Knowledge, Behavioral, and Sociocultural Factors Related to Human Papillomavirus Infection and Cervical Cancer Screening Among Inner-City Women in Panama.

Cervical cancer remains a leading cause of mortality in developing countries regardless of biomedical advances in prevention modalities. Specifically, Panama experiences one of the highest rates of cervical cancer worldwide. The objective of this study was to explore knowledge, behavioral, and sociocultural factors related to cervical cancer prevention among Panamanian women. A theory-guided, population-based quantitative survey following participatory processes was administered to a randomized sample of females (18-44 years) residing in a high-risk Panamanian community. Participants (n = 324) reported low knowledge regarding HPV, cervical cancer, and the purpose of the Pap test. Furthermore, low perceived susceptibility, high-risk sexual behaviors (e.g., low contraception and condom use) and adverse attitudes toward the Pap test (e.g., shame, fear) were identified. Television, newspapers/magazines, and relatives/friends/neighbors were common sources to receive health information. Significant gaps in knowledge and behavioral factors were identified, which may interfere with cervical cancer prevention efforts. Future strategies should reflect the sociocultural context, such as interpersonal relations, when developing and implementing cervical cancer programs, with the ultimate goal of decreasing the persistent burden among Latin American women.

Efficacy of pneumococcal nontypable Haemophilus influenzae protein D conjugate vaccine (PHiD-CV) in young Latin American children: A double-blind randomized controlled trial.

BACKGROUND: The relationship between pneumococcal conjugate vaccine-induced antibody responses and protection against community-acquired pneumonia (CAP) and acute otitis media (AOM) is unclear. This study assessed the impact of the ten-valent pneumococcal nontypable Haemophilus influenzae protein D conjugate vaccine (PHiD-CV) on these end points. The primary objective was to demonstrate vaccine efficacy (VE) in a per-protocol analysis against likely bacterial CAP (B-CAP: radiologically confirmed CAP with alveolar consolidation/pleural effusion on chest X-ray, or non-alveolar infiltrates and C-reactive protein ≥ 40 µg/ml); other protocol-specified outcomes were also assessed. METHODS AND FINDINGS: This phase III double-blind randomized controlled study was conducted between 28 June 2007 and 28 July 2011 in Argentine, Panamanian, and Colombian populations with good access to health care. Approximately 24,000 infants received PHiD-CV or hepatitis control vaccine (hepatitis B for primary vaccination, hepatitis A at booster) at 2, 4, 6, and 15-18 mo of age. Interim analysis of the primary end point was planned when 535 first B-CAP episodes, occurring ≥2 wk after dose 3, were identified in the per-protocol cohort. After a mean follow-up of 23 mo (PHiD-CV, n = 10,295; control, n = 10,201), per-protocol VE was 22.0% (95% CI: 7.7, 34.2; one-sided p = 0.002) against B-CAP (conclusive for primary objective) and 25.7% (95% CI: 8.4%, 39.6%) against World Health Organization-defined consolidated CAP. Intent-to-treat VE was 18.2% (95% CI: 5.5%, 29.1%) against B-CAP and 23.4% (95% CI: 8.8%, 35.7%) against consolidated CAP. End-of-study per-protocol analyses were performed after a mean follow-up of 28-30 mo for CAP and invasive pneumococcal disease (IPD) (PHiD-CV, n = 10,211; control, n = 10,140) and AOM (n = 3,010 and 2,979, respectively). Per-protocol VE was 16.1% (95% CI: -1.1%, 30.4%; one-sided p = 0.032) against clinically confirmed AOM, 67.1% (95% CI: 17.0%, 86.9%) against vaccine serotype clinically confirmed AOM, 100% (95% CI: 74.3%, 100%) against vaccine serotype IPD, and 65.0% (95% CI: 11.1%, 86.2%) against any IPD. Results were consistent between intent-to-treat and per-protocol analyses. Serious adverse events were reported for 21.5% (95% CI: 20.7%, 22.2%) and 22.6% (95% CI: 21.9%, 23.4%) of PHiD-CV and control recipients, respectively. There were 19 deaths (n = 11,798; 0.16%) in the PHiD-CV group and 26 deaths (n = 11,799; 0.22%) in the control group. A significant study limitation was the lower than expected number of captured AOM cases. CONCLUSIONS: Efficacy was demonstrated against a broad range of pneumococcal diseases commonly encountered in young children in clinical practice. TRIAL REGISTRATION: www.ClinicalTrials.gov NCT00466947.

