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Malagón T, Ribeiro AL, Montosa Nunes E, Gheit T, El-Zein M, Villa LL, Franco EL, Sichero L. Betapapillomavirus natural history and co-detection with alphapapillomavirus in cervical samples of adult women. J Med Virol 2023; 95:e29288. [PMID: 38054528 DOI: 10.1002/jmv.29288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 10/25/2023] [Accepted: 11/18/2023] [Indexed: 12/07/2023]
Abstract
Human papillomaviruses (HPV) of the genus Betapapillomavirus can infect both cutaneous and mucosal sites, but research on their natural history at mucosal sites remains scarce. We examined the risk factors and co-detection patterns of HPVs of the Betapapillomavirus and Alphapapillomavirus genera in cervical samples of the Ludwig-McGill cohort study. We assessed a subset of 505 women from the Ludwig-McGill cohort study from São Paulo, Brazil. Cervical samples over the first year of follow-up were tested for DNA of over 40 alphapapillomavirus types and 43 betapapillomavirus types using a type-specific multiplex genotyping polymerase chain reaction assay. We assessed the risk factors for prevalent and incident betapapillomavirus type detection, and whether types were detected more frequently together than expected assuming independence using permutation tests, logistic regression, and Cox regression. We observed significant within-genus clustering but not cross-genus clustering. Multiple betapapillomavirus types were co-detected in the same sample 2.24 (95% confidence interval [CI]: 1.65-3.29) times more frequently than expected. Conversely, co-detections of alphapapillomavirus and betapapillomavirus types in the same sample occurred only 0.64 (95% CI: 0.51-0.83) times as often as expected under independence. In prospective analyses, positivity to one HPV genus was associated with a nonsignificant lower incidence of detection of types in the other genus. Lifetime number of sex partners and new sex partner acquisition were associated with lower risks of prevalent and incident betapapillomavirus detection. Betapapillomaviruses are commonly found in the cervicovaginal tract. Results suggest potentially different mechanisms of transmission for betapapillomavirus genital infections other than vaginal sex.
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Affiliation(s)
- Talía Malagón
- Gerald Bronfman Department of Oncology, Division of Cancer Epidemiology, McGill University, Montréal, Canada
- St Mary's Research Centre, Montreal West Island Integrated University Health and Social Services Centre, Montréal, Canada
| | - Aline Lopes Ribeiro
- Center for Translational Research in Oncology, Instituto do Cancer do Estado de Sao Paulo ICESP: Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo FMUSP HC, São Paulo, Brazil
- Comprehensive Center for Precision Oncology, Universidade de Sao Paulo, São Paulo, Brazil
| | - Emily Montosa Nunes
- Center for Translational Research in Oncology, Instituto do Cancer do Estado de Sao Paulo ICESP: Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo FMUSP HC, São Paulo, Brazil
| | - Tarik Gheit
- Epigenomics and Mechanisms Branch, International Agency for Cancer Research (IARC), Lyon, France
| | - Mariam El-Zein
- Gerald Bronfman Department of Oncology, Division of Cancer Epidemiology, McGill University, Montréal, Canada
| | - Luisa L Villa
- Center for Translational Research in Oncology, Instituto do Cancer do Estado de Sao Paulo ICESP: Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo FMUSP HC, São Paulo, Brazil
- Comprehensive Center for Precision Oncology, Universidade de Sao Paulo, São Paulo, Brazil
- Department of Radiology and Oncology, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
| | - Eduardo L Franco
- Gerald Bronfman Department of Oncology, Division of Cancer Epidemiology, McGill University, Montréal, Canada
| | - Laura Sichero
- Center for Translational Research in Oncology, Instituto do Cancer do Estado de Sao Paulo ICESP: Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo FMUSP HC, São Paulo, Brazil
- Comprehensive Center for Precision Oncology, Universidade de Sao Paulo, São Paulo, Brazil
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Lototskaja E, Liblekas L, Piirsoo M, Laaneväli A, Ibragimov R, Piirsoo A. Phosphorylation of E2 Serine Residue 402 Is Required for the Transcription and Replication of the HPV5 Genome. J Virol 2023; 97:e0064323. [PMID: 37272841 PMCID: PMC10308906 DOI: 10.1128/jvi.00643-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 05/13/2023] [Indexed: 06/06/2023] Open
Abstract
Cutaneous human papillomavirus type 5 (HPV5) belongs to the supposedly oncogenic β-HPVs associated with specific types of skin and oral cavity cancers. Three viral proteins, namely, helicase E1 and transcription factors E2 and E8^E2, are master regulators of the viral life cycle. HPV5 E2 is a transcriptional activator that also participates in the E1-dependent replication and nuclear retention of the viral genome, whereas E8^E2 counterbalances the activity of E2 and inhibits HPV transcription and replication. In the present study, we demonstrate that the HPV5 E2 protein is extensively phosphorylated by cellular protein kinases, and serine residue 402 (S402) is the highest scoring phosphoacceptor site. This residue is located within a motif conserved among many β-HPVs and in the oncogenic HPV31 α-type. Using the nonphosphorylatable and phosphomimetic mutants, we demonstrate that phosphorylation of the E2 S402 residue is required for the transcription and replication of the HPV5 genome in U2OS cells and human primary keratinocytes. Mechanistically, the E2-S402-phopshodeficient protein is unable to trigger viral gene transcription and has an impaired ability to support E1-dependent replication, but the respective E8^E2-S213 mutant displays no phenotype. However, phosphorylation of the E2 S402 residue has no impact on the E2 stability, subcellular localization, self-assembly, DNA-binding capacity, and affinity to the E1 and BRD4 proteins. Further studies are needed to identify the protein kinase(s) responsible for this phosphorylation. IMPORTANCE Human papillomavirus type 5 (HPV5) may play a role in the development of specific types of cutaneous and head and neck cancers. The persistence of the HPV genome in host cells depends on the activity of its proteins, namely, a helicase E1 and transcription/replication factor E2. The latter also facilitates the attachment of episomal viral genomes to host cell chromosomes. In the present study, we show that the HPV5 E2 protein is extensively phosphorylated by host cell protein kinases, and we identify serine residue 402 as the highest scoring phosphoacceptor site of E2. We demonstrate that the replication of the HPV5 genome may be blocked by a single point mutation that prevents phosphorylation of this serine residue and switches off the transcriptional activity of the E2 protein. The present study contributes to a better understanding of β-HPV5 replication and its regulation by host cell protein kinases.
