Missed Opportunities: A Narrative Review on Why Nonoccupational Postexposure Prophylaxis for HIV Is Underutilized.

Postexposure prophylaxis (PEP) is an important tool for preventing HIV infection but remains underutilized. In this narrative review, we aim to summarize the frequency of missed opportunities for prescribing PEP among studies from around the world, discuss the complexities of the challenges facing PEP provision, and describe possible solutions. We identified 20 studies published in the last 10 years among 43 832 individuals, of whom an estimated 41 477 were eligible for PEP. Of those eligible for PEP, PEP was prescribed among 27 705 (66.8%). There was a significant difference in PEP prescriptions in acute compared with non-acute care settings (63.5% vs 94.5%; P < .001). Emergent themes contributing to PEP underutilization included lack of provider and patient awareness, reduced PEP acceptability, HIV stigma and homophobia, lack of access (either to care or to medication), and stigmatizing policies. Each of those issues should be the focus of future PEP implementation efforts.

Missed opportunities in the prevention and diagnosis of pediatric tuberculosis: a scoping review

Abstract Objectives: Identify potential barriers, delays, and missed opportunities in the prevention and diagnosis of childhood TB. Methods: Scoping review according to the PRISMA extension. The definitions considered for the selection followed the acronym PCC where the population (P) is children under 18years of age with TB disease, the concept (C) refers to missed opportunities for prevention and diagnosis, and context (C) is defined as a diagnosis of TB disease. The authors searched systematically in the databases; VHL/Lilacs, Medline via PubMed, Cochrane, Scopus, and Web of Science, without date or language limitation. Results: Seven studies were included. In developed countries, with low disease burden, the main shortcoming is the delay in diagnosing bacilliferous adults in contact with young children. This problem is concentrated in the portion of the population with socioeconomic vulnerability. In underdeveloped countries, with a high burden of disease, the biggest challenge is tracking children who come into contact with bacilliferous patients. Conclusions: There are still many missed opportunities in the prevention and diagnosis of childhood TB. The positive legacy of the COVID-19 pandemic should be taken advantage of and the encouragement of scientific development in the management of infectious diseases should be taken.

Timeliness of Childhood Vaccinations Following Strengthening of the Second Year of Life (2YL) Immunization Platform and Introduction of Catch-Up Vaccination Policy in Ghana.

Strengthening routine immunization systems to successfully deliver childhood vaccines during the second year of life (2YL) is critical for vaccine-preventable disease control. In Ghana, the 18-month visit provides opportunities to deliver the second dose of the measles-rubella vaccine (MR2) and for healthcare workers to assess for and provide children with any missed vaccine doses. In 2016, the Ghana Health Service (GHS) revised its national immunization policies to include guidelines for catch-up vaccinations. This study assessed the change in the timely receipt of vaccinations per Ghana's Expanded Program on Immunizations (EPI) schedule, an important indicator of service quality, following the introduction of the catch-up policy and implementation of a multifaceted intervention package. Vaccination coverage was assessed from household surveys conducted in the Greater Accra, Northern, and Volta regions for 392 and 931 children aged 24-35 months with documented immunization history in 2016 and 2020, respectively. Age at receipt of childhood vaccines was compared to the recommended age, as per the EPI schedule. Cumulative days under-vaccinated during the first 24 months of life for each recommended dose were assessed. Multivariable Cox regression was used to assess the associations between child and caregiver characteristics and time to MR2 vaccination. From 2016 to 2020, the proportion of children receiving all recommended doses on schedule generally improved, the duration of under-vaccination was shortened for most doses, and higher coverage rates were achieved at earlier ages for the MR series. More timely infant doses and caregiver awareness of the 2YL visit were positively associated with MR2 vaccination. Fostering a well-supported cadre of vaccinators, building community demand for 2YL vaccination, sustaining service utilization through strengthened defaulter tracking and caregiver-reminder systems, and creating a favorable policy environment that promotes vaccination over the life course are critical to improving the timeliness of childhood vaccinations.

HCV Cascade of Care in HIV/HCV Co-Infected Individuals: Missed Opportunities for Micro-Elimination.

