Evaluation of Immunization Status in Patients with Cerebral Palsy: Multicenter CP-VACC Study

Evaluation of Immunization Status in Patients with Cerebral Palsy: Multicenter CP-VACC Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Evaluation of Immunization Status in Patients with Cerebral Palsy: Multicenter CP-VACC Study Sema BOZKAYA YILMAZ, Eda KARADAG ONCEL, Nihal OLGAC DUNDAR, Pinar GENCPINAR, and 31 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-288533/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 05 Aug, 2021 Read the published version in European Journal of Pediatrics → Version 1 posted 3 You are reading this latest preprint version Abstract Children with chronic neurological diseases,including cerebral palsy(CP)are especially susceptible to vaccine-preventable infections and face an increased risk of severe respiratory infections and decompensation of their disease.This study aims to examine age-appropriate immunization status and related factors in the CP population of our country. This cross-sectional prospective multicentered survey study included 18 pediatric neurology clinics around Turkey,wherein outpatients children with CP were included in the study.Data on patient and CP characteristics,concomitant disorders as well as vaccination status included in the National Immunization Program(NIP),administration and recommendation of influenza vaccine were collected at a single visit. A total of 1194 patients were enrolled.Regarding immunization records,the most frequently administrated and schedule completed vaccines were BCG(90.8%),hepatitis B(88.9%)and oral poliovirus vaccine (88.5%).MMR was administered to 77.3% and DTaP-IPV-HiB was administered to 60.5% of patients.For the pneumococcal vaccines,54.1% of children had received PCV in the scope of the NIP, and 15.2% of children were not fully vaccinated for their age.The influenza vaccine, was administered only to 3.4% of the patients at any time and had never been recommended to 1122 parents(93.9%).In the patients with severe(grade 4 and 5)motor dysfunction,the frequency of incomplete/none vaccination of hepatitis B,BCG, DTaP-IPV-HiB,OPV,MMR were statistically more common than mild to moderate(grade 1–3)motor dysfunction(p = 0.003, p < 0.001, p < 0.001, p < 0.00, and p < 0.001, respectively).Influenza vaccine recommendation by physicians was higher in the severe motor dysfunction group and the difference was statistically significant(p = 0.029). Children with CP had lower immunization rates and incomplete immunization programs.Clinicians must ensure children with CP receive the same preventative health measures as healthy children,including vaccines. Pediatrics cerebral palsy vaccine influenza Figures Figure 1 Introduction Cerebral palsy (CP) is the most common chronic neurological disorder and the most common cause of physical disability in childhood. Patients have decreased muscle tone, weakness, inability to handle the secretions, and impairment of pulmonary functions. Children with neurological disorders have a 5–7 times higher risk of hospitalization due to respiratory diseases among all children ( 1 ). Recurrent respiratory infections are one of the most important causes of morbidity and mortality for these patients. Like in healthy children, routine immunization is one of the most important preventive measures for infectious disease among children with chronic neurological diseases, including CP. Health authorities have defined chronic neurological diseases as high-risk conditions for influenza and pneumococcal infections, and they recommend vaccines against these infections ( 2 ). Although children with chronic diseases face greater risks, their vaccine coverage rates appear to be lower than in the general population ( 3 ); nonetheless, exact figures are unavailable. In previous studies, it was revealed that patients with chronic neurological diseases were vaccinated more delayed and less frequently than the healthy population ( 1 , 4 , 5 ). Today, an up-to-date vaccination schedule is established in Turkey with the gradual development of new vaccines, strains, and application methods. Turkey's National Immunization Program (NIP) is effective against 13 different antigens (tetanus, diphtheria, pertussis, polio, Hemophilus influenza type B, hepatitis B, tuberculosis, mumps, measles, rubella, pneumococcus, hepatitis A, varicella). There are only a few studies in Turkey that determine the immunization status of children with chronic illnesses especially chronic neurologic diseases ( 5 ). Immunization in these children is particularly important as they often have underlying chronic illnesses that result in a significantly higher risk of complications from infectious diseases that are vaccine-preventable (e.g. influenza and invasive pneumococcal disease). There are many misconceptions about the adverse reactions to vaccines. In truth, vaccinations may elicit serious adverse reactions, such as anaphylaxis, which is a very rare occurrence ( 6 ). Often there are myths to dispel, such as fears about the overload of the immune system, to do more injections in the same session, excessive reactogenicity, and some false contraindications. Parents of patients with CP may also have prejudices about the vaccines, as epilepsy usually accompanies the clinical picture. Also, given the multiple health-care providers involved in children with disabilities, no particular clinicians may take on the role of ensuring preventative health measures are addressed. The main objective of the present study is to examine vaccination rates in the CP population of our country. The secondary objective is to explore whether there is an association between demographic, medical, and receipt of the vaccines which are included in NIP. We hypothesized that patients with CP receive the vaccinations less frequently than the healthy population. Methods Study Protocol In August 2018, a questionnaire form including demographic and clinical features, vaccination status of patients with CP, and the vaccination recommendation of clinicians was prepared at the Izmir Tepecik Training and Research Hospital Pediatric Infection Diseases and İzmir Katip Celebi University Pediatric Neurology Clinics. In September 2018, we contacted the hospitals via e-mails requesting that the questionnaire be completed by a pediatric neurologist from each center. Detailed information about the study was given to the clinics that accepted to participate in the study. Pediatric neurologists were asked to fill in the questionnaire forms by obtaining an informed consent form from the parents/legal guardians of the patients. Printed questionnaires were sent to centers that agreed to participate in the study and data were collected from September 2018 to February 2019. Data Sources Data on patient demographics (age, gender), CP characteristics [etiology and type of CP, affected body parts, GMFCS (Gross Motor Function Classification System) level], concomitant nonneuromotor impairments, hospitalization in the last year, number of hospitalizations and reasons, medicines used regularly, vaccination status for each antigen (included and non-included in NIP), recommended influenza vaccine from clinicians were collected at a single visit. The evaluation of the immunization rate in the population included immunization cards/records provided by parents. We defined “complete” or “incomplete” vaccinations, considering whether the vaccine was available in the NIP during the children’s immunization period. CP was clinically categorized into spastic, dyskinetic or extrapyramidal, cerebellar or ataxic, hypotonic, and mixed, based on the predominant motor impairment ( 7 ). GMFCS was used to classify the severity of motor impairment into five subgroups including level I (walks without limitations), level II (walks with limitations), level III (walks using a hand-held mobility device), level IV (self-mobility with limitations, may use powered mobility) and level V (transported in a manual wheelchair) according to published criteria ( 8 ). Study Population Patients diagnosed with CP and ages under 18 years were included in the study. Of 1202 patients initially enrolled from 18 centers, 1194 patients were found eligible to participate in this study since 8 patients were excluded due to detection of protocol violation (all vaccine data were missing) after enrollment. Written informed consent/assent was obtained from children and/or children's parents or legal guardian following a detailed explanation of the objectives and protocol. The study was conducted following the ethical principles stated in the “Declaration of Helsinki” and approved by the institutional ethics committees (number: 21.02.2018/92). Statistical Analysis The obtained questionnaires were transferred to IBM SPSS (Windows, Version 23.0, Armonk, NY: IBM Corp) program on the computer. The suitability of the variables to normal distribution was examined by visual (histogram and probability plots (PP Plot)) and analytical methods (Kolmogorov-Smirnov test for n > 50) Descriptive data were given as mean and standard deviation for continuous variables and median (minimum-maximum values) for categorical variables. The parameters with normal distribution were compared by independent samples t -test in independent groups and non-normally parameters were compared with the Mann-Whitney U test. Comparisons for categorical variables were made using the Pearson chi-square test and Fischer’s exact test in 2x2 order. In the study, the significance of the p-value was considered as < 0.05. Results Questionnaires were obtained from 1202 patients and 8 patients were excluded due to significant missing data. Overall, 1194 children (57.7% boys and 42.3% girls) with CP and ages between 8 months to 18 years from 18 Pediatric Neurology Clinics. The number of patients according to centers was shown in Fig. 1. The mean age of patients was 93.9 ± 57.6 months (IQR; 44–135 months). The main etiology of CP were asphyxia (39.7%) and prematurity (39.6%), most of the patients had level V gross motor dysfunction (42.1%). Spastic CP (83.4%) with quadriplegic (29.2.0%) or hemiplegic (17.3%) topography was the most common type. The etiology and characteristics of CP have been summarized in Table 1 . The most common concomitant diseases were epilepsy (56.2%), orthopedic problems (15.2%), and growth retardation (29.1%). Most of the patients were using medications (63.9%), the most frequently used drugs were antiepileptics (44.2%), and muscle relaxants (6.8%). Among patients with CP, 342 (28.6%) of them were hospitalized in the last year, of whom 178 were hospitalized due to pneumonia (Table 2 ). Table 1 Etiology and characteristics of cerebral palsy Etiology* n % Asphyxia 474 39.7 Prematurity 473 39.6 Structural abnormalities 81 6.8 Intracranial hemorrhage 76 6.4 Metabolic encephalopathy 58 4.9 Multiple births 53 4.4 Meningitis encephalitis sequela 38 3.2 Head injury 22 1.8 Intrauterine infections 13 1.1 Others 18 1.5 Unknown origin 96 8.0 Clinical category Spastic 996 83.4 Atonic 54 4.5 Dyskinetic 40 3.4 Mixed 56 4.7 Missing data 48 4.0 Topography Quadriplegic 349 29.2 Hemiplegic 206 17.3 Paraplegic 138 11.6 Diplegic 84 7.0 Monoplegic 6 0.5 Missing data 411 35 Gross motor dysfunction Level 5 503 42.1 Level 4 140 11.7 Level 3 184 15.4 Level 2 181 15.2 Level 1 115 9.6 Missing data 71 5.9 *Some patients may have more than one cause Table 2 Demographical and clinical characteristics of patients with CP Characteristics Age a 93.9 ± 57.6 Gender (male) b 689 (57.7) Concomitant diseases b 959 (80.3) epilepsy 671 (56.2) orthopedic problems 500 (41.9) growth retardation 348 (29.1) visual disorders 182 (15.2) recurrent pneumonia 116 (9.7) auditory disorders 33 (2.8) Using medications b 763 (63.9) antiepileptics 528 (44.2) antiepileptics + muscle relaxants 105 (8.8) muscle relaxants 81 (6.8) antipsychotics 13 (1.1) antiepileptics + antipsychotics 11 (0.9) muscle relaxants + antipsychotics 4 (0.3) antiepileptics + muscle relaxants + antipsychotics 2 (0.2) others 19 (1.6) Hospitalization in the last year b 342 (28.6) Hospitalization in the last year due to pneumonia b 178 (14.9) a Values were given as mean ± SD, b Values were give as percentage Regarding immunization records, the most frequently administrated and schedule completed vaccines were Bacillus Calmette-Guerin (BCG) (n = 1084, 90.8%), hepatitis B (n = 1062, 88.9%), and oral poliovirus vaccine (n = 1057, 88.5%). Measles-mumps-rubella (MMR) were administered to 77.3% (n = 923) of patients and Diphtheria-Tetanus-acellular Pertussis-Inactivated Polio vaccine-Haemophilus influenzae type B (DTaP-IPV-HiB) were administered to 60.5% (n = 722) of patients (Table 3 ). In Turkey, conjugated pneumococcal vaccine-7 (PCV7) was introduced to the NIP in April 2008 and was switched to PCV13 in November 2011. Before 2008, PCV requires a specific recommendation for patients. In our study population, 30.8% (n = 367) of the study group had not been previously vaccinated with PCV. For the pneumococcal vaccines, 646 children (54.1%) had received PCV in the scope of the NIP, and 181 children (15.2%) were not fully vaccinated for their age. The varicella vaccine, which was included to NIP in 2012 and started to be administered in 2013, was not administered to 611 children (54.4%). Similarly, the hepatitis A vaccine, which was included in the NIP in 2012, was not administered to 650 children (54.4%). Age-appropriate vaccination according to the NIP were depicted in Table 3 . The influenza vaccine, which is still not included in our NIP, was administered only to 3.4% of the patients at any time. There were only 27 (2.3%) patients who received the influenza vaccine during the season of the study. Influenza vaccine had never been recommended to 1122 parents (93.9%). Table 3 Age-appropriate vaccination according to the National Immunization programme Vaccines Completed Incomplete None Hepatitis B 1062 (88.9) 41 (3.4) 91 (7.6) BCG a 1084 (90.8) - 110 89.2) DTaP-IPV-Hib b 722 (60.5) 379 (31.7) 93 (7.8) OPV c 1057 (88.5) 26 (2.2) 111 (9.3) Pneumococcus 646 (54.1) 181 (15.2) 367 (30.8) MMR d 923 (77.3) 111 (9.3) 160 (13.4) Varicella 583 (48.8) - 611 (51.1) Hepatitis A 492 (41.2) 52 (4.4) 650 (54.4) a Bacillus Calmette-Guerin, b Diphtheria, Tetanus, acellular Pertussis - Inactivated Polio vaccine - Haemophilus influenzae type B, c oral polio vaccine, d measles-mumps-rubella Considering the administration rates of vaccines not included in the NIP, the rotavirus vaccine was administered to 4.8% (n = 58) and the meningococcal vaccine to 3.2% (n = 39) of the patients. None of the children with CP received the human papillomavirus vaccine. In Turkey, MMR and DTaP-IPV were administered to children in the first grade of primary school. Among the reported reasons, the most important one for incomplete