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Affiliation(s)
| | - Lisett Liblekas
- Institute of Technology, University of Tartu, Tartu, Estonia
| | - Marko Piirsoo
- Institute of Technology, University of Tartu, Tartu, Estonia
| | | | | | - Alla Piirsoo
- Institute of Technology, University of Tartu, Tartu, Estonia
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Karimi A, Mohebbi E, Mckay-Chopin S, Rashidian H, Hadji M, Peyghambari V, Marzban M, Naghibzadeh-Tahami A, Gholipour M, Kamangar F, Tommasino M, Gheit T, Zendehdel K. Human Papillomavirus and Risk of Head and Neck Squamous Cell Carcinoma in Iran. Microbiol Spectr 2022; 10:e0011722. [PMID: 35708339 PMCID: PMC9431561 DOI: 10.1128/spectrum.00117-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Accepted: 04/19/2022] [Indexed: 12/09/2022] Open
Abstract
Human papillomavirus (HPV) causes a subset of head and neck squamous cell carcinoma (HNSCC). Knowledge of determinants of α-, β-, and γ-HPVs types in the oral cavity is required for a better understanding of HNSCC development. Oral rinse samples of 498 HNSCC cases and 242 controls from the IROPICAN study-a large multicenter case-control study in Iran-were screened for 21 α-HPV, 46 β-HPVs, and 52 γ-HPVs using bead-based HPV genotyping assays. α-HPVs were detected only in 1.2% of the patients and 2.9% of the controls from which HPV16 was the most prevalent type among participants. β-HPVs were detected in 43.8% of the patients and 38.6% of the controls where the lip and oral cavity (45.5%) had the highest positivity. Values for γ-HPV prevalence in patients and controls were 26.1% and 24.7%, respectively. The highest percentage of γ-HPV positivity was found in the larynx (30.4%). Concerning the β genus, HPV23 and HPV38 were the most prevalent types among the patients and controls, respectively. For the γ genus, SD2 in cases and HPV134 in controls were the most prevalent types. Overall, detection of α-HPVs (aOR, 0.40; 95% CI = 0.1 to 1.2; P = 0.11), β-HPVs (aOR, 1.9; 95% CI = 0.9 to 1.6; P = 0.29), and γ-HPVs infections (aOR, 1.04; 95% CI = 0.7 to 1.5; P = 0.83) was not associated with the HNSCC development. Our data did not suggest an HPV-related etiology for HNSCC pathogenesis. Nonetheless, this study provides novel insights into the diversity of β-, and γ-HPVs in different HNSCC anatomical subsites. IMPORTANCE Infection with human papillomavirus (HPV) is responsible for a subset of neck squamous cell carcinoma (HNSCC), but knowledge of the prevalence of and risk factors for oral HPV infection, especially cutaneous types in Iran, remains unknown. In a large retrospective study, the authors used a sensitive assay for the detection of α-, β-, and γ-HPVs in oral rinse samples of HNSCC and matched controls. They find that the α-HPV contribution to HNSCC in Iran is lower than global prevalence. High-risk α-HPVs or cutaneous β- and γ-HPVs were not associated with the HNSCC development. Besides, this study provides novel insights into the diversity of β- and γ-HPVs in different HNSCC anatomical subsites.
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Affiliation(s)
- Abbas Karimi
- Department of Molecular Medicine, Faculty of Advanced Medical Sciences, Tabriz University of Medical Sciences, Tabriz, Iran
- Early Detection, Prevention and Infections Branch, International Agency for Research on Cancer (IARC), Lyon, France
| | - Elham Mohebbi
- Cancer Research Center, Cancer Institute, Tehran University of Medical Sciences, Tehran, Iran
- Pathology and Stem Cell Research Center, Kerman University of Medical Sciences, Kerman, Iran
| | - Sandrine Mckay-Chopin
- Early Detection, Prevention and Infections Branch, International Agency for Research on Cancer (IARC), Lyon, France
| | - Hamideh Rashidian
- Cancer Research Center, Cancer Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Hadji
- Cancer Research Center, Cancer Institute, Tehran University of Medical Sciences, Tehran, Iran
- Health Sciences Unit, Faculty of Social Sciences, Tampere University, Tampere, Finland
| | - Vahideh Peyghambari
- Cancer Research Center, Cancer Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Marzban
- Department of Public Health, School of Public Health, Bushehr University of Medical Science, Bushehr, Iran
- Clinical Research Development Center, The Persian Gulf Martyrs, Bushehr University of Medical Science, Bushehr, Iran
| | - Ahmad Naghibzadeh-Tahami
- Social Determinants of Health Research Center, Institute for Future Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
- Department of Biostatistics and Epidemiology, Kerman University of Medical Sciences, Kerman, Iran
| | - Mahin Gholipour
- Metabolic Disorders Research Center, Golestan University of Medical Sciences, Gorgan, Iran
| | - Farin Kamangar
- Department of Biology, School of Computer, Mathematical, and Natural Sciences, Morgan State University, Baltimore, Maryland, USA
| | - Massimo Tommasino
- Early Detection, Prevention and Infections Branch, International Agency for Research on Cancer (IARC), Lyon, France
| | - Tarik Gheit
- Early Detection, Prevention and Infections Branch, International Agency for Research on Cancer (IARC), Lyon, France
| | - Kazem Zendehdel
- Cancer Research Center, Cancer Institute, Tehran University of Medical Sciences, Tehran, Iran
- Cancer Biology Research Center, Cancer Institute, Tehran University of Medical Sciences, Tehran, Iran
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Human Papillomaviruses-Associated Cancers: An Update of Current Knowledge. Viruses 2021; 13:v13112234. [PMID: 34835040 PMCID: PMC8623401 DOI: 10.3390/v13112234] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 10/26/2021] [Accepted: 10/29/2021] [Indexed: 12/21/2022] Open
Abstract
Human papillomaviruses (HPVs), which are small, double-stranded, circular DNA viruses infecting human epithelial cells, are associated with various benign and malignant lesions of mucosa and skin. Intensive research on the oncogenic potential of HPVs started in the 1970s and spread across Europe, including Croatia, and worldwide. Nowadays, the causative role of a subset of oncogenic or high-risk (HR) HPV types, led by HPV-16 and HPV-18, of different anogenital and head and neck cancers is well accepted. Two major viral oncoproteins, E6 and E7, are directly involved in the development of HPV-related malignancies by targeting synergistically various cellular pathways involved in the regulation of cell cycle control, apoptosis, and cell polarity control networks as well as host immune response. This review is aimed at describing the key elements in HPV-related carcinogenesis and the advances in cancer prevention with reference to past and on-going research in Croatia.
