HPV vaccination has been recommended and reimbursed for girls in Germany since 2007. In June 2018 the German Standing Committee on Vaccination (STIKO) recommended the gender-neutral vaccination of adolescents aged 9 to 14 years with catch-up through age 17. Objectives of this study were to describe the uptake of vaccination in boys before and during the COVID-19 pandemic.The study used data from a proprietary electronic medical record database and a database with information on nationally dispensed vaccine doses. The monthly number of first doses of HPV vaccinations in boys and girls aged 9–17 years in the period from 01/2018 to 12/2021 was determined. In addition, for boys the cumulative vaccination rates were calculated for initiated and completed vaccination series.Four months after the introduction of mandatory reimbursement for boys, the monthly numbers of first doses were comparable to that of girls. Compared to the same month in 2019, the number of first doses declined by up to 49% (girls) in 2020 and 71% (boys) in 2021. At the end of 2021, the vaccination rate for 15-year-old boys (2006 birth cohort) reached 44.4% for initiated and 26.4% for completed series.After an initial dynamic increase in HPV vaccinations in boys, the impact of COVID-19 was particularly strong in the second year of the pandemic. At the end of 2021 vaccination rates were still low. Efforts are needed to catch-up on adolescents that missed doses during the pandemic and to increase uptake. Human papillomaviruses (HPV) are the most common sexually transmitted pathogens, with nearly 100% of all women and men contracting an HPV infection at least once in their life [HPV infection can cause a number of diseases in women and men, including genital warts (condylomata acuminata) and various types of cancers . HPV is HPV vaccination for girls – initially only for the 12–17-year-old age group with a 3-dose-schedule – has been recommended by the Standing Vaccination Committee (STIKO) since 2007. Since 2014 the recommendation has included standard vaccination for girls aged 9–14 (2 doses in months 0 and 6–12) and catch-up vaccination for girls aged 15–17 . Both vaccination schedules should be completed within a year. [The high burden of disease of HPV-associated cancers in menThe proven efficacy and safety of HPV vaccination in menThe estimated positive epidemiological impact on HPV-associated cancer case numbers in Germany, especially given the low vaccination rate for girls and the resulting still moderate level of herd immunityGender equalityIn June 2018 the STIKO extended the HPV vaccination recommendation to boys in the same age groups . This deBased on the decision of the Federal Joint Committee (G-BA) of September 20, 2018, HPV vaccination has been reimbursed as a compulsory benefit of all the statutory health insurance schemes for both sexes aged 9–17 since January 2019 [Generally only physicians are permitted to vaccinate in Germany and there is no general invitation or reminder system. Exceptions only exist for COVID-19 vaccinations . For HPVTo our knowledge, this is the first study to examine the uptake of HPV vaccination among boys based on the monthly number of vaccinations in Germany, including the dynamic during the COVID-19 pandemic. The primary aim of the study was to describe the nationwide number of administered monthly first doses of HPV vaccinations in boys aged 9–17 for 01/ 2018 to 12/2021 to observe the dynamic of the vaccination uptake and compare those data to those of girls. The monthly breakdown of administered doses is an outcome that is not reported from other data sources but is a unique tool to assess short-term uptake dynamics, particularly during COVID-19. The evaluation was stratified according to the old (former West Germany) and new  federal states of Germany, relevant medical specialist groups and co-administration of other vaccines with the HPV vaccine. To also consider the size of the eligible population and to make results comparable to other national and international reports, our secondary aim was the calculation of the cumulative vaccination rates for boys as a measure of population-wide coverage by male birth cohort.The study is a retrospective cohort study based on two proprietary databases: IQVIA™ Vaccine Analyzer  and IQVIA™ PharmaScope Vaccine DocSplit . The Vaccine Analyzer database has been previously shown to be representative and suitable for pharmacoepidemiologic studies by Ohl et al. . In thisThe Vaccine Analyzer identifies HPV vaccinations administered in a nationally representative panel of 460 office-based physicians from 353 practices in the specialist groups of general practitioners and internists , pediatricians and gynecologists. Information is collected on the patient’s gender, year of birth, date of vaccination, vaccine product administered, co-administration of other vaccines, physician’s specialty and region of the practice . Additionally, an anonymized patient ID is generated for each patient. For the analysis of co-administrations, only those vaccines  were selected for which the National Advisory Committee “STIKO” recommends boosters for the respective age group which are also those vaccines for which data on concurrent administration exist according to the Summary of Product Characteristics (SmPCs) of the European Medicines Agency (EMA).The nation-wide numbers were then extrapolated utilizing the second database (PharmaScope) together with the distribution per month observed in the Vaccine Analyzer for stratifications by gender, age group, and other the variables. The PharmaScope database provides information on the number of nationally prescribed doses within the statutory and private health insurance sector in Germany without information on gender, age or other variables: For the doses reimbursed through statutory health insurances (relevant for approximately 85% of the German population) data from all relevant German pharmacy data processing centers are captured . For doses reimbursed by private health insurances (relevant for the remaining approximately 15% of the German population) individual prescription data from a panel of approximately 4500 pharmacies  are used and extrapolated to the total number of pharmacies in Germany, taking into account certain characteristics. Pharmacies are stratified into 77 clusters, partially without geographical adjacency. Those 77 clusters are defined by sociodemographic homogeneity, purchasing power, population structure and insurance status and other factors and separated by, e.g., metropolitan from provincial areas in Germany. Additionally, 3 pharmacy turnover-size classes are defined : S constitutes 30% of the total national sales potential, M the middle next 30%, L the top last 40%.The terms “patient”, “physician”, “medical practice”, and “pharmacy” used in connection with the data refer to anonymous, not personal, information pursuant to relevant data-protection regulations.In accordance with the vaccination age recommended by STIKO, the analysis included 9–14 and 15–17-year-old male and female adolescents born between 2000 and 2012 who received at least one HPV vaccine dose during the study period (January 2018 to December 2021). Since the database does not contain information on the exact date of birth, the vaccinees’ age was calculated as the year of the respective dose (first or last dose for completed series) minus the year of birth.Bivalent and 9-valent vaccines  were available in Germany during this time.A dose was classified as first dose if no other dose was recorded in the database within 18 months before the vaccination date. According to the vaccine product labels and STIKO, the vaccination series should be completed within 12 or 13 months (depending on 2-or 3-doses scheme), so the 18-month window provided an additional buffer period. Vaccination series completion was defined as having 2 (for 9–14-year-olds) or 3 (for 15–17-year-olds) doses observed within the study period. It is possible for someone to have received a dose in a practice outside of the utilized panel, which would not be captured in the Vaccine Analyzer database, resulting in some misclassification. Additionally, because of the missing exact age some misclassification may occur for 15-year-old individuals. The birth cohort turning 15 in a given year was counted to the 9–14-year-old age group and thus 2 doses were considered as series completion, although they may have actually been already 15 when they received their first dose and consequently required 3 doses for completion.For the primary study objective, the nation-wide number of administered first HPV vaccination doses was calculated for each month between January 2018 and December 2021 using monthly numbers of doses from the Vaccine Analyzer database and applying those to the nation-wide number of dispensed vaccine doses in the PharmaScope database. Thereby, nation-wide estimates on administered doses stratified by gender, age , specialist group , and region (West excluding Berlin vs. East including Berlin) were generated. In addition, the frequency of co-administration with tetanus, diphtheria, pertussis and polio vaccinations was analyzed. This study focused on descriptive statistical analyses of the available data.For the secondary objective, the cumulative vaccination rates in boys, were estimated per birth cohort for the observation periods 2018, 2018–2019, 2018–2020 and 2018–2021. For those vaccination rates, the number of patients with a documented full series of vaccinations in the Vaccine Analyzer was extrapolated to national level with the aid of PharmaScope. The vaccination rates were calculated as the ratio of extrapolated vaccinated patients and the German population number based on the German Federal Statistical Office. Because of the time lag in the publication of the annual population figures by the Federal Statistics Office, the population estimates for 2018 were the denominator for all observation periods.While monthly numbers of vaccines administered to girls were included in the analysis, the cumulative vaccination rates for girls were not calculated in the present analysis because, unlike boys, girls had already been eligible for vaccinations for several years before the start of the study, and the size of girls already vaccinated before the study period and the size of still unvaccinated girls was not known in the study population.This study was conducted according to Guidelines for Good Pharmacoepidemiology Practices. The utilized databases contain only anonymized data and address all data protection regulations in Germany. Therefore, no ethics review was needed by an independent ethics committee or institutional review board.In each month between January and May 2018, between 49 and 681 boys in the 9–14 age group and between 0 and 268 boys in the 15–17 age group across Germany received a first dose of HPV vaccination. The monthly number of first doses of HPV vaccination in girls between January and May 2018 was 25,028–33,009 (9–14 years) and 5123–10,257 (15–17 years). After the STIKO recommendation for boys was issued (June 2018), the number of monthly HPV vaccinations in boys increased from 366 to 7560 in the 9–14 age group and from 466 to 2110 in the 15–17 age group between June and December 2018 , the number of first doses of vaccination in the 9–14 age group increased by a factor of 2.7 compared to the previous month  over the entire year up to March 2021 . Looking at the younger and older age groups, 21% of the girls and 19% of the boys in the 9–14 age group and 43% of the boys and 27% of the girls in the 15–17-year age group received their first vaccination from a general practitioner. 