Impact of the COVID-19 Pandemic on Fecal Immunochemical Testing, Colonoscopy Services, and Colorectal Neoplasia Detection in a Large United States Community-based Population.

BACKGROUND & AIMS: The COVID-19 pandemic has affected clinical services globally, including colorectal cancer (CRC) screening and diagnostic testing. We investigated the pandemic's impact on fecal immunochemical test (FIT) screening, colonoscopy utilization, and colorectal neoplasia detection across 21 medical centers in a large integrated health care organization. METHODS: We performed a retrospective cohort study in Kaiser Permanente Northern California patients ages 18 to 89 years in 2019 and 2020 and measured changes in the numbers of mailed, completed, and positive FITs; colonoscopies; and cases of colorectal neoplasia detected by colonoscopy in 2020 vs 2019. RESULTS: FIT kit mailings ceased in mid-March through April 2020 but then rebounded and there was an 8.7% increase in kits mailed compared with 2019. With the later mailing of FIT kits, there were 9.0% fewer FITs completed and 10.1% fewer positive tests in 2020 vs 2019. Colonoscopy volumes declined 79.4% in April 2020 compared with April 2019 but recovered to near pre-pandemic volumes in September through December, resulting in a 26.9% decline in total colonoscopies performed in 2020. The number of patients diagnosed by colonoscopy with CRC and advanced adenoma declined by 8.7% and 26.9%, respectively, in 2020 vs 2019. CONCLUSIONS: The pandemic led to fewer FIT screenings and colonoscopies in 2020 vs 2019; however, after the lifting of shelter-in-place orders, FIT screenings exceeded, and colonoscopy volumes nearly reached numbers from those same months in 2019. Overall, there was an 8.7% reduction in CRC cases diagnosed by colonoscopy in 2020. These data may help inform the development of strategies for CRC screening and diagnostic testing during future national emergencies.

Natural Language Processing for the Accurate Identification of Colorectal Cancer Mismatch Repair Status in Lynch Syndrome Screening.

Lynch syndrome (LS) is the most common type of hereditary colorectal cancer (CRC) syndrome caused by pathogenic variants in mismatch repair (MMR) genes.1 Current multisociety guidelines recommend screening all CRC tumors for LS.2,3 The most widely adopted screening method is MMR immunohistochemistry (IHC) followed by germline analysis if indicated.2,3 However, the text-based nature of pathology and IHC reports used for LS screening results impedes creation of an efficient tracking system for identifying affected patients and screening outcomes.4 In this study, we developed and validated a natural language processing (NLP) tool for extracting MMR IHC results in LS screening in a large, diverse, multicenter, community-based setting.5.

Validation of an Algorithm to Identify Patients at Risk for Colorectal Cancer Based on Laboratory Test and Demographic Data in Diverse, Community-Based Population.

BACKGROUND & AIMS: Approximately 30%-40% of screening-eligible adults in the United States are not up to date with colorectal cancer (CRC) screening. We aimed to validate a predictive score, generated by a machine learning algorithm with common laboratory test data, to identify patients at high risk for CRC in a large, community-based, ethnically diverse cohort. METHODS: We performed a nested case-control study using data from members of Kaiser Permanente Northern California (1996-2015). Cases were cohort members who received a complete blood cell count at ages 50-75 y, did not have a prior or current diagnosis of CRC diagnosis at the time of the blood cell count, and were subsequently diagnosed with CRC. We used data from the cohort to validate the ability of an algorithm that uses laboratory and demographic information to identify patients at increased risk for CRC. Test performance was evaluated using area under the receiver operating characteristic curve (AUROC) and odds ratios (OR) with 95% CI values to compare high (defined as 97% specificity or more) vs low scores. RESULTS: A high score from the algorithm identified patients with a CRC diagnosis within the next 6 months with 35.4% sensitivity (95% CI, 33.8-36.7) and an AUROC of 0.78 (95% CI, 0.77-0.78). Patients with a high score had an increased risk of diagnosis with early-stage CRC (OR, 13.1; 95% CI, 11.8-14.3) and advanced stage CRC (OR, 24.8; 95% CI, 22.4-27.3) within the next 6 months. In patients with high scores, the ORs for proximal and distal cancers were 34.7 (95% CI, 31.5-37.7) and 12.1 (95% CI, 10.1-13.9), respectively. The algorithm's accuracy decreased with the time interval between blood test result and CRC diagnosis; performance did not differ by sex or race. CONCLUSIONS: We validated a predictive model that uses complete blood cell count and demographic data to identify patients at high risk of CRC. The algorithm identified 3% of the population who require an investigation and identified 35% of patients who received a diagnosis of CRC within the next 6 months.

Trends in Gonorrhea and Chlamydia Testing and Infections Across the COVID-19 Pandemic in Adolescents and Young Adults in an Integrated Health System.

