Delays in Care by Race, Ethnicity, and Gender Before and During the COVID-19 Pandemic Using Cross-Sectional Data From National Institutes of Health's All of Us Research Program.

PURPOSE: Delays in receiving medical care are an urgent problem. This study aims to determine whether the odds of, and reasons for, experiencing care delays differ by gender, race-ethnicity, and survey completion before versus during the COVID-19 pandemic. METHODS: We conducted a cross-sectional analysis of survey data from participants age ≥18 in the National Institutes of Health's All of Us Research Program collected from May 6, 2018, to January 1, 2022. Logistic regressions were performed to assess the association of gender, race-ethnicity, and survey completion date with any of nine reasons for delaying care in the past 12 months. RESULTS: Of 119,983 participants, 37.8% reported delaying care in the past 12 months. After adjusting for employment status, education, income, marital status, health insurance, and age, women of every race-ethnicity and Black and other race-ethnicity men were more likely than white men to report delays in care: Asian women (odds ratio [OR] 1.23; 95% confidence interval [CI] [1.13, 1.34]), Black men (OR 1.15; 95% CI [1.05, 1.25]) and women (OR 1.46; 95% CI [1.38, 1.54]), Hispanic women (OR 1.36; 95% CI [1.28, 1.44]), white women (OR 1.55; 95% CI [1.50, 1.60]), and other race-ethnicity men (OR 1.15; 95% CI [1.05, 1.27]) and women (OR 1.79; 95% CI [1.67, 1.91]). A small but statistically significant difference was seen in reports of care delays for non-pandemic-related reasons during versus before the COVID-19 pandemic (OR 0.88; 95% CI [0.83, 0.93]). CONCLUSIONS: In this study of diverse U.S. participants, women and Black and other race-ethnicity men were more likely than white men to report delays in care, both before and during COVID-19. Addressing care delays may be necessary to ameliorate health disparities by race-ethnicity and gender.

Association of tobacco use and the presence of anal warts in people who attend the anal Neoplasia clinic in Puerto Rico.

Background: Limited research exists regarding the association between smoking and anal warts. In this study, we evaluated this association among a clinic-based Hispanic population in Puerto Rico. Methods: Cross-sectional study among eligible patients seen at the Anal Neoplasia Clinic of the University of Puerto Rico Comprehensive Cancer Center (2016-2023) (n = 920). Sociodemographic and clinical variables were collected from medical records. Patients underwent a high-resolution anoscopy (HRA) during the clinical visit; physicians assessed anal condylomas on HRA. Poisson regression models with robust standard errors were used to evaluate the association between smoking and anal warts. Demographic and clinical factors were also assessed. Results: The mean age of participants was 45.8 ± 13.1 years, 66.4 % were men, and 21.6 % were current smokers. While 10.8 % self-reported a history of anogenital condylomas, 18.9 % had anal condylomas on clinical evaluation. A higher prevalence of anal condylomas was observed among current smokers (PR = 1.28, 95 % CI: 0.94-1.75) in comparison to non-smokers in adjusted analysis, but this was not statistically significant. However, a higher prevalence of anal condylomas was observed among younger individuals (PR = 0.96, 95 % CI: 0.96-0.98) and individuals with anal high-grade squamous intraepithelial lesions (HSIL) as compared to those with benign histology (PR = 1.74. 95 % CI: 1.09-2.77). Conclusions: Although current smoking seemed to be positively associated with anal condylomas in this high-risk Hispanic population, this finding was not statistically significant as the power to detect an association was limited. However, younger age and HSIL diagnosis were associated with a higher prevalence of anal condylomas.

Compliance with Influenza Vaccination and Cervical, Breast, and Colorectal Cancer Screening in a Sample of Women in Puerto Rico: Community Engagement Efforts from PR-CEAL.

OBJECTIVE: There are an estimated 5,570 yearly cancer deaths in Puerto Rico. Breast and colorectal are the most common malignancies among Puerto Rican women. Therefore, prevention and early detection of these cancer types are critical to reducing morbidity and mortality. This study assessed whether women who received the influenza vaccine had increased adherence to cervical, breast, and colorectal cancer screening. METHODS: The Puerto Rico Community Engagement Alliance (PR-CEAL) against COVID-19 Disparities team attended community outreach events throughout Puerto Rico and completed a face-to-face survey among women 18 years or older. The survey gathered demographic information and adherence to influenza vaccination and cervical, breast, and colorectal screening in the past year. The initial sample included 400 women, of whom 347 met the age inclusion criteria (21-74 years). Chi-square tests were used to compare cancer screening adherence according to influenza vaccination status. A p-value <0.05 was considered statistically significant. RESULTS: Of all participants, 47.0% received the influenza vaccine in the past year. Cancer screening rates among vaccinated and non-vaccinated women were as follows: 64.5% vs. and 13.0% vs. 8.0% for colorectal cancer (p-value=0.19). CONCLUSION: Adherence to cervical, breast, and colorectal cancer screening in the past year did not differ by influenza vaccination status. Influenza vaccination appointments may therefore represent a missed opportunity to promote preventative cancer screening in Puerto Rico.

