ICO/IARC Information Centreon HPV and Cancer

INDICATOR GUIDELINES
Version posted at www.hpvcentre.net on 22 October 2021

- ii -

Copyright and Permissions©ICO/IARC Information Centre on HPV and Cancer (HPV Information Centre) 2021
All rights reserved. HPV Information Centre publications can be obtained from the HPV Information Centre Secretariat, Institut Català d’Oncologia, Avda. Gran Via de l’Hospitalet, 199-203 08908
L’Hospitalet del Llobregat (Barcelona) Spain. E-mail: hpvcentre@iconcologia.net. Requests for permission to reproduce or translate HPV Information Centre publications - whether for sale or for noncommercial distribution- should be addressed to the HPV Information Centre Secretariat, at the above
address. Any digital or printed publication of the information provided in the web site should be accompanied by an acknowledgment of HPV Information Centre as the source.
The designations employed and the presentation of the material in this publication do not imply theexpression of any opinion whatsoever on the part the HPV Information Centre concerning the legal
status of any country, territory, city or area or of its authorities, or concerning the delimitation of its
frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may
not yet be full agreement. The mention of specific companies or of certain manufacturers products does
not imply that they are endorsed or recommended the HPV Information Centre in preference to othersof a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietaryproducts are distinguished by initial capital letters. All reasonable precautions have been taken by the
HPV Information Centre to verify the information contained in this publication. However, the publishedmaterial is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the HPVInformation Centre be liable for damages arising from its use.

Recommended citation:

Bruni L, Albero G, Serrano B, Mena M, Collado JJ, Gómez D, Muñoz J, Bosch FX, de Sanjosé
S. ICO/IARC Information Centre on HPV and Cancer (HPV Information Centre). INDICATORGUIDELINES 20 October 2021. [Date Accessed]

ICO/IARC HPV Information Centre

LIST OF CONTENTS- iii -

Contents
1 Introduction

iv

2 Region and Country Definitions
2.1 Member States, by sub-regions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

v
v

3 Glossary of cancer sites, histologies and cytologyvii
3.1 Histology/cytology of the cervix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vii
3.2 Other anogenital cancers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . viii
3.3 Head and Neck cancers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix
4 Cancer statisticsx
4.1 Incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . x
4.2 Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xiii
5 Human papillomavirus (HPV) related statistics

xv

6 Factors contributing to HPV-related cancers
xxv
6.1 Smoking (Current smoking of any tobacco prevalence, Daily smoking of any tobacco prevalence, Current cigarette smoking prevalence, Daily cigarette smoking prevalence) . . . . . xxv
6.2 Parity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxvi
6.3 Oral Contraceptive Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxvii
6.4 Human immunodeficiency virus (HIV) prevalence . . . . . . . . . . . . . . . . . . . . . . . . . xxviii
7 Sexual and reproductive health behaviour indicatorsxxix
7.1 Time of sexual intercourse/High-risk sexual behaviour . . . . . . . . . . . . . . . . . . . . . . xxix
7.2 Marriage Patterns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxx
7.3 Contraceptive Use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxxi
8 HPV Preventive strategies
xxxiii
8.1 Cervical cancer screening practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxxiii
8.2 HPV vaccination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxxvi
9 Protective factors for cervical cancer
xxxvii
9.1 Male circumcision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxxvii
9.2 Condom use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxxviii
10 Demographic and socioeconomic factors
xxxix
10.1 Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxxix

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1

INTRODUCTION- iv -

Introduction

The Catalan Institute of Oncology (ICO) and the International Agency for Research on Cancer (IARC)
have joined forces to expand the HPV Information Centre. The HPV Information Centre is being developed by the Cancer Epidemiology Research Program (CERP) of the ICO. The Centre was originallylaunched by ICO with the collaboration of World Health Organization, WHO’s Immunisation, Vaccines
and Biologicals (IVB) department and support from the Bill and Melinda Gates Foundation to to accelerate the introduction of HPV vaccines in countries with the highest burden of cervical cancer andreduce the incidence of this disease and related lesions among women.
Aggregated information is derived from data and official reports produced by the WHO, IARC, United
Nations, The World Bank, and published literature. Indicators include relevant statistics on HPVrelated cancer sites, epidemiological determinants of cervical cancer such as demographics, socioeconomic factors and other risk factors, estimates on the burden of HPV infection, data on immunizationand cervical cancer screening.

ICO/IARC HPV Information Centre

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REGION AND COUNTRY DEFINITIONS

2Region and Country Definitions

2.1

Member States, by sub-regions-v-

Countries have been grouped into either developed and developing regions, five continents (Africa,
Americas, Asia, Europe, and Oceania) and 21 sub-regions outlined by the United Nations for geographic disaggregation of the statistics (http://unstats.un.org/unsd/methods/m49/m49regin.htm).
The categorization of countries or areas is for statistical convenience and does not imply any assumption
regarding political or other affiliation of countries or territories by the United Nations or the ICO/IARC
Information Centre on HPV and Cancer.
Table 1: Developed and developing regions classification
Term
Developed regions
Developing regions

Definition
Northern America, Europe, Japan, Australia and New ZealandAfrica, Americas (excluding Northern America), Caribbean, Central America, South America, Asia
excluding Japan, and Oceania excluding Australia and New Zealand

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REGION AND COUNTRY DEFINITIONS- vi -

Table 2: Member States, by Sub-Regions.
Continent

RegionCountries

Eastern Africa

Burundi, Comoros, Djibouti, Eritrea, Ethiopia, Kenya, Madagascar,
Mozambique, Mauritius, Malawi, Rwanda, Somalia, South Sudan,
Seychelles, United Republic of Tanzania, Uganda, Zambia, Zimbabwe

Middle Africa

Angola, Central African Republic, Cameroon, Democratic Republic of
the Congo, Congo, Gabon, Equatorial Guinea, Sao Tome and Principe,
ChadNorthern Africa

Algeria, Egypt, Western Sahara, Libya, Morocco, Sudan, Tunisia

Southern Africa

Botswana, Lesotho, Namibia, Eswatini, South Africa

Western Africa

Benin, Burkina Faso, Côte d’Ivoire, Cabo Verde, Ghana, Guinea,
Gambia, Guinea-Bissau, Liberia, Mali, Mauritania, Niger, Nigeria,
Senegal, Sierra Leone, Togo

Caribbean

Antigua and Barbuda, Bahamas, Barbados, Cuba, Dominica, Dominican Republic, Grenada, Haiti, Jamaica, Saint Kitts and Nevis, Saint
Lucia, Trinidad and Tobago, Saint Vincent and the Grenadines & The
Grenadines, Trinidad & Tobago

Central America

Belize, Costa Rica, Guatemala, Honduras, Mexico, Nicaragua,
Panama, El Salvador

South America

Argentina, Bolivia, Brazil, Chile, Colombia, Ecuador, Guyana, Peru,
Paraguay, Suriname, Uruguay, Venezuela (Bolivarian Republic of)Northern America

Canada, United States of America

Eastern Asia

China, Japan, Republic of Korea, Mongolia, Democratic People’s Republic of Korea, Taiwan

