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Since 2000, many countries have achieved considerable success in improving child survival, but localized progress remains unclear. To inform efforts towards United Nations Sustainable Development Goal 3.2-to end preventable child deaths by 2030-we need consistently estimated data at the subnational level regarding child mortality rates and trends. Here we quantified, for the period 2000-2017, the subnational variation in mortality rates and number of deaths of neonates, infants and children under 5 years of age within 99 low- and middle-income countries using a geostatistical survival model. We estimated that 32% of children under 5 in these countries lived in districts that had attained rates of 25 or fewer child deaths per 1,000 live births by 2017, and that 58% of child deaths between 2000 and 2017 in these countries could have been averted in the absence of geographical inequality. This study enables the identification of high-mortality clusters, patterns of progress and geographical inequalities to inform appropriate investments and implementations that will help to improve the health of all populations.
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Mortalidade da Criança/tendências , Mortalidade Infantil/tendências , Criança , Geografia , Saúde Global , Humanos , Lactente , Recém-Nascido , Objetivos Organizacionais , Saúde Pública , Fatores Socioeconômicos , Nações UnidasRESUMO
Studies have suggested the effectiveness of COVID-19 vaccines in preventing SARS-CoV-2 reinfection among those previously infected. However, it is not yet clear if one dose of the vaccine is enough to prevent breakthrough infections compared to two doses. Using data from Optum deidentified COVID-19 Electronic Health Record (EHR) data set, we assessed breakthrough infection risks in individuals previously infected, comparing those with one vaccine dose to those with two doses. Propensity scores were applied to mitigate confounding factors. Follow-up spanned 6 months, beginning 2 weeks postvaccination. Among 213 845 individuals, those receiving one vaccine dose had a significantly higher breakthrough infection risk than the two-dose group (HR 1.69, 95% CI 1.54-1.85). This pattern was observed across genders, racial/ethnic groups, age categories, and vaccine types. This study reveals a substantial disparity in the risk of breakthrough infections between individuals receiving one versus two doses of the COVID-19 vaccine, suggesting that a single dose may not provide adequate protection against reinfection.
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Vacinas contra COVID-19 , COVID-19 , Feminino , Humanos , Masculino , Infecções Irruptivas , SARS-CoV-2 , Reinfecção , COVID-19/prevenção & controleRESUMO
BACKGROUND: Human immunodeficiency virus and acquired immune deficiency syndrome (HIV/AIDS) is still among the leading causes of disease burden and mortality in sub-Saharan Africa (SSA), and the world is not on track to meet targets set for ending the epidemic by the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the United Nations Sustainable Development Goals (SDGs). Precise HIV burden information is critical for effective geographic and epidemiological targeting of prevention and treatment interventions. Age- and sex-specific HIV prevalence estimates are widely available at the national level, and region-wide local estimates were recently published for adults overall. We add further dimensionality to previous analyses by estimating HIV prevalence at local scales, stratified into sex-specific 5-year age groups for adults ages 15-59 years across SSA. METHODS: We analyzed data from 91 seroprevalence surveys and sentinel surveillance among antenatal care clinic (ANC) attendees using model-based geostatistical methods to produce estimates of HIV prevalence across 43 countries in SSA, from years 2000 to 2018, at a 5 × 5-km resolution and presented among second administrative level (typically districts or counties) units. RESULTS: We found substantial variation in HIV prevalence across localities, ages, and sexes that have been masked in earlier analyses. Within-country variation in prevalence in 2018 was a median 3.5 times greater across ages and sexes, compared to for all adults combined. We note large within-district prevalence differences between age groups: for men, 50% of districts displayed at least a 14-fold difference between age groups with the highest and lowest prevalence, and at least a 9-fold difference for women. Prevalence trends also varied over time; between 2000 and 2018, 70% of all districts saw a reduction in prevalence greater than five percentage points in at least one sex and age group. Meanwhile, over 30% of all districts saw at least a five percentage point prevalence increase in one or more sex and age group. CONCLUSIONS: As the HIV epidemic persists and evolves in SSA, geographic and demographic shifts in prevention and treatment efforts are necessary. These estimates offer epidemiologically informative detail to better guide more targeted interventions, vital for combating HIV in SSA.
