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Vaccination of healthcare workers against influenza is a crucial strategy to reduce transmission amongst vulnerable populations, facilitate patient uptake of vaccination, and bolster pandemic preparedness. Globally, vaccination coverage of health workers varied from 10 % to 88 %. Understanding health workers' knowledge and acceptance of the influenza vaccine, particularly among physicians, is crucial for the fine-tuning and continued success of influenza vaccination campaigns. We conducted a cross-sectional survey of 472 health workers in Abidjan, Côte d'Ivoire, to inform subsequent subnational and national introductions of influenza vaccine and subsequent campaigns targeting health workers in 2019 (14302), 2020 (14872), and 2021 (24473). Using a purposive sample of university hospitals, general hospitals, rural, and urban health facilities, we interviewed a convenience sample of health workers aged 18 years and older. Physicians had the lowest intention to receive the influenza vaccine (58 %), while nurses (78 %) and midwives (76 %) were the most willing. Across all occupations, intention to receive vaccination increased if the vaccine was offered for free or if recommended by the Ministry of Health. 76 % of respondents believed that the influenza vaccine could prevent illness in health workers. Communication strategies, including about the benefits of influenza vaccination, could raise awareness and acceptance among health workers prior to vaccination campaigns. Influenza vaccination coverage rates between 2019 and 2021 were on par with rates of intention to receive vaccination in the 2018 survey; in 2019, 2020, and 2021, coverage among physicians was 73 %, 73 %, and 52 % and coverage among nurses and midwives was 86 %, 86 %, and 74 % respectively. Improving health workers' knowledge and acceptance of the influenza vaccine, particularly among physicians, is crucial for the continued success of influenza vaccination campaigns., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Daouda Coulibaly reports financial support was provided by The Task Force for Global Health. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Alfred Douba reports financial support was provided by The Task Force for Global Health. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Rotavirus group A (RVA) is the most common cause of severe childhood diarrhea worldwide. The introduction of rotavirus vaccination programs has contributed to a reduction in hospitalizations and mortality caused by RVA. From 2016 to 2021, we conducted surveillance to monitor RVA prevalence and genotype distribution in Nam Dinh and Thua Thien Hue (TT Hue) provinces where a pilot Rotavin-M1 vaccine (Vietnam) implementation took place from 2017 to 2020. Out of 6626 stool samples, RVA was detected in 2164 (32.6%) by ELISA. RT-PCR using type-specific primers were used to determine the G and P genotypes of RVA-positive specimens. Whole genome sequences of a subset of 52 specimens randomly selected from 2016 to 2021 were mapped using next-generation sequencing. From 2016 to 2021, the G9, G3 and G8 strains dominated, with detected frequencies of 39%, 23%, and 19%, respectively; of which, the most common genotypes identified were G9P[8], G3P[8] and G8P[8]. G1 strains re-emerged in Nam Dinh and TT Hue (29.5% and 11.9%, respectively) from 2020 to 2021. G3 prevalence decreased from 74% to 20% in TT Hue and from 21% to 13% in Nam Dinh province between 2017 and 2021. The G3 strains consisted of 52% human typical G3 (hG3) and 47% equine-like G3 (eG3). Full genome analysis showed substantial diversity among the circulating G3 strains with different backgrounds relating to equine and feline viruses. G9 prevalence decreased sharply from 2016 to 2021 in both provinces. G8 strains peaked during 2019-2020 in Nam Dinh and TT Hue provinces (68% and 46%, respectively). Most G8 and G9 strains had no genetic differences over the surveillance period with very high nucleotide similarities of 99.2-99.9% and 99.1-99.7%, respectively. The G1 strains were not derived from the RVA vaccine. Changes in the genotype distribution and substantial diversity among circulating strains were detected throughout the surveillance period and differed between the two provinces. Determining vaccine effectiveness against circulating strains over time will be important to ensure that observed changes are due to natural secular variation and not from vaccine pressure., Competing Interests: Declaration of competing interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention – USA. Trang Nguyen reports financial support for this project was provided byBill & Melinda Gates Foundation - USA. If there are other authors, they declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024. Published by Elsevier B.V.)