South-Eastern Asia

Brunei Darussalam, Indonesia, Cambodia, Lao People’s Democratic
Republic, Myanmar, Malaysia, Philippines, Singapore, Thailand,
Timor-Leste, Viet Nam

Southern Asia

Afghanistan, Bangladesh, Bhutan, India, Iran, Sri Lanka, Maldives,
Nepal, Pakistan

Central Asia

Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan, Uzbekistan

Western Asia

Armenia, Azerbaijan, Bahrain, Georgia, Iraq, Israel, Jordan, Kuwait,
Lebanon, Oman, State of Palestine, Qatar, Saudi Arabia, Syrian Arab
Republic, Turkey, United Arab Emirates, Yemen

Eastern Europe

Bulgaria, Belarus, Czechia, Hungary, Republic of Moldova, Poland,
Romania, Russian Federation, Slovakia, Ukraine

Northern Europe

Channel Islands, Denmark, Estonia, Finland, United Kingdom ofGreat Britain and Northern Ireland, Ireland, Iceland, Lithuania,
Latvia, Norway, Sweden

Southern Europe

Albania, Andorra, Bosnia and Herzegovina, Cyprus, Spain, Greece,
Croatia, Italy, Republic of North Macedonia, Malta, Montenegro, Portugal, San Marino, Serbia, Slovenia

Western Europe

Austria, Belgium, Switzerland, Germany, France, Liechtenstein,
Luxembourg, Monaco, Netherlands

Australia/New ZealandAustralia, New Zealand

Melanesia

Fiji, Papua New Guinea, Solomon Islands, Vanuatu

Micronesia

Micronesia, Kiribati, Marshall Islands, Nauru, Palau

Poynesia

Cook Islands, Niue, Samoa, Tonga, Tuvalu

AfricaAmerica

Asia

EuropeOceania

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GLOSSARY OF CANCER SITES, HISTOLOGIES AND CYTOLOGY- vii -

3

Glossary of cancer sites, histologies and cytology

3.1

Histology/cytology of the cervix

Terminology

Cytologically normal women
No abnormal cells are observed on the surface of their cervix upon cytology.

Cervical Intraepithelial Neoplasia (CIN) / Squamous Intraepithelial Lesions (SIL)
SIL and CIN are two commonly used terms to describe precancerous lesions or the abnormal growthof squamous cells observed in the cervix. SIL is an abnormal result derived from cervical cytologicalscreening or Pap smear testing. CIN is a histological diagnosis made upon analysis of cervical tissue
obtained by biopsy or surgical excision. The condition is graded as CIN 1, 2 or 3, according to the thickness of the abnormal epithelium (1/3, 2/3 or the entire thickness).
Low-grade cervical lesions (LSIL/CIN-1)
Low-grade cervical lesions are defined by early changes in size, shape, and number of abnormal cells
formed on the surface of the cervix and may be referred to as mild dysplasia, LSIL, or CIN-1.
High-grade cervical lesions (HSIL/ CIN-2 / CIN-3 / CIS)
High-grade cervical lesions are defined by a large number of precancerous cells on the surface of thecervix that are distinctly different from normal cells. They have the potential to become cancerous cells
and invade deeper tissues of the cervix. These lesions may be referred to as moderate or severe dysplasia, HSIL, CIN-2, CIN-3 or cervical carcinoma in situ (CIS).

Carcinoma in situ (CIS)Preinvasive malignancy limited to the epithelium without invasion of the basement membrane. CIN 3
encompasses the squamous carcinoma in situ.

Invasive cervical cancer (ICC) / Cervical cancer
If the high-grade precancerous cells invade the basement membrane is called ICC. ICC stages range
from stage I (cancer is in the cervix or uterus only) to stage IV (the cancer has spread to distant organs,such as the liver).
Invasive squamous cell carcinoma
Invasive carcinoma composed of cells resembling those of squamous epithelium.
Adenocarcinoma
Invasive tumour with glandular and squamous elements intermingled.

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GLOSSARY OF CANCER SITES, HISTOLOGIES AND CYTOLOGY

3.2- viii -Other anogenital cancers

Terminology
Cancer of the anus
Cancer that forms in tissues of the anus, which is the opening of the rectum (last part of the large intestine) to the outside of the body.

Cancer of the penis
Cancer that forms on the skin or in the tissues of the penis.

Cancer of the vagina
Cancer that forms in the tissues of the vagina (birth canal). The vagina leads from the cervix (the opening of the uterus) to the outside of the body.

Cancer of the vulva
Cancer of the vulva occurs in the external female genital organs which include the clitoris, vulvar lips,
and the opening to the vagina.

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GLOSSARY OF CANCER SITES, HISTOLOGIES AND CYTOLOGY

3.3- ix -

Head and Neck cancers

Terminology
Oral cavity cancer
Cancer (mainly squamous cell carcinoma) that arises in mucosal surfaces of the oral cavity (the mouth).
Those include the anterior two thirds of the tongue, the lips, the gum, the floor of the mouth, the hardpalate and other and unspecified parts of the oral cavity such as the buccal mucosa and the retromolar
area.
Oropharyngeal cancer
Cancer (mainly squamous cell carcinoma) that arises in mucosal surfaces of the oropharynx. Those
include the tonsils, the base of tongue, the uvula, the soft palate, the Waldeyer’s ring and other andunspecified parts of the oropharynx such as the vallecula and the lateral and posterior walls of theoropharynx.
Larynx cancer
Cancer (mainly squamous cell carcinoma) that arises in mucosal surfaces of the larynx. Those include
the glottis, the supraglottis, the subglottis and other and unspecified parts of the larynx such as thelaryngeal cartilague.

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CANCER STATISTICS

4-x-

Cancer statistics
Table 3: Classification of cancer sites.

CancerInternational Classification of Disease (ICD, 10th revision) code
GLOBOCAN 2020

Cancer Incidence 5 Continents

Cervical

C53

C53

Anal

C21

C21

Vulvar

C51

C51

VaginalC52

C52

Penile

C60

C60

Oral Cavity

C00-C06

C00-C06

Oropharynx

C09-C10

C09-C10

C32

C32

Larynx4.1

Incidence

Incidence is the number of new cases that occurs during a given period of time in a specified population.
It can be expressed as an absolute number of cases per year or as a rate per 100,000 persons per year.
Incidence data are available from cancer registries. They cover entire national populations, or samples of such populations from selected regions.
Crude incidence rate
For a specific cancer site and population, a crude rate is calculated by dividing the number of newcancers observed during a given time period by the corresponding number of people at risk in the population. The result is usually given as a rate per 100000 person-years of observation.
This rate is called crude because it relates to each population as a whole and is influenced by theage structure of each population.
It cannot be used for comparison purposes.

Age-specific incidence rate
The age-specific rate in each age class can be calculated by dividing the number of cases in the age-classby the corresponding population.
Age-specific incidence rates should always be the starting point and foundation of any thorough analysis of the incidence data.