25% of the 9–17-year-old girls were vaccinated by a gynecologist . The comparative figures for girls aged 9–17 was 23.7%   and 1.2% . By the end of 2019 the vaccination rates (2018–2019) for first doses increased to values between 6.5%  and 20.9% . End of 2020, the first year of the COVID-19 pandemic, the vaccination rates (2018–2020) ranged between 5.8%  and 35.2% . At the end of the study period in December 2021, the cumulative vaccination rates for first doses for boys was between 6.2%  and 44.4%   between 0.8%  and 8.0%  and at the of 2020 (2018–2020) between 0.9%  and 18.7%  of boys completed a full series of HPV vaccination. Between 1.1%  and 26.4%  of boys received a full HPV vaccination series by the end of the study period (December 2021)  and 18-year-olds (2000–2003 cohort) were especially looked at. In 2018, the year of the recommendation, few first doses of HPV vaccination were given in both age groups: 0.8% in 15-year-olds and 0.5% in 18-year-olds. At the end of 2019, 18.0% of 15-year-old boys and 7.2% of 18-year-old boys received their first HPV vaccination. By the end of 2020, 33.9% of 15-year-old and 19.5% of 18-year-old boys had started an HPV vaccination series, and by the end of 2021 those figures had risen to 44.4 and 29.7%, respectively  reached 44.4% for first doses of vaccination and 26.4% for a full vaccination series. The number of HPV vaccine doses administered per month fell substantially among German adolescents during the COVID-19 pandemic (2020/2021 compared to the same months in 2019). In 2020, the biggest declines were seen during the first lockdown. The dip in first doses of HPV vaccinations was even greater in 2021, with the monthly uptake falling short of the 2019 figures by up to 71% for boys and 60% for girls. While initially COVID-19 vaccinations for adults were provided largely in public COVID-19 immunization centers, since April 2021 COVID-19 vaccinations were also offered by most office-based physicians. In June 2021 STIKO published a COVID-19 vaccination recommendation also for children and as for adults, vaccinations were provided by office-based physicians in addition to immunization centers. Initially the recommendation was only for children of high risk 12–17 years old, in August for all children 12–17 years old and since December 2021 also for children 5–11 years old .Vaccination rates for both, first doses and full vaccination series were generally higher in the new federal states (former GDR) than in the old federal states of Germany (former West Germany). This is in line with HPV vaccination reports from the Robert-Koch-Institute . It poinInitial data from the vaccination surveillance by the RKI have so far only been published for 2018 and 2019 and show HPV vaccination rates of 5.1 and 2.5% for complete vaccination series for 15- and 18-year-old boys, respectively, at the end of 2019  and hencFor girls, the costs of the HPV vaccination were covered for the first time in 2007 for 12–17-year-olds, and in a survey later that year 23.8% of the girls in this age group reported having received at least one HPV vaccination . At firsIt is striking that the percentage of boys who did not complete an initiated vaccination series is almost twice that of girls if comparing our data with those official figures from girls. This might be due to the COVID-19 pandemic. Another reason for this gap in series completion might be the limitation of the data source: the results can only provide a snapshot with regard to completion, since the study period did not always allow a full vaccination series to be given, e.g., people administered dose 1 in 2nd half of 2021 may not be eligible for dose 2 in the same year. Moreover, there is the methodological limitation that the Vaccine Analyzer does not allow patients to be tracked across different medical practices, so that the data do not reflect the completion of a vaccination series in cases where patients changed practices. It is reasonable to surmise that this affects mainly the older age group in which patients transitioned from a pediatrician to general practitioner. Nevertheless, those potential methodological limitations inherent to the Vaccine Analyzer can likely be considered as minor because the methodology has been validated against the official surveillance data from the RKI for other vaccines and calendar periods and good agreement has been found .The results of the study also provide insights into the implementation of HPV vaccination in terms of the vaccinating physician’s specialty and co-administered other vaccines on the day of HPV vaccination. For both sexes, we found that pediatricians cover the majority of HPV vaccinations, mainly in the younger cohort of 9–14-year-old children with 61% of first doses in girls and 77% of first doses in boys. But particularly in the older age group of 15–17-year-old adolescents we show that general practitioners and in girls also gynecologists cover a significant amount of HPV vaccinations. To not miss older children before they drop out of reimbursement, it is important that general practitioners and gynecologists are aware of their key role and implement HPV vaccinations in their practice accordingly. This may be particularly important now to catch-up on those that missed doses during the COVID-19 pandemic. Another important finding is that approximately only a quarter of HPV vaccinations in the study population were given concomitantly with Tdap-IPV vaccines. It may be worth exploring whether appointments for other vaccinations may be more often used also for HPV vaccinations, as long as in line, with the product’s label.th among 25 European countries and is nowhere near to reaching the WHO’s 90% target for girls up to the age of 15 until the year 2030 [From an international point of view, the published German HPV vaccination rates for girls are generally at a low level. Germany only ranks 17ear 2030 , 17, 18.ear 2030 . Hence, ear 2030 . Accordiear 2030 . These sear 2030 .The decline in primary HPV vaccinations during the COVID-19 pandemic described here exacerbates the problem of low vaccination coverage and calls for additional measures. Models exist for the USA, where a similar decline was observed, after which several years of intensified vaccination activity would be required to make up the deficit , and manIn summary it can be concluded from our study that after an initial dynamic increase in HPV vaccinations in boys, the impact of COVID-19 was particularly strong in the second year of the pandemic. At the end of 2021 vaccination rates for boys were still at low level, which may be due to the still relatively short time since the recommendation in 2018 and universal reimbursement in 2019, as well as due to the COVID-19 pandemic. Efforts are needed to increase HPV vaccination rates in Germany and catch-up on adolescents that missed doses during the pandemic.


GTF2I-NCF1 intergenic region as a strong susceptibility locus for multiple autoimmune disorders, with the missense mutation NCF1 rs201802880 as the causal polymorphism. In this work, we aimed to perform a comprehensive meta-analysis of the association of the GTF2I-NCF1 locus with various autoimmune diseases and to provide a systemic review on potential mechanisms underlying the effect of the causal NCF1 risk variants. The frequencies of the two most extensively investigated polymorphisms within the locus, GTF2I rs117026326 and NCF1 rs201802880, vary remarkably across the world, with the highest frequencies in East Asian populations. Meta-analysis showed that the GTF2I-NCF1 locus is significantly associated with primary Sjögren’s syndrome, systemic lupus erythematosus, systemic sclerosis, and neuromyelitis optica spectrum disorder. The causal NCF1 rs201802880 polymorphism leads to an amino acid substitution of p.Arg90His in the p47phox subunit of the phagocyte NADPH oxidase. The autoimmune disease risk His90 variant results in a reduced ROS production in phagocytes. Clinical and experimental evidence shows that the hypoactive His90 variant might contribute to the development of autoimmune disorders via multiple mechanisms, including impairing the clearance of apoptotic cells, regulating the mitochondria ROS-associated formation of neutrophil extracellular traps, promoting the activation and differentiation of autoreactive T cells, and enhancing type I IFN responses. In conclusion, the identification of the association of NCF1 with autoimmune disorders demonstrates that ROS is an essential regulator of immune tolerance and autoimmunity mediated disease manifestations.Genetic association studies have discovered the  GTF2I–NCF1 intergenic region at 7q11.23 was identified for primary Sjögren’s syndrome (pSS), with the GTF2I rs117026326 as the most significant polymorphism  [Genome-wide association studies (GWAS) have revolutionized the dissection of the genetic basis of autoimmune disorders. GWAS often lead to the discovery of a large number of susceptibility loci, each of which shows a mild contribution to the disease. For example, multiple GWAS in the last 15 years have uncovered more than 200 genetic loci that are independently associated with multiple sclerosis, while none of them show a odds ratio (OR) of more than 1.5 [× 10−53)  and exteGTF2I rs117026326 is an intronic SNP, efforts have been made to identify the causal variant of this novel susceptibility locus for multiple autoimmune diseases. In 2017, two studies reported that a missense mutation in neutrophil cytosolic factor 1 (NCF1) within the locus is associated with SLE, pSS and rheumatoid arthritis (RA) [NCF1 rs201802880 G > A polymorphism that is associated disease susceptibility, age at diagnosis but not disease activity in SLE leads to a shift from Arg to His at position 90 which is a evolutionarily conserved residue in the p47phox subunit of the phagocyte NADPH oxidase complex [GTF2I–NCF1 intergenic susceptibility locus. This notion was verified by experimental evidence obtained from NCF1-His90 knock-in (KI) mice [GTF2I–NCF1 intergenic susceptibility locus with various autoimmune diseases. In addition, we aimed to provide an overview of potential mechanisms underlying the role of the causal NCF1-His90 variant in autoimmune conditions.Since the tis (RA) ,9. The N complex . The disGTF2I–NCF1 locus and autoimmune diseases, we carried out a comprehensive meta-analysis. A search of the Medline database (https://www.ncbi.nlm.nih.gov/pubmed (accessed on 30 March 2022)) was performed to identify eligible studies. First of all, the keyword ‘rs117026326’ and ‘(Arg90His) OR (rs201802880)’ were used for the search without any limitations. In a second step, the full text of all articles from step one were reviewed to identify eligible studies. The following studies were excluded: (a) review articles or comment, (b) non-genetic association studies, and (c) genetic studies for non-autoimmune diseases.To obtain an overview of the association between the Data extraction was conducted as described previously . Brieflyp < 0.10), otherwise the common/fixed effect model was used. By comparing frequencies of alleles, the odds ratio (OR), 95% confidence intervals (CI), and p values were estimated for each individual case–control study. Meta-analysis was performed to calculate the pooled OR, 95% CI and p values. The presence of publication bias was evaluated by examining the asymmetry of the funnel plot using Egger’s regression test. All statistical analyses were performed using the R software (version 4.1.2) and Comprehensive Meta-Analysis computer program .Cochran’s Q-statistics was applied to evaluate the heterogeneity across studies. The random-effect model was used for meta-analysis when heterogeneity was indicated by a significant Q-statistic  [Due to highly homologous sequences among  methods . To obta methods ,17. The GTF2I rs117026326 and NCF1 rs201802880 polymorphisms are population dependent, with higher frequencies in East Asian populations than in others, which explains the strong association of the GTF2I-NCF1 locus with autoimmune diseases in China, Korea, and Japan.Taken together, allele frequencies of p values of Egger’s regression test were >0.05, suggesting that there was no publication bias for the association of the two polymorphisms within the GTF2I-NCF1 loci with pSS or SLE (The keyword ‘rs117026326´ and ‘(Arg90His) OR (rs201802880)’ were used for the search without any limitations, which identified 11 and 8 articles, respectively. Further