To investigate knowledge, perceptions and practices of parents of girls aged 11–18 years old in Greece toward HPV vaccination, and determine which factors are associated with parents' decision to vaccinate their daughters.A close-end questionnaire was constructed and telephone interviews were conducted upon informed consent. The sample was random, national, stratified by geographic region and representative of the general population of parents of girls aged 11–18. The data collected include: general knowledge, attitudes and perceptions concerning HPV and HPV vaccine, information regarding their daughters' HPV vaccination, and sociodemographic characteristics. Statistical analysis included descriptives and a logistic regression model to investigate which factors are associated with HPV vaccination.Overall, 1,000 parents participated in the study, 99.4% of which knew what HPV is and 98.8% knew there is a vaccine available against HPV. Furthermore, 47% of the parents stated that their daughters had been vaccinated against HPV, while further analysis revealed that only 35% had received all the recommended doses. In the logistic regression analysis, the following variables had a statistically significant association with HPV vaccination: perceived ease of contracting HPV (OR = 1.105), level of trust in medical profession regarding information on prevention (OR = 1.205), overall perception regarding importance of children's vaccination (OR = 0.618), internet/social media as a source of parent information regarding HPV (OR = 0.886), participant (parent) age (OR = 1.125), and daughter's treating physician's recommendation for HPV vaccination (OR = 7.319).HPV vaccination coverage is still suboptimal. Comprehension of the obstacles toward this goal is important and the role of healthcare professionals is crucial to increase acceptance. Human Papilloma Virus (HPV) is the main cause of almost every case of cervical cancer, while it is also responsible for a number of anogenital and oropharyngeal cancers . The maiCervical cancer is the fourth most common cancer type in women worldwide, accounting for 604,127 cases in 2020, while it is also the fourth cause of cancer death in women globally with 341,831 deaths  was employed in order to ensure proportional representation for the national sample. Computer Assisted Telephone Interviews (CATI) system automatically generated random telephone numbers. For reasons of anonymity, the professional and specially trained interviewers did not know the telephone number of the interviewee. Upon informed consent, telephone interviews were carried out in morning, afternoon, and evening, to ensure that both working and not working parents were reached.Filter questions for the fulfillment of the inclusion criteria were: (a) region of residence and urbanization level, (b) having children, (c) gender and age of all children, (d) if 1+ girls aged 11–18 years, inclusion in the study, (e) if 2+ girls aged 11–18 years, selection of one girl based on a random digits table, and information given to parent participant that for the interview the daughter selected should be kept in mind, (f) that the responder is the parent who participates in the decision-making for health issues of the daughter, and (g) knowledge of the HPV vaccine. Study interviews were conducted during June-July 2019 and all necessary ethics approvals were obtained from the Bioethics and Research Ethics Committee of the Hellenic National School of Public Health (3568/9.11.2018).For the questionnaire construction, a thorough review of the existing literature on the subject was performed by the research team, in order to acquire the necessary items regarding the factors/determinants that are associated with the decision toward vaccination against HPV. Accordingly, the acquired items were transformed into questions, based on the general context of the KAP method .The questionnaire of the study consisted of the following broad question categories: (a) general knowledge concerning HPV as a virus and its vaccine, (b) attitudes and perceptions toward the vaccine, (c) whether their daughter has been vaccinated against HPV and why/why not. Additional data were collected on various sociodemographic characteristics of the participants. Also, it should be noted that, while most questions were either categorical or had specific levels of scales, a few of the items in the questionnaire required the participants to respond in a numerical form on a 0–10 scale . In particular, these were: degree of avocation with religion, trust in various sources to inform the public on prevention and how easy people believe it is to get HPV.Additionally to the main reporting whether the respondents' daughters had been vaccinated against HPV or not, the status of vaccination (full or not) was also estimated. In particular, this estimation was based on the age that the girls received the first dose of the HPV vaccine and the respective doses required for full vaccination, according to the National Programme of Vaccination for children and adolescents .The statistical analysis was performed with the SPSS statistical software (v.20). Additionally to the descriptive analysis of the sample, a binary logistic regression analysis was also employed, in order to investigate which factors are associated with the decision to vaccinate. In this analysis, the dependent variable was the status of vaccination, while the independent variables were selected on the basis of the univariate associations of the various items of the questionnaire with vaccination coverage, as follows: perception on how easy it is to contract HPV, level of trust in the medical profession as a source of information on prevention, overall perception on the importance of children/adolescents' vaccination, physician as a source of information about the virus, whether the daughter's treating physician has recommended HPV vaccination, internet/social media as a source for HPV information, age of the participant parent and degree of avocation with religion. Initial model construction analysis including sociodemographic variables failed to detect any statistically significant associations with the dependent variable, thus, most sociodemographic characteristics were not used in the final model analysis, which was performed with the Enter method.n = 990), with a mean age of 45.56 years old (SD = 5.005), while the majority was married/living with a spouse . Regarding education, 42.5% (n = 421) of the study sample had tertiary education and more than 6 out of 10 participants were occupied as employees . Also, almost every participant had public social insurance . Additionally, the participants were asked to state the level of their avocation with religion, resulting in a mean score of 6.98 (SD = 2.134). The medical profession was found to be the most trusted source of information on health prevention issues  when compared to other sources, like the Ministry of Health, the National Drug Organization, pharmacists, the pharmaceutical industry, the internet, and the press.Overall, the study sample consisted of 1,000 parents of girls aged 11–18 years old at the time of the survey. The main characteristics of the sample are presented in n = 992) of the study sample knew about Human Papilloma Virus and the main source of information regarding the virus were physicians , internet/social media , and friends/family . Intercourse was perceived as the main mode of HPV transmission by the majority of participants , while a small proportion thinks that HPV can be transmitted with common use of syringes . Regarding prevention of HPV transmission, use of condom during intercourse was the first choice for 87.6% (n = 842) of the study sample, while the second most common choice was Pap smear .According to the analysis, 99.4% (n = 879) and genital and anal warts . Also, the participants were asked how cervical cancer can be prevented, with 3 out of 4  choosing HPV vaccination as the main preventive method.Concerning the perceptions of the study participants concerning which diseases are associated with HPV, the majority recognizes that it is linked with cervical cancer , while they were also asked to assess how easy it is to get the virus, which resulted in a mean score of 7.50 .Furthermore, participants were asked to rate the seriousness of the consequences associated with contracting HPV on a 0–10 scale , which derived a mean score of 8.77  of the study participants know that there is a vaccine against HPV, with health care professionals being the most common source of information regarding the vaccine . The effectiveness of HPV vaccine is recognized by the participants, since the majority of them consider it high and very high in prevention of genital warts  and cervical cancer . Furthermore, the role of their daughters' treating physician concerning HPV vaccination was investigated. Based on the answers of the respondents, more than 9 out of 10 physicians have informed the parents/daughters about HPV vaccination  and have recommended it .Overall, 98.8% (n = 468). However, further analysis on the number of doses the girls had received, revealed that only 35.0% (n = 345) of the overall sample was fully vaccinated up until the survey (2 doses for girls vaccinated at age <15y.o. and 3 doses for girls vaccinated at age ≥15y.o.). The main reason that drove their decision to have their daughters vaccinated was physician recommendation , while an equally significant proportion of participants stated that they wanted to protect their daughters from being infected with HPV in the future   .n = 214) and that their daughters were too young to be vaccinated against HPV . It should be noted than 1 in 5 participants  stated that they did not believe that the vaccine is safe as a reason for not vaccinating their daughters. Nevertheless, 68.2% (n = 227) of those who had not vaccinated their daughters declared that they plan to do it in the future. Finally, the participants were asked to state their overall agreement/disagreement toward importance of vaccination in general for children, which resulted in agreement from more than 9 out of 10 participants .On the other hand, regarding those participants who had not had their daughters vaccinated up to the time of the survey, the most common reasons were that they did not have enough information available to decide   than their counterparts not having vaccinated their daughter . Trust in the medical profession was higher  among respondents who reported having vaccinated their daughter than their counterparts not having vaccinated their daughter  (p < 0.001).Based on the univariate analyses, marital status, occupation, education, income, and public social insurance coverage of the study sample were not found to be associated with vaccination status of the sample's daughter. Similarly, degree of avocation with religion did not differ among the parents who had and those who had not vaccinated their daughter. Parents reporting vaccinated daughter were somewhat, but at statistically significant level, older (p < 0.001) for respondents who had vaccinated their daughter  when compared to those who had not done so .Perceived ease that somebody contracts HPV during his/her lifetime was found to be significantly higher  had knowledge of the HPV virus, as expected, while 450 (96.2%) reported physician as their source of information about the virus, this being by far the most important and positively associated factor with vaccination coverage . In contOverall, HPV vaccination coverage of daughters aged 11–18 year is significantly related  to theirThe results of the binary regression model are presented in Specifically, probability of HPV vaccination increases as the perceived ease of contracting HPV increases , as level of trust in medical profession to provide information on prevention increases  and as the participant age increases . Furthermore, as the perceived importance of children's vaccination decreases, the probability of HPV vaccination decreases . Also, a particularly strong positive statistical association was found between daughter's treating physician's recommendation for HPV vaccination and HPV vaccination . On the other hand, probability of HPV vaccination is lower for those who have internet/social media as a source of information regarding HPV, compared to persons who have other sources of information on the virus .No statistically significant association with HPV vaccination was found for the variables “Physician as a source of parent information on HPV” and “degree of avocation with religion.”HPV is a serious public health issue, as it is responsible for the overall incidence of cervical cancer, while it is also related to various other types of cancer. The development of an effective and safe HPV vaccine has been an important achievement. However, wide acceptance of the vaccine by the public is yet to be achieved, despite the increasing literature evidence supporting its effectiveness and safety. The present study is the first extensive and multifactorial investigation of HPV vaccination coverage in Greece, as well as of the determinants associated with vaccination.According to the results of the analysis, HPV is common knowledge among Greek parents of adolescent girls, with medical community emerging as the main source of information. On the other hand, a study on Greek adolescents' knowledge on HPV has revealed that only 43% of them know about the virus , which iAlmost all study participants know the existence of the HPV vaccine, with healthcare professionals and more particularly pediatricians, pathologists, and gynecologists as their main source of