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Background: The incidence of anogenital warts (AGW) decreased after the introduction of the quadrivalent human papillomavirus (qHPV) vaccine in multiple jurisdictions. We studied how comparing AGW incidence rates with different outcomes affects the interpretation of the qHPV vaccination program. To do this, we replicated multiple study designs within a single jurisdiction (Manitoba). Methods: We measured the incidence rates of AGW, AGW-related prescriptions, chlamydia, and gonorrhea (the latter two as sham outcomes) between 2001 and 2017 using several clinical and administrative health databases from Manitoba. We then used incidence rate ratios (IRRs) to compare, for each outcome, the rate for the 1997–1998 birth cohort (the first cohorts eligible for the publicly funded qHPV vaccination program) and the older 1995–1996 birth cohort. Results: AGW incidence in Manitoba dropped 72% (95% confidence interval 54–83%) among 16–18 year-old girls and 51% (14–72%) among boys after the introduction of the female-only qHPV vaccination program. Trends in AGW-related prescriptions were different from trends in AGW diagnoses as these prescriptions peaked shortly after the introduction of the publicly funded qHPV vaccine program. Chlamydia and gonorrhea incidence rates also decreased 12% (5–18%) and 16% (-1-30%), respectively, for 16–18 year-old girls. Conclusions: The publicly funded school-based qHPV vaccine program reduced AGW incidence in Manitoba by three-quarters in young females. AGW-related prescriptions are a poor proxy for medically attended AGW after the introduction of the publicly funded qHPV vaccination program. Different sexual habits in adolescents are, at most, responsible for a small portion of the reduction in AGW incidence. [ABSTRACT FROM AUTHOR]

Background: Changes to pertussis vaccination programmes can have impacts on disease burden that should be estimated independently from factors such as age- and period-related trends. We used age-period-cohort (APC) models to explore pertussis incidence in Manitoba over a 25-year period (1992-2017).Methods: We identified all laboratory-confirmed cases of pertussis from Manitoba's Communicable Diseases Database and calculated age-standardized incidence rates. We used APC models to investigate trends in pertussis incidence.Results: During the study period, 2479 cases were reported. Age-standardized rates were highest during a large outbreak in 1994 (55 cases/100 000 person-years), with much lower peaks in 1998, 2012 and 2016. We saw strong age and cohort effects in the APC models, with a steady decrease in incidence with increasing age and increased risk in the cohort born between 1980 and 1995.Conclusions: The highest risk for pertussis was consistently in young children, regardless of birth cohort or time period. The 1981 programme change to an adsorbed whole-cell pertussis vaccine with low effectiveness resulted in reduced protection in the 1981-95 birth cohort and contributed to the largest outbreak of disease during the 25-year study period. [ABSTRACT FROM AUTHOR]

Several epidemiological studies have found an association between maternal antibiotics use during pregnancy and increased risk of certain cancer types, although conclusions differ between studies. We examined this association in a cohort study including 262 116 mother‐child pairs of Manitoba births between 1996 and 2013. Maternal antibiotics use during prepregnancy (6 months prior to pregnancy) and pregnancy periods was assessed. Children's cancer incidence was tracked up to the end of the follow‐up period (December 2015). We calculated incidence rate and used Cox regression to estimate adjusted hazard ratios (HRs). Antibiotics use during pregnancy was not associated with overall cancer (HR = 1.1, 95% confidence interval 0.9‐1.4), leukemias (1.3, 0.9‐1.8), or acute lymphocytic leukemia (1.1, 0.7‐1.6). The association between antibiotics use and overall cancer risk differed by trimester: 1.5 (1.1‐1.9) in the first, 0.8 (0.6‐1.0) in the second, and 1.1 (0.8‐1.5) in the third trimester. Further research is necessary to confirm the association between first‐trimester exposure and cancer risk after a better controlling of confounding factors. [ABSTRACT FROM AUTHOR]

Background: Prenatal antibiotic exposure induces changes in infants’ gut microbiota composition and is suggested as a possible contributor in the development of autism spectrum disorders (ASD). In this study, we examined the association between prenatal antibiotic exposure and the risk of ASD. Methods: This was a population-based cohort study utilizing the Manitoba Population Research Data Repository. The cohort included 214 834 children born in Manitoba, Canada between April 1, 1998 and March 31, 2016. Exposure was defined as having filled one or more antibiotic prescription during pregnancy. The outcome was autism spectrum disorder diagnosis. Multivariable Cox proportional hazards regression was used to estimate the risk of developing ASD in the overall cohort and in a sibling cohort. Results: Of all subjects, 80 750 (37.6%) were exposed to antibiotics prenatally. During follow-up, 2965 children received an ASD diagnosis. Compared to children who were not exposed to antibiotics prenatally, those who were exposed had a higher risk of ASD: (adjusted HR 1.10 [95% CI 1.01, 1.19]). The association was observed in those exposed to antibiotics in the second or third trimester (HR 1.11 [95% CI 1.01, 1.23] and 1.17 [95% CI 1.06, 1.30], respectively). In the siblings’ cohort, ASD risk estimate remained unchanged (adjusted HR 1.08 [95% CI 0.90, 1.30], although it was not statistically significant. Conclusions: Prenatal antibiotic exposure is associated with a small increase in the risk of ASD. Given the potential of residual confounding beyond what it was controlled through our study design and because of possible confounding by indication, such a small risk increase in the population is not expected to be clinically significant. [ABSTRACT FROM AUTHOR]

