cervical cancer and hpv philippines

Human Papillomavirusand

Cervical Cancer

Summary Report

PHILIPPINESUpdated year 2007 (r1)

- ii -

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 Catalàd’Oncologia, Avda. Gran Via, s/n Km 2.7 08907 L’Hospitalet de Llobregat (Barcelona, Spain)(e-mail:[email protected]). Requests for permission to reproduce or translate HPV InformationCentre publications - whether for sale or for noncommercial distribution - should be addressed toHPV Information Centre Secretariat, at the above address (e-mail: [email protected]).

The designations employed and the presentation of the material in this publication do not imply theexpression of any opinion whatsoever on the part of the HPV Information Centre concerning the legalstatus of any country, territory, city or area or of its authorities, or concerning the delimitation of itsfrontiers or boundaries. Dotted lines on maps represent approximate border lines for which there maynot yet be full agreement.

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Recommended citation:

WHO/ICO Information Centre on HPV and Cervical Cancer (HPV Information Centre). Summaryreport on HPV and cervical cancer statistics in Philippines. 2007. [Date accessed].Available at www. who. int/ hpvcentre

c©WHO/ICO Information Centre on HPV and Cervical Cancer

www.who.int/hpvcentre

- iii -

Preface

The main aim of this report is to summarize the information available on human papillomavirus (HPV)and cervical cancer at the country-specific level. The World Health Organization (WHO) in collabora-tion with the Institut Català d’Oncologia (ICO) have developed the WHO/ICO Information Centre onHPV and Cervical Cancer (HPV Information Centre) to evaluate the burden of disease in the countryand to help facilitate stakeholders and relevant bodies of decision makers to formulate recommen-dations on cervical cancer prevention, including the implementation of the newly developed HPVvaccines.

Data aggregated are derived from data and official reports produced by the World Health Orga-nization (WHO), International Agency for Research on Cancer (IARC), United Nations, The WorldBank, and published literature. Indicators include relevant statistics on cancer, epidemiological de-terminants 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 awebsite (www.who.int/hpvcentre) to provide a user-friendly tool to assess the best available informa-tion in each country.

The information presented here is intended as a resource for all who are working towards the pre-vention of cervical cancer.


http://www.who.int/hpvcentre

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Executive summary

Human papillomavirus (HPV) infection is now a well-established cause of cervical cancer. HPV types16 and 18 are responsible for about 70% of all cervical cancer cases worldwide. Recently, two HPVvaccines that prevent specific HPV infections and have the potential to reduce the incidence of cervi-cal and other anogenital cancers, have been or are being licensed worldwide.

This report provides key information for Philippines on cervical cancer, HPV-related statistics, factorscontributing to cervical cancer, cervical cancer screening, and immunization. The report is intendedto strengthen the guidance for health policy implementation of primary and secondary cervical cancerprevention strategies in the country.

Philippines has a population of 26.98 millions women ages 15 years and older who are at risk ofdeveloping cervical cancer. Current estimates indicate that every year 6000 women are diagnosedwith cervical cancer and 4349 die from the disease. Cervical cancer ranks the 2nd most frequentcancer in women in Philippines, and the 2nd most frequent cancer among women between 15 and44 years of age.

About 9.3% of women in the general population are estimated to harbour cervical HPV infectionat a given time, and 64.4% of invasive cervical cancers in Philippines are attributed to HPVs 16 or18.

Table 1: Key StatisticsPopulationWomen at risk of cervical cancer (Female population aged >=15 yrs) in millions 26.98

Burden of Cervical cancerNumber of cervical cancer cases diagnosed annually 6000

Number of deaths due to cervical cancer annually 4349

Burden of cervical HPV infectionHPV prevalence (%) in general population (in women with normal cytology) 9.3

Prevalence (%) of HPV 16 or HPV 18 in women with cervical cancer 64.4

Screening practicesCervical screening coverage -

Other factors contributing to cervical cancerHIV rate (%) in adults (15-49 years) <0.1

Smoking prevalence in women (%) 7.60

Fertility rate (live births per women) 3.8

Oral Contraceptive Use (%) 13.2

Other relevant factors for HPV vaccine introductionVaccination coverage (%) in 2005 of DTP (3rd dose completed) 79

Immunization system performance (% of districts >=80% DTP3 coverage) 48


LIST OF CONTENTS - v -

Contents

Preface iii

Executive summary iv

List of Figures vi

List of Tables vii

1 Introduction 11.1 Demographic and socioeconomic factors . . . . . . . . . . . . . . . . . . . . . . . . . 3

2 Cervical cancer burden 52.1 Incidence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52.2 Mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 82.3 Comparison of incidence and mortality . . . . . . . . . . . . . . . . . . . . . . . . . . . 112.4 Prevalent cases and survival . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

3 HPV burden in women 133.1 Terminology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143.2 HPV prevalence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153.3 HPV type distribution . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163.4 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

4 Screening practices 20

5 Factors contributing to cervical cancer 21

6 Other relevant factors for HPV vaccine introduction 226.1 Immunization practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

6.1.1 Immunization coverage estimates . . . . . . . . . . . . . . . . . . . . . . . . . 226.1.2 Immunization schedule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 256.1.3 Other immunization indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

6.2 Reproductive health indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Note to the reader 28

Acknowledgments 28

Contact information 28


LIST OF FIGURES - vi -

List of Figures

1 Philippines in South-Eastern Asia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Population pyramid of Philippines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33 Population trends in Philippines by four selected age groups . . . . . . . . . . . . . . . 34 Cervical cancer incidence in Philippines compared to other cancers in women of all ages 55 Specific cervical cancer incidence in Philippines compared to other cancers in women

of 15-44 years of age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 Cervical cancer age-standardized (ASR) incidence rates in countries of South-Eastern

Asia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Age-specific incidence rates of cervical cancer in Philippines as compared to estimates

for South-Eastern Asia and the World . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 Annual number of new cases of cervical cancer according to age in Philippines and

