Genetic Diversity in the Major Capsid L1 Protein of HPV-16 and HPV-18 in the Netherlands.

OBJECTIVES: Intratypic molecular variants of human papillomavirus (HPV) type-16 and -18 exist. In the Netherlands, a bivalent vaccine, composed of recombinant L1 proteins from HPV-16 and -18, is used to prevent cervical cancer since 2009. Long-term vaccination could lead to changes in HPV-16 and -18 virus population, thereby hampering vaccination strategies. We determined the genetic diversity of the L1 gene in HPV-16 and -18 viral strains circulating in the Netherlands at the start of vaccination in order to understand the baseline genetic diversity in the Dutch population. METHODS: DNA sequences of the L1 gene were determined in HPV-16 (n = 241) and HPV-18 (n = 108) positive anogenital samples collected in 2009 and 2011 among Dutch 16- to 24-year old female and male attendees of the sexually transmitted infection (STI) clinics. Phylogenetic analysis was performed and sequences were compared to reference sequences HPV-16 (AF536179) and HPV-18 (X05015) using BioNumerics 7.1. RESULTS: For HPV-16, ninety-five single nucleotide polymorphism (SNPs) were identified, twenty-seven (28%) were non-synonymous variations. For HPV-18, seventy-one SNPs were identified, twenty-nine (41%) were non-synonymous. The majority of the non-silent variations were located in sequences encoding alpha helix, beta sheet or surface loops, in particular in the immunodominant FG loop, and may influence the protein secondary structure and immune recognition. CONCLUSIONS: This study provides unique pre-vaccination/baseline data on the genetic L1 diversity of HPV-16 and -18 viruses circulating in the Netherlands among adolescents and young adults.

Correction: Genetic Diversity in the Major Capsid L1 Protein of HPV-16 and HPV-18 in the Netherlands.

[This corrects the article DOI: 10.1371/journal.pone.0152782.].

Six-month incidence and persistence of oral HPV infection in HIV-negative and HIV-infected men who have sex with men.

OBJECTIVES: Our aim was to assess incidence and persistence of oral HPV infection in HIV-negative and HIV-infected men who have sex with men (MSM). METHODS: MSM aged ≥18 years were included in Amsterdam (the Netherlands) in 2010-2011, and followed up 6 months later. Participants completed risk factor questionnaires. HPV DNA was analyzed in oral-rinse and gargle specimens using the SPF10-PCR DEIA/LiPA25 system (version 1). A subset of oral samples was subjected to SPF10 sequencing to identify additional HPV types. Multivariable logistic regression analyses using generalized estimating equations (GEE) were performed to assess determinants for oral high-risk HPV incidence and persistence. RESULTS: 689/795 participant MSM provided both baseline and 6-month data. Baseline prevalence of high-risk HPV was 9.4% in HIV-negative and 23.9% in HIV-infected MSM (P<0.001). 56/689 MSM acquired ≥1 high-risk HPV infection (6-month incidence 8.1%; 95%CI 6.2-10.4%); incidence was 4.1% in HIV-negative and 14.1% in HIV-infected MSM (P<0.001). HIV infection and recent use of cannabis were both independently associated with high-risk HPV incidence. Persistent high-risk HPV was observed in 48/130 (36.9%) infections. CONCLUSION: Incidence of oral high-risk HPV infection in MSM is substantial, and is associated with HIV infection. Over a third of HPV infections persisted over a 6-month period.

Patterns of human papillomavirus DNA and antibody positivity in young males and females, suggesting a site-specific natural course of infection.

BACKGROUND: To monitor the impact of human papillomavirus types 16 and 18 vaccine on HPV infection dynamics in the Netherlands, we started an ongoing study in sexually transmitted infection (STI) clinics in 2009. Here, we analyze baseline type-specific HPV DNA and HPV-specific antibody positivity rates. METHODS: We enrolled 3569 men and women, 16-24 years of age, from 14 STI clinics, and estimated genital and anal HPV DNA and antibody positivity rates of 7 main carcinogenic HPV types. Generalized estimating equations regression analyses were applied to determine risk factors for, and associations between, type-specific HPV DNA and antibody positivity. RESULTS: Genital HPV DNA positivity rates were higher in women than in men; anal HPV DNA was especially high in men who have sex with men (MSM). HPV antibody seropositivity rates were also highest in women and MSM. High-risk sexual behavior was predictive of both HPV DNA and antibody positivity. Despite a strong correlation in serological profiles for multiple HPV types, seropositivity was independently associated with homologous HPV DNA detection. CONCLUSIONS: HPV DNA and antibody positivity rates are higher in women and MSM than in heterosexual men, but their association is similar across gender. This suggests a site-specific natural course of infection.

