MAJOR ARTICLE

The Burden of Genital Warts: A Study of Nearly

70,000 Women from the General Female
Population in the 4 Nordic Countries
Susanne Krüger Kjær,1,2 Trung Nam Tran,4,a Par Sparen,4 Laufey Tryggvadottir,5 Christian Munk,1 Erik Dasbach,3
Kai-Li Liaw,3 Jan Nygård,6 and Mari Nygård6

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1Institute of Cancer Epidemiology, Danish Cancer Society, and 2Department of Obstetrics and Gynecology, Rigshospitalet, Copenhagen, Denmark;
3Merck Research Laboratories, Merck & Co., Inc., Upper Gwynedd, Pennsylvania; 4Department of Medical Epidemiology and Biostatistics,
Karolinska Institute, Stockholm, Sweden; 5Icelandic Cancer Society, Reykjavik, Iceland; 6Cancer Registry of Norway, Olso, Norway

(See the article by the Future II Study Group, on pages 1438 – 46, and the editorial commentary by Hildesheim and
Herrero, on pages 1431–2.)
Objective. To asses the burden and correlates of genital warts in women.
Methods. We conducted a population-based cross-sectional study in 69,147 women (18 – 45 years of age) ran-
domly chosen from the general population in Denmark, Iceland, Norway, and Sweden. Information on clinically
diagnosed genital warts and lifestyle habits was collected using a questionnaire.
Results. Overall, 10.6% reported ever having had clinically diagnosed genital warts. In addition, 1.3% reported
having experienced genital warts within the past 12 months. The cumulative incidence for different birth cohorts,
estimated on the basis of age at first diagnosis of genital warts, increased with each subsequent younger birth cohort
(P ⬍ .01). The lifetime number of sex partners was strongly correlated with a history of genital warts (odds ratio for
肁15 partners vs. 1 partner, 9.45 [95% confidence interval, 7.89 –11.30]). The likelihood of reporting genital warts also
increased with a history of sexually transmitted disease, use of hormonal contraceptives, use of condoms, smoking,
and higher education.
Conclusions. The data suggest that ⬃1 in 10 women in the Nordic countries experience genital warts before the
age of 45 years, with an increasing occurrence in younger birth cohorts. These data are important for developing and
evaluating strategies (e.g., human papillomavirus [HPV] vaccination) to control and prevent HPV infection and
disease in the population.

Genital human papillomavirus (HPV) infection is the (STI). The pathogenetic spectrum of genital HPV infec-
most common viral sexually transmitted infection tions is broad, ranging from cancer to genital warts.
Even though a condition with genital warts is not life-
threatening, these lesions can cause clinical symptoms,
Received 11 January 2007; accepted 17 April 2007; electronically published 31
October 2007. such as burning, itching, bleeding, and pain. A diagnosis
Potential conflicts of interest: S.K.K. has received paid advisory-board fees and of genital warts can also cause psychosocial stress, result-
grant support from Merck & Co., Inc. S.K.K. and C.M. have received travel funds
to present study results at the EUROGIN in April 2006 in Paris, France; at the ing in decreased self-esteem, negative self-perception,
International Papillomavirus Conference in September 2006 in Prague, Czech embarrassment, and anxiety [1, 2]. Although the HPV
Republic; and at FIGO in November 2006 in Kuala Lumpur, Malaysia. All other
authors report no potential conflicts. types associated with genital warts (HPV-6 and HPV-11
Financial support: Merck & Co., Inc. (research grant EPO 8014.016). Merck has account for ⬃90% of episodes) may not cause cervical
been involved in the study design; in the collection, analysis, and interpretation of
the data; in the writing of the report; and in the decision to submit the paper for cancer, women with a history of genital warts have been
publication. shown to have an increased risk of cervical intraepithe-
a Present affiliation: Merck Research Laboratories, Merck & Co., Inc., Upper