The effectiveness of a vaccination program is influenced by its design and implementation details and by the target population characteristics. Using routinely collected population‐based individual‐level data, we assessed the effectiveness (against cervical dysplasia) of Manitoba's quadrivalent human papillomavirus (qHPV) routine school‐based vaccination program and a short‐lived campaign that targeted women at high‐risk of developing cervical cancer. Females ≥9 years old who received the qHPV vaccine in Manitoba (Canada) between September 1, 2006, and March 31, 2013 (N = 31,442) were matched on age and area of residence to up to three unvaccinated females. Cox proportional hazards models were used to estimate qHPV VE against high‐grade (HSILs) and low‐grade squamous intraepithelial lesions (LSILs) and atypical squamous cells of undetermined significance (ASCUS). Among 14–17‐year‐old participants who had Pap cytology after enrollment, the adjusted qHPV VE estimates were 30% (17–58%) and 36% (21–48%) against the detection of HSILs and LSILs, respectively. There was, however, no evidence of program effectiveness among females vaccinated at ≥18 years of age and among those with a history of abnormal cytology, who were mostly vaccinated as part of the high‐risk program. Estimates of VE for females vaccinated in the school‐based program are consistent with the expected benefits from qHPV vaccination. No similar benefits were detected among women vaccinated at an older age, and those with abnormal cytology, who were targeted by the high‐risk program. Further efforts should be targeted at achieving higher vaccine coverage among preadolescents, prior to the initiation of sexual activity. What's new? Vaccination with the quadrivalent human papillomavirus (qHPV) prevents infection with HPV types responsible for the vast majority of cervical cancers and genital warts. In Manitoba, the qHPV vaccine has been available in school‐based vaccination programs since 2008. This study shows that levels of protection against cervical dysplasia among adolescent girls vaccinated in Manitoba's routine school‐based qHPV vaccination program are similar to benefit levels estimated from randomized clinical trials. Women vaccinated at age 18 or older or who had a history of abnormal cytology did not experience comparable benefits, likely owing to a combination of factors, including prior HPV exposure. [ABSTRACT FROM AUTHOR]

Background: Despite the public health significance of annual influenza outbreaks, the literature comparing the epidemiology of influenza A and B infections is limited and dated and may not reflect recent trends. In Canada, the relative contribution of influenza A and B to the burden of morbidity is not well understood. We examined rates of laboratory-confirmed cases of influenza A and B (LCI-A and LCI-B) in the Canadian province of Manitoba between 1993 and 2008 and compared cases of the two types in terms of socio-demographic and clinical characteristics. Methods: Laboratory-confirmed cases of influenza A and B in Manitoba between 1993 and 2008 were identified from the Cadham Provincial Laboratory (CPL) Database and linked to de-identified provincial administrative health records. Crude and age-adjusted incidence rates of LCI-A and LCI-B were calculated. Demographic characteristics, health status, health service use, and vaccination history were compared by influenza type. Results: Over the study period, 1,404 of LCI-A and 445 cases of LCI-B were diagnosed, corresponding to an annual age-standardized rate of 7.2 (95% CI: 6.5-7.9) for LCI-A and 2.2 (CI: 1.5 - 3.0) per 100,000 person-years for LCI-B. Annual rates fluctuated widely but there was less variation in the LCI-B rates. For LCI-A, but not LCI-B, incidence was inversely related to household income. Older age, urban residence and past hospitalization were associated with increased detection of LCI-A whereas receipt of the influenza vaccine was associated with decreased LCI-A detection. Once socio-demographic variables were controlled, having a pre-existing chronic disease or immune suppression was not related to influenza type. Conclusion: Influenza A and B affected different segments of the population. Older age was associated with increased LCI-A detection, but not with pre-existing chronic diseases. This information may be useful to public health professionals in planning and evaluating new and existing seasonal influenza vaccines. [ABSTRACT FROM AUTHOR]

Abstract: Background: Females who receive the human papillomavirus (HPV) vaccine may believe they are protected from developing cervical cancer and no longer require screening. Concern has also been expressed that vaccinated females are those that would be screened regularly. This study assesses the Pap testing behavior of vaccinated and non-vaccinated females. Methods: For this population-based retrospective cohort study, vaccination and screening registries were linked for 3540 vaccinated females aged 15 years and over and 9592 matched non-vaccinated females. Conditional logistic regression, the Kaplan–Meier method and Cox regression were used to examine the association between vaccination and Pap testing. Results: Vaccinated females were more likely to have had a Pap test within the year prior to the index date than non-vaccinated females (15–19 years old: OR=1.38, 95% CI 1.20–1.59; 20+ years old: OR=2.34, 95% CI 1.98–2.76). In the three-year period after the index date, vaccinated females had a significantly higher cumulative probability of having a Pap test (83.3%) than non-vaccinated females (66.1%). Females who had a Pap test within three years prior to the index date were more likely to have a Pap test after the index date (vaccinated: HR=5.03, 95% CI 4.65–5.45; non-vaccinated HR=3.97, 95% CI 3.70–4.24). Being vaccinated had a significant effect on Pap testing (15–19 years old: HR=1.54, 95% CI 1.39–1.69; 20+ years old: HR=1.87, 95% CI 1.52–2.31). 80.1% of vaccinated females who had a Pap test prior to the index date also had one subsequent to it, compared to 70.1% for non-vaccinated females. 41.1% of females had not been vaccinated nor had a Pap test. Conclusion: The majority of vaccinated females continue to participate in screening, and do so at a higher rate than non-vaccinated females. Renewed efforts need to be made to include the large proportion of non–vaccinated, non–screened females in vaccination and/or screening. [Copyright &y& Elsevier]

We conducted a population-based study in Manitoba, Canada, to investigate whether use of inactivated trivalent influenza vaccine (TIV) during the 2008-09 influenza season was associated with subsequent infection with influenza A(H1N1)pdm09 virus during the first wave of the 2009 pandemic. Data were obtained from a provincewide population-based immunization registry and laboratory-based influenza surveillance system. The test-negative case-control study included 831 case-patients with confirmed influenza A(H1N1)pdm09 virus infection and 2,479 controls, participants with test results negative for influenza A and B viruses. For the association of TIV receipt with influenza A(H1N1)pdm09 virus infection, the fully adjusted odds ratio was 1.0 (95% CI 0.7-1.4). Among case-patients, receipt of 2008-09 TIV was associated with a statistically nonsignificant 49% reduction in risk for hospitalization. In agreement with study findings outside Canada, our study in Manitoba indicates that the 2008-09 TIV neither increased nor decreased the risk for infection with influenza A(H1N1)pdm09 virus. [ABSTRACT FROM AUTHOR]

