Advisory Committee on Immunization Practices Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger - United States, 2023

At its October 2022 meeting, the Advisory Committee on Immunization Practices* (ACIP) approved the Recommended Child and Adolescent Immunization Schedule for Ages 18 Years or Younger, United States, 2023. The 2023 child and adolescent immunization schedule, available on the CDC immunization schedule website (https://www.cdc.gov/vaccines/schedules), summarizes ACIP recommendations, including several changes from the 2022 immunization schedule^† on the cover page, tables, notes, and appendix. Health care providers are advised to use the tables, notes, and appendix together to determine recommended vaccinations for patient populations. This immunization schedule is recommended by ACIP (https://www.cdc.gov/vaccines/acip) and approved by CDC (https://www.cdc.gov), the American Academy of Pediatrics (https://www.aap.org), the American Academy of Family Physicians (https://www.aafp.org), the American College of Obstetricians and Gynecologists (http://www.acog.org), the American College of Nurse-Midwives (https://www.midwife.org), the American Academy of Physician Associates (https://www.aapa.org), and the National Association of Pediatric Nurse Practitioners (https://www.napnap.org).

Advisory Committee on Immunization Practices Recommended Immunization Schedule for Adults Aged 19 Years or Older - United States, 2023

At its October 2022 meeting, the Advisory Committee on Immunization Practices* (ACIP) approved the Recommended Adult Immunization Schedule for Ages 19 Years or Older, United States, 2023. The 2023 adult immunization schedule summarizes ACIP recommendations, including several changes to the cover page, tables, notes, and appendix from the 2022 immunization schedule.^† This schedule can be found on the CDC immunization schedule website (https://www.cdc.gov/vaccines/schedules). Health care providers are advised to use the cover page, tables, notes, and appendix together to determine recommended vaccinations for patient populations. This adult immunization schedule is recommended by ACIP (https://www.cdc.gov/vaccines/acip) and approved by CDC (https://www.cdc.gov), the American College of Physicians (https://www.acponline.org), the American Academy of Family Physicians (https://www.aafp.org), the American College of Obstetricians and Gynecologists (https://www.acog.org), the American College of Nurse-Midwives (https://www.midwife.org), the American Academy of Physician Associates (https://www.aapa.org), the American Pharmacists Association (https://www.pharmacist.com), and the Society for Healthcare Epidemiology of America (https://shea-online.org).

Multi-tiered intervention to increase maternal immunization coverage: A randomized, controlled trial

OBJECTIVE

To evaluate the impact of a multi-component intervention package of maternal immunization uptake in obstetric care clinics.

METHODS

In a multi-level, cluster- and individually-randomized controlled trial we implemented an evidence-based intervention that targeted practice-, provider- and patient-level barriers to vaccine uptake. Obstetric practices were randomized to receive the practice and provider-level interventions or continue their normal standard of care. We enrolled pregnant women at practices in Georgia and Colorado and randomized women into patient-level intervention and control groups, resulting in four study arms. The primary outcomes were receipt of the influenza and tetanus, diphtheria and acellular pertussis (Tdap) vaccines during pregnancy. A sample size of 550 women per arm (2200 total) was planned and enrolled to compare the intervention between the four study arms.

RESULTS

Between June 2017 and July 2018, 4907 women were screened and 2200 women were randomized, 550 to each of the four study arms. We were unable to follow-up with 108 women, for a final sample size of 2092. Sample characteristics and sample size were similar among study arms. There was no significant increase in Tdap or influenza vaccine uptake overall. Among women who had no intention of or were unsure about receiving the influenza vaccine during pregnancy, those who received just the patient-level intervention were 61% more likely to receive the influenza vaccine than those in the control arm (Relative risk: 1.61; 95% Confidence Interval: 1.18-2.21). There was no significant difference in vaccine uptake for either influenza or tetanus, diphtheria and acellular pertussis between the four arms of the study.

CONCLUSIONS

This trial highlights the need for more targeted interventions to improve vaccine uptake. Future work should focus on clinics with low baseline vaccine uptake and the patient-level intervention should be expanded and targeted towards women with low vaccine confidence.

Advisory Committee on Immunization Practices Recommended Immunization Schedule for Adults Aged 19 Years or Older - United States, 2022

At its November 2021 meeting, the Advisory Committee on Immunization Practices* (ACIP) approved the Recommended Adult Immunization Schedule for Ages 19 Years or Older, United States, 2022. The 2022 adult immunization schedule summarizes ACIP recommendations, including several changes to the cover page, tables, and notes from the 2021 immunization schedule.^† In addition, the 2022 adult immunization schedule provides an appendix that lists the contraindications to and precautions for all routinely recommended vaccines in the schedule. This schedule can be found on the CDC immunization schedule website (https://www.cdc.gov/vaccines/schedules). Health care providers are advised to use the cover page, tables, notes, and appendix together. This adult immunization schedule is recommended by ACIP (https://www.cdc.gov/vaccines/acip) and approved by CDC (https://www.cdc.gov), the American College of Physicians (https://www.acponline.org), the American Academy of Family Physicians (https://www.aafp.org), the American College of Obstetricians and Gynecologists (https://www.acog.org), the American College of Nurse-Midwives (https://www.midwife.org), the American Academy of Physician Associates (https://www.aapa.org), and the Society for Healthcare Epidemiology of America (https://www.shea-online.org).

Attitudes toward Rubella and Varicella Vaccination during Preconception Care

Introduction

Studies of anti-vaccine attitudes in the perinatal time period previously have not paid special attention to the MMR and varicella vaccines. Because both contain live attenuated virus, a contraindication during pregnancy, it is important to assess barriers to vaccination clinically during preconception to avoid the known fetal morbidity associated with congenital rubella or varicella infection.