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Síndrome da Imunodeficiência Adquirida , Infecções por HIV , Masculino , Feminino , Adulto , Humanos , Gravidez , Adolescente , Adulto Jovem , Pessoa de Meia-Idade , HIV , Síndrome da Imunodeficiência Adquirida/epidemiologia , Prevalência , Estudos Soroepidemiológicos , Infecções por HIV/prevenção & controle , África Subsaariana/epidemiologiaRESUMO
Objectives: To examine the current complementary feeding practices among infants and young children aged 6 to 23 months in India, and factors influencing these practices at child, parental, household and community levels. Material and methods: Data on 74,095 last-born children aged 6 to 23 months used in this study were obtained from the 2015 India Demographic and Health Survey (IDHS). Complementary feeding indicators (timely introduction of complementary foods to infants aged 6 to 8 months old, minimum meal frequency, minimum dietary diversity, and minimum acceptable diets) were estimated, and their associated factors were identified using descriptive and multivariate (logistic regression) analyses. Results: The prevalence of the timely introduction of complementary foods to infants aged 6 to 8 months was 45.1%. The proportion of children between ages 6 to 23 months who received the minimum meal frequency, minimum dietary diversity and minimum acceptable diets were 36%, 21% and 9.1%, respectively. Findings from the multivariate analyses revealed that mothers of infants delivered at home, mothers who had no antenatal check-up, mothers who are Hindus, mothers living in rural areas or those from the Western/Northern geographical regions of India were at higher risk of suboptimal complementary feeding practices.Conclusions. Our findings indicate that, among other factors, achieving the recommended four or more antenatal visits was consistently associated with improved complementary feeding practices. Thus, policies that ensure increased coverage and quality of antenatal check-up could improve complementary feeding practices of mothers in India, and help towards achieving sustainable development goal 2, targeted at eradicating hunger and malnutrition.
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Alimentação com Mamadeira , Aleitamento Materno , Feminino , Humanos , Criança , Lactente , Pré-Escolar , Fatores Socioeconômicos , Inquéritos Epidemiológicos , Alimentos Infantis/análise , Fenômenos Fisiológicos da Nutrição do Lactente , Mães , Comportamento Alimentar , Dieta , ÍndiaRESUMO
OBJECTIVES: To examine the association between socioeconomic status (SES) and antibiotic prescribing, controlling for the presence of common chronic conditions and other potential confounders and variation amongst GP practices and clusters. METHODS: This was an electronic cohort study using linked GP and Welsh Index of Multiple Deprivation (WIMD) data. The setting was GP practices contributing to the Secure Anonymised Information Linkage (SAIL) Databank 2013-17. The study involved 2.9 million patients nested within 339 GP practices, nested within 67 GP clusters. RESULTS: Approximately 9 million oral antibiotics were prescribed between 2013 and 2017. Antibiotic prescribing rates were associated with WIMD quintile, with more deprived populations receiving more antibiotics. This association persisted after controlling for patient demographics, smoking, chronic conditions and clustering by GP practice and cluster, with those in the most deprived quintile receiving 18% more antibiotic prescriptions than those in the least deprived quintile (incidence rate ratio = 1.18; 95% CI = 1.181-1.187). We found substantial unexplained variation in antibiotic prescribing rates between GP practices [intra-cluster correlation (ICC) = 47.31%] and GP clusters (ICC = 12.88%) in the null model, which reduced to ICCs of 3.50% and 0.85% for GP practices and GP clusters, respectively, in the final adjusted model. CONCLUSIONS: Antibiotic prescribing in primary care is increased in areas of greater SES deprivation and this is not explained by differences in the presence of common chronic conditions or smoking status. Substantial unexplained variation in prescribing supports the need for ongoing antimicrobial stewardship initiatives.
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Antibacterianos , Gestão de Antimicrobianos , Antibacterianos/uso terapêutico , Estudos de Coortes , Humanos , Padrões de Prática Médica , Atenção Primária à Saúde , Classe SocialRESUMO
Health service utilization is an important component of child health promotion. Evidence shows that two-thirds of child deaths in low and middle income countries could be prevented if current interventions were adequately utilized. Aim of this study was to identify determinants of variation in health services utilization for children in communities in Nigeria. Multivariable negative binomial regression model attempting to explain observed variability in health services usage in Nigerian communities was applied to the 2013 Nigeria Demographic and Health Survey data. We included the index of maternal deprivation, gender of child, community environmental factor index, and maternal health seeking behaviour, multiple childhood deprivation index and ethnicity diversity index as the independent variables. The outcome variable was under-fives' hospital attendance rates for acute illness. Of the 7577 children from 896 communities in Nigeria that were sick 1936 (25.6%) were taken to the health care facilities for treatment. The final model revealed that both multiple childhood deprivation (incidence rate ratio [IRR]=1.23, 95% confidence interval [CI] 1.12 to 1.35) and children living in communities with a high ethnic diversity were associated with higher rate of health service use. Maternal health seeking behaviour was associated with a significantly lower rate of health care service use. There are significant variations in health services utilization for sick children across Nigeria communities which appear to be more strongly determined by childhood deprivation factors and maternal health seeking behaviour than by health system functions.
