Chlamydia Retesting Among Safety-Net Clinic Patients: Infertility Prevention Project.

BACKGROUND: Due to high reinfection rates, the Centers for Disease Control and Prevention (CDC) recommend retesting everyone diagnosed with chlamydia after treatment. However, retesting rates are often low, and research on retesting is limited. METHODS: Infertility Prevention Project (IPP) was a national chlamydia screening and treatment project in the United States. We completed a retrospective longitudinal analysis using IPP testing data from 8,266 women with at least 1 positive test result from 2010 to 2013. We calculated the proportion of women retested 2-12 months after a chlamydia diagnosis and used Cox proportional hazards models to explore associated factors. RESULTS: Only 32% of women had evidence of retesting by 12 months of follow-up. Being younger (multivariate hazard ratio [mHR]: 0.96; 95% confidence interval [CI]: 0.95-0.96), black (mHR: 1.29; 95% CI: 1.12-1.50), or attending a county sexually transmitted diseases (STD; mHR: 1.91; 95% CI: 1.68-2.17), county family planning (mHR: 1.53; 95% CI: 1.39-1.69), or school-based (mHR: 2.34; 95% CI: 2.07-2.65) clinic relative to a nonprofit community health clinic were associated with increased retesting rates. CONCLUSIONS: Less than one-third of women are retested. Our results show that some clinic settings may have systematic differences which facilitate retesting, such as use of automated reminders, closed patient populations, and makeup of patient populations. Investigation of clinical environments through site visits and further data analyses may be keys to improving retesting rates.

Surveillance of Extrapulmonary Nontuberculous Mycobacteria Infections, Oregon, USA, 2007-2012.

Limited data are available describing extrapulmonary nontuberculous mycobacteria (NTM) infections in the general population. We describe results from statewide population-based laboratory surveillance in Oregon, USA, during 2007-2012. We defined a case of extrapulmonary NTM infection as >1 isolate from skin/soft tissue, disseminated sites, lymph node, joint, or other sites. The annual incidence of extrapulmonary NTM infection (other than Mycobacterium gordonae) was stable, averaging 1.5 cases/100,000 population. Median age of the 334 patients was 51 years, and 53% of patients were female. Half of cases were caused by M. avium complex, but rapid-growing NTM species accounted for one third of cases. Most extrapulmonary NTM infections are skin/soft tissue. Compared with pulmonary NTM infection, more extrapulmonary infections are caused by rapid-growing NTM species. the designation of NTM as a reportable disease in Oregon in 2014 will result in better detection of changes in the incidence and patterns of disease in the future.

Mortality after Respiratory Isolation of Nontuberculous Mycobacteria. A Comparison of Patients Who Did and Did Not Meet Disease Criteria.

RATIONALE: The mortality of patients with respiratory tract isolates of nontuberculous mycobacteria (NTM) and their risk factors for death are not well described. OBJECTIVES: To determine age-adjusted mortality rates for patients with respiratory NTM isolates and their causes of death and to examine whether American Thoracic Society/Infectious Diseases Society of America (ATS/IDSA) diagnostic criteria identify those at higher risk of death after NTM isolation. METHODS: We linked vital records registries with a previously identified Oregon population-based cohort of patients with NTM respiratory isolation. We excluded patients with Mycobacterium gordonae (n = 33) and those who died (n = 21) at the time of first isolation. We calculated 5-year age-adjusted mortality rates. We used Kaplan-Meier and Cox proportional hazards analysis to examine the association of ATS/IDSA criteria and other risk factors with death. RESULTS: Of 368 subjects with respiratory NTM isolates in 2005-2006, 316 were included in the survival analysis. Most (84%) of their cultures isolated Mycobacterium avium complex. 35.1% died in the 5 years following respiratory isolation. Five-year age-adjusted mortality rates were slightly higher for those meeting (28.7/1,000) versus not meeting (23.4/1,000) ATS/IDSA criteria. In multivariate analysis, older age (adjusted hazard ratio [aHR], 1.06; 95% confidence interval [CI], 1.04-1.07) and lung cancer (aHR, 2.77; 95% CI, 1.51-5.07) were associated with an increased risk of death. A trend was noted between meeting ATS/IDSA criteria and subsequent death (aHR, 1.37; 95% CI, 0.95-1.97). Among cases, male sex, older age, and immunosuppressive therapy use were independent risk factors for death. CONCLUSIONS: In the State of Oregon, patients with NTM respiratory isolates have high mortality, regardless of whether they meet ATS/IDSA criteria for pulmonary NTM disease. Most patients die as a result of causes other than NTM infection.

