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Objective To estimate the case-fatality ratio (CFR) for measles in Nepal, determine the role of risk factors, such as political instability, for measles mortality, and compare the use of a nationally representative sample of outbreaks versus routine surveillance or a localized study to establish the national CFR (nCFR). Methods This was a retrospective study of measles cases and deaths in Nepal. Through two-stage random sampling, we selected 37 districts with selection probability proportional to the number of districts in each region, and then randomly selected within each district one outbreak among all those that had occurred between 1 March and 1 September 2004. Cases were identified by interviewing a member of each and every household and tracing contacts. Bivariate analyses were performed to assess the risk factors for a high CFR and determine the time from rash onset until death. Each factor&apos;s contribution to the CFR was determined through multivariate logistic regression. From the number of measles cases and deaths found in the study we calculated the total number of measles cases and deaths for all of Nepal during the study period and in 2004. Findings We identified 4657 measles cases and 64 deaths in the study period and area. This yielded a total of about 82 000 cases and 900 deaths for all outbreaks in 2004 and a national CFR of 1.1% (95% confidence interval, CI: 0.5-2.3). CFR ranged from 0.1% in the eastern region to 3.4% in the mid-western region and was highest in politically insecure areas, in the Ganges plains and among cases < 5 years of age. Vitamin A treatment and. measles immunization were protective. Most deaths occurred during the first week of illness. Conclusion To our knowledge, this is the first CFR study based on a nationally representative sample of measles outbreaks. Routine surveillance and studies of a single outbreak may not yield an accurate nCFR. Increased fatalities associated with political insecurity are a challenge for health-care service delivery. The short period from disease onset to death and reduced mortality from treatment with vitamin A suggest the need for rapid, field-based treatment early in the outbreak. Objectif Estimer le taux de letalite (TL) pour la rougeole au Nepal, determiner le role de facteurs de risque tels que l&apos;instabilite politique dans la mortalite par rougeole et comparer les resultats obtenus en utilisant un echantillon representatif au plan national de flambees epidemiques et la surveillance de routine ou encore d&apos;une etude localisee pour etablir le taux de letalite national (TLn). Methodes Nous presentons ici une etude retrospective des cas et des deces dus a la rougeole au Nepal. Par un sondage aleatoire en deux etapes, nous avons selectionne 37 districts, la probabilite de selection etant proportionnelle au nombre de districts par region, puis nous avons selectionne au hasard dans chaque district une flambee parmi celles survenues entre le 1er mars et le 1er septembre 2004. Nous avons identifie les cas en interrogeant un membre de chacun des menages concernes et en retrouvant les contacts. Nous avons realise des analyses bivariees pour evaluer les facteurs de risque pour un taux de letalite eleve et determiner le temps ecoule entre l&apos;apparition de l&apos;eruption et le deces. Nous avons determine la contribution de chaque facteur au taux de letalite par regression logistique multivariee. A partir des nombres de cas et de deces dus a la rougeole trouves dans l&apos;etude, nous avons calcule le nombre total de cas et de deces dus a cette maladie pour l&apos;ensemble du Nepal sur la periode etudiee et en 2004. Resultats Nous avons identifie 4657 cas de rougeole et 64 deces dus a cette maladie pendant la periode et dans la zone etudiees. Nous avons ainsi abouti a un total d&apos;environ 82 000 cas et 900 deces pour l&apos;ensemble des flambees survenues en 2004 et a un TLn de 1,1 % (intervalle de confiance a 95 %, IC: 0,5-2,3). Ce taux variait de 0,1% dans l&apos;Est a 3,4 % dans la region moyen-orientale et atteignait ses niveaux les plus eleves dans les zones d&apos;insecurite politique, dans les plaines du Ganges et parmi les cas ages de moins de 5 ans. La prise de vitamine A et la vaccination antirougeoleuse jouaient un role protecteur. La plupart des deces sont survenus pendant la premiere semaine de maladie. Conclusion A notre connaissance, il s&apos;agit de la premiere etude du taux de letalite reposant sur un echantillon representatif de flambees rougeoleuses. La surveillance de routine et les etudes portant sur une seule flambee peuvent ne pas fournir une valeur exacte du TLn. L&apos;augmentation du nombre de morts liee a l&apos;insecurite politique fait obstacle a la delivrance des services de sante. La brievete du laps de temps entre l&apos;apparition de la maladie et le deces, ainsi que la baisse de la mortalite resultant de l&apos;administration de vitamine A, suggerent la necessite d&apos;un traitement rapide sur le terrain, au tout debut de la flambee. Objetivo Estimar la tasa de letalidad por sarampion en Nepal, determinar el papel de los factores de riesgo -como la inestabilidad politica- para la mortalidad por sarampion, y comparar el uso de una muestra de brotes representativa a nivel nacional y la vigilancia sistematica o los estudios Iocalizados como medidas para calcular la tasa de letalidad nacional. Metodos Se llevo a cabo un estudio retrospectivo de los casos de sarampion y las defunciones por esa causa en Nepal. Mediante muestreo aleatorio bietapico, seleccionamos 37 distritos con una probabilidad de seleccion proporcional al numero de distritos en cada region y a continuacion seleccionamos aleatoriamente dentro de cada distrito un determinado brote entre todos los que se habian producido entre el 1 de marzo y el 1 de septiembre de 2004. Se identificaron los casos entrevistando a un miembro de cada uno de los hogares y rastreando los contactos. Se realizaron analisis bifactoriales para evaluar los factores de riesgo de una tasa de letalidad alta y determinar el tiempo transcurrido entre la aparicion de la erupcion y la muerte. La contribucion de cada factor a la tasa de letalidad se determino mediante regresion logistica multifactorial. A partir del numero de casos de sarampion y de defunciones por esa causa hallados en el estudio calculamos el numero total de casos y defunciones para todo Nepal durante el periodo estudiado y en 2004. Resultados Identificamos 4657 casos de sarampion y 64 muertes atribuibles a la enfermedad en el periodo y zona estudiados. Eso se traduce en unos 82 000 casos y 900 defunciones en todos los brotes registrados en 2004 y una tasa de letalidad nacional del 1,1% (intervalo de confianza del 95%: 0,5-2,3). La tasa de letalidad se situaba entre el 0,1% de la region oriental y el 3,4% de la region medio-occidental, alcanzando su valor maximo en las zonas con inestabilidad politica, en las planicies del Ganges y entre los menores de 5 anos. El tratamiento con vitamina A y la inmunizacion antisarampionosa tenian un efecto protector. La mayoria de las defunciones se produjeron durante la primera semana de la enfermedad. Conclusion Por lo que sabemos, este es el primer estudio de la tasa de letalidad basado en una muestra nacionalmente representativa de los brotes de sarampion. La vigilancia sistematica y los estudios de un solo brote no permiten calcular con precision la tasa de letalidad nacional. El incremento de las defunciones asociado a la inestabilidad politica constituye un reto para la dispensacion de servicios de salud. El breve intervalo entre la aparicion de la enfermedad y la defuncion, asi como la disminucion de la mortalidad conseguida mediante el tratamiento con vitamina A, parecen indicar que es necesario tratar rapidamente a los afectados sobre el terreno al comienzo del brole. Une traduction en francais de ce resume figure a la fin de l&apos;article. Al final del articulo se facilita una traduccion al espanol., Introduction Estimates of measles-related deaths are critical for monitoring progress towards global measles elimination goals and for prioritizing measles control in relation to other public health interventions. However, such estimates [...]

