Laura Costas

New interventions to increase influenza vaccination rates in health care workers

BACKGROUND The most effective strategy for avoiding nosocomial influenza outbreaks is through vaccination of health care workers (HCWs). In Spain, HCW vaccination coverage rarely exceeds 25%. The objective of this study was to determine whether an active vaccination campaign promoting communication among HCWs increased influenza vaccination coverage rates and permitted a shorter campaign. METHODS This was a before-after trial, comparing free mobile vaccination teams without and with strategies promoting HCW involvement by means of weekly educational and promotional messages through electronic mail, including 2 prize draws for vaccinated HCWs and a Web page including pictures of vaccinated HCWs and all senior hospital management. Weekly coverages were publicized, the staff of mobile units was increased, and their routes in the hospital were advertised. The study population was >4500 HCWs (permanent and temporary staff) at a Spanish university hospital during the 2007-08 and 2008-09 influenza seasons. RESULTS Coverage was 23% (95% confidence interval [CI], 22.5%-24.9%) in the 2007-08 season and 37% (95% CI, 34.7%-37.4%) in 2008-09 season. The vaccination rate was highest in HCWs aged > or =65 years and in physicians. The weekly vaccination rates were significantly higher for the 2008-09 season compared with the 2007-08 season except for the first and third weeks; for example, in week 2, the rate was 1.7 HCWs per 100 persons-week (95% CI, 1.3-2.1) in 2007-08, compared with 3.7 HCWs per 100 persons-week (95% CI, 3.2-4.4) in 2009-09. Rate increases were concentrated in the first weeks of the program, with a peak occurring in week 3 during the 2007-08 season and in week 2 during the 2008-09 season. CONCLUSION This intervention improved influenza vaccination coverage of HCWs and allowed more rapid achievement of higher coverage.

Cervical cancer vaccination indications, efficacy, and side effects

Due to the limited contact of the human papillomavirus (HPV) with the immune system, past infection does not guarantee lasting protection. Two preventive vaccines (Gardasil and Cervarix) that can impede persistent HPV infection and its consequences are now available. They use structural L1 capsular proteins obtained by genetic recombination and antigens for genotypes 16 and 18, which are responsible for around 70% of cases of uterine cancer worldwide. Evaluation of their protective efficacy is based on the capacity of the vaccine to prevent persistent infection and cervical intraepithelial neoplasia (CIN). Phase I and II trials showed the safety of these vaccines and their capacity to produce very-high titers of antibodies (low or non-existent after natural infection). Phase II and III trials have confirmed these aspects and shown an efficacy of nearly 100% in the protocol analysis in preventing infection and the CIN associated with oncogenic vaccine genotypes. Some trials have also shown cross-protection against infections produced by other genotypes (such as 45 and 31). The optimal vaccination strategy is vaccination of girls aged 8-14 years. Other strategies should include the catch-up of adolescent and women not yet sexually-active, as well as the vaccination of sexually-active women. The progressive development of primary prevention strategies should coexist with secondary prevention with redesigned screening programs. The successful development of vaccination programs will require the support of public health authorities, the coordination of health workers from different areas and increased public awareness.

Menstrual and reproductive factors, and hormonal contraception use: associations with non-Hodgkin lymphoma in a pooled analysis of InterLymph case–control studies

BACKGROUND The two most common forms of non-Hodgkin lymphoma (NHL) exhibit different sex ratios: diffuse large B-cell lymphoma (DLBCL) occurs more frequently in men and follicular lymphoma (FL) more frequently in women. Looking among women alone, this pooled analysis explores the relationship between reproductive histories and these cancers. MATERIALS AND METHODS Self-reported reproductive histories from 4263 women with NHL and 5971 women without NHL were pooled across 18 case-control studies (1983-2005) from North America, Europe and Japan. Study-specific odd ratios (ORs) and confidence intervals (CIs) were estimated using logistic regression and pooled using random-effects meta-analyses. RESULTS Associations with reproductive factors were found for FL rather than NHL overall and DLBCL. In particular, the risk of FL decreased with increasing number of pregnancies (pooled ORtrend=0.88, 95% CI 0.81-0.96). FL was associated with hormonal contraception (pooled OR=1.30, 95% CI 1.04-1.63), and risks were increased when use started after the age of 21, was used for <5 years or stopped for >20 years before diagnosis. DLBCL, on the other hand, was not associated with hormonal contraception (pooled OR=0.87, 95% CI 0.65-1.16). CONCLUSIONS Hormonal contraception is associated with an increased risk of FL but not of DLBCL or NHL overall.

