233 Prevalence of Human Papillomavirus a Sexually Takeyoshi Infection Transmitted in Women Disease Attending Clinic KUBOTA1), Kazuhisa ISHI2), Masaaki SUZUKI3), Sakae UTSUNO1) and Jun IGARF2) 1)Department of Obstetrics 2)Department and Gynecology, Juntendo of Clinical Pathology, Juntendo 3)Department of Obstetrics and Gynecology, (Received: sexually transmitted Juntendo University, School ofMedicine Urayasu October8, (Accepted: Key words: University, Ichikawa UrayasuHospital City Hospital 1998) January25, 1999) diseases, human papillomavirus capture HPV DNA assay, cervical intraepithelial (HPV), hybrid neoplasia Abstract The purpose of this study was to determine (HPV) types of high and intermediate cervical neoplasia. The subjects (STD) clinic in a metropolitan the prevalence of infection due to human papillomavirus oncogenic risk, which was mostfrequently were236prostitutes who visited area in1998. Another95women a sexually associated with uterine transmitted diseases who visited a university hospital were se- lected as a normal control group. A swab sample collected from the uterine cervix and external subjected to hybrid capture assays for low-oncogenic-risk HPV types(HPV 43and44) and high- and intermediate-oncogenic-risk 45, 51, 52, 56, 58, 59 and68), HPV types A; including types6, 11, 42, including16, 18, 31, 33, 35, 39, Chlamydia trachomatis and Neisseriagonorrhoeae. Fisher's exact test was used for statistical analyses. Among the microorganisms tested, the positive rate for HPV B was the highest both in the women attending the STD clinic (STD group) HPV B in the STD group was47.5%(112of236), in the control group (HPVB; os was (p<0.0001). and in the control group. The positive rate for and this was significantly higher than the5.3%(5of95) These findings suggest that HPVexamination is recommended for women who visit an STD clinic to assess the future risk of cervicalneoplasia. Introduction High-and intermediate-oncogenic-risk ciated with uterine cervical intraepithelial type human papillomavirus neoplasia (HPV) are most frequently (CIN) and invasive cervical cancer1.2) Using the hy- brid capture assay, we3) previously detected HPV DNA of high- and intermediate-oncogenic-risk 13.9%(23of169) of samples from women with Pap smear Class I or II,and70.6%(48of68) with Pap smear Class III, IV or V (p<0.0001). We also detected women with no evidence of cervical intraepithelial Correspondence Department to: Takeyoshi of Obstetrics 279-0021, Chiba, Japan 平成11年3月20日 KUBOTA, and Gynecology, asso- HPV DNA in29.0%(18of62) types in of samples of the neoplasia and 78.6% (44of56) in those with cervical in- M. D. Juntendo University, Juntendo Urayasu Hospital, 2-1-1Tomioka, Urayasu-city, Takeyoshi 234 traepithelial KUBOTA lesions or cervical cancer (p<0.0001). with chlamydial and gonococcal infections4), et al Since HPV infection occurs frequently in conjunction examination of HPV DNA is recommended Chlamydia trachomatis and Neisseria gonorrhoeae in patients suspected gated the prevalence of HPV infection together tients who visited a Sexually transmitted tween subjects disease June known. and Their group (STD) age 1.0ml from17to73years for cervix hybrid and external of preserving Hybrid two types, intermediate-oncogenic-risk were Briefly, zation. The RNA hybrid with alkaline the and and value Fisher's The another RNA-DNA index value were sample 33, of the 35, 39, probes (RNA) of 52, the two detected by value/positive 56, was added coated 58. for with 59and hybridi- anti-DNA- mixture value) high- in previous conjugated chemoluminescence. control HPV microorgan- explained hybridantibody for low-oncogenic- 51, probe us- B, detects 45, a microplate containing kit for as across performed detects designated manufacture acid surface tube capture A, mixture, anti-DNA-RNA hybrids (test the