The Advisory Committee on Immunization Practices (ACIP) recommends that adolescents aged 11-12 years routinely receive tetanus, diphtheria, and acellular pertussis (Tdap); meningococcal conjugate (MenACWY); and human papillomavirus (HPV) vaccines. Catch-up vaccination is recommended for hepatitis B (HepB); hepatitis A (HepA); measles, mumps, and rubella (MMR); and varicella (VAR) vaccines for adolescents whose childhood vaccinations are not current. Adolescents are also recommended to receive a booster dose of MenACWY vaccine at age 16 years, and shared clinical decision-making is recommended for the serogroup B meningococcal vaccine (MenB) for persons aged 16-23 years (1). To estimate coverage with recommended vaccines, CDC analyzed data from the 2020 National Immunization Survey-Teen (NIS-Teen) for 20,163 adolescents aged 13-17 years.* Coverage with ≥1 dose of HPV vaccine increased from 71.5% in 2019 to 75.1% in 2020. The percentage of adolescents * Eligible participants were born during January 2002-January 2008. Tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine represents coverage with ≥1 Tdap dose at age ≥10 years. Meningococcal conjugate vaccine represents coverage with the quadrivalent meningococcal conjugate vaccine or meningococcal-unknown type vaccine. HPV vaccination coverage includes receipt of any HPV vaccine and does not distinguish between nine-valent (9vHPV), quadrivalent (4vHPV), or bivalent (2vHPV) vaccines. Some adolescents might have received more than the 2 or 3 recommended HPV vaccine doses. Hepatitis A, hepatitis B, varicella, and measles, mumps, and rubella vaccines are considered childhood vaccinations and are recommended for adolescents who are not up to date with these vaccinations. Estimates in this report include those who might have received vaccinations on-time or as catch-up. Except as noted, coverage estimates for ≥1 and ≥2 varicella vaccine doses were obtained among adolescents with no history of varicella disease.

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Disparities in vaccination coverage by social vulnerability, defined as social and structural factors associated with adverse health outcomes, were noted during the first 2.5 months of the U.S. COVID-19 vaccination campaign, which began during mid-December 2020 (1). As vaccine eligibility and availability continue to expand, assuring equitable coverage for disproportionately affected communities remains a priority. CDC examined COVID-19 vaccine administration and 2018 CDC social vulnerability index (SVI) data to ascertain whether inequities in COVID-19 vaccination coverage with respect to county-level SVI have persisted, overall and by urbanicity. Vaccination coverage was defined as the number of persons aged ≥18 years (adults) who had received ≥1 dose of any Food and Drug Administration (FDA)-authorized COVID-19 vaccine divided by the total adult population in a specified SVI category. † SVI was examined overall and by its four themes (socioeconomic status, household composition and disability, racial/ethnic minority status and language, and housing type and transportation). Counties were categorized into SVI quartiles, in which quartile 1 (Q1) represented the lowest level of vulnerability and quartile 4 (Q4), the highest. Trends in vaccination coverage were assessed by SVI quartile and urbanicity, which was categorized as large central metropolitan, large fringe metropolitan (areas surrounding large cities, e.g., suburban), medium and small metropolitan, and nonmetropolitan counties. § During December 14, 2020-May 1, 2021, disparities in vaccination coverage by SVI increased, especially in large † Vaccination coverage was calculated by summing the number of vaccinated adults in each SVI category and dividing by the total adult population in the specified SVI category. Population denominators were obtained from the U.S. Census Bureau. § Urbanicity was defined on the basis of the 2013 National Center for Health Statistics urban-rural classification scheme. For this analysis, categories included large central metropolitan counties, large fringe metropolitan counties, medium and small metropolitan counties, and nonmetropolitan counties. Large central metropolitan counties are counties in metropolitan statistical areas (MSAs) with ≥1 million population; large fringe metropolitan counties are counties in MSAs with ≥1 million population that did not qualify as large central metropolitan counties; medium metropolitan counties are counties in MSAs with populations of 250,000-999,999; small metropolitan counties are counties in MSAs with populations <250,000; nonmetropolitan counties are all micropolitan and noncore counties. https://www.cdc.gov/nchs/data_access/urban_rural.htm fringe metropolitan (e.g., suburban) and nonmetropolitan counties. By May 1, 2021, vaccination coverage was lower among adults living in counties with the highest overall SVI; differences were most pronounced in large fringe metropolitan (Q4 coverage = 45.0% versus Q1 coverage = 61.7%) and nonmetropolitan (Q4 = 40.6% versus Q1 = 52.9%) counties. ...

