The First Reported Case of Co-Infection with Neisseria Meningitidis and Bordetella Pertussis in the Cerebrospinal Fluid Specimen of a Normal Four-Year-Old Child

Pertussis is an acute and highly contagious respiratory disease caused by Bordetella pertussis(B.pertussis),which occurs in people of all ages and is most dangerous for young children,especially infants.The introduction of whole-cell pertussis vaccines(wPVs)in the 1950s dramatically reduced the incidence of pertussis worldwide[1].However,over the past two decades,many studies have reported the resurgence of pertussis in different countries[2].Epidemiological surveillance in Hubei Province over the last 3 years revealed a clear increasing trend in the incidence of pertussis during the coronavirus disease 2019(COVID-19)epidemic.

Risk factors for pertussis among children hospitalized for pertussis during 2016-2017, in Guizhou Province of China: a case-control study

Aim:Pertussis is a respiratory tract infection,the vaccine for which was introduced in the Expanded Programme on Immunization(EPI)in Guizhou Province of China(hereafter referred as Guizhou)in the 1980s.This vaccine rapidly decreased incidence rates of pertussis in the province,however,despite the wide high coverage of the diphtheria,tetanus and acellular pertussis(DTaP)combined vaccine,there has been a resurgence of pertussis since 2014.Even with this recent increase in disease transmission,risk factors for pertussis infection have not been evaluated in Guizhou.We aimed to provide information on pertussis risk factors and insight on designing targeted pertussis control policies and measures through this study.Methods:A 1:2 matched retrospective case-control study was conducted between 2016 and 2017,involving infants and children younger than 6 years old and parents of the participants.The enrolled cases included clinical and laboratory confirmed pertussis cases according to the WHO-recommended pertussis definition.Controls were selected from children in the same neighborhood who were not diagnosed with pertussis prior to our investigation and did not exhibit any clinical manifestations of pertussis.Results:The household size[Matched odds ratio(OR_(m)=1.4,95%confidence interval(Cl):1.1-1.7]and household members with antecedent cough(OR_(m)=3.6,95%CI:1.8-7.2)were significantly associated with their child’s pertussis onset.The parents’occupations were significantly associated with their child’s pertussis onset(ORm=9.4,95%CI:1.6-54.8,for mother side;ORm=4.5,95%CI:1.2-16.5,for father side),when they worked in the business and/or service industry.Having family members with a history of cough was an independent risk factor for pertussis[Adjusted odds ratio(AOR)=43.6,95%CI:2.7-694.0].Besides,the parents’demographic characteristics and DTaP doses were not found to be independent factors.Conclusion:Household exposure is an important risk factor for pertussis infection in infants and young children and should therefore be considered as a major factor during formulation of pertussis control policies and measures.

Epidemiological Characteristics and Risk Factors of the Pertussis in Infants < 12 Months of Age in Tianjin, China

The epidemiologic characteristics of 631 infant pertussis cases 〈 12 months, which accounted for 57.42% of the total cases, were analyzed by descriptive epidemiology in Tianjin, between 2010 and 2015. The incidence of infants was 104.66/100,000, which was 118 times higher than in other age groups （P 〈 0.001）. The primary type of pertussis simultaneously presented in households was adult-to-infant （70.51%）. The parents were identified as the source of infection in 80.18% of cases for infants. The positive rate of placental antibody transfer was 31.06% and 3.13% for 3-month-old infants. Infants presented the highest age-specific pertussis incidence. The most important reason was parents were the important sources of infection, and secondly the lower level of antibodies in neonates and the rapid waning of maternal antibody titer.

Research on pharmacological mechanism of the treatment of Asthma by oral Bordetella pertussis

