Trends in Reported Babesiosis Cases - United States, 2011-2019.

Babesiosis is a tickborne disease caused by intraerythrocytic Babesia parasites. In the United States, most babesiosis cases are caused by Babesia microti, transmitted from bites of blacklegged ticks, Ixodes scapularis, in northeastern and midwestern states. Transmission can also occur through blood transfusions, transplantation of organs from infected donors, or congenital (mother-to-child) transmission (1). Babesia infection can be asymptomatic or cause mild to severe illness that can be fatal. Overall, U.S. tickborne disease cases have increased 25%, from 40,795 reported in 2011 to 50,856 in 2019 (2). Babesiosis trends were assessed in 10 states* where babesiosis was reportable during 2011-2019. Incidence increased significantly in Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Rhode Island, and Vermont (p<0.001), with the largest increases reported in Vermont (1,602%, from two to 34 cases), Maine (1,422%, from nine to 138), New Hampshire (372%, from 13 to 78), and Connecticut (338%, from 74 to 328). Unlike the other seven states, Maine, New Hampshire, and Vermont, were not included as states with endemic disease in previous CDC babesiosis surveillance summaries. These three states should now be considered to have endemic transmission comparable to that in other high-incidence states; they have consistently identified newly acquired cases every year during 2011-2019 and documented presence of Babesia microti in the associated tick vector (3). Because incidence in Northeastern states, including Maine, New Hampshire, and Vermont, is increasing, tick prevention messaging, provider education, and awareness of infection risk among travelers to these states should be emphasized.

JYNNEOS Vaccination Coverage Among Persons at Risk for Mpox - United States, May 22, 2022-January 31, 2023.

From May 2022 through the end of January 2023, approximately 30,000 cases of monkeypox (mpox) have been reported in the United States and >86,000 cases reported internationally.* JYNNEOS (Modified Vaccinia Ankara vaccine, Bavarian Nordic) is recommended for subcutaneous administration to persons at increased risk for mpox (1,2) and has been demonstrated to provide protection against infection (3-5). To increase the total number of vaccine doses available, the Food and Drug Administration (FDA) issued an Emergency Use Authorization (EUA) on August 9, 2022, recommending administration of the vaccine intradermally (0.1 mL per dose) for persons aged ≥18 years who are recommended to receive it (6); intradermal administration can generate an equivalent immune response to that achieved through subcutaneous injection using approximately one fifth the subcutaneous dose (7). CDC analyzed JYNNEOS vaccine administration data submitted to CDC from jurisdictional immunization information systems (IIS)† to assess the impact of the EUA and to estimate vaccination coverage among the population at risk for mpox. During May 22, 2022-January 31, 2023, a total of 1,189,651 JYNNEOS doses (734,510 first doses and 452,884 second doses)§ were administered. Through the week of August 20, 2022, the predominant route of administration was subcutaneous, after which intradermal administration became predominant, in accordance with FDA guidance. As of January 31, 2023, 1-dose and 2-dose (full vaccination) coverage among persons at risk for mpox is estimated to have reached 36.7% and 22.7%, respectively. Despite a steady decline in mpox cases from a 7-day daily average of more than 400 cases on August 1, 2022, to five cases on January 31, 2023, vaccination for persons at risk for mpox continues to be recommended (1). Targeted outreach and continued access to and availability of mpox vaccines to persons at risk are important to help prevent and minimize the impact of a resurgence of mpox.

Severe Acute Respiratory Syndrome Coronavirus 2 Transmission in a Georgia School District-United States, December 2020-January 2021.

