HPV and cervical cancer: screening or vaccination?

HPV16 mutant E6/E7 construct is protective in mouse model

BACKGROUND

Human papillomavirus type 16 (HPV-16) infection is strongly associated with considerable parts of cervical, neck, and head cancers. Performed investigations have had moderate clinical success, so research to reach an efficient vaccine has been of great interest. In the present study, the immunization potential of a newly designed HPV-16 construct was evaluated in a mouse model.

RESULTS

Initially, a construct containing HPV-16 mutant (m) E6/E7 fusion gene was designed and antigen produced in two platforms (i.e., DNA vaccine and recombinant protein). Subsequently, the immunogenicity of these platforms was investigated in five mice) C57BL/6 (groups based on several administration strategies. Three mice groups were immunized recombinant protein, DNA vaccine, and a combination of them, and two other groups were negative controls. The peripheral blood mononuclear cells (PBMCs) proliferation, Interleukin-5 (IL-5) and interferon-γ (IFN-γ) cytokines, IgG1 and IgG2a antibody levels were measured. After two weeks, TC-1 tumor cells were injected into all mice groups, and subsequently further analysis of tumor growth and metastasis and mice survival were performed according to the schedule. Overall, the results obtained from in vitro immunology and tumor cells challenging assays indicated the potential of the mE6/E7 construct as an HPV16 therapeutic vaccine candidate. The results demonstrated a significant increase in IFN-γ cytokine (P value < 0.05) in the Protein/Protein (D) and DNA/Protein (E) groups. This finding was in agreement with in vivo assays. Control groups show a 10.5-fold increase (P value < 0.001) and (C) DNA/DNA group shows a 2.5-fold increase (P value < 0.01) in tumor growth compared to D and E groups. Also, a significant increase in survival of D and E (P value < 0.001) and C (P value < 0.01) groups were observed.

CONCLUSIONS

So, according to the findings, the recombinant protein could induce stronger protection compared to the DNA vaccine form. Protein/Protein and DNA/Protein are promising administration strategies for presenting this construct to develop an HPV-16 therapeutic vaccine candidate.

Human papillomavirus genotyping using next generation sequencing (NGS) in cervical lesions: Genotypes by histologic grade and their relative proportion in multiple infections

Sensitive and specific genotyping of human papillomaviruses (HPVs) is critical for the surveillance and monitoring of the vaccine effectiveness. Here, HPV genotypes were identified in 137 cervical samples with different histology (79 ≤CIN1 and 58 CIN3+) using Nested-PCR followed by Next-Generation sequencing (NGS) and relative proportions for each genotype in multiple infections were computed. All samples had been previously genotyped by PCR-Reverse Blotting Hybridization (PCR-RBH) thus allowing for a concordance analysis between both techniques. Multiple infections were present in 85% of ≤CIN1 cases compared to only 41% in CIN3+ cases (p<0.001). Among ≤CIN1 cases a towering genotypic diversity was observed, considering both low (LR-) and high risk (HR-) HPV genotypes; while among CIN3+, diversity was lower, HR-HPVs prevailing in most cases, especially HPV16. Furthermore, the predominance of HR-HPV genotypes in the proportions identified in each sample was higher in CIN3+ cases [(HPV16 (62.5%), followed by HPV31 and HPV58 (8.3% each)], than in ≤CIN1 cases [(HPV16 (17.7%), followed by HPV52 (14.7%) and HPV31 (10.3%)]. Agreement between PCR-RBH and NGS was higher than 90% for all genotypes (with an overall Kappa of 0.7), even though NGS identified eighty-nine positive results for HPV genotypes that had not been detected by PCR-RBH, evidencing its greater sensitivity. These results suggest that a reduction in genotypic diversity and/or an increase in the relative proportion of HR-HPVs in multiple infections can be considered as a biomarker for the potential risk of malignant progression.

Distribution of human papillomavirus genotypes by severity of cervical lesions in HPV screened positive women from the ESTAMPA study in Latin America

The proportion of HPV16 and 18-associated cervical cancer (CC) appears rather constant worldwide (≥70%), but the relative importance of the other HR-HPV differs slightly by geographical region. Here, we studied the HPV genotype distribution of HPV positive Latin American (LA) women by histological grade, in a sub-cohort from the ESTAMPA study; we also explored the association of age-specific HPV genotypes in severe lesions. Cervical samples from 1,252 participants (854 ≤CIN1, 121 CIN2, 194 CIN3 and 83 CC) were genotyped by two PCRs-Reverse Blotting Hybridization strategies: i) Broad-Spectrum General Primers 5+/6+ and ii) PGMY9/11 PCRs. HPV16 was the most frequently found genotype in all histological grades, and increased with the severity of lesions from 14.5% in ≤ CIN1, 19.8% in CIN2, 51.5% in CIN3 to 65.1% in CC (p < 0.001). For the remaining HR-HPVs their frequency in CC did not increase when compared to less severe categories. The nonavalent vaccine HR-types ranked at the top in CC, the dominant ones being HPV16 and HPV45. HR-HPV single infection occurs, respectively, in 57.1% and 57.0% of ≤CIN1 and CIN2, increasing to 72.2% and 91.6% in CIN3 and CC (p<0.001). No association between age and HPV type was observed in CC, although the risk of HPV16 infection in CIN3 cases increased with age. Results confirm the relevance of HPV16 in the whole clinical spectrum, with a strong rise of its proportion in CIN3 and cancer. This information will be relevant in evaluating the impact of HPV vaccination, as a baseline against which to compare genotype changes in HPV type-specific distribution as vaccinated women participate in screening in LA region. Likewise, these data may help select the best HPV testing system for HPV-based efficient, affordable, and sustainable screening programmes.

How Providing Cervical Cancer Screening Results via Cell Phone Affects Patient Follow-Up Rates in Western Kenya

Purpose

Human papillomavirus (HPV) testing is being more widely used in simplified cervical cancer screening protocols in low-resource settings. One challenge to successful implementation is the multiple visits necessary to provide results and follow-up. mHealth strategies may reduce visit burden by providing information through text message.

Methods

As part of a cluster-randomized trial to compare HPV testing in clinics and community health campaigns in western Kenya, we carried out a mixed-methods study to assess women’s preferences and experiences with different strategies to receive their results. Women could opt to receive their HPV results via text message, cell phone call, home visit, or return clinic visit. We examined overall receipt of results, follow-up rates, and acceptability by notification method.

