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Background: Two vaccines protect against human papillomaviruses (HPV) 16 and 18, which cause 70% of cervical cancer and 50% of cervical intraepithelial neoplasia 2/3 and adenocarcinoma in situ (CIN2+). Monitoring HPV types in CIN2+ may be used to assess HPV vaccine impact.Methods: As part of a multisite vaccine impact monitoring project (HPV-IMPACT), biopsy specimens used to diagnose CIN2+ were obtained for HPV DNA typing for women aged 18-39 years.Results: Among 4,121 CIN2+ cases reported during 2008-2009 in 18- to 39-year-old women 3058 (74.2%) were tested; 96% were HPV DNA positive. HPV 16 was most common (49.1%), followed by HPV 31 (10.4%) and HPV 52 (9.7%). HPV 18 prevalence was 5.5% overall. Proportion of CIN2+ cases associated with HPV 16/18 was highest (56.3%) in 25- to 29-year-old women. HPV 16/18-associated lesions were less common in non-Hispanic blacks (41.9%) and Hispanics (46.3%) compared with non-Hispanic whites (59.1%) (P < .0001); the difference remained significant when adjusted for covariates. Compared to non-Hispanic whites, HPV 35 and 58 were significantly more common in non-Hispanic blacks (14.5% vs 4.2%; 12.3% vs 3.4%) and HPV 45 was higher in Hispanics (3.7% vs 1.5%).Conclusions: Age and racial/ethnic differences in HPV type distribution may have implications for vaccine impact and should be considered in monitoring trends. [ABSTRACT FROM AUTHOR]

Background: Inaccurate perceptions about whether a partner has concurrent sexual partners are associated with current sexually transmitted infections status. Despite high sexually transmitted infection rates among pregnant adolescents, studies have not investigated the accuracy of perceptions about sexual concurrency among young pregnant adolescents. The objectives were to assess (1) the accuracy of perceptions about whether one's partner ever had concurrent sexual partners during the relationship and (2) whether self-reported concurrency and relationship factors are related to inaccurate perceptions.Methods: Sociodemographic, psychosocial, and sexual behavior data were collected from 296 couples recruited from antenatal clinics. Couples included pregnant adolescents, aged 14 to 21 years, and the father of the baby, aged ≥ 14 years. Percentage agreement and κ statistics assessed the accuracy of perceptions about whether one's partner ever had concurrent sexual partners during the relationship. Logistic regression models using generalized estimating equations assessed associations between respondents' self-reported concurrency, relationship factors, and inaccurate perceptions.Results: Among participants whose partner was concurrent (n = 171), 60% did not accurately report their partner's concurrency, and greater relationship satisfaction (adjusted odds ratio [AOR]: 1.54) increased the likelihood of inaccuracy. Among participants with a nonconcurrent partner (n = 418), 17% were inaccurate; self-reported concurrency (AOR: 2.69) and greater partnership duration (AOR: 1.25) increased the likelihood of inaccuracy, whereas greater relationship satisfaction decreased the likelihood of inaccuracy (AOR: 0.68).Conclusions: Many pregnant adolescents and their partners inaccurately perceived their partner's concurrency status. Self-reported concurrency and relationship factors were associated with inaccuracy, reinforcing the need to improve sexual communication among this population. [ABSTRACT FROM AUTHOR]

We assessed risk behaviour in a heterosexual cohort undergoing prescreening for the first Phase I/II HIV vaccine trials in Soweto. We developed a survey and collected self-reported data from HIV-negative potential volunteers. Of 488 participants, most were single and approximately half were from households with incomes below the poverty level. Males reported higher rates of heavy alcohol use (P < 0.001), marijuana use (P < 0.001) and other recreational drug use (P < 0.01). Males reported more sex partners than females in the previous six months (P < 0.001), as well as more casual/anonymous partners (P < 0.001) and one-night stands (P < 0.001). Multivariate analyses revealed substance use and male gender predicted higher risk behaviours, including <100% condom use with known/suspected HIV-positive partners, having casual/anonymous partners and having more than two partners. For this population, male volunteers may need increased risk-reduction counselling during Phase I/II trials and additional recruitment methods may be necessary to identify high-risk female volunteers for Phase III efficacy trials. [ABSTRACT FROM AUTHOR]

