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Zhong F, Wang T, Li W, Zhang H, Zeng X, Geisler D, Zhou X, Cong Q, Sui L, Tao X, Zhao C. Associations of Single Versus Multiple Human Papillomavirus Infections With the Prevalence of Cervical Intraepithelial Neoplasia 2/3 and Squamous Cell Carcinoma Lesions: Human Papillomavirus Type-Specific Attribution. J Transl Med 2024; 104:100328. [PMID: 38237737 DOI: 10.1016/j.labinv.2024.100328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 12/26/2023] [Accepted: 01/07/2024] [Indexed: 02/12/2024] Open
Abstract
The risk of developing cervical squamous lesions in women with multiple high-risk human papillomavirus (hrHPV) infections is uncertain. The aim of this retrospective study was to investigate the type-specific attribution and phylogenetic effects of single and multiple hrHPV subtypes in cervical squamous lesions. All cases with cervical histopathologic diagnosis and human papillomavirus (HPV) genotyping results in the 6 months preceding biopsy from October 2018 to December 2022 were studied and analyzed. Over the study period, 70,361 cases with histopathologic follow-up and prior HPV genotyping were identified. The hrHPV-positive rate was 55.6% (39,104/70,361), including single hrHPV detected in 27,182 (38.6%), 2 types of hrHPV detected in 8158 (11.6%), and 3 types of hrHPV detected in 2486 (3.5%). Among 16,457 cases with a histologically diagnosed squamous lesion (cervical intraepithelial neoplasia 1: 11411; cervical intraepithelial neoplasia 2/3: 4192; squamous cell carcinoma: 854 cases), the prevalence of single hrHPV infection increased, but the rate of multiple concomitant hrHPV infections showed negative association as the degree of squamous lesions increased. Among women with a single HPV16 infection, cervical intraepithelial neoplasia 2/3 and squamous cell carcinoma (CIN2+) diagnostic rate was 30.6%, and it increased to 47.6% when coinfected with HPV33 (P < .001) but significantly decreased when coinfected with all other hrHPV types (P < .05). By comparing CIN2+ diagnostic rates in 40 most common 2 types of hrHPV infections with related single hrHPV infection, CIN2+ rates were decreased in 12 combinations (30.0%), equivalent in 26 combinations (65.0%), and increased in 2 combinations (5.0%). The cases with 3 types of HPV infections reduced the risk for CIN2+ compared with related single HPV infections. HPV16+52+53, HPV16+52+68, HPV16+52+51, HPV16+39+52, and HPV16+58+53 significantly decreased the risk of CIN2+ compared with HPV16 single infection (P < .05). This study demonstrates that multiple hrHPV infections are not associated with cumulatively higher risk for CIN2+ development, suggesting that oncogenic progression of multiple hrHPV-associated cervical squamous lesions is neither synergistic nor a cumulative effect at the phylogenetic level, possibly a way of competitive interference.
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Affiliation(s)
- Fangfang Zhong
- Department of Pathology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Tiannan Wang
- Department of Pathology, University of Southern California, Los Angeles, California
| | - Wenzhi Li
- Department of Obstetrics and Gynecology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Huina Zhang
- Department of Pathology, University of Rochester Medical Center, Rochester, New York
| | - Xianxu Zeng
- Department of Pathology, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Daniel Geisler
- Department of Pathology, Magee-Womens Hospital of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Xianrong Zhou
- Department of Pathology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Qing Cong
- Center of Diagnosis and Treatment for Cervical Diseases, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Long Sui
- Center of Diagnosis and Treatment for Cervical Diseases, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China
| | - Xiang Tao
- Department of Pathology, Obstetrics and Gynecology Hospital of Fudan University, Shanghai, China.
| | - Chengquan Zhao
- Department of Pathology, Magee-Womens Hospital of University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
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Kong L, Xiao X, Xu T, Wan R, Chen F. Immediate histologic correlation in patients with different HPV genotypes and ages: a single center analysis in China. BMC Cancer 2023; 23:1211. [PMID: 38066444 PMCID: PMC10704629 DOI: 10.1186/s12885-023-11697-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 11/30/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Human papillomavirus (HPV) has been confirmed as a major causative factor for malignant transformation of cervical epithelial cells and for the development of cervical intraepithelial neoplasia (CIN) and invasive cervical cancer. We carried out this study to investigate the association of different HPV genotypes and ages with immediate histological cervical lesions in opportunistic screening patients in a single center. METHODS A total of 1,661 samples with biopsy-confirmed histologic findings were collected from the gynecological clinic of our hospital between October 2017 and May 2020 for analysis. The distribution of single-type HPV genotypes in CIN of different severities and the age-dependent prevalence for single-type HPV infection were analyzed. RESULTS In both CIN2 and CIN3 group, HPV16, 58, 52, 33 and 31/18 were detected as top 5 high-risk human papillomavirus (hrHPV) types, which accounts for 89.25% and 88.54% of single HPV infection incidence respectively. Besides, not a single case of HPV45 was found in CIN2 and CIN3. HPV16 was the dominant genotype in both CIN2 and CIN3, accounted for 46.24% and 55.21%, respectively. The prevalence of HPV16 was the most frequent in all the age groups, except ≥ 65 years group in CIN3, and almost one in three HPV16-positive patients were diagnosed with high grade CIN. The peak of the incidence of CIN3 was observed at 25 ~ 34 years (33.68%), followed by 35 ~ 44 years (31.58%). CONCLUSION High grade CIN peak at 25 ~ 44 years, women of this age are recommended for normative screening if conditions permit. HPV16-positive patients should be given high priority in opportunistic screening, while the single-center data suggesting a low risk of CIN2/3 in HPV45-positive patients. For women ≥ 65 years old, patients infected with other HPV types should be also taken seriously. In general, HPV16, 58, 52, 33, 31 and 18 were the most common genotypes in CIN2/3, and a vaccine including these predominant genotypes might be of great significance for cervical cancer prevention in China.