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Brennan S, Baird AM, O’Regan E, Sheils O. The Role of Human Papilloma Virus in Dictating Outcomes in Head and Neck Squamous Cell Carcinoma. Front Mol Biosci 2021; 8:677900. [PMID: 34250016 PMCID: PMC8262095 DOI: 10.3389/fmolb.2021.677900] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 05/10/2021] [Indexed: 12/29/2022] Open
Abstract
The Human Papilloma Virus (HPV) is an oncogenic virus which is associated with the development of head and neck squamous cell carcinoma (HNSCC), predominantly within the oropharynx. Approximately 25% of oropharyngeal squamous cell carcinoma (OPSCC) cases worldwide are attributable to HPV infection, with an estimated 65% in the United States. Transmission is via exposure during sexual contact, with distinctive anatomical features of the tonsils providing this organ with a predilection for infection by HPV. No premalignant lesion is identifiable on clinical examination, thus no comparative histological features to denote the stages of carcinogenesis for HPV driven HNSCC are identifiable. This is in contrast to HPV-driven cervical carcinoma, making screening a challenge for the head and neck region. However, HPV proffers a favorable prognosis in the head and neck region, with better overall survival rates in contrast to its HPV negative counterparts. This has resulted in extensive research into de-intensifying therapies aiming to minimize the morbidity induced by standard concurrent chemo-radiotherapy without compromising efficacy. Despite the favorable prognosis, cases of recurrence and/or metastasis of HPV positive HNSCC do occur, and are linked with poor outcomes. HPV 16 is the most frequent genotype identified in HNSCC, yet there is limited research to date studying the impact of other HPV genotype with respect to overall survival. A similar situation pertains to genetic aberrations associated in those with HPV positive HNSCC who recur, with only four published studies to date. Somatic mutations in TSC2, BRIP1, NBN, TACC3, NFE2l2, STK11, HRAS, PIK3R1, TP63, and FAT1 have been identified in recurrent HPV positive OPSCC. Finding alternative therapeutic strategies for this young cohort may depend on upfront identification of HPV genotypes and mutations which are linked with worse outcomes, thus ensuring appropriate stratification of treatment regimens.
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Affiliation(s)
- Shane Brennan
- School of Medicine, Faculty of Health Sciences, Trinity College, Dublin, Ireland
| | - Anne-Marie Baird
- School of Medicine, Faculty of Health Sciences, Trinity College, Dublin, Ireland
| | - Esther O’Regan
- Department of Histopathology, St. James’s Hospital, Dublin, Ireland
| | - Orla Sheils
- School of Medicine, Faculty of Health Sciences, Trinity College, Dublin, Ireland
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HPV Infection in Middle Ear Squamous Cell Carcinoma: Prevalence, Genotyping and Prognostic Impact. J Clin Med 2021; 10:jcm10040738. [PMID: 33673300 PMCID: PMC7918549 DOI: 10.3390/jcm10040738] [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: 12/04/2020] [Revised: 02/07/2021] [Accepted: 02/10/2021] [Indexed: 11/17/2022] Open
Abstract
Middle ear squamous cell carcinoma (MESCC) is rare. Human Papilloma Virus (HPV) infection has been found in a significant number of cases of MESCC. Despite the emerging role of HPV in oncogenesis, its role in the pathogenesis and prognosis of MESCC is not known. This study aims to identify the prognostic impact of alpha and beta HPV in MESCC and its correlation with p16 protein. We retrospectively investigated 33 patients with MESCC surgically treated between 2004 and 2016. HPV DNA was ascertained by polymerase chain reaction (PCR) and P16INK4a detection was performed. Disease-specific survival (DSS) and cumulative incidence of recurrence were calculated in relation to HPV presence and genotype. p16 sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) in predicting HPV infection were calculated. HPV was detected in 66.7% of patients (36.4% alpha HPV, 63.6% beta HPV). Five-year DSS was 55.0% and was not statistically related to HPV presence (p = 0.55) or genotype (p = 0.87). Five-year cumulative incidence of recurrence was 46 %, and was not statistically related to HPV presence (p = 0.22) or genotype (p = 0.44). p16 sensitivity, specificity, PPV, and NPV in predicting HPV infection were 27.3%, 36.4%, 46.2%, and 20.0%, respectively. In our experience, beta HPV was more frequent than alpha HPV in MESCC. Neither HPV presence nor HPV genotypes relate to DSS or cumulative incidence of recurrence. p16 expression was not predictive for HPV infection in MESCC. The role of HPV infection in oncogenesis, maintenance, and prognosis of MESCC seems to be different from that in oropharynx and skin cancer.
