A case study of an influenza vaccination program for health care workers in Vietnam.

BACKGROUND: In 2017, the Vietnam Ministry of Health conducted a demonstration project to introduce seasonal influenza vaccination to health care workers. A total of 11,000 doses of influenza vaccine, single-dose prefilled syringes, were provided free to HCWs at 29 selected hospitals, clinics, and research institutes in four provinces: Hanoi, Khanh Hoa, Dak Lak and Ho Chi Minh City. METHODS: Before the campaign, a workshop was organized to discuss an implementation plan including technical requirements, cold chain, uptake reporting, and surveillance for adverse events following immunization. All sites distributed communication materials and encouraged their staff to register for vaccination. Following immunization sessions, sites sent reports on uptake and adverse events following immunization. Left-over vaccine was transferred to other sites to maximize vaccine use. RESULTS: The average uptake was 57% for all health care workers, with 11 sites achieving 90% and above. These 11 sites were small with less than 500 staff, including 5 primary hospitals, 3 preventive medicine units, and 2 referral hospitals. Among the six biggest sites with over 1000 staff, four sites had the lowest uptake (14-47%). Most of the high-uptake sites were from the central to the south; only one site, a referral hospital, was from the north. After redistribution of left-over vaccine, only 130 vaccine doses (1.2%) were not used and destroyed. Based on factors that affected uptake, including registration levels, differing communication strategies, availability of vaccination, and commitment by health facility leaders, we recommended ways to increase health care worker coverage; recommendations to improve reporting adverse events following immunization were also made. CONCLUSIONS: The project demonstrated that it was feasible to conduct influenza vaccination campaigns among health care workers in Vietnam. Improvements in promotion of registration, more intense pre-planning, especially at larger facilities, and wider, more consistent availability of communication materials will result in increased efficiency and coverage in this program's future expansion.

Japanese Encephalitis Surveillance and Immunization - Asia and Western Pacific Regions, 2016.

Japanese encephalitis (JE) virus is the most important vaccine-preventable cause of encephalitis in the Asia-Pacific region. The World Health Organization (WHO) recommends integration of JE vaccination into national immunization schedules in all areas where the disease is a public health priority (1). This report updates a previous summary of JE surveillance and immunization programs in Asia and the Western Pacific in 2012 (2). Since 2012, funding for JE immunization has become available through the GAVI Alliance, three JE vaccines have been WHO-prequalified,* and an updated WHO JE vaccine position paper providing guidance on JE vaccines and vaccination strategies has been published (1). Data for this report were obtained from a survey of JE surveillance and immunization practices administered to health officials in countries with JE virus transmission risk, the 2015 WHO/United Nations Children's Fund Joint Reporting Form on Immunization, notes and reports from JE meetings held during 2014-2016, published literature, and websites. In 2016, 22 (92%) of 24 countries with JE virus transmission risk conducted JE surveillance, an increase from 18 (75%) countries in 2012, and 12 (50%) countries had a JE immunization program, compared with 11 (46%) countries in 2012. Strengthened JE surveillance, continued commitment, and adequate resources for JE vaccination should help maintain progress toward prevention and control of JE.

Prevalence of asymptomatic poliovirus infection in older children and adults in northern India: analysis of contact and enhanced community surveillance, 2009.

BACKGROUND: In 2009, enhanced poliovirus surveillance was established in polio-endemic areas of Uttar Pradesh and Bihar, India, to assess poliovirus infection in older individuals. METHODS: In Uttar Pradesh, stool specimens from asymptomatic household and neighborhood contacts of patients with laboratory-confirmed polio were tested for polioviruses. In Bihar, in community-based surveillance, children and adults from 250 randomly selected households in the Kosi River area provided stool and pharyngeal swab samples that were tested for polioviruses. A descriptive analysis of surveillance data was performed. RESULTS: In Uttar Pradesh, 89 of 1842 healthy contacts of case patients with polio (4.8%) were shedding wild poliovirus (WPV); 54 of 85 (63.5%) were ≥5 years of age. Shedding was significantly higher in index households than in neighborhood households (P<.05). In Bihar, 11 of 451 healthy persons (2.4%) were shedding WPV in their stool; 6 of 11 (54.5%) were ≥5 years of age. Mean viral titer was similar in older and younger children. CONCLUSIONS: A high proportion of persons≥5 years of age were asymptomatically shedding polioviruses. These findings provide indirect evidence that older individuals could have contributed to community transmission of WPV in India. Polio vaccination campaigns generally target children<5 years of age. Expanding this target age group in polio-endemic areas could accelerate polio eradication.

