ObjectivesObesity adversely inhibits antibody response to vaccination. Three doses of HPV4 may or may not provide adequate long term protection against HPV 16/18 in obese females. The aim of this study was to determine whether adherence to HPV4 vaccination in a safety net population was reduced with increasing body mass index (BMI).MethodsWe designed a historical prospective study evaluating the number and dates of HPV4 dosing that occurred from July 1, 2006 through October 1, 2009 by the demographic characteristics of the 10–26 year old recipient females. The defined dosing intervals were adapted from the literature and obesity categories were defined by the WHO.Results1240 females with BMI measurements received at least one dose of HPV4; 38% were obese (class I, II and III) and 25% were overweight. Females with normal BMI received on-time triplet dosing significantly more often than did the obese class II and III females (30% vs. 18%, p<0.001). Obese class II/III females have a significant 45% less chance of completing the on-time triplet HPV4 series than normal women (OR = 0.55, 95% CI: 0.37, 0.83). Pregnancy history has a significant influence on BMI and HPV4 dosing compliance in this safety net population where 71% had been gravid. Hispanic females were less likely to complete HPV4 dosing regardless of BMI (aOR = 0.39, 95% CI: 0.16, 0.95).ConclusionsObesity, as well as gravidity and Hispanic race, are risk factors for lack of HPV4 vaccine adherence among young females in a safety net population.
The POBASCAM trial (1) was one of the earliest and longest randomized controlled trials to address the test performance of high-risk HPV (hrHPV) testing to detect cervical precancerous lesions. It builds on the evidence presented in HART (2). Of importance is the 29-year-old starting age for study enrollment. The European cohort study (3) included younger women starting at 20 years from Denmark, France, and Spain. The US industry-sponsored ATHENA cohort trial started at 21 years (4). Most trials showed that the prevalence of hrHPV is highest in those younger than 30 years and lowest between 35 and 54 years of age, after which it increases again (5).The United States has recently moved the age to start screening up from 3 years after initiation of sexual intercourse to 21 years (6-8), which has omitted all of the adolescent and early-college health screenings. These recommendations are strongly supported by the evidence, but acceptance by both health-care professionals and women has been slow (9). Much of the Western world has adopted screening initiation at age 30. Age of the woman screened is highly related to the efficiency of the screening test used.Dijkstra and colleagues (10), as well as other screening HPV testing studies (3, 4), have shown that positive hrHPV testing immediately triaged with cytology results in a specificity of above 50%, the threshold at which the chance of ruling in cervical intraepithelial neoplasia (CIN) grade 3 or worse (CIN 3 þ ) disease is a coin flip. This management strategy results in the fewest referrals to colposcopy (31%), but the lowest detection of CIN 3 þ disease (10). By adding HPV 16/18 genotyping to the cytology triage test, Dijkstra and colleagues showed that the detection of CIN 3 þ improves significantly, but at a large cost of sending more than half of the population to repeated testing and colposcopy. This calls cost-effectiveness into the discussion.Cost-effectiveness models show that triennial screening strategies between 21 and 30 years of age are most costeffective when atypical squamous cells of undetermined significance (ASCUS) cytology is followed by high-risk HPV testing among unvaccinated women, increasing the interval to every 5 years for vaccinated women (11).For women 30 years and older, several cost-effective strategies have been identified: in increasing order of incremental cost-effectiveness ratio for quality-adjusted life years (11), screening every 5 years among unvaccinated women with cytology followed by hrHPV testing for ASCUS; screening every 5 years among unvaccinated women with hrHPV testing followed by cytology for positive hrHPV; screening every 5 years among vaccinated women with cytology followed by hrHPV triage; screening every 5 years among vaccinated women with hrHPV followed by cytology triage; and, finally, screening every 3 years among unvaccinated women with hrHPV followed by cytology triage. There is no cost-effective strategy for screening vaccinated women 30 years and older at a 3-year interval (11); nor does cotesting with hrH...
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