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Marembo T, Fitzpatrick MB, Dube Mandishora RS. Human papillomavirus genotype distribution patterns in Zimbabwe; is the bivalent vaccine sufficient? Intervirology 2024; 67:000531347. [PMID: 38574482 PMCID: PMC11057445 DOI: 10.1159/000531347] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 05/12/2023] [Indexed: 04/06/2024] Open
Abstract
BACKGROUND Vaccination against Human papillomavirus (HPV) is the primary preventative strategy that has been shown to reduce the burden of HPV related diseases. Zimbabwe introduced the bivalent vaccine (HPV 16/18) in the vaccination program targeting prepubescent girls in 2018. This review is an analysis of the distribution of HPV genotypes from various studies conducted in Zimbabwe to ascertain the effectiveness of the bivalent vaccine and make recommendations for future HPV vaccine choices. SUMMARY Zimbabwean studies have mostly reported on cervical HPV in the urban areas. The most frequent HPV genotypes from cervical sites were 16, 18, 33, 35, 45, 56 and 58. These were identified from samples with normal cytology, pre-cancer and invasive cervical cancer. The few studies that have been done in rural areas reported HPV 35 as the most frequent cervicovaginal genotype. From the anal region of individuals reporting for routine screening, HPV 16, 18, 35 52 and 58 were the most frequent. A study on genital warts identified HPV 6, 11, 16, 40, 51and 54. In a study on children with recurrent respiratory papillomatosis (RRP), HPV 6 and 11 were the most common and HPV 35 was also identified in these children. There is no available published data on HPV distribution in head and neck cancers in Zimbabwe. KEY MESSAGES Given that 83% of cervical cancers in Zimbabwe are caused by HPV 16/18, the bivalent vaccine could cover a significant proportion of HPV related cervical cancer. The current limitation of the bivalent vaccine is its failure to prevent benign lesions such as genital warts and RRP or all cervical cancer cases in Zimbabwe. For the prevention of most HPV related conditions, the nonavalent vaccine would be the most appropriate option for the Zimbabwean population. Currently there is no vaccine that includes HPV 35, yet this genotype was frequently identified in HPV related diseases. Vaccine developers may need to consider HPV 35 when manufacturing the next generation HPV vaccines. Furthermore, boys should also be included in HPV vaccination programs to improve herd immunity, as well as prevent RRP and HPV-related head and neck cancers.
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Affiliation(s)
- Takudzwa Marembo
- Department of Medical Microbiology, Midlands State University Faculty of Medicine, Gweru, Zimbabwe
- Africa Centres for Disease Control and Prevention, African Union Commission, Addis Ababa, Ethiopia
| | | | - Racheal S. Dube Mandishora
- Department of Medical Microbiology, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
- Infections and Cancer Biology Group, International Agency for Research on Cancer-WHO, Lyon, France
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Nakigozi H, Ategyeka PM, Nabadda S, Ndejjo R. Positivity rates, trends and experiences of health workers on human papillomavirus screened using genexpert in Uganda: a three-year retrospective cohort study. BMC Cancer 2024; 24:375. [PMID: 38528459 DOI: 10.1186/s12885-024-12141-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 03/18/2024] [Indexed: 03/27/2024] Open
Abstract
INTRODUCTION Cervical cancer is a major public health issue in Uganda, with high incidence due to limited screening especially in rural areas. In 2019, HPV DNA testing using GeneXpert was rolled out to improve screening access. Assessing progress and challenges since its introduction is important. AIM To determine genotype distribution and explore health worker experiences with HPV screening using GeneXpert in Uganda. METHODS We conducted a retrospective cohort study where HPV screening data from 66 GeneXpert labs from March 2021-May 2023 country wide was analyzed. We used descriptive statistics to provide percentages and proportions from the data. Seven focus group discussions and five interviews were done with health workers to understand experiences. RESULTS We extracted 24,497 HPV tests that were done, and 39.1% were HPV positive. Other high-risk HPV genotypes were the most common at 65%, followed by HPV 16 (17%) and HPV 18/45 (18%). 15% of the HPV positive cases had more than one genotype. Qualitative findings showed inconsistent health worker knowledge, high workload, and complex care seeking behaviors as main challenges. It also revealed low community awareness, care seeking from traditional healers, CONCLUSION: HPV DNA testing has been expanding since its rollout, but the yield of HPV cases is lower than expected, signaling need to address supply-side challenges. Limited information on HPV among health workers especially community health workers, demand-side barriers like myths, medical pluralism and social norms must also be tackled through trainings of health workers and awareness campaigns engaging communities. Although access to GeneXpert services has increased, health system weaknesses pose bottlenecks to screening HPV. Targeted interventions are required to strengthen HPV diagnosis, prevent cervical cancer and save lives.