Objective To examine the effect of oral Bordetella pertussis on the asthma mice sensitized by ovalbumin(OVA),and explore the possible mechanism.Methods Culture the B.pertussis in Bordet-Gengou agar containing 25% rabbit blood.Collect the bacteria and inactive them at 80 ℃ for 30 min to get whole killed B.pertussis.32 BALB/C mice were randomly divided into control group,model-control group,model group and treatment group.The mice were sensitized and challenged with OVA to establish asthma model.Asthma mice in treatment group were orally administrated with B.pertussis 7 days before sensitization.The mice in control group and model-control group were challenged with saline.After 24 hours of last challenge,bronchoaveolar lavage fluid(BALF)and peripheral blood were collected.The total cells and eosinophils were counted in BALF.Results Compared with the control group(2.03±0.42,0.33±0.82)×105 mL-1 and model-control group(2.16±0.48,0.16±0.41)×105 mL-1,the total cells(10.13±1.33)×105 mL-1 and eosinophils(11.83±4.573)×105 mL-1 in BALF were more in asthma mice(P<0.01).The number of total cells(5.50±1.55)×105 mL-1 and eosinophils(0.66±0.82)×105 mL-1 in BALF were reduced in asthma mice treated with B.pertussis compared with asthma mice(P<0.01).Conclusions Oral B.pertussis can inhabit airway inflammation of asthma mice and has the potential of treating asthma.

Characterization of two Achromobacter xylosoxidans isolates from patients with pertussis-like symptoms

Objective:To characterize two Achromobaeter xylosoxidans recovered from 2 patients diagnosed with pertussis during a Bordetella pertussis surveillance program.Methods:Nasopharyngeal swabs from 2 children under 1 year of age with clinical suspicion of pertussis were analyzed by culture and PCR.Results:Two Achromobaeter xylosoxidans A8,closely related to Bordetella spp.were recovered from 2 patients diagnosed of pertussis,both carrying the ptxA gene and IS418 the pertussis toxin encoding gene.Subsequently,antibiotic susceptibility was evaluated by disk-diffusion method and by PCR.Conclusions:Although more detailed studies are needed,the present data highlight the possibility that Achromobaeter xylosoxidans.closely related Bordetella pertussis microorganisms and not covered under the vaccine umbrella,might also result in cases of whooping cough.Thereby further surveillance is necessary to determine the extension and relevance of their pathogenic role in order to discriminate their real public health implication.

Aberration detection of pertussis from the Mazandaran province, Iran, from 2012 to 2018: Application of discrete wavelet transform

Objective:To define the level of alarm threshold for pertussisaberrations and to detect the aberrations of the reported suspectedcases of pertussis from the Mazandaran province in the north ofIran.Methods:The included cases were composed of the suspectedpertussis patients who came from Mazandaran province andregistered in the Center for Disease Control and Prevention from20 March 2012 to 20 March 2018.A discrete wavelet transformbasedmethod was used to detect the aberrations.All analyseswere performed using MATLAB Software version 2018a andExcel 2010.Results:A total of 1162 cases were recruited in the study,including 545(46.90%)males and 617(53.10%)females,withmedian age of 1.47(0.22-9.56)years.The median age of maleswas 1.18(0.21-8.24)years,while that of females was 1.82(0.21-10.75)years.Concerning the level of the alarm threshold,it was1.28 case/d when k=2,while it was 1.34 case/d when k=3.Thetotal detected aberration days were 123 d and 57 d by consideringk=2 and 3,respectively.The most defined alarm threshold wasrelated to spring(>2 cases/d)and summer(>1 case/d),respectively.Conclusions:The sensitivity of the surveillance system issubjected to a different time.Thus,determining the level of alarmthreshold periodically using different methods is recommended.

Analysis of prevailing pertussis strains from different regions in China after the application of acellular vaccines

To the Editor:With the extensive uptake of pertussis vaccine,morbidity and mortality related to pertussis have decreased significantly.The application of acellular vaccines(ACVs)occurred later in China than in developed countries;correspondingly,the pertussis resurgence in China also began later.The latest global genotype dynamic prediction model cannot explain the B.pertussis genotype change trend in China.[1]Chinese B.pertussis strains gradually formed their own unique developmental branches.[2]Here,a phylogenetic tree of prevailing B.pertussis strains from three different regions of China was visualized by EvolView(http://www.evolgenius.info/evolview.html).A total of 199 isolated B.pertussis strains were used for the phylogenetic analysis.The B.para-pertussis strain isolated from Tianjin was used as the out-group,and Chinese strain(CS),which is widely used as a vaccine strain for ACV production in China,was used as the reference strain.In particular,we analyzed the multilocus sequence typing(MLST)and macrolide-resistance-conferring gene mutations.

