Do pregnant persons want influenza vaccines? Knowledge, attitudes, perceptions, and practices toward influenza vaccines in 8 low- and middle-income countries.

BACKGROUND: While vaccination is the most effective way to prevent influenza infection and adverse outcomes, and despite WHO recommendations to vaccinate pregnant persons, access to seasonal influenza vaccines remains low. We explored knowledge, attitudes, and practices of pregnant persons about seasonal influenza vaccines to inform actions to improve vaccine uptake among this priority population. METHODS: We pooled individual-level data from cross-sectional surveys assessing pregnant persons' attitudes toward seasonal influenza vaccines in eight low- and middle-income countries during 2018-2019. The eight countries used a standard protocol and questionnaire to measure attitudes and intents toward influenza vaccination. We stratified by country-level (presence/absence of a national influenza vaccination program, country income group, geographic region) and individual-level factors. FINDINGS: Our analysis included 8,556 pregnant persons from eight low- and middle-income countries with and without seasonal influenza vaccination programs. Most pregnant persons (6,323, 74%) were willing to receive influenza vaccine if it was offered for free. Willingness differed by presence of an existing influenza vaccination program; acceptance was higher in countries without influenza vaccination programs (2,383, 89%) than in those with such programs (3,940, 67%, p < 0.001). INTERPRETATION: Most pregnant persons in middle-income countries, regardless of influenza vaccination program status, were willing to be vaccinated against influenza if the vaccine was provided free of charge. National investments in influenza vaccination programs may be well-received by pregnant persons, leading to averted illness both in pregnant persons themselves and in their newborn babies. FUNDING: US Centers for Disease Control and Prevention.

A comparative analysis of knowledge, attitude, and practice (KAP) towards influenza and influenza vaccination among healthcare workers in Kyrgyzstan prior to and during the COVID-19 pandemic.

INTRODUCTION: Influenza, a globally significant respiratory illness with pandemic potential, affects around 1 billion individuals annually, leading to increased risk for severe illness and mortality. Despite recommendations from the WHO Strategic Advisory Group of Experts on Immunization (SAGE) and MoH prioritization, influenza vaccination coverage rate among HCWs in Kyrgyzstan remains low, ranging between 16 % and 46 % over the past five years. Understanding the Knowledge, Attitudes, and Practices (KAP) dynamics of HCWs regarding influenza vaccinations, both before and during the COVID-19 pandemic is crucial for refining national strategies and institutional approaches to enhance vaccination coverage rates in this important risk group. METHOD: This study employed cross sectional investigations aimed at assessing KAPs among HCWs regarding influenza disease and vaccination. Conducted prior to and during the initial phase of the COVID-19 pandemic, the project involved 2400 participants from diverse medical disciplines. EPI Info was utilized to run biostatistical analyses, with descriptive and logistic regression models, to elucidate the dynamics of KAP over time. RESULTS: The findings indicate that HCWs with over 5 years of experience were more likely to get vaccinated or recommend it to patients (p = 0.000). Low confidence in vaccine effectiveness influenced on recommendations of influenza vaccination in pre-pandemic time, where insufficient (95 %CI 0.08-0.6; p = 0.003) or uncertain assurance in vaccine effectiveness (95 %CI 0.007-0.18; p = 0.000) was a barrier for vaccine promotion during the pandemic. The study underscores to consider mandatory influenza vaccination for HCWs which may impact on likelihood of flu vaccination (p = 0.001). Priority groups for influenza vaccination shifted during the COVID-19 period, emphasizing older adults, individuals with existing conditions, and HCWs, compared to the pre-pandemic focus on HCWs, children, and patients with pre-existing conditions. CONCLUSION: Our investigation provides valuable insights into HCWs KAP concerning influenza vaccination in Kyrgyzstan, highlighting the need for targeted interventions addressing factors influencing vaccine acceptance. The study suggests policy implications, advocating for the revision of national strategies to strengthen capacity building for medical staff.

Costs of in- and outpatient respiratory disease and the seasonal influenza vaccination program in Armenia - 2020-2021.