Postmenopausal hormone therapy and non-Hodgkin lymphoma: a pooled analysis of InterLymph case–control studies

BACKGROUND Non-Hodgkin lymphoma (NHL) subtypes, diffuse large B-cell (DLBCL) and follicular lymphoma (FL) have different sex ratios and are diagnosed at ages over 60 years; DLBCL is more common in men and diagnosed at older ages than FL, which occurs more among women. This analysis of postmenopausal women examines the relationship between postmenopausal hormone therapy and NHL. DESIGN Self-reported use of postmenopausal hormone therapy from 2094 postmenopausal women with NHL and 2731 without were pooled across nine case-control studies (1983-2005) from North America, Europe and Japan. Study-specific odds ratios (OR) and 95% confidence intervals (CI) estimated using logistic regression were pooled using random-effects meta-analyses. RESULTS Postmenopausal women who used hormone therapy were at decreased risk of NHL (pooled OR = 0.79, 95% CI 0.69-0.90). Risks were reduced when the age of starting was 50 years or older. There was no clear trend with number of years of use. Current users were at decreased risk while those stopping over 2 years before diagnosis were not. Having a hysterectomy or not did not affect the risk. Favourable effects were present for DLBCL (pooled OR = 0.66, 95% CI 0.54-0.80) and FL (pooled OR = 0.82, 95% CI 0.66-1.01). CONCLUSION Postmenopausal hormone therapy, particularly used close to menopause, is associated with a decreased risk of NHL.BACKGROUND Non-Hodgkin lymphoma (NHL) subtypes, diffuse large B-cell (DLBCL) and follicular lymphoma (FL) have different sex ratios and are diagnosed at ages over 60 years; DLBCL is more common in men and diagnosed at older ages than FL, which occurs more among women. This analysis of postmenopausal women examines the relationship between postmenopausal hormone therapy and NHL. DESIGN Self-reported use of postmenopausal hormone therapy from 2094 postmenopausal women with NHL and 2731 without were pooled across nine case-control studies (1983-2005) from North America, Europe and Japan. Study-specific odds ratios (OR) and 95% confidence intervals (CI) estimated using logistic regression were pooled using random-effects meta-analyses. RESULTS Postmenopausal women who used hormone therapy were at decreased risk of NHL (pooled OR = 0.79, 95% CI 0.69-0.90). Risks were reduced when the age of starting was 50 years or older. There was no clear trend with number of years of use. Current users were at decreased risk while those stopping over 2 years before diagnosis were not. Having a hysterectomy or not did not affect the risk. Favourable effects were present for DLBCL (pooled OR = 0.66, 95% CI 0.54-0.80) and FL (pooled OR = 0.82, 95% CI 0.66-1.01). CONCLUSION Postmenopausal hormone therapy, particularly used close to menopause, is associated with a decreased risk of NHL.

Medical history, lifestyle, family history, and occupational risk factors for sporadic Burkitt lymphoma/leukemia: the Interlymph Non-Hodgkin Lymphoma Subtypes Project.

BACKGROUND The etiologic role of medical history, lifestyle, family history, and occupational risk factors in sporadic Burkitt lymphoma (BL) is unknown, but epidemiologic and clinical evidence suggests that risk factors may vary by age. METHODS We investigated risk factors for sporadic BL in 295 cases compared with 21818 controls in a pooled analysis of 18 case-control studies in the International Lymphoma Epidemiology Consortium (InterLymph). Cases were defined to include typical BL or Burkitt-like lymphoma. Odds ratios (ORs) and 95% confidence intervals (CIs) for associations were calculated separately for younger (<50 years) and older (≥ 50 years) BL using multivariate logistic regression. RESULTS Cases included 133 younger BL and 159 older BL (age was missing for three cases) and they were evenly split between typical BL (n = 147) and Burkitt-like lymphoma (n = 148). BL in younger participants was inversely associated with a history of allergy (OR = 0.58; 95% CI = 0.32 to 1.05), and positively associated with a history of eczema among individuals without other atopic conditions (OR = 2.54; 95% CI = 1.20 to 5.40), taller height (OR = 2.17; 95% CI = 1.08 to 4.36), and employment as a cleaner (OR = 3.49; 95% CI = 1.13 to 10.7). BL in older participants was associated with a history of hepatitis C virus seropositivity (OR = 4.19; 95% CI = 1.05 to 16.6) based on three exposed cases. Regardless of age, BL was inversely associated with alcohol consumption and positively associated with height. CONCLUSIONS Our data suggest that BL in younger and older adults may be etiologically distinct.

Reproductive factors and non-Hodgkin lymphoma: A systematic review

Considerable efforts have been made to elucidate non-Hodgkin lymphomas (NHL) etiology during the last decades. Some evidence points to an association with reproductive factors, as incidence rates for most NHL subtypes are usually higher in men than in women, and several subtypes express hormonal receptors. Although the evidence is not compelling, some studies show an inverse association with gravidity. Associations with postmenopausal hormone therapy are usually derived from unopposed estrogen use, rather than for the combination of estrogen with progestin, but these findings vary by study design. Inconsistencies in the results are likely due to the complex relationship between reproductive, biological, and sociodemographic factors, as well as to study limitations. Elucidating the role of hormonal factors should provide clues for therapeutic options and public health decisions. We provide an overview of the available evidence on reproductive factors in NHL etiology, underscoring potential sources of discrepancies and bias.