The purpose of this study is to assess changes in sexual risk behaviors, attitudes toward using condoms, and perceived susceptibility to fiuture STDs for adolescent females who recently were diagnosed with an incident STD compared to those who were not diagnosed with an incident STD. Adolescent females (N = 308) were assessed at two time points, 6 months apart. Ninety-two participants were diagnosed with an STD, and 216 were not diagnosed with an STD in between the two time points. Results indicated that adolescents did not significantly change their behaviors, attitudes, or perceptions following the diagnosis of an incident STD compared to those who were not diagnosed with an incident STD. This suggests that an STD diagnosis alone is not sufficient to motivate adolescent females to reduce their sexual risk behavior and change their sexual risk attitudes and perceptions. [ABSTRACT FROM AUTHOR]

PURPOSE: To determine the association between new sex partner acquisition and incident STDs, to describe predictors of acquiring a new sex partner, and to compare new and established sex partnerships among adolescent females. METHODS: Interview data and biological specimens for STD testing were collected from a sample of 411 adolescent females (average age 17.3 years, 44% black and 42% Hispanic) enrolled in a longitudinal study. The relationship between having a new sex partner and incident STD infection was estimated with logistic regression. RESULTS: Acquisition of a new sex partner during the 12-month follow-up period was common (24%) and significantly associated with an incident STD infection (OR = 3.0, 95% CI = 1.6-5.7). Predictors of new partner acquisition were younger age, younger age at first intercourse, and alcohol or drug use before sex in past 30 days. Being in a new partnership was significantly associated with greater uncertainty about the partners' STD history and recent sex with others. CONCLUSIONS: Being in a new sex partnership is an important predictor of incident STD infection. Awareness of this risk can help clinicians identify individuals who are more likely to get STDs and therefore target STD testing and appropriate prevention messages. [ABSTRACT FROM AUTHOR]

Context: Reports of outbreaks of varicella in highly immunized groups have increased concern about the effectiveness of varicella vaccine.Objective: To assess whether the effectiveness of varicella vaccine is affected either by time since vaccination or by age at the time of vaccination.Design: Case-control study conducted from March 1997 through June 2003.Setting: Twenty different group practices in southern Connecticut.Participants: Case subjects, identified by active surveillance of all practices, consisted of 339 eligible children 13 months or older who were clinically diagnosed as having chickenpox and who also had a polymerase chain reaction (PCR) test result that was positive for varicella-zoster virus DNA. For each case subject, 2 controls were selected, matched by both age and pediatric practice.Main Outcome Measures: The effectiveness of the vaccine, especially the effects of time since vaccination and age at the time of vaccination, adjusted for possible confounders.Results: Although the adjusted overall effectiveness of the vaccine was 87% (95% confidence interval, 81%-91%; P<.001), there was a substantial difference in the vaccine's effectiveness in the first year after vaccination (97%) and in years 2 to 8 after vaccination (84%, P =.003). The vaccine's effectiveness in year 1 was substantially lower if the vaccine was administered at younger than 15 months (73%) than if it was administered at 15 months or older (99%, P =.01), although the difference in effectiveness overall for children immunized at younger than 15 months was not statistically significantly different than for those immunized at 15 months or older (81% vs 88%, P =.17). Most cases of chickenpox in vaccinees were mild.Conclusions: Although varicella vaccine is effective, its effectiveness decreases significantly after 1 year, although most cases of breakthrough disease are mild. If administered at younger than 15 months, the vaccine's effectiveness was lower in the first year after vaccination, but the difference in effectiveness was not statistically significant for subsequent years. [ABSTRACT FROM AUTHOR]

PURPOSE: To describe patterns and changes in contraceptive use among pregnant adolescents in early and later postpartum compared with nonpregnant adolescents. METHODS: One-hundred-seventy-six pregnant and 187 nonpregnant adolescents, recruited through community clinics, were interviewed three times (baseline, 6-month follow-up, 12-month follow-up) about their condom and hormonal contraceptive practices. Changes in contraception use and patterns of consistent hormonal and/or condom use were examined. Statistical analyses included General Estimating Equations (GEE) and multinomial regression. RESULTS: Pregnant adolescents increased hormonal contraceptive use from baseline to early postpartum, but decreased use from early postpartum to late postpartum. Nonpregnant adolescents did not change their hormonal contraceptive use over time. Neither group changed condom use over time. Pregnant adolescents were more likely to be consistent dual users and hormonal-only users during the 6-month follow-up compared with nonpregnant adolescents. These findings persisted at the 12-month follow-up, although there was a decline in hormonal contraception use. CONCLUSIONS: Adolescents change their contraceptive use during the postpartum period. Given the slight decline in contraceptive use in late postpartum in this sample, more work is necessary to maintain motivation to continue these positive postpartum trends. [ABSTRACT FROM AUTHOR]