South-Eastern Asia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Cervical cancer mortality in Philippines compared to other cancers in women of all ages 810 Specific cervical cancer mortality in Philippines compared to other cancers in women

of 15-44 years of age . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 911 Cervical cancer age-standardized (ASR) mortality rates in countries of South-Eastern

Asia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 912 Age-specific mortality rates of cervical cancer in Philippines as compared to estimates

for South-Eastern Asia and the World . . . . . . . . . . . . . . . . . . . . . . . . . . . 1013 Annual number of deaths from cervical cancer according to age in Philippines and

South-Eastern Asia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1014 A comparison of age-specific incidence rates and age-specific mortality rates of cervi-

cal cancer in Philippines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1115 Age-specific crude prevalence in women with normal cytology in Philippines compared

to South-Eastern Asia and the World. . . . . . . . . . . . . . . . . . . . . . . . . . . . 1516 Ten most frequent HPV types in women with normal cytology in Philippines as com-

pared to South-Eastern Asia and the World . . . . . . . . . . . . . . . . . . . . . . . . 1617 Ten most frequent HPV types in women with low-grade cervical lesions (LSIL/CIN-1)

in Philippines as compared to South-Eastern Asia and the World . . . . . . . . . . . . 1618 Ten most frequent HPV types in women with high-grade cervical lesions (CIN-2, CIN-3,

CIS and HSIL) in Philippines as compared to South-Eastern Asia and the World . . . 1719 Ten most frequent HPV types in women with invasive cervical cancer in Philippines as

compared to South-Eastern Asia and the World . . . . . . . . . . . . . . . . . . . . . . 1720 DTP (Diphtheria, Tetanus and Pertussis) vaccine coverage (3rd dose completed) in

Philippines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2221 Hepatitis B vaccine coverage (3rd dose completed) in Philippines . . . . . . . . . . . . 2322 Measles-containing vaccine coverage in Philippines . . . . . . . . . . . . . . . . . . . 2323 Polio vaccine coverage (3rd dose completed) in Philippines . . . . . . . . . . . . . . . 24


LIST OF TABLES - vii -

List of Tables

1 Key Statistics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iv2 Sociodemographic indicators of Philippines . . . . . . . . . . . . . . . . . . . . . . . . 43 Incidence of cervical cancer in Philippines, South-Eastern Asia and the World . . . . . 54 Mortality of cervical cancer in Philippines, South-Eastern Asia and the World . . . . . 85 Prevalent cases of cervical cancer in Philippines . . . . . . . . . . . . . . . . . . . . . 126 Prevalence of HPV in women with normal cytology, precancerous cervical lesions and

invasive cervical cancer in Philippines. . . . . . . . . . . . . . . . . . . . . . . . . . . . 157 Type-specific HPV prevalence in women with normal cytology, precancerous cervical

lesions and invasive cervical cancer in Philippines . . . . . . . . . . . . . . . . . . . . 188 Main characteristics of cervical cancer screening in Philippines. . . . . . . . . . . . . . 209 Factors contributing to cervical carcinogenesis in Philippines . . . . . . . . . . . . . . 2110 General immunization schedule. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2511 Relevant indicators of vaccine implementation in Philippines. . . . . . . . . . . . . . . 2612 Reproductive health indicators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27


1 INTRODUCTION - 1 -

1 Introduction

Figure 1: Philippines in South-Eastern Asia

The WHO/ICO Information Centre on HPV and Cervical Cancer (HPV Information Centre) aims tocompile and centralize updated data and statistics on human papillomavirus (HPV) and cervical can-cer. This report aims to summarize the data available to fully evaluate the burden of disease inPhilippines and to facilitate stakeholders and relevant bodies of decision makers to formulate recom-mendations on cervical cancer prevention. Data include relevant cancer statistic estimates, epidemi-ological determinants of cervical cancer such as demographics, socioeconomic factors, risk factors,burden of HPV infection, screening and immunization. The report is structured into the following 6sections:

Section 1 summarizes the socio-demographic profile of the country. For analytical purposes, Philip-pines is classified in the geographical region of South-Eastern Asia (Figure 1, lighter blue), whichis composed of the following countries:∗ Brunei Darussalam, Cambodia, Indonesia, Lao People’sDemocratic Republic, Malaysia, Myanmar, Philippines, Singapore, Thailand, Timor-Leste and VietNam. Throughout the report, Philippines estimates will be complemented with the correspondingestimates in the South-Eastern Asia region to provide the regional situation. When data are not avail-able for Philippines only the regional estimates are shown.

Section 2 describes the current burden of invasive cervical cancer in Philippines and the South-Eastern Asia region with estimates of prevalence, incidence and mortality rates.

Section 3 reports on the HPV prevalence and HPV type-specific distribution in women with nor-

∗See http://unstats.un.org/unsd/methods/m49/m49regin.htm for more information.


http://unstats.un.org/unsd/methods/m49/m49regin.htm


mal cytology, women with cervical neoplasia and women with invasive cervical cancer.

Section 4 includes a brief description on screening practices in the country when available.

Section 5 describes factors that can modify the natural history of HPV and cervical carcinogene-sis such as the use of hormonal contraceptives, parity, tobacco smoking, and co-infection with HIV.

Section 6 presents data on immunization coverage and practices for selected vaccines. This in-formation will be relevant for assessing the country’s capacity to introduce and implement the newHPV vaccines. The data are periodically updated and posted on the WHO Immunization surveillance,assessment and monitoring website. (http://www.who.int/immunization_monitoring/data/data_subject/en/index.html). Other reproductive health factors present proxy measures of sexual be-haviour that may play a role in HPV infection


http://www.who.int/immunization_monitoring/data/data_subject/en/index.html



1.1 Demographic and socioeconomic factors

Figure 2: Population pyramid of Philippines

505020849860454885049

45261414037250

35811893054830

26267242225061

18581661531362

1139663879976

630305431471

219104107198

43931

481263447668424685352

43586113914357

34942193002370

26093262236164

18928461586932

1152886936546

722031511623

305546172613

80000

Under 55−9

10−1415−1920−2425−2930−3435−3940−4445−4950−5455−5960−6465−6970−7475−7980−84

85+

Population of Philippines by sex and age group

2005 Estimates

Data source: United Nations, Population Division.

