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Review article
Abstract Purpose: Global data on age-specific prevalence of human papillomavirus (HPV) infection overall,
and for high-risk HPV types 16 and 18, are essential for the future implementation of HPV prophylac-
tic vaccines for cervical cancer prevention.
Methods: A systematic review of peer-reviewed publications was conducted to summarize world-
wide data on genital HPV-DNA prevalence in women. Studies with clear descriptions of polymerase
chain reaction or hybrid capture detection assays were included.
Results: A total of 346,160 women were included in 375 studies. Of 134 studies with age-stratified
HPV prevalence data (116 low sexual risk populations, 18 high sexual risk populations), over 50%
were from Europe and the Middle East (38%) and North America (19%), with smaller proportions
from Asia and Australia (21%), Central and South America (11%), and Africa (10%). Across all geo-
graphical regions, data on HPV prevalence were generally limited to women over 18 years of age. Con-
sistently across studies, HPV infection prevalence decreased with increasing age from a peak
prevalence in younger women (25 years of age). In middle-aged women (35–50 years), maximum
HPV prevalence differed across geographical regions: Africa (~20%), Asia/Australia (~15%), Central
and South America (~20%), North America (~20%), Southern Europe/Middle East (~15%), and
Northern Europe (~15%). Inconsistent trends in HPV prevalence by age were noted in older women,
with a decrease or plateau of HPV prevalence in older ages in most studies, whereas others showed an
increase of HPV prevalence in older ages. Similar trends of HPV 16 and/or 18 prevalence by age were
noted among 12 populations with available data.
Discussion: Genital HPV infection in women is predominantly acquired in adolescence, and peak
prevalence in middle-aged women appears to differ across geographical regions. Worldwide variations
in HPV prevalence across age appear to largely reflect differences in sexual behavior across geograph-
ical regions. Further studies of HPV prevalence in adolescents are needed for all geographic regions.
Ó 2008 Society for Adolescent Medicine. All rights reserved.
Key words: Human papillomavirus; Cervical cancer; Epidemiology
Highly effective prophylactic vaccines against human pap- 80%) of ICC cases worldwide. ICC is the second most com-
illomavirus (HPV) types 16 and 18 [1,2] (the most common mon cancer in women worldwide, with most (83%) of the
types in invasive cervical cancer [ICC]) [3,4]) are uniquely ef- 493,000 estimated global cases occurring in less-developed
fective for the prevention of the majority (approximately 70%– countries [5]. Vulvar, vaginal, oropharygeal, and anal cancers
in women are also manifestations of HPV infection [6,7].
HPV is one of the most common sexually transmitted in-
This study was funded by Worldwide Epidemiology, GlaxoSmithKline fections (STIs) worldwide [8] and in the United States (US),
(GSK).
*Address correspondence to: Jennifer S. Smith, Ph.D., Department of
where it is estimated that 24.9 million women aged 14 to 59
Epidemiology, University of North Carolina, Chapel, Hill, NC 27599 years are infected [9]. Although the estimated risk of HPV is
E-mail address: jennifers@unc.edu notably high over a woman’s lifetime (~80%) [10], most
1054-139X/08/$ – see front matter Ó 2008 Society for Adolescent Medicine. All rights reserved.
doi:10.1016/j.jadohealth.2008.07.009
S6 J.S. Smith et al. / Journal of Adolescent Health 43 (2008) S5–S25
women who acquire HPV infection do not develop more se- of study; dates of sample collection; HPV detection method-
rious high-grade cervical neoplasia or invasive cancer, as ology (i.e., PCR primers or HCII); anatomical site and
most infections are transient [11]. methods of sample collection; population description (i.e.,
Among cross-sectional population-based samples in dif- national survey, antenatal, or commercial sex worker
ferent geographical areas, a broader range of HPV prevalence [CSW]); mean or median age of sample, with range when
and type-distribution has been detected in women with nor- available; sample size; and prevalence of HPV in the total
mal cytology than in women with ICC [12]. The prevalence population sample (overall, high risk, low risk, HPV 16,
of HPV infection, overall and by age, varies by country, re- and HPV 18). Populations were stratified into ‘‘high risk’’
gion within country, and population subgroup. To compare and ‘‘low risk.’’ Populations classified as ‘‘high risk’’ were
HPV prevalence between geographic areas or countries, those at greater risk of having genital HPV infection, such
data on age-specific or age-adjusted prevalence using sensi- as HIV-positive women, CSWs, and women with other
tive HPV detection methods are needed. Age-specific data STIs; all others were classified as ‘‘low-risk’’ populations
on HPV prevalence among female adolescents would also [13]. When published results were presented only graphi-
be useful (in conjunction with data on age at first intercourse) cally, prevalence was estimated from the graphs. In some
to inform future policies to maximize the potential benefits of cases, age-stratified sample sizes were not available. In these
HPV prophylactic vaccination. cases, overall HPV prevalence was reported, for which a sam-
This review summarizes the available published data on the ple size was available with the mean or median age. For arti-
prevalence of HPV-DNA based on highly sensitive HPV de- cles that presented data on HPV prevalence for both PCR and
tection techniques as well as associated HPV prevalence curves HC, all results were presented in the tables, although only the
by age for different female populations throughout the world. PCR results were presented in the figures. For quality control,
all data were entered twice by two independent data abstrac-
Methods tors, and every numbered reference in the text and tables was
crosschecked with those in the bibliography; any discordant
Material reviewed results were resolved by consensus. For studies that pre-
Source material was extracted from a systematic literature sented data on HPV with the same population in multiple
search from January 1, 1989 through March 1, 2007, result- publications, the largest publication was chosen and refer-
ing in approximately 5000 abstracts generated by MEDLINE ences to all corresponding publications were included in
(via PubMed) and references cited in the selected papers. Key data tables for that particular study. Where HPV data are de-
search words included papillomavirus, human, polymerase fined in the tables for individuals within an age group, the
chain reaction (PCR), hybrid capture I or II (HCI/II [Digene mean of the age range was used as data points on the graphs.
Corporation, Gaithersberg, MD]), and DNA. The literature Within each geographic area, studies were ordered by
search was restricted to peer-reviewed articles that provided country and city/region within the country, and are reported
a clear description of PCR or HC methodology for the detec- in Tables 1 and 2 (refer to appendices at http://jahonline.
tion of HPV infection. Studies citing the use of relatively less org). Studies with overall HPV prevalence data for specific
sensitive detection methods (i.e., in situ hybridization) or the age groups are shown in Figures 1 to 5 for low-risk popula-
detection of HPV serum antibodies were excluded. Studies tions by geographic region. Figure 6 shows age-specific prev-
were limited to those that provided data on age; sample sizes alence for HPV 16 and 18. Trends in HPV prevalence by age
were required to be at least 20 subjects per age group, and age were based on data presented in the smoothed curves shown
groups were combined when necessary. There were no lan- as insets in the upper right-hand corner of their respective fig-
guage restrictions on publications included. Of all publica- ure. The curves were estimated using locally weighted regres-
tions, only approximately 3% were published in a foreign sion of HPV prevalence by age with combined data for each
language. For these, the data were extracted and confirmed region and regression estimations were conducted using the
by a second, independent reviewer fluent in the language. As- least-squared methods [14].
sistance with interpretation was requested when needed. In
Results
addition, studies were only included if baseline cytology
was stated as normal, or if from a screening or population- Age-specific HPV prevalence in low-risk groups
based study and had <30% of women with abnormal cytol-
ogy of low-grade squamous intraepithelial lesions (LSIL) Africa
or greater. Articles were reviewed in full if study abstracts In comparison with other geographical regions, few data
gave an indication of fulfilling these criteria. Conference ab- were available on HPV-DNA prevalence by age in Africa,
stracts and other unpublished manuscripts were excluded. with a total of 15 countries surveyed. Available studies orig-
inated from countries in Northern Africa, Western Africa,
and south of the Sahara Desert (Table 1); no data were avail-
Data extraction and analysis
able from Central Africa. The 13 populations with HPV-
For each study, the following information was extracted: DNA data stratified by age were generally limited to women
first author, publication journal, and date; country and city aged 20 to 65 years (smoothed curve of Figure 1). Overall
J.S. Smith et al. / Journal of Adolescent Health 43 (2008) S5–S25 S7
90
60
Prevalence (%)
80
70 40
Prevalence (%)
60
20
50
40 0
20 30 40 50 60 70
30 Age
20
10
0
0 20 40 60 80 100
Age (Years)
Figure 1. HPV prevalence by age in Africa among low-risk female populations by country, city, and study.
