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Problem/Condition: An increasing proportion of adults have received recommended vaccinations against influenza, pneumococcal infection, and tetanus. However, in 1995, fewer than 60% of adults were vaccinated as recommended. Reporting Period Covered: 1993-1997. Description of System: Data were obtained from the state-based Behavioral Risk Factor Surveillance System (BRFSS) for 1993, 1995, and 1997 and from the National Health Interview Survey (NHIS) for 1995 to describe national, regional, and state-specific patterns of use of influenza and pneumococcal vaccines and tetanus toxoid among noninstitutionalized adults aged >/=18 years. Results: Among adults aged >/=65 years in 1995, 58% reported receiving an influenza vaccination during the previous 12 months, and 34% reported ever receiving a pneumococcal vaccination. In this age group, non-Hispanic whites were more likely to report receipt of influenza (61%) and pneumococcal vaccines (36%) than non-Hispanic blacks (40% and 22%, respectively) and Hispanics (50% and 23%, respectively). Among the 50 states and the District of Columbia, the median vaccination level among older adults (i.e., persons aged >/=65 years) increased from 51% in 1993 to 66% in 1997 for influenza vaccine, and from 28% in 1993 to 46% in 1997 for pneumococcal vaccine. Adults with chronic medical conditions had low vaccination levels. Those aged 50-64 years were more likely than those aged 18-49 years to report influenza (38% versus 20%) and pneumococcal vaccination (20% versus 12%). In 1995, the proportion of adults who reported receiving a tetanus vaccination during the previous 10 years decreased with age, from 65% among those aged 18-49 years to 54% among those aged 50-64 years and to 40% among those aged >/=65 years. In each age group, women were less likely than men to report receiving tetanus toxoid; and among adults aged >/=65 years, Hispanics and Asians/Pacific Islanders were least likely among all racial/ ethnic groups to report receiving tetanus toxoid. Interpretation: By 1995, the Healthy People 2000 objective to increase to at least 60% the proportion of persons aged >/=65 years who had received annual influenza vaccination had been achieved among non-Hispanic whites (objective 20.11). However, substantial improvement is needed among non-Hispanic blacks, Hispanics, and adults aged <65 years with high-risk medical conditions. Public Health Actions: Continued surveillance of vaccine coverage among adults will direct attention to undervaccinated populations that may be disproportionately affected by vaccine-preventable diseases. Vaccination coverage data can be used to guide efforts to increase awareness among health-care providers and the public about the benefits of vaccination, establish systems to ensure that every contact with the health-care system is used to update vaccinations, and further support financial mechanisms to increase vaccine delivery. [ABSTRACT FROM AUTHOR]

The first nationally representative, population-based study of schistosomiasis seroprevalence in Nigeria was conducted using blood samples and risk-factor data collected during the 2018 Nigeria HIV/AIDS Indicator and Impact Survey (NAIIS). Schistosomiasis seroprevalence was estimated by analyzing samples for reactivity to schistosome soluble egg antigen (SEA) in a multiplex bead assay; NAIIS survey data were assessed to identify potential risk factors for seropositivity. The SEA antibody data were available for 31,459 children aged 0 to 14 years. Overall seroprevalence was 17.2% (95% CI: 16.3-18.1%). Seropositive children were identified in every age group, including children < 5 years, and seroprevalence increased with increasing age (P < 0.0001). Several factors were associated with increased odds of seropositivity, including being a boy (odds ratio [OR] = 1.34, 95% CI: 1.24-1.45), living in a rural area (OR = 2.2, 95% CI: 1.9-2.5), and animal ownership (OR = 1.67, 95% CI: 1.52-1.85). Access to improved sanitation and drinking water sources were associated with decreased odds of seropositivity (OR = 0.52, 95% CI: 0.47-0.58 and OR = 0.53, 95% CI: 0.47-0.60, respectively) regardless of whether the child lived in a rural (sanitation: adjusted odds ratio [aOR] = 0.7, 95% CI: 0.6-0.8; drinking water: aOR = 0.7, 95% CI: 0.6-0.8) or urban area (sanitation: aOR = 0.6, 95% CI: 0.5-0.7; drinking water: aOR = 0.5, 95% CI: 0.4-0.6), highlighting the importance of these factors for schistosomiasis prevention and control. These results identified additional risk populations (children < 5 years) and a new risk factor (animal ownership) and could be used to monitor the impact of control programs.

Background: Plasmodium falciparum malaria is a leading cause of child mortality in Nigeria. Neonates are born with maternal antibodies from placental transfer which may protect against malaria infection in the first months of life. The IgG dynamics of the transition from passively transferred antimalarial antibodies to actively acquired IgG from natural exposure have not been well elucidated., Methods: Blood samples collected during a 2018 Nigeria nationwide HIV/AIDS household survey were available for 9,443 children under 5 years of age, with a subset of infants under 2 months of age having maternal samples available (n=41). Samples were assayed for the P. falciparum HRP2 antigen and anti-malarial IgG antibodies. LOESS regression examined the dynamics in IgG response in the first 5 years of life. Correlation with maternal IgG levels was assessed for mother/child pairs., Results: Consistent decreases were observed in median IgG levels against all Plasmodium spp. antigen targets for the first months of life. At a population level, P. falciparum apical membrane antigen-1 (AMA1) and merozoite surface protein-1 19kD (PfMSP1) IgG decreased during the first 12 months of life before reaching a nadir, whereas IgGs to other targets only declined for the first 4 months of life. Seropositivity showed a similar decline with the lowest seropositivity against AMA1 and PfMSP1 at 10-12 months, though remaining above 50% during the first 2 years of life in higher transmission areas. No protective association was observed between IgG positivity and P. falciparum infection in infants. Maternal antibody levels showed a strong positive correlation with infant antibody levels for all P. falciparum antigens from birth to 2 months of age, but this correlation was lost by 6 months of age., Discussion: Maternally transferred anti-malarial IgG antibodies rapidly decline during the first 6 months of life, with variations among specific antigens and malaria transmission intensity. From 3-23 months of age, there was a wide range in IgG levels for the blood-stage antigens indicating high individual variation in antibody production as children are infected with malaria. Non- falciparum species-specific antigens showed similar patterns in waning immunity and correlation with paired mother's IgG levels compared to P. falciparum antigens., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2023 Leonard, Uhomoibhi, Abubakar, Ogunniyi, Mba, Greby, Okoye, Iriemenam, Ihekweazu, Steinhardt, Rogier and NMS4 Technical Working Group.)

Background: The role of vaccine hesitancy on influenza vaccination is not clearly understood. Low influenza vaccination coverage in U.S. adults suggests that a multitude of factors may be responsible for under-vaccination or non-vaccination including vaccine hesitancy. Understanding the role of influenza vaccination hesitancy is important for targeted messaging and intervention to increase influenza vaccine confidence and uptake. The objective of this study was to quantify the prevalence of adult influenza vaccination hesitancy (IVH) and examine association of IVH beliefs with sociodemographic factors and early-season influenza vaccination., Methods: A four-question validated IVH module was included in the 2018 National Internet Flu Survey. Weighted proportions and multivariable logistic regression models were used to identify correlates of IVH beliefs., Results: Overall, 36.9% of adults were hesitant to receive an influenza vaccination; 18.6% expressed concerns about vaccination side effects; 14.8% personally knew someone with serious side effects; and 35.6% reported that their healthcare provider was not the most trusted source of information about influenza vaccinations. Influenza vaccination ranged from 15.3 to 45.2 percentage points lower among adults self-reporting any of the four IVH beliefs. Being female, age 18-49 years, non-Hispanic Black, having high school or lower education, being employed, and not having primary care medical home were associated with hesitancy., Conclusions: Among the four IVH beliefs studied, being hesitant to receiving influenza vaccination followed by mistrust of healthcare providers were identified as the most influential hesitancy beliefs. Two in five adults in the United States were hesitant to receive an influenza vaccination, and hesitancy was negatively associated with vaccination. This information may assist with targeted interventions, personalized to the individual, to reduce hesitancy and thus improve influenza vaccination acceptance., 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.)