World Population Prospects − the 2004 revision. New York, 2005.

Males Females

Figure 3: Population trends in Philippines by four selected age groups

Girls 10−14 yrs

Women 15−24 yrs

2.0

4.0

6.0

8.0

10.0

Num

ber

of w

omen

(in

mill

ions

)

1950

1955

1960

1965

1970

1975

1980

1985

1990

1995

2000

2005

2010

2015

2020

2025

2030

2035

2040

2045

2050

Projections

Women 25−64 yrs

All Women

0.0

20.0

40.0

60.0

Num

ber

of w

omen

(in

mill

ions

)

1950

1955

1960

1965

1970

1975

1980

1985

1990

1995

2000

2005

2010

2015

2020

2025

2030

2035

2040

2045

2050

Projections

Female population trends in Philippines

Number of women by year and age group

Data source: United Nations, Population Division.

World Population Prospects − the 2004 revision. New York, 2005.



Table 2: Sociodemographic indicators of PhilippinesIndicator Male Female TotalPopulation in 1000s a - - 830541

Population annual growth rate (%) a - - 1.81

Population in urban areas (%) a - - 631

Crude birth rate per 1000 population b - - -Crude death rate per 1000 population b - - 4.962

Life expectancy at birth (years) c 652 722 -Adult mortality rate per 1000 (population between 15 and 60 years) c 2692 1492 -Under 5 mortality rate (per 1000 live births) c 402 282 342

Infant mortality rate (per 1000 live births) d - - 262

Maternal mortality rate (per 100,000 live births) e - - 2003

Neonatal mortality rate (per 1000 live births) e - - 153

Gross National Income (GNI) per capita, atlas method (current US$) f - - 13001

Population living below the poverty line (% with <$1 day) g - - 15.53

Total expenditure on health as % of gross domestic product c - - 3.24

Per capita total expenditure on health at international US$ rate c - - 1744

Per capita government expenditure on health at international US$ rate c - - 764

General government expenditure on health as % of total expenditure on health c - - 43.74

General government expenditure on health as % of total government expenditure c - - 5.94

Private expenditure on health as % total expenditure on health c - - 56.34

Physicians per 1000 c - - 0.583

Adult literacy rate (>=15 years) (%) h 92.55 92.75 92.65

Youth literacy rate (15-24 years) (%) h 94.55 95.75 95.15

Net enrollment rate (%), primary level i 92.992 94.972 93.962

Primary school education completion rate (%) i 93.362 99.872 96.552

Net enrollment rate (%), secondary level i 55.722 66.682 61.092

Year of estimation:12005; 22004; 32000; 42003; 52000-2004Data sources:a Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat (2005). WorldPopulation Prospects: The 2004 Revision. New York: United Nations.b World Bank’s Health, Nutrition and Population data (http://devdata.worldbank.org/hnpstats/)c The World health report 2006: working together for health. Geneva, World Health Organization, 2006.(http://www.who.int/whr/2006/annex/en)d WHO Mortality Database. World Health Organization. (http://www.who.int/healthinfo/morttables/en/index.html); (ii)United Nations Children’s Fund. State of the World’s Children 2006. New York: United Nations Children’s Fund, 2005.e The World health report 2005: make every mother and child count. Geneva, World Health Organization, 2005.(http://www.who.int/whr/2005/en/index.html)f The World Bank Group. (http://siteresources.worldbank.org/DATASTATISTICS/Resources/GNIPC.pdf)g The World Bank Group. (http://devdata.worldbank.org/wdi2006/contents/Section2.htm; Table 2.7Expenditure Baseh United Nations Educational, Scientific and Cultural Organization. (http://gmr.uis.unesco.org/selectindicators.aspx)i Education Group of the Human Development Network (HDNED) of the World Bank in collaboration with its internalpartner Development Economics Data Group (DECDG) (http://devdata.worldbank.org/edstats/cd.asp)


2 CERVICAL CANCER BURDEN - 5 -

2 Cervical cancer burden

This section describes the current burden of invasive cervical cancer in Philippines and the South-Eastern Asia region with estimates of prevalence, incidence and mortality rates.

2.1 Incidence

Table 3: Incidence of cervical cancer in Philippines, South-Eastern Asia and the World

Indicator Philippines South-Eastern Asia World

Crude incidence rate 15.4 15.9 16

Age-standardized incidence rate 20.9 18.7 16.2

Cumulative risk (%). Age period 0-64 years 1.5 1.5 1.3

Standardized incidence ratio (SIR) 123 112 100

Annual number of new cancer cases 6000 42538 493243

Rates are per 100,000 women.Standardized rates have been estimated using the direct method and the World population as the reference.

Data sources:IARC, Globocan 2002

Figure 4: Cervical cancer incidence in Philippines compared to other can-cers in women of all ages

0.30.30.60.60.70.81.01.51.61.62.02.63.03.4

4.34.34.6

6.58.68.6

9.615.415.4

33.5

0 10 20 30 40

Annual crude incidence rate per 100,000

Philippines: Female (All ages)

Hodgkin lymphomaMelanoma of skin

LarynxMultiple myeloma

OesophagusBladder

Other pharynxKidney etc.

Brain, nervous systemNasopharynx

PancreasNon−Hodgkin lymphoma

Oral cavityStomach

Corpus uteriLiver

LeukaemiaThyroid

Ovary etc.Lung

Colon and rectumCervix uteri

Breast

Data source: IARC, Globocan 2002



Figure 5: Specific cervical cancer incidence in Philippines compared toother cancers in women of 15-44 years of age

0.10.10.10.10.20.20.30.30.40.70.81.01.11.21.41.51.6

2.43.0

5.85.9

10.110.118.0

0 10 20

Annual crude incidence rate per 100,000

Philippines: Females aged 15−44 years

Multiple myelomaOesophagus

BladderLarynx

Melanoma of skinOther pharynx

Hodgkin lymphomaPancreas

Kidney etc.Oral cavity

StomachBrain, nervous system

LiverNasopharynxCorpus uteri

Non−Hodgkin lymphomaLung

Colon and rectumLeukaemiaOvary etc.

