Screw Position Following Percutaneous Versus Mini-Open Intramedullary Retrograde Screw Fixation of Metacarpal Fractures.

BACKGROUND: Metacarpal fracture fixation using the retrograde intramedullary screw technique can be performed through two different approaches. The mini-open approach requires greater soft tissue dissection but allows for direct visualization of the metacarpal head compared with the percutaneous approach. Our aim was to determine which approach resulted in optimal screw position. METHODS: Eighty-one consecutive patients that underwent intramedullary screw fixation for metacarpal fractures from 2016 to 2021 were identified. Patients were treated by 4 fellowship-trained orthopedic hand surgeons who employed the mini-open or percutaneous approach. Postoperative radiographs were reviewed for screw position. RESULTS: A total of 81 patients (41 mini-open, 40 percutaneous) were included in this study. There were no significant differences between the two groups in age, sex, hand dominance, or affected digit. Postoperative screw position at first postoperative visit was not significantly different between the two groups on anteroposterior or lateral radiographs. CONCLUSION: Postoperative screw position is not significantly different between the mini-open and percutaneous approaches for intramedullary screw fixation of metacarpal fractures. LEVEL OF EVIDENCE: Level III, therapeutic.

Routine Vaccination Coverage - Worldwide, 2022.

In 2020, the World Health Assembly endorsed the Immunization Agenda 2030 (IA2030), the 2021-2030 global strategy that envisions a world where everyone, everywhere, at every age, fully benefits from vaccines. This report reviews trends in World Health Organization and UNICEF immunization coverage estimates at global, regional, and national levels through 2022 and documents progress toward improving coverage with respect to the IA2030 strategy, which aims to reduce the number of children who have not received the first dose of a diphtheria-tetanus-pertussis-containing vaccine (DTPcv1) worldwide by 50% and to increase coverage with 3 diphtheria-tetanus-pertussis-containing vaccine doses (DTPcv3) to 90%. Worldwide, coverage ≥1 dose of DTPcv1 increased from 86% in 2021 to 89% in 2022 but remained below the 90% coverage achieved in 2019. Estimated DTPcv3 coverage increased from 81% in 2021 to 84% in 2022 but also remained below the 2019 coverage of 86%. Worldwide in 2022, 14.3 million children were not vaccinated with DTPcv1, a 21% decrease from 18.1 million in 2021, but an 11% increase from 12.9 million in 2019. Most children (84%) who did not receive DTPcv1 in 2022 lived in low- and lower-middle-income countries. COVID-19 pandemic-associated immunization recovery occurred in 2022 at the global level, but progress was unevenly distributed, especially among low-income countries. Urgent action is needed to provide incompletely vaccinated children with catch-up vaccinations that were missed during the pandemic, restore national vaccination coverage to prepandemic levels, strengthen immunization programs to build resiliency to withstand future unforeseen public health events, and further improve coverage to protect children from vaccine-preventable diseases.

The Effect of Percutaneous Retrograde Metacarpal Intramedullary Screw Insertion on the Extensor Tendon.