BACKGROUND: Despite the substantial global impact of influenza, there are limited economic data to guide influenza vaccination programs investments in middle-income countries. We measured the costs of influenza and the costs of an influenza vaccination program in Armenia, using a societal perspective. METHODS: During December 2022 through March 2023, retrospective cost data were collected from case-patients and healthcare providers through structured questionnaires at 15 healthcare facilities selected through stratified sampling. Medical costs included medications, laboratory costs, laboratory and diagnostic tests, and routine health care service costs and direct and indirect societal costs were included. Vaccination program costs from the 2021-2022 influenza season were identified using accounting records and categorized as: planning, distribution, training, social mobilization and outreach, supervision and monitoring, procurement, and national- and facility-level administration and storage. RESULTS: The mean costs per episode for SARI and ILI case-patients were $US 823.6 and $US 616.57, respectively. Healthcare service costs were the largest direct expenses for ILI and SARI case-patients. Total costs of the 2021-2022 influenza vaccination program to the government were $US 4,353,738, with the largest costs associated with national- and facility-level administration and storage (30% and 65% respectively). The total cost per dose administered was $US 25.61 ($US 7.73 per dose for procurement and $US 17.88 for the marginal administration cost per dose). CONCLUSIONS: These data on the costs of seasonal influenza prevention programs and the societal costs of influenza illness in Armenia may inform national vaccine policy decisions in Armenia and may be useful for other middle-income countries. Influenza vaccines, like other vaccine programs, are recognized as substantially contributing to the reduction disease burden and associated mortality and further driving economic growth. However, a formal cost-effectiveness analysis should be performed once burden of disease data are available.

Supporting National Immunization Technical Advisory Groups (NITAGs) in development of evidence-based vaccine recommendations and NITAG assessments - New tools and approaches.

Increasing opportunities for prevention of infectious diseases by new, effective vaccines and the expansion of global immunization programs across the life course highlight the importance and value of evidence-informed decision-making (EIDM) by National Immunization Technical Advisory Groups (NITAGs). The U.S. Centers for Disease Control and Prevention (CDC) and Task Force for Global Health (TFGH) have developed and made available new tools to support NITAGs in EIDM. These include a toolkit for conducting facilitated training of NITAGs, Secretariats, or work groups on the use of the Evidence to Recommendations (EtR) approach to advise Ministries of Health (MoH) on specific vaccine policies, and an eLearning module on the EtR approach for NITAG members, Secretariat and others. The CDC and TFGH have also supported final development and implementation of the NITAG Maturity Assessment Tool (NMAT) for assessing maturity of NITAG capabilities in seven functional domains. The EtR toolkit and eLearning have been widely promoted in collaboration with the World Health Organization (WHO) Headquarters and Regional Offices through workshops engaging over 30 countries to date, and the NMAT assessment tool used in most countries in 3 WHO regions (Americas, Eastern Mediterranean, African). Important lessons have been learned regarding planning and conducting trainings for multiple countries and additional ways to support countries in applying the EtR approach to complete vaccine recommendations. Priorities for future work include the need to evaluate the impact of EtR training and NMAT assessments, working with partners to expand and adapt these tools for wider use, synergizing with other approaches for NITAG strengthening, and developing the best approaches to empower NITAGs to use the EtR approach.

A qualitative assessment of influenza vaccine uptake among children in Kenya.