prevalence ranged from 12% in women without cervical can- prevalence in South America (64%) was reported in a cervical
cer (mean age ¼ 39 years) in South Africa [15,16] to 46% in cancer screening sample of Guarani Indian women (mean age
women attending clinics for antenatal care or general genital 15 years) in Argentina [33,34]. Age-stratified data showed
symptoms in Gabon (mean age ¼ 26 years) [17]. high prevalence rates of 54% and 59% from 14- to 24-year-
Stratified data on HPV prevalence in younger women old females attending a gynecologic clinic in Argentina [35]
were limited. Studies on nine low-risk populations [18–27] and an older group of cytologically normal women in Recife,
included women less than 25 years of age. The highest prev- Brazil (mean age 43 years), respectively [36]. A similar trend
alence was 55% in women aged 14 to 20 years from a rural of high HPV prevalence was observed in the youngest age
community in Manhica, Mozambique [27]. groups of other age-stratified studies in South American
Patterns of HPV prevalence by age appeared to differ females [37–42] (Figure 2). In Central America, the highest
across surveyed countries (Figure 1). Only a few studies, HPV prevalence was reported among clinic-based controls
however, included a relatively wide age-band of reproductive aged 15 to 24 years in Tegucigalpa, Honduras (71%) [43–47].
years (15–49 years). In Tunisia [25,26], Kenya [19], Uganda Within the region, the majority of studies with age-specific
[22], and Zimbabwe [28–30], HPV-DNA prevalence was HPV prevalence data followed a slight U-shaped curve
highest in young women and decreased steadily with age. (smoothed curve of Figure 2). Studies from Honduras [43–
In Nigeria [20], Kenya [31], and Mozambique [27], HPV 47], Mexico [48–50], Colombia [39–41], Costa Rica [51–
positivity also declined with age but generally reached a pla- 60], Chile [42], and Brazil [38] found a high HPV prevalence
teau at approximately 40 years of age. In contrast, HPV pos- in women under 30 years old that steadily decreased thereafter
itivity increased slightly in older aged women in Senegal with an upward trend in older women (Figure 2). The age of the
(over 45 years of age) [32] and in South Africa (over 50 years second increase in HPV prevalence in older women in these
of age) [15,16]. In comparison, women surveyed in Gambia studies appeared to differ by geographical location, being
seemed to have a relatively constant prevalence of HPV in- over 40 years in Honduras [43–47], Chile [42], Port Alegre,
fection among those aged 15 to 54 years [18]. Overall, the Brazil [38], and Mexico [48–50], and over 50 years in Costa
highest prevalence of HPV was 58% in a study of family Rica [51–60] and Colombia [39–41]. In contrast, Sao Paulo,
planning clinic attendees aged 25 to 29 years in Nairobi, Brazil [61], and Concordia, Argentina [37], demonstrated
Kenya [31]. a consistent downward trend of HPV prevalence by age.
90
Prevalence (%)
60
80
40
70
Prevalence (%)
60 20
50
0
40 20 40 60 80
Age
30
20
10
0
0 20 40 60 80 100
Age (Years)
Figure 2. HPV prevalence by age in Central and South America among low-risk female populations by country, city, and study.
were from the US. A recent report of population-based age- In 10 studies from China, HPV prevalence ranged from
specific HPV prevalence in the US National Health and Nu- 5.5% among women aged 30 to 60 years (no city reported)
trition Examination Survey showed a sharp increase from 14 [100] to 53% among women aged 22 to 36 years in Shenyang
to 19 years of age (24.5%) to peak prevalence at 20 to 24 [97]. In Xiangyan and Yangchen [98], age-specific preva-
years of age (44.8%), after which HPV prevalence declined lence was essentially constant across women aged 30 to 50
to 19.6% in 50- to 59-year-olds [9]. In terms of regional dif- years. In 15 studies from India, age-specific HPV was as
ferences within the US, HPV prevalence was particularly low as 0% in a study of 30 women in Vellore (median age
high (55%-70%) in urban youths aged 13 to 20 years in At- 45 years) [113], and as high as 45% in a study of pregnant
lanta, Georgia [62]. Similarly, HPV prevalence was high (ap- women aged 30 to 39 years from Kolkata [108]. Of 17 studies
proximately 24%–55%) among female college students in in Japan, HPV prevalence was generally low, with 12 studies
Berkeley, California [63,64], Maryland [65], New Jersey reporting a prevalence of less than 15% [115,118,121–
[66,67], and New Mexico [68,69]. 127,129–131]. In Australia, four populations [87–91] re-
Among age-stratified low-risk populations, there was ported prevalences ranging from 6% in women with
a clear peak in prevalence in younger women (approximately a mean age of 19 years (range ¼ 13–44 years) [89] to 41%
20–25 years of age), with a downward trend as age increased in women aged 18 to 20 years [87,88] (Table 1). No data
(smoothed curve of Figure 3) [9,70–82]. HPV prevalence were reported from New Zealand.
varied widely, ranging from 2% in women 50 to 59 years
of age in Douglas, Arizona [83], to 70% in females 16 years Europe and the Middle East
of age in Atlanta, Georgia [62]. Data from 111 low-risk populations were available for
Overall, studies in Canada reflected a slightly lower prev- many European countries [25,139,157–271]. For the Middle
alence of HPV compared with the US. Most studies had East, information was available for Egypt [272], Lebanon
a peak prevalence of approximately 20% to 25% in 20- [273], and Turkey [274].
year-old females and a decline associated with increasing In Northern Europe (smoothed curve of Figure 5A), over-
age [84–86]. all HPV prevalence was generally less than 20% and gener-
ally lower than in North America (smoothed curve of
Asia (including Australia) Figure 3). In one large study of 4000 women in Germany,
Seventy-one studies have been conducted in Australia HPV prevalence peaked at 14% in 18- to 25-year-olds, and
[87–91], China [92–101], India [102–114], Japan [115– steadily decreased to 0% in 61- to 70year-olds [198]. One no-
131], Korea [132–138], the Phillippines [139], Taiwan table exception was a study of 90 women attending cervical
[140–145], Thailand [146–155], and Vietnam [156] (Table cancer screening in a gynecology clinic in Poland [241]. HPV
1). HPV prevalence generally tended to be lower than in other prevalence was 59% in women aged 45 to 55 years, and ap-
areas of the world (smoothed curve of Figure 4), with the ex- proximately 26% in women over age 55 [241].
ception of studies in Japan [120], Australia [87,88,90], China In Southern Europe (smoothed curve of Figure 5B),
[97], and India [108,112] (Figure 4). HPV prevalence was generally comparable to that in
J.S. Smith et al. / Journal of Adolescent Health 43 (2008) S5–S25 S9
100
90
60
80
Prevalence (%)
70 40
Prevalence (%)
60
20
50
40 0
20 30 40 50 60 70
30
Age
20
10
0
0 20 40 60 80 100
Age (Years)
Figure 3. HPV prevalence by age in North America among low-risk female populations by country, city, and study.
Northern Europe (Figure 5A), and generally showed peak of females aged 14 to 75 years [247,248]. Studies in Italy
prevalences in women in their early 20s. In two studies in revealed differing age-specific prevalence trends. One
Reims, France [190,191], female adolescents from 15 study of women in Genova reported an HPV prevalence
years were sampled, with the peak prevalence observed of 15% in women 44 years of age and younger, and
in those aged 21 to 30 years (24% vs. 28%). In Spain, found the highest prevalence (19%) in women 60 years
HPV prevalence was low—1% to 11% in a large sample of age and older [215]. Another study in Turin, Italy,
80 50
40
70
Prevalence (%)
30
60 20
50 10
0
40
20 40 60 80 100
30 Age
20
10
0
0 20 40 60 80 100
Age (Years)
Figure 4. HPV prevalence by age in Asia/Australia among low-risk female populations by country, city, and study.
S10 J.S. Smith et al. / Journal of Adolescent Health 43 (2008) S5–S25
Denmark 171
Denmark, Copenhagen1 67170
England, London176, 178
Prevalence (%)
60
80
70 40
Prevalence (%)
60
20
50
40 0
20 40 60 80
30 Age
20
10
0
0 20 40 60 80 100
Age (Years)
80 50
70 40
Prevalence (%)
30
60
20
50 10
0
40
20 40 60 80
30 Age
20
10
0
0 20 40 60 80 100
Age (Years)
Figure 5. (A) HPV prevalence by age in Northern Europe among low-risk populations by country, city, and study. (B) HPV prevalence by age in Southern Europe
among low-risk female populations by country, city, and study.
showed a peak prevalence (14%) in women aged 35 to 39 63%) in Senegal [275], South Africa [276], and Tunisia
years that decreased thereafter [220]. [26]. When compared with HIV negative women, overall
HPV prevalence was more than three times higher in
HIV-positive women in Senegal [277] and twice as high
Age-specific HPV prevalence among high-risk groups
in HIV-positive women in rural Zimbabwe [278] (Table
Among the 86 high-risk populations studied, seven 1). The highest reported prevalence in Africa was 75%
were in Africa, nine in Central and South America, 19 in HIV-positive women attending infectious disease clinics
in North America, 14 in Asia and Australia, and 37 in Eu- (mean age ¼ 29 years) in Dakar, Senegal [277], with four
rope/Middle East (Table 2). In Africa, overall HPV preva- of seven studies reporting prevalences greater than 50%
lence was consistently high in female sex workers (39%– (Table 2).
