Comparison of Hybribio-H13 and Hybrid Capture® 2 human papillomavirus tests for detection of CIN2+ and CIN3. / Comparación de las pruebas para el virus del papiloma humano Hybribio-H13 y Hybrid Capture® 2 para la detección de NIC2+ y NIC3+

INTRODUCTION: Low-cost, accurate high-risk HPV tests are needed for cervical cancer screening in limited-resource settings. OBJECTIVE: To compare the performance of the low-cost Hybribio-H13 test with the Hybrid Capture® 2 to detect cervical intraepithelial neoplasia grade 2 or 3 (CIN2 and CIN3). MATERIALS AND METHODS: Archived baseline samples tested by the Hybrid Capture® 2 from women of the ASCUS-COL trial, aged 20 to 69 years, with biopsy-colposcopy directed diagnosis of CIN2+ (n = 143), CIN3+ (n = 51), and < CIN2 (n = 632) were blindly tested by the Hybribio-H13 test. RESULTS: The relative sensitivity of the Hybribio-H13 test versus the Hybrid Capture® 2 for detecting CIN2+ was 0.89 (90% CI = 0,80-0,98; NIT = 0,66), and for CIN3+ was 0,92 (90% CI = 0,85-0,98; NIT = 0,35). Relative specificity was 1.19 (90% CI = 1.05-1.33; NIT <0.00001). In the analysis restricted to women older than 30 years, the relative sensitivity of the Hybribio-H13 for CIN3+ was marginally below unity (ratio = 0.97; 90% CI = 0.95-0.99), and the specificity remained higher than the Hybrid Capture® 2 test. CONCLUSION: The Hybribio-H13 test was as specific as the Hybrid Capture® 2 for detecting CIN2+ or CIN3+ but less sensitive. Considering these results and the young age of the population recruited for screening because of ASCUS cytology, we suggest our results warrant the evaluation of the Hybribio-H13 for screening cervical cancer, especially in the evaluated population.

Introducción. Se necesitan pruebas para detectar genotipos de VPH de alto riesgo, precisas y de bajo costo, para la tamización del cáncer de cuello uterino en entornos de recursos limitados. Objetivo. Comparar el desempeño de la prueba de bajo costo Hybrid-H13 con la de Hybrid Capture® 2 para detectar NIC2+ y NIC3+. Materiales y métodos. Se analizaron en ciego muestras de la línea base provenientes de mujeres del estudio ASCUS-COL, entre los 20 y los 69 años, con diagnóstico dirigido por biopsia-colposcopia de NIC2+ (n = 143), NIC3 + (n = 51) y < NIC2 (n = 632) con la prueba para detección de virus de papiloma humano Hybribio-H13. Estas muestras fueron previamente evaluadas con la prueba Hybrid Capture® 2. Resultados. La sensibilidad relativa de Hybribio-13 versus la de Hybrid Capture® 2 para detectar NIC2+ fue de 0,89 (IC90%: 0,80-0,98; NIT = 0,66) y para NIC3+ fue de 0,92 (IC90%: 0,85-0,98; NIT = 0,35). La especificidad relativa fue de 1,19 (IC90%: 1,05-1,33; NIT <0,00001). En el análisis restringido a mujeres mayores de 30 años, la sensibilidad relativa de Hybribio-H13 para NIC3+ estuvo marginalmente por debajo de la unidad (proporción = 0,97; IC90%: 0,95-0,99) y la especificidad permaneció más alta que la de la prueba Hybrid Capture® 2. Conclusión. La prueba de Hybribio-H13 fue tan específica como la de Hybrid Capture® 2, pero menos sensible para detectar NIC2+ o NIC3+. Teniendo en cuenta estos resultados y la temprana edad de la población reclutada en la tamización por la presencia de ASCUS en la citología, se sugiere continuar con la evaluación de la prueba Hybribio-H13 para la detección de cáncer de cuello uterino en poblaciones con las mismas características que las de la aquí evaluada.

Folate deficiency modifies the risk of CIN3+ associated with DNA methylation levels: a nested case-control study from the ASCUS-COL trial.

