Chlamydia trachomatis infection and persistence of human papillomavirus

Mechanisms of crosstalk between the oropharyngeal microbiome and human papillomavirus in oropharyngeal carcinogenesis: a mini review

Head and neck squamous cell carcinoma (HNSCC) is the sixth most common cancer globally. Notably, human papillomavirus (HPV)-positive oropharyngeal squamous cell carcinoma (OPSCC) is on the rise, accounting for 70% of all OPSCC cases. Persistent high-risk HPV infection is linked to various cancers, but HPV infection alone is not sufficient to cause cancer. Advances in next-generation sequencing have improved our understanding of changes in the human microbiome of cancerous environments. Yet, there remains a dearth of knowledge on the impact of HPV-microbiome crosstalk in HPV-positive OPSCC. In this review, we examine what is known about the oropharyngeal microbiome and the compositional shifts in this microbiome in HPV-positive OPSCC. We also review potential mechanisms of crosstalk between HPV and specific microorganisms. Additional research is needed to understand these interactions and their roles on cancer development and progression.

Chlamydia trachomatis enhances HPV persistence through immune modulation

Chlamydia trachomatis (CT) is the most common sexually transmitted infections globally, and CT infection can enhance HPV persistence. Epidemiological analysis has shown that patients with CT/HPV coinfection have a higher risk of developing cervical cancer and exhibit more rapid progression to cervical cancer than patients with HPV infection alone. However, the mechanism has not been fully elucidated. Here, we report that CT infection supports HPV persistence by further suppressing the functions of Langerhans cells (LCs); in particular, CT further activates the PI3K pathway and inhibits the MAPK pathways in LCs, and these pathways are frequently involved in the regulation of immune responses. CT/HPV coinfection also impairs LC functions by reducing the antigen-presenting ability and density of LCs. Moreover, CT/HPV coinfection can alter T-cell subsets, resulting in fewer CD4 + and CD8 + T cells and more infiltrating Tregs. Moreover, CT/HPV coinfection decreases the CD4 + /CD8 + T cell ratio to below 1, coinfection also induces greater T lymphocytes' apoptosis than HPV infection, thus impairing cell-mediated immunity and accelerating the progress to cervical cancer.

Expression of HPV-16 E6 and E7 oncoproteins alters Chlamydia trachomatis developmental cycle and induces increased levels of immune regulatory molecules

Introduction

Infection with Human Papillomavirus (HPV) is a recognized risk factor for Chlamydia trachomatis (CT) infection and vice versa. Coinfection of HPV and CT in women is a very common and usually asymptomatic finding that has been linked to increased risk of cervical cancer. It has been demonstrated that CT facilitates the entry of multiple high risk HPV genotypes, leading to damage of the mucosal barrier and interfering with immune responses and viral clearance, which ultimately favours viral persistence and malignant transformation. Although the facilitating effects elicited by CT infection on viral persistence have been reported, little is known about the consequences of HPV infection on CT development.

Methods

Herein, we took advantage of a genetically modified human cervical cell line co-expressing HPV-16 major oncogenic proteins E6 and E7, as an experimental model allowing to investigate the possible effects that HPV infection would have on CT development.

Results and discussion

Our results show that CT infection of HPV-16 E6E7 expressing cells induced an upregulation of the expression of E6E7 oncoproteins and host cell inhibitory molecules PD-L1, HVEM and CD160. Additionally, smaller chlamydial inclusions and reduced infectious progeny generation was observed in E6E7 cells. Ultrastructural analysis showed that expression of E6 and E7 did not alter total bacterial counts within inclusions but resulted in increased numbers of reticulate bodies (RB) and decreased production of infectious elementary bodies (EB). Our results indicate that during CT and HPV coinfection, E6 and E7 oncoproteins impair RB to EB transition and infectious progeny generation. On the other hand, higher expression of immune inhibitory molecules and HPV-16 E6E7 are cooperatively enhanced in CT-infected cells, which would favour both oncogenesis and immunosuppression. Our findings pose important implications for clinical management of patients with HPV and CT coinfection, suggesting that screening for the mutual infection could represent an opportunity to intervene and prevent severe reproductive health outcomes, such as cervical cancer and infertility.

Risk factors for human papillomavirus infection, cervical intraepithelial neoplasia and cervical cancer: an umbrella review and follow-up Mendelian randomisation studies

BACKGROUND

Persistent infection by oncogenic human papillomavirus (HPV) is necessary although not sufficient for development of cervical cancer. Behavioural, environmental, or comorbid exposures may promote or protect against malignant transformation. Randomised evidence is limited and the validity of observational studies describing these associations remains unclear.

METHODS

In this umbrella review, we searched electronic databases to identify meta-analyses of observational studies that evaluated risk or protective factors and the incidence of HPV infection, cervical intra-epithelial neoplasia (CIN), cervical cancer incidence and mortality. Following re-analysis, evidence was classified and graded based on a pre-defined set of statistical criteria. Quality was assessed with AMSTAR-2. For all associations graded as weak evidence or above, with available genetic instruments, we also performed Mendelian randomisation to examine the potential causal effect of modifiable exposures with risk of cervical cancer. The protocol for this study was registered on PROSPERO (CRD42020189995).

RESULTS

We included 171 meta-analyses of different exposure contrasts from 50 studies. Systemic immunosuppression including HIV infection (RR = 2.20 (95% CI = 1.89-2.54)) and immunosuppressive medications for inflammatory bowel disease (RR = 1.33 (95% CI = 1.27-1.39)), as well as an altered vaginal microbiome (RR = 1.59 (95% CI = 1.40-1.81)), were supported by strong and highly suggestive evidence for an association with HPV persistence, CIN or cervical cancer. Smoking, number of sexual partners and young age at first pregnancy were supported by highly suggestive evidence and confirmed by Mendelian randomisation.

CONCLUSIONS

Our main analysis supported the association of systemic (HIV infection, immunosuppressive medications) and local immunosuppression (altered vaginal microbiota) with increased risk for worse HPV and cervical disease outcomes. Mendelian randomisation confirmed the link for genetically predicted lifetime smoking index, and young age at first pregnancy with cervical cancer, highlighting also that observational evidence can hide different inherent biases. This evidence strengthens the need for more frequent HPV screening in people with immunosuppression, further investigation of the vaginal microbiome and access to sexual health services.

Chlamydia trachomatis as a Current Health Problem: Challenges and Opportunities

Chlamydia is one of the most common sexually transmitted bacterial infections (STIs) worldwide. It is caused by Chlamydia trachomatis (CT), which is an obligate intracellular bacterium. In some cases, it can occur in coinfection with other parasites, increasing the pathologic potential of the infection. The treatment is based on antibiotic prescription; notwithstanding, the infection is mostly asymptomatic, which increases the risk of transmission. Therefore, some countries have implemented Chlamydia Screening Programs in order to detect undiagnosed infections. However, in Portugal, there is no CT screening plan within the National Health Service. There is no awareness in the general healthcare about the true magnitude of this issue because most of the methods used are not Nucleic Acid Amplification Technology-based and, therefore, lack sensitivity, resulting in underreporting infection cases. CT infections are also associated with possible long-term severe injuries. In detail, persistent infection triggers an inflammatory milieu and can be related to severe sequels, such as infertility. This infection could also trigger gynecologic tumors in women, evidencing the urgent need for cost-effective screening programs worldwide in order to detect and treat these individuals adequately. In this review, we have focused on the success of an implemented screening program that has been reported in the literature, the efforts made concerning the vaccine discovery, and what is known regarding CT infection. This review supports the need for further fundamental studies in this area in order to eradicate this infection and we also suggest the implementation of a Chlamydia Screening Program in Portugal.

Low-Grade Squamous Intraepithelial Lesion in the Setting of Human Papillomavirus and Chlamydia Coinfection

Human papillomavirus (HPV) is the most common sexually transmitted infection (STI) in the United States. It most commonly affects the genital areas, as well as the mouth and throat. Research has shown that HPV is a cause of cervical cancer and Chlamydia trachomatis is a potential cofactor in the development of cervical intraepithelial neoplasia (CIN). However, there have been limited cases reported on understanding this coinfection and its mechanism through the lens of molecular biology. We present a case of a 22-year-old female with complaints of persistent lesions on the labia for more than 6 months that have increased in number. Histopathology was suggestive of HPV. This case report emphasizes the importance of HPV and chlamydia coinfection as leading causes for persistence of condyloma acuminatum and low-grade squamous intraepithelial lesion (LSIL), and the importance of screening and clinically managing vaginal HPV.

Association of Chlamydia trachomatis infection with cervical atypia in adolescent women with short-term or long-term use of oral contraceptives: a longitudinal study in HPV vaccinated women

OBJECTIVE

We assessed the relationship between Chlamydia trachomatis infection, duration of oral contraceptive (OC) use and cervical atypia among young adult Finnish women.

