Vaccines

CHICAGO – Addressing vaccine-hesitant parents can cause physicians considerable stress. However, they can feel more confident by adopting one of two communication strategies after gauging the strength of antivaccine beliefs, results of a pilot study suggest.

“We found that physicians frequently feel anxious and uncomfortable when confronted with parents who are strongly vaccine hesitant. They frequently lack confidence in dispelling the various safety concerns raised by parents and find themselves frequently combating an internal desire to just avoid the conflict,” said Paul J. Carson, MD, an expert in infectious diseases in the department of public health at North Dakota State University in Fargo.

Wavebreakmedia/Thinkstock

pdnews@frontlinemedcom.com

CHICAGO – Addressing vaccine-hesitant parents can cause physicians considerable stress. However, they can feel more confident by adopting one of two communication strategies after gauging the strength of antivaccine beliefs, results of a pilot study suggest.

“We found that physicians frequently feel anxious and uncomfortable when confronted with parents who are strongly vaccine hesitant. They frequently lack confidence in dispelling the various safety concerns raised by parents and find themselves frequently combating an internal desire to just avoid the conflict,” said Paul J. Carson, MD, an expert in infectious diseases in the department of public health at North Dakota State University in Fargo.

Wavebreakmedia/Thinkstock

pdnews@frontlinemedcom.com

CHICAGO – Addressing vaccine-hesitant parents can cause physicians considerable stress. However, they can feel more confident by adopting one of two communication strategies after gauging the strength of antivaccine beliefs, results of a pilot study suggest.

“We found that physicians frequently feel anxious and uncomfortable when confronted with parents who are strongly vaccine hesitant. They frequently lack confidence in dispelling the various safety concerns raised by parents and find themselves frequently combating an internal desire to just avoid the conflict,” said Paul J. Carson, MD, an expert in infectious diseases in the department of public health at North Dakota State University in Fargo.

Wavebreakmedia/Thinkstock

pdnews@frontlinemedcom.com

African American, Hispanic, American Indian, and Alaskan Native women continue to be disproportionately affected by cervical cancer compared with white women. From 2006 to 2010, the incidence of cervical cancer in African American women was 10.3 per 100,000; in white women it was 7.2.¹ The mortality rate from cervical cancer in African American women is twice that in white women.¹ Although cervical cancer rates have decreased nationwide, significant racial health disparities persist.

See related editorial

As the first-line healthcare providers for many women, the primary care physician and the general obstetrician-gynecologist are optimally positioned to reduce these disparities.

Cervical cancer is the third most common gynecologic cancer, after uterine and ovarian cancer. Nearly 13,000 new cases are diagnosed each year in the United States, and more than 4,000 women die of it.² Fortunately, cervical cancer can be significantly prevented with adequate screening and vaccination against human papillomavirus (HPV).

WHY ARE BLACK WOMEN MORE LIKELY TO DIE OF CERVICAL CANCER?

Later stage at diagnosis. African American women are more likely to present with advanced cervical cancer than non-Hispanic white women.^3–6

Less-aggressive treatment. African American women are more likely to receive no treatment after a cancer diagnosis.⁶ Differences in treatment may be attributed to comorbid conditions, stage at cancer diagnosis, and patient refusal.^5,7

Less access to care. A study from the Surveillance, Epidemiology, and End Results program of the National Cancer Institute looked at 7,267 women (4,431 non-Hispanic white women, 1,830 Hispanic white women, and 1,006 non-Hispanic African American women) who were diagnosed with primary invasive cervical cancer from 1992 to 1996 and followed through 2000. African American women had a 19% higher mortality rate compared with non-Hispanic white women during follow-up despite adjusting for age, stage, histology, and time of first treatment.⁸

However, a later study from the same program found no such difference after 1995, when the data were adjusted for marital status, disease stage, age, treatment, grade, and histology.⁶  

Equal access to healthcare may eliminate most of the disparity.⁷ A study in women with cervical cancer who sought treatment within the United States military healthcare system found no difference in treatment or 5- and 10-year survival rates between African American and white women.⁵ Equal access to comprehensive healthcare eliminated any disparity once cervical cancer was diagnosed.

CERVICAL CANCER SCREENING

The value of cervical cancer screening and prevention is well established. In 1941, Papanicolau reported that cervical cancer could be detected from vaginal smears.⁹ Since the development and widespread implementation of the “Pap” smear, cervical cancer rates have decreased dramatically in the United States.

Another major advance was the discovery that persistent infection with HPV is necessary for the development of cervical cancer, precancerous lesions, and genital warts.¹⁰

With advancing research, guidelines for cervical cancer screening have changed considerably over the years. Today, combined cervical cytologic and HPV testing is the mainstay. (Isolated HPV testing is generally not available outside clinical trials.)

Who should be screened?

Previous recommendations called for women to undergo Pap testing when they first became sexually active and then every year. However, cervical lesions are likely to regress in young women.¹¹ One study found that 28% of cervical intimal neoplasia (CIN) grade 2 and 3 lesions spontaneously regressed by 15 weeks, although lesions associated with HPV 16 infection were less likely to regress than with other HPV types.¹² A study of college women found that HPV infection persisted in only 9% of women after 24 months.¹³

To minimize unnecessary treatment of young women with dysplasia, the American Society for Colposcopy and Cervical Pathology in 2012 recommended cytologic screening for all women 21 years or older, regardless of age at first sexual encounter.¹⁴ Screening intervals were changed from every year to every 3 years until age 30, at which time cotesting with cytology and HPV testing is performed every 5 years. Routine cotesting is not recommended for women younger than 30, who have a high likelihood of HPV infection and spontaneous regression.

In 2014, the US Food and Drug Administration approved primary HPV screening (ie, testing for HPV first, and then performing cytology in samples that test positive) for women age 25 and older.¹⁵

Patients who need further evaluation and testing should be referred for colposcopy. The current guidelines for patients who have abnormal results on cervical cancer screening¹⁶ can be reviewed at www.asccp.org/asccp-guidelines.

As screening guidelines continue to evolve, primary care physicians will need to stay current and also help educate their patients. For example, many of our patients have undergone annual Pap screening for most of their lives and may not yet know about the new testing intervals.

Are there disparities in screening and follow-up?

Disparities in screening and follow-up may exist, but the evidence is not clear-cut.

In a 2013 National Health Interview Survey report, the rates of cervical cancer screening with Pap tests did not differ between African American and white women.¹⁷ However, the information on Pap testing was based on a single question asking participants if they had had a Pap test in the last 3 years. In our experience, patients may confuse Pap tests with speculum examinations.

Once women are screened, adequate and timely follow-up of abnormal results is key.

In a study from the National Breast and Cervical Cancer Early Detection Program,¹⁸ women who had cytology findings of atypical squamous cells of undetermined significance or low-grade squamous intraepithelial lesions were to undergo repeat Pap testing every 4 to 6 months for 2 years. African American women were the least likely to have a follow-up Pap smear compared with other racial groups.  

On the other hand, there was no difference related to race in follow-up rates of abnormal Pap tests in women ages 47 to 64 in the South Carolina Breast and Cervical Cancer Early Detection Program.¹⁹

In a study in an urban population (predominantly African African), the overall follow-up rate was only 26% at 12 months from an initial abnormal Pap smear. This study did not find any differences in follow-up according to race or ethnicity; however, it had insufficient power to detect a difference because only 15% of the study participants were white.²⁰

HPV is implicated in progression to both squamous cell carcinoma and adenocarcinoma of the cervix. Worldwide, HPV genotypes 16 and 18 are associated with 73% of cases of invasive cervical cancer; most of the remainder are associated with, in order of decreasing prevalence, genotypes 58, 33, 45, 31, 52, 35, 59, 39, 51, and 56.²¹

High-grade cervical lesions in African American women may less often be positive for HPV 16 and 18 than in white women.^22,23 On the other hand, the proportion of non-Hispanic black women infected with HPV 35 and 58 was significantly higher than in non-Hispanic white women.²² Regardless, HPV screening is recommended for women of all races and ethnicities.

The 2-valent and 4-valent HPV vaccines do not cover HPV 35 or 58. The newer 9-valent vaccine covers HPV 58 (but not 35) and so may in theory decrease any potential disparity related to infection with a specific oncogenic subtype.

