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It has been suggested that asymmetric hypsarrhythmia is associated with structural etiology. We devised the Hypsarrhythmic Asymmetric Scoring Scheme (HASS) to quantify the degree of hypsarrhythmic asymmetry in a retrospective series of patients who underwent surgical treatment at our center. The present study aimed to investigate the role of HASS in predicting the postsurgical seizure outcomes.We retrospectively analyzed the records of 46 children with hypsarrhythmia who underwent resective epilepsy surgery between 2018 and 2020 and were followed up for at least 1 year after surgery. Hypsarrhythmia severity in each hemisphere was quantified and scored. The HASS score was calculated as the difference between the two hemispheres. Univariate results were submitted to logistic regression models to identify independent predictors for favorable surgical outcomes.Of the 46 patients who underwent resective surgery, Engel's class I-Ⅱ outcomes were achieved in 34 (73.9%). The Engel I-Ⅱ group had a significantly higher HASS score than the Engel Ⅲ-Ⅳ group (p0.001). Multivariate analysis showed that the HASS score was the only significant predictor of good outcomes (p = 0.011). Further receiver operating characteristic analysis showed that a threshold of 7 yielded a better seizure outcome with a sensitivity of 97.06% and specificity of 83.33%.As the first hypsarrhythmia scoring system specially designed for presurgical evaluation, the HASS score may contribute to predicting the postsurgical seizure outcome from the electroencephalography perspective.

We evaluated the efficacy and safety of vigabatrin in focal epilepsy associated with tuberous sclerosis complex by retrospectively reviewing patients with focal epilepsy and tuberous sclerosis complex treated with vigabatrin at a pediatric epilepsy center over an 8-year period. Of 85 patients, 20 (23.5%) were seizure-free for >12 months, 45 (52.9%) were responders (≥50% seizure reduction), and 20 (23.5%) were nonresponders. The median age (in months) at seizure onset in the seizure-free group (median, 15; interquartile range [IQR], 6-23.3) was higher than that of responders (median, 5; IQR, 3-14) and nonresponders (median, 6; IQR, 2-12). Fewer patients in the seizure-free group had calcification in their largest tubers, but the presence of tuber calcification did not differ among groups. Vigabatrin is more likely to result in seizure freedom in children with tuberous sclerosis complex who have later infantile onset of focal seizures and no calcification in their largest tuber.

Estrogen can promote the acceleration of bone maturation and phthalate esters (PAEs) have estrogen-mimicking effects. We investigated whether PAEs are associated with the acceleration of bone age (BA) in girls with early onset of puberty (EOP). This case–control study enrolled 254 girls with EOP from the Endocrinology Department at Shenzhen Children’s Hospital between December 2018 and August 2019. Ultra-performance liquid chromatography and tandem mass spectrometry were used to analyze the 10 metabolites of PAEs (mPAEs) in urine samples. BA was measured using an artificial intelligence system. BA exceeding the chronological age (CA) by > 2 years (BA-CA ≥ 2 years) was referred to as significant BA advancement. Participants were divided into groups A (BA-CA ≥ 2 years; case group) and B (BA-CA P P P > 0.05). Our findings suggested that MEP was positively associated with BA advancement in girls with EOP. Exposure to PAEs may promote accelerated bone maturation.

Introduction Endemic measles persists in China, despite >95% reported coverage of two measles-containing vaccine doses and nationwide campaign that vaccinated >100 million children in 2010. An increasing proportion of infections now occur among adults and there is concern that persistent susceptibility in adults is an obstacle to measles elimination in China. We performed a case-control study in six Chinese provinces between January 2012 to June 2013 to identify risk factors for measles virus infection and susceptibility among adults. Methods Persons ≥15 years old with laboratory-confirmed measles were age and neighborhood matched with three controls. Controls had blood specimens collected to determine their measles IgG serostatus. We interviewed case-patients and controls about potential risk factors for measles virus infection and susceptibility. Unadjusted and adjusted matched odds ratios and 95% confidence intervals (CIs) were calculated via conditional logistic regression. We calculated attributable fractions for infection for risk factors that could be interpreted as causal. Results 899 cases and 2498 controls were enrolled. Among controls, 165 (6.6%) were seronegative for measles IgG indicating persistent susceptibility to infection. In multivariable analysis, hospital visit and travel outside the prefecture in the prior 1–3 weeks were significant risk factors for measles virus infection. Occupation and reluctance to accept measles vaccination were significant risk factors for measles susceptibility. The calculated attributable fraction of measles cases from hospital visitation was 28.6% (95% CI: 20.6–38.8%). Conclusions Exposure to a healthcare facility was the largest risk factor for measles virus infection in adults in China. Improved adherence to hospital infection control practices could reduce risk of ongoing measles virus transmission and increase the likelihood of achieving and sustaining measles elimination in China. The use of control groups stratified by serological status identified distinct risk factors for measles virus infection and susceptibility among adults.

Purpose Although gender nonconformity (GNC) and transgender identity are both linked to bullying victimization, few studies have examined them with bullying victimization simultaneously. Using a sample of Youth Risk Behavior Survey, we investigated the associations of GNC and transgender identity with bullying victimization within the same study. Methods We analyzed data from the cross-sectional school-based Youth Risk Behavior Survey in 2017 (n = 25,378). The exposures were GNC and transgender identity. The main outcomes were traditional victimization, cyber victimization, and combined victimization. We calculated adjusted prevalence ratios (APRs) with 95% confidence intervals (CIs) using Poisson regression models. Results There were 22.15% of high school students with GNC, and 1.61% identified themselves as transgender. GNC is associated with traditional (APR,1.45;95%CI, 1.21–1.73), cyber (APR,2.00; 95%CI, 1.66–2.40) and combined victimization (APR,1.61;95%CI, 1.42–1.83) respectively among assigned male at birth (AMAB) students only. Transgender male and female students are both at higher risk of bullying victimization for all the three outcomes than cisgender peers. Conclusions AMAB GNC and transgender identity are associated with a higher risk of bullying victimization. Providing support systems and celebrating gender diversity within and outside schools are important.