Barriers and facilitators to anal cancer screening among people living with HIV in Puerto Rico.

BACKGROUND: Anal cancer (AC) disproportionally affects people living with HIV (PLWH). Although there are no consensus-based AC screening guidelines, experts recommend anal pap as a primary screening tool in settings where high-resolution anoscopy (HRA) is available. We aimed to assess barriers and facilitators to anal cancer screening in a sample of Hispanic PLWH in Puerto Rico. METHODS: To assess their knowledge and attitudes, we conducted a cross-sectional survey from 2020-2021 among PLWH in Puerto Rico (n = 212). Data was collected through a telephone interview that assessed information on sociodemographics, knowledge, and attitudes about AC, and the history of AC screening. The chi-square test, Fisher exact test, and logistic regression models were used to assess factors associated with screening uptake. RESULTS: Anal Pap and HRA awareness were 60.4% and 30.7%, respectively. Anal Pap and HRA uptake was 51.5% and 19.3%, respectively. The most common barriers for anal Pap and HRA were lack of knowledge about the test and lack of physician recommendation. MSM were more likely to have heard of anal Pap (OR: 2.15, 95% CI:1.30-3.54) than MSW. MSM (OR: 3.04, 95% CI: 1.79-5.19) and women (OR: 3.00, 95% CI: 1.72-5.20) were also more likely to have undergone anal Pap. Similarly, individuals with a history of genital warts were more likely to have heard of anal Pap and HRA and have undergone anal Pap and HRA. Awareness of where to go for concerns about anal health was positively associated with having received anal Pap and HRA. CONCLUSIONS: With emerging evidence on the effectiveness of screening and treatment for anal cancer, several organizations are steering toward generating consensus-based anal cancer screening recommendations. Our study provides foundational data on barriers and facilitators to anal cancer screening in Puerto Rico that will be critical to informing screening implementation in this US territory.

Breast and Colorectal Cancer Screening Utilization after Hurricane María and the COVID-19 Pandemic in Puerto Rico.

Puerto Rico (PR) has faced environmental and public health challenges that could have significantly affected cancer screening access. Using administrative claims data from PR's Medicaid population, this study assessed trends in colorectal and breast cancer screening from 2016 to 2021, the impact of disasters in screening, and the absolute deficit in screening due to the pandemic. The monthly rates of claims were analyzed using Poisson regression. Significant reductions in breast and colorectal cancer screening utilization were observed. The colorectal cancer screening rate in 2017 was 77% lower a month after Hurricanes Irma and María [RRadj: 0.23; 95% CI: 0.20, 0.25] compared to the same time period in 2016. Breast cancer screening dropped 50% in November 2017 compared to November 2016 [RRadj: 0.50; 95% CI: 0.47, 0.54]. Prospectively, a recovery in utilization has been observed only for breast cancer screening. The results revealed that cancer screening utilization substantially declined after environmental disasters and the pandemic. These findings have potentially severe long-term implications for cancer health disparities and mortality in PR.

COVID-19 Vaccine Booster Hesitancy among Hispanic Adults: A Cross-Sectional Study from the Puerto Rico Community Engagement Alliance against COVID-19 Disparities (PR-CEAL).

Hispanic/Latino communities have suffered a disproportionate burden of the COVID-19 pandemic. Although Puerto Rico has one of the highest COVID-19 primary series vaccination rates nationwide, this estimate contrasts with the reported booster doses' low uptake. This study aimed to assess health belief correlates of COVID-19 vaccine booster uptake. Using a convenience sampling approach, the Puerto Rico-Community Engagement Alliance (PR-CEAL) conducted a cross-sectional study where 787 participants were recruited using online and in-person strategies between December 2021 and February 2022. Participants were adults 18 years or older, Spanish-speaking, and residents of Puerto Rico. The Health Belief Model was used to evaluate attitudes and beliefs. A total of 784 participants were used in this analysis. Adjusted Poisson regression models were used to estimate prevalence ratios (PR) and 95% confidence intervals (CI) of booster refusal. Overall, 22% of participants refused the vaccine booster or had not gotten it yet. Adjusted models showed that (i) participants who disagreed that getting the booster dose either made them feel less worried about COVID-19 or (ii) felt that the vaccine decreased their chances of getting COVID-19 presented higher booster-refusal prevalence ratios (PR = 4.20, 95% CI: 3.00, 5.90; PR = 3.70, 95% CI: 2.64, 5.18). Moreover, participants that (iii) reported having concerns for booster side effects [PR = 2.47; 95% CI = 1.73, 3.51], (iv) booster efficacy [PR = 2.50; 95% CI = 1.75, 3.58], and (v) booster safety [PR = 2.80; 95% CI = 1.96, 3.99] were significantly more likely to refuse the booster. In conclusion, booster vaccination refusal was associated with lower perceived vaccine benefits and greater barriers among adults in Puerto Rico. These results informed the development of PR-CEAL's targeted community outreach strategies and public health campaigns to increase booster vaccine uptake.

