Elsevier

The Lancet

Volume 366, Issue 9490, 17–23 September 2005, Pages 991-998
The Lancet

Articles
Worldwide distribution of human papillomavirus types in cytologically normal women in the International Agency for Research on Cancer HPV prevalence surveys: a pooled analysis

https://doi.org/10.1016/S0140-6736(05)67069-9Get rights and content

Summary

Background

The proportion of women infected with human papillomavirus (HPV) varies greatly across populations, as might the distribution of HPV types. We aimed to compare HPV-type distribution in representative samples of women from different world regions.

Methods

Women were randomly selected from the general population of 13 areas from 11 countries (Nigeria, India, Vietnam, Thailand, Korea, Colombia, Argentina, Chile, the Netherlands, Italy, and Spain). A standardised protocol was used for cervical specimen collection. All HPV testing was by GP5+/6+ PCR-based EIA. The proportion of HPV-positive women infected with different HPV types was compared by study area and between pooled regions with age-adjusted odds ratios (ORs) with corresponding 95% floating CIs.

Findings

15 613 women aged 15–74 years without cytological abnormalities were included in a pooled analysis. Age-standardised HPV prevalence varied nearly 20 times between populations, from 1·4% (95% CI 0·5–2·2) in Spain to 25·6% (22·4–28·8) in Nigeria. Although both overall HPV prevalence and HPV16 prevalence were highest in sub-Saharan Africa, HPV-positive women in Europe were significantly more likely to be infected with HPV16 than were those in sub-Saharan Africa (OR 2·64, p=0·0002), and were significantly less likely to be infected with high-risk HPV types other than HPV16 (OR 0·57, p=0·004) and/or low-risk HPV types (OR 0·44. p=0·0002). Women from South America had HPV-type distribution in between those from sub-Saharan Africa and Europe. Heterogeneity between areas of Asia was significant.

Interpretation

Heterogeneity in HPV type distribution among women from different populations should be taken into account when developing screening tests for the virus and predicting the effect of vaccines on the incidence of infection.

Introduction

The prevalence of cervical infection with human papillomavirus (HPV) in women varies greatly worldwide, and is closely related to the corresponding risk of cervical cancer.1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13 Detection of high-risk HPV is becoming increasingly attractive as a primary screening tool, because of sensitivity and cost-effectiveness.14 However, HPV-screening assays identify a large group of women without cytological abnormalities, many of whom harbour HPV types with very different progressive potential. Thus, testing for only a subset of high-risk types might improve cost-effectiveness.

Population-based data for HPV-type distribution is prerequisite to development of new HPV-screening tests and to assessment of the effect of future vaccination on HPV infections of differing severity, but these data are limited or missing for many world regions. Furthermore, relevant studies are difficult to combine or compare because of varying study designs, especially in enrolment of women and HPV-testing protocols.

In our pooled analysis, we aimed to use the population-based sampling and centralised HPV-testing protocols from the International Agency for Research on Cancer (IARC) HPV prevalence surveys13 to compare HPV-type distribution in representative samples of women from 13 areas in 11 countries across sub-Saharan Africa, Asia, South America, and Europe.

Section snippets

Study participants

Similar protocols were developed for each of 13 areas in 11 countries, chosen to represent regions of low, intermediate, and high incidence of cervical cancer. Surveys were done between 19935 and 2003.1 Complete population-sampling methods have been described for the individual areas: Ibadan, Nigeria;13 Ambilikai, India;1 Hanoi and Ho Chi Minh City, Vietnam;2 Songkla and Lampang, Thailand;3 Busan, Korea;4 Bogota, Colombia;5 Concordia, Argentina;6 Santiago, Chile;7 Amsterdam, Netherlands;8

Results

15 613 sexually active women aged between 15 and 74 years, all with valid HPV test results and normal cytological findings, were included in the analyses (table 1). Overall HPV prevalence was lowest in Spain and highest in Nigeria. After pooling by region, age-standardised HPV prevalence was approximately five times higher in sub-Saharan Africa than in Europe, with intermediate prevalence in South America and Asia. The proportion of HPV-positive women with multiple infections ranged from 11·5%

Discussion

Pooled analysis of the IARC HPV prevalence surveys shows variation of nearly 20 times in overall HPV prevalence between different areas. However, it also provides evidence for regional variation in distribution of HPV type for women without cytological abnormalities. The most relevant difference between regions was in the prevalence of HPV16 in relation to other HPV types. Although HPV16 prevalence was higher in sub-Saharan Africa than in Europe, HPV-positive women in sub-Saharan Africa were

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