Gwynedd, Pennsylvania. lial neoplasia (CIN) and cancer [3, 4], which is most
Reprints or correspondence: Prof. Susanne Krüger Kjær, Inst. of Cancer Epidemiol- likely explained by a higher risk of having other, carci-
ogy, Danish Cancer Society, and Dept. of Obstetrics and Gynecology, Rigshospitalet,
Strandboulevarden 49, Copenhagen DK-2100, Denmark ([email protected]). nogenic HPV types.
The Journal of Infectious Diseases 2007; 196:1447–54 Genital warts represent not only a health problem for
© 2007 by the Infectious Diseases Society of America. All rights reserved.
the individual but also an economic burden for society.
0022-1899/2007/19610-0005$15.00
DOI: 10.1086/522863 One study of genital warts among privately insured in-

Genital Wart Burden in Nordic Countries ● JID 2007:196 (15 November) ● 1447
dividuals estimated an annual cost of $140 million for US private Norway). Women who had moved or emigrated, who had died
health plans in relation to the diagnosis and treatment of genital before our contact, or who did not speak the respective Nordic lan-
warts [5]. Results from a recent study estimated a cost of £10.1 guage were ineligible for the study, leaving 27,272 Danish women,
million for managing incident cases of genital warts only in 2003 27,548 Icelandic women, 24,424 Norwegian women, and 24,689
in the United Kingdom [6]. Swedish women as potential participants. A total of 1737 Danish
Several studies have suggested that HPV infection, including women, 422 Icelandic women, 2409 Norwegian women, and 1661
infection with HPV-6 and HPV-11, is a major and most likely Swedish women explicitly stated that they did not want to partici-
increasing problem [7–9]. However, the majority of studies of pate in the study, whereas no response was obtained from 3336
the prevalence and incidence of genital warts have been con- Danish women, 12,075 Icelandic women, 5411 Norwegian women,
ducted in selected populations, such as sexually transmitted dis- and 7315 Swedish women. Thus, we recruited for the study 22,199
ease (STD) clinic attendees, university students, or individuals Danish women (participation rate, 81.4%), 15,051 Icelandic
insured through private health plans [5, 10 –12]. Thus, few data women (54.6%), 16,604 Norwegian women (68.0%), and 15,713
have originated from general population studies [13, 14]. As a Swedish women (63.6%), for a total of 69,567 women. We excluded
result, knowledge about the overall and dynamic occurrence of 81 women who had incomplete questionnaires or a discrepancy

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genital warts across different birth cohorts in the female popu- between their PIN and the year of birth reported, such that the
lation is limited. Such data are important for developing and population in this study consisted of 69,486 women (22,173 from
evaluating strategies to control and prevent HPV infection and Denmark, 15,025 from Iceland, 16,575 from Norway, and 15,713
disease (e.g., genital warts) in the population. Given that a pro- from Sweden). For this article, we excluded 339 women who did not
phylactic vaccine against HPV-16, -18, -6, and -11 has recently answer the question about genital warts; consequently, a total of
become publicly available in many countries, establishing and 69,147 women were available for the present analysis.
understanding the burden of genital warts at the general popu- Data collection. To guarantee confidentiality for the partic-
lation level can inform vaccine policy decisions. ipants, all invited women were appointed a unique study num-
The overall aim of the present study was to assess the occur- ber by the national study centers. An invitation letter and a self-
rence and correlates of genital warts in random samples of the administered structured questionnaire were mailed to each
general female population in the 4 Nordic countries. woman in Denmark, Iceland, and Norway. It was also possible to
answer the questions by means of a Web-based questionnaire,
SUBJECTS, MATERIALS, AND METHODS which could be accessed using the unique study number and a
personal access code, which were provided in the invitation let-
Study population. In each of the 4 countries (Denmark, Ice- ter (in Sweden, this was initially the only option). In all 4 coun-
land, Norway, and Sweden), each citizen has a unique personal tries, women who did not respond within 3– 4 weeks received a
identification number (PIN), comprising information about sex reminder, including the questionnaire, by postal mail. For those
and date of birth. These PINs are registered in a national, com- who still did not respond, either the women were contacted by
puterized central population registry in each country, together phone and reminded about the study (Iceland) or a telephone
with information on vital status, migration, and current address interview was conducted whenever possible (Denmark, Norway,
on the individual level. By use of these computerized population and Sweden). The telephone interview comprised the same
registries, which cover the entire population in the respective questions as those included in the self-administered paper- or
country, a random sample of women (18 – 45 years of age) was Web-based questionnaire.
drawn from the general female population in each country, us- Via the survey, we obtained information on sociodemo-
ing the PIN as the key identifier. Informed consent was obtained graphic variables as well as on smoking history, alcohol intake,
from each study participant. The study was approved in each reproductive history, contraceptive use, and sexual habits. In
country by the data protection board and the scientific ethics addition, we collected information on ever having had a clinical
committee. diagnosis of genital warts, genital warts during the previous 12
Our goal was to include at least 14,000 women in each coun- months, age at first diagnosis of genital warts, and previous ep-
try. A priori, we anticipated an overall response rate of 50%– isodes of other STIs (genital chlamydial infection, gonorrhea,
60%, implying that ⬃25,000 –28,000 women in each country genital herpes, and trichomoniasis).
should be invited for the study. The final number of invited Statistical analysis. Correlates of self-reported genital warts
women in each country was mostly dependent on what was lo- were examined using univariate and multiple logistic regression, by
gistically feasible in the respective country. which odds ratios (ORs) and the corresponding 95% confidence
From November 2004 to June 2005, a total of 28,000 women intervals (CIs) were estimated. Variables were selected on the basis
were invited to participate in both Denmark and Iceland, whereas of the current literature. The multivariate analysis was initially per-
25,001 women and 25,000 women were invited from Norway and formed separately for each country; however, because the results
Sweden, respectively (1 extra woman was erroneously drawn from were very similar (data not shown), we included all 4 countries in 1