Background Grade repetition is practiced worldwide and varies considerably across the globe. Globally, around 32.2 million students repeated a grade at the primary education level in 2010. Although a large body of research has documented grade repetition’s academic and non-academic effects, the limited evidence on associations between grade repetition and school bullying is inconsistent and ambiguous. This study aimed to investigate the global association of grade repetition with bullying victimization in a large-scale school-based cross-sectional study. Methods and findings We used the latest global data from the Program for International Student Assessment (PISA) 2018. PISA 2018 was conducted between March and August 2018 in 80 countries and economies among students aged 15–16 years attending secondary education. The students reported their experiences of repeating a grade at any time point before the survey and of being bullied in the past 12 months. The outcome measures were 6 types of bullying victimization. We accounted for the complex survey design and used multivariate logistic regression models to estimate the odds ratios (ORs) with 95% confidence intervals (CIs) of grade repetition with bullying victimization after adjusting for potential confounders (sex; age group; migrant status; school type; economic, social, and cultural status; and parental emotional support). This study included 465,146 students (234,218 girls and 230,928 boys) with complete data on grade repetition and bullying victimization in 74 countries and economies. The lifetime prevalence of grade repetition was 12.26%, and 30.32% of students experienced bullying at least a few times a month during the past 12 months. Grade repetition was statistically significantly associated with each type of bullying victimization. The OR (95% CI) of overall bullying victimization for grade repeaters compared with their promoted peers was 1.42 (95% CI 1.32–1.52, p < 0.001). The sex-specific analysis produced similar results in both boys and girls. Furthermore, girls who repeated a grade had higher risks of being made fun of, being threatened, having possessions taken away, and being pushed around than boys. The major limitation is that this study only included students attending schools and therefore may be subject to possible selection bias. In addition, the cross-sectional design hinders us from establishing causality between grade repetition and bullying victimization. Conclusions In this study, we observed that, globally, both boys and girls who repeat a grade are at increased risk of being bullied compared with promoted peers, but girls may experience higher risks than boys of specific types of bullying associated with repeating a grade. These findings provide evidence for the association of grade repetition with bullying victimization. Sex differences in risk of experiencing some types of bullying suggest that tailored interventions for girls who repeat a grade may be warranted., In a cross-sectional study, Qiguo Lian and colleagues investigate associations between repeating a grade and experiencing bullying victimization among adolescents enrolled in schools in 74 countries and economies., Author summary Why was this study done? Preventing school violence is a specific target of the United Nations Sustainable Development Goals. Few empirical studies involving large samples have examined the association of grade repetition with bullying victimization. What did the researchers do and find? We examined the association of grade repetition with bullying victimization among 465,146 15-year-old students in 74 countries and economies. The prevalence of grade repetition and bullying victimization varied widely across countries and economies. Grade repetition was associated with bullying victimization in both boys and girls. Girls who repeated a grade experienced higher risks than boys of being made fun of, being threatened, having possessions taken away, and being pushed around. What do these findings mean? The experience of repeating a grade may suggest a need for bullying interventions among both boys and girls. Tailored interventions for girls who repeat a grade may be warranted.

Myelin oligodendrocyte glycoprotein (MOG) antibodies mediate inflammatory demyelinating diseases of the central nervous system. This study aimed to understand the clinical characteristics of MOG antibody-associated aseptic meningitis (MOGAM).Here, we report the cases of two children with MOGAM. A systematic literature review was conducted and included patients who had MOGAM only, without neurological parenchymal lesions. The clinical characteristics that may have affected the outcome were statistically analyzed.We reviewed 12 cases of MOGAM; male: female = 9: 3. Prolonged fever lasting over 7 days (11/12) was the most frequent symptom, followed by headache (10/12), vomiting (5/12), and seizures (4/12). None of the patients had focal neurological manifestations or parenchymal lesions on imaging. Cerebrospinal fluid (CSF) leukocytosis was observed in all patients (12/12), and blood leukocytosis and elevated CSF pressure was observed in all patients who had corresponding results (9/9 and 4/4, respectively). Seizures occurrence was lower than that of MOG antibody-associated cortical encephalitis. Seven cases progressed to other MOG antibody-associated diseases (MOGADs) in the later phase of MOGAM. Patients who did not progress to other MOGADs had a shorter disease duration from onset to the initiation of intravenous methylprednisolone than those who did. All the patients achieved full recovery after steroid treatment. One patient had relapses.MOGAM without inflammatory demyelination is a rare but distinct phenotype of MOGAD, with fewer clinical manifestations mimicking bacterial or viral meningitis/encephalomeningitis. Delayed diagnosis and treatment may induce the progression to other severe MOGADs. Early recognition of this unique autoimmune aseptic meningitis may contribute to early diagnosis, treatment, and better outcomes.

Purpose To explore and analyze the causes and related influencing factors of pediatric fractures, and provide theoretical basis for reducing the incidence and adverse effects of pediatric fractures. Methods This study retrospectively analyzed the epidemiological characteristics of fractures in pediatric aged ≤18 years old who were admitted to the our hospital between July 2015 and February 2020. Results A total of 10,486 pediatric patients were included in the study, of whom 6961 (66.38%) were boys, and 3525 (33.62%) were girls. For the fracture incidence, age group of the 3-6 years reached the peak. 5584 (60.76%) children were operated upon within 12 h after admission. The top three types of fractures were the distal humerus (3843 sites, 27.49%), distal ulna (1740 sites, 12.44%), and distal radius (1587 sites, 11.35%). The top three causes of injury were falls (7106 cases, 82.10%), car accidents (650 cases, 65.72%), and clipping (465 cases, 5.37%). Fractures predominantly occurred between July and November (4664 cases, 48.87%) and on Saturdays and Sundays (3172 cases, 33.24%). The highest number of hospital visits occurred between 20:00 and 00:00 (4339 cases, 45.46%). Conclusion For pediatric fractures, we should take appropriate and effective preventive measures to reduce the incidence of children’s fractures according to the distribution characteristics of age, gender, cause of injury, and fracture site.

Background Measles is among the most highly infectious human diseases. By virtue of increasingly effective childhood vaccination, together with targeted supplemental immunization activities (SIAs), health authorities in the People’s Republic of China have reduced measles’ reproduction number from about 18 to 2.3. Despite substantial residual susceptibility among young adults, more in some locales than others, sustained routine childhood immunization likely would eliminate measles eventually. To support global eradication efforts, as well as expedite morbidity and mortality reductions in China, we evaluated alternative SIAs via mechanistic mathematical modelling. Methods Our model Chinese population is stratified by immune status (susceptible to measles infection; infected, but not yet infectious; infectious; and recovered or immunized), age (0, 1–4, 5–9, …, 65+ years) and location (31 provinces). Contacts between sub-populations are either empirical or a mixture of preferential and proportionate with respect to age and decline exponentially with distance between locations at age-dependent rates. We estimated initial conditions and most parameters from recent cross-sectional serological surveys, disease surveillance and demographic observations. Then we calculated the reproduction numbers and gradient of the effective number with respect to age- and location-specific immunization rates. We corroborated these analytical results by simulating adolescent and young adult SIAs using a version of our model in which the age-specific contact rates vary seasonally. Results Whereas the gradient indicates that vaccinating young adults generally is the optimal strategy, simulations indicate that a catch-up campaign among susceptible adolescent schoolchildren would accelerate elimination, with timing dependent on uptake. Conclusions These results are largely due to indirect effects (i.e. fewer infections than immunized people might otherwise cause), which meta-population models with realistic mixing are uniquely capable of reproducing accurately.

