Most deaths (80%) from cervical cancer occur in regions lacking adequate screening infrastructures or ready access to them. In contrast, most developed countries now embrace human papillomavirus (HPV) analyses as standalone screening; this transition threatens to further widen the resource gap.Methods: We describe the development of a DNA-focused digital microholography platform for point-of-care HPV screening, with automated readouts driven by customized deep-learning algorithms. In the presence of high-risk HPV 16 or 18 DNA, microbeads were designed to bind the DNA targets and form microbead dimers. The resulting holographic signature of the microbeads was recorded and analyzed.Results: The HPV DNA assay showed excellent sensitivity (down to a single cell) and specificity (100% concordance) in detecting HPV 16 and 18 DNA from cell lines. Our deep learning approach was 120-folder faster than the traditional reconstruction method and completed the analysis in < 2 min using a single CPU. In a blinded clinical study using patient cervical brushings, we successfully benchmarked our platform's performance to an FDA-approved HPV assay.Conclusions: Reliable and decentralized HPV testing will facilitate cataloguing the high-risk HPV landscape in underserved populations, revealing HPV coverage gaps in existing vaccination strategies and informing future iterations. Through a proof-of-concept clinical study using cervical brushings from high-risk patients, we successfully benchmarked our platform's performance to an FDA-approved HPV screening test.Here, we describe an approach coined Artificial Intelligence Monitoring for HPV (AIM-HPV), that integrates low and high-tech solutions for DNA-based and POC cancer screening. First, cervical biopsies were replaced by cervical brushings to (i) improve clinical workflow, (ii) maximize patient acceptability/safety, (iii) obviate the need for skilled operators, and (iv) transition from triage to screening. We devised a disposable DNA extraction kit based on manual syringe operations. We developed a new POC microholography platform and assay scheme to detect target nucleic acids. In the presence of HPV 16 and/or 18, microbeads were designed to bind the DNA target and form microbead dimers. The resulting holographic signature was recorded and analyzed. To achieve scalable and low-cost DNA-based cancer screening of populations in areas of greatest need, we leveraged machine learning strategies to enable complete on-site analytics. This eliminated the need for cloud computing and attendant high fixed-costs, thus rendering a genuine POC screening strategy unencumbered by wireless data services or expensive computational resources  using the bead filter was 137.7 ng/µl, comparable with the amount extracted using a commercial Qiagen kit (179.1 ng/µl). In terms of the final assay signals, we saw no significant difference  between HPV DNA isolated by either method.The DNA extraction device is built on a bead-loaded disposable filter to directly isolate DNA from cell lysates  19. We ue.g., high-power LED, CMOS image sensor with more pixels) controlled by a one-touch switch and can readily link to tablets or laptop computers  were estimated by dividing the number of dimers (di) with the product of PS (ps) and silica (si) bead counts: S = k·di·(ps·si)-1, where k is a constant value of 105 to scale it to 0-100. We used a housekeeping gene  as a positive control for the assay. Without any DNA, the level of HPV signal was about 0.8 ± 0.5 , as seen in bright-field microscopy . We previously sought to circumvent such demands on end-users by leveraging cloud computing tactics. While a step forward, the approach did not fully allay cost concerns from cellular data transmission, cloud hardware, and maintenance expenses, notably in resource-limited settings. To realize on-spot detection with cancer screening intentions, we trained deep learning algorithms to differentiate and count the numbers of PS and silica beads  and HPV 16 and 18 positivity. Trained algorithms did not require high-power computing resources and were readily installed on-device to achieve independence from internet connections and cloud computing hardware needs.Conventional digital microholography employs numerical reconstruction of holograms to retrieve microscopic object images . For each image, we predicted PS and silica bead counts Figure A and genR2 = 0.96, Figure During the development and validation, we used the heatmaps to access the accuracy and locations of bead dimers. Using 13,000 images (128 × 128 pixels) for training, our algorithms showed accuracies of 99% for PS beads, 98% for silica beads and 82% for dimers, calculated by a linear correlation between expected and predicted counts on an unseen validation set of sub-images . Without DNA amplification, the assay showed sub-femtomole detection sensitivity Figure A. In tern = 7) of different HPV status  to test both effectiveness and specimen requirements for the AIM-HPV assay. In all cases, we observed a good correlation of AIM-HPV signals for samples collected by brushings and biopsies  and screened them for HPV 16 and 18 status. We used a commercially available Cobas HPV test (Roche Diagnostics) clinically used at Massachusetts General Hospital as the gold standard, which reports the positivities for HPV 16 and 18. Our AIM-HPV assay showed significantly different signals  between groups positive and negative for both HPV 16 , PS and silica beads coated with DNA probes complementary to the 3' and 5' ends of HPV target DNA formed dimers. By using two bead types, we discriminated target-specific dimers from self-aggregated beads. Our deep learning algorithms afforded rapid analyses and accurate diagnoses, circumventing costly cloud computing options and reliance on wireless data transmission.i.e., secondary analysis to ensure that final dimer counts are accurate). We achieved these multiplexed tasks by sharing parameters and common upstream steps between two modules. In all, this new approach reduces the number of required trainable parameters, the likelihood of overfitting, and computational cost while improving overall detection accuracies.Rapid and accurate algorithmic analyses are key components for translating digital microholography to POC settings. Our use of digital holography provides several advantages over conventional microscopic systems: i) the simple and lens-free optical configuration minimizes our device footprint and cost; ii) we reach field-of-views >100-times larger than conventional microscopes; and iii) both field-of-view and resolution can be quickly improved by upgrading image sensor technology. However, computationally expensive image reconstruction required ether a powerful local server  or high-speed internet connection for cloud-based computing, both impractical in low-resource settings. We aimed to address the limitation by adopting deep learning algorithms that can detect target features without computational imaging reconstruction. We previously demonstrated accurate detection of basic cellular holograms and assessed biomarker expression through deep learning algorithms without the need for numeric reconstruction e.g., HPV 31, 58) e.g., novel microfluidic cartridgesExpanding on this inaugural DNA microholography platform, we intend to enhance the assay for expanded testing in resource-poor geographies. These will include i) integrating an isothermal amplification method such as recombinase polymerase amplification  or loop-The AIM-HPV device was equipped with a five-megapixel monochromatic complementary metal-oxide-semiconductor (CMOS) image sensor mounted on a USB 2.0 interface board (The Imaging Source). The light source consisted of a 1.4 A high-power 405-nm LED (Thorlabs) heat-sinked by a metal printed circuit board (PCB) and a custom machined aluminum holder, a 220-grit optical diffuser (Thorlabs) and a 50 µm pinhole (Thorlabs). Optical components were aligned by machined acrylonitrile butadiene styrene (ABS) mounts. An integrated 128 × 32 monochrome OLED Display (Wise Semiconductor) provided a real-time view of system status, and a simple momentary switch controlled the LED. Images were directly transferred via USB to a laptop computer. The unit was powered by a regulated 5V, 15W adapter (Meanwell). The device housing was 3D-printed in white photopolymer resin (Formlabs) and was light-proofed using flocking papers (Edmund Optics). The machined-aluminum door was fastened with 1/8 inch neodymium disc magnets (Grainger).2. All cell lines used for experiments were tested regularly for mycoplasma contamination using a mycoplasma detection kit . We extracted DNA from approximately 500,000 cells. The total DNA concentration was around 200 ng/µl quantified by Nanodrop. Following that, we used 250 ng DNA for each test.C33A, CaSki, and HeLa cervical cancer cell lines were purchased from American Type Culture Collection (ATCC). Cell lines were maintained in ATCC recommended growth medium  supplemented with 10% heat-inactivated fetal bovine serum, 100 IU penicillin and 100 µg/mL streptomycin at 37 °C in a humidified atmosphere of 5% COThe clinical study was approved by the Partners Healthcare Institutional Review Board . Informed consent was obtained from adult women who were referred to the Colposcopy Clinic for previously abnormal Pap smears. Samples were obtained by brushing and/or cervical biopsy. One clinical provider (M.A.-W.) performed all cervical procedures and provided excess or otherwise discarded ectocervical or endocervical specimens. Biopsies entailed visualizing the exocervix and bathing with 5% acetic acid using clinically standard procedures. Before the use of acetic acid, brushing samples were collected with surgical brushes . Cells were carefully removed from the cervical brushes by swirling the brushes in PBS. The entire brushing sample was used up for DNA isolation. DNA was collected fresh within 30 min from the collection of samples; otherwise, the cells were stored at -80 °C. In order to store the samples, we first fixed the samples using BDPhosflow 1x lyse/fix solution and stored them at -80°C until ready to be analyzed. For each patient sample, we have three aliquots for HPV16, 18, and β-globin .We used poly(methyl-methacrylate) microbeads  with silica coatingTarget sequences (~50 nucleotides) unique to HPV 16, HPV 18, and β-globin (control gene) DNA were selected for hybridization-based sandwich assay . Pairs oFull-sized sample images were analyzed on a local machine by two convolutional neural networks described below to produce PS bead, silica bead, and PS-silica dimer counts. The second module additionally generated heat maps indicating the expected centroid location of each dimer. These values were then used to determine the AIM-HPV signal and classify positive/negative samples.Dataset. From 12 full-sized sample images, 13,196 sub-images were generated by passing a 128×128 box through each image with a 50% overlap in the x- and y-direction  is used to improve the final count where the first sum term denotes the square count error, the second denotes CAM layer regularization using Huber loss, and the final term is L2 regularization.Module 2: Dimer Counting and Localization Module. The dimer detection network begins with three units of two convolutional and one max-pooling layers (Figure h is related to the predicted dimer count by . This is also the case for the ground truth count, Y, and ground truth heatmap, H. The loss function used was:where each sum term is the same as for Module 1.Analysis Workflow. AIM-HPV acquired images were split into sets of smaller images of size 128 pixels by 128 pixels. These images were fed into each of the above modules ( modules . Heat maSupplementary figures and tables.Click here for additional data file.