PURPOSE: The COVID-19 pandemic impacted testing and incidence of sexually transmitted infections (STIs), with some studies showing uneven effects across sociodemographic groups. We aim to determine whether rates of gonorrhea and chlamydia testing and infections were affected by the pandemic, overall and by subgroups, defined by sociodemographic factors and comorbidities. METHODS: We conducted a retrospective cohort study from January 1, 2016, through December 31, 2022, among adolescents and young adults ages 15-29 years within Kaiser Permanente Northern California (KPNC). We determined the rate of testing for gonorrhea/chlamydia, and the incident rates of infections before and during the COVID-19 pandemic by sociodemographic factors. We compared incidence rates of gonorrhea/chlamydia testing and infection before and during the pandemic using Poisson regression. RESULTS: Gonorrhea/chlamydia testing during the pandemic was 19% lower than prepandemic baseline. Testing among Black patients was 1.8-fold higher than White patients. Black patients had 5.5 and 3.6-fold higher rate of gonorrhea and chlamydia infections, respectively, compared with White patients. Patients living in more deprived neighborhoods also had higher rates of infection compared to those in the least deprived neighborhoods. In multivariable analyses stratified by the period before and during the COVID-19 pandemic, there were no significant differences in the incidence rate ratios of testing or infections for any specific sociodemographic factor. DISCUSSION: STI testing in adolescents and young adults dropped dramatically after the start of the pandemic and has not recovered to its prior levels. Preexisting disparities in STI testing and infections were not exacerbated by the pandemic.

Development and External Validation of a Prediction Model for Colorectal Cancer Among Patients Awaiting Surveillance Colonoscopy Following Polypectomy.

Background and Aims: Demand for surveillance colonoscopy can sometimes exceed capacity, such as during and following the coronavirus disease 2019 pandemic, yet no tools exist to prioritize the patients most likely to be diagnosed with colorectal cancer (CRC) among those awaiting surveillance colonoscopy. We developed a multivariable prediction model for CRC at surveillance comparing performance to a model that assigned patients as low or high risk based solely on polyp characteristics (guideline-based model). Methods: Logistic regression was used for model development among patients receiving surveillance colonoscopy in 2014-2019. Candidate predictors included index colonoscopy indication, findings, and endoscopist adenoma detection rate, and patient and clinical characteristics at surveillance. Patients were randomly divided into model development (n = 36,994) and internal validation cohorts (n = 15,854). External validation was performed on 30,015 patients receiving surveillance colonoscopy in 2020-2022, and the multivariable model was then updated and retested. Results: One hundred fourteen, 43, and 71 CRCs were detected at surveillance in the 3 cohorts, respectively. Polyp size ≥10 mm, adenoma detection rate <32.5% or missing, patient age, and ever smoked tobacco were significant CRC predictors; this multivariable model outperformed the guideline-based model (internal validation cohort area under the receiver-operating characteristic curve: 0.73, 95% confidence interval (CI): 0.66-0.81 vs 0.52, 95% CI: 0.45-0.60). Performance declined at external validation but recovered with model updating (operating characteristic curve: 0.72 95% CI: 0.66-0.77). Conclusion: When surveillance colonoscopy demand exceeds capacity, a prediction model featuring common clinical predictors may help prioritize patients at highest risk for CRC among those awaiting surveillance. Also, regular model updates can address model performance drift.

Maternal SARS-CoV-2 vaccination and infant protection against SARS-CoV-2 during the first six months of life.

We examined the effectiveness of maternal vaccination against SARS-CoV-2 infection in 30,311 infants born at Kaiser Permanente Northern California from December 15, 2020, to May 31, 2022. Using Cox regression, the effectiveness of ≥2 doses of COVID-19 vaccine received during pregnancy was 84% (95% confidence interval [CI]: 66, 93), 62% (CI: 39, 77) and 56% (CI: 34,71) during months 0-2, 0-4 and 0- 6 of a child's life, respectively, in the Delta variant period. In the Omicron variant period, the effectiveness of maternal vaccination in these three age intervals was 21% (CI: -21,48), 14% (CI: -9,32) and 13% (CI: -3,26), respectively. Over the entire study period, the incidence of hospitalization for COVID-19 was lower during the first 6 months of life among infants of vaccinated mothers compared with infants of unvaccinated mothers (21/100,000 person-years vs. 100/100,000 person-years). Maternal vaccination was protective, but protection was lower during Omicron than during Delta. Protection during both periods decreased as infants aged.

Effectiveness of COVID-19 vaccination during pregnancy by circulating viral variant.

