U.S. Women with Invasive Cervical Cancer: Characteristics and Potential Barriers to Prevention

Objectives: Although invasive cervical cancer (ICC) rates have declined since the advent of screening, the annual age-adjusted ICC rate in the United States remains 7.5 per 100,000 women. Failure of recommended screening and management often precedes ICC diagnoses. The study aimed to evaluate characteristics of women with incident ICC, including potential barriers to accessing preventive care. Materials and Methods: We abstracted medical records for patients with ICC identified during 2008-2020 in five U.S. population-based surveillance sites covering 1.5 million women. We identified evidence of adverse social and medical conditions, including uninsured/underinsured, language barrier, substance use disorder, incarceration, serious mental illness, severe obesity, or pregnancy at diagnosis. We calculated descriptive frequencies and compared potential barriers by race/ethnicity, and among women with and without symptoms at diagnosis using chi-square tests. Results: Among 1,606 women with ICC (median age: 49 years; non-White: 47.4%; stage I: 54.7%), the majority (68.8%) presented with symptoms. Forty-six percent of women had at least one identified potential barrier; 15% had multiple barriers. The most common potential barriers among all women were being underinsured/uninsured (17.3%), and language (17.1%). Presence of any potential barrier was more frequent among non-White women and women with than without symptoms (p < 0.05). Conclusions: In this population-based descriptive study of women with ICC, we identified adverse circumstances that might have prevented women from seeking screening and treatment to prevent cancer. Interventions to increase appropriate cervical cancer screening and management are critical for reducing cervical cancer rates.

Human Papillomavirus Vaccination Status and Correlates Among Mid-Adult Women: Connecticut, USA, 2016-2019

Background: In 2019, the CDC expanded their recommendations for human papillomavirus (HPV) vaccination beyond age 26 years to include shared clinical decision-making (SCDM) among adults aged 27-45 years ("mid-adults"). The purpose of this study was to describe HPV vaccination status among mid-adult women before the implementation of SCDM for HPV vaccination. Methods: A cross-sectional survey was conducted during 2016-2019 in Connecticut, United States, and enrolled women born in 1981 or later (birth cohorts eligible for HPV vaccination). This analysis was restricted to participants aged 27 years and older at the time of the survey. Correlates of vaccination status, sources of vaccine information, and reasons for not receiving the vaccine were examined. Results: Among 298 participants, 64.4% had not received HPV vaccine. Other than age (younger age was associated with being vaccinated), no other demographic or behavioral correlates were associated with vaccination. Compared with unvaccinated women, vaccinated women were more likely to have heard about the HPV vaccine from a doctor (odds ratio [OR] = 3.45, 95% confidence interval [CI]: 2.00-5.88) and less likely to have heard about it from television (OR = 0.23, 95% CI: 0.13-0.41). The main reasons for not being vaccinated were "vaccine not offered" (48%) and "too old" (40%). Conclusions: A majority of mid-adult women in this study were not previously vaccinated against HPV, signaling the large opportunity for SCDM with this population. This may be facilitated by ensuring health care providers and mid-adult women know about the availability and potential benefits of HPV vaccination to inform decision making.

Human papillomavirus vaccine effectiveness by age at vaccination: A systematic review

Human papillomavirus (HPV) vaccines work by preventing infections prior to natural exposure. Thus, it is likely more effective at younger ages, and it is important to understand how effectiveness might be diminished when administered at older ages. We conducted a systematic review of HPV vaccine effectiveness studies published between 2007 and 2022 that included an analysis of effectiveness against vaccine-type HPV infections, anogenital warts, cervical abnormalities and cervical cancer by age at vaccine initiation or completion. Searching multiple databases, 21 studies were included and results were summarized descriptively. Seventeen studies found the highest vaccine effectiveness in the youngest age group. Vaccine effectiveness estimates for younger adolescents ages 9-14 years ranged from approximately 74% to 93% and from 12% to 90% for adolescents ages 15-18 years. These results demonstrate that the HPV vaccine is most effective against HPV-related disease outcomes when given at younger ages, emphasizing the importance of on-time vaccination.

Failure to Complete Multidose Vaccine Series in Early Childhood

BACKGROUND

Most early childhood immunizations require 3 to 4 doses to achieve optimal protection. Our objective was to identify factors associated with starting but not completing multidose vaccine series.

METHODS

Using 2019 National Immunization Survey-Child data, US children ages 19 to 35 months were classified in 1 of 3 vaccination patterns: (1) completed the combined 7-vaccine series, (2) did not initiate ≥1 of the 7 vaccine series, or (3) initiated all series, but did not complete ≥1 multidose series. Associations between sociodemographic factors and vaccination pattern were evaluated using multivariable log-linked binomial regression. Analyses accounted for the survey's stratified design and complex weighting.

RESULTS

Among 16 365 children, 72.9% completed the combined 7-vaccine series, 9.9% did not initiate ≥1 series, and 17.2% initiated, but did not complete ≥1 multidose series. Approximately 8.4% of children needed only 1 additional vaccine dose from 1 of the 5 multidose series to complete the combined 7-vaccine series. The strongest associations with starting but not completing multidose vaccine series were moving across state lines (adjusted prevalence ratio [aPR] = 1.45, 95% confidence interval [CI]: 1.18-1.79), number of children in the household (2 to 3: aPR = 1.29, 95% CI: 1.05-1.58; 4 or more: aPR = 1.68, 95% CI: 1.30-2.18), and lack of insurance coverage (aPR = 2.03, 95% CI: 1.42-2.91).

CONCLUSIONS

More than 1 in 6 US children initiated but did not complete all doses in multidose vaccine series, suggesting children experienced structural barriers to vaccination. Increased focus on strategies to encourage multidose series completion is needed to optimize protection from preventable diseases and achieve vaccination coverage goals.

Understanding the Factors Influencing Health Care Provider Recommendations about Adolescent Vaccines: A Proposed Framework

Health care provider recommendations are among the most important factors influencing parents' decisions to vaccinate their adolescents. However, delivery of high-quality health care provider recommendations for vaccination is not universal. There is wide variation in the strength, timeliness and consistency of the delivery of recommendations for all adolescent vaccines. The factors that influence health care providers' recommendations are multi-level and can be conceptualized in much the same way as vaccine acceptance among parents. Health care providers are influenced by their own attitudes and beliefs about a vaccine and also by the patient they are treating and by the community in which they practice as well as state and national level vaccine policy. We propose a multi-level framework for understanding the factors that influence health care providers' recommendations at the individual, interpersonal and community level to both develop and adapt interventions to improve providers' recommendations.

Messaging of Different Disease Outcomes for Human Papillomavirus Vaccination: A Systematic Review

PURPOSE

The purpose of this systematic review was to assess how messaging for human papillomavirus (HPV) vaccination to prevent different health outcomes (sexually transmitted infection, anogenital warts ([AGW], and/or cancer) influences intentions or initiation for the vaccine series.

METHODS

We searched PubMed, MEDLINE, and Embase databases for all previously published articles with an evaluation, discussion, or comparison of messages containing content about HPV infections, AGW, precancers, or cancer through June 3, 2021. Results about messages were summarized by study population and design.

RESULTS

We identified 25 studies evaluating or comparing messages containing content about HPV-associated outcomes. Study designs included randomized trials (n = 12), cross-sectional surveys (n = 8), and qualitative approaches (n = 5). Few studies directly compared different messages using randomized designs or included vaccination uptake as the outcome. While many studies found support for cancer prevention messages, some studies also found equal or greater support for messages focusing on prevention of sexually transmitted infection/AGW. Variability was observed within and between studied populations (parents/adults, adolescents, young adults, healthcare providers, and adult males) and gender (male and female adolescents).

DISCUSSION

A greater understanding and deeper attention to myriad health outcomes of HPV infections could increase vaccination uptake in a variety of populations for health promotion across the lifespan.

Computable Clinical Phenotyping of Postacute Sequelae of COVID-19 in Pediatrics Using Real-World Data

Many questions remain unanswered concerning the long-term effects of COVID-19 on children. In this report, we describe a computable phenotyping algorithm for identifying children and adolescents with postacute sequelae of COVID-19 (PASC) and pilot this tool to characterize the clinical epidemiology of pediatric PASC in a large healthcare delivery network.