Results

Among the 4,947 women who underwent HPV-based cervical cancer screening, 1,596 (32%) received results via text message, 1,181 (24%) via cell phone call, 1,563 (32%) via clinic visit, and 605 (12%) via home visit. Women opting for texts or calls were younger and had higher rates of prior cervical cancer screening, HIV testing, and modern contraceptive use (P < .001 for all). Home visits were associated with a significantly higher rate of treatment acquisition (45%) than texts (38%), cell phone calls (38%), and clinic visits (23%; P < .001). In a model controlling for age, prior screening, HIV testing, and contraceptive use, clinic visits remained significantly associated with decreased odds of treatment (adjusted odds ratio, 0.45; 95% CI, 0.29 to 0.69) compared with texts. Among treated women, there was no difference in time to treatment by notification method.

Conclusion

Cell phone–based results notification strategies were preferred by women with greater health-seeking behavior; however, HPV-positive women who received results via home visit were more likely to pursue for treatment.

SALL4 promotes the tumorigenicity of cervical cancer cells through activation of the Wnt/β-catenin pathway via CTNNB1

SALL4 is overexpressed in many cancers and is found to be involved in tumorigenesis and tumor progression. However, the function of SALL4 in cervical cancer remains unknown. Here, we showed that the expression of SALL4 was gradually increased from normal cervical tissue to high-grade squamous intraepithelial lesions and then to squamous cervical carcinoma. SALL4 was upregulated or downregulated in cervical cancer cells by stably transfecting a SALL4-expressing plasmid or a shRNA plasmid targeting SALL4, respectively. In vitro, cell growth curves and MTT (3-(4,5-dimethylthiazole-2-yl)-2,5-diphenyltetrazolium bromide) assays showed that SALL4 promoted the cell proliferation of cervical cancer cells. In vivo, xenograft experiments verified that SALL4 enhanced the tumor formation of cervical cancer cells in female BALB/c Nude mice. Cell cycle analysis by fluorescence-activated cell sorting found that SALL4 accelerates cell cycle transition from the G0 /G1 phase to the S phase. TOP/FOP-Flash reporter assay revealed that SALL4 significantly upregulates the activity of Wnt/β-catenin pathway. Western blotting showed that the expression levels of β-catenin and important downstream genes, including c-Myc and cyclin D1, were increased by SALL4 in cervical cancer cells. Furthermore, dual-luciferase reporter and chromatin immunoprecipitation assays confirmed that SALL4 transcriptionally activated CTNNB1 by physically interacting with its promoters. Taken together, The results of this study demonstrated that SALL4 may promote cell proliferation and tumor formation of cervical cancer cells by upregulating the activity of the Wnt/β-catenin signaling pathway by directly binding to the CTNNB1 promoter and trans-activating CTNNB1.

Papillomavirus Immune Evasion Strategies Target the Infected Cell and the Local Immune System

Persistent infection with human papillomavirus (HPV) initiates ~5% of all human cancers, and particularly cervical and oropharyngeal cancers. HPV vaccines prevent HPV infection, but do not eliminate existing HPV infections. Papillomaviruses induce hyperproliferation of epithelial cells. In this review we discuss how hyperproliferation renders epithelial cells less sensitive to immune attack, and impacts upon the efficiency of the local immune system. These observations have significance for the design of therapeutic HPV cancer immunotherapies.

Label-free cervicovaginal fluid proteome profiling reflects the cervix neoplastic transformation

Cervicovaginal fluid (CVF) is a valuable source of clinical information about the female reproductive tract in both nonpregnant and pregnant women. The aim of this study is to specify the CVF proteome at different stages of cervix neoplastic transformation by label-free quantitation approach based on liquid chromatography tandem mass spectrometry (LC-MS/MS) method. The proteome composition of CVF from 40 women of reproductive age with human papillomavirus (HPV)-associated cervix neoplastic transformation (low-grade squamous intraepithelial lesion [LSIL], high-grade squamous intraepithelial lesion [HSIL], and CANCER) was investigated. Hierarchical clustering and principal component analysis (PCA) of the proteomic data obtained by a label-free quantitation approach show the distribution of the sample set between four major clusters (no intraepithelial lesion or malignancy [NILM], LSIL, HSIL and CANCER) depending on the form of cervical lesion. Multisample ANOVA with subsequent Welch's t test resulted in 117 that changed significantly across the four clinical stages, including 27 proteins significantly changed in cervical cancer. Some of them were indicated as promising biomarkers previously (ACTN4, VTN, ANXA1, CAP1, ANXA2, and MUC5B). CVF proteomic data from the discovery stage were analyzed by the partial least squares-discriminant analysis (PLS-DA) method to build a statistical model, allowing to differentiate severe dysplasia (HSIL and CANCER) from the mild/normal stage (NILM and LSIL), and receiver operating characteristic (ROC) area under the curve (AUC) were obtained on an independent set of 33 samples. The sensitivity of the model was 77%, and the specificity was 94%; AUC was equal to 0.87. CVF proteome proved to be reflect the stage of cervical epithelium neoplastic process.

Recurring infection with ecologically distinct HPV types can explain high prevalence and diversity

The high prevalence of human papillomavirus (HPV), the most common sexually transmitted infection, arises from the coexistence of over 200 genetically distinct types. Accurately predicting the impact of vaccines that target multiple types requires understanding the factors that determine HPV diversity. The diversity of many pathogens is driven by type-specific or "homologous" immunity, which promotes the spread of variants to which hosts have little immunity. To test for homologous immunity and to identify mechanisms determining HPV transmission, we fitted nonlinear mechanistic models to longitudinal data on genital infections in unvaccinated men. Our results provide no evidence for homologous immunity, instead showing that infection with one HPV type strongly increases the risk of infection with that type for years afterward. For HPV16, the type responsible for most HPV-related cancers, an initial infection increases the 1-year probability of reinfection by 20-fold, and the probability of reinfection remains 14-fold higher 2 years later. This increased risk occurs in both sexually active and celibate men, suggesting that it arises from autoinoculation, episodic reactivation of latent virus, or both. Overall, our results suggest that high HPV prevalence and diversity can be explained by a combination of a lack of homologous immunity, frequent reinfections, weak competition between types, and variation in type fitness between host subpopulations. Because of the high risk of reinfection, vaccinating boys who have not yet been exposed may be crucial to reduce prevalence, but our results suggest that there may also be large benefits to vaccinating previously infected individuals.

