Prevalence of oral HPV infection in the United States, 2009-2010

Abstract

Context: Human papillomavirus (HPV) infection is the principal cause of a distinct form of oropharyngeal squamous cell carcinoma that is increasing in incidence among men in the United States. However, little is known about the epidemiology of oral HPV infection.

Objective: To determine the prevalence of oral HPV infection in the United States.

Design, setting, and participants: A cross-sectional study was conducted as part of the National Health and Nutrition Examination Survey (NHANES) 2009-2010, a statistically representative sample of the civilian noninstitutionalized US population. Men and women aged 14 to 69 years examined at mobile examination centers were eligible. Participants (N = 5579) provided a 30-second oral rinse and gargle with mouthwash. For detection of HPV types, DNA purified from oral exfoliated cells was evaluated by polymerase chain reaction and type-specific hybridization. Demographic and behavioral data were obtained by standardized interview. Statistical analyses used NHANES sample weights to provide weighted prevalence estimates for the US population.

Main outcome measures: Prevalence of oral HPV infection.

Results: The prevalence of oral HPV infection among men and women aged 14 to 69 years was 6.9% (95% CI, 5.7%-8.3%) and of HPV type 16 was 1.0% (95% CI, 0.7%-1.3%). Oral HPV infection followed a bimodal pattern with respect to age, with peak prevalence among individuals aged 30 to 34 years (7.3%; 95% CI, 4.6%-11.4%) and 60 to 64 years (11.4%; 95% CI, 8.5%-15.1%). Men had a significantly higher prevalence than women for any oral HPV infection (10.1% [95% CI, 8.3%-12.3%] vs 3.6% [95% CI, 2.6%-5.0%], P < .001; unadjusted prevalence ratio [PR], 2.80 [95% CI, 2.02-3.88]). Infection was less common among those without vs those with a history of any type of sexual contact (0.9% [95% CI, 0.4%-1.8%] vs 7.5% [95% CI, 6.1%-9.1%], P < .001; PR, 8.69 [95% CI, 3.91-19.31]) and increased with number of sexual partners (P < .001 for trend) and cigarettes smoked per day (P < .001 for trend). Associations with age, sex, number of sexual partners, and current number of cigarettes smoked per day were independently associated with oral HPV infection in multivariable models.

Conclusion: Among men and women aged 14 to 69 years in the United States, the overall prevalence of oral HPV infection was 6.9%, and the prevalence was higher among men than among women.

Figure 1. Prevalence of Oral HPV Infection by Individual Genotypes in the US Population Aged 14 to 69 Years

The weighted prevalence (and 95% CI) for each of the 37 human papillomavirus (HPV) types evaluated is stratified by classification as high-risk or low-risk HPV types based on epidemiological associations with cervical cancer. HPV type 64 was not detected. The data are derived from the 5501 NHANES participants with evaluable samples. Error bars indicate 95% CIs.

Figure 2. Association of Age With Oral HPV Prevalence in the US Population Aged 14 to 69 Years

Observed and modeled human papillomavirus (HPV) prevalence by individual age as well as 95% CI for each age. To evaluate the influence of covariates on HPV prevalence across age, the model was adjusted for sex, race, smoking, marital status, and lifetime number of (any) sex partners. Given the standardization for covariates included in the multivariate model, the HPV prevalence curve obtained from the adjusted model is presented at the mean levels of the covariates (sex, race, smoking, marital status, and lifetime number of any sex partners, as appropriate) and aligned with the HPV prevalence curve in the unadjusted model to enable visual display of the data. P<.001 for unadjusted model; P=.02 for adjusted. P values less than .05 for spline terms denote statistical evidence for bimodality in the data.

Figure 3. Modeled HPV Prevalence Across Age in the US Population Aged 14 to 69 Years by Sex and HPV Types

Age was modeled using restricted cubic splines with 5 knots (age and 3 spline terms). To evaluate the influence of covariates on human papillomavirus (HPV) prevalence across age, models were adjusted for sex, race, smoking, marital status, and lifetime number of (any) sex partners, as appropriate. Given the standardization for covariates included in the multivariate models, the HPV prevalence curves obtained from the adjusted models are presented at the mean levels of the covariates (sex, race, smoking, marital status, and lifetime number of any sex partners, as appropriate) and aligned with the HPV prevalence curve in the unadjusted models to enable visual display of the data. For men, unadjusted P<.001; adjusted P=.002. For women, unadjusted P=.07; adjusted P=.14. For high-risk HPV, unadjusted P<.001; adjusted P<.001. For low-risk HPV, unadjusted P=.10; adjusted P=.64. P values less than .05 for spline terms denote statistical evidence for bimodality in the data.

Figure 4. Association of Number of Lifetime Sexual Partners With Prevalent Oral HPV Infection in the US Population Aged 14 to 59 Years

Human papillomavirus (HPV) prevalence ratio was adjusted for age (as a linear term), sex, race/ethnicity, marital status, and cigarette use. The analysis was restricted to individuals aged 14 to 59 years, for whom detailed sexual behavior data were available. Given high colinearity across sexual behaviors, each behavior was evaluated in separate models. P<.001 for trend in all 3 categories of sexual partner. Lifetime number of partners for performing oral sex included the sum of same- and opposite-sex partners; the reference category was 0 lifetime partners. Error bars indicate 95% CIs.