Human Papillomavirus and Related Diseases Report WORLD

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1 Human Papillomavirus and Related Diseases Report WORLD Version posted on in April 8 th, 2014

2 - ii - Rights ICO Information Centre on HPV and Cancer (HPV Information Centre) 2014 All rights reserved. Publications of the ICO Information Centre on HPV and Cancer (HPV Information Centre) can be obtained from HPV Information Centre Secretariat, Institut Català d Oncologia, Avda. Gran Via de l Hospitalet, L Hospitalet del Llobregat (Barcelona, Spain, hpvcentre@iconcologia.net). Requests for permission to reproduce or translate HPV Information Centre publications - whether for sale or for noncommercial distribution- should be addressed to HPV Information Centre Secretariat, at the above address ( hpvcentre@iconcologia.net). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part the HPV Information Centre concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers products does not imply that they are endorsed or recommended the HPV Information Centre in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the HPV Information Centre to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the HPV Information Centre be liable for damages arising from its use. Recommended citation: Bruni L, Barrionuevo-Rosas L, Serrano B, Brotons M, Cosano R, Muñoz J, Bosch FX, de Sanjosé S, Castellsagué X. ICO Information Centre on HPV and Cancer (HPV Information Centre). Human Papillomavirus and Related Diseases in World. Summary Report [Data Accessed]

3 - iii - Abbreviations Abbreviation HPV PREHDICT Project Table 1: Abbreviations Full term Human papillomavirus infection health-economic modelling of PREvention strategies for Hpv-related Diseases in European CounTries WHO/ICO Information Centre on HPV and Cervical Cancer Genital Warts Recurrent respiratory papillomatosis Squamous Intraepithelial Lesions Low-grade cervical lesions High-grade cervical lesions Invasive cervical cancer Carcinoma in situ Cervical Intraepithelial Neoplasia HPV Information Centre GW RRP SIL LSIL HSIL ICC CIS CIN AIN2/3 Anal intraepithelial neoplasia of grade 2 and/or 3 VIN 2/3 Vulvar intraepithelial neoplasia of grade 2 and/or 3 VAIN 2/3 Vaginal intraepithelial neoplasia of grade 2 and/or 3 PeIN 2/3 Penile intraepithelial neoplasia of grade 2 and/or 3 95% CI 95% Confidence Interval N Number of cases tested HPV Prev HPV prevalence ASR Age-standardized rate MSM Men who have sex with men Non MSM Heterosexual men SCC Squamous cell carcinomas STI Sexually transmitted infections HIV/AIDS Human immunodeficiency virus/acquired immunodeficiency syndrome TS Type Specific EIA Enzyme ImmunoAssay RLBM Reverse Line Blotting Method RFLP Restriction Fragment Length Polymorphism RHA Reverse Hybridization Assay RLH Reverse Line Hybridisation LiPA Line Probe Assay SBH Southern Blot Hybridization ISH In Situ Hybridization MABA Micro Array-Based Assay LBA Line-Blot Assay HC2 Hybrid Capture 2 SAT Suspension Array Technology PCR Polymerase Chain Reaction SPF Short Primer Fragment q-pcr quantitative Polymerase Chain Reaction RLBH Reverse Line Blot Hybridization RT-PCR Real Time Polymerase Chain Reaction DBH Dot Blot Hybridization HR High Risk DSA Direct Sequence Analysis MAA Microchip Array Assay

4 - iv - Executive summary Human papillomavirus (HPV) infection is now a well-established cause of cervical cancer and there is growing evidence of HPV being a relevant factor in other anogenital cancers (anus, vulva, vagina and penis) and head and neck cancers. HPV types 16 and 18 are responsible for about 70% of all cervical cancer cases worldwide. HPV vaccines that prevent against HPV 16 and 18 infection are now available and have the potential to reduce the incidence of cervical and other anogenital cancers. This report provides key information for Less developed regions on cervical cancer, other anogenital cancers and head and neck cancers, HPV-related statistics, factors contributing to cervical cancer, cervical cancer screening practices, HPV vaccine introduction, and other relevant immunization indicators. The report is intended to strengthen the guidance for health policy implementation of primary and secondary cervical cancer prevention strategies in the region. Less developed regions has a population of 2,540 millions women aged 15 years and older who are at risk of developing cervical cancer. Current estimates indicate that every year 527,624 women are diagnosed with cervical cancer and 265,653 die from the disease. Cervical cancer ranks as the 3rd most frequent cancer among women in the World. Population Table 2: Key statistics in the World Women at risk for cervical cancer (Female population aged >=15 yrs) in millions Burden of cervical cancer Annual number of new cervical cancer cases 527, ,546 83,078 Standardized incidence rates per 100,000 population in cervical cancer Annual number of cervical cancer deaths 265, ,158 35,495 Standardized mortality rates per 100,000 population in cervical cancer Burden of cervical HPV infection HPV prevalence (%) in the general population (women with normal cytology) Prevalence (%) of HPV 16 and/or HPV 18 among women with: World Less developed regions More developed regions Normal cytology Low-grade cervical lesions (LSIL/CIN-1) High-grade cervical lesions (HSIL/ CIN-2 / CIN-3 / CIS) Cervical cancer LSIL, low-grade intraepithelial lesions; HSIL, high-grade intraepithelial lesions; CIN-2/3, cervical intraepithelial neoplasia grade 2 or 3; CIS, carcinoma in-situ.

5 LIST OF CONTENTS - v - Contents Abbreviations Executive summary iii iv 1 Introduction 1 2 Demographic and socioeconomic factors (last update 25 nov 2013) 3 3 Burden of HPV related cancers Cervical cancer Incidence (last update 15 ene 2014) Mortality Anogenital cancers other than the cervix Anal cancer (last update 13 dic 2013) Vulvar cancer (last update 13 dic 2013) Vaginal cancer (last update 13 dic 2013) Penile cancer (last update 20 sep 2013) Head and neck cancers Oral cavity (last update 15 ene 2014) Pharynx (excluding nasopharynx) (last update 15 ene 2014) HPV related statistics HPV burden in women with normal cytology, precancerous cervical lesions or invasive cervical cancer HPV prevalence in women with normal cytology (last update 16 dic 2013, data as of 30 nov 2011) HPV type distribution among women with normal cytology, precancerous cervical lesions and cervical cancer (last update 16 dic 2013, data as of 30 nov 2011) Terminology HPV burden in anogenital cancers other than cervix Anal cancer and precancerous anal lesions (last update 15 sep 2010) Vulvar cancer and precancerous vulvar lesions (last update 15 sep 2010) Vaginal cancer and precancerous vaginal lesions (last update 15 sep 2010) Penile cancer and precancerous penile lesions (last update 15 sep 2010) HPV burden in men (last update 15 sep 2010) Factors contributing to cervical cancer (last update 27 ene 2014) Reproductive and sexual behaviour (last update 08 ago 2013) HPV preventive strategies Cervical cancer screening practices (last update 30 jul 2013) HPV vaccination HPV vaccine licensure and introduction (last update 26 nov 2013) Male Circumcision and condom use (last update 30 sep 2013) References 130

6 LIST OF FIGURES - vi - List of Figures 1 World s geographical regions Population pyramid estimates of the World compared to developing and developed regions for Population trends of four selected age groups in the World compared to developing and developed regions Age-standardized incidence rates of cervical cancer in the World Ranking of cervical cancer to others cancers among all women and women ages years, according to incidence rates in the World World age-standarized incidence rates compared to regions and sub-regions Ten most frequent cancer in all women in the World compared to developing and developed regions Ten most frequent cancer in all women in the World compared to the continents Ten most frequent cancers in women ages yrs in the World compared to developing and developed regions Ten most frequent cancers in women ages yrs in the World compared to the continents Age-specific incidence of cervical cancer in the World compared to developed and developing regions and five continents Annual number of new cases of cervical cancer by age group in develop and developing regions and five continents World age-standarized moratlity rates of cervical cancer World age-standardized mortality rates of cervical cancer compared to regions and sub-regions Ranking of cervical cancer to others cancers among all women and women ages years, according to mortality rates in World World age-specific mortality of cervical cancer in the World compared to developed and developing regins and five continents Annual number of deaths of cervical cancer by age group in developed and developing regions and five continents Comparison of incidence and mortality rates of oral cavity (includes lip) of male by age group Comparison of incidence and mortality rates of oral cavity (includes lip) of male by age group Comparison of incidence and mortality rates of oral cavity (includes lip) of female by age group Comparison of incidence and mortality rates of oral cavity (includes lip) of female by age group Comparison of incidence and mortality rates of cancer of the pharynx (excluding nasopharynx) of male by age group in the World. Includes ICD-10 codes:c09-10,c Comparison of incidence and mortality rates of cancer of the pharynx (excluding nasopharynx) of male by age group in the World. Includes ICD-10 codes:c09-10,c Comparison of incidence and mortality rates of cancer of the pharynx (excluding nasopharynx) of female by age group in the World. Includes ICD-10 codes:c09-10,c Comparison of incidence and mortality rates of cancer of the pharynx (excluding nasopharynx) of female by age group in the World. Includes ICD-10 codes:c09-10,c Prevalence of HPV among women with normal cytology in the World Crude age-specific HPV prevalence (%) and 95% confidence interval (grey shadow) in women with normal cytology in the World compared to developing and developed regions Crude age-specific HPV prevalence (%) and 95% confidence interval (grey shadow) in women with normal cytology in the World compared to five continents Prevalence of HPV among women with normal cytology in Africa by country and study Prevalence of HPV among women with normal cytology in Americas by country and study Prevalence of HPV among women with normal cytology in Asia by country and study Prevalence of HPV among women with normal cytology in Europe by country and study Prevalence of HPV among women with normal cytology in Oceania by country and study Prevalence of HPV 16 among women with normal cytology in Europe by country and study Prevalence of HPV 16 among women with normal cytology in Africa by country and study Prevalence of HPV 16 among women with normal cytology in Americas by country and study Prevalence of HPV 16 among women with normal cytology in Asia by country and study Prevalence of HPV 16 among women with low-grade cervical lesions in Europe by country and study Prevalence of HPV 16 among women with low-grade cervical lesions in Africa by country and study Prevalence of HPV 16 among women with low-grade cervical lesions in Americas by country and study Prevalence of HPV 16 among women with low-grade cervical lesions in Oceania by country and study Prevalence of HPV 16 among women with low-grade cervical lesions in Asia by country and study Prevalence of HPV 16 among women with High-grade cervical lesions in Europe by country and study Prevalence of HPV 16 among women with High-grade cervical lesions in Africa by country and study Prevalence of HPV 16 among women with High-grade cervical lesions in Americas by country and study Prevalence of HPV 16 among women with High-grade cervical lesions in Oceania by country and study Prevalence of HPV 16 among women with High-grade cervical lesions in Asia by country and study Prevalence of HPV 16 among women with invasive cervical cancer in Europe by country and study Prevalence of HPV 16 among women with invasive cervical cancer in Africa by country and study Prevalence of HPV 16 among women with invasive cervical cancer in Americas by country and study Prevalence of HPV 16 among women with invasive cervical cancer in Oceania by country and study Prevalence of HPV 16 among women with invasive cervical cancer in Asia by country and study Prevalence of HPV 16 among women with invasive cervical adenocarcinoma in Europe by country and study.. 85

7 LIST OF FIGURES - vii - 54 Prevalence of HPV 16 among women with invasive cervical adenocarcinoma in Africa by country and study Prevalence of HPV 16 among women with invasive cervical adenocarcinoma in Americas by country and study Prevalence of HPV 16 among women with invasive cervical adenocarcinoma in Oceania by country and study Prevalence of HPV 16 among women with invasive cervical adenocarcinoma in Asia by country and study Prevalence of HPV 16 among women with invasive cervical squamous cell carcinoma in Europe by country and study Prevalence of HPV 16 among women with invasive cervical squamous cell carcinoma in Africa by country and study Prevalence of HPV 16 among women with invasive cervical squamous cell carcinoma in Americas by country and study Prevalence of HPV 16 among women with invasive cervical squamous cell carcinoma in Oceania by country and study Prevalence of HPV 16 among women with invasive cervical squamous cell carcinoma in Asia by country and study Ten most frequent HPV types among women with and without cervical lesions in the World compared to developing and developed regions Ten most frequent HPV types among women with invasive cervical cancer by histology in the World compared to developing and developed regions HPV prevalence among cases of anal cancer in the World, by histology Ten most frequent HPV types among anal cancer cases in the World HPV prevalence among cases of vulvar cancer by histology in the World Ten most frequent HPV types among vulvar cancer cases in the World Ten most frequent HPV types among vaginal cancer cases in the World HPV prevalence among cases of penile cancer by histology in the World Ten most frequent HPV types among penile cancer cases in the World Prevalence of female tobacco smoking in the World Total fertility rates in the World Prevalence of oral contraceptive use in World Prevalence of HIV in the World Proportion of young women (15-24 years) who have had sex before the age of 15 in the World Licensure status of current HPV vaccines in the World Status of HPV vaccination programs in the World Prevalence of male circumcision in the World Prevalence of condom use in the World World

8 LIST OF TABLES - viii - List of Tables 1 Abbreviations iii 2 Key statistics in the World iv 3 Population (in millions) estimates in the World Sociodemographic indicators in the World Incidence of cervical cancer by regions and sub-regions in the World Cervical cancer mortality in regions and sub-regions in the World Incidence of anal cancer by cancer registry and sex Incidence of vulvar cancer by cancer registry Incidence of vaginal cancer by cancer registry Incidence of penile cancer by cancer registry Incidence of cancer of the oral cavity (includes lip) by sex by regions and sub-regions in the World Mortality of cancer of the oral cavity (includes lip) by sex by regions and sub-regions in the World Incidence of cancer of the pharynx (excluding nasopharynx) by sex by regions ans sub-regions in the World. Includes ICD-10 codes:c09-10,c Mortality of cancer of the pharynx (excluding nasopharynx) by sex by regions and sub-regions in the World. Includes ICD-10 codes:c09-10,c Prevalence of HPV among women with normal cytology Prevalence of HPV 16/18 in women with normal cytology, precancerous cervical lesions and invasive cervical cancer by regions and sub-regions in the World Type-specific HPV prevalence in women with normal cytology, precancerous cervical lesions and invasive cervical cancer in the World Type-specific HPV prevalence among invasive cervical cancer cases by histology in the World Prevalence of HPV in anogenital cancers other than the cervix in the World Pooled estimate of HPV prevalence among anal cancer cases, by sex Pooled estimate of HPV prevalence among men who have sex with men (MSM) and non-msm with anal cancer Studies on HPV prevalence among cases of vaginal cancer in the World Studies on HPV prevalence among men in the World Cervical cancer screening policy in the World HPV vaccination policy in female population in the World References of studies included

9 1 INTRODUCTION Introduction Figure 1: World s geographical regions Northern Europe Eastern Europe Northern America Western Europe Central Asia Caribbean Southern Europe Northern Africa Western Asia Southern Asia Eastern Asia Central America Western Africa South Eastern Asia Micronesia Middle Africa Eastern Africa Polynesia Melanesia South America Australia and New Zealand Southern Africa United Nations Statistics Division- Standard Country and Area Codes Classifications. The ICO Information Centre on HPV and Cervical Cancer (HPV Information Centre) aims to compile and centralize updated data and statistics on human papillomavirus (HPV) and HPV-related cancers. This report aims to summarize the data available to fully evaluate the burden of disease in the World and to facilitate stakeholders and relevant bodies of decision makers to formulate recommendations on the prevention of cervical cancer and other HPV-related cancers. Data include relevant cancer statistic estimates, epidemiological determinants of cervical cancer such as demographics, socioeconomic factors, risk factors, burden of HPV infection in women and men, and cervical screening and immunization practices. The report is structured into the following sections: Section 2, Demographic and socioeconomic factors (last update 25 nov 2013). summarizes the socio-demographic profile of the World. For analytical purposes, World divided into five continents: Africa, Americas, Asia, Europe, Oceania (Figure). Section 3, Burden of HPV related cancers. This section describes the current burden of invasive cervical cancer and other HPV-related cancers in the World with estimates of prevalence, incidence and mortality rates. Section 4, HPV related statistics. reports on prevalence of HPV and HPV type-specific distribution in women with normal cytology, women with precancerous lesions and invasive cervical cancer. In addition, the burden of HPV in other anogential cancers (anus, vulva, vagina, and penis) are presented. Section 5, Factors contributing to cervical cancer (last update 27 ene 2014). This section describes factors that can modify the natural history of HPV and cervical carcinogenesis such as the use of smoking, parity, oral contraceptive use and co-infection with HIV. Section 6, Reproductive and sexual behaviour (last update 08 ago 2013). This section presents sexual and reproductive behaviour indicators that may be used as proxy measures of risk for HPV infection and anogenital cancers. Section 7, HPV preventive strategies. This section presents preventive strategies that include basic characteristics and performance of cervical cancer screening status, status of HPV vaccine licensure introduction, and recommendations in national immunization programs and the prevalence of male

10 1 INTRODUCTION circumcision and condom use.

11 2 DEMOGRAPHIC AND SOCIOECONOMIC FACTORS (LAST UPDATE 25 NOV 2013) Demographic and socioeconomic factors (last update 25 nov 2013) Figure 2: Population pyramid estimates of the World compared to developing and developed regions for 2013 Males World Females Under 5 44,862,128 73,318,461 47,910,524 61,545,144 67,885,516 79,626,349 92,674, ,444, ,858, ,594, ,112, ,137, ,877, ,866, ,770, ,271, ,972, ,301, ,485, ,427, ,036, ,933, ,560, ,586, ,471, ,981, ,020, ,040, ,160, ,073, ,123, ,574, ,685, ,926,471 Less developed regions Males Females Under 5 25,381,703 36,238,908 30,537,994 36,942,931 45,663,506 51,399,344 63,956,538 69,080,503 96,065,750 98,275, ,043, ,447, ,378, ,166, ,939, ,611, ,493, ,600, ,448, ,482, ,577, ,108, ,505, ,830, ,275, ,522, ,435, ,164, ,798, ,331, ,037, ,145, ,701, ,723,888 More developed regions Males Females Under 5 19,480,425 37,079,553 17,372,530 24,602,213 22,222,010 28,227,005 28,717,611 33,363,657 35,792,924 40,318,598 40,069,549 43,690,433 43,499,236 45,700,353 43,830,363 44,659,461 43,478,510 43,700,586 43,037,604 42,944,904 43,458,578 42,824,505 44,055,137 42,756,090 41,196,586 39,458,982 36,585,899 34,876,664 34,362,149 32,741,693 35,086,071 33,428,405 35,983,991 34,202,583 Population by sex and age group Estimated population in a country, area or region as of 1 July of the year indicated. United Nations, Department of Economic and Social Affairs, Population Division (2013). World Population Prospects: The 2012 Revision, CD-ROM Edition. Available at:

12 2 DEMOGRAPHIC AND SOCIOECONOMIC FACTORS (LAST UPDATE 25 NOV 2013) Figure 3: Population trends of four selected age groups in the World compared to developing and developed regions Projections World Projections Number of women (in millions) Women yrs Girls yrs Number of women (in millions) 5,200 4,200 3,200 2,200 1, All Women Women yrs Less developed regions Projections Number of women (in millions) Women yrs Girls yrs More developed regions Projections Projections Number of women (in millions) 5,200 4,200 3,200 2,200 1, All Women Women yrs Projections Number of women (in millions) Women yrs Girls yrs Number of women (in millions) 5,200 4,200 3,200 2,200 1, All Women Women yrs Female population trends Number of women by year and age group Estimated population in a country, area or region as of 1 July of the year indicated. United Nations, Department of Economic and Social Affairs, Population Division (2013). World Population Prospects: The 2012 Revision, CD-ROM Edition. Available at:

13 2 DEMOGRAPHIC AND SOCIOECONOMIC FACTORS (LAST UPDATE 25 NOV 2013) Table 3: Population (in millions) estimates in the World Region / Country Male Female years 15+ years Total years 15+ years Total World Less developed regions More developed regions Africa Eastern Africa Middle Africa Northern Africa Southern Africa Western Africa Americas Caribbean Central America Northern America South America Asia Central Asia Eastern Asia South-Eastern Asia Southern Asia Western Asia Europe Eastern Europe Northern Europe Southern Europe Western Europe Oceania Australia & New Zealand Melanesia Micronesia Polynesia Estimated population in a country, area or region as of 1 July of the year indicated. Americas: Including Bermuda, Greenland, and Saint-Pierre-et-Miquelon. Caribbean: Including Anguilla, Antigua, Aruba, British Virgin Islands, Cayman Islands, Domi Including Saint Helena, Ascension, and Tristan da Cunha. Eastern Africa: Including Seychelles. Less developed regions: The less developed regions comprise all regions of Africa, Asia (excluding Japan Micronesia: Including Falkland Islands (Malvinas). Including Kiribati, Marshall Islands, Nauru, Northern Mariana Islands and Palau. More developed regions: The more developed regions comprise all regions of Europe plus Northern America Northern America: Including Bermuda, Greenland, and Saint-Pierre-et-Miquelon. Including Anguilla, British Virgin Islands, Caribbean Netherlands, Cayman Islands, Dominica, Montserrat, Saint Kitts and Nevis, Sint Maarten (Dutch part) and Turks and Caicos Islands. Northern Europe: Including Faeroe Islands, and Isle of Man. Polynesia: Including American Samoa, Cook Islands, Pitcairn, Tokelau, Tuvalu, and Wallis an Including Marshall Islands, Nauru, Northern Mariana Islands, and Palau. South America: Including Falkland Islands (Malvinas). Including Bermuda, Greenland, and Saint Pierre and Miquelon. Southern Europe: Including Andorra, Gibraltar, Holy See, and San Marino. Aggregated by the HPV Information Centre pooling its individual areas/countries. Western Africa: Including Liechtenstein, and Monaco. Including Saint Helena, Ascension and Tristan da Cunha. Western Europe: Including Andorra, Gibraltar, Holy See, and San Marino. Including Liechtenstein, and Monaco. United Nations, Department of Economic and Social Affairs, Population Division (2013). World Population Prospects: The 2012 Revision, CD-ROM Edition. Available at: Table 4: Sociodemographic indicators in the World Indicator Male Female Total Population in 1,000s 1,a 3,551,649.3 b 3,610,470.1 b 7,162,119.2 b Population growth rate (%) c Median age of the population (years) d Population living in urban areas (%) d Crude birth rate (births per 1,000 population) c Crude death rate (deaths per 1,000 population) c Life expectancy at birth (years) Adult mortality rate (probability of dying between 15 and years per 1,000 population) Under-five mortality rate (per 1,000 live births) Gross national income per capita (PPP int $) ,079 e Density of physicians (per 10,000 population) (Continued)

14 2 DEMOGRAPHIC AND SOCIOECONOMIC FACTORS (LAST UPDATE 25 NOV 2013) Table 4 Continued Indicator Male Female Total Adult (15 years and over) literacy rate (%) Youth (15-24 years) literacy rate (%) Net primary school enrollment ratio d 89.7 d 88.8 d Net secondary school enrollment ratio d 63.7 d 62.5 d PPP int. $: purchasing power parity at international dollar rate. a Estimated population in a country, area or region as of 1 July of the year indicated. Year of estimation: b 2013 ; c ; d 2010 ; e 2012; 1 United Nations, Department of Economic and Social Affairs, Population Division (2013). World Population Prospects: The 2012 Revision, CD-ROM Edition. Available at: 2 United Nations, Department of Economic and Social Affairs, Population Division (2012). World Urbanization Prospects : The 2011 Revision. CD-ROM Edition - Data in digital form (POP/ DB/WUP/Rev.2011). 3 World Development Indicators Database, Washington, DC, World Bank. Available at: [Accessed on July 2013] 4 UNESCO Institute for Statistics Data Centre [online database]. Montreal, UNESCO Institute for Statistics, Available at: [Accessed on July 2013]

15 3 BURDEN OF HPV RELATED CANCERS Burden of HPV related cancers 3.1 Cervical cancer Cancer of the cervix uteri is the third most common cancer among women worldwide, with an estimated 530,232 new cases and 275,008 deaths in Worldwide, mortality rates of cervical cancer are substantially lower than incidence with a ratio of mortality to incidence to 52% (IARC, GLOBOCAN 2008). The majority of cases are squamous cell carcinoma followed by adenocarcinomas. (Vaccine 2006, Vol. 24, Suppl 3; Vaccine 2008, Vol. 26, Suppl 10; Vaccine 2012, Vol. 30, Suppl 5; IARC Monographs 2007, Vol. 90) This section describes the current burden of invasive cervical cancer in the World and its regions with estimates of annual number of new cases, deaths, and incidence and mortality rates Incidence (last update 15 ene 2014) KEY STATS. 527,624 new cervical cancer cases are diagnosed annually in World. Cervical cancer ranks as the 4 th cause of female cancer in World. Cervical cancer is the 2 nd most common female cancer in women aged 15 to 44 years in World. Figure 4: Age-standardized incidence rates of cervical cancer in the World ASR, age-standardized incidence rates; Rates per 100,000 women per year. Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM, Forman D, Bray F. GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11 [Internet]. Lyon, France: International Agency for Research on Cancer; Available from: accessed on 15/01/2014.

