Date of Award

January 2012

Document Type

Open Access Thesis

Degree Name

Master of Public Health (MPH)


School of Public Health

First Advisor

Linda Niccolai



The human papillomavirus is a necessary cause of cervical cancer leading to >12,000 cervical cancer diagnoses and >4,000 deaths in the United States in 2007. In 2006, the first HPV vaccine was approved by the US FDA, which prevents the acquisition of high-risk types of HPV (16/18) that cause 70% cervical cancer cases in the US and 50% of precancerous lesions. Our objectives were to examine HPV type distribution among women with cervical intraepithelial neoplasia 2/3 (CIN2+) by area-based measures of race, ethnicity, and poverty and individual level characteristics.


In 2008, the Connecticut Department of Public Health (DPH) mandated reporting of CIN2+. Diagnostic specimens from women aged 18-39 years residing in New Haven County and reported during 2008-2010 were sent to the CDC to ascertain HPV type(s) which were subsequently coded as vaccine type (16/18 with or without other HPV types) or non-vaccine type (all others). Cases were also geocoded to census tracts (neighborhood level) and linked to measures of percent of the population living below the federal poverty level, proportion of population Hispanic, and proportion of population black. Statistical analyses included chi-square tests, logistic regression, and generalized estimating equations.


Our sample consisted of 917 women who had HPV typing data available. Among these women, 41.9% had an HPV type (16 or 18) that is covered by the vaccine. In areas where 20% or greater of the population is living below poverty level, a significantly higher proportion of women had non-vaccine type HPV (60%) compared to women living in areas where less than 5% of women lived below poverty (50.5%%, p=0.05). Individual race/ethnicity analysis shows that black and Hispanic women were more likely to have non-vaccine type HPV (63.8% and 61.2% respectively). Analysis by area-based race and ethnicity showed that women who live in areas with higher proportions of black or Hispanic populations had higher proportions of non-vaccine type HPV. Specific non-vaccine HPV types were more prevalent in non-Hispanic blacks and Hispanics compared to non-Hispanic whites. Some main types included 35, 52, and 58 that together accounted for 35.8% of the HPV found among black women, 23.3% of HPV among Hispanic women and only 14.8% of HPV among white women.


Area-based results showed that women who live in areas with higher proportions of the population black, Hispanic or living below poverty have higher percentages of non-vaccine type HPV than vaccine type HPV (16/18). Similarly for individual level characteristics, non-Hispanic black and Hispanic women were also more likely to have non-vaccine type HPV compared to white women. HPV types not included in the current vaccines are causing a significant amount of precancerous lesion morbidity among minority women. These baseline differences need to be taken into account when evaluating the impact of the current HPV vaccines and when considering the development of future multi-valent HPV vaccines.


This is an Open Access Thesis.