BACKGROUND: To inform prevention strategies, we assessed the extent of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission and settings in which transmission occurred in a Georgia public school district. METHODS: During 1 December 2020-22 January 2021, SARS-CoV-2-infected index cases and their close contacts in schools were identified by school and public health officials. For in-school contacts, we assessed symptoms and offered SARS-CoV-2 reverse-transcription polymerase chain reaction (RT-PCR) testing; performed epidemiologic investigations and whole-genome sequencing to identify in-school transmission; and calculated secondary attack rate (SAR) by school setting (eg, sports, elementary school classroom), index case role (ie, staff, student), and index case symptomatic status. RESULTS: We identified 86 index cases and 1119 contacts, 688 (61.5%) of whom received testing. Fifty-nine of 679 (8.7%) contacts tested positive; 15 of 86 (17.4%) index cases resulted in ≥2 positive contacts. Among 55 persons testing positive with available symptom data, 31 (56.4%) were asymptomatic. Highest SARs were in indoor, high-contact sports settings (23.8% [95% confidence interval {CI}, 12.7%-33.3%]), staff meetings/lunches (18.2% [95% CI, 4.5%-31.8%]), and elementary school classrooms (9.5% [95% CI, 6.5%-12.5%]). The SAR was higher for staff (13.1% [95% CI, 9.0%-17.2%]) vs student index cases (5.8% [95% CI, 3.6%-8.0%]) and for symptomatic (10.9% [95% CI, 8.1%-13.9%]) vs asymptomatic index cases (3.0% [95% CI, 1.0%-5.5%]). CONCLUSIONS: Indoor sports may pose a risk to the safe operation of in-person learning. Preventing infection in staff members, through measures that include coronavirus disease 2019 vaccination, is critical to reducing in-school transmission. Because many positive contacts were asymptomatic, contact tracing should be paired with testing, regardless of symptoms.

Better late than never: Brachytherapy is more important than timing in treatment of locally advanced cervical cancer.

PURPOSE: To evaluate the utilization of brachytherapy and duration of treatment on overall survival for locally advanced cervical cancer. METHODS: The National Cancer Database (NCDB) was queried to identify stage II-IVA cervical cancer patients diagnosed in the United States between 2004 and 2015 who were treated with definitive chemoradiation therapy. We defined standard of care (SOC) treatment as receiving external beam radiation therapy (EBRT) and concurrent chemotherapy, brachytherapy (BT), and completing treatment within 8 weeks, and compared SOC treatment to non-SOC. The primary outcome was overall survival (OS). We also evaluated the effect of sociodemographic and clinical variables on receiving SOC. RESULTS: We identified 10,172 women with locally advanced cervical cancer primarily treated with chemotherapy and concurrent EBRT of which 6047 (59.4%) patients received brachytherapy, and only 2978 (29.3%) completed treatment within 8 weeks (SOC). Receipt of SOC was associated with significantly improved overall survival (median OS 131.0 mos vs 95.5 mos, 78.1 mos, 49.2 mos; p < 0.0001). Furthemore, in patients whose treatment extended beyond 8 weeks, brachytherapy was still associated with an improved survival (median OS 95.5 vs 49.2 mos, p < 0.0001). More advanced stage, Non-Hispanic Black race, lower income, lack of insurance or government insurance, less education, and rural residence were associated with decreased likelihood of receiving SOC. CONCLUSIONS: Completing standard of care concurrent chemoradiation therapy and brachytherapy in the recommended 8 weeks was associated with a superior overall survival. Patients who received brachytherapy boost show superior survival to patients receiving EBRT alone, regardless of treatment duration. Disparities in care for vulnerable populations highlight the challenges and importance of care coordination for patients with cervical cancer.

Representation of Sexual and Gender Minority People in Patient Nondiscrimination Policies of Cancer Centers in the United States.

BACKGROUND: Sexual and gender minority (SGM) people are an underserved population who face high rates of discrimination in healthcare, including receipt of cancer treatment. Several national organizations have identified the importance of patient nondiscrimination policies that explicitly recognize SGM people in creating safe healthcare environments. METHODS: We performed a web-based analysis of NCI-designated Cancer Centers to evaluate the landscape of patient nondiscrimination policies in major cancer centers with regard to representation of SGM people. RESULTS: We found that 82% of cancer centers had a patient nondiscrimination policy on their website. The most commonly mentioned SGM-related term was "sex" (n=48; 89%), followed by "sexual orientation" (n=37; 69%) and "gender identity" (n=36; 67%). None of the policies included "sex assigned at birth" or "LGBTQ/SGM identity." Of the policies reviewed, 65% included protections for both sexual orientation and gender identity. Cancer centers with academic affiliations were significantly more likely to have policies that included both of these protections compared with nonacademic institutions (100% vs 79%; P=.005). CONCLUSIONS: Our study shows that patient nondiscrimination policies across NCI-designated Cancer Centers are not always accessible to patients and their families online and do not consistently represent SGM people in their content. Because the SGM population is both at higher risk for cancer and for discrimination in the healthcare setting, it is crucial to create inclusive, safe, and equitable cancer care environments for this group. Administrators and clinicians should view the patient nondiscrimination policy as an opportunity to offer expansive protections to SGM people that extend beyond those offered in federal and state laws. Additionally, the patient nondiscrimination policy should be visible and accessible to patients seeking cancer care as a signal of safety and inclusion.