Bhutan successfully introduced multiple vaccines since the establishment of the Vaccine Preventable Disease Program in 1979. Surveillance and subsequent introduction of influenza vaccination became a public health priority for the Ministry of Health following the influenza A(H1N1)pdm09 pandemic. Sentinel surveillance for influenza in Bhutan began in 2008, and a study of severe acute respiratory infection was conducted in 2017, which found the highest influenza burden in children aged <5 years and adults ≥50 years. Following review of surveillance and burden of disease data, the National Technical Advisory Group presented recommendations to Bhutan's Ministry of Health which approved influenza vaccine introduction for all five high-risk groups in the country. Upon the official launch of the program in June 2018, the Vaccine Preventable Disease Program began planning, budgeting, and procurement processes with technical and financial support from the Partnership for Influenza Vaccine Introduction, the United States Centers for Disease Control and Prevention, the Bhutan Health Trust Fund, and the World Health Organization. Influenza vaccination for high-risk groups was integrated into Bhutan's routine immunization services in all health care facilities beginning in November 2019 and vaccinated all populations in 2020 in response to the COVID-19 pandemic. Coverage levels between 2019 and 2022 were highest in children aged 6-24 months (62.5%-96.9%) and lowest in pregnant women (47.7%-62.5%). Bhutan maintained high coverage levels despite the COVID-19 pandemic by continued provision of influenza vaccine services at health centers during lockdowns, conducting communication and sensitization efforts, and using catch-up campaigns. Bhutan's experience with introducing and scaling up the influenza vaccine program contributed to the country's capacity to rapidly deploy its COVID-19 vaccination program in 2021., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Introduction: The World Health Organization's Global Strategy on Human Resources for Health: Workforce 2030 sets policy recommendations and targets for in-service and pre-service training programs to improve workforce competency. To date, comprehensive reviews on immunization training have mainly focused on in-service trainings. This systematic review aimed to synthesize current literature on pre-service immunization training, including primary immunization competencies covered, methods used, outcomes on improving competencies and behavior change for immunization service delivery, and student readiness for immunization practice, in both low-resource and high-income settings., Methods: A systematic search of seven scholarly databases identified published literature on pre-service training on immunization published between January 2001 and November 2021. It included all geographic regions and languages, study designs, and individuals preparing to enter the immunization workforce. Additional search methods included reviewing references of retrieved articles, scanning journals, and engaging pre-service training experts for unpublished reports., Results: Search results yielded 5,611 articles; 39 articles met the inclusion criteria. Five articles were identified through other search methods. Studies took place mostly in high-income countries (35/44), targeted professional (medical, nursing, and pharmacy) students and tutors at health training institutions. Eight of the ten recommended immunization competencies were included in the curricula and methods used to deliver pre-service training varied. Teaching techniques and applied learning strategies using realistic situations increased students' knowledge, attitudes, and awareness of vaccine benefits; built confidence to administer vaccines and communicate with hesitant patients; and increased the likelihood of recommending vaccines., Conclusion: This review was the first step to understanding pre-service training on immunization. Further research is needed to inform pre-service training programs in low- and middle-income countries, particularly for nurses, vaccinators with low-level educational backgrounds, and other healthcare professional students. Prioritizing essential audiences, designing and delivering practical training, and evaluating results will help prepare students for the immunization challenges of tomorrow., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Published by Elsevier Ltd.)

Background: Controlled infection studies in malaria-naive adults suggest increased vaccine efficacy for fractional-dose versus full-dose regimens of RTS,S/AS01. We report first results of an ongoing trial assessing different fractional-dose regimens in children, in natural exposure settings., Methods: This open-label, phase 2b, randomised controlled trial is conducted at the Malaria Research Center, Agogo, Ashanti Region (Ghana), and the Kenya Medical Research Institute and the US Centers for Disease Control and Prevention site in Siaya County (Kenya). We enrolled children aged 5-17 months without serious acute or chronic illness who had previously received three doses of diphtheria, tetanus, pertussis, and hepatitis B vaccine and at least three doses of oral polio vaccine. Children were randomly assigned (1:1:1:1:1) using a web-based randomisation system with a minimisation procedure accounting for centre to receive rabies control vaccine (M012 schedule) or two full doses of RTS,S/AS01 E at month 0 and month 1, followed by either full doses at months 2 and 20 (group R012-20 [standard regimen]), full doses at months 2, 14, 26, and 38 (R012-14), fractional doses at months 2, 14, 26, and 38 (Fx012-14), or fractional doses at months 7, 20, and 32 (Fx017-20). The fractional doses were administered as one fifth (0·1 mL) of the full RTS,S dose (0·5 mL) after reconstitution. All vaccines were administered by intramuscular injection in the left deltoid. The primary outcome was occurrence of clinical malaria cases from month 2·5 until month 14 for the Fx012-14 group versus the pooled R012-14 and R012-20 groups in the per-protocol set. We assessed incremental vaccine efficacy of the Fx012-14 group versus the pooled R012-14 and R012-20 group over 12 months after dose three. Safety was assessed in all children who received at least one vaccine dose. This trial is registered with ClinicalTrials.gov, NCT03276962., Findings: Between Sept 28, 2017, and Sept 25, 2018, 2157 children were enrolled, of whom 1609 were randomly assigned to a treatment group (322 to each RTS,S/AS01 E group and 321 to the rabies vaccine control group). 1500 children received at least one study vaccine dose and the per-protocol set comprised 1332 children. Over 12 months after dose three, the incremental vaccine efficacy in the Fx012-14 group versus the pooled R012-14 and R12-20 groups was -21% (95% CI -57 to 7; p=0·15). Up to month 21, serious adverse events occurred in 48 (16%) of 298 children in the R012-20 group, 45 (15%) of 294 in the R012-14 group, 47 (15%) of 304 in the Fx012-14 group, 62 (20%) of 311 in the Fx017-20 group, and 71 (24%) of 293 in the control group, with no safety signals observed., Interpretation: The Fx012-14 regimen was not superior to the standard regimen over 12 months after dose three. All RTS,S/AS01 E regimens provided substantial, similar protection against clinical malaria, suggesting potential flexibility in the recommended dosing regimen and schedule. This, and the effect of annual boosters, will be further evaluated through 50 months of follow-up., Funding: GlaxoSmithKline Biologicals; PATH's Malaria Vaccine Initiative., Competing Interests: Declaration of interests The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the US Centers for Disease Control and Prevention. OO-A, LS, ML, DM, ABo, FR, and EJ are employees of the GSK group of companies. OO-A, LS, DM, FR, and EJ have restricted shares in the GSK group of companies. All other authors declare no competing interests., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Background: Cervical cancer is a leading cause of cancer-associated mortality among women in India, with 96,922 new cases and 60,078 deaths each year, almost one-fifth of the global burden. In 2018, Sikkim state in India introduced human papillomavirus (HPV) vaccine for 9-13-year-old girls, primarily through school-based vaccination, targeting approximately 25,000 girls. We documented the program's decision-making and implementation processes., Methods: We conducted a post-introduction evaluation in 2019, concurrent with the second dose campaign, by interviewing key stakeholders (state, district, and local level), reviewing planning documents, and observing cold chain sites in two purposefully-sampled community areas in each of the four districts of Sikkim. Using standard questionnaires, we interviewed health and education officials, school personnel, health workers, community leaders, and age-eligible girls on program decision-making, planning, training, vaccine delivery, logistics, and communication., Results: We conducted 279 interviews and 29 observations in eight community areas across four districts of Sikkim. Based on reported administrative data, Sikkim achieved >95% HPV vaccination coverage among targeted girls for both doses via two campaigns; no severe adverse events were reported. HPV vaccination was well accepted by all stakeholders; minimal refusal was reported. Factors identified for successful vaccine introduction included strong political commitment, statewide mandatory school enrollment, collaboration between health and education departments at all levels, and robust social mobilization strategies., Conclusions: Sikkim successfully introduced the HPV vaccine to multiple-age cohorts of girls via school-based vaccination, demonstrating a model that could be replicated in other regions in India or similar low- and middle-income country settings., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021. Published by Elsevier Ltd.)