OBJECTIVES:A higher proportion of colorectal neoplasia among women occurs in the proximal colon, which might be more frequently missed by colonoscopy. There are no data on predictors of developing colorectal cancer (CRC) after a negative colonoscopy in usual clinical practice. We evaluated gender differences and predictors of CRC occurring after a negative colonoscopy.METHODS:All individuals 40 years or older with negative colonoscopy were identified from Manitoba's provincial physicians’ billing claims database. Individuals with less than 5 years of coverage by the provincial health plan, earlier CRC, inflammatory bowel disease, resective colorectal surgery, or lower gastrointestinal endoscopy were excluded. CRC risk after negative colonoscopy was compared to that in the general population by standardized incidence ratios. Cox regression analysis was performed to determine the independent predictors of CRC occurring after negative colonoscopy.RESULTS:A total of 45,985 individuals (18,606 men; 27,379 women) were followed up for 229,090 person-years. After a negative colonoscopy, men had a 40–50% lower risk of CRC diagnosis through most of the follow-up time. Risk among women was similar to that of women in the general population in the first 3 years and then was 40–50% lower. Older subject age and performance of index colonoscopy by non-gastroenterologists were independent predictors for early/missed CRC (cancers occurring within 3 years of negative colonoscopy).CONCLUSIONS:Women may have a higher rate of missed/early CRCs after negative colonoscopy. Predictors of missed/early CRCs after negative colonoscopy include older age and performance of index colonoscopy by a non-gastroenterologist. [ABSTRACT FROM AUTHOR]

OBJECTIVES:We conducted a population-based cohort study to determine the effect of long-term regular use of statins on the risk of colorectal cancer (CRC).METHODS:Individuals who were dispensed statins regularly were identified from Manitoba's population-based prescription drug database and followed up until diagnosis of CRC, migration out of province, death, or December 2005. The incidence of CRC in this group was compared with that among individuals who were never dispensed statins. Stratified analysis was performed to determine the risk after 5 years of regular statin use. Multivariate Poisson regression models were used to adjust for potential confounding by age, sex, and history of diabetes, inflammatory bowel disease, coronary heart disease, lower gastrointestinal endoscopy, resective colorectal surgery, use of nonsteroidal anti-inflammatory drugs, hormone replacement therapy (among women), and median household income. The dose effect was evaluated in defined daily dose units.RESULTS:In total, 35,739 individuals were dispensed statins regularly. In all, 10,287 (49% males; 51% females) long-term (≥5 years) regular statin users were followed up for up to 5 additional years. In multivariate analysis, the incidence rate ratio (IRR) of CRC among those dispensed statins regularly compared with those who were never dispensed statins (n=377,532) was 1.13 (95% confidence interval (CI): 1.02–1.25). The CRC risk among the long-term regular statin users was similar to that for individuals never dispensed statins (IRR, 0.89; 95% CI: 0.70–1.13). A statistically nonsignificant risk reduction was observed among high-dose long-term regular statin users.CONCLUSIONS:These findings suggest that long-term regular use of statins for the current clinical indications does not protect against CRC. The benefit of high-dose long-term statin use needs further evaluation. [ABSTRACT FROM AUTHOR]

Background: Hospitalization and lab confirmed cases of H1N1 have been reported during the first wave of the 2009 pandemic but these are not accurate measures of influenza incidence in the population. We estimated the cumulative incidence of pandemic (H1N1) influenza among pregnant women in the province of Manitoba during the first wave of the 2009 pandemic. Methods: Two panels of stored frozen serum specimens collected for routine prenatal screening were randomly selected for testing before (March 2009, n = 252) and after (August 2009, n = 296) the first wave of the pandemic. A standard hemagglutination inhibition assay was used to detect the presence of IgG antibodies against the pandemic (H1N1) 2009 virus. The cumulative incidence of pandemic (H1N1) influenza was calculated as the difference between the point prevalence rates in the first and second panels. Results: Of the specimens collected in March, 7.1% were positive for the IgG antibodies (serum antibody titre ≥ 1:40). The corresponding prevalence was 15.7% among the specimens collected in August. The difference indicated a cumulative incidence of 8.6% (95% confidence interval [CI] 3.2%-13.7%). The rate differed geographically, the highest being in the northern regions (20.8%, 95% CI 7.9%-31.8%), as compared with 4.0% (95% CI 0.0%-11.9%) in Winnipeg and 8.9% (95% CI 0.0%-18.8%) in the rest of the province. Interpretation: We estimated that the cumulative incidence of pandemic (H1N1) influenza among pregnant women in Manitoba during the first wave of the 2009 pandemic was 8.6%. It was 20.8% in the northern regions of the province. [ABSTRACT FROM AUTHOR]

• An interrupted time series analysis of impact of USIVP in Manitoba. • Increased absolute change in SIV uptake percentage in the lowest income quintiles and with less healthcare utilization among 5–17-year-olds. • An upward annual trend in SIV uptake percentage among 5–17-year-olds. • A downward annual trend in SIV uptake percentage among 45–64-year-olds. • A downward annual trend across all strata of assessed population characteristics within all age groups in Northern Manitoba. Universal seasonal influenza vaccination policy (USIVP) was introduced in Manitoba, Canada in 2010. Its impact on seasonal influenza vaccine (SIV) uptake remains underexplored. We used population-wide data from Manitoba to assess the impact of the USIVP on SIV uptake. The study covered twenty influenza seasons (2000/01–2019/20). We summarized SIV uptake for influenza seasons before and after the USIVP. Utilizing a single-group interrupted time series analysis and appropriately accounting for autocorrelation, we estimated absolute change and annual trend in SIV uptake percentages among 5–17-, 18–44-, and 45–64-year-olds across strata of certain population socioeconomic and health-related characteristics following the USIVP. Average SIV uptake percentage in all age groups was significantly higher after compared with before the USIVP. Following the USIVP, there was no significant absolute change in SIV uptake percentage among 18–44- and 45–64-year-olds overall; however, a significant decrease was observed among 18–44-year-old males in the higher income quintiles, across healthcare utilization, and in some regions of residence. A significant increase was observed among 5–17-year-olds in the lowest income quintiles, in Northern Manitoba, and among those with less healthcare utilization, and no chronic disease. Overall, there was mostly no significant annual trend in SIV uptake percentage among 18–44-year-olds, and while a significant upward and downward trend was observed among 5–17-year-olds and 45–64-year-olds, respectively, a significant downward trend was observed across all strata of population characteristics within all age groups in Northern Manitoba. The USIVP in Manitoba was followed by an absolute increase in SIV uptake percentage only in some socioeconomically disadvantaged subpopulations among 5–17-year-olds. While there was mostly an upward annual trend in SIV uptake percentage among 5–17-year-olds, a downward trend was observed among 45–64-year-olds and across all age groups and subpopulations in socioeconomically disadvantaged Northern Manitoba. These findings are novel for Manitoba and require investigation and public health attention. [ABSTRACT FROM AUTHOR]

