The infection with human papilloma virus and cervical cancer

Bad habits can cause skin infections are common. So far it is estimated
That the warts of the skin are present in 10% of the population, but this figure only considers the obvious warts. Beginning in the mid-sixties there has been an increase in sexually transmitted wart, or condylomata acuminata, and now the epidemiological studies indicate that the genital infection caused by the human papillomavirus (HPV) is the most common Sexually transmitted. It is estimated that 5 to 20% of the sexually-active mind has warts sexually transmitted.
Of the human papillomavirus (HPV) is not the only virus linked to cancer in humans, but the more significant. HPV infection is a cause for the development of cervical cancer. In a global study, reported in 1991, was found HPV DNA in 93% of the tumors of this type of cancer. The problem does not end there: behind him are all women with pre-malignant lesions, namely those where the infection becomes chronic and causes cellular changes prior to cancer, which is known as cervical intraepithelial neoplasia.

Immunosuppressed patients such as AIDS patients and those undergoing immunosuppressive therapy because of organ transplants, are more susceptible to HPV infection than the general population.

What is human papillomavirus?
In general, HPV are widely distributed throughout the world and even infect several animal species, are more common in humans. The infección1 HPV is very common and occurring mainly in the skin and mucous membranes. This type of virus is related to various injuries, including benign and malignant tumors. HPV infection is also associated with cancer of the larynx, trachea, bronchi, digestive tract, penis, prostate, bladder, renal pelvis, endometrium, ovaries and mammary glands, but with less intensity than cervical cancer.

The skin infections occur in a predisposed due to superficial lesions, are self inoculated, in some cases can be transmitted from person to person by sexual contact. People with immunodeficiencies (low defenses) suffer from warts and scattered forms very resistant to treatment.

Warts and HPV
Certain types of warts are a symptom of HPV infection. There are many types of HPV, as they have identified more than 100, but only 15 of them are considered high risk for cervical cancer, it is that they can develop pre-malignant lesions and cancer in the neck of the womb. HPV 16 and HPV 18 causes 70% of cases of cervical cancer.
Some viruses that involve less risk can also cause certain types of warts:
Warts vulgar. Popularly known as petty, these warts can be seen anywhere on the body, especially on the exposed parts of skin, such as face, hands and forearms. They can be single or multiple lesions, irregular surface rough and dry skin color or grayish. When presented on the edge of the nail can deform and cause much pain. The warts of the mouth are called papillomas, and can be disseminated within it.
Flat warts or juveniles. They are small lesions that form a slight stress on the skin is the color of the skin and usually very numerous, but gave no discomfort.
Plantar warts or "fish eyes." Are located on the soles of the feet or between the toes, you can submit a single wart or joined up to thirty or forty injury, giving the appearance of mosaic; are yellowish white with some dark areas or bleeding. Pressuring the hurt. They can last for months or years and heal without leaving a scar.

Condylomata. Injuries are soft pink salmon or gray, with small projections digitiformes looking cauliflower, you can submit one or more. Shown on wet surfaces, preferably at the level of foreskin, in the urethral meatus, the vulva, vagina and perianal region. One serious consequence of infection with these types of viruses are the genitoanales malignancies, particularly cervical cancer. After which the infection can spend three weeks to eight months to demonstrate the condylomata, hence the importance of being vigilant to prevent this serious disease.
Some warts disappear without treatment, this can take up to two years. Whether they are treated or not, warts can reappear. Genital warts are highly contagious, while common warts, flat and plantar have much less likely to spread from person to person, but it is common that some warts will disseminate in the body.

Can I prevent HPV infection?
The human papilloma virus have lived with us for a long time, so most we become immune to certain types of HPV, other viruses are inactivated and lose their power with infectious detergents, but it is also true that resist temperatures of up to 55 ° C, as well as freezing and drying. However, of more than 100 types identified to date, 35 have been found on the genitals and 11 of them are considered high risk.

Treatments
The treatment continue to depend on each patient, the type of lesion and the site where it is located. In the surgical treatment using various techniques. Until now the treatment of HPV infection had been approached to eliminate advanced cervical lesions. The techniques used today are the cryosurgery, electrosurgery, and the Laser.
Today, the National Program for early detection of cervical cancer is the main measure to control the serious health problem which means that evil in Mexico, because of their frequency and the consequent deaths. Even if the test commonly known as Pap is not the ideal diagnostic method for HPV, the ability to detect one of its most severe, that is, pre-malignant lesions of the cervix. From March 2008 to the Mexican market, there are two vaccines available.

