Episode 150: Re-update on COVID Vaccines and Cervical Cancer COVID vaccines have been updated (again). The bivalent m-RNA COVID-19 vaccines are no longer authorized in the US. Sabrina explains that the monovalent COVID-19 vaccines will be available soon to target XBB lineage and more. Future Dr. Rodriguez explains the USPSTF cervical cancer screening guidelines. Dr. Arreaza adds comments and insight.
Episode 150: Re-update on COVID Vaccines and Cervical Cancer
COVID vaccines have been updated (again). The bivalent m-RNA COVID-19 vaccines are no longer authorized in the US. Sabrina explains that the monovalent COVID-19 vaccines will be available soon to target XBB lineage and more. Future Dr. Rodriguez explains the USPSTF cervical cancer screening guidelines. Dr. Arreaza adds comments and insight.
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Celebrating our episode 150.
Written by Hector Arreaza, MD.
In our previous episode, we gave you an update on COVID-19 vaccines, but we need to give a new update. This is the risk you take when you try to become a news agency instead of an educational podcast, so you need to keep giving updates, and we’ll tell you about the newest change in COVID-19 vaccines in a few minutes.
This is episode number 150! And I wanted to take a moment to celebrate this milestone. Our first episode was released a few days before the lockdown for COVID-19 on March 3, 2020. Those were gloomy days. I was excited about having a weekly podcast, but I also was overwhelmed by COVID-19. I remember considering putting a hold on the podcast, but I decided to continue. We had a few episodes about COVID-19 and, as expected for a novel disease, we made some mistakes. For example, we gave the wrong recommendations to not wear a mask at the very beginning of the lockdown, but that was the initial recommendation. However, I got to accentuate the positive, I’m proud that we were probably the first place to report hiccups as a symptom of COVID. Soon I realized it would be impossible to keep up with the daily changes in recommendations and updates on COVID, so we focused on other topics, and it has been a great experience so far.
This podcast was created for the Rio Bravo residents, and thankfully the medical students have become the main collaborators of this program. I have enjoyed every second I have spent with all our guests, including residents, nurses, medical assistants, specialists, scientists, and of course medical students. I feel very fortunate to have reviewed many relevant topics of family medicine with you. A colleague once mentioned to me that I may run out of topics, but I think it is impossible to run out of topics in family medicine, don’t you think? So, I’m hoping to continue bringing to you brief discussions and pearls of knowledge every week. Now, let’s listen to Sabrina.
Re-update on COVID-19 Vaccines.
Written by Sabrina Hawatmeh, MSIII, Ross University School of Medicine.
Hi, my name is Sabrina Hawatmeh, I’m a 3rd-year medical student from Ross University School of Medicine. I’m so excited to be here today, huge thank you to Dr. Arreaza for having me here today! As mentioned by Dr. Arreaza, during our episode 149 we gave you an update on COVID-19 vaccines and now today it’s time for a new update.
Most recently, Pfizer/BioNTech and Moderna have updated their vaccines to target specific strains of the virus, and the American Academy of Family Physicians has given its approval to federal actions allowing the use of these updated vaccines for the Fall/Winter of 2023. The decision follows FDA approval for these vaccines for children and adults aged 12 and older, as well as CDC recommendation of emergency use authorization for children aged 6 months to 11 years. The AAFP's Board Chair, Sterling Ransone, M.D., accepted the recommendation to approve these actions as of September 14th, 2023. The vaccines may be available soon for administration.
Bivalent vaccines were the most recent formula administered for immunization. Studies had shown that there was continued protection against circulating sublineages of Omicron and XBB.1.5. However, the vaccine effectiveness against Omicron decreases over time. Neutralizing antibody titers against XBB sublineages via bivalent vaccines are lower compared to titers induced by the matched BA.4/BA.5 sublineage.