BACKGROUND: SARS-CoV-2 infection in pregnancy can result in a spectrum of asymptomatic to critical COVID-19 outcomes, including hospitalization, admission to the intensive care unit, or death. OBJECTIVE: This study aimed to investigate the effectiveness of messenger RNA COVID-19 vaccination during pregnancy against both hospitalization and infection, stratified by different variant circulations and by time since the last vaccine dose. STUDY DESIGN: This was a retrospective cohort study among pregnant persons who were members of Kaiser Permanente Northern California and delivered between December 15, 2020, and September 30, 2022. Pregnant persons who received any vaccine dose before the pregnancy onset date were excluded. The primary outcome was hospitalization for COVID-19, and the secondary outcome was polymerase chain reaction-confirmed SARS-CoV-2 infection. Exposure was receipt of a messenger RNA vaccine during pregnancy. Poisson regression was used to estimate the risk ratio of hospitalization by comparing vaccinated pregnant persons with unvaccinated pregnant persons adjusted for sociodemographic factors and calendar time. Cox regression was used to estimate the hazard ratio of infection by comparing vaccinated pregnant persons with unvaccinated pregnant persons. Vaccine effectiveness was estimated as 1 minus the rate ratio or the hazard ratio multiplied by 100. Vaccine effectiveness was estimated overall and by variant periods (before Delta, Delta, Omicron, and subvariants). RESULTS: Of 57,688 pregnant persons, 16,153 (28%) received at least 1 dose of a messenger RNA COVID-19 vaccine during pregnancy; moreover, 4404 pregnant persons tested positive for SARS-CoV-2 infection, and 108 pregnant persons were hospitalized during pregnancy. Overall, 2-dose vaccine effectiveness against hospitalization was 91% within <150 days of vaccination and 48% >150 days after vaccination. The 2-dose vaccine effectiveness within <150 days after vaccination was 100% during the original virus strain and Delta variant periods of the virus; vaccine effectiveness was 51% during the Omicron period. Of the hospitalization cases, 97% of pregnant persons were unvaccinated. During hospitalization, none of the vaccinated pregnant persons required ventilation or were admitted to the intensive care unit. Moreover, 2-dose vaccine effectiveness against infection was 54% within <150 days after vaccination and 26% ≥150 days after vaccination. CONCLUSION: Messenger RNA COVID-19 vaccination during pregnancy was effective against hospitalization for COVID-19 and SARS-CoV-2 infection. COVID-19 was mild among pregnant persons who were vaccinated compared with those who were unvaccinated. Thus, all pregnant persons should be strongly encouraged to receive messenger RNA COVID-19 vaccines to prevent severe disease.

Individual and neighborhood factors associated with being unvaccinated against COVID-19 among pregnant persons.

We investigated whether unvaccinated pregnant persons cluster geographically and determined factors associated with being unvaccinated using spatial and multivariate logistic regression analyses. Pregnant persons with deliveries from December 15, 2020, through September 30, 2022, at Kaiser Permanente Northern California were included. Of the 85,852 pregnant persons in the study, 46.6% were unvaccinated before and during pregnancy. Spatial analysis identified 5 clusters with high prevalence of unvaccinated pregnant persons. Within these clusters, the proportion of unvaccinated varied from 53% to 62% versus 39% outside the clusters. In covariate-adjusted analyses, residence in a cluster increased the odds of being unvaccinated by 1.64 (95% confidence interval (CI): 1.59,1.69). The odds of being unvaccinated increased among those aged 16-24 years (odds ratio [OR] = 2.69, CI: 2.55, 2.83), aged 25-34 years (OR = 1.59, CI: 1.54, 1.64) compared with age ≥ 35 years, black race (OR = 1.45, CI:1.37, 1.54), and subsidized insurance (OR = 1.32, CI: 1.26, 1.38). The odds of being unvaccinated also increased for pregnant persons living in neighborhoods where the proportion of adults with high school education or less was greater than 20%. Geographic clustering of unvaccinated pregnant persons suggests a need for population-specific-interventions to increase vaccine coverage.

Maternal SARS-CoV-2 Vaccination and Infant Protection Against SARS-CoV-2 During the First 6 Months of Life.

We examined the effectiveness of maternal vaccination against SARS-CoV-2 infection in 30,288 infants born at Kaiser Permanente Northern California from December 15, 2020, to May 31, 2022. Using Cox regression, the effectiveness of maternal vaccination was 85% (95% confidence interval [CI]: 67, 93), 64% (CI: 43, 78) and 57% (CI: 36,71) during the first 2, 4 and 6 months of life, respectively, in the Delta variant period. In the Omicron variant period, the effectiveness of maternal vaccination in these three age intervals was 22% (CI: -18,48), 14% (CI: -10,32) and 12% (CI: -4,26), respectively. Over the entire study period, the incidence of hospitalization for COVID-19 was lower during the first 6 months of life among infants of vaccinated mothers compared with infants of unvaccinated mothers (21/100,000 person-years vs. 100/100,000 person-years). Maternal vaccination was protective, but protection was lower during Omicron than during Delta. Protection during both periods decreased as infants aged.