Plasmodium falciparum (Pf) is the dominant malaria parasite in Nigeria though P. vivax (Pv), P. ovale (Po), and P. malariae (Pm) are also endemic. Blood samples (n = 31,234) were collected from children aged 0-14 years during a 2018 nationwide HIV survey and assayed for Plasmodium antigenemia, Plasmodium DNA, and IgG against Plasmodium MSP1-19 antigens. Of all children, 6.6% were estimated to have Pm infection and 1.4% Po infection with no Pv infections detected. The highest household wealth quintile was strongly protective against infection with Pm (aOR: 0.11, 95% CI: 0.05-0.22) or Po (aOR= 0.01, 0.00-0.10). Overall Pm seroprevalence was 34.2% (95% CI: 33.3-35.2) with lower estimates for Po (12.1%, 11.6-12.5) and Pv (6.3%, 6.0-6.7). Pm seropositivity was detected throughout the country with several local government areas showing >50% seroprevalence. Serological and DNA indicators show widespread exposure of Nigerian children to Pm with lower rates to Po and Pv., (© 2023. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Prevalence estimates are critical for malaria programming efforts but generating these from non-malaria surveys is not standard practice. Malaria prevalence estimates for 6-59-month-old Nigerian children were compared between two national household surveys performed simultaneously in 2018: a Demographic and Health Survey (DHS) and the Nigeria HIV/AIDS Indicator and Impact Survey (NAIIS). DHS tested via microscopy (n = 8298) and HRP2-based rapid diagnostic test (RDT, n = 11,351), and NAIIS collected dried blood spots (DBS) which were later tested for histidine-rich protein 2 (HRP2) antigen (n = 8029). National Plasmodium falciparum prevalence was 22.6% (95% CI 21.2- 24.1%) via microscopy and 36.2% (34.6- 37.8%) via RDT according to DHS, and HRP2 antigenemia was 38.3% (36.7-39.9%) by NAIIS DBS. Between the two surveys, significant rank-order correlation occurred for state-level malaria prevalence for RDT (Rho = 0.80, p < 0.001) and microscopy (Rho = 0.75, p < 0.001) versus HRP2. RDT versus HRP2 positivity showed 24 states (64.9%) with overlapping 95% confidence intervals from the two independent surveys. P. falciparum prevalence estimates among 6-59-month-olds in Nigeria were highly concordant from two simultaneous, independently conducted household surveys, regardless of malaria test utilized. This provides evidence for the value of post-hoc laboratory HRP2 detection to leverage non-malaria surveys with similar sampling designs to obtain accurate P. falciparum estimates., (© 2023. This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply.)

Objectives: Determining an accurate estimate of SARS-CoV-2 seroprevalence has been challenging in African countries where malaria and other pathogens are endemic. We compared the performance of one single-antigen assay and three multi-antigen SARS-CoV-2 IgG assays in a Nigerian population endemic for malaria., Methods: De-identified plasma specimens from SARS-CoV-2 RT-PCR positive, dried blood spot (DBS) SARS-CoV-2 RT-PCR positive, and pre-pandemic negatives were used to evaluate the performance of the four SARS-CoV-2 assays (Tetracore, SARS2MBA, RightSign, xMAP)., Results: Results showed higher sensitivity with the multi-antigen (81% (Tetracore), 96% (SARS2MBA), 85% (xMAP)) versus the single-antigen (RightSign (64%)) SARS-CoV-2 assay. The overall specificities were 98% (Tetracore), 100% (SARS2MBA and RightSign), and 99% (xMAP). When stratified based on <15 days to ≥15 days post-RT-PCR confirmation, the sensitivities increased from 75% to 88.2% for Tetracore; from 93% to 100% for the SARS2MBA; from 58% to 73% for RightSign; and from 83% to 88% for xMAP. With DBS, there was no positive increase after 15-28 days for the three assays (Tetracore, SARS2MBA, and xMAP)., Conclusion: Multi-antigen assays performed well in Nigeria, even with samples with known malaria reactivity, and might provide more accurate measures of COVID-19 seroprevalence and vaccine efficacy., Competing Interests: The authors have no conflicts of interest to declare.

Serosurveillance can provide estimates of population-level exposure to infectious pathogens and has been used extensively during the COVID-19 pandemic. Simultaneous, serological testing for multiple pathogens can be done using bead-based immunoassays to add value to disease-specific serosurveys. We conducted a validation of four SARS-CoV-2 antigens-full-length spike protein, two receptor binding domain proteins, and the nucleocapsid protein-on our existing multiplex bead assay (MBA) for enteric diseases, malaria, and vaccine preventable diseases. After determining the optimal conditions for coupling the antigens to microsphere beads, the sensitivity and specificity of the assay were determined on two instruments (Luminex-200 and MAGPIX) when testing singly (monoplex) versus combined (multiplex). Sensitivity was assessed using plasma from 87 real-time reverse transcription polymerase chain reaction (rRT-PCR) positive persons collected in March-May of 2020 and ranged from 94.3% to 96.6% for the different testing conditions. Specificity was assessed using 98 plasma specimens collected prior to December 2019 and plasma from 19 rRT-PCR negative persons and ranged from 97.4% to 100%. The positive percent agreement was 93.8% to 97.9% using 48 specimens collected > 21 days post-symptom onset, while the negative percent agreement was ≥ 99% for all antigens. Test performance was similar using monoplex or multiplex testing. Integrating SARS-CoV-2 serology with other diseases of public health interest could add significant value to public health programs that have suffered severe programmatic setbacks during the COVID-19 pandemic.

The observed epidemiology of SARS-CoV-2 in sub-Saharan Africa has varied greatly from that in Europe and the United States, with much lower reported incidence. Population-based studies are needed to estimate true cumulative incidence of SARS-CoV-2 to inform public health interventions. This study estimated SARS-CoV-2 seroprevalence in four selected states in Nigeria in October 2020. We implemented a two-stage cluster sample household survey in four Nigerian states (Enugu, Gombe, Lagos, and Nasarawa) to estimate age-stratified prevalence of SARS-CoV-2 antibodies. All individuals in sampled households were eligible for interview, blood draw, and nasal/oropharyngeal swab collection. We additionally tested participants for current/recent malaria infection. Seroprevalence estimates were calculated accounting for the complex survey design. Across all four states, 10,629 (96·5%) of 11,015 interviewed individuals provided blood samples. The seroprevalence of SARS-CoV-2 antibodies was 25·2% (95% CI 21·8-28·6) in Enugu State, 9·3% (95% CI 7·0-11·5) in Gombe State, 23·3% (95% CI 20·5-26·4) in Lagos State, and 18·0% (95% CI 14·4-21·6) in Nasarawa State. Prevalence of current/recent malaria infection ranged from 2·8% in Lagos to 45·8% in Gombe and was not significantly related to SARS-CoV-2 seroprevalence. The prevalence of active SARS-CoV-2 infection in the four states during the survey period was 0·2% (95% CI 0·1-0·4). Approximately eight months after the first reported COVID-19 case in Nigeria, seroprevalence indicated infection levels 194 times higher than the 24,198 officially reported COVID-19 cases across the four states; however, most of the population remained susceptible to COVID-19 in October 2020., Competing Interests: The authors have declared that no competing interests exist., (Copyright: This is an open access article, free of all copyright, and may be freely reproduced, distributed, transmitted, modified, built upon, or otherwise used by anyone for any lawful purpose. The work is made available under the Creative Commons CC0 public domain dedication.)

