Miriam Cremer

HPV Vaccine Acceptability by Latino Parents: A Comparison of U.S. and Salvadoran Populations

STUDY OBJECTIVEnTo characterize and compare acceptability of human papillomavirus (HPV) vaccination by Latino parents at an urban medical center in the United States and a community hospital in El Salvador.nnnDESIGNnAfter reading an information sheet on HPV, 148 subjects at Bellevue Hospital in New York City and 160 subjects at Hospital Nacional de Santa Gertrudis in San Vicente, El Salvador, completed a survey. Results were analyzed using chi-square, Fishers exact test, and Students t-tests.nnnRESULTS AND CONCLUSIONSnParental acceptance of HPV vaccination was higher in a sample of Salvadoran subjects than in a sample of U.S. Latinas (P<0.001 for daughters and sons). Reasons for objecting to HPV vaccination differ in the two locations. There are important differences between Salvadoran and U.S. subjects. Salvadorans are more accepting of HPV vaccination, and parental acceptance is unlikely to be a barrier to widespread vaccination in El Salvador. Targeted educational materials are needed in both locations.

The comparative and cost-effectiveness of HPV-based cervical cancer screening algorithms in El Salvador.

Cervical cancer is the leading cause of cancer death among women in El Salvador. Utilizing data from the Cervical Cancer Prevention in El Salvador (CAPE) demonstration project, we assessed the health and economic impact of HPV‐based screening and two different algorithms for the management of women who test HPV‐positive, relative to existing Pap‐based screening. We calibrated a mathematical model of cervical cancer to epidemiologic data from El Salvador and compared three screening algorithms for women aged 30–65 years: (i) HPV screening every 5 years followed by referral to colposcopy for HPV‐positive women (Colposcopy Management [CM]); (ii) HPV screening every 5 years followed by treatment with cryotherapy for eligible HPV‐positive women (Screen and Treat [ST]); and (iii) Pap screening every 2 years followed by referral to colposcopy for Pap‐positive women (Pap). Potential harms and complications associated with overtreatment were not assessed. Under base case assumptions of 65% screening coverage, HPV‐based screening was more effective than Pap, reducing cancer risk by ∼60% (Pap: 50%). ST was the least costly strategy, and cost

Adequacy of visual inspection with acetic acid in women of advancing age.

2,040 per year of life saved. ST remained the most attractive strategy as visit compliance, costs, coverage, and test performance were varied. We conclude that a screen‐and‐treat algorithm within an HPV‐based screening program is very cost‐effective in El Salvador, with a cost‐effectiveness ratio below per capita GDP.

Cervical Cancer Screening in Low‐ and Middle‐Income Countries

The present study assessed the adequacy and predictive performance of visual inspection with acetic acid (VIA) in women over the age of 50 years and compared the specificity and sensitivity of VIA with that of the conventional cytology.

Adolescent Comprehension of Emergency Contraception in New York City.

Cervical cancer is a leading cause of death among women in the developing world. Conventional cytology-based cervical cancer screening programs have been largely ineffectual at reducing the cervical cancer burden in low-resource settings. In response, alternative strategies have been tested, such as visual inspection with acetic acid (VIA) screening and human papillomavirus (HPV) DNA-based testing. This manuscript reviews literature addressing the programmatic approaches to implementing cervical cancer screening programs in low-resource settings, highlighting the challenges, barriers, and successes related to the use of cytology, VIA, and HPV-DNA based screening programs.

Cytology versus visual inspection with acetic acid among women treated previously with cryotherapy in a low-resource setting

OBJECTIVE: To estimate comprehension of the over-the-counter emergency contraception label among female adolescents aged 12 through 17 years, and to compare the results with a similar study that focused on adults. METHODS: Surveys were administered to female adolescents in New York City in public venues such as malls, movie theaters, and parks. Participants were asked to read the emergency contraception (levonorgestrel) label before answering survey questions. Comparisons were made in SPSS version 13.0 using χ2 tests of independence and Fisher exact tests for sparse data. RESULTS: One thousand eighty-five girls between the ages of 12 and 17 participated in the study. Overall, adolescents demonstrated high comprehension of the key points of emergency contraception: (1) that it is a method of preventing pregnancy 92% (confidence interval [CI] 91–94%); (2) that it has to be taken within the first 72 hours after unprotected intercourse 83% (CI 83–87%); (3) that if you are already pregnant emergency contraception will not be effective 87% (CI 85–89%); (4) that emergency contraception will not protect against human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) 95% (CI 94–96%); and (5) that emergency contraception should not be used as a method of long-term birth control 85% (CI 83–87%). CONCLUSION: After reading the emergency contraception (levonorgestrel) label, female adolescents aged 12 to 17 understood the information necessary to use emergency contraception safely and effectively as well as their adult counterparts. LEVEL OF EVIDENCE: III

Effect of cervicitis on visual inspection with acetic acid.