1448 ● JID 2007:196 (15 November) ● Kjær et al.

 Table 1. Mode of response, by country. women (1.3%) had experienced genital warts during the past 12
months (data not shown). The prevalence of ever having had
Included by means of genital warts ranged from 12.0% (95% CI, 11.5%–12.6%) in
Paper-based Web-based Telephone Iceland to 9.5% (95% CI, 9.0%–9.9%) in Norway (table 2). The
Country questionnaire questionnaire interview same pattern was reflected in the mean lifetime number of sex
Denmark 76 9 15 partners, for which Icelandic women and Norwegian women
Iceland 59 38 3 had, respectively, the highest (8.8) and the lowest (7.4) mean
Norway 78 12 10 lifetime number of sex partners. Icelandic women also had the
Sweden 53 36 11 lowest mean age at first diagnosis of genital warts (21.3 years),
NOTE. Data are percentage of subjects. whereas the Norwegian women had the highest mean age at first
diagnosis of genital warts (22.7 years), with Denmark and Swe-
den in between (21.9 years).
analysis, adjusting for country in the final statistical model. We also
We examined the proportion of women reporting having had
examined the results restricted to each mode of response (i.e.,
genital warts during the past 12 months in relation to age of the
paper-based questionnaire, Web-based questionnaire, and tele-

