Human Papillomavirus and Related Diseases Report: Version Posted at On 17 June 2019

Human Papillomavirus
and
Related Diseases Report
MALAYSIA
Version posted at www.hpvcentre.net on 17 June 2019
- ii -
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Recommended citation:
Bruni L, Albero G, Serrano B, Mena M, Gómez D, Muñoz J, Bosch FX, de Sanjosé S. ICO/IARC
Information Centre on HPV and Cancer (HPV Information Centre). Human Papillomavirus and Related
Diseases in Malaysia. Summary Report 17 June 2019. [Date Accessed]
ICO/IARC HPV Information Centre

- iii -
Executive summary
Human papillomavirus (HPV) infection is now a well-established cause of cervical cancer and there is
growing evidence of HPV being a relevant factor in other anogenital cancers (anus, vulva, vagina and
penis) as well as head and neck cancers. HPV types 16 and 18 are responsible for about 70% of all cer-
vical cancer cases worldwide. HPV vaccines that prevent HPV 16 and 18 infections are now available
and have the potential to reduce the incidence of cervical and other anogenital cancers.
This report provides key information for Malaysia on: cervical cancer; other anogenital cancers and
head and neck cancers; HPV-related statistics; factors contributing to cervical cancer; cervical cancer
screening practices; HPV vaccine introduction; and other relevant immunisation indicators. The report
is intended to strengthen the guidance for health policy implementation of primary and secondary cer-
vical cancer prevention strategies in the country.
Table 1: Key Statistics

Population
Women at risk for cervical cancer (Female population aged >=15 years) 12.0 million
Burden of cervical cancer and other HPV-related cancers
Annual number of cervical cancer cases 1,682
Annual number of cervical cancer deaths 944
Crude incidence rates per 100,000 and year: Male Female
Cervical cancer - 10.8
Anal cancer ‡ 0.0-0.3 0.0-1.2
Vulvar cancer ‡ - 0.0-0.6
Vaginal cancer ‡ - 0.0-0.5
Penile cancer ‡ 0.1-0.4 -
Oropharyngeal cancer 0.5 0.2
Burden of cervical HPV infection
Prevalence (%) of HPV 16 and/or HPV 18 among women with:
Normal cytology 1.0
Low-grade cervical lesions (LSIL/CIN-1) 30.4
High-grade cervical lesions (HSIL/CIN-2/CIN-3/CIS) 49.3
Cervical cancer 88.7
Other factors contributing to cervical cancer
Smoking prevalence (%), women 1.5 [1.0-2.2]
Total fertility rate (live births per women) 2.1
Oral contraceptive use (%) among women 13.2
HIV prevalence (%), adults (15-49 years) 0.4 [0.3 - 0.5]
Sexual behaviour
Percentage of 15-year-old who have had sexual intercourse (men/women) -/-
Range of median age at first sexual intercourse (men/women) -/-
Cervical screening practices and recommendations
Cervical cancer screening cov- 22.2% (All women aged 20-65 screened every 1y, Annual Report 2012 Malaysia)
erage, % (age and screening in-
terval, reference)
Screening ages (years) 20-65
Screening interval (years) or 3 years
frequency of screens
HPV vaccine
HPV vaccine introduction
HPV vaccination programme National program
Date of HPV vaccination routine immunization programme start 2010
‡Please see the specific sections for more information.

CONTENTS - iv -
Contents
Executive summary iii
1 Introduction 2
2 Demographic and socioeconomic factors 4
3 Burden of HPV related cancers 6

3.1 Cervical cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
3.1.1 Cervical cancer incidence in Malaysia . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
3.1.2 Cervical cancer incidence by histology in Malaysia . . . . . . . . . . . . . . . . . . . . 11
3.1.3 Cervical cancer incidence in Malaysia across South-Eastern Asia . . . . . . . . . . . 13
3.1.4 Cervical cancer mortality in Malaysia . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
3.1.5 Cervical cancer mortality in Malaysia across South-Eastern Asia . . . . . . . . . . . 19
3.1.6 Cervical cancer incidence and mortality comparison, Premature deaths and dis-
ability in Malaysia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
3.2 Anogenital cancers other than the cervix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
3.2.1 Anal cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
3.2.2 Vulvar cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
3.2.3 Vaginal cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
3.2.4 Penile cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
3.3 Head and neck cancers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
3.3.1 Oropharyngeal cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
4 HPV related statistics 31

4.1 HPV burden in women with normal cervical cytology, cervical precancerous lesions or
invasive cervical cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
4.1.1 HPV prevalence in women with normal cervical cytology . . . . . . . . . . . . . . . . 32
4.1.2 HPV type distribution among women with normal cervical cytology, precancerous
cervical lesions and cervical cancer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
4.1.3 HPV type distribution among HIV+ women with normal cervical cytology . . . . . . 42
4.1.4 Terminology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
4.2 HPV burden in anogenital cancers other than cervix . . . . . . . . . . . . . . . . . . . . . . . 44
4.2.1 Anal cancer and precancerous anal lesions . . . . . . . . . . . . . . . . . . . . . . . . . 44
4.2.2 Vulvar cancer and precancerous vulvar lesions . . . . . . . . . . . . . . . . . . . . . . . 46
4.2.3 Vaginal cancer and precancerous vaginal lesions . . . . . . . . . . . . . . . . . . . . . 48
4.2.4 Penile cancer and precancerous penile lesions . . . . . . . . . . . . . . . . . . . . . . . 50
4.3 HPV burden in men . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
4.4 HPV burden in the head and neck . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
4.4.1 Burden of oral HPV infection in healthy population . . . . . . . . . . . . . . . . . . . . 53
4.4.2 HPV burden in head and neck cancers . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
5 Factors contributing to cervical cancer 55
6 Sexual and reproductive health behaviour indicators 57
7 HPV preventive strategies 58

7.1 Cervical cancer screening practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
7.2 HPV vaccination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
8 Protective factors for cervical cancer 61

LIST OF CONTENTS -v-
9 Indicators related to immunisation practices other than HPV vaccines 63

9.1 Immunisation schedule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
9.2 Immunisation coverage estimates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
10 Glossary 65

LIST OF FIGURES - vi -
List of Figures
1 Malaysia and South-Eastern Asia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
2 Population pyramid of Malaysia for 2017 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
3 Population trends in four selected age groups in Malaysia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
4 HPV-related cancer incidence in Malaysia (estimates for 2012) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
5 Comparison of cervical cancer incidence to other cancers in women of all ages in Malaysia (estimates for 2018) 8
6 Comparison of age-specific cervical cancer to age-specific incidence of other cancers among women 15-44 years
of age in Malaysia (estimates for 2018) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
7 Annual number of cases and age-specific incidence rates of cervical cancer in Malaysia (estimates for 2018) . . . 10
8 Time trends in cervical cancer incidence in Malaysia (cancer registry data) . . . . . . . . . . . . . . . . . . . . . . . 12
9 Age-standardised incidence rates of cervical cancer of Malaysia (estimates for 2018) . . . . . . . . . . . . . . . . . 13
10 Annual number of new cases of cervical cancer by age group in Malaysia (estimates for 2018) . . . . . . . . . . . 14
11 Comparison of cervical cancer mortality to other cancers in women of all ages in Malaysia (estimates for 2018) 16
12 Comparison of age-specific mortality rates of cervical cancer to other cancers among women 15-44 years of age
in Malaysia (estimates for 2018) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
13 Annual number of deaths and age-specific mortality rates of cervical cancer in Malaysia (estimates for 2018) . . 18
14 Comparison of age-standardised cervical cancer mortality rates in Malaysia and countries within the region
(estimates for 2018) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
15 Annual deaths number of cervical cancer by age group in Malaysia (estimates for 2018) . . . . . . . . . . . . . . . 20
16 Comparison of age-specific cervical cancer incidence and mortality rates in Malaysia (estimates for 2018) . . . . 21
17 Comparison of annual premature deaths and disability from cervical cancer in Malaysia to other cancers among
women (estimates for 2008) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
18 Time trends in anal cancer incidence in Malaysia (cancer registry data) . . . . . . . . . . . . . . . . . . . . . . . . . 24
19 Time trends in vulvar cancer incidence in Malaysia (cancer registry data) . . . . . . . . . . . . . . . . . . . . . . . 25
20 Time trends in vaginal cancer incidence in Malaysia (cancer registry data) . . . . . . . . . . . . . . . . . . . . . . . 26
21 Time trends in penile cancer incidence in Malaysia (cancer registry data) . . . . . . . . . . . . . . . . . . . . . . . . 27
22 Comparison of incidence and mortality rates of the oropharynx by age group and sex in Malaysia (estimates for
2018). Includes ICD-10 codes: C09-10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
23 Crude age-specific HPV prevalence (%) and 95% confidence interval in women with normal cervical cytology in
Malaysia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
24 HPV prevalence among women with normal cervical cytology in Malaysia, by study . . . . . . . . . . . . . . . . . 32
25 HPV 16 prevalence among women with normal cervical cytology in Malaysia, by study . . . . . . . . . . . . . . . 33
26 HPV 16 prevalence among women with low-grade cervical lesions in Malaysia, by study . . . . . . . . . . . . . . . 33
27 HPV 16 prevalence among women with high-grade cervical lesions in Malaysia, by study . . . . . . . . . . . . . . 34
28 HPV 16 prevalence among women with invasive cervical cancer in Malaysia, by study . . . . . . . . . . . . . . . . 34
29 Comparison of the ten most frequent HPV oncogenic types in Malaysia among women with and without cervical
lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
30 Comparison of the ten most frequent HPV oncogenic types in Malaysia among women with invasive cervical
cancer by histology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
31 Comparison of the ten most frequent HPV types in anal cancer cases in Asia and the World . . . . . . . . . . . . 45
32 Comparison of the ten most frequent HPV types in AIN 2/3 cases in Asia and the World . . . . . . . . . . . . . . . 45
33 Comparison of the ten most frequent HPV types in cases of vulvar cancer in Asia and the World . . . . . . . . . . 47
34 Comparison of the ten most frequent HPV types in VIN 2/3 cases in Asia and the World . . . . . . . . . . . . . . . 47
35 Comparison of the ten most frequent HPV types in cases of vaginal cancer in Asia and the World . . . . . . . . . 49
36 Comparison of the ten most frequent HPV types in VaIN 2/3 cases in Asia and the World . . . . . . . . . . . . . . 49
37 Comparison of the ten most frequent HPV types in cases of penile cancer in Asia and the World . . . . . . . . . . 51
38 Comparison of the ten most frequent HPV types in PeIN 2/3 cases in Asia and the World . . . . . . . . . . . . . . 51
39 Estimated coverage of cervical cancer screening in Malaysia, by age and study . . . . . . . . . . . . . . . . . . . . 59
40 Reported HPV vaccination coverage in females by birth cohort in National HPV Immunization programme in
Malaysia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

LIST OF TABLES -1-
List of Tables
1 Key Statistics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . iii
2 Sociodemographic indicators in Malaysia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
3 Cervical cancer incidence in Malaysia (estimates for 2018) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
4 Cervical cancer incidence in Malaysia by cancer registry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
5 Age-standardised incidence rates of cervical cancer in Malaysia by histological type and cancer registry . . . . . 11
6 Cervical cancer mortality in Malaysia (estimates for 2018) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
7 Premature deaths and disability from cervical cancer in Malaysia, South-Eastern Asia and the rest of the world
(estimates for 2008) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
8 Anal cancer incidence in Malaysia by cancer registry and sex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
9 Vulvar cancer incidence in Malaysia by cancer registry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
10 Vaginal cancer incidence in Malaysia by cancer registry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
11 Penile cancer incidence in Malaysia by cancer registry . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
12 Incidence and mortality of cancer of the oropharynx in Malaysia, South-Eastern Asia and the rest of the world
by sex (estimates for 2018). Includes ICD-10 codes: C09-10 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
13 Incidence of oropharyngeal cancer in Malaysia by cancer registry and sex . . . . . . . . . . . . . . . . . . . . . . . 30
14 Prevalence of HPV16 and HPV18 by cytology in Malaysia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
15 Type-specific HPV prevalence in women with normal cervical cytology, precancerous cervical lesions and invasive
cervical cancer in Malaysia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
16 Type-specific HPV prevalence among invasive cervical cancer cases in Malaysia by histology . . . . . . . . . . . . 40
17 Studies on HPV prevalence among HIV women with normal cytology in Malaysia . . . . . . . . . . . . . . . . . . 42
18 Studies on HPV prevalence among anal cancer cases in Malaysia (male and female) . . . . . . . . . . . . . . . . . 44
19 Studies on HPV prevalence among cases of AIN2/3 in Malaysia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
20 Studies on HPV prevalence among vulvar cancer cases in Malaysia . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
21 Studies on HPV prevalence among VIN 2/3 cases in Malaysia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
22 Studies on HPV prevalence among vaginal cancer cases in Malaysia . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
23 Studies on HPV prevalence among VaIN 2/3 cases in Malaysia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
24 Studies on HPV prevalence among penile cancer cases in Malaysia . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
25 Studies on HPV prevalence among PeIN 2/3 cases in Malaysia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
26 Studies on HPV prevalence among men in Malaysia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
27 Studies on HPV prevalence among men from special subgroups in Malaysia . . . . . . . . . . . . . . . . . . . . . . 52
28 Studies on oral HPV prevalence among healthy in Malaysia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
29 Studies on HPV prevalence among cases of oral cavity cancer in Malaysia . . . . . . . . . . . . . . . . . . . . . . . 53
30 Studies on HPV prevalence among cases of oropharyngeal cancer in Malaysia . . . . . . . . . . . . . . . . . . . . . 54
31 Studies on HPV prevalence among cases of hypopharyngeal or laryngeal cancer in Malaysia . . . . . . . . . . . . 54
32 Factors contributing to cervical carcinogenesis (cofactors) in Malaysia . . . . . . . . . . . . . . . . . . . . . . . . . . 55
33 Percentage of 15-year-olds who have had sexual intercourse in Malaysia . . . . . . . . . . . . . . . . . . . . . . . . 57
34 Marriage patterns in Malaysia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57
35 Main characteristics of cervical cancer screening in Malaysia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
36 Estimated coverage of cervical cancer screening in Malaysia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
37 Estimated coverage of cervical cancer screening in Malaysia , by region . . . . . . . . . . . . . . . . . . . . . . . . . 60
38 National HPV Immunization programme in Malaysia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
39 Prevalence of male circumcision in Malaysia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
40 Prevalence of condom use in Malaysia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
41 General immunization schedule in Malaysia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
42 Immunization coverage estimates in Malaysia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
43 Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

1 INTRODUCTION -2-
1 Introduction
Figure 1: Malaysia and South-Eastern Asia
The HPV Information Centre aims to compile and centralise updated data and statistics on human
papillomavirus (HPV) and related cancers. This report aims to summarise the data available to fully
evaluate the burden of disease in Malaysia and to facilitate stakeholders and relevant bodies of de-
cision makers to formulate recommendations on cervical cancer prevention. Data include relevant
cancer statistic estimates, epidemiological determinants of cervical cancer such as demographics, so-
cioeconomic factors, risk factors, burden of HPV infection, screening and immunisation. The report is
structured into the following sections:
Section 2, Demographic and socioeconomic factors. This section summarises the socio-demo-
graphic profile of country. For analytical purposes, Malaysia is classified in the geographical region
of South-Eastern Asia (Figure 1, lighter blue), which is composed of the following countries: Brunei,
Indonesia, Cambodia, Laos, Myanmar, Malaysia, Philippines, Singapore, Thailand, Timor-Leste, Viet
Nam. Throughout the report, Malaysia estimates will be complemented with corresponding regional
estimates.
Section 3, Burden of HPV related cancers. This section describes the current burden of inva-
sive cervical cancer and other HPV-related cancers in Malaysia and the South-Eastern Asia region with
estimates of prevalence, incidence, and mortality rates.
Section 4, HPV related statistics. This section reports on prevalence of HPV and HPV type-specific
distribution in Malaysia, in women with normal cytology, precancerous lesions and invasive cervical
cancer. In addition, the burden of HPV in other anogenital cancers (anus, vulva, vagina, and penis) and
men are presented.