To compare visual inspection with acetic acid (VIA) with conventional cervical cytology as a follow‐up cervical cancer screening method in women who had been treated previously with cryotherapy.

Self-Administered Lidocaine Gel for Intrauterine Device Insertion in Nulliparous Women: A Randomized Controlled Trial.

Objective. The objective of this study was to determine whether the presence of cervicitis influenced the accuracy of visual inspection with acetic acid (VIA). Materials and Methods. In a pilot study, 502 women from rural El Salvador were screened for cervical cancer using methods including colposcopy and VIA. The presence of cervicitis was assessed by grading the amount of inflammation on each womans cervical biopsy. Data from 495 women found to be free of cervical neoplasia were analyzed for the present study. Results. In this study population, 74% of women were classified as having cervicitis. Both the result of visual inspection and the result of colposcopy were highly associated with the presence of cervicitis (p =.007 and p =.006, respectively). Women with cervicitis were twice as likely to have a positive VIA result as women without cervicitis (odds ratio = 2.0, 95% CI: 1.0-3.7). Conclusions. The presence of cervicitis may influence the accuracy of results obtained from colposcopy and VIA. This observation may be of particular importance in low-resource settings such as El Salvador where visual inspection methods are more commonly used in screening for cervical cancer.

Digital assessment of the reproductive tract versus colposcopy for directing biopsies in women with abnormal Pap smears.

OBJECTIVE: To evaluate self-administration of vaginal lidocaine gel to decrease pain with intrauterine device (IUD) insertion in nulliparous women. METHODS: In this randomized, double-blind, placebo-controlled trial, women self-administered 2% lidocaine or placebo vaginal gel 5 minutes before IUD insertion. The primary outcome was change in pain from baseline to IUD insertion on a 100-mm visual analog scale. We also assessed pain after speculum insertion, tenaculum placement, uterine sounding, and 5 minutes after IUD insertion. Secondary outcomes included patient acceptability, ease of IUD insertion, and need for pain medication for up to 7 days. RESULTS: From July 2012 to May 2013, 59 women were randomized; 30 received lidocaine gel and 29 placebo. Baseline demographics, including age, race, and body mass index, were similar. There was no difference in median change in pain during IUD insertion in women receiving lidocaine (61 mm [interquartile range 53–71]) compared with placebo (69 mm [interquartile range 63–80], P=.06). Women receiving lidocaine experienced less pain with tenaculum placement (32 mm [interquartile range 18–54]) compared with placebo (56 mm [interquartile range 26–75], P=.02). Most (76%) women were satisfied with their IUD insertion experience and 86% would probably or definitely recommend an IUD to a friend. Thirty-four percent of women required pain medication for at least 3 days after IUD insertion. CONCLUSION: For nulliparous women, self-administered vaginal lidocaine gel does not reduce pain with IUD insertion, but does decrease pain with tenaculum placement. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, http://clinicaltrials.gov, NCT01534520.

Prevalence and risk factors for pelvic floor symptoms in women in rural El Salvador

Objective: This study aimed to compare digital camera assessment of the reproductive tract (DART) to colposcopy for the evaluation of abnormal Pap smears. Materials and Methods: Participants included 207 women with abnormal Pap smears. Colposcopy and DART were performed on each patient by separate examiners with the goal of lesion detection. Analysis was performed per patient and per biopsy. Results: Patients had an average of 2.9 biopsies. Forty-two patients and 81 biopsies were positive for cervical intraepithelial neoplasia 2+. Both DART and colposcopy detected 41 (97.6%) of 42 patients (95% CI = 85.9%-99.9%). Digital camera assessment of the reproductive tract detected 66/81 (81.4%; CI = 70.7%-88.9%) and colposcopy detected 69/81 (85.2%; CI = 73.2%-92.4%) of biopsies that were cervical intraepithelial neoplasia 2+. Conclusions: Digital camera assessment of the reproductive tract detects high-grade lesions of the cervix with similar sensitivity to colposcopy. It holds great promise to expand cervical cancer precursor lesion detection in areas with limited resources.