Methods in HPV Surveillance: Experiences from a Population-Based Study of HPV Infection among Women in the San Juan Metropolitan Area of Puerto Rico.

This article describes the methodology of the first population-based study of human papillomavirus (HPV) infection among women aged 16-64 years residing in the San Juan Metropolitan Area of Puerto Rico (PR). The sample was identified through a complex sampling design of households. The sampling frame was selected in four stages, using census tracts maps from the Census Bureau. Women completed a face-to-face interview and a computer-assisted self-interview using the Audio CASI system, for the collection of demographic, clinical, and lifestyle variables, and sampling acceptability. Anal, cervical, and oral specimens were collected through self-collection methods for HPV DNA testing using a modified pool of MY09/MY11 consensus HPV L1 and human ß-globin amplification primers. Anthropometric measurements were taken using the Third National Health and Nutrition Examination Survey methodology. Blood samples were collected to create a bio-repository for future HPV-related studies. Fifty census tract blocks were randomly selected. We recruited 566 women, with a response rate of 83.4%. Response rates did not vary by age-group (p>0.05); although they varied by socioeconomic (SES) census block stratums (p<0.05), response rates were good (>75%) in all SES strata. All participants agreed to respond to the surveys and provide the requested anogenital and oral samples. Overall, more than 98% understood and more than 50% felt comfortable with the cervical, anal, and oral self-collection methods used. This article documents the feasibility of performing population-based studies for HPV surveillance in women in PR.

Knowledge of viral hepatitis among Puerto Rican adults: implications for prevention.

Although primary prevention of HAV and HBV can be achieved through vaccination, the burden of HCV can only be reduced through behavioral interventions to reduce its risk factors. This study evaluated knowledge regarding transmission, clinical manifestations and prevention of viral hepatitis in Puerto Rico. We assessed the level of knowledge about HAV (six questions), HBV (12 questions) and HCV (eight questions) among non-institutionalized Puerto Rican adults aged 21-64 years. Demographic characteristics and self-reported knowledge of these infections were determined through a face-to-face interview. A mean knowledge score was computed by summing correct responses to each scale. Mean knowledge scores according to demographics were compared using ANOVA or the Kruskal-Wallis test. Mean knowledge scores for HAV, HBV and HCV infections were 2.6 ± 1.5, 6.1 ± 2.4, and 3.6 ± 1.1, respectively. For HAV and HBV infections, the mean knowledge score significantly (P < 0.05) increased with age, level of counseling received and number of sources of information. However, for HCV infection the mean knowledge score significantly increased with decreasing age, increased educational level and increased annual family income. Contrary to HBV, a higher HAV and HCV knowledge score was observed among individuals with history of vaccination for HAV and HBV, seropositive status for HAV and HCV, and history of drug use. A sizeable proportion of adults in this study demonstrated an inadequate level of knowledge, especially about transmission routes. Health education must be focused on transmission and prevention methods, including the availability of a vaccine for HAV and HBV, especially among those with chronic liver disease.

Seroepidemiology of viral hepatitis, HIV and herpes simplex type 2 in the household population aged 21-64 years in Puerto Rico.

BACKGROUND: Viral hepatitis and sexually transmitted infections (STIs) are key public health problems that pose an enormous risk for disease transmission in the general population. This study estimated, for the first time, prevalence estimates of serologic markers of HCV, HBV, HAV, HIV and HSV-2 in the adult population of Puerto Rico and assessed variations across sociodemographic and behavioral characteristics. METHODS: A seroepidemiologic survey was employed using a stratified cluster probability sample of households in Puerto Rico. Participants completed a face-to-face interview, a self-administered questionnaire using an ACASI system, and provided blood specimens for antibody testing. Prevalence estimates of viral hepatitis, HIV and HSV-2 were estimated using a logistic regression model weighting for the probability of participation in each household block and the inverse of the probability of selection according to geographic strata, households' blocks, and sex distribution. RESULTS: A total of 1,654 adults participated in the study. Seroprevalence estimates for HCV (2.3%, 95% CI: 1.3%-4.2%), HBV (3.1%, 95% CI: 2.0%-4.7%), and HSV-2 (22.3%, 95% CI: 18.5%-26.7%) in Puerto Rico are roughly in agreement with estimates obtained in the US population; however, HAV (41.3%, 95% CI: 36.9%-45.8%) and HIV (1.1%, 95% CI: 0.5%-2.3%) seroprevalence estimates in Puerto Rico were higher. The proportion of individuals that were unaware of their serostatus was as follows: 80% for HCV, 98.3% for HBV, 96.4% for HAV, 36.4% for HIV, and 97.8% for HSV-2. Post-stratification estimates of seroprevalence varied significantly by demographic and risk related characteristics. CONCLUSION: This data underscore the disproportionate impact of some viral infections across selected population subgroups in Puerto Rico. A concerted island-wide effort is needed to strengthen viral hepatitis and STIs prevention and control strategies, support surveillance to monitor chronic infections, and ensure appropriate counseling, testing, and medical management of infected persons. Integration of HCV, HBV, and HSV-2 counseling into HIV existing prevention services and outreach through social networks might represent a valuable approach to reach high-risk individuals.