THE ROLE OF PREVENTION

HPV vaccination

The Females United to Unilaterally Reduce Endo/Ectocervical Disease study demonstrated that the 4-valent vaccine was highly effective against cervical intraepithelial neoplasia due to HPV 16 and 18.²⁴ In another study, the 2-valent vaccine reduced the incidence of CIN 3 or higher by 87% in women who received all 3 doses and who had no evidence of HPV infection at baseline.²⁵

HPV vaccination is expensive. Each shot costs about $130, plus the cost of administering it. Although the Vaccines for Children program covers the HPV vaccine for uninsured and underinsured children and adolescents under age 19, Medicaid coverage varies from state to state for adults over age 21.

The Advisory Committee on Immunization Practices (ACIP)²⁶ recommends routine vaccination for:

• Males 11 or 12 years old
• Females ages 9 to 26.

In October 2016, the ACIP approved a 2-dose series given 6 to 12 months apart for patients starting vaccination at ages 9 through 14 years who are not immunocompromised. Others should receive a 3-dose series, with the second dose given 1 to 2 months after the first dose and the third dose given 6 months after the first dose.²⁷ Previously, 3 doses were recommended for everyone.

Disparities in HPV vaccination rates

HPV vaccination rates among adolescents in the United States increased from 33.6% in 2013 to 41.7% in 2014.²⁸ However, HPV vaccination rates continue to lag behind those of other routine vaccines, such as Tdap and meningococcal conjugate.

Reagan-Steiner et al²⁸ reported that more black than white girls age 13 through 17 received at least 1 dose of a 3-dose HPV vaccination series, but more white girls received all 3 doses (70.6% vs 61.6%). In contrast, a meta-analysis by Fisher et al²⁹ found African American and uninsured women generally less likely to initiate the HPV vaccination series. Kessels et al³⁰ reported similar findings.

Barriers to HPV vaccination

Barriers to HPV vaccination can be provider-dependent, parental, or institutional.

Malo et al³¹ surveyed Florida Medicaid providers and found that those who participated in the Vaccines for Children program were less likely to cite lack of reimbursement as a barrier to vaccination.

Meites et al³² surveyed sexually transmitted disease clinics and found that common reasons for not offering HPV vaccine were cost, staff time, and difficulty coordinating follow-up visits to complete the series.  

Providers report lack of urgency or lack of perception of cervical cancer as a true public health threat, safety concerns regarding the vaccine, and the inability to coadminister vaccines as barriers.³³

Studies have shown that relatively few parents (up to 18%) of parents are concerned about the effect of the vaccine on sexual activity.³⁴ Rather, they are most likely to cite lack of information regarding the vaccine, lack of physician recommendation, and not knowing where to receive the vaccine as barriers.^35,36

Guerry et al³⁷ determined that the single most important factor in vaccine initiation was physician recommendation, a finding reiterated in other studies.^35,38 A study in North Carolina identified failure of physician recommendation as one of the missed opportunities for vaccination of young women.³⁹

Therefore, the primary care physician, as the initial contact with the child or young adult, holds a responsibility to narrow this gap. In simply discussing and recommending the vaccine, physicians could increase vaccination rates.

REPRODUCTIVE HEALTH

Although 80% of women will be infected with HPV in their lifetime, only a small proportion will develop cervical cancer, suggesting there are other cofactors in the progression to cervical cancer.⁴⁰

Given the infectious etiology of cervical cancer, other contributing reproductive health factors have been described. As expected, the number of sexual partners correlates with HPV infection.^41,42 Younger age at first intercourse has been linked to development of cervical neoplasia, consistent with persistent infection leading to neoplasia.^41,42

Primary care physicians should provide timely and comprehensive sexual education, including information on safe sexual practices and pregnancy prevention.

Human immunodeficiency virus

In 2010, the estimated rate of new human immunodeficiency virus (HIV) infections in African American women was nearly 20 times greater than in white women.⁴³ Previous studies have shown a clear relationship between HIV and HPV-associated cancers, including cervical neoplasia and invasive cervical cancer.^44,45

Women with HIV should receive screening for cervical cancer at the time of diagnosis, 6 months after the initial diagnosis, and annually thereafter.⁴⁶

Conflicting evidence exists regarding the effect of highly active antiretroviral therapy on the incidence of HPV-related disease, so aggressive screening and management of cervical neoplasia is recommended for women with HIV, regardless of CD4+ levels or viral load.^47–49

Coinfection with other sexually transmitted infections, specifically Chlamydia, herpes, and HIV, has been associated with cervical neoplasia and invasive cervical cancer. A positive linear association exists between the number of sexually transmitted infections and cervical neoplasia.⁵⁰

C trachomatis is the most common sexually transmitted infection in the United States, with a 6-times higher rate in African American women.⁵¹ Women who are seropositive for C trachomatis are at twofold higher risk of developing squamous cell cervical cancer.^52,53 Women who are seropositive for Chlamydia infection, herpes virus 2, or HPV are at markedly increased risk of invasive cervical cancer.⁵⁰

Tobacco use

The negative impact of smoking on numerous other cancers resulted in investigation of its role in cervical cancer.

Early case-control studies found an association between cervical cancer and smoking,⁵⁴ but because these studies did not account for HPV infection status, they could not establish causality. Subsequently, several studies did control for HPV infection; the risk of squamous cervical cancer was twice as high in women who had ever smoked.⁵⁵ Furthermore, the more cigarettes smoked per day, the higher the risk of  cervical neoplasia.^41,56

According to the US Centers for Disease Control and Prevention in 2014, the highest prevalence of smoking was among American Indian and Alaskan Native women, 32.5% of whom said they smoked every day, compared with 17.2% of white women and 13.7% of African American women.⁵⁷

HOW CAN PRIMARY CARE PHYSICIANS CLOSE THE GAP?

By promoting HPV vaccination to children and young adults, primary care physicians can help prevent cervical cancer. Moreover, primary care physicians will see most adolescents for a nonpreventive health visit, an optimal opportunity to discuss sexual activity practices and HPV vaccination.⁵⁸ Including the HPV vaccine as routine with other vaccinations can close the gap.³⁸

Screening and treatment of sexually transmitted infection during these visits can affect the risk that future HPV infection will progress to neoplasia or cancer. Persistent lifestyle modification counseling, especially smoking cessation through motivational interviewing, can lessen the risk of cervical cancer neoplasia progression.

Additionally, in light of recent changes in cervical cancer screening guidelines, the primary care physician’s role as educator is of utmost importance. In one study, although 99% of women had received a Pap test, 87% could not identify the purpose of the Pap test.⁵⁹ The primary care physician’s role is perhaps the most influential in preventing disease and, as such, has the greatest impact on a patient’s disease process.

African American, Hispanic, American Indian, and Alaskan Native women continue to be disproportionately affected by cervical cancer compared with white women. From 2006 to 2010, the incidence of cervical cancer in African American women was 10.3 per 100,000; in white women it was 7.2.¹ The mortality rate from cervical cancer in African American women is twice that in white women.¹ Although cervical cancer rates have decreased nationwide, significant racial health disparities persist.

See related editorial

As the first-line healthcare providers for many women, the primary care physician and the general obstetrician-gynecologist are optimally positioned to reduce these disparities.

Cervical cancer is the third most common gynecologic cancer, after uterine and ovarian cancer. Nearly 13,000 new cases are diagnosed each year in the United States, and more than 4,000 women die of it.² Fortunately, cervical cancer can be significantly prevented with adequate screening and vaccination against human papillomavirus (HPV).

WHY ARE BLACK WOMEN MORE LIKELY TO DIE OF CERVICAL CANCER?

Later stage at diagnosis. African American women are more likely to present with advanced cervical cancer than non-Hispanic white women.^3–6

Less-aggressive treatment. African American women are more likely to receive no treatment after a cancer diagnosis.⁶ Differences in treatment may be attributed to comorbid conditions, stage at cancer diagnosis, and patient refusal.^5,7

Less access to care. A study from the Surveillance, Epidemiology, and End Results program of the National Cancer Institute looked at 7,267 women (4,431 non-Hispanic white women, 1,830 Hispanic white women, and 1,006 non-Hispanic African American women) who were diagnosed with primary invasive cervical cancer from 1992 to 1996 and followed through 2000. African American women had a 19% higher mortality rate compared with non-Hispanic white women during follow-up despite adjusting for age, stage, histology, and time of first treatment.⁸

However, a later study from the same program found no such difference after 1995, when the data were adjusted for marital status, disease stage, age, treatment, grade, and histology.⁶  

Equal access to healthcare may eliminate most of the disparity.⁷ A study in women with cervical cancer who sought treatment within the United States military healthcare system found no difference in treatment or 5- and 10-year survival rates between African American and white women.⁵ Equal access to comprehensive healthcare eliminated any disparity once cervical cancer was diagnosed.