This study demonstrates that the clinical sensitivity, specificity, and reproducibility of the novel cobas human papillomavirus (HPV) test on the cobas 6800 system for high-risk HPV types fulfills the criteria for use in population-based cervical screening. The criteria were formulated by an international consortium, using the cobas 4800 HPV test as a validated reference assay. This study demonstrates that the clinical sensitivity, specificity, and reproducibility of the novel cobas human papillomavirus (HPV) test on the cobas 6800 system for high-risk HPV types fulfills the criteria for use in population-based cervical screening. The criteria were formulated by an international consortium, using the cobas 4800 HPV test as a validated reference assay. The cobas HPV test detected over 98% of histologically confirmed cervical intraepithelial neoplasia grade 2+ (CIN2+) lesions in women age 30 years or older, with a specificity of 98.9% compared with the reference cobas 4800 test. Both the intra- and interlaboratory agreement for the cobas HPV test were 98%. The clinical performance of the cobas HPV test is comparable to those of longitudinally validated HPV assays and fulfills the criteria for its use in primary cervical screening. As national cervical screening programs start to transition from cytology to human papillomavirus (HPV)-based primary testing, there is a need for high-volume clinically validated HPV assays. As of June 2018, only two countries had launched national HPV-based cervical screening programs, the Netherlands and Australia. Both countries utilize assays that test for the presence of clinically relevant levels of nucleic acids  from the following 14 oncogenic HPV types: HPV16, HPV18, HPV31, HPV33, HPV35, HPV39, HPV45, HPV51, HPV52, HPV56, HPV58, HPV59, HPV66, and HPV68. Clinical validation has generally followed the criteria first published by an international consortium in 2009 24, as spe7–me high-risk HPV, BD Onclarity HPV, Seegene Anyplex II HR HPV, Cepheid Xpert HPV, Hologic Aptima HPV, Greiner PapilloCheck HPV-screening, and Self-Screen HPV-Risk assays. All Roche cobas HPV assays (the established 4800 and the novel HPV test run on 6800/8800) also give partial genotyping by separately identifying HPV16 and HPV18, with the results for the remaining 12 types reported in a combined “pool.” The novel cobas HPV assays also utilize a human beta-globin gene as a control for inhibition and cellularity. The cobas HPV test for use on the 6800 and 8800 systems is currently being validated for HPV primary screening in a U.S.-based clinical trial.The Roche cobas HPV test, which can be run on either the Roche cobas 6800 or 8800 system, has yet to be clinically validated for sensitivity, specificity, or reproducibility. This assay tests for the same 14 HPV types as the cobas 4800 HPV, Abbott RealTiThe study population was drawn from women who participated in the Compass Main Trial, a population-based cervical screening trial comparing primary HPV testing with cytology-based cervical screening in Australia in women age 25 to 64 years . Women iFrom this pool of samples, we selected samples from women age at least 30 years for our analyses following the principles published by Meijer and colleagues  and at a(i) Clinical sensitivity. For clinical sensitivity, we identified a set of 60 cervical screening samples from women who subsequently had histologically confirmed cervical intraepithelial neoplasia grade 2 (CIN2), adenocarcinoma in situ (AIS), or worse within 6 months of subsequent follow-up (referred to here as “cases”). The median age of cases was 33 years . During the period of this study, the Compass Trial was only recruiting women born after 30 June 1980, which, when combined with the minimum inclusion age of 30, meant that nearly all participants were between 30 and 35 years of age. Only samples with a valid test result on the cobas 4800 assay were included in the cases. In the Compass Trial, specimens returned invalid results on the cobas 4800 HPV assay at a rate of <0.2%. The cases comprised 21 CIN2, 3 CIN2/CIN3, 22 CIN3, 10 CIN3/carcinoma in situ (CIS), 3 AIS, and 1 mixed AIS/CIS.(ii) Clinical specificity. For clinical specificity, we identified a set of 805 cervical screening samples from women who had no evidence of histologically confirmed CIN2, AIS, or worse within 6 months of subsequent follow-up (referred to as controls). We excluded samples from any woman whose test was undertaken in follow-up of a previous abnormality, a positive HPV test, or as “test-of-cure” in the follow-up of histologically confirmed and treated high-grade squamous intraepithelial lesion (HSIL). The median age of controls was 33 years . Only samples with a valid test result on the cobas 4800 HPV test were included in the controls.(iii) Intralaboratory reproducibility. For intralaboratory reproducibility, we identified a set of 500 cervical samples, of which 150 samples were positive on the cobas 4800 HPV test. All 500 samples were tested twice at Victorian Cytology Service (VCS) Pathology using the novel cobas HPV test, with a median interval of 150 days .(iv) Interlaboratory reproducibility. For interlaboratory reproducibility, the samples were then tested at another laboratory  using the novel cobas HPV test. Only samples with a valid test result on both the cobas 6800 and cobas 4800 instruments were included in the analysis. The median interval between testing at VCS Pathology and NRL was 60 days .The cobas 4800 HPV test is a real-time PCR assay that detects the presence of 14 HPV types, with HPV16 and HPV18 detected individually and a pool of 12 other HPV types . We used the Roche cobas 4800 HPV test as the reference assay, as its sensitivity, specificity, and reproducibility have been demonstrated to be equivalent and statistically noninferior to Hybrid Capture 2 in cross-sectional comparisons –9.–The novel cobas HPV test is similar to the cobas 4800 HPV test in that it uses real-time PCR to detect the presence of the same 14 HPV types with the same partial genotyping. The main difference is that the assay is of a shorter duration by over an hour , which indicates that changes have been made to the chemistry of the assay. The cobas HPV test for use on the 6800 and 8800 systems is currently being validated for HPV primary screening in a U.S.-based clinical trial.1) agreement coefficient (1 score of at least 0.5 was used as a threshold. The level of significance (α) was set at 0.05. Microsoft Excel 2013 was used for calculations of noninferiority scores using the formulae specified in the guidelines paper  of the novel cobas HPV and cobas 4800 HPV tests for detection of CIN2+ lesions separately. We also examined type-specific HPV detection using the two assays in cases and controls . We then compared the clinical sensitivity and specificity values of the novel cobas HPV test with those of the cobas 4800 HPV test using the noninferiority score test. The relative sensitivity threshold for CIN2+ is defined to be at least 90% of the reference validated assay, and the relative specificity threshold for CIN2+ is at least 98% as proposed in the consensus guidelines . In comparison, all 60 cases were positive on the cobas 4800 HPV test, giving a clinical sensitivity of 100% . Relative to the cobas 4800 HPV test, the novel cobas HPV test had a specificity of 98.9% for histologically confirmed CIN2+ lesions in women age 30 years or older. Among the controls, 93 (11.6%) were positive on the cobas 6800 system, and 85 (10.6%) were positive on cobas 4800 test. Of the 8 controls that tested positive on the cobas 6800 system but were negative on the cobas 4800 test, 5 were HPV16, 2 were HPV18, and 1 was non-HPV16/18 positive  (720/805 controls). Both clinical sensitivity and specificity of the novel cobas HPV test were noninferior to the cobas 4800 HPV test  and an AC1 value of 0.98 for the second test .The intralaboratory reproducibility over time was 98.2% , with an AC of 0.97 . The intond test . Both thThree samples that tested positive in the first test and negative for their repeat test were all positive for non-HPV16/18 HPV, with two of the three testing negative in the NRL (the other one was positive for non-HPV16/18 HPV in the NRL). Of the six samples that tested positive in the repeated test but were negative on the original test, 3 were HPV16, 1 was HPV18, and 2 were non-HPV16/18 HPV. The three HPV16-positive samples and the one HPV18-positive sample that were detected in the second test were tested by the novel cobas HPV test at the NRL (see Tables SA to SF).In this study, the clinical performance of the novel cobas HPV test processed on the cobas 6800 system was compared to the validated cobas 4800 HPV test in a cohort of screening participants age 30 years or older. The clinical sensitivity and specificity for histologically confirmed CIN2+ of the novel cobas HPV test were noninferior to those for the cobas 4800 HPV test, which we consider a validated reference assay. The novel cobas HPV test also demonstrated high levels of intra- and interlaboratory reproducibility. The use of the cobas 4800 HPV test as the reference assay also allowed the comparison of partially genotyped results. The benefit of being able to undertake this comparison is relevant for some national cervical screening programs, like Australia’s, which use partial genotyping as part of the clinical management of HPV-positive women.The strengths of this study are the use of a representative screening population recruited from routine practice in Australia, the large number of samples of known clinical history provided by the Victorian Cytology Service Registry, which records primary and follow-up test results, and the use of agreed published international methodological criteria for assessment. The main limitation is that we were unable to utilize either of the previous reference assays (Digene Hybrid Capture 2 or GP5+/6+-PCR-EIA) as our comparator, as neither are in current use in Australia. The current study represents the first validation utilizing the framework of the Meijer criteria protocol using a reference assay other than the Hybrid Capture 2 or GP5+/6+ EIA, which were described in the original manuscript .According to requirements for laboratories reporting tests for the National Cervical Screening Program from Australia’s National Pathology Accreditation Advisory Council , HPV scrme or Hologic Aptima, were to be used as the comparator, there would likely be variation in sensitivity and specificity. We support the use of the cobas 4800 as a reference assay for clinical validation based on its performance in detecting CIN2+ while maintaining high levels of specificity. A recent manuscript , although the size and weight  of the cobas 6800 system make it more difficult to fit into a laboratory compared to other smaller-volume systems. Prospective clinical validation of its performance in real-world screening will follow in the short term, as comprehensive and complete data capture of screening results and subsequent diagnoses occur as part of Australia’s renewed cervical screening program. In particular, confirmation of the adequacy of the assay’s specificity, when combined with reflex cytology in routine use, will be important. In conclusion, the novel cobas HPV test processed on the cobas 6800 system fulfills all requirements, as outlined by an international consortium (