Background: Partner notification (PN), originally designed for syphilis control, has been used to control the spread of HIV since 1985. Because HIV infection is noncurable, the benefit of contact tracing and treatment demonstrated for the control of syphilis may not apply to HIV. For HIV, PN must facilitate behavior change that will reduce the spread of the infection. One concern is that HIV PN can promote the breakup of old partnerships and increase the acquisition of new partners, thereby spreading HIV infections.Goal: The purpose of this study was to determine the effect of partner notification (PN) on sexual behavior and relationship stability among HIV partnerships, with use of syphilis partnerships for comparison.Study Design: Partnerships were eligible if the index case was interviewed by a disease intervention specialist (DIS) for PN and named at least one sex partner. Partnership information was reported by index cases interviewed at baseline and 3 and 6 months post-PN. Trends in partnership dissolution and acquisition, sexual abstinence, condom use, emotional abuse, and physical violence reported by HIV infection and syphilis index cases were compared.Results: A total of 157 index cases (76 HIV infection and 81 syphilis) reported 220 partnerships (94 HIV and 126 syphilis). The PN process was completed for 32.7% of partnerships and it was completed more often for partnerships that were classified as main and cohabiting. After PN, 46.8% of partnerships dissolved, 15.9% of cases acquired a new partner, and emotional abuse and physical violence decreased significantly. HIV index cases were somewhat more likely to report using condoms at last sex act and less likely to acquire a new sex partner after PN compared to syphilis index cases. There was no difference post-PN between HIV infection and syphilis partnerships for partnership dissolution, physical violence, emotional abuse and abstention from sex.Conclusion: HIV PN did not appear to cause greater partnership dissolution, new partner acquisition, or violence compared with syphilis PN. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this study was to determine the level of high-risk sexual behaviors and the prevalence of chlamydia and gonorrhea among pregnant adolescents.Study Design: These analyses used data from 203 pregnant and 209 nonpregnant adolescents who were recruited from public health clinics. Data sources included interviewer-administered questionnaires, ligase chain reaction tests for chlamydia/gonorrhea in the third trimester of pregnancy, and state health department reports of chlamydia/gonorrhea. Statistical analyses included logistic regression.Results: Pregnant adolescents were significantly more likely to have not used condoms during sexual intercourse in the past 30 days compared with nonpregnant adolescents, although other sexual risk behaviors were reduced. Nineteen percent of pregnant adolescents had chlamydia or gonorrhea diagnosed during the pregnancy.Conclusion: Pregnant adolescents have high levels of sexually transmitted diseases during pregnancy, and many adolescents use condoms inconsistently. Prenatal care providers may be in a unique position to decrease sexually transmitted diseases among pregnant adolescents by encouraging the reduction of risk behaviors and aggressively screening for sexually transmitted diseases as part of routine prenatal care. [ABSTRACT FROM AUTHOR]

Importance: Nirsevimab, a long-acting monoclonal antibody, has demonstrated efficacy against RSV-related lower respiratory tract infections (LRTIs) in clinical trials. Post-licensure monitoring is essential to confirm these benefits in real-world settings., Objective: To evaluate the real-world effectiveness of nirsevimab against medically attended RSV infections in infants and to assess how effectiveness varies by disease severity, dosage, and time since immunization., Design Setting and Participants: This test-negative case-control study used inpatient, outpatient, and emergency room data from the Yale New Haven Health System. Nirsevimab-eligible infants who were tested for RSV using polymerase chain reaction between October 1, 2023 and May 9, 2024 were included. Cases were infants with confirmed RSV infections; controls were those who tested negative., Exposure: Nirsevimab immunization, verified through state immunization registries., Main Outcomes and Measures: Effectiveness was estimated using multivariable logistic regression, adjusting for age, calendar month, and individual risk factors. Separate models examined effectiveness by clinical setting, disease severity, dose, and time since immunization. Broader outcomes, including all-cause LRTI and LRTI-related hospitalization, were also analyzed, with stratification by early and late respiratory seasons., Results: The analytic sample included 3,090 infants (median age 6.7 months, IQR 3.6-9.7), with 680 (22.0%) RSV-positive and 2,410 (78.0%) RSV-negative. 21 (3.1%) RSV-positive and 309 (12.8%) RSV-negative infants received nirsevimab. Effectiveness against RSV infection was 68.4% (95% CI, 50.3%-80.8%). Effectiveness was 61.6% (95% CI, 35.6%-78.6%) for outpatient visits and 80.5% (95% CI, 52.0%-93.5%) for hospitalizations. The highest effectiveness, 84.6% (95% CI, 58.7%-95.6%), was observed against severe RSV outcomes requiring ICU admission or high-flow oxygen. Although effectiveness against RSV infections declined over time, it remained significant at 55% (95% credible interval, 16%-75%) at 14 weeks post-immunization. Protective effectiveness was also observed against all-cause LRTI and LRTI-related hospitalizations during peak RSV season (49.4% [95% CI, 10.7%-72.9%] and 79.1% [95% CI, 27.6%-94.9%], respectively). However, from February to May, when RSV positivity was low, effectiveness against these broader outcomes was negligible., Conclusions and Relevance: Nirsevimab provided substantial protection against RSV-related outcomes for at least three months. These findings support the continued use of nirsevimab and provide evidence that may help build public confidence in the immunization program., Competing Interests: Competing interests: VEP was previously a member of the WHO Immunization and Vaccine-related Implementation Research Advisory Committee (IVIR-AC). All other authors declare no conflicts of interest.

