The Impact of Vaccine Concerns on Racial/Ethnic Disparities in Influenza Vaccine Uptake Among Health Care Workers

OBJECTIVES

We explored whether collective concerns about the safety, effectiveness, and necessity of influenza vaccines mediate racial/ethnic disparities in vaccine uptake among health care workers (HCWs).

METHODS

We used a self-administered Web-based survey to assess race/ethnicity (exposure), concerns about influenza vaccination (mediator; categorized through latent class analysis), and influenza vaccine uptake (outcome) for the 2012 to 2013 influenza season among HCWs at St. Jude Children's Research Hospital in Memphis, Tennessee. We used mediation analysis to estimate prevalence ratios (PRs) and 95% confidence intervals (CIs) for the total, direct, and indirect effects of race/ethnicity on influenza vaccine uptake.

RESULTS

Non-Hispanic Blacks had lower influenza vaccine uptake than non-Hispanic Whites (total effect: PR = 0.87; 95% CI = 0.75, 0.99), largely mediated by high concern about influenza vaccines (natural indirect effect: PR = 0.89; 95% CI = 0.84, 0.94; controlled direct effect: PR = 0.98; 95% CI = 0.85, 1.1). Hispanic and Asian HCWs had modestly lower uptake than non-Hispanic Whites, also mediated by high concern about influenza vaccines.

CONCLUSIONS

Racial/ethnic disparities among HCWs could be attenuated if concerns about the safety, effectiveness, and necessity of influenza vaccines were reduced.

Inequalities in vaccination coverage for young females whose parents are informal caregivers

The effects of caregiver strain and stress on preventive health service utilization among adult family members are well-established, but the effects of informal caregiving on children of caregivers are unknown. We aimed to assess whether inequalities in vaccination coverage (specifically human papillomavirus [HPV] and influenza) exist for females aged 9 to 17 years whose parents are informal caregivers (i.e., care providers for family members or others who are not functionally independent) compared with females whose parents are not informal caregivers. Data from the 2009 Behavioral Risk Factor Surveillance System were analyzed using Poisson regression with robust variance to estimate overall and subgroup-specific HPV and influenza vaccination prevalence ratios (PRs) and corresponding 95% confidence limits (CL) comparing females whose parents were informal caregivers with females whose parents were not informal caregivers. Our unweighted study populations comprised 1645 and 1279 females aged 9 to 17 years for the HPV and influenza vaccination analyses, respectively. Overall, both HPV and influenza vaccination coverage were lower among females whose parents were informal caregivers (HPV: PR = 0.72, 95% CL: 0.53, 0.97; Influenza: PR = 0.89, 95% CL: 0.66, 1.2). Our results suggest consistently lower HPV and influenza vaccination coverage for young females whose parents are informal caregivers. Our study provides new evidence about the potential implications of caregiving on the utilization of preventive health services among children of caregivers.

Influenza vaccination coverage among adult survivors of pediatric cancer

BACKGROUND

A large proportion of long-term survivors of childhood cancer have treatment-related adverse cardiac and pulmonary late-effects, with related mortality. Consequently, this population of approximately 379,000 individuals in the U.S. is at high risk of complications from influenza infections.

PURPOSE

To estimate influenza vaccination coverage overall and among subgroups of adult survivors of pediatric cancer aged 18-64 years and to compare coverage with the general adult U.S. population.

METHODS

Data from the 2009 Behavioral Risk Factor Surveillance System were analyzed in 2013 using binomial regression to estimate influenza vaccination coverage differences (CDs) and corresponding 95% confidence limits (CLs) between adult survivors of pediatric cancer and the general U.S. population. Analyses were stratified by demographic characteristics and adjusted for design effects, non-coverage, and non-response.

RESULTS

Influenza vaccination coverage was 37% for adult pediatric cancer survivors overall and 31% for the general adult U.S. population (CD=6.3%, 95% CL=0.04%, 13%). Dramatically lower coverage was observed for non-Hispanic black survivors (6%) than for non-Hispanic blacks in the general U.S. population (26%; CD=-18%, 95% CL=-25%, -11%).

CONCLUSIONS

Although influenza vaccination coverage was modestly higher among adult survivors of pediatric cancer than the general U.S. population, coverage was less than desirable for a population with a high prevalence of cardiopulmonary conditions and early mortality, and far lower than the Healthy People 2010 goal of 60% or Healthy People 2020 goal of 80% for the general population.

