Health care worker exposures to pertussis: missed opportunities for prevention

Adaptive immune response to bordetella pertussis during vaccination and infection: emerging perspectives and unanswered questions

INTRODUCTION

Whooping cough, also known as pertussis, remains a significant challenge as a vaccine-preventable disease worldwide. Since the switch from the whole-cell Pertussis (wP) vaccine to the acellular Pertussis vaccine (aP), cases of whooping cough have increased in countries using the aP vaccine. Understanding the immune system's response to pertussis vaccines and infection is crucial for improving current vaccine efficacy.

AREAS COVERED

This review of the literature using PubMed records offers an overview of the qualitative differences in antibody and T cell responses to B. pertussis (BP) in vaccination and infection, and their potential association with decreased efficacy of the aP vaccine in preventing infection and subclinical colonization. We further discuss how asymptomatic infections and carriage are widespread among vaccinated human populations, and explore methodologies that can be employed for their detection, to better understand their impact on adaptive immune responses and identify key features necessary for protection against the disease.

EXPERT OPINION

An underappreciated human BP reservoir, stemming from the decreased capacity of the aP vaccine to prevent subclinical infection, offers an alternative explanation for the increased incidence of clinical disease and recurrent outbreaks.

Pertussis antibodies and vaccination coverage among healthcare professionals in Brazil is inadequate: A cross-sectional serological study

INTRODUCTION

Worldwide, tetanus-diphtheria-acellular pertussis (Tdap) vaccination coverage of healthcare professionals (HCPs) is below 40%, but this data is not available for Brazil. We hypothesize that a high number of HCPs are not immune to pertussis in Brazil. Main objective was to determine the seroprevalence of anti-pertussis toxin (anti-PT IgG) among HCPs. Secondary objectives were to evaluate Tdap vaccination coverage, to assess predictive factors associated with anti-PT IgG, and to estimate the decay of anti-PT IgG and time to Tdap vaccination.

METHODS

Observational cross-sectional serological study in 352 HCPs who worked at São Paulo Hospital - Federal University of São Paulo (UNIFESP) in 2020, approved by UNIFESP Ethics Committee. Data collected included sociodemographics, knowledge about Tdap, and vaccination status. Anti-PT IgG were quantified by ELISA: <10 IU/mL seronegative and ≥ 10-1000 IU/mL seropositive. Titers ≥ 10-50 IU/mL were classified low positivity, indicating no recent B. pertussis infection or Tdap vaccination; >50 IU/mL high positivity, indicating recent B. pertussis infection or Tdap vaccination, and > 100 IU/mL as acute B. pertussis infection or Tdap vaccination in the previous year. Comparisons were done by Chi-square test, multivariable logistic regression, and Pearsońs correlation, at 5% p-level.

RESULTS

331/352 HCPs were not aware the Brazilian National Immunization Program recommends Tdap for all HCPs and pregnant women. 68/339 HCPs received Tdap (mean 3.1 ± 2.0 years). 55/352 were seronegative for pertussis, all unvaccinated. 56/271 with no history of Tdap vaccination had high positivity. The probability of anti-PT IgG > 50 IU/mL was 11.5 times higher in Tdap vaccinated HCPs than in non-vaccinated (p < 0.001). There was a weak but significant correlation between anti-PT IgG and interval of Tdap vaccination (r = 0.404; p = 0.001). Anti-PT IgG dropped 5 IU/mL/year (p = 0.001).

CONCLUSION

Better education of HCPs on needs and benefits of Tdap vaccination is critical. Goals must be to improve HCPs vaccination coverage.

Improving vaccination rates in older adults and at-risk groups: focus on pertussis

