Cancer of the cervix is the most common cancer in women in Swaziland where most women never undergo cervical screening. The extremely high prevalence of HIV/AIDS in Swaziland complicates the management of preinvasive and invasive cervical cancer. The purpose of this study was to assess the current status of cervical cytology in Swaziland, its strengths and limitations.The study is a retrospective review of 12,188 conventional cervical smears received by the Central Public Health Laboratory in Swaziland from June 2004 to May 2006.Review of results showed very high rates of cytologic abnormalities with 43.2% of smears screened reported as abnormal. The percentages of abnormalities were as follows: atypical squamous cells of undermined significance (ASC-US), 19.8%; atypical squamous cells, cannot exclude HSILs (ASC-H), 8.8%; low-grade squamous intraepithelial lesions (LSIL), 9.0%; high-grade squamous intraepithelial lesions (HSIL), 4.6%; squamous cell carcinomas, 0.5%; atypical endocervical cells, 0.6%; and atypical endometrial cells, 0.4%. Just over 5% of smears were inadequate. The highest rates of HSILs and invasive squamous carcinoma occurred in women aged 50–59 years.This study underscores the need to reduce the incidence of cervical cancer and its precursor lesions in Swaziland women. Based on studies of human papillomavirus (HPV) types in other Southern African countries, current HPV vaccines would reduce the incidence and mortality from cervical cancer in the future, but cervical screening would still be required, both for women already infected with the HPV and for HPV subtypes not covered by current vaccines. The most cost-effective combination of screening modalities such as visual inspection, HPV DNA testing, and cytology should be investigated. Cervical cancer reduction needs to be managed within the greater framework of the HIV/AIDS epidemic. Cervical cancer is an important public health problem. Worldwide, as the second most common cancer in women, it comprises approximately 12% of all cancers but is the most common in developing countries. Cervical2 and is landlocked, with Mozambique to its east and South Africa to its north, west, and south.[The Kingdom of Swaziland is a small, independent, low-resource nation in Southern Africa. It covers an area of 17,364 kmnd south. The 2007Therefore, Swaziland falls into the category of countries without a well-established and organized cervical cancer screening program. In Swaziland, cancer of the cervix is the commonest cancer in women and its incidence is increasing. At the end of 1983 (ASIR 28.2), it was 17The purpose of this study was to assess the current status of cytology in Swaziland and to determine its strengths and limitations. As far as can be determined, there are no other publications on cervical screening in Swaziland.The study is based on a retrospective review of conventional cervical smears received, processed, and reported in the Department of Anatomical Pathology at the Central Public Health Laboratory from June 2004 to May 2006. As this laboratory is the only one in the country, these data are representative of the status of cervical smear pathology in the country. Written permission to undertake this study was obtained from all relevant health authorities, in addition to ethics permission being granted.To improve sensitivity of cervical screening by reducing the number of false negative smears, instructions and procedures as provided by several articles and books12 were sThe microscopic examination of cervical smears was performed by registered cytotechnicians. All the findings were recorded and classified according to the 2001 Bethesda System. All slidQuality assurance was performed by cytologic–histologic correlations, follow-up cytologic material and follow-up information on the patient. The full rescreening of a 10% random sample of slides originally reported as negative or a rapid review of 100% reportedly negative smears was attempted as far as possible, but was not always feasible given the severe staff shortages.All premalignant and malignant cytology reports were correlated with subsequent histopathology reports. Cytohistologic correlations were a helpful educational tool in the diagnosis of both cytology and tissue specimens. The corrData were analyzed using CanReg4 package, a software program provided free of charge by the International Agency for Research on Cancer, based in Lyon, France. It is a variant of EPI.INFO, but specifically designed for cancer registries.A total of 12,323 Pap smears were screened between 2004 and 2006. Fifty-five (0.43%) were broken beyond repair and 567 (4.48%) reported to be inadequate because they were obscured by purulent exudates (17%) or blood (21%), without transformation zone cells (42%) or with air-dried artifact (20%) .The number of inadequate slides decreased with time . This was the result of adopting the Bethesda System for reporting cervical cytology, as an adequacy statement was included which provided important feedback to clinicians regarding specimen collection and preparation techniques, and contributed to continuous quality improvement. The patient age varied between 18 and 88 years with a peak at 43 years. The age was unknown in 1.18% of cases.The number of Pap smears reported to be adequate was 11,701, and the distribution by category diagnosis and age group is displayed in The greatest numbers of atypical squamous cells of undermined significance (ASC-US) were seen in the age group 20–29 years while LSILs were mostly seen in the 20–29 and over–40 age group. This is an unusual finding in older women as LSIL rates seem to decrease in women over the age of 35 years. The greatest percentage of HSILs was seen in women over the age of 50 years.From the 11,701 adequate Pap smears, 252 (2.2%) and 303 (2.6%) cases, respectively, at LSIL and HSIL thresholds were correlated with histologic findings in order to evaluate the accuracy of cytology in detecting cervical lesions; histology being considered the gold standard, although not the perfect diagnostic test. Using the LSIL threshold, 114 (45.2%) women were tested positive. The proportion of positive women decreased to 68 (22.4%) when the HSIL threshold was used. The distribution of histopathology findings by LSIL and HSIL thresholds are given in Tables in situ, 4 cases of endocervical adenocarcinoma, 4 cases of endometrial adenomatous hyperplasia, 3 cases of endometrial adenocarcinoma, 4 cases of moderate cervical intraepithelial neoplasia, 2 cases of squamous carcinoma in situ, and 1 case of invasive squamous carcinoma). Additional training is required for more accurate cytologic diagnosis of glandular lesions. Fifteen smears initially positive were negated in the follow-up and confirmed as such in histology. They were five cases of reparative changes, three cases of ASC-US, four cases of immature squamous metaplasia, and three of infection .At the LSIL threshold , there wThe accuracy of detecting cervical lesions at the LSIL threshold  was 82.8% for sensitivity, 91.3% for specificity, 65.8% for the positive predictive value, and 96.3% for the negative predictive value. When glandular cell abnormalities were taken into consideration, the accuracy of detecting cervical lesions at the LSIL threshold was 64.5% for sensitivity, 83.1% for specificity, 55.5% for the positive predictive value, and 87.7% for the negative predictive value. Most discrepancies between cytology and histology follow-up were, on review, found to be due to sampling errors.in situ, 3 cases of endometrial carcinoma in situ, 2 cases of endometrial adenocarcinoma, 3 cases of severe cervical intraepithelial neoplasia, and 2 cases of microinvasive squamous cell carcinoma). Five smears initially positive were negated in the follow-up and confirmed as such in histology. They were two cases of reparative changes, one case of immature squamous metaplasia, one case of cytomegalovirus infection, and one case of fungal infection, probably coccidioidomycosis.At the HSIL threshold , there wThe accuracy of detecting cervical lesions at the HSIL threshold (excluding glandular cell lesions) was 80.7% for sensitivity, 93.8% for specificity, 58.3% for the positive predictive value, and 97.8% for the negative predictive value. When glandular cell abnormalities were taken into consideration, the accuracy of detecting cervical lesions at the HSIL threshold was 43.5% for sensitivity, 90.8% for specificity, 46.5% for the positive predictive value, and 89.8% for the negative predictive value.The HIV serostatus of women undergoing cervical cytology is currently unknown. This will be the subject of a further study.The Cytopathology Service is equipped to screen 4,000 smears annually. It is located at the Central Public Health Laboratory with reliable transport of slides and test results to and from the Laboratory. Most of the cervical smears screened (>34%) are taken for diagnosis rather than for screening of cervical lesions. A well-established and well-organized cervical cancer prevention program does not exist and is urgently needed since 43.2% of smears screened are abnormal . Several reports from other Southern African nations also show high rates of cervical cytologic abnormalities. A study from Zimbabwe noted 59% abnormal smears with 12% LSILs and 3.6% HSILs. A cross-et al. in Zimbabwe[Prevention of cervical cancer can be primary or secondary. Primary prevention modalities include changes in sexual behavior and human papillomavirus (HPV) vaccination. The former should be encouraged to prevent HIV, HPV, and other sexually transmitted diseases. The HPV serotypes in Swaziland have never been determined. There have been limited HPV studies in other Southern African nations that are probably relevant to Swaziland. The most common HPV type in Southern Africa appears to be HPV 16 that has a prevalence of between 17% and 82% depending on the type of specimen  and underlying pathology . The prevalence of HPV 18 again varies in different Southern African studies from 1.6 to 21%. The prevalence (in parentheses) of other common HPV types in the region include HPV 52 4–27%), HPV 53 20%), HPV 58 (2–24%), HPV 51 (15%), HPV 45 (13%), HPV 31 (2–11%), HPV 33 (5–14%), and HPV 35 (2–10%).%, HPV 58 In addit Zimbabwe found th%, HPV 53Swaziland, as a Southern African nation, probably has similar rates of HPV infection and subtypes. Thus, it appears as if vaccination against HPV 16 and 18 in Swaziland would prevent many cases of cervical cancer in the future. However, given the high prevalence of HIV in Swaziland, the efficacy of HPV vaccination in HIV-positive women needs to be evaluated. It would be recommended to vaccinate girls before they are exposed to both HIV and HPV.Secondary prevention of cervical cancer includes visual inspection of the cervix (VIA), cervicoscopy, HPV testing. and cytology.The results of test accuracy in large cross-sectional, randomized controlled trials in developing countries indicate that the sensitivity of visual inspection of the cervix with acetic acid (VIA) to detect high-grade precancerous lesions ranges from 66 to 96% (median 84%); the specificity varied from 64 to 98% (median 82%); the positive predictive value ranged from 10 to 20% and the negative predictive value from 92 to 97%.29 The maCervicography or magnified visual inspection with acetic acid (VIAM) involves examination of magnified photographic documentation of the acetic acid-impregnated cervix. The results from cross-sectional studies established that VIAM does not improve the test performance of VIA over and above that of naked-eye visualization. Its sensitivity is lower than that of cytology and VIA to detect high-grade lesions, although the specificity is comparable to that of cytology.HPV testing has a high negative predictive value but low positive predictive value as the vast majority of women will clear an HPV infection spontaneously, especially women below the age of 30 years. Other disadvantages of HPV DNA testing are the cost; the dependence on reagents currently produced by very few commercial manufacturers; the requirement for a sophisticated and expensive laboratory equipment (molecular diagnostic laboratory); and trained personnel. Advantages of HPV DNA testing in developed countries include good inter- and intraobserver correlation; reliable quality assurance; and very high sensitivity. However, HPV DNA test as a primary screening method, at this time, is recommended for use only in pilot projects or other closely monitored settings. It can be used in conjunction with cytological or other screening tests, where sufficient resources exist.