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Background In 2016, the Japanese government set the National Action Plan on antimicrobial resistance to reduce antibiotic prescriptions. However, the trends and variations of antibiotic prescription patterns in a routine healthcare setting during the fiscal year 2013–2018 across different clinics at a national level are unclear. Methods This retrospective cohort study included all clinics with >100 pediatric outpatients with infectious diseases per month during the fiscal year 2013–2018 using a national database in Japan. We investigated the trends in antibiotic prescription rates and their patterns and variations across different clinics over the six years following the 2019 World Health Organization Access, Watch, Reserve antibiotic groups, and Amoxicillin Index. Results A total of 2278 clinics with 94,414,170 infectious disease-related visits were eligible for the study. Most clinics showed higher Watch percentages (median 85.4%; IQR, 68.5–95.1) than Access percentages (median, 13.8%; IQR, 4.2–30.7) and Amoxicillin Index (median, 13.3%; IQR, 3.9–30.4). The introduction of the Action Plan changed annual absolute reductions in the antibiotic prescription rates from −16.0 DOTs/1000 visitors (95%CI, −16.4–15.6) to −239.3 per 1000 visitors (95%CI, −240.0–238.6). However, these impacts were heterogeneous across clinics. From 2013 to 2018, 41.4% reduced the antibiotic prescription rates by >33.3% (median, −1035.5 DOTs/1000 visitors; IQR, −1519.4–680.2), 18.7% did not change the rates (median, −40.3 DOTs/1000 visitors; IQR, −168.4–68.6), and 7.3% increased the rates by >10% (499.5 DOTs per 1000 visitors; IQR, 232.6–837.5). Conclusions We observed the National Action Plan's impacts and extensive prescription variations across different pediatric clinics. However, one-fourth of clinics did not improve antibiotic prescription patterns even after introducing the Action Plan.

The historical and empirical evidence presented in this special section highlights the lessons learned that can be directly useful for public health policy, intervention, and practice to mitigate the dire consequences ofhurricanes, wildfires, and other natural disasters Previous AJPH editorials, "Public Health Disasters: Be Prepared," which outlines the dilemma public health emergency preparedness professionals and societies face in paying the price for preparedness,1 and "Medical Countermeasures: A Stitch in Time Saves Nine,"2 which notes the competing choices to be made among priorities, help our thinking with respect to preventing untoward things from occurring in the first place (primary prevention) and preventing things that do occur from becoming even more serious (secondary prevention) "SOWING THE WIND" Perhaps, in the broadest view-and especially cogent in the light of the current level of raised awareness of the systemic racism still highly prevalent in the United States-the sowing ofthe wind of systemic racism reaped the whirlwind of much of the destruction caused by Hurricane Katrina in terms ofloss oflife and property that disproportionally affected Blacks (even considering their large percentage of the population), who were living in poorer areas at high risk for flooding, had less opportunities for early evacuation to areas of safety, and had higher levels of preexisting medical conditions that made them more vulnerable to the trauma and stress of Katrina

Objective-This report compares prevalence of and change over time for five infectious disease outcomes for the Los Angeles County (LAC) and the U.S. populations. The infectious disease outcomes examined are: herpes simplex virus type 1 (HSV-1) and type 2 (HSV-2), any hepatitis B virus (HBV) infection, HBV immunization, and hepatitis A virus (HAV) from infection or immunization, available for 1999-2006 and 2007-2014, as well as any human papillomavirus (HPV) and high-risk HPV infection, available for the 2007-2014 period only. Methods-LAC was sampled in every 2-year cycle of the current National Health and Nutrition Examination Survey, enabling creation of two 8-year samples (1999-2006 and 2007-2014). Demographic differences associated with disease prevalence were examined between LAC and the United States. Changes over time and differences in prevalence, unadjusted, age adjusted, and "fully" adjusted by direct standardization for these demographic variables, were evaluated between the United States and LAC for 2007-2014. Results-Compared with the United States, persons in LAC were more likely to be Mexican American, born outside of the United States, and live below the poverty level. Prevalence varied significantly by demographic subgroup for each outcome in the United States and for some outcomes in LAC. Differences between LAC and the United States existed for some outcomes but varied with adjustment. Over time, prevalence of HSV-1, HSV-2, and HBV infection decreased, and HBV immunization and HAV infection or immunization increased for the U.S. population. The direction of changes over time were mostly similar for LAC, but significance varied.