Clinical and Public Health Considerations for HPV Vaccination in Midadulthood: A Narrative Review

Human papillomavirus (HPV) is an important cause of anogenital and oropharyngeal cancers, anogenital warts, and recurrent respiratory papillomatosis. Beginning in 2019, US guidelines recommended shared clinical decision-making (SCDM) for HPV vaccination among midadults (27-45 years). We conducted a narrative review of existing literature on HPV vaccination in midadults. The available evidence demonstrates that HPV vaccination in midadults is safe, efficacious, and likely to benefit both HPV-naïve midadults and those with previous infections. However, gaps in knowledge related to HPV vaccination have been identified among clinicians and midadult patients. Universal midadult HPV vaccination in the United States could avert 20 934-37 856 cancer cases over 100 years, costing $141 000-$1 471 000 per quality-adjusted life-year gained. Wide variation in these estimates reflects uncertainties in sexual behavior, HPV natural history, and naturally acquired immunity. Greater awareness among clinicians and midadult patients and broad implementation of SCDM may accelerate progress toward eliminating HPV-associated cancers and other diseases.

Parents' Acceptance of COVID-19 Compared to Human Papillomavirus Vaccines

PURPOSE

The first vaccine against SARS-CoV-2 (COVID-19) for adolescents 16 years and older in the United States received Emergency Use Authorization in December 2020. Soon after its approval, parents expressed concerns about vaccine safety for adolescents. Similar concerns about vaccine safety partially explain suboptimal human papillomavirus (HPV) vaccine uptake. This qualitative study explores similarities and differences in parents' attitudes about these two vaccines.

METHODS

Parents were recruited through social media and at health centers in Alabama. Semi-structured interviews with parents of adolescents aged 9-17 years were conducted before and after Alabama expanded age eligibility to those 16 and older. Topics included knowledge about HPV and COVID-19 vaccines, and parents' intentions to have children vaccinated. Interviews were analyzed using thematic analysis.

RESULTS

From March 11, 2021 to April 24, 2021, 21 in-depth interviews were conducted. Parents discussed the importance of HPV and COVID-19 vaccines for protecting their children's health but differences between the two related to community protection. Parents were concerned about vaccine safety but media coverage about the COVID-19 vaccine led to more favorable attitudes about the benefits of vaccination, which was not observed for HPV vaccines. Instead for HPV vaccination, parents wanted their healthcare providers' opinions about the vaccine before making a vaccination decision.

DISCUSSION

Parents had similar concerns about HPV and COVID-19 vaccines. Although provider recommendations can improve vaccine uptake, local news reports were seen to have a positive impact on COVID-19 vaccine acceptance in lieu of provider recommendation. Disseminating information online could be beneficial to promote HPV and COVID-19 vaccines.

Trends in Precancerous Cervical Lesions by Area-Based Measures of Poverty, Race, and Ethnicity, Connecticut, 2008-2018

OBJECTIVES

Trends in the incidence of precancerous cervical lesions can be monitored to evaluate the impact of human papillomavirus (HPV) vaccination. The objective of this analysis was to determine whether declines in precancerous cervical lesions varied by area-based measures of poverty, race, and ethnicity.

METHODS

We analyzed 11 years of incidence data (2008-2018) from a statewide active surveillance system of precancerous cervical lesions in Connecticut. We divided area-based measures of poverty, race, and ethnicity (percentage of the population in a census tract who were living below the federal poverty level, who were Black, and who were Hispanic) at the census-tract level into 4 groups (<5.0%, 5.0%-9.9%, 10.0%-19.9%, ≥20.0%) using recommended cut points from the Public Health Disparities Geocoding Project. We estimated incidence rates and average annual percentage changes (AAPCs) stratified by age and each area-based measure using Joinpoint regression software. We used total population and estimated screened population as denominators for each age group to calculate rates and AAPCs.

RESULTS

During 2008-2018 in Connecticut, 18 878 women aged 21-39 were diagnosed with precancerous cervical lesions. After adjusting for screening, the largest declines occurred among women aged 21-24 (AAPC = -11.5%; 95% CI, -13.6% to -9.4%). We found significant and similar annual declines (~10%-12%) in this age group across all 4 levels of poverty, race, and ethnicity.

CONCLUSIONS

This analysis adds to the growing body of evidence demonstrating the positive impact of population-level HPV vaccination among young women that appears similar across area-based measures of sociodemographic characteristics. Monitoring is necessary to ensure the continuation of this progress in all communities.

HPV type-specific trends in cervical precancers in the United States, 2008-2016

Declines in cervical intraepithelial neoplasia grades 2-3 and adenocarcinoma in situ (CIN2+) observed among young women suggest impact from human papillomavirus (HPV) vaccination. To further evaluate vaccine impact including cross-protection and type replacement, we described high-risk (HR)-HPV type-specific cervical precancer incidence rates among women aged 20-39 years, 2008-2016. We analyzed cross-sectional population-based data on 18,344 cases of CIN2+ from a 5-site surveillance system. Diagnostic specimens were tested for individual HPV types, including 14 HR-HPV types (HPV16/18/31/33/35/39/45/51/52/56/58/59/66/68). We estimated age-specific annual HR-HPV type-specific CIN2+ incidence per 100,000 screened women for individual types, vaccine HR-HPV types (HPV16/18) and non-vaccine HR-HPV types (non-HPV16/18). We evaluated trends using average annual percent changes (AAPC) and 95% confidence intervals (CI), and estimated total declines by comparing 2015-2016 to 2008-2009 using incidence rate ratios. Among 20-24-year-olds, HPV16/18-CIN2+ declined from 2008 through 2016 (AAPC: -21.3%, 95% CI: -28.1%, -13.8%), whereas no trend was observed for non-HPV16/18-CIN2+ (AAPC: -1.8%, 95% CI: -8.1%, 4.9%). After 2010, CIN2+ among 20-24-year-olds was more often caused by non-vaccine versus vaccine HR-HPV types. No significant declining trends were observed in older age groups. In 2015-2016 compared to 2008-2009, HPV16-CIN2+ declined 78%, HPV18-CIN2+ 72%, and HPV31-CIN2+ 51% among 20-24-year-olds; no increases were observed in type-specific CIN2+ incidence. Among 25-29-year-olds, HPV16-CIN2+ declined 18%; CIN2+ attributed to seven nonvaccine types increased significantly. No significant declines were observed in older groups. Significant declines in HPV16/18-CIN2+ in 20-24-year-olds and HPV16-CIN2+ in 25-29-year-olds corroborate impact of HPV vaccination. A declining trend in HPV31-CIN2+ is consistent with cross-protection from vaccination.

Assessment of Clinical Effectiveness of BNT162b2 COVID-19 Vaccine in US Adolescents

Importance

The emergence of the B.1.617.2 (Delta) variant of SARS-CoV-2 has led to increases in both infections and hospitalizations among adolescents. Little is known about the effectiveness of the BNT162b2 vaccine in adolescents in the general population, as opposed to a clinical trial population.

Objective

To estimate the effectiveness of the BNT162b2 vaccine in adolescents aged 12 to 18 years.

Design, Setting, and Participants

This was a matched case-control study among adolescents (aged 12-18 years) who had results from a SARS-CoV-2 reverse transcription-polymerase chain reaction (RT-PCR) test. Immunization histories, relevant clinical data, and RT-PCR test results were obtained from the Yale New Haven Health System's medical records between June 1, 2021, and August 15, 2021, when the Delta variant caused 92% of infections in Connecticut. Case participants were defined as adolescents who had a positive test result and an associated medical encounter. Control participants were defined as those who had a negative test result and were matched to a case participant by age, county of residence, and date of testing.

Exposures

Adolescents were defined as fully immunized if they had received 2 doses of vaccine at least 14 days before focal time.

Main Outcomes and Measures

The primary outcome measured was SARS-CoV-2 infection confirmed by RT-PCR. The vaccine's effectiveness (VE) was estimated using matched odds ratios from conditional logistic regression models. Secondary measures included estimated VE by clinical symptoms, number of vaccine doses received, and elapsed time from immunization.

Results

A total of 6901 adolescents were tested for SARS-CoV-2. The final sample comprised 186 case participants and 356 matched control participants. The median age was 14 (IQR, 13-16) years, 262 (48%) identified as female, 81 (15%) as Black, 82 (15%) as Hispanic, and 297 (55%) as White. Overall, 134 (25%) were fully immunized (case participants, 10 [5%]; control participants, 124 [35%]). The median time between immunization and the SARS-CoV-2 test was 62 days (range, 17-129 days). Within 4 months of receiving 2 doses, VE against any infection was estimated to be 91% (95% CI, 80%-96%); against asymptomatic infection, 85% (95% CI, 57%-95%). Effectiveness after a single dose was estimated to be 74% (95% CI, 18%-92%).

Conclusions and Relevance

In this retrospective case-control study of US adolescents, 2 doses of BNT162b2 vaccine appeared to provide excellent protection for at least 4 months after immunization against both symptomatic and asymptomatic SARS-CoV-2 infections.

