title: Potential impact of a 9-valent HPV vaccine in HPV-related cervical disease in 4 emerging countries (Brazil, Mexico, India and China).
abstract: BACKGROUND
  We estimated the potential impact of an investigational 9-valent human papillomavirus (HPV) vaccine (HPVs 6/11/16/18/31/33/45/52/58) in HPV-related cervical disease in Brazil, Mexico, India and China, to help to formulate recommendations on cervical cancer prevention and control.
  
  
  METHODS
  Estimations for invasive cervical cancer (ICC) were based on an international study including 1356 HPV-positive cases for the four countries altogether, and estimations for precancerous cervical lesions were extracted from a published meta-analysis including 6 025 HPV-positive women from the four mentioned countries. Globocan 2012 and 2012 World Population Prospects were used to estimate current and future projections of new ICC cases.
  
  
  RESULTS
  Combined proportions of the 9 HPV types in ICC were 88.6% (95%CI: 85.2-91.3) in Brazil, 85.7% (82.3-88.8) in Mexico, 92.2% (87.9-95.3) in India and 97.3% (93.9-99.1) in China. The additional HPV 31/33/45/52/58 proportions were 18.8% (15.3-22.7) in Brazil, 17.6% (14.2-21.2) in Mexico, 11.3% (7.5-16.1) in India and 11.9% (7.5-17.2) in China. HPV6 and 11 single types were not identified in any of the samples. Proportion of the individual 7 high risk HPV types included in the vaccine varied by cytological and histological grades of HPV-positive precancerous cervical lesions. HPV 16 was the dominant type in all lesions, with contributions in low grade lesions ranging from 16.6%(14.3-19.2) in Mexico to 39.8% (30.0-50.2) in India, and contributions in high grade lesions ranging from 43.8% (36.3-51.4) in Mexico to 64.1% (60.6-67.5) in Brazil. After HPV 16, variations in other majors HPV types were observed by country, with an under representation of HPV 18 and 45 compared to ICC.
  
  
  CONCLUSIONS
  The addition of HPVs 31/33/45/52/58 to HPV types included in current vaccines could increase the ICC preventable fraction in a range of 12 to 19% across the four countries, accounting the 9-types altogether 90% of ICC cases. Assuming the same degree of efficacy of current vaccines, the implementation of the 9-valent HPV vaccine in Brazil, Mexico, India and China would substantially impact on the reduction of the world cervical cancer burden.
authors.affiliation: Unit of Infections and Cancer. Catalan Institute of Oncology, Barcelona, Spain. Electronic address: bea.iconcologia@gmail.com.
authors.forename: Beatriz
authors.initials: B
authors.lastname: Serrano
authors.affiliation: Unit of Infections and Cancer. Catalan Institute of Oncology, Barcelona, Spain; CIBER Epidemiología y Salud Pública, CIBERESP, Barcelona, Spain. Electronic address: lalemany@iconcologia.net.
authors.forename: Laia
authors.initials: L
authors.lastname: Alemany
authors.affiliation: Hospital General de México, México. Electronic address: ruizalonso01@aol.com.
authors.forename: Patricia Alonso de
authors.initials: PA
authors.lastname: Ruiz
authors.affiliation: Unit of Infections and Cancer. Catalan Institute of Oncology, Barcelona, Spain. Electronic address: stous@iconcologia.net.
authors.forename: Sara
authors.initials: S
authors.lastname: Tous
authors.affiliation: Hospital Dr. Hélio Angotti, Uberaba, Brazil. Electronic address: lapc@mednet.com.br.
authors.forename: Marcus Aurelho
authors.initials: MA
authors.lastname: Lima
authors.affiliation: Unit of Infections and Cancer. Catalan Institute of Oncology, Barcelona, Spain. Electronic address: lbruni@iconcologia.net.
authors.forename: Laia
authors.initials: L
authors.lastname: Bruni
authors.affiliation: Cancer Prevention and Relief Society, Raipur, India. Electronic address: dr.ashajain@smsaraipur.co.in.
authors.forename: Asha
authors.initials: A
authors.lastname: Jain
authors.affiliation: International Agency for Research on Cancer, Lyon, France. Electronic address: clifford@iarc.fr.
authors.forename: Gary M
authors.initials: GM
authors.lastname: Clifford
authors.affiliation: National Cancer Center, Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China. Electronic address: qiaoy@cicams.ac.cn.
authors.forename: You Lin
authors.initials: YL
authors.lastname: Qiao
authors.affiliation: Global Health Outcomes, Merck & Co., Inc., West Point, PA USA. Electronic address: thomas_weiss@merck.com.
authors.forename: Thomas
authors.initials: T
authors.lastname: Weiss
authors.affiliation: Unit of Infections and Cancer. Catalan Institute of Oncology, Barcelona, Spain. Electronic address: x.bosch@iconcologia.net.
authors.forename: F Xavier
authors.initials: FX
authors.lastname: Bosch
authors.affiliation: Unit of Infections and Cancer. Catalan Institute of Oncology, Barcelona, Spain; CIBER Epidemiología y Salud Pública, CIBERESP, Barcelona, Spain. Electronic address: s.sanjose@iconcologia.net.
authors.forename: Silvia
authors.initials: S
authors.lastname: de Sanjosé
mesh_terms: D001938:Brazil; D002681:China; D005260:Female; D005838:Genotype; D006801:Humans; D007194:India; D008800:Mexico; D008875:Middle Aged; D027383:Papillomaviridae / Q000276:immunology*; D053918:Papillomavirus Vaccines / Q000276:immunology*; D002583:Uterine Cervical Neoplasms / Q000453:epidemiology / Q000473:pathology / Q000628:therapy*
chemical_list: D053918:Papillomavirus Vaccines
keywords: Brazil; China; Epidemiology; Genotype; Human papillomavirus; Human papillomavirus vaccines; India; Mexico; Uterine cervical neoplasms