Pertussis vaccine effectiveness following country-wide implementation of a hexavalent acellular pertussis immunization schedule in infants and children in Panama.

Despite high pediatric vaccination coverage rates (VCRs), pertussis incidence has increased worldwide, including in several countries in Latin America in the last two decades. Given the few vaccine effectiveness (VE) studies in Latin American countries, this retrospective, observational, cohort study estimated the effectiveness of hexavalent acellular (aP) primary and booster vaccination (wP) against pertussis in infants (6.5-18.5 months) and children (18.5-48.5 and 48.5-72.5 months) in Panama. Age-specific incidence rates (IRs) were calculated for the vaccine's pre-initiation (2001-2013), initiation (2014), and post-initiation (2015-2019) periods. VCRs and trends were determined, and VE was analyzed using a case coverage or screening method to compare proportions of vaccinated cases and vaccinated individuals in the population. Between 2001-2019, 868 confirmed pertussis cases were reported in Panama; 712 (82.0%; 54.8 cases/year) during the pre-initiation period, 19 (2.2%; 19 cases/year) during the initiation period, and 137 (15.8%; 27.4 cases/year) during the post-initiation period. Panama underwent cyclical increases in IRs, which varied between age groups. VCRs increased for primary and booster doses. Between 2015 and 2019, third-dose yearly vaccine coverage increased, on average, 3.3%. Specifically, during the post-initiation period, 109/137 (79.6%) of cases were unvaccinated. Relative VE was estimated at 96.2% [95% CI: 86.5%, 98.9%] with three doses; 100% with 4 and 5 booster doses. Absolute VE was estimated at 99.3% with three doses only. These results show that vaccination played an important role in maintaining a low number of pertussis cases in Panama, affirming the need for sustained investment and commitment to vaccination programs.

Incidence of influenza and other respiratory viruses among pregnant women: A multi-country, multiyear cohort.

OBJECTIVE: To quantify rates of influenza illness and assess value of influenza vaccination among pregnant women in Panama and El Salvador. METHODS: Pregnant women were enrolled and followed each week in a prospective cohort study to identify acute respiratory illnesses (ARI). Nasopharyngeal swabs obtained from women with febrile ARI were tested by reverse-transcription polymerase chain reaction for influenza and other respiratory viruses. RESULTS: We enrolled 2556 women between October 2014 and April 2017. Sixteen percent developed at least one ARI; 59 had two ARI, and five had three ARI for a total of 463 ARI. Women in El Salvador and Panama contributed 297 person-years (py) and 293 py, respectively, during influenza circulation. Twenty-one (11%) of 196 sampled women tested positive for influenza. Influenza incidence was 5.0/100 py (5.7/100 py in El Salvador and 4.3/100 py in Panama). Only 13% of women in El Salvador and 43% in Panama had been vaccinated against influenza before influenza epidemics (P < 0.0001). CONCLUSIONS: One in six pregnant women developed ARI and more than one in ten ARI were attributable to vaccine-preventable influenza. While women were at risk of influenza, few had been vaccinated before each epidemic. Such findings suggest the utility of evaluations to optimize vaccine timing and coverage.

Incidence of respiratory virus illness and hospitalizations in a Panama and El Salvador birth cohort, 2014-2018.

