1.Mechanism of active ingredient compatibility of Dimocarpus longan Lour. leaves in improving glucose and lipid metabolism disorders in type 2 diabetic mellitus rats
Yanli LIANG ; Shijia AN ; Fengsheng LI ; Jiani MAI ; Anqi HUO ; Jiali WEI ; Zejuan ZHANG ; Shuyan QIN ; Wenqing HUANG ; Jie LIANG
China Pharmacy 2026;37(13):1697-1703
OBJECTIVE To explore the mechanism of the active ingredient compatibility(quercetin, quercitrin and kaempferol at a mass ratio of 2∶9∶3)of Dimocarpus longan Lour. leaves(abbreviated as CDL) on ameliorating glucose and lipid metabolism disorders in type 2 diabetes mellitus (T2DM) rats. METHODS SD rats were randomly divided into blank control group, model group, metformin hydrochloride group (100 mg/kg), and CDL high-, medium- and low-dose groups (280, 140, 75 mg/kg), with 10 rats in each group. Rats in the blank control group were fed with standard chow, while rats in the other groups were given high-sugar and high-fat diet combined with intraperitoneal injection of streptozotocin to establish the T2DM rat model. After successful modeling, rats in each administration group were given corresponding drug solution, and rats in the blank control group and model group were intragastrically administered with equal volume of pure water, once a day, for consecutive 4 weeks. Fasting blood glucose (FBG) was detected at fixed time every week. The curves of oral glucose tolerance test (OGTT) and intraperitoneal insulin tolerance test (IPITT) were plotted, and the area under curve (AUC) was calculated. The pancreatic islet function indexes [fasting insulin (FINS), homeostasis model assessment of insulin resistance (HOMA-IR), insulin sensitivity index (ISI)],blood lipid indexes [total cholesterol (TC), triglyceride (TG), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C)] and hepatic glycogen content were determined. The pathological morphological changes of liver and pancreatic tissues were observed. The protein and mRNA expression levels of molecules related to phosphatidylinositol 3-kinase (PI3K)/protein kinase B (Akt) signaling pathway in liver tissues were detected. RESULTS Compared with the blank control group, the FBG, AUC of IPITT curve, AUC of OGTT curve, HOMA-IR, the levels of FINS, TC, TG and LDL-C, as well as the protein and mRNA expression of phosphatase and tensin homolog, forkhead box protein O1 and glycogen synthase kinase-3β in liver tissues were significantly increased in the model group ( P <0.05). ISI, the levels of HDL-C and hepatic glycogen content, along with the protein and mRNA expression of PI3K, insulin receptor substrate-1, Akt and protein expression of phosphorylated Akt in liver tissues were markedly decreased ( P <0.05). In model group rats, the arrangement of hepatocytes was irregular, the overall structure of pancreatic lobules was disordered, and a large number of inflammatory cell infiltration was observed. Compared with the model group, most of the above quantitative indexes were significantly reversed in the CDL high-dose group ( P <0.05), and the pathological lesions of liver and pancreas were obviously alleviated. CONCLUSIONS CDL can regulate glucose and lipid metabolism disorders, elevate insulin sensitivity and relieve insulin resistance in T2DM rats. Its mechanism may be related to the activation of the PI3K/Akt signaling pathway.
