Medical Exemptions Research Articles

Characteristics Associated With Measles, Mumps, and Rubella Coverage and Exemptions After a School Immunization Law Change in Washington, 2019-2020.

We aimed to better understand the impact of statewide legislation removing personal belief exemptions (PBEs) for the measles, mumps, and rubella (MMR) school immunization requirement and factors associated with resulting health-seeking behaviors. We used chi-squared tests and logistic regression models to determine individual- and school-level characteristics associated with holding a MMR PBE and with post-law MMR immunization status among students linked to the Washington State Immunization Information System. Of students with a MMR PBE pre-law change, 43.0% completed the MMR vaccine series and 40.4% sought another exemption type. Religious exemptions made up most new MMR exemptions signed (71.8%), followed by medical exemptions (18.5%), and religious membership exemptions (9.7%). Students were more likely to complete the vaccine series post-law change if they attended a school with a low school-level MMR exemption rate, a public school, or held a lower number of school-required immunization exemptions. This study confirms previous concerns that parents might replace their PBE with another exemption type; however, nearly half the students in the cohort completed the MMR vaccine series. Our findings suggest that targeted immunization policies can increase MMR coverage 1-year post-law change but must account for a replacement effect when exemption categories are eliminated.

Epidemic Situation in Osh, Kyrgyz Republic on Infections Controlled by Specific Prevention Means and Analysis of Population Awareness on Measles Infection

The article reflects a long-term (2009-2023) retrospective epidemiological analysis of measles incidence among the population in Osh, characterized by a periodic increase in incidence every two to three years and a decline after the adopted response measures to outbreaks, such as additional mass immunization of vulnerable groups of the population. However, the increase in measles incidence that began in 2018 continued for three years (2018-2020). Also, the increase in measles incidence, which began in the spring-summer period in 2023, despite the organization of preventive and anti-epidemic measures, continues in 2024, starting from the winter-spring period. This study revealed low vaccination coverage of children in the period from 2019 to 2023 at the level of 85.0-95.0%, which is associated with various reasons (underage, medical exemptions, parental refusal to vaccinate, population migration and unknown vaccination status, etc.).

Validity of medical exemptions from vaccination in persons with allergic disorders

Despite the enormous successes that have been achieved in the fight against infectious diseases thanks to mass preventive vaccination, primarily the reduction of child mortality, оutbreaks of vaccine-preventable diseases sometimes occur. One of the reasons is unjustified medical exemptions from vaccinations, which were widely used in the past, the shortcomings of taking into account adverse events after immunization as well as parental refusals (complete or partial) from preventive vaccinations. The article presents data from a retrospective analysis of medical records of patients sent for consultation with an allergist-immunologist to decide on the possibility of vaccination against the new coronavirus infection (COVID-19), including to confirm previously issued medical exemptions. The study included 87 patients (39 men and 48 women), most of them were of working age. Sixty-eight patients (78.2%) had previously received medical exemptions from vaccination, including 14 (20.6%) based on information about adverse events after immunization, and 32 (47.1%) based on adverse reactions for the administration of other medications, and in 22 (32.3%) only on the basis of a diagnosis of any allergic disease. At the same time, medical documentation confirming the facts of adverse events after immunization or adverse reactions to medications was absent in the vast majority of cases. In addition, 3 patients were not vaccinated in childhood due to parental refusal, and another 16 patients were contacted to assess the potential risk of developing side effects after vaccination due to the presence of allergic diseases (bronchial asthma, allergic rhinitis, atopic dermatitis, chronic urticaria, recurrent angioedema). Based on clinical and anamnestic data and, if necessary, laboratory and instrumental studies, temporary contraindications for vaccination were identified in only 6 (27.2%) patients. There were no absolute contraindications. In other cases, stable remission was observed or the disease was fully or partially controlled with medication, which was not a contraindication for vaccination at the time of treatment. Thus, in most cases, medical exemptions from vaccinations are unfounded or become irrelevant over time. At the same time, the lack of medical documentation seriously makes it difficult to objectively assess the risk of developing adverse events after immunization in patients with allergic diseases.

Prescription charge policy acceptance among UK adults with and without long-term health conditions: a mixed-method survey

ObjectivesSince their introduction in 1952, per-prescribed item charges in England have continually risen. This study investigated the acceptability and impact of per-prescribed item charges, and awareness and use of initiatives...

An Investigation Into the Orthoptist Experience of Instilling Eye Drops in Children Attending the Eye Clinic.