PURPOSE: Both limited-open and percutaneous techniques have been described for retrograde insertion of intramedullary metacarpal screws. The percutaneous approach does not allow direct visualization of the starting point at the metacarpal head. However, it limits soft tissue dissection and expedites the procedure. The purpose of our study was to determine whether percutaneous, retrograde intramedullary screw fixation causes substantial iatrogenic damage to the extensor tendon. We also investigated whether larger sized screws would cause greater tendon injury compared to smaller screws. METHODS: Eight fresh frozen cadaver hands were used for percutaneous, retrograde intramedullary screw insertion of the index, long, ring, and small finger metacarpals of each specimen. Three different types of headless compression screws were used: a small fully threaded screw, a large fully threaded screw, and a Herbert-style partially threaded screw. After insertion, dissection was carried down to the screw entry site. Extensor tendon damage was evaluated, including tendon defect size and any irregularities noted in the tendon. RESULTS: There was no statistical difference with respect to how frequently a screw perforated the extensor tendons between all four finger metacarpals. Overall, the defect width caused by the screw was minimal, ranging from 0.66 mm to 1.89 mm for all finger and screw types. The large style screw did cause the greatest mean defect width, however, this was not statistically significant. When normalized to total tendon width, the defect was less than 28% of the total tendon width, with an average of 20% for all finger and screw types. Upon gross inspection, there was no fraying or irregularity noted at the screw-tendon insertion site, and it was often difficult to identify the screw entry site through the tendon by direct visualization alone. No tendon ruptures were noted. CONCLUSIONS: This study found that percutaneous insertion of a retrograde, intramedullary metacarpal screw causes minimal extensor tendon injury. In contrast to the limited-open approach, the percutaneous technique requires less soft tissue dissection and the possibility of reduced swelling, scarring, and risk of adhesions. Moreover, it has the potential to allow for early functional rehabilitation and reduced operative time. Interestingly, none of the tendons demonstrated fraying or rupture, as one might expect to occur with blind passage of a drill and screw through a tendon. Overall, the percutaneous, retrograde intramedullary screw technique appears to cause minimal iatrogenic injury to the extensor tendon.

Improving Equity in Urban Immunization in Low- and Middle-Income Countries: A Qualitative Document Review.

INTRODUCTION: As the world continues to urbanize, particularly in low- and middle-income countries, understanding the barriers and effective interventions to improve urban immunization equity is critical to achieving both Immunization Agenda 2030 targets and the Sustainable Development Goals. Approximately 25 million children missed one or more doses of the diphtheria, tetanus and pertussis (DTP3) vaccine in 2021 and it is estimated that close to 30% of the world's children missing the first dose of DTP, known as zero-dose, live in urban and peri-urban settings. METHODS: The aim of this research is to improve understanding of urban immunization equity through a qualitative review of mixed method studies, urban immunization strategies and funding proposals across more than 70 urban areas developed between 2016 and 2020, supported by Gavi, the Vaccine Alliance. These research studies and strategies created a body of evidence regarding the barriers to vaccination in urban settings and potential interventions relevant to low- and middle-income countries (LMICs) with a focus on the vaccination of urban poor, populations of concern and residents of informal settlements. Through the document review we identified common challenges to achieving equitable coverage in urban areas and mapped proposed interventions. RESULTS: We identified 70 documents as part of the review and categorized results across (1) social determinants of health, (2) immunization service-delivery barriers and (3) quality of services. Barriers and solutions identified in the documents were categorized in these thematic areas, drawing information from results in more than 21 countries. CONCLUSION: Populations of concern such as migrants, refugees, residents of informal settlements and the urban poor face barriers to accessing care which include poor availability and quality of service. Example solutions proposed to these challenges include tailored delivery strategies, improved use of digital data collection and child-friendly services. More research is required on the efficacy of the proposed interventions identified and on gender-specific dynamics in urban poor areas affecting equitable immunization coverage.

Achieving the IA2030 Coverage and Equity Goals through a Renewed Focus on Urban Immunization.

The 2021 WHO and UNICEF Estimates of National Immunization Coverage (WUENIC) reported approximately 25 million under-vaccinated children in 2021, out of which 18 million were zero-dose children who did not receive even the first dose of a diphtheria-tetanus-pertussis-(DPT) containing vaccine. The number of zero-dose children increased by six million between 2019, the pre-pandemic year, and 2021. A total of 20 countries with the highest number of zero-dose children and home to over 75% of these children in 2021 were prioritized for this review. Several of these countries have substantial urbanization with accompanying challenges. This review paper summarizes routine immunization backsliding following the COVID-19 pandemic and predictors of coverage and identifies pro-equity strategies in urban and peri-urban settings through a systematic search of the published literature. Two databases, PubMed and Web of Science, were exhaustively searched using search terms and synonyms, resulting in 608 identified peer-reviewed papers. Based on the inclusion criteria, 15 papers were included in the final review. The inclusion criteria included papers published between March 2020 and January 2023 and references to urban settings and COVID-19 in the papers. Several studies clearly documented a backsliding of coverage in urban and peri-urban settings, with some predictors or challenges to optimum coverage as well as some pro-equity strategies deployed or recommended in these studies. This emphasizes the need to focus on context-specific routine immunization catch-up and recovery strategies to suit the peculiarities of urban areas to get countries back on track toward achieving the targets of the IA2030. While more evidence is needed around the impact of the pandemic in urban areas, utilizing tools and platforms created to support advancing the equity agenda is pivotal. We posit that a renewed focus on urban immunization is critical if we are to achieve the IA2030 targets.