Tafazzin (TAZ) promotes the tumorigenicity of cervical cancer cells and inhibits apoptosis

Tafazzin (TAZ) is often aberrantly expressed in some cancers, including rectal cancer and thyroid neoplasms. However, the function of TAZ in cervical cancer cells remains unknown. This study aims to explore the expression and function of TAZ in cervical cancer cells. Here, we determined the expression of TAZ protein in normal cervical tissue (NC, n = 27), high-grade squamous intraepithelial lesions (HSIL, n = 26) and squamous cervical carcinoma (SCC, n = 41) by immunohistochemistry, the expression of TAZ protein gradually increased from NC to HSIL to SCC. TAZ was overexpressed or down-regulated in cervical cancer cells by stably transfecting a TAZ-expressing plasmid or a shRNA plasmid targeting TAZ. In vitro, the cell growth curves and MTT assays showed that TAZ may promote the growth and viability of cervical cancer cells. In vivo, xenografts experiment showed that TAZ may increase tumor-forming ability. The percentage of apoptosis cells analyzed by FACS and TUNEL assays consistently showed that TAZ inhibits apoptosis in cervical cancer cells. Furthermore, the Cleaved Caspase 9 and Cleaved Caspase 3 were down-regulated by TAZ in cervical cancer cells. Taken together, this study demonstrated that TAZ is overexpressed in cervical cancer and may promote tumorigenicity of cervical cancer cells and inhibit apoptosis.

Human uterus transplantation in focus

INTRODUCTION

Uterus transplantation (UTx) is introduced as the first treatment for absolute uterine factor infertility (AUFI), affecting 1:500 fertile aged women. This review presents potential patients, research and human UTx cases.

SOURCES OF DATA

Published articles and our research experience.

AREAS OF AGREEMENT

The first UTx live births in 2014 established UTx as a possible treatment for AUFI. This was proceeded by 15 years of systematic research.

AREAS OF CONTROVERSY

Is a deceased donor UTx as effective as the proven successful live donor UTx?.

GROWING POINTS

Human UTx trials will accumulate data on risks, effectiveness and long-term consequences for donors, recipients and children. These should also include aspects of quality of life, psychological well-being and cognitive/neuropsychiatric development of children.

AREAS TIMELY FOR DEVELOPING RESEARCH

All new activities in human UTx within the coming years should be conducted as prospective observational studies, and data should also be collected within an international registry.

Catching Up With the HPV Vaccine: Challenges and Opportunities in Primary Care

PURPOSE

Data confirm that high rates of human papillomavirus (HPV) vaccination have not been achieved despite strong clinician endorsement of the vaccine. We conducted a study of primary care clinicians to assess the broad range of health care delivery, health policy, and attitudinal factors influencing vaccination uptake and opportunities for informed decision making.

METHODS

We implemented a mixed methods study in RIOS Net, a primary care practice-based research network in New Mexico. We first conducted qualitative, in-depth interviews with primary care clinicians, health policy makers, and immunization experts, and followed up with a confirmatory survey distributed to RIOS Net clinician members.

RESULTS

Health service delivery challenges emerged as the greatest barrier to HPV vaccination, specifically the lack of capacity to track and distribute reminders to eligible patients. Clinicians also reported variations in counseling approaches attributable to both age and emphasis on the cancer prevention benefits of the vaccine. There was no evidence of sociocultural influences on vaccine decision making, nor did concerns about perceived overprotection emerge.

CONCLUSIONS

Our findings, based on a long-term program of research, suggest that both patients' attributes and health system delivery are most influential in HPV vaccination coverage challenges. Interventions targeting innovative communication techniques, as well as health system changes that build on efforts toward coordinated care and utilization of other venues to promote vaccination, will be necessary to address these challenges.

Vaccination against human papilloma virus infection in male adolescents: knowledge, attitudes, and acceptability among parents in Italy

OBJECTIVES

To elicit information about parents' knowledge, attitudes, and acceptability toward HPV infection and vaccination of male adolescents in Italy; to identify subgroups of this population who exhibit poor knowledge about prevention of HPV infection and reveal negative attitudes toward HPV vaccination in relation to their male sons.

STUDY DESIGN

Data were collected via self-administered anonymous questionnaire from 1021 parents of males aged 10 to 14 y who were recruited from a random sample of public secondary schools in the South of Italy.

RESULTS

Three-quarters (72.6%) reported that the vaccine is a preventive measure for HPV infection and 55.8% that condom use reduces the risk of HPV infection. A high education level, abundant sources of information about HPV infection received from physicians, and knowledge about HPV infection were factors significantly associated with high level of knowledge about preventive measures for HPV infection. 71% revealed their intentions to vaccinate their sons, and this intention was significantly associated with perceived benefits both for HPV vaccination for girls and for childhood recommended vaccinations as well as a need for additional information about HPV vaccination. 53.7% of the eligible parents reported that their daughters had been vaccinated against HPV.

CONCLUSION

Results of the study suggest that the risk of acquiring HPV infection and HPV-related diseases is sorely underestimated. Knowledge on the benefits of adolescents' HPV vaccination in cancer prevention in both sexes should be improved to maximize uptake of HPV vaccination.

Detection of human papillomavirus DNA in routine cervical scraping samples: use for a national cervical cancer screening program in a developing nation

BACKGROUND

Human papillomavirus is a well-established cause of the development of a variety of epithelial lesions in the cervix. However, as yet, incorporation of HPV testing into cervical cancer screening either as an adjunct or stand alone test is limited due to its cost. We therefore here ascertained the presence and type specificity of human papilloma virus (HPV) DNA in routine cervical scrapings.

MATERIALS AND METHODS

Cervical scrapings were collected from women attending clinics for routine Pap smear screening. HPV-DNA was detected by PCR using MY09/11 and GP5+/GP6+ primer sets and genotyping was accomplished by cycle-sequencing.

