Factors influencing completion of multi-dose vaccine schedules in adolescents: a systematic review.

BACKGROUND: Completion of multiple dose vaccine schedules is crucial to ensure a protective immune response, and maximise vaccine cost-effectiveness. While barriers and facilitators to vaccine uptake have recently been reviewed, there is no comprehensive review of factors influencing subsequent adherence or completion, which is key to achieving vaccine effectiveness. This study identifies and summarises the literature on factors affecting completion of multi-dose vaccine schedules by adolescents. METHODS: Ten online databases and four websites were searched (February 2014). Studies with analysis of factors predicting completion of multi-dose vaccines were included. Study participants within 9-19 years of age were included in the review. The defined outcome was completion of the vaccine series within 1 year among those who received the first dose. RESULTS: Overall, 6159 abstracts were screened, and 502 full texts were reviewed. Sixty one studies were eligible for this review. All except two were set in high-income countries. Included studies evaluated human papillomavirus vaccine, hepatitis A, hepatitis B, and varicella vaccines. Reported vaccine completion rates, among those who initiated vaccination, ranged from 27% to over 90%. Minority racial or ethnic groups and inadequate health insurance coverage were risk factors for low completion, irrespective of initiation rates. Parental healthcare seeking behaviour was positively associated with completion. Vaccine delivery in schools was associated with higher completion than delivery in the community or health facilities. Gender, prior healthcare use and socio-economic status rarely remained significant risks or protective factors in multivariate analysis. CONCLUSIONS: Almost all studies investigating factors affecting completion have been carried out in developed countries and investigate a limited range of variables. Increased understanding of barriers to completion in adolescents will be invaluable to future new vaccine introductions and the further development of an adolescent health platform. PROSPERO reg# CRD42014006765.

Reporting vaccine complications: what do obstetricians and gynecologists know about the Vaccine Adverse Event Reporting System?

BACKGROUND: Obstetrician-gynecologists are increasingly called upon to be vaccinators as an essential part of a woman's primary and preventive health care. Despite the established safety of vaccines, vaccine adverse events may occur. A national Vaccine Adverse Event Reporting System (VAERS) is a well-established mechanism to track adverse events. However, we hypothesized that many obstetrician-gynecologists are naive to the role and use of VAERS. METHODS: We devised a ten-question survey to a sample of ACOG fellows to assess their knowledge and understanding of VAERS. We performed descriptive and frequency analysis for each of the questions and used one-way analysis of variance for continuous and chi-squared for categorical variables. RESULTS: Of the 1000 fellows who received the survey, 377 responded. Only one respondent answered all nine knowledge questions correctly, and 9.2% of physicians had used VAERS. Older physicians were less familiar with VAERS in general and with the specific objectives of VAERS in particular (χ(2) = 10.7, P = .005). CONCLUSIONS: Obstetrician-gynecologist familiarity with VAERS is lacking. Only when the obstetrician-gynecologist is completely knowledgeable regarding standard vaccine practices, including the availability and use of programs such as VAERS, will providers be functioning as competent and complete vaccinators.

Sexual assault victims: factors associated with follow-up care.

OBJECTIVE: This study was undertaken to describe patient, assault, and examination characteristics associated with compliance with follow-up in sexual assault victims. STUDY DESIGN: We conducted a retrospective cohort study of consecutive women presenting to an urban hospital after sexual assault over a 36-month period. We compared those who did and did not follow-up by using standardized history, examination, and data collection forms. RESULTS: Eight hundred twelve women met inclusion criteria; 288 (35.5%) attended follow-up. Young age (odds ratio [OR] = 2.70), assault at home (OR = 1.90), amnesia (OR = 1.80), alcohol use (OR = 1.55), genital trauma (OR = 1.55), and receipt of postexamination medications (OR = 1.87) were associated with greater follow-up; homelessness (OR = 0.30), psychiatric diagnosis (OR = 0.34), assault by an intimate partner (OR = 0.47), and cocaine use (OR = 0.29) with less. CONCLUSION: Although only 35.5% of sexual assault victims seek follow-up, we found many factors positively and negatively associated with this. These findings may inform care strategies designed to improve follow-up for women who are at risk for significant sequelae.