PURPOSE: To our knowledge, there are very few studies evaluating if the levels of folate modify the risk of cervical intraepithelial neoplasia grade 2 and higher (CIN2+ and CIN3+) associated with the levels of HPV genome methylation, two cofactors related to single carbon metabolism and independently associated with cervical cancer in previous studies. We conducted a case-control study nested in a three-arm randomized clinical pragmatic trial (ASCUS-COL trial) to evaluate the risk of CIN3+ associated with methylation levels according to serum folate concentrations. METHODS: Cases (n = 155) were women with histologically confirmed CIN2+ (113 CIN2, 38 CIN3, and 4 SCC) and controls were age and follow-up time at diagnosis-matched women with histologically confirmed ≤ CIN1 (n = 155), selected from the 1122 hrHPV + women of this trial. The concentrations of serum folate were determined by the radioimmunoassay SimulTRAC-SNB-VitaminB12/Folate-RIAKit and the methylation levels by the S5 classifier. Stepwise logistic regression models were used to estimate the association between folate or methylation levels and CIN2+ or CIN3+. The joint effect of folate levels and methylation on the risk of CIN3+ was estimated using combinations of categorical stratifications. RESULTS: Folate levels were significantly lower in women with CIN3+ than in other diagnostic groups (p = 0.019). The risk of CIN3+ was eight times higher (OR 8.9, 95% CI 3.4-24.9) in women with folate deficiency and high methylation levels than in women with normal folate and high methylation levels (OR 1.4, 95% CI 0.4-4.6). CONCLUSION: High methylation and deficient folate independently increased the risk of CIN3+ while deficient folate combined with high methylation was associated with a substantially elevated risk of CIN3+.

Consumption of industrial processed foods and risk of premenopausal breast cancer among Latin American women: the PRECAMA study.

Ultra-processed food intake has been linked to an increased risk of breast cancer in Western populations. No data are available in the Latin American population although the consumption of ultra-processed foods is increasing rapidly in this region. We evaluated the association of ultra-processed food intake to breast cancer risk in a case-control study including 525 cases (women aged 20-45 years) and 525 matched population-based controls from Chile, Colombia, Costa Rica and Mexico. The degree of processing of foods was classified according to the NOVA classification. Overall, the major contributors to ultra-processed food intake were ready-to-eat/heat foods (18.2%), cakes and desserts (16.7%), carbonated and industrial fruit juice beverages (16.7%), breakfast cereals (12.9%), sausages and reconstituted meat products (12.1%), industrial bread (6.1%), dairy products and derivatives (7.6%) and package savoury snacks (6.1%). Ultra-processed food intake was positively associated with the risk of breast cancer in adjusted models (OR T3-T1=1.93; 95% CI=1.11 to 3.35). Specifically, a higher risk was observed with oestrogen receptor positive breast cancer (ORT3-T1=2.44, (95% CI=1.01 to 5.90, P-trend=0.049), while no significant association was observed with oestrogen receptor negative breast cancer (ORT3-T1=1.87, 95% CI=0.43 to 8.13, P-trend=0.36). Our findings suggest that the consumption of ultra-processed foods might increase the risk of breast cancer in young women in Latin America. Further studies should confirm these findings and disentangle specific mechanisms relating ultra-processed food intake and carcinogenic processes in the breast.

Effective methylation triage of HPV positive women with abnormal cytology in a middle-income country.

The S5-methylation test, an alternative to cytology and HPV16/18 genotyping to triage high-risk HPV-positive (hrHPV+) women, has not been widely validated in low-middle-income countries (LMICs). We compared S5 to HPV16/18 and cytology to detect cervical intraepithelial neoplasia Grade 2 or worse (CIN2+) and CIN3+ in hrHPV+ women selected from a randomized pragmatic trial of 2661 Colombian women with an earlier-borderline abnormal cytology. We included all hrHPV+ CIN2 and CIN3+ cases (n = 183) age matched to 183

Project profile: a multicenter study on breast cancer in young women in Latin America (PRECAMA study).