information. Additionally, the effectiveness of HPV vaccine is widely recognized for both the prevention of genital warts and cervical cancer, which is in line with the international literature . RegardiThe role of healthcare professionals in the HPV vaccination is highlighted, since half the participants stated that physician recommendation was the main reason for their decision to vaccinate their daughters against HPV. Additionally, according to the results of the binary logistic regression analysis, physician recommendation is the factor with the highest positive association with the decision to vaccinate one's daughter against HPV. Physician influence has been consistently observed in the international literature, as recommendation for HPV vaccination is associated with higher acceptance rates , 26. MorOverall, childhood vaccination rates in Greece are remarkably high, exceeding 95% , which iGiven that HPV vaccination has optimal effectiveness when performed in early adolescence (11 years old), while in Greece it is also available for girls aged 9 years old, special consideration should be given in order to enhance provision of valid information to the wider public and especially parents regarding this recommendation and its justification, based on available research data. More importantly, this information should be conveyed in a simple and comprehensive way, in order to be understood by the general population.Based on the findings, the present study confirms that optimal coverage of HPV vaccination is yet to be achieved. The role of healthcare professionals has been highlighted as a significant factor in the parents' decision to vaccinate their daughters against HPV, which can and should be utilized in order to increase public acceptance of the vaccine. Further research on the reasons why parents decide to not vaccinate their daughters against HPV would be of great interest in the field.The size of the study sample and the fact that it is representative of the overall population of parents of girls aged 11–18 years old in Greece, based on the methodology and design of the study, constitute an important advantage for the validity of the results of the analysis.However, the present study may be subject to a few limitations, as is common in similar research studies. As the objective of the study involves a serious health issue and the participants' responses may reflect their “interest” in their children's health, the possibility of social desirability bias cannot be excluded. Also, a number of questions refer to past time  and therefore recall bias may be present. Furthermore, adolescents, who are the main interested party in the study objective, were not included as participants in the survey.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Bioethics and Research Ethics Committee of the Hellenic National School of Public Health (3568/9.11.2018). Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.KA, JK, and EP: conceptualization and supervision. KA and EP: methodology. EP and PN: design of research tools. PN, DZ, and KA: formal analysis and investigation. PN: writing—original draft preparation. KA, DZ, JK, and EP: writing—review and editing. All authors contributed to the article and approved the submitted version.The present study was financially supported by MSD Hellas.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The cooling effects of blue–green spaces on the urban heat island effect are complex and different. The purpose of this study is to simulate how the cooling effect of blue–green space changes with its size and shape. The cooling effects of 53 green patches and 28 water bodies in Changsha were extracted based on Landsat images. A surface fitting model was used to quantitatively reveal the relationship between the cooling effect of blue–green space and its size and shape. The results show that the cooling effects of blue–green spaces were enhanced with the increasing size, and then would become stable after a certain range (threshold). Certain thresholds were identified between the blue and green space areas  and the cooling distance, and between the blue and green space areas  and the cooling magnitude. In addition, the green space with an area of 9.08 ha and landscape shape index (LSI) of 2.97 could achieve a better cooling distance (413.46 m); and the blue space with an area of 29.4 ha and LSI of 1.75 could achieve a better cooling magnitude (5.17 °C). These findings provide useful guidelines for urban planning and improving urban livability in other regions with terrain and climate conditions similar to Changsha. In recent decades, global warming, rapid urbanization expansion, an increase in population, and the loss of blue–green spaces have caused a continuous increase in land surface temperature (LST), raising a series of urban thermal environmental issues ,2. The dThe UHI effect refers to the phenomenon in which higher LSTs occur in urban areas than in surrounding rural areas ,8. UrbanAs one of the ten hottest cities in China, the urban heat island effect in Changsha is especially serious in August . The purChangsha, as the capital of Hunan Province, is located in the midcentral region of China . The locFor Changsha, the most significant urban heat island effect occurs in August , i.e., tConsidering the spatial resolution of the thermal infrared data are 120 m for Landsat TM5 and 100 m for Landsat 8, the blue–green spaces lower than 1.44 ha in 1998 and 2009 and lower than 1 ha in 2019 were removed to reduce the effect of mixed pixels. The spatial distribution of selected blue–green spaces is shown in To evaluate the cooling effect of blue–green space patches, eight straight lines were defined along the edges of every selected patch with a fixed length (1500 m) in eight sampling directions d. The orArea and shape have been shown to be the dominant factors affecting the cooling effect of blue–green spaces . The lanD is the perimeter of a single blue–green space patch and A is the area of a single blue–green space patch. Note that D and A of single blue–green space extracted from remote sensing images are approximate values. Larger LSI values indicate a more complicated shape, where the shape is a circle for LSI = 1 and a square for LSI = 1.13 [The LSI is applied to reflect the shape of the patches, which can be calculated as:I = 1.13 .Previous studies indicated that the cooling effect has a positive relationship with patch size. However, with a further increasing area, the increase in the cooling effect shows a trend of first decelerating and then stabilizing within a certain range . To revef is the cooling effect, for example, the cooling distance or cooling magnitude; x1 is the area; and x2 is the LSI. All processes were completed by Origin Pro 2018 [Surface fitting is a common method to obtain relevant and general information from the system under examination, and this method is widely used in engineering sciences ,36,37. TPro 2018 .The cooling island effect of each blue–green space shows the trend of increasing LSTs as the distance of the cooling island increases; however, after reaching a certain distance, the change in LST begins to fluctuate or stabilize, showing that the cooling island effect has a certain range of influence.Among the 53 analysed green spaces , the maxThe cooling distances of the green spaces were positively correlated with the green space areas and LSIs, indicating that a larger area and more complex shape led to longer cooling distances. The results show that a significant threshold was identified in the green space area with regard to the cooling effect; however, in the LSI results, no noticeable threshold relationship was found with the cooling effect.The green space area was found to be the dominant factor affecting the cooling distance and cooling magnitude . The resThe changes in the areas and LSIs of green spaces significantly influenced the cooling distance; the green space with an area of 9.08 ha and LSI of 2.97 could achieve a cooling distance of 413.46 m a. Among The changes in the areas and LSIs of green spaces significantly influenced the cooling magnitude a; the grAmong the 28 analysed blue spaces , the areSimilar to the findings obtained for green spaces, the cooling distances of the blue spaces were positively correlated with their area and LSI, indicating that a larger area and more complex shape led to longer cooling distances. A significant threshold was identified in the area of blue spaces with regard to the cooling effect; however, no obvious threshold relationship was found between the LSI and the cooling effect.The area of a blue space is the dominant factor affecting its cooling distance and cooling magnitude . A thresThe changes in the areas and LSIs of blue spaces significantly influenced the cooling distance a; the blThe changes in the blue space area and LSI significantly influenced the cooling magnitudes of blue spaces, and this model indicated a higher explanatory rate than that obtained for green spaces a. This wAmong all selected samples (28 blue spaces), the largest cooling magnitude was 5.04 °C with an area of 29.99 ha and an LSI of 1.52 b, while 2 of green space could reduce the temperature by 1 °C, while 650 m2 of larger parks could form a temperature reduction by up to 2 °C [2 of water could cool the environment by 0.6 °C. These differences could be explained by four aspects: (1) differences in the selected blue–green space samples representing different study regions with various topographic and geomorphologic conditions, including the depth and volume of blue spaces and NDVI in green spaces, (2) differences in urban climate and Landsat images date, (3) differences in the urbanization levels of the studied cities, and (4) differences in the impact of different remote sensing satellite sensors.This research reveals that the average cooling distance and cooling magnitude of green spaces are 163.33 m and 1.8 °C, respectively, while the average cooling distance and cooling magnitude of blue spaces are 175.58 m and 2 °C, respectively. These findings differ from the results of previous studies; for instance, Du et al.  found th to 2 °C . Zeng et to 2 °C  revealedThe results obtained herein reflect different cooling effects of blue and green spaces; blue spaces had a superior cooling effect than green spaces. This finding is consistent with previous studies. For example, Lin et al. ,42 and YIn this research, we determined that the efficient threshold sizes were 3.15 ha (for the green space cooling distance), 4.92 ha (for the green space cooling magnitude), 2.98 ha (for the blue space cooling distance), and 4.84 ha (for the blue space cooling magnitude). These threshold size values represent the change points of the cooling efficiencies of blue–green spaces; past these change points, the cooling effect per unit area of blue–green spaces does not increase significantly ,43,49. FHow the cooling effect of blue–green spaces changes with their sizes and shapes in Changsha (China) was quantitatively simulated based on Landsat images in this study area. The average cooling distances of green and blue spaces were found to be 163.33 m and 175.58 m, respectively, while the average cooling magnitudes of green and blue spaces were 1.8 °C and 2 °C, respectively. In addition, certain thresholds were found to influence the cooling effects of blue–green spaces, where the cooling effect would slow down after the blue–green space area reached these identified thresholds. Meanwhile, a more efficient cooling effect was obtained at these thresholds. The thresholds were 3.15 ha for the green space cooling distance, 2.98 ha for the blue space cooling distance, 4.92 ha for the green space cooling magnitude, and 4.84 ha for the blue space cooling magnitude; these values are applicable in urban planning projects to achieve more efficient possible blue–green spaces. Furthermore, it was found that 9.08 ha of green space with an LSI of 2.97 could achieve a cooling distance of 413.46 m, while 24.08 ha of blue space with an LSI of 1.75 could achieve a cooling distance of 391.37 m. Additionally, 14.64 ha of green space with an LSI of 1.88 could achieve a cooling magnitude of 3.98 °C, while 24.08 ha of blue space with an LSI of 1.75 could achieve a cooling magnitude of 5.17 °C. The findings provide useful guidelines for the future urban planning of Changsha and other cities facing similar issues.However, there are some limitations that need to be noted. The internal factors of the blue–green space itself, such as the density, type, proportion of different types, and height of green spaces, and the depth, volume, and water amount of blue spaces; and the external factors, such as landscape indicators, wind speed, and wind direction, were not considered in the study. Thus, there are still many works needed to be done in the future if more kinds of remote sensing data and meteorological data are available. Moreover, since the excessive cooling may provide more issues, the cooling effect of blue–green spaces in different seasons, especially in winter, needs to be studied in the future. In addition, this research was based on the subtropical monsoon climate of Changsha (China). It could be further carried out in regions with different climatic characteristics to find differences and commonalities in the cooling effects of blue–green spaces under different climatic characteristics. Therefore, the study would provide theoretical guidance and practical suggestions for planning blue–green spaces and for formulating policies aiming to alleviate urban thermal environment issues in other regions with diverse climatic characteristics.


