Planning for human papillomavirus (HPV) vaccination in sub-Saharan Africa: A modeling-based approach

Background

Human papillomavirus (HPV) vaccines have the potential to reduce cervical cancer incidence and mortality, particularly in the parts of the developing world that bear the greatest burden of disease. This research sought to predict the impact and cost-effectiveness of an HPV vaccination program in an example low-resource country with a high burden of cervical cancer: Mali, West Africa.

Methods

Novel compartmental mathematical models projected the impact of adolescent HPV vaccination in urban and rural areas of Mali. The models accounted for two high-risk vaccine-types: HPV 16 and 18. We then attached comprehensive real cost and cost-effectiveness estimates.

Results

Our models predict that HPV vaccination in Mali will reduce cervical cancer burden by a factor roughly equal to vaccine coverage. A point vaccination program was simulated in a cohort of 333,146 urban and 588,982 rural Malian women, age 10–14. Vaccination of 50% of girls reduced the peak prevalence of HPV 16/18 to 5.0% in the urban setting and 9.6% in the rural setting, down from 11.7% and 22.0%, respectively, with no vaccination. The 50% vaccination scenario averted 1145 cervical cancer deaths in the urban group and 2742 in the rural group. The cost per discounted life-year saved in this scenario was 1030 US dollars (urban) and 725 dollars (rural). The cost per life-year saved was higher at 90% coverage, but was still in the range of a “cost-effective” public health intervention.

Conclusions

This research yielded the most comprehensive real cost estimates of HPV vaccination yet published for sub-Saharan Africa. Our models indicate that HPV vaccination in Mali will be cost-effective when introduced. To maximize the benefit using limited resources, vaccination programs may begin with a target coverage of about 50%. We anticipate that costs of reaching late adopters after the First Vaccinated Wave of vaccination will be higher, but worthwhile.     

Dimensions of psychotic experiences among women in the general population

Full‐information factor analysis of ordinal data was employed to determine the factorial structure of the responses of 31,822 adult Swedish women to the 20 “positive” psychotic experience items of the Community Assessment of Psychic Experiences (CAPE) questionnaire. Five separable but correlated trait dimensions were found, reflecting Paranoia, Grandiosity, Magical Thinking, Delusions, and Hallucinations. High scores on any dimension were associated with a higher probability of questionnaire‐assessed lifetime major depressive episodes or generalized anxiety disorder, though Grandiosity was so only to a very small degree. Our results closely match previous findings among adolescents and young women, and demonstrate that psychotic experiences cannot be considered a single trait. Copyright © 2013 John Wiley & Sons, Ltd.     

Atrophy of the cholinergic basal forebrain in dementia with Lewy bodies and Alzheimer’s disease dementia

Similar to Alzheimer’s disease (AD), dementia with Lewy bodies (DLB) is characterized by a profound degeneration of cortically-projecting cholinergic neurons of the basal forebrain (BF) and associated depletion of cortical cholinergic activity. We aimed to investigate subregional atrophy of the BF in DLB in vivo and compare it to the pattern of BF atrophy in AD. Structural MRI scans of 11 patients with DLB, 11 patients with Alzheimer’s disease, and 22 healthy controls were analysed using a recently developed technique for automated BF morphometry based on high-dimensional image warping and cytoarchitectonic maps of BF cholinergic nuclei. For comparison, hippocampus volume was assessed within the same morphometric framework using recently published consensus criteria for the definition of hippocampus outlines on MRI. The DLB group demonstrated pronounced and subregion-specific atrophy of the BF which was comparable to BF atrophy in AD: volume of the nucleus basalis Meynert was significantly reduced by 20–25 %, whereas rostral BF nuclei were only marginally affected. By contrast, hippocampus volume was markedly less affected in DLB compared to AD. Global cognition as determined by MMSE score was associated with BF volume in AD, but not in DLB, whereas visuoperceptual function as determined by the trail making test was associated with BF volume in DLB, but not in AD. DLB may be characterized by a more selective degeneration of the cholinergic BF compared to AD, which may be related to the differential cognitive profiles in both conditions.     