Prevalence, incidence and persistence of genital HPV infections in a large cohort of sexually active young women in the Netherlands.

BACKGROUND: We assessed age- and type-specific HPV prevalence, incidence and persistence and their associated risk factors in young women prior to vaccination, to enable monitoring of the impact of introduction of HPV vaccination in the years before participation in the cervical screening program. METHODS: The HPV status was assessed in 3282 women aged 16-29 who participated in a Chlamydia trachomatis screening implementation program, of which 2014 women (61%) participated in two rounds (one year apart). Self-collected vaginal swab were analyzed by SPF(10) LiPA on the presence of HPV DNA. Risk factors for prevalent, incident and persistent HPV infections were calculated using generalized estimating equation. RESULTS: The prevalence of any HPV in the first round amounted to 54%, while 34% of the women who participated in the second round had a persistent infection and 45% an incident infection. The five most common HPV types found in this study were HPV16, -51, -52, -31 and -53. HPV16 and/or HPV18 prevalence, incidence and persistence in the second round were 15%, 8% and 9%, respectively and for HPV6 and/or HPV11 6%, 4% and 2%, respectively. Relatively to other HPV genotypes, hrHPV types were found more often as a persistent infection than as an incident infection. Furthermore, there is an age-dependent increase within this age range for persistent infections but not for incident infections. CONCLUSION: The HPV prevalence (54%), incidence (45%) and persistence (34%) is high among sexually active young women in the Netherlands. The different HPV type distribution and risk factors for prevalent, incident and persistent infections, as well as the observed age-trends should be taken into account in interpreting data obtained after vaccine introduction. Repeating measurements post-immunization are particularly relevant until the age when screening starts (i.e. 30 years in the Netherlands).

Oral human papillomavirus infection in HIV-negative and HIV-infected MSM.

OBJECTIVE: Oral infection with human papillomavirus (HPV) is associated with a subset of head and neck cancers. We compared prevalence of, and risk factors for, oral HPV infection among HIV-negative and HIV-infected MSM. DESIGN: Analysis of baseline data from a prospective cohort study. METHODS: MSM aged 18 years or older were recruited from three study sites in Amsterdam, the Netherlands. Participants completed a self-administered risk-factor questionnaire. Oral-rinse and gargle specimens were analyzed for HPV DNA and genotyped using a highly sensitive PCR and reverse line blot assay [short PCR fragment (SPF)10-PCR-DNA Enzyme Immuno Assay (DEIA)/LiPA25 system]. RESULTS: In 2010-2011, 794 MSM were included, of whom 767 participants had sufficient data for analysis. Median age was 40.1 years [interquartile range (IQR) 34.8-47.5] and 314 men were HIV-infected (40.9%). Any of 25 typable HPV types was present in 24.4% of all oral samples. Oncogenic HPV types were detected in 24.8 and 8.8% of oral samples from HIV-infected and HIV-negative MSM, respectively (P < 0.001). Of these high-risk types, HPV-16 was the most common (overall 3.4%). Oral infection with high-risk HPV was associated with HIV infection in multivariable analysis (P < 0.001). Increasing age was significantly associated with oral HPV infection in HIV-negative, but not in HIV-infected MSM. CONCLUSION: Oral HPV infection is very common among MSM. HIV infection was independently associated with high-risk oral HPV infection, suggesting an important role of HIV in oral HPV infection.

Changes in antibody seroprevalence of seven high-risk HPV types between nationwide surveillance studies from 1995-96 and 2006-07 in The Netherlands.

OBJECTIVE: This study evaluates trends in antibody seroprevalences of seven high-risk human papillomavirus (hr-HPV) serotypes (HPV16, 18, 31, 33, 45, 52, and 58) between the 1995-96 and 2006-07 sero-surveys among the Dutch general population in the pre-vaccination era. METHODS: Serum samples of men and women (0-79 years of age) from two cross-sectional population-based serosurveillance studies performed in 1995-96 (n = 3303) and 2006-07 (n = 6384) were tested for HPV-specific antibodies in a VLP-based multiplex immunoassay. RESULTS: HPV16-specific antibody seroprevalence increased during adolescence and shifted to younger ages in the 2006-07 survey compared to the 1995-96 survey. This step-up in HPV16 seroprevalence was most pronounced in women, while a more gradual increase was observed in men. Also in cohorts older than 49 years, HPV16 seroprevalence was higher in 2006-07 as compared to 1995-96 survey. A higher overall seroprevalence in individuals older than 15 years of age was found for HPV16, 18, 31 and 45 in 2006-07 as compared to 1995-96. For HPV33, 52 and 58 seroprevalences were comparable over this 11-year time period. Seropositivity for one or more HPV types was significantly higher in 2006-07 (23.1%) than in 1995-96 (20.0%) (p = 0.013). Multi-seropositivity increased from 7.1% in 1995-96 up to 10.2% in 2006-07 (p<0.0001). Differences in HPV seropositivity for at least one of the seven HPV types between both surveys could be explained in addition to demographic characteristics (age, sex, urbanization degree and ethnicity), also by changes in sexual behaviour (marital status, age of sexual debut and ever reported an STI). CONCLUSION: The observed increase in particular HPV16 seroprevalence could be due to changes in sexual behaviour over the years, and especially in age of sexual debut. Seroprevalence studies provide insight into the distribution of HPV types and infection dynamics in the general population over time, which is important to assess the impact of HPV-vaccination.