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Flores-Miramontes MG, Olszewski D, Artaza-Irigaray C, Willemsen A, Bravo IG, Vallejo-Ruiz V, Leal-Herrera YA, Piña-Sánchez P, Molina-Pineda A, Cantón-Romero JC, Martínez-Silva MG, Jave-Suárez LF, Aguilar-Lemarroy A. Detection of Alpha, Beta, Gamma, and Unclassified Human Papillomaviruses in Cervical Cancer Samples From Mexican Women. Front Cell Infect Microbiol 2020; 10:234. [PMID: 32582561 PMCID: PMC7296070 DOI: 10.3389/fcimb.2020.00234] [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] [Received: 01/23/2020] [Accepted: 04/23/2020] [Indexed: 11/13/2022] Open
Abstract
Background: Cervical cancer (CC) is associated to high-risk human papillomavirus (HPV) infections, for this reason it is crucial to have sensitive and accurate HPV diagnostic tests. To date, most research is focused on HPVs within the Alphapapillomavirus (α-PVs) genus and little attention has been paid to cervical infections with other HPV genotypes, like those of the Betapapillomavirus (β-PVs) and Gammapapillomavirus (γ-PVs) genera. The aim of this study was to determine the HPV genotypes from different genera in women with CC using Next-Generation Sequencing (NGS). Methods: The study comprised 48 HPV positive CC samples evaluated with the Linear Array HPV Genotyping test and individually sequenced by 454 NGS using PGMY09/11 and FAP primers. To determine the HPV genotypes present in each sample, the obtained sequences were compared with all HPV L1 gene reference sequences from the Papillomavirus Episteme database (PaVE). Moreover, 50 HPV positive low-grade cervical lesion samples individually genotyped with NGS were also included to determine the genotypes present preferentially in CC patients. Results: Among the 48 CC samples, 68.75% consisted of multiple HPV infections, 51 different genotypes were detected, of which 7 are still unclassified, 28 belong to α-PVs (6, 11, 16, 18, 26, 30, 33, 35, 39, 42, 43, 44, 45, 51, 52, 53, 54, 59, 62, 66, 68, 69, 70, 71, 74, 81, 102, 114), 10 to β-PVs (5, 12, 21, 37, 38b, 47, 80, 107, 118, 122), and 6 to γ-PVs (101, 103, 123, 135, 147, 214). Among them, HPV16 was the most prevalent genotype (54.2%), followed by HPV18 (16.7%), HPV38b (14.6%), and HPVs 52/62/80 (8.3%). Some genotypes were exclusively found in CC when compared with Cervical Intraepithelial Neoplasia grade 1 (CIN1) samples, such as HPVs 5, 18, 38b, 107, 122, FA39, FA116, mSK_120, and mSK_136. Conclusions: This work demonstrates the great diversity of HPV genotypes detected by combining PGMY and FAP primers with NGS in cervical swabs. The relatively high attribution of β- and γ- PVs in CC samples suggest their possible role as carcinogenic cofactors, but deeper studies need to be performed to determine if they have transforming properties and the significance of HPV-coinfections.
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Affiliation(s)
| | - Dominik Olszewski
- Department of Molecular Life Sciences, University of Zurich, Zurich, Switzerland
| | - Cristina Artaza-Irigaray
- Centro de Investigación Biomédica de Occidente (CIBO)-Instituto Mexicano del Seguro Social (IMSS), Guadalajara, Mexico
| | - Anouk Willemsen
- Centre National de la Recherche Scientifique (CNRS), Laboratory MIVEGEC (UMR CNRS IRD Uni Montpellier), Montpellier, France
| | - Ignacio G Bravo
- Centre National de la Recherche Scientifique (CNRS), Laboratory MIVEGEC (UMR CNRS IRD Uni Montpellier), Montpellier, France
| | - Verónica Vallejo-Ruiz
- Centro de Investigación Biomédica de Oriente, Instituto Mexicano del Seguro Social (IMSS), Metepec, Mexico
| | - Yelda Aurora Leal-Herrera
- Centro Institucional de Capacitación y Registro de Cáncer (CICyRC), Unidad Médica de Alta Especialidad (UMAE), Instituto Mexicano del Seguro Social (IMSS), Mérida, Mexico
| | - Patricia Piña-Sánchez
- Laboratorio de Oncología Molecular, Unidad de Investigación Médica en Enfermedades Oncológicas (UIMEO), Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | - Andrea Molina-Pineda
- Centro de Investigación Biomédica de Occidente (CIBO)-Instituto Mexicano del Seguro Social (IMSS), Guadalajara, Mexico.,Programa de Doctorado en Ciencias Biomédicas, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Mexico
| | - Juan Carlos Cantón-Romero
- Unidad Médica de Alta Especialidad (UMAE), Hospital de Ginecología y Obstetricia, Centro Médico Nacional de Occidente, Instituto Mexicano del Seguro Social (IMSS), Guadalajara, Mexico
| | - María Guadalupe Martínez-Silva
- Departamento de Anatomía Patológica, Centro Médico Nacional de Occidente, Instituto Mexicano del Seguro Social (IMSS), Guadalajara, Mexico