Frankliniella intonsa (Trybom) is one of the most economically important pests in cowpea greenhouses in China. Widespread pesticide resistance of thrips and the negative environmental effects limit the application of pesticides for thrips control. Two commercial cowpea greenhouse experiments were designed to determine the color preference of F. intonsa to colored cards, including white, pink, pale green, light yellow, powder blue, crimson, yellow green, deep sky blue, dark slate blue, dark orange, medium orchid, gold, and black. Clear pieces of plastic were used as the control cards. Additionally, the effects of placement height and orientation  of the cards were also studied. Both greenhouse trials showed that white cards were significantly more attractive to F. intonsa than the other 13 card colors, followed by deep sky blue cards. White or deep sky blue cards placed low to the ground were found to be most attractive to F. intonsa. Orientation of the colored cards also affected the attractiveness to F. intonsa. The results indicate that white sticky cards were significantly more attractive to F. intonsa than blue cards and therefore can be recommended to monitor F. intonsa population densities and to control them in cowpea greenhouses as part of integrated pest management programs.The flower thrips  Vigna unguiculata (Linn.) Walp.), also known as Chinese long bean, is widely cultivated as a vegetable in China1. Thysanoptera (thrips), one of most economically important insect pest, regularly cause serious damage to cowpea grown in protected fields through direct feeding and virus transmission3. The flower thrips Frankliniella intonsa (Trybom) is one of the most important thrips species affecting the yield and market value of cowpea in China4.Cowpea  and placement height of the cards was evaluated.The current study was designed to determine the color preference of P = 0.05)  Figs .Figure 1P = 0.05)     Fig. . After 405) Fig. . Further05) Fig. , which a05) Fig. . After 605) Fig. , and dee05) Fig. .P = 0.05). In addition, the number of thrips attracted to the powder blue cards was similar to medium orchid cards, but significantly higher than the rest of the colors (P = 0.05)     after 2 h, followed by deep sky blue, powder blue, medium orchid and the other colors , except for the middle position in trial I at 6 h. For the deep sky blue cards, the number of thrips attracted at the low position was also always significantly higher than at the middle or high position (P = 0.05), except for the middle position in trial I at 4 h. In both trials, whether the cards were white or deep sky blue, there was no significant difference between the middle position and the high position at 2 h, 4 h and 6 h (P = 0.05)  Table .Table 1TP = 0.05). However, the significant difference disappeared at 4 h or 6 h. There was no significant difference between cardinal directions in trial II (P = 0.05), except for the side facing east at 4 h (Table P = 0.05). However, there were more thrips attracted to the side facing south than to other cardinal directions in trial II (P = 0.05).The white and deep sky blue cards, as the two most attractive colors, were also selected to evaluate the effect of card orientation  on thrips. The number of thrips attracted to the white or deep sky blue cards varied with card orientation Table . For whi h Table . For theP = 0.05)  Table .F. intonsa in a balsam pear field15 and a strawberry field16, followed in attractiveness by white, but there was no significant difference between blue and white in the balsam pear field15. However, white cards were found here to have a significantly stronger attractive ability than blue cards (deep sky blue or powder blue) for F. intonsa in our two cowpea greenhouse trials. Furthermore, the attractiveness to F. intonsa varied among different blue colors in the two trials, for example, deep sky blue, powder blue and dark slate blue   Table , which cF. intonsa in each case. Indeed, there are many thrips species infesting different crops in the field, but different species of thrips are attracted to different colors19. To effectively monitor thrips population densities and control different thrips species, first testing different colored cards to screen for optimal color is necessary before applying colored cards in the field. To enhance the pest control of F. intonsa, pheromone could be used in combination with white sticky cards20.In our two cowpea greenhouse trials, the main species of thrips was identified to be F. intonsa with IPM, other biological control agents should also be considered21, for example, silver stripe mulching film22, predatory mites23, and entomopathogenic fungi24. No beneficial insects were present during our two greenhouse trials, so the potential effect of colored cards on beneficial insects  should also be considered in future work25.Additionally, in order to successfully control F. intonsa among the 13 different colored cards in each of two cowpea greenhouse trials. However, more detailed work on potential combinations with pheromones or other biological agents  are necessary before white sticky cards can be recommended as an efficient method to control F. intonsa in cowpea greenhouses in China.In summary, white cards showed the strongest attraction ability for Two greenhouse trials were conducted in two commercial cowpea greenhouses in Fangshan, Beijing . There was no pesticide application for thrips control during the trials.http://encycolorpedia.com/) for making colored cards . Cards of all of the above colors were printed on A4-size paper (297 mm × 210 mm) and sealed with two pieces of clear laminating film. Clear pieces of plastic with the same size were used as the untreated control. The RGB values of the above cards are listed in Table Thirteen colors were selected from the Encycolorpedia  and were placed randomly in each plot. The number of thrips attracted by both sides of the cards were counted at 2 h, 4 h and 6 h after the placement of cards. The whole experimental design was briefly descripted in Fig. The thirteen colored cards and clear controls were employed as randomized blocks with four replicates each in trials I and II in July, 2017. Two cardinal direction  and three placement heights  were studied at the same time. Every plot area was designed in 15 mThe average number of thrips per card, including both sides, for each color in each plot were used to evaluate the attraction effect of the different colors. The average number of thrips per card for each height by two different cardinal directions  in each plot were used to evaluate the attraction effect of card height. The average number of thrips attracted per side of each card for each of the four cardinal directions and by three different placement heights  in each plot were used to evaluate the attraction effect of card orientation.P = 0.0527.All of the treatments were performed with four plot replicates at each of the two trials. Data for thrips populations were transformed as necessary for statistical analyses , but all data are reported as untransformed values. Data were analyzed using ANOVA with SPSS (version 22.0 for Windows). Significant differences among means were tested with Fisher’s LSD at Supplementary Information


A majority of United States Veterans are older adults, compelling healthcare systems such as Veterans Health Administration to attend to their unique needs when designing and implementing programs for workforce development and service delivery. In this symposium authors will present findings from four studies examining how older Veterans’ needs and preferences affect implementation and sustainment in a variety of settings. Presenters demonstrate how: 1) understanding Veterans’ perspectives and preferences for measuring functional status may inform the improvement of care coordination in the primary care setting; 2) the role of population characteristics in implementation of geriatric patient centered medical home teams ; 3) the interaction of patient, provider, and delivery system information needs in limiting sustainment of diverse initiatives to improve osteoporosis screening and management for Veterans; and 4) the factors affecting transferability and sustainment of rural and geriatrics-focused quality improvement initiatives beyond local settings. Beyond their focus on how older adults’ needs are reflected or shape implementation, the studies illustrate the application of qualitative data to clinical practice and workforce development.