–34Cervical cytology is currently the only cervical screening method that is available in Swaziland. When detecting a cervical abnormality at the LSIL threshold (when glandular lesions were excluded), the sensitivity was 82.8%, specificity was 91.3%, positive predictive value was 65.8%, and negative predictive value was 96.3%. When detecting a cervical abnormality when HSIL was the threshold, the sensitivity was 80.7%, specificity was 93.8%, positive predictive value was 58.3%, and negative predictive value was 97.8%. This may improve with the implementation of more stringent internal and external quality assurance modalities.et al.[Concerning the cost-effectiveness, Goldie et al.36 studieA combination of screening methods may be appropriate to Swaziland, e.g., HPV DNA testing first and then cervical cytology of those patients found to be positive for high-risk HPV subtypes in urban women; while rural women may benefit from a combination of visual inspection and cervical cytology. Additional studies are required in this regard. Other areas for research include potential efficacy of HPV vaccination and cost-effectiveness of liquid-based cytology in Swaziland. Colposcopy and the whole arsenal of ablative  and excisional (LEEP or LLETZ) surgery used for outpatients do not exist in Swaziland. Therefore, treatment services require significant strengthening, as only punch biopsy and hysterectomy are available.There is an extremely high prevalence of HIV/AIDS in Swaziland. The prevalence of HIV/AIDS infection in adults was estimated to be 25.3, 38.2, and 42.4% in 1999, 2001, and 2003 respectively. Women inThere are no competing interests to declare by any of the authors.http://www.icmje.org) “author” is generally considered to be someone who has made substantive intellectual contributions to a published study. Authorship credit should be based on (1) substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; (2) drafting the article or revising it critically for important intellectual content; and (3) final approval of the version to be published. Authors should meet conditions 1, 2, and 3. Other contributors, who do not meet these criteria for authorship, are listed in an acknowledgments section. All authors of this article declare that we qualify for authorship as defined by ICMJE http://www.icmje.org/#author. Each author has participated sufficiently in the work and takes public responsibility for appropriate portions of the content of this article.Each author acknowledes that the final version was read and approved. According to International Committee of Medical Journal Editors (ICMJE


High-risk human papillomaviruses (HPVs) could be important risk factors for breast carcinogenesis and metastasis. Based on this hypothesis, we recently studied the effect of E6/E7 onco-proteins of high-risk HPV type 16 in two non-invasive human breast cancer cell lines, BT20 and MCF7; we reported that E6/E7 converts these cell lines to invasive cells. This is accompanied by an overexpression of Id-1, which is an important regulator of breast metastasis. In this investigation, we examined the presence of high-risk HPVs  and the expression of their E6 onco-protein as well as their correlation with Id-1 gene expression, using polymerase chain reaction (PCR) and tissue microarray (TMA) analysis, respectively, in a cohort of 113 Syrian breast cancer patients. We found that high-risk HPV types 16, 18, 31, 33 and 35 are present in 8.84, 9.73, 7.07, 55.75 and 37.16% of our samples, respectively, which represent invasive breast cancers. Overall, 69 (61.06%) of the 113 samples are HPV positive; among these specimens 24 tissues (34.78%) are coinfected with more than one HPV type. Furthermore, we report that the expression of the E6 onco-protein of these high-risk HPVs is correlated with Id-1 overexpression in the majority of invasive breast cancer tissue samples. Our data suggest that high-risk HPV infections are associated with human breast cancer progression in Syrian women. High-risk human papillomaviruses (HPVs) are important risk factors for numerous human cancers including cervical, colorectal and head and neck (HN); as roughly 96, 80 and 28% of these cancers are positive for high-risk HPVs, respectively . E6 faciSeveral recent studies reported that approximately 50% of human breast cancers are positive for high-risk HPVs, especially types 16, 18 and 33 (The Id-1 gene (inhibitor of differentiation and DNA binding), a member of the helix-loop-helix transcription factor family, has multiple functions, including inhibition of differentiation, induction of proliferation and delaying replicative senescence (This study aims to recognise the specific types of high-risk HPV infections present in Syrian women and their association with tumour aggressiveness and Id-1 overexpression.μg of purified DNA (from each sample) was analysed for HPV by multiplex PCR targets to the conserved L1 region of the viral genome by use of PGMY09/11 L1 primer pools  years were used in this study. Formalin-fixed , paraffin-embedded tumour materials were obtained from the Department of Pathology, Faculty of Medicine, University of Aleppo. The use of these specimens and data in research was approved by the Ethics Committee of the Faculty of Medicine of Aleppo University. Five er pools . In paraer pools . PCR proThe tissue microarray (TMA) construction was performed as described by M sodium citrate solution (pH 6.0) for 10 min. The TMA slides were cooled and equilibrated in Optimax™ wash buffer then incubated overnight (15 h) at 4°C with primary antibodies for Id-1  and E6 . In all cases, the diluent was 0.6% BSA in Optimax wash buffer. Sections were then washed (4 × 1 min), and the appropriate secondary HRP-conjugated antibody was applied for 1 h at room temperature . The slides were counterstained with haematoxylin and mounted.Immunohistochemical procedures examining the expression of Id-1 and E6 were carried out using standard procedures as previously described (To determine the role of high-risk HPV infections in human breast cancer in Middle Eastern women, we investigated the presence of high-risk HPV types 16, 18, 31, 33 and 35 in a cohort of 113 breast cancer samples from Syrian women by PCR analysis using specific primers for their E6 and/or E7 genes . Our stuin situ cancer tissues (in situ breast carcinomas, which are HPV-positive, will ultimately progress into invasive carcinomas under the effect of these HPVs, as they are already intermediate to high nuclear grade. Moreover, to confirm the association between E6/E7 of HPV types 16, 18, 31, 33 and 35 and Id-1, we investigated the presence of E6 and/or E7 of these viruses by PCR using specific primers for E6/E7 genes (To assess the association between the presence of HPV types 16, 18, 31, 33 and 35 with tumour aggressiveness and Id-1 expression in breast cancer in Syrian women, we examined the expression of the E6 onco-protein of high-risk HPVs along with Id-1 expression in all our breast tissue samples by immunohistochemistry using tissue microarray methodology. We found that E6 expression is correlated with Id-1 overexpression in 94.25% of invasive breast cancer samples as opposed to 30.76% of  tissues ; whereasE7 genes . By meanE7 genes .This is, to the best of our knowledge, the first study on the presence of high-risk HPVs and their relation with tumour aggressiveness in breast cancer in Syrian women. Earlier studies on breast cancer have reported that HPV types 11, 16 and 18 are the most frequent in women living in the United States and Brazil . HPV typin vivo. Separately, we reported that the presence of E6/E7 of HPV type 16 is correlated with Id-1 overexpression in human invasive and metastatic breast cancer tissues in Canadian women. Moreover, we revealed that E6/E7 of HPV type 16 affects Id-1 deregulation through the activation of its promoter (Regarding the association between high-risk HPV and tumour aggressiveness, recent studies, including ours, have reported that the presence of HPV type 16, in human breast cancer, is correlated with invasive carcinomas (In conclusion, we demonstrate that high-risk HPV types 16, 18, 31, 33 and 35 are present in human breast cancer in Syrian women. In addition, HPV types 33 and 35 are the most dominant types of HPV infection found in Middle Eastern women, based on the combination of this study and a study by


Abnormal fragile histidine triad transcripts were found in 20–30% of CIN2/3 lesions and 11% of normal cervical biopsies by RT–PCR. Bi-allelic loss of the fragile histidine triad gene and the loss of fragile histidine triad protein expression detectable by immunochemical staining with a polyclonal fragile histidine triad specific antibody was rare. The genomic changes showed no association with the presence of human papillomavirus types which carry high risk for cervical cancer (high risk human papillomavirus) as assessed by a type-specific multiplex PCR. The presence of abnormal fragile histidine triad transcripts in a subset of CIN2/3 lesions with no high risk human papillomavirus suggests that this could be an independent risk factor associated with an alternative carcinogenic pathway.British Journal of Cancer (2002) 86, 376–381. DOI: 10.1038/sj/bjc/6600077www.bjcancer.comThe Cancer Research Campaign© 2002  Cervical cancer is the second most common malignancy in women worldwide. It is generally accepted that the development of cervical cancer from precancers (CIN2/3) involves multistep molecular changes and is therefore a preventable disease if precancers are detected and treated early.et al, 1996). However, infection with HR HPV does not invariably lead to the development of high grade cervical lesions and there is a clear requirement for other co-factors, presumably to advance the oncogenic process initiated by HR HPV (The major risk factor for CIN2/3 and cancer is infection with high risk human papillomavirus (HR HPV) types which include HPV16, HPV18, HPV31, HPV33, HPV35, HPV45, HPV51, HPV52, HPV56, HPV58, HPV59 and HPV68. One or more of these virus types have been reported to be present in 90–95% of CIN2/3 lesions and in nearly all cancers  at −70°C. HPV assays were carried out using 50 μl aliquots which were centrifuged at 14 000 g and 4°C for 15 min. The pellet was re-dissolved in 20 μl of TE . Thirteen HR HPV types were assayed by a multiplex type specific PCR (mts–PCR) using primers that are completely homologous to the corresponding HPV genome sequence  and subsequently amplified for 30 cycles  with primers FH203S (forward) and FH1038 (reverse). The efficiency of reverse transcription was monitored using aldolase PCR primers  at 250 μg mlNucleic acid sequencing was carried out using an ALF-Express automatic sequencer.Paraffin blocks from corresponding cases used for the FHIT transcript study were not available due to re-organizations in the National Health Service. For this analysis 114 biopsies of normal cervix and CIN lesions from a total of 42 women participating in two previous studies of cervical cancer risk factors (Ptrend<0.001 in the transcript study and Ptrend=0.012 in the protein study).The histological grades and the HR HPV status of the lesions used in this study, subdivided into those used for FHIT transcript or protein detection, are shown in Table 1Ptrend<0.001) .Figure 3 lesions . One of A full length FHIT transcript was detected in all normal cervical tissue samples and in all but 3% (7 out of 223) of CIN lesions . The preWhen compared against stromal cells within the same section, expression of FHIT protein in epithelial cells was found in all normal tissues and low grade CIN1 as well as in most high grade CIN2/3 lesions . This isRecent evidence suggests that FHIT instability may play a synergistic role with HR HPV in the pathogenesis of high grade cervical lesions (Ptrend<0.001) or abnormal FHIT protein expression (Ptrend<0.004) represents a risk factor for the development of high grade CIN lesions. This suggests that genomic instability at the FHIT locus induced by other risk factors  could account for the development of those high grade cervical lesions which are HR HPV negative and which may have a lower risk of cancer and tend to regress in the absence of persistent HR-HPV infection. For clinical or epidemiological purposes, testing for FHIT protein, rather than FHIT transcripts, would have obvious advantages since it can be carried out using low cost and simple procedures on routine paraffin sections.Our results indicate that, after adjusting for HR HPV, abnormal FHIT transcript expression (