Background: Respiratory viruses remain a key cause of early childhood illness, hospitalization, and death globally.The recent pandemic has rekindled interest in the control of respiratory viruses among paediatric populations. We estimate the burden of such viruses among children <2 years. Methods: Enrolled neonates were followed until two years of age. Weekly active symptom monitoring for the development of acute respiratory illnesses (ARI) defined as cough, rhinorrhoea, difficulty breathing, asthenia, anorexia, irritability, or vomiting was conducted. When the child had ARI and fever, nasopharyngeal swabbing was performed, and samples were tested through singleplex RT-PCR. Incidence of respiratory viruses was calculated by dividing the number of laboratory-confirmed detections by the person-time accrued during weeks when that virus was detectable through national surveillance then corrected for under-ascertainment among untested children. Findings: During December 2014-November 2017, 1567 enrolled neonates contributed 2,186.9 person-years (py). Six in ten (64·4%) children developed ARI (total 2493 episodes). Among children <2 years, incidence of respiratory syncytial virus (RSV)-associated ARI episodes (21·0, 95%CI 19·3-22·8, per 100py) and rhinovirus-associated (20·5, 95%CI 20·4-20·7) were similar and higher than parainfluenza 1-3-associated (14·2, 95%CI 12·2-16·1), human metapneumovirus-associated (9·2, 95%CI 7·7-10·8), influenza-associated (5·9, 95%CI 4·4-7·5), and adenovirus-associated ARI episodes (5·1, 95%CI 5·0-5·2). Children aged <3 months had the highest rates of RSV ARI (49·1, 95%CI 44·0-54·1 per 100py) followed by children aged 3-5 (25·1, 95%CI 20·1-30·0), 6-11 (17·6, 95%CI 13·2-21·9), and 12-23 months (11·9, 95%CI 10·8-12·9). One in ten children with RSV was referred to the hospital (2·5, 95%CI 2·1-2·8, per 100py). Interpretation: Children frequently developed viral ARI and a substantive proportion required hospital care. Such findings suggest the importance of exploring the value of new interventions and increasing uptake of existing prevention measures to mitigate burden of epidemic-prone respiratory viruses. Funding: The study was supported by the Centers for Disease Control and Prevention.

Lower cognitive scores among toddlers in birth cohorts with acute respiratory illnesses, fevers, and laboratory-confirmed influenza.

BACKGROUND: We established cohorts to assess associations between viral influenza and cognitive development to inform the value proposition of vaccination. METHODS: From 2014 through 2017, we called women seeking care at four prenatal clinics in Panama and El Salvador to identify acute respiratory illnesses (ARIs). Within 2 weeks of childbirth, mothers were asked to enroll their neonates in the cognitive development study. Staff obtained nasopharyngeal swabs from children with febrile ARIs for real-time reverse transcription polymerase chain reaction (rtPCR) detection of viral RNA. Toddlers were administered Bayley developmental tests at ages 12 and 18-24 months. We used multilevel linear regression to explore associations between Bayley scores, ARIs, fever, and laboratory-confirmed influenza, controlling for maternal respiratory or Zika illnesses, infant influenza vaccination, birth during influenza epidemics, and the number of children in households. RESULTS: We enrolled 1567 neonates of which 68% (n = 1062) underwent developmental testing once and 40% (n = 623) twice. Children with previous ARIs scored an average of 3 points lower on their cognitive scores than children without ARIs (p = 0.001). Children with previous fevers scored an average of 2.1 points lower on their cognitive scores than afebrile children (p = 0.02). In the second year, children with previous laboratory-confirmed influenza scored 4 points lower on their cognitive scores than children without influenza (p = 0.04, after controlling for first Bayley cognitive scores). CONCLUSIONS: ARIs and fever during infancy were associated with lower Bayley scores at 12 months, and laboratory-confirmed influenza was associated with lower cognitive scores at 24 months suggesting the potential value of vaccination to prevent non-respiratory complications of influenza.

Parent reported outcomes to measure satisfaction, acceptability, and daily life impact after vaccination with whole-cell and acellular pertussis vaccine in Chile.

AIM: To compare parental satisfaction and impact on daily life among parents of children receiving whole-cell pentavalent + oral polio vaccine (Arm1) with an acellular hexavalent vaccine (Hexaxim; Arm2). METHODS: Self-administered electronic questionnaire at vaccination and one week later in six community health clinics of metropolitan Santiago, Chile, exploring parent-reported outcomes on satisfaction, acceptability, and impact on daily life after immunization. Univariate and multivariate analyses were conducted to determine differences in the responses in both groups (α = 0.05). RESULTS: The study enrolled 800 participants and 65% (222 in Arm1, 296 in Arm2) were included for according-to-protocol analysis. Demographic characteristics were comparable, except for a higher proportion of mothers answering the questionnaire at the 6-month visit. Regardless of the study arm, parental knowledge and perception of the immunization practices were good, and there were no differences in vaccination experiences in the prior 5 years. However, satisfaction with vaccination and intention to vaccinate were statistically significantly higher in Arm2 after the 6-month visit. Also, more parents in Arm2 reported no disruption in several aspects of the everyday activities of the parent, the child, and other children in the household. Parents in Arm2 were more likely to be satisfied with the vaccine received (OR 2.82; 95% CI, 1.22-7.07); return for other vaccine dose (OR 2.62; 95% CI, 1.45-4.84); follow a healthcare professional recommendation (OR 2.24; 95% CI, 1.57-3.21); and, to be confident that the vaccine will not disrupt the family's daily routine (OR 1.89; 95% CI, 1.32-2.71). CONCLUSIONS: Overall, satisfaction, intention for future vaccination, and lower impact on the family daily routine were significantly better in the group receiving the hexavalent vaccine. We also found that health care providers' recommendations to vaccinate and participants' access to health services were important factors favoring immunization.

