Persistence of multiple genotypes and of HPV 16/18 with or without other HR genotypes show a significant impact on relapse free survival. HPV genotyping as “test-of-cure” enables a personalized risk-based management, by identifying women at higher risk of relapse who need intensive follow-up and avoiding risk of over-treatment in women with new HPV genotype infection after surgery.Women diagnosed with cervical intraepithelial neoplasia grade 2 or worse (CIN2+) and treated by excisional procedures remain at high risk for recurrence over time. “Treatment failure” has been reported in up to 23% of women within two years after treatment. The aim of this study was to investigate the impact of HPV same genotype persistence on CIN2+ recurrence. Our findings confirm that HPV same genotype persistence has 30-fold increased odds of developing CIN2+ recurrence (p < 0.001), in women with persistent multiple infections , and with the persistence of at least one genotype between 16 and 18, irrespective of the presence of other HR genotypes , but not significantly different from women positive for single infections or any other HR genotype, but not for 16 and 18. The risk of CIN2+ recurrence should not be underestimated when same HPV genotype infection persists after treatment.To evaluate the significance of HPV persistence as a predictor for the development of CIN2+ recurrence and the impact of multiple genotypes and of HPV 16/18 on recurrence risk. A prospective cohort observational study was carried out at the European Institute of Oncology, Milan, Italy, from December 2006 to December 2014. A total of 408 women surgically treated by excisional procedure for pre-neoplastic and neoplastic cervical lesions were enrolled. HPV test was performed at baseline and at first follow-up visit planned at 6 ± 3 months after treatment. Two-year cumulative incidences for relapse were estimated and compared by the Gray’s test. Overall, 96 (23.5%) patients were persistent for at least one genotype at three to nine months from baseline and 21 (5.1%) patients relapsed. The two-year cumulative relapse incidence was higher in HPV persistent patients compared to not-persistent (CIF = 27.6%, 95% CI: 16.2–40.2% versus CIF = 1.7%, 95% CI: 0.3–5.8%,  Women diagnosed with cervical intraepithelial neoplasia (CIN) or invasive cervical carcinoma (ICC) and conservatively treated by excisional procedures remain at high risk for persistence or recurrence of CIN grade 2 or worse (CIN2+) over time. Persistent or recurrent CIN2+, also known as “treatment failure”, have been reported in up to 23% of women after treatment, and most cases occur within two years after treatment ,2,3. TheSeveral risk factors for “treatment failure” have been identified and include patients’ characteristics  and pathological characteristics , but they do not accurately predict CIN2+ recurrence ,5.It has been widely proven that persistent Human Papillomavirus (HPV) infection, in particular of High-Risk (HR) genotypes, is the main risk factor for the development of pre-cancerous and cancerous cervical lesions ,7. The pThe most recent guidelines from Italian group for cervical cancer screening (GISCi) and American Society for Colposcopy and Cervical Pathology (ASCCP) have included HR HPV testing at 6 and 12 months, respectively, as the most accurate surveillance strategy to predict “treatment failure” with high sensitivity ,11.The aim of this study was to investigate the magnitude and the significance of HPV persistence as a predictor for the development of CIN2+ recurrence. As secondary outcomes, we evaluated the impact of multiple genotypes and of specific HR genotype, especially HPV 16/18, on recurrence risk.All women affected by precancerous and cancerous cervical lesions and surgically treated by excisional procedures at the Preventive Gynaecology Unit of the European Institute of Oncology, Milan, Italy, from December 2006 to December 2014, were asked to participate in a prospective cohort observational study.The local Institutional Review Board approved the study protocol and written informed consent for the use of data for scientific purposes was obtained from all subjects prior to treatment.Patients were included if the following criteria were met: (a) age at diagnosis of 18 years or older; (b) conservative surgical treatment, including loop electrosurgical excision procedure (LEEP) and laser conization, for the removal of persistent CIN1 (not regressing after at least 3 years) or CIN2+; (c) histological confirmation of any grade of CIN, adenocarcinoma in situ (AIS), and ICC, including squamous carcinomas and adenocarcinomas; (d) known HPV status and (e) expressed willingness to undergo follow-up visits at the European Institute of Oncology, Milan. Patients were excluded in case of (a) negative histology; (b) previous history of HPV vaccination; (c) negative HPV test, unknown HPV genotype