Cervical cancer is predicted to strike 1 in 53 Indian women throughout their lifetime, compared to 1 in 100 women in more developed parts of the globe (Bobdey et al., 2016). In India, 122,844 women are diagnosed with cervical cancer each year, with 67,477 dying as a result of the disease. There are 432.2 million women in India aged 15 and up who are at risk of developing cancer. India also has the highest age-standardized incidence of cervical cancer in South Asia, with 22 cases per 100,000 people, compared to 19.2 in Bangladesh, 13 in Sri Lanka, and 2.8 in Iran (Bruni et al., 2023). As a result, it is critical to comprehend the epidemiology of cervical cancer in India. (Sreedevi et al., 2015). The elevated prevalence of HPV coupled with a low to moderate standard of living and inadequate screening, are the main factors contributing to the significant burden of cervical cancer in India and other Southeast Asian countries (Sankaranarayanan et al., 2001). The geographic, socioeconomic, cultural, and genetic factors related to the viral genome variability, as well as intrinsic individual factors such as age, gender, anatomic site, and health state, all have a significant impact on the epidemiologic distribution of HPV infection and HPV-associated burden ( LeConte et al., 2018). In the current study, we found 68 HPV high-risk positive infections from the 3009 samples screened. In the population that we screened, the total percentage of HPV positive was approximately 4%. The majority of Indian cancer registries report age-adjusted incidence rates of cancer cervix that are significantly higher than the global age-adjusted incidence rate of 7.9/100,000 population, but lower or comparable to cervical cancer incidence rates of 19.2/100,000 population seen in the Southeast Asian region (Bpbdey et al., 2016). Studies in India have reported varying prevalence rates (15–85%) of HPV infection in cervical cancer patients (Chatterjee et al., 2016).
In the present study, our analysis indicated that women within the age group 30–40 found to be prominently prone to HPV infection. In addition, among the samples analyzed in 2023, this age group had the highest number i.e., 36 positive samples as compared to the other age groups. Presently in India, cervical cancer exhibits a higher prevalence, particularly among sexually active women aged 15–44 years. Approximately 469.10 million women in India aged 15 years and above are at risk of developing cervical cancer. Annually, 122,844 women receive a diagnosis of cervical cancer, leading to 67,477 deaths each year from the disease (Bhattacharya et al.,2018). In Maharashtra, high-risk HPV are linked to advancing age, lower educational attainment, engagement in manual labor, an early onset of sexual activity, and being widowed or separated (Sauvaget et al., 2018).
The prevalence of HPV infection among Indian women has been noted to occur between the ages of 26 and 35, which is a decade later than in developed countries. In this demographic, cancer linked to HPV typically emerges between the ages of 45 and 59 (ICMR. 2014). Sharma et al. found that the highest prevalence of high-risk HPV was observed in the 15–35 age group, with a decrease in subsequent years (Sharma et al., 2012). A similar study by Dutta et al. has also shown that a higher risk of HPV infection was found in women aged 25–34 years, as well as in married women below 20 years of age and those with parity ≥ 4 (Dutta et al., 2012). A study by Travasso et al. highlighted that HPV infection is more common among adolescent and young adult girls in India's tribal regions compared to urban areas (Travasso et al. 2015). In addition to this Sharma et al., revealed a high prevalence of HPV infection in rural women, with increasing age being associated with higher HPV prevalence (Sharma et al., 2020). These papers collectively suggest that HPV prevalence varies across different age groups in the Indian population, with higher rates observed in younger age groups and specific demographic subgroups. Therefore, there exists a substantial time lag between the onset of infection and the development of invasive cancer, providing ample opportunities for preventive interventions.