Factors impacting injury documentation after sexual assault: role of examiner experience and gender.

OBJECTIVE: This study was undertaken to determine whether physician gender or level of experience is associated with the prevalence of trauma documented in victims after sexual assault. STUDY DESIGN: All female patients 15 years or older reporting to an urban hospital with a complaint of sexual assault between January 1997 and September 1999 underwent a standardized history and physical examination by a second- or third-year resident in obstetrics and gynecology. Data were abstracted and verified. A chi(2) or Fisher exact test was used for categoric analysis. RESULTS: The overall prevalence of genital trauma was 21% in the 662 patients available for analysis. The prevalence of genital trauma documented by second- and third-year residents was 50 of 191 patients (26.2%) and 90 of 471 patients (19.1%), respectively (P=.04), despite similar assault characteristics between the 2 groups. The prevalence of genital trauma documented by male examiners (105/499 [21.0%]) and female examiners (35/160 [21.9%]) did not differ (P=.8). All examiners documented a similar prevalence of body trauma (52%). CONCLUSION: This study supports the hypothesis that the examiner's experience level may influence the prevalence of genital trauma documented after a sexual assault. Genital trauma documented was not associated with examiner gender in this study.

The antimicrobial treatment of subacute endometritis: a proof of concept study.

OBJECTIVE: Our purpose was to evaluate the antimicrobial therapy effect on clinical and laboratory findings among women at risk for endometritis. STUDY DESIGN: A prospective antimicrobial treatment trial of 153 women was performed to characterize subacute endometritis and to determine the treatment effect on endometritis resolution. RESULTS: After antimicrobial treatment, significant reductions occurred in abnormal bleeding (60% vs 29%), mucopurulent cervicitis (20% vs 6%), uterine tenderness (20% vs 6%), and histologic endometritis (38% vs 4%), all P<.001. In women with prior pelvic inflammatory disease (PID), endometritis was present in 43% with and 28% without current Chlamydia trachomatis or Neisseria gonorrhoeae. In women without prior PID, endometritis was present in 23% with and 12% without current C trachomatis or N gonorrhoeae (P=.002 for trend). CONCLUSIONS: In women without a clinical diagnosis of PID, antimicrobial therapy decreased abnormal clinical findings and histologic endometritis. Prior PID is additive with current cervical infection as a risk for endometritis.

Physical injury after sexual assault: findings of a large case series.

OBJECTIVE: This study was undertaken to determine characteristics associated with physical injury in female sexual assault victims. STUDY DESIGN: All females who were 15 years or older presenting after sexual assault to an urban emergency department during a 34-month period underwent standardized evaluation. Analysis was performed by chi(2) and logistic regression. RESULTS: Of 819 women, 52% had general body and 20% had genital-anal trauma; 41% were without injury. General body trauma was independently associated with being hit or kicked (odds ratio [OR]=7.7, 95% CI, 5.1-11.7), attempted strangulation (OR=4.2, 95% CI, 2.5-7.2), oral or anal penetration (OR=1.7, 95% CI, 1.2-2.3), and stranger (OR=2.4, 95% CI, 1.7-3.4) assault. Genital-anal injury was more frequent in victims younger than 20 and older than 49 years (P<.05), in virgins (OR=2.7, 95% CI, 1.4-5.4) and those examined within 24 hours (OR=1.7, 95% CI, 1.2-2.4) and after anal assault (OR=1.7, 95% CI, 1.1-2.6). CONCLUSION: General body injury is primarily associated with situational factors, whereas genital-anal injury is less frequent and related to victim age, virginal status, and time to examination.

Histologic endometritis in asymptomatic human immunodeficiency virus-infected women: characterization and effect of antimicrobial therapy.