Methods

The primary outcome of this study was to determine prevalence of patients with nonimmune status for rubella and varicella in the setting of advanced reproductive care. Secondary outcomes of interest included further understanding nonimmune reproductive-aged women's attitudes toward MMR and varicella vaccination during preconception. Patient records with laboratory orders for rubella or varicella immunoglobulin titers, placed at the KU Advanced Reproductive Care clinic between January 2017 and June 2020, were reviewed (n = 2,217). A cross-sectional survey was administered to patients with a laboratory reported negative titer result.

Results

Prevalence of nonimmunity to either rubella or varicella represented 6.0% (n = 134) and 3.8% (n = 85) of records, respectively; nineteen records (0.6%) demonstrated nonimmunity to both. The women who did not receive recommended vaccines following a non-immune titer result (n = 19) most commonly cited their rationale was to not delay fertility treatment further (n = 8), a requirement when receiving live attenuated virus vaccines.

Conclusions

The prevalence of nonimmune persons in the study population fell within the range recognized to be sufficient for herd immunity. The majority of survey respondents indicated that CDC recommended vaccinations were of high personal importance, with strong congruence of thought among those who answered in favor of vaccines when posed with several true or false statements about personal beliefs and vaccine efficacy. The risk/benefit analysis of postponing fertility treatment to achieve adequate levels of immunity should be a focused discussion when establishing fertility treatment goals with patients in the setting of advanced reproductive care.

Attitudes toward Rubella and Varicella Vaccination during Preconception Care

Introduction. MMR and Varicella vaccines contain live attenuated virus, a contraindication during pregnancy. For this reason, it is important to clinically assess barriers to vaccination during the preconception time period to avoid the known fetal morbidity associated with congenital Rubella or Varicella infection. Methods. To determine the prevalence of patients with nonimmune status for Rubella and Varicella in the setting of advanced reproductive care. Secondary outcomes of interest included further understanding nonimmune reproductive-aged women's attitudes toward MMR and Varicella vaccination during the preconception time frame. Patient records were with lab orders for Rubella or Varicella immunoglobulin titers, placed at the KU Advanced Reproductive Care clinic between January 2017 and June 2020. A cross-sectional survey was administered to patients with a laboratory reported negative titer result. Results. Prevalence of nonimmunity within the study population to either Rubella and/or Varicella was 10.7% (n=1,979), to Rubella, 6.0% (n=134) and to Varicella, 3.8% (n=85) out of a total 2,217 patient records reviewed. The women who did not receive recommended vaccines following a nonimmune titer result (n=19) most commonly cited their rationale was to not further delay fertility treatment (n=8). Conclusions. The prevalence of nonimmune persons in the study population fell within the range recognized to be sufficient for herd immunity. The risk/benefit analysis of postponing fertility treatment to achieve adequate levels of immunity should be a focused discussion when establishing fertility treatment goals with patients in the setting of advanced reproductive care.

ISIDOG Consensus Guidelines on COVID-19 Vaccination for Women before, during and after Pregnancy

Introduction. Sars-CoV-2 infection poses particular problems in pregnancy, as the infection more frequently causes severe complications than in unaffected pregnant women or nonpregnant women with SARS-CoV-2 infection. Now that vaccination is available and rapidly being implemented worldwide, the question arises whether pregnant women should be vaccinated, and if so, whether they should receive priority. Methods. Available scientific data and available guidelines about vaccination against SARS-CoV-2 were collected by the Guideline Committee of the International Society of Infectious Diseases in Obstetrics and Gynecology (ISIDOG) and were analyzed, discussed and summarized as guidelines for healthcare workers caring for pregnant women. Concluding statements were graded according to the Oxford evidence-based medicine grading system. Results. There is evidence to consider pregnancy as a risk factor for serious complications of COVID-19 infection, even in the absence of additional risk factors, such as hypertension, diabetes and obesity which increase these risks even more in pregnancy. Currently available data slightly favor mRNA-based vaccines above vector-based vaccines during pregnancy and breastfeeding, until more safety data become available. Conclusion. ISIDOG advises policy makers and societies to prioritize pregnant women to receive vaccination against SARS-CoV-2 and favor the mRNA vaccines until further safety information becomes available.

Recommendations for Delivering COVID-19 Vaccine in Jails: Evidence from Kansas, Iowa, Nebraska, and Missouri

We report on data we collected from a 2018 survey examining jails' human papillomavirus virus vaccine delivery capacity and on a secondary analysis we conducted to describe factors similarly associated with delivery planning for the COVID-19 vaccine. We provide recommendations for delivering the COVID-19 vaccine in jails, based on evidence from Kansas, Iowa, Nebraska, and Missouri. Our key finding is that jails have limited staff to implement vaccination and will require collaboration between jail administrators, jail medical staff, and local health departments.

Advisory Committee on Immunization Practices Recommended Immunization Schedule for Children and Adolescents Aged 18 Years or Younger - United States, 2021

At its October 2020 meeting, the Advisory Committee on Immunization Practices* (ACIP) approved the 2021 Recommended Child and Adolescent Immunization Schedule for Ages 18 Years or Younger. After Emergency Use Authorization of Pfizer-BioNTech COVID-19 vaccine by the Food and Drug Administration (FDA), ACIP issued an interim recommendation for use of Pfizer-BioNTech COVID-19 vaccine in persons aged ≥16 years at its December 12, 2020, meeting (1). In addition, ACIP approved an amendment to include COVID-19 vaccine recommendations in the child and adolescent immunization schedule. After Emergency Use Authorization of Moderna COVID-19 vaccine by FDA, ACIP issued an interim recommendation for use of Moderna COVID-19 vaccine in persons aged ≥18 years at its December 19, 2020, emergency meeting (2).