People living with HIV-HCV co-infection comprise a target group for HCV-micro-elimination. We conducted an HCV cascade of care (CoC) for HIV-HCV co-infected individuals living in Greece and investigated factors associated with different HCV-CoC stages. We analyzed data from 1213 participants from the Athens Multicenter AIDS Cohort Study. A seven-stage CoC, overall and by subgroup (people who inject drugs (PWID), men having sex with men (MSM), men having sex with women (MSW), and migrants], was constructed, spanning from HCV diagnosis to sustained virologic response (SVR). Logistic/Cox regression models were employed to identify factors associated with passing through each CoC step. Among 1213 anti-HCV-positive individuals, 9.2% died before direct-acting antiviral (DAA) availability. PWID exhibited higher mortality rates than MSM. Of 1101 survivors, 72.2% remained in care and underwent HCV-RNA testing. Migrants and PWID showed the lowest retention rates. HCV-RNA was available for 79.2% of those in care, with 77.8% diagnosed with chronic HCV. Subsequently, 71% initiated DAAs, with individuals with very low CD4 counts (<100 cells/µL) exhibiting lower odds of DAA initiation. SVR testing was available for 203 individuals, with 85.7% achieving SVR. The SVR rates did not differ across risk groups. In 2023, significant gaps and between-group differences persisted in HCV-CoC among HIV-HCV co-infected individuals in Greece.

Implementation of the vaccination program in Guinea-Bissau: Coverage and missed opportunities for BCG at birth.

BACKGROUND: The Bacillus Calmette-Guérin (BCG) vaccine is recommended at birth in Guinea-Bissau but often given with delay. Delays are not evident in routine coverage estimates since coverage is measured by 12 months of age. Studies show that BCG protects against other infections than tuberculosis and lowers neonatal mortality. Hence, the timing of BCG is important since the children should benefit from these non-specific effects as early as possible. METHODS: Using data from a nationally representative health and demographic surveillance system in Guinea-Bissau, we assessed BCG coverage at birth (within the first 3 days of life), 1 month, and 12 months for children born in 2013-19. We measured the proportion of children who had a documented health system contact within the first 3 days of life, thus an opportunity for BCG at birth, and whether the opportunities were utilized. In binomial regression models, we investigated factors associated with missed opportunities for vaccination. RESULTS: Among the 22,178 children only 19 % were vaccinated at birth. By 1 month and 12 months, BCG coverages were 64 % and 93 %. The timeliness of BCG improved over time, with coverage at birth increasing from 16 % in 2013 to 25 % in 2019 and 1-month coverage from 63 % in 2013 to 75 % in 2019. If all vaccination opportunities had been utilized, the BCG coverage at birth could have reached 45 % (in the 1-month cohort) instead of the actual coverage of 19 %, as only 40 % of the vaccination opportunities were utilized. Region of residence was associated with having a missed opportunity for vaccination. CONCLUSION: The high coverage estimates at 12 months falsely imply that the vaccine is being administered according to the recommended schedule. Our findings suggest that early coverage could be markedly improved by ensuring that children are vaccinated at their first contact with the health system.

Missed opportunities for human papillomavirus vaccination using Iowa's Immunization Registry Information System.

PURPOSE: Adolescent human papillomavirus (HPV) vaccination rates continue to remain lower than other adolescent vaccines, both nationwide and in Iowa. This study examined predictors of missed opportunities for first-dose HPV vaccine administrations in Iowa in order to conduct more targeted outreach and improve adolescent HPV vaccine uptake. METHODS: A retrospective study was conducted to identify predictors of missed opportunities for first-dose HPV vaccination in Iowa adolescents using Iowa's Immunization Registry Information System. The study population included 154,905 adolescents aged 11-15 years between 2019 and 2022. Missed opportunity for first-dose HPV vaccination was defined as a vaccination encounter where an adolescent received a Tdap and/or MenACWY vaccine but did not receive the first-dose HPV vaccine during the same encounter. FINDINGS: Over a third of the study population experienced a missed opportunity for HPV vaccination between 2019 and 2022. Missed opportunity for vaccination was most common among individuals living in a rural county (aOR = 1.36), underinsured adolescents (aOR = 1.74), males (aOR = 1.12), teens 13-15 years of age (aOR = 1.76), and White race and non-Hispanic ethnicity. CONCLUSION: This study builds on previously reported predictors of missed opportunity for HPV vaccination in adolescents. Increased understanding of provider needs and barriers to administering HPV vaccination and further analysis of how the Vaccines for Children Program can play a role in HPV vaccination uptake is necessary to improve HPV vaccination rates among adolescents in Iowa and more specifically in rural communities.