Disseminated Nontuberculous Mycobacteria in HIV-Infected Patients, Oregon, USA, 2007-2012.

We determined disseminated nontuberculous mycobacteria incidence in the HIV-infected population of Oregon, USA, during 2007-2012 by using statewide laboratory surveillance. We identified 37 disseminated nontuberculous mycobacteria cases among 7,349 patients with median annual incidence of 110/100,000 HIV person-years and the highest incidence in those with CD4 counts <50 cells/mm3 (5,300/100,000 person-years).

"Out of Care" HIV Case Investigations: A Collaborative Analysis Across 6 States in the Northwest US.

BACKGROUND: HIV care continuum estimates derived from laboratory surveillance typically assume that persons without recently reported CD4 count or viral load results are out of care. METHODS: We conducted a multistate project (Alaska, Idaho, Montana, Oregon, Washington, and Wyoming) to ascertain the status of HIV cases that appeared to be out of care during a 12-month period. We used laboratory surveillance to identify cases in all states but Idaho, where viral load reporting is not mandatory, requiring us to rely on clinic records. After complete investigation, we assigned each case one of the following dispositions: moved out of state, died, in HIV care, no evidence of HIV care, or data error. RESULTS: We identified 3866 cases with no CD4 count or viral load result in a ≥12-month period during 2012-2014, most (85%) of which were in Washington or Oregon. A median of 43% (range: 20%-67%) of cases investigated in each state had moved, 9% (0%-16%) had died, and 11% (8%-33%) were in care during the 12-month surveillance period. Only 28% of investigated cases in the region and a median of 30% (10%-57%) of investigated cases in each state had no evidence of care, migration, or death after investigation. CONCLUSIONS: Most persons living with HIV in the Northwest United States who appear to be out of care based on laboratory surveillance are not truly out of care. Our findings highlight the importance of improving state surveillance systems to ensure accurate care continuum estimates and guide Data to Care efforts.

On the Reportability of Nontuberculous Mycobacterial Disease to Public Health Authorities.

Nontuberculous mycobacteria (NTM) are environmental pathogens that are an increasingly common cause of pulmonary and extrapulmonary disease. Electronic laboratory-based reporting is a straightforward mechanism for identifying NTM infections and for monitoring trends in disease. Oregon was the first state to make NTM reportable, although at this time the reporting requirement is limited to extrapulmonary infection. This has assisted authorities in detecting outbreaks and healthcare-related infections. However, further consideration should be given to the reportability of pulmonary NTM disease. Pulmonary NTM disease is more common than tuberculosis in the United States and is of emerging public health concern. Although the direct public health action that would be triggered by a pulmonary NTM disease report is not clear, without surveillance, public health is missing an opportunity to better understand pulmonary NTM disease trends and reasons for its increasing recognition within our population. We believe state health authorities should conduct surveillance for pulmonary NTM, either by mandating reporting of laboratory isolates or by other mechanisms as we have done in Oregon.

Early Syphilis Among Men Who Have Sex with Men in the US Pacific Northwest, 2008-2013: Clinical Management and Implications for Prevention.