J.S. Smith et al. / Journal of Adolescent Health 43 (2008) S5–S25 S11
40
Prevalence (%)
30
20
10
0
0 20 40 60 80 100
Age (Years)
Figure 6. HPV 16/18 prevalence by age in women by country, city, and study. HPV 16, solid black or gray lines; HPV 18, black or gray dashed lines; HPV 16/18,
closed gray symbol and solid gray line.
In Central and South America, the highest prevalence of clinic attendees in Sydney, Australia (mean age ¼ 28 years),
HPV was 88% in HIV-positive women in Sao Paulo, Brazil reported an HPV prevalence of greater than 50% [297], de-
(mean age ¼ 32 years) [279]. Four of nine studies, primarily spite the fact that the populations sampled included CSWs,
of HIV-positive women and/or CSWs, reported a prevalence HIV-positive women, and women attending STI clinics.
of greater than 50% [279–282]. Among studies from Central High-risk studies in Europe had findings similar to those
America, three high-risk populations from Mexico [281,283, of North America. The highest prevalence reported was
284] and one from Honduras [285] were described. Peak also 91% in HIV positive women (mean age ¼ 31 years) in
HPV prevalence was observed in the youngest age groups Milan, Italy [217]. Also similar to North America, approxi-
in age-specific studies and generally decreased with increas- mately half of the 36 studies with high-risk populations had
ing age. a prevalence of greater than 50%, which included studies
In North America, 63% (12 of 19) of the high-risk popu- of STI clinic attendees and/or CSWs. A particularly high
lations had a prevalence greater than 40%, and two-thirds of prevalence was observed in STI clinic attendees (85%) under
the studies reported prevalences greater than 50%. The ma- 20 years of age in Greenland [38] and in Spanish CSWs
jority of studies in North America were conducted on STI (75%) of the same age [298]. HIV-positive women in Paris
clinic attendees. The highest HPV prevalence (91%) was re- [299], Germany [196], and Italy [214,300–302] all reported
ported in females aged 11 to 20 years attending STI and uni- an HPV prevalence of 60% or greater.
versity clinics in Baltimore, Maryland [286]. All studies in
North America that included HIV-positive women reported
HPV 16 and 18 prevalence stratified by age
an HPV prevalence of 50% or greater. The highest HPV prev-
alence rates were reported in a multicenter survey of metro- Thirteen studies reported HPV 16 or 18 stratified by age
politan areas (Women’s Interagency HIV Study [WIHS] (Figure 6). Among those sampled in lower sexual risk popu-
cohort) [287-293] and in a study of HIV positive women in lations (n ¼ 11), HPV 16 was generally less than one-quarter
Canada [294,295], both of which had a prevalence of approx- of the overall prevalence (Table 1). Generally, type-specific
imately 63%. prevalence for either HPV 16 or 18 was less than 8% and
Similar to data from low-risk populations, Asia had the overall prevalence of any HPV type was less than 30%. How-
lowest overall HPV prevalence among high-risk populations ever, there were a few notable exceptions, such as family
in comparison with other regions (Table 2). The highest prev- planning clinic attendees in Dalian City, China (mean age
alence reported was 69% in CSWs less than 18 years of age in 29 years), who had a prevalence of 34% for HPV 16 [93].
Bali, Indonesia [296]. Only one other population of STI Relatively higher prevalences for HPV 16 and 18 were
S12 J.S. Smith et al. / Journal of Adolescent Health 43 (2008) S5–S25
observed in Europe, with a few studies in Spain, Denmark, pronounced and occurs at different ages within different geo-
Germany, and Italy reporting type-specific prevalences of graphical regions, these data suggest that the higher preva-
over 25% and 5% for HPV 16 and 18, respectively lence in older age women is largely because of newly
[166,200,215,250]. In Poznan, Poland [241], cervical cancer acquired HPV infections, primarily reflecting differences in
screening patients aged 45 to 78 years with an overall HPV sexual behavior across global regions. Alternatively, the
prevalence of 49% had a generally high prevalence of both U-shaped curves of HPV by age may potentially be explained
HPV 16 and 18; prevalence was the highest for women by reactivation of latent HPV infections in older women.
aged 45 to 49 years, 39% and 27%, respectively, and de- A previous meta-analysis of 157,879 women by de San-
creased to 26% and 17%, respectively, in women aged 56 jose and colleagues [8] summarized the global literature
to 78 years [241]. One study in Khon Kaen, Thailand, also among women with normal cytology. The present review ex-
reported an approximately 11% prevalence for HPV 18 pands upon this previous work by presenting data on women
among women 25 to 60 years of age, with a prevalence of with normal cytology as well as those included in population-
3.8% for HPV 16 [154]. based surveys or routine screening programs to provide
Among the 85 studies conducted on high-risk populations, estimates that more closely represent those of the general
44 had prevalence data for HPV 16 and/or 18. Across all re- population. In the de Sanjose et al [8] review, age data
gions, prevalence of HPV 16 was approximately one-third were grouped into five specific categories, beginning with
to one-half of the overall prevalence reported for the same those aged 25 years or less to women greater than 54 years
studies (Table 2). In some cases, type-specific prevalence of age [8]. In comparison, age ranges were further delineated
rates for HPV 16 and 18 were comparable with overall prev- in the present review (15 years up to 90 years or older), pro-
alence rates. In Europe, sex workers in Copenhagen, Den- viding a clearer understanding of HPV prevalence trends by
mark [303] (mean age ¼ 31 years), had an overall HPV age within and among different geographical regions world-
prevalence of 32% and an HPV 16 prevalence of 31%. HIV wide.
positive women in Ancona, Italy [214], had an overall HPV Given the heterogeneity in laboratory assays employed for
prevalence of 67% and an HPV 16 prevalence of 48%. Sex HPV infection detection, populations surveyed, and the ob-
workers in a brothel (mean age ¼ 19 years) in Bangkok, Thai- served variation in HPV positivity across the different stud-
land [304], had higher HPV prevalence (approximately 26% ies, we have chosen not to present a summary estimate for
and 9% for HPV 16 and 18, respectively) than massage parlor overall HPV prevalence for geographical regions or for
sex workers (mean age ¼ 30 years; approximately 8% and 2% specific age groups [305]. Instead, this review provides
for HPV 16 and 18, respectively) (Table 2). HPV 16 and 18 both age- and country-specific data on HPV infection preva-
prevalence rates were highest in brothel workers 15 to 19 lence to allow for the examination of age-specific trends of
years of age (31% and 13%, respectively) [304]. These studies HPV prevalence within a particular region or a population
suggest that oncogenic HPV types 16 and 18 (included in cer- subgroup of interest. Within specific regions, data trends ap-
vical cancer vaccines) can comprise significant proportions of pear to be generally similar to those presented by de Sanjose
HPV infection in many high-risk populations worldwide. et al [8]. Although for studies in Africa, HPV prevalence was
previously reported to be between 20% and 30% [8], whereas
we observed prevalences that ranged from approximately 7%
Discussion
to 60%, with half of the studies showing less than 20% prev-
This review represents, to our knowledge, the largest alence. For Central and South America, the highest HPV
study of HPV prevalence worldwide, including HPV-DNA prevalence was previously shown to be approximately
prevalence data from over 346,000 women from 70 countries 25%, with a nadir at 10% among females aged 35 to 44 years
worldwide. Age-stratified HPV prevalence varied consider- [8]. This data curve was clearly U-shaped, suggesting a com-
ably across geographical regions, and depended upon many parably higher HPV prevalence in older age groups. In com-
factors, including age, country and region, and type of popu- parison, the present review similarly shows a U-shaped
lation surveyed. Across all geographical regions, observed pattern by age in Central and South America, although rela-
HPV prevalence was strongly associated with age, although tively flatter, with HPV prevalence ranging from less than 5%
age curves of HPV infection differed notably across regions. to approximately 70%. For studies in North America, we
The shapes of the curves were declining in older ages, flat show a decline in HPV prevalence with increasing age; this
across age, or characterized by a U shape, with a relatively is in contrast to data obtained by de Sanjose et al [8] for fe-
higher HPV prevalence in younger and older ages. Overall males above 35 years of age. Also, in contrast to an HPV
HPV prevalence in most geographical regions consistently prevalence of less than 25%, we observed prevalence rates
peaked in women aged 25 years of age, with a decrease of 2% to approximately 56%. For studies in Europe, the
in older age groups. In contrast, age curves of HPV preva- data were divided into northern and southern regions. HPV
lence among women in Central and South America and prevalence was generally similar between these two geo-
Africa were characterized by an increased or stable HPV graphical regions (up to 60%), yet prevalence estimates ap-
prevalence among women aged 45 years or older. Given peared to be relatively higher than those observed by de
that a second peak in HPV prevalence appears to be more Sanjose et al [8] for all of Europe (<25%). In the present
J.S. Smith et al. / Journal of Adolescent Health 43 (2008) S5–S25 S13
study, data from Asia and Australia were grouped and ap- population than the collection of cervicovaginal samples.