New England Journal of Medicine (NEJM) at 5:00 PM on April 1, 2009, were dramatic. “In a low resource setting, a single round of HPV testing was associated with a significant reduction in the numbers of advanced cancers or deaths from cervical cancer.” Furthermore, the study abstract asserted, “No significant reductions in the numbers of associated deaths were observed in the cytology testing group or in the VIA group, as compared with the control group.”[The study conclusions, released from prepublication embargo by the NEJM customer service office confirmed on April 14 that pre-embargo release was not from the journal.Simultaneously, at 5:00 PM on April 1, 2009, a press release from Qiagen, a Netherlands Holding Company and a manufacturer of the digene HPV test, stated: “Landmark study in New England Journal of Medicine shows HPV testing significantly reduces deaths from cervical cancer, compared to other methods including Pap.”[NEJM paper suggests that unexpected biases might have occurred in some of the test group arms of the study which sought to compare a single round of cervical cancer screening with HPV testing, cytology, and visual inspection with acetic acid (VIA) among over 131,746 “healthy women between the ages of 30 and 59 years” in rural India. In fact, the study acknowledged that the positive predictive value (PPV) for detecting CIN 2–3 was 19.3% in the cytologic testing group, higher than 11.3% in the HPV testing group, and study results indicate that essentially the same numbers of cervical cancers were detected after positive screening test results in the cytology arm (88) as in the HPV arm (87). Cervical cancer detection rates were 0.344% in the cytologic testing group and 0.321% in the HPV testing group [A close look at the ng group . Among cng group . The preThe 2009 publication employed the well-recognized “intention-to-treat-principle” in which all eligible patients assigned to a study arm are included in the final analyses for each study arm, whether or not the patients adhere to the research protocol management strategy. ThereforNEJM report does acknowledge that “both practitioners and subjects were aware of the study group assignments.”[Other aspects of the study data also support the hypothesis that bias was introduced in the study group arms during treatment of patients who developed cervical cancer. For example, the death rate for clinically detected cervical cancer patients in the HPV test-negative group of the HPV arm was 0% as compared to 40.9% among clinically detected cancer patients in the cytology-negative group of the cytology arm . Remarkagnments.”NEJM publication reports that the study was supported by the Bill and Melinda Gates Foundation, through the Alliance for Cervical Cancer Prevention (ACCP). The paper also states that “no potential conflict of interest was reported.” However, questions have been raised in the peer-reviewed literature as to whether or not the Gates Foundation and the ACCP might have in effect “become enamored with the promise of science and new technologies at the expense of delivering available preventives today”.[Vaccine entitled “Overview of Human Papillomavirus-Based and Other Novel Options for Cervical Cancer Screening in Developed and Developing Countries.”[NEJM article and one of the NEJM editorial writers are specifically listed among the large number of international contributors. The presence of not even a single cytopathologist among the very large number of contributors supported for international travel and meetings clearly suggests an anticytology bias for the proceedings, one perhaps mirrored in the NEJM. The two selected authors of the accompanying NEJM editorial[NEJM.[The s today”. Questions today”.–7 Similauntries.” The HPV untries.” acknowleeditorial also turial[NEJM.NEJM study upon first inspection may be interpreted as applying primarily to low-resource settings where even very limited screening and diagnostic testing are difficult to support, the accompanying editorial,[New York Times (NYT), the study indicates broadly that a “new DNA test outperforms the Pap smear.”[Although the ditorial, press reditorial, and mediditorial, Accordinp smear.” Strangelp smear.” Sixty-fop smear.” The deatp smear.”P = 0.2655), even before taking into consideration other study biases. Furthermore, the study's cytology screeners were trained for only 3 months, one-fourth of the usual year-long training for cytotechnologists. This was almost certainly suboptimal to confront the challenging conditions in the rural Osmanabad district. Pap screening, when successfully implemented, reduces cervical cancer rates by 60–90% within 3 years of introduction to populations that have not been screened; these reductions in incidence and mortality are consistent and dramatic across populations.[5NEJM. As noted by many of the same authors in their 2005 publication, “Our results clearly show that good quality cytology can be implemented even in a rural setting of a developing country with reasonable investment, while HPV testing does not give any better detection of CIN2/3 lesions, despite the higher investments.”[The unexpected increase in the presence of cervical cancer in both the unscreened cytology and VIA arms of the study was a key foundation for the authors' surprising statement that “no significant reductions in the numbers of advanced cancers or deaths were observed in the cytologic-testing group or in the VIA group, as compared with the control group.” When unslations.5 Even a sNo competing interest to declare by any of the authors.http://www.icmje.org/#author.All authors of this article declare that we qualify for authorship as defined by ICMJE Each author has participated sufficiently in the work and take public responsibility for appropriate portions of the content of this article.Each author acknowledges that this final version was read and approved.


Human papillomavirus (HPV) infection is a causative factor for cervical cancer. Early detection of high risk HPV types might help to identify women at high risk of cervical cancer. The aim of the present study was to examine the HPV prevalence and distribution in cervical smears in a sample of Greek women attending a gynecological outpatient clinic and to explore the determinants of the infection.A total of 225 women were studied. All women underwent a regular gynecological control. 35 HPV types were studied; 6, 11, 16, 18, 26, 31, 33, 35, 39, 40, 42, 43, 44, 45, 51, 52, 53, 54, 56, 58, 59, 61, 62, 66, 68, 70, 71, 72, 73, 81, 82, 83, 84, 85 and 89. Also, basic demographic information, sociodemographic characteristics and sexual behavior were recorded.HPV was detected in 22.7% of the study population. The percentage of the newly diagnosed women with HPV infection was 17.3%. HPV-16 was the most common type detected (5.3%) followed by HPV-53 (4.9%). 66.2% of the study participants had a Pap test during the last year without any abnormalities. HPV infection was related positively with alcohol consumption  and number of sexual partners , and negatively with age , and monthly income .The prevalence of HPV in women attending an outpatient clinic is high. Number of sexual partners and alcohol consumption were the most significant risk factors for HPV infection, followed by young age and lower income. Cervical cancer is the second most common cancer in women worldwide . SeveralWomen with normal cervical cytology who are infected with high risk HPV type have an approximately 100-fold increased risk of developing cervical cancer compared to uninfected women . TherefoSince, the prevalence of the high risk HPV types varies among different populations we conducted the present study in order to examine the HPV prevalence and distribution in cervical smears in a sample of Greek women attending a gynecological outpatient clinic and to explore the determinants of the infection.The study population consisted of a consecutive sample of 225 women attending the gynecological outpatient clinic of the Maternal and Perinatal Hospital "Elena Venizelou" between October 2007 and May 2008, for regular gynecological control. "Elena Venizelou" Hospital is a tertiary maternal hospital responsible for the greater region of Athens, the capital of Greece. Pregnant women or women with a recent delivery were not enrolled into the study. The refusal rate was low; only 2 women denied taking part into the study.Basic demographic information, sociodemographic characteristics, medical history, smoking status, alcohol consumption and sexual and reproductive behaviour was obtained at the time of the gynecological visit by a study nurse. Additional questions were asked on age at first sex, number of lifetime partners, past history of sexually transmitted infections, and use of a condom.Participants were considered as newly diagnosed cases for HPV infection if they had a negative history for HPV infection according to their medical records. In addition, newly diagnosed cases included women who had never been screened for HPV infection. Subjects were considered as non-smokers if they have never smoked or if they had given up smoking for at least three consecutive years. Heavy drinking was defined as consuming an average of more than 1 drink per day. Participants were stratified according to their monthly income and education level as it is stated at Additional file All subjects underwent their scheduled examination, which included the placement of a speculum in the vagina, visualization of the cervix, and collection of cervical cells using a wooden Ayre spatula and endocervical brush. After the preparation of a standard cervical smear, the remaining cells were placed in tubes with 0.9% saline and stored at -20°C prepared for HPV molecular analysis. Pap smears were classified according to the Bethesda system by local cytopathologists.The Hospital's ethical committee provided approval for this study. All participants gave their written consent before enrollment to the study. The study was in accordance with the Helsinki declaration.The cervical cells removed from the swabs and centrifuged in order to be in a pellet form. The supernatant discarded and the remaining cells were dissolved in 100 μl 1× Phosphate Buffer Saline (PBS). The dissolved cells transferred to 200 μl Tissue Lysis Buffer and 20 μl Proteinase K according the instruction manual of CLINICAL ARRAY 'S (HPV) (Biogenomica Spain). The extracted DNA eluted in 100 μl Elution buffer (Biogenomica Spain) and stored in -20°C. The sensitivity and specificity of the CLINICAL ARRAY' S HPV kit is 92.3% and 89%, respectively .Five microliters (5 μl) of eluted DNA were used in the PCR amplification of pre alliquoted ready to use vials-kept at -20°C in alliquots (Biogenomica Spain). The PCR reaction includes two internal controls in order to avoid the false negative results from the extraction procedure and from the PCR inhibitors. The first amplifies a 892 bp fragment of the human CFTR gene and indicates the DNA existence and the second is a 1202 bp fragment from a modified plasmid and indicates if there is inhibitors or not.The PCR product