16 3 BURDEN OF HPV RELATED CANCERS Table 5: Incidence of cervical cancer by regions and sub-regions in the World Cumulative risk (%) Ranking of CC Area N cases Crude rate a ASR a ages 0-74 yrs b All women Women yrs World 527, Less developed 444, regions More developed 83, regions Africa 99, Eastern Africa 45, Middle Africa 11, Northern Africa 5, Southern Africa 8, Western Africa 27, Americas 83, Caribbean 5, Central America 18, Northern America 14, South America 45, Asia 284, Central Asia 5, Eastern Asia 78, South-Eastern 50, Asia Southern Asia 145, Western Asia 4, Europe 58, Eastern Europe 33, Northern Europe 5, Southern Europe 9, Western Europe 9, Oceania 2, Australia & New Zealand Melanesia 1, Micronesia Polynesia ASR: Age-standardised rate. a Rates per 100,000 women per year. b Cumulative risk (incidence) is the probability or risk of individuals getting from the disease during ages 0-74 years. For cancer, it is expressed as the % of new born children who would be expected to develop from a particular cancer before the age of 75 if they had the rates of cancer observed in the period in the absence of competing causes. Western Asia estimates for Globocan 2008 do not include Cyprus. Cyprus accounts for Southern Europe estimates. Standardised rates have ben estimated using the direct method and the World population as the reference. Ranking of cervical cancer incidence to other cancers among all women ages years according to highest incidence rates (ranking 1st). Ranking is based on crude incidence rates (actual number of cervical cancer cases). Ranking using ASR may differ. Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM, Forman D, Bray, F. GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11 [Internet]. Lyon, France: International Agency for Research on Cancer; Available from: accessed on 15/01/2014.

17 3 BURDEN OF HPV RELATED CANCERS Figure 5: Ranking of cervical cancer to others cancers among all women and women ages years, according to incidence rates in the World Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM, Forman D, Bray F. GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11 [Internet]. Lyon, France: International Agency for Research on Cancer; Available from: accessed on 15/01/2014. Includes anal cancer (C21).

18 3 BURDEN OF HPV RELATED CANCERS Figure 6: World age-standarized incidence rates compared to regions and sub-regions World, developed and developing regions Continent's sub regions Less developed regions 15.7 Eastern Africa 42.7 Melanesia 33.3 Southern Africa 31.5 Middle Africa 30.6 World 14.0 Western Africa 29.3 Central America 23.5 Caribbean 21.0 South America 20.3 More developed regions 9.9 Southern Asia Central Asia South Eastern Asia 16.3 Africa Five continents 27.6 Eastern Europe Polynesia Micronesia Americas 14.9 Northern Europe Southern Europe Eastern Asia 7.9 Asia 12.7 Western Europe 7.3 Northern America 6.6 Europe 11.4 Northern Africa Australia & New Zealand Oceania 10.2 Western Asia Cervical cancer: Age standardized incidence rate per 100,000 women per year World Standard. Female (All ages) Rates per 100,000 women per year. Western Asia estimates for Globocan 2008 do not include Cyprus. Cyprus accounts for Southern Europe estimates. Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM, Forman D, Bray, F. GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11 [Internet]. Lyon, France: International Agency for Research on Cancer; Available from: accessed on 15/01/2014. Figure 7: Ten most frequent cancer in all women in the World compared to developing and developed regions Less developed regions More developed regions World Breast 31.3 Breast 74.1 Breast 43.3 Cervix uteri 15.7 Colorectum 23.6 Colorectum 14.3 Lung 11.1 Lung 19.6 Cervix uteri 14.0 Colorectum 9.8 Corpus uteri 14.7 Lung 13.6 Stomach 7.8 Thyroid 11.1 Corpus uteri 8.2 Liver 6.6 Cervix uteri 9.9 Stomach 7.5 Corpus uteri 5.5 Melanoma of skin 9.3 Ovary 6.1 Ovary 5.0 Ovary 9.1 Thyroid 6.1 Thyroid 4.7 Non Hodgkin lymphoma 7.1 Liver 5.4 Oesophagus 4.1 Stomach 6.7 Non Hodgkin lymphoma Age standardized incidence rate per 100,000 women per year Kaposi sarcoma estimates available for Sub-Saharan Africa countries only. Includes HIV disease resulting in Kaposi sarcoma The cancer of Colorectum: Includes anal cancer (C21). The cancer of Kaposi sarcoma: Includes B21.0 (HIV disease resulting in Kaposi sarcoma). The cancer of Non-Hodgkin lymphoma: Includes HIV disease resulting in malignant neoplasms (B21). Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM, Forman D, Bray, F. GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11 [Internet]. Lyon, France: International Agency for Research on Cancer; Available from: accessed on 15/01/2014.

19 3 BURDEN OF HPV RELATED CANCERS Figure 8: Ten most frequent cancer in all women in the World compared to the continents Africa Europe Breast 36.2 Breast 71.1 Cervix uteri 27.6 Colorectum 23.6 Colorectum 5.8 Lung 15.1 Liver 5.8 Corpus uteri 13.9 Ovary 4.8 Cervix uteri 11.4 Non Hodgkin lymphoma 3.8 Ovary 9.9 Oesophagus 3.5 Melanoma of skin 8.9 Corpus uteri 3.5 Thyroid 7.8 Stomach 3.2 Stomach 6.4 Kaposi sarcoma 2.9 Non Hodgkin lymphoma Americas Oceania Breast 67.6 Breast 79.2 Lung 21.6 Colorectum 29.2 Colorectum 17.6 Melanoma of skin 25.5 Cervix uteri 14.9 Lung 20.0 Corpus uteri 12.3 Corpus uteri 12.3 Thyroid 12.1 Thyroid 11.3 Non Hodgkin lymphoma 7.0 Cervix uteri 10.2 Ovary 6.8 Non Hodgkin lymphoma 9.4 Melanoma of skin 6.2 Ovary 8.0 Leukaemia 5.6 Leukaemia Asia World Breast 29.1 Breast 43.3 Cervix uteri 12.7 Colorectum 14.3 Lung 12.7 Cervix uteri 14.0 Colorectum 11.1 Lung 13.6 Stomach 9.3 Corpus uteri 8.2 Liver 6.9 Stomach 7.5 Corpus uteri 5.9 Ovary 6.1 Ovary 5.0 Thyroid 6.1 Thyroid 5.0 Liver 5.4 Oesophagus 4.3 Non Hodgkin lymphoma Age standardized incidence rate per 100,000 women per year Kaposi sarcoma estimates available for Sub-Saharan Africa countries only. Includes HIV disease resulting in Kaposi sarcoma The cancer of Colorectum: Includes anal cancer (C21). The cancer of Kaposi sarcoma: Includes B21.0 (HIV disease resulting in Kaposi sarcoma). The cancer of Non-Hodgkin lymphoma: Includes HIV disease resulting in malignant neoplasms (B21). Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM, Forman D, Bray, F. GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11 [Internet]. Lyon, France: International Agency for Research on Cancer; Available from: accessed on 15/01/2014.

20 3 BURDEN OF HPV RELATED CANCERS Figure 9: Ten most frequent cancers in women ages yrs in the World compared to developing and developed regions Less developed regions More developed regions World Breast 19.0 Breast 37.7 Breast 21.9 Cervix uteri 11.0 Cervix uteri 11.8 Cervix uteri 11.1 Thyroid 4.7 Thyroid 11.7 Thyroid 5.8 Ovary 2.8 Melanoma of skin 8.2 Ovary 3.1 Colorectum 2.1 Ovary 4.8 Colorectum 2.5 Leukaemia 2.1 Colorectum 4.4 Corpus uteri 2.2 Corpus uteri 2.0 Corpus uteri 3.4 Leukaemia 2.1 Brain, nervous system 1.6 Hodgkin lymphoma 2.9 Brain, nervous system 1.7 Stomach 1.5 Brain, nervous system 2.7 Non Hodgkin lymphoma 1.6 Non Hodgkin lymphoma 1.4 Non Hodgkin lymphoma 2.7 Lung Age standardized incidence rate per 100,000 women per year Kaposi sarcoma estimates available for Sub-Saharan Africa countries only. Includes HIV disease resulting in Kaposi sarcoma The cancer of Colorectum: Includes anal cancer (C21). The cancer of Kaposi sarcoma: Includes B21.0 (HIV disease resulting in Kaposi sarcoma). The cancer of Non-Hodgkin lymphoma: Includes HIV disease resulting in malignant neoplasms (B21). Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM, Forman D, Bray F. GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11 [Internet]. Lyon, France: International Agency for Research on Cancer; Available from: accessed on 15/01/2014.

21 3 BURDEN OF HPV RELATED CANCERS Figure 10: Ten most frequent cancers in women ages yrs in the World compared to the continents Africa Europe Breast 20.3 Breast 36.1 Cervix uteri 12.5 Cervix uteri 13.2 Kaposi sarcoma 3.9 Melanoma of skin 8.0 Ovary 2.4 Thyroid 7.3 Non Hodgkin lymphoma 2.3 Ovary 5.1 Colorectum 1.9 Colorectum 3.8 Liver 1.6 Hodgkin lymphoma 3.2 Thyroid 1.5 Brain, nervous system 2.8 Leukaemia 1.4 Corpus uteri 2.5 Stomach 0.7 Non Hodgkin lymphoma Americas Oceania Breast 27.2 Breast 37.2 Cervix uteri 15.3 Melanoma of skin 15.8 Thyroid 12.2 Cervix uteri 12.7 Melanoma of skin 3.9 Thyroid 11.6 Colorectum 3.6 Colorectum 4.2 Ovary 3.2 Ovary 4.0 Leukaemia 2.5 Corpus uteri 2.7 Brain, nervous system 2.4 Non Hodgkin lymphoma 2.6 Corpus uteri 2.3 Hodgkin lymphoma 2.4 Non Hodgkin lymphoma 2.3 Lip, oral cavity Asia World Breast 18.8 Breast 21.9 Cervix uteri 9.5 Cervix uteri 11.1 Thyroid 5.1 Thyroid 5.8 Ovary 3.0 Ovary 3.1 Corpus uteri 2.5 Colorectum 2.5 Colorectum 2.2 Corpus uteri 2.2 Leukaemia 2.2 Leukaemia 2.1 Brain, nervous system 1.7 Brain, nervous system 1.7 Stomach 1.7 Non Hodgkin lymphoma 1.6 Lung 1.5 Lung Age standardized incidence rate per 100,000 women per year Kaposi sarcoma estimates available for Sub-Saharan Africa countries only. Includes HIV disease resulting in Kaposi sarcoma The cancer of Colorectum: Includes anal cancer (C21). The cancer of Kaposi sarcoma: Includes B21.0 (HIV disease resulting in Kaposi sarcoma). The cancer of Non-Hodgkin lymphoma: Includes HIV disease resulting in malignant neoplasms (B21). Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM, Forman D, Bray F. GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11 [Internet]. Lyon, France: International Agency for Research on Cancer; Available from: accessed on 15/01/2014.

22 3 BURDEN OF HPV RELATED CANCERS Figure 11: Age-specific incidence of cervical cancer in the World compared to developed and developing regions and five continents WORLD, DEVELOPED AND DEVELOPING REGIONS Age specific rates of cervical cancer per 100, Less developed regions More developed regions World >=75 WORLD AND FIVE CONTINENTS Age specific rates of cervical cancer per 100, Africa Americas Asia 100 Europe Oceania World >=75 Rates per 100,000 women per year. Age group (years) Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM, Forman D, Bray, F. GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11 [Internet]. Lyon, France: International Agency for Research on Cancer; Available from: accessed on 15/01/2014.

23 3 BURDEN OF HPV RELATED CANCERS Figure 12: Annual number of new cases of cervical cancer by age group in develop and developing regions and five continents DEVELOPED AND DEVELOPING REGIONS Less developed regions More developed regions Annual number of new cases of cervical cancer Asia Africa FIVE CONTINENTS Americas Europe Oceania Annual number of new cases of cervical cancer Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM, Forman D, Bray, F. GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11 [Internet]. Lyon, France: International Agency for Research on Cancer; Available from: accessed on 15/01/2014.

24 3 BURDEN OF HPV RELATED CANCERS Mortality KEY STATS. 265,653 new cervical cancer deaths occur annually in the World. Cervical cancer ranks as the 4 th cause of female cancer deaths in the World. Cervical cancer is the 2 nd most common female cancer deaths in women aged 15 to 44 years in the World. Figure 13: World age-standarized mortality rates of cervical cancer ASR, age-standardized moratlity rates; Rates per 100,000 women per year. Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM, Forman D, Bray F. GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11 [Internet]. Lyon, France: International Agency for Research on Cancer; Available from: accessed on 15/01/2014.

25 3 BURDEN OF HPV RELATED CANCERS Table 6: Cervical cancer mortality in regions and sub-regions in the World Cumulative risk (%) Ranking of CC Area N cases Crude rate a ASR a ages 0-74 yrs b All women Women yrs World 265, Less developed 230, regions More developed 35, regions Africa 60, Eastern Africa 28, Middle Africa 7, Northern Africa 2, Southern Africa 4, Western Africa 16, Americas 35, Caribbean 2, Central America 6, Northern America 7, South America 19, Asia 144, Central Asia 2, Eastern Asia 36, South-Eastern 23, Asia Southern Asia 79, Western Asia 1, Europe 24, Eastern Europe 15, Northern Europe 1, Southern Europe 3, Western Europe 3, Oceania 1, Australia & New Zealand Melanesia Micronesia Polynesia ASR: Age-standardised rate. a Rates per 100,000 women per year. b Cumulative risk (mortality) is the probability or risk of individuals dying from the disease during ages 0-74 years. For cancer, it is expressed as the % of new born children who would be expected to die from a particular cancer before the age of 75 if they had the rates of cancer observed in the period in the absence of competing causes. Western Asia estimates for Globocan 2008 do not include Cyprus. Cyprus accounts for Southern Europe estimates. Standardised rates have ben estimated using the direct method and the World population as the reference. Ranking of cervical cancer mortality to other cancers among all women ages years according to highest mortality rates (ranking 1st). Ranking is based on crude mortality rates(actual number of cervical cancer deaths). Ranking using AST may differ. Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM, Forman D, Bray, F. GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11 [Internet]. Lyon, France: International Agency for Research on Cancer; Available from: accessed on 15/01/2014.

26 3 BURDEN OF HPV RELATED CANCERS Figure 14: World age-standardized mortality rates of cervical cancer compared to regions and subregions World, developed and developing regions Continent's sub regions Less developed regions 8.3 Eastern Africa 27.6 Middle Africa 22.2 Melanesia 20.7 Western Africa 18.5 World 6.8 Southern Africa 17.9 Southern Asia 11.0 Central America 8.9 South America 8.6 More developed regions 3.3 Caribbean South Eastern Asia Central Asia 7.7 Africa Five continents 17.5 Eastern Europe Polynesia Eastern Asia Asia 6.4 Northern Africa Micronesia Northern America 2.6 Americas 5.9 Southern Europe 2.4 Northern Europe 2.2 Oceania 4.5 Western Asia Western Europe Europe 3.8 Australia & New Zealand Cervical cancer: Age standardized mortality rate per 100,000 women per year World Standard. Female (All ages) Rates per 100,000 women per year. Western Asia estimates for Globocan 2008 do not include Cyprus. Cyprus accounts for Southern Europe estimates. Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM, Forman D, Bray, F. GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11 [Internet]. Lyon, France: International Agency for Research on Cancer; Available from: accessed on 15/01/2014.

27 3 BURDEN OF HPV RELATED CANCERS Figure 15: Ranking of cervical cancer to others cancers among all women and women ages years, according to mortality rates in World Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM, Forman D, Bray F. GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11 [Internet]. Lyon, France: International Agency for Research on Cancer; Available from: accessed on 15/01/2014. Includes anal cancer (C21).

28 3 BURDEN OF HPV RELATED CANCERS Figure 16: World age-specific mortality of cervical cancer in the World compared to developed and developing regins and five continents WORLD, DEVELOPED AND DEVELOPING REGIONS Age specific mortality rates of cervical cancer per 100, Less developed regions More developed regions World >=75 WORLD AND FIVE CONTINENTS Age specific mortality rates of cervical cancer per 100, Africa Americas Asia Europe Oceania World >=75 Age group (years) Rates per 100,000 women per year. Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM, Forman D, Bray, F. GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11 [Internet]. Lyon, France: International Agency for Research on Cancer; Available from: accessed on 15/01/2014.

29 3 BURDEN OF HPV RELATED CANCERS Figure 17: Annual number of deaths of cervical cancer by age group in developed and developing regions and five continents DEVELOPED AND DEVELOPING REGIONS Less developed regions More developed regions Annual number of cervical cancer deaths Asia Africa FIVE CONTINENTS Americas Europe Oceania Annual number of cervical cancer deaths Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM, Forman D, Bray, F. GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11 [Internet]. Lyon, France: International Agency for Research on Cancer; Available from: accessed on 15/01/2014.

30 3 BURDEN OF HPV RELATED CANCERS Anogenital cancers other than the cervix Data on HPV role in anogenital cancers other than the cervix are limited, but there is an increasing body of evidence strongly linking HPV DNA with cancers of the anus, vulva, vagina, and penis. Although these cancers are much less frequent compared to cervical cancer, their association with HPV make them potentially preventable and subject to similar preventative strategies as those for cervical cancer. (Vaccine 2006, Vol. 24, Suppl 3; Vaccine 2008, Vol. 26, Suppl 10; Vaccine 2012, Vol. 30, Suppl 5; IARC Monographs 2007, Vol. 90) Anal cancer (last update 13 dic 2013) Anal cancer is rare in general population with an average worldwide incidence of 1 per 100,000, but is reported to be increasing in more developed regions. Globally, there are an estimated 27,000 new cases every year (de Martel C et al. Lancet Oncol 2012;13(6):607-15). Women have higher incidences of anal cancer than men. Incidence is particularly high among populations of men who have sex with men (MSM), women with history of cervical or vulvar cancer, and immunosuppressed populations, including those who are HIV-infected and patients with a history of organ transplantation. These cancers are predominantly squamous cell carcinoma, adenocarcinomas, or basaloid and cloacogenic carcinomas. Table 7: Incidence of anal cancer by cancer registry and sex Male Female Country / Registry Period N cases a Crude rate b ASR b N cases a Crude rate c ASR c Algeria Algeria Setif Egypt Gharbiah Gambia National Libya Benghazi Malawi Blantyre Mali Bamako South Africa PROMEC Tunisia North Uganda Kyadondo county Zimbabwe Harare Argentina Argentina Mendoza Tierra del Fuego Cordoba Bahia Blanca Brazil Cuiaba Canada Sao Paulo Aracaju Belo Horizonte Fortaleza Goiania (Continued)

31 3 BURDEN OF HPV RELATED CANCERS Table 7 Continued Male Female Country / Registry Period N cases a Crude rate b ASR b N cases a Crude rate c ASR c Alberta British Columbia Manitoba National New Brunswick Northwest Territories Nova Scotia Newfoundland and Labrador Prince Edward Island Quebec Saskatchewan Yukon Ontario Chile Region of Antofagasta Valdivia Biobio Province Colombia Cali Bucaramanga Pasto Manizales Costa Rica National Cuba Villa Clara Ecuador Cuenca Quito Jamaica Kingston and St Andrew Peru Trujillo United States of America NPCR Uruguay National Bahrain Bahrain National China Nangang District, Harbin City Cixian County Shanghai City Hong Kong Wuhan City Zhongshan City Beijing City Qidong County Macao Yangcheng County (Continued)

32 3 BURDEN OF HPV RELATED CANCERS Table 7 Continued Male Female Country / Registry Period N cases a Crude rate b ASR b N cases a Crude rate c ASR c Yanting County Jiaxing City Jiashan County Haining County Cyprus National India Bangalore Chennai Karunagappally Mumbai New Delhi Poona Trivandrum Barshi, Paranda and Bhum Bhopal Dindigul, Ambillikai Mizoram Sikkim State Iran Golestan Province Israel National National National Japan Fukui Prefecture Miyagi Prefecture Aichi Prefecture Nagasaki Prefecture Hiroshima Saga Prefecture Niigata Prefecture Osaka Prefecture Korea, Republic of Busan Daejeon Gwangju Incheon National Daegu Ulsan Jejudo Seoul Kuwait National National National Malaysia Penang Penang (Continued)

33 3 BURDEN OF HPV RELATED CANCERS Table 7 Continued Male Female Country / Registry Period N cases a Crude rate b ASR b N cases a Crude rate c ASR c Penang Penang Oman Omani Pakistan South Karachi Philippines Manila Rizal Qatar National Saudi Arabia Riyadh Singapore National National National National Thailand Bangkok Chiang Mai Khon Kaen Lampang Songkhla Chonburi Turkey Antalya Izmir Edirne Trabzon Viet Nam Hanoi Ho Chi Minh City Austria Austria National Vorarlberg Tyrol Belarus National Belgium National Bulgaria National Croatia National Czech Republic National Denmark National Estonia National Finland National France (Continued)

34 3 BURDEN OF HPV RELATED CANCERS Table 7 Continued Male Female Country / Registry Period N cases a Crude rate b ASR b N cases a Crude rate c ASR c Calvados Doubs Bas-Rhin Herault Isere Martinique Loire Atlantique Manche Somme Tarn Vendee Haut-Rhin Germany Brandenburg Hamburg Free State Of Saxony Munich North Rhine-Westphalia Bremen Schleswig-Holstein Mecklenburg-Western Pomerania Saarland Iceland National Ireland National Italy Biella Province Ferrara Province Florence and Prato Provinces Genova Province Brescia Province Modena Province Naples Parma Province Ragusa Province Reggio Emilia Province Romagna Region Salerno Province Sassari Province Sondrio Syracuse Province Latina Umbria Region Lombardy, Milan Lombardy, Varese Province Veneto Region Alto Adige Catania and Messina (Continued)

35 3 BURDEN OF HPV RELATED CANCERS Table 7 Continued Male Female Country / Registry Period N cases a Crude rate b ASR b N cases a Crude rate c ASR c Catanzaro Friuli-Venezia Giulia Lombardy, Como Province Lombardy, Lecco Province Lombardy, Mantova Province Nuoro Palerme South Lombardy Trapani Trento Torino Latvia National Lithuania National Malta National Netherlands National Eindhoven Norway National Poland Cracow Kielce Lower Silesia Rzeszow Portugal Azores Russian Federation St Petersburg Serbia Central Slovakia National Slovenia National Spain Albacete Asturias Basque Country Canary Islands Cuenca Girona Mallorca Murcia Navarra Tarragona Ciudad Real La Rioja Granada (Continued)

36 3 BURDEN OF HPV RELATED CANCERS Table 7 Continued Male Female Country / Registry Period N cases a Crude rate b ASR b N cases a Crude rate c ASR c Sweden National Switzerland Basel Graubunden and Glarus Neuchatel Geneva Ticino Vaud St Gall-Appenzell Zurich Valais Ukraine National United Kingdom England England, North Western England, Oxford Region England, South and Western Regions England, Thames England, Trent England, West Midlands Northern Ireland Scotland England, East of England Region Wales England, Northern and Yorkshire Australia Australia Northern Territory New South Wales Queensland Northern Territory Northern Territory Tasmania Victoria National Australian Capital Territory National New Zealand National National National National a Accumulated number of cases during the period in the population covered by the corresponding registry. b Rates per 100,000 men per year. c Rates per 100,000 women per year. 1 Forman D, Bray F, Brewster DH, Gombe Mbalawa C, Kohler B, Piñeros M, Steliarova-Foucher E, Swaminathan R and Ferlay J eds (2013). Cancer Incidence in Five Continents, Vol. X (electronic version) Lyon, IARC. last accessed on Curado. M. P., Edwards, B., Shin. H.R., Storm. H., Ferlay. J., Heanue. M. and Boyle. P., eds (2007). Cancer Incidence in Five Continents, Vol. IX. IARC Scientific Publications No. 160, Lyon, IARC. 3 Parkin, D.M., Whelan, S.L., Ferlay, J., Teppo, L., and Thomas, D.B., eds (2002). Cancer Incidence in Five Continents, Vol. VIII. IARC Scientific Publications No. 155, Lyon, IARC.

