This report provides recommendations by CDC's Advisory Committee on Immunization Practices (ACIP) regarding the use of vaccine against infection with novel influenza A (H1N1) virus. Information on vaccination for seasonal influenza has been published previously (CDC. Prevention and control of seasonal influenza with vaccines: recommendations of the Advisory Committee on Immunization Practices [ACIP], 2009. MMWR 2009;58[No. RR-8]). Vaccines against novel influenza A (H1N1) virus infection have not yet been licensed; however, licensed vaccine is expected to be available by mid-October 2009. On July 29, 2009, ACIP reviewed epidemiologic and clinical data to determine which population groups should be targeted initially for vaccination. ACIP also considered the projected vaccine supply likely to be available when vaccine is first available and the expected increase in vaccine availability during the following 6 months. These recommendations are intended to provide vaccination programs and providers with information to assist in planning and to alert providers and the public about target groups comprising an estimated 159 million persons who are recommended to be first to receive influenza A (H1N1) 2009 monovalent vaccine. The guiding principle of these recommendations is to vaccinate as many persons as possible as quickly as possible. Vaccination efforts should begin as soon as vaccine is available. State and local health officials and vaccination providers should make decisions about vaccine administration and distribution in accordance with state and local conditions. Highlights of these recommendations include 1) the identification of five initial target groups for vaccination efforts (pregnant women, persons who live with or provide care for infants aged <6 months, health-care and emergency medical services personnel, children and young adults aged 6 months-24 years, and persons aged 25-64 years who have medical conditions that put them at higher risk for influenza-related complications), 2) establishment of priority for a subset of persons within the initial target groups in the event that initial vaccine availability is unable to meet demand, and 3) guidance on use of vaccine in other adult population groups as vaccine availability increases. Vaccination and health-care providers should be alert to announcements and additional information from state and local health departments and CDC concerning vaccination against novel influenza A (H1N1) virus infection. Additional information is available from state and local health departments and from CDC's influenza website (http://www.cdc.gov/flu).

This article summarizes what is currently known about the 2019 novel coronavirus and offers interim guidance.

As part of the federal response to the opioid crisis, the Opioid Rapid Response Team project (2018-2019) was created to provide rapid short-term assistance to requesting US jurisdictions responding to an acute opioid-related event. The project used an approach that maximized overall value by leveraging existing federal resources and harnessing opportunities to meet project-specific objectives while also enhancing general response capacity at the federal, state, and local levels. This tandem capacity building for both opioid rapid response and general response focused on systems and operations, workforce readiness, technical assistance, and partnerships. In this article, we demonstrate the ancillary value that issue-specific response activities can contribute to broader public health response capacity.

Hindsight may or may not be 2020, but beginnings look different from the end of a public health career. A constellation of public health crises has brought attention to strengthening the nations public health capacity. Building the pipeline for the workforce we need is more critical than ever. | I was keen to contribute to recognizing the first 10 years of the CDC Undergraduate Public Health Scholars (CUPS) program, even if it meant that the pages of this supplement would runneth over. While other articles on CUPS in this special issue of Pedagogy in Health Promotion will provide descriptive and quantitative assessments of the who, what, where, how, and wherefore, my entry represents the personal reflections of a recent retiree from public health on this gem of a program, and will at least be brief.

BACKGROUND: The effect of malaria infection on rVSVΔG-ZEBOV-GP (ERVEBO®) immunogenicity is unknown. METHODS: The Sierra Leone Trial to Introduce a Vaccine against Ebola (STRIVE) vaccinated 7998 asymptomatic adults with rVSVΔG-ZEBOV-GP during the 2014-6 Ebola epidemic. In STRIVE's immunogenicity sub-study, participants provided blood samples at baseline, 1, 6, and 9-12 months. Anti-glycoprotein (GP) binding and neutralizing antibodies were measured using validated assays. Baseline samples were tested for malaria parasites by PCR. RESULTS: Overall, 506 participants enrolled in the immunogenicity sub-study and had ≥1 post-vaccination antibody titer. Of 499 participants with a result, baseline malaria parasitemia was detected in 73(14.6%). All GP-ELISA and plaque reduction neutralization test (PRNT) geometric mean titers (GMTs) at 1, 6, and 9-12 months were above baseline, and 94.1% of participants seroresponded by GP-ELISA (≥2-fold rise AND ≥200 EU/ml), while 81.5% seroresponded by PRNT (≥4-fold rise) at ≥1 post-vaccination assessment. In participants with baseline malaria parasitemia, the PRNT seroresponse proportion was lower, while PRNT GMTs and GP-ELISA seroresponse and GMTs showed a trend toward lower responses at 6 and 9-12 months. CONCLUSION: Asymptomatic adults with and without malaria parasitemia had robust immune responses to rVSVΔG-ZEBOV-GP persisting for 9-12 months. Responses in those with malaria parasitemia were somewhat lower.