peared to be in contrast, for Asia only, to results obtained However, urine-based samples have also resulted in a lower
by de Sanjose et al [8]. HPV prevalence was previously re- sensitivity for HPV-DNA detection than sampling from other
ported to be between 5% and 11%, and these present data sites in the cervicovaginal tract [308].
show specific Asian regions with higher positivity in Japan The present systematic review, to our knowledge, repre-
(0%–50%) and Australia (20%–40%). sents the largest to date, with a comprehensive examination
Both this present review and the review by de Sanjose et al of HPV-DNA prevalence in all major geographical regions.
[8] consistently showed that HPV prevalence was highest For quality assurance, data were extracted and double-
among younger women for all major world regions, reflect- checked by two independent abstractors, and a complete list-
ing a higher probability of acquiring new infections at youn- ing of country and age-specific HPV prevalence data are
ger ages. We observed that HPV-DNA prevalence differed presented in appendices located at http://jahonline.org (Ta-
across geographical regions, with peak HPV prevalence bles 1 and 2). Results are further presented for global regions
among older aged women (35–50 years) differing somewhat of the Caribbean, Western Asia, and Australia, for which data
across geographical regions, being approximately 20% in were not previously presented for women with normal cytol-
Africa, North America, and Central and South America, ogy [8]. Given that few data are available in the literature on
and 15% in Asia/Australia, Southern Europe/Middle East, trends in HPV prevalence over time within specific popula-
and Northern Europe. Relative differences in HPV-DNA tions, data provided in this present review may be useful as
prevalence from one geographical region to another, how- baseline, prevaccination HPV prevalence data. This may be
ever, are not as striking as those seen for HSV-2 (herpes sim- most beneficial for future HPV vaccine evaluation efforts if
plex virus-2) seropositivity, which is characteristic of sequential HPV testing is conducted within individual popu-
a notably higher HSV-2 seropositivity in Africa, and lower lations postvaccination.
HSV-2 seropositivity within several geographical regions, Among study limitations, type-specific data for individual
including Asia [306]. These differences are likely attributed carcinogenic HPV types other than 16 and 18 (i.e., HPV 45,
to differences in the ascertainment methods used to quantify 31, 33, 52, 58, etc.) were not included in the present review,
the burden of HSV-2 (serum antibody detection indicative of although these data have been presented for women with nor-
cumulative exposure) and HPV (DNA detection indicative of mal cytology in the de Sanjose et al [8] review. HPV preva-
current, persistent, or reactivated HPV infection). At present, lence estimates presented here are also largely limited to
currently available methods to detect HPV serum antibodies sexually active or married women. Prevalence results for
[307] are not capable of accurately measuring a woman’s cu- low-risk populations may not entirely reflect those of the gen-
mulative exposure to HPV. Reliable data on a woman’s life- eral population. To provide estimates that may be more rep-
time risk (cumulative, ever-exposure) of acquiring an HPV resentative of general female populations, and because
infection would have been useful to assess the potential previous reviews have focused on comparing HPV type-dis-
long-term impact of prophylactic HPV vaccines. tribution in these female populations with women with low-
Comparisons of HPV prevalence by geographical area or and high-grade cervical precancerous lesions, data were not
country are generally hampered by differences among study limited to women with normal cytology [3,309]. Further,
populations surveyed, laboratory methods used, and the var- this review is limited to cross-sectional prevalence rather
iation in HPV types detected (i.e., overall HPV positivity, than the ascertainment of persistent HPV, which has been
high-risk HPV types, low-risk HPV types, or type-specific shown to be highly predictive of a woman’s future risk of
[i.e., HPV 16 or 18] positivity). To reduce the possibility of high-grade cervical neoplasia or cancer [170,310,311].
an underestimation of overall or type-specific prevalence, Few population-based prevalence surveys of HPV infec-
study criteria included the detection of HPV using PCR or tion have been conducted worldwide. This is likely because
HCII detection assays. Although PCR and HCII detection as- of expense as well as the difficulty in collecting physician-
says have been shown to have a relatively higher sensitivity based samples, which are associated with relatively higher
for HPV detection than earlier detection assays (i.e., dot-blot HPV-DNA detection than currently available self-collected
or Southern blot), the sensitivity of HPV-DNA detection for sampling techniques [9,312]. Further, detailed data presented
studies presented here may not have been optimal if there on different types of HPV detection assays focused on the
were differences in the ability of PCR primers to detect spe- type of PCR consensus primers used, rather than on differ-
cific HPV types, or if there was an underdetection of HPV be- ences in typing methods employed for HPV-positive speci-
cause of in-house laboratory testing procedures. Across mens, which may notably differ across testing laboratories.
geographical regions, HPV-DNA was generally detected us- A limited number of studies provided data on dual DNA
ing GP5þ/6þ, MY09/11, HCII, or type-specific PCR primer positivity to HPV types 16 and 18 in exfoliated cell speci-
systems, with the exception of Japan, where a relatively mens. Available data presented here on HPV-DNA preva-
larger proportion of studies used L1 primers. The sensitivity lence for HPV types 16 and 18 worldwide have
of detecting HPV may also vary based on the type of speci- implications for vaccination programs. In a randomized trial
men analyzed. Although not commonly used in this survey, of women in Costa Rica who were HPV-DNA-positive for
urine specimens may allow for easier sampling within the types 16 and 18, prophylactic HPV vaccination had no
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Table 1
S25.e1
HPV prevalence estimates in women from low-risk populations by continent, country, and study year.