State Laws Permitting Adolescent Consent to Human Papillomavirus Vaccination and Rates of Immunization

This national cohort study examines National Immunization Survey–Teen to assess the association of adolescents’ ability to consent to human papillomavirus vaccination without parental involvement with vaccination rates.

Parents' Perspectives on Communication and Shared Decision Making for Febrile Infants ≤60 Days Old

OBJECTIVES

Decisions about the management of febrile infants ≤60 days old may be well suited for shared decision making (SDM). Our objectives were to learn about parents' experiences with receiving and understanding information in the emergency department (ED) and their perspectives on SDM, including for decisions about lumbar puncture (LP).

METHODS

We conducted semistructured interviews with 23 parents of febrile infants ≤60 days old evaluated in the pediatric ED at an urban, academic medical center. Interviews assessed parents' experiences in the ED and their perspectives on communication and SDM. Two investigators coded the interview transcripts, refined codes, and identified themes using the constant comparative method.

RESULTS

Parents' unmet need for information negatively impacted parents' understanding, stress, and trust in the physician. Themes for parents' perspectives on SDM included the following: (1) giving parents the opportunity to express their opinions and concerns builds confidence in the decision making process, (2) parents' preferences for participation in decision making vary considerably, and (3) different perceptions about risks influence parents' preferences about having their infant undergo an LP. Although some parents would defer decision making to the physician, they still wanted to be able to express their opinions. Other parents wanted to have the final say in decision making. Parents valued risks and benefits of having their child undergo an LP differently, which influenced their preferences.

CONCLUSIONS

Physicians need to adequately inform parents to facilitate parents' understanding of information and gain their trust. Shared decision making may be warranted for decisions about whether to perform an LP, although parents' preferences for participating in decision making vary.

Factors Associated With Receipt of Meningococcal B Vaccine Among United States Adolescents, National Immunization Survey-Teen, 2017-2018

PURPOSE

In this study, we evaluated factors associated with receipt of meningococcal serogroup B (MenB) vaccine among adolescents in the United States.

METHODS

We used public use data files from the National Immunization Survey-Teen from 2017 to 2018. Logistic regression was used to model associations among sociodemographic, healthcare, and vaccination variables of interest and MenB vaccine receipt (≥1 vs. 0 dose). To explore associations between state-level meningococcal vaccination requirements and MenB vaccine uptake, we performed a secondary analysis stratified by presence of a quadrivalent meningococcal (MenACWY) vaccination requirement for secondary school attendance in the adolescent's state of residence (no requirement vs. a one- or two-dose requirement).

RESULTS

Among 7,288 adolescents, MenB vaccine receipt was significantly associated with up-to-date human papillomavirus (adjusted odds ratio [aOR] 1.74, 95% confidence interval [CI] 1.29-2.35) and MenACWY (aOR 5.81, 95% CI 4.14-8.13) vaccination status in multivariable analysis. Adolescents with private insurance were less likely to be vaccinated (aOR .61, 95% CI .46-.79) compared to adolescents with other health insurance types. In secondary analyses, health insurance was no longer significantly associated with MenB vaccine uptake among adolescents in states with a MenACWY requirement.

CONCLUSIONS

We found that MenB vaccination is associated with receipt of other vaccines recommended for use in adolescents. Adolescents with private health insurance were less likely to be vaccinated against MenB, although state MenACWY requirements appeared to modify the effect of insurance on MenB vaccine receipt. Further work to understand how these factors may influence delivery and acceptance of MenB vaccine can inform interventions and strategies to improve uptake.

Patterns of recommended vaccine receipt among women ages 24-45 years: a cross-sectional analysis

Background

Vaccine receipt among mid-adults remains low, with only one quarter of adults being up to date for all recommended vaccines. It is important to understand the myriad factors that influence vaccine receipt among mid-adult women to address these low rates.

Methods

We conducted a cross-sectional analysis of data from women ages 24–45 years collected as part of an ongoing case-control study of the effectiveness of HPV vaccine. We examined associations between demographic characteristics and healthcare utilization and receipt of individual vaccines and combinations of multiple vaccines using logistic regression analyses for three routinely recommended vaccines: tetanus, influenza and HPV.

Results

Among the 309 women enrolled in the study, only 19 (6.2%) were up to date for all three recommended vaccines and 41 (13.3%) had not received any of the recommended vaccines. A greater number of health care visits in the past year was associated with receipt of influenza (aOR = 6.37, 95% CI = 2.53, 16.1) and tetanus (aOR = 2.17, 95% CI = 1.14, 4.12) vaccines. White women were more likely to have received HPV vaccine (aOR = 2.39, 95% CI = 1.07, 5.36).

Conclusions

Uptake of recommended vaccines is low among young and mid-adult women. There is a need for greater understanding of the underlying factors influencing vaccine receipt in this population.

Housing Instability and HIV Risk: Expanding our Understanding of the Impact of Eviction and Other Landlord-Related Forced Moves

The study purpose is to comprehensively measure landlord-related forced moves (inclusive of, but not restricted to, legal eviction), and to examine whether landlord-related forced moves is associated with HIV risk. Baseline survey data was collected between 2017 and 2018 among 360 low-income participants in New Haven, Connecticut. We used multivariable logistic regression analyses to examine associations between landlord-related forced moves and HIV sexual risk outcomes. Seventy seven out of three hundred and sixty participants reported a landlord-related forced move in the past 2 years, of whom 19% reported formal eviction, 56% reported informal eviction and 25% reported both. Landlord-related forced moves were associated with higher odds of unprotected sex (AOR 1.98), concurrent sex (AOR 1.94), selling sex for money or drugs (AOR 3.28), exchange of sex for a place to live (AOR 3.29), and an HIV sexual risk composite (ARR 1.46) (p < .05 for all). We found robust associations between landlord-related forced moves and HIV sexual risk. Findings suggest that the social and economic consequences of landlord-related forced moves may impact sexual vulnerability.

SARS-CoV-2 in Nursing Homes after 3 Months of Serial, Facilitywide Point Prevalence Testing, Connecticut, USA

Nursing homes house populations that are highly vulnerable to coronavirus disease. Point prevalence surveys (PPSs) provide information on the severe acute respiratory syndrome coronavirus 2 infection status of staff and residents in nursing homes and enable isolation of infectious persons to halt disease spread. We collected 16 weeks of public health surveillance data on a subset of nursing homes (34/212) in Connecticut, USA. We fit a Poisson regression model to evaluate the association between incidence and time since serial PPS onset, adjusting for decreasing community incidence and other factors. Nursing homes conducted a combined total of 205 PPSs in staff and 232 PPSs in residents. PPS was associated with 41%-80% reduction in incidence rate in nursing homes. Our findings provide support for the use of repeated PPSs in nursing home staff and residents, combined with strong infection prevention measures such as cohorting, in contributing to outbreak control.

Effectiveness of HPV vaccine by age at vaccination and number of doses: protocol for a population-based matched case-control study

INTRODUCTION

In 2006, the first human papillomavirus (HPV) vaccine was approved by the Food and Drug Administration in the USA based on pre-licensure clinical trials that found it to be highly efficacious at preventing persistent infection and precancerous, high-grade cervical lesions (HGCLs) caused by viral types the vaccine protects against. However, the real-world effectiveness of HPV vaccines as used in clinical practice may be quite different from the efficacy found in pre-licensure clinical trials. More than 10 years have passed since the introduction of the vaccine programme. It is critical to determine if the full benefits of HPV are being realised in real-world settings.

METHODS AND ANALYSIS

The objectives of this study were to estimate the effectiveness of HPV vaccines as used in real-world clinical settings and to determine the degree to which the vaccine's effectiveness varies based on age at the time of immunisation and the number of doses received. The study will be a population-based, matched case-control study. Cases will be women with newly diagnosed HGCL associated with HPV types 16 and 18. Matched controls will be women with a normal Pap test result, matched individually to cases in a 2:1 ratio by age, a practice and date of testing. Medical records will be reviewed to determine dates of receipt of the HPV vaccine for all participants. We will use multivariate conditional logistic regression to control for potential confounders.

ETHICS AND DISSEMINATION

This protocol presents minimal risk to the subjects. This protocol has received approval from the Institutional Review Board of Yale University (HIC: 1502015308), and a Health Insurance Portability and Accountability Act (HIPAA) Waiver of Authorisation has been granted to allow investigators to recruit subjects for the study. Findings will be disseminated through peer-reviewed, open-access scientific journals and conference presentations.

