Objective: to measure the HPV vaccination rate and knowledge about HPV and its vaccine among foreign-born college students; additionally, to measure the effect of acculturation and HBM constructs on the HPV vaccination behavior among foreign-born college students. Methods: a cross-sectional design with a non-probability sample of foreign-born college students was collected via a web-based self-administered survey that measured the HPV vaccination rate, assessed knowledge about HPV and its vaccine, and evaluated the effect of acculturation and HBM constructs on HPV vaccination behavior among foreign-born college students. Results: Foreign-born college students had moderate knowledge about HPV and the HPV vaccine, and about 63% were HPV-vaccinated. Perceived susceptibility, perceived barriers, and cues to action were significantly associated with the HPV vaccination behavior, while knowledge levels about HPV and the HPV vaccine and acculturation levels were not significantly associated with the HPV vaccination behavior of foreign-born college students. Conclusions: The current study shows a moderate vaccination rate and moderate knowledge about HPV and its vaccine among foreign-born college students. Additionally, vaccination campaigns need to increase awareness about the susceptibility to acquiring HPV and minimize the barriers to receiving the vaccine to increase the HPV vaccination rate among foreign-born college students. Human papillomavirus (HPV) is the most prevalent sexually transmitted disease (STD), with over 43 million people already carrying HPV and 14 million contracting it yearly in the United States . The HPVIn 2018, over 1.7 million foreign-born students attended colleges and universities in the U.S., representing 9% of the U.S. college student population . RegardiForeign-born college students come from countries with different languages, beliefs, values, and backgrounds, and they must choose how much of their cultural identity to preserve and how much to adapt to the host culture when interacting with their new environment . AccultuAcculturation significantly impacts how foreign-born adults seek health information . HoweverThe Health Belief Model (HBM), a cognitive theory, was developed by psychologists to explain why many individuals failed to participate in a program that prevented and detected disease . The HBMThe HBM is one of the most extensively used conceptual frameworks in health behavior research, used to explain changes in health-related behaviors as well as to guide intervention design ,16. NumeWhile limited studies measured the HPV vaccination rate and knowledge levels about HPV and the HPV vaccine among foreign-born college students in the U.S., this study aimed to measure the HPV vaccination rate and knowledge about HPV and the HPV vaccine among foreign-born college students in the U.S. Additionally, while limited studies measured the effect of acculturation levels of foreign-born college students on HPV vaccination behavior, and no prior research measured the impact of six HBM constructs on the HPV vaccination behavior among foreign-born college students in the U.S., this study aimed to estimate the effect of acculturation levels and the six HBM constructs on the HPV vaccination behavior of foreign-born college students in the U.S.A quantitative cross-sectional survey with a non-probability sample of college students at Nova Southeastern University (NSU) was collected via a self-administered web-based survey. REDCap (Research Electronic Data Capture) is a secure online system for developing and administering web-based surveys. In April 2022, an email with a study invitation and survey link was sent to all NSU students. Students were eligible to participate in the study based on these inclusion criteria: (1) 18 years old and older, (2) proficient in English, and (3) able to provide informed consent. To increase the response rate, the first 400 student participants received a USD 15 gift card as compensation for their participation after completing the survey. A total of 2843 college students filled up the online survey. Only foreign-born college students were included in the analysis of this study (n = 376).The study survey consisted of a series of validated instruments, including a sociodemographic, HPV vaccination status, knowledge about HPV and the HPV vaccine, HBM constructs, and acculturation instruments. Ten student volunteers pre-tested these instruments to ensure the adequacy of the survey instruments.The HPV vaccination behavior was measured by using one item whereby students who received at least one dose of the HPV vaccine were coded as (HPV-vaccinated = 1), and those who did not receive any dose of the HPV vaccine were coded as (non-HPV-vaccinated = 0).Students were asked a series of questions regarding HPV and the HPV vaccine  adapted from different studies  vaccination is recommended only for women and girls” “HPV can infect the oral cavity, respiratory tract, and eyes” and “A person usually has symptoms when infected with HPV”) ,22,23. RThe HBM instrument contained six constructs of HBM  adapted from the literature ,25,26. TAcculturation was measured using a modified version of the East Asian Acculturation Measure (EAAM). EAAM was developed by Berry (2001), contained 29 items, and used a 7-point Likert scale to measure four acculturation modes: Assimilation, Integration, Separation, and Marginalization [t-test was computed to test the mean difference in HPV knowledge scores, perceived susceptibility, perceived severity, perceived benefits, perceived barriers, self-efficacy, and cues to action constructs across different HPV vaccination statutes and acculturation levels. Finally, multivariate logistic regression analysis was conducted to determine the unique effect of independent variables  on the outcome variable (HPV vaccination status of foreign-born college students). All data analyses were performed using IBM® Statistical Package for the Social Sciences (SPSS), version 28.0.Descriptive analysis was used to summarize and describe the data. The Chi-square test was calculated to test the difference in HPV vaccination rate and acculturation levels across different sociodemographic characteristics of foreign-born college students. Additionally, the independent samples A total of 376 foreign-born college students were included in this study. About 67% of them were females. The mean age was 25.4 years old, and about 65% were young adult students (18 to 26 years old). About 33% of foreign-born college students identified themselves as international students. Additionally, 42%, 22%, and 20% of foreign-born college students were Hispanic/Latino, White, and Asian, respectively. Further, 58% of foreign-born college students had been living in the U.S for ten years or less. A majority were in a health professional major (69%). Additionally, about 7% were HPV-positive and 5% had a family history of cervical cancer .p-value < 0.001). Additionally, about 72% and 46% of young adult students (18 to 26 years old) and middle-aged adults (26 years old and older) of foreign-born college students were HPV-vaccinated, respectively . Further, 72%, 69%, and 63% of Hispanic/Latino, Black, and White foreign-born college students were HPV-vaccinated, respectively . About 71% of foreign-born college students with more than ten years of living in the U.S. were HPV-vaccinated, while about 57% of foreign-born college students with ten years or less of living in the U.S. were HPV-vaccinated . About 54% of international foreign-born college students were HPV-vaccinated, while about 68% of non-international foreign-born college students were HPV-vaccinated   .p-value < 0.001). On the other hand, about 50% of low acculturated foreign-born college students were females and 63% were international students . Additionally, about 51% of foreign-born college students with high acculturation had ten years or less of living in the U.S. In comparison, about 85% of foreign-born college students with low acculturation had ten years or less of living in the U.S. .According to their acculturation score, 80% of foreign-born college students had a high acculturation level. A Chi-square test was performed to identify any significant difference in the sociodemographic characteristics between the two acculturation levels. About 72% of high acculturated foreign-born college students were female and 25% were international students   .Foreign-born college students had moderate knowledge about HPV and the HPV vaccine . Eighty-three percent of foreign-born college students did not know that no screening is used to test males for HPV infection. Additionally, about 61%, 60%, and 57% of foreign-born college students did not know that HPV infection can cause penile cancer, anal cancer, and oropharyngeal cancer, respectively. Additionally, about 79% of them did not realize that a condom does not prevent HPV infection .t-test was conducted to test the mean difference in HPV knowledge levels among foreign-born college students across different HPV vaccination statuses and acculturation levels. Foreign-born college students who received at least one dose of the HPV vaccine had higher knowledge levels about HPV and the HPV vaccine than those who did not receive the HPV vaccine . Additionally, foreign-born college students with a high acculturation level had higher knowledge levels about HPV and the HPV vaccine than those with a low acculturation level  (An independent sample < 0.001) .Foreign-born college students perceived the high severity of HPV and HPV-related diseases (M = 4.07), high self-efficacy to receive the HPV vaccine (M = 4.02), and high benefits of receiving the HPV vaccine (M = 3.99). In addition, they perceived high to moderate susceptibility to acquiring HPV (M = 3.12). Additionally, Foreign-born college students perceived low to moderate cues to receive the HPV vaccine (M = 2.86) and barriers to receiving the HPV vaccine (M = 2.30).t-test was conducted to test the mean difference of the six HBM constructs levels among foreign-born college students across different HPV vaccination statuses and acculturation levels. Foreign-born college students who received at least one dose of the HPV vaccine perceived a high susceptibility to acquiring HPV, perceived a high severity of HPV-related diseases, perceived more benefits of receiving the HPV vaccine, perceived fewer barriers to receiving the HPV vaccine, perceived more cues to receive the HPV vaccine, and perceived more self-efficacy to receive the HPV vaccine compared with those who did not receive the HPV vaccine .An independent sample p-value < 0.05)  .2 = 108.6, p-value < 0.001) and explained roughly 34% of the variation in HPV vaccination behavior of foreign-born college students (Nagelkerke R2 = 0.343). Three constructs of HBM  were significantly associated with the HPV vaccination status of foreign-born college students. Perceived susceptibility and cues to action were significantly associated with increased HPV vaccination behavior . The perceived barrier to receiving the HPV vaccine was significantly associated with decreased HPV vaccination behavior . However, knowledge levels about HPV and the HPV vaccine and acculturation levels were not significantly associated with the HPV vaccination uptake of foreign-born college students  on the HPV vaccination behavior of foreign-born college students. The model was significant . These results are consistent with other studies, whereas college students have moderate knowledge about HPV and the HPV vaccine . Most foPerceived susceptibility, perceived barriers, and cues to action constructs of HBM were significant predictors of HPV vaccination behavior among foreign-born college students. Foreign-born college students who perceived high susceptibility to acquiring HPV or HPV-related diseases were more likely to be HPV-vaccinated. This finding is consistent with other studies ,42. As aContrary to expectations, acculturation levels were not significantly associated with the HPV vaccination behavior of foreign-born college students, which is consistent with previous studies. Acculturation level did not affect Latina parents’ decision to vaccinate their children against HPV, and it did not affect the HPV vaccine completion among Latina adolescents ,43,44. HThe outcomes of this study have significant implications for researchers and healthcare providers. This study indicates that the HPV vaccination rate among foreign-born college students remains lower than the target of 2020 healthy people of 80%. Additionally, the findings of this study highlight a low to moderate knowledge level about HPV and the HPV vaccine among them. The study’s results help identify foreign-born college student categories with lower HPV vaccination rates. Additionally, this study’s results may help develop interventions to encourage foreign-born college students to receive the HPV vaccine. Educating foreign-born college students on the risks and vulnerabilities associated with HPV infection, providing a recommendation for receiving the HPV vaccine, and removing obstacles to receiving the vaccine can enhance their attitudes toward HPV vaccination. Therefore, healthcare professionals and student health centers can provide recommendations and education to encourage more college students to receive the HPV vaccine. Additionally, community pharmacists play a crucial role in boosting the HPV vaccination as they provide immunization services. Community pharmacists help educate foreign-born students about the importance of receiving the HPV vaccine and give recommendations for receiving the vaccine . This stSeveral limitations need to be acknowledged. First, the only language in which the study’s questionnaires were given out was English. Therefore, only foreign-born college students who were proficient in English were able to respond. Second, the convenience sampling method used in this study restricted the generalizability of the results to other populations. Third, foreign-born college students in this study were recruited from one university, which also restricted the generalizability of the results. Fourth, conclusions regarding causality were limited because of the use of a cross-sectional design in this study. Fifth, using a self-report survey in this study may include recall bias, which might overstate or understate the strength of the suggested correlations. Sixth, the lack of standardization for the health belief model instrument for the HPV vaccination behavior is another limitation of this study. Seventh, this study measured HPV and the HPV vaccine knowledge levels without evaluating the awareness of HPV and the HPV vaccine, which might overstate or understate their knowledge levels about HPV and the HPV vaccine. Lastly, this study compared foreign-born college students who received at least one dose of the HPV vaccine and those who did not without estimating the rate of foreign-born college students who received all doses of the HPV vaccine.This study was one of few studies that aimed to assess the HPV vaccination rate and knowledge of HPV and the HPV vaccine among foreign-born college students in the U.S. Additionally, it examined the effect of acculturation levels and six HBM constructs on the HPV vaccination behavior of foreign-born college students. This study indicates the percentage of HPV vaccination among foreign-born college students is still below the 80% target for healthy people in 2020. About three-fifths of foreign-born college students received at least one dose of the HPV vaccine, and they had a moderate knowledge level about HPV and the HPV vaccine. In addition, foreign-born college students with low acculturation had very low HPV vaccination rates and very low knowledge levels about HPV and the HPV vaccine compared with those with high acculturation. Perceived susceptibility, perceived barriers, and cues to the action of HBM constructs were significantly associated with HPV vaccination behavior among foreign-born college students. However, acculturation was not significantly associated with HPV vaccination behavior. Therefore, increasing awareness about the vulnerability of acquiring the HPV, recommending the HPV vaccine, and eliminating barriers associated with receiving the vaccine can improve the HPV vaccination rate among foreign-born college students. The results of this study offer relevant findings about HPV vaccination behavior and predictor factors of receiving the HPV vaccine among foreign-born college students in the U.S. Additionally, these findings may help in developing an intervention to enhance the vaccination behavior among this minor group of college students.