Eye drops instillation in children is a fundamental part of accurately examining a child's eyes. Unfortunately eye drops can be a distressing experience for children, parents/guardians and orthoptists. The purpose of this research is to focus on the experiences of orthoptists and delve deeper into their views and explore if improvements can be made. This was a Qualitative study involving semi-structured interviews with 8 registered and currently practicing orthoptists in the UK. The interviews were undertaken online via Microsoft TEAMS. Thematic analysis was carried out for the purposes of data analysis. 3 major themes were identified (1) how orthoptist frame instilling eye drops, (2) techniques to address challenges, and (3) improvements to eye drops instillation process. Orthoptists were aware that instilling eye drops in children brought specific challenges such as distress and resistance; however they saw it as an essential part of their job. Orthoptists understood their role within a wider team which delivered eye care to children effectively and that there was a division of they believed that. Orthoptists were aware that the eye drops may cause some distress, however this did not affect compliance with treatment such as wearing glasses and/or a patch. Orthoptists believed verbal and non-verbal communication with the child was essential. Help was sought from parents or colleagues for physical restraint if required. Orthoptists suggested adapting to children with additional needs and giving out eye drops to parents/carers to instill at home if dilation in the eye clinic became difficult. They suggested improvements such as assistance from play specialists, developing a pre-procedural information video, practise as a student, the study of the medical exemptions module and the potential of using eye sprays instead of eye drops. The study reiterates the importance of verbal and non-verbal communication. The results may facilitate recommendations for change such as encouraging the study of medical exemptions and help support a case for play specialist support regularly, and the encouragement to develop a pre-procedural information video to improve quality of care. This is currently inconsistent across different Trusts in the UK. The study could result in improvements to current practise and influence other fields of medicine such as blood tests and MRI scans in children. The study also recommends further studies to investigate the parental perspective of instillation of eye drops in their child's eyes when they attend the eye clinic.

Epidemiological Assessment of the Incidence of Measles (Morbilli), Old - New Infection in the Population in the Territory Jalal-Abad Kyrgyz Republic (Group of Family Doctors no. 2, Family Medicine Center)

The article carried out an epidemiological analysis of the incidence of measles in the territory of Family Doctors Group (FGP) no. 2, Family Medicine Center (FMC) in Jalal-Abad. For 2023, the incidence rate of measles in the population was registered at 3.5 per 1000 children. The rise of measles in the FGP territory began in October, where 1.4 cases per 1000 children were registered, in November 1.2 cases per 1000 children, and a subsequent decline in cases in December — 0.6 cases per 1000 children. Among those with measles, a large proportion were children under 14 years of age — 92.2%, adolescents — 1.3% and adults — 6.5%. The prevalence of measles among young children is high, in first place among children aged 1-2 years (28.2 per 1000 children), in second place among children under one year of age (26.6 per 1000 children) and in third place among children 3-5 years old (16.7 per 1000 children). In terms of contingents, a large share was made up of unorganized children (68.8%) and schoolchildren (23.3%). By gender, 51.9% of men and 48.1% of women fell ill with measles. Among those sick with measles, 10.3% were vaccinated against measles, information on preventive vaccinations was unknown or there was no form no. 063 — 20.9%, those not vaccinated against measles amounted to 68.8%, by age 18.8%, by medical exemption 20.8% and refusing 60.4%. There are only 216 contacts in the measles outbreaks, of which 18 (8.3%) children fell ill. Focal morbidity was noted with one case in 59 foci, 2 cases in 4, 3 cases in 2 and 4 cases in one family.

School Vaccine Coverage and Medical Exemption Uptake After the New York State Repeal of Nonmedical Vaccination Exemptions