An introduction is presented in which the author discusses the journal's special supplement entitled "Public Health Emergencies: Unpacking Medical Countermeasures Management for Preparedness and Response," and it mentions medical personnel training, medications, and pandemic influenza management.

To evaluate trends in rates of personal belief exemptions (PBEs) to immunization requirements for private kindergartens in California that practice alternative educational methods.We used California Department of Public Health data on kindergarten PBE rates from 2000 to 2014 to compare annual average increases in PBE rates between schools.Alternative schools had an average PBE rate of 8.7%, compared with 2.1% among public schools. Waldorf schools had the highest average PBE rate of 45.1%, which was 19 times higher than in public schools (incidence rate ratio = 19.1; 95% confidence interval = 16.4, 22.2). Montessori and holistic schools had the highest average annual increases in PBE rates, slightly higher than Waldorf schools (Montessori: 8.8%; holistic: 7.1%; Waldorf: 3.6%).Waldorf schools had exceptionally high average PBE rates, and Montessori and holistic schools had higher annual increases in PBE rates. Children in these schools may be at higher risk for spreading vaccine-preventable diseases if trends are not reversed.

An introduction is presented in which the author discusses the articles in a special public health preparedness supplement of the journal, and it mentions topics such as the funding of public health and emergency management preparedness programs, as well as investments in the U.S.

Hospitals are the normal setting for physician residency training within the United States. When a hospital cannot provide the specific training needed, a special rotation for that experience is arranged. Linkages between clinical and public health systems are vital to achieving improvements in overall health status in the United States. Nevertheless, most physicians in postgraduate residency programs receive neither training nor practical experience in the practice of public health. For many years, public health rotations have been available within the Los Angeles County Department of Public Health (and its antecedent organizations). Arrangements that existed with local medical schools for residents to rotate with Los Angeles County Department of Health hospitals were extended to include a public health rotation. A general model for the rotation ensured that each resident received education and training relevant to the clinician in practice. Some parts of the model for experience have changed over time while others have not. Also, the challenges and opportunities for both trainees and preceptors have evolved and varied over time. A logic model demonstrates the components and changes with the public health rotation. Changes included alterations in recruitment, expectations, evaluation, formal education, and concepts related to the experience. Changes in the rotation model occurred in the context of other major environmental changes such as new electronic technology, changing expectations for residents, and evolving health services and public health systems. Each impacted the public health rotation. The evaluation method developed included content tests, assessment of competencies by residents and preceptors, and satisfaction measures. Results from the evaluation showed increases in competency and a high level of satisfaction after a public health rotation. The article includes examples of challenges and benefits to a local health department in providing a public health rotation for physicians-in-training and how these challenges were overcome.

Vaccinations are one of public health’s greatest achievements. However, an ethical dilemma lies in the balance of personal autonomy and choice versus protection of the entire at risk population. Vaccines have become readily available in most parts of the world, yet debates continue as to the appropriateness of requirements for vaccinations, including legal mandates of vaccinations during public health emergencies and more routinely for school entry. This paper addresses ethical issues concerning vaccination requirements in the context of historical as well as current immunization program activities. Five important programmatic focus areas for immunization programs are identified for minimizing conflicts among the relevant ethical principles when developing and implementing vaccination requirements; namely: 1) reviewing and evaluating current vaccination mandates in the relevant health jurisdiction; 2) increasing the use of non-compulsory vaccination strategies; 3) addressing parent/guardian vaccine safety concerns; 4) enhancing public awareness of vaccine-preventable disease risks; and 5) promoting a better public understanding of herd immunity. We suggest that strengthening these programmatic focus areas can lead to a greater public acceptance of vaccination requirements.