The role of human papillomavirus (HPV) antibodies acquired through natural infection and their role in protection for subsequent cervical or oral HPV-carriage remains unclear.A total of 267 women, with a 36-months follow-up, from the Finnish Family HPV (FFHPV) study were evaluated to shed more light on persistent HPV-specific antibodies to genital or oral HPV-carriage, clearance or persistence during the three years follow-up. The type-specific seroprevalence for HPV genotypes 6, 11, 16, 18 and 45 in these women was assessed in relation to the detection of the same genotype or any HPV in their oral and genital samples. The following HPV serological outcomes where detected: being always seronegative, seroconversion or persistent seropositivity.Genital HPV16 infections were most prevalent at the end of the follow-up (24- and 36-month visit) among women who tested always seronegative for HPV16. No such associations between serology and HPV detection were established for the other HPV genotypes in the genital or oral samples. The development of long-term type-specific HPV 6,11,16,18 and 45 persistence (≥ 24 months) or clearance of the genital or oral infections was not different among the women with high HPV genotype specific antibody levels and those testing always HPV-seronegative.No significant role was disclosed for the acquired natural high-level- or persistent HPV antibodies as determinants of the genital or oral HPV infection outcomes in these young, non-vaccinated women. Most mucosal human papillomavirus (HPV) -infections are transient and clear spontaneously by active immunological response within a few years –3. StillHPV infections in both oral and genital mucosa are known to elicit an immunological response producing HPV-type-specific antibodies , 6. HoweIn this study, we investigated type-specific HPV6, 11, 16, 18 and 45 antibody levels and their serological outcomes (i) persistent seropositivity, ii) seroconversion, and iii) always seronegative) during a 36-month follow-up, with special reference to the different outcomes of genital and oral HPV infections among young non-vaccinated women in a long-term cohort study.The Finnish Family HPV (FFHPV) study is a prospective cohort study conducted at the Department of Obstetrics and Gynecology, Turku University Hospital, University of Turku and at the Institute of Dentistry, Faculty of Medicine, University of Turku, Turku, Finland. The cohort included 329 pregnant women who were recruited between 1998 and 2001 (minimum of 36 weeks of pregnancy) and were followed-up for six years after the delivery. All participants were Caucasian origin and had the same ethnic background. The HPV results of the whole FFHPV study cohort (331 mothers and 131 fathers) have been reported in a series of previous publications, only few cited here , 13. A wThe present study focuses on naturally acquired HPV antibody levels for HPV genotypes 6, 11, 16, 18 and 45 and their association to the genital and oral HPV infection outcomes among 267 unvaccinated women from the FFHPV study . Of the Genital and oral scrapings from the women were collected for HPV-testing with a cytobrush  as described before . HPV genBlood samples were taken at baseline and at 12-, 24- and 36 months of the follow-up. The samples were collected between the years of 1998 to 2003. All samples were stored after collection first at − 20 °C for no longer than one week, and then at − 70 °C until the analyzed between the year 2008 to 2009 as previously described , 17. ThiP-value < 0.05 level.Frequency tables were analyzed using the χ2 test or the Fisher’s exact test for categorical variables. Differences in the means of continuous variables (i.e. log-transformed HPV antibody titres) were analyzed using ANOVA  after controlling for their normal distribution . Women’sThe mean age of the women at the time of enrolment to the FFHPV cohort was 25.5 years range 18–38). The key characteristics and the dynamics of seroprevalence, seroconversion and antibody decay of these women have been described in detail previously 8–38. The.First, we looked at genotype-specific serological outcomes as related to any-HPV genotype detection in the genital samples at the five follow-up visits as described in Table HPV-genotype-specific serological outcomes as related to the any-HPV detection in the oral samples at the follow-up visits are shown in Table Genotype-specific serological outcomes (high-titre antibodies (> 400MFI) vs. always seronegative) were compared among women with i) persistent (> 24-month) HPV, and ii) HPV clearance, in the oral and genital samples, separately Table . BecauseThe role of naturally acquired high-level HPV antibodies and their role in providing protections against new HPV-infections is conflicting . Our aimIn these analyses Tables  and 2, sWe also assessed the effect of higher-level (> 400 MFI) HPV 6, 11, 16, 18 and 45 L1-antibodies as predictors of long-term persistence or HPV-clearance of genital and oral infections, using the HPV6,11,16,18 and 45-negative serostatus as the reference. Thus, four subgroups arise: 1) high-titer HPV-persistent; 2) high-titer HPV cleared; 3) seronegative HPV-persistent, and 4) seronegative HPV cleared (Table With this present study, we were unable to demonstrate that categorization of HPV serology based on three-year follow-up or even using higher cut-off for HPV seropositivity for HPV6, 11, 16, 18 or 45 L1 proteins could confer a measurable protection against the infections by the respective HPV genotypes in young, non-vaccinated women. Some protection by the naturally acquired HPV L1-antibodies is likely, given that the strong antibody responses to prophylactic HPV vaccines are believed to be accountable for the protection against the future HPV infections among vaccinated women . The pro


Immunization is the most successful method in preventing and controlling infectious diseases, which has helped saving millions of lives worldwide. The discovery of the human papillomavirus (HPV) infection being associated with a variety of benign conditions and cancers has driven the development of prophylactic HPV vaccines. Currently, four HPV vaccines are available on the pharmaceutical market: Cervarix, Gardasil, Gardasil-9, and the recently developed Cecolin. Multiple studies have proven the HPV vaccines’ safety and efficacy in preventing HPV-related diseases. Since 2006, when the first HPV vaccine was approved, more than 100 World Health Organization member countries reported the implementation of HPV immunization. However, HPV vaccination dread, concerns about its safety, and associated adverse outcomes have a significant impact on the HPV vaccine implementation campaigns all over the world. Many developed countries have successfully implemented HPV immunization and achieved tremendous progress in preventing HPV-related conditions. However, there are still many countries worldwide which have not created, or have not yet implemented, HPV vaccination campaigns, or have failed due to deficient realization plans associated with establishing successful HPV vaccination programs. Lack of proper HPV information campaigns, negative media reflection, and numerous myths and fake information have led to HPV vaccine rejection in many states. Thus, context-specific health educational interventions on HPV vaccination safety, effectiveness, and benefits are important to increase the vaccines’ acceptance for efficacious prevention of HPV-associated conditions. Vaccines are one of the greatest healthcare successes of the 20th century, which facilitated a significant reduction in morbidity and mortality from diverse infectious agents ,2,3.The discovery of the causative role of human papillomavirus (HPV) in the development and progression of various benign and malignant conditions is considered one of the most significant events in medicine and global healthcare ,5,6. It According to the Centers for Disease Control (CDC), HPV is linked to more than 90% of anal cancer and cervical cancer cases, nearly 70% of vaginal cancer cases, and more than 60% of penile malignancy cases . These dThe worldwide HPV vaccination coverage in 2018 was reported to be 12.2% ,16. AccoVery early investigations of cervical cancer etiologies are now known to stem from the 19th-century works of Rigoni-Stern, who established a greater prevalence of cervical cancer among sexually active women compared to virgins and nuns ,19,20. LTremendous changes in the understanding of cervical cancer etiology and natural history have appeared after zur Hausen’s suggestion that cervical cancer could have an infectious etiology ,21,23. CIn 1979, Lutz Gissmann and Ethel-Michele de Villiers isolated the first DNA of HPV-6 from genital warts, which was not isolated from cervical cancer biopsies ,27,28,29In 1981, Professor Ian Frazer began his research career at the University of Queensland working on hepatitis B and the causes of liver diseases ,19,20. AIn order to elucidate the mechanism of cancerogenesis and to study the effect of persistent infection of the skin by HPV, Professor Frazer visited Dr. Margaret Stanley’s laboratory at Cambridge to work on mouse transgenic models of the HPV E6 and E7 oncoproteins ,36. AlthThe ideas of two genius minds resulted in a series of experiments. In 1990, they started working together to build the papillomavirus shell containing viral capsid proteins in monkey kidney cells using a recombinant vaccinia virus vector  19,37,3,39,40. TThere were multiple challenges on the way to success in the production of the first HPV vaccine as business developers and vaccine production companies were not convinced at the beginning about the necessity and the convenience of the market for such a vaccine ,19,33.In order to persuade the vaccine companies such as Merck and GlaxoSmithKline (GSK) of the importance of developing HPV preventive vaccine based on VLPs, it was necessary to prove that high-risk HPVs linked to cervical cancer are rather common among the female population ,33. StudProphylactic HPV vaccines’ mechanism of action is based on a deep understanding of HPV infection pathogenesis. Thus, in order to understand the mechanism of action of HPV vaccines, the pathogenesis of HPV infection needs to be revisited and fully elucidated.HPV is a double-stranded circular DNA virus with a genome consisting of nearly 8000 base pairs ,48. AfteIn order to clear the HPV infection, the host immune system activates CD4+ and CD8+ lymphocytes, macrophages, and natural killer cells, and produces neutralizing