The microbiome is able to modulate immune responses, alter the physiology of the human organism, and increase the risk of viral infections and development of diseases such as cancer. In this review, we address changes in the cervical microbiota as potential biomarkers to identify the risk of cervical intraepithelial neoplasia (CIN) development and invasive cervical cancer in the context of human papillomavirus (HPV) infection. Current approaches for clinical diagnostics and the manipulation of microbiota with the use of probiotics and through microbiota transplantation are also discussed. Cervical cancer (CC) is the fourth most common cancer in women worldwide, with an incidence estimate of 569,847 cases and 311,365 deaths according to the latest Globocan report , of whicAlthough HPV infection per se is not sufficient to promote CC, the development of persistent infection is a major factor for cervical lesion progression and cancer outcome. The majority of HPV-infected women do not develop cervical cancer because immune response control infection, preventing cervical lesion development and its progression to cancer . Thus, oThe human body is a surprising ecosystem that presents trillions of microorganisms. The coevolution that occurred between man and microbes created a complex interaction network ,16. MostThe identification of bacteria began in 1876 when Robert Koch created the methods to culture, isolate and identify the Anthrax agent . This apThe 16S rRNA gene has approximately 1.5 kb and nine variable regions (V1 to V9) intercalated by conserved regions that allow PCR amplification of different bacterial orders using universal primers . For a lThe 21st century advanced technology brought the capability to generate large volumes of sequencing data faster and with high precision. Today it is possible to characterize the diversity of microorganisms present at different human anatomical sites . The firThe concept of the human microbiome was first suggested in 2001 for Joshua Lederberg when he coined the term “microbiome” to refer to the community of commensal, symbiotic, and pathogenic microorganisms, which share the same space with and form a complex interaction with specific human tissue compartments ,26.Changes in human microbiome homeostasis may impair the symbiotic relationship between host and microorganisms, promote physiological changes in the individual, and lead to the development of diseases such as cancer . Recent Streptococcus and Veillonella), which was related to upregulation of signaling pathways commonly associated with lung carcinogenesis [Campylobacter and Lactobacillus) was correlated with esophageal adenocarcinoma [Helicobacter pylori infection is a recognized risk factor for gastric cancer development, but other species from the gastric microbiome are also being associated with carcinogenesis [F. nucleatum and colorectal carcinoma has been reported [The relationship between lung cancer and local bacterial composition has also been explored. The lower airways of lung cancer patients exhibited an enrichment of oral commensal bacteria  in cultured mammalian cells [E. coli were also reported to modify the physiology of intestinal epithelial cell lines leading to an increased production of growth factors and, therefore, stimulating cell proliferation [Altogether, the reports mentioned above harbor evidence from distinct organs linking the microbiome to cancer outcomes. However, the direction of this relationship is not completely understood. Whether microbes could act as carcinogenic agents leading to neoplasia or the tumor microenvironment modulates its surrounding microbial community still remains to be elucidated. Despite that, several microbial carcinogenesis mechanisms are being described, suggesting a driver role of microbes on cancer development . For exaan cells . Besidesferation . The cytferation . Indeed,feration .E. coli was shown to induce a pro-carcinogenic effect only when an inflammatory host response was present [Fusobacterium nucleatum exhibited a proinflammatory expression pattern [F. nucleatum binds to E-cadherin expressed by CRC cells, inducing signaling pathways that lead to proliferation and other oncogenic responses [In addition to genotoxic effects, microbial communities have also been reported to modulate cancer through induction of an inflammatory milieu. In fact, microbial components induce activation of tumor-associated myeloid cells, leading to enhanced secretion of IL-23 and IL-17, cytokines able to stimulate colorectal tumor growth in mice . Similar present  and colo pattern . Taken t pattern , while T pattern . Howeveresponses , therefoH. pylori was able to abrogate T lymphocyte proliferation and induced its cell cycle arrest in G1 phase [F. nucleatum density in CRC tissues was inversely proportional to T-cell abundance [F. nucleatum Fap2 protein was reported to interact with an inhibitory receptor of NK cells (TIGIT), leading to cytotoxic activity blockade and tumor survival [H. pylori expressed B7-H1 (PD-L1) and induced naïve T-cells to differentiate into a regulatory T-cell (Treg) phenotype, an immunosuppressive pathway [Several studies have reported a microbial-dependent immune evasion that could facilitate tumor establishment. The γ-glutamyl transpeptidase (GGT) protein produced by G1 phase , while Fbundance . Those asurvival . Also, g pathway . Those r pathway . Therefo pathway ,63.Lactobacillus crispatus, L. gasseri, L. iners, and L. jensenii as the dominant species, respectively. CST IV exhibit bacterial high diversity, with increased frequency of anaerobic species such as Gardnerella, Megasphera, Atopobium, and Prevotella [Lactobacillus abundance, like CST IV, characterizes a state named dysbiosis. Some women with dysbiosis develop symptoms such as abnormal vaginal discharge, inflammation, odor, and pruritus, being diagnosed, under these conditions, with bacterial vaginosis [The cervicovaginal microbiota can be classified into five groups based on the 16S rRNA high-throughput sequencing (16S-HTS) data according to the bacterial species present . Those gevotella ,65,66. Taginosis ,68. AlthLactobacillus genus shows high abundance in cervicovaginal microbiota and was first described in 1892 by Döderlein [Lactobacillus species like L. crispatus, L. gasseri, and L. jensenii are able to produce lactic acid and hydrogen peroxide (H2O2), which inhibit the growth of other bacteria and viruses [L. iners is considered a transitional species to the dysbiosis state [In general, the öderlein . Lactoba viruses . On the is state .diabetes mellitus, and stress [Lactobacillus species [Lactobacillus species, L. iners has a small genome and is unable to produce D-lactic acid and H2O2 [L. iners produces L-lactic acid and several studies correlate the presence of the latter with viral infections. L. iners can produce inerolysin, a cholesterol-dependent cytolysin [Gardnerella [Lactobacillus species also produce antimicrobial peptides such as bacteriocins and biosurfactants, which inhibit pathogen growth and establishment [The composition of the cervicovaginal microbiota is dynamic, changing due to the hormonal fluctuations that occur during women’s reproductive cycle, use of oral contraceptives, sexual activity, vaginal douching, lactation, d stress . During d stress . Glycoge species . Of the  species ,73. Inteand H2O2 ,72. Instytolysin . Inerolydnerella ,74,75 whlishment ,72.2O2 that have a protective effect against viral and bacterial infections [Lactobacillus dominance, except for L. iners. The L. iners microbiota (CST III) has also been associated with higher frequency of HIV, HPV, and HSV-2 infection [L. gasseri is positively associated with HPV elimination [The microbiota plays an important role controlling viral infections, such as those caused by HPV or HIV ,77,78,79fections ,72  [The profile of CSTs varies according to women’s ancestry ,65. While model) . The abiProteomic studies have been performed on cervicovaginal fluid to analyze and understand the role of the microbiota on the cervical region metabolism ,88,89. AAlthough HPV infection is a necessary cause, it is not determinant for cervical cancer development. HPV infects squamous epithelial basal cells, inducing lesions and even cervical cancer when it is not eliminated . HoweverIn many countries, Pap cytology is the primary screening test either alone or in conjunction with HPV DNA test (co-testing), although in some European countries a switch to primary HPV-DNA technique followed by cytology (Pap smear) has been recommended . The AmeThe HPV-DNA test is a high-sensitive method, so the absence of high-risk HPV-DNA indicates low risk for CIN3 and cancer development, which may allow safe prolonging of cervicovaginal screening test intervals . AdditioAcknowledging a biomarker potential, high diversity microbiota has been frequently shown to correlate with HPV status and different severities of cervical dysplasia, suggesting a potential in indicating vaginal health and disease . TherefoLactobacillus spp. when compared to their HPV- matches. Moreover, bacteria of the Sneathia genus was remarkably associated with HPV positivity and suggested as a biomarker for viral status [Different reports consistently demonstrated the relationship between HPV infection and/or persistence and microbiome composition. In fact, a study reported that HPV+ women exhibited a more complex microbiome diversity than HPV- counterparts . Similarl status . Taken tL. gasseri was related to a faster HPV clearance, while microbiomes with lower Lactobacillus levels and higher abundance of Atopobium, Gardnerella, and Prevotella were associated with a slower infection resolution [L. crispatus was the most prevalent Lactobacillus spp. in Italian women that cleared HPV infection or were consistently HPV-, while a microbiome composition characterized for lower Lactobacillus spp. counts and higher abundance of Gardnerella, Prevotella, Atopobium, and Sneathia  was the most frequent among women with persistent hr-HPV infection during one year. Also, among patients with persistent HPV infection, L. iners was the most abundant Lactobacillus species [Lactobacillus spp. and greater representation of anaerobic bacteria was more frequent in HPV+ than in HPV- subjects [Lactobacillus spp. dominated microbiota is noteworthy, while its paucity and increased amounts of other bacterial genera is related with higher HPV risk. Nevertheless, a study has recently provided some insights into possible interactions between viruses and the vaginal microbiome. The authors demonstrated that cervicovaginal samples with CSTs I or IV that were positive for oncogenic viruses (HPV and/or polyomaviruses) showed increased abundance of L. crispatus as well as P. timonensis and S. sanguinegens, respectively, when compared to its counterparts without any virus detected [L. gasseri  was more frequent in HPV+ subjects compared to HPV- in a Chinese cohort [L. mucosae and Enterococcus faecalis were the most dominant species among women from Northeast India [In this scenario, a study following women for 16 weeks showed that a vaginal microbiota dominated by solution . Further species . Accordisubjects . Altogetdetected . That sue cohort  as well st India , which oL. crispatus-dominated microbiota registered significantly less frequent HIV, HSV-2, and HPV infections and bacterial STIs when compared to other compositions [L. crispatus-dominated environment has been associated with the presence of polyomaviruses, a longitudinal analysis of those patients revealed that CST I was associated with increased rates of viral clearance, while women harboring CSTs III or IV commonly progressed to persistent infections [It is also important to highlight that microbiome composition has also been related to other viral infections. For example, African women with ositions . A reporfections .Gardnerella, Prevotella, Atopobium, and decreased abundance of Lactobacillus spp. occurring together with CIN and cancer. However, again, the cause–effect relationship between microbiome and cervical dysplasia has not been elucidated well [As discussed above, the vaginal microbiota composition has been extensively associated with HPV positivity and suggested as a promising biomarker for HPV risk. Accordingly, HPV infection is strongly recognized as a necessary, but not sufficient, cause for cervical carcinogenesis. Therefore, since specific bacterial compositions are linked