RESULTS

A total of 635 women were recruited into the study with mean ± SD age of 43 ± 10.5 years. Of these 92.6% (588/635) were reported as within normal limits (WNL) on cytology. The presence of HPV infection detected by nested MY/GP+-PCR was 4.4% (28/635). The overall prevalence of high-risk HPV (HR-HPV) in abnormal Pap smears was 53.8% (7/13). HPVs were also seen in 3.1% (18/588) of smears reported as WNL by cytology and 5.9% (2/34) in smears unsatisfactory for evaluation.

CONCLUSIONS

The overall percentage of HPV positivity in routine cervical screening samples is comparable with abnormal findings in cytology. Conventional Pap smear 'missed' a few samples. Since HPV testing is expensive, our results may provide valuable information for strategising implementation of effective cervical cancer screening in a country with limited resources like Malaysia. If Pap smear coverage could be improved, HPV testing could be used as an adjunct method on cases with ambiguous diagnoses.

Attitudes towards cytology and human papillomavirus self-sample collection for cervical screening among Hindu women in London, UK: a mixed methods study

Objectives

To explore the attitudes, views and understanding of women attending a Hindu temple in London, UK towards cervical screening, human papillomavirus (HPV) testing and two HPV self-sample collection devices: the Dacron swab and Evalyn^® brush.

Methods

A mixed methods design comprising a survey and four focus groups was adopted. Focus group discussions were recorded and transcribed verbatim and explored using thematic framework analysis.

Results

A total of 185 Hindu women completed surveys and 23 attended focus groups. Of the respondents 75% aged 25–64 years reported having cervical screening within the last 5 years; 85% had attended college or university. Familiar barriers to attendance for screening were identified: fear of pain and the test result, embarrassment, screener's attitude, inconvenient appointment times and difficulty with child care. Additional barriers cited included age and country of birth, with older and Indian-born women thought to be less likely to attend for screening. Self-collected sampling had a mixed reception. Women were not confident that their sample would be as good as a clinician sample and expressed concern about the impact that a positive HPV result might have on their relationships.

Conclusions

Screening attendance in this highly educated group of Hindu women was slightly lower than in the general population (75% of women aged 25–64 years had been screened in the last 5 years compared with 79% in England as a whole). Familiar barriers to screening were identified. Women felt able to collect their own sample for HPV testing with a Dacron swab but lacked confidence that it would be as good as that obtained by a clinician.

Optimizing technology for cervical cancer screening in high-resource settings

Although historically successful in reducing the burden of cervical cancer, Papanicolaou (Pap) testing faces numerous limitations. A growing body of evidence suggests that modern screening practice will benefit from primary screening for high-risk human papillomavirus (HPV) infection, the causative agent of cervical cancer. Molecular tests detecting the presence of HPV nucleic acids consistently demonstrate high sensitivity relative to Pap testing, and provide reliable, dichotomous results. Pap cytology is ideally suited to triage HPV-positive cases owing to its high test specificity, and the accuracy of cytological readings will be maximized in high-prevalence conditions. This algorithm of primary HPV testing with Pap triage has been shown to maintain the high sensitivity of HPV testing without compromising Pap cytology's strong ability to rule out falsely positive diagnoses. Given the anticipated decline of high-risk HPV-16 and -18 infections in the emergent post-HPV vaccination era, highly sensitive primary HPV testing is especially warranted. Novel screening technologies that identify HPV viral gene expression continue to emerge and seek to complement current HPV testing by identifying those women who may be at risk of progressive disease. How to best incorporate these new technologies into clinical practice presents our next great challenge. Implementation of novel algorithms for cervical screening is not a trivial task. Avoidance of exceedingly complex screening algorithms is an important priority.

Revising ecological assumptions about Human papillomavirus interactions and type replacement

The controversy over whether vaccine-targeted HPV types will be replaced by other oncogenic, non-vaccine-targeted types remains unresolved. This is in part because little is known about the ecology of HPV types. Patient data has been interpreted to suggest independence or facilitative interactions between types and therefore replacement is believed to be unlikely. With a novel mathematical model, we investigated which HPV type interactions and their immune responses gave qualitatively similar patterns frequently observed in patients. To assess the possibility of type replacement, vaccination was added to see if non-vaccine-targeted types increased their 'niche'. Our model predicts that independence and facilitation are not necessary for the coexistence of types inside hosts, especially given the patchy nature of HPV infection. In fact, independence and facilitation inadequately represented co-infected patients. We found that some form of competition is likely in natural co-infections. Hence, non-vaccine-targeted types that are not cross-reactive with the vaccine could spread to more patches and can increase their viral load in vaccinated hosts. The degree to which this happens will depend on replication and patch colonization rates. Our results suggest that independence between types could be a fallacy, and so without conclusively untangling HPV within-host ecology, type replacement remains theoretically viable. More ecological thinking is needed in future studies.

Current methods for preventing the development of cervical cancer in patients with papilloma viral infection

The article presents the results of recent studies of the role of human papillomavirus in potentiating cancer in the cervix. the authors describe methods for organizing efforts aimed at early diagnostics of cancer pathologies associated with papilloma viral infection. they describe aspects of the prevention of cervical cancer in Russia and abroad. they also disclose current screening strategies related to cancer pathologies of the cervix based on a combination of diagnostics methods.

HPV vaccination and cervical cancer

Cervical cancer is the third most common cancer in women worldwide and often affects women under 40 years with young families. Vaccination against the human papillomavirus (HPV) is a major advance, since it offers primary prevention against the infectious agent that is the main cause of the disease. Two prophylactic vaccines have shown great promise in clinical trials. One of these (Gardasil(®)) contains all four HPV types, offering protection against genital warts (types 6 and 11) as well as cervical cancer (types 16 and 18). The other (Cervarix(®)) contains types 16 and 18, targeting cervical cancer alone, but also has a degree of cross-protection against types 31 and 45, which could significantly increase the level of protection. Adolescent girls remain the primary target of vaccination programmes, but the issues of vaccinating boys and older women are increasingly debated.

Human papillomavirus screening in north Indian women

OBJECTIVES

Human papillomavirus (HPV) is the major etiological agent of cervical cancer, a leading cause of morbidity and mortality in women worldwide. Screening strategies for reducing the burden of HPV-mediated carcinogenesis are emerging as an effective means for cervical cancer control and prevention in developing countries. Our study, therefore, aimed to identify HPV infection status in North Indian women during random population screening.