CERVICAL CANCER SCREENING

The value of cervical cancer screening and prevention is well established. In 1941, Papanicolau reported that cervical cancer could be detected from vaginal smears.⁹ Since the development and widespread implementation of the “Pap” smear, cervical cancer rates have decreased dramatically in the United States.

Another major advance was the discovery that persistent infection with HPV is necessary for the development of cervical cancer, precancerous lesions, and genital warts.¹⁰

With advancing research, guidelines for cervical cancer screening have changed considerably over the years. Today, combined cervical cytologic and HPV testing is the mainstay. (Isolated HPV testing is generally not available outside clinical trials.)

Who should be screened?

Previous recommendations called for women to undergo Pap testing when they first became sexually active and then every year. However, cervical lesions are likely to regress in young women.¹¹ One study found that 28% of cervical intimal neoplasia (CIN) grade 2 and 3 lesions spontaneously regressed by 15 weeks, although lesions associated with HPV 16 infection were less likely to regress than with other HPV types.¹² A study of college women found that HPV infection persisted in only 9% of women after 24 months.¹³

To minimize unnecessary treatment of young women with dysplasia, the American Society for Colposcopy and Cervical Pathology in 2012 recommended cytologic screening for all women 21 years or older, regardless of age at first sexual encounter.¹⁴ Screening intervals were changed from every year to every 3 years until age 30, at which time cotesting with cytology and HPV testing is performed every 5 years. Routine cotesting is not recommended for women younger than 30, who have a high likelihood of HPV infection and spontaneous regression.

In 2014, the US Food and Drug Administration approved primary HPV screening (ie, testing for HPV first, and then performing cytology in samples that test positive) for women age 25 and older.¹⁵

Patients who need further evaluation and testing should be referred for colposcopy. The current guidelines for patients who have abnormal results on cervical cancer screening¹⁶ can be reviewed at www.asccp.org/asccp-guidelines.

As screening guidelines continue to evolve, primary care physicians will need to stay current and also help educate their patients. For example, many of our patients have undergone annual Pap screening for most of their lives and may not yet know about the new testing intervals.

Are there disparities in screening and follow-up?

Disparities in screening and follow-up may exist, but the evidence is not clear-cut.

In a 2013 National Health Interview Survey report, the rates of cervical cancer screening with Pap tests did not differ between African American and white women.¹⁷ However, the information on Pap testing was based on a single question asking participants if they had had a Pap test in the last 3 years. In our experience, patients may confuse Pap tests with speculum examinations.

Once women are screened, adequate and timely follow-up of abnormal results is key.

In a study from the National Breast and Cervical Cancer Early Detection Program,¹⁸ women who had cytology findings of atypical squamous cells of undetermined significance or low-grade squamous intraepithelial lesions were to undergo repeat Pap testing every 4 to 6 months for 2 years. African American women were the least likely to have a follow-up Pap smear compared with other racial groups.  

On the other hand, there was no difference related to race in follow-up rates of abnormal Pap tests in women ages 47 to 64 in the South Carolina Breast and Cervical Cancer Early Detection Program.¹⁹

In a study in an urban population (predominantly African African), the overall follow-up rate was only 26% at 12 months from an initial abnormal Pap smear. This study did not find any differences in follow-up according to race or ethnicity; however, it had insufficient power to detect a difference because only 15% of the study participants were white.²⁰

HPV is implicated in progression to both squamous cell carcinoma and adenocarcinoma of the cervix. Worldwide, HPV genotypes 16 and 18 are associated with 73% of cases of invasive cervical cancer; most of the remainder are associated with, in order of decreasing prevalence, genotypes 58, 33, 45, 31, 52, 35, 59, 39, 51, and 56.²¹

High-grade cervical lesions in African American women may less often be positive for HPV 16 and 18 than in white women.^22,23 On the other hand, the proportion of non-Hispanic black women infected with HPV 35 and 58 was significantly higher than in non-Hispanic white women.²² Regardless, HPV screening is recommended for women of all races and ethnicities.

The 2-valent and 4-valent HPV vaccines do not cover HPV 35 or 58. The newer 9-valent vaccine covers HPV 58 (but not 35) and so may in theory decrease any potential disparity related to infection with a specific oncogenic subtype.

THE ROLE OF PREVENTION

HPV vaccination

The Females United to Unilaterally Reduce Endo/Ectocervical Disease study demonstrated that the 4-valent vaccine was highly effective against cervical intraepithelial neoplasia due to HPV 16 and 18.²⁴ In another study, the 2-valent vaccine reduced the incidence of CIN 3 or higher by 87% in women who received all 3 doses and who had no evidence of HPV infection at baseline.²⁵

HPV vaccination is expensive. Each shot costs about $130, plus the cost of administering it. Although the Vaccines for Children program covers the HPV vaccine for uninsured and underinsured children and adolescents under age 19, Medicaid coverage varies from state to state for adults over age 21.

The Advisory Committee on Immunization Practices (ACIP)²⁶ recommends routine vaccination for:

• Males 11 or 12 years old
• Females ages 9 to 26.

In October 2016, the ACIP approved a 2-dose series given 6 to 12 months apart for patients starting vaccination at ages 9 through 14 years who are not immunocompromised. Others should receive a 3-dose series, with the second dose given 1 to 2 months after the first dose and the third dose given 6 months after the first dose.²⁷ Previously, 3 doses were recommended for everyone.

Disparities in HPV vaccination rates

HPV vaccination rates among adolescents in the United States increased from 33.6% in 2013 to 41.7% in 2014.²⁸ However, HPV vaccination rates continue to lag behind those of other routine vaccines, such as Tdap and meningococcal conjugate.

Reagan-Steiner et al²⁸ reported that more black than white girls age 13 through 17 received at least 1 dose of a 3-dose HPV vaccination series, but more white girls received all 3 doses (70.6% vs 61.6%). In contrast, a meta-analysis by Fisher et al²⁹ found African American and uninsured women generally less likely to initiate the HPV vaccination series. Kessels et al³⁰ reported similar findings.

Barriers to HPV vaccination

Barriers to HPV vaccination can be provider-dependent, parental, or institutional.

Malo et al³¹ surveyed Florida Medicaid providers and found that those who participated in the Vaccines for Children program were less likely to cite lack of reimbursement as a barrier to vaccination.

Meites et al³² surveyed sexually transmitted disease clinics and found that common reasons for not offering HPV vaccine were cost, staff time, and difficulty coordinating follow-up visits to complete the series.  

Providers report lack of urgency or lack of perception of cervical cancer as a true public health threat, safety concerns regarding the vaccine, and the inability to coadminister vaccines as barriers.³³

Studies have shown that relatively few parents (up to 18%) of parents are concerned about the effect of the vaccine on sexual activity.³⁴ Rather, they are most likely to cite lack of information regarding the vaccine, lack of physician recommendation, and not knowing where to receive the vaccine as barriers.^35,36

Guerry et al³⁷ determined that the single most important factor in vaccine initiation was physician recommendation, a finding reiterated in other studies.^35,38 A study in North Carolina identified failure of physician recommendation as one of the missed opportunities for vaccination of young women.³⁹

Therefore, the primary care physician, as the initial contact with the child or young adult, holds a responsibility to narrow this gap. In simply discussing and recommending the vaccine, physicians could increase vaccination rates.

REPRODUCTIVE HEALTH

Although 80% of women will be infected with HPV in their lifetime, only a small proportion will develop cervical cancer, suggesting there are other cofactors in the progression to cervical cancer.⁴⁰

Given the infectious etiology of cervical cancer, other contributing reproductive health factors have been described. As expected, the number of sexual partners correlates with HPV infection.^41,42 Younger age at first intercourse has been linked to development of cervical neoplasia, consistent with persistent infection leading to neoplasia.^41,42

Primary care physicians should provide timely and comprehensive sexual education, including information on safe sexual practices and pregnancy prevention.