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Diversidade Cultural , Acessibilidade aos Serviços de Saúde , Serviços de Saúde/estatística & dados numéricos , Pré-Escolar , Etnicidade , Feminino , Inquéritos Epidemiológicos , Humanos , Lactente , Recém-Nascido , Masculino , Nigéria , Fatores SocioeconômicosRESUMO
BACKGROUND: Under-five mortality remains high in sub-Saharan Africa despite global decline. One quarter of these deaths are preventable through interventions such as immunization. The aim of this study was to examine the independent effects of individual-, community- and state-level factors on incomplete childhood immunization in Nigeria, which is one of the 10 countries where most of the incompletely immunised children in the world live. METHODS: The study was based on secondary analyses of cross-sectional data from the 2013 Nigeria Demographic and Health Survey (DHS). Multilevel multivariable logistic regression models were applied to the data on 5,754 children aged 12-23 months who were fully immunized or not (level 1), nested within 896 communities (level 2) from 37 states (level 3). RESULTS: More than three-quarter of the children (76.3%) were not completely immunized. About 83% of children of young mothers (15-24 years) and 94% of those whose mothers are illiterate did not receive full immunization. In the fully adjusted model, the chances of not being fully immunized reduced for children whose mothers attended antenatal clinic (adjusted odds ratio [aOR] = 0.49; 95% credible interval [CrI] = 0.39-0.60), delivered in health facility (aOR = 0.62; 95% CrI = 0.51-0.74) and lived in urban area (aOR = 0.66; 95% CrI = 0.50-0.82). Children whose mothers had difficulty getting to health facility (aOR = 1.28; 95% CrI = 1.02-1.57) and lived in socioeconomically disadvantaged communities (aOR = 2.93; 95% CrI = 1.60-4.71) and states (aOR = 2.69; 955 CrI =1.37-4.73) were more likely to be incompletely immunized. CONCLUSIONS: This study has revealed that the risk of children being incompletely immunized in Nigeria was influenced by not only individual factors but also community- and state-level factors. Interventions to improve child immunization uptake should take into consideration these contextual characteristics.
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Acessibilidade aos Serviços de Saúde/estatística & dados numéricos , Programas de Imunização/estatística & dados numéricos , Imunização/estatística & dados numéricos , Mães/estatística & dados numéricos , Adolescente , Estudos Transversais , Demografia , Feminino , Letramento em Saúde/estatística & dados numéricos , Inquéritos Epidemiológicos , Humanos , Imunização/psicologia , Lactente , Modelos Logísticos , Masculino , Mães/psicologia , Análise Multinível , Nigéria , Razão de Chances , Cuidado Pré-Natal/estatística & dados numéricos , Características de Residência/estatística & dados numéricos , Adulto JovemRESUMO
OBJECTIVE: To identify predictors of variations of childhood mortality between Nigerian communities and to identify high-risk communities where childhood mortality was higher than expected. STUDY DESIGN: Secondary analysis of the 2013 Nigeria Demographic and Health Survey data using prognostic univariable and multivariable mixed Poisson regression models. Likelihood ratio test, Hosmer-Lemeshow goodness-of-fit, and variance inflation factor were used to evaluate the fitness of the final model. RESULTS: The final adjusted model revealed that communities with high rating of multiple childhood deprivation (relative risk 1.14, 95% CI 1.09-1.19) and maternal socioeconomic deprivation (relative risk 1.22, 95% CI 1.14-1.29) were associated significantly with the risk of childhood mortality. Communities with enhanced maternal hospital-based health-seeking behaviors and more advantageous environmental conditions had reduced risks of childhood mortality. Similarly, children living in communities with high ethnic diversity were significantly less likely to die before their fifth birthday (relative risk 0.96, 95% CI 0.94-0.97). About 64% of the observed heterogeneity in childhood mortality in these communities was explained by the final model. Eleven of the 896 communities had higher than expected childhood mortality rates during the study period. CONCLUSIONS: Of the 31â482 children included in this survey, 2886 had died before their fifth birthday (128 deaths per 1000 live births). There are variations in childhood mortality across Nigerian communities that are not determined only by health system functions but also by factors beyond the scope of health authorities and healthcare delivery systems.
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Mortalidade da Criança , Modelos Estatísticos , Criança , Humanos , Nigéria/epidemiologia , Prognóstico , Características de Residência , RiscoRESUMO
BACKGROUND: The burden of cervical cancer remains huge globally, more so in sub-Saharan Africa. Effectiveness of screening, rates of recurrence following treatment and factors driving these in Africans have not been sufficiently studied. The purpose of this study therefore was to investigate factors associated with recurrence of cervical intraepithelial lesions following thermo-coagulation in HIV-positive and HIV-negative Nigerian women using Visual Inspection with Acetic Acid (VIA) or Lugol's Iodine (VILI) for diagnosis. METHODS: A retrospective cohort study was conducted, recruiting participants from the cervical cancer "see and treat" program of IHVN. Data from 6 sites collected over a 4-year period was used. Inclusion criteria were: age ≥18 years, baseline HIV status known, VIA or VILI positive and thermo-coagulation done. Logistic regression was performed to examine the proportion of women with recurrence and to examine factors associated with recurrence. RESULTS: Out of 177 women included in study, 67.8 % (120/177) were HIV-positive and 32.2 % (57/177) were HIV-negative. Recurrence occurred in 16.4 % (29/177) of participants; this was 18.3 % (22/120) in HIV-positive women compared to 12.3 % (7/57) in HIV-negative women but this difference was not statistically significant (p-value 0.31). Women aged ≥30 years were much less likely to develop recurrence, adjusted OR = 0.34 (95 % CI = 0.13, 0.92). Among HIV-positive women, CD4 count <200cells/mm(3) was associated with recurrence, adjusted OR = 5.47 (95 % CI = 1.24, 24.18). CONCLUSION: Recurrence of VIA or VILI positive lesions after thermo-coagulation occurs in a significant proportion of women. HIV-positive women with low CD4 counts are at increased risk of recurrent lesions and may be related to immunosuppression.