ThyroidCervix uteri

Breast


Figure 6: Cervical cancer age-standardized (ASR) incidence rates in coun-tries of South-Eastern Asia

13.2

15.7

15.7

16.8

18.7

19.8

20.2

20.920.9

24.6

38.7

0 10 20 30 40

Cervical cancer: Age−standardized incidence rate per 100,000 and year

World Standard. Female (All ages)

Timor−Leste**

Singapore

Malaysia

Indonesia

Laos*

Brunei*

Thailand

Viet Nam

Philippines

Myanmar

Cambodia


*No country−specific data are available, calculated from the average of those of neighbouring countries

** No rates are available

Rates are standardized using the direct method and the World population as reference.



Figure 7: Age-specific incidence rates of cervical cancer in Philippines ascompared to estimates for South-Eastern Asia and the World

0

20

40

60

80C

ervi

cal c

ance

r in

cide

nce

rate

per

100

,000

Fem

ale

(All

ages

)

0−14 yrs 15−44 yrs 45−54 yrs 55−64 yrs 65+ yrs

Age group

Philippines

South−Eastern Asia

World


Figure 8: Annual number of new cases of cervical cancer according to agein Philippines and South-Eastern Asia

12234

1859

14013

1686

9437

1342

6854

1113

0

5,000

10,000

15,000

Cer

vica

l can

cer

Ann

ual n

umbe

r of

new

cas

es

15−44 yrs 45−54 yrs 55−64 yrs 65+ yrs

Age group


South−Eastern Asia Philippines



2.2 Mortality

Table 4: Mortality of cervical cancer in Philippines, South-Eastern Asia and the World

Indicator Philippines South-Eastern Asia World

Crude mortality rate 11.2 8.4 8.9

Age-standardized mortality rate 15.6 10.2 9

Cumulative risk (%). Age period 0-64 years 1.1 0.8 0.7

Standardized mortality ratio (SMR) 171 112 100

Annual number of deaths 4349 22594 273505

Rates are per 100,000 women.Standardized rates have been estimated using the direct method and the World population as the reference.


Figure 9: Cervical cancer mortality in Philippines compared to other can-cers in women of all ages

0.10.20.40.50.60.70.71.01.11.31.61.61.81.8

3.03.43.83.8

4.66.2

8.011.211.2

19.5

0 10 20

Annual crude mortality rate per 100,000

Philippines: Female (All ages)

Hodgkin lymphomaMelanoma of skin

LarynxMultiple myeloma

BladderOther pharynx

OesophagusKidney etc.

NasopharynxBrain, nervous system

Oral cavityCorpus uteri

Non−Hodgkin lymphomaPancreasStomach

ThyroidLeukaemia

LiverOvary etc.

Colon and rectumLung

Cervix uteriBreast




Figure 10: Specific cervical cancer mortality in Philippines compared toother cancers in women of 15-44 years of age

0.00.00.10.10.10.10.10.20.30.30.3

0.70.70.80.90.9

1.41.8

2.42.4

2.96.26.2

11.0

0 5 10

Annual crude mortality rate per 100,000

Philippines: Females aged 15−44 years

LarynxOesophagus

Hodgkin lymphomaBladder

Multiple myelomaOther pharynx

Melanoma of skinKidney etc.Oral cavityPancreas

Corpus uteriBrain, nervous system

StomachNasopharynx

Non−Hodgkin lymphomaLiverLung

Colon and rectumLeukaemia

ThyroidOvary etc.

Cervix uteriBreast


Figure 11: Cervical cancer age-standardized (ASR) mortality rates in coun-tries of South-Eastern Asia

8.1

8.4

8.4

8.4

8.8

9.6

11.2

13.1

15.615.6

21.6

0 10 20

Cervical cancer: Age standardized mortality rate per 100,000 and year

World Standard. Female (All ages)

Timor−Leste**

Indonesia

Thailand

Singapore

Malaysia

Laos*

Brunei*

Viet Nam

Myanmar

Philippines

Cambodia


*No country−specific data are available, calculated from the average of those of neighbouring countries

** No rates are available

Rates are standardized using the direct method and the World population as reference.



Figure 12: Age-specific mortality rates of cervical cancer in Philippines ascompared to estimates for South-Eastern Asia and the World

0

20

40

60C

ervi

cal c

ance

r m

orta

lity

rate

per

100

,000

Fem

ale

(All

ages

)


Age group

Philippines

South−Eastern Asia

World


Figure 13: Annual number of deaths from cervical cancer according to agein Philippines and South-Eastern Asia

5132

1131

6948

1185

5968

1103

4546

930

0

2,000

4,000

6,000

8,000

Cer

vica

l can

cer

Ann

ual n

umbe

r of

dea

ths

15−44 yrs 45−54 yrs 55−64 yrs 65+ yrs

Age group


South−Eastern Asia Philippines



2.3 Comparison of incidence and mortality

Figure 14: A comparison of age-specific incidence rates and age-specificmortality rates of cervical cancer in Philippines

0

20

40

60

80

Cer

vica

l can

cer

Age

−sp

ecifi

c cr

ude

rate

s pe

r 10

0,00

0 in

Phi

lippi

nes


Age group

Incidence

Mortality




2.4 Prevalent cases and survival

Table 5: Prevalent cases of cervical cancer in Philippines

Age group 1 year survival 3 years survival 5 years survival

0-14 yrs - - -

15-44 yrs 1322 3368 4909

45-54 yrs 1296 3383 5069

55-64 yrs 1379 3575 5361

65+ yrs 871 2322 3631

Total 4868 12648 18970

The number of cases are calculated according to the number of new cases and its probability of survival by time. Formore information: http://www-dep.iarc.fr/globocan/methods.htm, prevalence section.



http://www-dep.iarc.fr/globocan/methods.htm

3 HPV BURDEN IN WOMEN - 13 -

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

The statistics shown in this section focus on HPV infection in the cervix uteri. HPV cervical infec-tion 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, paraffinembedded or exfoliated cells).