Seroprevalence of seven high-risk HPV types in The Netherlands.

BACKGROUND: To obtain insight into the age-specific seroprevalence for seven high-risk human papillomavirus (hr-HPV) serotypes (HPV16, 18, 31, 33, 45, 52, and 58) among the general population in the pre-vaccination era in The Netherlands. METHODS: From a cross-sectional population-based study (ISRCTN 20164309) performed in 2006/2007 6384 sera of men, women and children were tested for seven hr-HPV specific antibodies using a fluorescent bead-based multiplex immunoassay with virus-like particles of the seven HPV serotypes. RESULTS: An increase in seroprevalence was observed in adolescents, especially for the most prevalent HPV type 16 (up to 11.3%). The increase was most pronounced in women, but was less clear for the other six HPV serotypes. Relatively stable seroprevalences were found in the middle aged cohorts and a slight decrease in the elderly. For the age cohorts >14 years, the seroprevalence among women (25.2%) was higher compared with men (20.3%) (p=0.0002). We found that 10.1% of the population was seropositive for multiple HPV serotypes. CONCLUSIONS: The HPV vaccination program is targeted at preadolescents as is justified by the results in this study in which a step-up in HPV seroprevalence is observed at ages of sexual debut. Although direct interpretation of seroprevalence data are hampered by cross-reactivity and seroconversion rate, these data are useful as baseline to evaluate long-term population effects of the HPV16/18 vaccination program.

Global co-existence of two evolutionary lineages of parvovirus B19 1a, different in genome-wide synonymous positions.

Parvovirus B19 (B19V) can cause infection in humans. To date, three genotypes of B19V, with subtypes, are known, of which genotype 1a is the most prevalent genotype in the Western world. We sequenced the genome of B19V strains of 65 asymptomatic, recently infected Dutch blood donors, to investigate the spatio-temporal distribution of B19V strains, in the years 2003-2009. The sequences were compared to B19V sequences from Dutch patients with fifth disease, and to global B19V sequences as available from GenBank. All Dutch B19V strains belonged to genotype 1a. Phylogenetic analysis of the strains from Dutch blood donors showed that two groups of genotype 1a co-exist. A clear-cut division into the two groups was also found among the B19V strains from Dutch patients, and among the B19V sequences in GenBank. The two groups of genotype 1a co-exist around the world and do not appear to differ in their ability to cause disease. Strikingly, the two groups of B19V predominantly differ in synonymous mutations, distributed throughout the entire genome of B19V. We propose to call the two groups of B19V genotype 1a respectively subtype 1a1 and 1a2.

Mumps vaccine effectiveness in primary schools and households, the Netherlands, 2008.

To estimate the mumps vaccine effectiveness (VE) during a large genotype D mumps outbreak, we conducted a cross-sectional study in eight primary schools and associated households in the Netherlands. Questionnaires were used to collect information on the occurrence of mumps. Multivariate analyses were used to estimate VE. Among schoolchildren we estimated the VE against mumps. Among household contacts where the schoolchild was the index case we estimated the VE against mumps and against mumps infectiousness. In total 1175 children and 2281 household contacts participated in the study. The mumps attack rate among schoolchildren was 17%. The mumps VE in schoolchildren was 92% [95% confidence interval (CI) 83-96%] and 93% [85-97%] for one and two doses of the measles, mumps, rubella (MMR) vaccine, respectively. The adjusted mumps VE among household contacts was 67% [65-95%] and 11% [-4 to 88%] against mumps and mumps infectiousness, respectively. Our study indicates that the mumps component of the MMR vaccine offered adequate protection against mumps among schoolchildren. The relatively low VE among household contacts is of concern.