Challenges Accessing Food, Water, Healthcare Services, and Medications During the COVID-19 Pandemic Among Adults in Puerto Rico and Their Association with Self-Rated Health: Assessments of PR-CEAL.

BACKGROUND: The COVID-19 pandemic created challenges in accessing food, water, medications, and healthcare services some of which are linked with lower self-rated health (SRH). These challenges have already been documented in the US, but it remains unknown how the pandemic affected access to food, water, medications and healthcare services, and how these challenges relate to SRH in this group, a population experiencing profound health disparities and limited resources prior to the pandemic. OBJECTIVE: To assess associations between challenges accessing food, water, healthcare, and medications during the COVID-19 pandemic and SRH among adults in Puerto Rico. METHODS: Cross-sectional analysis of Puerto Rico-CEAL. Adults (>18 years; n=582) completed an online survey (December 30, 2021-February 8, 2022). Presence of each challenge during the past 30 days was measured and analyzed individually and combined (0, 1, >2). SRH (rated from poor-excellent) was measured before and at pandemic. Change in SRH was calculated. Adjusted Poisson models with robust variance errors estimated prevalence ratios (PR). RESULTS: Experiencing food, water, medication, and healthcare challenges (vs. not) were associated with pandemic fair-poor SRH (PR=1.44, 95%CI=1.06-1.97; PR=1.59, 95%CI=1.15-2.18; PR=1.38, 95%CI=1.05-1.81; and PR=1.56,9 5%CI=1.15-2.12, respectively). Experiencing 2+ challenges (vs. none) was associated with pandemic fair-poor SRH (PR=1.77, 95%CI=1.22-2.55). Additionally, experiencing food, medication, and healthcare challenges (vs. not) was associated with decreased SRH (PR=1.35, 95%CI=1.08-1.69; PR=1.24, 95%CI=1.01-1.51; and PR=1.25, 95%CI=1.01-1.54, respectively), as well as experiencing 2+ challenges (vs. none; PR =1.49, 95%CI=1.15-1.92). CONCLUSION: Challenges accessing food, water, medications, and healthcare services during the pandemic were associated with fair-poor SRH and decreased SRH in Puerto Rico. Public health policy should ensure access to basic needs.

Evaluating the performance of anal cytology and high-risk HPV genotyping for detecting anal HSIL in a clinic-based sample of people living with and without HIV in Puerto Rico.

BACKGROUND: Given the disproportionately elevated anal cancer risk in high-risk populations, it is important to assess the performance of commonly used anal cancer screening tools to improve the effectiveness of detection and treatment methods. This study evaluates 1) the concordance between anal cytology and histology results and 2) the performance of cytology and high-risk human papillomavirus (HR-HPV) genotyping as screening tools for detecting histologically confirmed anal high-grade squamous intraepithelial lesions (HSIL). METHODS: Data from the Anal Neoplasia Clinic in Puerto Rico (2014-2021; n = 466) was used. The clinical performance of anal cytology and HR-HPV genotyping to detect HSIL was compared to the gold standard: high-resolution anoscopy-guided biopsy. Sensitivity, specificity, positive predictive value, negative predictive value, and κ coefficients were calculated. RESULTS: A total of 66.95% of the patients were men, 74.0% were people living with HIV, 76.2% had anal HR-HPV infection, and 40.34% had histologically confirmed anal HSIL. The weighted κ statistic between the tests (cytology and histology) was 0.25 (p < .001). The sensitivity and specificity of cytology alone to detect anal HSIL were 84.3% (95% confidence interval [CI], 78.3%-89.1%) and 36.0% (95% CI, 30.3%-42.0%), respectively. Anal HR-HPV genotyping had higher sensitivity (92.2%; 95% CI, 87.4%-95.6%) and similar specificity (34.8%; 95% CI, 29.2%-40.7%) compared to cytology. The two tests combined (positive results following cytology or HR-HPV test) improved sensitivity to detect anal HSIL (97.9%; 95% CI, 94.8%-99.4%), but specificity was compromised (19.2%; 95% CI, 14.7%-24.4%). CONCLUSION: Although HR-HPV genotyping improved the detection of anal HSIL, HR-HPV testing had lower specificity than anal cytology alone.

'More stressful than cancer': Treatment Experiences Lived During Hurricane Maria among Breast and Colorectal Cancer Patients in Puerto Rico.

Background: This study explored experiences in cancer care and disruption after Hurricanes Irma and Maria's aftermath in Puerto Rico (PR). Methods: A total of three focus groups were conducted among breast and colorectal cancer patients diagnosed six months before the disaster. Results: The most prevalent themes were (a) barriers related to their cancer treatment, (b) facilitators related to their cancer treatment, and (c) treatment experiences during the hurricane. Participants discussed struggles regarding their experience with treatment and access to care during and after Hurricanes Irma and Maria and how household limitations due to lack of electricity and water deter their intention to continue their treatment. Moreover, stressors directly linked with the disaster were the most challenging to cope with. Conclusions: Our study identifies the hardships experienced by cancer patients living during a disaster. Similarly, our study highlights the impending need to address in future emergency plans the individual and system needs of cancer patients in active treatment to minimize the delay in continuing cancer care.