Although New York State (NYS) recently adopted legislation eliminating nonmedical vaccination exemption options from school-entry requirements, the implications of the law for school vaccine coverage and medical vaccine exemption uptake have not been examined. To evaluate the implications of the repeal of school-entry nonmedical vaccination exemptions for vaccine coverage and medical exemption uptake at NYS schools outside of New York City (NYC). This cohort study had an interrupted time-series design and used generalized estimating equation models to examine longitudinal school immunization compliance data from the 2012 to 2013 through 2021 to 2022 school years. The cohort comprised NYS public and nonpublic schools, excluding NYC schools, with any students enrolled in kindergarten to 12th grade. Eligible schools had enrollment and immunization data before and after the implementation of the Senate Bill 2994A legislation. Data analyses were conducted in July 2023. Senate Bill 2994A was passed in June 2019, eliminating school-entry nonmedical vaccination exemptions. Since compliance with the law was evaluated for most students during the next school year, the 2019 to 2020 school year was considered to be the law's effective date. The primary outcomes were school vaccine coverage (defined as the percentage of students at each school who completed grade-appropriate requirements for all required vaccines) and medical exemption uptake (defined as the percentage of students at each school who received a medical exemption). Among the 3821 eligible schools, 3632 (95.1%) were included in the analysis, representing 2794 (96.9% of eligible) public schools and 838 (89.2% of eligible) nonpublic schools. The implementation of Senate Bill 2994A was associated with absolute increases in mean vaccine coverage of 5.5% (95% CI, 4.5%-6.6%) among nonpublic schools and 0.9% (95% CI, 0.7%-1.1%) among public schools, with additional annual increases in vaccine coverage observed through the 2021 to 2022 school year. The law's implementation was also associated with a 0.1% (95% CI, 0.0%-0.1%) mean absolute decrease in medical vaccination exemption uptake at both public and nonpublic schools, and small but significant mean annual decreases in medical vaccination exemptions (0.02%; 95% CI, 0.01%-0.03%) through the end of the study period. Results of this cohort study suggested that repeal of school-entry nonmedical vaccination exemptions was associated with increased vaccine coverage at NYS schools outside of NYC. Coverage gains were not replaced by increases in medical vaccination exemptions.

Electronic sanitary database: a new potential tool to identify occult chronic liver disease in general population

Chronic liver disease (CLD) is a leading global cause of mortality, morbidity, and healthcare resource utilization. However, the burden of CLD is underestimated because the course of the disease is often asymptomatic until clinical decompensation and the development of life-threatening complications. In this study, we assessed the use of available blood tests from electronic medical records for identifying individuals with undiagnosed CLD in the general population. We analyzed a total of 202,529 blood tests obtained from 99,848 adults recorded in the Electronic Health Records of the Padova Teaching Hospital. Transaminases levels > 1.5 times the normal value indicated occult CLD, while platelet counts < 120,000/μL identified occult cirrhosis. We characterized patients using Italian Medical Exemptions (IME), excluding oncologic cases. Overt and occult cirrhosis prevalence was 1% and 4.18%, respectively, while overt and occult CLD affected 2.85% and 4.61% of the population. The epidemiology of patients with overt and occult cirrhosis was similar but significantly different from that of the controls. Among subjects aged 60–70 years, working disability was twofold higher in those with occult cirrhosis compared to those with overt cirrhosis. Occult CLD and cirrhosis had higher prevalence rates than diagnosed cases in the general population. Electronic medical record data may serve as a valuable tool for CLD identification, potentially reducing cirrhosis development and clinical decompensation. This, in turn, may lead to a decrease in the economic impact on the healthcare system.

Medical exemptions to mandatory vaccinations: The state of play in Australia and a pressure point to watch.

Australia's mandatory vaccination policies have historically allowed for non-medical exemptions (NMEs), but this changed in 2016 when the Federal Government discontinued NMEs for childhood vaccination requirements. Australian states introduced further mandatory vaccination policies during the COVID-19 pandemic for a range of occupations including healthcare workers (HCWs). There is global evidence to suggest that medical exemptions (MEs) increase following the discontinuation of NMEs; the new swathe of COVID-19 mandatory vaccination policies likely also placed further pressure on ME systems in many jurisdictions. This paper examines the state of play of mandatory vaccination and ME policies in Australia by outlining the structure and operation of these policies for childhood vaccines, then for COVID-19, with a case study of HCW mandates. Next, the paper explores HCWs' experiences in providing vaccine exemptions to patients (and MEs in particular). Finally, the paper synthesizes existing literature and reflects on the challenges of MEs as a pressure point for people who do not want to vaccinate and for the clinicians who care for them, proposing areas for future research and action.

Patient Care During Ramadan: A Narrative Review.

Ramadan is the Islamic holy month when Muslims around the world fast from dawn to sunset. This 30-day pattern of intermittent diurnal fasting can have a significant physiologic impact on the body. Importantly, oral intake is forbidden during this time, and many patients do not wish to take medications. From a clinical perspective, this potentially impacts healthcare delivery and chronic disease states. Despite these important changes, awareness of individual patient practices remains limited among healthcare providers in North America, which may worsen health disparities in Muslim patients. A fundamental understanding of the cultural and physiological implications of fasting during Ramadan can improve cultural competence and patient outcomes. In this paper, we review the physiologic changes during fasting, medical exemptions to fasting, and special considerations for the care of Muslim patients with chronic conditions who may fast during Ramadan.

