Human Papillomavirus and Cervical Cancer

Summary Report

AMERICAS
Updated year 2007 (r1)

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Rights

c WHO/ICO Information Centre on HPV and Cervical Cancer (HPV Information Centre) 2007 All rights reserved. Publications of the WHO/ICO Information Centre on HPV and Cervical Cancer (HPV Information Centre) can be obtained from HPV Information Centre Secretariat, Institut Catal dOncologia, Avda. Gran Via, s/n Km 2.7 08907 LHospitalet de 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 HPV Information Centre Secretariat, at the above address (e-mail: hpvcentre@iconcologia.net). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of 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 specic companies or of certain manufacturers products does not imply that they are endorsed or recommended by the HPV Information Centre in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products 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 published material 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 HPV Information Centre be liable for damages arising from its use.

Recommended citation: WHO/ICO Information Centre on HPV and Cervical Cancer (HPV Information Centre). Summary report on HPV and cervical cancer statistics in Spain. 2007. [Date accessed]. Available at www. who. int/ hpvcentre

c WHO/ICO Information Centre on HPV and Cervical Cancer

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Preface
The main aim of this report is to summarize the information available on human papillomavirus (HPV) and cervical cancer at the country-specic level. The World Health Organization (WHO) in collaboration with the Institut Catal dOncologia (ICO) have developed the WHO/ICO Information Centre on HPV and Cervical Cancer (HPV Information Centre) to evaluate the burden of disease in the country and to help facilitate stakeholders and relevant bodies of decision makers to formulate recommendations on cervical cancer prevention, including the implementation of the newly developed HPV vaccines. Data aggregated are derived from data and ofcial reports produced by the World Health Organization (WHO), International Agency for Research on Cancer (IARC), United Nations, The World Bank, and published literature. Indicators include relevant statistics on cancer, epidemiological determinants of cervical cancer such as demographics, socioeconomic factors and other risk factors, estimates on the burden of HPV infection, data on immunization and cervical cancer screening. These statistics are essential when planning and implementing cervical cancer prevention strategies. Therefore, we have integrated the most important information for each country into a report and on a website (www.who.int/hpvcentre) to provide a user-friendly tool to assess the best available information in each country. The information presented here is intended as a resource for all who are working towards the prevention of cervical cancer.

c WHO/ICO Information Centre on HPV and Cervical Cancer

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Executive summary
Human papillomavirus (HPV) infection is now a well-established cause of cervical cancer. HPV types 16 and 18 are responsible for about 70% of all cervical cancer cases worldwide. Recently, two HPV vaccines that prevent specic HPV infections and have the potential to reduce the incidence of cervical and other anogenital cancers, have been or are being licensed worldwide. This report provides key information for America on cervical cancer, HPV-related statistics, factors contributing to cervical cancer, cervical cancer screening, and immunization. The report is intended to strengthen the guidance for health policy implementation of primary and secondary cervical cancer prevention strategies in the region. America has a population of 336.5 millions women ages 15 years and older who are at risk of developing cervical cancer. Current estimates indicate that every year 86532 women are diagnosed with cervical cancer and 38436 die from the disease. Cervical cancer ranks the 4th most frequent cancer in women in America, and the 2nd most frequent among women between 15 and 44 years of age. In America, about 15.6% of women in the general population are estimated to harbour cervical HPV infection at a given time, and 70.7% of invasive cervical cancers in America are attributed to HPVs 16 or 18.

Table 1: Key Statistics

America continent Population Women at risk of cervical cancer (Female population aged >=15 yrs) in millions Burden of Cervical cancer Number of cervical cancer cases diagnosed annually Number of deaths due to cervical cancer annually Burden of cervical HPV infection HPV prevalence (%) in general population (in women with normal cytology) Prevalence (%) of HPV 16 or HPV 18 in women with cervical cancer 15.6 20.5 14.3 13.8 86532 38436 6369 3113 17165 8124 48328 21402 14670 5796 336.5 14.4 51.1 136.1 134.9 Caribbean Central America South America Northern America

70.7

64.5

58.4

67.4

76.4

c WHO/ICO Information Centre on HPV and Cervical Cancer

LIST OF CONTENTS

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Contents
Preface Executive summary List of Figures List of Tables 1 Region prole 1.1 Population . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Burden of invasive cervical cancer 2.1 Incidence . . . . . . . . . . . . . . . . . 2.2 Mortality . . . . . . . . . . . . . . . . . . 2.3 Comparison of incidence with mortality . 2.4 Prevalent cases and survival . . . . . . 3 HPV burden in women 3.1 Terminology . . . . . 3.2 HPV prevalence . . 3.3 HPV type distribution 3.4 References . . . . . iii iv vi vii 1 2 3 3 8 13 14 15 16 17 18 22

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Note to the reader Acknowledgments Contact information

24 24 24

c WHO/ICO Information Centre on HPV and Cervical Cancer

LIST OF FIGURES

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List of Figures
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Americas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ranking of cervical cancer in comparison to other cancers in women in each country, according to incidence. Highest incidence ranking 1st (ALL WOMEN) . . . . . . . . . Ranking of cervical cancer in comparison to other cancers in women in each country, according to incidence. Highest incidence ranking 1st (WOMEN 15-44 yrs) . . . . . . Age-standardized incidence rates of cancer in Americass regions. World standard (*) Geographical distribution of age-standardized incidence rate (per 100,000 women) in Americas. World standard. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Age-specic incidence of cervical cancer in Americas and the world . . . . . . . . . . Annual number of new cases of cervical cancer in Americas by age . . . . . . . . . . Ranking of cervical cancer in comparison to other cancers in women in each country, according to mortality. Highest mortality ranking 1st (ALL WOMEN) . . . . . . . . . . . Ranking of cervical cancer in comparison to other cancers in women in each country, according to mortality. Highest mortality ranking 1st (WOMEN 15-44 yrs) . . . . . . . Age-standardized mortality rates of cancer in Americass regions. World standard (*) . Geographical distribution of age-standardized mortality rates (per 100,000 women) in Americas. World standard. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Age-specic mortality of cervical cancer in Americas and the world . . . . . . . . . . . Annual number of deaths of cervical cancer in Americas by age. . . . . . . . . . . . . A comparison of age-specic incidence rates and age-specic mortality rates of cervical cancer in Americas. Rates per 100,000 women. . . . . . . . . . . . . . . . . . . . Ten most frequent HPV types in women with normal cytology in Americas. . . . . . . . Ten most frequent HPV types in women with LSIL/CIN-1 in Americas. . . . . . . . . . Ten most frequent HPV types in women with HSIL (CIN-2, CIN-3, CIS and HSIL) in Americas. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ten most frequent HPV types in women with invasive cervical cancer in Americas. . . 1 3 3 5 6 6 7 8 8 10 11 11 12 13 18 19 20 21