The relative frequency of HPV-16/18 increases with the severity of the lesion. Worldwide, HPV-16 and 18 contribute to over 70% of all cervical cancer cases, between 41 and 67% of high-gradecervical lesions and 16-32% of low-grade cervical lesions. After HPV-16/18, the six most commonHPV types are the same in all world regions, namely 31, 33, 35, 45, 52 and 58; these account for anadditional 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 causedby HPV types 6 and 11.

Note: The methodologies used to compile the information on HPV bur-den presented in this section are derived from a systematic review andmeta-analysis of the literature. Because of the limitations of HPV DNAdetection techniques and study designs used, these data should be in-terpreted cautiously and used only as a guidance to assess the burdenof HPV infection in the population.

For instance, the prevalence of low risk types HPV-6 and 11 may be un-derestimated because most studies used assays that only detected highrisk types



3.1 Terminology

Cytologically normal womenNo 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 abnormalgrowth of squamous cells observed in the cervix. SIL is an abnormal result derived from cer-vical cytological screening or Pap smear testing. CIN is a histological diagnosis made uponanalysis of cervical tissue obtained by biopsy or surgical excision.

Low-grade cervical lesions (LSIL/CIN-1)Low-grade cervical lesions are defined by early changes in size, shape, and numberof abnormal cells formed on the surface of the cervix and may be referred to as milddysplasia, 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 thesurface of the cervix that are distinctly different from normal cells. They have the potentialto become cancerous cells and invade deeper tissues of the cervix. These lesions may bereferred to as moderate or severe dysplasia, HSIL, CIN-2, CIN-3, or cervical carcinomain situ (CIS).

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

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



3.2 HPV prevalence

Table 6: Prevalence of HPV in women with normal cytology, precancerous cervical lesions and inva-sive cervical cancer in Philippines.Philippines South-Eastern Asia World

No. HPV prevalence No. HPV Prevalence No. HPV Prevalence

tested % (95% CI) tested % (95%CI) tested % (95%CI)

Normal cytology 377 9.3 (6.6-12.7) 4194 6.2 (5.5-6.9) 157879 10.0 (9.8-10.1)

Low-grade lesionsa - - - 27 33.3 (16.5-54.0) 8640 71.6 (70.6-72.5)

High-grade lesionsb - - - 207 61.8 (54.8-68.5) 7094 84.9 (84.1-85.7)

Cervical Cancer 356 93.5 (90.5-95.9) 1090 92.1 (90.3-93.6) 14595 87.2 (86.7-87.8)

The samples for HPV testing come from cervical specimens (fresh / fixed biopsies or exfoliated cells).

Abbreviations used:95% CI: 95% Confidence Intervala Low-grade lesions: LSIL or CIN-1b High-grade lesions: CIN-2, CIN-3, CIS or HSIL

Data sources: See sources at the end of the chapter

Figure 15: Age-specific crude prevalence in women with normal cytologyin Philippines compared to South-Eastern Asia and the World.

*0

5

10

15

20

0−24

yrs

25−3

4 yr

s

35−4

4 yr

s

45−5

4 yr

s

55+

yrs

.

PHILIPPINES

0

5

10

15

20

0−24

yrs

25−3

4 yr

s

35−4

4 yr

s

45−5

4 yr

s

55+

yrs

.

SOUTH−EASTERN ASIA

0

5

10

15

20

0−24

yrs

25−3

4 yr

s

35−4

4 yr

s

45−5

4 yr

s

55+

yrs

.

WORLD

Age−specific crude HPV prevalence(%) and 95% confidence interval (grey shadow)

Women with normal cytology

*No data available

Data source: WHO/ICO Information Centre on HPV and Cervical Cancer



3.3 HPV type distribution

Figure 16: Ten most frequent HPV types in women with normal cytology inPhilippines as compared to South-Eastern Asia and the World

0.5

0.5

0.5

0.5

0.5

0.5

0.8

1.1

1.3

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45

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CP6108

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PHILIPPINES

0.3

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16


0.4

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2.5

0 .5 1 1.5 2 2.5.

42

35

56

51

33

52

58

31

18

16

WORLD

Type−specific HPV prevalence (%)

Women with normal cytology

Data source: WHO/ICO Information Centre on HPV and Cervical Cancer

Figure 17: Ten most frequent HPV types in women with low-grade cervicallesions (LSIL/CIN-1) in Philippines as compared to South-Eastern Asia and

the World

0 5 10 15 20.

10th: NA*

9th: NA*

8th: NA*

7th: NA*

6th: NA*

5th: NA*

4th: NA*

3rd: NA*

2nd: NA*

1st: NA*

PHILIPPINES

3.7

0 5 10 15 20.

10th: NA*

9th: NA*

8th: NA*

7th: NA*

6th: NA*

5th: NA*

4th: NA*

3rd: NA*

2nd: NA*

18


6.1

6.3

6.4

6.6

6.9

7.4

7.8

8.3

8.3

20.3

0 5 10 15 20.

18

6

58

66

52

56

53

51

31

16

WORLD


Women with low grade lesions (LSIL, CIN−1)

Data source: IARC, Infection and Cancer Epidemiology Unit

*NA=Not available. No more types than shown were tested or were positive



Figure 18: Ten most frequent HPV types in women with high-grade cervicallesions (CIN-2, CIN-3, CIS and HSIL) in Philippines as compared to South-

Eastern Asia and the World

0 10 20 30 40 50.

10th: NA*

9th: NA*

8th: NA*

7th: NA*

6th: NA*

5th: NA*

4th: NA*

3rd: NA*

2nd: NA*

1st: NA*

PHILIPPINES

1.6

3.4

11.1

22.2

0 10 20 30 40 50.