Prevalence (%)d
Study location, dates, Assay Site of specimen Group tested Mean or median Sample Overall High Low HPV HPV
reference age, size HPV risk risk 16 18
years (range)
Africa
Algeria, Algiers, 1997–9 [315] GP5þ/6þ Ectocervix—spatula Hospital-based controls 52 (30–88) 145 12.4 6.2 0.7
Endocervix—brush
Gabon, Libreville, 2001 [17] MY09/11 Cervicovaginal—lavage Women attending clinics for 26.4 (18–44) 354 46.0 25.4 10.2 4.5 1.1
antenatal check-up or for
general genital symptoms
Gambia, Farafenni, 1999 [18] GP5þ/6þ Cervix—brush Population-based sample in rural 33.0a (15–54) 710 13.4
S25.e2
41–53 10.3
(Continued )
Table 1
S25.e3
Continued
Prevalence (%)d
Study location, dates, Assay Site of specimen Group tested Mean or median Sample Overall High Low HPV HPV
reference age, size HPV risk risk 16 18
years (range)
Tunisia, Sousse, 2002 [26] MY09/11, pu-1M/pu-2R, Cervix—brush Family-planning clients 35 (20–45) 96 14.6
and pu-31B/pu-2R
20–30 17.0a
31–40 14.0a
41–45 13.0a
Uganda, Rakai District, 1996–7 HCII Vagina—swab Community-based trial for HIV 31.3a (15–59) 737 16.3
[22] prevention
S25.e4
(Continued )
Table 1
S25.e5
Continued
Prevalence (%)d
Study location, dates, Assay Site of specimen Group tested Mean or median Sample Overall High Low HPV HPV
reference age, size HPV risk risk 16 18
years (range)
Brazil, Sao Paulo, 1993–7 MY09/11 Ecto/endocervix—smear Population-based cohort 33.3, 33 (18–60) 1425 13.8 2.7 0.8
[332,333]
18–34 17.1
35–60 9.8
Chile, Santiago, 2000–1 [42] GP5þ/6þ Ectocervix—spatula Population-based random sample 41.0a (15–69) 955 12.8 9.1 3.7 2.6 0.5
Endocervix—brush
S25.e6
population 85)
(Continued )
Table 1
S25.e7
Continued
Prevalence (%)d
Study location, dates, Assay Site of specimen Group tested Mean or median Sample Overall High Low HPV HPV
reference age, size HPV risk risk 16 18
years (range)
Vagina—swab (self-sampled) 15–24 495 14.0a
25–34 2035 10.0a
35–44 2047 7.0a
45–54 1602 8.5a
55–64 992 11.0a
65–85 565 12.0a
Mexico, Morelos, 1999–2000 HCII Vagina—swab (self-sampled) Cross-sectional screening study of 25.7 (16–39) 274 37.1
S25.e8
exam
(Continued )
Table 1
S25.e9
Continued
Prevalence (%)d
Study location, dates, Assay Site of specimen Group tested Mean or median Sample Overall High Low HPV HPV
reference age, size HPV risk risk 16 18
years (range)
USA, Nationwide, 1998–9[358] MY09/11 (16, L1) Cervicovaginal—avage and swab Population-based sample 20a (16–25) 2392 5.4
USA, Nationwide, 2003–4 [9] MY09/11 Self-collected cervicovaginal Population-based sample— (14–59) 1921 26.8 15.2 17.8 1.5 0.8
sample women from NHANES
14–19 652 24.5 17.0a 14.0a
20–24 189 44.8 29.0a 31.0a
25–29 174 27.4 14.0a 22.0a
30–39 328 27.5 16.0a 17.0a
S25.e10
(Continued )
Table 1
S25.e11
Continued
Prevalence (%)d
Study location, dates, Assay Site of specimen Group tested Mean or median Sample Overall High Low HPV HPV
reference age, size HPV risk risk 16 18
years (range)
USA, Maryland, College Park, MY09/11, GP1/2, and type- Cervix—spatula and brush US students undergoing routine 23 (18–40) 79 29.0
1996–7 [342] specific PCR (15 types from L1 cervical exam
region)
USA, Massachusetts, Boston, HCII Cervix—smear Healthy subjects; normal cytology 38.9 (30–45) 1000 3.9
2005 [373]
30–35 300 6.7
36–40 200 3.0
USA, North Carolina, No city Type-specific PCR with L1 Cervix—swab Pregnant and postpartum women 22.5 (12–50) 215 78.1 17.7
reported, 1989 [376] primers (6, 11, 16, 18)
Nonpregnant women 26.4 160 25.6 5.6
USA, Oregon, Portland, 1989–90 Type-specific PCR (6/11, 16, 18, Cervicovaginal—lavage Cytologically normal women 34 (16–81) 453 17.7 7.1 10.6 2.6 0.2
[75–80,377] 26, 31, 33, 35, 39, 40, 42, 45, presenting for routine Pap
51, 52, 53, 54, 55, 57, 59, smear
USA, Oregon, Portland, 1989–90 HCII Cervicovaginal—lavage Routine Pap smear 34.0b 16 20514 13.9 2.2 0.8
[79,378]
USA, Pennsylvania, Philadelphia, HCI Women undergoing routine care 25.6 (18–70) 93 34.6
1999 [379] or colposcopy
Cervicovaginal—tampon (self- 46 29.0 17.2 3.2
sampled)
Ecto/endocervix—swab 47 25.8 14.0 3.2
(physician-sampled)
USA, South Carolina, No city HCI Cervix—smear Family planning clinic-based 28.1 (16–45) 427 18.5
reported, 1995–8 [380] normal controls
USA, South Carolina, Trident PCR with E6 primers (6, 11, 16, Cervix—spatula, brush Routine smear at family planning 23.5 223 2.7
Health District, 1991 [381] 18, 33) visit
USA, South Carolina, Trident MY09/11 Cervix—spatula, brush Routine family planning clinic 29.3 1083 32.5 23.4 9.2
Health District, 1991–2 [382] visit
USA,Texas, Harris County, Type-specific PCR with L1 Cervix—brush Family planning and screening 26.9 (18) 270 19.3
1991–4 [383,384] primers (16, 18, 31, 33, 45, 51, attendees
52, 56)
USA, Washington; Pennsylvania; MY09/11 Cervicovaginal—swab Random sample of population- 40.9a (18–69) 285 17.2 12.6 4.6
Connecticut, 1992–6 [385,386] based controls
USA, Washington, No city MY09/11 and HMBO1 Endocervix—swab Planned Parenthood clinic sample 25a (18–50) 4075 18.3 3.9 5.3 1.5
reported, 1997–2000 [82]
18–19 21.0a
20–24 22.0a
25–29 18.0a
30–34 12.0a
S25.e12
35–50 5.0a
(Continued )
Table 1
S25.e13
Continued
Prevalence (%)d
Study location, dates, Assay Site of specimen Group tested Mean or median Sample Overall High Low HPV HPV
reference age, size HPV risk risk 16 18
years (range)
USA, Washington, Seattle, 1990– MY09/11 and HMBO1 Cervix and vulvovaginal—swab University-based random sample 19.2 (18–20) 553 19.7
7 [387]
USA, Washington, Seattle, 1990– MY09/11 (6, 11, 16, 18) Ecto/endocervix and University students (18–20) 588 8.2 4.1
8 [388–391] vulvovaginal—swab
USA, Washington, Seattle, 1994– L1 primers Cervix—brush spatula, swab University students 19.2 305 16.0
6 [392]
USA, Washington, DC. 1984–7 PCR, MY09/11, HMBO1, GH20, Cervicovaginal—lavage Women undergoing routine 26 (16–72) 404 33.7
China, Shenyang, 1993 [97] Type-specific PCR with L1 Cervical secretions Pregnant women hospitalized for 22–36 30 53.3
primers (6, 11, 16, 18, 31, 33, delivery
35, 38)
China, Xiangyuan and HCII Cervix—smear Population-based study 30–50 9683 27.4
Yangcheng Countyc [98]
Xiangyuan 30–34 148 25.0
35–39 2566 26.4
40–44 1892 26.5
45–50 1491 26.0
Yangcheng 30–34 93 23.7
35–59 1536 28.9
40–44 1028 31.3
45–50 929 29.6
India, No city reported, 2001 HPV 16 with E6 and E2 PCR Cervix—spatula Clinic-based controls (24–45) 31 34.1
[102] primers
India, No city reportedc [112] Type-specific PCR (16, 18) Cervix—scrape Normal controls attending (16–80) 201 41.8
reproductive clinic
India, Chennai, 1998–9 [107] GP5þ/6þ Ectocervix—spatula Cancer institute-based controls 34 (16–81) 184 27.7 21.7 6.0 18.5 2.2
Endocervix— brush
India, Dindigul, 2003 [111] GP5þ/6þ Cervix—broom, brush Population-based controls 33.1a (16–59) 1891 16.9 12.5 6.0 3.8 1.0