This is the first time seroprevalence of antibody to these nine infectious diseases have been available for LAC. Differences in the race and ethnicity distribution of the United States and LAC were observed. Because disease prevalence varies by race and ethnicity, in some instances these demographic differences affected the population differences seen between the United States and LAC in the seroprevalence of the infectious diseases reported in this study. Seroprevalence for HAV was higher in LAC as compared with the United States among the total population and among the Mexican-American population. California is 1 of 11 states in which routine vaccination of children was recommended in 1999 by the Advisory Committee on Immunization Practices (ACIP) because mean incidence rates in these states were at least twice the national mean from 1987–1997 (9). Seroprevalence to CMV and T. gondii have been shown to be higher among Mexican-American persons then other race and ethnicity groups (1,3). The higher seropositivity for CMV and T. gondii among persons from LAC is due to the higher proportion of Mexican-American persons in the LAC population. No differences in seropositivity were observed when comparing Mexican-American persons in the United States and LAC for these two outcomes. No significant differences in seroprevalence between the United States and LAC were seen for measles, mumps, rubella, varicella, HSV-1, and HSV-2. Estimates of seropositivity from immunization or disease for LAC may assist in policy development, program planning, and measuring health disparities.

The author discusses the theme of National Public Health Week "A Healthier America: One Community at a Time." He mentions that to meet this goal, health disparities in less advantaged communities around the globe must be addressed. He discusses threats to global health including unhealthy lifestyles, human-made changes to the environment and war.

This paper highlights the achievements, lessons learned, goals, policies, strategies and approaches for the Expanded Programme on Immunization for the 1990s. The Programme's Global Advisory Group endorsed the paper in October 1991, together with actions proposed for the 1990s. Figures showing immunization coverage and estimates of prevented and current mortality and morbidity are included.

IN May 1988, the World Health Assembly declared that the World Health Organization was committed to the global eradication of poliomyelitis by the year 2000.1 The eradication of poliomyelitis, as with smallpox, involves the additional criterion of the elimination of indigenous transmission of wild virus. This paper reviews the progress that has been achieved, outlines current objectives, and highlights the research and development required to meet the target of global eradication. Background The initiative for the global eradication of poliomyelitis is being coordinated by the Expanded Programme on Immunization (EPI), established by the World Health Assembly in 1974. The initial . . .

Background Adult film production is a legal, multibillion dollar industry in California. In response to reports of human immunodeficiency virus (HIV) transmission by an adult film worker, we sought to determine the extent of HIV infection among exposed workers and to identify means of improving worker safety. Methods The Los Angeles County Department of Health Services initiated an outbreak investigation that included interviews of infected workers to elicit information about recent sex partners, review of the testing agency's medical records and laboratory results, molecular analysis of HIV isolates from the 4 infected workers, and a risk assessment of HIV transmission in the adult film industry. Results Many adult film workers participate in a monthly program of screening for HIV infection by means of polymerase chain reaction-based technology to detect HIV DNA in blood. A male performer tested negative for HIV on 12 February 2004 and 17 March 2004, then tested positive for HIV on 9 April 2004. During the period between the negative test results, he experienced a flulike illness after performing unprotected vaginal and anal intercourse for an adult film produced outside the United States by a US company. After returning to California, he performed unprotected sex acts for adult films with 13 female partners who had all tested negative for HIV in the preceding 30 days; 3 subsequently tested positive for HIV (a 23% attack rate). Contact tracing identified no reasonable sources of infection other than the male index patient. Conclusion Although current testing methods may shorten the window period to diagnosis of new HIV infection, they fail to prevent occupational acquisition of HIV in this setting. A California Occupational Safety and Health Administration-approved written health and safety program that emphasizes primary prevention is needed for this industry.