Human immunodeficiency virus

In 2010, the estimated rate of new human immunodeficiency virus (HIV) infections in African American women was nearly 20 times greater than in white women.⁴³ Previous studies have shown a clear relationship between HIV and HPV-associated cancers, including cervical neoplasia and invasive cervical cancer.^44,45

Women with HIV should receive screening for cervical cancer at the time of diagnosis, 6 months after the initial diagnosis, and annually thereafter.⁴⁶

Conflicting evidence exists regarding the effect of highly active antiretroviral therapy on the incidence of HPV-related disease, so aggressive screening and management of cervical neoplasia is recommended for women with HIV, regardless of CD4+ levels or viral load.^47–49

Coinfection with other sexually transmitted infections, specifically Chlamydia, herpes, and HIV, has been associated with cervical neoplasia and invasive cervical cancer. A positive linear association exists between the number of sexually transmitted infections and cervical neoplasia.⁵⁰

C trachomatis is the most common sexually transmitted infection in the United States, with a 6-times higher rate in African American women.⁵¹ Women who are seropositive for C trachomatis are at twofold higher risk of developing squamous cell cervical cancer.^52,53 Women who are seropositive for Chlamydia infection, herpes virus 2, or HPV are at markedly increased risk of invasive cervical cancer.⁵⁰

Tobacco use

The negative impact of smoking on numerous other cancers resulted in investigation of its role in cervical cancer.

Early case-control studies found an association between cervical cancer and smoking,⁵⁴ but because these studies did not account for HPV infection status, they could not establish causality. Subsequently, several studies did control for HPV infection; the risk of squamous cervical cancer was twice as high in women who had ever smoked.⁵⁵ Furthermore, the more cigarettes smoked per day, the higher the risk of  cervical neoplasia.^41,56

According to the US Centers for Disease Control and Prevention in 2014, the highest prevalence of smoking was among American Indian and Alaskan Native women, 32.5% of whom said they smoked every day, compared with 17.2% of white women and 13.7% of African American women.⁵⁷

HOW CAN PRIMARY CARE PHYSICIANS CLOSE THE GAP?

By promoting HPV vaccination to children and young adults, primary care physicians can help prevent cervical cancer. Moreover, primary care physicians will see most adolescents for a nonpreventive health visit, an optimal opportunity to discuss sexual activity practices and HPV vaccination.⁵⁸ Including the HPV vaccine as routine with other vaccinations can close the gap.³⁸

Screening and treatment of sexually transmitted infection during these visits can affect the risk that future HPV infection will progress to neoplasia or cancer. Persistent lifestyle modification counseling, especially smoking cessation through motivational interviewing, can lessen the risk of cervical cancer neoplasia progression.

Additionally, in light of recent changes in cervical cancer screening guidelines, the primary care physician’s role as educator is of utmost importance. In one study, although 99% of women had received a Pap test, 87% could not identify the purpose of the Pap test.⁵⁹ The primary care physician’s role is perhaps the most influential in preventing disease and, as such, has the greatest impact on a patient’s disease process.

African American, Hispanic, American Indian, and Alaskan Native women continue to be disproportionately affected by cervical cancer compared with white women. From 2006 to 2010, the incidence of cervical cancer in African American women was 10.3 per 100,000; in white women it was 7.2.¹ The mortality rate from cervical cancer in African American women is twice that in white women.¹ Although cervical cancer rates have decreased nationwide, significant racial health disparities persist.

See related editorial

As the first-line healthcare providers for many women, the primary care physician and the general obstetrician-gynecologist are optimally positioned to reduce these disparities.

Cervical cancer is the third most common gynecologic cancer, after uterine and ovarian cancer. Nearly 13,000 new cases are diagnosed each year in the United States, and more than 4,000 women die of it.² Fortunately, cervical cancer can be significantly prevented with adequate screening and vaccination against human papillomavirus (HPV).

WHY ARE BLACK WOMEN MORE LIKELY TO DIE OF CERVICAL CANCER?

Later stage at diagnosis. African American women are more likely to present with advanced cervical cancer than non-Hispanic white women.^3–6

Less-aggressive treatment. African American women are more likely to receive no treatment after a cancer diagnosis.⁶ Differences in treatment may be attributed to comorbid conditions, stage at cancer diagnosis, and patient refusal.^5,7

Less access to care. A study from the Surveillance, Epidemiology, and End Results program of the National Cancer Institute looked at 7,267 women (4,431 non-Hispanic white women, 1,830 Hispanic white women, and 1,006 non-Hispanic African American women) who were diagnosed with primary invasive cervical cancer from 1992 to 1996 and followed through 2000. African American women had a 19% higher mortality rate compared with non-Hispanic white women during follow-up despite adjusting for age, stage, histology, and time of first treatment.⁸

However, a later study from the same program found no such difference after 1995, when the data were adjusted for marital status, disease stage, age, treatment, grade, and histology.⁶  

Equal access to healthcare may eliminate most of the disparity.⁷ A study in women with cervical cancer who sought treatment within the United States military healthcare system found no difference in treatment or 5- and 10-year survival rates between African American and white women.⁵ Equal access to comprehensive healthcare eliminated any disparity once cervical cancer was diagnosed.

CERVICAL CANCER SCREENING

The value of cervical cancer screening and prevention is well established. In 1941, Papanicolau reported that cervical cancer could be detected from vaginal smears.⁹ Since the development and widespread implementation of the “Pap” smear, cervical cancer rates have decreased dramatically in the United States.

Another major advance was the discovery that persistent infection with HPV is necessary for the development of cervical cancer, precancerous lesions, and genital warts.¹⁰

With advancing research, guidelines for cervical cancer screening have changed considerably over the years. Today, combined cervical cytologic and HPV testing is the mainstay. (Isolated HPV testing is generally not available outside clinical trials.)

Who should be screened?

Previous recommendations called for women to undergo Pap testing when they first became sexually active and then every year. However, cervical lesions are likely to regress in young women.¹¹ One study found that 28% of cervical intimal neoplasia (CIN) grade 2 and 3 lesions spontaneously regressed by 15 weeks, although lesions associated with HPV 16 infection were less likely to regress than with other HPV types.¹² A study of college women found that HPV infection persisted in only 9% of women after 24 months.¹³

To minimize unnecessary treatment of young women with dysplasia, the American Society for Colposcopy and Cervical Pathology in 2012 recommended cytologic screening for all women 21 years or older, regardless of age at first sexual encounter.¹⁴ Screening intervals were changed from every year to every 3 years until age 30, at which time cotesting with cytology and HPV testing is performed every 5 years. Routine cotesting is not recommended for women younger than 30, who have a high likelihood of HPV infection and spontaneous regression.

In 2014, the US Food and Drug Administration approved primary HPV screening (ie, testing for HPV first, and then performing cytology in samples that test positive) for women age 25 and older.¹⁵

Patients who need further evaluation and testing should be referred for colposcopy. The current guidelines for patients who have abnormal results on cervical cancer screening¹⁶ can be reviewed at www.asccp.org/asccp-guidelines.

As screening guidelines continue to evolve, primary care physicians will need to stay current and also help educate their patients. For example, many of our patients have undergone annual Pap screening for most of their lives and may not yet know about the new testing intervals.

Are there disparities in screening and follow-up?

Disparities in screening and follow-up may exist, but the evidence is not clear-cut.

In a 2013 National Health Interview Survey report, the rates of cervical cancer screening with Pap tests did not differ between African American and white women.¹⁷ However, the information on Pap testing was based on a single question asking participants if they had had a Pap test in the last 3 years. In our experience, patients may confuse Pap tests with speculum examinations.

Once women are screened, adequate and timely follow-up of abnormal results is key.

In a study from the National Breast and Cervical Cancer Early Detection Program,¹⁸ women who had cytology findings of atypical squamous cells of undetermined significance or low-grade squamous intraepithelial lesions were to undergo repeat Pap testing every 4 to 6 months for 2 years. African American women were the least likely to have a follow-up Pap smear compared with other racial groups.  

On the other hand, there was no difference related to race in follow-up rates of abnormal Pap tests in women ages 47 to 64 in the South Carolina Breast and Cervical Cancer Early Detection Program.¹⁹

In a study in an urban population (predominantly African African), the overall follow-up rate was only 26% at 12 months from an initial abnormal Pap smear. This study did not find any differences in follow-up according to race or ethnicity; however, it had insufficient power to detect a difference because only 15% of the study participants were white.²⁰

HPV is implicated in progression to both squamous cell carcinoma and adenocarcinoma of the cervix. Worldwide, HPV genotypes 16 and 18 are associated with 73% of cases of invasive cervical cancer; most of the remainder are associated with, in order of decreasing prevalence, genotypes 58, 33, 45, 31, 52, 35, 59, 39, 51, and 56.²¹

High-grade cervical lesions in African American women may less often be positive for HPV 16 and 18 than in white women.^22,23 On the other hand, the proportion of non-Hispanic black women infected with HPV 35 and 58 was significantly higher than in non-Hispanic white women.²² Regardless, HPV screening is recommended for women of all races and ethnicities.