Prevalence of risk behaviors and correlates of SARS-CoV-2 positivity among in-school contacts of confirmed cases in a Georgia school district in the pre-vaccine era, December 2020-January 2021.

BACKGROUND: There is a continuing risk for COVID-19 transmission in school settings while transmission is ongoing in the community, particularly among unvaccinated populations. To ensure that schools continue to operate safely and to inform implementation of prevention strategies, it is imperative to gain better understanding of the risk behaviors of staff and students. This secondary analysis describes the prevalence of COVID-19 risk behaviors in an exposed population of students and school staff in the pre-vaccine era and identifies associations between these behaviors and testing positive for SARS-CoV-2. METHODS: From December 2020-January 2021, school staff and students exposed to confirmed COVID-19 cases in a Georgia school district were tested for SARS-CoV-2 and surveyed regarding risk behaviors in and out of school. Prevalence of risk behaviors was described by age group and school level, and associations with SARS-CoV-2 positivity were identified using chi squared tests. RESULTS: Overall, 717 students and 79 school staff participated in the investigation; SARS-CoV-2 positivity was 9.2%. In the 2 weeks prior to COVID-19 exposure, 24% of participants reported unmasked indoor time at school, 40% attended social gatherings with non-household members, and 71% visited out-of-school indoor locations, including 19% who ate indoors in restaurants. Frequencies of risk behaviors increased by age. Among students, 17% participated in school sports, of whom 86% participated without a mask. SARS-CoV-2 positivity was significantly associated with school sports and unmasked time in sports. Among K-5 students, positivity was associated with exposure to a teacher index case. CONCLUSIONS: This analysis highlights the high prevalence of risk behaviors in an unvaccinated population exposed to COVID-19 in school and identifies an association between student sports participation and SARS-CoV-2 positivity. These findings illustrate the importance of school-level prevention measures to reduce SARS-CoV-2 transmission, including limiting close-contact indoor sports and promoting consistent mask use in unvaccinated individuals. Future research could explore the role of community vaccination programs as a strategy to reduce COVID-19 transmission and introductions into school settings.

Clusters of SARS-CoV-2 Infection Among Elementary School Educators and Students in One School District - Georgia, December 2020-January 2021.

In-person learning benefits children and communities (1). Understanding the context in which transmission of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19), occurs in schools is critical to improving the safety of in-person learning. During December 1, 2020-January 22, 2021, Cobb and Douglas Public Health (CDPH), the Georgia Department of Public Health (GDPH), and CDC investigated SARS-CoV-2 transmission in eight public elementary schools in a single school district. COVID-19 cases* among educators and students were either self-reported or identified by local public health officials. Close contacts (contacts)† of persons with a COVID-19 case received testing. Among contacts who received positive test results, public health investigators assessed epidemiologic links, probable transmission directionality, and the likelihood of in-school transmission.§ Nine clusters of three or more epidemiologically linked COVID-19 cases were identified involving 13 educators and 32 students at six of the eight elementary schools. Two clusters involved probable educator-to-educator transmission that was followed by educator-to-student transmission and resulted in approximately one half (15 of 31) of school-associated cases. Sixty-nine household members of persons with school-associated cases were tested, and 18 (26%) received positive results. All nine transmission clusters involved less than ideal physical distancing, and five involved inadequate mask use by students. Educators were central to in-school transmission networks. Multifaceted mitigation measures in schools, including promotion of COVID-19 precautions outside of school, minimizing in-person adult interactions at school, and ensuring universal and correct mask use and physical distancing among educators and students when in-person interaction is unavoidable, are important in preventing in-school transmission of SARS-CoV-2. Although not required for reopening schools, COVID-19 vaccination should be considered as an additional mitigation measure to be added when available.

Treatment of a zone III extensor tendon injury using a single relative motion with dorsal hood orthosis and a modified short arc motion protocol-A case report.