vaccination was the lack of primary school vaccination in our study population. Less reported reasons were parents thought that their children's’ immune system was not strong enough to handle the vaccines, the cause of CP was due to vaccines, ACTH or IVIG therapy as it affects vaccination. In the patients with severe (grade 4 and 5) motor dysfunction, the frequency of incomplete/none vaccination of hepatitis B, BCG, DTaP-IPV-HiB, OPV, MMR were statistically more common than mild to moderate (grade 1–3) motor dysfunction (p = 0.003, p < 0.001, p < 0.001, p < 0.00, and p < 0.001, respectively). Influenza vaccine recommendation by physicians was higher (in the severe motor dysfunction group and the difference was statistically significant (p = 0.029). Administration of influenza vaccine at any time or during the study period was also higher in patients with severe dysfunction but the differences were not statistically significant (p = 0.313, and p = 0.163). There was no statistical significance between severe and mild to moderate motor dysfunction in terms of pneumococcal vaccine administration (p = 0.470) It was noted that BCG, OPV, MMR, and PCV vaccines were administered statistically more frequently in hospitalized patients with pneumonia in the last year (p < 0.001, p < 0.001, p < 0.001, and p = 0.004, respectively). And also, influenza vaccine recommendation, getting an influenza vaccine at any time and during the season of the study were statistically more common in this group (p < 0.001, p = 0.034, and p = 0.022, respectively). Discussion Our study aimed to explore immunization status in CP patients and examine whether there is an association between demographic, medical, and receipt of the vaccines which are included in NIP. To the best of our knowledge, the present multicenter study is the first in the English literature to investigate the immunization status of the CP population. Our results showed that the vaccination rate of children with CP for vaccines included in the Ministry of Health’s NIP was lower than healthy children. These findings are similar to a Canadian study ( 9 ) that examined vaccination status in children with physical disabilities and included 57 children with CP. Their results showed lower than expected rates of vaccination (63%). The study results from Australia were found more remarkable, and the 'up-to-date' vaccination rate was demonstrated to be 19.2% in CP patients ( 10 ). In contrast, a study from Turkey ( 5 ), showed no significant difference between immunization rates of children with chronic neurologic diseases versus the healthy population. This study put forth the vaccination rate in 95.6% of patients with chronic neurologic diseases received age-appropriate vaccination according to the Ministry of Health’s NIP. In our study, it was noticed that the administration rates were higher in vaccines that were included in the NIP previously (e.g., hepatitis B, BCG, OPV, MMR, DTaP-IPV-Hib), and lower in those added lastly (e.g., PCV, varicella, hepatitis A). This was attributed to the fact that nearly half of the patients presented in our study were born before vaccines were included in the NIP. MMR and DTaP-IPV-Hib vaccines, which are the other components of childhood vaccinations, have been found less completed with a rate of 77.3% and 60.5% respectively in this group than the vaccines included in the NIS for a long time. Similarly, Greenwood et al. evaluated the vaccination status of patients with CP, and the MMR vaccine was reported to be the most missed vaccine followed by DTaP -Hib, and OPV ( 10 ). The patients with CP have a higher risk of morbidity and mortality than the healthy population for vaccine-preventable diseases. Respiratory diseases are the most frequently reported cause of morbidity and mortality in CP, hence, by ameliorating respiratory status, quality of life, and life expectancy might be augmented. All studies of CP mortality investigating cause attribute more than half of the observed deaths to respiratory diseases ( 11 ). It is important to implement pneumococcal and influenza vaccines that cause pneumonia not to aggravate respiratory problems, which are the cause of almost half of the deaths. As with typically developing children, children with CP should be vaccinated per the currently used vaccination schedule. The rate of complete vaccination with PCV, which is recommended for all Turkish children, was lower in our study than in the general population, among which it is reported to exceed 95% after 2008 ( 12 ). Because of the recent implementation of the PCV, most of the older children born in Turkey before 2008 had not received it as a generally administered vaccine-like our patients. The most common cause associated with required hospitalization was pneumonia, with a rate of 52%, in the last year in our study population. It was noted that the rate of none/incomplete vaccination was higher in those hospitalized patients for pneumonia. Also, it was found that not only the pneumococcal vaccine but also BCG, OPV, and MMR vaccines were implemented at a lower rate in this group. Another remarkable result was that influenza vaccination was recommended for patients hospitalized due to pneumonia at a higher rate, and patients were administered influenza vaccine more common. This may be because preventive implementation and vaccines are considered more frequently during follow-up in patients hospitalized due to pneumonia. Advisory Committee on Immunization Practices recommended influenza vaccine for people with chronic pulmonary, cardiovascular, renal, hepatic, neurological, hematological, metabolic diseases or immunocompromised people in their recommendations for 2020–2021 Control of Seasonal Influenza with Vaccines ( 13 ). In a cohort study by Keren et al., 322 of 745 patients with laboratory-confirmed influenza, had one or more chronic diseases. Neurological and neuromuscular diseases are independent risk factors for respiratory failure ( 14 ). In another study of 830 pediatric deaths associated with laboratory-confirmed influenza reported to the Center of Disease Control between October 2004 and September 2012, an underlying neurological disease was found at a rate of 33% ( 15 ). In the meta-analysis by Gill et al. in 2014, in 27 studies involving 14086 patients, neurological diseases were accepted as a high-risk factor for influenza-related hospitalizations ( 16 ). In a study by Pandolfi et al., among 275 patients with chronic diseases, the lowest vaccination rate for influenza vaccine was found in patients with a neurological disease with 25% ( 17 ). Considering that the frequency of influenza vaccination is generally low in our country, it is low in patients with CP, who are in the risk group. In our study, only 3.4% of the patients with CP were vaccinated against influenza throughout their lives. Similarly, only 2.6% of the patients were vaccinated during the season of the study. In a study from our country, Dinleyici et al. evaluated the vaccination of 366 patients with chronic neurological disease and found that 86.6% of patients had never been vaccinated against influenza in their life ( 5 ). Although it is not as rare as in our country, there are examples of missing vaccination opportunities for these patients in other countries in the literature. In a study from the US, Havers et al. evaluated the vaccination records of 184460 patients with ≥ 1 neurological disease(s) between 2006 and 2014. They found that even in the 2013–2014 season when vaccination was the highest, less than half of the patients and 1/3 of these in the 10–17 years age group were vaccinated against influenza ( 18 ). Worldwide, we need to develop interventions to increase the vaccination rates of the patients with CP who are in the risk group for influenza complications. CP develops in the fetal or infant brain causing activity restriction and is not progressive. It is a group of diseases that affects movement and posture ( 19 ). In a study conducted by Serdaroğlu et al. with 41861 children aged between 2–16 years in our country, the prevalence of CP was reported as 4.4 per 1000 live births ( 20 ). Patients may encounter many problems commonly seen in this disease, e.g., intellectual disability, behavioral disorders, epilepsy, somatosensation disability, visual and auditory disorders, orthopedic deformities, gastrointestinal and nutritional problems. The most common concomitant diseases were epilepsy, orthopedic problems, and growth retardation in our study population. More than half of patients who present to our study have severe motor dysfunction, which makes it difficult to move. Children with CP who had higher levels of motor dysfunction (level 4 and 5) were more likely to be overdue immunizations. A study from Canada ( 9 ) showed that children with moderate to severe disabilities are less likely than those with a mild disability to have received a basic series of immunizations. Similarities in this study and those observed associations between severe motor dysfunction and vaccination prompted us to investigate the potential role of the immunization status of this disease. In our study, the vaccination rate of hepatitis B, BCG, DTaP-IPV-Hib, OPV, and MMR was statistically significantly lower in patients with severe motor dysfunction. The clinical picture of the association between low vaccination rate and severe motor dysfunction is most likely a result of a complex interplay between direct and indirect effects of CP. It may be that this group of children have an ongoing severe chronic illness resulting in frequent hospitalizations delaying age-appropriate immunizations or that the high level of care required may limit the time available for immunization appointments. Or, vaccines may have been neglected because the physicians who follow patients are concerned with other medical problems. Despite our results, Greenwood et al. demonstrated no association with motor dysfunction level and vaccination rate ( 10 ). They discussed that the results may have been influenced by survival bias as most children who died were severe motor dysfunction, and the immunization records for these children had been removed from their national database. Barriers to vaccination of patients with CP are familial factors and false contraindications of both parents and healthcare professionals. The most important reason for incomplete vaccination in our study was due to primary school vaccination in children. Therefore, we think that the administration of primary school vaccinations from primary care physicians and the development of a catch-up vaccination schedule for those patients without an age-appropriate vaccination will be of great benefit in protecting against diseases and increasing the quality of life in children with CP. One study concluded that some parents may be concerned that the possible adverse outcomes of immunizations may outweigh the potential benefits, such as increasing frequency of seizures and a small proportion of parents may believe that immunizations contributed or caused their child’s disability ( 10 ). These concerns were rarely mentioned by the parents of our patients. Conclusion Although the management of CP is not curative, it is a disease in which the quality of life of patients and their relatives can be increased with an appropriate approach. One of the most important approaches to achieve increasing the quality of life is the prevention and control of infections, including vaccination. This study demonstrates that children with CP have a high risk of incomplete and delayed immunization, a significant concern given to their increased healthcare needs and vulnerability to infectious diseases. Consequently, providing information to parents and clinicians following these patients on influenza and other vaccination practices are important, not only for the vaccination of these children but also of their parents. And also, the clinician must be aware of immunization status both in outpatients and inpatients of children with CP. Investigations can include immunization cards, and awareness to none/incomplete vaccination both including and excluding NIP. Only in this way will it be possible to increase the rates of vaccination in the CP population. References Havers F, Fry AM, Chen J et al. Hospitalizations Attributable to Respiratory Infections among Children with Neurologic Disorders. J Pediatr. 2016 Mar;170:135-41.e1-5. doi: 10.1016/j.jpeds.2015.11.030. Epub 2015 Dec 11. PMID: 26687576. Campbell AJP, Grohskopf LA. Updates on Influenza Vaccination in Children. Infect Dis Clin North Am. 2018;32(1):75–89. Pandolfi E, Graziani MC, Ieraci R et al. A comparison of populations vaccinated in a public service and in a private hospital setting in the same area. BMC Public Health. 2008;8:278. Tillmann BU, Tillmann HC, Heininger U et al. Acceptance and timeliness of standard vaccination in children with chronic neurological deficits in north-western Switzerland. Eur J Pediatr. 2005 May;164(5):320-5. Dinleyici M, Carman KB, Kilic O et al. The immunization status of children with chronic neurological disease and serological assessment of vaccine-preventable diseases. Hum Vaccin Immunother. 2018;14(8):1970-1976. Gasparini R, Panatto D, Lai PL et al. The “urban myth” of the association between neurological disorders and vaccinations. J Prev Med Hyg. 2015 Jun 10;56(1):E1–8. Rosenbaum P. , Paneth N., Leviton A .et al. A report: the definition and classification of cerebral palsy April 2006. Dev Med Child Neurol. 2007; 49: 8-14 Palisano R., Rosenbaum P., Walter S et al. Development and reliability of a system to classify gross motor function in children with cerebral palsy. Dev Med Child Neurol. 1997; 39: 214-223. Tervo RC, Taylor B. Vaccinations and the physically handicapped child. CMAJ 1982; 127: 475–7. Greenwood VJ, Crawford NW, Walstab JE et al.Immunisation coverage in children with cerebral palsy compared with the general population. J Paediatr Child Health. 2013 Feb;49(2):E137-41. Blair E, Langdon K, McIntyre S et al. Survival and mortality in cerebral palsy: observations to the sixth decade from a data linkage study of a total population register and National Death Index. BMC Neurol. 2019 Jun 4;19(1):111. https://www.who.int/immunization/monitoring_surveillance/data/tur.pdf (access date 11.05.2020). Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP)—United States, 2020-21 Summary of Recommendations . https://www.cdc.gov/flu/professionals/acip/summary/summary-recommendations.htm Keren R, Zaoutis TE, Bridges CB et al. Neurological and neuromuscular disease as a risk factor for respiratory failure in children hospitalized with influenza infection. JAMA. 2005 Nov 2;294(17):2188-94. Wong KK, Jain S, Blanton L et al.Influenza-associated pediatric deaths in the United States, 2004-2012. Pediatrics. 