Chapter 3Infectious Diseases Related To Travel

Eileen F. Dunne, Lauri E. Markowitz

INFECTIOUS AGENT

Human papillomavirus (HPV) is a small DNA virus.

MODE OF TRANSMISSION

There are more than 100 HPV types. More than 40 mucosal HPV types are commonly found on the genitals and are transmitted primarily by sexual contact, most commonly sexual intercourse. Sometimes transmission occurs by other routes (such as mother-to-child transmission). Infection with HPV is specific to humans.

EPIDEMIOLOGY

HPV is common worldwide. Studies in multiple countries show that the prevalence of HPV varies from 3% to 70%. There are no unique or inherent risks for travelers.

CLINICAL PRESENTATION

HPV infection is usually subclinical and asymptomatic. HPV infection is presumed when there are anogenital warts or when cervical cell changes are detected on a Papanicolaou test (Pap test). Persistent HPV infection with oncogenic types can lead to cervical cancer; >70% of cervical cancers are caused by 2 HPV types, HPV 16 or 18. HPV can also cause rare conditions and cancers, including recurrent respiratory papillomatosis; anogenital cancers such as vaginal, vulvar, anal, and penile cancers; and certain oropharyngeal and oral cancers.

DIAGNOSIS

HPV infection is most commonly asymptomatic and transient. When clinical disease occurs, diagnosis is usually made when genital warts are seen in men or women, or by results of a Pap test, HPV test, or colposcopy in women. Definitive diagnosis is made by biopsy.

TREATMENT

There is no treatment for HPV, but there are treatments for HPV-associated conditions such as genital warts and cervical cell changes.

PREVENTIVE MEASURES FOR TRAVELERS

Vaccine

Two HPV vaccines, a quadrivalent HPV vaccine (HPV4) and a bivalent HPV vaccine (HPV2), are licensed and recommended for use in adolescents and young adults (Table 3-07).

• HPV4 is approved by the Food and Drug Administration (FDA) for girls/women and boys/men aged 9–26 years, although the Advisory Committee on Immunization Practices (ACIP) does not recommend HPV4 for routine use among boys or men.
• HPV2 is FDA approved for girls/women aged 10–25 years. HPV2 is not FDA approved for boys or men.

ACIP recommends routine vaccination of girls aged 11–12 years, although the vaccination series can be started beginning at age 9 years. Vaccination is recommended for girls/women aged 13–26 years who have not been vaccinated previously or who have not completed the 3-dose series. If a woman reaches age 26 years before the vaccination series is complete, remaining doses can be administered after age 26 years. Ideally, vaccine should be administered before potential exposure to HPV through sexual contact.

Cervical cancer screening with a Pap test should be continued even with vaccination, because the vaccine does not prevent all types of HPV associated with cervical cancers.

BIBLIOGRAPHY

1. CDC. FDA licensure of bivalent human papillomavirus vaccine (HPV2, Cervarix) for use in females and updated HPV vaccination recommendations from the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 2010 May 28;59(20):626–9.
2. CDC. FDA licensure of quadrivalent human papillomavirus vaccine (HPV4, Gardasil) for use in males and guidance from the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep. 2010 May 28;59(20):630–2.
3. Franceschi S, Herrero R, Clifford GM, Snijders PJ, Arslan A, Anh PT, et al. Variations in the age-specific curves of human papillomavirus prevalence in women worldwide. Int J Cancer. 2006 Dec 1;119(11):2677–84.
4. Markowitz LE, Dunne EF, Saraiya M, Lawson HW, Chesson H, Unger ER. Quadrivalent human papillomavirus vaccine: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 2007 Mar 23;56(RR-2):1–24.