Despite the implementation of effective paediatric vaccination programmes, pertussis remains a global health problem. Disease epidemiology has changed over time, shifting towards the adolescent and adult populations. In adults, the true burden of pertussis is greatly underestimated and pertussis vaccine coverage rates are suboptimal, including individuals with chronic conditions. Here, we report the outcomes of a virtual international scientific workshop to assess the evidence on the burden of pertussis in older adults and identify potential solutions to improve uptake of pertussis vaccines. In adults, pertussis is underdiagnosed in part due to atypical or milder clinical presentation and the lack of testing and case confirmation. However, contemporary epidemiological data denoted an increase in the burden of pertussis among adolescents and adults. This might be related to a variety of reasons including the waning of immunity over time, the lack of booster vaccination, and the improved diagnostic methods that led to increased recognition of the disease in adults. Pertussis sequelae can be severe in older adults, particularly those with existing chronic medical conditions, and the vulnerability of these groups is further enhanced by low pertussis vaccine coverage. Possible measures to increase vaccine uptake include strengthening and harmonisation of immunisation guidelines, healthcare professionals taking a more active role in recommending pertussis vaccination, involvement of vaccination centres and pharmacies in the vaccination process, and improving knowledge of pertussis burden and vaccine efficacy among the general population.

Infection Control Measures, in situ Simulation, and Failure Modes and Effect Analysis to Fine-Tune Change Management during COVID-19

Coronavirus disease 2019 (COVID-19) was an impetus for a multitude of transformations – from the ever-changing clinical practice frameworks, to changes in our execution of education and research. It called for our decisiveness, innovativeness, creativity, and adaptability in many circumstances. Even as care for our patients was always top priority, we tried to integrate, where possible, educational and research activities in order to ensure these areas continue to be harnessed and developed. COVID-19 provided a platform that stretched our ingenuity in all these domains.

One of the mnemonics we use at SingHealth in responding to crisis is PACERS:

P: Preparedness (in responding to any crisis, this is critical)

A: Adaptability (needed especially with the ever-changing situation)

C: Communications (the cornerstone in handling any crisis)

E: Education (must continue, irrespective of what)

R: Research (new opportunities to share and learn)

S: Support (both physical and psychological).

This article shares our experience integrating the concept of simulation-based training, quality improvement, and failure mode analysis.

Pertussis immunization in healthcare workers working in pediatric settings: Knowledge, Attitudes and Practices (KAP) of Occupational Physicians. Preliminary results from a web-based survey (2017)

Introduction

The present study aims to characterize knowledge, attitudes and practices in a sample of occupational physicians (OPh) towards pertussis immunization in healthcare workers (HCWs) from pediatric settings.

Material and methods

A total of 148 OPh (45.9% males, mean age of 40.3 ± 13.2 years) compiled a web questionnaire including a knowledge test on Italian recommendations for HCWs, epidemiology and pathology of pertussis infection, being then investigated about risk perceptions and vaccination practices. A General Knowledge Score (GKS) and a Risk Perception Score (RPS) were calculated. Multivariate odds ratios (OR) for predictors of vaccine propensity were calculated through regression analysis.

Results

78 participants regularly recalled pertussis vaccination status and/or performed pertussis vaccination in HCWs (52.7%). Proactive status was correlated with the aim to avoid pertussis infection in HCWs and its diffusion to other adults (p < 0.001, both statements). GKS was satisfying (72.4% ± 14.9), but participants underestimated the clinical issues of pertussis infection (RPS 60.8% ± 9.5) when confronted with influenza (73.9% ± 10.9) and HBV infection (68.1% ± 10.1). GKS and RPS were well correlated (r = 0.244, p = 0.003). Eventually, a better GKS and the aim to avoid pertussis infection in HCWs were predictive of a proactive status for pertussis vaccination (OR 4.186 95%CI 1.809-9.685 and OR 11.459, 95%CI 3.312-39.651, respectively).

Conclusions

Adherence of OPh to HCWs pertussis vaccination was unsatisfying. As knowledge status was predictive for vaccine propensity, information programs for OPh should be more appropriately designed, stressing that HCWs may represent a significant reservoir for pertussis infection in high risk groups (e.g. children/newborns, frail elderly).

Vaccines for Health Care Personnel

Medical Center Occupational Health (MCOH) programs must protect health care personnel (HCP) against the occupational risk of vaccine-preventable diseases. This thematic review outlines the rationale for the use of recommended vaccines in HCP; summarizes the available evidence regarding vaccine effectiveness, administration, and assessment of immunity; and provides guidance for MCOH programs navigating challenging situations.