The bacterial cell surface is the first structure the host immune system targets to prevent infection. Cationic antimicrobial peptides of the innate immune system bind to the membrane of Gram-negative pathogens via conserved, surface-exposed lipopolysaccharide (LPS) molecules. We recently reported that modern strains of the global intestinal pathogen Vibrio cholerae modify the anionic lipid A domain of LPS with a novel moiety, amino acids. Remarkably, glycine or diglycine addition to lipid A alters the surface charge of the bacteria to help evade the cationic antimicrobial peptide polymyxin. However, the regulatory mechanisms of lipid A modification in V. cholerae are unknown. Here, we identify a novel two-component system that regulates lipid A glycine modification by responding to important biological cues associated with pathogenesis, including bile, mildly acidic pH, and cationic antimicrobial peptides. The histidine kinase Vc1319 (VprB) and the response regulator Vc1320 (VprA) respond to these signals and are required for the expression of the almEFG operon that encodes the genes essential for glycine modification of lipid A. Importantly, both the newly identified two-component system and the lipid A modification machinery are required for colonization of the mammalian host. This study demonstrates how V. cholerae uses a previously unknown regulatory network, independent of well-studied V. cholerae virulence factors and regulators, to respond to the host environment and cause infection.

Immunization has been described as a "global health and development success story," and worldwide is estimated to prevent 2-3 million deaths annually.* In the United States, the Advisory Committee on Immunization Practices (ACIP) currently recommends vaccination against 14 potentially serious illnesses by the time a child reaches age 24 months (1). CDC monitors coverage with ACIP-recommended vaccines through the National Immunization Survey-Child (NIS-Child); data from the survey were used to estimate vaccination coverage at the national, regional, state, territorial, and selected local area levels † among children born in 2016 and 2017. National coverage by age 24 months was ≥90% for ≥3 doses of poliovirus vaccine, ≥3 doses of hepatitis B vaccine (HepB), and ≥1 dose of varicella vaccine (VAR); national coverage was ≥90% for ≥1 dose of measles, mumps, and rubella vaccine (MMR), although MMR coverage was <90% in 14 states. Coverage with ≥2 doses of influenza vaccine was higher for children born during 2016-2017 (58.1%) than for those born during 2014-2015 (53.8%) but was the lowest among all vaccines studied. Only 1.2% of children had received no vaccinations by age 24 months. Vaccination coverage among * https://www.who.int/health-topics/vaccines-and-immunization#tab=tab_1. † Estimates for states, selected local areas, and the territories of Guam and Puerto Rico are available online at https://www.cdc.gov/vaccines/imz-managers/ coverage/childvaxview/data-reports/index.html. Certain local areas that receive federal Section 317 immunization funds are sampled separately and included in the NIS-Child sample every year

BACKGROUND AND OBJECTIVES: California implemented Senate Bill 277 (SB277) in 2016, becoming the first state in nearly 30 years to eliminate nonmedical exemptions from immunization requirements for schoolchildren. Our objectives were to determine (1) the impacts of SB277 on the percentage of kindergarteners entering school not up-to-date on vaccinations and (2) if geographic patterns of vaccine refusal persisted after the implementation of the new law. METHODS: At the state level, we analyzed the magnitude and composition of the population of kindergarteners not up-to-date on vaccinations before and after the implementation of SB277. We assessed correlations between previous geographic patterns of nonmedical exemptions and patterns of the remaining entry mechanisms for kindergarteners not up-to-date after the law's implementation. RESULTS: In the first year after SB277 was implemented, the percentage of kindergartners entering school not up-to-date on vaccinations decreased from 7.15% to 4.42%. The conditional entrance rate fell from 4.43% to 1.91%, accounting for much of this decrease. Other entry mechanisms for students not up-to-date, including medical exemptions and exemptions for independent study or homeschooled students, largely replaced the decrease in the personal belief exemption rate from 2.37% to 0.56%. In the second year, the percentage of kindergartners not up-to-date increased by 0.45%, despite additional reductions in conditional entrants and personal belief exemptions. The correlational analysis revealed that previous geographic patterns of vaccine refusal persisted after the law's implementation. CONCLUSIONS: Although the percentage of incoming kindergarteners up-to-date on vaccinations in California increased after the implementation of SB277, we found evidence for a replacement effect. WHAT'S KNOWN ON THIS SUBJECT: Recently, California has attempted to increase the number of kindergarteners entering school who are fully up-to-date on required vaccinations. SB277 eliminated the nonmedical exemption option; however, the law also contains several provisions allowing students not up-to-date to enter school. WHAT THIS STUDY ADDS: We found that the percentage of kindergarteners who were not up-to-date on school-entry vaccinations decreased after eliminating nonmedical exemptions. However, we found evidence that nonmedical exemptions were replaced by other mechanisms allowing kindergarteners not up-to-date on vaccinations to enter school.