The prevalence of vertebral fractures in San Juan, Puerto Rico: a population-based study among females aged 50 years and over.

OBJECTIVE: The participation of Puerto Rico in the Latin American Vertebral Osteoporosis Study (LAVOS) has allowed us to study the magnitude of the problem of osteoporosis in the female population residing in San Juan. The objective of LAVOS was to estimate the prevalence of vertebral fractures in Latin American women using a random sample of females selected from cities across five Latin American countries. METHODS: A probability cluster design was employed to select a random sample of households in San Juan, Puerto Rico, in order to interview 400 females aged 50 years and over. A 30-minute face-to-face interview gathered data on demographics, risk factors, and life styles. Data regarding bone mineral densities of the spine and hip by DXA and lateral dorsolumbar X-rays were obtained using international protocols; digital morphometry was used to determine vertebral deformities, with the results being classified according to Eastell criteria. This article summarizes the main findings observed in San Juan, Puerto Rico. RESULTS: Overall weighted prevalence of vertebral fractures was 11.2% (95% CI: 8.5%, 14.7%). Age-specific prevalence of vertebral fractures was as follows: 5.4% (95% CI: 2.7%, 10.7%) in the 50-59 years age group, 8.3% (95% CI: 4.4%, 15.1%) in the 60-69 years group, 16.2% (95% CI: 10.5%, 25.0%) in the 70-79 years group, and 22.4% (95% CI: 13.3%, 35.1%) in participants > or = 80 years. Factors significantly associated with vertebral fractures were being 70-79 years old (adjusted POR70-79 vs. 50-59 = 2.9; 95% CI: 1.1, 7.4), being > or = 80 years old (adjusted POR > or = 80 vs .50-59 = 3.3; 95% CI: 1.2, 9.4), and a T-score < or = -2.5 in the lumbar spine (adjusted POR = 2.5; 95% CI: 1.5, 5.7) and in the femoral neck (adjusted POR = 3.5; 95% CI: 1.5, 8.0). Personal history of fractures was marginally associated with vertebral fractures after adjusting for the remaining risk factors (adjusted POR = 2.0; 95% CI: 1.0, 4.0). Nearly 94% of the women with vertebral fractures were not aware of their bone status. Using the WHO classification, we determined that 71% had osteoporosis, 21%, osteopenia, and 8%, normal bone mineral densities. Bone mineral densities in the lumbar spine and femoral neck were significantly lower in women with vertebral fractures. Non-vertebral fractures were more common in women with a personal history of prior vertebral fractures. The prevalence of the most common non-vertebral fractures were hip, 1% (95% CI: 0.4%, 2.7%), and wrist, 5.9% (95% CI: 4.0%, 8.7%), respectively. CONCLUSION: This is the first population-based study of osteoporotic fractures in Puerto Rico and should serve as a guide to health providers and policy makers in the prevention and treatment of this disease.

Feasibility of collecting biologic specimens in population-based surveys: experiences from the epidemiology of hepatitis C in the household, adult population of Puerto Rico study.

The Behavioral Risk Factor Surveillance System (BRFSS) collects data on preventive health practices and risk behaviors that are linked to chronic diseases, injuries, and preventable infectious diseases that affect the adult population in all states and territories in the US. The BRFSS is currently the only survey conducted annually in Puerto Rico in the population aged 18 years and older; however, prevalence estimates are based on self-reports and therefore are subject to reporting errors. Although surveillance data are useful for the purpose of evaluation, program planning and health policy, surveys that collect biological specimens and clinical data provide a more accurate assessment of prevalence and a comprehensive picture of disease distribution and their risk factors. This article summarizes the methodology employed in a population-based study to estimate the seroprevalence of hepatitis C and other viral infections in Puerto Rico and shows the feasibility of combining different modes of data collection in population-based surveys that collect biologic specimens.

Same-Sex Behavior and its Relationship with Sexual and Health-Related Practices Among a Population-Based Sample of Women in Puerto Rico: Implications for Cancer Prevention and Control.

This secondary data analysis aimed to estimate the prevalence of same-sex behavior and sexual and health-related practices of a population-based sample (n=560) of women aged 16-64 years in Puerto Rico (PR). Data collection included interviews and biologic samples. Seven percent of the sample had had sex with other women (WSW). Age-adjusted logistic regression models indicated that WSW had higher odds of history of cancer, having ≥ 7 lifetime sexual partners, using sex toys and sharing them, and use of tobacco and illicit drugs. Future research is needed to address the health needs of WSW, including cancer-related risk factors and sexual practices.