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Affiliation(s)
- Linghua Kong
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, National Clinical Research Center for Obstetric & Gynecologic Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Xiaoping Xiao
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, National Clinical Research Center for Obstetric & Gynecologic Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Tao Xu
- Institute of Basic Medical Sciences, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Ru Wan
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, National Clinical Research Center for Obstetric & Gynecologic Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Fei Chen
- Department of Obstetrics and Gynecology, Peking Union Medical College Hospital, National Clinical Research Center for Obstetric & Gynecologic Diseases, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China.
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Jalil AT, Khan MUF, Muhammed HA, Kawen AA, Saeed BQ, Karevskiy A. Detection of HPV16 viral load in L2 gene as a related predictor of cervical cancer among women in Dhi-Qar province by qRT-PCR. Mol Biol Rep 2022; 49:11847-11853. [PMID: 36214947 DOI: 10.1007/s11033-022-07955-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 09/16/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND The most common infection among young women that increases the risk of developing cervical cancer (CC) is human papillomavirus (HPV). In this study, we are going to assess whether HPV16 DNA concentration helps indicate cervical cancer progression ,As well as for age groups and their relationship to cervical cancer. METHODS Present study included 93 adult females suffering from cervical cancer during the period from 2017 to 2020. Molecular detection of HPV was done using amplification of the L2 gene (minor capsid protein). RESULTS Present results showed that 60 (65%) of the patients from 93 cervical cancer cases were infected by HPV16 while only 5 (8%) of healthy patients from the control group were positive for HPV16. So, the current study revealed high HPV16 load in cervical cancer ranged from 1.09 × 102 IU/ml to 5.07 × 103 IU/ml with a mean ± SD of viral load was 1043.25 ± 8.50 IU/ml while in healthy individuals very low viral load ranging from 88 IU/ml to 101 IU/ml and mean ± SD of viral load was 91.25 ± 2.90 IU/ml was reported. CONCLUSION HPV16 viral load is significantly associated with cervical carcinoma among women in Dhi-Qar Province.
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Affiliation(s)
- Abduladheem Turki Jalil
- Faculty of Biology and Ecology, Yanka Kupala State University of Grodno, Ozhesko str., 22, Grodno, Belarus. .,Department, Medical Laboratories Techniques, Al-Mustaqbal University College, Babylon, 51001, Hilla, Iraq.
| | | | | | | | - Balsam Qubais Saeed
- Clinical Sciences Department, College of Medicine, University of Sharjah, Sharjah, UAE
| | - Aleksandr Karevskiy
- Dean Faculty of Biology and Ecology, Yanka Kupala State University of Grodno, Ozhesko str., 22, Grodno, Belarus
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HPV-genotyping versus conventional cervical cytology as a screening method to detect dysplastic cervical epithelial changes. Sci Rep 2022; 12:17828. [PMID: 36280748 PMCID: PMC9592588 DOI: 10.1038/s41598-022-22438-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 10/14/2022] [Indexed: 01/20/2023] Open
Abstract
The world health organization (WHO) called for coordinated global action in 2018 to eliminate cervical cancer, ensuring that every woman is screened and treated for precancerous lesions (World Health Organization. Cervical cancer: an NCD we can overcome. Geneva, 2018. http://www.who.int/director-general/speeches/detail/cervical-cancer-an-ncd-we-can-overcome.tegy ). Cytology-based screening has been for decades the conventional method of screening. Ancillary techniques have been added like immunocytochemistry with P16/Ki67 and L1-Capsid, but these methods require maintenance of complex infrastructure and highly trained personnel as well as relatively short screening intervals. HPV-based screening method to detect high-risk groups is a faster and automated method, which does not need morphologically highly qualified personal with high social costs. In the study, we have focused on the distribution of cervical lesions in the age groups with concordance of detection HPV high-risk subtypes (HPV-HR) and on the safety of the screening method. In the Institute for Pathology and Cytology-Schuettorf-Leer-Germany 146.800 samples of women from the age of and above 35 years were analyzed between the beginnings of 2020 until the beginning of 2021. 