Healthcare workers' vaccination at European and Italian level: a narrative review

Today some vaccine-preventable diseases remain an important cause of morbidity and mortality worldwide despite the availability of new vaccines. Healthcare workers are particularly at risk to acquire an infection disease, playing a fundamental role in nosocomial transmission, which makes them an important target group for vaccination. The vaccination recommendations of HCWs, as well as the general population, differ from country to country. Furthermore, coverage rates vary widely a lot over the world, making HCWs vulnerable to disease and so healthcare settings to outbreaks. The motivations of vaccine hesitancy are many and maybe other studies would help policymakers and stake-holders to shape programs to improve vaccination coverage and the control of infectious diseases through the correct application of guidelines on prevention. (www.actabiomedica.it)

Pertussis vaccination status and vaccine acceptance among medical students: multicenter study in Germany and Hungary

BACKGROUND

Medical students are at risk of contracting and transmitting infectious diseases such as pertussis. Complete vaccination status is important to protect own, patient and public health. Knowing own vaccination status is elementary for following current vaccination recommendations, including boosters. We aimed to assess pertussis vaccination status and vaccination acceptance among medical students of different nationalities.

METHODS

A cross-sectional multicenter health survey at German and Hungarian universities enclosed international medical students in the 1st, 3rd and 5th year of study. Self-reported data from 2655 students regarding pertussis vaccination status were analyzed. Subgroup analysis enclosed data of German (n = 1217), Hungarian (n = 960) and other nationality (n = 478) students ("other").

RESULTS

More Hungarians reported basic immunization (39.0% vs 15.8% Germans vs 24.3% others, p ≤ 0.05). Booster vaccination was reported more by Germans (60.5% vs 43.6% Hungarians vs 36.0% others, p ≤ 0.05). Germans were more likely to report being unvaccinated (3.7% vs 0.9% Hungarians, p ≤ 0.05). More medical students of other nationalities were unaware of their pertussis vaccination status (37.4% vs 20.0% Germans/ 16.5% Hungarians, p ≤ 0.05). 75.2% (n = 1931) rated pertussis vaccinations as absolutely necessary (86.2% Hungarians vs 69.8% Germans/ 66.1% others, p ≤ 0.05).

CONCLUSIONS

Positive attitudes towards vaccinations were reported but a large group reported insufficient vaccination status and being not aware of their status, especially among international students. Hungarians possibly have a better vaccination status than reported, based on mandatory vaccinations in childhood. The low awareness of vaccination status has implications for future booster vaccinations. All students should be informed about current recommendations and receive vaccination offers in frames of low-threshold medical services.

La prévention et le contrôle des infections au cabinet du pédiatre

La transmission d’infections au cabinet du pédiatre est une source de préoccupation croissante. Le présent document traite des voies de transmission des infections et des principes de contrôle des infections actuellement en vigueur. La prévention englobe un aménagement du cabinet et des politiques administratives appropriés, le triage, les pratiques de soins habituelles pour tous les patients (p. ex., hygiène des mains; port de gants, de masques, d’un dispositif de protection oculaire et de blouses pour certaines interventions; nettoyage, désinfection et stérilisation des surfaces et de l’équipement, y compris les jouets; technique d’asepsie pour les interventions invasives), ainsi que les précautions additionnelles en cas d’infections particulières. Les membres du personnel doivent avoir reçu les vaccins nécessaires, et ceux qui sont atteints d’une infection doivent respecter les politiques de restriction au travail.

A quality improvement initiative to increase Tdap (tetanus, diphtheria, acellular pertussis) vaccination coverage among direct health care providers at a children's hospital

OBJECTIVES

Health care providers (HCP) are at high risk of acquiring and transmitting pertussis to susceptible family members, co-workers, and patients. Public health authorities recommend administering a single dose of Tdap (tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis) vaccine to all adults, including HCP, to increase adult immunity to pertussis. We set a quality improvement goal to increase Tdap vaccination coverage among HCP who provided direct patient care at a children's hospital from 58% to 90% over 18 months.

DESIGN

A multidisciplinary working group comprised of Occupational Health Program (OHP) staff and representatives of various medical services drew from a variety of qualitative methods and previous studies of vaccination programs in the healthcare system to understand barriers to Tdap vaccination within the institution and to develop interventions to increase vaccination rates.

INTERVENTIONS

Interventions included changes to OHP processes, a general education campaign, improved access to vaccine, and personal engagement of HCP by task force members.

RESULTS

Overall vaccination rates increased to 90% over 15 months, a rate that has been sustained by systematically assessing new employees' vaccination status and vaccinating those without documentation of previous Tdap vaccination.