Late presentations and missed opportunities among newly diagnosed HIV patients presenting to a specialty clinic in Lebanon.

Late presentation to medical care of individuals infected with the human immunodeficiency virus (HIV) is linked to poor outcomes and increased morbidity and mortality. Missed opportunities for a prompt diagnosis are frequently reported among late presenters. We aimed to estimate the proportion of late presenters and missed opportunities in diagnosis among newly diagnosed HIV-positive subjects presenting to a specialty clinic in Lebanon. This is a retrospective chart review of all newly diagnosed adult HIV-positive subjects presenting to clinic from 2012 to 2022. Demographic, laboratory, and clinical data were collected at initial HIV diagnosis or presentation to medical care. We defined late presentation as having a CD4 count < 350 or AIDS-defining event regardless of CD4 count. Advanced disease is defined as having a CD4 count below 200 cells/µL or the presence of an AIDS-defining illness, regardless of the CD4 count. A missed opportunity was defined as the presence of an indicator condition (IC) that suggests infection with HIV/AIDS during 3 years preceding the actual HIV diagnosis and not followed by a recommendation for HIV testing. The proportions for demographic, epidemiological, and clinical characteristics are calculated by excluding cases with missing information from the denominator. Our cohort included 150 subjects (92.7% males; 63.6% men who have sex with men (MSM); 33.3% heterosexuals; median age 30.5 years at diagnosis). 77 (51.3%) were late presenters and 53 (35.3% of all subjects, 68.8% of late presenters) had advanced HIV on presentation. Up to 76.5% of late presenters had a presentation with an HIV-related condition at a healthcare provider without getting HIV test within the previous 3 years. The most frequent ICs were weight loss, generalized lymphadenopathy, constitutional symptoms, and chronic idiopathic diarrhea. Overall mortality rate was 4% (6/150 individuals). All-cause mortality among those who presented with AIDS was 15.4% (6/39 subjects). In our setting, late presentations and missed opportunities for HIV diagnosis are common. In the Middle East, AIDS mortality remains high with a large gap in HIV testing. To effectively influence policies, comprehensive analyses should focus on estimating the preventable health and financial burdens of late HIV presentations. Another concern pertains to healthcare providers' attitudes and competencies.

Missed opportunities in the prevention and diagnosis of pediatric tuberculosis: a scoping review.

OBJECTIVES: Identify potential barriers, delays, and missed opportunities in the prevention and diagnosis of childhood TB. METHODS: Scoping review according to the PRISMA extension. The definitions considered for the selection followed the acronym PCC where the population (P) is children under 18 years of age with TB disease, the concept (C) refers to missed opportunities for prevention and diagnosis, and context (C) is defined as a diagnosis of TB disease. The authors searched systematically in the databases; VHL/Lilacs, Medline via PubMed, Cochrane, Scopus, and Web of Science, without date or language limitation. RESULTS: Seven studies were included. In developed countries, with low disease burden, the main shortcoming is the delay in diagnosing bacilliferous adults in contact with young children. This problem is concentrated in the portion of the population with socioeconomic vulnerability. In underdeveloped countries, with a high burden of disease, the biggest challenge is tracking children who come into contact with bacilliferous patients. CONCLUSIONS: There are still many missed opportunities in the prevention and diagnosis of childhood TB. The positive legacy of the COVID-19 pandemic should be taken advantage of and the encouragement of scientific development in the management of infectious diseases should be taken.

