Guide to Genital HPV Diseases and Prevention

As indicated in the title and further stated in the Preface, this book is not a description of the state-of-the-art research on genital human papillomavirus (HPV), but rather a ‘readable and accessible’ guide to genital HPV diseases. The book is written by seven authors, all world-class experts on HPV-induced genital disease, and particularly on epidemiology, diagnostics and vaccination. The editor, William Bonnez, was one of the most critical researchers in the discovery and development of the current HPV vaccines.

The readership is envisioned as being mostly composed of practicing clinicians and other healthcare providers who are interested in a deeper understanding of the virus and the diseases. However, researchers working on molecular and cellular aspects of HPV infection may also find this book to be a readable and accessible guide, in this case to the clinical implications of the agent of their research. The book may also be of interest to early virology and even medical virology students interested in deepening their understanding of HPV and their clinical effects. Even scientifically literate parents of adolescent girls can use this guide as an important help in deciding whether or not to have their daughters vaccinated against HPV. In this respect, it is of note that one of the coauthors, Cynthia Rand, is involved in educating the public about HPV vaccines. The book is concise and mostly sharply focused on the objective of being a general guide. The few oversimplifications, or even mistakes (e.g., cavitation is improperly defined), will hopefully be corrected in future editions.

The book is organized into seven chapters, an Introduction and a brief Preface. The seven authors wrote the chapters in different collaborations, from a single-author chapter (Chapter 2) to a four-author one (Chapter 5). As in most multi-author books, the organization of different chapters varies somewhat. Chapter 1 (Biology) is divided into two major topics (Virology and Pathogenesis), for example, whereas Chapter 2 (Epidemiology) is divided into eight topics. Likewise, whereas most chapters discuss the issues from a most current perspective, Chapter 7 (Prevention) is discussed largely from a historical perspective. Moreover, the logic of discussing treatments in Chapter 4, before discussing diagnosis in Chapter 5, is not obvious (many readers will probably read Chapter 5 before Chapter 4). A more consistent organization of the chapters would have facilitated more efficient finding of relevant information, a critical property for a brief guide. Hopefully, any future editions will improve in chapter consistency and organization.

Being a general guide aimed at the practitioner, it is perhaps surprising that the virological aspects are only so briefly discussed in Chapter 1. All the virology is described in only six pages. This section is likely to disappoint the target audience, although it is appropriate for other readers, such as molecular virologists interested in learning about the clinical effects and importance of the virus. The rest of the chapter introduces, also very succinctly, HPV pathogenesis, including a basic introduction to HPV immunology. This second part of Chapter 1 should certainly be expanded, as all other chapters (with the possible exception of Chapter 2) are written assuming a good understanding of HPV pathogenesis. Although this may or may not be a problem for any particular reader, one would expect a general guide to contain sufficient introduction for all readers.

The relevant aspects of HPV epidemiology are nicely summarized in Chapter 2. General rates are discussed, with their inherent uncertainties, and specific examples are provided to nicely illustrate the general discussions. There is perhaps a little too much emphasis on ‘defending’ HPV as the causal agent of cervical cancer, which is nowadays almost universally accepted.

The major strengths of the book start in Chapter 3, which describes and discusses the different diseases produced by HPV. The chapter is concise but the descriptions are clear, precise and comprehensive enough. The chapter is illustrated with clear and informative pictures, and has useful references. The only surprise is the inclusion in this chapter of a table dealing with differential diagnostics, which would fit much better in Chapter 5 (Diagnosis). Chapter 4 is an also concise but comprehensive discussion of potential treatments, including those that are probably not effective. Most readers will probably find this chapter to be extremely useful.

The following two chapters deal with diagnostic approaches and their use in preventive screening. Although both are also extremely useful, Chapter 5 could have been organized better. The discussion of HPV diagnostics is intrinsically complicated by the existence of several diagnostic criteria and guidelines in use, which are not necessarily fully consistent. Moreover, a proper understanding of the discussion of diagnostic approaches, such as cytology and histology, requires some previous knowledge of the diseases produced by HPV. As already discussed, the introduction to pathogenesis in Chapter 1 is just too brief to introduce all the nuisances of HPV disease required to fully understand all diagnostic implications of the techniques described in Chapter 5 and used in the screenings described in Chapter 6.

Chapter 7 (Prevention) is the core of the book. As expected from the authors, this chapter includes a comprehensive discussion of HPV vaccines. However, it also includes a brief but sufficient discussion of environmental prevention, condoms and microbicides as prophylactic tools. The chapter starts with a very nice introduction to the history of the scientific breakthroughs (and false leads) that eventually resulted in the development of the two existing HPV vaccines. It then continues with an excellent and concise review of the preclinical and clinical studies of Gardasil^® and Cervarix^®. This section is the highlight of the book. The review is critical and generally exhaustive (for the brief format), although the omission of a few important numbers is noted. For example, the description of the first Phase I clinical trial of Gardasil states that none of the vaccinees got infected, but fails to enunciate the number of vaccinees. Moreover, the number of vaccinees who reported at least one serious adverse effect is mentioned in page 109, but the actual number of serious adverse events is not, which precludes the reader from deducing the actual number of vaccine-related serious reactions from the statement “only 0.05% of the serious reactions were judged to be vaccine related”. Despite these and other similar omissions, the arguments for and against the use of HPV vaccines, and their use in certain target populations are balanced. Moreover, adverse effects and limitations are clearly presented. This chapter will probably be of interest to any scientifically informed parent trying to make a decision of whether or not to use the vaccines in his or her children.

The presentation and format of the book are generally good, and most appropriate for a field guide (with the limitations about chapter structure and organization already discussed). The small size makes the book a portable guide, the fonts are clear and easy to read, and the pagination is clear and accessible. The figures are also generally clear and informative. However, it is most disappointing that a figure is wrongly described and credited. Panel B in Figure 1.1 is described as an “electron micrograph of a BPV1 virion”, whereas it actually presents a 3D computer reconstruction of the structure of a BPV1 virion (based on 521 images). Furthermore, this figure is credited to Wikipedia, whereas the original figure was published in [1]. This oversight is most disappointed in an otherwise carefully edited book. As a minor issue, some information in Figures 1.3, 1.5 and 1.6 that is most relevant to the discussions in later chapters (diagnostic, screening and prevention) could be better highlighted and referred to.

The tables are the weakest point of the book, often being not sufficiently clear or informative. The inclusion criteria for Table 4.1 are obscure, for example, not including many treatments discussed in the text and missing one relapsing rate. As another example, the information in Table 5.3 would be better presented in multiple columns than in the two-column format chosen. The alignments of some tables (e.g., Tables 4.2 and 5.2) are difficult to follow. Tables 7.3A, B and C appear to repeat most of the information. Some abbreviations used in tables, such as N/A and N/D, are not defined. Although these are minor issues, they are disappointing in an otherwise so well-edited book.

In summary, the Guide to Genital HPV Disease and Prevention is a most useful introduction book for general health practitioners interested in acquiring a deeper understanding of the science behind HPV vaccines, for basic researchers interested in acquiring a deeper understanding of the clinical effects of the virus, and for scientifically literate parents interested in learning about HPV- induced disease and HPV vaccines.

Financial & competing interests disclosure

The author has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.