Background: Outbreaks of circulating vaccine-derived polioviruses (cVDPVs) pose a threat to the eventual eradication of all polioviruses. In 2017, an outbreak of cVDPV type 2 (cVDPV2) occurred in the midst of a war in Syria. We describe vaccination-based risk factors for and the successful response to the outbreak., Methods: We performed a descriptive analysis of cVDPV2 cases and key indicators of poliovirus surveillance and vaccination activities during 2016-2018. In the absence of reliable subnational coverage data, we used the caregiver-reported vaccination status of children with non-polio acute flaccid paralysis (AFP) as a proxy for vaccination coverage. We then estimated the relative odds of being unvaccinated against polio, comparing children in areas affected by the outbreak to children in other parts of Syria in order to establish the presence of poliovirus immunity gaps in outbreak affected areas., Findings: A total of 74 cVDPV2 cases were reported, with paralysis onset ranging from 3 March to 21 September 2017. All but three cases were reported from Deir-ez-Zor governorate and 84% had received < 3 doses of oral poliovirus vaccine (OPV). After adjusting for age and sex, non-polio AFP case-patients aged 6-59 months in outbreak-affected areas had 2.5 (95% CI: 1.1-5.7) increased odds of being unvaccinated with OPV compared with non-polio AFP case-patients in the same age group in other parts of Syria. Three outbreak response rounds of monovalent OPV type 2 (mOPV2) vaccination were conducted, with governorate-level coverage mostly exceeding 80%., Interpretation: Significant declines in both national and subnational polio vaccination coverage, precipitated by war and a humanitarian crisis, led to a cVDPV2 outbreak in Syria that was successfully contained following three rounds of mOPV2 vaccination., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Published by Elsevier Ltd.)

Background: Japanese encephalitis (JE) virus is an important cause of neurological disease in Asia. JE vaccine is recommended for travelers with higher JE risk itineraries. Inactivated Vero cell culture-derived JE vaccine (JE-VC) is the only JE vaccine currently available in the United States. An inactivated mouse brain-derived JE vaccine (JE-MB) previously was available but production was discontinued. One JE-VC dose administered to adults previously vaccinated with ≥3 doses of JE-MB provides good short-term protection for at least one month, but data on longer-term protection are limited. We evaluated non-inferiority of the JE virus neutralizing antibody response at 12-23 months in JE-MB-vaccinated adults administered one JE-VC dose compared with JE vaccine-naïve adults administered a JE-VC two-dose primary series., Methods: We obtained archived sera from U.S. military personnel and performed a 50% plaque reduction neutralization test for anti-JE virus neutralizing antibodies. We compared the geometric mean titer (GMT) and seroprotection rate at 12-23 months after one JE-VC dose in previously JE-MB-vaccinated personnel and after the second JE-VC dose in previously JE vaccine-naïve personnel. Non-inferiority was concluded if the lower bound of the two-sided 95% confidence interval (CI) of the GMT ratio in previously vaccinated to vaccine-naïve personnel was >1/1.5., Results: The GMT in previously JE-MB-vaccinated persons was 75 (95% CI 63-90) and in previously JE vaccine-naïve persons was 12 (95% CI 11-14), and seroprotection rates were 94% (235/250) and 54% (135/250), respectively. The ratio of GMTs was 6.3 (95% CI: 5.0-7.7), satisfying the criterion for non-inferiority., Conclusions: One JE-VC dose in previously JE-MB-vaccinated military personnel provides good protection for at least 1-2 years. The benefits of administration of a single JE-VC dose in previously JE-MB-vaccinated adults include a shorter time to completion of re-vaccination before travel, a decrease in the risk of adverse events, and reduced costs., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Published by Elsevier Ltd.)