1 INTRODUCTION -3-
Section 5, Factors contributing to cervical cancer. This section describes factors that can modify
the natural history of HPV and cervical carcinogenesis such as smoking, parity, oral contraceptive use,
and co-infection with HIV.
Section 6, Sexual and reproductive health behaviour indicators. This section presents sexual
and reproductive behaviour indicators that may be used as proxy measures of risk for HPV infection
and anogenital cancers.
Section 7, HPV preventive strategies. This section presents preventive strategies that include ba-
sic characteristics and performance of cervical cancer screening status, status of HPV vaccine licensure
introduction, and recommendations in national immunisation programmes.
Section 8, Protective factors for cervical cancer. This section presents the prevalence of male
circumcision and condom use.
Section 9, Indicators related to immunisation practices other than HPV vaccines. This section
presents data on immunisation coverage and practices for selected vaccines. This information will be
relevant for assessing the country’s capacity to introduce and implement the new vaccines. The data are
periodically updated and posted on the WHO immunisation surveillance, assessment and monitoring
website at http://www.who.int/immunization_monitoring/en/.

2 DEMOGRAPHIC AND SOCIOECONOMIC FACTORS -4-
2 Demographic and socioeconomic factors
Figure 2: Population pyramid of Malaysia for 2017

Males Females
80+ 150,252 127,177

75−79 159,953 168,530
70−74 253,652 277,787
65−69 390,648 429,607
60−64 523,742 577,720
55−59 669,055 742,310
50−54 787,684 855,835
45−49 907,187 911,415
40−44 1,004,808 975,210
35−39 1,193,977 1,192,597
30−34 1,450,201 1,430,683
25−29 1,488,171 1,455,333
20−24 1,410,142 1,466,566
15−19 1,324,717 1,413,785
10−14 1,211,833 1,291,561
5−9 1,151,910 1,167,390
Under 5 1,351,651 1,251,088
Data accessed on 27 Mar 2017.

Please refer to original source for methods of estimation.
Including Sabah and Sarawak.
Year of estimate: 2017;
Data sources:
United Nations, Department of Economic and Social Affairs, Population Division (2015). World Population Prospects: The 2015 Revision, DVD Edition. Available at: https://esa.un.org/
unpd/wpp/Download/Standard/Population/. [Accessed on March 21, 2017].
Figure 3: Population trends in four selected age groups in Malaysia

Projections Projections
Number of women (in millions)
Number of women (in millions)
Women 15−24 yrs All Women

3
20
2 15
Women 25−64 yrs
Girls 10−14 yrs 10
1
5
0 0
1950
1960
1970
1980
1990
2000
2010
2020
2030
2040
2050
2060
2070
2080
2090
2100
1950
1960
1970
1980
1990
2000
2010
2020
2030
2040
2050
2060
2070
2080
2090
2100
Female population trends in Malaysia

Number of women by year and age group

Including Sabah and Sarawak.
Data sources:
United Nations, Department of Economic and Social Affairs, Population Division (2015). World Population Prospects: The 2015 Revision, DVD Edition. Available at: https://esa.un.org/
unpd/wpp/Download/Standard/Population/. [Accessed on March 21, 2017].

2 DEMOGRAPHIC AND SOCIOECONOMIC FACTORS -5-
Table 2: Sociodemographic indicators in Malaysia

Indicator Male Female Total
1,±
Population in thousands 15,429.6 15,734.6 31,164.2
1,a,∓
Population growth rate (%) - - 1.5
1,a,∗
Median age of the population (in years) - - 28.5
2,a,∗
Population living in urban areas (%) - - 74.7
Crude birth rate (births per 1,000)1,a,∓ - - 16.9
1,a,∓
Crude death rate (deaths per 1,000) - - 4.8
3,b,c,∗
Life expectancy at birth (in years) 72.7 77.3 75.0
Adult mortality rate (probability of dying between 15 and 60 years old per 167 79 123
1,000)4,∗
Maternal mortality ratio (per 100,000 live births)3,d,∗ - - 40
3,e,∗
Under age five mortality rate (per 1,000 live births) - - 7.0
5, f ,?
Density of physicians (per 1,000 population) - - 1.281
6,g,∗
Gross national income per capita (PPP current international $) - - 26190
Adult literacy rate (%) (aged 15 and older)7,h,∗ 96.2 93.1 94.6
7,h,∗
Youth literacy rate (%) (aged 15-24 years) 98.3 98.5 98.4
7,∗
Net primary school enrollment ratio 97.8 98.4 98.1
7,∗
Net secondary school enrollment ratio 65 72.3 68.5
a Including Sabah and Sarawak.
b World Population Prospects, the 2015 revision (WPP2015). New York (NY): United Nations DESA, Population Division.
c WHO annual life tables for 1985–2015 based on the WPP2015, on the data held in the WHO Mortality Database and on HIV mortality estimates prepared by UNAIDS. WHO Member
States with a population of less than 90 000 in 2015 were not included in the analysis.
d WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. Trends in maternal mortality: 1990 to 2015. Estimates by WHO, UNICEF, UNFPA,
World Bank Group and the United Nations Population Division. Geneva: World Health Organization; 2015 (http://www.who.int/reproductivehealth/publications/monitoring/
maternal-mortality-2015/en/, accessed 25 March 2016). WHO Member States with a population of less than 100 000 in 2015 were not included in the analysis.
e Levels & Trends in Child Mortality. Report 2015. Estimates Developed by the UN Inter-agency Group for Child Mortality Estimation. New York (NY), Geneva and Washington (DC):
United Nations Children’s Fund, World Health Organization, World Bank and United Nations; 2015 (http://www.unicef.org/publications/files/Child_Mortality_Report_2015_
Web_9_Sept_15.pdf, accessed 26 March 2016).
f Number of medical doctors (physicians), including generalist and specialist medical practitioners, per 1 000 population.
g GNI per capita based on purchasing power parity (PPP). PPP GNI is gross national income (GNI) converted to international dollars using purchasing power parity rates. An international
dollar has the same purchasing power over GNI as a U.S. dollar has in the United States. GNI is the sum of value added by all resident producers plus any product taxes (less subsidies)
not included in the valuation of output plus net receipts of primary income (compensation of employees and property income) from abroad. Data are in current international dollars based
on the 2011 ICP round.
h UIS Estimation
Year of estimate: ± 2017; ∓ 2010-2015; ∗ 2015; ? 2011;
Data sources:
1 United Nations, Department of Economic and Social Affairs, Population Division (2015). World Population Prospects: The 2015 Revision, DVD Edition. Available at: https://esa.un.
org/unpd/wpp/Download/Standard/Population/. [Accessed on March 21, 2017].
2 United Nations, Department of Economic and Social Affairs, Population Division (2014). World Urbanization Prospects: The 2014 Revision, CD-ROM Edition. Available at: https:
//esa.un.org/unpd/wup/CD-ROM/. [Accessed on March 21, 2017].
3 World Health Statistics 2016. Geneva, World Health Organization, 2016. Available at: http://who.int/entity/gho/publications/world_health_statistics/2016/en/index.
html. [Accessed on March 21, 2017].
4 World Health Organization. Global Health Observatory data repository. Available at: http://apps.who.int/gho/data/view.main.1360?lang=en. [Accessed on March 21, 2017].
5 The 2016 update, Global Health Workforce Statistics, World Health Organization, Geneva (http://www.who.int/hrh/statistics/hwfstats/). [Accessed on March 21, 2017].
6 World Bank, World Development Indicators Database. Washington, DC. International Comparison Program database. Available at: http://databank.worldbank.org/data/reports.
aspx?source=world-development-indicators#. [Accessed on March 21, 2017].
7 UNESCO Institute for Statistics Data Centre [online database]. Montreal, UNESCO Institute for Statistics. Available at: http://stats.uis.unesco.org [Accessed on March 21, 2017].

3 BURDEN OF HPV RELATED CANCERS -6-
3 Burden of HPV related cancers

HPV is the cause of almost all cervical cancer cases and is responsible for an important fraction of other
anogenital and head and neck cancer. Here, we present the most recent estimations on the burden of
HPV-associated cancer.
Figure 4: HPV-related cancer incidence in Malaysia (estimates for 2012)
Cervix uteri 15.6
Other anogenital (a) 0.6
Head and neck (b) 0.2
0 5 10 15
Age−standardised incidence rate per 100,0000 women

World Standard
Data accessed on 08 May 2017.

a Other anogenital cancer cases (vulvar, vaginal, anal, and penile).
b Head and neck cancer cases (oropharynx, oral cavity and larynx).
ASR: Age-standardized rate, rates per 100,000 per year.
Please refer to original source for methods.
GLOBOCAN quality index for availability of incidence data: High quality regional (coverage lower than 10%).
GLOBOCAN quality index of methods for calculating incidence: Methods to estimate the sex- and age-specific incidence rates of cancer for a specific country: Estimated as the weighted
average of the local rates
Data sources:
de Martel C, Plummer M, Vignat J, Franceschi S. Worldwide burden of cancer attributable to HPV by site, country and HPV type. Int J Cancer. 2017
3.1 Cervical cancer

Cancer of the cervix uteri is the 3rd most common cancer among women worldwide, with an estimated
569,847 new cases and 311,365 deaths in 2018 (GLOBOCAN). The majority of cases are squamous cell
carcinoma followed by adenocarcinomas. (Vaccine 2006, Vol. 24, Suppl 3; Vaccine 2008, Vol. 26, Suppl
10; Vaccine 2012, Vol. 30, Suppl 5; IARC Monographs 2007, Vol. 90)
This section describes the current burden of invasive cervical cancer in Malaysia and in comparison
to geographic region, including estimates of the annual number of new cases, deaths, incidence, and
mortality rates.
3.1.1 Cervical cancer incidence in Malaysia
KEY STATS.
About 1,682 new cervical cancer cases are diagnosed annually in

Malaysia (estimates for 2018).
Cervical cancer ranks* as the 3rd leading cause of female cancer in

Malaysia.
Cervical cancer is the 2 th most common female cancer in women aged

15 to 44 years in Malaysia.

* Ranking of cervical cancer incidence to other cancers among all women according to highest incidence rates (ranking 1st) excluding non-melanoma skin cancer and considering separated
colon, rectum and anus. Ranking is based on crude incidence rates (actual number of cervical cancer cases). Ranking using age-standardized rate (ASR) may differ.
Table 3: Cervical cancer incidence in Malaysia (estimates for 2018)

Indicator Malaysia South-Eastern Asia World
Annual number of new cancer cases 1,682 62,456 569,847
a
Crude incidence rate 10.8 19.0 15.1
Age-standardized incidence ratea 10.5 17.2 13.1
Cumulative risk (%) at 75 years oldb 1 2 1

Data accessed on 05 Oct 2018.
For more detailed methods of estimation please refer to http://gco.iarc.fr/today/data-sources-methods
a Rates per 100,000 women per year.
b Cumulative risk (incidence) is the probability or risk of individuals getting from the disease during ages 0-74 years. For cancer, it is expressed as the % of new born children who would be
expected to develop from a particular cancer before the age of 75 if they had the rates of cancer observed in the period in the absence of competing causes.
Data sources:
Ferlay J, Ervik M, Lam F, Colombet M, Mery L, Piñeros M, Znaor A, Soerjomataram I, Bray F (2018). Global Cancer Observatory: Cancer Today. Lyon, France: International Agency for
Research on Cancer. Available from: https://gco.iarc.fr/today, accessed [05 October 2018].
Table 4: Cervical cancer incidence in Malaysia by cancer registry

1
Cancer registry Period N casesa Crude rateb ASRb
Penang 2008-2010 245 11.2 10.4
Penang (Chinese) 2008-2010 178 17.9 13.9
Penang (Malay) 2008-2010 43 4.5 5.5
Penang (Indian) 2008-2010 22 9.3 9.0
ASR: Age-standardized rate, Standardized rates have been estimated using the direct method and the World population as the reference;
Please refer to original source (available at http://ci5.iarc.fr/CI5-XI/Default.aspx)
a Accumulated number of cases during the period in the population covered by the corresponding registry.
b Rates per 100,000 women per year.
Data sources:
1 Bray F, Colombet M, Mery L, Piñeros M, Znaor A, Zanetti R and Ferlay J, editors (2017). Cancer Incidence in Five Continents, Vol. XI (electronic version). Lyon: International Agency for
Research on Cancer. Available from: http://ci5.iarc.fr, accessed [05 October 2018].

Figure 5: Comparison of cervical cancer incidence to other cancers in women of all ages in Malaysia
(estimates for 2018)
Breast 48.9
Colon 11.0
Cervix uteri 10.8
Ovary 8.2
Lung 8.1
Corpus uteri 7.1
Rectum 6.5
Non−Hodgkin lymphoma 5.0
Leukaemia 4.9
Stomach 4.8
Thyroid 3.3
Nasopharynx 3.2
Liver 3.1
Pancreas 2.8
Lip, oral cavity 2.1
Brain, nervous system 2.1
Kidney 2.1
Gallbladder 1.3
Bladder 1.3
Oesophagus 0.8
Multiple myeloma 0.6
Hodgkin lymphoma 0.5
Melanoma of skin 0.4
Salivary glands 0.4
Vulva 0.3
Larynx 0.2
Oropharynx 0.2
Vagina 0.0
Mesothelioma 0.0
Kaposi sarcoma 0.0
Hypopharynx 0.0
Anus 0.0
0 10 20 30 40 50 60
Annual crude incidence rate per 100,000
Malaysia: Female (All ages)
Non-melanoma skin cancer is not included.
Rates per 100,000 women per year.
Data sources:

Figure 6: Comparison of age-specific cervical cancer to age-specific incidence of other cancers among
women 15-44 years of age in Malaysia (estimates for 2018)
Breast 25.4
Cervix uteri 5.3
Ovary 3.8
Thyroid 3.1
Corpus uteri 2.9
Leukaemia 2.6
Nasopharynx 2.0
Colon 1.6
Stomach 1.1
Rectum 0.9
Lung 0.7
Kidney 0.6
Salivary glands 0.3
Liver 0.3
Pancreas 0.3
Bladder 0.2
Gallbladder 0.1
Vulva 0.1
Oropharynx 0.1
Larynx 0.1
Oesophagus 0.0
Vagina 0.0
Mesothelioma 0.0
Kaposi sarcoma 0.0
Hypopharynx 0.0
Anus 0.0
0 5 10 15 20 25 30
Annual crude incidence rate per 100,000
Malaysia: Female (15−44 years)
Data sources:

3 BURDEN OF HPV RELATED CANCERS - 10 -
Figure 7: Annual number of cases and age-specific incidence rates of cervical cancer in Malaysia (esti-
mates for 2018)
Age−specific rates of
●
●
40
cervical cancer
●
●
●
30 ●
20
●
●
10
●
●
0 ●
15−19 ●
20−24
25−29
30−34
35−39
40−44
45−49
50−54
55−59
60−64
65−69
70−74
75+
999
Annual number of new cases of cervical cancer
1000
60−64 yrs:
209 cases
800
55−59 yrs:
218 cases
600
50−54 yrs:
212 cases 430
400
253* 45−49 yrs:

201 cases
200
40−44 yrs:
159 cases
0
15−39 40−64 65+
Age group (years)
*15-19 yrs: 0 cases. 20-24 yrs: 1 cases. 25-29 yrs: 38 cases. 30-34 yrs: 89 cases. 35-39 yrs: 125 cases.
Data sources:

3.1.2 Cervical cancer incidence by histology in Malaysia
Table 5: Age-standardised incidence rates of cervical cancer in Malaysia by histological type and cancer
registry
Carcinoma
Cancer registry Period Squamous Adeno Other Unspec.
Penang 2008-2010 6.4 2.2 0.0 1.4

Penang (Chinese) 2008-2010 8.7 3.0 0.1 1.7
Penang (Indian) 2008-2010 6.9 1.7 - 0.5
Penang (Malay) 2008-2010 2.8 1.5 - 0.9
Adeno: adenocarcinoma; Other: Other carcinoma; Squamous: Squamous cell carcinoma; Unspec: Unspecified carcinoma;
Standarized rates have been estimated using the direct method and the World population as the references.
Data sources:

Figure 8: Time trends in cervical cancer incidence in Malaysia (cancer registry data)
Cervix uteri
Annual crude incidence rate
(per 100,000)
All ages (2)

No data available
15−44 yrs (2)
45−74 yrs (2)
1975
1980
1985
1990
1995
Cervix uteri: Squamous cell carcinoma
(per 100,000)
All ages (2)

No data available
15−44 yrs (2)
45−74 yrs (2)
1975
1980
1985
1990
1995
Cervix uteri: Adenocarcinoma

(per 100,000)
All ages (2)

No data available
15−44 yrs (2)
45−74 yrs (2)
1975
1980
1985
1990
1995
Data accessed on 27 Apr 2015.

