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VOLUME 29 NUMBER 4OCTOBER / NOVEMBER 2017CONTENTS: Influenza . . . page 6 Childhood Immunizations . . . page 9 STD Surveillance Report . . . page 10 Selected Morbidity Report . . . page 39All Women Count! Breast and Cervical Cancer Screening for South Dakota WomenOverviewCervical cancer, a preventable cancer with the appropriate screening, occurs mostly in women older than30 years of age. In the United States, the age-adjusted incidence rate is 7.2 per 100,000 women per year and2.3 deaths per 100,000 women.1 Compared to surrounding states, South Dakota has the second highest ageadjusted incidence rate (7.3), after the state of Nebraska (7.4) (Figure 1).1, 2 However, the age-adjusted mortality rate in South Dakota is one of the lowest (1.6 per 100,000 women).Figure 1. Age-adjusted incidence rate of cervical cancer in the United States, 2013*Rates are per 100,000 and are age-adjusted to the 2000 U.S. standard population.‡Rates are not shown if the state did not meet USCS publication criteria or if the state did not submit data to CDC.†Source: U.S. Cancer Statistics Working Group. United States Cancer Statistics: 1999–2013 Incidence and Mortality Web-based Report.Atlanta (GA): Department of Health and Human Services, Centers for Disease Control & Prevention, and National Cancer Institute; 2016

In 1991, the Centers for Disease Control and Prevention (CDC) established the National Breast and Cervical Cancer Early Detection Program (NBCCEDP) as part of an effort to support low income women in completing the recommended screening schedule for breast and cervical cancer.3 The NBCCEDP delivers screening and diagnostic services to low income, uninsured, or underinsured women. In South Dakota, the All Women Count! (AWC!) Program is part of the national program funded through CDC since 1997. The AWC! Program works with 230 provider sites across South Dakota.4According to the US Preventive Services Task Force (USPSTF), women ages 21 to 65 should be screenedregularly for cervical cancer.5 The standard screening method is the Pap test (cytology) and the results are categorized using the Bethesda system. The most recent recommendation by the USPSTF for cervical cancerscreening is a Pap test every three years among women who have had three normal Pap tests within the lastfive years. However, the screening frequency may be less if a human papillomavirus (HPV) test is performedalong with a Pap test, also called HPV co-testing. HPV is a common virus and two HPV types (16 and 18) areassociated with 70% of cervical cancers and pre-cancerous cervical lesions. Hence, the USPSTF recommendsthe HPV co-test every five years for women ages 30-65 that have had negative HPV and normal Pap test results. Finally, cervical screening is not recommended for women aged 65 and older with low risk for cervicalcancer or with previous cervical screening results that were normal. In addition, it is important to mention thatCDC also recommends two doses of HPV vaccine for 11- to 12-year-olds to prevent cervical cancer and othercancers caused by HPV.6Eligibility CriteriaCervical cancer screening and diagnostic services are available through the AWC! Program for women whomeet the eligibility criteria. The services provided by the AWC! Program for cervical cancer screening includePap tests and HPV co-tests. To be eligible, women must be: 1) below or at 200% of federal poverty level, 2)uninsured or underinsured which is defined as those who cannot afford the copayments or deductibles orwhose insurance does not cover breast or cervical cancer screening services, and 3) between the ages of 30 and64 years.Sociodemographic of AWC! ParticipantsFrom 2001-2015, the AWC! Program served 17,794 women in South Dakota. Among AWC! participantswhose information on previous screening was available, 1,817 (13%) had rarely or never been screened (lastscreen 5 years). The race and ethnicity distribution of women screened and served in the AWC! Program isshown in Figure 2. The majority of women screened were white (71%), 17% were American Indian, followedby Hispanics (8%), and other/unknown (4%) (e.g., Asian and Black/African American).According to the data shown in Figure 3, 52% of the AWC! participants reported having some college orhigher degree as their highest level of education. Women with a high school degree accounted for 31%, followed by some high school or less (17%).South Dakota Public Health Bulletin — October/November 2017 — Page 2

Figure 2Racial/ethnicity distribution (%) of womenreceiving AWC! cervical service, 2001-2015Hispanic8%Other/Unknown4%Figure 3Education level distribution (%) of womenreceiving AWC! cervical service, 2001-201560%52%50%40%American Indian17%31%30%17%20%10%White71%0%Some high school or less High school or equivalent Some college or higherAWC! Cervical ScreeningsFigure 4 shows trends in the number of cervical cancer screening services (Pap test and HPV co-test) received by women in All Women Count!. From 2001 to 2009, an increase in the number of Pap tests was observed; an increase in the number of HPV co-tests was seen from 2012-2015. A steady decrease in the numberof Pap tests occurred from 2012-2015. This may be due to changes in cervical cancer screening guidelines in2009 (introduction of HPV testing) and in 2012 (USPSTF screening guideline change).Figure 4Number of cervical screenings (Pap test and HPV testing) provided through AWC!, 2001-2015Beginning ofHPV 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015Pap testHPV testSouth Dakota Public Health Bulletin — October/November 2017 — Page 3