The COVID-19 pandemic has exposed weaknesses in disease surveillance in nearly all countries. Early identification of COVID-19 cases and clusters for rapid containment was hampered by inadequate diagnostic capacity, insufficient contact tracing, fragmented data systems, incomplete data insights for public health responders, and suboptimal governance of all these elements. Once SARS-CoV-2 became widespread, interventions to control community transmission were undermined by weak surveillance of cases and insufficient national capacity to integrate data for timely adjustment of public health measures.1, 2 Although some countries had little or no reliable data, others did not share data consistently with their own populations and with WHO and other multilateral agencies. The emergence of SARS-CoV-2 variants has highlighted inadequate national pathogen genomic sequencing capacities in many countries and led to calls for expanded virus sequencing. However, sequencing without epidemiological and clinical surveillance data is insufficient to show whether new SARS-CoV-2 variants are more transmissible, more lethal, or more capable of evading immunity, including vaccine-induced immunity.3, 4

From January 21 through February 23, 2020, a total of 14 cases of coronavirus disease 2019 (COVID-19) were diagnosed in six U.S. states, including 12 cases in travelers arriving from China and two in household contacts of persons with confirmed infections. An additional 39 cases were identified in persons repatriated from affected areas outside the United States (1). Starting in late February, reports of cases with no recent travel to affected areas or links to known cases signaled the initiation of pandemic spread in the United States (2). By mid-March, transmission of SARS-CoV-2, the virus that causes COVID-19, had accelerated, with rapidly increasing case counts indicating established transmission in the United States. Ongoing traveler importation of SARS-CoV-2, attendance at professional and social events, introduction into facilities or settings prone to amplification, and challenges in virus detection all contributed to rapid acceleration of transmission during March. Public health responses included intensive efforts to detect cases and trace contacts, and implementation of multiple community mitigation strategies. Because most of the population remains susceptible to infection, recognition of factors associated with amplified spread during the early acceleration period will help inform future decisions as locations in the United States scale back some components of mitigation and strengthen systems to detect a potential transmission resurgence. U.S. circulation of SARS-CoV-2 continues, and sustained efforts will be needed to prevent future spread within the United States.

During the past 3 weeks, new major epidemic foci of coronavirus disease 2019 (COVID-19), some without traceable origin, have been identified and are rapidly expanding in Europe, North America, Asia, and the Middle East, with the first confirmed cases being identified in African and Latin American countries. By March 16, 2020, the number of cases of COVID-19 outside China had increased drastically and the number of affected countries, states, or territories reporting infections to WHO was 143.1 On the basis of ”alarming levels of spread and severity, and by the alarming levels of inaction”, on March 11, 2020, the Director-General of WHO characterised the COVID-19 situation as a pandemic.2

The need for closer linkages between scientific and programmatic areas focused on addressing vaccine-preventable and acute respiratory infections led to establishment of the National Center for Immunization and Respiratory Diseases (NCIRD) at the Centers for Disease Control and Prevention. During its first 10 years (2006-2015), NCIRD worked with partners to improve preparedness and response to pandemic influenza and other emergent respiratory infections, provide an evidence base for addition of 7 newly recommended vaccines, and modernize vaccine distribution. Clinical tools were developed for improved conversations with parents, which helped sustain childhood immunization as a social norm. Coverage increased for vaccines to protect adolescents against pertussis, meningococcal meningitis, and human papillomavirus-associated cancers. NCIRD programs supported outbreak response for new respiratory pathogens and oversaw response of the Centers for Disease Control and Prevention to the 2009 influenza A(H1N1) pandemic. Other national public health institutes might also find closer linkages between epidemiology, laboratory, and immunization programs useful.