STUDY DESIGN: Case report. INTRODUCTION: Zone III extensor tendon injuries are typically treated with early mobilization or by a period of immobilization followed by gradual motion. In both scenarios, the use of multiple orthoses is required. PURPOSE OF THE STUDY: This case report examines the effective use of a single, modified relative motion orthosis throughout the protected rehabilitation phase after a zone III extensor tendon repair. METHODS: A patient with extensor tendon zone III laceration to his index finger (10th revision of the International Statistical Classification of Diseases and Related Health Problems s66.328) was treated using a single, relative motion with dorsal hood orthosis. The exercise protocol followed a modified immediate short arc motion program. RESULTS: Following laceration and complete rupture of the central slip, the patient regained full range of motion, strength, and function. DISCUSSION: It is becoming more common to use a relative motion flexion (RMF) orthosis to correct or improve extensor lag due to boutonniere deformity or stiffness after finger fractures. There is very little literature to support the use of the RMF orthosis after zone III extensor tendon repair. To produce a single orthosis that is useful through the entire protected phase of rehabilitation, the RMF orthosis is easily modified by addding a dorsal hood to create the relative motion dorsal hood orthosis (RMDH). CONCLUSION: Our case report shows the successful treatment of a zone III extensor tendon repair using a single relative motion with dorsal hood orthosis and early active motion throughout the entire protected phase of rehabilitation.

Is Symptom Screening Useful for Identifying COVID-19 Infection in School Settings? Georgia, USA.

This study's goal was to characterize the utility of symptom screening in staff and students for COVID-19 identification and control of transmission in a school setting. We conducted a secondary analysis of cross-sectional data for staff, students and associated household members in a Georgia school district exposed to COVID-19 cases who received RT-PCR testing and symptom monitoring. Among positive contacts, 30/49 (61%) of students and 1/6 (17%) of staff reported no symptoms consistent with COVID-19. Symptom sensitivity was 30% in elementary students and 42% in middle/high students. Fifty-three percent (10/19) of symptomatic positive contacts had at least one household member test positive for SARS-CoV-2 compared with 50% (10/20) of asymptomatic positive contacts. The absence of symptoms in children is not indicative of a lack of SARS-CoV-2 infection or reduced risk of infection for associated household members. Testing all close contacts of people with COVID-19 in schools is needed to interrupt transmission networks.

Health Literacy Among In-Care Older HIV Diagnosed Persons with Multimorbidity: MMP NYS (Excluding NYC).

Older persons living with diagnosed HIV (PLWDH) are also at risk for age-related chronic conditions. With conflicting results on studies assessing health literacy and durable viral suppression, this study is the first in assessing this relationship using representative data on older in-care HIV-diagnosed persons with multimorbidity. Weighted data collected 2009-2014 from the Medical Monitoring Project (MMP) was used. Health literacy was assessed using the three-item Brief Health Literacy Screen (BHLS). The mean health literacy score was 11.22 (95% CI 10.86-11.59), and the mean multimorbidity was 4.75 (SE = 0.32). After adjusting, health literacy (OR 0.87, 95% CI 0.77-0.99) was found to be significantly associated with durable viral suppression. Adequate health literacy can help with achieving durable viral suppression. For these persons, addressing health literacy might increase their ability to access and navigate the healthcare system, thereby helping them stay engaged and maintain adherence to HIV care.

Evaluating a community-based cervical cancer screening strategy in Western Kenya: a descriptive study.