Objective: There is a need for reliable serological assays to determine accurate estimates of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) seroprevalence. Most single target antigen assays have shown some limitations in Africa. To assess the performance of a multi-antigen assay, we evaluated a commercially available SARS-CoV-2 Multi-Antigen IgG assay for human coronavirus disease 2019 (COVID-19) in Nigeria., Methods: Validation of the xMAP SARS-CoV-2 Multi-Antigen IgG assay was carried out using well-characterized SARS-CoV-2 reverse transcription polymerase chain reactive positive (97) and pre-COVID-19 pandemic (86) plasma panels. Cross-reactivity was assessed using pre-COVID-19 pandemic plasma specimens (213) from the 2018 Nigeria HIV/AIDS Indicator and Impact Survey (NAIIS)., Results: The overall sensitivity of the xMAP SARS-CoV-2 Multi-Antigen IgG assay was 75.3% [95% CI: 65.8%- 82.8%] and specificity was 99.0% [95% CI: 96.8%- 99.7%]. The sensitivity estimate increased to 83.3% [95% CI: 70.4%- 91.3%] for specimens >14 days post-confirmation of diagnosis. However, using the NAIIS pre-pandemic specimens, the false positivity rate was 1.4% (3/213)., Conclusions: Our results showed overall lower sensitivity and a comparable specificity with the manufacturer's validation. There appears to be less cross-reactivity with NAIIS pre-pandemic COVID-19 specimens using the xMAP SARS-CoV-2 Multi-Antigen IgG assay. In-country SARS-CoV-2 serology assay validation can help guide the best choice of assays in Africa., Competing Interests: The authors have declared that no competing interests exist.

Introduction: Parental vaccine hesitancy can be a barrier to routine childhood immunization and contribute to greater risk for vaccine-preventable diseases. This study examines the impact of parental vaccine hesitancy on childhood vaccination rates., Methods: This study assessed the association of parental vaccine hesitancy on child vaccination coverage with ≥4 doses of diphtheria, tetanus toxoid, and acellular pertussis vaccine; ≥1 dose of measles, mumps, and rubella vaccine; up-to-date rotavirus vaccine; and combined 7-vaccine series coverage for a sample of children aged 19-35 months using data from the 2018 and 2019 National Immunization Survey-Child (N=7,645). Adjusted differences in multivariable analyses of vaccination coverage were estimated among vaccine hesitant and nonhesitant parents and population attributable risk fraction of hesitancy on undervaccination, defined as not being up to date for each vaccine., Results: Almost a quarter of parents reported being vaccine hesitant, with the highest proportion of vaccine hesitancy among parents of children who are non-Hispanic Black (37.0%) or Hispanic (30.1%), mothers with a high school education or less (31.9%), and households living below the poverty level (35.6%). Childhood vaccination coverage for all vaccines was lower for children of hesitant than nonhesitant parents, and the population attributable fraction of hesitancy on undervaccination ranged from 15% to 25%, with the highest percentage for ≥1 dose of measles, mumps, and rubella vaccine., Conclusions: Parental vaccine hesitancy may contribute up to 25% of undervaccination among children aged 19-35 months. Implementation of strategies to address parental vaccine hesitancy is needed to improve vaccination coverage for children and minimize their risk of vaccine-preventable diseases., (Published by Elsevier Inc.)

Validated assays are essential for reliable serosurveys; however, most SARS-CoV-2 immunoassays have been validated using specimens from China, Europe, or U.S. populations. We evaluated the performance of five commercial SARS-CoV-2 immunoassays to inform their use in serosurveys in Nigeria. Four semiquantitative enzyme-linked immunosorbent assays (ELISAs) (Euroimmun anti-SARS-CoV-2 nucleocapsid protein [NCP] immunoglobulin G [IgG], Euroimmun spike SARS-CoV-2 IgG, Mologic Omega COVID-19 IgG, Bio-Rad Platelia SARS-CoV-2 Total Ab) and one chemiluminescent microparticle immunoassay (Abbott Architect SARS-CoV-2 IgG) were evaluated. We estimated the analytical performance characteristics using plasma from 100 SARS-CoV-2 PCR-positive patients from varied time points post-PCR confirmation and 100 prepandemic samples (50 HIV positive and 50 hepatitis B positive). The Bio-Rad assay failed the manufacturer-specified validation steps. The Euroimmun NCP, Euroimmun spike, and Mologic assays had sensitivities of 73.7%, 74.4%, and 76.9%, respectively, on samples taken 15 to 58 days after PCR confirmation and specificities of 97%, 100%, and 83.8%, respectively. The Abbott assay had 71.3% sensitivity and 100% specificity on the same panel. Parallel or serial algorithms combining two tests did not substantially improve the sensitivity or specificity. Our results showed lower sensitivity and, for one immunoassay, lower specificity compared to the manufacturers' results and other reported validations. Seroprevalence estimates using these assays might need to be interpreted with caution in Nigeria and similar settings. These findings highlight the importance of in-country validations of SARS-CoV-2 serological assays prior to use to ensure that accurate results are available for public health decision-making to control the COVID-19 pandemic in Africa. IMPORTANCE This study used positive and negative sample panels from Nigeria to test the performance of several commercially available SARS-CoV-2 serological assays. Using these prepandemic and SARS-CoV-2-positive samples, we found much lower levels of sensitivity in four commercially available assays than most assay manufacturer reports and independent evaluations. The use of these assays with suboptimal sensitivity and specificity in Nigeria or countries with population exposure to similar endemic pathogens could lead to a biased estimate of the seroprevalence, over- or underestimating the true disease prevalence, and limit efforts to stop the spread of SARS-CoV-2. It is important to conduct in-country validations of serological SARS-CoV-2 assays prior to their widespread use, especially in countries with limited representation in published assay validations.

Background: The need for accurate HIV annual program planning data motivated the compressed timeline for the 2018 Nigerian HIV/AIDS Indicator and Impact Survey (NAIIS). The survey team used stakeholder cooperation and responsive design, using survey process and paradata to refine survey implementation, to quickly collect high-quality data. We describe processes that led to generation of data for program and funding decisions, ensuring HIV services were funded in 2019., Setting: Nigeria is the most populous country in Africa, with approximately 195 million people in 36 states and the Federal Capital Territory. Challenges include multiple security threats, poor infrastructure, seasonal rains, and varied health system capacity., Methods: Stakeholders worked together to plan and implement NAIIS. Methods from other population-based HIV impact assessments were modified to meet challenges and the compressed timeline. Data collection was conducted in 6 webs. Responsive design included reviewing survey monitoring paradata and laboratory performance. Costs required to correct data errors, for example, staff time and transportation, were tracked., Results: NAIIS data collection was completed in 23 weeks, ahead of the originally scheduled 24 weeks. Responsive design identified and resolved approximately 68,000 interview errors, affecting approximately 62,000 households, saving about US$4.4 million in costs. Biweekly field laboratory test quality control improved from 50% to 100% throughout NAIIS., Conclusions: Cooperation across stakeholders and responsive design ensured timely release of NAIIS results and informed planning for HIV epidemic control in Nigeria. Based on NAIIS results, funds were provided to place an additional 500,000 HIV-positive Nigerians on antiretroviral therapy by the end of 2020, pushing Nigeria toward epidemic control., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Multiplex assays for malaria antigen detection can gather data from large sample sets, but considerations for the consistency and quality assurance (QA) of mass testing lack evaluation. We present a QA framework for a study occurring November 2019 to March 2020 involving 504 assay plates detecting four Plasmodium antigens: pan-Plasmodium aldolase and lactate dehydrogenase (LDH), histidine-rich protein 2 (HRP2), P. vivax LDH (PvLDH). Controls on each plate included buffer blank, antigen negative blood, and 4-point positive dilution curve. The blank and negative blood provided consistently low signal for all targets except for pAldolase, which showed variability. Positive curve signals decreased throughout the 5-month study duration but retained a coefficient of variation (CV) of < 5%, with the exception of HRP2 in month 5 (CV of 11%). Regression fittings for inter-plate control signals provided mean and standard deviations (SDs), and of 504 assay plates, 6 (1.2%) violated the acceptable deviation limits and were repeated. For the 40,272 human blood samples assayed in this study, of 161,088 potential data points (each sample × 4 antigens), 160,641 (99.7%) successfully passed quality checks. The QA framework presented here can be utilized to ensure quality of laboratory antigen detection for large sample sets.