antibodies (NAbs). These HPV-specific NAbs target only viral particles, leaving infected cells out ,50,51,52The main purpose of preventative HPV vaccines is to induce a neutralizing antibody response to viral particles ,20; hencAccording to recent reports, the cellular immune response has been known to be crucial in the regression of the cervical lesions. This is due to the increased CD4:CD8 lymphocyte ratio in the cervical stroma, the CD4+ T-cell helper responses to E2, and the high amount of CD8+ T-cells against E6 and E7 proteins in spontaneously regressed tissues ,50.Currently, there are four prophylactic HPV vaccines available ,71,72,73The first vaccines were approved in 2006 and 2007 , and witAll prophylactic vaccines contain synthetically manufactured VLPs of the L1 epitope . In compHowever, since all currently available HPV vaccines are based on L1-VLPs, they are able to induce mostly type-specific immune responses . This isThere are two bivalent vaccines developed to prevent HPV-16 and HPV-18 infection: Cervarix by GSK and Cecolin by Xiamen Innovax Biotech Co., Ltd.The bivalent HPV prophylactic vaccine Cervarix was the first ever available HPV vaccine, produced by GSK and approved in 2007 for the prevention of HPV-related cervical cancer ,56. CervCompared to Gardasil, Cervarix has not been shown to be effective in the prophylaxis of cervical cancer . HoweverHowever, there are many other studies concerning the persistence of antibody responses following HPV vaccination ,67. SomeThe bivalent HPV vaccine Cecolin is a mixture of two aluminum hydroxide adjuvant-adsorbed recombinant L1 capsid proteins of HPV-16 and HPV-18, each self-assembled into VLPs. The formulation comprises 40 μg of HPV-16 and 20 μg of HPV-18 L1-VLPs suspended in 0.5 mL of buffered saline containing 208 μg of aluminum adjuvant ,69. The Cecolin has been available in China since 2020  and is iThe advantage of Cecolin  is in itThe quadrivalent HPV vaccine Gardasil was licensed in 2006 for the prevention of genital warts; cervical, vulvovaginal, anal intraepithelial lesions; and cancer in women and men aged 9–26 years  71,72,7,772,73. This vaccine is also recommended for girls and boys 11–12 years old, whilst there is a possibility to obtain a concurrent catch-up vaccination for the older generation. The original three-dose regimen at 0, 2, and 6 months was recently suggested by the WHO to be changed to a two-dose regimen 6 or 12 months apart, as the immunogenicity with two doses in prepubertal girls was noninferior to the immunogenicity with three doses in women aged 16–26 . The vacThe prophylactic efficacy has been evaluated in a number of phase II and III randomized, double-blind, placebo-controlled, multicenter studies, such as FUTURE I, II, and III, among more than 30,000 women of different age categories . The stuThe nonavalent HPV vaccine Gardasil-9 was licensed in 2014 for the prevention of genital warts; cervical, vulvovaginal, anal intraepithelial lesions; and cancer in women and men aged 9–45 years, covering five additional HPV strains compared to Gardasil  ,77. It hIn phase III trials and clinical studies, the efficacy of the quadrivalent and nonavalent HPV vaccines for the prevention of HPV-associated CIN I and II, and vulvar and vaginal intraepithelial lesions grade 2 and 3, was compared among 14,000 females aged 16–26 ,76. The A German study to evaluate the public health effects and cost-effectiveness of vaccination with Gardasil-9 indicated that the vaccination of boys with the nonavalent vaccine decreased the incidence of cervical cancer by 24% . This stMultiple reports have been published on the HPV vaccines’ local and general side effects, investigating and reporting on the vaccines’ safety ,80,81,82A systematic review that analyzed a total of 29,540 individuals reported that the most frequent adverse reaction associated with the HPV vaccines was pain and edema at the injection site, followed by fever, fatigue, and headaches ,83.In the HPV vaccines safety report by Arbyn et al. (2018), the risk of serious adverse events was shown to be similar in control and HPV-vaccinated women of all ages . In the Based on the available data, local symptoms were reported as the most common side effect ,74. HoweImmunogenicity is the capacity to create an immune response that could be measured either by antibody formation or cell-mediated immunity via cytotoxic T-lymphocytes .In the case of HPV vaccine immunogenicity investigations, the majority of studies measure serum-neutralizing antibodies as an immune response correlate ,88,89. HBivalent and quadrivalent HPV vaccines induce excellent protection against persistent HPV-16 and HPV-18 types ,89,90. Np < 0.0001) [A comparison of the immunogenicity between the bivalent vaccine Cervarix and quadrivalent vaccine Gardasil in healthy adult women aged 18–45 years showed serum-neutralizing antibody responses for HPV-16 and HPV-18 types induced by the bivalent vaccine to be 7.8-fold (in the 18–26-year-old group), 5.6-fold (in the 27–35-year-old group), and 2.3-fold (in the 36–45-year-old group) higher than the levels observed with the quadrivalent vaccine ( 0.0001) ,92. Acco 0.0001) .However, the age-related difference in immune response was documented with vaccine-induced antibody levels being higher in teenage girls and boys than in young women ,56,72,79The study on the immunogenicity of the bivalent vaccine Cecolin involving women aged 9–26 years (NCT02562508)  showed nAlthough the HPV vaccine efficacy is doubtless ,63,89, fVaccine schedules are usually planned with the aim of producing a strong and sustained antibody response for possible future infections. A three-dose regimen is a typical regimen for vaccines based on inactivated proteins for infants . The secConflicting data exist on the efficacy of the two-dose schedule over the three-dose schedule vaccination. In a secondary analysis of data from a randomized clinical trial (RCT) conducted more than a decade ago, Kreimer et al. 2011) observed that fewer doses received by 20% of the study population (women aged 18–25 years) in Costa Rica showed a similar incidence of HPV infection that persisted for >12 months compared to the population with a three-dose schedule 11 observ,97. AccoThe Indian RCT among girls aged 10–18 years vaccinated with the quadrivalent vaccine Gardasil has also demonstrated that participants who received three doses had an incidence rate of infection of 0.4% , whereas the two-dose schedule was associated with a higher incidence of 0.8%  , but thiNowadays, the data demonstrate that fewer than three doses of Cervarix and Gardasil provide protection against HPV infection and associated conditions ,90,99. IIn a Swedish study, one million women aged 10–24 years were followed-up for 6 months . The stuCurrently, available data demonstrate that fewer than three doses of bivalent and quadrivalent vaccines are at least partially prophylactic for preventing HPV-associated conditions . The sigIn the study by Iversen et al. 2016), for Gardasil-9, a two-dose schedule (0 and 6 or 0 and 12 months) in girls and boys aged 9–14 years, and a three-dose schedule  in women aged 16–26 years, were compared 16, for G. In thisAccording to a Cochrane review of 31,940 immunized participants with follow-ups up to 5 years, the immunogenicity of the two-dose HPV vaccine was similar to the three-dose schedule. Antibody response was stronger with a longer interval of 6 or 12 months between the first and the second doses than with an interval of fewer than 6 months .The analysis of data from the CVT and PATRICIA trial, which aimed to assess the efficacy of fewer than three doses among young women vaccinated against HPV-16 and HPV-18, has shown an efficacy rate of 77% for three-dose schedules, 76% for two-dose schedules, and 85.7% for a single-dose schedule after 4 years of follow-up ,100,104.Since many countries worldwide have not yet included the HPV vaccination in their national vaccine programs yet due to financial constraints, an opportunity for a single-dose HPV vaccination is of great interest as it may offer robust protection against vaccine-specific HPV types ,105.In the CVT and PATRICIA trial, researchers have demonstrated the efficacy of a single dose of the bivalent HPV vaccine against HPV-16 and HPV-18 ,100,104.Similar results were provided in an Indian trial among 17,729 vaccinated girls, where the immune response against HPV-16 and HPV-18 after a single dose was robust and sustained . HoweverThe proposal of a single-dose HPV vaccination is included in the HPV-FASTER protocol, which combines HPV screening and vaccination and aims to accelerate the reduction of cervical cancer incidence and mortality ,107. AccHowever, it is still questionable whether a single-dose or two-dose schedule for older age groups will be sufficient for high and long-lasting immunity . DefinitCurrently, the Costa Rica ESCUDDO trial, a double-blind, randomized, noninferiority clinical trial, is running to evaluate and compare the efficacy of one or two doses of the HPV vaccine . The resSince 2006, when the approval of the first HPV vaccine occurred, 55% of the WHO member states reported implementation of partial or national HPV vaccination ,17. AccoAlthough HPV vaccines are proven to be safe and their efficacy in preventing HPV-related conditions is well recognized ,63,78,79Many countries have succeeded with national HPV vaccination. There are several high-income countries that developed and implemented strong and sustainable HPV vaccination programs: Australia, the UK (England and Scotland), the USA, New Zealand, Sweden, Denmark, Canada, and Germany ,109. An Australia was the first country to implement a governmental, population-wide HPV vaccination campaign . The vacA meta-analysis of the studies from nine developed high-income countries , with the aim to investigate the population-level impact and herd effects following HPV vaccination, reported a significant decrease in HPV-16 and HPV-18 type prevalence in 68% of countries with HPV vaccination coverage of at least 50% . SubsequThe experience of two South American countries, Brazilian and Argentina, with HPV vaccination shows a good example of middle-income countries that developed a successful plan for the HPV vaccine implementation ,113,114.In Argentina, the HPV vaccine was approved in 2011 for female immunization as part of the national program on cervical cancer prevention . The tarHowever, there are still many countries worldwide that have not developed and implemented HPV