Reproductive & Genital Health & Risk of Cervical Human Papillomavirus Infection: Results from the Ludwig-Mcgill Cohort Study

Background

There are inconsistencies in the literature on reproductive and genital health determinants of human papillomavirus (HPV) infection, the primary cause of cervical cancer. We examined these factors in the Ludwig-McGill Cohort Study, a longitudinal, repeated-measurements investigation on the natural history of HPV infection.

Methods

We analyzed a cohort subset of 1867 women with one complete year of follow-up. We calculated odds ratios (OR) and 95 % confidence intervals (CI) for reproductive and genital health characteristics from questionnaire and laboratory data in relation to 1-year period prevalence of HPV infection. Two outcomes were measured; the first based on phylogenetic grouping of HPV types based on tissue tropism and oncogenicity (Alphapapillomavirus Subgenus 1: species 1, 8, 10 and 13; Subgenus 2: species 5, 6, 7, 9, 11; Subgenus 3: species 3, 4 and 14) and the second based on transient or persistent HPV infections.

Results

Lifetime (Subgenus 3 OR = 2.00, CI: 1.23–3.24) and current (Subgenus 3 OR = 2.00, CI: 1.15–3.47) condom use and use of contraceptive injections (Subgenus 1 OR = 1.96, CI: 1.22–3.16, Subgenus 2 OR = 1.34, CI: 1.00–1.79) were associated with increased risk of HPV infection. Intrauterine device use was protective (Subgenus 1 OR = 0.48, CI: 0.30–0.75, Subgenus 2 OR = 0.78, CI: 0.62–0.98). These factors were not associated with persistence of HPV infection. Tampon use, previous gynecologic infections and cervical inflammation were associated with an overall increased risk of HPV infection.

Conclusions

Cervical HPV infection was associated with reproductive and genital health factors. Further studies are necessary to confirm the low to moderate associations observed.

Associations between reproductive health and vaginal hygiene factors and the 1-year period prevalence of HPV infection by phylogenetic group in the Ludwig-McGill cohort study

