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1. Recent cervical cancer incidence, stage at diagnosis, and mortality trends in Puerto Rico, 2001–2019

Author: Ana P. Ortiz, Carlos R. Torres-Cintrón, Eduardo J. Santiago-Rodríguez, Jeslie M. Ramos-Cartagena, Tonatiuh Suárez-Ramos, Haluk Damgacioglu, Vivian Colón-López, Karen J. Ortiz-Ortiz, and Ashish A. Deshmukh
Subjects: Cervical cancer, Incidence, Mortality, Epidemiology, Puerto Rico, Medicine
Abstract: Abstract Background Cervical cancer incidence is rising in Puerto Rico (PR). Whether the increase is real or reflective of increased diagnostic scrutiny remains unclear. Methods Using data from the PR Central Cancer Registry for 2001–2019, we estimated trends of hysterectomy-corrected cervical cancer incidence and mortality rates, overall, and by stage at diagnosis and age. Results Overall, cervical cancer incidence (per 100,000) increased 1.6%/year (95% CI, -0.5% to 3.8%) from 12.5 to 15.3, with a prominent increase in distant-stage disease (4.5%/year [95% CI, 1.6% to 8.0%]), particularly among screening age eligible (25–64-year-old) women (5.8%/year [95% CI, 2.1% to 10.6%]). Mortality rates in this age-group remained stable during the study period. Conclusions Increased occurrence of distant-stage disease among screening-eligible women is troubling and may reflect a real increase. Future research is needed to elucidate the factors underlying these trends. Improved prevention is also an urgent priority to reverse the rising cervical cancer incidence in PR.
Published: 2024
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2. Cervical Pap screening among women living with HIV in Puerto Rico and the United States – Medical Monitoring Project, 2018–2021

Author: Marievelisse Soto-Salgado, Lorena González-Sepúlveda, Maritza Cruz-Cortés, Michael I. Rivera-Morales, Sharee Umpierre, Jane R. Montealegre, and Ana P. Ortiz
Subjects: Cervical cancer screening, Women, HIV, Medical Monitoring Project, Puerto Rico, United States, Gynecology and obstetrics, RG1-991, Neoplasms. Tumors. Oncology. Including cancer and carcinogens, RC254-282
Abstract: Our objective was to determine the prevalence of cervical Pap screening among women living with HIV (WLWH) in Puerto Rico (P.R.) and other selected United States (U.S.) jurisdictions. Additionally, we sought to compare selected characteristics of WLWH who underwent cervical Pap screening between P.R. and the other U.S. jurisdictions. We analyzed data from the 2018–2021 cycles of CDC’s Medical Monitoring Project (MMP), a national surveillance system among adults with HIV residing in P.R. (n = 218) and 22 other MMP jurisdictions (n = 3,653). Weighted percentages and 95 % confidence intervals (CIs) for selected characteristics were estimated. Prevalence ratios with predicted marginal means were calculated. An estimated 91.6 % and 84.6 % of WLWH underwent cervical Pap screening in P.R. and the other 22 MMP jurisdictions, respectively (Prevalence Ratio = 1.08, 95% CI = 1.03–1.13). Among WLWH who underwent cervical Pap screening, those in P.R. were more likely to be 50+ years of age, have a household annual income below $20,000, engage in binge drinking, never smoke, and have Medicaid/other public insurance than those in the other 22 MMP jurisdictions (p
Published: 2024
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3. The Puerto Rico community engagement alliance (PR-CEAL) against COVID-19 disparities: outreach and research engagement efforts in disproportionately affected communities

Author: Adriana D. Pons-Calvo, Cynthia M. Pérez, Karelys Canales-Birriel, Zaydelis Tamarit-Quevedo, Norangelys Solís-Torres, Andrea López-Cepero, Enid García-Rivera, María Larriuz, Edna Acosta-Pérez, Marcilyn Colón, Zuleska Soto Román, Ana P. Ortiz, Fabiola Rivera-Gastón, and Vivian Colón-López
Subjects: COVID-19, vaccine, disparities, outreach, research, prevention, Public aspects of medicine, RA1-1270
Abstract: In September 2020, the National Institutes of Health acted in response to the COVID-19 pandemic, recognizing the critical need to combat misinformation, particularly in communities disproportionately affected by the crisis. The Community Engagement Alliance (CEAL) emerged as an initiative dedicated to fostering reliable, science-based information, diversity, and inclusion; aiming to implement effective strategies to mitigate the spread of COVID-19 nationwide. One of the teams participating in this initiative is Puerto Rico-CEAL (PR-CEAL). Our whose goal was to raise awareness about the coronavirus disease and advance research, mainly focusing on vulnerable and underserved populations. This concept paper seeks to outline PR-CEAL’s infrastructure during its initial two cycles, providing insights into the research and community engagement activities designed to enhance prevention, counter misinformation, and foster awareness and uptake of COVID-19 vaccines. Ultimately, our objective is to reflect on the strengths and challenges encountered thus far as we endeavor to sustain this robust infrastructure, addressing ongoing public health issues with a forward-looking approach.
Published: 2024
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4. Association Between Body Mass Index and Cancer Screening Adherence Among Latinas in the United States and Puerto Rico

Author: Maira A. Castaneda-Avila, Jonggyu Baek, Mara M. Epstein, Sarah N. Forrester, Ana P. Ortiz, and Kate L. Lapane
Subjects: cancer, health disparities, obesity, colorectal cancer, epidemiology, Gynecology and obstetrics, RG1-991, Public aspects of medicine, RA1-1270
Abstract: Background: Research on the role of body size on cancer screening is mixed with few studies among Latinas in the United States. We evaluated the association between body size and cancer screening adherence among Latinas living in Puerto Rico and the rest of the United States. Methods: We conducted a cross-sectional study using 2012?2018 Behavioral Risk Factor Surveillance System data among Latinas 50?64 years of age (n?=?16,410). Breast, cervical, and colorectal cancer screening (guideline adherent: yes/no), height and weight were self-reported. Prevalence ratios (PRs) derived from Poisson models were estimated for each cancer screening utilization for Puerto Rico versus rest of the United States by body mass index (BMI) category. Results: Nearly a quarter of women lacked adherence with breast and cervical cancer screening and 43.6% were nonadherent to colorectal cancer screening. Latinas with BMI ?40.0?kg/m2 in both groups were more likely to lack adherence to cervical cancer screening than women with BMI 18.5?24.9?kg/m2. For those with BMI ?40.0?kg/m2, Latinas in Puerto Rico were more likely to lack adherence to colorectal cancer screening recommendations than Latinas living in the rest of the United States (adjusted PR: 1.38; 95% confidence interval?=?1.12?1.70). Conclusions: The role of body size in cancer screening utilization among Latinas differs in women living in Puerto Rico versus in the rest of the United States and varies by cancer type. Understanding Latinas' experience can inform culturally adapted interventions to promote cancer screening.
Published: 2022
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5. Effect of chronic comorbidities on quality of life of gynecologic cancer patients in Puerto Rico

Author: Gloriáliz G. Santiago-Pérez, Claudia P. Amaya-Ardila, Sharee A. Umpierre, and Ana P. Ortiz-Martinez
Subjects: quality of life, genital neoplasms, female, cardiovascular diseases, diabetes mellitus, autoimmune diseases, puerto rico, Medicine, Arctic medicine. Tropical medicine, RC955-962, Public aspects of medicine, RA1-1270
Abstract: Objective. To describe prevalence of chronic diseases and evaluate associations between comorbidities and quality of life in gynecologic cancer patients in Puerto Rico. Methods. A cross-sectional study among 233 women aged ≥21 years with a gynecologic cancer diagnosis. Through telephone interviews, information on comorbidities, quality of life, and other covariates were assessed. Quality of life included six items, assessing physical and mental health. Multivariate logistic regression models were used to estimate magnitude of association between the comorbidities under study (diabetes, cardiovascular and autoimmune diseases) and quality-of-life items, through adjusted prevalence odds ratio (aPOR; 95% confidence interval [CI]). Results. Most women (90.1%) reported one or more comorbidities in addition to their cancer diagnosis; cardiovascular diseases (63.1%) were more common than autoimmune diseases (37.3%) and diabetes (33.9%). Between 30% and 40% of the sample indicated dysfunctions in their general health (39.5%) and frequent physical (33.9%) and mental distress (31.8%). Adjusting for age and gross family income, women with autoimmune diseases presented higher prevalence of frequent limitations for daily activities (aPOR 2.00; 95% CI 1.05–3.81), poor general health (aPOR 3.52; 95% CI 1.90–6.49), frequent mental distress (aPOR 2.19; 95% CI 1.19–4.03), and dissatisfaction with life (aPOR 4.86; 95% CI 1.82–12.95) compared to those who did not report autoimmune diseases. No associations with cardiovascular diseases and diabetes were observed. Conclusions. Quality-of-life dysfunctions were highly prevalent in this population of gynecologic cancer patients. Suffering from autoimmune comorbidities significantly exacerbated those dysfunctions.
Published: 2022
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6. Oral Inflammation and Human Papilloma Virus Association among Hispanics

Author: Maira A. Castañeda-Avila, Cynthia M. Pérez, José Vivaldi, Elba C. Díaz-Toro, Jeslie M. Ramos-Cartagena, Oelisoa M. Andriankaja, and Ana P. Ortiz
Subjects: Dentistry, RK1-715
Abstract: Background. Identifying factors related to persistent human papillomavirus (HPV) infection is essential to reduce the incidence of HPV-related cancers. Objective. To evaluate whether gingival/periodontal inflammation is associated with oral HPV infection. Methods. This cross-sectional study (n = 740) uses data from the follow-up visit of the San Juan Overweight Adults Longitudinal Study, which recruited overweight/obese adults aged 40–65 from Puerto Rico. Participants completed a dental examination and two interviews (face-to-face/ACASI) and provided oral rinse samples for HPV detection. Oral inflammation was assessed using two definitions: (1) the number of sites with bleeding on probing (BOP), and (2) the number of teeth with probing pocket depths (PPD) ≥ 4 mm and BOP. Multivariate logistic regression was used to assess the association between oral inflammation and oral HPV. Results. Nearly three-quarters (72%) of participants were female, and 68% had 50 years or older. Participants with HPV had a higher mean number of sites with BOP (15.5 vs. 10.1) and teeth with PPD ≥ 4 mm and BOP (8.5 vs. 3.2) than participants without HPV (p
Published: 2023
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7. Attitudes towards HPV and COVID school-entry policies among adults living in Puerto Rico

Author: Jessica N. Rivera-Rivera, Olga L. Díaz-Miranda, Diana T. Medina-Laabes, Erick Suárez, Ana P. Ortiz, and Vivian Colón-López
Subjects: covid vaccine, hpv vaccine, vaccine knowledge, source of information, school-entry requirement, puerto rico, Immunologic diseases. Allergy, RC581-607, Therapeutics. Pharmacology, RM1-950
Abstract: Prior to the COVID pandemic, Puerto Rico (PR) had one of the highest Human Papillomavirus (HPV) vaccine rates in the United States. The COVID pandemic and administration of COVID vaccines might have impacted attitudes toward HPV vaccination. This study compared attitudes toward HPV and COVID vaccines with respect to school-entry policies among adults living in PR. A convenience sample of 222 adults (≥21 years old) completed an online survey from November 2021 to January 2022. Participants answered questions about HPV and COVID vaccines, attitudes toward vaccination policies for school-entry, and perceptions of sources of information. We assessed the magnitude of association between the agreement of school-entry policies for COVID and HPV vaccination by estimating the prevalence ratio (PRadjusted) with 95% Confidence Intervals (95% CI). The most trusted source of information for HPV and COVID vaccines were healthcare providers (42% and 17%, respectively) and the CDC (35% and 55%, respectively), while the least trusted were social media (40% and 39%, respectively), and friends and family (23% n = 47, and 17% n = 33, respectively). Most participants agreed that HPV (76% n = 156) and COVID vaccines (69% n = 136) should be a school-entry requirement. Agreement with school policy requiring COVID vaccination was significantly associated with agreement of school policy requiring HPV vaccination (PRadjusted:1.96; 95% CI:1.48–2.61) after controlling for potential confounders. Adults living in PR have an overall positive attitude about mandatory HPV and COVID vaccination school-entry policies, which are interrelated. Further research should elucidate the implications of the COVID pandemic on HPV vaccine attitudes and adherence rates.
Published: 2023
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8. Esfuerzos realizados en Puerto Rico hacia la consolidación de políticas públicas para la prevención de cánceres asociados al VPH

Author: Diana T Medina-Laabes, Vivian Colón-López, Vilnery Rivera-Figueroa, Coralia Vázquez-Otero, Glizette O Arroyo-Morales, Lara Arce-Cintrón, Paola Fernández-Rivera, Idamaris Vega, Roxana Soto-Abreu, Olga L Díaz-Miranda, Ángel Rivera, Iris Cardona, Ana P. Ortiz, Lilliam Rodríguez Capó, and Pamela C. Hull
Subjects: vacunas contra papillomavirus, infecciones por papillomavirus, prevención de enfermedades, política pública, puerto rico, Medicine, Arctic medicine. Tropical medicine, RC955-962, Public aspects of medicine, RA1-1270
Abstract: El propósito de este informe especial es describir cronológicamente los eventos que contribuyeron al desarrollo y aprobación de la legislación e implementación del requisito escolar de vacunación en Puerto Rico (PR), con el fin de prevenir el VPH y los cánceres asociados a este. A partir del 2010, PR inició las aprobaciones de políticas públicas con el objetivo de mejorar el registro de casos de los cánceres y la cobertura de la vacuna contra el VPH a través de los planes médicos en adolescentes de 11 a 18 años. En el 2014, los esfuerzos científicos y comunitarios lograron documentar la magnitud de las enfermedades causadas por el VPH, y desarrollar en conjunto, estrategias de prevención y promoción de la vacuna contra el VPH. En agosto de 2018, PR logró ser uno de los primeros cuatro territorios de los Estados Unidos de América en implementar la vacuna contra el VPH como requisito escolar con el fin de disminuir la incidencia de cánceres asociados al VPH en la isla. En el 2019 se garantizó por ley que todo proveedor de vacunación debe reportar al Registro de Inmunización. El caso de PR demuestra que el desarrollo de políticas públicas junto con colaboraciones entre coaliciones académicas, científicas y comunitarias, logran cambios poblacionales y resultados medibles dirigidos a la prevención de VPH. Países con una problemática de salud pública similar podrían adoptar esfuerzos similares a los presentados, y alinearlos al objetivo de la Organización Mundial de la Salud: erradicación del cáncer cervical para 2030.
Published: 2022
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9. Digital Teaching Competence and Educational Inclusion in Higher Education. A Systematic Review

Author: Ada Janeth Zarceño García De Soriano, Miriam Agreda Montoro, and Ana María Ortiz Colón
Abstract: This article presents a systematic review of the literature with the aim of providing an updated framework for the scientific production developed in the field of digital competence and inclusive education in Higher Education, as indexed in the Web of Science (WoS) and SCOPUS databases. Twenty-one scientific articles published between 2016-2023 were included and analyzed, with no temporal cohort established. The search matches yielded a first document of the topic of study in 2016 in the Social Sciences Citation Index. The results obtained on the conceptual structure of the analyzed documents were carried out through a multiple correspondence analysis (MCA) observing the existence of two dimensions composed of three clusters. Cluster one was composed of studies on digital competence, virtual learning environments, digital divide, and functional diversity, among others. Cluster two comprised studies carried out on digital tools and competencies, inclusive education, educational processes, and digital strategies; while cluster three was made up of educational inclusion related to interculturality and digital competence. Among its limitations, there were aspects related to the heterogeneity of the studies, which make it difficult to compare the data, and the sample and size of the study, which makes the results obtained and the generated data have a lower percentage of generalization compare to studies that use larger simples. This study has implications for researchers and Higher Education institutions interested in research on digital competence for inclusive education, with the possibilities of digital competence for inclusive education being established from the studied variables, allowing teachers to adapt and personalize learning to meet individual student needs. All of this is in line with the goals of the 2030 Agenda, concerning the empowerment of citizens and the digitization of public services to ensure the population's access to such services via the internet.
Published: 2024

10. Effect of Hurricane Maria on HPV, Tdap, and meningococcal conjugate vaccination rates in Puerto Rico, 2015–2019

Author: Vivian Colón-López, Olga L. Díaz-Miranda, Diana T. Medina-Laabes, Roxana Soto-Abreu, Idamaris Vega-Jimenez, Ana P. Ortiz, and Erick L. Suárez
Subjects: hurricane maria, hpv vaccine, immunization, tdap vaccine, meningococcal vaccine, natural disasters, Immunologic diseases. Allergy, RC581-607, Therapeutics. Pharmacology, RM1-950
Abstract: In September 2017, Hurricane Maria devastated the Caribbean region, among them the US territory of Puerto Rico (PR). Vaccination distribution and uptake suffered from the impact. This study evaluated the trends in monthly vaccination initiation rates for human papilloma virus (HPV), Tdap and meningococcal conjugate (MenACWY) adolescent vaccines from 2015 to 2019, during which it was possible to observe and analyze the impact of Hurricane Maria on vaccine initiation. Monthly initiation rates were estimated. Age-standardized initiation rate ratio (SRR) and 95% CI were estimated. The analysis included 85,340 adolescents; 52.3% were male, and 47.7% were females. September 2017 showed HPV vaccine initiation had the lower rates of all the studied vaccines, with a rate of 75% after the disaster (from a rate of almost 90% in July 2017). Tdap and MenACWY vaccines rates remained above 90% in the same period. The SRR of HPV vaccine for September and October 2017 showed an estimated reduction of 5% and 8% in vaccine initiation rates, respectively for each month, when 2016 was the reference year (p > .05). The SRR of Tdap and MenACWY vaccines for November 2017 showed significant reductions when 2015 and 2016 were reference years (p
Published: 2021
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11. Squamous Cell Carcinoma of the Anus Incidence, Mortality, and Survival Among the General Population and Persons Living With HIV in Puerto Rico, 2000-2016

