A new study shows that early signs of being more susceptible to type 2 diabetes (T2D) as an adult can be seen in children as young as age 8 years, decades before it is likely to be diagnosed, according to researchers from the University of Bristol.

Researchers looked at the effects of a genetic risk score for developing T2D as an adult on metabolism, measured from blood samples taken from participants in the study when they were aged 8, 16, 18, and 25 years.

Over 4000 participants were analyzed from the health study, “Children of the 90s,” which was established at the University of Bristol in the early 1990s. Researchers combined genetic information with an approach called metabolomics, involving measures of many small molecules in a blood sample to try and identify patterns that are specific to early stages of T2D development.

“We knew that diabetes doesn’t develop overnight. What we didn’t know is how early in life the first signs of disease activity become visible and what these early signs look like,” said lead investigator Josh Bell, MD, in a press release. “We addressed these by looking at the effects of being more genetically prone to type 2 diabetes in adulthood on measures of metabolism taken across early life.”

The study was conducted among younger people who were generally free of T2D and other chronic diseases to see how early in life the effects of being more susceptible to adult diabetes became visible. Certain types of high-density lipoprotein cholesterol were reduced at 8 years of age before other types of cholesterol including low-density lipoprotein were raised. Inflammation and amino acids were also elevated by 16 and 18 years of age, with these differences widening over time.

“We’re talking about the effects of susceptibility rather than of clinical disease itself,” Bell said in the press release. “This does not mean that young people ‘already have adult diabetes’; these are subtle differences in the metabolism of young people who are more prone to developing it later in life.”

These findings help reveal the biology of how diabetes unfolds and what features may be targetable much earlier on to prevent the onset of disease and its complications, according to the study authors.

“This is important because we know that the harmful effects of blood glucose, such as on heart disease, are not exclusive to people with diagnosed diabetes but extend to a smaller degree to much of the population,” Bell said.

Signs of being prone to adult diabetes are already visible at age 8 years old. University of Bristol. 

https://www.bristol.ac.uk/alspac/news/2020/early-signs-of-diabetes.html

. Published June 19, 2020. Accessed June 22, 2020.

Articles

Early signs of being more susceptible to type 2 diabetes (T2D) as an adult can be seen in children as young as age 8 years, decades before it is likely to be diagnosed, according to researchers from the University of Bristol.

Study: Signs of Adult Diabetes Already Visible by Age 8 Years

 spoke with Robert Schumm, MBA, president of Ascensia Diabetes Care, about the challenges that patients with diabetes are facing during the coronavirus disease 2019 (COVID-19) pandemic.

Many challenges are the same for those with and without diabetes, Schumm said, including the isolation of stay-at-home orders and shortages of household items or other essentials.

“The thing is that for people with diabetes, sometimes these things have all that much more of an importance,” Schumm said.

For example, the loss of a job could not only add to financial strain, but it could make it impossible to get necessary medications, such as insulin. Increased stress can also impact blood glucose levels, Schumm said, leading to greater concerns around glycemic control.

There are some solutions, however. Schumm emphasized that patients should have enough supplies of their medications and equipment, whether that’s by getting a 90-day supply or asking their pharmacist for other solutions. Telemedicine has also proven to be extremely helpful during the pandemic, as patients with diabetes can still contact their providers with questions or concerns, while staying safely at home. Online options also offer a different way to obtain medical supplies that might normally be purchased at the pharmacy, Schumm said, and patients should become more comfortable with ecommerce options.

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Contemporary Clinic spoke with Robert Schumm, MBA, president of Ascensia Diabetes Care, about the challenges that patients with diabetes are facing during the COVID-19 pandemic. 

Patients with Diabetes Face Unique Challenges During COVID-19 Pandemic

A new, multi-ethnic study found older adults with low vitamin K levels were more likely to die within 13 years compared with those whose vitamin K levels were adequate. The data suggest that vitamin K, a nutrient found in leafy greens and vegetable oils, may offer protective health benefits as people get older, according to the researchers.

A meta-analysis was conducted, involving approximately 4000 Americans from 54 to 76 years of age, one-third of whom were non-white. The participants were categorized according to their vitamin K levels and heart disease. However, those with the lowest vitamin K levels had a 19% higher risk of death, compared with those whose vitamin K levels reflected adequate vitamin K intake.