OBJECTIVE: To estimate the prevalence, risk factors, clinical symptoms and signs, and response to antimicrobial therapy of histologic endometritis in human immunodeficiency virus (HIV)-infected women without clinical salpingitis. METHODS: This was a cross-sectional study of 42 HIV-infected women enrolled from a single clinic. Subjects underwent standardized history, examination, and laboratory determinations, including endometrial biopsy. Women with suspected pelvic inflammatory disease were excluded. All women were given antibiotics and repeat evaluation in 5-7 weeks. Histologic endometritis was defined by at least one stromal plasma cell per 120x field and five or more surface polymorphonuclear leukocytes per 400x field. Chi-square and Fisher exact tests were used as appropriate. RESULTS: Histologic endometritis was present among 16 (38%) of 42 evaluable HIV-infected women, none of whom had Chlamydia trachomatis or Neisseria gonorrhoeae. Douching three or more times per month, history of ectopic pregnancy, and two or more prior urinary tract infections were associated with endometritis, as was elevated erythrocyte sedimentation rate (P < or = .05). Physical examination findings and mean CD4+ lymphocyte count were similar among those with and without endometritis. In the nine HIV-infected women with a repeat biopsy, endometritis decreased from four (44%) to two (22%) after treatment (P = .30). CONCLUSION: The prevalence of histologic endometritis in HIV-infected women was high despite few examination findings and no demonstrated pathogens. Endometritis in HIV-infected women might be related to pathogens not evaluated, to prior infection, or to reduced immunity from HIV.

Abdominal pregnancy with lithopedion formation presenting as a pelvic abscess.

BACKGROUND: Abdominal pregnancy with lithopedion formation is rare and its presentation as a pelvic abscess has not been reported. CASE: A 38-year-old, gravida 1, para 0, presented with signs and symptoms of a pelvic abscess, which turned out to be a lithopedion from a 16-week abdominal pregnancy that had been terminated by a potassium chloride injection 2 years earlier. Intravenous antibiotics were followed by surgical removal of the lithopedion. CONCLUSION: Pelvic abscess is an added complication of a lithopedion. Surgical removal to prevent such complications can be considered, balanced against the high operative risks.

Quantitative Chlamydia trachomatis cultures: correlation of chlamydial inclusion-forming units with serovar, age, sex, and race.

The number of inclusion-forming units (IFUs) observed in quantitative chlamydial cultures may be a surrogate for infectivity or transmissibility. Therefore, we conducted a cross-sectional study of 11,034 patients with Chlamydia trachomatis infection who presented to the Seattle-King County public health department clinics between 1988 and 1996, to determine relationships between the number of IFUs observed in culture and sex, age, race, and serovar class. Of the 11,034 cases of infection we studied, 6801 (62%) were cervical infections in women, and 4233 (38%) were urethral infections in men. The median count was 450 IFU for women and 72 IFU for men (P<.001). Overall, both men and women infected with B-class serovars had significantly higher IFU counts than did those infected with C-class serovars (P<.001). The median IFU count fell consistently with increasing age for both women (625 IFU for those <16 years old to 185 IFU for those >30 years old; P<.001) and men (210 IFU for those <16 years old to 40.5 IFU for those >30 years old; P<.001). We found, by use of multiple regression analysis, that sex, age, race, and serovar class remained independently related to IFU count, with counts being highest among young white women infected with B-class serovars.

Risk factors for urinary tract infection in the postpartum period.

OBJECTIVE: We sought to examine risk factors for urinary tract infection in postpartum women. STUDY DESIGN: Subjects (n = 931) with maternal urinary tract infections and control subjects (n = 1862) were identified by using a linked Washington State birth certificate and Birth Events Records Database for the years 1987-1993; stratified analysis was performed by using Mantel-Haenszel procedures. RESULTS: Increased risk for postpartum urinary tract infection was associated with black, Native American, or Hispanic race-ethnicity (odds ratio, 1.30; 95% confidence interval, 1.03-1.64) and unmarried status (odds ratio, 1.33; 95% confidence interval, 1.11-1.58). Cesarean delivery (odds ratio, 2.70; 95% confidence interval, 2.27-3.20) and tocolysis (odds ratio, 3.30; 95% confidence interval, 2.15-5.06) also contributed to maternal risk of acquiring a urinary tract infection. Maternal risk factors included renal disease (adjusted odds ratio, 3.89; 95% confidence interval, 1.80-8.41) and preeclampsia-eclampsia (adjusted odds ratio, 3.21; 95% confidence interval, 2.36-4.38). Among women undergoing vaginal delivery, renal disease (odds ratio, 5.47; 95% confidence interval, 2.04-14.64) and abruptio placentae (odds ratio, 5.02; 95% confidence interval, 1.84-13.64) were risk factors. Length of hospital stay was significantly associated with urinary tract infection. CONCLUSION: Maternal medical conditions and procedures that predispose to urinary tract infections are those that also are associated with urethral catheterization. In addition, maternal urinary tract infections may contribute significantly to duration of postpartum hospital stay.

