In 2019, India, along with other countries in the World Health Organization (WHO) South-East Asia Region,* adopted the goal of measles and rubella elimination by 2023,(†) a revision of the previous goal of measles elimination and control of rubella and congenital rubella syndrome (CRS) by 2020(§) (1-3). During 2017-2021, India adopted a national strategic plan for measles and rubella elimination (4), introduced rubella-containing vaccine (RCV) into the routine immunization program, launched a nationwide measles-rubella supplementary immunization activity (SIA) catch-up campaign, transitioned from outbreak-based surveillance to case-based acute fever and rash surveillance, and more than doubled the number of laboratories in the measles-rubella network, from 13 to 27. Strategies included 1) achieving and maintaining high population immunity with at least 95% vaccination coverage by providing 2 doses of measles- and rubella-containing vaccines; 2) ensuring a sensitive and timely case-based measles, rubella and CRS surveillance system; 3) maintaining an accredited measles and rubella laboratory network; 4) ensuring adequate outbreak preparedness and rapid response to measles and rubella outbreaks; and 5) strengthening support and linkages to achieve these strategies, including planning and progress monitoring, advocacy, social mobilization and communication, identification and utilization of synergistic linkages of integrated program efforts, research, and development. This report describes India's progress toward the elimination of measles and rubella during 2005-2021, with a focus on the years 2017-2021.(¶) During 2005-2021, coverage with the first dose of a measles-containing vaccine (MCV) administered through routine immunization increased 31%, from 68% to 89%. During 2011-2021, coverage with a second MCV dose (MCV2) increased by 204%, from 27% to 82%. During 2017-2021, coverage with a first dose of RCV (RCV1) increased almost 14-fold, from 6% to 89%. More than 324 million children received a measles- and rubella-containing vaccine (MRCV) during measles-rubella SIAs completed in 34 (94%) of 36 states and union territories (states) during 2017-2019. During 2017-2021, annual measles incidence decreased 62%, from 10.4 to 4.0 cases per 1 million population, and rubella incidence decreased 48%, from 2.3 to 1.2 cases per 1 million population. India has made substantial progress toward measles and rubella elimination; however, urgent and intensified efforts are required to achieve measles and rubella elimination by 2023.

Afghanistan is one of two countries where wild poliovirus (WPV) type 1 remains endemic. We conducted a facility-based cross-sectional survey of antipoliovirus antibodies in children in 14 provinces of Afghanistan. The provinces were selected based on programmatic priorities for polio eradication. Children aged 6-11 and 36-48 months attending outpatient clinics were enrolled in the study. We collected venous blood, isolated serum, and conducted neutralization assays to detect poliovirus neutralizing antibodies. A total of 2086 children from the 14 provinces were enrolled. Among the enrolled children, 44.3% were girls; the median age in the 6-11-month group was 9.4 months, and in the 36-48-month group, it was 41.8 months. The most common spoken language was Pashtu (70.8%). Eighty-two percent of children were fully immunized against all the diseases in the vaccination schedule of Afghanistan. In the children aged 6-11 months, seroprevalence to poliovirus type 1 (PV1) was 96.5% and seroprevalence to poliovirus type 3 (PV3) was 93%; in children aged 36-48 months, seroprevalence to PV1 was 99.5% and to PV3 was 98%. Antipoliovirus antibody prevalence for poliovirus type 2 (PV2) was 70.5% in the younger group compared with 90.9% in the older children. Children from Herat and Laghman provinces had almost 100% seroprevalence to PV1, and other provinces also had high prevalence, ranging from 92.0% to 99.0%. A similar finding was seen for antibodies against PV3, ranging from 88% to 100% by province. On the contrary, antibodies to PV2 were low, ranging from 53% for children in the Khost province to around 89% in Kunduz. There was a cluster of 18 seronegative children in the Nuristan province. Overall, the polio eradication program of Afghanistan has been successful in achieving high seroprevalence of poliovirus neutralizing antibodies in the parts of the country included in this study.