a Estimated annual percentage change based on the trend variable from the net drift for the most recent two 5-year periods.
Data sources:
1 Vaccarella S, Lortet-Tieulent J, Plummer M, Franceschi S, Bray F. Worldwide trends in cervical cancer incidence: Impact of screening against changes in disease risk factors. eur J Cancer
2013;49:3262-73.
2 Ferlay J, Bray F, Steliarova-Foucher E and Forman D. Cancer Incidence in Five Continents, CI5plus: IARC CancerBase No. 9 [Internet]. Lyon, France: International Agency for Research
on Cancer; 2014. Available from: http://ci5.iarc.fr

3.1.3 Cervical cancer incidence in Malaysia across South-Eastern Asia
Figure 9: Age-standardised incidence rates of cervical cancer of Malaysia (estimates for 2018)
Indonesia 23.4
Myanmar 21.5
Brunei 20.6
Thailand 16.2
Philippines 14.9
Cambodia 13.5
Timor−Leste 12.5
Laos 11.4
Malaysia 10.5
Singapore 7.7
Viet Nam 7.1
0 5 10 15 20 25 30
Cervical cancer: Age−standardised incidence rate per 100,000 women

World Standard. Female (All ages)

Data sources:

Figure 10: Annual number of new cases of cervical cancer by age group in Malaysia (estimates for
2018)
Malaysia South−Eastern Asia
9635
9000 8899 8809

7500
6989 7015
6000
4922
4755
4500
3903
3127
3000 2829
1500 1243
* 89 125 159 201 212 218 209 177 127 126

* 38
0
15−19 20−24 25−29 30−34 35−39 40−44 45−49 50−54 55−59 60−64 65−69 70−74 >=75
Age group (years)
*0 cases for Malaysia and 45 cases for South-Eastern Asia in the 15-19 age group. 1 cases for Malaysia and 191 cases for South-Eastern Asia in the 20-24 age group.
Data sources:

3.1.4 Cervical cancer mortality in Malaysia
KEY STATS.
About 944 cervical cancer deaths occur annually in Malaysia (esti-

mates for 2018).
Cervical cancer ranks* as the 4 th leading cause of female cancer deaths

in Malaysia.
Cervical cancer is the 3rd leading cause of cancer deaths in women

aged 15 to 44 years in Malaysia.
* Ranking of cervical cancer incidence to other cancers among all women according to highest incidence rates (ranking 1st) excluding non-melanoma skin cancer and considering separated
colon, rectum and anus. Ranking is based on crude incidence rates (actual number of cervical cancer cases). Ranking using age-standardized rate (ASR) may differ.
Table 6: Cervical cancer mortality in Malaysia (estimates for 2018)

Indicator Malaysia South-Eastern Asia World
Annual number of deaths 944 35,738 311,365
a
Crude mortality rate 6.1 10.9 8.2
Age-standardized mortality ratea 6.0 10.0 6.9
Cumulative risk (%) at 75 years oldb 0.7 1.2 0.8

b Cumulative risk (mortality) is the probability or risk of individuals dying from the disease during ages 0-74 years. For cancer, it is expressed as the % of new born children who would be
expected to die from a particular cancer before the age of 75 if they had the rates of cancer observed in the period in the absence of competing causes.
Data sources:

Figure 11: Comparison of cervical cancer mortality to other cancers in women of all ages in Malaysia
Breast 18.7
Lung 6.9
Colon 6.6
Cervix uteri 6.1
Ovary 5.2
Stomach 4.0
Leukaemia 4.0
Rectum 3.2
Liver 3.0
Pancreas 2.5
Corpus uteri 2.1
Nasopharynx 1.7
Kidney 1.1
Gallbladder 1.1
Oesophagus 0.8
Bladder 0.7
Thyroid 0.4
Larynx 0.2
Salivary glands 0.1
Vulva 0.1
Oropharynx 0.1
Vagina 0.0
Mesothelioma 0.0
Kaposi sarcoma 0.0
Hypopharynx 0.0
Anus 0.0
0 5 10 15 20 25 30
Annual crude mortality rate per 100,000
Malaysia: Female (All ages)
Data sources:

Figure 12: Comparison of age-specific mortality rates of cervical cancer to other cancers among women
15-44 years of age in Malaysia (estimates for 2018)
Breast 5.9
Leukaemia 2.7
Cervix uteri 1.3
Ovary 1.3
Colon 0.6
Stomach 0.6
Nasopharynx 0.6
Lung 0.5
Corpus uteri 0.4
Rectum 0.3
Pancreas 0.2
Liver 0.2
Kidney 0.2
Salivary glands 0.1
Larynx 0.1
Gallbladder 0.1
Bladder 0.1
Thyroid 0.1
Oropharynx 0.0
Vulva 0.0
Oesophagus 0.0
Vagina 0.0
Mesothelioma 0.0
Kaposi sarcoma 0.0
Hypopharynx 0.0
Anus 0.0
0 5 10
Annual crude mortality rate per 100,000
Malaysia: Female (15−44 years)
Data sources:

Figure 13: Annual number of deaths and age-specific mortality rates of cervical cancer in Malaysia
50
●
cervical cancer
40
●
30
●
20 ●
●
10 ●
●
●
●
0 ●
15−19 ● ●
20−24
25−29
30−34
35−39
40−44
45−49
50−54
55−59
60−64
65−69
70−74
75+
Annual number of deaths of cervical cancer
480 468
422
420 60−64 yrs:
133 cases
360
300 55−59 yrs:

116 cases
240
180 50−54 yrs:

96 cases
120
45−49 yrs:
74 cases
60 54*
40−44 yrs:
49 cases
0
15−39 40−64 65+
Age group (years)
* 15-19 yrs: 0 cases. 20-24 yrs: 1 cases. 25-29 yrs: 6 cases. 30-34 yrs: 16 cases. 35-39 yrs: 31 cases.
Data sources:

3.1.5 Cervical cancer mortality in Malaysia across South-Eastern Asia
Figure 14: Comparison of age-standardised cervical cancer mortality rates in Malaysia and coun-
tries within the region (estimates for 2018)
Indonesia 13.9
Myanmar 13.1
Cambodia 10.1
Thailand 9
Philippines 8.8
Laos 7
Timor−Leste 6.2
Brunei 6.1
Malaysia 6
Viet Nam 4
Singapore 3.8
0 5 10 15 20
Cervical cancer: Age−standardised mortality rate per 100,000 women

World Standard. Female (All ages)

Data sources:

Figure 15: Annual deaths number of cervical cancer by age group in Malaysia (estimates for 2018)
Malaysia South−Eastern Asia
7000
6000
5208
5000 4817 4927
4512
4049
4000 3859
3154
3000
2654
2000
1545
1000
691
* 74 96 116 133 138 124 160

* * 16 31 49
0
15−19 20−24 25−29 30−34 35−39 40−44 45−49 50−54 55−59 60−64 65−69 70−74 >=75
Age group (years)
*0 cases for Malaysia and 21 cases for South-Eastern Asia in the 15-19 age group. 1 cases for Malaysia and 51 cases for South-Eastern Asia in the 20-24 age group. 6 cases for Malaysia and
203 cases for South-Eastern Asia in the 25-29 age group.
Data sources:

3.1.6 Cervical cancer incidence and mortality comparison, Premature deaths and disability
in Malaysia
Figure 16: Comparison of age-specific cervical cancer incidence and mortality rates in Malaysia (esti-
mates for 2018)
50 Incidence
Mortality
Age−specific rates of cervical cancer
40
30
20
10
0
15−19
20−24
25−29
30−34
35−39
40−44
45−49
50−54
55−59
60−64
65−69
70−74
>=75
Age group (years)
Data sources:
Table 7: Premature deaths and disability from cervical cancer in Malaysia, South-Eastern Asia and the
rest of the world (estimates for 2008)
Malaysia South-Eastern Asia World
Indicator Number ASR (W) Number ASR (W) Number ASR (W)
Estimated disability-adjusted life 21,795 177 692,606 243 8,738,004 293
years (DALYs)
Years of life lost (YLLs) 18,027 149 615,604 218 7,788,282 264
Years lived with disability (YLDs) 3,768 28 77,002 25 949,722 28
Data accessed on 04 Nov 2013.
Data sources:
Soerjomataram I, Lortet-Tieulent J, Parkin DM, Ferlay J, Mathers C, Forman D, Bray F. Global burden of cancer in 2008: a systematic analysis of disability-adjusted life-years in 12 world
regions. Lancet. 2012 Nov 24;380(9856):1840-50.

Figure 17: Comparison of annual premature deaths and disability from cervical cancer in Malaysia to
other cancers among women (estimates for 2008)
Breast ca. 64,063

Colorectal ca. 26,179
Leukaemia 26,089
Lung ca. 21,888
Cervix uteri ca. 21,795
Ovarian ca. 21,390
Stomach ca. 14,270
Nasopharyngeal ca. 9,989
Non−Hodgkin lymphoma 9,885
Ca. of the brain and CNS 7,987
Liver ca. 7,380
Corpus uteri ca. 5,175
Pancreatic ca. 4,258
Thyroid ca. 4,046
Ca. of the lip and oral cavity 3,751
Oesophageal ca. 3,748
Kidney ca. 3,376
Gallbladder 3,215
Multiple myeloma 1,974
Other pharynx ca. 1,955
Bladder ca. 1,504
Hodgkin lymphoma 1,399
Laryngeal ca. 414
Melanoma of skin 348
YLLs
Kaposi sarcoma 0 YLDs
0 10000 20000 30000 40000 50000 60000 70000
Estimated disability−adjusted life years (DALYs).

Data accessed on 04 Nov 2013.
CNS: Central Nervous System; YLDs: years lived with disability; YLLs: Years of life lost;
Data sources:
Soerjomataram I, Lortet-Tieulent J, Parkin DM, Ferlay J, Mathers C, Forman D, Bray F. Global burden of cancer in 2008: a systematic analysis of disability-adjusted life-years in 12 world
regions. Lancet. 2012 Nov 24;380(9856):1840-50.

3.2 Anogenital cancers other than the cervix

Data on HPV role in anogenital cancers other than cervix are limited, but there is an increasing body
of evidence strongly linking HPV DNA with cancers of anus, vulva, vagina, and penis. Although these
cancers are much less frequent compared to cervical cancer, their association with HPV make them
potentially preventable and subject to similar preventative strategies as those for cervical cancer. (Vac-
cine 2006, Vol. 24, Suppl 3; Vaccine 2008, Vol. 26, Suppl 10; Vaccine 2012, Vol. 30, Suppl 5; IARC
Monographs 2007, Vol. 90).
3.2.1 Anal cancer
Anal cancer is rare in the general population with an average worldwide incidence of 1 per 100,000,
but is reported to be increasing in more developed regions. Globally, there are an estimated 27,000 new
cases every year (de Martel C et al. Lancet Oncol 2012;13(6):607-15). Women have higher incidences of
anal cancer than men. Incidence is particularly high among populations of men who have sex with men
(MSM), women with history of cervical or vulvar cancer, and immunosuppressed populations, including
those who are HIV-infected and patients with a history of organ transplantation. These cancers are
predominantly squamous cell carcinoma, adenocarcinomas, or basaloid and cloacogenic carcinomas.
Table 8: Anal cancer incidence in Malaysia by cancer registry and sex

MALE FEMALE
1 a b b a
Cancer registry Period N cases Crude rate ASR N cases Crude rate c ASR c
Penang 2008-2010 6 0.3 0.3 14 0.6 0.6
Penang (Chinese) 2008-2010 3 0.3 0.2 12 1.2 0.8
Penang (Malay) 2008-2010 3 0.3 0.5 1 0.1 0.1
Penang (Indian) 2008-2010 0 0.0 0.0 0 0.0 0.0
b Rates per 100,000 men per year.
c Rates per 100,000 women per year.
Data sources:

Figure 18: Time trends in anal cancer incidence in Malaysia (cancer registry data)
Anal cancer in men
(per 100,000)
All ages
No data available
15−44 yrs
45−74 yrs
1975
1980
1985
1990
1995
Anal cancer in women
(per 100,000)
All ages
No data available
15−44 yrs
45−74 yrs
1975
1980
1985
1990
1995
Year

Data sources:
Ferlay J, Bray F, Steliarova-Foucher E and Forman D. Cancer Incidence in Five Continents, CI5plus: IARC CancerBase No. 9 [Internet]. Lyon, France: International Agency for Research

3.2.2 Vulvar cancer
Cancer of the vulva is rare among women worldwide, with an estimated 27,000 new cases in 2008, rep-
resenting 4% of all gynaecologic cancers (de Martel C et al. Lancet Oncol 2012;13(6):607-15). Worldwide,
about 60% of all vulvar cancer cases occur in more developed countries. Vulvar cancer has two distinct
histological patterns with two different risk factor profiles: (1) basaloid/warty types (2) keratinising
types. Basaloid/warty lesions are more common in young women, are very often associated with HPV
DNA detection (75-100%), and have a similar risk factor profile as cervical cancer. Keratinising vulvar
carcinomas represent the majority of the vulvar lesions (>60%), they occur more often in older women
and are more rarely associated with HPV (IARC Monograph Vol 100B).
Table 9: Vulvar cancer incidence in Malaysia by cancer registry

1
Penang 2008-2010 7 0.3 0.3
Penang (Chinese) 2008-2010 6 0.6 0.4
Penang (Malay) 2008-2010 1 0.1 0.2
Penang (Indian) 2008-2010 0 0.0 0.0
Data sources:
Figure 19: Time trends in vulvar cancer incidence in Malaysia (cancer registry data)
(per 100,000)
All ages
No data available
15−44 yrs
45−74 yrs
1975
1980
1985
1990
1995
Year

Data sources:

3.2.3 Vaginal cancer
Cancer of the vagina is a rare cancer, with an estimated 13,000 new cases in 2008, representing 2% of
all gynaecologic cancers (de Martel C et al. Lancet Oncol 2012;13(6):607-15). Similar to cervical cancer,
the majority of vaginal cancer cases (68%) occur in less developed countries. Most vaginal cancers are
squamous cell carcinoma (90%) generally attributable to HPV, followed by clear cell adenocarcinomas
and melanoma. Vaginal cancers are primarily reported in developed countries. Metastatic cervical
cancer can be misclassified as cancer of the vagina. Invasive vaginal cancer is diagnosed primarily in
old women (≥ 65 years) and the diagnosis is rare in women under 45 years whereas the peak incidence
of carcinoma in situ is observed between ages 55 and 70 (Vaccine 2008, Vol. 26, Suppl 10).
Table 10: Vaginal cancer incidence in Malaysia by cancer registry

1
Penang (Chinese) 2008-2010 5 0.5 0.5
Penang (Malay) 2008-2010 0 0.0 0.0
Penang (Indian) 2008-2010 0 0.0 0.0
Penang 2008-2010 5 0.2 0.2
Data sources:
Figure 20: Time trends in vaginal cancer incidence in Malaysia (cancer registry data)
(per 100,000)
All ages
No data available
15−44 yrs
45−74 yrs
1975
1980
1985
1990
1995
Year

Data sources:

3.2.4 Penile cancer
The annual burden of penile cancer has been estimated to be 22,000 cases worldwide with incidence
rates strongly correlating with those of cervical cancer (de Martel C et al. Lancet Oncol 2012;13(6):607-
15). Penile cancer is rare and most commonly affects men aged 50-70 years. Incidence rates are higher
in less developed countries than in more developed countries, accounting for up to 10% of male cancers
in some parts of Africa, South America and Asia. Precursor cancerous penile lesions (PeIN) are rare.
Cancers of the penis are primarily of squamous cell carcinomas (SCC) (95%) and the most common
penile SCC histologic sub-types are keratinising (49%), mixed warty-basaloid (17%), verrucous (8%)
warty (6%), and basaloid (4%). HPV is most commonly detected in basaloid and warty tumours but is
less common in keratinising and verrucous tumours. Approximately 60-100% of PeIN lesions are HPV
DNA positive.
Table 11: Penile cancer incidence in Malaysia by cancer registry

Penang (Chinese) 2008-2010 4 0.4 0.4
Penang (Malay) 2008-2010 1 0.1 0.1
Penang (Indian) 2008-2010 1 0.4 0.5
Penang 2008-2010 6 0.3 0.3
b Rates per 100,000 men per year.
Data sources:
Figure 21: Time trends in penile cancer incidence in Malaysia (cancer registry data)
(per 100,000)
Penis
No data available
15−44
45−74
1975
1980
1985
1990
1995
Year

Data sources:

