Piret Veerus

Introduction: Prevalence of high risk human papillomavirus (hrHPV) and its subtypes by sociodemographic factors and the related cytological findings in the Estonian cancer screening population were examined, with the aim to improve cancer prevention. Methods: This cross-sectional study included all women who participated in the Estonian cervical cancer screening programme from January 1, 2021 to January 31, 2022 and had a valid HPV test result reported to the Estonian Cancer Screening Registry (n = 37 537, aged 30, 35, 40, 45, 50, 55, 60, and 65). Limited sample (N = 18 784) within the total sample consisted of women who used self-sampling (N = 3535) or whose clinician collected sample was analysed using lab methodology that differentiates HPV16, 18, and 45. Data on HPV and cytology results were obtained from the Estonian Cancer Screening Registry, whereas data on education, nationality, and marital status were obtained from the Estonian Population Registry. Results: hrHPV was detected in the samples of 3307 (8.8%) women, and the prevalence was significantly higher in age groups under 40, in women with lower education, of Estonian nationality, and with no partner. The overall prevalence of HPV16 was 1.8%, ranging from 4.4% in 30-year-old women to 0.9% in 55-year-old women. The proportion of normal cytology was 50% among all hrHPV positive women and 35% in all HPV16 positive women, while it was 47% for HPV16 alone and 24% for HPV16 plus other hrHPV subtypes. The probability of normal cytology was significantly higher in women aged 50 and older compared to women aged 30 and 35 for total hrHPV and HPV16. Conclusion: All countries should monitor HPV prevalence across different age groups. As different HPV genotypes have a different oncogenic risk profile, extended or complete genotyping would help personalised risk-based screening approaches, with less health care costs, less harms, and a bigger net benefit. In addition, lab methodology should be harmonised.

Background: Cervical cancer incidence in Estonia ranks among the highest in Europe, but screening attendance has remained low. This randomized study aimed to evaluate the impact of opt-in and opt-out human papillomavirus (HPV) self-sampling options on participation in organized screening. Methods: A random sample of 25,591 women were drawn from the cervical cancer screening target population who were due to receive a reminder in autumn 2021 and thereafter randomly allocated to two equally sized intervention arms (opt-out and opt-in) receiving a choice between HPV self-sampling or clinician sampling. In the opt-out arm, a self-sampler was sent to home address by regular mail; the opt-in arm received an e-mail containing a link to order a self-sampler online. The remaining 30,102 women in the control group received a standard reminder for conventional screening. Participation by intervention arm, age and region of residence was calculated; a questionnaire was used to assess self-sampling user experience. Results: A significant difference in participation was seen between opt-out (41.7%) (19.8% chose self-sampling and 21.9% clinician sampling), opt-in (34.1%) (7.9% self-sampling, 26.2% clinician sampling) and control group (29.0%, clinician sampling only). All age groups and regions in the intervention arms showed higher participation compared to the control group, but the size of the effect varied. Among self-sampling users, 99% agreed that the device was easy to use and only 3.5% preferred future testing at the clinic. Conclusion: Providing women with a choice between self-sampling and clinician sampling significantly increased participation in cervical cancer screening. Opt-in and opt-out options had a different effect across age groups, suggesting the need to adapt strategies.

Introduction: Data from different countries show partly controversial impact of SARS‐CoV‐2 infection on pregnancy outcomes. A nationwide register‐based study was conducted in Estonia to assess the impact of SARS‐CoV‐2 infection at any time during pregnancy on stillbirth, perinatal mortality, Apgar score at 5 minutes, cesarean section rates, rates of preterm birth and preeclampsia.Material and methods: Data on all newborns and their mothers were obtained from the Estonian Medical Birth Registry, and data on SARS‐CoV‐2 testing dates, test results and vaccination dates against SARS‐CoV‐2 from the Estonian Health Information System. Altogether, 26 211 births in 2020 and 2021 in Estonia were included. All analyses were performed per newborn. Odds ratios with 95% confidence intervals (CI) were analyzed for all outcomes, adjusted for mother's place of residence, body mass index, age of mother at delivery and hypertension and for all the aforementioned variables together with mother's vaccination status using data from 2021 when vaccinations against SARS‐CoV‐2 became available. For studying the effect of a positive SARS‐CoV‐2 test during pregnancy on preeclampsia, hypertension was omitted from the models to avoid overadjustment.Results: SARS‐CoV‐2 infection during pregnancy was associated with an increased risk of stillbirth (adjusted odds ratio [aOR] 2.81; 95% CI 1.37–5.74) and perinatal mortality (aOR 2.34; 95% CI 1.20–4.56) but not with a lower Apgar score at 5 minutes, higher risk of cesarean section, preeclampsia or preterm birth. Vaccination slightly decreased the impact of SARS‐CoV‐2 infection during pregnancy on perinatal mortality.Conclusions: A positive SARS‐CoV‐2 test during pregnancy was associated with higher rates of stillbirth and perinatal mortality in Estonia but was not associated with change in preeclampsia, cesarean section or preterm birth rates.