CONCLUSIONS

Tdap vaccination coverage in our institution was significantly increased by an intensive, multipronged educational campaign, and by improving processes of screening and vaccination of HCP. The use of direct engagement of vaccine hesitant populations to increase vaccination rates warrants further study.

Tdap Vaccination Among Healthcare Personnel, Internet Panel Survey, 2012-2014

INTRODUCTION

Healthcare personnel (HCP) are at risk for pertussis infection exposure or transmitting the disease to patients in their work settings. The Advisory Committee on Immunization Practices recommends tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccination for HCP to minimize these risks. This study assessed Tdap vaccination coverage among U.S. HCP by sociodemographic and occupation-related characteristics.

METHODS

The 2012, 2013, and 2014 Internet Panel Surveys were analyzed in 2015 to assess HCP Tdap vaccination. Effective sample sizes for 2012, 2013, and 2014 survey years were 2,038, 1613, and 1633, respectively. Missing values were assigned using multiple imputation. Multivariable logistic regression identified factors independently associated with HCP Tdap vaccination. Statistical measures were calculated with an assumption of random sampling.

RESULTS

Overall, Tdap vaccination coverage among HCP was 34.8% (95% CI=30.6%, 39.0%); 40.2% (95% CI=36.1%, 44.4%); and 42.4% (95% CI=38.7%, 46.0%) in 2012, 2013, and 2014, respectively. Nurse practitioners/physician's assistants, physicians, nurses, and HCP working in hospitals and ambulatory care settings had higher Tdap coverage. Having contact with an infant aged ≤6 months and influenza vaccination receipt were associated with increased Tdap vaccination. Non-Hispanic black race/ethnicity, having an associate/bachelor's degree, being below poverty, non-clinical personnel status, and working in a long-term care setting were associated with decreased Tdap vaccination.

CONCLUSIONS

HCP Tdap vaccination coverage increased during 2012-2014; however, coverage remains low. Vaccination coverage varied widely by healthcare occupation, occupational setting, and sociodemographic characteristics. Evidence-based employer strategies used to increase HCP influenza vaccination, if applied to Tdap, may increase Tdap coverage.

Essentials of infection prevention in the pediatric population

Application of infection prevention and control (IP&C) measures is synonymous with safety, quality, resource saving, and the rights of all patients, staff and visitors. An extensive literature review was undertaken to identify key IP&C measures that address pediatric-specific requirements, taking into account age-related factors, diseases that occur most frequently among pediatric populations, and the important role of the caregiver in prevention and disease transmission. IP&C initiatives that target and incorporate both human (intrinsic) and environmental (extrinsic) sources of infection are population specific and guide practices and provide safe caring environments when used appropriately. Categories of care specifically geared to the pediatric age-group (0-14 years) are divided into two categories: within-the-healthcare system and outside-of-the-healthcare setting. By taking into account the child's developmental age; physiological, psycho-social and immunological development; differing impacts on the body's natural defense mechanisms, including procedural, device type and length of utilization; and availability of specific technologies and disciplines, the caregiver IP&C strategies can be developed and tailored to address specific needs. Within-the-healthcare setting strategies focus on surveillance, standard and transmission-based precautions, the immune system, age-related factors, institutional regulations, the family and visitation. Outside the healthcare setting preventative and protective measures are vital for providing maximum and comprehensive care. Care provided within and outside the healthcare setting can either be independent of each other or work together to maximize the health and safety of the child. This review article highlights the importance of IP&C knowledge, need for strict adherence to approved standards, and need for auditing compliance to achieve the ultimate goal of providing safe, quality care as well as an infection-free environment.

Vaccination of healthcare workers: A review

Vaccine-preventable diseases are a significant cause of morbidity and mortality. As new vaccines are proving to be effective and as the incidence of some infections decreases, vaccination practices are changing. Healthcare workers (HCWs) are particularly exposed to and play a role in nosocomial transmission, which makes them an important target group for vaccination. Most vaccine-preventable diseases still carry a significant risk of resurgence and have caused outbreaks in recent years. While many professional societies favor vaccination of HCWs as well as the general population, recommendations differ from country to country. In turn, vaccination coverage varies widely for each microorganism and for each country, making hospitals and clinics vulnerable to outbreaks. Vaccine mandates and non-mandatory strategies are the subject of ongoing research and controversies. Optimal approaches to increase coverage and turn the healthcare workforce into an efficient barrier against infectious diseases are still being debated.