METHODOLOGY

Cervical/vaginal exfoliated cells and/or Pap smear specimens were collected from 890 women of North Indian ethnicity residing in Lucknow and adjoining areas, during random population screening from June 2009-March 2012. HPV viral loads in clinical specimens were determined by the Hybrid Capture (hc)-2 HPV DNA assay, and subsequently, positive/negative/borderline HPV status was calculated.

RESULTS

The HPV incidence in the present study was 11.7%. 751 out of a total of 890 women (84.4%) participating in our HPV screening program were HPV negative (HPV -), 104 (11.7%) tested positive (HPV +) while 35 (3.9%) showed borderline (HPV *) infection status. Furthermore, in the HPV + subjects (N=104), 18 (17.3%) showed strong positivity. We observed that HPV positivity tends to increase with age in North Indian women; the higher the viral load with increasing age, higher is the susceptibility to HPV-mediated cervical cancer.

CONCLUSIONS

HPV viral load/genotyping may help in identifying women at risk of developing cervical cancer. However, cost- effective HPV screening protocols with a wider population coverage are warranted so as to reduce the burden of cervical cancer in women worldwide in the vaccine-era.

The impact of human papillomavirus (HPV) types 6, 11 in women with genital warts

OBJECTIVE

Human papillomaviruses (HPV) are etiologically associated with the development of virtually all genital warts. HPV-6 and HPV-11 are the most commonly detected HPV genotypes, but at least 20 other HPV genotypes have occasionally been found in genital wart tissue specimens.

STUDY DESIGN

The aim of this study was to determine from 100 genital wart tissue specimens collected from female patients using multiplex gap-PCR technique the prevalence of various genital HPV among women with HPV genital warts in south of Iran. 100 genital wart tissue specimens were tested for the presence of HPV PG5/PG6 and also for HPV type using polymerase chain reaction (PCR).

RESULTS

Based on the collected data, 73 (73 %) samples were detected positive for HPV DNA and 23 (23 %) samples out of 100 samples were detected negative for HPV DNA. 49 (49 %) and 67 (67 %) of patients were detected positive for HPV type 6 and 11, respectively. There was a significant association between marital status and HPV genotype 6 (OR = 0.51, 95 % CI = 0.37-0.70, P = 0.01). Nevertheless, no significant association was found between marriage and HPV genotype 11 (OR = 0.85, 95 % CI = 0.58-1, 24, P = 0.7). Similarly, this result was demonstrated, in combined marriage and HPV-general (OR = 0.80, 95 % CI = 0.62-0.05, P = 0.4).

CONCLUSION

Concerning the prevalence of HPV in our study, determination of genital HPV prevalence and multiple infections among the normal population of women of Hormozgan Province is recommended.

Cervical cancer control in India: taking evidence to action

The most prevalent types of human papillomavirus in cervical cancer in India are HPV 16 and HPV 18, found in 60.7 per cent and 16 per cent of cases respectively. A comprehensive strategy with a judicious mix of interventions on health promotion, specific protection (vaccination), early diagnosis (screening), and treatment should be instituted to prevent and control cervical cancer in India. Proponents of vaccination and screening argue for enhanced investments on these interventions based on their relative cost-effectiveness. For policymakers, the major concerns about these interventions remain affordability and cost to government. Herein we try to review comprehensively the evidence on prevention and control interventions and to recommend appropriate policies to guide public health decision-making.

Human papillomavirus vaccination uptake and factors related to uptake in a traditional desert city in the United Arab Emirates

It is important to assess uptake of a new vaccine. The present survey estimated the uptake of the recently introduced human papillomavirus vaccine (HPVV) in the emirate of Abu Dhabi and also explored barriers to uptake. A questionnaire survey was conducted in secondary schools, enrolling 334 girls. The uptake percentage was estimated and factors associated with uptake were assessed with multilevel logistic regression. Crude vaccination uptake was 53%. Factors positively associated with uptake were, among others, having knowledge on human papillomavirus (vaccine) and having United Arab Emirates (UAE) nationality. The HPVV uptake of just over 50% could probably be improved by educating the target group and their parents before offering the HPVV and by making it free of costs for everyone.

Human papillomavirus: science and technologies for the elimination of cervical cancer

INTRODUCTION

Academic research has made a significant advancement in understanding the viral causes of cervical cancer and generating the technology for prevention, both at the primary and secondary levels. Human papillomaviruses (HPVs) have been recognized as the first necessary cause of cervical cancer, the second most common cancer in women worldwide.

AREAS COVERED

This paper reviews the epidemiological evidence of the causality of HPV in relation to cervical cancer, other genital tract cancers and some cancers of the oral cavity and oropharynx. The review also covers HPV DNA testing as a screening tool. DNA probes of high-risk HPV types in different formats have been fully validated as primary screening tests, as secondary triage tests and as a prognostic marker following treatment of high grade squamous intraepithelial lesions (HSIL). They consistently showed significant superiority over the conventional Pap smears. Biomarkers of the activation of oncogenes (HPV mRNA, p16 and other) are being tested as screening options to improve in sensitivity and specificity, with promising results. HPV vaccines against the two most common HPV types in cancer have completed their Phase III trials with excellent results in efficacy and safety. Combined strategies of HPV vaccination and HPV-based screening tests could theoretically control cervical cancer in any population in which a large coverage with both preventive options is ensured. Accessibility of developing countries to vaccination and low-cost HPV screening options are the barriers to overcome at present.

EXPERT OPINION

This paper provides a synthesis of the evidence available supporting the novel paradigm for cervical cancer prevention that has reached a large consensus within the mainstream HPV and cervical cancer prevention research communities. The available technology for prevention and its developments allows real opportunities for cervical cancer elimination in defined populations to be foreseen.