We think of this Supplement of the Journal of Infectious Diseases as a figurative manual of operations for how to build an airplane while flying it through a storm. The human toll of the Ebola virus disease (Ebola) epidemic of 2014–2016 was worse than that experienced in all previously recognized Ebola epidemics put together. The idea of testing experimental vaccines that were just entering Phase 1 studies in humans felt both essential and incredibly daunting, given the chaos of this epidemic and the setting of an ongoing epidemic where medical management and monitoring capacity were already strained and most commercial air carriers had cancelled routes. Nonetheless, our team of figurative airplane designers built the airplane, flew it, and landed it safely. Our airplane, the Sierra Leone Trial to Introduce a Vaccine Against Ebola (STRIVE) (Figure 1), forged strong partnerships between institutions in Sierra Leone and the broader public health and research community. With the successful collection of safety data on approximately 8000 vaccinated persons, the study findings also bring the world closer to having a safe and effective vaccine for preventing Ebola. (Clinical Trial Registration. ClinicalTrials.gov [NCT02378753] and Pan African Clinical Trials Registry [PACTR201502001037220].)

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

Clinical Trials Registration: ClinicalTrials.gov [NCT02378753] and Pan African Clinical Trials Registry [PACTR201502001037220].

Why was human papillomavirus (HPV) vaccine different from all other vaccines? For other routine vaccines included in the child and adolescent immunization schedules, pediatricians in the United States responded to recommendations from the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices (ACIP) and American Academy of Pediatrics by incorporating the vaccine into their routine practice workflow. For HPV vaccine, for much of the 10 years since the ACIP's first recommendations, receiving HPV vaccine together with other preteen immunizations was the exception, rather than the rule. “HPV exceptionalism” might be reminiscent of HIV exceptionalism1 and might account for the persistent gap between coverage of HPV vaccine and teen coverage of tetanus-diphtheria-acellular pertussis (Tdap) or meningococcal A,C,Y,W-135 conjugate (MenACWY) vaccines. Re-evaluation of the elements that created HPV exceptionalism can prompt an end to differential treatment for HPV vaccination, and strengthen its full integration into routine pediatric practice.

The United States is in the midst of an opioid overdose epidemic. Between 1999 and 2010, prescription opioid–related overdose deaths increased substantially in parallel with increased prescribing of opioids.1 In 2015, opioid-involved drug overdoses accounted for 33 091 deaths, approximately half involving prescription opioids.2 Additionally, an estimated 2 million individuals in the United States have opioid use disorder (addiction) associated with prescription opioids, accounting for an estimated $78.5 billion in economic costs annually.3 Proven strategies are available to manage chronic pain effectively without opioids, and changing prescribing practices is an important step in addressing the opioid overdose epidemic and its adverse effects on US communities. | On July 6, 2017, the US Centers for Disease Control and Prevention reported that between 2006 and 2015 the amount of opioids prescribed in the United States peaked in 2010 at 782 morphine milligram equivalents (MME) per capita and then decreased each year through 2015 to 640 MME per capita. Prescribing rates increased from 72.4 to 81.2 prescriptions per 100 persons between 2006 and 2010, were constant between 2010 and 2012, and then declined to 70.6 per 100 persons from 2012 to 2015, a 13.1% decline.1 Yet the amount of opioids prescribed in 2015 remains more than 3 times higher than in 1999, when the amount prescribed was 180 MME per capita, and is nearly 4 times higher than in Europe in 2015.

This article describes measles and measles vaccination, along with the challenges, successes, and progress in the postelimination era.

In 2010, the US Centers for Disease Control and Prevention (CDC) identified 6 focus areas termed Winnable Battles, in which concerted effort could lead to substantial health improvement in a short time.1 Teams selected a limited set of strategies that could enable rapid progress, established ambitious targets, aligned efforts within the CDC, and worked with federal and other partners to leverage each entity’s capacity. | Principles and Selection | Each of the 6 selected focus areas represented a leading cause of illness, injury, disability, death or presented large societal costs. For each problem, proven, effective, scalable, but underused interventions were identified. Measurable improvement could be achieved with increased implementation, but was unlikely to occur without intensified effort. Results could be achieved in less than 5 years. | The focus areas involved infectious diseases (including health care–associated infections and human immunodeficiency virus [HIV]), injury (motor vehicle fatalities), chronic disease prevention (smoking), and reproductive health (teen pregnancy). One focus area combined nutrition, physical activity, obesity, and food safety.