<25 334 16.8
25–34 847 16.2
35–44 446 18.4
45–54 228 17.1
55 36 16.7
India, Kolkata, 1999–2001 [108] MY09/11 Endocervix— brush Pregnant women 26.5a (20–39) 135 28.1 9.6 5.2
20–29 106 23.6
S25.e14
30–39 29 44.8
(Continued )
Table 1
S25.e15
Continued
Prevalence (%)d
Study location, dates, Assay Site of specimen Group tested Mean or median Sample Overall High Low HPV HPV
reference age, size HPV risk risk 16 18
years (range)
India, Kolkata, 1999–2003 [114] HCII Ecto/endocervix—broom, brush Population-based controls 25–65 17365 5.8
India, Maharastra, 1999–2003 HCII Cervix—brush Healthy women attending primary 39.3 (30–59) 2841 10.3
[109] village healthcare center
India, Manipur, 2001–6 [110] MY09/11 Ectocervix—spatula Women attending free 41.05 (20–80) 692 7.4 1.4 2.0
Endocervix—brush annual cervical screening
and general health
exam
India, Vellore, 2001–3 [113] MY09/11 Cervix—biopsy Women undergoing hysterectomy 45.3 (37–62) 30 0.0
not
associated with
HPV
India, West Bengal, MY09/11 Endocervix—brush Women attending gynecology 30.67 (14–80) 1112 13.0 8.5 0.9
1999–2002 [110] Ectocervix—spatula clinics for routine contraception
Japan, Chiba, 1998–2003 [131] HCII Cervix—swab Hospital-based population 35 (17–73) 420 12.1 10.2 2.9
<19 15 46.7 33.3 26.7
20–29 115 21.7 19.1 4.3
30–39 101 9.9 7.9 1.9
40–49 108 1.9 1.9 0
50–59 62 11.3 9.7 1.6
60–69 14 0 0 0
>70 5 0 0 0
Japan, Hokuriku, 1995–9 [118] PCR with E7 primers (11, 16, 18, Cervix—smear Routine cervical cancer screening 16–72 1562 9.7
S25.e16
31, 51, 56, 58, 72, 72)
(Continued )
Table 1
S25.e17
Continued
Prevalence (%)d
Study location, dates, Assay Site of specimen Group tested Mean or median Sample Overall High Low HPV HPV
reference age, size HPV risk risk 16 18
years (range)
Japan, Hokkaido, 1990 [119] Type-specific PCR (16, Cervix—swab Cytologically normal obstetrics/ 38.5 (18–73) 83 6.0
18, 33) gynecology department
attendees
Japan, Ishikawa, 1998–2002 Type-specific PCR (16, 18, 31, Ecto/endocervix—brush Cytologically normal women 31 120 44.2
[120] 45) visiting outpatient gynecology
clinic
17–23 29 48
Japan, Osaka, 1989–92 [126] PCR with E6 primers Cervix—smear Hospital clinic attendees 40.9 (18–72) 800 6.6
(16, 18)
18–29 142 5.6
30–39 182 7.7
40–49 308 7.5
50–59 111 6.3
60–72 57 1.8
Japan, Tokyo, 1997–2002 [127] Type-specific PCR (6, 11, 16, Cervix—smear Autopsy subjects without 82.7 (60–105) 335 2.7 2.1 0.6
18, 31, 33, 35, cervical
52b, 58) cancer
60–69 25 0.0 0.0 0.0
70–79 104 3.8 3.8 0.0
80–89 133 2.3 0.8 1.5
90–105 73 2.7 2.7 0.0
Japan, Urayasu and Ichikawa MY09/11 and GP5þ/6þ Cervix—swab Histologically normal women 41.5 (17–73) 56 32.1
City, 1997–8 [128] with previous abnormal
smear or routine
screening
(Continued )
S25.e18
Table 1
S25.e19
Continued
Prevalence (%)d
Study location, dates, Assay Site of specimen Group tested Mean or median Sample Overall High Low HPV HPV
reference age, size HPV risk risk 16 18
years (range)
Philippines, Manila, 1991–3 GP5þ/6þ Cervix—brush Hospital-based controls 46.8 381 9.2 1.3 1.3
[139]
South Korea, Bundang, 2001–2 GP5þ/6þ Cervix—swab Hospital-based population 30–54 1143 35.1 2.4 16.1
[138]
South Korea, Busan, 1999–2000 Type-specific PCR and GP5þ/6þ Ecto/endocervix—brush Population-based random sample 38.1a (15þ) 863 10.4 6.3 4.2 0.8 0.1
[136]
15–34 156 14.1
S25.e20
Endocervix—brush
(Continued )
Table 1
S25.e21
Continued
Prevalence (%)d
Study location, dates, Assay Site of specimen Group tested Mean or median Sample Overall High Low HPV HPV
reference age, size HPV risk risk 16 18
years (range)
Ho Chi Minh City Family-planning clinic sample 41 922 11.0 3.3 1.2
<25 157 22.3
25–34 174 10.9
35–44 185 7.6
45–54 154 7.1
55–64 167 8.4
65 85 9.4
Europe/Middle East
Austria, Vienna, 1997–8 [157] HCII Cervix—swab Pregnant women undergoing 29.5 (15.3–46.2) 179 24.6 20.7 10.1
chorionic villus sampling
15–25 46 39.1
26–30 59 22.0
31–35 42 16.7
35–46 32 18.8
Belgium, No city reported, 1993 MY09/11 and GP1/2 Cervix—brush Gynecological outpatient 34.2 (19–43) 200 4.0 1.5 0.5
[164] population
Belgium, Antwerp, 2000 [158] GP5þ/6þ and type-specific PCR Cervix—brush Routine cervical cancer screening 39.4 (17–78) 286 10.8 2.8 1.4
(6, 11, 16, 18, 31, 33)
Belgium, Antwerp, 2001–2[159] GP5þ/6þ Cervix—smear Women undergoing routine 58.4a 1907 4.1 1.5 0.5
screening
50–54 701 5a
55–59 492 3.2a
60–64 321 3.5a
65–69 171 4.2a
70 222 4.5a
Belgium, Brusselsc [160,161] PCR (16, 18, 33) Cervix—scrape Routine cervical cancer screening 36 (20–70) 323 14.2 5.0 1.9
20–30 15.0a
31–40 13.0a
41–50 8.5a
51–60 10.0a
61–70 0.8a
Belgium, Flanders, 2000–1[162] MY09/11 Cervix—brush Population-based sample 40.1 (17–85) 287 24.0 4.2 1.7
(Continued )
Table 1
Continued
Prevalence (%)d
Study location, dates, Assay Site of specimen Group tested Mean or median Sample Overall High Low HPV HPV
reference age, size HPV risk risk 16 18
years (range)
Belgium, Flanders, 2000– MY09/11 Cervix—brush Women with normal cytology 39.6 (17–85) 581 26.7 17.9
2[139,163] referred after routine exam or
screening
Belgium, Wilrijk, 2001–3 [394] GP5þ/6þ Cervix—smear Routine cervical cancer screening 35.8 2293 6.9 2.1 0.8
20–24 314 8.9
25–29 396 9.1
30–34 411 9.2
S25.e22
Table 1
S25.e23
Continued
Prevalence (%)d
Study location, dates, Assay Site of specimen Group tested Mean or median Sample Overall High Low HPV HPV
reference age, size HPV risk risk 16 18
years (range)
Finland, Turku, 1998–2000 MY09/11 and GP5þ/6þ Cervix—brush Third trimester pregnant women 25 (18–35) 76 16a
[183,395]
France, No city reported, 1999– HCII Cervix—brush Women attending screening at 34.5 1785 30.1 22.6 3.2
2000 [195] gynecology clinic
France, Amiens, 2000–1 [184] HCII Cervix—brush Women undergoing routine 38.9 (20–62) 3832 14.3
screening
20–24 513 16.6
S25.e24
26–30 697 9.5a
(Continued )
Table 1
S25.e25
Continued
Prevalence (%)d
Study location, dates, Assay Site of specimen Group tested Mean or median Sample Overall High Low HPV HPV
reference age, size HPV risk risk 16 18
years (range)
31–35 881 7.5a
36–40 776 6.0a
41–45 574 6.5a
46–50 350 4.5a
51–55 272 3.0a
56–60 179 2.0a
61–65 80 0.0a
S25.e26
Italy, Rome, 1998 [219] MY09/11 Cervix—spatula, swab Routine cytology screening 34 (21–48) 24 33.3
(Continued )
Table 1
S25.e27
Continued
Prevalence (%)d
Study location, dates, Assay Site of specimen Group tested Mean or median Sample Overall High Low HPV HPV
reference age, size HPV risk risk 16 18
years (range)
Italy, Turin, 2002 [220] GP5þ/6þ Cervix—brush Population-based sample (25–64) 1013 8.8 7.1 1.7 2.6 0.1
25–29 115 13.0 11.5a 1.8a
30–34 110 13.6 12.5a 1.0a
35–39 115 13.9 11.5a 2.8a
40–44 113 11.5 8.0a 3.5a
45–49 114 5.3 3.5a 1.8a
50–54 115 6.1 4.5a 1.8a
S25.e28
29–33 246 8.3
(Continued )
Table 1
S25.e29
Continued
Prevalence (%)d