Missed opportunities for HIV diagnosis among incarcerated people in the Federal District, Brasilia, Brazil

Objective. Evaluate the pattern of contact with the healthcare system, including prison health facilities, and HIV testing. Method. This was a quantitative case-control study of HIV infected and uninfected incarcerated people serving time in 2019 in the Federal District, matched by age. Results. There was no difference in the pattern of contact with the healthcare system or the pattern of testing between HIV-infected and uninfected incarcerated people. Most of the infected patients were diagnosed in the prison environment and had early infections, demonstrating the effectiveness of screening in this scenario. Conclusion: The pattern of contact with the healthcare system among the individuals in this study probably reflects that of young men in general, i.e., less contact with primary care outpatient services and trauma as the main reason for contact in emergency departments. 

Objetivo. Evaluar el patrón de contacto con el sistema sanitario, incluidos los centros sanitarios penitenciarios, y las pruebas del VIH. Método. Estudio cuantitativo de casos y controles de personas infectadas y no infectadas por el VIH que cumplían condena en 2019 en el Distrito Federal, emparejadas por edad. Resultados. No hubo diferencias en el patrón de contacto con el sistema de salud ni en el patrón de realización de pruebas entre personas encarceladas infectadas y no infectadas por VIH. La mayoría de los pacientes infectados fueron diagnosticados en el medio penitenciario y presentaron infecciones precoces, lo que demuestra la eficacia del cribado en este escenario. Conclusiones. El patrón de contacto con el sistema sanitario entre los individuos de este estudio probablemente refleja el de los hombres jóvenes en general, es decir, menor contacto con los servicios ambulatorios de atención primaria y traumatismos como principal motivo de contacto en los servicios de urgencias. 

Objetivo. O estudo avaliou o padrão de contato com o sistema de saúde e de testagem para HIV, incluindo as unidades de saúde prisionais.  Métodos. Trata-se de estudo quantitativo de caso-controle em detentos que cumpriam pena em 2019 no Distrito Federal, pareados por idade. Resultados. Não houve diferença no padrão de contato com o sistema de saúde e padrão de oferta de testagem entre detentos infectados ou não com HIV. A maior parte dos infectados teve o diagnóstico realizado no ambiente prisional e de maneira precoce, evidenciando efetividade do rastreamento nesse cenário. Conclusão. O padrão de contato com o sistema de saúde dos indivíduos neste estudo reflete provavelmente o de homens jovens como um todo: pouco contato com serviços ambulatoriais de atenção primária e trauma como principal motivo de contato, em prontos-socorros.  

Analysing Early Diagnosis Strategies for HIV Infection: A Retrospective Study of Missed Diagnostic Opportunities.

Early diagnosis of a Human Immunodeficiency Virus (HIV)-infected person represents a cornerstone of HIV prevention, treatment, and care. Numerous publications have developed recommendations where HIV serology is indicated to reduce missed diagnostic opportunities (MDOs). This retrospective study analyses new HIV infection diagnoses and the relationship between late diagnosis (LD)/advanced HIV disease (AHD), baseline characteristics, and MDOs. Sociodemographic data and data related to contact with the health system in the 5 years before diagnosis were collected. Most of the 273 diagnoses were made in primary care (48.5%). Approximately 50.5% and 34.4% had LD and AHD criteria, respectively. Female sex was associated with a higher incidence of LD. Persons infected through the heterosexual route and those at an older age had a higher risk for LD and AHD. People with previous HIV serology presented a lower percentage of LD and AHD. In total, 10% of the health contact instances were classified as MDOs, mostly occurring in primary care. A significant increase in the median of MDOs was observed in patients with LD/AHD. Female sex and hepatitis C virus co-infection were associated with an increase in the number of MDOs. The high percentage of LD and AHD and the significant number of MDOs show that the current screening system should be improved.

Missed Opportunities in Type 2 Diabetes Mellitus: A Narrative Review.