High-risk human papillomaviruses (HR HPVs) are associated with multiple human cancers and comprise 5% of the human cancer burden. Although most infections are transient, persistent infections are a major risk factor for cancer development. The life cycle of HPV is intimately linked to epithelial differentiation. HPVs establish infection at a low copy number in the proliferating basal keratinocytes of the stratified epithelium. In contrast, the productive phase of the viral life cycle is activated upon epithelial differentiation, resulting in viral genome amplification, high levels of late gene expression, and the assembly of virions that are shed from the epithelial surface. Avoiding activation of an innate immune response during the course of infection plays a key role in promoting viral persistence as well as completion of the viral life cycle in differentiating epithelial cells. This review highlights the recent advances in our understanding of how HPVs manipulate the host cell environment, often in a type-specific manner, to suppress activation of an innate immune response to establish conditions supportive of viral replication. Human papillomaviruses (HPV) are small, non-enveloped, double-stranded DNA viruses that exhibit a strict tropism for epithelial cells. Over 400 types of HPVs have been identified, which are classified into five different genera  and target the stratified epithelium at different body sites . HPVs caAlthough the lifetime risk of developing a genital HPV infection is greater than 80%, most of these infections are transient. On average, however, clearance of viral infections by the immune response can take 1–2 years, indicating that HPVs have evolved mechanisms to escape immune surveillance . AdditioAll HPV genomes are approximately 8 kb and exist in infected cells as extrachromosomal elements (episomes). The viral DNA is histone-associated in the virion as well as in infected cells and is subject to epigenetic regulation through histone post-translational modifications as well as DNA methylation . HPVs shThe HPV life cycle is linked to epithelial differentiation . HPVs esThe limited coding capacity of the HPV genome renders the virus reliant on cellular factors for viral replication. However, epithelial differentiation normally results in an exit from the cell cycle. To provide an environment conducive to productive replication, HPV has evolved mechanisms to push differentiating cells back into the cell cycle, largely through E6 and E7′s ability to deregulate cell cycle control, including the degradation of the p53 and pRb tumor suppressors, respectively . ProductThe interferon (IFN)-mediated response serves as the first line of defense against viral infection. The IFN family is divided into three types; Type I , Type II , and Type III . The Type I and Type III IFN responses are initiated for the most part by the recognition of pathogen associated molecular patterns (PAMPS), mainly viral nucleic acids, by multiple pattern recognition receptors (PRR) A 32,33],3332,33]Despite recognizing distinct PAMPs, the cGAS-STING and RLR-MAVS pathways converge on activation of TANK-binding kinase 1 (TBK1), which phosphorylates and activates the transcription factors IRF-3/IRF-7 to induce Type I and Type III IFN expression A 54]. I. I54]. IKeratinocytes, the target cells of HPV, are immune sentinels that express several PRRs and can respond to PAMPs to mediate an immune response . Genome-Multiple approaches have been used to investigate the mechanisms by which HPVs interfere with activation of an innate immune response. Infection of keratinocytes with HPV pseudovirions (L1/L2 encasing a reporter plasmid), quasivirions (L1/L2 encasing the HPV genome), or virions harvested from HPV positive organotypic raft cultures have been used to study early events in HPV infection ,68,69; HInnate surveillance pathways serve as a major obstacle to viral infection. Indeed, many DNA viruses have been shown to activate cGAS/STING during entry, trafficking and uncoating, including herpesviruses , Kaposi’s sarcoma associated herpesvirus (KSHV)), adenoviruses, and poxviruses ,74,75,76Upon entry into the nucleus, PML (promyelocytic leukemia) proteins associate with and assemble around HPV genomes . PML proThe establishment of infection allows production of HPV early proteins that can directly block proximal viral nucleic acid detection machinery of the cGAS-STING and RLR-MAVs pathways as well as disrupt components of antiviral signaling that are shared among DNA and RNA virus sensors. HPV interferes with multiple steps in the pathway to block cell intrinsic and extrinsic responses. The constitutive reduction in ISGs can be attributed at least in part to HPVs ability to suppress IFN production.The HPV18 and HPV16 E7 proteins suppress STING-dependent IFN responses through distinct mechanisms. HPV18 E7 binds to STING to antagonize its function . In contThe dsRNA sensors RIG-I and MDA5 are also targets of HPV early proteins. Through in vitro studies, Chiang et al. demonstrated that the HPV16 E6 protein inactivates two upstream activators of RIG-I, TRIM25 and USP15, and blocks the RIG-I-induced IFN response to Sendai virus infection . E6 protPRR-adaptor signaling induces IFN production through the activation of IRFs. Type I and Type III IFNs are induced by the activation of IRF3 and/or IRF7 through the activity of TBK1 . ActivatThe regulation of IFN-κ plays a critical role in HPV’s ability to dampen an innate immune response. IFN-κ is a Type I IFN that is constitutively expressed in keratinocytes and can drive basal levels of ISG expression . In contSeveral mechanisms have been described for HPV-mediated repression of IFN-κ. The expression of the HPV16, 18, and 31 E6 and to a lesser extent E7 is sufficient to decrease expression of IFN-κ . IFN-κ lType I and Type III IFNs can act in an autocrine or paracrine manner to induce anti-viral activity through the expression of ISGs . All TypAs noted, numerous ISGs are reduced in expression in HPV infected cells, including STAT1, which is a critical component of the ISGF3 complex. Lack of STAT1 expression likely plays a critical role in HPV’s ability to repress ISG expression and promote viral replication. In support of this, ectopic expression of STAT1 results in loss of HPV31 episomes and the emergence of cells containing integrated viral genomes . While sAlthough several mechanisms have been identified by which HPV blocks production of IFN and/or interferes with ISG expression, the majority of these studies have been carried out in monolayer cultures and/or with overexpression of the HPV early genes. As such, our knowledge regarding the mechanisms that HPV employs to suppress an IFN response in differentiating keratinocytes is lacking. Several approaches are commonly used to study the differentiation-dependent phase of the viral life cycle. Organotypic raft cultures mimic in vivo epithelial differentiation and support all phases of the viral life cycle, including virion production . SuspensRNA-sequencing analysis of differentiating HPV16 positive NIKs as well as CIN1-derived HPV16 positive W12E cells revealed massive changes to the transcriptome upon calcium-induced differentiation, including the upregulation of genes associated with a Type I IFN response . We and Several ISGs have been identified as restriction factors for late gene expression and/or productive replication. Depletion of IFI16, a dsDNA sensor as well as ISG, in NIK-HPV18 positive cells results in increased viral replication and transcription upon methylcellulose-induced differentiation through the removal of repressive heterochromatin on the early and late viral promoters ,139. DepThe mitochondria and apoptotic caspases (cysteine proteases) have been established as important regulators of innate immunity ,142. ApoMOMP triggers the release of mitochondrial DNA (mtDNA) that activates the cGAS-STING pathway, initiating a Type I IFN response that can result in a pro-inflammatory type of cell death  146,147147. MOMPHPV31 activates low levels of apoptotic caspases  upon methylcellulose- and calcium-induced differentiation in the absence of morphological features of apoptosis and requires this activity for productive replication . We founIn this review, we discuss the multiple mechanisms that HPVs use to target the antiviral innate immune response. However, our knowledge regarding how HPV manipulates the cellular environment to avoid and/or block activation of the innate immune response during the course of the viral life cycle is just starting to be elucidated. Several outstanding questions remain: (i) how HPV’s ability to target components of the innate immune response contributes to long-term infection and cancer development, (ii) how HPV subverts activation of an antiviral response despite the presence of persistent DNA damage, which when mislocalized alerts cytoplasmic DNA sensors, and (iii) whether the mechanisms identified for HPV proteins to interfere with innate immune signaling in overexpression studies are conserved in the context of viral infection. Further understanding of how HPVs hijack cellular processes to subvert antiviral signaling may identify novel therapeutic targets for treatment of HPV-associated diseases.