The smallpox virus is a high-priority, Category-A agent that poses a global, terrorism security risk because it: (1) easily can be disseminated and transmitted from person to person; (2) results in high mortality rates and has the potential for a major public health impact; (3) might cause public panic and social disruption; and (4) requires special action for public health preparedness. In recognition of this risk, the Los Angeles County Department of Health Services (LAC-DHS) developed the Smallpox Preparedness, Response, and Recovery Plan for LAC to prepare for the possibility of an outbreak of smallpox. A unique feature of the LAC-DHS plan is its explicit use of the Standardized Emergency Management System (SEMS) framework for detailing the functions needed to respond to a smallpox emergency. The SEMS includes the Incident Command System (ICS) structure (management, operations, planning/intelligence, logistics, and finance/administration), the mutual-aid system, and the multi/interagency coordination required during a smallpox emergency. Management for incident command includes setting objectives and priorities, information (risk communications), safety, and liaison. Operations includes control and containment of a smallpox outbreak including ring vaccination, mass vaccination, adverse events monitoring and assessment, management of confirmed and suspected smallpox cases, contact tracing, active surveillance teams and enhanced hospital-based surveillance, and decontamination. Planning/intelligence functions include developing the incident action plan, epidemiological investigation and analysis of smallpox cases, and epidemiological assessment of the vaccination coverage status of populations at risk. Logistics functions include receiving, handling, inventorying, and distributing smallpox vaccine and vaccination clinic supplies; personnel; transportation; communications; and health care of personnel. Finally, finance/administration functions include monitoring costs related to the smallpox emergency, procurement, and administrative aspects that are not handled by other functional divisions of incident command systems. The plan was developed and is under frequent review by the LAC-DHS Smallpox Planning Working Group, and is reviewed periodically by the LAC Bioterrorism Advisory Committee, and draws upon the Smallpox Response Plan and Guidelines of the Centers for Disease Control and Prevention (CDC) and recommendations of the Advisory Committee on Immunization Practices (ACIP). The Smallpox Preparedness, Response, and Recovery Plan, with its SEMS framework and ICS structure, now is serving as a model for the development of LAC-DHS plans for responses to other terrorist or natural-outbreak responses.

The author reflects on progress and setbacks related to addressing and managing infectious diseases across the globe. In the article he offers his opinions on factors which have obstructed efforts to eradicate infectious diseases and on the obligation that public health professionals have to find solutions to the global problems associated with infectious diseases.

Abstract. Since the development of attenuated oral polio vaccine, Dr Albert Sabin consistently maintained that the global eradication of wild poliovirus was possible, but that to achieve polio eradication in developing countries would require the mass administration of the oral vaccine. Experience in Cuba and Czechoslovakia proved the effectiveness of this technique, but it was only with its deployment in Brazil in 1980 that its role in eradicating the virus from a broad geographical area started to be realized. With the declaration in 1985 of a target of regional polio eradication, extension of this policy, allied with the development of effective surveillance of acute flaccid paralysis in children, with laboratory confirmation of diagnosis rapidly led to apparent interruption of wild poliovirus transmission throughout the Americas. The World Health Assembly in 1988 committed WHO to the global eradication of poliomyelitis. Based on experience in the Americas and building on the solid foundation established by the Expanded Programme on Immunization, WHO has defined the strategies through which the global target could be achieved. Progress is encouraging and where the advocated strategies have been fully implemented, the incidence of poliomyelitis has declined dramatically. Significant geographical areas in Western Europe, the Maghreb, the Arabian peninsula, the Pacific basin and Southern Africa, each incorporating several countries, are now thought to be free of the disease caused by wild poliovirus. The target of a world free of polio by the year 2000 can be achieved.