• Assessed impact of universal seasonal influenza vaccination policy on seasonal influenza vaccine uptake in Manitoba, Canada. • Significantly increased odds of vaccination 5-years post-policy relative to pre-policy among age groups except ≥65-year-olds. • Mostly homogeneous effect estimates within age groups across strata of assessed socioeconomic/health-related characteristics. • Largely consistent findings irrespective of sex and region of residence. In 2010, the government of the province of Manitoba, Canada introduced universal seasonal influenza vaccination policy (USIVP), providing free-of-charge vaccination to all registered residents of the province at least six months of age. Impact of the policy on seasonal influenza vaccine (SIV) uptake (receipt of vaccine) in Manitoba remains unclear, as there is a lack of published evaluations. We conducted an ecological study, utilizing population-wide data from several linked de-identified Manitoba Health and Seniors Care administrative health databases. The study period was from 2000/01–2019/20 influenza seasons. The primary exposure was USIVP (five influenza seasons pre-policy [2005/06–2009/10] compared with post-policy [2010/11–2014/15]). The outcome was SIV uptake. We conducted pre/post logistic regression analysis stratified by age group (<5-, 5–17-, 18–44-, 45–64-, ≥65-year-olds) and certain population socioeconomic and health-related characteristics. Results are adjusted odds ratios with associated 95 % confidence intervals. We observed significantly increased adjusted odds of SIV uptake post-policy relative to pre-policy in all age groups except ≥65-year-olds already covered from inception of the vaccination programme. The adjusted odds ratios ranged from 0.76 (0.75–0.76) among ≥65-year-olds to 2.15 (2.13–2.18) among 5–17-year-olds, and were largely homogeneous within age groups across sex, income quintiles, regions of residence, and categories of number of visits to primary care physician/hospitalization one year prior to an influenza season except among <5- and 5–17-year-olds. These findings were mostly consistent irrespective of sex and region of residence although there was variability across income quintiles in Northern Manitoba region. Introduction of the USIVP in Manitoba was followed by a significant increase in SIV uptake in the five years post policy among <65-year-olds, with similar increased relative odds of vaccination observed within age groups across subpopulations. The observed variations in the relative odds of vaccination across income quintiles in Northern Manitoba region requires administrative attention. [ABSTRACT FROM AUTHOR]

Pertussis remains poorly controlled relative to other diseases targeted by childhood vaccination programs. We combined estimates from four population-based studies of pertussis vaccine effectiveness (VE) in three Canadian provinces using a meta -analytic approach to improve precision and explore regional variation in VE and durability of protection. Studies were conducted in Alberta, Manitoba, and Ontario over periods ranging from 1996 to 2015. Adjusted log odds ratios (OR; VE = 100*[1-OR]) of the effect of vaccination on pertussis risk were estimated by time since last vaccination in each study and pooled using DerSimonian and Laird random-effects models. We used the I2 statistic to estimate between-study heterogeneity and assessed methodological and clinical heterogeneity through subgroup analyses of study design and age. Data on 3,270 pertussis cases and 23,863 controls were available. Pertussis VE declined from 86% (95% CI 79%-90%, I2 = 81.5%) at < 1 year since last vaccination to 51% (11%-74%, I2 = 80.9%) by ≥ 8 years. Effect estimates were the most heterogeneous in the least and most elapsed time periods since last vaccine dose. This was attributable mostly to variation between provinces in the distribution of age groups and number of vaccine doses received within time periods, as well as study design and small numbers in the most elapsed time period. Interpretation : Consistent trends of decreasing pertussis VE with increasing time since last vaccination across three Canadian provinces indicate the need for immunization schedules and vaccine development to optimize protection for all individuals, especially for adolescents and young adults at greatest risk of infection. [ABSTRACT FROM AUTHOR]

• Comparison of vaccine uptake in 2 and 7 year-old children with and without epilepsy. • Vaccine coverage is similar between children with and without epilepsy. • Children diagnosed early have slightly lower vaccine coverage at age 2 years. Children with epilepsy are at increased risk of complications from vaccine-preventable infections, yet information on vaccine coverage in these children is scarce. We aimed to compare vaccine coverage among children with epilepsy to children without epilepsy. We conducted a retrospective cohort study including all 2005–2013 births in Manitoba and Ontario, Canada, creating two cohorts: 2-year-olds and 7-year-olds (followed to age 2 and 7 years). We split each cohort into epilepsy and non-epilepsy subcohorts. We assessed vaccination coverage based on provincial schedules and determined timeliness of MMR (measles, mumps, rubella) dose 1 (recommended at 12 months) and DTaP (diphtheria, tetanus, pertussis) dose 4 (recommended at 18 months). We used logistic regression to calculate adjusted odds ratios (aORs) of the association between epilepsy and vaccination, combining both provincial estimates using random effects meta -analysis. We included 16,558 2-year-olds (Manitoba, 653; Ontario, 15,905) and 13,004 7-year-olds (Manitoba, 483; Ontario, 12,521) with epilepsy. At age 2 years, the aOR for up-to-date vaccination among children with versus without epilepsy was 0.9 (95% confidence interval 0.8–1.1); at age 7 years it was 1.0 (0.9–1.1). Infants diagnosed with epilepsy before age 6 months were less likely to be up-to-date at age 2 years (0.9; 0.8–0.9), although this difference disappeared by age 7 years. Vaccine timeliness was similar between children with and without epilepsy for MMR dose 1 and DTaP dose 4. Overall, this study suggests that children with epilepsy are not significantly under-vaccinated compared to their peers without epilepsy. As children with epilepsy are at a higher risk of complications from vaccine-preventable diseases, vaccination in children with epilepsy should be optimized, especially early in life, as these children may not be able to rely on herd protection. [ABSTRACT FROM AUTHOR]

• A nested case-control study measuring pertussis vaccine effectiveness (VE). • Acellular pertussis vaccine was effective in preventing disease. • There was a possible decline in protection 8 years post-vaccination. • VE was lower during a large outbreak. • Outbreak periods should be analyzed separately in VE studies. Pertussis persists in Manitoba despite the universal availability of pertussis vaccines. Recent cases have included previously vaccinated individuals, raising concerns about declining vaccine effectiveness (VE). We measured pertussis VE and duration of protection using Manitoba's provincial immunization and communicable disease registries. Using a nested case-control design, individuals with laboratory-confirmed pertussis in Manitoba diagnosed between April 1, 1992, and March 31, 2015, were matched to up to five population-based controls on age, gender, geography, and case physician or number of physician visits. Conditional logistic regression was used to estimate VE against pertussis for both the whole-cell (wP) and acellular (aP) pertussis vaccines. Duration of protection was assessed using time since last dose. Data on 534 eligible cases and 2614 controls were available for analysis. The adjusted VE estimate for aP-containing vaccines was 85% (95%CI: 74–91%); VE was 89% (66–96%) one to three years after the last vaccination. The adjusted VE of wP-containing vaccines was –15% (–91–31%) during a large outbreak in 1994 and 1995 compared to 35% (–26–66%) during non-outbreak years. Our estimates suggest that the aP vaccine was effective in preventing pertussis since its introduction in Manitoba. VE was lower during a large outbreak, highlighting the importance of separately analyzing outbreak periods when estimating pertussis VE over time. [ABSTRACT FROM AUTHOR]