37 3 BURDEN OF HPV RELATED CANCERS Vulvar cancer (last update 13 dic 2013) Cancer of the vulva is rare among women worldwide, with an estimated 27,000 new cases in 2008, representing 4% of all gynaecologic cancers (de Martel C et al. Lancet Oncol 2012;13(6):607-15). Worldwide, about 60% of all vulvar cancer cases occur in more developed countries. Vulvar cancer has two distinct histological patterns with two different risk factor profiles: (1) basaloid/warty types (2) keratinizing types. Basaloid/warty lesions are more common in young women, are very often associated with HPV DNA detection (75-100%), and have a similar risk factor profile as cervical cancer. Keratinizing vulvar carcinomas represent the majority of the vulvar lesions (>60%), they occur more often in older women and are more rarely associated with HPV (IARC Monograph Vol 100B) Table 8: Incidence of vulvar cancer by cancer registry Female Country Cancer registry Period N cases a Crude rate b ASR b Africa Algeria 1 Setif Egypt 1 Gharbiah Gambia 2 National Libya 1 Benghazi Malawi 1 Blantyre Mali 2 Bamako South Africa 1 PROMEC Tunisia 1 North Uganda 1 Kyadondo county Zimbabwe 1 Harare (African) Americas Argentina 1 Bahia Blanca Tierra del Fuego Cordoba Mendoza Brazil 1 Fortaleza Cuiaba Goiania Sao Paulo Belo Horizonte Aracaju Canada 1 National British Columbia Manitoba New Brunswick Alberta Newfoundland and Labrador Northwest Territories Nova Scotia Ontario Quebec Saskatchewan Yukon Prince Edward Island Chile 1 Valdivia Biobio Province Region of Antofagasta Colombia 1 Cali Pasto Bucaramanga Manizales Costa Rica 1 National Cuba 1 Villa Clara (Continued)

38 3 BURDEN OF HPV RELATED CANCERS Table 8 Continued Female Country Cancer registry Period N cases a Crude rate b ASR b Ecuador 1 Cuenca Quito Jamaica 1 Kingston and St Andrew Peru 3 Trujillo United States of NPCR America 1 Uruguay 1 National Asia Bahrain 1 National (Bahraini) China 1 Cixian County Hong Kong Jiashan County Qidong County Wuhan City Nangang District, Harbin City Haining County Jiaxing City Macao Yangcheng County Shanghai City Yanting County Zhongshan City Beijing City Cyprus 1 National India 1 Bangalore Chennai Karunagappally Mumbai New Delhi Poona Trivandrum Barshi, Paranda and Bhum Bhopal Dindigul, Ambillikai Mizoram Sikkim State Iran 1 Golestan Province Israel 1 National National (Jews) National (Non-Jews) Japan 1 Fukui Prefecture Miyagi Prefecture Aichi Prefecture Nagasaki Prefecture Hiroshima Saga Prefecture Niigata Prefecture Osaka Prefecture Korea, Republic of 1 Busan Daejeon Gwangju Incheon National Daegu Ulsan Jejudo (Continued)

39 3 BURDEN OF HPV RELATED CANCERS Table 8 Continued Female Country Cancer registry Period N cases a Crude rate b ASR b Seoul Kuwait 1 National National (Kuwaitis) National (Non-Kuwaitis) Malaysia 1 Penang Penang (Chinese) Penang (Indian) Penang (Malay) Oman 3 Omani Pakistan 3 South Karachi Philippines 1 Manila Rizal Qatar 1 National (Qatari) Saudi Arabia 1 Riyadh (Saudi) Singapore 1 National National (Chinese) National (Indian) National (Malay) Thailand 1 Bangkok Chiang Mai Khon Kaen Lampang Songkhla Chonburi Turkey 1 Antalya Izmir Edirne Trabzon Viet Nam 2 Hanoi Ho Chi Minh City Europe Austria 1 National Vorarlberg Tyrol Belarus 1 National Belgium 1 National Bulgaria 1 National Croatia 1 National Czech Republic 1 National Denmark 1 National Estonia 1 National Finland 1 National France 1 Calvados Doubs Bas-Rhin Herault Isere Martinique Loire Atlantique Manche Somme Tarn Vendee Haut-Rhin Germany 1 Brandenburg Hamburg (Continued)

40 3 BURDEN OF HPV RELATED CANCERS Table 8 Continued Female Country Cancer registry Period N cases a Crude rate b ASR b Free State Of Saxony Munich North Rhine-Westphalia Bremen Schleswig-Holstein Mecklenburg-Western Pomerania Saarland Iceland 1 National Ireland 1 National Italy 1 Biella Province Ferrara Province Florence and Prato Provinces Genova Province Brescia Province Modena Province Naples Parma Province Ragusa Province Reggio Emilia Province Romagna Region Salerno Province Sassari Province Sondrio Syracuse Province Latina Umbria Region Lombardy, Milan Lombardy, Varese Province Veneto Region Alto Adige Catania and Messina Catanzaro Friuli-Venezia Giulia Lombardy, Como Province Lombardy, Lecco Province Lombardy, Mantova Province Nuoro Palerme South Lombardy Trapani Trento Torino Latvia 1 National Lithuania 1 National Malta 1 National Netherlands 1 National Eindhoven Norway 1 National Poland 1 Cracow Kielce Lower Silesia Rzeszow Portugal 1 Azores Russian Federation 1 St Petersburg Serbia 1 Central Slovakia 1 National (Continued)

41 3 BURDEN OF HPV RELATED CANCERS Table 8 Continued Female Country Cancer registry Period N cases a Crude rate b ASR b Slovenia 1 National Spain 1 Albacete Asturias Basque Country Canary Islands Cuenca Girona Mallorca Murcia Navarra Tarragona Ciudad Real La Rioja Granada Sweden 1 National Switzerland 1 Basel Geneva Neuchatel St Gall-Appenzell Ticino Graubunden and Glarus Valais Zurich Vaud Ukraine 1 National United Kingdom 1 England England, North Western England, Oxford Region England, South and Western Regions England, Thames England, Trent England, West Midlands Northern Ireland Scotland England, East of England Region Wales England, Northern and Yorkshire Oceania Australia 1 New South Wales Northern Territory Northern Territory (Indigenous) Queensland Tasmania Northern Territory (Non-Indigenous) Victoria National Australian Capital Territory National New Zealand 1 National (Maori) National National (Other) National (Pacific Islander) a Accumulated number of cases during the period in the population covered by the corresponding registry. b Rates per 100,000 women per year. 1 Forman D, Bray F, Brewster DH, Gombe Mbalawa C, Kohler B, Piñeros M, Steliarova-Foucher E, Swaminathan R and Ferlay J eds (2013). Cancer Incidence in Five Continents, Vol. X (electronic version) Lyon, IARC. last accessed on Curado. M. P., Edwards, B., Shin. H.R., Storm. H., Ferlay. J., Heanue. M. and Boyle. P., eds (2007). Cancer Incidence in Five Continents, Vol. IX. IARC Scientific Publications No. 160, Lyon, IARC. 3 Parkin, D.M., Whelan, S.L., Ferlay, J., Teppo, L., and Thomas, D.B., eds (2002). Cancer Incidence in Five Continents, Vol. VIII. IARC Scientific Publications No. 155, Lyon, IARC.

42 3 BURDEN OF HPV RELATED CANCERS Vaginal cancer (last update 13 dic 2013) Cancer of the vagina is a rare cancer, with an estimated 13,000 new cases in 2008, representing 2% of all gynaecologic cancers (de Martel C et al. Lancet Oncol 2012;13(6):607-15). Similar to cervical cancer, the majority of vaginal cancer cases (68%) occur in less developed countries. Most vaginal cancers are squamous cell carcinoma (90%) generally attributable to HPV, followed by clear cell adenocarcinomas and melanoma. Vaginal cancers are primarily reported in developed countries. Metastatic cervical cancer can be misclassified as cancer of the vagina. Invasive vaginal cancer is diagnosed primarily in old women (>=65 years) and the diagnosis is rare in women under 45 years whereas the peak incidence of carcinoma in situ is observed between ages 55 and 70 (Vaccine 2008, Vol. 26, Suppl 10) Table 9: Incidence of vaginal cancer by cancer registry Female Country Cancer registry Period N cases a Crude rate b ASR b Africa Algeria 1 Setif Egypt 1 Gharbiah Gambia 2 National Libya 1 Benghazi Malawi 1 Blantyre Mali 2 Bamako South Africa 1 PROMEC Tunisia 1 North Uganda 1 Kyadondo county Zimbabwe 1 Harare (African) Americas Argentina 1 Bahia Blanca Tierra del Fuego Cordoba Mendoza Brazil 1 Fortaleza Cuiaba Goiania Sao Paulo Belo Horizonte Aracaju Canada 1 National British Columbia Manitoba New Brunswick Alberta Newfoundland and Labrador Northwest Territories Nova Scotia Ontario Quebec Saskatchewan Yukon Prince Edward Island Chile 1 Valdivia Biobio Province Region of Antofagasta Colombia 1 Cali Pasto Bucaramanga Manizales Costa Rica 1 National Cuba 1 Villa Clara (Continued)

43 3 BURDEN OF HPV RELATED CANCERS Table 9 Continued Female Country Cancer registry Period N cases a Crude rate b ASR b Ecuador 1 Cuenca Quito Jamaica 1 Kingston and St Andrew Peru 3 Trujillo United States of NPCR America 1 Uruguay 1 National Asia Bahrain 1 National (Bahraini) China 1 Cixian County Hong Kong Jiashan County Qidong County Wuhan City Nangang District, Harbin City Haining County Jiaxing City Macao Yangcheng County Shanghai City Yanting County Zhongshan City Beijing City Cyprus 1 National India 1 Bangalore Chennai Karunagappally Mumbai New Delhi Poona Trivandrum Barshi, Paranda and Bhum Bhopal Dindigul, Ambillikai Mizoram Sikkim State Iran 1 Golestan Province Israel 1 National National (Jews) National (Non-Jews) Japan 1 Fukui Prefecture Miyagi Prefecture Aichi Prefecture Nagasaki Prefecture Hiroshima Saga Prefecture Niigata Prefecture Osaka Prefecture Korea, Republic of 1 Busan Daejeon Gwangju Incheon National Daegu Ulsan Jejudo (Continued)

44 3 BURDEN OF HPV RELATED CANCERS Table 9 Continued Female Country Cancer registry Period N cases a Crude rate b ASR b Seoul Kuwait 1 National National (Kuwaitis) National (Non-Kuwaitis) Malaysia 1 Penang Penang (Chinese) Penang (Indian) Penang (Malay) Oman 3 Omani Pakistan 3 South Karachi Philippines 1 Manila Rizal Qatar 1 National (Qatari) Saudi Arabia 1 Riyadh (Saudi) Singapore 1 National National (Chinese) National (Indian) National (Malay) Thailand 1 Bangkok Chiang Mai Khon Kaen Lampang Songkhla Chonburi Turkey 1 Antalya Izmir Edirne Trabzon Viet Nam 2 Hanoi Ho Chi Minh City Europe Austria 1 National Vorarlberg Tyrol Belarus 1 National Belgium 1 National Bulgaria 1 National Croatia 1 National Czech Republic 1 National Denmark 1 National Estonia 1 National Finland 1 National France 1 Calvados Doubs Bas-Rhin Herault Isere Martinique Loire Atlantique Manche Somme Tarn Vendee Haut-Rhin Germany 1 Brandenburg Hamburg (Continued)

45 3 BURDEN OF HPV RELATED CANCERS Table 9 Continued Female Country Cancer registry Period N cases a Crude rate b ASR b Free State Of Saxony Munich North Rhine-Westphalia Bremen Schleswig-Holstein Mecklenburg-Western Pomerania Saarland Iceland 1 National Ireland 1 National Italy 1 Biella Province Ferrara Province Florence and Prato Provinces Genova Province Brescia Province Modena Province Naples Parma Province Ragusa Province Reggio Emilia Province Romagna Region Salerno Province Sassari Province Sondrio Syracuse Province Latina Umbria Region Lombardy, Milan Lombardy, Varese Province Veneto Region Alto Adige Catania and Messina Catanzaro Friuli-Venezia Giulia Lombardy, Como Province Lombardy, Lecco Province Lombardy, Mantova Province Nuoro Palerme South Lombardy Trapani Trento Torino Latvia 1 National Lithuania 1 National Malta 1 National Netherlands 1 National Eindhoven Norway 1 National Poland 1 Cracow Kielce Lower Silesia Rzeszow Portugal 1 Azores Russian Federation 1 St Petersburg Serbia 1 Central Slovakia 1 National (Continued)

46 3 BURDEN OF HPV RELATED CANCERS Table 9 Continued Female Country Cancer registry Period N cases a Crude rate b ASR b Slovenia 1 National Spain 1 Albacete Asturias Basque Country Canary Islands Cuenca Girona Mallorca Murcia Navarra Tarragona Ciudad Real La Rioja Granada Sweden 1 National Switzerland 1 Basel Geneva Neuchatel St Gall-Appenzell Ticino Graubunden and Glarus Valais Zurich Vaud Ukraine 1 National United Kingdom 1 England England, North Western England, Oxford Region England, South and Western Regions England, Thames England, Trent England, West Midlands Northern Ireland Scotland England, East of England Region Wales England, Northern and Yorkshire Oceania Australia 1 New South Wales Northern Territory Northern Territory (Indigenous) Queensland Tasmania Northern Territory (Non-Indigenous) Victoria National Australian Capital Territory National New Zealand 1 National (Maori) National National (Other) National (Pacific Islander) a Accumulated number of cases during the period in the population covered by the corresponding registry. b Rates per 100,000 women per year. 1 Forman D, Bray F, Brewster DH, Gombe Mbalawa C, Kohler B, Piñeros M, Steliarova-Foucher E, Swaminathan R and Ferlay J eds (2013). Cancer Incidence in Five Continents, Vol. X (electronic version) Lyon, IARC. last accessed on Curado. M. P., Edwards, B., Shin. H.R., Storm. H., Ferlay. J., Heanue. M. and Boyle. P., eds (2007). Cancer Incidence in Five Continents, Vol. IX. IARC Scientific Publications No. 160, Lyon, IARC. 3 Parkin, D.M., Whelan, S.L., Ferlay, J., Teppo, L., and Thomas, D.B., eds (2002). Cancer Incidence in Five Continents, Vol. VIII. IARC Scientific Publications No. 155, Lyon, IARC.

47 3 BURDEN OF HPV RELATED CANCERS Penile cancer (last update 20 sep 2013) The annual burden of penile cancer has been estimated to be 22,000 cases worldwide with incidence rates strongly correlating with those of cervical cancer (de Martel C et al. Lancet Oncol 2012;13(6):607-15). Penile cancer is rare and most commonly affects men aged years. Incidence rates are higher in less developed countries than in more developed countries, accounting for up to 10% of male cancers in some parts of Africa, South America and Asia. Precursor cancerous penile lesions (PeIN) are rare. Cancers of the penis are primarily of squamous cell carcinomas (SCC) (95%) and the most common penile SCC histologic sub-types are keratinizing (49%), mixed warty-basaloid (17%), verrucous (8%) warty (6%), and basaloid (4%). HPV is most commonly detected in basaloid and warty tumours but is less common in keratinizing and verrucous tumours. Approximately % of PeIN lesions are HPV DNA positive. Table 10: Incidence of penile cancer by cancer registry Male Country Cancer registry Period N cases a Crude rate b ASR b Africa Algeria 1 Setif Egypt 1 Gharbiah Gambia 3 National Libya 1 Benghazi Malawi 1 Blantyre Mali 3 Bamako Mozambique 4 Lourenco Marques Nigeria 5 Ibadan Senegal 6 Dakar South Africa 1 PROMEC Tunisia 1 North Uganda 1 Kyadondo county Zimbabwe 1 Harare (African) Americas Argentina 1 Bahia Blanca Tierra del Fuego Mendoza Cordoba Brazil 1 Cuiaba Fortaleza Goiania Sao Paulo Aracaju Belo Horizonte Canada 1 National British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Ontario Prince Edward Island Quebec Saskatchewan Yukon Alberta Chile 1 Biobio Province Region of Antofagasta Valdivia Colombia 1 Cali (Continued)

48 3 BURDEN OF HPV RELATED CANCERS Table 10 Continued Male Country Cancer registry Period N cases a Crude rate b ASR b Bucaramanga Manizales Pasto Costa Rica 1 National Cuba 1 Villa Clara Ecuador 1 Quito Cuenca Jamaica 1 Kingston and St Andrew Paraguay 2 Asuncion Region Peru 7 Trujillo United States of NPCR America 1 Uruguay 1 National Asia Bahrain 1 National (Bahraini) China 1 Hong Kong Shanghai City Cixian County Wuhan City Zhongshan City Beijing City Haining County Jiaxing City Macao Yangcheng County Yanting County Nangang District, Harbin City Qidong County Jiashan County Cyprus 1 National India 1 Chennai Bangalore Karunagappally Poona Trivandrum Dindigul, Ambillikai Mizoram Sikkim State Mumbai New Delhi Barshi, Paranda and Bhum Bhopal Iran 1 Golestan Province Israel 1 National National (Non-Jews) National (Jews) Japan 1 Hiroshima Fukui Prefecture Aichi Prefecture Miyagi Prefecture Osaka Prefecture Saga Prefecture Niigata Prefecture Nagasaki Prefecture Korea, Republic of 1 Gwangju National (Continued)

49 3 BURDEN OF HPV RELATED CANCERS Table 10 Continued Male Country Cancer registry Period N cases a Crude rate b ASR b Incheon Daegu Daejeon Jejudo Busan Ulsan Seoul Kuwait 1 National National (Kuwaitis) National (Non-Kuwaitis) Kyrgyzstan 2 National Malaysia 1 Penang (Malay) Penang Penang (Chinese) Penang (Indian) Oman 7 Omani Pakistan 7 South Karachi Philippines 1 Manila Rizal Qatar 1 National (Qatari) Saudi Arabia 1 Riyadh (Saudi) Singapore 1 National National (Chinese) National (Indian) National (Malay) Thailand 1 Bangkok Chiang Mai Khon Kaen Lampang Songkhla Chonburi Turkey 1 Antalya Izmir Edirne Trabzon Viet Nam 3 Hanoi Ho Chi Minh City Europe Austria 1 Tyrol National Vorarlberg Belarus 1 National Belgium 1 National Bulgaria 1 National Croatia 1 National Czech Republic 1 National Denmark 1 National Estonia 1 National Finland 1 National France 1 Calvados Bas-Rhin Haut-Rhin Herault Isere Martinique Loire Atlantique (Continued)

50 3 BURDEN OF HPV RELATED CANCERS Table 10 Continued Male Country Cancer registry Period N cases a Crude rate b ASR b Manche Somme Tarn Vendee Doubs Germany 1 Mecklenburg-Western Pomerania Brandenburg Munich Hamburg Bremen Schleswig-Holstein Free State Of Saxony North Rhine-Westphalia Saarland Hungary 2 County Vas County Szabolcs-Szatmar Iceland 1 National Ireland 1 National Italy 1 Biella Province Brescia Province Genova Province Lombardy, Milan Modena Province Naples Parma Province Ferrara Province Florence and Prato Provinces Salerno Province Sassari Province Latina Syracuse Province Torino Umbria Region Lombardy, Varese Province Veneto Region Alto Adige Ragusa Province Reggio Emilia Province Romagna Region Trapani Trento Sondrio Friuli-Venezia Giulia Lombardy, Como Province Lombardy, Lecco Province Lombardy, Mantova Province Nuoro Palerme South Lombardy Catania and Messina Catanzaro Latvia 1 National Lithuania 1 National Malta 1 National Montenegro 3 Vojvodina Netherlands 1 National (Continued)

51 3 BURDEN OF HPV RELATED CANCERS Table 10 Continued Male Country Cancer registry Period N cases a Crude rate b ASR b Eindhoven Norway 1 National Poland 1 Kielce Lower Silesia Rzeszow Cracow Portugal 1 Azores Romania 2 County Cluj Russian Federation 1 St Petersburg Serbia 1 Central Slovakia 1 National Slovenia 1 National Spain 1 Albacete Canary Islands Cuenca Granada Mallorca Murcia Navarra Asturias Basque Country Ciudad Real La Rioja Girona Tarragona Sweden 1 National Switzerland 1 Geneva Graubunden and Glarus Neuchatel Vaud Basel Zurich Valais St Gall-Appenzell Ticino Ukraine 1 National United Kingdom 1 England England, Northern and Yorkshire England, North Western England, Thames England, Trent England, West Midlands England, Oxford Region England, South and Western Regions England, East of England Region Wales Northern Ireland Scotland Oceania Australia 1 Victoria New South Wales National Northern Territory Northern Territory (Indigenous) Northern Territory (Non-Indigenous) Queensland (Continued)

52 3 BURDEN OF HPV RELATED CANCERS Table 10 Continued Male Country Cancer registry Period N cases a Crude rate b ASR b National Australian Capital Territory Tasmania New Zealand 1 National (Pacific Islander) National (Other) National (Maori) National a Accumulated number of cases during the period in the population covered by the corresponding registry. b Rates per 100,000 men per year. 1 Forman D, Bray F, Brewster DH, Gombe Mbalawa C, Kohler B, Piñeros M, Steliarova-Foucher E, Swaminathan R and Ferlay J eds (2013). Cancer Incidence in Five Continents, Vol. X (electronic version) Lyon, IARC. last accessed on Curado. M. P., Edwards, B., Shin. H.R., Storm. H., Ferlay. J., Heanue. M. and Boyle. P., eds (2007). Cancer Incidence in Five Continents, Vol. IX. IARC Scientific Publications No. 160, Lyon, IARC. 3 Parkin, D.M., Whelan, S.L., Ferlay, J., Teppo, L., and Thomas, D.B., eds (2002). Cancer Incidence in Five Continents, Vol. VIII. IARC Scientific Publications No. 155, Lyon, IARC. 4 Parkin, D.M.,Muir, C.S.,Whelan, S.L.,Gao, Y.-T.,Ferlay, J.,Powell, J., eds (1992). Cancer Incidence in Five Continents, Vol. VI. IARC Scientific Publications No. 120, Lyon, IARC. 5 Waterhouse, J.,Muir, C.S.,Shanmugaratnam, K.,Powell, J., eds (1982). Cancer Incidence in Five Continents, Vol. IV. IARC Scientific Publications No. 42, Lyon, IARC. 6 Waterhouse, J.,Muir, C.S.,Correa, P.,Powell, J., eds (1976). Cancer Incidence in Five Continents, Vol. III. IARC Scientific Publications No. 15, Lyon, IARC. 7 Doll, R.,Payne, P.,Waterhouse, J.A.H., eds (1966). Cancer Incidence in Five Continents, Vol. I. Union Internationale Contre le Cancer, Geneva.