c WHO/ICO Information Centre on HPV and Cervical Cancer

LIST OF TABLES

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List of Tables
1 2 3 4 5 6 Key Statistics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Population in millions. 2005 estimates. . . . . . . . . . . . . . . . . . . . . . . . . . . . Incidence of cervical cancer in Americas. . . . . . . . . . . . . . . . . . . . . . . . . . Mortality of cervical cancer in Americas. . . . . . . . . . . . . . . . . . . . . . . . . . . Prevalent cases of cervical cancer in Americas. . . . . . . . . . . . . . . . . . . . . . . Prevalence of HPV in women with normal cytology, precancerous cervical lesions and invasive cervical cancer. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv 2 4 9 14 17

c WHO/ICO Information Centre on HPV and Cervical Cancer

REGION PROFILE

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Region prole
Figure 1: Americas

Northern America

Caribbean Central America

South America

For analytical purposes, Americas has been subdivided into several geographical regions . This report will show data compiled by these regions and also at country-specic level

See http://unstats.un.org/unsd/methods/m49/m49regin.htm for more information c WHO/ICO Information Centre on HPV and Cervical Cancer

REGION PROFILE

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1.1

Population
Table 2: Population in millions. 2005 estimates.

Region / Country Americas Continenta Caribbeanb Antigua & Barbuda Bahamas Barbados Cuba Dominica Dominican Republic Grenada Haiti Jamaica Saint Kitts & Nevis Saint Lucia Saint Vincent & The Grenadines Trinidad & Tobago Central America Belize Costa Rica El Salvador Guatemala Honduras Mexico Nicaragua Panama South Americac Argentina Bolivia Brazil Chile Colombia Ecuador Guyana Paraguay Peru Suriname Uruguay Venezuela Northern America Canada United States of America
a

Female 10-14 years 38.64 1.79 0.02 0.01 0.37 0.47 0.49 0.14 0.01 0.01 0.05 7.89 0.02 0.21 0.37 0.80 0.44 5.57 0.34 0.15 17.48 1.71 0.54 8.15 0.73 2.30 0.68 0.03 0.36 1.47 0.02 0.14 1.34 11.49 1.04 10.45 15+ years 336.49 14.39 0.12 0.11 4.58 2.98 2.75 0.94 0.06 0.04 0.52 51.13 0.08 1.53 2.35 3.77 2.19 38.38 1.70 1.12 136.09 14.76 2.89 69.05 6.24 16.15 4.49 0.28 1.92 9.48 0.16 1.37 9.22 134.88 13.51 121.32 Total 452.05 19.72 0.17 0.14 5.63 4.41 4.33 1.34 0.08 0.06 0.66 74.86 0.13 2.13 3.50 6.46 3.57 54.72 2.74 1.60 189.60 19.80 4.61 94.53 8.23 23.07 6.60 0.39 3.06 13.91 0.23 1.78 13.31 167.87 16.27 151.53 10-14 years 40.11 1.85 0.02 0.01 0.39 0.48 0.51 0.15 0.01 0.01 0.05 8.10 0.02 0.22 0.38 0.81 0.46 5.71 0.35 0.16 18.10 1.76 0.56 8.43 0.76 2.39 0.71 0.04 0.37 1.52 0.02 0.14 1.39 12.07 1.09 10.97

Male 15+ years 319.66 13.87 0.11 0.10 4.54 3.01 2.58 0.89 0.06 0.04 0.50 47.69 0.09 1.57 2.19 3.38 2.19 35.48 1.65 1.13 130.03 13.74 2.79 65.43 6.00 15.31 4.45 0.25 1.92 9.48 0.15 1.25 9.18 128.08 13.08 114.95 Total 439.90 19.41 0.16 0.13 5.64 4.49 4.20 1.31 0.08 0.06 0.64 72.17 0.14 2.20 3.38 6.14 3.63 52.31 2.74 1.63 185.59 18.95 4.57 91.87 8.06 22.53 6.63 0.36 3.10 14.06 0.22 1.68 13.44 162.74 15.99 146.68

Comments: a Including Bermuda, Greenland, and Saint-Pierre-et-Miquelon. b Including Anguilla, Antigua, Aruba, British Virgin Islands, Cayman Islands, Dominica, Grenada, Montserrat, Saint Kitts and Nevis, and Turks and Caicos Islands. c Including Falkland Islands (Malvinas). Data sources: United Nations, Population Division. World Population Prospects - the 2004 revision. New York, 2005.

c WHO/ICO Information Centre on HPV and Cervical Cancer

BURDEN OF INVASIVE CERVICAL CANCER

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2
2.1

Burden of invasive cervical cancer

Incidence
Figure 2: Ranking of cervical cancer in comparison to other cancers in women in each country, according to incidence. Highest incidence ranking 1st (ALL WOMEN)

_
1st 2nd to 3rd 4th to 5th 6th and more Not available Data source: IARC Globocan 2002

Figure 3: Ranking of cervical cancer in comparison to other cancers in women in each country, according to incidence. Highest incidence ranking 1st (WOMEN 15-44 yrs)

_
1st 2nd to 3rd 4th to 5th 6th and more Not available Data source: IARC Globocan 2002

c WHO/ICO Information Centre on HPV and Cervical Cancer

BURDEN OF INVASIVE CERVICAL CANCER

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Table 3: Incidence of cervical cancer in Americas.