Inpatient Immunization With HPV Vaccine: A Qualitative Study With Postpartum Women

INTRODUCTION

Rates of immunization with human papillomavirus (HPV) vaccine among adolescent and young adult females remain suboptimal. There is a continued need to focus on catch-up immunization. Some hospitals in the United States have implemented inpatient postpartum HPV immunization programs (IPP-HPV) as part of a strategy to improve rates of catch-up immunization. Patients' perspectives are critical to facilitating broad adoption of IPP-HPV. The objectives of this study were to understand the experiences and perspectives of postpartum women recommended to receive HPV vaccine before hospital discharge and to identify facilitators of and barriers to program implementation.

METHODS

We conducted in-depth semistructured interviews with postpartum women eligible for IPP-HPV. We used purposive sampling to ensure representation across race, ethnicity, and language. Interviews were analyzed using an iterative thematic approach.

RESULTS

The median age of participants (n = 24) was 22 years (range, 15-26 years), and six had declined the inpatient dose of HPV vaccine. Overall, women viewed IPP-HPV favorably. Facilitators of program implementation included viewing HPV vaccine as prevention, normalization of the vaccine, convenience of IPP-HPV, and the experience of a patient-centered approach. Barriers included the peripartum environment and associated stress, vaccine hesitancy, and a lack of both awareness of and knowledge about HPV vaccine.

CONCLUSIONS

IPP-HPV immunization is a strategy well-received by women for improving rates of catch-up immunization. The implementation of such programs may be optimized by increasing awareness that the vaccine is available and recommended for postpartum women, and by using a patient-centered approach that is sensitive to the needs of postpartum patients.

Monitoring HPV vaccine impact on cervical disease: Status and future directions for the era of cervical cancer elimination

Post-licensure monitoring of the impact of HPV vaccines is critical to track the progress being made toward cervical cancer elimination and to identify areas where further progress can accelerate the achievement of this important public health goal. Over the past decade, a large body of evidence has revealed convincing benefits of HPV vaccination in preventing cervical infections and precancers at the individual-level (i.e., direct effectiveness) as well as in reducing the population-level burden of disease (i.e., overall effectiveness). At this time, effectiveness of the vaccines on preventing cervical cancer is just beginning to emerge given that there is a prolonged latency period for invasive disease. As we enter the era of cervical cancer elimination, these early and promising results may be expected in other countries in the near future. Thus, monitoring the direct and overall effectiveness for cervical cancer is an urgent research priority. In this article, we summarize what is known about the effectiveness of HPV vaccines on precancerous outcomes, and we highlight considerations for continuing these important public health activities going forward to monitor progress toward cervical cancer elimination.

Development of an App to Facilitate Communication and Shared Decision-making With Parents of Febrile Infants ≤ 60 Days Old

OBJECTIVES

We aimed to develop and test a tool to engage parents of febrile infants ≤ 60 days of age evaluated in the emergency department (ED). The tool was designed to improve communication for all parents and to support shared decision-making (SDM) about whether to perform a lumbar puncture (LP) for infants 29 to 60 days of age.

METHODS

We conducted a multiphase development and testing process: 1) individual, semistructured interviews with parents and clinicians (pediatric and general emergency medicine [EM] physicians and pediatric EM nurses) to learn their preferences for a communication and SDM tool; 2) design of a "storyboard" of the tool with design impression testing; 3) development of a software application (i.e., app) prototype, called e-Care; and 4) usability testing of e-Care, using qualitative assessment and the system usability scale (SUS).

RESULTS

We interviewed 27 parents and 23 clinicians. Interviews revealed several themes, including that a communication tool should augment but not replace verbal communication; a Web-based format was preferred; and information about infections and testing, including the rationales for specific tests, would be valuable. We then developed separate versions of e-Care for infants ≤ 28 days and 29 to 60 days of age, in both English and Spanish. The e-Care app includes four sections: 1) homepage; 2) why testing is done; 3) what tests are done; and 4) what happens after testing, including a table for parents of infants 29 to 60 days of age to compare the risks/benefits of LP in preparation for an SDM conversation. Parents and clinicians reported that e-Care was understandable and helpful. The mean SUS score was 90.3 (95% confidence interval = 84 to 96.6), representing "excellent" usability.

CONCLUSIONS

The e-Care app is a useable and understandable tool to support communication and SDM with parents of febrile infants ≤ 60 days of age in the ED.

Evaluation of an Inpatient Postpartum Human Papillomavirus Immunization Program

OBJECTIVE

To evaluate the result of an inpatient postpartum human papillomavirus (HPV) immunization pilot program in a diverse, low-income patient population from an urban, hospital-based obstetrics and gynecology clinic.

METHODS

In this cohort study, we present results from the first 2 years of the inpatient postpartum HPV immunization program, in which vaccine-eligible postpartum women were identified and immunized during their hospital stays. The program was implemented after educational outreach with prenatal and postpartum clinicians and nurses. Associations between receipt of the HPV vaccine as an inpatient and the characteristics of patients, and the likelihood of and missed opportunities for receiving a subsequent dose of the HPV vaccine as an outpatient were determined using logistic regression, time-to-event analyses, chi-squared tests and t-tests.

RESULTS

From April 11, 2017, to April 10, 2019, 394 (59.2%) of 666 postpartum women were eligible for the inpatient postpartum HPV immunization program. The majority (265/394, 67.3%) received the immunization pilot program HPV dose; 36 of those 265 (13.6%) completed the series with that dose. Among women due for additional doses after hospital discharge, those who received the inpatient dose were more likely to receive a subsequent outpatient dose (138/229) than were those who did not receive an inpatient dose (39/129; hazard ratio 2.51, 95% CI 1.76-3.58). On average, there were 30.7 fewer (95% CI 5.8-55.6, P<.02) missed opportunities for subsequent outpatient doses for every 100 eligible visits among women who received the inpatient dose, compared with women who did not. By the end of the study, the proportion of women who had completed the vaccine series was higher among women who received the inpatient dose (95/265, 35.8%) than in those who did not (12 out 129, 9.3%; odds ratio 5.45, 95% CI 2.86-10.38).

CONCLUSION

The inpatient postpartum HPV immunization program was associated with increased rates of immunization and addressed a previously missed opportunity. Inpatient immunization programs can serve as a critical way to address gaps in vaccine uptake.

Natural Language Processing for Surveillance of Cervical and Anal Cancer and Precancer: Algorithm Development and Split-Validation Study

Background

Accurate identification of new diagnoses of human papillomavirus–associated cancers and precancers is an important step toward the development of strategies that optimize the use of human papillomavirus vaccines. The diagnosis of human papillomavirus cancers hinges on a histopathologic report, which is typically stored in electronic medical records as free-form, or unstructured, narrative text. Previous efforts to perform surveillance for human papillomavirus cancers have relied on the manual review of pathology reports to extract diagnostic information, a process that is both labor- and resource-intensive. Natural language processing can be used to automate the structuring and extraction of clinical data from unstructured narrative text in medical records and may provide a practical and effective method for identifying patients with vaccine-preventable human papillomavirus disease for surveillance and research.

Objective

This study's objective was to develop and assess the accuracy of a natural language processing algorithm for the identification of individuals with cancer or precancer of the cervix and anus.

Methods

A pipeline-based natural language processing algorithm was developed, which incorporated machine learning and rule-based methods to extract diagnostic elements from the narrative pathology reports. To test the algorithm’s classification accuracy, we used a split-validation study design. Full-length cervical and anal pathology reports were randomly selected from 4 clinical pathology laboratories. Two study team members, blinded to the classifications produced by the natural language processing algorithm, manually and independently reviewed all reports and classified them at the document level according to 2 domains (diagnosis and human papillomavirus testing results). Using the manual review as the gold standard, the algorithm’s performance was evaluated using standard measurements of accuracy, recall, precision, and F-measure.

Results

The natural language processing algorithm’s performance was validated on 949 pathology reports. The algorithm demonstrated accurate identification of abnormal cytology, histology, and positive human papillomavirus tests with accuracies greater than 0.91. Precision was lowest for anal histology reports (0.87, 95% CI 0.59-0.98) and highest for cervical cytology (0.98, 95% CI 0.95-0.99). The natural language processing algorithm missed 2 out of the 15 abnormal anal histology reports, which led to a relatively low recall (0.68, 95% CI 0.43-0.87).

Conclusions

This study outlines the development and validation of a freely available and easily implementable natural language processing algorithm that can automate the extraction and classification of clinical data from cervical and anal cytology and histology.

Disparities in the Epidemiology of Anal Cancer: A Cross-Sectional Time Series

Purpose: To assess the trends and sociodemographic disparities of anal cancer.

Methods: For this time series, billing claims were reviewed for all encounters between 2007 and 2011 in the Yale New Haven Health System.