Participants on the blood thinner warfarin were excluded because vitamin K counteracts the anti-clotting effects of warfarin, according to the study authors. Additionally, all participants were free of heart disease at baseline and had vitamin K levels measured during a single medical exam that was part of each study’s regular protocol.

“The possibility that vitamin K is linked to heart disease and mortality is based on our knowledge about proteins in vascular tissue that require vitamin K to function. These proteins help prevent calcium from building up in artery walls, and without enough vitamin K, they are less functional,” said study author Kyla Shea in a press release.

The limitations to the study include that circulating phylloquinone was measured from a single blood draw, rather than from repeated blood tests over time. Further, there were fewer heart disease events compared with total deaths, which may have limited researchers’ ability to detect statistically significant risk of heart disease.

The study authors concluded that this study cannot establish a causal relationship between low vitamin K levels and risk of death because it is observational, although the study adds existing evidence that vitamin K may have protective health benefits.

Multi-ethnic study suggests vitamin K may offer protective health benefits in older age. TuftsNow. 

https://now.tufts.edu/news-releases/multi-ethnic-study-suggests-vitamin-k-may-offer-protective-health-benefits-older-age

. Published June 15, 2020. Accessed June 16, 2020.

The data suggest that vitamin K, a nutrient found in leafy greens and vegetable oils, may offer protective health benefits as people get older, according to the researchers.

Study Suggests Vitamin K May Offer Protective Health Benefits in Older Age

The authors of an editorial published in the 

 call for rapid policy reform and investment in nurses and nursing in order to leverage the skills of the nursing workforce, according to a press release from the University of Pennsylvania School of Nursing.

The editorial outlines the following areas for improvement:

Multisectoral investments to redesign and innovate existing health services.

Forge supportive regulations and legislation for nurses.

Optimize nursing contributions to best meet global public health needs and increase the potential to contain and manage the pandemic and future public health and humanitarian crises.

“The far-reaching consequences of COVID-19 have shown that we need widespread, rapid, and intelligent investment in nursing through informed action that fully leverages the health care workforce,” said study author William E. Rosa, PhD, MBE, NP-BC, FAANP, FAAN, and Linda H. Aiken, PhD, RN, FAAN, FRCN. “Our communities and the health of populations worldwide depend on these urgently needed policy reforms and increased investment in nursing now more than ever.”

The recommendations in the editorial are based on a 2018 World Innovation Summit for Health report and include implications for nurses and advanced practice nurses, policy makers, governmental and nongovernmental health partners.

Calling for Nursing Support Amid COVID-19 Pandemic. Penn Nursing. 

https://www.nursing.upenn.edu/live/news/1687-calling-for-nursing-support-amid-covid-19-pandemic

The recommendations in the editorial are based on a 2018 World Innovation Summit for Health report and include implications for nurses and advanced practice nurses, policy makers, governmental and nongovernmental health partners. 

Nursing Support, Policy Reform Needed Amid COVID-19 Pandemic

At the 2020 Virtual Conference on Pediatric Health Care, Susan Van Cleve, DNP, RN, CPNP-PC, PMHS, FAANP, FAAN, discussed identifying and treating anxiety in children and teens, especially in relation to the high incidence of comorbidity in that population.

According to Van Cleve, approximately 15% to 20% of children and teens in the United States suffer from either a mental, emotional, or behavioral disorder. Of that population, 3 of 4 children aged 3 to 17 years who have depression also have anxiety (73.8%), while approximately 1 of 3 children in that age range have behavior problems (37.9%), and depression (32.3%).

“There's so much comorbidity in terms of children and teens who have either depression with anxiety or ADHD, mostly inattentive ADHD, and anxiety, that it really requires that the clinician conduct a comprehensive assessment and evaluation for all these different disorders so that we don't miss a disorder,” said Van Cleve, in an interview with 

Van Cleve explained that since anxiety often exists alongside other comorbidities, it can make diagnosis a difficult process.

“Diagnosis of anxiety requires a fair amount of time. It requires asking a lot of questions and getting information from teachers, parents, kids, the children themselves, as well as looking at their symptoms, and how much those symptoms are interfering with the child’s functioning. We then need to come up with an appropriate diagnosis and treatment plan,” Van Cleve said.

Van Cleve explained that a key term in this evaluation process is the functional impairment of the child in relation to their symptoms. Functional impairment, which occurs when a child does not function in a typical way for his or her age, is a major criteria when considering whether to look into an issue that a child or teen may be having because without that element, a diagnosis of anxiety may not be helpful or relevant.