Attitudes towards HPV and COVID school-entry policies among adults living in Puerto Rico.

Prior to the COVID pandemic, Puerto Rico (PR) had one of the highest Human Papillomavirus (HPV) vaccine rates in the United States. The COVID pandemic and administration of COVID vaccines might have impacted attitudes toward HPV vaccination. This study compared attitudes toward HPV and COVID vaccines with respect to school-entry policies among adults living in PR. A convenience sample of 222 adults (≥21 years old) completed an online survey from November 2021 to January 2022. Participants answered questions about HPV and COVID vaccines, attitudes toward vaccination policies for school-entry, and perceptions of sources of information. We assessed the magnitude of association between the agreement of school-entry policies for COVID and HPV vaccination by estimating the prevalence ratio (PRadjusted) with 95% Confidence Intervals (95% CI). The most trusted source of information for HPV and COVID vaccines were healthcare providers (42% and 17%, respectively) and the CDC (35% and 55%, respectively), while the least trusted were social media (40% and 39%, respectively), and friends and family (23% n = 47, and 17% n = 33, respectively). Most participants agreed that HPV (76% n = 156) and COVID vaccines (69% n = 136) should be a school-entry requirement. Agreement with school policy requiring COVID vaccination was significantly associated with agreement of school policy requiring HPV vaccination (PRadjusted:1.96; 95% CI:1.48-2.61) after controlling for potential confounders. Adults living in PR have an overall positive attitude about mandatory HPV and COVID vaccination school-entry policies, which are interrelated. Further research should elucidate the implications of the COVID pandemic on HPV vaccine attitudes and adherence rates.

Seroprevalence and risk factors associated with hepatitis C: a cross-sectional study of persons who inject drugs in Puerto Rico, 2018.

BACKGROUND: People Who Inject Drugs (PWID) are at a higher risk of acquiring bloodborne infections. We aimed to estimate the seroprevalence of the Hepatitis C Virus (HCV) in PWID and identify correlates and risk factors using data from the Puerto Rico National HIV Behavioral Surveillance System, PWID cycle 5, conducted in 2018. METHODS: A total of 502 San Juan Metropolitan Statistical Area participants were recruited through the Respondent Driven Sampling method. Sociodemographic, health-related, and behavioral characteristics were assessed. Testing for HCV antibodies was completed after the face-to-face survey. Descriptive and logistic regression analyses were performed. RESULTS: Overall seroprevalence of HCV was 76.5% (95% CI: 70.8-81.4%). A significantly (p < 0.05) higher HCV seroprevalence was observed among PWID with the following characteristics: heterosexuals (78.5%), high school graduates (81.3%), tested for sexually transmitted infections (STI) in the past 12 months (86.1%), frequent speedball injection (79.4%), and knowing the HCV serostatus of the last sharing partner (95.4%). Adjusted logistic regression models showed that having completed high school and reported STI testing in the past 12 months were significantly associated with HCV infection (ORa = 2.23; 95% CI: 1.06-4.69; ORa = 2.14; 95% CI: 1.06-4.30, respectively). CONCLUSIONS: We report a high seroprevalence of HCV infection in PWID. Social health disparities and potential missed opportunities validate the continuing call for local action for public health and prevention strategies.

Knowledge, Attitudes, and Beliefs About Colorectal Cancer Screening in Puerto Rico.

The purpose of this study was to describe the psychosocial factors influencing participation in colorectal cancer screening (CRCS) among Puerto Rican men and women. We conducted seven focus groups in metropolitan and rural areas of Puerto Rico (PR) with men and women (using gender specific groups) aged 50 to 80 years (n = 51) who were non-adherent to CRC guidelines. The focus group guide included questions related to colorectal cancer (CRC) and CRC screening knowledge, attitudes, and beliefs. We analyzed data using a modified grounded theory approach to identify emergent themes. Focus groups revealed seven major themes that represented barriers to CRCS: (1) lack of CRC knowledge, (2) lack of knowledge about colorectal cancer screening tests as well as the required preparation, (3) embarrassment, (4) low perceived benefit of CRCS and sense of fatalism, (5) transportation (mostly among participants in rural areas), (6) lack of time, and (7) financial burden. All participants understood the benefits of CRCS once the procedure was explained. Additionally, participants reported a lack of provider recommendation for CRCS. In this group of Puerto Rican participants who were non-adherent to CRCS, there were misconceptions about CRC, screening tests available, and preparation and testing procedures. Participants' low levels of knowledge and negative attitudes concerning CRCS and low reported provider recommendation were important deterrents to screening. These findings suggest the need for educational efforts to increase knowledge and attitudes about CRCS and improved patient-provider communication to reduce missed opportunities to recommend.

The Puerto Rico Community Cancer Control Outreach Program: Developing Capacity-Building Activities on Cancer Screening Guidelines and HPV Vaccination Recommendations for Health Care Professionals.