Background: Influenza is a significant contributor to acute respiratory infections (ARI), and children < 5 years are at increased risk of severe influenza disease. In Kenya the influenza vaccine is not included in the Kenya Expanded Programme on Immunization (KEPI). To inform roll-out of a national influenza vaccination program, we implemented an influenza vaccine demonstration project in Nakuru and Mombasa counties in Kenya from 2019 to 2021 and set out to establish factors driving influenza vaccine acceptance and hesitancy among caregivers of children aged 6-23 months. Methods: Using semi-structured questionnaires, we conducted eight focus group discussions among community members and twelve key informant interviews among healthcare workers to elicit both lay and expert opinions. Thematic analysis of the interviews was conducted using the World Health Organization's "3 Cs" model of vaccine hesitancy to determine reasons for acceptance or hesitancy of the influenza vaccine. Results: The influenza vaccine was well received among community members and healthcare workers though concerns were raised. Vaccine hesitancy was fuelled by misconceptions about reasons for introducing the vaccine (confidence), perceptions that influenza was not a serious disease (complacency) and administrative fees required at some facilities (convenience). Despite the use of various advocacy, communication and social mobilisation strategies targeted at educating the community on the influenza disease and importance of vaccination, there remained a perception of inadequate reach of the sensitization among some community members. Contextual factors such as the COVID-19 pandemic affected uptake, and parents expressed concern over the growing number of vaccines recommended for children. Conclusion: Despite lingering concerns, caregivers had their children vaccinated indicating that vaccine hesitancy exists, even among those who accepted the vaccine for their children. Efforts targeted at increasing confidence in and reducing misconceptions towards vaccines through effective communication strategies, are likely to lead to increased vaccine uptake.

Knowledge, attitudes, and practices (KAP) towards seasonal influenza and influenza vaccine among pregnant women in Kyrgyzstan: A cross-sectional study.

Influenza is an acute respiratory disease of global importance due to its pandemic potential. Pregnant women are more susceptible to severe illness and adverse outcomes of influenza, and vaccination is the most effective preventive measure for mother and infant. The coverage rate of influenza immunization in Kyrgyzstan is below national targets, despite the World Health Organization's (WHO) recommendation to prioritize pregnant women for vaccination. This study sought to understand drivers and barriers to influenza vaccine uptake in pregnant women in Kyrgyzstan. A knowledge, attitudes, and practices (KAP) survey was administered from December 2018 to March 2019 to 1,193 pregnant women aged 18 and older attending public health institutions in Kyrgyzstan. Multivariate regression analysis was used to determine the association between variables and outcomes of interest.Nearly half (56.2 %) of the 1,193 participants expressed willingness to be vaccinated during their current pregnancy. Participants with only a high school education had a significantly greater intention for vaccination (95 % CI: 1.4-3.2, p < 0.005) in the multivariate analysis compared to participants with university degrees. Participants with underlying health conditions had a higher intention of being vaccinated (95 % CI: 1.2-1.9, p < 0.005). The main reason for vaccine refusal was the belief that influenza vaccines could have adverse effects on the fetus (28.4 %); belief that vaccines could harm their pregnancy (24.3 %); and concern about vaccine effectiveness (10.6 %).These findings are important as they can inform targeted strategies and policy updates to facilitate influenza vaccine implementation and improve uptake among pregnant women in Kyrgystan, and may support strengthening of national influenza vaccine programs in other countries in Central Asia.

Resilience of routine childhood immunization services in two counties in Kenya in the face of the COVID-19 pandemic.

The recently emerged coronavirus disease 2019 (COVID-19) has caused considerable morbidity and mortality worldwide and disrupted health services. We describe the effect of the COVID-19 pandemic on utilization of childhood vaccination services during the pandemic. Using a mixed methods approach combining retrospective data review, a cross-sectional survey, focus group discussions among care givers and key informant interviews among nurses, we collected data between May and September 2021 in Mombasa and Nakuru counties. Overall, there was a <2 % decline in the number of vaccine doses administered during the pandemic period compared to the pre-pandemic period but this was statistically insignificant, both for the pentavalent-1 vaccine (ß = -0.013, p = 0.505) and the pentavalent-3 vaccine (ß = -0.012, p = 0.440). In government health facilities, there was 7.7 % reduction in the number of pentavalent-1 (ß = -0.08, p = 0.010) and 10.4 % reduction in the number of pentavalent-3 (ß = -0.11, p < 0.001) vaccine doses that were administered during the pandemic period. In non-government facilities, there was a 25.8 % increase in the number of pentavalent-1 (ß=0.23, p < 0.001) and 31.0 % increase in the number of pentavalent-3 (ß = -0.27, p < 0.001) vaccine doses that were administered facilities during the pandemic period. The strategies implemented to maintain immunization services during the pandemic period included providing messaging on the availability and importance of staying current with routine vaccination and conducting catch-up vaccinations and vaccination outreaches. Our findings suggest that the COVID-19 pandemic did not impact childhood vaccination services in Mombasa and Nakuru counties in Kenya. The private health facilities cushioned vaccination services against the effects of the pandemic and the strategies that were put in place by the ministry of health ensured continuation of vaccination services and encouraged uptake of the services during the pandemic period in the two counties in Kenya. These findings provide useful information to safeguard vaccination services during future pandemics.

