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1.  Estimation of Geographic Variation in Human Papillomavirus Vaccine Uptake in Men and Women: An Online Survey Using Facebook Recruitment 
Federally funded surveys of human papillomavirus (HPV) vaccine uptake are important for pinpointing geographically based health disparities. Although national and state level data are available, local (ie, county and postal code level) data are not due to small sample sizes, confidentiality concerns, and cost. Local level HPV vaccine uptake data may be feasible to obtain by targeting specific geographic areas through social media advertising and recruitment strategies, in combination with online surveys.
Our goal was to use Facebook-based recruitment and online surveys to estimate local variation in HPV vaccine uptake among young men and women in Minnesota.
From November 2012 to January 2013, men and women were recruited via a targeted Facebook advertisement campaign to complete an online survey about HPV vaccination practices. The Facebook advertisements were targeted to recruit men and women by location (25 mile radius of Minneapolis, Minnesota, United States), age (18-30 years), and language (English).
Of the 2079 men and women who responded to the Facebook advertisements and visited the study website, 1003 (48.2%) enrolled in the study and completed the survey. The average advertising cost per completed survey was US $1.36. Among those who reported their postal code, 90.6% (881/972) of the participants lived within the previously defined geographic study area. Receipt of 1 dose or more of HPV vaccine was reported by 65.6% women (351/535), and 13.0% (45/347) of men. These results differ from previously reported Minnesota state level estimates (53.8% for young women and 20.8% for young men) and from national estimates (34.5% for women and 2.3% for men).
This study shows that recruiting a representative sample of young men and women based on county and postal code location to complete a survey on HPV vaccination uptake via the Internet is a cost-effective and feasible strategy. This study also highlights the need for local estimates to assess the variation in HPV vaccine uptake, as these estimates differ considerably from those obtained using survey data that are aggregated to the state or federal level.
PMCID: PMC4180348  PMID: 25231937
online recruitment; social media; Facebook; local estimation; geographic variability; human papillomavirus; HPV
2.  Screening for Cervical Cancer: A Modeling Study for the U.S. Preventive Services Task Force 
This study addresses three questions posed by the United States Preventive Services Task Force (USPSTF): 1) At what age should screening for cervical cancer begin; 2) At what age should screening for cervical cancer end; and 3) How do the benefits and potential harms of screening strategies that use human papillomavirus (HPV) DNA testing in conjunction with cytology (co-testing) compare to those strategies that use cytology only?
A Markov model was updated and used to quantify clinical outcomes (i.e. colposcopies, cancers, life expectancy) associated with different screening strategies.
Screening in the teenage years is associated with a high number of colposcopies small differences in cancers detected and, as a result, small gains in life expectancy. Screening women beginning in the early 20s provides a reasonable balance of the harms and benefits of screening. Among women who have been screened according to the current recommendations for cervical cancer (beginning at age 21, and conducted every 3 years with cytology), screening beyond age 65 is associated with small additional gains in life expectancy but large increases in colposcopies. In terms of co-testing, a strategy of cytology only conducted every 3 years, followed by co-testing conducted every 5 years (for women aged 30+ years) is associated with fewer colposcopies and greater gains in life-expectancy compared to screening with cytology-only conducted every 3 years.
The results of this modeling study support current USPSTF recommendations for cervical cancer screening.
PMCID: PMC3608928  PMID: 23519288
cervical cancer screening; colposcopies; modeling
3.  Modeling Preventative Strategies against HPV-Related Disease in Developed Countries 
Vaccine  2012;30(0 5):F157-F167.
