25%, 26–50%, and 51–75% rural populations (0·81, 0·92, and 0·81, respectively). The highest isolation rate (3·19) was in children aged 1–4 years. Infections were seasonal with 49% of isolates collected during July to September. Research into reasons for higher incidence in northern states and for seasonality could guide strategies to prevent illnesses.

OBJECTIVE: Although amphibians are known Salmonella carriers, no such outbreaks have been reported. We investigated a nationwide outbreak of human Salmonella Typhimurium infections occurring predominantly among children from 2008 to 2011. METHODS: We conducted a matched case-control study. Cases were defined as persons with Salmonella Typhimurium infection yielding an isolate indistinguishable from the outbreak strain. Controls were persons with recent infection with Salmonella strains other than the outbreak strain and matched to cases by age and geography. Environmental samples were obtained from patients’ homes; traceback investigations were conducted. RESULTS: We identified 376 cases from 44 states from January 1, 2008, to December 31, 2011; 29% (56/193) of patients were hospitalized and none died. Median patient age was 5 years (range CONCLUSIONS: ADFs were the source of this nationwide pediatric predominant outbreak. Pediatricians should routinely inquire about pet ownership and advise families about illness risks associated with animals.

SUMMARYIn November 2009, we initiated a multistate investigation of Salmonella Montevideo infections with pulsed-field gel electrophoresis pattern JIXX01.0011. We identified 272 cases in 44 states with illness onset dates ranging from 1 July 2009 to 14 April 2010. To help generate hypotheses, warehouse store membership card information was collected to identify products consumed by cases. These records identified 19 ill persons who purchased company A salami products before onset of illness. A case-control study was conducted. Ready-to-eat salami consumption was significantly associated with illness (matched odds ratio 8·5, 95% confidence interval 2·1–75·9). The outbreak strain was isolated from company A salami products from an environmental sample from one manufacturing plant, and sealed containers of black and red pepper at the facility. This outbreak illustrates the importance of using membership card information to assist in identifying suspect vehicles, the potential for spices to contaminate ready-to-eat products, and preventing raw ingredient contamination of these products.

Background Salmonella enterica serovar Typhi (Salmonella Typhi) causes an estimated 22 million typhoid fever cases and 216 000 deaths annually worldwide. In Africa, the lack of laboratory diagnostic capacity limits the ability to recognize endemic typhoid fever and to detect outbreaks. We report a large laboratory-confirmed outbreak of typhoid fever in Uganda with a high proportion of intestinal perforations (IPs). Methods A suspected case of typhoid fever was defined as fever and abdominal pain in a person with either vomiting, diarrhea, constipation, headache, weakness, arthralgia, poor response to antimalarial medications, or IP. From March 4, 2009 to April 17, 2009, specimens for blood and stool cultures and serology were collected from suspected cases. Antimicrobial susceptibility testing and pulsed-field gel electrophoresis (PFGE) were performed on Salmonella Typhi isolates. Surgical specimens from patients with IP were examined. A community survey was conducted to characterize the extent of the outbreak. Results From December 27, 2007 to July 30, 2009, 577 cases, 289 hospitalizations, 249 IPs, and 47 deaths from typhoid fever occurred; Salmonella Typhi was isolated from 27 (33%) of 81 patients. Isolates demonstrated multiple PFGE patterns and uniform susceptibility to ciprofloxacin. Surgical specimens from 30 patients were consistent with typhoid fever. Estimated typhoid fever incidence in the community survey was 8092 cases per 100 000 persons. Conclusions This typhoid fever outbreak was detected because of an elevated number of IPs. Underreporting of milder illnesses and delayed and inadequate antimicrobial treatment contributed to the high perforation rate. Enhancing laboratory capacity for detection is critical to improving typhoid fever control.

Raw produce is an increasingly recognized vehicle for salmonellosis. We investigated a nationwide outbreak that occurred in the United States in 2008.We defined a case as diarrhea in a person with laboratory-confirmed infection with the outbreak strain of Salmonella enterica serotype Saintpaul. Epidemiologic, traceback, and environmental studies were conducted.Among the 1500 case subjects, 21% were hospitalized, and 2 died. In three case-control studies of cases not linked to restaurant clusters, illness was significantly associated with eating raw tomatoes (matched odds ratio, 5.6; 95% confidence interval [CI], 1.6 to 30.3); eating at a Mexican-style restaurant (matched odds ratio, 4.6; 95% CI, 2.1 to ∞) and eating pico de gallo salsa (matched odds ratio, 4.0; 95% CI, 1.5 to 17.8), corn tortillas (matched odds ratio, 2.3; 95% CI, 1.2 to 5.0), or salsa (matched odds ratio, 2.1; 95% CI, 1.1 to 3.9); and having a raw jalapeño pepper in the household (matched odds ratio, 2.9; 95% CI, 1.2 to 7.6). In nine analyses of clusters associated with restaurants or events, jalapeño peppers were implicated in all three clusters with implicated ingredients, and jalapeño or serrano peppers were an ingredient in an implicated item in the other three clusters. Raw tomatoes were an ingredient in an implicated item in three clusters. The outbreak strain was identified in jalapeño peppers collected in Texas and in agricultural water and serrano peppers on a Mexican farm. Tomato tracebacks did not converge on a source.Although an epidemiologic association with raw tomatoes was identified early in this investigation, subsequent epidemiologic and microbiologic evidence implicated jalapeño and serrano peppers. This outbreak highlights the importance of preventing raw-produce contamination.