“So, if a child comes to us with a complaint of inattention in school and we go through our whole evaluation process and determine that the child may have inattentive ADHD but also anxiety, we have to decide what treatment is going to be appropriate because that diagnosis will affect the treatment, and so by doing a thorough evaluation and really looking at the symptoms that are interfering with that child's level of functioning, we can choose the appropriate treatment plan,” Van Cleve said.

She explained further that many times in her practice, she will sit down with parents and children to see what is causing the most harm in the child’s life right now: Is it the anxiety, or is it the inattentive ADHD? Once those needs are made clear by the parent and the child, they are able to determine an appropriate treatment plan based on the right diagnosis.

Screening tools also are a critical tool available for diagnosis of children and teens due to the tools’ ability to provide objectivity, according to Van Cleve. They allow providers the opportunity to hear from people that are not present during the visit, such as a teacher, a daycare worker, a counselor, or a therapist. Furthermore, screening tools allow children to self-report their symptoms in order to inform the provider of exactly what their feeling and their struggles.

“The use of screening tools when diagnosing a child is invaluable, and I really think that we should recommend their use for every practice when screening for depression and anxiety. We screen for all kinds of behavioral issues with our patients; it's very important.”

From this point of diagnosis, since children’s brains are more pliable than adults, Van Cleve explained that children often respond very well to treatment. She added that currently, the strongest evidence-based treatment option available is cognitive behavioral therapy (CBT). CBT is able to act as a method for cognitive restructuring that allows children to change how they think about their lives, how they behave, and how they feel about themselves and their behaviors.

“It's very interesting. Cognitive behavioral therapy does work and children's brains are very pliable, so it's a wonderful thing to see when children can learn these skills and really reframe how they think about things,” Van Cleve said.

Since the FDA has not yet approved any drugs for anxiety in children and teens, CBT is the first option when treating patients, as any pharmaceutical treatments available for children are off-label, according to Van Cleve. She explained that CBT acts either as an adjunct to be used with medication or a treatment before medication is considered.

Van Cleve added that one of the benefits of approaching medication cautiously is the opportunity to build trust with the parents of the child, as they will feel that the provider is not just throwing a medication at a child’s issue.

“I think we have to use medication really carefully,” Van Cleve said. “We have to start at low doses, we have to go slowly, and we need to include the family as part of the decision-making, and as we progress with dosages.”

Van Cleve S. Worrying, Fear and Angst: How to Identify and Treat Anxiety in Children and Teens. Presented at: 2020 Virtual Conference on Pediatric Health Care; June 4 – 6, 2020; virtual. Accessed June 11, 2020.

Since anxiety often exists alongside other comorbidities, it can make diagnosis a difficult process.

Management of Anxiety in the Pediatric Population

The CDC’s update to the Immunization Schedule highlights the new best practices and the efficacy and safety of crucial vaccines for children, according to a session at the virtual National Association of Pediatric Nurse Practitioners 2020 Annual Meeting.

Mary Beth Koslap-Petraco, DNP, PPCNP-BC, CPNP, FAANP, lead the discussion on specific vaccine revisions that are crucial to note. For example, the Haemophilus influenzae B vaccine (HIB booster) was revised, which indicates that catch-up vaccination is not recommended for previously unvaccinated children who are 5 years of age and older.

“Unless you have a child who is high risk, they no longer need to have the HIB booster,” Koslap-Petraco said.

Further, the hepatitis A vaccine was revised to recommend catch-up in all children and adolescents ages 2 through 18 years who have not previously received the hepatitis A vaccine.

“Whether they are homeless children or adults, this vaccine is recommended, but all children and adolescents are recommended to complete the 2-dose series,” Koslap-Petraco said.

Koslap-Petraco also mentioned the changes in the hepatitis B, meningitis A and B (MenACWY), and polio vaccines, each with different dosage schedules that can be found on the 

.

In the influenza vaccine realm, the NanoFlu vaccine for adults aged 65 years and older is a recombinant quadrivalent seasonal influenza vaccine candidate adjuvanted with Matrix-M™. This vaccine’s technology and improvement over egg-based vaccines may be helpful in finding the right coronavirus disease 2019 (COVID-19) vaccine, according to Koslap-Petraco.