Through its Vital Signs report, the Centers for Disease Control and Prevention (CDC) recently highlighted the preventable burden of disability associated with alcohol-exposed pregnancies, and emphasized long-standing recommendations that physicians screen all patients for harmful alcohol use and that women avoid alcohol at all times during pregnancy.2,3 Because nearly one-half of pregnancies are unplanned and most are not recognized in the first several weeks, the CDC targeted reproductive-aged women who were not using contraception. Key Steps in Alcohol Screening and Brief Counseling Ask patients about their drinking Talk with patients in plain language about what they think is good and not so good about their drinking Provide options: ask if patients want to stop drinking, cut down on drinking, seek help, or continue with their present drinking pattern, and come up with a plan Close on good terms, regardless of patient response Adapted from Centers for Disease Control and Prevention. More than 50% of nonpregnant women report recent alcohol use, compared with about 10% of pregnant women, suggesting that most women avoid alcohol once they find out they are pregnant.9 Although physicians need to warn patients about the risks of alcohol use at any time during pregnancy, they should also provide reassurance to women who drank alcohol before they realized they were pregnant that good birth outcomes are still likely.

On January 15, 2016, the Centers for Disease Control and Prevention advised pregnant women not to travel to areas where the Zika virus was spreading. Six months later, more than 60 countries or territories have reported new local transmission of Zika. By August 4, 2016, nearly 1700 cases of travel-associated Zika infection, including 479 in pregnant women, had been reported in the continental United States; Puerto Rico is experiencing rapid and extensive spread of the epidemic.1 Florida has documented 5 symptomatic and 8 asymptomatic locally acquired Zika infections in a 6-block area north of downtown Miami. Comprehensive mosquito control efforts, including reduction of standing water, provision of repellants containing diethyltoluamide (DEET), and application of pyrethroid insecticides and larvicides using backpack sprayers and trucks to eliminate adult and larval forms of mosquitoes, were initiated on confirmation of the first cases. Persistent findings of Aedes aegypti mosquitoes led to a decision to also use aerial spraying with naled and larvicide within 3 days of documentation of the risk of ongoing Zika transmission. | The association between Zika infection (both symptomatic and asymptomatic) and serious birth defects, including microcephaly, has been confirmed.2 Sexual transmission of Zika from both male and female partners can occur, and the virus may be able to remain viable in semen for months. The competent vectors—A aegypti as well as the less efficient vector Aedes albopictus—put 30 and 41 US states, respectively, at risk for local mosquito-borne transmission of Zika. Risk of microcephaly after Zika infection early in pregnancy may range from 1% to 13%; the full spectrum of congenital Zika virus syndrome is not known, nor is it known whether infants exposed to Zika during pregnancy who appear healthy at birth will have neurologic or other problems.

In October 2014, the College of Medicine and Allied Health Sciences of the University of Sierra Leone, the Sierra Leone Ministry of Health and Sanitation, and CDC joined the global effort to accelerate assessment and availability of candidate Ebola vaccines and began planning for the Sierra Leone Trial to Introduce a Vaccine against Ebola (STRIVE). STRIVE was an individually randomized controlled phase II/III trial to evaluate efficacy, immunogenicity, and safety of the recombinant vesicular stomatitis virus Ebola vaccine (rVSV-ZEBOV). The study population was health care and frontline workers in select chiefdoms of the five most affected districts in Sierra Leone. Participants were randomized to receive a single intramuscular dose of rVSV-ZEBOV at enrollment or to receive a single intramuscular dose 18-24 weeks after enrollment. All participants were followed up monthly until 6 months after vaccination. Two substudies separately assessed detailed reactogenicity over 1 month and immunogenicity over 12 months. During the 5 months before the trial, STRIVE and partners built a research platform in Sierra Leone comprising participant follow-up sites, cold chain, reliable power supply, and vaccination clinics and hired and trained at least 350 national staff. Wide-ranging community outreach, informational sessions, and messaging were conducted before and during the trial to ensure full communication to the population of the study area regarding procedures and current knowledge about the trial vaccine. During April 9-August 15, 2015, STRIVE enrolled 8,673 participants, of whom 453 and 539 were also enrolled in the safety and immunogenicity substudies, respectively. As of April 28, 2016, no Ebola cases and no vaccine-related serious adverse events, which by regulatory definition include death, life-threatening illness, hospitalization or prolongation of hospitalization, or permanent disability, were reported in the study population. Although STRIVE will not produce an estimate of vaccine efficacy because of low case frequency as the epidemic was controlled, data on safety and immunogenicity will support decisions on licensure of rVSV-ZEBOV.The activities summarized in this report would not have been possible without collaboration with many U.S. and international partners (http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/partners.html).