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Affiliation(s)
- Harriet Nakigozi
- National Health Laboratory and Diagnostic Services, Ministry of Health, Kampala, Uganda.
| | - Paul Mukama Ategyeka
- School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Susan Nabadda
- National Health Laboratory and Diagnostic Services, Ministry of Health, Kampala, Uganda
| | - Rawlance Ndejjo
- School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
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Salcedo MP, Lathrop E, Osman N, Neves A, Rangeiro R, Mariano AAN, Nkundabatware JC, Tivir G, Carrilho C, Monteiro ECS, Burny R, Thomas JP, Carns J, Andrade V, Mavume C, Paulo Mugolo R, Atif H, Hoover H, Chivambo E, Chissano M, Oliveira C, Milan J, Varon ML, Fellman BM, Baker E, Jeronimo J, Castle PE, Richards-Kortum R, Schmeler KM, Lorenzoni C. The Mulher Study: cervical cancer screening with primary HPV testing in Mozambique. Int J Gynecol Cancer 2023; 33:1869-1874. [PMID: 37907263 DOI: 10.1136/ijgc-2023-004958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2023] Open
Abstract
OBJECTIVE To evaluate cervical cancer screening with primary human papillomavirus (HPV) testing in Mozambique, a country with one of the highest burdens of cervical cancer globally. METHODS Women aged 30-49 years were prospectively enrolled and offered primary HPV testing using either self-collected or provider-collected specimens. Patients who tested positive for HPV underwent visual assessment for treatment using visual inspection with acetic acid to determine eligibility for thermal ablation. If ineligible, they were referred for excision with a loop electrosurgical excision procedure, for cold knife conization, or for cervical biopsy if malignancy was suspected. RESULTS Between January 2020 and January 2023, 9014 patients underwent cervical cancer screening. Median age was 37 years (range 30-49) and 4122 women (45.7%) were patients living with HIV. Most (n=8792, 97.5%) chose self-collection. The HPV positivity rate was 31.1% overall and 39.5% among patients living with HIV. Of the 2805 HPV-positive patients, 2588 (92.3%) returned for all steps of their diagnostic work-up and treatment, including ablation (n=2383, 92.1%), loop electrosurgical excision procedure (n=169, 6.5%), and cold knife conization (n=5, 0.2%). Thirty-one patients (1.2%) were diagnosed with cancer and referred to gynecologic oncology. CONCLUSION It is feasible to perform cervical cancer screening with primary HPV testing and follow-up in low-resource settings. Participants preferred self-collection, and the majority of screen-positive patients completed all steps of their diagnostic work-up and treatment. Our findings provide important information for further implementation and scale-up of cervical cancer screening and treatment services as part of the WHO global strategy for the elimination of cervical cancer.
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Affiliation(s)
- Mila Pontremoli Salcedo
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Eva Lathrop
- Population Services International, Washington, District of Columbia, USA
| | | | - Andrea Neves
- Hospital Geral e Centro de Saúde José Macamo, Maputo, Mozambique
| | | | | | | | | | | | | | | | - Joseph P Thomas
- Oncology Care & Research IS, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jennifer Carns
- Department of Bioengineering, Rice University, Houston, Texas, USA
| | | | - Celda Mavume
- Ministério da Saúde de Moçambique (MISAU), Maputo, Mozambique
| | | | - Hira Atif
- Ministério da Saúde de Moçambique (MISAU), Maputo, Mozambique
| | - Hannah Hoover
- Population Services International, Washington, District of Columbia, USA
| | | | | | | | - Jessica Milan
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Melissa Lopez Varon
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Bryan M Fellman
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Ellen Baker
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | | | | | | | - Kathleen M Schmeler
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
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Effah K, Wormenor CM, Tekpor E, Amuah JE, Essel NOM, Gedzah I, Kemawor S, Hansen BT, Atuguba BH, Klutsey GB, Sesenu E, Danyo S, Akakpo PK. Evaluating operational parameters of the careHPV, GeneXpert, AmpFire, and MA-6000 HPV systems for cervical precancer screening: Experience from Battor, Ghana. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001639. [PMID: 37624774 PMCID: PMC10456161 DOI: 10.1371/journal.pgph.0001639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 08/07/2023] [Indexed: 08/27/2023]
Abstract
In response to calls by the World Health Organization for cervical precancer screening services in low-resource settings to lean toward HPV DNA testing, a number of testing platforms have been made available. This study aimed to evaluate the operational parameters of four HPV testing systems in previous (careHPV) and current (GeneXpert, AmpFire, and MA-6000) use in a secondary healthcare setting in terms of 'appropriateness', ease of use, throughput, and diagnostic yield. This descriptive retrospective cohort analysis included 6056 women who presented to our facility between June 2016 and March 2022 for cervical precancer screening via HPV testing. A large majority of this cohort underwent AmpFire testing (55.8%), followed by careHPV (23.3%), MA-6000 (14.7%), and GeneXpert (6.1%). MA-6000 showed the highest hr-HPV positivity rate of 26.4% (95% CI, 23.6-29.5), followed by AmpFire (17.2%; 95% CI, 15.9-17.5). GeneXpert and careHPV showed similar hr-HPV positivity rates of 14.8% (95% CI, 11.3-18.8) and 14.8% (95% CI, 13.0-16.8), respectively. For the AmpFire and MA-6000 platforms, which utilize similar detection and reporting formats, we found a significant excess detection rate of 9.2% (95% CI, 6.1-12.4; p-value <0.0001) for MA-6000 compared to AmpFire. At the genotype level, MA-6000 also detected significantly higher rates of HPV 16 and other hr-HPV types (both p-values <0.001) than AmpFire; there was no difference in detection for HPV 18. Based on our experiences and preliminary analysis, we believe that the choice of HPV testing platform cannot be accomplished with a one-size-fits-all approach. Factors worth considering are the financial implications of platform acquisition, costs to clients, and throughput when screening programs are not sufficiently large. We describe our successes and challenges with the different platforms which we believe will be helpful to centers in low-income countries as they transition into using HPV DNA testing for cervical precancer screening.