OBJECTIVE. To examine uptake of varicella vaccine, a live attenuated vaccine licensed in 1995 and recommended in 1996 for routine vaccination of US children 12 to 18 months of age. METHODS. Data were for 178 616 children (19-35 months of age) and were collected in the 1997 to 2004 National Immunization Survey. The main outcome measures were estimated varicella vaccine coverage from 1997 to 2004, coverage among susceptible children (ie, those without a history of varicella disease), racial/ethnic disparities, risk factors for nonvaccination, missed opportunities to vaccinate simultaneously with other recommended vaccines, and projected increases in coverage after elimination of missed opportunities for simultaneous vaccination. RESULTS. Varicella vaccine coverage rates increased from 26% in 1997 to 87% in 2004. State-specific coverage rates increased 44 to 80 percentage points and were >80% in 42 states and >90% in 13 states by 2004. Coverage among susceptible children increased from 62% in 1999 to 88% in 2004. From 1998 onward, no statistically significant differences in coverage were found between white and black children, whereas Hispanic children had higher coverage rates than white children in 1998 to 2001 and 2004. Risk factors for undervaccination included living in the Midwest region, living in a household with >1 child, living in nonmetropolitan areas, living below the poverty level, having a mother who did not have a college degree, and having public providers. If missed opportunities for simultaneous vaccination had been eliminated, then coverage rates would have increased from 58% to 94% in 1999 and from 87% to 96% in 2004. CONCLUSIONS. Uptake of varicella vaccine has been steady and is an example of successful elimination of racial and ethnic disparities. Additional focus should be placed on reducing missed opportunities for simultaneous vaccination, improving coverage in rural areas and the Midwest region, and closing remaining gaps related to maternal education, provider type, and multiple-children households. Key Words varicella vaccine, racial disparities, vaccination coverage, immunization Abbreviations CDC--Centers for Disease Control and Prevention NIS--National Immunization Survey MSA--metropolitan statistical area MMR--measles-mumps-rubella Hib--Haemophilus infuenzae type b DTaP--diphtheria-tetanus-acellular pertussis VFC--Vaccines for Children SCHIP--State Children's Health Insurance Program, BEFORE THE AVAILABILITY of vaccine, almost everyone developed varicella disease (ie, chickenpox) during their lifetimes, with ~4 million cases occurring annually in the United States and leading to an estimated […]