OBJECTIVE: To describe the rationale and the methodology of a multicenter project to study the etiology of breast cancer in young Latin American women. MATERIALS AND METHODS: The International Agency for Research on Cancer has established an international collaborative population-based case-control study in four countries in Latin America: Chile, Colombia, Costa Rica, and Mexico (the PRECAMA study). Standardized methodologies were developed to collect information on reproductive variables, lifestyle, anthropometry, diet, clinical and pathological data, and biological specimens. The study will be extended to other countries in the region. CONCLUSIONS: PRECAMA is unique in its multidisciplinary approach that combines genetics, genomics, and metabolomics with lifestyle factors. Then data generated through this project will be instrumental to identify major risk factors for molecular subtypes of breast cancer in young women, which will be important for pre- vention and targeted screening programs in Latin America.

OBJETIVO: Describir la justificación y la metodología para el establecimiento de un proyecto multicéntrico sobre el cáncer de mama en mujeres jóvenes de América Latina. MATERIAL Y MÉTODOS: La Agencia Internacional para la Investigación del Cáncer (IARC) ha establecido un estudio colaborativo internacional de casos y controles con base poblacional en cuatro países de América Latina: Chile, Colombia, Costa Rica y México (el estudio PRECAMA). Se han desarrollado metodologías estandarizadas para recolectar información sobre variables reproductivas, estilos de vida, antropometría y dieta, datos clínicos y patológicos y muestras biológicas. CONCLUSIONES: PRECAMA es único en su enfoque multidisciplinario. Los datos generados a través de este proyecto serán fundamentales para identificar los principales factores de riesgo del cáncer de mama en mujeres jóvenes. Los hallazgos serán relevantes para la prevención y los programas de detección oportuna en América Latina, con beneficios clínicos inmediatos.

Project profile: a multicenter study on breast cancer in young women in Latin America (PRECAMA study) / Perfil de Proyecto: Un estudio multicéntrico sobre el cáncer de mama en mujeres jóvenes en América Latina (estudio PRECAMA)

Abstract: Objective: To describe the rationale and the methodology of a multicenter project to study the etiology of breast cancer in young Latin American women. Materials and methods: The International Agency for Research on Cancer has established an international collaborative population-based case-control study in four countries in Latin America: Chile, Colombia, Costa Rica, and Mexico (the PRECAMA study). Standardized methodologies were developed to collect information on reproductive variables, lifestyle, anthropometry, diet, clinical and pathological data, and biological specimens. The study will be extended to other countries in the region. Conclusion: PRECAMA is unique in its multidisciplinary approach that combines genetics, genomics, and metabolomics with lifestyle factors. The data generated through this project will be instrumental to identify major risk factors for molecular subtypes of breast cancer in young women, which will be important for prevention and targeted screening programs in Latin America.

Resumen: Objetivo: Describir la justificación y la metodología para el establecimiento de un proyecto multicéntrico sobre el cáncer de mama en mujeres jóvenes de América Latina. Material y métodos: La Agencia Internacional para la Investigación del Cáncer (IARC) ha establecido un estudio colaborativo internacional de casos y controles con base poblacional en cuatro países de América Latina: Chile, Colombia, Costa Rica y México (el estudio PRECAMA). Se han desarrollado metodologías estandarizadas para recolectar información sobre variables reproductivas, estilos de vida, antropometría y dieta, datos clínicos y patológicos y muestras biológicas. Conclusión: PRECAMA es único en su enfoque multidisciplinario. Los datos generados a través de este proyecto serán fundamentales para identificar los principales factores de riesgo del cáncer de mama en mujeres jóvenes. Los hallazgos serán relevantes para la prevención y los programas de detección oportuna en América Latina, con beneficios clínicos inmediatos.

Perception about barriers and facilitators of the school-based HPV vaccine program of Manizales, Colombia: A qualitative study in school-enrolled girls and their parents.