Costs of seasonal influenza vaccine delivery in a pediatric demonstration project for children aged 6-23 months - Nakuru and Mombasa Counties, Kenya, 2019-2021.

BACKGROUND: During November 2019-October 2021, a pediatric influenza vaccination demonstration project was conducted in four sub-counties in Kenya. The demonstration piloted two different delivery strategies: year-round vaccination and a four-month vaccination campaign. Our objective was to compare the costs of both delivery strategies. METHODS: Cost data were collected using standardized questionnaires and extracted from government and project accounting records. We reported total costs and costs per vaccine dose administered by delivery strategy from the Kenyan government perspective in 2021 US$. Costs were separated into financial costs (monetary expenditures) and economic costs (financial costs plus the value of existing resources). We also separated costs by administrative level (national, regional, county, sub-county, and health facility) and program activity (advocacy and social mobilization; training; distribution, storage, and waste management; service delivery; monitoring; and supervision). RESULTS: The total estimated cost of the pediatric influenza demonstration project was US$ 225,269 (financial) and US$ 326,691 (economic) for the year-round delivery strategy (30,397 vaccine doses administered), compared with US$ 214,753 (financial) and US$ 242,385 (economic) for the campaign strategy (25,404 doses administered). Vaccine purchase represented the largest proportion of costs for both strategies. Excluding vaccine purchase, the cost per dose administered was US$ 1.58 (financial) and US$ 5.84 (economic) for the year-round strategy and US$ 2.89 (financial) and US$ 4.56 (economic) for the campaign strategy. CONCLUSIONS: The financial cost per dose was 83% higher for the campaign strategy than the year-round strategy due to larger expenditures for advocacy and social mobilization, training, and hiring of surge staff for service delivery. However, the economic cost per dose was more comparable for both strategies (year-round 22% higher than campaign), balanced by higher costs of operating equipment and monitoring activities for the year-round strategy. These delivery cost data provide real-world evidence to inform pediatric influenza vaccine introduction in Kenya.

Comparing performance of year-round and campaign-mode influenza vaccination strategies among children aged 6-23 months in Kenya: 2019-2021.

INTRODUCTION: In 2016, the Kenya National Immunization Technical Advisory Group requested additional programmatic and cost effectiveness data to inform the choice of strategy for a national influenza vaccination program among children aged 6-23 months of age. In response, we conducted an influenza vaccine demonstration project to compare the performance of a year-round versus campaign-mode vaccination strategy. Findings from this demonstration project will help identify essential learning lessons for a national program. METHODS: We compared two vaccine delivery strategies: (i) a year-round vaccination strategy where influenza vaccines were administered throughout the year at health facilities. This strategy was implemented in Njoro sub-county in Nakuru (November 2019 to October 2021) and Jomvu sub-county in Mombasa (December 2019 to October 2021), (ii) a campaign-mode vaccination strategy where vaccines were available at health facilities over four months. This strategy was implemented in Nakuru North sub-county in Nakuru (June to September 2021) and Likoni sub-county in Mombasa (July to October 2021). We assessed differences in coverage, dropout rates, vaccine wastage, and operational needs. RESULTS: We observed similar performance between strategies in coverage of the first dose of influenza vaccine (year-round strategy 59.7 %, campaign strategy 63.2 %). The coverage obtained in the year-round sub-counties was similar (Njoro 57.4 %; Jomvu 63.1 %); however, more marked differences between campaign sub-counties were observed (Nakuru North 73.4 %; Likoni 55.2 %). The campaign-mode strategy exceeded the cold chain capacity of participating health facilities, requiring thrice monthly instead of once monthly deliveries, and was associated with a two-fold increase in workload compared to the year-round strategy (168 vaccines administered per day in the campaign strategy versus 83 vaccines administered per day in the year-round strategy). CONCLUSION: Although both strategies had similar coverage levels, the campaign-mode strategy was associated with considerable operational needs that could significantly impact the immunization program.