BackgroundUnintentional injury is one of the top three causes of death for infants. However, the epidemiological studies of skeletal trauma and skull fractures in infants younger than 1 year were poorly understood in China. Therefore, our study aimed to examine accidental and emergency attendance in infants under 1 year. It also tried to determine the prevalence and severity of accident types in infants.MethodsA retrospective analysis was performed on the demographic characteristics of infants younger than 1 year with skeletal trauma and skull fractures who visited the Shenzhen Children’s Hospital from January 1, 2016 to December 31, 2019. Age, gender, fracture site and type, mechanism of injury, length of visit, length of hospital stay, hospitalization cost, and treatment methods were analyzed.ResultsA total number of 675 fractures in 664 infants were included, the median age was 187days (IQR,90-273days), including 394 males and 270 females. The top three fracture sites were the skull (430 sites, 63.70 %), long bones of the limbs (168 sites, 24.89 %), and clavicle (53 sites, 7.85 %). The top three causes of injury were locomotion injuries (256 cases, 38.55 %), falls or trips from low height (from beds, tables, chairs, etc.) (130 cases, 19.58 %), and birth injuries (97 cases, 14.61 %). The greatest amount of fractures occurred in children 1–28 days of life (d) reached a top of 101 cases, followed by 331–365 days, accounting for 15.21 and 10.24 %, respectively. The number of fractures reached a trough of 29 cases in the 29-60d group (4.37 %). And increased again to 65 cases in the 151-180d group (9.79 %). The proportion remained relatively constant at 9 % in the 181-210d group (9.19 %) and 211-240d group (9.64 %). The interval between injury and visiting our hospital was ≤ 72 h in 554 cases.ConclusionsSpecial attention should be given to the demographic characteristics of fractures in infants under 1 year of age, and appropriate outreach should be implemented. For example, health education should be provided to aid in the prevention especially for frequently occurring locomotion injuries, and prompt access to specialist medical care should be recommended for skull fractures, which are prone to delayed treatment. In addition, multidisciplinary collaboration should be implemented in trauma care, while also promoting the establishment of trauma centers in specialist children’s hospitals with a stronger capacity to treat pediatric trauma, and a regional system for pediatric trauma treatment.

Background Virological detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) through RT-PCR has limitations for surveillance. Serological tests can be an important complementary approach. We aimed to assess the practical performance of RT-PCR-based surveillance protocols and determine the extent of undetected SARS-CoV-2 infection in Shenzhen, China. Methods We did a cohort study in Shenzhen, China and attempted to recruit by telephone all RT-PCR-negative close contacts (defined as those who lived in the same residence as, or shared a meal, travelled, or socially interacted with, an index case within 2 days before symptom onset) of all RT-PCR-confirmed cases of SARS-CoV-2 detected since January, 2020, via contact tracing. We measured anti-SARS-CoV-2 antibodies in serum samples from RT-PCR-negative close contacts 2-15 weeks after initial virological testing by RT-PCR, using total antibody, IgG, and IgM ELISAs. In addition, we did a serosurvey of volunteers from neighbourhoods with no reported cases, and from neighbourhoods with reported cases. We assessed rates of infection undetected by RT-PCR, performance of RT-PCR over the course of infection, and characteristics of individuals who were seropositive on total antibody ELISA but RT-PCR negative. Findings Between April 12 and May 4, 2020, we enrolled and collected serological samples from 2345 (53·0%) of 4422 RT-PCR-negative close contacts of cases of RT-PCR-confirmed SARS-CoV-2. 1175 (50·1%) of 2345 were close contacts of cases diagnosed in Shenzhen with contact tracing details, and of these, 880 (74·9%) had serum samples collected more than 2 weeks after exposure to an index case and were included in our analysis. 40 (4·5%) of 880 RT-PCR-negative close contacts were positive on total antibody ELISA. The seropositivity rate with total antibody ELISA among RT-PCR-negative close contacts, adjusted for assay performance, was 4·1% (95% CI 2·9-5·7), which was significantly higher than among individuals residing in neighbourhoods with no reported cases (0·0% [95% CI 0·0-1·1]). RT-PCR-positive individuals were 8·0 times (95% CI 5·3-12·7) more likely to report symptoms than those who were RT-PCR-negative but seropositive, but both groups had a similar distribution of sex, age, contact frequency, and mode of contact. RT-PCR did not detect 48 (36% [95% CI 28-44]) of 134 infected close contacts, and false-negative rates appeared to be associated with stage of infection. Interpretation Even rigorous RT-PCR testing protocols might miss a substantial proportion of SARS-CoV-2 infections, perhaps in part due to difficulties in determining the timing of testing in asymptomatic individuals for optimal sensitivity. RT-PCR-based surveillance and control protocols that include rapid contact tracing, universal RT-PCR testing, and mandatory 2-week quarantine were, nevertheless, able to contain community spread in Shenzhen, China. Funding The Bill & Melinda Gates Foundation, Special Foundation of Science and Technology Innovation Strategy of Guangdong Province, and Key Project of Shenzhen Science and Technology Innovation Commission.

Background The prevalence of being bullied traditionally among U.S. high school students is expected to reduce to 17.9%, according to Healthy People 2020 Initiatives. We examined trends in traditional victimization and cybervictimization with the latest large-scale time-series data in the United States. Methods We analyzed the data from the 2011–2019 national Youth Risk Behavior Survey (YRBS) to access the trends in traditional victimization and cybervictimization among U.S. high school students. We identified the temporal trends using multivariate logistic regression analyses, accounting for survey design features of YRBS. Participants included 72,605 high school students. Results The overall prevalence of victimization was 19.74% for traditional bullying and 15.38% for cyberbullying, suggesting that cyberbullying is not a low frequent phenomenon. The prevalence of victimization ranged from 20.19 to 19.04% for traditional victimization and 16.23 to 14.77% for cybervictimization, and the declined trends for the two kinds of bullying victimization were both statistically non-significant. The degree of overlap between the two kinds of bullying victimization was about 60%. Besides, female students reported more traditional victimization and cybervictimization than male peers within each survey cycle. Conclusions No declined trends in traditional victimization and cybervictimization were observed during 2011–2019. Female students are more likely to experience school bullying. To achieve the Healthy People 2020 goal on bullying, more work is needed to explore the underlying reasons behind these unchanging trends.

Purpose Early pubertal onset may relate to more involvement in bullying in adolescent girls, both as a target and as a perpetrator. However, the few studies of the association between early menarche and school bullying have shown mixed findings. The present study examined whether early menarche is associated with bullying victimization and perpetration. Methods We obtained survey data on adolescent girls from the 2001–2002, 2005–2006, and 2009–2010 cycles of the Health Behaviour in School-aged Children study in 35 European and North American countries. We identified school bullying in the past 2 months using the Revised Olweus Bully/Victim Questionnaire. We defined early menarche as a reported onset of menarche before 11 years and tested the associations between early menarche and bullying victimization and perpetration using three-level logistic regression models. Results The sample included 227,443 adolescent girls with a mean age of 13.64 (standard deviation [SD] 1.63) years, of which 10,172 (4.47%) were early matured; 62,528 (28.33%) and 56,582 (25.67%) were occasional victims and perpetrators, respectively; and 21,985 (9.96%) and 14,115 (6.40%) were frequent victims and perpetrators, respectively. Early menarche related to occasional victimization (adjusted odds ratio [OR] [95% confidence interval [CI] = 1.21 [1.12–1.31]) and perpetration (aOR [95% CI] = 1.19 [1.11–1.27]) and to frequent victimization (aOR [95% CI] = 1.35 [1.22–1.50]) and perpetration (aOR [95% CI] = 1.46 [1.31–1.63]). Conclusions Early menarche in European and North American adolescent girls positively relates to bullying victimization and perpetration. Early-maturing girls should not be neglected in antibullying programs.