In 2013, member states of the World Health Organization (WHO) South-East Asia Region* (SEAR) adopted the goal of measles elimination and rubella and congenital rubella syndrome control(†) by 2020 (1). In 2014, to provide impetus toward achieving this goal, the Regional Director declared measles elimination and rubella control one of the Regional Flagship Priorities. In 2019, SEAR member states declared a revised goal of eliminating both measles and rubella(§) by 2023 (2). The recommended strategies to achieve elimination include 1) achieving and maintaining ≥95% coverage with 2 doses of measles- and rubella-containing vaccine in every district through routine or supplementary immunization activities(¶) (SIAs); 2) developing and sustaining a sensitive and timely case-based surveillance system that meets recommended performance indicators**; 3) developing and maintaining an accredited laboratory network; 4) achieving timely identification, investigation, and response to measles outbreaks; and 5) collaborating with other public health initiatives to achieve the preceding four strategies. This report updates a previous report and describes progress toward measles elimination in SEAR during 2003-2020 (3). In 2002, coverage with the first dose of a measles-containing vaccine in routine immunization (MCV1) was 70%, and only three countries in SEAR had added a second routine dose of measles-containing vaccine in routine immunization (MCV2). During 2003-2020, all countries introduced MCV2, and estimated coverage with MCV1 increased 35%, from 65% to 88%, and coverage with MCV2 increased 1,233% from 6% to 80%. Approximately 938 million persons were vaccinated in SIAs. Annual reported measles incidence declined by 92%, from 57.0 to 4.8 cases per 1 million population, and estimated deaths decreased by 97%; an estimated 9.3 million deaths were averted by measles vaccination. By 2020, five countries were verified as having achieved measles elimination. To achieve measles elimination in the region by 2023, additional efforts are urgently needed to strengthen routine immunization services and improve measles-containing vaccine (MCV) coverage, conduct periodic high-quality SIAs, and strengthen measles case-based surveillance and laboratory capacity.

OBJECTIVE: During the COVID-19 pandemic, the unemployment rate in the United States peaked at 14.8% in April 2020. We examined patterns in unemployment following this peak in counties with rapid increases in COVID-19 incidence. METHOD: We used CDC aggregate county data to identify counties with rapid increases in COVID-19 incidence (rapid riser counties) during July 1-October 31, 2020. We used a linear regression model with fixed effect to calculate the change of unemployment rate difference in these counties, stratified by the county's social vulnerability (an indicator compiled by CDC) in the two months before the rapid riser index month compared to the index month plus one month after the index month. RESULTS: Among the 585 (19% of U.S. counties) rapid riser counties identified, the unemployment rate gap between the most and least socially vulnerable counties widened by 0.40 percentage point (p<0.01) after experiencing a rapid rise in COVID-19 incidence. Driving the gap were counties with lower socioeconomic status, with a higher percentage of people in racial and ethnic minority groups, and with limited English proficiency. CONCLUSION: The widened unemployment gap after COVID-19 incidence rapid rise between the most and least socially vulnerable counties suggests that it may take longer for socially and economically disadvantaged communities to recover. Loss of income and benefits due to unemployment could hinder behaviors that prevent spread of COVID-19 (e.g., seeking healthcare) and could impede response efforts including testing and vaccination. Addressing the social needs within these vulnerable communities could help support public health response measures.

In addition to affecting individual health the COVID-19 pandemic has disrupted efforts to deliver essential health services around the world. In this article we present an overview of the immediate programmatic and epidemiologic impact of the pandemic on polio eradication as well as the adaptive strategic and operational measures taken by the Global Polio Eradication Initiative (GPEI) from March through September 2020. Shortly after the World Health Organization (WHO) declared a global pandemic on 11 March 2020, the GPEI initially redirected the programme's assets to tackle COVID-19 and suspended house-to-house supplementary immunization activities (SIAs) while also striving to continue essential poliovirus surveillance functions. From March to May 2020, 28 countries suspended a total of 62 polio vaccine SIAs. In spite of efforts to continue poliovirus surveillance, global acute flaccid paralysis (AFP) cases reported from January-July 2020 declined by 34% compared with the same period in 2019 along with decreases in the mean number of environment samples collected per active site in the critical areas of the African and Eastern Mediterranean regions. The GPEI recommended countries should resume planning and implementation of SIAs starting in July 2020 and released guidelines to ensure these could be done safely for front line workers and communities. By the end of September 2020, a total of 14 countries had implemented circulating vaccine-derived poliovirus type 2 (cVDPV2) outbreak response vaccination campaigns and Afghanistan and Pakistan restarted SIAs to stop ongoing wild poliovirus type 1 (WPV1) transmission. The longer-term impacts of disruptions to eradication efforts remain to be determined, especially in terms of the effect on poliovirus epidemiology. Adapting to the pandemic situation has imposed new considerations on program implementation and demonstrated not only GPEI's contribution to global health security, but also identified potential opportunities for coordinated approaches across immunization and health services.