So, it makes sense that all this data suggested that vaccine modification be directed toward more closely matched strain composition to current circulating sublineages. I also think it's worth noting that the original version of Omicron is no longer circulating—neither is the original strain of the SARS-CoV-2 virus. For that reason, updated vaccines were created by Moderna and Pfizer/BioNTech, so the bivalent vaccines are no longer authorized for use in the United States.
The updated vaccine recommendations include eligibility criteria for different age groups, regardless of previous vaccination status, and specify the number of doses needed. The CDC has also updated its vaccine recommendations, especially for moderately or severely immunocompromised individuals. The new vaccines are monovalent mRNA vaccines, designed to protect against omicron subvariant, XBB 1.5.
While the subvariant XBB.1.5 is the target of the vaccines, the expectation is that they will offer immunization against multiple current strains. (XXB lineage, EG.5.1 (Eris), Fl.1.5.1 (Fornax), BA.2.86). Moderna (randomized controlled trial of 101 individuals) and Pfizer (mouse studies) evidence suggests that the vaccines will also serve to protect against the new mutated subvariant that has recently sparked some concern, BA.2.86.
As a reminder, FDA granted emergency use authorization for Novavax COVID-19 vaccine, Adjuvant in July 2022 for the prevention of COVID-19 pneumonia in patients aged 12 and older. Now the updated Novavax formula for 2023-2024 (targeting the XBB strain) was authorized by CDC on September 12, 2023, but it is still under review by the U.S. FDA for emergency use authorization for individuals aged 12 and older. When authorized, Novavax's protein-based vaccine will be the only non-mRNA COVID vaccine available in the U.S.
These updated vaccines are expected to be covered by most public and private insurance plans, but concerns have been raised about uninsured individuals having to pay out of pocket for the vaccines, which cost $120 to $130. The AAFP urged the government to ensure equitable access and financial support for primary care practices offering these vaccines.
Cervical Cancer Screening Guidelines.
Written by Adriana Rogriguez, MSIV, Ross University School of Medicine.
Arreaza: Cervical canceris the 3rd most common gynecological cancer in the US. For 2023, the American Cancer Society estimates that about 13,000 new cases of cervical cancer will be diagnosed, and more than 4,000 women will die this year. Cervical cancer was once one of the most fatal types of cancer in women, but the mortality rate has been significantly decreased with the increased use of pap smears and the HPV test.
Adriana: Another fun fact is that cervical cancer is the only cancer preventable by a vaccine—the HPV vaccine.
Arreaza: Why is cervical cancer screening important?
Adriana: Cervical Cancer screening is very important as it reduces mortality due to cervical disease. Intervention at early stages reduces the development of squamous cell carcinoma or adenocarcinoma of the cervix due to HPV. In fact, studies have shown that in resource-poor settings, one cervical screening reduces the incidence of cervical cancer by up to 50%.
Arreaza: What would prevent a patient from wanting to get a Pap smear?
Adriana: Many things can and do deter a patient from obtaining their cervical cancer screening. Patient discomfort and the psychosocial consequences of performing these screenings such as anxiety should be taken into consideration. Personal example. Also, a patient may be concerned about the costs, the effects of false-positive results, the risks of treatment during pregnancy (ex., increased risk/o 2nd-trimester pregnancy loss, PPROM, preterm delivery, perinatal mortality).
Arreaza: We should mention the cultural implications of a pap smear in a 21-year-old who is considered a “virgin”. Some cultures try to preserve the hymen intact as a sign of purity. You can address this concern with your patients and explain that a hymen is not always present, it may be easily ripped by sports, biking, tampon use, and more. A small speculum may be used for your patients who have never been sexually active at age 21.
Arreaza: We perform screening BEFORE we diagnose a disease. The age of diagnosis of cervical cancer is age 50, most patients fall between 35 and 45 years old. How can we determine who is at risk and needs a pap smear?