review of the 19 articles led to the identification of 11 eligible studies for the meta-analysis . To acceS or SLE .GTF2I rs117026326 polymorphism exerts the strongest association with pSS in the discovery study of the susceptibility locus [GTF2I rs117026326 polymorphism with pSS, SLE, SSc and NMOSD has been investigated in at least two case–control studies, making them applicable for meta-analysis   (GTF2I rs117026326 polymorphism and SSc with two case–control studies [p = 9.36 × 10−11)   A. The as× 10−16) B. Meta-a× 10−11) C. The asociation . The met= 0.054) D.GTF2I rs117026326 polymorphism [GTF2I is supported by our recent studies reporting that the GTF2I rs73366469, another Taq-SNP of the intergenic locus, is associated with NMOSD, but not with MS, myelin oligodendrocyte glycoprotein-associated disorders or anti-N-Methyl-D-Aspartate receptor encephalitis [Unlike the four autoimmune diseases mentioned above, MS and AAV are reported not to be associated with the phalitis ,20.NCF1 rs201802880 has been investigated for its association with 5 autoimmune conditions, namely SLE, pSS, RA, SSc, and AAV [NCF1 rs201802880 polymorphism with SLE has been investigated in 9 case–control studies, and all of them reported that the minor allele is significantly associated with an increased risk of SLE [NCF1 rs201802880 polymorphism with SLE, where the minor allele conferred a more than 3-fold risk of developing the disease . Meta-analysis of the association between the NCF1 rs201802880 polymorphism and pSS was performed with two case–control studies [p < 1 × 10−16)  B. AssociGTF2I-NCF1 intergenic locus is associated with multiple autoimmune diseases, including pSS, SLE, SSc, and NMOSD. A major limitation of this study is the relative small number of studies retrieved for the analysis. Since the causal mutation within the GTF2I-NCF1 locus was identified in 2017, its association with autoimmune diseases has not been extensively investigated. It is conceivable that some other autoimmune disorders are also associated with the susceptibility locus, and examination of the pattern of the association will help to understand the underlying mechanisms of the association.In the present study, we performed a meta-analysis demonstrating that the NCF1 rs201802880 polymorphism which leads to the p.Arg90His substitution. NCF1 encodes the p47phox which is one of five subunits of the NADPH oxidase 2 (NOX2), and the p.Arg90His residue is located in the phox domain which mediates binding of p47phox to the cellular membrane. It has been shown that the evolutionary conserved Arg90 residue is essentially involved in the binding to the cellular membrane and the NAPDH oxidase activity in response to various stimuli [NCF1 variants that reduce NOX2-derived ROS production in rat and mice have also been shown to promote multiple experimental autoimmune diseases, such as pristane-induced arthritis, experimental autoimmune encephalomyelitis, and SLE-like disease [NCF1 mutations and various autoimmune disorders suggests an essential role of NOX2-derived ROS in the regulation of development of autoimmune disorders [Both clinical and experimental evidence have shown that the causal variation is the  stimuli . Compare stimuli . In acco disease ,24,25. Tisorders . ClinicaNCF1 [NCF1 variants that lead to hypofunction of the NOX2 might impair the physiological function of phagocytes. Very recently, Geng and colleagues reported that bone marrow-derived macrophages from NCF1 His90-KI mice result in an impaired efferocytosis [gp91phox encoding another NOX2 subunit show an impaired ability to clear apoptotic cells [The phagocyte NOX2 complex is composed of two catalytic transmembrane subunits and three regulatory cytosolic subunits, including the p47phox encoded by NCF1 . ROS-redocytosis . Compareocytosis . This obic cells .NCF1 variant causes a defective efferocytosis and thus impairs clearance of apoptotic cells, which further contributes to the development of SLE. This concept is supported by the observation that mice carrying hypoactive NCF1 variant produce SLE-associated autoantibodies and develop chronic kidney inflammation spontaneously or after application of pristane [Under physiological condition, most tissue undergoes routine turnover of cells which mainly die via apoptosis, and the rapid removal of those apoptotic cells by phagocytes via efferocytosis is an essential step for the maintenance of tissue homeostasis. Defective clearance of apoptotic cells is associated with many pathological conditions, including autoimmune diseases, such as SLE . For exapristane ,25. In lpristane .As a crucial component in the first line of defense against micro-organisms, neutrophils are equipped with multiple anti-infective strategies, including phagocytosis, generation of ROS, proteases, and formation of neutrophil extracellular traps (NETs) . Apart fIn SLE, neutrophils from patients are characterized with multiple abnormalities in their functions, such as increased apoptosis, elevated release of NETs, aberrant NETosis, impaired phagocytosis, and enriched circulating low-density granulocytes ,38,39,40NCF1 His90 variant show a decreased NET formation in response to PMA stimulation, compared to Arg90 neutrophils [Neutrophils from patients with CGD are unable to produce NETs , highligtrophils . Moreovetrophils . Apart ftrophils . When NOtrophils . By conttrophils ,52,53, itrophils . HoweverNCF1 variants in the regulation of T cell homeostasis. Although T cells do not exert oxidative burst, multiple evidence show that NCF1 mutation are able to regulate T cell homeostasis via antigen presenting cells (APCs).Dysregulated autoreactive T cell responses have been observed in mice carrying His90 allele or other ROS-reducing variants ,23,54, sAs compared with WT mice, His90 KI mice are featured by increased ratios of splenic follicular T helper 2 (Tfh2) to either T follicular regulatory (Tfr) or Tfh1 cells , suggestNCF1 variants also promote the expansion of autoreactive effector T helpers. In 2017, Sarelia and colleagues reported that KI mice carrying a ROS-reducing NCF1 variant originated from rat, develop severe collagen induced arthritis (CIA) while mice expressing functional NCF1 develop only mild symptoms [NCF1 variant promotes the expansion of immunodominant collagen II-specific Th17 cells [NCF1 variant [Hypoactive symptoms , demonst17 cells  which ar17 cells . The eff variant . A possi variant ,58. Acco variant ,58.NCF1, animals carrying hypoactive NCF1 variant show similar levels of naïve Tregs but a decreased levels of induced Tregs, suggesting that NOX2-derived ROS is require for the induction of Tregs [+CD25+FoxP3+ Tregs in a ROS-dependent manner [NCF1 variant might contribute to T cell autoimmunity by promoting autoreactive T helpers and inhibiting the induction of Tregs.In addition to the regulation of T helper cells, NOX2-derieved ROS is also involved in the induction of regulatory T cells (Tregs). Compared to controls with functional of Tregs . This not manner . Taken tNCF1 His90 variant is associated with an increased expression of type 1 interferon-regulated genes in patients with autoimmune diseases, such as RA and SLE [NCF1 His90 KI mice show an elevated type I IFN response and SLE-associated autoantibodies compared to WT littermate controls [NCF1 mutated mice, Kelkka and colleagues showed that the upregulated type I IFN response associated with reduced ROS is of endogenous origin [In 2014, Kelkka and colleagues reported that both chronic granulomatous disease (CGD) patients and mice lacking functional NOX2 complex exhibit a prominent type I interferon (IFN) response signature and elevated levels of autoantibodies , suggest and SLE ,10. Furtcontrols . Therefocontrols ,61. By is origin .NCF1 variant leads to elevated type I IFN responses and the expansion of germinal center (GC) B cells in mice [There is an increasing body of evidences that type I IFN response is associated with autoimmune conditions, especially autoimmune rheumatoid diseases, such as SLE, pSS, and RA ,63. Elev in mice . Given t in mice  that pre in mice , and tha in mice , it is cGTFI-NCF1 susceptibility locus is associated with multiple autoimmune diseases. The causal NCF1 His90 variant leads to an impaired NOX2 activity and confers a risk for various autoimmune conditions. Experimental and clinical evidence suggests that the hypoactive NCF1 His90 variant might contribute to autoimmune conditions via multiple pathways, including impairing apoptotic cell clearance, regulating the formation of N.The meta-analysis in this study demonstrates that the NCF1 variant-caused autoimmune conditions might be regulating the homeostasis of autophagy. Of note, the NCF1 His90 variant might contribute to different autoimmune diseases via different mechanisms, e.g., impairment of apoptotic cell clearance likely contributes to SLE. Since NOX2 is expressed in all phagocytes, the hypoactive His90 variant might contribute to autoimmune diseases via other mechanisms which need to be explored in future studies. In addition, given that susceptibility polymorphisms may impact the treatment of disease [NCF1 His90 variant with response to treatment in autoimmune diseases. In conclusion, the identification of the autoimmune disease risk NCF1 His90 variant demonstrates an essential role of NOX2-derived ROS in the development of autoimmune diseases.ETs, promoting the differentiation of autoreactive T cells, and increasing type I IFN responses. In addition, since NOX2-derived ROS play an important role in autophagy and aberrations of autophagy has been observed in autoimmune diseases, such as SLE ,78, a po disease , it is i


Mature cystic teratoma is the most common ovarian germ cell tumor. The malignant transformation of ovarian mature cystic teratoma (MCT) is very rare, but the prognosis is poor. We present a case of ovarian mature cystic teratoma with human papillomavirus infection and malignant transformation into ovarian squamous cell carcinoma (SCC). The occurrence of this case may prove that high-risk human papillomavirus infection is a pathogenic factor inducing malignant transformation of mature cystic teratoma to SCC.A 38-year-old woman with a solid cystic mass of 8 cm on the right ovary, and human papillomavirus (HPV) test of her cervix showed HPV-16 infection.The transvaginal ultrasound was performed, and there was a cystic solid mass of 5.9 × 4.5 × 5.5 cm in the right adnexal area with unclear cystic fluid and rich blood flow signals in the capsule wall. HPV test of cervix showed HPV-16 infection. Diagnostic suspicion: cystic teratoma.The patient signed an laparoendoscopic surgery was performed to remove the right ovarian mass. Intraoperative pathology consultation revealed the malignant transformation of mature teratoma of the right ovary and the formation of squamous or adeno-SCC. We performed laparoscopic comprehensive surgical staging  were made.The operation was successful and the postoperative recovery was smooth, was discharged 7 days after operation. Now the patient is recovering well and is continuing chemotherapy as planned.HR-HPV infection might be a causal factor for inducing malignant transformation of ovarian MCT to SCC, and the Jumping metastasis of lymph nodes may be the characteristic of SCC-MCT, but further verification is still needed. Histologically, MCT contains 3 germ layers . The malignant transformation of MCT can occur in any of the 3 germ layers, and its malignant transformation rate is low. Among all ovarian MCTs, the incidence of squamous cell carcinoma (SCC) in MCT (SCC-MCT) is 0.17% to 2%, and 80% of SCC-MCT is derived from ectoderm. However, compared with epithelial ovarian cancer, the prognosis of SCC-MCT is significantly worse. The mechanism and relevant biomarkers of SCC-MCT are still unrevealed, because there are few reports discussing about it. Patients with SCC-MCT do not present any typical symptoms and signs in the early stage and are diagnosed unexpectly based on intraoperative or postoperative pathologic examination.Mature cystic teratoma (MCT), also known as the dermoid cyst, is the most common ovarian germ cell tumor, accounting for 10% to 20% of all ovarian tumors.