53 3 BURDEN OF HPV RELATED CANCERS Head and neck cancers The majority of head and neck cancers are associated with high tobacco and alcohol consumption. However, increasing trends in the incidence at specific sites suggest that other etiological factors are involved, and infection by certain high-risk types of human papillomavirus (i.e. HPV16) have been reported to be associated with head and neck cancers, in particular with oropharyngeal cancer. Current evidence suggests that HPV16 is associated with tonsil cancer (including Waldeyer ring cancer), base of tongue cancer and other oropharyngeal cancer sites. Associations with other head and neck cancer sites such as oral cancer are neither strong nor consistent when compared to molecular-epidemiological data on HPV and oropharyngeal cancer. Association with laryngeal cancer is still unclear (IARC Monograph Vol 100B) Oral cavity (last update 15 ene 2014) Table 11: Incidence of cancer of the oral cavity (includes lip) by sex by regions and sub-regions in the World MALE FEMALE Area N cases Crude a ASR a Cum risk b N cases Crude a ASR a Cum risk b rate (%) ages rate (%) ages World 198, , Less developed regions 130, , More developed regions 68, , Africa 10, , Eastern Africa 4, , Middle Africa 1, Northern Africa 2, , Southern Africa 1, Western Africa 1, , Americas 31, , Caribbean 1, Central America 1, , Northern America 18, , South America 10, , Asia 111, , Central Asia 1, Eastern Asia 25, , South-Eastern Asia 10, , Southern Asia 71, , Western Asia 2, , Europe 42, , Eastern Europe 17, , Northern Europe 4, , Southern Europe 7, , Western Europe 12, , Oceania 2, , Australia & New Zealand 1, Melanesia Micronesia Polynesia a Male: Rates per 100,000 men per year. Female: Rates per 100,000 women per year. b Cumulative risk (incidence) is the probability or risk of individuals getting from the disease during ages 0-74 years. For cancer, it is expressed as the % of new born children who would be expected to develop from a particular cancer before the age of 75 if they had the rates of cancer observed in the period in the absence of competing causes. Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM, Forman D, Bray, F. GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11 [Internet]. Lyon, France: International Agency for Research on Cancer; Available from: accessed on 15/01/2014. Table 12: Mortality of cancer of the oral cavity (includes lip) by sex by regions and sub-regions in the World MALE FEMALE Area N cases Crude a ASR a Cum risk b N cases Crude a ASR a Cum risk b rate (%) ages rate (%) ages World 97, , (Continued)

54 3 BURDEN OF HPV RELATED CANCERS Table 12 Continued MALE FEMALE Area N cases Crude a ASR a Cum risk b N cases Crude a ASR a Cum risk b rate (%) ages rate (%) ages Less developed regions 74, , More developed regions 23, , Africa 6, , Eastern Africa 2, , Middle Africa Northern Africa Southern Africa Western Africa Americas 8, , Caribbean Central America Northern America 3, , South America 4, , Asia 65, , Central Asia Eastern Asia 12, , South-Eastern Asia 5, , Southern Asia 46, , Western Asia Europe 17, , Eastern Europe 10, , Northern Europe 1, Southern Europe 2, , Western Europe 3, , Oceania Australia & New Zealand Melanesia Micronesia Polynesia a Male: Rates per 100,000 men per year. Female: Rates per 100,000 women per year. b Cumulative risk (mortality) is the probability or risk of individuals dying from the disease during ages 0-74 years. For cancer, it is expressed as the % of new born children who would be expected to die from a particular cancer before the age of 75 if they had the rates of cancer observed in the period in the absence of competing causes. Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM, Forman D, Bray, F. GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11 [Internet]. Lyon, France: International Agency for Research on Cancer; Available from: accessed on 15/01/2014. Figure 18: Comparison of incidence and mortality rates of oral cavity (includes lip) of male by age group 40 World 40 Less developed regions 40 More developed regions Age specific rates of oral cavity cancer per 100, Incidence Mortality Rates per 100,000 men per year. Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM, Forman D, Bray, F. GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11 [Internet]. Lyon, France: International Agency for Research on Cancer; Available from: accessed on 15/01/2014.

55 3 BURDEN OF HPV RELATED CANCERS Figure 19: Comparison of incidence and mortality rates of oral cavity (includes lip) of male by age group 50 World 50 Asia >=75 Africa Europe >=75 Age specific rates of oral cavity cancer per 100, >= >=75 50 Americas 50 Oceania >=75 Incidence Mortality >=75 Age group (years) Rates per 100,000 men per year. Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM, Forman D, Bray, F. GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11 [Internet]. Lyon, France: International Agency for Research on Cancer; Available from: accessed on 15/01/2014.

56 3 BURDEN OF HPV RELATED CANCERS Figure 20: Comparison of incidence and mortality rates of oral cavity (includes lip) of female by age group 20 World 20 Less developed regions 20 More developed regions Age specific rates of oral cavity cancer per 100, Incidence Mortality Rates per 100,000 women per year. Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM, Forman D, Bray, F. GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11 [Internet]. Lyon, France: International Agency for Research on Cancer; Available from: accessed on 15/01/2014.

57 3 BURDEN OF HPV RELATED CANCERS Figure 21: Comparison of incidence and mortality rates of oral cavity (includes lip) of female by age group World Asia >= >=75 Africa Europe Age specific rates of oral cavity cancer per 100, Americas >= Oceania >= >=75 Incidence 10 0 Mortality >=75 Age group (years) Rates per 100,000 women per year. Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM, Forman D, Bray, F. GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11 [Internet]. Lyon, France: International Agency for Research on Cancer; Available from: accessed on 15/01/2014.

58 3 BURDEN OF HPV RELATED CANCERS Pharynx (excluding nasopharynx) (last update 15 ene 2014) Table 13: Incidence of cancer of the pharynx (excluding nasopharynx) by sex by regions ans sub-regions in the World. Includes ICD-10 codes:c09-10,c12-14 MALE FEMALE Area N cases Crude a ASR a Cum risk b N cases Crude a ASR a Cum risk b rate (%) ages rate (%) ages World 115, , Less developed regions 70, , More developed regions 44, , Africa 3, , Eastern Africa Middle Africa Northern Africa Southern Africa Western Africa Americas 17, , Caribbean Central America Northern America 10, , South America 5, , Asia 65, , Central Asia Eastern Asia 13, , South-Eastern Asia 6, , Southern Asia 43, , Western Asia Europe 28, , Eastern Europe 10, , Northern Europe 2, Southern Europe 4, Western Europe 11, , Oceania Australia & New Zealand Melanesia Micronesia Polynesia a Male: Rates per 100,000 men per year. Female: Rates per 100,000 women per year. b Cumulative risk (incidence) is the probability or risk of individuals getting from the disease during ages 0-74 years. For cancer, it is expressed as the % of new born children who would be expected to develop from a particular cancer before the age of 75 if they had the rates of cancer observed in the period in the absence of competing causes. Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM, Forman D, Bray, F. GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11 [Internet]. Lyon, France: International Agency for Research on Cancer; Available from: accessed on 15/01/2014. Table 14: Mortality of cancer of the pharynx (excluding nasopharynx) by sex by regions and sub-regions in the World. Includes ICD-10 codes:c09-10,c12-14 MALE FEMALE Area N cases Crude a ASR a Cum risk b N cases Crude a ASR a Cum risk b rate (%) ages rate (%) ages World 77, , Less developed regions 56, , More developed regions 21, , Africa 2, , Eastern Africa Middle Africa Northern Africa Southern Africa Western Africa Americas 8, , Caribbean Central America Northern America 3, South America 4, Asia 51, , Central Asia (Continued)

59 3 BURDEN OF HPV RELATED CANCERS MALE FEMALE Area N cases Crude a ASR a Cum risk b N cases Crude a ASR a Cum risk b rate (%) ages rate (%) ages Eastern Asia 7, , South-Eastern Asia 5, , Southern Asia 36, , Western Asia Europe 15, , Eastern Europe 7, Northern Europe 1, Southern Europe 2, Western Europe 4, Oceania Australia & New Zealand Melanesia Micronesia Polynesia a Male: Rates per 100,000 men per year. Female: Rates per 100,000 women per year. b Cumulative risk (mortality) is the probability or risk of individuals dying from the disease during ages 0-74 years. For cancer, it is expressed as the % of new born children who would be expected to die from a particular cancer before the age of 75 if they had the rates of cancer observed in the period in the absence of competing causes. Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM, Forman D, Bray, F. GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11 [Internet]. Lyon, France: International Agency for Research on Cancer; Available from: accessed on 15/01/2014. Figure 22: Comparison of incidence and mortality rates of cancer of the pharynx (excluding nasopharynx) of male by age group in the World. Includes ICD-10 codes:c09-10,c12-14 Age specific rates of pharyngeal cancer (excluding nasopharynx) per 100, World Incidence 25 Less developed regions More developed regions Mortality Rates per 100,000 men per year. Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM, Forman D, Bray, F. GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11 [Internet]. Lyon, France: International Agency for Research on Cancer; Available from: accessed on 15/01/2014.

60 3 BURDEN OF HPV RELATED CANCERS Figure 23: Comparison of incidence and mortality rates of cancer of the pharynx (excluding nasopharynx) of male by age group in the World. Includes ICD-10 codes:c09-10,c World Asia Age specific rates of pharyngeal cancer (excluding nasopharynx) per 100, Africa Americas >= >= Europe Oceania >= >= >=75 Incidence Mortality >=75 Age group (years) Rates per 100,000 men per year. Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM, Forman D, Bray, F. GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11 [Internet]. Lyon, France: International Agency for Research on Cancer; Available from: accessed on 15/01/2014.

61 3 BURDEN OF HPV RELATED CANCERS Figure 24: Comparison of incidence and mortality rates of cancer of the pharynx (excluding nasopharynx) of female by age group in the World. Includes ICD-10 codes:c09-10,c12-14 Age specific rates of pharyngeal cancer (excluding nasopharynx) per 100,000 5 World Incidence 5 Less developed regions More developed regions Mortality Rates per 100,000 women per year. Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM, Forman D, Bray, F. GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11 [Internet]. Lyon, France: International Agency for Research on Cancer; Available from: accessed on 15/01/2014.

62 3 BURDEN OF HPV RELATED CANCERS Figure 25: Comparison of incidence and mortality rates of cancer of the pharynx (excluding nasopharynx) of female by age group in the World. Includes ICD-10 codes:c09-10,c World 5 Asia Age specific rates of pharyngeal cancer (excluding nasopharynx) per 100, Africa Americas >= >= Europe Oceania >= >= >=75 Incidence Mortality >=75 Age group (years) Rates per 100,000 women per year. Ferlay J, Soerjomataram I, Ervik M, Dikshit R, Eser S, Mathers C, Rebelo M, Parkin DM, Forman D, Bray, F. GLOBOCAN 2012 v1.0, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11 [Internet]. Lyon, France: International Agency for Research on Cancer; Available from: accessed on 15/01/2014.

63 4 HPV RELATED STATISTICS HPV related statistics HPV infection is commonly found in the anogenital tract of men and women with and without clinical lesions. The aetiological role of HPV infection among women with cervical cancer is well-established, and there is growing evidence of its central role in other anogenital sites. HPV is also responsible for other diseases such as recurrent juvenile respiratory papillomatosis and genital warts, both mainly caused by HPV types 6 and 11(Lacey CJ, Vaccine 2006; 24(S3):35). For this section, the methodologies used to compile the information on HPV burden are derived from systematic reviews and meta-analyses of the literature. Due to the limitations of HPV DNA detection methods and study designs used, these data should be interpreted cautiously and used only as a guidance to assess the burden of HPV infection in the population. (Vaccine 2006, Vol. 24, Suppl 3; Vaccine 2008, Vol. 26, Suppl 10; Vaccine 2012, Vol. 30, Suppl 5; IARC Monographs 2007, Vol. 90). 4.1 HPV burden in women with normal cytology, precancerous cervical lesions or invasive cervical cancer The statistics shown in this section focus on HPV infection in the cervix uteri. HPV cervical infection results in cervical morphological lesions ranging from normalcy (cytologically normal women) to different stages of precancerous lesions (CIN-1, CIN-2, CIN-3/CIS) and invasive cervical cancer. HPV infection is measured by means of HPV DNA detection in cervical cells (fresh tissue, paraffin embedded or exfoliated cells). The prevalence of HPV increases with severity of the lesion. HPV causes virtually 100% of cases of cervical cancer, and an underestimation of HPV prevalence in cervical cancer is most likely due to the limitations of study methodologies. Worldwide, HPV-16 and 18, the two vaccine-preventable types. contribute to over 70% of all cervical cancer cases, between 41%-67% of high-grade cervical lesions and 16-32% of low-grade cervical lesions. After HPV-16/18, the six most common HPV types are the same in all world regions, namely 31, 33, 35, 45, 52 and 58; these account for an additional 20% of cervical cancers worldwide (Clifford G et al. Vaccine 2006;24(S3):26-34).

64 4 HPV RELATED STATISTICS HPV prevalence in women with normal cytology (last update 16 dic 2013, data as of 30 nov 2011) Table 15: Prevalence of HPV among women with normal cytology Region No tested % (95%CI) World 1,031, ( ) Less developed regions 102, ( ) More developed regions 929, ( ) Africa 9, ( ) Eastern Africa 1, ( ) Middle Africa Northern Africa ( ) Southern Africa 2, ( ) Western Africa 4, ( ) Americas 680, ( ) Caribbean ( ) Central America 24, ( ) Northern America 641, ( ) South America 13, ( ) Asia 99, ( ) Central Asia Eastern Asia 69, ( ) South-Eastern Asia 4, ( ) Southern Asia 23, ( ) Western Asia 1, ( ) Europe 241, ( ) Eastern Europe 2, ( ) Northern Europe 97, ( ) Southern Europe 57, ( ) Western Europe 84, ( ) Oceania 2, ( ) Australia & New Zealand 1, ( ) Melanesia ( ) Micronesia Polynesia Abbreviations used: 95% CI:95% Confidence Interval. See references in Section 8

65 4 HPV RELATED STATISTICS Figure 26: Prevalence of HPV among women with normal cytology in the World The samples for HPV testing come from cervical specimens (fresh / fixed biopsies or exfoliated cells). See references in Section 8

66 4 HPV RELATED STATISTICS Figure 27: Crude age-specific HPV prevalence (%) and 95% confidence interval (grey shadow) in women with normal cytology in the World compared to developing and developed regions HPV prevalence (%) Less developed regions More developed regions World < < < Age group (years) See references in Section 8.

67 4 HPV RELATED STATISTICS Figure 28: Crude age-specific HPV prevalence (%) and 95% confidence interval (grey shadow) in women with normal cytology in the World compared to five continents HPV prevalence (%) Europe Oceania < < HPV prevalence (%) Africa Asia < < HPV prevalence (%) Americas World < < Age group (years) See references in Section 8.

68 4 HPV RELATED STATISTICS Figure 29: Prevalence of HPV among women with normal cytology in Africa by country and study Country Study N Prevalence 95%CI Algeria Hammouda (2005) Côte d Ivoire La Ruche (1998) Adjorlolo Johnson (2010) Egypt Abdel Aziz (2006) Gambia Wall (2005) Guinea Keita (2009) Kenya De Vuyst (2003) De Vuyst (2010) Morocco Amrani (2003) Chaouki (1998) Mozambique Castellsague (2001) Nigeria Schnatz (2008) Thomas (2004) Senegal Xi (2003) Astori (1999) South Africa Wright (2000) Allan (2008) Jones (2007a) Tunisia Hassen (2003) Zimbabwe Womack (2000b) Overall Prevalence (%) The samples for HPV testing come from cervical specimens (fresh/fixed biopsies or exfoliated cells). Abbreviations used: N: number of women tested; 95% CI: 95 % Confidence Interval. See references in Section 8.

69 4 HPV RELATED STATISTICS Figure 30: Prevalence of HPV among women with normal cytology in Americas by country and study Country Study N Prevalence 95%CI Argentina Matos (2003) Abba (2003) Belize Cathro (2009) Brazil Noronha Vânia (2005) Carestiato (2006a) Trottier (2006) Munoz (1996) Lorenzato (2000) Canada Mayrand (2006) Sellors (2000) Moore (2009) Kapala (2007) Richardson (2003) Young (1997) Chile Ferreccio (2004) Colombia Munoz (1996) Molano (2002) Leon (2009) Costa Rica Herrero (2005) Safaeian (2007b) Ecuador Brown (2009) Greenland Svare (1998) Guatemala Valles (2009) Honduras Tabora (2005) Ferrera (1999) LatinAm.&Caribbe (a) Paavonen (2008) Mexico Sanchez Anguiano (2006) Giuliano (2005) Salmeron (2003) Giuliano (2001) Pina Sanchez (2006) Lazcano Ponce (2001) Rojo Contreras (2008) Illades Aguiar (2008) North America (b) Paavonen (2008) Paraguay Rolon (2000) Peru Garcia (2004) Almonte (2007) Santos (2001) Trinidad & Tobago Ragin (2007) USA Zhao (2007a) Cibas (2007) Castle (2009) Hernandez (2004) Giuliano (1999) Khanna (2007) Smith (2003) Insinga (2007) Sherman (2003) Giuliano (2001) Datta (2008) Smith (2004) Chaturvedi (2005a) Swan (1999) Goodman (2008) Evans (2006) Kotloff (1998) Tarkowski (2004) Moscicki (2001) Overall Prevalence (%) The samples for HPV testing come from cervical specimens (fresh/fixed biopsies or exfoliated cells). Abbreviations used: N: number of women tested; 95% CI: 95 % Confidence Interval. See references in Section 8.

70 4 HPV RELATED STATISTICS Figure 31: Prevalence of HPV among women with normal cytology in Asia by country and study Country Study N Prevalence 95%CI Bahrain China India Indonesia Japan Korea, Rep of Mongolia Philippines Taiwan Thailand Turkey Viet Nam Overall (a) (b) (c) (d) (e) (f) (g) (h) (i) (j) (k) Hajjaj (2006) Chan (2002) Dai (2006) Wu (2007) Li (2006a) Belinson (2001) Belinson (2003) He (2008) Yeoh (2006) Sankaranarayanan (2004) Sankaranarayanan (2004) Sankaranarayanan (2004) Laikangbam (2007) Bhatla (2008b) Sankaranarayanan (2004) Arora (2005) Laikangbam (2007) Laikangbam (2007) Franceschi (2005a) Gupta (2008) Aggarwal (2006) de Boer (2006) Sasagawa (1997) Inoue (2006) Saito (1995) Sasagawa (2001) Asato (2004) Maehama (2005) Ishi (2004) Yoshikawa (1999) Nishiwaki (2008) Sasagawa (2005) Masumoto (2004) Onuki (2009) Oh (2001) Bae (2009) Lee (2003) Shin (2003) Cho (2003) An (2003) Hwang (2004) Dondog (2008) Ngelangel (1998) Huang (2008) Liaw (1995) Chao (2008) Chen (2011) Lin (2005) Tsai (2005) Jeng (2005) Sukvirach (2003) Siritantikorn (1997) Sukvirach (2003) Sriamporn (2006) Settheetham Ishida (2005) Chichareon (1998) Chaiwongkot (2007) Inal (2007) Pham (2003) Pham (2003) Prevalence (%) a Trivandrum; b Kolkata (2); c Mumbai; d Manipur; e Kolkata (1); f Sikkim; g West Bengal; h Songkla; i Lampang; j Hanoi; k Ho Chi Minh City; The samples for HPV testing come from cervical specimens (fresh/fixed biopsies or exfoliated cells). Abbreviations used: N: number of women tested; 95% CI: 95 % Confidence Interval. See references in Section 8.

71 4 HPV RELATED STATISTICS Figure 32: Prevalence of HPV among women with normal cytology in Europe by country and study Country Study N Prevalence 95%CI (a) Belgium Baay (2005) Baay (2001) Arbyn (2009) Depuydt (2003) Croatia Grahovac (2007) Denmark Nielsen (2008) Svare (1998) Kjaer (2008) Eastern Europe Kulmala (2007) Finland Leinonen (2008) France Beby Defaux (2004) Clavel (2001) Boulanger (2004) Monsonego (2011) Vaucel (2001) Riethmuller (1999) Dalstein (2003) Monsonego (2005a) Pannier Stockman (2008) Germany Petry (2003) Schneider (2000) Iftner (2010) Greece Agorastos (2004) Paraskevaidis (2001) Tsiodras (2010) Panotopoulou (2007) Tsiodras (2011) Hungary Nyari (2006) Ireland Keegan (2007) Italy Carozzi (2000) Ronco (2006b) Zappacosta (2009) Ronco (2005) Ronco (2006a) Giorgi Rossi (2011) Tornesello (2008) Agarossi (2009) Tenti (1997) Centurioni (2005) Masia (2009) Tornesello (2006) Astori (1997) Verteramo (2009) Ammatuna (2008) Piana (2011) Lithuania Gudleviciene (2005) Netherlands Bulkmans (2004) Jacobs (2000) Rozendaal (2000) Zielinski (2001) Norway Molden (2005) Gjooen (1996) Molden (2006) Poland Bardin (2008) Portugal Pista (2011a) Russian FederationShipitsyna (2010) Alexandrova (1999) Slovenia Ucakar (2011) Spain De Sanjose (2003) Munoz (1996) Dillner (2008) Gonzalez (2006) Castellsagué (2012) Bernal (2008) Sweden Kjellberg (1998) Naucler (2007) Ylitalo (2000) Switzerland Bigras (2005) United Kingdom Cuzick (1999) Cuzick (1995) Hibbitts (2008) Peto (2004) Kitchener (2006) Cuschieri (2004) Herbert (2007) Grainge (2005) Overall Prevalence (%) a Including Belarus, Latvia and Russian Federation; The samples for HPV testing come from cervical specimens (fresh/fixed biopsies or exfoliated cells). Abbreviations used: N: number of women tested; 95% CI: 95 % Confidence Interval. See references in Section 8.

72 4 HPV RELATED STATISTICS Figure 33: Prevalence of HPV among women with normal cytology in Oceania by country and study Country Study N Prevalence 95%CI Australia Garland (2011) Vanuatu McAdam (2010) Overall Prevalence (%) The samples for HPV testing come from cervical specimens (fresh/fixed biopsies or exfoliated cells). Abbreviations used: N: number of women tested; 95% CI: 95 % Confidence Interval. See references in Section 8.

73 4 HPV RELATED STATISTICS HPV type distribution among women with normal cytology, precancerous cervical lesions and cervical cancer (last update 16 dic 2013, data as of 30 nov 2011) Table 16: Prevalence of HPV 16/18 in women with normal cytology, precancerous cervical lesions and invasive cervical cancer by regions and sub-regions in the World Cervical cancer High-grade lesions Low-grade lesions Normal cytology Country /Region No. HPV Prev No. HPV Prev No. HPV Prev No. HPV Prev tested (95% CI) tested (95% CI) tested (95% CI) tested (95% CI) World 33, ( ) 26, ( ) 30, ( ) 224, ( ) Less developed regions 13, ( ) 6, ( ) 7, ( ) 44, ( ) More developed regions 20, ( ) 20, ( ) 23, ( ) 180, ( ) Africa 2, ( ) ( ) ( ) 6, ( ) Eastern Africa ( ) ( ) ( ) 1, ( ) Middle Africa ( ) ( ) Northern Africa ( ) ( ) ( ) ( ) Southern Africa ( ) ( ) ( ) 1, ( ) Western Africa ( ) ( ) ( ) 3, ( ) Americas 5, ( ) 7, ( ) 8, ( ) 30, ( ) Caribbean ( ) ( ) ( ) ( ) Central America ( ) ( ) 1, ( ) 12, ( ) Northern America 2, ( ) 5, ( ) 5, ( ) 11, ( ) South America 2, ( ) 1, ( ) 1, ( ) 5, ( ) Asia 13, ( ) 5, ( ) 5, ( ) 49, ( ) Central Asia Eastern Asia 10, ( ) 5, ( ) 4, ( ) 39, ( ) South-Eastern Asia 1, ( ) ( ) ( ) 4, ( ) Southern Asia 1, ( ) ( ) ( ) 5, ( ) Western Asia ( ) ( ) ( ) ( ) Europe 11, ( ) 12, ( ) 15, ( ) 138, ( ) Eastern Europe 1, ( ) ( ) ( ) 1, ( ) Northern Europe 4, ( ) 5, ( ) 4, ( ) 66, ( ) Southern Europe 3, ( ) 3, ( ) 8, ( ) 21, ( ) Western Europe 2, ( ) 2, ( ) 2, ( ) 49, ( ) Oceania ( ) 1, ( ) ( ) Australia & New Zealand ( ) ( ) ( ) Melanesia ( ) Micronesia Polynesia Low-grade lesions: CIN-1 or LSIL. High-grade lesions: CIN-2, CIN-3, CIS or HSIL. Abbreviations used: 95% CI:95% Confidence Interval. See references in Section 8.

74 4 HPV RELATED STATISTICS Figure 34: Prevalence of HPV 16 among women with normal cytology in Europe by country and study Country Study N Prevalence 95%CI (a) Belgium Baay (2005) Arbyn (2009) Baay (2001) Depuydt (2003) Croatia Grahovac (2007) Denmark Nielsen (2008) Kjaer (2008) Svare (1998) Eastern Europe Kulmala (2007) France Beby Defaux (2004) Vaucel (2001) Pannier Stockman (2008) Germany Klug (2007) Iftner (2010) Greece Tsiodras (2010) Agorastos (2004) Panotopoulou (2007) Tsiodras (2011) Ireland Keegan (2007) Italy Ronco (2005) Tornesello (2008) Agarossi (2009) Astori (1997) Tornesello (2006) Centurioni (2005) Lithuania Gudleviciene (2005) Netherlands Jacobs (2000) Bulkmans (2007) Zielinski (2001) Rozendaal (2000) Norway Molden (2005) Gjooen (1996) Poland Bardin (2008) Russian FederationShipitsyna (2010) Alexandrova (1999) Spain De Sanjose (2003) Gonzalez (2006) Munoz (1996) Castellsagué(2012) Dillner (2008) Sweden Kjellberg (1998) Naucler (2007) Ylitalo (2000) United Kingdom Cuzick (1999) Cuzick (1995) Grainge (2005) Hibbitts (2006) Sargent (2008) Cuschieri (2004) Overall Prevalence (%) a Including Belarus, Latvia and Russian Federation; The samples for HPV testing come from cervical specimens (fresh/fixed biopsies or exfoliated cells). Abbreviations used: N: number of women tested; 95% CI: 95 % Confidence Interval. See references in Section 8.