3.3 Head and neck cancers

The majority of head and neck cancers are associated with high tobacco and alcohol consumption. How-
ever, increasing trends in the incidence at specific sites suggest that other aetiological factors are in-
volved, and infection by certain high-risk types of HPV (i.e. HPV16) have been reported to be associated
with head and neck cancers, in particular with oropharyngeal cancer. Current evidence suggests that
HPV16 is associated with tonsil cancer (including Waldeyer ring cancer), base of tongue cancer and
other oropharyngeal cancer sites. Associations with other head and neck cancer sites such as oral can-
cer are neither strong nor consistent when compared to molecular-epidemiological data on HPV and
oropharyngeal cancer. Association with laryngeal cancer is still unclear (IARC Monograph Vol 100B).
3.3.1 Oropharyngeal cancer
Table 12: Incidence and mortality of cancer of the oropharynx in Malaysia, South-Eastern Asia and the
rest of the world by sex (estimates for 2018). Includes ICD-10 codes: C09-10
MALE FEMALE
Indicator Malaysia South- World Malaysia South- World
Eastern Eastern
Asia Asia
INCIDENCE
Annual number of new cancer cases 90 3,130 74,472 29 932 18,415
Crude incidence ratea 0.5 1.0 1.9 0.2 0.3 0.5
Age-standardized incidence ratea 0.6 1.0 1.8 0.2 0.3 0.4
Cumulative risk (%) at 75 years oldb 0.1 0.1 0.2 0 0 0
MORTALITY
Annual number of deaths 46 1,686 42,116 10 406 8,889
Crude mortality ratea 0.3 0.5 1.1 0.1 0.1 0.2
Age-standardized mortality ratea 0.3 0.5 1.0 0.1 0.1 0.2
Cumulative risk (%) at 75 years old c 0 0.1 0.1 0 0 0
a Male: Rates per 100,000 men per year. Female: Rates per 100,000 women per year.
b Cumulative risk (incidence) is the probability or risk of individuals getting from the disease during ages 0-74 years. For cancer, it is expressed as the % of new born children who would be
expected to develop from a particular cancer before the age of 75 if they had the rates of cancer observed in the period in the absence of competing causes.
c Cumulative risk (mortality) is the probability or risk of individuals dying from the disease during ages 0-74 years. For cancer, it is expressed as the % of new born children who would be
expected to die from a particular cancer before the age of 75 if they had the rates of cancer observed in the period in the absence of competing causes.
Data sources:

Figure 22: Comparison of incidence and mortality rates of the oropharynx by age group and sex in
Malaysia (estimates for 2018). Includes ICD-10 codes: C09-10
MALE FEMALE
4
oropharyngeal cancer
0
0
4
4
4
4
4
4
9
9
9
39
4
4
75
75
14
14
−7
−7
−4
−5
−6
−4
−5
−6
−5
−5
−6
−6
−4
−4
−3
−
>=
>=
0−
0−
70
70
45
55
65
45
55
65
50
50
60
60
40
40
15
15
Age groups (years)

Incidence Mortality
Male: Rates per 100,000 men per year. Female: Rates per 100,000 women per year.
Data sources:

Table 13: Incidence of oropharyngeal cancer in Malaysia by cancer registry and sex
MALE FEMALE
Cancer registry1,α Periodα N casesa Crude rateb ASRα N casesa Crude rateb ASRb
Tongue (ICD-10 code: C01-02)
Penang (Chinese) 2008-2010 11 1.1 0.9 13 1.3 1.0
Penang (Malay) 2008-2010 9 1.0 1.4 3 0.3 0.4
Penang (Indian) 2008-2010 5 2.2 2.2 3 1.3 1.5
Penang 2008-2010 25 1.1 1.2 20 0.9 0.9
Tonsillar cancer (ICD-10 code: C09)
Penang (Chinese) 2008-2010 4 0.4 0.3 2 0.2 0.2
Penang (Malay) 2008-2010 3 0.3 0.4 1 0.1 0.1
Penang (Indian) 2008-2010 2 0.9 0.7 0 0.0 0.0
Penang 2008-2010 9 0.4 0.4 3 0.1 0.1
Cancer of the oropharynx (excludes tonsil) (ICD-10 code: C10)
Penang (Chinese) 2008-2010 1 0.1 0.1 0 0.0 0.0
Penang (Malay) 2008-2010 1 0.1 0.2 1 0.1 0.1
Penang (Indian) 2008-2010 2 0.9 1.3 0 0.0 0.0
Penang 2008-2010 4 0.2 0.2 1 0.0 0.0
ASR: Age-standardised rate. Standardised rates have been estimated using the direct method and the World population as the reference.
b Male: Rates per 100,000 men per year. Female: Rates per 100,000 women per year.
α Please refer to original source (available at http://ci5.iarc.fr/CI5-XI/Default.aspx)
Data sources:

4 HPV RELATED STATISTICS - 31 -
4 HPV related statistics

HPV infection is commonly found in the anogenital tract of men and women with and without clinical
lesions. The aetiological role of HPV infection among women with cervical cancer is well-established,
and there is growing evidence of its central role in other anogenital sites. HPV is also responsible for
other diseases such as recurrent juvenile respiratory papillomatosis and genital warts, both mainly
caused by HPV types 6 and 11 (Lacey CJ, Vaccine 2006; 24(S3):35). For this section, the methodologies
used to compile the information on HPV burden are derived from systematic reviews and meta-analyses
of the literature. Due to the limitations of HPV DNA detection methods and study designs used, these
data should be interpreted with caution and used only as a guide to assess the burden of HPV infection
within the population. (Vaccine 2006, Vol. 24, Suppl 3; Vaccine 2008, Vol. 26, Suppl 10; Vaccine
2012,Vol. 30, Suppl 5; IARC Monographs 2007, Vol. 90).
4.1 HPV burden in women with normal cervical cytology, cervical precancerous
lesions or invasive cervical cancer
The statistics shown in this section focus on HPV infection in the cervix uteri. HPV cervical infection re-
sults 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 HPV DNA detection in cervical cells (fresh tissue, paraffin embedded or exfoliated cells).
The prevalence of HPV increases with lesion severity. HPV causes virtually 100% of cervical cancer
cases, and an underestimation of HPV prevalence in cervical cancer is most likely due to the limitations
of study methodologies. Worldwide, HPV16 and 18 (the two vaccine-preventable types) 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 HPV16/18, 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, Vaccine 2006;24(S3):26).
Methods: Prevalence and type distribution of human papillomavirus in cervical carcinoma,

low-grade cervical lesions, high-grade cervical lesions and normal cytology: systematic re-
view and meta-analysis
A systematic review of the literature was conducted regarding the worldwide HPV-prevalence and type
distribution for cervical carcinoma, low-grade cervical lesions, high-grade cervical lesions and normal
cytology from 1990 to ’data as of ’ indicated in each section. The search terms for the review were ’HPV’
AND cerv* using Pubmed. There were no limits in publication language. References cited in selected
articles were also investigated. Inclusion criteria were: HPV DNA detection by means of PCR or HC2,
a minimum of 20 cases for cervical carcinoma, 20 cases for low-grade cervical lesions, 20 cases for high-
grade cervical lesions and 100 cases for normal cytology and a detailed description of HPV DNA detec-
tion and genotyping techniques used. The number of cases tested and HPV positive extracted for each
study were pooled to estimate the prevalence of HPV DNA and the HPV type distribution globally and
by geographical region. Binomial 95% confidence intervals were calculated for each HPV prevalence.
For more details refer to the methods document.

4.1.1 HPV prevalence in women with normal cervical cytology
Figure 23: Crude age-specific HPV prevalence (%) and 95% confidence interval in women with normal
cervical cytology in Malaysia
4
HPV prevalence (%)
No data available
4
4
54
5
−3
+
−4
<2
55
25
45
35
Age group (years)

Data updated on 11 Jun 2019 (data as of 30 Jun 2015).
Data sources:
Based on systematic reviews and meta-analysis performed by ICO. The ICO HPV Information Centre has updated data until June 2014. Reference publications: 1) Bruni L, J Infect Dis
2010; 202: 1789. 2) De Sanjosé S, Lancet Infect Dis 2007; 7: 453
Figure 24: HPV prevalence among women with normal cervical cytology in Malaysia, by study
Study Age N % (95% CI)

Tay 2009 (Johor and Singapore) 18−77 745 22.0 (19.2−25.1)
Othman 2014a − 588 3.1 (1.9−4.8)
Chong 2010 (Southern Selangor)b 19−69 180 46.7 (39.5−53.9)
0% 10% 20% 30% 40% 50% 60%

95% CI: 95% Confidence Interval; N: number of women tested;
The samples for HPV testing come from cervical specimens (fresh/fixed biopsies or exfoliated cells).
a North-Eastern region os West Malaysia
b Women from the general population, including some with cytological cervical abnormalities
Data sources:
Chong PP, Asian Pac J Cancer Prev 2010; 11: 1645 | Othman N, Asian Pac J Cancer Prev 2014; 15: 2245 | Tay SK, Aust N Z J Obstet Gynaecol 2009; 49: 323

4.1.2 HPV type distribution among women with normal cervical cytology, precancerous cer-
vical lesions and cervical cancer
Table 14: Prevalence of HPV16 and HPV18 by cytology in Malaysia

HPV 16/18 Prevalence
No. tested % (95% CI)
Normal cytology1,2 588 1.0 (0.5-2.2)
Low-grade lesions3,4 23 30.4 (15.6-50.9)
High-grade lesions5,6 73 49.3 (38.2-60.5)
Cervical cancer7,8 426 88.7 (85.4-91.4)

Data updated on 11 Jun 2019 (data as of 30 Jun 2015 / 30 Jun 2015).
95% CI: 95% Confidence Interval; High-grade lesions: CIN-2, CIN-3, CIS or HSIL; Low-grade lesions: LSIL or CIN-1;
The samples for HPV testing come from cervical specimens (fresh / fixed biopsies or exfoliated cells)
Data sources:
1 Based on systematic reviews and meta-analysis performed by ICO. The ICO HPV Information Centre has updated data until June 2014. Reference publications: 1) Bruni L, J Infect Dis
2 Othman N, Asian Pac J Cancer Prev 2014; 15: 2245
3 Based on meta-analysis performed by IARC’s Infections and Cancer Epidemiology Group up to November 2011, the ICO HPV Information Centre has updated data until June 2015.
Reference publications: 1) Guan P, Int J Cancer 2012;131:2349 2) Clifford GM, Cancer Epidemiol Biomarkers Prev 2005;14:1157
4 Contributing studies: Sharifah NA, Asian Pac J Cancer Prev 2009; 10: 303
Reference publications: 1) Guan P, Int J Cancer 2012;131:2349 2) Smith JS, Int J Cancer 2007;121:621 3) Clifford GM, Br J Cancer 2003;89:101.
6 Contributing studies: Quek SC, Int J Gynecol Cancer 2013; 23: 148
Reference publications: 1) Guan P, Int J Cancer 2012;131:2349 2) Li N, Int J Cancer 2011;128:927 3) Smith JS, Int J Cancer 2007;121:621 4) Clifford GM, Br J Cancer 2003;88:63 5) Clifford
GM, Br J Cancer 2003;89:101.
8 Contributing studies: Cheah PL, Malays J Pathol 2008; 30: 37 | Hamzi Abdul Raub S, Asian Pac J Cancer Prev 2014; 15: 651 | Quek SC, Int J Gynecol Cancer 2013; 23: 148 | Sharifah
NA, Asian Pac J Cancer Prev 2009; 10: 303 | Yadav M, Med J Malaysia 1995; 50: 64
Figure 25: HPV 16 prevalence among women with normal cervical cytology in Malaysia, by study
Study N % (95% CI)

Othman 2014 588 0.9 (0.4−2.0)
0% 10%

Data sources:
Othman N, Asian Pac J Cancer Prev 2014; 15: 2245
Figure 26: HPV 16 prevalence among women with low-grade cervical lesions in Malaysia, by study
Study N % (95% CI)

Sharifah 2009 23 26.1 (12.5−46.5)
10% 20% 30% 40% 50%

95% CI: 95% Confidence Interval; Low-grade lesions: LSIL or CIN-1; N: number of women tested;
Data sources:
Based on meta-analysis performed by IARC’s Infections and Cancer Epidemiology Group up to November 2011, the ICO HPV Information Centre has updated data until June 2015.
Sharifah NA, Asian Pac J Cancer Prev 2009; 10: 303

Figure 27: HPV 16 prevalence among women with high-grade cervical lesions in Malaysia, by study
Study N % (95% CI)

Quek 2013 73 41.1 (30.5−52.6)
30% 40% 50% 60%

95% CI: 95% Confidence Interval; High-grade lesions: CIN-2, CIN-3, CIS or HSIL; N: number of women tested;
Data sources:
Quek SC, Int J Gynecol Cancer 2013; 23: 148
Figure 28: HPV 16 prevalence among women with invasive cervical cancer in Malaysia, by study
Study N % (95% CI)

Hamzi Abdul Raub 2014 280 57.5 (51.6−63.2)
Quek 2013 101 36.6 (27.9−46.4)
Yadav 1995 23 73.9 (53.5−87.5)
Cheah 2008 11 72.7 (43.4−90.3)
Sharifah 2009 11 18.2 (5.1−47.7)
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Data sources:
GM, Br J Cancer 2003;89:101.
Cheah PL, Malays J Pathol 2008; 30: 37 | Hamzi Abdul Raub S, Asian Pac J Cancer Prev 2014; 15: 651 | Quek SC, Int J Gynecol Cancer 2013; 23: 148 | Sharifah NA, Asian Pac J Cancer
Prev 2009; 10: 303 | Yadav M, Med J Malaysia 1995; 50: 64

Figure 29: Comparison of the ten most frequent HPV oncogenic types in Malaysia among women
with and without cervical lesions
16 0.9
Normal cytology(a, b) 58 0.7
18 0.2
HPV−type
33 0.2
5th*
6th*
7th*
8th*
9th*
10th*
51 26.1
Low−grade lesions(c, d)
16 26.1
52 17.4
HPV−type
56 8.7
31 4.3
18 4.3
66 4.3
8th*
9th*
10th*
16 41.1
High−grade lesions(e, f)
52 20.5
58 8.2
HPV−type
18 8.2
33 6.8
51 5.5
31 5.5
45 4.1
9th*
10th*
16 52.8
Cervical Cancer(g, h)
18 35.9
52 10.7
HPV−type
45 8.9
58 8.9
33 7.7
56 6.1
39 5.5
59 4.5
31 2.4
0 10 20 30 40 50 60
Prevalence (%)
*No data available. No more types than shown were tested or were positive.
High-grade lesions: CIN-2, CIN-3, CIS or HSIL; Low-grade lesions: LSIL or CIN-1;
The samples for HPV testing come from cervical specimens (fresh / fixed biopsies or exfoliated cells).
Data sources:
a Based on systematic reviews and meta-analysis performed by ICO. The ICO HPV Information Centre has updated data until June 2014. Reference publications: 1) Bruni L, J Infect Dis
b Othman N, Asian Pac J Cancer Prev 2014; 15: 2245
c Based on meta-analysis performed by IARC’s Infections and Cancer Epidemiology Group up to November 2011, the ICO HPV Information Centre has updated data until June 2015.
d Contributing studies: Sharifah NA, Asian Pac J Cancer Prev 2009; 10: 303
e Based on meta-analysis performed by IARC’s Infections and Cancer Epidemiology Group up to November 2011, the ICO HPV Information Centre has updated data until June 2015.
(Continued on next page)

( Figure 29 – continued from previous page)

f Contributing studies: Quek SC, Int J Gynecol Cancer 2013; 23: 148
g Based on meta-analysis performed by IARC’s Infections and Cancer Epidemiology Group up to November 2011, the ICO HPV Information Centre has updated data until June 2014.
GM, Br J Cancer 2003;89:101.
h Contributing studies: Cheah PL, Malays J Pathol 2008; 30: 37 | Hamzi Abdul Raub S, Asian Pac J Cancer Prev 2014; 15: 651 | Quek SC, Int J Gynecol Cancer 2013; 23: 148 | Sharifah
Figure 30: Comparison of the ten most frequent HPV oncogenic types in Malaysia among women
with invasive cervical cancer by histology
16 52.8
18 35.9
Cervical Cancer
52 10.7
HPV−type
45 8.9
58 8.9
33 7.7
56 6.1
39 5.5
59 4.5
31 2.4
Squamous cell carcinoma
16 56.6
18 31.1
52 12.9
HPV−type
58 11.2
45 8.4
33 7.7
59 5.8
39 5.8
56 4.9
31 2.9
18 53.8
16 39.6
Adenocarcinoma
45 10.4
HPV−type
56 9.4
33 7.5
52 4.7
39 4.7
58 2.8
59 0.9
31 0.9
16 72.7
2nd*
3rd*
Unespecified
HPV−type
4th*
5th*
6th*
7th*
8th*
9th*
10th*
0 10 20 30 40 50 60 70 80
Prevalence (%)
Data updated on 19 May 2017 (data as of 30 Jun 2015).