Region / Country Americas Continent Caribbean Antigua & Barbuda Bahamas Barbados Cuba Dominica Dominican Republic Grenada Haiti Jamaica Saint Kitts & Nevis Saint Lucia St Vincent & the Grenadines Trinidad & Tobago Central America Belize Costa Rica El Salvador Guatemalaa Hondurasa Mexico Nicaragua Panama South America Argentina Bolivia Brazil Chile Colombia Ecuador Guyana Paraguay Peru Suriname Uruguay Venezuela Northern America Canada United States of America Crude rate 20.1 32.7 15.7 32.5 24 24.3 64.7 28.8 28.3 24.4 34.6 19 36.6 19.4 19.9 24.4 30.2 25.8 26.9 25.5 42 22.2 27.5 31 30.4 40.7 39.6 40.4 24.2 22.6 30.9 9.1 9.5 9 ASR* 18.8 32.6 16.7 24.9 20.2 30.8 87.3 31.2 27.1 30.6 52.4 21.5 45.6 30.6 30.6 29.5 47.2 28.2 28.6 23.2 55 23.4 25.8 36.4 38.7 47.3 53.2 48.2 27 18.8 36 7.7 7.7 7.7 Cum. risk* 1.4 2.4 1.1 1.6 1.5 2.1 6.1 2.3 1.9 2.1 3.9 1.5 3.3 2.1 2.1 2 3.1 2 2.1 1.7 3.9 1.8 1.7 2.4 2.4 3.5 3.9 3.3 1.6 1.4 2.6 0.6 0.6 0.6 SIR* 117 204 103 168 124 178 540 197 167 184 300 132 277 181 180 177 281 175 177 143 339 144 163 218 224 288 331 292 173 114 223 43 44 43 New cases 86532 6369 25 46 1346 1032 2774 383 186 17165 40 392 1213 1153 664 12516 809 375 48328 4924 1831 19603 2163 6815 1978 160 1131 5400 51 392 3845 14670 1502 13162 Ranking of cervical cancer All women 4th 2nd 2nd 2nd 2nd 2nd 1st 2nd 2nd 1st 1st 2nd 1st 1st 1st 1st 1st 2nd 2nd 2nd 1st 2nd 2nd 1st 1st 1st 1st 1st 2nd 3rd 1st 12th 11th 13th Women 15-44 years 2nd 1st 2nd 2nd 1st 2nd 1st 1st 2nd 1st 1st 1st 1st 1st 1st 1st 1st 1st 2nd 2nd 1st 2nd 1st 1st 1st 1st 1st 1st 1st 2nd 1st 4th 2nd 4th

*ASR, Age-standardized rate; Cum. risk, Cumulative risk; SIR, Standardized incidence ratio Rates are per 100,000 women. Standardized rates have been estimated using the direct method and the World population as the reference. Comments:
a

No data are available, calculated from the average of those of neighbouring countries.

Data sources: IARC, Globocan 2002.

c WHO/ICO Information Centre on HPV and Cervical Cancer

Northern America
22.0 35.6 32.8 10.8 7.4 7.2 6.5 5.6 4.9 4.5 4.5 4.5 3.8 3.7 2.5 1.7 1.7 1.4 1.2 1.1 0.9 0.6 0.4 0.2 0 10 20 30 40 50 60 70 80 99.4 30.6 25.9

BURDEN OF INVASIVE CERVICAL CANCER

Central America

Breast Lung Colon and rectum Corpus uteri Melanoma of skin NonHodgkin lymphoma Ovary etc. Thyroid Cervix uteri Leukaemia Bladder Pancreas Kidney etc. Brain, nervous system Stomach Oral cavity Multiple myeloma Hodgkin lymphoma Liver Oesophagus Larynx Other pharynx Nasopharynx 20 30 40 50 60 70 80 90 100 90 100

11.7 11.0 10.7 8.1 7.7 7.3 6.4 6.3 5.9 4.5 3.4 3.3 3.0 2.4 1.9 1.3 1.2 0.9 0.2

Cervix uteri Breast Stomach Colon and rectum Ovary etc. Lung Thyroid Liver Pancreas Leukaemia Corpus uteri NonHodgkin lymphoma Kidney etc. Brain, nervous system Melanoma of skin Bladder Oral cavity Multiple myeloma Hodgkin lymphoma Oesophagus Other pharynx Larynx Nasopharynx

10

Caribbean
32.9 32.6 Breast Cervix uteri Colon and rectum Stomach Ovary etc. Lung Corpus uteri Leukaemia NonHodgkin lymphoma Pancreas Thyroid Brain, nervous system Liver Kidney etc. Bladder Melanoma of skin Oesophagus Oral cavity Multiple myeloma Hodgkin lymphoma Larynx Other pharynx Nasopharynx 50 60 70 80 90 100 0 14.8 12.2 7.7 7.6 6.7 4.9 4.4 4.2 4.2 3.8 2.8 2.8 2.7 2.3 2.0 1.8 1.3 0.8 0.7 0.7 0.1 10 20

South America
28.6 46.0

incidence rates for gure 4 may result in different rankings of the rates of cervical cancer.
20 30 40 30 40 50 60 70 80 90 100

Breast Cervix uteri Colon and rectum Lung Corpus uteri Stomach Liver Ovary etc. Thyroid Leukaemia NonHodgkin lymphoma Pancreas Brain, nervous system Bladder Oral cavity Kidney etc. Oesophagus Hodgkin lymphoma Other pharynx Multiple myeloma Melanoma of skin Larynx Nasopharynx

15.1 9.9 8.8 6.7 4.5 4.3 3.8 3.4 3.3 3.1 2.6 2.5 2.3 1.9 1.7 1.3 1.2 1.2 1.1 1.1 0.2

Figure 4: Age-standardized incidence rates of cancer in Americass regions. World standard (*)

10

Annual agespecific incidence rate per 100,000 Female (all ages). World standard

* The use of crude incidence rates for the ranking calculation in table 3 and the use of age-standardized

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c WHO/ICO Information Centre on HPV and Cervical Cancer

BURDEN OF INVASIVE CERVICAL CANCER

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Figure 5: Geographical distribution of age-standardized incidence rate (per 100,000 women) in Americas. World standard.