or only Low Risk (LR) genotypes infection before treatment.Data regarding principal clinic, laboratory, and pathological characteristics of patients were recorded in a dedicated database.HPV test was performed at the time of treatment (“baseline”) and as “test-of-cure” at first follow-up visit planned at 6 ± 3 months after treatment. Patients with a first follow-up visit outside the planned 3–9 months range were excluded from the analysis .HPV same genotype persistence is defined as the post-treatment detection of at least one genotype that was involved in the development of the original cervical lesion and already found at “baseline”.Recurrence or “treatment failure” is defined as occurrence of high-grade CIN (CIN2+) after treatment that requires re-excisional surgical treatment during follow-up.All histological diagnoses at baseline and at recurrence, when occurred, were made on surgical tissue, by dedicated gynecological pathologists working at the Pathology Division of our Institute . Glandular crypts involvement and status of surgical margins, detailed as ectocervical and endocervical margins, were described.A ThinPrep PreservCyt  cervical sample was collected in all patients at baseline and at post-treatment visits, to perform Hybrid Capture 2 HR-HPV Test  and Linear Array HPV Genotyping Test , in case of positive HC2 test.The HC2 test is a sandwich capture molecular hybridization assay. It is a signal amplification detection method based on chemiluminescence that detects the following 13 HR-HPV types: HPV 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, and 68. The DNA:RNA hybrids are captured on a microplate, and the emitted light is measured in a luminometer as relative light units (RLUs). Samples are considered as positive if the ratio RLU/cut-off was >1.0 . All samples with RLU between 1 and 2.5 should be retested as requested in package insert instructions.The Linear Array test employs biotinylated PGMY09/11 consensus primers to amplify a 450-bp region of the L1 gene, in order to detect the following 37 HPV genotypes: HPV 6, 11, 16, 18, 26, 31, 33, 35, 39, 40, 42, 45, 51, 52, 53, 54, 55, 56, 58, 59, 61, 62, 64, 66, 67, 68, 69, 70, 71, 72, 73 (MM9), 81, 82 (MM4), 83 (MM7), 84 (MM8), and IS39 e CP6108. Thereafter, the denatured polymerase chain reaction products are hybridized to an array strip containing immobilized oligonucleotide probes. The results are visually interpreted by using the provided reference guide according to manufacturer’s protocol by 2 independent operators and the results should be compared to reach the final one.Patients’ characteristics at baseline were cross tabulated with HPV persistence status at 3–9 months and summarized by counts and percentages, age was summarized by median and interquartile range (IQR). Transition probabilities from single and multiple genotypes infection to negative, single, and multiple infection status at 3–9 months from baseline, were estimated as the proportion of patients in each level status with respect to the status at baseline. Categorical variables were compared using the Fisher’s exact test. Between persistence, status age difference was tested using the Wilcoxon two-sample test. HR genotypes distribution at baseline and at the first follow-up visit by single and multiple was summarized by count and percent; transition probabilities were tabulated and plotted as radar-charts. The null-hypothesis that the infection status at baseline do not differ from infection status at first follow-up visit was tested by the Bowker test ,13. RelaFrom December 2006 to December 2014, 1530 women affected by precancerous and cancerous cervical lesions were surgically treated by excisional procedures at the Preventive Gynecology Unit of the European Institute of Oncology, inclusion/exclusion criteria were applied and led to a final sample size of 408 .p = 0.09) (p = 0.01). HPV persistence also showed a significantly (p = 0.009) monotone inverse relationship with the number of genotypes detected at baseline irrespective of the genotype. Among 96 persistent patients, 60 (20.3%) had only one genotype, 23 (27.7%) had two different genotypes, and 13 (44.8%) had three or more different genotypes, respectively  patients were persistent for at least one genotype. Median age at baseline was 40 years (IQR: 35–46). Age, histology, glandular crypts involvement, ectocervical and endocervical margins, as well as overall surgical margins at baseline, were not significantly associated with HPV persistence status after three to nine months. The lowest not-significant variable was histology ( = 0.09) . The proectively .p < 0.001, Among 296 patients with single infection at baseline, at three to nine months, 236 (79.7%) were HPV-free, 55 (18.6%) still had a single infection, and 5 (1.7%) were positive for more than one genotype. Among 112 patients with multiple infection at baseline, 76 (67.9%) were HPV-free after three to nine months, 19 (17.0%) were positive for only one genotype, and 17 (15.2%) for more than one genotype, respectively  and multiple (51.8%) infections, followed by HPV 31 in both single (26.4%) and multiple (29.5%) infections, respectively . All othPrevalence of genotypes 16, 18, 59, 66, and 68 increased at three to nine months from baseline both in single and multiple infections, whereas genotypes 31, 33, 35, and 45 showed a decreasing trend. Other genotypes showed a mixed pattern: proportion decreased in single infections but increased in multiple infections , or increased in single infections but decreased in multiple infections (HPV 39 and 56) from baseline to three to nine months .Overall, 21 (5.1%) patients relapsed within two years from the first follow-up visit and the overall two-year CIF was 8.6% (95% CI: 5.1–13.2%) .p < 0.001) (Compared to 2 (0.6%) HPV not-persistent patients, 19 (19.8%) HPV persistent patients relapsed within two years  A.p < 0.001) and for multiple infection versus HPV negative (p < 0.001), but not for single versus multiple infections (p = 0.70). The two-year cumulative relapse incidence was highest for women with the persistence of at least one genotype between 16 and 18 at first follow-up visit, irrespective of the presence of other HR genotypes , but not significantly different from women positive for any other HR genotype; however, not for 16 and 18 . (At 2 years cumulative relapse incidences were: 1.7% (95% CI: 0.3–5.8%), 26.2% (95% CI: 14.1–40.2%) and 27.2% (95% CI: 7.3–52.3%) for women that were HPV-negative (not-persistent), with single or multiple infections at the first follow-up visit, respectively B. Gray’s= 0.13). C.No other variables were significantly associated with the cumulative incidence of relapse .p = 0.49 for single versus multiple infections at baseline and p = 0.30 for negative versus single versus multiple infections at first follow-up visit, respectively) (Infection status was not significantly associated with histology (ctively) .p = 0.68)  .N = 21) of events.No multivariable analyses were done due the overall low number (p < 0.001).CIN2+ treatment showed a favorable long-term outcome with a two-year cumulative incidence of 8.6%. Our findings confirm that persistent HPV infection after treatment is the only significant predictor for the development of CIN2+ recurrence. Whereas histological grade, glandular crypt involvement, and margin status are not significantly related with treatment failure, HPV same genotype persistence has 30-fold increased odds of developing relapse  than women with clear margins, and the effect was dependent on the type of margin involvement [Furthermore, according to our results, histological grade, glandular crypts involvement, and surgical margins are not significantly associated with post-treatment HPV persistence and did not affect relapse free survival, as already sustained by Byun et al. . On the olvement . Indeed,olvement  confirmeolvement . Women wolvement .Positive HR HPV testing after treatment has been proven to be more sensitive and similarly specific compared with the surgical margins’ involvement. Although recurrences are more frequent in women with both involved margins and positive HR HPV test after treatment, combination of both risk factors does not show a significant improvement of protection against “treatment failure”. Post-treatment HR HPV positivity seems to be the strongest and most accurate predictor of relapse free survival ,15.Our results confirmed the clinical impact of HPV genotyping on management and post-treatment surveillance of CIN2+, as previously outlined by a recent systematic review . DetectiPersistence of HPV 16 or 18 is associated with a greater risk of “treatment failure”, as widely reported by previous literature ,16,17,26Furthermore, persistence of multiple infections showed a higher CIN2+ recurrence rate, as already found by Zhang et al. . HoweverLimits of the study include selection bias related to single center analysis and small sample size, with a total 408 patients, of which 96 (23.5%) tested HPV positive after treatment and only 21 (5.1%) experienced CIN2+ recurrence. Moreover, confidence intervals of hazard ratios are wide due to the small number of recurrence events and thus suggesting an uncertain magnitude of the effect.The risk of CIN2+ recurrence should not be underestimated when same HPV genotype infection persists after treatment, even in women with negative resection margins. HPV genotyping can be useful to identify women at higher risk of relapse and to avoid risk of over-treatment in women with new HPV genotype infection after surgery. Thus, HPV genotyping as “test-of-cure” enables a personalized risk-based management, by stratifying women who need more appropriate and intensive follow-up strategies and reassuring women cured by surgical treatment.