( Figure 30 – continued from previous page)

The samples for HPV testing come from cervical specimens (fresh / fixed biopsies or exfoliated cells). The ranking of the ten most frequent HPV types may present less than ten types beause
only a limited number of types were tested or were HPV-positive.
Data sources:
GM, Br J Cancer 2003;89:101.
Contributing studies: Cheah PL, Malays J Pathol 2008; 30: 37 | Hamzi Abdul Raub S, Asian Pac J Cancer Prev 2014; 15: 651 | Quek SC, Int J Gynecol Cancer 2013; 23: 148 | Sharifah

Table 15: Type-specific HPV prevalence in women with normal cervical cytology, precancerous cervical
lesions and invasive cervical cancer in Malaysia
Normal cytology1,2 Low-grade lesions3,4 High-grade lesions5,6 Cervical cancer7,8

HPV Type No. HPV Prev No. HPV Prev No. HPV Prev No. HPV Prev
tested % (95% CI) tested % (95% CI) tested % (95% CI) tested % (95% CI)
ONCOGENIC HPV TYPES
High-risk HPV types
16 588 0.9 (0.4-2.0) 23 26.1 (12.5-46.5) 73 41.1 (30.5-52.6) 426 52.8 (48.1-57.5)
18 588 0.2 (0.0-1.0) 23 4.3 (0.8-21.0) 73 8.2 (3.8-16.8) 426 35.9 (31.5-40.6)
31 - - 23 4.3 (0.8-21.0) 73 5.5 (2.2-13.3) 415 2.4 (1.3-4.4)
33 588 0.2 (0.0-1.0) - - 73 6.8 (3.0-15.1) 404 7.7 (5.5-10.7)
35 - - - - 73 0.0 (0.0-5.0) 381 1.0 (0.4-2.7)
39 - - - - 73 0.0 (0.0-5.0) 381 5.5 (3.6-8.3)
45 - - - - 73 4.1 (1.4-11.4) 381 8.9 (6.5-12.2)
51 - - 23 26.1 (12.5-46.5) 73 5.5 (2.2-13.3) 381 1.8 (0.9-3.7)
52 - - 23 17.4 (7.0-37.1) 73 20.5 (12.9-31.2) 392 10.7 (8.0-14.2)
56 - - 23 8.7 (2.4-26.8) 73 0.0 (0.0-5.0) 392 6.1 (4.1-8.9)
58 588 0.7 (0.3-1.7) 23 0.0 (0.0-14.3) 73 8.2 (3.8-16.8) 392 8.9 (6.5-12.2)
59 - - - - 73 0.0 (0.0-5.0) 381 4.5 (2.8-7.0)
Probable/possible carcinogen
26 - - - - - - - -
30 - - - - - - - -
34 - - - - 73 0.0 (0.0-5.0) 101 0.0 (0.0-3.7)
53 - - - - 73 0.0 (0.0-5.0) 101 0.0 (0.0-3.7)
66 - - 23 4.3 (0.8-21.0) 73 0.0 (0.0-5.0) 112 0.0 (0.0-3.3)
67 - - - - - - - -
68 - - - - 73 0.0 (0.0-5.0) 101 2.0 (0.5-6.9)
69 - - - - - - - -
70 - - - - 73 0.0 (0.0-5.0) 101 0.0 (0.0-3.7)
73 - - - - - - - -
82 - - - - - - - -
85 - - - - - - - -
97 - - - - - - - -
NON-ONCOGENIC HPV TYPES
6 588 0.2 (0.0-1.0) 23 4.3 (0.8-21.0) 73 0.0 (0.0-5.0) 123 0.0 (0.0-3.0)
11 - - 23 4.3 (0.8-21.0) 73 0.0 (0.0-5.0) 123 0.8 (0.1-4.5)
32 - - - - - - - -
40 - - - - 73 0.0 (0.0-5.0) 101 0.0 (0.0-3.7)
42 - - - - 73 0.0 (0.0-5.0) 101 0.0 (0.0-3.7)
43 - - - - 73 0.0 (0.0-5.0) 101 0.0 (0.0-3.7)
44 - - - - 73 0.0 (0.0-5.0) 101 0.0 (0.0-3.7)
54 - - - - 73 0.0 (0.0-5.0) 101 0.0 (0.0-3.7)
55 - - - - - - - -
57 - - - - - - - -
61 - - - - - - - -
62 - - - - - - - -
64 - - - - - - - -
71 - - - - - - - -
72 - - - - - - - -
74 - - - - 73 0.0 (0.0-5.0) 101 0.0 (0.0-3.7)
81 - - - - - - - -
83 - - - - - - - -
84 - - - - - - - -
86 - - - - - - - -
87 - - - - - - - -
89 - - - - - - - -
90 - - - - - - - -
91 - - - - - - - -
95% CI: 95% Confidence Interval; High-grade lesions: CIN-2, CIN-3, CIS or HSIL; Low-grade lesions: LSIL or CIN-1;
Data sources:
1 Based on systematic reviews and meta-analysis performed by ICO. The ICO HPV Information Centre has updated data until June 2014. Reference publications: 1) Bruni L, J Infect Dis
2 Othman N, Asian Pac J Cancer Prev 2014; 15: 2245
4 Contributing studies: Sharifah NA, Asian Pac J Cancer Prev 2009; 10: 303

( Table 15 – continued from previous page)

6 Contributing studies: Quek SC, Int J Gynecol Cancer 2013; 23: 148
GM, Br J Cancer 2003;89:101.
8 Contributing studies: Cheah PL, Malays J Pathol 2008; 30: 37 | Hamzi Abdul Raub S, Asian Pac J Cancer Prev 2014; 15: 651 | Quek SC, Int J Gynecol Cancer 2013; 23: 148 | Sharifah

Table 16: Type-specific HPV prevalence among invasive cervical cancer cases in Malaysia by histology
Any Histology Squamous cell carcinoma Adenocarcinoma Unespecified
HPV Type No. HPV Prev No. HPV Prev No. HPV Prev No. HPV Prev
tested % (95% CI) tested % (95% CI) tested % (95% CI) tested % (95% CI)
ONCOGENIC HPV TYPES
High-risk HPV types
16 426 52.8 (48.1-57.5) 309 56.6 (51.1-62.0) 106 39.6 (30.8-49.1) 11 72.7 (43.4-90.3)
18 426 35.9 (31.5-40.6) 309 31.1 (26.2-36.4) 106 53.8 (44.3-63.0) 11 0.0 (0.0-25.9)
31 415 2.4 (1.3-4.4) 309 2.9 (1.5-5.4) 106 0.9 (0.2-5.2) - -
33 404 7.7 (5.5-10.7) 298 7.7 (5.2-11.3) 106 7.5 (3.9-14.2) - -
35 381 1.0 (0.4-2.7) 275 1.1 (0.4-3.2) 106 0.9 (0.2-5.2) - -
39 381 5.5 (3.6-8.3) 275 5.8 (3.6-9.2) 106 4.7 (2.0-10.6) - -
45 381 8.9 (6.5-12.2) 275 8.4 (5.6-12.2) 106 10.4 (5.9-17.6) - -
51 381 1.8 (0.9-3.7) 275 2.2 (1.0-4.7) 106 0.9 (0.2-5.2) - -
52 392 10.7 (8.0-14.2) 286 12.9 (9.5-17.3) 106 4.7 (2.0-10.6) - -
56 392 6.1 (4.1-8.9) 286 4.9 (2.9-8.0) 106 9.4 (5.2-16.5) - -
58 392 8.9 (6.5-12.2) 286 11.2 (8.0-15.4) 106 2.8 (1.0-8.0) - -
59 381 4.5 (2.8-7.0) 275 5.8 (3.6-9.2) 106 0.9 (0.2-5.2) - -
Probable/possible carcinogen
26 - - - - - - - -
30 - - - - - - - -
34 101 0.0 (0.0-3.7) 78 0.0 (0.0-4.7) 23 0.0 (0.0-14.3) - -
53 101 0.0 (0.0-3.7) - - - - - -
66 112 0.0 (0.0-3.3) 89 0.0 (0.0-4.1) 23 0.0 (0.0-14.3) - -
67 - - - - - - - -
68 101 2.0 (0.5-6.9) 78 2.6 (0.7-8.9) 23 0.0 (0.0-14.3) - -
69 - - - - - - - -
70 101 0.0 (0.0-3.7) - - - - - -
73 - - - - - - - -
82 - - - - - - - -
85 - - - - - - - -
97 - - - - - - - -
NON-ONCOGENIC HPV TYPES
6 123 0.0 (0.0-3.0) - - - - - -
11 123 0.8 (0.1-4.5) - - - - - -
27 - - - - - - - -
32 - - - - - - - -
40 101 0.0 (0.0-3.7) - - - - - -
42 101 0.0 (0.0-3.7) 78 0.0 (0.0-4.7) 23 0.0 (0.0-14.3) - -
43 101 0.0 (0.0-3.7) - - - - - -
44 101 0.0 (0.0-3.7) 78 0.0 (0.0-4.7) 23 0.0 (0.0-14.3) - -
54 101 0.0 (0.0-3.7) - - - - - -
55 - - - - - - - -
57 - - - - - - - -
60 - - - - - - - -
61 - - - - - - - -
62 - - - - - - - -
64 - - - - - - - -
71 - - - - - - - -
72 - - - - - - - -
74 101 0.0 (0.0-3.7) - - - - - -
76 - - - - - - - -
81 - - - - - - - -
83 - - - - - - - -
84 - - - - - - - -
86 - - - - - - - -
87 - - - - - - - -
89 - - - - - - - -
90 - - - - - - - -
91 - - - - - - - -
No Data Available - -- - -- - -- - --
Data updated on 19 May 2017 (data as of 30 Jun 2015).
95% CI: 95% Confidence Interval;
Data sources:
GM, Br J Cancer 2003;89:101.
Contributing studies: Cheah PL, Malays J Pathol 2008; 30: 37 | Hamzi Abdul Raub S, Asian Pac J Cancer Prev 2014; 15: 651 | Quek SC, Int J Gynecol Cancer 2013; 23: 148 | Sharifah


4.1.3 HPV type distribution among HIV+ women with normal cervical cytology
Table 17: Studies on HPV prevalence among HIV women with normal cytology in Malaysia
HPV detection Prevalence of 5 most
method and targeted HPV prevalence frequent HPVs
Study HPV types No. Tested % (95% CI) HPV type (%)
No Data Available - - - - -
Data updated on 31 Jul 2013 (data as of 31 Dec 2011). Only for European countries.
Data sources:
Systematic review and meta-analysis were performed by the ICO HPV Information Centre up to December 2011. Selected studies had to include at least 20 HIV positive women who had
both normal cervical cytology and HPV test results (PCR or HC2).

4.1.4 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. The condition is graded as CIN 1, 2 or 3,
according to the thickness of the abnormal epithelium (1/3, 2/3 or the entire thickness).
Low-grade cervical lesions (LSIL/CIN-1)

Low-grade cervical lesions are defined by early changes in size, shape, and number of ab-
normal 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 defined by a large number of precancerous cells on the sur-
face 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).
Carcinoma in situ (CIS)

Preinvasive malignancy limited to the epithelium without invasion of the basement membrane.
CIN 3 encompasses the squamous carcinoma in situ.
Invasive cervical cancer (ICC) / Cervical cancer

If the high-grade precancerous cells invade the basement membrane is called ICC. ICC stages
range from stage I (cancer is in the cervix or uterus only) to stage IV (the cancer has spread to
distant organs, such as the liver).
Invasive squamous cell carcinoma

Invasive carcinoma composed of cells resembling those of squamous epithelium.
Adenocarcinoma
Invasive tumour with glandular and squamous elements intermingled.

4.2 HPV burden in anogenital cancers other than cervix

Methods: Prevalence and type distribution of human papillomavirus in carcinoma of the
vulva, vagina, anus and penis: systematic review and meta-analysis
A systematic review of the literature was conducted on the worldwide HPV-prevalence and type dis-
tribution for anogenital carcinomas other than cervix from January 1986 to ’data as of ’ indicated in
each section. The search terms for the review were ’HPV’ AND (anus OR anal) OR (penile) OR vagin*
OR vulv* using Pubmed. There were no limits in publication language. References cited in selected
articles were also investigated. Inclusion criteria were: HPV DNA detection by means of PCR, a mini-
mum of 10 cases by lesion and a detailed description of HPV DNA detection and genotyping techniques
used. The number of cases tested and HPV positive cases were extracted for each study to estimate
the prevalence of HPV DNA and the HPV type distribution. Binomial 95% confidence intervals were
calculated for each HPV prevalence.
4.2.1 Anal cancer and precancerous anal lesions
Anal cancer is similar to cervical cancer with respect to overall HPV DNA positivity, with approximately
88% of cases associated with HPV infection worldwide (de Martel C et al. Lancet Oncol 2012;13(6):607-
15). HPV16 is the most common type detected, representing 73% of all HPV-positive tumours. HPV18
is the second most common type detected and is found in approximately 5% of cases. HPV DNA is also
detected in the majority of precancerous anal lesions (AIN) (91.5% in AIN1 and 93.9% in AIN2/3) (De
Vuyst H et al. Int J Cancer 2009; 124: 1626-36). In this section, the burden of HPV among cases of anal
cancers and precancerous anal lesions in Malaysia are presented.
Table 18: Studies on HPV prevalence among anal cancer cases in Malaysia (male and female)
Data sources:
Based on systematic reviews (up to 2008) performed by ICO for the IARC Monograph on the Evaluation of Carcinogenic Risks to Humans volume 100B and IARC’s Infections and Cancer
Epidemiology Group. The ICO HPV Information Centre has updated data until June 2015. Reference publications: 1) Bouvard V, Lancet Oncol 2009;10:321 2) De Vuyst H, Int J Cancer
2009;124:1626
Table 19: Studies on HPV prevalence among cases of AIN2/3 in Malaysia

95% CI: 95% Confidence Interval; AIN 2/3: Anal intraepithelial neoplasia of grade 2/3;
Data sources:
2009;124:1626

Figure 31: Comparison of the ten most frequent HPV types in anal cancer cases in Asia and the World
Asia (a) World (b)
16 67.3 16 71.4
18 3.8 18 4.2
35 3.8 33 3.0
56 1.9 6 2.4
58 1.9 31 2.0
6th* 35 1.6
7th* 58 1.6
8th* 11 1.4
9th* 39 1.2
10th* 52 1.2
0 10 20 30 40 50 60 70 80 0 10 20 30 40 50 60 70 80
Type−specific HPV prevalence (%) of

anal cancer cases
Data updated on 09 Feb 2017 (data as of 30 Jun 2014).
a Includes cases from Bangladesh,India and South Korea
b Includes cases from Europe (Bosnia-Herzegovina, Czech Republic, France, Germany, Poland, Portugal, Slovenia, Spain and United Kingdom); America (Chile, Colombia, Ecuador,
Guatemala, Honduras, Mexico, Paraguay and United States); Africa (Mali, Nigeria and Senegal); Asia (Bangladesh,India and South Korea)
Data sources:
Data from Alemany L, Int J Cancer 2015; 136: 98. This study has gathered the largest international series of anal cancer cases and precancerous lesions worldwide using a standard protocol
with a highly sensitive HPV DNA detection assay.
Figure 32: Comparison of the ten most frequent HPV types in AIN 2/3 cases in Asia and the World
Asia World (a)
1st* 16 72.1
2nd* 6 9.3
3rd* 11 7.0
4th* 18 4.7
5th* 31 4.7
No data available
6th* 51 4.7
7th* 74 4.7
8th* 35 2.3
9th* 44 2.3
10th* 45 2.3
0 10 20 30 40 50 60 70 80

AIN 2/3 cases
AIN 2/3: Anal intraepithelial neoplasia of grade 2/3;
a Includes cases from Europe (Bosnia-Herzegovina, Czech Republic, France, Germany, Poland, Portugal, Slovenia, Spain and United Kingdom); America (Chile, Colombia, Ecuador,
Guatemala, Honduras, Mexico, Paraguay)
Data sources:
Data from Alemany L, Int J Cancer 2015; 136: 98. This study has gathered the largest international series of anal cancer cases and precancerous lesions worldwide using a standard protocol
with a highly sensitive HPV DNA detection assay.

