Elsevier

Vaccine

Volume 24, Supplement 1, 30 March 2006, Pages S4-S15
Vaccine

The epidemiology of genital human papillomavirus infection

https://doi.org/10.1016/j.vaccine.2005.09.054Get rights and content

Abstract

Clinical and subclinical human papillomavirus (HPV) infections are the most common sexually transmitted infections in the world, and most sexually-active individuals are likely to be exposed to HPV infection during their lifetimes. More than 40 genotypes of HPV infect the epithelial lining of the anogenital tract and other mucosal areas of the body; of these, 13–18 types are considered to be high-oncogenic risk HPV types (HR-HPV). Persistent infection with HR-HPVs is now unequivocally established as a necessary cause of cervical cancer and is likely to be responsible for a substantial proportion of other anogenital neoplasms and upper aero-digestive tract cancers. Low oncogenic risk HPV types (LR-HPV) are also responsible for considerable morbidity as the cause of genital warts. Youth and certain sexual characteristics are key risk factors for HPV acquisition and persistence of HPV infection, but other mediating factors include smoking, oral contraceptive (OC) use, other STIs (e.g. chlamydia, herpes simplex virus), chronic inflammation, immunosuppressive conditions including HIV infection, parity, dietary factors, and polymorphisms in the human leukocyte antigen system. Not surprisingly, these factors are also established or candidate cofactors identified in epidemiologic studies of cervical cancer. HPV transmissibility and molecular events in HPV-induced carcinogenesis have been the focus of recent multidisciplinary epidemiologic studies. This shift in research focus coincides with a shift in cancer prevention techniques towards immunization with HPV vaccines and HPV testing of precancerous lesions.

Introduction

More than 120 different human papillomavirus (HPV) types have been catalogued so far [1], [2], of which more than 40 infect the epithelial lining of the anogenital tract and other mucosal areas of the body. Some 13–18 types have been identified as probable or definite high-oncogenic risk HPV types (HR-HPV) (Table 1). It is now widely accepted that HR-HPV infections are a necessary, but not sufficient, cause of virtually all cases of cervical cancer worldwide and are a likely cause of a substantial proportion of other anogenital neoplasms and oral squamous cell carcinomas. Infection with low oncogenic risk HPV types (LR-HPV), such as HPV 6 and 11, can cause benign lesions of the anogenital areas known as condylomata acuminata (genital warts), as well as a large proportion of low-grade squamous intraepithelial lesions of the cervix. LR-HPV clinical infections are responsible for substantial morbidity and invoke high costs associated with the treatment of clinically relevant lesions. In this report, we review the essential aspects of the epidemiology of genital HPV infections and outline the risk factors for becoming infected with an emphasis on the role of HPVs as cancer causing agents, particularly cervical carcinomas.

Section snippets

How common is genital HPV infection?

HPV infections are the most common diagnosed sexually transmitted diseases today. Studies utilizing HPV DNA testing of asymptomatic women in the general population estimate the prevalence of HPV infection to be in the range of 2–44% [3], [4], [5], [6], [7], [8], [9]. This wide variation in prevalence estimates is largely explained by age differences among population samples studied, and by differences in the molecular sensitivity of the various HPV DNA assays used to detect viral DNA [7]. It is

HPV infection as the causal intermediate in cervical carcinogenesis

Fig. 2 shows the various components of the etiological model for the natural history of HPV infection and cervical carcinogenesis. The distal risk factor is sexual activity, which has been known for at least five decades to be the most important correlate of cervical cancer risk. As discussed above, the role of persistent HPV infection is central to this etiologic model.

A role for HPV infection in the sexually transmitted disease model of cervical cancer was proposed in the mid-1970s [57].

Risk factors for HPV infection

Risk determinants for HPV infection that have been identified in various cross-sectional and prospective cohort studies include number of sexual partners (lifetime and recent), age at first intercourse, smoking, oral contraceptive (OC) use, other STIs (e.g. chlamydia and herpes simplex virus), chronic inflammation, immunosuppressive conditions including HIV infection, and parity [8], [31], [47], [67], [68], [69], [70]. Results have been inconsistent partly owing to the fact that different

Conclusion

Molecular epidemiologic studies of the natural history of HPV infection and cervical neoplasia have provided much of the knowledge base that has led to the ongoing paradigm changes in cervical cancer prevention via HPV screening and HPV vaccination. The contributions of epidemiology in this process during the last 15 years have been focused on the demonstration that HPV infection is the cause of cervical cancer, and as such, they have dealt with the virus mostly as an intermediate endpoint in

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