2013 Nov;132(5):796-804. Gill PJ, Ashdown HF, Wang K et al.Identification of children at risk of influenza-related complications in primary and ambulatory care: a systematic review and meta-analysis. Lancet Respir Med. 2015 Feb;3(2):139-149. Pandolfi E, Carloni E, Marino MG et al. Immunization coverage and timeliness of vaccination in Italian children with chronic diseases. Vaccine. 2012 Jul 20;30(34):5172-8. Havers FP, Fry AM, Peacock G et al. Influenza Vaccination Coverage in Children With Neurologic Disorders and Their Siblings, July 2006 to June 2014. Pediatr Infect Dis J. 2018 Aug;37(8):814-816. Bax M, Goldstein M, Rosenbaum P et al.Executive Committee for the Definition of Cerebral Palsy. Proposed definition and classification of cerebral palsy, April 2005. Dev Med Child Neurol. 2005 Aug;47(8):571-6. Serdaroğlu A, Cansu A, Ozkan S et al. Prevalence of cerebral palsy in Turkish children between the ages of 2 and 16 years. Dev Med Child Neurol. 2006 Jun;48(6):413-6. Tables Table 1. Etiology and characteristics of cerebral palsy Etiology * n % Asphyxia 474 39.7 Prematurity 473 39.6 Structural abnormalities 81 6.8 Intracranial hemorrhage 76 6.4 Metabolic encephalopathy 58 4.9 Multiple births 53 4.4 Meningitis encephalitis sequela 38 3.2 Head injury 22 1.8 Intrauterine infections 13 1.1 Others 18 1.5 Unknown origin 96 8.0 Clinical category Spastic 996 83.4 Atonic 54 4.5 Dyskinetic 40 3.4 Mixed 56 4.7 Missing data 48 4.0 Topography Quadriplegic 349 29.2 Hemiplegic 206 17.3 Paraplegic 138 11.6 Diplegic 84 7.0 Monoplegic 6 0.5 Missing data 411 35 Gross motor dysfunction Level 5 503 42.1 Level 4 140 11.7 Level 3 184 15.4 Level 2 181 15.2 Level 1 115 9.6 Missing data 71 5.9 *Some patients may have more than one cause Table 2. Demographical and clinical characteristics of patients with CP Characteristics Age a 93.9 ± 57.6 Gender (male) b 689 (57.7) Concomitant diseases b 959 (80.3) epilepsy 671 (56.2) orthopedic problems 500 (41.9) growth retardation 348 (29.1) visual disorders 182 (15.2) recurrent pneumonia 116 (9.7) auditory disorders 33 (2.8) Using medications b 763 (63.9) antiepileptics 528 (44.2) antiepileptics + muscle relaxants 105 (8.8) muscle relaxants 81 (6.8) antipsychotics 13 (1.1) antiepileptics + antipsychotics 11 (0.9) muscle relaxants + antipsychotics 4 (0.3) antiepileptics + muscle relaxants + antipsychotics 2 (0.2) others 19 (1.6) Hospitalization in the last year b 342 (28.6) Hospitalization in the last year due to pneumonia b 178 (14.9) a Values were given as mean ± SD, b Values were give as percentage Table 3. Age-appropriate vaccination according to the National Immunization programme Vaccines Completed Incomplete None Hepatitis B 1062 (88.9) 41 (3.4) 91 (7.6) BCG a 1084 (90.8) - 110 89.2) DTaP-IPV-Hib b 722 (60.5) 379 (31.7) 93 (7.8) OPV c 1057 (88.5) 26 (2.2) 111 (9.3) Pneumococcus 646 (54.1) 181 (15.2) 367 (30.8) MMR d 923 (77.3) 111 (9.3) 160 (13.4) Varicella 583 (48.8) - 611 (51.1) Hepatitis A 492 (41.2) 52 (4.4) 650 (54.4) a Bacillus Calmette-Guerin, b Diphtheria, Tetanus, acellular Pertussis - Inactivated Polio vaccine - Haemophilus influenzae type B, c oral polio vaccine, d measles-mumps-rubella Cite Share Download PDF Status: Published Journal Publication published 05 Aug, 2021 Read the published version in European Journal of Pediatrics → Version 1 posted Reviews received at journal 19 Mar, 2021 Editor assigned by journal 12 Mar, 2021 First submitted to journal 01 Mar, 2021 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-288533","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":17772687,"identity":"89abf4ca-91b7-4760-bda9-f35cc11f639c","order_by":0,"name":"Sema BOZKAYA YILMAZ","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABH0lEQVRIiWNgGAWjYJACZiA2ALMSCoAEewOIb0GsFhDFcwDElyBSC5iSSACxcGuRb+9O/FxQUWfMPyP5mcQDg23y8jOfX93wo0CCgb+9OwGbFoMzZzdLzzjDZiZxI81MIsHgtmHj7Jyymz1Ah0mcObsBqxaJ3A3SvG08Ngw3EsBaGJulc9Ju8AC1gKSwOmz+282/edskbORvpH8DabFvkzyTdvMPHi0MN3i3AW0xMDO4kQO2JbFHgv3YbXy2GJzJ3WY940yCseGZN8UWQC3JM3hy2G7LGEjw4PKLfPvZzbeBIWY473j6xps/Km7bzm8//uzmmz82cvztvdgdBgcCCSzQuOABRxIPfuUgwH+A+QOExf6AsOpRMApGwSgYSQAAL4dk0v9fAZYAAAAASUVORK5CYII=","orcid":"https://orcid.org/0000-0002-5389-5616","institution":"Izmir Tepecik Training and Research Hospital: TC Saglik Bakanligi Izmir Il Saglik Mudurlugu Izmir Saglik Bilimleri Universitesi Tepecik Egitim ve Arastirma Hastanesi","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Sema","middleName":"BOZKAYA","lastName":"YILMAZ","suffix":""},{"id":17772688,"identity":"7efa7794-75df-452a-ae61-b9f6d16adf85","order_by":1,"name":"Eda KARADAG ONCEL","email":"","orcid":"","institution":"Izmir Tepecik Training and Research Hospital: TC Saglik Bakanligi Izmir Il Saglik Mudurlugu Izmir Saglik Bilimleri Universitesi Tepecik Egitim ve Arastirma Hastanesi","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Eda","middleName":"KARADAG","lastName":"ONCEL","suffix":""},{"id":17772689,"identity":"7143342c-dca4-4b23-8f17-1f76389852f3","order_by":2,"name":"Nihal OLGAC DUNDAR","email":"","orcid":"","institution":"Izmir Katip Celebi University: Izmir Katip Celebi Universitesi","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Nihal","middleName":"OLGAC","lastName":"DUNDAR","suffix":""},{"id":17772690,"identity":"d8364dea-6f74-45cb-86d6-ec66dc8eeb38","order_by":3,"name":"Pinar GENCPINAR","email":"","orcid":"","institution":"Izmir Katip Celebi University: Izmir Katip Celebi Universitesi","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Pinar","middleName":"","lastName":"GENCPINAR","suffix":""},{"id":17772691,"identity":"41f6169a-735c-4408-a2e4-58257697a7fd","order_by":4,"name":"Berrak SARIOGLU","email":"","orcid":"","institution":"Izmir Tepecik Training and Research Hospital: TC Saglik Bakanligi Izmir Il Saglik Mudurlugu Izmir Saglik Bilimleri Universitesi Tepecik Egitim ve Arastirma Hastanesi","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Berrak","middleName":"","lastName":"SARIOGLU","suffix":""},{"id":17772692,"identity":"fad64ffd-e2e1-44ce-9dc7-44160d81b759","order_by":5,"name":"Pinar ARICAN","email":"","orcid":"","institution":"Izmir Tepecik Training and Research Hospital: TC Saglik Bakanligi Izmir Il Saglik Mudurlugu Izmir Saglik Bilimleri Universitesi Tepecik Egitim ve Arastirma Hastanesi","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Pinar","middleName":"","lastName":"ARICAN","suffix":""},{"id":17772693,"identity":"1fc55471-937f-4434-aba1-31690bf16f20","order_by":6,"name":"Atilla ERSEN","email":"","orcid":"","institution":"Izmir Tepecik Training and Research Hospital: TC Saglik Bakanligi Izmir Il Saglik Mudurlugu Izmir Saglik Bilimleri Universitesi Tepecik Egitim ve Arastirma Hastanesi","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Atilla","middleName":"","lastName":"ERSEN","suffix":""},{"id":17772694,"identity":"30368ab1-9644-4dce-ad2b-546208b2905c","order_by":7,"name":"Dilek YILMAZ CIFTDOGAN","email":"","orcid":"","institution":"Izmir Katip Celebi University: Izmir Katip Celebi Universitesi","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Dilek","middleName":"YILMAZ","lastName":"CIFTDOGAN","suffix":""},{"id":17772695,"identity":"6598230c-bac7-4785-8f0e-c56e2bb21118","order_by":8,"name":"Merve Feyza YUKSEL","email":"","orcid":"","institution":"Ankara University: Ankara Universitesi","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Merve","middleName":"Feyza","lastName":"YUKSEL","suffix":""},{"id":17772696,"identity":"8a8bb878-fd9c-4180-bfde-b4e26d7f2f3e","order_by":9,"name":"Omer BEKTAS","email":"","orcid":"","institution":"Ankara University: Ankara Universitesi","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Omer","middleName":"","lastName":"BEKTAS","suffix":""},{"id":17772697,"identity":"8e0b4848-4225-4c17-b0b1-9a050c898b7e","order_by":10,"name":"Serap TEBER","email":"","orcid":"","institution":"Ankara University: Ankara Universitesi","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Serap","middleName":"","lastName":"TEBER","suffix":""},{"id":17772698,"identity":"0939c2ea-b39e-46fc-aa96-e55e70a0292f","order_by":11,"name":"Betul KILIC","email":"","orcid":"","institution":"Istanbul Medipol University: Istanbul Medipol Universitesi","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Betul","middleName":"","lastName":"KILIC","suffix":""},{"id":17772699,"identity":"1e6c647e-da54-41da-b74c-7f58127cb0ce","order_by":12,"name":"Mustafa CALIK","email":"","orcid":"","institution":"Harran University: Harran Universitesi","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Mustafa","middleName":"","lastName":"CALIK","suffix":""},{"id":17772700,"identity":"6b9e4524-21ea-421e-9acb-eadaa031f5fe","order_by":13,"name":"Meryem KARACA","email":"","orcid":"","institution":"Istanbul University Istanbul Faculty of Medicine: Istanbul Universitesi Istanbul Tip Fakultesi","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Meryem","middleName":"","lastName":"KARACA","suffix":""},{"id":17772701,"identity":"9269b4d8-37a9-4181-a2d9-8c13e7fc845b","order_by":14,"name":"Mehmet CANPOLAT","email":"","orcid":"","institution":"Erciyes University: Erciyes Universitesi","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Mehmet","middleName":"","lastName":"CANPOLAT","suffix":""},{"id":17772702,"identity":"e52600af-6970-47a9-8e7d-5b50f996c96e","order_by":15,"name":"Sefer KUMANDAS","email":"","orcid":"","institution":"Erciyes University: Erciyes Universitesi","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Sefer","middleName":"","lastName":"KUMANDAS","suffix":""},{"id":17772703,"identity":"3a6a7974-df37-4200-9527-7a4eb3cc0f65","order_by":16,"name":"Huseyin PER","email":"","orcid":"","institution":"Erciyes University: Erciyes Universitesi","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Huseyin","middleName":"","lastName":"PER","suffix":""},{"id":17772704,"identity":"3c57049a-30a6-452e-a789-cd73ae6d87b3","order_by":17,"name":"Hakan GUMUS","email":"","orcid":"","institution":"Erciyes University: Erciyes Universitesi","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Hakan","middleName":"","lastName":"GUMUS","suffix":""},{"id":17772705,"identity":"a805aada-c56e-4ac4-a0e3-eb48ef9af7e9","order_by":18,"name":"Selcan OZTURK","email":"","orcid":"","institution":"Erciyes University: Erciyes Universitesi","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Selcan","middleName":"","lastName":"OZTURK","suffix":""},{"id":17772706,"identity":"cc2fe151-c3d1-432f-bf69-019e4a248912","order_by":19,"name":"Cetin OKUYAZ","email":"","orcid":"","institution":"Mersin University: Mersin Universitesi","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Cetin","middleName":"","lastName":"OKUYAZ","suffix":""},{"id":17772707,"identity":"721f7806-3025-4ffc-9c10-4fbf5565611d","order_by":20,"name":"Mustafa KOMUR","email":"","orcid":"","institution":"Mersin University: Mersin Universitesi","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Mustafa","middleName":"","lastName":"KOMUR","suffix":""},{"id":17772708,"identity":"22432e88-f4cc-4b78-b11a-2314fad783cb","order_by":21,"name":"Rojan IPEK","email":"","orcid":"","institution":"Mersin University: Mersin Universitesi","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Rojan","middleName":"","lastName":"IPEK","suffix":""},{"id":17772709,"identity":"85ba1c95-ce23-4ba8-9642-418ab7c61a02","order_by":22,"name":"Pinar OZBUDAK","email":"","orcid":"","institution":"Gazi University: Gazi Universitesi","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Pinar","middleName":"","lastName":"OZBUDAK","suffix":""},{"id":17772710,"identity":"b23d31d6-3ed2-4dcf-9e3b-363001fc1b66","order_by":23,"name":"Ebru ARHAN","email":"","orcid":"","institution":"Gazi University: Gazi Universitesi","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ebru","middleName":"","lastName":"ARHAN","suffix":""},{"id":17772711,"identity":"e7ec3de4-2b1b-487a-9048-06b10d613b1e","order_by":24,"name":"Hulya INCE","email":"","orcid":"","institution":"Medical Park Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Hulya","middleName":"","lastName":"INCE","suffix":""},{"id":17772712,"identity":"58be92f9-22f4-4aee-976a-ab9aee7b9a8f","order_by":25,"name":"Gurkan GURBUZ","email":"","orcid":"","institution":"Namik Kemal University: Tekirdag Namik Kemal Universitesi","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Gurkan","middleName":"","lastName":"GURBUZ","suffix":""},{"id":17772713,"identity":"35c8025c-f8b9-4c64-8ee5-63b91b334f1f","order_by":26,"name":"Gulen GUL MERT","email":"","orcid":"","institution":"Cukurova University: Cukurova Universitesi","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Gulen","middleName":"GUL","lastName":"MERT","suffix":""},{"id":17772714,"identity":"42576549-2098-4bca-9478-3f94c46053bf","order_by":27,"name":"Neslihan OZCAN","email":"","orcid":"","institution":"Cukurova University: Cukurova Universitesi","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Neslihan","middleName":"","lastName":"OZCAN","suffix":""},{"id":17772715,"identity":"ae7c67eb-4355-48c1-97f6-131c5a3b42ff","order_by":28,"name":"Akgun OLMEZ TURKER","email":"","orcid":"","institution":"Turkiye Cumhuriyeti Saglik Bakanligi","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Akgun","middleName":"OLMEZ","lastName":"TURKER","suffix":""},{"id":17772716,"identity":"543489d8-1c9b-4caf-beef-6f18f339fc47","order_by":29,"name":"Hande GAZETECI TEKIN","email":"","orcid":"","institution":"Bakircay University: Bakircay Universitesi","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Hande","middleName":"GAZETECI","lastName":"TEKIN","suffix":""},{"id":17772717,"identity":"470ec19f-81bd-4ae2-8192-0386c4114a02","order_by":30,"name":"Serkan KIRIK","email":"","orcid":"","institution":"Firat University: Firat Universitesi","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Serkan","middleName":"","lastName":"KIRIK","suffix":""},{"id":17772718,"identity":"85e6f568-81b4-40c1-9ff6-b25e639b7c64","order_by":31,"name":"Ceren GUNBEY","email":"","orcid":"","institution":"Hacettepe University: Hacettepe Universitesi","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Ceren","middleName":"","lastName":"GUNBEY","suffix":""},{"id":17772719,"identity":"ea30294d-198e-4fd1-a277-9aa442bd41f2","order_by":32,"name":"Kursat Bora CARMAN","email":"","orcid":"","institution":"Eskisehir Osmangazi University: Eskisehir Osmangazi Universitesi","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Kursat","middleName":"Bora","lastName":"CARMAN","suffix":""},{"id":17772720,"identity":"64b9fbd8-f629-45ba-96a9-ed63084a3f05","order_by":33,"name":"Coskun YARAR","email":"","orcid":"","institution":"Eskisehir Osmangazi University: Eskisehir Osmangazi Universitesi","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Coskun","middleName":"","lastName":"YARAR","suffix":""},{"id":17772721,"identity":"66aba5bf-6b1e-4388-a82e-c4856ca5838c","order_by":34,"name":"Dilek