Introduction Endemic measles persists in China, despite >95% reported coverage of two measles-containing vaccine doses and nationwide campaign that vaccinated more than 100 million children in 2010. We performed a case–control study in six Chinese provinces during January 2012 through June 2013 to identify risk factors for measles infection among children aged 0–7 months. Methods Children with laboratory-confirmed measles were neighborhood matched with three controls. We interviewed parents of case and control infants on potential risk factors for measles. Adjusted matched odds ratios (mOR) and 95% confidence intervals (CIs) were calculated by multivariable conditional logistic modeling. We calculated attributable fractions for risk factors that could be interpreted as causal. Results Eight hundred thirty cases and 2303 controls were enrolled. In multivariable analysis, male sex (mOR 1.6 [1.3, 2.0]), age 5–7 months (mOR 3.9 [3.0, 5.1]), migration between counties (mOR 2.3 [1.6, 3.4]), outpatient hospital visits (mOR 9.4 [6.6, 13.3]) and inpatient hospitalization (mOR 107.1 [48.8, 235.1]) were significant risk factors. The calculated attributable fractions for hospital visits was 43.1% (95% CI: 40.1, 47.5%) adjusted for age, sex and migration. Conclusions Hospital visitation was the largest risk factor for measles infection in infants. Improved hospital infection control practices would accelerate measles elimination in China.

BACKGROUND: China reduced hepatitis B virus (HBV) infection by 90% among children under 5 years old with safe and effective hepatitis B vaccines (HepB). In December 2013 this success was threatened by widespread media reports of infant deaths following HepB administration. Seventeen deaths and one case of anaphylactic shock following HBV vaccination had been reported. METHODS: We conducted a telephone survey to measure parental confidence in HepB in eleven provinces at four points in time; reviewed maternal HBV status and use of HepB for newborns in birth hospitals in eight provinces before and after the event; and monitored coverage with hepatitis B vaccine and other programme vaccines in ten provinces. RESULTS: HepB from the implicated company was suspended during the investigation which showed that the deaths were not caused by HepB vaccination. Before the event 85% respondents regarded domestic vaccines as safe decreasing to 26.7% during the event. During the height of the crisis 30% of parents reported being hesitant to vaccinate and 18.4% reported they would refuse HepB. Use of HepB in the monitored provinces decreased by 18.6% from 53 653 doses the week before the event to 43 688 doses during the week that Biokangtai HepB was suspended. Use of HepB within the first day of life decreased by 10% among infants born to HBsAg-negative mothers and by 6% among infants born to HBsAg-positive mothers. Vaccine refusal and HepB birth dose rates returned to baseline within 2 months; confidence increased but remained below baseline. CONCLUSIONS: The HBV vaccine event resulted in the suspension of a safe vaccine which was associated with a decline of parental confidence and refusal of vaccination. Suspension of a vaccine can lead to loss of confidence that is difficult to recover. Timely and credible investigation accompanied by proactive outreach to stakeholders and the media may help mitigate negative impact of future coincidental adverse events following immunization. (c) The Author 2016; all rights reserved. Published by Oxford University Press on behalf of the International Epidemiological Association.

Introduction Endemic measles persists in China, despite >95% reported coverage of two measles-containing vaccine doses and nationwide campaign that vaccinated more than 100 million children in 2010. In 2011, almost half of the 9943 measles cases in China occurred in children eligible for measles vaccination. We conducted a case-control study during 2012–2013 to identify risk factors for measles infection in children aged 8 months–14 years. Methods Children with laboratory-confirmed measles were age- and neighborhood-matched with three controls. We interviewed parents of case and control infants on potential risk factors for measles. We calculated adjusted matched odds ratios and 95% confidence intervals of risk factors. We calculated attributable fractions for risk factors that could be interpreted as causal and vaccine efficacy (VE) for the measles containing vaccine (MCV) used in the Chinese immunization program. Results In all, 969 case-patients and 2845 controls were enrolled. In multivariable analysis, lack of measles vaccination both overall (mOR 22.7 [16.6, 31.1] and when stratified by region (east region, mOR 74.2 [27.3, 202]; central/western regions mOR 17.4 [12.5, 24.3]), hospital exposure (mOR 63.0, 95% CI [32.8, 121]), and migration among counties (overall mOR 3.0 [2.3, 3.9]) were significant risk factors. The calculated VE was 91.9–96.1% for a single dose of MCV and 96.6–99.5% for 2 doses. Conclusions Lack of vaccination was the leading risk factor for measles infection, especially in children born since the 2010 supplementary immunization activity. Reducing missed vaccination opportunities, improving immunization access for migrant children, and strengthening school/kindergarten vaccine checks are needed to strengthen the routine immunization program and maintain progress toward measles elimination in China.

Background As China approaches the elimination of measles, outbreaks of measles continue to occur. Healthcare workers (HCWs) are known to be at high risk of infection and transmission of measles virus. A measles outbreak occurred in a hospital in Xinjiang Uighur Autonomous Region of the People’s Republic of China. We report an investigation of this outbreak and its implications for measles elimination and outbreak preparedness. Methods We conducted a retrospective search for measles cases using hospital records. Information on cases was collected by interview, and was used to determine epidemiological linkages. We surveyed HCWs to determine their demographic characteristics, disease history and vaccination status, and knowledge about measles. Results We identified 19 cases, ages 18 to 45 years, in Hospital W between December 2015 and January 2016; 14 were laboratory-confirmed, and 5 were epidemiologically linked. The primary case was a 25-year-old neurology department nurse who developed a rash on 22 December 2015 that was reported on 11 January 2016. She continued working and living with her workmates in a dormitory during her measles transmission period. Among the 19 infected HCWs, 2 had received a dose of measles-containing vaccine (MCV) before the outbreak, and 16 had unknown vaccination status. Outbreak response immunization activities were started on 8 January in a non-selective manner by offering vaccine regardless of vaccination history; 605(68%) of 890 HCWs were vaccinated. The HCW survey had a 73% response rate (646/890); 41% of HCWs reported that they had received MCV before outbreak, and 56% exhibited good knowledge of measles symptoms, transmission, complications, and vaccination. Conclusions Low MCV coverage, low measles knowledge among HCWs, delayed reporting of measles cases, and absence of proper case management were associated with this outbreak. Training and vaccinating HCWs against measles are essential activities to prevent measles virus transmission among HCWs.