Adriana: When looking at cervical screening guidelines and recommendations, we are looking at the patient who is:
Arreaza: Those are the patients we are going to screen for cervical cancer. Let’s start with the basics of the United States Preventive Services Task Force (USPSTF) guideline. We start screening at age 21 regardless of sexual activity.
Adriana: Yes
Arreaza: Actually, the treatment of CIN2 and CIN3 before age 21 may increase the risk of adverse pregnancy outcomes.
Adriana: 21-29: begin at age 21, cervical cytology Q3yrs.
Arreaza: Tell me about patients older than 30.
Adriana: 30-65: Primary HPV testing (FDA approved test) Q5yrs, Co-testing (Pap AND HPV) Q5yrs, or Pap test alone Q3yrs.
Arreaza: The most common method in our clinic is:
What about the grandmas older than 65?
Adriana: >65: Both USPSTF and ACS suggest discontinuing screening in average-risk patients if she has had adequate screening with NORMAL results. Discontinuing screening predicated on meeting both following criteria:
Arreaza: The guidelines also recommend keeping routine screening for at least 20 years after spontaneous regression or appropriate management of a precancerous lesion, even if the patient turns 65 years of age.
Adriana: Data for stopping age for cervical cancer screening are limited. Other countries use older age to stop screening. For example, Australia has the lowest cervical cancer mortality rate in the world, and their guidelines recommend discontinuing screening at 74 yo. With that said, some clinicians continue to offer screening through age 74 for those w/ life expectancy of at least 10 yrs. Conversely, screening can also be d/c’d for patients w/ limited life expectancy.
Arreaza: Who does not get screened?
Adriana: Women before age 21 or older than 65 who have had adequate screenings, as we just described a few moments ago, and Patients s/p hysterectomy for benign disease.
Arreaza: You mentioned patients s/p hysterectomy receive different screening.
Adriana: Yes, they do!
Arreaza: You mentioned that the guidelines earlier were for patients at average risk for cervical disease. What would make a Patient high risk?
Adriana: High risk patients include patients with immunosuppression, ie., a person whose immune system cannot fight off hrHPV, and is at higher risk of developing squamous cell carcinoma or adenocarcinoma of the cervix later on. Also at high risk are patients with in-utero exposure to di-ethyl-stilbestrol (DES).
Arreaza: Let’s review the recommendation for patients who are immunosuppressed.
Adriana: HIV Patients and Immunosuppressed patients w/o HIV:
Arreaza: Normal: Sample was adequate for evaluation and the report may state: Negative for intraepithelial lesion. What is considered an abnormal result?
Adriana: Results are abnormal if any of the following occur:
These are all a wide array of results and considered abnormal, but receive different surveillance and or treatments.
Arreaza: So, what happens if the average Patient has a history of abnormal cervical cancer screenings?
Adriana: These patients are now managed w/ active surveillance, not screening. It gets a little complicated and out of the scope of this episode.
Arreaza: At this point, I recommend to our listeners to download the ASCCP app.
Adriana: Conclusion: Pap smear is one the strongest arsenals in the physicians’ toolbox. Start screening at age 21, until 65 years old.
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Conclusion: Now we conclude episode number 150, “Re-update on COVID Vaccines and Cervical Cancer.” Sabrina gave a very good summary of the updated COVID vaccines, and we are hoping to have good coverage for the most common strains. Make sure you get your updated vaccine as it becomes available soon. Future Dr. Rodriguez explained that pap smears and HPV tests are some of the most powerful tools we have to prevent cervical cancer. Dr. Arreaza added some ideas about how to overcome the cultural barrier to start screening at the age of 21.
Today we celebrate our episode 150! We look forward to many more episodes in the future! This week we thank Hector Arreaza, Sabrina Hawatmeh, and Adriana Rodriguez. Audio editing by Adrianne Silva.
Even without trying, every night you go to bed a little wiser. Thanks for listening to Rio Bravo qWeek Podcast. We want to hear from you, send us an email at RioBravoqWeek@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. See you next week!
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