–6 However, there was no evidence to prove that MCT-SCC could be induced by HR-HPV infection.As we know, high-risk human papillomavirus (HR-HPV) infection, especially HPV-16 and HPV-18, is highly associated to many kinds of SCC, such as cervical, vaginal and vulvar, and oropharyngeal SCC, etc. Limited reports considered that HR-HPV is mostly to blame for the primary ovarian SCC.We herein present a case that SCC and HPV-16 were both discovered in ovarian MCT. We considered that the malignant transformation of ovarian MCT, especially SCC, could be induced by HR-HPV from genital tract infection. Consequently, patients with both ovarian MCT and genital tract HR-HPV infections should be vigilant about the malignant transformation of SCC-MCT, and it will provide a relevant preventive measure for SCC-MCT.A 38-year-old woman presented to our hospital with her annul medical examination report which emphasized that there was a solid cystic mass of 8 cm on the right ovary. Upon obtaining a complete clinical history, the patients reported that she had no lower abdominal pain, and the menstrual cycle was regular  with no cessation of menstruation or irregular bleeding. The transvaginal ultrasound was performed, and there was a cystic solid mass of 5.9 × 4.5 × 5.5 cm in the right adnexal area with unclear cystic fluid and rich blood flow signals in the capsule wall (diagnostic suspicion: cystic teratoma). Interestingly, no abnormal tumor markers were found . Her medical examination report showed that the Pap smear screening was negative this year; however, HPV test of her cervix showed HPV-16 infection. The patient signed an informed consent and laparoendoscopic surgery was performed to remove the right ovarian mass. We found that the right ovary is enlarged, with a 6 × 5 × 4 cm solid cystic mass containing the lipid and scalps tissues. Interestingly, the presence of scattered dark brown nodules inside the cyst was found. The endocystic wall is thin and smooth. We removed the right ovarian mass completely during operation. Intraoperative pathology consultation revealed the malignant transformation of mature teratoma of the right ovary and the formation of squamous or adenoSCC. Tumor stage was preliminary determined as stage 1A according the FIGO stage. Due to no fertility desired for this patient, after getting the verbal consent from her husband, we performed laparoscopic comprehensive surgical staging  were made.On entering the abdomen, peritoneal lavage were collected for peritoneal cytologic test. And then, describing a normal uterus, left ovary presented with normal appearance, with adhesions to epiploic appendages from the tube. The lymph nodes around the abdominal aorta and the surface of the inferior vena cava were typically enlarged with dark brown pigmentation, however, no enlarged pelvic lymph nodes were found. Intestine, omentum, appendix, peritoneum, small intestine, diaphragmatic domes, liver, and stomach without implants. Intraoperative pathology consultation revealed the lymph nodes around the abdominal aorta was infiltrated by the tumor. Para-aortic lymph node dissection was performed by stripping the nodal tissue from the vena cava and the aorta bilaterally to the level of the renal vessels. The method of dissecting pelvic lymph nodes is bilateral removal of lymph nodes overlying and anterolateral to the common iliac vessel, overlying and medial to the external iliac vessel, overlying and medial to the hypogastric vessels, and from the obturator fossa at a minimum anterior to the obturator nerve.A final diagnosis of malignant transformation of mature teratoma of the right ovary, which was divided into medium to poorly differentiated SCC Fig. . And HR-The operation was successful and the postoperative recovery was smooth, was discharged 7 days after operation. Now the patient is recovering well and is continuing chemotherapy as planned.Informed consent was obtained from the patient for the publication of case details and images. Teratoma is a germ cell tumor that may consist of mature or immature tissues derived from 3 germ cell layers. MCT accounts for 62% of all ovarian tumors in women under the age of 40. The treatment mainly depends on surgical resection. Its malignant transformation rate is low. Among all ovarian MCTs, the incidence of malignant transformation to SCC is 0.17% to 2%, but its prognosis is very poor. However, there are few cases of HPV in ovarian SCC. To our knowledge, only 4 cases of primary ovarian SCC associated with HPV have been reported so far.–6 For the malignant transformation of MCT to SCC with HPV infection, there has been no relevant case report. Due to its low incidence rate, few related studies, and unclear pathogenesis, its diagnosis mainly depends on postoperative examination, which makes its prevention, diagnosis, and treatment face great challenges. A multicenter retrospective study in Taiwan suggested that patients with tumors that spread beyond the ovary (FIGO stages II–IV) had a very low probability of long-term survival. The 5-year survival rate for stage I patients was 93%, indicating that the early detection of malignant transformation before the occurrence of invasion or metastasis is essential for treating SCC. However, at present, the mechanism of MCT to SCC is not completely clear, which makes its early treatment and early detection a big problem. Therefore, it is particularly important to explore the mechanism of malignant transformation from MCT to SCC and detect its malignant transformation potential early in clinical practice.The incidence rate of ovarian SCC is low, most of which originate from malignant transformation of teratoma, Brenner tumor, or endometriosis. At present, more than 100 kinds of HPV have been identified, of which at least 20 are related to cervical cancer. HPV infection is usually a self-limiting process, but almost all cervical cancers are associated with HR-HPV infection, suggesting that persistent HPV infection may be an important factor in inducing cancer. Cervical cancer mostly originates from the cervical transformation zone where the columnar epithelium of the cervix changes to the squamous epithelium of the cervix. HPV infects the basal cells of the squamous epithelium of the cervix. Once inside the host cell, the HPV DNA replicates as the basal cells differentiate and progress to the surface of the epithelium. The HPV gene expression becomes unlinked to the state of cellular differentiation of infected epithelial cells, and deregulation expression of the early region of the viral genome results in a dramatic increase in the expression of the 2 HPV oncoproteins (E6 and E7). This results in the loss of the normal cell cycle control of the epithelium, thus leading to the occurrence of diseases. Microscopically, the MCT is usually composed of elements from all 3 germ cell layers: ectoderm , mesoderm , and endoderm , although often ectodermal derivatives predominate. Therefore, we speculate that HPV infection may act on the squamous epithelium of MCT ectoderm, leading to the malignant transformation of MCT. Chiang et al detected HPV infection in 4 SCC-MCT ovarian samples through IHC and ISH (4/4), suggesting that HPV infection may be related to SCC-MCT, and HPV infection was also detected in the adjacent reproductive tissues of SCC-MCT cases, which indicates that virus particles may spread in the reproductive system, and HPV particles in the cervix and cervical tube may spread to the ovary through the ascending route of the endometrium and fallopian tube. High-risk HPV infection might be a causal factor for inducing malignant transformation of ovarian MCT to SCC. This is consistent with our case. The patient had cervical HPV-16 infection. This time, ovarian teratoma was found, and malignant transformation into SCC. HR-HPV-16 was also found on the ovary. HPV particles in the cervix and cervical tube may spread to the ovary through the ascending route of the endometrium and fallopian tube. It causes HPV virus to act on the squamous epithelium of MCT ectoderm, thus promoting the malignant transformation of MCT. Therefore, we highly suspect that the malignant transformation of ovarian teratoma into SCC may be caused by the infection of HPV-16 in the squamous epithelial cells of teratoma. But it still needs further verification. Therefore, patients with teratoma should pay attention to screening HPV and be alert to the malignant transformation of squamous epithelium into SCC in teratoma caused by HPV infection.Human papillomavirus (HPV) infection is considered to be the main cause of infection-related cervical cancer, vulvar cancer, vaginal cancer, anal cancer, oropharyngeal cancer, and penile cancer. This may be due to the unique lymph node metastasis pathway of ovarian cancer. In ovarian cancer there are 3 main pathways in lymphatic drainage: along the ovarian vessels to the para-aortic nodes, the round ligament of the uterus to the groin area and the uterine vessels to the iliac lymph compartments. Lymph node metastasis of ovarian cancer often metastasizes with ovarian arteriovenous reflux, especially venous reflux. The vein of the left ovary flows back to the left renal vein and the right to the inferior vena cava. Therefore, the first stop of lymph node metastasis pathway of ovarian cancer is the location of para-aortic lymph node . A prospective study by Ditto A et al pointed out that among early epithelial ovarian cancer with lymph node metastasis, the proportion involving lymph node metastasis in the para-aortic region was as high as 86.6%. This is consistent with the unique metastasis pattern of ovarian cancer. However, there is no relevant report about SCC-MCT. This case is an early case, but it is found that the abdominal para-aortic lymph nodes are positive and the pelvic lymph nodes are negative, indicating that the SCC-MCT may have the metastasis of the abdominal para-aortic lymph nodes in the early stage, and the cancer cells may mainly flow back to the renal vein or the inferior vena cava region through the ovarian vein, resulting in the metastasis of the abdominal para-aortic lymph nodes, while the pelvic lymph nodes are negative. This jumping metastasis may be the characteristic of SCC-MCT, but further verification is still needed. Therefore, we should pay attention to identifying the risk of early para-aortic lymph node metastasis for patients with ovarian mature teratoma SCC.Interestingly, this case of SCC was accidentally found in MCT, however the lymph nodes around the abdominal aorta and the surface of the inferior vena cava were typically enlarged with dark brown pigmentation, no enlarged pelvic lymph nodes were found. And intraoperative pathology consultation revealed the lymph nodes around the abdominal aorta was infiltrated by the tumor. Ovarian cancer is more likely to metastasize via intraperitoneal dissemination than hematogenously or via lymphatics. However, periaortic lymph node metastasis of ovarian cancer occurred at an early stage in our case. It indicates that ovarian teratoma SCC may have periaortic lymph node metastasis at an early stage. A systematic review of 14 articles showed that the mean incidence of lymph node metastases in clinical stages I-II early ovarian cancer was 14.2% (range 6.1–29.6%), of which 7.1% only in the para-aortic region, and 4.3% both in the para-aortic and pelvic region.We would like to thank the patient for agreeing to reveal the case details for publication.Zhixian Shi took the lead in drafting the article, Lingyun Yang and Ce Bian provided supervision revised article, and finally approved the version to be published. All authors read and approved the final < article.Conceptualization: Zhixian Shi, Lingyun Yang, Ce Bian.Data curation: Zhixian Shi, Lingyun Yang.Formal analysis: Lingyun Yang, Ce Bian.Investigation: Zhixian Shi.Methodology: Lingyun Yang.Supervision: Lingyun Yang, Ce Bian.Writing—original draft: Zhixian Shi.Writing—review and editing: Lingyun Yang.