DESIGN

A longitudinal study.

SETTING AND PARTICIPANTS

Women who were included in this study participated in a community-randomised trial on the effectiveness of human papillomavirus (HPV) vaccination and C. trachomatis screening at ages 18.5 and 22 years in Finland. They completed questionnaires on both visits about sexual behaviours. The cytology test results at age 18.5 and 22 years were also available for those women. The total number of participants in this study at 18.5 years of age were 11 701 and at 22 years of age were 6618.

MAIN OUTCOME MEASURE

ORs with 95% CIs using univariable and multivariable logistic regression were used to assess the association between C. trachomatis infection, duration of OC and squamous intraepithelial lesions (SIL).

RESULTS

There were 940 cytological SIL cases at the first screening visit and 129 cytological SIL cases at the second screening visit. Among the 22 years old, more than fourfold adjusted risk of SIL was associated with C. trachomatis positivity. The HPV16/18, condom use, smoking and number of sexual partners adjusted joint effect of prolonged OC use and C. trachomatis was significantly increased (OR 4.7, 95% CI 1.7 to 12.8) in the 22-year-old women. This observed joint effect was 1.6 times higher than expected on a multiplicative scale. On additive scale, the observed relative excess risk from interaction was 1.8.

CONCLUSION

The risk of SIL in HPV vaccinated women is significantly increased if they are C. trachomatis positive and have used OC for 5 or more years. The biological basis may be lack of condom facilitated protection against sexually transmitted diseases.

TRIAL REGISTRATION NUMBER

NCT00534638.

Risk factors of cervical cancer after a negative cytological diagnosis in Polish cervical cancer screening programme

Risk factors of cervical cancer (CC) development are well investigated, however, those influencing the risk of a potential false negative cytology preceding diagnosis of an invasive CC are not. We have aimed to explore these factors according to the data from Organised Cervical Cancer Screening Programme (OCCSP) in Poland. A total of 2.36 million of Pap tests sampled in 2010–2012 within OCCSP were merged with the Polish National Cancer Registry to identify CC cases after abnormal cytology and after normal cytology within 3 years of screening. Of 1460 invasive CCs, 1025 were preceded by abnormal and 399 by normal cytology result. Multivariate logistic analysis indicated that the presence of microorganisms in the Pap (OR = 2.18, 95% CI 1.65–2.87), evaluation by smaller (below 9000 slides processed per year) laboratories (OR = 1.60, 95% CI 1.22–2.09) and non‐squamous histology of cancer increased the odds for a potential false negative result (OR = 3.39, 95% CI 2.37–4.85 for adenocarcinoma, OR = 1.99, 95% CI 1.11–3.55 for other types of carcinoma), whereas cervical ectropion, other macroscopic changes on the cervix and smoking decrease the odds for a potential false negative Pap test result preceding CC (OR = 0.61, 95% CI 0.45–0.82, OR = 0.41, 95% CI 0.25–0.67, OR = 0.60, 95% CI 0.46–0.78, respectively). Proper triage of women with microscopic signs of microorganisms in the Pap smear should be reconsidered and cytology should be assessed in laboratories processing over 9000 slides annually to decrease the odds for negative Pap test result in 2 years before CC diagnosis. Information on macroscopic changes on the cervix provided to cytomorphologist may reduce the risk of a potential false negative cytology result.

Detection of sexually transmitted pathogens and co-infection with human papillomavirus in women residing in rural Eastern Cape, South Africa

Background

South African women of reproductive age have a high burden of sexually transmitted infections (STIs), including human papillomavirus (HPV) infection. However, there is limited information on the prevalence of sexually transmitted pathogens in women from rural Eastern Cape Province, South Africa. The study aims at determining the prevalence of sexually transmitted pathogens and co-infection with high-risk (HR) HPV among women from rural Eastern Cape Province, South Africa.

Methods

A total of 205 cervical specimens were collected from women aged ≥ 30 years from a rural community-based clinic. The samples were tested for a panel of pathogenic STIs [Chlamydia trachomatis (serovars A-K & L1-L3), Haemophilus ducreyi, Herpes Simplex Virus (Types 1 & 2), Neisseria gonorrhoeae, Treponema pallidum, Trichomonas vaginalis (TV), and pathobionts [Mycoplasma genitalium (MG), Mycoplasma hominis (MH) and Ureaplasma spp. (UP)] using a multiplex PCR STD direct flow chip assay through a manual Hybrispot platform (Master Diagnostica, Granada, Spain). HR-HPV detection was performed by Hybrid Capture-2 assay.

Results

High-risk HPV prevalence was 32.2% (66/205) and HIV-1 prevalence was 38.5% (79/205). The overall prevalence of six pathogenic STIs was 22.9% (47/205), with TV having the highest prevalence (15.6%; 32/205). UP (70.2%, 144/205) and MH (36.6%, 75/205) were the most frequently detected pathobionts. Co-infection with ≥ 2 pathogens pathobionts was observed among 52.7% (108/205) participants. Of the six pathogenic STIs, three participants had more than one STI (1.46%) with the presence of MH and UP. HSV-2 (OR: 4.17, CI [1.184-14.690]) and HIV infection (OR: 2.11, CI [1.145-3.873]) were independent STIs associated with HR-HPV infection.

Conclusions

The high prevalence of pathogenic STIs underscores the need to improve syndromic management policy by implementing effective strategies of prevention, screening tests, and management. HSV-2 and HIV positive remain strongly associated with HR-HPV infection.

Association Between Common Vaginal Infections and Cervical Non-Human Papillomavirus (HPV) 16/18 Infection in HPV-Vaccinated Women

BACKGROUND

How vaginal infections such as bacterial vaginosis, Candida spp, and Trichomonas vaginalis affect persistence of human papillomavirus (HPV) infection is not well established. Our study aimed to evaluate the association between common vaginal infections and cervical non-HPV16/18 infection, as risk factors associated with persistence of nonvaccine HPV types will become increasingly relevant in the setting of HPV vaccination.

METHODS

We performed an analysis in 2039 AS04-HPV16/18-vaccinated women enrolled in a phase II/III trial in China, who were HPV DNA negative at month 0 and 6 and had at least 1 subsequent follow-up visit. Vaginal infections were detected in liquid-based cytology according to the diagnostic criteria of the Bethesda System. Associations between vaginal infections and incident and 6-month persistent non-HPV16/18 infections in the cervix were evaluated using generalized estimating equations, adjusting for the age at initial vaccination, as well as HPV types in the persistence analysis.

RESULTS

Study visits with any vaginal infection had a statistically significant increased risk of incident non-HPV16/18 infection compared to those without vaginal infections (odds ratio [OR], 1.44 [95% confidence interval {CI}, 1.09-1.92]). However, vaginal infections were not associated with 6-month persistent non-HPV16/18 infection (OR, 1.02 [95% CI, .62-1.69]).

CONCLUSIONS

Our study suggests that common vaginal infections are not associated with persistence of non-HPV16/18 infection among HPV16/18-vaccinated women.

Outcomes in women with biopsy-confirmed cervical intraepithelial neoplasia grade 1 or normal cervix and related cofactors: A 15-year population-based cohort study from China

OBJECTIVE

To estimate long-term outcomes of biopsy-confirmed cervical intraepithelial neoplasia grade 1 (CIN1) or normal cervix and identify the cofactors during disease progression.

METHODS

In 1999, a cervical cancer screening cohort in Shanxi, China, enrolled 1997 women aged 35-45. They were followed up at year 6, 11, and 15 after enrollment with high-risk human papillomavirus (hrHPV) DNA testing, liquid-based cytology, and visual inspection with acetic acid. Progression, persistence, and regression rates were calculated, stratified by baseline hrHPV and cytological status. Risk factors associated with hrHPV acquisition, persistence, and progression were examined.

RESULTS

The cumulative rates of progression to CIN2+ among CIN1 over 6, 11, and 15 years were 7.5%, 21.4%, and 24.0%, respectively; the regression rates to normal cervix were 85.0%, 76.7%, and 72.9%, respectively. Over 6, 11, and 15 years, 0.7%, 2.9%, and 5.2% of normal cervix developed CIN2+, respectively, but over 90% remained normal after 15 years. CIN1 or normal cervix positive for hrHPV had significantly higher progression rates to CIN2+ than those without hrHPV. Similarly, the severity of cytological status was found to be associated with an increased risk of developing CIN2+. Women who had an earlier sexual debut were at a higher risk of acquiring new HPV infection and repeated HPV infections.

CONCLUSIONS

Clinical follow-up strategies for women with CIN1 or normal cervix could be adjusted accordingly based on hrHPV/cytology status.