denaturated in 95°C for 15 minutes in iQ Thermocycler and then thawed in 4°C. Five microliters (5 μl) of the PCR product proceeded in hybridization on the specific Array Tubes according the instruction manual (Biogenomica Spain) on the ATS Workstation (CLONDIAG Chip Technologies GMBH). The hybridization results were interpreted by the Specific CLINICAL ARRAYS Human Papilloma virus software program which it has been preinstalled and ready to use on the ATS Workstation (CLONDIAG Chip Technologies GMBH).The following 35 HPV types were studied; 6, 11, 16, 18, 26, 31, 33, 35, 39, 40, 42, 43, 44, 45, 51, 52, 53, 54, 56, 58, 59, 61, 62, 66, 68, 70, 71, 72, 73, 81, 82, 83, 84, 85 and 89. The oncogenic risk of the HPV types detectable with CE marked and IVD marked kit of Genomica are according to the Munoz et al .A recent meta-analysis examined the association between detection of HPV DNA and high-grade cervical intraepithelial neoplasia and invasive cervical cancer, showing a strong association .t-test was used to assess differences in continuous variables, while a chi-square test was used for categorical variables. Univariate binary logistic analysis was performed to look for the relationship between HPV infection and the variables of interest in the sample population. Then, multivariate analysis was performed (backward stepwise method) to look for independent associations between HPV infection and the variables of interest. All independent variables in the multivariate analysis were tested for multicolinearity. P < 0.05 (two-tailed) was considered statistically significant.Statistical analysis was preformed using programs available in the SPSS statistical package . All variables were tested for normal distribution of the data. Data are shown as mean ± SD, unless it is stated otherwise. A two sample The characteristics of the study population are summarized in Additional file Condom was the most common contraceptive method ever used (58.6%). It is noteworthy that almost the one third of the study participants did not use any contraceptive method (34.2%). Of the study population, 10.6% had a history of a previous HPV infection and 48% a history of sexually transmitted disease. 8.0% had never done a Pap test, while 66.2% had a Pap test during the last year without any abnormalities. Only one third of the women were smokers (39.1%), and 48.8% reported regular alcohol consumption.The age of HPV-positive women n = 51) was (mean age ± standard deviation) 28.5 ± 6.7 years. Condom was the most common contraceptive method ever used (60.8%), while 29.4% did not use any contraceptive method. Of the HPV-positive women, 23.5% had a history of a previous HPV infection and 54.9% a history of sexually transmitted disease. 13.7% had never done a Pap test, while 58.8% had a Pap test during the last year. 55.0% of the HPV-positive women were smokers and 62.8% reported regular alcohol consumption  . The percentage of the newly diagnosed women with HPV infection was 17.3% (39/225). In addition, it must be mentioned that 12 women with a previous history for HPV infection were found in the HPV negative subsample. These cases were included in the HPV-negative group for the further analysis.16.4% (37/225) of the study population was infected with a single type and 6.2% (14/225) was infected with at least two HPV types. In the entire study population, HPV-16 was the most common type detected (5.3%) either as a single type or in combination with other types, followed by HPV-53 (4.9%). It is noteworthy that the prevalence of oncogenic HPV-18 was low (0.9%). Oncogenic  and nononcogenic  types were detected in 14.2% and 8.2% of the HPV-positive women, respectively.The prevalence of HPV infection among females aged 21 to 30 years was 26.6% whereas the corresponding prevalence among females aged 16 to 20 years was 57.1%. In detail, the prevalence of HPV-16 and HPV-53 among females aged 21 to 30 years old were 5.5%, 2.8%, respectively, whereas the corresponding prevalences among females aged 16 to 20 years were 14.3% and 14.3%, respectively : 0.94, 95% Confidence Intervals (95% CI): 0.89-0.98], monthly income , marital status , number of full term pregnancies , number of sexual partners , smoking status , and alcohol consumption . No any significant relationships were found between HPV infection and educational level, nationality, methods of contraception, age at first sexual intercourse, and history of previous HPV infection or other sexual transmitted diseases  and number of sexual partners , and negatively with age  and monthly income   among women aged 16 to 20 years.The percentage of the newly diagnosed women with HPV infection was 17.3%. Oncogenic HPV types were detected in 14.2% of the HPV-positive women. The overall prevalence of high risk HPV-16, HPV-53 and HPV-18 were 5.3%, 4.9% and 0.9% respectively. Similar prevalence of HPV-positive women has been reported in a large sample of US females aged 14 to 59 years (26.8%)  as well HPV-16 was the most prevalent oncogenic type either as a single type or in combination with other types, while the prevalence of HPV-18 was low. A lot of studies in different populations have shown that HPV-16 was the most common among the others HPV types -25. EvenOf the total study population, 16.4% was infected with a single type and 6.2% was infected with at least two HPV types. The observed prevalence of multiple infections is low in comparison with the results from studies from different countries -35. The The results of the multivariate analysis demonstrated that HPV infection was related positively with alcohol consumption and number of sexual partners, and negatively with age and monthly income. A lot of previous studies have showed that the main risk factor for HPV infection was the number of sexual partners -38. AlsoOur study has some limitations. As it is mentioned above, 12 women with a previous HPV infection were found in the HPV-negative subgroup. This is partially explained by the results of two studies showing that a single negative HPV test result could lead to missed HPV infection  and thatIn conclusion, the prevalence of HPV in women attending an outpatient clinic is high showing the importance of the early screening as well as the necessity of preventive measures. The number of sexual partners and alcohol consumption were the most significant risk factors for HPV infection, followed by young age and lower income. Since, the vaccine against the most prevalent and high risk HPV subtypes is in use in policies regarding prevention of HPV infection might help to reduce the risk of infection and cervical cancer. However, larger epidemiological studies in different regions of our country are needed in order to report the accurate prevalence of HPV infection.The authors declare that they have no competing interests.All authors participated in the collection, analysis, interpretation of data and writing of the paper. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2334/10/27/prepubTable S1. The demographic characteristics of the study population [the variables are expressed as n (%)].Click here for fileTable S2. Univariate and multivariate logistic analysis: the association between various parameters with HPV infection in the study population.Click here for file


Three populations active in human spontaneous cytotoxicity have been identified. Two of these are E-rosette positive, and differ in their adherence to nylon wool. The third is E-rosette negative. The E-rosette positive fraction which does not adhere to nylon consistently does not lyse a breast-cancer-derived target, MDA-157. When tested simultaneously on 4 other tumour target cells lines--Raji, Chang, K562 and Molt 4--however, all three populations are cytolytic. The MDA-157 target is consistently lysed by a nylon-adherent T-cell fraction, irrespective of whether the E rosettes are formed under optimal or the limiting conditions giving only "high-affinity" T cells. The observation that a given effector fraction can lyse one target but not another, whereas other fractions are cytolytic on both, implies that different targets may differentiate effector populations differing in their lytic mechanism.


Cervical cancer is increasing at 1.5% per year in Ireland with 50% mortality giving 2.2% of all cancer deaths. In the Mid-West region a pilot screening programme has begun to screen all women 25–60 years. 66% of Genitourinary/Sexually transmitted disease (GU/STD) clinics' abnormal smears are <25 years. Requests to abandon "opportunistic" screening prompted this GU/STD clinic audit.221(8.4%) patients referred to colposcopy over 4 years were audited. Retrospective analysis was carried out on GU/STD clinic files, hospital files and computer records for biopsy reports. Ethical approval was prospectively granted.2637 smears were carried out from November 1999 – September 2003.221 patients referred to colposcopy were audited.1%, 3%, 5% had severe, moderate and, mild dyskaryosis, respectively, on cervical screening while 0.8%, 1.2%, 1.5% had CIN3, CIN2, CIN1 abnormalities, respectively, on biopsy with 3.5% having no abnormality .53% referred to colposcopy were <25 years.2% had high grade lesions. 37% of high grade lesions are <25 years.Chlamydia trachomatis (27% of CIN3) and 44% had HPV despite Relative Risks (RR) being 0.75 and 1.09 respectively. Older women had higher grade changes.Of the high grade lesions 13% had No statistical difference was found for progression, regression and persistence in those over and under 25. Cervical cancer is the second most common cancer in women worldwide and accounts for 273,000 deaths  annually and 2.7 million of women life years lost worldwide , but onlCytological analysis of cervical smears satisfies most of the Wilson and Junger principles for a screening programme as cervical cancer is prevalent in the community; its natural history is reasonably well understood, with a believed long latency period from HPV infection to invasive disease. Treatment at an early stage is advantageous for the patient and the community, and adequate facilities are available for the diagnosis and treatment of abnormalities identified. However, the Pap cervical smear is not without its problems with sensitivity of ~55% but regular screening may account for the success of the programmes. Problems with this programme have been noted; high risk women have not attended, false negative results (18.5–48%) have been noted. A high grade abnormality does not automatically mean a high grade lesion or visa versa.A Department of Health Cervical Screening Committee in Ireland reported in 1996 that it is worthwhile to screen 25–60 year olds, 10 years longer than is recommended by World Health Organisation (WHO) and International Agency for Cancer Research (IACR).The basis for this recommendation is that despite the high rate of abnormal smear results in women under 25 years, invasive cervical cancer is rare in this age bracket . Some haChlamydia trachomatis(Ct) (LCx Abbott test). Correlation of Pap smear and biopsies was undertaken.All cervical smear results from November 1999 to September 2003 were audited in the GU/STD Clinic, Mid Western Regional Hospital, Limerick. All Pap smears were taken by Ayers spatula and Cytobrush ,11. All Relative risks (RR) and 95% confidence intervals (CI) differences were calculated using Excel spreadsheets. Those aged <25 years were compared to the entire group. Histology was taken as the "gold standard". Ethical approval was granted by the Drug and Therapeutic Ethical Committee of the Mid Western Regional Hospital, Limerick, Ireland.2637 smear results were audited. 7% were deemed "unsatisfactory" for reporting. 