Knowledge and attitude of Kenyan healthcare workers towards pandemic influenza disease and vaccination: 9 years after the last influenza pandemic.

BACKGROUND: Healthcare workers (HCWs) are at high risk of exposure and transmission of infectious respiratory pathogens like influenza. Despite the potential benefits, safety and efficacy of influenza vaccination, vaccines are still underutilized in Africa, including among HCWs. METHOD: From May-June 2018, we conducted a cross-sectional, self-administered, written survey among HCWs from seven counties in Kenya and assessed their knowledge attitudes and perceptions towards pandemic influenza disease and vaccination. Using regression models, we assessed factors that were associated with the HCW's knowledge of pandemic influenza and vaccination. RESULTS: A total of 2,035 HCWs, representing 49% of the targeted respondents from 35 health facilities, completed the question. Sixty eight percent of the HCWs had ever heard of pandemic influenza, and 80.0% of these were willing to receive pandemic influenza vaccine if it was available. On average, Kenyan HCWs correctly answered 55.0% (95% CI 54.0-55.9) of the questions about pandemic influenza and vaccination. Physicians (65.6%, 95% CI 62.5-68.7) and pharmacists (61.7%, 95% CI 57.9-65.5) scored higher compared to nurses (53.1%, 95% CI 51.7-54.5). HCWs with 5 or more years of work experience (55.8, 95% CI 54.5-57.0) had marginally higher knowledge scores compared to those with less experience (53.9%, 95% CI 52.5-55.3). Most participants who were willing to receive pandemic influenza vaccine did so to protect their relatives (88.7%) or patients (85.9%). CONCLUSION: Our findings suggest moderate knowledge of pandemic influenza and vaccination by HCWs in Kenya, which varied by cadre and years of work experience. These findings highlight the need for continued in-service health education to increase the HCW's awareness and knowledge of pandemic influenza to increase acceptance of influenza vaccination in the case of a pandemic.

Ancillary benefits of seasonal influenza vaccination in middle-income countries.

While seasonal influenza vaccines (SIV) remain the best method to prevent influenza-associated illnesses, implementing SIV programs may benefit countries beyond disease reduction, strengthening health systems and national immunization programs, or conversely, introduce new challenges. Few studies have examined perceived impacts of SIV introduction beyond disease reduction on health systems; understanding such impacts will be particularly salient in the context of COVID-19 vaccine introduction. We collected qualitative data from key informants-Partnership for Influenza Vaccine Introduction (PIVI) contacts in six middle-income PIVI vaccine recipient countries-to understand perceptions of ancillary benefits and challenges from SIV implementation. Respondents reported benefits associated with SIV introduction, including improved attitudes to SIV among risk groups (characterized by increased demand) and perceptions that SIV introduction improved relationships with other ministries and collaboration with mass media. Challenges included sustaining investment in SIV programs, as vaccine supply did not always meet coverage goals, and managing SIV campaigns.

Sociodemographic predictors of pattern and volume of alcohol consumption across Hispanics, Blacks, and Whites: 10-year trend (1992-2002).