OBJECTIVE: This study evaluated physicians' knowledge of cancer screening guidelines and human papillomavirus (HPV) recommendations. METHODS: The Puerto Rico Community Cancer Control Outreach Program in collaboration with the Comprehensive Cancer Control Program and the Breast and Cervical Cancer Early Detection Program developed an educational activity for physicians who attended a professional annual meeting. This activity consisted of 2 sessions: one about cancer screening guidelines and the other about HPV and HPV vaccination. A survey measuring the attendees' knowledge of the session topics was administered before and after each session. Changes in knowledge were assesed using McNemar's test with a significance level of 0.05. RESULTS: A total of 43 physicians responded to the survey about cancer screening, and 67 responded to the survey about HPV. A significant increase in the mean score of the pre-test (3.3 ± 1.42) and post-test (6.7 ± 1.38) of the cancer screening guidelines was observed as well as in that of the pre-test (7.82 ± 1.44) and post-test (9.66 ± 0.53) of HPV. The results showed that there were improvements regarding the most recent cervical cancer screening and colonoscopy guidelines as well as in the knowledge of HPV serotypes. CONCLUSION: This mid-day educational activity significantly improved knowledge among primary care physicians. Given its feasibility, future efforts should discuss the most recent cancer guidelines and emerging socio behavioral factors that impact vaccination.

Provider-Initiated HIV Testing in Puerto Rico from Data of the National HIV Behavioral Surveillance-Heterosexual Cycle (NHBS-HET) 2016: National Cross-sectional Survey.

BACKGROUND: According to the Centers for Disease Control and Prevention and World Health Organization guidelines, all individuals aged 13-64 years should get screened for HIV infection as part of their routine medical examinations. Individuals at high risk should get tested annually. OBJECTIVE: This study aimed to identify the sociodemographic, health care, and sexual behavioral characteristics of provider-initiated HIV testing using data from the Puerto Rico National HIV Behavioral Surveillance 2016 cycle, directed toward heterosexual individuals at increased risk of HIV infection. METHODS: A sample of 358 eligible participants were recruited through respondent-driven sampling, where sociodemographic characteristics, health care use, and HIV test referral were used to assess a description of the study sample. Pearson chi-square and Fisher tests were used to evaluate proportional differences. Multivariate logistic regression models were performed to determine the association between independent variables and HIV test referral. Adjusted prevalence ratios by sex and age with their 95% CIs were determined using a statistical significance level of .05. RESULTS: Despite 67.9% (243/358) of participants showing high-risk sexual behavioral practices and 67.4% (236/350) reporting a low perceived risk of HIV infection among those who visited a health care provider within the last 12 months, 80.7% (289/358) of the study sample did not receive an HIV test referral at a recent medical visit. Multivariate analysis showed that the estimated prevalence of the participants who received an HIV test referral among those who reported being engaged in high-risk sexual behaviors was 41% (adjusted prevalence ratio .59, 95% CI .39-.91; P=.02) lower than the estimated prevalence among those who did not engage in high-risk sexual behavior. CONCLUSIONS: This sample of Puerto Rican adults reported a significantly lower prevalence of receiving an HIV test referral among heterosexual individuals at increased risk of HIV infection who engaged in high-risk behaviors. This study further emphasizes the need for health care providers to follow recommended guidelines for HIV test referrals in health care settings. Promotion practices in the future should include enhancing referral and access to HIV tests and implementing preventive measures to counteract the HIV epidemic in Puerto Rico.

Religiosity and Beliefs toward COVID-19 Vaccination among Adults in Puerto Rico.

Religiosity may influence COVID-19 vaccination. However, it remains unclear how religiosity is associated with beliefs toward COVID-19 and vaccination against it, particularly amongst ethnic minorities. This study examined the association between religiosity, vaccination intent, beliefs, and attitudes related to COVID-19 and vaccination among adults in Puerto Rico. Data from an online survey conducted between December 2020-February 2021 among adults (≥18 yr; n = 1895) residing in Puerto Rico were used. Rating of the importance of religiosity was used to capture the level of religiosity ('less important', 'somewhat important', 'important', and 'very important'). The health belief model (HBM) assessed beliefs and attitudes toward COVID-19 and vaccination against it. Adjusted Poisson models with robust error variance estimated prevalence ratios (PR) and 95% confidence intervals for vaccination intent and individual COVID-19 HBM constructs. Compared to individuals rating religiosity as 'less important' to them, those rating it as 'very important' were more likely to be unwilling or uncertain to get the COVID-19 vaccine (PR = 1.51, 95% CI = 1.10-2.05). Higher ratings of importance of religiosity, compared to the lowest level, were associated with significantly lower perceived COVID-19 susceptibility, more vaccine barriers, and lower vaccine benefits (all p < 0.05). Individuals who reported religiosity being very important to them were more likely to report that they will get the COVID-19 vaccine only if given adequate information about it (PR = 1.14, 95% CI = 1.02-1.27) and more likely to get the vaccine if more people decide to receive it (all p < 0.05). In conclusion, our results suggest an association between religiosity and COVID-19 vaccination intent and beliefs and attitudes toward vaccination. The study highlights important guidelines for public health campaigns to increase vaccine uptake among religious communities in Puerto Rico.