Background: Sixty cases of rabies in international travellers from 1990 to 2012 were previously reviewed. We present here an update of rabies cases in international travellers from 2013 to 2019., Methods: We systematically reviewed the existing literature and collected 23 cases of rabies in individuals who crossed an international border between the time of infection and diagnosis, or who were infected following expatriation or migration., Results: Most cases were in male adult travellers and diagnosed in Europe and the Middle East, with most exposures in Asia or in Africa. Migrants originating from rabies-endemic low-and-middle income countries and their descendants accounted for two thirds of cases. Other cases were in tourists, business travellers and expatriates. Median travel duration (excluding migration trip) was 60 days (range 7-240 days). Most cases were due to dog bites and most common clinical presentation was furious rabies. In most patients (74%), no rabies post-exposure prophylaxis (RPEP) was administered before rabies symptoms appeared. Other patients received incomplete RPEP series., Conclusion: Rabies should be suspected in any patient with encephalitis or paralysis who travelled to, or migrated from a rabies-endemic country. Comprehensive information about a rabies risk should be given to travellers to rabies endemic countries, notably migrants visiting friends and relatives., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: Data on congenital cytomegalovirus (CMV) infection in Africa are limited., Objective: To describe the prevalence of congenital CMV infection in a population with high prevalence of maternal HIV and malaria infection in western Kenya., Study Design: We screened newborns for CMV by polymerase chain reaction assay of saliva swabs and dried blood spots (DBS), and assessed maternal CMV immunoglobulin G (IgG) status by testing serum eluted from newborn's DBS. We calculated adjusted prevalence ratios (aPRs) using log-binomial regression models., Results: Among 1066 mothers, 210 (19·7%) had HIV infection and 207 (19·4%) had malaria infection; 33 (3·1%) mothers had both. Maternal CMV IgG prevalence was 93·1% (95% confidence interval [CI]: 88·3%-96·0%). Among 1078 newborns (12 sets of twins), 39 (3·6%, 95% CI: 2·7-4·9%) were CMV positive. The prevalence of congenital CMV infection by maternal HIV and malaria infection status was 5·0% (95% CI: 2·7-9·2%) for HIV only, 5·1% (95% CI: 2·7-9·4%) for malaria only, 8·8 (95% CI: 3·1-23·0) for HIV and malaria co-infection, and 2·6% (95% CI: 1·7-4·1%) for none. Congenital CMV infection was independently associated with maternal HIV infection (aPR=2·1; 95% CI: 1·0-4·2), adjusting for maternal age, parity, and malaria infection., Conclusions: The prevalence of congenital CMV infection was higher than the 0·2-0·7% in developed countries. Maternal HIV infection may increase the risk of congenital CMV infection, but the role of maternal malaria on intrauterine transmission of CMV remains unclear., (Published by Elsevier B.V.)

Introduction: Limited evidence is available about the effectiveness of strategies to remind caregivers when to bring children back for future vaccinations in low- and middle-income country settings. We evaluated the effectiveness of two reminder strategies based on home-based vaccination records (HBR) in Indonesia., Methods: In this cluster-randomized controlled trial involving 3616 children <1 year of age, 90 health facilities were randomly assigned to either a control group or one of two intervention groups: (1) HBR-only group, where healthcare workers provided an HBR to any child without an HBR during a vaccination visit and instructed the caregiver to keep it at home between visits, or (2) HBR + sticker group, where, in addition to HBR provision, healthcare workers placed vaccination appointment reminder stickers on the HBR. The primary outcome was receipt of the third dose of diphtheria-tetanus-pertussis-containing vaccine (DTPcv3) within 7 months and the secondary outcome was receipt of a timely DTPcv3 dose., Results: Control group DTPcv3 coverage was 81%. In intention-to-treat analysis, neither intervention group had significantly different DTPcv3 coverage compared with the control group (RR = 0.94, 95% confidence interval [CI] 0.87; 1.02 for HBR-only group; RR = 0.97, 95% CI 0.90; 1.04 for HBR + sticker group) by study end. However, children in the HBR + sticker group were 50% more likely to have received a DTPcv3 vaccination (RR = 1.46, 95% CI 1.02, 2.09) within 60 days of DTPcv1 vaccination, compared with children in the control group; children in the HBR-only group were not more likely to have done so (RR = 1.05, 95% CI 0.71, 1.55)., Discussion: Reminder stickers had an immediate effect on coverage by improving the proportion of children who received a timely DTPcv3 dose but no effect on the proportion who received DTPcv3 after 7 months. Coupling reminder stickers with strategies to address other reasons why children do not return for vaccination visits should be further explored., (Published by Elsevier Ltd.)