Advisory Committee on Immunization Practices Recommended Immunization Schedule for Adults Aged 19 Years or Older - United States, 2021

At its October 2020 meeting, the Advisory Committee on Immunization Practices (ACIP)* approved the Recommended Immunization Schedule for Adults Aged 19 Years or Older, United States, 2021. After the Emergency Use Authorization of Pfizer-BioNTech COVID-19 vaccine by the Food and Drug Administration, ACIP issued an interim recommendation for use of Pfizer-BioNTech COVID-19 vaccine in persons aged ≥16 years at its December 12, 2020, emergency meeting (1). In addition, ACIP approved an amendment to include COVID-19 vaccine recommendations in the child and adolescent and adult immunization schedules. After Emergency Use Authorization of Moderna COVID-19 vaccine by the Food and Drug Administration, ACIP issued an interim recommendation for use of Moderna COVID-19 vaccine in persons aged ≥18 years at its December 19, 2020, emergency meeting (2).

Duration of Cellular and Humoral Responses after Quadrivalent Human Papillomavirus Vaccination in Healthy Female Adults with or without Prior Type 16 and/or 18 Exposure

Human papillomavirus virus (HPV) vaccines aim to provide durable protection and are ideal to study the association of cellular with humoral responses. We assessed the duration and characteristics of immune responses provided by the quadrivalent HPV (4vHPV) vaccine in healthy female adults with or without prior exposure with type 16 and 18 HPV. In a prospective cohort, vaccine naïve females received three doses of 4vHPV vaccine and were followed for two years to assess cellular (intracellular cytokine staining, proliferation and B cell ELISpot assays) and humoral (multiplex L1/L2 viral-like particles (VLP) and M4 ELISAs) responses. Frequencies of vaccine-specific CD4+ T cells correlated with antibody responses. Higher HPV antibody titers were found at all time points in participants previously exposed to HPV, except for anti-HPV-18 at Day 187 (one week post the third vaccination). Retrospective cohorts enrolled females who had previously received two or three 4vHPV doses and tested antibody titers by M4 ELISA and pseudovirion neutralization assay along with memory B cells (MBCs). Almost all women enrolled in a retrospective cohort with two prior doses and all women enrolled in a retrospective cohort with three prior doses had sustained antibody and memory responses. Our findings indicate that HPV vaccination induces a long-lasting, robust cellular and humoral immune responses.

Validating self-reported cervical cancer screening among women leaving jails

BACKGROUND

Despite women with criminal justice involvement reporting routine Papanicolaou (Pap) testing, significant disparities in cervical cancer outcomes exist when compared to women without criminal justice involvement. A possible reason for the discrepancy is that this group of women may be misreporting Pap testing. The objective of this study was to validate self-reported cervical cancer screening among women leaving jails.

METHODS

We used three methods to validate self-reported cervical cancer screening for women recently released from jail: 1) Medical record review; 2) Semi-structured interview; 3) Pap test knowledge survey. After validating women's self-reported Pap tests with a review of their medical records, we scored interviews for Pap test recall, and used Pap test knowledge survey scores to compare scores between women who accurately reported Pap tests vs. those who did not.

RESULTS

Sixty-one percent (N = 14/23) self-reported cervical cancer screenings were accurate per medical record review. Comparing participants who did and did not accurately self-report a Pap test, we found a significant difference in Pap test recall scores (1.90 vs. 0.00, t = 3.87, p < .01) and Pap test knowledge scores (13.50 vs. 12.13, t = 2.42, p < .05).

CONCLUSION

Self-report of cervical cancer screening was more likely to be accurate if a woman's Pap test knowledge was high. Clinicians might take extra care in describing screening and distinguishing between Pap tests and pelvic exams to support the cervical health of women with lower knowledge.

Human Papillomavirus Vaccine Knowledge and Intention Among Adult Inmates in Kansas, 2016-2017

OBJECTIVES

To assess human papillomavirus (HPV) knowledge and vaccine awareness, intention, and uptake among adult inmates in Kansas jails.

METHODS

We administered a survey with questions adapted from the US National Cancer Institute's Health Information National Trends Survey to 571 adult inmates in 3 Kansas jails from October 10 to 12, 2016, and January 25 to 27, 2017, to assess HPV knowledge and vaccine awareness, intention, and uptake.

RESULTS

Although most adults across demographic groups recognized HPV as causing cervical cancer, knowledge was lower about other HPV-related cancers. Vaccine awareness was higher for women (70%) than men (41%). Only 8% of age-eligible men reported ever receiving the vaccine. Most adults across demographic groups reported "definitely" wanting to get the vaccine if offered in jail at no cost.

CONCLUSIONS

Low uptake of HPV vaccine and high interest in receiving the vaccine in jails may indicate that vaccination availability for jail populations needs to be reexamined. Public Health Implications. Expanding HPV vaccine programs or partnerships to facilitate vaccine provision in jails could increase inmates' knowledge of and intention to receive vital health services.

Clinician perspectives on strategies to improve patient maternal immunization acceptability in obstetrics and gynecology practice settings

Pregnancy is an ideal time to communicate with women about vaccines for themselves and their infants, yet maternal immunization rates remain suboptimal. This study aimed to identify clinic, provider, and staff-related attributes and facilitators to be utilized for a comprehensive vaccine intervention in ob-gyn clinical settings. We conducted in-depth interviews with 24 providers, both healthcare providers (e.g., physicians, nurse practitioners, midwives) and practice managers, from urban and suburban ob-gyn practices in Georgia and Colorado about their immunization attitudes, practices, and patient experiences. Qualitative analyses included Pearson correlation tests to evaluate patterns and relationships within the data to determine themes. Six major themes emerged: 1) strong provider "buy in" for maternal immunization; 2) the supporting role of clinical/interpersonal cues for vaccine promotion; 3) varying provider-patient communication approaches and its influence on maternal and pediatric uptake; 4) an urgent need for a designated office immunization champion; 5) reimbursement and practice implementation challenges; and 6) region differences in attitudes and values toward maternal immunization. Although providers expressed strong support for maternal immunization practices and offered environmental cues for vaccine promotion, practices often lacked a designated, structured role for an immunization champion equipped to manage delicate conversations with patients. The findings reflect needs for immunization champion identification, training, and support, along with best practices guidelines to improve coordination of vaccine promotion and delivery efforts in ob-gyn provider offices. Additionally, provider training on communication approaches to enhance acceptance and uptake of maternal vaccines is warranted.