Accurate SARS-CoV-2 serological assays are critical for COVID-19 serosurveillance. However, previous studies have indicated possible cross-reactivity of these assays, including in areas where malaria is endemic. We tested 213 well-characterized prepandemic samples from Nigeria using two SARS-CoV-2 serological assays, Abbott Architect IgG and Euroimmun NCP IgG assay, both targeting SARS-CoV-2 nucleocapsid protein. To assess antibody binding strength, an avidity assay was performed on these samples and on plasma from SARS-CoV-2 PCR-positive persons. Thirteen (6.1%) of 212 samples run on the Abbott assay and 38 (17.8%) of 213 run on the Euroimmun assay were positive. Anti- Plasmodium IgG levels were significantly higher among false positives for both Abbott and Euroimmun; no association was found with active Plasmodium falciparum infection. An avidity assay using various concentrations of urea wash in the Euroimmun assay reduced loosely bound IgG: of 37 positive/borderline prepandemic samples, 46%, 86%, 89%, and 97% became negative using 2 M, 4 M, 5 M, and 8 M urea washes, respectively. The wash slightly reduced avidity of antibodies from SARS-CoV-2 patients within 28 days of PCR confirmation; thereafter, avidity increased for all urea concentrations except 8 M. This validation found moderate to substantial cross-reactivity on two SARS-CoV-2 serological assays using samples from a setting where malaria is endemic. A simple urea wash appeared to alleviate issues of cross-reactivity.

Researchers strive to design and implement high-quality surveys to maximize the utility of the data collected. The definitions of quality and usefulness, however, vary from survey to survey and depend on the analytic needs. Survey teams must evaluate the trade-offs of various decisions, such as when results are needed and their required level of precision, in addition to practical constraints like budget, before finalizing the design. Characteristics within the concept of fit for purpose (FfP) can provide the framework for considering the trade-offs. Furthermore, this tool can enable an evaluation of quality for the resulting estimates. Implementation of a FfP framework in this context, however, is not straightforward. In this article, we provide the reader with a glimpse of a FfP framework in action for obtaining estimates on early season influenza vaccination coverage estimates and on knowledge, attitudes, behaviors, and barriers related to influenza and influenza prevention among civilian noninstitutionalized adults aged 18 years and older in the United States. The result is the National Internet Flu Survey (NIFS), an annual, two-week internet survey sponsored by the US Centers for Disease Control and Prevention. In addition to critical design decisions, we use the established NIFS FfP framework to discuss the quality of the NIFS in meeting the intended objectives. We highlight aspects that work well and other survey traits requiring further evaluation. Differences found in comparing the NIFS to the National Flu Survey, the National Health Interview Survey, and Behavioral Risk Factor Surveillance System are discussed via their respective FfP characteristics. The findings presented here highlight the importance of the FfP framework for designing surveys, defining data quality, and providing a set a metrics used to advertise the intended use of the survey data and results.

Objectives: To quantify the prevalence of parental vaccine hesitancy (VH) in the United States and examine the association of VH with sociodemographics and childhood influenza vaccination coverage., Methods: A 6-question VH module was included in the 2018 and 2019 National Immunization Survey-Flu, a telephone survey of households with children age 6 months to 17 years., Results: The percentage of children having a parent reporting they were "hesitant about childhood shots" was 25.8% in 2018 and 19.5% in 2019. The prevalence of concern about the number of vaccines a child gets at one time impacting the decision to get their child vaccinated was 22.8% in 2018 and 19.1% in 2019; the prevalence of concern about serious, long-term side effects impacting the parent's decision to get their child vaccinated was 27.3% in 2018 and 21.7% in 2019. Only small differences in VH by sociodemographic variables were found, except for an 11.9 percentage point higher prevalence of "hesitant about childhood shots" and 9.9 percentage point higher prevalence of concerns about serious, long-term side effects among parents of Black compared with white children. In both seasons studied, children of parents reporting they were "hesitant about childhood shots" had 26 percentage points lower influenza vaccination coverage compared with children of parents not reporting hesitancy., Conclusions: One in 5 children in the United States have a parent who is vaccine hesitant, and hesitancy is negatively associated with childhood influenza vaccination. Monitoring VH could help inform immunization programs as they develop and target methods to increase vaccine confidence and vaccination coverage., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2020 by the American Academy of Pediatrics.)

The Sierra Leone Trial to Introduce a Vaccine against Ebola (STRIVE), a phase 2/3 trial of investigational rVSV∆G-ZEBOV-GP vaccine, was conducted during an unprecedented Ebola epidemic. More than 8600 eligible healthcare and frontline response workers were individually randomized to immediate (within 7 days) or deferred (within 18-24 weeks) vaccination and followed for 6 months after vaccination for serious adverse events and Ebola virus infection. Key challenges included limited infrastructure to support trial activities, unreliable electricity, and staff with limited clinical trial experience. Study staff made substantial infrastructure investments, including renovation of enrollment sites, laboratories, and government cold chain facilities, and imported equipment to store and transport vaccine at ≤-60oC. STRIVE built capacity by providing didactic and practical research training to >350 staff, which was reinforced with daily review and feedback meetings. The operational challenges of safety follow-up were addressed by issuing mobile telephones to participants, making home visits, and establishing a nurse triage hotline. Before the Ebola outbreak, Sierra Leone had limited infrastructure and staff to conduct clinical trials. Without interfering with the outbreak response, STRIVE responded to an urgent need and helped build this capacity., Clinical Trials Registration: ClinicalTrials.gov [NCT02378753] and Pan African Clinical Trials Registry [PACTR201502001037220].

Introduction: Pregnant women are at risk for severe influenza-related complications; however, only 52% reported receiving an influenza vaccination during the 2013-2014 influenza season. Text4baby, a free national text service, provides influenza vaccination education and reminders to pregnant women. This study examined reported influenza vaccination during pregnancy among Text4baby participants who reported receiving influenza messages and women who reported never participating in Text4baby., Methods: Opt-in Internet Panel Surveys (April 2013 and 2014) of pregnant women collected demographic and other characteristics; influenza vaccination knowledge, attitudes, and behaviors; and Text4baby participation. Women aged 18-49 years, pregnant anytime from October to January (N=3,321) were included. Text4baby influenza message recallers reported receiving Text4baby influenza messages during their current/most recent pregnancy (n=377). Text4baby non-participants reported never receiving Text4baby messages (n=2,824). Multivariable logistic regression was performed (2014-2016) controlling for demographic and other characteristics, high-risk conditions, and provider recommendation and offer to vaccinate. Adjusted prevalence ratios (APRs) were calculated. Random sampling was assumed for this non-probability sample., Results: Text4baby recallers were more likely than non-participants to report influenza vaccination regardless of receipt of provider recommendation and/or offer to vaccinate (provider recommendation/offer APR=1.29, 95% CI=1.21, 1.37, provider recommendation/no offer APR=1.52, 95% CI=1.07, 2.17). Among women receiving neither a provider recommendation nor offer to vaccinate, Text4baby recallers were more than three times as likely to report influenza vaccination compared with non-participants (APR=3.39, 95% CI=2.03, 5.67)., Conclusions: Text4baby status was associated with higher influenza vaccination, especially among women whose provider did not recommend or offer the vaccine. Encouraging Text4baby enrollment may help ensure influenza vaccination is given to protect mothers and infants., (Copyright © 2017 American Journal of Preventive Medicine. All rights reserved.)