with increased viral infections, the microbial community could also be associated with cervical dysplasia development and inform about cytological abnormalities. Indeed, different studies have already described a cervicovaginal microbiome shift with increased proportions of bacteria such as ted well .L. crispatus and L. iners were respectively the predominant species for HPV- and HPV+ women without cytologic alterations, Sneathia spp. and Fusobacterium spp. were predominant in squamous intraepithelial lesions and cervical cancer, respectively [Lactobacillus spp.) frequency was shown to be directly proportional to cervical abnormalities severity: the cluster was gradually more abundant in low-grade squamous intraepithelial lesions (LSIL), high-grade SIL (HSIL) and cervical cancer. Moreover, HSIL samples had greater abundance of Sneathia sanguinegens, Anaerococcus tetradius, and Peptostreptococcus anaerobius than LSIL, suggesting shifts in microbiome composition according to disease severity [Lactobacillus dominance decreased together with cervical dysplasia severity while Sneathia spp. were increased in low/ high grade precancerous lesions and invasive cervical carcinoma [Lactobacillus and increased relative abundance of other species as a factor associated with cervical abnormality development. Those reports also indicate that each stage of cervical dysplasia is associated with a corresponding microbial pattern. For example, while Lactobacillus spp. are more associated with normal cytology and absence of HPV, a higher abundance of Sneathia spp. was observed throughout cancer development and, therefore, could be used as indicative of vaginal disease together with other species mentioned above.Differences in microbiota composition were found between normal cytology, cervical lesions and cancer. That is, while ectively . Similarseverity . Likewisarcinoma . In thisA. vaginae, G. vaginalis, and L. iners together with L. crispatus in low levels was suggested as the most hazardous combination for CIN development, with an odds ratio of 34.1 for CIN in the presence of hr-HPV [B. fragilis, L. delbrueckii, and S. agalactiae had an indirect effect on cervical cancer mediated by HPV infection, while A. vaginae and P. stutzeri also exhibited a direct effect on cervical carcinogenesis independently of HPV status [Prevotella and lacking a consistent dominant species shifted significantly to an L. iners dominated community after three months of LEEP intervention [Lactobacillus spp. and L. iners was significantly associated with CIN 2 and CIN 3 in women with hr-HPV [L. iners was already described to be related with CIN [Lactobacillus species was previously reported as a protective factor, but this cohort showed a different observation for unclassified Lactobacillus spp. In this scenario, Hispanic ethnicity by itself was associated with a decrease in Lactobacillus dominance and Sneathia spp. enrichment when compared to non-Hispanic women living in the U.S [Additional evidence corroborates the findings described above. First, the presence of f hr-HPV . MoreoveV status . Of notervention . Howeverh hr-HPV . Althougwith CIN  or HPV pwith CIN , the dom the U.S .L. iners, Moryella, Schlegelella, and Gardnerella associated with CIN with significant odds ratios of 40 for Moryella and of 3.5 for Schlegelella [Gardnerella appeared with a higher frequency in CIN when compared to normal status [G. vaginalis and A. vaginae and lack of L. crispatus when compared to HIV- pregnant participants. Also, L. iners enrichment was observed in HIV- individuals and in HIV+ subjects with preconceptional ART exposure [HIV-positive women show increased risk of HPV acquisition and CIN development ,107,108.egelella . In a lol status . Similarexposure . These fGardnerella, Prevotella, and Atopobium as dominant species, and other diverse species with variable abundance, like Anaerococcus sp., Peptostreptococcus sp., Fusobacterium sp., Moryella, Sneathia, and Schlegelella [The bacterial abundance in the cervicovaginal microenvironment is variable and the term CST is used to indicate the dominant species present, as described above. CST IV is the most diverse type and has bacterial species linked with CIN, such as egelella ,12,13. Tegelella .Clinical samples encompass a complex array of multiple bacterial species, posing a challenge to proper microbial identification methods. The cost of 16S-HTS has decreased during the last decade and can be applied as a diagnostic method in medical microbiology laboratories . The maiLactobacillus morphotypes), gram-negative or gram-variable (BV flora) bacteria observed from the secretion collected through a Pap exam. Due to their limitations, novel methods using molecular diagnostics have been developed [G. vaginalis with high sensitivity (90–94%) and specificity (97–81%) when compared to Amsel criteria and Nugent score methods [A. vaginae, BVAB-2, Megasphaera type 1 and 2, L. acidophilus, L. crispatus, L. jensenii, and G. vaginalis with high sensibility (90–99%) and variable specificity (70.2–95%) when compared to Nugent score and Amsel criteria [Women with bacterial vaginosis (BV), irrespective of their symptomatic status, show higher frequency of viral infections and cervical lesions ,66. In geveloped ,119,120.criteria . The varcriteria . Some bacriteria .Lactobacillus spp. [Women with BV show a high diversity microbiota and the most traditional treatment is the use of prescribed antibiotics such as metronidazole and clindamycin that do not ensure cervicovaginal recolonization by lus spp.  and coullus spp. . Moreovelus spp. , lack oflus spp. , and intlus spp. . In thisLactobacillus spp. could overcome the presence of pathogens and promote a healthy state to the vaginal microbiome [L. fermentum 57A, L. plantarum 57B, and L. gasseri 57C, together with metronidazole, was able to lengthen the intervals without BV when compared to antimicrobial therapy alone [L. rhamnosus BMX 54 as an adjuvant to antimicrobial therapy was shown to improve the rates of healthy vaginal microbiota in BV-diagnosed patients comparing to those receiving antibiotics alone [L. rhamnosus GR-1 and L. reuteri RC-14 together with tinidazole significantly reduced Shannon’s diversity of vaginal microbiota in BV-diagnosed women and increased the relative abundance of Lactobacillus spp. when compared to patients treated only with antibiotics [Probiotics are “live microorganisms which, when administered in adequate amounts, confer a health benefit on the host” . Therefocrobiome . Over thpy alone . Moreovecs alone . In agreibiotics .L. rhamnosus IMC 501 and L. paracasei IMC 502 were tested in apparently healthy women. The authors registered 40% of patients with an intermediate Nugent score before the treatment and half of them returned to a normal state (low Nugent score) after the intervention [L. fermentum 57A, L. plantarum 57B and L. gasseri 57C were able to significantly reduce vaginal pH and Nugent score, suggesting a shift to a healthy vaginal microbiota profile. Also, probiotic administration caused a transient increase in the abundance of Lactobacillus spp. originally present in the capsules. That is, the preparation significantly increased Lactobacillus spp. amounts after seven days of treatment, but the levels slowly declined during the following eight days without intervention [L. acidophilus GLA-14 and L. rhamnosus HN001 against pathogens associated with BV  [Lactobacillus-based probiotics concerning the maintenance of vaginal microbiome homeostasis.The potential of probiotics as a single therapy has also been documented . In thisrvention . Besidesrvention . Likewisvaginae) . AltogetLactobacillus spp. strains have been isolated from healthy women and their potential as probiotics has been investigated. L. plantarum and L. fermentum strains isolated from healthy Cuban women exhibited antagonic activity against G. vaginalis, C. albicans, as well as remarkable adhesive capacities and lactic acid production [L. fermentum 9LB6, 4LB16, and 10LB1 and L. plantarum 9LB4 strains were isolated from Algerian women and suggested as probiotic candidates based on their relevant inhibitory activity of pathogens, lack of hemolytic capability and other beneficial properties according to in vitro studies [L. crispatus LbV 88, L. gasseri LbV 150N, L. jensenii LbV 116, and L. rhamnosus LbV96 strains, originally obtained from healthy pregnant women, were selected as relevant for vaginal health [Interestingly, oduction . Similar studies . Howeverl health  and furtl health .Bifidobacterium adolescentis, a reduction in HPV E6 and E7 mRNA production was noticed. Acknowledging the relevance of HPV for cervical cancer development, probiotics could also be linked to cancer prevention. In this context, in vitro studies demonstrated that the combination of L. gasseri and L. crispatus present cytotoxic effect in HeLa cervical cancer cells naturally infected with HPV-18 and this effect did not occur in normal cervical cell lines [L. casei had a significantly higher chance of resolving cytological abnormalities compared to untreated women, yet both groups did not differ significantly with respect to HPV clearance [Lactobacillus rhamnosus BMX 54 delivered as vaginal tablets. The authors showed that the group receiving long-term probiotic treatment (for 6 months) exhibited not only a significant higher chance of resolving cytological abnormalities but also showed increased rates of HPV clearance when compared to the group receiving short-term probiotic therapy (for 3 months) [Evidence linking probiotics to HPV clearance has been published . When thll lines ,139. An learance  Table 1 months)   promoted a successful vaginal colonization by the strain when tested in macaques [Given the potential use of probiotics in vaginal health, new approaches for their administration are being developed. A mucoadhesive vaginal tablet containing microbes . Interesmicrobes . Moreovemacaques .After the currently recognized effectiveness of fecal microbiota transplant, vaginal microbiota transplant (VMT) has also been proposed as an interesting field of research for future probiotic therapy . In thisLactobacillus species coupled with a simultaneous decrease in members of Bifidobacterium, Prevotella, and other genera. Interestingly, three patients required repeated VMT (and even a donor change for one of them) to reach BV remission [In addition to mother-to-infant transplantation, VMT has been recently evaluated as a treatment option for patients with recurrent BV after being subjected to different antimicrobial regimens . Vaginalemission , suggestLactobacillus-dominated donors in order to reduce the risk of pathogen transmission. The authors suggested a list of tests to perform on donor candidates before VMT, such as HIV (1 and 2), HAV, HBV, HCV, EBV, Treponema pallidum, Chlamydia trachomatis, Neisseria gonorrhoeae, Toxoplasma gondii, and others. According to their criteria, from 20 candidates enrolled in the study, only seven were eligible for vaginal fluid donations, indicating the importance of donor screening prior to VMT [A potential risk limiting VMT feasibility is the transmission of pathogens between donor and recipient. DeLong and collaborators proposed a screening protocol for cervicovaginal fluid from r to VMT .Lactobacillus species (except for L. iners-dominant) can promote HPV clearance and the absence of cervical lesions. Thus, specific bacteria or the high diversity microbiota may function as biomarkers for cervical alterations, and can as well as be used to identify women at high risk to develop persistent HPV infection, CIN, and cancer. However, the mechanisms involved in the role of the microbiota on the promotion of, or protection to those conditions are yet to be fully elucidated.The cervicovaginal microbiome is a dynamic network of microorganisms able to modulate a host’s immune responses and promote an environment susceptible to viral infection acquisition and development of CIN. Recent studies showed the association between high-diversity cervical microbiota and HPV infection, CIN and cervical cancer. On the other hand, women with dominant The use of probiotics is demonstrated in vivo and in vitro for HPV clearance and significant CIN regression. Therefore, the manipulation of the microbiota by the use of probiotics or by VMT may be a feasible option to induce HPV infection clearance, CIN regression, and stop progression to cervical cancer.