Breastfeeding promotion and immunization are important interventions of child survival programs, especially in developing countries. Linkages between breastfeeding promotion programs and the Expanded Programme on Immunization (EPI) in developing countries mean that health care workers can make use of every contact with the mother and child to reinforce the educational messages of both programs. Breastfeeding does not interfere with vaccinations administered in accordance with the routine schedule recommended by the EPI Global Advisory Group for use in developing countries. Breastfeeding benefits the EPI and the EPI also benefits breastfeeding. The maximum reduction of morbidity and mortality will be achieved when all child survival interventions are applied in a balanced, complementary manner as envisaged in the concept of primary health care.Breastfeeding promotion and immunization are important interventions of child survival programs, especially in developing countries. Linkages between breastfeeding programs and the Expanded Program on Immunization (EPI) in developing countries mean that healthcare workers can use every contact with the mother and child to reinforce educational messages conveyed by both programs. Breastfeeding does not interfere with vaccinations administered in accordance with the routine schedule recommended by the EPI Global Advisory Group for use in developing countries. Breastfeeding benefits the EPI and the reverse is true as well. The maximum reduction of morbidity and morality will be achieved when all child survival interventions are applied in a balanced, complementary manner as seen in the concept of primary healthcare.

An outbreak of mumps in a middle school (grades 6 to 8) in Ohio during 1981 was investigated to describe the clinical findings, health impact, and costs. Individuals with clinical mumps in the middle school and in family members were questioned concerning symptoms, complications, hospitalizations, school days absent, and parental work days missed. There were 62 cases of clinical mumps in the middle school and 13 cases among family members. Parotitis lasted an average of 7.4 days and fever (if present) lasted an average of 2.5 days with a mean temperature of 38.6°C (101.4°F). The duration of parotitis and fever increased with age. Complications included encephalitis, aseptic meningitis, orchitis, oophoritis, mastitis, and pancreatitis. Visits to physicians were made by 62.7% (47/75) of the individuals with mumps for a total of 63 visits, and two patients were hospitalized for a total of six days. Persons who attended middle school missed an average of 4.9 days of school. The estimated direct and indirect costs associated with this outbreak were $2,460 and $1,353, respectively, or $51 per case. States lacking mumps immunization requirements experienced a three-times greater incidence of mumps in 1982 than States that required all school pupils to be immunized. We recommend that all States institute compulsory mumps school immunization laws for all school children.

The changing annual vaccination status of the population and the greater than 1,000-fold drop in reported annual incidence of paralytic poliomyelitis between the early 1950s and early 1970s indicate that the control of poliomyelitis in the United States must be attributed to the use of both the inactivated poliovirus vaccine and oral poliovirus vaccine. The containment, in 1972 and 1979, of rare epidemics in poorly vaccinated subpopulations and the existence of only three reported cases of paralytic poliomyelitis clearly attributable to wild poliovirus in the last three years document a major triumph for public health. The continuing occurrence of vaccine-associated paralysis (six or seven reported cases per year, 1980-1982) indicates the necessity, despite the accomplishments, for continued review of the current vaccination strategy.

From February 5 through April 23, 1982, 110 cases of mumps were reported among 357 students in a middle school in Ashtabula County, Ohio, an overall attack rate of 31%. Vaccine efficacy was calculated using a variety of case definitions, case surveillance systems, and vaccination-status ascertainment methods to evaluate their effects on the estimated vaccine efficacy. From data collected at the school for case ascertainment and vaccination status, clinical vaccine efficacy was initially estimated at 37%. By means of a uniform case definition (parotitis lasting two days or more) and only cases and vaccination status ascertained from parental questionnaires, estimated vaccine efficacy increased to 70%. From secondary attack rates in household members with provider-verified vaccination status, the vaccine efficacy further increased to 85%. This outbreak investigation confirms that the methods used to ascertain cases and determine vaccination status greatly affect estimates of vaccine efficacy. Studies relying solely on school records for case finding and determination of immunization status may provide misleadingly low estimates of vaccine efficacy for mumps vaccine as well as for other vaccines. Appropriate methods demonstrate that mumps vaccine is highly effective and support recommendations for its continued use.