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Eletrocoagulação/normas , Infecções por HIV/complicações , Infecções por HIV/terapia , Displasia do Colo do Útero/fisiopatologia , Adulto , Estudos de Coortes , Eletrocoagulação/métodos , Feminino , Infecções por HIV/epidemiologia , HIV-1/patogenicidade , HIV-1/efeitos da radiação , Humanos , Terapia a Laser/métodos , Terapia a Laser/normas , Pessoa de Meia-Idade , Nigéria/epidemiologia , Estudos Retrospectivos , Neoplasias do Colo do Útero/diagnóstico , Neoplasias do Colo do Útero/radioterapia , Displasia do Colo do Útero/complicações , Displasia do Colo do Útero/epidemiologiaRESUMO
IMPORTANCE: Interpreting screening mammograms is a difficult repetitive task that can result in missed cancers and false-positive recalls. In the United Kingdom, 2 film readers independently evaluate each mammogram to search for signs of cancer and examine digital mammograms in batches. However, a vigilance decrement (reduced detection rate with time on task) has been observed in similar settings. OBJECTIVE: To determine the effect of changing the order for the second film reader of batches of screening mammograms on rates of breast cancer detection. DESIGN, SETTING, AND PARTICIPANTS: A multicenter, double-blind, cluster randomized clinical trial conducted at 46 specialized breast screening centers from the National Health Service Breast Screening Program in England for 1 year (all between December 20, 2012, and November 3, 2014). Three hundred sixty readers participated (mean, 7.8 readers per center)-186 radiologists, 143 radiography advanced practitioners, and 31 breast clinicians, all fully qualified to report mammograms in the NHS breast screening program. INTERVENTIONS: The 2 readers examined each batch of digital mammograms in the same order in the control group and in the opposite order to one another in the intervention group. MAIN OUTCOMES AND MEASURES: The primary outcome was cancer detection rate; secondary outcomes were rates of recall and disagreements between readers. RESULTS: Among 1,194,147 women (mean age, 59.3; SD, 7.49) who had screening mammograms (596,642 in the intervention group; 597,505 in the control group), the images were interpreted in 37,688 batches (median batch size, 35; interquartile range [IQR]; 16-46), with each reader interpreting a median of 176 batches (IQR, 96-278). After completion of all subsequent diagnostic tests, a total of 10,484 cases (0.88%) of breast cancer were detected. There was no significant difference in cancer detection rate with 5272 cancers (0.88%) detected in the intervention group vs 5212 cancers (0.87%) detected in the control group (difference, 0.01% points; 95% CI, -0.02% to 0.04% points; recall rate, 24,681 [4.14%] vs 24,894 [4.17%]; difference, -0.03% points; 95% CI, -0.10% to 0.04% points; or rate of reader disagreements, 20,471 [3.43%] vs 20,793 [3.48%]; difference, -0.05% points; 95% CI, -0.11% to 0.02% points). CONCLUSIONS AND RELEVANCE: Interpretation of batches of mammograms by qualified screening mammography readers using a different order vs the same order for the second reading resulted in no significant difference in rates of detection of breast cancer. TRIAL REGISTRATION: isrctn.org Identifier: ISRCTN46603370.
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Atenção , Neoplasias da Mama/diagnóstico por imagem , Mamografia , Radiologia , Método Duplo-Cego , Inglaterra , Feminino , Humanos , Modelos Logísticos , Mamografia/estatística & dados numéricos , Pessoa de Meia-Idade , Variações Dependentes do Observador , Radiologia/estatística & dados numéricos , Tamanho da AmostraRESUMO
PURPOSE: To determine the pattern of dental care utilisation of people living with HIV (PLHIV). MATERIALS AND METHODS: A cross-sectional questionnaire survey of 239 PLHIV patients in three care centres was done. Information on sociodemographics, dental visit, risk groups, living arrangement, medical insurance and need of dental care was recorded. The EC Clearinghouse and WHO clinical staging was used to determine the stage of HIV/AIDS infection following routine oral examinations under natural daylight. Multivariate logistic regression models were created after adjusting for all the covariates that were statistically significant at univariate/bivariate levels. RESULTS: The majority of subjects were younger than 50 years, about 93% had not seen a dentist before being diagnosed HIV positive and 92% reported no dental visit after contracting HIV. Among nonusers of dental care, 14.3% reported that they wanted care but were afraid to seek it. Other reasons included poor awareness, lack of money and stigmatisation. Multivariate analysis showed that lack of dental care was associated with employment status, living arrangements, educational status, income per annum and presenting with oral symptoms. The area under the receiver operating curve was 84% for multivariate logistic regression model 1, 70% for model 2, 67% for model 3 and 71% for model 4, which means that the predictive power of the models were good. CONCLUSION: Contrary to our expectations, dental utilisation among PLHIV was generally poor among this group of patients. There is serious and immediate need to improve the awareness of PLHIVs in African settings and barriers to dental care utilisation should also be removed or reduced.