A matched prospective study of human immunodeficiency virus serostatus, human papillomavirus DNA, and cervical lesions detected by cytology and colposcopy.

OBJECTIVE: To compare the prevalence and type of human papillomavirus (HPV) infections in the genital tract of human-immunodeficiency-virus- (HIV) seropositive and -seronegative women matched for cytology and to examine prospectively the relationship of HPV DNA, colposcopic findings and cervical squamous intraepithelial lesions (SIL) in these matched seropositive and seronegative cohorts. METHODS: A matched prospective study of HIV-seropositive and -seronegative women undergoing cytologic screening, colposcopy, and testing for HPV DNA and other infections at each visit. RESULTS: Twenty-three HIV-seropositive women were matched with 23 seronegative women by cervical cytology reading, lifetime number of sexual partners, age, and follow-up length. Fourteen pairs of these women had follow-up visits every 4 months, for 56 and 53 total visits in seropositive and seronegative women, respectively. After matching, the groups had a similar overall prevalence of HPV DNA and of HPV oncogenic (high risk) types at baseline. On follow up, HIV-seropositive women were more likely than seronegative women to develop SIL (38% vs. 10%), less likely to have negative cytology (34% vs. 60%, overall P = 0.03), more visits with HPV DNA detected (68% vs. 40% P = 0.04), and more visits with multiple HPV DNA types detected (18% vs. 0%, P = 0.02). Colposcopic lesions in the seropositive women were more likely to have sharp borders or mosaicism or to be thick white (P = 0.009). CONCLUSIONS: After matching for baseline Papanicolaou smear readings, these data suggest that over time seropositive women have more visits that yield abnormal cytology, more persistent HPV DNA detection, and more colposcopic abnormalities than seronegative women.

Vulvovaginal candidiasis: clinical manifestations, risk factors, management algorithm.

OBJECTIVE: To correlate symptoms, signs, and risk factors with positive wet mounts or cultures for Candida albicans and to develop an algorithm to diagnose vulvovaginal candidiasis. METHODS: This cross-sectional study of 774 randomly selected women from an urban sexually transmitted disease (STD) clinic evaluated symptoms, signs, and risk factors associated with C albicans, detected by wet mount and culture, and constructed an algorithm. RESULTS: C albicans, recovered from 186 (24%) of the 774 women, was associated with chief complaints of vulvar pruritus or burning. Elicited symptoms were vulvar pruritus, pain or burning, and external dysuria; signs were vulvar erythema, edema, fissures, vaginal erythema, and thick, curdy vaginal discharge. Among 545 women with symptoms of either increased vaginal discharge or vulvar pruritus or burning, only 155 (28%) had positive C albicans cultures, whereas bacterial vaginosis or other sexually transmitted infections were found in 288 (53%). In multivariate analysis, risk factors for positive C albicans culture included condom use, presentation after the 14th menstrual cycle day, sexual intercourse more than four times per month, recent antibiotic use, young age, past gonococcal infection, and absence of current gonorrhea or bacterial vaginosis. A clinical algorithm based on symptoms, signs, and selective use of wet mounts and cultures would have provided prompt treatment to 150 of 167 (90%) women with vulvovaginal candidiasis while minimizing the number of cultures performed. CONCLUSION: A simple algorithm using symptoms, signs, wet mounts, and selective cultures can identify 90% of women with vulvovaginal candidiasis. In this STD clinic, vulvovaginal symptoms also require assessment for bacterial vaginosis, trichomoniasis, and cervical infection.

Prevalence and correlates of antibody to chlamydial heat shock protein in women attending sexually transmitted disease clinics and women with confirmed pelvic inflammatory disease.