75 4 HPV RELATED STATISTICS Figure 35: Prevalence of HPV 16 among women with normal cytology in Africa by country and study Country Study N Prevalence 95%CI Algeria Hammouda (2005) Guinea Keita (2009) Kenya De Vuyst (2003) De Vuyst (2010) Morocco Amrani (2003) Chaouki (1998) Mozambique Castellsague (2001) Nigeria Thomas (2004) Senegal Xi (2003) Astori (1999) South Africa Jones (2007a) Allan (2008) Tunisia Hassen (2003) Overall Prevalence (%) The samples for HPV testing come from cervical specimens (fresh/fixed biopsies or exfoliated cells). Abbreviations used: N: number of women tested; 95% CI: 95 % Confidence Interval. See references in Section 8.

76 4 HPV RELATED STATISTICS Figure 36: Prevalence of HPV 16 among women with normal cytology in Americas by country and study Country Study N Prevalence 95%CI Argentina Matos (2003) Abba (2003) Belize Cathro (2009) Brazil Noronha Vânia (2005) Munoz (1996) Lorenzato (2000) Canada Moore (2009) Chile Ferreccio (2004) Colombia Molano (2002) Munoz (1996) Costa Rica Herrero (2005) Greenland Svare (1998) Guatemala Valles (2009) Honduras Tabora (2005) Ferrera (1999) Mexico Giuliano (2005) Giuliano (2001) Lazcano Ponce (2001) Sanchez Anguiano (2006) Pina Sanchez (2006) Rojo Contreras (2008) Illades Aguiar (2008) Paraguay Rolon (2000) Peru Garcia (2004) Santos (2001) South America (a) Tonon (1999) Trinidad & Tobago Ragin (2007) USA Cibas (2007) Chaturvedi (2005a) Hernandez (2004) Giuliano (2001) Wideroff (1998) Swan (1999) Goodman (2008) Insinga (2007) Evans (2006) Moscicki (2001) Overall Prevalence (%) The samples for HPV testing come from cervical specimens (fresh/fixed biopsies or exfoliated cells). Abbreviations used: N: number of women tested; 95% CI: 95 % Confidence Interval. See references in Section 8.

77 4 HPV RELATED STATISTICS Figure 37: Prevalence of HPV 16 among women with normal cytology in Asia by country and study Country Study N Prevalence 95%CI Bahrain China Viet Nam Overall Hajjaj (2006) Wu (2007) Li (2006a) Dai (2006) India (a) Laikangbam (2007) Bhatla (2008b) Franceschi (2005a) Aggarwal (2006) (b) Laikangbam (2007) (c) Laikangbam (2007) Arora (2005) Gupta (2008) Indonesia de Boer (2006) Japan Maehama (2005) Asato (2004) Yoshikawa (1999) Sasagawa (1997) Inoue (2006) Sasagawa (2001) Onuki (2009) Nishiwaki (2008) Korea, Rep of Oh (2001) Shin (2003) Lee (2003) Hwang (2004) An (2003) Cho (2003) Mongolia Dondog (2008) Philippines Ngelangel (1998) Taiwan Chao (2008) Huang (2008) Tsai (2005) Lin (2005) Thailand (d) Sukvirach (2003) (e) Sukvirach (2003) Siritantikorn (1997) Chichareon (1998) Sriamporn (2006) Settheetham Ishida (2005) (f) (g) Chaiwongkot (2007) Pham (2003) Pham (2003) Prevalence (%) a Manipur; b Sikkim ; c West Bengal; d Lampang; e Songkla (1); f Hanoi; g Ho Chi Minh City; The samples for HPV testing come from cervical specimens (fresh/fixed biopsies or exfoliated cells). Abbreviations used: N: number of women tested; 95% CI: 95 % Confidence Interval. See references in Section 8.

78 4 HPV RELATED STATISTICS Figure 38: Prevalence of HPV 16 among women with low-grade cervical lesions in Europe by country and study Country Study Belarus Kulmala (2007) Belgium Beerens (2005) Depuydt (2003) Arbyn (2009) Baay (2001) Croatia Grce (1997) Grce (2004) Grce (2001) Czech Republic Tachezy (2011) Denmark Kjaer (2008) Hording (1995) France Monsonego (2008) Vaucel (2010) Bergeron (1992) Pretet (2008) Humbey (2002) Germany Klug (2007) Nindl (1999) Meyer (2001) Merkelbach Bruse (1999) Greece Panotopoulou (2007) Labropoulou (1997) Adamopoulou (2009) Tsiodras (2011) Mammas (2008) Kroupis (2007) Ireland Butler (2000) Murphy (2003) Italy Venturoli (2002) Capra (2008) Chironna (2010) Zerbini (2001) Gargiulo (2007) Agarossi (2009) Venturoli (2008) Giori Rossi (2010) Sandri (2009) Menegazzi (2010) Astori (1997) Voglino (2000) Laconi (2000) Agodi (2009) Tornesello (2006) Spinillo (2009) Latvia Kulmala (2007) Lithuania Gudleviciene (2005) Netherlands Prinsen (2007) Bollen (1997) Reesink Peters (2001) Norway Roberts (2006) Molden (2005) Portugal Nobre (2010) Medeiros (2005) Romania Anton (2011) Russian FederationKulmala (2007) Spain de Ona (2010) Garcia Sierra (2009) Domenech Peris (2010) Martin (2011) Conesa Zamore (2009) de Mendez (2009) Sweden Kalanta (1997) Andersson (2005) Brismar Wendel (2009) Söderlund Strand (2011) Zehbe (1996) Switzerland Dobec (2011) United Kingdom Southern (2001) Cuzick (1999) Giannoudis (1999) Arends (1993) Sargent (2008) Howell Jones (2010) Cuzick (1994) Hibbitts (2008) Jamison (2008) Cuschieri (2004) Woo (2010) Overall N Prevalence %CI Prevalence (%) The samples for HPV testing come from cervical specimens (fresh/fixed biopsies or exfoliated cells). Low-grade lesions: LSIL or CIN-1. Abbreviations used: N: number of women tested; 95% CI: 95 % Confidence Interval. See references in Section 8.

79 4 HPV RELATED STATISTICS Figure 39: Prevalence of HPV 16 among women with low-grade cervical lesions in Africa by country and study Country Study N Prevalence 95%CI Algeria Hammouda (2010) Congo, DR Hovland (2010) Côte d Ivoire La Ruche (1998) Guinea Keita (2009) Kenya De Vuyst (2011) De Vuyst (2010) De Vuyst (2003) Morocco Alhamany (2010) Nigeria Thomas (2004) Gage (2011) Rwanda Singh (2009) Senegal Xi (2003) Chabaud (1996) South Africa Allan (2008) Zimbabwe Sawaya (2008) Overall Prevalence (%) The samples for HPV testing come from cervical specimens (fresh/fixed biopsies or exfoliated cells). Low-grade lesions: LSIL or CIN-1. Abbreviations used: N: number of women tested; 95% CI: 95 % Confidence Interval. See references in Section 8.

80 4 HPV RELATED STATISTICS Figure 40: Prevalence of HPV 16 among women with low-grade cervical lesions in Americas by country and study Country Argentina Argentina/Paraguay Belize Brazil Canada Chile Colombia Cuba Ecuador Honduras Jamaica Mexico Nicaragua Paraguay USA Venezuela Overall Study Deulaca (2004) Chouhy (2006) Eiguchi (2008) Abba (2003) Tonon (1999) Cathro (2009) Krambeck (2008) Pitta (2010) Fernandes (2009) Lorenzato (2000) Freitas (2007) Franco (1999) Ribeiro (2011) Tomita (2010) Carestiato (2006) Antonishyn (2008) Tran Thanh (2002) Richardson (2003) Koushik (2005) Coutlée (2011) Moore (2009) Sellors (2000) Lopez (2010) Ili (2011) Molano (2002) Garcia (2011) Soto (2007) Tornesello (2008) Ferrera (1999) Strickler (1999) Rattray (1996) Torroella Kouri (1998) Gonzalez Losa (2004) Illades Aguiar (2010) Velazquez Marquez (2009) Giuliano (2001) Carrillo (2004) Pina Sanchez (2006) Hindryckx (2006) Mendoza (2011) Guo (2007) Lee (2009) Schiff (2000) Einstein (2006) Evans (2002) Jarboe (2004) Liaw (1999) Bell (2007) Castle (2011) Hu (2005) Swan (1999) Stoler (2011) Tortolero Luna (1998) Giuliano (2001) Zuna (2007) Evans (2006) Kulasingam (2002) Park (2007) Voss (2009) Moscicki (2008) Wheeler (2006) Wentzensen (2009) Wheeler (2009) Kong (2007) Brown (2002) Adam (2000) Correnti (2011) N Prevalence 95%CI Prevalence (%) The samples for HPV testing come from cervical specimens (fresh/fixed biopsies or exfoliated cells). Low-grade lesions: LSIL or CIN-1. Abbreviations used: N: number of women tested; 95% CI: 95 % Confidence Interval. See references in Section 8.

81 4 HPV RELATED STATISTICS Figure 41: Prevalence of HPV 16 among women with low-grade cervical lesions in Oceania by country and study Country Study N Prevalence 95%CI Australia Stevens (2009) Garland (2011) Brestovac (2005) Overall Prevalence (%) The samples for HPV testing come from cervical specimens (fresh/fixed biopsies or exfoliated cells). Low-grade lesions: LSIL or CIN-1. Abbreviations used: N: number of women tested; 95% CI: 95 % Confidence Interval. See references in Section 8.

82 4 HPV RELATED STATISTICS Figure 42: Prevalence of HPV 16 among women with low-grade cervical lesions in Asia by country and study Country Study N Prevalence 95%CI China India Iran Japan Korea, Rep of Kuwait Malaysia Pakistan Taiwan Thailand Turkey Overall Liu (2008) Jin (2010) Wu (2010) Zhao (2008) Hong (2008) Chan (2011) Yuan (2010) Guo (2010) Chan (1999) Tao (2006) Liu (2010) Berlin Grace (2009) Nair (1999) Singh (2009) Franceschi (2005) Nagpal (2002) Khodakaram (2011) Esameili (2008) Ghaffari (2006) Saito (2001) Yoshida (2004) Sasagawa (2001) Matsumoto (2010) Tsuda (2003) Nishiwaki (2008) Inoue (2006) Yamasaki (2011) Konno (2011) Hwang (2003) Kang (2009) Oh (2001) Lee (2007) Cho (2003) An (2003) Al Awadhi (2011) Sharifah (2009) Raza (2010) Huang (2008) Chao (2008) Ding (2008) Bhattarakosol (2002) Chansaenroj (2010) Ekalaksananan (2001) Chaiwongkot (2007) Suwannaruruk (2009) Ozgul (2008) Ergunay (2008) Prevalence (%) The samples for HPV testing come from cervical specimens (fresh/fixed biopsies or exfoliated cells). Low-grade lesions: LSIL or CIN-1. Abbreviations used: N: number of women tested; 95% CI: 95 % Confidence Interval. See references in Section 8.

83 4 HPV RELATED STATISTICS Figure 43: Prevalence of HPV 16 among women with High-grade cervical lesions in Europe by country and study Country Study Belarus Kulmala (2007) Belgium Arbyn (2009) Beerens (2005) Depuydt (2003) Baay (2001) Croatia Grce (2001) Grce (2004) Czech Republic Tachezy (2011) Denmark Kjaer (2008) Hording (1995) Sebbelov (1994) France Monsonego (2008) Vaucel (2010) Pretet (2008) Germany Nindl (1997) Meyer (2001) Klug (2007) Nindl (1999) Merkelbach Bruse (1999) Greece Paraskevaidis (2001) Labropoulou (1997) Panotopoulou (2007) Kroupis (2007) Tsiodras (2011) Daponte (2006) Agorastos (2005) Hungary Szoke (2003) Iceland Sigurdsson (2007) Ireland Butler (2000) Murphy (2003) O Leary (1998) Italy Giori Rossi (2010) Gargiulo (2007) Capra (2008) Tornesello (2006) Laconi (2000) Zerbini (2001) Agarossi (2009) Venturoli (2008) Carozzi (2010) Sandri (2009) Latvia Kulmala (2007) Lithuania Gudleviciene (2005) Netherlands Prinsen (2007) Cornelissen (1992) Reesink Peters (2001) Bulkmans (2005) van Duin (2003) Tang (2009) Norway Sjoeborg (2010) Molden (2005) Roberts (2006) Kraus (2004) Portugal Pista (2010) Nobre (2010) Medeiros (2005) Romania Anton (2011) Russian FederationKulmala (2007) Slovenia Kovanda (2009) Spain de Ona (2010) Conesa Zamore (2009) Garcia Sierra (2009) Martin (2011) Bosch (1993) Munoz (1992) de Mendez (2009) Sweden Kalantari (1997) Andersson (2005) Zehbe (1996) Switzerland Dobec (2011) United Kingdom Hibbitts (2008) Sargent (2008) Cuschieri (2004) Jamison (2008) Arends (1993) Howell Jones (2010) Herrington (1995) Southern (1998) Cuzick (1994) Overall N Prevalence %CI Prevalence (%) The samples for HPV testing come from cervical specimens (fresh/fixed biopsies or exfoliated cells). Abbreviations used: N: number of women tested; 95% CI: 95 % Confidence Interval. High-grade lesions: CIN-2, CIN-3, CIS or HSIL. See references in Section 8.

84 4 HPV RELATED STATISTICS Figure 44: Prevalence of HPV 16 among women with High-grade cervical lesions in Africa by country and study Country Study N Prevalence 95%CI Algeria Hammouda (2010) Congo, DR Hovland (2010) Côte d Ivoire La Ruche (1998) Equatorial Guinea Garcia Espinosa (2009) Guinea Keita (2009) Kenya De Vuyst (2010) De Vuyst (2003) De Vuyst (2011) Morocco Alhamany (2010) Nigeria Gage (2011) Rwanda Singh (2009) Senegal Xi (2003) Chaba (1996) South Africa Said (2009) Allan (2008) De Vuyst (2011) Zimbabwe Sawaya (2008) Overall Prevalence (%) The samples for HPV testing come from cervical specimens (fresh/fixed biopsies or exfoliated cells). Abbreviations used: N: number of women tested; 95% CI: 95 % Confidence Interval. High-grade lesions: CIN-2, CIN-3, CIS or HSIL. See references in Section 8.

85 4 HPV RELATED STATISTICS Figure 45: Prevalence of HPV 16 among women with High-grade cervical lesions in Americas by country and study Country Study N Prevalence 95%CI Argentina Belize Brazil Canada Chile Colombia Costa Rica Cuba Honduras Jamaica Mexico Nicaragua Paraguay USA Overall Abba (2003) Alonio (2003) Chouhy (2006) Deulaca (2004) Cathro (2009) Krambeck (2008) Camara (2003) Freitas (2007) Ribeiro (2011) Pitta (2010) Fernandes (2009) Lorenzato (2000) Tomita (2010) Fernandes (2010) Carestiato (2006) Terra (2007) Antonishyn (2008) Moore (2009) Coutlée (2011) Ili (2011) Bosch (1993) Munoz (1992) Garcia (2011) Herrero (2005) Soto (2007) Ferrera (1999) Strickler (1999) Rattray (1996) Velazquez Marquez (2009) Giuliano (2001) Illades Aguiar (2010) Pina Sanchez (2006) Torroella Kouri (1998) Hindryckx (2006) Mendoza (2011) Giuliano (2001) Guo (2007) Bell (2007) Hu (2005) Einstein (2006) Zuna (2007) Castle (2011) Moscicki (2008) Wheeler (2006) Evans (2006) Kong (2007) Adam (1998) Stoler (2011) Wheeler (2009) Wentzensen (2009) Castle (2010) Lee (2009) Voss (2009) Evans (2003) Prevalence (%) The samples for HPV testing come from cervical specimens (fresh/fixed biopsies or exfoliated cells). Abbreviations used: N: number of women tested; 95% CI: 95 % Confidence Interval. High-grade lesions: CIN-2, CIN-3, CIS or HSIL. See references in Section 8.

86 4 HPV RELATED STATISTICS Figure 46: Prevalence of HPV 16 among women with High-grade cervical lesions in Oceania by country and study Country Study N Prevalence 95%CI Australia Brestovac (2005) Stevens (2006) Garland (2011) Stevens (2009) Fiji Tabrizi (2011) Overall Prevalence (%) The samples for HPV testing come from cervical specimens (fresh/fixed biopsies or exfoliated cells). Abbreviations used: N: number of women tested; 95% CI: 95 % Confidence Interval. High-grade lesions: CIN-2, CIN-3, CIS or HSIL. See references in Section 8.

87 4 HPV RELATED STATISTICS Figure 47: Prevalence of HPV 16 among women with High-grade cervical lesions in Asia by country and study Country Study N Prevalence 95%CI China India Iran Japan Korea, Rep of Kuwait Pakistan Taiwan Thailand Overall Jin (2010) Chan (1996) Chan (1999) Zhao (2008) Li (2010) Guo (2010) Wu (1994) Chan (2011) Liu (2008) Tao (2006) Yuan (2010) Franceschi (2005) Singh (2009) Nagpal (2002) Khodakaram (2011) Esameili (2008) Ghaffari (2006) Tsuda (2003) Matsumoto (2010) Nishiwaki (2008) Yoshida (2004) Inoue (2006) Sasagawa (2001) Niwa (2003) Nagai (2000) Ichimura (2003) Yamasaki (2011) Konno (2011) Hwang (2003) Kang (2009) Oh (2001) Cho (2003) Al Awadhi (2011) Raza (2010) Chao (2008) Ho (2005) Chao (2010) Lai (2003) Lin (2005) Yang (2004) Chansaenroj (2010) Limpaiboon (2000) Suwannaruruk (2009) Sukasem (2011) Prevalence (%) The samples for HPV testing come from cervical specimens (fresh/fixed biopsies or exfoliated cells). Abbreviations used: N: number of women tested; 95% CI: 95 % Confidence Interval. High-grade lesions: CIN-2, CIN-3, CIS or HSIL. See references in Section 8.

88 4 HPV RELATED STATISTICS Figure 48: Prevalence of HPV 16 among women with invasive cervical cancer in Europe by country and study Country Austria Belarus Belgium Bulgaria Croatia Czech Republic Denmark Finland France Germany Greece Greenland Hungary Iceland Ireland Italy Latvia Lithuania Luxembourg Netherlands Norway Poland Portugal Russian Federation Slovenia Spain Sweden United Kingdom Overall Study Bachtiary (2002) Widschwendter (2003) Kulmala (2007) Beerens (2005) Baay (2001) Todorova (2010) Hadzisejdic (2007) Dabic (2008) Tachezy (1999) Slama (2009) Tachezy (2011) Hording (1997) Kjaer (2008) Sebbelov (2000) Iwasawa (1996) Lombard (1998) Riou (1990) de Cremoux (2009) Pretet (2008) Milde Langosch (1995) Bosch (1995) Klug (2007) Dokianakis (1999) Panotopoulou (2007) Kof (1994) Adamopoulou (2009) Labropoulou (1997) Daponte (2006) Sebbelov (2000) Konya (1995) Sigurdsson (2007) Skyldberg (1999) Fay (2009) O Leary (1998) Butler (2000) Garzetti (1998) Venturoli (2008) Ciotti (2006) Tornesello (2011) Tornesello (2006) Gargiulo (2007) Lillo (2009) Sideri (2009) Rolla (2009) Carozzi (2010) Voglino (2000) Del Mistro (2006) Silins (2004) Kulmala (2007) Gudleviciene (2005) Ressler (2007) Zielinski (2003) De Boer (2005) Bulk (2006) Krul (1999) Baay (1996) Bulkmans (2005) Tang (2009) Resnick (1990) van den Bru (1991) Bertelsen (2006) Karlsen (1996) Pirog (2000) Dybikowska (2002) Kwasniewska (2009) Bardin (2008) Bosch (1995) Biesaga (2012) Baay (2009) Nobre (2010) Medeiros (2005) Kleter (1999) Kulmala (2007) Jancar (2009) Mazarico (2012) Martró (2012) Alemany (2012) Munoz (1992) Bosch (1995) Rodriguez (1998) Andersson (2001) Skyldberg (1999) Andersson (2003) Hagmar (1992) Wallin (1999) Zehbe (1997) Du (2011) Andersson (2005) Graflu (2004) Sargent (2008) Tawfik El Mansi (2006) Arends (1993) Cuschieri (2010) Howell Jones (2010) Cuzick (2000) Powell (2009) Crook (1992) Giannoudis (1999) N Prevalence 95%CI Prevalence (%) The samples for HPV testing come from cervical specimens (fresh/fixed biopsies or exfoliated cells). Abbreviations used: N: number of women tested; 95% CI: 95 % Confidence Interval. See references in Section 8.

89 4 HPV RELATED STATISTICS Figure 49: Prevalence of HPV 16 among women with invasive cervical cancer in Africa by country and study Country Study N Prevalence 95%CI Algeria Bosch (1995) Hammouda (2005) Benin Bosch (1995) Ethiopia Fanta (2005) Guinea Bosch (1995) Keita (2009) Kenya De Vuyst (2008) Mali Bosch (1995) Bayo (2002) Morocco Meftah el khair (2009) Chaouki (1998) Mozambique Castellague (2008) Naucler (2004) Senegal Xi (2003) Lin (2001) South Africa Williamson (1994) Pegoraro (2002) Kay (2003) Tanzania ter Meulen (1992) Bosch (1995) Uganda Odida (2008) Bosch (1995) Zimbabwe Stanczuk (2003) Overall Prevalence (%) The samples for HPV testing come from cervical specimens (fresh/fixed biopsies or exfoliated cells). Abbreviations used: N: number of women tested; 95% CI: 95 % Confidence Interval. See references in Section 8.

90 4 HPV RELATED STATISTICS Figure 50: Prevalence of HPV 16 among women with invasive cervical cancer in Americas by country and study Country Study N Prevalence 95%CI Argentina Bolivia Brazil Canada Chile Colombia Costa Rica Cuba Honduras Jamaica Mexico Nicaragua Panama Paraguay Peru Suriname USA Overall Alonio (2003) Bosch (1995) Turazza (1997) Golijow (2005) Bosch (1995) Cambruzzi (2005) Bosch (1995) Rabelo Santos (2009) Rabelo Santos (2003) Eluf Neto (1994) Tomita (2010) Lorenzato (2000) Duggan (1995) Tran Thanh (2003) Bosch (1995) Bosch (1995) Valdivia (2009) Roa (2009) Murillo (2009) Bosch (1995) Munoz (1992) Moreno Acosta (2008) Herrero (2005) Bosch (1995) Ferrera (1999) Strickler (1999) Gonzalez Losa (2004) Meyer (1998) Torroella Kouri (1998) Alarcon Romero (2009) Illades Aguiar (2009) Pina Sanchez (2006) Hindryckx (2008) Bosch (1995) Rolon (2000) Santos (2001) De Boer (2005) Ferguson (1998) Pirog (2000) Paquette (1993) Burger (1996) Wheeler (2009) Bosch (1995) Wentzensen (2009) Zuna (2007) Bryan (2006) Schwartz (2001) Patel (2009) Quint (2009) Wistuba (1997) Guo (2007) Burnett (1992) Resnick (1990) Sebbelov (2000) Prevalence (%) The samples for HPV testing come from cervical specimens (fresh/fixed biopsies or exfoliated cells). Abbreviations used: N: number of women tested; 95% CI: 95 % Confidence Interval. See references in Section 8.

91 4 HPV RELATED STATISTICS Figure 51: Prevalence of HPV 16 among women with invasive cervical cancer in Oceania by country and study Country Study N Prevalence 95%CI Australia Plunkett (2003) Stevens (2006) Chen (1999) Liu (2004) Thompson (1994) Brestovac (2005) Overall Prevalence (%) The samples for HPV testing come from cervical specimens (fresh/fixed biopsies or exfoliated cells). Abbreviations used: N: number of women tested; 95% CI: 95 % Confidence Interval. See references in Section 8.