Human Papillomavirus (HPV) vaccination, intended for young women aged 11–14 years old, has been introduced in Switzerland in 2007. Ten years after its introduction, only a few studies have explored the reasons associated with uptake and non-uptake of the vaccination. Our objective was to identify the sociodemographic characteristics of a population of vaccinated and unvaccinated undergraduate healthcare female students, to define the reasons of non-uptake of vaccination, and compare our findings with those found in other Swiss cantons.Between January and November 2017, women studying in Health Sciences School and Medical School in Geneva, aged 18–31 years old, were recruited in a large trial assessing HPV prevalence. As part of a smaller, observational study nested in this larger trial, women were invited to complete a questionnaire. Self-reported HPV vaccination uptake or non-uptake, as well as knowledge and attitude about HPV vaccination were assessed. T-Test and Chi square test were used to compare characteristics of vaccinated and unvaccinated women.p < 0.001).Overall, 409 women were recruited in the study. The majority of them (69.1%) reported having been vaccinated for HPV, while 30.9% of them had never received any dose of the HPV vaccine. The only factor associated with a higher vaccination rate was the participants’ origin, as women from Geneva were more represented in the vaccinated group than women from other Swiss regions or countries. Unvaccinated women were more likely to consider HPV vaccination as less important than the vaccinated ones (50.4% vs 3.5% Although no typical profile can be established in this studied population of unvaccinated women, a lack of information was a major reason of non-uptake of vaccination among the study participants. An effort by health authorities and carefully designed messages are essential to increase the population’s awareness over cervical cancer and its prevention.cliniclatrials.gov with the identifier: NCT03474211.The trial was registered under  Human Papillomavirus (HPV) is responsible for the most prevalent sexually transmitted infection worldwide, which represents a major public health challenge . It is e® and Cervarix®, both of which protect against HPV genotypes 16 and 18, which are responsible for the development of cervical cancer in over 70% of cases [®, which has been available on the market since 2007, also covers against genotypes 6 and 11, which are mostly responsible for the development of genital condylomas [HPV vaccination represents a fundamental primary prevention measure for the development of cervical cancer. The currently available vaccines in Switzerland are GardasilThe Swiss recommendations for HPV vaccination were first published in 2007, advising the vaccination for all females between the ages of 11 and 14 years while also recommending a catch-up vaccination for women aged 15 to 19 years .Service de L’Enfant et de la Jeunesse (SSJ) in public schools, which inform families and offer vaccination to all female school children aged 11–19 years old. According to a study on HPV vaccination carried out 4 years after the first campaign, the majority of 13–14 year-old girls had been vaccinated through the SSJ, thus proving its efficiency [In the Canton of Geneva, the first HPV vaccination campaign tookplace in September 2008. The greatest asset of the campaign in Geneva is the strong involvement of school health services, such as the The aim of this study was (i) to compare the sociodemographic characteristics of a population of vaccinated and unvaccinated undergraduate female healtcare students in the Geneva canton, (ii) to define the reasons for not having undergone vaccination in the latter group, and (iii) to compare the reasons for non-vaccination to those found in other Swiss cantons.Recruitement of the study participants took place from January to November 2017 at the Medical school and at the School of Health Sciences of the Medical University of Geneva, located in the city of Geneva, Switzerland. Women aged 18–31 years, currently attending either Medical School to obtain a medical doctor degree or the School of Health Sciences in Geneva to obtain a nurse or midwife degree, were invited to participate in the study.This study has been carried out as a nested, observational study within a larger trial evaluating the HPV vaccine’s effectiveness by analyzing the HPV prevalence using a cervico-vaginal self-sampling method .Announcements about the study were given by previously-informed professors teaching classes at the School of Health Sciences and at the Medical School in Geneva. An email was also sent by the study investigators to the students prior to their recruitement. After having delivered a short presentation about the HPV infection and the project’s design, the study investigators distributed the kits to those students who expressed an interest to participate in the study. The kits contained a cotton swab for HPV self-sampling , illustrated instructions on how to use the swab for self-sampling, an informed consent form, an explanatory document about the HPV infection and a questionnaire on sociodemographics and their reasons of non vaccinated choice. Each kit also contained an identification number, to which the participants could refer to obtain their HPV test results. The students were given 1 week to return the kit and the questionnaire to the study investigators. The results of the HPV analysis were given to the students by a designated study investigator upon request.The questionnaire which women were invited to complete in order to fulfill the aim of this study included questions about the HPV vaccination uptake or non-uptake, the participants’ knowledge and attitudes over the HPV vaccination, their sexual behavior and country or Swiss canton of origin.The sample size was calculated based on the primary outcome of the main study . It was p value of less than 0.05 was considered as statistically significant.Statistical analyses were run using STATA 13. The normality of the distribution was tested by the Kolmogorov-Smirnov test. Descriptive statistics and frequencies were analysed for all variables. The T-test and Chi square test were used for the descriptive statistics and for the comparaison between variables. A cliniclatrials.gov with the identifiers: NCT03474211.The study protocol was approved by the ethical cantonal board in Geneva  with the identification number 15–357. All participants signed an informed consent form prior to taking part in the study. The trial was registered under , p = 0.017). We found that only 2.8% (8/284) of vaccinated women were infected by the HPV strains 6, 11, 16 and 18, while up to 11% (17/125) of the unvaccinated participants were infected by these same 4 strains. The participants’ sociodemographic and clinical characteristics are reported in Table Out of 500 kits distributed, a total of 409 were given back, thus obtaining a response rate of 81.8% (409/500). Among the 409 participants included in the study, 55% of them (225/409) were enrolled in Medical School while 45% (184/409) of them attended the School of Health Sciences. A total of 46% of the study participants reported their vaccination status based on their own personal notion, without verifying such data on their vaccination booklet. Women coming from the Geneva canton were more represented in the vaccinated  than in the nonvaccinated group of participants , whereas women coming from other Swiss cantons, who were grouped together with women coming from other countries  were more represented in the nonvaccinated group  than in the vaccinated one . A total of 4.6% (13/284) and 0.8% (1/125) vaccinated and unvaccinated women, respectively, believed that the HPV vaccination was more important than other types of vaccination. There were 3.5% (10/284) and 50.4% (63/125) of vaccinated and unvaccinated women, respectively, who believed that the HPV vaccination was less important than others. The participants’ perceptions of the importance of the HPV vaccination are reported in Table Overall, 91.9% 261/284) of the vaccinated women believed that the HPV vaccination was as important as other vaccinations, while only 48.8% (61/125) of the unvaccinated participants believed that the HPV vaccination was as important as the others 61/284 ofp = 0.35). On the contrary, the proportion of women who believed that the HPV vaccination was either more than or as important as other vaccinations increased with the women’s age (< 20 years: 38% (19/50); 20–23 years: 54.4% (31/57); > 23 years: 61.1% (11/18); p = 0.07).Among unvaccinated participants, the proportion of women who believed that the HPV vaccination was less important than others decreased as the women’s age increased (62% of the < 20 years group (31/50), 45.6% of the 20–23 years (26/57), 38.9% of the > 23 years (7/18); Among unvaccinated participants who believed that the HPV vaccination was less important , 57.1% of them (36/63) used the condom sometimes/never, whereas 42.9% (27/63) of them used it often/always. Among women who considered the HPV vaccination as/more important than other vaccinations , 51.2% (32/62) used the condom often or always, while 48.8% (30/62) used it sometimes/never. The association between the participants’ opinion about the HPV vaccination and their frequency of condom use is reported in Fig. A total of 41.6% (52/125) of the unvaccinated women did not give any information or did not know why they had not been vaccinated. Among women who gave a reason for not having been vaccinated 58.4%, 73/125), the reported reasons included: fear of side effects ; parents being against the vaccination, either in general or the HPV-one ; the physician in private practice being against the HPV vaccination ; the vaccination not being considered as useful ; the person being against vaccinations in general ; sexual inactivity ; insufficient evidence on the vaccine’s efficacy and side effects . The reasons for not having been vaccinated are reported in Table /125, theThis is the first study to evaluate the acceptability of the HPV vaccine in Geneva since the introduction of the HPV vaccination in the canton. Our results revealed that 69.4% of our study population was vaccinated against HPV, a rate higher than the rest of Switzerland where, according to the results of a survey conducted in 2016, only 53.6% of women aged 18–24 years were vaccinated . AnotherHowever, Our results reflect a reality in which, despite the remarkable efforts to reach the optimal vaccination coverage rate, the resistance to the vaccination prevents public health workers from reaching the optimal coverage rate. When looking at reasons for non-vaccination, three of them stood out: fear of side effects (21.6%), parents being against the HPV vaccination (14.4%) and the physician being against the vaccination 8.8%). Similarly, in a study including women aged 18–24 years living in the French-speaking region in Switzerland , the mai.8%. SimiConcerning the opinion about the importance of the HPV vaccination, we found that the difference between vaccinated and unvaccinated women was compatible with their immunization status. Over 50.4% of unvaccinated women considered the vaccination as less important than other vaccinations, while 91.9% of vaccinated women considered it as as important as other vaccinations. Another study carried out in Italy obtained similar results among women aged 18–21 years old, thus demonstrating that one of the factors associated with not having been vaccinated was the lower perception of its benefits .A small majority (51.1%) of our population sample had been vaccinated between the ages of 15 and 19 years old, although vaccination for women in this age range was meant to be a catch-up for those who had missed their opportunity to be vaccinated in the first place. Knowing that the moment for the ideal vaccination is before first sexual intercourse, which in our population took place at a median age of 17.2 years old, baseline vaccination for all 15–19 years-olds seems to be a reasonable target to improve prevention. Nevertheless, the median age when receiving the first vaccine dose in our study population was 14.8 years old. The small percentage of vaccinated women after the age of 20 years old (4.2%) is not surprising considering that the campaign mainly targets the younger part of the population. Such results are in line with those of a study  evaluatiWhen studying the sociodemographic characteristics of our population, only nationality was found to be significantly associed to vaccination status, as a greater proportion of women coming from Geneva and its surroundings were vaccinated when compared to women coming from other cantons and countries. Given the difference of the vaccination campaigns and policies in other cantons and countries, such finding highlights the efficacy of the vaccination campaign in the canton of Geneva, where a particularly active role was played by the SSJ in public and private schools. Other studies have confirmed that, when the SSJ was involved in vaccination campaigns, as is the case in other French-speaking cantons in Switzerland, such finding resulted in better vaccination rates than those in the German-speaking part of Switzerland .One strength of our study was given by the fact that we chose a population of young, future healthcare providers, whose opinion is fundamental in the view of spreading the vaccination uptakein the near future. In addition, this population sample of young adults has never been studied in such geographical area.One limitation of our study was the sample’s relatively small size, which limited the power of some of our observations. A selection bias also may have occurred, as all the participants not only had a high educational degree but also studied medical and health sciences, which does not reflect the heterogeneity of the general population. Additionally, the HPV kits were offered to the students who proactively expressed an interest to participate in the study, excluding the girls possibly having another opinion about the HPV vaccination. Finally, 46.3% of our participants had not checked their vaccination record to answer the questionnaire, an aspect which may have altered some of the study results.The suboptimal HPV vaccination rate among our study population of undergraduate women shows that, despite the vaccine’s proven efficacy, the coverage rate is still far from reaching 80%. The majority of vaccinated women in our study population came from the Geneva Canton, a finding which further highlights the discrepancies in vaccination campaigns in the country. Proactive education about the HPV infection’s natural history and the vaccination’s role, to be delievered by the women’s personal healthcare providers, represents a fundamental step in increasing the vaccination coverage rate across the country.