Background Rubella-containing vaccine (RCV) became available in China in 1993 and was introduced nationwide into the Expanded Immunization Program (EPI) in 2008. We evaluated implementation and impact of RCV from 2 years prior to nationwide introduction through the 10 years after nationwide introduction. Methods We analyzed RCV lot-release (doses distributed) data, 1- and 2-dose RCV coverage, and rubella data from China’s nationwide disease surveillance system to describe the current status and changes in rubella epidemiology between 2005 and 2017. Results While the vaccine was included into the routine immunization program in 2008, its full implementation required 4 years due to sporadic vaccine supply constraints. RCV1 and RCV2 coverage increased from 51.5% and 39.0% in 2008 to >95% during 2012 through 2016. From 2005 to 2017, the annual incidences (per million) of rubella ranged from 91.09 in 2008 down to 1.16 in 2017; reductions occurred in all age groups. The proportion of cases among individuals ≥20 years old increased from 0.97% in 2005 to 31.2% in 2017. In the better-developed eastern China, most cases were among adults; in central and western China, most cases were among children or adolescents. Conclusions The marked decrease rubella was a result of inclusion of RCVs into EPI targeting children less than 2 years of age and achieving high level of 2-dose coverage. Rubella was reduced in absolute terms, and its epidemiology was changed to older cases with substantial inter-province variation. Ensuring full vaccination of school children and identifying strategies to reach adults with measles and rubella combined vaccines will be important to hasten elimination of rubella and prevent CRS outbreaks.

In July 2013, the National Immunization Program of China was notified by the US Centers for Disease Control and Prevention that measles was detected in 3 newly adopted, special needs children with cerebral palsy (CP) from China. We report an investigation of measles transmission in China that led to infection of these children. Interviews were conducted with welfare institute staff and panel physicians; health records of the potentially exposed population were reviewed; and immunization coverage was assessed among institute residents. Five residents with CP, all unvaccinated against measles, among who were the 3 adoptees, were linked epidemiologically into 3 generations of measles transmission antecedent to the US outbreak. In a random sample of residents, first dose of measles containing vaccine (MCV1) and MCV2 coverage was 16 of 17 (94%) and 7 of 11 (64%) among children with CP, and 100% (32 of 32) and 96% (21 of 22) among children without CP. Vaccinators reported reluctance to vaccinate children with CP because the China pharmacopeia lists encephalopathy as a contraindication to vaccination. Panel physicians reported to investigators no necessity of vaccination for adoptees to the United States if US parents sign an affidavit exempting the child from vaccination. We recommend that the China pharmacopeia vaccine contraindications be reviewed and updated, the United States should reconsider allowing vaccination exemptions for internationally adopted children unless there are true medical contraindications to vaccination, and US pediatricians should counsel adopting parents to ensure that their child is up-to-date on recommended vaccinations before coming to the United States.

Background Communication for Development (C4D) is a strategy promoted by the United Nations Children’s Fund to foster positive and measurable changes at the individual, family, community, social, and policy levels of society. In western China, C4D activities have previously been conducted as part of province-level immunization programs. In this study, we evaluated the association of C4D with changes in parental knowledge of immunization services, measles disease, and measles vaccine, and changes in their children’s measles vaccine coverage. Methods From April 2013 to April 2014, C4D activities were implemented as part of provincial immunization programs in the Inner Mongolia, Guangxi, Chongqing, Guizhou, Tibet, Shaanxi, Gansu, Ningxia, and Qinghai provinces. We used a before-and-after study design and employed face-to-face interviews to assess changes in parental knowledge and vaccination coverage. Results We surveyed 2 107 households at baseline and 2 070 households after 1 year of C4D activities. Following C4D, 95% of caregivers were aware of the vaccination record check requirement for entry into kindergarten and primary school; 80% of caregivers were aware that migrant children were eligible for free vaccination; more than 70% of caregivers knew that measles is a respiratory infectious disease; and 90% of caregivers knew the symptoms of measles. Caregivers’ willingness to take their children to the clinic for vaccination increased from 51.3% at baseline to 67.4% in the post-C4D survey. Coverage of one-dose measles-containing vaccine (MCV) increased from 83.8% at baseline to 90.1% after C4D. One-dose MCV coverage was greater than 95% in the Guangxi, Shaanxi, and Gansu provinces. Two-dose MCV coverage increased from 68.5 to 77.6%. House-to-house communication was the most popular C4D activity among caregivers (91.6% favoring), followed by posters and educational talks (64.8 and 49.9% favoring). Conclusions C4D is associated with increased caregiver knowledge about measles, increased willingness to seek immunization services for their children, and increased measles vaccination coverage. Tailored communication strategies based on insights gained from these analyses may be able to increase vaccination coverage in hard-to-reach areas. C4D should be considered for larger scale implementation in China. Electronic supplementary material The online version of this article (doi:10.1186/s40249-017-0261-y) contains supplementary material, which is available to authorized users.