Functional Outcomes of Flexor Tendon Repair in the Fingers: A Comparison of Wide-Awake Local Anesthesia No Tourniquet Versus Traditional Anesthesia.

BACKGROUND: Flexor tendon lacerations in the fingers are challenging injuries that can be repaired using the wide-awake local anesthesia no tourniquet (WALANT) technique or under traditional anesthesia (TA). The purpose of our study was to compare the functional outcomes and complication rates of patients undergoing flexor tendon repair under WALANT versus TA. METHODS: All patients who underwent a primary flexor tendon repair in zone I and II without tendon graft for closed avulsions or open lacerations between 2015 and 2019 were identified. Electronic medical records were reviewed to record and compare patient demographics, range of motion, functional outcomes, complications, and reoperations. RESULTS: Sixty-five zone I (N = 21) or II (N = 44) flexor tendon repairs were included in the final analysis: 23 WALANT and 42 TA. There were no statistical differences in mean age, length of follow-up, proportion of injured digits, or zone of injury between the groups. The final Quick Disabilities of the Arm, Shoulder, and Hand score in the WALANT group was 17.2 (SD: 14.4) versus 23.3 (SD: 18.5) in the TA group. There were no statistical differences between the groups with any final range of motion (ROM) parameters, grip strength, or Visual Analog Scale pain scores at the final follow-up. The WALANT group was found to have a slightly higher reoperation rate (26.1% vs 7.1%; P = .034) than the TA group. CONCLUSIONS: This study represents one of the first clinical studies reporting outcomes of flexor tendon repairs performed under WALANT. Overall, we found no difference in rupture rates, ROM, and functional outcomes following zone I and II flexor tendon repairs when performed under WALANT versus TA.

Use of catch-up vaccinations in the second year of life (2YL) platform to close immunity gaps: A secondary DHS analysis in Pakistan, Philippines, and South Africa.

BACKGROUND: Immunity gaps caused by COVID-19-related disruptions highlight the importance of catch-up vaccination. Number of countries offering vaccines in second year of life (2YL) has increased, but use of 2YL for catch-up vaccination has been variable. We assessed pre-pandemic use of 2YL for catch-up vaccination in three countries (Pakistan, the Philippines, and South Africa), based on existence of a 2YL platform (demonstrated by offering second dose of measles-containing vaccine (MCV2) in 2YL), proportion of card availability, and geographical variety. METHODS: We conducted a secondary data analysis of immunization data from Demographic and Health Surveys (DHS) in Pakistan (2017-2018), the Philippines (2017), and South Africa (2016). We conducted time-to-event analyses for pentavalent vaccine (diphtheria-tetanus-pertussis-Hepatitis B-Haemophilus influenzae type b [Hib]) and MCV and calculated use of 2YL and MCV visits for catch-up vaccination. RESULTS: Among 24-35-month-olds with documented dates, coverage of third dose of pentavalent vaccine increased in 2YL by 2%, 3%, and 1% in Pakistan, Philippines, and South Africa, respectively. MCV1 coverage increased in 2YL by 5% in Pakistan, 10% in the Philippines, and 3% in South Africa. In Pakistan, among 124 children eligible for catch-up vaccination of pentavalent vaccine at time of a documented MCV visit, 45% received a catch-up dose. In the Philippines, among 381 eligible children, 38% received a pentavalent dose during an MCV visit. In South Africa, 50 children were eligible for a pentavalent vaccine dose before their MCV1 visit, but only 20% received it; none with MCV2. CONCLUSION: Small to modest vaccine coverage improvements occurred in all three countries through catch-up vaccination in 2YL but many missed opportunities for vaccination continue to occur. Using the 2YL platform can increase coverage and close immunity gaps, but immunization programmes need to change policies, practices, and monitor catch-up vaccination to maximize the potential.