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Assistência Odontológica/estatística & dados numéricos , Soropositividade para HIV/diagnóstico , Adolescente , Adulto , Fatores Etários , Área Sob a Curva , Atitude Frente a Saúde , Candidíase Bucal/diagnóstico , Estudos Transversais , Escolaridade , Emprego , Medo/psicologia , Feminino , Soropositividade para HIV/psicologia , Humanos , Renda , Seguro Saúde , Masculino , Pessoa de Meia-Idade , Avaliação das Necessidades , Nigéria , Úlceras Orais/diagnóstico , Curva ROC , Características de Residência , Medição de Risco , Estereotipagem , Adulto JovemRESUMO
Introduction To enhance the diagnosis of anatomic left ventricular hypertrophy (LVH) using electrocardiography (ECG), we aimed to identify common ECG amplitude and non-amplitude abnormalities in Nigerian patients with hypertensive echocardiographic LVH. Method The study included 1,765 patients with essential hypertension aged 18 years and older from the Federal Medical Centre Abuja Hypertension Registry (FMCAHR). Participants underwent echocardiography and ECG following the American College of Cardiology and the American Society of Echocardiography guidelines. Results The prevalence of overall ECG LVH amplitude criteria (43.8%) and individual criteria of Cornell voltage (27.1%), Sokolow-Lyon voltage (23.2%), and Gubner-Ungerleider (13.9%) were higher than non-amplitude ECG abnormalities among patients with echocardiographic LVH. The sensitivity and specificity of LVH criteria were 43.8% and 79.5% for overall ECG LVH, 23.2% and 87.2% for Sokolow-Lyon voltage, 27.1% and 93.3% for Cornell voltage, and 13.9% and 95.4% for Gubner-Ungerleider criteria, respectively. After multivariable adjustment, non-amplitude ECG changes, including prolonged corrected QT (QTc) (odds ratio (OR): 1.68, 95% confidence interval (CI): 1.06-2.66), left ventricular (LV) strain pattern (OR: 1.83, CI: 1.23-2.72), left axis deviation (OR: 1.56, CI: 1.09-2.24), poor R wave progression (OR: 2.36, CI: 1.40-3.97), premature ventricular contractions (OR: 1.80, CI: 1.10-2.91), premature atrial contractions (OR: 2.06, CI: 1.10-3.87), atrial fibrillation (OR: 2.40, CI: 1.20-4.82), and left atrial abnormality (OR: 8.43, CI: 2.95-24.05), were associated with echocardiographic LVH (p < 0.05). Conclusion In our cohort of hypertensive patients, ECG LVH amplitude criteria were the most frequently observed abnormalities associated with echocardiographic LVH. Our findings suggest that despite the low sensitivity, ECG LVH amplitude criteria may remain valuable in diagnosing echocardiographic LVH.
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The true prevalence and cardiovascular comorbidities of resistant hypertension (RH) in Nigeria and Africa are not known. We sought to determine the prevalence and cardiovascular comorbidities of resistant hypertension in a treated Nigerian hypertensive population. We analyzed 1,378 patients with essential hypertension from a prospective clinical registry, the Federal Medical Centre Abuja Hypertension Registry. Resistant hypertension was defined as blood pressure ≥140/90 mmHg despite the use of ≥3 guideline-recommended antihypertensive medications including a diuretic, reninangiotensin system blocker and calcium-channel blocker at optimal or best-tolerated doses or blood pressure <140/90 mmHg on ≥4 antihypertensive medications. Resistant hypertension was confirmed with the use of home blood pressure monitoring while adherence was determined by monitoring prescription orders. The prevalence of resistant hypertension was 15.5%, with 12.3% as controlled resistant hypertension and 3.3% as uncontrolled resistant hypertension. Risk factors independently associated with the odds of resistant hypertension were male sex (adjusted odds ratio [AOR]: 1.62, 95% confidence interval [CI] 1.19-2.21, p = 0.002), obesity, and diabetes mellitus. Furthermore, patients with resistant hypertension were more likely to have heart failure with preserved ejection fraction (AOR: 3.36, 95% CI 1.25-9.07, p = 0.017), cerebrovascular disease, and chronic kidney disease. In our treated hypertensive cohort, resistant hypertension was associated with an increased risk of cerebrovascular disease, chronic kidney disease, and heart failure with preserved ejection fraction, and it appears this burden maybe 2-3 times more in those with resistant hypertension compared to those without. Concerted efforts to prevent or promptly treat resistant hypertension in our population will reduce cardiovascular comorbidities.