10th: NA*

9th: NA*

8th: NA*

7th: NA*

6th: NA*

5th: NA*

11

33

18

16


2.3

2.9

3.6

3.8

5.1

6.9

7.0

7.3

8.7

45.4

0 10 20 30 40 50.

45

56

51

35

52

18

58

33

31

16

WORLD


Women with high grade lesions (CIN−2, CIN−3, CIS and HSIL)


*NA=Not available. No more types than shown were tested or were positive

Figure 19: Ten most frequent HPV types in women with invasive cervicalcancer in Philippines as compared to South-Eastern Asia and the World

0.6

0.6

1.1

2.0

2.5

2.5

2.8

12.9

25.6

38.8

0 20 40 60.

56

31

66

59

58

51

52

45

18

16

PHILIPPINES

0.6

1.1

1.1

1.5

1.8

3.1

3.5

7.1

25.0

46.8

0 20 40 60.

35

51

33

31

59

58

52

45

18

16


0.7

1.0

1.7

2.5

3.3

3.5

3.7

4.3

15.9

54.4

0 20 40 60.

51

59

35

52

58

31

45

33

18

16

WORLD


Women with invasive cervical cancer




Table 7: Type-specific HPV prevalence in women with normal cytology, precancerous cervical lesionsand invasive cervical cancer in Philippines

Normal cytology Low-grade lesionsa High-grade lesionsb Cervical cancerHPV Type Women HPV Prev Women HPV Prev Women HPV Prev Women HPV Prev

tested % (95%CI) tested % (95%CI) tested % (95%CI) tested % (95%CI)6 377 0.8 (0.2-2.3) - - - - - - 356 0.0 (0.0-1.0)

11 377 0.3 (0.0-1.5) - - - - - - 356 0.0 (0.0-1.0)16 377 1.3 (0.4-3.1) - - - - - - 356 38.8 (33.7-44.0)18 377 1.6 (0.6-3.4) - - - - - - 356 25.6 (21.1-30.4)22 - - - - - - - - - - - -26 377 0.0 (0.0-1.0) - - - - - - - - -30 - - - - - - - - - - - -31 377 0.5 (0.1-1.9) - - - - - - 356 0.6 (0.1-2.0)32 - - - - - - - - - - - -33 377 0.0 (0.0-1.0) - - - - - - 356 0.0 (0.0-1.0)34 377 0.0 (0.0-1.0) - - - - - - - - -35 377 0.0 (0.0-1.0) - - - - - - 356 0.0 (0.0-1.0)39 377 0.0 (0.0-1.0) - - - - - - 356 0.3 (0.0-1.6)40 377 0.3 (0.0-1.5) - - - - - - - - -42 377 0.0 (0.0-1.0) - - - - - - - - -43 377 0.0 (0.0-1.0) - - - - - - - - -44 377 0.3 (0.0-1.5) - - - - - - - - -45 377 0.5 (0.1-1.9) - - - - - - 356 12.9 (9.6-16.9)51 377 0.0 (0.0-1.0) - - - - - - 356 2.5 (1.2-4.7)52 377 0.5 (0.1-1.9) - - - - - - 356 2.8 (1.4-5.1)53 - - - - - - - - - - - -54 377 0.3 (0.0-1.5) - - - - - - - - -55 - - - - - - - - - - - -56 377 0.3 (0.0-1.5) - - - - - - 356 0.6 (0.1-2.0)57 377 0.0 (0.0-1.0) - - - - - - - - -58 377 0.5 (0.1-1.9) - - - - - - 356 2.5 (1.2-4.7)59 377 0.0 (0.0-1.0) - - - - - - 356 2.0 (0.8-4.0)61 377 0.0 (0.0-1.0) - - - - - - - - -62 - - - - - - - - - - - -64 - - - - - - - - - - - -66 377 0.0 (0.0-1.0) - - - - - - 356 1.1 (0.3-2.9)67 - - - - - - - - - - - -68 377 0.0 (0.0-1.0) - - - - - - 356 0.6 (0.1-2.0)69 - - - - - - - - - - - -70 377 0.0 (0.0-1.0) - - - - - - 356 0.0 (0.0-1.0)71 - - - - - - - - - - - -72 377 0.0 (0.0-1.0) - - - - - - - - -73 377 0.3 (0.0-1.5) - - - - - - 356 0.3 (0.0-1.6)74 - - - - - - - - - - - -81 377 1.1 (0.3-2.7) - - - - - - - - -82 377 0.5 (0.1-1.9) - - - - - - 356 0.3 (0.0-1.6)83 377 0.0 (0.0-1.0) - - - - - - - - -84 - - - - - - - - - - - -85 - - - - - - - - - - - -86 - - - - - - - - - - - -89 - - - - - - - - - - - -90 - - - - - - - - - - - -91 - - - - - - - - - - - -

CP6108 377 0.5 (0.1-1.9) - - - - - - - - -JC9710 - - - - - - - - - - - -

X - - - - - - - - - - - -multiple 377 - - - - - - - - 356 8.4 (5.8-11.8)

The samples for HPV testing come from cervical specimens (fresh / fixed biopsies or exfoliated cells).

Abbreviations used:95% CI: 95% Confidence Intervala Low-grade lesions: LSIL or CIN-1b High-grade lesions: CIN-2, CIN-3, CIS or HSIL

Data sources: See sources at the end of the chapter



3.4 References

See the methods file www.who.int/hpvcentre for a list of references contributing to regional andworld estimates. Some authors have been contacted and have provided complementary data notshown in the paper.

Data on precancerous lesions and invasive cervical cancer have been compiled by the IARC Unitof Infection and Cancer Epidemiology and published as a systematic review and meta-analysis inClifford GM. Cancer Epidemiol Biomarkers Prev. 2005; 14: 1157, Clifford GM. Br J Cancer. 2003;89: 101, Clifford GM. Br J Cancer. 2003; 88: 63 and Smith JS. Int J Cancer. 2007; 121: 621. Dataon cytologically normal women have been compiled by ICO Epidemiology and Cancer RegistryUnit and published in De Sanjosé S. Lancet Infect Dis. 2007; 7: 453.

