Human papillomavirus

HPV

  • Overview
  • In Depth
  • Vaccines
  • Video

Human papillomaviruses (HPV) are common sexually transmitted viruses that can cause many types of cancer and other illnesses like genital warts.

HPV can spread through skin to skin contact as well as sexual intercourse. The Ministry of Health information pamphlet Immunise against HPV (code HE2012) is available from www.healthed.govt.nz. The pamphlet is also available electronically in Chinese Simplified, Chinese Traditional, Cook Islands Māori, Hindi, Māori, Sāmoan, and Tongan.

A brief history

There are more than 100 types of HPV, at least 13 of those are types known to cause cancer. HPVs are common viruses that can infect the skin and mucous membranes. They are grouped into high-risk and low-risk types based on how likely chronic infection is to cause cancer.

About four out of five people are infected with HPV at some time in their lives, usually within the first two years of commencing sexual activity. High-risk HPV-types (16, 18, 31, 33, 45, 52, and 58) have been implicated in around 83–90% of anogenital cancers (anal, cervical, vaginal, vulval, and penile), and around 94% of HPV positive oropharyngeal cancers. The absolute numbers of HPV-related cancers are low when you consider that most people are infected with HPV within the first two years of sexual activity.

Infection with low-risk HPV-types can cause warts such as palmar, plantar or genital warts. Although the virus is never cleared, infection with low-risk HPV-types does not usually lead to cancer. Types 6 and 11 cause approximately 90% of genital warts and are also known to cause respiratory papillomatosis (warty growths on the throat or vocal cords).

Most people infected with a high-risk HPV-type clear the virus around 18 months after being infected, reinfection is possible. Some people will develop a persistent infection that may cause cell changes, which if not detected and treated can cause cancers such as laryngeal, cervical or anal cancer.

NZ Situation

There is no current information in New Zealand to show the percentage of people infected with HPV.

In a study of more than 2,000 women in the Wellington area, over a 9 month period between 1989-1990, 10.9% tested positive for HPV.

Every year in New Zealand around 160 women are diagnosed with cervical cancer and around 60 die from the disease. Many other women have abnormalities in the cells of their cervix which are detected by cervical screening. These require invasive treatment to prevent the development of cancer. In New Zealand cervical cancer is the third most common cause of cancer in women aged 25-44 years. There are significant disparities with rates 2-3 fold higher for Māori.

Symptoms

Some HPV types cause warts but do not lead to cancers. Other HPV types cause no obvious infection at the time, but can persist in cells of the genital tract.

If left undetected, HPV can lead to cervical cancer as well as other cancers affecting the mouth, throat, vulva, vagina, cervix, penis and anus. It takes usually about 10-20 years from infection to the development of cancer.

Symptoms of genital warts include raised or flat bumps in the genital areas described as soft, moist or flesh coloured and often taking a cauliflower shape.  These can appear in the weeks or months following infection. In women, warts can appear on the vulva, areas inside or surrounding the vagina, cervix and anus. In men, warts can appear on the scrotum, penis and area inside or surrounding the anus.

Symptoms of cervical cancer include bleeding or spotting between menstrual periods, bleeding or spotting after sexual intercourse, bleeding or spotting after menstrual periods have stopped (after menopause), unusual discharge from your vagina, persistent pain in your pelvis, or pain during sexual intercourse.

Individuals can be infected with HPV without showing any signs or symptoms.  For this reason, it is important for women to undergo regular Papanicolaou (Pap) cervical smear tests (every three years if no abnormalities are present).

How do you get it?

HPV is very contagious and sexual intercourse is not the only way to spread the virus. The virus can be spread through skin to skin contact, including orogenital contact, and through sexual intercourse. and from infected mothers to their newborn baby during the birth process.

Most HPV infections do not show any symptoms so most people do not know when they are infected. An infected person can still spread the virus to others even if there are no signs or symptoms of HPV infection.

What are the risks?