Background: Parents' attitudes and beliefs in vaccination are important to understand for shaping vaccine acceptance and demand interventions. Little research has focused on developing a validated scale to measure parents' attitudes towards vaccinations in low and middle-income countries; Ghana provided an opportunity develop a caregiver vaccination attitudes scale (CVAS) validated against childhood vaccine compliance., Methods: We conducted a cluster survey of 373 households with children aged 12-35 months of age from Northern Region, Ghana. Caregivers responded to 22 vaccination behavior and belief survey items and provided the child's vaccination status. In exploratory factor analysis (EFA) to assess CVAS content validity, we used parallel analysis to guide the number of factors to extract and principal axis factor analysis for factor extraction. Reliability of the scale was assessed using McDonald's Omega coefficient. Criterion validity of scale and subscales was assessed against receipt of vaccinations by 12 months of age and vaccination delay, using number of days undervaccinated., Results: EFA of CVAS responses resulted in removing 11 of 22 survey items due to loadings <0.30 and development of a 5-factor structure with subscales for Vaccine-Preventable Disease (VPD) Awareness, Vaccine Benefits, Past Behavior, Vaccine Efficacy and Safety, and Trust. The 5 factors accounted for 69% of the common variance and omega coefficients were >0.73 for all subscales. Validity analysis indicated that for every unit increase in the parent's scale score, the odds of the child being vaccinated decreased by 0.58 (95% confidence interval [CI]: 0.37, 0.68) and the number of days under-vaccinated increased by 86 (95%CI: 28, 143). The final 3-factor scale included Vaccine Benefits, Past Behavior, and Vaccine Efficacy and Safety., Discussion: The final CVAS included three factors associated with vaccine compliance in Ghana, although several survey items suggested for use in vaccine acceptance scales were dropped. Replicating this study in several country settings will provide additional evidence to assist in refining a tool for use in routine vaccine acceptance and demand surveillance efforts., (Copyright © 2019. Published by Elsevier Ltd.)

Introduction: Hepatitis A can cause widespread outbreaks. Until 2018, postexposure prophylaxis (PEP) in the United States for individuals >40 years consisted of immune globulin (IG) administered as soon as possible after exposure, ideally within 14 days whereas those aged ≤40 should receive hepatitis A (HepA) vaccine. However, state health departments reporting difficulty quickly accessing and administering IG, costs of higher IG doses and importance of long-term HAV protection prompted CDC to review immunogenicity data for use of HepA vaccine for PEP in older adults. We reviewed literature on use of HepA vaccine in adults >40 years and existing recommendations for HepA vaccine for use as PEP in other countries., Methods: We searched PubMed and EMBASE from January 1, 1992-January 7, 2017 using the terms "hepatitis A vaccine∗" and "HAV vaccine∗." Two reviewers read each abstract and articles were preserved if they included results (seroprotection, mean titers) within 28 days of HepA vaccine administration in adults >40 years. Additionally, we reviewed PEP recommendations from six other jurisdictions., Results: A total of 1,039 unique articles were identified, of which eight were retained and two added from references. Three studies included direct comparisons between individuals aged >40 years and those ≤40 years and one other study included three age groups over 40 years, finding lowest immunogenicity in the oldest adults. All found higher proportions seroprotected (definition varied by study) in younger age groups (ages varied by study) at 15 days post-vaccination but similar seroprotection at 30 days. Most other jurisdictions reviewed recommended vaccine alone or in conjunction with IG for PEP in older adults., Conclusions: Immunogenicity of HepA vaccine may be diminished in older adults, especially in the very oldest age groups. HepA vaccine should be administered as soon as possible within 14 days after exposure to achieve the best possible immune response., (Published by Elsevier Ltd.)

Background: This study aims to assess the association between socio-demographic and health characteristics of older adults in Eastern China and knowledge, attitudes, and practices (KAP) about the influenza virus and vaccine., Methods: A prospective cohort of 1506 older adults (aged ≥60 years) was enrolled from November to December 2015 in Jiangsu Province. We examined the association between demographics, health and functional status, and cognitive impairment at enrollment with awareness of influenza virus and vaccine and KAP items focused on five Health Belief Model domains. At a 12-month follow-up interview we assessed change in awareness and readiness to be vaccinated., Results: One in five older adults was aware of the influenza virus (21%) or vaccine (20%); even fewer reported having at least "a little" knowledge of the virus and vaccine (7% and 4%, respectively); less than 1% reported ever receiving an influenza vaccine. Retirement, higher education and income, and normal cognitive status were consistently associated with both awareness and knowledge of influenza virus. The odds of having at least "a little" knowledge of the vaccine was 2.9-fold (95% CI = 1.6-5.3) higher among older adults with at least some secondary schooling. Among the 108 with knowledge of the virus, 55% said they "worry about getting the flu this season." Among the 73 with knowledge of the vaccine, 92% believed the vaccine was at least somewhat effective and less than half (43%) thought that influenza vaccination was safe. At a 12-month follow-up interview, 33% (442/1333) increased from no knowledge to at least "a little"., Conclusions: If and when influenza vaccines become widely available to older adults in China, our results indicate that influenza vaccination campaigns with basic information on the virus and vaccine could be beneficial for all older adults, especially those with less education and/or more cognitive impairment., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