While 9-valent human papillomavirus vaccination (HPV-9) is approved by the U.S. Food and Drug Administration for use in adolescents as young as age 9, providers typically recommend it at ages 11–12 per Centers for Disease Control and Prevention recommendations. Studies suggest that recommending HPV-9 at 9 or 10 years of age could increase up-to-date vaccination by age 13, which could benefit rural populations with reduced access to primary health care and lower HPV-9 coverage than urban areas. This pilot study aimed to assess the feasibility of earlier recommendation of HPV-9 in rural clinics. We conducted in-depth interviews with providers and staff from two primary care clinics in central North Carolina, to understand attitudes toward recommending HPV-9 to 9- and 10-year-olds. All interviewees agreed that HPV-9 was important for cancer prevention and should be recommended before the onset of sexual activity, and agreed that HPV-9 could be initiated before age 11 to improve timeliness and completion of the vaccination series. However, opinions were mixed on whether it should be initiated as young as 9-years-old. Two key informants recruited from two urban clinics described their experiences recommending HPV-9 to 9- and 10-year-olds, including a modified vaccination schedule that promotes HPV-9 during routine well-child visits, prior to pubertal onset, and alongside other recommended adolescent vaccines. Earlier recommendation and administration of HPV-9 is possible with minimal changes to current clinical practices and could increase convenience and acceptability of HPV-9 in under-vaccinated settings. The CDC routinely recommends initiating HPV-9 at ages 11–12 as part of an adolescent vaccination package with tetanus-containing (Tdap) and quadrivalent meningococcal (MenACWY) vaccines, and defines “up-to-date” vaccination as receipt of two doses by age 13. In contrast, the American Cancer Society and American Academy of Pediatrics have recently recommended routine initiation at age 9,10 while the CDC only allows discretional use of HPV-9 for those ages 9-10.11 Studies from urban centers have shown that adolescents who initiate HPV-9 at ages 9–10 are more likely to be fully vaccinated by age 13, compared to those who initiate at age 11 or older.13 A benefit of earlier HPV-9 to 9- and 10-year-olds includes allowing more time to complete the vaccination series by age 13 and before the initiation of sexual activity, which may be beneficial to adolescent who experience health care disruptions or reduced access to routine preventive care.While the Food and Drug Administration (FDA) has approved HPV-9 for adolescents starting at age 9 based on safety and efficacy data from clinical trials,14 Thus, an earlier HPV-9 strategy could possibly be feasible in rural settings where provider willingness is high.While early HPV-9 findings are promising, questions remain about the feasibility of translating these findings into health system change, specifically in rural communities where the need is greatest. To effectively implement early HPV-9 recommendations, clinics must be able to monitor vaccination rates of 9- and 10-year-olds, and vaccine providers must be willing to recommend and provide HPV-9 to this younger age group. In a recent national survey, only 21% of primary care professionals reported that they routinely recommend HPV-9 at ages 9–10; however, 61% reported being willing to start recommending earlier, with no differences in willingness between urban and rural providers.15 North Carolina’s (NC) offers opportunities to test HPV-9 promotion strategies in rural populations with reduced access to cancer screening and treatment. This pilot study aimed to assess the feasibility of earlier recommendation of HPV-9 in a small sample of NC clinics that provide HPV-9 to adolescents and serve rural populations. Findings from this pilot study will inform the design of larger and more in-depth studies to assess clinic workflow around HPV-9 administration, feasibility of recommending HPV-9 uptake, and developing clinic-based interventions to recommend earlier HPV-9 initiation and potentially increase up-to-date HPV-9 coverage in rural NC.With a rural population of approximately 2 million people,We actively recruited from two NC clinics that serve rural populations as part of a system of federally qualified health centers that serve patients throughout central NC. The study was reviewed and approved by health system leadership, and clinic-based leaders identified clinicians and other clinic personnel to complete interviews. Eligible clinics recommended routine HPV-9 to adolescents at ages 11–12 years and served communities with majority-rural residents. Eligible interviewees within clinics included any provider who discussed HPV-9 with patients and caregivers, medical staff who administered HPV-9, and administrative staff who monitored HPV-9 rates, conducted patient outreach for HPV-9, or scheduled HPV-9 visits.post hoc in-depth key-informant interviews to describe their experiences and best practices for recommending earlier HPV-9.In addition, we identified providers at urban practices in a neighboring academic health system who indicated that they were already recommending and providing HPV-9 to 9- and 10-year-old patients during the course of a separate research study on HPV-9. We invited these providers to participate in We asked a clinic administrator or a lead provider in each rural clinic to respond to a questionnaire describing characteristics of their clinics and patients, and clinical practices around HPV-9. Using existing EHR queries developed and validated by clinic IT staff, we estimated the number of active patients eligible for two-dose HPV-9  in the clinic in the last 18 months) and the proportion who had initiated or completed the HPV-9 series in each clinic.19 The guide was reiteratively developed in collaboration with a master’s-level Qualitative Research Specialist in implementation science and reviewed by a primary care provider with over 20 years of experience in family medicine and maternal and child health. The guide probed rural clinic personnel on the perceived importance of HPV-9, the messages used to recommend HPV-9, willingness to promote early HPV-9, and the perceived facilitators and barriers to promoting early HPV-9.The research team, which included members with expertise in public health education and communication, developed the interview guide (Appendix 1) using an iterative process. We created questions based on a literature review identifying key themes around clinical practices for adolescent and early HPV-9, in accordance with the study aim.post hoc, after learning that they were already recommending HPV-9 to their younger patients. The same interview guide that was used for rural clinic personnel interviews was used for key informant interviews, though some questions were modified to ask key informants specifically about their process for recommending HPV-9 to 9- and 10-year-old patients, rather than their willingness to do so (Appendix 2). Key informants were also asked to assess feasibility of implementing earlier HPV-9 on a larger scale, including in clinics with fewer human and technological resources.Key informant interviews were conducted Thirty-minute interviews were conducted via Zoom by the study Principal Investigator (NAV) and a qualitative research assistant (RML) between April and July 2022. This study of provider practices and attitudes toward HPV-9 was determined not to constitute human subjects research by the Institutional Review Board of the University of North Carolina at Chapel Hill (UNC) (IRB #: 21–0182). As such, written informed consent was not required, and interviewees were instead emailed a description of the study design ahead of time, informing them of the nature of the interview prompts and the fact that interviews would be digitally recorded. Interviewees verbally consented to audio and video recording at the start of each interview prior to initiating the recording and received $50 Amazon gift cards for completing the interview. Zoom’s auto-transcription feature was used to generate preliminary transcripts. The research assistant then reviewed and corrected auto-transcription errors for each interview to reflect the content of the interview based on audio and video recordings.We used a rapid assessment approach to identify overarching patterns and used thematic content analysis to summarize key findings. To address our research aim of assessing the feasibility of earlier recommendation of HPV-9 in rural clinics, we identified and agreed upon an initial set of topical codes and interpretive codes using preliminary memos and discussion of themes. A codebook was developed to further define each code prior to coding all the transcripts. We used the online Dedoose software version 9.0.54  to apply topical codes to excerpts from qualitative transcripts. To address inter-rater reliability, two study staff  independently coded two different transcripts. Frequency and consistency of code application between the study staff was compared using the Code Application feature in Dedoose and discussed between the study staff to increase consistency between coders and increase the internal validity of the study analysis. In the first two transcripts, the two study staff had 65.5% agreement in code use. After resolving coding discrepancies, we fine-tuned the codebook to indicate more specifically when to apply and not to apply each code. While this pilot study did not intend to reach saturation of themes from a small number of interviews, we identified several themes that were reported by multiple interviewees and report these in the main results.We completed a total of 10 in-depth interviews with personnel from two rural clinics, including 2 providers, 4 nursing staff, 3 medical assistants, and 1 practice manager (Table 1). We also completed two in-depth interviews with key informants who were both medical providers in urban academic clinics; one provider was employed at a family medicine clinic, and the other was employed at a pediatrics clinic (Table 1).Rural clinic A was located in a county where most residents lived in rural areas, in contrast to rural clinic B . Both clBoth clinics had comparable proportions of patients with documented HPV-9 in their EMR , and similar distributions of HPV-9 initiation and completion by current patient age . CompletWe identified four predominant themes from the interviews: 1) clinics have created opportunities to recommend HPV-9 during well-child visits; 2) providers educate caregivers who are hesitant about HPV-9; 3) providers often consider the benefits of HPV-9 in the context of adolescent social and physical development; and 4) providers are generally willing and able to promote earlier HPV-9 in the clinic.Interviewees at both clinics reported that HPV-9 is standard of care for adolescents, and predominantly occurs during routine well-child visits. In preparation for well-child visits, a medical assistant (MA) will review the patient’s EMR to identify any gaps in vaccination according to the CDC’s recommended vaccine schedule. MAs also review the North Carolina Immunization Registry (NCIR), where use of state-purchased vaccines is required to be reported, to review patient eligibility for vaccination. Alerts are triggered in both systems at age 11, when a patient is eligible to receive adolescent vaccines per CDC recommendations.Though not routine, vaccinations are occasionally offered during sick visits to take advantage of the opportunity:“There are times where kids come in for non-well-child checks and are due for vaccines…. sometimes people will be like well, it's not a well-child check, so we're not going to do vaccines. I'm like well, they're here.” In addition, both clinics offer “nursing only” visits in which patients can receive vaccines without a provider consultation.Interviewees at both clinics reported that they rarely encountered hesitancy from caregivers to vaccinate their adolescent against HPV. However, interviewees had difficulty estimating their adolescent vaccination rates, and perceptions of the need to improve HPV-9 practices differed even within clinics.“We have no idea. We see a lot of adolescents.” "I guess I have not had anyone that I remember that refused the HPV-9.” “We need to work on the HPV-9 rate.” When asked how they handled HPV-9 hesitancy or questions from caregivers, all interviewees responded that they educate caregivers on the purpose of HPV-9 and its safety profile. The most common messages include the vaccine’s role in preventing HPV-associated cancers later in life.