Hepatitis C virus seroprevalence in the Netherlands.

A population-based anti-hepatitis C virus (HCV) prevalence is important for surveillance purposes and it provides an insight into the burden of disease. In The Netherlands, a recent HCV seroprevalence estimate is not available. This national population-based cross-sectional serosurvey (PIENTER-2) resulted in a weighted national HCV seroprevalence of 0.30% (95% confidence interval 0.05-0.55%). About 70% of the HCV positive individuals found were born in an HCV-endemic country.

Type-specific human papillomavirus infections among young heterosexual male and female STI clinic attendees.

BACKGROUND: Baseline genotype-specific human papillomavirus (HPV) prevalence rates and associated risk factors per gender enable future assessment of the impact of vaccination on HPV dynamics. METHODS: Before the start of national HPV vaccination for girls, data were collected cross-sectionally in nationwide Dutch sexually transmitted infections (STI) clinics among heterosexual males (n = 430) and females (n = 1136) aged 16 to 24 years. Self-collected vaginal or penile swabs were analyzed by a sensitive polymerase chain reaction (SPF10) and genotyped with line probe assay. Logistic regression was applied to estimate determinants of HPV prevalent infections. RESULTS: HPV prevalence was 54% among males and 72% among females. High-risk (HR) HPV was present in males and females, 40% and 58%, respectively. Independent risk factors for HR-HPV infection were female gender, number of lifetime sex partners and a history of chlamydia or gonorrhea. In addition, not having a casual partner and consistent condom use were protective factors in women, but not in men. For low-risk (LR) HPV, the odds were smaller. Multiple HR-HPV and sexual risk behavior showed a stronger association compared with a single HR-HPV infection. CONCLUSIONS: Prevalence of HR-HPV is high in both genders. Infection with multiple HR-HPV types was more associated with high-risk sexual behavior than infection with LR-HPV types or a single HR-HPV type.

Transmission of mumps virus from mumps-vaccinated individuals to close contacts.

During a recent mumps epidemic in the Netherlands caused by a genotype D mumps virus strain, we investigated the potential of vaccinated people to spread mumps disease to close contacts. We compared mumps viral titers of oral fluid specimens obtained by quantitative PCR from vaccinated (n=60) and unvaccinated (n=111) mumps patients. We also investigated the occurrence of mumps infection among the household contacts of vaccinated mumps patients. We found that viral titers are higher for unvaccinated patients than for vaccinated patients during the 1st 3 days after onset of disease. While no symptomatic cases were reported among the household contacts (n=164) of vaccinated mumps patients (n=36), there were cases with serological evidence of asymptomatic infection among vaccinated household contacts (9 of 66 vaccinated siblings). For two of these siblings, the vaccinated index patient was the most probable source of infection. We conclude that, in this particular outbreak, the risk of a close contact becoming infected by vaccinated patients was small, but present.

Assessing the potential effects and cost-effectiveness of programmatic herpes zoster vaccination of elderly in the Netherlands.

BACKGROUND: Herpes zoster (HZ) is a painful disease affecting a considerable part of the elderly. Programmatic HZ vaccination of elderly people may considerably reduce HZ morbidity and its related costs, but the extent of these effects is unknown. In this article, the potential effects and cost-effectiveness of programmatic HZ vaccination of elderly in the Netherlands have been assessed according to a framework that was developed to support evidence-based decision making regarding inclusion of new vaccines in the Dutch National Immunization Program. METHODS: An analytical framework was used combining a checklist, which structured relevant data on the vaccine, pathogen and disease, and a cost-effectiveness analysis. The cost-effectiveness analysis was performed from a societal perspective, using a Markov-cohort-model. Simultaneous vaccination with influenza was assumed. RESULTS: Due to the combination of waning immunity after vaccination and a reduced efficacy of vaccination at high ages, the most optimal cost-effectiveness ratio (21716 euro per QALY) for HZ vaccination in the Netherlands was found for 70-year olds. This estimated ratio is just above the socially accepted threshold in the Netherlands of 20000 euro per QALY. If additional reduction of postherpetic neuralgia was included, the cost-effectiveness ratio improved (approximately 10000 euro per QALY) but uncertainty for this scenario is high. CONCLUSIONS: Vaccination against HZ at the age of 70 years seems marginally cost-effective in the Netherlands. Due to limited vaccine efficacy a considerable part of the disease burden caused by HZ will remain, even with optimal acceptance of programmatic vaccination.

Molecular sequence data of hepatitis B virus and genetic diversity after vaccination.