Objective. We examined the timeliness of vaccine administration among children aged 24 to 35 months for each state of the United States and the District of Columbia. Methods. We analyzed the timeliness of vaccinations in the 2000-2002 National Immunization Survey. We used a modified Bonferroni adjustment to compare a reference state with all other states. Results. Receipt of all vaccinations as recommended ranged from 2% (Mississippi) to 26% (Massachusetts), with western states having less timeliness than eastern states. Conclusions. Vaccination coverage measures usually focus on the number of vaccinations accumulated by specified ages. Our analysis of timeliness of administration shows that children rarely receive all vaccinations as recommended. State health departments can use timeliness of vaccinations along with other measures to determine children's susceptibility to vaccine-preventable diseases and to evaluate the quality of vaccination programs. States can use the modified Bonferroni comparison to appropriately compare their results with other states. (doi:10.2105/AJPH.2004.046284)

A study is conducted to determine the extent of delay of vaccination during the first 24 months of life of children in the United States. The study concluded that more than 1 in 3 children were undervaccinated for more than 6 months during their first 24 months of life and 1 in 4 children were delayed for at least 4 vaccines.

The effects of changes in recommendations regarding administration of a hepatitis B birth dose on vaccination coverage is determined. Reductions in hepatitis B vaccine birth-dose coverage persisted after recommendations were made to resume previous newborn vaccination practices.

Objective. Mothers can be instrumental in gaining access to vaccination services for their children. This study examines maternal characteristics associated with vaccination in US preschool children. Methods. We analyzed data from 21 212 children aged 19 to 35 months in the National Immunization Survey. Bivariate and multivariate analyses were used to identify maternal characteristics associated with completion of all recommended vaccinations in these children. Results. Factors most strongly associated with under-vaccination included having mothers who were black; had less than a high school education; were divorced, separated, or widowed; had multiple children; were eligible for the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) but not participating; or had incomes below 50% of the federal poverty level. Conclusion. Because most mothers play an important role in their children&apos;s vaccination, it is important to address maternal concerns and barriers when developing public health interventions for promoting childhood vaccinations. Encouraging eligible women and their children to participate in the WIC program and providing support and encouragement for immunization to mothers with multiple children may improve early childhood vaccination coverage. Pediatrics 2003;111:1215-1218; vaccination, immunization, children, mother, maternal characteristics., ABBREVIATIONS. NIS, National Immunization Survey; WIC, Special Supplemental Nutrition Program for Women, Infants, and Children; OR, odds ratio. Vaccinations are one of the simplest and most effective ways that we [...]

