- Email: [email protected]
Evaluation of human papillomavirus DNA detection in samples obtained for routine Chlamydia trachomatis screening
G Model
ARTICLE IN PRESS
JCV 3232 1–4
Journal of Clinical Virology xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
Journal of Clinical Virology journal homepage: www.elsevier.com/locate/jcv
2
Q1
Evaluation of human papillomavirus DNA detection in samples obtained for routine Chlamydia trachomatis screening
3
Q2
Anna Söderlund-Strand a , Arne Wikström b , Joakim Dillner c,∗
1
4 5 6
a b c
Division of Laboratory Medicine, Department of Clinical Microbiology, Jan Waldenströms gata 59, 20502 Malmö, Sweden Department of Dermatovenereology, Karolinska University Hospital Solna, 171 76 Stockholm, Sweden Department of Laboratory Medicine, Karolinska Institutet, F56Huddinge, 14188 Stockholm, Sweden
7
8 19
a r t i c l e
i n f o
a b s t r a c t
9 10 11 12 13
Article history: Received 18 November 2014 Received in revised form 5 January 2015 Accepted 10 January 2015
14
18
Keywords: Human papillomavirus prevalence Human papillomavirus DNA detection Sampling technique evaluation
20
1. Background
15 16 17
21 22 23 24 25 26 27 28 29 30 31 32
Background: The costs and logistics involved in obtaining samples is a bottleneck in large-scale studies of the circulation of human papillomavirus (HPV), which are useful for monitoring and optimisation of HPV-vaccination programs. Residual samples obtained after screening for Chlamydia trachomatis could constitute a convenient, low-cost solution. Objectives: We evaluated HPV DNA detection and typing using (i) the residual samples routinely taken for C. trachomatis screening or (ii) the sample types used in large-scale phase III HPV vaccination trials (cervical, vulvar, labial, perineal, perianal, scrotal and penile shaft samples). Study design: Samples from 127 men and 110 women attending two sexual health clinics were analysed using PCR for HPV DNA, with typing using mass spectrometry. Results: The HPV DNA prevalence was 7.1% in male urine samples, but 57.3% in female urine/vaginal samples, which was even higher than the HPV prevalence found in cervical samples (54.1%). The sensitivity for HPV DNA detection in the urine/vaginal samples was 7.9% (95% CI 3.0–16.4) for men and 78.9% (95% CI 67.6–87.7) for women, using detection in any one of the reference samples as reference. With cervical samples as reference, the sensitivity was 89.3 % (95% CI 78.1–95.9). Conclusions: Among men, low sensitivity of urine for HPV detection suggests limited usefulness. Among women, the high sensitivity of urine/vaginal samples for HPV detection suggests a useful low-cost solution for the study of HPV epidemiology. © 2015 Published by Elsevier B.V.
In Europe, almost all countries have national recommendations regarding human papillomavirus (HPV)-vaccination [1]. Following the introduction of national vaccination against HPV, HPV monitoring studies that exploit cervical screening samples are being pursued as a post-licensure requirement [2]. The effects of vaccination can be monitored in several ways [3]. Monitoring changes in type-specific HPV prevalences will provide information on effects of vaccination much earlier than data on reduced number of cervical lesions as there is a lag time between infection and development of cervical lesions. Also, it will take many years for the vaccinated cohorts to reach an age where it will be possible to monitor the effect of the HPV vaccination program using the cervical screening
Abbreviations: HPV, human papillomavirus; CI, confidence interval. ∗ Corresponding author. Tel.: +46768871126; fax: +4640337312. E-mail address: [email protected] (J. Dillner).
program and no information on sex-specific changes in HPV occurrence will be obtained. A rapid evaluation of the impact of HPV vaccination on the circulation of HPV could be to test for the presence of HPV DNA in the urine/vaginal samples that are obtained for Chlamydia trachomatis testing, before and after the widespread use of HPV vaccination. Since this testing primarily targets the sexually active population and starts already in adolescence, a vaccine impact on the circulation of specific HPV types could be rapidly visible in this population. Widespread Chlamydia testing is ongoing in e.g. the UK, the Netherlands, Finland, Sweden, Norway, Denmark, and Estonia [4]. That HPV vaccination programmes can affect the circulation of HPV has been reported from several countries [5–7]. The recommended sampling for Chlamydia testing is first void urine samples for men and vaginal swabs immersed in first void urine for women [8]. Because the sensitivity and specificity of urine samples to detect the presence of genital HPV DNA may depend on the technology used to detect HPV DNA and on the sampling method, we evaluated the impact of sample type on HPV DNA detection. We compared the presence of HPV DNA in urine/vaginal
http://dx.doi.org/10.1016/j.jcv.2015.01.008 1386-6532/© 2015 Published by Elsevier B.V.
Please cite this article in press as: A. Söderlund-Strand, et al., Evaluation of human papillomavirus DNA detection in samples obtained for routine Chlamydia trachomatis screening, J Clin Virol (2015), http://dx.doi.org/10.1016/j.jcv.2015.01.008
33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51
G Model JCV 3232 1–4
A. Söderlund-Strand et al. / Journal of Clinical Virology xxx (2015) xxx–xxx
2 52 53 54
55
56 57 58 59
samples obtained for Chlamydia testing with the presence of HPV DNA in genital samples obtained by a reference method [9,10] using a high-throughput HPV DNA detection system for analysis [11]. 2. Objectives We evaluated the performance of HPV DNA detection and typing using (i) the samples routinely obtained for C. trachomatis testing and (ii) the samples used in large-scale phase III vaccination trials of an HPV vaccine (reference sampling method).
60
3. Study design
61
3.1. Sample collection
62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90
91
92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109
ARTICLE IN PRESS
Enrolment and sample collection was performed at two sexual health clinics in Stockholm, Sweden. The study protocol was approved by the ethical review board of Lund, Sweden. Informed written consent was obtained from all participants. We obtained: (1) one sample for Chlamydia testing which was afterwards also tested for HPV DNA, and (2) a set of samples for reference HPV DNA testing obtained according to the method used in the clinical trial programmes of the quadrivalent HPV vaccine [9,10]. The urine samples for Chlamydia analysis were collected using the Abbott multi-collect specimen collection kit (Abbott, USA). The tube contained 1.2 ml of transport buffer (guanidine thiocyanate in Tris buffer), and approximately 3 ml of urine was added to the tube at the time of sampling. The reference samples were collected in Hybrid Capture specimen transport medium (which contains preservative to retain the integrity of the DNA) (Qiagen, Germany), according to the protocol used in the clinical trial programmes of the quadrivalent HPV-vaccine. The tubes were transported at room temperature and extracted within a few days (urine samples) or within a few weeks (reference samples) from collection, according to the recommendations of the manufacturers. The Chlamydia sample from women was a self-obtained vaginal swab immersed in first-void urine and for men a first-void urine sample. The reference HPV samples from women were (1) a combination of two swabs obtained from the labial, vulvar, perineal and perianal areas, and (2) a cervical swab. The reference HPV samples from men were separate swab samples obtained from (1) the shaft, (2) the scrotum, and (3) the perineum/perianal area. All samples were obtained by clinical staff. 3.2. Sample analysis All samples were extracted using the m2000sp system for Chlamydia sample extraction (Abbott, USA). 400 l of each sample was processed. The extraction was not preceded by centrifugation. The samples were stored as extracted DNA before analysis; either at −20 ◦ C (long-term storage) or at +4 ◦ C (short-term storage) All samples were analysed at the same time using a high-throughput PCR-based method that uses matrix-assisted laser desorption timeof-flight (MALDI-TOF) mass spectrometry for detection of HPV DNA [11]. In short, a PCR reaction was performed using the MGP consensus primer system targeting the L1 gene [12], followed by a mass extension (ME) reaction with a single ME primer of distinct mass that is specific for each HPV genotype. After completion of the ME reaction, unextended primers demonstrate the absence and extended primers the presence and identity of each specific genotype. This method was proficient for the 2010 WHO Global HPV LabNet HPV DNA typing proficiency panel [13]. Since the system shows slight cross-reaction between HPV 11 and HPV 89 and between HPV 68 and HPV 70, confirmative testing of all sam-
ples positive for HPV 11 and/or HPV 68 was performed using the Luminex platform, including detection of HPV 68A (GenBank accession number DQ080079) and HPV 68B (GenBank accession number M73258 for the original sequence ME180) separately [11,12]. Amplifiability was checked using quantitative real-time PCR targeting the HBB gene (haemoglobin, beta) [14]. HPV-negative samples were included in the data analysis only if the result of the betaglobin-testing was positive. HPV-positive samples were included in the data analysis regardless of the results of the betaglobin-testing. Study subjects with HPV-negative and betaglobin-negative Chlamydia samples were excluded. The agreement between the urine/vaginal sample for Chlamydia testing and the genital reference samples was determined by the degree of detection of the same specific HPV type(s) in both the urine/vaginal sample and in at least one of the genital reference samples, and absence of an HPV type in both the urine/vaginal sample and in all the reference samples. The sensitivity was determined as the number of urine/vaginal samples obtained for Chlamydia testing that contained an HPV type that was also found in at least one of the genital reference samples from the same individual divided by the total number of urine/vaginal samples analysed from individuals that were positive for HPV in at least one of the genital reference samples. The specificity was determined as the number of urine/vaginal samples that did not contain a given HPV type and for which all genital reference samples were negative for the given HPV type in the same individual divided by the total number of urine/vaginal samples analysed in individuals that were negative for the given HPV type in all the genital reference samples. 3.3. Statistical analysis
4. Results
112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138
140 141
142
We enrolled 152 men and 115 women, but 25 men had a nonamplifiable urine sample leaving 127 men with adequate samples. 5 women were excluded due to failure to register the personal identifying number at enrolment. 1 man and 5 women were HPVvaccinated, 4 men and 5 women had unknown HPV vaccination status whereas the other participants were unvaccinated. Male participants had a mean age of 29.8 years (median age 28.0 years, range 21–56), and females had a mean age of 29.9 years (median age 28.0, range 19–52 years). All but one study subject were older than 20 years. Most were 21–30 years old (Table 1). HPV-prevalences were highest among 21–30-years-old men and women, and much higher in the Chlamydia samples from women than from men: 62.0% and 7.7%, respectively (Table 1). For men, the HPV prevalence in the urine samples was 7.1% whereas the HPV-prevalence in the genital reference swab samples was much higher, with the highest prevalence (48.8%) being detected in the shaft samples (Table 2). For both men and women, the differences in prevalence between the reference sampling Table 1 HPV prevalence (any of 16HPV-types) in Chlamydia samples obtained from 127 men and 110 women.
−20 21–30 31+ All ages
111
139
Differences in prevalence were tested using the chi-square test. P-values < 0.05 were considered significant.
Age group
110
N HPV+ men (%) 0 (0) 6/78 (7.7) 3/49 (6.1) 9/127 (7.1)
N HPV+ women (%) 0/1 (0) 44/71 (62.0) 19/38 (50.0) 63/110 (57.3)
Please cite this article in press as: A. Söderlund-Strand, et al., Evaluation of human papillomavirus DNA detection in samples obtained for routine Chlamydia trachomatis screening, J Clin Virol (2015), http://dx.doi.org/10.1016/j.jcv.2015.01.008
143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161
G Model
ARTICLE IN PRESS
JCV 3232 1–4
A. Söderlund-Strand et al. / Journal of Clinical Virology xxx (2015) xxx–xxx
3
Table 2 HPV type distribution according to sample type and sample site among 127 men and 110 women. HPV
Urine, men N = 127 (%)
Shaft N = 127 (%)
Scrotum N = 125a (%)
Perianal/ perineum, men N = 122b (%)
Urine/vaginal, women N = 110 (%)
Labia/ vulva/ perineum/ perianal, women N = 110 (%)
Cervix N = 109c (%)
6 11 16 18 31 33 35 39 45 51 52 56 58 59 66 68 Any HPV
2 (1.6) 0 (0) 1 (0.79) 3 (2.4) 1 (0.79) 0 (0) 1 (0.79) 1 (0.79) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 9 (7.1)
15 (11.8) 0 (0) 11 (8.7) 5 (3.9) 9 (7.1) 1 (0.79) 9 (7.1) 7 (5.5) 5 (3.9) 11 (8.7) 7 (5.5) 6 (4.7) 6 (4.7) 2 (1.6) 16 (12.6) 3 (2.4) 62 (48.8)
10 (8.0) 0 (0) 4 (3.2) 7 (5.6) 10 (8.0) 2 (1.6) 6 (4.8) 3 (2.4) 2 (1.6) 7 (5.6) 5 (4.0) 3 (2.4) 3 (2.4) 1 (0.80) 10 (8.0) 2 (1.6) 49 (39.2)
5 (4.1) 0 (0) 3 (2.5) 6 (4.9) 10 (8.2) 1 (0.82) 2 (1.6) 3 (2.5) 14 (11.5) 9 (7.4) 2 (1.6) 2 (1.6) 3 (2.5) 1 (0.82) 6 (4.9) 0 (0) 45 (36.9)
6 (5.5) 0 (0) 12 (10.9) 8 (7.3) 9 (8.2) 1 (0.91) 4 (3.6) 6 (5.5) 9 (8.2) 10 (9.1) 4 (3.6) 7 (6.4) 9 (8.2) 5 (4.5) 10 (9.1) 1 (0.91) 63 (57.3)
10 (9.1) 0 (0) 13 (11.8) 12 (10.9) 8 (7.3) 0 (0) 5 (4.5) 9 (8.2) 11 (10.0) 13 (11.8) 7 (6.4) 8 (7.3) 6 (5.5) 5 (4.5) 11 (10.0) 4 (3.6) 70 (63.6)
7 (6.4) 0 (0) 13 (11.9) 10 (9.2) 9 (8.3) 0 (0) 3 (2.8) 7 (6.4) 10 (9.2) 10 (9.2) 4 (3.7) 8 (7.3) 5 (4.6) 5 (4.6) 6 (5.5) 0 (0) 59 (54.1)
a b c
Two betanegative samples. Five betanegative samples. One sample excluded due to failed HPV-analysis.
193
sites were non-significant, although the difference in prevalence between the sample sites “shaft” and “perineum/perianal area” was close to significant (P = 0.057). The most commonly detected HPVtypes among men varied depending on the sample site. The most common HPV-types in the shaft samples were HPV 66 (12.6%) followed by HPV 6 (11.8%) and HPV 16 and 51 (8.7%). In the scrotal samples the most common types were HPV 6, 31, and 66 (equal number of observations, 8.0%) followed by 18 and 51 (5.6%), but in the perineum/perianal samples it was HPV 45 (11.5%) followed by HPV 31 (8.2%) and 18 and 66 (4.9%). For women, the urine/vaginal samples obtained for Chlamydia testing showed a high HPV prevalence, 57.3%, similar to the prevalences in the genital reference samples. The pooled samples obtained from the female external genital sites showed a higher HPV-prevalence than the cervical samples (63.6% and 54.1%, respectively (Table 2)). HPV16 was the most common HPVtype among women, regardless of sample type (prevalence range 10.9%–11.9%). The agreement was 0.58 for samples from women (moderate agreement). There were too few HPV-positives in the urine samples from men to meaningfully analyse concordance in men. For men, the sensitivity for HPV detection in urine samples was 7.9% (95% CI 3.0–16.4). For women, the sensitivity of urine/vaginal samples was 78.9% (95% CI 67.6–87.7). When only considering the cervical samples for reference, the sensitivity for women was 89.3% (95% CI 78.1–95.9). The sensitivity for any HPV (regardless of type) was 11.4% (95% CI 5.4–20.5) for men and 77.0% (95% CI 65.8–86.0) for women. The specificity for HPV detection in urine samples was 94.1% (95% CI 83.7–98.7) for men and 82.1% (95% CI 66.5–92.4) for urine/vaginal samples from women ((77.4% (95% CI 63.8–87.7) with the cervical samples as reference)).
194
5. Discussion
162
Q3 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192
195 196 197 198 199
The main findings were that (i) a vaginal swab immersed in urine obtained from women provided adequate material for HPV DNA detection, with high levels of sensitivity and specificity, and with a pattern of type-specific infections similar to what was detected in the samples obtained with the reference sampling method used for
HPV DNA testing in the HPVvaccination trials, and (ii) urine samples obtained from men for Chlamydia testing showed a very low prevalence and sensitivity and were considered to be suboptimal for HPV DNA detection. The HPV-prevalences were similar regardless of age, which is expected in an STD clinic settting. The HPV-positivity in male urine samples has been reported to be low also in other studies. A study of young men 16–25 years old showed an HPV-prevalence of 36.7% [15], whereas other studies report HPV-prevalences of 6.9% and 5.8% [16,17]. We found a higher extent of betaglobin-negative samples among the male urine samples than in the male genital reference samples (in which more cellular material is collected), which corresponds with the findings of other studies [18,19]. Extraction controls were successfully used throughout the processing of all samples. Also, Abbott-extracted samples can be stored for years without detectable degradation of DNA, and the analysis method is very sensitive and detects very low amounts of HPV DNA [11,12]. Thus, the high level of inadequate male urine samples is most likely associated with this type of sample. In samples obtained for Chlamydia testing from women, the vaginal swab adds more cellular material to the sample making HPV DNA detection more likely [7,11]. The highest HPV-prevalence in men was detected in the shaft samples (48.8%). Other studies have shown HPV-prevalences of 29.1% and 52% in shaft samples [15,19], 28.1% in foreskin samples [17], and 42.7% in urethra samples [16]. The HPV-prevalence found in urine/vaginal samples from women was 57.3%, which is in concordance with other studies where sample collection was performed at STD clinics – rates of 65% and 75% have been reported [20,21]. The HPV-prevalence of the reference cervical samples was 54.1%. Other similar studies report HPV-prevalences rates of 78% and 90% in cervical samples, which is somewhat higher than our findings [20,21]. The sensitivity and specificity for HPV detection in female urine samples compared with cervical samples has been reported to be 90.6% and 67.6%, respectively [15], which is similar to our findings of 78.9% sensitivity and 82.1% specificity when compared to a joint reference category with detection in any one of the cervical/vulvar/labial/perineal/perianal samples, and 89.3% sensitivity and 77.4% specificity when using cervical samples as reference.
Please cite this article in press as: A. Söderlund-Strand, et al., Evaluation of human papillomavirus DNA detection in samples obtained for routine Chlamydia trachomatis screening, J Clin Virol (2015), http://dx.doi.org/10.1016/j.jcv.2015.01.008
200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226 227 228 229 230 231 232 233 234 235 236 237 238 239
G Model JCV 3232 1–4
ARTICLE IN PRESS A. Söderlund-Strand et al. / Journal of Clinical Virology xxx (2015) xxx–xxx
4
259
In a recent meta-analysis on the accuracy of HPV-testing on selfcollected samples compared with clinician-collected samples, the sensitivity was found to be over 90% and similar for both sample categories when PCR-based HPV-testing was used [22]. Although the male HPV prevalences were comparable with the findings of others, the low sensitivity for HPV detection in male urine samples suggests that epidemiological studies of male urine samples need to be interpreted with caution. In conclusion, the sensitivity for HPV in the urine/vaginal samples from women was high and comparable with that found in the genital reference samples. The distribution of HPV types was also very similar in both urine/vaginal samples and cervical samples. Thus, the urine/vaginal sample used for Chlamydia testing among women appears to adequately reflect the HPV prevalence found in genital samples obtained by the “gold standard” sampling methodology. The present study indicates that the use of Chlamydia screening samples from women provides an adequate, efficient and low-cost alternative for the study of HPV epidemiology in women, which will undoubtedly provide a strong basis for the continued HPV monitoring projects that use this type of samples.
260
Funding
240 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 256 257 258
264
This study was sponsored by Sanofi Pasteur MSD, a vendor of HPV vaccines. All data from the study were kept by the authors and the sponsor had no role in the analysis or interpretation of data or in the decision to submit the study for publication.
265
Competing interests
261 262 263
266
267
None. Ethical approval
269
Research Ethics Committee approval was obtained from the Ethics Review Board in Lund, Sweden (Ref 2011/298).
270
Authors’ contributions
268
271 272 273 274 275 276 277
278
279 280 281
Conception and design: JD, AS-S. Development of methodology: AS-S. Study supervision: JD, AW, AS-S. Acquisition of data: AW, AS-S. Data analysis: JD, AS-S. Writing of paper: JD, AS-S. All authors read and approved the final manuscript. Acknowledgements We thank Kia Sjölin for excellent help with laboratory work. We also thank the staff at the Sesam City clinic and the RFSU clinic, Stockholm, for kind assistance with enrolment and sample collection.
References [1] V. Kesic, M. Poljak, S. Rogovskaya, Cervical cancer burden and prevention activities in Europe, Cancer Epidemiol. Biomarkers Prev. 21 (2012) 1423–1433. [2] P. Bonanni, C. Cohet, S.K. Kjaer, et al., A summary of the post-licensure surveillance initiatives for GARDASIL/SILGARD, Vaccine 28 (2010) 4719–4730. [3] International Agency for Research on Cancer working group. Primary end-points for prophylactic HPV vaccine trials. Vol. 7, IARC, Lyon, France, 2014. [4] European Centre for Disease Prevention and Control. Technical report: review of Chlamydia control acitivites in EU countries, 2008. [5] K. Kavanagh, K.G. Pollock, A. Potts, et al., Introduction and sustained high coverage of the HPV bivalent vaccine leads to a reduction in prevalence of HPV 16/18 and closely related HPV types, Br. J. Cancer 110 (2014) 2804–2811. [6] K.G. Pollock, K. Kavanagh, A. Potts, et al., Reduction of low- and high-grade cervical abnormalities associated with high uptake of the HPV bivalent vaccine in Scotland, Br. J. Cancer 111 (2014) 1824–1830. [7] A. Soderlund-Strand, I. Uhnoo, J. Dillner, Change in population prevalences of human papillomavirus after initiation of vaccination: the high-throughput HPV monitoring study, Cancer Epidemiol. Biomarkers Prev. 23 (2014) 2757–2764. [8] A. Airell, L. Ottosson, S.M. Bygdeman, et al., Chlamydia trachomatis PCR (Cobas Amplicor) in women: endocervical specimen transported in a specimen of urine versus endocervical and urethral specimens in 2-SP medium versus urine specimen only, Int. J. STD AIDS 11 (2000) 651–658. [9] S.M. Garland, M. Hernandez-Avila, C.M. Wheeler, et al., Quadrivalent vaccine against human papillomavirus to prevent anogenital diseases, N. Engl. J. Med. 356 (2007) 1928–1943. [10] A.R. Giuliano, J.M. Palefsky, S. Goldstone, et al., Efficacy of quadrivalent HPV vaccine against HPV Infection and disease in males, N. Engl. J. Med. 364 (2011) 401–411. [11] A. Soderlund-Strand, J. Dillner, High-throughput monitoring of human papillomavirus type distribution, Cancer Epidemiol. Biomarkers. Prev. 22 (2013) 242–250. [12] A. Soderlund-Strand, J. Carlson, J. Dillner, Modified general primer PCR system for sensitive detection of multiple types of oncogenic human papillomavirus, J. Clin. Microbiol. 47 (2009) 541–546. [13] C. Eklund, O. Forslund, K.L. Wallin, T. Zhou, J. Dillner, The 2010 global proficiency study of human papillomavirus genotyping in vaccinology, J. Clin. Microbiol. 50 (2012) 2289–2298. [14] K. Hazard, L. Eliasson, J. Dillner, O. Forslund, Subtype HPV38b[FA125] demonstrates heterogeneity of human papillomavirus type 38, Int. J. Cancer 119 (2006) 1073–1077. [15] K. Cuschieri, R. Nandwani, P. McGough, et al., Urine testing as a surveillance tool to monitor the impact of HPV immunization programs, J. Med. Virol. 83 (2011) 1983–1987. [16] E. Lazcano-Ponce, R. Herrero, N. Munoz, et al., High prevalence of human papillomavirus infection in Mexican males: comparative study of penile-urethral swabs and urine samples, Sex. Transm. Dis. 28 (2001) 277–280. [17] B.A. Weaver, Q. Feng, K.K. Holmes, et al., Evaluation of genital sites and sampling techniques for detection of human papillomavirus DNA in men, J. Infect. Dis. 189 (2004) 677–685. [18] A.R. Giuliano, C.M. Nielson, R. Flores, et al., The optimal anatomic sites for sampling heterosexual men for human papillomavirus (HPV) detection: the HPV detection in men study, J. Infect. Dis. 196 (2007) 1146–1152. [19] B.Y. Hernandez, L.R. Wilkens, X. Zhu, et al., Circumcision and human papillomavirus infection in men: a site-specific comparison, J. Infect. Dis. 197 (2008) 787–794. [20] S. Strauss, J.Z. Jordens, D. McBride, et al., Detection and typing of human papillomavirus DNA in paired urine and cervical scrapes, Eur. J. Epidemiol. 15 (1999) 537–543. [21] D.L. Jacobson, S.D. Womack, L. Peralta, et al., Concordance of human papillomavirus in the cervix and urine among inner city adolescents, Pediatr. Infect. Dis. J. 19 (2000) 722–728. [22] M. Arbyn, F. Verdoodt, P.J. Snijders, et al., Accuracy of human papillomavirus testing on self-collected versus clinician-collected samples: a meta-analysis, Lancet Oncol. 15 (2014) 172–183.
Please cite this article in press as: A. Söderlund-Strand, et al., Evaluation of human papillomavirus DNA detection in samples obtained for routine Chlamydia trachomatis screening, J Clin Virol (2015), http://dx.doi.org/10.1016/j.jcv.2015.01.008
282
283 284 285 286 287 288 289 290 291 292 293 294 295 296 297 298 299 300 301 302 303 304 305 306 307 308 309 310 311 312 313 314 315 316 317 318 319 320 321 322 323 324 325 326 327 328 329 330 331 332 333 334 335 336 337 338 339 340 341 342 343 344 345 346 347 348 349
ARTICLE IN PRESS
JCV 3232 1–4
Journal of Clinical Virology xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
Journal of Clinical Virology journal homepage: www.elsevier.com/locate/jcv
2
Q1
Evaluation of human papillomavirus DNA detection in samples obtained for routine Chlamydia trachomatis screening
3
Q2
Anna Söderlund-Strand a , Arne Wikström b , Joakim Dillner c,∗
1
4 5 6
a b c
Division of Laboratory Medicine, Department of Clinical Microbiology, Jan Waldenströms gata 59, 20502 Malmö, Sweden Department of Dermatovenereology, Karolinska University Hospital Solna, 171 76 Stockholm, Sweden Department of Laboratory Medicine, Karolinska Institutet, F56Huddinge, 14188 Stockholm, Sweden
7
8 19
a r t i c l e
i n f o
a b s t r a c t
9 10 11 12 13
Article history: Received 18 November 2014 Received in revised form 5 January 2015 Accepted 10 January 2015
14
18
Keywords: Human papillomavirus prevalence Human papillomavirus DNA detection Sampling technique evaluation
20
1. Background
15 16 17
21 22 23 24 25 26 27 28 29 30 31 32
Background: The costs and logistics involved in obtaining samples is a bottleneck in large-scale studies of the circulation of human papillomavirus (HPV), which are useful for monitoring and optimisation of HPV-vaccination programs. Residual samples obtained after screening for Chlamydia trachomatis could constitute a convenient, low-cost solution. Objectives: We evaluated HPV DNA detection and typing using (i) the residual samples routinely taken for C. trachomatis screening or (ii) the sample types used in large-scale phase III HPV vaccination trials (cervical, vulvar, labial, perineal, perianal, scrotal and penile shaft samples). Study design: Samples from 127 men and 110 women attending two sexual health clinics were analysed using PCR for HPV DNA, with typing using mass spectrometry. Results: The HPV DNA prevalence was 7.1% in male urine samples, but 57.3% in female urine/vaginal samples, which was even higher than the HPV prevalence found in cervical samples (54.1%). The sensitivity for HPV DNA detection in the urine/vaginal samples was 7.9% (95% CI 3.0–16.4) for men and 78.9% (95% CI 67.6–87.7) for women, using detection in any one of the reference samples as reference. With cervical samples as reference, the sensitivity was 89.3 % (95% CI 78.1–95.9). Conclusions: Among men, low sensitivity of urine for HPV detection suggests limited usefulness. Among women, the high sensitivity of urine/vaginal samples for HPV detection suggests a useful low-cost solution for the study of HPV epidemiology. © 2015 Published by Elsevier B.V.
In Europe, almost all countries have national recommendations regarding human papillomavirus (HPV)-vaccination [1]. Following the introduction of national vaccination against HPV, HPV monitoring studies that exploit cervical screening samples are being pursued as a post-licensure requirement [2]. The effects of vaccination can be monitored in several ways [3]. Monitoring changes in type-specific HPV prevalences will provide information on effects of vaccination much earlier than data on reduced number of cervical lesions as there is a lag time between infection and development of cervical lesions. Also, it will take many years for the vaccinated cohorts to reach an age where it will be possible to monitor the effect of the HPV vaccination program using the cervical screening
Abbreviations: HPV, human papillomavirus; CI, confidence interval. ∗ Corresponding author. Tel.: +46768871126; fax: +4640337312. E-mail address: [email protected] (J. Dillner).
program and no information on sex-specific changes in HPV occurrence will be obtained. A rapid evaluation of the impact of HPV vaccination on the circulation of HPV could be to test for the presence of HPV DNA in the urine/vaginal samples that are obtained for Chlamydia trachomatis testing, before and after the widespread use of HPV vaccination. Since this testing primarily targets the sexually active population and starts already in adolescence, a vaccine impact on the circulation of specific HPV types could be rapidly visible in this population. Widespread Chlamydia testing is ongoing in e.g. the UK, the Netherlands, Finland, Sweden, Norway, Denmark, and Estonia [4]. That HPV vaccination programmes can affect the circulation of HPV has been reported from several countries [5–7]. The recommended sampling for Chlamydia testing is first void urine samples for men and vaginal swabs immersed in first void urine for women [8]. Because the sensitivity and specificity of urine samples to detect the presence of genital HPV DNA may depend on the technology used to detect HPV DNA and on the sampling method, we evaluated the impact of sample type on HPV DNA detection. We compared the presence of HPV DNA in urine/vaginal
http://dx.doi.org/10.1016/j.jcv.2015.01.008 1386-6532/© 2015 Published by Elsevier B.V.
Please cite this article in press as: A. Söderlund-Strand, et al., Evaluation of human papillomavirus DNA detection in samples obtained for routine Chlamydia trachomatis screening, J Clin Virol (2015), http://dx.doi.org/10.1016/j.jcv.2015.01.008
33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51
G Model JCV 3232 1–4
A. Söderlund-Strand et al. / Journal of Clinical Virology xxx (2015) xxx–xxx
2 52 53 54
55
56 57 58 59
samples obtained for Chlamydia testing with the presence of HPV DNA in genital samples obtained by a reference method [9,10] using a high-throughput HPV DNA detection system for analysis [11]. 2. Objectives We evaluated the performance of HPV DNA detection and typing using (i) the samples routinely obtained for C. trachomatis testing and (ii) the samples used in large-scale phase III vaccination trials of an HPV vaccine (reference sampling method).
60
3. Study design
61
3.1. Sample collection
62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90
91
92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109
ARTICLE IN PRESS
Enrolment and sample collection was performed at two sexual health clinics in Stockholm, Sweden. The study protocol was approved by the ethical review board of Lund, Sweden. Informed written consent was obtained from all participants. We obtained: (1) one sample for Chlamydia testing which was afterwards also tested for HPV DNA, and (2) a set of samples for reference HPV DNA testing obtained according to the method used in the clinical trial programmes of the quadrivalent HPV vaccine [9,10]. The urine samples for Chlamydia analysis were collected using the Abbott multi-collect specimen collection kit (Abbott, USA). The tube contained 1.2 ml of transport buffer (guanidine thiocyanate in Tris buffer), and approximately 3 ml of urine was added to the tube at the time of sampling. The reference samples were collected in Hybrid Capture specimen transport medium (which contains preservative to retain the integrity of the DNA) (Qiagen, Germany), according to the protocol used in the clinical trial programmes of the quadrivalent HPV-vaccine. The tubes were transported at room temperature and extracted within a few days (urine samples) or within a few weeks (reference samples) from collection, according to the recommendations of the manufacturers. The Chlamydia sample from women was a self-obtained vaginal swab immersed in first-void urine and for men a first-void urine sample. The reference HPV samples from women were (1) a combination of two swabs obtained from the labial, vulvar, perineal and perianal areas, and (2) a cervical swab. The reference HPV samples from men were separate swab samples obtained from (1) the shaft, (2) the scrotum, and (3) the perineum/perianal area. All samples were obtained by clinical staff. 3.2. Sample analysis All samples were extracted using the m2000sp system for Chlamydia sample extraction (Abbott, USA). 400 l of each sample was processed. The extraction was not preceded by centrifugation. The samples were stored as extracted DNA before analysis; either at −20 ◦ C (long-term storage) or at +4 ◦ C (short-term storage) All samples were analysed at the same time using a high-throughput PCR-based method that uses matrix-assisted laser desorption timeof-flight (MALDI-TOF) mass spectrometry for detection of HPV DNA [11]. In short, a PCR reaction was performed using the MGP consensus primer system targeting the L1 gene [12], followed by a mass extension (ME) reaction with a single ME primer of distinct mass that is specific for each HPV genotype. After completion of the ME reaction, unextended primers demonstrate the absence and extended primers the presence and identity of each specific genotype. This method was proficient for the 2010 WHO Global HPV LabNet HPV DNA typing proficiency panel [13]. Since the system shows slight cross-reaction between HPV 11 and HPV 89 and between HPV 68 and HPV 70, confirmative testing of all sam-
ples positive for HPV 11 and/or HPV 68 was performed using the Luminex platform, including detection of HPV 68A (GenBank accession number DQ080079) and HPV 68B (GenBank accession number M73258 for the original sequence ME180) separately [11,12]. Amplifiability was checked using quantitative real-time PCR targeting the HBB gene (haemoglobin, beta) [14]. HPV-negative samples were included in the data analysis only if the result of the betaglobin-testing was positive. HPV-positive samples were included in the data analysis regardless of the results of the betaglobin-testing. Study subjects with HPV-negative and betaglobin-negative Chlamydia samples were excluded. The agreement between the urine/vaginal sample for Chlamydia testing and the genital reference samples was determined by the degree of detection of the same specific HPV type(s) in both the urine/vaginal sample and in at least one of the genital reference samples, and absence of an HPV type in both the urine/vaginal sample and in all the reference samples. The sensitivity was determined as the number of urine/vaginal samples obtained for Chlamydia testing that contained an HPV type that was also found in at least one of the genital reference samples from the same individual divided by the total number of urine/vaginal samples analysed from individuals that were positive for HPV in at least one of the genital reference samples. The specificity was determined as the number of urine/vaginal samples that did not contain a given HPV type and for which all genital reference samples were negative for the given HPV type in the same individual divided by the total number of urine/vaginal samples analysed in individuals that were negative for the given HPV type in all the genital reference samples. 3.3. Statistical analysis
4. Results
112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133 134 135 136 137 138
140 141
142
We enrolled 152 men and 115 women, but 25 men had a nonamplifiable urine sample leaving 127 men with adequate samples. 5 women were excluded due to failure to register the personal identifying number at enrolment. 1 man and 5 women were HPVvaccinated, 4 men and 5 women had unknown HPV vaccination status whereas the other participants were unvaccinated. Male participants had a mean age of 29.8 years (median age 28.0 years, range 21–56), and females had a mean age of 29.9 years (median age 28.0, range 19–52 years). All but one study subject were older than 20 years. Most were 21–30 years old (Table 1). HPV-prevalences were highest among 21–30-years-old men and women, and much higher in the Chlamydia samples from women than from men: 62.0% and 7.7%, respectively (Table 1). For men, the HPV prevalence in the urine samples was 7.1% whereas the HPV-prevalence in the genital reference swab samples was much higher, with the highest prevalence (48.8%) being detected in the shaft samples (Table 2). For both men and women, the differences in prevalence between the reference sampling Table 1 HPV prevalence (any of 16HPV-types) in Chlamydia samples obtained from 127 men and 110 women.
−20 21–30 31+ All ages
111
139
Differences in prevalence were tested using the chi-square test. P-values < 0.05 were considered significant.
Age group
110
N HPV+ men (%) 0 (0) 6/78 (7.7) 3/49 (6.1) 9/127 (7.1)
N HPV+ women (%) 0/1 (0) 44/71 (62.0) 19/38 (50.0) 63/110 (57.3)
Please cite this article in press as: A. Söderlund-Strand, et al., Evaluation of human papillomavirus DNA detection in samples obtained for routine Chlamydia trachomatis screening, J Clin Virol (2015), http://dx.doi.org/10.1016/j.jcv.2015.01.008
143 144 145 146 147 148 149 150 151 152 153 154 155 156 157 158 159 160 161
G Model
ARTICLE IN PRESS
JCV 3232 1–4
A. Söderlund-Strand et al. / Journal of Clinical Virology xxx (2015) xxx–xxx
3
Table 2 HPV type distribution according to sample type and sample site among 127 men and 110 women. HPV
Urine, men N = 127 (%)
Shaft N = 127 (%)
Scrotum N = 125a (%)
Perianal/ perineum, men N = 122b (%)
Urine/vaginal, women N = 110 (%)
Labia/ vulva/ perineum/ perianal, women N = 110 (%)
Cervix N = 109c (%)
6 11 16 18 31 33 35 39 45 51 52 56 58 59 66 68 Any HPV
2 (1.6) 0 (0) 1 (0.79) 3 (2.4) 1 (0.79) 0 (0) 1 (0.79) 1 (0.79) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 9 (7.1)
15 (11.8) 0 (0) 11 (8.7) 5 (3.9) 9 (7.1) 1 (0.79) 9 (7.1) 7 (5.5) 5 (3.9) 11 (8.7) 7 (5.5) 6 (4.7) 6 (4.7) 2 (1.6) 16 (12.6) 3 (2.4) 62 (48.8)
10 (8.0) 0 (0) 4 (3.2) 7 (5.6) 10 (8.0) 2 (1.6) 6 (4.8) 3 (2.4) 2 (1.6) 7 (5.6) 5 (4.0) 3 (2.4) 3 (2.4) 1 (0.80) 10 (8.0) 2 (1.6) 49 (39.2)
5 (4.1) 0 (0) 3 (2.5) 6 (4.9) 10 (8.2) 1 (0.82) 2 (1.6) 3 (2.5) 14 (11.5) 9 (7.4) 2 (1.6) 2 (1.6) 3 (2.5) 1 (0.82) 6 (4.9) 0 (0) 45 (36.9)
6 (5.5) 0 (0) 12 (10.9) 8 (7.3) 9 (8.2) 1 (0.91) 4 (3.6) 6 (5.5) 9 (8.2) 10 (9.1) 4 (3.6) 7 (6.4) 9 (8.2) 5 (4.5) 10 (9.1) 1 (0.91) 63 (57.3)
10 (9.1) 0 (0) 13 (11.8) 12 (10.9) 8 (7.3) 0 (0) 5 (4.5) 9 (8.2) 11 (10.0) 13 (11.8) 7 (6.4) 8 (7.3) 6 (5.5) 5 (4.5) 11 (10.0) 4 (3.6) 70 (63.6)
7 (6.4) 0 (0) 13 (11.9) 10 (9.2) 9 (8.3) 0 (0) 3 (2.8) 7 (6.4) 10 (9.2) 10 (9.2) 4 (3.7) 8 (7.3) 5 (4.6) 5 (4.6) 6 (5.5) 0 (0) 59 (54.1)
a b c
Two betanegative samples. Five betanegative samples. One sample excluded due to failed HPV-analysis.
193
sites were non-significant, although the difference in prevalence between the sample sites “shaft” and “perineum/perianal area” was close to significant (P = 0.057). The most commonly detected HPVtypes among men varied depending on the sample site. The most common HPV-types in the shaft samples were HPV 66 (12.6%) followed by HPV 6 (11.8%) and HPV 16 and 51 (8.7%). In the scrotal samples the most common types were HPV 6, 31, and 66 (equal number of observations, 8.0%) followed by 18 and 51 (5.6%), but in the perineum/perianal samples it was HPV 45 (11.5%) followed by HPV 31 (8.2%) and 18 and 66 (4.9%). For women, the urine/vaginal samples obtained for Chlamydia testing showed a high HPV prevalence, 57.3%, similar to the prevalences in the genital reference samples. The pooled samples obtained from the female external genital sites showed a higher HPV-prevalence than the cervical samples (63.6% and 54.1%, respectively (Table 2)). HPV16 was the most common HPVtype among women, regardless of sample type (prevalence range 10.9%–11.9%). The agreement was 0.58 for samples from women (moderate agreement). There were too few HPV-positives in the urine samples from men to meaningfully analyse concordance in men. For men, the sensitivity for HPV detection in urine samples was 7.9% (95% CI 3.0–16.4). For women, the sensitivity of urine/vaginal samples was 78.9% (95% CI 67.6–87.7). When only considering the cervical samples for reference, the sensitivity for women was 89.3% (95% CI 78.1–95.9). The sensitivity for any HPV (regardless of type) was 11.4% (95% CI 5.4–20.5) for men and 77.0% (95% CI 65.8–86.0) for women. The specificity for HPV detection in urine samples was 94.1% (95% CI 83.7–98.7) for men and 82.1% (95% CI 66.5–92.4) for urine/vaginal samples from women ((77.4% (95% CI 63.8–87.7) with the cervical samples as reference)).
194
5. Discussion
162
Q3 163 164 165 166 167 168 169 170 171 172 173 174 175 176 177 178 179 180 181 182 183 184 185 186 187 188 189 190 191 192
195 196 197 198 199
The main findings were that (i) a vaginal swab immersed in urine obtained from women provided adequate material for HPV DNA detection, with high levels of sensitivity and specificity, and with a pattern of type-specific infections similar to what was detected in the samples obtained with the reference sampling method used for
HPV DNA testing in the HPVvaccination trials, and (ii) urine samples obtained from men for Chlamydia testing showed a very low prevalence and sensitivity and were considered to be suboptimal for HPV DNA detection. The HPV-prevalences were similar regardless of age, which is expected in an STD clinic settting. The HPV-positivity in male urine samples has been reported to be low also in other studies. A study of young men 16–25 years old showed an HPV-prevalence of 36.7% [15], whereas other studies report HPV-prevalences of 6.9% and 5.8% [16,17]. We found a higher extent of betaglobin-negative samples among the male urine samples than in the male genital reference samples (in which more cellular material is collected), which corresponds with the findings of other studies [18,19]. Extraction controls were successfully used throughout the processing of all samples. Also, Abbott-extracted samples can be stored for years without detectable degradation of DNA, and the analysis method is very sensitive and detects very low amounts of HPV DNA [11,12]. Thus, the high level of inadequate male urine samples is most likely associated with this type of sample. In samples obtained for Chlamydia testing from women, the vaginal swab adds more cellular material to the sample making HPV DNA detection more likely [7,11]. The highest HPV-prevalence in men was detected in the shaft samples (48.8%). Other studies have shown HPV-prevalences of 29.1% and 52% in shaft samples [15,19], 28.1% in foreskin samples [17], and 42.7% in urethra samples [16]. The HPV-prevalence found in urine/vaginal samples from women was 57.3%, which is in concordance with other studies where sample collection was performed at STD clinics – rates of 65% and 75% have been reported [20,21]. The HPV-prevalence of the reference cervical samples was 54.1%. Other similar studies report HPV-prevalences rates of 78% and 90% in cervical samples, which is somewhat higher than our findings [20,21]. The sensitivity and specificity for HPV detection in female urine samples compared with cervical samples has been reported to be 90.6% and 67.6%, respectively [15], which is similar to our findings of 78.9% sensitivity and 82.1% specificity when compared to a joint reference category with detection in any one of the cervical/vulvar/labial/perineal/perianal samples, and 89.3% sensitivity and 77.4% specificity when using cervical samples as reference.
Please cite this article in press as: A. Söderlund-Strand, et al., Evaluation of human papillomavirus DNA detection in samples obtained for routine Chlamydia trachomatis screening, J Clin Virol (2015), http://dx.doi.org/10.1016/j.jcv.2015.01.008
200 201 202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226 227 228 229 230 231 232 233 234 235 236 237 238 239
G Model JCV 3232 1–4
ARTICLE IN PRESS A. Söderlund-Strand et al. / Journal of Clinical Virology xxx (2015) xxx–xxx
4
259
In a recent meta-analysis on the accuracy of HPV-testing on selfcollected samples compared with clinician-collected samples, the sensitivity was found to be over 90% and similar for both sample categories when PCR-based HPV-testing was used [22]. Although the male HPV prevalences were comparable with the findings of others, the low sensitivity for HPV detection in male urine samples suggests that epidemiological studies of male urine samples need to be interpreted with caution. In conclusion, the sensitivity for HPV in the urine/vaginal samples from women was high and comparable with that found in the genital reference samples. The distribution of HPV types was also very similar in both urine/vaginal samples and cervical samples. Thus, the urine/vaginal sample used for Chlamydia testing among women appears to adequately reflect the HPV prevalence found in genital samples obtained by the “gold standard” sampling methodology. The present study indicates that the use of Chlamydia screening samples from women provides an adequate, efficient and low-cost alternative for the study of HPV epidemiology in women, which will undoubtedly provide a strong basis for the continued HPV monitoring projects that use this type of samples.
260
Funding
240 241 242 243 244 245 246 247 248 249 250 251 252 253 254 255 256 257 258
264
This study was sponsored by Sanofi Pasteur MSD, a vendor of HPV vaccines. All data from the study were kept by the authors and the sponsor had no role in the analysis or interpretation of data or in the decision to submit the study for publication.
265
Competing interests
261 262 263
266
267
None. Ethical approval
269
Research Ethics Committee approval was obtained from the Ethics Review Board in Lund, Sweden (Ref 2011/298).
270
Authors’ contributions
268
271 272 273 274 275 276 277
278
279 280 281
Conception and design: JD, AS-S. Development of methodology: AS-S. Study supervision: JD, AW, AS-S. Acquisition of data: AW, AS-S. Data analysis: JD, AS-S. Writing of paper: JD, AS-S. All authors read and approved the final manuscript. Acknowledgements We thank Kia Sjölin for excellent help with laboratory work. We also thank the staff at the Sesam City clinic and the RFSU clinic, Stockholm, for kind assistance with enrolment and sample collection.
References [1] V. Kesic, M. Poljak, S. Rogovskaya, Cervical cancer burden and prevention activities in Europe, Cancer Epidemiol. Biomarkers Prev. 21 (2012) 1423–1433. [2] P. Bonanni, C. Cohet, S.K. Kjaer, et al., A summary of the post-licensure surveillance initiatives for GARDASIL/SILGARD, Vaccine 28 (2010) 4719–4730. [3] International Agency for Research on Cancer working group. Primary end-points for prophylactic HPV vaccine trials. Vol. 7, IARC, Lyon, France, 2014. [4] European Centre for Disease Prevention and Control. Technical report: review of Chlamydia control acitivites in EU countries, 2008. [5] K. Kavanagh, K.G. Pollock, A. Potts, et al., Introduction and sustained high coverage of the HPV bivalent vaccine leads to a reduction in prevalence of HPV 16/18 and closely related HPV types, Br. J. Cancer 110 (2014) 2804–2811. [6] K.G. Pollock, K. Kavanagh, A. Potts, et al., Reduction of low- and high-grade cervical abnormalities associated with high uptake of the HPV bivalent vaccine in Scotland, Br. J. Cancer 111 (2014) 1824–1830. [7] A. Soderlund-Strand, I. Uhnoo, J. Dillner, Change in population prevalences of human papillomavirus after initiation of vaccination: the high-throughput HPV monitoring study, Cancer Epidemiol. Biomarkers Prev. 23 (2014) 2757–2764. [8] A. Airell, L. Ottosson, S.M. Bygdeman, et al., Chlamydia trachomatis PCR (Cobas Amplicor) in women: endocervical specimen transported in a specimen of urine versus endocervical and urethral specimens in 2-SP medium versus urine specimen only, Int. J. STD AIDS 11 (2000) 651–658. [9] S.M. Garland, M. Hernandez-Avila, C.M. Wheeler, et al., Quadrivalent vaccine against human papillomavirus to prevent anogenital diseases, N. Engl. J. Med. 356 (2007) 1928–1943. [10] A.R. Giuliano, J.M. Palefsky, S. Goldstone, et al., Efficacy of quadrivalent HPV vaccine against HPV Infection and disease in males, N. Engl. J. Med. 364 (2011) 401–411. [11] A. Soderlund-Strand, J. Dillner, High-throughput monitoring of human papillomavirus type distribution, Cancer Epidemiol. Biomarkers. Prev. 22 (2013) 242–250. [12] A. Soderlund-Strand, J. Carlson, J. Dillner, Modified general primer PCR system for sensitive detection of multiple types of oncogenic human papillomavirus, J. Clin. Microbiol. 47 (2009) 541–546. [13] C. Eklund, O. Forslund, K.L. Wallin, T. Zhou, J. Dillner, The 2010 global proficiency study of human papillomavirus genotyping in vaccinology, J. Clin. Microbiol. 50 (2012) 2289–2298. [14] K. Hazard, L. Eliasson, J. Dillner, O. Forslund, Subtype HPV38b[FA125] demonstrates heterogeneity of human papillomavirus type 38, Int. J. Cancer 119 (2006) 1073–1077. [15] K. Cuschieri, R. Nandwani, P. McGough, et al., Urine testing as a surveillance tool to monitor the impact of HPV immunization programs, J. Med. Virol. 83 (2011) 1983–1987. [16] E. Lazcano-Ponce, R. Herrero, N. Munoz, et al., High prevalence of human papillomavirus infection in Mexican males: comparative study of penile-urethral swabs and urine samples, Sex. Transm. Dis. 28 (2001) 277–280. [17] B.A. Weaver, Q. Feng, K.K. Holmes, et al., Evaluation of genital sites and sampling techniques for detection of human papillomavirus DNA in men, J. Infect. Dis. 189 (2004) 677–685. [18] A.R. Giuliano, C.M. Nielson, R. Flores, et al., The optimal anatomic sites for sampling heterosexual men for human papillomavirus (HPV) detection: the HPV detection in men study, J. Infect. Dis. 196 (2007) 1146–1152. [19] B.Y. Hernandez, L.R. Wilkens, X. Zhu, et al., Circumcision and human papillomavirus infection in men: a site-specific comparison, J. Infect. Dis. 197 (2008) 787–794. [20] S. Strauss, J.Z. Jordens, D. McBride, et al., Detection and typing of human papillomavirus DNA in paired urine and cervical scrapes, Eur. J. Epidemiol. 15 (1999) 537–543. [21] D.L. Jacobson, S.D. Womack, L. Peralta, et al., Concordance of human papillomavirus in the cervix and urine among inner city adolescents, Pediatr. Infect. Dis. J. 19 (2000) 722–728. [22] M. Arbyn, F. Verdoodt, P.J. Snijders, et al., Accuracy of human papillomavirus testing on self-collected versus clinician-collected samples: a meta-analysis, Lancet Oncol. 15 (2014) 172–183.
Please cite this article in press as: A. Söderlund-Strand, et al., Evaluation of human papillomavirus DNA detection in samples obtained for routine Chlamydia trachomatis screening, J Clin Virol (2015), http://dx.doi.org/10.1016/j.jcv.2015.01.008
282
283 284 285 286 287 288 289 290 291 292 293 294 295 296 297 298 299 300 301 302 303 304 305 306 307 308 309 310 311 312 313 314 315 316 317 318 319 320 321 322 323 324 325 326 327 328 329 330 331 332 333 334 335 336 337 338 339 340 341 342 343 344 345 346 347 348 349