2.Mechanism of active ingredient compatibility of Dimocarpus longan Lour. leaves in improving glucose and lipid metabolism disorders in type 2 diabetic mellitus rats
Yanli LIANG ; Shijia AN ; Fengsheng LI ; Jiani MAI ; Anqi HUO ; Jiali WEI ; Zejuan ZHANG ; Shuyan QIN ; Wenqing HUANG ; Jie LIANG
China Pharmacy 2026;37(13):1697-1703
OBJECTIVE To explore the mechanism of the active ingredient compatibility(quercetin, quercitrin and kaempferol at a mass ratio of 2∶9∶3)of Dimocarpus longan Lour. leaves(abbreviated as CDL) on ameliorating glucose and lipid metabolism disorders in type 2 diabetes mellitus (T2DM) rats. METHODS SD rats were randomly divided into blank control group, model group, metformin hydrochloride group (100 mg/kg), and CDL high-, medium- and low-dose groups (280, 140, 75 mg/kg), with 10 rats in each group. Rats in the blank control group were fed with standard chow, while rats in the other groups were given high-sugar and high-fat diet combined with intraperitoneal injection of streptozotocin to establish the T2DM rat model. After successful modeling, rats in each administration group were given corresponding drug solution, and rats in the blank control group and model group were intragastrically administered with equal volume of pure water, once a day, for consecutive 4 weeks. Fasting blood glucose (FBG) was detected at fixed time every week. The curves of oral glucose tolerance test (OGTT) and intraperitoneal insulin tolerance test (IPITT) were plotted, and the area under curve (AUC) was calculated. The pancreatic islet function indexes [fasting insulin (FINS), homeostasis model assessment of insulin resistance (HOMA-IR), insulin sensitivity index (ISI)],blood lipid indexes [total cholesterol (TC), triglyceride (TG), low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C)] and hepatic glycogen content were determined. The pathological morphological changes of liver and pancreatic tissues were observed. The protein and mRNA expression levels of molecules related to phosphatidylinositol 3-kinase (PI3K)/protein kinase B (Akt) signaling pathway in liver tissues were detected. RESULTS Compared with the blank control group, the FBG, AUC of IPITT curve, AUC of OGTT curve, HOMA-IR, the levels of FINS, TC, TG and LDL-C, as well as the protein and mRNA expression of phosphatase and tensin homolog, forkhead box protein O1 and glycogen synthase kinase-3β in liver tissues were significantly increased in the model group ( P <0.05). ISI, the levels of HDL-C and hepatic glycogen content, along with the protein and mRNA expression of PI3K, insulin receptor substrate-1, Akt and protein expression of phosphorylated Akt in liver tissues were markedly decreased ( P <0.05). In model group rats, the arrangement of hepatocytes was irregular, the overall structure of pancreatic lobules was disordered, and a large number of inflammatory cell infiltration was observed. Compared with the model group, most of the above quantitative indexes were significantly reversed in the CDL high-dose group ( P <0.05), and the pathological lesions of liver and pancreas were obviously alleviated. CONCLUSIONS CDL can regulate glucose and lipid metabolism disorders, elevate insulin sensitivity and relieve insulin resistance in T2DM rats. Its mechanism may be related to the activation of the PI3K/Akt signaling pathway.
3.Efficacy of low temperature plasma in treatment of rats with Pseudomonas aeruginosa wound infection
Jiali ZHANG ; Ming ZHOU ; Gongzi ZHANG ; Yangxiaoxue LIU ; Tianshu ZHAO ; Min XIN ; Gang WANG ; Liping HUANG
Chinese Journal of Nosocomiology 2025;35(13):1921-1926
OBJECTIVE To explore the efficacy of low temperature plasma(LTP)in treatment of the rats with Pseudomonas aeruginosa(PA)wound infection.METHODS Totally 20 SD rats were assigned to establish the PA wound infection models and were randomly divided into the LTP group with 10 rats and the air control group with 10 rats.The wound healing dynamics,bacterial loading capacity,histopathology,levels of cytokines and microen-vironment features were observed during the healing process.RESULTS LTP accelerates the healing of PA infec-tion wound,the wound area reduced after the treatment for 3 days,and the inflammatory reactions alleviated;the infection symptoms subsided after the treatment for 7 days,and the wounds became dry and scabbed;the wounds reduced in size by day 15,showing favorable healing trends.Repeated measurement analysis of variance(ANOVA)indicated that there was significant difference in the impact of LTP on the covering rate of wounds(Ftime=10.230,P<0.001;Fbetween-group=11.340,P=0.001;Finteraction=2.890,P=0.042).The result of quantitative bacterial loads analysis showed that the bacterial loads of the LTP group were lower than those of the control group after the treatment for 3,7 and 15 days(P<0.05).The result of histopathology indicated that the infiltra-ted wound inflammatory cells of the LTP group reduced,the collagen fibers were well-aligned,and the neovascu-larization and formation of granulation tissues were evident.In addition,the pH value of wound tissues and reac-tive oxygen species(ROS)level were improved after the treatment with LTP,which was matched with the process of wound healing.The result of cytokines test showed that LTP could upregulate the levels of VEGF and TGF-β1,downregulate the levels of IL-1β and TNF-α,and promote the wound healing,with statistically signifi-cant differences observed(P<0.05).CONCLUSION LTP may facilitate the control of infections by reducing the bacterial colony counts,establish the effective microenvironment for tissue healing,and accelerate the healing of wounds with PA infection by regulating the release of healing-related cytokines.