Maternal, fetal, and neonatal outcomes associated with measles during pregnancy: Namibia, 2009-2010.

BACKGROUND: Previous studies of maternal, fetal, and neonatal complications of measles during pregnancy suggest the possibility of increased risk for morbidity and mortality. In 2009-2011, a nationwide laboratory-confirmed measles outbreak occurred in Namibia, with 38% of reported cases among adults. This outbreak provided an opportunity to describe clinical features of measles in pregnant women and assess the relative risk for adverse maternal, fetal, and neonatal outcomes. METHODS: A cohort of pregnant women with clinical measles was identified retrospectively from 6 district hospitals and clinics over a 12-month period. Each pregnant woman with measles was matched with 3 pregnant women without measles, randomly selected from antenatal clinic registers at the same hospital during the same time interval. We reviewed hospital and clinic records and conducted in-person interviews to collect demographic and clinical information on the pregnant women and their infants. RESULTS: Of 55 pregnant women with measles, 53 (96%) were hospitalized; measles-related complications included diarrhea (60%), pneumonia (40%), and encephalitis (5%). Among pregnant women with known human immunodeficiency virus (HIV) status, 15% of those without measles and 19% of those with measles were HIV positive. Of 42 measles-related pregnancies with known outcomes, 25 (60%) had ≥1 adverse maternal, fetal, or neonatal outcome and 5 women (12%) died. Compared with 172 pregnancies without measles, after adjusting for age, pregnancies with measles carried significantly increased risks for neonatal low birth weight (adjusted relative risk [aRR] = 3.5; 95% confidence interval [CI], 1.5-8.2), spontaneous abortion (aRR = 5.9; 95% CI, 1.8-19.7), intrauterine fetal death (aRR = 9.0; 95% CI, 1.2-65.5), and maternal death (aRR = 9.6; 95% CI, 1.3-70.0). CONCLUSIONS: Our findings suggest that measles virus infection during pregnancy confers a high risk of adverse maternal, fetal, and neonatal outcomes, including maternal death. Maximizing measles immunity among women of childbearing age would decrease the incidence of gestational measles and the attendant maternal, fetal, and neonatal morbidity and mortality.

Maternal and child health epidemic-assistance investigations, 1946-2005.

In this article, the authors focus on epidemic-assistance investigations that dealt with maternal and child health problems, including unintended and adolescent pregnancy and family planning; international reproductive health surveys among refugees; pregnancy outcomes, including abortion, maternal mortality, infant mortality, and birth defects; leukemia; and Reye syndrome. During 1946-2005, a total of 1,969 investigations had sufficient data to classify them as possibly related to maternal and child health and were characterized by distinctive periods. Those related to family planning, pregnancy intention, and reproductive health among refugees began in the early 1970s and continued through 2005. Abortion-related investigations occurred during 1971-1982. Investigations of non-abortion-related maternal morbidity and mortality began in 1979 and included 2 international epidemic-assistance investigations. Investigations of clusters of disease among infants began in the 1960s, with a special focus on Reye syndrome during 1964-1984. Investigations of childhood cancer and birth defects began in the late 1950s. The Centers for Disease Control and Prevention has used the epidemic-assistance investigations mechanism to respond to a wide range of health concerns of women and children. The investigations of abortion-related health problems might have had the best-documented impact on public policy and public health.

Association between obesity during pregnancy and increased use of health care.