A cross-sectional study of 306 women was done to correlate antibody to the chlamydial hsp60 (Chsp60) with epidemiologic, serologic, and laparoscopic findings of women with and without pelvic inflammatory disease (PID). Of the 306 women, 150 had confirmed PID by laparoscopic (n = 69) or histologic (n = 81) criteria, and 156 sexually transmitted disease clinic attendees without clinical PID did (n = 94) or did not (n = 62) have chlamydia. In multivariate analyses, Chsp60 antibody was independently associated with confirmed PID, age > 20 years, nonwhite race, > 10 lifetime sex partners, current oral contraceptive use, and IgG antibody titers; it was not associated with a positive Chlamydia trachomatis culture. Among the 69 women with laparoscopic evidence of PID, the highest level of Chsp60 antibody (optical density > 1.0) was found in 8 (80%) of 10 women with occluded tubes, compared with 11 (19%) of 58 with patent tubes (P < .001). We conclude that antibody to Chsp60 was significantly correlated with risk factors for PID, confirmed PID, and occluded fallopian tubes but not with acute C. trachomatis infection without PID.

The inflammatory Papanicolaou smear: what does it mean?

OBJECTIVE: To determine the correlation between inflammation detected on Papanicolaou smear and specific lower genital tract agents, and, based on these findings, to develop recommendations for follow-up tests and treatment of young women with inflammation on smears. METHODS: A high-risk population of 779 randomly selected women attending a sexually transmitted disease (STD) clinic and a low-risk population of 1050 consecutive women presenting for annual examination at a university student health center underwent a standardized history and gynecologic examination. Univariate and multivariate analyses, focusing on the association between dense inflammation on Papanicolaou smear and specific lower genital tract pathogens or findings on cervical examination, were done for each population. RESULTS: Dense inflammation was present on the Papanicolaou smear of 256 (33%) of the 779 women in the STD clinic and 200 (19%) of 1050 students. Dense inflammation on Papanicolaou smear was independently associated with mucopus, cervical ectopy, cervical infection with Neisseria gonorrhoeae, Chlamydia trachomatis, herpes simplex virus (HSV), and vaginal infection by Trichomonas vaginalis in the STD population; in the student population, it was associated with cervical ectopy, C trachomatis, and mucopus. CONCLUSION: Although dense inflammation on Papanicolaou smear was a common finding in both the high- and low-risk populations, about half of the inflammation detected in the high-risk setting was associated with a specific microbial organism (C trachomatis, N gonorrhoeae, HSV, or T vaginalis), whereas less than 10% of the dense inflammation detected in the low-risk setting was linked with a specific pathogen (C trachomatis). In both settings, a substantial population of sexually active women had dense inflammation associated with cervical ectopy but none of the specific organisms evaluated in this study.

Epidural analgesia and cesarean section for dystocia: risk factors in nulliparas.

A retrospective study assessing the effect of epidural analgesia in labor on the incidence of cesarean section was performed. The first 500 consecutive nulliparas meeting the following criteria were included in this study: term (37 weeks or longer) and singleton gestation, cephalic presentation, spontaneous onset of labor, and 5 cm or less of cervical dilation on admission. Patients were grouped according to their rate of cervical dilation in early labor (greater than or equal to 1 cm/hr, and less than 1 cm/hr) and the timing of epidural placement (none, early, or late). There was no effect of epidural analgesia on the incidence of cesarean section for fetal distress. The incidence of cesarean section for dystocia was significantly greater (p greater than 0.000001) in the epidural group (15.6%) than in the nonepidural group (2.4%). The greatest effect of epidural analgesia on the incidence of cesarean section for dystocia was observed in nulliparas who dilated at slower rates (less than 1 cm/hr) in early labor and who had epidural analgesia placed at 5 cm or less of cervical dilation (20.6% versus 3.4%, relative risk of 6, p less than 0.0005). The increase of cesarean section for dystocia associated with epidural analgesia could not be accounted for when other possibly confounding variables were studied. Both the dilation rate prior to epidural placement and the cervical dilation at epidural placement were significantly correlated to frequency of cesarean section for dystocia (p less than 0.01). This study suggests that epidural analgesia in labor may increase the incidence of cesarean section for dystocia in nulliparas.