_
<=9.3 9.4-16.2 16.3-26.2 26.3-32.6 32.7-87.3 Not available Data source: IARC Globocan 2002

Figure 6: Age-specic incidence of cervical cancer in Americas and the world

150 Caribbean Central America Northern America South America Cervical cancer incidence rate per 100,000 100 World

50

0 014 yrs 1544 yrs 4554 yrs 5564 yrs 65+ yrs Age group
Data source: IARC, Globocan 2002

c WHO/ICO Information Centre on HPV and Cervical Cancer

BURDEN OF INVASIVE CERVICAL CANCER

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Figure 7: Annual number of new cases of cervical cancer in Americas by age

Caribbean Northern America
30,000

Central America South America

Cervical cancer Annual number of new cases

15774 20,000

12489 10646 10,000 6796 2798 5133 2245 0 2126 4736 3174 1681 1094 4122 1349 9419

2950

1544 yrs

4554 yrs

5564 yrs

65+ yrs Age group

Data source: IARC, Globocan 2002

c WHO/ICO Information Centre on HPV and Cervical Cancer

BURDEN OF INVASIVE CERVICAL CANCER

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2.2

Mortality
Figure 8: Ranking of cervical cancer in comparison to other cancers in women in each country, according to mortality. Highest mortality ranking 1st (ALL WOMEN)

_
1st 2nd to 3rd 4th to 5th 6th and more Not available Data source: IARC Globocan 2002

Figure 9: Ranking of cervical cancer in comparison to other cancers in women in each country, according to mortality. Highest mortality ranking 1st (WOMEN 15-44 yrs)

_
1st 2nd to 3rd 4th to 5th 6th and more Not available Data source: IARC Globocan 2002

c WHO/ICO Information Centre on HPV and Cervical Cancer

BURDEN OF INVASIVE CERVICAL CANCER

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Table 4: Mortality of cervical cancer in Americas.

Region / Country Americas Continent Caribbean Antigua & Barbuda Bahamas Barbados Cuba Dominica Dominican Republic Grenada Haiti Jamaica Saint Kitts & Nevis Saint Lucia St Vincent & the Grenadines Trinidad & Tobago Central America Belize Costa Rica El Salvador Guatemalaa Hondurasa Mexico Nicaragua Panama South America Argentina Bolivia Brazil Chile Colombia Ecuador Guyana Paraguay Peru Suriname Uruguay Venezuela Northern America Canada United States of America Crude rate 8.9 16 5.7 12.9 10.1 13.3 34.6 11.3 11.1 11.6 14.6 10.2 18.4 10.6 10.8 11.2 13.2 11.5 11.9 8.7 22.6 9.4 11.9 15 16.3 18.2 18 19.9 12.3 9.3 13.7 3.6 3.7 3.6 ASR* 8.1 16 6.2 9.4 8.3 17.3 48.1 12.2 10.7 15 23 12 23.5 17.2 17.2 14.1 22.3 12.9 12.9 7.8 30.4 10.2 10.9 18.2 21 22.2 26.1 24.6 14 7 16.8 2.3 2.5 2.3 Cum. risk* 0.5 1.1 0.4 0.5 0.6 1 3.4 0.8 0.7 0.9 1.5 0.7 1.5 1.2 1.2 0.9 1.3 0.8 0.9 0.6 2.2 0.7 0.6 1.1 1.2 1.5 1.8 1.4 0.7 0.5 1.1 0.1 0.1 0.1 SMR* 93 181 69 116 91 184 554 141 120 165 244 133 260 190 190 154 241 145 145 84 347 113 126 199 227 245 290 271 164 79 187 29 29 29 New cases 38436 3113 9 18 567 562 1484 151 73 8124 16 210 609 628 361 5777 354 166 21402 1679 987 8286 931 3296 1064 71 513 2663 26 162 1705 5796 581 5214 Ranking of cervical cancer All women 4th 1st 3rd 3rd 4th 1st 1st 2nd 2nd 1st 1st 3rd 1st 1st 1st 1st 1st 1st 2nd 4th 1st 2nd 3rd 1st 2nd 1st 1st 1st 1st 5th 1st 12th 10th 12th Women 15-44 years 2nd 1st 2nd 2nd 1st 1st 1st 1st 2nd 1st 1st 2nd 1st 1st 1st 1st 1st 1st 1st 1st 1st 1st 1st 1st 1st 1st 1st 1st 1st 2nd 1st 8th 3rd 9th

*ASR, Age-standardized rate; Cum. risk, Cumulative risk; SMR, Standardized mortality ratio Rates are per 100,000 women. Standardized rates have been estimated using the direct method and the World population as the reference. Comments:
a

No data are available, calculated from the average of those of neighbouring countries.

Data sources: IARC, Globocan 2002.

c WHO/ICO Information Centre on HPV and Cervical Cancer

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Figure 10: Age-standardized mortality rates of cancer in Americass regions. World standard (*)

Lung Breast Colon and rectum Ovary etc. Pancreas NonHodgkin lymphoma Leukaemia Brain, nervous system Corpus uteri Cervix uteri Stomach Multiple myeloma Kidney etc. Liver Bladder Melanoma of skin Oesophagus Oral cavity Other pharynx Hodgkin lymphoma Larynx Thyroid Nasopharynx 6.1 6.0 4.5 4.1 2.8 2.6 2.3 2.3 2.2 2.1 2.0 1.9 1.4 1.3 1.2 0.6 0.4 0.3 0.3 0.3 0.1 0 10 20 30 11.6 19.2

26.7

Cervix uteri Breast Stomach Liver Lung Pancreas Colon and rectum Leukaemia Ovary etc. Corpus uteri NonHodgkin lymphoma Brain, nervous system Kidney etc. Thyroid Multiple myeloma Bladder Oesophagus Oral cavity Melanoma of skin Hodgkin lymphoma Larynx Other pharynx Nasopharynx 0