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.

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.

Importance  Few recent studies have examined neurocognitive functioning (NCF) in patients with sinonasal and nasopharyngeal cancers (NPCs) prior to and following multimodality therapy or the potential differences in NCF by disease variables such as disease site. Objective  The objective of this study is to determine rates of NCF impairments prior to and following multimodality therapy, declines in NCF following radiotherapy (RT), and possible differences in NCF by the disease site. Design, Setting, and Participants  We conducted a retrospective chart review of 39 patients with sinonasal and NPCs who underwent comprehensive neuropsychological evaluations. Twenty patients were evaluated prior to RT, of which eleven received follow-up evaluation after completion of RT. Nineteen patients were evaluated following various treatments without a pre-RT evaluation. Main Outcomes and Measures  Patients completed comprehensive neuropsychological evaluations. Decline from pre-RT to follow-up was defined on the basis of reliable change indices. Results  Thirty-nine patients completed comprehensive neuropsychological evaluations. For the entire cohort, the most frequently demonstrated impairments were in verbal memory (47%) and learning (43%), executive functioning (33%), and verbal fluency (22%). At post-RT follow-up, the most frequently observed declines were in verbal learning (46%) and memory (18%). Demographic and disease variables were not significantly associated with NCF at pre-RT or post-RT. Conclusion and Relevance  Patients with sinonasal and NPCs are at risk for NCF impairments in multiple areas at baseline and memory decline following RT. Future prospective studies are needed to investigate the impact of each treatment modality on NCF and specific risk factors for cognitive dysfunction., Competing Interests: Conflict of Interest C.D.F. received/receives funding and salary support during the period of study execution from: the National Institutes of Health (NIH) NIBIB Research Education Programs for Residents and Clinical Fellows Grant (R25EB025787–01); NIDCR Academic Industrial Partnership Grant (R01DE028290); NCI Parent Research Project Grant (R01CA258827) NCI Early Phase Clinical Trials in Imaging and Image-Guided Interventions Program (1R01CA218148); an NIH/NCI Cancer Center Support Grant (CCSG) Pilot Research Program Award from the UT MD Anderson CCSG Radiation Oncology and Cancer Imaging Program (P30CA016672); and an NSF Division of Civil, Mechanical, and Manufacturing Innovation (CMMI) grant (NSF 1933369). He has received direct industry grant support, honoraria, and travel funding from Elekta AB unrelated to this project. Direct infrastructure support is provided by the multidisciplinary the Radiation Oncology/Cancer Imaging Program (P30CA016672–44) of the MD Anderson Cancer Center Support Grant (P30CA016672) and the MD Anderson Program in Image-guided Cancer Therapy., (Thieme. All rights reserved.)

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., (Copyright © 2023 by the American Academy of Pediatrics.)

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.

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., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

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., (Copyright © 2022 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Declines in cervical intraepithelial neoplasia grades 2 to 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 to 39 years, 2008 to 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 nonvaccine 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 nonvaccine vs vaccine HR-HPV types. No significant declining trends were observed in older age groups. In 2015-2016 compared with 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., (© 2022 UICC. This article has been contributed to by U.S. Government employees and their work is in the public domain in the USA.)