This study aimed to analyze the cognition, attitude, and willingness to pay (WTP) for imported and domestic human papillomavirus (HPV) vaccines in Chinese medical students.Medical students in Eastern, Central and Western China were investigated. We used the HPV cognitive list to measure the cognition of participants and implemented contingent valuation method (CVM) to value WTP. Tobit model was used to analyze the factors associated with WTP.P < 0.05).The participants' average score for the 21 cognitive questions was 13.05 (±5.09). Among the participants, 60.82 and 88.01% reported that they would wish to be vaccinated and support the partners to be vaccinated. In addition, 92.54% (670) of the participants were willing to pay for HPV vaccines, at mean values (in RMB) of 1,689.80 (±926.13), 2,216.61 (±1190.62), and 3,252.43 (±2064.71) for imported bivalent, quadrivalent, and 9-valent vaccines, respectively, and at 910.63 (±647.03), 1,861.69 (±1147.80), and 2,866.96 (±1784.41) for their domestic counterparts, respectively. The increase in cognitive score has a positive effect on the WTP for imported vaccines (Most of the participants were likewise willing to receive the HPV vaccines. Their perceptions of the HPV vaccines valent and origin may affect their willingness to be vaccinated and pay for the vaccines. Increasing awareness of the HPV vaccines and the inclusion of the HPV vaccines in a Medicare reimbursement policy or immunization program could increase the coverage of the HPV vaccine. The human papillomavirus (HPV) vaccine was designed to protect humans from the risk of disease caused by HPV. When vaccinated, a vaccinated person can expect their immune system to respond to the virus, if exposed . Both maThe World Health Organization has stated that all three registered HPV vaccines, namely, the bivalent, quadrivalent, and 9-valent vaccines, have good safety, efficacy, and effectiveness . StudiesAt present, 110 countries and regions worldwide have included the HPV vaccine in their immunization programs and vaccinated the target population for free . Howeverhttps://www.wjx.cn/. We applied the CVM to evaluate the WTP of each participant. Each respondent received 2RMB in cash as remuneration, which was paid through online payment. The Harbin Medical University School of Health Management & nstitutional Research Board approved the study protocol (HMUIRB20210006).We conducted an anonymous survey on medical students in Harbin Medical University, Hebei Medical University, and Chengdu University of Traditional Chinese Medicine, representing central, eastern, and western China, respectively, from November 2020 to March 2021. We used online forms to collect information via Table 2). The score for this measure was the cumulative number of items answered correctly by the participant (1 point per correct response). The score ranged from 0 to 21 points, with higher scores indicating a higher likelihood of the participant having richer knowledge of HPV infections and vaccines. We also calculated the percentage of each item that was answered correctly to analyze the participants' perception of each knowledge item. Those who reported negative responses to the questions “Have you heard of HPV?” and “Have you heard of the HPV vaccine?” were not asked to answer this cognitive list. Notably, before responding to the above two questions related to vaccination attitudes, the respondents read the WHO introduction on HPV , and supplementary content through derived from pre-surveys and interviews. We mixed all cognitive content into a pool of cognitive items. Duplicate items were eliminated, and the items were further filtered to form the final list ( file 1) , 13. ThiRespondents who expressed acceptance of the HPV vaccine answered the WTP questionnaire. We calculated WTP as the amount of money willing to spend on vaccines. We used the questions “If the HPV vaccine is included in the national immunization program and can be availed for free, would you be willing to be vaccinated?” and “If the HPV vaccine needs to be availed at your own expense, will you get yourself vaccinated?” to analyze respondents' attitude toward the HPV vaccine when it is provided for free and at their own expense. If the respondent was still unwilling to be vaccinated under the assumption of zero price, then the respondent was asked to report the reason. Those willing to pay for vaccination were asked about their views on the different full-dose prices of HPV vaccines.The contingent valuation method was used to obtain the respondents' WTP. To simulate the real-market environment, we adopted the iterative bidding game (IBG) methods  in our i* 2 RMB”.Given that only bivalent vaccines are available as domestic vaccines in China , and theWe limited the vaccine valence types that the respondents could fill in by setting age limits. Females aged 9–26 years could answer the WTP for full valent vaccines, whereas females aged 27–45 years were only allowed to answer the WTP for bivalent and quadrivalent vaccines . In mainP < 0.05 was considered significant.Statistical analyses were performed using Stata Version 15 and Microsoft Excel Version 2016. We analyzed the participants' degree of knowledge reserve, vaccination attitudes, and WTP for different valence vaccines. The McNemar's test was used to compare whether there were differences in the acceptance rate of vaccines from different origins. Tobit model was used to analyze the influencing factors of WTP. Respondent who unwilling to pay for the vaccine, his WTP is recorded as 0, and there is a censorship of the lower limit of WTP. At the same time, limited by the scope of the WTP scale, WTP has an upper limit of censorship. Tobit model is suitable for analyzing dependent variable has upper or lower limit. Among the respondents, 751 (92.83%) had heard of HPV, and 728 (89.99%) had heard of the HPV vaccine. A total of 728 respondents answered the questions in the cognitive list. The average cognitive score was 13.05 (±5.09) points. The respondents maintained a high level of cognition of HPV infection, transmission, and vaccination population but reported insufficient awareness of post-vaccination. Most of them correctly replied that HPV could be sexually transmitted (86.81%) and that males and females contracted HPV (79.95%) . MoreoveRegarding the applicable population of HPV vaccine, 78.16% of the participants knew that males can also get the HPV vaccine, 60.85% knew that vaccination is not be recommended for pregnant females, and 55.49% knew that males need to receive the HPV vaccine. More than half (57.69%) of the respondents knew that those who have contracted HPV could also be vaccinated.Of the post-vaccination part, 30% did not know that they still need cervical cancer screening after HPV vaccination. About 30% could not clearly recognize that the HPV vaccine reduces the risk of cervical cancer but not eliminate it. Nearly 40% of the respondents hold the erroneous view that 9-valent has the highest protective effect, and that vaccination with other valence types is meaningless if the 9-valent vaccine cannot be vaccinated. Meanwhile, 39.56% reported misinformation that China's vaccines are obsolete abroad, and 30% had the false view that an HPV vaccine is harmful to the health and leads to HPV infection.We investigated the attitudes of respondents themselves and their partners toward HPV. A total of 60.82% of the people reported that they would like to be vaccinated, 30.90% of the respondents said that they did not have the willingness to be vaccinated at this stage, and a total of 8.28% were unwilling to be vaccinated. Excluding 67 people (8.28%) who were unwilling to receive the HPV vaccine, a total of 742 people filled out the WTP questionnaire. Under the condition that the HPV vaccine is contained in the national immunization program, 724 (97.57%) respondents indicated their willingness to be vaccinated. The reluctance of the remaining 18 (2.43%) respondents was due to the unclear complications and low confidence in free vaccines.In the case of the HPV vaccine charges, 670 (92.54%) of the respondents were willing to be vaccinated. The 54 (7.46%) who were unwilling to pay for the vaccine stated the following reasons other than the price: “I think it is unnecessary,” “After vaccination, it is not once and for all,” “HPV can be prevented by condoms, and there is no need to spend so much money on vaccination,” “Vaccination is painful,” and “Lack of authoritative evidence for long-term side effects.”P < 0.01). Respondents whose WTP for imported vaccines exceeded the current market price of 1,740 RMB accounted for 76.96% of the target population for the bivalent. Respondents with a WTP higher than 2,469 RMB accounted for 66.38% of the total population of those willing to be vaccinated with a quadrivalent vaccine. Respondents with a WTP higher than 4,000 RMB accounted for 49.14% of the target population of the 9-valent vaccine ( vaccine .P < 0.05). The increase in cognitive score has a positive effect on the WTP for imported vaccines (P < 0.05). Female's WTP for domestic quadrivalent and imported 9-valent HPV vaccines was higher than that of male (P < 0.05). After controlling for the fact that WTP has upper and lower limit, female is expected to increase the WTP by 387.23 and 612.72 yuan, ceteris paribus.The dependent variables of the multiple regression include respondents who are unwilling to pay for the vaccine . Rural hOur research reported respondents' awareness of HPV transmission, pathogenesis, vaccination, and the applicable population. The results showed that Chinese medical students were no strangers to HPV or its vaccines. Almost all (92.83%) of the respondents had heard of HPV. This result is slightly lower than that of an Italian study of nursing students (96%) . It is aOur participants lacked or had poor knowledge of HPV's transmission channels. Most of them knew that HPV is a sexually transmitted virus and that both males and females can be infected (>80%). Nonetheless, they did not know that HPV can be transmitted through mother-to-child transmission (60%) and indirect contact (48.08%). Moreover, 20% of them did not understand that males need to be vaccinated against HPV. People often consider HPV vaccines as cervical cancer vaccines. Once a vaccine is labeled as a sex vaccine, more effort is needed to correct misconceptions.Males can directly benefit from HPV vaccination. A meta-analysis showed that vaccination with a quadrivalent vaccine can reduce the incidence of genital warts in boys . In our The willingness to be vaccinated and to support the partners to be vaccinated tended to paint an optimistic trend. Only 8.28% of the participants clearly indicated their unwillingness to receive the HPV vaccine, and 1.11% did not support the partners to be vaccinated. Our results showed that 60.82% of the respondents were willing to be vaccinated. This result is similar to that in studies in Italian nursing students (65.3%)  and mediAt present, there are bivalent domestic vaccines in China to replace imported bivalent vaccines. A randomized clinical experimental study in China showed that the domestic bivalent HPV vaccine has a high protection efficacy against uterine cancer . HoweverCrowd psychology may be at play in the choice of the 