“Mostly it's in the 30s that we're seeing positive [HPV tests] for women, and I saw one male have a positive, so they're like your child can get this later in life. We can vaccinate now to prevent.” “[HPV is] a virus that causes really gross warts in your private area, but it can also lead to cancer later… we know that any person can get cancer in the future.” At times, an MA will brief the caregiver and patient on vaccines that are due, and they will report to the provider if any hesitancy was expressed. Providers reported that they were often able to persuade a hesitant or questioning caregiver to accept HPV-9 following a brief discussion of the benefits of the vaccine. Other times, caregivers have misconceptions about the HPV-9, which the provider must then correct.“if the provider [is] still kind of reviewing the next patient’s chart, I’ll kind of just get them real quick, I’m like hey they have questions, concerns. Because some parents will say yes to the provider.” “Sometimes they’re like, ‘well he’s a male, he won’t get it.’ I said, ‘you’re wrong because it can affect males as well as females.’” The child’s age and developmental stage was a common consideration among interviewees when discussing HPV-9 with caregivers. Several reported that caregivers expressed that HPV-9 was not appropriate for their adolescent, either because they are not yet sexually active and not at risk for HPV, or because they perceived HPV-9 as an enticement to initiate sexual activity. Several interviewees reported that they had children or grandchildren of their own and would want them to be protected against HPV-associated cancers.“I’ve certainly heard of people being hesitant to receive the vaccine because of concern regarding sexual promiscuity at a young age.” “I’m a mom. I have three kids, one of them is a male and two females. I really want them to be as protected as they can be.” When asked for their opinions on the ideal age to initiate HPV-9, all interviewees reported that 11–12 years (n = 2) or younger (n = 7) was ideal. The common justification was that HPV-9 should be given prior to the onset of sexual behavior to be most effective. Some interviewees reported that the youngest eligible age  was ideal, as they had heard of or encountered adolescents who became sexually active before age 11.When asked if they would be willing to recommend HPV-9 at ages 9–10 years, some interviewees themselves expressed hesitancy. Some believed that age 9 was too young, and that age 10 or older was sufficiently early to initiate HPV-9.“… It does feel a little bit funny and maybe that's because I have children in the single digits. I don't want my child to be a teenager at 9…” "Ten and 11 go to where you're going to middle school now and they are hearing more and more about it. 9, I think it is too young. It’s only one year difference, but I don't know, it sounds young.” Some interviewees initially questioned the benefits of earlier vaccination. When the interviewers provided some probes), interviewees tended to support earlier vaccination. Interviewees also generally agreed that earlier vaccination could be implemented in their practices with additional training and some minimal changes to current practices. However, some expressed reservations, suggesting that staff are not always amenable to change and that it could be difficult to convince all personnel to embrace earlier HPV-9."I will say more training and acknowledgement of this vaccine would be a really nice factor. Like reeducate staff on how to approach when it comes to offering a vaccine and using the word ‘highly recommended.’” “I’ll be honest, at our site… change is hard here.” Two key informants, one physician in a pediatrics practice (urban clinic A) and one in a family practice (urban clinic B) (Table 1), reported beginning discussions about HPV-9 with their 9- and 10-year-old patients. The pediatrician reported that the shift to vaccinating younger patients was a response to the clinic’s quality improvement (QI) metrics, and that initiating discussions about HPV-9 earlier at ages 9 and 10 increased the number of patients who received on-time vaccination according to clinic records.Other providers in the practice also adopted this strategy, in part to receive monetary incentives for having high metric scores. However, adoption was not universal, and a provider hesitated to support practice-wide mandates for early vaccination:“And so, I’ve been reluctant to have a practice-wide policy on timing [sic: age] about administration. I think it's fine to have a practice-wide policy on promotion.” This provider implemented an alternative vaccination schedule that retained the CDC-recommendation to co-administration of HPV with Tdap and Men4 vaccines, but allowed for earlier completion of the series, more time to complete the series on time, and fewer vaccinations per visit. When asked about challenges to implementing earlier HPV-9 across the practice, this provider mentioned very few barriers apart from having support from all providers. It was expressed that monitoring vaccination at ages 9–10 was easy as long as vaccinations were aligned with annual well-child visits:“That’s not hard… We try to do well visits on or after the birthday. With 6 to 12 months between doses one and two, if you just give it at your 10-year-old well-visit and then your 11-year-old well-visit, you're fine, you don't really need to track [the timing between doses].” A family medicine provider reported recommending earlier vaccination in response to the possibility of early sexual initiation. They also reported using every clinical opportunity to encourage vaccination, usually in advance of the CDC-recommended timeline:“The more times you mentioned something, the more likely someone is to be comfortable with it and just get it done… I talk about vaccines at almost every visit for everybody….” In contrast to the pediatric practice, one interviewee noted a limitation to implementing an earlier vaccination approach in a family medicine practice given the small number of adolescent patients and less urgency to adapt their existing systems.“It's difficult because if you don't have as many kids, then you don't really have the structure to make it really easy for parents.” This provider suggested earlier vaccination could reasonably be incorporated into current practice, and that modifications to existing EMR-based alert systems that provide notices when a patient is overdue for recommended vaccines would facilitate earlier vaccination.“So, if it doesn't add to the number of visits, then it seems to make sense to just do [HPV-9] at 9 and 10 and you can kind of get that over with, and then at 12, then they get their next you know set of vaccines… If they need time to think about it, then they have time to think about it. So, I feel like it makes sense to talk about it earlier rather than later.” “I do think that, if the [EMR alerts] fired at age 9 and said… your patient is now due for HPV, it probably would make a difference… At least we give the vaccination information sheet at that visit and then they have it ahead of time.” In interviews with providers and staff from clinics serving rural adolescent populations, we found a high level of support for earlier HPV-9 at ages 9 and 10 years of age. Interviewees suggested that their clinic procedures could reasonably be adapted to start recommending vaccine earlier than the CDC-recommended 11–12 years, with additional staff education needed. While EMR data from participating clinics show that fewer than half of patients had completed the HPV series by age 13, there is evidence that patients who initiated earlier were more likely to have completed vaccination, and to have completed on time. According to interviews with key informants from urban academic settings, some providers are already successfully providing HPV-9 earlier, and lessons learned can possibly be adapted to other primary care settings to improve the coverage of on-time HPV-9.21 In our study, two interviewees were not aware that 11 years was not the minimum age for HPV-9, suggesting that they had not previously considered vaccinating younger patients and that they had no preconceived notions about the practice. Furthermore, even among interviewees who were aware of the FDA approval for 9- and 10-year-olds, several could not initially describe any benefits to earlier HPV-9. Continuing education for providers and clinic staff should emphasize not only that HPV-9 is indicated for younger patients, but also that emerging data suggest that it can lead to better on-time coverage and optimal prevention.One important consideration of earlier HPV-9 recommendations is whether clinic personnel are aware that it can be administered to 9- and 10-year-olds. Prior studies on clinic personnel experiences with earlier HPV-9 did not measure their initial awareness of this option, which might have implications for its perceived acceptability.26 and only the pediatrician key informant emphasized QI metrics as a motivator to vaccinate earlier. In contrast, family practitioners tend to see fewer adolescent patients than pediatricians and are possibly less likely to report or fulfill QI measures related to adolescent vaccines, including HPV-9.29 While this pilot study cannot draw firm conclusions on the differences in motivations between pediatrics and family practices, more research on this topic is warranted.The two key informants from two academic clinics were in different stages of implementation of earlier HPV-9 vaccination: one had developed a protocol for early vaccination, including an alternative vaccine schedule, whereas the other simply introduced HPV-9 earlier. These differing approaches could reflect differences in the perceived importance of tracking adolescent vaccination rates between pediatrics and family practices. Tracking patient vaccination rates using EMR or immunization registries is an evidence-based practice to motivate providers to vaccinate their patients in a timely manner,30 Changes to these recommended ages identified by these alert systems might impel staff and providers to recommend vaccination to 9- and 10-year-olds without making any additional efforts. This successful change has been documented in a prior study of QI measures in a primary care network based in Columbus, Ohio, and more information is needed to understand how software programming decisions and modifications can be made in different clinic systems.12Some practice-based challenges make it difficult to start recommending and administering HPV-9 at ages 9–10. Interviewees reported relying on notifications from EMR or NCIR to determine when a patient was due for vaccination. While NCIR indicates an “earliest date” for vaccination at age 9, based on the patient’s recorded age, the “recommended date” is age 11 in accordance with CDC recommendations.This pilot study included a small number of clinics, all of which were affiliated with or proximal to a large, well-resourced academic center, and do not represent the experiences of clinics in more remote areas and with fewer pediatric providers. In addition, all participating clinics had sophisticated EMR that could be programmed to indicate when vaccines were due. One limitation of this data is that clinic EMR do not capture vaccinations that happened outside of the clinic system, and vaccination coverage based on EMR is likely underreported. Clinics with more rudimentary systems or paper records would have to identify other strategies for identifying vaccine-eligible 9- and 10-year-olds and monitoring vaccine receipt. However, the alternative vaccination timeline proposed by one of the key informants , could be implemented in any primary care clinic, with no need for additional tracking or alerts.HPV-9 of 9- and 10-year-olds carries several advantages and could be facilitated with provider education and support. However, while modifications to vaccination schedules can be implemented without major disruptions to current practice, it can be difficult to build support for such changes in settings with high patient volumes and limited time. This exploratory qualitative study provides insight regarding the current status of how HPV-9 vaccine is perceived by providers in real world settings and allows the research team to find effective methods to promote earlier HPV-9 as an effective, convenient, and acceptable practice for patients in rural settings.An earlier vaccination practice could be piloted in a small number of clinics that are willing and able, and lessons learned could be used to make practice-specific improvements to earlier vaccination practices. Findings from these studies could support effectiveness trials of a novel early HPV-9 intervention, and recommendations for implementing early vaccination in a variety of settings.