The incidence of human papillomavirus infection following treatment for cervical neoplasia: a systematic review

OBJECTIVE

To systematically review the published literature in order to estimate the incidence and describe the variability of human papillomavirus (HPV) infection in women following treatment for cervical neoplasia.

METHODS

Several scientific literature databases (e.g. PubMed, ISI Web of Science) were searched through January 31, 2012. Eligible articles provided data on (i) baseline HPV infection status within 6 months prior to or at time of treatment (pre-treatment); and (ii) HPV test results for women's first visit after treatment occurring within 36 months (post-treatment). We abstracted and summarized the post-treatment incidence of newly detected HPV genotypes that were not present at pre-treatment, overall and stratified by study and other population characteristics.

RESULTS

A total of 25 studies were included, reporting post-treatment HPV incidence in nearly 2000 women. Mean patient age ranged from 31 to 43 years (median 36). Most studies used cervical exfoliated cell specimens to test for HPV DNA (n=20; 80%), using polymerase chain reaction (n=21; 84%). Cervical neoplasia treatment included loop electrical excision procedure (n=11; 44%); laser conization (n=2; 8%); laser ablation, surgical conization, cryotherapy, alpha-interferon (n=1; 4% each); or multiple treatment regimens (n=8; 32%). Follow-up times post-treatment ranged from 1.5 to 36 months (median 6). More than half of studies (n=17; 68%) estimated the incidence of any HPV type following treatment, while 7 (28%) focused specifically on high-risk (HR) HPV. HPV incidence after treatment varied widely, ranging from 0 to 47% (interquartile range: 0%-15%) in up to 3 years of follow-up after treatment. Lower HPV incidence was observed among studies that included relatively younger women, used laser conization, focused on HR-HPV rather than overall HPV infection, and had a lower proportion of recurrent cervical disease.

CONCLUSIONS

These modest summary incidence estimates from the published literature can guide clinicians, epidemiologists and health economists in developing best practices for post-treatment cervical cancer prevention.

Guillain-Barre syndrome following quadrivalent human papillomavirus vaccination among vaccine-eligible individuals in the United States

Post-marketing surveillance studies provide conflicting evidence about whether Guillain-Barre syndrome occurs more frequently following quadrivalent human papillomavirus (HPV4) vaccination. We aimed to assess whether Guillain-Barre syndrome is reported more frequently following HPV4 vaccination than other vaccinations among females and males aged 9 to 26 y in the United States. We used adverse event reports received by the United States Vaccine Adverse Event Reporting System (VAERS) between January 1, 2010 and December 31, 2012 to estimate overall, age-, and sex-specific proportional reporting ratios (PRRs) and corresponding Χ2 values for reports of Guillain-Barre syndrome between 5 and 42 d following HPV vaccination. Minimum criteria for a signal using this approach are 3 or more cases, PRR≥2, and Χ2≥4. Guillain-Barre syndrome was listed as an adverse event in 45 of 14,822 reports, of which 9 reports followed HPV4 vaccination and 36 reports followed all other vaccines. The overall, age-, and sex-specific PRR estimates were uniformly below 1. In addition, the overall, age-, and sex-specific Χ2 values were uniformly below 3. Our analysis of post-marketing surveillance data does not suggest that Guillain-Barre syndrome is reported more frequently following HPV4 vaccination than other vaccinations among vaccine-eligible females or males in the United States. Our findings may be useful when discussing the risks and benefits of HPV4 vaccination.

Human papillomavirus-associated subsequent malignancies among long-term survivors of pediatric and young adult cancers