[Efforts towards the consolidation of public policies for the prevention of HPV-associated cancers in Puerto RicoEsforços realizados em Porto Rico para a consolidação de políticas públicas de prevenção de cânceres associados ao HPV]. / Esfuerzos realizados en Puerto Rico hacia la consolidación de políticas públicas para la prevención de cánceres asociados al VPH.

The purpose of this special report is to describe chronologically the events that contributed to the development and approval of legislation and subsequent implementation of a school vaccination mandate in order to prevent HPV and HPV-associated cancers in Puerto Rico (PR). Starting in 2010, PR initiated public-policy approvals aimed at improving cancer registries and HPV vaccine coverage through health insurance for adolescents aged 11 to 18 years. In 2014, scientific and community efforts succeeded in documenting the magnitude of morbidity caused by HPV and jointly developing HPV vaccine prevention and promotion strategies. In August 2018, PR became one of the first four territories of the United States of America to implement the HPV vaccine school entry requirement to decrease the incidence of HPV-associated cancers on the island. In 2019, it was enshrined in law that every immunization provider must submit immunization data to the Puerto Rico Immunization Registry. The case of PR demonstrates that public policy-making alongside collaboration between academic, scientific, and community coalitions can achieve population change and measurable outcomes aimed at HPV prevention. Countries with a similar public health problem could adopt efforts similar to those presented herein and align them with the World Health Organization goal of eradicating cervical cancer by 2030.

O propósito deste relatório especial é descrever cronologicamente os eventos que contribuíram para o desenvolvimento e a aprovação de legislação, e a implementação da exigência escolar de vacinação em Porto Rico (PR), a fim de prevenir o HPV e os cânceres associados a ele. A partir de 2010, PR iniciou as aprovações de políticas públicas com o objetivo de aprimorar o registro dos casos de câncer e a cobertura vacinal contra o HPV, por meio de planos de saúde, em adolescentes de 11 a 18 anos. Em 2014, esforços científicos e comunitários permitiram documentar a magnitude das doenças causadas pelo HPV e elaborar conjuntamente estratégias de prevenção e promoção da vacina contra o HPV. Em agosto de 2018, PR foi um dos primeiros quatro territórios dos Estados Unidos da América a implementar a vacina contra o HPV como exigência escolar, a fim de diminuir a incidência de cânceres associados ao HPV na ilha. Em 2019 ficou garantido por lei que todos os vacinadores devem enviar informações ao Registro de Imunização. O caso de PR demonstra que o desenvolvimento de políticas públicas, em conjunto com parcerias entre coalizões acadêmicas, científicas e comunitárias, alcança mudanças populacionais e resultados mensuráveis dirigidos à prevenção do HPV. Países com uma problemática de saúde pública similar poderiam adotar esforços semelhantes aos apresentados e alinhá-los ao objetivo da Organização Mundial da Saúde: a erradicação do câncer cervical até 2030.

Association of smoking with anal high-risk HPV infection and histologically confirmed anal high-grade squamous intraepithelial lesions among a clinic-based population in Puerto Rico.

INTRODUCTION: Current smoking is a risk factor for anal cancer. Yet, its association with anal human papillomavirus infection (HPV) and anal high-grade squamous intraepithelial lesions (HSIL) remains unclear. We assessed the association of smoking with 1) anal high-risk HPV (HR-HPV) infection and 2) anal HSIL. METHODS: Data from the baseline visit of patients from the Anal Neoplasia Clinic of the University of Puerto Rico Comprehensive Cancer Center (May 2015- June 2021) was analyzed. Patients were eligible if they had information on smoking status, complete high-resolution anoscopy (HRA) with biopsy, and HR-HPV testing (n =  427). Logistic regression models estimated the odds ratio (OR) with 95% confidence intervals (CIs) adjusting for covariates. RESULTS: Mean age was 44 ± 13 years, 69% were men, 74% were HIV-infected, and 25% reported being current smokers. 74% had anal HR-HPV infection. HSIL was diagnosed in 40% of patients. Current smokers had significantly higher odds (OR: 1.71, 95% CI: 1.04-2.82) of having HSIL compared to non-smokers after adjusting for age, sexual risk group, lifetime number of sexual partners, HIV status, and HR-HPV infection. Smoking was not associated with HR-HPV infection (OR: 1.56, 95% CI: 0.83-2.95) after adjusting for age, sexual risk group, lifetime number of sexual partners, and HIV status. CONCLUSIONS: Current smoking was associated with histologically confirmed HSIL but not with HR-HPV infection among this high-risk Hispanic population. Results highlight the need to explore targeted smoking cessation campaigns among populations at higher risk of developing HSIL, as an anal cancer prevention strategy.