Author: Karen J. Ortiz-Ortiz, Jeslie M. Ramos-Cartagena, Ashish A. Deshmukh, Carlos R. Torres-Cintrón, Vivian Colón-López, and Ana P. Ortiz
Subjects: Neoplasms. Tumors. Oncology. Including cancer and carcinogens, RC254-282
Abstract: PURPOSESquamous cell carcinoma of the anus (SCCA) is common among persons living with HIV (PLWH). We described SCCA incidence and survival among the general population and among PLWH in Puerto Rico (PR), along with mortality of anal cancer.METHODSPR HIV/AIDS Surveillance Program and the PR Central Cancer Registry databases were linked (2000-2016). Incidence rates (IRs) and trends (annual percent change [APC]) in SCCA and mortality rates and trends for anal cancer were estimated. Relative survival and relative excess risk (RER) of death were calculated.RESULTSFrom 2000 to 2016, 991 individuals in PR were diagnosed with anal cancer; 73% of cases were SCCA 9.1% of SCCA and 1.5% of non-SCCA cases were in PLWH (P < .0001). SCCA incidence was higher among PLWH than the general population (IR = 27.7/100,000). Among PLWH, SCCA incidence (per 100,000) was the highest among men who have sex with men (IR = 60.5). From 2001-2016, SCCA incidence increased among the general population (APC: 4.90, P < .05); however, no significant change was observed among PLWH (APC = 0.19 and P = .96). The APC for anal cancer mortality in the general population was positive (3.9%) from 2000 to 2016, but not significant (P > .05). The 5-year relative survival of SCCA was 56.9% among PLWH and 66.8% among the general population. In multivariate analysis, the RER of death for SCCA 5 years postdiagnosis was affected by stage at diagnosis (distant: RER = 7.6, 95% CI, 2.36 to 24.25) but not by PLWH status (RER = 1.4, 95% CI, 0.67 to 3.01).CONCLUSIONOur findings highlight the relevance of anal cancer screening in PLWH and HPV vaccination in both PLWH and the general population in PR, which could have an impact on the disease trend in the next few decades.
Published: 2021
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12. Implementation of the human papillomavirus school-entry requirement in Puerto Rico: barriers and facilitators using the consolidated framework for implementation research

Author: Vivian Colón-López, Roxana Soto-Abreu, Diana T. Medina-Laabes, Olga L. Díaz-Miranda, Ana P. Ortiz, Erick L. Suárez, and Pamela C. Hull
Subjects: cfir, hpv vaccine, school entry requirement, puerto rico, implementation research, hispanic, stakeholders, Immunologic diseases. Allergy, RC581-607, Therapeutics. Pharmacology, RM1-950
Abstract: In 2018, Puerto Rico (PR) enacted a Human papillomavirus (HPV) vaccine school-entry requirement for students ages 11 to 12. Using the Consolidated Framework for Implementation Research (CFIR), we aimed to identify potential barriers and facilitators of this implementation. We conducted 38 qualitative interviews with stakeholders in PR from different organizations (Department of Health, Schools, Healthcare Providers, and Community organizations). We evaluated construct rating variability between the organizations to determine barriers and facilitators. The strongest facilitator determined was stakeholder’s awareness of the parent’s and student’s needs to meet the HPV school-entry requirement. Other facilitators included initiatives for school-entry policies and the relative advantage of this requirement over different strategies. The strongest barriers included was the cost for private providers to administer the HPV vaccine, the negative influence of social media about the vaccine, which affected parents’ acceptance, and the lack of school nurses as available staff resources for the school entry requirement. Findings from this study can be used to improve implementation (adaptations/modifications) and inform other states and countries in earlier stages of consideration of the adoption of similar immunization policies. Most barriers can be modifiable with the implementation of educational programs/training across schools, considering that they are the first line of response to parents of this school entry requirement.
Published: 2021
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13. Understanding parents’ views toward the newly enacted HPV vaccine school entry policy in Puerto Rico: a qualitative study

Author: Vivian Colón-López, Diana T. Medina-Laabes, Roxana Soto Abreu, Olga L. Díaz Miranda, Ana P. Ortiz, María E. Fernández, and Pamela C. Hull
Subjects: HPV vaccine, School entry policy, Parental perspective, Hispanic, Public aspects of medicine, RA1-1270
Abstract: Abstract Background The Human papillomavirus vaccine (HPV) is an essential tool for the prevention of HPV-related cancers. In Puerto Rico, the Secretary of Health established a school entry requirement of at least one dose of HPV vaccination in girls and boys aged 11 and 12 years, taking effect in August 2018. Our study aimed to examine parents’ and guardians’ views of unvaccinated children about the process of implementation of the new HPV vaccination school entry policy in Puerto Rico and identify potential barriers and facilitators related to the implementation of this requirement. Methods During April through November 2019, we conducted three focus groups (n = 12) and eight in-depth semi-structured interviews with parents of children aged 11 and 12 who had not yet initiated the HPV vaccine series. The interview topics addressed were: perception of vaccination, HPV vaccine and it is inclusion as new school entry requirement practice, procedure of the sources of information, influencers, and willingness to change. The interviews were recorded and transcribed by our staff members. We identified emergent themes through thematic analysis. Results The participants’ perspective on the HPV vaccine school requirement was mixed. Lack of information of the HPV vaccines and lack of communication about the school-entry requirement were the themes most mentioned in the interviews. Moreover, previous negative experiences from friends or family members and adverse effects deterred some participants from vaccinating their kids. We discussed barriers in the process of soliciting an exemption. Conclusion Most barriers mentioned by study participants are modifiable. Information about the HPV vaccine mandate’s implementation and educational materials regarding HPV vaccine safety need to be provided to address parents’ concerns related to the vaccine’s side effects. Schools (teachers, principal directors, and administrative staff), the government, and parent organizations need to be part of these efforts. This multilevel approach will help to improve disseminating information about HPV vaccination to clarify doubts and misinformation among parents.
Published: 2021
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14. Sex and educational attainment differences in HPV knowledge and vaccination awareness among unvaccinated-sexually active adults in Puerto Rico

Author: Maira A. Castañeda-Avila, Carla J. Oramas Sepúlveda, Cynthia M. Pérez, Jeslie M. Ramos-Cartagena, Kimil Acosta Pagán, Josué Pérez-Santiago, Filipa Godoy-Vitorino, and Ana P. Ortiz
Subjects: hpv, education, vaccination, knowledge, awareness, men, women, Immunologic diseases. Allergy, RC581-607, Therapeutics. Pharmacology, RM1-950
Abstract: Human papillomavirus (HPV) knowledge and HPV vaccination uptake remain suboptimal. We assessed sex and educational attainment differences in HPV knowledge and vaccine awareness. Data from a cross-sectional study (2018–2021) in Puerto Rico among adults aged 21–49 was analyzed (n = 278). Adequate knowledge was defined as a score of ≥70% of correct responses on a 13-item knowledge scale. Multivariable logistic regression was used to assess the association of sex (men vs. women) and education (high school or less vs. more than high school) categories with adequate HPV knowledge and vaccine awareness. Adequate HPV knowledge was higher among women (53%) and men (46%) with more than high school and was lower among women (46%) and men (27%) with high school or less. For HPV vaccine awareness, similar results were observed. Women (OR = 3.0 ; 95%CI = 1.4–6.2) and men (OR = 2.3 , 95%CI = 1.1–4.8) with more than high school and women with high school or less (OR = 2.3 , 95%CI = 1.0–5.2) were more likely to have adequate HPV vaccine knowledge than men with high-school or less education. Heightened HPV vaccine awareness was also seen among more educated women and men and women with similar lower education when compared to men with ≤ high school. Men and individuals with lower educational attainment were more likely to have inadequate HPV knowledge and vaccine awareness. HPV vaccine-oriented educational interventions should target these high-risk groups.
Published: 2022
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15. Oral microbiota and periodontitis severity among Hispanic adults

Author: Ana P. Ortiz, Kimil T. Acosta-Pagán, Carla Oramas-Sepúlveda, Maira A. Castañeda-Avila, Brayan Vilanova-Cuevas, Jeslie M. Ramos-Cartagena, José A. Vivaldi, Josué Pérez-Santiago, Cynthia M. Pérez, and Filipa Godoy-Vitorino
Subjects: oral cavity, microbiota, 16S rRNA, periodontitis (inflammatory), hispanics, Microbiology, QR1-502
Abstract: BackgroundPeriodontitis, one of the most common bacterial infections characterized by chronic inflammation, is also known to be a risk factor for chronic conditions, including cardiovascular disease and cancer. This inflammation is driven by an altered microbiota with an increase in pathogenic bacteria. We evaluated the association between oral microbiota and periodontitis severity in high-risk Hispanics.MethodThis cross-sectional study recruited 134 sexually active participants aged 21 to 49 years old from STI Clinics in Puerto Rico. A periodontal examination, saliva collection, and an interviewer-administered questionnaire were performed. Periodontal severity was categorized as: having no disease, mild, and moderate/severe and BOP and tooth loos was noted. Saliva samples were collected for genomic DNA extraction, downstream 16S rDNA amplification sequencing, and bioinformatics analyses.ResultsThe structure, composition, and diversity of bacterial communities differed significantly according to periodontal severity. The richness and overall diversity also differed between participants without periodontitis and participants with some level of periodontal disease. A higher abundance of Prevotella, Veillonella, or Treponema was attributed to periodontal disease and Aggregatibacter to severe bleeding on probing, while Neisseria was found in higher abundance in healthy participants, decreasing its levels with drinking, smoking, and oral sex practices.ConclusionsOur findings indicate that dysbiosis occurs as periodontal disease progresses, and both alcohol consumption and smoking habits pose risk factors for oral dysbiosis. These results are of public health and clinical impact, as several bacteria identified could serve in the future as biomarkers for periodontitis and oral cancer risk.
Published: 2022
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16. Content analysis of digital media coverage of the human papillomavirus vaccine school-entry requirement policy in Puerto Rico

Author: Vivian Colón-López, Vilnery Rivera-Figueroa, Glizette O. Arroyo-Morales, Diana T. Medina-Laabes, Roxana Soto-Abreu, Manuel Rivera-Encarnación, Olga L. Díaz-Miranda, Ana P. Ortiz, Katelyn B. Wells, Coralia Vázquez-Otero, and Pamela C. Hull
Subjects: Human papillomavirus, HPV vaccine implementation, School-entry policy requirements, Content analysis, Puerto Rico, Public aspects of medicine, RA1-1270
Abstract: Abstract Background In August 2018, Puerto Rico (PR) became the 4th state or territory in the United States to adopt a human papillomavirus (HPV) vaccine school-entry requirement, for students 11–12 years old. Evidence suggests that the content of media coverage may impact people’s perception of HPV vaccine and their willingness to vaccinate. This study aimed to analyze the content of digital news coverage related to the implementation of the policy in PR. Methods A content review was conducted of digital media published from January 2017 through December 2018. The content reviewed was carried out in two steps: 1) creating a matrix to summarize each article’s content about the policy and 2) qualitative analysis using a grounded theory approach. Results The search resulted in 34 articles obtained from 17 online local and international news outlets that reported the policy's implementation. Analyses showed that 61% of the news articles did not mention the number of required doses, and 79% discussed the new policy concerning cancer prevention. In 2017, news coverage focused mostly on describing the policy, while 2018 coverage focused on controversies surrounding the implementation. Neutral emergent codes included: 1) Description of the policy; 2) Information about HPV related cancers; and 3) General information about HPV vaccine. Negative emergent codes included: 1) infringement to patient and parental autonomy; 2) Hesitancy from the political sector, and 3) Hesitancy from groups and coalitions. Positive content included: 1) knowledge and acceptance of HPV vaccine for cancer prevention; 2) importance of education and protective sexual behaviors; and 3) new vaccination law proposal. Conclusions Most of the media coverage in PR was neutral and included limited information related to the vaccine, HPV, and HPV-related cancers. Neutral and negative themes could influence public concerns regarding the new policy, as well as HPV vaccination rates in PR.
Published: 2021
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17. Disruptions in Oncology Care Confronted by Patients with Gynecologic Cancer Following Hurricanes Irma and Maria in Puerto Rico

Author: William A. Calo PhD, Mirza Rivera MS, Pablo A. Mendez-Lazaro PhD, Sandra I. Garcia-Camacho MPH, Yanina M. Bernhardt Utz MPH, Edna Acosta-Perez PhD, and Ana P. Ortiz PhD
Subjects: Neoplasms. Tumors. Oncology. Including cancer and carcinogens, RC254-282
Abstract: Background In September 2017, hurricanes Irma and Maria affected Puerto Rico (PR) and the US Virgin Islands (USVI), causing major disruptions in basic services and health care. This study documented the stressors and experiences of patients with gynecologic cancer receiving oncology care in PR following these hurricanes. Methods We conducted 4 focus groups (December 2018-April 2019) among women aged ≥21 years from PR who were diagnosed with gynecological cancer between September 2016 and September 2018 (n = 24). Using the same eligibility criteria, we also interviewed patients from the USVI (n = 2) who were treated in PR. We also conducted key-informant interviews with oncology care providers and administrators (n = 23) serving gynecologic cancer patients in PR. Discussions were audio-recorded, transcribed verbatim, and coded to identify emergent themes using a constant comparison method. Results Analyses of focus group discussions and interviews allowed us to identify the following emergent themes: 1) disruptions in oncology care were common; 2) communication between oncology providers and patients was challenging before and after the hurricanes hit; 3) patient resilience was key to resume care; and 4) local communities provided much-needed social support and resources. Conclusions This study provides firsthand information about the disruptions in oncology care experienced by and the resiliency of women with gynecologic cancer following hurricanes Irma and Maria. Our findings underscore the need to incorporate oncology care in the preparedness and response plans of communities, health systems, and government agencies to maintain adequate care for cancer patients during and after disasters such as hurricanes.
Published: 2022
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18. Human papillomavirus vaccine initiation and up-to-date vaccine coverage for adolescents after the implementation of school-entry policy in Puerto Rico

Author: Vivian Colón-López, Pamela C. Hull, Olga L. Díaz-Miranda, Mark Machin, Idamaris Vega-Jimenez, Diana T. Medina-Laabes, Roxana Soto-Abreu, María Fernandez, Ana P. Ortiz, and Erick L. Suárez-Pérez
Subjects: Public aspects of medicine, RA1-1270
Abstract: The human papillomavirus (HPV) vaccine has been proven effective in the prevention of infection with high-risk HPV types, which can lead to the development of six HPV-related cancers. Puerto Rico (PR) adopted a mandatory HPV vaccination school-entry policy that took effect in August 2018. While school-entry requirements are generally accepted as an effective approach for increasing vaccination rates, there are few studies that have documented their impact on improving HPV vaccination rates. The objective of this study was to evaluate the impact of the HPV school-entry policy in PR on HPV vaccine coverage. We used a pre-post natural experiment. The study population included adolescents registered in the PR Immunization Registry during 2008–2019. We calculated HPV vaccine initiation and up-to-date (UTD) vaccine coverage rates. We estimated age-standardized rates (ASR) and standardized rate ratio with 95%CI. Vaccine data corresponding to a total of 495,327 adolescents were included for analysis; 50.9% were male and 49.1% were females. After policy implementation, a marked increase in raw HPV vaccine initiation among 11- to 12-year-old adolescents was observed across years 2017 (a pre-policy year), 2018, and 2019 (58.3%, 76.3%, and 89.8%, respectively). UTD coverage also showed a moderate increase after policy implementation among 11- to 12-year-old adolescents. The gap between sexes in vaccine initiation and UTD coverage narrowed over time; the ASRs in 2019 showed an increase of 19% in initiation and 7% increase in UTD relative to 2017 for males and females combined (both significant at p
Published: 2022

19. Pre-vaccination prevalence of anogenital and oral human papillomavirus in young HIV-infected men who have sex with men

Author: Jessica A. Kahn, Marvin Belzer, Xiaofei Chi, Jeannette Lee, Aditya H. Gaur, Kenneth Mayer, Jaime Martinez, Donna C. Futterman, Elizabeth A. Stier, Mary E. Paul, Elizabeth Y. Chiao, Daniel Reirden, Steven E. Goldstone, Ana P. Ortiz Martinez, Edward R. Cachay, Luis F. Barroso, Maria Da Costa, Craig M. Wilson, and Joel M. Palefsky
Subjects: Infectious and parasitic diseases, RC109-216
Abstract: The aims of this study were to: 1) determine prevalence of anogenital and oral HPV, 2) determine concordance between HPV at anal, perianal, scrotal/penile, and oral sites; and 3) describe factors associated with anogenital HPV types targeted by the 9-valent vaccine. Data were collected from 2012 to 2015 among men who have sex with men 18–26 years of age enrolled in a vaccine trial (N = 145). Penile/scrotal, perianal, anal, and oral samples were tested for 61 HPV types. Logistic regression was used to identify factors associated with types in the 9-valent vaccine. Participants’ mean age was 23.0 years, 55.2% were African-American, and 26.2% were Hispanic; 93% had anal, 40% penile, and 6% oral HPV. Among those with anogenital infection, 18% had HPV16. Concordance was low between anogenital and oral sites. Factors independently associated with a 9-valent vaccine-type HPV were: race (African-American vs. White, OR=2.67, 95% CI=1.11–6.42), current smoking (yes vs. no, OR=2.37, 95% CI=1.03–5.48), and number of recent receptive anal sex partners (2+ vs. 0, OR=3.47, 95% CI=1.16–10.4). Most MSM were not infected with HPV16 or HPV18, suggesting that they may still benefit from HPV vaccination, but anogenital HPV was very common, highlighting the importance of vaccinating men before sexual initiation. Clinical trial number: NCT01209325 Keywords: Adolescents, Clinical trials, Men who have sex with men, Vaccine, Human papillomavirus, HIV
Published: 2019
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20. Influence of Health Beliefs on COVID-19 Vaccination among Individuals with Cancer and Other Comorbidities in Puerto Rico

Author: McClaren Rodriguez, Andrea López-Cepero, Ana P. Ortiz-Martínez, Emma Fernández-Repollet, and Cynthia M. Pérez
Subjects: COVID-19, vaccination, cancer, Puerto Rico, Health Belief Model, Medicine
Abstract: Ethnic minority populations are more likely to suffer from chronic comorbidities, making them more susceptible to the poor health outcomes associated with COVID-19 infection. Therefore, ensuring COVID-19 vaccination among vulnerable populations is of utmost importance. We aimed to investigate health behaviors and perceptions of COVID-19 vaccination among adults self-reporting diagnosis of cancer and of other chronic comorbidities in Puerto Rico (PR). This secondary analysis used data from 1911 participants who completed an online survey from December 2020 to February 2021. The Health Belief Model was used to measure perceptions surrounding COVID-19 vaccination among individuals self-reporting diagnosis of cancer and of other chronic comorbidities, and healthy adults. Among study participants, 76% were female, 34% were 50 years or older, 5% self-reported cancer diagnosis, and 70% had other chronic comorbidities. Participants self-reporting a cancer diagnosis had two times higher odds of getting vaccinated than healthy individuals (95% CI: 1.00–4.30). Compared to healthy participants, those self-reporting being diagnosed with cancer and those with chronic conditions other than cancer had significantly higher perceived COVID-19 susceptibility and severity. Our findings elucidate the effect of disease status on health-related decision-making and highlights information needed to be included in education campaigns to increase vaccine uptake among ethnic minority populations.
Published: 2021
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21. Is obesity a risk for anal neoplasia in a group of HIV-infected Hispanics from Puerto Rico?