Optimising Physical Education Classes in Schools Using Technology: The use of mobile apps for active participation of medically exempt students with a focus on skill development and medical rehabilitation

The literature focuses more on healthy students, and the methodologies for organising physical education lessons do not address in depth the problem of physically exempt students who, with time, transform from exempt students into possible patients. This research aims to develop the application "Info-Scutit-Efort" in physical educa-tion lessons to facilitate learning, assessment of medically exempt students and their en-gagement in directed/adapted effort recovery programs in the physical education lesson. The research also aims to extend the use of the application to cover a broader range of needs. This study highlights the usefulness of the "Info-Scutit-Efort" app to actively and consciously engage 55 medically exempt students (58.2% of the total and 42.8% partially) in physical education lessons. The app, in an enhanced form, offers free and flexible access to different functionalities, in line with all the content of the curriculum and the Medical Checklist, transformed into questions so that the exempted student can access information about previously taught homework, homework taught in real-time, or information about general or particular medical recommendations depending on the diagnosis. In the assessment section, students can access tasks and tests to assess their knowledge, and in the self-assessment section, they can use tools to track their progress. The assessment provided by the app after the session can give the student a grade for previously taught information if they access the homework from the lessons covered, or it can provide a grade for the current assessment to test active and conscious participation in the lesson just taught as well as information about the indications, recovery programs, received from doctors for various conditions for which students have received medical exemption. The results of the simple linear regression analysis revealed that the relationship between the time spent accessing the application (minutes = 18.60±4.821) and the grade received is significant (p &lt;0.05), with a regression coefficient of 0.241 and an R² of 0.762, which means that the time spent accessing the application explains 76.2% of the variation in the grade received.

Выявление и профилактика железодефицитного состояния у доноров крови (компонентов крови)

The problem of iron deficiency among donors is relevant and directly affects the provision of hemocomponents to the blood service. Donors, being a risk group for the development of iron deficiency, are examined before donation, including a study of hemoglobin levels. However, there is no information about the state of iron stores, when depleted, iron deficiency anemia develops. In turn, anemia is a contraindication to donation and, therefore, leads to medical exemptions from donation. The purpose of the study was to evaluate the main indicators of iron metabolism in donors of blood and (or) blood components at risk of developing latent iron deficiency. The examination of 174 donors included a hemogram, assessment of the level of hemoglobin, serum ferritin (SF), transferrin, and soluble transferrin receptors. When assessing the intensity of changes in reserve and transport iron indicators, 228 deviations from the reference range were analyzed. The criterion for the risk of developing iron deficiency was hemoglobin values at the lower limit of normal (130–135 g/l in men and 120–125 g/l in women) and the threshold level of ferritin (30 μg/l in male donors and 20 μg/l in women). The risk group included 58.3% of young donors — women who donate blood 1–2 times during the year (p &lt; 0.01) and 66.6% (p &lt; 0.01) of donors — men who donate blood regularly throughout 4 and &gt; years. The average ferritin level in male donors was 27.37 μg/l (p &lt; 0.02) and lower than the reference values. It is concluded that it is advisable to assess the indicators of iron metabolism in donors in the case of borderline hemoglobin levels, in women of reproductive age after 2 blood donations and in men with the number of donations ≥ 10. To replenish the iron depot in the body, when iron deficiency is detected in donors, it is necessary to consider the issue of prevention.

Kindergarten Vaccination Status in California After Changes to Medical Exemption Policy

This study evaluates changes in medical exemptions and geographic distribution of kindergarteners in California not up to date on vaccination after changes to state legislation.

Overdiagnosis of vaccine allergy: Skin testing and challenge at a public specialized unit (CRIE) in Rio de Janeiro, Brazil.