92 4 HPV RELATED STATISTICS Figure 52: Prevalence of HPV 16 among women with invasive cervical cancer in Asia by country and study Country China India Indonesia Iran Japan Jordan Korea, Rep of Malaysia Mongolia Nepal Pakistan Philippines Syria Taiwan Thailand Turkey Overall Study Huang (1997) Peng (1991) Gao (2003) Liu (2008) Lin (1998) Lo K (2001) Liu (2004) Zhao (2008) Tao (2006) Chan P (2009) Stephen (2000) Hong (2008) Liu (2005) Shah (2009) Lo (2002) Wu (2008) Yu (2003) Liu (2010) Wu (2008) Chen (2009) Qiu (2007) Cai (2009) Cai (2008) Wu (2009) Munirajan (1998) Sowjanya (2006) Peedicayil (2006) Nagpal (2002) Franceschi (2003) Munagala (2009) Basu (2009) Nair (1999) Nambura (2009) Bhatla (2006) Peedicayil (2009) Gheit (2009) Neyaz (2008) Bosch (1995) De Boer (2005) Schellekens (2004) Hamkar (2002) Esameili (2008) Mortazavi (2002) Ghaffari (2006) Harima (2002) Tsuda (2003) Maehama (2005) Kanao (2004) Yamakawa (1994) Inoue (2006) Yoshida (2004) Saito (2000) Yoshida (2009) Asato (2004) Nakagawa (1996) Nakagawa (2002) Kashiwabara (1992) Sasagawa (2001) Maki (1991) Fujinaga (1991) Ishikawa (2001) Nawa (1994) Sughayer (2010) Hwang (1999) An (2005) Tong (2007) Lee (2007) Hwang (2003) Kim (1995) Cho (2003) An (2003) Song (2007) Kim (2009) Sharifah (2009) Cheah (2008) Yadav (1995) Chimeddorj (2008) Sherpa A (2009) Khan (2007) Ngelangel (1998) Bosch (1995) Darnel (2009) Ho (2005) Yang (2004) Ding (2008) Chen (1994) Chen (1993) Lai (2007) Lai (1999) Lin (2005) Su (2007) Yang (1997) Chao (2009) Huang (2004) Bhattarakosol (1996) Chichareon (1998) Siritantikorn (1997) Bosch (1995) Settheetha Ishiba (2005) Chopjitt (2009) Siriaunkgul (2008) Ozgul (2008) Usubutun (2009) N Prevalence 95%CI Prevalence (%) The samples for HPV testing come from cervical specimens (fresh/fixed biopsies or exfoliated cells). Abbreviations used: N: number of women tested; 95% CI: 95 % Confidence Interval. See references in Section 8.

93 4 HPV RELATED STATISTICS Figure 53: Prevalence of HPV 16 among women with invasive cervical adenocarcinoma in Europe by country and study Country Study N Prevalence 95%CI Belgium Croatia Denmark Finland France Germany Greece Hungary Iceland Ireland Italy Lithuania Netherlands Poland Russian Federation Slovenia Spain Sweden United Kingdom Overall Baay (2001) Hadzisejdic (2007) Dabic (2008) Hording (1997) Iwasawa (1996) Lombard (1998) Riou (1990) de Cremoux (2009) Pretet (2008) Milde Langosch (1995) Dokianakis (1999) Konya (1995) Sigurdsson (2007) Skyldberg (1999) Del Mistro (2006) Tornesello (2011) Voglino (2000) Carozzi (2010) Lillo (2009) Gudleviciene (2005) Zielinski (2003) Bulk (2006) Resnick (1990) Kwasniewska (2009) Pirog (2000) Bardin (2008) Kleter (1999) Jancar (2009) Alemany (2012) Zehbe (1997) Andersson (2001) Skyldberg (1999) Andersson (2003) Du (2011) Sargent (2008) Cuschieri (2010) Cuzick (2000) Tawfik El Mansi (2006) Howell Jones (2010) Arends (1993) Powell (2009) Crook (1992) Prevalence (%) The samples for HPV testing come from cervical specimens (fresh/fixed biopsies or exfoliated cells). Abbreviations used: N: number of women tested; 95% CI: 95 % Confidence Interval. See references in Section 8.

94 4 HPV RELATED STATISTICS Figure 54: Prevalence of HPV 16 among women with invasive cervical adenocarcinoma in Africa by country and study Country Study N Prevalence 95%CI Algeria Bosch (1995) Hammouda (2005) Ethiopia Fanta (2005) Guinea Bosch (1995) Keita (2009) Mali Bosch (1995) Morocco Chaouki (1998) Meftah el khair (2009) South Africa Williamson (1994) Tanzania Bosch (1995) Uganda Bosch (1995) Odida (2008) Zimbabwe Stanczuk (2003) Overall Prevalence (%) The samples for HPV testing come from cervical specimens (fresh/fixed biopsies or exfoliated cells). Abbreviations used: N: number of women tested; 95% CI: 95 % Confidence Interval. See references in Section 8.

95 4 HPV RELATED STATISTICS Figure 55: Prevalence of HPV 16 among women with invasive cervical adenocarcinoma in Americas by country and study Country Study N Prevalence 95%CI Argentina Bosch (1995) Bolivia Bosch (1995) Brazil Cambruzzi (2005) Tomita (2010) Rabelo Santos (2009) Bosch (1995) Rabelo Santos (2003) Eluf Neto (1994) Canada Bosch (1995) Duggan (1995) Chile Bosch (1995) Colombia Murillo (2009) Cuba Bosch (1995) Honduras Ferrera (1999) Mexico Torroella Kouri (1998) Illades Aguiar (2009) Panama Bosch (1995) Paraguay Rolon (2000) Peru Santos (2001) USA Bosch (1995) Ferguson (1998) Burger (1996) Paquette (1993) Pirog (2000) Wheeler (2009) Schwartz (2001) Quint (2009) Resnick (1990) Burnett (1992) Overall Prevalence (%) The samples for HPV testing come from cervical specimens (fresh/fixed biopsies or exfoliated cells). Abbreviations used: N: number of women tested; 95% CI: 95 % Confidence Interval. See references in Section 8.

96 4 HPV RELATED STATISTICS Figure 56: Prevalence of HPV 16 among women with invasive cervical adenocarcinoma in Oceania by country and study Country Study N Prevalence 95%CI Australia Chen (1999) Plunkett (2003) Overall Prevalence (%) The samples for HPV testing come from cervical specimens (fresh/fixed biopsies or exfoliated cells). Abbreviations used: N: number of women tested; 95% CI: 95 % Confidence Interval. See references in Section 8.

97 4 HPV RELATED STATISTICS Figure 57: Prevalence of HPV 16 among women with invasive cervical adenocarcinoma in Asia by country and study Country Study N Prevalence 95%CI China India Indonesia Iran Japan Korea, Rep of Malaysia Philippines Taiwan Thailand Turkey Overall Peng (1991) Stephen (2000) Zhao (2008) Huang (1997) Lo (2002) Yu (2003) Peedicayil (2006) Franceschi (2003) Basu (2009) Bosch (1995) Schellekens (2004) Esameili (2008) Nakagawa (2002) Yoshida (2004) Kashiwabara (1992) Sasagawa (2001) Nakagawa (1996) Yamakawa (1994) Yoshida (2009) Hwang (1999) Lee (2007) Cho (2003) Tong (2007) An (2005) An (2003) Sharifah (2009) Ngelangel (1998) Bosch (1995) Chen (1993) Chen (1994) Lai (1999) Ding (2008) Yang (1997) Lai (2007) Siritantikorn (1997) Bosch (1995) Chichareon (1998) Usubutun (2009) Prevalence (%) The samples for HPV testing come from cervical specimens (fresh/fixed biopsies or exfoliated cells). Abbreviations used: N: number of women tested; 95% CI: 95 % Confidence Interval. See references in Section 8.

98 4 HPV RELATED STATISTICS Figure 58: Prevalence of HPV 16 among women with invasive cervical squamous cell carcinoma in Europe by country and study Country Belgium Bulgaria Czech Republic Denmark Finland France Germany Greece Greenland Hungary Iceland Ireland Italy Lithuania Luxembourg Netherlands Poland Russian Federation Slovenia Spain Sweden United Kingdom Overall Study Baay (2001) Todorova (2010) Tachezy (2011) Sebbelov (2000) Iwasawa (1996) Lombard (1998) de Cremoux (2009) Riou (1990) Pretet (2008) Milde Langosch (1995) Bosch (1995) Klug (2007) Dokianakis (1999) Panotopoulou (2007) Sebbelov (2000) Konya (1995) Sigurdsson (2007) Fay (2009) O Leary (1998) Garzetti (1998) Venturoli (2008) Lillo (2009) Ciotti (2006) Gargiulo (2007) Tornesello (2011) Carozzi (2010) Del Mistro (2006) Voglino (2000) Gudleviciene (2005) Ressler (2007) Baay (1996) Bulk (2006) Resnick (1990) van den Bru (1991) Dybikowska (2002) Kwasniewska (2009) Bardin (2008) Bosch (1995) Biesaga (2012) Kleter (1999) Jancar (2009) Mazarico (2012) Martró (2012) Alemany (2012) Munoz (1992) Bosch (1995) Hagmar (1992) Zehbe (1997) Du (2011) Andersson (2005) Sargent (2008) Arends (1993) Cuschieri (2010) Howell Jones (2010) Powell (2009) Cuzick (2000) Crook (1992) Giannoudis (1999) N Prevalence 95%CI Prevalence (%) See references in Section 8.

99 4 HPV RELATED STATISTICS Figure 59: Prevalence of HPV 16 among women with invasive cervical squamous cell carcinoma in Africa by country and study Country Study N Prevalence 95%CI Algeria Bosch (1995) Hammouda (2005) Benin Bosch (1995) Ethiopia Fanta (2005) Guinea Bosch (1995) Keita (2009) Kenya De Vuyst (2008) Mali Bosch (1995) Bayo (2002) Morocco Chaouki (1998) Meftah el khair (2009) South Africa Williamson (1994) Pegoraro (2002) Tanzania Bosch (1995) Uganda Odida (2008) Bosch (1995) Zimbabwe Stanczuk (2003) Overall Prevalence (%) See references in Section 8.

100 4 HPV RELATED STATISTICS Figure 60: Prevalence of HPV 16 among women with invasive cervical squamous cell carcinoma in Americas by country and study Country Study N Prevalence 95%CI Argentina Bolivia Brazil Canada Chile Colombia Cuba Honduras Mexico Nicaragua Panama Paraguay Peru USA Overall Alonio (2003) Bosch (1995) Turazza (1997) Golijow (2005) Bosch (1995) Bosch (1995) Rabelo Santos (2003) Eluf Neto (1994) Tomita (2010) Rabelo Santos (2009) Bosch (1995) Bosch (1995) Valdivia (2009) Murillo (2009) Bosch (1995) Munoz (1992) Bosch (1995) Ferrera (1999) Torroella Kouri (1998) Illades Aguiar (2009) Alarcon Romero (2009) Pina Sanchez (2006) Hindryckx (2008) Bosch (1995) Rolon (2000) Santos (2001) Wentzensen (2009) Wheeler (2009) Burger (1996) Bosch (1995) Wistuba (1997) Paquette (1993) Schwartz (2001) Burnett (1992) Guo (2007) Resnick (1990) Sebbelov (2000) Prevalence (%) See references in Section 8.

101 4 HPV RELATED STATISTICS Figure 61: Prevalence of HPV 16 among women with invasive cervical squamous cell carcinoma in Oceania by country and study Country Study N Prevalence 95%CI Australia Chen (1999) Brestovac (2005) Overall Prevalence (%) See references in Section 8.

102 4 HPV RELATED STATISTICS Figure 62: Prevalence of HPV 16 among women with invasive cervical squamous cell carcinoma in Asia by country and study Country Study N Prevalence 95%CI China India Indonesia Iran Japan Korea, Rep of Malaysia Mongolia Philippines Taiwan Thailand Turkey Overall Huang (1997) Peng (1991) Chan P (2009) Chan P (2009) Zhao (2008) Shah (2009) Lo (2002) Stephen (2000) Chen (2009) Yu (2003) Cai (2009) Sowjanya (2006) Nagpal (2002) Peedicayil (2006) Franceschi (2003) Basu (2009) Nair (1999) Gheit (2009) Bosch (1995) Schellekens (2004) Esameili (2008) Ghaffari (2006) Kanao (2004) Asato (2004) Nakagawa (1996) Yoshida (2004) Sasagawa (2001) Kashiwabara (1992) Ishikawa (2001) Nakagawa (2002) Nawa (1994) Hwang (1999) Tong (2007) Lee (2007) An (2003) Cho (2003) Sharifah (2009) Yadav (1995) Chimeddorj (2008) Ngelangel (1998) Bosch (1995) Ding (2008) Chen (1994) Chen (1993) Lai (2007) Lai (1999) Su (2007) Yang (1997) Chao (2009) Bhattarakosol (1996) Chichareon (1998) Settheetha Ishiba (2005) Bosch (1995) Siritantikorn (1997) Chopjitt (2009) Siriaunkgul (2008) Usubutun (2009) Prevalence (%) See references in Section 8.

103 4 HPV RELATED STATISTICS Figure 63: Ten most frequent HPV types among women with and without cervical lesions in the World compared to developing and developed regions World Less developed regions More developed regions Cervical Cancer HPV type High grade lesions HPV type Low grade lesions HPV type Normal cytology HPV type Prevalence (%) Prevalence (%) Prevalence (%) The samples for HPV testing come from cervical specimens (fresh / fixed biopsies or exfoliated cells). See references in Section 8.

104 4 HPV RELATED STATISTICS Figure 64: Ten most frequent HPV types among women with invasive cervical cancer by histology in the World compared to developing and developed regions World Less developed regions More developed regions Any Histology HPV type Squamous cell carcinoma HPV type Adenocarcinoma HPV type Unespecified HPV type Prevalence (%) Prevalence (%) Prevalence (%) The samples for HPV testing come from cervical specimens (fresh / fixed biopsies or exfoliated cells). See references in section 8.

105 4 HPV RELATED STATISTICS Table 17: Type-specific HPV prevalence in women with normal cytology, precancerous cervical lesions and invasive cervical cancer in the World Cervical cancer High-grade lesions Low-grade lesions Normal cytology HPV Type No. HPV Prev No. HPV Prev No. HPV Prev No. HPV Prev tested % (95% CI) tested % (95% CI) tested % (95% CI) tested % (95% CI) 6 22, ( ) 18, ( ) 20, ( ) 114, ( ) 11 21, ( ) 17, ( ) 19, ( ) 105, ( ) 16 33, ( ) 26, ( ) 30, ( ) 224, ( ) 18 33, ( ) 26, ( ) 30, ( ) 224, ( ) 26 15, ( ) 12, ( ) 11, ( ) 72, ( ) 30 3, ( ) 1, ( ) 2, ( ) 14, ( ) 31 27, ( ) 25, ( ) 28, ( ) 214, ( ) 32 2, ( ) , ( ) 33 28, ( ) 25, ( ) 28, ( ) 215, ( ) 34 9, ( ) 6, ( ) 5, ( ) 53, ( ) 35 23, ( ) 22, ( ) 23, ( ) 204, ( ) 39 21, ( ) 20, ( ) 21, ( ) 194, ( ) 40 9, ( ) , ( ) 42 9, ( ) , ( ) 43 8, ( ) , ( ) 44 8, ( ) , ( ) 45 23, ( ) 21, ( ) 23, ( ) 200, ( ) 51 21, ( ) 21, ( ) 20, ( ) 197, ( ) 52 24, ( ) 21, ( ) 21, ( ) 199, ( ) 53 17, ( ) 17, ( ) 16, ( ) 96, ( ) 54 9, ( ) , ( ) 55 5, ( ) , ( ) 56 21, ( ) 20, ( ) 21, ( ) 198, ( ) 57 5, ( ) , ( ) 58 25, ( ) 22, ( ) 23, ( ) 203, ( ) 59 21, ( ) 20, ( ) 20, ( ) 194, ( ) 61 7, ( ) , ( ) 62 4, ( ) , ( ) 64 4, ( ) , ( ) 66 19, ( ) 18, ( ) 19, ( ) 142, ( ) 67 9, ( ) 10, ( ) 9, ( ) 43, ( ) 68 18, ( ) 17, ( ) 19, ( ) 193, ( ) 69 5, ( ) 9, ( ) 8, ( ) 47, ( ) 70 17, ( ) 12, ( ) 12, ( ) 64, ( ) 71 5, ( ) , ( ) 72 6, ( ) , ( ) 73 14, ( ) 12, ( ) 12, ( ) 63, ( ) 74 4, ( ) , ( ) 81 6, ( ) , ( ) 82 15, ( ) 14, ( ) 12, ( ) 72, ( ) 83 5, ( ) , ( ) 84 4, ( ) , ( ) 85 1, ( ) 2, ( ) 2, ( ) 12, ( ) 86 1, ( ) , ( ) 89 6, ( ) , ( ) 90 1, ( ) , ( ) 91 1, ( ) , ( ) The samples for HPV testing come from cervical specimens (fresh / fixed biopsies or exfoliated cells). Low-grade lesions: CIN-1 or LSIL. High-grade lesions: CIN-2, CIN-3, CIS or HSIL. Abbreviations used: 95% CI:95% Confidence Interval. See references in Section 8.

106 4 HPV RELATED STATISTICS Table 18: Type-specific HPV prevalence among invasive cervical cancer cases by histology in the World Any Histology Squamous cell carcinoma Adenocarcinoma Unespecified HPV Type No. HPV Prev No. HPV Prev No. HPV Prev No. HPV Prev tested % (95% CI) tested % (95% CI) tested % (95% CI) tested % (95% CI) 6 22, ( ) 14, ( ) 2, ( ) 5, ( ) 11 21, ( ) 14, ( ) 1, ( ) 5, ( ) 16 33, ( ) 20, ( ) 3, ( ) 9, ( ) 18 33, ( ) 19, ( ) 3, ( ) 9, ( ) , ( ) 10, ( ) 1, ( ) 3, ( ) 30 3, ( ) 2, ( ) ( ) ( ) 31 27, ( ) 16, ( ) 2, ( ) 8, ( ) 32 2, ( ) 1, ( ) ( ) ( ) 33 28, ( ) 17, ( ) 3, ( ) 8, ( ) 34 9, ( ) 5, ( ) ( ) 2, ( ) 35 23, ( ) 14, ( ) 2, ( ) 6, ( ) 39 21, ( ) 13, ( ) 2, ( ) 5, ( ) 40 9, ( ) 5, ( ) ( ) 3, ( ) 42 9, ( ) 5, ( ) ( ) 3, ( ) 43 8, ( ) 4, ( ) ( ) 2, ( ) 44 8, ( ) 5, ( ) ( ) 2, ( ) 45 23, ( ) 14, ( ) 2, ( ) 6, ( ) 51 21, ( ) 13, ( ) 2, ( ) 5, ( ) 52 24, ( ) 15, ( ) 2, ( ) 6, ( ) 53 17, ( ) 11, ( ) 1, ( ) 4, ( ) 54 9, ( ) 6, ( ) ( ) 2, ( ) 55 5, ( ) 2, ( ) ( ) 2, ( ) 56 21, ( ) 13, ( ) 2, ( ) 5, ( ) 57 5, ( ) 2, ( ) ( ) 2, ( ) 58 25, ( ) 15, ( ) 2, ( ) 7, ( ) 59 21, ( ) 13, ( ) 2, ( ) 5, ( ) 61 7, ( ) 4, ( ) ( ) 2, ( ) 62 4, ( ) 2, ( ) ( ) 2, ( ) 64 4, ( ) 2, ( ) ( ) 1, ( ) 66 19, ( ) 12, ( ) 1, ( ) 5, ( ) 67 9, ( ) 5, ( ) ( ) 2, ( ) 68 18, ( ) 12, ( ) 1, ( ) 4, ( ) 69 5, ( ) 3, ( ) ( ) 1, ( ) 70 17, ( ) 11, ( ) 1, ( ) 4, ( ) 71 5, ( ) 3, ( ) ( ) 1, ( ) 72 6, ( ) 4, ( ) ( ) 2, ( ) 73 14, ( ) 10, ( ) 1, ( ) 3, ( ) 74 4, ( ) 2, ( ) ( ) 1, ( ) 81 6, ( ) 3, ( ) ( ) 2, ( ) 82 15, ( ) 10, ( ) 1, ( ) 3, ( ) 83 5, ( ) 3, ( ) ( ) 2, ( ) 84 4, ( ) 2, ( ) ( ) 2, ( ) 85 1, ( ) ( ) ( ) ( ) 86 1, ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) 89 6, ( ) 3, ( ) ( ) 1, ( ) 90 1, ( ) ( ) ( ) ( ) 91 1, ( ) ( ) ( ) ( ) The samples for HPV testing come from cervical specimens (fresh / fixed biopsies or exfoliated cells). Abbreviations used: 95% CI:95% Confidence Interval. See references in section 8.

107 4 HPV RELATED STATISTICS Terminology Cytologically normal women No abnormal cells are observed on the surface of their cervix upon cytology. Cervical Intraepithelial Neoplasia (CIN) / Squamous Intraepithelial Lesions (SIL) SIL and CIN are two commonly used terms to describe precancerous lesions or the abnormal growth of squamous cells observed in the cervix. SIL is an abnormal result derived from cervical cytological screening or Pap smear testing. CIN is a histological diagnosis made upon analysis of cervical tissue obtained by biopsy or surgical excision. The condition is graded as CIN 1, 2 or 3, according to the thickness of the abnormal epithelium (1/3, 2/3 or the entire thickness). Low-grade cervical lesions (LSIL/CIN-1) Low-grade cervical lesions are defined by early changes in size, shape, and number of abnormal cells formed on the surface of the cervix and may be referred to as mild dysplasia, LSIL, or CIN-1. High-grade cervical lesions (HSIL/ CIN-2 / CIN-3 / CIS) High-grade cervical lesions are defined by a large number of precancerous cells on the surface of the cervix that are distinctly different from normal cells. They have the potential to become cancerous cells and invade deeper tissues of the cervix. These lesions may be referred to as moderate or severe dysplasia, HSIL, CIN-2, CIN-3 or cervical carcinoma in situ (CIS). Carcinoma in situ (CIS) Preinvasive malignancy limited to the epithelium without invasion of the basement membrane. CIN 3 encompasses the squamous carcinoma in situ. Invasive cervical cancer (ICC) / Cervical cancer If the high-grade precancerous cells invade the basement membrane is called ICC. ICC stages range from stage I (cancer is in the cervix or uterus only) to stage IV (the cancer has spread to distant organs, such as the liver). Invasive squamous cell carcinoma Invasive carcinoma composed of cells resembling those of squamous epithelium. Adenocarcinoma Invasive tumour with glandular and squamous elements intermingled.

108 4 HPV RELATED STATISTICS HPV burden in anogenital cancers other than cervix Table 19: Prevalence of HPV in anogenital cancers other than the cervix in the World HPV prevalence HPV 16/18 prevalence No. tested % (95% CI) No. tested % (95% CI) Anal cancer ( ) ( ) Vulvar cancer ( ) ( ) Vaginal cancer ( ) ( ) Penile cancer ( ) ( ) Note: HPV prevalence is highly variable according to the histology, refer to specific sections in 4.2 for details See references in Section Anal cancer and precancerous anal lesions (last update 15 sep 2010) Anal cancer is similar to cervical cancer with respect to overall HPV DNA positivity, with approximately 88% of cases associated with HPV infection worldwide(de Martel C et al. Lancet Oncol 2012;13(6):607-15). HPV16 is the most common detected type, representing 73% of all HPV-positive tumours. HPV18 is the second most common type detected and is found in approximately 5% of cases. HPV DNA is also detected in the majority of precancerous anal lesions (AIN) (91.5% in AIN1 and 93.9% in AIN2/3)(De Vuyst H et al. Int J Cancer 2009; 124: ). In this section, the burden of HPV among cases of anal cancers in the World is presented. Figure 65: HPV prevalence among cases of anal cancer in the World, by histology N Prevalence % (95% CI) Others ( ) Adenocarcinoma ( ) Unespecified SCC ( ) Keratinizing SCC ( ) Basaloid/Cloacogenic SCC ( ) Any Histology ( ) HPV prevalence (%) SCC, squamous cell carcinoma See references in Section 8.

109 . 4 HPV RELATED STATISTICS Table 20: Pooled estimate of HPV prevalence among anal cancer cases, by sex Sex No. tested HPV prevalence % (95% CI) Female ( ) Male ( ) Unespecified ( ) See references in Section 8. Table 21: Pooled estimate of HPV prevalence among men who have sex with men (MSM) and non-msm with anal cancer HPV prevalence MSM No. tested % (95% CI) MSM ( ) Non-MSM ( ) Unespecified ( ) See references in Section 8. Figure 66: Ten most frequent HPV types among anal cancer cases in the World / th: NA* 8th: NA* 9th: NA* 10th: NA* Type specific HPV prevalence (%) of anal cancer cases *NA=Not available. No more types than shown were tested or were positive See references in Section 8.