63.710 cases under 35 years old were analyzed. The samples were processed for both conventional cytological techniques and for molecular detection and subtyping of HPV-HR according to the advice and measurements of BD-manufacture. In this study, we have studied the histopathological results (Table 2) after colposcopy according to the age subgroups. The histopathological results were subdivided into no dysplasia, cervical intraepithelial neoplasia I (CIN I), cervical intraepithelial neoplasia II (CIN II), cervical intraepithelial neoplasia III (CIN III), squamous cell carcinoma (Sq.c.c), adenocarcinoma in situ (AIS), endometrial carcinoma, endocervical adenocarcinoma and cases without biopsy during the colposcopy (COB). We have used the muenchener classification III (Table 3) as a subgrading system for the cytological specimens. The frequency of detecting HPV56/59/66 is higher as detecting HPV-16 and HPV18 in age groups under 35 years old, 41-50 years old and 51-60 years old. HPV16 is detected higher in age groups 35-40 years old and above 60 years. The incidence of high squamous intraepithelial lesions (CIN II and III) is 0.92% in age group 35-40 years, 0.54% in age under 35 years, 0.59% in age group 41-50 years old, 0.35% in age group 51-60 years old and 0.15% in age group above 60 years old. There is no significance (p value = 0.4060). Low grade cervical lesions (CIN I) were 0.13% (< 35 Ys), 0.35% (35-40 Ys), 0.36% (41-50 Ys), 0.25% (51-60 Ys) and 0.098% (> 60Y s), which was statistically significant (p value = 0.04,0.60). Without dysplasia 0.19% (< 35 Ys), 0.5% (35-40 Ys), 0.56% (41-50 Ys), 0.51 (51-60 Ys) and 0.26% (> 60 Ys). There is no significance between occurrence of cervical dysplasia and without dysplasia despite of detection of HPV-HR subtypes (p value = 0.1754). The only use of HPV-subtyping is not a secure method and a protective way for women. There are worldwide many HPV-positive cases, which have been psychologically impaired with higher costs, although they have no cervical epithelial changes during the HPV-infection. There are many HPV-negative cases, in some studies up to 13% of cases, which develop cervical cancer. We have the opinion and are convinced that the screening should be both morphologically via cytological examination and may be with adding immunocytochemistry to detect the really dysplastic cervical lesions. HPV-subtyping may be added every three years to detect the concomitant subtype.
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Wang L, Yu C, Ni X, Wang F, Wen C, Jin M, Chen J, Zhang K, Wang J. Prevalence characteristics of human papillomavirus (HPV) infection among women receiving physical examinations in the Shangcheng District, Hangzhou city, China. Sci Rep 2021; 11:16538. [PMID: 34400720 PMCID: PMC8368293 DOI: 10.1038/s41598-021-96131-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 08/02/2021] [Indexed: 11/23/2022] Open
Abstract
This paper aimed to investigate the characteristics of female HPV infection in the Shangcheng District, Hangzhou city, China. The retrospective study was designed to analyze the HPV prevalence rate of 22,382 women receiving physical examinations from 2016 to 2020 in the Shangcheng District of Hangzhou city in China. A commercial kit was designed to detect the HPV genotypes. Trends were examined for age-specific groups (≤ 30 years, 31–44 years, 45–54 years, 55–64 years, ≥ 65 years). A receiver operating characteristic (ROC) analysis was used to assess the correlation of age classification in high risk HPV (HR-HPV) infection. 22.41% (5015/22,382) of samples were HPV positive, 91.28% (4578/5015) of HPV positive women were infected by HR-HPV. The most prevalent HR-HPV genotypes were 16, 52, 18, 58, 56, and 51. The trend of HPV prevalence showed the significant differences in age-specific groups (χ2 = 164.70, P < 0.001). Moreover, the areas under ROC curve (AUC) was 0.712 in 55–64 years group which showed a strong contribution of age classification for HR-HPV infection. This study provided baseline data on the prevalence characteristics of HPV infection and the critical age group of HR-HPV prevalence rate was 55–64 y among the samples receiving physical examinations.
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Affiliation(s)
- Lu Wang
- Department of Obstetrics and Gynecology, Hangzhou Women's Hospital, Hangzhou, China
| | - Chunfeng Yu
- Department of Obstetrics and Gynecology, Hangzhou Women's Hospital, Hangzhou, China
| | - Xiaoling Ni
- Department of Obstetrics and Gynecology, Hangzhou Women's Hospital, Hangzhou, China
| | - Fang Wang
- Department of Obstetrics and Gynecology, Hangzhou Women's Hospital, Hangzhou, China
| | - Caihe Wen
- Department of Obstetrics and Gynecology, Hangzhou Women's Hospital, Hangzhou, China
| | - Mei Jin
- Department of Obstetrics and Gynecology, Hangzhou Women's Hospital, Hangzhou, China
| | - Juanjuan Chen
- Department of Obstetrics and Gynecology, Hangzhou Women's Hospital, Hangzhou, China
| | - Kunming Zhang
- Department of Clinical Laboratory, Affiliated Hangzhou Cancer Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jiahao Wang
- Department of Radiation Oncology, Affiliated Hangzhou Cancer Hospital, Zhejiang University School of Medicine, Hangzhou, China.