Influenza vaccination is recommended for all persons aged ≥6 months. Influenza vaccination coverage estimates are available at https://www.cdc.gov/flu/ fluvaxview/index.htm. COVID-19 vaccination has been recommended within the scope of the Emergency Use Authorization by ACIP for children and adolescents aged ≥12 years since May 12, 2021. Estimates of COVID-19 vaccination coverage are available at https://covid.cdc.gov/covid-datatracker/#vaccination-demographics-trends and https://www.cdc.gov/vaccines/ imz-managers/coverage/covidvaxview/interactive/children.html. † Eligible adolescents were born January 2003-January 2009. Estimates in this report include those who might have received on-time or catch-up vaccinations. § Tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine represents coverage with ≥1 Tdap dose at age ≥10 years. ¶ Meningococcal conjugate vaccine represents coverage with the quadrivalent meningococcal conjugate vaccine or meningococcal-unknown type vaccine.the following vaccines occurred from 2020 to 2021: ≥1 dose of HPV** vaccine (from 75.1% to 76.9%); adolescents who were up to date with HPV vaccination (HPV UTD) † † (from ** HPV vaccination coverage includes receipt of any HPV vaccine and does not distinguish between 9-valent, quadrivalent, or bivalent vaccines. † † HPV UTD includes adolescents with ≥3 doses, and those with 2 doses when the first HPV vaccine dose was initiated at age <15 years and there was ≥5 months minus 4 days between the first and second dose (https://www.cdc. gov/vaccines/programs/iis/cdsi.html). This update to the HPV vaccine recommendation occurred in December 2016. Some adolescents might have received more than the 2 or 3 recommended HPV vaccine doses.

Residents of long-term care facilities (LTCFs) and health care personnel (HCP) working in these facilities are at high risk for COVID-19-associated mortality. As of March 2021, deaths among LTCF residents and HCP have accounted for almost one third (approximately 182,000) of COVID-19-associated deaths in the United States (1). Accordingly, LTCF residents and HCP were prioritized for early receipt of COVID-19 vaccination and were targeted for on-site vaccination through the federal Pharmacy Partnership for Long-Term Care Program (2). In December 2020, CDC's National Healthcare Safety Network (NHSN) launched COVID-19 vaccination modules, which allow U.S. LTCFs to voluntarily submit weekly facility-level COVID-19 vaccination data.* CDC analyzed data submitted during March 1-April 4, 2021, to describe COVID-19 vaccination coverage among a convenience sample of HCP working in LTCFs, by job category, and compare HCP vaccination coverage rates with social vulnerability metrics of the surrounding community using zip code tabulation area (zip code area) estimates. Through April 4, 2021, a total of 300 LTCFs nationwide, representing approximately 1.8% of LTCFs enrolled in NHSN, reported that 22,825 (56.8%) of 40,212 HCP completed COVID-19 vaccination. † Vaccination coverage was highest among physicians and advanced practice providers (75.1%) and lowest among nurses (56.7%) and aides (45.6%). Among aides (including certified nursing assistants, nurse aides, medication aides, and medication assistants), coverage was lower in facilities located in zip code areas with higher social vulnerability (social and structural factors associated with adverse health outcomes), corresponding to vaccination disparities present in the wider community (3). Additional efforts are needed to improve LTCF immunization policies and practices, build confidence in COVID-19 vaccines, and promote COVID-19 vaccination. CDC and partners have prepared education and training resources to help educate HCP and promote COVID-19 vaccination coverage among LTCF staff members. § *