Substantial increases in syphilis during 2008-2013 were reported in the US Pacific Northwest state of Oregon, especially among men who have sex with men (MSM). The authors aimed to characterize the ongoing epidemic and identify possible gaps in clinical management of early syphilis (primary, secondary, and latent syphilis ≤1 year) among MSM in Multnomah County, Oregon to inform public health efforts. Administrative databases were used to examine trends in case characteristics during 2008-2013. Medical records were abstracted for cases occurring in 2013 to assess diagnosis, treatment, and screening practices. Early syphilis among MSM increased from 21 cases in 2008 to 229 in 2013. The majority of cases occurred in HIV-infected patients (range: 55.6%-69.2%) diagnosed with secondary syphilis (range: 36.2%-52.4%). In 2013, 119 (51.9%) cases were diagnosed in public sector medical settings and 110 (48.0%) in private sector settings. Over 80% of HIV-infected patients with syphilis were in HIV care. Although treatment was adequate and timely among all providers, management differed by provider type. Among HIV-infected patients, a larger proportion diagnosed by public HIV providers than private providers were tested for syphilis at least once in the previous 12 months (89.6% vs. 40.0%; p < 0.001). The characteristics of MSM diagnosed with early syphilis in Multnomah County remained largely unchanged during 2008-2013. Syphilis control measures were well established, but early syphilis among MSM continued to increase. The results suggest a need to improve syphilis screening among private clinics, but few gaps in clinical management were identified.

A case-control study evaluating the role of internet meet-up sites and mobile telephone applications in influencing a syphilis outbreak: Multnomah County, Oregon, USA 2014.

OBJECTIVES: Early syphilis in Multnomah County, Oregon, USA, increased 16-fold during 2007-2013. Cases predominantly occurred among men who have sex with men (MSM); 55% were HIV coinfected. We conducted a case-control study to evaluate the association between meeting sex partners online and early syphilis. METHODS: Cases subjects (cases) were Multnomah County resident, English speaking, MSM, aged ≥18 years with laboratory-confirmed early syphilis reported 1 January to 31 December 2013. We recruited two MSM controls subjects (controls) per case, frequency matched by HIV status and age. Participants completed self-administered questionnaires. We performed multivariable logistic regression. RESULTS: Seventy per cent (40/57) of cases and 42% (50/119) of controls met partners online (p<0.001). Cases more frequently met partners online (adjusted OR (aOR)=3.0; 95% CI 1.2 to 6.7), controlling for presumptive confounders. Cases reported more partners than controls (medians 5, 2; p<0.001). When including number of partners, aOR decreased to 1.4 (95% CI 0.5 to 3.9). CONCLUSIONS: Early syphilis was associated with meeting partners online. We believe this association may be related to number of sex partners acting as an intermediate variable between use of online resources to meet sex partners and early syphilis. Online meet-up sites might represent areas for public health interventions targeting at-risk individuals.

Use of claims data to estimate annual cervical cancer screening percentages in Portland metropolitan area, Oregon.

BACKGROUND: Human papillomavirus (HPV) vaccine should reduce cervical dysplasia before cervical cancer. However, dysplasia diagnosis is screening-dependent. Accurate screening estimates are needed. PURPOSE: To estimate the percentage of women in a geographic population that has had cervical cancer screening. METHODS: We analyzed claims data for (Papanicolau) Pap tests from 2008-2012 to estimate the percentage of insured women aged 18-39 years screened. We estimated screening in uninsured women by dividing the percentage of insured Behavioral Risk Factor Surveillance Survey respondents reporting previous-year testing by the percentage of uninsured respondents reporting previous-year testing, and multiplying this ratio by claims-based estimates of insured women with previous-year screening. We calculated a simple weighted average of the two estimates to estimate overall screening percentage. We estimated credible intervals using Monte-Carlo simulations. RESULTS: During 2008-2012, an annual average of 29.6% of women aged 18-39 years were screened. Screening increased from 2008 to 2009 in all age groups. During 2009-2012, the screening percentages decreased for all groups, but declined most in women aged 18-20 years, from 21.5% to 5.4%. Within age groups, compared to 2009, credible intervals did not overlap during 2011 (except age group 21-29 years) and 2012, and credible intervals in the 18-20 year group did not overlap with older groups in any year. CONCLUSIONS: This introduces a novel method to estimate population-level cervical cancer screening. Overall, percentage of women screened in Portland, Oregon fell following changes in screening recommendations released in 2009 and later modified in 2012.