Age-standardised incidence rate
The age-standardised rate is a summary of the individual age-specific rates using an external population called a standard population. This is the incidence that would be observed if the population had theage structure of the standard population, and corresponds to the crude incidence rate in the standard
population. The age-standardised incidence rate is expressed, as is the crude incidence rate, as thenumber of new cases per 100 000 person-years.
The standard worldwide used is the Segi standard population (Segi, 1960).

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CANCER STATISTICS- xi -It should be stressed that the objective of age standardisation is essentially to establish rates for comparison purposes.

Cumulative Risk
The cumulative rate is an approximation of the probability to develop a cancer during a certain periodfor example, a lifetime. For cancer, it is often expressed as the risk accumulated over the age period
0-74. This has the advantage of summarising the age-specific rates independently of the age structureof the population, and gives the probability of an individual developing a cancer. This calculation istheoretical and assumes that no death occurs in the period, and that the age-specific incidence rates
will be stable for an individual.
Like the age-standardised rate, it permits comparisons between populations with different age structures.
The cumulative risk is expressed as a percentage.

Annual number of new cancer cases
The number of new cases that occurs during a given period of time in a specified population. Usually
they are expressed as an absolute number of cases per year.
In the HPV Information Centre, cancer incidence data presented are only from the cancer registries
compiled by the IARC.
Cancer data are always collected and compiled sometime after the events to which they relate, so thatthe most recent statistics available are always ’late’. GLOBOCAN 2020 presents estimates for the year
2020. However, although the populations of the different countries are those estimated for the middleof 2020, the disease rates are not those for the year 2020, but from the most recent data available, generally 2-5 years earlier.
In Cancer Incidence in Five Continents (CI5), Volume XI, numbers of cancer cases are reported forthe period 2008-2012.
These estimates are based on the most recent incidence data available at IARC, but more recent figures may be available directly from local sources.

Ranking of cervical cancer among other cancers
The order of frequency of cervical cancer resulting of sorting crude incidence rates by cancer site. Reflects burden of disease. Ranking based on age-standardized rates may differ.

Data Sources
Cancer incidence from cancer registries
Bray F, Colombet M, Mery L, Piñeros M, Znaor A, Zanetti R and Ferlay J, editors (2017)
Cancer Incidence in Five Continents, Vol. XI (electronic version). Lyon: International Agency for Research on Cancer. Available from: https://ci5.iarc.fr
Ferlay J, Ervik M, Lam F, Colombet M, Mery L, Piñeros M, Znaor A, Soerjomataram I, Bray F (2020).
Global Cancer Observatory: Cancer Today. Lyon, France: International Agency for Research on Cancer.
Available from: https://gco.iarc.fr/today
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CANCER STATISTICS

Disaggregation
Age and sex

Comments
None

ICO/IARC HPV Information Centre- xii -

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CANCER STATISTICS

4.2- xiii -Mortality

Mortality is the number of deaths occurring in a given period in a specified population. It can be expressed as an absolute number of deaths per year or as a rate per 100,000 persons per year.
Mortality data by cause are available for many countries through the registration of vital events, although the degree of detail and quality of the data vary considerably.
Crude mortality rate
For a specific cancer site and population, a crude rate is calculated by dividing the number of cancer
deaths observed during a given time period by the corresponding number of people at risk in the population. The result is usually given as a rate per 100000 person-years of observation.
This rate is called crude because it relates to each population as a whole and is influenced by theage structure of each population.
It cannot be used for comparison purposes.

Age-specific mortality rate
The age-specific rate in each age class can be calculated by dividing the number of deaths in the ageclass by the corresponding population.
Age-specific mortality rates should always be the starting point and foundation of any thorough analysis of the mortality data.

Age-standardised mortality rate
The age-standardised rate is a summary of the individual age-specific rates using an external population called a standard population. This is the mortality that would be observed if the population had theage structure of the standard population, and corresponds to the crude mortality rate in the standard
population. The age-standardised mortality rate is expressed, as is the crude mortality rate, as thenumber of deaths per 100 000 person-years.
The standard worldwide used is the Segi standard population (Segi, 1960).
It should be stressed that the objective of age standardisation is essentially to establish rates for comparison purposes

Cumulative Risk
The cumulative rate is an approximation of the probability of dying from a cancer during a certain
period-for example, a lifetime. For cancer, it is often expressed as the risk accumulated over the age
period 0-74. This has the advantage of summarising the age-specific rates independently of the age
structure of the population, and gives the probability of an individual dying from a cancer. This calculation is theoretical and assumes assuming no other causes of death are in operation, and that theage-specific mortality rates will be stable for an individual.
Like the age-standardised rate, it permits comparisons between populations with different age structures.
The cumulative risk is expressed as a percentage.

ICO/IARC HPV Information Centre

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CANCER STATISTICS- xiv -

Annual number of deaths
The number of deaths that occurs during a given period of time in a specified population. Usually they
are expressed as an absolute number of deaths per year.
In the HPV Information Centre, cancer mortality data presented are compiled by the International
Agency for Research on Cancer (IARC) from country-specific national mortality data. These estimatesare based on the most recent mortality data available at IARC, but more recent figures may be available
directly from local sources.

Ranking of cervical cancer among other cancers
The order of frequency of cervical cancer resulting of sorting crude mortality rates by cancer site. Reflects burden of disease. Ranking based on age-standardized rates may differ.

Data Sources
Ferlay J, Ervik M, Lam F, Colombet M, Mery L, Piñeros M, Znaor A, Soerjomataram I, Bray F (2020).
Global Cancer Observatory: Cancer Today. Lyon, France: International Agency for Research on Cancer.
Available from: https://gco.iarc.fr/today, accessed on 27 January 2021.
For specific estimation methodology refer to https://gco.iarc.fr/today/data-sources-methods

Disaggregation
Age and sex

Comments
None

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5

HUMAN PAPILLOMAVIRUS (HPV) RELATED STATISTICS- xv -

Human papillomavirus (HPV) related statistics

Definitions
HPV Prevalence
HPV prevalence is the proportion of subjects infected by the human papillomavirus (HPV) according toan HPV DNA test at a specific time point.

Type-specific HPV prevalenceHPV-type prevalence is the proportion of subjects infected by a specific HPV genotype according to a
type-specific HPV DNA test at a given time point.