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Transtornos Cerebrovasculares , Insuficiência Cardíaca , Hipertensão , Insuficiência Renal Crônica , Humanos , Masculino , Feminino , Anti-Hipertensivos/uso terapêutico , Anti-Hipertensivos/farmacologia , Prevalência , Estudos Prospectivos , Hipertensão/tratamento farmacológico , Hipertensão/epidemiologia , Hipertensão/complicações , Pressão Sanguínea , Fatores de Risco , Insuficiência Cardíaca/epidemiologia , Insuficiência Renal Crônica/complicações , Nigéria/epidemiologiaRESUMO
BACKGROUND: Kidney transplant recipients (KTRs) have elevated risks of cervical pre-cancers and cancers, and guidelines recommend more frequent cervical cancer screening exams. However, little is known about current trends in cervical cancer screening in this unique population. We described patterns in the uptake of cervical cancer screening exams among female KTRs and identified factors associated with screening utilization. METHODS: This retrospective cohort study included female KTRs between 20-65 years old, with Texas Medicare fee-for-service coverage, who received a transplant between January 1, 2001, and December 31, 2017. We determined the cumulative incidence of receiving cervical cancer screening post-transplant using ICD-9, ICD-10, and CPT codes and assessed factors associated with screening utilization, using the Fine and Gray model to account for competing events. Subdistribution hazards models were used to assess factors associated with screening uptake. RESULTS: Among 2,653 KTRs meeting the inclusion and exclusion criteria, the 1-, 2-, and 3-year cumulative incidences of initiating a cervical cancer screening exam post-transplant were 31.7% (95% confidence interval (CI), 30.0-33.6%), 48.0% (95% CI, 46.2-49.9%), and 58.5% (95% CI, 56.7-60.3%), respectively. KTRs who were 55-64 years old (vs. <45 years old) and those with a higher Charlson Comorbidity Score post-transplant were less likely to receive cervical cancer screening post-transplant. CONCLUSIONS: Cervical cancer screening uptake is low in the years immediately following a kidney transplant. IMPACT: Our findings highlight a need for interventions to improve cervical cancer screening utilization among KTRs.
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OBJECTIVE: Per- and polyfluoroalkyl substances (PFAS) alter immune function increasing infectious diseases risk. We examined the relationship between PFAS and chlamydia. METHODS: A total of 3965 nonpregnant adults ages 18-39 years from the National Nutrition Examination Survey 2003-2016 cycles were included. Poisson regression with robust error variance estimated the prevalence ratio and 95% confidence intervals for the association between PFAS and chlamydia. A g computation model was used to examine PFAS mixtures and chlamydia. RESULTS: In adjusted age and sex-stratified models, an increase in PFAS mixtures by one quintile was associated with chlamydia in older males and younger females. Associations were not observed before stratification. CONCLUSIONS: PFAS exposure associated with higher chlamydia prevalence, but only in stratified models suggesting biological differences by gender and age. However, small sample sizes could have affected the precision of our models.
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Infecções por Chlamydia , Chlamydia trachomatis , Fluorocarbonos , Inquéritos Nutricionais , Humanos , Feminino , Masculino , Adulto , Adulto Jovem , Adolescente , Infecções por Chlamydia/epidemiologia , Estados Unidos/epidemiologia , Prevalência , Exposição Ambiental/efeitos adversos , Exposição Ambiental/análise , Estudos Transversais , Poluentes AmbientaisRESUMO
Importance: The current method of BRCA testing for breast and ovarian cancer prevention, which is based on family history, often fails to identify many carriers of pathogenic variants. Population-based genetic testing offers a transformative approach in cancer prevention by allowing for proactive identification of any high-risk individuals and enabling early interventions. Objective: To assess the lifetime incremental effectiveness, costs, and cost-effectiveness of population-based multigene testing vs family history-based testing. Design, Setting, and Participants: This economic evaluation used a microsimulation model to assess the cost-effectiveness of multigene testing (BRCA1, BRCA2, and PALB2) for all women aged 30 to 35 years compared with the current standard of care that is family history based. Carriers of pathogenic variants were offered interventions, such as magnetic resonance imaging with or without mammography, chemoprevention, or risk-reducing mastectomy and salpingo-oophorectomy, to reduce cancer risk. A total of 2000 simulations were run on 1â¯000â¯000 women, using a lifetime time horizon and payer perspective, and costs were adjusted to 2022 US dollars. This study was conducted from September 1, 2020, to December 15, 2023. Main Outcomes and Measures: The main outcome measure was the incremental cost-effectiveness ratio (ICER), quantified as cost per quality-adjusted life-year (QALY) gained. Secondary outcomes included incremental cost, additional breast and ovarian cancer cases prevented, and excess deaths due to coronary heart disease (CHD). Results: The study assessed 1â¯000â¯000 simulated women aged 30 to 35 years in the US. In the base case, population-based multigene testing was more cost-effective compared with family history-based testing, with an ICER of $55â¯548 per QALY (95% CI, $47â¯288-$65â¯850 per QALY). Population-based multigene testing would be able to prevent an additional 1338 cases of breast cancer and 663 cases of ovarian cancer, but it would also result in 69 cases of excess CHD and 10 excess CHD deaths per million women. The probabilistic sensitivity analyses show that the probability that population-based multigene testing is cost-effective was 100%. When the cost of the multigene test exceeded $825, population-based testing was no longer cost-effective (ICER, $100â¯005 per QALY; 95% CI, $87â¯601-$11â¯6323). Conclusions and Relevance: In this economic analysis of population-based multigene testing, population-based testing was a more cost-effective strategy for the prevention of breast cancer and ovarian cancer when compared with the current family history-based testing strategy at the $100â¯000 per QALY willingness-to-pay threshold. These findings support the need for more comprehensive genetic testing strategies to identify pathogenic variant carriers and enable informed decision-making for personalized risk management.