Background: Health care personnel (HCP) working while experiencing influenza-like illness (ILI) contribute to influenza transmission in health care settings. Studies focused on certain HCP occupations or work settings have demonstrated that some HCP often continue to work while ill., Methods: Using a national nonprobability Internet panel survey of 1,914 HCP during the 2014-2015 influenza season, we calculated the frequency of working with self-reported ILI (ie, fever and cough or sore throat) and examined reasons for working with ILI by occupation and work setting., Results: Overall, 414 (21.6%) HCP reported ILI, and 183 (41.4%) reported working with ILI (median, 3 days; range, 0-30 days). Pharmacists (67.2%) and physicians (63.2%) had the highest frequency of working with ILI. By work setting, hospital-based HCP had the highest frequency of working with ILI (49.3%). The most common reasons for working while ill included still being able to perform job duties and not feeling bad enough to miss work. Among HCP at long-term care facilities, the most common reason was inability to afford lost pay., Conclusions: More than 40% of HCP with ILI work while ill. To reduce HCP-associated influenza transmission, potential interventions could target HCP misconceptions about working while ill and paid sick leave policies., (Published by Elsevier Inc.)

Introduction: Healthcare personnel (HCP) are at risk for pertussis infection exposure or transmitting the disease to patients in their work settings. The Advisory Committee on Immunization Practices recommends tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccination for HCP to minimize these risks. This study assessed Tdap vaccination coverage among U.S. HCP by sociodemographic and occupation-related characteristics., Methods: The 2012, 2013, and 2014 Internet Panel Surveys were analyzed in 2015 to assess HCP Tdap vaccination. Effective sample sizes for 2012, 2013, and 2014 survey years were 2,038, 1613, and 1633, respectively. Missing values were assigned using multiple imputation. Multivariable logistic regression identified factors independently associated with HCP Tdap vaccination. Statistical measures were calculated with an assumption of random sampling., Results: Overall, Tdap vaccination coverage among HCP was 34.8% (95% CI=30.6%, 39.0%); 40.2% (95% CI=36.1%, 44.4%); and 42.4% (95% CI=38.7%, 46.0%) in 2012, 2013, and 2014, respectively. Nurse practitioners/physician's assistants, physicians, nurses, and HCP working in hospitals and ambulatory care settings had higher Tdap coverage. Having contact with an infant aged ≤6 months and influenza vaccination receipt were associated with increased Tdap vaccination. Non-Hispanic black race/ethnicity, having an associate/bachelor's degree, being below poverty, non-clinical personnel status, and working in a long-term care setting were associated with decreased Tdap vaccination., Conclusions: HCP Tdap vaccination coverage increased during 2012-2014; however, coverage remains low. Vaccination coverage varied widely by healthcare occupation, occupational setting, and sociodemographic characteristics. Evidence-based employer strategies used to increase HCP influenza vaccination, if applied to Tdap, may increase Tdap coverage., (Copyright © 2017 American Journal of Preventive Medicine. All rights reserved.)

Pregnant women and their infants are at increased risk for severe influenza-associated illness (1), and since 2004, the Advisory Committee on Immunization Practices (ACIP) has recommended influenza vaccination for all women who are or might be pregnant during the influenza season, regardless of the trimester of the pregnancy (2). To assess influenza vaccination coverage among pregnant women during the 2016-17 influenza season, CDC analyzed data from an Internet panel survey conducted during March 28-April 7, 2017. Among 1,893 survey respondents pregnant at any time during October 2016-January 2017, 53.6% reported having received influenza vaccination before (16.2%) or during (37.4%) pregnancy, similar to coverage during the preceding four influenza seasons. Also similar to the preceding influenza season, 67.3% of women reported receiving a provider offer for influenza vaccination, 11.9% reported receiving a recommendation but no offer, and 20.7% reported receiving no recommendation; among these women, reported influenza vaccination coverage was 70.5%, 43.7%, and 14.8%, respectively. Among women who received a provider offer for vaccination, vaccination coverage differed by race/ethnicity, education, insurance type, and other sociodemographic factors. Use of evidence-based practices such as provider reminders and standing orders could reduce missed opportunities for vaccination and increase vaccination coverage among pregnant women.

The Advisory Committee on Immunization Practices (ACIP) recommends that all health care personnel (HCP) receive an annual influenza vaccination to reduce influenza-related morbidity and mortality among HCP and their patients and to reduce absenteeism among HCP (1-4). To estimate influenza vaccination coverage among HCP in the United States during the 2016-17 influenza season, CDC conducted an opt-in Internet panel survey of 2,438 HCP. Overall, 78.6% of survey respondents reported receiving vaccination during the 2016-17 season, similar to reported coverage in the previous three influenza seasons (5). Vaccination coverage continued to be higher among HCP working in hospitals (92.3%) and lower among HCP working in ambulatory (76.1%) and long-term care (LTC) (68.0%) settings. As in previous seasons, coverage was highest among HCP who were required by their employer to be vaccinated (96.7%) and lowest among HCP working in settings where vaccination was not required, promoted, or offered on-site (45.8%). Implementing workplace strategies found to improve vaccination coverage among HCP, including vaccination requirements or active promotion of on-site vaccinations at no cost, can help ensure that HCP and patients are protected against influenza (6).

The Advisory Committee on Immunization Practices recommends annual influenza vaccination for all health care personnel to reduce influenza-related morbidity and mortality among both health care personnel and their patients (1-4). To estimate influenza vaccination coverage among U.S. health care personnel for the 2015-16 influenza season, CDC conducted an opt-in Internet panel survey of 2,258 health care personnel during March 28-April 14, 2016. Overall, 79.0% of survey participants reported receiving an influenza vaccination during the 2015-16 season, similar to the 77.3% coverage reported for the 2014-15 season (5). Coverage in long-term care settings increased by 5.3 percentage points compared with the previous season. Vaccination coverage continued to be higher among health care personnel working in hospitals (91.2%) and lower among health care personnel working in ambulatory (79.8%) and long-term care settings (69.2%). Coverage continued to be highest among physicians (95.6%) and lowest among assistants and aides (64.1%), and highest overall among health care personnel who were required by their employer to be vaccinated (96.5%). Among health care personnel working in settings where vaccination was neither required, promoted, nor offered onsite, vaccination coverage continued to be low (44.9%). An increased percentage of health care personnel reporting a vaccination requirement or onsite vaccination availability compared with earlier influenza seasons might have contributed to the overall increase in vaccination coverage during the past 6 influenza seasons.

Context: Use of Immunization information systems (IISs) by providers can improve vaccination rates by identifying missed opportunities. However, provider reporting of children's vaccination histories to IISs remains suboptimal., Objective: To assess factors associated with provider reporting to an IIS., Design: Analysis of 2006-2012 National Immunization Survey (NIS) and NIS-Teen data. NIS and NIS-Teen are ongoing random-digit-dial telephone surveys of households with children and adolescents, respectively, followed by a mail survey to providers to obtain the patient's vaccination history., Setting and Participants: A total of 115 285 children aged 19 to 35 months and 83 612 adolescents aged 13 to 17 years and their immunization providers in the United States., Main Outcome Measures: The percentage of children and adolescents with 1 or more providers reporting to or obtaining vaccination information from their local IISs. Multivariable logistic regression was used to examine patient and provider factors associated with provider reporting to IISs and adjusted prevalence of children and adolescents with 1 or more providers reporting to IISs., Results: In 2012, 79.4% of children and 77.4% of adolescents had 1 or more providers report any of their vaccination data to an IIS, and 41.9% of children and 51.5% of adolescents had providers who obtained any of their vaccination histories from an IIS. During 2006-2012, children and adolescents were more likely to have any of their vaccination data reported to an IIS if they received care from all public versus all private providers (children: 84.4% vs 69.6%, P < .0001; adolescents: 84.6% vs 66.4%, P < .0001), had 1 or more providers who ordered vaccines from a state or local health department (children: 76.7% vs 59.5%, P < .0001; adolescents: 77.0% vs 55.6%, P < .0001), or had 1 or more providers obtain vaccination information from the IIS (children: 86.1% vs 71.2%, P < .0001; adolescents: 83.7% vs 64.6%, P < .0001)., Conclusions: Health department staff should target providers less likely to use IIS services, including private providers, and providers not ordering vaccines from health departments to ensure they use IIS services.