Data source
HPV Infection statistics in the HPV Information Centre are generated from the findings of systematic review of the literature. Systematic reviews of the literature are performed at the Institut Catalàd´Oncologia or the International Agency for Research on Cancer. These reviews have been publishedin the peer-reviewed literature, and the resulting papers represent the basis of further updates. Once
initially published, all these analyses are periodically updated and uploaded in the website. Table 4
presents the different sections of HPV infection statistics and their reference publications.
Table 4: Reference publications for HPV prevalence and type distribution statistics by site and lesion
Date of update Date of update
Site/lesion forofthemost HPV InformaHPV
preva- References
recent original tion centre inlence statistics
publication
October, 2021
Bruni L, Diaz M, Castellsagué X, Ferrer E, Bosch FX, de Sanjosé S. Cervicalhuman papillomavirus prevalence in 5
Women with norcontinents: meta-analysis of 1 million Jun 2014
Jun 2015
mal cytology
women with normal cytological findings. J Infect Dis. 2010;202(12):178999.
De Sanjosé S, Diaz M, Castellsagué X,
Clifford G, Bruni L, Munoz N, Bosch
FX. Worldwide prevalence and genotype distribution of cervical human papillomavirus DNA in women with normal cytology: a meta-analysis. Lancet
Infect Dis. 2007;7(7):453-9.
Guan P, Howell-Jones R, Li N, Bruni
L, de Sanjosé S, Franceschi S, Clifford
GM. Human papillomavirus types in
Low-grade cerviJun 2015
115,789 HPV-positive women: a meta- Nov 2011
cal lesions
analysis from cervical infection to cancer. Int J Cancer. 2012;131(10):234959.
Continued on next page

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HUMAN PAPILLOMAVIRUS (HPV) RELATED STATISTICS

Site/lesion for
HPV
prevalence statistics

High-grade cervical lesions

Invasive cervicalcancer- xvi -

Table 4 – continued from previous page
Date of update Date of updateofthemost HPV InformaReferences
recent original tion centre in
publication
October, 2021
Clifford GM, Rana RK, Franceschi S,
Smith JS, Gough G, Pimenta JM. Human papillomavirus genotype distribution in low-grade cervical lesions:comparison by geographic region andwith cervical cancer. Cancer Epidemiol
Biomarkers Prev. 2005;14(5):1157-64.
Guan P, Howell-Jones R, Li N, Bruni
L, de Sanjosé S, Franceschi S, Clifford
GM. Human papillomavirus types in
115,789 HPV-positive women: a meta- Nov 2011
Jun 2015
analysis from cervical infection to cancer. Int J Cancer.2012;131(10):234959.
Smith JS, Lindsay L, Hoots B, Keys
J, Franceschi S, Winer R, Clifford
GM. Human papillomavirus type distribution in invasive cervical cancer
and high-grade cervical lesions: ameta-analysis update. Int J Cancer.
2007;121(3):621-32.
Clifford GM, Smith JS, Aguado T,
Franceschi S. Comparison of HPV type
distribution in high-grade cervical lesions and cervical cancer: a metaanalysis. Br J Cancer. 2003 Jul
7;89(1):101-5.
Guan P, Howell-Jones R, Li N, Bruni
L, de Sanjosé S, Franceschi S, Clifford
GM. Human papillomavirus types in
115,789 HPV-positive women: a meta- Nov 2011
Jun 2015
analysis from cervical infection to cancer. Int J Cancer. 2012;131(10):234959.
Li N, Franceschi S, Howell-Jones
R, Snijders PJ, Clifford GM. Human papillomavirus type distribution in 30,848 invasive cervical cancers worldwide: Variation by geographical region, histological type andyear of publication. Int J Cancer.
2011;128(4):927-35.
Continued on next page

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HUMAN PAPILLOMAVIRUS (HPV) RELATED STATISTICS

Site/lesion for
HPV
prevalence statistics

Anal,
vulvar,vaginal cancers
and precancerous
lesions

Penilecancerand precancerous
lesions- xvii -Table 4 – continued from previous page
Date of update Date of updateofthemost HPV InformaReferences
recent original tion centre in
publication
October, 2021
Smith JS, Lindsay L, Hoots B, Keys
J, Franceschi S, Winer R, Clifford
GM. Human papillomavirus typedistribution in invasive cervical cancer
and high-grade cervical lesions: ameta-analysis update. Int J Cancer.
2007;121(3):621-32.
Clifford GM, Smith JS, Plummer M,
Munoz N, Franceschi S. Human papillomavirus types in invasive cervicalcancer worldwide: a meta-analysis. Br
J Cancer. 2003;88(1):63-73.
Clifford GM, Smith JS, Aguado T,
Franceschi S. Comparison of HPV type
distribution in high-grade cervical lesions and cervical cancer: a metaanalysis. Br J Cancer. 2003 Jul
7;89(1):101-5.
Bouvard V, Baan R, Straif K, Grosse
Y, Secretan B, El Ghissassi F,
Benbrahim-Tallaa L, Guha N, Freeman C, Galichet L, Cogliano V,onbehalf of the WHO International Jun 2015
Jun 2015
Agency for Research on Cancer Monograph Working Group.
2012.
A
review of human carcinogens-Part B:
biological agents.
De Vuyst H, Clifford GM, Nascimento
MC, Madeleine MM, Franceschi S.
Prevalence and type distribution of human papillomavirus in carcinoma andintraepithelial neoplasia of the vulva,
vagina and anus: a meta-analysis. Int
J Cancer. 2009;124(7):1626-36
Bouvard V, Baan R, Straif K, Grosse
Y, Secretan B, El Ghissassi F,
Benbrahim-Tallaa L, Guha N, Freeman C, Galichet L, Cogliano V,onbehalf of the WHO International Jun 2014
Jun 2015
Agency for Research on Cancer Monograph Working Group.
2012.
A
review of human carcinogens-Part B:
biological agentsContinued on next page

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HUMAN PAPILLOMAVIRUS (HPV) RELATED STATISTICS

Site/lesion for
HPV
prevalence statistics

Anogenital sites
in Men from thegeneralpopulation or from
special subgroups

Head and neckcancers- xviii -Table 4 – continued from previous page
Date of update
of
the
most
References
recent original
publication
Miralles-Guri C, Bruni L, Cubilla AL,
Castellsagué X, Bosch FX, de Sanjosé S. Human papillomavirus prevalence and type distribution in penile
carcinoma.
J Clin Pathol.
2009
Oct;62(10):870-8.
Smith JS, Gilbert PA, Melendy A,
Rana RK, Pimenta JM. Age-specificprevalence of human papillomavirus
Oct 2015
infection in males: a global review. J
Adolesc Health. 2011 Jun;48(6):54052.
Dunne EF, Nielson CM, Stone KM,
Markowitz LE, Giuliano AR. Prevalence of HPV infection among men: A
systematic review of the literature. J
Infect Dis 2006;194:1044–57.
Olesen TB, Munk C, Christensen J,
Andersen KK, Kjaer SK. Human papillomavirus prevalence among men in
sub-Saharan Africa: a systematic review and meta-analysis. Sex Transm
Infect 2014.
Hebnes JB, Olesen TB, DuunHenriksen AK, Munk C, Norrild
B, Kjaer SK. Prevalence of Genital
Human Papillomavirus among Men in
Europe: Systematic Review and MetaAnalysis. J Sex Med 2014;11:2630–44.
Ndiaye C, Mena M, Alemany L, Arbyn M, Castellsagué X, Laporte L,
et al.
HPV DNA, E6/E7 mRNA,and p16INK4a detection in head and Feb 2012neck cancers: a systematic review
and meta-analysis.
Lancet Oncol
2014;15:1319–31.
Kreimer AR, Clifford GM, Boyle P,
Franceschi S. Human papillomavirus
types in head and neck squamous cell
carcinomas worldwide: a systematic
review. Cancer Epidemiol Biomarkers
Prev 2005;14:467–75.