The 2-valent and 4-valent HPV vaccines do not cover HPV 35 or 58. The newer 9-valent vaccine covers HPV 58 (but not 35) and so may in theory decrease any potential disparity related to infection with a specific oncogenic subtype.

THE ROLE OF PREVENTION

HPV vaccination

The Females United to Unilaterally Reduce Endo/Ectocervical Disease study demonstrated that the 4-valent vaccine was highly effective against cervical intraepithelial neoplasia due to HPV 16 and 18.²⁴ In another study, the 2-valent vaccine reduced the incidence of CIN 3 or higher by 87% in women who received all 3 doses and who had no evidence of HPV infection at baseline.²⁵

HPV vaccination is expensive. Each shot costs about $130, plus the cost of administering it. Although the Vaccines for Children program covers the HPV vaccine for uninsured and underinsured children and adolescents under age 19, Medicaid coverage varies from state to state for adults over age 21.

The Advisory Committee on Immunization Practices (ACIP)²⁶ recommends routine vaccination for:

• Males 11 or 12 years old
• Females ages 9 to 26.

In October 2016, the ACIP approved a 2-dose series given 6 to 12 months apart for patients starting vaccination at ages 9 through 14 years who are not immunocompromised. Others should receive a 3-dose series, with the second dose given 1 to 2 months after the first dose and the third dose given 6 months after the first dose.²⁷ Previously, 3 doses were recommended for everyone.

Disparities in HPV vaccination rates

HPV vaccination rates among adolescents in the United States increased from 33.6% in 2013 to 41.7% in 2014.²⁸ However, HPV vaccination rates continue to lag behind those of other routine vaccines, such as Tdap and meningococcal conjugate.

Reagan-Steiner et al²⁸ reported that more black than white girls age 13 through 17 received at least 1 dose of a 3-dose HPV vaccination series, but more white girls received all 3 doses (70.6% vs 61.6%). In contrast, a meta-analysis by Fisher et al²⁹ found African American and uninsured women generally less likely to initiate the HPV vaccination series. Kessels et al³⁰ reported similar findings.

Barriers to HPV vaccination

Barriers to HPV vaccination can be provider-dependent, parental, or institutional.

Malo et al³¹ surveyed Florida Medicaid providers and found that those who participated in the Vaccines for Children program were less likely to cite lack of reimbursement as a barrier to vaccination.

Meites et al³² surveyed sexually transmitted disease clinics and found that common reasons for not offering HPV vaccine were cost, staff time, and difficulty coordinating follow-up visits to complete the series.  

Providers report lack of urgency or lack of perception of cervical cancer as a true public health threat, safety concerns regarding the vaccine, and the inability to coadminister vaccines as barriers.³³

Studies have shown that relatively few parents (up to 18%) of parents are concerned about the effect of the vaccine on sexual activity.³⁴ Rather, they are most likely to cite lack of information regarding the vaccine, lack of physician recommendation, and not knowing where to receive the vaccine as barriers.^35,36

Guerry et al³⁷ determined that the single most important factor in vaccine initiation was physician recommendation, a finding reiterated in other studies.^35,38 A study in North Carolina identified failure of physician recommendation as one of the missed opportunities for vaccination of young women.³⁹

Therefore, the primary care physician, as the initial contact with the child or young adult, holds a responsibility to narrow this gap. In simply discussing and recommending the vaccine, physicians could increase vaccination rates.

REPRODUCTIVE HEALTH

Although 80% of women will be infected with HPV in their lifetime, only a small proportion will develop cervical cancer, suggesting there are other cofactors in the progression to cervical cancer.⁴⁰

Given the infectious etiology of cervical cancer, other contributing reproductive health factors have been described. As expected, the number of sexual partners correlates with HPV infection.^41,42 Younger age at first intercourse has been linked to development of cervical neoplasia, consistent with persistent infection leading to neoplasia.^41,42

Primary care physicians should provide timely and comprehensive sexual education, including information on safe sexual practices and pregnancy prevention.

Human immunodeficiency virus

In 2010, the estimated rate of new human immunodeficiency virus (HIV) infections in African American women was nearly 20 times greater than in white women.⁴³ Previous studies have shown a clear relationship between HIV and HPV-associated cancers, including cervical neoplasia and invasive cervical cancer.^44,45

Women with HIV should receive screening for cervical cancer at the time of diagnosis, 6 months after the initial diagnosis, and annually thereafter.⁴⁶

Conflicting evidence exists regarding the effect of highly active antiretroviral therapy on the incidence of HPV-related disease, so aggressive screening and management of cervical neoplasia is recommended for women with HIV, regardless of CD4+ levels or viral load.^47–49

Coinfection with other sexually transmitted infections, specifically Chlamydia, herpes, and HIV, has been associated with cervical neoplasia and invasive cervical cancer. A positive linear association exists between the number of sexually transmitted infections and cervical neoplasia.⁵⁰

C trachomatis is the most common sexually transmitted infection in the United States, with a 6-times higher rate in African American women.⁵¹ Women who are seropositive for C trachomatis are at twofold higher risk of developing squamous cell cervical cancer.^52,53 Women who are seropositive for Chlamydia infection, herpes virus 2, or HPV are at markedly increased risk of invasive cervical cancer.⁵⁰

Tobacco use

The negative impact of smoking on numerous other cancers resulted in investigation of its role in cervical cancer.

Early case-control studies found an association between cervical cancer and smoking,⁵⁴ but because these studies did not account for HPV infection status, they could not establish causality. Subsequently, several studies did control for HPV infection; the risk of squamous cervical cancer was twice as high in women who had ever smoked.⁵⁵ Furthermore, the more cigarettes smoked per day, the higher the risk of  cervical neoplasia.^41,56

According to the US Centers for Disease Control and Prevention in 2014, the highest prevalence of smoking was among American Indian and Alaskan Native women, 32.5% of whom said they smoked every day, compared with 17.2% of white women and 13.7% of African American women.⁵⁷

HOW CAN PRIMARY CARE PHYSICIANS CLOSE THE GAP?

By promoting HPV vaccination to children and young adults, primary care physicians can help prevent cervical cancer. Moreover, primary care physicians will see most adolescents for a nonpreventive health visit, an optimal opportunity to discuss sexual activity practices and HPV vaccination.⁵⁸ Including the HPV vaccine as routine with other vaccinations can close the gap.³⁸

Screening and treatment of sexually transmitted infection during these visits can affect the risk that future HPV infection will progress to neoplasia or cancer. Persistent lifestyle modification counseling, especially smoking cessation through motivational interviewing, can lessen the risk of cervical cancer neoplasia progression.

Additionally, in light of recent changes in cervical cancer screening guidelines, the primary care physician’s role as educator is of utmost importance. In one study, although 99% of women had received a Pap test, 87% could not identify the purpose of the Pap test.⁵⁹ The primary care physician’s role is perhaps the most influential in preventing disease and, as such, has the greatest impact on a patient’s disease process.

Primary care providers play a crucial role in cancer control, including screening and follow-up.^1,2 In particular, they are often responsible for performing the initial screening and, when necessary, discussing appropriate treatment options. However, cancer screening practices in primary care can vary significantly, leading to disparities in access to these services.³

See related article

Arvizo and Mahdi,⁴ in this issue of the Journal, discuss disparities in cervical cancer screening, noting that African American women have a higher risk of developing and dying of cervical cancer than white women, possibly because they are diagnosed at a later stage and have lower stage-specific survival rates. The authors state that equal access to healthcare may help mitigate these factors, and they also discuss how primary care providers can reduce these disparities.

PRIORITIZING CERVICAL CANCER SCREENING

Even in patients who have access to regular primary care, other barriers to cancer screening may exist. A 2014 study used self-reported data from the Behavioral Risk Factor Surveillance System survey to assess barriers to cervical cancer screening in older women (ages 40 to 65) who reported having health insurance and a personal healthcare provider.⁵ Those who were never or rarely screened for cervical cancer were more likely than those who were regularly screened to have a chronic condition, such as heart disease, chronic obstructive pulmonary disease, arthritis, depression, kidney disease, or diabetes.

This finding suggests that cancer screening may be a low priority during an adult primary care visit in which multiple chronic diseases must be addressed. To reduce disparities in cancer screening, primary care systems need to be designed to optimize delivery of preventive care and disease management using a team approach.