221(8%) were referred to Colposcopy. All GU/STD clinic files (221) and 140 hospital files were available for audit. A computer search for reports revealed another 9 reports.Table High grade lesions were found in 22%, 42%, 64% of mild, moderate andsevere dyskaryosis while in <25 year olds it was 14%, 36% & 57%.Human PapillomaBiopsy results were accrued and compared for Virus (HPV) and Chlamydia trachomatis (CT).These results are seen in Table HPV and Ct were evaluated for referral to colposcopy and having a high grade lesion with these infections.The RR of patients who attended the clinic with The results are as follows:HPV = 1.09 and (2) Ct = 0.75. RR of referral to colposcopy from clinic with (3) HPV = 1.22, (4) Ct = 0.22. However, if referred to colposcopy RR of high grade lesion with (5) HPV = 0.88 and (6) Ct = 1.7.RR of high grade lesion (moderate and severe dyskaryosis) at smear with (1) In Table All smears were analysed together and those over and the under 25 years were separated and 95% CI of the differences between those over and under 25 were calculated.No difference was seen between the <25 and >25 year olds as both age groups progress, regress and persist at similar rates.2218.4%) patients screened were referred to colposcopy of whom 117 (53%) were less than 25 years of age similar to another Irish GU/STD clinic (56%) [.4% patieHigh grade lesions were found in 25% of mild, 41% of moderate and 61% of severe dyskaryosis. The literature reports that mild, moderate and severe dyskaryosis will give high grade lesions histologically (CIN2 and CIN3) in 50%, 50–75%, 80–90%, respectively, while CIN3 will have 5% invasion rate . Any difIt is accepted Progression, Regression and Persistence have been noted in mild dyskaryosis; 16%, 62%, 22%, moderate dyskaryosis; 35%, 50%,15% ,14, and Human Papilloma Virus (Type 16) has long been associated with cervical cancer. There is a 12% risk of recurrent abnormalities in women with low-risk HPV (non 16 or 18 subtypes) and up to a 50% risk of recurrence in women with certain types of HPV infection . A change in the disease process in recent years is suggested in findings in the UK and Switzerland [Chlamydia trachomatis [tzerland  where hichomatis .Transient HPV infection has been postulated for regression rates found. HPV associated changes have been reported in literature in 80% of women ≤ 25 years of age, 66% in the age group 26 to 35 years, 51% in the age group 36 to 45 years and 38% in women aged ≥ 46 years (p = 0.03). In this study there has been a high but not as high a rate of high grade lesions in the >25 year olds (35/54 = 65%) but the rates of progression, regression and persistence are the same in the <25 year olds as was reported by Wright et al in their study of teenagers with 18% having high grade lesions .In this study RR of a high grade lesion with clinical HPV infection was 1.09 but 50% of high grade lesions had HPV. This RR is in agreement with the advice given to women on smear programmes that they do not need to come more often than the general population.Chlamydia trachomatis [Chlamydia trachomatis in this clinic similar to 9.6% in a Dublin clinic [Other Sexually Transmitted Infections have been implicated in causing dyskaryosis especially chomatis . There in clinic . 27% of Early sexual debut has not been audited in many studies ,23. YounRecent analyses of cost-effectiveness suggest that the addition of molecular HPV DNA testing for women aged over 30 years may allow the screening interval to be lengthened to 3 years for most women but women at high risk for HPV infection and its associated cellular atypias warrant closer monitoring and follow-up. These patients would include organ transplant recipients, women exposed to diethylstilbestrol (DES) and HIV-infected women .37% of oCytology-based screening programs for cervical cancer have been effective in reducing cancer incidence and preventing premature deaths worldwide. Although the causal association between infection with certain high-risk types of HPV and the development of cervical cancer has been clearly established, testing for the major risk factor is not part of current screening practice. Screening under 25 year olds has had much discussion.Chlamydia trachomatis. Of the 12 patients with Chlamydia trachomatis 6 had CIN3. 66% (4/6) were under 25 years. 62% (5/8) of those under 25 with high grade lesions had sexual debut under 14 years of age.2% (n = 54) of all patient screened  had high grade lesions in this study of which 37% (n = 20) were <25 years. 50% of these had HPV while 13% had Chlamydia trachomatis, early sexual debut or number of sexual partners pre-empts high grade lesions leading to cancer of the cervix needs further evaluation. As GUM patients have a 10 fold increase in CIN3 [Whether or not HPV,  in CIN3  (20–24 yThe authors declare that they have no competing interests.COC, HM, MOC carried out data collection, analysed data and prepared paper.JC AR, MT, DMcG, KOS carried out data collection.All authors have read and approved the final version of the manuscript


To investigate whether the high frequency of human papillomavirus infection in butchers may be linked to their higher than average incidence of lung cancer, we have examined lung cancers from 40 butchers and 26 controls for the presence of DNA from both HPV type 7, which is found almost uniquely in hand warts from butchers and fishermen, and for those HPV types associated with laryngeal and genital cancers. No HPV 7, and only a low frequency of HPV DNA was found, suggesting that HPV infection does not make an important contribution to the elevated levels of lung cancer in meat handlers. In addition, the frequency of p53 mutation was shown to be slightly lower than previously reported in lung cancers.


Racial and ethnic disparities in cervical cancer screening have been attributed to socioeconomic, insurance, and cultural differences. Our objective was to explore racial and ethnic differences in adherence to cervical cancer screening recommendations among female post-graduate physicians.We conducted a cross-sectional survey at one university hospital among a convenience sample of 204 female post-graduate physicians , examining adherence to United States Preventive Services Task Force cervical cancer screening recommendations, perception of adherence to recommendations, and barriers to obtaining care.Overall, 83% of women were adherent to screening recommendations and 84% accurately perceived adherence or non-adherence. Women who self-identified as Asian were significantly less adherent when compared with women who self-identified as white . Women who self-identified as East Indian were significantly less likely to accurately perceive adherence or non-adherence when compared to women who self-identified as white . Women who self-identified as Asian were significantly more likely to report any barrier to obtaining care when compared with women who self-identified as white  and there was a non-significant tendency toward women who self-identified as East Indian being more likely to report any barrier to obtaining care when compared with women who self-identified as white .Among a small group of insured, highly-educated physicians who have access to health care, we found racial and ethnic differences in adherence to cervical cancer screening recommendations, suggesting that culture may play a role in cervical cancer screening. Racial and ethnic disparities in cancer diagnosis and prognosis have been well documented. One explMany factors have been associated with decreased cervical cancer screening, including obesity,7 and olThe challenge of disentangling racial and ethnic differences in cervical cancer screening from differences related to socioeconomic status, education, insurance, or acculturation is immense. However, by studying cervical cancer screening among female post-graduate physicians, we had a unique opportunity to examine a group of insured, highly-educated women who have access to care and professional experience in cervical cancer and prevention. Physician preventive health care utilization has not been widely studied, but in instances when it has, some studies have found physicians to use preventive care services at high rates, -22 whileA cross-sectional survey was administered to female post-graduate physicians at Montefiore Medical Center, the University Hospital of the Albert Einstein College of Medicine, Bronx, NY, identified using a register of all trainees. All female post-graduate physicians were eligible for participation. Between May 2003 and January 2004, women were approached in-person by an investigator  to complete a self-administered, anonymous survey examining "health behaviors." Most housestaff were approached while alone in the hospital's medical library or cafeteria. After consenting to participate, housestaff were given an unmarked survey and an envelope that contained other completed surveys. The investigator stepped away for complete privacy and retrieved the envelope after the survey had been completed and placed with the others in the envelope, which required approximately five minutes. Completed surveys were not taken out of the envelope until the project's data collection phase was finished in order to further protect participants' privacy. Surveys were not distributed by electronic or inter-office mail because of response rate concerns. Institutional review board approval was obtained prior to the study.The survey assessed socio-demographic characteristics, including self-identified race/ethnicity, and had been piloted for readability but not validated. Multiple-choice questions were used to assess the following primary outcomes: 1) adherence to United States Preventive Services Task Force (USPSTF) recommendations for cervical cancer screening, 2) perception of personal adherence to recommendations, and 3) barriers to obtaining care among women who perceived themselves to be non-adherent to USPSTF recommendations. The following barrier responses were provided: no health insurance; no physician; not comfortable having Pap smear at own institution; no time; not sexually active; test inaccurate; and other (with space provided). Where appropriate, respondents could select more than one proposed response and additional space was provided for open-ended responses.The USPSTF gave cervical cancer screening an A recommendation, using indirect evidence to determine that screening women with a cervix within three years of sexual activity (or age 21) and at least every three years thereafter captures most of the benefit in terms of reducing morbidity and mortality. However,Data analysis was performed using SPSS version 11.5 . Associations between self-identified race/ethnicity and our primary outcomes were assessed using Pearson's Chi-Square and Fisher's Exact Test, depending upon the sample size for analysis, using self-identified white race as the reference group. Kappa was used to test for agreement beyond chance between adherence and perception of adherence to recommendations. All statistical tests were two-tailed.Among 393 female post-graduate physicians identified using a register of trainees, 206 were approached for participation. Response rate was > 99% (204 of 206); two declined participation, one citing urgent patient care responsibility and one citing no interest. Therefore, surveys were completed by 52% (204 of 393) of all female post-graduate physicians, representing a convenience sample.Mean age of respondents was 30 years; 53% self-identified themselves as white, 24% as Asian, 8% as African-American, 7% as East Indian, and 5% as Hispanic/Latina Table . Two eleOverall, 83% of women were adherent to USPSTF screening recommendations Table . Women wOverall, 84% of women accurately perceived personal adherence or non-adherence , which was reported by 50% of self-identified Asian women, 47% of self-identified East Indian women, and 30% of self-identified white women. Women who self-identified as Asian were more likely to report not feeling comfortable having a Pap smear at her workplace institution as a barrier to obtaining screening when compared with women who self-identified as white , while women who self-identified as East Indian were more likely to report not being sexually active as a barrier to obtaining screening when compared with women who self-identified as white . No women reported not having health insurance as a barrier to obtaining cervical cancer screening, nor did any women report cultural barriers to obtaining