Monitoring Effect of Human Papillomavirus Vaccines in US Population, Emerging Infections Program, 2008-2012.

In 2007, five Emerging Infections Program (EIP) sites were funded to determine the feasibility of establishing a population-based surveillance system for monitoring the effect of human papillomavirus (HPV) vaccine on pre-invasive cervical lesions. The project involved active population-based surveillance of cervical intraepithelial neoplasia grades 2 and 3 and adenocarcinoma in situ as well as associated HPV types in women >18 years of age residing in defined catchment areas; collecting relevant clinical information and detailed HPV vaccination histories for women 18-39 years of age; and estimating the annual rate of cervical cancer screening among the catchment area population. The first few years of the project provided key information, including data on HPV type distribution, before expected effect of vaccine introduction. The project's success exemplifies the flexibility of EIP's network to expand core activities to include emerging surveillance needs beyond acute infectious diseases. Project results contribute key information regarding the impact of HPV vaccination in the United States.

Population-based trends in high-grade cervical lesions in the early human papillomavirus vaccine era in the United States.

BACKGROUND: Cervical intraepithelial neoplasia grade 2, 3, and adenocarcinoma in situ (CIN2+) lesions can be monitored as early indicators of human papillomavirus (HPV) vaccine impact. Changes to screening utilization will affect observed reductions in CIN2+ rates and complicate the interpretation of vaccine impact. METHODS: From 2008 to 2012, 9119 cases of CIN2+ among 18- to 39-year-old residents of catchment areas in California, Connecticut, New York, and Oregon were reported to the HPV-IMPACT Project, a sentinel system for monitoring the population impact of HPV vaccine. Age-stratified CIN2+ incidence rates were calculated for each catchment. Annual cervical screening was estimated for California, New York, and Oregon catchments with administrative and survey data. The Cochran-Armitage test was used to examine trends. RESULTS: From 2008 to 2012, the incidence of CIN2+ significantly decreased among 18- to 20-year-olds (California, from 94 to 5 per 100,000 women; Connecticut, from 450 to 57 per 100,000 women; New York, from 299 to 43 per 100,000 women; and Oregon, from 202 to 37 per 100,000 women; Ptrend < .0001) and among 21- to 29-year-olds in Connecticut (from 762 to 589 per 100,000 women) and New York (from 770 to 465 per 100,000 women; Ptrend < .001); rates did not differ among 30- to 39-year-olds. During the same period, screening rates also declined, with the largest decreases among 18- to 20-year-olds (from 67% in Oregon to 88% in California) and with smaller declines among 21- to 29-year-olds (13%-27%) and 30- to 39-year-olds (3%-21%). CONCLUSIONS: The declines in CIN2+ detection in young women were likely due to reduced screening but could also reflect the impact of vaccination. These data illustrate challenges in interpreting CIN2+ ecologic trends in the new era of cervical cancer prevention and emphasize the importance of information such as HPV types detected in lesions to assess the impact of HPV vaccine on cervical precancers.

Reduction in HPV 16/18-associated high grade cervical lesions following HPV vaccine introduction in the United States - 2008-2012.