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Oyervides-Muñoz MA, Pérez-Maya AA, Sánchez-Domínguez CN, Berlanga-Garza A, Antonio-Macedo M, Valdéz-Chapa LD, Cerda-Flores RM, Trevino V, Barrera-Saldaña HA, Garza-Rodríguez ML. Multiple HPV Infections and Viral Load Association in Persistent Cervical Lesions in Mexican Women. Viruses 2020; 12:E380. [PMID: 32244347 PMCID: PMC7232502 DOI: 10.3390/v12040380] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Revised: 03/18/2020] [Accepted: 03/22/2020] [Indexed: 12/04/2022] Open
Abstract
Persistent high-risk human papillomavirus (HR-HPV) infections play a major role in the development of invasive cervical cancer (CC), and screening for such infections is in many countries the primary method of detecting and preventing CC. HPV typing can be used for triage and risk stratification of women with atypical squamous cells of undetermined significance (ASC-US)/low-grade cervical lesions (LSIL), though the current clinical practice in Mexico is to diagnose CC or its preceding conditions mainly via histology and HR-HPV detection. Additional information regarding these HPV infections, such as viral load and co-infecting agents, might also be useful for diagnosing, predicting, and evaluating the possible consequences of the infection and of its prevention by vaccination. The goal of this follow-up hospital case study was to determine if HPV types, multiple HPV infections, and viral loads were associated with infection persistence and the cervical lesion grade. A total of 294 cervical cytology samples drawn from patients with gynecological alterations were used in this study. HPV types were identified by real-time PCR DNA analysis. A subset of HPV-positive patients was reevaluated to identify persistent infections. We identified HPV types 16, 18, and 39 as the most prevalent. One hundred five of the patients (59%) were infected with more than one type of HPV. The types of HPV associated with multiple HPV infections were 16, 18, and 39. In the follow-up samples, 38% of patients had not cleared the initially detected HPV infection, and these were considered persistent. We found here an association between multiple HPV infections and high viral loads with and infection persistence. Our findings suggest there are benefits in ascertaining viral load and multiple HPV infections status of HR-HPV infections for predicting the risk of persistence, a requirement for developing CC. These findings contribute to our understanding of HPV epidemiology and may allow screening programs to better assess the cancer-developing risks associated with individual HR-HPV infections.
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Affiliation(s)
- Mariel A. Oyervides-Muñoz
- Departamento de Bioquímica y Medicina Molecular, Facultad de Medicina, Universidad Autónoma de Nuevo León, Av. Francisco I. Madero S/N, Mitras Centro Monterrey, 64460 Nuevo León, Mexico; (M.A.O.-M.); (A.A.P.-M.); (C.N.S.-D.)
| | - Antonio A. Pérez-Maya
- Departamento de Bioquímica y Medicina Molecular, Facultad de Medicina, Universidad Autónoma de Nuevo León, Av. Francisco I. Madero S/N, Mitras Centro Monterrey, 64460 Nuevo León, Mexico; (M.A.O.-M.); (A.A.P.-M.); (C.N.S.-D.)
| | - Celia N. Sánchez-Domínguez
- Departamento de Bioquímica y Medicina Molecular, Facultad de Medicina, Universidad Autónoma de Nuevo León, Av. Francisco I. Madero S/N, Mitras Centro Monterrey, 64460 Nuevo León, Mexico; (M.A.O.-M.); (A.A.P.-M.); (C.N.S.-D.)
| | - Anais Berlanga-Garza
- Departamento de Ginecología y Obstetricia, Hospital Universitario “Dr. José Eleuterio González”, Universidad Autónoma de Nuevo León, Av. Francisco I. Madero S/N, Mitras Centro, 64460 Nuevo León, Mexico; (A.B.-G.); (M.A.-M.); (L.D.V.-C.)
| | - Mauro Antonio-Macedo
- Departamento de Ginecología y Obstetricia, Hospital Universitario “Dr. José Eleuterio González”, Universidad Autónoma de Nuevo León, Av. Francisco I. Madero S/N, Mitras Centro, 64460 Nuevo León, Mexico; (A.B.-G.); (M.A.-M.); (L.D.V.-C.)
| | - Lezmes D. Valdéz-Chapa
- Departamento de Ginecología y Obstetricia, Hospital Universitario “Dr. José Eleuterio González”, Universidad Autónoma de Nuevo León, Av. Francisco I. Madero S/N, Mitras Centro, 64460 Nuevo León, Mexico; (A.B.-G.); (M.A.-M.); (L.D.V.-C.)
| | - Ricardo M. Cerda-Flores
- Facultad de Enfermería, Universidad Autónoma de Nuevo León, Av. Dr. José Eleuterio González 1500, Mitras Centro, 64460 Nuevo León, Mexico;
| | - Victor Trevino
- Tecnologico de Monterrey, Escuela de Medicina y Ciencias de la Salud, 3000 Av. Morones Prieto, Colonia Los Doctores, 64710 Nuevo León, Mexico;
| | - Hugo A. Barrera-Saldaña
- Vitagénesis SA. Blvd. Puerta del Sol 1005. Colinas de San Jerónimo. Monterrey, 64630 Nuevo León, Mexico
| | - María L. Garza-Rodríguez
- Centro Universitario contra el Cancer, Hospital Universitario “Dr. José Eleuterio González”, Universidad Autónoma de Nuevo León, Av. Francisco I. Madero S/N, Mitras Centro, 64460 Nuevo León, Mexico
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Epidemiological evaluation of human papillomavirus genotypes and their associations in multiple infections. Epidemiol Infect 2020; 147:e132. [PMID: 30869020 PMCID: PMC6518506 DOI: 10.1017/s0950268818003539] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
The aim of this study was to determine the frequency of multiple type human papillomavirus (HPV) infections, and whether any types are involved in multiple HPV-type infections (mHPV) more or less frequently than expected. From January 2012 to February 2018, 2848 cervico-vaginal swabs were analysed in the UOC Microbiology and Virology of Policlinico of Bari, Italy. HPV DNA detection was performed using initially nested-polymerase chain reaction (PCR) and subsequently multiplex real-time PCR assay. 1357/2848 samples (47.65%) were HPV DNA positive and 694/1357 (51.14%) showed mHPVs. The median number of mHPVs was 2 (interquartile range: 2–3). HPV-types more frequently detected were 42 (9.97%), 16 (8.92%), 53 (7.23%) and 31 (7.16%). Each detected HPV-type was involved in mHPVs in more than 50% of cases. Statistical analysis showed significant associations for all HPV-types except for 33, 43, 51, 58 and 82 HPV-types. The major number of significant pairwise associations were detected for the types 42 and 70. Only positive associations were detected. Further data are necessary to evaluate the clinical impact of the single combinations.