Pneumococcus, or Streptococcus pneumoniae, the “captain of the men of death” in the parlance of Sir William Osler, has killed millions of people while repeatedly frustrating clinicians, vaccine experts, and epidemiologists. The advent of effective antibiotics did not eliminate deaths from pneumococcal disease. Pneumococcal morbidity has remained substantial among the elderly population even though most have received the 23-valent pneumococcal polysaccharide vaccine (PPSV-23). Diagnostic tests for pneumonia are relatively insensitive and nonspecific.1 Thus, it is difficult to evaluate the efficacy of pneumococcal vaccines against pneumonias that do not lead to detectable bloodstream infection.

Accomplishments of this program have provided numerous dividends and might benefit areas outside infectious diseases.

For a viral illness first described a thousand years ago, vaccine-preventable for 50 years, and eliminated from the USA in 2000, the interest associated with measles in 2015 is notable [1–4]. Most virologists only dream of a solution as successful as live-attenuated measles vaccine, with 97% two-dose efficacy and literally billions ‘served.’ Success can breed complacency, skepticism or even attack. All these reactions play a role in the current US experience with measles. The dynamics involved with recent US measles outbreaks may have more to do with cultural attitudes and consumer behavior than with R0 and airborne transmission. | From 4 January to 10 April 2015, 159 people were reported to have measles in the USA [1]. Seventy percent of cases are part of an outbreak associated with Disney amusement parks in Southern California. Eighteen states and the District of Columbia have identified measles cases so far this year, with multiple genotypes (B3, D4, D8, D9 and H1) detected. Based on available information, 45% of the reported cases occurred in people who were never vaccinated (68 of 155 US residents), while more than a third (60 or 38%) had unknown vaccination status. Of those who had not been vaccinated, 29 (43%) were unvaccinated because of personal, philosophical or parental beliefs, while 26 (35%) were too young to receive the vaccine. Cases with links back to the Disney parks occurred in seven states, Mexico and Canada. In 2015, smaller outbreaks unrelated to the amusement parks have involved a childcare center in Illinois, extended family in Washington State, and community exposures in Nevada.

This issue of the journal presents a milestone in expanding coverage against cancers associated with human papillomavirus (HPV). Joura and coauthors’ report of a randomized controlled trial of 9-valent vs. quadrivalent HPV vaccine in over 14,000 young women found vaccine efficacy of nearly 97% against high-grade cervical/vulvar/vaginal disease related to types 31, 33, 45, 52, and 581. The intent-to-treat analysis found no benefit of 9-valent vs. quadrivalent vaccine, presumably because so many of the 16–26 year old study subjects had already been infected with the five additional HPV-types by the study’s onset. The rationale for vaccination at 11–12 years is to provide protection before HPV acquisition. | What HPV researchers talk about when they talk about “coverage” is the distribution of HPV-types in cancers. Earlier formulations targeted the most common oncogenic types, 16 and 18, responsible for about 70% of cervical cancers. The 9-valent vaccine’s additional types are expected to target up to 15–20% more cervical cancers and 5–20% more of other HPV-related cancers2,3. While HPV-related cancer coverage can now expand, other types of coverage present ongoing challenges.