screening as an open-ended response .Among a small group of female post-graduate physicians at a single institution, racial and ethnic differences in current adherence to cervical cancer screening recommendations were found. Specifically, self-identified Asian women were less adherent to recommendations, while self-identified East Indian women less accurately perceived adherence or non-adherence to recommendations, erring in their perception of being non-adherent to recommendations when they were adherent. While barriers to obtaining screening were frequently reported, self-identified Asian women were more likely to report such barriers. Self-identified East Indian women also tended to be more likely to report such barriers, although this association was not statistically significant. Moreover, across all races and ethnicities, women reported barriers that are typical of physicians in post-graduate training: no time to schedule or keep an appointment.To our knowledge, this study is the first to examine cervical cancer screening among a racially and ethnically diverse group of post-graduate physicians, highly-educated women with professional experience in cervical cancer and prevention. Moreover, all housestaff during the time of the study were provided individual insurance policies at no cost and were able to access care either at the workplace (at on-site affiliated clinics) or outside of the workplace (at off-site affiliated or non-affiliated clinics). Because we found no differences in cervical cancer screening between self-identified white women and either African-American or Hispanic/Latina women, our study indirectly confirms prior research that demonstrated that adjusting for socioeconomic status and access to care explained observed differences in cervical cancer screening between white women and both African-American and Hispanic/Latina women.However, the observed difference in adherence to recommendations between self-identified Asian and white women, which has been shown in prior research,,16 suggeThere are several considerations in interpreting this study. First, the survey relied on open-ended responses for report of cultural barriers to care, such as orientation towards Eastern medicine or discomfort around sexuality. Perhaps physicians in post-graduate training were preoccupied by immediate barriers to obtaining care (lack of time) and did not consider reporting cultural barriers. Second, sub-samples of post-graduate female physicians by race/ethnicity were small, prohibiting conclusive comparisons, and only half of all post-graduate female physicians at this one large academic medical center were surveyed. Third, because we initiated the study in May 2003, our opportunity to survey the substantial number of post-graduate physicians in their final year of training was small . However, nearly all approached post-graduate physicians completed the survey, minimizing potential selection bias, and there was no difference in survey response by academic department. Fourth, our study is based on self-reported data. The tendency of respondents to over-report health promotion and disease-prevention activities is widely recognized. -29 HowevThis exploratory pilot study among insured, highly-educated physicians who have access to care found racial and ethnic differences in adherence to cervical cancer screening recommendations, suggesting that culture may play a role in cervical cancer screening. To address disparities in preventive service utilization, these results suggest that education, health literacy, insurance and access to care may be insufficient. Further work exploring cultural differences is needed.The authors declare that they have no competing interests.Drs. Ross and Nuñez-Smith were scholars in the Robert Wood Johnson Clinical Scholars Program at Yale University sponsored by the Robert Wood Johnson Foundation at times during their project involvement. Dr. Ross is currently supported by the Hartford Foundation and the Department of Veterans Affairs Health Services Research and Development Service project no. TRP-02-149. The views expressed in this article are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs. Neither the Robert Wood Johnson nor Hartford Foundation had any role in the design or conduct of the study; collection, management, analysis or interpretation of the data; preparation, review or approval of the manuscript.JSR had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the analysis.Study concept and design: JSR, BAFAcquisition of data: JSR, BAFAnalysis and interpretation of data: JSR, MN-S, JRRDrafting of the manuscript: JSRCritical revision of the manuscript for important intellectual content: JSR, MN-S, BAF, JRRStatistical analysis: JSRAdministrative, technical, or material support: JSRStudy supervision: JSRThe pre-publication history for this paper can be accessed here:


P<0.01), as evaluated by real-time PCR and a 44% risk , as evaluated by HC2. The two viral load measures correlated well . Such evaluations of viral load changes (increased or not increased) through repeat HPV DNA testing could predict progression of disease in LSIL cases of HPV types 16, 18, 52, and 58, which correlates to clinical implications.To better predict risk of progression of low-grade squamous intraepithelial lesions (LSILs) of the uterine cervix in women with human papillomavirus (HPV) infections, 294 baseline cervical specimens from women with LSILs were evaluated. Specimens were tested for HPV DNA using hybrid capture 2 (HC2) and PCR-reverse line blotting. 65 LSILs with HPV DNA types 16, 18, 52, or 58 were examined for physical status, E2/E6 ratio and viral load at two time points, along with patient age. Women with LSILs whose viral loads increased between baseline and 6 month follow-up had a 45% risk of developing HSIL (OR=7.6, 95% CI=1.9–29.4,  Human papillomavirus (HPV) plays an important role in the carcinogenesis of cervical cancer .Approximately 50% of atypical squamous cells of undetermined significance (ASCUS) and 80% of LSILs are infected by oncogenic types of HPV . A repeavs low) and viral load change (increased vs not increased) between baseline and follow-up among women with LSILs. To examine this issue, we evaluated the 2-year cumulative risk for HSIL attributable to HPV 16, 18, 52, and 58, the most common oncogenic types in pre-invasive cervical lesions including LSILs and HSILs in Asia, and questioned whether the integration of HPV oncogenes into a host genome contributed to the risk of LSILs progressing to HSILs. In addition, we determined if E6 viral load and its change contributed to the risk of LSILs progressing to HSILs during the 6-month interval between baseline diagnosis of LSIL by Pap smear and the 6-month follow-up visit by repeat Pap smear.As a result of the lack of sufficiently large prospective longitudinal follow-up studies and the different geographic distributions of HPV types, it has not been established how the risk of HSILs differs during transition by physical status of HPV 16, 18, 52, and 58 DNA  during longitudinal follow-up, viral loads (high n=431), LSIL (n=437), and HSIL (n=373), from August 1999 to March 2004 were enrolled. The details of the study design and population have been published (The Taiwan Cooperative Oncology Group (TCOG), conducted a multicenter study – T1899, entitled, ‘Human Papillomavirus DNA in Squamous Intraepithelial Lesions and Longitudinal Follow-up of Its Clinical Significance in Low-grade Squamous Intraepithelial Lesions of Uterine Cervix’, under the supervision of the National Health Research Institute of Taiwan. A total of 1246 women with abnormal Pap smears, including those diagnosed with ASCUS or AGUS (n=437) had Pap smears, HPV testing, and colposcopic examinations every 3 months during the follow-up period. Participants were excluded from the study if they had no follow-up data (n=60), baseline cancer on pathological examination (n=1), fewer than four follow-up visits (n=82), or no baseline HPV data (n=2). Women with histologically confirmed HSIL were defined as having disease progression were treated and exited from the study. Women with LSIL with two consecutive normal Pap smears and showed HPV clearance during the follow-up period were defined as in remission and also exited. Women with LSIL not in remission or progression were defined as having persistent disease. HPV persistence was defined as HPV positivity for a given type tested on two consecutive occasions vs clearance.Women with LSIL (n=14), 18 (n=8), 52 (n=30), and 58 (n=13) were collected at baseline and followed-up every 6 months until follow-up showed disease progression. Patients with LSIL from HPV types other than HPV 16, 18, 52, or 58 were excluded from our study due to diffuse distribution and relatively small sample sizes in each type. The specimens were further tested for viral load, E2/E6 ratio and viral load change using real-time PCR. Of the 187 specimens, 12 (6%) were mixed infections. Four samples lacking of follow-up HPV DNA were excluded from final analysis. In addition, 212 HSIL positive patients with HPV 16 (n=92), 18 (n=5), 52 (n=57), or 58 (n=58) infections were also obtained and tested for viral load, E2/E6 ratio, and physical status of HPV DNA using real-time PCR to compare with data from LSIL specimens. We also tested the specimens for viral load and viral load change by hybrid capture two and compared these results to those obtained by real-time PCR to predict disease progression.A total of 294 women with LSIL, having at least four follow-up visits every 3 months, were tested for HPV DNA using both HC2 and PCR-reverse line blotting and were included in our longitudinal follow-up study (unpublished data). Among the 294 patients with LSIL, 187 specimens from 65 women with HPV 16 . The HPV genotyping strips contained 29 probe lines plus one reference line, detecting 27 individual HPV genotypes and two concentrations of the β-globin control probe. Two bovine serum albumin (BSA)-conjugated probes per HPV probe per HPV type, corresponding to each of two hypervariable regions within the MY09/MY11 amplicon, were deposited in a single line for each of the following HPV types: 16, 18, 26, 31, 33, 35, 39, 42, 45, 51–59, 66, 68, MM4, MM7, MM8, and MM9.HC2  was used to examine for HPV DNA in each specimen, including a mixture of probes for cervical cancer-associated HPV types: 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, and 68. The US Food and Drug Administration approved threshold of 1 pg of HPV DNA mlμl−1. The number of threshold cycles obtained from E2 PCR and from E6 PCR was equivalent in each run. Linear plots of the log of copy number vs the number of the threshold cycle were consistently obtained for both genes, and the correlation coefficient was between 0.995 and 1.00 in each run.DNA amplifications were carried out in a 96-well reaction plate format in an ABI Prism 5700 Sequence Detection System. Amplification and quantification of the E2 and E6 genes were performed simultaneously in separate reaction tubes. Both the HPV E2 and E6 PCR reactions were performed in triplicate. Multiple negative water blanks were included in every analysis. The reactions of real-time PCR are described elsewhere (The technique was developed on the assumption that: (1) preferential disruption of E2 causes the absence of E2 gene sequences in the PCR product following integration, (2) copy numbers of both genes should be equal when viral DNA presents in episomal forms, and (3) E2 gene copy numbers are smaller than that for E6 in concomitant forms.Concentrations of HPV DNA were expressed as copies of the HPV genome in 100 ng of cellular DNA. Ratios of E2–E6 of less than 1 indicated the presence of both integrated and episomal forms. The integrated E6 was calculated by subtracting the copy numbers of E2 . The ratio of E2 to integrated E6 represented the amount of the episomal form in relation to the integrated form.vs not increased), high viral load (>105vs ⩽105), age (⩾ 30 vs <30 years) and repeat Pap smear . The correlation between HPV loads determined by real-time PCR and