annual selected. stick were hybrid designated respective a ribonucleic onto was a Dacron gonorrhoeae 18, 31, the V. collection .The probe directions and with mixture, other un- Gynecology, an and with a specimen USA) types16, to the a swab Neisseria Maryland, contained captured reacted and including denatured were into assayed. were A control and IV be- (mean•}SD). wiping it was The gonorrhoeae was hybrids if the types, N. firmly probe women March1998for of37.0•}12.2years trachomatis One the area (mean•}SD). Classes IIIa, IIIb, placed 43and44. according specimen phosphatase. positive mixtures. of 4.9years October1997and by Diagnostics. 11, 42, performed antibodies, index probe HPV DNA-RNA considered (Digene types6, C. trachomatis assays reports3.5). the including for The Kits until in a metropolitan findings of29.1•} smear immediately Chlamydia clinic DepartmentofObstetrics between age STD cytological the obtained at-80•Ž HPV, an age visited a mean were was stored for HPV and isms. and separate HPV kits swab The Assay risk 68. The os. assays Capture contained assays The Papanicolaou with capture fluid capture Hybrid with visited a mean who in pa- Methods checkup. University, those of STD. For this reason we investi- clinic. who with Juntendo excluding ranged Samples STD women Hospital, checkup, Their an from18to48years of95consecutive Urayasu routine ing ranged and prostitutes September1998for age consisting Juntendo the were236consecutive with with that of chlamydial infection and gonorrhea Materials The together Samples was1.0, and were negative if was<1.0. exact test was used for statistical analyses. A p value less than0.05was considered signifi- cant. Results In the STD, intermediate-risk tive for for HPV were negative HPV (HPV B), B alone, C. trachomatis of less 98women The for HPV positive 14for alone, than4women. positive types In B alone. rate for both HPV and 4 for the control The HPV A, C. 86women patterns the B, 12for B and group, in all4probes C. trachomatis, A and HPV other B for consisted STD group [low-risk and HPV N. gonorrhoeael. were of less was47.5% The HPV other negative ( HPV Seventy-four C. trachomatisand trachomatis. types B. (112of236),and high-and women were HPV A alone, 11for patterns of detection forall4probes. than4subjects A), Four posi10 consisted women were (Table1). this 感染症学雑誌 was significantly 第73巻第3号 Prevalence Table1•@ cervix Results in of women hybrid capture attending an of HPV infection assays STD Comparison gonorrhoeae ―posltlve HPV of between results higher than the5.3%(5of95) HPV types positive women of hybrid A: low-oncogenic-risk HPV B: high-and HPV, C. trachomatis and 235 N. gonorrhoeae in the uterine clinic HPV A: low-oncogenic-risk HPV types HPV B: high-and intermediate-oncogenic-risk Table2•@ for in STD clinic HPV rates attending capture for an assays HPV, STD C. clinic performed trachomatis and and women control on cervical N. samples. types intermediate-oncogenic-risk HPV types in the control group (p<0.0001)(Table2). The positive rates for the other 3probes were also significantly higher in the STD group than in the control group. Among the microorganisms in control groups (Table2). 平成11年3月20日 tested, the positive rate for HPV B was the highest in both the STD and There were no differences in the positiverate for HPV B among different age 236 Takeyoshi Table3•@ of HPV Relationship HPV types) B between age and positive (high-and intermediate-oncogenic-risk in attending women an STD KUBOTA et al Table4•@ rate prostitute and between positive intermediate-oncogenic-risk clinic uterine groups in the STD group (Table3). Relationship cervix However, a significant differencein depended on the length of time the woman had been a prostitute rate length for HPV HPV in women attending of tine B (high-and types) an STD as in a the