Imiquimod cream 2.5% and 3.75% applied once daily to treat external genital warts in men

We assess the safety and efficacy of imiquimod cream 3.75% and 2.5% in men with external genital warts (EGWs). Two multicenter, randomized, double-blind, placebo-controlled studies were conducted in a total of 447 (225 from study 1 and 222 from study 2) male patients (aged ≥12 years) with 2 to 30 EGWs and a total wart area of 150 mm2 or greater. Participants were randomized (2:2:1) to imiquimod cream 3.75% or 2.5% or placebo applied once daily until complete clearance or a maximum of 8 weeks (end of treatment [EOT]). There was an 8-week follow-up period (end of study [EOS]) for participants who did not achieve complete clearance by EOT. Participants who achieved complete clearance were observed for an additional 12 weeks. The primary efficacy end point was complete clearance rate. Safety assessments included visual assessment of local skin reactions, number and duration of required rest periods, adverse events (AEs), and clinical laboratory tests. Study results indicated that new imiquimod formulations are beneficial in treating EGWs in men.

Influence of a loop electrosurgical excision procedure (LEEP) on levels of cytokines in cervical secretions

Over the past decade, there has been heightened interest in determining if there is an increased risk of adverse reproductive outcomes among women who had a loop electrosurgical excision procedure (LEEP) to remove cervical intraepithelial neoplasia (CIN). The objective of this exploratory study was to determine if the treatment of CIN with a LEEP is associated with changes in cervical soluble immune markers. Cervical cytokine concentrations were measured in women treated with LEEP and a control group of women who had colposcopy only and did not undergo LEEP. Cytokines were examined in cervical secretions collected in Merocel(®) sponges at study entry and at 6-month follow-up. Cytokines were measured using a Luminex 18-plex cytokine bead assay. The mean cytokine levels were not significantly changed from baseline to follow-up in either group, with the exception of TNF-α, which decreased among women who underwent a LEEP. When the mean levels of cytokines of the treated and untreated groups at baseline or follow-up were compared, cytokine levels tended to be lower in the treated group (particularly IFN-γ, IL-6, IL-8, and MCP-1). Findings from adjusted repeated measures analyses revealed no differences between the two groups with regard to changes in cytokine levels over time. Overall, women undergoing a LEEP showed few changes in the cervical microenvironment relative to untreated women. Future studies with additional cervical environment markers and larger sample sizes are needed to determine if a LEEP is associated with dysregulation of the cervical microenvironment.

Recruitment and retention of pregnant women into clinical research trials: an overview of challenges, facilitators, and best practices

Pregnant women are a vulnerable group who are needed in clinical research studies to advance prevention and treatment options for this population. Yet, pregnant women remain underrepresented in clinical research. Through the lens of the socioecological model, we highlight reported barriers and facilitators to recruitment and retention of pregnant women in studies that sought their participation. We trace historical, policy-based reasons for the exclusion of pregnant women in clinical studies to present-day rationale for inclusion of this group. The findings highlight why it has been difficult to recruit and retain this population over time. A body of literature suggests that integrative sampling and recruitment methods that leverage the influence and reach of prenatal providers will overcome recruitment challenges. We argue that these strategies, in combination with building strong engagement with existing community-based organizations, will enable teams to more effectively promote and retain pregnant women in future longitudinal cohort studies.

Research on vaccines during pregnancy: protocol design and assessment of safety

The Division of Microbiology and Infectious Diseases at the National Institute of Allergy and Infectious Diseases, National Institutes of Health organized a series of conferences, entitled "Enrolling Pregnant Women in Clinical Trials of Vaccines and Therapeutics", to discuss study design and the assessment of safety in clinical trials conducted in pregnant women. A panel of experts was charged with developing guiding principles for the design of clinical trials and the assessment of safety of vaccines during pregnancy. Definitions and a grading system to evaluate local and systemic reactogenicity, adverse events, and other events associated with pregnancy and delivery were developed. The purpose of this report is to provide investigators interested in vaccine research in pregnancy with a basic set of tools to design and implement maternal immunization studies which may be conducted more efficiently using consistent definitions and grading of adverse events to allow the comparison of safety reports from different trials. These guidelines and safety assessment tools may be modified to meet the needs of each particular protocol based on evidence collected as investigators use them in clinical trials in different settings and share their findings and expertise.

Human papillomavirus vaccination: current indications and future directions

Human papillomavirus (HPV) is one of the most common sexually transmitted infections affecting both men and women worldwide. The development of the prophylactic HPV vaccines is a significant pharmaceutical innovation with potential to reduce HPV-related morbidity. However, barriers to the universal use and acceptability of the HPV vaccines continue to exist in both economically privileged and disadvantaged countries. It may be decades before the impact of preventive vaccines on HPV-related diseases caused by the considerable burden of HPV infections will be seen. Collaborative efforts must continue to promote vaccine implementation.