In 2012, Colombia implemented a school-based HPV vaccination program of a 3-dose series for nine year old girls. Following a mass psychogenic response after vaccination in a Colombian town, vaccination rates dropped from 80% in 2012-2013 to 5% in 2016. The study aimed to identify barriers and facilitators of HPV vaccine uptake among girls eligible for vaccination in the initial years of vaccine implementation from 2012 to 2014, and their parents. We conducted 19 individual qualitative interviews and 18 focus groups with an average of 5 girls, in Manizales, Colombia between 2016 and 2017. In total, 49 girls from six schools and 58 of their parents participated in the study. Participants had some degree of awareness about cervical cancer, especially among those of middle and upper socioeconomic level. However, the vaccine was known as a prevention measure only after pap-smears and condoms. The main facilitator for vaccine uptake for parents was the desire to prevent diseases in general and for girls, it was facilitated by receiving positive information about the vaccine. The main barriers for vaccine uptake or for three doses completion were the event in Carmen de Bolivar, fear of adverse effects and fear of needles. Girls and parents stated that they received little or no information from schools or health care services about the HPV vaccine prior to vaccination. Our results suggest that improving HPV vaccination rates in Colombia will require a comprehensive education program including mass media information about HPV vaccine.

Secular trends of HPV genotypes in invasive cervical cancer in Cali, Colombia 1950-1999.

UNLABELLED: Aim To estimate relative contribution and time trends of HPV types in cervical cancer in Cali, Colombia over a 50 years' period. METHODS: Paraffin blocks of 736 cervical cancer histological confirmed cases were retrieved from the pathology laboratory at Hospital Universitario del Valle (Cali, Colombia) and HPV genotyped using SPF10-PCR/DEIA/LiPA25 (version 1) assay. Marginal effect of age and year of diagnosis in secular trends of HPV type prevalence among HPV+ cases were assessed by robust Poisson regression analysis. RESULTS: 64.7% (95%CI: 59.9-69.2) of squamous cell carcinomas (SCCs) were attributed to HPV 16 and 18, 78.2% (95%CI: 74-82) to HPV 16, 18, 31, 33 and 45 and 84.8% (95%CI: 81-88.1) to HPV 16, 18, 31, 33, 45, 52 and 58 while ninety-three percent of adenocarcinomas (ADCs) were attributed to HPV 16, 18 and 45 only. The prevalence of specific HPV types did not change over the 50-year period. A significant downward trend of prevalence ratios of HPV16 (​P=0.017) and α7 but HPV 18 (i.e., HPV 39, 45, 68, 70, ​P=0.024) with increasing age at diagnosis was observed. In contrast, the prevalence ratio to other HPV genotypes of α9 but HPV 16 genotypes (i.e., HPV 31, 33, 35, 52, 58, 67, ​P=0.002) increased with increasing age at diagnosis. CONCLUSION: No changes were observed in the relative contribution of HPV types in cervical cancer in Cali, Colombia during the 50 years. In this population, an HPV vaccine including the HPV 16, 18, 31, 33, 45, 52 and 58 genotypes may have the potential to prevent ∼85% and 93% of SCC and ADC cases respectively.

Nuevos paradigmas y desafíos en la prevención y control del cáncer de cuello uterino en América Latina / New paradigms and challenges in cervical cancer prevention and control in Latin America

El cáncer de cuello uterino sigue siendo un problema de salud pública en Latinoamérica. El uso de la citología para la detección de lesiones pre-cancerosas no ha tenido mayor impacto en las tasas de incidencia y mortalidad, que aún se mantienen altas en la región. La disponibilidad de nuevas técnicas de tamizaje para la detección de lesiones pre-cancerosas y de vacunas altamente eficaces que previenen casi todas las lesiones relacionadas con VPH-16 y VPH-18 en mujeres no expuestas previamente al virus representan una gran oportunidad para la prevención del cáncer de cuello uterino en la región. En este manuscrito resumimos la evidencia científica y la experiencia de la región en i) el uso de pruebas de VPH y de la inspección visual después del ácido acético (IVAA) en tamizaje primario, y ii) la implementación de programas de vacunación en adolescentes. Finalmente enumeramos una serie de recomendaciones adecuadas para distintos escenarios. La factibilidad de implementar un programa nacional de prevención de cáncer de cuello uterino exitoso y sostenible en países latinoamericanos dependerá de las prioridades de salud, la infraestructura y personal de salud disponible, determinadas luego de un riguroso análisis situacional local.