Vaccination strategies against hepatitis A in travelers older than 40 years: an economic evaluation.

BACKGROUND In recent years, the number of travelers aged >40 years who acquire hepatitis A while traveling has increased. Therefore, there is a need to review hepatitis A vaccination protocols in travelers. The aims of the study were to assess immunity levels to hepatitis A virus (HAV) in international travelers >40 years and to determine the least costly immunization strategy. METHODS A serological examination of HAV antibodies in 427 international travelers aged >40 years traveling endemic zones was carried out. The prevalence of antibodies in each age group was assessed. The costs of two preventive strategies, direct vaccination of all subjects (independent of the immune status) or screening and subsequent vaccination of susceptible subjects were compared. The critical value of prevalence (CVP) (the value at which the costs for the two strategies are equal) was calculated. RESULTS Total prevalence of HAV antibodies was 78.9% [95% confidence interval (CI): 74.8-82.5] and was 80.0% (95% CI: 73.8-85.2) in men and 77.9% (95% CI: 71.9-83.2) in women. There was a positive association with age. In the 40 to 49, 50 to 59, 60 to 69, and 70 to 95 years age groups, the prevalence rates were 62.6 (95% CI: 53.8-71.5), 76.8 (95% CI: 70.0-82.7), 91.7 (95% CI: 85.2-95.6), and 97.5% (95% CI: 87.4-99.6), respectively. The CVP was 58.4% using two doses of vaccine. CONCLUSIONS The CVP was lower than the prevalence rate found in our international travelers. Therefore, we recommend systematic screening for HAV antibodies before selective vaccination of international travelers aged >40 years traveling to hepatitis A endemic zones.

Hormonal contraception and postmenopausal hormone therapy in Spain: time trends and patterns of use.

Objective:This study aims to describe time trends in and patterns of use of hormonal contraception and postmenopausal hormone therapy and to identify factors associated with their use among Spanish women. Methods:We performed a cross-sectional analysis using data from 1,954 population controls (aged 24-85 y) in 12 provinces of Spain who were enrolled in the Multi Case-Control Spain study (2007-2013). Data were collected from a questionnaire conducted face-to-face by trained personnel. We collected information on sociodemographic factors, lifestyle, sleep patterns, reproductive history, and occupational history. Results:Overall, 48.5% of Spanish women reported ever use of hormonal contraception, and 9.8% of women in the postmenopausal group reported use of postmenopausal hormone therapy. Younger cohorts used hormonal contraception for a longer period, whereas postmenopausal hormone therapy use dramatically dropped in the 2000s. Women with higher education levels (including education of partners) and smoking history were the most probable users of hormonal contraception, whereas inverse associations were observed among housewives, obese women, and nulliparous women. Postmenopausal hormone therapy use was associated with a surgical or therapeutic cause of menopause and with occupational history of rotating shifts. Conclusions:In this Spanish population, several demographic, lifestyle, occupational, and reproductive factors are associated with use of hormonal compounds. Characterizing hormonal users and monitoring trends in the use of these hormonal compounds are essential from a public health perspective.

Motivations for participating in a clinical trial on an avian influenza vaccine.

In this study we describe the sociodemographic characteristics of people participating in a clinical trial on the safety and immunogenicity of a H5N1 influenza vaccine and we identify the main motivations for joining it.

A Pooled Analysis of Alcohol Consumption and Risk of Multiple Myeloma in the International Multiple Myeloma Consortium

Background: Recent findings suggest that alcohol consumption may reduce risk of multiple myeloma. Methods: To better understand this relationship, we conducted an analysis of six case–control studies participating in the International Multiple Myeloma Consortium (1,567 cases, 7,296 controls). Summary ORs and 95% confidence intervals (CI) relating different measures of alcohol consumption and multiple myeloma risk were computed by unconditional logistic regression with adjustment for age, race, and study center. Results: Cases were significantly less likely than controls to report ever drinking alcohol (men: OR = 0.72; 95% CI, 0.59–0.89; women: OR = 0.81; 95% CI, 0.68–0.95). The inverse association with multiple myeloma was stronger when comparing current to never drinkers (men: OR = 0.57; 95% CI, 0.45–0.72; women: OR = 0.55; 95% CI, 0.45–0.68), but null among former drinkers. We did not observe an exposure–response relationship with increasing alcohol frequency, duration, or cumulative lifetime consumption. Additional adjustment for body mass index, education, or smoking did not affect our results; and the patterns of association were similar for each type of alcohol beverage examined. Conclusions: Our study is, to our knowledge, the largest of its kind to date, and our findings suggest that alcohol consumption may be associated with reduced risk of multiple myeloma. Impact: Prospective studies, especially those conducted as pooled analyses with large sample sizes, are needed to confirm our findings and further explore whether alcohol consumption provides true biologic protection against this rare, highly fatal malignancy. Cancer Epidemiol Biomarkers Prev; 22(9); 1620–7. ©2013 AACR.