BACKGROUND: The incidence of cervical cancer in Kenya is among the highest in the world. Few Kenyan women are able to access screening, thus fueling the high cervical cancer burden. Self-collected human papilloma Virus (HPV) tests, administered during community-health campaigns in rural areas may be a way to expand access to screening. METHODS: In December 2015, we carried out a four-day community health campaign (CHC) to educate participants about cervical cancer prevention and offer self-administered HPV screening. Community enumeration, outreach and mobilization preceded the CHC. Samples were sent to Migori County Hospital for HPV DNA testing using careHPV Test Kits. Women were notified of results through their choice of short message service (SMS), phone call, home visit or clinic visit. HPV positive women were referred for cryotherapy following a screen-and-treat strategy. RESULTS: Door-to-door enumeration identified approximately 870 eligible women in Ngodhe Community in Migori County. Among the 267 women attending the campaign, 255 women enrolled and collected samples: 243 tests were successfully resulted and 12 were indeterminate. Of the 243 resulted tests, 47 (19%) were positive for HPV, with young age being the only significant predictor of positivity. In multivariate analysis, each additional year of age conferred about a 4% decrease in the odds of testing positive (95% CI 0.1 to 7%, p = 0.046). Just over three-quarters of all women (195/255), were notified of their results. Those who were unable to be reached were more likely to prefer receiving results from clinic (54/60, 90%) and were less likely to have mobile phones (24/60, 73%). Although 76% of HPV positive women were notified of their results, just half (51%) of those testing positive presented for treatment. HPV positive women who successfully accessed the treatment facility did not differ from their non-presenting counterparts by demographics, health history, desired route of notification or access to a mobile phone. CONCLUSION: Nearly a third of eligible women in Ngodhe Community attended the CHC and were screened for cervical cancer. Nearly all women who attended the CHC underwent cervical cancer screening by self-collected HPV tests. Three-quarters of all participants received results, but just half of HPV positive participants presented for treatment in a timely fashion, suggesting that linkage to treatment remains a major challenge. TRIAL REGISTRATION: NCT02124252 , Registered 25 April 2014.

The past, present, and future of opioid prescribing: Perioperative opioid use in gynecologic oncology patients after laparotomy at a single institution from 2012 to 2021.

Objective: To describe the evolution of perioperative opioid management in gynecologic oncology patients after open surgeries and determine current opioid over-prescription rates. Methods: Part one of this two-part study was a retrospective chart review of adult patients who underwent laparotomy by a gynecologic oncologist from July 1, 2012 to June 30, 2021, comparing changes in clinical characteristics, pain management and discharge opioid prescription sizes between fiscal year 2012 (FY2012) and 2020 (FY2020). In part two, we prospectively surveyed patients after laparotomy in 2021 to determine opioid use after hospital discharge. Results: 1187 patients were included in the chart review. Demographic and surgical characteristics remained stable from FY2012 to FY2020 with differences notable for increased rates of interval cytoreductive surgeries for advanced ovarian cancer and decreased rates of full lymph node dissection. Median inpatient opioid use decreased by 62 % from FY2012 to FY2020. Median discharge opioid prescription size was 675 oral morphine equivalents (OME) per patient in FY2012 and decreased by 77.7 % to 150 OME in FY2020. Of 95 surveyed patients in 2021, median self-reported opioid use after discharge was 22.5 OME. Patients had an excess of opioids equivalent to 1331 doses of 5-milligram oxycodone tablets per 100 patients. Conclusion: Inpatient opioid use in our gynecologic oncology open surgical patients and post-discharge opioid prescription size significantly decreased over the last decade. Despite this progress, our current prescribing patterns continue to significantly overestimate patients' actual opioid use after hospital discharge. Individualized point of care tools are needed to determine an appropriate opioid prescription size.

Predictors of Willingness to Participate in COVID-19 Screening Testing from a Pilot School Survey in the United States.

BACKGROUND: COVID-19 screening testing (ST) can detect asymptomatic or pre-symptomatic cases, allowing for prompt identification of cases and close contacts. This study examined parents' and school staffs' knowledge and attitudes toward to a pilot school-based ST program in a school district in southern Arizona. METHODS: In May 2021, online surveys to parents and school staff were administered to examine attitudes toward ST and impacts of the COVID-19 pandemic. Unweighted percent estimates were calculated, and bivariate differences were examined by demographics. Associations were assessed using chi-square tests and logistic regression. RESULTS: The survey had response rates of 10% (606/6085) and 22% (187/849) among parents and staff, respectively. Approximately one-third of responding parents (35%) would or already allow their child to participate in school-based ST, 37% would not participate; 28% were unsure. Among responding staff, 46% would or already participate in ST, 33% would not; 21% were unsure. The top concern (38%) among responding staff was taking job-related leave if testing positive. CONCLUSION: Schools work to balance the needs of students, families, and staff by implementing supportive and flexible policies and practices founded on buy-in and acceptance from their communities.

Test-to-Stay Implementation in 4 Pre-K-12 School Districts.