Recommended Health Care Personnel Immunization: Exploring Immunization Rates, Motivators, and Barriers to Immunization in Health Care Personnel

Immunization rates among health care personnel (HCP) have remained low despite advances in vaccine development with reported rates ranging from 27% to 72% for commonly recommended vaccines. Within the United States, HCP are placing patients, families, and themselves at considerable risk for vaccine-preventable diseases. A significant source of infection, HCP are carriers of infectious agents and often unknowingly transmit these contagious diseases while experiencing minimal or no symptoms. This study examined the current immunization rates of HCP for influenza, tetanus, diphtheria, and pertussis (Tdap), and hepatitis B in Nebraska, as well as identified motivators and barriers to vaccination. Nebraska HCP surveyed included physicians, physician assistants, nurse practitioners, registered nurses, licensed practical nurses, medical assistants, nursing assistants, and clerical or administrative staff of nonrestricted ethnic backgrounds age 19 years and older. Nebraska HCP immunization rates were statistically above the national rates. Motivators and barriers were also identified for each vaccine.

Seroprevalence of pertussis amongst healthcare professionals in Spain

INTRODUCTION

This multi-center, hospital-based observational study determined the seroprevalence of pertussis antibodies amongst healthcare professionals from three different hospitals in Spain to ascertain the health status of professionals attending to susceptible groups who are at risk of contracting and transmitting pertussis.

METHODS

Medical professionals from three hospitals in Spain were recruited for this study (NCT01706224). Serum samples from subjects were assessed for anti-pertussis antibodies by ELISA. The percentage of subjects positive for anti-pertussis antibodies were determined by age-strata, gender, vaccination status, professional level (physicians, nurses, ancillary nurses and midwives), hospital department, number of working years, numbers of hours spent with the patient as well as number of children in the household.

RESULTS

Overall, 31.2% of subjects were seropositive; 3.3% of these healthcare professionals had ELISA values indicative of current or recent infection. There were no significant differences in terms of pertussis prevalence with respect to age, gender, hospital department, profession, number of working years and number of hours spent with patients. These levels of seronegativity amongst healthcare workers further strengthen the rationale for vaccination amongst this specific population against pertussis.

Protecting Newborns Against Pertussis: Treatment and Prevention Strategies

Pertussis is a potentially severe respiratory disease, which affects all age groups from young infants to older adults and is responsible for an estimated 195,000 deaths occurred globally in 2008. Active research is ongoing to better understand the pathogenesis, immunology, and diagnosis of pertussis. For diagnosis, molecular assays (e.g., polymerase chain reaction) for detection of Bordetella pertussis have become more widely available and support improved outbreak detection. In children, pertussis vaccines have been incorporated into routine immunization schedules and deployed for pertussis outbreak control. Lower levels of vaccine coverage are now being observed in communities where vaccine hesitancy is rising. Additionally, recognition that newborn babies are at risk of pertussis in the USA and UK has led to recommendations to immunize pregnant women. Among adolescents and older adults in the USA, Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular pertussis (Tdap) Vaccines are recommended, but substantial individual- and system-level barriers exist that will make achieving national Healthy People 2020 targets for immunization challenging. Current antimicrobial regimens for pertussis are focused on reducing the severity of disease, reducing rates of sequelae, and minimizing transmission of infection to susceptible individuals. Continued surveillance for pertussis will be important to identify opportunities for reducing young infants' exposure and reducing the impact of outbreaks among school-aged children. Laboratory-based surveillance for newly emerging strains of B. pertussis will be important to identify strains that may evade protection elicited by currently available vaccines. Efforts to develop new-generation pertussis vaccines should be considered now in anticipation of vaccine development programs, which may require ten or more years to deliver a licensed vaccine.

Comparative acceptance of pertussis and influenza immunization among health-care personnel

BACKGROUND

Pertussis and influenza immunization in health-care professionals (HCP) has been shown to lead to significant reduction of nosocomial infections. Parallel campaigns of pertussis and seasonal influenza immunization gave us a unique opportunity to compare attitudes towards influenza and pertussis immunization among HCP and to determine acceptance rates for both or either one of the two immunizations or refusal of both.