Missed opportunities: a national survey of obstetricians about attitudes on maternal and infant immunization

The recent reoccurrence of several vaccine-preventable diseases demonstrates the need for new techniques to promote childhood vaccination. Many mothers make decisions regarding vaccination of their children during pregnancy. As a result, obstetricians have a unique opportunity to influence maternal decisions on this crucial component of child health. Our objective was to understand OB/GYNs' attitudes, beliefs, and current practices toward providing vaccinations to pregnant patients and providing information about routine childhood immunizations during standard prenatal care. We surveyed OB/GYNs in the United States about their vaccination practices and perceptions during the 2009 H1N1 outbreak. Most (84%) respondents indicated their practice would be administering H1N1 vaccines to pregnant patients. While a majority (98%) of responding providers felt childhood vaccination is important, relatively few (47%) felt that they could influence mothers' vaccination choices for their children. Discussion of routine childhood immunization between obstetricians and their patients is an area for future improvements in childhood vaccination.

Neonatal outcomes after antenatal influenza immunization during the 2009 H1N1 influenza pandemic: impact on preterm birth, birth weight, and small for gestational age birth

BACKGROUND

Influenza infection during pregnancy is associated with adverse fetal outcomes such as preterm birth and small for gestational age (SGA). Maternal influenza immunization may prevent these adverse infant outcomes during periods of influenza circulation.

METHODS

We conducted a retrospective cohort study of live births within Kaiser Permanente (KP) Georgia and Mid-Atlantic States (n = 3327) during the period of 2009 influenza A (H1N1) virus circulation. Primary outcomes were third-trimester preterm birth (27-36 weeks), birth weight, low birth weight (LBW, <2500 g), and SGA.

RESULTS

There were 327 (9.8%) preterm, 236 (7.4%) LBW, and 267 (8.4%) SGA births. Among H1N1-vaccinated mothers (n = 1125), there were 86 (7.6%) preterm, 68 (6.4%) LBW, and 99 (9.3%) SGA births, and the mean birth weight was 3308.5 g (95% confidence interval [CI], 3276.6-3340.4). Among unvaccinated mothers (n = 1581), there were 191 (12.1%) preterm, 132 (8.8%) LBW, and 123 (8.2%) SGA births, and the mean birth weight was 3245.3 g (95% CI, 3216.5-3274.2). Infants of H1N1-vaccinated mothers had 37% lower odds of being born preterm than infants of unvaccinated mothers (adjusted odds ratio, 0.63 [95% CI, .47-.84]). The mean birth weight difference between infants of H1N1-vaccinated mothers and infants of unvaccinated mothers was 45.1 g (95% CI, 1.8-88.3). There was no significant association between maternal H1N1 influenza immunization and LBW or SGA.

CONCLUSIONS

Pregnant women who received H1N1 influenza vaccine were less likely to give birth preterm, and gave birth to heavier infants. The findings support US vaccine policy choices to prioritize pregnant women during the 2009 influenza A (H1N1) pandemic.

Sexual activity-related outcomes after human papillomavirus vaccination of 11- to 12-year-olds

OBJECTIVE

Previous surveys on hypothesized sexual activity changes after human papillomavirus (HPV) vaccination may be subject to self-response biases. To date, no studies measured clinical markers of sexual activity after HPV vaccination. This study evaluated sexual activity-related clinical outcomes after adolescent vaccination.

METHODS

We conducted a retrospective cohort study utilizing longitudinal electronic data from a large managed care organization. Girls enrolled in the managed care organization, aged 11 through 12 years between July 2006 and December 2007, were classified by adolescent vaccine (HPV; tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis, adsorbed; quadrivalent meningococcal conjugate) receipt. Outcomes (pregnancy/sexually transmitted infection testing or diagnosis; contraceptive counseling) were assessed through December 31, 2010, providing up to 3 years of follow-up. Incidence rate ratios comparing vaccination categories were estimated with multivariate Poisson regression, adjusting for health care-seeking behavior and demographic characteristics.

RESULTS

The cohort included 1398 girls (493 HPV vaccine-exposed; 905 HPV vaccine-unexposed). Risk of the composite outcome (any pregnancy/sexually transmitted infection testing or diagnosis or contraceptive counseling) was not significantly elevated in HPV vaccine-exposed girls relative to HPV vaccine-unexposed girls (adjusted incidence rate ratio: 1.29, 95% confidence interval [CI]: 0.92 to 1.80; incidence rate difference: 1.6/100 person-years; 95% CI: -0.03 to 3.24). Incidence rate difference for Chlamydia infection (0.06/100 person-years [95% CI: -0.30 to 0.18]) and pregnancy diagnoses (0.07/100 person-years [95% CI: -0.20 to 0.35]), indicating little clinically meaningful absolute risk differences.

CONCLUSIONS

HPV vaccination in the recommended ages was not associated with increased sexual activity-related outcome rates.

Imiquimod 3.75% cream applied daily to treat anogenital warts: combined results from women in two randomized, placebo-controlled studies

OBJECTIVE

To evaluate if new imiquimod formulations using a shorter treatment duration are safe and efficacious to treat anogenital warts.

METHODS

In two studies 534 women ≥12 years of age (mean 33.4) with 2-30 warts (mean 7.9) and total wart area ≥10 mm(2) (mean 166.3) were randomized (1:2:2) to placebo (106), imiquimod 2.5% (212) or 3.75% (216) creams applied once daily until complete clearance or a maximum of 8 weeks.

RESULTS

For placebo, imiquimod 2.5% and 3.75%, respectively, complete clearance of all warts was achieved in 14.2%, 28.3%, and 36.6% of women (intent-to-treat, P = 0.008 imiquimod 2.5%, and P < 0.001 3.75% versus placebo). Mean changes in wart counts were -10.7%, -50.9%, and -63.5% (per-protocol, P < 0.001 each active versus placebo) and safety-related discontinuation rates 0.9%, 1.4%, and 2.3%.

CONCLUSIONS

Imiquimod 3.75% applied daily for up to 8 weeks was well tolerated and superior to placebo in treating women with external anogenital warts.