BACKGROUND: Afghanistan is one of two countries with endemic wild poliovirus type 1 (WPV1). The oral poliovirus vaccine (OPV) is the predominant vaccine used for polio eradication. Although OPV has been administered in routine childhood immunization and during frequent supplementary immunization activities, WPV1 continues to circulate in Afghanistan and case incidence has been increasing since 2017. We estimated the effectiveness of OPV in Afghanistan during 2010-2020. METHODS: We conducted a matched case-control analysis using acute flaccid paralysis (AFP) surveillance data from 29,370 children < 15 years with AFP onset between January 1, 2010 and December 31, 2020. We matched children with confirmed WPV1 (cases) with children with non-polio AFP (controls) by age at onset of paralysis (+/- 3 months), date of onset of paralysis (+/- 3 months), and province of residence, and compared their reported OPV vaccination history to estimate the effectiveness of OPV in preventing paralysis by WPV1 using conditional logistic regression. To account for changes in OPV formulations provided over the analysis period, we stratified the analysis based on dates of the global switch from trivalent OPV (tOPV) to bivalent OPV (bOPV) in April 2016. RESULTS: Between January 1, 2010 and December 31, 2020, there were 329 WPV1 cases in Afghanistan. The per-dose estimated effectiveness of OPV against WPV1 was 19% (95% CI: 15%-22%) and of ≥ 7 doses was 94% (95% CI: 90%-97%). Before the global switch from tOPV to bOPV, the per-dose estimated effectiveness of OPV was 14% (95% CI: 11%-18%) and of ≥ 7 doses was 92% (95% CI: 85%-96%). After the switch, the per-dose estimated effectiveness of OPV against WPV1 was 32% (24%-39%) and of ≥ 7 doses was 96% (95% CI: 90%-99%). DISCUSSION: OPV is highly effective in preventing paralysis by WPV1; these results indicate that continued WPV1 transmission in Afghanistan is due to failure to vaccinate, not failure of the vaccine. Although difficult to implement in parts of country, improving the administration of OPV in routine immunization and supplementary immunization activities will be critical for achieving polio eradication in Afghanistan.

BACKGROUND AND OBJECTIVE: Community mitigation strategies could help reduce COVID-19 incidence. In a national county-level analysis, we examined the probability of being identified as a county with rapidly increasing COVID-19 incidence (rapid riser identification) during the summer of 2020 by implementation of mitigation policies prior to the summer, overall and by urbanicity. METHODS: We analyzed county-level data on rapid riser identification during June 1-September 30, 2020 and statewide closures and statewide mask mandates starting March 19 (obtained from state government websites). Poisson regression models with robust standard error estimation were used to examine differences in the probability of rapid riser identification by implementation of mitigation policies (P-value<.05); associations were adjusted for county population size. RESULTS: Counties in states that closed for 0-59 days were more likely to become a rapid riser county than those that closed for >59 days, particularly in nonmetropolitan areas. The probability of becoming a rapid riser county was 43% lower among counties that had statewide mask mandates at reopening (adjusted prevalence ratio [aPR] = 0.57; 95% confidence intervals [CI] = 0.51-0.63); when stratified by urbanicity, associations were more pronounced in nonmetropolitan areas. CONCLUSIONS: These results underscore the potential value of community mitigation strategies in limiting the COVID-19 spread, especially in nonmetropolitan areas.