vaccination campaigns yet due to limited funding and poor plans for realization ,17. MoreIn France, the HPV vaccination program has also experienced barriers to its implementation. France launched the HPV immunization program in 2007, initially covering 14-year-old girls . Later, Romania is another example of HPV vaccination failure. The HPV vaccination campaign started in 2008, targeting 10–11-year-old girls . HoweverSimilar issues related to unsuccessful HPV immunization and inappropriate information campaigns on HPV vaccination have occurred in many other countries. The initial Japanese HPV vaccination experience appeared with several reports on side effects, and in June 2013, the Japanese Ministry of Health partially suspended the HPV vaccination campaign . A similAs was discussed previously, HPV vaccine coverage leave much to be desired in many countries worldwide . There aRecent publications have identified and summarized several of the most spread myths about HPV vaccination ,126. TheDispelling myths and fake information, and providing evidence-based facts related to the HPV vaccination, will help to improve HPV immunization coverage by supporting parents who are willing to provide the best protection for their children .In 2018, the WHO announced the Global Strategy for Cervical Cancer Elimination, which assumes that 90% of girls will be fully vaccinated with any of the available HPV vaccines by the age of 15 ,128. DesEven with the many advantages that HPV immunization brings with its proper implementation, there are many drawbacks and limitations which might impact the vaccination coverage, and thus, should be explained and discussed. These limitations include: (1) the vaccines’ type specificity associated with L1 capsid proteins, specific for each HPV type; (2) the intramuscular or subcutaneous route of administration; (3) the target age group of early adolescence, which creates parental hesitance; (4) the considerable complexity of the vaccines’ formulation and maintenance due to cold-chain storage requirements; (5) the potential communication challenges due to the nature of the HPV infection being an STI and the diversity of cultural/religious beliefs; (6) the cost; and (7) the original three-dose schedule ,130,131.Each of the drawbacks should be addressed separately to improve the HPV vaccination uptake. The studies on the development of L2 protein-based HPV vaccines may potentially help to overcome HPV vaccines’ type specificity ,130,132.HPV vaccine information communication issues and the subsequent low vaccine uptake should be addressed via proper community education information campaigns by addressing parental concerns prior to and/or during the implementation of HPV vaccination, highlighting the vaccines’ safety and effectiveness in girls and boys in preventing HPV-related diseases; this is of paramount importance ,126,133.In 2018, the WHO announced and launched the Global Strategy for Cervical Cancer Elimination, with HPV vaccination being one of the important parts of this campaign. HPV vaccination effectively prevents HPV infection dissemination and the development of associated conditions, which include precancerous cervical lesions, genital warts, and laryngeal papillomas. Although research data show HPV vaccine safety, misinformation leading to HPV vaccination-related concerns has slowed the vaccines’ implementation and coverage in many countries. Moreover, the majority of LMICs do not have enough resources to launch HPV vaccination campaigns. Appropriate educational interventions, adequate implementation plans, and a continuous supply of HPV vaccines could contribute to and facilitate HPV vaccination campaigns and improve the coverage rates.


To investigate the influencing factors of the recurrence of IB1-IIA2 cervical squamous cell carcinoma after surgical treatment, and to explore the relationship between high-risk human papillomavirus (HR-HPV) infection and postoperative cervical squamous cell carcinoma recurrence.Patients (n = 312) diagnosed with stage IB1-IIA2 cervical cancer and treated by radical hysterectomy and lymphadenectomy at this hospital were accrued between January 2014 and December 2016. The clinical data of these patients were analysed, and the association among clinicopathological factors, the association among clinicopathological factors, HPV infection and recurrences was investigated through Cox regression.6 copy number / 104 cells). Twenty-nine patients had a postoperative persistent high level of HPV-DNA (9.3%). On multivariate analysis, deep 1/3 stromal invasion  and postoperative persistence of high HPV-DNA levels within 12 months  and 24 months  were associated with a higher local recurrence rate.The median follow-up time was 59.2 months (with a range of 14–77.9 months). The pre-operative HPV infection rate was 85.3% (266/312), and 74 patients had a high level of HPV-DNA (> 5 × 10Continuous high HPV-DNA levels within 24 months of an operation and deep 1/3 interstitial infiltration were independent risk factors for local recurrences of cervical cancer. The relationship between postoperative HPV infection and cervical cancer recurrences was explored for the first time.The genotypes and viral loads of 15 types of HR-HPV were determined.Continuous HR-HPV positivity after surgery and deep 1/3 interstitial infiltration were risk factors for the recurrence of cervical cancer. Cervical cancer is the fourth most common cancer among women worldwide. In 2018, there were an estimated 570,000 new cases and 311,000 deaths worldwide, including 106,000 cases and 48,000 deaths in China alone . Either the chi-square or Fisher's exact test was used for comparison between groups. Spearman rank correlation was used in the correlation analysis. The factors affecting postoperative recurrence were explored by univariate analysis, and the meaningful factors were then included in multivariate Cox regression analysis to further explore the independent risk factors affecting postoperative recurrence. The inspection level α = 0.05, The data of 1,030 patients from January 2014 to December 2016 were reviewed, of which 312 met the inclusion criteria. All 312 patients were treated by RH with lymphadenectomy, while 123 patients (39.4%) with pathological risk factors also received postoperative adjuvant radio/chemotherapy. The average age of the 312 patients was 47 (with a range of 25–73) years old. Pathologists confirmed no patients had parametrial invasions or positive resection margins. The average follow-up time was 59.2 months (with a range of 14–77.9 months). The characteristics of the patients are shown in Table Among the 312 patients, 266 patients (85.3%) were HPV-positive before the operation, including 227 patients (72.8%) infected by HPV-16/18 and 39 (12.5%) patients infected by 13 other genotypes of HR-HPV. There were 192 patients in the low HPV-DNA level group and 74 patients in the high HPV-DNA level group  patients were cleared of HPV 24 months post-operation. Regarding the postoperative level of HPV-DNA, 59 patients had a low level of HPV-DNA, and 29 patients had a persistently high level, including 11 patients within 12 months, 8 patients within 12–24 months and 10 patients longer than 24 months (Table The median follow-up time was 59.2 months (with a range of 14–77.9 months). Seven patients had a local recurrence and five patients had distant metastasis. The average local recurrence time was 12 months (with a range of 6–18 months). Three patients died of an uncontrolled local recurrence, while one died of liver metastasis. The five-year local recurrence-free survival rate was 97.8% (305/312 patients), and the five-year overall survival rate was 98.7% (308/312). The recurrence status of seven patients is demonstrated in Table p = 0.014*) and postoperative persistent high levels of HPV-DNA within 12 months  and 12–24 months  were associated with a higher local recurrence. Pre-operative HPV-DNA levels and HPV-16/18 infections had no impact on the local recurrence rate. Multivariate Cox regression analysis showed that the deep 1/3 stromal invasion , postoperative persistent high levels of HPV-DNA within 12 months  and 12–24 months  were the independent risk factors for local recurrence , which was in accordance with the former study. In addition to pathological risk factors, some studies focused on other factors, such as HPV infection status, including genotypes and viral load.Early-stage patients had a better prognosis than advanced-stage patients (IIB-IV) –18, but At present, more than 200 genotypes of HPV have been isolated and the carcinogenicity of different HPV genotypes varies widely . In the 4 cells might have a higher risk for residual lesions (p = 0.007). Furthermore, except for HPV-31/33, the viral loads of HP-16/52/58 showed significant differences in the number of residual lesions . Thus, they concluded that HR-HPV viral loads could be a reliable predictor of residual lesions [p > 0.05). Similar findings have been reported by previous studies [p < 0.001*) and 12–24 months  were independent risk factors for a higher local recurrence. Although this conclusion is inconsistent with Mahantshetty et al. [Chen et al. reported that women with viral loads ≥ 5.22 copies/10 lesions . The pre studies , 29. Howy et al. , both stCervical intraepithelial neoplasia is the precursor of cervical cancer . Adcock This study has some highlights. On the one hand, the genotypes and viral loads of 15 HR-HPV types were evaluated using a highly sensitive and specific HPVqRT-PCR kit. However, this study is the first to examine the relationship between postoperative HPV infection and recurrence. In addition, this study is a statistical analysis based on clinical data, which has high clinical significance. Nevertheless, there are also some limitations to this study. First, it was retrospective and lacked prospective interventional studies to verify. Second, statistics on postoperative complications were lacking, which is also a potential factor that has a great impact on the outcome. Thus, future prospective studies will be conducted to evaluate the prognostic value of postoperative HPV viral loads in IB1-IIA2 cervical cancer patients.This study shows that a continuously high HPV-DNA level within 24 months after the operation and deep 1/3 interstitial infiltration are independent risk factors for a local recurrence of cervical cancer. Therefore, early and accurate postoperative HPV-DNA detection is useful in evaluating the risk of postoperative recurrence for patients.