To analyse the epidemiology of measles in China and determine the progress made towards the national elimination of the disease.We analysed measles surveillance data - on the age, sex, residence and vaccination status of each case and the corresponding outcome, dates of onset and report and laboratory results - collected between January 2005 and October 2013.Between 2005 and October 2013, 596 391 measles cases and 368 measles-related deaths were reported in China. Annual incidence, in cases per 100 000 population, decreased from 9.95 in 2008 to 0.46 in 2012 but then rose to more than 1.96 in 2013. The number of provinces that reported an annual incidence of less than one case per million population increased from one in 2009 to 15 in 2012 but fell back to one in 2013. Median case age decreased from 83 months in 2005 to 14 months in 2012 and 11 months in January to October 2013. Between 2008 and 2012, the incidence of measles in all age groups, including those not targeted for vaccination, decreased by at least 93.6%. However, resurgence started in late 2012 and continued into 2013. Of the cases reported in January to October 2013, 40% were aged 8 months to 6 years.Although there is evidence of progress towards the elimination of measles from China, resurgence in 2013 indicated that many children were still not being vaccinated on time. Routine immunization must be strengthened and the remaining immunity gaps need to be identified and filled.Analyser l'épidémiologie de la rougeole en Chine et déterminer les progrès réalisés sur la voie de l'élimination nationale de la maladie.Nous avons analysé les données de surveillance de la rougeole – concernant l'âge, le sexe, le lieu de résidence et le statut vaccinal de chaque cas et les résultats correspondants, les dates de l'apparition et de signalement de la maladie, et les résultats de laboratoire –collectées entre janvier 2005 et octobre 2013.Entre 2005 et octobre 2013, 596 391 cas de rougeole et 368 décès liés à la rougeole ont été signalés en Chine. L'incidence annuelle exprimée en cas pour 100 000 habitants a diminué de 9,95 en 2008 à 0,46 en 2012, mais a ensuite augmenté à plus de 1,96 en 2013. Le nombre de provinces ayant signalé une incidence annuelle inférieure à un cas pour un million d'habitants a augmenté de 1 en 2009 à 15 en 2012, mais est retombé à 1 en 2013. L'âge médian des cas a diminué de 83 mois en 2005 à 14 mois en 2012 et à 11 mois pendant la période allant de janvier à octobre 2013. Entre 2008 et 2012, l'incidence de la rougeole dans tous les groupes d'âge, y compris ceux qui ne sont pas ciblés pour la vaccination, a diminué d'au moins 93,6%. Cependant, la résurgence a commencé à la fin de l'année 2012 et s'est poursuivie en 2013. Parmi les cas signalés de janvier à octobre 2013, 40% étaient âgés de 8 mois à 6 ans.Bien qu'il y ait des preuves de progrès vers l'objectif d'élimination de la rougeole en Chine, la résurgence de 2013 indique que de nombreux enfants n'étaient toujours pas vaccinés à temps. La vaccination de routine doit être renforcée et les lacunes immunitaires restantes doivent être identifiées et comblées.Analizar la epidemiología del sarampión en China y determinar el progreso hecho hacia la erradicación nacional de la enfermedad.Hemos analizado los datos de vigilancia del sarampión recogidos entre enero de 2005 y octubre de 2013 en base a la edad, el sexo, la residencia y el estado de vacunación de cada caso y el resultado correspondiente, las fechas de inicio de la enfermedad y de su comunicación, y los resultados de laboratorio.Entre 2005 y octubre de 2013, se registraron 596 391 casos de sarampión y 368 muertes relacionadas con el sarampión en China. La incidencia anual, en casos por 100 000 habitantes, descendió del 9,95 en 2008 al 0,46 en 2012, pero volvió a aumentar en el 2013 hasta más del 1,96. El número de provincias que informó acerca de una incidencia anual de menos de un caso por millón de habitantes aumentó de una en 2009 a 15 en 2012, pero volvió a caer a una en 2013. La edad media de los casos disminuyó de 83 a 14 meses en 2012, y a 11 meses de enero a octubre de 2013. Entre 2008 y 2012, la incidencia del sarampión en todos los grupos de edad, incluidos los que no estaban incluidos en la vacunación, se redujo en al menos un 93,6 %. Sin embargo, un resurgimiento comenzó a finales de 2012 y continuó en 2013. De los casos comunicados de enero a octubre de 2013, el 40 % tenía entre 8 meses y 6 años.Aunque hay pruebas de los progresos hacia la erradicación del sarampión en China, el resurgimiento en el año 2013 mostró que todavía hay muchos niños que no reciben la vacuna a tiempo. Es necesario reforzar la vacunación sistemática e identificar y completar las lagunas restantes en la inmunización.تحليل وبائيات الحصبة في الصين وتحديد التقدم المحرز تجاه القضاء على الحصبة على الصعيد الوطني.أجرينا تحليلاً لبيانات ترصد الحصبة – حول العمر والجنس ومحل الإقامة وحالة التطعيم لكل حالة والنتيجة المقابلة، وتواريخ البدء والتقرير ونتائج المختبر – التي تم جمعها بين كانون الثاني/يناير 2005 وتشرين الأول/أكتوبر 2013.بين عام 2005 وتشرين الأول/أكتوبر 2013، تم الإبلاغ عن 596391 حالة حصبة و368 حالة وفاة ناجمة عن الحصبة في الصين. وانخفض معدل الحدوث السنوي، في الحالات لكل 100000 نسمة، من 9.95 في عام 2008 إلى 0.46 في عام 2012 ولكنه ارتفع بعد ذلك إلى أكثر من 1.96 في عام 2013. وزاد عدد المقاطعات التي أبلغت عن حدوث سنوي لأقل من حالة واحدة لكل مليون نسمة من حالة واحدة في عام 2009 إلى 15 في عام 2012، ولكنه انخفض مرة أخرى إلى حالة واحدة في عام 2013. وانخفض العمر المتوسط للحالة من 83 شهرا في عام 2005 إلى 14 شهرا في عام 2012 و11 شهراً في كانون الثاني/يناير 2005 إلى تشرين الأول/أكتوبر 2013. وبين عامي 2008 و2012، انخفض حدوث الحصبة في جميع الفئات العمرية، بما في ذلك تلك التي لم يستهدفها التطعيم، بنسبة 93.6 ٪ على الأقل. ومع ذلك، بدأت عودة الظهور في أواخر عام 2012 واستمر حتى عام 2013. ومن بين الحالات التي تم الإبلاغ عنها في كانون الثاني/يناير حتي تشرين الأول/أكتوبر 2013، كانت نسبة 40 ٪ في عمر 8 أشهر إلى 6 سنوات.على الرغم من وجود أدلة على إحراز تقدم نحو القضاء على الحصبة من الصين، إلا أن عودة الظهور في عام 2013 أشارت إلى أنه لا يزال هناك العديد من الأطفال الذين لا يجري تطعيمهم في الوقت المحدد. ويجب تعزيز التمنيع الروتيني، كما يتعين تحديد ثغرات المناعة المتبقية وسدها.分析中国麻疹流行病学，确定全国消除麻疹所取得的进展。我们分析了2005年1月和2013年10月之间收集的麻疹监测数据，这些数据包括每个病例的年龄、性别、居住地、疫苗接种状态和相应结局、发生和报告日期以及实验室结果。2005年至2013年10月，中国报告了596391个麻疹病例和368例与麻疹相关的死亡。每十万人口的年发病率从2008年的9.95降低到2012年的0.46，但在其后的2013年上升到1.96以上。报告年发病率少于每百万人口1个病例的省份从2009年的1个增加到2012年的15个，但是在2013年回落到1个。病例年龄中值从2005年的83个月降低到2012年的14个月和2013年1月到10月的11个月。在2008年至2012年之间，所有年龄组（包括非疫苗接种目标人群）麻疹的发病率减少了至少93.6%。但是，在2012年末开始回升，并在2013年继续了这种趋势。在2013年1月到10月报告的病例中，40%病人年龄为8个月到6岁。虽然，有证据表明中国消除麻疹取得了进展，2013年的反弹显示有的地区很多孩子仍没有及时接种疫苗。必须加强常规疫苗接种，并需要识别和填补余下的免疫空白。Проанализировать эпидемиологию кори в Китае и оценить результаты элиминации данной болезни в национальном масштабе.Были проанализированы данные эпиднадзора за корью (включающие возраст, пол, место проживания, статус вакцинации в каждом случае и соответствующий результат, даты проявления и сообщения о заболевании, а также лабораторные результаты), собранные в период с января 2005 по октябрь 2013 гг.В период с 2005 по октябрь 2013 гг. в Китае было зарегистрировано 596 391 случаев заболевания корью и 368 смертельных исходов. Ежегодная заболеваемость, измеряемая в количестве случаев на 100 000 населения, снизилась с 9,95 случаев в 2008 году до 0,46 в 2012 году, но затем превысила 1,96 случаев в 2013 году. Число провинций, сообщивших о годовой заболеваемости менее одного случая на миллион населения, увеличилось с одной в 2009 году до пятнадцати в 2012 году, но вновь уменьшилось до одной в 2013 году. Средний возраст заболевших уменьшился с 83 месяцев в 2005 году до 14 месяцев в 2012 году и до 11 месяцев в период с января по октябрь 2013 года. В 2008-2012 гг. заболеваемость корью во всех возрастных группах, включая группы, не предназначенные для вакцинации, снизилась как минимум на 93,6%. Тем не менее, в конце 2012 года наблюдался рост заболеваемости, который продолжился в 2013 году. Из числа случаев, зарегистрированных в январе-октябре 2013 года, 40% заболевших были в возрасте от 8 месяцев до 6 лет.Несмотря на имеющиеся доказательства элиминации кори в Китае, рост заболеваемости в 2013 году показал, что многие дети не проходят своевременную вакцинацию. Необходимо усилить меры по плановой иммунизации, а также определить и устранить оставшиеся пробелы в формировании иммунитета.