We report shedding duration of 2009 pandemic influenza A (pH1N1) virus from a school-associated outbreak in Pennsylvania during May through June 2009. Outbreak-associated students or household contacts with influenza-like illness (ILI) onset within 7 days of interview were recruited. Nasopharyngeal specimens, collected every 48 hours until 2 consecutive nonpositive tests, underwent real-time reverse transcriptase polymerase chain reaction (rRT-PCR) and culture for pH1N1 virus. Culture-positive specimens underwent virus titrations. Twenty-six (median age, 8 years) rRT-PCR-positive persons, for pH1N1 virus, were included in analysis. Median shedding duration from fever onset by rRT-PCR was 6 days (range, 1-13) and 5 days (range, 1-7) by culture. Following fever resolution virus was isolated for a median of 2 days (range, 0-5). Highest and lowest virus titers detected, 2 and 5 days following fever onset, were 3.2 and 1.2 log(10) TCID(50)/mL respectively. Overall, shedding duration in children and adults were similar to seasonal influenza viruses.

Much research into food-borne human pathogens has focused on transmission from foods of animal origin. However, recent investigations have identified fruits and vegetables are the source of many disease outbreaks. Now believed to be a much larger contributor to produce-associated outbreaks than previously reported, norovirus outbreaks are commonly caused by contamination of foods from hands of infected workers. Although infections with Shiga toxin-producing E. coli O157 have been linked to beef more often than to any other food product, severe outbreaks have been traced to consumption of contaminated radish sprouts and pre-packaged spinach. Similarly, while infections with Salmonella have mainly been linked to consumption of foods of animal origin, many outbreaks have been traced to contaminated fresh produce. E. coli O157 binds to lettuce leaves by alternative mechanisms involving the filamentous type III secretions system, flagella and the pilus curli. Association of Salmonella with fresh produce appears to be serovar-specific involving flagella, curli, cellulose, and O antigen capsule. A better understanding of plant, microbiological, environmental, processing and food handling factors that facilitate contamination will allow development of evidence-based policies, procedures and technologies aimed at reducing the risk of contamination of fresh produce.

Background Vaccination Week in the Americas (VWA) is an annual initiative in countries and territories of the Americas every April to highlight the work of national expanded programs on immunization (EPI) and increase access to vaccination services for high-risk population groups. In 2011, as part of VWA, Venezuela targeted children aged less than 6 years in 25 priority border municipalities using social mobilization to increase institution-based vaccination. Implementation of social communication activities was decentralized to the local level. We conducted a survey in one border municipality of Venezuela to evaluate the outcome of VWA 2011 and provide a snapshot of the overall performance of the routine EPI at that level. Methods We conducted a coverage survey, using stratified cluster sampling, in the Venezuelan municipality of Bolivar (bordering Colombia) in August 2011. We collected information for children aged 85%, with a few exceptions. Conclusion Low levels of VWA awareness among caregivers probably contributed to the limited vaccination of eligible children during the VWA activities in Bolivar in 2011. However, vaccine coverage for most EPI vaccines was high. Additionally, high vaccination card availability and high participation in VWA among those caregivers aware of it in 2011 suggest public trust in the EPI program in the municipality. Health authorities have used survey findings to inform changes to the routine EPI and better VWA implementation in subsequent years.

Indigenous wild poliovirus has been eliminated in 98% of endemic countries since 1988, with a decrease from 350 000 cases in 1988 to 223 confirmed cases in 2012 [1]. The success of polio eradication efforts has been dependent on increasing population immunity through routine immunization and supplementary immunization activities and by improving surveillance for acute flaccid paralysis (AFP). AFP surveillance systems are expected to annually identify ≥2 nonpolio AFP (NPAFP) cases per 100 000 population under 15 years of age to demonstrate that their systems are sensitive enough to detect paralytic polio cases [2]. All countries within the Horn of Africa region have successfully eliminated endemic poliovirus circulation, with Kenya successfully presenting in 2005 their complete country documentation outlining polio-free status. However, the region has remained at high risk for reintroduction and has had multiple outbreaks in recent years. An outbreak of 19 cases of wild poliovirus occurred in Turkana, Kenya, in 2009, and was followed by an outbreak of 22 cases in Uganda in 2010. In 2011, another wild poliovirus case was detected in western Kenya and was found to be genetically related to the 2010 outbreak in Uganda. These outbreaks indicated missed circulation within the region over a 3-year period. As of 31 December, 203 confirmed cases of WPV had been confirmed in the Horn of Africa in 2013. All of these outbreaks underscore the regional struggle to achieve the surveillance sensitivity and population immunity necessary to prevent transmission of imported poliovirus. In the midst of these outbreaks, the health system in Kenya has been decentralized, with both increased administrative autonomy at the district level and an increase in number of districts. Following a risk analysis performed in January 2012, which showed that 121 of 159 (77%) of districts in Kenya were at high or medium risk for a polio outbreak, the Kenya Ministry of Public Health and Sanitation (MoPHS) engaged the US Centers for Disease Control and Prevention (CDC), World Health Organization (WHO), United Nations Children’s Fund (UNICEF), and other international partners to assist in a review of the national surveillance and routine immunization systems. The purpose of the review was to identify gaps in the programs, as well as to provide recommendations toward improving detection of imported poliovirus and preventing poliovirus circulation during this period of health system decentralization [3].