Rapid and accurate diagnosis of Chlamydia trachomatis in the urogenital tract by a dual-gene multiplex qPCR method

Introduction. Chlamydia trachomatis (C. trachomatis, CT) is an obligatory intracellular bacterium that causes urogenital tract infections and leads to severe reproductive consequences. Therefore, a rapid and accurate detection method with high sensitivity and specificity is an urgent requirement for the routine diagnosis of C. trachomatis infections.Aim. In this study, we aimed to develop a multiplex quantitative real-time PCR (qPCR) assay based on two target regions for accurate detection of C. trachomatis in urogenital tract infections.Methodology. Primers and probes based on the conserved regions of the cryptic plasmid and 23S rRNA gene were designed. Then, two qPCR assays were established to screen for the optimal probe and primers for each of the two target regions. Subsequently, the multiplex qPCR method was developed and optimized. For the diagnostic efficiency evaluation, 1284 urogenital specimens were tested by the newly developed multiplex qPCR method, an immunological assay and a singleplex qPCR assay widely used in hospitals.Results. The multiplex qPCR method could amplify both target regions in the range of 1.0×10²-1.0×10⁸ copies ml^-1 with a strong linear relationship, and lower limits of detection (LODs) for both targets reached 2 copies PCR^-1. For the multiplex qPCR method, the diagnostic sensitivity and specificity was 100.0 % (134/134) and 99.3 % (1142/1150), respectively. For the singleplex qPCR assay, the diagnostic sensitivity and specificity was 88.8 % (119/134) and 100.0 % (1150/1150), respectively. For the immunological assay, the diagnostic sensitivity and specificity was 47.0 % (63/134) and 100.0 % (1150/1150), respectively.Conclusion. In this study, a multiplex qPCR assay with high sensitivity and specificity for rapid (≤2.0 h) and accurate diagnosis of C. trachomatis was developed. The qPCR assay has the potential to be used as a routine diagnostic method in clinical microbiology laboratories.

Chlamydia Trachomatis Infection in High-Risk Human Papillomavirus Based on Cervical Cytology Specimen

Objective:

High-risk human papillomavirus (HR HPV) was associated with the development of cervical cancer. Asymptomatic Chlamydia trachomatis (C. trachomatis) infection is the most common bacterial, sexually-transmitted infection. This study aimed to investigate the association of C. trachomatis in positive HR HPV and the cytological results from liquid-based cytology (LBC).

Methods:

150 residual LBC specimens were collected; all of which had undergone cytology and HPV testing by Cobas. The samples were established as C. trachomatis using real-time PCR (RT-PCR) with Cryptic F/Cryptic R primers.

Results:

Of 150 positive HPV findings, the most common (72.7%, 109/150) were the 12 other HR HPVs (viz., 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, and 68). The cervical cytology of those positive HR HPVs were mostly negative (70.0%, 105/150). The C. trachomatis infections in positive HR HPV were 16% (24/150) HPV. The analysis of the abnormal cytology revealed that 41.6% had C. trachomatis co-infection (C. trachomatis and HPV infection) viz., LSIL (20.8%), HSIL (12.5%), and ASC-US (8.3%). A comparison with positive HPV without C. trachomatis co-infection revealed that the highest prevalence was for LSIL, ASC-US, and HSIL (11.1%, 10.3%, and 6.4%, respectively). There was no difference between the abnormalities and negative cervical cytology with negative and positive C. trachomatis co-infection in HR HPV positive (p = 0.174).

Conclusion:

C. trachomatis infection was not significantly associated HR-HPV and abnormal cytology. This study confirms the increasing rate of C. trachomatis infection in asymptomatic women so routine screening for these infections has been suggested to (a) prevent complications such as the chronic pelvic pain associated with prolong infection and (b) reduce sexual transmission of the infection.

The Burden of Human Papillomavirus and Chlamydia trachomatis Coinfection in Women: A Large Cohort Study in Inner Mongolia, China

Background

Chlamydia trachomatis may coinfect with human papillomavirus (HPV) and complicate the cervical pathogenesis. This study aimed to evaluate the prevalence, risk factors, and clinical outcomes of HPV/C. trachomatis coinfection in women from Inner Mongolia, China.

Methods

We performed a polymerase chain reaction (PCR)-based HPV/C. trachomatis screening and cervical samples were analyzed by thinprep cytologic test. Statistical analysis was used to assess the association between demographic factors and coinfection.

Results

Among the 2345 women recruited, the prevalences of HPV, C. trachomatis, and HPV/C. trachomatis coinfection were 36.0%, 14.3%, and 4.8%, respectively. The rate of multiple HPV genotypes was higher in coinfected women. HPV66 was the most frequently identified genotype in coinfected participants. The HPV DNA load was significantly higher in HPV monoinfected cases. In contrast, the DNA load of C. trachomatis was significantly higher in the coinfection group. Risk factors, including single women (odds ratio [OR] = 6.0, 95% confidence interval [CI], 4.044-8.782) and women with multiple sex partners (OR = 1.9, 95% CI, 1.324-2.824), were associated with coinfection. Importantly, coinfection was associated with increased risk for high-grade squamous intraepithelial lesions.

Conclusions

HPV and C. trachomatis coinfection is an important risk factor for the progression of cervical lesions.

Oropharyngeal Squamous Cell Carcinoma: Human Papilloma Virus Coinfection with Streptococcus anginosus

Abstract Introduction: Human papilloma virus (HPV) and oral bacteria capable of acetaldehyde production from ethanol, such as Streptococcus anginosus, Prevotella melaninogenica, and Fusobacterium naviforme are among oropharyngeal squamous cell carcinoma (OSCC) infectious risk factors. Objective: Determine associations with HPV and S. anginosus, P. melaninogenica, and F. naviforme in patients with and without OSCC. Methods: Presence of HPV and HPV-16 was determined in 26 patients with OSCC and 26 without OSCC by conventional PCR and simultaneous presence of S. anginosus, P. melaninogenica, and F. naviforme quantification through q-PCR. Statistical analysis was carried out using Pearson’s X² and Student’s-t test. Results: Patients with OSCC had HPV and HPV-16 frequencies of 84% and 61.5%, respectively, in contrast for patients without OSCC frequencies were 34.6 and 30.7%. P. melaninogenica, and F. naviforme microorganisms were not present in any participant in this study. S. anginosus frequency in patients with OSC was 38.4% and in patients without OSCC was 30.7%. Patients with OSCC had S. anginosus + HPV co-infection at a 38.4% frequency and S. anginosus + HPV-16 at a 23.1% frequency. For individuals without OSCC S. anginosus + HPV co-infection was 3.8% and S. anginosus + HPV-16 3.8%. A greater frequency of S. anginosus + HPV co-infection and S. anginosus + HPV-16 was observed in patients with OSCC in comparison with individuals without OSCC, suggesting the importance of detecting HPV/HPV-16 and S. anginosus simultaneously in individuals at risk of developing OSCC

Developing and validating the Personal Risk of Oncogenic Human Papillomavirus infection score in US Women

BACKGROUND

Determining risk scores for genital high-risk human papillomavirus (HRHPV) infection in women will support more efficient cervical cancer screening strategies.

OBJECTIVE

We developed and validated point scores to predict the likelihood of any genital HRHPV infection in women.

METHODS

We conducted the cross-sectional analysis in 2017 and used data from the 2005-14 US National Health and Nutrition Examination Survey (7337 women aged 25-59 years; 6300 women aged 30-59 years). Predictors were reproductive health practices, risk behaviors and demographic variables. The outcome was a positive result for any of the 21 genital HRHPV genotypes. The 2005-12 cohorts were used as training and testing sets to develop scores that best classified women into three risk groups: low risk (<20%), average risk (20-30%) and high risk (>30%). The 2013-14 cohort was used to validate the final scores.

RESULTS

Two-point scores with six self-reported variables were created to predict any HRHPV risks for the two age groups: the Personal Risk of Oncogenic HPV (PRO-HPV25) for women aged 25-59 years old and PRO-HPV30 for women aged 30-59 years old. The scores were successfully prospectively validated, with good calibration with regards to the predicted and observed rates of HRHPV infection. The scores had fair discrimination (c-statistics: 0.67-0.68).

CONCLUSION

The PRO-HPV risk scores can identify groups at low, average and high risk of genital HRHPV infection. This information can be used to prioritize women for cervical cancer screening in low-resource settings or to personalize screening intervals.