Biosynthesis and transfer of 2‑acetamido‑4‑methylamino‑l‑fucose to the core‑lipid A in Bordetella pertussis

The trisaccharide unit in lipopolysaccharide of Bordetella pertussis is important for immune recognition,but how the rare sugar 2-acetamido-4-methylamino-fucose in the trisaccharide unit is synthesized and transferred to the core of lipopolysaccharide in B.pertussis remains unclear.In this study,we demonstrated that the genes bplF,bplG,bplL and bplI are involved in the synthesis and transfer of 2-acetamido-4-methylamino-fucose to the core of lipopolysaccharide in B.pertussis.These genes were overexpressed with various combination in a recombinant E.coli strain which can synthesize B.pertussis corelipid A.Lipopolysaccharides were isolated from these strains and analyzed by using SDS-PAGE,ion chromatography and NMR.Based on these analyses,the mechanism of biosynthesis and transfer of 2-acetamido-4-methylamino-l-fucose to the core-lipid A in B.pertussis is proposed.

Coverage rates for diphtheria,tetanus,poliomyelitis,and pertussis age-specific booster recommendations in France:2018 update of the real-world cohort analysis

The French National Immunization Program was updated in 2013 for vaccination against diphtheria,tetanus,per-tussis,and poliomyelitis.Our previous findings on the evolution of age-specific booster vaccination coverage rates(VCRs)up to 2017 suggested suboptimal vaccination coverages due to the pre-2013 recommendation-residual vaccination practices.In the current analysis,we evaluated all age-specific booster VCR and distribution of age at vaccination visits in 2018.In this retrospective observational cohort study,the cumulative booster VCRs were updated at all vaccination visits up to 2018 among the people who were eligible for a booster vaccination,using a 1/97th random sample of French national healthcare reimbursement databases.The cumulative booster VCR for individuals from all age groups increased from 2017 to 2018,except for 85-years-old vaccination visit.Majority of the individuals from all age groups were vaccinated(boosted)with a vaccine containing the pertussis valence.In 2018,sharp peaks corresponding to the recommended ages for booster vaccination visits were observed for individuals aged 6,11 to 13,25,45,and 65 years.Our study reiterates suboptimal coverages in France and implies the need for booster vaccination throughout life for the protection of the population.

Clinical characteristics,molecular epidemiology and antimicrobial susceptibility of pertussis among children in southern China

Background Increasing numbers of pertussis cases have been reported in recent years.The reported cases from Shenzhen Children's Hospital were close to one tenth of all cases in China.The epidemiology of antigenic genotype and antibiotic resistance of circulating strains in children have been unknown in Shenzhen,southern China.The aim of this study was to describe the clinical features and explore the genotypes and antimicrobial susceptibility of circulating Bordetella pertussis among children in Shenzhen.Methods Data of hospitalized children with pertussis in Shenzhen Children's Hospital from August 2015 to April 2017 were collected.The genetic variability of isolates was investigated and Etest was performed for phenotypic susceptibility to erythromycin,azithromycin,clarithromycin,clindamycin,and trimethoprim/sulfamethoxazole.Results 469 children with pertussis confirmed by real-time quantitative polymerase chain reaction were hospitalized and strains were isolated from 105 patients.White blood cell count≥20×10^9/L and lymphocyte proportion≥60%were observed in 39.29%of infants younger than 3 months.The two predominant profiles of virulence-associated allelic genes were ptxA1/ptxC1/ptxPl/prnl(48.6%)and ptxA1/ptxC2/ptxP3/prn2(44.8%).Among the isolates,48.6%(51/105)were found resistant to macrolides.Conclusions These findings indicate that leukocytosis is not a sensitive indicator of pertussis.Isolates with the gene profile ptxP3/prn2 were highly circulating in Shenzhen and less resistant to macrolides,different from patterns observed in other parts of China.

Pertussis toxin modulation of sodium channels in the central neurons of cyhalothrin-resistant and cyhalothrinsusceptible cotton bollworm, Helicoverpa armigera