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Affiliation(s)
- Kofi Effah
- Catholic Hospital, Battor, via Sogakope, Volta Region, Ghana
| | | | - Ethel Tekpor
- Catholic Hospital, Battor, via Sogakope, Volta Region, Ghana
| | - Joseph Emmanuel Amuah
- Catholic Hospital, Battor, via Sogakope, Volta Region, Ghana
- Faculty of Medicine, School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
| | - Nana Owusu M. Essel
- Faculty of Medicine and Dentistry, Department of Emergency Medicine, College of Health Sciences, University of Alberta, Edmonton, AB, Canada
| | - Isaac Gedzah
- Catholic Hospital, Battor, via Sogakope, Volta Region, Ghana
| | - Seyram Kemawor
- Catholic Hospital, Battor, via Sogakope, Volta Region, Ghana
| | | | | | | | - Edna Sesenu
- Catholic Hospital, Battor, via Sogakope, Volta Region, Ghana
| | - Stephen Danyo
- Catholic Hospital, Battor, via Sogakope, Volta Region, Ghana
| | - Patrick Kafui Akakpo
- Department of Pathology, University of Cape Coast, School of Medical Sciences, Clinical Teaching Center, Cape Coast, Ghana
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Tchouaket MCT, Ka’e AC, Semengue ENJ, Sosso SM, Simo RK, Yagai B, Nka AD, Chenwi CA, Abba A, Fainguem N, Perno CF, Colizzi V, Fokam J. Variability of High-Risk Human Papillomavirus and Associated Factors among Women in Sub-Saharan Africa: A Systematic Review and Meta-Analysis. Pathogens 2023; 12:1032. [PMID: 37623992 PMCID: PMC10458438 DOI: 10.3390/pathogens12081032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 07/29/2023] [Accepted: 08/03/2023] [Indexed: 08/26/2023] Open
Abstract
BACKGROUND Sub-Saharan Africa (SSA) carries the highest burden of high-risk human papillomavirus (HR-HPV) in the world, driven by, and together with, HIV infection. This systematic review aimed to identify HR-HPV genotypes and their associated factors among women in SSA. METHODS A systematic review and meta-analysis of studies conducted in SSA on HR-HPV was conducted. Standard electronic databases were searched. R software version 3.6.0 was used for meta-analysis, with p < 0.05 considered statistically significant. RESULTS We included 28 articles with a total of 22,652 participants. The overall pooled prevalence of HR-HPV genotypes was 55.13%, albeit high heterogeneity between studies. The overall pooled prevalence of HR-HPV genotypes in HIV-positive individuals was 75.51%, compared to 52.97% in HIV-negatives (OR = 4.68 (0.71-30.76)). HPV 16 (18%), 35 (10.12%), 52 (9.98%), 18 (9.7%) and 45 (6.82%) genotypes were the most prevalent. Twelve studies identified the most frequently reported risk factors associated with HR-HPV, with HIV infection (66.66%), multiple sexual partners (41.66%) and young age (41.66%) being the most reported risk factors. CONCLUSIONS The combined prevalence of HR-HPV genotypes among women in general and HIV-infected women in particular remains high in SSA. The presence of several genotypes not covered by the vaccine is remarkable and suggests the need for revision of current vaccination policies to prevent HR-HPV infections.
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Affiliation(s)
- Michel Carlos Tommo Tchouaket
- Chantal BIYA International Reference Centre for Research on HIV/AIDS Prevention and Management, Yaoundé P.O. Box 3077, Cameroon (S.M.S.); (R.K.S.); (B.Y.); (A.D.N.); (C.A.C.); (A.A.); (N.F.)
- School of Health Sciences, Catholic University of Central Africa, Yaoundé P.O. Box 1110, Cameroon
| | - Aude Christelle Ka’e
- Chantal BIYA International Reference Centre for Research on HIV/AIDS Prevention and Management, Yaoundé P.O. Box 3077, Cameroon (S.M.S.); (R.K.S.); (B.Y.); (A.D.N.); (C.A.C.); (A.A.); (N.F.)
- Faculty of Sciences, University of Rome “Tor Vergata”, 00133 Rome, Italy
| | - Ezechiel Ngoufack Jagni Semengue
- Chantal BIYA International Reference Centre for Research on HIV/AIDS Prevention and Management, Yaoundé P.O. Box 3077, Cameroon (S.M.S.); (R.K.S.); (B.Y.); (A.D.N.); (C.A.C.); (A.A.); (N.F.)