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Tawe L, MacDuffie E, Narasimhamurthy M, Wang Q, Gaseitsiwe S, Moyo S, Kasvosve I, Shin SS, Zetola NM, Paganotti GM, Grover S. Human papillomavirus genotypes in women with invasive cervical cancer with and without human immunodeficiency virus infection in Botswana. Int J Cancer 2020; 146:1667-1673. [PMID: 31325316 PMCID: PMC7055961 DOI: 10.1002/ijc.32581] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 06/21/2019] [Accepted: 07/04/2019] [Indexed: 01/01/2023]
Abstract
Cervical cancer remains a significant cause of morbidity and mortality in women worldwide and is the leading cause of cancer-related death in Botswana. It is well established that women with HIV have a higher risk of persistent HPV infection leading to cervical cancer. We assessed HPV prevalence and genotype distribution in 126 tissue specimens from confirmed invasive cervical cancer cases using Abbott real-time PCR assay. Overall, 88 (69.8%) women were HIV-infected. Fifty-seven (64.8%) of the HIV-infected women had a baseline CD4+ count ≥350 cells/μl, and 82 (93.2%) were on antiretroviral therapy at the time of cervical cancer diagnosis. The median age of HIV-infected patients was significantly younger than that of HIV-uninfected patients (p < 0.001). HPV DNA was detected in all of 126 (100%) of tissues analyzed in our study. The HPV genotypes identified included the HPV-16 (75.4%), HPV-18 (28.6%) and other high-risk (hr) HPV genotypes (16.7%). HIV infection was positively associated with the presence of the HPV-16 genotype (p = 0.036), but not with HPV-18 or with other high-risk (hr)-HPV genotypes. Thirty-three percent of the patients had multiple hr-HPV genotypes, with higher rates in HIV-infected women. These results highlight the importance and potential impact of large-scale HPV vaccination programs covering HPV-16 and HPV-18 genotypes in countries like Botswana with high burden of HIV infection.
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Affiliation(s)
- Leabaneng Tawe
- Department of Medical Laboratory Sciences, Faculty of Health Sciences, University of Botswana, Gaborone, Botswana,Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana
| | - Emily MacDuffie
- Warren Alpert Medical School of Brown University, Providence, RI
| | - Mohan Narasimhamurthy
- Department of Pathology, Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | - Qiao Wang
- Sue & Bill Gross School of Nursing, University of California Irvine, Irvine, CA
| | - Simani Gaseitsiwe
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana,Department of Immunology and Infectious Diseases, Harvard School of Public Health, Boston, MA
| | - Sikhulile Moyo
- Botswana Harvard AIDS Institute Partnership, Gaborone, Botswana,Department of Immunology and Infectious Diseases, Harvard School of Public Health, Boston, MA
| | - Ishmael Kasvosve
- Department of Medical Laboratory Sciences, Faculty of Health Sciences, University of Botswana, Gaborone, Botswana
| | - Sanghyuk S. Shin
- Sue & Bill Gross School of Nursing, University of California Irvine, Irvine, CA
| | - Nicola M. Zetola
- Botswana-University of Pennsylvania Partnership, Gaborone, Botswana
| | - Giacomo M. Paganotti
- Botswana-University of Pennsylvania Partnership, Gaborone, Botswana,Department of Biomedical Sciences, Faculty of Medicine, University of Botswana, Gaborone, Botswana,Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Surbhi Grover
- Botswana-University of Pennsylvania Partnership, Gaborone, Botswana,Department of Radiation Oncology, Perelman School of Medicine
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Ji Y, Ma XX, Li Z, Peppelenbosch MP, Ma Z, Pan Q. The Burden of Human Papillomavirus and Chlamydia trachomatis Coinfection in Women: A Large Cohort Study in Inner Mongolia, China. J Infect Dis 2019; 219:206-214. [PMID: 30192954 DOI: 10.1093/infdis/jiy497] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 08/29/2018] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Yunpeng Ji
- Biomedical Research Center, Northwest Minzu University, Lanzhou, China.,Department of Genetics, Inner Mongolia Maternal and Child Care Hospital, Hohhot, China.,Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Xiao-Xia Ma
- Biomedical Research Center, Northwest Minzu University, Lanzhou, China
| | - Zhaocai Li
- State Key Laboratory of Veterinary Etiological Biology, Lanzhou Veterinary Research Institute, Chinese Academy of Agricultural Sciences, Gansu, China