Many people with HPV infection will clear the virus without any complications.

  • About 25% of people with HPV infection will develop genital warts which can be uncomfortable and embarrassing.
  • Some types of HPV cause cancers including cancers of the mouth, throat, vulva, vagina, cervix, penis and anus.
  • Cervical cancer can spread to the bladder, intestines, lungs and liver and is ultimately fatal. Early detection is very important.
Who is the most at risk?

HPV is very common and most men and women will be infected at some point in their lives.

  • Individuals with multiple sexual partners are at higher risk for HPV.
  • In New Zealand, women over 40 years of age, and women who are Māori or Pacific are at higher risk for cervical cancer if they are infected with HPV.
  • Māori women are almost twice as likely to get cervical cancer and almost three times as likely to die from it compared to non-Māori women.
  • Women who smoke or take a birth control pill are at higher risk for cervical cancer if they are infected with HPV.
  • Additional risk factors include: early start of sexual activity, multiple sexual partners, women who don’t participate in regular cervical screening and smoking.
  • Having regular cervical smears can reduce a woman’s risk of developing cancer by 90%.
Treating the symptoms

There is no treatment for persistent HPV infection itself, however, there is treatment for abnormal or precancerous cervical cells caused by HPV and for genital warts. Treatment for abnormal, precancerous or cancerous cervical cells vary depending on the severity of the cell changes and include cauterisation (burning), laser surgery, cone biopsy or loop excision, hysterectomy, radiotherapy and chemotherapy.

Treatments for genital warts depend on the size, location, and severity of the warts and include creams and solutions that are applied directly onto the skin or infected area. Other types of treatment include burning, freezing, laser or surgical removal of warts. These treatments cannot prevent the genital warts from reappearing.

Preventing the disease from spreading

Use of condoms is recommended but cannot completely prevent the spread of HPV.

Having a Papanicolaou (Pap) cervical smear tests every three years (if no abnormalities are present) is the best way to detect changes to the cells of the cervix that may later lead to cancer.

Immunisation with the HPV vaccine is highly effective in  preventing infection with the most common HPV types.

Risk of disease vs. vaccine side effects
Human papillomavirus Effects of disease Side effects of vaccine

Human papillomaviruses (HPV) are common sexually transmitted viruses that can cause many types of cancer and other illnesses including genital warts and respiratory papillomatosis.

  • Genital warts.
  • Cancers of the mouth, throat, vulva, vagina, cervix, penis and anus.
Common side effects
  • Mild pain, redness and swelling around injection site.
  • Fainting – more common in adolescent girls
Uncommon side effects
Rare/very rare side effects
  • Severe pain and swelling at injection site.
  • Severe allergic reaction (anaphylaxis).

Human papillomaviruses (HPV) are a family of sexually transmitted viruses that cause cutaneous and genital warts and some cancers, most notably cervical cancer. HPV is the most common sexually transmitted infection (STI), it is easy transmissible, and it affects most men and women at some point in their lives. Many people clear HPV infections within 6-24 months, but certain strains can develop into genital warts or cancer.

HPV is present in the biopsies of more than 99% of cervical cancer specimens. During persistent infection with high-risk HPV-types, virus DNA may integrate with host cell DNA and cause cell changes, which if not detected and treated can become cancer cells.

As well as cervical cancer HPV can cause oropharyngeal cancer (mouth and throat), cancer of the vulva, vagina, penis and anus.

Recurrent respiratory papillomatosis (RRP) is caused by HPV infection of the respiratory tract. It is a rare disease. It is usually benign but papillomas can sometimes block the respiratory tract, and in a few cases can become cancerous. The majority of cases occur in children, probably contracted from the mother during birth (this is called vertical transmission of the virus). RRP is most often caused by HPV types 6 and 11.

Causative organism

Double helix DNA viruses that infect skin or mucosal cells.

Clinical signs, symptoms and complications

Around 98% of infections resolve with no problems. About 2%, however, are still present after five years.