Variable	Subgenus 1a (n = 108)		Subgenus 2a (n = 495)		Subgenus 3a (n = 131)
	ORb	95 % CI	ORb	95 % CI	ORb	95 % CI
Reproductive Health Factors
Condom Use
Former vs. Never	1.28	0.79, 2.07	0.90	0.71, 1.15	2.00	1.23, 3.24
Current vs. Never	1.43	0.83, 2.48	1.09	0.82, 1.45	2.00	1.15, 3.47
Oral Contraceptives
< 6 years vs. Never	1.25	0.66, 1.38	0.98	0.71, 1.35	1.40	0.83, 2.37
6+ years vs. Never	1.23	0.60, 2.53	1.00	0.70, 1.43	0.62	0.32, 1.19
Intrauterine Device
Yes vs. No	0.48	0.30, 0.75	0.78	0.62, 0.98	0.73	0.49, 1.08
Tubal Sterilization
Yes vs. No	1.24	0.65, 1.36	0.84	0.59, 1.21	0.65	0.33, 1.30
Contraceptive Injection
Yes vs. No	1.96	1.22, 3.16	1.34	1.00, 1.79	1.34	0.83, 2.17
Natural Products
Yes vs. No	-	-	0.37	0.13, 1.05	0.74	0.17, 3.20
Vaginal Products
Yes vs. No	-	-	0.82	0.37, 1.81	0.32	0.04, 2.40
Genital Health and Hygiene Factors
Menstrual Cloth
Yes vs. No	0.54	0.32, 0.91	0.93	0.74, 1.18	1.02	0.68, 1.53
Hygienic Tampon
Yes vs. No	1.49	0.87, 2.54	1.33	0.98, 1.81	1.30	0.79, 2.14
Douching
Frequent vs. Infrequent	1.20	0.53, 2.69	1.29	0.83, 2.00	0.11	0.02, 0.81
Douching Products
Natural vs. None	0.96	0.60, 1.54	0.92	0.72, 1.17	0.90	0.57, 1.41
Medical vs. None	1.09	0.23, 5.15	0.97	0.46, 2.06	2.75	0.98, 7.73
Unknown vs. None	1.18	0.27, 5.22	0.51	0.21, 1.21	2.92	1.20, 7.12
Genital Discomfort
Yes vs. No	0.96	0.64, 1.45	0.96	0.78, 1.20	0.89	0.60, 1.31
Recent Discomfort
Yes vs. No	0.99	0.65, 1.50	1.11	0.89, 1.38	1.22	0.84, 1.75
Pain or Bleeding
Yes vs. No	2.83	0.59, 13.51	1.14	0.34, 3.75	0.91	0.12, 7.00
Gynecologic Products
Antibiotic
Former vs. Never	3.86	0.86, 17.34	0.83	0.51, 1.33	1.43	0.52, 3.97
Current vs. Never	5.95	1.14, 30.97	0.97	0.53, 1.79	1.84	0.56, 6.02
Antifungal
Former vs. Never	5.14	1.17, 22.52	1.10	0.70, 1.75	1.85	0.68, 5.02
Current vs. Never	1.64	0.22, 12.24	1.06	0.56, 2.02	1.74	0.49, 6.11
Abrasion
Former vs. Never	-	-	1.68	0.40, 7.72	-	-
Current vs. Never	-	-	1.10	0.08, 16.23	-	-
External Products
Former vs. Never	0.75	0.20, 2.84	-	-	-	-
Current vs. Never	1.36	0.48, 3.89	-	-	-	-
Unknown Products
Former vs. Never	2.82	0.64, 12.42	0.96	0.62, 1.49	2.21	0.81, 6.01
Current vs. Never	3.44	0.63, 18.68	1.10	0.60, 2.03	2.82	0.83, 9.53
Home-made Products
Natural vs. None	1.22	0.78, 1.92	0.91	0.72, 1.15	0.98	0.66, 1.47
Medical vs. None	0.80	0.27, 2.40	1.26	0.77, 2.04	0.76	0.29, 2.02
Unknown vs. None	2.75	0.53, 14.15	1.33	0.45, 3.91	5.33	1.80, 15.82
Vaginal Health Characteristics
Cervical Ectropion
Yes vs. No	0.37	0.05, 2.77	0.89	0.42, 1.91	0.74	0.17, 3.10
Gynecologic Surgery
Yes vs. No	2.05	1.11, 3.79	0.90	0.60, 1.37	0.89	0.42, 1.89
Gynecologic Treatment/Infection
Yes vs. No	1.73	1.13, 2.65	1.17	0.92, 1.50	1.26	0.83, 1.89
Previous Gynecologic Infection
HPV vs. None	3.87	2.09, 7.14	2.02	1.27, 3.19	1.21	0.54, 2.71
Non-HPV vs. None	1.33	0.81, 2.19	1.03	0.78, 1.34	1.27	0.82, 1.97
Cytology Observations
Bacterial Infection
Yes vs. No	1.28	0.63, 2.63	1.30	0.88, 1.91	1.31	0.68, 2.52
Fungal Infection
Yes vs. No	1.25	0.61, 2.54	1.29	0.88, 1.87	1.48	0.83, 2.66
General Inflammation
Yes vs. No	2.10	1.37, 3.22	1.53	1.21, 1.94	1.12	0.74, 1.69

a Subgenus 1 (HPVs-6, 11, 32, 40, 42, 44, 54 and 55), Subgenus 2 (HPVs-16, 18, 26 31, 33–35, 39, 45, 51–53, 56, 58, 59, 66–70, 73 and 82) and Subgenus 3 (HPVs-57, 61, 62, 71, 72, 81, 83, 84 and 89) infections were determined based on the phylogenetic classification of HPV types

b Odds ratios were adjusted for age, lifetime number of sexual partners and empirical confounders (identified using a 5 % change in estimate strategy) such as race, marital status, education, age at first intercourse, age at menarche, number of pregnancies, smoking, alcohol drinking and years since last Pap smear

Full article at:   http://goo.gl/bWRJrg

By:  Eileen Shaw, Agnihotram V. Ramanakumar, Mariam El-Zein, Flavia R. Silva, Lenice Galan, Maria L. Baggio, Luisa L. Villa, Eduardo L. Franco, and for the Ludwig-McGill Cohort Study

Division of Cancer Epidemiology, Department of Oncology, McGill University, Montreal, Canada

Department of Epidemiology, Biostatistics and Occupational Health, McGill University, 546 Pine Avenue West, Montreal, QC H2W 1S6 Canada

Ludwig Institute for Cancer Research, São Paulo, Brazil

Molecular Biology Laboratory, Centre of Translational Oncology, Instituto do Câncer do Estado de São Paulo, São Paulo, Brazil

BMC Infect Dis. 2016; 16: 116. Published online 2016 Mar 8. doi:  10.1186/s12879-016-1446-x

More at:  https://twitter.com/hiv insight

And: http://twitter.com/Prison Health

Significant Reduction in the Incidence of Genital Warts in Young Men 5 Years Into the Danish Human Papillomavirus Vaccination Program for Girls and Women

BACKGROUND:

Denmark introduced the quadrivalent human papillomavirus vaccine into the vaccination program for 12- to 15-year-old girls in 2008 to 2009. In 2012, the program was supplemented with a catch-up program for women aged up to 27 years. We evaluated the effectiveness of the Danish vaccination program on the nationwide incidence of genital warts (GWs), after the second catch-up by including information on both hospital treatments and on self-administered treatment with podophyllotoxin. Genital wart incidence was investigated in both sexes; however, the main focus was on potential herd protection of men.