Alzheimer's disease might depend on enabling pathogens which do not necessarily cross the blood-brain barrier

The development of Alzheimer's Disease (AD) might reflect, in its acquired aspects, a cooperative pathogenesis whereby infectious enablers which do not necessarily cross the blood-brain barrier augment the invasive properties of a less virulent organism, thus enabling it to infect the brain. An example interaction is described which involves Chlamydia species, Human papillomavirus (HPV), microbiota, and yeast, where yeast is a pathogen of low virulence which crosses the blood-brain barrier. The cooperative pathogenesis begins at the mucosal epithelium. Infection by Chlamydia, HPV, or dysbiosis of commensal bacteria disrupts the integrity of the mucosal epithelium, thereby allowing colonizing yeast to penetrate the epithelial barrier and enter into the bloodstream. Chlamydia and enabling commensals promote insulin resistance, which provides yeast with glucose and also sets the stage for accumulation of amyloid beta protein (ABP). Meanwhile, HPV-induced and hyperglycemia-induced immunological changes enable the spread of newly invasive yeast to the brain, where the release of inflammatory cytokines in response to yeast promotes production of ABP. Chlamydia also cross reacts with Candida species, which may stimulate further brain inflammation in response to Candida and may augment production of ABP thereby The yeast's less virulent origins, coupled with immune modulation by enablers, might explain why AD as a model of infectious encephalitis is always slow and insidious rather than occasionally febrile, accompanied by seizures, or marked by signs of meningeal inflammation.

HPV-Chlamydial Coinfection, Prevalence, and Association with Cervical Intraepithelial Lesions: A Pilot Study at Mbarara Regional Referral Hospital

Background

Human Pappilloma Virus (HPV) is the necessary cause of cervical cancer. A number of risk factors are believed to influence the role of HPV in the development of cervical cancer. This is so because majority of HPV infections are cleared and only a few are able to result into cancer. Chlamydia trachomatis (CT) is considered a potential cofactor in the development of cervical intraepithelial neoplasia (CIN), although different studies have produced contradicting information (Silins et al., 2005, Bellaminutti et al., 2014, and Bhatla et al., 2013). The objective of this cross-sectional study was to determine the prevalence and association of HPV-Chlamydial coinfection with cervical intraepithelial lesions and other risk factors for cervical intraepithelial lesions at a hospital in south western Uganda (MRRH).

Methods

The study included 93 participants, with an age range of 25 to 80 years, from whom cervical specimens were collected and enrolment forms were completed upon consent. Experienced midwives collected one cervical smear and two endocervical swabs from each participant. The swabs were used for HPV DNA and Chlamydia trachomatis antigen testing. Data was entered in Microsoft excel and analysed using STATA 12 software. With the help of spearman's correlation at the 0.05 level of significance, bivariate and multivariate analysis were done by logistic regression, to determine associations of risk factors to cervical lesions.

Results

The results showed the prevalence of HPV-Chlamydial coinfection to be 8.6% (8/93). Positive Pap smear results were found in 60.22% (56/93) participants, most of whom had low grade squamous intraepitherial lesion (LSIL) (54.84%). HPV-Chlamydial coinfection showed a significant correlation with a positive cytology result and only relatively significantly correlated with LSIL grade of cytological positivity. HPV was found to be the risk factors associated with cervical intraepithelial lesions at MRRH.

Conclusion

HPV, Chlamydia, and HPV-Chlamydial coinfection are prevalent infections and there is a likelihood of association between HPV-Chlamydial coinfection and with cervical intraepithelial lesions. This study recommends general sexually transimitted infections (STIS) screening for every woman that turns up for cervical cancer screening and a larger study, probably a multicentre study.

The macroecology of cancer incidences in humans is associated with large-scale assemblages of endemic infections

It is now well supported that 20% of human cancers have an infectious causation (i.e., oncogenic agents). Accumulating evidence suggests that aside from this direct role, other infectious agents may also indirectly affect cancer epidemiology through interactions with the oncogenic agents within the wider infection community. Here, we address this hypothesis via analysis of large-scale global data to identify associations between human cancer incidence and assemblages of neglected infectious agents. We focus on a gradient of three widely-distributed cancers with an infectious cause: bladder (~2% of recorded cancer cases are due to Shistosoma haematobium), liver (~60% consecutive to Hepatitis B and C infection) and stomach (Helicobacter pylori is associated with ~70% of cases). We analyzed countries in tropical and temperate regions separately, and controlled for many confounding social and economic variables. First, we found that particular assemblages of bacteria are associated with bladder cancer incidences. Second, we observed a specific and robust association between helminths and liver cancer incidences in both biomes. Third, we show that certain assemblages of viruses may facilitate stomach cancer in tropical area, while others protect against its development in temperate countries. Finally, we discuss the implications of our results in terms of cancer prevention and highlight the necessity to consider neglected diseases, especially in tropics, to adapt public health strategies against infectious diseases and cancer.

Cervical Cancer Induction Enhancement Potential of Chlamydia Trachomatis: A Systematic Review

Human papillomavirus (HPV) persistent infection is the necessary but not sufficient cause of cervical cancer. Other co-factors are required to induce cell transformation that will evolve to malignant cervical cancer. These co-factors include physical elements, other sexually transmitted infections, and immune response. Chlamydia trachomatis the most common bacterial sexually transmitted infection is often asymptomatic but causes various syndromes such as cervicitis, endometritis, pelvic inflammatory disease, and infertility. It is established that this bacterium is involved in cell proliferation process and inhibit apoptosis. Furthermore, C. trachomatis may induce chronic inflammation, interfere with immune response by decreasing the number of antigen presenting cells, and reduce the cell-mediated immunity allowing the persistence of HPV. However, it is unclear whether this bacterium plays a particular role in cervical cancer induction. We therefore aimed at enlightening the actual knowledge about the relationship between C. trachomatis and cervical cancer or precursor lesions through a systematic literature review. We summarized and analyzed the epidemiological data on C. trachomatis and its co-infection with HPV and their association to cervical cancer.

Prevalence of Chlamydia trachomatis and Neisseria gonorrhea and associated factors among women living with Human Immunodeficiency Virus in Brazil: a multicenter study

Background

Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) cause infections in the female genital tract, increasing susceptibility to and infectiousness of HIV. The objectives of the present study were to determine the prevalence and associated factors of CT and GC infection among HIV-infected women in Brazil.

Methods

Cross-sectional study conducted from March to December 2015, including HIV-infected women attending referral centers in nine states of Brazil, aged 18–49 years, nonpregnant. An interview was conducted including socio-demographic, epidemiological and clinical characteristics. After the interview, gynecological examination was conducted to collect cervical cytology and vaginal secretion to C. trachomatis and N. gonorrhoeae tests through molecular biology.

Results

A total of 802 (89.1%) women participated. The prevalence of CT was 2.1% (17/802) and CG was 0.9% (7/802). The prevalence of a positive test for both CT and/or GC was 2.7%. The factors associated with positive CT/GC test in the multivariate logistic regression analysis were abnormal Papanicolau smear (OR 4.1; 95% CI: 1.54–11.09) and the presence of abnormal cervical discharge (OR 2.6; 95% CI: 1.02–6.71). Among 377 women who reported previous STI 245 (65.0%) reported using condom more frequently after being diagnosed. 62 (16.4%) discovered the STI after the partner told he was infected; 157 (41.6%) had STI symptoms and looked for care, and 158 (41.9%) discovered it in a routine consultation for another reason.

Conclusions

The control of STI represents a unique opportunity to improve reproductive health of women living with HIV. STI diagnosis can change their behavior and reduce the sexual transmission of HIV and bacterial STI.

[Pap smear before 25 years old]

OBJECTIVES

Current French recommendations advocate cervical-vaginal screening for cervical cancer from age 25 whereas earlier screening is mostly found in current clinical practice although its consequences are not well understood.

METHODS

A literature review using the MedLine database on the natural history of HPV infections, cytological screening, management of cytological and histological anomalies in adolescents and young women.

RESULTS

The adolescent and young woman have some characteristics that distinguish them from adult women: a high prevalence of HPV infections (making the use of the HPV test unprofitable), accompanied by a higher clearance; frequency of minor cytological abnormalities (for which a cytological surveillance without colposcopy is sufficient) and low-grade histological lesions of low grade the usual prognosis of which is complete recovery; and rarity of CIN3 lesions and absence of invasive lesions, allowing no treatment in patients with CIN2 lesions and compliant to cytological and colposcopic surveillance.

CONCLUSION

Cervical screening in the adolescent and young woman is not a logical attitude and the discovery of cytological or histological lesions requires specific behavior in this particular population.

Infections and cancer: the "fifty shades of immunity" hypothesis

BACKGROUND

Since the beginning of the twentieth century, infection has emerged as a fundamental aspect of cancer causation with a growing number of pathogens recognized as oncogenic. Meanwhile, oncolytic viruses have also attracted considerable interest as possible agents of tumor destruction.