Enhanced specificity of HPV16 E6E7 siRNA by RNA-DNA chimera modification

Although efforts have been made to develop new drugs for infectious and neoplastic diseases utilizing synthetic small interfering RNA(siRNAs), those intrinsically have undesirable effects, including silencing of unintended genes (off-target effect) and nonspecific cytotoxicity. Off-target effects can be avoided by DNA substitution in the guide strand (GS) seed region of nucleotide positions 1-8 and its complementary part of the passenger strand plus the 3' overhang, which is designated as a double-strand RNA-DNA chimera (dsRDC). In this study, we found that the specificity of potent siRNAs targeting human papillomavirus 16 (HPV16) E6 and E7 oncogenes, which we previously reported, could be enhanced by short dsRDC modification (first six nucleotides from the 5' end of the GS and its complementary nucleotides of the passenger strand). Such dsRDC modification reduced nonspecific cytotoxicity in two of three siRNAs (497 and 752), although not in the other (573), which correlated with their off-target effects. In addition, silencing activity was marginally impaired in two dsRDCs (497 and 573) and moderately in one (752). Finally, dsRDC-497 induced E6E7-specific growth suppression of cervical cancer cells as well as E6E7-immortalized human keratinocytes. Our results show that dsRDC modification enhances the specificity of E6E7 siRNA, which is required for use in in vivo settings.

Economic evaluation of human papilloma virus vaccination in the European Union: a critical review

The human papilloma virus (HPV) vaccine is a new and expensive vaccine potentially effective in the prevention of a cancer. We reviewed the economic evaluations (EEs) on the vaccine in the EU to assess their potential contribution to public decision-making in a fairly homogeneous setting where HPV vaccination has been widely adopted. A literature search on PubMed selected EEs on HPV vaccines in the EU for the period 2007-2010 using the terms "HPV vaccines" and "Costs and cost analysis." Fifteen articles were eventually selected. All studies were based on modelling techniques, either "cohort" or "dynamic transmission": three were cost utility, three cost-effectiveness, and the remainder included both. The ten studies explicitly assessing one of the two vaccines were all sponsored by their manufacturer, while the five studies unrelated to the vaccine type were funded by public agencies. Apart from two studies, utility estimates were always obtained from three US sources. Direct costs were always vaccination, diagnosis and treatment of related pathologies. Incremental cost-effectiveness ratio (ICER) results were less favourable when life years gained were valued rather than quality-adjusted life years, genital warts were excluded, and booster doses and extension of vaccination to men were included in the base-case analysis. All but one of the sponsored EEs recommend in favour of the vaccination strategy, which is dominant in one English study. The ICER results were very sensitive to discount rates, followed by duration of protection and vaccine price. At such an early stage, when the vaccines' efficacy have been demonstrated by well-designed studies, it is not possible (and not even reasonable) to wait for several years to measure their effectiveness; public decision-makers might benefit more from EEs designed to indicate sustainable prices using realistic estimates of crucial variables like coverage rates, rather than referring to a large number of assumptions in order to show acceptable cost-effectiveness.

HPV vaccine: Cervarix

IMPORTANCE OF THE FIELD

Cervical cancer is a major cause of morbidity and mortality worldwide and is common in relatively young women. Cervical screening programs, while successful if properly carried out, are difficult and expensive to implement, and offer secondary, not primary prevention. Vaccination against the human papillomavirus (HPV), which is the major cause of cervical cancer, is a significant step forward.

AREAS COVERED IN THIS REVIEW

The data on Cervarix, the GSK HPV vaccine, are reviewed and placed in the context of HPV vaccination as a whole. A literature review using PubMed listed publications and official product websites has been carried out.

WHAT THE READER WILL GAIN

The reader will gain an understanding of the issues involved in HPV vaccination and of the data to date.

TAKE HOME MESSAGE

Cervarix has been shown to have high efficacy against disease associated with both HPV-16 and HPV-18. Its antibody response profile allows for optimism regarding the duration of immunity. The fact that it is a virus-like particle, rather than a live-virus vaccine, is reassuring regarding safety, as are the reasonably extensive safety data for the vaccine preparation so far accrued. Cross protection against oncogenic non-vaccine HPV types, in particular HPV-45, may be important in the prevention of cervical adenocarcinoma, which is currently not well served by screening.

Human papillomavirus genotypes in asymptomatic young women from public schools in Rio de Janeiro, Brazil

INTRODUCTION: The aim of this work was to survey HPV information from a random population of young women from Rio de Janeiro, Brazil. METHODS: This cross-sectional study included cervical samples from 241 female students. To determine human papillomavirus status, polymerase chain reaction amplification was performed. HPV typing was determined by restriction fragment length polymorphism analysis. Demographic data, life style, sexual and gynecological history were obtained through use of a structured questionnaire. RESULTS: The average age of the women was 19.6 years-old (SD=3.4 years). HPV prevalence was 27.4%. Nineteen different HPV genotypes were detected, including 13 high risk types. HPV 16 was the most prevalent type (6.2%), followed by 31 (4.1 %) and 66 (3.7%). Most of the oncogenic types belonged to the A9 species (28/48). The frequency of women infected by at least one oncogenic type was significantly higher than those only infected by low risk types (18.7% versus 7.5%). Cervical changes were detected in 12.5% of the sample and were significantly linked to infection with HPV types of the A9 species. Demographic variables, sexual initiation, or number of sexual partners were not associated with HPV prevalence, variety of HPV genotypes or oncogenic types. CONCLUSIONS: The relative frequency of HPV genotypes other than vaccine types in young females should be taken into account when evaluating vaccination strategies. Due to the high prevalence of HPV infection among the population studied, implementation of sex education in schools, promotion of condom use and an organized screening program to prevent cervical cancer must be encouraged for this age group.

Exploring the acceptability of two self-sampling devices for human papillomavirus testing in the cervical screening context: a qualitative study of Muslim women in London

Objectives

We explored Muslim women's attitudes to self-sampling for human papillomavirus (HPV) in the context of cervical cancer screening and their responses to two self-sampling devices.

Setting

A Muslim community centre in north-east London.

Methods

Following a talk given on the subject of cervical cancer and HPV at the community centre, 28 women were recruited to take part in three focus group discussions. The discussion covered cervical screening, self-sampling and HPV testing. Women were also asked for their responses to a swab self-sampling kit and a cervico-vaginal lavage device. Discussions were recorded and transcribed verbatim and the qualitative data were analysed using Framework Analysis.

Results

Participants were generally positive about cervical screening but acknowledged that some women in their community were reluctant to attend because of embarrassment, language difficulties, fear or because they were unmarried and did not want to communicate implicit messages about being sexually active. Self-sampling met a mixed response – women were concerned about not doing the test correctly, but thought that it might overcome barriers to screening for some women. HPV testing itself was thought to raise potentially difficult issues relating to trust and fidelity within marriages. Although most women said they would prefer to continue to have screening by a health professional, if they were to perform self-sampling, there was overwhelming preference for the swab over the lavage kit.