Date of update
HPV Information centre in
October, 2021

Oct 2015

Feb 2012

Continued on next page

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HUMAN PAPILLOMAVIRUS (HPV) RELATED STATISTICS

Site/lesion for
HPV
prevalence statistics

Head and neckin healthy population- xix -

Table 4 – continued from previous page
Date of update
of
the
most
References
recent original
publication
Mena M, Taberna M, Monfil L, Arbyn M, de Sanjosé S, Bosch FX, Alemany L, Bruni L. Might Oral Human Papillomavirus (HPV) Infection
in Healthy Individuals Explain Differ- May 2015
ences in HPV-Attributable Fractions in
Oropharyngeal Cancer? A Systematic
Review and Meta-analysis. J Infect
Dis 2019;219(10):1574-1585.

Date of update
HPV Information centre in
October, 2021

Oct 2021

Methods of estimation
HPV prevalence estimates are computed following the methodology of the papers above (table 4) and as
follows.

Systematic review of the literature
The HPV Information Centre follows standardized procedures to review the literature (Figure 1). First
search is performed through MESH terms and key words depending on the indicator in search engines
such as Pubmed or Scopus. Other search engines include LILACS, IME, Google scholar. A first screening round is done using were very sensitive search terms but unspecific, such as "HPV". Additionally,
to improve specificity, a second round of searches and screening is made specifying the generic searchterms as before but together with the name of each country one by one.
Selection of papers is done according to pre-established inclusion/exclusion criteria (Table 5). A first
triage is done by title and abstract, but a second triage is done at full text level. Full texts are also
screened for further references that may meet inclusion criteria but are missed by search engines.
Quality control ensures that at least a fraction of the papers are reviewed by another reviewer as well.
Discrepancies and doubts are resolved by consensus within the reviewers. Eventually, authors are requested to provide further detail of data if targeted data is incomplete. Data is entered in the system
database by the reviewers themselves and afterwards is validated and statistically analysed.

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HUMAN PAPILLOMAVIRUS (HPV) RELATED STATISTICS

Figure 1: Algorithm for the systematic review

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HUMAN PAPILLOMAVIRUS (HPV) RELATED STATISTICS- xxi -

Table 5: Search terms and inclusion and exclusion criteria for HPV statistics
Site/lesion for HPV prevalence
Generic search terms
Criteria
statistics
Detailed description of HPV
detection methodology
HPV DNA detection by meansof PCR or HC2
Minimum number of cases:
1st round: "HPV" AND- Initially (until 2009): at"cerv*"
least 100 cases
Women with normal cytology
2nd round: "HPV" AND- 2011-onwards:
specific country name• 100 cases in the absenceof other studies in the country• Same magnitude or morecases than studies already included in the country (USA/Canada, pending Europe)
Detailed description of HPV
detection methodology
HPV DNA detection by meansof PCR
Genotype distribution performed.
Since 2011 only
studies genotyping at least 2
1st round: "HPV" AND HPV types in the absence ofother studies in the country,"cerv*"
Low- and high-grade cervical lesions
2nd round: "HPV" AND otherwise at least 5 genotypes
testedspecific country nameMinimum number of cases:- Initially (until 2011): At
least 20- 2011-onwards: 20 cases in
the absence of other studies in
the country, otherwise at least
100 cases tested
Continued on next page

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HUMAN PAPILLOMAVIRUS (HPV) RELATED STATISTICS- xxii -Table 5 – continued from previous page
Site/lesion for HPV prevalence
Generic search terms
Criteria
statistics
Detailed description of HPV
detection methodology
HPV DNA detection by meansof PCR
Genotype distribution performed.
Since 2011 only
studies genotyping at least 2
1st round: "HPV" AND HPV types in the absence ofother studies in the country,"cerv*"
Invasive cervical cancer
2nd round: "HPV" AND otherwise at least 5 genotypes
testedspecific country nameMinimum number of cases:- Initially (until 2011): At
least 20 cases- 2011-onwards: 20 cases in
the absence of other studies in
the country, otherwise at least
50 cases tested
Detailed description of HPV
detection methodology
HPV DNA detection by means"HPV" AND ("anus" ORof PCR
Anal, penile, vulvar, vaginal cancers"anal") OR ("penile") OR
Genotype distribution perand precancerous lesions"vagin*" OR "vulv*"
formedMinimum number of cases: atleast 10 cases
Detailed description of HPV
Anogenital sites in Men from the gendetection methodology
eral population or from special sub- "HPV" AND "Male"HPV DNA detection by meansgroupsof PCR or HC2. (ISH if there
is no country data)
Detailed description of HPV
detection methodology
HPV DNA detection by meansof PCRAt least one of the following"papillomaviridae"
and cancer sites or subsites: oral
"head and neck neo- cavity, oropharynx, hypopharplasms" in combination ynx, and larynx
Head and neck cancers
with keywords "poly- Identification of the histologimerase chain reaction" or cal classification as squamous"PCR"
cell carcinoma
Primary tumour
Diagnosis of a tumour confined in only one site
Minimum number of cases: atleast 20 cases
Continued on next page

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HUMAN PAPILLOMAVIRUS (HPV) RELATED STATISTICS- xxiii -Table 5 – continued from previous page
Site/lesion for HPV prevalence
Generic search terms
Criteria
statistics
Detailed description of HPV
detection methodology.
Minimum number of cases: atleast 50 healthy individuals.
The following exclusion criteria were used:studies
involving subjects vaccinatedagainst HPV, individuals with
HPV-related pathology and"oral"
and("papillo- other high-risk populations;
Head and neck in healthy population
studies involving
mavirus" or "HPV").
pregnant women or infants
and children (age <=13 years);studies that had HPV test
results for <50 subjects anddid not use DNA-based HPV
testing methods; and studies
that did not provide information on the sex distribution ofparticipants.

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HUMAN PAPILLOMAVIRUS (HPV) RELATED STATISTICS- xxiv -Statistical analysis
For each study included in any of the categories above, at least the following data are collected: thenumber of cases tested, the number of cases positive for HPV, the number of cases positive for eachspecific HPV type tested, and the HPV detection technique. These numbers can be stratified by age
group in the case of women with normal cytology, histology in the case of cancers, sex when applicableand some special populations such as MSM or HIV.
The number of cases tested and HPV positive extracted for each study are pooled to estimate the prevalence of HPV DNA and the HPV type distribution by country, geographical region and globally. Pools
are made by the summation of the number of cases positives for HPV divided by the summation of cases
tested from all the studies. HPV prevalences are presented as percentages and binomial 95% confidence
intervals using the score method (Wilson) are calculated for each of them.
Disaggregation
Data are presented disaggregated by sex, age and histological groups (squamous cell carcinoma, adenocarcinoma, and unspecified histology) when available.
Comments
Because of limitations of the HPV DNA detection techniques and study designs used, data should beinterpreted cautiously and used only as a guidance to assess the burden of HPV infection in the population.