It is possible to eliminate cervical cancer by fully vaccinating 90% of girls by the age of 15, screening 70% of women between the ages of 35 and 45, and treating 90% of cervical cancer patients in low- and middle-income countries. Cervical cancer can now be prevented with HPV vaccination and screening, as well as treated with effective surgery, radiotherapy, and chemotherapy. Nonetheless, over 500,000 new cases were reported worldwide , Brazil , Philippines , Rwanda and Sierra Leone , China  , Peru , Latin American countries , and Kenya , written by experts on various aspects of the field that describe the issues, options, and outcomes available.This Research Topic is an excellent starting point for the project. It includes nine articles from Nepal .The main focus of these studies from low and middle income countries is the importance of laboratory readiness in the successful implementation of HPV testing. High readiness, however, is insufficient to ensure high continuity capacity for HPV testing, which necessitates the establishment of a quality culture that includes regular training, robust monitoring, and quality assurance systems tailored to the local context. All efforts to improve HPV laboratories are valuable and necessary to ensure the successful implementation of HPV-based cervical screening .The incorporation of new technologies and approaches in those fronts is expected to help drive the country toward an elimination target, single-dose HPV vaccination, and HPV self-sampling testing, which are very effective cervical cancer prevention strategies in low- and middle-income countries. Local and international collaborations are also required to improve secondary prevention and management by establishing a reliable infrastructure to treat HPV-related pre-invasive and invasive cancer . Improving data quality and completeness, which is a priority among national stakeholders, is critical. Investing in systems to improve the detection and treatment of precancerous lesions can improve patient outcomes and, in the long run, lower the costs associated with the much more expensive treatment of later-stage detection .Other studies on the Research Agenda should be conducted, such as implementation research, epidemiological studies, and clinical research on the cost-effectiveness and efficacy of various traditional and novel treatment strategies, in order to develop a locally applicable system for implementing a national cervical cancer screening and HPV vaccination program .Another issue raised by experts from low and middle income countries is awareness. Without policymakers' and the public's awareness and willingness to fund cervical cancer programs, the prioritization of cervical cancer activities, the availability of resources, an adequate health workforce and infrastructure, cross-sectional collaboration and planning, inter-sectorial, national, regional, and international partnerships, the goal of cervical cancer elimination would not be achievable in countries . Age, a history of alcohol consumption, marital status, reproductive diseases, education level, and the number of live births were all risk factors for HPV infection. Therefore, cervical cancer screening should be made available to women over the age of 30 in rural areas, particularly those aged 41–45 . Future research is required to clarify the relationship between empowerment and worker performance in order to inform the expansion of HPV self-sampling social entrepreneurship programs .Another important issue raised by the experts is socioeconomic inequalities, risk factors, and community-based social entrepreneurship. In low and middle income countries, rural-urban inequality and socioeconomic inequalities continue to be problems (The completion of such a task at the appropriate time indicates that the international scientific community strongly supports low-income countries in the field of cervical cancer, and thus future scientific support should be available when required. Our challenge is to reduce the mortality rate from cervical cancer, an infectious disease with well-established and highly effective prevention methods. In this regard, the prospects for low and middle-income countries should be brighter than they have ever been.The author confirms being the sole contributor of this work and has approved it for publication.


Objective: We aimed to investigate the relationship between titin (TTN) gene mutations and thyroid cancer (THCA) and to explore the feasibility of the TTN gene as a potential prognostic indicator of THCA.Methods: From TCGA-THCA cohort, we performed a series of analyses to evaluate the prognostic value and potential mechanism of TTN in THCA. These patients were divided into the mutant-type (MUT) group and the wild-type (WT) group. Differentially expressed genes (DEGs) in the two groups were screened using the ‘DESeq2’ R package. Functional enrichment analysis was performed, and the protein–protein interaction (PPI) network, transcription factor (TF)-target interaction networks, and competitive endogenous RNA (ceRNA) regulatory networks were established for the DEGs. The TIMER database was applied for immune cell infiltration. Survival analysis and Cox regression analysis were used to analyze the potential prognostic value of the TTN gene.Results: Differential expression analysis showed that 409 genes were significantly up-regulated and 36 genes were down-regulated. Functional enrichment analysis revealed that TTN gene mutations played a potential role in the development of THCA. Analysis of the immune microenvironment indicated that TTN gene mutations were significantly associated with enrichment of M0 macrophages. Survival analysis showed that the MUT group predicted poorer prognosis than the WT group. Cox regression analysis demonstrated that TTN gene mutations were an independent risk factor for THCA. Nomograms also confirmed the prognostic values of the TTN gene in THCA.Conclusions In summary, our results demonstrated that TTN gene mutations predict poor prognosis in patients with THCA. This is the first study to research TTN gene mutations in THCA and to investigate their prognostic value in THCA. Thyroid cancer (THCA) is the most common endocrine malignancy, and its incidence is increasing rapidly worldwide . ImplemeIn recent years, with the rapid development of molecular biology, it has been found that the occurrence and development of cancer are related to gene mutation and methylation. Many genes and biomarkers related to THCA have been reported. Currently, BRAF mutation, NTRK3 fusion, NRAS mutation, and RET fusion are of concern ,9. The dStudies have shown that titin (TTN) gene mutations are related to the occurrence and development of tumors. TTN genes, also known as TMD, CMH9, CMD1G, CMPD4, and EOMFC, encode proteins in striated muscle. The 127 TTN-coding sequence variants associated with human conditions are distributed as follows: 33 nonsense mutations, 32 frameshifts, 36 missense variants, and 22 splice-site variants . Recent In the present study, we aimed to explore the relationship between TTN gene mutations and THCA and to explore the feasibility of the TTN gene as a potential prognostic indicator of THCA. The results suggested that TTN gene mutations were closely related to patients with THCA and that the TTN gene was a potential clinical biomarker of THCA.n=568) were downloaded. In addition, clinical data of the control group (n=507) were downloaded using TCGA GDC software, including age, survival status, follow-up time, clinical stage, etc. Due to the exclusion of data with no survival information and incomplete TNM-staging information, 495 patients were retained for further analysis of clinical baseline data. These data were divided into the TTN gene mutation  group and the wild-type (WT) group.‘Masked Somatic Mutation’ data can be obtained from the TCGA GDC website and was defined as somatic mutation data in patients with THCA in the present study. Data were processed using VarScan software, and visualization of somatic mutations was performed using the MAFTools R package . Gene exhttps://cloud.genepattern.org) , WT group A. UnivarP=0.001] B. MoreovP=0.001] C. The efP=0.001] D.Finally, we analyzed the effect of TTN gene mutations on the drug sensitivity of patients with THCA and found that a variety of drugs were correlated with the level of TTN gene mutations, especially the druggable genome A. PathwaMany molecular alterations represent novel diagnostic and prognostic molecular markers and therapeutic targets for cancer, which provide unprecedented opportunities for further research and clinical development of novel treatment strategies . In receTTN mutations associated with human conditions include nonsense mutations, frameshift mutations, missense mutations, and splice site mutations. Studies have reported that TTN missense mutations are correlated with lung squamous cell carcinoma ,43. Our P<0.05).Increasing evidence has shown that immune infiltration is closely related to cancer . Novel-tP=0.001) than the WT group. Then, Cox regression analysis demonstrated that TTN gene mutations were an independent risk factor for THCA . More importantly, we combined TTN gene mutations with clinicopathological features to construct a nomogram. The nomogram also confirmed the prognostic value of the TTN gene in THCA. In addition, TTN mutations resulted in increased thyroid cancer sensitivity to eight drugs (P<0.05), especially the druggable genome. These results suggest that the TTN gene plays a unique and crucial role in the prognosis of THCA.Interestingly, we focused on the clinical significance of TTN gene mutations in THCA and discovered that TTN gene mutations may be a potential prognostic indicator for patients with THCA. First, survival analysis showed that the MUT group had a poorer predicted prognosis (PFI, HR=0.22, , Nevertheless, there are some limitations to our study. First, although bioinformatics analysis is a powerful and efficient tool to aid in understanding of molecular mechanisms and for identifying potential biomarkers underlying THCA, further experimental validations of the TTN gene are needed at the molecular, cellular, and organismal levels. Second, the present study focused on the prognostic value rather than the predictive value of TTN mutations in patients with THCA. Finally, further experimental evidence, such as evidence obtained from real-time PCR, western blot, and immunohistochemistry assays, is required to fully elucidate the role of hub genes and the underlying mechanisms of THCA.In conclusion, further exploration of the potential value of the TTN gene as a therapeutic target is highly warranted and may ultimately lead to the development of innovative drug therapies for complex and serious diseases. This is the first study to demonstrate TTN gene mutations in THCA and to investigate their prognostic value in THCA. The present study will provide a potential therapeutic strategy for thyroid cancers.In summary, new gene mutations in THCA have been identified through bioinformatics analysis, and these results contribute to the treatment and prognosis of thyroid cancer. This is the first study to demonstrate TTN gene mutations in THCA and to investigate their prognostic value in THCA.Click here for additional data file.