CAVUSOGLU","email":"","orcid":"","institution":"Afyon Kocatepe University: Afyon Kocatepe Universitesi","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Dilek","middleName":"","lastName":"CAVUSOGLU","suffix":""}],"badges":[],"createdAt":"2021-03-01 12:07:55","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-288533/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-288533/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s00431-021-04219-4","type":"published","date":"2021-08-05T15:01:37+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":7235031,"identity":"5662ab44-1404-49d3-b951-10e9073f7853","added_by":"auto","created_at":"2021-03-22 19:16:25","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":30773,"visible":true,"origin":"","legend":"The number of patients according to centers was shown in Figure 1. ","description":"","filename":"fig.1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-288533/v1/9a57e5daf34cad350bba9938.jpeg"},{"id":13681925,"identity":"e2355578-3c3f-48fb-9052-c8c23fa42400","added_by":"auto","created_at":"2021-09-17 11:54:25","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":387949,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-288533/v1/888b9884-3135-4684-8528-e7811e24ba9d.pdf"}],"financialInterests":"","formattedTitle":"Evaluation of Immunization Status in Patients with Cerebral Palsy: Multicenter CP-VACC Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCerebral palsy (CP) is the most common chronic neurological disorder and the most common cause of physical disability in childhood. Patients have decreased muscle tone, weakness, inability to handle the secretions, and impairment of pulmonary functions. Children with neurological disorders have a 5\u0026ndash;7 times higher risk of hospitalization due to respiratory diseases among all children (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). Recurrent respiratory infections are one of the most important causes of morbidity and mortality for these patients. Like in healthy children, routine immunization is one of the most important preventive measures for infectious disease among children with chronic neurological diseases, including CP. Health authorities have defined chronic neurological diseases as high-risk conditions for influenza and pneumococcal infections, and they recommend vaccines against these infections (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Although children with chronic diseases face greater risks, their vaccine coverage rates appear to be lower than in the general population (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e); nonetheless, exact figures are unavailable. In previous studies, it was revealed that patients with chronic neurological diseases were vaccinated more delayed and less frequently than the healthy population (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eToday, an up-to-date vaccination schedule is established in Turkey with the gradual development of new vaccines, strains, and application methods. Turkey's National Immunization Program (NIP) is effective against 13 different antigens (tetanus, diphtheria, pertussis, polio, Hemophilus influenza type B, hepatitis B, tuberculosis, mumps, measles, rubella, pneumococcus, hepatitis A, varicella). There are only a few studies in Turkey that determine the immunization status of children with chronic illnesses especially chronic neurologic diseases (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Immunization in these children is particularly important as they often have underlying chronic illnesses that result in a significantly higher risk of complications from infectious diseases that are vaccine-preventable (e.g. influenza and invasive pneumococcal disease).\u003c/p\u003e\u003cp\u003eThere are many misconceptions about the adverse reactions to vaccines. In truth, vaccinations may elicit serious adverse reactions, such as anaphylaxis, which is a very rare occurrence (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Often there are myths to dispel, such as fears about the overload of the immune system, to do more injections in the same session, excessive reactogenicity, and some false contraindications. \u003cdiv class=\"Ethics-ToolTip\"\u003eParents of patients with CP may also have prejudices about the vaccines, as epilepsy usually accompanies the clinical picture.\u003c/div\u003e Also, given the multiple health-care providers involved in children with disabilities, no particular clinicians may take on the role of ensuring preventative health measures are addressed.\u003c/p\u003e\u003cp\u003eThe main objective of the present study is to examine vaccination rates in the CP population of our country. The secondary objective is to explore whether there is an association between demographic, medical, and receipt of the vaccines which are included in NIP. We hypothesized that patients with CP receive the vaccinations less frequently than the healthy population.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Protocol\u003c/h2\u003e\u003cp\u003eIn August 2018, a questionnaire form including demographic and clinical features, vaccination status of patients with CP, and the vaccination recommendation of clinicians was prepared at the Izmir Tepecik Training and Research Hospital Pediatric Infection Diseases and İzmir Katip Celebi University Pediatric Neurology Clinics. In September 2018, we contacted the hospitals via e-mails requesting that the questionnaire be completed by a pediatric neurologist from each center. Detailed information about the study was given to the clinics that accepted to participate in the study. Pediatric neurologists were asked to fill in the questionnaire forms by obtaining an informed consent form from the parents/legal guardians of the patients. Printed questionnaires were sent to centers that agreed to participate in the study and data were collected from September 2018 to February 2019.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003eData Sources\u003c/h2\u003e\u003cp\u003eData on patient demographics (age, gender), CP characteristics [etiology and type of CP, affected body parts, GMFCS (Gross Motor Function Classification System) level], concomitant nonneuromotor impairments, hospitalization in the last year, number of hospitalizations and reasons, medicines used regularly, vaccination status for each antigen (included and non-included in NIP), recommended influenza vaccine from clinicians were collected at a single visit. The evaluation of the immunization rate in the population included immunization cards/records provided by parents. We defined \u0026ldquo;complete\u0026rdquo; or \u0026ldquo;incomplete\u0026rdquo; vaccinations, considering whether the vaccine was available in the NIP during the children\u0026rsquo;s immunization period.\u003c/p\u003e\u003cp\u003eCP was clinically categorized into spastic, dyskinetic or extrapyramidal, cerebellar or ataxic, hypotonic, and mixed, based on the predominant motor impairment (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). GMFCS was used to classify the severity of motor impairment into five subgroups including level I (walks without limitations), level II (walks with limitations), level III (walks using a hand-held mobility device), level IV (self-mobility with limitations, may use powered mobility) and level V (transported in a manual wheelchair) according to published criteria (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003eStudy Population\u003c/h2\u003e\u003cp\u003ePatients diagnosed with CP and ages under 18 years were included in the study. Of 1202 patients initially enrolled from 18 centers, 1194 patients were found eligible to participate in this study since 8 patients were excluded due to detection of protocol violation (all vaccine data were missing) after enrollment. \u003cdiv class=\"Ethics-ToolTip\"\u003eWritten informed consent/assent was obtained from children and/or children's parents or legal guardian following a detailed explanation of the objectives and protocol.\u003c/div\u003e\u003cdiv class=\"Ethics-ToolTip\"\u003eThe study was conducted following the ethical principles stated in the \u0026ldquo;Declaration of Helsinki\u0026rdquo; and approved by the institutional ethics committees (number: 21.02.2018/92).\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eThe obtained questionnaires were transferred to IBM SPSS (Windows, Version 23.0, Armonk, NY: IBM Corp) program on the computer. The suitability of the variables to normal distribution was examined by visual (histogram and probability plots (PP Plot)) and analytical methods (Kolmogorov-Smirnov test for n\u0026thinsp;\u0026gt;\u0026thinsp;50) Descriptive data were given as mean and standard deviation for continuous variables and median (minimum-maximum values) for categorical variables. The parameters with normal distribution were compared by independent samples \u003cem\u003et\u003c/em\u003e-test in independent groups and non-normally parameters were compared with the \u003cem\u003eMann-Whitney U test.\u003c/em\u003e Comparisons for categorical variables were made using the Pearson chi-square test and Fischer\u0026rsquo;s exact test in 2x2 order. In the study, the significance of the p-value was considered as \u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":" \u003cp\u003eQuestionnaires were obtained from 1202 patients and 8 patients were excluded due to significant missing data. Overall, 1194 children (57.7% boys and 42.3% girls) with CP and ages between 8 months to 18 years from 18 Pediatric Neurology Clinics. The number of patients according to centers was shown in Fig.\u0026nbsp;1. The mean age of patients was 93.9\u0026thinsp;\u0026plusmn;\u0026thinsp;57.6 months (IQR; 44\u0026ndash;135 months). The main etiology of CP were asphyxia (39.7%) and prematurity (39.6%), most of the patients had level V gross motor dysfunction (42.1%). Spastic CP (83.4%) with quadriplegic (29.2.0%) or hemiplegic (17.3%) topography was the most common type. The etiology and characteristics of CP have been summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The most common concomitant diseases were epilepsy (56.2%), orthopedic problems (15.2%), and growth retardation (29.1%). Most of the patients were using medications (63.9%), the most frequently used drugs were antiepileptics (44.2%), and muscle relaxants (6.8%). Among patients with CP, 342 (28.6%) of them were hospitalized in the last year, of whom 178 were hospitalized due to pneumonia (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eEtiology and characteristics of cerebral palsy\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEtiology*\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAsphyxia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e474\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrematurity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e473\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStructural abnormalities\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntracranial hemorrhage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMetabolic encephalopathy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMultiple births\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMeningitis encephalitis sequela\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHead injury\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntrauterine infections\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOthers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnknown origin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eClinical category\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpastic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e996\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e83.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAtonic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDyskinetic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMixed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMissing data\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTopography\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQuadriplegic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e349\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e29.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHemiplegic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e206\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17.3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParaplegic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e138\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiplegic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e84\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMonoplegic\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMissing data\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e411\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGross motor dysfunction\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLevel 5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e503\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e42.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLevel 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e140\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLevel 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e184\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLevel 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e181\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLevel 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e115\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMissing data\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"3\"\u003e*Some patients may have more than one cause\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographical and clinical characteristics of patients with CP\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristics\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e93.9\u0026thinsp;\u0026plusmn;\u0026thinsp;57.6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender (male)\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e689 (57.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConcomitant diseases\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e959 (80.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eepilepsy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e671 (56.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eorthopedic problems\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e500 (41.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003egrowth retardation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e348 (29.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003evisual disorders\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e182 (15.