Successful Implementation and Results of an HPV Vaccination Program in Geneva Canton,Switzerland

We describe a human papillomavirus (HPV) vaccination program implemented since 2007 in Geneva Canton, Switzerland, that used school services, a public hospital, and private physicians as vaccination providers. We assessed program performance with the evolution of immunization coverage during the first four years of program implementation. We measured vaccination coverage of the target population using individual records of vaccination status collected by service providers and transmitted to the Geneva Canton Medical Office. The target population was 20,541 adolescent girls aged 11–19 years as of September 1, 2008, who resided in the canton when the program began. As of June 30, 2012, HPV vaccination coverage was 72.6% and 74.8% in targeted cohorts for three and two doses, respectively. The global coverage for three doses increased by 27 percentage points from December 2009 to June 2012. Coverage for girls aged 16–18 years at the beginning of the program reached 80% or more four years into the program. High coverage by this HPV vaccination program in Geneva was likely related to free vaccination and easy access to the vaccine using a combination of delivery services, including school health services, a public hospital, and private physicians, covering most eligible adolescent girls.Human papillomavirus (HPV) represents a group of sexually transmitted viruses of particular interest because of their high prevalence and strong causal association with cervical cancer.¹ Cervical cancer is the second most frequently occurring cancer in the world for women.² Every year in Switzerland, 5,000 women present with a precancerous lesion of the cervix or an in situ carcinoma, and 320 women present with an invasive cervical carcinoma requiring surgical or laser treatment.¹ Half of the women presenting with a precancerous lesion of the cervix or an in situ carcinoma are <50 years of age at the time of diagnosis.³ In Geneva, Switzerland, 400 cases of in situ and 30 cases of invasive cervical cancer are diagnosed annually, resulting in 5–10 deaths per year.⁴ Both morbidity and mortality associated with this infection can be reduced through vaccination.⁵Two vaccines to prevent HPV infections have been developed by two companies, Sanofi Pasteur MSD and GSK,^6–8 that decrease the incidence of precancerous lesions of the cervix and also that of genital warts, another HPV-related infection.⁹ Since 2006, following the European Medicine Agency approval of Cervarix^® and Gardasil^®, these two vaccines have been used in most European countries.⁵ Cervarix targets HPV-16, -18, -31, -33, and -45, the five most common cancer-causing viral types, including most causes of adenocarcinoma. Gardasil targets HPV-16, -18, and -31, the three common squamous cell cancer-causing viral types, as well as HPV-6 and -11, which are associated with genital warts and respiratory papillomatosis.¹⁰ As in the United States, national recommendations on immunization in Switzerland are implemented by states (cantons), which have a wide level of autonomy on health-related matters. In Geneva Canton, the operational strategy was to vaccinate as many eligible (i.e., aged 11–18 years) adolescent girls as possible by sending them individual letters and making vaccination free of charge through all potential health-care providers of this age group (e.g., pediatricians, general practitioners, gynecologists, public hospital clinics, and school health services). This article provides an overview of the establishment of a publicly funded HPV vaccination program in Geneva Canton, preliminary coverage results, and key features of success.     

Early and late half-life of human chorionic gonadotropin as a predictor of persistent trophoblast after laparoscopic conservative surgery for tubal pregnancy

BACKGROUND: To determine if the early or late half-lives (T0.5) of human chorionic gonadotropin (hCG) can identify patients with persistent trophoblastic activity after conservative surgery for tubal pregnancy. DESIGN: Prospective cohort study. SETTING: Department of obstetrics and gynecology of a university hospital. METHODS: All patients with a tubal pregnancy treated by laparoscopic salpingostomy between June 1997 and September 2000 were enrolled in the study. Postoperative sequential hCG sampling was performed at days 0, 2 (+/- 1) and 7 (+/- 2) and followed until levels were undetectable. Taking the biexponential hCG declining curve as a model, we calculated the early (days 0-2) and late (days 2-7) T0.5 hCG values. MAIN OUTCOME MEASURE: To assess success or failure of surgical treatment. RESULTS: Seventy-three patients with an ectopic pregnancy were managed by conservative surgery. Early and late T0.5 allowed us to identify 2/10 and 9/10 women, respectively, with persistent trophoblast. Late T0.5 levels revealed two patients with false-positive values, but one patient showed a secondary increase in hCG after day 7 (false-negative) despite a normal late T0.5. CONCLUSIONS: Early and late half-lives of hCG do not identify all women at risk for persistent ectopic pregnancy. To exclude persistent trophoblast, postoperative serum hCG determination should be performed until levels are undetectable.     

Nosocomial nontyphoidal salmonellosis after antineoplastic chemotherapy: reactivation of asymptomatic colonization?