SYSTEMATIC FOLLOW-UP

Arvizo and Mahdi also discuss the follow-up of abnormal screening Papanicolaou (Pap) smears. While appropriate follow-up is a key factor in the management of cervical dysplasia, follow-up rates vary among African American women. System-level interventions such as the use of an electronic medical record-based tracking system in primary care settings⁶ with established protocols for follow-up may be effective.

But even with such systems in place, patients may face psychosocial barriers (eg, lack of health literacy, distress after receiving an abnormal cervical cytology test result⁷) that prevent them from seeking additional care. To improve follow-up rates, providers must be aware of these barriers and know how to address them through effective communication.

VACCINATION FOR HPV

Finally, the association between human papilloma virus (HPV) infection and cervical cancer makes HPV vaccination a crucial step in cervical cancer prevention. Continued provider education regarding HPV vaccination can improve knowledge about the HPV vaccine,⁸ as well as improve vaccination rates.⁹ The recent approval of a 2-dose vaccine schedule for younger girls¹⁰ may also help improve vaccine series completion rates.

The authors also suggest that primary care providers counsel all patients about risk factors for cervical cancer, including unsafe sex practices and tobacco use.

OPTIMIZING SCREENING AND PREVENTION

I commend the authors for their discussion of cervical cancer disparities and for raising awareness of the important role primary care providers play in reducing these disparities. Improving cervical cancer screening rates and follow-up will require providers and patients to be aware of cervical cancer risk factors. Further, system-level practice interventions will optimize primary care providers’ ability to engage patients in cancer screening conversations and ensure timely follow-up of screening tests.

Primary care providers play a crucial role in cancer control, including screening and follow-up.^1,2 In particular, they are often responsible for performing the initial screening and, when necessary, discussing appropriate treatment options. However, cancer screening practices in primary care can vary significantly, leading to disparities in access to these services.³

See related article

Arvizo and Mahdi,⁴ in this issue of the Journal, discuss disparities in cervical cancer screening, noting that African American women have a higher risk of developing and dying of cervical cancer than white women, possibly because they are diagnosed at a later stage and have lower stage-specific survival rates. The authors state that equal access to healthcare may help mitigate these factors, and they also discuss how primary care providers can reduce these disparities.

PRIORITIZING CERVICAL CANCER SCREENING

Even in patients who have access to regular primary care, other barriers to cancer screening may exist. A 2014 study used self-reported data from the Behavioral Risk Factor Surveillance System survey to assess barriers to cervical cancer screening in older women (ages 40 to 65) who reported having health insurance and a personal healthcare provider.⁵ Those who were never or rarely screened for cervical cancer were more likely than those who were regularly screened to have a chronic condition, such as heart disease, chronic obstructive pulmonary disease, arthritis, depression, kidney disease, or diabetes.

This finding suggests that cancer screening may be a low priority during an adult primary care visit in which multiple chronic diseases must be addressed. To reduce disparities in cancer screening, primary care systems need to be designed to optimize delivery of preventive care and disease management using a team approach.

SYSTEMATIC FOLLOW-UP

Arvizo and Mahdi also discuss the follow-up of abnormal screening Papanicolaou (Pap) smears. While appropriate follow-up is a key factor in the management of cervical dysplasia, follow-up rates vary among African American women. System-level interventions such as the use of an electronic medical record-based tracking system in primary care settings⁶ with established protocols for follow-up may be effective.

But even with such systems in place, patients may face psychosocial barriers (eg, lack of health literacy, distress after receiving an abnormal cervical cytology test result⁷) that prevent them from seeking additional care. To improve follow-up rates, providers must be aware of these barriers and know how to address them through effective communication.

VACCINATION FOR HPV

Finally, the association between human papilloma virus (HPV) infection and cervical cancer makes HPV vaccination a crucial step in cervical cancer prevention. Continued provider education regarding HPV vaccination can improve knowledge about the HPV vaccine,⁸ as well as improve vaccination rates.⁹ The recent approval of a 2-dose vaccine schedule for younger girls¹⁰ may also help improve vaccine series completion rates.

The authors also suggest that primary care providers counsel all patients about risk factors for cervical cancer, including unsafe sex practices and tobacco use.

OPTIMIZING SCREENING AND PREVENTION

I commend the authors for their discussion of cervical cancer disparities and for raising awareness of the important role primary care providers play in reducing these disparities. Improving cervical cancer screening rates and follow-up will require providers and patients to be aware of cervical cancer risk factors. Further, system-level practice interventions will optimize primary care providers’ ability to engage patients in cancer screening conversations and ensure timely follow-up of screening tests.

Primary care providers play a crucial role in cancer control, including screening and follow-up.^1,2 In particular, they are often responsible for performing the initial screening and, when necessary, discussing appropriate treatment options. However, cancer screening practices in primary care can vary significantly, leading to disparities in access to these services.³

See related article

Arvizo and Mahdi,⁴ in this issue of the Journal, discuss disparities in cervical cancer screening, noting that African American women have a higher risk of developing and dying of cervical cancer than white women, possibly because they are diagnosed at a later stage and have lower stage-specific survival rates. The authors state that equal access to healthcare may help mitigate these factors, and they also discuss how primary care providers can reduce these disparities.

PRIORITIZING CERVICAL CANCER SCREENING

Even in patients who have access to regular primary care, other barriers to cancer screening may exist. A 2014 study used self-reported data from the Behavioral Risk Factor Surveillance System survey to assess barriers to cervical cancer screening in older women (ages 40 to 65) who reported having health insurance and a personal healthcare provider.⁵ Those who were never or rarely screened for cervical cancer were more likely than those who were regularly screened to have a chronic condition, such as heart disease, chronic obstructive pulmonary disease, arthritis, depression, kidney disease, or diabetes.

This finding suggests that cancer screening may be a low priority during an adult primary care visit in which multiple chronic diseases must be addressed. To reduce disparities in cancer screening, primary care systems need to be designed to optimize delivery of preventive care and disease management using a team approach.

SYSTEMATIC FOLLOW-UP

Arvizo and Mahdi also discuss the follow-up of abnormal screening Papanicolaou (Pap) smears. While appropriate follow-up is a key factor in the management of cervical dysplasia, follow-up rates vary among African American women. System-level interventions such as the use of an electronic medical record-based tracking system in primary care settings⁶ with established protocols for follow-up may be effective.

But even with such systems in place, patients may face psychosocial barriers (eg, lack of health literacy, distress after receiving an abnormal cervical cytology test result⁷) that prevent them from seeking additional care. To improve follow-up rates, providers must be aware of these barriers and know how to address them through effective communication.

VACCINATION FOR HPV

Finally, the association between human papilloma virus (HPV) infection and cervical cancer makes HPV vaccination a crucial step in cervical cancer prevention. Continued provider education regarding HPV vaccination can improve knowledge about the HPV vaccine,⁸ as well as improve vaccination rates.⁹ The recent approval of a 2-dose vaccine schedule for younger girls¹⁰ may also help improve vaccine series completion rates.

The authors also suggest that primary care providers counsel all patients about risk factors for cervical cancer, including unsafe sex practices and tobacco use.

OPTIMIZING SCREENING AND PREVENTION

I commend the authors for their discussion of cervical cancer disparities and for raising awareness of the important role primary care providers play in reducing these disparities. Improving cervical cancer screening rates and follow-up will require providers and patients to be aware of cervical cancer risk factors. Further, system-level practice interventions will optimize primary care providers’ ability to engage patients in cancer screening conversations and ensure timely follow-up of screening tests.

“If you are 6 months or older in the U.S., there’s a flu vaccine for you,” William Schaffner, MD, of Vanderbilt University, Nashville, said in a press briefing sponsored by the National Foundation for Infectious Diseases.

Some good news about the flu – vaccination rates increased slightly last year, compared with the previous year among all individuals aged 6 months and older without contraindications, according to data from the Centers for Disease Control and Prevention.

Heidi Splete/Frontline Medical News

pdnews@frontlinemedcom.com

“If you are 6 months or older in the U.S., there’s a flu vaccine for you,” William Schaffner, MD, of Vanderbilt University, Nashville, said in a press briefing sponsored by the National Foundation for Infectious Diseases.

Some good news about the flu – vaccination rates increased slightly last year, compared with the previous year among all individuals aged 6 months and older without contraindications, according to data from the Centers for Disease Control and Prevention.

Heidi Splete/Frontline Medical News

pdnews@frontlinemedcom.com

“If you are 6 months or older in the U.S., there’s a flu vaccine for you,” William Schaffner, MD, of Vanderbilt University, Nashville, said in a press briefing sponsored by the National Foundation for Infectious Diseases.