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women at enrollment in the study, and the same picture
phone interview), but, because we found no substantial differences
emerged in all 4 countries—namely, a decreasing proportion of
in the overall results according to mode of response, only the com-
women with genital warts during the past 12 months with in-
bined analysis is presented here.
creasing age (figure 1). The proportions for all 4 countries were
On the basis of information on age at first diagnosis of genital
similar from ages 26 to 45 years, whereas younger Icelandic
warts, the cumulative incidence of having had genital warts up to
women were much more likely to report genital warts during the
a certain age was estimated by means of the life table (actuarial)
past 12 months (4.7% vs. ⬃2% in the other 3 countries).
method, stratified by country and birth cohort.
In figure 2A, the cross-sectional proportion of women report-
RESULTS ing ever having had clinically diagnosed genital warts according
to birth cohort is presented for each country. For Iceland, Nor-
Denmark provided the highest proportion of women (32%), fol- way, and Sweden, the prevalence initially increased with increas-
lowed by Norway (23.9%), Sweden (22.5%), and Iceland (21.6%). ing birth cohort. However, for older birth cohorts, a lower prev-
Table 1 shows the distribution of mode of response by country, with alence of having had genital warts was observed. In contrast, a
Iceland and Sweden having the highest proportion of women re- continuously increasing prevalence with increasingly older birth
sponding by means of the Web-based questionnaire and Denmark cohorts was found among Danish women. Icelandic women
and Norway having the highest proportion responding by mail. born after 1973 reported a much higher prevalence of genital
Nearly 8% of the women in the overall study population were warts than in any other country (figure 2A). Sexual activity in
20 years of age or younger, with 16%–20% in each of the subse- terms of mean lifetime number of sex partners by birth cohort in
quent 5-year age groups and the age distribution being similar in the different Nordic countries (figure 2B) mirrored the picture
the 4 countries (mean age, 31.8 years for Denmark, 32.2 years for observed for the age-specific prevalence of genital warts. We ob-
Iceland, 31.2 years for Norway, and 32.2 years for Sweden). The served a tendency, most pronounced for Iceland, for younger
majority of the women were married or cohabiting (69.6%). The birth cohorts to report more partners than older cohorts, with
median lifetime number of sex partners was 5 and the median the exception of women in the youngest birth cohort, who had
age at first intercourse was 16 years. A little more than 1 in 5 not yet accumulated that many partners. The pattern differed in
women reported ever having had an STD other than genital Denmark, where the number of partners remained constant for
warts (data not shown). the birth cohorts born in 1974 or before.
A total of 7351 women (10.6%) reported having had at least 1 Table 3 displays correlates associated with a history of clini-
previous episode of clinically diagnosed genital warts, and 912 cally diagnosed genital warts. We found that the most important

Table 2. Selected characteristics with regard to sexual habits and genital warts in the 4 Nordic countries.

Characteristic Denmark Iceland Norway Sweden

Self-reported history of clinically diagnosed
genital warts, % (95% CI) 10.1 (9.7–10.5) 12.0 (11.5–12.6) 9.5 (9.0–9.9) 11.3 (10.8–11.8)
Lifetime no. of sex partners, mean (range) 8.4 (0–500) 8.8 (0–100) 7.4 (0–100) 8.6 (0–450)
Age at first diagnosis of genital warts, mean (range), years 21.9 (6–45) 21.3 (14–43) 22.7 (3–45) 21.9 (14–44)
Genital warts during the last 12 months, % (95% CI) 1.3 (1.2–1.5) 1.9 (1.7–2.1) 1.1 (1.0–1.3) 1.0 (0.9–1.2)

NOTE. CI, confidence interval.

Genital Wart Burden in Nordic Countries ● JID 2007:196 (15 November) ● 1449
 Figure 1. Proportion of self-reported clinically diagnosed genital warts during the past 12 months, by age and country

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factor was the lifetime number of sex partners (OR for 肁15 part- dom use, ever having had an abortion, more education, and
ners compared with 1 partner, 9.45 [95% CI, 7.89 –11.30]). smoking for ⬎59 pack-years increased the probability of report-
Other important correlates included older age and a history of ing genital warts.In contrast, a history of genital warts was not
other STIs. In addition, use of hormonal contraceptives, con- strongly correlated with marital status (data not shown), age at

Figure 2. Prevalence of self-reported clinically diagnosed genital warts (A) and mean lifetime no. of sex partners (B) among 69,147 women 18 – 45
years of age, by birth cohort and country.

1450 ● JID 2007:196 (15 November) ● Kjær et al.

Table 3. Correlates of ever receiving a clinical diagnosis of genital warts among
69,147 women from the 4 Nordic countries.