BACKGROUND: There have been limited trend studies examining variations on the patterns of alcohol consumption among Whites, Blacks, and Hispanics in the United States. The current paper reports national trends in drinking patterns, volume of drinking (number of drinks per month), binge drinking, and drinking to intoxication among Blacks, Whites, and Hispanics over a period of 10 years and identifies sociodemographic predictors of these behaviors across the 3 ethnic groups. METHODS: Data are from the 1991 to 1992 National Longitudinal Alcohol Epidemiologic Survey (NLAES; n = 42,862) and the 2001 to 2002 National Epidemiologic Study on Alcohol and Related Conditions (NESARC; n = 43,093). Both surveys used multistage cluster sample procedures to select respondents 18 years of age and older from the U.S. household population. RESULTS: Trends varied across different dimensions of drinking and ethnic groups. There were no statistically significant differences in the mean number of drinks consumed per month among men and women in any of the 3 ethnic groups between 1992 and 2002, but there was a significant rise in the proportion of current drinkers in both genders and in all 3 ethnic groups. Multivariate analysis indicated that, compared to Whites in 1992, Blacks and Hispanics did not increase their volume of drinking, but Whites did. Drinking 5 or more drinks in day at all did not increase between 1992 and 2002, but drinking 5 or more drinks at least once a month was more likely for all groups in 2002 compared to Whites in 1992. Drinking to intoxication at all was more likely among Whites in 2002 than 1992, but drinking to intoxication at least once a month was more likely among Whites and Blacks in 2002 than 1992. CONCLUSION: The only common trend between 1992 and 2002 across both genders and 3 ethnic groups was a rise in the proportion of drinkers. There was also a rise in drinking 5 or more drinks in a day (Whites, Blacks, and Hispanics) and drinking to intoxication (Whites and Blacks), but this was limited to those reporting such drinking at least once a month. The reasons for these changes are many and may involve complex sociodemographic changes in the population. It is important for the field to closely monitor these cross-ethnic trends in alcohol consumption.

Program cost analysis of influenza vaccination of health care workers in Albania.

BACKGROUND: Since 2012, WHO has recommended influenza vaccination for health care workers (HCWs), which has different costs than routine infant immunization; however, few cost estimates exist from low- and middle-income countries. Albania, a middle-income country, has self-procured influenza vaccine for some HCWs since 2014, supplemented by vaccine donations since 2016 through the Partnership for Influenza Vaccine Introduction (PIVI). We conducted a cost analysis of HCW influenza vaccination in Albania to inform scale-up and sustainability decisions. METHODS: We used the WHO's Seasonal Influenza Immunization Costing Tool (SIICT) micro-costing approach to estimate incremental costs from the government perspective of facility-based vaccination of HCWs in Albania with trivalent inactivated influenza vaccine for the 2018-19 season based on 2016-17 season data from administrative records, key informant consultations, and a convenience sample of site visits. Scenario analyses varied coverage, vaccine presentation, and vaccine prices. RESULTS: In the baseline scenario, 13,377 HCWs (70% of eligible HCWs) would be vaccinated at an incremental financial cost of US$61,296 and economic cost of US$161,639. Vaccine and vaccination supplies represented the largest share of financial (89%) and economic costs (44%). Per vaccinated HCW financial cost was US$4.58 and economic cost was US$12.08 including vaccine and vaccination supplies (US$0.49 and US$6.76 respectively without vaccine and vaccination supplies). Scenarios with higher coverage, pre-filled syringes, and higher vaccine prices increased total economic and financial costs, although the economic cost per HCW vaccinated decreased with higher coverage as some costs were spread over more HCWs. Across all scenarios, economic costs were <0.07% of Albania's estimated government health expenditure, and <5.07% of Albania's estimated immunization program economic costs. CONCLUSIONS: Cost estimates can help inform decisions about scaling up influenza vaccination for HCWs and other risk groups.

Alcohol availability and intimate partner violence among US couples.