DISCUSSION

Lost in the dichotomy between oncogenic and oncolytic agents, the indirect influence of infectious organisms on carcinogenesis has been largely unexplored. We describe the various ways - from functional aspects to evolutionary considerations such as modernity mismatches - by which infectious organisms could interfere with oncogenic processes through immunity. Finally, we discuss how acknowledging these interactions might impact public health approaches and suggest new guidelines for therapeutic and preventive strategies both at individual and population levels. Infectious organisms, that are not oncogenic neither oncolytic, may play a significant role in carcinogenesis, suggesting the need to increase our knowledge about immune interactions between infections and cancer.

The effect of intrauterine devices on acquisition and clearance of human papillomavirus

BACKGROUND

Previous studies have shown a decrease in cervical cancer associated with intrauterine device use. It has been hypothesized that intrauterine device use may alter the natural history of human papillomavirus infections, preempting development of precancerous lesions of the cervix and cervical cancer, but the effect of intrauterine devices on the natural history of human papillomavirus infection and subsequent development of cervical cancer is poorly understood.

OBJECTIVE

The purpose of this study was to evaluate the association between intrauterine device use and cervical high-risk human papillomavirus acquisition and clearance.

STUDY DESIGN

This is a prospective cohort study conducted from October 2000 through June 2014 among 676 sexually active young women and girls enrolled from family planning clinics in San Francisco, CA. Data were analyzed using a Cox proportional hazards model, including time-varying indicators of intrauterine device use, and adjusting for fixed and time-dependent predictor variables.

RESULTS

A total of 85 women used an intrauterine device at some time during follow-up. Among 14,513 study visits, women reported intrauterine device use at 505 visits. After adjusting for potential behavioral confounders, there was no association between intrauterine device use and human papillomavirus acquisition (hazard ratio, 0.50; 95% confidence interval, 0.20-1.23; P = .13) or clearance of human papillomavirus infection (hazard ratio, 1.44; 95% confidence interval, 0.76-2.72; P = .26).

CONCLUSION

Current intrauterine device use is not associated with acquisition or persistence of human papillomavirus infection. Intrauterine device use is safe among women and girls with human papillomavirus infections and at risk for human papillomavirus acquisition. Intrauterine device use may play a role further downstream in the natural history of cervical cancer by inhibiting the development of precancerous lesions of the cervix in human papillomavirus-infected women, or enhancing clearance of established precancerous lesions.

Associations Between Vaginal Infections and Potential High-risk and High-risk Human Papillomavirus Genotypes in Female Sex Workers in Western Kenya

PURPOSE

Infection with and persistence of high-risk human papillomavirus (HR HPV) are the strongest risk factors for cervical cancer. Little is known about the prevalence and role of concurrent sexually transmitted infections (STIs) found in HPV-infected female sex workers (FSW) in Africa. This study purports to test our a priori hypotheses that STIs are associated with genotypes pertaining to the α-group species 9. The objectives were to determine the prevalence of bacterial vaginosis (BV), Trichomonas vaginalis, and Candida spp in FSW, the association between these STIs and the prevalence of any potential HR and HR HPV genotypes in FSWs.

METHODS

A cross-sectional study design of 616 FSW from Western Kenya aged between 18 and 61 years during 2009-2015 using a peer recruitment sampling strategy. Inclusion criteria for the study entailed female sex and >18 years of age and having engaged in transactional sex in exchange for money, goods, services, or drugs in the last 3 months. Women were excluded if they were pregnant, <18 years of age, had a history of cervical dysplasia or cancer, had current abnormal bleeding, or had a hysterectomy.

FINDINGS

Of the FSW, 33.3% had HIV and 57.7% harbored a potential HR and HR HPV genotype. The 2 most prevalent potential HR and HR genotypes were HPV 16 (16.10%) and HPV 59 (12.20%). BV was the most common infection (48.3%), followed by Trichomonas vaginalis (31.4%) and Candida spp (19.9%). A multivariate regression revealed significant associations with both α-group 9 and 6; BV and HPV 58 (adjusted odds ratio [aOR] = 2.3; 95% CI, 1.0-5.2; P = 0.05), Trichomonas vaginalis and HPV 31 and HPV 35 (aOR = 2.0; 95% CI, 1.0-3.8; P = 0.04 and aOR = 1.8; 95% CI, 1.0-3.3, P = 0.05 respectively); and between Candida spp and HPV 53 (aOR = 2.0; 95% CI, 1.1-4.0; P = 0.03) and 16 (aOR = 1.9; 95% CI, 1.1-3.3; P = 0.03).

IMPLICATIONS

Snowball sampling may have inadvertently excluded FSW less likely to benefit from a social network. Significant associations between BV and HPV 58 and between Candida spp and HPV 16 and 53 suggest the need for sexually transmitted disease management within a cervical cancer prevention program. The probable synergistic effects of the vaginal microbiota should be elucidated, especially within this vulnerable population. Given the potential for FSW to transmit STIs, robust epidemiologic sampling methods are urgently required that account for the heterogeneity of the FSW population.

Chlamydia trachomatis infection and HPV/Chlamydia trachomatis co-infection among HPV-vaccinated young women at the beginning of their sexual activity

PURPOSE

This study investigated the prevalence of Chlamydia trachomatis infection, co-infection with Human Papillomavirus (HPV) and associated risk factors in a cohort of sexually active young women enrolled in an ongoing trial on HPV vaccination at the European Institute of Oncology (IEO, Milan, Italy).

METHODS

Cervical samples were collected from 591 girls (median age 18.8 years) at the beginning of their sexual activity. At the time of sample collection, 354 women had not yet been vaccinated, and 237 women had been vaccinated for at least 12 months. All samples were analyzed through a molecular assay for the detection of C. trachomatis infection. Demographic, behavioral risk factors and high-risk HPV (HR-HPV) status were investigated.

RESULTS

The prevalence of C. trachomatis infection was 4.9 % and HPV/C. trachomatis co-infection rate was 1.5 %. The exact analysis has not underlined statistical significance for the variables considered, except for the infection with HR-HPV (p < 0.001). The prevalence of C. trachomatis infection among women who had not been immunized and those already vaccinated was similar (5.6 vs 3.8 %). However, the rate of HPV/C. trachomatis co-infection was twice as high in unvaccinated women (2 %) compared to vaccinated women (0.8 %).

CONCLUSIONS

Over 16 % of young women had at least one of the two STIs investigated. The risk of C. trachomatis infection was higher in HR-HPV infected compared to HR-HPV uninfected young women. The rate of co-infection was halved in HPV-vaccinated compared to unvaccinated women. This study underlines that HPV vaccination can confer benefits also in terms of co-infections prevention, leading to a decreased risk of developing cervical malignancies.

Associations between sexually transmitted infections, high-risk human papillomavirus infection, and abnormal cervical Pap smear results in OB/GYN outpatients

Objective

This study aimed to examine the meaning and usefulness of sexually transmitted infection (STI) test when caring for patients who have abnormal cervical cytology and/or positive high-risk human papillomavirus (HPV) DNA test results.

Methods

Among patients who underwent liquid-based cervical cytology and HPV DNA tests at the Obstetrics and Gynecology outpatient clinic, 800 patients who showed abnormal cervical cytology were compared with 200 patients in the control group. Both groups were simultaneously tested via multiplex real-time polymerase chain reaction for seven types of STI-causative microorganisms.

Results

The positive rate of high-risk HPV infection in total STIs positive group was 1.47 times higher than that of total STIs negative group. The probability of a cytological diagnosis of a grade equal to or higher than atypical squamous cells-cannot exclude high grade squamous intraepithelial lesion (ASC-H) was significantly higher in patients testing positive for total STIs (1.46 times), Chlamydia trachomatis (3.21 times), or Mycoplasma genitalicum (3.58 times) than in those testing negative. The total STIs positive rate was significantly higher for those having a cytological diagnosis of a grade equal to or higher than atypical squamous cells of undetermined significance (ASC-US) when high-risk HPV test result was negative.

Conclusion

Correlations were present not only between STIs and high-risk HPV infection but also between abnormal cervical cytology and STIs. Therefore, additional evaluation of STIs will be helpful to appropriately diagnose and treat patients with abnormal cervical cytology, positive results on high-risk HPV DNA test, or a cytological diagnosis of ASC-US despite negative high-risk HPV DNA test result.

The Role of Chlamydia trachomatis in High-Risk Human Papillomavirus Persistence Among Female Sex Workers in Nairobi, Kenya

BACKGROUND

Little is known about risk factors for persistent high-risk human papillomavirus (hrHPV) infection in low-income settings, and prior research has not quantified the relative duration of hrHPV infections stratified by risk factors. We compared the duration of hrHPV infection among female sex workers (FSWs) by exposure to sexually transmitted infections (STIs), using a highly sensitive biomarker assay.