4.Efficacy of low temperature plasma in treatment of rats with Pseudomonas aeruginosa wound infection
Jiali ZHANG ; Ming ZHOU ; Gongzi ZHANG ; Yangxiaoxue LIU ; Tianshu ZHAO ; Min XIN ; Gang WANG ; Liping HUANG
Chinese Journal of Nosocomiology 2025;35(13):1921-1926
OBJECTIVE To explore the efficacy of low temperature plasma(LTP)in treatment of the rats with Pseudomonas aeruginosa(PA)wound infection.METHODS Totally 20 SD rats were assigned to establish the PA wound infection models and were randomly divided into the LTP group with 10 rats and the air control group with 10 rats.The wound healing dynamics,bacterial loading capacity,histopathology,levels of cytokines and microen-vironment features were observed during the healing process.RESULTS LTP accelerates the healing of PA infec-tion wound,the wound area reduced after the treatment for 3 days,and the inflammatory reactions alleviated;the infection symptoms subsided after the treatment for 7 days,and the wounds became dry and scabbed;the wounds reduced in size by day 15,showing favorable healing trends.Repeated measurement analysis of variance(ANOVA)indicated that there was significant difference in the impact of LTP on the covering rate of wounds(Ftime=10.230,P<0.001;Fbetween-group=11.340,P=0.001;Finteraction=2.890,P=0.042).The result of quantitative bacterial loads analysis showed that the bacterial loads of the LTP group were lower than those of the control group after the treatment for 3,7 and 15 days(P<0.05).The result of histopathology indicated that the infiltra-ted wound inflammatory cells of the LTP group reduced,the collagen fibers were well-aligned,and the neovascu-larization and formation of granulation tissues were evident.In addition,the pH value of wound tissues and reac-tive oxygen species(ROS)level were improved after the treatment with LTP,which was matched with the process of wound healing.The result of cytokines test showed that LTP could upregulate the levels of VEGF and TGF-β1,downregulate the levels of IL-1β and TNF-α,and promote the wound healing,with statistically signifi-cant differences observed(P<0.05).CONCLUSION LTP may facilitate the control of infections by reducing the bacterial colony counts,establish the effective microenvironment for tissue healing,and accelerate the healing of wounds with PA infection by regulating the release of healing-related cytokines.
5.Detection of Adulterated Fritillaria thunbergii Miq.in Juhong Pills Based on National Drug Sampling and Testing
Ping XUE ; Xiaolu ZHANG ; Jiali ZHANG ; Qiangyan HUANG ; Zhengrong GU ; Minhong LIU ; Jialiang ZHU
Herald of Medicine 2025;44(9):1410-1417
Objective To establish a method for the simultaneous determination of peimine,peiminine,and hupehenine in Juhong pills,to investigate the raw material usage of Fritillaria thunbergii Miq.,and to preliminarily develop a detection approach for identifying adulteration with Fritillaria hupehensis Hsiao et K.C.Hsia.Methods The high-performance liquid chromatography-triple quadruple mass spectrometry(HPLC-MS/MS)was performed on an Agilent Poroshell 120 SB C18 column(2.1 mm×100 mm,2.7 μm)with a mobile phase consisting of acetonitrile-methanol(1∶1)and 0.1%formic acid under gradient elution.The flow rate was set at 0.3 mL·min-1.The column temperature was maintained at 35℃,and the injection volume was 2 μL.Electrospray ionization(ESI)in positive ion mode and multiple reaction monitoring were employed to quantify the three components in 170 batches of Juhong pills.Simulated positive samples with varying adulteration ratios of Fritillaria hupehensis Hsiao et K.C.Hsia were prepared to establish a simple yet efficient detection limit for adulteration.Results Three components showed good linear correlation within their ranges(r≥0.997 5),and the averaged recoveries ranged from 92.0%-106.2%.A total of 61 batches were suspected of Fritillaria thunbergii Miq.adulteration with Fritillaria hupehensis Hsiao et K.C.Hsia in raw material inputs,with the peimine to peiminine ratio below 1.15.Among these samples,27 batches were large honey-bound pills with hupehenine levels of 2.636-9.939 μg·g-1;34 batches were water-honeyed pills showing significantly higher hupehenine contamination at 6.752-48.137 μg·g-1.Conclusion The established method is simple,reliable,and accurate for the quality control of Fritillaria thunbergii Miq.adulteration in Juhong pills without imposing significant additional costs.