OBJECTIVES: We examined the relation between alcohol outlet density (the number of alcohol outlets per capita by zip code) and male-to-female partner violence (MFPV) or female-to-male partner violence (FMPV). We also investigated whether binge drinking or the presence of alcohol-related problems altered the relationship between alcohol outlet density and MFPV or FMPV. METHODS: We linked individual and couple sociodemographic and behavioral data from a 1995 national population-based sample of 1,597 couples to alcohol outlet data and 1990 US Census sociodemographic information. We used logistic regression for survey data to estimate unadjusted and adjusted odds ratios between alcohol outlet density and MFPV or FMPV along with 95% confidence intervals (CIs) and p-values. We used a design-based Wald test to derive a p-value for multiplicative interaction to assess the role of binge drinking and alcohol-related problems. RESULTS: In adjusted analysis, an increase of one alcohol outlet per 10,000 persons was associated with a 1.03-fold increased risk of MFPV (p-value for linear trend = 0.01) and a 1.011-fold increased risk of FMPV (p-value for linear trend = 0.48). An increase of 10 alcohol outlets per 10,000 persons was associated with 34% and 12% increased risk of MFPV and FMPV respectively, though the CI for the association with FMPV was compatible with no increased risk. The relationship between alcohol outlet density and MFPV was stronger among couples reporting alcohol-related problems than those reporting no problems (p-value for multiplicative interaction = 0.01). CONCLUSIONS: We found that as alcohol outlet density increases so does the risk of MFPV and that this relationship may differ for couples who do and do not report alcohol-related problems. Given that MFPV accounts for the majority of injuries related to intimate partner violence, policy makers may wish to carefully consider the potential benefit of limiting alcohol outlet density to reduce MFPV and its adverse consequences.

The partnership for influenza vaccine introduction (PIVI): Supporting influenza vaccine program development in low and middle-income countries through public-private partnerships.

Influenza vaccination remains the most effective tool for reducing seasonal influenza disease burden. Few Low and Middle-Income Countries (LMICs) have robust, sustainable annual influenza national vaccination programs. The Partnership for Influenza Vaccine Introduction (PIVI) was developed as a public-private partnership to support LMICs to develop and sustain national vaccination programs through time-limited vaccine donations and technical support. We review the first 5 years of experience with PIVI, including the concept, country progress toward sustainability, and lesson learned. Between 2013 and 2018, PIVI worked with Ministries of Health in 17 countries. Eight countries have received donated vaccines and technical support; of these, two have transitioned to sustained national support of influenza vaccination and six are increasing national support of the vaccine programs towards full transition to local vaccine program support by 2023. Nine additional countries have received technical support for building the evidence base for national policy development and/or program evaluation. PIVI has resulted in increased use of vaccines in partner countries, and early countries have demonstrated progress towards sustainability, suggesting that a model of vaccine and technical support can work in LMICs. PIVI expects to add new country partners as current countries transition to self-reliance.

Alcohol/drug exposure, HIV-related sexual risk among urban American Indian and Alaska Native Youth: evidence from a national survey.

BACKGROUND: Migration of the native populations from reservations to the urban areas has resulted in mixed ethnicities of American Indian/Alaskan Native (AIAN) children. Minority youth require special attention and services in urban schools as they disproportionately experience poverty, low educational attainment, unemployment, and single-parent status. METHODS: We used 2005 and 2007 Youth Risk Behavior Survey data to examine alcohol/drug use patterns and their association with sexual risk taking among AIAN only (single-racial) and biracial youth in combination with White, African American, or Hispanic ethnicities (N = 1178). RESULTS: Overall, one half of the students were sexually active, with significantly higher rates among males; AIAN-Black students initiated sex earlier than the other groups. Condom nonuse is higher among AIAN-Whites (>50%) compared to one third of AIAN-Hispanics and one fourth of AIAN-Blacks. Nearly 10% of all students, except AIAN-Blacks, reported lifetime use of heroin/meth. Sexual behavior was significantly associated with episodic drinking. Students with Hispanic background have twice the odds of being sexually active compared to AIANs. CONCLUSIONS: Our findings underscore growing health care needs and targeted prevention initiatives for mixed racial underserved native youth. Urban school settings have potential to deliver services and offer alcohol/drug prevention programs to address the needs of mixed racial native urban youth. Using the School Based Health Clinic model has been successful; we need to reform prevention approaches to accommodate needs of multiracial urban native youth.