OBJECTIVES: Globally, coronavirus disease 2019 (COVID-19) has affected how children learn. We evaluated the impact of Test to Stay (TTS) on secondary and tertiary transmission of severe acute respiratory syndrome coronavirus 2 and potential impact on in-person learning in 4 school districts in the United States from September 13 to November 19, 2021. METHODS: Implementation of TTS varied across school districts. Data on index cases, school-based close contacts, TTS participation, and testing results were obtained from 4 school districts in diverse geographic regions. Descriptive statistics, secondary and tertiary attack risk, and a theoretical estimate of impact on in-person learning were calculated. RESULTS: Fifty-one schools in 4 school districts reported 374 coronavirus disease COVID-19 index cases and 2520 school-based close contacts eligible for TTS. The proportion participating in TTS ranged from 22% to 79%. By district, the secondary attack risk and tertiary attack risk among TTS participants ranged between 2.2% to 11.1% and 0% to 17.6%, respectively. Nine clusters were identified among secondary cases and 2 among tertiary cases. The theoretical maximum number of days of in-person learning saved by using TTS was 976 to 4650 days across jurisdictions. CONCLUSIONS: TTS preserves in-person learning. Decisions to participate in TTS may have been influenced by ease of access to testing, communication between schools and families, testing logistics, and school resources. Tertiary attack risk determination became more complicated when numbers of close contacts increased. Minimizing exposure through continued layered prevention strategies is imperative. To ensure adequate resources for TTS, community transmission levels should be considered.

Acute, sublethal cyanide poisoning in mice is ameliorated by nitrite alone: complications arising from concomitant administration of nitrite and thiosulfate as an antidotal combination.

Sodium nitrite alone is shown to ameliorate sublethal cyanide toxicity in mice when given from ∼1 h before until 20 min after the toxic dose as demonstrated by the recovery of righting ability. An optimum dose (12 mg/kg) was determined to significantly relieve cyanide toxicity (5.0 mg/kg) when administered to mice intraperitoneally. Nitrite so administered was shown to rapidly produce NO in the bloodsteam as judged by the dose-dependent appearance of EPR signals attributable to nitrosylhemoglobin and methemoglobin. It is argued that antagonism of cyanide inhibition of cytochrome c oxidase by NO is the crucial antidotal activity rather than the methemoglobin-forming action of nitrite. Concomitant addition of sodium thiosulfate to nitrite-treated blood resulted in the detection of sulfidomethemoblobin by EPR spectroscopy. Sulfide is a product of thiosulfate hydrolysis and, like cyanide, is known to be a potent inhibitor of cytochrome c oxidase, the effects of the two inhibitors being essentially additive under standard assay conditions rather than dominated by either one. The findings afford a plausible explanation for an observed detrimental effect in mice associated with the use of the standard nitrite-thiosulfate combination therapy at sublethal levels of cyanide intoxication.

Total hip arthroplasty in the ankylosed hip.

Altered biomechanics secondary to hip ankylosis often result in degeneration of the lumbar spine, ipsilateral knee, and contralateral hip and knee. Symptoms in these joints may be reduced with conversion total hip arthroplasty (THA) of the ankylosed hip. THA in the ankylosed hip is a technically challenging procedure, and the overall clinical outcome is generally less satisfactory than routine THA performed for osteoarthritis and other etiologies. Functional integrity of the hip abductor muscles is the most important predictor of walking ability following conversion THA. Many patients experience persistent limp, and it can take up to 2 years to fully assess final functional outcome. Risk factors cited for increased risk of failed THA include prior surgical ankylosis and age <50 years at the time of conversion THA.

Obstetrics and Gynecology and Reparations: The Debt We Owe (and Continue to Accumulate).

Obstetrics and gynecology (OBGYN) is rife with exploitation and oppression of Black individuals and disparate health outcomes. We posit that racial disparities in OBGYN are fueled by racism and the racial wealth gap stemming from slavery, legal segregation, and institutionalized discrimination against Black Americans. We believe reparations are not only morally requisite, but would also improve health outcomes for our patients. Supporting legislation to explore and remedy the harms of slavery and its legacy is critical to address systemic racism that results in disparate health outcomes.

Surgical candidacy and treatment initiation among women with cervical cancer at public referral hospitals in Kampala, Uganda: a descriptive cohort study.