Category, parameter No. % with genital warts ORa ORb (95% CI)

Country
Denmark 22,106 10.1 1 1
Iceland 14,955 12.0 1.21c 1.13 (1.05–1.23)
Norway 16,499 9.5 0.95 0.99 (0.91–1.07)
Sweden 15,587 11.3 1.10c 1.13 (1.05–1.22)
Age
18–20 years 7178 4.3 1 1
21–25 years 13,354 9.1 2.21c 1.48 (1.27–1.74)
26–30 years 10,978 12.1 3.03c 1.68 (1.43–1.98)
31–35 years 12,321 12.3 3.10c 1.83 (1.54–2.16)
36–40 years 13,061 12.4 3.12c 1.93 (1.62–2.30)
41–45 years 12,255 10.3 2.55c 1.64 (1.37–1.95)

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Pregnancy history
Never pregnant 23,630 8.4 1 1
Pregnant but no births 4937 15.8 1.75c 1.16 (1.05–1.28)
1 birth 10,984 12.9 1.23c 1.04 (0.95–1.14)
2 births 17,879 11.0 0.98 0.99 (0.90–1.09)
3 births 8280 10.4 0.92 1.02 (0.91–1.14)
肁4 births 2393 8.4 0.73 0.81 (0.68–0.98)
Hormonal contraceptives
Never 7319 4.2 1 1
Ever 61,314 11.4 2.75c 1.55 (1.36–1.77)
Condom use
Never 8385 4.3 1 1
Ever 60,157 11.6 2.75c 1.44 (1.27–1.63)
Age at first intercourse
肁20 years or never 9044 4.5 1 1
17–19 years 23,668 9.4 2.22c 0.97 (0.85–1.10)
15–16 years 26,786 12.5 3.17c 1.01 (0.88–1.14)
聿14 years 7452 16.5 4.50c 1.06 (0.92–1.22)
Lifetime no. of sex partners
0 1139 1.1 0.64 0.97 (0.62–1.52)
1 8995 1.9 1 1
2–4 16,642 5.2 2.80c 2.60 (2.17–3.11)
5–9 18,231 11.1 6.25c 4.98 (4.18–5.93)
10–14 9500 16.6 9.93c 6.96 (5.81–8.33)
肁15 10,441 23.1 14.82c 9.45 (7.89–11.30)
STDd
Never 54,033 7.7 1 1
Ever 14,866 21.2 3.12c 1.91 (1.80–2.02)
Education
聿12 years 27,810 9.2 1 1
13–16 years 27,166 11.4 1.19c 1.13 (1.06–1.20)
肁17 years 13,217 12.2 1.20c 1.16 (1.07–1.25)
Smoking (pack-years)
Never 35,799 8.2 1 1
Less than or equal to median 15,900 12.8 1.59c 1.07 (1.00–1.15)
More than median 15,965 14.1 1.82c 1.11 (1.03–1.18)
Alcohol (drinks per week)
Never 8404 7.2 1 1
Less than or equal to median 29,835 10.1 1.44c 1.05 (0.95–1.16)
More than median 29,781 12.3 1.91c 1.10 (0.99–1.21)

NOTE. Missing values were excluded from the analysis. CI, confidence interval; STD, sexually
transmitted disease; OR, odds ratio.
a Adjusted for age.
b All factors mutually adjusted.
c 95% CI excludes 1.0.
d Includes genital chlamydial infection, gonorrhea, trichomoniasis, and herpes.
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Figure 3. Estimated cumulative incidence of self-reported clinically diagnosed genital warts, by country and birth cohort. The cumulative incidence
of having had genital warts up to a certain age was estimated on the basis of information on age at first diagnosis of genital warts.