Compared to the HPV infection rate of women aged 56–65, that in women aged 35–45  and 46–55  decreased significantly. To conclude, risk factors of HPV infection among female patients include high school age and below, initial sexual encounter at age ≤ 19 years, number of sexual partners > 1, ASCUS and above, non-condom contraception, nationalities other than Han nationality and rural population. Collectively, this study provides insights for the improved prevention and treatment of cervical cancer.The different human papillomavirus (HPV) strains cause warts in various regions of the body. However, considering that the status and genotype distribution of HPV infection in women in Shenyang remain unknown, herein, we investigated the epidemiological characteristics of high-risk HPV (HR-HPV) infection in women in Shenyang, as well as the current state of HPV infection in Shenyang, to provide a theoretical basis for the prevention and treatment of cervical cancer. From December 2018 to December 2021, 6,432 urban and rural women from the Liaoning Cancer Hospital and the Sujiatun Women and Infants’ Hospital were assessed via the Thinprep cytology test (TCT) and HR-HPV detection. Of the 5,961 women enrolled, 739 were HPV positive (12.40%) and 562 were TCT positive (9.43%). Statistical analyses identified the following HPV risk factors: high school education or lower [OR = 1.426 (1.199–1.696),  In women, cervical cancer ranks fourth among all cancers in incidence (13.1%) and mortality (6.9%), only after breast cancer, colorectal cancer, and lung cancer . In 2020Human papillomavirus (HPV), a double-stranded circular DNA virus, is a papillomavirus belonging to the family Papillomaviridae. To date, more than 100 HPV genotypes have been characterized, forty of which are associated with human reproductive tract infections via uncontrolled induction of squamous epithelia proliferation within the mucosa . HPV repSignificant differences have been reported in HPV infection rates and types among people in different regions . For exaFrom a clinical point of view, epidemiological studies investigating HPV infection among women in different regions have been conducted to help reduce the prevalence of infection among women. However, to date, no study has reported on the status and genotype distribution of HPV infection in women in Shenyang. Therefore, the current cross-sectional study examines the prevalence and high-risk factors of HPV infection within women in Shenyang. Moreover, the epidemiological characteristics of HR-HPV in women in this region are assessed, and a novel strategy for the prevention and treatment of cervical cancer is proposed.This study was approved by the Ethics Committee of the Liaoning Cancer Hospital (ethics batch number: 20180106), and informed consent was obtained from all participants included in this study.From April 2018 through December 2021, 6,432 women in Liaoning were screened for cervical cancer at the Liaoning Cancer Hospital and the Shenyang Sujiatun District Women’s and Infant Hospital. The women selected for this study had an average age of 51.56 ± 6.621 years and a median age of 51 years. Community population and hospital outpatient opportunistic screenings were employed to evaluate whether participants met the following inclusion criteria: (1) the screening participants were selected by the community (village committee) and did not represent a single occupational group; (2) women from urban and rural populations with high incidence rates and mortalities and good population compliance were selected as the target population; (3) only participants with a registered residence in their regions  were screened; (4) women with a history of sexual life, aged between 35 and 65 years old (subject to the date of birth on the ID card); and (5) women with no serious organ dysfunction or mental disease, who voluntarily participate in and can accept the questionnaire survey. Exclusion criteria for screening objects included the following: (1) Women who have been diagnosed with a tumor; (2) women who are currently being treated for other serious internal and external diseases; (3) women who have had a hysterectomy; and (4) women who are pregnant and lactating.The Thinprep cytology test (TCT) was combined with HPV detection technology to screen cervical lesions. Each medical examiner took the stone cutting position. The vulva was fully disinfected and the cervix exposed with a vaginal dilator. Next, the cervix was wiped with a sterile cotton swab to remove excess cervical secretions. Finally, a disposable cervical cell sampling brush was rotated ten times within the scaly columnar junction of the cervix, removed, and stored in a cell preservation solution.A TCT (Thinprep cytologic test purchased from Hologic.lnc 20160621) test was used to obtain materials for production. The accompanying report was prepared based on The Bethesda System (TBS) for Reporting Cervical Cytology (2014). Abnormal results included negative for intraepithelial lesion or malignant tumor (NILM), atypical squamous cells of undetermined significance (ASCUS), atypical squamous cells cannot exclude high-grade squamous intraepithelial lesion (ASCH), low-grade squamous intraepithelial lesion (LSIL), high grade squamous intraepithelial lesion (HSIL), squamous cell carcinoma (SCC), and atypical glandular cells (AGC). A positive TCT diagnosis included patients with ASCUS, ASC-H, LSIL, HSIL, SCC, or AGC.The E6/E7 mRNA detection kit —an FDA-approved assay for detecting HPV—was used to detect 14 HR-HPV-mRNA causing cervical cancers . The results for HPV type 16 and 18 detection can be made available to provide clinical guidance. The kit detects E6 and E7, rather than L1, mRNAs of the HR-HPV virus to avoid the missed diagnosis of high-level lesions and cancer. Moreover, the test avoids cross-reactivity with low-risk HPV types, has fewer false positives, and avoids unnecessary colposcopy and overdiagnosis.Cervical exfoliative cells were examined using cervical liquid-based TCT. The diagnostic criteria are based on the TBS classification as outlined above . ColposcFor quality control purposes, 20% of the positive cervical exfoliative cell smears and 5–10% of the negative smears were randomly selected. All selected smears were rechecked by experts. The qualified rate of smear results reached 80%. Quality control of colposcopy samples entailed a spot check for 10% of the normal reports and 20% of abnormal reports, as well as subsequent analysis by experts. The standard rate of the report results reached 90%. Quality control of histopathological examination entailed a spot check of 10% of the pathological sections, subsequently rechecked by experts. The coincidence rate of the diagnostic results reached 90%.Analysis was performed on the basic population information, as well as the living habits, physiological indicators, psychological and emotional conditions, screening willingness, and other high-risk factors. The questionnaire posed question regarding demographic characteristics and risk factors that may be associated with HR-HPV infections. Additionally, participants answered questions meant to reflect their level of knowledge about, and overall attitudes toward, cervical cancer, HPV, and the correlation between the two. All questions were answered directly by each participant or by dictating answers to a study nurse.2) test. The influencing factors were analyzed using univariate and multivariate logistic regression to evaluate the correlation between the relevant factors mentioned in the questionnaire and HPV infection.Statistical analysis of the relevant data was conducted using the statistical package for the social science (SPSS) version 19.0 software. The count data rate (%) was analyzed using the chi-square , 941 were 41–45 years old (15.79%), 1,581 were 46–50 years old (26.52%), 1,443 were 51–55 years old (24.21%), 1,115 were 56–60 years old (18.70%), and 619 were 61–65 years old 10.38%; .Menarche age occurred between 12 and 18 years old in 97.94% of the participants. Menopause had occurred in 52.86% of the participants, most of whom were over 50 years of age. Moreover, 83.14% of the participants had a history of breast-feeding, and 71.26% breast-fed for more than 6 months. The population with multiple sexual partners accounted for 8.92 and 3.00% of the participants were aged < 19 years old at the time of their