Prevalence of Human Papilloma Virus Among Female Patients Aged 30 and above Screened for Cervical Cancer at an Urban Health Promotion Centre, Kathmandu Metropolitan City, Nepal

ABSTRACT

Cervical cancer remains a significant public health concern in Nepal. This cross-sectional study aimed to assess the prevalence of human papilloma virus (HPV) among women aged 30 and older in Ward 10 of Kathmandu Metropolitan City (KMC), a major commercial hub. HPV DNA testing, the most sensitive method for detection, was employed to identify high-risk HPV genotypes associated with cervical cancer.

The study found that 7.7% of participants tested positive for HPV, with the highest prevalence observed in the 40-49 age group (60%). Ethnically, the Brahmin/Chhetri group accounted for the largest proportion of HPV-positive cases (53.33%), while the Janajati group represented 26.67%. Notably, there were no reported cases among Dalit participants, indicating potential under- representation or barriers to healthcare access in this community. The majority of infections were linked to “Other High Risk” HPV genotypes (73.33%), followed by HPV 16 (13.33%) and HPV 18 (6.67%).

These findings underscore the importance of targeted HPV screening programs, particularly for women in the 40-49 age group, and highlight the need for inclusive strategies that consider ethnic disparities. The study calls for more comprehensive data collection on risk factors such as sexual behaviours and geographic distribution to better inform future public health initiatives.

In conclusion, the study advocates for large-scale, cost-effective HPV vaccination and screening programs to address the widespread prevalence of high-risk HPV genotypes in urban and rural Nepal.

INTRODUCTION

The global burden of cancer continues to rise despite advancements in diagnostics and treatment. According to the World Health Organization (WHO), approximately 20 million new cancer cases were diagnosed in 2022, resulting in 9.7 million deaths worldwide [1]. This figure is projected to increase significantly to 35 million by 2050, primarily due to population growth [1]. While lung, breast, and colorectal cancers have become more prevalent globally, cervical cancer remains a major concern, particularly in low- and middle-income countries [2]. In Nepal, cervical cancer is the second most common cancer among women, following breast cancer [3].

To address this public health challenge, the WHO launched “The Global Strategy for the Elimination of Cervical Cancer,” aiming for its elimination by 2030 [4]. This strategy emphasises three key areas: prevention through vaccination, early detection, and treatment [4]. While Nepal has implemented screening programs using Visual Inspection with Acetic Acid (VIA), Papanicolaou tests (Pap smears), and more recently, Human Papilloma Virus (HPV) DNA testing, along with vaccination initiatives to support global elimination efforts, challenges persist. These include limited skilled manpower, low screening coverage, and restricted access to treatment options.

HPV is the most prevalent sexually transmitted infection, with most sexually active individuals acquiring it at some point. Of the over 200 HPV genotypes, 12 are high-risk for cervical cancer, with HPV 16 and 18 being the most significant contributors [5]. Globally, 73% of cervical malignancies are attributed to HPV 16 and 18 [5]. Studies in Nepal have shown a total HPV prevalence of 8.6%, with HPV 16 and 18 responsible for 80.3% of invasive cervical malignancies, highlighting the critical role of HPV in cervical cancer development within the country [6, 7].

This research paper presents a small-scale exploratory study of cervical cancer screening conducted among women residing in Ward 10 of Kathmandu Metropolitan City, utilising convenient access to the Ward 10 urban clinic. The primary objective was to identify HPV using HPV DNA testing and provide counselling to HPV-positive individuals for further evaluation and management. Existing studies have primarily focused on rural areas, with limited data available for urban populations. This study aims to address this gap by providing insights into the potential for cervical cancer in an urban setting, specifically Ward 10 of Kathmandu Metropolitan City, where access to diagnostic facilities and awareness are relatively high.

METHODOLOGY

• Study design

The cross-sectional study was designed to assess the the prevalence of HPV in women aged above 30 years screened for cervical cancer in an urban setting of the Kathmandu district, Nepal.