| | - Luis Felipe Jave-Suárez
- Centro de Investigación Biomédica de Occidente (CIBO)-Instituto Mexicano del Seguro Social (IMSS), Guadalajara, Mexico
| | - Adriana Aguilar-Lemarroy
- Centro de Investigación Biomédica de Occidente (CIBO)-Instituto Mexicano del Seguro Social (IMSS), Guadalajara, Mexico
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Winer RL, Gheit T, Feng Q, Stern JE, Lin J, Cherne S, Tommasino M. Prevalence and Correlates of β- and γ-Human Papillomavirus Detection in Oral Samples From Mid-Adult Women. J Infect Dis 2020; 219:1067-1075. [PMID: 30395247 DOI: 10.1093/infdis/jiy632] [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: 07/21/2018] [Accepted: 10/29/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Little is known about the epidemiology of β and γ human papillomaviruses (HPVs) in oral cavities of healthy women. METHODS We performed multiplex polymerase chain reaction analysis for detection of 46 β-HPVs and 51 γ-HPVs in stored oral rinse samples from healthy mid-adult women (age, 30-50 years). A total of 407 women were tested for β-HPVs, and 310 were tested for γ-HPVs. We used log-binomial regression to identify determinants of β-HPV and γ-HPV in separate models. Using paired fingernail data from a subset of 184 women, we also evaluated whether fingernail β-HPV detection was associated with concurrent detection of the same type in the oral cavity. RESULTS Oral HPV prevalence was 20.6% for β-HPV and 10.7% for γ-HPV. In multivariate analysis, oral β-HPV detection was associated with increasing age (adjusted prevalence ratio [aPR] per 5-year difference, 1.37; 95% confidence interval [CI], 1.01-1.86) and a greater lifetime number of oral sex partners (aPR for reporting ≥6 vs 0-5 partners, 2.06; 95% CI, 1.01-4.20). In a separate model, concurrent detection of the same β-HPV type in fingernails was strongly associated with oral β-HPV detection (aPR, 31.44; 95% CI, 19.81-49.49). No significant determinants of γ-HPV detection were identified. CONCLUSIONS Our results suggest a sexual transmission route for β-HPVs and support the hypothesis that fingers may serve as a source of transmission or autoinoculation of β-HPVs to the oral cavity.
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Affiliation(s)
| | - Tarik Gheit
- Department of Pathology, University of Washington
| | - Qinghua Feng
- Department of Global Health, University of Washington
| | - Joshua E Stern
- Infections and Cancer Biology Group, International Agency for Research on Cancer, World Health Organization, Lyon, France
| | - John Lin
- Department of Epidemiology, University of Washington
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Di Bonito P, Galati L, Focà A, Brambilla M, Bisaglia C, Bonanno Ferraro G, Mancini P, Iaconelli M, Veneri C, La Rosa G. Evidence for swine and human papillomavirus in pig slurry in Italy. J Appl Microbiol 2019; 127:1246-1254. [PMID: 31251456 PMCID: PMC7166630 DOI: 10.1111/jam.14363] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 06/15/2019] [Accepted: 06/20/2019] [Indexed: 01/10/2023]
Abstract
AIMS The diversity and the geographical distribution of swine papillomaviruses (PVs) are virtually unknown. The occurrence and the diversity of swine PV were therefore investigated in pig slurry collected in Italy, to contribute towards filling this gap in knowledge. METHODS AND RESULTS Twenty-two slurry samples underwent analysis by nested PCR and DNA sequencing using published and newly designed specific primer pairs for Sus scrofa papillomavirus (SsPV) type 1 and 2 (SsPV1 and 2), along with degenerate PV-specific primers targeting the major coat protein L1 and the helicase protein E1. Overall, three samples (13·6%) were positive for SsPV1 by specific primers, and nucleotide (nt) sequences showed 99-100% nt identity with SsPV1 variant a (EF395818), while SsPV2 was not found in any sample. Using generic primers, eight samples (36·4%) were tested positive for human papillomavirus (HPV), and were characterized as follows: β1-HPV8, β1-HPV14, β1-HPV206, β2-HPV113, β2-HPV120 and γ1-HPV173. Moreover, one unclassified γ-type was detected. CONCLUSIONS Both swine and human PVs were detected in pig slurry in this study. The unexpected presence of HPV in pig waste could be explained as the result of an improper use of the sewage collection pits and/or with improper procedures of the operators. SIGNIFICANCE AND IMPACT OF THE STUDY This study reports the first detection of SsPV1 in Italy, along with the first detection of HPVs in pig slurry samples in Italy, and expands our knowledge about PV diversity and geographic distribution.