first sexual encounter. A total of 71.25% had a history of abortion; those with lover’s redundant prepuce and sexual bleeding accounted for 5.54 and 6.46%, respectively. A total of 22.18 and 17.55% women had a history of gynecological diseases and family histories of tumors, respectively .Current smokers accounted for 8.37% of all participants, while those who had quit smoking accounted for 1.21%. Passive smokers accounted for 62.44 and 82.17% of them were exposed to cooking oil smoke almost every day. Additionally, 11.06% of the participants had a history of alcohol consumption, and 1.02% reported current alcohol consumption. Moreover, 85.82% did not often participate in outdoor physical exercise, and 92.70% did not drink tea. More than 50% of the women had an insufficient intake of fresh vegetables and fruits with vegetable intake < 5 kg per week, and fruit intake < 2.5 kg per week. Approximately 70% of women did not meet the dietary guideline requirements set forth for Chinese residents .Of the participants, 60.69% had a good health status or self-rated their health status as good. An additional 9.21% had a history of hypertension, 3.62% of diabetes, 11.84% of hyperlipidemia, and 0.22% of mental health illness. Moreover, 20.33% of the participants experienced negative life events, 32.52% had depression or anxiety symptoms, and 35.31% had poor sleep quality .A total of 22.38% of the participants believed they could easily develop cancer, while 31.74% had been previously screened for cancer. Cancer screening for 27.38% of the participants was paid for by the government. Moreover, 28.07% indicated that they would fully accept cancer screening. Those who did not accept cancer screening listed time concerns and no conscious symptoms.In the case of abnormal inspection results, most women were willing to be re-inspected and felt they were able to cover the associated expenses. However, the acceptance rate for self-paid expenses was typically below 200 Yuan. Moreover, 92.35% of the participants indicated that they were willing to accept a follow-up visit in the case of abnormal results. The primary reason preventing participants from accepting subsequent appointments was the time requirement.Additionally, 91.01% of the participants indicated that they were willing to try new, more effective screening technologies, with acceptable out-of-pocket expenses for these technologies concentrated below 200 Yuan. The participants who were unwilling to accept new, more effective screening technologies, primarily showed concern for the scientific validity and safety of the new methods .All participants  completed gynecological examinations for cervical cancer screenings . The detin situ, and adenocarcinoma were not detected. Moreover, TCT-/HPV + accounted for 7.68% of the cases, TCT+/HPV- for 4.71%, and TCT + /HPV + for 4.71%.Of the 6,432 participants, 471 were excluded from the survey results. The remaining 5,961 participants were screened for cervical cancer and included in the statistical analysis . The aveOf the 5,961 participants, 739 (12.40%) tested positive for HPV , of whicThe 5,961 participants that were enrolled for TCT and HR-HPV screening from December 2018 to December 2021 were divided into six age groups, and the positive detection rates were determined for each. It was found that 35–40, 41–45, 46–50, 51–55, 56–60, and 61–65 year old participants had TCT positive detection rates of 9.92, 10.51, 10.94, 9.36, 7.71, and 6.95%, respectively . The prep < 0.05; A total of 28 potential risk factors may be related to HR- HPV infection. Univariate logistic analysis showed that HPV infection was correlated with different age groups, educational level, age at first sexual encounter, number of sexual partners, contraceptive methods, TCT positivity, nationality, and population , p = 0.046], number of sexual partners > 1 , assigned TBS classification of ASCUS or above , non-condom-based contraception , other nationalities except Han , and rural residence  were risk factors for HPV infection (p = 0.001] and 46–55  were significantly reduced.The results of the multivariate unconditional logistic regression analysis showed that high school education or lower [odds ratio (OR) = 1.426 (1.199–1.696), nfection . Comparein vivo, typically occurs over a span of approximately 10 years. Hence, interrupting the early stages of HPV infection, or early stages of cervical lesion formation may effectively prevent, or delay, the occurrence and development of cervical lesions and cervical cancer.Currently, cervical cancer is the second most common female malignant tumor after breast cancer. The incidence rate of cervical cancer has increased significantly and has become increasingly prevalent in younger women. As such, establishing effective preventative and therapeutic strategies for cervical cancer has become increasing important. Various studies  have repA recent study  found thAge differences were also observed with regard to HPV infection rate, in the current study. Previous studies have reported that HPV infection is more common in elderly women . Here, wPrevious studies have reported that first sexual encounters occurring before the age of 19 years represents an independent risk factor for HR-HPV infection. The cervical epithelial repair function and autoimmune function of women under 19 years of age are not yet fully mature, rendering them susceptible to HR-HPV . MoreoveConsistent with other studies , the curThis study also found that living in rural areas represents a high-risk factor for HPV infection, which may be due to a lack of cervical cancer screening services, poverty in rural areas, and poor education. Indeed, An international study conducted by IARC in 2011 showed that compared to those who never smoked, the risk of cervical cancer for current smokers was OR = 1.94  ; howeverCurrently, HPV vaccine research (preventive and therapeutic) has significantly increased. A study in the United States found that HPV preventive vaccines  are safe and have preventive and protective effects . HoweverThe occurrence and development of cervical cancer is a multi-factor, complex, and progressive biological process. Currently, the relationship between HPV infection, cervical cancer, and precancerous lesions is clear. Through cervical screening of female HPV infection rate, this study identified that a high school education or lower, age at first sexual encounter ≤ 19 years, number of sexual partners > 1, TBS classification of ASCUS or above, non-condom-based contraception, other nationalities except Han, and rural population serve as risk factors for HPV infection. It is, therefore, necessary to establish and improve the cervical cancer screening system according to the relevant factors affecting the incidence of cervical cancer, screen out and follow-up with high-risk groups, strengthen public education on prevention and treatment of cervical cancer, and improve awareness of cancer prevention among the general population. Moreover, targeted improvement measures for women in different regions are fundamental to reducing the positivity rate of HPV infection. Improving the living environment, improving education level, expanding health education, developing beneficial health habits, and actively preventing and treating HPV infection are the basic and effective ways to reduce the positive rate of HPV infection. Only by providing a large amount of epidemiological data can we carry out effective vaccine research and development while also optimizing the cost-effectiveness of vaccinating the Chinese population. Collectively, the results of this study provide epidemiological data for the development of an HPV vaccine, to effectively reduce the incidence of cervical cancer in Shenyang.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.This study was approved by the Ethics Committee of the Liaoning Cancer Hospital (Ethics batch number: 20180106), and informed consent was obtained from all participants included in this study. The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.HP and CW designed and supervised the project. DY, JZ, and XC collected the clinical data samples. DY collected and processed the data, performed the data analysis, and drafted the manuscript. JM translated and edited the manuscript. All authors reviewed, discussed and edited version of the manuscript, and agreed with the final manuscript.