BACKGROUND: Type 2 diabetes mellitus (T2DM) is a significant health problem around the world. OBJECTIVE: This review aims to define missed opportunities and how they apply to patients with T2DM. METHOD: This narrative review describes the natural history of T2DM and also describes where missed opportunities may arise. RESULTS: Missed opportunities may relate to prevention, early detection, diagnosis, and treatment of diabetes. The cornerstone of T2DM prevention is the control of modifiable risk factors and lifestyle changes to potentially prevent diabetes. Early detection of T2DM is important as it is a chronic condition that can progress rapidly if untreated. Missed opportunities related to the diagnosis of T2DM draw attention to the heterogeneous presentation of diabetes. The condition can be incidentally identified in asymptomatic patients, so all healthcare professionals should be aware of the disease. Furthermore, it is not unexpected that patients with atypical symptoms may have a delay in diagnosis. The treatment-related missed opportunities in T2DM are broad and include self-care, education, remission of T2DM, risk factor management, prevention of complications, medication therapy and compliance, as well as individualized care. Considering patient pathways is a useful approach to evaluate missed opportunities in patient care. CONCLUSION: Missed opportunities are a concept that is not often considered in diabetes care, which calls upon reflection of real-world activities and consideration of whether patient outcomes could have been improved with changes in decision-making. Future studies that aim to improve patient care should consider this concept.

Trends in Vaccine Completeness in Children Aged 0-23 Months in Cape Town, South Africa.

BACKGROUND: We have previously determined that the occurrence of missed vaccination opportunities in children in Cape Town, South Africa, is shaped by both individual and contextual factors. These factors present valuable openings for enhancing quality and implementing broader strategies to enhance the delivery of routine Immunisation services. METHODS: Here, we are further reporting regional-level data on the coverage and factors influencing vaccination completion within a similar study population, based on extensive data analysis from the 2016 South African Demographic and Health Survey. RESULTS AND DISCUSSION: The study reveals commendable vaccination coverage for most vaccines within recommended schedules, with high rates of initial vaccinations at birth and during the primary vaccination schedule. However, there are notable areas for improvement, particularly in ensuring complete coverage for the second measles vaccine and the 18-month vaccine. Socio-demographic factors also play a role, with maternal education and caregiver awareness campaigns showing the potential to positively influence vaccination completeness. This study emphasises the importance of timely vaccinations during the early months of life and underscores the need for interventions to maintain coverage as children age. Specific sub-districts, such as Tygerberg, may require targeted efforts to enhance vaccination completeness. Additionally, assessing caregiver knowledge about child vaccination is deemed vital, as it can impact vaccination decisions and adherence. CONCLUSIONS: The findings provide valuable insights for public health interventions in Cape Town, aimed at reducing the burden of vaccine-preventable diseases and ensuring the health of the region's youngest population.

Missed opportunities for vaccination at point of care and their impact on coverage and urban-rural coverage inequity in the Gambia.

INTRODUCTION: Identifying actionable targets is crucial to improve overall and equity in vaccination coverage, and in line with the global Immunization Agenda 2030. Therefore, this study seeks to assess the prevalence of missed opportunities for simultaneous vaccination (MOSVs) and their impact on vaccination coverage and urban-rural inequity in The Gambia. METHODS: We used data of children aged 12-23 months from The Gambia 2019/2020 demographic and health survey (weighted n = 1355) with seen vaccination cards. We analyzed: the frequency of MOSVs; percentage point coverage reduction attributable to MOSVs for 18 vaccine doses and full basic vaccination; and MOSVs' contribution to urban-rural coverage inequity through Blinder-Oaxaca decomposition. RESULTS: Sixty percent of children experienced MOSVs, in both urban and rural areas, but urban MOSVs were more seldom corrected (35.9 % vs 45.3 %). All eighteen vaccine doses assessed could have achieved between one to eleven percentage points higher coverage if MOSVs had been avoided, with full basic vaccination gaining even more. While MOSV correction did not impact overall urban-rural coverage inequity, it did exacerbate (explained coefficient = -0.1007; P = 0.002) inequities among children who experienced MOSVs, explaining 95 % of the observed difference. CONCLUSION: Our study highlights the prevalence and negative impact of MOSVs on overall vaccination coverage. Although MOSVs did not contribute significantly to the total urban-rural inequity in coverage, they have detrimental effects on vaccination coverage and urban-rural inequity among children who had experienced MOSVs. Addressing MOSVs, can enhance coverage and reduce the risk of under-vaccination, aligning with global initiatives.