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Affiliation(s)
- P Di Bonito
- Viral Hepatitis, Oncoviruses and Retroviruses (EVOR) Unit, Department of Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - L Galati
- Viral Hepatitis, Oncoviruses and Retroviruses (EVOR) Unit, Department of Infectious Diseases, Istituto Superiore di Sanità, Rome, Italy
| | - A Focà
- School of medicine, "Magna Graecia" University, Catanzaro, Italy
| | - M Brambilla
- Consiglio per la ricerca in agricoltura e l'analisi dell'economia agraria (CREA), Research Centre for Engineering and Agri Food Processing, Treviglio, BG, Italy
| | - C Bisaglia
- Consiglio per la ricerca in agricoltura e l'analisi dell'economia agraria (CREA), Research Centre for Engineering and Agri Food Processing, Treviglio, BG, Italy
| | - G Bonanno Ferraro
- Department of Environment and Health, Istituto Superiore di Sanità, Rome, Italy
| | - P Mancini
- Department of Environment and Health, Istituto Superiore di Sanità, Rome, Italy
| | - M Iaconelli
- Department of Environment and Health, Istituto Superiore di Sanità, Rome, Italy
| | - C Veneri
- Department of Environment and Health, Istituto Superiore di Sanità, Rome, Italy
| | - G La Rosa
- Department of Environment and Health, Istituto Superiore di Sanità, Rome, Italy
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10
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Gheit T. Mucosal and Cutaneous Human Papillomavirus Infections and Cancer Biology. Front Oncol 2019; 9:355. [PMID: 31134154 PMCID: PMC6517478 DOI: 10.3389/fonc.2019.00355] [Citation(s) in RCA: 159] [Impact Index Per Article: 31.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 04/17/2019] [Indexed: 12/13/2022] Open
Abstract
Papillomaviridae is a family of small non-enveloped icosahedral viruses with double-stranded circular DNA. More than 200 different human papillomaviruses (HPVs) have been listed so far. Based on epidemiological data, a subgroup of alphapapillomaviruses (alpha HPVs) was referred to as high-risk (HR) HPV types. HR HPVs are the etiological agents of anogenital cancer and a subset of head and neck cancers. The cutaneous HPV types, mainly from beta and gamma genera, are widely present on the surface of the skin in the general population. However, there is growing evidence of an etiological role of betapapillomaviruses (beta HPVs) in non-melanoma skin cancer (NMSC), together with ultraviolet (UV) radiation. Studies performed on mucosal HR HPV types, such as 16 and 18, showed that both oncoproteins E6 and E7 play a key role in cervical cancer by altering pathways involved in the host immune response to establish a persistent infection and by promoting cellular transformation. Continuous expression of E6 and E7 of mucosal HR HPV types is essential to initiate and to maintain the cellular transformation process, whereas expression of E6 and E7 of cutaneous HPV types is not required for the maintenance of the skin cancer phenotype. Beta HPV types appear to play a role in the initiation of skin carcinogenesis, by exacerbating the accumulation of UV radiation-induced DNA breaks and somatic mutations (the hit-and-run mechanism), and they would therefore act as facilitators rather than direct actors in NMSC. In this review, the natural history of HPV infection and the transforming properties of various HPV genera will be described, with a particular focus on describing the state of knowledge about the role of cutaneous HPV types in NMSC.
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Affiliation(s)
- Tarik Gheit
- Infections and Cancer Biology Group, International Agency for Research on Cancer (IARC), Lyon, France
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11
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Sias C, Salichos L, Lapa D, Del Nonno F, Baiocchini A, Capobianchi MR, Garbuglia AR. Alpha, Beta, gamma human PapillomaViruses (HPV) detection with a different sets of primers in oropharyngeal swabs, anal and cervical samples. Virol J 2019; 16:27. [PMID: 30832688 PMCID: PMC6398256 DOI: 10.1186/s12985-019-1132-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Accepted: 02/15/2019] [Indexed: 02/05/2023] Open
Abstract
Background Recent studies have shown a 13-fold increase of oropharyngeal cancer in the presence of HPV, while α-HPV detection seems to be rare in oral cavity in comparison to anal or cervical district, many novel β and γ types have been isolated in this anatomical site suggesting a wide tropism range. Currently, there are no guidelines recommending HPV oral cavity screening as a mandatory test, and it remains unknown which HPV types should be included in HPV screening programs. Our goal was to assess HPV prevalence in oropharyngeal, anal, and cervical swabs using different sets of primers,which are able to amplify α, β, γ HPV types. Methods We analysed the presence of HPV DNA in oropharyngeal (n = 124), anal (n = 186), cervical specimens (n = 43) from HIV positive and negative patients using FAP59/64 and MY09/11 primers. All untyped strains were genetically characterized through PCR amplification and direct sequencing of partial L1 region, and the resulting sequences were classified through phylogenetic analysis. Results HPV prevalence was 20.9% in 124 oropharyngeal swab samples, including infections with multiple HPV types (5.6%). HPV prevalence in this anatomical site was significantly associated with serostatus: 63.3%in HIV positive and 36.3% in HIV negative patients (p < 0.05). Unclassified types were detected in 6 specimens. In our analysis, we did not observe any difference in HPV (α, β, γ) prevalence between men and women. Overall, β species were the most frequently detected 69.7%. When using anal swabs, for HIV positive patients, β genus prevalence was 1% and γ genus was 3.7% including 6 unclassified types. In cervical samples from 43 HIV positive women (18 HPV negative and 25 positive by MY09/11 PCR), only one sample was positivite for β1 species (2.4%) using FAP primers. Six of the untyped strains clustered with sequences from species 7, 9, 10, 8,12 of γ genus. Four sequences remained unclassified. Finally, β and γ HPV prevalence was significantly lower than their respective HPV prevalence as identified by the Luminex system in all anatomical sites that were analyzed in previous studies. Conclusion This study provides new information about viral isolates present in oropharyngeal site and it will contribute to improve the monitoring of HPV infection. Electronic supplementary material The online version of this article (10.1186/s12985-019-1132-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Catia Sias
- Laboratory of Virology, "Lazzaro Spallanzani" National Institute for Infectious Diseases, IRCCS, Via Portuense, 292, 00149, Rome, Italy
| | - Leonidas Salichos
- Program in Computational Biology and Bioinformatics, Yale University, New Haven, CT, 06520, USA
| | - Daniele Lapa
- Laboratory of Virology, "Lazzaro Spallanzani" National Institute for Infectious Diseases, IRCCS, Via Portuense, 292, 00149, Rome, Italy
| | - Franca Del Nonno
- Laboratory of Pathology, "Lazzaro Spallanzani" National Institute for Infectious Diseases, IRCCS, Rome, Italy
| | - Andrea Baiocchini
- Laboratory of Pathology, "Lazzaro Spallanzani" National Institute for Infectious Diseases, IRCCS, Rome, Italy
| | - Maria Rosaria Capobianchi
- Laboratory of Virology, "Lazzaro Spallanzani" National Institute for Infectious Diseases, IRCCS, Via Portuense, 292, 00149, Rome, Italy
| | - Anna Rosa Garbuglia
- Laboratory of Virology, "Lazzaro Spallanzani" National Institute for Infectious Diseases, IRCCS, Via Portuense, 292, 00149, Rome, Italy.