The Advisory Committee on Immunization Practices recommends annual influenza vaccination for all health care personnel (HCP) to reduce influenza-related morbidity and mortality among both HCP and their patients and to decrease absenteeism among HCP. To estimate influenza vaccination coverage among U.S. HCP for the 2014–15 influenza season, CDC conducted an opt-in Internet panel survey of 1,914 HCP during March 31–April 15, 2015. Overall, 77.3% of HCP survey participants reported receiving an influenza vaccination during the 2014–15 season, similar to the 75.2% coverage among HCP reported for the 2013–14 season. Vaccination coverage was highest among HCP working in hospitals (90.4%) and lowest among HCP working in long-term care (LTC) settings (63.9%). By occupation, coverage was highest among pharmacists (95.3%) and lowest among assistants and aides (64.4%). Influenza vaccination coverage was highest among HCP who were required by their employer to be vaccinated (96.0%). Among HCP without an employer requirement for vaccination, coverage was higher for HCP working in settings where vaccination was offered on-site at no cost for 1 day (73.6%) or multiple days (83.9%) and lowest among HCP working in settings where vaccine was neither required, promoted, nor offered on-site (44.0%). Comprehensive vaccination strategies that include making vaccine available at no cost at the workplace along with active promotion of vaccination might help increase vaccination coverage among HCP and reduce the risk for influenza to HCP and their patients.

Pregnant women and infants are at increased risk for influenza-related complications and hospitalization. Influenza vaccination can reduce the risk for influenza-related illness among pregnant women and their infants. Since 2004, the Advisory Committee on Immunization Practices (ACIP) and the American College of Obstetricians and Gynecologists (ACOG) have recommended influenza vaccination for all women who are or will be pregnant during the influenza season, regardless of trimester of pregnancy. To assess influenza vaccination coverage among pregnant women during the 2014–15 influenza season, CDC analyzed data from an Internet panel survey conducted during March 31–April 6, 2015. Among 1,702 survey respondents who were pregnant at any time during October 2014–January 2015, 50.3% reported receiving influenza vaccination before or during pregnancy, similar to the reported coverage in the preceding season. Overall, 64.9% of respondents reported receiving a provider offer of influenza vaccination, 14.8% received a recommendation but no offer, and 20.3% received no recommendation. Vaccination coverage among these groups of women was 67.9%, 33.5%, and 8.5%, respectively. Reminder systems and standing orders that allow health care personnel other than the attending provider to assess vaccination status and administer vaccination, can help to ensure that influenza vaccination is recommended and offered to a pregnant woman at each provider visit to increase pregnant women’s vaccination coverage.

State and local jurisdictions require children to be vaccinated before starting school to maintain high vaccination coverage and protect schoolchildren from vaccine-preventable diseases. State vaccination requirements, which include school vaccination and exemption laws and health department regulations, permit medical exemptions for students with a medical contraindication to receiving a vaccine or vaccine component and may allow nonmedical exemptions for religious reasons or philosophic beliefs. To monitor state and national vaccination coverage and exemption levels among children attending kindergarten, CDC analyzes school vaccination data collected by federally funded state, local, and territorial immunization programs. This report describes vaccination coverage estimates in 49 states and the District of Columbia (DC) and vaccination exemption estimates in 46 states and DC that reported the number of children with at least one exemption among kindergartners during the 2014-15 school year. Median vaccination coverage* was 94.0% for 2 doses of measles, mumps, and rubella (MMR) vaccine; 94.2% for the local requirements for diphtheria, tetanus, and acellular pertussis vaccine (DTaP); and 93.6% for 2 doses of varicella vaccine among the 39 states and DC with a 2-dose requirement. The median percentage of any exemptions† was 1.7%. Although statewide vaccination coverage among kindergartners was high during the 2014-15 school year, geographic pockets of low vaccination coverage and high exemption levels can place children at risk for vaccine-preventable diseases. Appropriate school vaccination coverage assessments can help immunization programs identify clusters of low coverage and develop partnerships with schools and communities to ensure that children are protected from vaccine-preventable diseases.

Background: Hepatitis B (HepB) vaccination is the most effective measure to prevent HBV infection. Routine HepB vaccination was recommended for infants in 1991 and catch-up vaccination has been recommended for adolescents since in 1995. The purpose of this study is to assess HepB vaccination among adolescents 13-17 years., Methods: The 2006-2012 NIS-Teen were analyzed. Vaccination trends and coverage by birth cohort among adolescents were evaluated. Multivariable logistic regression and predictive marginal models are used to identify factors independently associated with HepB vaccination., Results: HepB vaccination coverage increased from 81.3% in 2006 to 92.8% in 2012. Coverage varied by birth cohort and 79-83% received vaccination before 2 years of age for those who were born during 1995 and 1999. Among those who had not received vaccination by 11 years of age, for the 1993-1995 birth cohorts, 9-15% were vaccinated during ages 11-12 years, and 27-37% had been vaccinated through age 16 years. Coverage among adolescents 13-17 years in 2012 ranged by state from 84.4% in West Virginia to 98.7% in Florida (median 93.3%). Characteristics independently associated with a higher likelihood of HepB vaccination included living more than 5 times above poverty level, living in Northeastern or Southern region of the United States, and having a mixed facility as their vaccination provider. Those with a hospital listed as their vaccination provider and those who did not have a well-child visit at age 11-12 years were independently associated with a lower likelihood of HepB vaccination., Conclusions: Efforts focused on groups with lower coverage may reduce disparities in coverage and prevent hepatitis B infection. Parents and providers should routinely review adolescent immunizations. Routine reminder/recall, expanded access in health care settings, and standing order programs should be incorporated into routine clinical care of adolescents., (Published by Elsevier Ltd.)

Influenza is a major cause of morbidity and mortality among older adults in the United States, who may also have chronic medical conditions that place them at high risk for complications from influenza. The U.S. Public Health Service recommended influenza vaccination of adults ≥ 65 y and chronically ill persons since 1961 and beginning with the 2010-11 influenza season, the Advisory Committee on Immunization Practices (ACIP) has expanded its recommendation to vaccinate all persons 6 months of age and older. Medicare coverage for influenza vaccination began in 1993. However, despite the presence of a safe and effective vaccine, long-standing recommendations on vaccination, and federal financial support for vaccination, vaccination levels among adults ≥ 65 y are not optimal. Studies have shown that influenza vaccination coverage among U.S. adults ≥ 65 y steadily increased from 30.1% in 1989 to 64.2% in 1997, but plateaued near 65% from 1998 to 2013. Increasing influenza vaccination coverage among older adults in the United States will require more cooperation among health-care providers, professional organizations, vaccine manufacturers, and public health departments to raise public awareness about the benefits of influenza vaccination and to ensure continued administration of vaccinations throughout the influenza season.

State and local vaccination requirements for school entry are implemented to maintain high vaccination coverage and protect schoolchildren from vaccine-preventable diseases. Each year, to assess state and national vaccination coverage and exemption levels among kindergartners, CDC analyzes school vaccination data collected by federally funded state, local, and territorial immunization programs. This report describes vaccination coverage in 49 states and the District of Columbia (DC) and vaccination exemption rates in 46 states and DC for children enrolled in kindergarten during the 2013-14 school year. Median vaccination coverage was 94.7% for 2 doses of measles, mumps, and rubella (MMR) vaccine; 95.0% for varying local requirements for diphtheria, tetanus toxoid, and acellular pertussis (DTaP) vaccine; and 93.3% for 2 doses of varicella vaccine among those states with a 2-dose requirement. The median total exemption rate was 1.8%. High exemption levels and suboptimal vaccination coverage leave children vulnerable to vaccine-preventable diseases. Although vaccination coverage among kindergartners for the majority of reporting states was at or near the 95% national Healthy People 2020 targets for 4 doses of DTaP, 2 doses of MMR, and 2 doses of varicella vaccine, low vaccination coverage and high exemption levels can cluster within communities. Immunization programs might have access to school vaccination coverage and exemption rates at a local level for counties, school districts, or schools that can identify areas where children are more vulnerable to vaccine-preventable diseases. Health promotion efforts in these local areas can be used to help parents understand the risks for vaccine-preventable diseases and the protection that vaccinations provide to their children.