BACKGROUND: In the United States, obesity during pregnancy is common and increases obstetrical risks. An estimate of the increase in use of health care services associated with obesity during pregnancy is needed. METHODS: We used electronic data systems of a large U.S. group-practice health maintenance organization to identify 13,442 pregnancies among women 18 years of age or older at the time of conception that resulted in live births or stillbirths. The study period was between January 1, 2000, and December 31, 2004. We assessed associations between measures of use of health care services and body-mass index (BMI, defined as the weight in kilograms divided by the square of the height in meters) before pregnancy or in early pregnancy. The women were categorized as underweight (BMI <18.5), normal (BMI 18.5 to 24.9), overweight (BMI 25.0 to 29.9), obese (BMI 30.0 to 34.9), very obese (BMI 35.0 to 39.9), or extremely obese (BMI > or =40.0). The primary outcome was the mean length of hospital stay for delivery. RESULTS: After adjustment for age, race or ethnic group, level of education, and parity, the mean (+/-SE) length of hospital stay for delivery was significantly (P<0.05) greater among women who were overweight (3.7+/-0.1 days), obese (4.0+/-0.1 days), very obese (4.1+/-0.1 days), and extremely obese (4.4+/-0.1 days) than among women with normal BMI (3.6+/-0.1 days). A higher-than-normal BMI was associated with significantly more prenatal fetal tests, obstetrical ultrasonographic examinations, medications dispensed from the outpatient pharmacy, telephone calls to the department of obstetrics and gynecology, and prenatal visits with physicians. A higher-than-normal BMI was also associated with significantly fewer prenatal visits with nurse practitioners and physician assistants. Most of the increase in length of stay associated with higher BMI was related to increased rates of cesarean delivery and obesity-related high-risk conditions. CONCLUSIONS: Obesity during pregnancy is associated with increased use of health care services.

Preparing for influenza after 2009 H1N1: special considerations for pregnant women and newborns.

Pregnant women and their newborn infants are at increased risk for influenza-associated complications, based on data from seasonal influenza and influenza pandemics. The Centers for Disease Control and Prevention (CDC) developed public health recommendations for these populations in response to the 2009 H1N1 pandemic. A review of these recommendations and information that was collected during the pandemic is needed to prepare for future influenza seasons and pandemics. The CDC convened a meeting entitled "Pandemic Influenza Revisited: Special Considerations for Pregnant Women and Newborns" on August 12-13, 2010, to gain input from experts and key partners on 4 main topics: antiviral prophylaxis and therapy, vaccine use, intrapartum/newborn (including infection control) issues, and nonpharmaceutical interventions and health care planning. Challenges to communicating recommendations regarding influenza to pregnant women and their health care providers were also discussed. After careful consideration of the available information and individual expert input, the CDC updated its recommendations for these populations for future influenza seasons and pandemics.

Impact of maternal immunization on influenza hospitalizations in infants.

We sought to determine whether maternal vaccination during pregnancy was associated with a reduced risk of laboratory-confirmed influenza hospitalizations in infants <6 months old. Active population-based, laboratory-confirmed influenza surveillance was conducted in children hospitalized with fever and/or respiratory symptoms in 3 US counties from November through April during the 2002 through 2009 influenza seasons. The exposure, influenza vaccination during pregnancy, and the outcome, positive/negative influenza testing among their hospitalized infants, were compared using logistic regression analyses. Among 1510 hospitalized infants <6 months old, 151 (10%) had laboratory-confirmed influenza and 294 (19%) mothers reported receiving influenza vaccine during pregnancy. Eighteen (12%) mothers of influenza-positive infants and 276 (20%) mothers of influenza-negative infants were vaccinated (unadjusted odds ratio, 0.53; 95% confidence interval, 0.32-0.88 and adjusted odds ratio, 0.52; 95% confidence interval, 0.30-0.91). Infants of vaccinated mothers were 45-48% less likely to have influenza hospitalizations than infants of unvaccinated mothers. Our results support the current influenza vaccination recommendation for pregnant women.

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.

Using death certificates to characterize sudden infant death syndrome (SIDS): opportunities and limitations.

OBJECTIVE: To examine cause-of-death terminology written on death certificates for sudden infant death syndrome (SIDS) and to determine the adequacy of this text data in more fully describing circumstances potentially contributing to SIDS deaths. STUDY DESIGN: With 2003 and 2004 US mortality files, we analyzed all deaths that were assigned the underlying cause-of-death code for SIDS (R95). With the terminology written on the death certificates, we grouped cases into SIDS-related cause-of-death subcategories and then assessed the percentage of cases in each subcategory with contributory or possibly causal factors described on the certificate. RESULTS: Of the 4408 SIDS-coded deaths, we subcategorized 67.2% as "SIDS" and 11.0% as "sudden unexplained (or unexpected) infant death." The terms "probable SIDS" (2.8%) and "consistent with SIDS" (4.6%) were found less frequently. Of those death certificates that described additional factors, "bedsharing or unsafe sleep environment" was mentioned approximately 80% of the time. Most records (79.4%) did not mention any additional factors. CONCLUSION: Our death certificate analysis of the cause-of-death terminology provided a unique opportunity to more accurately characterize SIDS-coded deaths. However, the death certificate was still limited in its ability to more fully describe the circumstances leading to SIDS death, indicating the need for a more comprehensive source of SIDS data, such as a case registry.