110 4 HPV RELATED STATISTICS Vulvar cancer and precancerous vulvar lesions (last update 15 sep 2010) HPV attribution for vulvar cancer is 43(1) basaloid/warty types (2) keratinizing types. Basaloid/warty lesions are more common in young women, are frequently found adjacent to VIN, are very often associated with HPV DNA detection (86%), and have a similar risk factor profile as cervical cancer. Keratinizing vulvar carcinomas represent the majority of the vulvar lesions (>60%). These lesions develop from non-hpv-related chronic vulvar dermatoses, especially lichen sclerosus and/or squamous hyperplasia, their immediate cancer precursor lesion is dif-ferentiated VIN, they occur more often in older women, and are rarely associated with HPV (6%) or with any of the other risk factors typical of cervical cancer. HPV prevalence is frequently detected among cases of high-grade VIN (VIN2/3) (85.3%). HPV 16 is the most common detected type followed by HPV 33 (De Vuyst H et al. Int J Cancer 2009; 124: ). In this section, the HPV burden among cases of vulvar cancers in the World is presented Figure 67: HPV prevalence among cases of vulvar cancer by histology in the World N Prevalence % (95% CI) Adenocarcinoma 2 0 ( ) Unespecified SCC ( ) Verrucous SCC ( ) Keratinizing SCC ( ) Warty Basaloid SCC ( ) Any Histology ( ) HPV prevalence (%) SCC, squamous cell carcinoma See references in Section 8.

111 . 4 HPV RELATED STATISTICS Figure 68: Ten most frequent HPV types among vulvar cancer cases in the World / Type specific HPV prevalence (%) of vulvar cancer cases See references in Section 8.

112 4 HPV RELATED STATISTICS Vaginal cancer and precancerous vaginal lesions (last update 15 sep 2010) Vaginal and cervical cancers share similar risk factors and it is generally accepted that both carcinomas share the same aetiology of HPV infection although there is limited evidence available. Women with vaginal cancer are more likely to have a history of other ano-genital cancers, particularly of the cervix, and these two carcinomas are frequently diagnosed simultaneously. HPV DNA is detected among 70% of invasive vaginal carcinomas and 91% of high-grade vaginal neoplasias (VaIN2/3). HPV16 is the most common type in high grade vaginal neoplasias and it is detected in at least 70% of HPV-positive carcinomas (de Martel C et al. Lancet Oncol 2012;13(6):607-15; De Vuyst H et al. Int J Cancer 2009; 124:162636). In this section, the HPV burden among cases of vaginal cancers in the World is presented. Table 22: Studies on HPV prevalence among cases of vaginal cancer in the World No. HPV prevalence Study HPV detection method Histology tested % (95% CI) Ferreira 2008 (Portugal) INNO-LiPA. SCC ( ) Madsen 2008 (Denmark) GP5+/6+ PCR-EIA assay and type-specific for HPV16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66 & 68 and other 23 low risk HPV. Habermann 2004 (Sweden) SCC ( ) PGMY09/11. SCC ( ) Koyamatsu 2003 (Japan) E7 ( bp) for HPV16, HPV 18, L1 (250bp) for HPV 6,11,16,18,31,33,42,52,58. Daling 2002 (United States of America) Carter 2001 (United States of America) Waggoner 1994 (United States of America) Kiyabu 1989 (United States of America) SCC ( ) MY09/11 for 6/11, 16, 18/45, 31. SCC ( ) MY09/11 and RFLP; type-specific for 16, 18. SCC ( ) L1 primers & E6/E/7. Adenocarcinoma ( ) E6 for HPV16 and HPV18. SCC ( ) SCC, squamous cell carcinoma See references in Section 8.

113 . 4 HPV RELATED STATISTICS Figure 69: Ten most frequent HPV types among vaginal cancer cases in the World / Type specific HPV prevalence (%) of vaginal cancer cases See references in Section 8.

114 4 HPV RELATED STATISTICS Penile cancer and precancerous penile lesions (last update 15 sep 2010) HPV DNA is detectable in approximately 50% of all penile cancers(de Martel C et al. Lancet Oncol 2012;13(6):607-15). Among HPV-related penile tumours, HPV16 is the most common type detected, followed by HPV18 and HPV types 6/11 (Miralles C et al. J Clin Pathol 2009;62:870-8). Over 95% of invasive penile cancers are SCC and the most common penile SCC histologic sub-types are keratinizing (49%), mixed warty-basaloid (17%), verrucous (8%), warty (6%), and basaloid (4%). HPV is most commonly detected in basaloid and warty tumours but is less common in keratinizing and verrucous tumours. In this section, the HPV burden among cases of penile cancers in the World is presented. Figure 70: HPV prevalence among cases of penile cancer by histology in the World N Prevalence % (95% CI) Non keratinizing SCC ( ) Carc. In situ ( ) Warty SCC ( ) Keratinizing SCC ( ) Basaloid SCC ( ) Verrucous SCC ( ) SCC (unspecified) ( ) Any Histology ( ) HPV prevalence (%) SCC, squamous cell carcinoma See references in Section 8.

115 . 4 HPV RELATED STATISTICS Figure 71: Ten most frequent HPV types among penile cancer cases in the World / Type specific HPV prevalence (%) of penile cancer cases See references in Section 8.

116 4 HPV RELATED STATISTICS HPV burden in men (last update 15 sep 2010) The information to date regarding penile HPV infection is primarily derived from studies that examined husbands of female cervical cancer cases, cross-sectional studies of selected populations such as individuals with sexually transmitted infections (STI) and military recruits, as well as from small prospective studies. HPV infection in the genital tract has been detected in up to 73% of healthy men. Like other STIs, HPV may be transmitted more readily from men to women than from women to men. (Vaccine 2008, Vol. 26, Supl 10) Table 23: Studies on HPV prevalence among men in the World Anatomic sites HPV detection Age HPV prev Country Study samples method Population (years) N % (95% CI) Brazil Franceschi 2002 Glans, corona and urethra Brazil Franceschi 2002 Glans, corona and urethra Brazil Nicolau 2005 Glans, urethra, internal and external prepuce, scrotum and anus Brazil Giuliano 2008 Corona sulcus, glans, shaft and scrotum Colombia Franceschi 2002 Glans, corona and urethra Colombia Franceschi 2002 Glans, corona and urethra Colombia Franceschi 2002 Glans, corona and urethra Denmark Kjaer 2005 Glans, coronal sulcus PCR-GP5+/6+ PCR-GP5+/6+ HC2 HR, LR PCR- PGMY09/11 and GP5/6+ PCR-GP5+/6+ PCR-GP5+/6+ PCR-GP5+/6+ PCR-GP5+/6+ and TS (HPV 6, 11, 16, 18, 31, 33) Finland Rintala 2005 Distal urethra PCR-MY09/11, GP5+/6+ Finland Rintala 2002 Vas deferens PCR-MY09/11, GP5+/6+ Finland Hippelainen 1993 Glans, meatus prepuce, coronal sulcus, urethral meatus PCR-MY09/11 TS (HPV 6, 11, 16, 18, 31, 33) Italy Nasca 2006 Penile mucosa PCR-MY09/11, GP5+/6+ Japan Takahashi 2005 Glans, corona and inner surface of prepuce Japan Takahashi 2003 Glans, corona and inner prepuce HC2 HR, LR HC2 HR, LR (Continued) Husbands of control women Husbands of women with invasive cervical cancer Partners of women with HPV General population Husbands of women with invasive cervical cancer Husbands of women with cervical carcinoma in situ Husbands of control women Military conscripts Husbands of third trimester pregnant women Clinically healthy males undergoing vasectomy Voluntary conscripts Hospital based controls attending clinic for nongenital complaints STD clinic attendees University students ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) Mean ( ) ( ) ( ) ( )

117 4 HPV RELATED STATISTICS Table 23 Continued Anatomic sites HPV detection Age HPV prev Country Study samples method Population (years) N % (95% CI) Kenya Ng ayo 2008 Glans and corona sulcus, shaft of the penis, the scrotum and the perianal region Korea, Republic of Mexico Shin 2004 Lazcano-Ponce 2001 Glans, corona, scrotum, prepuce and urethra Corona and urethra Mexico Giuliano 2008 Corona sulcus, glans, shaft and scrotum Mexico Vaccarella 2006 Scrotum, coronal sulcus, the glans and the opening of the meatus Mexico Lajous 2005 Corona, shaft, upper third of the scrotum, urethral meatus and urethra Philippines Franceschi 2002 Glans, corona and urethra Philippines Franceschi 2002 Glans, corona and urethra Spain Franceschi 2002 Glans, coronal sulcus, urethra PCR MY09/MY11 HMB01 Men worked in the fishing industry ( ) PCR-SPF10 Male students Median ( ) PCR-GP5+/6+ PCR- PGMY09/11 and GP5/6+ PCR- PGMY09/11 PCR BGH 20 and BPCO4 PCR-GP5+/6+ PCR-GP5+/6+ PCR-GP5+/6+ Sweden Forslund 1993 Urethra PCR-TS (HPV 6, 11, 16, 18, 31, 33, 35) and unespecified consensus primer Thailand Franceschi 2002 Glans, corona and urethra Thailand Franceschi 2002 Glans, corona and urethra PCR-GP5+/6+ PCR-GP5+/6+ Uganda Tobian 2009 Preputial cavity PCR- PGMY09/11 United States of America United States of America United States of America Weaver 2004 Fife 2003 Giuliano 2008b Glans, prepuce, shaft and scrotum Glans, corona, shaft, inguinal skin, scrotum, perineum, perianal and urine Corona sulcus, glans, shaft and scrotum PCR-MY09/11 HMB 01 PCR-Type specific (6 and 11) PCR- PGMY09/11 (Continued) Sexually active college students and industry workers General population and organized health care systems Men who requested a vasectomy Military conscripts Husbands of women with invasive cervical cancer Husbands of control women Husbands of control women Military conscripts Husbands of control women Husbands of women with invasive cervical cancer Men from a male circumcision trial, men HIV negative and seronegative HSV-2, baseline data University students STD clinic attendees General population ( ) ( ) Mean ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( )

118 4 HPV RELATED STATISTICS Table 23 Continued Anatomic sites HPV detection Age HPV prev Country Study samples method Population (years) N % (95% CI) United States of America United States of America United States of America United States of America United States of America United States of America Baldwin 2003 Glans, corona and urethra PCR PGMY09/11 STD clinic attendees Baken 1995 Penis PCR-MY09/11 Heterosexual partners of STD clinic attendees Partridge 2007 Hernandez 2008 Giuliano 2008a Nielson 2007 Glans, urethral meatus, penile shaft and scrotum Glans, corona sulcus, penile shaft and scrotum Corona sulcus, glans, shaft and scrotum Glans, corona sulcus, penile shaft and scrotum PCR-MY09/11 HMB 01 PCR- PGMY09/11 PCR- PGMY09/11 and GP5/6+ PCR- PGMY09/11 PCR: Polymerase Chain Reaction. LiPA: Line Probe Assay. SPF: Short Primer Fragment. TS: Type Specific. See references in Section 8. Heterosexual university students University population, primarily heterosexual, adult males General population and population from University General population volunteers and STD clinic attendees ( ) > ( ) ( ) Mean ( ) ( ) ( )

119 5 FACTORS CONTRIBUTING TO CERVICAL CANCER (LAST UPDATE 27 ENE 2014) Factors contributing to cervical cancer (last update 27 ene 2014) HPV is a necessary cause of cervical cancer, but it is not a sufficient cause. Other cofactors are necessary for progression from cervical HPV infection to cancer. Tobacco smoking, high parity, long-term hormonal contraceptive use, and co-infection with HIV have been identified as established cofactors. Co-infection with Chlamydia trachomatis and herpes simplex virus type-2, immunosuppression, and certain dietary deficiencies are other probable cofactors. Genetic and immunological host factors and viral factors other than type, such as variants of type, viral load and viral integration, are likely to be important but have not been clearly identified. (Muñoz N, Vaccine 2006; 24(S3): 1-10). In this section, the prevalence of smoking, parity (fertility), oral contraceptive use, and HIV in World are presented. Figure 72: Prevalence of female tobacco smoking in the World Adjusted and age-standardized prevalence estimates of tobacco use by country, for the year These rates are constructed solely for the purpose of comparing tobacco use prevalence estimates across countries, and should not be used to estimate the number of smokers in the population. Smoking any form of tobacco, including cigarettes, cigars, pipes, etc. and excluding smokeless tobacco. ; Smoking at the time of the survey, including daily and non-daily smoking. For Palestine the note is: Refers to a territory. WHO report on the global tobacco epidemic, 2013: The MPOWER package. Geneva, World Health Organization, Available at

120 5 FACTORS CONTRIBUTING TO CERVICAL CANCER (LAST UPDATE 27 ENE 2014) Figure 73: Total fertility rates in the World For Morocco and Mozambique the note is: Data pertain to nationals of the country. Fertility rate estimates by country are presented as a proxy measure of parity. Parity is the number of times a woman has given birth, while fertility rate is the average number of live births per woman, assuming the age-specific fertility rate observed in a given year or period. For Bahrain, Bosnia & Herzegovina, Canada, Costa Rica, Cuba, Egypt, El Salvador, Fiji, Guatemala, Israel, Jamaica, Japan, Korea, Republic of, Kuwait, Kyrgyzstan, Malaysia, Marshall Islands, Mauritius, Mexico, Micronesia, Mongolia, New Zealand, Qatar, Republic of Moldova, Singapore, St Vincent & The Grenadines, Suriname, Thailand, Tunisia, Tuvalu and United States of America the note is: The number of women by age is estimated by the United Nations Population Division and published in the World Population Prospects Revision For Saudi Arabia the note is: Data pertain to Saudi women only. For South Sudan and Sudan the note is: Data pertain to Northern Sudan and urban areas of Southern Sudan. For Austria, Belgium, Bulgaria, Croatia, Cyprus, Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Italy, Latvia, Liechtenstein, Lithuania, Luxembourg, Macedonia, TFYR, Malta, Montenegro, Netherlands, Norway, Poland, Portugal, Romania, Russian Federation, Serbia, Slovakia, Slovenia, Spain, Sweden, Switzerland, Turkey and United Kingdom the source is: Eurostat - Statistical office of the European Comission [web site]. Luxembourg: European Commission; Available at: [Accessed on July 2013] For Afghanistan, Albania, Algeria, Andorra, Angola, Antigua & Barbuda, Argentina, Armenia, Australia, Azerbaijan, Bahamas, Bahrain, Bangladesh, Barbados, Belarus, Belize, Benin, Bhutan, Bolivia, Bosnia & Herzegovina, Botswana, Brazil, Brunei, Burkina Faso, Burundi, Cambodia, Cameroon, Canada, Cape Verde, Central African Republic, Chad, Chile, China, Colombia, Comoros, Congo, Congo, DR, Cook Islands, Costa Rica, Côte d Ivoire, Cuba, Djibouti, Dominica, Dominican Republic, Ecuador, Egypt, El Salvador, Equatorial Guinea, Eritrea, Ethiopia, Fiji, Gabon, Gambia, Georgia, Ghana, Grenada, Guatemala, Guinea, Guinea-Bissau, Guyana, Haiti, Honduras, India, Indonesia, Iran, Iraq, Israel, Jamaica, Japan, Jordan, Kazakhstan, Kenya, Kiribati, Korea, DPR, Korea, Republic of, Kuwait, Kyrgyzstan, Laos, Lebanon, Lesotho, Liberia, Libya, Madagascar, Malawi, Malaysia, Maldives, Mali, Marshall Islands, Mauritania, Mauritius, Mexico, Micronesia, Mongolia, Morocco, Mozambique, Myanmar, Namibia, Nauru, Nepal, New Zealand, Nicaragua, Niger, Nigeria, Niue, Oman, Pakistan, Palau, Palestine, Panama, Papua New Guinea, Paraguay, Peru, Philippines, Qatar, Republic of Moldova, Rwanda, Samoa, San Marino, Sao Tome & Principe, Saudi Arabia, Senegal, Seychelles, Sierra Leone, Singapore, Solomon Islands, Somalia, South Africa, South Sudan, Sri Lanka, St Kitts & Nevis, St Lucia, St Vincent & The Grenadines, Sudan, Suriname, Swaziland, Syria, Tajikistan, Tanzania, Thailand, Timor-Leste, Togo, Tonga, Trinidad & Tobago, Tunisia, Turkmenistan, Tuvalu, Uganda, Ukraine, United Arab Emirates, United States of America, Uruguay, Uzbekistan, Vanuatu, Venezuela, Viet Nam, Yemen, Zambia and Zimbabwe the source is: United Nations, Department of Economic and Social Affairs, Population Division. World Fertility Data (POP/DB/Fert/Rev2008). Available at: [Accessed on July 2013]

121 5 FACTORS CONTRIBUTING TO CERVICAL CANCER (LAST UPDATE 27 ENE 2014) Figure 74: Prevalence of oral contraceptive use in World For Austria, Bulgaria, Cook Islands, Denmark, Estonia, Greece, Grenada, Guam, Hungary, Italy, Korea, DPR, Latvia, Lithuania, Mauritania, Mauritius, New Zealand, Pakistan, Poland, Puerto Rico, Reunion, Singapore, Slovenia, Tunisia and Turkmenistan the note is: Adjusted. For Argentina, Belgium, Denmark and Greece the note is: Data pertain to sexually active women of reproductive age. For Belgium the note is: Data pertain to methods used during the last 12 months. For Anguilla, Cook Islands, Croatia, Guadeloupe, Kiribati, Martinique, N Mariana Islands, Palau, Reunion and Uruguay the note is: Data pertain to all women of reproductive age, irrespective of marital status. For Anguilla and Croatia the note is: Data pertain to methods used during the last two months. For Estonia, Guam, Portugal, Puerto Rico and US Virgin Islands the note is: Data pertain to sexually active, non-pregnant women. For Estonia the note is: Data pertain to methods used during the last month. For Israel the note is: Data pertain to the Jewish population. For Malta the note is: Data pertain to married women who visited a practitioner belonging to the Malta College of Family Doctors. For Norway the note is: Data pertain to women who were sexually active during the three months prior to the interview. For Poland the note is: Data pertain to women who were sexually active during the month prior to the interview. For Australia and Slovakia the note is: Data pertain to women exposed to the risk of pregnancy. For Canada and Sweden the note is: Data pertain to women who have ever had sex. For Sweden the note is: Data pertain to methods used at last sex. For United Kingdom the note is: Excluding Northern Ireland. For Jamaica and United Kingdom the note is: Including emergency contraception. For Uruguay the note is: Data pertain to men and women of reproductive age who are married or in a union. For Bahrain, Kuwait, Oman, Qatar, Saudi Arabia and United Arab Emirates the note is: Data pertain to nationals of the country. For Chile the note is: Data pertain to men and women of reproductive age. For Guyana, Lesotho, Maldives, Nauru, Sri Lanka, Tanzania and Timor-Leste the note is: Preliminary data. For Malaysia the note is: Data pertain to Peninsular Malaysia. For Korea, Republic of and Uruguay the note is: Estimate. For Sri Lanka the note is: Excluding the Northern Province. For South Sudan and Sudan the note is: Including data for Sudan and South Sudan (Sudan presecession). Proportion of women using hormonal contraception among those of reproductive age (15-49 years) who are married or in union. For Iran and Kuwait the note is: Data pertain to non-pregnant women. United Nations, Department of Economic and Social Affairs, Population Division (2011). World Contraceptive Use 2010 (POP/DB/CP/Rev2010) (

122 5 FACTORS CONTRIBUTING TO CERVICAL CANCER (LAST UPDATE 27 ENE 2014) Figure 75: Prevalence of HIV in the World Estimates include all people with HIV infection, regardless of whether they have developed symptoms of AIDS. For Afghanistan, Algeria, Angola, Argentina, Armenia, Australia, Austria, Azerbaijan, Bahamas, Bangladesh, Barbados, Belarus, Belgium, Belize, Benin, Bhutan, Bolivia, Botswana, Brazil, Bulgaria, Burkina Faso, Burundi, Cambodia, Cameroon, Canada, Cape Verde, Central African Republic, Chad, Chile, China, Colombia, Comoros, Congo, Costa Rica, Côte d Ivoire, Croatia, Cuba, Czech Republic, Denmark, Djibouti, Dominican Republic, Ecuador, Egypt, El Salvador, Equatorial Guinea, Eritrea, Estonia, Ethiopia, Fiji, Finland, France, Gabon, Gambia, Georgia, Germany, Ghana, Greece, Guatemala, Guinea, Guinea-Bissau, Guyana, Haiti, Honduras, Hungary, Iceland, Indonesia, Iran, Ireland, Israel, Italy, Jamaica, Japan, Kazakhstan, Kenya, Korea, Republic of, Kyrgyzstan, Laos, Latvia, Lebanon, Lesotho, Liberia, Lithuania, Luxembourg, Madagascar, Malawi, Malaysia, Maldives, Mali, Malta, Mauritania, Mauritius, Mexico, Mongolia, Morocco, Mozambique, Myanmar, Namibia, Nepal, Netherlands, New Zealand, Nicaragua, Niger, Nigeria, Norway, Pakistan, Panama, Papua New Guinea, Paraguay, Peru, Philippines, Poland, Portugal, Republic of Moldova, Romania, Russian Federation, Rwanda, Sao Tome & Principe, Senegal, Serbia, Sierra Leone, Singapore, Slovakia, Slovenia, Somalia, South Africa, South Sudan, Spain, Sri Lanka, Sudan, Suriname, Swaziland, Sweden, Switzerland, Tajikistan, Tanzania, Thailand, Togo, Trinidad & Tobago, Tunisia, Turkey, Uganda, Ukraine, United Kingdom, United States of America, Uruguay, Venezuela, Viet Nam, Yemen, Zambia and Zimbabwe the source is: 2012 UNAIDS Report on the Global AIDS Epidemic ( For Albania, Bosnia & Herzegovina, Cyprus, Jordan, Libya, Macedonia, TFYR, Qatar, Saudi Arabia, Syria, Turkmenistan and United Arab Emirates the source is: Global report: UNAIDS report on the global AIDS epidemic 2008: Annex 1: HIV and AIDS estimates and data, 2007 and Available at:

123 6 REPRODUCTIVE AND SEXUAL BEHAVIOUR (LAST UPDATE 08 AGO 2013) Reproductive and sexual behaviour (last update 08 ago 2013) Sexual intercourse is the primary route of transmission of genital HPV infection. Information about sexual and reproductive health behaviours is essential to the design of effective preventive strategies against anogenital cancers. In this section, we describe sexual and reproductive health indicators that may be used as proxy measures of risk for HPV infection and anogenital cancers. Several studies have reported that earlier sexual debut is a risk factor for HPV infection, although the reason for this relationship is still unclear. In this section, information on sexual and reproductive health behavior in World is presented. Figure 76: Proportion of young women (15-24 years) who have had sex before the age of 15 in the World

124 7 HPV PREVENTIVE STRATEGIES HPV preventive strategies It is established that well-organised cervical screening programmes or widespread good quality cytology can reduce cervical cancer incidence and mortality. The introduction of HPV vaccination could also effectively reduce the burden of cervical cancer in the coming decades. In addition, male circumcision and the use of condoms have shown a significant protective effect against HPV transmission and may offer an alternative preventive strategy. This section presents indicators on basic characteristics and performance of cervical cancer screening, status of HPV vaccine licensure, introduction and country recommendations and the prevalence of male circumcision and condom use in World. 7.1 Cervical cancer screening practices (last update 30 jul 2013) Screening strategies differ between countries. Some countries have population-based programmes, where in each round of screening women in the target population are individually identified and invited to attend screening. This type of programme can be implemented nationwide or only in specific regions of the country. In opportunistic screening, invitations depend on the individual s decision or on encounters with health-care providers. The most frequent method for cervical cancer screening is cytology, and there are alternative methods such as HPV DNA tests and Visual inspection with acetic acid (VIA). VIA is an alternative to cytology-based screening in low-resource settings ( see and treat approach). HPV DNA testing is being introduced into some countries as an adjunct to cytology screening ( co-testing ) or as the primary screening test to be followed by a secondary, more specific test, such as cytology. Table 24: Cervical cancer screening policy in the World Screening Screening Screening HPV Country name type ages (years) interval VIA DNA test (years) Africa Algeria No visual inspection Angola Pilot Benin Pilot Botswana Pilot Burkina Faso Pilot Burundi No visual inspection Cameroon Pilot Cape Verde No visual inspection Central African Republic No visual inspection Chad No visual inspection Comoros No visual inspection Congo Pilot Congo, DR No visual inspection Côte d Ivoire Pilot Djibouti No visual inspection Egypt No visual inspection Equatorial Guinea No visual inspection Eritrea No visual inspection (Continued)