6.Detection of Adulterated Fritillaria thunbergii Miq.in Juhong Pills Based on National Drug Sampling and Testing
Ping XUE ; Xiaolu ZHANG ; Jiali ZHANG ; Qiangyan HUANG ; Zhengrong GU ; Minhong LIU ; Jialiang ZHU
Herald of Medicine 2025;44(9):1410-1417
Objective To establish a method for the simultaneous determination of peimine,peiminine,and hupehenine in Juhong pills,to investigate the raw material usage of Fritillaria thunbergii Miq.,and to preliminarily develop a detection approach for identifying adulteration with Fritillaria hupehensis Hsiao et K.C.Hsia.Methods The high-performance liquid chromatography-triple quadruple mass spectrometry(HPLC-MS/MS)was performed on an Agilent Poroshell 120 SB C18 column(2.1 mm×100 mm,2.7 μm)with a mobile phase consisting of acetonitrile-methanol(1∶1)and 0.1%formic acid under gradient elution.The flow rate was set at 0.3 mL·min-1.The column temperature was maintained at 35℃,and the injection volume was 2 μL.Electrospray ionization(ESI)in positive ion mode and multiple reaction monitoring were employed to quantify the three components in 170 batches of Juhong pills.Simulated positive samples with varying adulteration ratios of Fritillaria hupehensis Hsiao et K.C.Hsia were prepared to establish a simple yet efficient detection limit for adulteration.Results Three components showed good linear correlation within their ranges(r≥0.997 5),and the averaged recoveries ranged from 92.0%-106.2%.A total of 61 batches were suspected of Fritillaria thunbergii Miq.adulteration with Fritillaria hupehensis Hsiao et K.C.Hsia in raw material inputs,with the peimine to peiminine ratio below 1.15.Among these samples,27 batches were large honey-bound pills with hupehenine levels of 2.636-9.939 μg·g-1;34 batches were water-honeyed pills showing significantly higher hupehenine contamination at 6.752-48.137 μg·g-1.Conclusion The established method is simple,reliable,and accurate for the quality control of Fritillaria thunbergii Miq.adulteration in Juhong pills without imposing significant additional costs.
7.Changes in voltage-dependent anion channel 3 in an animal model of sepsis-induced myocardial injury
Jiali WANG ; Huiting ZHOU ; Nana WANG ; Xuexia XIA ; Yue CAO ; Fan ZHANG ; Xin HUANG ; Na LI ; Jie HUANG
Chinese Journal of Comparative Medicine 2025;35(6):1-11
Objective To observe changes in voltage-dependent anion channel 3(VDAC3)in a mouse model of sepsis-induced myocardial injury and to explore its potential mechanism.Methods Twenty male C57BL/6J mice were divided randomly into a Sham group and Sepsis group,respectively(n=10 mice per group).Sepsis was induced by the cecal ligation and puncture(CLP).Serum levels of interleukin(IL)-6,tumor necrosis factor(TNF)-α,creatine kinase MB(CK-MB),and cardiac troponin T(cTnT)were detected by enzyme-linked immunosorbent assay.Pathological changes in heart tissue were observed by hematoxylin and eosin staining.Structural and functional changes in the heart were evaluated by echocardiography.Changes in total glutathione,reduced glutathione(GSH),oxidized glutathione,and malondialdehyde(MDA)in heart tissue were detected by spectrophotometry.The morphological structure of mitochondria in mouse cardiomyocytes was observed by transmission electron microscopy.Expression levels of IL-6,IL-1β,VDAC3,glutathione peroxidase 4(GPX4),solute carrier family 7 member 11(SLC7A11),lipocalin-2(LCN2),and prostaglandin-endoperoxide synthase 2(PTGS2)mRNA were detected by real-time quantitative polymerase chain reaction and the localization and expression of VDAC3 and GPX4 proteins in mouse heart tissue were detected by immunofluorescence staining.The correlations between VDAC3 mRNA and GPX4,SLC7A11,PTGS2,LCN2,IL-6,and IL-1β mRNA were analyzed.Expression levels of VDAC3,GPX4,and SLC7A11 proteins were detected by Western blot.Results IL-6,TNF-α,CK-MB,and cTnT levels were significantly higher in the Sepsis group compared with the Sham group(P<0.05).In the Sepsis group,myocardial fibers were torn,the ventricular wall was thickened and edematous,the mitochondrial membrane was ruptured,and mitochondrial cristae were broken or absent.GSH levels were significantly reduced in the Sepsis group(P<0.05)and the lipid peroxide MDA was increased in the Sepsis group(P<0.05)compared with the Sham group.VDAC3,GPX4 and SLC7A11 mRNA and protein levels were all lower in the Sepsis group compared with the Sham group(P<0.05),while expression levels of IL-6,IL-1β,LCN2,and PTGS2 mRNA were increased(P<0.05).VDAC3 mRNA was positively correlated with GPX4 and SLC7A11 mRNA levels,and negatively correlated with LCN2,PTGS2,IL-6,and IL-1β.Conclusions VDAC3 expression decreases in myocardial injury,and it may participate in the occurrence of sepsis-induced myocardial injury by regulating ferroptosis.