Immunization programs to support primary health care and achieve universal health coverage.

Gains in immunization coverage and delivery of primary health care service have stagnated in recent years. Remaining gaps in service coverage reflect multiple underlying reasons that may be amenable to improved health system design. Immunization systems and other primary health care services can be mutually supportive, for improved service delivery and for strengthening of Universal Health Coverage. Improvements require that dynamic and multi-faceted barriers and risks be addressed. These include workforce availability, quality data systems and use, leadership and management that is innovative, flexible, data driven and responsive to local needs. Concurrently, improvements in procurement, supply chain, logistics and delivery systems, and integrated monitoring of vaccine coverage and epidemiological disease surveillance with laboratory systems, and vaccine safety will be needed to support community engagement and drive prioritized actions and communication. Finally, political will and sustained resource commitment with transparent accountability mechanisms are required. The experience of the impact of COVID-19 pandemic on essential PHC services and the challenges of vaccine roll-out affords an opportunity to apply lessons learned in order to enhance vaccine services integrated with strong primary health care services and universal health coverage across the life course.

Routine Vaccination Coverage - Worldwide, 2021.

In 2020, the World Health Assembly endorsed the Immunization Agenda 2030, an ambitious global immunization strategy to reduce morbidity and mortality from vaccine-preventable diseases (1). This report updates a 2020 report (2) with global, regional,* and national vaccination coverage estimates and trends through 2021. Global estimates of coverage with 3 doses of diphtheria-tetanus-pertussis-containing vaccine (DTPcv3) decreased from an average of 86% during 2015-2019 to 83% in 2020 and 81% in 2021. Worldwide in 2021, 25.0 million infants (19% of the target population) were not vaccinated with DTPcv3, 2.1 million more than in 2020 and 5.9 million more than in 2019. In 2021, the number of infants who did not receive any DTPcv dose by age 12 months (18.2 million) was 37% higher than in 2019 (13.3 million). Coverage with the first dose of measles-containing vaccine (MCV1) decreased from an average of 85% during 2015-2019 to 84% in 2020 and 81% in 2021. These are the lowest coverage levels for DTPcv3 and MCV1 since 2008. ​Global coverage estimates were also lower in 2021 than in 2020 and 2019 for bacillus Calmette-Guérin vaccine (BCG) as well as for the completed series of Haemophilus influenzae type b vaccine (Hib), hepatitis B vaccine (HepB), polio vaccine (Pol), and rubella-containing vaccine (RCV). The COVID-19 pandemic has resulted in disruptions to routine immunization services worldwide. Full recovery to immunization programs will require context-specific strategies to address immunization gaps by catching up missed children, prioritizing essential health services, and strengthening immunization programs to prevent outbreaks (3).

Zero- or missed-dose children in Nigeria: Contributing factors and interventions to overcome immunization service delivery challenges.

'Zero-dose' refers to a person who does not receive a single dose of any vaccine in the routine national immunization schedule, while 'missed dose' refers to a person who does not complete the schedule. These peopleremain vulnerable to vaccine-preventable diseases, and are often already disadvantaged due to poverty, conflict, and lack of access to basic health services. Globally, more 22.7 million children are estimated to be zero- or missed-dose, of which an estimated 3.1 million (∼14 %) reside in Nigeria.We conducted a scoping review tosynthesize recent literature on risk factors and interventions for zero- and missed-dosechildren in Nigeria. Our search identified 127 papers, including research into risk factors only (n = 66); interventions only (n = 34); both risk factors and interventions (n = 18); and publications that made recommendations only (n = 9). The most frequently reported factors influencing childhood vaccine uptake were maternal factors (n = 77), particularly maternal education (n = 22) and access to ante- and perinatal care (n = 19); heterogeneity between different types of communities - including location, region, wealth, religion, population composition, and other challenges (n = 50); access to vaccination, i.e., proximity of facilities with vaccines and vaccinators (n = 37); and awareness about immunization - including safety, efficacy, importance, and schedules (n = 18).Literature assessing implementation of interventions was more scattered, and heavily skewed towards vaccination campaigns and polio eradication efforts. Major evidence gaps exist in how to deliver effective and sustainable routine childhood immunization. Overall, further work is needed to operationalise the learnings from these studies, e.g. through applying findings to Nigeria's next review of vaccination plans, and using this summary as a basis for further investigation and specific recommendations on effective interventions.