Results: There were 80 new cases identified. Decreasing trends were seen in women and increasing trend in men (−30.1% and 27.3%). Diagnoses were more common in areas with the highest proportion of racial minorities (incidence rate ratio [IRR]=1.75; p≤0.01) and poverty (IRR=1.72; p=0.04).

Conclusions: Anal cancer continues to rise in men during the postvaccine era. Communities with the highest proportion of poverty and racial/ethnic minority groups bear the highest burden of disease.

Trends in High-grade Cervical Lesions and Cervical Cancer Screening in 5 States, 2008-2015

BACKGROUND

We describe changes in rates of cervical intraepithelial neoplasia grades 2, 3 and adenocarcinoma in situ (CIN2+) during a period of human papillomavirus (HPV) vaccine uptake and changing cervical cancer screening recommendations.

METHODS

We conducted population-based laboratory surveillance for CIN2+ in catchment areas in 5 states, 2008-2015. We calculated age-specific CIN2+ rates per 100000 women by age groups. We estimated incidence rate ratios (IRR) of CIN2+ for 2-year periods among all women and among screened women to evaluate changes over time.

RESULTS

A total of 16572 CIN2+ cases were reported. Among women aged 18-20 and 21-24 years, CIN2+ rates declined in all sites, whereas in women aged 25-29, 30-34, and 35-39 years, trends differed across sites. The percent of women screened annually declined in all sites and age groups. Compared to 2008-2009, rates among screened women were significantly lower for all 3 periods in women aged 18-20 years (2010-2011: IRR 0.82, 95% confidence interval [CI] 0.67-0.99; 2012-2013: IRR 0.63, 95% CI 0.47-0.85; 2014-2015: IRR 0.44, 95% CI 0.28-0.68) and lower for the latter 2 time periods in women aged 21-24 years (2012-2013: IRR 0.86, 95% CI 0.79-0.94; 2014-2015: IRR 0.61, 95% CI 0.55-0.67).

CONCLUSIONS

From 2008-2015, both CIN2+ rates and cervical cancer screening declined in women aged 18-24 years. The significant decreases in CIN2+ rates among screened women aged 18-24 years are consistent with a population-level impact of HPV vaccination.

Human Papillomavirus 16/18-Associated Cervical Lesions: Differences by Area-Based Measures of Race and Poverty

INTRODUCTION

This analysis evaluates trends in cervical lesions with human papillomavirus 16/18 detected by area-based measures of race, ethnicity, and poverty during 2008-2015.

METHODS

Trends in the proportion of lesions with human papillomavirus 16/18 detected among residents of New Haven County, Connecticut were examined by area-based measures of race, ethnicity, and poverty. Area-based measures are aggregate descriptors of census tract characteristics useful for measuring differences in health outcomes in the context of where people live. Multivariable logistic regression modeling was conducted, adjusted for individual-level race, ethnicity, and insurance status to assess the independent effects of area-based measures. Data were analyzed in 2018-2019.

RESULTS

Among women aged 21-24 years and 25-29 years, significant declines in the proportion of lesions with human papillomavirus 16/18 were observed. Among women aged 21-24 years, declines began earlier and were greater in magnitude in areas of lower poverty (OR=0.55, 95% CI=0.36, 0.85 for 2010-2012 vs 2008-2009 and OR=0.30, 95% CI=0.18, 0.51 for 2013-2015 vs 2008-2009) compared with higher poverty (OR=1.66, 95% CI=0.86, 3.21 and OR=0.48, 95% CI=0.19, 1.20). Similar patterns were observed for women aged 25-29 years, and for area-based measures of race and ethnicity.

CONCLUSIONS

Differences were observed in declines in the proportion of human papillomavirus 16/18 lesions by area-based measures since the introduction of human papillomavirus vaccines, with greater and earlier declines in areas with fewer residents living in poverty and racial minorities. Ongoing human papillomavirus vaccine impact monitoring is necessary to track differences by sociodemographic characteristics.

Effectiveness of 1, 2, and 3 Doses of Human Papillomavirus Vaccine Against High-Grade Cervical Lesions Positive for Human Papillomavirus 16 or 18

Before 2016, human papillomavirus (HPV) vaccination was recommended on a 3-dose schedule. However, many vaccine-eligible US females received fewer than 3 doses, which provided an opportunity to evaluate the real-world vaccine effectiveness (VE) of 1, 2, and 3 doses. We analyzed data on cervical intraepithelial neoplasia (CIN) grades 2-3 and adenocarcinoma in situ (designated CIN2+) from the HPV Vaccine Impact Monitoring Project (HPV-IMPACT; 2008-2014). Archived tissue from CIN2+ lesions was tested for 37 types of HPV. Women were classified by number of doses received ≥24 months before CIN2+ detection. Using a test-negative design, VE was estimated as 1 minus the adjusted odds ratio from a logistic regression model that compared vaccination history for women whose lesions tested positive for HPV-16/18 (vaccine-type cases) with that for women who had all other CIN2+ lesions (controls). Among 3,300 women with available data on CIN2+, typing results, and vaccine history, 1,561 (47%) were HPV-16/18-positive, 136 (4%) received 1 dose of HPV vaccine, 108 (3%) received 2 doses, and 325 (10%) received 3 doses. Adjusted odds ratios for vaccination with 1, 2, and 3 doses were 0.53 (95% confidence interval (CI): 0.37, 0.76; VE = 47%), 0.45 (95% CI: 0.30, 0.69; VE = 55%), and 0.26 (95% CI: 0.20, 0.35; VE = 74%), respectively. We found significant VE against vaccine-type CIN2+ after 3 doses of HPV vaccine and lower but significant VE with 1 or 2 doses.

Cognitive Bias in Clinicians' Communication about Human Papillomavirus Vaccination

National guidelines recommend human papillomavirus (HPV) vaccination for all 11-12-year-olds, but uptake among United States adolescents remains low. A major barrier to greater uptake is the lack of effective recommendations for HPV vaccine from clinicians. One potential influence on clinicians' recommendations for HPV vaccine that has been relatively unexplored is that of cognitive biases, or errors in judgement that result from 'mental shortcuts' used to make decisions under uncertainty. Therefore, we analyzed qualitative data from interviews with 32 pediatric clinicians using a framework of nine cognitive biases relevant to HPV vaccination: omission bias, ambiguity aversion, present bias, availability bias, optimism bias, naturalness bias, protected values, anchoring bias, and confirmation bias. We used a directed content analysis approach to iteratively code and analyze all transcripts in the dataset. We found evidence for several cognitive biases that were related to weaker recommendations for HPV vaccine. Commonly identified biases included anchoring bias (perception that vaccination unnecessary due to age/pubertal status); present bias (perception of burdens related to discussing vaccination), and optimism bias (belief that patient at low risk for HPV acquisition). We found less frequent evidence for ambiguity aversion (perception of missing information regarding vaccination) and omission bias (deferring vaccination). Other biases were identified infrequently or not at all. Our findings suggest that several cognitive biases may be an influence on clinicians' communication about HPV vaccine. Raising awareness of cognitive biases related to making HPV vaccine recommendations could help to strengthen the recommendations that clinicians provide.

A Multiregion Analysis of Shale Drilling Activity and Rates of Sexually Transmitted Infections in the United States

BACKGROUND

Fossil fuel extraction from deep shale rock formations using new drilling technologies such as hydraulic fracturing has rapidly increased in the Unites States over the past decade. Increases in nonlocal, specialized workers to meet the demands of this complex industry have been suggested to influence the rates of sexually transmitted infections (STIs) in counties with shale drilling activity; these associations may vary geographically. In this multiregion analysis, we examine the associations between shale drilling activity and rates of 3 reportable STIs in Colorado, North Dakota, and Texas, states with active shale drilling.

METHODS

We obtained annual reported rates of chlamydia, gonorrhea, and syphilis from the Centers for Disease Control and Prevention, number of active shale wells from Enverus (formerly known as DrillingInfo), and sociodemographic covariates from the US Census Bureau. We used multivariable mixed-effects Poisson regression modeling to estimate rate ratios (RR) with 95% confidence intervals (CIs) adjusted for potential confounders and secular trends.

RESULTS

In Texas, county-years with high drilling activity had 10% increased rates of chlamydia (RR, 1.10; 95% CI, 1.04-1.17) and 15% increased rates of gonorrhea (RR, 1.15; 95% CI, 1.04-1.28), compared with county-years with no drilling. No statistically significant associations were reported for syphilis or for any STIs in Colorado or North Dakota.

CONCLUSIONS

Associations between shale drilling and chlamydia and gonorrhea in Texas may reflect increased risk in areas with higher drilling activity and a greater number of major metropolitan areas. Interstate differences highlight the need for local epidemiology to prioritize community health policies.