The Advisory Committee on Immunization Practices recommends that all health care personnel (HCP) be vaccinated annually against influenza. Vaccination of HCP can reduce influenza-related morbidity and mortality among both HCP and their patients. To estimate influenza vaccination coverage among HCP during the 2013-14 season, CDC analyzed results of an opt-in Internet panel survey of 1,882 HCP conducted during April 1-16, 2014. Overall, 75.2% of participating HCP reported receiving an influenza vaccination during the 2013-14 season, similar to the 72.0% coverage among participating HCP reported in the 2012-13 season. Coverage was highest among HCP working in hospitals (89.6%) and lowest among HCP working in long-term care (LTC) settings (63.0%). By occupation, coverage was highest among physicians (92.2%), nurses (90.5%), nurse practitioners and physician assistants (89.6%), pharmacists (85.7%), and "other clinical personnel" (87.4%) compared with assistants and aides (57.7%) and nonclinical personnel (e.g., administrators, clerical support workers, janitors, and food service workers) (68.6%). HCP working in settings where vaccination was required had higher coverage (97.8%) compared with HCP working in settings where influenza vaccination was not required but promoted (72.4%) or settings where there was no requirement or promotion of vaccination (47.9%). Among HCP without an employer requirement for vaccination, coverage was higher for HCP working in settings where vaccination was offered on-site at no cost for 1 day (61.6%) or multiple days (80.4%) compared with HCP working in settings not offering free on-site vaccination (49.0%). Comprehensive vaccination strategies that include making vaccine available at no cost at the workplace along with active promotion of vaccination might be needed to increase vaccination coverage among HCP and minimize the risk for influenza to HCP and their patients.

Pregnant women and infants are at increased risk for influenza-related complications and hospitalization. Influenza vaccination among pregnant women can reduce their risk for respiratory illness and reduce the risk for influenza in their infants aged <6 months. Since 2004, the Advisory Committee on Immunization Practices and the American College of Obstetricians and Gynecologists have recommended influenza vaccination for all women who are or will be pregnant during the influenza season, regardless of trimester. To assess influenza vaccination coverage among pregnant women during the 2013-14 influenza season, CDC analyzed data from an Internet panel survey conducted March 31-April 11, 2014. Among 1,619 survey respondents pregnant at any time during October 2013-January 2014, 52.2% reported vaccination before or during pregnancy (17.6% before and 34.6% during pregnancy), similar to the coverage in the preceding season. Overall, 65.1% of women reported receiving a clinician recommendation and offer of influenza vaccination, 15.1% received a clinician recommendation but no offer of vaccination, and 19.8% received no clinician recommendation or offer. Vaccination coverage among these women was 70.5%, 32.0%, and 9.7%, respectively. Continued efforts are needed to encourage clinicians to strongly recommend and offer influenza vaccination to their pregnant patients.

Problem/condition: Substantial improvement in annual influenza vaccination of recommended groups is needed to reduce the health effects of influenza and reach Healthy People 2020 targets. No single data source provides season-specific estimates of influenza vaccination coverage and related information on place of influenza vaccination and concerns related to influenza and influenza vaccination., Reporting Period: 2007-08 through 2011-12 influenza seasons., Description of Systems: CDC uses multiple data sources to obtain estimates of vaccination coverage and related data that can guide program and policy decisions to improve coverage. These data sources include the National Health Interview Survey (NHIS), the Behavioral Risk Factor Surveillance System (BRFSS), the National Flu Survey (NFS), the National Immunization Survey (NIS), the Immunization Information Systems (IIS) eight sentinel sites, Internet panel surveys of health-care personnel and pregnant women, and the Pregnancy Risk Assessment and Monitoring System (PRAMS)., Results: National influenza vaccination coverage among children aged 6 months-17 years increased from 31.1% during 2007-08 to 56.7% during the 2011-12 influenza season as measured by NHIS. Vaccination coverage among children aged 6 months-17 years varied by state as measured by NIS. Changes from season to season differed as measured by NIS and NHIS. According to IIS sentinel site data, full vaccination (having either one or two seasonal influenza vaccinations, as recommended by the Advisory Committee on Immunization Practices for each influenza season, based on the child's influenza vaccination history) with up to two recommended doses for the 2011-12 season was 27.1% among children aged 6 months-8 years and was 44.3% for the youngest children (aged 6-23 months). Influenza vaccination coverage among adults aged ≥18 years increased from 33.0% during 2007-08 to 38.3% during the 2011-12 influenza season as measured by NHIS. Vaccination coverage by age group for the 2011-12 season as measured by BRFSS was <5 percentage points different from NHIS estimates, whereas NFS estimates were 6-8 percentage points higher than BRFSS estimates. Vaccination coverage among persons aged ≥18 years varied by state as measured by BRFSS. For adults aged ≥18 years, a doctor's office was the most common place for receipt of influenza vaccination (38.4%, BRFSS; 32.5%, NFS) followed by a pharmacy (20.1%, BRFSS; 19.7%, NFS). Overall, 66.9% of health-care personnel (HCP) reported having been vaccinated during the 2011-12 season, as measured by an Internet panel survey of HCP, compared with 62.4%, as estimated through NHIS. Vaccination coverage among pregnant women was 47.0%, as measured by an Internet panel survey of women pregnant during the influenza season, and 43.0%, as measured by BRFSS during the 2011-12 influenza season. Overall, as measured by NFS, 86.8% of adults aged ≥18 years rated the influenza vaccine as very or somewhat effective, and 46.5% of adults aged ≥18 years believed their risk for getting sick with influenza if unvaccinated was high or somewhat high., Interpretation: During the 2011-12 season, influenza vaccination coverage varied by state, age group, and selected populations (e.g., HCP and pregnant women), with coverage estimates well below the Healthy People 2020 goal of 70% for children aged 6 months-17 years, 70% for adults aged ≥18 years, and 90% for HCP., Public Health Actions: Continued efforts are needed to encourage health-care providers to offer influenza vaccination and to promote public health education efforts among various populations to improve vaccination coverage. Ongoing surveillance to obtain coverage estimates and information regarding other issues related to influenza vaccination (e.g., knowledge, attitudes, and beliefs) is needed to guide program and policy improvements to reduce morbidity and mortality associated with influenza by increasing vaccination rates. Ongoing comparisons of telephone and Internet panel surveys with in-person surveys such as NHIS are needed for appropriate interpretation of data and resulting public health actions. Examination of results from all data sources is necessary to fully assess the various components of influenza vaccination coverage among different populations in the United States.

Background: Seasonal influenza vaccination has been routinely recommended for adults with high-risk conditions. The Advisory Committee on Immunization Practices recommended that persons 25 to 64 years of age with high-risk conditions be one of the initial target groups to receive H1N1 vaccination during the 2009-2010 season., Methods: We used data from the 2009-2010 Behavioral Risk Factor Surveillance System survey. Vaccination levels of H1N1 and seasonal influenza vaccination among respondents 25 to 64 years with high-risk conditions were assessed. Multivariable logistic regression models were performed to identify factors independently associated with vaccination., Results: Overall, 24.8% of adults 25 to 64 years of age were identified to have high-risk conditions. Among adults 25 to 64 years of age with high-risk conditions, H1N1 and seasonal vaccination coverage were 26.3% and 47.6%, respectively. Characteristics independently associated with an increased likelihood of H1N1 vaccination were as follows: higher age; Hispanic race/ethnicity; medical insurance; ability to see a doctor if needed; having a primary doctor; a routine checkup in the previous year; not being a current smoker; and having high-risk conditions other than asthma, diabetes, and heart disease. Characteristics independently associated with seasonal influenza vaccination were similar compared with factors associated with H1N1 vaccination., Conclusion: Immunization programs should work with provider organizations to review efforts made to reach adults with high-risk conditions during the recent pandemic and assess how and where they can increase vaccination coverage during future pandemics., (Published by Mosby, Inc.)