Seasonal influenza vaccination in middle-income countries: Assessment of immunization practices in Belarus, Morocco, and Thailand.

BACKGROUND: Vaccines for the control of seasonal influenza are recommended by the World Health Organization (WHO) for use in specific risk groups, but their use requires operational considerations that may challenge immunization programs. Several middle-income countries have recently implemented seasonal influenza vaccination. Early program evaluation following vaccine introduction can help ascertain positive lessons learned and areas for improvement. METHODS: An influenza vaccine post-introduction evaluation (IPIE) tool was developed jointly by WHO and the U.S. Centers for Disease Control and Prevention to provide a systematic approach to assess influenza vaccine implementation processes. The tool was used in 2017 in three middle-income countries: Belarus, Morocco and Thailand. RESULTS: Data from the three countries highlighted a number of critical factors: Health workers (HWs) are a key target group, given their roles as key influencers of acceptance by other groups, and for ensuring vaccine delivery and improved coverage. Despite WHO recommendations, pregnant women were not always prioritized and may present unique challenges for acceptance. Target group denominators need to be better defined, and vaccine coverage should be validated with vaccine distribution data, including from the private sector. There is a need for strengthening adverse events reporting and for addressing potential vaccine hesitancy through the establishment of risk communication plans. The assessments led to improvements in the countries' influenza vaccination programs, including a revision of policies, changes in vaccine management and coverage estimation, enhanced strategies for educating HWs and intensified collaboration between departments involved in implementing seasonal influenza vaccination. CONCLUSION: The IPIE tool was found useful for delineating operational strengths and weaknesses of seasonal influenza vaccination programs. HWs emerged as a critical target group to be addressed in follow-up action. Findings from this study can help direct influenza vaccination programs in other countries, as well as contribute to pandemic preparedness efforts. The updated IPIE tool is available on the WHO website http://www.who.int/immunization/research/development/influenza/en/index1.html.

Gestational weight gain among US women who deliver twins, 2001-2006.

OBJECTIVE: Current guidelines recommend a gestational weight gain of 35-45 pounds for a twin pregnancy, but actual levels of weight gain during pregnancy among US women delivering twins are currently unknown. STUDY DESIGN: We assessed gestational weight gain among 6345 US women who delivered twins from 2001 to 2006, using data collected from 28 states and New York City participating in a population-based surveillance system (PRAMS). RESULTS: Approximately one-third of mothers who delivered twins gained 45 pounds or more during pregnancy. Weight gains were higher among women with lower prepregnancy body mass indexes. The percentage of twins with a normal birthweight increased with increasing gestational weight gains, except among obese women with the highest level of gain (>/= 65 pounds). CONCLUSION: A notable percentage of US women who deliver twins gain above the current guidelines. The benefits of high gestational weight gain during twin pregnancies need to be balanced against an increased risk of maternal weight retention and later obesity.

Gestational weight gain by body mass index among US women delivering live births, 2004-2005: fueling future obesity.

OBJECTIVE: Current pregnancy weight gain guidelines are based on prepregnancy body mass indices (BMI), but gestational weight gains by BMI class among US women are unknown. STUDY DESIGN: We assessed the amount of gestational weight gain among 52,988 underweight, normal-weight, overweight, and obese US women who delivered a singleton, full-term infant in 2004-2005. Excessive weight gain during pregnancy was defined as gaining 35 or more pounds for normal-weight and 25 or more pounds for overweight women. RESULTS: Approximately 40% of normal-weight and 60% of overweight women gained excessive weight during pregnancy. Obese women gained the least, although one-fourth of these women gained 35 or more pounds. Excessive weight gain levels were highest among women aged 19-years-old or younger and those having their first birth. CONCLUSION: Excessive gestational weight gains were common, especially among the youngest and those who were nulliparous. These results predict higher obesity levels from pregnancy weight gains among US women.