Among 14 HPV high-risk strains observed in the study, HPV16 was the most prominent followed by HPV 33 then 18, and 51. Similar data as also shown by Kulkarni et al., found high prevalence rates of HPV 16 and 18 in cervical cancer patients in Karnataka, India (Kulkarni et al., 2011). Similarly, Vijayaraghavan et al found that 60% of invasive cervical cancer patients in South India were positive for HPV 16, while 22% were positive for HPV 18 (Vijayaraghavan et al.,2020). This is in line with the report by Bruni et al., where HPV16 and 18 have been the most prevalent oncogenic types in cancer accounting for > 83% of the cancer of the cervix cases (Bruni et al., 2023). It has been reported that the prevalence of any HPV is 9.9% in women without cervical cancer in Eastern India, where HPV 18 is more prevalent than HPV 16. This implies that type 16 infection is associated with higher oncogenicity (Dutta et al., 2012). A study conducted in Bihar, India also reported a very high prevalence of HPV 16 and 18 in cervical cancer patients (Kumar et al., 2021). We have also found the HPV 33 strain to be prominent in our study population. Basu et al. conducted a multi-center study in India and found that HPV-16 and HPV-18 were the most common types, but also detected HPV-33 in a smaller percentage of cases (Basu et al., 2009). In summary, our findings are in line with these studies suggesting that HPV types 16 and 18 are prevalent in the Indian population with cervical cancer. In patients from south and east India found that HPV-16 and HPV-18 were the most frequent types, but also identified HPV-33 among other high-risk types (Banerjee et al., 2020, Peedicayil et al., 2006). Several studies on the prevalence of HPV and the types associated with cervical cancer have been conducted across the country. In the north-eastern states of India like Sikkim and Manipur a comparative profile of the prevalence of human papillomavirus type 16/18 infections about age was done (Laikangbam et al., 2006). In South, Pargana, and West Bengal have found HPV 16, 18, and 33 are the most prevalent types (Duttagupta et al., 2002). It is dictated by this evidence that the most prevalent genotype of HPV is 16, followed by 18. HPV-33 is present in the Indian population with cervical cancer, although it may not be as prevalent as HPV-16 and HPV-18. While the specific prevalence of HPV 51 has not been mentioned, they do provide information on the overall prevalence of HPV genotypes in cervical cancer cases in India. A histopathological examination of tissue obtained through biopsy guided by colposcopy is the standard method for diagnosing cervical precancerous lesions. When abnormalities are found a cervical biopsy confirms the cancer diagnosis. In the present study, HPV 16 alone or a co-infection with other high-risk phenotypes showed Chronic cervicitis with moderately dysplastic changes in cervical intraepithelial neoplasia II (CIN II) and High-grade dysplasia CIN-III in patients. CIN is graded on a three-tiered scale based on the number of immature neoplastic basaloid cells involving the epithelium, cytologic atypia, and mitotic activity: High-Grade Squamous Intraepithelial Lesion (HSIL)/CIN2/3 and Low-Grade Squamous Intraepithelial Lesion (LSIL)/CIN1. LSIL/CIN1 is distinguished by the proliferation of immature basal/parabasal cells that extend no higher than one-third of the epithelial thickness. LSIL category includes HPV-associated cellular changes, mild dysplasia, and CIN1. On the other hand, HSIL includes moderate/severe dysplasia, CIS, and CIN2/CIN3. Because HPV16 oncoproteins play an important role in the development of cervical cancer, nucleotide variations in the HPV16 E6 and E7 genes are linked to cervical cancer progression (Dai et al.,2021). This is one of the reasons that HPV 16 has been shown to have most patients who have developed serious cervical intraepithelial neoplasia.
Conducting studies on HPV prevalence in India is imperative for several reasons. Firstly, understanding the prevalence of HPV infection is crucial for public health planning and policy formulation. Secondly, cancer screening has demonstrated its ability to reduce mortality by facilitating early diagnosis and treatment. To effectively decrease the death rate from cancer, two conditions must be met in screening. Firstly, the screening process should expedite the detection of tumors that have the potential to become fatal. Secondly, there should be a discernible advantage in treating these malignancies at an early stage compared to when they initially appear. Despite the existence of HPV vaccines and cost-effective technologies for the early detection and management of cervical cancer in the contemporary era, it continues to pose a significant public health challenge in India.
Nene et al. investigated the factors associated with cervical cancer screening and treatment, as well as the cost-effectiveness of visual inspection with acetic acid (VIA), cytological screening, and HPV testing in lowering the incidence and mortality from carcinoma cervix in Maharashtra (Nene et al., 2007). To achieve the coverage required for an effective decline in cervical cancer mortality, a less invasive and more user-friendly primary screening strategy, such as self-collected swabs or urine for HPV-DNA testing is the need of the time. The strategic integration of effective cervical cancer screening initiatives and robust HPV vaccination programs would greatly facilitate the eradication of cervical cancer in both India and globally. Recently, the Indian Ministry of Health and Family Welfare communicated with seven state governments, spanning from Himachal Pradesh in the northern region to Tamil Nadu in the southern part of the country, urging them to initiate preparations for the implementation of the HPV vaccine targeting girls aged 9–14 years. These initiatives mark the initial phase of India's planned introduction of the HPV vaccine. Once the specified states have completed the vaccination of children aged 9–14 years, the HPV vaccine will be integrated into their routine immunization programs. The comprehensive plan aims to vaccinate 68 million girls in India against HPV by the program's conclusion (Burki et al., 2023).
India has distinct demographic, cultural, and healthcare characteristics that can influence the prevalence of HPV. Investigating these factors helps tailor interventions to the specific needs of the population, considering regional variations and socio-economic factors. Prevalence studies contribute valuable data that can be utilized to design educational campaigns, raising awareness among healthcare professionals and the general public.