Inmate contact with the correctional health care system provides public health professionals an opportunity to offer HIV screening to a population that might prove difficult to reach otherwise. We report on publicly funded human immunodeficiency virus (HIV) voluntary counseling, testing, and referral (VCTR) services provided to incarcerated persons in the United States. Incarcerated persons seeking VCTR services received pretest counseling and gave a blood specimen for HIV antibody testing. Specimens were considered positive if the enzyme immunoassays were repeatedly reactive and the Western blot or immunofluorescent assay was reactive. Demographics, HIV risk information, and laboratory test results were collected from each test episode. Additional counseling sessions provided more data. From 1992 to 1998, there were 527,937 records available from correctional facilities from 48 project areas; 484,277 records included a test result and 459,155 (87.0%) tests came with complete data. Overall, 3.4% (16,797) of all tests were reactive for HIV antibodies. Of reactive tests accompanied by self-reports of previous HIV test results (15,888), previous test results were 44% positive, 23% negative, 6% inconclusive or unspecified, and 27% no previous test. This indicates that 56% of positive tests were newly identified. During the study period, the number of tests per year increased three-fold. Testing increased among all racial/ethnic groups and both sexes. The largest increase was for heterosexuals who reported no other risk, followed by persons with a sex partner at risk. Overall, the greatest number of tests was reported for injection drug users (IDUs) (128,262), followed by men who have sex with men (MSM) (19,928); however, episodes for MSM doubled during the study, while for IDUs, they increased 74%. The absolute number of HIV-positive (HIV+) tests increased 50%; however, the percentage of all tests that were HIV+ decreased nearly 50% due to the increased number of tests performed. HIV+ tests fell 50% among blacks (7.6% to 3.7%), Hispanics (6.7% to 2.5%), and males (5.1% to 2.5%); 33% among females (4.5% to 3.1%); 95% among IDUs (8.6% to 4.4%); and 64% among MSM (19.3% to 11.8%). Among HIV+ episodes, those for IDUs dropped from 61.5% to 36.6%, while episodes for heterosexuals with no reported risk factor increased from 4.3% to 18.2%. The use of VCTR services by incarcerated persons rose steadily from 1992 to 1998, and 56% of HIV+ tests were newly identified. High numbers of tests that recorded risk behaviors for contracting HIV indicate that correctional facilities provide an important access point for prevention efforts.

Problem/condition: An increasing proportion of adults have received recommended vaccinations against influenza, pneumococcal infection, and tetanus. However, in 1995, fewer than 60% of adults were vaccinated as recommended., Reporting Period Covered: 1993-1997., Description of System: Data were obtained from the state-based Behavioral Risk Factor Surveillance System (BRFSS) for 1993, 1995, and 1997 and from the National Health Interview Survey (NHIS) for 1995 to describe national, regional, and state-specific patterns of use of influenza and pneumococcal vaccines and tetanus toxoid among noninstitutionalized adults aged > or = 18 years., Results: Among adults aged > or = 65 years in 1995, 58% reported receiving an influenza vaccination during the previous 12 months, and 34% reported ever receiving a pneumococcal vaccination. In this age group, non-Hispanic whites were more likely to report receipt of influenza (61%) and pneumococcal vaccines (36%) than non-Hispanic blacks (40% and 22%, respectively) and Hispanics (50% and 23%, respectively). Among the 50 states and the District of Columbia, the median vaccination level among older adults (i.e., persons aged > or = 65 years) increased from 51% in 1993 to 66% in 1997 for influenza vaccine, and from 28% in 1993 to 46% in 1997 for pneumococcal vaccine. Adults with chronic medical conditions had low vaccination levels. Those aged 50-64 years were more likely than those aged 18-49 years to report influenza (38% versus 20%) and pneumococcal vaccination (20% versus 12%). In 1995, the proportion of adults who reported receiving a tetanus vaccination during the previous 10 years decreased with age, from 65% among those aged 18-49 years to 54% among those aged 50-64 years and to 40% among those aged > or = 65 years. In each age group, women were less likely than men to report receiving tetanus toxoid; and among adults aged > or = 65 years, Hispanics and Asians/Pacific Islanders were least likely among all racial/ethnic groups to report receiving tetanus toxoid., Interpretation: By 1995, the Healthy People 2000 objective to increase to at least 60% the proportion of persons aged > or = 65 years who had received annual influenza vaccination had been achieved among non-Hispanic whites (objective 20.11). However, substantial improvement is needed among non-Hispanic blacks, Hispanics, and adults aged < 65 years with high-risk medical conditions., Public Health Actions: Continued surveillance of vaccine coverage among adults will direct attention to undervaccinated populations that may be disproportionately affected by vaccine-preventable diseases. Vaccination coverage data can be used to guide efforts to increase awareness among health-care providers and the public about the benefits of vaccination, establish systems to ensure that every contact with the health-care system is used to update vaccinations, and further support financial mechanisms to increase vaccine delivery.

Problem/condition: In 1995, a total of 55 million persons aged > or =55 years lived in the United States. The members of this large and growing segment of the population are major consumers of health care. Their access to medical and dental preventive services contributes to their likelihood of healthy later years and influences their long-term impact on the health-care delivery system., Reporting Period: 1995-1997., Description of Systems: This report summarizes data from the National Health Interview Survey (NHIS), the state-based Behavioral Risk Factor Surveillance System (BRFSS), and the Medicare Current Beneficiary Study (MCBS) to describe national, regional, and state-specific patterns of access to and use of preventive services among persons aged > or =55 years., Results: During 1995-1997, approximately 90% of persons aged > or =55 years living in the United States reported having a regular source of health-care services. However, only 75%-80% reported receiving a routine checkup during the preceding 2 years. The estimated percentage of persons who reported not being able to receive medical care because of cost was highest for those aged 55-64 years. Within this age group, the percentage was highest among Hispanics (4%) and persons without a high school diploma. Approximately 11% of Medicare beneficiaries reported delaying care be cause of cost or because they had no particular source of care. Percentage estimates varied according to age, race/ethnicity, and sociodemographic status. Approximately 95% of persons aged > or =55 years reported having their blood pressure checked during the preceding 2 years, but only 85%-88% had received a cholesterol evaluation during the preceding 5 years. The percentage of women receiving breast and cervical cancer screening decreased with increasing age, and the percentage of persons aged > or =55 years who had received some form of screening for colorectal cancer was low approximately 25% for fecal occult blood testing (FOBT) and 45% for endoscopy. State-specific rates of compliance with vaccination recommendations among persons aged > or =65 years were higher for influenza vaccine (range: 54%-74%) than for pneumococcal vaccine (range: 32%-59%), and compliance increased with advancing age. State-specific estimates of the percentage of annual dental visits varied 40%-75%, and 41%-88% of persons aged > or =65 years reported not having dental insurance., Interpretation: Access to medical services among adults living in the United States is greater for persons aged > or =65 years, compared with those aged <65 years, presumably because of Medicare coverage. In contrast, use of dental services decreased, despite increased need for preventive and restorative dental care. Although Medicare covers many medical services for older adults, financial, personal, and physical barriers to both medical and dental care create racial, regional, and sociodemographic disparities in health status and use of health services in the United States., Public Health Action: Continued surveillance of access to and use of health services among older adults (i.e., persons aged > or =65 years), as well as among persons aged 55-64 years, will help health-care providers target underserved groups, make Medicare coverage decisions, and develop public health programs to ensure equitable access to services and improve the health of older adults.