Risk factors for acquiring HPV infection
• Life sexually active.
• High-risk sexual practices, including having multiple sexual partners.
• Deficiency of folate and vitamins A, C and E because of an inadequate diet, which generally does not include enough fruit and vegetables.
• The suffering of diseases that suppress the body's defenses, such as HIV / AIDS, lupus or scleroderma (a chronic degenerative disease affecting the skin, joints and internal organs).
• Smoking.
• Medications such as birth control pills, or immunosuppressive drug therapy in women who have had transplants.
• During pregnancy increases the frequency and persistence of infection due to the decrease of normal defenses, but at the end of pregnancy the infection disappear spontaneously in most cases.

Interview
In previous years we have tried in these pages the issue of HPV and cervical cancer; today, just a few weeks to market the new vaccine against the human papilloma virus, there are new data on the disease and its prospects in our country. To know the doctor interviewed Jorge Salmeron, a researcher and doctor of Epidemiology, who heads the Unit for Epidemiological Research in Health Services and the Delegation of Morelos.

Doctor, what point is the national campaign of prevention and combat of cervical cancer?
Are doing great things in research and improvement of health services, but we must also recognize that much work remains to be done. The budget problem is one of the most pressing.

Is it true that the prevalence of papilloma virus is higher in Latin America than in Europe or the United States?
The largest presence is discreet in relation to the rest of the world, but if you compare it with some countries in particular, Mexico is likely to have five times more than others, that means that the patterns of infection vary, depending on the customs and of how to relate sexually. If we compare with some European countries, we have between two and five times more. If we compare ourselves with the United States, we have a little more, in both men and women, but Brazil has more than us.
Regardless of the patterns, can do something in terms of prevention?
What we could do to prevent cervical cancer is a set of actions, not just one. The first step you can take is the prevention of HPV.
It's difficult. Unfortunately there is a general measure of hygiene or sexual it becomes effective. The only alternative is really promising vaccination.

How many types of papilloma there?
More than a hundred, but only 15 of them are linked to cervical cancer, and nothing more than a few give very serious problems. Precisely these are the ones who must try to identify early on, when there is infection and when this infection becomes chronic. It must be said that the infection is a chronic disease that we care, not passing the infection.

How the infection is acquired?
HPV infection is a sexually transmitted disease such as syphilis, gonorrhea, herpes. It is a very common infection and highly contagious. Between 60 and 70% of adult women have been infected with HPV at some point in their lives, and among men the percentage is even higher. The probability that a woman or a man is infected by having healthy relationships with an infected partner is very high. To prevent AIDS, the condom is fantastic, but to prevent HPV infection is ineffective. The routes of infection with HPV are not only the seminal fluid, or vaginal fluids, but the contact of skin with skin or mucous lining is more than enough and that the infection is found throughout the genital area: vulva, vagina, perineum, glans penis, penis, scrotum ... There is no way to avoid infection with a condom. Furthermore, some studies suggest that after ten relationships with the same partner is not as if nothing had been used.
If you prevent infection is almost impossible, then what do we have?
The alternative is the most promising vaccine, but it could take several years before achieving a vaccine to cover all types of high risk and to achieve good coverage to eliminate the infection completely.
For the moment, as is done successfully introduce universal vaccination, what we have left is to try to detect early infection that, after years, became chronic, which has the potential to become cancer.
There is an outline for the development of this disease which is very enlightening (1). If you do not do anything, we would see that in certain women, for particular conditions of defense, remains the infection persists and becomes chronic. That is what becomes cancer. At the time there are some changes in the cells of the neck of the matrix that form what is known as pre-cancerous lesions or pre-malignant, they evolve until they turn into cancer. If you do not detect these lesions, which unfortunately continues to make progress until this cancer becomes incurable and the woman dies.
Currently the program of early detection of cervical cancer works in the segment of women who developed chronic infection, in order to detect pre-malignant lesions clinically obvious to those offered treatment and thus avoid their progress to invasive cancer. To this must be done every three years a study Pap for all women between the ages of 25 and 65 years.
Fortunately, there are now on the market tests to detect only very helpful to women infected and to monitor only those, because only they run the risk of developing pre-cancerous lesions. Less than 2% of those infected are left with chronic infection. That is a lot cheaper than studying the whole population every three years.
The entire world had been working solely on this segment of opportunity to detect and prevent injuries advanced deaths from cervical cancer, new techniques for detection of HPV infection will enable us to take much longer to prevent the deaths as cases of advanced cancer .