Background: Killed whole-cell oral cholera vaccines (kOCVs) are becoming a standard cholera control and prevention tool. However, vaccine efficacy and direct effectiveness estimates have varied, with differences in study design, location, follow-up duration, and vaccine composition posing challenges for public health decision making. We did a systematic review and meta-analysis to generate average estimates of kOCV efficacy and direct effectiveness from the available literature., Methods: For this systematic review and meta-analysis, we searched PubMed, Embase, Scopus, and the Cochrane Review Library on July 9, 2016, and ISI Web of Science on July 11, 2016, for randomised controlled trials and observational studies that reported estimates of direct protection against medically attended confirmed cholera conferred by kOCVs. We included studies published on any date in English, Spanish, French, or Chinese. We extracted from the published reports the primary efficacy and effectiveness estimates from each study and also estimates according to number of vaccine doses, duration, and age group. The main study outcome was average efficacy and direct effectiveness of two kOCV doses, which we estimated with random-effect models. This study is registered with PROSPERO, number CRD42016048232., Findings: Seven trials (with 695 patients with cholera) and six observational studies (217 patients with cholera) met the inclusion criteria, with an average two-dose efficacy of 58% (95% CI 42-69, I 2 =58%) and effectiveness of 76% (62-85, I 2 =0). Average two-dose efficacy in children younger than 5 years (30% [95% CI 15-42], I 2 =0%) was lower than in those 5 years or older (64% [58-70], I 2 =0%; p<0·0001). Two-dose efficacy estimates of kOCV were similar during the first 2 years after vaccination, with estimates of 56% (95% CI 42-66, I 2 =45%) in the first year and 59% (49-67, I 2 =0) in the second year. The efficacy reduced to 39% (13 to 57, I 2 =48%) in the third year, and 26% (-46 to 63, I 2 =74%) in the fourth year., Interpretation: Two kOCV doses provide protection against cholera for at least 3 years. One kOCV dose provides at least short-term protection, which has important implications for outbreak management. kOCVs are effective tools for cholera control., Funding: The Bill & Melinda Gates Foundation., (Copyright This is an Open Access article published under the CC BY 3.0 IGO license which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. In any use of this article, there should be no suggestion that WHO endorses any specific organisation, products, or services. The use of the WHO logo is not permitted. This notice should be preserved along with the article's original URL.)

Purpose: To investigate ocular involvement (prevalence, incidence, lesion characteristics) following postnatally acquired infection with an "atypical" genotype of Toxoplasma gondii during a well-characterized 2001 outbreak in Santa Isabel do Ivaí, Brazil, attributed to a contaminated municipal reservoir., Design: Prospective longitudinal cohort study., Methods: We performed ophthalmic examinations on 290 of 454 individuals with serologic evidence of T gondii infection during the epidemic (positive IgM antibody tests). Prevalence of ophthalmic findings (intraocular inflammatory reactions [including transient, isolated retinal whitening without clinically apparent retinal necrosis] and necrotizing retinochoroiditis) at initial examination (baseline) and incidence of new findings during 10.5 months of follow-up were calculated. Cumulative risks of ophthalmic events were determined (Kaplan-Meier technique)., Results: Ocular involvement was present in 33 of 288 IgM+ individuals (11.5%) at baseline, including 17 with focal retinal whitening only and 13 with necrotizing retinochoroiditis. Incidence of new ocular involvement was estimated to be 1.73 events per 100 person-months (PM); cumulative risk at 10.5 months was 30.1%. Incident necrotizing retinochoroiditis was more common among those with focal retinal whitening at baseline (6.7/100 PM) than among those with no ocular involvement at baseline (1.11/100 PM; hazard ratio 6.07 [1.94-19.01]; P < .0001)., Conclusions: Waterborne infection with an atypical genotype of T gondii is associated with substantial risk of ocular involvement. Lesions may continue to develop during the first year after infection. The increased risk of late necrotizing retinochoroiditis associated with isolated focal retinal whitening at presentation suggests the early presence of parasites in the retina, despite initial lack of observable retinal necrosis., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Purpose: To determine the incidence of, and risk factors for, ocular involvement among people known to have postnatally acquired Toxoplasma gondii infection in a region of southern Brazil where there is a high prevalence of endemic disease., Design: Retrospective longitudinal cohort study., Methods: Records of 302 patients with serologic evidence of recent T gondii infection (a positive anti-T gondii IgM antibody test) from Erechim, Rio Grande do Sul state, Brazil (1974-2002) were analyzed. The incidence of ocular involvement was calculated in terms of person-years (PY) of follow-up. Risk factors for ocular involvement were analyzed using log-rank and Fisher exact tests., Results: At initial ocular examination (baseline), 30 patients (9.9%) had intraocular inflammation only (anterior chamber cells and flare, vitreous inflammatory reactions, retinal whitening), without clinically apparent necrotizing retinochoroiditis. At baseline, men were more likely to have ocular involvement (P = .043) and antiparasitic treatment was associated with less ocular involvement (P = .015). Follow-up examinations were performed on 255 patients (median follow-up, 13.7 months [range 0.4-261.9 months]). Among those without ocular involvement at baseline, the incidence of necrotizing retinochoroiditis was 6.4/100 PY. Patients >40 years of age at first IgM test had a greater risk of incident necrotizing retinochoroiditis (hazard ratio = 4.47, 95% CI = 1.67-11.93, P = .003) than younger patients. The incidence of recurrent necrotizing retinochoroiditis was 10.5/100 PY., Conclusion: Isolated intraocular inflammatory reactions can be an initial manifestation of T gondii infection, with necrotizing retinochoroiditis occurring months or years later. Male sex and older age are risk factors for toxoplasmic retinochoroiditis. Antitoxoplasmic treatment may protect against early ocular involvement., (Copyright © 2015 Elsevier Inc. All rights reserved.)