Cervical adenocarcinoma in situ: Human papillomavirus types and incidence trends in five states, 2008-2015

Primary prevention through the use of human papillomavirus (HPV) vaccination is expected to impact both cervical intraepithelial neoplasia (CIN) and adenocarcinoma in situ (AIS). While CIN is well described, less is known about the epidemiology of AIS, a rare cervical precancer. We identified AIS and CIN grade 3 (CIN3) cases through population-based surveillance, and analyzed data on HPV types and incidence trends overall, and among women screened for cervical cancer. From 2008 to 2015, 470 AIS and 6,587 CIN3 cases were identified. The median age of women with AIS was older than those with CIN3 (35 vs. 31 years; p < 0.01). HPV16 was the most frequently detected type in both AIS and CIN3 (57% in AIS; 58% in CIN3), whereas HPV18 was the second most common type in AIS and less common in CIN3 (38% vs. 5%; p < 0.01). AIS lesions were more likely than CIN3 lesions to be positive for high-risk types targeted by the bivalent and quadrivalent vaccines (HPV16/18, 92% vs. 63%; p < 0.01), and 9-valent vaccine (HPV16/18/31/33/45/52/58, 95% vs. 87%; p < 0.01). AIS incidence rates decreased significantly in the 21-24 year age group (annual percent change [APC] overall: -22.1%, 95% CI: -33.9 to -8.2; APC among screened: -16.1%, 95% CI: -28.8 to -1.2), but did not decrease significantly in any older age group. This report on the largest number of genotyped AIS cases to date suggests an important opportunity for vaccine prevention of AIS, and is the first to document a decline in AIS incidence rates among young women during the vaccine era.

Feasibility and Accuracy of a Computer-Assisted Self-Interviewing Instrument to Ascertain Prior Immunization With Human Papillomavirus Vaccine by Self-Report: Cross-Sectional Analysis

Background

Ascertaining history of prior immunization with human papillomavirus (HPV) vaccine can be challenging and resource-intensive. Computer-assisted self-interviewing instruments have the potential to address some of the challenges of self-reporting, and may also reduce the time, costs, and efforts associated with ascertaining immunization status.

Objective

This study assesses both the feasibility and the accuracy of a computer-assisted self-interviewing instrument to ascertain a patient’s history of immunization with the HPV vaccine.

Methods

We developed both a survey and a Web-based data collection system using computer-assisted self-interviewing to ascertain self-reported HPV vaccine immunization history. We implemented the instrument in a sample of adult women enrolled in an ongoing study of the HPV vaccine. Vaccine records from prior sources of care were reviewed to verify reported immunization history.

Results

Among the 312 participants who provided HPV vaccine immunization history by self-report, almost all (99%) were able to do so using the computer-assisted self-interviewing instrument. The median survey completion time was 10 minutes (IQR 7-17). The accuracy of self-report was 84%, sensitivity was 89%, specificity was 80%, and the negative predictive value was 92%.

Conclusions

We found that it is feasible to collect a history of immunization with the HPV vaccine using a computer-assisted self-interviewing instrument. This approach is likely to be acceptable to adult women and is reasonably accurate in a clinical research setting.

Trends in Anogenital Wart Diagnoses in Connecticut, 2013-2017

This cross-sectional study examines trends in the diagnosis of anogenital warts over the course of 5 years in Connecticut, a state that achieved moderate uptake of human papillomavirus vaccine.

Assessing sociodemographic differences in human papillomavirus vaccine impact studies in the United States: a systematic review using narrative synthesis

OBJECTIVES

Sociodemographic disparities in the incidence and mortality of human papillomavirus (HPV)-associated conditions have been well documented in the pre-HPV vaccine era. It is still unknown if the introduction of routine vaccination has been effective in reducing these prevaccine era inequalities. The purpose of this review was to determine the utilization of sociodemographic variables to assess for disparities in population-level HPV vaccine impact research and to evaluate the current evidence for disparities in the reduction of HPV-associated conditions after vaccine introduction in the United States (US).

STUDY DESIGN

A systematic review of the literature from January 2007 through March 2018 was carried out to identify studies evaluating the impact HPV vaccines have had on the rates of HPV infection, genital warts, and cervical dysplasia (cervical intraepithelial neoplasia grades 1+) in the US. An in-depth review was then performed to synthesize these data and to assess the way prior studies have reported and evaluated for potential disparities in the vaccine's impact within various racial, ethnic, and/or socio-economic subgroups of the population.

METHODS

Vaccine impact studies measure the change in the population-level burden of disease prelicensure versus postlicensure of the vaccine. We systematically searched PubMed/Medline and Embase, combining search terms related to the HPV vaccine, sentinel surveillance, and HPV-associated conditions. Eligible studies were those with population-level, postvaccine introduction data that were conducted in the US. Finally, a cited reference search was conducted for all included articles using the Web of Science platform that accesses three major citation indexes: Science Citation Index, Social Sciences Citation Index, and Arts and Humanities Citation Index. This allowed us to screen not only the articles that were cited by our final collection of studies but also the articles that used our selected studies as one of their references. The study protocol is registered in PROSPERO (#CRD42018107579).

RESULTS

Overall, 23 of the 4139 references retrieved assessed the population-level impact of HPV vaccines between January 1, 2007, and March 29, 2018. Among these, 13 (57%) reported sociodemographic data. Only two articles reported stratified results by sociodemographic factors, thereby allowing assessment for potential disparate impact. One of these studies described differences in the impact of the vaccine by race, ethnicity, and income.

CONCLUSION

Although approximately half of the studies that assessed the impact of the HPV vaccine measured sociodemographic characteristics, few presented results in a way that allowed for the identification of potential differences in impact between the relevant subgroups of the population. Determining to what extent, if any, vaccines are reducing known sociodemographic disparities is an important public health priority and an essential step in developing immunization strategies that are beneficial for all.

Missed Opportunities for HPV Vaccination Among Vaccine-Eligible Women with High Grade Cervical Lesions

BACKGROUND

Incidence of high-grade cervical lesions (HGCL) has declined in the U.S following the introduction of the human papillomavirus (HPV) vaccine in 2006. However, many women continue to be diagnosed with HGCLs, including those eligible to receive the vaccine but did not. We determined self-reported barriers to and correlates of HPV vaccination in vaccine-eligible women diagnosed with cervical intraepithelial neoplasia grades 2, 2/3, 3 and adenocarcinoma in situ (CIN2+).

METHODS

Data from a statewide surveillance system in Connecticut for CIN 2+ during 2008-2015 were used for this analysis. Enhanced surveillance data were collected for women residing in New Haven County, including HPV vaccine history and demographic factors, through chart review and patient interviews. Women who reported being unvaccinated were asked why they did not receive the vaccine. We evaluated trends in reasons for not receiving the vaccine using a two-sided Cochran Armitage trend test. Log-binomial analysis was used to assess associations between sociodemographic characteristics and vaccination status.

RESULTS

Between 2008 and 2015, 1625 vaccine-eligible women were diagnosed with CIN2+, with 882 of these women reporting never receiving the HPV vaccine. The proportion of unvaccinated vaccine-eligible women did not significantly change from 2008 to 2015 (p = 0.18, range 49.1% to 60.0%). The most commonly reported reason for being unvaccinated was age/too old, followed by previous HPV diagnosis and no provider recommendation. Women who had public or no insurance were significantly more likely than privately insured women to report being unvaccinated (p = <0.001, p = 0.0034).

CONCLUSIONS

Commonly cited barriers to vaccination, such as age/too old and previous HPV diagnosis, are not contraindications for vaccination. Furthermore, frequent reporting of no provider recommendation underscores the important role providers play in the immunization of their patients. These results indicate the need for greater efforts by providers to dispel myths about HPV vaccine eligibility and to promote vaccination for all of their eligible patients.

HIV testing among people who inject drugs in Ivanovo and Novosibirsk, Russia

OBJECTIVE

HIV testing among people who inject drugs (PWID) in Russia has been documented to be low; however, few studies have been conducted outside of the major metropolitan cities. The aim of this study was to determine how many PWID were aware of their HIV serostatus and what motivators were associated with getting tested for HIV.

METHODS

Our analysis describes HIV testing behaviours among 593 PWID in Ivanovo and Novosibirsk, Russia. Participants completed a questionnaire and consented to HIV testing. We used logistic regression modelling to determine demographic and behavioural correlates of HIV testing.