And what is required?, What women go to apply for testing?
Unfortunately, this still does not have in the IMSS or in the public health system, although it is testing ways to implement it. The Pap smear is a test that has a wide margin of error for detecting precancerous lesions. In Mexico, that margin is around 50% in most developed countries becomes 30 or 25%. When it comes to detecting an injury through the Pap test is repeated two or three times to get a confirmation, and this, plus that comes very expensive, it is very distressing. The new test detects the presence of HPV with a sensitivity exceeding 95%. Without doubt the combination of the two tests is the best scenario. That is the scheme worthwhile and that is what we have tried to suggest in the IMSS. The test is still expensive, but governments must negotiate with companies to reduce prices. This test detects all infected women, although it can not discern in what the infection and became chronic, it is necessary to repeat the test to see who is still infected.
We must insist on working with detection systems and more sophisticated fine, because when he comes vaccine will be more necessary to do so, since the vaccine does not protect against all types of viruses that cause cancer, 20% of cancer will remain there and will be more complicated to detect it: by reducing the presence of lesions in the population will also reduce the ability of the Pap smear to detect it. That is, the cytotechnologists will have more difficulties to detect an injury while they are less frequent. That is why it is necessary additional evidence that would allow limiting the work of the technical, rather than reviewing all the glasses, you'll have to analyze only 2%, which will be those that really have a chance of presenting injuries and a greater proportion.
That is the procedure that we should already be doing. And if we're going to start vaccinating girls of 12 years, we have to lay off these new detection schemes in parallel. We still need to develop strategies to vaccinate adolescent girls (no previous experience) and perfect the vaccine, perhaps, apply it to smaller girls, and prepare society to accept it.

Do you currently what is the dimension of the problem in our country?
Mexico die each year in approximately 4 000 women for cervical cancer. Today we have more women of childbearing age to develop cancer than thirty years ago, but back then women used to have more children than now, which has been reduced in a natural way to take the risk of cervical cancer. These demographic factors can explain, among other things, why the figures have remained constant for so long.
The proof of timely detection of human papilloma virus is called "proof of hybrids capture" (HC2, for its initials in Spanish). In private practice currently costs about 800 pesos.
The advantage is that if a woman is sexually active this test every five or ten years and is negative on two occasions, can only practiced once.
In 1997, was mounted in Morelos a pilot research project to reorganize the program for early detection of cervical cancer. Fortunately, I came to be there and see how it is implemented across the state, with more modern than it had in the world. So he mounted the first colposcopy clinic as part of the program of early detection and devised a program to provide electronic files of the results of smear and follow up of participants. Then, the scheme was reproduced and today there are about forty colposcopy clinics throughout the country, and an automated registration of running the program nationwide.
However, in Mexico we are still dying of cancer for women because the system is very complicated. It has many steps to ensure the successful handling of a case, and each stage has a high probability of failure. Once we get women to come and take the test, we took the wrong and why we lose an opportunity. Or look bad sample in the foil or it breaks along the way: another missed opportunity. Let us assume that this far all goes well, and the cytotechnologists analyzes the foil, but it turns out that that day was tired and did not see the injury: we lose another opportunity. Imagine that the test was between 50% to smear technique to detect achieves success, but if you do not warn women, we go back to the opportunity. And if women do not believe us or not is ...
In the end, each step further complicates the situation, which is why an outline of early detection works well cost a fortune. Earlier, before an injury evident in the best case, the woman he had a hysterectomy, with all costs and risks involved. This is why we created the colposcopy clinics, and the result is that ceased to be thousands of unnecessary hysterectomies.
The political problem is that years of work were required to observe the results of all these programs. Take time, but we have to improve this program because we will still need over the next fifty years. Just as we took years to eradicate polio, cervical cancer is also going to take years, but over time we will see a huge reduction in the costs of care, as we have seen with colposcopy clinics.
What there is new information on vaccines to prevent infection by HPV?
The public health professionals we know that we at fiesta with two vaccines to prevent infection by the main types of HPV high risk for cervical cancer.