Pertussis toxin （FIX） inhibits the activation of the α-subunit of the inhibitory heterotrimeric G-proteins （Cαi/o） and modulates voltage-gated sodium channels, which may be one of the primary targets of pyrethroids. To investigate the potential mechanisms of agricultural pests resistance to pyrethroid insecticides, we examined the modulations by PTX on sodium channels in the central neurons of the 3rd-4th instar larvae of cyhalothrin-resistant （Cy-R） and cyhaiothrin-susceptible （Cy-S） Helicoverpa armigera by the whole-cell patch-clamp technique. The isolated neurons were cultured for 12-16 h in an improved L15 insect culture medium with or without PTX （400 ng/mL）. The results showed that both the Cy-R and Cy-S sodium channels exhibited fast kinetics and tetrodotoxin （TTX） sensitivity. The Cy-R sodium channels exhibited not only altered gating properties, including a 8.88-mV right shift in voltage-dependent activation （V0.5act） and a 6.54-mV right shift in voltage-dependent inactivation （V0.5inact）, but also a reduced peak in sodium channel density （Ⅰdensity） （55.2% of that in Cy-S neurons）. Cy-R sodium channels also showed low excitability, as evidenced by right shift of activation potential （Ⅴacti） by 5-10 mV and peak potential （Ⅴpcak） by 20 mV. FIX exerted significant effects on Cy-S sodium channels, reducing sodium channel density by 70.04%, right shifting V0.5act by 14.41 mV and V0.5inact by 9. 38 mV. It did not cause any significant changes of the parameters mentioned above in the Cy-R sodium channels. The activation time （Tpeak） from latency to peak at peak voltage and the fast inactivation time constant （τinact） in both Cy-S and Cy-R neurons were not affected. The results suggest that cotton bollworm resistant to pyrethroid insecticides involves not only mutations and allosteric alterations of voltage-gated sodium channels, but also might implicate perturbation of PTX-sensitive Gαi/o-COupled signaling Wansduction pathways.

Protective Effect of Anisodsmine on Brain Edema Induced by Pertussis Bacilli in Rabbits

Objective: To observe the effect of 654-2 on brain edema model induced by pertussis bacilli in rabbits. Methods: Brain edema model of 26 rabbits induced by pertussis bacilli was prepared for observation,their brain water content and brain glutamate level were determined before and after treatment. Results: 654-2could decline the water content of brain and increase the glutamate level in brain tissue of the treatment group as compared with group without treatment. Conclusion: 654-2 has protective effect on brain edema induced by pertussis bacilli.

Investigation of temporal and spatial heterogeneities of the immune responses to Bordetella pertussis infection in the lung and spleen of mice via analysis and modeling of dynamic microarray gene expression data

Bordetella pertussis(B.pertussis)is the causative agent of pertussis,also referenced as whooping cough.Although pertussis has been appropriately controlled by routine immunization of infants,it has experienced a resurgence since the beginning of the 21st century.Given that elucidating the immune response to pertussis is a crucial factor to improve therapeutic and preventive treatments,we re-analyzed a time course microarray dataset of B.pertussis infection by applying a newly developed dynamic data analysis pipeline.Our results indicate that the immune response to B.pertussis is highly dynamic and heterologous across different organs during infection.Th1 and Th17 cells,which are two critical types of T helper cell populations in the immune response to B.pertussis,and follicular T helper cells(TFHs),which are also essential for generating antibodies,might be generated at different time points and distinct locations after infection.This phenomenon may indicate that different lymphoid organs may have their unique functions during infection.These findings provide a better understanding of the basic immunology of bacterial infection,which may provide valuable insights for the improvement of pertussis vaccine design in the future.

A scoping review of studies on women's knowledge regarding Tdap vaccination during Pregnancy

This review aimed to determine and identify the knowledge and attitude of the mothers or pregnant women toward the Tdap vaccine during pregnancy.Whooping cough,Diphtheria disease and tetanus are infectious and pathogenic bacterial diseases that mainly affect children too young to complete basic vaccinations,and deaths associated with infectious diseases are frequent among them.Therefore,it is advisable for pregnant women to take the triple bacterial vaccine(tetanus,diphtheria and pertussis).This scoping review was conducted,and various electronic databases were searched,including Medline and PubMed.Moreover,Google Scholar,CDC,and immunization research group websites were searched to investigate the literature on the Tdap vaccine.As a result,13 studies were included in this review.Based on the findings of this review,the level of knowledge of ladies and pregnant women about the importance of the vaccine depended upon several factors,including education level,occupation,age,sources of vaccine information,maternal desire,being born outside the country,lower household income,religious misconception,residing in a province or area where the pertussis vaccine was not free,having given birth to live children in the past,and receiving maternity care from a midwife.Therefore,it can be concluded that the increase in the level of knowledge about the importance of Tdap vaccine increased the percentage of women who supported and accepted the vaccine.Studies have also shown that some mothers refused vaccination due to reservations about vaccine safety and efficacy since they did not have sufficient knowledge or experience.