Missed opportunities in the diagnosis of heart failure: a real-world assessment.

AIMS: Heart failure (HF) is a leading cause of hospitalization worldwide. An early HF diagnosis is key to reducing hospitalizations. We used electronic health records (EHRs) to characterize HF pathways at the primary care physician (PCP) level prior to a first HF hospitalization (hHF). This study aimed to identify missed opportunities for HF diagnosis and management at the PCP level before a first hHF. METHODS AND RESULTS: This cohort study used EHRs of a large health care organization in Portugal. Patients with incident hHF between 2017 and 2020 were identified. Missed opportunities were defined by the absence of any of the following work-up in the 6 months after signs or symptoms had been recorded: lab results and electrocardiogram, natriuretic peptides, echocardiogram, referral to HF specialist, or HF medication initiation. A total of 2436 patients with a first hHF were identified. The median (interquartile range) age at the time of hospitalization was 81 (14) years, and 1361 (56%) were women. Most patients were treated with cardiovascular drugs prior or at index event. A total of 720 (30%) patients had records of HF signs or symptoms, 94% (n = 674) within 6 months prior to hHF. Among patients with recorded HF signs or symptoms, 410 (57%) had clinical management considered adequate before signs and symptoms were recorded. Of the 310 remaining patients, 155 (50%) had a follow-up that was considered inadequate. CONCLUSIONS: Relatively few patients with a first hHF had primary care records of signs or symptoms prior to admission. Of these, nearly half had inadequate management considering diagnosis and treatment. These data suggest the need to improve PCP HF awareness.

HIV and HCV screening by non-infectious diseases physicians: can we improve testing and hidden infection rates?

Background: Missed opportunities for Human Immunodeficiency Virus (HIV) and Hepatitis C Virus (HCV) testing remain high. We aimed to ascertain the knowledge of screening guidelines and attitudes of non-infectious disease (ID) hospital physicians and assess the impact of a 1-h session on screening rates and diagnoses. Methods: This interventional study consisted of a 1-h training session on HIV and HCV epidemiology and testing guidelines for non-ID physicians. Pre-and post-session questionnaires compared the knowledge of the guidelines and attitudes toward screening before and after the session. Rates of screening and diagnoses were compared in three 6 months periods: before, immediately after, and 24 months ±4 after the session. Results: A total of 345 physicians from 31 departments participated in these sessions. Before the session, 19.9% (28% medical, 8% surgical) and 17.9% (30% medical, 2.7% surgical) were aware of HIV and HCV testing guidelines, respectively. The willingness to routinely test increased from 5.6 to 22%, whereas not ordering tests decreased from 34.1 to 2.4%. HIV screening rates significantly increased by 20% after the session (7.7 vs. 9.3 tests per 103 patients; p < 0.001), and the effect persisted until the long-term period. The HIV diagnosis rate increased globally (3.6 vs. 5.2 HIV diagnoses per 105 patients; p = 0.157), mainly because of medical services (4.7 vs. 7.7 per 105 patients; p = 0.082). The HCV screening rate increased significantly immediately and in the long term only in medical services (15.7 and 13.6%, respectively). The new active HCV infection rates increased immediately and declined steeply thereafter. Conclusion: A short session for non-ID physicians can improve HIV/HCV screening, increase diagnosis, and contribute to disease elimination.

Missed Opportunities for Adolescent Immunizations at Well-Care Visits During the COVID-19 Pandemic.