4.2.2 Vulvar cancer and precancerous vulvar lesions
HPV attribution for vulvar cancer is 43% worldwide (de Martel C et al. Lancet Oncol 2012;13(6):607-
15). Vulvar cancer has two distinct histological patterns with two different risk factor profiles: (1) basa-
loid/warty types (2) keratinising types. Basaloid/warty lesions are more common in young women, are
frequently found adjacent to VIN, are very often associated with HPV DNA detection (86%), and have
a similar risk factor profile as cervical cancer. Keratinising vulvar carcinomas represent the majority
of the vulvar lesions (>60%). These lesions develop from non HPV-related chronic vulvar dermatoses,
especially lichen sclerosus and/or squamous hyperplasia, their immediate cancer precursor lesion is dif-
ferentiated VIN, they occur more often in older women, and are rarely associated with HPV (6%) or with
any of the other risk factors typical of cervical cancer. HPV prevalence is frequently detected among
cases of high-grade VIN (VIN2/3) (85.3%). HPV 16 is the most common type detected followed by HPV
33 (De Vuyst H et al. Int J Cancer 2009; 124: 1626-36).In this section, the HPV burden among cases of
vulvar cancer cases and precancerous vulvar lesions in Malaysia are presented.
Table 20: Studies on HPV prevalence among vulvar cancer cases in Malaysia
Data sources:
2009;124:1626
Table 21: Studies on HPV prevalence among VIN 2/3 cases in Malaysia
95% CI: 95% Confidence Interval; VIN 2/3: Vulvar intraepithelial neoplasia of grade 2/3;
Data sources:
2009;124:1626

Figure 33: Comparison of the ten most frequent HPV types in cases of vulvar cancer in Asia and the
World
Asia (a) World (b)
16 18.1 16 19.4
18 1.6 33 1.8
44 1.6 18 1.5
45 1.1 45 0.9
52 1.1 6 0.6
58 1.1 31 0.6
11 0.5 44 0.6
26 0.5 52 0.5
30 0.5 51 0.4
31 0.5 56 0.4
0 10 20 0 10 20

vulvar cancer cases

a Includes cases from Bangladesh, India, Israel, South Korea, Kuwait, Lebanon, Philippines, Taiwan and Turkey.
b Includes cases from America (Argentina, Brazil, Chile, Colombia, Ecuador, Guatemala, Honduras, Mexico, Paraguay, Uruguay, United States of America and Venezuela); Africa (Mali,
Mozambique, Nigeria, and Senegal); Oceania (Australia and New Zealand); Europe (Austria, Belarus, Bosnia-Herzegovina, Czech Republic, France, Germany, Greece, Italy, Poland, Portugal,
Spain and United Kingdom); and in Asia (Bangladesh, India, Israel, South Korea, Kuwait, Lebanon, Philippines, Taiwan and Turkey)
Data sources:
Data from de Sanjosé S, Eur J Cancer 2013; 49: 3450. This study has gathered the largest international series of vulva cancer cases and precancerous lesions worldwide using a standard
protocol with a highly sensitive HPV DNA detection assay.
Figure 34: Comparison of the ten most frequent HPV types in VIN 2/3 cases in Asia and the World
Asia (a) World (b)
16 80.0 16 67.1
6 5.0 33 10.2
18 5.0 6 2.4
33 5.0 18 2.4
35 5.0 31 1.9
54 5.0 52 1.4
7th* 51 1.2
8th* 56 0.9
9th* 74 0.9
10th* 66 0.7
0 10 20 30 40 50 60 70 80 90 0 10 20 30 40 50 60 70 80 90

VIN 2/3 cases
a Includes cases from Bangladesh, India, Israel, South Korea, Kuwait, Lebanon, Philippines, Taiwan and Turkey.
b Includes cases from America (Argentina, Brazil, Chile, Colombia, Ecuador, Guatemala, Honduras, Mexico, Paraguay, Uruguay and Venezuela); Oceania (Australia and New Zealand);
Europe (Austria, Belarus, Bosnia-Herzegovina, Czech Republic, France, Germany, Greece, Italy, Poland, Portugal, Spain and United Kingdom); and in Asia (Bangladesh, India, Israel, South
Korea, Kuwait, Lebanon, Philippines, Taiwan and Turkey)
Data sources:
Data from de Sanjosé S, Eur J Cancer 2013; 49: 3450. This study has gathered the largest international series of vulva cancer cases and precancerous lesions worldwide using a standard

4.2.3 Vaginal cancer and precancerous vaginal lesions
Vaginal and cervical cancers share similar risk factors and it is generally accepted that both carcinomas
share the same aetiology of HPV infection although there is limited evidence available. Women with
vaginal cancer are more likely to have a history of other ano-genital cancers, particularly of the cervix,
and these two carcinomas are frequently diagnosed simultaneously. HPV DNA is detected among 70%
of invasive vaginal carcinomas and 91% of high-grade vaginal neoplasias (VaIN2/3). HPV16 is the
most common type in high-grade vaginal neoplasias and it is detected in at least 70% of HPV-positive
carcinomas (de Martel C et al. Lancet Oncol 2012;13(6):607-15; De Vuyst H et al. Int J Cancer 2009;
124:1626-36). In this section, the HPV burden among cases of vaginal cancer cases and precancerous
vaginal lesions in Malaysia are presented.
Table 22: Studies on HPV prevalence among vaginal cancer cases in Malaysia
Data sources:
2009;124:1626
Table 23: Studies on HPV prevalence among VaIN 2/3 cases in Malaysia
95% CI: 95% Confidence Interval; VAIN 2/3: Vaginal intraepithelial neoplasia of grade 2/3;
2009;124:1626
Data sources:
2009;124:1626

Figure 35: Comparison of the ten most frequent HPV types in cases of vaginal cancer in Asia and the
World
Asia (a) World (b)
16 39.4 16 43.6
33 3.0 31 3.9
68 3.0 18 3.7
18 3.0 33 3.7
26 3.0 45 2.7
45 3.0 58 2.7
51 3.0 52 2.2
52 3.0 51 1.7
56 3.0 73 1.7
59 3.0 39 1.5
0 10 20 30 40 50 0 10 20 30 40 50

vaginal cancer cases

a Includes cases from Bangladesh, India, Israel, South Korea, Kuwait, Philippines, Taiwan and Turkey
b Includes cases from Europe (Austria, Belarus, Czech Republic, France, Germany, Greece, Poland, Spain and United Kingdom); America (Argentina, Brazil, Chile, Colombia, Ecuador,
Guatemala, Mexico, Paraguay, Uruguay, United states of America and Venezuela); Africa (Mozambique, Nigeria); Asia (Bangladesh, India, Israel, South Korea, Kuwait, Philippines, Taiwan
and Turkey); and Oceania (Australia)
Data sources:
Data from Alemany L, Eur J Cancer 2014; 50: 2846. This study has gathered the largest international series of vaginal cancer cases and precancerous lesions worldwide using a standard
Figure 36: Comparison of the ten most frequent HPV types in VaIN 2/3 cases in Asia and the World
Asia (a) World (b)
16 53.8 16 56.1
52 15.4 18 5.3
59 15.4 52 5.3
45 7.7 73 4.8
73 7.7 33 4.2
6th* 59 3.7
7th* 56 2.6
8th* 51 2.1
9th* 6 1.6
10th* 35 1.6
0 10 20 30 40 50 60 0 10 20 30 40 50 60

VaIN 2/3 cases
VAIN 2/3: Vaginal intraepithelial neoplasia of grade 2/3;
a Includes cases from Australia, Bangladesh, India, Israel, South Korea, Kuwait, Philippines, Taiwan and Turkey.
b Includes cases from Europe (Austria, Belarus, Czech Republic, France, Germany, Greece, Poland, Spain and United Kingdom); America (Argentina, Brazil, Chile, Colombia, Ecuador,
Guatemala, Mexico, Paraguay, Uruguay, United states of America and Venezuela); Asia (Bangladesh, India, Israel, South Korea, Kuwait, Philippines, Taiwan and Turkey); and Oceania
(Australia)
Data sources:
Data from Alemany L, Eur J Cancer 2014; 50: 2846. This study has gathered the largest international series of vaginal cancer cases and precancerous lesions worldwide using a standard

4.2.4 Penile cancer and precancerous penile lesions
HPV DNA is detectable in approximately 50% of all penile cancers (de Martel C et al. Lancet Oncol
2012;13(6):607-15). Among HPV-related penile tumours, HPV16 is the most common type detected,
followed by HPV18 and HPV types 6/11 (Miralles C et al. J Clin Pathol 2009;62:870-8). Over 95% of
invasive penile cancers are SCC and the most common penile SCC histologic sub-types are keratinising
(49%), mixed warty-basaloid (17%), verrucous (8%), warty (6%), and basaloid (4%). HPV is commonly
detected in basaloid and warty tumours but is less common in keratinising and verrucous tumours. In
this section, the HPV burden among cases of penile cancer cases and precancerous penile lesions in
Malaysia are presented.
Table 24: Studies on HPV prevalence among penile cancer cases in Malaysia
Data sources:
The ICO HPV Information Centre has updated data until June 2015. Reference publications (up to 2008): 1) Bouvard V, Lancet Oncol 2009;10:321 2) Miralles-Guri C,J Clin Pathol
2009;62:870
Table 25: Studies on HPV prevalence among PeIN 2/3 cases in Malaysia
Study Method No. Tested % (95% CI) HPV type (%)
95% CI: 95% Confidence Interval; PeIN 2/3: Penile intraepithelial neoplasia of grade 2/3;
Data sources:
The ICO HPV Information Centre has updated data until June 2014. Reference publication (up to 2008): Bouvard V, Lancet Oncol 2009;10:321

Figure 37: Comparison of the ten most frequent HPV types in cases of penile cancer in Asia and the
World
Asia (a) World (b)
16 9.0 16 22.8
33 1.5 6 1.6
35 1.5 33 1.2
45 1.5 35 1.0
5th* 45 1.0
6th* 52 0.9
7th* 11 0.7
8th* 18 0.7
9th* 59 0.7
10th* 74 0.6
0 10 20 30 0 10 20 30

penile cancer cases
a Includes cases from Bangladesh, India, South Korea, Lebanon, Philippinesy
b Includes cases from Australia, Bangladesh, India, South Korea, Lebanon, Philippines, Chile, Colombia, Ecuador, Guatemala, Honduras, Mexico, Paraguay, Venezuela and United States,
Mozambique, Nigeria, Senegal, Czech Republic, France, Greece, Poland, Portugal, Spain and United Kingdom.
Data sources:
Alemany L, Eur Urol 2016; 69: 953
Figure 38: Comparison of the ten most frequent HPV types in PeIN 2/3 cases in Asia and the World
Asia World (a)
1st* 16 69.4
2nd* 33 5.9
3rd* 58 4.7
4th* 31 3.5
5th* 51 3.5
No data available
6th* 52 3.5
7th* 6 2.4
8th* 18 2.4
9th* 45 2.4
10th* 53 2.4
0 10 20 30 40 50 60 70

PeIN 2/3 cases
a Includes cases from Australia, Bangladesh, India, South Korea, Lebanon, Philippines, Chile, Colombia, Ecuador, Guatemala, Honduras, Mexico, Paraguay, Venezuela, Mozambique,
Nigeria, Senegal, Czech Republic, France, Greece, Poland, Portugal, Spain and United Kingdom.
Data sources:
Alemany L, Eur Urol 2016; 69: 953

4.3 HPV burden in men

The information to date regarding anogenital HPV infection is primarily derived from cross-sectional
studies of selected populations such as general population, university students, military recruits, and
studies that examined husbands of control women, as well as from prospective studies. Special sub-
groups include mainly studies that examined STD (sexually transmitted diseases) clinic attendees,
MSM (men who have sex with men), HIV positive men, and partners of women with HPV lesions, CIN
(cervical intraepithelial neoplasia), cervical cancer or cervical carcinoma in situ. Globally, prevalence of
external genital HPV infection in men is higher than cervical HPV infection in women, but persistence
is less likely. As with genital HPV prevalence, high numbers of sexual partners increase the acquisition
of oncogenic HPV infections (Vaccine 2012, Vol. 30, Suppl 5). In this section, the HPV burden among
men in Malaysia is presented.
Methods
HPV burden in men was based on published systematic reviews and meta-analyses (Dunne EF, J Infect
Dis 2006; 194: 1044, Smith JS, J Adolesc Health 2011; 48: 540, Olesen TB, Sex Transm Infect 2014;
90: 455, and Hebnes JB, J Sex Med 2014; 11: 2630) up to October 31, 2015. The search terms for the
review were human papillomavirus, men, polymerase chain reaction (PCR), hybrid capture (HC), and
viral DNA. References cited in selected articles were also investigated. Inclusion criteria were: HPV
DNA detection by means of PCR or HC (ISH if data are not available for the country), and a detailed
description of HPV DNA detection and genotyping techniques used. The number of cases tested and
HPV positive cases were extracted for each study to estimate the anogenital prevalence of HPV DNA.
Binomial 95% confidence intervals were calculated for each anogenital HPV prevalence.
Table 26: Studies on HPV prevalence among men in Malaysia

Anatomic sites HPV detection Age HPV prevalence
Study samples method Population (years) No % (95% CI)
No Data Avail- - - - - - --
able
Data updated on 11 Jun 2019 (data as of 31 Oct 2015).
Data sources:
Based on published systematic reviews, the ICO HPV Information Centre has updated data until October 2015. Reference publications: 1) Dunne EF, J Infect Dis 2006; 194: 1044 2) Smith
JS, J Adolesc Health 2011; 48: 540 3) Olesen TB, Sex Transm Infect 2014; 90: 455 4) Hebnes JB, J Sex Med 2014; 11: 2630.
Table 27: Studies on HPV prevalence among men from special subgroups in Malaysia
Anatomic sites HPV detection Age HPV prevalence
Study samples method Population (years) No % (95% CI)
No Data Avail- - - - - - --
able
Data updated on 11 Jun 2019 (data as of 31 Oct 2015).
Data sources:
Based on published systematic reviews, the ICO HPV Information Centre has updated data until October 2015. Reference publications: 1) Dunne EF, J Infect Dis 2006; 194: 1044 2) Smith
JS, J Adolesc Health 2011; 48: 540 3) Olesen TB, Sex Transm Infect 2014; 90: 455 4) Hebnes JB, J Sex Med 2014; 11: 2630.

4.4 HPV burden in the head and neck

The last evaluation of the International Agency for Research in Cancer (IARC) on the carcinogenicity of
HPV in humans concluded that (a) there is enough evidence for the carcinogenicity of HPV type 16 in
the oral cavity, oropharynx (including tonsil cancer, base of tongue cancer and other oropharyngeal can-
cer sites), and (b) limited evidence for laryngeal cancer (IARC Monograph Vol 100B). There is increasing
evidence that HPV-related oropharyngeal cancers constitute an epidemiological, molecular and clinical
distinct form as compared to non HPV-related ones. Some studies indicate that the most likely expla-
nation for the origin of this distinct form of head and neck cancers associated with HPV is a sexually
acquired oral HPV infection that is not cleared, persists and evolves into a neoplastic lesion. The most
recent figures estimate that 25.6% of all oropharyngeal cancers are attributable to HPV infection with
HPV16 being the most frequent type (de Martel C. Lancet Oncol. 2012;13(6):607). In this section, the
HPV burden in the head and neck in Malaysia is presented..
4.4.1 Burden of oral HPV infection in healthy population
Table 28: Studies on oral HPV prevalence among healthy in Malaysia

Method HPV detection Prev. of 5 most
specimen method frequent
collection and and targeted Age No. HPV prevalence HPVs
Study anatomic site HPV types Population (years) Tested % (95% CI) HPV type (%)
MEN
No Data - - - - - -- -
Available
WOMEN
No Data - - - - - -- -
Available
BOTH OR UNSPECIFIED
No Data - - - - - -- -
Available
Data as of 29 Feb 2012. Only for European countries.
Data sources:
Systematic review and meta-analysis was performed by ICO HPV Information Centre until July 2012. Pubmed was searched using the keywords oral and papillomavirus. Inclusion criteria:
studies reporting oral HPV prevalence in healthy population in Europe; n > 50. Exclusion criteria: focused only in children or immunosuppressed population; not written in English;
case-control studies; commentaries and systematic reviews and studies that did not use HPV DNA detection methods.
4.4.2 HPV burden in head and neck cancers
Table 29: Studies on HPV prevalence among cases of oral cavity cancer in Malaysia
MEN
WOMEN
BOTH OR UNSPECIFIED
Lim 2007 GP5+/GP6+ (L1) Amplification 20 85.0 (64.0-94.8) HPV 18 (75.0%)
with TS primers (16. 18) HPV 16 (30.0%)
Data as of 31 Dec 2015. Only for European countries.
TS: Type Specific;
Data sources:
Based on systematic reviews and meta-analysis performed by ICO. Reference publications: 1) Ndiaye C, Lancet Oncol 2014; 15: 1319 2) Kreimer AR, Cancer Epidemiol Biomarkers Prev
2005; 14: 467
Lim KP, Oncol Rep 2007; 17: 1321