clinic the positive rate for HPV B which was observed (Table4). Discussion A high detection rate of HPV in women attending STD clinics has been noted. Horn et al (1991) 6reported that52% of116such women in Maryland, USA were judged to be infected with HPV by at least one of the three criteria: the presence of genital warts, cytopathlogic evidence of HPV in Papanicolaou smear, and the presence of HPV DNA in Southern hybridization analysis of cervical scrapings. However, when Southern hybridization alone was used, the prevalence was12% for HPV DNA in cervical scrapes. Borg (1993) 7)analyzed377women who visited an Australian STD clinicand detected HPV DNA (types 6, 11, 16, 18, 31, 33and35) in12% of ectocervical samples using Dotblot hybridization. Figueroa et al (1995) 8)studied the prevalence of HPV among202STD clinic patientsin Jamaica by performing Southern blot hybridization on cervical and vaginal cell samples, and identified58 (28.7%) women as HPV positive. In the present study, we were able to compare the HPV detection rate between a group of women attending an STD clinic (STD group) and a normal control group, which was not explicitly reported in the past studies. The HPV B detection rate in the STD group was47.5%(112of236), and this was significantly higher than the rate of5.3%(5of95) in the control group (p<0.0001). When low-risk HPV type and/or high- and intermediate-risk HPV type STD clinic patients were calculated, the proportion was52.5 %(124/236), which is in agreement with Horns' prevalence rate of52%. The purpose of this study was to compare the prevalence of HPV B infection between a group of women attending an STD clinic (prostitutes) and a normal control group. For the normal control, we selected95consecutive women who visited the University Hospital for an annual routine checkup, excluding those with Papanicolaou smear Classes IIIa, IIIb, IV and V. If those with Papanicolaou smear Classes IIIa, IIIb, IV and V were included, there were100consecutive women (including4patients with Class Ma who were negative for HPV A. HPV B, C. trachomatis and N. gonorrhoeae,and1patient with Class V who was positive for HPV B and negative for HPVA, C. trachomatis and N. gonorrhoeae). The positiverate for HPV B in the prostitutes was 47.5%(112of236), and this was also significantly higher than the 6.0%(6of100) in the100of consecutive women who visited the University Hospital (p<0.0001). 感染症学雑誌第73巻第3号 Prevalence of HPV infection in STD clinic 237 HPV infection occurs frequently in conjunction with chlamydial and gonococcal infections4). In the presert study, the presence of these three microorganisms in a subject could easily be investigated from one cervical swab sample using hybrid capture assays. Using these assays, the positive rates for HPV A, HPV B, C. trachoniatis and N. gonorrhoeaewere significantly higher in the STD group than in the control group. Among the four microorganisms, the positive rate for HPV B was higher than those of the other three. This was more prominent in the STD group than in the control group. Ichinose9)reported that the positive rates for C. trachornatisand N. gonorrhoeaein Japanese patients who visited ordinal gynecologic clinics in Tokyo with any symptoms suspected of STD were10.4% (1987-1997, n=50,535, by either enzyme immunoassay or DNA probe method) and3.7%(1992-1997, n=5,872, by DNA probe method), respectively. Compared to these results, in our study the positive rates in the control group (4.2% for C. trachomatisand0% for N. gonorrhoeae) were lower and the positive rates in the STD group (13.6% for C. trachomatisand5.1% for N. gonorrhoeae) were higher. Therefore, our results are reasonable. Previous studies have reported an age-dependent difference in HPV prevalence. According to the results of a Finnish nationwide cervical cancer screening