Many epidemiological studies have suggested that human papillomavirus (HPV), especially type 16, is involved in the genesis of squamous cell carcinoma of the oral cavity and oropharynx, especially in young, non-smoking patients; thus, its detection in lesions in this region is important.To clarify the capacity of the brushing sampling method to detect the presence of HPV in oral or oropharyngeal lesions through polymerase chain reaction (PCR) testing, and to compare the results with those obtained by biopsy.Prospective study of adult patients with oral or oropharyngeal lesions assessed by PCR, comparing biopsy specimens with samples obtained by the brushing method. The study was approved by the Research Ethics Committee of the institution.A total of 35 sample pairs were analyzed, but 45.7% of the brushing samples were inadequate (16/35) and, thus, only 19 pairs could be compared. There was agreement of results in 94.7% (18/19) of the pairs, with HPV identified in 16 of them. HPV DNA was detected in 8.6% (3/35) of biopsy and 5.7% (2/35) of brushing samples.There was no statistically significant difference between the two methods, but the brushing sampling method showed a higher number of inadequate samples, suggesting that it is an unreliable method for surveillance. Squamous cell carcinoma (SCC) comprises more than 80% of the mouth and oropharynx carcinomas and its incidence in the head and neck has been increasing over the last thirty years, especially in non-smokers and patients younger than 45 years of age.6For these reasons, it appears important to establish an affordable and reliable surveillance method for clinical or subclinical infection with high-risk HPV in oral and oropharyngeal mucosa for head and neck SCC prevention. HPV detection methods in SCC of the mouth and oropharynx show broad variations in sensitivity and specificity, with prevalence ranging between 0% and 78%; thus, it is very important to choose a method that has high sensitivity and specificity for HPV detection.Currently, the most often used method is reverse hybridization with degenerate primers labeled with biotin found in commercial kits, which allows the genotyping of most types of high and low-risk HPV. There are many factors that can affect viral detection, such as lesion location, presence or absence of keratinization, type of sample collected, and collection procedure , in addition to the methods used in detection.9Biopsy remains the preferred method for obtaining otopharyngeal lesion material, since, in addition to providing a more detailed morphological study, the biopsy sample allows the recovery of basal layer cells, where the HPV could be found in its latent form.This study aimed to compare, through polymerase chain reaction (PCR) and linear array hybridization, HPV presence in material collected by the brushing sampling method and biopsy of mouth and oropharynx lesions, testing the viability of the brushing sampling for collection of material from mouth and oropharynx lesions.This was a prospective cross-sectional study of 35 volunteers with oral or oropharyngeal lesions with indication for biopsy, consecutively treated at the otorhinolaryngology clinic of a general hospital, from April of 2012 to December of 2012, who met the following inclusion criteria: individuals aged >21 years of age, with white or red, vegetating, infiltrating, and/or ulcerated lesions in the oral or oropharyngeal cavity lasting more than 15 days. The exclusion criteria were clinical contraindication to the surgical procedure and antiviral use. HPV screening results were compared in the material obtained by brushing sampling method and biopsy of the same lesion.The project was approved by the Human Research Ethics Committee, registered under No. 192/09. Before being submitted to material collection, the selected patients signed the informed consent and answered a questionnaire on epidemiological data that included age, gender, tobacco and alcohol consumption, number of sexual partners during their lifetime and in the last six months, type of partner, and the duration and location of the lesion.Collection of the biological samples was performed by the same professional in a surgical environment, using aseptic techniques and locoregional infiltrative anesthesia with 1% lidocaine. Material collection was first performed using the brushing sampling method, by rubbing a Cytobrush Plus™ brush over the lesion using three forward–backward movements, followed by the biopsy performed with a scalpel blade, avoiding areas of necrosis and, whenever possible, including tissue adjacent to the lesion.The brush with the material was stored in a cryovial containing 0.9% aqueous saline solution, which was immediately frozen in liquid nitrogen at −170 °C. Subsequently, the biopsy was performed and the material was divided into three fragments: the first was placed in a 10% formaldehyde buffered aqueous solution for anatomopathological analysis, the second was used in this research, and the third was stored at the Biobank. The fragments were placed in separate and dry cryotubes and immediately frozen in the same container. All samples were transported to the freezer together, remaining frozen at −80 °C until they were processed by the Molecular Biology Laboratory.Samples were processed according to existing biosecurity standards. The in-house method was used for DNA extraction, in which the sample was digested with proteinase K, followed by purification with phenol/chloroform/isoamyl alcohol  and quantified in a Nanodrop1000 spectrophotometer (Thermo Scientific).The quality of the obtained DNA was verified by performing PCR of human β-globin with the PCO3/PCO4 primer with 110-bp amplicon . Both positive and negative samples for human β-globin were genotyped using a Linear Array Hybridization kit (Roche Diagnostics), which allows the identification of 37 types of HPV of high and low risk through linear reverse hybridization.z” test was used for quantitative variables. The null hypothesis was no significant difference between the two proportions, with a significance level of 0.05. The XLSTAT 2013.4.02 program was used to test the two proportions, with a right-tailed one-sided, 95% confidence interval for the difference between proportions.The statistical analysis of this study was descriptive, with the help of measures of location, and the results are shown in Biblioteca Virtual em Saúde (LILACS), using the following subject descriptors: polymerase chain reaction, human papillomavirus, oral mucosa, oropharyngeal mucosa, oropharynx, detection, brushing, and biopsy.The literature review was conducted online, using the databases of the US National Library of Medicine of the National Institutes of Health (PubMed) and the A total of 35 individuals were evaluated, 26 men and nine women, with an approximate male to female ratio of 3:1. Age ranged from 37 to 77 years, with a mean of 54 years. All individuals declared they were heterosexuals. Regarding social habits, 11 (31.4%) had never consumed alcohol regularly, 18 (51.4%) were not current users, and six (17.1%) still consumed; four (11.4%) had never smoked, 11 (31.4%) were ex-smokers, and 20 (57.1%) were current smokers.SCC was identified in 21 (60%) of 35 lesions (21/35); of these, 15 (71.4%) were moderately differentiated (15/21), three (14.3%) were well-differentiated (3/21), and three (14.3%) were poorly differentiated (3/21). Of the remaining lesions (14/35), five (35.7%) received an anatomopathological diagnosis of papillomatosis, three (21.4%) of squamous cell papilloma; three (21.4%) of ulcerated chronic inflammatory processes, two (14.3%) of lymphoma, and one (7.2%) of fibroepithelial polyp.As for lesion location, ten (28.6%) were located on the tongue, of which six were at the base of the tongue; nine (25.7%) in the palatine tonsil; seven (20%) in the soft palate; three (8.6%) in the cheek mucosa; two on the mouth floor (5.7%), and one each (2.9%) in the following locations: anterior pillar, uvula, lower lip, and oropharynx mucosa.All samples obtained through biopsy were 100% positive for β-globin; in contrast, in samples obtained by the brushing sampling method, positivity was 54.3% (19/35). Nineteen pairs were compared; in 18, there was agreement concerning the presence or absence of HPV DNA. Of the biopsy samples, three lesions were positive for HPV DNA: type HPV-16 in a patient also submitted to the brushing sampling method, type HPV-6 in a patient with base of the tongue lymphoma and HPV-11 in an oropharynx papilloma. For brushing sampling cases, HPV DNA was isolated from two cases of moderately differentiated palatine tonsil SCC .z-test for two proportions was right-tailed and one-sided, with a 95% confidence interval. The difference between the proportions was 0.020 and the z  was 0.230, with z  of 1.645 and p-value (one-sided) of 0.409; showing that there was no statistically significant difference between the proportions of HPV in both types of samples.Of the 35 samples obtained by the brushing sampling method, only 19 were analyzed, which were positive for the β-globin reaction, and of these, two were positive for HPV (2/19), with a proportion of 0.105263. As for the tissue samples obtained by biopsy, 100% were positive for β-globin, with three being positive for HPV, with a proportion of 0.085714. Only a pair of positive samples showed agreement with the genotyping of the correspondent sample obtained by the brushing method. The XLSTAT 2013.4.02 program was used to test the two proportions. The Head and neck tumors have a global incidence of 460,000 new cases per year, leading to 228,000 deaths estimated in 2014, according to the National Cancer Institute of Brazil. HPV-16 is responsible for 25% of all squamous cell carcinomas of the head and neck, and it is present in 45–90% of all cases of oropharynx tumors and approximately 24% of larynx and oral cavity tumors.p = 0.36), with an estimated error of 3% to define the sample size required for the analysis.17For this study, the number of cases was established based on the literature, where the prevalence of HPV in mouth and pharynx lesions is approximately 36%  agreement in pairs of samples. Termine et al., in a similar study, but not in oropharyngeal lesions, observed that the frequency of detection through brushing and biopsy sampling methods also showed no statistically significant difference, but the biopsy method showed to be more accurate in high-risk HPV detection.Lawton et al. assessed three sampling methods and concluded that mouth-rinsing, when used alone is the best method, but positivity can be increased when combined with other methods for material collection.Even though the brushing sampling method was performed according to standardized procedures and following previously established protocols, 45.7% of the samples (16/35) were inadequate for HPV screening, suggesting low sensitivity of the collection method, or incapacity of the brush, intended for use in gynecological collection, to obtain material from the mouth and oropharynx lesions, or because the medium in which samples were placed was not able to preserve them. Perhaps the choice of fixation and preservation solutions to be used with the brushing sampling method, such as PreservCyt™ solution,These results confirm the involvement of HPV in oral and oropharyngeal lesions, but further studies are needed to detail the collection method, with the investment in specific kits that can detect scarce cells, which will allow better identification of HPV in these HPV-related oral and oropharyngeal lesions, resulting in improved prevention and treatment.There was no statistical difference between the brushing and biopsy methods for detection of viral DNA in oral and oropharyngeal lesions, but the large number of inadequate samples obtained by brushing suggests this method is inefficient when obtaining samples from this type of lesion.10.13039/501100001807FAPESP.This study was funded by The authors declare no conflicts of interest.


Cancer in the head and neck region (HNSCC) is exponentially increasing due to human papillomavirus (HPV) infections. This paper helps us to understand the complexity of the inflammatory networks and the mechanisms of immune evasion in HPV+ HNSCC to open up new avenues and drive the discovery of useful tools to be translated clinically in the screening and treatment of these cases, especially to overcome resistance and improve patients’ quality of life.Head and neck squamous cell carcinomas (HNSCC) are a heterogeneous group of malignancies which have shown exponential incidence in the last two decades especially due to human papillomavirus (HPV) infection. The HPV family comprises more than 100 types of viruses with HPV16 and HPV18 being the most prevalent strains in HNSCC. Literature data reveal that the mutation profile as well as the response to chemotherapy and radiotherapy are distinct among HPV+ versus HPV-negative tumors. Furthermore, the presence of the virus induces activation of an immune response, in particular the recruitment of specific antiviral T lymphocytes to tumor sites. These T cells when activated produce soluble factors including cytokines and chemokines capable of modifying the local immune tumor microenvironment and impact on tumor response to the treatment. In this comprehensive review we investigated current knowledge on how the presence of an HPV can modify the inflammatory response systemically and within the tumor microenvironment’s immunological responses, thereby impacting on disease prognosis and survival. We highlighted the research gaps and emerging approaches necessary to discover novel immunotherapeutic targets for HPV-associated HNSCC. TP53 (84%), CDKN2A (58%), CCND1 (31%), and the overexpression of PI3K pathways (30%) in HPV-negative cases associated with tobacco, but fewer genomic alterations were observed in HPV+ HNSCC [Head and neck squamous cell carcinoma (HNSCC) represents the sixth most frequent cancer worldwide . HNSCC iTP53 8%, CDKN2AHPV+ OPSCC presents distinctive differences from HPV- tumors in the infiltrating immune cell population profile, underlining a unique biology of this malignancy ,8,9. TheInflammation in cancer has been described to initiate genetic instability in tumor cells . During The better prognosis of HPV+ HNSCC when compared to HPV- HNSCC has been associated with the higher number of TILs ,21,22. T+ T lymphocytes [The major components in the TME are the tumor-associated macrophages (TAMs) and they are highly dynamic and heterogeneous and are tamed by tumor cells to promote tumor growth and progression . TAMs caphocytes ,43. The phocytes ,17,25,26HPV is a group containing more than 100 different types of viruses with pathogenic behavior to humans . They arAmong HPV types, HPV16 and HPV18 are considered as high risk (HR) HPV and they are detected in 90% of the HPV+ HNSCC patients ,63,64. AThe HPV persistent infection also requires a tolerant TME-supporting virus evasion and/or the suppression of the immunological responses . The intIn HPV+ HNSCC, a higher M1/M2 TAM ratio can be observed ,88. M1 mdim [In general, HPV+ HNSCC show significantly higher levels of TILs, especially CD8+ T cells . Circuladim ,101. It dim ,103. A cdim . This laThe main treatment for HNSCC includes surgery or radiation for the early-stage disease . For recFurthermore, radiotherapy alone is known to induce substantial changes in the immune microenvironment in solid tumors . RadiothStandard treatment for locally advanced HNSCC consists mainly of chemoradiation using docetaxel, cisplatin, and/or fluorouracil in an attempt to eradicate potential microscopic residual cancer cells and ultimately improve loco-regional control and survival . HoweverThe determination of the HPV status may guide clinicians in their prognostic assessment and treatment decision-making in the HNSCC population . HPV+ HNThe adoption of anti-viral strategies to combat HPV infections, including anti-HPV vaccines, might also modulate the TME and influence the tumor response. HPV vaccines have a clear role in preventing cervical cancer and conditions related to HPV infection ,144. TheHPV vaccines commercially available to date  are able to induce immune response by blocking the viral fusion and entry into the host cell . SpecifiIn this review we discussed how the presence of HPV interferes with the local and systemic immune response that may lead to a complete response or resistance to the treatment and consequently impact on the prognosis and survival of patients with HNSCC. Understanding the immunological dynamic associated with tumor cell behavior is the key to developing novel immunotherapeutic targets and strategies to treat HNSCC.