Gestational diabetes mellitus: all Asians are not alike.

OBJECTIVE: To estimate the prevalence of gestational diabetes mellitus (GDM) prevalence estimates for subgroups of US Asian and Pacific Islander (API) women by using data from 2005 and 2006 birth certificates. METHODS: Using 2005-2006 natality files from states that implemented the revised 2003 US birth certificate, which differentiates between GDM and preexisting diabetes (2005: 12 states; 2006: 19 states), we calculated age-adjusted GDM prevalence estimates for API mothers who delivered singleton infants. RESULTS: Among 3,108,877 births, US APIs had a substantially higher age-adjusted prevalence of GDM (6.3%) than whites (3.8%), blacks (3.5%), or Hispanics (3.6%). Among API subgroups, age-adjusted GDM prevalence varied significantly, from 3.7% among women of Japanese descent to 8.6% among women of Asian Indian descent. Foreign-born APIs had significantly higher GDM rates than US-born APIs except among women of Japanese and Korean ancestry. CONCLUSION: Overall, US API women have the highest risk for GDM among all US racial/ethnic groups. However, APIs are a heterogeneous group by genetic background, culture, and diet and other lifestyle behaviors. Our findings imply that, whenever possible, API subgroups should be evaluated separately in health research.

Prepregnancy obesity prevalence in the United States, 2004-2005.

OBJECTIVE: To provide a current estimate of the prevalence of prepregnancy obesity in the United States. METHODS: We analyzed 2004-2005 data from 26 states and New York City (n = 75,403 women) participating in the Pregnancy Risk Assessment Monitoring System, an ongoing, population-based surveillance system that collects information on maternal behaviors associated with pregnancy. Information was obtained from questionnaires self-administered after delivery or from linked birth certificates; prepregnancy body mass index was based on self-reported weight and height. Data were weighted to provide representative estimates of all women delivering a live birth in each particular state. RESULTS: In this study, about one in five women who delivered were obese; in some state, race/ethnicity, and Medicaid status subgroups, the prevalence was as high as one-third. State-specific prevalence varied widely and ranged from 13.9 to 25.1%. Black women had an obesity prevalence about 70% higher than white and Hispanic women (black: 29.1%; white: 17.4%; Hispanic: 17.4%); however, these race-specific rates varied notably by location. Obesity prevalence was 50% higher among women whose delivery was paid for by Medicaid than by other means (e.g., private insurance, cash, HMO). CONCLUSION: This prevalence makes maternal obesity and its resulting maternal morbidities (e.g., gestational diabetes mellitus) a common risk factor for a complicated pregnancy.

Immunogenicity and safety of measles-rubella vaccine co-administered with attenuated Japanese encephalitis SA 14-14-2 vaccine in infants aged 8 months in China: a non-inferiority randomised controlled trial.