Objective: There is a lack of published evidence on factors associated with adherence (maintenance of cumulative vaccination) to seasonal influenza vaccination (SIV) in Manitoba, Canada. We sought to assess the associations., Methods: A cohort study utilizing Manitoba administrative health databases. Participants received SIV in 2010/11 influenza season, remained registered Manitoba residents and received at least one SIV during the 2011/12‒2019/20 seasons. We dichotomized adherence into "more adherent" (6‒9 SIVs) and "less adherent" (1‒5 SIVs) and used multivariable adjusted generalized estimating equation logistic regression models to assess association between adherence and socioeconomic, health-related, and primary care physician (PCP) characteristics, stratified by age group (< 5, 5‒17, 18‒44, 45‒64, ≥ 65) and sex. Results are adjusted odds ratios with 95% confidence intervals., Results: There were 152,493 participants. Males had lower odds of being more adherent except among ≥ 65-year-olds (1.03, 95% CI 1.01‒1.05). Compared with the lowest income quintile, those in higher income quintiles had higher odds of being more adherent. The odds mostly increased with increase in income quintile. Those with more contact with their PCP/hospitalization one year prior had higher odds of being more adherent. The odds increased with increased contact among those 18‒44, 45‒64 and ≥ 65 years old. Those who had PCP with more years of practice had higher odds of being more adherent. The odds increased as years of practice increased. These observations were mostly consistent irrespective of sex., Conclusion: Female gender, having higher income, having more contact with the health system, and having an experienced PCP may determine increased adherence to SIV in Manitoba. These findings require attention., (© 2024. The Author(s) under exclusive license to The Canadian Public Health Association.)

Background: Better CLL patient survival has been reported for specialized CLL clinics/hematologists (compared to other CLL patients). It is possible that improved survival is driven by a better prognosis of referred patients., Methods: We used logistic regression to calculate the odds ratios (ORs) and 95 % confidence intervals 95 %CIs) of the association between patient characteristics and CLL referral of all persons diagnosed in 2005-2016 with a pathologically-confirmed CLL or SLL., Results: Two-thirds of 1293 patients were referred to the CLL clinic. Referred patients were younger (16 % vs 44 % were 80 +) and in better health (47 % vs 56 % with a chronic diseases) than non-referred patients. Referral increased over time: in 2005-2010, about 60 % of patients were referred; in 2011-2016, this increased to 76 %. Gender did not affect referral (the OR for females is 1.0, 95 %CI 0.8-1.2), but age played a major role; CLL patients diagnosed at age 80 + were less likely to be referred than patients diagnosed < 60, 0.2 (0.1-0.3)., Conclusion: Because referral to Manitoba's specialized CLL clinic is associated with age and the patient's overall health before referral, one should be careful in interpreting differences in outcomes between CLL patients based on referral status alone., Competing Interests: Disclosure of financial relationships CHR has received an unrestricted research grant from Pfizer for an unrelated study. JBJ and VB have received unrestricted research grants from Lundbeck, Gilead and Janssen Pharmaceuticals for unrelated studies and sit on advisory boards for Gilead, Janssen, and Abbvie Pharmaceuticals. VB received consulting fees from AstraZeneca. SMM received research funding from Assurex, GSK, Merck, Pfizer, Roche and Sanofi for unrelated studies and is/was a member of advisory boards for GSK, Merck, Sanofi and Seqirus. None of the other authors have a financial relationship to disclose., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

We assessed Clostridioides difficile toxin testing and positivity for all patients in Manitoba hospitals during June 2016-November 2018. The testing rate was 30 per 10,000 patient bed days (95% confidence interval [CI], 30-31) and the incidence rate was 3.5 per 10,000 patient bed days (95% CI, 3.3-3.7). The context of testing is essential to the interpretation of data among jurisdictions.

Background: In children with epilepsy, fever and illness are known triggers for seizure; therefore, clinicians and parents could be concerned that immunization-induced inflammation and fever could also trigger seizures. We sought to estimate the risk of emergency department (ED) visit or hospitalization for epilepsy/seizure and all causes after immunization in children younger than 7 years of age with epilepsy., Methods: We conducted a self-controlled case series of children diagnosed with epilepsy before their 7th birthday and immunized from 2005 to 2015 in Ontario (population 14.2 million) and Manitoba (population 1.3 million), Canada, using administrative healthcare data. We estimated the age- and season-adjusted relative incidence (aRI) of epilepsy/seizure-related and all-cause ED visits/hospitalizations during various risk periods 0-28 days after inactivated and live immunizations versus a control period 35-83 days postimmunization. Estimates from each province were analyzed separately and then combined in a random-effects meta-analysis., Results: The combined risk of epilepsy/seizure-related hospitalization/ED visit was increased 0-2 days after inactivated vaccines (aRI = 1.5, 95% confidence interval: 1.1-1.9) and 7-10 days after live vaccines (aRI = 1.9, 1.4-2.7). For all-cause ED visit/hospitalization, the combined aRI estimate was 0.9 (0.8-1.2) 0-2 days after inactivated vaccines and 1.3 (1.1-1.5) 7-10 days after live vaccines., Conclusions: The risk of epilepsy/seizure-related ED visit/hospitalization was modestly increased among children with epilepsy during peak periods of fever and inflammation following inactivated and live vaccines. These risks must be balanced against the risk of complications from vaccine-preventable diseases.