In Indonesia, where diarrhea remains a major cause of mortality among children

In May 2009, one of the earliest outbreaks of 2009 pandemic influenza A virus (pH1N1) infection resulted in the closure of a semi-rural Pennsylvania elementary school. Two sequential telephone surveys were administered to 1345 students (85% of the students enrolled in the school) and household members in 313 households to collect data on influenza-like illness (ILI). A total of 167 persons (12.4%) among those in the surveyed households, including 93 (24.0%) of the School A students, reported ILI. Students were 3.1 times more likely than were other household members to develop ILI (95% confidence interval [CI], 2.3-4.1). Fourth-grade students were more likely to be affected than were students in other grades (relative risk, 2.2; 95% CI, 1.2-3.9). pH1N1 was confirmed in 26 (72.2%) of the individuals tested by real-time reverse-transcriptase polymerase chain reaction. The outbreak did not resume upon the reopening of the school after the 7-day closure. This investigation found that pH1N1 outbreaks at schools can have substantial attack rates; however, grades and classrooms are affected variably. Additional study is warranted to determine the effectiveness of school closure during outbreaks.

Much research into food-borne human pathogens has focused on transmission from foods of animal origin. However, recent investigations have identified fruits and vegetables are the source of many disease outbreaks. Now believed to be a much larger contributor to produce-associated outbreaks than previously reported, norovirus outbreaks are commonly caused by contamination of foods from hands of infected workers. Although infections with Shiga toxin-producing E. coli O157 have been linked to beef more often than to any other food product, severe outbreaks have been traced to consumption of contaminated radish sprouts and pre-packaged spinach. Similarly, while infections with Salmonella have mainly been linked to consumption of foods of animal origin, many outbreaks have been traced to contaminated fresh produce. E. coli O157 binds to lettuce leaves by alternative mechanisms involving the filamentous type III secretions system, flagella and the pilus curli. Association of Salmonella with fresh produce appears to be serovar-specific involving flagella, curli, cellulose, and O antigen capsule. A better understanding of plant, microbiological, environmental, processing and food handling factors that facilitate contamination will allow development of evidence-based policies, procedures and technologies aimed at reducing the risk of contamination of fresh produce.

SUMMARYA multistate outbreak ofEscherichia coliO157:H7 infections occurred in the USA in November–December 2006 in patrons of restaurant chain A. We identified 77 cases with chain A exposure in four states – Delaware, New Jersey, New York, and Pennsylvania. Fifty-one (66%) patients were hospitalized, and seven (9%) developed haemolytic uraemic syndrome; none died. In a matched analysis controlling for age in 31 cases and 55 controls, illness was associated with consumption of shredded iceberg lettuce [matched odds ratio (mOR) 8·0, 95% confidence interval (CI) 1·1–348·1] and shredded cheddar cheese (mOR 6·2, CI 1·7–33·7). Lettuce, an uncooked ingredient, was more commonly consumed (97% of patients) than cheddar cheese (84%) and a single source supplied all affected restaurants. A single source of cheese could not explain the regional distribution of outbreak cases. The outbreak highlights challenges in conducting rapid multistate investigations and the importance of incorporating epidemiological study results with other investigative findings.

Background: Globally, injuries accounts for 9% of all deaths, but India account for 11%. Due to limited data on injury characteristics, National Injury Surveillance Centre (NISC) was established in 2014 in New Delhi. Aim & Objectives: To evaluate attributes of NISC and make evidence-based recommendations. Methods and Material: We conducted cross-sectional study and used US Centers for Disease Control and Prevention guidelines to assess simplicity, flexibility, acceptability, stability, timeliness, representativeness, usefulness, and data quality. We reviewed 2015 records and interviewed 20 key-informants. We used Epi-Info7 for analysis. Results: NISC captured 4043 injuries in 2015 from one hospital. Among five data entry operators, four reported lengthy format, but all reported it easy. Among ten relevant key-informants, all reported data-management software easy. System demonstrated flexibility in three variables. All 20 staff reported willingness to participate, and 90% felt quarterly reporting acceptable. Regarding stability, data was collected for 361/365 days. Quarterly reports were available but only submitted annually. Regarding usefulness, all WHO-recommended variables included. Regarding data quality, 17% data-fields were missing. Conclusion: NISC is simple, flexible, stable, acceptable and potentially useful based on data captured. Timeliness based on annual reporting is high, can be improved to quarterly. We recommend training to improve data quality and integration of additional hospitals to improve representativeness.