METHODS:

Incident cases of GWs were identified from the Danish National Patient Register and through redemptions of prescription for podophyllotoxin in the Danish National Prescription Registry in 2006 to 2013. Age-specific incidence rates (IRs) were assessed, and estimated annual percentage change (EAPC) was calculated by Poisson regression.

RESULTS:

Genital wart incidence was either stable or increased in both sexes in 2006 to 2008. After introduction of the vaccination program, GW incidence decreased significantly in women aged 12 to 35 years and men aged 12 to 29 years, with rapid decrease among 16- to 17-year-olds (IRwomen, from 1071 to 58 per 100,000 person-years [EAPC, -55.1%; 95% confidence interval, -58.7 to-51.2]; IRmen, from 365 to 77 per 100,000 person-years [EAPC, -36.6%; 95% confidence interval, -40.5 to -32.5] in 2008-2013).

CONCLUSIONS:

We found a significantly decreasing incidence of GWs in women up to 35 years of age after the start of the human papillomavirus vaccination program. A similar pattern was observed for men aged 12 to 29 years, indicating substantial herd protection.

Purchase full article at:  http://goo.gl/7LNc8l

By:  Bollerup S1, Baldur-Felskov B, Blomberg M, Baandrup L, Dehlendorff C, Kjaer SK.

• 1From the *Virus, Lifestyle and Genes, Danish Cancer Society Research Center, Copenhagen, Denmark; †Statistics, Bioinformatics and Registry, Danish Cancer Society Research Center, Copenhagen, Denmark; and ‡Department of Gynecology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
• Sex Transm Dis. 2016 Apr;43(4):238-42. doi: 10.1097/OLQ.0000000000000418. 

More at:  https://twitter.com/hiv insight

And: http://twitter.com/Prison Health

Diagnosis of HIV-Associated Oral Lesions in Relation to Early versus Delayed Antiretroviral Therapy

Oral mucosal lesions that are associated with HIV infection can play an important role in guiding the decision to initiate antiretroviral therapy (ART). The incidence of these lesions relative to the timing of ART initiation has not been well characterized. 

A randomized controlled clinical trial was conducted at the GHESKIO Center in Port-au-Prince, Haiti between 2004 and 2009. 816 HIV-infected ART-naïve participants with CD4 T cell counts between 200 and 350 cells/mm³ were randomized to either immediate ART initiation (early group; N = 408), or initiation when CD4 T cell count was less than or equal 200 cells/mm³ or with the development of an AIDS-defining condition (delayed group; N = 408). Every 3 months, all participants underwent an oral examination. 

The incidence of oral lesions was 4.10 in the early group and 17.85 in the delayed group (p-value <0.01). In comparison to the early group, there was a significantly higher incidence of candidiasis, hairy leukoplakia, herpes labialis, and recurrent herpes simplex in the delayed group. The incidence of oral warts in delayed group was 0.97 before therapy and 4.27 post-ART initiation (p-value <0.01). In the delayed group the incidence of oral warts post-ART initiation was significantly higher than that seen in the early group (4.27 versus 1.09; p-value <0.01). 

The incidence of oral warts increased after ART was initiated, and relative to the early group there was a four-fold increase in oral warts if ART was initiated following an AIDS diagnosis. Based upon our findings, candidiasis, hairy leukoplakia, herpes labialis, and recurrent herpes simplex indicate immune suppression and the need to start ART. In contrast, oral warts are a sign of immune reconstitution following ART initiation.

Below:

Full article at:   http://goo.gl/W2pd06

By:   

Ashita S. Batavia, Jean William Pape, Daniel W. Fitzgerald 
Weill Cornell Medical Center, New York, New York, United States of America

Rode Secours, Marc Antoine Jean Juste, Patrice Severe, Jean William Pape 

Groupe Haitien d’Etude du Sarcome de Kaposi et des Infections Opportunistes (GHESKIO), Port-au-Prince, Haiti

Patrice Espinosa

University of California San Francisco School of Dentistry, San Francisco, California, United States of America

More at:  https://twitter.com/hiv insight

And: http://twitter.com/Prison Health

Comparison of HPV Prevalence Between HPV-Vaccinated & Non-Vaccinated Young Adult Women (20-26 Years)

There is some concern about the effectiveness of the HPV vaccine among young adult women due to the risk of prior HPV infection. This study used National Health and Nutrition Examination Survey (NHANES) 2007-2012 data to evaluate the effectiveness of HPV vaccination among women 20-26 years of age who were vaccinated after 12 years of age. 