BACKGROUND: Prevention of pre-invasive cervical lesions is an important benefit of HPV vaccines, but demonstrating impact on these lesions is impeded by changes in cervical cancer screening. Monitoring vaccine-types associated with lesions can help distinguish vaccine impact from screening effects. We examined trends in prevalence of HPV 16/18 types detected in cervical intraepithelial neoplasia 2, 3, and adenocarcinoma in situ (CIN2+) among women diagnosed with CIN2+ from 2008 to 2012 by vaccination status. We estimated vaccine effectiveness against HPV 16/18-attributable CIN2+ among women who received ≥1 dose by increasing time intervals between date of first vaccination and the screening test that led to detection of CIN2+ lesion. METHODS: Data are from a population-based sentinel surveillance system to monitor HPV vaccine impact on type-specific CIN2+ among adult female residents of five catchment areas in California, Connecticut, New York, Oregon, and Tennessee. Vaccination and cervical cancer screening information was retrieved. Archived diagnostic specimens were obtained from reporting laboratories for HPV DNA typing. RESULTS: From 2008 to 2012, prevalence of HPV 16/18 in CIN2+ lesions statistically significantly decreased from 53.6% to 28.4% among women who received at least one dose (Ptrend<.001) but not among unvaccinated women (57.1% vs 52.5%; Ptrend=.08) or women with unknown vaccination status (55.0% vs 50.5%; Ptrend=.71). Estimated vaccine effectiveness for prevention of HPV 16/18-attributable CIN2+ was 21% (95% CI: 1-37), 49% (95% CI: 28-64), and 72% (95% CI: 45-86) in women who initiated vaccination 25-36 months, 37-48 months, and >48 months prior to the screening test that led to CIN2+ diagnosis. CONCLUSIONS: Population-based data from the United States indicate significant reductions in CIN2+ lesions attributable to types targeted by the vaccines and increasing HPV vaccine effectiveness with increasing interval between first vaccination and earliest detection of cervical disease.

Population-based Incidence of Pulmonary Nontuberculous Mycobacterial Disease in Oregon 2007 to 2012.

RATIONALE: Pulmonary nontuberculous mycobacteria (NTM) disease is a chronic, nonreportable illness, making it difficult to monitor. Although recent studies suggest an increasing prevalence of NTM disease in the United States, the incidence and temporal trends are unknown. OBJECTIVES: To describe incident cases and calculate the incidence and temporal trends of pulmonary NTM disease in Oregon. METHODS: We contacted all laboratories performing mycobacterial cultures on Oregon residents and collected demographic and specimen information for patients with NTM isolated during 2007 to 2012. We defined a case of pulmonary NTM disease using the 2007 American Thoracic Society/Infectious Disease Society of America microbiologic criteria. We used similar state-wide mycobacterial laboratory data from 2005 to 2006 to exclude prevalent cases from our calculations. We calculated annual pulmonary NTM disease incidence within Oregon during 2007 to 2012, described cases demographically and microbiologically, and evaluated incidence trends over time using a Poisson model. MEASUREMENTS AND MAIN RESULTS: We identified 1,146 incident pulmonary NTM cases in Oregon residents from 2007 to 2012. The median age was 69 years (range, 0.9-97 yr). Cases were more likely female (56%), but among patients less than 60 years old, disease was more common in male subjects (54%). Most (86%) were Mycobacterium avium/intracellulare cases; 68 (6%) were Mycobacterium abscessus/chelonae cases. Although not statistically significant, incidence increased from 4.8/100,000 in 2007 to 5.6/100,000 in 2012 (P for trend, 0.21). Incidence increased with age, to more than 25/100,000 in patients 80 years of age or older. CONCLUSIONS: This is the first population-based estimate of pulmonary NTM disease incidence in a region within the United States. In Oregon, disease incidence rose slightly during 2007 to 2012, and although more common in female individuals overall, disease was more common among male individuals less than 60 years of age.

HPV type attribution in high-grade cervical lesions: assessing the potential benefits of vaccines in a population-based evaluation in the United States.