HC2 was estimated using Pearson's correlation. The differences in HPV integration status between LSIL and HISL groups were analysed using Fisher's exact test. All statistical analyses were performed using SAS 9.13.The 2-year cumulative risks stratified by the change of viral load at the first two time points  for histologically confirmed HSIL attributable to HPV 16, 18, 52, or 58 were analysed via the Kaplan-Meier method. Logistic regression analysis was used to calculate the odds ratios (OR) and their 95% confidence intervals (CIs) for HSIL associated with change of HPV load , 18 (2.4%), 52 (10.9%), 58 (4.1%), 53 (8.5%), and 51 (6.8%). The prevalence of HPV 16, 18, 52, and 58 in HSIL were as follows: 31.7% (92/290) – type 16, followed by 20.0% (58/290) – type 58, 19.7% (57/290) – type 52, and 1.7% (5/290) – type 18.P=0.049 for HPV 16 E6, P=0.032 for HPV 52 E6). The median viral loads of HPV types 18 and 58 among women with LSILs and HSILs did not differ significantly . The median viral load ranged from 1.3 × 104 to 3.7 × 104 copies per 100 ng of DNA. Therefore, high viral loads were defined as those greater than 105 copies per 100 ng of DNA. The HPV 16, 18, 52, or 58 viral loads tested by real-time PCR varied from 2.4 × 102–7.6 × 106 copies per 100 ng of DNA, which is equivalent to 15 151 cells. Whereas, the HPV 16, 18, 52, or 58 loads tested by HC2 varied from 5.1 × 103–1.1 × 108 copies per 100 ng of DNA, which is equivalent to about 15 000 cells. Women who had high viral loads (>105 copies) vs low viral loads (⩽105 copies) at baseline had marginally significant increased risk of disease progression (P=0.07).For the 61 eligible women with LSILs, the clinical characteristics and median viral loads are shown in P=0.34), 12.5% (1/8) with HPV 18 , 26.9% (7/26) with HPV 52 , and 7.7% (1/13) with HPV 58   with HPV 16  .P<0.01) (P=0.27)  . Overall(P=0.27) .P<0.001).Women with LSILs due to HPV 16, 18, 52, or 58, who had increases in viral loads between baseline and 6 month follow-up had risk of persistent abnormal Pap smears 45-fold greater than those without increased viral loads  or HC2 . In addition, women with LSILs, repeat abnormal Pap smears , and aged younger than 30 years  did not show an increase in risk of developing HSILs .Real-time PCR and HC2 correlated well for determining viral load change (increased or not increased) at baseline and 6-month follow-up to predict disease progression. Based on viral load change tested by HC2, women with LSILs due to HPV 16, 18, 52, or 58 who had viral load increase between baseline and 6 month follow-up had risk of developing HSILs of 44%, six-fold greater than those without increased viral loads . This result is consistent with real-time PCR of 45%, seven-fold greater than those without increased viral loads by real-time PCR. The logarithm of HPV 16, 18, 52, or 58 viral loads estimated by real-time PCR were plotted as functions of the logarithm of HPV viral loads estimated by HC2. The two measurements for viral load correlated well (Pearson's correlation coefficient P<0.001). A significant difference or trend in the physical status of HPV 52, 18, or 58 DNA was found between patients with LSILs and HSILs . However, no significant difference in the physical status of HPV 16 DNA was found between patients with LSILs and HSILs (P=0.46). When the comparison was confined to tissue proved HSIL cases, the prevalence of integration of HPV 16, 18, 52, or 58 DNA between LSIL and HSIL cases was still significantly increased (P<0.001). A significant difference or trend in the physical status of HPV 52 or 58 DNA was found between patients with LSILs and HSILs . However, the physical status of HPV 16 and 18 DNA was not significantly different between patients with LSILs and HSILs (P=0.3 for type 16 and P=0.22 for type 18).The prevalence of both integrated and episomal (mixed type) infections for women with LSILs at baseline for HPV 16, 18, 52, and 58 were as follows: 7.1% (1/14) – type 16, 12.5% (1/8) – type 18, 7.7% (2/26) – type 52, and 0% (0/13) – type 58. No pure single type of viral integration was found in women with LSILs due to HPV 16, 18, 52, and 58 at baseline or during follow-up. Integrated and episomal HPV 16, 18, 52, or 58 DNA was detected in only 1 of 13 (7.7%) specimens in progression among women during transition from LSILs to HSILs. The prevalence of integration of HPV 16, 18, 52, or 58 DNA between women with LSILs and HSILs increased significantly . The frequent monitoring of these women allowed an early diagnosis of high-risk (HR) HPV, and thereby, early therapeutic intervention. Indeed HR HPV and especially HPV 16, 18, 52, and 58 infections persisted and progressed throughout the follow-up period. We observed a 45%, 2-year cumulative risk of clinically relevant HSIL for HPV 16, 18, 52, and 58 in women with LSILs and whose viral loads increased between baseline and 6-month follow-up. Moreover, women with LSILs who had viral load increase between baseline and 6 month follow-up for HPV 16, 18, 52, or 58, had risk of persistent abnormal Pap smear 45-fold greater than did those who had no increase in viral loads  at baseline reached marginal significance (P=0.07) in predicting disease progression among women with LSILs, consistent with Women with LSIL cytology who were HPV 16 DNA positive at baseline did not have significantly increased risk of developing HSIL . One possible explanation for this is the number of women with LSILs due to HPV 16 was limited (only 9%), compared to 21% in The increase of viral load detected by both HC2 and real-time PCR methods predicted disease progression to HSIL, with HPV 16, 18, 52, and 58 viral loads detection correlating well (only 6% of tested specimens had mixed HPV types) and similar to Although, specimens with HPV 16, 18, 52, and 58 represent about 43% of all LSILs . Nonethein situ before any intraepithelial lesions are detectable  for women with normal cytologies and 4.3 × 106 HPV 16/scrape for women with abnormal cytologies. The real-time PCR and HC2 measurements of viral load correlated well, even without cell normalization in our study . Load changes determined by HC2 also precisely predicted histological progression of LSILs to HSILs.The value of 1 pg of HPV genome mlP<0.001), which is comparable with previous studies showing that integration is often detected in HSILs  samples with the episomal form. Additionally, no pure integration was found in women with LSILs due to HPV 16, 18, 52, and 58 at baseline and during follow-up. Furthermore, integration  of HPV 16, 18, 52, or 58 DNA was detected in only 1 of 13 (7.7%) specimens of women during transition from LSILs to HSILs. Although some studies (In conclusion, we recommend that patients with LSIL, HPV types 16, 18, 52, or 58, consider detecting the viral load with real-time PCR or HC2 at the first visit and 6 months subsequently. Those with elevated viral loads are at risk of disease progression and should be carefully evaluated by colposcopy.


Only 2.5% cited HPV as the cause of cervical cancer without prompting; up from 0.9% in 2002. Public education about HPV is urgently needed.We assessed awareness of human papillomavirus (HPV) in a population sample of British women ( There has been dramatic progress in understanding the role of human papillomavirus (HPV) in the aetiology of cervical cancer . Human p’, the percentage mentioning HPV was less than 2% in surveys in the United Kingdom and Mexico  omnibus survey. Using the Post Office Address File (PAF), 6100 addresses in England, Wales and Scotland were selected for recruitment between November 2006 and February 2007. The selected addresses were sent a letter informing them about the research. Data were collected during face-to-face computer-assisted interviews.Women were first asked an open question; ‘Thinking of cervical cancer, what do you think is its main cause’. This was followed by ‘What, if any, are other causes of cervical cancer’. Women were prompted using the phrase ‘anything else’ to encourage multiple responses. This was the same format as used in the 2002 survey (χ2) analyses revealed some socio-demographic differences between the two samples, so log-linear analysis was used, controlling for potentially confounding variables.Data were analysed using SPSS version 14.0. To assess associations between demographic factors and HPV awareness, each variable was entered individually into a logistic regression analysis. Data from the recall question were recoded so that any mention of a risk factor was included in the analysis and results were merged with the data from 2002 to analyse changes over time. Chi-square (n=1620), but the recruitment method meant that response rates could only be calculated for both sexes. Respondents were aged 50 years on average and most were white (94%). See There were 5585 eligible addresses at which 2981 productive interviews were carried out (response rate=53.4%). The questions in this survey were only asked in interviews with women (n=388) said they were aware of HPV. There were some age differences, with 29% of respondents who were in the cervical cancer screening age (25–64 years) reporting awareness of HPV compared with only 15% aged 16–24 years or 65 and over. Differences in HPV awareness by ethnic group were not significant, but awareness was lower in respondents with lower levels of education and income (see On the basis of the simple question about awareness of HPV that was asked at the end of the interview (the term ‘HPV’ was not used previously by the interviewer), a quarter of participants , unspecified sexually transmitted virus/infection (7%), sex at a young age (7%), frequency of sex (3%), not using condoms (3%) or unspecified sexual activity (4%). Other sexually transmitted diseases  were cited by 2% of respondents. Additional responses included a virus/infection not specifying transmission type (5%), smoking (7%), and not going for regular screening (5%).χ2(3)=9.36, P=0.025) and were less likely to be in ethnic minority groups (χ2(4)=14.36, P=0.006) than respondents from 2002. Further analyses controlled for these variables.Respondents from 2007 had slightly higher incomes , and an increase in the number of respondents who mentioned virus/infection (from 2 to 5%). However, fewer respondents mentioned other factors relating to sexual activity, including number of sexual partners , sex at a young age (13–7%), and not using condoms (7–3%). There were also significant decreases in citing wart virus (2–1%), genital warts (2–1%), not attending for smears (15–5%), smoking (15–7%), the pill (7–1%), older age (2–1%) and family history of cervical cancer (16–8%).In this survey, a quarter of respondents answered ‘yes’ to the question ‘Were you aware of HPV’; which is similar to previous findings in selected samples in the United Kingdom . What has also emerged, as predicted, is a significant SES gradient in awareness of HPV.Public understanding of HPV is necessary to ensure informed consent for vaccination and testing. There is therefore an urgent need for educational programmes. Given that lower SES is known to be associated with lower attendance at cervical screening (e.g.,


A simple method of calculating the best ages for carrying out cervical cytology screening procedures is proposed. The argument is graphical, the outcomes are readily understood by visual and intuitive methods, but a computer program for assisting the calculations is constructed. Use of the method indicates that relatively high rates of screening should be employed in women over 45, and that routine screening in women under 30 years of age is likely to be ineffective in reducing mortality. The method predicts that, if we assume a negative error rate for the test of 0-2, and a natural history with a mean interval between detectability and incurability of about 6 years, a series of 10 tests deployed between 35 and 80 years in England and Wales should give a yield of 0-67 deaths saved per 1000 tests performed, and should be capable of saving about 77% of all deaths from cervical cancer in women who conform with the recommendation.