Esfuerzos realizados en Puerto Rico hacia la consolidación de políticas públicas para la prevención de cánceres asociados al VPH

[RESUMEN]. El propósito de este informe especial es describir cronológicamente los eventos que contribuyeron al desarrollo y aprobación de la legislación e implementación del requisito escolar de vacunación en Puerto Rico (PR), con el fin de prevenir el VPH y los cánceres asociados a este. A partir del 2010, PR inició las aprobaciones de políticas públicas con el objetivo de mejorar el registro de casos de los cánceres y la cobertura de la vacuna contra el VPH a través de los planes médicos en adolescentes de 11 a 18 años. En el 2014, los esfuerzos científicos y comunitarios lograron documentar la magnitud de las enfermedades causadas por el VPH, y desarrollar en conjunto, estrategias de prevención y promoción de la vacuna contra el VPH. En agosto de 2018, PR logró ser uno de los primeros cuatro territorios de los Estados Unidos de América en implementar la vacuna contra el VPH como requisito escolar con el fin de disminuir la incidencia de cánceres asociados al VPH en la isla. En el 2019 se garantizó por ley que todo proveedor de vacunación debe reportar al Registro de Inmunización. El caso de PR demuestra que el desarrollo de políticas públicas junto con colaboraciones entre coaliciones académicas, científicas y comunitarias, logran cambios poblacionales y resultados medibles dirigidos a la prevención de VPH. Países con una problemática de salud pública similar podrían adoptar esfuerzos similares a los presentados, y alinearlos al objetivo de la Organización Mundial de la Salud: erradicación del cáncer cervical para 2030.

[ABSTRACT]. The purpose of this special report is to describe chronologically the events that contributed to the development and approval of legislation and subsequent implementation of a school vaccination mandate in order to prevent HPV and HPV-associated cancers in Puerto Rico (PR). Starting in 2010, PR initiated public policy approvals aimed at improving cancer registries and HPV vaccine coverage through health insurance for adolescents aged 11 to 18 years. In 2014, scientific and community efforts succeeded in documenting the magnitude of morbidity caused by HPV and jointly developing HPV vaccine prevention and promotion strategies. In August 2018, PR became one of the first four territories of the United States of America to implement the HPV vaccine school entry requirement to decrease the incidence of HPV-associated cancers on the island. In 2019, it was enshrined in law that every immunization provider must submit immunization data to the Puerto Rico Immunization Registry. The case of PR demonstrates that public policy-making alongside collaboration between academic, scientific, and community coalitions can achieve population change and measurable outcomes aimed at HPV prevention. Countries with a similar public health problem could adopt efforts similar to those presented herein and align them with the World Health Organization goal of eradicating cervical cancer by 2030.

[RESUMO]. O propósito deste relatório especial é descrever cronologicamente os eventos que contribuíram para o desenvolvimento e a aprovação de legislação, e a implementação da exigência escolar de vacinação em Porto Rico (PR), a fim de prevenir o HPV e os cânceres associados a ele. A partir de 2010, PR iniciou as aprovações de políticas públicas com o objetivo de aprimorar o registro dos casos de câncer e a cobertura vacinal contra o HPV, por meio de planos de saúde, em adolescentes de 11 a 18 anos. Em 2014, esforços científicos e comunitários permitiram documentar a magnitude das doenças causadas pelo HPV e elaborar conjuntamente estratégias de prevenção e promoção da vacina contra o HPV. Em agosto de 2018, PR foi um dos primeiros quatro territórios dos Estados Unidos da América a implementar a vacina contra o HPV como exigência escolar, a fim de diminuir a incidência de cânceres associados ao HPV na ilha. Em 2019 ficou garantido por lei que todos os vacinadores devem enviar informações ao Registro de Imunização. O caso de PR demonstra que o desenvolvimento de políticas públicas, em conjunto com parcerias entre coalizões acadêmicas, científicas e comunitárias, alcança mudanças populacionais e resultados mensuráveis dirigidos à prevenção do HPV. Países com uma problemática de saúde pública similar poderiam adotar esforços semelhantes aos apresentados e alinhá-los ao objetivo da Organização Mundial da Saúde: a erradicação do câncer cervical até 2030.

Human papillomavirus vaccine initiation and up-to-date vaccine coverage for adolescents after the implementation of school-entry policy in Puerto Rico.

The human papillomavirus (HPV) vaccine has been proven effective in the prevention of infection with high-risk HPV types, which can lead to the development of six HPV-related cancers. Puerto Rico (PR) adopted a mandatory HPV vaccination school-entry policy that took effect in August 2018. While school-entry requirements are generally accepted as an effective approach for increasing vaccination rates, there are few studies that have documented their impact on improving HPV vaccination rates. The objective of this study was to evaluate the impact of the HPV school-entry policy in PR on HPV vaccine coverage. We used a pre-post natural experiment. The study population included adolescents registered in the PR Immunization Registry during 2008-2019. We calculated HPV vaccine initiation and up-to-date (UTD) vaccine coverage rates. We estimated age-standardized rates (ASR) and standardized rate ratio with 95%CI. Vaccine data corresponding to a total of 495,327 adolescents were included for analysis; 50.9% were male and 49.1% were females. After policy implementation, a marked increase in raw HPV vaccine initiation among 11- to 12-year-old adolescents was observed across years 2017 (a pre-policy year), 2018, and 2019 (58.3%, 76.3%, and 89.8%, respectively). UTD coverage also showed a moderate increase after policy implementation among 11- to 12-year-old adolescents. The gap between sexes in vaccine initiation and UTD coverage narrowed over time; the ASRs in 2019 showed an increase of 19% in initiation and 7% increase in UTD relative to 2017 for males and females combined (both significant at p<0.05). This study demonstrated evidence of improvement in HPV vaccination rates following implementation of the school-entry policy and a narrowed sex gap in vaccine rates over time in PR. Future analyses should assess how the policy continues to affect vaccine coverage in subsequent years and how the COVID-19 pandemic has impacted HPV vaccination uptake.