Outpatient Visit Current Procedural Terminology Code Level Selection Trends in Hand Surgery Following Criteria Changes by the American Medical Association.

INTRODUCTION:  Beginning on January 1, 2021, the American Medical Association (AMA) and the Centers for Medicare and Medicaid Services (CMS) implemented considerable revisions with regard to the outpatient evaluation and management (E/M) criteria dictating the Current Procedural Terminology (CPT) code level selection. The primary goal of the current study was to determine how the recent E/M coding criteria changes have impacted code level selection by orthopedic hand surgeons in the outpatient setting. MATERIALS AND METHODS:  All outpatient visits within the hand and wrist surgery division of a single orthopedic practice were collected during two timeframes: March 1, 2019, to June 30, 2019, and March 1, 2021, to June 30, 2021. Procedure codes and insurance categories were collected for each visit. The primary endpoint analyzed was the visit level of care based on CPT E/M codes. For each timeframe, we determined the number of total visits that were coded at each level and expressed them as a percentage of the total visits for that time period. The insurance plan billed for each visit was recorded and classified as Medicare, Medicaid, Workers' Compensation, or commercial. RESULTS:  In 2019, prior to the billing level requirement changes, 7.2% of all visits were billed as level 2, 84.8% of all visits were billed as level 3, and 7.8% of all visits were billed as level 4. In 2021, 1.9% of visits were billed as level 2, 47.3% of visits were billed as level 3, and 50.5% of visits were billed as level 4. Level 1 and 5 visits did not exceed 0.5% in either timeframe. Within each insurance category, the proportion of visit levels of care followed a similar trend of reduced level 2 and 3 visits and increased level 4 visits from 2019 to 2021. CONCLUSION: We noted a significant trend toward higher code level selection following the recent code level changes, and we anticipate these recent code selection trends to have major financial implications moving forward.

Association between childhood immunisation coverage and proximity to health facilities in rural settings: a cross-sectional analysis of Service Provision Assessment 2013-2014 facility data and Demographic and Health Survey 2015-2016 individual data in Malawi.

OBJECTIVES: Despite significant progress in childhood vaccination coverage globally, substantial inequality remains. Remote rural populations are recognised as a priority group for immunisation service equity. We aimed to link facility and individual data to examine the relationship between distance to services and immunisation coverage empirically, specifically using a rural population. DESIGN AND SETTING: Retrospective cross-sectional analysis of facility data from the 2013-2014 Malawi Service Provision Assessment and individual data from the 2015-2016 Malawi Demographic and Health Survey, linking children to facilities within a 5 km radius. We examined associations between proximity to health facilities and vaccination receipt via bivariate comparisons and logistic regression models. PARTICIPANTS: 2740 children aged 12-23 months living in rural areas. OUTCOME MEASURES: Immunisation coverage for the six vaccines included in the Malawi Expanded Programme on Immunization schedule for children under 1 year at time of study, as well as two composite vaccination indicators (receipt of basic vaccines and receipt of all recommended vaccines), zero-dose pentavalent coverage, and pentavalent dropout. FINDINGS: 72% (706/977) of facilities offered childhood vaccination services. Among children in rural areas, 61% were proximal to (within 5 km of) a vaccine-providing facility. Proximity to a vaccine-providing health facility was associated with increased likelihood of having received the rotavirus vaccine (93% vs 88%, p=0.004) and measles vaccine (93% vs 89%, p=0.01) in bivariate tests. In adjusted comparisons, how close a child was to a health facility remained meaningfully associated with how likely they were to have received rotavirus vaccine (adjusted OR (AOR) 1.63, 95% CI 1.13 to 2.33) and measles vaccine (AOR 1.62, 95% CI 1.11 to 2.37). CONCLUSION: Proximity to health facilities was significantly associated with likelihood of receipt for some, but not all, vaccines. Our findings reiterate the vulnerability of children residing far from static vaccination services; efforts that specifically target remote rural populations living far from health facilities are warranted to ensure equitable vaccination coverage.