The specific references for Philippines HPV estimates are shown below:

Normal cytology:Ngelangel C, J Natl Cancer Inst 1998; 90: 43

Low-grade lesions:No data available

High-grade lesions:No data available

Cervical cancer:Ngelangel C, J Natl Cancer Inst 1998; 90: 43



4 SCREENING PRACTICES - 20 -

4 Screening practices

Table 8: Main characteristics of cervical cancer screening in Philippines.Indicator ValueScreening ages (years) -Screening interval (years) or Frequency of screens -Lifetime number of recommended smears -Estimated Coverage -Smear taker -

Comments:The Department of Health in the Philippines has proposed an organized cervical cancer screening programme, withrecommendations for regular cytological tests every three years, although a recent policy shift has recommended visualinspection methods (Ngelangel and Wang, 2002; Ngelangel et al., 2003). Changes in public health policy, includingaspects related to education of screening personnel, strategies for ensuring compliance with screening and healthinsurance coverage for preventive services, have been mentioned as barriers to the development and implementationof a screening programme (Ngelangel et al., 2003). The lack of a skilled workforce is also an issue. The PhilippinesCancer Society is involved in cytological testing, although this is not widely available (http://www.kanser.com.ph).

Data source:All information has been extracted from: IARC Handbooks of Cancer Prevention Vol. 10: Cervix Cancer Screening.IARC Press. Lyon, 2005.


5 FACTORS CONTRIBUTING TO CERVICAL CANCER - 21 -

5 Factors contributing to cervical cancer

HPV is a necessary cause of cervical cancer, but it is not a sufficient cause. Other cofactors arenecessary for progression from cervical HPV infection to cancer. Long-term use of hormonal contra-ceptives, high parity, tobacco smoking, and co-infection with HIV have been identified as establishedcofactors; co-infection with Chlamydia trachomatis and herpes simplex virus type-2, immunosuppres-sion, and certain dietary deficiencies are other probable cofactors. Genetic and immunological hostfactors and viral factors other than type, such as variants of type, viral load and viral integration, arelikely to be important but have not been clearly identified (Muñoz N, Vaccine 2006; 24S3: S3-1).

Table 9: Factors contributing to cervical carcinogenesis in Philippines.Fertility rate is used as a ”proxy” for parity.

Cofactors Indicator Male Female Total

Smoking Prevalence of smoking (% of adults) a 40.501 7.601 -

Parity

Total Fertility Rate per Woman b - 3.82 -

Age-specific fertility rate per 1000women b

15-19 yrs - 502 -

20-24 yrs - 1772 -

25-29 yrs - 2102 -

30-34 yrs - 1612 -

35-39 yrs - 1062 -

40-44 yrs - 432 -

45-49 yrs - 82 -

HIV

HIV rate (%), adults (15-49 years) c - - <0.13

HIV rate (%), young adults (15-24 years) c - - -

Number of adults and children with HIV c - - 120003

Number of adults (15+ years) with HIV c - 34003 120003

Number of children (0-14 years) with HIV c - - -

HIV Antiretroviral Therapy Coverage (%) d - - <0.13

Hormonal Contraception Oral Contraceptive Use (%) e - - 13.23

Year of estimation:12003; 21996; 32005Data sources:a World Bank’s Health, Nutrition and Population data (http://devdata.worldbank.org/hnpstats)b World Fertility Patterns, 2004; World Population Prospects: The 2004 Revision. Population database. PopulationDivision, Department of Economic and Social Affairs, United Nations Secretariat. (http://esa.un.org/unpp)c 2006 Report on the global AIDS epidemic, UNAIDS/WHO, May 2006.d Progress on global access to HIV antiretroviral therapy. A report on ’3 by 5’ and beyond. Geneva, World HealthOrganization and Joint United Nations Programme on HIV/AIDS, March 2006. Data for high-income countries havebeen added to the original liste United Nations, Department of Economic and Social Affairs, Population Division. World Contraceptive Use 2005(http://www.un.org/esa/population/publications/contraceptive2005/WCU2005.htm)


6 OTHER RELEVANT FACTORS FOR HPV VACCINE INTRODUCTION - 22 -

6 Other relevant factors for HPV vaccine introduction

This section presents data on immunization coverage and practices for selected vaccines. This in-formation will be relevant for assessing the country’s capacity to introduce and implement the newHPV vaccines. The data are periodically updated and posted on the WHO Immunization surveillance,assessment and monitoring website. (http://www.who.int/immunization_monitoring/data/data_subject/en/index.html). Other reproductive health factors present proxy measures of sexual be-haviour that may play a role in HPV infection

6.1 Immunization practices

6.1.1 Immunization coverage estimates

Figure 20: DTP (Diphtheria, Tetanus and Pertussis) vaccine coverage (3rddose completed) in Philippines

7979797980 81808081

707573

7680

88 9087

79

66

73

595754 5554

47

0

25

50

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Vac

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2005

DTP Diphtheria, Tetanus and Pertussis vaccine (3rd dose) coverage

Philippines: WHO/UNICEF coverage estimates 1980−2005, as of August 2006

Data source: WHO Immunization surveillance, assessment and monitoring

http://www.who.int/immunization_monitoring/routine/immunization_coverage/en/index4.html





Figure 21: Hepatitis B vaccine coverage (3rd dose completed) in Philip-pines

444247

3835

80

353531

3835

**** **** **** ***0

25

50

75

100V

acci

ne c

over

age

%

1980

1981

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2000

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2004

2005

Hepatitis B vaccine (3rd dose) coverage


*Data not available



Figure 22: Measles-containing vaccine coverage in Philippines

8080808081 8080807972

767578

8185 8383

77

51

68

4944

9

27

**0

25

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Vac

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e %

1980

1981

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2005

Measles−containing vaccine coverage


*Data not available





Figure 23: Polio vaccine coverage (3rd dose completed) in Philippines

8080808081 8080807972

767578

8185 8383

77

51

68

4944

9

27

**0

25

50

75

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Vac

cine

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e %

1980

1981

1982

1983

1984

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1989

1990

1991

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1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

Polio vaccine (3rd dose) coverage


*Data not available





6.1.2 Immunization schedule

Table 10: General immunization schedule.