4.4 4.4 3.8 3.6 2.0 2.0 1.8 1.6 1.0 0.9 0.8 0.8 0.5 0.5 0.5 0.4 0.3 0.1

8.3 6.7 6.3

10.5

15.0

Caribbean
Cervix uteri Breast Lung Colon and rectum Stomach Liver Corpus uteri Pancreas Leukaemia Ovary etc. Brain, nervous system NonHodgkin lymphoma Oesophagus Multiple myeloma Bladder Oral cavity Kidney etc. Larynx Hodgkin lymphoma Other pharynx Thyroid Melanoma of skin Nasopharynx 5.3 5.2 4.3 3.3 3.1 2.6 2.0 1.7 1.6 1.3 1.2 1.0 0.9 0.8 0.7 0.7 0.6 0.3 0.1 0 10 9.9 9.6 12.7 16.0 Breast Cervix uteri Stomach Lung Colon and rectum Liver Pancreas Ovary etc. Leukaemia Brain, nervous system NonHodgkin lymphoma Corpus uteri Oesophagus Kidney etc. Multiple myeloma Bladder Oral cavity Thyroid Larynx Melanoma of skin Other pharynx Hodgkin lymphoma Nasopharynx 20 30 0

South America

gure 10 may result in different rankings of the rates of cervical cancer.

10

20

30

* The use of crude mortality rates for the ranking calculation in table 4 and the use of age-standardized mortality rates for

Northern America

Central America

BURDEN OF INVASIVE CERVICAL CANCER

4.6 4.2 3.7 3.7 3.0 2.4 2.0 1.9 1.3 1.1 1.0 0.8 0.7 0.6 0.6 0.4 0.3 0.1

7.5 7.4

9.3

15.1 12.9 12.9

10

20

30

Annual agespecific mortality rate per 100,000

Female (all ages). World standard

c WHO/ICO Information Centre on HPV and Cervical Cancer

BURDEN OF INVASIVE CERVICAL CANCER

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Figure 11: Geographical distribution of age-standardized mortality rates (per 100,000 women) in Americas. World standard.

_
<=3.8 3.9-7.9 8.0-14.0 14.1-23.4 23.5-55.6 Not available Data source: IARC Globocan 2002

Figure 12: Age-specic mortality of cervical cancer in Americas and the world
80 Caribbean Central America Northern America Cervical cancer mortality rate per 100,000 60 South America World

40

20

0 014 yrs 1544 yrs 4554 yrs 5564 yrs 65+ yrs Age group
Data source: IARC, Globocan 2002

c WHO/ICO Information Centre on HPV and Cervical Cancer

BURDEN OF INVASIVE CERVICAL CANCER

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Figure 13: Annual number of deaths of cervical cancer in Americas by age.

Caribbean Northern America
15,000

Central America South America

Cervical cancer Annual number of deaths

6776 10,000

4889 5,000

5255 4468 3406

553 1718 0 910

756 1900 771

1081 1617 601

2887 831

1544 yrs

4554 yrs

5564 yrs

65+ yrs Age group

Data source: IARC, Globocan 2002

c WHO/ICO Information Centre on HPV and Cervical Cancer

2.3

Caribbean
150 Incidence Mortality 100

Central America

150

Incidence

Mortality

100

Cervical cancer agespecific rates

BURDEN OF INVASIVE CERVICAL CANCER

0 5564 yrs Age group 65+ yrs 014 yrs 1544 yrs 4554 yrs

Cervical cancer agespecific rates 50 0 5564 yrs 65+ yrs Age group

50

014 yrs

1544 yrs

4554 yrs

Northern America
150 Incidence Mortality 100

South America

Comparison of incidence with mortality

150

Incidence

Mortality

100

Cervical cancer agespecific rates

0 5564 yrs Age group 65+ yrs

Cervical cancer agespecific rates 50 0 014 yrs 1544 yrs

50

014 yrs

1544 yrs

4554 yrs

4554 yrs

5564 yrs

65+ yrs Age group

Figure 14: A comparison of age-specic incidence rates and age-specic mortality rates of cervical cancer in Americas. Rates per 100,000 women.

Data source: IARC, Globocan 2002

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2.4

Prevalent cases and survival

Table 5: Prevalent cases of cervical cancer in Americas.
1 year survival 73665 5336 20 38 1130 863 2328 321 156 14413 34 330 1020 968 559 10508 679 315 40548 4133 1538 16457 1818 5731 1649 135 950 4535 43 330 3229 13368 1368 12000 3 years survival 184245 13066 51 91 2776 2081 5720 789 378 35089 83 804 2481 2369 1366 25546 1669 771 98890 10137 3771 40105 4429 13949 3961 328 2333 11048 104 803 7922 37200 3805 33395 5 years survival 265279 18437 72 126 3931 2904 8098 1114 530 49345 114 1132 3491 3343 1927 35886 2363 1089 139249 14343 5330 56418 6236 19623 5513 463 3297 15548 149 1130 11199 58248 5955 52293

Region / Country Americas Continent Caribbean Antigua & Barbuda Bahamas Barbados Cuba Dominica Dominican Republic Grenada Haiti Jamaica Saint Kitts & Nevis Saint Lucia Saint Vincent & The Grenadines Trinidad & Tobago Central America Belize Costa Rica El Salvador Guatemalaa Hondurasa Mexico Nicaragua Panama South America Argentina Bolivia Brazil Chile Colombia Ecuador Guyana Paraguay Peru Suriname Uruguay Venezuela Northern America Canada United States of America

The number of cases are calculated according to the number of new cases and its probability of survival by time. Comments: a No data are available, calculated from the average of those of neighbouring countries. Data sources: IARC, Globocan 2002. Methods: http://www-dep.iarc.fr/globocan/methods.htm, Prevalence section.

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HPV burden in women with normal cytology, precancerous cervical lesions or invasive cervical cancer

The statistics shown in this section focus on HPV infection in the cervix uteri. HPV cervical infection results in cervical morphological lesions ranging from normalcy (cytologically normal women) to different stages of precancerous lesions (CIN-1, CIN-2, CIN-3/CIS) and invasive cervical cancer. HPV infection is measured by means of HPV DNA detection in cervical cells (fresh tissue, parafn embedded or exfoliated cells). The relative frequency of HPV-16/18 increases with the severity of the lesion. Worldwide, HPV16 and 18 contribute to over 70% of all cervical cancer cases, between 41 and 67% of high-grade cervical lesions and 16-32% of low-grade cervical lesions. After HPV-16/18, the six most common HPV types are the same in all world regions, namely 31, 33, 35, 45, 52 and 58; these account for an additional 20% of cervical cancers worldwide (Clifford G et al. Vaccine 2006;24(S3):26). HPV is also responsible for other benign genital infections such as genital warts, mainly caused by HPV types 6 and 11.