The near complete mitochondrial genome for Cyclospora cayetanensis is 6184 bp in length with three protein-coding genes (Cox1, Cox3, CytB) and numerous lsrDNA and ssrDNA fragments. Gene arrangements were conserved with other coccidia in the Eimeriidae, but the C. cayetanensis mitochondrial genome is not circular-mapping. Terminal transferase tailing and nested PCR completed the 5'-terminus of the genome starting with a 21 bp A/T-only region that forms a potential stem-loop. Regions homologous to the C. cayetanensis mitochondrial genome 5'-terminus are found in all eimeriid mitochondrial genomes available and suggest this may be the ancestral start of eimeriid mitochondrial genomes., (Copyright © 2015 Australian Society for Parasitology Inc. All rights reserved.)

Background: To develop a successful model for accelerating measles elimination in poor areas of China, we initiated a seven-year project in Guizhou, one of the poorest provinces, with reported highest measles incidence of 360 per million population in 2002., Methods: Project strategies consisted of strengthening routine immunization services, enforcement of school entry immunization requirements at kindergarten and school, conducting supplemental measles immunization activities (SIAs), and enhancing measles surveillance. We measured coverage of measles containing vaccines (MCV) by administrative reporting and population-based sample surveys, systematic random sampling surveys, and convenience sampling surveys for routine immunization services, school entry immunization, and SIAs respectively. We measured impact using surveillance based measles incidence., Results: Routine immunization coverage of the 1st dose of MCV (MCV1) increased from 82% to 93%, while 2nd dose of MCV (MCV2) coverage increased from 78% to 91%. Enforcement of school entry immunization requirements led to an increase in MCV2 coverage from 36% on primary school entry in 2004 to 93% in 2009. Province-wide SIAs achieved coverage greater than 90%. The reported annual incidence of measles dropped from 200 to 300 per million in 2003 to 6 per million in 2009, and sustained at 0.9-2.2 per million in 2010-2013., Conclusions: This project found that a package of strategies including periodic SIAs, strengthened routine immunization, and enforcing school entry immunization requirements, was an effective approach toward achieving and sustaining measles elimination in less-developed area of China., (Copyright © 2015. Published by Elsevier Ltd.)

Background: Surveillance for acute flaccid paralysis with laboratory confirmation has been a key strategy in the global polio eradication initiative, and the laboratory platform established for polio testing has been expanded in many countries to include surveillance for cases of febrile rash illness to identify measles and rubella cases. Vaccine-preventable disease surveillance is essential to detect outbreaks, define disease burden, guide vaccination strategies and assess immunization impact. Vaccines now exist to prevent Japanese encephalitis (JE) and some etiologies of bacterial meningitis., Methods: We evaluated the feasibility of expanding polio-measles surveillance and laboratory networks to detect bacterial meningitis and JE, using surveillance for acute meningitis-encephalitis syndrome in Bangladesh and China and acute encephalitis syndrome in India. We developed nine syndromic surveillance performance indicators based on international surveillance guidelines and calculated scores using supervisory visit reports, annual reports, and case-based surveillance data., Results: Scores, variable by country and targeted disease, were highest for the presence of national guidelines, sustainability, training, availability of JE laboratory resources, and effectiveness of using polio-measles networks for JE surveillance. Scores for effectiveness of building on polio-measles networks for bacterial meningitis surveillance and specimen referral were the lowest, because of differences in specimens and techniques., Conclusions: Polio-measles surveillance and laboratory networks provided useful infrastructure for establishing syndromic surveillance and building capacity for JE diagnosis, but were less applicable for bacterial meningitis. Laboratory-supported surveillance for vaccine-preventable bacterial diseases will require substantial technical and financial support to enhance local diagnostic capacity., (Published by Elsevier Ltd.)

Background: The World Health Organization (WHO) recommends the introduction of rotavirus vaccine in the immunization program of all countries. In the Central African Republic (CAR), sentinel surveillance for rotavirus gastroenteritis was established in 2011 by the Ministry of Health, with the support of the Surveillance en Afrique Centrale Project (SURVAC). The purpose of this study was to assess the burden of rotavirus gastroenteritis and to identify rotavirus strains circulating in CAR before the introduction of rotavirus vaccine planned for this year, 2014., Methods: One sentinel site and one laboratory at the national level were designated by the CAR Ministry of Health to participate in this surveillance system. Stool samples were collected from children who met the WHO rotavirus gastroenteritis case definition (WHO, 2006). The samples were first screened for group A rotavirus antigen by enzyme immunoassay (EIA), and genotyping assays performed using a multiplex reverse transcriptase PCR (RT-PCR) technique., Results: Between October 2011 and September 2013, 438 stool samples were collected and analyzed for detection of rotavirus antigen; 206 (47%) were positive. Among the 160 (78%) that could be genotyped, G2P[6] was the predominant strain (47%) followed by G1P[8] (25%) and G2P[4] (13%)., Conclusions: Almost half of stool samples obtained from children hospitalized with gastroenteritis were positive for rotavirus. These baseline rotavirus surveillance data will be useful to health authorities considering rotavirus vaccine introduction and for evaluating the efficacy of rotavirus vaccine once it is introduced into the routine immunization system., (Published by Elsevier B.V.)