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., Competing Interests: Potential conflicts of interest. L.M.K. reports no other conflicts. J.A.L. has received consulting fees and grants from Pfizer, Inc., and from Merck Sharp & Dohme Corp. and consulting fees from VaxCyte, each for unrelated work. L.M.N. has received consulting fees and grants from Merck Sharp & Dohme for related work., (© The Author(s) 2023. Published by Oxford University Press on behalf of Infectious Diseases Society of America.)

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., (Copyright © 2022 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

Background: Chlamydia vaccination is a potentially important strategy to prevent infections and reduce the global burden of disease. Ideally, chlamydia immunization programs would require vaccinating adolescents before they engage in sexual activity. Communication by health care providers (HCPs) has been shown to have an impact on vaccine acceptance. Therefore, it is imperative to understand their opinions on chlamydia vaccines and factors that would promote strong vaccine recommendations to patients to promote uptake., Methods: Semi-structured interviews with adolescent HCPs were conducted and focused on perceived need for chlamydia vaccine. Additional topics included vaccine characteristics, such as efficacy, cost, and booster vaccines, and potential vaccine recommendation strategies., Results: From January to July 2021, 22 interviews were completed. Health care providers discussed how chlamydia vaccines are needed, especially in settings with high prevalence rates. Health care providers thought a chlamydia vaccine would need to be very efficacious in preventing infections and related sequalae and cost-effective. However, there were concerns about low completion rates if this vaccine required multiple doses or boosters. In addition, vaccine misinformation was prevalent among HCPs regarding potential benefits of vaccination., Conclusions: Health care providers' perceptions that an adolescent chlamydia vaccine would be beneficial offers great promise for future promotion. However, there is need for targeted education programs about chlamydia and the benefits of vaccination for HCPs. These programs will be especially important in order for HCPs to effectively communicate about the benefits of vaccination to parents and adolescents provide strong vaccine recommendations., Competing Interests: Conflict of Interest: L.M.N. has served as a scientific advisor for Merck, Moderna, and Janssen. G.D.Z. has served as a consultant and advisory committee member for Merck regarding HPV vaccination and as an advisory committee member for Moderna regarding COVID-19 vaccination. He has also received investigator-initiated research funding from Merck, administered through Indiana University. E.T.O. served as a consultant for ViiV. All other authors have no conflicts to disclose., (Copyright © 2022 American Sexually Transmitted Diseases Association. All rights reserved.)

Background: Chlamydia vaccines are currently under development and have the potential to lower the incidence of infection and disease, which are highest among adolescents and young adults. Ideally, a chlamydia vaccine would be administered to adolescents before sexual debut, a time when parents are the primary vaccine decision makers. This study explores parent opinions about an adolescent chlamydia vaccine to understand barriers and facilitators to uptake., Methods: Semistructured interviews were conducted with parents of adolescents. Topics included conversations parents have with their children about chlamydia, opinions on chlamydia vaccine development, and vaccine characteristics, such as efficacy and cost. Interviews were analyzed using a thematic analysis approach., Results: From March to April 2021, 21 interviews were completed. Few parents discuss chlamydia with their children and sex education was seen as limited. Overall, 16 parents indicated that a chlamydia vaccine is needed. However, there were mixed opinions about vaccinating their own children, related to the need to vaccinate at a young age, vaccine efficacy, and confusion about benefits of vaccination. Finally, healthcare provider recommendations were seen as important before deciding to vaccinate a child., Conclusions: Although parents think that chlamydia vaccines are needed, lack of awareness about infections and potential benefits of vaccination could serve as barriers to uptake. Healthcare provider recommendations can help to improve knowledge and vaccine uptake. However, there is a need for multilevel approaches to improve chlamydia awareness and ensure that vaccination initiation and completion rates remain high., Competing Interests: Conflict of Interest and Sources of Funding: Dr Niccolai has served as a scientific advisor for Merck, Moderna, and Janssen. Dr Zimet has served as a consultant and advisory committee member for Merck regarding human papillomavirus vaccination and as an advisory committee member for Moderna regarding COVID-19 vaccination. He has also received investigator-initiated research funding from Merck, administered through Indiana University. Dr Overton served as a consultant for ViiV. All other authors have no conflicts to disclose., (Copyright © 2022 American Sexually Transmitted Diseases Association. All rights reserved.)

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.

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.

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., Competing Interests: Disclosure: The authors declare no conflict of interest and no financial relationships relevant to this article., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

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., (Copyright © 2021 Society for Adolescent Health and Medicine. Published by Elsevier Inc. All rights reserved.)

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.