Subgroup Variations in Bone Mineral Density Response to Zoledronic Acid After Hip Fracture

Minimizing post‐fracture bone loss is an important aspect of recovery from hip fracture, and determination of factors that affect bone mineral density (BMD) response to treatment after hip fracture may assist in the development of targeted therapeutic interventions. A post hoc analysis of the HORIZON Recurrent Fracture Trial was done to determine the effect of zoledronic acid (ZOL) on total hip (TH) and femoral neck (FN) BMD in subgroups with low‐trauma hip fracture. A total of 2127 patients were randomized (1:1) to yearly infusions of ZOL 5 mg (n = 1065) or placebo (n = 1062) within 90 days of operation for low‐trauma hip fracture. The 1486 patients with a baseline and at least one post‐baseline BMD assessment at TH or FN (ZOL = 745, placebo = 741) were included in the analyses. Percentage change from baseline in TH and FN BMD was assessed at months 12 and 24 and compared across subgroups of hip fracture patients. Percentage change from baseline in TH and FN BMD at months 12 and 24 was greater (p < 0.05) in ZOL‐treated patients compared with placebo in most subgroups. Treatment‐by‐subgroup interactions (p < 0.05) indicated that a greater effect on BMD was observed for TH BMD at month 12 in females, in patients in the lower tertile body mass index at baseline (≤22.6 kg/m²), and in patients with baseline FN BMD T‐score of ≤ –2.5; for FN BMD in patients who received ZOL for >6 weeks post‐surgery; and for TH and FN BMD in patients with a history of one or more prior fractures. All interactions were limited to the first 12 months after treatment with none observed for the 24‐month comparisons. (Clinical trial registration number NCT00046254.) © 2014 American Society for Bone and Mineral Research.     

Impact of Combat Deployment on Psychological and Relationship Health: A Longitudinal Study

Although previous research has indicated an elevated prevalence of posttraumatic stress disorder (PTSD) and other mental health problems among veterans of Operations Iraqi Freedom and Enduring Freedom following deployment, most of this research has been cross‐sectional and has focused on a limited range of military groups and outcome criteria. This investigation was a longitudinal study of U.S. Air Force security forces assigned to a year‐long high‐threat ground mission in Iraq to determine the degree to which airmen's emotional and behavioral health and committed relationships were adversely impacted by an extended deployment to a warzone. Participants were a cohort of 164 security forces airmen tasked to a 365‐day deployment to train Iraqi police. Airmen completed study measures both prior to and 6–9 months following deployment. Rates of deterioration in individual and interpersonal adjustment were both significant and medium to large in magnitude of effect, d = 0.43 to 0.90. Results suggest that the negative effects of deployment are related to levels of traumatic experiences and do not spontaneously remit within the first 6–9 months following return from deployment—particularly among those service members having relatively lower levels of social support.     

Determining the effect of immunosuppressant adherence on graft failure risk among renal transplant recipients

The objective was to use the United States Renal Data System (USRDS) to quantify the relationship between immunosuppressant therapy (IST) adherence and risk of graft failure among adult renal transplant recipients (RTRs). A secondary objective was to examine the relationship among select patient characteristics and IST adherence. The study sample included adult RTRs who: received primary transplant between January 1, 1999 and December 31, 2005; experienced graft survival for at least 12 months post‐transplant and had at least 12 months of data in the USRDS; utilized Medicare coverage for IST; and were prescribed cyclosporine or tacrolimus. IST adherence was measured by medication possession ratio (MPR). Pearson chi‐square tests were used to examine associations between patient characteristics and MPR quartiles. Cox proportional hazards regression was used to assess relationships among time to graft failure, MPR, and patient characteristics. Thirty‐one thousand nine hundred and thirteen RTRs met inclusion criteria. Older age, female gender, white race, deceased donors, and tacrolimus were associated with greater adherence (p < 0.001). Cox proportional hazard modeling indicated greater adherence, white race, and having a living donor were significantly associated with longer graft survival (p < 0.05). Future prospective studies should further examine the clinical significance of IST nonadherence as it relates to graft failure.