Vaccination is an extremely safe public health intervention, but rare IgE-mediated adverse events must be identified to avoid the risk of anaphylaxis in the event of reexposure. However, using only clinical history to diagnose previous allergic reactions may lead to overdiagnosis of vaccine allergy and even to the use of medical exemptions as a subterfuge to mandatory vaccination. We conducted a retrospective study to describe the outcomes of patients with a history of vaccine or vaccine component allergy who were evaluated at our unit from 2011 to 2017. Data on allergy history, skin test results, vaccines prescribed, and adverse events were retrieved from the medical records at the Centro de Referência para Imunobiológicos Especiais (Reference Center of Special Immunobiologicals)-Fiocruz, in Rio de Janeiro, Brazil. Of 34 adults with history of allergy to vaccine or vaccine components, 32 (94.1%) were successfully vaccinated without serious adverse events after our evaluation. In 12 patients (35%), the time elapsed between the allergy symptoms and evaluation in the Centro de Referência para Imunobiológicos Especiais-Fiocruz was more than 10 years. Specialized care and use of skin tests allowed safe vaccination of the majority of patients. An objective, systematic evaluation of a history of vaccine allergy can prevent its improper use to avoid mandatory vaccination and reduce missed opportunities for immunization.

COVID-19 vaccine uptake before and after a vaccine mandate at a major academic hospital: Trends by race/ethnicity and level of patient contact

ObjectivesTo assess vaccine coverage rates before and after implementation of a COVID-19 vaccine mandate among Health care Personnel (HCP) and demographic characteristics associated with vaccine uptake Design, Setting, and Participants: Cohort study conducted among 10,889 hospital employees followed from Dec 16, 2020 - October 31, 2021, at a large academic hospital in Philadelphia. Main Outcome and Measures: Time to COVID-19 vaccination and vaccine series completion rates before and after implementation of a COVID-19 vaccine mandate based on age, gender, race/ethnicity, and level of patient contact/occupational group. ResultsThe vaccination series completion rate was 86.0% prior to mandate announcement, and increased to 98.7% after mandate implementation. Rates before mandate announcement were highest among Asians (96.2%), Whites (94.0%), males (89.7%), employees ≥ 65 years of age (95.2%), and employees with direct patient care (physicians, 99.0%, and nurses, 93.3%). Hospital educational initiatives (including Town Halls and discussions with Black and Hispanic employees with the lowest vaccination rates) appeared to improve uptake. The largest increase in series completion after mandate announcement occurred among Blacks, those of other/multiracial backgrounds, and Hispanics (35.6%, 22.4%, and 10.8%, respectively) as well as those with some or no direct patient contact (24.5% and 18.3%, respectively). Medical or religious exemptions were approved for 64 (<0.6%) employees and 38 (<0.4%) left their positions (8 voluntary, 30 involuntary) specifically due to the COVID-19 vaccine mandate. No clinically meaningful differences by age, gender, or race/ethnicity for those who were vaccinated under the mandate versus those who left their positions were noted. Conclusions and RelevanceThese results suggest that while mandates may be challenging to institutions and enforcement unpopular, they play an important role in reducing hesitancy and securing high vaccination rates among HCP, a group at high risk of COVID-19 given their employment and who can be a source of disease transmission to patients.

The Arbitrariness of Faith-Based Medical Exemptions

There are a variety of reasons for which one might claim an exemption from a public health mandate such as a required COVID-19 vaccine. Good-faith exemption requests—for medical, religious, or other reasons—are generally recognized as legitimate and granted to individuals when the imposition of the mandate on the requestor is perceived to outweigh the corresponding risk their lack of vaccination poses to the health and rights of others. This paper develops a method of analysis rooted in Western analytic philosophy designed to examine these issues and arrive at a framework for assessing the scientific, moral, and religious claims for exemptions from COVID-19 vaccinations. I argue that some empirical and moral beliefs are epistemically superior to others when they have a correspondence with agreed-upon facts about the world, are grounded in shared human experience, employ strong and substantive reasons for their claims, and embrace common convictions evidenced in the character of moral agents. Such facts must be demonstrable in the form of observably verifiable evidence and reliable testimony. Only then should a request for an exemption to an otherwise-required public health mandate (including a vaccine) be recognized. The alternative creates various difficulties, including the problem of moral arbitrariness.