METHODS

From 2009 to 2011, 350 FSWs enrolled in this longitudinal study. Every 3 months, sociodemographic and sexual behavior data were collected via questionnaire, and APTIMA assays were used to detect the rRNA of Chlamydia trachomatis (CT), Neisseria gonorrhea, Trichomonas vaginalis, Mycoplasma genitalium, and messenger RNA of the E6/E7 oncoproteins expressed by hrHPV. Among 173 FSW who were infected with hrHPV during the observation period, accelerated failure time models estimated time ratios (TRs) for duration of hrHPV infection, comparing FSW infected with STIs at baseline to STI-uninfected FSWs.

RESULTS

Median follow-up time was 26.2 months (interquartile range, 18.8-27.5 months). The median duration of hrHPV infection among all FSWs was 9.3 months (95% confidence interval [CI], 9.3-11.5). The duration of hrHPV infection among FSW infected with CT at baseline was greater than that among FSWs who were uninfected (adjusted TR, 1.7; 95% CI, 1.2-2.6). Among FSWs who were coinfected with hrHPV and CT at baseline, the adjusted TR was 3.4 (95% CI, 2.5-5.4) compared with FSWs infected with hrHPV only. No other STI was associated with hrHPV duration.

CONCLUSIONS

Recent or concurrent CT infection was associated with prolonged hrHPV infection among a cohort of Nairobi FSWs. Management of CT could reduce risk for hrHPV persistence.

HPV genotypes distribution in Chlamydia trachomatis co-infection in a large cohort of women from north-east Italy

Human papillomavirus (HPV) and Chlamydia trachomatis are pathogens with oncogenic potential associated with persistent infections. Epidemiological data on C. trachomatis infection status, C. trachomatis/HPV co-infection and the relationship between HPV genotypes in Italian women are only preliminary. The aim of the present study was to characterize the relationship between HPV genotypes and C. trachomatis in an extending cohort of asymptomatic immunocompetent women from an area of north-east Italy. A retrospective study was conducted using Luminex technology on cervical swabs from asymptomatic immunocompetent women, comprising 921 attending the prevention centre for the Cervical Cancer Program and 6214 who had been referred to the Sexually Transmitted Infections Center, with clinical indications of HPV and C. trachomatis infections. A quantitative real-time PCR was performed to assess chronic C. trachomatis infection by heat-shock protein 60 (Hsp60) gene expression. The overall prevalence of the investigated pathogens was 39 % (359/921) for HPV and 4 % (251/6214) for C. trachomatis. The Hsp60 gene was detected in 57 % of the women infected with C. trachomatis. HPV co-infection was present in 58 % of C. trachomatis-infected women. A high prevalence of co-infection was found in women with chronic C. trachomatis infection (68 %, P = 0.0002), especially in women ≤ 25 years (72 %) where HPV multiple infections were found in 78 % (P = 0.022). HPV genotype distribution showed that uncommon low-risk genotypes were associated with C. trachomatis. These results indicate a high frequency of co-detection of multiple HPV genotypes in chronically infected young women and suggest that the expression of the C. trachomatis Hsp60 gene may favour HPV infection.

Chlamydia Trachomatis Infection-Associated Risk of Cervical Cancer: A Meta-Analysis

As whether Chlamydia trachomatis infection increases the risk of cervical cancer is controversial in the literature, we performed a meta-analysis.Based on a comprehensive search of publications in the Medline, Cochrane, and EMBASE databases, we identified and extracted data from all relevant articles examining C. trachomatis infection and the risk of cervical cancer. The quality of each included study was assessed according to the 9-star Newcastle-Ottawa scale. The strength of association between the C. trachomatis and risk of cervical cancer was estimated by odds ratio (OR) and 95% confidence intervals (CIs). This review was registered at PROSPERO with registration No. CRD42014015672. A total of 22 studies with 4291 cervical cancer cases and 7628 controls were identified. Overall, C. trachomatis was significantly linked to increased cervical cancer risk in prospective studies (OR = 2.21, 95% CI: 1.88-2.61, P < 0.001), as well as in retrospective studies (OR = 2.19, 95% CI: 1.74-2.74, P < 0.001). Additionally, with a multivariate logistic regression analysis adjusted for HPV and age, C. trachomatis infection was identified as an independent predictor of cervical cancer in 11 studies (OR = 1.76, 95% CI: 1.03-3.01, P = 0.04). Coinfection of human papilloma virus and C. trachomatis has a higher risk of cervical cancer (OR = 4.03, 95% CI: 3.15-5.16, P < 0.001). A subgroup analysis based on histological type indicated an elevated risk for both squamous cell carcinoma (OR = 2.21, 95% CI: 2.00-2.45, P < 0.001), and adenocarcinoma (OR = 1.61, 95% CI: 1.21-2.15, P = 0.001), in associated with C. trachomatis. Subgroup analysis by where C. trachomatis infection was detected showed a significantly higher risk of cervical cancer associated with C. trachomatis infection detected in serum (OR = 2.20, 95% CI: 2.01-2.42, P < 0.001), cervical tissue blocks (OR = 2.88, 95% CI: 1.21-6.83, P = 0.02), and cervical secretion (OR = 2.71, 95% CI: 1.41-5.20, P = 0.003), especially in serum with no obvious heterogeneity.In conclusion, our novel data demonstrate that individuals infected with C. trachomatis have a higher risk of cervical cancer. Therefore, it is necessary to expand C. trachomatis infection screening and treat women with C. trachomatis promptly, particularly those with human papilloma virus infections. This approach will not only protect against pelvic inflammatory disease and infertility, but may also prevent cervical cancer.

Chlamydia trachomatis Frequency in a Cohort of HPV-Infected Colombian Women

Background

Chlamydia trachomatis (C. trachomatis), an obligate intracellular bacterium, is the commonest infectious bacterial agent of sexual transmission throughout the world. It has been shown that the presence of this bacteria in the cervix represents a risk regarding HPV persistence and, thereafter, in developing cervical cancer (CC). Prevalence rates may vary from 2% to 17% in asymptomatic females, depending on the population being analysed. This study reports the identification of C. trachomatis in a cohort of 219 HPV-infected Colombian females.

Methods

C. trachomatis infection frequency was determined during each of the study’s follow-up visits; it was detected by amplifying the cryptic plasmid sequence by polymerase chain reaction (PCR) using two sets of primers: KL5/KL6 and KL1/KL2.

Infection was defined as a positive PCR result using either set of primers at any time during the study. Cox proportional risk models were used for evaluating the association between the appearance of infection and a group of independent variables.

Results

Base line C. trachomatis infection frequency was 28% (n = 61). Most females infected by C. trachomatis were infected by multiple types of HPV (77.42%), greater prevalence occurring in females infected with HPV-16 (19.18%), followed by HPV-58 (17.81%). It was observed that females having had the most sexual partners (HR = 6.44: 1.59–26.05 95%CI) or infection with multiple types of HPV (HR = 2.85: 1.22–6.63 95%CI) had the greatest risk of developing C. trachomatis.

Conclusions

The study provides data regarding the epidemiology of C. trachomatis /HPV coinfection in different population groups of Colombian females and contributes towards understanding the natural history of C. trachomatis infection.

Human papillomavirus genotypes distribution among Gabonese women with normal cytology and cervical abnormalities

BACKGROUND

Cervical cancer is one of the most common tumors affecting women with a disproportionate mortality occurring in developing countries. Despite the high prevalence of cervical cancer and cervical neoplasia in Gabon, few studies have been performed to evaluate the prevalence and determinants of HPV infection in this country. The aim of this study was to determine the HPV prevalence and distribution in a population of Gabonese women with normal cytology and cervical abnormalities.

METHODS

A total of 200 cervical samples collected in the "Departement d'Anatomie et de Cytologie Pathologiques" of the "Faculté de Medecine et des Sciences de la Santé" in Libreville, Gabonwere analyzed. Cytological status was classified according to Bethesda 2001. Nested polymerase chain reaction (PCR) using consensus degenerate PCR primers (MY09/11 and GP5+/6+) was performed for the detection of HPV DNA and HPV typing was done by DNA sequencing.

RESULTS

Cytological analysis showed that 87 % of women had normal cytology (n = 174/200). Among the 26 women with cytological abnormalities, predominance (61.5 %; 16/26) of low grade squamous intraepithelial lesion (LSIL) was found and no cervical cancer case was detected. Overall, HPV DNA was detected in 60 % of women (120/200). With respect to the cytological status, HPV DNA was found in 57.5 % of women with normal cervix and 76.9 % of women with abnormal cytology. HPV genotyping was performed on 114 HPV positive cases and revealed the presence of 11 distinct genotypes: 16, 18, 33, 31, 56, 6, 66, 70, 35, 45 and 81. The high risk type HPV 16 was the most common genotype found in all cytological categories. Six HPV positive samples could not be typed by DNA sequencing, probably due to multiple HPV infection. Evaluation of possible risk factors showed that HPV infection was related positively with number of sexual partners (≥3, OR = 2.3; 95 % CI, 1.3-4.3), history of sexually transmitted infection (Chlamydia, OR = 1.9; 95 % CI, 1.01-3.4) and marital status (single, OR = 2.0; 95 % CI, 1.1-3.5).