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FACTORS CONTRIBUTING TO HPV-RELATED CANCERS- xxv -

6

Factors contributing to HPV-related cancers

6.1

Smoking (Current smoking of any tobacco prevalence, Daily smoking of any tobacco prevalence, Current cigarette smoking prevalence, Daily cigarette smoking prevalence)

Definitions
The percentage of men and women who smoke:
Smoking any tobacco product
Smoking any form of tobacco, including cigarettes, cigars, pipes, or any other smoked tobacco products
and excluding smokeless products.
Smoking cigarettes
Smoking manufactured cigarettes.
Current smoking
Smoking at the time of the survey, including both daily and non-daily or occasional smoking.
Daily smoking
Smoking every day at the time of the survey.

Data Sources
WHO global report on trends in prevalence of tobacco use 2000–2025, third
edition. Geneva: World Health Organization; 2019. Available at https://www.who.int/publications/

i/item/who-global-report-on-trends-in-prevalence-of-tobacco-use-2000-2025-third-edition
Methods of estimation
WHO global report on trends in prevalence of tobacco use 2000–2025, third
edition. Geneva: World Health Organization; 2019. Available at https://www.who.int/publications/

i/item/who-global-report-on-trends-in-prevalence-of-tobacco-use-2000-2025-third-edition

Disaggregation
Sex

Comments
None

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FACTORS CONTRIBUTING TO HPV-RELATED CANCERS

6.2- xxvi -ParityDefinitions
Parity is the number of times a woman has given birth. High parity has been associated with an increased risk of invasive cervical cancer.
Total fertility rate
Total fertility rate is the average number of live births per woman, assuming the age-specific fertility
rate observed in a given year or period.
Age-specific fertility rate
Age-specific fertility rate is the annual number of births per 1000 women in a particular age group in agiven year or period.
Data Sources
United Nations, Department of Economic and Social Affairs, Population Division (2017). World Population Prospects: The 2017 Revision, DVD Edition. Available at: https://www.un.org/en/development/
desa/population/publications/dataset/fertility/wfd2017.asp. [Accessed on November 13, 2019].

Methods of estimation
United Nations, Department of Economic and Social Affairs, Population Division (2017). World Population Prospects: The 2017 Revision, DVD Edition. Available at: https://www.un.org/en/development/
desa/population/publications/dataset/fertility/wfd2017.asp. [Accessed on November 13, 2019].

Disaggregation
Age

Comments
None

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FACTORS CONTRIBUTING TO HPV-RELATED CANCERS

6.3- xxvii -Oral Contraceptive Use

Refer to Contraceptive Use (7.3) in the Reproductive Health section of the indicator guidelines for definition, source and methods of estimation.

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FACTORS CONTRIBUTING TO HPV-RELATED CANCERS

6.4- xxviii -Human immunodeficiency virus (HIV) prevalence

Definitions
Adults and children HIV estimates
Estimated number of adults (15+ years) and children (0-14 years) living with HIV.
Adults (15+ years) HIV estimate
Estimated number of adults (15+ years) living with HIV.
Adults (15-49 years) HIV prevalence (%)
The percentage of adults aged 15-49 years living with HIV.
Women (15+ years) HIV estimate
Estimated number of women (15+ years) living with HIV.
Young women (15-24 years) HIV rate (%)
Estimated percentage of young women aged 15-24 living with HIV.
Young men (15-24 years) HIV rate (%)
Estimated percentage of young men aged 15-24 living with HIV.
AIDS deaths in adults and children
Estimated number of AIDS deaths in adults (15+ years) and children (0-14 years).
HIV prevalence among female sex workers in the capital city
Estimated percentage of female sex workers in the capital city living with HIV.
HIV prevalence among men who sex with men in capital city
Estimated percentage of men who have sex with men in the capital city living with HIV.
Data Sources
UNAIDS database [internet]. Available at: http://aidsinfo.unaids.org/ [Accessed on November
21, 2019]
Methods of estimation
Figures are based on modelled HIV estimates. Please see the "Annex on methods" from "Seizing the
moment—Tackling entrenched inequalities to end epidemics" for more information on HIV estimates
methodology. Available at: https://www.unaids.org/en/resources/documents/2020/global-aids-

reportDisaggregation
Sex
Comments
None

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SEXUAL AND REPRODUCTIVE HEALTH BEHAVIOUR INDICATORS- xxix -7

Sexual and reproductive health behaviour indicators

7.1

Time of sexual intercourse/High-risk sexual behaviour

Definitions
Time of sexual intercourse
Median age at first sexual intercourse among young men and women
The age by which half of young people aged 15-24 have had penetrative sex (median age).
Median age at first sexual intercourse among men (25-54 years) and women (25-49 years)
The age by which half of people aged 25-54 years have had penetrative sex (median age).
Sex before age of 15% of young people aged 15-24 who had penetrative sexual intercourse before the age of 15.
Abstinence of never-married young men and women
Proportion of never married young women and men aged 15-24 who have never had sex.
High-risk sexual behaviour
Extramarital sex
Percentage of respondents who have had sex with a non-marital, non-cohabiting partner in the last 12
months of all respondents who have reported sexual activity in the last 12 months.
Commercial sex in the last year
Percentage of male respondents reporting sex with a sex worker in the last 12 months.
Multiple partners in the last year among sexually active respondents aged 15-49
Percentage of women and men age 15-49 who have had sexual intercourse with more than one partnerin the last 12 months, among respondents aged 15-49, who were sexually active in the last 12 months.
Data Sources
Welling K, Collumbien M, Slaymaker E, Singh S, Hodges Z, Patel D, Bajos N. Sexual behaviouir in context: a global perspective. Lancet 2006; 368(9548):1706-28.
Estimates are derived from available survey data from nationally representative population-based
surveys undertaken such as the MEASURE DHS (Demographic and Health Surveys, http://www.
measuredhs.com) project, national survey data, and from Reproductive Health Surveys.
Methods of estimation
Methods are specific to each survey used. Refer to country-specific reference for full description of
methodologies used.
Disaggregation
Age and sex
Comments
None

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SEXUAL AND REPRODUCTIVE HEALTH BEHAVIOUR INDICATORS

7.2- xxx -

Marriage Patterns

Definitions
Average Age at first marriage
Average age at which men or women ever married between the ages of 15 and 50 years, an age after
which first marriages are rare.

Percentage of ever married, (%)
Proportion of ever married persons aged 15-19, 20-24, and 40-48.

Difference in Average Age at First Marriage between Men and Women% of young people aged 15-24 who had penetrative sexual intercourse before the age of 15.

Women aged 15-49, married or in union
Number of women of reproductive age (15-49 years) who are married or in a union. A union is involves
a man and a woman regularly cohabiting in a marriage-like relationship.