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12
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Kerge S, Vuorinen J, Hurme S, Soukka T, Gheit T, Tommasino M, Syrjänen S, Rautava J. Benign proliferative epithelial lesions of oral mucosa are infrequently associated with α-, β-, or γ human papillomaviruses. Laryngoscope Investig Otolaryngol 2019; 4:43-48. [PMID: 30828618 PMCID: PMC6383307 DOI: 10.1002/lio2.222] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Revised: 09/20/2018] [Accepted: 10/03/2018] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Oral papillomas and verruca vulgaris have been associated with human papillomavirus (HPV) infection. However, approximately half of these have remained HPV-negative when tested for mucosal HPV genotypes. In this study, we evaluated presence of α-, β-, and γ-HPVs in benign papillary and verrucous lesions. METHODS Eighty-three clinical lesions with suspected HPV etiology were analyzed for HPV types of genus α (n = 24), β (n = 46), and γ (n = 52). Immunohistochemistry was used for p16 as a possible surrogate marker of high-risk HPV, accompanied by Ki-67 proliferation marker. RESULTS Altogether, α-HPVs were detected in 6.4%, β-HPVs in 2.4%, and γ-HPV in 4.8%. The following genotypes were identified: HPV6, 8, 11, 16, 22, 161, and 170. Neither Ki-67 nor p16 positivity alone were associated with HPV but combined staining showed significant inverse association (P = .042). CONCLUSION HPV infection is found only in a minority of benign verrucous and papillary oral lesions, with the predominance of α-HPVs. LEVEL OF EVIDENCE 4.
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Affiliation(s)
- Sirli Kerge
- Department of Oral DiseasesTurku University HospitalTurkuFinland
| | - Jessi Vuorinen
- Department of Oral PathologyUniversity of TurkuTurkuFinland
| | - Saija Hurme
- Department of BiostatisticsUniversity of TurkuTurkuFinland
| | - Tero Soukka
- Department of Oral DiseasesTurku University HospitalTurkuFinland
| | - Tarik Gheit
- Infections and Cancer Biology GroupInternational Agency for Research on CancerLyonFrance
| | - Massimo Tommasino
- Infections and Cancer Biology GroupInternational Agency for Research on CancerLyonFrance
| | - Stina Syrjänen
- Department of PathologyTurku University HospitalTurkuFinland
- Department of Oral PathologyUniversity of TurkuTurkuFinland
| | - Jaana Rautava
- Department of PathologyTurku University HospitalTurkuFinland
- Department of Oral PathologyUniversity of TurkuTurkuFinland
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13
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Winer RL, Gheit T, Cherne S, Lin J, Stern JE, Poljak M, Feng Q, Tommasino M. Prevalence and correlates of beta human papillomavirus detection in fingernail samples from mid-adult women. PAPILLOMAVIRUS RESEARCH 2018; 5:1-5. [PMID: 29807613 PMCID: PMC5886955 DOI: 10.1016/j.pvr.2017.11.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 09/20/2017] [Accepted: 11/07/2017] [Indexed: 01/05/2023]
Abstract
Cutaneous human papillomaviruses (HPVs) have not been evaluated in fingernails from healthy individuals. To determine prevalence and correlates of β-HPVs in fingernails from healthy mid-adult women, we tested archived samples collected from 2011 to 2012 using a multiplex PCR combined with Luminex technology for 46 β-HPV genotypes. One hundred thirteen (61.1%) of 185 fingernail samples were positive for β-HPV, and the median number of types detected in positive samples was 2 (interquartile range: 1–4). The most common genotypes detected were HPV-23 (β−2) (13.5%), HPV-38 (β−2) (13.0%), HPV-5 (β−1) (9.2%), HPV-107 (β−2) (8.7%), and HPV-120 (β−2) (8.7%). In multivariate analysis, β-HPV detection was associated with age (prevalence ratio [PR] for women 40–51 years versus 30–39 years = 1.30, 95% CI: 1.05–1.62) and race (PR for non-white versus white race = 0.65, 95% CI: 0.45–0.94). The prevalence of β-HPV in fingernail samples from healthy mid-adult women was similar to the prevalence of β-HPV reported at other cutaneous sites in prior studies. We did not identify any significant health or sexual behavior predictors of β-HPV detection in fingernails. Our results support the hypothesis that fingers may serve as a source of transmission or autoinoculation of cutaneous HPVs to other anatomic sites.
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Affiliation(s)
- Rachel L Winer
- Department of Epidemiology, University of Washington, Seattle, WA, USA.
| | - Tarik Gheit
- Infections and Cancer Biology Group, International Agency for Research on Cancer-World Health Organization, Lyon, France.
| | - Stephen Cherne
- Department of Pathology, University of Washington, Seattle, WA, USA.
| | - John Lin
- Department of Pathology, University of Washington, Seattle, WA, USA.
| | - Joshua E Stern
- Department of Global Health, University of Washington, Seattle, WA, USA.
| | - Mario Poljak
- Institute of Microbiology and Immunology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia.
| | | | - Massimo Tommasino
- Infections and Cancer Biology Group, International Agency for Research on Cancer-World Health Organization, Lyon, France.