Background: Timely vaccination, i.e., the receipt of all scheduled vaccinations in an age-appropriate fashion, is critical for the prevention of deadly diseases in infants and achievement of the UN Millennium Development Goal to reduce infant mortality. Infants, especially in rural or underprivileged settings often receive delayed vaccinations leaving them susceptible to vaccine-preventable illnesses early in the first year of life. In this study, we examined rates of timely vaccination among 24,435 infants born in Gaibandha and Rangpur rural districts of Bangladesh from 2001 to 2007., Methods: Vaccinations due by 14 weeks of age and administered through routine government immunization services were assessed using interviews with enrolled mothers between 11 and 18 weeks postpartum. We created a Timely Vaccination (TV) score to classify infants as vaccinated fully and on schedule (TV=1) or not (TV=0), and used multivariable logistic regression to identify maternal characteristics associated with infant's timely vaccination status., Results: Our results suggest that only 19% of infants in this cohort received scheduled vaccinations on time by 11-18 weeks postpartum. Mothers' engagement in paid employment [OR=1.13, 95% CI: 1.03-1.23], receipt of tetanus toxoid vaccination [OR=1.24, 95% CI: 1.11-1.38], history of antenatal care [OR=1.22, 95% CI: 1.12-1.32], or higher socioeconomic status [OR=1.07, 95% CI: 1.03-1.11] were positively associated with timely vaccination of their infants. Mother's perception of small infant size at birth was negatively associated with timely vaccination [OR=0.89, 95% CI: 0.82-0.97]., Conclusion: Timely vaccination coverage of infants in rural Gaibandha and Rangpur districts is extremely low. This analysis identifies important shortcomings associated with the 1-year vaccination benchmark of routine immunization performance and suggests the need for specific interventions based on potential maternal determinants as well as known system and programmatic barriers of timely vaccination among infants in rural Bangladesh., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Introduction: In seven southern African countries (Botswana, Lesotho, Malawi, Namibia, South Africa, Swaziland and Zimbabwe), following implementation of a measles mortality reduction strategy starting in 1996, the number of annually reported measles cases decreased sharply to less than one per million population during 2006-2008. However, during 2009-2010, large outbreaks occurred in these countries. In 2011, a goal for measles elimination by 2020 was set in the World Health Organization (WHO) African Region (AFR). We reviewed the implementation of the measles control strategy and measles epidemiology during the resurgence in the seven southern African countries., Methods: Estimated coverage with routine measles vaccination, supplemental immunization activities (SIA), annually reported measles cases by country, and measles surveillance and laboratory data were analyzed using descriptive analysis., Results: In the seven countries, coverage with the routine first dose of measles-containing vaccine (MCV1) decreased from 80% to 65% during 1996-2004, then increased to 84% in 2011; during 1996-2011, 79,696,523 people were reached with measles vaccination during 45 SIAs. Annually reported measles cases decreased from 61,160 cases to 60 cases and measles incidence decreased to <1 case per million during 1996-2008. During 2009-2010, large outbreaks that included cases among older children and adults were reported in all seven countries, starting in South Africa and Namibia in mid-2009 and in the other five countries by early 2010. The measles virus genotype detected was predominantly genotype B3., Conclusion: The measles resurgence highlighted challenges to achieving measles elimination in AFR by 2020. To achieve this goal, high two-dose measles vaccine coverage by strengthening routine immunization systems and conducting timely SIAs targeting expanded age groups, potentially including young adults, and maintaining outbreak preparedness to rapidly respond to outbreaks will be needed., (Published by Elsevier Ltd.)

Recommended childhood vaccines have typically been provided through routine immunization programs. Recently, implementation of strategies that use campaign-like features for providing all the recommended childhood immunizations have been utilized to increase vaccination coverage. Between January 2006 and January 2008, Assam, India, conducted Immunization Weeks (IWs), a periodic campaign-like approach for providing the recommended childhood vaccines generally administered through the routine Universal Immunization Program (UIP). Using data from a household vaccination coverage survey conducted in 5 districts of Assam in late-2007/early-2008 among children 12-28 months of age, a secondary analysis was conducted for a subset of children with vaccination cards to assess the impacts of implementing the IW-strategy. Sixty-five percent of the 3310 surveyed children received at least one vaccine dose through an IW. Without IWs, coverage would likely have been lower for all vaccines (e.g., 75% measles vaccine coverage including IWs doses and an estimated 61% without IWs). The proportion of children receiving at least one IW dose was significantly different depending on the child's residence; 72% in hard-to-reach char areas, 66% in rural areas and 53% in urban areas (p=0.01). Overall, 2085 (63%) of children were fully vaccinated; of these 60% received a combination of IW and UIP doses, 35% received doses only through the UIP, and 5% received doses only through IWs. A delay in administration later than the recommended ages was found for both UIP doses and for IW doses (e.g., for measles vaccine, UIP doses were 6.9 weeks delayed and IW doses 13.6 weeks delayed). Among this sample of vaccinated children, IWs appeared to increase vaccination coverage and improve access to services in hard-to-reach areas. However, the UIP appeared to be a better system for ensuring that children received all doses in the recommended vaccination series., (Published by Elsevier Ltd.)