Data Sources
United Nations, Department of Economic and Social Affairs, Population Division (2019). World Marriage Data 2019 (POP/DB/Marr/Rev2019). Available at: https://population.un.org/MarriageData/
Index.html#/home Accessed on February 24, 2020

Methods of estimation
Estimates are derived from censuses, surveys, and civil registries. The data is housed within databases
maintained by the Population Division and the Statistics Division of the United Nations Department of
Economic and Social Affairs.
Estimates and projections of the number of married or in-union women of reproductive-age (15-49 years)
are provided for the period from 1970 to 2030 for 201 countries or areas, and for regions and development groups. Estimates and projections of the proportions of married or in-union women, by five-year
age group and for women of reproductive-age (15-49 years), are provided for the period from 2000 to
2030 for 201 countries or areas.

Disaggregation
Age and sex

Comments
None

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SEXUAL AND REPRODUCTIVE HEALTH BEHAVIOUR INDICATORS

7.3- xxxi -Contraceptive Use

Definitions
Any contraceptive use, (%)
Contraceptive prevalence is the proportion of women who are using (or whose partner is using) a contraceptive method among those of reproductive age (15-49 years) who are married or in union.
Prevalence of modern methods, (%)
Prevalence of modern methods is the proportion of women using modern method contraception among
those of reproductive age (15-49 years) who are married or in union.
Modern methods include: sterilization (male/female); oral contraceptives/pill; injectable or implant; intrauterine device (IUD); condoms; vaginal barrier methods (diaphragms, cervical caps and spermicidal
foams, jelly, cream and sponges); other methods (emergency contraception, female condom and modern
methods not reported separately).
Sterilization, (%)
Proportion of women or male partners who were sterilized, among women of reproductive age (15-49
years) who are married or in union.
Oral Contraceptive Use / Pill, (%)
Proportion of women using oral contraceptives, also known as the pill, among those of reproductive age(15-49 years) who are married or in union.
Injectable (%)
Proportion of women using hormonal contraception in the form of injections among those of reproductive age (15-49 years) who are married or in union.
Implant (%)
Proportion of women using hormonal contraception in the form of implants among those of reproductiveage (15-49 years) who are married or in union.
Intrauterine device (IUD), (%)
Proportion of women using intrauterine device as a form of birth control among those of reproductiveage (15-49 years) who are married or in union.
Condom use, (%)
Proportion of male partners who are using condoms with their female partners of reproductive age (1549 years) who are married or in union.
Vaginal barrier method, (%)
Proportion of women using barrier methods among those of reproductive age (15-49 years) who are married or in union.
Vaginal barrier methods include diaphragms, cervical caps and spermicidal foams, jelly, cream andsponges.
Other modern methods, (%)
Proportion of women using other methods among those of reproductive age (15-49 years) who are married or in union. Other modern methods include emergency contraception, female condom and modern
methods not reported separately.
Contraception of other traditional methods, (%)
Proportion of women using traditional methods among those of reproductive age (15-49 years) who are
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SEXUAL AND REPRODUCTIVE HEALTH BEHAVIOUR INDICATORS- xxxii -married or in union.
Traditional methods include rhythm (periodic abstinence or the calendar method), withdrawal andother methods (Including prolonged abstinence, breastfeeding, douching, various folk methods and traditional methods not reported separately).
Rhythm, (%)
Proportion of women using the traditional contraceptive method of rhythm, also known as periodic abstinence or the calendar method, among those of reproductive age (15-49 years) who are married or inunion.
Withdrawal, (%)
Proportion of women using the traditional contraceptive method of withdrawal among those of reproductive age (15-49 years) who are married or in union.
Other traditional method, (%)
Proportion of women using other traditional contraceptive methods among those of reproductive age(15-49 years) who are married or in union. Other traditional methods include prolonged abstinence,breastfeeding, douching, various folk methods and traditional methods not reported separately.
Data Sources
United Nations, Department of Economic and Social Affairs, Population Division (2020). World Contraceptive Use 2020 (POP/DB/CP/Rev2020). Available at https://www.un.org/en/development/desa/

population/publications/dataset/contraception/wcu2020.asp

Methods of estimation
The indicators presented have been estimated using data from nationally-representative household surveys for women of reproductive age (from 15 to 49 years). Data pertain to countries or areas of the worldfrom 1950 or later. For country estimates, the most recent data came from the United Nations Population Division based on survey data. Weights used are the estimated numbers of women aged 15-49 whoare married or in a consensual union.
The number of women of reproductive age who are married or in a consensual union was estimatedbased on data on the proportion of women married or in union in each country containined in World
Marriage Data and on estimates of the number of women by age group obtained from World Population
Prospects.
Disaggregation
Sex (prevalence of sterilization)
Comments
None

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HPV PREVENTIVE STRATEGIES

8HPV Preventive strategies

8.1

Cervical cancer screening practices- xxxiii -Cervical cancer screening, recommended age for screening, screening interval, estimatedscreening coverage, screening tests
Definitions
Pap smear
Cervical cancer screening is a public health intervention used on a population at risk or target population. A Papanicolau (or Pap) smear is a cervical screening test used to detect premalignant andmalignant (cancerous) processes in the ectocervix. A medical professional uses a swab or stick to wipe
cells off from the cervix, the opening lining of the womb (uterus) and these cells are then evaluated todetermine presence or absence of abnormalities. Screening is not undertaken to diagnose cervical cancer disease, but to identify individuals with a high probability of having or developing cervical cancer(by detecting precancerous changes in the cervix uteri, which untreated, may lead to cancer). Histological diagnosis is the "gold standard" for identifying precancerous and cancerous lesions.

Screening interval (years) or frequency of screens
The recommended interval between one screening test and the subsequent test when the result is negative for abnomalities. Recommendations may vary between organizations and guidelines, so a rangeof the screening interval is recorded in some instances.

Lifetime number of recommended smears
Proportion of women in the target age group who are screened at the recommended age intervals during a given time period. The number of screening tests performed is not considered coverage, since thisnumber may include women outside the target group, and women may be screened more often thanrecommended.

Number of women
Number of women in the sample who have been asked about their Pap smear history.

Age range
Age interval of the sample of women who received a Pap smear ranging form the youngest to the oldest
woman.

Estimated coverage of cervical screening within the last year(s)Proportion of women in the total sample of the mentioned age range in the country or region that reported having a Pap smear during a given time period (e.g., last year, last 2, 3, 5 years or ever).

Populations studied
General female population
Sample of women representative of the general population of the specific country and the specific age
range. The information is generally collected directly from households through national censuses, ormore commonly through household surveys. The latter may be collected as part of a broader national
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HPV PREVENTIVE STRATEGIES- xxxiv -survey or may be focused only on health topics.
National screening programme
Women of a determined age range are invited (actively or not) to attend the screening programmethroughout the whole nation or country. National guidelines specify who are at risk of cervical cancer
and eligible to attend the programme. Eligible women may attend regularly within the specified interval. Different screening intervals may apply depending on age. This sample of women is based on
information extracted from the registry data and it generally addresses women of reproductive age.
Regional screening programme
Women attending a screening programme in a specific region or city. The sample may not represent
women from the whole country.
Women attending health services
Women visiting health care facilities: primary health care centres, antenatal clinics, sexually transmitted infections clinics, family planning clinics, gynaecology/obstetrics wards or hospitals for any reason
who receive a Pap smear. This sample of women may be more health conscious or wealthy than the general population, thus classified separately to avoid selection bias as they may not be representative of
the whole female population. More information on the sample may be included in the comments section.
Selected sample
Group of women with specific attributes that have been asked regarding their last Pap smear. See description of sample in the comments section.
Health care personnel
Sample of female health care attendants asked for their level of utilization of Pap smears to provide an
insight into the general knowledge and awareness of the community. Health care providers may play asignificant role in dissemination of medical information in the community, and increase the utilizationof cytology services if aware of the benefits of screening.