Presentation can vary according to type, of which there are more than 100, for example:

  • Types 2 and 7 - common warts
  • Types 1, 2, 4 and 63 - plantar warts
  • Types 6, 11, 42, 44 and others - anogenital warts
  • Types 6, 7, 11 and 16 - oral papillomas (non-cancerous growth)
  • Types 6 and 11- throat papillomatosis
  • Types 16 and 18 - most common types causing cervical, genital and anal cancers
  • Type 16 - oropharyngeal (mouth and throat) cancers

“Low-risk” types  of HPV cause benign warts and verrucae.

Low-grade cervical dysplasias identified in Papanicolaou (Pap) cervical smear tests indicate productive HPV infection; most resolve spontaneously, probably the result of cell-mediated immune responses. A small percentage progress to cancer.

Cervical intraepithelial neoplasia (CIN) is another method of signifying atypical cellular findings on a Pap smear, which commonly is HPV caused.
CIN is categorised into CIN 1, 2, or 3, depending on the severity of the abnormality and the thickness of the abnormal cell layer.

“High-risk” type 16 is associated with approximately 50% of cervical cancers and type 18 another 20%.
HPV causes over 99% of cervical cancers, 90% of anal cancers, 40% of external genitalia cancers, 12% of oropharyngeal cancers, and at least 3% of oral cancers.

HPV types 6 and 11 cause about 90% of external warts in the anogenital area.
Penile/perineal/perianal intraepithelial neoplasia (PIN), atypical cellular findings in males, are categorised into PIN 1, 2, or 3, depending on the severity of the abnormality. These are precursor states for penile/perineal/perianal cancer.

Method of transmission

HPV is sexually transmitted and highly infectious, yet sexual intercourse is not required for transmission. HPVs can be spread through skin to skin contact, including orogenital contact.

Vertical transmission, or transmission from infected mother to newborn during birth is possible.

Public health significance

All sexually active people are susceptible to HPV infection.

  • By three years post the onset of sexual activity, up to two thirds of women have been asymptomatically infected.
  • Most people, male and female, will have had a genital HPV infection after 5 years of sexual activity.
  • Genital warts are not usually fatal but cause significant morbidity and substantial health care costs.
  • Ongoing infection, usually over many years can lead to cancer, although shorter time periods are also seen. Cervical cancer generally affects younger women in comparison to other cancers.
  • In 2008 it was estimated that worldwide there were 530,200 cases and 275,000 deaths annually from cervical cancer.
  • The current method of cervical cancer prevention worldwide involves identification of pre-malignant lesions by regular Papanicolaou (Pap) cervical smear tests.
New Zealand epidemiology

In 2004 there were 3822 new diagnoses of genital warts in males and females in sexual health clinics; population rates cannot be calculated. The age group most affected by genital warts is young adults aged 15−24 years. The number of new cases seen has increased over time, although some of the increase may represent changes in presentation at clinics rather than a change in incidence.

In considering options for timing an HPV vaccine for the immunisation schedule in New Zealand, it is useful to consider the results of the 2001 Youth Health Survey, which provides information on sexual behaviours. Among secondary school students in years 9 to 13, 17 percent of students aged 13 years reported they had had sexual intercourse, 33 percent of those aged 15 years, and 49 percent of students aged 17 years.

An Auckland study of 513 cervical swabs, mainly from women attending colposcopy clinics, found that 221 specimens (43 percent) were positive for HPV. Twenty-two different types of HPV were detected, and 14 were oncogenic types, representing 14 of the 18 known oncogenic types. Types 16, 18, and 31 were the most common detected, representing 39 percent, 10 and 10 percent of the oncogenic types found, respectively. The other 11 oncogenic HPV types ranged in prevalence from 7.4 to 0.6 percent.