Objective. To examine the timeliness of vaccine administration among infants and young children in the United States. Methods. We analyzed age at receipt of vaccines among 16 211 children aged 24 to 35 months in the 2000 National Immunization Survey and examined receipt at the recommended time of each dose and selected vaccination series, as well as receipt at 4 additional time frames: acceptably early, late, never by 24 months, and too early to be considered valid. We also examined the relationship between timeliness of vaccinations and characteristics of the child, mother, and immunization provider, using multivariate logistic regression. Results. Only 9% of children received all recommended vaccines at the recommended ages. The rates varied significantly by antigen, ranging from 24% for all Haemophilus influenzae type b doses to 75% for all hepatitis B doses as recommended. Overall, 55% of children did not receive all recommended doses by 24 months of age, and 8% of children received at least 1 vaccination dose too early to be considered valid. Factors associated with not receiving all vaccines as recommended were having more children in the household, mothers younger than 30 years, use of public providers, and multiple vaccination providers. Conclusions. By 24 months of age, 9 of 10 children received at least 1 vaccine outside the recommended age ranges. High vaccination status of children at 24 months of age does not reflect the reality that many vaccinations are not given at the appropriate ages. Timeliness of vaccination is critical to prevent disease outbreaks, protect children through their first 2 years of life, and minimize the need to repeat doses. Pediatrics 2002;110:935-939; childhood immunizations, vaccination, vaccination coverage, timeliness, age-appropriate., In the United States, the national childhood immunization schedule calls for children to receive approximately 15 vaccinations by 19 months of age and specifies ages for administration of each vaccine [...]

Abstract Background Lack of methodological rigor can cause survey error, leading to biased results and suboptimal public health response. This study focused on the potential impact of 3 methodological "shortcuts" pertaining to field surveys: relying on a single source for critical data, failing to repeatedly visit households to improve response rates, and excluding remote areas. Methods In a vaccination coverage survey of young children conducted in the Commonwealth of the Northern Mariana Islands in July 2005, 3 sources of vaccination information were used, multiple follow-up visits were made, and all inhabited areas were included in the sampling frame. Results are calculated with and without these strategies. Results Most children had at least 2 sources of data; vaccination coverage estimated from any single source was substantially lower than from all sources combined. Eligibility was ascertained for 79% of households after the initial visit and for 94% of households after follow-up visits; vaccination coverage rates were similar with and without follow-up. Coverage among children on remote islands differed substantially from that of their counterparts on the main island indicating a programmatic need for locality-specific information; excluding remote islands from the survey would have had little effect on overall estimates due to small populations and divergent results. Conclusion Strategies to reduce sources of survey error should be maximized in public health surveys. The impact of the 3 strategies illustrated here will vary depending on the primary outcomes of interest and local situations. Survey limitations such as potential for error should be well-documented, and the likely direction and magnitude of bias should be considered.

Objective: To examine changes in diabetes-related preventable hospitalization costs and to determine the contribution of each underlying factor to these changes.Research Design and Methods: We used data from the 2001-2014 U.S. National (Nationwide) Inpatient Sample (NIS) for adults (≥18 years old) to estimate the trends in hospitalization costs (2014 USD) in total and by condition (short-term complications, long-term complications, uncontrolled diabetes, and lower-extremity amputation). Using regression and growth models, we estimated the relative contribution of following underlying factors: total number of hospitalizations, rate of hospitalization, the number of people with diabetes, mean cost per admission, length of stay, and cost per day.Results: During 2001-2014, the estimated total cost of diabetes-related preventable hospitalizations increased annually by 1.6% (92.9 million USD; P < 0.001). Of this 1.6% increase, 75% (1.2%) was due to the increase in the number of hospitalizations, which is a result of a 3.8% increase in diabetes population and a 2.6% decrease in the hospitalization rate, and 25% (0.4%) was due to the increase in cost per admission, for a net result of a 1.6% increase in cost per day and a 1.3% decline in mean length of stay. By component, the cost of short-term complications, lower-extremity amputations, and long-term complications increased annually by 4.2, 1.9, and 1.5%, respectively, while the cost of uncontrolled diabetes declined annually by 2.6%.Conclusions: The total cost of diabetes-related preventable hospitalizations had been increasing during 2001-2014, mainly resulting from increases in number of people with diabetes and cost per hospitalization day. The underlying factors identified in our study could lead to efforts that may lower future hospitalization costs. [ABSTRACT FROM AUTHOR]

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