The prevalence of hrHPV among the isolated community in the Highland of Bario, Sarawak, East Malaysia

Background: Malaysia has introduced the free Pap smear as the primary cervical cancer screening program since the 1960s but has only achieved the national coverage of 22%. The coverage would be much lower in the rural communities especially in Sarawak where many villages and communities are still living in low resource settings and inaccessible by road. In this study, we have evaluated Qiagen’s careHPV system as a point-of-careHPV diagnostic test together with the visualization using acetic acid (VIA) in the isolated communities in the Highland of Bario, Sarawak, East Malaysia. Methods: Women attending the cervical cancer outreach program were recruited. Consent was obtained and a cervical swab was clinician-collected and screened for High-risk HPV DNA using the careHPV system. Cervical examination using VIA was offered to all women age <50-year. hrHPV positive women were recruited during their follow-up session and the second cervical swab was collected for HPV genotyping using consensus primer-nested PCR to elucidate the infecting HPV genotypes. Results: Seventy-five women aged 27-83 (mean age 55) attended the cervical cancer screening clinic and 8% (n=6/75) of them were positive for hrHPV. Only 33 women were screened using VIA and 21.2% (n=7/33) were found to be positive. A majority of the women (58.6%) were above the age of 50-year and not recommended for VIA to be performed. Thus, it was not feasible to correlate the results obtained from the HPV DNA test and VIA. Only four hrHPV positive women returned for follow-up and genotyping revealed HPV52 in 2 of four women tested suggesting that HPV52 may be the predominant genotype in Bario. Conclusions: The careHPV system is portable and can be used in low resource settings as long as reliable electricity is available. We found that careHPV HPV DNA test is more objective compared to VIA and can be used to screen women outside the recommended eligible age. This is especially true for older women in the rural who have never had any form of cervical cancer screening before

The Prevalence of Human Papillomavirus Among the Indigenous Population in Serian, Sarawak, Malaysian Borneo

Introduction: Cervical cancer remains a significant problem worldwide, particularly in resource-limited countries, and having persistent HRHPV infection is a necessary risk factor. HPV16/18 are generally regarded as the cause of 70% cervical cancer incidences worldwide, and effective vaccines have been developed against these two HPVs. Although Malaysia has officially adopted an HPV vaccination strategy into the National Vaccination Program, the comprehensive prevalence data on each endemic HPV genotypes was absent in East Malaysia and most parts of the country except for major cities in Peninsular Malaysia. Objective: The objective of this study is to elucidate the endemic HPV genotypes that are circulating in the suburban population in Serian Division, Sarawak, Malaysia. Methods: Non-virgin women who were attending the Women's health campaign on the 5th and 23rd October 2018 were recruited. Informed consent was obtained, and a cervical swab was clinician-collected. The presence of HPV in the cervical swab was detected using MY09/MY11 followed by GP5+/GP6+ nested-PCR and its corresponding genotypes identified via sequencing. HRHPV positive women were screened using Results: We have recruited 43 sexually active women with median age of 51-year-old. HPV18, 39, 52, 56, and 84 were detected at an equal ratio. The overall prevalence rate of HPV, HRHPV and URHPV were 11.62% (5/43), 9.3% (4/43) and 2.3% respectively. Only 20% (n=1/5) of the HRHPV positive women were positive by VIA. Conclusion: HPV18, 39, 52, 56, and 84 were detected in Serian at an equal ratio. HPV16 was absent, and HPV18 was the only vaccine-genotype detected. HPV 39, 52, 56, and 84 were not covered by the bivalent and tetravalent HPV vaccines

Self-sampling in Human Papillomavirus screening during and post-COVID-19 pandemic