OBJECTIVES: This study aimed to report the proportion of women with a new diagnosis of cervical cancer recommended for curative hysterectomy as well as associated factors. We also report recommended treatments by stage and patterns of treatment initiation. DESIGN: This was an observational cohort study. Inperson surveys were followed by a phone call. SETTING: Participants were recruited at the two public tertiary care referral hospitals in Kampala, Uganda. PARTICIPANTS: Adult women with a new diagnosis of cervical cancer were eligible: 332 were invited to participate, 268 met the criteria and enrolled, and 255 completed both surveys. PRIMARY AND SECONDARY OUTCOMES MEASURES: The primary outcome of interest was surgical candidacy; a secondary outcome was treatment initiation. Descriptive and multivariate statistical analyses examined the associations between predictors and outcomes. Sensitivity analyses were performed to examine outcomes in subgroups, including stage and availability of radiation. RESULTS: Among 268 participants, 76% were diagnosed at an advanced stage (IIB-IVB). In total, 12% were recommended for hysterectomy. In adjusted analysis, living within 15 km of Kampala (OR 3.10, 95% CI 1.20 to 8.03) and prior screening (OR 2.89, 95% CI 1.22 to 6.83) were significantly associated with surgical candidacy. Radiotherapy availability was not significantly associated with treatment recommendations for early-stage disease (IA-IIA), but was associated with recommended treatment modality (chemoradiation vs primary chemotherapy) for locally advanced stage (IIB-IIIB). Most (67%) had started treatment. No demographic or health factor, treatment recommendation, or radiation availability was associated with treatment initiation. Among those recommended for hysterectomy, 55% underwent surgery. Among those who had initiated treatment, 82% started the modality that was recommended. CONCLUSION: Women presented to public referral centres in Kampala with mostly advanced-stage cervical cancer and few were recommended for surgery. Most were able to initiate treatment. Lack of access to radiation did not significantly increase the proportion of early-stage cancers recommended for hysterectomy.

Prevalence, correlates, and predictive value of high-risk human papillomavirus mRNA detection in a community-based cervical cancer screening program in western Uganda.

BACKGROUND: New strategies are needed to combat the high incidence of cervical cancer in resource-limited settings such as sub-Saharan Africa. Screening for high-risk human papillomavirus (hrHPV) DNA is sensitive for pre-cancer, but its lack of specificity results in substantial overtreatment in low resource settings where additional testing (e.g., colposcopy) is rarely available. Testing for hrHPV E6/E7 mRNA may enhance specificity, but little is known about its performance characteristics in resource-limited settings. METHODS: In a series of community health fairs in rural Uganda, women aged 25 to 49 years provided self-collected vaginal samples, which were tested for hrHPV (types 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66 and 68) E6/E7 mRNA with the Aptima® assay. Positive specimens underwent testing for HPV-16 and 18/45. After excluding pregnant women, all women testing positive for any hrHPV subsequently were offered cervical biopsy to determine pathology. RESULTS: A total of 1892 women provided a vaginal sample for hrHPV testing during 24 health fairs. The median age was 34 years, HIV prevalence was 10, and 95% had not been previously screened. Prevalence of any hrHPV E6/E7 mRNA was 21% (95% confidence interval (CI): 19 to 23%); the prevalence of HPV-16 was 2.6%, HPV-18/45 1.9%, and HPV 16 and 18/45 were jointly found in 0.1% of the study population. Younger age, pregnancy and HIV-positivity were independently associated with any hrHPV infection. Of the 255 evaluable cervical biopsies, the positive predictive value of detecting any hrHPV E6/E7 mRNA for presence of cervical intraepithelial neoplasia grade 2 or higher ("CIN 2+") was 8.2% (95% CI: 5.1 to 12%). The positive predictive value associated with detection of HPV-16 mRNA (15%) or HPV-18/45 mRNA (15%) was only slightly higher. CONCLUSION: Among community-based women in Uganda, the prevalence of any hrHPV E6/E7 mRNA in vaginal samples was high, but the prevalence of the most oncogenic HPV types (16, 18, or 45) was substantially lower. Positive predictive value of hrHPV mRNA-positivity for CIN 2+ was also low, including when restricting to HPV 16/18/45-positivity. The findings emphasize the need to identify more specific screening approaches for cervical cancer.