Candida albicans (VVC) , Chlamydia trachomatis (CT) , and Ureaplasma urealyticum (UU) . BV was also related to CIN . This meta-analysis of available literature suggested an intimate association of vaginal microecology and HPV infection with CIN. BV, CT and UU were associated to increased HPV infection, VVC was associated to decreased HPV infection, Lactobacillus is not associated to increased HPV infection, BV was associated to increased CIN development risk. Further large-scale studies are needed to confirm our findings.Microecology is an emerging discipline in recent years. The female reproductive tract is an important microecological region, and its microecological environment can directly affect women’s cervical health. This meta-analysis aimed to analyze the effects of vaginal microecology on Human papillomavirus (HPV) infection and cervical intraepithelial neoplasia (CIN). PubMed and Web of Science were systematically searched for eligible publications from January 2000 to December 2017. Articles were selected on the basis of specific inclusion and exclusion criteria. The design and quality of all studies were evaluated using the Newcastle-Ottawa Scale (NOS). Odds ratios (ORs) with a 95% confidence interval (95% CI) were calculated. Thirteen eligible studies were selected to evaluate the association of vaginal microecology with HPV infection and CIN. The factors related to HPV infection were bacterial vaginosis (BV) ,  Cervical cancer is the second most common malignant tumor among women worldwide, second only to breast cancer . Human pIdentifying risk factors for the development of CIN and cervical cancer has been the objective of recent studies . Normal Relevant studies on the association between vaginal microecology and HPV or CIN were identified through an extensive search of PubMed and Web of Science between January 2000 and December 2017 based on the following keywords: ‘vaginal microecology’,‘vaginal microenvironment’, ‘vaginal environment’, ‘vaginal microbiota’, ‘vaginal flora’, ‘cervicovaginal coinfections’ or ‘cervical inflammation’, in combination with ‘cervical intraepithelial neoplasia’, ‘cervical lesions’, ‘cervical dysplasia’, ‘human papillomavirus’, ‘papillomavirus infections’ or ‘HPV’. Studies were limited to those written in English. We performed a second search based on the references in the original literature.Candida albicans (VVC). The design and quality of all studies were evaluated using the Newcastle-Ottawa Scale (NOS) [Studies describing the relationship between vaginal microecology and CIN or HPV infection were included in this meta-analysis. Eligible studies were required to have clinical or pathological diagnostic information related to HPV and CIN. Articles were included if they presented data for calculation. Conference abstracts and other unpublished articles were excluded as these could not be systematically reviewed and the data could not be verified. Duplicate reports with similar content from the same author were excluded. Studies containing special occupational groups were excluded. The selected studies focused mainly on bacterial vaginosis (BV),Trichomonas vaginitis (TV),Chlamydia trachomatis (CT),Ureaplasma urealyticum (UU), lactobacillus, le (NOS) . For eac2 statistic test. The fixed effect model (Mantel and Haenszel method) was selected if the results showed P > 0.10 and I2 < 50%; otherwise, the random effect model (DerSimonian and Laird method) was chosen. P < 0.05 was considered to be statistically significant.Data from each observation in the experimental and control groups were extracted. We used Review Manager 5.3 software to analyze the data and calculate the odds ratio (OR) and its 95% confidence interval (95% CI). The results were visualized in a forest plot. Study homogeneity was quantified by IWe selected 13 studies from hundreds of articles based on established standards. These publications included nine studies on vaginal microecology and HPV infection, three studies on vaginal microecology and CIN and one study on vaginal microecology with HPV infection and CIN. A total of 5639 women were included in the in case group and 19,561 women in the control group.P < 0.05) were statistically significant , and that in the HPV-negative group was 6.6% (845/12752). The total results based on all eight studies , and that in the HPV-negative group was 4.1% (305/7480). A summary of all data showed that this association was statistically significant  , and that in the HPV-negative group was 1.7% 175/10293). A summary analysis of five studies showed that the OR of Trichomonas did not differ between the HPV-positive and -negative group   in the HPV-positive group and 2.8% (196/6982) in the HPV-negative group. There was a statistically significant association when the results of all studies were analyzed together  Fig. .Fig. 4CP < 0.05)  , and in the control group it was 10.0% 636/6375). The summary results showed that the difference was statistically significant .Three papers researched the correlation between TV and CIN. All studies concluded that there was no significant correlation between TV and CIN. Among these studies, the detection rate of TV in the CIN group was 1.4% (8/556) and that in the control group was 0.9% (60/6341). As shown in Fig. P = 0.98) , and that in the control group was 1.7% (104/6015). We combined the results to show that VVC and CIN were not significantly associated , therefore BV may increase the risk of cervical HPV infection and CIN development. Sodhani P et al. [P < 0.0001). Meanwhile, Zhang,H et al. [BV is the most common vaginal infection in women of childbearing age. Previous systematic reviews  reportedP et al.  found thH et al.  reportedCandida albicans is an opportunistic pathogen that usually does not cause disease on the vaginal mucosa but may cause disease when the body’s immunity is reduced or the vaginal acidic environment changes [P > 0.05), and that VVC is a protective factor for HPV infection  and had no correlation with CIN(P > 0.05). Meanwhile, Engberts MK et al. [TV and VVC infections are common genital tract infections in women.  changes . TV is a changes . Whether changes  conclude changes  analyzedK et al.  also conK et al. . Based oP < 0.05; OR 1.35, 95% CI 1.20–1.51, P < 0.05). This indicating that both UU and CT increased the risk of HPV infection; the risk of HPV infection increased by 1.35-times in UU-positive patients and by 3.16-times in CT-positive patients. Different studies have reported that UU plays an important role in initiating abnormalities and persistence of viral cells, and it is a cofactor for HPV to promote precancerous lesions that lead to cervical cancer [In recent years, reports on the relationship between mycoplasma and chlamydia infection and HPV infection and cervical lesions have gradually increased . Whetherl cancer , 49. Thel cancer , involvil cancer  also foul cancer . In this2O2, and biosurfactants bacteriocin [The changes in vaginal pH may play a major role during the progression of HPV infection and CIN to cervical cancer. Under normal circumstances, Lactobacillus is the most dominant bacterial genus in the female vagina, and it can regulate the structure of vaginal flora and maintain the stability of vaginal microenvironment by producing a variety of bacteriostatic and bacteriocidal metabolites, such as lactic acid, Hteriocin . HPV infteriocin . This witeriocin . conductteriocin  reportedCandida albicans infections are not significantly associated to HPV infection and CIN development and may have a protective effect. In short, the female genital tract system is a complex microbial environment, and avoiding a vaginal flora imbalance may have a significant effect on preventing HPV infection and CIN development. This meta-analysis suggests an intimate connection between vaginal microecology and HPV infection or CIN. Considering that these conditions are very common among women worldwide, further research in this field is imperative.To conclude, this meta-analysis indicated that BV, UU, CT and reduction of Lactobacilli are associated to increase risk of HPV infection and CIN development, while TV and This meta-analysis was limited to that of published studies, which could have caused publication bias, resulting from tendency to selectively publish results that are statistically significant. Additionally, the lack of some literature data may lead to a bias in results. Therefore, more rigorous controlled studies with increased sample sizes are required to provide a more reliable experimental basis.