Background: A link between statin use and prostate cancer risk has been proposed. Epidemiologic evidence is, however, inconclusive, and data for specific statin types as well as for period, duration, and dose of use are lacking., Methods: We conducted a population-based nested case- control study using administrative data in Manitoba, Canada. Prostate cancer cases were matched to cancer-free controls, and their statin use (including period, duration, and dose of use) was assessed (with adjustment for prostate cancer screening) for statins as a class and for each specific statin., Results: We matched 9,384 prostate cancer cases to 46,749 cancer-free controls. Ever use of any statin was not associated with prostate cancer risk, odds ratio (OR) 0.96 (95% confidence interval, 0.90-1.03). Except for pravastatin, 0.82 (0.71-0.96), individual statins were not associated with prostate cancer risk. There was no dose or duration response for pravastatin (or any other statin)., Conclusions: We found limited evidence of an association between statin use and prostate cancer risk. The association between pravastatin and prostate cancer risk may be due to chance., Impact: We show that statin use is not associated with prostate cancer risk after adjustment for screening for a large population with data going back to the mid-1990s., (©2019 American Association for Cancer Research.)

Objectives: Autism spectrum disorders (ASD) are among the leading causes of disabilities in children. We examined the annual prevalence and incidence rate of ASD between 2004 and 2015 in children aged 1 to 5 years residing in Manitoba., Methods: A population-based study was conducted using the Manitoba Population Research Data Repository. The study included children aged 1 to 5 years residing in Manitoba between 2004 and 2015. Standard identification algorithm was used to identify ASD cases from hospital abstracts and medical claims. Annual prevalence and incidence rates were calculated for the overall population and then stratified according to sex, region, and socio-economic status (SES). Multivariable negative binomial regression models, adjusted for sex, region, and SES, were used to examine changes in prevalence and incidence over study years., Results: Among children aged 1 to 5 years, 1685 ASD cases were diagnosed between 2004 and 2015. The crude ASD prevalence increased from 0.46% in 2004 to 0.97% in 2015 (p = 0.002). The crude incidence rate increased from 0.16% in 2004 to 0.39% in 2015 (p = 0.002). The increase in ASD prevalence and incidence was observed in all subgroups based on sex, region, and SES. The adjusted negative binomial model showed an annual relative risk increase, since 2004, for both prevalence and incidence of 1.69 (95% CI 1.56-1.83) and 1.84 (95% CI 1.62-2.09), respectively., Conclusion: During the period from 2004 to 2015, both prevalence and incidence rates of diagnosed ASD in preschoolers and toddlers residing in Manitoba increased significantly.

Background: Changes in microbiota composition as a result of antibiotics use in early life has been proposed as a possible contributor in the aetiology of autism spectrum disorders (ASD). We aimed to examine the association between early life antibiotic exposure and risk of ASD., Methods: This was a population-based cohort study which included all live births in Manitoba, Canada, between 1 April 1998 and 31 March 2016. We used administrative health data from the Manitoba Population Research Data Repository. Exposure was defined as having filled one or more antibiotic prescription during the first year of life. The main outcome was ASD diagnosis. Cox proportional hazards regression models were used to estimate the risk of developing ASD in the overall population and in a sibling cohort., Results: Of all subjects in the cohort (n = 214 834), 94 024 (43.8%) filled an antibiotic prescription during the first year of life. During follow-up, 2965 children received an ASD diagnosis. Compared with children who did not use antibiotics during the first year of life, those who received antibiotics had a reduced risk of ASD [adjusted hazardz ratio (HR) 0.91, 95% confidence interval (CI) 0.84-0.99). Number of treatment courses and cumulative duration of antibiotic exposure were not associated with ASD. In the sibling-controlled analysis, early life antibiotic exposure was not associated with ASD (adjusted HR 1.03, 95% CI 0.86-1.23)., Conclusions: Our findings suggested no clinically significant association between early life antibiotics exposure and risk of autism spectrum disorders, and should provide reassurance to concerned prescribers and parents.

Antibiotic use during infancy alters gut microbiota and immune development and is associated with an increased risk of childhood asthma. The impact of prenatal antibiotic exposure is unclear. We sought to characterise the association between prenatal antibiotic exposure and childhood asthma.We performed a population-based cohort study using prescription records, hospitalisation records and physician billing claims from 213 661 mother-child dyads born in Manitoba, Canada between 1996 and 2012. Associations were determined using Cox regression, adjusting for maternal asthma, postnatal antibiotics and other potential confounders. Sensitivity analyses evaluated maternal antibiotic use before and after pregnancy.36.8% of children were exposed prenatally to antibiotics and 10.1% developed asthma. Prenatal antibiotic exposure was associated with an increased risk of asthma (adjusted hazard ratio (aHR) 1.23, 95% CI 1.20-1.27). There was an apparent dose response (aHR 1.15, 95% CI 1.11-1.18 for one course; aHR 1.26, 95% CI 1.21-1.32 for two courses; and aHR 1.51, 95% CI 1.44-1.59 for three or more courses). Maternal antibiotic use during 9 months before pregnancy (aHR 1.27, 95% CI 1.24-1.31) and 9 months postpartum (aHR 1.32, 95% CI 1.28-1.36) were similarly associated with asthma.Prenatal antibiotic exposure was associated with a dose-dependent increase in asthma risk. However, similar associations were observed for maternal antibiotic use before and after pregnancy, suggesting the association is either not directly causal, or not specific to pregnancy., Competing Interests: Conflict of interest: M.B. Azad reports grants (unrestricted research grants) from Heart and Stroke Foundation of Canada/Canadian Lung Association /Canadian Respiratory Research Network/Allergy, Genes and Environment Network of Centres of Excellence (co-funders), and from Children's Hospital Foundation of Manitoba, during the conduct of the study. Conflict of interest: S.M. Mahmud reports grants (unrestricted research grants) from GlaxoSmithKline, Sanofi Pasteur, Pfizer, Merck and Roche, outside the submitted work., (Copyright ©ERS 2018.)

To investigate a potential risk for multiple sclerosis (MS) after vaccination with Arepanrix, the GlaxoSmithKline AS03-adjuvanted influenza A(H1N1)pdm09 vaccine, we used the provincewide immunization registry for Manitoba, Canada, to match 341,347 persons vaccinated during the 2009 pandemic to 485,941 unvaccinated persons on age, sex, address, and a propensity score measuring the probability of vaccination. We used a previously validated algorithm to identify MS cases from provincial hospital, physician, and prescription drug claims databases. After 12 months of follow-up, the age-adjusted incidence rate of MS was 17.7 cases per 100,000 person-years in the Arepanrix cohort and 24.2 per 100,000 in the unvaccinated cohort. The corresponding adjusted hazard ratio was 0.9. We observed similar patterns when we measured incidence over the entire follow-up period. The AS03 adjuvant, a candidate for inclusion in future pandemic vaccines, does not appear to increase the short-term risk for MS when included in influenza vaccines.