Study location, dates, Assay Site of specimen Group tested Mean or median Sample Overall High Low HPV HPV
reference age, size HPV risk risk 16 18
years (range)
59–61 38 2
The Netherlands, Utrecht, 1976– PCR with L1 primers Cervix—smear Population-based controls 38.6 (35–54) 270 11.5 8.5 3.0 1.1
84 [230]
The Netherlands, Zeeland, 1976– GP5þ/6þ Cervix—smear Population-based cervical cancer 43 (34–54) 104 6.7 1.8 1.8
96 [231] screening
Norway, Trondheim, 1992 [237] GP5þ/6þ and Cpl/CPIIG Cervix—smear Archived, normal cervical smears 33 (21–67) 48 16.7
Poland, Gdansk, 2001 [238] PCR with L1 primers (6, 11, 16, Cervix—scrape, swab Healthy women undergoing 58a (28–82) 229 1.7 0.4
18, 31, 33) routine gynecological exam
Poland, Krakow, 2001 [239] HCII Cervix—smear Population-based, pregnant 18–37 145 13.1
women
Population-based, nonpregnant 18–37 145 9.7
women—screening for
cervical cancer
Poland, Krakow, 2006 [240] SPF10 Cervix—brush Healthy controls undergoing 28 (23–33) 42 21.4
preventative exam before
planned pregnancy
Poland, Poznan, 2002 [241] Type-specific PCR (2, 5, 6, 8, 11, Cervix—brush Cervical cancer screening (45–78) 90 48.9 33.3 22.2
13, 16, 18, 26, 27, 30, 31, 32, gynecology clinic
33, 35, 39, 40, 41, 42, 43)
45–49 41 58.5 39.0 26.8
50–55 26 53.8 30.8 19.2
56–78 23 26.1 26.1 17.4
Poland, Warsaw, 2000–02 [242] Type-specific PCR (6, 11, 16) Vaginal discharge Pregnant women with and without 28a (18–38) 45 26.7 20.0 11.1
insulin-dependent diabetes
mellitus
Russia, Latvia and Belarus, 1998– HCII Cervix—smear Women attending gynecology 37.5a (15–60) 448 46.7
2002 [245] clinics or STI clinics for
cervical screening
(Continued )
Table 1
Continued
Prevalence (%)d
Study location, dates, Assay Site of specimen Group tested Mean or median Sample Overall High Low HPV HPV
reference age, size HPV risk risk 16 18
years (range)
Russia, St. Petersburg, MY09/11 Cervix—swab Healthy attendants at gynecology 30.2 (15–45) 309 29.1 6.6 1.6
1999[243,244] practice
15–20 29 31.0
21–25 64 37.5
26–30 67 28.4
31–35 59 27.1
36–40 46 26.1
Spain, Alava, Girona, Guipuzcoa, Type-specific PCR (6, 11, 16, 18, Cervix—scrape Population-based controls 36.1 (18–68) 193 4.7 0.5 0.0
Murcia, Navarra, Salamanca, 31, 33, 35)
Sevilla, Vizcaya, Zaragoza,
1985–8 [4,155,334–340]
Spain, Barcelona, 1992 [247] Type-specific PCR (16, 18) Cervicovaginal—spatula Cytologically normal controls 29 (16–40) 64 10.9
Spain, Barcelona, 1998–2000 GP5þ/6þ Random sample (population- 43 (14–75) 973 3.0 2.2 0.5 0.6
[248] based sample)
14–24 174 7.0a
25–34 147 2.8a
35–44 175 3.0a
45–54 177 1.0a
55–64 175 1.8a
54–75 125 2.2a
Spain, Basque Region, 1991 Type-specific PCR (6, 11, 16, 18) Cervix—spatula Cytologically normal women 34 (16–82) 75 11.0
[249] attending family planning
clinic
Spain, Basque Region, 1994[250] Type-specific PCR (16) Cervix—spatula Women undergoing routine smear 32 (18–57) 38 42.1
Sweden, No city reported, 1993 Type-specific PCR (6, 11, 16, 18, Ectocervix—brush Women attending routine (20–29) 230 13.0 6.1 1.7
[266] 31, 33, 35) screening
Sweden; Finland; Holland, 1994 GP5þ/6þ and type-specific PCR Cervix—brush, spatula Cytologically normal women 28 (18–35) 366 10.9
[268] (6, 11, 16, 18, 31, 33) participating in a clinical trial
for a contraceptive device
Sweden, Nationwide, 2001[267] GP5þ/6þ Cervix—brush Population-based cervical 32–38 6123 6.8 2.1 0.6
screening program
Sweden, Karlstad, 1989–90[251] MY09/11 and type-specific PCR Cervix—brush Upper secondary school students 16.3 (15–17) 52 11.5
(6, 11, 16, 18, 31, 33)
Sweden, Malmo, 1992 [252] Type-specific PCR (6, 11, 16, 18, Cervix—brush Controls with normal cytology 25.1 (17–39) 30 10.0 3.3
31, 33) presenting for contraceptive
counseling
Sweden, Stockholm and MY09/11 and Cpl/CPIIG Cervix—smear Population-based cervical cancer 44 (20–74) 118 2.5
Vasterbotten, 1969–95 [254] screening
(Continued )
S25.e30
Table 1
S25.e31
Continued
Prevalence (%)d
Study location, dates, Assay Site of specimen Group tested Mean or median Sample Overall High Low HPV HPV
reference age, size HPV risk risk 16 18
years (range)
Sweden, Stockholm and Uppsala, MY09/11 Cervix—swab Virgins attending adolescent and 18 (10–25) 130 1.5
1994 [253] primary healthcare clinic
Sweden, Stockholm, 1994 [255] MY09/11 and type-specific PCR Cervix—brush Population-based gynecologic 25 478 13.4 3.1 1.5
health screening
30 15.7
31–40 2.2a
41 11.1
Sweden, Uppsala, 2007 [262] GP5þ/6þ andHCII Self-sampled vaginal smear Healthy women who have not 40.8a (35–50) 369 25.6
been screened in 6 years
35–42 264 31.3
43–50 105 13.5
Sweden, Vasterbotten, 1993–6 MY09/11 and GP5þ/6þ (11, 16, Cervix—brush Population-based cervical cancer 40 (20–63) 315 7.0
[263,264] 18, 33) screening
Sweden, Wuzburg, 1989–90[265] MY09/11 Cervix—brush Adolescents at healthcare 16.1 (15–17) 89 4.9 2.4
program
Switzerland, Multiple cities, 2005 HCII Cervix—brush Women attending gynecology 44.4 (17–93) 13842 8.2
[269] clinics
16–20 21.0a
21–25 18.0a
26–30 15.0a
31–35 10.0a
36–40 9.0a
41–45 7.0a
46–50 8.0a
51–55 6.0a
56–60 7.0a
61–65 6.0a
(Continued )
Table 1
Continued
Prevalence (%)d
Study location, dates, Assay Site of specimen Group tested Mean or median Sample Overall High Low HPV HPV
reference age, size HPV risk risk 16 18
years (range)
66–70 7.0a
71–75 6.0a
76 10.0a
Switzerland, Genevac [270] HCI Ecto/endocervix—brush Outpatient adolescent clinic; 17.5a (14–20) 134 14.2
sexually active
Turkey, Istanbul, 1996 [274] MY09/11 Cervix—brush Pregnant women 17–36 21 9.5
UK, Multiple cities, 1998– HCII Cervix—brush, spatula Women attending screening 42 (30–60) 10358 7.5
S25.e32
40–44 926 2.8 1.6
(Continued )
Table 1
S25.e33
Continued
Prevalence (%)d
Study location, dates, Assay Site of specimen Group tested Mean or median Sample Overall High Low HPV HPV
reference age, size HPV risk risk 16 18
years (range)
45–49 508 3.5 2.2
50–54 1104 2.9 1.6
55–69 114 1.8 0.9
UK, England, Nottingham, 1988– GP5þ/6þ (16, 18) Cervix—smear Clinic-based controls with normal 591 15.4 3.0 2.9
92 [179] smears
<20 100 18 5.0 3.0
Senegal, Dakar, Thies, and Hybridization of genomic Cervix—swab Sex workers 30.9a 681 43.0 10.7 (16, 18, 45)
Mbour, 1990–3 [275] DNA with type-specific
probes
South Africa, Kwazulu, MY09/11 Cervix—smear Commercial sex workers 26 (16–48) 99 62.6 10.5
1998 [276]
Tanzania, Dar es Salaam, GP5þ/6þ Cervix—swab Gynecologic in-patient 30.2 (15–70) 359 58.8 7.8 10.3
1991 [404] population with various
gynecologic complaints
14–24 20.5
25–34 16.5
35–44 14.7
45–70 3.2
Tunisia, Sousse, 2002 [26] MY09/11, pU-1M/pU-2R, Cervix—brush Legal prostitutes 30 (20–45) 51 39.2 23.5 7.8 11.8
and pU-31B/pU-2R
Zimbabwe, Mupfurec [278] GP5þ/6þ Cervix—lavage HIVþ population-based (15–49) 61 54.1 3.3 9.8
rural community
screening
Central and South
