Abstract
Simple SummaryHuman papillomavirus (HPV) vaccination disparities between urban and rural regions may moderate the vaccine’s impact on reducing cervical precancer (CIN2+) and cancer incidence. We assessed population-level trends in CIN2+ incidence (2008–2018) in urban and rural areas among Medicaid-enrolled women aged 18–39 years in Tennessee, United States. A sub-group analysis among women screened for cervical cancer was conducted to control for changing screening trends. CIN2+ incidence among young women aged 18–20 and 21–24 years, who most likely benefited from the HPV vaccine, declined similarly between urban and rural areas, although significant declines began earlier in urban versus rural areas. Our results suggest evidence of HPV vaccine impact regardless of urbanicity but demonstrate lagged impact in rural areas. These findings emphasize the importance of reducing barriers to HPV vaccination, particularly in rural areas, to improve the reduction of cervical precancer and cancer incidence, toward the World Health Organization’s goals of eliminating cervical cancer.Disparities in human papillomavirus (HPV) vaccination exist between urban (metropolitan statistical areas (MSAs)) and rural (non-MSAs) regions. To address whether the HPV vaccine’s impact differs by urbanicity, we examined trends in cervical intraepithelial neoplasia grades 2 or 3 and adenocarcinoma in situ (collectively, CIN2+) incidence in MSAs and non-MSAs among Tennessee Medicaid (TennCare)-enrolled women aged 18–39 years and among the subset screened for cervical cancer in Tennessee, United States. Using TennCare claims data, we identified annual age-group-specific (18–20, 21–24, 25–29, 30–34, and 35–39 years) CIN2+ incidence (2008–2018). Joinpoint regression was used to identify trends over time. Age–period–cohort Poisson regression models were used to evaluate age, period, and cohort effects. All analyses were stratified by urbanicity (MSA versus non-MSA). From 2008–2018, 11,243 incident CIN2+ events (7956 in MSAs; 3287 in non-MSAs) were identified among TennCare-enrolled women aged 18–39 years. CIN2+ incident trends (2008–2018) were similar between women in MSAs and non-MSAs, with largest declines among ages 18–20 (MSA average annual percent change (AAPC): −30.4, 95% confidence interval (95%CI): −35.4, −25.0; non-MSA AAPC: −30.9, 95%CI: −36.8, −24.5) and 21–24 years (MSA AAPC: −14.8, 95%CI: −18.1, −11.3; non-MSA AAPC: −15.1, 95%CI: −17.9, −12.2). Significant declines for ages 18–20 years began in 2008 in MSAs compared to 2010 in non-MSAs. Trends were largely driven by age and cohort effects. These patterns were consistent among screened women. Despite evidence of HPV vaccine impact on reducing CIN2+ incidence regardless of urbanicity, significant declines in CIN2+ incidence were delayed in non-MSAs versus MSAs.
Highlights
The current nonavalent human papillomavirus (HPV) vaccine can prevent up to 90%of cervical cancer cases [1]
Vaccine’s impact on CIN2+ by urbanicity, we examined temporal trends in CIN2+ incidence, including age, period, and birth cohort effects, from 2008 through 2018, in urban and rural areas in Tennessee among (1) women aged 18–39 years enrolled in the Tennessee Medicaid (TennCare) program and (2) the subset of women who were screened for cervical cancer to control for changes in screening rates over time
For urbanicity-stratified CIN2+ incidence by age group over time, we found similar patterns and evidence of HPV vaccine impact on reducing CIN2+ incidence in both metropolitan statistical areas (MSAs) and non-MSAs, despite varying HPV vaccination coverage by urbanicity
Summary
Of cervical cancer cases [1]. Despite being vaccine-preventable, cervical cancer remains the fourth most common incident cancer in women worldwide, causing over 300,000 cervical cancer-related deaths annually [2]. Lower odds of HPV vaccine initiation for adults aged 18–26 years in rural areas compared to urban areas across eight US states [8] These geographic differences may be attributed to rural areas having more barriers to vaccination, including lack of health care access, lack of knowledge and awareness of HPV and its link to cancer, increased negative community messaging regarding the vaccine, and more prevalent religious and cultural beliefs that may not support vaccination [10]. Given these large geographic disparities in both adolescent and adult HPV vaccination, examining whether urbanicity has modified the vaccine’s impact on reducing HPV-related outcomes is important for informing HPV vaccination guidelines and public health interventions to improve vaccination rates. To better understand the HPV vaccine’s impact on CIN2+ by urbanicity, we examined temporal trends in CIN2+ incidence, including age, period, and birth cohort effects, from 2008 through 2018, in urban and rural areas in Tennessee among (1) women aged 18–39 years enrolled in the Tennessee Medicaid (TennCare) program and (2) the subset of women who were screened for cervical cancer to control for changes in screening rates over time
Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have