BACKGROUND: Two currently available vaccines targeting human papillomavirus (HPV) types 16 and 18 could prevent 70% of cervical cancers and 50% of high-grade cervical lesions. Next-generation vaccines against additional types, such as a candidate 9-valent vaccine against HPV6/11/16/18/31/33/45/52/58, could further reduce HPV-associated disease burden. METHODS: HPV was typed in archived tissues from women ages 21 to 39 years residing in five catchment areas in the United States with cervical intraepithelial neoplasia 2/3 and adenocarcinoma in situ (CIN2+) using L1 consensus PCR and type-specific hybridization. Type attribution was estimated using weights to account for lesions with multiple types detected. RESULTS: From 2008 to 2011, 5,498 of 6,306 (87.2%) specimens obtained from 8,469 women with CIN2+ had valid typing results; HPV DNA was detected in 97.3%. Overall, 50.1% of lesions were attributable to HPV16/18, ranging from 50.3% to 52.4% among those ages 21 to 34 years, and significantly declined in 35 to 39 year-olds (43.5%). HPV16/18 attribution was higher in non-Hispanic whites (56.4%) versus racial/ethnic minorities (range, 41.8%-45.9%; P < 0.001). HPV31/33/45/52/58 attribution was 25.0% overall and increased with age (P < 0.001). A higher proportion of CIN2+ was attributable to HPV31/33/45/52/58 in non-Hispanic black (29.9%), Hispanic (29.2%), and Asian (33.1%) women compared with non-Hispanic whites (22.8%; P < 0.001). CONCLUSIONS: Overall, 75% of lesions were attributable to 7 oncogenic HPV types: 50% to HPV16/18 and 25% to HPV31/33/45/52/58. HPV16/18 had the largest attributable fraction in CIN2+ across all subpopulations, although to a lesser extent in older women and racial/ethnic minorities. IMPACT: Vaccines targeting additional oncogenic HPV types could prevent more high-grade cervical lesions, especially among racial/ethnic minorities.

Monitoring retention in care: using multiple laboratory tests as an indicator for HIV medical care.

Retention in care is an important strategy for HIV prevention. Unfortunately, surveillance systems were not designed to capture face-to-face visits with HIV health care providers to assess retention in care. Instead, HIV-related laboratory tests are used as a surrogate measure. This study estimated the sensitivity (90%) and specificity (28%) of two HIV-related laboratory tests separated by at least 90 days for two face-to-face visits among people receiving HIV-related health care in Oregon. Overall accuracy of the surrogate was good but slightly overestimated the proportion of people living with HIV/AIDS actually retained in care.

Hepatitis C treatment eligibility among HIV-hepatitis C virus coinfected patients in Oregon: a population-based sample.

Approximately 287,000 individuals in the USA are coinfected with HIV and hepatitis C. Recently, new hepatitis C regimens have become available, increasing rates of sustained virologic response in the monoinfected, with studies evaluating their success in the coinfected under way. Previous investigators estimated eligibility for hepatitis C therapy among the coinfected patients, but all had significant methodological limitations. Our study is the first to use a multi-year, statewide, population-based sample to estimate treatment eligibility, and the first to estimate eligibility in the setting of an interferon-free regimen. In a population-based sample of 161 patients infected with HIV and hepatitis C living in Oregon during 2007-2010, 21% were eligible for hepatitis C therapy. Despite the anticipation surrounding an interferon-sparing regimen, eligibility assuming an interferon-free regimen increased only to 26%, largely due to multiple simultaneous contraindications. Obesity was described for the first time as being associated with decreased eligibility (OR: 0.11). Active alcohol abuse was the most common contraindication (24%); uncontrolled mental health (22%), recent injection drug use (21%), poor antiretroviral adherence (22%), and infection (21%) were also common excluding conditions. When active drug or alcohol abuse was excluded as contraindications to therapy, the eligibility rate was 34%, a 62% increase. Assuming an interferon-free regimen and the exclusion of active drug or alcohol abuse as contraindications to therapy, the eligibility rate increased to 42%. Despite the availability of direct-acting anti-viral regimens, eligibility rates in HIV-hepatitis C virus (HCV) coinfection are modest. Many factors precluding hepatitis C therapy are reversible, and targeted interventions could result in increased eligibility.

Oregon patients with HIV infection who experience delayed diagnosis.