Cervical cancer continues to be a significant health problem in Latin America. The use of conventional cytology to detect precancerous cervical lesions has had almost no major impact on reducing cervical cancer incidence and mortality rates, which are still high in the region. The availability of new screening tools to detect precancerous lesions provide great opportunities for cervical cancer prevention in the region, as do highly efficacious HPV vaccines able to prevent nearly all lesions associated with HPV-16 and -18 when applied before viral exposure. This paper summarizes the scientific evidence and regional experiences related to: i) the use of HPV testing and visual inspection after the application of acetic acid (VIA) in primary screening and ii) the implementation of adolescent HPV vaccination programs. Finally, we outline a number of recommendations for different resource settings. The feasibility of implementing successful and sustainable national cervical cancer prevention programs in Latin American countries in the region will depend on health priorities and the availability of infrastructure and health personnel-as determined by rigorous local situational analysis.

[New paradigms and challenges in cervical cancer prevention and control in Latin America]. / Nuevos paradigmas y desafíos en la prevención y control del cáncer de cuello uterino en América Latina.

Cervical cancer continues to be a significant health problem in Latin America. The use of conventional cytology to detect precancerous cervical lesions has had almost no major impact on reducing cervical cancer incidence and mortality rates, which are still high in the region. The availability of new screening tools to detect precancerous lesions provide great opportunities for cervical cancer prevention in the region, as do highly efficacious HPV vaccines able to prevent nearly all lesions associated with HPV-16 and -18 when applied before viral exposure. This paper summarizes the scientific evidence and regional experiences related to: i) the use of HPV testing and visual inspection after the application of acetic acid (VIA) in primary screening and ii) the implementation of adolescent HPV vaccination programs. Finally, we outline a number of recommendations for different resource settings. The feasibility of implementing successful and sustainable national cervical cancer prevention programs in Latin American countries in the region will depend on health priorities and the availability of infrastructure and health personnel--as determined by rigorous local situational analysis.

Estructura moleuular y antigénica de la vacuna ontra el virus del papiloma hummano 16 (vph 16) / Antigenic and Molecular Structure of Human Papillomavirus (HPV) 16 Vaccine

La proteína L1 del Virus del Papiloma Humano (VPH) constituye el 80% de la cápside viral. Las vacunas profilácticas contra el VPH son sintetizadas a partir de la proteína L1 ensamblada en Partículas similares al Virus (del inglés VLP), las cuales son altamente inmunogénicas generando anticuerpos específicos de tipo y en algunos casos pueden presentar reacción cruzada entre tipos de VPH filogenéticamente próximos. La estructura de la proteína L1 del VPH es importante porque confiere estabilidad a la cápside mediante el establecimiento de interacciones intra e intercapsoméricas lo que asegura la integridad viral y antigénicamente porque contiene los epítopes que inducen la respuesta inmune protectora. En estudios en los que se evaluó la antigenicidad de la proteína L1 se determinó que los epítopes inmunodominantes de la cápside viral se encuentran en los bucles B-C, D-E, F-G, H-I y en el extremo C-terminal. Estos bucles son poco conservados entre los diferentes genotipos y se encuentran en segmentos de la proteína expuestos en la superficie de la cápside. Los aminoácidos situados en los bucles B-C, F-G y H-I son primordiales para el reconocimiento por los anticuerpos neutralizantes. Los diferentes subtipos y variantes presentan cambios en estos aminoácidos o en residuos que conforman otros epítopes. En esta revisión se presentará un estado del arte de la proteína L1 del VPH genotipo 16, la estructura y su importancia en el desarrollo de vacunas contra la infección producida por este virus.

Human Papillomavirus L1 protein makes up 80% of the viral capsid and self assembles in Virus-like Particles (VLP); these particles are immunogenic, generate type-specific antibodies and can induce very limited cross-reactivity among highly homologous HPV types. In addition to its structural function, it confers the stability to the capsid by establishing disulfide bonds and other intra and intercapsomeric interactions, and also contains the epitopes that induce the protective immune response of prophylactic vaccines. Immunological studies of this protein have concluded that the main epitopes of the HPV viral capsid are found in the loops B-C, D-E, F-G, H-I and the C-terminal arm. These loops are exposed on the surface of the viral capsid and have a low degree of conservation among the different genotypes. Specifically, amino acid 50 located on loop B-C and aminoacids 266, 271 and 288 located on loop F-G are important for the recognition on neutralizing antibodies. The different genotypes and variants exhibit mutations on these residues.