OBJECTIVE: To explore associations between demographic, occupational, and mental health characteristics and negative attitudes toward mental illness among veterinarians. DESIGN: Cross-sectional survey. SAMPLE: 9,522 veterinarians employed in the United States. PROCEDURES: Data from a previously conducted voluntary, anonymous, web-based survey were used. Negative attitude was defined as slight or strong disagreement with 2 statements: "Treatment can help people with mental illness lead normal lives" (treatment effectiveness) and "People are generally caring and sympathetic to people with mental illness" (social support). Multivariable logistic regression was used to identify variables associated with negative attitudes. RESULTS: Of the 9,522 respondents, 6,585 (69.2%) were female, 4,523 (47.5%) were 40 to 59 years old, 291 (3.1%) had a negative attitude toward treatment effectiveness, and 4,504 (47.3%) had a negative attitude toward social support. After adjusting for other variables, negative attitude toward treatment effectiveness was significantly more likely in males, those with 10 to 19 (vs 1 to 9) years of practice experience, solo practitioners, those in government (vs "other") practice, those with evidence of serious psychological distress, and those reporting suicidal ideation after veterinary school and significantly less likely in those receiving mental health treatment. A negative attitude toward social support was significantly less likely in males and significantly more likely in 40 to 59 (vs 20 to 39) year olds, childless respondents, solo practitioners, those without membership in a veterinary association, those with evidence of serious psychological distress, those reporting depression during or after veterinary school, and those reporting suicidal ideation after veterinary school. CONCLUSIONS AND CLINICAL RELEVANCE: Characteristics such as age, sex, practice setting, and mental illness history might be useful to consider when targeting interventions to support and educate veterinarians about mental illness.

INTRODUCTION: In 2015, Idaho had the fifth highest suicide rate in the United States. Little is known about the characteristics of areas in Idaho with high suicide rates. To aid suicide prevention efforts in the state, we sought to identify and characterize spatial clusters of suicide. METHODS: We obtained population data from the 2010 US Census and the 2010-2014 American Community Survey, analyzed data on suicides from death certificates, and used a discrete Poisson model in SaTScan to identify spatial clusters of suicide. We used logistic regression to examine associations between suicide clustering and population characteristics. RESULTS: We found 2 clusters of suicide during 2010-2014 that accounted for 70 (4.7%) of 1,501 suicides in Idaho. Areas within clusters were positively associated with the following population characteristics: median age </=31.1 years versus >31.1 years (multivariable-adjusted odds ratio [aOR] = 2.4; 95% confidence interval [CI], 1.04-5.6), >53% female vs </=53% female (aOR = 2.7; 95% CI, 1.3-5.8; P = .01), >1% American Indian/Alaska Native vs </=1% American Indian/Alaska Native (aOR = 2.9; 95% CI, 1.4-6.3), and >30% never married vs </=30% never married (aOR = 3.4; 95% CI, 1.5-8.0; P = .004). CONCLUSION: Idaho suicide prevention programs should consider using results to target prevention efforts to communities with disproportionately high suicide rates.

During 2011-2015 in Idaho, 14 (7%) of 193 persons with early syphilis had repeat syphilis. Persons with repeat infections were more likely to have had secondary or early latent syphilis (P = 0.037) and be infected with HIV (P < 0.001) compared with those having one infection.

On May 25, 2016, a detainee at a U.S. Immigration and Customs Enforcement (ICE) detention center in Arizona who had been hospitalized with fever and a generalized maculopapular rash was confirmed to have measles by real-time polymerase chain reaction (rPCR). A second case of measles in a staff member was confirmed by rPCR the next day. The privately operated, city-contracted facility housed 1,425 detainees, and employed 510 staff members, including 95 federal ICE staff and 415 contract staff of four distinct employers. Outbreak control measures consisted of administration of measles-mumps-rubella (MMR) vaccine to 1,424 detainees housed at the facility during May 29–31 and isolation of the detainee patient and any additional detainee patients identified during their remaining infectious period (until 4 days after rash onset). Recommendations were made by federal, state, and local public health partners to exclude staff members with measles-compatible symptoms as well as exposed staff members without presumptive evidence of immunity to measles.* | Epidemiologic investigations by local and state health departments and CDC identified 31 total cases of measles in 22 detainees and nine staff members, with rash onsets occurring May 6–June 26 (Figure). Initial reports of rash illness among a few detainees were attributed to varicella (chickenpox) based on clinical presentation; some detainees also reported that they did not initially seek medical attention when they became ill, likely leading to the delay in diagnosing the first few cases of measles. The median detainee patient age was 34 years (range = 19–52 years), and the median staff patient age was 41 years (range = 22–49 years). Seven of the nine ill staff members reported receipt of at least 1 dose of MMR vaccine in the past, but no vaccination records were available at the time the outbreak was recognized. Three of the nine ill staff members received 1 dose of MMR vaccine 7–13 days before becoming ill, suggesting that exposure might have occurred before sufficient immunity developed from vaccination, because the incubation period for measles ranges from 7–21 days.† On June 17 and June 21, MMR staff member vaccination clinics were conducted on-site. Two additional clinics were conducted on July 15 and July 19. Staff members were encouraged to obtain their immunization records and to bring them to the facility to be recorded. Federal personnel policies and contractual agreements that do not require staff members to be vaccinated and the initial unavailability of staff member vaccination records might have contributed to low participation in the first two staff member vaccination clinics; only 120 MMR doses were administered, and 202 (40%) staff members were still considered to not have evidence of measles immunity.