Vaccine Schedule Coverage*

Bacille Calmette-Guérin vaccine (BCG) birth entire

Diphtheria and tetanus toxoid with whole cell pertussisvaccine (DTwP)

6, 10, 14 weeks entire

Hepatitis B vaccine (HepB) 6, 10, 14 weeks entire

Measles vaccine (Measles) 9 months entire

Meningococcal C conjugate vaccine (MenC_conj) - -

Oral polio vaccine (OPV) 6, 10, 14 weeks entire

Tetanus toxoid (TT) CBAW 1st contact; 1, 6 months;+1, +1 year

entire

Vitamin A supplementation (VitaminA) 6, 12, 18, 24, 30, 36 months entire

*Entire or part of the population covered.

Data sources:WHO Immunization surveillance, assessment and monitoring (http://www.who.int/immunization_monitoring/data/data_subject/en/)


http://www.who.int/immunization_monitoring/data/data_subject/en/

http://www.who.int/immunization_monitoring/data/data_subject/en/


6.1.3 Other immunization indicators

Table 11: Relevant indicators of vaccine implementation in Philippines.Indicator Value*

Immunization planning andmanagement

Was there a strategic plan for the national immunization system thatcovers three to five years?

Yes1

Was there an annual budget for advocacy and communication? Yes1

Was there an updated inventory (models, location, age and workingstatus) of all regrigeration equipement in the country?

Partially1

Immunization system performance% of districts >=80% DTP3 coverage 481

Drop-out rate between DTP1 and DTP3 coverage estimates 3.661

Surveillance Feedback included coverage by district (at least DTP3) Yes1

Safety

Sterilizable: Type of injection equipment used for routine immuniza-tions

-

Non AD disposables: Type of injection equipment used for routineimmunizations

Yes1

Are safety boxes distributed with all vaccine deliveries No1

Was there any monitoring for immunization safety (i.e. monitoringof adverse events following immunization)?

Yes1

Finance

Was there a line item in the national budget for purchase of vaccinesused in routine immunizations?

Yes1

Was there a line item in the national budget for purchase of injec-tion supplies (syringes, needles, sharp boxes) for routine immuniza-tions?

No1

What percentage of routine vaccine costs was financed by the gov-ernment (including loans)

1001

% of immunization spending financed using Government funds 1001

New vaccine introductionIs Hepatitis B vaccine integrated into the routine immunization sys-tems?

Yes1

Is Rubella vaccine integrated into the routine immunization sys-tems?

No1

*’A’ means Adolescents, ’E’ means Estimates and ’P’ means Partial

Reported for year:12005

Data sources:WHO Immunization surveillance, assessment and monitoring (http://www.who.int/immunization_monitoring/data/data_subject/en/)



6.2 Reproductive health indicators

Table 12: Reproductive health indicatorsFactor Indicator Male Female Total

Contraceptiveuse

Any contraceptive use (%) a - - 48.91

Modern methods a

Condom use (%) - - 1.91

Intrauterine device (%) - - 4.11

Injectable or implant (%) - - 3.11

Pill (%) - - 13.21

Sterilization (%) 0.11 10.51 -

Vaginal barrier method (%) - - 0.01

Other modern methods (%) - - 0.41

Total prevalence of modern meth-ods, (%)

- - 33.41

Traditional methods a

Withdrawal (%) - - 8.21

Rhythm (%) - - 6.71

Other traditional method (%) - - 0.61

Age at firstmarriage

Average age first marriage b 26.32 23.82 -

Age specific percentage of evermarried b

Ages 15-19 3.02 10.52 -

Ages 20-24 26.82 44.32 -

Ages 45-49 95.52 93.92 -

Difference in average age at first marriage between men and women b - - 2.52

Married or inunion

Women aged 15-49, married or in union (in thousands) a - - 127183

For fertility rates and oral contraceptives, see section 5.

Year of estimation:12003; 21990; 32005

Data sources:a United Nations, Department of Economic and Social Affairs, Population Division. World Contraceptive Use 2005(http://www.un.org/esa/population/publications/contraceptive2005/WCU2005.htm)b World Marriage Patterns, 2000. Population Division, Department of Economic and Social Affairs, United NationsSecretariat. (http://esa.un.org/unpp)


- 28 -

Note to the reader

Anyone who is aware of relevant published data that may not have been included in the WHO/ICOInformation Centre on HPV and Cervical Cancer is encouraged to contact the HPV Information Cen-tre for potential contributions.

Although efforts have been made by the HPV Information Centre to prepare and include as accu-rately as possible the data presented, mistakes may occur. Readers are requested to communicateany 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 Catalàd’Oncologia (ICO, Catalan Institute of Oncology) in collaboration with the WHO’s Department of Im-munization, Vaccines and Biologicals (IVB), which receives support from the Bill and Melinda GatesFoundation.

Institut Català d’Oncologia (ICO)F. Xavier Bosch, Xavier Castellsagué, Silvia de Sanjosé, Ginesa Albero, Laia Bruni, Mireia Diaz,Elena Ferrer, Karly S. Louie, Jesus Muñoz, Cristina Rajo

World Health Organization (WHO)Teresa Aguado, Olivier Beauvais, Susan Byrne, Marta Gacic-Dobo

Licensed Logo Use

Use, reproduction, copying, or redistribution of HPV Information Centre logos are strictly prohibitedwithout written permission from Arnau Bosch Prats and the WHO/ICO Information Centre on HPVand Cervical Cancer.

Contact information:

WHO/ICO Information Centre on HPV and Cervical CancerInstitut Català d’OncologiaAvda. Gran Via, s/n Km 2.708907 L’Hospitalet de Llobregat (Barcelona, Spain)e-mail: [email protected] adress: www.who.int/hpvcentre



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