- Faculty of Sciences, University of Rome “Tor Vergata”, 00133 Rome, Italy
- Faculty of Sciences, Evangelical University of Bandjoun, Bandjoun P.O. Box 127, Cameroon;
| | - Samuel Martin Sosso
- Chantal BIYA International Reference Centre for Research on HIV/AIDS Prevention and Management, Yaoundé P.O. Box 3077, Cameroon (S.M.S.); (R.K.S.); (B.Y.); (A.D.N.); (C.A.C.); (A.A.); (N.F.)
| | - Rachel Kamgaing Simo
- Chantal BIYA International Reference Centre for Research on HIV/AIDS Prevention and Management, Yaoundé P.O. Box 3077, Cameroon (S.M.S.); (R.K.S.); (B.Y.); (A.D.N.); (C.A.C.); (A.A.); (N.F.)
| | - Bouba Yagai
- Chantal BIYA International Reference Centre for Research on HIV/AIDS Prevention and Management, Yaoundé P.O. Box 3077, Cameroon (S.M.S.); (R.K.S.); (B.Y.); (A.D.N.); (C.A.C.); (A.A.); (N.F.)
- Faculty of Sciences, Evangelical University of Bandjoun, Bandjoun P.O. Box 127, Cameroon;
| | - Alex Durand Nka
- Chantal BIYA International Reference Centre for Research on HIV/AIDS Prevention and Management, Yaoundé P.O. Box 3077, Cameroon (S.M.S.); (R.K.S.); (B.Y.); (A.D.N.); (C.A.C.); (A.A.); (N.F.)
- Faculty of Sciences, University of Rome “Tor Vergata”, 00133 Rome, Italy
- Faculty of Sciences, Evangelical University of Bandjoun, Bandjoun P.O. Box 127, Cameroon;
| | - Collins Ambe Chenwi
- Chantal BIYA International Reference Centre for Research on HIV/AIDS Prevention and Management, Yaoundé P.O. Box 3077, Cameroon (S.M.S.); (R.K.S.); (B.Y.); (A.D.N.); (C.A.C.); (A.A.); (N.F.)
- Faculty of Sciences, University of Rome “Tor Vergata”, 00133 Rome, Italy
| | - Aissatou Abba
- Chantal BIYA International Reference Centre for Research on HIV/AIDS Prevention and Management, Yaoundé P.O. Box 3077, Cameroon (S.M.S.); (R.K.S.); (B.Y.); (A.D.N.); (C.A.C.); (A.A.); (N.F.)
| | - Nadine Fainguem
- Chantal BIYA International Reference Centre for Research on HIV/AIDS Prevention and Management, Yaoundé P.O. Box 3077, Cameroon (S.M.S.); (R.K.S.); (B.Y.); (A.D.N.); (C.A.C.); (A.A.); (N.F.)
- Faculty of Sciences, University of Rome “Tor Vergata”, 00133 Rome, Italy
- Faculty of Sciences, Evangelical University of Bandjoun, Bandjoun P.O. Box 127, Cameroon;
| | | | - Vittorio Colizzi
- Faculty of Sciences, Evangelical University of Bandjoun, Bandjoun P.O. Box 127, Cameroon;
| | - Joseph Fokam
- Chantal BIYA International Reference Centre for Research on HIV/AIDS Prevention and Management, Yaoundé P.O. Box 3077, Cameroon (S.M.S.); (R.K.S.); (B.Y.); (A.D.N.); (C.A.C.); (A.A.); (N.F.)
- School of Health Sciences, Catholic University of Central Africa, Yaoundé P.O. Box 1110, Cameroon
- Faculty of Sciences, University of Rome “Tor Vergata”, 00133 Rome, Italy
- Faculty of Sciences, Evangelical University of Bandjoun, Bandjoun P.O. Box 127, Cameroon;
- Faculty of Health Sciences, University of Buea, Buéa P.O. Box 63, Cameroon
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Murangwa A, Desai KT, Gage JC, Murenzi G, Tuyisenge P, Kanyabwisha F, Musafili A, Kubwimana G, Mutesa L, Anastos K, Kim HY, Castle PE. Agreement between Xpert and AmpFire tests for high-risk human papillomavirus among HIV-positive women in Rwanda. Afr J Lab Med 2022; 11:1827. [PMID: 36353194 PMCID: PMC9639372 DOI: 10.4102/ajlm.v11i1.1827] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 05/26/2022] [Indexed: 08/27/2023] Open
Abstract
BACKGROUND High-risk human papillomavirus (hrHPV) may cause more than 99% of cervical cancers worldwide. Little is known about performance differences in tests for hrHPV. OBJECTIVE This study analysed agreement for detection of hrHPV between the established, clinically validated Xpert HPV assay and the novel isothermal amplification-based AmpFire HPV genotyping assay. METHODS This study was nested in a larger project on cervical cancer screening among approximately 5000 women living with HIV in Kigali, Rwanda. This sub-study included 298 participants who underwent initial screening for cervical cancer using the Xpert HPV assay and visual inspection with acetic acid in 2017 and tested positive by either or both. Participants were rescreened using colposcopy, and cervical samples were collected between June 2018 and June 2019. Samples were then tested for HPV using the Xpert HPV assay and AmpFire HPV genotyping assay. Agreement between results from both tests was analysed using an exact version of McNemar test and chi-square test. RESULTS Overall agreement and kappa value for detection of hrHPV by Xpert and AmpFire were 89% and 0.77 (95% confidence interval: 0.70-0.85). AmpFire was marginally more likely to diagnose hrHPV-positive than Xpert (p = 0.05), due primarily to the extra positivity for HPV16 (p < 0.001). CONCLUSION Overall, there was good to excellent agreement between the Xpert and AmpFire when testing hrHPV types among women living with HIV. AmpFire was more likely to test extra cases of HPV16, the most carcinogenic HPV type, but the clinical meaning of detecting additional HPV16 infections remains unknown.