This cross-sectional study examined 878 young adult women (20-26 years) with complete information on HPV prevalence and HPV vaccination status from NHANES 2007-2012. Vaginal swab specimens were analyzed for HPV DNA by L1 consensus polymerase chain reaction followed by type-specific hybridization. Multivariate logistic regression models controlling for sociodemographic characteristics and sexual behaviors were used to compare type-specific HPV prevalence between vaccinated and unvaccinated women. 

A total of 21.4% of young adult women surveyed through NHANES between 2007 and 2012 received the HPV vaccine. 

• Vaccinated women had a lower prevalence of vaccine types than unvaccinated women (7.4% vs 17.1%, prevalence ratio 0.43, 95% CI 0.21-0.88). 
• The prevalence of high-risk nonvaccine types was higher among vaccinated women than unvaccinated women (52.1% vs 40.4%, prevalence ratio 1.29, 95% CI 1.06-1.57), 
• but this difference was attenuated after adjusting for sexual behavior variables (adjusted prevalence ratio 1.19, 95% CI 0.99-1.43). 

HPV vaccination was effective against all 4 vaccine types in young women vaccinated after age 12. However, vaccinated women had a higher prevalence of high-risk nonvaccine types, suggesting that they may benefit from newer vaccines covering additional types.

Via: http://ht.ly/SslWp 

By: Guo F1, Hirth JM1, Berenson AB1.

• 1a Department of Obstetrics & Gynecology ; Center for Interdisciplinary Research in Women's Health; The University of Texas Medical Branch ; Galveston , TX USA.

Giant Condyloma Acuminatum of Vulva: A Frustrating Treatment Challenge

Below:  Patient with giant condyloma prior to reconstructive surgery

Below:  Patient following the healing process

Giant condylomata are not usually seen nowadays in developed nations, but such cases are still seen in the under-resourced countries. Condylomata acuminata are commonly transmitted through sexual intercourse. Generally diagnosed based on their appearance. Giant condyloma acuminata also named Buschke- Löwenstein tumour (BLT) is a slow growing cauliflower-like tumor, locally aggressive and destructive, with possible malignant transformation. Common clinical treatment of anogenital warts is conservative, however, in extreme cases conservative therapy is insufficient and surgical excision is required. A case of common presentation of giant condylomata in a 50 years old, divorced, multiparous woman is presented and the literature is reviewed. She presented with 15 years history of slowly progressive vulval lesion and associated itching, contact bleeding, malodorous vaginal discharge and difficulty in walking. She had previously been treated with podophyllin and cryosurgery without success. The growth measured 30×10 cm in each side and was successfully excised with no evidence of malignancy concomitant and reconstruction also done.

Read more at:  http://ht.ly/ReE5K 

If there was a vaccine against cancer, wouldn't you get it for your keiki?

Via:  http://ht.ly/QErc8  Posters at: (boy) http://ht.ly/QEqTI (girl) http://ht.ly/QEr0e 

Death Rates for Cervical Cancer, US, 1999–2013

Via:  http://ht.ly/HMjBI RT @CDCMMWR 

Prevalence of Type-Specific HPV among Female University Students from Northern Brazil

Read: http://ht.ly/Q6zIS HT @UFPA_Oficial

Specimens were collected from 265 university students during routine cervical cancer screening. The HPV DNA was assessed by Polymerase Chain Reaction and positive samples were genotyped by Restriction Fragment Length Polymorphism. Most students (85.7 %) had normal cytological results. The prevalence of HPV was 25.3 % (67/265), with a high frequency of multiple infections and non-vaccine high-risk HPV genotypes. The most prevalent type was HPV-61 (5.3 %), followed by types 82, 16, 59, and 6. Multiple infections were associated with high-risk and possibly high-risk HPVs.

We demonstrated a high prevalence of HPV infection in university students from northern Brazil. Vaccine high-risk types were relatively rare, emphasizing the predominance of carcinogenic genotypes that are not prevented by the currently available vaccines. Our study highlights the need to reinforce cytological screening in women from northern Brazil, and promote the early diagnosis and treatment of the precancerous lesions associated with cervical cancer.

Below: Absolute frequency of the 20 types of HPV detected in single and multiple infections (HPV: human papillomavirus; *oncogenic types)