End-of-study safety, immunogenicity, and efficacy of quadrivalent HPV (types 6, 11, 16, 18) recombinant vaccine in adult women 24-45 years of age

BACKGROUND

Previous analyses from a randomised trial in women aged 24-45 years have shown the quadrivalent human papillomavirus (qHPV) vaccine to be efficacious in the prevention of infection, cervical intraepithelial neoplasia (CIN), and external genital lesions (EGLs) related to HPV 6/11/16/18. In this report, we present end-of-study efficacy, safety, and immunogenicity data with a median follow-up time of 4.0 years.

METHODS

We enrolled 3819 24-45-year-old women with no history of cervical disease or genital warts in the past 5 years. Women received quadrivalent vaccine or placebo at day 1, and at months 2 and 6. Ascertainment of CIN/EGL was accomplished through Pap testing, genital inspection, and cervicovaginal sampling (every 6 months). The main analysis was conducted in a per-protocol efficacy population (that received three doses, was naive to the relevant HPV types at day 1, and remained free of infection through month 7). Efficacy was also estimated in other naive and non-naive populations.

RESULTS

Vaccine efficacy against the combined incidence of persistent infection, CIN/EGL related to HPV6/11/16/18 in the per-protocol population was 88.7% (95% CI: 78.1, 94.8). Efficacy for women who were seropositive and DNA negative for the relevant vaccine HPV type at the time of enrolment who received at least 1 dose was 66.9% (95% CI: 4.3, 90.6). At month 48, 91.5, 92.0, 97.4, and 47.9% of vaccinated women were seropositive to HPV 6/11/16/18, respectively. No serious vaccine-related adverse experiences were reported.

CONCLUSIONS

The qHPV vaccine demonstrated high efficacy, immunogenicity, and acceptable safety in women aged 24-45 years, regardless of previous exposure to HPV vaccine type.

Barriers to cervical cancer screening in Mulanje, Malawi: a qualitative study

BACKGROUND

In Malawi, cervical cancer is the most prevalent form of cancer among women, with an 80% mortality rate. The Mulanje Mission Hospital has offered free cervical cancer screening for eight years; however, patients primarily seek medical help for gynecologic complaints after the disease is inoperable.

METHODS

We investigated how women in rural Malawi make health-seeking decisions regarding cervical cancer screening using qualitative research methods. The study was conducted between May and August of 2009 in Mulanje, Malawi.

RESULTS

This study found that the primary cue to action for cervical cancer screening was symptoms of cervical cancer. Major barriers to seeking preventative screening included low knowledge levels, low perceived susceptibility and low perceived benefits from the service. Study participants did not view cervical cancer screening as critical health care. Interviews suggested that use of the service could increase if women are recruited while visiting the hospital for a different service.

CONCLUSION

This study recommends that health care providers and health educators target aspects of perceived susceptibility among their patients, including knowledge levels and personal risk assessment. We believe that continued support and advertisement of cervical cancer screening programs along with innovative recruitment strategies will increase usage density and decrease unnecessary deaths from cervical cancer in Malawi.

CXCL13 expression in Chlamydia trachomatis infection of the female reproductive tract

Chlamydia trachomatis is the most common cause of acute salpingitis worldwide. The socioeconomic impact of sexually transmitted infections (STI) caused by C. trachomatis is considerable. The purpose of this study was to investigate secretion of a unique chemokine, CXCL13, during the inflammatory process in human fallopian tube tissue in response to infection with C. trachomatis. We employed two models for our experiments: archived fallopian tube paraffin sections from known cases of salpingitis of unknown etiology and human fallopian tube organ culture established from fresh fallopian tube biopsies subsequently infected in vitro with C. trachomatis serovar E. We used immunohistochemistry, microarray analysis and cytometric bead array to study these specimens. In both models, we found that the fallopian tissue infected with C. trachomatis expressed CXCL13 and other characteristics of tertiary lymphoid tissue. In addition, we found that CXCL13 was expressed in multiple cell types, including endothelial cells, demonstrating a mechanism for the lymphoid aggregation seen in fallopian tube tissue during salpingitis and infection with C. trachomatis.

Safety, immunogenicity, and efficacy of quadrivalent human papillomavirus (types 6, 11, 16, 18) recombinant vaccine in women aged 24-45 years: a randomised, double-blind trial

BACKGROUND

Although the peak incidence of human papillomavirus (HPV) infection occurs in most populations within 5-10 years of first sexual experience, all women remain at risk for acquisition of HPV infections. We tested the safety, immunogenicity, and efficacy of the quadrivalent HPV (types 6, 11, 16, 18) L1 virus-like-particle vaccine in women aged 24-45 years.

METHODS

Women aged 24-45 years with no history of genital warts or cervical disease were enrolled from community health centres, academic health centres, and primary health-care providers into an ongoing multicentre, parallel, randomised, placebo-controlled, double-blind study. Participants were allocated by computer-generated schedule to receive quadrivalent HPV vaccine (n=1911) or placebo (n=1908) at day 1, and months 2 and 6. All study site investigators and personnel, study participants, monitors, and central laboratory personnel were blinded to treatment allocation. Coprimary efficacy endpoints were 6 months' or more duration of infection and cervical and external genital disease due to HPV 6, 11, 16, 18; and due to HPV 16 and 18 alone. Primary efficacy analyses were done in a per-protocol population, but intention-to-treat analyses were also undertaken. This study is registered with ClinicalTrials.gov, number NCT00090220.

FINDINGS

1910 women received at least one dose of vaccine and 1907 at least one dose of placebo. In the per-protocol population, efficacy against the first coprimary endpoint (disease or infection related to HPV 6, 11, 16, and 18) was 90.5% (95% CI 73.7-97.5, four of 1615 cases in the vaccine group vs 41/1607 in the placebo group) and 83.1% (50.6-95.8, four of 1601 cases vs 23/1579 cases) against the second coprimary endpoint (disease or infection related to HPV 16 and 18 alone). In the intention-to-treat population, efficacy against the first coprimary endpoint was 30.9% (95% CI 11.1-46.5, 108/1886 cases vs 154/1883 cases) and against the second coprimary endpoint was 22.6% (-2.9 to 41.9, 90/1886 cases vs 115/1883 cases), since infection and disease were present at baseline. We recorded no vaccine-related serious adverse events.