New Zealand’s National Cervical Screening Programme, administered by the National Screening Unit of the Ministry of Health, became operational in 1991 and now achieves over 70 percent coverage of eligible women (ie, the 20–69 year age range). Over the past 10 years cervical screening has led to a 40 percent reduction in the incidence of invasive cervical cancer. However, incidence remains approximately twice as high among Mäori than among non Mäori women. Over the same period, mortality from cervical cancer has fallen about 60 percent. Again, ethnic inequalities remain, with mortality among Mäori still approximately 4 times that of non Mäori.

Both cervical cancer incidence and mortality have fallen dramatically in New Zealand (as in other developed countries) over the last decade, due to cervical screening however approx 160 New Zealand women are diagnosed with cervical cancer each year and on average 60 women die of the disease each year.

Prevention

Condom use is recommended but cannot completely prevent HPV transmission as other infected areas of skin may be exposed.

Regular Papanicolaou (Pap) cervical smear tests (every 3 years) are recommended to detect any abnormalities around the cervix caused by HPV infection.

Gardasil® and Gardasil® 9 are the HPV vaccines currently available in New Zealand that protect against genital warts strains (6 and 11) and cancer strains (Gardasil® - types 16, 18 and Gardasil® 9 - types 16, 18, 31, 33, 45, 52, 58).

A primary course of vaccine is recommended and funded for:

  • Eligible males and females* from 9 years to under 27 years of age with their family doctor or at school in year 8 with the public health nurses.

A fourth/booster vaccine dose is recommended and funded for:

  • Eligible males and females aged under 27 years who are post-chemotherapy.

* Non-resident males and females must be aged under 18 years to start a funded HPV vaccine course. They can go on to complete the course when aged 18 years or older.

* Resident males and females must be aged under 27 years to start a funded HPV vaccine course. They can go on to complete the course when aged 27 years or older.

 

Treatment

There is no treatment for HPV infection. Most HPV infections will clear without intervention.

Most genital warts clear up spontaneously over time. However, many people prefer to have them treated because they can be uncomfortable and/or unpleasant to look at. Treatments for genital warts include the application of chemicals, e.g., solutions and creams, cryotherapy (freezing the wart off), laser therapy and surgery. With the exception of surgery treatment of warts takes several applications/visits and may need a variety of approaches.

Treatment for cervical cancer means removing abnormal cells. In the early stages cauterisation (burning), laser surgery, cone biopsy or loop excision may be effective. In more severe cases hysterectomy,  the surgical removal of the uterus and cervix or removal of the uterus and about two centimetres of upper vagina and tissues around the cervix may be required. The ovaries, fallopian tubes and lymph nodes in the pelvis may also need to be removed. Radiation treatment may be used when a woman is not well enough for major surgery or if the cancer has spread into the tissues surrounding the cervix. Chemotherapy may also be used alone or in combination with radiation treatment.

Gardasil®

Human papillomavirus (HPV4)

Gardasil® protects against four types of human papillomavirus (HPV) infection. HPV types 6 and 11 cause anogenital warts and HPV types 16 and 18 can cause persistent infection leading to mouth, throat, cervical, vaginal, vulvar, penile and anal cancers. The Ministry of Health information pamphlet Immunise against HPV (code HE2012) is available from www.healthed.govt.nz. The pamphlet is also available electronically in Chinese Simplified, Chinese Traditional, Cook Islands Māori, Hindi, Māori, Sāmoan, and Tongan.

Gardasil® 9

Human papillomavirus (HPV9)

Gardasil® 9 protects against nine types of human papillomavirus (HPV) infection. HPV types 6 and 11 cause anogenital warts and HPV types 16, 18, 31, 33, 45, 52, 58  can cause persistent infection leading to mouth, throat, cervical, vaginal, vulvar, penile and anal cancers. The Ministry of Health information pamphlet Immunise against HPV (code HE2012) is available from www.healthed.govt.nz. The pamphlet is also available electronically in Chinese Simplified, Chinese Traditional, Cook Islands Māori, Hindi, Māori, Sāmoan, and Tongan.

Listed below are the available videos for this disease