Conclusions

There was limited enthusiasm for self-sampling in this group of Muslim women who had mostly attended for cervical screening, but a clear preference for a swab rather than a cervico-vaginal lavage.

Feasibility of focused ultrasound therapy for recurrent cervicitis with high-risk human papillomavirus infection

OBJECTIVE

To investigate the feasibility of focused ultrasound therapy for recurrent cervicitis with high-risk human papillomavirus (HR-HPV) infection.

METHODS

This was a prospective clinical study, in which 20 patients with HR-HPV-positive recurrent cervicitis were enrolled. Focused ultrasound therapy was performed by one gynecologist. All patients were followed up for 6 months after ultrasound therapy. Telephone interviews, colposcopic examinations and Hybrid Capture II tests were performed to assess the safety and effectiveness of focused ultrasound therapy for HR-HPV-positive cervicitis.

RESULTS

Ultrasound therapy was tolerated well, and no severe complications were observed in any patient. Vaginal discharge was found intermittently in 95% of patients. Without any intervention this disappeared 1 month after ultrasound therapy. Patients' symptoms were relieved significantly by ultrasound therapy, including 88.9% patients who had abundant leukorrhea, 80% who had pelvic pain and 87.5% who had postcoital bleeding. No colposcopic evidence of cervicitis remained postoperatively in 75% of patients, and cytological examination showed that the lesions had disappeared in 80% of patients. Follow-up HPV testing revealed that 75% of patients presented negative HR-HPV infection following treatment.

CONCLUSIONS

Focused ultrasound therapy is feasible and effective in the treatment of patients with HR-HPV-positive cervicitis. It may provide a useful non-invasive treatment for recurrent cervicitis with HR-HPV infection.

[HPV detection and typing by INNO-LiPA assay on liquid cytology media Easyfix Labonord after extraction QIAamp DNA Blood Mini Kit Qiagen and Nuclisens easyMAG Biomérieux]

OBJECTIVES

The objective of this study is to validate the use of test INNO-LIPA HPV Genotyping Extra (Innogenetics) on liquid cytology media EasyFix Labonord by comparing the extraction kit QIAamp DNA Blood Mini Kit (Qiagen) and an automated method, Nuclisens easyMAG (Biomérieux).

METHODS

Thirty-two samples were typed by the technique Hybrid Capture 2 (HC2) Digene (Qiagen). DNA was extracted through manual or automated extraction and quality controlled PCR "HLA". Typing was performed with the INNO-LIPA test. A nested PCR followed by sequencing was used to compare different results.

RESULTS

Similar results were found for the two types of extraction, with an increase of sensitivity after automated extraction. Among the nine patients with a negative result with the HC2 test, seven had a negative result in INNO-LIPA and two a positive result (one untypable and one HPV66). On the 23 patients with a positive result with the HC2 test, 17 are consistent results. The six discordant results include one negative, one HPV54, two untypable HPV and two HPV53. The overall concordance between the HC2 and INNO-LIPA tests is 81% with a kappa test of 0.79.

CONCLUSION

Coupled with an automated extraction, the test INNO-LIPA confirmed its high sensitivity for detecting and typing HPV in the EasyFix media Labonord, especially in the presence of multiple genotypes. This typing systematic approach is becoming increasingly relevant in the context of HPV vaccination.

The HPV vaccines--which to prefer?

This review presents an unbiased comparison between the two vaccines available against human papillomavirus (HPV). We conducted a PUBMED and Google search for the years 1998 to October 2008 using the terms: cervical cancer vaccine, HPV vaccine, Gardasil, and Cervarix; and also reviewed abstracts from international meetings. Both vaccines are intended to protect against cervical cancer and high-grade CIN caused by HPV 16 and HPV 18. Only the quadrivalent vaccine is designed to prevent condylomata acuminata and low-grade CIN caused by HPV 6 and HPV 11. It has been approved by the FDA for women aged 9 to 26 years against vulvar and vaginal cancer, and against cervical cancer and precancer. The adjuvant of the bivalent vaccine more significantly accelerates an immune reaction. Both vaccines demonstrate cross-protection, although against different HPV types. The bivalent vaccine is registered for above age 26 in Australia and Israel, and the quadrivalent vaccine in the Philippines and Ecuador. Time will verify claims and reveal differences. In the meantime, both vaccines are safe and effective for their approved indications and, recommendations should be based on individual patient characteristics.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to describe the viral targets of the two HPV vaccines, explain the potential benefits of HPV vaccination to patients, and compare the data regarding the two HPV vaccines.

Evaluation of an array-based method for human papillomavirus detection and genotyping in comparison with conventional methods used in cervical cancer screening

Cervical cancer is the second-most prevalent cancer in young women around the world. Infection with human papillomavirus (HPV), especially high-risk HPV types (HR-HPV), is necessary for the development of this cancer. HPV-DNA detection is increasingly being used in cervical cancer screening programs, together with the Papanicolau smear test. We evaluated the usefulness of introducing this new array-based HPV genotyping method (i.e., Clinical Arrays Papillomavirus Humano) in the cervical cancer screening algorithm in our center. The results obtained using this method were compared to those obtained by the hybrid capture II high-risk HPV DNA test (HC-II) and Papanicolau in a selected group of 408 women. The array-based assay was performed in women that were HC-II positive or presented cytological alterations. Among 246 array-positive patients, 123 (50%) presented infection with >or=2 types, and HR-HPV types were detected in 206 (83.7%), mainly HPV-16 (24.0%). Up to 132 (33.2%) specimens were classified as ASCUS (for atypical squamous cells of undetermined significance), and only 48 (36.4%) of them were HPV-DNA positive by either assay; however, 78.7% of these cases were caused by HR-HPV types. The agreement between both HPV-DNA detection techniques was fairly good (n = 367). Screening with Papanicolau smear and HC-II tests, followed by HPV detection and genotyping, provided an optimal identification of women at risk for the development of cervical cancer. Furthermore, with the identification of specific genotypes, either in single or multiple infections, a better prediction of disease progression was achieved. The array method also made allowed us to determine the possible contribution of the available vaccines in our setting.

Defining a strategy to evaluate cervical cancer prevention and early detection in the era of HPV vaccination

OBJECTIVE

The purpose of this paper is to outline the short-, medium- and long-term requirements of a strategy to evaluate the impact of HPV immunization and to define a framework to facilitate planning and evaluation.