PURPOSE: The Coronavirus Disease 2019 pandemic disrupted healthcare, but the impact on vaccination missed opportunities (MOs, vaccine-eligible visits without vaccination) is unknown. We evaluated pandemic-related trends in MOs at adolescent well-care visits for three vaccines: human papillomavirus; quadrivalent meningococcal conjugate; and tetanus, diphtheria, and acellular pertussis (Tdap). METHODS: We analyzed electronic health record data from 24 pediatric primary care practices in 13 states from 1/1/2018 to 12/31/2021. Segmented logistic regression estimated risk differences for MOs during the pandemic relative to prepandemic trends. RESULTS: Among 106,605 well-care visits, we observed decreases in MOs prepandemic followed by an increase in MOs during the pandemic for all three vaccines. Relative to prepandemic, MOs increased for human papillomavirus (+15.9%, 95% confidence interval [CI]: 11.7%, 20.1%), meningococcal conjugate (+9.4%, 95% CI: 5.2%, 13.7%), and tetanus, diphtheria, and acellular pertussis (Tdap) (+ 8.2%, 95% CI: 4.3%, 12.1%). DISCUSSION: Increases in vaccine MOs during the pandemic equaled or exceeded pre-pandemic decreases. Reducing MOs in adolescent well-care could raise vaccine coverage.

Missed opportunities for immunization among children 0 to 11 months of age that were attended to at debre tabor comprehensive specialized hospital, south gondar zone, Ethiopia.

Background: The World Health Organization's Expanded Immunization Program was established in 1974 and aimed to provide vaccines to children all over the world. Since the inception of this program, numerous initiatives and campaigns have been launched, and millions of children around the world have been saved from death. Many vaccine-preventable diseases, however, remain prevalent in developing countries. This is because most of those countries have low immunization coverage for an unknown number of reasons. As a result, the goal of this study was to examine missed opportunities for immunization among children aged 0 to 11 months. Methods: A cross-sectional survey was carried out from May to August 2022. A structured questionnaire was used to collect data, and the sample was chosen using a simple random sampling technique. Before being entered into the Epidata and exported to the Statistical Package for Social Science for analysis, the data were checked for consistency and completeness. The statistical significance was determined using binary and multiple logistic regression analyses. The statistical level of significance was established at p ≤ 0.05. Result: In this study, 49.1% of immunization opportunities were missed. Education status [AOR = 2.45, 95% CI = 2.14, 4.22], rural residence [AOR = 4.32, 95% CI = 3.11, 6.38], and perception of caretakers [AOR = 2.13, 95% CI = 1.89, 4.07] were associated with the missed opportunity of immunization. Conclusion: When compared to previous studies, the proportion of missed immunization opportunities was high in this study. The healthcare staff should be applying the multi-dose vial policy, which is recommended by the World Health Organization to increase the services. The doses for BCG and measles should be minimized to lower doses per vial in order to conduct immunization without having to wait for enough children and without worrying about vaccine waste. All infants who visit the hospital should be linked to immunization services.

Improving the diagnostic process for patients with possible bladder and kidney cancer: a mixed-methods study to identify potential missed diagnostic opportunities.

BACKGROUND: Patients with bladder and kidney cancer may experience diagnostic delays. AIM: To identify patterns of suboptimal care and contributors of potential missed diagnostic opportunities (MDOs). DESIGN AND SETTING: Prospective, mixed-methods study recruiting participants from nine general practices in Eastern England between June 2018 and October 2019. METHOD: Patients with possible bladder and kidney cancer were identified using eligibility criteria based on National Institute for Health and Care Excellence (NICE) guidelines for suspected cancer. Primary care records were reviewed at recruitment and at 1 year for data on symptoms, tests, referrals, and diagnosis. Referral predictors were examined using logistic regression. Semi-structured interviews were undertaken with 15 patients to explore their experiences of the diagnostic process, and these were analysed thematically. RESULTS: Participants (n = 940) were mostly female (n = 657, 69.9%), with a median age of 71 years (interquartile range 64-77 years). In total, 268 (28.5%) received a referral and 465 (48.5%) had a final diagnosis of urinary tract infection (UTI). There were 33 (3.5%) patients who were diagnosed with cancer, including prostate (n = 17), bladder (n = 7), and upper urothelial tract (n = 1) cancers. Among referred patients, those who had a final diagnosis of UTI had the longest time to referral (median 81.5 days). Only one-third of patients with recurrent UTIs were referred despite meeting NICE referral guidelines. Qualitative findings revealed barriers during the diagnostic process, including inadequate clinical examination, female patients given repeated antibiotics without clinical reviews, and suboptimal communication of test results to patients. CONCLUSION: Older females with UTIs might be at increased risk of MDOs for cancer. Targeting barriers during the initial diagnostic assessment and follow-up might improve quality of diagnosis.