Efficacy of 10-valent pneumococcal non-typeable Haemophilus influenzae protein D conjugate vaccine against acute otitis media and nasopharyngeal carriage in Panamanian children - A randomized controlled trial.

We previously reported 10-valent pneumococcal non-typeable Haemophilus influenzae (NTHi) protein D conjugate vaccine (PHiD-CV) efficacy in a double-blind randomized trial (ClinicalTrials.gov: NCT00466947) against various diseases, including acute otitis media (AOM). Here, we provide further analyses. In the Panamanian subset, 7,359 children were randomized (1:1) to receive PHiD-CV or control vaccine at age 2/4/6 and 15-18 months. Of these, 2,000 had nasopharyngeal swabs collected. AOM cases were captured when parents sought medical attention for children with AOM symptoms; surveillance was enhanced approximately 2 y into the study through regular telephone calls or home visits by study personnel, who advised parents to visit the clinic if their child had AOM symptoms. Mean follow-up was 31.4 months. Clinical AOM (C-AOM) cases were assessed by physicians and confirmed by otorhinolaryngologists. Middle ear fluid samples, taken from children with C-AOM after specific informed consent, and nasopharyngeal samples were cultured for pathogen identification. For 7,359 children, 2,574 suspected AOM cases were assessed by a primary healthcare physician; 649 cases were C-AOM cases as per protocol definition. From the 503 MEF samples collected, 158 resulted in a positive culture. In the intent-to-treat cohort (7,214 children), PHiD-CV showed VE against first C-AOM (24.0% [95% CI: 8.7, 36.7]) and bacterial (B-AOM) episodes (48.0% [20.3, 66.1]) in children <24 months, which declined thereafter with age. Pre-booster VE against C-AOM was 30.7% [12.9, 44.9]; post-booster, -6.7% [-36.4, 16.6]. PHiD-CV VE was 17.7% [-6.1, 36.2] against moderate and 32.7% [-20.5, 62.4] against severe C-AOM. VE against vaccine-serotype pneumococcal NPC was 31.2% [5.3, 50.3] 3 months post-booster, and 25.6% [12.7, 36.7] across all visits. NTHi colonization rates were low and no significant reduction was observed. PHiD-CV showed efficacy against C-AOM and B-AOM in children younger than 24 months, and reduced vaccine-serotype NPC.

Screening and community outreach programs for priority populations: considerations for oncology managers.

The goals of screening and community outreach efforts are to translate knowledge into relevant interventions to enhance health, prevent disease and manage chronic illness. Despite recent progress in the fight against cancer, a disproportionate share of the cancer burden is observed among ethnic minorities and medically underserved populations. Studies consistently link low socioeconomic status to low survival rates for nearly all types of cancer. Cultural differences, low literacy skills, language barriers and limited access to health care pose additional barriers to preventative health care for priority populations. Reaching priority populations with effective, appropriate and measurable ways to reduce cancer morbidity and mortality are key considerations for oncology managers seeking to provide comprehensive screening and community outreach care. This article addresses the importance of culture and literacy when developing screening and community outreach programs for at-risk populations, highlights the value of community partnerships to achieve programmatic goals, and outlines key considerations for creating successful breast screening and community outreach among Hispanic farmworker and rural women.

Participatory Processes Applied to Developing Culturally Appropriate Educational Material Among the Ngäbe-Buglé Women of Panama for Domestic Violence Prevention.

