Human Papillomavirus Prevalence and Type-Distribution, Cervical Cancer Screening Practices and Current Status of Vaccination Implementation in Central and Eastern Europe

Highlights

• Mean prevalence of HPV infection in 8610 women with normal cytology is 12.6%.

• HPV DNA was found in 86.6% of cervical cancers.

• The prevalence of HPV16/18 among HPV-positive cervical cancers was 87.5%.

• Seven countries have organized and 9 countries opportunistic cervical screening.

• Only 6 countries integrated HPV vaccination into national immunization programmes.

Abstract

We present a review of current cervical cancer screening practices, the implementation status of vaccination against human papillomaviruses (HPV) and available data concerning the burden of HPV infection and HPV type-specific distribution in 16 Central and Eastern European countries: Albania, Bosnia and Herzegovina, Bulgaria, Croatia, Czech Republic, Estonia, Hungary, Latvia, Lithuania, Montenegro, Poland, Romania, Serbia, Slovakia, Slovenia and the Former Yugoslav Republic (FYR) of Macedonia. Since published data were relatively scarce, two detailed surveys were conducted during August–October 2011 and in January 2013 to obtain relevant and updated information. The mean prevalence of HPV infection in 8610 women with normal cervical cytology from the region was 12.6%, with HPV16 being the most frequent HPV type. The overall HPV DNA prevalence in women with high-grade cervical lesions was 78.1%. HPV DNA was found in 86.6% of cervical cancers; the combined prevalence of HPV16/18 among HPV positive cases was 87.5%. The overall HPV DNA prevalence in genital warts and laryngeal papillomas was 94.8% and 95.2%, respectively, with HPV6 and HPV11 being the most frequent types. Opportunistic and organized cervical screening, mainly based on conventional cytology, is performed in nine and seven countries in the region, respectively, with the proposed age of the start of screening ranging from 20 to 30 years and the estimated coverage ranging from a few percent to over 70%. At least one of the current HPV prophylactic vaccines is registered in all Central and Eastern European countries except Montenegro. Only Bulgaria, Czech Republic, FYR Macedonia, Latvia, Romania and Slovenia have actually integrated HPV vaccination into their national immunization programme and currently provide routine vaccination free of charge to the primary target population. The key reasons for lack of implementation of HPV vaccination into the national immunization programme are high vaccine cost and negative public perception.

This article forms part of a regional report entitled “Comprehensive Control of HPV Infections and Related Diseases in the Central and Eastern Europe and Central Asia Region” Vaccine Volume 31, Supplement 7, 2013. Updates of the progress in the field are presented in a separate monograph entitled “Comprehensive Control of HPV Infections and Related Diseases” Vaccine Volume 30, Supplement 5, 2012.

Introduction

Central and Eastern Europe is a fairly diverse geographic region in which around 126 million of people currently live in 16 different countries. The burden of cervical cancer in this area is substantially higher than in the rest of Europe and, in certain countries, the incidence and mortality from cervical cancer are rising; yearly, about 14,300 women develop cervical cancer and 7200 die from the disease ([1] and see Bray F et al., Vaccine, this issue [2]). In the last two decades, the process of post-socialistic transition, taking place at a different pace in each country in the region, has significantly affected all health-associated issues and the political attitude towards health problems, including disease prevention in general and cervical cancer prevention, in particular.

In this paper, we provide a review of current cervical cancer screening practices and the implementation status of vaccination against human papillomaviruses (HPV) in 16 Central and Eastern European countries: Albania, Bosnia and Herzegovina, Bulgaria, Croatia, Czech Republic, Estonia, Hungary, Latvia, Lithuania, Montenegro, Poland, Romania, Serbia, Slovakia, Slovenia and the Former Yugoslav Republic of Macedonia (FYR). A similar review for other Eastern European countries is available in Rogovskaya SI et al., Vaccine, this issue [3]. Available data concerning the burden of HPV infection in targeted countries and the HPV type distribution in cervical cancer and its immediate precursors are presented. In addition, HPV prevalence and type distribution data are provided for two HPV vaccine-preventable benign tumours: genital warts and laryngeal papillomas, since this knowledge in our region is scarce.

Data for this study have been collected by a detailed review of published peer-reviewed literature through Medline/Pubmed, Web of Science, Scopus and Google Scholar without language and time limitations. The initial search was performed in May 2011 and repeated again in January 2013. The inclusion criteria for HPV prevalence and type distribution studies were: (i) at least 10 subjects with a clinical condition of interest, (ii) the use of Hybrid Capture^® 2 (HC2) (Qiagen Gaithersburg, Inc., MD, USA [previously Digene Corp.]) or polymerase chain reaction (PCR) for HPV detection and (iii) a detailed methodological description of HPV DNA detection and genotyping methods. Since published data concerning current cervical cancer screening practices and HPV vaccination implementation in the 16 targeted countries are relatively scarce, available only for a limited number of countries or out of date, two detailed surveys (with 59 and 28 questions, respectively) were conducted by the authors of this review during August–October 2011, updated in January 2013 and used as the main data source. Persons who provided data are listed in the Acknowledgements. Due to limited space, supplementary data can be found in the online version of this manuscript.