Author: Humberto M. Guiot, M, Cristina Muñoz-Massó, MT, MS, Diana Medina-Laabes, MS, Ana P. Ortiz, MPH, PhD, Vivian Colón-López, MPH, PhD, and Maribel Tirado-Gómez, MD
Subjects: Infectious and parasitic diseases, RC109-216
Abstract: Background: Obesity has been associated with the development of cancer, including cervical cancer, probably due metabolic dysregulation and chronic inflammation. Given the similarity in the pathophysiology of cervical and anal neoplasia, we aimed at evaluating if overweight (BMI: 25–29.9 kg/m2) and obesity (BMI ≥30 kg/m2) are a risk for anal high-grade squamous intraepithelial lesions (HSIL) in a group of HIV-infected Hispanics from Puerto Rico. Methods: A cross-sectional study was performed using data from the medical records of 291 HIV-positive patients of the Anal Neoplasia Clinic of the University of Puerto Rico Comprehensive Cancer Center from June 2015 to April 2018. Logistic regression models were used to estimate the odds ratio (OR) with 95% confidence intervals (CI) for estimating the association between overweight and obesity with HSIL (based on histopathology and based on the definition of the LAST project), controlling for potential confounders. Results: Overall, 35.4% and 25.1% of patients were overweight and obese, respectively. The prevalence of HSIL was 45.2% among under/normal weight patients, 36.9% among overweight patients and 35.6% for obese patients (p-trend=0.16). Although decreased odds of HSIL were observed among overweight (OR=0.67, 95% CI=0.37–1.21) and obese (OR=0.71, 95% CI=0.36–1.38) patients than under/normal weight patients after adjusting for age, gender, history of diabetes, and having > 10 lifetime sexual partners, these results were not statistically significant. Conclusions: Overweight and obesity are frequent among our patients, but we found no significant association between overweight/obesity and HSIL. Although our study may be limited in sample size, future studies should further assess this association and the potential biological mechanisms for it.
Published: 2018
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22. A Recurrent BRCA2 Mutation Explains the Majority of Hereditary Breast and Ovarian Cancer Syndrome Cases in Puerto Rico

Author: Hector J. Diaz-Zabala, Ana P. Ortiz, Lisa Garland, Kristine Jones, Cynthia M. Perez, Edna Mora, Nelly Arroyo, Taras K. Oleksyk, Miguel Echenique, Jaime L. Matta, Michael Dean, and Julie Dutil
Subjects: breast cancer genetics, BRCA1/BRCA2, founder effect, Hispanic and Latino populations, Neoplasms. Tumors. Oncology. Including cancer and carcinogens, RC254-282
Abstract: Breast cancer is the most common cause of cancer diagnosis in women and is responsible for considerable mortality among the women of Puerto Rico. However, there are few studies in Puerto Rico on the genetic factors influencing risk. To determine the contribution of pathogenic mutations in BRCA1 and BRCA2, we sequenced these genes in 302 cases from two separate medical centers, who were not selected for age of onset or family history. We identified nine cases that are carriers of pathogenic germline mutation. This represents 2.9% of unselected cases and 5.6% of women meeting National Comprehensive Cancer Network (NCCN) criteria for BRCA testing. All of the identified pathogenic mutations were in the BRCA2 gene and the most common mutation is the p.Glu1308Ter (E1308X) mutation in BRCA2 found in eight out of nine cases, representing 89% of the pathogenic carriers. The E1308X mutation has been identified in breast and ovarian cancer families in Spain, and analysis of flanking DNA polymorphisms shows that all E1308X carriers occur on the same haplotype. This is consistent with BRCA2 E1308X being a founder mutation for the Puerto Rican population. These results will contribute to better inform genetic screening and counseling of breast and ovarian cancer cases in Puerto Rico and Puerto Rican populations in mainland United States.
Published: 2018
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23. [Untitled]

Author: Vivian Colón-López, Ana P. Ortiz, Marievelisse Soto-Salgado, Mariela Torres-Cintrón, Curtis A. Pettaway, Antonio Puras-Báez, Magaly Martínez-Ferrer, and Erick Suárez
Subjects: Urogenital Neoplasms, Penile Neoplasms, Epidemiology, Minority Health, Healthcare Disparities, Diseases of the genitourinary system. Urology, RC870-923
Abstract: PurposeThis study compares incidence and mortality of penile cancer in Puerto Rico (PR) with other racial/ethnic groups in the United States (US) and evaluates the extent in which socioeconomic position index (SEP) or its components influence incidence and mortality in PR.Materials and MethodsAge-standardized rates were calculated for incidence and mortality based on data from the PR Cancer Registry and the US National Cancer Institute's Surveillance, Epidemiology and End Results program, using the direct method.ResultsPR men had approximately 3-fold higher incidence of penile cancer as compared to non-Hispanic white (Standardized rate ratio [SRR]: 3.33; 95%CI=2.80-3.95). A higher incidence of penile cancer was also reported in PR men as compared to non-Hispanic blacks and Hispanics men. Mortality from penile cancer was also higher for PR men as compared to all other ethnic/racial groups. PR men in the lowest SEP index had 70% higher incidence of penile cancer as compared with those PR men in the highest SEP index. However, the association was marginally significant (SRR: 1.70; 95%CI=0.97, 2.87). Only low educational attainment was statistically associated with higher penile cancer incidence (SRR: 2.18; 95%CI=1.42-3.29).ConclusionsAlthough penile cancer is relatively uncommon, our results support significant disparities in the incidence and mortality rates among men in PR. Low educational attainment might influence the high incidence of penile cancer among PR men. Further studies are strongly recommended to explore these disparities.
Published: 2012

24. Penile Cancer Disparities in Puerto Rican Men as compared to the United States Population

Author: Vivian Colón-López, Ana P. Ortiz, Marievelisse Soto-Salgado, Mariela Torres-Cintrón, Curtis A. Pettaway, Antonio Puras-Báez, Magaly Martínez-Ferrer, and Erick Suárez
Subjects: Urogenital Neoplasms, Penile Neoplasms, Epidemiology, Minority Health, Healthcare Disparities, Diseases of the genitourinary system. Urology, RC870-923
Abstract: PurposeThis study compares incidence and mortality of penile cancer in Puerto Rico (PR) with other racial/ethnic groups in the United States (US) and evaluates the extent in which socioeconomic position index (SEP) or its components influence incidence and mortality in PR.Materials and MethodsAge-standardized rates were calculated for incidence and mortality based on data from the PR Cancer Registry and the US National Cancer Institute's Surveillance, Epidemiology and End Results program, using the direct method.ResultsPR men had approximately 3-fold higher incidence of penile cancer as compared to non-Hispanic white (Standardized rate ratio [SRR]: 3.33; 95%CI=2.80-3.95). A higher incidence of penile cancer was also reported in PR men as compared to non-Hispanic blacks and Hispanics men. Mortality from penile cancer was also higher for PR men as compared to all other ethnic/racial groups. PR men in the lowest SEP index had 70% higher incidence of penile cancer as compared with those PR men in the highest SEP index. However, the association was marginally significant (SRR: 1.70; 95%CI=0.97, 2.87). Only low educational attainment was statistically associated with higher penile cancer incidence (SRR: 2.18; 95%CI=1.42-3.29).ConclusionsAlthough penile cancer is relatively uncommon, our results support significant disparities in the incidence and mortality rates among men in PR. Low educational attainment might influence the high incidence of penile cancer among PR men. Further studies are strongly recommended to explore these disparities.
Published: 2012
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25. Emergency Presentation and Short-Term Survival Among Patients With Colorectal Cancer Enrolled in the Government Health Plan of Puerto Rico

Author: Karen J. Ortiz-Ortiz, Ruth Ríos-Motta, Heriberto Marín-Centeno, Marcia R. Cruz-Correa, and Ana P. Ortiz
Subjects: Medicine (General), R5-920, Public aspects of medicine, RA1-1270
Abstract: Objective: In this study, we examine factors associated with the use of the emergency room (ER) as an entry point into the health-care system to initiate a cancer diagnosis among Puerto Rico’s Government Health Plan (GHP) patients and compare the 1-year survival of GHP patients that initiated cancer diagnosis in the emergency room (ER) presentation with those that initiated the diagnosis in a physician’s office. Methods: Data for patients with colorectal cancer (CRC) aged 50 to 64 years and diagnosed in 2012 were obtained from the Puerto Rico Central Cancer Registry and linked to the Puerto Rico Health Insurance Administration database (n = 190). Crude odds ratio, adjusted odds ratio, and their 95% confidence intervals were reported. We used the Kaplan-Meier method to generate survival curves. Multivariate Cox regression analysis was performed to evaluate the association between ER presentation and 1-year cause-specific survival. Results: We found that 37.37% of the study population had an ER presentation. Male patients had a higher occurrence of having an ER presentation (66.20%), while 76.06% of the patients with an ER presentation were diagnosed in late stage. Emergency room presentation was a highly predictive factor for cancer mortality in the year following the diagnosis. These patients had between 3.99 to 4.24 times higher mortality risk than non-ER presentation patients ( P < .05). Conclusion: Late presentation for CRC diagnosis through an ER visit is a significant concern that influences negatively on the patient’s outcome. Efforts at increasing primary care visits and routine screening tests among GHP beneficiaries could improve survival.
Published: 2016
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26. Pre-vaccination prevalence of anogenital and oral human papillomavirus in young HIV-infected men who have sex with men

Author: Kahn, Jessica A, Belzer, Marvin, Chi, Xiaofei, Lee, Jeannette, Gaur, Aditya H, Mayer, Kenneth, Martinez, Jaime, Futterman, Donna C, Stier, Elizabeth A, Paul, Mary E, Chiao, Elizabeth Y, Reirden, Daniel, Goldstone, Steven E, Martinez, Ana P Ortiz, Cachay, Edward R, Barroso, Luis F, Da Costa, Maria, Wilson, Craig M, Palefsky, Joel M, and Interventions, for the AIDS Malignancy Consortium and Adolescent Medicine Trials Network for HIV AIDS
Subjects: Biomedical and Clinical Sciences, Clinical Sciences, HIV/AIDS, Infectious Diseases, Prevention, Urologic Diseases, Immunization, Sexually Transmitted Infections, Cancer, HPV and/or Cervical Cancer Vaccines, Vaccine Related, Clinical Research, Infection, Good Health and Well Being, Adolescent, Adult, Anal Canal, Genitalia, Male, HIV Infections, Homosexuality, Male, Humans, Male, Mouth, Papillomaviridae, Papillomavirus Infections, Prevalence, Young Adult, Adolescents, Clinical trials, Men who have sex with men, Vaccine, Human papillomavirus, HIV, AIDS Malignancy Consortium and Adolescent Medicine Trials Network for HIV/AIDS Interventions, Medical microbiology, Oncology and carcinogenesis
Abstract: The aims of this study were to: 1) determine prevalence of anogenital and oral HPV, 2) determine concordance between HPV at anal, perianal, scrotal/penile, and oral sites; and 3) describe factors associated with anogenital HPV types targeted by the 9-valent vaccine. Data were collected from 2012 to 2015 among men who have sex with men 18-26 years of age enrolled in a vaccine trial (N = 145). Penile/scrotal, perianal, anal, and oral samples were tested for 61 HPV types. Logistic regression was used to identify factors associated with types in the 9-valent vaccine. Participants' mean age was 23.0 years, 55.2% were African-American, and 26.2% were Hispanic; 93% had anal, 40% penile, and 6% oral HPV. Among those with anogenital infection, 18% had HPV16. Concordance was low between anogenital and oral sites. Factors independently associated with a 9-valent vaccine-type HPV were: race (African-American vs. White, OR=2.67, 95% CI=1.11-6.42), current smoking (yes vs. no, OR=2.37, 95% CI=1.03-5.48), and number of recent receptive anal sex partners (2+ vs. 0, OR=3.47, 95% CI=1.16-10.4). Most MSM were not infected with HPV16 or HPV18, suggesting that they may still benefit from HPV vaccination, but anogenital HPV was very common, highlighting the importance of vaccinating men before sexual initiation. CLINICAL TRIAL NUMBER: NCT01209325.
Published: 2019

27. Screening History and Survival Among Women With Cervical Cancer in Puerto Rico

Author: Vanessa, Gómez-Vargas, Karen J, Ortiz-Ortiz, Israel, Almodóvar-Rivera, Carlos R, Torres-Cintrón, Ashish A, Deshmukh, and Ana P, Ortiz
Subjects: Obstetrics and Gynecology, General Medicine
Abstract: Cervical cancer incidence is rising in Puerto Rico (PR). Screening for cervical cancer could prevent the occurrence of the disease or lead to its early detection, translating to survival benefits. In this study, we evaluated the association of cervical cancer screening status with tumor diagnosis and survival among Hispanic women living in PR.We analyzed data for 506 incident cases of primary cervical cancer diagnosed from the period 2011-2014, identified through the PR Central Cancer Registry. We ascertained screening status 3 years before cervical cancer diagnosis using data from the period 2008-2014 from the PR Central Cancer Registry-Health Insurance Linkage Database. Patients were followed until 2019. Our outcomes of interest were stage at diagnosis and survival.Most women (78.86%) were covered by public insurance (Medicare and/or Medicaid), and 69.57% underwent screening 3 years before their diagnosis. The proportion of cases diagnosed with localized stage was significantly greater among the screened group compared with those unscreened (43.5% vs 33.1%, p.0001). Multivariate analysis showed that women insured through Medicaid were less likely to have been screened when compared with women with private insurance (odds ratio = 0.29; 95% CI = 0.16-0.52). Five-year survival was significantly greater among screened (72%) than unscreened (54%) women (plog-rank0.05). The multivariate Cox proportional hazards model showed that women who received screening had a 39% (hazard ratio [HR] = 0.61; 95% CI = 0.43-0.87) lower risk of death compared with unscreened women.Our findings exemplify survival benefits among women who underwent cervical cancer screening in PR. Interventions to improve screening uptake and adherence are a public health priority.
Published: 2022

28. Association Between the Hypertriglyceridemic Waist Phenotype, Prediabetes, and Diabetes Mellitus Among Adults in Puerto Rico

Author: Díaz-Santana, Mary Vanellys, Pérez, Erick L. Suárez, Martínez, Ana P. Ortiz, Serrano, Manuel Guzmán, and Cardona, Cynthia M. Pérez
Published: 2016

29. Age-Specific Prevalence of Anal and Cervical Human Papillomavirus Infection and High-Grade Lesions in 11 177 Women by Human Immunodeficiency Virus Status: A Collaborative Pooled Analysis of 26 Studies

Author: Feixue Wei, Ningshao Xia, Rebeca Ocampo, Marc T Goodman, Nancy A Hessol, Beatriz Grinsztejn, Ana P Ortiz, Fanghui Zhao, Erna M Kojic, Rupert Kaul, Isabelle Heard, Imran O Morhason-Bello, Anna-Barbara Moscicki, Alexandra de Pokomandy, Joel M Palefsky, Luana L S Rodrigues, Racheal S Dube Mandishora, Reshmie A Ramautarsing, Silvia Franceschi, Sheela V Godbole, Fernanda K Tso, Lynette J Menezes, Chunqing Lin, and Gary M Clifford
Subjects: Adult, HPV, Adolescent, Squamous Intraepithelial Lesions, Anal Canal, Uterine Cervical Neoplasms, HIV Infections, Cervix Uteri, Cervical Cancer, Medical and Health Sciences, Microbiology, Young Adult, cervix, Prevalence, Immunology and Allergy, Humans, 2.2 Factors relating to the physical environment, Aetiology, Papillomaviridae, Early Detection of Cancer, Cancer, Human papillomavirus 16, Prevention, Papillomavirus Infections, Age Factors, virus diseases, HIV, Human Papillomavirus Viruses, anus, Biological Sciences, Anus Neoplasms, female genital diseases and pregnancy complications, Infectious Diseases, Good Health and Well Being, Sexually Transmitted Infections, HIV/AIDS, Female, women, Infection
Abstract: Background Age-specific data on anal, and corresponding cervical, human papillomavirus (HPV) infection are needed to inform female anal cancer prevention. Methods We centrally reanalyzed individual-level data from 26 studies reporting HPV prevalence in paired anal and cervical samples by human immunodeficiency virus (HIV) status and age. For women with HIV (WWH) with anal high-grade squamous intraepithelial lesions or worse (HSIL+), we also investigated concurrent cervical cytopathology. Results In HIV-negative women, HPV16 prevalence decreased significantly with age, both at anus (4.3% at 15–24 years to 1.0% at ≥55 years; ptrend = 0.0026) and cervix (7.4% to 1.7%; ptrend < 0.0001). In WWH, HPV16 prevalence decreased with age at cervix (18.3% to 7.2%; ptrend = 0.0035) but not anus (11.5% to 13.9%; ptrend = 0.5412). Given anal HPV16 positivity, concurrent cervical HPV16 positivity also decreased with age, both in HIV-negative women (ptrend = 0.0005) and WWH (ptrend = 0.0166). Among 48 WWH with HPV16-positive anal HSIL+, 27 (56%) were cervical high-risk HPV-positive, including 8 with cervical HPV16, and 5 were cervical HSIL+. Conclusions Age-specific shifts in HPV16 prevalence from cervix to anus suggest that HPV infections in the anus persist longer, or occur later in life, than in the cervix, particularly in WWH. This is an important consideration when assessing the utility of cervical screening results to stratify anal cancer risk.
Published: 2023

30. Implementation of the human papillomavirus school-entry requirement in Puerto Rico: barriers and facilitators using the consolidated framework for implementation research

Author: Olga L Díaz-Miranda, Ana P. Ortiz, Roxana Soto-Abreu, Vivian Colón-López, Erick Suárez, Diana T. Medina-Laabes, and Pamela C. Hull
Subjects: Pharmacology, Medical education, Schools, Papillomavirus Infections, Puerto Rico, education, Immunology, virus diseases, School entry, Alphapapillomavirus, humanities, Political science, Humans, Immunology and Allergy, Papillomavirus Vaccines, Implementation research, Human papillomavirus, Child, Papillomaviridae, geographic locations, Research Paper
Abstract: Background: In 2018, Puerto Rico (PR) enacted a Human papillomavirus (HPV) vaccine school-entry requirement for students ages 11 to 12. Using the Consolidated Framework for Implementation Research (CFIR), we aimed to identify potential barriers and facilitators of this implementation.Methods: We conducted a total of 36 qualitative interviews with key informants who were stakeholders from different organizations (Department of Health, Schools, Healthcare Providers, and Community organizations in favor of the requirement) from July 2018 to January 2020. Three researchers performed the interview guide, data coding, and analysis according to the CFIR framework. We evaluated construct rating variability between the organizations to determine barriers and facilitators. Results: The strongest facilitators determined under the CFIR construct include the stakeholder's awareness of the parent's and student's needs to meet the HPV school-entry requirement. Other facilitators include initiatives for school-entry policies and the relative advantage of this requirement over different strategies. The strongest barriers included the cost for private providers to administer the HPV vaccine, the negative influence of social media about the vaccine, which affected parents' acceptance, and the lack of school nurses as available staff resources for the school entry requirement. Conclusions: Findings from this study can be used to improve implementation (adaptations/modifications) and inform other US states and countries in earlier stages of consideration of the adoption of similar immunization policies. Most barriers can be modifiable with the implementation of educational programs/training across schools, considering that they are the first line of response to parents of this school entry requirement.
Published: 2021

31. Abstract 721: Vaccination barriers for HPV vaccine initiation and completion: A perception analysis using the Association of Immunization Managers annual survey

Author: Alondra Katerina Mercado-Andino, Erick L. Suárez-Pérez, Olga L. Díaz-Miranda, Diana T. Medina-Labees, Ana P. Ortiz, Katelyn Wells, and Vivian Colón-López
Subjects: Cancer Research, Oncology
Abstract: Background: Human Papillomavirus (HPV) is the most common sexually transmitted infection in the United States of America (USA) and it is associated with six types of cancers. Vaccines that protect against HPV infection have been introduced since 2006. Despite many national efforts, vaccination rates remain under 80% and many individual and systematic barriers influence HPV vaccine uptake and completion. Addressing the stem of these barriers at a national level and their regional differences, will help in understanding necessary policies for the acceptance of HPV vaccine. Objective: This study aims to describe the frequency of immunization program managers’ perceptions of the most relevant barriers to HPV vaccination in each national jurisdiction. Methods: Immunization Program Managers (IPMs) in the USA were surveyed from August 2021 to February 2022 as part of the Implementation of School-Entry Policies for Papilloma Virus Vaccination (HPV-PIVac) study with the collaboration of the Association of Immunization Managers. We gathered IPMs perceptions on the most relevant barriers to HPV vaccination within their jurisdiction. Four vaccine barriers were evaluated; for each one, IPMs reported the level (moderate, significant, no barrier) in a three-item scale. The three-item scale was merged into a two-item scale (low/high) and multiple answers from the same state were grouped. Descriptive analysis was performed for each question and results were mapped. Fisher’s exact test was performed to determine the relation between barriers. IPMs that refused or didn’t know their jurisdiction’s barriers were removed from the analysis. Results: 49 IPMs from 31 states and territories participated, resulting in a 53.4% participation rate. For the cost barrier to complete HPV vaccination of children, most IPMs perceived low barriers (51.7%) within their jurisdiction. For the perception of geographical difficulties to complete HPV vaccination, higher barriers (67.9%) were reported among participants. Limited number of providers offering the HPV vaccine was perceived equally as low or high level (50.0%), whereas lack of a strong provider recommendation or failure of providers to discuss and strongly recommend the HPV vaccine was the most significant barrier with a higher level (96.7%). Fisher’s exact test indicated independency between all barriers (p>0.05). For most variables, the Western region reported a greater level of barriers. Conclusion: This analysis documents the IPMs perception of prevalent HPV vaccine barriers for vaccine initiation and completion nationally. These results confirmed the need of further engagement for the accessibility of the vaccine, as preliminary data from NIS-Teen 2021 shows an average adolescent HPV vaccine initiation and UTD coverage of 78.2 and 62.7, respectfully. Funding: NCI Grant #R01CA232743 Citation Format: Alondra Katerina Mercado-Andino, Erick L. Suárez-Pérez, Olga L. Díaz-Miranda, Diana T. Medina-Labees, Ana P. Ortiz, Katelyn Wells, Vivian Colón-López. Vaccination barriers for HPV vaccine initiation and completion: A perception analysis using the Association of Immunization Managers annual survey [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 721.
Published: 2023

32. Abstract 4179: Anal cancer risk factors and utilization of cancer preventive strategies in people living with HIV in Puerto Rico

Author: Sandra I. Garcia-Camacho, Jeslie M. Ramos-Cartagena, Marievelisse Soto-Salgado, Vivian Colon-Lopez, Karen J. Ortiz-Ortiz, Ashish A. Deshmukh, and Ana P. Ortiz
Subjects: Cancer Research, Oncology
Abstract: Introduction: Anal cancer (AC) risk is greatly elevated among persons living with HIV (PLWH), particularly men who have sex with men (MSM). The incidence of anal cancer among PLWH in Puerto Rico is 60.5 per 100,000 in MSM. Smoking and sexual behaviors may enhance anal cancer risk among PLWH. Therefore, we describe the prevalence of risk factors for AC, overall and by sexual risk group (MSM, women, and men who have sex with women [MSW]). We also evaluated receipt of cancer preventive strategies: HPV vaccination and AC screening, among a sample of PLWH in Puerto Rico. Methods: A cross-sectional study was conducted (Sept 2020 - Dec 2021) among PLWH ≥26 aged in Puerto Rico (n=212). Participants answered a phone interview that collected information on relevant characteristics. AC risk factors evaluated were current smoking, age of sexual initiation (≤15 years), lifetime anal sex, 10 or more lifetime sexual partners, history of AIDS, genital warts, and HPV infection. HPV vaccination and AC screening status were also evaluated. The overall and sexual risk group specific prevalence of AC risk factors and preventive behaviors were described. In addition, the prevalence ratio (PR) of the variables of interest, comparing the sexual risk groups, was estimated with 95% confidence intervals using Poisson regression. Results: Mean age of participants was 52.8 ± (SD=10.2); 44.1% were MSM, 23.2% were MSW, and 32.7% were women. Most PLWH had public health insurance (84.4%), an education level of high-school or less (45.7%), and 9.5% had a history of intravenous drug use. Regarding the prevalence of AC risk factors, 58.3% had 10 or more lifetime sex partners, 51% had their first sexual relationship at age ≤15 years, 29.3% were current smokers, and 75.8% of women had history of anal sex. In addition, 20.8% reported being diagnosed with AIDS, 16.5% had a history of genital warts, and 12.0% had HPV infection. Only 7.5% reported HPV vaccination and 52.2% reported ever having had an anal pap test. MSM had the highest prevalence of risky sexual behaviors, although no statistical difference was seen in the PRs. For preventive strategies, women (PR: 3.13, 95% CI 1.52-6.46) and MSM (PR: 3.42, 95% CI 1.70-6.90) had higher prevalence of anal pap uptake than MSW. Conclusion: Persons living with HIV in Puerto Rico had high prevalence of current smoking use and risky sexual behavior. Despite their increased risk of AC, and only over half had been screened for AC. Continued education and awareness about AC risk factors, smoking cessation, and importance of prevention strategies are important among PLWH. Citation Format: Sandra I. Garcia-Camacho, Jeslie M. Ramos-Cartagena, Marievelisse Soto-Salgado, Vivian Colon-Lopez, Karen J. Ortiz-Ortiz, Ashish A. Deshmukh, Ana P. Ortiz. Anal cancer risk factors and utilization of cancer preventive strategies in people living with HIV in Puerto Rico. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 4179.
Published: 2023

33. Abstract A128: National partnerships for HPV promotion: An evaluation using the Association of Immunization Managers annual survey

Author: Alondra K. Mercado-Andino, Yiana G. Toro-Garay, Olga L. Díaz-Miranda, Diana T. Medina-Laabes, Ana P. Ortiz, Katelyn Wells, Erick Suárez, and Vivian Colón-López
Subjects: Oncology, Epidemiology
Abstract: Background: Human Papillomavirus (HPV) is the most common sexually transmitted infection in the United States of America (USA). Strategies from immunization programs aimed to promote HPV vaccine uptake through different alliances, including health community-based organizations and coalitions have been implemented nationally. Despite these efforts, vaccination rates remain under 80%. Understanding the extent of these partnerships and the geographic differences in the number of collaborations will aid in identify successful alliances at the national level for the promotion of HPV vaccine. Objective: This study aims to describe the frequency and the degree of partnerships for the promotion of the HPV vaccine. Methods: Immunization Program Managers (IPMs) in the USA were surveyed from August 2021 to February 2022 as part of the Implementation of School-Entry Policies for Papilloma Virus Vaccination (HPV-PIVac) study. A survey gathered information from IPMs on established partnerships and their extent of collaborations at two different levels. Of 22 partners, IPMs reported which groups or organizations had partnerships for HPV vaccine promotion occurred within the past year. Then, from each of the partnerships reported, IPMs categorized their collaboration strength by rank (networking, cooperating, coordinating, and/or collaborating). Descriptive and inferential analyses were performed to assess the patterns in the number of collaborations and their strength. The results were geographically mapped among the participant states and territories that completed the survey. To assess the relationship between the number of collaborations and the strength of collaborations, the Pearson correlation coefficient was estimated. Afterward, a linear regression model was used to compare the magnitude of association between the number of collaborations and the strength of those collaborations. Results: A total of 49 IPMs from 32 different states and territories participated, resulting in a 54.2% participation rate. The most common partnerships reported were with local health departments (80.0%), community health centers (78.0%), American Cancer Society (74.0%), and immunization coalitions (74.0%). The relationship between number of collaborations and strength of collaborations resulted in a positive and strong linear relationship (r = 0.91; p Citation Format: Alondra K. Mercado-Andino, Yiana G. Toro-Garay, Olga L. Díaz-Miranda, Diana T. Medina-Laabes, Ana P. Ortiz, Katelyn Wells, Erick Suárez, Vivian Colón-López. National partnerships for HPV promotion: An evaluation using the Association of Immunization Managers annual survey [abstract]. In: Proceedings of the 15th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2022 Sep 16-19; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr A128.
Published: 2023

34. Abstract A129: National assessment of the HPV acceptance: Public attitudes and policy climate

Author: Yiana G. Toro-Garay, Alondra K. Mercado-Andino, Olga L. Diaz-Miranda, Diana T. Medina-Laabes, Ana P. Ortiz, Katelyn Wells, Erick Suárez, and Vivian Colón-López
Subjects: Oncology, Epidemiology
Abstract: Background: Human Papillomavirus (HPV) is a common sexually transmitted infection that has been associated with the development of cancers, most of them preventable if the HPV vaccine is administered before exposure. HPV school-entry policies could affect the HPV rates at a population level, hence the need for monitoring nationally the support of policies to assess acceptance at different levels. Objective: This study describes the state-level immunization program managers’ (IPMs) perception of the degree of the general public and policymakers’ acceptance or opposition to the HPV vaccine policies to increase HPV vaccination across their state or territory. Methods: As part of the study entitled Implementation of School-Entry Policies for Human Papilloma Virus Vaccination (HPV-PIVac), IPMs were surveyed about their perception regarding the acceptance or opposition of either (1) the public and (2) policymakers towards HPV vaccine policies. Five questions inquired about the degree of public concern towards HPV-related cancers, public hesitancy towards the HPV vaccine, public opposition towards HPV policies, and acceptance or resistance from policymakers regarding HPV vaccine policies using a five-item scale transformed into a three-item scale. Descriptive statistics were used to assess the managers perception about HPV vaccine policies. Fisher’s exact test was conducted to assess regional differences and the relationship between perception items from the public and policymakers. Results: 49 IPMs from 32 different states and territories participated in this study. In relation to the public concern towards HPV-related cancers, 93.8% of IPMs perceived that the public from their participant states and territories had moderate/mild concern. In comparison, only 6.3% perceived strong/overwhelming concern. For public hesitancy towards the HPV vaccine, 81.3% of IPMs perceived that the public had moderate/mild hesitancy, while 18.8% perceived strong/overwhelming reluctance. For public opposition towards HPV vaccine policies, 21.9% of IPMs perceived strong/overwhelming opposition. On the other hand, 40.6% of IPMs reported that the policymakers were resistant to education policies that promote the HPV vaccine. Similarly, 59.4% of IPMs reported that policymakers were resistant to HPV-school entry vaccination policies. No significant differences between regions were observed in the items analyzed (p>0.05). Fisher’s exact test indicated a significant association between the public opposition towards the HPV vaccine policies and the posture of policymakers towards HPV education policies (p Citation Format: Yiana G. Toro-Garay, Alondra K. Mercado-Andino, Olga L. Diaz-Miranda, Diana T. Medina-Laabes, Ana P. Ortiz, Katelyn Wells, Erick Suárez, Vivian Colón-López. National assessment of the HPV acceptance: Public attitudes and policy climate [abstract]. In: Proceedings of the 15th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2022 Sep 16-19; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr A129.
Published: 2023

35. Abstract A025: HPV and COVID-19 vaccines attitudes and preferred sources of information among adults living in Puerto Rico

Author: Jessica N. Rivera-Rivera, Olga L. Díaz-Miranda, Diana T. Medina-Laabes, Erick Suárez, Ana P. Ortiz, and Vivian Colón-López
Subjects: Oncology, Epidemiology
Abstract: Prior to the COVID-19 pandemic, Puerto Rico (PR) had one of the highest Human Papillomavirus (HPV) vaccine rates in the United States. Yet, widespread misleading information about the COVID-19 vaccine might negatively impact HPV vaccine attitudes. This study aims to assess and compare HPV and COVID-19 vaccines attitudes toward school-entry policies among adults living in PR. A convenience sample of 222 adults (≥21 years old) living in PR were recruited through social media and completed an online survey from November 2021 to January 2022. Participants answered questions about HPV and COVID-19 vaccines knowledge (ranging from 0=none to 3=high knowledge), attitudes toward vaccination policies for school-entry, and perceptions of trusted and untrusted sources of information. Descriptive statistics were computed to identify the demographics characteristics of the participants. We also estimated the prevalence ratio (PRadjusted) using a logistic regression model to assess the magnitude of association between COVID-19 vaccination for the school-entry policy and HPV vaccination for school-entry policy agreement, adjusting for different confounders. The mean age of the study sample was 36.73 ± 11.18 years. The majority of the sample were female (87%, n=194), with at least some college of education (92%; n=205) and employed (61%; n=165). One-fifth of the participants reported having children between ages 11 and 16 (n=46). Participants’ perceived knowledge about the HPV vaccine was moderate (mean=1.72; SD=1.12), while for COVID-19 vaccine was moderately high (mean=2.47; SD=.68). The most trusted form of information for HPV and COVID-19 vaccines were health care providers (42% and 17%, respectively), the Centers for Disease Control and Prevention (35% and 55%, respectively), and the Department of Health (15% and 19%, respectively). The least trusted source of information included social media (40% and 39%, respectively), friends and family (23% n=47, and 17% n=33, respectively), and the Department of Health (15% n=30, and 18% n=36, respectively). More than half of the participants agreed that HPV (76% n=156) and COVID vaccines (69% n=136) should be required for school-entry. Agreement with COVID-19 vaccination for the school-entry policy was significantly associated with HPV vaccination for school-entry policy agreement (PRadjusted:1.96; 95% CI:1.48-2.61) after controlling for age, sex, education, and having children between age 11 and 16. Findings suggest that adults living in PR have an overall positive attitude about mandatory HPV and COVID-19 vaccination school-entry policies, and these attitudes are interrelated. Yet, it is concerning that the Department of Health is identified as one of the least trusted sources of information, as it has a prominent role in implementing HPV and COVID-19 vaccine policies in PR. Further research should elucidate why the Department of Health is considered an untrusted source of information among adults living in PR and evaluate the implications of the COVID-19 pandemic on HPV vaccine attitudes and adherence rates. Citation Format: Jessica N. Rivera-Rivera, Olga L. Díaz-Miranda, Diana T. Medina-Laabes, Erick Suárez, Ana P. Ortiz, Vivian Colón-López. HPV and COVID-19 vaccines attitudes and preferred sources of information among adults living in Puerto Rico [abstract]. In: Proceedings of the 15th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2022 Sep 16-19; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr A025.
Published: 2023

36. Abstract A052: Lifetime cost of care associated with squamous cell carcinoma of the anus in Puerto Rico

Author: Karen J. Ortiz-Ortiz, Axel Gierbolini-Bermúdez, Ana P. Ortiz, Karen Pabón-Cruz, Chi-Fang Wu, Jeslie Ramos-Cartagena, Reydi Morales-Martínez, and Ashish A. Deshmukh
Subjects: Oncology, Epidemiology
Abstract: Background: Squamous cell carcinoma of the anus (SCCA), caused by human papillomavirus infection (HPV), is the most frequently diagnosed form of anal cancer (85%-90%). SCCA incidence has increased dramatically among the general population in Puerto Rico (nearly 5% annually) and the risk is disproportionately elevated among patients living with HIV. SCCA is preventable through HPV vaccination and screening. Therefore, the study of the cost of anal cancer care could have significant implications for understanding preventable economic burden in Puerto Rico. Objective: Determine the lifetime and phase-specific cost of SCCA cases aged ≥21 diagnosed during 2009-2016 in Puerto Rico. Method: This population-based study used the Puerto Rico Central Cancer Registry-Health Insurance Linkage Database (PRCCR-HILD), which links PRCCR data with health insurance claim data from the principal health insurance companies and the government health plan. PRCCR-HILD has information for almost 90% of Puerto Rico's cancer cases from 2008. We matched SCCA cases and non-cancer control (1:1) by age and sex for each phase of care (initial, continuation, and terminal). SCCA-related costs were calculated by subtracting the costs between SCCA patients and the control group. We used the phase-specific monthly cost estimates combined with survival data, stratified by age and cancer stage (localized, regional, and distance), to calculate the lifetime and average annual cost (discount at 3%) for SCCA. The cost was adjusted to 2019 US dollars using the consumer price index. We used the number of SCCA incident cases for 2019, stratified by age group and multiplied by the lifetime SCCA cost estimates, to calculate the SCCA-related lifetime economic burden for Puerto Rico. Results: Of the 351 patients with SCCA included in this study, the mean age at diagnosis was 64 years, 66.4% were women, 57.6% were diagnosed at a localized stage, and 23.1% were enrolled in private insurance. The overall survival after cancer diagnosis was 18 years. Meanwhile, the average monthly costs per patient were higher in the initial phase ($4,755), followed by the terminal phase ($3,499). The main cost driver in all phases was the outpatient costs. However, inpatient costs increased substantially at the terminal phase of care. The average lifetime cost for patient with SCCA was $137,343 (95% CI: $130,873-$145,241) (2019 US dollars). The average SCCA per year cost was $9,193 (95% CI: $8,744-$9,895), while the SCCA-related lifetime economic burden for 2018 in Puerto Rico was nearly $8.7 million. Conclusion: To our knowledge, this is the first study to describe the cost of SCCA management in Puerto Rico. Although SCCA continues to be relatively rare among the general population, our study shows that the SCCA-related lifetime economic burden is substantial and could continue to rise due to the rising SCCA burden in Puerto Rico. These findings could support the evaluation of the impact of strategies to reduce the SCCA burden through HPV vaccination and anal cancer screening for high-risk populations. Citation Format: Karen J. Ortiz-Ortiz, Axel Gierbolini-Bermúdez, Ana P. Ortiz, Karen Pabón-Cruz, Chi-Fang Wu, Jeslie Ramos-Cartagena, Reydi Morales-Martínez, Ashish A. Deshmukh. Lifetime cost of care associated with squamous cell carcinoma of the anus in Puerto Rico [abstract]. In: Proceedings of the 15th AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; 2022 Sep 16-19; Philadelphia, PA. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2022;31(1 Suppl):Abstract nr A052.
Published: 2023

37. Age-specific prevalence of anal and cervical HPV infection and high-grade lesions in 11 177 women by HIV status: a collaborative pooled analysis of 26 studies

Author: Feixue, Wei, Ningshao, Xia, Rebeca, Ocampo, Marc T, Goodman, Nancy A, Hessol, Beatriz, Grinsztejn, Ana P, Ortiz, Fanghui, Zhao, Erna M, Kojic, Rupert, Kaul, Isabelle, Heard, Imran O, Morhason Bello, Anna-Barbara, Moscicki, Alexandra, de Pokomandy, Joel M, Palefsky, Luana L S, Rodrigues, Racheal S Dube, Mandishora, Reshmie A, Ramautarsing, Silvia, Franceschi, Sheela V, Godbole, Fernanda K, Tso, Lynette J, Menezes, Chunqing, Lin, and Gary M, Clifford
Subjects: Major Article
Abstract: BACKGROUND: Age-specific data on anal, and corresponding cervical, human papillomavirus (HPV) infection are needed to inform female anal cancer prevention. METHODS: We centrally reanalyzed individual-level data from 26 studies reporting HPV prevalence in paired anal and cervical samples by human immunodeficiency virus (HIV) status and age. For women with HIV (WWH) with anal high-grade squamous intraepithelial lesions or worse (HSIL+), we also investigated concurrent cervical cytopathology. RESULTS: In HIV-negative women, HPV16 prevalence decreased significantly with age, both at anus (4.3% at 15–24 years to 1.0% at ≥55 years; p(trend) = 0.0026) and cervix (7.4% to 1.7%; p(trend) < 0.0001). In WWH, HPV16 prevalence decreased with age at cervix (18.3% to 7.2%; p(trend) = 0.0035) but not anus (11.5% to 13.9%; p(trend) = 0.5412). Given anal HPV16 positivity, concurrent cervical HPV16 positivity also decreased with age, both in HIV-negative women (p(trend) = 0.0005) and WWH (p(trend) = 0.0166). Among 48 WWH with HPV16-positive anal HSIL+, 27 (56%) were cervical high-risk HPV-positive, including 8 with cervical HPV16, and 5 were cervical HSIL+. CONCLUSIONS: Age-specific shifts in HPV16 prevalence from cervix to anus suggest that HPV infections in the anus persist longer, or occur later in life, than in the cervix, particularly in WWH. This is an important consideration when assessing the utility of cervical screening results to stratify anal cancer risk.
Published: 2022

38. Association of body mass index with anal human papillomavirus infection and histologically confirmed high-grade squamous intraepithelial lesions in people who receive services at the Anal Neoplasia Clinic in Puerto Rico

Author: Kehvyn Cedeño, Claudia P. Amaya-Ardila, Jeslie M. Ramos-Cartagena, Humberto M. Guiot, Cristina Muñoz, Maribel Tirado-Gómez, and Ana P. Ortíz
Subjects: HR-HPV infection, Anal cancer, Hispanics, Anal intraepithelial lesions, BMI, Medicine
Abstract: Objective: This study aimed to assess the association of body mass index (BMI) with anal high-risk human papillomavirus (HR-HPV) and biopsy-confirmed histologic anal high-grade squamous intraepithelial lesions (HSIL) among a clinic-based sample of Hispanics in Puerto Rico. Methods: This cross-sectional study evaluated medical records of adults who received services at the Anal Neoplasia Clinic of the University of Puerto Rico Comprehensive Cancer Center between October 2014 and December 2022. The study included 543 records with complete clinical information regarding anal HR-HPV and anal HSIL status. Chi-square and logistic regression analyses were performed. Results: Mean age of participants was 44.10 ± 13.24 years, 65.2% were men, 71.7% were HIV-infected, 74.4% had anal HR-HPV infection, and 37.9% had biopsy-confirmed HSIL. Regarding BMI, 2.4% were underweight, 31.9% normal weight, and 39.0 % overweight; while 17.3 % had class I, 5.2% class II, and 4.2% class III obesity. No significant association was observed between BMI and anal HR-HPV infection in adjusted analyses. Lower odds of anal HSIL were observed among overweight individuals (OR: 0.63, 95% CI: 0.41 – 0.99) and those with class II/III obesity (OR: 0.48, 95% CI: 0.22 – 1.01) compared to adults with underweight/normal BMI, after adjusting for potential confounders. No significant association was observed for class I obesity. Conclusion: BMI was not associated with anal HR-HPV infection. Overweight and obese individuals had lower odds of having anal HSIL than adults with underweight/normal BMI. This finding could suggest underdiagnosis of HSIL among overweight/obese individuals, or reduced risk in this group.
Published: 2024
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39. Strengthening Resilience and Adaptive Capacity to Disasters in Cancer Control Plans: Lessons Learned from Puerto Rico

Author: Jessica Cabrera-Marquez, William A. Calo, Guillermo Tortolero-Luna, Sandra I García-Camacho, Pablo Méndez-Lázaro, Ana Mercado-Casillas, and Ana P. Ortiz
Subjects: 0301 basic medicine, Economic growth, Epidemiology, Natural Disasters, 03 medical and health sciences, Extreme weather, 0302 clinical medicine, Cancer control, Risk Factors, Neoplasms, Health care, medicine, Humans, Resilience (network), Adaptive capacity, Jurisdiction, business.industry, Puerto Rico, Cancer, medicine.disease, United States, 030104 developmental biology, Emergency response, Oncology, 030220 oncology & carcinogenesis, business
Abstract: Patients with cancer are among the most vulnerable populations in the aftermath of a disaster. They are at higher risk of medical complications and death due to the collapse of or disruptions in the health care system, the community infrastructure, and the complexity of cancer care. The United Nations' Sendai Framework for Disaster Reduction states that people with life-threatening and chronic diseases should be considered in disaster plans to manage their risks. With extreme weather or disasters becoming more intense and frequent and with the high burden of cancer in the United States and its territories, it is important to develop region-specific plans to mitigate the impact of these events on the cancer patient population. After Hurricanes Irma and Maria hit Puerto Rico and the U.S. Virgin Islands in 2017, the need to develop and implement such plans for patients with cancer was evident. We describe ongoing efforts and opportunities for disseminating and implementing emergency response plans to maintain adequate cancer care for patients during and after disasters. While plans for patients with cancer should be housed within the emergency support function infrastructure of each jurisdiction, the Centers for Disease Control and Prevention's Comprehensive Cancer Control Plans provide excellent community-centered mechanisms to support these efforts.
Published: 2020

40. Assessment of Anal Cancer Screening Tools in Detecting High-Grade Anal Squamous Intraepithelial Lesions in Women

Author: Maribel Tirado-Gomez, Claudia P Amaya-Ardilla, Ana P. Ortiz, Jeslie M Ramos-Cartagena, Cynthia M. Pérez, and Humberto M. Guiot
Subjects: Adult, medicine.medical_specialty, Adolescent, Genotyping Techniques, Cross-sectional study, Biopsy, Squamous Intraepithelial Lesions, Cytological Techniques, Sensitivity and Specificity, Gastroenterology, Article, Young Adult, 03 medical and health sciences, 0302 clinical medicine, Predictive Value of Tests, Cytology, Internal medicine, Humans, Medicine, Anal cancer, Young adult, Papillomaviridae, Early Detection of Cancer, Aged, 030219 obstetrics & reproductive medicine, medicine.diagnostic_test, business.industry, Puerto Rico, Obstetrics and Gynecology, Anoscopy, Endoscopy, Histology, General Medicine, Middle Aged, Anus Neoplasms, medicine.disease, Cross-Sectional Studies, 030220 oncology & carcinogenesis, Predictive value of tests, Female, business
Abstract: OBJECTIVE The aim of the study was to evaluate the validity of anal cytology against high-resolution anoscopy in the detection of anal high-grade squamous intraepithelial lesions (HSILs) among women in a clinical setting in Puerto Rico, alone and in combination with high-risk human papillomavirus (HR-HPV) typing. MATERIALS AND METHODS A cross-sectional study was done among 128 eligible women who attended the Anal Neoplasia Clinic of the University of Puerto Rico Comprehensive Center between 2014 and 2019. Kappa (κ) coefficient, sensitivity, specificity, positive predictive value, and negative predictive value were calculated using high-resolution anoscopy with biopsy as the criterion standard test. Poisson regression was used to estimate the adjusted prevalence ratio of anal HR-HPV infection. RESULTS Overall, 71.1% of women were HIV infected and 78.9% had anal HR-HPV infection. Squamous intraepithelial lesions were detected with anal cytology and histology in 70.3% and 81.3% of women, respectively. The κ statistic between the tests (cytology and histology) was 0.32 (p < .05). Measured against the results from histology, the sensitivity of anal cytology alone to detect HSIL was 85.4% (95% CI = 72.2%-93.9%), whereas specificity was 38.8% (95% CI = 28.1%-50.3%). Although the sensitivity of the 2 tests combined (anal cytology and HR-HPV typing) to detect histologically confirmed HSIL increased (100.0%, 95% CI = 92.6%-100.0%), the specificity decreased (16.3%, 95% CI = 9.0%-26.2%). Meanwhile, women with HSIL had a higher prevalence of anal HR-HPV infection than those with no SIL/LSIL (prevalence ratio = 6.23, 95% CI = 1.50-25.83). CONCLUSIONS Anal cytology in combination with HR-HPV typing for the screening of anal intraepithelial neoplasia improved the detection of HSIL in women.
Published: 2020

41. Association of Body Mass Index With Adherence to Cervical Cancer Screening Recommendations in Hispanic Women

Author: Daisy González-Barrios, Cynthia M. Pérez, Jeslie M Ramos-Cartagena, and Ana P. Ortiz
Subjects: Adult, medicine.medical_specialty, Population, Uterine Cervical Neoplasms, Overweight, Body Mass Index, Young Adult, 03 medical and health sciences, 0302 clinical medicine, Surveys and Questionnaires, medicine, Humans, Obesity, Young adult, education, Early Detection of Cancer, Cervical cancer, education.field_of_study, 030219 obstetrics & reproductive medicine, Class III obesity, Obstetrics, business.industry, Puerto Rico, Obstetrics and Gynecology, Hispanic or Latino, General Medicine, Odds ratio, Middle Aged, medicine.disease, United States, 030220 oncology & carcinogenesis, Patient Compliance, Female, medicine.symptom, Underweight, business, Body mass index, Facilities and Services Utilization
Abstract: Objective Obese women have higher cervical cancer incidence and mortality than their counterparts, possibly related to nonadherence to screening recommendations. We assessed the association of body mass index with adherence to cervical cancer screening recommendations in Hispanic women living in Puerto Rico, a minority population with the highest incidence of cervical cancer in the United States. Materials and methods We included 536 Hispanic women aged 21 to 64 years enrolled in a population-based study of human papillomavirus (HPV) infection. Demographic and clinical characteristics and risky behaviors were collected using structured interviews. Weight and height were measured to classify body mass index as underweight, normal, overweight, and obesity (class I, class II, class III). Adherence to cervical cancer screening recommendations was self-reported. Logistic regression models were fit to estimate the odds ratio with 95% CI after adjusting for covariates. Results Nearly one third (29.7%) of women were overweight and 43.5% were obese (class I: 22.6%, class II: 11.0%, class III: 9.9%). Overall adherence to cervical cancer screening within the past 3 years was 78.5%, being lowest among women with class III obesity (60.4%). After multivariable adjustment, only women with class III obesity had significantly higher odds (odds ratio = 2.5, 95% CI: 1.2-5.1) of reporting nonadherence to cervical cancer screening compared with normal weight women. Conclusions Adherence to cervical cancer screening in this population was below the Healthy People 2020 target of 93%, especially for women with morbid obesity. These findings highlight the importance of adequate interventions to decrease cervical cancer screening disparities in these women.
Published: 2020

42. Heterogeneous contributions of change in population distribution of body mass index to change in obesity and underweight

Author: Maryam Sharafkhah, Emanuel Zitt, Majid Ezzati, Luxia Zhang, Young-Ho Khang, Ellina Rakhimova, Kairit Mikkel, Tiina Vlasoff, Eruke E. Egbagbe, Sidsel Graff-Iversen, Ilona Nenko, Magdalena Klimek, Mathilde Savy, Sanjib Kumar Sharma, Alfonso Siani, Luís Lopes, Vanina Bongard, Gregor Jurak, Jacqueline F. Price, Christina-Paulina Lambrinou, Maria Lc Iurilli, Rainford J. Wilks, Bontha V. Babu, Fereidoun Azizi, Harunobu Nakamura, Marialaura Bonaccio, Angela Döring, Zhenyu Zhang, Naser Ahmadi, Jolanta Słowikowska-Hilczer, Ana Paula Carlos Cândido, Clive Osmond, Thirunavukkarasu Sathish, Robert J. Adams, Themistoklis Tzotzas, Reina Engle-Stone, Atul Trivedi, Shoichiro Tsugane, Niels Møller, Jorge Bezerra, Dénes Molnár, Muhammad Fadhli Mohd Yusoff, Badreya Al-Lahou, J. Jaime Miranda, Bahram Mohajer, Sigmund A. Anderssen, Lital Keinan Boker, Eero Kajantie, Martin Gulliford, Maties Torrent, Sumit Bharadwaj, Toshiharu Ninomiya, Zbigniew Gaciong, Nayu Ikeda, Li Juan Wu, Adrian Richter, Licia Iacoviello, Marc J. Gunter, Wenbin Wei, Norsyamlina Che Abdul Rahim, Eman Aly, Ambady Ramachandran, Nils Lehmann, Soile E. Puhakka, Giovanni Veronesi, Hongsheng Bi, Eiji Oda, Jia Li Duan, Per Tynelius, José María Huerta, Janne Schurmann Tolstrup, Rodrigo M. Carrillo-Larco, Rosangela Fernandes Lucena Batista, Victoria E Soto-Rojas, Hanno Ulmer, Shukri F. Mohamed, Anthony Kafatos, Suyeon Park, Mohsen Ibrahim, Hamed Pouraram, Bin Zhou, May Soe Aung, Lars Bo Andersen, Erfan Ghasemi, René Charles Sylva, Himanshu K. Chaturvedi, Luc Dauchet, Ahmad Ali Zainuddin, Angela Chetrit, Dan Zhu, Valérie Deschamps, Ko Ko Zaw, Peter Vollenweider, Tomas Vega, Yves Martin-Prével, Mahfuzar Rahman, Dorja Vočanec, Roman Topor-Madry, Vinay Nangia, Herculina S. Kruger, Asher Fawwad, Emily Sonestedt, Elena Pahomova, Aleksander Giwercman, Elżbieta Dziankowska-Zaborszczyk, Cecilia Björkelund, Tatjana Hejgaard, Maria Puiu, Maria Benedetta Donati, Andrew Wong, Carlos P. Boissonnet, Santosh K. Bhargava, Patrick Kolsteren, Dermot O'Reilly, Bahareh Kheiri, Wolfgang Kratzer, Susanne R. de Rooij, H. Bas Bueno-de-Mesquita, Günther Fink, José R. Banegas, Michele Monroy-Valle, Drude Molbo, Mahmudur Rahman, Hynek Pikhart, Rafael N. Pichardo, Massimo Salvetti, Hui Cai, Sarah Filippi, Georg Posch, Hung-Kwan So, Yonghua Hu, Katsuyasu Kouda, Joana Carvalho, Gailute Bernotiene, Hannu Uusitalo, Thein Thein Htay, Felix Kaducu, Maigeng Zhou, Lars Ängquist, Thi Tuyet-Hanh Tran, Charles Lunogelo, Michel Joffres, Sabina Zambon, Ronald D. 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Magliano, Jitendra Jonnagaddala, Konstantinos Gkiouras, Paola Nardone, Alberto Barceló, Tomi-Pekka Tuomainen, Francesco Gianfagna, Stefania Maggi, Mohammad Hossein Somi, Behrooz Hamzeh, Miquel Porta, Vesna Jureša, Alexander D. Deev, David Faeh, Antonio Bernabe-Ortiz, Sirkka Keinänen-Kiukaanniemi, Ian Hambleton, Stefan Savin, Andre Pascal Kengne, R. Krishna Kumar, Kurt Widhalm, Marco M Ferrario, Parisa Amiri, Anjani Kumar Jha, Thamara Hubler Figueiró, Jana Kratenova, Claudia M. Hormiga, Maria Tsigga, Zivka Dika, Indrapal I. Meshram, Ei Ei K. Nang, Ian Rouse, Rusidah Selamat, Paul Korrovits, Grethe S. Tell, Julie Taylor, Anabela Mota-Pinto, Paolo Vineis, Kotsedi D Monyeki, Khuong Quynh Long, Frank J Rühli, Shelly R. McFarlane, Sara Santos Sanz, Edyta Łuszczki, Maria G. Stathopoulou, Tara Coppinger, Karin De Ridder, Lucie Viet, Anna Bugge, Mehdi Yaseri, Safiah Md Yusof, Sandra C. 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Liu , J Jaime Miranda , Olfa Saidi , Sylvain Sebert , Maroje Sorić , Gregor Starc , Edward W Gregg , Leandra Abarca-Gómez , Ziad A Abdeen , Shynar Abdrakhmanova , Suhaila Abdul Ghaffar , Hanan F Abdul Rahim , Niveen M Abu-Rmeileh , Jamila Abubakar Garba , Benjamin Acosta-Cazares , Robert J Adams , Wichai Aekplakorn , Kaosar Afsana , Shoaib Afzal , Imelda A Agdeppa , Javad Aghazadeh-Attari , Carlos A Aguilar-Salinas , Charles Agyemang , Mohamad Hasnan Ahmad , Noor Ani Ahmad , Ali Ahmadi , Naser Ahmadi , Soheir H Ahmed , Wolfgang Ahrens , Gulmira Aitmurzaeva , Kamel Ajlouni , Hazzaa M Al-Hazzaa , Badreya Al-Lahou , Rajaa Al-Raddadi , Monira Alarouj , Fadia AlBuhairan , Shahla AlDhukair , Mohamed M Ali , Abdullah Alkandari , Ala'a Alkerwi , Kristine Allin , Mar Alvarez-Pedrerol , Eman Aly , Deepak N Amarapurkar , Parisa Amiri , Norbert Amougou , Philippe Amouyel , Lars Bo Andersen , Sigmund A Anderssen , Lars Ängquist , Ranjit Mohan Anjana , Alireza Ansari-Moghaddam , Hajer Aounallah-Skhiri , Joana Araújo , Inger Ariansen , Tahir Aris , Raphael E Arku , Nimmathota Arlappa , Krishna K Aryal , Thor Aspelund , Felix K Assah , Maria Cecília F Assunção , May Soe Aung , Juha Auvinen , Mária Avdicová , Shina Avi , Ana Azevedo , Mohsen Azimi-Nezhad , Fereidoun Azizi , Mehrdad Azmin , Bontha V Babu , Maja Bæksgaard Jørgensen , Azli Baharudin , Suhad Bahijri , Jennifer L Baker , Nagalla Balakrishna , Mohamed Bamoshmoosh , Maciej Banach , Piotr Bandosz , José R Banegas , Joanna Baran , Barbagallo CM, Alberto Barceló , Amina Barkat , Aluisio Jd Barros , Mauro Virgílio Gomes Barros , Abdul Basit , Joao Luiz D Bastos , Iqbal Bata , Anwar M Batieha , Rosangela L Batista , Zhamilya Battakova , Assembekov Batyrbek , Louise A Baur , Robert Beaglehole , Silvia Bel-Serrat , Antonisamy Belavendra , Habiba Ben Romdhane , Judith Benedics , Mikhail Benet , Ingunn Holden Bergh , Salim Berkinbayev , Antonio Bernabe-Ortiz , Gailute Bernotiene , Heloísa Bettiol , Jorge Bezerra , Aroor Bhagyalaxmi , Sumit Bharadwaj , Santosh K Bhargava , Zulfiqar A Bhutta , Hongsheng Bi , Yufang Bi , Daniel Bia , Elysée Claude Bika Lele, Mukharram M Bikbov , Bihungum Bista , Dusko J Bjelica , Peter Bjerregaard , Espen Bjertness , Marius B Bjertness , Cecilia Björkelund , Katia V Bloch , Anneke Blokstra , Simona Bo , Martin Bobak , Lynne M Boddy , Bernhard O Boehm , Heiner Boeing , Jose G Boggia , Elena Bogova , Carlos P Boissonnet , Stig E Bojesen , Marialaura Bonaccio , Vanina Bongard , Alice Bonilla-Vargas , Matthias Bopp , Herman Borghs , Lien Braeckevelt , Lutgart Braeckman , Marjolijn Ce Bragt , Imperia Brajkovich , Francesco Branca , Juergen Breckenkamp , João Breda , Hermann Brenner , Lizzy M Brewster , Garry R Brian , Lacramioara Brinduse , Sinead Brophy , Graziella Bruno , H Bas Bueno-de-Mesquita , Anna Bugge , Marta Buoncristiano , Genc Burazeri , Con Burns , Antonio Cabrera de León , Joseph Cacciottolo , Hui Cai , Tilema Cama , Christine Cameron , José Camolas , 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Cottel , Chris Cowell , Cora L Craig , Amelia C Crampin , Ana B Crujeiras , Semánová Csilla , Alexandra M Cucu , Liufu Cui , Felipe V Cureau , Ewelina Czenczek-Lewandowska , Graziella D'Arrigo , Eleonora d'Orsi , Liliana Dacica , María Ángeles Dal Re Saavedra , Jean Dallongeville , Camilla T Damsgaard , Rachel Dankner , Thomas M Dantoft , Parasmani Dasgupta , Saeed Dastgiri , Luc Dauchet , Kairat Davletov , Guy De Backer , Dirk De Bacquer , Giovanni de Gaetano , Stefaan De Henauw , Paula Duarte de Oliveira , David De Ridder , Karin De Ridder , Susanne R de Rooij , Delphine De Smedt , Mohan Deepa , Alexander D Deev , Vincent Jr DeGennaro , Abbas Dehghan , Hélène Delisle , Francis Delpeuch , Stefaan Demarest , Elaine Dennison , Katarzyna Dereń , Valérie Deschamps , Meghnath Dhimal , Augusto F Di Castelnuovo , Juvenal Soares Dias-da-Costa , María Elena Díaz-Sánchez , Alejandro Diaz , Zivka Dika , Shirin Djalalinia , Visnja Djordjic , Ha Tp Do , Annette J Dobson , Maria Benedetta Donati , 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, Daniel Fernández-Bergés , Daniel Ferrante , Thomas Ferrao , Marika Ferrari , Marco M Ferrario , Catterina Ferreccio , Eldridge Ferrer , Jean Ferrieres , Thamara Hubler Figueiró , Anna Fijalkowska , Günther Fink , Krista Fischer , Leng Huat Foo , Maria Forsner , Heba M Fouad , Damian K Francis , Maria do Carmo Franco , Ruth Frikke-Schmidt , Guillermo Frontera , Flavio D Fuchs , Sandra C Fuchs , Isti I Fujiati , Yuki Fujita , Matsuda Fumihiko , Takuro Furusawa , Zbigniew Gaciong , Mihai Gafencu , Andrzej Galbarczyk , Henrike Galenkamp , Daniela Galeone , Myriam Galfo , Fabio Galvano , Jingli Gao , Manoli Garcia-de-la-Hera , Marta García-Solano , Dickman Gareta , Sarah P Garnett , Jean-Michel Gaspoz , Magda Gasull , Adroaldo Cesar Araujo Gaya , Anelise Reis Gaya , Andrea Gazzinelli , Ulrike Gehring , Harald Geiger , Johanna M Geleijnse , Ali Ghanbari , Erfan Ghasemi , Oana-Florentina Gheorghe-Fronea , Simona Giampaoli , Francesco Gianfagna , Tiffany K Gill , Jonathan Giovannelli , Glen 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, Zhanna Kalmatayeva , Ofra Kalter-Leibovici , Yves Kameli , Freja B Kampmann , Kodanda R Kanala , Srinivasan Kannan , Efthymios Kapantais , Argyro Karakosta , Line L Kårhus , Khem B Karki , Marzieh Katibeh , Joanne Katz , Peter T Katzmarzyk , Jussi Kauhanen , Prabhdeep Kaur , Maryam Kavousi , Gyulli M Kazakbaeva , Ulrich Keil , Lital Keinan Boker , Sirkka Keinänen-Kiukaanniemi , Roya Kelishadi , Cecily Kelleher , Han Cg Kemper , Andre P Kengne , Maryam Keramati , Alina Kerimkulova , Mathilde Kersting , Timothy Key , Yousef Saleh Khader , Davood Khalili , Kay-Tee Khaw , Bahareh Kheiri , Motahareh Kheradmand , Alireza Khosravi , Ilse Msl Khouw , Ursula Kiechl-Kohlendorfer , Stefan Kiechl , Japhet Killewo , Dong Wook Kim , Hyeon Chang Kim , Jeongseon Kim , Jenny M Kindblom , Heidi Klakk , Magdalena Klimek , Jeannette Klimont , Jurate Klumbiene , Michael Knoflach , Bhawesh Koirala , Elin Kolle , Patrick Kolsteren , Jürgen König , Raija Korpelainen , Paul Korrovits , Magdalena Korzycka , 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Morteza Shamshirgaran , Coimbatore Subramaniam Shanthirani , Maryam Sharafkhah , Sanjib K Sharma , Jonathan E Shaw , Amaneh Shayanrad , Ali Akbar Shayesteh , Lela Shengelia , Zumin Shi , Kenji Shibuya , Hana Shimizu-Furusawa , Dong Wook Shin , Majid Shirani , Rahman Shiri , Namuna Shrestha , Khairil Si-Ramlee , Alfonso Siani , Rosalynn Siantar , Abla M Sibai , Antonio M Silva , Diego Augusto Santos Silva , Mary Simon , Judith Simons , Leon A Simons , Agneta Sjöberg , Michael Sjöström , Gry Skodje , Jolanta Slowikowska-Hilczer , Przemyslaw Slusarczyk , Liam Smeeth , Hung-Kwan So , Fernanda Cunha Soares , Grzegorz Sobek , Eugène Sobngwi , Morten Sodemann , Stefan Söderberg , Moesijanti Ye Soekatri , Agustinus Soemantri , Reecha Sofat , Vincenzo Solfrizzi , Mohammad Hossein Somi , Emily Sonestedt , Yi Song , Thorkild Ia Sørensen , Elin P Sørgjerd , Charles Sossa Jérome , Victoria E Soto-Rojas , Aïcha Soumaré , Slavica Sovic , Bente Sparboe-Nilsen , Karen Sparrenberger , Angela Spinelli , Igor Spiroski , Jan A Staessen , Hanspeter Stamm , Maria G Stathopoulou , Kaspar Staub , Bill Stavreski , Jostein Steene-Johannessen , Peter Stehle , Aryeh D Stein , George S Stergiou , Jochanan Stessman , Ranko Stevanovic , Jutta Stieber , Doris Stöckl , Tanja Stocks , Jakub Stokwiszewski , Ekaterina Stoyanova , Gareth Stratton , Karien Stronks , Maria Wany Strufaldi , Lela Sturua , Ramón Suárez-Medina , Machi Suka , Chien-An Sun , Johan Sundström , Yn-Tz Sung , Jordi Sunyer , Paibul Suriyawongpaisal , Boyd A Swinburn , Rody G Sy , Holly E Syddall , René Charles Sylva , Moyses Szklo , Lucjan Szponar , E Shyong Tai , Mari-Liis Tammesoo , Abdonas Tamosiunas , Eng Joo Tan , Xun Tang , Maya Tanrygulyyeva , Frank Tanser , Yong Tao , Mohammed Rasoul Tarawneh , Jakob Tarp , Carolina B Tarqui-Mamani , Radka Taxová Braunerová , Anne Taylor , Julie Taylor , Félicité Tchibindat , William R Tebar , Grethe S Tell , Tania Tello , Yih Chung Tham , K R Thankappan , Holger Theobald , Xenophon Theodoridis , Lutgarde Thijs , Nihal Thomas , Betina H Thuesen , Lubica Tichá , Erik J Timmermans , Anne Tjonneland , Hanna K Tolonen , Janne S Tolstrup , Murat Topbas , Roman Topór-Madry , Liv Elin Torheim , María José Tormo , Michael J Tornaritis , Maties Torrent , Laura Torres-Collado , Stefania Toselli , Giota Touloumi , Pierre Traissac , Thi Tuyet-Hanh Tran , Dimitrios Trichopoulos , Antonia Trichopoulou , Oanh Th Trinh , Atul Trivedi , Lechaba Tshepo , Maria Tsigga , Shoichiro Tsugane , Azaliia M Tuliakova , Marshall K Tulloch-Reid , Fikru Tullu , Tomi-Pekka Tuomainen , Jaakko Tuomilehto , Maria L Turley , Gilad Twig , Per Tynelius , Themistoklis Tzotzas , Christophe Tzourio , Peter Ueda , Eunice Ugel , Flora Am Ukoli , Hanno Ulmer , Belgin Unal , Zhamyila Usupova , Hannu Mt Uusitalo , Nalan Uysal , Justina Vaitkeviciute , Gonzalo Valdivia , Susana Vale , Damaskini Valvi , Rob M van Dam , Johan Van der Heyden , Yvonne T van der Schouw , Koen Van Herck , Hoang Van Minh , Natasja M 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Weghuber , Wenbin Wei , Aneta Weres , Bo Werner , Peter H Whincup , Kurt Widhalm , Indah S Widyahening , Andrzej Wiecek , Rainford J Wilks , Johann Willeit , Peter Willeit , Julianne Williams , Tom Wilsgaard , Bogdan Wojtyniak , Roy A Wong-McClure , Andrew Wong , Jyh Eiin Wong , Tien Yin Wong , Jean Woo , Mark Woodward , Frederick C Wu , Jianfeng Wu , Li Juan Wu , Shouling Wu , Haiquan Xu , Liang Xu , Nor Azwany Yaacob , Uruwan Yamborisut , Weili Yan , Ling Yang , Xiaoguang Yang , Yang Yang , Nazan Yardim , Mehdi Yaseri , Tabara Yasuharu , Xingwang Ye , Panayiotis K Yiallouros , Moein Yoosefi , Akihiro Yoshihara , Qi Sheng You , San-Lin You , Novie O Younger-Coleman , Safiah Md Yusof , Ahmad Faudzi Yusoff , Luciana Zaccagni , Vassilis Zafiropulos , Ahmad A Zainuddin , Seyed Rasoul Zakavi , Farhad Zamani , Sabina Zambon , Antonis Zampelas , Hana Zamrazilová , Maria Elisa Zapata , Abdul Hamid Zargar , Ko Ko Zaw , Tomasz Zdrojewski , Kristyna Zejglicova , Tajana Zeljkovic Vrkic , Yi Zeng 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Lundqvist, Robert, Lunet, Nuno, Lunogelo, Charle, Lustigová, Michala, Łuszczki, Edyta, Ma, Guansheng, Ma, Jun, Ma, Xu, Machado-Coelho, George LL, Machado-Rodrigues, Aristides M, Macieira, Luisa M, Madar, Ahmed A, Maggi, Stefania, Magliano, Dianna J, Magnacca, Sara, Magriplis, Emmanuella, Mahasampath, Gowri, Maire, Bernard, Majer, Marjeta, Makdisse, Marcia, Mäki, Päivi, Malekzadeh, Fatemeh, Malekzadeh, Reza, Malhotra, Rahul, Rao, Kodavanti Mallikharjuna, Malyutina, Sofia K, Maniego, Lynell V, Manios, Yanni, Mann, Jim I, Mansour-Ghanaei, Fariborz, Manzato, Enzo, Margozzini, Paula, Markaki, Anastasia, Markey, Oonagh, Ioannidou, Eliza Markidou, Marques-Vidal, Pedro, Marques, Larissa Pruner, Marrugat, Jaume, Martin-Prevel, Yve, Martin, Rosemarie, Martorell, Reynaldo, Martos, Eva, Maruszczak, Katharina, Marventano, Stefano, Mascarenhas, Luis P, Masoodi, Shariq R, Mathiesen, Ellisiv B, Mathur, Prashant, Matijasevich, Alicia, Matsha, Tandi E, Mavrogianni, Christina, Mazur, Artur, Mbanya, Jean Claude N, McFarlane, Shelly R, McGarvey, Stephen T, McKee, Martin, McLachlan, Stela, McLean, Rachael M, McLean, Scott B, McNulty, Breige A, Benchekor, Sounnia Mediene, Medzioniene, Jurate, Mehdipour, Parinaz, Mehlig, Kirsten, Mehrparvar, Amir Houshang, Meirhaeghe, Aline, Meisfjord, Jørgen, Meisinger, Christa, Menezes, Ana Maria B, Menon, Geetha R, Mensink, Gert BM, Menzano, Maria Teresa, Mereke, Alibek, Meshram, Indrapal I, Metspalu, Andre, Meyer, Haakon E, Mi, Jie, Michaelsen, Kim F, Michels, Nathalie, Mikkel, Kairit, Milkowska, Karolina, Miller, Jody C, Minderico, Cláudia S, Mini, GK, Miquel, Juan Francisco, Mirjalili, Mohammad Reza, Mirkopoulou, Daphne, Mirrakhimov, Erkin, Mišigoj-Durakovic, Marjeta, Mistretta, Antonio, Mocanu, Veronica, Modesti, Pietro A, Moghaddam, Sahar Saeedi, Mohajer, Bahram, Mohamed, Mostafa K, Mohamed, Shukri F, Mohammad, Kazem, Mohammadi, Zahra, Mohammadifard, Noushin, Mohammadpourhodki, Reza, Mohan, Viswanathan, Mohanna, Salim, Yusoff, Muhammad Fadhli Mohd, Mohebbi, Iraj, Mohebi, Farnam, Moitry, Marie, Molbo, Drude, Møllehave, Line T, Møller, Niels C, Molnár, Déne, Momenan, Amirabba, Mondo, Charles K, Monroy-Valle, Michele, Monterrubio-Flores, Eric, Monyeki, Kotsedi Daniel K, Moon, Jin Soo, Moosazadeh, Mahmood, Moreira, Leila B, Morejon, Alain, Moreno, Luis A, Morgan, Karen, Morin, Suzanne N, Mortensen, Erik Lykke, Moschonis, George, Mossakowska, Malgorzata, Mostafa, Aya, Mota-Pinto, Anabela, Mota, Jorge, Motlagh, Mohammad Esmaeel, Motta, Jorge, Moura-dos-Santos, Marcos André, Mridha, Malay K, Msyamboza, Kelias P, Mu, Thet Thet, Muc, Magdalena, Mugoša, Boban, Muiesan, Maria L, Mukhtorova, Parvina, Müller-Nurasyid, Martina, Murphy, Neil, Mursu, Jaakko, Murtagh, Elaine M, Musa, Kamarul Imran, Milanovic, Sanja Music, Musil, Vera, Mustafa, Norlaila, Nabipour, Iraj, Naderimagham, Shohreh, Nagel, Gabriele, Naidu, Balkish M, Najafi, Farid, Nakamura, Harunobu, Námešná, Jana, Ei K Nang, Ei, Nangia, Vinay B, Nankap, Martin, Narake, Sameer, Nardone, Paola, Nauck, Matthia, Neal, William A, Nejatizadeh, Azim, Nekkantti, Chandini, Nelis, Keiu, Nelis, Lii, Nenko, Ilona, Neovius, Martin, Nervi, Flavio, Nguyen, Chung T, Nguyen, Nguyen D, Nguyen, Quang Ngoc, Nieto-Martínez, Ramfis E, Nikitin, Yury P, Ning, Guang, Ninomiya, Toshiharu, Nishtar, Sania, Noale, Marianna, Noboa, Oscar A, Nogueira, Helena, Norat, Teresa, Nordendahl, Maria, Nordestgaard, Børge G, Noto, Davide, Nowak-Szczepanska, Natalia, Al Nsour, Mohannad, Nuhoglu, Irfan, Nurk, Eha, O'Neill, Terence W, O'Reilly, Dermot, Obreja, Galina, Ochimana, Caleb, Ochoa-Avilés, Angélica M, Oda, Eiji, Oh, Kyungwon, Ohara, Kumiko, Ohlsson, Clae, Ohtsuka, Ryutaro, Olafsson, Örn, Olinto, Maria Teresa A, Oliveira, Isabel O, Omar, Mohd Azahadi, Onat, Altan, Ong, Sok King, Ono, Lariane M, Ordunez, Pedro, Ornelas, Rui, Ortiz, Ana P, Ortiz, Pedro J, Osler, Merete, Osmond, Clive, Ostojic, Sergej M, Ostovar, Afshin, Otero, Johanna A, Overvad, Kim, Owusu-Dabo, Elli, Paccaud, Fred Michel, Padez, Cristina, Pagkalos, Ioanni, Pahomova, Elena, de Paiva, Karina Mary, Pajak, Andrzej, Palli, Domenico, Palloni, Alberto, Palmieri, Luigi, Pan, Wen-Harn, Panda-Jonas, Songhomitra, Pandey, Arvind, Panza, Francesco, Papandreou, Dimitrio, Park, Soon-Woo, Park, Suyeon, Parnell, Winsome R, Parsaeian, Mahboubeh, Pascanu, Ionela M, Pasquet, Patrick, Patel, Nikhil D, Pecin, Ivan, Pednekar, Mangesh S, Peer, Nasheeta, Pei, Gao, Peixoto, Sergio Viana, Peltonen, Markku, Pereira, Alexandre C, Peres, Marco A, Pérez-Farinós, Napoleón, Pérez, Cynthia M, Peterkova, Valentina, Peters, Annette, Petersmann, Astrid, Petkeviciene, Janina, Petrauskiene, Ausra, Pettenuzzo, Emanuela, Peykari, Niloofar, Pham, Son Thai, Pichardo, Rafael N, Pierannunzio, Daniela, Pigeot, Iri, Pikhart, Hynek, Pilav, Aida, Pilotto, Lorenza, Pistelli, Francesco, Pitakaka, Freda, Piwonska, Aleksandra, Pizarro, Andreia N, Plans-Rubió, Pedro, Poh, Bee Koon, Pohlabeln, Hermann, Pop, Raluca M, Popovic, Stevo R, Porta, Miquel, Posch, Georg, Poudyal, Anil, Poulimeneas, Dimitrio, Pouraram, Hamed, Pourfarzi, Farhad, Pourshams, Akram, Poustchi, Hossein, Pradeepa, Rajendra, Price, Alison J, Price, Jacqueline F, Providencia, Rui, Puder, Jardena J, Pudule, Iveta, Puhakka, Soile E, Puiu, Maria, Punab, Margu, Qasrawi, Radwan F, Qorbani, Mostafa, Bao, Tran Quoc, Radic, Ivana, Radisauskas, Ricarda, Rahimikazerooni, Salar, Rahman, Mahfuzar, Rahman, Mahmudur, Raitakari, Olli, Raj, Manu, Rakhimova, Ellina, Rakhmatulloev, Sherali, Rakovac, Ivo, Rao, Sudha Ramachandra, Ramachandran, Ambady, Ramke, Jacqueline, Ramos, Elisabete, Ramos, Rafel, Rampal, Lekhraj, Rampal, Sanjay, Rarra, Vayia, Rascon-Pacheco, Ramon A, Rasmussen, Mette, Rech, Cassiano Ricardo, Redon, Josep, Reganit, Paul Ferdinand M, Regecová, Valéria, Revilla, Lui, Rezaianzadeh, Abba, Ribas-Barba, Lourde, Ribeiro, Robespierre, Riboli, Elio, Richter, Adrian, Rigo, Fernando, Rinaldo, Natascia, de Wit, Tobias F Rinke, Rito, Ana, Ritti-Dias, Raphael M, Rivera, Juan A, Robitaille, Cynthia, Roccaldo, Romana, Rodrigues, Daniela, Rodríguez-Artalejo, Fernando, del Cristo Rodriguez-Perez, María, Rodríguez-Villamizar, Laura A, Roggenbuck, Ulla, Rojas-Martinez, Rosalba, Rojroongwasinkul, Nipa, Romaguera, Dora, Romeo, Elisabetta L, Rosario, Rafaela V, Rosengren, Annika, Rouse, Ian, Roy, Joel GR, Rubinstein, Adolfo, Rühli, Frank J, Ruidavets, Jean-Bernard, Ruiz-Betancourt, Blanca Sandra, Ruiz-Castell, Maria, Moreno, Emma Ruiz, Rusakova, Iuliia A, Jonsson, Kenisha Russell, Russo, Paola, Rust, Petra, Rutkowski, Marcin, Sabanayagam, Charumathi, Sacchini, Elena, Sachdev, Harshpal S, Sadjadi, Alireza, Safarpour, Ali Reza, Safiri, Saeid, Saki, Nader, Salanave, Benoit, Martinez, Eduardo Salazar, Salmerón, Diego, Salomaa, Veikko, Salonen, Jukka T, Salvetti, Massimo, Samoutian, Margarita, Sánchez-Abanto, Jose, Sandjaja, null, Sans, Susana, Marina, Loreto Santa, Santos, Diana A, Santos, Ina S, Santos, Lèlita C, Santos, Maria Paula, Santos, Osvaldo, Santos, Rute, Sanz, Sara Santo, Saramies, Jouko L, Sardinha, Luis B, Sarrafzadegan, Nizal, Sathish, Thirunavukkarasu, Saum, Kai-Uwe, Savva, Savva, Savy, Mathilde, Sawada, Norie, Sbaraini, Mariana, Scazufca, Marcia, Schaan, Beatriz D, Rosario, Angelika Schaffrath, Schargrodsky, Herman, Schienkiewitz, Anja, Schipf, Sabine, Schmidt, Carsten O, Schmidt, Ida Maria, Schnohr, Peter, Schöttker, Ben, Schramm, Sara, Schramm, Stine, Schröder, Helmut, Schultsz, Constance, Schutte, Aletta E, Sein, Aye Aye, Selamat, Rusidah, Sember, Vedrana, Sen, Abhijit, Senbanjo, Idowu O, Sepanlou, Sadaf G, Sequera, Victor, Serra-Majem, Lui, Servais, Jennifer, Ševcíková, Ludmila, Shalnova, Svetlana A, Shamah-Levy, Teresa, Shamshirgaran, Morteza, Shanthirani, Coimbatore Subramaniam, Sharafkhah, Maryam, Sharma, Sanjib K, Shaw, Jonathan E, Shayanrad, Amaneh, Shayesteh, Ali Akbar, Shengelia, Lela, Shi, Zumin, Shibuya, Kenji, Shimizu-Furusawa, Hana, Shin, Dong Wook, Shirani, Majid, Shiri, Rahman, Shrestha, Namuna, Si-Ramlee, Khairil, Siani, Alfonso, Siantar, Rosalynn, Sibai, Abla M, Silva, Antonio M, Silva, Diego Augusto Santo, Simon, Mary, Simons, Judith, Simons, Leon A, Sjöberg, Agneta, Sjöström, Michael, Skodje, Gry, Slowikowska-Hilczer, Jolanta, Slusarczyk, Przemyslaw, Smeeth, Liam, So, Hung-Kwan, Soares, Fernanda Cunha, Sobek, Grzegorz, Sobngwi, Eugène, Sodemann, Morten, Söderberg, Stefan, Soekatri, Moesijanti YE, Soemantri, Agustinu, Sofat, Reecha, Solfrizzi, Vincenzo, Somi, Mohammad Hossein, Sonestedt, Emily, Song, Yi, Sørensen, Thorkild IA, Sørgjerd, Elin P, Jérome, Charles Sossa, Soto-Rojas, Victoria E, Soumaré, Aïcha, Sovic, Slavica, Sparboe-Nilsen, Bente, Sparrenberger, Karen, Spinelli, Angela, Spiroski, Igor, Staessen, Jan A, Stamm, Hanspeter, Stathopoulou, Maria G, Staub, Kaspar, Stavreski, Bill, Steene-Johannessen, Jostein, Stehle, Peter, Stein, Aryeh D, Stergiou, George S, Stessman, Jochanan, Stevanovic, Ranko, Stieber, Jutta, Stöckl, Dori, Stocks, Tanja, Stokwiszewski, Jakub, Stoyanova, Ekaterina, Stratton, Gareth, Stronks, Karien, Strufaldi, Maria Wany, Sturua, Lela, Suárez-Medina, Ramón, Suka, Machi, Sun, Chien-An, Sundström, Johan, Sung, Yn-Tz, Sunyer, Jordi, Suriyawongpaisal, Paibul, Swinburn, Boyd A, Sy, Rody G, Syddall, Holly E, Sylva, René Charle, Szklo, Moyse, Szponar, Lucjan, Tai, E Shyong, Tammesoo, Mari-Lii, Tamosiunas, Abdona, Tan, Eng Joo, Tang, Xun, Tanrygulyyeva, Maya, Tanser, Frank, Tao, Yong, Tarawneh, Mohammed Rasoul, Tarp, Jakob, Tarqui-Mamani, Carolina B, Braunerová, Radka Taxová, Taylor, Anne, Taylor, Julie, Tchibindat, Félicité, Tebar, William R, Tell, Grethe S, Tello, Tania, Tham, Yih Chung, Thankappan, KR, Theobald, Holger, Theodoridis, Xenophon, Thijs, Lutgarde, Thomas, Nihal, Thuesen, Betina H, Tichá, Lubica, Timmermans, Erik J, Tjonneland, Anne, Tolonen, Hanna K, Tolstrup, Janne S, Topbas, Murat, Topór-Madry, Roman, Torheim, Liv Elin, Tormo, María José, Tornaritis, Michael J, Torrent, Matie, Torres-Collado, Laura, Toselli, Stefania, Touloumi, Giota, Traissac, Pierre, Tran, Thi Tuyet-Hanh, Trichopoulos, Dimitrio, Trichopoulou, Antonia, Trinh, Oanh TH, Trivedi, Atul, Tshepo, Lechaba, Tsigga, Maria, Tsugane, Shoichiro, Tuliakova, Azaliia M, Tulloch-Reid, Marshall K, Tullu, Fikru, Tuomainen, Tomi-Pekka, Tuomilehto, Jaakko, Turley, Maria L, Twig, Gilad, Tynelius, Per, Tzotzas, Themistokli, Tzourio, Christophe, Ueda, Peter, Ugel, Eunice, Ukoli, Flora AM, Ulmer, Hanno, Unal, Belgin, Usupova, Zhamyila, Uusitalo, Hannu MT, Uysal, Nalan, Vaitkeviciute, Justina, Valdivia, Gonzalo, Vale, Susana, Valvi, Damaskini, van Dam, Rob M, Van der Heyden, Johan, van der Schouw, Yvonne T, Van Herck, Koen, Van Minh, Hoang, Van Schoor, Natasja M, van Valkengoed, Irene GM, Vanderschueren, Dirk, Vanuzzo, Diego, Varbo, Anette, Varela-Moreiras, Gregorio, Varona-Pérez, Patricia, Vasan, Senthil K, Vega, Toma, Veidebaum, Tooma, Velasquez-Melendez, Gustavo, Velika, Biruta, Veronesi, Giovanni, Verschuren, WM Monique, Victora, Cesar G, Viegi, Giovanni, Viet, Lucie, Villalpando, Salvador, Vineis, Paolo, Vioque, Jesu, Virtanen, Jyrki K, Visser, Marjolein, Visvikis-Siest, Sophie, Viswanathan, Bharathi, Vladulescu, Mihaela, Vlasoff, Tiina, Vocanec, Dorja, Vollenweider, Peter, Völzke, Henry, Voutilainen, Ari, Voutilainen, Sari, Vrijheid, Martine, Vrijkotte, Tanja GM, Wade, Alisha N, Wagner, Aline, Waldhör, Thoma, Walton, Janette, Wambiya, Elvis OA, Bebakar, Wan Mohamad Wan, Mohamud, Wan Nazaimoon Wan, de Souza Wanderley Júnior, Rildo, Wang, Ming-Dong, Wang, Ningli, Wang, Qian, Wang, Xiangjun, Wang, Ya Xing, Wang, Ying-Wei, Wannamethee, S Goya, Wareham, Nichola, Weber, Adelheid, Wedderkopp, Niel, Weerasekera, Deepa, Weghuber, Daniel, Wei, Wenbin, Weres, Aneta, Werner, Bo, Whincup, Peter H, Widhalm, Kurt, Widyahening, Indah S, Wiecek, Andrzej, Wilks, Rainford J, Willeit, Johann, Willeit, Peter, Williams, Julianne, Wilsgaard, Tom, Wojtyniak, Bogdan, Wong-McClure, Roy A, Wong, Andrew, Wong, Jyh Eiin, Wong, Tien Yin, Woo, Jean, Woodward, Mark, Wu, Frederick C, Wu, Jianfeng, Wu, Li Juan, Wu, Shouling, Xu, Haiquan, Xu, Liang, Yaacob, Nor Azwany, Yamborisut, Uruwan, Yan, Weili, Yang, Ling, Yang, Xiaoguang, Yang, Yang, Yardim, Nazan, Yaseri, Mehdi, Yasuharu, Tabara, Ye, Xingwang, Yiallouros, Panayiotis K, Yoosefi, Moein, Yoshihara, Akihiro, You, Qi Sheng, You, San-Lin, Younger-Coleman, Novie O, Md Yusof, Safiah, Yusoff, Ahmad Faudzi, Zaccagni, Luciana, Zafiropulos, Vassili, Zainuddin, Ahmad A, Zakavi, Seyed Rasoul, Zamani, Farhad, Zambon, Sabina, Zampelas, Antoni, Zamrazilová, Hana, Zapata, Maria Elisa, Zargar, Abdul Hamid, Ko Zaw, Ko, Zdrojewski, Tomasz, Zejglicova, Kristyna, Vrkic, Tajana Zeljkovic, Zeng, Yi, Zhang, Luxia, Zhang, Zhen-Yu, Zhao, Dong, Zhao, Ming-Hui, Zhao, Wenhua, Zhen, Shiqi, Zheng, Wei, Zheng, Yingfeng, Zholdin, Bekbolat, Zhou, Maigeng, Zhu, Dan, Zins, Marie, Zitt, Emanuel, Zocalo, Yanina, Cisneros, Julio Zuñiga, Zuziak, Monika, Ezzati, Majid, Filippi, Sarah, Cohortes épidémiologiques en population (CONSTANCES), Université de Versailles Saint-Quentin-en-Yvelines (UVSQ)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Université Paris-Saclay-Université Paris Cité (UPCité), Université Paris Cité (UPCité), Centre International de Hautes Études Agronomiques Méditerranéennes (CIHEAM)-Centre International de Hautes Études Agronomiques Méditerranéennes (CIHEAM)-Institut National de Recherche pour l’Agriculture, l’Alimentation et l’Environnement (INRAE)-Institut Agro - Montpellier SupAgro, and Institut national d'enseignement supérieur pour l'agriculture, l'alimentation et l'environnement (Institut Agro)-Institut national d'enseignement supérieur pour l'agriculture, l'alimentation et l'environnement (Institut Agro)
Subjects: Population -- Health aspects, Leanness, Baixo peso/Underweight, none, Double burden, alipainoisuus, tulotaso, global health, systematic analysis, Sedentary behaviors, RC1200, Prospective associations, 0302 clinical medicine, underweight, nälänhätä, Biology (General), skin and connective tissue diseases, Children, ComputingMilieux_MISCELLANEOUS, Body mass index, Human Nutrition & Health, education.field_of_study, Humane Voeding & Gezondheid, ylipaino, General Medicine, kansainvälinen vertailu, 3. Good health, World health, Medicine, A100 Pre-clinical Medicine, Population distribution, medicine.medical_specialty, QH301-705.5, Science, Socio-culturale, Nursing, Social sciences, General Biochemistry, Genetics and Molecular Biology, 03 medical and health sciences, Thinness, SDG 3 - Good Health and Well-being, BMI, epidemiology, obesity, None, Humans, Obesidade/Obesity, SDG 2 - Zero Hunger, education, VLAG, US adults, Omvårdnad, body mass index, malnutrition, obesity, underweight, nutritional and metabolic diseases, medicine.disease, terveellisyys, Obesity, Faculdade de Ciências Sociais, Body Mass Index, Prevalence, Risk Factors, General Biochemistry, WIAS, lihavuus, RA, Demography, N.A, double burden, Settore MED/09 - Medicina Interna, alueelliset erot, Nutrition and Disease, Animal Nutrition, [SDV]Life Sciences [q-bio], Medizin, 030204 cardiovascular system & hematology, 0601 Biochemistry and Cell Biology, Change distribution of body mass index, RA0421, Voeding en Ziekte, Epidemiology, Medicine and Health Sciences, Global health, Índice de massa corporal/Body Mass Index, 030212 general & internal medicine, Underweight, painoindeksi, 2. Zero hunger, General Neuroscience, aliravitsemus, elintarvikkeet, health, Public Health, Global Health, Social Medicine and Epidemiology, Diervoeding, 3142 Public health care science, environmental and occupational health, purl.org/pe-repo/ocde/ford#3.01.03 [https], Chinese adults, pooled analysis, medicine.symptom, Diet quality, B120 Physiology, Research Article, trends, purl.org/pe-repo/ocde/ford#1.06.03 [https], prevalence, Population, Mothers, Genetics and Molecular Biology, 3121 Internal medicine, medicine, Life Science, ddc:610, 3125 Otorhinolaryngology, ophthalmology, kehonkoostumus, Nutrition, Australian adults, General Immunology and Microbiology, purl.org/pe-repo/ocde/ford#3.01.04 [https], Ciências sociais, Folkhälsovetenskap, global hälsa, socialmedicin och epidemiologi, Malnutrition, Epidemiology and Global Health, sense organs, Estilos de Vida e Impacto na Saúde
Abstract: From 1985 to 2016, the prevalence of underweight decreased, and that of obesity and severe obesity increased, in most regions, with significant variation in the magnitude of these changes across regions. We investigated how much change in mean body mass index (BMI) explains changes in the prevalence of underweight, obesity, and severe obesity in different regions using data from 2896 population-based studies with 187 million participants. Changes in the prevalence of underweight and total obesity, and to a lesser extent severe obesity, are largely driven by shifts in the distribution of BMI, with smaller contributions from changes in the shape of the distribution. In East and Southeast Asia and sub-Saharan Africa, the underweight tail of the BMI distribution was left behind as the distribution shifted. There is a need for policies that address all forms of malnutrition by making healthy foods accessible and affordable, while restricting unhealthy foods through fiscal and regulatory restrictions., Wellcome Trust, Medical Research Council, peer-reviewed
Published: 2021

43. Tdap-HPV vaccination bundling in the USA: Trends, predictors, and implications for vaccine series completion

Author: Yenan Zhu, Chi-Fang Wu, Anna R. Giuliano, Maria E. Fernandez, Ana P. Ortiz, Cecilia Ganduglia Cazaban, Ruosha Li, Ashish A. Deshmukh, and Kalyani Sonawane
Subjects: Adolescent, Epidemiology, Papillomavirus Infections, Vaccination, Public Health, Environmental and Occupational Health, Humans, Female, Papillomavirus Vaccines, Toxoids, Child, United States, Retrospective Studies
Abstract: The Centers for Disease Control and Prevention (CDC) promotes taking a 'bundling approach' (i.e., administering Tetanus, diphtheria toxoids, and acellular pertussis [Tdap] and human papillomavirus [HPV] vaccines in the same way and on the same day) for adolescent vaccinations. Recent trends and patterns in Tdap-HPV vaccination bundling in the USA remain undocumented. In addition, the implications of bundling Tdap-HPV vaccination for HPV vaccine series completion remain unknown. To address these critical knowledge gaps, we performed a retrospective study using a nationwide sample of privately insured adolescents (Optum's de-identified Clinformatics® Data Mart Database). Tdap-HPV vaccination bundling (per 100 Tdap vaccination encounters) during 2014-2018 was estimated overall, for 50 states, and by adolescents' age, sex, and provider specialties. Survival model estimated the likelihood of series completion among 9-14-year-old adolescents. From 2014 to 2018, 560,806 adolescents received a Tdap vaccine of which 172,604 (30.8%) received the HPV vaccines on the same day. Tdap-HPV vaccination bundling (per 100 Tdap vaccinations) increased nationally, from 22.9 in 2014 to 39.1 in 2018 (P
Published: 2021