AWC! Cervical Results and DiagnosisFrom 2001-2015, the AWC! Program provided 33,650 Pap tests. Over this period, the percentage of womenwith an abnormal Pap test was 8.5% (Table 1). An abnormal Pap test includes low-grade squamous intraepithelial lesion (LSIL), high-grade squamous intraepithelial lesion (HSIL), atypical squamous cells of undeterminedsignificance - cannot exclude HSIL (ASC-H), atypical glandular cells (AGC), and squamous cell cancer.Table 1. Pap test results among women receiving screening services through the AWC! Program, 2001 - 2015Pap Test Results (2001-2015)Negative for intraepithelial lesion or malignancy (NIL)Atypical squamous cells of undetermined significance (ASC-US)Low-grade squamous intraepithelial lesion (LSIL)(including HPV/mild dysplasia/CINI)Atypical squamous cells cannot exclude HSIL (ASC-H)High-grade squamous intraepithelial lesion (HSIL)Squamous cell carcinomaAtypical glandular cells (including Atypical, EndocervicalAdenocarcinoma in situ, and Adenocarcinoma)Other/result pending/unsatisfactory/unknownTotal Pap test provided (2001-2015)Total number of abnormal als include Pap test results of: low-grade squamous intraepithelial lesion (LSIL), high-grade squamous intraepithelial lesion (HSIL),atypical squamous cells of undetermined significance - cannot exclude HSIL (ASC-H), atypical glandular cells (AGC), and squamous cell cancer.According to the data shown on Table 2, 388 women who had an HPV co-test were positive for HPV. In addition, 146 women who were diagnosed with a pre-malignant cancer were also HPV positive on the HPV cotesting. Of the women that have had an HPV co-test through the AWC! Program since 2009, 42% were under40, 32% were 40-49 years old, and 26% were 50-64 years old.Table 2. HPV results among women served through the AWC! Program, 2009 - 2015HPV test (2009-2015)Total number of HPV testsHPV HPV HPV and abnormal Pap testHPV and cervical pre malignant cancerHPV and cervical cancer (malignant and in situ)Number1,3971,0093883121465Note. HPV results are not mutually exclusive.Table 3 provides the number of cervical cancers detected. Among the 1,493 diagnostic tests provided, 31%were CINI/Mild dysplasia, followed by CINIII (15%), and CINII (11%).Table 3. Diagnostic results among women served through the AWC! Program, 2001 - 2015Final Diagnosis ta/AtypiaCINI/Mild dysplasia (biopsy diagnosis)CINII/Moderate dysplasia (biopsy diagnosis)CINIII/Severe dysplasia/Carcinoma in situ (stage 0) orAdenocarcinoma In Situ of the cervix (AIS) (biopsy diagnosis)Invasive cervical carcinoma (biopsy 37.81.431.010.615.240191,4932.71.3100South Dakota Public Health Bulletin — October/November 2017 — Page 4

Since 2004, the AWC! Program has linked the cases of cancer the program has detected with the South Dakota Cancer Registry. Figure 5 shows trends in the number of cervical cancers detected through the AWC! Program from 2004 to 2015. The highest number of cancers diagnosed was in 2011, with a considerable decreaseobserved in the following years (2012 to 2015).Figure 5Number of cervical cancers diagnosed among AWC! participants, 2004 - 2015 (N 34)ConclusionThe AWC! Program, which strives to reach and screen low-income, uninsured, and underinsured women inSD, has served nearly 18,000 women and provided 33,650 Pap tests, 1,397 HPV co-tests, and 1,493 diagnostictests from 2001-2015 combined. Moreover, 34 cervical cancers were diagnosed from 2004-2015. The AWC!Program has the capacity to screen more women for cervical cancer. In order to find women eligible for cervical cancer screening and the AWC! Program, clinicians are encouraged to utilize electronic medical records(EMR) to implement provider and client reminders to increase cervical cancer screening.7 Early diagnosis ofcervical cancer improves survival rates and reduces mortality rates.3 Continued efforts targeting the underserved population in South Dakota is a priority of the AWC! Program.References1. U.S. Cancer Statistics Working Group. United States Cancer Statistics: 1999–2013 Incidence and Mortality. Web-based ReportAtlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention and National Cancer Institute; 2016 [Available at https://nccd.cdc.gov/uscs/].2. South Dakota Cancer Registry. An Annual Report on Cancer Incidence and Mortality Among South Dakotans, 2013. South Dakota Department of Health, 2016.3. CDC. National Breast and Cervical Cancer Early Detection Program (NBCCEDP) 2016 [Available at http://www.cdc.gov/cancer/nbccedp/about.htm].4. South Dakota Department of Health. All Women Count! 2016 [Available at https://getscreened.sd.gov/count/].5. CDC. Cervical Cancer Screening Guidelines for Average-Risk Women. 2016. Screening. [Available at .pdf].6. CDC. Human Papillomavirus (HPV). [Available at https://www.cdc.gov/hpv/].7. The Community Guide. [Available at eening].Authors: Patricia Da Rosa, Public Health Data Analyst, College of Nursing, SDSUAshley Miller, Chronic Disease Epidemiologist, SD Department of HealthKaren Cudmore, Cancer Programs Director, SD Department of HealthSouth Dakota Public Health Bulletin — October/November 2017 — Page 5