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Neoplasias da Mama , Feminino , Humanos , Análise Custo-Benefício , Neoplasias da Mama/diagnóstico , Neoplasias da Mama/genética , Neoplasias da Mama/prevenção & controle , Mastectomia , Mama , MamografiaRESUMO
Introduction: Despite being almost entirely preventable, cervical cancer is the fourth most frequently diagnosed cancer among women worldwide. Cervical cancer incidence suggests missed opportunities for prevention. Geospatial analysis could strategically guide public health interventions. This study aimed to identify geographic clusters of cervical cancer incidence in Texas, a state with higher than national rates of cervical cancer incidence and mortality. Methods: In this population-based cross-sectional study, the authors analyzed incident cervical cancer data among Texas women aged 30-64 years, from 2014 to 2018. The authors conducted a purely spatial Poisson-based analysis function in SaTScan to examine geographic clusters of higher-than-expected proportions of cervical cancer incidence (i.e., hot spots) and adjusted for age. Results: A total of 5,060 women aged 30-64 years with incident cervical cancer diagnosis (mean age: 45.7 years, SD=9.6), including 1,840 (36.4%) Hispanic, 591 (11.7%) non-Hispanic Black, 2,397 (47.4%) non-Hispanic White, and 232 (4.6%) other races, were analyzed. Spatial scan analysis detected 7 significant hot spots of cervical cancer incidence. Hot spots were identified in the South Texas Plains (near Mexico border), Gulf Coast (Houston), Prairies and Lakes (North Texas), Panhandle Plains (Northwest Texas), and Piney Woods (Southeast Texas) regions of Texas. Hot spots, compared with the rest of Texas, had higher proportions of Hispanic population and individuals with socioeconomic disadvantages. Conclusions: This study found spatial variation in cervical cancer incidence in Texas. The hot spot areas can benefit from targeted, novel, scalable, and cost-effective interventions to increase human papillomavirus vaccination and screening and early detection and treatment of precancerous cervical lesions.
RESUMO
BACKGROUND: While cervical cancer incidence rates (IR) in the United States have dropped in the last 20 years, non-cervical human papillomavirus (HPV) associated cancers increased. Many people in Texas (TX) live in medically underserved areas and have higher risk of developing HPV-associated cancers. Since previous studies of these regions focused on cervical cancer, we included other HPV-associated cancers in our analysis of IR in East TX and the TX-Mexico Border compared to other TX regions. METHODS: Cancer data from 2006 to 2019 were obtained from the TX Cancer Registry. Cases of HPV-associated cervical, vaginal, vulvar, penile, anal, and oropharyngeal cancers and corresponding patient-level demographic data were included. We calculated IR per 100,000 and drew heat maps to visualize cancer IR by county. To control potential confounders, we added county-level risk factors: rates for smoking, excessive drinking, obesity, STIs, primary care provider availability and dentist availability, from the County Health Rankings and Roadmaps program. We reported IRs by region and time and estimated unadjusted and adjusted risk ratio (RR) for association of each type of cancer and region. Lastly, we created adjusted models for each cancer by period to see time trends of regional differences. RESULTS: Risk of anal, cervical, and oropharyngeal cancer was lower at parts of the Border than in the rest of TX in the adjusted model. We also observed increasing anal and oropharyngeal cancer risk and decreasing cervical and vaginal cancer risk over time. CONCLUSION: Patient sociodemographics, behavioral risk factors, and access to care may contribute to some observed differences in cancer IR across regions. This indicates that targeted prevention efforts towards these regions, especially in low socioeconomic status communities, may benefit future generations.