• Sample population

All the women aged above 30 who were dwelling inside the area within Ward 10 of Kathmandu Metropolitan City at the designated time period.

• Sample size :

All the women who visited the the Urban Clinic in Ward 10 for the service on the designated date as circulated beforehand.

• Sampling

All screening cases were enrolled in the study who met the inclusion criteria of the study. A total of 196 patients were then collected among them who met all the criteria.

• Inclusion and exclusion criteria

1. Participants must be 30 and above age of years. The age limit was designated as such because the acquired HPV infection takes at least 5-10 years to develop into precancerous lesion and 20 years to develop into cancers.
2. Participants must be married women.
3. Participants must not be menstruating at the time of testing.
4. Participants must have completed her 5 days of menstrual cycle.
5. Participants must not have had sexual relationship for at least 3-5 days.

PROCEDURE

The study, a one-day program, was conducted in May at the Urban Health Clinic in Ward 10 of Kathmandu District. Ward 10, located in the Baneshwor area of Kathmandu Metropolitan City, is a bustling residential and commercial hub with an estimated population of 39,820. It’s a thriving area, known for its numerous businesses and opportunities, making it one of the most developed parts of Nepal.

First, a day was designated for the screening program in coordination with the urban clinic, ward office, and Kathmandu Metropolitan City (KMC) health division. Subsequently, the KMC health division appointed two gynecologists who developed a comprehensive guideline for the testing procedure and subsequently trained the nurses in sample collection methods. An orientation program was then conducted for the staff of the urban clinic, including the existing medical officer, female community health volunteers (FCHVs), and the people’s representative from the ward office. The orientation informed them about the program’s design, the established guidelines, the nature of the testing method, exclusion and inclusion criteria, proper sample collection techniques, and the referral process. The oriented personnel (FCHVs, people’s representatives, and urban clinic staff) disseminated information about the program to the community through various methods. FCHVs circulated pamphlets within their assigned areas, while the people’s representative and urban clinic staff provided information to walk-in patients and community members.

As the urban clinic lacked the necessary equipment for HPV DNA testing (more details on kits), a tertiary hospital was designated for this purpose. This information was also disseminated during the orientation. Furthermore, the medical officer was responsible for reviewing the reports, explaining them to the participants, and providing counselling. Positive cases were to be referred by the medical officer to the assigned gynaecologist at a higher center for further examination and cone biopsy, provided free of cost. Participants were counselled that any cases with CIN III post biopsy would be referred to the designated tertiary hospital for further treatment and would be provided with monetary assistance.

SPECIMEN COLLECTION

Cervical specimens were collected by a gynaecologist and a trained nurse. The specimens were collected using a sterile dry cotton swabs for HPV DNA detection which were transported in transport medium to the Department of Microbiology, Civil Service Hospital, Baneshwor Kathmandu on the same day. The samples were stored at 2-4 degree celcius until further analyses.

HPV DETECTION

At the Department of Microbiology, Civil Service Hospital, the samples were analysed using the real time polymerase chain reaction (PCR) assay which primarily focused on the detection of high risk genotypes including HPV (16,18 and others: 31,33,35,39,45,51,52,56,58,59,66, &68).

ETHICAL CONSIDERATION

A written consent was signed by all the patients who agreed to the HPV DNA testing. Participants who were illiterate were read aloud the contents of the consent in the presence of an eyewitness such as a family member, and their thumbprints were taken. Nonetheless, the patients who declined participation were counselled about the cervical cancer and the need for screening tests while respecting their autonomy.

REPORT DISSEMINATION

The reports were dispatched and delivered to the urban clinic two days later. Participants had been previously informed to visit the clinic on the respective day to discuss their results with the medical officer.

The medical officer was responsible for maintaining strict confidentiality for all participants, regardless of their results, and provided appropriate counselling. All participants received comprehensive explanations about the nature of the HPV test, its purpose, and the implications of the results. Participants with negative results were counseled about the importance of repeat screening every five years.