METHOD

This strategy was developed in Ontario from January to August 2008. Literature review was completed to assess existing material relevant to vaccine evaluation, and HPV vaccine specifically. Scientists and epidemiologists within our organization attended meetings to brainstorm and identify key requirements for vaccine evaluation. Other selected internal and external experts were consulted to review preliminary lists of potential indicators and questions for inclusion in an evaluation strategy.

RESULTS

Results are reported in three sections--literature review, proposed evaluation framework and data requirements.

CONCLUSION

The first vaccine evaluation strategy that integrates primary and secondary prevention of cervical cancer is presented. Among women who are neither screened nor immunized, customized interventions will be required to ensure that they are aware of potential risks and benefits. This evaluation strategy may serve as a useful outline for jurisdictions in Canada and elsewhere. This new paradigm of combined primary and secondary intervention will encourage cooperation for effective evaluation of an integrated approach for control of cervical cancer and other HPV-related disease.

Human papillomavirus profile of women in Belize City, Belize: correlation with cervical cytopathologic findings

Cervical carcinoma is the most common cancer among Belizean women; however, data regarding the frequency of human papillomavirus (HPV) genotypes and their association with cervical cancer are nonexistent. We therefore included HPV genotyping as part of a week-long cervical cancer screening campaign conducted in Belize City in 2007. Conventional Papanicolaou smears with Hybrid Capture (HC) 2 HPV testing were performed on 463 women. All HC2-positive samples were genotyped using a developmental GP5+/GP6+ polymerase chain reaction-coupled Luminex assay for 2 low-risk and 18 high-risk HPV types. The prevalence of high-risk HPV was 15.6% in the total population, 10.1% in those with normal cytologic findings, and 93.3% in women with a high-grade squamous intraepithelial lesion. Of patients with HPV infections, 35% had multiple types (5.4% of the total group). Of all women and of women with normal cytologic findings, 5.2% and 2.8%, respectively, had HPV16 or 18. For all women, HPV16, 18, 56, and 52 were present in decreasing order of frequency. HPV11 was present in only one patient, and none had HPV6. HPV16 was found in 47% of high-grade squamous epithelial lesions; however, no case of HSIL had HPV18 or 45. HPV35 and HPV58 were the next most common types in high-grade squamous intraepithelial lesion, each occurring in 20% of cases of high-grade squamous intraepithelial lesion, followed by HPV31 in 13.3%. Although women younger than 25 years old were underrepresented, these data suggest that the HPV profile of this cohort of Belizean women differs somewhat from that in the region. In addition, these data are of importance with regard to the development of HPV vaccines that will be used in less developed countries, where care should be taken not to implement vaccination at the cost of basic screening and diagnostic services.

Evaluating the impact of human papillomavirus vaccines

While two prophylactic HPV vaccines have been proven notably efficacious in clinical trials, the effectiveness of these vaccines at the population level remains to be evaluated. To lay the foundation for understanding the strengths and limitations of different endpoints for future effectiveness research, we present a comprehensive review of HPV-related clinical outcomes, including: (i) HPV type-specific positivity and persistence, (ii) Pap diagnoses (ASC-US, LSIL, and HSIL), (iii) histologic cervical cancer precursor lesions (i.e., CIN1, CIN2, and CIN3), (iv) invasive cervical cancer (ICC), (v) anogenital warts, (vi) recurrent respiratory papillomatosis (RRP), and (vii) other HPV-associated cancers (vulvar, vaginal, anal, penile, and oropharyngeal). While research on the vaccines' effects on these HPV clinical outcomes in the general population is presently limited, numerous large trials will soon be completed, making a priori discussion of these potential outcomes especially urgent. Furthermore, population level systems to track HPV-associated clinical outcomes may need to be developed for HPV vaccine effectiveness evaluation.

New paradigms in cervical cancer prevention: opportunities and risks

Testing for the DNA of high-risk types of papilloma virus (HPV) is more sensitive than cytology in detecting pre-cancerous lesions. One of the main advantages will be the possibility of applying prolonged screening intervals. However adequate screening protocols (age of start and stop, screening intervals, management of HPV positive women) need to be applied in order to avoid over-referral to colposcopy and over-treatment and to maintain sustainable costs. Further follow-up of running trials and research on molecular markers will better define these parameters. The new situation will require organised screening programmes with rigorous protocols and monitoring. This will be even more needed when women vaccinated for HPV 16 and 18 will be screened. Research on how to best screen vaccinated women is a priority. This paper proposes an overview of the plausible impact of new technologies in cervical cancer screening in the near future and in the vaccinated cohorts.

Vaccination and screening programs: harmonizing prevention strategies for HPV-related diseases

HPV vaccine is an exciting promise of the preventive medicine. Although HPV-immunization programs still reveal a number of unanswered questions, they represent a novel opportunity for primary prevention against cervical cancer and other HPV-related pre-neoplastic and neoplastic diseases. It is reasonable that the short and long-term benefits of vaccination on cervical and vulvo-vaginal HPV-related pathology will emerge when assuring over time a clear and complete information to the community and harmonizing the prevention strategies. Indeed, HPV-vaccination programs will require an understanding of new paradigms of infection and cancer control, and thus will require a rationale integration with the currently operating screening systems.

Human Papillomavirus Vaccines and Vaccine Implementation

Countries are now challenged by the rapid development of vaccines aimined at the primary prevention of infections. In the years to come, several vaccines will need to be considered as potential candidates in routine immunization programs. Recently, two new vaccines against two/four types of human papillomavirus (HPV) have been commercialized. Bivalent HPV 16 and 18 (Cervarix™) and quadrivalent HPV 6, 11, 16 and 18 (Gardasil®) vaccines are now extensively used in some countries. These vaccines will prevent infection and long-running complications, such as cervical cancer, other HPV-related cancers and genital warts (for the quadrivalent vaccine). The beneficial effect of these vaccines will be largely observed in women. This article summarizes the burden of HPV preventable disease worldwide and briefly describes the impact of secondary prevention and the most relevant aspects of the current available vaccines, their efficacy and safety. Finally, some major aspects that are likely to impact the introduction of these vaccines around the world are outlined, with particular emphasis on developing countries.