Note: The methodologies used to compile the information on HPV burden presented in this section are derived from a systematic review and meta-analysis of the literature. Because of the limitations of HPV DNA detection techniques and study designs used, these data should be interpreted cautiously and used only as a guidance to assess the burden of HPV infection in the population. For instance, the prevalence of low risk types HPV-6 and 11 may be underestimated because most studies used assays that only detected high risk types

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3.1

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 growth of squamous cells observed in the cervix. SIL is an abnormal result derived from cervical cytological screening or Pap smear testing. CIN is a histological diagnosis made upon analysis of cervical tissue obtained by biopsy or surgical excision. Low-grade cervical lesions (LSIL/CIN-1) Low-grade cervical lesions are dened 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 dened by a large number of precancerous cells on the surface of the cervix 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).

Cervical Carcinoma in situ (CIS) Cancerous cells are conned to the cervix and have not spread to other parts of the body.

Invasive cervical cancer (ICC) / Cervical cancer If the high-grade precancerous cells invade deeper tissues of the cervix or to other tissues or organs, then the disease is called invasive cervical cancer or cervical cancer.

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3.2

HPV prevalence
Table 6: Prevalence of HPV in women with normal cytology, precancerous cervical lesions and invasive cervical cancer.
Normal cytology Low-grade lesionsa Women tested 3651 248 248 390 181 44 165 548 334 89 70 55 2465 170 2295 HPV Prev % (95%CI) 75.8 (74.4-77.2) 60.9 (54.5-67.0) --------60.9 (54.5-67.0) ----55.1 (50.0-60.1) -72.9 (65.8-79.3) --47.7 (32.5-63.3) 37.6 (30.2-45.4) --79 (75.4-82.4) 82.9 (78.5-86.8) -71.9 (61.4-80.9) -55.7 (43.3-67.6) --96.4 (87.5-99.6) ----79.9 (78.3-81.5) 87.6 (81.7-92.2) 79.3 (77.6-81.0) High-grade lesionsb Women tested 1922 66 66 280 108 81 91 487 207 155 125 1089 58 1001 HPV Prev % (95%CI) 83.9 (82.1-85.5) 80.3 (68.7-89.1) --------80.3 (68.7-89.1) ----86.8 (82.2-90.5) -89.8 (82.5-94.8) --79 (68.5-87.3) 90.1 (82.1-95.4) --80.1 (76.3-83.5) 94.7 (90.7-97.3) -74.2 (66.6-80.9) -63.2 (54.1-71.6) -------85 (82.8-87.1) 98.3 (90.8-100.0) 84.9 (82.5-87.1) Cervical cancer Women tested 2813 45 45 341 35 104 129 73 1041 131 49 347 80 125 113 196 1386 172 1182 HPV Prev % (95%CI) 89 (87.8-90.1) 97.8 (88.2-99.9) ---97.8 (88.2-99.9) ---------90.3 (86.7-93.2) -97.1 (85.1-99.9) --79.8 (70.8-87.0) 91.5 (85.3-95.7) -100 (95.1-100.0) 91.1 (89.2-92.7) 97.7 (93.5-99.5) 95.9 (86.0-99.5) 86.2 (82.1-89.6) 98.8 (93.2-100.0) 80 (71.9-86.6) --96.5 (91.2-99.0) 94.9 (90.8-97.5) ---86.8 (84.9-88.5) 83.7 (77.3-88.9) 87.3 (85.3-89.2)

Country /Region

Women tested

HPV Prev % (95%CI) 15.6 (15.2-15.9) --------------20.5 (19.7-21.3) -22.4 (21.5-23.4) --38.8 (34.2-43.6) 11.0 (9.7-12.3) --14.3 (13.3-15.4) 15.4 (13.0-18.0) -17.0 (12.0-23.1) 11.2 (9.2-13.4) 14.5 (13.0-16.0) --19.8 (12.2-29.4) 17.7 (12.4-24.2) ---13.8 (13.4-14.3) 21.7 (19.9-23.6) 13.1 (12.6-13.5)

Americas Continent Caribbean Antigua & Barbuda Bahamas Barbados Cuba Dominica Dominican Republic Grenada Haiti Jamaica Saint Kitts & Nevis Saint Lucia Saint Vincent & The Grenadines Trinidad & Tobago Central America Belize Costa Rica El Salvador Guatemala Honduras Mexico Nicaragua Panama South America Argentina Bolivia Brazil Chile Colombia Ecuador Guyana Paraguay Peru Suriname Uruguay Venezuela Northern America Canada United States of America

40399 10232 7459 438 2335 4354 843 194 913 2138 91 175 25813 2010 23685

Comments: The samples for HPV testing come from cervical specimens (fresh / xed biopsies or exfoliated cells). 95% CI: 95% Condence Interval a Low-grade lesions: LSIL or CIN-1 b High-grade lesions: CIN-2, CIN-3, CIS or HSIL Data sources: See sources at the end of the chapter.

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HPV BURDEN IN WOMEN

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3.3

HPV type distribution

Figure 15: Ten most frequent HPV types in women with normal cytology in Americas.

Americas continent 16 18 58 31 33 45 53 51 11 35 0
3.6 1.3 1.2 1.1 0.8 0.7 0.7 0.7 0.7 0.6

Caribbean 1st: NA* 2nd: NA* 3rd: NA* 4th: NA* 5th: NA* 6th: NA* 7th: NA* 8th: NA* 9th: NA* 10th: NA* 0 1 2
.

2
.

Central America 16 31 18 53 58 11 33 66 70 52 0
4.0 1.9 1.8 1.5 1.2 1.1 0.9 0.9 0.7 0.6

Northern America 16 53 18 51 31 45 6 11 58 73 0
4.1 1.1 1.0 1.0 0.9 0.8 0.6 0.6 0.6 0.5

HPV type

2
.