HPV in head and neck cancers is commonly diagnosed by p16 IHC or by RT-qPCR of HPV-16 E6 and E7 oncoproteins. Droplet digital PCR has been reported as an ultrasensitive and highly precise method of nucleic acid quantification for biomarker analysis and has been used to detect oncogenic HPV in oropharyngeal and cervical cancers.Human papillomavirus (HPV) is responsible for most cervical cancers and some head and neck cancers, including oropharyngeal squamous cell carcinoma and sinonasal carcinoma. Cervical cancer is commonly diagnosed by liquid-based cytology, followed by HPV testing using commercially available DNA polymerase chain reaction (PCR), p16 immunohistochemistry (IHC), or DNA/RNA  Human papillomavirus (HPV) is the most common sexually transmitted infection (STI) in the world . and claCervical cancer screening and diagnosis is minimally invasive. It combines liquid-based cytology stained Papanicolaou stain (Pap smear) and HPV testing using DNA/RNA PCR-based methods , 13. TheFor head and neck cancers, p16INK4a (p16) immunohistochemistry (IHC) is a widely used surrogate marker for oncogenic HPV , 20. SinDroplet digital polymerase chain reaction (ddPCR) is a promising technology for the minimally invasive detection of oncogenic HPV. It allows for the quantification of the absolute amount of target nucleic acid present with high precision and reproducibility . ddPCR iHPV infection is recognized as one of the major causes of viral-related cancers in both men and women. It is classified into two categories: low-risk HPVs (LR-HPVs), which are responsible for skin warts on the hands, feet, and around the genitals and the anus, and high-risk HPVs (HR-HPVs) associated with anogenital  and head and neck cancers  . There aCervical cancer (CC) which includes the two major histology types squamous cellcarcinoma (SCC) and adenocarcinoma (AC), is the fourth most common cancer among women worldwide , 28, 29,e.g., United States, Canada, Australia, Sweden) have experienced an increase in the incidence of oropharyngeal cancer over the past two decades due to HPV infection, especially in men under 60 years of age (Head and neck squamous cell carcinoma (HNSCC) is the sixth most common malignancy worldwide , 31, 32 s of age . HNSCC as of age . HPV 16 s of age , 7. Mosts of age .Although sinonasal malignancies are rare, accounting for approximately 0.2% of all cancers and 3 to 5% of head and neck cancers , the sinAn understanding of transformation processes initiated by HPV infection has relied on the study of premalignant uterine cervical cells and has led to a recognized model of HPV carcinogenesis. The model parallels the normal HPV life cycle with initial infection, establishment, and maintenance, but with persistent infection of basal or stem cells, carcinogenesis can be initiated . PersistThe HPV oncoproteins E5, E6, and E7 play a role in infiltrating many signaling pathways to create favorable conditions for cellular transformation. The E5 protein has been demonstrated to play an important role during the productive viral life cycle of HPV . The rolAlmost all cervical cancers are caused by persistent infections with oncogenic strains of HPV, leading to the development of premalignant lesions and, eventually, invasive cancer . Since HHPV-related OPSCC is clinically distinct, affecting younger patients with fewer comorbidities, responding favorably to treatment, and portending survival outcomes compared to HPV-negative OPSCC, affecting older patients with a significant history of tobacco use and alcohol consumption , 50. HPVWhile the incidence of sinonasal carcinoma is low, their histology is among the most diverse ofall head and neck sites with several uncommon and distinct subtypes, several SCC variants,interesting etiologic lesions and HPV- related tumors . HPV-relBecause almost all cervical cancers and rising proportions of OPSCCs are attributable to HPV infections, universal access to vaccination against HPV could effectively reduce the incidence of these and other HPV-associated cancers . By reduCervical cancer screening and diagnosis is combined liquid-based cytology stained Papanicolaou stain  and HPV testing using DNA/RNA PCR-based methods , 13, 61.The current reporting system for Pap smears is the Bethesda System, which was introduced in 1988 and amended in 1991 to replace the cervical intraepithelial neoplasia (CIN) system. Burd et al.  summarizCytology screening is one of the most successful public health prevention activities worldwide. It has led to significant reductions in cervical cancer incidence and mortality, but it has significant limitations, such as low sensitivity and poor reproducibility . HPV tesPrimary HPV testing followed by cytology was accepted in Canada and Europe because of its safety relative to co-testing and reduction of required tests nearly in half, with a consequent reduction in the cost for screening programs . CombiniCollege of American Pathologists (CAP) and the 8th edition of the American Joint Commission on Cancer (AJCC8) recommend that, for a result to be considered positive, a threshold of at least 70–75% of tumor cells must show moderate to strong nuclear and cytoplasmic staining of the neoplastic cells. The threshold of at least 70% of positive tumor cells might be too high because it was found that there is a presence of nuclear and cytoplasmic staining in 50–70% of tumor cells associated with HR-HPV in a subset of patients (Immunohistochemistry (IHC) for p16INK4a (p16) is commonly used as a surrogate marker for the presence of HR-HPV E7 in tumor tissues and has become the clinical standard for HPV testing , 22, 68.patients . IHC forpatients .In situ hybridization (ISH) is a method used to detect nucleotide sequences based on the complementary binding of a nucleotide probe  to a specific target sequence of RNA or DNA in cells, tissue sections, or an entire tissue  is a widely used technique that allows a specific stretch of DNA to be copied exponentially in a short amount of time –77. TherThermus aquaticus for its heat stability, as it allows the enzyme to withstand the heating needed to denature DNA and maintain activity at relatively high temperatures which improve primer specificity  HPV DNA test was developed by Digene Corporation  and is now marketed by Qiagen  and approved by the FDA in 1999, and it replaced the original Hybrid Capture (HC1) tube-format assay, which was approved in 1995. It was the only test available until 2009. The HC2 is a microtiter-format nucleic acid hybridization assay with signal amplification for cervical specimens collected using the HC2 DNA collection device or HC cervical sampler  . The spevs. 4 ml) and has lower cross-reactivity with some LR HPV types compared to HC2  was approved by the FDA in 2009. It utilizes proprietary Invader Chemistry to generate signal amplification of a fluorescent probe to detect HPV DNAs from 14 HR types, including the same 13 types detected by the HC2 test plus HPV66 . The anad to HC2 . Its anad to HC2 .The APTIMA HPV assay  was approved by the FDA in late 2012. The assay qualitatively detects E6/E7 mRNA transcripts of 14 high-risk HPV types and uses a noninfectious RNA transcript as extrinsic process control . The assThe Cobas 4800 HPV test  was approved by the FDA in 2011 but has been available in the European market since 2009. It is a target amplification assay that detects the same 14 HR HPV types as the Cervista and APTIMA tests but also distinguishes HR-HPV types 16 and 18 , 79, 80.™ Cervical Test  is a qualitative lateral flow assay (strip test) that detects the elevated level of E6 oncoprotein expressed from HPV infected cells associated with the most common oncogenic HPV types 16 and 18  and more reproducible (Cohen’s kappa coefficient k = 0.60–0.93 vs. k = 0.46) but less specific (94.3 and 97.3%) compared to cytology for the detection of cervical pathology  and American Society of Clinical Oncology Guidelines (ASCO) is p16 IHC, and additional molecular HPV-DNA testing may also be performed at the physician’s discretion. However, HPV testing is not recommended for other HNSCC  ) for Aptima HPV E6/E7 mRNA and 78.9–86.9% (k 0.49–0.58) for cobas HPV DNA (89). Agustin et al.  from plasma by using ultra-sensitive droplet digital PCR (ddPCR) has garnered a growing clinical interest in HNSCC and CSCC. HPV ctDNA detection in the plasma of HPV-related OPSCC patients using ddPCR is highly sensitive and specific in identifying HPV16 and HPV33 subtypes in a similar distribution as reported in major genomic profiling studies . Their rThe quantitative method of ddPCR is characterized by its high sensitivity, its accuracy, and its inter-laboratory and intra-laboratory reproducibility , 71. The®) but in smaller volume-precise reactions or partitions which are then run individually. Positive reactions are checked and calculated among each partition using Poisson distribution  in CSCC. HPV VL is an important determinant of virus persistence, and therefore VL quantification is a useful tool in preventive strategies as well as a biomarker for monitoring treatment response and prognosis estimation in HPV-related diseases , 97. ddPHPV detection using ddPCR has been demonstrated in OPSCC FFPE tissues, tissue biopsy, fine needle aspiration (FNA) biopsy, and swabs. Schiavetto et al.  detectedSeveral studies have demonstrated the effectiveness of self-sampling vaginal swabs as a screening tool for CSCC in the minorities and lower socioeconomic groups, remote or hard-to-reach areas, and low-resource settings. The HPV self-sampling was effective in detecting HPV and as sensitive as clinician cytology samples to detect CIN2 or higher , 101–103The routine practice for cervical cancer diagnosis is minimally invasive and utilizes liquid-based cytology, followed by HPV testing using commercially available p16 IHC, DNA/RNA ISH, or DNA/RNA PCR. For OPSCC, the main HPV detection method available is for fresh, frozen, or FFPE tissues using p16 IHC and/or DNA/RNA PCR. For other HPV-related HNSCC, however, HPV testing is not a standard procedure. The sinonasal tract is the second anatomic subsite of the head andneck for HPV-related carcinomas and favorable HPV prognosis is unresolved, therefore moreresearch studies is essential to better understand the role of HR HPVs in sinonasal carcinoma.Self-sampling HPV testing could be used in the future to replace Pap smears and cervical exams as first-line screening for cervical cancer. However, to ensure similar or better accuracy compared to clinician-collected samples, a test with high analytical sensitivity and specificity is required. For HPV-related HNSCC, swabs will be sufficient for diagnosis, without the need for highly invasive tissue biopsy. p16 IHC is the most widely used method due to its availability in laboratories, but the results can be highly variable, as the criteria for interpretation are not standardized. The commercially available HPV testing methods approved for cervical samples, including HC2, Cervista, Aptima, and Cobas 4800, all have comparable sensitivity and specificity. In comparison to cytology and p16 IHC, they have higher sensitivity but lower specificity.The new generation of HPV assay, such as ddPCR, is highly sensitive and can be performed on non-invasive samples, such as those obtained using swabs. ddPCR has the potential clinical applicability in early HPV detection for screening, diagnosis, and disease surveillance. It has the ability to amplify a target sequence from minimal RNA samples and provides significantly higher precision and sensitivity for specific DNA/RNA compared to traditional PCR.JW designed the manuscript and wrote the first draft. MK and VB edited the first draft. JW and VB edited and revised the manuscript. All authors contributed to the article and approved the submitted version.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.