Sir,High-risk human papilloma viruses (HPVs) have been consistently identified in 13–86% of breast tumours in the 10 studies published since 1999 .P-values for difference=0.001) . These data are compatible with the hypothesis that HPV-positive breast cancers occur in younger women than those with HPV-negative breast cancers, and that high-risk HPVs may have been transmitted by sexual activity with HPV-positive sexual partners.We have reviewed the ages of Australian women with HPV-positive and -negative breast cancer in our study published in this Journal (


Human papillomavirus detection is very important for the evaluation of prevention strategies in cervical cancer. In the Azorean population, the virus prevalence has never been studied, and there is no data available to preview a successful outcome with HPV vaccination. In this article, our objective is to characterise the HPV genotypes in Terceira Island, contributing for the epidemiological knowledge on the virus infection.® kits (Genomica) were used to perform HPV genotyping. 30 women were HPV positive, with a median age of 41 years old. Our results show that the overall HPV prevalence was 10.49%. Seventeen genotypes were identified, including 58.82% high risk, 17.65% low risk and 23.53% undetermined risk.Cervical samples were collected from 289 women aged 16–81 in the Gynaecological Outpatient Clinic of the Hospital de Santo Espírito de Angra do Heroísmo (HSEAH). HPV DNA was amplified by Polymerase Chain Reaction using the general consensus primers PGMYO9/PGMY11. Commercially available Papillomavirus Clinical ArraysUnlike other epidemiological studies, HPV31 was the most frequent type (26.67%) in Terceira Island, followed by HPV16 (10.00%), HPV51, HPV53, HPV70 and HPV82 (6.67%). Further studies are needed to investigate if the HPV types found in our population are associated with the risk of progression to high-grade squamous intraepithelial lesions or cervical cancer. Human Papillomavirus (HPV) is the main responsible of one of the most common sexually transmitted diseases worldwide and persistent infection is the major risk factor for the development of cervical cancer.To date, more than one hundred genotypes have been identified and 40 types are sexually transmitted and infect the cervix ,2. Most Detailed epidemiological studies of HPV infection, CIN and progression to cancer have tailored which are the most frequent types playing a key role in cervical carcinogenesis (high risk types), and optimal strategies are been designed to prevent, via HPV screening and vaccination, the approximately 200,000 deaths caused by this disease annually worldwide .Epidemiological studies on the prevalence of HPV types in cervical cancer show that 50% of all cases are related to HPV 16. The others are associated mainly with HPVs 18, 45, 31, 33, 52, 58 and 35, including infections with both single and multiple types [In the European Union, there were over two million incident cases of cancer in 2006 and over one million cancer deaths. In women, breast cancer was the most common form of cancer, followed by colorectal cancer and there were 82 500 (8.0%) cases of cervical cancer . PortugaCervical cancer is largely preventable through cytological screening programs designed to facilitate the detection and treatment of immediate precancerous lesions. These evaluations require trained cytotechnologists and up to three visits for screening . AlternaDespite the fact that prevalent HPV types are almost the same in all regions of the world, it is important to improve HPV genotype characterisation worldwide, including under-reported regions such as the population of the Azores, helping to define preventive strategies better.The aim of this study is to participate in the global effort to characterise HPV genotypes, contributing for the fulfilment on the epidemiology of HPV infection.A total of 289 women with a median age of 41 years (range 16 to 81 years) participated in this study between February 2006 and January 2007. The population was consecutively recruited from the Gynaecology Outpatient Clinic at the Department of Obstetrics and Gynaecology of the Hospital de Santo Espírito de Angra do Heroísmo (HSEAH). The Ethics Committee of Hospital de Santo Espírito de Angra do Heroísmo, approved the study protocol.Sample material was rinsed into a liquid medium , transported to Serviço Especializado de Epidemiologia e Biologia Molecular (SEEBMO) of HSEAH and stored at 4°C before DNA extraction.® (Genomica) kit, according to the manufacturer's instructions. Briefly, after 1 ml cell suspension centrifugation , the lysis buffer and the proteinase K (20 mg/ml) were added on the pelleted cells and incubated 2–3 hours ate 56°C in a Thermomixer Comfort Eppendorf. After 10 minutes proteinase K inactivation period at 70°C, DNA purification was performed, using DNA purification columns and the pelleted DNA was resuspended in 100 μl Elution Buffer.The DNA from cervical samples was extracted and purified, using Papillomavirus Clinical ArraysThe amplification reaction was carried out in a total volume of 50 μl, containing 5 μl of extracted DNA and 45 μl of a PCR mix with PGMYO9/PGMY11 generic consensus primers. The PCR mix contains, beside the generic consensus primers, two internal controls that will validate each sample genotyping: genomic DNA control and amplification control. The first control consists in a primer set that amplifies a 892 bp CFTR gene fragment and the second control amplifies 1202 bp of a modified plasmid, using the same primers as the CFTR gene.The mixture was submitted to 45 cycles of amplification, using a DNA thermalcycler T-Gradient (Biometra). Each cycle included a denaturation step at 94°C for 30 seconds, followed by an annealing step at 55°C for 1 minute and a chain elongation step at 72°C for 90 seconds. Each PCR was initiated with a 9 minutes denaturation step at 95°C and finished by an 8 minutes extension-step at 72°C.Different laboratory areas were used for sample handling (pre-PCR area), product amplification (PCR area) and HPV genotyping (post-PCR area).® (Genomica) kit was used for HPV DNA genotyping. All samples were analysed for the presence of he following HPV types: 6, 11, 16, 18, 26, 31, 33, 35, 39, 40, 42, 43, 44, 45, 51, 52, 53, 54, 56, 58, 59, 61, 62, 66, 68, 70, 71, 72, 73, 81, 82, 83, 84, 85 and 89.The commercially available Papillomavirus Clinical ArraysHPV detection was conducted using PGMYO9/PGMY11 general consensus primers designed to amplify a 450 bp HPV L1 gene fragment. This region is used because it is highly conserved between different HPV types but has sufficient variation for the identification of each one .The detection of the amplified PCR product was performed with a new technological platform using a low density Microarray, anchored in 2 ml tube-AT tube. It allows simultaneous detection of multiple molecular markers in the L1 fragment of 35 different HPV types and in the necessary controls to insure a feasible assay. All process was followed according to the manufacture's standard protocol.PCR products were marked with biotin and, after amplification, they hybridised with the respective probes in specific known AT tube areas. Biotin binds to streptavidin-peroxidase after incubation. The addition of the TMB substrate  generates an insoluble product after hybridisation.The results were processed by software, which allows detection, interpretation and reporting for each sample.The study encompasses two hundred and eighty nine women with a mean age of 41 years and was stratified in 5-year age groups.Two hundred and seventy five (95.2%) women had normal cytology. Epithelial cell abnormalities were detected in 14 women: 4 were labelled as atypical squamous cell of undetermined significance , 7 had cervical intraepithelial neoplasia , and 3 women (1.04%) had been treated for cervical carcinoma and were excluded from the study sample. The three exclusion cases were HPV positive: HPV16, HPV61 and 66 and HPV58.HPV-DNA was detected in thirty (10.49%) out of tow hundred and eighty six eligible women and only one had cytological abnormalities (CIN).Figure Seventeen HPV types were detected, encompassing three low-risk types (17.65%) – including a double low risk infection, ten high-risk types (58.82%), and four undetermined risk types (23.53%).Single infections were found in 26 women (86.67%) and multiple infections were detected in 4 (13.33%), ranging from 2 to 3 different genotypes (average of 1.17 types per women).The most common types of Human Papillomavirus in Terceira Island were HPV31, followed by HPV16, HPV51, HPV 53, HPV70 and HPV82  was concordant with the range of 2 to 44% world-wide .Burchell et al showed that age-specific HPV prevalence among women with normal cytology was highest for younger women (<20) and decreased in the middle age groups, to increase again at age 65 and older . This fiThe second major peak of infection identified in our population, as described in other studies, was in the peri- or post-menopausal years. Although the reason for this "menopausal peak" is still unclear, it may be related to the reactivation of latent infections acquired earlier in life, due to a gradual loss of type-specific immunity or to acquisition of new infections by sexual contacts with new partners later in life ,9.The most common HPV types in Clifford et al meta-analysis, in either single and multiple infections, were HPV16, HPV 42, HPV 58, HPV 31, HPV 18, HPV 56, HPV 81, HPV 35, HPV 33 and HPV 45 .In our sample, the majority of HPV-positive women were infected with the high-risk HPV 31 – 26.67%  were quite similar to those in Asia (14%) and much lower than in Europe (21%).HPV18 infection among women was very similar across all world regions, varying from 4 to 5%; slightly lower results were obtained in the Azores population (3.33%).The discrepancy between our data and previous European publications may be related to important influxes of groups coming from Europe; especially Eastern Europe (Ukraine and Russia), Africa (Cabo Verde), Latin America and North America.Prevention of HPV infection through vaccination is expected to dramatically reduce the morbidity and mortality associated with HPV infection. These vaccines are based on the major capsid protein of the virus, L1 proteins, which are capable of self-assembling into virus like particles (VLPs) when expressed in cells. These VLPs share great similarity to native HPV virions, are non-infectious and non-oncogenic and can induce high levels of neutralizing antibodies ,11.® Merck & Co) that includes HPV16, HPV18, HPV6 and HPV11; these last two types cause the majority of genital warts (approximately 90%) in both men and women [Two vaccines are currently available and they incorporate HPV types more frequently associated with cervical cancer. A bivalent VLP vaccine (Cervarix™ GlaxoSmithKline) is composed of the assembled VLPs of HPV16 and HPV18 L1, and a quadrivalent VLP based vaccine (Gardasilnd women .The proportions of high-risk HPV infections preventable by a vaccine for HPV16 and HPV18 vary by region, being highest in Europe and lowest in Sub-Saharan Africa . HoweverDetermining whether any significant protection is provided between genotypes will be a prerequisite to increase the breadth of genotype coverage for prophylactic vaccines. If VLP vaccines are found to confer a high rate of type-specific protection but no significant cross-protection, alternative second-generation vaccines may be needed to protect against other high risk HPV types, such as HPV45 and HPV31, to perform a major reduction in cervical cancer .Future studies are necessary to confirm some study issues. It is extremely important to enlarge our sample in order to confirm the very high HPV31 prevalence not only in normal cytology but also in high-grade lesions and in cervical cancer.These findings will let us know about the efficacy of the existing vaccines and if a new one should be tailored for the population under investigation.The authors declare that they have no competing interests.MBA, FT and LM carried out cervical sample collection. MS, MRS and ARC carried out DNA extraction. ID carried out DNA extraction, HPV genotyping, and drafted the manuscript. SH reviewed the manuscript. JBA coordinated and reviewed manuscript. All authors read and approved the final manuscript.