Introduction: Cervical cancer is the third most common cancer among Malaysian women. Sarawak, the largest state in Malaysia has consistently recorded the highest cervical cancer rate in the country where nearly half of its population still live in the rural areas and is at increased risk of the disease due to inequitable access to healthcare. The countrywide lockdown due to the COVID-19 pandemic had halted the accessibility to cervical cancer screening programme. The aim of the study is to determine the feasibility of providing primary HPV DNA test using the selfsampling method to the hard-to-reach population in the interior of Sarawak during the COVID-19 pandemic. Materials and Methods: This is a cross-sectional study where women aged between 20-80 years were recruited via convenient sampling from villages in Long Banga, Sarawak over a five-day outreach programme. Cervicovaginal selfsamples were obtained and screened for the presence of high-risk human papillomavirus DNA (HR-HPV) using the careHPVTM Test. A self-administered questionnaire was also administered to determine the sociodemographic and perception towards the self-sampling method. Results: The 55 women recruited consist of ethnic backgrounds of Penan (58.18%), Kenyah (25.45%), Iban (5.45%), Saban (3.64%), Kelabit (3.64%), Malay (1.82%) and Chinese (1.82%). The prevalence of HR-HPV was 1.85% (n=1/55). Nearly 80% of the women were unemployed, and more than half have had attended primary education. Nine (16.4%) have heard about HPV, and seven (13%) knew HPV infection could cause cervical cancer. Three of them had HPV vaccination, and only one (1.85%) knew the brand of the HPV vaccine. Although 40% preferred self-sampling over clinician-collection, only ten (18.2%) women have completed the self-collection perception questionnaire. Conclusion: Primary HPV DNA screening using the self-sampling method can be carried out in the remote areas during the COVID-19 pandemic without compromising mobility restrictio

Prevalence of Human Papillomavirus in Women with Abnormal Cervical Smears from Sarawak, Malaysia

Introduction Cervical cancer is common cancer and ranked in fourth place in both incidence and mortality worldwide. It is 3rd most common female cancer in Malaysia with a lifetime risk of 1 in 116. Infection with high-risk oncogenic human papillomavirus (HPV) is recognized as one of the substantial risk factors for the development of cervical cancers. Methods It was a cross-sectional study conducted to determine the prevalence of HPV infection and its subtypes among women with various degrees of abnormal smears, who were seen in the colposcopy clinic of Sarawak General Hospital within six months’ period from January to June 2018. We recruited 56 participants. There were 23 each for an atypical squamous cell of undetermined significance (ASC-US) and low-grade squamous intraepithelial lesion (LSIL) and 10 high- grade squamous intraepithelial lesion (HSIL). DNA was extracted, and HPV genotypes were determined via polymerase chain reaction (PCR) using two primer pairs MY09/MY11 and GP5+/GP6+. Results The age ranged from 23 to 56 years, with a mean age of 42.96 years. HPV was detected in 20 out of 56 (35.7%). There were 6 high-risk oncogenic HPVs (18, 51, 52, 56, 58, 68) detected in participants and the most prevalent subtypes were 18, 52, and 58 (20% each). Four low-risk HPVs detected were 6, 53, 70, and 84. There was a significant association between the severity of cervical lesions and HPV positivity (P < 0.004). HSIL had the highest positive predictive value to have HPV infection as 70% compared to 43.4% of LSIL and 9.3% of ASC-US. Conclusion Distribution of HPV subtypes from women with abnormal smears from Sarawak indicated a high prevalence of HPV 18, 52, and 58. We also identified HPV 70, which has never been reported in West Malaysia. These findings could contribute valuable information for HPV vaccination strategies, particularly for Sarawakian women

Ovarian teratoma-associated anti-NMDAR encephalitis in a 12-year-old girl

aspartate receptor (anti-NMDAR) is one of the most commonautoimmune encephalitis syndromes and it is a serious andpotentially fatal pathology that occurs in young women. Thiscase report describes of a pediatric patient with anti-NMDARencephalitis. A-12-year-old girl presented with abnormalbehavior for one week came to Emergency Department ofSarawak General Hospital, Malaysia. She had psychoticspectrum symptoms including suicidal tendency. She wasdiagnosed with anti-NMDAR encephalitis as positiveantibody was seen in her cerebrospinal fluid. She wastreated with Injection Immunoglobulin. She turned out tohave teratoma which was successfully removed later. Herprogress was remarkable after the surgery with theImmunoglobulin. A multi-disciplinary team involving apsychiatrist, neurologist and gynaecologist liaised withintensivist to successfully manage the case and achieve thegood outcome