| | - Maikel P Peppelenbosch
- Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Zhongren Ma
- Biomedical Research Center, Northwest Minzu University, Lanzhou, China
| | - Qiuwei Pan
- Biomedical Research Center, Northwest Minzu University, Lanzhou, China.,Department of Gastroenterology and Hepatology, Erasmus University Medical Center, Rotterdam, The Netherlands
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10
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Badial RM, Dias MC, Stuqui B, Melli PPDS, Quintana SM, do Bonfim CM, Cordeiro JA, Rabachini T, Calmon MDF, Provazzi PJS, Rahal P. Detection and genotyping of human papillomavirus (HPV) in HIV-infected women and its relationship with HPV/HIV co-infection. Medicine (Baltimore) 2018; 97:e9545. [PMID: 29620669 PMCID: PMC5902291 DOI: 10.1097/md.0000000000009545] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
HPV have been identified as high-risk and low-risk, depending on their association with the development of cancer. HPV infections can be facilitated by co-infection with HIV. Here, we investigated HPV prevalence and genotypes and the risk factors affecting HPV/HIV co-infection. Forty HIV-positive patients had 80 cervical swab samples collected in 2 consecutive years. Polymerase chain reaction and DNA direct sequencing were used to perform HPV genotyping. Statistical analyses were performed regarding risk factors for HPV/HIV co-infection and the occurrence of cervical lesions. HPV DNA was detected in 59 samples (73.75%), and high-risk HPVs were predominant (59.3%). The most prevalent type was HPV56 (17%), followed by HPV16 (15.3%). Patient age did not affect the risk of cervical cancer (P = .84) or HPV prevalence in different years (P = .25/P = .63). CD4 count also did not affect the risk for cervical lesions in the tested samples (P = .15/P = .28). Although the HIV viral load was not correlated with an increase in cervical lesion detection in the first group of analyzed samples (P = .12), it did affect cervical cancer risk in the group of samples analyzed in the following year (P = .045). HIV-infected patients presented a high prevalence of HPV co-infection, and HPV16 and HPV56 were the most prevalent genotypes. Considering this, it is possible that immunodeficiency can contribute to increased susceptibility to HPV56 infection in HIV-infected patients. The association between HIV viral load and the lesions also confirmed the importance of monitoring HIV/HPV co-infected patients with high HIV viral loads.
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Affiliation(s)
| | - Marina Carrara Dias
- Department of Biology, São Paulo State University – UNESP, São José do Rio Preto/SP
| | - Bruna Stuqui
- Department of Biology, São Paulo State University – UNESP, São José do Rio Preto/SP
| | | | - Silvana Maria Quintana
- Department of Gynecology and Obstetrics, Medical School of Ribeirão Preto, University of São Paulo – USP
| | | | - José Antônio Cordeiro
- Department of Epidemiology and Public Health, Faculty of Medicine of São José do Rio Preto – FAMERP, São José do Rio Preto/SP, Brazil
| | | | | | | | - Paula Rahal
- Department of Biology, São Paulo State University – UNESP, São José do Rio Preto/SP
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11
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Ma L, Lu S, Jiang Y, Li M, Cong X, Cao Y. Distribution of human papillomavirus genotypes (2014–2016) in women with genital warts at a sexually transmitted disease clinic in Beijing, China. Future Virol 2018. [DOI: 10.2217/fvl-2017-0097] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Aim: The aim of this study was to analyze the distribution of human papillomavirus (HPV) genotypes among women with genital warts in the Beijing region of China. Methods: A total of 350 women diagnosed with genital warts between 2014 and 2016 were analyzed by real-time polymerase chain reaction (PCR) to test for high-risk and low-risk HPV subtypes. Results: The results show that 52.6% (184/350) of cases were positive for HPV6+11. The three most common high-risk HPVs detected were HPV52, HPV16 and HPV58, detected in 12.0% (42/350), 10.6% (37/350) and 10.0% (35/350) of all cases, respectively. Conclusion: These results indicate that vaccines targeting HPV subtypes 6, 11, 16, 52 and 58 would have the greatest impact among sexually active women living in Beijing.