44. Effect of Hurricane Maria on HPV, Tdap, and meningococcal conjugate vaccination rates in Puerto Rico, 2015-2019

Author: Ana P. Ortiz, Roxana Soto-Abreu, Olga L Díaz-Miranda, Vivian Colón-López, Erick Suárez, Idamaris Vega-Jimenez, and Diana T. Medina-Laabes
Subjects: Male, Adolescent, Immunology, Meningococcal Vaccines, Meningococcal vaccine, Meningococcal conjugate vaccination, Alphapapillomavirus, Rate ratio, Diphtheria-Tetanus-acellular Pertussis Vaccines, Immunology and Allergy, Medicine, Humans, Papillomavirus Vaccines, Papillomaviridae, Immunization Schedule, Pharmacology, Human papilloma virus, business.industry, Cyclonic Storms, Papillomavirus Infections, Puerto Rico, Vaccination, Immunization, Female, business, Demography
Abstract: In September 2017, Hurricane Maria devastated the Caribbean region, among them the US territory of Puerto Rico (PR). Vaccination distribution and uptake suffered from the impact. This study evaluated the trends in monthly vaccination initiation rates for human papilloma virus (HPV), Tdap and meningococcal conjugate (MenACWY) adolescent vaccines from 2015 to 2019, during which it was possible to observe and analyze the impact of Hurricane Maria on vaccine initiation. Monthly initiation rates were estimated. Age-standardized initiation rate ratio (SRR) and 95% CI were estimated. The analysis included 85,340 adolescents; 52.3% were male, and 47.7% were females. September 2017 showed HPV vaccine initiation had the lower rates of all the studied vaccines, with a rate of 75% after the disaster (from a rate of almost 90% in July 2017). Tdap and MenACWY vaccines rates remained above 90% in the same period. The SRR of HPV vaccine for September and October 2017 showed an estimated reduction of 5% and 8% in vaccine initiation rates, respectively for each month, when 2016 was the reference year (p > .05). The SRR of Tdap and MenACWY vaccines for November 2017 showed significant reductions when 2015 and 2016 were reference years (p
Published: 2021

45. ¡Habla de VPH! An Educational Activity for College Students in Puerto Rico

Author: Vivian, Colón-López, Alelí, Ayala-Marín, Camille, Vélez-Alamo, Marievelisse, Soto-Salgado, Lizbeth, Medina-Cortés, Adrianna I, Acevedo-Fontanez, Ana P, Ortiz, Natalie, Fernández-Espada, Marta, Sánchez-Aracil, and Omayra, Salgado-Cruz
Subjects: Male, Health Knowledge, Attitudes, Practice, Adolescent, Universities, Papillomavirus Infections, Puerto Rico, Uterine Cervical Neoplasms, Patient Acceptance of Health Care, Young Adult, Surveys and Questionnaires, Humans, Female, Papillomavirus Vaccines, Students, Program Evaluation
Abstract: To evaluate human papillomavirus (HPV) infection knowledge, willingness to get vaccinated, and vaccination uptake, following a brief educational activity entitled ¡Habla de VPH! (Let's talk about HPV!) in a sample of college students at the University of Puerto Rico, Bayamón.Participants completed a self-administered questionnaire developed by the research team, which gathered information regarding sociodemographic characteristics, HPV vaccination status, and willingness to receive the vaccine. Once the participant completed the survey, the staff of the Outreach Program conducted an educational activity. Study participants completed a pre- and post-test, which included a scale with items related to knowledge about HPV infection, associated malignancies, and the vaccine. To compute the mean knowledge score for each test, the correct responses were summed; the total scores for each test ranged from 0 to 11. Follow-up interviews (3 and 6 months) explored knowledge changes and-in the previously unvaccinated students-vaccine uptake.A total of forty students answered the questionnaire. A significant difference between the average knowledge before (7.6 ± 2.1) and after the intervention (10.6 ±0.6) (P.001) was observed. Of the non-vaccinated group, 59.3% reported being interested in receiving the vaccine. By the 3- and 6-month follow-ups, only 2 students had started the vaccine series.Knowledge about HPV and associated malignancies increased significantly. However, few students initiated the vaccine after either of the followups. Future efforts should line up the vaccine promotion and outreach activities with immunization services, making the vaccine available in the communities to be impacted.
Published: 2021

46. Cervical Cancer Screening Among Medicaid Patients During Natural Disasters and the COVID-19 Pandemic in Puerto Rico, 2016 to 2020

Author: Jeslie M Ramos-Cartagena, Vivian Colón-López, Karen J. Ortiz-Ortiz, Axel Gierbolini-Bermúdez, Ashish A. Deshmukh, Ana P. Ortiz, and Kalyani Sonawane
Subjects: 2019-20 coronavirus outbreak, Coronavirus disease 2019 (COVID-19), Databases, Factual, Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), Uterine Cervical Neoplasms, Cervical cancer screening, Environmental health, Pandemic, Earthquakes, Research Letter, Medicine, Humans, Mass Screening, Natural disaster, Pandemics, Mass screening, Early Detection of Cancer, Retrospective Studies, business.industry, Cyclonic Storms, Medicaid, SARS-CoV-2, Research, Puerto Rico, COVID-19, General Medicine, United States, Online Only, Female, Public Health, business, geographic locations
Abstract: This cohort study examines rates of cervical cancer screening in Puerto Rico among women with Medicaid health coverage following the 2017 hurricanes, earthquakes in late 2019-2020, and the 2020 COVID-19 lockdown.
Published: 2021

47. Trends in the Incidence of Human Papillomavirus-Associated Cancers by County-Level Income and Smoking Prevalence in the United States, 2000-2018

Author: Yueh-Yun Lin, Haluk Damgacioglu, Ryan Suk, Chi-Fang Wu, Yenan Zhu, Ana P Ortiz, Sehej Kaur Hara, Kalyani Sonawane, and Ashish A Deshmukh
Subjects: Male, Cancer Research, Vulvar Neoplasms, Incidence, Papillomavirus Infections, Smoking, Alphapapillomavirus, Anus Neoplasms, United States, Oncology, Prevalence, Humans, Female, Papillomaviridae
Abstract: Human papillomavirus (HPV)-associated cancer burden is rising in the United States. Trends in the incidence by county-level income and smoking prevalence remain undescribed. We used the Surveillance, Epidemiology, and End Results 21 database to ascertain HPV-associated cancers during 2000-2018. Trends were estimated by county-level income and smoking prevalence quartiles. Anal and vulvar cancer incidence among women and anal cancer incidence among men increased markedly in the lowest-income counties, whereas the increases were slower in the highest-income counties (eg, for vulvar cancer, incidence increased 1.9% per year, 95% confidence interval [CI] = 0.9% to 2.9%, in the lowest-income counties vs 0.8% per year, 95% CI = 0.6% to 1.1%, in the highest-income counties). In recent years, cervical cancer incidence plateaued (0.0% per year [95% CI = −0.5% to 0.5%]) in the highest-income counties; in the lowest-income counties, the annual percentage change was 1.6% per year (95% CI = −0.7% to 4.0%). Counties with high smoking prevalence had marked increases in incidence compared with their counterparts (eg, anal cancer among men increased 4.4% per year [95% CI = 2.7% to 6.0%] for those living in counties with the highest smoking prevalence vs 1.2% per year [95% CI = 0.7% to 1.7%] for those living in counties with the lowest smoking prevalence). Improved and targeted prevention is needed to combat the widening disparities.
Published: 2021

48. Understanding parents’ views toward the newly enacted HPV vaccine school entry policy in Puerto Rico: a qualitative study

Author: Olga L. Díaz Miranda, Roxana Soto Abreu, Ana P. Ortiz, Diana T. Medina-Laabes, Pamela C. Hull, Vivian Colón-López, and Maria E. Fernandez
Subjects: Male, Parents, medicine.medical_specialty, Health Knowledge, Attitudes, Practice, education, Hispanic, HPV vaccines, Medicine, Humans, Misinformation, Papillomavirus Vaccines, Child, School entry policy, HPV vaccine, Schools, business.industry, Public health, Research, Parental perspective, Papillomavirus Infections, Puerto Rico, Vaccination, Public Health, Environmental and Occupational Health, Patient Acceptance of Health Care, Focus group, Policy, Family medicine, Female, Thematic analysis, Public aspects of medicine, RA1-1270, business, Inclusion (education), Qualitative research
Abstract: Background The Human papillomavirus vaccine (HPV) is an essential tool for the prevention of HPV-related cancers. In Puerto Rico, the Secretary of Health established a school entry requirement of at least one dose of HPV vaccination in girls and boys aged 11 and 12 years, taking effect in August 2018. Our study aimed to examine parents’ and guardians’ views of unvaccinated children about the process of implementation of the new HPV vaccination school entry policy in Puerto Rico and identify potential barriers and facilitators related to the implementation of this requirement. Methods During April through November 2019, we conducted three focus groups (n = 12) and eight in-depth semi-structured interviews with parents of children aged 11 and 12 who had not yet initiated the HPV vaccine series. The interview topics addressed were: perception of vaccination, HPV vaccine and it is inclusion as new school entry requirement practice, procedure of the sources of information, influencers, and willingness to change. The interviews were recorded and transcribed by our staff members. We identified emergent themes through thematic analysis. Results The participants’ perspective on the HPV vaccine school requirement was mixed. Lack of information of the HPV vaccines and lack of communication about the school-entry requirement were the themes most mentioned in the interviews. Moreover, previous negative experiences from friends or family members and adverse effects deterred some participants from vaccinating their kids. We discussed barriers in the process of soliciting an exemption. Conclusion Most barriers mentioned by study participants are modifiable. Information about the HPV vaccine mandate’s implementation and educational materials regarding HPV vaccine safety need to be provided to address parents’ concerns related to the vaccine’s side effects. Schools (teachers, principal directors, and administrative staff), the government, and parent organizations need to be part of these efforts. This multilevel approach will help to improve disseminating information about HPV vaccination to clarify doubts and misinformation among parents.
Published: 2021

49. Cancer statistics for the US Hispanic/Latino population, 2021

Author: Stacey A. Fedewa, Priti Bandi, Hannah E. Fuchs, Ahmedin Jemal, Rebecca L. Siegel, Paulo S. Pinheiro, Adair K. Minihan, Dinorah Martinez Tyson, Ana P. Ortiz, Guillermo Tortolero-Luna, and Kimberly D. Miller
Subjects: Adult, Male, Adolescent, Population, Rate ratio, Health Services Accessibility, White People, Young Adult, Breast cancer, Risk Factors, Neoplasms, Medicine, Humans, Young adult, education, Stomach cancer, Survival rate, Early Detection of Cancer, Aged, education.field_of_study, business.industry, Incidence (epidemiology), Incidence, Puerto Rico, Cancer, Hematology, Hispanic or Latino, Middle Aged, medicine.disease, United States, Survival Rate, Oncology, Female, business, Demography
Abstract: The Hispanic/Latino population is the second largest racial/ethnic group in the continental United States and Hawaii, accounting for 18% (60.6 million) of the total population. An additional 3 million Hispanic Americans live in Puerto Rico. Every 3 years, the American Cancer Society reports on cancer occurrence, risk factors, and screening for Hispanic individuals in the United States using the most recent population-based data. An estimated 176,600 new cancer cases and 46,500 cancer deaths will occur among Hispanic individuals in the continental United States and Hawaii in 2021. Compared to non-Hispanic Whites (NHWs), Hispanic men and women had 25%-30% lower incidence (2014-2018) and mortality (2015-2019) rates for all cancers combined and lower rates for the most common cancers, although this gap is diminishing. For example, the colorectal cancer (CRC) incidence rate ratio for Hispanic compared with NHW individuals narrowed from 0.75 (95% CI, 0.73-0.78) in 1995 to 0.91 (95% CI, 0.89-0.93) in 2018, reflecting delayed declines in CRC rates among Hispanic individuals in part because of slower uptake of screening. In contrast, Hispanic individuals have higher rates of infection-related cancers, including approximately two-fold higher incidence of liver and stomach cancer. Cervical cancer incidence is 32% higher among Hispanic women in the continental US and Hawaii and 78% higher among women in Puerto Rico compared to NHW women, yet is largely preventable through screening. Less access to care may be similarly reflected in the low prevalence of localized-stage breast cancer among Hispanic women, 59% versus 67% among NHW women. Evidence-based strategies for decreasing the cancer burden among the Hispanic population include the use of culturally appropriate lay health advisors and patient navigators and targeted, community-based intervention programs to facilitate access to screening and promote healthy behaviors. In addition, the impact of the COVID-19 pandemic on cancer trends and disparities in the Hispanic population should be closely monitored.
Published: 2021

50. [Efforts towards the consolidation of public policies for the prevention of HPV-associated cancers in Puerto RicoEsforços realizados em Porto Rico para a consolidação de políticas públicas de prevenção de cânceres associados ao HPV]

Author: Diana T, Medina-Laabes, Vivian, Colón-López, Vilnery, Rivera-Figueroa, Coralia, Vázquez-Otero, Glizette O, Arroyo-Morales, Lara, Arce-Cintrón, Paola, Fernández-Rivera, Idamaris, Vega, Roxana, Soto-Abreu, Olga L, Díaz-Miranda, Ángel, Rivera, Iris, Cardona, Ana P, Ortiz, Lilliam Rodríguez, Capó, and Pamela C, Hull
Abstract: The purpose of this special report is to describe chronologically the events that contributed to the development and approval of legislation and subsequent implementation of a school vaccination mandate in order to prevent HPV and HPV-associated cancers in Puerto Rico (PR). Starting in 2010, PR initiated public-policy approvals aimed at improving cancer registries and HPV vaccine coverage through health insurance for adolescents aged 11 to 18 years. In 2014, scientific and community efforts succeeded in documenting the magnitude of morbidity caused by HPV and jointly developing HPV vaccine prevention and promotion strategies. In August 2018, PR became one of the first four territories of the United States of America to implement the HPV vaccine school entry requirement to decrease the incidence of HPV-associated cancers on the island. In 2019, it was enshrined in law that every immunization provider must submit immunization data to the Puerto Rico Immunization Registry. The case of PR demonstrates that public policy-making alongside collaboration between academic, scientific, and community coalitions can achieve population change and measurable outcomes aimed at HPV prevention. Countries with a similar public health problem could adopt efforts similar to those presented herein and align them with the World Health Organization goal of eradicating cervical cancer by 2030.O propósito deste relatório especial é descrever cronologicamente os eventos que contribuíram para o desenvolvimento e a aprovação de legislação, e a implementação da exigência escolar de vacinação em Porto Rico (PR), a fim de prevenir o HPV e os cânceres associados a ele. A partir de 2010, PR iniciou as aprovações de políticas públicas com o objetivo de aprimorar o registro dos casos de câncer e a cobertura vacinal contra o HPV, por meio de planos de saúde, em adolescentes de 11 a 18 anos. Em 2014, esforços científicos e comunitários permitiram documentar a magnitude das doenças causadas pelo HPV e elaborar conjuntamente estratégias de prevenção e promoção da vacina contra o HPV. Em agosto de 2018, PR foi um dos primeiros quatro territórios dos Estados Unidos da América a implementar a vacina contra o HPV como exigência escolar, a fim de diminuir a incidência de cânceres associados ao HPV na ilha. Em 2019 ficou garantido por lei que todos os vacinadores devem enviar informações ao Registro de Imunização. O caso de PR demonstra que o desenvolvimento de políticas públicas, em conjunto com parcerias entre coalizões acadêmicas, científicas e comunitárias, alcança mudanças populacionais e resultados mensuráveis dirigidos à prevenção do HPV. Países com uma problemática de saúde pública similar poderiam adotar esforços semelhantes aos apresentados e alinhá-los ao objetivo da Organização Mundial da Saúde: a erradicação do câncer cervical até 2030.
Published: 2021

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