America
Brazil, Sao Paulo, 1997–8 HCI Cervix—smear Prison inmates 32.4 209 34 16.3 4.8
[405]
Brazil, Sao Paulo, 1997–9 MY09/11 and PC04/GH20 Cervix—scrape Routine gynecology visit, 32 (18–67) 223 87.5 27.1 13.3
[279] HIVþ women
Brazil, Sao Paulo, 1997–9 SPF10 Cervix—brush Routine gynecology visit, 32.1 (18–67) 22 4.5 9.1
[406] HIVþ women
Brazil, Sao Paulo, 1997–9 HCII Cervicovaginal—brush Routine gynecology visit, 32.4, 32b (18–67) 265 65.3 33.6 7.5
[280] HIVþ women
Honduras, Tegucigalpa, GP5þ/6þ Cervix—spatula HIVþ and HIV prostitutes 32 51 35.3
1994–5 [285]
Mexico, Mexico City, 1998 MY09/11 and HMB01 Cervix and vagina—swab Sex workers 28.6 (18–62) 495 48.9 11.1 3.6
[281]
S25.e34
18–22 107 75.7
(Continued )
Table 2
S25.e35
Continued
Prevalence (%)d
Study location, dates, Assay (PCR consensus Site of specimen Group tested Mean or median age, Sample Overall High risk Low HPV HPV
reference primer or HCI/II) years (range) size HPV risk 16 18
23–27 165 57.6
28–32 97 40.2
33–62 126 21.4
Mexico, Mexico City, 1998– Type-specific PCR (5, 6, 8, Cervix—smear Cytologically normal, HIVþ 37.2 (20–60) 24 41.7
9 [283] 11, 16, 18, 31, 33, 35, 39, women
45, 51, 56, 58)
Mexico, Hermosillo; Peru, MY09/11 Endocervix—brush (self- Cytology normal women 36.9a (18–67) 144 17.4
Lima; USA, Arizona, sampled) attending colposcopy
USA, Baltimore; Rhode PCR with L1 primers Cervicovaginal—lavage HERS cohort: women at risk 35 1157 51.5 15.2 22.8 5.1 4.6
Island, Providence; for HIV
Detroit; New York,
Bronx, 1993–5 [407–409]
USA, New York, Bronx, MY09/11 and HMB01 Cervicovaginal—lavage WIHS cohort: HIVþ women 37 (17–73) 1778 63.4
Manhattan, and Brooklyn;
Chicago; California, Los
Angeles and San
Francisco; Washington,
DC, 1994–5 [287–293]
WIHS cohort: HIV women 35 (17–62) 500 29.8
17–29 512 73.6
30–39 1035 57.2
40–62 718 52.5
(Continued )
Table 2
Continued
Prevalence (%)d
Study location, dates, Assay (PCR consensus Site of specimen Group tested Mean or median age, Sample Overall High risk Low HPV HPV
reference primer or HCI/II) years (range) size HPV risk 16 18
USA (13 cities in the US), MY09/11 and HMB01 Cervicovaginal—lavage REACH cohort: cervical 13–18 188 70.7 47.3 5.3
1996–7 [410] samples from high-risk
adolescent girls
USA (13 cities in the US)c MY09/11 and HMB01 Anus—swab REACH cohort: cervical 16.9a (13–18) 265 26.4 14.7 8.3 4.9 5.3
[411] samples from high-risk
adolescent girls
13–16 94 25.5
17–18 171 26.9
USA, Michigan, Ann Arbor, PCR with E1 primers Cervix—swab Women attending clinic for 31.8 (18–50) 273 21.2 5.5 1.8
1990–2 [414–417] symptoms of vaginitis
USA, New York, Brooklyn, Hybridization with HPV- Cervicovaginal—lavage Attendees of medical/drug 31 (18–50) 221 16.7
1990–1 [418] DNA probes treatment clinics and
community health centers
<30 110 27.3
30–39 74 9.5
40 37 0
USA, New York, New York, PCR with L1 primers (16, Cervicovaginal—lavage STI clinic attendees 34a 669 48.4 6.0 2.8
1991–3 [419–421] 18)
USA, New York, New York, PCR with L1 primers Cervicovaginal—lavage, Cytologically normal renal 43.9 (26–63) 21 4.8
1995 [422] brush transplant patients
USA, North Carolina, Fort MY09/11, HMB01, and Vagina—swab Military women with 24 (18–59) 768 36.5
Bragg, 1997–8 [423] type-specific PCR (6, 11, genitourinary symptoms
16, 18, 26, 31, 33, 35, 39, or STI screening
40, 45, 51–56, 58, 59, 66,
68, 73)
USA, Washington, Seattle, MY09/11 Cervix and perianal area— STI clinic attendees 26.5 50 72.0 20.0
S25.e36
1991–2 [424] swab
(Continued )
Table 2
S25.e37
Continued
Prevalence (%)d
Study location, dates, Assay (PCR consensus Site of specimen Group tested Mean or median age, Sample Overall High risk Low HPV HPV
reference primer or HCI/II) years (range) size HPV risk 16 18
<25 25 84.0
25 25 60.0
USA, Washington, Seattle, MY09/11 Cervix and vulvovaginal Pregnant women from high 22.7a 144 41.0 11.8 3.5
1997 [425] area—swab HPV prevalent
populations attending
obstetrics clinic
USA, Washington, Seattle, MY09/11 and HMB01 Cervix and vagina—broom Women who have sex with 31 (17–56) 248 12.5 9.3 4.8 2.8 0.8
1998 [426] women
S25.e38
35–39 33 24.2
(Continued )
Table 2
S25.e39
Continued
Prevalence (%)d
Study location, dates, Assay (PCR consensus Site of specimen Group tested Mean or median age, Sample Overall High risk Low HPV HPV
reference primer or HCI/II) years (range) size HPV risk 16 18
40–44 13 23.1
45 14 14.3
Denmark, Copenhagen, GP5þ/6þ Cervix—swab STI clinic attendees 27.2 124 35.8
1993 [38]
<20 56.0a
20–24 44.0a
25–29 41.0a
30–34 7.0a
Finland, Helsinki, 2000–1 HCII Ectocervix/vagina— Women with gynecologic 38.3 (15–86) 1999 23.0
[437] spatulaEndocervix— disorders attending
brush outpatient clinics
France, Paris, 1992 [299] MY09/11 Cervix, vagina, and vulva— HIVþ women 29 (21–40) 30 63.3 13.3 16.7
biopsy
France, Paris; French PCR with L1 and E6 primers Cervix—brush STI clinic attendees 31 320 21.3 5.0
Guyana, 1993–5 [438] and GP1/GP2
MY09/11 and GP5þ/6þ Ectocervix— spatula, brush HIVþ women 32 (19–72) 307 49.5
Endocervix—swab
France, Reims, 1997–8 [439] HCII Cervix—scrape, brush, Women undergoing routine 37 (15–72) 1518 22.3 16.7 5.6
spatula screening, family
planning clinic attendees,
and women at high risk
for STIs
15–20 85 25.9 20.0 5.9
21–30 411 31.1 25.1 6.1
31–40 484 19.6 14.7 4.9
41–50 369 17.6 11.4 6.2
51–60 128 17.2 10.9 6.2
61–72 41 14.6 14.6 0.0
Germany, No city reported, MY09/11 Cervix—swab Women with previous 33.8 550 56.2
1991–2 [196] cervical lesions or
partners of men with HPV
HIVþ women 32.9 61 62.3
Greenland, Nuuk, 1993 [38] GP5þ/6þ Cervix—swab STI clinic attendees 27.4 153 23.5
<20 85.0a
20–24 25.0a
25–29 12.0a
30–34 19.0a
35 19.0a
(Continued )
Table 2
Continued
Prevalence (%)d
Study location, dates, Assay (PCR consensus Site of specimen Group tested Mean or median age, Sample Overall High risk Low HPV HPV
reference primer or HCI/II) years (range) size HPV risk 16 18
Israel, No city reported, 1997 MY09/11 Vagina—biopsy Women undergoing 17–55 86 53.5
[440] perineoplasty for vulvar
vestibulitis
Italy, Multicenter, 1994–5 MY09/11 Endocervix—brush Women at risk for HIV 26.9 236 36.4
[441–443] infection
17–29 116 40.5
30–45 118 32.2
S25.e40
Table 2
S25.e41
Continued
Prevalence (%)d
Study location, dates, Assay (PCR consensus Site of specimen Group tested Mean or median age, Sample Overall High risk Low HPV HPV
reference primer or HCI/II) years (range) size HPV risk 16 18
Norway, Porsgrunnc [449] Type-specific PCR (6, 11, Cervix—biopsy Women undergoing 30 (15–54) 100 5.0 0.0 4.0
16, 18, 33) dilatation and curettage
for either termination of
pregnancy or benign
conditions
Russia; Latvia; Belarus, HCII Cervix—smear STI clinic attendees 27.5 706 44.9
2000 [450]
Spain, Oviedo, 2003 [298] MY09/11 Cervix—smear Sex workers attending 187 27.7 10.2 3.7