RESULTS

Self-reported history of HIV testing was 52% in Ivanovo and 54% in Novosibirsk. Prior knowledge of serostatus was very low among PWID who tested positive (3 of 102 in Ivanovo and 0 of 11 in Novosibirsk). The most common reason for testing was doctor referral, and the most common locations were government HIV/AIDS centres and prisons. HIV testing was rarely client initiated or led by a personal motivation for being tested.

CONCLUSIONS

HIV testing in Ivanovo and Novosibirsk is suboptimal, resulting in poor knowledge of HIV serostatus. More programmes to promote HIV testing among PWID are urgently needed in both cities.

Physicians' and Nurses' Perspectives on the Decision to Perform Lumbar Punctures on Febrile Infants ≤8 Weeks Old

OBJECTIVES

There is wide variation in the decision of whether to perform lumbar punctures (LPs) on well-appearing febrile infants ≤8 weeks old. Our objectives were to identify factors that influence that decision and the barriers and facilitators to shared decision-making about LP with parents of febrile infants.

METHODS

We conducted semistructured interviews with 15 pediatric and general emergency medicine physicians and 8 pediatric emergency medicine nurses at an urban, academic medical center. Through interviews, we assessed physicians' practices and physicians' and nurses' perspectives about communication and decision-making with parents of febrile infants. Two researchers independently reviewed the transcripts, coded the data using the constant comparative method, and identified themes.

RESULTS

Five themes emerged for factors that influence physicians' decisions about whether to perform an LP: (1) the age of the infant; (2) the physician's clinical experience; (3) the physician's use of research findings; (4) the physician's values, particularly risk aversion; and (5) the role of the primary care pediatrician. Barriers and facilitators to shared decision-making identified by physicians and by nurses included factors related to their perceptions of parents' understanding and acceptance of risks, parents' emotions, physicians' assessment of whether there is clinical equipoise, and availability of follow-up with the primary care pediatrician.

CONCLUSIONS

Differences in physicians' values, use of research findings, and clinical experience likely contribute to decisions of whether to perform an LP on well-appearing febrile infants. Incorporation of parents' preferences through shared decision-making may be indicated, although there are barriers that would need to be overcome.

Trends in Human Papillomavirus Vaccine Types 16 and 18 in Cervical Precancers, 2008-2014

BACKGROUND

The impact of human papillomavirus (HPV) vaccination has been observed in the United States through declining cervical precancer incidence in young women. To further evaluate vaccine impact, we described trends in HPV vaccine types 16/18 in cervical precancers, 2008-2014.

METHODS

We analyzed data from a 5-site, population-based surveillance system. Archived specimens from women age 18-39 years diagnosed with cervical intraepithelial neoplasia grades 2-3 or adenocarcinoma in situ (CIN2+) were tested for 37 HPV types. We described the proportion and estimated number of cases of CIN2+ by HPV-type groups over time. Trends in HPV16/18-positive CIN2+ were examined, overall and by vaccination status, age, histologic grade, and race/ethnicity, using Cochrane-Armitage tests.

RESULTS

In 10,206 cases, the proportion and estimated number of cases of HPV16/18-positive CIN2+ declined from 52.7% (1,235 cases) in 2008 to 44.1% (819 cases) in 2014 (P < 0.001). Declining trends in the proportion of HPV16/18-positive CIN2+ were observed among vaccinated (55.2%-33.3%, P < 0.001) and unvaccinated (51.0%-47.3%, P = 0.03) women; ages 18-20 (48.7%-18.8%, P = 0.02), 21-24 (53.8%-44.0%, P < 0.001), 25-29 (56.9%-42.4%, P < 0.001), and 30-34 (49.8%-45.8%, P = 0.04) years; CIN2 (40.8%-29.9%, P < 0.001) and CIN2/3 (61.8%-46.2%, P < 0.001); non-Hispanic white (59.5%-47.9%, P < 0.001) and non-Hispanic black (40.7%-26.5%, P < 0.001).

CONCLUSIONS

From 2008-2014, the proportion of HPV16/18-positive CIN2+ declined, with the greatest declines in vaccinated women; declines in unvaccinated women suggest herd protection.

IMPACT

The declining proportion of HPV16/18-positive CIN2+ provides additional evidence of vaccine impact in the United States.

Eviction From Renter-occupied Households and Rates of Sexually Transmitted Infections: A County-level Ecological Analysis

BACKGROUND

Housing instability is linked to numerous health outcomes, but the specific impact of eviction from renter-occupied households, an event that has immediate implications for residential stability for low-income individuals, on sexually transmitted infections (STI) rates has not been adequately studied.

METHODS

We examined county-level associations between eviction rates in 2014 and rates of chlamydia and gonorrhea in the following year using publicly available data sources (Eviction Lab National Database and AtlasPlus, respectively). Descriptive statistics compared medians and nonparametric distributions with Krusal-Wallis tests. Linear regression was used to compare tertile categories of eviction rates and STI rates while controlling for potential confounders.

RESULTS

Median rates of chlamydia in counties with low, medium, and high rates of eviction were 229, 270, and 358 cases per 100,000 population, respectively (P < 0.001). The corresponding median rates of gonorrhea were 25, 37, and 75 cases per 100,000 population (P < 0.001). These associations remained statistically significant after controlling for all covariates in adjusted models. The beta coefficients and 95% confidence intervals (95% CI) for chlamydia and gonorrhea comparing high to low county-level eviction rates were 63.8 (95% CI, 45.1-82.5) and 20.4 (95% CI, 13.5-27.4), respectively. Similar associations were observed across levels of poverty and in both metropolitan and nonmetropolitan counties.

CONCLUSIONS

County-level eviction rates are associated with chlamydia and gonorrhea rates in a significant and robust way independent of other known predictors of STI. These results suggest that evictions result in residential instability in a way that may increase STI risk.

2465. A Pilot Program to Improve Human Papillomavirus Vaccination Status of Adolescents at a School-Based Health Center

Background

Human papillomavirus (HPV) vaccine uptake is suboptimal in the United States. School-based health centers (SBHCs) could improve rates of uptake by making HPV vaccination available in schools and more accessible and convenient to adolescents and families. To explore the potential of SBHCs to expand HPV vaccine uptake, we sought to determine whether a pilot program to actively promote the SBHC as a venue for HPV vaccine receipt could improve HPV vaccination status.

Methods

A pilot program aimed at increasing HPV vaccine uptake was implemented at a SBHC affiliated with a hospital-based primary care center (PCC) between October 2016 and June 2017. This SBHC is located in a high school and provides vaccination services, including HPV vaccine, but no systematic protocol existed to actively identify, and target for vaccination, patients who accessed clinical services at the PCC and were also enrolled in the SBHC. Immunization status of adolescents enrolled in the SBHC who were also patients of the PCC was screened by review of the common electronic health record (EHR) that is shared between both sites. Patients were eligible for inclusion if they were in need of ≥1 dose of HPV vaccine. Eligible patients were contacted by clinic staff and offered the opportunity to receive HPV vaccine at the SBHC in accordance with usual clinic practices.

Results

Of 86 patients screened, 13 were found to be eligible for HPV vaccination at the SBHC (Figure 1). By the end of the project period, 62% of those eligible had received ≥1 dose of HPV vaccine (n = 8) and 38% (n = 5) also received another vaccine (flu, meningococcal) at the same time as HPV vaccination.

Conclusion

A pilot program consisting of determining HPV immunization status and actively offering the opportunity to receive needed doses of HPV vaccine at a SBHC resulted in improvement of vaccination status among eligible patients. Success was limited by the relatively small number of patients identified. While SBHCs may be one strategy to address missed opportunities for HPV vaccination, lack of centralized immunization records among patients who receive care from multiple providers and processes to directly communicate with parents about vaccination during school hours were identified as primary challenges.

Disclosures

L. M. Niccolai, Merck: Scientific Advisor, Consulting fee.

Shale gas activity and increased rates of sexually transmitted infections in Ohio, 2000-2016

Background

The growing shale gas (“fracking”) industry depends on a mobile workforce, whose influx could have social impacts on host communities. Sexually transmitted infections (STIs) can increase through sexual mixing patterns associated with labor migration. No prior studies have quantified the relationship between shale gas activity and rates of three reportable STIs: chlamydia, gonorrhea, and syphilis.

Methods

We conducted a longitudinal, ecologic study from 2000–2016 in Ohio, situated in a prolific shale gas region in the United States (US). Data on reported cases of chlamydia, gonorrhea, and syphilis by county and year were obtained from the Ohio Department of Health. All 88 counties were classified as none, low, and high shale gas activity in each year, using data from the Ohio Department of Natural Resources. Annual rate ratios (RR) and 95% confidence intervals (95% CIs) were calculated from mixed-effects Poisson regression models evaluating the relationship between shale gas activity and reported annual STI rates while adjusting for secular trends and potential confounders obtained from the US Census.