Long-term survivors of pediatric and young adult (PAYA) cancers have a high incidence of subsequent neoplasms, but few risk factors other than cancer treatment have been identified. We aimed to describe the burden of human papillomavirus (HPV)-associated malignancies among survivors of PAYA cancers to assess whether HPV infections might be a reasonable area of future etiologic research on subsequent malignancies in this population. We used longitudinal data from 9 population-based registries of the Surveillance, Epidemiology, and End Results program collected between 1973 and 2010 to assemble a cohort of individuals who were diagnosed with any cancer between the ages of 0 and 29 years and survived at least 5 years post-diagnosis. We estimated sex-specific standardized incidence ratios (SIRs) with corresponding 95% confidence limits (CL) of HPV-associated subsequent malignancies (cervical, vaginal, vulvar, penile, anal, tongue, tonsillar, and oropharyngeal). Our study population comprised 64,547 long-term survivors of PAYA cancers diagnosed between 1973 and 2010. Compared with females in the general US population, female PAYA cancer survivors had a 40% relative excess of HPV-associated malignancies overall (SIR = 1.4, 95% CL: 1.2, 1.8). Compared with males in the general US population, male PAYA cancer survivors had a 150% relative excess of HPV-associated malignancies overall (SIR = 2.5, 95% CL: 1.9, 3.4). Our findings suggest an excess of HPV-associated malignancies among PAYA cancer survivors compared with the general US population. We hypothesize that a portion of subsequent malignancies among PAYA cancer survivors may be directly attributable to HPV infection. This hypothesis warrants exploration in future studies.

Epidemiology, policy, and racial/ethnic minority health disparities

PURPOSE

Epidemiologists have long contributed to policy efforts to address health disparities. Three examples illustrate how epidemiologists have addressed health disparities in the United States and abroad through a "social determinants of health" lens.

METHODS

To identify examples of how epidemiologic research has been applied to reduce health disparities, we queried epidemiologists engaged in disparities research in the United States, Canada, and New Zealand, and drew upon the scientific literature.

RESULTS

Resulting examples covered a wide range of topic areas. Three areas selected for their contributions to policy were: (1) epidemiology's role in definition and measurement, (2) the study of housing and asthma, and (3) the study of food policy strategies to reduce health disparities. Although epidemiologic research has done much to define and quantify health inequalities, it has generally been less successful at producing evidence that would identify targets for health equity intervention. Epidemiologists have a role to play in measurement and basic surveillance, etiologic research, intervention research, and evaluation research. However, our training and funding sources generally place greatest emphasis on surveillance and etiologic research.

CONCLUSIONS

The complexity of health disparities requires better training for epidemiologists to effectively work in multidisciplinary teams. Together we can evaluate contextual and multilevel contributions to disease and study intervention programs to gain better insights into evidenced-based health equity strategies.

Family history of non-hematologic cancers among Waldenstrom macroglobulinemia patients: a preliminary study

BACKGROUND

Little is known about the epidemiology and etiology of Waldenstrom macroglobulinemia (WM). Despite several studies of the relation between family history and B-cell disorders and WM, family history of non-hematologic cancers has not been systematically investigated. We thus examined associations of family history of breast, colorectal, lung, ovarian, and prostate cancers with WM.

METHODS

All probands aged 20-79 years with bone marrow biopsy-confirmed diagnosis of WM between May 1, 1999 and January 1, 2010 at the Bing Center for Waldenstrom Macroglobulinemia were eligible for inclusion in our analysis. We reviewed medical records for eligible probands to determine family history of cancer (defined as a cancer diagnosis for ≥1 first-degree relative(s) of the proband). Using expected values constructed from the United States National Health Interview Survey, we estimated age- and race-standardized rate ratios (RRs) for family history of breast, colorectal, lung, ovarian, and prostate cancers by WM subtype.

RESULTS

Family history of prostate cancer had the largest overall rate ratio (RR=1.4, 95% confidence limits [CL]: 1.1, 1.7), and among sporadic cases, family history of prostate and breast cancer had the largest rate ratios (prostate: RR=1.3, 95% CL: 1.1, 1.7; breast: RR=1.3, 95% CL: 1.2, 1.6).

CONCLUSION

Our study suggests that it may be worthwhile to pursue these associations in a case-control study with uniform selection and data collection for cases and controls, and at least some record-based information on family history.

Correlation coefficients in ecologic studies of environment and cancer

The objective of this study was to determine the proportion of ecologic studies published during a 20-year period regarding environmental exposures and cancer in which correlation coefficients or coefficients of determination were used as a measure of association. The authors performed a descriptive analysis of published literature by conducting a systematic review of PubMed to identify eligible ecologic studies published between 1991 and 2010. The reported measure of association was extracted for all eligible studies. During the 20-year study period, 35/105 (33%, 95% confidence limits [CL]: 25%, 43%) ecologic studies used correlation coefficients or coefficients of determination as a measure of association. These results indicate that the use of correlation coefficients and coefficients of determination as measures of association in ecologic studies of environmental exposures and cancer is relatively common, despite extensive literature discouraging their interpretation as valid measures of association.