Although there is a COVID-19 vaccine in development, Koslap-Petraco mentioned that Paul Offit, MD, vaccine expert, head of Vaccine Information Center at Children’s Hospital of Philadelphia, cautions that a vaccine could be multiple years away, not months. “The FDA looks to see that those in a vaccinated group of clinical trials have less of targeted disease than those in control group,” Koslap-Petraco said. “Further, this vaccine must be safe and cause few and mild side effects.”

More specifically with children, there was a reported 64 suspected cases of pediatric multisystem inflammatory syndrome being investigated in New York as of May 5, 2020. This syndrome has features that overlap with Kawasaki Disease and toxic shock syndrome, according to Koslap-Petraco.

“Some patients have developed cardiogenic or vasogenic shock and have required intensive care, and it may occur days to weeks after acute COVID-19 illness.”

With this new information, Koslap-Petraco emphasized to keep children up to date with routine child health vaccines and emphasizing safe appointment practices, such as checking on well children in the morning and sick children in the afternoon to avoid cross contamination.




Koslap-Petraco MB. CDC Immunization Update 2020-Focus on the Schedule. 2020 NAPNAP Virtual Conference.

The CDC’s update to the Immunization Schedule highlights the new best practices and the efficacy and safety of crucial vaccines for children, according to a session at the virtual National Association of Pediatric Nurse Practitioners 2020 Annual Meeting.

CDC Releases 2020 Immunization Update

, the global authority in rankings and consumer advice, and 

®, the leading multimedia pharmacy network for pharmacists, today released the 

. As integral members of the health care team, pharmacists serve as a valuable resource for patients and caregivers. Excedrin became the No. 1 pick among pharmacists for treating headaches, and Delsym products remained favorites for cough relief in adults and children.

®, provides recommendations from thousands of pharmacists for more than 1,000 over-the-counter (OTC) brands across 149 product categories, 135 of which U.S. News also publishes, giving pharmacists and patients a trusted resource to promote wellness, prevent and treat acute ailments and illnesses, and manage more complex conditions to improve patient outcomes.

Pharmacists are on the front lines of health care and serve as trusted health care providers for patients suffering from common ailments. During the COVID-19 pandemic, the role of pharmacists has been essential to maintaining public health and wellness.

Nearly 75 percent of patients rely on pharmacists to provide OTC medications to treat illnesses and injuries, according to the HRA® 2019 Value of the Pharmacist Study. The No. 1 pharmacist-recommended brands include:

Insect bite and sting management: After Bite

To keep children healthy year-round, the 2020 top-recommended health products for common ailments such as allergies, sore throat and cough include:

Children's allergy: Children's Zyrtec Allergy Syrup

Children's cough and cold: Children's Delsym

Children's sore throat: Chloraseptic Kids Sore Throat Spray

This year's picks feature at-home testing products, including Omron digital thermometer, OneTouch blood glucose monitors and Omron blood pressure monitors.

"During these unprecedented times, the ability to find fast and easy-to-comprehend information about over-the-counter products is more important than ever," said Angela Haupt, assisting managing editor of health at 

® with the in-depth journalism and analysis from 

 empowers consumers to pinpoint the right product for their ailment and know that they made the most informed decision for their health."

Ed Cohen, Pharm.D., FAPhA, executive vice president of pharmacy advocacy for 

® gives consumers everywhere insight into which over-the-counter products pharmacists trust. We are proud to be working with 

once again to put together this comprehensive guide of pharmacist recommendations, and we are thankful for the time and effort pharmacists put into taking the survey."

® began collaborating in 2012 to bring pharmacist recommendations to consumers nationwide. 

® evaluates pharmacists' insights and preferences through an annual research program conducted by 

HRA® – Healthcare Research and Analytics

, a consultative health care market research practice. Through 

Drugs & Treatments section, health.usnews.com/drugs, consumers have an easy and searchable way to access the information produced by pharmacists' recommendations. 

 displays brands that received at least 1 percent of pharmacists' votes but awards a No. 1 Pharmacist Recommended Brand designation only to the top-ranked product in each category.

 to access the rankings and search pharmacist recommendations by symptom, product or category.

U.S. News & World Report is the global leader in quality rankings that empower people to make better, more informed decisions about important issues affecting their lives. A digital news and information company focused on Education, Health, Money, Travel, Cars and News, 

 provides consumer advice, rankings and analysis to serve people making complex decisions throughout all stages of life. More than 40 million people visit 

 each month for research and guidance. Founded in 1933, U.S. News & World Report is headquartered in Washington, D.C.