Over the last five years, prophylactic vaccination against Human Papillomavirus (HPV) in pre-adolescent females has been introduced in most developed countries, supported by modeled evaluations which have almost universally found vaccination of pre-adolescent females to be cost-effective. Studies to date suggest that vaccination of pre-adolescent males may also be cost-effective at a cost per vaccinated individual ~US$400–500 if vaccination coverage in females cannot be increased above ~50%; but if it is possible, increasing coverage in females appears to be a better return on investment. Comparative evaluation of the quadrivalent (HPV16,18,6,11) and bivalent (HPV16,18) vaccines centers around the potential tradeoff between protection against anogenital warts and vaccine-specific levels of cross-protection against infections not targeted by the vaccines. Future evaluations will also need to consider the cost-effectiveness of a next generation nonavalent vaccine designed to protect against ~90% of cervical cancers. The timing of the effect of vaccination on cervical screening programs will be country-specific and will depend on vaccination catch-up age range and coverage and the age at which screening starts. Initial evaluations suggest that if screening remains unchanged it will be less cost-effective in vaccinated compared to unvaccinated women but, in the context of current vaccines, will remain an important prevention method. Comprehensive evaluation of new approaches to screening will need to consider the population-level effects of vaccination over time. New screening strategies of particular interest include delaying the start age of screening, increasing the screening interval and switching to primary HPV screening. Future evaluations of screening will also need to focus on the effects of disparities in screening and vaccination uptake, the potential effects of vaccination on screening participation, and the effects of imperfect compliance with screening recommendations.
PMCID: PMC3783354  PMID: 23199959
HPV; Intraepithelial neoplasia; Uterine cervical neoplasms; Vulvar; vaginal; anal; oral cavity and oropharyngeal cancer; Anogenital warts; Recurrent Respiratory Papillomatoses; Vaccines; Mathematical models; Cervical cancer screening; Cost-effectiveness analysis; Developed countries
4.  Accuracy and Cost-Effectiveness of Cervical Cancer Screening by High-Risk HPV DNA Testing of Self-Collected Vaginal Samples 
Estimate the accuracy and cost-effectiveness of cervical cancer screening strategies based on high-risk HPV DNA testing of self-collected vaginal samples.
Materials and Methods
A subset of 1,665 women (18-50 years of age) participating in a cervical cancer screening study were screened by liquid-based cytology and by high-risk HPV DNA testing of both self-collected vaginal swab samples and clinician-collected cervical samples. Women with positive/abnormal screening test results and a subset of women with negative screening test results were triaged to colposcopy. Based on individual and combined test results, five screening strategies were defined. Estimates of sensitivity and specificity for cervical intraepithelial neoplasia grade 2 or worse were calculated and a Markov model was used to estimate the incremental cost-effectiveness ratios (ICERs) for each strategy.
Compared to cytology-based screening, high-risk HPV DNA testing of self-collected vaginal samples was more sensitive (68%, 95%CI=58%-78% versus 85%, 95%CI=76%-94%) but less specific (89%, 95%CI=86%-91% versus 73%, 95%CI=67%-79%). A strategy of high-risk HPV DNA testing of self-collected vaginal samples followed by cytology triage of HPV positive women, was comparably sensitive (75%, 95%CI=64%-86%) and specific (88%, 95%CI=85%-92%) to cytology-based screening. In-home self-collection for high-risk HPV DNA detection followed by in-clinic cytology triage had a slightly lower lifetime cost and a slightly higher quality-adjusted life expectancy than did cytology-based screening (ICER of triennial screening compared to no screening was $9,871/QALY and $12,878/QALY, respectively).
Triennial screening by high-risk HPV DNA testing of in-home, self-collected vaginal samples followed by in-clinic cytology triage was cost-effective.
PMCID: PMC2898894  PMID: 20592553
cervical cancer; screening; hpv; self-collect; cost-effectiveness
5.  Depot-medroxyprogesterone Acetate and Combined Oral Contraceptive Use and Cervical Neoplasia among Women with Oncogenic Human Papillomavirus Infection 
Examine the relationship of depot-medroxyprogesterone acetate (DMPA) and combined oral contraceptive (COC) use with cervical intraepithelial neoplasia (CIN).