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Affiliation(s)
| | - Kanan T. Desai
- Division of Cancer Epidemiology & Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland, United States
| | - Julia C. Gage
- Division of Cancer Epidemiology & Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland, United States
| | | | | | | | - Aimable Musafili
- Department of Paediatrics and Child Health, School of Medicine and Pharmacy, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Gallican Kubwimana
- Rwanda Military Hospital, Kigali, Rwanda
- Research for Development (RD Rwanda), Kigali, Rwanda
| | - Leon Mutesa
- Research for Development (RD Rwanda), Kigali, Rwanda
- Centre for Human Genetics, College of Medicine and Health Sciences, University of Rwanda, Kigali, Rwanda
| | - Kathryn Anastos
- Departments of Medicine and Epidemiology & Population Health, Albert Einstein College of Medicine and Montefiore Health Systems, Bronx, New York, United States
| | - Hae-Young Kim
- Department of Public Health, New York Medical College, Valhalla, New York, United States
| | - Philip E. Castle
- Division of Cancer Epidemiology & Genetics, National Cancer Institute, National Institutes of Health, Rockville, Maryland, United States
- Division of Cancer Prevention, National Cancer Institute, National Institutes of Health, Rockville, Maryland, United States
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A novel cervical cancer screen-triage-treat demonstration project with HPV self-testing and thermal ablation for women in Malawi: Protocol for a single-arm prospective trial. Contemp Clin Trials Commun 2022; 26:100903. [PMID: 35243124 PMCID: PMC8857441 DOI: 10.1016/j.conctc.2022.100903] [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: 06/18/2021] [Revised: 12/20/2021] [Accepted: 02/07/2022] [Indexed: 01/25/2023] Open
Abstract
Cervical cancer is the leading cause of cancer mortality among Malawian women, despite being preventable through screening and preventive therapy. In 2004, Malawi implemented a national screening program, using visual inspection with acetic acid (VIA) and cryotherapy, but its success has been limited due to equipment and human resources challenges. Since the development of that program, new technologies for screening and treatment that are less resource-intensive and more scalable have become available. GeneXpert systems provide fast, accurate HPV results and are increasingly available in low-income countries. Self-collection for human papillomavirus (HPV) testing is a validated method for screening and improves uptake. Thermal ablation provides an alternative ablative treatment that is simpler to use than cryotherapy and can be performed with portable devices. Meanwhile, urine HPV testing methods provide promising options for primary screening. We designed a single-arm prospective study to investigate a novel HPV screen-triage-treat strategy among 1250 women in Lilongwe, Malawi. Our proposed strategy consists of (1) Xpert HPV testing of self-collected samples, (2) VIA and colposcopy for HPV-positive women, and (3) thermal ablation for HPV-positive/ablation-eligible women. We will collect cervical biopsies, Pap smears, and endocervical samples to validate the HPV results and VIA/colposcopy findings against endpoints of high-grade cervical intraepithelial neoplasia or cancer (CIN2+). We will evaluate same-day completion of our algorithm, its performance in triaging women for treatment, and 24-week treatment efficacy of thermal ablation. We will also explore the performance of HPV and methylation tests in urine samples, as compared to provider- and self-collected cervicovaginal samples.
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Lozar T, Nagvekar R, Rohrer C, Dube Mandishora RS, Ivanus U, Fitzpatrick MB. Cervical Cancer Screening Postpandemic: Self-Sampling Opportunities to Accelerate the Elimination of Cervical Cancer. Int J Womens Health 2021; 13:841-859. [PMID: 34566436 PMCID: PMC8458024 DOI: 10.2147/ijwh.s288376] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 08/30/2021] [Indexed: 12/24/2022] Open
Abstract
The persisting burden of cervical cancer in underserved populations and low-resource regions worldwide, worsened by the onset of the COVID-19 pandemic, requires proactive strategies and expanded screening options to maintain and improve screening coverage and its effects on incidence and mortality from cervical cancer. Self-sampling as a screening strategy has unique advantages from both a public health and individual patient perspective. Some of the barriers to screening can be mitigated by self-sampling, and resources can be better allocated to patients at the highest risk of developing cervical cancer. This review summarizes the implementation options for self-sampling and associated challenges, evidence in support of self-sampling, the available devices, and opportunities for expansion beyond human papillomavirus testing.