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003erecurrent pneumonia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e116 (9.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eauditory disorders\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33 (2.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUsing medications\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e763 (63.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eantiepileptics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e528 (44.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eantiepileptics\u0026thinsp;+\u0026thinsp;muscle relaxants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e105 (8.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emuscle relaxants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e81 (6.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eantipsychotics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (1.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eantiepileptics\u0026thinsp;+\u0026thinsp;antipsychotics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (0.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003emuscle relaxants\u0026thinsp;+\u0026thinsp;antipsychotics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (0.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eantiepileptics\u0026thinsp;+\u0026thinsp;muscle relaxants\u0026thinsp;+\u0026thinsp;antipsychotics\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (0.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eothers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (1.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHospitalization in the last year\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e342 (28.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHospitalization in the last year due to pneumonia\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e178 (14.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003e\u003csup\u003ea\u003c/sup\u003e Values were given as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, \u003csup\u003eb\u003c/sup\u003eValues were give as percentage\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eRegarding immunization records, the most frequently administrated and schedule completed vaccines were Bacillus Calmette-Guerin (BCG) (n\u0026thinsp;=\u0026thinsp;1084, 90.8%), hepatitis B (n\u0026thinsp;=\u0026thinsp;1062, 88.9%), and oral poliovirus vaccine (n\u0026thinsp;=\u0026thinsp;1057, 88.5%). Measles-mumps-rubella (MMR) were administered to 77.3% (n\u0026thinsp;=\u0026thinsp;923) of patients and Diphtheria-Tetanus-acellular Pertussis-Inactivated Polio vaccine-Haemophilus influenzae type B (DTaP-IPV-HiB) were administered to 60.5% (n\u0026thinsp;=\u0026thinsp;722) of patients (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). In Turkey, conjugated pneumococcal vaccine-7 (PCV7) was introduced to the NIP in April 2008 and was switched to PCV13 in November 2011. Before 2008, PCV requires a specific recommendation for patients. In our study population, 30.8% (n\u0026thinsp;=\u0026thinsp;367) of the study group had not been previously vaccinated with PCV. For the pneumococcal vaccines, 646 children (54.1%) had received PCV in the scope of the NIP, and 181 children (15.2%) were not fully vaccinated for their age. The varicella vaccine, which was included to NIP in 2012 and started to be administered in 2013, was not administered to 611 children (54.4%). Similarly, the hepatitis A vaccine, which was included in the NIP in 2012, was not administered to 650 children (54.4%). Age-appropriate vaccination according to the NIP were depicted in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. The influenza vaccine, which is still not included in our NIP, was administered only to 3.4% of the patients at any time. There were only 27 (2.3%) patients who received the influenza vaccine during the season of the study. Influenza vaccine had never been recommended to 1122 parents (93.9%).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAge-appropriate vaccination according to the National Immunization programme\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVaccines\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCompleted\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIncomplete\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHepatitis B\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1062 (88.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41 (3.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e91 (7.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBCG\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1084 (90.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e110 89.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDTaP-IPV-Hib\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e722 (60.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e379 (31.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e93 (7.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOPV\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1057 (88.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e26 (2.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e111 (9.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePneumococcus\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e646 (54.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e181 (15.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e367 (30.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMMR\u003csup\u003ed\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e923 (77.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e111 (9.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e160 (13.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVaricella\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e583 (48.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e611 (51.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHepatitis A\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e492 (41.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e52 (4.4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e650 (54.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003csup\u003ea\u003c/sup\u003eBacillus Calmette-Guerin, \u003csup\u003eb\u003c/sup\u003eDiphtheria, Tetanus, acellular Pertussis - Inactivated Polio vaccine - Haemophilus influenzae type B, \u003csup\u003ec\u003c/sup\u003eoral polio vaccine, \u003csup\u003ed\u003c/sup\u003emeasles-mumps-rubella\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eConsidering the administration rates of vaccines not included in the NIP, the rotavirus vaccine was administered to 4.8% (n\u0026thinsp;=\u0026thinsp;58) and the meningococcal vaccine to 3.2% (n\u0026thinsp;=\u0026thinsp;39) of the patients. None of the children with CP received the human papillomavirus vaccine.\u003c/p\u003e \u003cp\u003eIn Turkey, MMR and DTaP-IPV were administered to children in the first grade of primary school. Among the reported reasons, the most important one for incomplete vaccination was the lack of primary school vaccination in our study population. Less reported reasons were parents thought that their children's\u0026rsquo; immune system was not strong enough to handle the vaccines, the cause of CP was due to vaccines, ACTH or IVIG therapy as it affects vaccination.\u003c/p\u003e \u003cp\u003eIn the patients with severe (grade 4 and 5) motor dysfunction, the frequency of incomplete/none vaccination of hepatitis B, BCG, DTaP-IPV-HiB, OPV, MMR were statistically more common than mild to moderate (grade 1\u0026ndash;3) motor dysfunction (p\u0026thinsp;=\u0026thinsp;0.003, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, p\u0026thinsp;\u0026lt;\u0026thinsp;0.00, and p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, respectively). Influenza vaccine recommendation by physicians was higher (in the severe motor dysfunction group and the difference was statistically significant (p\u0026thinsp;=\u0026thinsp;0.029). Administration of influenza vaccine at any time or during the study period was also higher in patients with severe dysfunction but the differences were not statistically significant (p\u0026thinsp;=\u0026thinsp;0.313, and p\u0026thinsp;=\u0026thinsp;0.163). There was no statistical significance between severe and mild to moderate motor dysfunction in terms of pneumococcal vaccine administration (p\u0026thinsp;=\u0026thinsp;0.470)\u003c/p\u003e \u003cp\u003eIt was noted that BCG, OPV, MMR, and PCV vaccines were administered statistically more frequently in hospitalized patients with pneumonia in the last year (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, and p\u0026thinsp;=\u0026thinsp;0.004, respectively). And also, influenza vaccine recommendation, getting an influenza vaccine at any time and during the season of the study were statistically more common in this group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, p\u0026thinsp;=\u0026thinsp;0.034, and p\u0026thinsp;=\u0026thinsp;0.022, respectively).\u003c/p\u003e "},{"header":"Discussion","content":"\u003cp\u003eOur study aimed to explore immunization status in CP patients and examine whether there is an association between demographic, medical, and receipt of the vaccines which are included in NIP. To the best of our knowledge, the present multicenter study is the first in the English literature to investigate the immunization status of the CP population. Our results showed that the vaccination rate of children with CP for vaccines included in the Ministry of Health\u0026rsquo;s NIP was lower than healthy children. These findings are similar to a Canadian study (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) that examined vaccination status in children with physical disabilities and included 57 children with CP. Their results showed lower than expected rates of vaccination (63%). The study results from Australia were found more remarkable, and the 'up-to-date' vaccination rate was demonstrated to be 19.2% in CP patients (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). In contrast, a study from Turkey (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), showed no significant difference between immunization rates of children with chronic neurologic diseases versus the healthy population. This study put forth the vaccination rate in 95.6% of patients with chronic neurologic diseases received age-appropriate vaccination according to the Ministry of Health\u0026rsquo;s NIP. In our study, it was noticed that the administration rates were higher in vaccines that were included in the NIP previously (e.g., hepatitis B, BCG, OPV, MMR, DTaP-IPV-Hib), and lower in those added lastly (e.g., PCV, varicella, hepatitis A). This was attributed to the fact that nearly half of the patients presented in our study were born before vaccines were included in the NIP. MMR and DTaP-IPV-Hib vaccines, which are the other components of childhood vaccinations, have been found less completed with a rate of 77.3% and 60.5% respectively in this group than the vaccines included in the NIS for a long time. Similarly, Greenwood et al. evaluated the vaccination status of patients with CP, and the MMR vaccine was reported to be the most missed vaccine followed by DTaP -Hib, and OPV (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe patients with CP have a higher risk of morbidity and mortality than the healthy population for vaccine-preventable diseases. Respiratory diseases are the most frequently reported cause of morbidity and mortality in CP, hence, by ameliorating respiratory status, quality of life, and life expectancy might be augmented. All studies of CP mortality investigating cause attribute more than half of the observed deaths to respiratory diseases (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). It is important to implement pneumococcal and influenza vaccines that cause pneumonia not to aggravate respiratory problems, which are the cause of almost half of the deaths. As with typically developing children, children with CP should be vaccinated per the currently used vaccination schedule. The rate of complete vaccination with PCV, which is recommended for all Turkish children, was lower in our study than in the general population, among which it is reported to exceed 95% after 2008 (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Because of the recent implementation of the PCV, most of the older children born in Turkey before 2008 had not received it as a generally administered vaccine-like our patients. The most common cause associated with required hospitalization was pneumonia, with a rate of 52%, in the last year in our study population. It was noted that the rate of none/incomplete vaccination was higher in those hospitalized patients for pneumonia. Also, it was found that not only the pneumococcal vaccine but also BCG, OPV, and MMR vaccines were implemented at a lower rate in this group. Another remarkable result was that influenza vaccination was recommended for patients hospitalized due to pneumonia at a higher rate, and patients were administered influenza vaccine more common. This may be because preventive implementation and vaccines are considered more frequently during follow-up in patients hospitalized due to pneumonia.\u003c/p\u003e\u003cp\u003eAdvisory Committee on Immunization Practices recommended influenza vaccine for people with chronic pulmonary, cardiovascular, renal, hepatic, neurological, hematological, metabolic diseases or immunocompromised people in their recommendations for 2020\u0026ndash;2021 Control of Seasonal Influenza with Vaccines (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). In a cohort study by Keren et al., 322 of 745 patients with laboratory-confirmed influenza, had one or more chronic diseases. Neurological and neuromuscular diseases are independent risk factors for respiratory failure (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). In another study of 830 pediatric deaths associated with laboratory-confirmed influenza reported to the Center of Disease Control between October 2004 and September 2012, an underlying neurological disease was found at a rate of 33% (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). In the meta-analysis by Gill et al. in 2014, in 27 studies involving 14086 patients, neurological diseases were accepted as a high-risk factor for influenza-related hospitalizations (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). In a study by Pandolfi et al., among 275 patients with chronic diseases, the lowest vaccination rate for influenza vaccine was found in patients with a neurological disease with 25% (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Considering that the frequency of influenza vaccination is generally low in our country, it is low in patients with CP, who are in the risk group. In our study, only 3.4% of the patients with CP were vaccinated against influenza throughout their lives. Similarly, only 2.6% of the patients were vaccinated during the season of the study. In a study from our country, Dinleyici et al. evaluated the vaccination of 366 patients with chronic neurological disease and found that 86.6% of patients had never been vaccinated against influenza in their life (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). Although it is not as rare as in our country, there are examples of missing vaccination opportunities for these patients in other countries in the literature. In a study from the US, Havers et al. evaluated the vaccination records of 184460 patients with \u0026ge;\u0026thinsp;1 neurological disease(s) between 2006 and 2014. They found that even in the 2013\u0026ndash;2014 season when vaccination was the highest, less than half of the patients and 1/3 of these in the 10\u0026ndash;17 years age group were vaccinated against influenza (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Worldwide, we need to develop interventions to increase the vaccination rates of the patients with CP who are in the risk group for influenza complications.