Introduction: The number of cesarean sections (CSs) has grown steadily, but the underlying factors driving this increase remain unknown. Data from Medical Birth Registries were retrieved to analyze CS trends in Estonia and Finland during the period 1992–2016.Material and methods: All births in Estonia (n = 356 063) and Finland (n = 1 437 234) were included. The differences between Estonia and Finland in five‐year time periods for the total CS rate, and rates in Robson 1, 2, and 5 groups (R1, R2, R5) were analyzed by logistic regression. Total CS rates were adjusted for birthweight, parity, previous CS, gestational age, singleton pregnancy, cephalic position, induction, mother's age. R1; R2; R5 rates were adjusted for birthweight and mother's age.Results: In Estonia, the proportion of CSs increased from 6.5% to 21.0% and in Finland from 15.1% to 16.8% between 1992 and 2016. In 2016, Estonia and Finland remained within the target value with their R1 + 2 (Estonia 18%; Finland 16%) and R5 (Estonia 59%; Finland 42%) values.Conclusions: Comparing Robson groups in different countries can shed light on divergent CS rates and to improve the quality of perinatal and obstetric care.

Objective: Organised cervical cancer screening was started in Estonia in 2006, but participation is still low. Human papillomavirus (HPV) self-sampling has proved to increase screening uptake. This study addressed the feasibility of HPV self-sampling and the acceptance of this method among long-term screening non-attenders. Methods: A randomised intervention study was conducted in Estonia in 2020. Women born in 1958–1983 without a Pap smear in 2013–2019 were identified in the Estonian Health Insurance Fund database. From them, 12,000 women were randomly allocated to three equal-sized study groups. The opt-out group received a questionnaire and a Qvintip® sampling device by regular mail. Two opt-in groups received a questionnaire and an e-mail invitation to order a self-sampler online; one received Qvintip and the other Evalyn® Brush. Participantś background characteristics were obtained from the Population Register. The effect of covariates on participation rate was estimated with multivariate Poisson regression. Acceptance of self-sampling was analysed according to agreement with statements in the questionnaire. Results: The overall participation rate was 16% with significant differences between opt-out (26%) and opt-in (11%) groups. Compared to the opt-out Qvintip group, adjusted relative risks for the Qvintip and Evalyn Brush opt-in groups were 0.41 (95% confidence interval (CI) 0.37–0.45) and 0.44 (95% CI 0.40–0.49), respectively. Participation was associated with living place, citizenship, and education. Self-sampling was well accepted: 98% agreed that it was easy to use, 88% preferred it as a screening method in future. Conclusions: The results show the feasibility and good acceptance of HPV self-sampling among long-term screening non-attenders in Estonia.

On April 7, 2020 Mehreen Zaigham and Ola Andersson published a systematic review of maternal and perinatal outcomes in 108 pregnancies with Covid‐19 concluding that careful monitoring of such pregnancies and is warranted.¹ We would like to emphasise the need to assess objectively the impact of the novel Severe Acute Respiratory Coronavirus Type 2 (SARS‐CoV‐2) causing Covid‐19 disease on pregnancy and perinatal outcomes by conducting epidemiological studies among pregnant women.

Background: In Estonia, termination of pregnancy is allowed until 12 gestational weeks on request or for medical reasons, and until 22 gestational weeks only for women under 15 or over 45 years of age and for severe medical illness of the mother or the fetus. Information about all induced abortions is collected in the central digital Abortion Registry since 1996. The source document for collection of data is the Abortion Card which is filled in for every abortion that has taken place in a health care institution by all health care institutions (incl. private doctors) who do abortions or provide medical care to women who have had an abortion. The choice of contraceptive devices is large and their price is affordable. Sexual education is included in school curriculum. Councelling about contraception is free for all citizens until 25 years of age. Termination of pregnancy is free only for medical reasons, in other cases there is a small fee. Methods: Data for the analysis was obtained from the Estonian Abortion Registry. Results: The total number of induced abortions in Estonia decreased from 25803 in 1992 to 4017 in 2017. The abortion rate per 1000 women aged 15-49 declined from 69.6 in 1992 to 14.0 in 2017. The abortion rate among women under 20 has declined from 43 in 1996 to 10.8 in 2017. The abortion rate has always been the highest in the age group from 20 to 24 years. Abortion rates in 2017 varied in different counties from 7.4 to 17.3. In 1996, 97.8 % of preganancies were terminated surgically, in 2017, only 22.3%. Conclusions: Although induced abortion is legal and not restricted in Estonia, the abortion rate has fallen rapidly due to sexual education at school, free youth councelling services and easily available contraceptive devices. Abortion Registry database is a valuable source of information for evaluating and planning public health interventions. Regional differences in abortion rates deserve further interventions. Key messages: Abortion rates in Estonia have fallen rapidly due to sexual education, free councelling and available contraceptive devices. The Estonian Abortion Registry is a valuable source of information for public health interventions.