Study Design
Two case-control studies of women who presented for gynecological care and underwent cytologic and human papillomavirus (HPV) testing were performed. The first included oncogenic HPV-positive women grouped based on histology: negative(n=152), CIN1(n=133), and ≥CIN2-3(n=173). For the second, two groups were identified: negative HPV/negative histology(n=107) and positive oncogenic HPV/negative histology(n=152).
Among oncogenic HPV-positive women, DMPA use was inversely associated with ≥CIN2-3 (adjusted odds ratio[ORadj]=0.4;95% confidence interval[CI]=0.2–1.1) and CIN1 (ORadj=0.1;95% CI=0.01–0.6); COC use was not associated with either. Among histologically negative women, DMPA use was associated with oncogenic HPV (ORadj=4.7;95% CI=1.4–15.8).
Among women with oncogenic HPV, hormonal contraceptive use was not associated with an increased risk of ≥CIN2-3. Longer-term DMPA use may attenuate the colposcopic and histologic features of CIN as women reporting such use were more likely than others to have cervical oncogenic HPV without evidence of CIN.
PMCID: PMC2713031  PMID: 19375566
CIN; hormonal contraception; DMPA; Oncogenic HPV infection
6.  Human papillomavirus testing with Pap triage for cervical cancer prevention in Canada: a cost-effectiveness analysis 
BMC Medicine  2009;7:69.
Recently published results from a large randomized trial (Canadian Cervical Cancer Screening Trial study group) suggest that human papillomavirus testing followed by Pap smear-based triage for human papillomavirus positive women may be an effective way to screen women for cervical cancer. We determined the potential cost-effectiveness of including human papillomavirus tests for cervical cancer screening for Canada and three provinces: Alberta, Newfoundland and Ontario.
We developed four Markov decision models using data from relevant Canadian and provincial studies and databases. The models were used to determine the number of false positive test results, cancers, lifetime costs and life-expectancy for 27 different screening strategies that varied by age to begin screening (18 or 25 years), screening interval (one, two, three, or five years) and whether the currently recommended strategy (screening every year from age 18 until 21 and then every three years afterwards with conventional Paps) was conducted prior to age 25. Strategies were compared using incremental cost-effectiveness ratios.
Screening strategies beginning at age 18 were associated with a substantial increase in the number of false-positive test results but only small differences in the number of cancers compared to the same strategy conducted beginning at age 25. Strategies of human papillomavirus testing first, followed by triage with Pap smears were associated with lower costs and greater increases in life-expectancy than the currently recommended screening strategy in Canada.
A strategy of human papillomavirus testing beginning at age 25, with Pap triage for women with positive human papillomavirus results may be more effective at reducing cervical cancer at a lower cost than the current recommended strategy for screening in Canada.
PMCID: PMC2780455  PMID: 19900264
7.  Adding a quadrivalent human papillomavirus vaccine to the UK cervical cancer screening programme: A cost-effectiveness analysis 
We assessed the cost-effectiveness of adding a quadrivalent (6/11/16/18) human papillomavirus (HPV) vaccine to the current screening programme in the UK compared to screening alone.
A Markov model of the natural history of HPV infection incorporating screening and vaccination was developed. A vaccine that prevents 98% of HPV 6, 11, 16 and 18-associated disease, with a lifetime duration and 85% coverage, in conjunction with current screening was considered.
Vaccination with screening, compared to screening alone, was associated with an incremental cost-effectiveness ratio of £21,059 per quality adjusted life year (QALY) and £34,687 per life year saved (LYS). More than 400 cases of cervical cancer, 6700 cases of cervical intraepithelial neoplasia and 4750 cases of genital warts could be avoided per 100,000 vaccinated girls. Results were sensitive to assumptions about the need for a booster, the duration of vaccine efficacy and discount rate.
These analyses suggest that adding a quadrivalent HPV vaccine to current screening in the UK could be a cost-effective method for further reducing the burden of cervical cancer.
PMCID: PMC2290741  PMID: 18279515

Results 1-7 (7)