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Affiliation(s)
- Taja Lozar
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
- University of Wisconsin Carbone Cancer Center, University of Wisconsin School of Medicine & Public Health, Madison, WI, USA
- University of Ljubljana, Ljubljana, Slovenia
| | - Rahul Nagvekar
- Department of Genetics, Stanford University, Stanford, CA, USA
| | - Charles Rohrer
- Department of Pathology and Laboratory Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Racheal Shamiso Dube Mandishora
- University of Zimbabwe College of Health Sciences, Department of Medical Microbiology, Harare, Zimbabwe
- Early Detection, Prevention and Infections Group, International Agency for Research on Cancer, Lyon, France
| | - Urska Ivanus
- University of Ljubljana, Ljubljana, Slovenia
- National Cervical Cancer Screening Programme and Registry ZORA, Epidemiology and Cancer Registry, Institute of Oncology Ljubljana, Ljubljana, Slovenia
- Association of Slovenian Cancer Societies, Ljubljana, 1000, Slovenia
| | - Megan Burke Fitzpatrick
- University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
- Department of Pathology and Laboratory Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
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Mandiriri AM, Pascoe MJ, Shamu T, Lowe S. Cervical human papillomavirus prevalence, risk factors and outcomes in a cohort of HIV-infected women in Harare, Zimbabwe. South Afr J HIV Med 2020; 21:1123. [PMID: 33240535 PMCID: PMC7670035 DOI: 10.4102/sajhivmed.v21i1.1123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 08/30/2020] [Indexed: 12/25/2022] Open
Abstract
Background Human papillomavirus (HPV) associated invasive cervical cancer (ICC) is common in Zimbabwe, disproportionately affecting women living with HIV (WLHIV). Understanding high-risk HPV (hrHPV) infection in relation to cervical disease is important for ICC prevention amongst WLHIV. Objectives To describe the prevalence of cervical hrHPV, type distribution, associated risk factors and ICC screening outcomes in an urban cohort of Zimbabwean women. Methods In this cohort study, WLHIV were tested for hrHPV infection using the Cepheid Xpert® HPV assay and followed up for incident cervical disease. Follow-up assessments were done by visual inspection with acetic acid (VIA). Descriptive statistics and logistic regression were used to describe hrHPV burden and association between hrHPV and potential risk factors. Incidence rates (IR) and rate ratios of cervical disease by hrHPV infection status were also calculated. Results Amongst 321 WLHIV recruited, hrHPV prevalence was 24.9% (n = 80). Fifty-two of these women (65%) were positive for hrHPV types other than 16 or 18/45. Younger age (22–29 years), early sexual debut (13–16 years) and antiretroviral therapy (ART) regimen (second-line ART) were independently associated with hrHPV positivity. Positive VIA IR ratio between hrHPV-positive and -negative women was 12.57 (95% confidence interval [CI]: 4.14–38.19). Only women with hrHPV infection had incident cervical disease (IR: 6.41/100 person-years, (95% CI: 3.33–12.32). There were no ICC cases by the end of the 2-year follow-up. Conclusion There was a high prevalence of hrHPV infection other than 16 and 18/45 in this cohort. Integrating HPV testing in cervical cancer screening programmes may increase screening intervals in hrHPV-negative women, reducing costs for programmes. We recommend further research into cross protectivity of the bivalent and quadrivalent HPV vaccines against these other hrHPV types.
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Affiliation(s)
- Ardele M Mandiriri
- Newlands Clinic, Harare, Zimbabwe.,Department of Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | | | - Tinei Shamu
- Newlands Clinic, Harare, Zimbabwe.,Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Sara Lowe
- Newlands Clinic, Harare, Zimbabwe.,Department of Medicine, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
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10
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Orang'o EO, Were E, Rode O, Muthoka K, Byczkowski M, Sartor H, Vanden Broeck D, Schmidt D, Reuschenbach M, von Knebel Doeberitz M, Bussmann H. Novel concepts in cervical cancer screening: a comparison of VIA, HPV DNA test and p16 INK4a/Ki-67 dual stain cytology in Western Kenya. Infect Agent Cancer 2020; 15:57. [PMID: 33024449 PMCID: PMC7531147 DOI: 10.1186/s13027-020-00323-6] [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: 07/03/2020] [Accepted: 09/21/2020] [Indexed: 12/12/2022] Open
Abstract
Background Screening of unvaccinated women remains essential to mitigate the high morbidity/mortality of cervical cancer. Here, we compared visual inspection with acetic acid (VIA), recommended by WHO as the most cost-effective screening approach in LMICs, with HPV-based screening, and usage of p16INK4a/Ki-67 dual stain cytology. Methods We prospectively enrolled women participating in a VIA-based cervical cancer screening program in two peri-urban health centers of Kenya. Consenting women had a VIA examination preceded by collection of a liquid-based cytology sample from the cervix stored in PreservCyt medium (Hologic®). Analysis of all samples included a hrHPV DNA test and evaluation of a p16INK4a /Ki-67 (CINtecPLUS®) dual stained slide that was prepared using the ThinPrep® 2000 Processor and evaluated by a pathologist trained in the methodology. Results In 701 of a total of 800 women aged 18–64 years, all three investigations were performed and data could be analyzed. The HPV, VIA and dual stain cytology positivity were 33%, 7%, and 2% respectively. The HPV positivity rate of VIA positive cases was 32%. The five most common HPV types were HPV16, 52, 68, 58 and 35. The OR among HIV infected women of an HPV infection, VIA positivity and positive dual stain cytology were 2.6 (95%CI 1.5–4.3), 1.9 (95%CI 0.89–4.4) and 3.4 (95%CI 1.07–10.9) respectively. The sensitivity of VIA to detect a p16INK4a/Ki-67 positive transforming infection was 13% (95%CI 2–38). Conclusions Primary HPV testing appears feasible and should be considered as a primary screening test also in LMICs. The poor sensitivity of VIA renders it unsuitable as a triage test for HPV positive women. The utility of p16INK4a/Ki-67 dual stain cytology as a triage test for HPV positive women in LMICs should be further studied.