first sexual intercourse, number of births, and alcohol intake recent studies of a quadrivalent HPV-6/11/16/18 vaccine has shown
after adjusting for other risk factors. The analysis of correlates close to 100% protection against genital warts in women [15].
associated with the risk of genital warts was also performed sep- The prevalence of genital warts did not differ much across the
arately for each country, but only the analysis for all 4 countries 4 Nordic countries, but these prevalences are somewhat higher
combined is shown, because the results were similar for all coun- than those reported in previous prevalence studies that were
tries. In addition, the overall results did not vary according to the based on representative random population samples (e.g., from
way the women responded (data not shown). Australia [4.4% among 9134 women 16 –59 years of age]) [16].
Finally, we estimated age-specific incidences of self-reported The overall estimate, however, is a little lower than an estimate
clinically diagnosed genital warts by age at first diagnosis and reported in a previous Danish study (17% among 11,088 women
birth cohort. The age-specific incidences were generally higher 20 –29 years of age) [13]. Apart from the difference in the ages of
in Iceland, Denmark, and Sweden than in Norway. In Iceland participants between the Danish study and the present study,
and Norway especially, the age-specific incidence increased which can explain some of the variation, the Danish study in-
strongly with each subsequent younger birth cohort (figure 3), cluded only women from the greater Copenhagen area, where
whereas in Denmark the age-specific incidence did not differ
the lifetime number of sex partners is generally higher than that
much among the birth cohorts. The biggest difference between
for the entire country [17]. Our results for genital warts are in
birth cohorts was observed in Iceland, for which the age-specific
line with those regarding another STI, genital herpes simplex
incidence for the birth cohorts 1974 –1978 and 1979 –1986 ex-
virus (HSV) infection, for which a recent review concluded that
ceeded that for all of the other countries.
HSV-2 prevalence is higher in Scandinavia than in other areas of
DISCUSSION Europe [18]. The results of our study showing that Iceland had
the highest prevalence of genital warts, that Sweden and Den-
In this population-based study of nearly 70,000 women 18 – 45 mark had the next highest prevalence, and that Norway had the
years of age, we found that, overall, 10.6% reported ever having had lowest prevalence is consistent with observations for genital
a clinical diagnosis of genital warts. Thus, 1 in 10 Nordic women chlamydial infection, which displays a similar pattern [18].
experience the medical and psychosocial burden of genital warts, In 3 of the countries (Iceland, Norway, and Sweden) included
and society bears the economic burden of treatment. Results from in the present study, we found that the prevalence of genital

1452 ● JID 2007:196 (15 November) ● Kjær et al.

warts was higher among the recent birth cohorts, with the pat- but not all [24]. Consistent with other studies [13, 14, 25], we
tern being most pronounced in Iceland. This could be due to a observed that a history of genital warts correlated strongly with
truly increased exposure to HPV among younger birth cohorts, indicators of sexual habits, such as lifetime number of sex part-
or it could reflect differences in health-seeking behavior, imply- ners and previous STIs (genital chlamydial infection, gonorrhea,
ing that a higher proportion of women from younger birth co- genital herpes, and trichomoniasis), with 82% of all cases occur-
horts have their genital warts clinically diagnosed. A similar pat- ring in women with 5 or more partners. We also found that
tern could also arise if older women were consequently more reporting previous genital warts correlated with other health-
likely to forget and thus underreport episodes of genital warts. related behaviors and demographic variables, such as the use of
However, in Denmark, an increasing prevalence of genital warts hormonal contraceptives, smoking habits, and education, a
with increasingly older birth cohorts was observed. Interestingly, finding that has also been reported by others [13, 14, 25, 26].
the pattern of the mean lifetime number of sex partners accord- Some potential limitations of the study should be considered.
ing to birth cohort in the 4 countries also mirrored the pattern Even though we had a reasonably high overall response rate con-
observed for the prevalence of genital warts in a given birth co- sidering the sensitive nature of many of the questions in the
hort, supporting the view that genital warts is an increasing questionnaire, we cannot exclude the existence of bias pertain-