Table 30: Studies on HPV prevalence among cases of oropharyngeal cancer in Malaysia
MEN
WOMEN
BOTH OR UNSPECIFIED
Data sources:
2005; 14: 467
Table 31: Studies on HPV prevalence among cases of hypopharyngeal or laryngeal cancer in Malaysia
MEN
WOMEN
BOTH OR UNSPECIFIED
Data sources:
2005; 14: 467

5 FACTORS CONTRIBUTING TO CERVICAL CANCER - 55 -
5 Factors contributing to cervical cancer

HPV is a necessary cause of cervical cancer, but it is not a sufficient cause. Other cofactors are necessary
for progression from cervical HPV infection to cancer. Tobacco smoking, high parity, long-term hormonal
contraceptive use, and co-infection with HIV have been identified as established cofactors. Co-infection
with Chlamydia trachomatis and herpes simplex virus type-2, immunosuppression, and certain dietary
deficiencies are other probable cofactors. Genetic and immunological host factors and viral factors other
than type, such as variants of type, viral load and viral integration, are likely to be important but have
not been clearly identified. (Muñoz N, Vaccine 2006; 24(S3): 1-10). In this section, the prevalence of
smoking, parity (fertility), oral contraceptive use, and HIV in Malaysia are presented.
Table 32: Factors contributing to cervical carcinogenesis (cofactors) in Malaysia

INDICATORa MALE FEMALE TOTAL
Smoking
Smoking of any tobacco adjusted Current1,b,c,± 44.4 [31.1-61.2] 1.5 [1.0-2.2] 22.3 [15.5-30.7]
prevalence (%) [95% CI] Daily1,b,d,± 36.5 [25.1-49.9] 1.1 [0.6-1.6] 18.2 [12.5-24.9]
Cigarette smoking adjusted Current1,b,c,± 36.0 [20.6-51.9] 1.2 [0.6-1.9] 18.0 [10.3-26.1]
prevalence (%) [95% CI] Daily1,b,d,± 32.4 [21.5-44.4] 0.9 [0.5-1.3] 16.1 [10.7-22.1]
Parity
Total fertility rate per woman2,e,∓ - 2.1 -
15-19 years2,e,∓ - 12.7 -
20-24 years2,e,∓ - 54.0 -
25-29 years2,e,∓ - 122.8 -
Age-specific fertility rate
30-34 years2,e,∓ - 124.3 -
(per 1000 women)
35-39 years2,e,∓ - 74.1 -
40-44 years2,e,∓ - 21.1 -
45-49 years2,e,∓ - 1.8 -
Hormonal contraception
Oral contraceptive use (%) among women15-49yrs - 13.2 -
who are married or in union3,∗
Hormonal contraception use (%) (pill, injectable or - 18.8 -
implant), among women15-49yrs who are married
or in union3, f ,∗
HIV
Estimated percent of adults aged 15-49 who - - 0.4 [0.3 - 0.5]
are living with HIV [low estimate - high
estimate]4,g,?
Estimated percent of young adults aged 15-24 0.2 [0.1 - 0.2] <0.1 [<0.1 - <0.1] -
who are living with HIV [low estimate - high
estimate]4,g,?
HIV prevalence (%) among female sex workers in - 7.3 -
the capital city4,h,?
HIV prevalence (%) among men who have sex with 8.9 - -
men in the capital city4,?
Estimated number of adults (15+ years) living - 13 000 [12 000 - 14 000] 91 000 [80 000 - 110 000]
with HIV [low estimate - high estimate]4,i,?
Estimated number of adults and children living - - 91 000 [80 000 - 110 000]
with HIV [low estimate - high estimate]4,i,?
Estimated number of AIDS deaths in adults and - - 7200 [6400 - 8100]
children [low estimate - high estimate]4, j,?
a Please refer to original source for methods of estimation of the following indicators.
b Adjusted and age-standardized prevalence estimates of tobacco use by country, for the year 2013. These rates are constructed solely for the purpose of comparing tobacco use prevalence
estimates across countries, and should not be used to estimate the number of smokers in the population.
c "Current" means smoking at the time of the survey, including daily and non-daily smoking. "Tobacco smoking" means smoking any form of tobacco, including cigarettes, cigars, pipes,
hookah, shisha, water-pipe, etc. and excluding smokeless tobacco.
d "Daily" means smoking every day at the time of the survey. "Tobacco smoking" means smoking any form of tobacco, including cigarettes, cigars, pipes, hookah, shisha, water-pipe, etc. and
excluding smokeless tobacco.
e The number of women by age is estimated by the United Nations Population Division and published in World Population Prospects: the 2015 Revision.
f Proportion (%) of women using hormonal contraception (pill, injectable or implant), among those of reproductive age who are married or in union.
g Estimates include all people with HIV infection, regardless of whether they have developed symptoms of AIDS.
h Data on key populations at higher risk from country progress reports typically derive from surveys in capital cities and are not representative of the entire country. In particular, surveys
in capital cities are likely to overestimate national HIV prevalence and service coverage.
i The number of people with HIV infection, whether or not they have developed symptoms of AIDS, estimated to be alive at the end of a specific year.
j The estimated number of adults and children that have died due to HIV/AIDS in a specific year.
Year of estimate: ± 2013; ∓ 2012; ∗ 2014; ? 2015;
Data sources:
1 WHO report on the global tobacco epidemic, 2015: The MPOWER package. Geneva, World Health Organization, 2015. Available at http://www.who.int/tobacco/global_report/
2015/en/index.html

5 FACTORS CONTRIBUTING TO CERVICAL CANCER - 56 -

2 United Nations, Department of Economic and Social Affairs, Population Division (2015). World Fertility Data 2015 (POP/DB/Fert/Rev2015). Available at: http://www.un.org/en/
development/desa/population/publications/dataset/fertility/wfd2015.shtml. [Accessed on March 22, 2017].
3 United Nations, Department of Economic and Social Affairs, Population Division (2016). World Contraceptive Use 2016 (POP/DB/CP/Rev2016). http://www.un.org/en/development/
desa/population/publications/dataset/contraception/wcu2016.shtml. Available at: [Accessed on March 22, 2017].
4 UNAIDS database [internet]. Available at: http://aidsinfo.unaids.org/ [Accessed on March 22, 2017]

6 SEXUAL AND REPRODUCTIVE HEALTH BEHAVIOUR INDICATORS - 57 -
6 Sexual and reproductive health behaviour indicators

Sexual intercourse is the primary route of transmission of genital HPV infection. Information about
sexual and reproductive health behaviours is essential to the design of effective preventive strategies
against anogenital cancers. In this section, we describe sexual and reproductive health indicators that
may be used as proxy measures of risk for HPV infection and anogenital cancers. Several studies
have reported that earlier sexual debut is a risk factor for HPV infection, although the reason for this
relationship is still unclear. In this section, information on sexual and reproductive health behaviour in
Malaysia are presented.
Table 33: Percentage of 15-year-olds who have had sexual intercourse in Malaysia
Indicator Male Female
Percentage of 15-year-old subjects who report sexual intercourse - -
Please refer to original source for methods of estimation
Table 34: Marriage patterns in Malaysia

Indicator Male Female
Average age at first marriage1 28 25.7
Age-specific % of ever married2 15-19 years 5.1 6.09
20-24 years 24.2 32.9
25-29 years 47.0 62.2
30-34 years 71.6 82.1
35-39 years 83.3 89.2
40-44 years 90.1 93.3
45-49 years 93.5 94.6
Data sources:
1 The world bank: health nutrition and population statistics. Updated 16-Dec-2016. Accessed on March 16 2017. Available at http://data.worldbank.org/data-catalog/
health-nutrition-and-population-statistics
2 United Nations, Department of Economic and Social Affairs, Population Division (2015). World Marriage Data 2015 (POP/DB/Marr/Rev2015). Available at: http://www.un.org/en/
development/desa/population/theme/marriage-unions/WMD2015.shtml Accessed on April 3, 2017.

7 HPV PREVENTIVE STRATEGIES - 58 -
7 HPV preventive strategies

It is established that well-organised cervical screening programmes or widespread good quality cytology
can reduce cervical cancer incidence and mortality. The introduction of HPV vaccination could also
effectively reduce the burden of cervical cancer in the coming decades. This section presents indicators
on basic characteristics and performance of cervical cancer screening, status of HPV vaccine licensure
and introduction in Malaysia.
7.1 Cervical cancer screening practices

Screening strategies differ between countries. Some countries have population-based programmes,
where in each round of screening women in the target population are individually identified and in-
vited to attend screening. This type of programme can be implemented nationwide or only in specific
regions of the country. In opportunistic screening, invitations depend on the individual’s decision or
on encounters with health-care providers. The most frequent method for cervical cancer screening is
cytology, and there are alternative methods such as HPV DNA tests and visual inspection with acetic
acid (VIA). VIA is an alternative to cytology-based screening in low-resource settings (the ’see and treat’
approach). HPV DNA testing is being introduced into some countries as an adjunct to cytology screen-
ing (’co-testing’) or as the primary screening test to be followed by a secondary, more specific test, such
as cytology.
Table 35: Main characteristics of cervical cancer screening in Malaysia
Availability of a cervical cancer screening programmeα Yes

Quality assurance structure and mandate to supervise and to monitor the screening No
processβ
Active invitation to screeningγ No
Main screening test used for primary screening Cytology
Undergoing demonstration projects
Screening ages (years) 20-65
Screening interval or frequency of screenings 3 years
Data accessed on 31 Dec 2016.
α Public national cervical cancer screening program in place (Cytology/VIA/HPV testing). Countries may have clinical guidelines or protocols, and cervical cancer screening services in a
private sector but without a public national program. Publicly mandat
β Self-reported quality assurance: Organised programmes provide for a national or regional team responsible for implementation and require providers to follow guidelines, rules, or standard
operating procedures. They also define a quality assurance structur
γ Self-reported active invitation or recruitment, as organised population-based programmes, identify and personally invite each eligible person in the target population to attend a given
round of screening.
Data sources:
Adapting the Australian system: is an organized screening program feasible in Malaysia?–an overview of cervical cancer screening in both countries. Rashid RM, Dahlui M, Mohamed M,
Gertig D. Asian Pac J Cancer Prev. 2013;14(3):2141-6. PMID: 23679334

Table 36: Estimated coverage of cervical cancer screening in Malaysia

Reference Year Population Urban vs N Women Age range Within the Coverage
rural or last (%)b
both (all) year(s)
Annual Report 2012 2012 General female All - 20-65 1y 22 .2
Malaysia1,a population
Gan 20132,c 2006 General female All - - Ever 47 .3
population
Othman 20023,α,d 1992 - - - - 1y <2.0
1995 - - - - 1y 3 .5
1996 - - - - 1y 6 .2
WHS 2003 2002-2003 General female All 2,995 18-69 3y 23
Malaysia4,e population
2,566 25-64 3y 29 .8
Rural 1,072 18-69 3y 21 .9
Urban 1,923 18-69 3y 23 .6

a Ministry of Health. Annual Report 2012.
b Proportion of women in the total sample of the mentioned age range in the country or region that reported having a Pap smear during a given time period (e.g., last year, last 2, 3, 5 years
or ever).
c Cross-sectional survey was conducted in five rural districts in Perak, Malaysia. Data from the 2006 National Health and Morbidity Survey (NHMS III).
d Data from the Annual reports of the Ministry of Health (1980-1998). Government figures.
e WHO Household Surveys with multistage cluster sampling. Screening coverage among women aged 18-69. World Health Surveys. Geneva: World Health Organization (WHO); 2003.
α Data from the Annual reports of the Ministry of Health (1980-1998). Government figures. Othman NH. Cancer of the cervix - From bleak past to bright future; a review, with an emphasis
on cancer of the cervix in Malaysia. Malay J Med Sci 2003 Jan;10(1):13
Data sources:
1 Ministry of Health. Annual Report 2012. Malaysia. ISSN 1511 - 1512 MOH/S/RAN/55.13(AR)
2 Gan DEH, Dahlui M. Cervical screening uptake and its predictors among rural women in Malaysia. Singapore Med J 2013; 54(3): 163-168.
3 Othman NH. Cancer of the cervix - From bleak past to bright future; a review, with an emphasis on cancer of the cervix in Malaysia. Malay J Med Sci 2003 Jan;10(1):13-26.
4 World Health Organization (WHO). Malaysia-World Health Survey 2003 (MYS_2003_WHS_v01_M). Available at: http://apps.who.int/healthinfo/systems/surveydata/index.
php/catalog/95 [Accessed by October 2015]
Figure 39: Estimated coverage of cervical cancer screening in Malaysia, by age and study
− All women screened every 3y
in 2002−2003 − WHS 2003 Malaysia
Estimated cervical cancer screening coverage (%)(a)
100
80
60
40
36.6
28.8
20.9
20 14.6
5.5
0.0
0
18−29 30−39 40−49 50−59 60−69 >70
Age group (years)

WHO Household Surveys with geographical information system (GIS) multistage cluster sampling. Screening coverage among women aged 18-69.
a Proportion of women in the total sample of the mentioned age range in the country or region that reported having a Pap smear during a given time period (e.g., last year, last 2, 3, 5 years
or ever).
b WHO Household Surveys with multistage cluster sampling. Screening coverage among women aged 18-69. World Health Surveys. Geneva: World Health Organization (WHO); 2003.
Data sources:
ICO Information Centre on HPV and Cancer. Country-specific references identified in each country-specific report as general recommendation from relevant scientific organizations and/or
publications.
1 World Health Organization (WHO). Malaysia-World Health Survey 2003 (MYS_2003_WHS_v01_M). Available at: http://apps.who.int/healthinfo/systems/surveydata/index.
php/catalog/95 [Accessed by October 2015]

Table 37: Estimated coverage of cervical cancer screening in Malaysia , by region

Region N Women Age range LYa Population Coverage Year(s) Reference
(%)b studied
1,720 17-55 3y Selected sample 18.4 1999- Chee 20031
Kota Baru Penang, 2000
Bangi Hulu Kelang 1,720 17-55 Ever Selected sample 25.3 1999- Chee 20031
2000
Kuala Lumpur 403 - Ever Selected sample 38.0 2010 Abdullah 20112
Perak 959 20-64 3y General female 48.9 - Gan 20133

population
Cross-sectional survey of female workers in electronics assembly factories with at least 500 workers and in production for at least 2 years in 4 areas: Penang (northwestern state), Kota
Baru (capital of the north-eastern state of Kelantan), Hulu Kelang a
a LY: Within the last year(s).
b Proportion of women in the total sample of the mentioned age range in the country or region that reported having a Pap smear during a given time period (e.g., last year, last 2, 3, 5 years
or ever).
Data sources:
1 Chee H, Rashidah S, Shamsuddin K, Intan O. Factors related to the practice of breast self examination (BSE) and Pap smear screening among Malaysian women workers in selected
electronics factories. BMC Womens Health 2003 May 28;3(1):3.
2 Abdullah F, Aziz NA, Su TT. Factors related to poor practice of Pap smear screening among secondary school teachers in Malaysia. Asian Pac J Cancer Prev 2011; 12:1347-52.
3 Gan DEH, Dahlui M. Cervical screening uptake and its predictors among rural women in Malaysia. Singapore Med J 2013; 54(3): 163-168.

8 PROTECTIVE FACTORS FOR CERVICAL CANCER - 61 -
7.2 HPV vaccination
Table 38: National HPV Immunization programme in Malaysia

Female Male
Year of introduction 2010 -
Primary target age (years) 13 -
Organized catch-up age (years) - -
Opportunistic catch-up age (years) - -
Strategy Sch. and Health C. for unsch.ed girls -
Schedulea,b 3 doses standard -
Data updated on 11 Jul 2017 (data as of 31 Dec 2016)
a 2 doses: 0-6m if not otherwise stated. Since 2014, based on clinical trials results several agencies responsible for the scientific evaluation of medicines, like the European Medicines Agency,
aproved a two-dose schedule for girls aged less than 15 or 14 depending on the vaccine (Cervarix or Gardasil).
b 3-doses standard: administration of three doses following the standard vaccination schedule as 0-2-6 months for the quadrivalent vaccine or 0-1-6 months for the bivalent vaccine.
Data sources:
1 Adapted from Bruni et al 2016 Lancet Global Health (data up to October 2014).
Specifically, data from Malaysia was extracted from:
2 Garland SM, Bhatla N, Ngan HYS. Cervical cancer burden and prevention strategies: Asia Oceania perspective. Cancer Epidemiol Biomarkers Prev. 2012 Sep;21(9):1414-22.
Figure 40: Reported HPV vaccination coverage in females by birth cohort in National HPV
Immunization programme in Malaysia
100
90
HPV vaccination coverage (%)
80
70
60
No data available
50
40
30
20
10
Data updated on 11 Jul 2017 (data as of 31 Oct 2014)

Data sources:
1 Adapted from Bruni et al 2016 Lancet Global Health (data up to October 2014).
2 Ezat SWP, Hod R, Mustafa J, Mohd Dali AZH, Sulaiman AS, Azman A. National HPV immunisation programme: knowledge and acceptance of mothers attending an obstetrics clinic at a
teaching hospital, Kuala Lumpur. Asian Pac J Cancer Prev. 2013;14(5):2991–9.
8 Protective factors for cervical cancer

Male circumcision and the use of condoms have shown a significant protective effect against HPV trans-
mission.