Impact of the SARS-CoV-2 pandemic on vaccine-preventable disease campaigns.

BACKGROUND: The COVID-19 pandemic has contributed to the widespread disruption of immunization services, including the postponement of mass vaccination campaigns. METHODS: In May 2020, the World Health Organization and partners started monitoring COVID-19-related disruptions to mass vaccination campaigns against cholera, measles, meningitis A, polio, tetanus-diphtheria, typhoid, and yellow fever through the Immunization Repository Campaign Delay Tracker. The authors reviewed the number and target population of reported preventive and outbreak response vaccination campaigns scheduled, postponed, canceled, and reinstated at 4 time points: May 2020, December 2020, May 2021, and December 2021. FINDINGS: Mass vaccination campaigns across all vaccines were disrupted heavily by COVID-19. In May 2020, 105 of 183 (57%) campaigns were postponed or canceled in 57 countries because of COVID-19, with an estimated 796 million postponed or missed vaccine doses. Campaign resumption was observed beginning in July 2020. In December 2021, 77 of 472 (16%) campaigns in 54 countries, mainly in the African Region, were still postponed or canceled because of COVID-19, with about 382 million postponed or missed vaccine doses. INTERPRETATION: There is likely a high risk of vaccine-preventable disease outbreaks across all regions because of an increased number of susceptible persons resulting from the large-scale mass vaccination campaign postponement caused by COVID-19.

Economic-Related Inequalities in Zero-Dose Children: A Study of Non-Receipt of Diphtheria-Tetanus-Pertussis Immunization Using Household Health Survey Data from 89 Low- and Middle-Income Countries.

Despite advances in scaling up new vaccines in low- and middle-income countries, the global number of unvaccinated children has remained high over the past decade. We used 2000-2019 household survey data from 154 surveys representing 89 low- and middle-income countries to assess within-country, economic-related inequality in the prevalence of one-year-old children with zero doses of diphtheria-tetanus-pertussis (DTP) vaccine. Zero-dose DTP prevalence data were disaggregated by household wealth quintile. Difference, ratio, slope index of inequality, concentration index, and excess change measures were calculated to assess the latest situation and change over time, by country income grouping for 17 countries with high zero-dose DTP numbers and prevalence. Across 89 countries, the median prevalence of zero-dose DTP was 7.6%. Within-country inequalities mostly favored the richest quintile, with 19 of 89 countries reporting a rich-poor gap of ≥20.0 percentage points. Low-income countries had higher inequality than lower-middle-income countries and upper-middle-income countries (difference between the median prevalence in the poorest and richest quintiles: 14.4, 8.9, and 2.7 percentage points, respectively). Zero-dose DTP prevalence among the poorest households of low-income countries declined between 2000 and 2009 and between 2010 and 2019, yet economic-related inequality remained high in many countries. Widespread economic-related inequalities in zero-dose DTP prevalence are particularly pronounced in low-income countries and have remained high over the previous decade.

Do Postoperative Telehealth Visits Require a High Rate of Redundant In-Person Evaluation After Upper Extremity Surgery?