® is the industry-leading multimedia pharmacy network of community, health-system, oncology and specialty pharmacy platforms, providing practical clinical and professional information pharmacists can use in their everyday practices when counseling patients and interacting with other health care providers. Each issue and the website contain articles and features covering industry trends, medication errors, drug interactions, patient education, disease state management, patient counseling, product news, pharmacy law and more. Additionally, 

 is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. 

™, the largest privately held, independent, full-service medical media company in North America dedicated to delivering trusted health care news across multiple channels.

U.S. News & World Report, the global authority in rankings and consumer advice, and Pharmacy Times®, the leading multimedia pharmacy network for pharmacists, today released the top-recommended health products for 2020. 

U.S. News & World Report and Pharmacy Times® Reveal This Year's Top-Recommended Health Products

Teenagers who have obesity, type 2 diabetes (T2D), or high blood pressure may be more likely to have signs of premature blood vessel aging compared with teens without those health conditions, according to research published in the

Journal of the American Heart Association

Researchers evaluated 141 teens with normal weight, 156 who had obesity, and 151 who had T2D over the course of 5 years with an average age of 17.6 years at the beginning of the study. At the end of 5 years, the teens with either obesity, T2D, or high systolic blood pressure were significantly more likely to have thicker and stiffer carotid arteries, the main blood vessel that leads to the brain, according to the study.

Carotid artery health was assessed by non-invasive ultrasound and pulse wave velocity, which measured the thickness of the inner 2 layers of the blood vessel, called the carotid intima-media thickness. The pulse wave velocity gauges how fast blood flows through the vessels to determine arterial stiffness. Both measures were taken at the beginning of the study and 5 years later.

The researchers concluded that teens with obesity, T2D, or high systolic blood pressure had greater change in the thickness and stiffness of their arteries, compared with participants in the group with normal weight. This would suggest a greater risk of early heart attacks or strokes among the teens with obesity, T2D, or high systolic blood pressure, according to the study authors.

“Although [T2D] is treated aggressively in the US, obesity needs to be treated just as vigorously because it has the same increased risk for premature aging of the blood vessels, which is an early sign of cardiovascular dysfunction and a precursor to cardiovascular diseases in adulthood,” said lead study author Justin R. Ryder, PhD, in a press release.

A limitation of the research is that the teenagers were not followed into adulthood to track whether the premature aging of their blood vessels results in heart attacks, strokes, and other cardiovascular conditions. However, strengths of the study included its large population size and the objective measurements of carotid artery health 5 years apart.

Teen obesity, diabetes, or high blood pressure may lead to prematurely aged arteries [news release]. Dallas, TX; American Heart Association: May 6, 2020.

https://newsroom.heart.org/news/teen-obesity-diabetes-or-high-blood-pressure-may-lead-to-prematurely-aged-arteries

At the end of 5 years, the teens with either obesity, T2D, or high systolic blood pressure were significantly more likely to have thicker and stiffer carotid arteries, the main blood vessel that leads to the brain, according to the study.

Study: Teen Obesity, Diabetes, High Blood Pressure May Lead to Prematurely Aged Arteries

Sleep problems among children who have a sibling with autism spectrum disorder (ASD) may further raise the likelihood of an ASD diagnosis compared to at-risk children who do not have difficulty sleeping, according to a study from the

Previous research has shown that young children who have a sibling with ASD are at a higher risk for also being diagnosed with the condition, according to a NIH press release. These findings may give clinicians a tool to identify sleep problems early and provide interventions to reduce their effects on the health and development of children with autism. In addition, the findings may provide insight into the potential role of sleep problems in the development of ASD.

Researchers analyzed data from a long-term study of children who do and do not have siblings with ASD. When the children reached the ages of 6 months and 12 months, their parents were asked to respond to an infant temperament questionnaire that asks how much difficulty their child has falling asleep at bedtime and falling back to sleep after waking up during the night. At these time intervals, the children also received MRI scans to track their brain development.

The children were assessed for ASD at 24 months.

Four hundred and thirty-two children participated in the study, and 305 of these participants had a sibling previously diagnosed with ASD. Out of this group of 305, 71 were diagnosed with ASD at age 24 months, while 234 children in this group did not meet the diagnostic criteria for ASD.