INTERPRETATION

The quadrivalent HPV vaccine is efficacious in women aged 24-45 years not infected with the relevant HPV types at enrolment.

FUNDING

Merck (USA).

Age considerations when vaccinating against HPV

Human papillomavirus (HPV) vaccines have been shown to be both highly effective and safe, and there is now considerable enthusiasm among healthcare providers to use the vaccines to reduce the burden of HPV-associated disease in women. When considering who should be vaccinated, it is important that providers understand the complex relationships between age and HPV infections. HPV infections and cervical cancer have a widespread impact on society. Cervical cancer is the cause of a significant amount of morbidity and mortality throughout the world, making it crucial to implement prophylactic HPV vaccines to prevent cervical cancer. Nationally, the target group for vaccination is pre-adolescent females who have not been sexually active or who have recently become sexually active. In the United States, the Advisory Committee on Immunization Practices recommends HPV vaccination for females aged 11 to 12 years. "Catch-up" vaccination of females aged 13 to 26 years who have not been previously vaccinated or who have missed a vaccination is also recommended, as females within this age group have the highest prevalence of HPV infection. Vaccination can still benefit females over the age of 26 years who have not been previously exposed to HPV 6, 11, 16, or 18 and those who may have new sexual partners in the future. This review discusses the various considerations that should be addressed when making recommendations of who should be vaccinated against HPV.

Programmatic issues in the implementation of an HPV vaccination program to prevent cervical cancer

BACKGROUND

Cervical cancer remains an important health problem even in countries with effective cervical screening programs. HPV vaccines offer great potential for primary prevention of cervical cancer and other HPV-related diseases.

PERSPECTIVES

Eventual implementation of an HPV vaccination program raises several key issues, including universal vs. targeted vaccinations, the age and gender of vaccine recipients, the acceptability of this vaccine to health care providers, adolescents, and parents, and the effect of this vaccine on cervical cancer screening. These issues were explored among symposium attendees during an interactive question-and-answer session using computerized voting pads.

CONCLUSIONS

Preventative HPV vaccination programs should ideally be executed universally in both women and men with an emphasis on children and adolescents prior to their first sexual experience. Parent education on HPV disease and vaccine efficacy and safety will be critical to the acceptability of HPV vaccination for their children. HPV vaccination will not eliminate the need for Pap screening. Further research will be needed to develop rational and cost-effective cervical surveillance programs for women protected by HPV vaccines.

Adherence and blocking of Candida albicans to cultured vaginal epithelial cells: treatments to decrease adherence

BACKGROUND

Pathogenesis of mucosal microorganisms depends on adherence to the tissues they colonize and infect. For Candida albicans, cell surface hydrophobicity may play a significant role in tissue binding ability.

METHODS

A continuous cell line of vaginal epithelial cells (VEC) was grown in keratinocyte serum-free medium (KSFM) with supplements and harvested by trypsinization. VEC were combined with yeast cells to evaluate adherence and inhibition of adherence. In this experimental setup, yeast stained with fluorescein isothiocyanate were allowed to attach to VEC and the resulting fluorescent VEC were detected by flow cytometry.

RESULTS

VEC were cultured and examined daily after plating and showed morphology similar to basal epithelial cells. Culture media supplemented with estradiol showed increased VEC proliferation initially (first 24 h) but cell morphology was not altered. Fluorescinated Candida cells bound effectively to the cultured VEC. Using fresh cells exposed to various preparations of K-Y, we showed that all formulations of the product reduced Candida binding to VEC by 25% to 50%. While VEC were generally harvested for use in experiments when they were near confluent growth, we allowed some cultures to grow beyond that point and discovered that cells allowed to become overgrown or stressed appeared to bind yeast cells more effectively.

CONCLUSION

Flow cytometry is a useful method for evaluating binding of stained yeast cells to cultured VEC and has demonstrated that commercially available products have the ability to interfere with the process of yeast adherence to epithelial cells.

The innate immune system is activated by stimulation of vaginal epithelial cells with Staphylococcus aureus and toxic shock syndrome toxin 1

Despite knowledge of the effects of toxic shock syndrome (TSS) toxin 1 (TSST-1) on the adaptive immune system, little is known about stimulation of the innate immune system, particularly epithelial cells. This study investigated the interactions of TSS Staphylococcus aureus and TSST-1 with human vaginal epithelial cells (HVECs) and porcine mucosal surfaces. When cocultured with HVECs for 6 h, TSS S. aureus MN8 proliferated, formed aggregates on the HVEC surfaces, and produced exotoxins. Receptor binding studies showed that 35S-TSST-1 bound to 5 x 10(4) receptors per HVEC, with saturation at 15 min. Affymetrix Human GeneChip U133A microarray analysis determined S. aureus MNSM (100 bacteria/HVEC) caused at least twofold up- or down-regulation of 410 HVEC genes by 6 h; these data were also confirmed with S. aureus MN8. TSST-1 (100 microg/ml) caused up- or down-regulation of 2,386 HVEC genes by 6 h. In response to S. aureus, the HVEC genes most up-regulated compared to those in controls were those coding for chemokines or cytokines--MIP-3alpha, 478-fold; GRO-alpha, 26-fold; GRO-beta, 14-fold; and GRO-gamma, 30-fold--suggesting activation of innate immunity. TSST-1 also caused up-regulation of chemokine/cytokine genes. Chemokine/cytokine gene up-regulation was confirmed by enzyme-linked immunosorbent assays measuring the corresponding proteins induced by S. aureus and TSST-1. S. aureus MN8, when incubated with porcine vaginal tissue, increased the flux of 35S-TSST-1 across the mucosal surface. This was accompanied by influx of lymphocytes into the upper layers of the tissue. These data suggest innate immune system activation through epithelial cells, reflected in chemokine/cytokine production and influx of lymphocytes, may cause changes in vaginal mucosa permeability, facilitating TSST-1 penetration.