Esfuerzos realizados en Puerto Rico hacia la consolidación de políticas públicas para la prevención de cánceres asociados al VPH / Efforts towards the consolidation of public policies for the prevention of HPV-associated cancers in Puerto Rico / Esforços realizados em Porto Rico para a consolidação de políticas públicas de prevenção de cânceres associados ao HPV

RESUMEN El propósito de este informe especial es describir cronológicamente los eventos que contribuyeron al desarrollo y aprobación de la legislación e implementación del requisito escolar de vacunación en Puerto Rico (PR), con el fin de prevenir el VPH y los cánceres asociados a este. A partir del 2010, PR inició las aprobaciones de políticas públicas con el objetivo de mejorar el registro de casos de los cánceres y la cobertura de la vacuna contra el VPH a través de los planes médicos en adolescentes de 11 a 18 años. En el 2014, los esfuerzos científicos y comunitarios lograron documentar la magnitud de las enfermedades causadas por el VPH, y desarrollar en conjunto, estrategias de prevención y promoción de la vacuna contra el VPH. En agosto de 2018, PR logró ser uno de los primeros cuatro territorios de los Estados Unidos de América en implementar la vacuna contra el VPH como requisito escolar con el fin de disminuir la incidencia de cánceres asociados al VPH en la isla. En el 2019 se garantizó por ley que todo proveedor de vacunación debe reportar al Registro de Inmunización. El caso de PR demuestra que el desarrollo de políticas públicas junto con colaboraciones entre coaliciones académicas, científicas y comunitarias, logran cambios poblacionales y resultados medibles dirigidos a la prevención de VPH. Países con una problemática de salud pública similar podrían adoptar esfuerzos similares a los presentados, y alinearlos al objetivo de la Organización Mundial de la Salud: erradicación del cáncer cervical para 2030.

ABSTRACT The purpose of this special report is to describe chronologically the events that contributed to the development and approval of legislation and subsequent implementation of a school vaccination mandate in order to prevent HPV and HPV-associated cancers in Puerto Rico (PR). Starting in 2010, PR initiated public-policy approvals aimed at improving cancer registries and HPV vaccine coverage through health insurance for adolescents aged 11 to 18 years. In 2014, scientific and community efforts succeeded in documenting the magnitude of morbidity caused by HPV and jointly developing HPV vaccine prevention and promotion strategies. In August 2018, PR became one of the first four territories of the United States of America to implement the HPV vaccine school entry requirement to decrease the incidence of HPV-associated cancers on the island. In 2019, it was enshrined in law that every immunization provider must submit immunization data to the Puerto Rico Immunization Registry. The case of PR demonstrates that public policy-making alongside collaboration between academic, scientific, and community coalitions can achieve population change and measurable outcomes aimed at HPV prevention. Countries with a similar public health problem could adopt efforts similar to those presented herein and align them with the World Health Organization goal of eradicating cervical cancer by 2030.

RESUMO O propósito deste relatório especial é descrever cronologicamente os eventos que contribuíram para o desenvolvimento e a aprovação de legislação, e a implementação da exigência escolar de vacinação em Porto Rico (PR), a fim de prevenir o HPV e os cânceres associados a ele. A partir de 2010, PR iniciou as aprovações de políticas públicas com o objetivo de aprimorar o registro dos casos de câncer e a cobertura vacinal contra o HPV, por meio de planos de saúde, em adolescentes de 11 a 18 anos. Em 2014, esforços científicos e comunitários permitiram documentar a magnitude das doenças causadas pelo HPV e elaborar conjuntamente estratégias de prevenção e promoção da vacina contra o HPV. Em agosto de 2018, PR foi um dos primeiros quatro territórios dos Estados Unidos da América a implementar a vacina contra o HPV como exigência escolar, a fim de diminuir a incidência de cânceres associados ao HPV na ilha. Em 2019 ficou garantido por lei que todos os vacinadores devem enviar informações ao Registro de Imunização. O caso de PR demonstra que o desenvolvimento de políticas públicas, em conjunto com parcerias entre coalizões acadêmicas, científicas e comunitárias, alcança mudanças populacionais e resultados mensuráveis dirigidos à prevenção do HPV. Países com uma problemática de saúde pública similar poderiam adotar esforços semelhantes aos apresentados e alinhá-los ao objetivo da Organização Mundial da Saúde: a erradicação do câncer cervical até 2030.