Background The goal of polio eradication is to complete elimination and containment of all wild, vaccine-related and Sabin polioviruses. Vaccine-derived poliovirus (VDPV) surveillance in China from 2001–2013 is summarized in this report, which has important implications for the global polio eradication initiative. Methods Acute flaccid paralysis (AFP) cases and their contacts with VDPVs isolated from fecal specimens were identified in our AFP surveillance system or by field investigation. Epidemiological and laboratory information for these children were analyzed and the reasons for the VDPV outbreak was explored. Results VDPVs were isolated from a total of 49 children in more than two-thirds of Chinese provinces from 2001–2013, including 15 VDPV cases, 15 non-polio AFP cases and 19 contacts of AFP cases or healthy subjects. A total of 3 circulating VDPVs (cVDPVs) outbreaks were reported in China, resulting in 6 cVDPVs cases who had not been vaccinated with oral attenuated poliomyelitis vaccine. Among the 4 immunodeficiency-associated VDPVs (iVDPVs) cases, the longest duration of virus excretion was about 20 months. In addition, one imported VDPV case from Myanmar was detected in Yunnan Province. Conclusions Until all wild, vaccine-related and Sabin polioviruses are eradicated in the world, high quality routine immunization and sensitive AFP surveillance should be maintained, focusing efforts on underserved populations in high risk areas.

IntroductionFollowing implementation of China's 2006–2012 Action Plan for measles elimination, which led to a nadir of measles in 2012, a resurgence started in 2013 that continued into 2014. Measles typically is a disease that mainly affects children. We investigated a community outbreak in 2014 with measles virus transmission among adults without children serving as virus reservoirs. Our investigation highlights adult susceptibility to measles.MethodsWe conducted a retrospective active case search, and analyzed confirmed case data to describe person, place, and time characteristics of the outbreak. All individuals with measles with onset during the first 2 months of the outbreak were interviewed face-to-face to determine source(s) of infection and transmission route (from whom and to whom).ResultsAmong the 280 cases, 220 (77.6%) were among ≥20-year-old adults, 24 (8.6%) were among 8–23 month olds, 22 (7.9%) were among

Background After more than 10 years without a case of wild poliovirus (WPV) in China, an outbreak occurred in 2011 in Xinjiang Uyghur Autonomous Region. Methods Acute flaccid paralysis (AFP) case surveillance was strengthened with epidemiological investigations and specimen collection and serological surveys were conducted among hospitalized patients. Results There were 21 WPV cases and 23 clinical compatible polio cases reported. WPV was isolated from 14 contacts of AFP cases and 13 in the healthy population. Incidence of WPV and clinical compatible polio cases were both highest among children

Background During August 2011–February 2012, an outbreak of type Π circulating vaccine-derived poliovirus (cVDPVs) occurred in Sichuan Province, China. Methods A field investigation of the outbreak was conducted to characterize outbreak isolates and to guide emergency response. Sequence analysis of poliovirus capsid protein VP1 was performed to determine the viral propagation, and a coverage survey was carried out for risk assessment. Results One clinical compatible polio case and three VDPV cases were determined in Ngawa County, Ngawa Tibetan and Qiang Autonomous Prefecture, Sichuan Province. Case patients were unimmunized children, 0.8–1 years old. Genetic sequencing showed that the isolates diverged from the VP1 region of the type Π Sabin strain by 5–12 nucleotides (nt) and shared the same 5 nt VP1 substitutions, which indicate single lineage of cVDPVs. Of the 7 acute flaccid paralysis cases (all>6 months) reported in Ngawa Prefecture in 2011, 4 (57.1%) cases (including 2 polio cases) did not receive oral attenuated poliovirus vaccine. Supplementary immunization activities (SIAs) were conducted in February–May, 2012, and the strain has not been isolated since. Conclusion High coverage of routine immunization should be maintained among children until WPV transmission is globally eradicated. Risk assessments should be conducted regularly to pinpoint high risk areas or subpopulations, with SIAs developed if necessary.

Background China is approaching measles elimination, but indigenous measles still circulates. County L in China has reported measles-containing vaccine (MCV) coverage rates >95% since 2000. Despite high reported coverage, a large measles outbreak occurred among young children in L County. We measured MCV coverage using 5 different methods during an investigation on this outbreak and compared our estimates with reported rates. Methods Reported coverage rates are determined by aggregating clinic-based data across the county: doses administered in each clinic divided by the number of children registered in each clinic. Our methods estimated coverage for the 2010–2012 birth cohort, and were (1) administrative method: doses administered in clinics divided by the birth cohort recorded in the Statistical Year Book, (2) house-to-house convenience-sample survey of children living near cases, (3) vaccination clinic records review, (4) determination of a convenience sample of measles outbreak cases’ vaccination statuses and using the field vaccine efficacy outbreak equation to estimate population coverage, and (5) a seroprevalence survey using a convenience sample of residual blood samples from hospitals. Results The measles outbreak totaled 215 cases, representing an incidence of 195.8 per million population. Our estimated MCV coverage rates were: (1) administrative method: 84.1%-87.0% for MCV1 and 80.3%-90.0% for MCV2, (2) in-house survey: 83.3% of 9–17 month children received MCV1, and 74.5% of 24–47 month children received MCV2, (3) clinic record review: 85.5% of 9–17 month children received MCV1, and 73.2% of 24–59 month children received MCV2, (4) field VE method: 83.6% of 9–47 month children received one or more MCV doses, and (5) serology: seropositive rates were 95%, our 5 coverage assessments all showed substantially lower coverage. China should evaluate guidelines for reporting vaccination coverage and identify feasible improvements to the assessment methods.