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Affiliation(s)
- Liang Ma
- Department of Clinical Laboratory, China–Japan Friendship Hospital, Beijing 100029, PR China
| | - Shuang Lu
- Department of Clinical Laboratory, China–Japan Friendship Hospital, Beijing 100029, PR China
| | - Yongwei Jiang
- Department of Clinical Laboratory, China–Japan Friendship Hospital, Beijing 100029, PR China
| | - Min Li
- Department of Obstetrics & Gynecology, China–Japan Friendship Hospital, Beijing 100029, PR China
| | - Xiao Cong
- Department of Clinical Laboratory, China–Japan Friendship Hospital, Beijing 100029, PR China
| | - Yongtong Cao
- Department of Clinical Laboratory, China–Japan Friendship Hospital, Beijing 100029, PR China
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12
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Zhao XL, Hu SY, Zhang Q, Dong L, Feng RM, Han R, Zhao FH. High-risk human papillomavirus genotype distribution and attribution to cervical cancer and precancerous lesions in a rural Chinese population. J Gynecol Oncol 2018; 28:e30. [PMID: 28541628 PMCID: PMC5447139 DOI: 10.3802/jgo.2017.28.e30] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 01/12/2017] [Accepted: 01/29/2017] [Indexed: 11/30/2022] Open
Abstract
Objective To explore the genotype distribution of high-risk human papillomavirus (HR-HPV) and its attribution to different grades of cervical lesions in rural China, which will contribute to type-specific HPV screening tests and the development of new polyvalent HPV vaccines among the Chinese population. Methods One thousand two hundred ninety-two subjects were followed based on the Shanxi Province Cervical Cancer Screening Study I (SPOCCS-I), and screened by HPV DNA testing (hybrid capture® 2 [HC2]), liquid-based cytology (LBC), and if necessary, directed or random colposcopy-guided quadrant biopsies. HPV genotyping with linear inverse probe hybridization (SPF10-PCR-LiPA) was performed in HC2 positive specimens. Attribution of specific HR-HPV type to different grades of cervical lesions was estimated using a fractional contribution approach. Results After excluding incomplete data, 1,274 women were included in the final statistical analysis. Fifteen point two percent (194/1,274) of women were HR-HPV positive for any of 13 HR-HPV types (HPV16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, and 68) and the most common HR-HPV types were HPV16 (19.1%) and HPV52 (16.5%). The genotypes most frequently detected in HR-HPV-positive cervical intraepithelial neoplasia grade 1 (CIN1) were HPV52 (24.1%), HPV31 (20.7%), HPV16 (13.8%), HPV33 (13.8%), HPV39 (10.3%), and HPV56 (10.3%); in HR-HPV-positive cervical intraepithelial neoplasia grade 2 or worse (CIN2+): HPV16 (53.1%), HPV58 (15.6%), HPV33 (12.5%), HPV51 (9.4%), and HPV52 (6.3%). HPV52, 31, 16, 33, 39, and 56 together contributed to 89.7% of HR-HPV-positive CIN1, and HPV16, 33, 58, 51, and 52 together contributed to 87.5% of CIN2+. Conclusion In summary, we found substantial differences in prevalence and attribution of CINs between different oncogenic HPV types in a rural Chinese population, especially for HPV16, 31, 33, 52, and 58. These differences may be relevant for both clinical management and the design of preventive strategies.
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Affiliation(s)
- Xue Lian Zhao
- Department of Cancer Epidemiology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shang Ying Hu
- Department of Cancer Epidemiology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Qian Zhang
- Department of Cancer Epidemiology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Li Dong
- Department of Cancer Epidemiology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Rui Mei Feng
- Department of Cancer Epidemiology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ross Han
- Biological Sciences Division, University of Chicago, Chicago, IL, USA
| | - Fang Hui Zhao
- Department of Cancer Epidemiology, National Cancer Center/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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13
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Tang Z, Xu Y, Song N, Zou D, Liao Y, Li Q, Pan C. A comparison of the MeltPro ® HPV Test with the Cobas ® HPV Test for detecting and genotyping 14 high-risk human papillomavirus types. Arch Virol 2017; 163:725-730. [PMID: 29209810 DOI: 10.1007/s00705-017-3645-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 10/03/2017] [Indexed: 11/25/2022]
Abstract
The clinical performance of the newly developed MeltPro® HPV Test, based on multicolor melting curve analysis, was evaluated and compared with the commercially available Cobas® HPV Test for detection of HPV and genotyping of HPV-16 and HPV-18. A total of 1647 cervical samples were analyzed with both tests. The agreement values were 96.2% for HPV detection, 99.6% for HPV-16 identification, and 99.7% for HPV-18 identification. All genotyping results from MeltPro® HPV Test showed that HPV-52, HPV-58, and HPV-16 were the most common types in this study. Intra-laboratory reproducibility studies showed 97.8% agreement while inter-laboratory reproducibility studies showed 96.9% agreement for the MeltPro® HPV Test. The MeltPro® HPV Test and Cobas® HPV Test are highly correlative and are useful for monitoring HPV infection.
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Affiliation(s)
- Zhiteng Tang
- Zhongshan Hospital, Xiamen University, Xiamen, Fujian, China
| | - Ye Xu
- The State Key Laboratory of Cellular Stress Biology, State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics, Engineering Research Center of Molecular Diagnostics of the Ministry of Education, School of Life Sciences, Xiamen University, Xiamen, Fujian, China
| | - Najie Song
- Zeesan Biotechnology Company, Xiamen, Fujian, China
| | - Dongqing Zou
- Zeesan Biotechnology Company, Xiamen, Fujian, China
| | - Yiqun Liao
- The State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics, State Key Laboratory of Cellular Stress Biology, Engineering Research Center of Molecular Diagnostics of the Ministry of Education, School of Public Health, Xiamen University, Xiamen, Fujian, China.
| | - Qingge Li
- The State Key Laboratory of Cellular Stress Biology, State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics, Engineering Research Center of Molecular Diagnostics of the Ministry of Education, School of Life Sciences, Xiamen University, Xiamen, Fujian, China.
| | - Chao Pan
- Zhongshan Hospital, Xiamen University, Xiamen, Fujian, China.