125 7 HPV PREVENTIVE STRATEGIES Table 24 Continued Screening Screening Screening HPV Country name type ages (years) interval VIA DNA test (years) Ethiopia Pilot Gabon No visual inspection Gambia Pilot Ghana Pilot Guinea Pilot Guinea-Bissau No visual inspection Kenya National Lesotho Pilot Liberia No visual inspection Libya No visual inspection Madagascar Malawi - - Pilot - - National Mali Pilot Mauritania Pilot Mauritius No visual inspection Swaziland No visual inspection Tanzania - - National Togo Pilot Tunisia No visual inspection Uganda Non-populationbased Non-populationbased Morocco National Mozambique National Namibia Pilot Niger Pilot Nigeria Non-populationbased - - Pilot Rwanda National Pilot Sao Tome & Principe No visual inspection Senegal Pilot Seychelles No visual inspection Sierra Leone Pilot Somalia No visual inspection South Africa Non-populationbased >= Pilot South Sudan No visual inspection Sudan Pilot Non-populationbased Non-populationbased - - National Pilot (Continued)

126 7 HPV PREVENTIVE STRATEGIES Table 24 Continued Screening Screening Screening HPV Country name type ages (years) interval (years) VIA Western Sahara No visual inspection Zambia DNA test - - National Zimbabwe Pilot Americas Antigua & Barbuda No visual inspection Argentina Every 3 years after 2 consecutive annual negative smears (1-1-3) 3 No visual inspection Pilot program 4 Bahamas No visual inspection Pilot program 4 Barbados No visual inspection Belize No visual inspection Bolivia Brazil Non-populationbased Non-populationbased Non-populationbased Non-populationbased Canada Population-based >=18 (Northwest Territories, Yukon, Nunavut, Newfoundland, Nova Scotia);18-69 (Quebec, Alberta, British Columbia);20-69 (Prince Edward Island, Ontario) 8 Chile Colombia Costa Rica Cuba Non-populationbased (organized in some regions) Non-populationbased Non-populationbased Non-populationbased Every 3 years after 2 consecutive annual negative smears (1-1-3) 3 National No visual inspection Pilot program 4 Every 2 years after 3 normal annual smears; Annual if at high-risk; Annual in Alberta 8 No visual inspection Pilot program No visual inspection Pilot program National Pilot No visual inspection National program 4 Dominica No visual inspection Dominican Republic Ecuador El Salvador (months) 3 No visual inspection Pilot program No visual inspection National Pilot Non-populationbased Non-populationbased Non-populationbased Grenada Pilot Guatemala Non-populationbased National Guyana National (Continued)

127 7 HPV PREVENTIVE STRATEGIES Table 24 Continued Screening Screening Screening HPV Honduras Jamaica Mexico Nicaragua Panama Paraguay Pilot - - No visual inspection >=25 3 Every 3 years after 2 consecutive annual negative smears (1-1-3) Every 3 years after 3 consecutive annual negative smears ( ) 3 No visual inspection National National Pilot >= National Every 3 years National Pilot after 3 consecutive annual negative smears ( ) National Pilot St Lucia Pilot St Vincent & The Grenadines No visual inspection Suriname National Trinidad & Tobago United States of America Uruguay Venezuela Every 3 years after 2 consecutive annual negative smears (1-1-3) 3 No visual inspection No visual inspection National > No visual inspection Pilot program No visual inspection Pilot program 4 Asia Country name type ages (years) interval VIA DNA test (years) Haiti Non-populationbased - - Pilot Non-populationbased Non-populationbased Non-populationbased Non-populationbased Non-populationbased Non-populationbased Peru Non-populationbased St Kitts & Nevis No visual inspection Non-populationbased Non-populationbased Non-populationbased Non-populationbased Afghanistan No visual inspection Armenia Non-populationbased No visual inspection Azerbaijan No programme - - No visual inspection Bahrain No visual inspection Bangladesh National Bhutan Pilot Brunei No visual inspection Cambodia National China National Pilot (Continued)

128 7 HPV PREVENTIVE STRATEGIES Table 24 Continued Screening Screening Screening HPV Country name type ages (years) interval (years) Cyprus Georgia India Non-populationbased Non-populationbased (organized in 1 region) Non-populationbased VIA DNA test - - No visual inspection No visual inspection Pilot Pilot Pilot Indonesia National Iran No visual inspection Iraq No visual inspection Israel No visual inspection Japan Population-based >= No visual inspection Jordan No visual inspection Kazakhstan Non-populationbased (call-recall system in few regions on unregular basis) No visual inspection Korea, DPR No visual inspection Korea, Republic of National Health insurance Corp. (NHIC) >= No visual inspection Kuwait No visual inspection Kyrgyzstan No visual inspection Laos No visual inspection Lebanon No visual inspection Malaysia Non-populationbased No visual inspection Maldives Pilot Mongolia No visual inspection Myanmar Pilot Nepal Pilot Oman No visual inspection Pakistan No visual inspection Palestine No visual inspection Philippines National Qatar No visual inspection Saudi Arabia No visual inspection Singapore Every 3 years after 2 consecutive annual negative smears (1-1-3) 12 No visual inspection Sri Lanka No visual inspection (Continued)

129 7 HPV PREVENTIVE STRATEGIES Table 24 Continued Screening Screening Screening HPV Country name type ages (years) interval (years) VIA Syria No visual inspection Tajikistan Thailand No visual inspection DNA test National Uzbekistan Non-populationbased Non-populationbased Timor-Leste No visual inspection Turkey Non-populationbased 18 to no limit Pilot Pilot program 9 Turkmenistan Non-populationbased No visual inspection United Arab Emirates No visual inspection Non-populationbased (organized in some pilot regions) No visual inspection Viet Nam National Yemen No visual inspection Europe Albania No visual inspection Andorra Austria Belarus Belgium Bosnia & Herzegovina - - No visual inspection 18 to not 1 2 No visual inspection specified 2 18 to no limit No visual inspection No visual inspection 20 to no limit 2 Every 3 years after 3 consecutive annual negative smears ( ) 2 No visual inspection Finland Population-based (some counties 25-65) 10 France Germany Non-populationbased Non-populationbased Non-populationbased Non-populationbased Non-populationbased Bulgaria Non-populationbased No visual inspection Croatia Non-populationbased No visual inspection Czech Republic Population-based No visual inspection Denmark Population-based age: 3, No visual inspection age: 5 2 Estonia Population-based No visual inspection Non-populationbased (organized in some regions) Non-populationbased Non-populationbased Regional variation: From (20) 25 to not specified No visual inspection 3 2 No visual inspection 20 to not 1 2 No visual inspection Pilot specified No visual inspection Greece 20 to not specified 2 Hungary Population-based No visual inspection Iceland Population-based age: 2, 40-65(69) age: 4 2 (Continued) No visual inspection

130 7 HPV PREVENTIVE STRATEGIES Table 24 Continued Screening Screening Screening HPV Country name type ages (years) interval (years) VIA Ireland Population-based in age No visual inspection (regional but (5 for 45+ age) 2 nationwide planned) DNA test Italy Population-based No visual inspection Pilot Portugal Republic of Moldova Romania Russian Federation Russian Federation Latvia Population-based No visual inspection Liechtenstein No visual inspection Lithuania Population-based No visual inspection Luxembourg Non-populationbased 15 to not 1 2 No visual inspection specified 2 Macedonia, TFYR Non-populationbased No visual inspection Malta Non-populationbased - - No visual inspection Monaco No visual inspection Montenegro Non-populationbased No visual inspection Netherlands Population-based No visual inspection Norway Population-based No visual inspection Poland Population-based No visual inspection Population-based (some regions) Non-populationbased Non-populationbased (organized pilot in one region) Non-populationbased (call-recall system in few regions on unregular basis) Non-populationbased (call-recall system in few regions on unregular basis) No visual inspection 20 to no limit No visual inspection No visual inspection No visual inspection 18 to no limit No visual inspection San Marino No visual inspection Serbia Non-populationbased (organized in process of implementation) Non-populationbased (69) No visual inspection Slovakia No visual inspection Slovenia Population-based No visual inspection Spain Non-populationbased (organized in some regions) National No visual inspection Pilot Sweden Population-based age: 3, No visual inspection Pilot program age: 5 10 Switzerland Ukraine Non-populationbased Non-populationbased 20 to no limit No visual inspection No visual inspection (Continued)

131 7 HPV PREVENTIVE STRATEGIES Table 24 Continued Screening Screening Screening HPV Country name type ages (years) interval (years) VIA United Kingdom Population-based Regional 3 2 No visual inspection variation: From (20) 25 to (60) 64 2 DNA test Oceania Australia Population-based (under review) 6 No visual inspection Fiji No visual inspection Kiribati No visual inspection Marshall Islands No visual inspection Micronesia No visual inspection Nauru No visual inspection New Zealand Population-based No visual inspection Palau No visual inspection Papua New Guinea No visual inspection Samoa No visual inspection Solomon Islands No visual inspection Tonga No visual inspection Tuvalu No visual inspection Vanuatu Pilot 1 Cervical Cancer Action: a global Coalition to stop Cervical Cancer (CCa). Progress In Cervical Cancer Prevention: The CCA Report card. Update June 2013 [Accessed on July 2013], avaiable at The information represented there has been collected through interviews with individuals and organizations involved with the countries represented and has not been verified with individual Ministries of Health. Any versights or inaccuracies are unintentional. 2 Kesic V, Poljak M, Rogovskaya S.Cervical cancer burden and prevention activities in Europe. Cancer Epidemiol Biomarkers Prev Sep;21(9): Luciani S, Cabanes A, Prieto-Lara E, Gawryszewski V. Cervical and female breast cancers in the Americas: current situation and opportunities for action.bull World Health Organ. 2013;91(9): Murillo R, Almonte M, Pereira A, Ferrer E, Gamboa OA, Jerónimo J, Lazcano-Ponce E. Cervical cancer screening programs in Latin America and the Caribbean. Vaccine. 2008;26 Suppl 11:L Rogovskaya SI, et al. Human papillomavirus prevalence and type-distribution, cervical cancer screening practices and current status of vaccination implementation in Russian Federation, the Western countries of the former Soviet Union, Caucasus Region and Central Asia. Vaccine (2013), 6 Garland, S.M., Bhatla, N., Ngan, H.Y.S. Cervical cancer burden and prevention strategies: Asia oceania perspective (2012) Cancer Epidemiology Biomarkers and Prevention, 21 (9), pp Anttila A, von Karsa L, Aasmaa A, Fender M, Patnick J, Rebolj M, et al. Cervical cancer screening policies and coverage in Europe. Eur. J. Cancer Oct;45(15): Castle PE, de Sanjosé S, Qiao YL, Belinson JL, Lazcano-Ponce E, Kinney W. Introduction of human papillomavirus DNA screening in the world: 15 years of experience. Vaccine Nov 20;30 Suppl 5:F IARC Handbooks of Cancer Prevention Vol. 10: Cervix Cancer Screening. IARC Press. Lyon, Sander BB, Rebolj M, Valentiner-Branth P, Lynge E. Introduction of human papillomavirus vaccination in Nordic countries (2012) Vaccine, 30 (8): Abdullah F, Su TT. Enhancement of the cervical cancer screening program in Malaysia: a qualitative study. Asian Pac J Cancer Prev. 2010;11(5): Lee VJ, Tay SK, Teoh YL, Tok MY. Cost-effectiveness of different human papillomavirus vaccines in Singapore (2011) BMC Public Health, 11, art. no. 203.

132 7 HPV PREVENTIVE STRATEGIES HPV vaccination HPV vaccine licensure and introduction (last update 26 nov 2013) Figure 77: Licensure status of current HPV vaccines in the World For Afghanistan, Albania, Algeria, Andorra, Angola, Antigua & Barbuda, Argentina, Australia, Austria, Bahamas, Bahrain, Bangladesh, Barbados, Belgium, Belize, Benin, Bermuda, Bolivia, Bosnia & Herzegovina, Botswana, Brazil, Bulgaria, Burkina Faso, Burundi, Cambodia, Cameroon, Canada, Cape Verde, Cayman Islands, Central African Republic, Chad, Chile, China, Colombia, Comoros, Congo, Congo, DR, Cook Islands, Costa Rica, Côte d Ivoire, Croatia, Cuba, Cyprus, Czech Republic, Denmark, Djibouti, Dominica, Dominican Republic, Ecuador, Egypt, El Salvador, Equatorial Guinea, Eritrea, Estonia, Ethiopia, Finland, France, Gabon, Gambia, Germany, Gibraltar, Greece, Grenada, Guatemala, Guinea-Bissau, Guyana, Haiti, Honduras, Hong Kong SAR, Hungary, Iceland, India, Indonesia, Iran, Iraq, Ireland, Israel, Italy, Jamaica, Jordan, Kenya, Kiribati, Korea, DPR, Kuwait, Laos, Latvia, Lesotho, Liberia, Libya, Liechtenstein, Lithuania, Luxembourg, Macao SAR, Macedonia, TFYR, Madagascar, Malawi, Malaysia, Maldives, Malta, Marshall Islands, Mauritania, Mauritius, Mexico, Micronesia, Monaco, Mongolia, Montenegro, Morocco, Mozambique, Myanmar, Nauru, Nepal, Netherlands, New Zealand, Nicaragua, Niue, Norway, Oman, Pakistan, Palau, Panama, Papua New Guinea, Peru, Philippines, Poland, Portugal, Puerto Rico, Romania, Samoa, San Marino, Sao Tome & Principe, Saudi Arabia, Senegal, Serbia, Seychelles, Sierra Leone, Singapore, Slovakia, Slovenia, Solomon Islands, Somalia, South Africa, Spain, St Kitts & Nevis, St Lucia, St Vincent & The Grenadines, Sudan, Suriname, Swaziland, Sweden, Switzerland, Syria, Tanzania, Thailand, Timor-Leste, Togo, Tonga, Trinidad & Tobago, Turkey, Tuvalu, Uganda, United Arab Emirates, United Kingdom, United States of America, Uruguay, Vanuatu, Venezuela, Viet Nam, Yemen and Zimbabwe the source is: PATH, January 2011 [accessed on 2009]. For Armenia, Azerbaijan, Belarus, Georgia, Kazakhstan, Kyrgyzstan, Republic of Moldova, Russian Federation, Tajikistan, Turkmenistan, Ukraine and Uzbekistan the source is: Rogovskaya SI, et al. Human papillomavirus prevalence and type-distribution, cervical cancer screening practices and current status of vaccination implementation in Russian Federation, the Western countries of the former Soviet Union, Caucasus Region and Central Asia. Vaccine (2013), For Albania, Argentina, Australia, Austria, Bahamas, Bahrain, Barbados, Belgium, Bermuda, Bolivia, Bosnia & Herzegovina, Botswana, Brazil, Bulgaria, Burkina Faso, Cameroon, Canada, Cayman Islands, Central African Republic, Chad, Chile, Colombia, Congo, Congo, DR, Costa Rica, Côte d Ivoire, Croatia, Cyprus, Czech Republic, Denmark, Dominican Republic, Ecuador, Egypt, El Salvador, Equatorial Guinea, Estonia, Ethiopia, Finland, France, Gabon, Germany, Gibraltar, Greece, Guatemala, Honduras, Hong Kong SAR, Hungary, Iceland, India, Indonesia, Ireland, Israel, Italy, Jamaica, Jordan, Kenya, Korea, DPR, Kuwait, Latvia, Liechtenstein, Lithuania, Luxembourg, Macao SAR, Macedonia, TFYR, Malawi, Malaysia, Malta, Mauritania, Mauritius, Mexico, Montenegro, Morocco, Netherlands, New Zealand, Nicaragua, Norway, Pakistan, Panama, Peru, Philippines, Poland, Portugal, Puerto Rico, Romania, Saudi Arabia, Serbia, Singapore, Slovakia, Slovenia, South Africa, Spain, Sweden, Switzerland, Thailand, Togo, Trinidad & Tobago, Turkey, Uganda, United Arab Emirates, United Kingdom, United States of America, Uruguay and Viet Nam the source is: Quadrivalent: Merck & Co., Inc., Whitehouse Station, NJ, USA, March 2009 For Japan the source is: Garland, S.M., Bhatla, N., Ngan, H.Y.S. Cervical cancer burden and prevention strategies: Asia oceania perspective (2012) Cancer Epidemiology Biomarkers and Prevention, 21 (9), pp For Aruba, Australia & New Zealand, Bhutan, Brunei, Curaçao, Fiji, French Guiana, French Polynesia, Ghana, Guadeloupe, Guinea, Haiti, Japan, Korea, Republic of, Lebanon, Mali, Martinique, Mayotte, Namibia, New Caledonia, Niger, Nigeria, Paraguay, Qatar, Reunion, Rwanda, Sri Lanka, St-Martin (French part), St Pierre and Miquelon, Tunisia, Wallis & Futuna Islands and Zambia the source is: Gardasil (HPV Recombinant, Quadrivalent), Registrations status June Available at

133 7 HPV PREVENTIVE STRATEGIES Figure 78: Status of HPV vaccination programs in the World For Cyprus, Estonia, Finland, Hungary, Iceland, Lithuania, Poland and Slovakia the source is: European Centre for Disease Prevention and Control. Introduction of HPV vaccines in EU countries an update. Stockholm: ECDC; Available at For Afghanistan, Africa, Åland Islands, Albania, Algeria, Americas, Andorra, Angola, Anguilla, Antigua & Barbuda, Armenia, Aruba, Asia, Australia & New Zealand, Azerbaijan, Bahamas, Bahrain, Bangladesh, Barbados, Belarus, Belize, Benin, Bermuda, Bolivia, Bonaire, St Eustatius & Saba, Bosnia & Herzegovina, Botswana, British Virgin Islands, Brunei, Bulgaria, Burkina Faso, Burundi, Cambodia, Cameroon, Cape Verde, Caribbean, Cayman Islands, Central African Republic, Central America, Central Asia, Chad, Channel Islands, Chile, China, CIS, Colombia, Comoros, Congo, Congo, DR, Costa Rica, Côte d Ivoire, Croatia, Cuba, Curaçao, Czech Republic, Djibouti, Dominica, Dominican Republic, Eastern Africa, Eastern Asia, Eastern Europe, Ecuador, Egypt, El Salvador, Equatorial Guinea, Eritrea, Ethiopia, Europe, Europe PREHDICT, Faeroe Islands, Falkland Islands (Malvinas), French Guiana, French Polynesia, Gabon, Gambia, GAVI Countries, Georgia, Ghana, Greenland, Grenada, Guadeloupe, Guam, Guatemala, Guernsey, Guinea, Guinea-Bissau, Guyana, Haiti, Holy See, Honduras, Hong Kong SAR, India, Indonesia, Iran, Iraq, Isle of Man, Israel, Jamaica, Japan, Jersey, Jordan, Kazakhstan, Kenya, Korea, DPR, Korea, Republic of, Kuwait, Kyrgyzstan, Laos, Latin America & Caribbean, Least developed countries, Lebanon, Lesotho, Less developed regions, Liberia, Libya, Liechtenstein, Macao SAR, Madagascar, Malawi, Maldives, Mali, Martinique, Mauritania, Mauritius, Mayotte, Melanesia, Micronesia, Middle Africa, Monaco, Mongolia, Montenegro, Montserrat, More developed regions, Morocco, Mozambique, Myanmar, N Mariana Islands, Namibia, Nauru, Nepal, New Caledonia, Nicaragua, Niger, Nigeria, Niue, Norfolk Island, North America, Northern Africa, Northern America, Northern Europe, Oceania, Oman, Pakistan, Palestine, Papua New Guinea, Paraguay, Philippines, Pitcairn, Polynesia, Puerto Rico, Qatar, Republic of Moldova, Reunion, Samoa, Sao Tome & Principe, Sark, Saudi Arabia, Senegal, Serbia, Seychelles, Sierra Leone, Sint Maarten (Dutch part), Solomon Islands, Somalia, South-Central Asia, South-Eastern Asia, South Africa, South America, South Sudan, Southern Africa, Southern Asia, Southern Europe, Sri Lanka, St-Barthélemy, St-Martin (French part), St Helena, St Kitts & Nevis, St Lucia, St Pierre and Miquelon, St Vincent & The Grenadines, Sub-Saharan Africa, Sudan, Suriname, Svalbard & Jan Mayen Islands, Swaziland, Syria, Tajikistan, Tanzania, Thailand, Timor-Leste, Togo, Tokelau, Tonga, Transition countries, Transition countries of SE Europe, Trinidad & Tobago, Tunisia, Turkey, Turkmenistan, Turks & Caicos Islands, Tuvalu, Uganda, Ukraine, Uruguay, US Virgin Islands, Uzbekistan, Vanuatu, Venezuela, Viet Nam, Wallis & Futuna Islands, Western Africa, Western Asia, Western Europe, Western Sahara, World, Yemen, Zambia and Zimbabwe the source is: Cervical Cancer Action, June 2013 [accessed on July 15th 2013], available at The information represented here has been collected through interviews with individuals and organizations involved with the countries represented and has not been verified with individual Ministries of Health. Any versights or inaccuracies are unintentional. For Argentina, Australia, Austria, Belgium, Bhutan, Canada, Cook Islands, Denmark, Fiji, France, Germany, Gibraltar, Greece, Ireland, Italy, Kiribati, Latvia, Luxembourg, Macedonia, TFYR, Malaysia, Malta, Marshall Islands, Mexico, Micronesia, Netherlands, New Zealand, Norway, Palau, Panama, Peru, Portugal, Romania, Rwanda, San Marino, Singapore, Slovenia, Spain, Sweden, Switzerland, United Arab Emirates, United Kingdom and United States of America the source is: Markowitz LE, Tsu V, Deeks SL, Cubie H, Wang SA, Vicari AS, Brotherton JM. Human papillomavirus vaccine introduction the first five years. Vaccine Nov 20;30 Suppl 5:F For Iceland the source is: Health Ministry of Iceland (august 2012). HPV vaccination. Available at: For Brazil the source is: WHO vaccine-preventable diseases: monitoring system global summary. Available at: Last updated 20-Octl-2013 (data as of 16-Oct-2013); next overall update June For Russian Federation the source is: Kesic V, Poljak M, Rogovskaya S. Cervical cancer burden and prevention activities in Europe. Cancer Epidemiol Biomarkers Prev Sep;21(9):

134 7 HPV PREVENTIVE STRATEGIES Table 25: HPV vaccination policy in female population in the World Routine Immunization Catch-up campaigns Country Date of start Target age 3-dose HPV%(period) Age group Argentina Australia % (2009) Austria Belgium % (2010) Belize Bhutan Brazil Brunei Bulgaria No catch-up programme Canada Varies by province: 50%-86% 14-26, Varies by province Central African Republic Colombia Croatia Czech Republic No catch-up programme Denmark % (2010) Fiji France (2012) Georgia Germany Greece Guyana Iceland No catch-up programme Ireland Israel (School grade 8) - - Italy % (2009) depending on the region Japan Kiribati Latvia (2011) No catch-up programme Lesotho Libya Luxembourg % (2009) Macedonia, TFYR % (2011) Malawi Malaysia Malta Marshall Islands Mexico % (2010) - Micronesia Monaco Mozambique Netherlands New Zealand % (2010) Norway % (2011) - Palau Panama % (2010) - Paraguay Peru Portugal % (2009) 17 Republic of Moldova Romania <5% (Continued)

135 7 HPV PREVENTIVE STRATEGIES Table 25 Continued Routine Immunization Catch-up campaigns Country Date of start Target age 3-dose HPV%(period) Age group Russian Federation Rwanda In year 2 and 3, primary school 6 and secondary school 3 (9th school year) San Marino Singapore Slovenia % (2010) - Spain % (2009) - Suriname Sweden Switzerland Togo Trinidad & Tobago Uganda United Arab Emirates % (2011) United Kingdom % (2009) United States of America % (2010) Zimbabwe

136 7 HPV PREVENTIVE STRATEGIES Male Circumcision and condom use (last update 30 sep 2013) Figure 79: Prevalence of male circumcision in the World Data from Demographic and Health Surveys (DHS) and other publications to categorize the country-wide prevalence of male circumcision as <20%, 20-80%, or >80%. World Health Organization, Department of Reproductive Health and Research and Joint United Nations Programme on HIV/AIDS (UNAIDS). Male circumcision: global trends and determinants of prevalence, safety and acceptability Available from: