Multisite HPV infections in the United States (NHANES 2003-2014): An overview and synthesis

Abstract

HPV is the most common sexually transmitted infection in the U.S., infecting both anogenital and oral sites. Nationally representative data are collected through the National Health and Nutrition Examination Survey (NHANES). However, changing designations of HPV genotypes as high or low risk and varying underlying populations as new results are reported have made direct comparison of results difficult. We reanalyzed HPV data from NHANES derived from self-collected cervicovaginal swabs (women ages 18-59, 2003-14), penile swabs (men ages 18-59, 2013-14), and oral rinses (men and women ages 18-69, 2009-14), using consistent populations and definitions across NHANES cycles. These data strengthen our understanding of age trends in HPV prevalence: cervicovaginal prevalence decreases with age, penile prevalence increases with age, and oral prevalence is bimodal but with an earlier first peak in women. There is strong evidence for reduced prevalence of vaccine genotypes (6, 11, 16, 18) in vaccinated men and women (ages 18-24) at both genital (RR 0.2 (0.1-0.3) in women and 0.7 (0.1-5.4) in men) and oral sites (RR 0.1 (0.0-1.3) in women; no infections detected in vaccinated men). A more complete picture of the burden of HPV in the U.S. is emerging, including evidence for reduced HPV genital and oral prevalence in vaccinated individuals.

Keywords: Concordant infection; Human papillomavirus; Multisite; NHANES; Prevalence; Vaccine efficacy.

Figure 1:. Cervicovaginal HPV prevalence in women ages 18–59 by genotype group and concordance, stratified by age and race.

Stratification of cervicovaginal HPV prevalence in the U.S. by oncogenic potential (Group 1 genotypes are known to cause cancer) in the upper panels is given by age and race, where each bar represents survey cycles 2003–04, 2005–06, 2007–08, 2009–10, 2011–12, and 2013–14, respectively. Stratification by concordance (lower panels) is done similarly (concordant infections are defined as at least one simultaneous oral and genital infection of the same genotype). The points with error bars (95% CIs) give the average of the indicated outcome for the 2009–2014 data. The constraint to this time period allows comparison to oral outcomes.

Figure 2:. Penile HPV prevalence in men ages 18–59 by genotype group and concordance, stratified by age and race.

Stratification of penile HPV prevalence in the U.S. by oncogenic potential (Group 1 genotypes are known to cause cancer) in the upper panels is given by age and race, where each bar is survey cycle 2013–14. Stratification by concordance (lower panels) is done similarly (concordant infections are defined as at least one simultaneous oral and genital infection of the same genotype). Because there is only one survey with penile outcomes, the error bars (95% CIs) are for this year only.

Figure 3:. Oral HPV prevalence in women ages 18–69 by genotype group and concordance, stratified by age and race.

Stratification of oral HPV prevalence in women in the U.S. by oncogenic potential (Group 1 genotypes are known to cause cancer) in the upper panels is given by age and race (ages 18–59 only), where each bar represents survey cycles 2009–10, 2011–12, and 2013–14, respectively. Stratification by concordance (lower panels) is done similarly (concordant infections are defined as at least one simultaneous oral and genital infection of the same genotype). The points with error bars (95% CIs) give the 2009–14 average of the indicated outcome.

Figure 4:. Oral HPV prevalence in men ages 18–69 by genotype group and concordance, stratified by age and race.

Stratification of HPV prevalence in men in the U.S. by oncogenic potential (Group 1 genotypes are known to cause cancer) in the upper panels is given for by age and race (ages 18–59 only), where each bar represents survey cycles 2009–10, 2011–12, and 2013–14, respectively. Stratification by concordance (lower panels) is done similarly (concordant infections are defined as at least one simultaneous oral and genital infection of the same genotype). The points with error bars (95% CIs) give the 2009–14 average of the indicated outcome. Because penile outcomes are only available for 2013–14, the trend and error bars for penile–oral concordance are only for this survey.

Figure 5:. Genotype prevalence among women and with genital, oral, or concordant HPV infections.

Genotype prevalence in U.S. is the 2009–14 average in each case but (f), where it is 2013–14. Each subcaption gives the number of people with the given type of infection and what (weighted) percentage of the population that number represents. Genotypes are color coded by oncogenic potential: Group 1 is oncogenic, Group 2 is possibly oncogenic, and all other are low-risk.