Participants with positive HPV results received thorough counseling. They were counseled how an HPV infection does not automatically mean they have cancer and that it is not a social stigma. Additionally, they were referred to a higher center with a proper referral mechanism after explaining to them about the need for further intervention, such as a biopsy. They were also informed that the biopsy result would further define their treatment modalities.All participants were reassured that subsequent tests and any necessary treatments, including biopsies, would be provided free of cost. If any serious condition were discovered, they were guaranteed financial assistance by the KMC .

UTILIZATION OF FINDINGS:

This study will be the baseline data for further study and make planning to other wards of the Kathmandu metropolitan city, Kathmandu district and other municipalities of Nepal.

RESULTS

Study participants

In total, 286 women visited the clinic for the screening purposes, among which 196 patients were eligible for the screening campaign.The women who were reluctant to have them tested were not counted.

Demographic information

A valid HPV result was obtained for all the 196 tested women. The mean age with standard deviation for the participants is 43.6 years±7.8. Similarly, the demographic distribution of participants shows that the Brahmin/Chhetri ethnicity makes up the majority, comprising 68.37% (134) of the total sample. This is followed by the Janajati group, which represents 24.49 % (48). Other ethnic groups are present in much smaller proportions, including Dalit: 2.04% (4 ), Madhesi: 2.04% (4), and Others: 3.06% (6).

HPV Positive Cases:

Among the 196 participants, 15 participants (7.7%) tested positive for HPV. Out of the 15 HPV- positive cases, 40-49 years had the highest number of cases, representing 60.00% of the total (9 cases), 30-39 years accounted for 33.33% (5 cases), indicating a significant proportion of cases in relatively younger individuals while only 1 case (6.67%) was recorded in the 50-59 years age group. No cases were reported in the 60 and above age group.This distribution suggests that HPV infections are most prevalent in middle-aged individuals, particularly those in the 40-49 age range.

In regards to ethnicity, Brahmin/Chhetri made up the largest group, with 53.33% of cases (8 individuals), Janajati represented 26.67% of cases (4 individuals), Madhesi accounted for 6.67% (1 case) and Others comprised 13.33% (2 cases). Notably, there were no HPV-positive cases among Dalit individuals.This suggests that HPV positivity varies across ethnic groups, with a higher proportion among Brahmin/Chhetri and Janajati populations. However, the lack of HPV-positive cases in Dalit individuals and the low representation of marginalised groups could be influenced by several factors, including population distribution, limited access to healthcare, societal restrictions, or educational background. These factors may have resulted in under-representation of these groups in the study.

High-Risk HPV Type Distribution

Among the 15 confirmed cases of HPV, the 40-49 age group had the highest number of infections, representing 60.00% of cases, followed by the 30-39 age group at 33.33%. The 50-59 and 60+ age groups had relatively low numbers of infections. Ethnic distribution showed that the Brahmin/Chhetri group had the highest number of infections at 53.33%, with the Janajati ethnicity accounting for 26.67%. Notably, the Dalit ethnicity had no reported cases. In terms of HPV types, the majority of infections were categorised as “Other High Risk” HPV (73.33%), followed by HPV 16 (13.33%), HPV 18 (6.67%), and co-infection with both HPV 16 and 18 (6.67%). These findings suggest that the 40-49 age group may be at a higher risk for HPV, possibly due to increased exposure or other risk factors. The ethnic disparities observed in HPV prevalence may indicate differences in healthcare access, risk factors, or socioeconomic status. However, a limitation of this study is the relatively small, which may not fully represent the broader population.

DISCUSSION

The study findings show that the 40-49 age group had the highest prevalence of HPV infections (60%), which is consistent with findings in other studies, where HPV infection rates tend to peak among middle-aged women due to cumulative exposure over time. For example, the study by Thapa et al. (2018) in rural mid-western Nepal also reported a higher prevalence of HPV among women aged 40-49, supporting the notion that middle age may be a critical period for HPV exposure and transmission [6]. Additionally, the significant proportion of infections in the 30-39 age group (33.33%) observed in this study aligns with research by Serwa et al. (2022), which indicates that HPV infections in this age group are not uncommon and highlight the importance of early screening programs [7].