8.Analysis of tobacco use situation and related factors among occupational population in Beijing in 2018
Jianhui HUANG ; Ru ZHENG ; Li QI ; Guan WANG ; Ying SUN ; Jiali DUAN
Chinese Journal of Preventive Medicine 2025;59(5):634-639
Objective:To understand the tobacco use situation and related factors among the occupational population in Beijing in 2018.Methods:The data were obtained from a special survey on “Healthy Beijing People—Ten-year Action Plan for Health Promotion (2009—2018)”. From June to September 2018, 12 908 participants were recruited from 16 districts of Beijing using the stratified sampling method combined with the typical sampling method. Questionnaires were conducted to collect basic information, work situations, tobacco exposure in public places, and smoking cessation. The Chi-square test was used to compare the differences in current smoking rates, smoking cessation rates and second-hand smoke exposure rates among participants with different characteristics. Multivariate logistic regression analysis was used to analyze the related factors of tobacco use.Results:The present smoking rate of the occupational population in Beijing was 18.0% (95% CI: 17.3%-18.7%), and the passive smoking exposure rate of non-smokers was 61.0% (95% CI: 60.1%-61.9%). The smoking cessation rate among the working population was 22.2% (95% CI: 20.7%-23.7%), and the proportion of current smokers with the intention to quit was 63.9% (1 485/2 325). The present smoking rate of employees of different genders, ages, education levels and occupational nature showed statistically significant differences ( P<0.05). The results of multivariate logistic regression analysis showed that in males, compared with the age group of 16-29 years old, the risk of smoking increased in the age groups of 30-39 years old, 40-49 years old and over 50 years old [ OR (95% CI) values were 1.49 (1.27-1.74), 1.34 (1.13-1.59) and 1.30 (1.06-1.59)]. Compared with those with junior high school or lower education, participants with high school/vocational/college education group had a higher risk of smoking ( OR=1.38, 95% CI: 1.13-1.69), while those with master′s degree or above had a lower risk of smoking ( OR=0.30, 95% CI: 0.22-0.42). The physical workers ( OR=1.28, 95% CI: 1.11-1.47) had a higher risk of smoking than the mental workers. Conclusion:The current smoking rate among the occupational population in Beijing is lower than the national level during the same period, but the exposure rate to second-hand smoke is relatively high. Age, educational level, job nature and gender are related factors of smoking.