9-valent vaccine, instead of a full understanding of the differences between valence types. From the recommended age group of the 9-valent HPV vaccine, it is ideal for those entering puberty. However, owing to the shortage of imported 9-valent vaccines in the Chinese market, a large number of females are aspiring to be vaccinated with this type, which has further pushed up the market demand. Indeed, the Chinese public has called for high-level evidence to clarify the advantages of domestic and imported vaccines. Clinical trials and health economic evaluation methods can provide more evidence in terms of vaccine safety, effectiveness, and resource allocation efficiency. Meanwhile, more publicity and promotion are needed to expand public understanding of HPV and the different valence vaccines.Our findings on WTP indicated that most medical students were willing to pay for the HPV vaccine. However, under the premise of free vaccinations, 18 respondents expressed an unwillingness to receive the HPV vaccine for safety and other reasons. When it needs to be paid, the proportion of the respondents who were unwilling to be vaccinated increased from 2.43 to 7.46%. In China, the HPV vaccine is not included in the national immunization program. Many people refuse or postpone vaccination because they cannot pay for the vaccine. A study conducted in Hong Kong showed that 67.60% of doctors and 70.50% of nurses find HPV vaccines expensive . China'sThe WTP values for imported vaccines were all below the market price. The willingness to import value for 9-valence vaccines was also far lower than the market price. At present, the import price of 9-valent vaccines is deemed to be too high. The respondents reported having limited ability to pay, especially the higher fees for the imported 9-valent vaccines. Meanwhile, bivalent domestic vaccines are consistent with the market price. Domestic quadrivalent and 9-valent vaccines are not yet available; their pricing may refer to our evidence. Nonetheless, the respondents were willing to pay more for imported vaccines and less willing to pay for domestic vaccines. Specifically, the payment willingness for domestic bivalent vaccines was far lower than that for imported bivalent vaccines. This may be because China has already launched a domestic bivalent vaccine, and the respondents already have an anchor price. The bivalent HPV vaccine produced in China costs 329 RMB per vial, about half the price of the imported bivalent vaccine.Our research provides evidence on Chinese medical student' WTP for HPV vaccines and on HPV awareness and vaccination attitudes. The published studies have involved parents of adolescents , 10, 11,The following limitations must be considered when interpreting our findings. First, the respondents' WTP for vaccines may be underestimated owing to the price scale cap. Second, this study may be theoretically underrated given that the nationally produced quadrivalent and 9-valent HPV vaccines are not yet approved and permitted for distribution.Most of the respondents were willing to receive the HPV vaccine. The number of medical students who were willing to be vaccinated with domestically produced vaccines was lower compared with the trend for imported vaccines. Medical students' understanding of HPV vaccine valences, place of production, safety, and effectiveness need to be improved. Meanwhile, most of them were willing to pay for the HPV vaccine. Their perceptions of HPV vaccine valences and origin may affect their willingness to be vaccinated and pay for the vaccine. Government departments should fully consider the evidence regarding WTP when pricing vaccines. Medical insurance reimbursement policies or immunization program plans can eliminate the price barrier of vaccination to a certain extent, thus enhancing vaccination rates and protecting a larger population against HPV.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Harbin Medical University School of Health Management institutional Research Board (HMUIRB20210006). The patients/participants provided their written informed consent to participate in this study.LZ proposed and initiated this study. LZ and BG wrote the first draft of the manuscript. XZ, XX, and GL designed the project and oversaw the analysis and manuscript writing. YL, PC, BG, and YH drawn figures in the manuscript. YL and BG inserted tables in the manuscript. GL supervised the entire project. All co-authors provided feedback during the design and interpretation of the project. They also contributed to revisions of the manuscript. All authors read and approved the final manuscript.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.


To assess parent attitudes regarding orthodontists' role as potential administrators of human papilloma virus (HPV) vaccines.  275 parents of adolescents, aged 11–17, who attended the orthodontic clinic at an American university for orthodontic adjustment visits and met inclusion criteria were given information about HPV and HPV vaccines. A paper questionnaire was administered to assess comfort level with orthodontists as HPV vaccinators. Demographic and other potential explanatory characteristics were collected. Descriptive, bivariate, and multivariate ordinal logistic regression analyses were performed with SPSS statistical software v25. p < 0.05) of parents taking the survey in Spanish and parents' educational attainment with HPV vaccine administration comfort level. Multivariate ordinal logistic regression indicates that parents taking survey in Spanish  and parents of male children  were comfortable with orthodontists administering the HPV vaccine.  The majority of participants were between 31 and 40 years old, with 79.6% identifying as female. 54.3% of the subjects' children identified as female. Although 71.3% of participants identified as Hispanic, 55.3% of the total participants chose to respond to the questionnaire in Spanish. 66.7% of the participants reported education level as high school degree or less. Overall, 52.4% of parents responded that they would be comfortable with orthodontists administering HPV vaccines to their children. Bivariate analysis suggested a significant association ( The language of the survey influenced parents' comfort level with orthodontists as HPV vaccinators, with Spanish having a positive correlation to comfort level. Parents of male children were more comfortable with orthodontists as HPV vaccinator. In the United States, 79 million people, mostly in their late teens or early 20s, are infected with the human papilloma virus (HPV), which is the most common sexually transmitted disease . Every yThere have been over 200 different HPVs identified. These are characterized as low risk or high risk based on their potential to cause malignant HNSCC. High risk HPV strains, such as HPV16 and HPV18, can cause premalignant squamous intraepithelial neoplasia that can progress to cancer . When HPpRb prevents excessive cell growth by inhibiting cell cycle progression until a cell is ready to divide. When the cell is ready to divide, pRb is phosphorylated (inactivated) by cyclin-dependent kinases and the cell cycle can progress. Another tumor suppressor protein, p16, controls pRb phosphorylation by inhibiting cyclin-dependent kinases. The HPV viral oncoprotein, E7, inactivates pRb which causes an overexpression of p16 in HPV related tumors in an unsuccessful attempt to stop cell proliferation . IntraceSalivary biomarkers can be used to detect HPV infections and HPV related oral squamous cell cancers. Saliva analysis can be a pain-free, noninvasive option for the diagnosis of OSCC . The preIncreases in HPV infections in younger populations (<25 years old) reflect earlier sexual activity, increasing numbers of sexual partners, and orogenital sexual habits in this population . In 2011HPV vaccines became first available in 2006. Gardasil 9, a nonavalent HPV vaccine became available in 2014 and was recommended for use by the Advisory Committee on Immunization Practices in 2015 . After aDespite the HPV vaccine availability, reports in 2018 showed that only about half of adolescents in US had received the vaccination, and about 66% of teenagers aged 13–17 had received the first dose , 20, heaEarlier studies have looked at patient/parent characteristics associated with HPV vaccination. Females have been found to be more familiar with HPV infections and vaccines than males , 24–26. The purpose of this study is to assess parents' perceptions of orthodontists as potential administrators of the HPV vaccine. The rationale for this study is based on the growing prevalence of preventable HPV related oropharyngeal cancers and public health efforts to expand access to the HPV vaccine. Since the vaccine is targeted at adolescents, parents play a lead role in a child's health decisions. Additionally, parents of children undergoing orthodontic treatment have an excellent opportunity to establish a relationship with the orthodontist as the appointments are frequent and the treatment is normally years in duration. Exploring parent attitudes regarding orthodontists as potential HPV vaccinators can open new opportunities for getting more of the US adolescent population vaccinated against HPV, thereby decreasing the prevalence and incidence of HPV infections and associated cancers. Additionally, the results of this study may give good reasoning for orthodontists playing a future role in administering other vaccines, such as those developed for COVID-19.Inclusion criteria included parents of patients between the ages of 11 and 17 who had been treated by the same orthodontic provider for at least six months prior to our study, which was indicative of an ongoing relationship between the patient/parent and orthodontic provider. Parent subjects were approached at their child's monthly orthodontic appointment and given information by one of three clinician investigators on the research team. Each clinician read from a script in English or Spanish based on the subject's preference. The subject was given general information about HPV and HPV vaccines as well as the research project that they were being asked to participate in. Subjects were encouraged to ask questions about any aspect of HPV, HPV vaccines, and/or the present study. Once the subject agreed to participate, a paper survey instrument was used to collect sociodemographics, comfort level with orthodontists as administrators of the HPV vaccine, and participant's perceived benefits vs. concerns regarding orthodontists as vaccine administrators. Subjects signed a consent form to participate in the study and filled out the paper survey out in the waiting room. The participants were given the choice of completing the survey in either Spanish or English. Prior vaccination status of the child was not considered.The survey was a modification of that used in Lazalde et al.'s study, “parent perceptions of dentists' role in HPV vaccination,”  in whichα of 0.05 was used to test significance for all analyses, which were conducted using IBM SPSS software v25.Subjects were able to choose 5 responses to the question regarding comfort level of orthodontists as vaccinators: very uncomfortable, somewhat uncomfortable, neither uncomfortable nor comfortable, somewhat comfortable, and very comfortable. Participants were stratified by comfort with orthodontist administration of the HPV vaccine . These 3 categories were used for all statistical analyses. A Kruskal–Wallis test was used to assess the relationship between key sociodemographic variables and comfort with orthodontists as HPV vaccine administrators. These sociodemographic variables are listed in A convenience sample of 296 participants was approached to participate in the study, but 275 chose to participate resulting in a response rate of 92.9%. Characteristics of the participants are shown in 196 participants (71.3%) identified as Hispanic with 152 (55.2%) of the total participants choosing to complete the questionnaire in Spanish. 