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problem that is due to increasing exposure. There is no reason to ing to nonparticipation or recall bias. We only had information
believe that significant differences exist in recalling a previous about age in nonparticipants, and in all 4 countries the age dis-
episode of genital warts or lifetime number of sex partners be- tribution was very similar to that among the participating
tween the 4 Nordic countries. Therefore, these patterns may re- women (data not shown). In addition, the accuracy of self-
flect a paradigm shift in sexual practice in the younger birth reported genital warts has been questioned but is largely un-
cohorts, especially in Iceland but also in Norway and Sweden, known [27], and, in the United Kingdom, where STIs are rou-
with a higher lifetime number of sex partners. In contrast, such a tinely registered, a high consistency has been found between
shift may have happened earlier in Denmark (i.e., before the population rates and self-reported behavior [28]. However, in
cohorts analyzed in this study), resulting in the observed contin- one study, it was found that the concordance between self-
uously increasing prevalence of ever having had genital warts reported genital warts and a medical examiner’s finding in-
with older birth cohorts. Support for this comes from a study creased if the person had had a previous episode of genital warts.
that found that age at first intercourse remained unchanged Hence, to obtain the highest possible validity, we restricted our
among Danish adolescents from 1986 to 1993 [19] as well as analysis to include only clinically diagnosed genital warts, which
from another recent study that reported no significant changes may be easier to remember. On the other hand, this may imply
in the number of partners or in the proportion of sexually expe- that the estimated occurrence is most likely an underestimate of
rienced persons among adolescent women from 1982 to 2001 the true prevalence and/or incidence. Finally, in assessing corre-
[20]. Iceland is usually considered to be very similar to the other lates of genital warts, the association between a history of genital
Nordic countries, but, in the present study, it differed by having warts and some of the behavioral factors cannot automatically be
on average the highest lifetime number of sex partners and the interpreted as being causal or temporal, because of the cross-
youngest age at first intercourse. These findings are in line with a sectional nature of the study.
recent study reporting a significantly higher teenage pregnancy Our study has several strengths. First, this is the largest study
rate in Iceland than in the rest of the Nordic countries [21]. In to date to assess the occurrence of clinically diagnosed genital
addition, a recent Icelandic study [22] found an increase in the warts in 4 different countries. Second, in contrast to the majority
occurrence of high-grade lesions at the first screening visit in of studies of genital warts, this investigation was conducted on a
women ⬍25 years of age after 1980, possibly also indicating a nationwide basis, being based on random samples from the gen-
change in exposure to HPV. eral population in the respective countries, thus making the re-
Our results from the analysis of the age-specific incidences of sults potentially more generalizable. Third, the fairly high re-
genital warts by birth cohort give additional support to the view sponse rates, given the sensitive nature of the subject matter,
of a shift in sexual practices among younger birth cohorts. Be- help reduce potential selection bias.
cause the incidence of a first diagnosis of genital warts at a certain In conclusion, genital warts frequently occur among women
age increased with each subsequent younger birth cohort, the in the Nordic countries. At least 1 in 10 women reported having
effect could not be explained solely by the younger birth cohorts received a clinical diagnosis of genital warts before the age of 45
contracting genital warts earlier. years. In addition, the results of this study indicate an increasing
The results of our study indicating an increasing incidence of incidence of genital warts among younger birth cohorts. Re-
genital warts in the younger female population are in line with cently, a number of landmark clinical studies have demonstrated
those from other studies of incident episodes of genital warts [7], that a prophylactic HPV vaccine can prevent HPV infection and
with those from studies of rates of new genital wart claims [12], disease [29 –33]. Given the success of these studies, it is antici-
and with some HPV seroprevalences over calendar time [23], pated that an HPV vaccine that prevents infection, CIN, and

Genital Wart Burden in Nordic Countries ● JID 2007:196 (15 November) ● 1453
genital warts will soon be available in many countries. Although 15. Sattler C, for the FUTURE I Investigators. Efficacy of a prophylactic
clinical studies are sufficient for vaccine licensure, policymakers quadrivalent human papillomavirus (HPV) (types 6, 11, 16, 18) L1
virus-like particle (VLP) vaccine for prevention of cervical dysplasia and
will seek additional information to formulate HPV vaccination external genital lesions (EGL) [abstract LB2-25]. In: 45th Interscience
policy [34]. In particular, policymakers will seek information on Conference on Antimicrobial Agents and Chemotherapy. Washington,
the epidemiological trends in HPV infection and diseases in the DC: American Society for Microbiology, 2005.
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Acknowledgment tion habits among adolescents over the last 14 years: an investigation

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among 9th grade pupils in the municipality of Viborg.] Ugeskr Laeger
We are grateful to Kirsten Frederiksen for valuable guidance and com- 2002; 164:3207–11.
ments related to the statistical analyses. 20. Kangas I, Andersen B, McGarrigle CA, Ostergaard L, Alvarez FB. A com-
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1454 ● JID 2007:196 (15 November) ● Kjær et al.