Why is an article about global health included in a special issue on health in the USA? About half the produce that Americans consume is cultivated in other countries, 60 million Americans travel or work outside the USA, and most patients with measles and tuberculosis in the USA acquired their infection elsewhere. Emerging diseases, globalisation of foods and medicines, the rise in antimicrobial resistance, and the ease with which pathogens can be manipulated for good or harm increase each nation's vulnerability and interdependence. | The Centers for Disease Control and Prevention (CDC) has engaged in global health for more than 60 years. Although tackling infectious disease threats has been a constant, the agency has also provided humanitarian assistance in natural disasters, refugee crises, and famines; improved child survival; and strengthened scientific measurement of health metrics. CDC's workforce includes more than 300 internationally deployed public health professionals in addition to around 1330 locally employed staff working in about 60 countries (figure ). CDC's global health strategy aims to: achieve optimum health effects; strengthen global health capacity; improve global health security; and strengthen the organisation's capacity.1 This report describes selected programmes that illustrate these goals.

Since mid-March 2014, the frequency with which cases of Middle East respiratory syndrome coronavirus (MERS-CoV) infection have been reported has increased, with the majority of recent cases reported from Saudi Arabia and United Arab Emirates (UAE). In addition, the frequency with which travel-associated MERS cases have been reported and the number of countries that have reported them to the World Health Organization (WHO) have also increased. The first case of MERS in the United States, identified in a traveler recently returned from Saudi Arabia, was reported to CDC by the Indiana State Department of Health on May 1, 2014, and confirmed by CDC on May 2. A second imported case of MERS in the United States, identified in a traveler from Saudi Arabia having no connection with the first case, was reported to CDC by the Florida Department of Health on May 11, 2014. The purpose of this report is to alert clinicians, health officials, and others to increase awareness of the need to consider MERS-CoV infection in persons who have recently traveled from countries in or near the Arabian Peninsula. This report summarizes recent epidemiologic information, provides preliminary descriptions of the cases reported from Indiana and Florida, and updates CDC guidance about patient evaluation, home care and isolation, specimen collection, and travel as of May 13, 2014.

The Vaccines for Children (VFC) program was created by the Omnibus Budget Reconciliation Act of 1993 and first implemented in 1994. VFC was designed to ensure that eligible children do not contract vaccine-preventable diseases because of inability to pay for vaccine and was created in response to a measles resurgence in the United States that resulted in approximately 55,000 cases reported during 1989-1991. The resurgence was caused largely by widespread failure to vaccinate uninsured children at the recommended age of 12-15 months. To summarize the impact of the U.S. immunization program on the health of all children (both VFC-eligible and not VFC-eligible) who were born during the 20 years since VFC began, CDC used information on immunization coverage from the National Immunization Survey (NIS) and a previously published cost-benefit model to estimate illnesses, hospitalizations, and premature deaths prevented and costs saved by routine childhood vaccination during 1994-2013. Coverage for many childhood vaccine series was near or above 90% for much of the period. Modeling estimated that, among children born during 1994- 2013, vaccination will prevent an estimated 322 million illnesses, 21 million hospitalizations, and 732,000 deaths over the course of their lifetimes, at a net savings of $295 billion in direct costs and $1.38 trillion in total societal costs. With support from the VFC program, immunization has been a highly effective tool for improving the health of U.S. children.

Prior to the introduction of vaccines, Haemophilus influenzae type b (Hib) was the most common cause of bacterial meningitis and an important cause of severe pneumonia in children <5 years of age. Hib conjugate vaccines were introduced in developed countries during the early 1990s, resulting in a virtual elimination of Hib disease.1 However, the introduction of Hib vaccine in developing countries was delayed significantly due to multiple barriers, with major obstacles being the lack of local data on disease burden and the lack of awareness of the potential impact of the vaccine. In 2002, a group of scientific experts and public health officials gathered in Arizona, US, to discuss the epidemiology and control of Hib disease and recommended a multifaceted approach to overcome barriers for Hib vaccine introduction.2 In 2005, the GAVI Alliance funded the Hib Initiative, a consortium of public and private institutions (Johns Hopkins School of Public Health, the World Health Organization [WHO], the London School for Hygiene and Tropical Medicine, and the US Centers for Diseases Control and Prevention) to assist countries eligible for GAVI funding in making evidence-based decisions regarding the introduction of Hib vaccines into national immunizations programs. The Hib Initiative adopted a strategy based on improved communications, coordination with key partners at country, regional, and global levels, and supporting selected research studies to address gaps in Hib knowledge, particularly studies that could provide evidence and capacity to sustain vaccine programs beyond the period of GAVI support. Fortunately, significant progress in introduction of Hib vaccines has occurred over the last few years with all GAVI countries, having either introduced the vaccine already or are expected to introduce in 2013.3 | There frequently is tension in implementation programs regarding the appropriate role for research. The Hib Initiative focused on critical issues and geographic locations where scientific gaps remained and where strengthened capacity and systems could bridge to long term impacts. A decade after the Arizona meeting, the proceedings of which were reported in The Journal of Pediatrics, many scientific gaps have been filled, but a few questions still need to be answered.2 This Supplement features a number of projects that were supported by the Hib Initiative and that provide valuable lessons for meningitis and pneumonia control and accelerate uptake of new and underutilized vaccines.