\u003c/p\u003e\u003cp\u003eCP develops in the fetal or infant brain causing activity restriction and is not progressive. It is a group of diseases that affects movement and posture (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). In a study conducted by Serdaroğlu et al. with 41861 children aged between 2\u0026ndash;16 years in our country, the prevalence of CP was reported as 4.4 per 1000 live births (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). Patients may encounter many problems commonly seen in this disease, e.g., intellectual disability, behavioral disorders, epilepsy, somatosensation disability, visual and auditory disorders, orthopedic deformities, gastrointestinal and nutritional problems. The most common concomitant diseases were epilepsy, orthopedic problems, and growth retardation in our study population. More than half of patients who present to our study have severe motor dysfunction, which makes it difficult to move. Children with CP who had higher levels of motor dysfunction (level 4 and 5) were more likely to be overdue immunizations. A study from Canada (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e) showed that children with moderate to severe disabilities are less likely than those with a mild disability to have received a basic series of immunizations. Similarities in this study and those observed associations between severe motor dysfunction and vaccination prompted us to investigate the potential role of the immunization status of this disease. In our study, the vaccination rate of hepatitis B, BCG, DTaP-IPV-Hib, OPV, and MMR was statistically significantly lower in patients with severe motor dysfunction. The clinical picture of the association between low vaccination rate and severe motor dysfunction is most likely a result of a complex interplay between direct and indirect effects of CP. It may be that this group of children have an ongoing severe chronic illness resulting in frequent hospitalizations delaying age-appropriate immunizations or that the high level of care required may limit the time available for immunization appointments. Or, vaccines may have been neglected because the physicians who follow patients are concerned with other medical problems. Despite our results, Greenwood et al. demonstrated no association with motor dysfunction level and vaccination rate (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). They discussed that the results may have been influenced by survival bias as most children who died were severe motor dysfunction, and the immunization records for these children had been removed from their national database.\u003c/p\u003e\u003cp\u003eBarriers to vaccination of patients with CP are familial factors and false contraindications of both parents and healthcare professionals. The most important reason for incomplete vaccination in our study was due to primary school vaccination in children. Therefore, we think that the administration of primary school vaccinations from primary care physicians and the development of a catch-up vaccination schedule for those patients without an age-appropriate vaccination will be of great benefit in protecting against diseases and increasing the quality of life in children with CP. One study concluded that some parents may be concerned that the possible adverse outcomes of immunizations may outweigh the potential benefits, such as increasing frequency of seizures and a small proportion of parents may believe that immunizations contributed or caused their child\u0026rsquo;s disability (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). These concerns were rarely mentioned by the parents of our patients.\u003c/p\u003e"},{"header":"Conclusion","content":" \u003cp\u003eAlthough the management of CP is not curative, it is a disease in which the quality of life of patients and their relatives can be increased with an appropriate approach. One of the most important approaches to achieve increasing the quality of life is the prevention and control of infections, including vaccination. This study demonstrates that children with CP have a high risk of incomplete and delayed immunization, a significant concern given to their increased healthcare needs and vulnerability to infectious diseases. Consequently, providing information to parents and clinicians following these patients on influenza and other vaccination practices are important, not only for the vaccination of these children but also of their parents. And also, the clinician must be aware of immunization status both in outpatients and inpatients of children with CP. Investigations can include immunization cards, and awareness to none/incomplete vaccination both including and excluding NIP. Only in this way will it be possible to increase the rates of vaccination in the CP population.\u003c/p\u003e "},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eHavers F, Fry AM, Chen J et al. Hospitalizations Attributable to Respiratory Infections among Children with Neurologic Disorders. J Pediatr. 2016 Mar;170:135-41.e1-5. doi: 10.1016/j.jpeds.2015.11.030. Epub 2015 Dec 11. PMID: 26687576.\u003c/li\u003e\n\u003cli\u003eCampbell AJP, Grohskopf LA. Updates on Influenza Vaccination in Children. Infect Dis Clin North Am. 2018;32(1):75\u0026ndash;89.\u003c/li\u003e\n\u003cli\u003ePandolfi E, Graziani MC, Ieraci R et al. A comparison of populations vaccinated in a public service and in a private hospital setting in the same area. BMC Public Health. 2008;8:278.\u003c/li\u003e\n\u003cli\u003eTillmann BU, Tillmann HC, Heininger U et al. Acceptance and timeliness of standard vaccination in children with chronic neurological deficits in north-western Switzerland. Eur J Pediatr. 2005 May;164(5):320-5.\u003c/li\u003e\n\u003cli\u003eDinleyici M, Carman KB, Kilic O et al. The immunization status of children with chronic neurological disease and serological assessment of vaccine-preventable diseases. Hum Vaccin Immunother. 2018;14(8):1970-1976.\u003c/li\u003e\n\u003cli\u003eGasparini R, Panatto D, Lai PL et al. The \u0026ldquo;urban myth\u0026rdquo; of the association between neurological disorders and vaccinations. J Prev Med Hyg. 2015 Jun 10;56(1):E1\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eRosenbaum P. , Paneth N., Leviton A .et al. A report: the definition and classification of cerebral palsy April 2006. Dev Med Child Neurol. 2007; 49: 8-14\u003c/li\u003e\n\u003cli\u003ePalisano R., Rosenbaum P., Walter S et al. Development and reliability of a system to classify gross motor function in children with cerebral palsy. Dev Med Child Neurol. 1997; 39: 214-223.\u003c/li\u003e\n\u003cli\u003eTervo RC, Taylor B. Vaccinations and the physically handicapped child. CMAJ 1982; 127: 475\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003eGreenwood VJ, Crawford NW, Walstab JE et al.Immunisation coverage in children with cerebral palsy compared with the general population. J Paediatr Child Health. 2013 Feb;49(2):E137-41.\u003c/li\u003e\n\u003cli\u003eBlair E, Langdon K, McIntyre S et al. Survival and mortality in cerebral palsy: observations to the sixth decade from a data linkage study of a total population register and National Death Index. BMC Neurol. 2019 Jun 4;19(1):111.\u003c/li\u003e\n\u003cli\u003e\u003ca href=\"https://www.who.int/immunization/monitoring_surveillance/data/tur.pdf\"\u003ehttps://www.who.int/immunization/monitoring_surveillance/data/tur.pdf\u003c/a\u003e (access date 11.05.2020).\u003c/li\u003e\n\u003cli\u003ePrevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices (ACIP)\u0026mdash;United States, 2020-21 Summary of Recommendations . https://www.cdc.gov/flu/professionals/acip/summary/summary-recommendations.htm\u003c/li\u003e\n\u003cli\u003eKeren R, Zaoutis TE, Bridges CB et al. Neurological and neuromuscular disease as a risk factor for respiratory failure in children hospitalized with influenza infection. JAMA. 2005 Nov 2;294(17):2188-94.\u003c/li\u003e\n\u003cli\u003eWong KK, Jain S, Blanton L et al.Influenza-associated pediatric deaths in the United States, 2004-2012. Pediatrics. 2013 Nov;132(5):796-804.\u003c/li\u003e\n\u003cli\u003eGill PJ, Ashdown HF, Wang K et al.Identification of children at risk of influenza-related complications in primary and ambulatory care: a systematic review and meta-analysis. Lancet Respir Med. 2015 Feb;3(2):139-149.\u003c/li\u003e\n\u003cli\u003ePandolfi E, Carloni E, Marino MG et al. Immunization coverage and timeliness of vaccination in Italian children with chronic diseases. Vaccine. 2012 Jul 20;30(34):5172-8.\u003c/li\u003e\n\u003cli\u003eHavers FP, Fry AM, Peacock G et al. Influenza Vaccination Coverage in Children With Neurologic Disorders and Their Siblings, July 2006 to June 2014. Pediatr Infect Dis J. 2018 Aug;37(8):814-816.\u003c/li\u003e\n\u003cli\u003eBax M, Goldstein M, Rosenbaum P et al.Executive Committee for the Definition of Cerebral Palsy. Proposed definition and classification of cerebral palsy, April 2005. Dev Med Child Neurol. 2005 Aug;47(8):571-6.\u003c/li\u003e\n\u003cli\u003eSerdaroğlu A, Cansu A, Ozkan S et al. Prevalence of cerebral palsy in Turkish children between the ages of 2 and 16 years. Dev Med Child Neurol. 2006 Jun;48(6):413-6.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style='font-family: \"Times New Roman\", serif; color: rgb(0, 0, 0);'\u003eTable 1. Etiology and characteristics of cerebral palsy\u003c/span\u003e\u003c/p\u003e\n\u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003ctable style=\"width:460.5pt;margin-left:-5.4pt;border-collapse:collapse;border:none;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189.45pt;border-top: 1pt solid windowtext;border-left: none;border-bottom: 1pt solid windowtext;border-right: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cstrong\u003e\u003cspan style='line-height:115%;font-family:\"Times New Roman\",serif;'\u003eEtiology\u003c/span\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cspan style='font-size:19px;line-height:115%;font-family:\"Times New Roman\",serif;'\u003e*\u003c/span\u003e\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117.55pt;border-top: 1pt solid windowtext;border-left: none;border-bottom: 1pt solid windowtext;border-right: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003en\u003c/span\u003e\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 153.5pt;border-top: 1pt solid windowtext;border-left: none;border-bottom: 1pt solid windowtext;border-right: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e%\u003c/span\u003e\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189.45pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family: \"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Asphyxia\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117.55pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e474\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 153.5pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e39.7\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189.45pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family: \"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Prematurity\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117.55pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e473\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 153.5pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e39.6\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189.45pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family: \"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Structural abnormalities\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117.55pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e81\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 153.5pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e6.8\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189.45pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family: \"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Intracranial hemorrhage\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117.55pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e76\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 153.5pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e6.4\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189.45pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family: \"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Metabolic encephalopathy\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117.55pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e58\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 153.5pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e4.9\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189.45pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family: \"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Multiple births\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117.55pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e53\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 153.5pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e4.4\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189.45pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family: \"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Meningitis encephalitis sequela\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117.55pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e38\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 