Some good news about the flu – vaccination rates increased slightly last year, compared with the previous year among all individuals aged 6 months and older without contraindications, according to data from the Centers for Disease Control and Prevention.

Heidi Splete/Frontline Medical News

pdnews@frontlinemedcom.com

WASHINGTON – Flu vaccination rates remain below the 70% Healthy People 2020 goal for most of the U.S. population, but data show that a recommendation from a clinician can encourage individuals to get vaccinated and to vaccinate their children, according to a panel of experts who spoke at a press briefing sponsored by the National Foundation for Infectious Diseases.

“Annual vaccination is our first line of defense against the flu,” William Schaffner, MD, of Vanderbilt University, Nashville, Tenn., said at the briefing. The unpredictable nature of the flu makes annual vaccination even more important – and the earlier, the better, said Dr. Schaffner. “If you have seen one flu season, you have seen ... one flu season.”

In a video interview at the briefing, experts emphasized the safety and effectiveness of the flu vaccine for a range of populations, including children, pregnant women, and older adults. And they offered tips to convince patients of the importance of vaccination, as well as the need to make sure health care staff are protected.

Briefing participants included former Department of Health and Human Services Secretary Thomas A. Price, MD; Patricia A. Stinchfield, RN, MS, CPNP, CIC of Children’s Hospitals and Clinics of Minnesota, St. Paul; Kathleen M. Neuzil, MD, of the University of Maryland; and Daniel B. Jernigan, MD, of the Centers for Disease Control and Prevention.

The clinicians interviewed had no financial conflicts to disclose.

WASHINGTON – Flu vaccination rates remain below the 70% Healthy People 2020 goal for most of the U.S. population, but data show that a recommendation from a clinician can encourage individuals to get vaccinated and to vaccinate their children, according to a panel of experts who spoke at a press briefing sponsored by the National Foundation for Infectious Diseases.

“Annual vaccination is our first line of defense against the flu,” William Schaffner, MD, of Vanderbilt University, Nashville, Tenn., said at the briefing. The unpredictable nature of the flu makes annual vaccination even more important – and the earlier, the better, said Dr. Schaffner. “If you have seen one flu season, you have seen ... one flu season.”

In a video interview at the briefing, experts emphasized the safety and effectiveness of the flu vaccine for a range of populations, including children, pregnant women, and older adults. And they offered tips to convince patients of the importance of vaccination, as well as the need to make sure health care staff are protected.

Briefing participants included former Department of Health and Human Services Secretary Thomas A. Price, MD; Patricia A. Stinchfield, RN, MS, CPNP, CIC of Children’s Hospitals and Clinics of Minnesota, St. Paul; Kathleen M. Neuzil, MD, of the University of Maryland; and Daniel B. Jernigan, MD, of the Centers for Disease Control and Prevention.

The clinicians interviewed had no financial conflicts to disclose.

WASHINGTON – Flu vaccination rates remain below the 70% Healthy People 2020 goal for most of the U.S. population, but data show that a recommendation from a clinician can encourage individuals to get vaccinated and to vaccinate their children, according to a panel of experts who spoke at a press briefing sponsored by the National Foundation for Infectious Diseases.

“Annual vaccination is our first line of defense against the flu,” William Schaffner, MD, of Vanderbilt University, Nashville, Tenn., said at the briefing. The unpredictable nature of the flu makes annual vaccination even more important – and the earlier, the better, said Dr. Schaffner. “If you have seen one flu season, you have seen ... one flu season.”

In a video interview at the briefing, experts emphasized the safety and effectiveness of the flu vaccine for a range of populations, including children, pregnant women, and older adults. And they offered tips to convince patients of the importance of vaccination, as well as the need to make sure health care staff are protected.

Briefing participants included former Department of Health and Human Services Secretary Thomas A. Price, MD; Patricia A. Stinchfield, RN, MS, CPNP, CIC of Children’s Hospitals and Clinics of Minnesota, St. Paul; Kathleen M. Neuzil, MD, of the University of Maryland; and Daniel B. Jernigan, MD, of the Centers for Disease Control and Prevention.

The clinicians interviewed had no financial conflicts to disclose.

CHICAGO – The American Academy of Pediatrics has released a new policy statement that in part suggests that physicians can administer influenza vaccine to children and teenagers with egg allergies without any special precautions beyond those that apply to other vaccines.

This is some “egg-citing news,” said Mary Ann Jackson, MD. “In 28 studies with 4,315 egg allergic subjects, 656 of whom had severe allergies, there were no serious allergic reactions.” In other words, there was no respiratory distress or hypotension observed after participants received the influenza vaccine in these studies, she added.

Yangna/Thinkstock

Other reasons to recommend flu vaccination

Dr. Jackson also gave an overview of influenza epidemiology and why ongoing education of patients and families remains essential. “It’s almost flu season now. It’s inevitable – like RSV [respiratory syncytial virus] is inevitable – but when the seasons starts is unknown,” she said. “How severe and long the season will be is also unpredictable.” Which viruses are spread and whether there is a good match between circulating virus and the vaccine are additional unknowns each year.

CHICAGO – The American Academy of Pediatrics has released a new policy statement that in part suggests that physicians can administer influenza vaccine to children and teenagers with egg allergies without any special precautions beyond those that apply to other vaccines.

This is some “egg-citing news,” said Mary Ann Jackson, MD. “In 28 studies with 4,315 egg allergic subjects, 656 of whom had severe allergies, there were no serious allergic reactions.” In other words, there was no respiratory distress or hypotension observed after participants received the influenza vaccine in these studies, she added.

Yangna/Thinkstock

Other reasons to recommend flu vaccination

Dr. Jackson also gave an overview of influenza epidemiology and why ongoing education of patients and families remains essential. “It’s almost flu season now. It’s inevitable – like RSV [respiratory syncytial virus] is inevitable – but when the seasons starts is unknown,” she said. “How severe and long the season will be is also unpredictable.” Which viruses are spread and whether there is a good match between circulating virus and the vaccine are additional unknowns each year.

CHICAGO – The American Academy of Pediatrics has released a new policy statement that in part suggests that physicians can administer influenza vaccine to children and teenagers with egg allergies without any special precautions beyond those that apply to other vaccines.

This is some “egg-citing news,” said Mary Ann Jackson, MD. “In 28 studies with 4,315 egg allergic subjects, 656 of whom had severe allergies, there were no serious allergic reactions.” In other words, there was no respiratory distress or hypotension observed after participants received the influenza vaccine in these studies, she added.

Yangna/Thinkstock

Other reasons to recommend flu vaccination

Dr. Jackson also gave an overview of influenza epidemiology and why ongoing education of patients and families remains essential. “It’s almost flu season now. It’s inevitable – like RSV [respiratory syncytial virus] is inevitable – but when the seasons starts is unknown,” she said. “How severe and long the season will be is also unpredictable.” Which viruses are spread and whether there is a good match between circulating virus and the vaccine are additional unknowns each year.

Provider misconceptions about parental attitudes may be a more significant barrier to inpatient flu vaccination than the parents’ actual attitudes, reported Suchitra Rao, MD, of the University of Colorado, Aurora, and her colleagues.

Surveys assessing attitudes toward inpatient influenza vaccination were given to parents/caregivers of general pediatric inpatients and to inpatient physicians, residents, nurses, physician assistants, and nurse practitioners at Children’s Hospital Colorado in Aurora between October 2014 and March 2015. Response rates were 95% of the 1,053 parents/caregivers and 58% of the 339 providers.

luiscar/Thinkstock

cnellist@frontlinemedcom.com

Provider misconceptions about parental attitudes may be a more significant barrier to inpatient flu vaccination than the parents’ actual attitudes, reported Suchitra Rao, MD, of the University of Colorado, Aurora, and her colleagues.

Surveys assessing attitudes toward inpatient influenza vaccination were given to parents/caregivers of general pediatric inpatients and to inpatient physicians, residents, nurses, physician assistants, and nurse practitioners at Children’s Hospital Colorado in Aurora between October 2014 and March 2015. Response rates were 95% of the 1,053 parents/caregivers and 58% of the 339 providers.

luiscar/Thinkstock

cnellist@frontlinemedcom.com

Provider misconceptions about parental attitudes may be a more significant barrier to inpatient flu vaccination than the parents’ actual attitudes, reported Suchitra Rao, MD, of the University of Colorado, Aurora, and her colleagues.