study conducted between1981and1989 (reported 1991)10), the highest prevalence (6.1%) of genital HPV infection detected by cervicovaginal Papanicolaou smears was observed in women aged between20and29years, followed by2.2% in those aged30-39 years. Figueroa et al (1995)8)reported an HPV prevalence of39% in women15-19years old, 33% in women20-24years old, 31% in women25-29years old, and17% in those30years or older. In the control group in this study, the positive rate of HPV B in women aged under30years (n=35) was14.3%, and no women over30 (n=60) years were positive. Figueroa et al stated that the decrease in HPV prevalence in older women, which agrees with other studies, may be due to a biological effect, such as increased immunity to HPV with age. While a decrease in HPV prevalence in older women has been noted in other studies, our data showed no difference in the positive rate of HPV B among different age groups in the STD group [51.2%(70/136) in20to29year-olds, 44.8%(43/96) in30to39year-olds; p=0.4224]. These findings suggest that the prostitutes in our sample remain at high risk of acquiring HPV, even as they get older. Furthermore, our finding that women who have worked for a long period of time as a postitute are associated with a significantly higher prevalence of HPV B [within1year, 34.5%(19/55); more than1 year; 51.4%(93/181): p=0.0316] may support this hypothesis. The present findings suggest that HPV examination is recommended for women who visit STD clinics to assess the future risk of CIN and cervical cancer. References 1) TrofatterKFJr: Diagnosisof humanpapillomavirus genitaltract infection. AmJ Med1997;102: 21-27. 2) Sun XW,FererczyA,JohnsonD et al.: Evaluationof the HybridCapturehumanpapillomavirus deoxyribonucleic acid detectiontest. AmJ ObstetGynecol1995;173: 1432-1437. 3) KubotaT, IshiK,SuzukiMet al.: Usefulnessof hybridcaptureHPVDNAassay as a diagnostictoolfor humanpapillomavirusinfection. J J A Inf D 1998; 72 : 1219-1224. 4) FurugenY, UtsunoS, SuzukiM,KubotaT, TakadaM: Superinfections and problemsin treatmentof STDhighrisk group.LASTD1991;14: 190-195. 5) Ishiet al.: Usefulnessof hybrid-captureHPVDNAdetectionkit for the diagnosisofHPVinfection. JpnJ MedPharmSci 1998;38: 849-853. 6) HornJE, McQuillan GM,ShanKVet al.: Genitalhumanpapillomavirus infectionsin patientsattendingan inner-city STDclinic.SexTransmDis1991; 18: 183-187. 平成11年3月20日 238 Takeyoshi KUBOTA et al 7) Borg AJ, Medley G, Garland SM: Prevalence of HPV in a Melbourne female STD population: comparison of RNA and DNA probes in detecting HPV by dot blot hybridization. Int J STD AIDS 1993; 4: 159-164. 8) Figueroa JP, Ward E, Luthi TE et at.: Prevalence of human papillomavirus among STD clinic attenders in Jamaica: association of younger age and increased sexual activity. Sex Transm Dis1995; 22: 114-118. 9) Ichinose M, Kobayashi Y. Matsuda S. Ando S, Oh K: Prevalence of Chlamydia trachomatisand Neisseriagonorrome in gynecologic patients in Tokyo (1987-1997).(in Japanese) JASTD1998; 9: 42. 10) Syrjathaen K, Yliskoski M, Kataja V et al.: Prevalence of genital human papillomavirus infections in a mass-screened Finnish female population aged20-65years. Int J STD AIDS1990; 1: 410-415. STDクリニック受診例におけるHuman papillomavirus感染の蔓延状況 1)順天堂大学医学部附属順天堂浦安病院産婦人科 ,2)順天堂大学医学部臨床病理, 3)浦安市川市民病院産婦人科久保田武美1)石要和久2)鈴関連深い高度・中等度risk typesのHPVに感染の蔓延状況を知ることである.対来受診者)95例とcontrol群(通である.両過物を採取し,DNA診正明3)宇栄1)猪狩淳2) た.HPVBのよるロール群いずれの群においても最も高率であっ象はSTD 常の婦人科外群ともに,子宮頸部擦断法であるhybrid capture た.STD 陽性率はSTD 直接法を用い最も clinic受 clinic受診群,コ診群とcontrol群の検出率はそれぞれ47.5%,5.3%でを認めた(p<0.00001).STD ては,子法を利用して,HPVの6,11,42,43,44型(HPV HPVの A),16,18,31,33,35,39,45,51,52,56,58,59,68 れた. 型(HPVB)お津野の検出を試みた.分析にはFisherの旨この研究の目的は子宮頸部のneoplasiaと clinic受診例236例木ントでのHPVB あり有意差 clinic受診者におい宮頸部悪性病変のリスクを知るために検査を施行する意義のあることが示唆さよびC.trahomatis,N.gonorrhoeae 感染症学雑誌第73巻第3号