8 PROTECTIVE FACTORS FOR CERVICAL CANCER - 62 -
Table 39: Prevalence of male circumcision in Malaysia

Reference Prevalence % (95% CI) Methods
Drain 2006 >80 Data from Demographic and Health
Surveys (DHS) and other publications
to categorize the country-wide preva-
lence of male circumcision as <20%, 20-
80%, or >80%.
Tang 2011 53.1 (46.1-60.1) N=207: Men aged 18-70 years who at-
tended the primary care clinic between
June and August 2008
WHO 2007 >80 Data from Demographic and Health
Surveys (DHS) and other publications
to categorize the country-wide preva-
lence of male circumcision as <20%, 20-
80%, or >80%.
Data accessed on 31 Aug 2015.
Please refer to country-specific reference(s) for full methodologies.
Data sources:
Based on systematic reviews and meta-analysis performed by ICO. The ICO HPV Information Centre has updated data until August 2015. Reference publication: Albero G, Sex Transm
Dis. 2012 Feb;39(2):104-13.
Drain PK, BMC Infect Dis 2006; 6: 172 | Tang WS, J Sex Med 2011; 8: 2071 | WHO 2007: Male circumcision: Global trends and determinants of prevalence, safety and acceptability
Table 40: Prevalence of condom use in Malaysia

Indicator Year of estimate Prevalence %a
Condom use 2014 5.6
a Condom use: Proportion of male partners who are using condoms with their female partners of reproductive age (15-49 years) to whom they are married or in union by country.
Data sources:
United Nations, Department of Economic and Social Affairs, Population Division (2016). World Contraceptive Use 2016 (POP/DB/CP/Rev2016). http://www.un.org/en/development/
desa/population/publications/dataset/contraception/wcu2016.shtml. Available at: [Accessed on March 22, 2017].
Malaysia 2014 Population and Family Survey

9 INDICATORS RELATED TO IMMUNISATION PRACTICES OTHER THAN HPV VACCINES - 63 -
9 Indicators related to immunisation practices other than HPV vac-

cines
This section presents data on immunisation coverage and practices for selected vaccines. This infor-
mation will be relevant for assessing the country’s capacity to introduce and implement the new HPV
vaccines. The data are periodically updated and posted on the WHO Immunisation surveillance, assess-
ment and monitoring website at http://who.int/immunization_monitoring/en/.
9.1 Immunisation schedule
Table 41: General immunization schedule in Malaysia

Vaccine Schedule Coveragea Comment
Bacille Calmette-Guérin vaccine birth; entire -
Tetanus and diphtheria toxoid childrens’ 7 years; entire -
dose
Diphtheria and tetanus toxoid with acellu- 2, 3, 5, 18 months; entire -
lar pertussis, Hib and IPV vaccine
Hepatitis B adult dose vaccine 1st contact; +1, +6 entire HCWs
months
Hepatitis B pediatric dose vaccine birth; 1, 6 months; entire -
Human Papillomavirus vaccine 13 years; +6 entire -
months;
Influenza adult dose vaccine - entire adults with chronic ill-
ness, health care work-
ers, Haj and other trav-
ellers and any other risk
group
Influenza pediatric dose vaccine - entire children with chronic dis-
eases
Japanese encephalitis live vaccine 9, 12 months; part Sarawak
Measles vaccine 6 months; part Sabah and natives in
Perak & Kelantan
Meningococcal ACWY vaccine - entire Haj Pilgrims
Measles mumps and rubella vaccine 1 year; entire -
Measles and rubella vaccine 7 years; entire School based
Oral polio vaccine 7 years; entire -
Tetanus toxoid vaccine 15 years; entire school based and preg-
nant women
Typhoid fever vaccine - entire food handlers
Yellow fever vaccine - part travelers to endemic
countries
Data accessed on 27 Jan 2017.
The shedules are the country official reported figures
a Entire:introduced in the entire country. Part:partially introduced.
Data sources:
Annual WHO/UNICEF Joint Reporting Form (Update of 2015/July/15). Geneva, Immunization, Vaccines and Biologicals (IVB), World Health Organization. Available at: http://www.who.
int/immunization/monitoring_surveillance/en/
9.2 Immunisation coverage estimates
Table 42: Immunization coverage estimates in Malaysia

Indicator Year of estimation Coverage (%)
Third dose of diphtheria toxoid, tetanus toxoid and pertussis vaccine 2015 99

9 INDICATORS RELATED TO IMMUNISATION PRACTICES OTHER THAN HPV VACCINES - 64 -

Indicator Year of estimation Coverage (%)
Third dose of hepatitis B vaccine administered to infants 2015 99
Third dose of Haemophilus influenzae type B vaccine 2015 99
Measles-containing vaccine 2015 93
Third dose of polio vaccine 2015 99
Data accessed on 27 Jan 2017.
The coverage figures (%) are the country official reported figures. Immunization coverage levels are presented as a percentage of a target population that has been vaccinated.
Data sources:
Annual WHO/UNICEF Joint Reporting Form and WHO Regional offices reports (Update of 2015/July/16). Geneva, Immunization, Vaccines and Biologicals (IVB),World Health Organization.
Available at: http://www.who.int/immunization/monitoring_surveillance/en/

10 GLOSSARY - 65 -
10 Glossary
Table 43: Glossary

Term Definition
Incidence Incidence is the number of new cases arising in a given period in a specified
population. This information is collected routinely by cancer registries. It can be
expressed as an absolute number of cases per year or as a rate per 100,000
persons per year (see Crude rate and ASR below). The rate provides an
approximation of the average risk of developing a cancer.
Mortality Mortality is the number of deaths occurring in a given period in a specified
population. It can be expressed as an absolute number of deaths per year or as a
rate per 100,000 persons per year.
Prevalence The prevalence of a particular cancer can be defined as the number of persons in
a defined population who have been diagnosed with that type of cancer, and who
are still alive at the end of a given year, the survivors. Complete prevalence
represents the number of persons alive at certain point in time who previously
had a diagnosis of the disease, regardless of how long ago the diagnosis was, or if
the patient is still under treatment or is considered cured. Partial prevalence ,
which limits the number of patients to those diagnosed during a fixed time in the
past, is a particularly useful measure of cancer burden. Prevalence of cancers
based on cases diagnosed within one, three and five are presented as they are
likely to be of relevance to the different stages of cancer therapy, namely, initial
treatment (one year), clinical follow-up (three years) and cure (five years).
Patients who are still alive five years after diagnosis are usually considered
cured since the death rates of such patients are similar to those in the general
population. There are exceptions, particularly breast cancer. Prevalence is
presented for the adult population only (ages 15 and over), and is available both
as numbers and as proportions per 100,000 persons.
Crude rate Data on incidence or mortality are often presented as rates. For a specific
tumour and population, a crude rate is calculated simply by dividing the number
of new cancers or cancer deaths observed during a given time period by the
corresponding number of person years in the population at risk. For cancer, the
result is usually expressed as an annual rate per 100,000 persons at risk.
ASR (age-standardised An age-standardised rate (ASR) is a summary measure of the rate that a
rate) population would have if it had a standard age structure. Standardization is
necessary when comparing several populations that differ with respect to age
because age has a powerful influence on the risk of cancer. The ASR is a
weighted mean of the age-specific rates; the weights are taken from population
distribution of the standard population. The most frequently used standard
population is the World Standard Population. The calculated incidence or
mortality rate is then called age-standardised incidence or mortality rate
(world). It is also expressed per 100,000. The world standard population used in
GLOBOCAN is as proposed by Segi [1] and modified by Doll and al. [2]. The
age-standardised rate is calculated using 10 age-groups. The result may be
slightly different from that computed using the same data categorised using the
traditional 5 year age bands.
Cumulative risk Cumulative incidence/mortality is the probability or risk of individuals
getting/dying from the disease during a specified period. For cancer, it is
expressed as the number of new born children (out of 100, or 1000) who would be
expected to develop/die from a particular cancer before the age of 75 if they had
the rates of cancer observed in the period in the absence of competing causes.
Cytologically normal No abnormal cells are observed on the surface of their cervix upon cytology.
women
(Continued)

10 GLOSSARY - 66 -
Table 43 – Continued
Term Definition
Cervical Intraepithelial SIL and CIN are two commonly used terms to describe precancerous lesions or
Neoplasia (CIN) / the abnormal growth of squamous cells observed in the cervix. SIL is an
Squamous Intraepithelial abnormal result derived from cervical cytological screening or Pap smear testing.
Lesions (SIL) CIN is a histological diagnosis made upon analysis of cervical tissue obtained by
biopsy or surgical excision. The condition is graded as CIN 1, 2 or 3, according to
the thickness of the abnormal epithelium (1/3, 2/3 or the entire thickness).
Low-grade cervical lesions Low-grade cervical lesions are defined by early changes in size, shape, and
(LSIL/CIN-1) number of ab-normal cells formed on the surface of the cervix and may be
referred to as mild dysplasia, LSIL, or CIN-1.
High-grade cervical High-grade cervical lesions are defined by a large number of precancerous cells
lesions (HSIL / CIN-2 / on the sur-face of the cervix that are distinctly different from normal cells. They
CIN-3 / CIS) 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).
Carcinoma in situ (CIS) Preinvasive malignancy limited to the epithelium without invasion of the
basement membrane. CIN 3 encompasses the squamous carcinoma in situ.
Invasive cervical cancer If the high-grade precancerous cells invade the basement membrane is called
(ICC) / Cervical cancer ICC. ICC stages range from stage I (cancer is in the cervix or uterus only) to
stage IV (the cancer has spread to distant organs, such as the liver).
Invasive squamous cell Invasive carcinoma composed of cells resembling those of squamous epithelium
carcinoma
Adenocarcinoma Invasive tumour with glandular and squamous elements intermingled.
Eastern Europe References included in Belarus, Bulgaria, Czech Republic, Hungary, Poland,
Republic of Moldova, Romania, Russian Federation, Slovakia, and Ukraine.
Northern Europe References included in Denmark, Estonia, Finland, Iceland, Ireland, Latvia,
Lithuania, Norway, Sweden, and United Kingdom of Great Britain and Northern
Ireland.
Southern Europe References included in Albania, Bosnia and Herzegovina, Croatia, Greece, Italy,
Malta, Montenegro, Portugal, Serbia, Slovenia, Spain, The former Yugoslav
Republic of Macedonia.
Western Europe References included in Austria, Belgium, France, Germany, Liechtenstein,
Luxembourg, Netherlands, and Switzerland.
Europe PREHDICT References included in Albania, Austria, Belarus, Belgium, Bosnia and
Herzegovina, Bulgaria, Croatia, Cyprus, Czech Republic, Denmark, Estonia,
Finland, France, Germany, Greece, Hungary, Iceland, Ireland, Israel, Italy,
Latvia, Liechtenstein, Lithuania, Luxembourg, Malta, Montenegro,
Netherlands, Norway, Poland, Portugal, Republic of Moldova, Romania, Russian
Federation, Serbia, Slovakia, Slovenia, Spain, Sweden, Switzerland, The former
Yugoslav Republic of Macedonia, Turkey, Ukraine, and United Kingdom of Great
Britain and Northern Ireland.

10 GLOSSARY - 67 -
Acknowledgments
This report has been developed by the Unit of Infections and Cancer, Cancer Epidemiology Research
Program, at the Institut Català d’Oncologia (ICO, Catalan Institute of Oncology) within the PREHDICT
project (7th Framework Programme grant HEALTH-F3-2010-242061, PREHDICT). The HPV Informa-
tion Centre is being developed by the Institut Català d’Oncologia (ICO). The Centre was originally
launched by ICO with the collaboration of WHO’s Immunisation, Vaccines and Biologicals (IVB) depart-
ment and support from the Bill and Melinda Gates Foundation.
Institut Català d’Oncologia (ICO), in alphabetic order

Albero G, Barrionuevo-Rosas L, Bosch FX, Bruni L, de Sanjosé S, Gómez D, Mena M, Muñoz J, Serrano
B.
7th Framework Programme grant PREHDICT project: health-economic modelling of PREvention

strategies for Hpv-related Diseases in European CounTries. Coordinated by Drs. Johannes Berkhof
and Chris Meijer at VUMC, Vereniging Voor Christelijk Hoger Onderwijs Wetenschappelijk Onderzoek
En Patientenzorg, the Netherlands.
(http://cordis.europa.eu/projects/rcn/94423_en.html)
7th Framework Programme grant HPV AHEAD project: Role of human papillomavirus infec-
tion and other co-factors in the aetiology of head and neck cancer in India and Europe. Coordinated by
Dr. Massimo Tommasino at IARC, International Agency of Research on Cancer, Lyon, France.
(http://cordis.europa.eu/project/rcn/100268_en.html)
International Agency for Research on Cancer (IARC)

- 68 -
Note to the reader

Anyone who is aware of relevant published data that may not have been included in the present report
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.
Disclaimer
The information in this database is provided as a service to our users. Any digital or printed publica-
tion of the information provided in the web site should be accompanied by an acknowledgment of HPV
Information Centre as the source. Systematic retrieval of data to create, directly or indirectly, a scien-
tific publication, collection, database, directory or website requires a permission from HPV Information
Centre.
The responsibility for the interpretation and use of the material contained in the HPV Information
Centre lies on the user. In no event shall the HPV Information Centre be liable for any damages arising
from the use of the information.
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Use, reproduction, copying, or redistribution of PREHDICT or HPV Information Centre logos are strictly
prohibited without written explicit permission from the HPV Information Centre.
Contact information:

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08908 L’Hospitalet de Llobregat (Barcelona, Spain)
e-mail: info@hpvcentre.net
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Table 1: Key Statistics

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2 Demographic and socioeconomic factors 4

3 Burden of HPV related cancers 6

4 HPV related statistics 31

5 Factors contributing to cervical cancer 55

6 Sexual and reproductive health behaviour indicators 57

7 HPV preventive strategies 58

8 Protective factors for cervical cancer 61

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9 Indicators related to immunisation practices other than HPV vaccines 63

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ICO/IARC HPV Information Centre

Figure 1: Malaysia and South-Eastern Asia

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2 Demographic and socioeconomic factors

Figure 2: Population pyramid of Malaysia for 2017

80+ 150,252 127,177

Data accessed on 27 Mar 2017.

Figure 3: Population trends in four selected age groups in Malaysia

Number of women (in millions)

Women 15−24 yrs All Women

Female population trends in Malaysia

Data accessed on 27 Mar 2017.

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Table 2: Sociodemographic indicators in Malaysia

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3 Burden of HPV related cancers

Figure 4: HPV-related cancer incidence in Malaysia (estimates for 2012)

Cervix uteri 15.6

Other anogenital (a) 0.6

Head and neck (b) 0.2

Age−standardised incidence rate per 100,0000 women

Data accessed on 08 May 2017.

3.1 Cervical cancer

3.1.1 Cervical cancer incidence in Malaysia

About 1,682 new cervical cancer cases are diagnosed annually in

Cervical cancer ranks* as the 3rd leading cause of female cancer in

Cervical cancer is the 2 th most common female cancer in women aged

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Table 3: Cervical cancer incidence in Malaysia (estimates for 2018)

Age-standardized incidence ratea 10.5 17.2 13.1

Cumulative risk (%) at 75 years oldb 1 2 1

Table 4: Cervical cancer incidence in Malaysia by cancer registry

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ICO/IARC HPV Information Centre

ICO/IARC HPV Information Centre

253* 45−49 yrs:

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3.1.2 Cervical cancer incidence by histology in Malaysia

Penang 2008-2010 6.4 2.2 0.0 1.4

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All ages (2)

All ages (2)

Cervix uteri: Adenocarcinoma

All ages (2)

Data accessed on 27 Apr 2015.

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