Predictors of Chlamydia trachomatis infection among women attending rural Midwest family planning clinics

Objective: To determine predictors of Chlamydia trachomatis infection among women 14–24 years of age attending family planning clinics throughout a rural Midwestern state.

Methods: The study population included 16 756 women between the ages of 14 and 24 years attending family planning clinics for annual examinations throughout the state of Iowa in 1997. All women under 25 years of age having annual exams were tested for C. trachomatis during the visit. At the time of exam, both behavioral and demographic data were collected on all women participating in the study.

Results: The majority of women in the study (96%) reported no symptoms of chlamydia. Only 2.5% of all women had a positive test result. In the multivariate model, the odds ratios were significantly increased among the youngest age (14–17 years; OR = 2.2), those with mucopurulent cervicitis (OR = 3.4), cervical friability (OR = 2.2), symptomatic for infection (OR = 1.8), risk history (OR = 1.6), and black race (OR = 1.2) and predictive of a C. trachomatis infection.

Conclusions: Risk factors predictive of C. trachomatis infection among younger aged women attending family planning clinics in a Midwest rural population are consistent with predictors of infection among women attending family planning clinics across theUnited States. The overall findings suggest the importance of developing screening guidelines as a means of lowering chlamydia rates. This may be a particularly difficult task in light of the low rate of symptoms that would lead a woman to seek medical care, even in younger age women who are at higher risk. In addition, screening guidelines would be more difficult to implement in a rural setting.

Fox (forkhead) genes are involved in the dorso-ventral patterning of the Xenopus mesoderm

Fox (forkhead/winged helix) genes encode a family of transcription factors that are involved in embryonic pattern formation, regulation of tissue specific gene expression and tumorigenesis. Several of them are transcribed during Xenopus embryogenesis and are important for the patterning of ectoderm, mesoderm and endoderm. We have isolated three forkhead genes that are activated during gastrulation and play an important role in the dorso-ventral patterning of the mesoderm. XFKH1 (FoxA4b), the first vertebrate forkhead gene to be implicated in embryonic pattern formation, is expressed in the Spemann-Mangold organizer region and later in the embryonic notochord. XFKH7, the Xenopus orthologue of the murine Mfh1(Foxc2), is expressed in the presomitic mesoderm, but not in the notochord or lateral plate mesoderm. Finally, XFD-13'(FoxF1b)1 is expressed in the lateral plate mesoderm, but not in the notochord or presomitic mesoderm. Expression pattern and functional experiments indicate that these three forkhead genes are involved in the dorso-ventral patterning of the mesoderm.

Incidence of post transplant myelodysplasia/acute leukemia in non-Hodgkin's lymphoma patients compared with Hodgkin's disease patients undergoing autologous transplantation following cyclophosphamide, carmustine, and etoposide (CBV)

Secondary malignancies, particularly myelodysplasia (MDS), are serious events following high dose therapy with autologous stem cell support. We observed a higher frequency of secondary malignancies in patients with Hodgkin's disease (HD) than in patients with non-Hodgkin's lymphoma (NHL) undergoing high dose therapy with the same non-TBI conditioning regimen. Three hundred patients with Hodgkin's disease (HD) and non-Hodgkin's lymphoma (NHL) were treated with cyclophosphamide, carmustine and etoposide and autologous stem cell support from 1986 through 1994. Median follow up of survivors is 3.9 years. Five-year survival is 51% for HD and 48% for NHL. Eleven patients developed second malignancies (9/150 treated for HD vs. 2/150 treated for NHL) a median of 2.4 years from transplantation and 5.2 years from initial diagnosis. Six patients had myelodysplasia or acute leukemia (MDS/AML) and 5 had lymphomas or solid tumors. Actuarial risk of MDS/AML at five years for patients transplanted for non-Hodgkin's lymphoma is 3% (95% CI 0.6-9.6%). HD patients had significantly different pretreatment characteristics than patients with NHL. A Cox model showed that greater number of prior relapses and prior radiation therapy were significant risk factors for the development of MDS/AML. These data suggest that CBV is associated with a lower risk of secondary MDS/AML than TBI containing regimens and that much of the risk is associated with the pre-transplantation therapy. The use of autotransplantation early in the course of therapy for relapsed lymphoma might prevent some cases of MDS/AML.

Molecular basis for differing antineurogenic effects of GATA-1a and GATA-1b in Xenopus

The erythroid transcription factor GATA-1 in Xenopus has been cloned as a pair of presumably duplicated genes designated as xGATA-1a and xGATA-1b. Although both xGATA-1a and xGATA-1b are able to stimulate erythropoiesis, only xGATA-1b is capable of inhibiting neurogenesis in Xenopus embryos. Chimeras of these two genes were constructed by permuting coding and untranslated regions (UTR) on both ends of these two xGATA-1, and their neurogenesis-inhibitory effects were studied. These results reveal that (1) sequence variations between the coding regions alone do not account for the neurogenesis effect; (2) 3' UTR of xGATA-1a causes the loss of the neurogenesis inhibition of xGATA-1b; (3) 3' UTR of xGATA-1b is essential to inhibit neurogenesis. In addition, the presence of either UTR does not affect the stability of the mRNA in vitro. These observations suggest the influence of 3' UTR in xGATA-1 on the inhibition of neurogenesis.