Missed opportunities for HIV testing among those who accessed sexually transmitted infection (STI) services, tested for STIs and diagnosed with STIs: a systematic review and meta-analysis.

INTRODUCTION: Of 37.7 million people living with HIV in 2020, 6.1 million still do not know their HIV status. We synthesize evidence on concurrent HIV testing among people who tested for other sexually transmitted infections (STIs). METHODS: We conducted a systematic review using five databases, HIV conferences and clinical trial registries. We included publications between 2010 and May 2021 that reported primary data on concurrent HIV/STI testing. We conducted a random-effects meta-analysis and meta-regression of the pooled proportion for concurrent HIV/STI testing. RESULTS: We identified 96 eligible studies. Among those, 49 studies had relevant data for a meta-analysis. The remaining studies provided data on the acceptability, feasibility, barriers, facilitators, economic evaluation and social harms of concurrent HIV/STI testing. The pooled proportion of people tested for HIV among those attending an STI service (n = 18 studies) was 71.0% (95% confidence intervals: 61.0-80.1, I2 = 99.9%), people tested for HIV among those who were tested for STIs (n = 15) was 61.3% (53.9-68.4, I2 = 99.9%), people tested for HIV among those who were diagnosed with an STI (n = 13) was 35.3% (27.1-43.9, I2 = 99.9%) and people tested for HIV among those presenting with STI symptoms (n = 3) was 27.1% (20.5-34.3, I2 = 92.0%). The meta-regression analysis found that heterogeneity was driven mainly by identity as a sexual and gender minority, the latest year of study, country-income level and region of the world. DISCUSSION: This review found poor concurrent HIV/STI testing among those already diagnosed with an STI (35.3%) or who had symptoms with STIs (27.1%). Additionally, concurrent HIV/STI testing among those tested for STIs varied significantly according to the testing location, country income level and region of the world. A few potential reasons for these observations include differences in national STI-related policies, lack of standard operation procedures, clinician-level factors, poor awareness and adherence to HIV indicator condition-guided HIV testing and stigma associated with HIV compared to other curable STIs. CONCLUSIONS: Not testing for HIV among people using STI services presents a significant missed opportunity, particularly among those diagnosed with an STI. Stronger integration of HIV and STI services is urgently needed to improve prevention, early diagnosis and linkage to care services.

The use of Instagram by gynecologic oncology providers as a patient education tool for patients at high-risk of gynecologic cancer.

Social media outlets have increased in popularity within the last decade and are influencing the ways in which patients interact with the healthcare system. The objective of this study is to examine the presence of gynecologic oncology divisions on Instagram and to analyze the content of their posts. Secondary objectives included examining and analyzing the use of Instagram as a tool for patient education among people at increased genetic risk of gynecologic cancers. Seventy-one NCI-Designated Cancer Centers, their gynecologic oncology divisions and hereditary gynecologic cancer related posts were searched on Instagram. Content was reviewed and authorship was analyzed. Of the 71 NCI-designated Cancer Centers, 29 (40.8 %) had Instagram accounts, whereas, four (6 %) gynecologic oncology divisions had Instagram accounts. The search of the seven most common gynecologic oncology genetic terms yielded 126,750 posts with the majority under BRCA1(n = 56,900) and BRCA2 (n = 45,000) followed by Lynch syndrome (n = 14,700) and hereditary breast and ovarian cancer (n = 8,900). In terms of authorship, 93 (66 %) of all top 140 posts were written by patients, 20 (14.2 %) were written by health care providers and 27 (19.3 %) were written by "other." This study highlights the lack of presence of divisions of gynecologic oncology at NCI-designated Cancer Centers on Instagram but does demonstrate the existence of active discussion on hereditary gynecologic cancers on Instagram by patients.