153.5pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e3.2\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189.45pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family: \"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Head injury\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117.55pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e22\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 153.5pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e1.8\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189.45pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family: \"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Intrauterine infections\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117.55pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e13\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 153.5pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e1.1\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189.45pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family: \"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Others\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117.55pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e18\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 153.5pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e1.5\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189.45pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family: \"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Unknown origin\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117.55pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e96\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 153.5pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e8.0\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189.45pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003eClinical category\u003c/span\u003e\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117.55pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 153.5pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189.45pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family: \"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Spastic\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117.55pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e996\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 153.5pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e83.4\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189.45pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family: \"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; Atonic\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117.55pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e54\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 153.5pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e4.5\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189.45pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family: \"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; Dyskinetic\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117.55pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e40\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 153.5pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e3.4\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189.45pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family: \"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; Mixed\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117.55pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e56\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 153.5pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e4.7\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189.45pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family: \"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; Missing data\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117.55pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e48\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 153.5pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e4.0\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189.45pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003eTopography\u003c/span\u003e\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117.55pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 153.5pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189.45pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family: \"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; Quadriplegic\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117.55pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e349\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 153.5pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e29.2\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189.45pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family: \"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; Hemiplegic\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117.55pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e206\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 153.5pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e17.3\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189.45pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family: \"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; Paraplegic\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117.55pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e138\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 153.5pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e11.6\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189.45pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family: \"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Diplegic\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117.55pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e84\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 153.5pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e7.0\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189.45pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family: \"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; Monoplegic\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117.55pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e6\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 153.5pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e0.5\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189.45pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family: \"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; Missing data\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117.55pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e411\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 153.5pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e35\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189.45pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003eGross motor dysfunction\u003c/span\u003e\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117.55pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 153.5pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189.45pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family: \"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Level 5\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117.55pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e503\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 153.5pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e42.1\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189.45pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family: \"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Level 4\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117.55pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e140\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 153.5pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e11.7\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189.45pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family: \"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Level 3\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117.55pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e184\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 153.5pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e15.4\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189.45pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family: \"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Level 2\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117.55pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e181\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 153.5pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e15.2\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189.45pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family: \"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Level 1\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117.55pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e115\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 153.5pt;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e9.6\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 189.45pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family: \"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; Missing data\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 117.55pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e71\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 153.5pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:115%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e5.9\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e*Some patients may have more than one cause\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size:19px;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size:19px;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size:19px;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size:19px;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size:19px;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size:19px;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size:19px;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size:19px;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size:19px;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size:19px;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003eTable 2. Demographical and clinical characteristics of patients with CP\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style=\"font-size:19px;\"\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003ctable style=\"border-collapse:collapse;border:none;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 260.55pt;border-top: 1pt solid windowtext;border-left: none;border-bottom: 1pt solid windowtext;border-right: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003eCharacteristics\u003c/span\u003e\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 155.95pt;border-top: 1pt solid windowtext;border-left: none;border-bottom: 1pt solid windowtext;border-right: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family: \"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 260.55pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family: \"Times New Roman\",serif;'\u003eAge\u003csup\u003ea\u003c/sup\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 155.95pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e93.9 \u0026plusmn; 57.6\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 260.55pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family: \"Times New Roman\",serif;'\u003eGender (male)\u003csup\u003eb\u003c/sup\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 155.95pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e689 (57.7)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 260.55pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family: \"Times New Roman\",serif;'\u003eConcomitant diseases\u003csup\u003eb\u003c/sup\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 155.95pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e959 (80.3)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 260.55pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family: \"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;epilepsy\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 155.95pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e671 (56.2)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 260.55pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family: \"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;orthopedic problems\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 155.95pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e500 (41.9)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 260.55pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family: \"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;growth retardation\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 155.95pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e348 (29.1)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 260.55pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family: \"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;visual disorders\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 155.95pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e182 (15.2)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 260.55pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family: \"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;recurrent pneumonia\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 155.95pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e116 (9.7)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 260.55pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family: \"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;auditory disorders\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 155.95pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e33 (2.8)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 260.55pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family: \"Times New Roman\",serif;'\u003eUsing medications\u003csup\u003eb\u003c/sup\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 155.95pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e763 (63.9)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 260.55pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family: \"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; antiepileptics\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 155.95pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e528 (44.2)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 