METHODS

A questionnaire was sent to HCP to anonymously obtain demographic data, profession, numbers of previous influenza immunizations, acceptance of influenza immunization in the current 2012/13 season, pertussis immunization currently or within the last 10 years, and reasons for acceptance or decline of pertussis and influenza vaccination.

RESULTS

Of 638 HCP with patient contact, 314 (49%) responded and 303 (47%) were included in the analysis. Immunization acceptance rates were 33% for influenza, 57% for pertussis; 24% accepted both immunizations and 34% none of both. Acceptance of influenza immunization was significantly higher in those with one or more previous influenza vaccinations (p<0.005). Among 130 HCP who declined pertussis immunization, missed opportunity (28%) was the dominant reason. Of 204 HCP who declined influenza immunization, the most frequently stated reason was "lack of influenza immunization is not considered an issue" (36%).

CONCLUSIONS

Misconceptions about the efficacy and necessity of pertussis and especially influenza immunization continue to prevail among HCP. Active promotion, personal encouragement, providing more immunization opportunities and other incentives are measures that should be considered to increase the rate of immunization among HCP.

Preventing the Spread of Pertussis in Pediatric Healthcare Settings

The surge in pertussis incidence in recent years underscores a critical need for effective plans to prevent transmission in pediatric healthcare settings. Adolescents and adults are common sources of infection for unimmunized or incompletely immunized infants and children with waning immunity. Despite documented outbreaks being limited in size, pertussis poses a threat to pediatric healthcare facilities due to the risk for widespread transmission, potentially severe complications among vulnerable patient populations, and high outbreak control-related costs. Healthcare personnel, visitors, and parents have been identified as sources of outbreaks, underscoring the importance of coordinated efforts to prevent transmission in these settings. This comprehensive review demonstrates that the risk of pertussis transmission in pediatric healthcare settings warrants heightened focus on strategies to recognize disease earlier, improve diagnostic evaluation, and facilitate effective contact tracing and post-exposure prophylaxis measures. This review suggests that healthcare personnel can play a significant role in the prevention of healthcare-associated pertussis.

Factors affecting uptake of recommended immunizations among health care workers in South Australia

Despite the benefits of vaccination for health care workers (HCWs), uptake of recommended vaccinations is low, particularly for seasonal influenza and pertussis. In addition, there is variation in uptake within hospitals. While all vaccinations recommended for HCWs are important, vaccination against influenza and pertussis are particularly imperative, given HCWs are at risk of occupationally acquired influenza and pertussis, and may be asymptomatic, acting as a reservoir to vulnerable patients in their care. This study aimed to determine predictors of uptake of these vaccinations and explore the reasons for variation in uptake by HCWs working in different hospital wards. HCWs from wards with high and low influenza vaccine uptake in a tertiary pediatric and obstetric hospital completed a questionnaire to assess knowledge of HCW recommended immunizations. Multiple logistic regression was used to determine predictors of influenza and pertussis vaccination uptake. Of 92 HCWs who responded, 9.8% were able to identify correctly the vaccines recommended for HCWs. Overall 80% of respondents reported they had previously received influenza vaccine and 50.5% had received pertussis vaccine. Independent predictors of pertussis vaccination included length of time employed in health sector (P < 0.001), previously receiving hepatitis B/MMR (measles, mumps, rubella) vaccine (P < 0.001), and a respondent being aware influenza infections could be severe in infants (p = 0.023). Independent predictors of seasonal influenza vaccination included younger age (P < 0.001), English as first language (P < 0.001), considering it important to be vaccinated to protect themselves (P < 0.001), protect patients (p = 0.012) or awareness influenza could be serious in immunocompromised patients (p = 0.030). Independent predictors for receiving both influenza and pertussis vaccinations included younger age (P < 0.001), time in area of work (P = 0.020), previously receiving hepatitis B vaccine (P = 0.006) and awareness influenza could be severe in infants (P < 0.001). A knowledge gap exists around HCW awareness of vaccination recommendations. Assessment of the risk/benefit value for HCWs and their patients, determines uptake of HCW immunization programs and should be considered in promotional HCW vaccination programs.