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14
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Is incidence of multiple HPV genotypes rising in genital infections? J Infect Public Health 2017; 10:730-733. [DOI: 10.1016/j.jiph.2016.10.006] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 09/17/2016] [Accepted: 10/01/2016] [Indexed: 11/18/2022] Open
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15
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Wang X, Ji Y, Li J, Dong H, Zhu B, Zhou Y, Wang J, Zhou X, Wang Y, Peppelenbosch MP, Pan Q, Ji X, Liu D. Prevalence of human papillomavirus infection in women in the Autonomous Region of Inner Mongolia: A population-based study of a Chinese ethnic minority. J Med Virol 2017; 90:148-156. [PMID: 28661048 DOI: 10.1002/jmv.24888] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2016] [Accepted: 06/08/2017] [Indexed: 11/06/2022]
Affiliation(s)
- Xiaohua Wang
- State Key Laboratory of Reproductive Regulation & Breeding of Grassland Livestock; Inner Mongolia University, Hohhot; Inner Mongolian Autonomous Region China
- Department of Genetics; Inner Mongolia Maternal and Child Care Hospital; Hohhot Inner Mongolian Autonomous Region China
| | - Yunpeng Ji
- Department of Genetics; Inner Mongolia Maternal and Child Care Hospital; Hohhot Inner Mongolian Autonomous Region China
- Erasmus MC Cancer Center; Erasmus University Medical Center; Rotterdam The Netherlands
| | - Juan Li
- Erasmus MC Cancer Center; Erasmus University Medical Center; Rotterdam The Netherlands
| | - Hong Dong
- Department of Genetics; Inner Mongolia Maternal and Child Care Hospital; Hohhot Inner Mongolian Autonomous Region China
| | - Bo Zhu
- Department of Genetics; Inner Mongolia Maternal and Child Care Hospital; Hohhot Inner Mongolian Autonomous Region China
| | - Yan Zhou
- Department of Genetics; Inner Mongolia Maternal and Child Care Hospital; Hohhot Inner Mongolian Autonomous Region China
| | - Jie Wang
- Department of Genetics; Inner Mongolia Maternal and Child Care Hospital; Hohhot Inner Mongolian Autonomous Region China
| | - Xueyuan Zhou
- Department of Genetics; Inner Mongolia Maternal and Child Care Hospital; Hohhot Inner Mongolian Autonomous Region China
| | - Yan Wang
- Department of Genetics; Inner Mongolia Maternal and Child Care Hospital; Hohhot Inner Mongolian Autonomous Region China
| | | | - Qiuwei Pan
- Erasmus MC Cancer Center; Erasmus University Medical Center; Rotterdam The Netherlands
| | - Xiaoping Ji
- Department of Genetics; Inner Mongolia Maternal and Child Care Hospital; Hohhot Inner Mongolian Autonomous Region China
| | - Dongjun Liu
- State Key Laboratory of Reproductive Regulation & Breeding of Grassland Livestock; Inner Mongolia University, Hohhot; Inner Mongolian Autonomous Region China
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16
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Cao D, Zhang S, Zhang Q, Wei X, Zhao M, Ma Q, Li Y, Wang L, Pei M, Yang T, Zhao J, Yang X. Prevalence of high-risk human papillomavirus infection among women in Shaanxi province of China: A hospital-based investigation. J Med Virol 2016; 89:1281-1286. [PMID: 27935120 DOI: 10.1002/jmv.24748] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Revised: 11/02/2016] [Accepted: 11/30/2016] [Indexed: 11/10/2022]
Abstract
This study aimed to investigate the characteristics of female high-risk human papillomavirus (HR-HPV) infection in Shaanxi province of China. A total of 14 111 women were enrolled for HPV genotyping test, and a cytology, and/or cervix biopsy were performed in partial women. Of these women, the HPV infection rate was 30.21%, and 26.73% were caused by HR-HPV. The most common HR-HPV genotypes were HPV-16, HPV-58, HPV-52, HPV-18, and HPV-31. The prevalence of HR-HPV among women older than 50 years was significantly higher than the other groups (P < 0.05). The main carcinogenic genotypes were HPV-16, HPV-18, HPV-58, HPV-52, and HPV-31. HPV-16 and HPV-18 combined caused 80.79% of cervical cancer cases. The infection with multiple HR-HPVs was not a risk factor for cervical lesions. In conclusion, HPV infection was common among women in Shaanxi province. Women older than 50 years were a high-risk group for HR-HPV infection and cervical cancer. HPV-16 and HPV-18 were the main carcinogenic genotypes in this region.
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Affiliation(s)
- Di Cao
- Department of Gynecology and Obstetrics, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Shaohua Zhang
- Department of Gynecology and Obstetrics, The Affiliated Hospital of Xi'an Medical College, Xi'an, Shaanxi, China
| | - Qian Zhang
- Department of Gynecology and Obstetrics, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Xing Wei
- Department of Gynecology and Obstetrics, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Minyi Zhao
- Department of Gynecology and Obstetrics, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Qian Ma
- Department of Gynecology, The Affiliated Yan An Hospital of Kunming Medical University, Kunming, Yunnan, China
| | - Yang Li
- Department of Gynecology and Obstetrics, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Li Wang
- Department of Gynecology and Obstetrics, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Meili Pei
- Department of Gynecology and Obstetrics, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Ting Yang
- Department of Gynecology and Obstetrics, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Juan Zhao
- Department of Gynecology and Obstetrics, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Xiaofeng Yang
- Department of Gynecology and Obstetrics, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
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