2
.

South America 16 58 18 45 31 56 33 42 35 52 0
3.3 1.4 1.2 0.9 0.9 0.9 0.8 0.8 0.8 0.7

2
.

Typespecific HPV prevalence (%) Women with normal cytology

Data source: WHO/ICO Information Centre on HPV and Cervical Cancer *NA=Not available. No more types than shown were tested or were positive

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HPV BURDEN IN WOMEN

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Figure 16: Ten most frequent HPV types in women with LSIL/CIN-1 in Americas.

Americas continent 16 51 56 53 52 39 66 18 6 31 0
19.5 9.8 9.0 8.6 7.9 7.6 7.6 7.5 6.9 6.6

Caribbean 16 33 45 35 18 31 6 52 53 58
5.6 4.4 4.4 3.6 3.2 3.2 2.8 2.7 2.7 2.2

10

20
.

30

40

10

20
.

30

40

Central America 16 58 51 31 56 52 39 53 6 18 0
10.3 6.7 6.2 5.4 5.1 4.6 4.4 4.4 4.1 4.1

Northern America 16 51 56 53 52 66 18 39 59 31
19.4 12.5 10.6 9.9 9.2 9.2 9.0 8.9 7.6 7.3

HPV type

10

20
.

30

40

10

20
.

30

40

South America 16 53 6 58 33 31 18 52 39 56 0
33.2 14.8 13.1 6.9 6.6 6.2 5.1 5.0 4.1 4.1

10

20
.

30

40

Typespecific HPV prevalence (%) Women with low grade lesions (LSIL, CIN1)
Data source: IARC, Infection and Cancer Epidemiology *NA=Not available. No more types than shown were tested or were positive

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HPV BURDEN IN WOMEN

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Figure 17: Ten most frequent HPV types in women with HSIL (CIN-2, CIN3, CIS and HSIL) in Americas.

Americas continent 16 58 18 31 33 6 35 51 56 52 0
43.7 9.1 8.7 8.0 5.5 5.4 4.9 4.4 4.3 3.7

Caribbean 16 35 45 31 6 33 18 11 9th: NA* 10th: NA* 0

24.2 13.6 13.6 9.1 7.6 7.6 4.5 1.5

10

20
.

30

40

50

10 20 30 40 50
.

Central America 16 58 18 31 33 51 52 56 39 45 0
38.9 15.4 8.6 7.9 7.5 4.3 3.2 3.2 2.9 2.9

Northern America 16 6 18 31 58 35 33 56 52 66 50 0
46.0 9.9 9.6 9.4 6.7 6.4 5.5 5.2 5.0 3.8

HPV type

10

20
.

30

40

10

20
.

30

40

50

South America 16 58 18 51 6 31 33 11 45 35 0
43.7 8.4 7.2 6.9 6.4 4.7 4.1 3.8 3.3 1.1

10

20
.

30

40

50

Typespecific HPV prevalence (%) Women with high grade lesions (CIN2, CIN3, CIS and HSIL)
Data source: IARC, Infection and Cancer Epidemiology *NA=Not available. No more types than shown were tested or were positive

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HPV BURDEN IN WOMEN

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Figure 18: Ten most frequent HPV types in women with invasive cervical cancer in Americas.

Americas continent 16 18 5.4 31 4.4 45 3.8 33 52 2.3 58 1.6 35 1.2 39 1.2 59 1.0 0
53.6 17.1

Caribbean 16 18 31 45 39 51 52 56 59 73 0
57.8 6.7 6.7 6.7 4.4 2.2 2.2 2.2 2.2 2.2

20
.

40

60

20
.

40

60

Central America 16 18 31 45 58 33 52 59 39 6 0
44.3 14.1 7.3 7.0 5.0 4.7 2.9 2.6 1.5 1.2

Northern America 16 18 31 33 45 6 52 35 58 73 60 0
54.8 21.6 3.7 3.5 3.3 1.1 1.0 0.4 0.3 0.3

HPV type

20
.

40

20
.

40

60

South America 16 18 31 45 52 33 35 39 58 59 0
54.9 12.5 6.9 4.9 4.2 4.1 2.8 2.4 2.0 1.6

20
.

40

60

Typespecific HPV prevalence (%) Women with invasive cervical cancer

Data source: IARC, Infection and Cancer Epidemiology *NA=Not available. No more types than shown were tested or were positive