Background Industrialization and demographic transition generate nonstationary dynamics in human populations that can affect the transmission and persistence of infectious diseases. Decades of increasing vaccination and development have led to dramatic declines in the global burden of measles, but the virus remains persistent in much of the world. Here we show that a combination of demographic transition, as a result of declining birth rates, and reduced measles prevalence, due to improved vaccination, has shifted the age distribution of susceptibility to measles throughout China. Methods and findings We fit a novel time-varying catalytic model to three decades of age-specific measles case reporting in six provinces in China to quantify the change in the age-specific force of infection for measles virus over time. We further quantified the impact of supplemental vaccination campaigns on the reduction of susceptible individuals. The force of infection of measles has declined dramatically (90%–97% reduction in transmission rate) in three industrialized eastern provinces during the last decade, driving a concomitant increase in both the relative proportion and absolute number of adult cases, while three central and western provinces exhibited dynamics consistent with endemic persistence (24%–73% reduction in transmission rate). The reduction in susceptible individuals due to supplemental vaccination campaigns is frequently below the nominal campaign coverage, likely because campaigns necessarily vaccinate those who may already be immune. The impact of these campaigns has significantly improved over time: campaigns prior to 2005 were estimated to have achieved less than 50% reductions in the proportion susceptible in the target age classes, but campaigns from 2005 onwards reduced the susceptible proportion by 32%–87%. A limitation of this study is that it relies on case surveillance, and thus inference may be biased by age-specific variation in measles reporting. Conclusions The age distribution of measles cases changes in response to both demographic and vaccination processes. Combining both processes in a novel catalytic model, we illustrate that age-specific incidence patterns reveal regional differences in the progress to measles elimination and the impact of vaccination controls in China. The shift in the age distribution of measles susceptibility in response to demographic and vaccination processes emphasizes the importance of progressive control strategies and measures to evaluate program success that anticipate and react to this transition in observed incidence., Matthew Ferrari and colleagues use a mathematical modelling approach to explore the contribution of both demographic forces and immunization programs to the changing age-distribution of measles cases in China., Author summary Why was this study done? Though the incidence of measles has been greatly reduced, achieving elimination remains a significant public health challenge. The epidemiology of measles, in particular the age-specific patterns of incidence, is strongly influenced by both demographic rates and vaccination and control efforts. China has observed an increase in the number and proportion of measles cases in adults in recent years, a pattern that has been seen in many other countries with successful vaccination programs. Our study was designed to quantify the contribution of both demographic forces and immunization programs to the changing age distribution of measles cases in China. What did the researchers do and find? We analyzed 30 years of age-specific measles case reports from six provinces in China using a novel model that accounts for the impact of demographic change and age-targeted vaccination campaigns. We found that the increase in adult cases in China is more pronounced in eastern provinces and is consistent with indirect protection from exposure to measles infection in childhood due to herd immunity, but age incidence patterns in the central and western provinces are consistent with continued endemic measles transmission. We estimate that while historical supplemental vaccination campaigns resulted in lower immunity than expected based on coverage, recent campaigns have resulted in substantial improvements in population immunity. What do these findings mean? Progress towards measles elimination at the national level is often heterogeneous in space. Demographic and age-specific case surveillance data, linked via epidemiological models, can be integrated to provide evaluation of vaccine program performance.

Background A measles outbreak occurred in a western county of China in 2013, the year after China’s historic nadir of measles. We conducted a field investigation to identify gaps in measles vaccination coverage and immunization program weaknesses, and to provide recommendations for measles outbreak response and immunization program improvement. Methods We analyzed surveillance data from 2008 to 2013 to describe the measles epidemiology of the county. Measles-containing vaccine coverage was estimated using two methods: previously-reported administrative coverage and an estimation of coverage by clinic-kept vaccination records (n = 542). We conducted a rapid field coverage assessment in a migrant population village to evaluate coverage after emergency vaccination. We conducted a review of hospital records of measles cases to address the role hospital transmission played during the early stage of this outbreak. Results There were 153 cases in the outbreak, primarily among children too young to vaccinate, unvaccinated children less than 3 years old, and adults. Measles-containing vaccine coverage by the field assessment showed that 20% of children aged 8–17 months had zero doses, and 9% of ≥2 years old children had fewer than two doses. The vaccination statuses of all adult cases were either zero doses or unknown. At least 61% of cases had been hospitalized. The proportion of cases who had been hospital-exposed 7 to 21 days prior to rash onset decreased from 52% to 22% after hospitals strengthen their isolation measures. Conclusions This outbreak was a result of measles vaccination coverage gaps among young children and adults, and insufficient hospital isolation of cases. The lower coverage seen in the field estimation compared with reported coverage showed that reported coverage could have been overestimated. Hospitals were sites of transmission in the early stage of the outbreak. A strict hospital isolation policy could decrease spread of measles. Emergency vaccination was associated with stopping measles transmission in low coverage areas.

Background: Influenza-related hospitalizations impose a considerable economic and social burden. This study aimed to better understand the economic burden of influenza-related hospitalizations among patients in China in different age and risk categories. Methods: Laboratory-confirmed influenza-related hospitalizations between December 2009 and June 2011 from three hospitals participating in the Chinese Severe Acute Respiratory Infections (SARI) sentinel surveillance system were included in this study. Hospital billing data were collected from each hospital’s Hospital Information System (HIS) and divided into five cost categories. Demographic and clinical information was collected from medical records. Mean (range) and median (interquartile range [IQR]) costs were calculated and compared among children (#15 years), adults (16–64 years) and elderly ($65 years) groups. Factors influencing cost were analyzed. Results: A total of 106 laboratory-confirmed influenza-related hospitalizations were identified, 60% of which were children. The mean (range) direct medical cost was $1,797 ($80–$27,545) for all hospitalizations, and the median (IQR) direct medical cost was $231 ($164), $854 ($890), and $2,263 ($7,803) for children, adults, and elderly, respectively. Therapeutics and diagnostics were the two largest components of direct medical cost, comprising 57% and 23%, respectively. Cost of physician services was the lowest at less than 1%. Conclusion: Direct medical cost of influenza-related hospitalizations imposes a heavy burden on patients and their families in China. Further study is needed to provide more comprehensive evidence on the economic burden of influenza. Our study highlights the need to increase vaccination rate and develop targeted national preventive strategies.

BackgroundThe objectives of the survey were to identify the level of influenza vaccination coverage in China in three influenza seasons 2009/10 to 2011/12, and to find out potential predictors for seasonal influenza vaccination.MethodsIn September and October 2011, representative urban household telephone surveys were conducted in five provinces in China with a response rate of 6%. Four target groups were defined for analysis: 1) children ≤ 5 years old; 2) elderly persons aged ≥ 60 years old; 3) health care workers (persons working in the medical field) and 4) chronically ill persons.ResultsThe overall mean vaccination rate was 9.0%. Among the four target groups, the rate of vaccination of children aged ≤ 5 years old (mean = 26%) was highest and the rate of elderly people aged ≥ 60 years old (mean = 7.4%) was the lowest, while the rates of persons who suffer from a chronic illness (mean = 9.4%) and health care workers (9.5%) were similar. A subsidy for influenza vaccination, age group, health care workers, suffering from a chronic illness and living in Eastern China were independent significant predictors for influenza vaccination.ConclusionsThe seasonal influenza vaccination coverage rates among urban populations in selected cities and provinces in China were far below previously reported rates in developed countries. Influenza vaccination coverage rates differed widely between different target groups and provinces in China. Subsidy policy might have a positive effect on influenza vaccination rate, but further cost-effectiveness studies, as well as the vaccination rate associated factors studies are still needed to inform strategies to increase coverage.