HPV (human papillomavirus) is the virus most often responsible for sexually transmitted infections. The burden of HPV-related diseases on hospital resources represents a major public health problem. The objective of this study was to quantify the lifetime economic burden of HPV-related diseases based on hospital resources from the perspective of National Health Service (NHS) in England.Patients’ data were extracted, anonymised and aggregated by NHS digital from Hospital Episode Statistics (HES) database of patients admitted in 2015 and followed for three years. Data on hospitalizations were identified according to the International Classification of Diseases (ICD-10 CM). Health Resource Group (HRG) tariffs and National Reference Costs were used to estimate the hospitalization costs of anal, cervical, genital, oropharyngeal cancers as well as anogenital warts and cervical dysplasia.A total of 19,296 hospitalized patients were included in the estimation model, . Life-time costs per patients diagnosed with oropharyngeal cancer were £16,911 , penile cancer £12,539, vaginal cancer £12,676, anal cancer £13.773 . Cervical cancer accounted for £12,721, whereas cervical dysplasia for £3932. Resource used for hospitalized patients with anogenital warts was equal to £872 . On average, outpatient accounted for 39% of the total lifetime costs.The results of this study highlight that a substantial amount of resources is utilized for the treatment of HPV-related diseases at hospital level in England. These measures have the potential to inform policy decisions to ensure an optimal use of the NHS resources. Human papillomavirus (HPV) is the most common sexually transmitted virus and causes a substantial burden of disease in men and women . It is e® also protects against HPV 6 and 11. Gardasil9 was authorized in the European market in 2015 and protects against nine strains of HPV, including types 6, 11, 16, 18, 31, 33, 45, 52, and 58 [The availability of vaccines led to the beginning of population wide immunisation programmes in most Western countries. Three vaccines  are currently approved for the prevention of HPV infection. All of these vaccines are active against the high-risk HPV 16 and 18 strains, while Gardasil, and 58 .In 2018, following new scientific evidence and advice from an independent panel of experts (Joint Committee on Vaccination and Immunisation—JCVI), the UK Government extended the vaccination programme previously targeted to girls to include adolescent boys and protect them as well against HPV-related diseases. The decision followed that by the Italian Government which, in 2017, was the first of the G9 countries to introduce a universal, recommended and free vaccination for HPV for girls and boys at the age of 12 [As of today, the costs of treating HPV-related diseases in England are poorly understood. In specific, there is no evidence of studies providing a life-time estimations based on real-world data. Some studies provide snapshots of costs based on horizontal, multiperiod, analyses. For example, a study conducted in England on patients seen for outpatient and inpatient care with pre-cancerous and invasive vaginal and vulval cancer lesions, showed that between 2009/10 and 2014/15, the total cost of pre-cancerous and invasive vaginal and vulval cancer lesions in English secondary care amounted to over £14 million per year .Despite the above evidences, there has not been any attempt to estimate the lifetime costs of all the HPV-related diseases at hospital level in a single study. Furthermore, many of the published economic evaluations of HPV immunisation use estimations based on the cost of incurred by other countries.Thus, the objective of this research study is to estimate the lifetime costs of HPV-related diseases in England based on data from Hospital Episodes Statistics (HES). Specifically, the aim of this study is to estimate the current resource utilization for inpatient and outpatient procedures in England on patients diagnosed with anal, cervical, genital, oropharyngeal cancers as well as anogenital warts and cervical dysplasia.A retrospective case series analysis was conducted using patient level data extracted from the Hospital Episode Statistics (HES) database in England between 2015 and 2018. The HES database includes records of all care funded by the English NHS: all admissions, including patients resident outside of England, accident & emergency attendances, outpatient appointments at NHS hospitals in England, and care delivered by treatment centres (including those in the independent sector) funded by the NHS.Records were extracted on patients admitted in 2015/16 which was the latest full-year data available from HES at the time of data request. Patient data were collected based on ICD-10 codes which were identified based on advice from expert clinicians as well as previously published literature. Admitted patient care (APC) (inpatient) records were extracted from HES database based on the presence of the following ICD-10 codes: cervical cancer—C53, cervical dysplasia—N87, vaginal and vulvar cancers—C51-2, C57, anal cancer—C21, oropharyngeal cancers C01-2, C04, C06, C09-10, C12-14, C32, C49, penile cancer—C60, C63, anogenital warts—A63. Only patients who did not show any of the required ICD10 diagnoses in the three previous years to hospital admission and did not show any other malignant tumours in the two years prior to their first hospital admission were included. All finished consultant episodes (FCE) and outpatient attendances related to one of the selected ICD-10 codes were extracted from the HES database along with anonymised patient identification numbers to estimate the annual number of hospitalised patients. Each data extract was validated and cleaned prior to delivery by NHS Digital . The numThe annual management costs for anal, cervical, genital, oropharyngeal cancers as well as anogenital warts and cervical dysplasia were estimated from the health payers’ perspective. NHS funded healthcare providers in England are reimbursed under the Payment by Results (PbR) scheme. The currencies for payment under PbR are healthcare resource groups (HRG).To derive relevant HRGs for care delivered to patients with any of the HPV-related disease, inpatient FCEs were aggregated into spells of care . Core HRGs were then cross-referenced with the National Tariff 2015/18 to estimate the associated spell cost. Costing analyses were performed in Microsoft Excel 2016.The hospital cost per patient was calculated by first calculating the total HRG costs for each spell recorded in the data across all patients per year. Following this, the average hospital cost per patient was calculated by dividing the total HRG costs each year by the annual number of hospitalised patients in that specific year.Outpatient costs were estimated by grouping consultations by treatment specialty based on Treatment Function Codes (TFCs) and whether the consultation was the first of a series or a follow-up. Chemotherapy and radiotherapy costs are not included within the National Tariff due to wide regional variations in fees and practice. For such therapies, the HRGs derived from the HES data were cross-referenced with the 2016 National Reference Costs .Average inpatients and outpatients’ costs were then applied to the cohort of patients admitted in 2015 and followed for 3 years. By doing so, we sought to develop cost-per-case estimates that represented the current values of the total direct medical costs accrued from the time of diagnosis to the end of follow-up.Previous studies highlighted a great heterogeneity of data related to the epidemiology of HPV-related diseases. In specific, prevalence rates of HPV DNA and genotype attribution were reported to be very fragmented. To estimate the costs attributable to HPV types 6, 11, 16, 18, 31, 33, 45, 52 and 58, prevalence rates of HPV DNA and genotype attribution per condition were identified through a systematic review of the extant literature.Specifically, for each condition, we first retrieved the percentage of DNA attribution to exclude all cases that were not a result of HPV infection (Table The search was conducted in July 2020 and covered the period 2000–2020. Two independent researchers screened the titles and abstracts. Full-text articles were included if they reported: 1) epidemiological data on the prevalence of HPV DNA, (2) genotype attribution . Only studies derived based on real-world data, archival or population databases, such as national surveys or registries, were included. Due to the heterogeneity of the rates reviewed and the number of diseases involved, no standardization, meta-analyses or adjustments for the pyramidal stratification of the observed population were attempted. Data on cervical dysplasia were not robust, given that cases are not often reported in cancer registries. Therefore, confidence interval could not be extrapolated. The results of our search which was employed to estimate the HPV9 attributable fractions are illustrated in Table  epidemioA total of 19,296 patients diagnosed with anal, cervical, genital, oropharyngeal cancers, anogenital warts or cervical dysplasia were hospitalized in 2015 in England. Overall, 7,604 (39.4%) patients were males, aged on average 61, and 11,692 (60.6%) were females, with an average age of 50 years old. In Table Mean annual costs were calculated for each diagnosis. Life-time costs per patients diagnosed with oropharyngeal cancer were £16,911 , penile cancer £12,539, vaginal cancer £12,676, anal cancer £13.773 . Cervical cancer accounted for £12,721, whereas cervical dysplasia for £3932. Resource used for hospitalized patients with anogenital warts was equal to £872 . On average, outpatient accounted for 39% of the total lifetime costs. In Table Further, the total estimate of the annual economic impact on the NHS in England was calculated. As a result, hospitalizations for any of the HPV-related diagnoses accounted, on average, for £ 211.3 million Table .Table 4TThe fraction attributable to the nine HPV genotypes was £ 111 million (£ 99.3–£ 121.5) accounting for approximately 53% (47–57%) of the total annual burden of HPV-related diseases in England. Of these, £ 36.4 million (£ 36.1–£ 36.7) was referred to cervical conditions, whereas non-cervical malignancies accounted for £ 74.6 million (£ 63.2–£ 84.7). The fraction of HPV9 genotype costs attributable to men was equal to £ 45.4 million (£ 38–£52.3), while women accounted for €65.6 million (£ 61.3–£ 69.2). This corresponded to 59.1% (57–61%) of total costs attributable to HPV9 infections for women, whereas men accounted for 40.9% (38.3–43%).The purpose of this study was to estimate the economic burden of HPV-related diseases in England based on data from Hospital Episodes Statistics (HES). Moreover, this study estimated the current resource utilization for inpatient and outpatient procedures on patients diagnosed with anal, cervical, genital, oropharyngeal cancers as well as anogenital warts and cervical dysplasia.Our study adopted a real-world data approach to estimate lifetime hospitalization risk and costs and an overall estimation of the economic burden associated to HPV infection. Additionally, we included a stratification of the costs by year after the first hospitalization. Therefore, the present study was the first to measure the lifetime economic burden of HPV-related diseases in England considering a longitudinal perspective with newly available administrative data. By estimating the resource consumption attributable to the different diseases in a three-year time horizon, we aimed to estimate the overall economic burden sustained by NHS in England for inpatient and outpatient event associated with HPV-related diseases.According to the results of this study, the distribution of the patients profile by disease demonstrates the high impact of cervical dysplasia and oropharyngeal condition for adult patients , while cervical cancer and vaginal cancer occur in 18% of the total managed patients. When comparing our results to the available estimates in England, the results of our study confirm the economic burden caused by cervical and vulvar cancers to be major components of the overall direct costs estimations . Also, tThe present study has several limitations. First, real-world data from administrative archives were only available for inpatients and outpatients, and no assumptions were made regarding the cost of the drugs used for the treatment of these patients. Such partial use of the real costs may have led to the underestimation of the lifetime economic burden due to the lack of information about drugs. However, due to the increased number of outpatient management of these diseases  and the high impact of cancers on the productivity aspects of the diagnosed patients, we can assume that the economic burden estimated in this work represents just one-third of the total impact from the social perspective , 22–25.A second limitation refers to the possible codification problems; therefore some information may be missing and/or be wrongly reported. In this case, our analysis may have missed this information (due to the inclusion criteria), with the risk of underestimating the economic and epidemiological burden of the considered HPV-related diseases. Additionally, not all diseases led to hospitalization and this may be a further source of underestimation. These limitations should be considered in future research; however, in our opinion, they do not undermine the validity of the cost estimates in the present study or their estimated impact on the total economic burden of HPV-related diseases. Future research should address these gaps in epidemiological and cost data to reduce the uncertainty associated with the present estimates.This study represents the first economic analysis that estimates the effects of the overall HPV-related disease in England based on real-world data. Similar analyses have investigated only the burden of disease of some of the cancers considered in this study and often referred to the yearly costs sustained by the NHS perspective. This work is one of the first analyses to evaluate the effects of HPV-related disease management based on real-world data.