Results

Compared to counties with no shale gas activity, counties with high activity had 21% (RR = 1.21; 95%CI = 1.08–1.36) increased rates of chlamydia and 19% (RR = 1.27; 95%CI 0.98–1.44) increased rates of gonorrhea, respectively. No association was observed for syphilis.

Conclusion

This first report of a link between shale gas activity and increased rates of both chlamydia and gonorrhea may inform local policies and community health efforts.

Declines in Human Papillomavirus (HPV)-Associated High-Grade Cervical Lesions After Introduction of HPV Vaccines in Connecticut, United States, 2008-2015

Background

Trends in human papillomavirus (HPV)-associated cervical lesions can provide an indication of vaccine impact. Our purpose was to measure trends in cervical lesions during 2008-2015 and to consider possible explanations including vaccination coverage, changes in screening for cervical cancer, and risk behaviors for acquiring HPV.

Methods

Connecticut (CT) implemented mandatory reporting of cervical intraepithelial neoplasia grades 2/3 and adenocarcinoma in situ (cervical intraepithelial neoplasia grade 2 or higher [CIN2+]) in 2008. Trends by age and birth cohort were modeled using negative binomial regression and change-point methods. To evaluate possible explanations for changes, these trends were compared to changes in HPV vaccination coverage, cervical cancer screening, an antecedent event to detection of a high-grade lesion, and changes in sexual behaviors and Chlamydia trachomatis, an infection with similar epidemiology to and shared risk factors for HPV.

Results

A significant decline in CIN2+ was first evident among women aged 21 years in 2010, followed by successive declines in women aged 22-26 years during 2011-2012. During 2008-2015, the rates of CIN2+ declined by 30%-74% among women aged 21-26 years, with greater declines observed in the younger women. Birth cohorts between 1985 and 1994 all experienced significant declines during the surveillance period, ranging from 25% to 82%. Ecological comparisons revealed substantial increases in HPV vaccination during this time period, and more modest reductions in cervical cancer screening and sexual risk behaviors.

Conclusions

The age and cohort patterns in our data suggest that declines in CIN2+ during 2008-2015 are more likely driven by HPV vaccination, introduced in 2006, than by changes in screening or risk behavior.

Lack of school requirements and clinician recommendations for human papillomavirus vaccination

BACKGROUND

A strong recommendation from a clinician is one of the best predictors of human papillomavirus (HPV) vaccination among adolescents, yet many clinicians do not provide effective recommendations. The objective of this study was to understand how the lack of school entry requirements for HPV vaccination influences clinicians' recommendations.

DESIGN AND METHODS

Semi-structured interviews with a purposive sample of 32 clinicians were conducted in 2015 in Connecticut USA. Data were analysed using an iterative thematic approach in 2016-2017.

RESULTS

Many clinicians described presenting HPV vaccination as optional or non-urgent because it is not required for school entry. This was noted to be different from how other required vaccines were discussed. Even strong recommendations were often qualified by statements about the lack of requirements. Furthermore, lack of requirements was often raised initially by clinicians and not by parents. Many clinicians agreed that requirements would simplify the recommendation, but that parents may not agree with requirements. Personal opinions about school entry requirements were mixed.

CONCLUSIONS

The current lack of school entry requirements for HPV vaccination is an important influence on clinicians' recommendations that are often framed as optional or non-urgent. Efforts are needed to strengthen the quality of clinicians' recommendations in a way that remains strong and focused on disease prevention yet uncoupled from the lack of requirements that may encourage delays. Additionally, greater support for requirements among clinicians may be needed to successfully enact requirements in the future.

Early stages of HIV treatment cascade in people living with HIV in Saint-Petersburg, Russia

The proportion of people living with HIV (PLWH) in need of antiretroviral therapy (ART) is growing rapidly in Russia. Successful treatment outcomes reduces disease progression and contributes to HIV epidemic control. We conducted a pilot study following 100 PLWH newly found eligible for ART in St. Petersburg, Russia. We determined the proportion of PLWH who initiated ART, remained in treatment, and achieved an undetectable VL during 6-month follow up. Semi-structured interviews were conducted prior the initiation of ART and progress along the cascade was assessed through medical chart review. Individual characteristics associated with successful ART outcomes were assessed as part of efforts to generate hypotheses. Almost all (96%) participants initiated ART, full retention was demonstrated by 80%, among whom 71% achieved undetectable VL. Optimal retention was associated with older age and higher education (p < 0.05). There was no significant difference in ART outcomes between those who used illicit drugs and those had not. Interventions to improve treatment effectiveness should emphasize that initiation, optimal retention and achieving an undetectable VL are independent of drug abuse status. However, our pilot study highlights the need for the further research in the examining links between individual and structural factors and ART effectiveness.

Shared Decision-Making with Parents of Acutely Ill Children: A Narrative Review

BACKGROUND

Shared decision-making (SDM) has mostly been used with adults and parents in the primary care setting, and there is limited knowledge on the use of SDM with parents of acutely ill children. The objective of this study was to review the literature on SDM with parents in the management of acutely ill children.

METHODS

We searched MEDLINE, SCOPUS, PsycINFO, the Cochrane Library, and ClinicalTrials.gov for English language studies published from the time of database inception to February, 2017. Study eligibility criterion was use of SDM with parents for children aged 18 years or younger with an acute medical problem.

RESULTS

We identified 2 ongoing clinical trials and 10 published studies that met inclusion criteria: 2 using hypothetical SDM scenarios, 1 mixed methods study, and 7 intervention studies. Only 1 study compared an SDM intervention with usual care in a randomized controlled trial. The limited literature shows that parents of acutely ill children have differing preferences for testing and/or treatment, and that they generally want the opportunity to express those preferences through an SDM process. Use of SDM often results in acutely ill children undergoing fewer and/or less intensive testing or treatment, although the effect on outcomes is unclear.

CONCLUSIONS

Parents welcome participation in SDM for management decisions with their acutely ill child. Further investigation is needed to determine how best to implement SDM with parents of acutely ill children and to assess the effect of SDM on outcomes.

Knowledge and beliefs regarding cervical cancer screening and HPV vaccination among urban and rural women in León, Nicaragua

BACKGROUND

In Nicaragua, cervical cancer is the leading cause of cancer-related death for women ages 15-44, yet access to the HPV vaccine is limited to those with financial resources to pay for it. Cervical cytology is provided free of charge in public clinics; however, only 10% of women receive Pap smears at the nationally recommended frequency. Previous studies have not investigated how beliefs regarding cervical cancer screening may differ for urban and rural populations in Nicaragua. Furthermore, no investigation has assessed Nicaraguan women's beliefs about a potential HPV immunization campaign. Given beliefs' influence on health behavior, we investigated the structural, sociocultural, and knowledge-based factors influencing women's beliefs regarding cervical cancer screening among urban and rural women in León, Nicaragua, and assessed acceptance of a potential HPV immunization program.

METHODS

Our sequential explanatory mixed-methods study consisted of two phases: (1) a close-ended questionnaire, followed by (2) a qualitative, in-depth interview. Our quantitative sample contained 117 urban and 112 rural participants aged 18-49. We assessed beliefs regarding cervical cancer screening using a 22-item scale, with higher scores indicating screening-promoting beliefs in simple linear and multiple linear regressions. Twenty qualitative interviews, exploring the sociocultural dimensions of knowledge and attitudes indicated by our quantitative findings, were conducted with a sample of 13 urban and 7 rural women aged 19-46.

RESULTS

The multiple linear regression indicates that greater knowledge of Pap smears, HPV, and cervical cancer is significantly associated with screening-promoting beliefs after adjusting for other relevant factors. There was no significant difference in screening knowledge and beliefs for urban and rural women. Four recurrent themes representing determinants of knowledge, beliefs, and attitudes regarding cervical cancer screening arose from interviews and built on quantitative findings: (1) women's embarrassment due to the intimate nature of the Pap smear and male gender of exam provider discourages screening; (2) women believe Pap smears and cervical cancer are associated with sexual promiscuity, and this association stigmatizes women with the disease; (3) knowledge of cervical cancer prevention is limited to those who regularly attend health centers; and (4) women find screening inconvenient, believing understaffed clinics increase patient wait time, limit time patients spend with clinicians, and delay Pap results. A fifth theme indicates (5) participants' acceptance of a potential HPV immunization program.

DISCUSSION

Future interventions should focus on increasing access to information about cervical cancer prevention for women who do not regularly attend health centers. Furthermore, our results suggest that if funding were allocated to make the HPV vaccine accessible in Nicaragua, it would be well received.