This study aimed to provide basic data for the clinical application of urine samples to prevent cervical cancer due to persistent HR-HPV infection in women who refuse invasive cervical sampling. Pairs of cervical swabs and urine samples were collected from 210 asymptomatic women who visited the obstetrics and gynecology department from August to December 2020, and a total of 420 samples were collected. Using the PANA RealTyper™ HPV Screening Kit as a real-time PCR method, paired cervical swabs and random urine samples were tested. A total of 19 samples (9.1%) were both HPV positive and 177 (84.3%) were both negative. The concordance between the two types of samples was 93.3%, with κ = 0.69 . The HPV infection rate by age was highest in both cervical swabs and urine samples in women in their 30s, followed by those in their 20s. Thus, the HPV infection rate was high in young women under 40 at 69.2% in cervical swabs and 61.8% in urine samples. Urine samples are considered a valuable screening test for women who refuse invasive Pap tests to prevent cervical cancer caused by persistent HPV infection. Cervical cancer incidence in many developed countries has decreased significantly with the introduction of Pap test based cervical cancer screening programs, emphasizing the importance of early diagnosis and prevention . HoweverIn Korea, in order to prevent the increase in cervical cancer incidence and the rate of HPV infection among people in their 20s and 30s, a screening system has been established that allows women over 20 to receive a Pap test every two years for free . HoweverArbyn et al. 2014); Arbyn et al. 2018) recommended HPV testing using self-collected specimens as a strategy to increase the screening rate in women who do not undergo regular cervical cancer screening  recommen. However; Arbyn eThe purpose of this study was to confirm the usefulness of using urine samples as a screening test to prevent cervical cancer caused by persistent HR-HPV infection in women who refused invasive cervical sampling and to suggest an additional cervical screening process.A pair of cervical swabs and urine samples were collected from 210 asymptomatic women who visited the obstetrics and gynecology department from August to December 2020, and a total of 420 samples were collected. Cervical swab samples from patients who visited the obstetrics and gynecology department were collected by trained gynecologists, and urine samples were self-collected. This study was conducted under the approval of the Institutional Ethics Committee of the Catholic University of Busan .® 100 Resin solution  according to the manufacturer’s protocol. 200 μL of the sample was transferred to a new E-tube, centrifuged at 8000× g for 10 min, the supernatant was discarded, and 100 μL of 5% Chelex® 100 Resin solution was added to the remaining cell pellet, followed by vortexing and spinning down. Then, samples were incubated at 100 °C for 10 min, centrifuged at 11,000× g for 10 min, and supernatant transferred to a new E-tube. The extracted genomic DNA was checked for concentration and purity using a NanoDrop 2000  and stored at −18 °C before analysis.DNA extraction was performed using 5% ChelexThe PANA RealTyper™ HPV Screening Kit  detected HPV DNA through real-time PCR (qPCR) using CFX96  for 14 high-risk  and two low-risk  HPV subjects. For real-time PCR, 5 μL of DNA extracted from the sample, 19 μL of HPV mix, and 1 μL of Taq DNA polymerase were mixed to a total of 25 μL. Then, by setting a baseline for each fluorescent dye, infection and HPV genotype were confirmed according to the melt temperature value of the melting peak for each fluorescent signal.MY11/MY09 primers, and nested PCR was performed for secondary amplification using GP5/GP6 primers [MY11 is GCM CAG GGW CTA TAA YAA TGG, MY09 is CGT CCM ARR GGA WAC TGA TC, GP5 is TTT GTT ACW GTK GTR GAT AC, and GP6 is GAA AAA TAA ACT GTA AAT CAT ATT C. Each PCR product was analyzed by electrophoresis in 2% agarose gel. HPV-infected specimens were detected at 150 bp. Gels near 150 bp were extracted for HPV DNA sequencing. PCR products were re-amplified using BigDye Terminator  and GP5 primers, and HPV DNA sequencing was performed using ABI3730XL . The Basic Local Alignment Search Tool version 2.10.1  was used for HPV genotyping.For HPV DNA sequencing, primary amplification was performed using  primers . The nucConcordance between the results was analyzed using Kappa statistics  and defined as “None” (0.00 ≤ κ ≤ 0.19), “Minimal” (0.20 ≤ κ ≤ 0.39), “Weak” (0.40 ≤ κ ≤ 0.59), “Moderate” (0.60 ≤ κ ≤ 0.79), “Strong” (0.80 ≤ κ ≤ 0.89), “Almost perfect” (0.90 ≤ κ < 1), or “perfect” (=1) [A total of 420 cervical swabs (n = 210) and random urine samples (n = 210) were collected from 210 women aged 20 to 85 years (mean age 39.9 years) and used in this study. Of all 210 women, the age distribution included 42 (20.0%) women in their 20s, 81 (38.6%) in their 30s, 42 (20.0%) in their 40s, 25 (11.9%) in their 50s, and 20 (9.5%) in their 60s and older.Using the PANA RealTyper™ HPV Screening Kit as a real-time PCR method, 19  cervical swabs and random urine samples were HPV-positive, and 177 samples  were negative. The concordance between the two types of samples was 93.3%, with κ = 0.69 . The prevalence of HR-HPV positivity for 14 types, including HPV 6 and 11, was the same at 12.4% (26/210) in cervical swabs and urine samples .HPV positivity in cervical swabs was 30.8% (8/26), 38.4% (10/26), 11.5% (3/26), 11.5% (3/26), and 7.8% (2/26) in under 20, 30, 40, 50, and over 60 years of age, respectively. HPV positivity in random urine samples was 26.9% (7/26), 34.6% (9/26), 19.2% (5/26), 15.4% (4/268), and 3.9% (1/26) in under 20, 30, 40, 50, and over 60 years of age, respectively. The HPV infection rate by age was highest in both cervical swabs and urine samples for women in their 30s, followed by those in their 20s. That is, in young women under 40, HPV infection rate was high at 69.2% (18/26) in cervical swabs and 61.8% (16/26) in urine samples .In real-time PCR analysis, in the case of cervical swabs/urine (+/+), HPV DNA sequence was detected in 78.9% (15/19) of cervical swabs and 68.4% (13/19) in urine. In the case of cervical swab/urine (+/−), the cervical swab sequencing detection rate was 57.1% (4/7), which was higher than the urine sequencing detection rate of 14.3% (1/7). On the other hand, in the case of cervical swab/urine (−/+), the detection rate for cervical swab sequencing was 28.6% (2/7), which was lower than the urine sequencing detection rate of 57.1% (4/7). In the case of cervical swab/urine (−/−), the detection rates of cervical swab and urine sequencing were the same at 2.8% (5/177) .Persistent HPV infection is known as a major cause of cervical cancer . HoweverTM II HPV 28 , and Cobas 4800 HPV , which showed concordance rates of 84.2% (κ = 0.51), 81.2% (κ = 0.44) and 86.1% (κ = 0.33), respectively [In another study comparing HPV detection in cervix and urine samples from patients with high-grade lesions of the cervix, the concordance rates of the two types of samples were 79.8% (κ = 0.36) and 86.2% (κ = 0.72) ,13, respectively . Althougectively ,25. An Eectively , and HPVRecently, a high rate of HPV infection in women in their 20s has been reported in Korea . We deteMY11/MY09 and GP5/GP6 genes. When both a cervical swab and urine were positive for HPV real-time PCR, HPV DNA sequencing was detected in 15 out of 19 cases (78.9%) in cervical swab, and 13 cases (68.4%) in urine samples. The sequence was detected. Also, out of 177 cases where both cervical swab and urine were negative in HPV real-time PCR, HPV DNA sequencing was detected in five cases (2.8%) each of cervical swabs and urine samples. In this study, nested PCR is an HPV DNA sequencing method with high sensitivity and specificity, but it can detect only a single infection, limiting the accuracy of determining HPV complex infections. However, the results of this study suggested that HPV could also be detected in urine samples. In this study, an experiment was conducted on random urine from asymptomatic women. Various studies on urine samples, such as first-void urine, first urine in the morning, daily urine, and self-collected samples, should be continued to standardize the type, collection method, and storage of urine samples that are advantageous for HPV detection [In this study, HPV detection results using real-time PCR were 12.4% (26/210) in the cervix and urine samples, lower than the HPV prevalence demonstrated in other studies ,23. Thisetection ,29. In aetection , if the In this study, the concordance of HPV infection between cervical swabs and urine samples was found to be 93.3%. HPV DNA testing using urine samples is evaluated as a valuable screening test for cervical cancer prevention for women who refuse the invasive pap test. In addition, the introduction of an additional cervical screening process for clinical application of urine specimens is expected to help prevent cervical cancer caused by HPV infection by increasing the screening rate of women.