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Human papillomavirus infection in Bhutan at the moment of implementation of a national HPV vaccination programme

Ugyen Tshomo1, Silvia Franceschi2, Dorji Dorji3, Iacopo Baussano2, Vanessa Tenet2, Peter JF Snijders4, Chris JLM Meijer4, Maaike CG Bleeker4, Tarik Gheit2, Massimo Tommasino2 and Gary M Clifford2*

Author Affiliations

1 Department of Obstetrics & Gynaecology, Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan

2 International Agency for Research on Cancer, 150 cours Albert Thomas, 69372 Lyon, cedex 08, France

3 Department of Laboratory Services, Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan

4 VU University Medical Center, De Boelelaan 1117, 1081  HV Amsterdam, the Netherlands

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BMC Infectious Diseases 2014, 14:408  doi:10.1186/1471-2334-14-408

Published: 22 July 2014



Cervical cancer is the most common female cancer in Bhutan, the first low/middle-income country to implement a national human papillomavirus (HPV) vaccination programme.


To provide a robust baseline for future evaluations of vaccine effectiveness, cervical cell specimens were obtained from 2,505 women aged 18–69 years from the general population, and biopsies from 211 cervical intraepithelial neoplasia grade 3 (CIN3) and 112 invasive cervical cancer (ICC) cases. Samples were tested for HPV using GP5+/6+ PCR.


Among the general population, HPV prevalence was 26%, being highest (33%) in women ≤24 years, but remaining above 15% in all age-groups. Determinants of HPV included age, marital status, and number of sexual partners. Among the eight percent with cytological abnormalities, 24 CIN3 and 4 ICC were histologically confirmed. Even after additional testing with a sensitive E7 PCR, no infections with vaccine-targeted HPV types were detected in the few vaccinated women (n = 34) compared to 6% prevalence in unvaccinated women of similar age (p = 0 · 215).


Based upon type-specific prevalence among biopsies, at least 70% of ICC in Bhutan are theoretically preventable by HPV16/18 vaccination, but screening programmes should be expanded among older women, who have an important underlying burden of CIN3 and ICC.

Human papillomavirus; Prevalence; Cervical cancer; Bhutan