Background Telehealth platforms may save resources for patients and providers, but the precise impact of their incorporation during the postoperative period is not well understood. The goal of this study is to determine whether telehealth incorporation in the postoperative period leads to an overall increase in healthcare utilization after upper extremity surgery. Methodology Patients seen for a postoperative telehealth visit after upper extremity surgery were randomly selected and retrospectively enrolled. Complications and the total number of postoperative visits before clinical discharge were recorded and compared to controls matched by surgery type and surgeon. Results A total of 56 patients were seen for 60 telehealth visits. The most common surgical procedures were distal radius open-reduction internal fixation (n = 8), open carpal tunnel release (n = 8), and endoscopic carpal tunnel release (n = 6). One telehealth visit (1.7%) required conversion to in-person evaluation due to suspected superficial infection necessitating in-person physical examination. The average number of postoperative visits prior to clinical discharge was 2.6 in the telehealth group compared to 2.7 in matched controls (p = 0.886). Complication rates were similar between groups. Conclusions The rate of necessary in-person evaluation after postoperative telehealth visits was less than 2%. The incorporation of telehealth visits did not appear to increase healthcare utilization after upper extremity surgery. Accordingly, the postoperative period is likely an ideal application for safe and effective telehealth implementation.

Impact of the SARS-CoV-2 pandemic on routine immunisation services: evidence of disruption and recovery from 170 countries and territories.

BACKGROUND: The SARS-CoV-2 pandemic has revealed the vulnerability of immunisation systems worldwide, although the scale of these disruptions has not been described at a global level. This study aims to assess the impact of COVID-19 on routine immunisation using triangulated data from global, country-based, and individual-reported sources obtained during the pandemic period. METHODS: This report synthesised data from 170 countries and territories. Data sources included administered vaccine-dose data from January to December, 2019, and January to December, 2020, WHO regional office reports, and a WHO-led pulse survey administered in April, 2020, and June, 2020. Results were expressed as frequencies and proportions of respondents or reporting countries. Data on vaccine doses administered were weighted by the population of surviving infants per country. FINDINGS: A decline in the number of administered doses of diphtheria-pertussis-tetanus-containing vaccine (DTP3) and first dose of measles-containing vaccine (MCV1) in the first half of 2020 was noted. The lowest number of vaccine doses administered was observed in April, 2020, when 33% fewer DTP3 doses were administered globally, ranging from 9% in the WHO African region to 57% in the South-East Asia region. Recovery of vaccinations began by June, 2020, and continued into late 2020. WHO regional offices reported substantial disruption to routine vaccination sessions in April, 2020, related to interrupted vaccination demand and supply, including reduced availability of the health workforce. Pulse survey analysis revealed that 45 (69%) of 65 countries showed disruption in outreach services compared with 27 (44%) of 62 countries with disrupted fixed-post immunisation services. INTERPRETATION: The marked magnitude and global scale of immunisation disruption evokes the dangers of vaccine-preventable disease outbreaks in the future. Trends indicating partial resumption of services highlight the urgent need for ongoing assessment of recovery, catch-up vaccination strategy implementation for vulnerable populations, and ensuring vaccine coverage equity and health system resilience. FUNDING: US Agency for International Development.

Does Undergoing Outpatient Hand Surgery Lead to Prolonged Opioid Use? A Comparison of Surgical and Nonsurgical Patients.

BACKGROUND: Orthopedic surgical patients in general have been found to be at higher risk for developing opioid dependence in the postoperative period. However, there is conflicting evidence in the literature whether opioid exposure after hand surgery leads to prolonged use. In the absence of a nonoperative control group, it is not clear whether prolonged opioid use in hand surgical patients is related to undergoing a surgical intervention. The purpose of our study to compare opioid prescription fulfillment patterns in surgical and nonoperative patients in a hand surgery practice. METHODS: We retrospectively compared 320 patients that underwent elbow, wrist, and hand surgery procedures with 741 nonoperative patients treated by 2 hand surgeons. The Pennsylvania Drug Monitoring Program (PDMP), a mandatory statewide database, was used to evaluate the primary outcomes of filling more than one opioid prescription and filling opioid prescriptions beyond 6 months of the index surgery or clinic visit. Bivariate and multivariable logistic regression analysis was performed using the following variables: surgery, prior benzodiazepine use, and prior opioid use. RESULTS: There was no difference in prior opioid use (15.2% vs 16.9%, P = .51) or prior benzodiazepine (10.4% vs 8.4%, P = .33) use between the nonoperative and operative groups. Patients that underwent surgery had a higher incidence of filling more than one opioid prescription (20.9% vs 8.8%, P < .001). However, continued opioid use was not statistically different between nonoperative and operative patients (2.8% vs 5%, P = .08). Bivariate analysis demonstrated that prior opioids (odds ratio [OR] = 12.94, P < .001) and prior benzodiazepines (OR = 1.95, P < .001) were significant independent risk factors for prolonged opioid use. Multivariable analysis demonstrated prior opioid use to be the only independent risk factor for prolonged opioid use (OR = 12.58, P < .001). CONCLUSION: Undergoing outpatient hand surgery do not appear to be an independent risk factor for filling opioid prescriptions beyond 6 months. Significant risk factors for prolonged opioid use include prior use of controlled substances, particularly prior opioid use.