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HPV BURDEN IN WOMEN

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3.4

References

Normal cytology: Burk RD, Sex Transm Dis 1996; 23: 333 | Cope JU, J Clin Microbiol 1997; 35: 2262 | Ferreccio C, Cancer Epidemiol Biomarkers Prev 2004; 13: 2271 | Ferrera A, Int J Cancer 1999; 82: 799 | Giuliano AR, Cancer Epidemiol Biomarkers Prev 1999; 8: 615 | Giuliano AR, Cancer Epidemiol Biomarkers Prev 1999; 8: 615 | Hernandez BY, Nutr Cancer 2004; 49: 109 | Herrero R, J Natl Cancer Inst 2000; 92: 464 | Lazcano-Ponce E, Int J Cancer 2001; 91: 412 | Matos E, Sex Transm Dis 2003; 30: 593 | Molano M, Br J Cancer 2002; 87: 324 | Munoz N, Sex Transm Dis 1996; 23: 504 | Munoz N, Sex Transm Dis 1996; 23: 504 | Rolon PA, Int J Cancer 2000; 85: 486 | Santos C, Br J Cancer 2001; 85: 966 | Sellors JW, CMAJ 2000; 163: 503 | Sherman ME, J Natl Cancer Inst 2003; 95: 46 | Smith EM, Cancer Detect Prev 2003; 27: 472 | Smith EM, Int J Gynaecol Obstet 2004; 87: 131 | Svare EI, Eur J Cancer 1998; 34: 1230 | Swan DC, J Clin Microbiol 1999; 37: 1030 | Tarkowski TA, J Infect Dis 2004; 189: 46 | Wideroff L, Nutr Cancer 1998; 30: 130 | Young TK, Sex Transm Dis 1997; 24: 293 Low-grade lesions: Abba MC, Rev Argent Microbiol 2003; 35: 74 | Adam E, Am J Obstet Gynecol 2000; 182: 257 | ASCUS-LSIL Traige Study (ALTS) Group, Am J Obstet Gynecol 2003; 188: 1393 | Brown DR, Sex Transm Dis 2002; 29: 763 | Evans MF, Mod Pathol 2002; 15: 1339 | Ferrera A, Int J Cancer 1999; 82: 799 | Franco E, Rev Panam Salud Publica 1999; 6: 223 | Giuliano AR, Cancer Epidemiol Biomarkers Prev 2001; 10: 1129 | Gonzalez-Losa Mdel R, J Clin Virol 2004; 29: 202 | Herrero R, J Natl Cancer Inst 2000; 92: 464 | Jarboe EA, Hum Pathol 2004; 35: 396 | Kulasingam SL, JAMA 2002; 288: 1749 | Liaw KL, J Natl Cancer Inst 1999; 91: 954 | Lorenzato F, Int J Gynecol Cancer 2000; 10: 143 | Molano M, Br J Cancer 2002; 87: 1417 | Rattray C, J Infect Dis 1996; 173: 718 | Richardson H, Cancer Epidemiol Biomarkers Prev 2003; 12: 485 | Schiff M, Am J Epidemiol 2000; 152: 716 | Sellors JW, CMAJ 2000; 163: 503 | Sellors JW, CMAJ 2000; 163: 513 | Strickler HD, J Med Virol 1999; 59: 60 | Tonon SA, Infect Dis Obstet Gynecol 1999; 7: 237 | Torroella-Kouri M, Gynecol Oncol 1998; 70: 115 | Tortolero-Luna G, Cad Saude Publica 1998; 14 Suppl 3: 149 | Tran-Thanh D, Am J Obstet Gynecol 2003; 188: 129 High-grade lesions: Abba MC, Rev Argent Microbiol 2003; 35: 74 | Adam E, Am J Obstet Gynecol 1998; 178: 1235 | Alonio LV, J Clin Virol 2003; 27: 263 | Aoyama C, Diagn Mol Pathol 1998; 7: 324 | Bosch FX, Cancer Epidemiol Biomarkers Prev 1993; 2: 415 | Camara GN, Mem Inst Oswaldo Cruz 2003; 98: 879 | Chan JK, Br J Cancer 2003; 89: 1062 | Crum CP, J Infect Dis 2004; 189: 1348 | Evans MF, Eur J Gynaecol Oncol 2003; 24: 373 | Evans MF, Cancer 2006; 106: 1054 | Ferrera A, Int J Cancer 1999; 82: 799 | Golijow CD, Gynecol Oncol 2005; 96: 181 | Gonzalez-Losa Mdel R, J Clin Virol 2004; 29: 202 | Herrero R, J Infect Dis 2005; 191: 1796 | Hu L, Mod Pathol 2005; 18: 267 | Jarboe EA, Hum Pathol 2004; 35: 396 | Lorenzato F, Int J Gynecol Cancer 2000; 10: 143 | Rattray C, J Infect Dis 1996; 173: 718 | Schiff M, Am J Epidemiol 2000; 152: 716 | Sebbelov AM, Res Virol 1994; 145: 83 | Sellors JW, CMAJ 2000; 163: 513 | Torroella-Kouri M, Gynecol Oncol 1998; 70: 115 Cervical cancer: Alonio LV, J Clin Virol 2003; 27: 263 | Bosch FX, J Natl Cancer Inst 1995; 87: 796 | Bryan JT, J Med Virol 2006; 78: 117 | Burger RA, J Natl Cancer Inst 1996; 88: 1361 | Burnett AF, Gynecol Oncol 1992; 47: 343 | Duggan MA, Hum Pathol 1995; 26: 319 | Eluf-Neto J, Br J Cancer 1994; 69: 114 | Ferguson AW, Mod Pathol 1998; 11: 11 | Ferrera A, Int J Cancer 1999; 82: 799 | Golijow CD, Gynecol Oncol 2005; 96: 181 | Herrero R, J Infect Dis 2005; 191: 1796 | Lorenzato F, Int J Gynecol Cancer 2000; 10: 143 | Meyer T, J Infect Dis 1998; 178: 252 | Munoz N, Int J Cancer 1992; 52: 743 | Paquette RL, Cancer 1993; 72: 1272 | Pirog EC, Am J Pathol 2000; 157: 1055 | Rabelo-Santos SH, Mem Inst Oswaldo Cruz 2003; 98: 181 | Resnick RM, J Natl Cancer Inst 1990; 82: 1477 | Rolon PA, Int J Cancer 2000; 85: 486 | Santos C, Br J Cancer 2001; 85: 966 | Schwartz SM, J Clin Oncol 2001; 19: 1906 | Sebbelov AM, Microbes Infect 2000; 2: 121 | Torroella-Kouri M, Gynecol Oncol 1998; 70: 115
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| Tran-Thanh D, Am J Obstet Gynecol 2003; 188: 129 | Wistuba II, Cancer Res 1997; 57: 3154

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Note to the reader

Anyone who is aware of relevant published data that may not have been included in the WHO/ICO Information Centre on HPV and Cervical Cancer is encouraged to contact the HPV Information Centre for potential contributions. Although efforts have been made by the HPV Information Centre to prepare and include as accurately as possible the data presented, mistakes may occur. Readers are requested to communicate any errors to the HPV Information Centre, so that corrections can be made in future volumes.

Acknowledgments
This report has been developed by the Epidemiology and Cancer Registry Unit at the Institut Catal dOncologia (ICO, Catalan Institute of Oncology) in collaboration with the WHOs Department of Immunization, Vaccines and Biologicals (IVB), which receives support from the Bill and Melinda Gates Foundation.

Institut Catal dOncologia (ICO) F. Xavier Bosch, Xavier Castellsagu, Silvia de Sanjos, Ginesa Albero, Laia Bruni, Mireia Diaz, Elena Ferrer, Karly S. Louie, Jesus Muoz, Cristina Rajo World Health Organization (WHO) Teresa Aguado, Olivier Beauvais, Susan Byrne, Marta Gacic-Dobo

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