China has a high burden of head and neck cancer globally and oncogenic human papillomavirus (HPV) has been hypothesized as a risk factor for head and neck cancer, but research was absent for establishing HPV prevalence in China. We aimed to conduct a meta-analysis to estimate the high-risk HPV-18 prevalence of head and neck cancer in the Chinese population.This meta-analysis was reported following the guideline of PRISMA. The reports on HPV and head and neck cancer in a Chinese population published between Jan 1, 2006 and May 31, 2018 were retrieved via CNKI/WANFANG/MEDLINE/EMBASE/COCHRANE databases. A random-effect model was used to calculate pooled prevalence and corresponding 95% confidence intervals.A total of 1881 head and neck cancer cases from 19 studies were included in this meta-analysis. Overall, the pooled HPV-18 prevalence among head and neck cancer cases was 6.0% (4.1%–7.9%) in China, 31.2% (13.0%–49.4%) in laryngeal cancer, 7.2% (3.9%–10.5%) in oral cancer and 0.6% (0.0%–1.3%) in oropharyngeal cancer, 18.7% (6.2%–31.2%) in fresh or frozen biopsies and 4.3% (2.5%–6.1%) in paraffin-embedded fixed biopsies, 29.5% (15.6%–43.3%) by E6/E7 region and 3.9% (0.5%–7.4%) by L1 region of HPV gene. The highest HPV-18 prevalence was found in Central China.High prevalence of HPV-18 was found in the samples of Chinese head and neck cancers. Prophylactic HPV-vaccination may reduce the burden of HPV-related head and neck cancer in China. Except that, about 70% of the remaining squamous cell carcinomas of head and neck are caused by high-risk HPV infection, and the incidence of such subtypes is increasing year by year. However, the frequency of HPV infection in head and neck carcinomas varies between 3% and 84% in different studies. Based on the different nucleotide sequences, HPV can be divided into more than 200 genotypes by DNA sequencing, of which HPV16 and HPV18 as main high-risk types are more closely linked with malignant tumors.,8 However, unlike cervical carcinogenesis, the role of HPV-16/18 in the head and neck carcinogenesis has not been clearly defined.As a member of the papillomavirus family of viruses, human papillomavirus (HPV) can infect humans by attacking the squamous cell of skin and mucous membranes, including those of the cervix, anogenital region, and head and neck. Demographic and racial factors, sample condition, cancer location, and the viral detection method have been proposed to identify possible causes of differences in the results. However, as one of the second common subtype of HR-HPV, the HPV-18 prevalence in China has not been estimated so far.Even in the same country, the HPV prevalence in head and neck cancers range widely.The aim of the meta-analysis is to estimate the prevalence of HPV-18 detected in head and neck cancer cases and the influence of regions, different cancer sites, specimen types and detection methods in China from all published studies of English and Chinese language literature.2The methods were carried out in accordance with the approved guidelines. This study was approved by the ethics committee of Henan Cancer Hospital.2.1The key words “human papillomavirus”, “papillomavirus infections”, “head and neck neoplasms”, “head and neck cancer”, and “head and neck carcinoma” in Chinese language or in the English language were used in combination to search. The retrieved databases included MEDLINE (via PubMed), Excerpta Medica database (EMBASE), Cochrane database, Chinese National Knowledge Infrastructure (CNKI), and Wanfang Data Knowledge Service Platform. Date of the literature was specified between Jan 1, 2006 and May 31, 2018. Additional studies were also identified using cross-referencing.2.2The literature included in the present study meets the following criteria:(a)to use polymerase chain reaction (PCR)-based methods  or in situ hybridization (ISH) to amplify HPV DNA,(b)to report the prevalence of HPV-18 in head and neck cancer tissue samples,(c)have control group.The literature excluded in this study were mainly due to the following reasons: were cellular or animal studies; were not conducted in Chinese; necessary data could not be extracted or calculated directly from the original article; reviews; the literature include the repeated data.2.3 to assess the quality of included studies. The tool including 11 items with a total of 12 scores: External validityWe used a bias risk assessment tool proposed by Hoy D1.?6.Was an acceptable case definition used in the study?7.Was the study instrument that measured the parameter of interest shown to have validity and reliability?8.Was the same mode of data collection used for all subjects?9.Was the length of the shortest prevalence period for the parameter of interest appropriate?10.Were the numerator(s) and denominator(s) for the parameter of interest appropriate?11.Summary item on the overall risk of study bias.)2.4The data related to the meta-analysis were extracted by 2 independent authors (YFN and PL) based on a standardized data extraction program: first author's name, publication year, geographical areas, cancer site, clinical stage, numbers of cases, and HPV positive cases, HPV test method, specimen types .2.5 using the assumptions of a random-effects model. For studies with multiple HPV types infection (including HPV-18), the multiple HPV types were separated into different types and the HPV-18 type-specific prevalence represents types for cases with either single HPV-18 infection and multiple HPV-18 infections.Overall pooled point estimate and 95% confidence interval (95% CI) for HPV-18 prevalence were calculated through the method of DerSimonian and LairdQ test  and I2  was used to assess the heterogeneity between eligible studies. Subgroup analyses for HPV-18 prevalence were subsequently carried out according to the geographical areas of the study origin, cancer site, year of publication, number of patients, HPV detection method, types of specimen, and quality score. In the eligible studies, 2 studies contained different cancer sites, 2 studies contained different methods of HPV test and 3 studies contained different types of specimen. For these studies, we treated them as the separate studies and pooled them into appropriated groups when performing stratified analysis. Funnel plot and Begg adjusted rank correlation test for funnel plot asymmetry were performed to test any existing publication bias.Cochrane P <.05 with 2-tailed was considered statistically significant.The statistical analyses were performed using STATA SE version 15.0 for Windows . 33.1–31 Individual characteristics of the included 19 studies were summarised in Table Of 333 publications identified through an initial search of databases, 314 were excluded for reasons explained in Figure 3.2Q-test Pheterogeneity <.001, I2 = 92.6%).Figure 3.3Table 3.4P values of Begg test (0.421), and the near-symmetric funnel plot  in China for the highly lethal cancer. As we know, this is the first meta-analysis to exploring the prevalence of HPV-18 in Chinese head and neck cancer tissues. The results of the meta-analysis showed that more than 6% cases of head and neck cancer harbored HPV-18, indicating a high level of HPV 18 infection in head and neck cancer cases of China. Our results were little higher than the global prevalence, especially for laryngeal cancer. More cases involved and areas covered could be helpful in estimating the prevalence of HPV-18 in different head and neck cancer sites in the future.Characterizing the HPV-18 prevalence in head and neck cancer is an important preliminary step in assessing the relationship between HPV-18 and head and neck cancer. Estimates of the HPV prevalence in various cancer sites of head and neck cancer vary considerably. Our meta-analysis showed that laryngeal cancer had the highest HPV-18 prevalence (31.2%), followed by that in oral cancer (7.2%). Oropharyngeal cancer seemed not easily to be infected by the HPV-18, with the lowest prevalence (0.6%). Interestingly, the prevalence of HPV-18 in oropharyngeal cancer and oral cancer were much lower than Asian average but much higher in laryngeal cancer. The HPV infection status was determined on FFPE tissue in the majority of included studies. It is known that the low detection rate of HPV DNA occur with the fabric of FFPE, especially when a long DNA fragment was amplified.The detection rate of HPV-18 DNA in FF tissue was found much higher than that in FFPE tissue, given significant DNA degradation could be observed in FFPE tissue.–36 In our meta-analysis, PCR and ISH were just used as HPV detection methods, which focused on the HPV DNA detection method. Besides, for better PCR and ISH sensitivity and specificity, the literature time was limited from January 1, 2006 to May 31, 2018. HPV, a double-stranded circular DNA virus, encodes early proteins  and late proteins  with about 8000 bp genome size.,38 When stratifying the L1 and E6/E7 gene fragments, we found that, in E6/E7 gene fragment (29.5%), the detection rate of HPV-18 DNA was much higher than in L1 gene fragment (0.5%). This is mainly due to the disruption of L1 region when HPV is integrated into the host genome, which may be an important event in promoting and triggering head and neck cancer.Some possible reasons for variation in HPV prevalence among studies include small study sizes, different HPV testing, inter-laboratory variability, and manipulation of specimens leading to contamination.The highlights of this meta-analysis include a large sample size, both English and Chinese published studies are included with a strict inclusion criteria. By including English and Chinese studies, the selection bias caused by the publication language was avoided. Finally, by astricting studied published after 2006 and limiting PCR and ISH detection methods, we tried to minimize the HPV prevalence variation as much as possible.However, the meta-analysis has several limitations. First, the studies included in the meta-analysis are heterogeneous, which could be explained by changes in the population, the cancer site, the year of publication, the number of patients, the HPV detection method, the sample collection method, and the sensitivity of HPV primer PCR different protocols. To solve this issue, the random-effects model was used in the meta-analysis to combine data if significant heterogeneity was found. We directly tested heterogeneity by describing the HPV-18 prevalence in head and neck cancer cases by study area, cancer site, year of publication, number of patients, method of HPV detection, types of specimen, and quality score. Of course, we have not been fully able to explain the heterogeneity. Even in stratified outcomes , the prevalence estimates are still uneven. Second, the study estimates may be biased because the accuracy of these estimates depends on the test method used and the type of HPV evaluated. That is, some studies use multiple probes or wide primers to detect multiple types of HPV, while other studies only detect HPV-18 type. Finally, the possibility of confounder cannot be ruled out. Limited studies have implicated the effect of age and smoking on the prevalence of HPV. We could not determine whether the variation of HPV prevalence was due to differences in environmental factors: age, sexual habits, smoking, alcohol consumption, and other ethnic and cultural differences, as little or no information on these potential confounders in the studies involved. Therefore, studies with good designs to explore HPV infection by major confounding factors are likely to be required in future studies.In short, the current meta-analysis provides a quantitative estimate of HPV-18 prevalence in head and neck cancer lesions in China. Although this review is a preliminary step in assessing the relationship between HPV-18 and head and neck cancer in China, it may be useful to evaluate the effect of HPV-16/18 prophylactic vaccines against carcinogenesis in the future. Considering that HPV infection plays an important role in the tumorigenesis of head and neck, other scientific studies deserve to be done in the future.All authors have made substantial contributions to the conception and design of the study. LWG and FNY led protocol design, search, data extraction, statistical analysis, and manuscript drafting. YLY and PL contributed to search, data extraction, and manuscript modifications. XJZ, DFC, YL, and JW contributed to quality assessment and revision of the manuscript. LWG contributed to data interpretation and revision of the manuscript. All authors have reviewed and approved the final version.Conceptualization: Yulin Yin, Lanwei Guo.Data curation: Peng Li, Xiaojun Zhang, Yang Liu.Formal analysis: Defeng Chen.Investigation: Peng Li.Methodology: Yulin Yin, Jian Wang.Software: Jian Wang.Writing – original draft: Funa Yang, Xiaojun Zhang.Writing – review & editing: Lanwei Guo.