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Affiliation(s)
- Elkanah Omenge Orang'o
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.,Department of Reproductive Health, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
| | - Edwin Were
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.,Department of Reproductive Health, School of Medicine, College of Health Sciences, Moi University, Eldoret, Kenya
| | - Oliver Rode
- Applied Tumor Biology, Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany
| | - Kapten Muthoka
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | | | - Heike Sartor
- Applied Tumor Biology, Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany
| | - Davy Vanden Broeck
- International Centre of Reproductive Health, Ghent University, Ghent, Belgium.,National Reference Centre for HPV, Brussels, Belgium.,Laboratory of Molecular Pathology, AML, Antwerp, Belgium
| | - Dietmar Schmidt
- MVZ of Histology, Cytology and Molecular Diagnostics, Department of Cytopathology, Trier, Germany
| | - Miriam Reuschenbach
- Applied Tumor Biology, Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Hermann Bussmann
- Applied Tumor Biology, Institute of Pathology, Heidelberg University Hospital, Heidelberg, Germany
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11
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Thistle P, Parpia R, Pain D, Lee H, Manasa J, Schnipper LE. Prevalence and Subtype Distribution of High-Risk Human Papillomavirus Among Women Presenting for Cervical Cancer Screening at Karanda Mission Hospital. JCO Glob Oncol 2020; 6:1276-1281. [PMID: 32783640 PMCID: PMC7456322 DOI: 10.1200/go.20.00286] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE High-risk human papillomaviruses (hrHPV) are the primary cause of cervical cancer. Human papillomavirus (HPV) vaccination is expected to prevent cervical cancers caused by the HPV types included in vaccines and possibly by cross-protection from other types. This study sought to determine the hrHPV type distribution in women at a rural Zimbabwe hospital. METHODS We implemented a cross-sectional study at the Karanda Mission Hospital. Using the Visual Inspection with Acetic Acid Cervicography technique, clinicians collected cervical swabs from 400 women presenting for screening for cervical cancer. Samples were initially analyzed by Cepheid GeneXpert; candidate hrHPV genotypes were further characterized using the Anyplex II HPV28 Detection Kit. RESULTS Twenty-one percent of the 400 women were positive for a high-risk genotype when using the GeneXpert analyzer; 17% were positive when using the multiplex analysis. Almost two thirds of the hrHPV women had a single DNA type identified, whereas one third had multiple genotypes, ranging from 2 to 5. hrHPV was observed more frequently in HIV-positive than in HIV-negative women (27% v 15%). Of the 113 isolates obtained, 77% were hrHPV genotypes not included in the bivalent or quadrivalent vaccines, and 47% represented DNA types not covered in the nonavalent vaccine. Forty-seven percent of the women with hrHPV harbored a single genotype that was not covered by the nonavalent vaccine. CONCLUSION A large fraction of hrHPV isolates from women participating in a cervical cancer screening program in northern Zimbabwe are DNA types not covered by the bivalent, quadrivalent, or nonavalent vaccines. These findings suggest the importance of characterizing the hrHPV DNA types isolated from cervical neoplasia in this population and determining whether cross-immunization against these genotypes develops after administration of the vaccines in current use.
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Affiliation(s)
- Paul Thistle
- Karanda Mission Hospital, Mount Darwin, Zimbabwe
| | | | | | - Hang Lee
- Massachusetts General Hospital, Boston, MA
| | - Justen Manasa
- African Institute of Biomedical Science and Technologies Laboratory, Harare, Zimbabwe
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12
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Fitzpatrick M, Pathipati MP, McCarty K, Rosenthal A, Katzenstein D, Chirenje ZM, Pinsky B. Knowledge, attitudes, and practices of cervical Cancer screening among HIV-positive and HIV-negative women participating in human papillomavirus screening in rural Zimbabwe. BMC WOMENS HEALTH 2020; 20:153. [PMID: 32711530 PMCID: PMC7382027 DOI: 10.1186/s12905-020-01017-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 07/12/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND Women in low- and middle-income countries are at the highest risk of cervical cancer yet have limited access to and participation in cervical cancer screening programs. Integrating self-collected, community-based screening offers a potential primary screening method in areas of limited resources. In this paper, we present a study evaluating knowledge, attitudes, and practices of cervical cancer and Human Papilloma Virus (HPV) in rural Zimbabwe. METHODS We performed a community-based cross-sectional knowledge, attitudes and practices of HPV and cervical cancer study in rural Zimbabwe from January 2017-May 2017. Women were selected for the study via random number generation from complete lists of inhabitants in the study area if they satisfied the inclusion criteria (≥30-years-old, ≤65-years-old, not pregnant, intact uterus). If selected, they participated in a 19-question structured knowledge, attitudes and practices survey. The questionnaire included questions on demographics, education, knowledge of HPV, cervical cancer, and risk factors. Chi-squared tests were evaluated comparing knowledge, attitudes and practices relating to HPV and cervical cancer screening with actual infection with HPV. Women were also offered a voluntary HIV and self-collected HPV screening. RESULTS Six hundred seventy-nine women were included in the knowledge, attitudes and practices survey. Most women (81%) had heard of cervical cancer while the majority had not heard of HPV (12%). The number of women that had been screened previously for cervical cancer was low (5%). There were no significant differences between and within groups regarding knowledge of cervical cancer and actual overall infection with HR-HPV, HPV 16, and HPV 18/45 test results. CONCLUSIONS Most women in rural Zimbabwe have heard of cervical cancer, but the number that had been screened was low. Extending existing outreach services to include cervical cancer screening, potentially including HPV screening, should include cervical cancer/HPV education and screening triage. This approach would serve to bridge the gap between knowledge and screening availability to address some of the barriers to cervical cancer care still affecting women in many regions of the world.