260.55pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family: \"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; antiepileptics + muscle relaxants\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 155.95pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e105 (8.8)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 260.55pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family: \"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; muscle relaxants\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 155.95pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e81 (6.8)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 260.55pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family: \"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; antipsychotics\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 155.95pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e13 (1.1)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 260.55pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family: \"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; antiepileptics + antipsychotics\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 155.95pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e11 (0.9)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 260.55pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family: \"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; muscle relaxants + antipsychotics\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 155.95pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e4 (0.3)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 260.55pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family: \"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; antiepileptics + muscle relaxants + antipsychotics\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 155.95pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e2 (0.2)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 260.55pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family: \"Times New Roman\",serif;'\u003e\u0026nbsp; \u0026nbsp; others\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 155.95pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e19 (1.6)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 260.55pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family: \"Times New Roman\",serif;'\u003eHospitalization in the last year\u003csup\u003eb\u003c/sup\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 155.95pt;border: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e342 (28.6)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 260.55pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family: \"Times New Roman\",serif;'\u003eHospitalization in the last year due to pneumonia\u003csup\u003eb\u003c/sup\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 155.95pt;border-top: none;border-right: none;border-left: none;border-image: initial;border-bottom: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e178 (14.9)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003csup\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;'\u003ea\u0026nbsp;\u003c/span\u003e\u003c/sup\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;'\u003eValues were given as mean \u0026plusmn; SD, \u003csup\u003eb\u003c/sup\u003eValues were give as percentage\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-size:13px;font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003eTable 3. Age-appropriate vaccination according to the National Immunization programme\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e\u0026nbsp;\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n\u003ctable style=\"border-collapse:collapse;border:none;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 115.15pt;border: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003eVaccines\u003c/span\u003e\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115.15pt;border-top: 1pt solid windowtext;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-image: initial;border-left: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003eCompleted\u003c/span\u003e\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115.15pt;border-top: 1pt solid windowtext;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-image: initial;border-left: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003eIncomplete\u003c/span\u003e\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115.15pt;border-top: 1pt solid windowtext;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-image: initial;border-left: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cstrong\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003eNone\u003c/span\u003e\u003c/strong\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 115.15pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family: \"Times New Roman\",serif;'\u003eHepatitis B\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115.15pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e1062 (88.9)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115.15pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e41 (3.4)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115.15pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e91 (7.6)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 115.15pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family: \"Times New Roman\",serif;'\u003eBCG\u003csup\u003ea\u003c/sup\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115.15pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e1084 (90.8)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115.15pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e-\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115.15pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e110 89.2)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 115.15pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family: \"Times New Roman\",serif;'\u003eDTaP-IPV-Hib\u003csup\u003eb\u003c/sup\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115.15pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e722 (60.5)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115.15pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e379 (31.7)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115.15pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e93 (7.8)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 115.15pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family: \"Times New Roman\",serif;'\u003eOPV\u003csup\u003ec\u003c/sup\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115.15pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e1057 (88.5)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115.15pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e26 (2.2)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115.15pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e111 (9.3)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 115.15pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family: \"Times New Roman\",serif;'\u003ePneumococcus\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115.15pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e646 (54.1)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115.15pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e181 (15.2)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115.15pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e367 (30.8)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 115.15pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family: \"Times New Roman\",serif;'\u003eMMR\u003csup\u003ed\u003c/sup\u003e\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115.15pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e923 (77.3)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115.15pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e111 (9.3)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115.15pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e160 (13.4)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 115.15pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family: \"Times New Roman\",serif;'\u003eVaricella\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115.15pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e583 (48.8)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115.15pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e-\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115.15pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e611 (51.1)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 115.15pt;border-right: 1pt solid windowtext;border-bottom: 1pt solid windowtext;border-left: 1pt solid windowtext;border-image: initial;border-top: none;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family: \"Times New Roman\",serif;'\u003eHepatitis A\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115.15pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e492 (41.2)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115.15pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e52 (4.4)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 115.15pt;border-top: none;border-left: none;border-bottom: 1pt solid windowtext;border-right: 1pt solid windowtext;padding: 0in 5.4pt;vertical-align: top;\"\u003e\n \u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;text-align:center;line-height:150%;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003cspan style='font-family:\"Times New Roman\",serif;'\u003e650 (54.4)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp style='margin:0in;font-size:16px;font-family:\"Calibri\",sans-serif;'\u003e\u003cspan style=\"color: rgb(0, 0, 0);\"\u003e\u003csup\u003e\u003cspan style='font-size: 13px; font-family: \"Times New Roman\", serif;'\u003ea\u003c/span\u003e\u003c/sup\u003e\u003c/span\u003e\u003cspan style='font-size: 13px; font-family: \"Times New Roman\", serif; color: rgb(0, 0, 0);'\u003eBacillus Calmette-Guerin, \u003csup\u003eb\u003c/sup\u003eDiphtheria, Tetanus, acellular Pertussis - Inactivated Polio vaccine - Haemophilus influenzae type B, \u003csup\u003ec\u003c/sup\u003eoral polio vaccine, \u003csup\u003ed\u003c/sup\u003emeasles-mumps-rubella\u003c/span\u003e\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejpe","sideBox":"Learn more about [European Journal of Pediatrics](https://www.springer.com/journal/431)","snPcode":"431","submissionUrl":"https://submission.nature.com/new-submission/431/3","title":"European Journal of Pediatrics","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"cerebral palsy, vaccine, influenza","lastPublishedDoi":"10.21203/rs.3.rs-288533/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-288533/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eChildren with chronic neurological diseases,including cerebral palsy(CP)are especially susceptible to vaccine-preventable infections and face an increased risk of severe respiratory infections and decompensation of their disease.This study aims to examine age-appropriate immunization status and related factors in the CP population of our country.\u003c/p\u003e \u003cp\u003eThis cross-sectional prospective multicentered survey study included 18 pediatric neurology clinics around Turkey,wherein outpatients children with CP were included in the study.Data on patient and CP characteristics,concomitant disorders as well as vaccination status included in the National Immunization Program(NIP),administration and recommendation of influenza vaccine were collected at a single visit.\u003c/p\u003e \u003cp\u003eA total of 1194 patients were enrolled.Regarding immunization records,the most frequently administrated and schedule completed vaccines were BCG(90.8%),hepatitis B(88.9%)and oral poliovirus vaccine (88.5%).MMR was administered to 77.3% and DTaP-IPV-HiB was administered to 60.5% of patients.For the pneumococcal vaccines,54.1% of children had received PCV in the scope of the NIP, and 15.2% of children were not fully vaccinated for their age.The influenza vaccine, was administered only to 3.4% of the patients at any time and had never been recommended to 1122 parents(93.9%).In the patients with severe(grade 4 and 5)motor dysfunction,the frequency of incomplete/none vaccination of hepatitis B,BCG, DTaP-IPV-HiB,OPV,MMR were statistically more common than mild to moderate(grade 1\u0026ndash;3)motor dysfunction(p\u0026thinsp;=\u0026thinsp;0.003, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, p\u0026thinsp;\u0026lt;\u0026thinsp;0.00, and p\u0026thinsp;\u0026lt;\u0026thinsp;0.001, respectively).Influenza vaccine recommendation by physicians was higher in the severe motor dysfunction group and the difference was statistically significant(p\u0026thinsp;=\u0026thinsp;0.029).\u003c/p\u003e \u003cp\u003eChildren with CP had lower immunization rates and incomplete immunization programs.Clinicians must ensure children with CP receive the same preventative health measures as healthy children,including vaccines.\u003c/p\u003e","manuscriptTitle":"Evaluation of Immunization Status in Patients with Cerebral Palsy: Multicenter CP-VACC Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2021-03-22 19:16:23","doi":"10.21203/rs.3.rs-288533/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2021-03-20T00:00:00+00:00","index":0,"fulltext":""},{"type":"editorAssigned","content":"","date":"2021-03-13T00:00:00+00:00","index":"","fulltext":""},{"type":"submitted","content":"European Journal of Pediatrics","date":"2021-03-01T07:07:48+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"european-journal-of-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ejpe","sideBox":"Learn more about [European Journal of Pediatrics](https://www.springer.com/journal/431)","snPcode":"431","submissionUrl":"https://submission.nature.com/new-submission/431/3","title":"European Journal of Pediatrics","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"30f8230d-3ba5-4313-b87c-64fcaf12a7c6","owner":[],"postedDate":"March 22nd, 2021","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":3144553,"name":"Pediatrics"}],"tags":[],"updatedAt":"2021-08-22T15:11:01+00:00","versionOfRecord":{"articleIdentity":"rs-288533","link":"https://doi.org/10.1007/s00431-021-04219-4","journal":{"identity":"european-journal-of-pediatrics","isVorOnly":false,"title":"European Journal of Pediatrics"},"publishedOn":"2021-08-05 15:01:37","publishedOnDateReadable":"August 5th, 2021"},"versionCreatedAt":"2021-03-22 19:16:23","video":"","vorDoi":"10.1007/s00431-021-04219-4","vorDoiUrl":"https://doi.org/10.1007/s00431-021-04219-4","workflowStages":[]},"version":"v1","identity":"rs-288533","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-288533","identity":"rs-288533","version":["v1"]},"buildId":"ehx78VzkSd0WSzXnipQa-","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}