The Impact of Technology on Improving the Learning Process in Physical Education Lessons for Medically-Exempt Pupils

Background and Study Aim. The focus of our attention lies on the medically exempt students, who more often than not take part in physical education (P.E.) classes as spectators, without any tasks to complete in accord with the collective work of their classmates or the objective of the lesson. The purpose of the present research is to develop and implement the application Info-Scutit-Sport in the P.E. lesson to the purpose of teaching and assessing medically-exempt students, who are present, but do not take part in the lesson. Material and Methods. The present paper emphasises the usefulness of the Info-Scutit-Efort [Info-Exempt-Effort] application aimed at the active and mindful inclusion of 55 students (aged=11.29±1.84), who have a medical exemption (58.2% total and 42.8% partial) in the P.E. lesson. The appli-cation, in an improved form, comprises the entire content of the curriculum of physical edu-cation in secondary school, transformed into 2080 questions with three answer variants, with 1500 processed images, that may be accessed with the teacher’s accord, on the stu-dent’s own phone. The assessment obtained by means of the application after the working session may provide the student with a mark for the information taught before, if he accesses topics from the previous lessons, or a mark for the current assessment in order to test the ac-tive and mindful participation in the lesson which is being taught. Conclusions. The study utilized multiple statistical tests to establish a relationship between platform access time and student performance. The results of the tests demonstrated that platform use time has a significant impact on student performance, with longer platform access time leading to hi-gher marks. The study concluded that the proposed model is significant, as it identifies plat-form access time as a crucial factor in determining student performance. Moreover, the study found that even small increases in platform access time can lead to significant impro-vements in student performance, with an increase of one unit resulting in a 0.54% increase in marks.

Identifying COVID-19 clusters in Tennessee long-term care facilities based on weekly staff vaccination rates

Background: In September 2021, the CMS mandated that long-term care facility (LTCF) healthcare workers be vaccinated for COVID-19 unless medically or religiously exempt. Vaccinating healthcare workers reduces transmission of COVID-19 among patients and workers, reducing the risk of illness among residents and patients. We examined the relationship between COVID-19 clusters and staff vaccination rates in Tennessee LTCFs. Methods: COVID-19 cluster data were collected using REDCap from January 3, 2021, to September 25, 2022, and LTCF vaccination rates were collected from the NHSN. Clusters were identified in facilities with 2 or more cases. The staff vaccination rate 2 weeks prior to the cluster was used, accounting for the lag time between vaccination dose and reaching full immunity. We selected 75% as the critical immunization threshold. The facility case rate was calculated per 100 beds. A test was performed to determine whether reaching the critical vaccination threshold was associated with cluster occurrence. The relationship between vaccination rate and case number was tested using Pearson correlation. Statistical analyses were conducted using SAS version 9.4 software. Results: The average staff vaccination rate when NHSN first required long-term care facilities to report rates rose from 47% in June 2021 to 83% in September 2022. In total, 806 clusters were identified with 20,868 combined weeks from all facilities being reported after merging facilities’ weekly vaccine percentage rates with cluster data. Most weeks from all facilities did not identify a cluster (n = 20,064, 96.15%) and did not meet the critical immunization threshold (n = 11,050, 52.95%). The association between a cluster occurring and a facility meeting the threshold was significant (χ2 = 5.41; df = 1; P 95% CI, .7327–.9740). The Pearson correlation coefficient between vaccination rate and case number was 0.05560 (P = .2894). Conclusions: There was a significant association between facilities not reaching the immunization threshold and presence of a COVID-19 cluster. The facility case rate was not correlated with staff vaccination rate; however, a limitation of this analysis was that resident vaccination was not tested. Another limitation was that medical and religious exemptions could not be differentiated. Healthcare staff should consider getting vaccinated, if able, to reduce the risk of COVID-19 and to keep staff and residents safe from COVID-19.Disclosures: None

Changes in the Preventive Vaccination Procedures in Children’s City Outpatient’s Clinic and its Efficacy

This article describes the implementation stages of the changes in preventive vaccination procedures in Children’s City Outpatient’s Clinic №133 of the Moscow Department of Health since December 2019. Comprehensive work has been performed on increasing the adherence to vaccination among doctors of various specialties, vaccination and immunization coverage of the registered pediatric population. As a result of this project medical prevention department was reorganized, data on vaccinations, medical exemption and refusals were added to the electronic medical records, monthly monitoring of vaccination coverage rate was initiated, as well as doctors training in preventive immunization via three forms of education. Center for Medical Prevention of the Moscow Department of Health, pediatric department of the Pediatric Faculty of Pirogov Russian National Research Medical University, the Union of Pediatricians of Russia have participated in this work. Intermediate results on efficacy of implemented measures have been presented.

Civil War Settlers: Scandinavians, Citizenship, and American Empire, 1848–1870

Civil War Settlers: Scandinavians, Citizenship, and American Empire, 1848–1870