Ethnic disparities in HPV prevalence were also evident in this study, with the Brahmin/Chhetri group accounting for the majority of infections (53.33%). However, when adjusted for their larger representation in the sample, their proportion of HPV infections was lower than expected, which could indicate that other factors, such as socioeconomic status or healthcare access, may contribute to HPV prevalence within this group. In contrast, Janajati individuals represented a higher proportion of HPV-positive cases (26.67%) compared to their sample size (24.49%), suggesting they might be at a relatively higher risk for HPV. This is consistent with findings from Herpa et al. (2010), which highlighted ethnic and socioeconomic disparities in HPV infection rates in Nepal [8].

The absence of HPV-positive cases in Dalit participants in this study is a notable finding. This could reflect the limited presence of marginalised groups in the study, possibly due to barriers in accessing healthcare or sociocultural constraints. Similar presentation of marginalised groups has been reported in other studies as well. For instance, Thapa et al. (2018) also found lower HPV prevalence in Dalit populations, which may be influenced by limited access to healthcare services or other socioeconomic factors affecting these communities [6]. The study’s lack of data on other marginalised groups, such as Muslims and Madhesis, highlights the need for more inclusive recruitment strategies in future research to ensure a comprehensive understanding of HPV prevalence in Nepal’s diverse population.

In terms of HPV types, the study found that a majority of infections were due to “Other High Risk” HPV (73.33%), followed by HPV 16 (13.33%) and HPV 18 (6.67%). This mirrors the findings of Herpa et al. (2010), where HPV types 16 and 18 were common among women with cervical cancer in Nepal, but other high-risk types were also prevalent [8]. It is important to note that HPV 16 and 18, while being the most well-known high-risk genotypes, are not the only types that contribute to cervical cancer risk. The presence of other high-risk types in this study underlines the need for comprehensive HPV screening that includes a broad range of genotypes, as some of these lesser- known types may also contribute significantly to cervical cancer risk.

The study also found relatively low HPV positivity in the 50-59 and 60+ age groups, a trend that is supported by other studies, such as Thapa et al. (2018), which found a decline in HPV prevalence in older age groups, likely due to the natural immune response or reduced sexual activity in these populations [6]. This finding suggests that while HPV screening should begin in early adulthood, it may not be as critical for older women unless other risk factors are present.

This study’s limitations include the small sample size, particularly not well representation of marginalised groups, and the lack of data on socio-demographic and behavioural risk factors, such as education level, marital status, or sexual behaviour. The absence of these data makes it difficult to draw definitive conclusions regarding the role of these factors in HPV transmission in this population. Future studies should aim to include a more diverse sample and collect comprehensive data on these risk factors to better understand the epidemiology of HPV in Nepal.

In comparison with other studies, such as Thapa et al. (2018), which focused on rural populations in Nepal, the current study offers a valuable perspective on HPV prevalence in an urban setting. Thapa et al. (2018) found a slightly higher prevalence of HPV in rural areas, which may be attributed to different risk factors in rural settings, such as limited access to healthcare or fewer prevention initiatives [6]. Moreover, Herpa et al. (2010) highlighted the higher burden of cervical cancer due to HPV in both urban and rural populations, stressing the need for national HPV vaccination programs to address this health issue across all communities [8].

In conclusion, despite the study’s limitations, it provides important insights into the HPV burden in urban women in Nepal, emphasising the need for more inclusive recruitment, broader screening programs, and targeted HPV vaccination strategies. The study calls for action from health authorities to develop comprehensive strategies for HPV prevention and control, particularly in underrepresented and at-risk populations.

References:

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3. Nepal Cancer Information Portal. https://gco.iarc.who.int/media/globocan/factsheets/populations/524-nepal- fact-sheet.pdf (Accessed December 17, 2023).
4. World Health Organization (WHO). The Global Strategy for the Elimination of Cervical Cancer. Available at: https://www.who.int/initiatives/cervical-cancer-elimination-initiative
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