One hundred and twenty-seven study participants did not have a sibling with ASD, and none of the children met the diagnostic criteria for ASD.

According to the study authors, high-risk children who met criteria for ASD scored higher for sleep problems at ages 6 months and 12 months compared to the other groups. In addition, these children had more growth in the brain’s hippocampus region from ages 6 months to 24 months compared to the high-risk children without sleep problems. This finding is crucial to the researchers because the hippocampus is involved in storing and retrieving memories, and previous studies in adults have linked insomnia with a smaller hippocampus volume.

The study authors could not determine why sleep problems were linked with larger hippocampus volume in the children who went on to meet ASD criteria. Further, the authors noted that their study could not provide information about the overall quality of the children’s sleep, such as the degree of sleep fragmentation, and sleep duration.

Additional studies with more comprehensive measures of sleep was suggested to further confirm the researchers’ findings, according to the press release.

NIH-funded study links early sleep problems to autism diagnosis among at-risk children. NIH.

https://www.nih.gov/news-events/news-releases/nih-funded-study-links-early-sleep-problems-autism-diagnosis-among-risk-children

. Published May 7, 2020. Accessed May 7, 2020.

Previous research has shown that young children who have a sibling with ASD are at a higher risk for also being diagnosed with the condition.

Study Links Early Sleep Problems to Autism Diagnosis Among At-Risk Children

As people remain under stay-at-home orders around the world, experts are increasingly concerned that vaccine-preventable disease outbreaks could follow the coronavirus disease 2019 (COVID-19) outbreak, due to global interruptions of immunization programs.

Organizations such as the Measles & Rubella Initiative have warned that disruptions in immunization services could lead to outbreaks in many vaccine-preventable diseases, which could then further overwhelm health systems fighting COVID-19.

“Disease outbreaks must not remain a threat when we have safe and effective vaccines to protect us,” said World Health Organization (WHO) Director-General Tedros Adhanom, PhD, in a statement.

Measles is of particular concern. According to a statement from the Measles & Rubella Initiative, as many as 800,000 people may have been infected with measles in 2019, and a resurgence could follow later in 2020 if vaccination rates fall.

The WHO issued a document in April with guiding principles and recommendations for ensuring continued immunizations, including adapting new strategies to protect health workers, caregivers, and patients.

“Immunization is a core health service that should be prioritized for the prevention of communicable diseases and safeguarded for continuity during the COVID-19 pandemic, where feasible,” the statement said.

According to the WHO recommendations, vaccine-preventable disease surveillance should be maintained and reinforced, and should be monitored in tandem with the dynamics of COVID-19. If immunization services are impacted, individual countries should create strategies to catch up and should make plans to anticipate a gradual recovery. These strategies will require tracking and follow-up with individuals who missed vaccinations, assessing of immunity gaps, and re-establishing community demand.

These strategies and decisions will be influenced by local mandates regarding physical distancing and will depend on whether the local health systems have reached capacity. Wherever the capacity is intact and essential health services are still operational, fixed site immunization services and disease surveillance should be continued while maintaining safety procedures. Alternative strategies may be considered in some cases, however, and may include outreach or mobile services.

Finally, in areas where immunization services must be minimized or suspended, the WHO recommendations urged countries to reinstate their services as soon as possible once reduced local transmission of COVID-19 permits health services to resume. If resources are still limited, catch-up activities should prioritize outbreak-prone diseases such as measles, polio, diphtheria, and yellow fever.

“While the world strives to develop a new vaccine for COVID-19 at record speed, we must not risk losing the fight to protect everyone, everywhere against vaccine-preventable diseases,” Adhanom concluded in a statement from the WHO. “These diseases will come roaring back if we do not vaccinate.”

Hard fought gains in immunization coverage at risk without critical health services, warns WHO [news release]. Measles & Rubella Initiative; April 23, 2020.

https://measlesrubellainitiative.org/measles-news/hard-fought-gains-in-immunization-coverage-at-risk-without-critical-health-services-warns-who/

Guiding principles for immunization activities during the COVID-19 pandemic. World Health Organization; March 26, 2020.

https://apps.who.int/iris/bitstream/handle/10665/331590/WHO-2019-nCoV-immunization_services-2020.1-eng.pdf

Organizations have warned that disruptions in immunization services could lead to outbreaks in many vaccine-preventable diseases.

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