This project sought to understand factors contributing to the delayed diagnosis of HIV in the state of Oregon, USA in order to increase timely testing and diagnosis. People unaware of their positive HIV status account for a disproportionate number of transmissions of HIV, making delayed diagnosis a profound public health concern. We interviewed a sample of 17 adults, diverse in age, reported risk behaviors and sexual orientation, who were identified as being diagnosed late, about their experiences with testing and diagnosis. We defined delayed diagnosis as a diagnosis of AIDS within 12 months of the first positive HIV test. We conducted thematic analysis using NVivo® software for data management. Three overarching themes emerged: risk perception, missed opportunities for diagnosis, routine testing and the role of the medical community. Definitions of these themes, corresponding sub-themes, and illustrious quotations provide an informative description of characteristics of late testers, factors contributing to delayed diagnosis, and potential points of intervention to increase regular and timely testing. We conclude that routine HIV screening as part of regular medical care might significantly reduce the number of delayed diagnoses and minimize the stigma of testing by normalizing it as part of routine medical care. Earlier diagnosis of HIV will result in better outcomes for individual patients and lower rates of HIV transmission by unknowing individuals.

Mycobacterium chelonae facial infections following injection of dermal filler.

UNLABELLED: A cluster of 3 facial Mycobacterium chelonae infections occurred after cosmetic dermal filler injections at a plastic surgery clinic. Pulsed-field gel electrophoresis showed that M chelonae isolated from the clinic tap water were identical to the patient wound isolates. Review of injection procedures identified application of nonsterile ice to the skin prior to injection as a possible source of M chelonae. Surveys of regional laboratories and a national plastic surgery listserv identified no other cases related to the injection of this brand of dermal filler. This is the first report of cutaneous M chelonae infections following the injection of dermal fillers. It adds to a growing body of literature on postinjection M chelonae infections and reinforces the importance of optimal skin disinfection steps prior to percutaneous procedures. LEVEL OF EVIDENCE: 5.

Impact of human papillomavirus (HPV) vaccination on HPV 16/18-related prevalence in precancerous cervical lesions.

BACKGROUND: Vaccination against human papillomavirus (HPV) types 16 and 18 is recommended for girls aged 11 or 12 years with catch-up vaccination through age 26 in the U.S. Cervical intraepithelial neoplasia (CIN) grade 2 or 3 and adenocarcinoma in situ (CIN2+) are used to monitor HPV vaccine impact on cervical disease. This report describes vaccination status in women diagnosed with CIN2+ and examines HPV vaccine impact on HPV 16/18-related CIN2+. METHODS: As part of a vaccine impact monitoring project (HPV-IMPACT), females 18-31 years with CIN2+ were reported from pathology laboratories in CA, CT, NY, OR, TN from 2008 to 2011. One diagnostic block was selected for HPV DNA typing with Roche Linear Array. Demographic, abnormal Papanicolaou (Pap) test dates and vaccine status information were collected. The abnormal Pap test immediately preceding the CIN2+ diagnosis was defined as the 'trigger Pap'. RESULTS: Among 5083 CIN2+ cases reported to date, 3855 had vaccination history investigated; 1900 had vaccine history documented (vaccinated, with trigger Pap dates, or unvaccinated). Among women who initiated vaccination >24 months before their trigger Pap, there was a significantly lower proportion of CIN2+ lesions due to 16/18 compared to women who were not vaccinated (aPR=.67, 95% CI: .48-.94). Among the 1900 with known vaccination status, 20% initiated vaccination on/after their trigger screening. Women aged 21-23 years were more likely to initiate vaccination on/after the trigger Pap compared to 24-26 year olds (29.0% vs. 19.6%, p=.001), as were non-Hispanic blacks compared to non-Hispanic whites (27.3% vs. 19.0%, p=.001) and publicly compared to privately insured women (38.1% vs. 17.4%, p<.0001). CONCLUSION: We found a significant reduction in HPV 16/18-related lesions in women with CIN2+ who initiated vaccination at least 24 months prior to their trigger Pap. These preliminary results suggest early impact of the HPV vaccine on vaccine-type disease, but further evaluation is warranted.