SDF-1/CXCR4在骨髓增生异常综合征患者中的生物学作用

本研究主要探讨骨髓增生异常综合征(MDS)及白血病患者中基质细胞衍生因子-1(SDF-1)在细胞凋亡、迁移和黏附中的作用及相关的信号转导。选取37例初发MDS患者〔低危组(IPSS≤1.0)22例,高危组(IPSS≥1.5)15例〕、10例初发白血病患者及14例良性贫血患者(作为对照组),通过流式细胞术检测骨髓CD34+细胞表面CXCR4的表达水平及CD34+细胞的凋亡情况。选取4例低危MDS患者和5例高危MDS患者,通过微孔细胞迁移实验检测SDF-1对细胞的趋化作用。通过CCK-8法检测SDF-1对细胞之间黏附能力的影响。结果表明,低危MDS组骨髓内CD34+细胞的凋亡率明显高于高危MDS组(21.33%vs 7.27%,p<0.001),同样低危MDS组骨髓内CD34+细胞的凋亡率明显高于白血病组(21.33%vs 7.53%,p<0.001),未发现CD34+细胞的凋亡率与患者年龄性别有相关性。SDF-1能够促进高表达CXCR4患者的细胞黏附于基质细胞并能诱导该细胞的迁移,诱导细胞形态发生极化,上述作用可以被G蛋白抑制剂pertussis toxin、PI3K抑制剂wortmannin及CXCR4拮抗剂AMD3100明显抑制;而对低表达CXCR4的患者细胞则无上述抑制作用。结论:SDF-1/CXCR4通过PI3K信号通路提高细胞的迁移及黏附能力,发挥抗凋亡作用,上述作用可以被PI3K途径抑制剂和G蛋白抑制剂所阻断。

Vaccinations against respiratory infections in Arabian Gulf countries: Barriers and motivators

AIM To study the uptake, barriers and motivators of influen-za, pneumococcal, meningococcal and pertussis vaccines among members of public in Arabian Gulf countries.METHODS A cross-sectional survey among the Gulf Cooperation Council(GCC) countries' residents. Data collected electronically through a smartphone app. The survey variables aimed to investigate the respondents' awareness about vaccines against influenza, pneumococcal, meningococcal and pertussis infections. Collected data concerning the respondents' socio-demographic characteristics, their perception toward vaccine uptake and the factors that motivate or demotivate them from taking influenza vaccine. The data were analysed statistically using the SPSS v.23.0. Differences in the characteristics of users from different countries were quantified through bivariate analysis. Other important variables and controlling factors were studied using logistic regression. RESULTS A total of 1812 respondents participated in the study. Their mean age was 27 years, 82% were male and 24% had ≥ 1 chronic diseases. The overall uptake of influenza vaccine was 17%(21% among "at risk" people) and ranged from 15% in Saudi Arabia to 24% in Qatar. Doctor's advice(23%) and a perception of having low body immunity(21%) were the main cited reasons for being vaccinated, whereas unawareness about the vaccine(43%) was the main barrier. The overall uptake of pneumococcal vaccine in the preceding three years was 22%(25% among "at risk" individuals) and ranged from 0% in Bahrain to 79% in Kuwait. The overall uptake of pertussis vaccine was 16%(31% among "vulnerable" people), and ranged from 7% in Saudi Arabia to 75% in Oman. The overall uptake of meningococcal vaccine was 20%(29% among the "at risk" people) and ranged from 3% in Oman to 50% in Bahrain.CONCLUSION The vaccination uptake across GCC countries is suboptimal and varies widely across the countries. Further research is needed to unearth the reasons and formulate action plan.

diabetes mellitus

950257 Report of a case of glucagonoma misdiag-nosed as“eczema”and“hepatic angioma”for three yearsand review of literature.DAI Weixin(戴为信),et al.PUMC Hosp,Beijing,100730.Chin J Intern Med 1995;34(3):190-192.Glucagonoma is a rare pancreatic tumor,necrolyticmigratory erythema is its distinctive feature and it isoften associated with diabetes mellitus,weight loss.anemia,hypoaminoacidemia,glossitis and stomatitis.