The Ngäbe-Buglé is the largest underserved indigenous population in Panama facing extreme health disparities compounded by structural, social, and cultural factors. Contributing factors to the poor health outcomes in this region include extreme poverty, low education, high maternal and infant mortality, alcohol use, and an increasing trend of domestic violence. The present intervention used community participatory processes to develop tailored material within the Ngäbe-Buglé community and training health promoters to deliver health education to the most rural areas. There were 78 health promoters who were trained using the training-of-trainers approach. Promoters distributed the health messages to their communities using the tailored material, the main topic discussed being domestic violence. Almost 7,000 community members received health education, demonstrating increased knowledge and intent to act on information received. Future directions include further funding, research, and education of indigenous groups in Panama on domestic violence.

Impacting health disparities through community outreach: utilizing the CLEAN look (culture, literacy, education, assessment, and networking).

BACKGROUND: Community outreach programs are important vehicles for reducing the discovery-delivery disconnect by bringing cancer education and screening services directly to community members. Such programs are consistent with the priority areas of the Department of Health and Human Services' initiatives for reducing health disparities by 2010, and they support the use of culturally, linguistically, and literacy-specific approaches for eliminating cancer health disparities. METHODS: This article reviews the important tenets of culture and literacy when developing community outreach programs for medically underserved populations, examines a health education empowerment model for community program planning, and describes the use of the CLEAN Look Checklist (in which CLEAN is an easy-to-remember mnemonic of culture, literacy, education, assessment, and networking) for identifying cues and strategies to achieve relevant outreach. RESULTS: This article illustrates the application of this approach with an example of outreach strategies for reaching at-risk Haitian American women in our community. CONCLUSIONS: Meeting the challenge of a strong health disparities agenda requires integration of cultural and literacy considerations in outreach program, message, and intervention development. The use of a checklist may help clinicians, educators, and researchers create a sustainable model of community outreach guided by a paradigm that incorporates a multilevel approach to address cancer outcomes for disenfranchised populations.

Impact of culturally, linguistically, and literacy relevant cancer information among Hispanic farmworker women.

BACKGROUND: This pilot investigation describes the impact of culturally, linguistically, and literacy relevant cancer information in terms of knowledge, satisfaction, comfort level, and intentional and actual breast/cervical cancer screening practices among Hispanic migrant and seasonal farmworker women. METHODS; Study phases were: 1) formative research; 2) instrument development and pretesting; and 3) pilot evaluation among 65 women using a one-group pretest-posttest design. RESULTS: Participants' reactions to the intervention were highly favorable. While an increase in knowledge (p < 0.001) was observed, no change in comfort was noted. Ninety-seven percent stated that they would be willing to miss a day of work (intent) to get a health check-up. CONCLUSION: Educational tools that are culturally, linguistically, and low-literacy can be promising interventions to promote awareness about breast and cervical cancer screening.

Focus groups in the design of prostate cancer screening information for Hispanic farmworkers and African American men.

PURPOSE/OBJECTIVES: To gain a better understanding of men's everyday concerns as part of formative research for creating relevant prostate cancer screening education; to describe methods and processes used to conduct community-based focus groups. SETTING: Community-based settings in catchment areas surrounding Tampa, FL. SAMPLE: 8 community-based focus groups: a total of 71 Hispanic farmworkers and African American men. METHODS: Focus group discussions were tape-recorded, transcribed, and analyzed for identification of emergent themes. MAIN RESEARCH VARIABLES: General life and health priorities, prostate cancer knowledge, screening attitudes, cancer beliefs, and learning preferences. FINDINGS: Major themes among African American men were importance of work, family, and faith. Major themes among Hispanic farmworkers were importance of family, employment, education of children, and faith. A common issue that surfaced among most men was that a cancer diagnosis was considered to be a death sentence. Preferred learning methods included use of cancer survivors as spokespeople, interactive group education, and the provision of easy-to-understand information. Issues of trust, respect, and community involvement were key to the successful conduct of focus groups among ethnically diverse groups. CONCLUSIONS: Study findings have important implications for the content of information developed for prostate cancer education materials and media. IMPLICATIONS FOR NURSING: Insights gained from focus group methodology can help nurses and other healthcare professionals design and develop appropriate prostate cancer education tools for use in community-based prostate cancer screening programs.