Surveys assessing attitudes toward inpatient influenza vaccination were given to parents/caregivers of general pediatric inpatients and to inpatient physicians, residents, nurses, physician assistants, and nurse practitioners at Children’s Hospital Colorado in Aurora between October 2014 and March 2015. Response rates were 95% of the 1,053 parents/caregivers and 58% of the 339 providers.

luiscar/Thinkstock

cnellist@frontlinemedcom.com

Use of combination vaccines improves completion and compliance of recommended vaccination in U.S. children aged 24-35 months, reported Samantha K. Kurosky of RTI Health Solutions, Research Triangle Park, N.C., and her colleagues.

Data from the 2012 National Immunization Survey was used to assess vaccination completion and compliance in 11,561 children age 24-35 months. Most children had providers who were in private practice (58%); about half of the children were enrolled in Medicaid or the Children’s Health Insurance Program (CHIP).
 

Completion of the full 4:3:1:3:3:1:4 vaccine series (4 DTaP, 3 inactivated polio vaccine [IPV], 1 MMR, 3 or 4 Haemophilus influenzae type b [Hib], 3 hepatitis B, 1 varicella, and 4 pneumococcal conjugate vaccine) was better among those who received combination vaccines, at 69%, compared with children who received single-antigen vaccine only (50%).

copyright Sean Locke/iStockphoto.com

cnellist@frontlinemedcom.com

Use of combination vaccines improves completion and compliance of recommended vaccination in U.S. children aged 24-35 months, reported Samantha K. Kurosky of RTI Health Solutions, Research Triangle Park, N.C., and her colleagues.

Data from the 2012 National Immunization Survey was used to assess vaccination completion and compliance in 11,561 children age 24-35 months. Most children had providers who were in private practice (58%); about half of the children were enrolled in Medicaid or the Children’s Health Insurance Program (CHIP).
 

Completion of the full 4:3:1:3:3:1:4 vaccine series (4 DTaP, 3 inactivated polio vaccine [IPV], 1 MMR, 3 or 4 Haemophilus influenzae type b [Hib], 3 hepatitis B, 1 varicella, and 4 pneumococcal conjugate vaccine) was better among those who received combination vaccines, at 69%, compared with children who received single-antigen vaccine only (50%).

copyright Sean Locke/iStockphoto.com

cnellist@frontlinemedcom.com

Use of combination vaccines improves completion and compliance of recommended vaccination in U.S. children aged 24-35 months, reported Samantha K. Kurosky of RTI Health Solutions, Research Triangle Park, N.C., and her colleagues.

Data from the 2012 National Immunization Survey was used to assess vaccination completion and compliance in 11,561 children age 24-35 months. Most children had providers who were in private practice (58%); about half of the children were enrolled in Medicaid or the Children’s Health Insurance Program (CHIP).
 

Completion of the full 4:3:1:3:3:1:4 vaccine series (4 DTaP, 3 inactivated polio vaccine [IPV], 1 MMR, 3 or 4 Haemophilus influenzae type b [Hib], 3 hepatitis B, 1 varicella, and 4 pneumococcal conjugate vaccine) was better among those who received combination vaccines, at 69%, compared with children who received single-antigen vaccine only (50%).

copyright Sean Locke/iStockphoto.com

cnellist@frontlinemedcom.com

An electronic pop-up placed on clinicians’ electronic medical record may have had a positive impact on the human papillomavirus vaccination rates in a Texas pediatric clinic, according to a study presented at the annual meeting of the American Academy of Pediatrics.

jarun011/Thinkstock

Ms. Ferris said that the medical center is located near Mexico, and the patient population includes children and adolescents from Juarez. “We still have a lot of young women who are dying from cervical cancer. Really honing in on this population will have a long term effect. ...Pediatrics is really where it starts. This is where you want to capture them.”

The plan is to keep the pop-up reminder in place and continue its use to educate staff and families, said co-author Maria Theresa Villanos, MD, director of ambulatory pediatrics at Texas Tech. Part of the success of their project is “there is no missed opportunity. This pop-up reminder appears during well child visits as well as any time a child comes in sick or for acute care,” she said.

“The major barrier that needs to be addressed is probably pop-up fatigue,” Ms. Ferris said. Because the prompt is new, people are still reading it each time it comes up, but that behavior could wane over time, she said. “It would be interesting to look at long-term vaccination rates and whether the numbers stay the same or if there is a decline.”

Ms. Ferris and Dr. Villanos had no relevant financial disclosures.

An electronic pop-up placed on clinicians’ electronic medical record may have had a positive impact on the human papillomavirus vaccination rates in a Texas pediatric clinic, according to a study presented at the annual meeting of the American Academy of Pediatrics.

jarun011/Thinkstock

Ms. Ferris said that the medical center is located near Mexico, and the patient population includes children and adolescents from Juarez. “We still have a lot of young women who are dying from cervical cancer. Really honing in on this population will have a long term effect. ...Pediatrics is really where it starts. This is where you want to capture them.”

The plan is to keep the pop-up reminder in place and continue its use to educate staff and families, said co-author Maria Theresa Villanos, MD, director of ambulatory pediatrics at Texas Tech. Part of the success of their project is “there is no missed opportunity. This pop-up reminder appears during well child visits as well as any time a child comes in sick or for acute care,” she said.

“The major barrier that needs to be addressed is probably pop-up fatigue,” Ms. Ferris said. Because the prompt is new, people are still reading it each time it comes up, but that behavior could wane over time, she said. “It would be interesting to look at long-term vaccination rates and whether the numbers stay the same or if there is a decline.”

Ms. Ferris and Dr. Villanos had no relevant financial disclosures.

An electronic pop-up placed on clinicians’ electronic medical record may have had a positive impact on the human papillomavirus vaccination rates in a Texas pediatric clinic, according to a study presented at the annual meeting of the American Academy of Pediatrics.

jarun011/Thinkstock

Ms. Ferris said that the medical center is located near Mexico, and the patient population includes children and adolescents from Juarez. “We still have a lot of young women who are dying from cervical cancer. Really honing in on this population will have a long term effect. ...Pediatrics is really where it starts. This is where you want to capture them.”

The plan is to keep the pop-up reminder in place and continue its use to educate staff and families, said co-author Maria Theresa Villanos, MD, director of ambulatory pediatrics at Texas Tech. Part of the success of their project is “there is no missed opportunity. This pop-up reminder appears during well child visits as well as any time a child comes in sick or for acute care,” she said.

“The major barrier that needs to be addressed is probably pop-up fatigue,” Ms. Ferris said. Because the prompt is new, people are still reading it each time it comes up, but that behavior could wane over time, she said. “It would be interesting to look at long-term vaccination rates and whether the numbers stay the same or if there is a decline.”

Ms. Ferris and Dr. Villanos had no relevant financial disclosures.

Douglas R. Lowy, MD, and John T. Schiller, PhD, received the 2017 Lasker-DeBakey Clinical Medical Research Award for their development of the virus-like particle technology used to create the human papillomavirus (HPV) vaccine. Their team discovered that proteins making up the outer shell of HPV could form virus-like particles that closely resemble the original virus but are not infectious, and these particles could trigger the immune system to produce protective antibodies that could neutralize HPV in a later infection. These particles eventually became the basis of the HPV vaccines Gardasil, Gardasil 9, and Cervarix.

Daniel Sone/National Cancer Institute

Douglas R. Lowy, MD, and John T. Schiller, PhD, received the 2017 Lasker-DeBakey Clinical Medical Research Award for their development of the virus-like particle technology used to create the human papillomavirus (HPV) vaccine. Their team discovered that proteins making up the outer shell of HPV could form virus-like particles that closely resemble the original virus but are not infectious, and these particles could trigger the immune system to produce protective antibodies that could neutralize HPV in a later infection. These particles eventually became the basis of the HPV vaccines Gardasil, Gardasil 9, and Cervarix.

Daniel Sone/National Cancer Institute

Douglas R. Lowy, MD, and John T. Schiller, PhD, received the 2017 Lasker-DeBakey Clinical Medical Research Award for their development of the virus-like particle technology used to create the human papillomavirus (HPV) vaccine. Their team discovered that proteins making up the outer shell of HPV could form virus-like particles that closely resemble the original virus but are not infectious, and these particles could trigger the immune system to produce protective antibodies that could neutralize HPV in a later infection. These particles eventually became the basis of the HPV vaccines Gardasil, Gardasil 9, and Cervarix.

Daniel Sone/National Cancer Institute