National or regional coverage
National coverage presents data representative of the majority of women in the mentioned country. Regional data applies to the screening coverage representative of the majority of women in the mentioned
region or city.
Data Sources
IARC Handbooks of Cancer Prevention Vol. 10: Cervix Cancer Screening. IARC Press. Lyon, 2005.
Ronco G, van Ballegooijen M, Becker N, Chil A, Fender M, Giubilato P, et al. Process performanceof cervical screening programmes in Europe. Eur. J. Cancer. 2009 Oct;45(15):2659-2670.
Country-specific references identified in each country-specific report as general recommendation fromrelevant scientific organizations and/or publications.
Disaggregation
When available, data are disaggregated by rural or urban; by region when available; by type of population (general population, national screening programme, or other).
Comments
A summary of facts and figures are reported from the data sources of cervical cancer screening in the defined country, which is complementary to the other data presented, providing a screening profile within
their health system setting and an overview of each country’s cervical cancer situation. Data may be
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HPV PREVENTIVE STRATEGIES- xxxv -contradictory for the same country in some instances but it reflects the available literature of the different sources.
For additional data that may aid in the understanding of the presented values, refer to the originalreferences for the population studied.

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HPV PREVENTIVE STRATEGIES

8.2- xxxvi -HPV vaccination

Definitions
HPV vaccine introduction
HPV vaccine introduction into national immunization programmes
HPV vaccination program coverage
Describes the vaccination coverage according to the national schedule and the program’s eligibility criteria for each calendar year. It represents the number of doses of HPV vaccines provided in the calendar
year as a fraction of the program’s target population up to 14 years of age. Note that most countries
vaccinate a single cohort and current estimate excludes the population aged 15 and above even if they
were vaccinated in the given calendar year.
Vaccine in schedule
Whether or not the HPV vaccine is introduced as part of the vaccination schedule in the country andthe schedule of the doses vaccine.
Introduction in entire/part of the country
Year of introduction of the HPV vaccine in the entire or part of the country.
Vaccine schedule
Immunisation schedules for each country.
Recommendation for primary target population
Primary target ages for HPV vaccination.
Recommendation for catch-up population
Whether or not there is a program for catch-up vaccination for those not included in the primary target
population.
Data Sources
Human papillomavirus (HPV) vaccination coverage. World Health Organization. 2021. Available from:https://immunizationdata.who.int/pages/coverage/hpv.html, accessed [20 sep 2021]
Bruni L, Saura-Lázaro A, Montoliu A, Brotons M, Alemany L, Diallo MS, et al. HPV vaccination introduction worldwide and WHO and UNICEF estimates of national HPV immunization coverage 20102019. Prev Med. 2021;144(106399):106399.
Methods of estimation:
WHO and UNICEF collect information on new vaccines introduction. Refer to the reference Bruni L etal. Prev Med.2021;144(106399):106399.
Disaggregation
First dose and the full recommended schedule, and sex
Comments
None

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PROTECTIVE FACTORS FOR CERVICAL CANCER

9

Protective factors for cervical cancer

9.1

Male circumcision- xxxvii -Definitions
Circumcision
Surgical removal of the foreskin on the penis or prepuce.

Prevalence of circumcision
The prevalence of circumcision (or circumcision rate) refers to the proportion of males that are circumcised in a given population. It may also refer to the proportion of newborn males that are circumcised.

Data Sources
Refer to country report for specific references. The main data sources are:
Systematic reviews and meta-analysis performed by ICO. The ICO HPV Information Centre has updated data until August 2015. Reference publication: Albero G, Sex Transm Dis. 2012 Feb;39(2):104-13.
Williams BG, Lloyd-Smith JO, Gouws E, Hankins C, Getz WM, Hargrove J, de Zoysa I, Dye C, Auvert
B. The potential impact of male circumcision on HIV in Sub-Saharan Africa. PLoS Med. 2006;3(7):e262.
Drain PK, Halperin DT, Hughes JP, Klausner JD, Bailey RC. Male circumcision, religion, and infectious diseases: an ecologic analysis of 118 developing countries. BMC Infect Dis. 2006 Nov 30;6:172.
World Health Organization, Department of Reproductive Health and Research and Joint United Nations Programme on HIV/AIDS (UNAIDS). Male circumcision: global trends and determinants of prevalence, safety and acceptability. 2007. Available from: http://www.who.int/reproductivehealth/publications/rtis/9789241596169/en.

Methods of estimation
Refer to country-specific reference(s) in the country-specific report for full methodologies.

Disaggregation
None

Comments
None

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PROTECTIVE FACTORS FOR CERVICAL CANCER

9.2- xxxviii -Condom use

Refer to Condom use (7.3) in the Reproductive Health section of the indicator guidelines for definition,
source and methods of estimation.

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DEMOGRAPHIC AND SOCIOECONOMIC FACTORS

10

Demographic and socioeconomic factors

10.1

Population- xxxix -Definitions
Total Population
Population estimates include all residents regardless of legal status or citizenship.

Data Sources
United Nations, Department of Economic and Social Affairs, Population Division (2019). World Population Prospects 2019, Online Edition. Rev. 1. Available at: https://population.un.org/wpp/

Download/Standard/Population/

Methods of estimation
World Bank staff estimates are derived from civil registration, population registers, other administrative records, population and censuses, social and demographic surveys.

Disaggregation
Age and sex

Comments
None

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Acknowledgments
This report has been developed by the Unit of Infections and Cancer, Cancer Epidemiology Research
Program, at the Institut Català d’Oncologia (ICO, Catalan Institute of Oncology). This report was supported by a grant from the Instituto de Salud Carlos III (Spanish Government) through the projects
PI18/01137 and CIBERESP CB06/02/0073, and the Secretariat for Universities and Research of the Department of Business and knowledge of the Government of Catalonia grants to support the activities ofresearch groups (SGR 2017–2019) (Grant number 2017SGR1718). The report has also received funding
from the European Union’s Horizon 2020 research and innovation program under grant agreement No.
847845. We thank the CERCA Program / Generalitat de Catalunya for institutional support. The HPVInformation Centre is being developed by the ICO. The Centre was originally launched by ICO with thecollaboration of WHO’s Immunisation, Vaccines and Biologicals (IVB) department and support from theBill and Melinda Gates Foundation.
Institut Català d’Oncologia (ICO), in alphabetic order
Albero G, Bosch FX, Bruni L, Collado JJ, de Sanjosé S, Gómez D, Mena M, Muñoz J, Serrano B.
International Agency for Research on Cancer (IARC)

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