CONCLUSION

The prevalence of HPV infection among Gabonese women is high. Our findings highlight the need to set up a national program to fight cervical cancer, combining Pap smear test and HPV testing, to improve cervical cancer prevention in Gabon.

Exploration of testing practices and population characteristics support an increase in chlamydia positivity in Tasmania between 2001 and 2010

OBJECTIVE

The proportion of positive chlamydia tests in young people in Tasmania increased significantly between 2001 and 2010. While female positivity rates increased steadily, male positivity rose steeply to 2005 then stabilised. Crude positivity rates can be influenced by a variety of factors making interpretation difficult. Unique Tasmanian datasets were used to explore whether symptom status, reason for testing or sexual exposure could explain the observed positivity trends.

METHODS

Population-level chlamydia positivity rates in Tasmania over a 10-year period were compared with surveillance data collected on people aged 15 to 29 years notified with chlamydia.

RESULTS

The proportion of asymptomatic chlamydia cases increased, with the largest increase in males aged 15 to 19 years (28%). Opportunistic testing of cases increased (greatest in males, range 17-32%). Sexual exposure remained consistent.

CONCLUSIONS

After allowing for any changes in sexual exposure, symptom status and reason for testing, an increase in chlamydia positivity occurred over the 10 years. Healthcare providers have increased chlamydia testing in high-risk groups.

IMPLICATIONS

Monitoring chlamydia testing patterns and positivity rates at a population level is a step forward in surveillance practices. Targeted surveys provide valuable information to supplement routine surveillance data.

Incidence and persistence of carcinogenic genital human papillomavirus infections in young women with or without Chlamydia trachomatis co-infection

We assessed whether infection with chlamydia increases the incidence of carcinogenic human papillomavirus (HPV) infections and if HPV persistence is affected by chlamydia co-infection. For 1982 women (16–29 years-old) participating in two consecutive rounds of a chlamydia screening implementation trial, swabs were polymerase chain reaction tested to detect chlamydia and 14 carcinogenic HPV genotypes. HPV type-specific incidence and persistence rates were stratified for chlamydia positivity at follow-up. Associations were assessed by multilevel logistic regression analyses with correction for sexual risk factors. HPV type-specific incidence ranged from 1.4% to 8.9% and persistence from 22.7% to 59.4% after a median follow-up of 11 months (interquartile range: 11–12). Differences in 1-year HPV persistence rates between chlamydia -infected and noninfected women were less distinct than differences in HPV incidence rates (pooled adjusted odds ratios of 1.17 [95% CI: 0.69–1.96] and 1.84 [95% CI: 1.36–2.47], respectively). The effect of chlamydia co-infection on HPV-infection risk did not significantly differ by HPV genotype. In conclusion, infection with chlamydia increases the risk of infection by carcinogenic HPV types and may enhance persistence of some HPV types. Although these findings could reflect residual confounding through unobserved risk factors, our results do give reason to explore more fully the association between chlamydia and HPV type-specific acquisition and persistence.

Estimating seroprevalence of human papillomavirus type 16 using a mixture model with smoothed age-dependent mixing proportions

BACKGROUND

The presence in serum of antibodies to viral antigens is generally considered a well-defined marker of past infection or vaccination. However, analyses of serological data that use a cut-off value to classify individuals as seropositive are prone to misclassification bias, in particular when studying infections with a weak serological response, such as the sexually transmitted human papillomavirus (HPV).

METHODS

We analyzed the serological concentrations of HPV type 16 (HPV16) antibodies in the general Dutch population in 2006-2007, before the introduction of mass vaccination against HPV. We used a 2-component mixture model to represent persons who were seronegative or seropositive for HPV16. Component densities were assumed to be log-normally distributed, with parameters possibly dependent on sex. The age-dependent mixing proportions were smoothed using penalized splines to obtain a flexible seroprevalence profile.

RESULTS

Our results suggest that HPV16 seropositivity is associated with higher antibody concentrations in women as compared with men. Seroprevalence shows an increase starting from adolescence in men and women alike, coinciding with the age of sexual debut. Seroprevalence stabilizes in men around age 40, whereas it has a decreasing trend from age 50 onwards in women. Analyses that rely on a cut-off value to classify persons as seropositive yield substantially different seroprevalence profiles, leading to a qualitatively different interpretation of HPV16 infection dynamics.

CONCLUSIONS

Our results provide a benchmark for examining the effect of HPV16 vaccination in future serological surveys. Our method may prove useful for estimating seroprevalence of other infections with a weak serological response.

Lack of significant effects of Chlamydia trachomatis infection on cervical cancer risk in a nested case-control study in North-East Thailand

Cervical cancer continues to be an important public health problem in Thailand. While the high risk human papillomavirus (HPV) types have been established as the principle causative agent of both malignancies and the precursor lesions, cervical intraepithelial neoplasia (CIN), other factors may also be involved like other sexually transmitted diseases, as well as smoking. Chlamydia trachomatis is an obligate intracellular Gram-negative bacterium which has a tendency to cause chronic infection featuring inflammation and therefore might be expected to increase the risk of cervical cancer. In the present nested case-control study, 61 cases of cervical cancer and 288 matched controls with original serum samples were identified from the Khon Kaen Cohort, established in the North-East of Thailand, by linkage to the Khon Kaen population based cancer registry. C. trachomatis specific IgG antibodies at recruitment were measured by microimmunofluorescence and assessed for association with cervical cancer using STATA release10. No significant link was noted either with all cancers or after removal of adenocarcinomas. The results suggest no association between Chlamydia infection and cervical cancer development in North-East Thailand, but possible influencing factors must be considered in any future research on this topic.

An association between Trichomonas vaginalis and high-risk human papillomavirus in rural Tanzanian women undergoing cervical cancer screening

OBJECTIVE

The goal of this study was to determine the prevalence of vaginitis and its association with high-risk human papillomavirus (HR HPV) in women undergoing cervical cancer screening in rural Tanzania.

METHODS

For the purpose of cervical cancer screening, cytology and HR HPV polymerase chain reaction data were collected from 324 women aged between 30 and 60 years. Microscopy and gram stains were used to detect yeast and bacterial vaginosis. Cervical nucleic acid amplification test specimens were collected for the detection of Trichomonas vaginalis (TV), Chlamydia trachomatis, and Neisseria gonorrhoeae.

RESULTS

The majority of women were married (320 of 324) and reported having a single sexual partner (270 of 324); the median age of participants was 41 years. HR HPV was detected in 42 participants. Forty-seven percent of women had vaginitis. Bacterial vaginosis was the most common infection (32.4%), followed by TV (10.4%), and yeast (6.8%). In multivariable logistic regression analysis, TV was associated with an increased risk of HR HPV (odds ratio, 4.2 [95% CI, 1.7-10.3]). Patients with TV were 6.5 times more likely to have HPV type 16 than patients negative for TV (50% vs 13.3%) (odds ratio, 6.5 [95% CI, 1.1-37]).

CONCLUSIONS

Among rural Tanzanian women who presented for cervical cancer screening, Trichomonas vaginitis was significantly associated with HR HPV infection (specifically type 16).

Risk of first cervical HPV infection and pre-cancerous lesions after onset of sexual activity: analysis of women in the control arm of the randomized, controlled PATRICIA trial

BACKGROUND

More information is needed about time between sexual initiation and human papillomavirus (HPV) infection and development of cervical precancer.

METHODS

The objectives were to investigate the time between first sexual activity and detection of first cervical HPV infection or development of first cervical intraepithelial neoplasia (CIN), and associated factors in women from the double-blind, multinational, 4-year PATRICIA trial. PATRICIA enroled women aged 15-25 years with no more than 6 lifetime sexual partners. Women were randomized 1:1 to the HPV-16/18 AS04-adjuvanted vaccine or to control, but only women from the control arm who began sexual intercourse during the study or within 6 months before enrolment, and had no HPV infection detected before the recorded date of their first sexual intercourse, were included in the present analysis. The time between onset of sexual activity and detection of the first cervical HPV infection or development of the first CIN lesion was analyzed using Kaplan-Meier and univariate and multivariable Cox proportional-hazards models.