9.Knowledge, attitude and practice of salt reduction and hypertension status and related factors among restaurant practitioners in Beijing City
Jianhui HUANG ; Jingjuan REN ; Ru ZHENG ; Fei XU ; Yan QU ; Jiali DUAN ; Ye HAN
Chinese Journal of Preventive Medicine 2025;59(8):1299-1304
A convenience sampling method was employed to recruit 445 food service employees from 67 Chinese restaurants across all 16 administrative districts of Beijing City from August to December in 2022. A questionnaire survey was conducted to assess their knowledge, attitudes, and behaviors regarding salt reduction and hypertension. The results revealed that awareness was highest for the statement "Hypertensive patients should reduce salt intake" (88.3%), while awareness of "China′s diagnostic criteria for hypertension" was the lowest (23.8%). Positive attitude endorsement rates were 96.0% for willingness to reduce salt, 95.3% for perceived self-efficacy in salt reduction, and 93.0% for agreement with a low-salt diet. Regarding behaviors, the rates of actively reducing salt when ordering takeout or dining out, using low-sodium salt, and using salt-reducing spoons were 73.7%, 45.4%, and 55.5%, respectively. The overall compliance rate for salt-reduction related behaviors was 73.9%. Multivariable logistic regression analysis demonstrated that: compared to the 18-29 age group, employees aged 30-39 ( OR=2.19, 95% CI: 1.16-4.14), 40-49 ( OR=3.36, 95% CI: 1.52-7.42), and 50-59 ( OR=3.25, 95% CI: 1.25-8.50) were significantly more likely to achieve compliance with salt-reduction behaviors; chefs were significantly more likely to achieve behavioral compliance compared to managerial staff ( OR=2.08, 95% CI: 1.08-3.98); employees in catering with adequate knowledge about salt reduction and hypertension were significantly more likely to exhibit behavioral compliance compared to those with inadequate knowledge ( OR=3.32, 95% CI: 1.83-5.92); employees in catering with positive attitudes towards salt reduction were significantly more likely to achieve behavioral compliance compared to those with negative attitudes ( OR=5.81, 95% CI: 2.05-16.43). In conclusion, food service employees in Beijing exhibit insufficient knowledge about salt intake and hypertension. While they demonstrate strong willingness to reduce salt, this does not consistently translate into action. Compliance with salt-reduction behaviors is influenced by age, education level, and job position. There is an urgent need to strengthen the dissemination of knowledge regarding high salt intake and hypertension and to implement personalized interventions targeting salt-reduction behaviors and skills.
10.Analysis of the immunization status and related factors for children aged 0-7 years old with special health status in Tianhe District, Guangzhou City from 2023 to 2024
Chunhuan ZHANG ; Zhiwei ZHENG ; Yong HUANG ; Jun XIA ; Jueyu WU ; Yan KANG ; Zhoubin ZHANG ; Min CUI ; Jiali XIAO
Chinese Journal of Preventive Medicine 2025;59(9):1512-1520
Objective:To analyze the immunization status of routine vaccines for children aged 0-7 years old with special health status in Tianhe District, Guangzhou City, from 2023 to 2024.Methods:From April 2023 to March 2024, 42 vaccination units in Tianhe District, Guangzhou, were organized to collect data on diseases and vaccination history of children with special health status. Vaccination rates were calculated, and multivariate logistic regression models were used to explore the impact of special health status on vaccination rates.Results:A total of 1 976 children aged 0-7 years old with special health status were included, with an average of (1.26±0.58) diseases per participant. The average number of vaccine doses administered for routine immunizations was (14.29±4.27), and the full vaccination coverage was 72.76%. The vaccination rate of 10 doses in the immunization program vaccine was less than 90.00%. The timely rate of the first dose of hepatitis B vaccine (HepB1) was 74.14%, and that of the first dose of measles vaccine (MCV1) was 63.93%. Compared with children with infectious diseases, those with neonatal diseases were more likely to miss the third dose of poliomyelitis vaccine (PV3), MCV1 and the second dose of Group A meningococcal polysaccharide vaccine (MPSV-A2). Those with neuromuscular system diseases were more likely to miss PV3, MPSV-A2 and the first dose of Japanese encephalitis vaccine, live (JE-L1). Those with congenital heart disease were more likely to miss PV3, the third dose of diphtheria tetanus-acellular pertussis vaccine (DTaP3), MCV1, MPSV-A2, and JE-L1. Those with hematological disorders were more likely to miss PV3, MCV1, MPSV-A2, and JE-L1. Those with genetic diseases were more likely to miss MPSV-A2. Those with comorbidities were more likely to miss MCV1 and MPSV-A2. Those with neonatal diseases, neuromuscular system diseases, congenital heart disease, hematopoietic system diseases, genetic diseases, or comorbidities had difficulties in completing the full vaccination process.Conclusion:Children with special health conditions have lower rates of routine immunization and timely vaccination. More measures are needed to improve vaccination rates.

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