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14
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Chen AA, Gheit T, Stellin M, Lupato V, Spinato G, Fuson R, Menegaldo A, Mckay-Chopin S, Dal Cin E, Tirelli G, Da Mosto MC, Tommasino M, Boscolo-Rizzo P. Oncogenic DNA viruses found in salivary gland tumors. Oral Oncol 2017; 75:106-110. [PMID: 29224806 DOI: 10.1016/j.oraloncology.2017.11.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 10/02/2017] [Accepted: 11/04/2017] [Indexed: 02/01/2023]
Abstract
BACKGROUND Previous investigations studying the association of DNA viruses with salivary gland tumors (SGTs) have led to conflicting results. The aim of this study was to determine the prevalence of different DNA viruses by using a highly sensitive assay in a multi-center series of over 100 fresh frozen salivary gland samples. METHODS DNA was isolated from 84 SGTs (80 parotid tumors and 4 submandibular gland tumors) and 28 normal salivary tissue samples from 85 patients in Northeast Italy. Using a highly sensitive type-specific multiplex genotyping assay, we analyzed the samples for the presence of DNA from 62 different viruses including 47 papillomaviruses, 10 polyomaviruses, and 5 herpesviruses. RESULTS We observed a high prevalence of beta human papillomavirus DNA in malignant tumors. In contrast, polyomavirus DNA was present in benign, malignant, and non-tumor control samples. Most striking was the significant distribution of herpesvirus DNA in the SGT samples, in particular the high prevalence of Epstein-Barr type 1 and type 2 DNA in Warthin's tumor samples. CONCLUSION Our data provides evidence for the presence of DNA viruses in SGTs. Mechanistic studies are needed to further attribute tumor formation to these viruses.
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Affiliation(s)
- Alyce A Chen
- Section of Infections, International Agency for Research on Cancer, Lyon, France
| | - Tarik Gheit
- Section of Infections, International Agency for Research on Cancer, Lyon, France
| | - Marco Stellin
- Department of Neurosciences, ENT Clinic and Regional Center for Head and Neck Cancer, University of Padova, Treviso, Italy
| | - Valentina Lupato
- Unit of Otolaryngology, Azienda Ospedaliera "S. Maria degli Angeli", Pordenone, Italy
| | | | - Roberto Fuson
- ENT Department, Ospedale dell'Angelo, Venezia-Mestre, Italy
| | - Anna Menegaldo
- Department of Neurosciences, ENT Clinic and Regional Center for Head and Neck Cancer, University of Padova, Treviso, Italy
| | | | - Elisa Dal Cin
- Head and Neck Department, ENT Clinic, Azienda Sanitaria Universitaria Integrata di Trieste, Trieste, Italy
| | - Giancarlo Tirelli
- Head and Neck Department, ENT Clinic, Azienda Sanitaria Universitaria Integrata di Trieste, Trieste, Italy
| | - Maria Cristina Da Mosto
- Department of Neurosciences, ENT Clinic and Regional Center for Head and Neck Cancer, University of Padova, Treviso, Italy
| | - Massimo Tommasino
- Section of Infections, International Agency for Research on Cancer, Lyon, France
| | - Paolo Boscolo-Rizzo
- Department of Neurosciences, ENT Clinic and Regional Center for Head and Neck Cancer, University of Padova, Treviso, Italy.
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15
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Di Bonito P, Iaconelli M, Gheit T, Tommasino M, Della Libera S, Bonadonna L, La Rosa G. Detection of oncogenic viruses in water environments by a Luminex-based multiplex platform for high throughput screening of infectious agents. WATER RESEARCH 2017; 123:549-555. [PMID: 28704770 DOI: 10.1016/j.watres.2017.06.088] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 06/22/2017] [Accepted: 06/23/2017] [Indexed: 05/27/2023]
Abstract
Recent studies documented the detection of viruses strongly associated with human cancer in urban sewages and other water environments worldwide. The aim of this study was to estimate the occurrence of human oncogenic viruses in environmental samples (sewage, river, marine, and pool/spa water) using highly sensitive and specific multiplex bead-based assays (Luminex technology). A total of 33 samples were analysed for 140 oncogenic viral agents, including mucosal and cutaneous human papillomaviruses (HPVs), human polyomaviruses (HPyV), human herpesviruses (HHV) and mouse mammary tumour virus (MMTV). Eighty-eight percent of the samples tested positive for at least one viral pathogen and the simultaneous presence of more than one virus was frequent (mean number of positivities/sample = 3.03). A total of 30 different Alpha, Beta and Gamma HPVs were detected, including mucosal and cutaneous types. The high-risk type HPV16 was the most frequently detected virus, identified in 73% of the samples. Of the 12 HPyVs tested, only two (BKPyV and MCPyV) were detected. At least one of these two was present in 48% of the samples. MMTV was detected in 21% of the samples, while herpesviruses - HHV-6 and HHV-1 - were detected in two samples (6%). The present study is the first to provide a comprehensive picture of the occurrence of oncogenic viruses belonging to different families and species in diverse water environments, and the first to successfully use, in environmental samples, a Luminex-based multiplex platform for high throughput screening of infectious agents. Our findings, showing that oncogenic viruses are ubiquitous in water environments, pave the way for future studies on the fate of these pathogens in water environments as well as on their potential for transmission via the waterborne route.
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Affiliation(s)
- P Di Bonito
- Department of Infectious Diseases, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161 Rome, Italy
| | - M Iaconelli
- Department of Environment and Health, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161 Rome, Italy
| | - T Gheit
- International Agency for Research on Cancer, 69372 Lyon Cedex 08, France
| | - M Tommasino
- International Agency for Research on Cancer, 69372 Lyon Cedex 08, France
| | - S Della Libera
- Department of Environment and Health, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161 Rome, Italy
| | - L Bonadonna
- Department of Environment and Health, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161 Rome, Italy
| | - G La Rosa
- Department of Environment and Health, Istituto Superiore di Sanità, Viale Regina Elena 299, 00161 Rome, Italy.
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