RESULTS

A total of 9337 women were enroled in the control arm of PATRICIA of whom 982 fulfilled the required inclusion criteria for analysis. A cumulative total of 28%, 44%, and 62% of the subjects had HPV infection within 12, 24, and 48 months, respectively. The overall incidence rate was 27.08 per 100 person-years. The most common oncogenic types associated with 6-month persistent infection were HPV-16 (incidence rate: 2.74 per 100 person-years), HPV-51 (2.70), HPV-52 (1.66), HPV-66 (1.14), and HPV-18 (1.09). Increased infection risk was associated with more lifetime sexual partners, being single, Chlamydia trachomatis history, and duration of hormone use. CIN1+ and CIN2+ lesions were most commonly associated with HPV-16, with an overall incidence rate of 1.87 and 1.07 per 100 person-years, respectively. Previous cervical HPV infection was most strongly associated with CIN development.

CONCLUSIONS

More than 25% of women were infected with HPV within 1 year of beginning sexual activity. Without underestimating the value of vaccination at older ages, our findings emphasize its importance before sexual initiation.

TRIAL REGISTRATION

clinicaltrials.gov: NCT00122681 .

Genital tract infection with Chlamydia trachomatis in women attended at a cervical cancer screening program in Northeastern from Brazil

PURPOSE

This cross-sectional study aimed to estimate the prevalence of Chlamydia trachomatis (CT) infection alone and in combination with human papillomavirus (HPV). Furthermore, the study investigates whether the CT infection increases the risk of contracting HPV and whether the presence of both pathogens is associated with a higher prevalence of cervical lesions.

METHODS

Cervical samples of 1,134 asymptomatic women enrolled in a screening program for cervical cancer were analyzed. Two cervical specimens were collected from each patient, one for cytologic examination and the other for detection of CT by polymerase chain reaction (PCR), using a primer pair which amplifies a specific sequence of the DNA plasmid.

RESULTS

The overall prevalence rate infection was 10.9%, being 10% in the women with normal cytology, 13.8% in those with atypical squamous cells of undetermined significance (ASC-US), and 25% with low-grade squamous intraepithelial lesion (LSIL). The infection by CT did not increase the risk of acquiring HPV infection. The higher prevalence of LSIL in women co-infected with HPV and CT is possibly due to HPV.

CONCLUSION

CT infection was more prevalent in younger women aged up to 32 years, who had an early onset of reproductive activity and a history of having had multiple sexual partners lifelong may be at a greater risk of acquiring infection of the genital tract by C. trachomatis.

HPV and Chlamydia trachomatis co-detection in young asymptomatic women from high incidence area for cervical cancer

Chlamydia trachomatis causing chronic inflammatory diseases has investigated as possible human papillomavirus (HPV) cofactor in cervical cancer. The aim of this study is to evaluate the prevalence of Chlamydia trachomatis and HPV co-infection in different cohorts of asymptomatic women from a Northern Italy area at high incidence for cervical cancer. Cervical samples from 441 females were collected from Cervical Cancer Screening Program, Sexually Transmitted Infectious and Assisted Reproductive Technology centres. HPV and Chlamydia trachomatis were detected simultaneously and genotyped using a highly sensitive bead based assay. The overall prevalence of Chlamydia trachomatis was estimated 9.7%, in contrast with the reported national data of 2.3%, and co-infection with HPV was diagnosed in the 17% of the samples. In females ≤ 25 years of age, the infection reached a peak of 22% and co-infection with HPV of 45.8% (P < 0.001). Of note, in young females diagnosed with low grade cervical lesions, no significant difference between Chlamydia trachomatis and HPV distribution was observed, while differently, HPV co-infection was found significantly associated to the presence of intraepithelial lesions when compared to older females (20% vs. 1%; P < 0.001). In this study, the use of a high sensitive molecular technique exhibited higher analytical sensitivity than the referred assays for the diagnosis of Chlamydia trachomatis and HPV co-infection in asymptomatic females, leading to reduction of the potential to identify incorrectly the infection status. An active screening for timely treatment of Chlamydia trachomatis infection is suggested in young females to evaluate a possible decrease in incidence of pre-cancer intraepithelial lesions.

Prospective seroepidemiologic study on the role of Human Papillomavirus and other infections in cervical carcinogenesis: evidence from the EPIC cohort

To evaluate prospectively the association between serological markers of selected infections, including HPV, and risk of developing cervical cancer (CC) and precancer, we performed a nested case-control study within the European Prospective Investigation into Cancer and Nutrition (EPIC) study that included 184 cases of invasive CC (ICC), 425 cases of cervical intraepithelial neoplasia (CIN) grade 3 or carcinoma in situ (CIS), and 1,218 matched control women. At enrollment participants completed lifestyle questionnaires and provided sera. Subjects were followed-up for a median of 9 years. Immunoassays were used to detect serum antibodies to Human Herpes Virus 2 (HHV-2), Chlamydia trachomatis (CT), Chlamydia pneumoniae, L1 proteins of mucosal and cutaneous HPV types, E6/E7 proteins of HPV16/18, as well as to four polyomaviruses. Adjusted odds ratios (OR) [and 95% confidence intervals (CI)] for CIN3/CIS and ICC risk were respectively: 1.6 (1.2-2.0) and 1.8 (1.1-2.7) for L1 seropositivity to any mucosal HPV type, 1.0 (0.4-2.4) and 7.4 (2.8-19.7) for E6 seropositivity to HPV16/18, 1.3 (0.9-1.9) and 2.3 (1.3-4.1) for CT seropositivity, and 1.4 (1.0-2.0) and 1.5 (0.9-2.6) for HHV-2 seropositivity. The highest OR for ICC was observed for HPV16 E6 seropositivity [OR = 10.2 (3.3-31.1)]. Increasing number of sexually transmitted infections (STIs) was associated with increasing risk. Non-STIs were not associated with CC risk. In conclusion, this large prospective study confirms the important role of HPV and a possible contribution of CT and HHV-2 in cervical carcinogenesis. It further identifies HPV16 E6 seropositivity as the strongest marker to predict ICC well before disease development.

Chlamydia trachomatis and risk of cervical intraepithelial neoplasia grade 3 or worse in women with persistent human papillomavirus infection: a cohort study

OBJECTIVES

Some studies suggest that Chlamydia trachomatis (CT) enhances cervical carcinogenesis; however, a possible confounding effect of persistent human papillomavirus (HPV) infection was not addressed. We examined the potential role of CT infection in the development of subsequent cervical intraepithelial neoplasia grade 3 or worse (CIN3+) in women with prevalent HPV infection and in a subgroup of women with persistent HPV infection.

METHODS

Participants in this population-based cohort study underwent a structured interview, including history of CT infection, and subsequently cervical exfoliated cells were obtained for HPV DNA and CT DNA testing. Women with high-risk HPV DNA infection and no prevalent cervical disease constituted the overall study population (n=1390). A subgroup of women with persistent HPV infection (n=320) was also identified. All women were passively followed for development of cervical lesions in the national Pathology Data Bank. HRs and 95% CIs for CIN3+ during follow-up (up to 19 years) were estimated in an accelerated failure time model.

RESULTS

Women who reported more than one CT infection had a statistically significantly increased risk of CIN3+ (high-risk HPV-positive, HR=2.51, 95% CI 1.44 to 4.37) (persistent HPV infection, HR=3.65, 95% CI 1.53 to 8.70). We found no association between CT DNA and subsequent risk of CIN3+ among women who were HPV-positive or had a persistent HPV infection at baseline.

CONCLUSIONS

Repeated CT infections increased the risk of CIN3+ among women with prevalent as well as persistent high-risk HPV infection.

Chlamydia trachomatis infection and human papillomavirus in women with cervical neoplasia in Pernambuco-Brazil

Chlamydia trachomatis (CT) is the most common bacterial cause of sexually transmitted disease. High-risk human papillomavirus (HR-HPV) is considered the main etiological agent for cervical neoplasia. Evidences showed that the presence of co-infection of CT and HR-HPV plays a central role in the etiology of cervical intraepithelial neoplasia (CIN) and cervical cancer. The goals of this study were: evaluate the human papillomavirus (HPV) and CT prevalence among Brazilian women with abnormal cytology and provide the effect of this association on the severity of cervical neoplasia. The population of this study was composed by 142 women with incident histological incidence of CIN grades I, II, III or cervical cancer from Recife, Northeast of Brazil. The polymerase chain reaction method on a cervical brush specimen was used to detect both agents and the automatic sequencing method was used for HPV genotyping assay. The prevalence of HPV and CT was 100 and 24.65 %, respectively. Thirteen types of HPV were detected; HPV 16, 18, 31 and 33 were the most common. The most prevalent HPV types were HPV 16 and 18. A significant association between CT positive and HPV 16 infection was found (p < 0.0106; OR = 5.31; 95 % IC 1.59-17.67). In the study population, there was diversity of HPV infections, with high-risk types being the most common. Also, the data collected suggest that CT infection may play an important role in the natural history of HPV infection.