97.4% of the participants who completed the questionnaire in Spanish self-identified as Hispanic.27.3% of participants had less than a high school education, 38.2% graduated from high school, and 25.5% obtained Bachelor's degree. Only 6.3% of subjects achieved an education level higher than a Bachelor's degree.About half (52%) of parents reported that they would be “very” or “somewhat” comfortable with an orthodontist administering the HPV vaccine to their children. Approximately a third (32%) of parents reported that they would be “very” or “somewhat” uncomfortable, and 16% were “neither uncomfortable nor comfortable” .p < .05). The language of the questionnaire analysis shows that parents taking the survey in Spanish were more comfortable with orthodontists as vaccinators than those taking the survey in English (p < .001). There was an inverse correlation between comfort level and parent's education level (p=.042). The lower the educational attainment level, the higher the comfort level with orthodontists as vaccinators.Bivariable analysis results are shown in p < .05). The results are shown in p < .01) to be comfortable with an orthodontist administering the HPV vaccination compared to those taking it in English. Additionally, sex of the child had statistical significance to comfort level, with parents of male children being almost twice as likely  to be comfortable with orthodontists as HPV vaccinators than those with female children.Multivariate ordinal logistic regression was performed to identify any association between parent/child characteristics and parent's comfort level with orthodontists as HPV vaccinators (These pilot data suggest that 52.4% of parents attending an inner city university orthodontic clinic are comfortable with orthodontists administering HPV vaccines to their children. Participants taking the survey in Spanish were found to be more comfortable with orthodontists administering HPV vaccines than those taking the survey in English. Parental education level and sex of the child also have statistically significant associations with comfort in orthodontists administering the vaccine.Almost all of the participants who completed the questionnaire in Spanish identified themselves as Hispanic. This study showed that there was a statistically significant effect of the language used to complete the questionnaire on the parent's comfort level with orthodontists administering HPV vaccines to their child. In particular, those who completed the questionnaire in Spanish were more likely to be comfortable with orthodontists being HPV vaccinators than those who chose English. This finding was in agreement with other findings in literature that indicate that Hispanic and other minority adolescents are more likely to receive HPV vaccines than whites . HoweverThe data in our study indicate that the level of parental education attainment has a negative association with parent comfort with orthodontist administering HPV vaccines to their children. Specifically, the higher the education level, the less comfortable the subjects with orthodontists administering a vaccine. This is in contrast to the Dean et al. and Lazalde et al. studies where they found no correlation between education attainment and acceptance of HPV vaccination by dentists . 23. TheParticipants with male children were found to be more comfortable with orthodontists as HPV vaccine administrators than those with female children. This finding is concurrent with the Lazalde et al. study that also found that a parent with a female child had lower odds of being comfortable with their general dentist administering HPV vaccinations . Prior sNot only could dental professionals help lower HPV infections by administering the vaccine, but they also could play a role in monitoring HPV mediated oral cancer progression. Salivary biomarkers can be used to detect HPV infections and HPV related oral squamous cell cancers. Dental professionals routinely incorporate oral cancer screenings into their patient exams. Since collection of a salivary sample is relatively easy, dental professionals could provide an important role in HPV related OSCC risk detection by incorporating salivary analysis as part of their oral cancer screening exams.One limitation of this study involves the patient/parent population. The majority of patients who use dental services at the University are Hispanic. Since this is a convenience sample, it is not representative of the general population, but only of those in the area who access dental services at the university. Limitations also include the lack of data indicating how much cost is a factor in the decision to receive a vaccine. Studies have found that lack of access to healthcare via insurance results in lower acceptance of HPV vaccine uptake , 31. TheThe results of this study can be used to educate minority and Spanish-speaking populations regarding HPV vaccination administration by orthodontists and can be used to assess perceived comfort with administration of other vaccines. In response to the COVID-19 pandemic, the ADA House of Delegates passed a resolution in October of 2020 which acknowledges that dental professionals have the requisite knowledge and skills to administer critical vaccines. As a result, oral health professionals have been called upon by states to act as vaccine administrators of the multidose vaccine developed to combat COVID-19. Studies regarding patient comfort with oral health professionals administering vaccines will be a major step toward dentists becoming a permanent part of the current and future global vaccination effort.Future research should assess orthodontists' readiness to assume a role as a vaccine administrator as well as ways of coordinating this effort with the patient's other healthcare providers. Additional research on other roles orthodontists can play in vaccine education/administration along with a more detailed analysis of the reasons that affect comfort level of parent's uptake of HPV vaccination for their children should also be investigated.


Detection of p16 through immunohistochemistry (IHC) is the standard for determining the HPV status of the tumor according the TNM eighth edition released in 2017 and has become crucial for determining the HPV status of oropharyngeal squamous cell carcinomas (OPSCC) with direct impact on staging and prognostication. In recent years, detection of HPV DNA in mouthwashes has been proposed as a noninvasive alternative, both for OPSCCs and for other head and neck squamous cell carcinomas (HNSCCs). However, the prospect of using the mouthwashes to monitor the response to therapy is unclear. To evaluate the effect of curative therapy on the detection of HPV DNA, we performed a prospective study comparing the detection frequency of high-risk HPV DNA (HR-HPV-DNA) in pre- and post-therapy mouthwashes. We collected 137 mouthwashes from 88 pathologically confirmed HNSCC patients for DNA isolation and HPV genotyping with the Inno-LiPA assay. We show that HPV DNA in pretherapeutic mouthwashes can detect HPV-driven HNSCCs with a sensitivity of 50.0% and specificity of 85.4%, alongside a high negative predictive value of 79.5% and an accuracy of 74.5%. Furthermore, we observed a notable decrease in the detection frequency of HR-HPV-DNA after successful treatment (pre-therapy 50.0% (9/18) versus post-therapy 9.7% (3/28)). However, the comparatively low sensitivity regarding detection of HPV-driven OPSCC argues against its use in clinical routine. The significance of human papillomavirus (HPV) in head and neck squamous cell carcinoma (HNSCC), particularly in oropharyngeal squamous cell carcinomas (OPSCC), has been extensively researched in recent years. Along with smoking and alcohol, infection with oncogenic HPV subtypes followed by neoplastic transformation drives the development of OPSCC. Therefore, HPV is considered as one of the main risk factors for OPSCC, and the number of newly diagnosed OPSCC cases with HPV-associated OPSCC is clearly increasing . PatientINK4A (p16). As direct detection of E6 and E7 is challenging, the analyses of mRNA encoding these proteins, e.g., E6*I, a transcript spanning E6 and E7, is often used to define active involvement of HPV in neoplastic transformation driving the disease [INK4A followed by detection of HPV DNA [+ OPSCCs [+ OPSCC based on the significantly superior prognosis of HPV-related OPSCC [+ IHC by counting p16+ senescent cells without proliferation, a substantial pitfall if p16 is stained solely [According to several studies, HPV-driven tumors (detectable HPV DNA and HPV E6*I mRNA) were shown to be genetically diverse and are now considered as a special subgroup compared to HPV-negative OPSCC ,6,7,8,9. HPV DNA ,11,12. H+ OPSCCs . Howevered OPSCC ,15. In ced OPSCC . HoweverINK4A p. As direed OPSCC ,20,21,22d solely ; the latd solely . Moreoved solely . The insUsing 10 mL of phosphate-buffered saline, Koslabova and colleagues were able to detect HPV DNA in pre-therapy mouth rinses of 53.2% (75/141) HNSCC patients . They reAs demonstrated by Rosenthal and colleagues, the use of mouthwash could be a highly specific test for diagnosis of oropharyngeal cancer . Unfortu+ cases being required to answer the question about significance in the correlation of HR-HPV DNA detection in mouthwashes and HPV-driven HNSCC. After obtaining their informed consent, we accrued 88 HNSCC patients.The study was approved by the Ethics committee of the Medical Faculty of the University Leipzig  according to the Helsinki Declaration II. Eligible were patients with histologically confirmed HNSCC treated in the ENT department of the University Hospital Leipzig. The treatment of HNSCC followed the recommendations according to the personalized decisions of the multidisciplinary head and neck tumor conference of the University Hospital Leipzig based on NCCN guidelines. According to sample size estimation by taking into account the expected frequency of HPV-driven HNSCC [g and stored up to a maximum of 3 months at −80 °C until DNA was isolated. DNA was extracted from the pellet using QIAamp DNA Blood Mini Kit on a QIAcube according to the manufacturer’s instructions . Before storage at −20 °C, yield and purity of DNA were measured on a Synergy 2  using a Take 3 plate (BioTek) for measurement of absorbance at λ1 = 260 nm and λ2 = 280 nm and AE buffer (the extraction buffer from the QIAamp DNA Blood Mini Kit) for reference. Preliminary to HPV genotyping, we quantified the double-strand DNA (dsDNA) content of samples using a Qubit™ 4 Fluorimeter  applying the highly sensitive dsDNA