Prevalence of Human Papilloma virus in women with Abnormal Cervical Smears from Sarawak, Malaysia

Introduction: Cervical cancer is common cancer and ranked in fourth place in both incidence and mortality worldwide. It is 3rd most common female cancer in Malaysia with a lifetime risk of 1 in 116. Infection with high-risk oncogenic human papillomavirus (HPV) is recognized as one of the substantial risk factors for the development of cervical cancers. Methods: It was a cross-sectional study conducted to determine the prevalence of HPV infection and its subtypes among women with various degrees of abnormal smears, who were seen in the colposcopy clinic of Sarawak General Hospital within six months’ period from January to June 2018. We recruited 56 participants. There were 23 each for an atypical squamous cell of undetermined significance (ASC-US) and low-grade squamous intraepithelial lesion (LSIL) and 10 high- grade squamous intraepithelial lesion (HSIL). DNA was extracted, and HPV genotypes were determined via polymerase chain reaction (PCR) using two primer pairs MY09/MY11 and GP5+/GP6+. Results: The age ranged from 23 to 56 years, with a mean age of 42.96 years. HPV was detected in 20 out of 56 (35.7%). There were 6 high-risk oncogenic HPVs (18, 51, 52, 56, 58, 68) detected in participants and the most prevalent subtypes were 18, 52, and 58 (20% each). Four low-risk HPVs detected were 6, 53, 70, and 84. There was a significant association between the severity of cervical lesions and HPV positivity (P < 0.004). HSIL had the highest positive predictive value to have HPV infection as 70% compared to 43.4% of LSIL and 9.3% of ASC-US. Conclusion: Distribution of HPV subtypes from women with abnormal smears from Sarawak indicated a high prevalence of HPV 18, 52, and 58. We also identified HPV 70, which has never been reported in West Malaysia. These findings could contribute valuable information for HPV vaccination strategies, particularly for Sarawakian women

Visual Inspection of Acetic Acid (VIA) to Detect PreCancerous Cervical Cancer in Rural Areas of Sarawak

Introduction: Cervical cancer is still the leading cause of gynaecological cancer in Sarawak. Low awareness on cervical screening and logistic problems are the main reasons for delay in diagnosis, especially in rural areas. Although pap smear screening had been implemented for decades, failure to get early treatment and frequent defaulters are factors that need to be tackled for rural women. Objectives: The Sarawak Travelling Women Health Project is aimed to improve pre-cancerous cervical cancer detection in rural areas using the Visual Inspection of Acetic Acid (VIA) method. This project also helps to shorten the duration of follow up and treatment for patients with pre-cancerous lesion of cervix. Methods: Cervical screening campaigns outside Kuching areas were conducted from June until December 2018 by the Obstetrics and Gynaecology Department of Universiti Malaysia Sarawak (UNIMAS) in collaboration with Pink and Teal Empower, a Non-Government Organization. VIA was performed for all women below 50 years old. Patients with positive VIA were a colposcopy appointment and cervical biopsies are taken at the clinic. Results: During the campaign period, 83 out of 333 women were found to be VIA positive, but only 47 women turned up for the colposcopy. This high number of defaulters is mostly due to logistic reasons. Two cervical biopsies were confirmed as Cervical Intraepithelial Neoplasia (CIN) 2, 15 cases with CIN 1, one case of microglandular hyperplasia while 19 biopsies turned out to be cervicitis. The pickup rate for CIN during the outreach was about 20.4%. Conclusion: VIA is useful in low resource area with difficult access to tertiary centres as it enables faster diagnosis for CIN. However, proper training is needed to avoid false positive results and unnecessary intervention. To reduce the rate of defaulters, cervical biopsy for VIA positive women should be done in the field during the same setting