Background: Several epidemiological studies have shown a positive association between diabetes and increased risk of non-Hodgkin lymphoma (NHL), but the effect of diabetic treatment drugs such as metformin on the risk is unknown. Methods: We conducted a population-based nested case-control study involving 878 NHL cases and 4,364 controls diagnosed with diabetes. Use of metformin and other medications before diagnosis and medical condition histories were assessed using administrative databases. We used conditional logistic regression models to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for use of metformin, adjusting for confounders. Results: Risk of total NHLs is not associated with ever use of metformin (OR, 0.93; 95% CI, 0.79-1.10) among diabetic patients. NHL subtypes were also not associated with metformin use. Conclusions: Metformin use is not associated with overall or subtype NHL risk among diabetic patients. Impact: NHLs are etiologically heterogeneous and larger scale studies are warranted to test the potential effect of metformin by NHL subtype. Cancer Epidemiol Biomarkers Prev; 27(5); 610-2. ©2018 AACR ., (©2018 American Association for Cancer Research.)

Background: The total direct cost of screening and treating all human papillomavirus-related diseases (HPV-RD) has not been measured in a single study. Accurate cost estimates are needed to inform decisions on intervention priorities and evaluate the cost-effectiveness of existing programs. We used province-wide clinical, administrative, and accounting databases to measure direct medical costs of HPV infection in Manitoba (Canada)., Methods: All persons 9 years or older with health insurance coverage in Manitoba between April 2000 and March 2015 were eligible. We identified all persons with an incident HPV-RD and aggregated all medical costs (in 2014 Canadian dollars) related to that condition, including prescription drugs, diagnostic procedures, in-hospital and outpatient treatment, and physician visits., Results: We found that the median cost of treating a case of anogenital warts was $130. An episode of cervical dysplasia had a median cost of $220, compared to $1300 for an episode of cervical carcinoma in situ. The cost of treating HPV-related invasive cancer varied from $15,000 for cervical cancer to $33,000 for oral cavity cancer. Overall, 80% ($145 million) of the total cost was attributable to HPV infection. Cervical screening and follow-up accounted for $96 million (66%) of all costs and this cost component has declined following the introduction of new screening guidelines., Conclusions: Overall, the average direct medical cost of HPV infection was $720 per newborn. The economic burden of HPV remains significant, although changes in cervical screening guidelines, prompted by the introduction of a public HPV vaccine program, appear to have promoted a promising trend towards lower costs.

Background: We assessed the effectiveness of the quadrivalent human papillomavirus vaccine (qHPV) vaccination program in Manitoba, Canada, in reducing incident anogenital warts (AGWs) and to what extent effectiveness depends on age at vaccination and number of doses., Methods: Female participants 9 years or older who received the qHPV in Manitoba between September 2006 and March 2013 (n = 31,464) through the publicly funded school-based program and a high-risk catch-up program were included. They were matched on age and area of residence to unvaccinated female participants. Information on incident AGWs was obtained from provincial administrative databases using validated algorithms. Using stratified Cox regression models, we estimate hazard ratios (HRs) for the association between qHPV and AGWs., Results: For female participants vaccinated at age 18 years or younger, receipt of qHPV was associated with a 40% reduction in AGW risk (HR, 0.6; 95% confidence interval [CI], 0.4-0.8). Further adjustment for socioeconomic and medical history did not alter this estimate. For women vaccinated at age 19 years or older, we saw an increase in AGW incidence, especially among those who were sexually active (HR, 2.8; 95% CI, 2.1-3.7). Among female participants vaccinated at age 18 years or younger, risk of AGWs was lowest among those who received 3 doses, corresponding to a vaccine effectiveness of 56% (95% CI, 30%-70%). For women vaccinated at older age, risk of AGWs remained increased regardless of the number of doses., Conclusions: Women vaccinated at an older (≥19 years) age may be less protected against AGWs, particularly if sexually active before vaccine administration. Further efforts should be targeted at increasing vaccine uptake among preadolescents before the initiation of sexual activity.

Background: The extent to which A(H1N1)pdm09 influenza vaccines prevented hospital admissions with pneumonia and influenza (P&I) during the 2009 pandemic remains poorly understood. We evaluated the effectiveness of the A(H1N1)pdm09 and seasonal influenza vaccines (TIV) used during the 2009 mass vaccination campaign in Manitoba (Canada) in preventing P&I hospitalization., Methods: A population-based record-linkage nested case-control study. Cases (N = 1,812) were persons hospitalized with influenza (ICD-10:J09-J11) or pneumonia (ICD-10:J12-J18) during the study period. Age-, gender- and area of residence-matched controls (N = 7,915) were randomly sampled from Manitoba's Population Registry. Information on receipt of A(H1N1)pdm09 vaccine and TIV was obtained from the Manitoba Immunization Monitoring System, a province-wide vaccine registry., Results: Overall, the adjuvanted A(H1N1)pdm09 vaccine was 27% (95%CI 13-39%) effective against P&I hospitalization ≥ 14 days following administration. Effectiveness seemed lower among older (≥ 65 years) adults (10%; -16-30%), particularly when compared to under-5 children (58%; 30-75%). The number-needed-to-vaccinate to prevent 1 P&I admission was lowest among <4 year-olds (928) and ≥65 years (1,721). VE against hospitalization with laboratory-confirmed A(H1N1)pdm09 was 70% (39-85%) overall and (91%; 62-98%) ≥ 14 days following vaccination., Discussion: Our data suggest that the adjuvanted A(H1N1)pdm09 vaccine was effective in preventing about 55-60% of P&I hospitalizations among children and younger adults who were at much higher risk of infection. Unfortunately, the vaccine was less effective among 65 or older adults. Despite that the vaccine still had a significant population-based impact especially among the very young (<5) and the older (≥ 65 years).

Population-based studies from Europe have suggested that obesity is associated with more advanced stage colorectal cancer on presentation. Obesity is an even more prevalent issue in North America, but comparable data on associations with cancer are lacking. We reviewed the cases of 672 patients with colon cancer diagnosed between 2004 and 2008 in the province of Manitoba who underwent surgical resection at a Winnipeg Regional Health Authority–affiliated hospital. We tested if obesity was associated with more advanced cancer stage or grade. On multivariate analysis, after adjusting for age, sex,tumour location and socioeconomic status, we were unable to show any significant associations between body mass index of 30 or more and advanced stage or grade cancer on presentation. The reasons for the lack of association are likely multifactorial, including the pathophysiology of the disease and process factors, such as screening habits and colonoscopic diagnostic success rates in obese patients.