Variability in Medicaid Reimbursement in Hand Surgery May Lead to Inequality in Access to Patient Care.

BACKGROUND: Medicare (MCR) and Medicaid (MCD) remain the dominant providers of government-funded health insurance in the United States. The purpose of this study was to evaluate the variability between MCR and MCD reimbursements for common hand and wrist surgical procedures. We hypothesized that MCD reimbursement rates would have substantial variation between states, whereas MCR rates would remain relatively constant. METHODS: Using the Medicare Physician Fee Schedule Database, the 2019 reimbursements for 7 common hand and wrist procedures were recorded via the respective Current Procedural Terminology codes. The MCD reimbursement rates were then obtained from each state's physician fee schedule database. Comparisons of reimbursement for these procedures were then calculated between states and between MCD and MCR while adjusting for cost of living using the Medicare Wage Index. Finally, the coefficients of variation were computed to compare the extent of variability between the insurance types. RESULTS: Across all procedures, reimbursement rates for MCD ranged from 30.6% to 240% of the average MCR reimbursement, with the mean reimbursement for MCD valued at 78.3% of MCR. Endoscopic carpal tunnel release (CTR) is valued similarly by MCD compared with open CTR with an average of 77.7% and 78.2% reimbursement of MCR, respectively. The coefficients of variation for MCD reimbursements ranged from 0.25 to 0.45, whereas the value was 0.06 for all MCR procedures. CONCLUSIONS: These findings demonstrate a wide variation in MCD payments between states. When compared with MCR, the lower average state MCD reimbursement questions the sustainability for hand surgeons to accept these patients in practice.

Routine Vaccination Coverage - Worldwide, 2020.

Endorsed by the World Health Assembly in 2020, the Immunization Agenda 2030 (IA2030) strives to reduce morbidity and mortality from vaccine-preventable diseases across the life course (1). This report, which updates a previous report (2), presents global, regional,* and national vaccination coverage estimates and trends as of 2020. Changes are described in vaccination coverage and the numbers of unvaccinated and undervaccinated children as measured by receipt of the first and third doses of diphtheria, tetanus, and pertussis-containing vaccine (DTP) in 2020, when the COVID-19 pandemic began, compared with 2019. Global estimates of coverage with the third dose of DTP (DTP3) and a polio vaccine (Pol3) decreased from 86% in 2019 to 83% in 2020. Similarly, coverage with the first dose of measles-containing vaccine (MCV1) dropped from 86% in 2019 to 84% in 2020. The last year that coverage estimates were at 2020 levels was 2009 for DTP3 and 2014 for both MCV1 and Pol3. Worldwide, 22.7 million children (17% of the target population) were not vaccinated with DTP3 in 2020 compared with 19.0 million (14%) in 2019. Children who did not receive the first DTP dose (DTP1) by age 12 months (zero-dose children) accounted for 95% of the increased number. Among those who did not receive DTP3 in 2020, approximately 17.1 million (75%) were zero-dose children. Global coverage decreased in 2020 compared with 2019 estimates for the completed series of Haemophilus influenzae type b (Hib), hepatitis B vaccine (HepB), human papillomavirus vaccine (HPV), and rubella-containing vaccine (RCV). Full recovery from COVID-19-associated disruptions will require targeted, context-specific strategies to identify and catch up zero-dose and undervaccinated children, introduce interventions to minimize missed vaccinations, monitor coverage, and respond to program setbacks (3).