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., (Copyright © 2021 Jacobs Institute of Women's Health. Published by Elsevier Inc. All rights reserved.)

Objective: The aim of the study was to describe trends in human papillomavirus (HPV) testing preceding diagnosis of cervical precancer during a time of changing screening recommendations., Materials and Methods: We conducted a cross-sectional analysis of data from active, population-based, laboratory surveillance among 1.5 million residents of 5 areas in the United States. We included women aged 21-39 years diagnosed with cervical intraepithelial neoplasia grades 2, 2/3, or 3 or adenocarcinoma in situ (collectively, CIN2+) during 2008-2016, who had a cytology and/or HPV test before diagnosis (n = 16,359)., Results: The proportion of women with an HPV test preceding CIN2+ increased from 42.9% in 2008 to 73.3% in 2016 (p < .01); testing increased in all age groups (21-24 y: 35.3% to 47.6%, 25-29 y: 40.9% to 64.1%, 30-39 y: 51.7% to 85.9%, all p < .01). The HPV testing varied by cytology result and was highest among women with atypical squamous cells of unknown significance (n = 4,310/4,629, 93.1%), negative for intraepithelial lesion or malignancy (n = 446/517, 86.3%), and atypical glandular cells (n = 145/257, 56.4%). By 2016, at least half of all cases in every surveillance area had an HPV test before diagnosis., Conclusions: During 2008-2016, the proportion of women with an HPV test preceding CIN2+ increased significantly for all age groups, cytology results, and surveillance areas. By 2016, most (85.9%) women aged 30-39 years had an HPV test, consistent with recommendations. Increasing utilization of HPV tests, which have demonstrated improved sensitivity for detecting cervical disease, may in part explain increasing rates of cervical precancer among women 30 years and older., Competing Interests: L.M.N. serves as a scientific advisor for Merck, outside of submitted work. The other authors have declared they have no conflicts of interest., (Copyright © 2021, ASCCP.)

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.

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.

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., Competing Interests: Competing interests: Dr Niccolai has served as Scientific Advisor for Merck. Dr Sheth receives Gardasil 9 from Merck at no cost for research and has served as a consultant for Merck. All other authors declare no conflicts of interest., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

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., (Copyright © 2021 Elsevier Inc. All rights reserved.)

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., (© 2020 by the Society for Academic Emergency Medicine.)

Over the past 15 y, several vaccines have been added to the recommended immunization schedule for adolescents in the United States. In addition to annual influenza vaccination, the Advisory Committee on Immunization Practices recommends tetanus, diphtheria, and pertussis (Tdap), meningococcal conjugate (MenACWY), and human papillomavirus (HPV) vaccine for routine administration at ages 11-12 y, and a second dose of MenACWY at age 16. A vaccine against meningococcal disease caused by serogroup B (MenB) is also available and recommended for shared clinical decision-making. Though notable gains in uptake have been achieved for some adolescent vaccines, coverage varies considerably with lower rates for HPV vaccine and second dose of MenACWY. Coverage for MenB is especially low. While extensive research has focused on barriers to and solutions for higher uptake of HPV vaccine, limited attention has been given to the reasons for lower uptake of meningococcal vaccines among older adolescents. This purpose of this commentary is to discuss barriers to and solutions for higher uptake of meningococcal vaccines among older adolescents, and to identify gaps in knowledge that can inform research efforts going forward.

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., (©Carlos R Oliveira, Patrick Niccolai, Anette Michelle Ortiz, Sangini S Sheth, Eugene D Shapiro, Linda M Niccolai, Cynthia A Brandt. Originally published in JMIR Medical Informatics (http://medinform.jmir.org), 03.11.2020.)

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.

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., Competing Interests: Dr. L.M.N. reports previous work as a Scientific Advisor for Merck. All other authors declare no conflicts of interest., (© Carlos R. Oliveira et al., 2020; Published by Mary Ann Liebert, Inc.)

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., (Copyright © 2020 American Journal of Preventive Medicine. All rights reserved.)

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., (Published by Oxford University Press on behalf of the Johns Hopkins Bloomberg School of Public Health 2019. This work is written by (a) US Government employee(s) and is in the public domain in the US.)

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.

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.

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., (© 2019 UICC.)

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., (©Carlos R Oliveira, Lital Avni-Singer, Geovanna Badaro, Erin L Sullivan, Sangini S Sheth, Eugene D Shapiro, Linda M Niccolai. Originally published in JMIR Medical Informatics (http://medinform.jmir.org), 22.01.2020.)