New approaches to cervical cancer screening in Latin America and the Caribbean.

Cervical cancer remains an important public health problem in the Latin America and Caribbean region (LAC), with an expected significant increase in disease burden in the next decades as a result of population ageing. Prophylactic human papillomavirus (HPV) vaccine is currently unaffordable in LAC countries. However, even if vaccination was implemented, an additional two decades will be required to observe its impact on HPV related disease and cancer. With some exceptions, cytology-based screening programs have been largely ineffective to control the problem in the region, and there is a need for new approaches to the organization of screening and for use of newly developed techniques. Several research groups in LAC have conducted research on new screening methods, some of which are summarized in this paper. A recommendation to reorganize screening programs is presented considering visual inspection for very low resource areas, improvement of cytology where it is operating successfully and HPV DNA testing followed by visual inspection with acetic acid (VIA) or cytology as soon as this method becomes technically and economically sustainable. This could be facilitated by the incorporation of new, low-cost HPV DNA testing methods and the use of self-collected vaginal specimens for selected groups of the population. An important requisite for screening based on HPV testing will be the quality assurance of the laboratory and the technique by validation and certification measures.

Molecular and serological evidence of the epidemiological association of HPV 13 with focal epithelial hyperplasia: a case-control study.

BACKGROUND: Focal epithelial hyperplasia is a benign proliferative condition that is more frequently found in children of certain ethnic groups. Human papillomavirus 13 and 32 DNA has been consistently detected in these lesions. OBJECTIVE: To demonstrate the epidemiological association of HPV 13 with FEH in the Emberá-Chamí community of Antioquia, Colombia. METHODS: A population-based, case-control study was conducted. One hundred and thirty-eight children were screened and 17 clinical and histologically-confirmed cases were sex and age-matched with 27 controls. Biopsies from FEH lesions and mouth washes from controls were obtained for DNA analysis. HPV 13 DNA was identified using a previously described type-specific PCR test. HPV 13 VLPs were produced by cloning of L1 from the HPV 13 cloned genome and seroreactivity against HPV 13 VLPs of sera from cases and controls were evaluated by ELISA. RESULTS: Among the whole population the prevalence of FEH was 13%. One-hundred-percent of the cases and 29.6% of the controls were HPV 13 positive. There was a significant difference in HPV DNA status between cases and controls (one-tailed Fisher exact test: P<0.0001). Antibodies against HPV 13 VLPs were found in 58.8% of cases and in 33.3% of controls, this difference was not statistically significant (P=0.089 Fisher exact test). However, the median of the ODs of the ELISA positive sera of the cases was 0.596 (interquartile range: 0.5075-0.8245) versus 0.452 (interquartile range: 0.337-0.479) in the controls and this was significantly different (P=0.0041 Man-Whitney test). CONCLUSIONS: We demonstrated a risk for association of FEH with infection with HPV 13. The higher level of antibodies against HPV 13 VLPs in cases may suggest the requirement of higher viral load or viral persistence for disease development.

Uso de la tecnica inmuno-radiometrica (IRMA) en Anopheles de Colombia para la identificacion de esporozoitos de Plasmodium / Use of the immuno-radiometric technique (IRMA) in the colombian Anopheles for identification of Plasmodium sporozoites

El metodo inmuno-radiometrico (IRMA) que utiliza anticuerpos monoclonales con especificidad por la proteina CS de los esporozoitos de Plasmodium falciparum, se uso en el presente trabajo para determinar las tasas de infeccion de mosquitos del genero Anopheles (obtenidos en diversas regiones endemicas malaricas de Colombia). De las especies estudiadas, A.albimanus, A.darlingi, A.alloph y A.neomaculipalpus mostraron infecciones por P.falciparum. Solo las dos primeros habian sido incriminadas previamente como vectoras. Adicionalmente, A.albimanus fue el unico positivo para P.vivax. El metodo IRMA permitio en un corto tiempo y sobre un numero reducido de mosquitos determinar algunos probables vectores en el pais