BACKGROUND: In China, measles-rubella vaccine and live attenuated SA 14-14-2 Japanese encephalitis vaccine (LJEV) are recommended for simultaneous administration at 8 months of age, which is the youngest recommended age for these vaccines worldwide. We aimed to assess the effect of the co-administration of these vaccines at 8 months of age on the immunogenicity of measles-rubella vaccine. METHODS: We did a multicentre, open-label, non-inferiority, two-group randomised controlled trial in eight counties or districts in China. We recruited healthy infants aged 8 months who had received all scheduled vaccinations according to the national immunisation recommendations and who lived in the county of the study site. Enrolled infants were randomly assigned (1:1) to receive either measles-rubella vaccine and LJEV simultaneously (measles-rubella plus LJEV group) or measles-rubella vaccine alone (measles-rubella group). The primary outcome was the proportion of infants with IgG antibody seroconversion for measles 6 weeks after vaccination, and a secondary outcome was the proportion of infants with IgG antibody seroconversion for rubella 6 weeks after vaccination. Analyses included all infants who completed the study. We used a 5% margin to establish non-inferiority. This trial was registered at ClinicalTrials.gov (NCT02643433). FINDINGS: 1173 infants were assessed for eligibility between Aug 13, 2015, and June 10, 2016. Of 1093 (93%) enrolled infants, 545 were randomly assigned to the measles-rubella plus LJEV group and 548 to the measles-rubella group. Of the infants assigned to each group, 507 in the measles-rubella plus LJEV group and 506 in the measles-rubella group completed the study. Before vaccination, six (1%) of 507 infants in the measles-rubella plus LJEV group and one (<1%) of 506 in the measles-rubella group were seropositive for measles; eight (2%) infants in the measles-rubella plus LJEV group and two (<1%) in the measles-rubella group were seropositive for rubella. 6 weeks after vaccination, measles seroconversion in the measles-rubella plus LJEV group (496 [98%] of 507) was non-inferior to that in the measles-rubella group (499 [99%] of 506; difference -0·8% [90% CI -2·6 to 1·1]) and rubella seroconversion in the measles-rubella plus LJEV group (478 [94%] of 507) was non-inferior to that in the measles-rubella group (473 [94%] of 506 infants; difference 0·8% [90% CI -1·8 to 3·4]). There were no serious adverse events in either group and no evidence of a difference between the two groups in the prevalence of any local adverse event (redness, rashes, and pain) or systemic adverse event (fever, allergy, respiratory infections, diarrhoea, and vomiting). Fever was the most common adverse event (97 [19%] of 507 infants in the measles-rubella plus LJEV group; 108 [21%] of 506 infants in the measles-rubella group). INTERPRETATION: The evidence of similar seroconversion and safety with co-administered LJEV and measles-rubella vaccines supports the co-administration of these vaccines to infants aged 8 months. These results will be important for measles and rubella elimination and the expansion of Japanese encephalitis vaccination in countries where it is endemic. FUNDING: US Centers for Disease Control and Prevention, US Department of Health and Human Services; China-US Collaborative Program on Emerging and Re-emerging Infectious Diseases.

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.

Maternal obesity and risk of neural tube defects: a metaanalysis.

We conducted a metaanalysis of published evidence on the relationship between maternal obesity and the risk of neural tube defects (NTDs). Eligible studies were identified from 3 sources: (1) PubMed search of articles that were published from January 1980 through January 2007, (2) reference lists of publications that were selected from the PubMed search, and (3) reference lists of review articles on obesity and maternal outcomes that were published from January 2000 through January 2007. Twelve studies met inclusion criteria. A Bayesian random effects model was used for the metaanalysis and metaregression. Unadjusted odds ratios for an NTD-affected pregnancy were 1.22 (95% CI, 0.99-1.49), 1.70 (95% CI, 1.34-2.15), and 3.11 (95% CI, 1.75-5.46) among overweight, obese, and severely obese women, respectively, compared with normal-weight women. None of the study characteristics included in the metaregression analysis affected the results significantly. Maternal obesity is associated with an increased risk of an NTD-affected pregnancy.

Asian and Pacific Islander childhood vaccination coverage: National Immunization Survey, 2002-2004.

OBJECTIVE: Public health data on Asian/Pacific Islanders are most often collected and reported as one aggregated group. This aggregation of data can mask potential differences among the many ethnic/national/cultural groups classified as Asian/Pacific Islanders. We used data from the National Immunization Survey (NIS) to examine immunization status for all US children and four mutually exclusive groups: Asian only, Native Hawaiian only, Pacific Islander only, and other. METHODS: We included information from 64,718 US children 19-35 months of age who had adequate vaccination histories from provider(s) for 2002 to 2004; among these, 2673 (4.3%) were Asian only, Native Hawaiian only, or Pacific Islander only. The sample sizes reported are unweighted, while results are based on weighted analyses. RESULTS: Vaccination coverage estimates for children in the Native Hawaiian only group were consistently higher than estimates for all US children, whereas those in the Asian only group were nearly the same. Children in the Pacific Islander only group had vaccination coverage estimates that were lower than estimates for all US children. CONCLUSION: The results of this study indicated that although overall the Asian/Pacific Islander group had similar childhood vaccination coverage to all US children, the group does not have homogeneous coverage, with Pacific Islanders having lower coverage. Public health researchers should, whenever possible, examine individual groups of Asian/Pacific Islanders to more accurately measure the health status of this growing population.