In October 2016, the Idaho Bureau of Laboratories, Division of Public Health, was notified by hospital A’s clinical laboratory (a member of the Idaho Sentinel Laboratory Network) that a bacterial isolate cultured from a hospitalized patient’s knee joint fluid aspirate had been identified with 96% confidence as Francisella tularensis (a Tier 1 select agent*) by an in-house automated microbial identification system (AMIS). The isolate was submitted to the Idaho Bureau of Laboratories for confirmatory testing using Laboratory Response Network (LRN) reference methods. Hospital A laboratory personnel reported that the isolate had been manipulated on the open bench and certain laboratory workers had potentially been exposed. The Division of Public Health, hospital A, and Eastern Idaho Public Health initiated an investigation to confirm F. tularensis, assess potential laboratory exposures, and determine the source of infection. The investigation determined that the infectious agent was Veillonella and not F. tularensis. | The patient, a man aged >75 years, had a multiyear history of chronic unilateral knee pain, during which time he had received a series of three intra-articular injections of hyaluronate sodium 2 years previously, and several intra-articular injections of triamcinolone with bupivacaine, the last of which occurred 15 days before he sought care at hospital A for a swollen knee. Gram staining of an intra-articular aspirate obtained that day from the affected knee showed Gram-variable cocci. The aspirate was cultured under aerobic and anaerobic conditions. Slow-growing colonies of Gram-negative cocci were observed from the anaerobic culture, with limited growth in aerobic conditions. Because an anaerobic AMIS panel was not available, isolates from the aerobic culture were processed for identification and antimicrobial susceptibility on the AMIS using a panel specific for aerobic organisms. Identification of F. tularensis by the AMIS triggered notification of the Division of Public Health and revision of the patient’s antibiotic regimen from vancomycin, piperacillin, and tazobactam to ciprofloxacin. Eastern Idaho Public Health interviewed the patient and determined that he lived in a rural area and reported no recent exposure to potential sources of naturally occurring F. tularensis (e.g., ill animals, arthropod bites, contaminated water, or use of lawn mowers or string trimmers near dead animals).

In May 2015, Yersinia pestis, the bacterium that causes plague, was identified in dead Piute ground squirrels (Urocitellus mollis) reported through the Idaho Department of Fish and Game’s wildlife mortality monitoring program; in June 2015, the Idaho Division of Public Health (DPH) sent an advisory to veterinarians in four southwestern Idaho counties requesting that they notify their local public health officials of suspected plague in animals.* Y. pestis was not confirmed in any pets during 2015. | During May 30–July 26, 2016, local veterinarians notified public health officials that five dogs and 12 cats were being evaluated for possible plague. Local veterinarians also performed necropsies, when applicable, to establish the diagnosis. Idaho’s Central District Health Department and Eastern Idaho Public Health coordinated with DPH on submission of specimens to the DPH Bureau of Laboratories for Y. pestis testing and interviewed veterinary staff and pet owners. Specimens from blood, spleen, liver, and lymph nodes were screened using real–time polymerase chain reaction and confirmed by culture and phage lysis testing. | Among evaluated animals, Y. pestis was isolated from six of 12 cats; five of the six were from areas in southwestern Idaho where dead ground squirrels with confirmed Y. pestis had been reported in May 2016, and one was from from eastern Idaho. Among these six cats, specimen collection occurred during May 31–July 12, 2016; cats ranged in age from 10 months to 14.5 years (median = 4 years), four (67%) were male, five (83%) resided both indoors and outdoors, and one resided outdoor only. All six cats were domestic shorthair breed and had been neutered or spayed. Fever and lymphadenopathy (n = 4, 67%) were the most commonly reported signs of illness. None of the cats had known pulmonary involvement. Three of the six cats were treated with appropriate antibiotics (1); of these, two survived and one was euthanatized. The three other cats had died or had been euthanatized. All six cats reportedly had contact with ground squirrels and other wild rodents or rabbits before becoming ill; one had flea control administered before illness onset.