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Affiliation(s)
- Megan Fitzpatrick
- Department of Pathology, University of Wisconsin, 600 Highlands Ave, Madison, WI, USA.
| | - Mythili P Pathipati
- Department of Internal Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
| | - Kathy McCarty
- Chidamoyo Christian Hospital, P.O. Box 330, Karoi, Zimbabwe
| | - Anat Rosenthal
- Department of Health Systems Management, Ben-Gurion University of the Negev, P.O.B. 653, 8410501, Beer-Sheva, Israel
| | - David Katzenstein
- Biomedical Research and Training Institute of Zimbabwe, 10 Seagrave Rd, Mount Pleasant, Harare, Zimbabwe
| | - Z M Chirenje
- Department of Obstetrics and Gynecology, University of Zimbabwe College of Health Science, Harare, Zimbabwe
| | - Benjamin Pinsky
- Department of Pathology, Stanford Hospitals and Clinics, 300 Pasteur Drive, Stanford, CA, USA
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13
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Fitzpatrick MB, Hahn Z, Mandishora RSD, Dao J, Weber J, Huang C, Sahoo MK, Katzenstein DA, Pinsky BA. Whole-Genome Analysis of Cervical Human Papillomavirus Type 35 from rural Zimbabwean Women. Sci Rep 2020; 10:7001. [PMID: 32332798 PMCID: PMC7181610 DOI: 10.1038/s41598-020-63882-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 04/07/2020] [Indexed: 11/12/2022] Open
Abstract
Human papillomavirus (HPV) types differ by geographic location and the ethnicity of the human host, which may have implications for carcinogenicity. HPV35 is one of the least frequently identified high-risk types in North America and Europe but was the most common high-risk HPV (hrHPV) infection in a cohort in rural Zimbabwe. Whole genome analysis is limited for HPV35; no such studies have been performed in Zimbabwe. Of 648 women in the initial cohort in Zimbabwe, 19 (19/648, 2.9%) tested positive for HPV35, and eight samples were successfully sequenced for HPV35. The maximum number of sequence variants for the whole genome was 58 nucleotides (0.7%) compared to the prototype (58/7879). The maximum number of sequence variants in E6 and E7 was 3 (3/450, 0.7%) 2 (2/300, 0.7%), respectively. These are the first HPV35 whole genome sequences from Zimbabwe, and these data further lend support to the carcinogenicity of HPV35 despite limited sequence heterogeneity. Further studies to determine carcinogenic effects and impact of HPV vaccinations are warranted, especially in sub-Saharan Africa.
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Affiliation(s)
- Megan B Fitzpatrick
- Stanford Health Care, Stanford, CA, USA
- Stanford University School of Medicine, Department of Pathology, Stanford, CA, USA
| | - Zoe Hahn
- Stanford University School of Medicine, Department of Pathology, Stanford, CA, USA
| | - Racheal S Dube Mandishora
- University of Zimbabwe College of Health Sciences, Department of Medical Microbiology, Harare, Zimbabwe
| | - Jenny Dao
- Stanford University School of Medicine, Department of Pathology, Stanford, CA, USA
| | - Jenna Weber
- Stanford University School of Medicine, Department of Pathology, Stanford, CA, USA
| | - ChunHong Huang
- Stanford University School of Medicine, Department of Pathology, Stanford, CA, USA
| | - Malaya K Sahoo
- Stanford University School of Medicine, Department of Pathology, Stanford, CA, USA
| | - David A Katzenstein
- Stanford University School of Medicine, Department of Medicine, Division of Infectious Diseases and Geographic Medicine, Stanford, CA, USA
| | - Benjamin A Pinsky
- Stanford Health Care, Stanford, CA, USA.
- Stanford University School of Medicine, Department of Pathology, Stanford, CA, USA.
- Stanford University School of Medicine, Department of Medicine, Division of Infectious Diseases and Geographic Medicine, Stanford, CA, USA.
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