Assuntos
Área Carente de Assistência Médica , Infecções por Papillomavirus , Humanos , Texas/epidemiologia , Feminino , Incidência , Infecções por Papillomavirus/epidemiologia , Infecções por Papillomavirus/complicações , Infecções por Papillomavirus/virologia , Masculino , Pessoa de Meia-Idade , Adulto , Fatores de Risco , Idoso , Sistema de Registros , Neoplasias/epidemiologia , Neoplasias/etiologia , Neoplasias do Colo do Útero/epidemiologia , Neoplasias do Colo do Útero/virologia , Neoplasias Orofaríngeas/epidemiologia , Neoplasias Orofaríngeas/virologiaRESUMO
Importance: To inform the design and implementation of targeted interventions to reduce the future burden of human papillomavirus (HPV)-related cancers in Texas, it is necessary to examine the county and health service region (HSR) levels of (1) the proportion of children and teenagers aged 9 to 17 years who initiated and were up to date for HPV vaccination series and (2) HPV-related cancer incidence rates (IRs). Objective: To evaluate temporal trends and geospatial patterns of HPV vaccination initiation and up-to-date status as well as HPV-related cancer rates at county and HSR levels in Texas. Design, Setting, and Participants: This population-based cross-sectional study used data from the Texas Immunization Registry, the National Cancer Institute's Surveillance, Epidemiology, and End Results Program database, and Texas Department of State Health Services annual population counts from 2006 to 2022. The analysis of HPV vaccination rates was conducted among children and teenagers aged 9 to 17 years; the analysis of HPV-related cancer rates was conducted among adults aged 20 years and older. Data were extracted between June and July 2023 and statistical analysis was performed from February to April 2024. Main Outcomes and Measures: HPV vaccination initiation and up-to-date status rates and HPV-related cancer IR at county and HSR levels. Results: A total of 32â¯270â¯243 children and teenagers (65.8% female individuals and 34.2% male individuals) and 22â¯490â¯105 individuals aged 20 years and older (50.7% female individuals and 49.3% male individuals) were included. The mean 2021 to 2022 county-level HPV vaccination series initiation estimates ranged from 6.3% to 69.1% for female and from 7.0% to 77.6% for male children and teenagers aged 9 to 17 years. County-level vaccination up-to-date estimates were generally lower compared with those of initiation estimates and ranged from 1.6% to 30.4% for female and from 2.1% to 34.8% for male children and teenagers. The pattern of HPV vaccination rates stratified by sex were similar across counties and HSRs. The age-adjusted annual HPV-related cancer IR by county for years 2016 to 2020 ranged from 0 to 154.2 per 100â¯000 for female individuals and from 0 to 60.1 per 100â¯000 for male individuals. The counties located in North Texas, HSRs 2/3 and 4/5N, had lower HPV vaccination rates and higher IRs of HPV-related cancers for both female and male individuals compared with other regions. Conclusions and Relevance: In this study, the incidence of HPV-related cancers varied widely across the counties and HSRs of Texas. More counties in North Texas, HSRs 2/3 and 4/5N, had higher IRs of HPV-related cancers and a lower proportion of HPV vaccination rates than counties in other regions. Designing and implementing targeted interventions to increase uptake and completion of HPV vaccination series across counties with low HPV vaccination rates may help to reduce future the burden of HPV-related cancers.
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Infecções por Papillomavirus , Vacinas contra Papillomavirus , Humanos , Adolescente , Feminino , Vacinas contra Papillomavirus/administração & dosagem , Texas/epidemiologia , Criança , Infecções por Papillomavirus/prevenção & controle , Infecções por Papillomavirus/epidemiologia , Masculino , Estudos Transversais , Adulto , Incidência , Adulto Jovem , Vacinação/estatística & dados numéricos , Neoplasias do Colo do Útero/prevenção & controle , Neoplasias do Colo do Útero/epidemiologia , Neoplasias do Colo do Útero/virologia , Papillomavirus HumanoRESUMO
Endometrial cancer has continued to see a rising incidence in the US over the years. The main aim of this study was to assess current trends in patients' characteristics and outcomes of treatment for endometrial carcinoma over 16 years. A dataset from the National Cancer Database (NCDB) for patients diagnosed with endometrial carcinoma from 2005 to 2020 was used in this retrospective, case series study. The main outcomes and measures of interest included tumor characteristics, hospitalization, treatments, mortality, and overall survival. Then, 569,817 patients who were diagnosed with endometrial carcinoma were included in this study. The mean (SD) age at diagnosis was 62.7 (11.6) years, but 66,184 patients (11.6%) were younger than 50 years, indicating that more patients are getting diagnosed at younger ages. Of the patients studied, 37,079 (6.3%) were Hispanic, 52,801 (9.3%) were non-Hispanic Black, 432,058 (75.8%) were non-Hispanic White, and 48,879 (8.6%) were other non-Hispanic. Patients in the 4th period from 2017 to 2020 were diagnosed more with stage IV (7.1% vs. 5.2% vs. 5.4% vs. 5.9%; p < 0.001) disease compared with those in the other three periods. More patients with severe comorbidities (Charlson Comorbidity Index score of three) were seen in period 4 compared to the first three periods (3.9% vs. ≤1.9%). Systemic chemotherapy use (14.1% vs. 17.7% vs. 20.4% vs. 21.1%; p < 0.001) and immunotherapy (0.01% vs. 0.01% vs. 0.2% vs. 1.1%; p < 0.001) significantly increased from period 1 to 4. The use of laparotomy decreased significantly from 42.1% in period 2 to 16.7% in period 4, while robotic surgery usage significantly increased from 41.5% in period 2 to 64.3% in period 4. The 30-day and 90-day mortality decreased from 0.6% in period 1 to 0.2% in period 4 and 1.4% in period 1 to 0.6% in period 4, respectively. Over the period studied, we found increased use of immunotherapy, chemotherapy, and minimally invasive surgery for the management of endometrial cancer. Overall, the time interval from cancer diagnosis to final surgery increased by about 6 days. The improvements observed in the outcomes examined can probably be associated with the treatment trends observed.