Campus outbreaks and campus-associated cases together accounted for 51.1% of all reported measles cases in the first 26 weeks of 1983. This proportion is of particular concern because measles is a more serious disease in adults than in schoolchildren. For a substantial number of highly mobile young adults, college may be the last opportunity to ensure protection against measles and other preventable infections. Unfortunately, immunization levels on campuses are difficult to assess because very few institutions require immunization records. Nevertheless, colleges and universities have an obligation to their students to provide a safe and healthy learning environment; they also have a need to avoid costly and disruptive outbreaks on their campuses. To break the remaining chains of measles transmission on campus, colleges and universities should require all students born after 1956 to present a complete and up-to-date immunization record for matriculation and registration. Incoming freshmen should b...

A case-control study was done to determine the risk and pathogenesis of febrile spontaneous abortion for intrauterine device (IUD) wearers compared to non-wearers. Four groups of women coming to a large city hospital between 1970 and 1975 were compared: 1) women presenting with febrile spontaneous abortion, 2) women presenting with afebrile spontaneous abortion, 3) women presenting with afebrile spontaneous abortion which subsequently became febrile, and 4) women delivering a live infant. Pregnant women with an IUD in situ had a 5-fold higher risk of both febrile and afebrile spontaneous abortion compared to pregnant women without an IUD in situ. Women who had a spontaneous abortion that shifted from afebrile to febrile were somewhat more likely to be IUD wearers than the other 2 spontaneous abortion groups. In our study population, the increased risk of febrile spontaneous abortion for IUD wearers appeared primarily due to the increased risk of the spontaneous abortion event itself, rather than a primary IUD-related infection causing febrile spontaneous abortion.

To the Editor.— A recent book for physicians, nurses, and other medical personnel correctly states that diphtheria, tetanus, pertussis (DTP), rubella, mumps, and measles vaccines should be given at the regularly scheduled times to infants who are breast-fed. 1 However, the recommendations regarding oral polio vaccine (OPV) are not supported by the two major immunization advisory bodies in the United States, the Advisory Committee on Immunization Practices (ACIP) and the Committee on Infectious Diseases of the American Academy of Pediatrics (Red Book Committee). The author recommends that breast-feeding be postponed for at least 30 minutes after the administration of an OPV and that booster doses should be given as soon as the infant is weaned and one year after weaning. We believe that the author's recommendations have caused unnecessary confusion and are not supported by the available scientific literature. We have received several inquiries from physicians for clarification. Because of

• An outbreak of mumps in a middle school (grades 6 through 8) in Ohio during 1981 was investigated to determine the effectiveness of mumps vaccine. Of the 481 middle school students on whom questionnaires were completed, 62 (12.4%) exhibited clinical mumps. The overall vaccine efficacy was 81.2% when children with a history of mumps disease are excluded from the analysis. Using a logistic regression model with the presence or absence of clinical mumps as the dependent variable, three factors were found to be significant: mumps vaccine, a history of mumps disease, and sex. Factors that did not significantly affect the rate of disease among vaccinated pupils included (1) whether the mumps vaccine was administered singly or in combination with rubella and/or measles vaccine, (2) age at vaccination, (3) year of vaccination, and (4) month of vaccination. ( AJDC 1985;139:909-912)

In Reply.— The ratio of one case of paralytic poliomyelitis for every 3.2 million doses of OPV distributed represents the CDC's best estimate, based on available data, of the risk of polio to recipients and contacts after a single dose of OPV. Parents or guardians of children who receive vaccine purchased with federal funds are informed of this risk each time they appear in a clinic to have their children vaccinated. An estimate of the overall risk in a three- or four-dose series might be useful. However, it does not properly inform persons of the risk of a given dose administered on the day of the clinic visit. In addition, data to calculate the number of children vaccinated each year are not generally available. Simply dividing the number of doses distributed by 3 or 4 may not accurately reflect the number of vaccinated persons. Finally, rates per 100,000 live births