New vaccines
Have been recently registered with the Ministry of Health in Mexico vaccines from two pharmaceutical laboratories to prevent cervical cancer.
• The Merck Sharp & Dohme (MSD) acts against virus types 16 and 18 of HPV. It also showed complete security for types 6 and 11, responsible for 90% of genital condylomata. Is indicated for males and females between nine and 17 years to avoid
The transmission of HPV and genital warts.
• The vaccine GlaxoSmithKIine (GSK), which offers protection against the virus types 16 and 18. Additionally, it offers protection against precancerous lesions caused by types 45, 31 and 52. This vaccine should be given in three doses over a period of six months and is effective in a wide range of ages, from 10 years onwards.
Vaccines work at the beginning of the outline of the natural history of cervical cancer, that is, prevent women becoming infected. If there is no infection, no cancer. It is without doubt the most promising alternative for the control of cervical cancer, not only in Mexico but throughout the world.
None of the vaccine is still available under the universal vaccination schedule and it is not easy to estimate how much time will pass before it was officially incorporated some of these vaccines.
Congress allocated to the Ministry of Health 250 million pesos to invest in vaccines, but because they are so expensive (the commercial price is located at about 6 000 pesos three doses) this budget becomes nothing, just a touch of the huge program of cervical cancer. In addition, the impact of these vaccines will start to be in twenty years, not before. Since it is going to vaccinate girls aged 12, will spend at least twenty years before to avoid the first death, but while the vaccine is not available in the public health systems must be alert to parents that there is already a vaccine to prevent infection by HPV and which can be applied if their teenage daughters.
Why girls and not to children? Do HPV that cause cancer does not affect men?
Men also suffer from some cancers associated with HPV infection: the penis of anus, throat, pharynx, tongue, lips, and so on. However, these are cancers associated with HPV, are not as cervical cancer in women, in which HPV infection is a common cause "necessary". Furthermore, none of these cancers in men is as common as cervical cancer.
The study on the epidemiology of HPV in men is in its infancy compared with what we know about cervical cancer. Because the virus acts differently in various tissues, protection may also be different.
Just today, studies are under way in several countries to analyze the patterns of infection in men. In each of these studies involved the Social Security of Mexico along with the United States and Brazil.
However, existing studies to date on vaccines for HPV in men show that the production of antibodies after vaccination is the same in men than in women. The difference is that studies in women have been able to show that after several years, women do not develop lesions in the cervix, and men still do not have the studies to document a reduction in cancers associated with HPV.
Given the enormous benefits offered by the vaccine in women, as well as the existing cost-benefit calculations, the best alternative in terms of public health is to vaccinate adolescent girls between 12 and 13 years old, and maintain the maximum suggested by some authors, who said that starting the vaccination in males when the last vaccinated women.

FACTS ABOUT HPV
• HPV infection is a sexually transmitted disease more common. It is usually impossible to know who or when was acquired infection, because most of those infected do not know who they are.
• The presence of HPV infection does not mean it is recent: the virus could have been purchased several months or even years in advance and be undetectable with currently available evidence.
• The most important risk factor for developing cervical cancer is persistent HPV infection, although not all chronic infections result in cancer.
• Most women who are infected with the virus will heal spontaneously, ie without having to undergo treatment, in the course of a year.
• Although only takes a couple there is the possibility of sexual transmission. Many women with one partner develop cervical cancer, of course, the risk of infection increases with the number of couples, both women and men.
• The papillomavirus, which is transmitted by genital contact and sexual penetration without needing to-be can also infect using a condom, infected at some point in their lives until 80% of sexually active women.
• The Pap smear is a test to identify abnormalities in the cells of the cervix, and sometimes there is an image that can be compatible with infection, but this study is not sufficient for the diagnosis. Specific tests should be performed for the detection of HPV infection.
• Women with HPV infection that does not have an abnormality associated not require treatment, but must be monitored to prevent the infection becomes persistent or who develop cancer precursor lesions. Precursor lesions are fairly advanced they should be treated. The standard medical management is the destruction of the transformation zone of tissues.
• In spontaneously, eight out of ten women will have eliminated the infection in the course of a year. However, sometimes it is recommended that women treated with electrosurgery, cryotherapy or even hysterectomy without being necessary, which only causes distress, medical expenses and other health complications for the woman and her family.