kit.To investigate HPV DNA present in their throat and oral cavity, patients rinsed their mouth with 20 mL of sterile-filtrated tap water for 1 min by switching after 10 s each from gargling to purging. The fluid was sampled in a tube and immediately transferred at room temperature into the lab. Mucosa cells were then pelleted by 10 min centrifugation at 4000× 6 peripheral blood mononuclear cells (PBMCs) spiked into 20 mL of sterile filtered tap water. This finding corresponds to reliable detection of 0.1 ng of KB-derived DNA in a background of 100 ng of DNA (~8 cells containing HPV18 among >8000 cells).For HPV detection and genotyping, the line probe assay Inno-LiPa HPV Genotyping Extra II (CE) kit  was used . Based o+  or HPV-DNA−. As DNA of HPV16 was the predominant HPV subtype in HR-HPV-DNA+ HNSCC, RNA samples of HNSCC positive for this subtype separately underwent the E6*I mRNA RT-PCR assay for HPV16 detection, as previously described [+ whenever HPV16 E6*I transcripts were detected. Tumors were classified on the basis of combined results from HPV-DNA genotyping and detection of either HPV16 DNA+ RNA+ or HR-HPV DNA+ plus p16 positivity of >70% of tumor cells in immunohistochemistry by applying the CINtec® plus kit  as HPV-driven (HPV16 DNA+ RNA+ or HR-HPV DNA+ p16+) or not [HNSCC were classified on the basis of the results of HPV genotyping into HR-HPV-DNAescribed ,7,23. We) or not .Pearson’s chi-square (χ2) tests, Fisher’s exact tests, and McNemar tests to assess differences between categorical variables.The statistical analyses were performed using SPSS version 27  and included + cases with HR-HPV DNA in their primary HNSCC, 88 patients were included , the HPV status of their tumor was not HPV-related (p16-), whereas five OPSCC patients (23.8%) had HPV-driven tumors, but their mouthwashes were not found to be positive for HPV despite each having a sufficient PCR control. HR-HPV DNA was detected in mouth rinses of 7/12 (58.3%) OPSCC patients with HPV-driven tumors . However, HR-HPV DNA was additionally detected in 3/19 OPSCC (15.8%) with p16-negativity of the primary lesion , leading to an accuracy of the findings in 74.2% of mouthwashes regarding diagnosis of HPV-driven OPSCC. When it comes to detection of other HPV-driven HNSCC with primary localizations outside the oropharynx . Summarizing all localizations, the identification of HR-HPV DNA in pre-therapy mouth rinses correlated significantly with HPV-driven HNSCC . We found a specificity of 85.4% for HPV-driven HNSCC whenever HR-HPV DNA was detected in pre-therapy mouth rinses. However, if the correlation between HPV16 in the pre-therapeutic mouth rinse and the probability to identify an HPV16-driven tumor is considered, HPV16 detection was possible in only 27.8% of cases. This indicates a sensitivity problem. Additionally, we were unable to detect HR-HPV DNA in the majority of pre-therapy mouth rinses (50% of HPV-driven tumors had no HR-HPV DNA in their mouthwash). In summary, we demonstrated the limited ability to detect HPV-driven tumors by finding reasonable specificity of 85.4%, accompanied by a high negative predictive value of 79.5% and an accuracy of 74.6%, but a low sensitivity of 50%.Overall, there was a significant correlation of HR-HPV DNA detection in pre-therapeutic mouth rinses and HPV-driven OPSCC (+ mouthwashes from HPV-driven OPSCC patients could be associated with their status “cured” (no sign of disease) at time of post-therapy sampling. This is in line with the findings above described of the comparison between pre-therapy mouthwashes and the tumors’ HPV status. In these, absence of HR-HPV had a high negative predictive value of 79.5% and an accuracy of 63.8% in identification of HPV-driven disease.The comparison of HR-HPV DNA detection in post-therapeutic mouth rinses and HNSCC tumors was possible in 78 cases, 49 cases with OPSCC (62.8%) and 29 cases with primary in other localizations (37.2%). In 49 post-therapy mouthwashes from OPSCC patients, only two (8%) post-therapy mouthwashes contained HR-HPV DNA, and both were from patients without HPV-driven primaries. Independent from treatment modalities applied, the 24 cases with HPV-driven OPSCC among OPSCC were free from detectable HR-HPV DNA (100% negative) after curative treatment. Despite low sensitivity regarding identification of HPV-driven HNSCC (as detected in the pre-therapy mouthwashes), the post-therapy HR-HPV negative mouthwashes from prior (pre-therapy) HR-HPV DNAThe detection of other HPV types in post-therapeutic mouthwashes in a further eight (three HPV-driven and five not HPV-driven) out of 49  OPSCC patients demonstrated a lack in correlation of HR-HPV DNA in post-therapeutic specimens with the initial HPV status.Moreover, the only detection of HR-HPV in post-therapeutic mouthwashes of patients with a primary lesion outside the oropharynx 1/29 (3.4%) was in a case with a non-HPV-driven tumor. This, together with the lack of any correlation of HR-HPV detection in post-therapy mouthwashes with the HPV status of the primary tumor (HPV-driven or not) suggests a lack of correlation of HR-HPV DNA in post-therapeutic specimens with the initial HPV status. Absence of HR-HPV DNA in post-therapy mouthwashes, however, indicates successful treatment if there was detection of HR-HPV DNA in pre-therapy samples from HPV-driven OPSCC according to our finding in the small subgroup of HPV-driven OPSCC .Investigating the hypothesis that eradication of HPV-driven OPSCC will lead to loss of detectable HR-HPV in saliva, we demonstrated with a small but sufficiently large sample of 88 HNSCC patients including 49 cases with OPSCC (62.8%) that detection of HR-HPV-DNA in mouth-rinsing solutions before and absence of HR-HPV-DNA after treatment correlates with successful eradication of the HPV-driven OPSCC. However, pre-therapy mouthwashes do not contain in every HPV-driven HNSCC a sufficient amount of HR-HPV DNA and, therefore, do not allow for reliable detection of HPV-driven disease.+ cases being required to answer the question about a potential correlation of HR-HPV DNA detection in mouth rinses and HPV-driven HNSCC, with the same case number for post-therapy investigations . In total, 53 (60.2%) out of 88 patients accrued were OPSCC patients, and 35 (39.8%) were patients with another tumor localization in the head and neck region. Of 53 OPSCC, 25 (47%) were HPV-driven (HR-HPV DNA+ RNA+ or HR-HPV DNA+ p16+), and 28 (53%) had either a negative p16 or a negative HPV status.We selected the patients for our study by consecutively inviting all patients with histologically confirmed HNSCC to participate in the study. According to prospective sample size estimation, we expected a minimal number of ≥31 HR-HPV DNAINK4A IHC is considered an adequate surrogate marker for neoplastic transformation through HPV infection (20). However, the pooled sensitivity of p16INK4A IHC of 94%  91–97%) and specificity of 83% (CI 78–88%) compared to HPV DNA and RNA detection demonstrates some limitations of sole p16INK4A IHC and is not superior to HPV DNA PCR (sensitivity 98% (CI 94–100%), specificity 84% (CI 74–92%)). The most used threshold to declare HNSCC as p16+ is a nuclear and/or cytoplasmic staining of more than 70% of tumor cells [+ OPSCC being HPV16-negative in the polymerase chain reaction followed by in situ hybridization [+ OPSCC to be not HPV-driven (no detectable HPV DNA and/or RNA) associated with impaired outcome in some p16+ OPSCC [+ HR-HPV DNA+) tumors are treated differently in the future, this could have immense detrimental consequences given the outlined circumstances. Therefore, the recommendation is to determine both HR-HPV DNA and transcriptional activity of HR-HPV, the prerequisite for neoplastic transformation. Transcriptional activity can be detected via viral mRNA transcripts of oncogenes E6 and E7  using RT-PCR, which is considered the current gold standard [INK4A and Ki-67 [INK4A IHC and HR-HPV-DNA PCR . Today,In the search for a viable screening tool for HPV in OPSCC patients, Rosenthal et al. (2017) previously developed an oral rinse test that could serve as an early detection test for HPV-driven oropharyngeal carcinomas . EarlierWe wanted to investigate if there are hints that DNA detection in mouthwashes could serve as a screening tool for recurrence in the follow up of HPV-related OPSCC patients. The main advantage of obtaining a mouthwash for HPV detection is the noninvasive nature of the method that easily can be integrated into clinical routine. In addition, family doctors or dentists could regularly check the HPV status of OPSCC patients who have already completed treatment and are under follow-up.p = 0.010)) [+ cell counts of <200 cells per milliliter may have led to much higher sensitivity and specificity of HPV detection in oral rinses obtained from these patients, as, in such patient cohorts, the highest detection rate of HPV in oral samples was reported [Unfortunately, our analyses of HPV in pre-therapy taken mouthwashes of HNSCC patients demonstrate a relevant sensitivity problem (only 58.3% of HPV-driven OPSCC and 33.3% of other HNSCC could be detected). However, the method itself is sufficiently sensitive for reliable detection and genotyping of HPV in a mouthwash containing eight HPV18-positive cells among 8000 exfoliated cells with full concordant staining. Full concordant staining refers to full representation of staining patterns for typing of the HR-HPV subtype and presence of all internal quality controls. The detection of any HPV DNA might eventually be possible also at lower frequencies. This means that the sensitivity problem relates probably to other so far unknown causes. Loss of the L1 gene used for HPV genotyping or mutations in L1 preventing proper binding of primers and amplification during PCR could be excluded as the same HPV genotyping kit was used for HPV detection and genotyping of tumor tissue. Therefore, shedding only few malignant cells with intact HPV DNA and degradation of such cells or debris containing HPV DNA seem to be hypothetical explanations requiring experimental proof. Despite this sensitivity problem regarding the detection of HR-HPV in HPV-related OPSCC, for cases with pre-therapeutic detectable HR-HPV DNA, the analyses post-treatment mouthwashes appear to be able to indicate the successful cure of HPV-related OPSCC by eradication of HPV DNA . In cont 0.010)) . However 0.010)) , asympto 0.010))  reported 0.010)) . In an i 0.010)) , Ramirez 0.010))  showed t 0.010))  and Krei 0.010))  were obtreported .In 2018, Gipson and his research team published the meta-analysis “Sensitivity and specificity of oral HPV detection for HPV-positive head and neck cancer” . They alSummarizing our feasibility study’s results, the use of mouthwashes to detect HPV-driven HNSCC via detection and genotyping of HPV cannot be recommended as a diagnostic for HPV-driven HNSCC due to low sensitivity and specificity. As we detected HPV DNA independent from prior detection of HPV DNA in pre-therapeutic mouthwashes samples or not, particularly the pre-therapeutic HPV status of the primary HNSCC in some cured patients, there is also a low reliability regarding discrimination between residual disease and cure. We deem sole HPV DNA detection and genotyping as inadequate for the desired purpose.