Purpose: Effectiveness of the quadrivalent human papillomavirus (QHPV) vaccine against cervical dysplasia has not been estimated using population-based individual level data. We assessed the vaccine effectiveness (VE) of the QHPV vaccine against cervical dysplasia using data collected routinely in Manitoba., Methods: Females ≥ 15 years old who received the QHPV vaccine in Manitoba between September 2006 and April 2010 privately (n = 3,541) were matched on age to up to three nonvaccinated females (n = 9,594). We used Cox regression models to estimate the hazard ratios for three outcomes: atypical squamous cells of undetermined significance (ASCUS), low-grade squamous intraepithelial lesions (LSILs), and high-grade SILs (HSILs)., Results: Among the 15- to 17-year-olds, the adjusted VE estimates were 35% (95% CI, -19% to 65%), 21% (-10% to 43%), and -1% (-44% to 29%) against the detection of HSILs, LSILs, and ASCUS, respectively. The corresponding estimates were higher (46% [0% to 71%], 35% [10% to 54%], and 23% [-8% to 45%]) among those who had ≥ one Pap smear after enrollment. The QHPV vaccine was associated with 23% (-17% to 48%) reduction in HSIL risk among those ≥ 18 with no history of abnormal cytology, but there was no evidence of protection among those with such a history (-8% [-59% to 27%])., Conclusion: A significant percentage of vaccinated women may not be protected against HSIL and lesser dysplasia especially if they were vaccinated at older age (≥ 18) or had abnormal cytology before vaccination. These findings affirm the importance of vaccination before any significant exposure to HPV occurs and underscore the need for screening programs that cover all sexually active women, even if they were vaccinated.

Purpose: Site-specific risk of colorectal cancer (CRC) among survivors of endometrial cancer (EC) is not known. The objective of the present study was to assess the risk of CRC (overall and subsite specific) among EC survivors., Methods: A historical cohort study was performed by linking the Manitoba Cancer Registry and the Manitoba Health administrative databases. Each subject diagnosed with EC as her first cancer between 1987 and 2008 was age matched with up to five women with no history of invasive cancer on the index date (date of EC diagnosis). All subjects were followed up to the date of diagnosis of CRC or another cancer, death, migration, or study end point (December 31, 2009). Competing-risk proportional hazards models were used to compare the CRC incidence rates with adjustment for age, history of lower gastrointestinal endoscopy, and socioeconomic status. There were three mutually exclusive (and competing) outcomes: CRC, another primary cancer, and death., Results: A total of 3,115 women with EC and 15,084 without EC were followed up for a total of 145,502 person-years. Women diagnosed with EC at age ≤ 50 years had an increased risk of being diagnosed with CRC (all CRC: hazard ratio [HR] = 4.41; 95% CI, 1.47 to 13.26; right-sided CRC: HR = 7.48; 95% CI, 1.29 to 43.28). There was no increased risk of all CRC among women 51 to 65 years of age or those older than 65 years at the time of EC diagnosis. However, women 51 to 65 years of age at EC diagnosis had an increased risk of right-sided CRC (HR = 2.30; 95% CI, 1.05 to 5.01)., Conclusion: This study suggests young women (age ≤ 50 years) with EC are at increased risk of CRC; risk of right-sided CRC is also increased in women 51 to 65 years old at EC diagnosis.

Objectives: We assessed the performance of syndromic indicators based on Google Flu Trends (GFT) and emergency department (ED) data for the early detection and monitoring of the 2009 H1N1 pandemic waves in Manitoba., Methods: Time-series curves for the weekly counts of laboratory-confirmed H1N1 cases in Manitoba during the 2009 pandemic were plotted against the three syndromic indicators: 1) GFT data, based on flu-related Internet search queries, 2) weekly count of all ED visits triaged as influenza-like illness (ED ILI volume), and 3) percentage of all ED visits that were triaged as an ILI (ED ILI percent). A linear regression model was fitted separately for each indicator and correlations with weekly virologic data were calculated for different lag periods for each pandemic wave., Results: All three indicators peaked 1-2 weeks earlier than the epidemic curve of laboratory-confirmed cases. For GFT data, the best-fitting model had about a 2-week lag period in relation to the epidemic curve. Similarly, the best-fitting models for both ED indicators were observed for a time lag of 1-2 weeks. All three indicators performed better as predictors of the virologic time trends during the second wave as compared to the first. There was strong congruence between the time series of the GFT and both the ED ILI volume and the ED ILI percent indicators., Conclusion: During an influenza season characterized by high levels of disease activity, GFT and ED indicators provided a good indication of weekly counts of laboratory-confirmed influenza cases in Manitoba 1-2 weeks in advance.

Background & Aims: We evaluated the risk of cervical abnormalities in women with inflammatory bowel disease (IBD) in a population-based, nested, case-control study., Methods: Cases with abnormal Papanicolaou (Pap) smears or cervical biopsies were matched with up to 3 controls (normal Pap smears) by year of birth, year of first health care coverage, and number of Pap smears in the preceding 5 years. A diagnosis of IBD before the index date was identified from the University of Manitoba IBD Epidemiology Database. Exposures to immunosuppressant drugs and corticosteroids were determined from the provincial drug prescription database. Analyses were adjusted for socioeconomic status and exposure to oral contraceptives and nonsteroidal anti-inflammatory drugs., Results: 19,692 women with cervical cytologic and/or histologic abnormalities were matched with 57,898 controls with normal Pap smears. There was no association between cervical abnormalities and ulcerative colitis (odds ratio [OR], 1.03; 95% confidence interval [CI], 0.77-1.38). The increase in risk in women with Crohn's disease was limited to those exposed to 10 or more prescriptions of oral contraceptives (OR, 1.66; 95% CI, 1.08-2.54). The combined exposure to corticosteroids and immunosuppressants was associated with increased risk of cervical abnormalities (OR, 1.41; 95% CI, 1.09-1.81). There was no interaction between the effect of IBD and corticosteroids and/or immunosuppressants., Conclusions: These findings do not support an association between IBD itself and the risk of developing cervical abnormalities. An increased risk in patients given a combination of corticosteroids and immunosuppressants should be considered in managing women with IBD.