The effect of vaccination programs on transmission of infectious disease is usually assessed by monitoring programs that rely on notifications of symptomatic illness. For monitoring of infectious diseases with a high proportion of asymptomatic cases or a low reporting rate, molecular sequence data combined with modern coalescent-based techniques offer a complementary tool to assess transmission. Here, the authors investigate the added value of using viral sequence data to monitor a vaccination program that was started in 1998 and was targeted against hepatitis B virus in men who have sex with men in Amsterdam, the Netherlands. The incidence in this target group, as estimated from the notifications of acute infections with hepatitis B virus, was low; therefore, there was insufficient power to show a significant change in incidence. In contrast, the genetic diversity, as estimated from the viral sequence collected from the target group, revealed a marked decrease after vaccination was introduced. Taken together, the findings suggest that introduction of vaccination coincided with a change in the target group toward behavior with a higher risk of infection. The authors argue that molecular sequence data provide a powerful additional monitoring instrument, next to conventional case registration, for assessing the impact of vaccination.

[Management and treatment of pregnant women with hepatitis B]. / Beleid en behandeling bij zwangeren met hepatitis B.

Every year about 800 chronic hepatitis B infections are identified in the Netherlands as result of the nationwide pregnancy screening. About one-third of these are newly discovered infections. In recent years there has been a marked increase in treatment options for chronic hepatitis B infection using antiviral drugs. Pregnant women can now be treated as well. A pregnant woman with a low viral load does not require immediate treatment, as due to the passive immunisation and active vaccination of the newborn the chances of infection due to perinatal transmission are negligible. Treatment of the mother can therefore be postponed until after the birth. However, when the pregnant woman has a high viral load (>10(9) copies/ml in serum), perinatal transmission can still occur despite vaccination of the newborn. In these women, antiviral treatment in the last trimester of the pregnancy should be considered. At present, experience of treating HBV-infected pregnant women has only been gained with lamivudine. It appears that the quantity of circulating virus decreases due to the treatment. Treatment should always be supervised by a gastroenterologist or an infectiologist. Detection, referral and treatment of the mother and child are described in several guidelines that have recently been updated and harmonized with each other. These include a practice guideline from the Dutch College of General Practitioners, a guideline from the Centre for Infectious Disease Control of the National Institute for Public Health and the Environment, and a guideline from the Netherlands Society of Gastroenterology.

Acute hepatitis B in a healthcare worker: a case report of genuine vaccination failure.

BACKGROUND: Individuals who reach the antibody threshold level of 10IU/l against the surface protein of the hepatitis B virus (HBV) after completion of a series of hepatitis B vaccination are considered to be long-term protected against a clinically manifest HBV infection. CASE REPORT: Here we describe an acute hepatitis B infection in a patient who received five hepatitis B vaccinations. Although his initial response to vaccination was moderate, he finally reached an excellent hepatitis B surface antibody level (anti-HBs) titres of more than 1000 IU/l in response to a booster vaccination with a recombinant DNA vaccine. Nevertheless, he developed full-blown acute hepatitis due to an HBV infection 14years after this booster vaccination. A DNA analysis of the surface protein encoding region followed by phylogenetic analysis showed that our patient was infected with a normal HBV strain that is circulating among men who have sex with men. To our knowledge, this is the first report of a genuine hepatitis B vaccination failure in someone who acquired a high anti-HBs level in response to a recombinant DNA hepatitis B vaccine. CONCLUSION: Healthcare workers whose response to the initial hepatitis B vaccination is moderate might be vulnerable to hepatitis B virus infection.

Simultaneous vaccination with Prevenar and multicomponent vaccines for children: interference or no interference?

Multicomponent vaccines against as many as six infectious diseases are often given simultaneously with monovalent or multivalent vaccines against meningococcus and pneumococcus. Detailed analysis of simultaneous vaccinations, which can lead to suboptimal induced immune responses, should precede their combined use in national immunization programmes. By combining the results of the only two published studies evaluating simultaneous vaccinations with Infanrix hexa and Prevanar in a random-effect meta-analysis, we show that the one-sided 95% confidence interval of the HBV seroconversion rate includes the 95% limit that should be reached in universal programs. We advocate better assessment of potential interferences in immune responses after simultaneous vaccinations. Registration of new vaccines should include this assessment.

Air travel as a risk factor for introduction of measles in a highly vaccinated population.

Epidemiological and molecular investigation of two small measles clusters in The Netherlands in July/August 2007 revealed an association with travel by air of the index cases and nosocomial spread in the first cluster. Although these importations did not result in an outbreak among unvaccinated subjects, the observations illustrate the challenges for measles control in a country with high measles vaccination coverage (> 95%) but with pockets of low coverage.