23.PREVENTION

920405 Immunization of hepatitis Bvaccineintegrated with EPI schedule in children.

Treatment of acute lung injury in mice using Bai-Ri-Ke syrup

Objective:This study aimed to examine the therapeutic effects of Bai-Ri-Ke syrup(BRK)on mice with acute lung injury(ALI).Methods:Fifty male C57BL/6 mice were equally divided into the control group,model group,dexamethasone(DXM)group,Bai-Ri-Ke syrup(BRK)low-group,and BRK-high group,with six mice per group.An intratracheal injection of 5 mg/kg POLY(I:C)was used to construct an ALI mouse model.After a successful model construction,the mice in the DXM group were given[0.2 mg/10 g·d]dexamethasone sodium phosphate injection(1 mL:2 mg)on the following day via intraperitoneal injection.The mice in the BRK-low group were given 0.015 mL APS everyday by gavage,and the mice in the BRK-high group were given 0.030 mL APS everyday by gavage for three days.The wet to dry weight(W/D)ratio of the lungs was observed every day.Bronchoalveolar lavage fluids(BALFs)were collected from the left lungs to measure the BALF protein level and neutrophil count after 72 h of treatment.The IL-6,IL-1β,and TNF-αlevels in BALF were also measured.HE staining was done to observe the histopathological changes in the lungs.Results:The ALI mice in the BRK-high group had significantly increased W/D(P<0.01).ELISA results showed that the DXM group and BRK-high group had significantly decreased BALF protein content(P<0.01),neutrophil count(P<0.01),and IL-6,IL-1β,and TNF-αlevels(P<0.01).Hematoxylin and eosin(H&E)results showed that the DXM group and BRK-high group had alleviated alveolar tissue injury,edema,bleeding,and inflammation.Conclusions:The BRK can decrease the W/D,BALF protein content,neutrophil count,and TNF-α,IL-1β,and IL-6 levels and alleviate the histopathological changes in the lungs of ALI mice.

Prevalence and factors associated with pentavalent vaccination:a cross-sectional study in Southern China

Background Immunization is one of the most far-reaching and cost-effective strategies for promoting good health and saving lives.A complex immunization schedule,however,may be burdensome to parents and lead to reduced vaccine compliance and completion.Thus,it is critical to develop combination vaccines to reduce the number of injections and simplify the immunization schedule.This study aimed to investigate the current status of the pentavalent diphtheria-tetanus-acellular pertussis inactivated poliomyelitis andHaemophilus influenzae type B conjugate(DTaP-IPV/Hib)vaccination in Southern China as well as explore the factors in the general population associated with uptake and the differences between urban and rural populations.Methods A cross-sectional study was conducted with recently enrolled kindergarten students in Hainan Province between December 2022 and January 2023.The study employed a stratified multistage cluster random sampling method.Information regarding the demographic characteristics and factors that influence decisions were collected from the caregivers of children via an online questionnaire.Multivariate logistic regression was used to determine the factors associated with the status of DTap-IPV/Hib vaccinations.Results Of the 4818 valid responses,95.3%of children were aged 3-4 years,and 2856(59.3%)held ruralhukou.Coverage rates of the DTaP-IPV/Hib vaccine,from 1 to 4 doses,were 24.4%,20.7%,18.5%,and 16.0%,respectively.Caregivers who are concerned about vaccine efficacy[adjusted odds ratio(aOR)=1.53,95%confidence interval(CI):1.30-1.79],the manufacturer(aOR=2.05,95%CI:1.69-2.49),and a simple immunization schedule(aOR=1.26,95%CI:1.04-1.54)are factors associated with a higher likelihood of vaccinating children against DTaP-IPV/Hib.In addition,caregivers in urban areas showed more concern about the vaccine price(P=0.010)and immunization schedule(P=0.022)in regard to vaccinating children.Conclusions The DTaP-IPV/Hib vaccine coverage rate in Hainan Province remains low.Factors such as lower socioeconomic status,cultural beliefs,concerns about vaccine safety,and cost may hinder caregivers from vaccinating their children.Further measures,such as health education campaigns to raise knowledge and awareness,and encouragement of domestic vaccine innovation,which would reduce out-of-pocket costs,could be implemented to improve the coverage of DTap-IPV/Hib vaccination.