Most vaccine-preventable diseases in the U.S. are at record low levels, and immunization coverage among toddlers and teenagers is high or increasing. However, importations of measles virus from other countries, resurgences of pertussis and mumps, and the 2009 pandemic of influenza A H1N1 are reminders that Americans remain vulnerable to vaccine-preventable diseases and that sustained support for public health and clinician efforts is needed. Geographic areas with high rates of exemptions from vaccinations required for school attendance place communities at risk for disease outbreaks. There has been much progress internationally in reducing the toll of vaccine-preventable diseases, through public-private partnerships like the Global Alliance for Vaccines and Immunizations (GAVI). Paralytic poliomyelitis is on the verge of eradication, with wild virus transmission continuing in only three countries - Nigeria, Afghanistan and Pakistan. Intensified efforts in those countries are critical. The Decade of Vaccines Collaboration offers an opportunity to strengthen immunization in every community and country.

Although influenza seasons come and go, one unfortunate constant over the past decade has been a lack of measurable progress in protecting adults from influenza. Despite greater vaccine supply, rising vaccination rates in children, and universal recommendations for all adults to be vaccinated annually, vaccination rates among the general adult population have scarcely budged. This stagnation in population coverage accentuates the value of approaches that improve influenza vaccine efficacy in adults. In this issue of the Journal of Infectious Diseases Jackson reports on the comparative immunogenicity of multiple formulations of A(H1N1) 09pdm influenza vaccine among adults [1]. Their study has potential relevance for improved control of seasonal influenza, as well as better preparedness against future pandemic and avian influenza threats. | The availability of inactivated vaccine and the recurring burden of influenza and its complications led the US surgeon general in 1960 to issue the first recommendations for routine annual influenza vaccination of older adults, pregnant women, and others with chronic medical conditions [2]. Vaccination rates among the elderly increased substantially during the 1990s [3] but subsequently plateaued at approximately 60% to 70%. Older adults continue to experience a disproportionate burden of severe illness caused by influenza. Unfortunately, influenza vaccine effectiveness is generally lower among older populations, even during seasons when vaccine strains are well matched to circulating viruses. Efforts to overcome immune senescence and identify formulations with improved immunogenicity and clinical protection have been a focus of researchers, manufacturers, and the government. The potential roles of high-dose antigen formulations as well as adjuvants in improving immune response have been of particular interest with respect to both avian and seasonal influenza vaccines.

Mixing desirable components together is a staple of successful menu planning, but when it comes to health services, scientific evaluation should be an essential ingredient. In an optimized public health system, the whole should be greater than the sum of its parts, so that people with limited access to care can efficiently access multiple needed services through a single encounter. It is no surprise, therefore, that integration has become a key topic in the broad debate around the strengthening of health systems, itself a subject that has dominated global health discourse in recent years. Integration of services is intuitively logical and has been a response to criticisms that some major health programs—human immunodeficiency virus (HIV)/AIDS services the prime example—are excessively vertical. As with many passionately debated subjects, data on risks and benefits of integration are scarcer than might be expected. | There is increased pressure to integrate in cost-constrained environments and for vulnerable or hard-to-reach populations, but it is important to avoid overloading public health workers or population members, because “too much of a good thing” might lead to unintended results. It is possible for the combination of interventions to erode acceptance, program performance, or the quality of individual services. A strong scientific agenda for public health integration can inform how to protect successful programs, reduce the risks of replicating ineffective approaches, and identify key strategies that will maximize value when integration efforts are taken to scale.