An increased frequency of nontyphoidal salmonellosis is well established in cancer patients, but it is unclear whether this represents increased susceptibility to exogenous infection or opportunistic, endogenous reactivation of asymptomatic carriage. In a retrospective study, a simple case definition was used to identify the probable presence of reactivation salmonellosis in five cancer patients between 1996 and 2002. Reactivation salmonellosis was defined as the development of nosocomial diarrhea >72 h after admission and following the administration of antineoplastic chemotherapy in an HIV-seronegative cancer patient who was asymptomatic on admission, in the absence of epidemiological evidence of a nosocomial outbreak. Primary salmonellosis associated with unrecognized nosocomial transmission or community acquisition and an unusually prolonged incubation period could not entirely be ruled out. During the same time period, another opportunistic infection, Pneumocystis pneumonia, was diagnosed in six cancer patients. Presumably, asymptomatic intestinal Salmonella colonization was converted to invasive infection by chemotherapy-associated intestinal mucosal damage and altered innate immune mechanisms. According to published guidelines, stool specimens from patients hospitalized for longer than 72 h should be rejected unless the patient is neutropenic or 65 years old with significant comorbidity. However, in this study neutropenia was present in only one patient, and four patients were <65 years old. Guidelines should thus be revised in order not to reject stool culture specimens from such patients. In cancer patients, nosocomial salmonellosis can occur as a chemotherapy-triggered opportunistic reactivation infection that may be similar in frequency to Pneumocystis pneumonia.Presented in part at the 14th European Congress of Clinical Microbiology and Infectious Diseases, Prague, Czech Republic, 1–4 May 2004 (Abstract P1435) and at the Annual Meeting of the Swiss Society of Infectious Diseases, Lausanne, Switzerland, 12–14 May 2004.     

Long-term survival of patients with apparent early-stage (FIGO I-II) epithelial ovarian cancer: a population-based study

BACKGROUND: Women with presumed early-stage epithelial ovarian cancer (EOC) who have not received comprehensive surgical staging are at risk for recurrence. The aim of our study was to analyze the overall long term survival of EOC patients with a presumed early stage EOC. METHODS: A population-based cancer registry was used to identify patients with an early-stage EOC cancer diagnosed between 1989 and 1997. The area under study has no surgical gynecologic oncologist and no tertiary referral center. We categorized patients into two subgroups: low-risk (Ia-Ib well and moderately differentiated) and high-risk (Ia-Ib poorly differentiated or IC-II). Survival curves were calculated from the time of surgery using Kaplan-Meier methods and statistical comparisons were performed using the log-rank test and the Cox proportional hazards regression model. RESULTS: Fifty patients having an apparent early-stage disease (FIGO I-II) were evaluated. Forty-one patients have been operated by obstetrician-gynecologists and 9 by general surgeons. Twenty-one (42%) have been categorized as low-risk and 29 (58%) as high-risk. An optimal, modified, minimal and inadequate surgical staging was performed in 6, 10, 26 and 58, respectively. The median follow-up time was 147 months (range: 2.5-165). The 5- and 10-year overall survival was 95 and 89% for low-risk and 72 and 33% for high-risk subgroups, respectively. CONCLUSIONS: The surgical staging is frequently incomplete when performed in small hospitals with few patients by nonspecialists. Women in the high-risk group and incompletely staged have a less favorable prognosis than those reported in the literature.     

Comparison of automated strategies for surveillance of nosocomial bacteremia.

OBJECTIVE: Surveillance of nosocomial bloodstream infection (BSI) is recommended, but time-consuming. We explored strategies for automated surveillance. METHODS: Cohort study. We prospectively processed microbiological and administrative patient data with computerized algorithms to identify contaminated blood cultures, community-acquired BSI, and hospital-acquired BSI and used algorithms to classify the latter on the basis of whether it was a catheter-associated infection. We compared the automatic classification with an assessment (71% prospective) of clinical data. SETTING: An 850-bed university hospital. PARTICIPANTS: All adult patients admitted to general surgery, internal medicine, a medical intensive care unit, or a surgical intensive care unit over 3 years. RESULTS: The results of the automated surveillance were 95% concordant with those of classical surveillance based on the assessment of clinical data in distinguishing contamination, community-acquired BSI, and hospital-acquired BSI in a random sample of 100 cases of bacteremia. The two methods were 74% concordant in classifying 351 consecutive episodes of nosocomial BSI with respect to whether the BSI was catheter-associated. Prolonged episodes of BSI, mostly fungemia, that were counted multiple times and incorrect classification of BSI clinically imputable to catheter infection accounted for 81% of the misclassifications in automated surveillance. By counting episodes of fungemia only once per hospital stay and by considering all cases of coagulase-negative staphylococcal BSI to be catheter-related, we improved concordance with clinical assessment to 82%. With these adjustments, automated surveillance for detection of catheter-related BSI had a sensitivity of 78% and a specificity of 93%; for detection of other types of nosocomial BSI, the sensitivity was 98% and the specificity was 69%. CONCLUSION: Automated strategies are convenient alternatives to manual surveillance of nosocomial BSI.     

Molar pregnancy with a coexistent fetus after intracytoplasmic sperm injection. A case report

BACKGROUND: Normal fertilization is usually considered to have occurred when two pronculei (2PN) and two polar bodies are observed. Exceptions are the single pronucleated zygote resulting from asynchronous pronuclei. CASE: A 29-year-old woman entered a program of intracytoplasmic sperm injection and embryo transfer because of her husband's oligoasthenoteratozoospermia. Two cleavage-stage embryos (four blastomeres, grade 1 and 2) were obtained from one fertilized oocyte containing distinct 2PN and the other a single pronucleus (1PN). At 15 weeks' gestation the patient developed severe preeclampsia requiring termination of the pregnancy. Histopathologic examination and DNA ploidy by image analysis were consistent with a twin pregnancy combining a complete hydatidiform mole and normal pregnancy. CONCLUSION: We hypothesize that this 1PN was at the origin of the hydatidiform mole. This case highlights the danger of transferring an embryo having 1PN.