All but one were high-risk HPV genotypes . We identified seven different HPV genotypes, the most common being HPV16 , HPV18  and HPV 31 . All SMILEs showed a strong positive reaction to p16, CK7, CK19 and high Ki67 expression comparable to adjacent HSIL and/or AIS if present. SMILE showed variable mucin presence and p40-positive squamous differentiation suggesting phenotypic diversity in cervical precancerous lesions infected by single HPV.Stratified mucin-producing intraepithelial lesion (SMILE) is a rare high-grade cervical precancerous lesion designated a variant of adenocarcinoma in situ (AIS) in the WHO classification. We aimed to determine HPV genotypes, immunohistochemical phenotype and mucin presence in SMILE. Between 2010 and 2018, SMILE was diagnosed in 34 out of 6958 (0.5%) cervical biopsies, in 23 patients. Twenty-six tissue samples from twenty-one patients were available for further analysis, including 13 with SMILE alone, 12 with SIL and/or AIS and one with HSIL, AIS and endocervical adenocarcinoma. HPV genotyping was performed using the Seegene Anyplex II HPV 28 assay. Of the 26 samples, a single HPV genotype was identified in the majority of cases ( Stratified mucin-producing intraepithelial lesion (SMILE) is a rare cervical precancerous lesion exhibiting architectural features encompassing cellular stratification similar to squamous intraepithelial lesions (SIL), crowding, an increased nuclear/cytoplasmic ratio, hyperchromasia, mitoses and apoptosis. Additionally, cytoplasmic mucin is found in variable proportions of cells diffusely through all epithelial layers, showing as cytoplasmic vacuoles or, alternatively, as cytoplasmic clearing with increased distance between the nuclei, without classical gland formation ,2. In thIn the majority of cases reported, SMILE was associated with conventional high-grade squamous intraepithelial lesions (HSIL), adenocarcinoma in situ (AIS) or both ,5,6,7,8.By analogy to squamous intraepithelial lesions (SIL) and AIS, SMILE has been considered etiologically linked to persistent infection with high-risk human papillomavirus (HPV) genotypes, mostly due to strong diffuse block p16 nuclear and cytoplasmic positivity, although HPV genotyping has only been reported in a very small number of studies on a limited number of cases ,6,8,10.SMILE presumably originates from reserve cells of the transformation zone (TC), which are capable of multidirectional differentiation ,2. CytokMucinous differentiation in SMILE has been highlighted by Alcian Blue staining in some studies, while immunohistochemical staining for p63 was used in seminal studies to assess squamous differentiation ,2. p40 oThe aim of our study was to assess the distribution of HPV genotypes in SMILE, together with p16, Ki 67, CK7 and CK19 immunohistochemical staining to evaluate the integration of HPV and putative derivation from SCJ and/or reserve cells. The epithelial differentiation of SMILE was assessed by the immunohistochemical staining of p40 for putative squamous differentiation and by Alcian blue for mucin content reflecting glandular differentiation, and to compare it to adjacent SIL and/or AIS where present.We retrieved from the electronic archive of the Institute of Pathology, Faculty of Medicine, University of Ljubljana, all cases of cervical lesions diagnosed as SMILE between 2010 and 2018. Of the 6958 cervical tissue biopsies analyzed, 34 (0.5%) biopsies from 23 patients were diagnosed as SMILE  according to histomorphological criteria published by Park et al. [For HPV genotyping, three 10 μm thick sections were cut from each tissue block and processed for DNA extraction following our standard laboratory protocol, as described in detail previously . BrieflyImmunohistochemical staining for p16, Ki67, CK7, CK19 and p40 was performed using protocols summarized in Immunohistochemical stains and Alcian blue staining were independently assessed by two certified pathologists . In discrepant cases, slides were reviewed on a multihead microscope to achieve consensus. Immunoreaction to p16 was considered positive when diffuse block nuclear and cytoplasmic positivity was observed. For squamous lesions and SMILE, Ki-67 increased expression was assessed as nuclear positivity found in the lower third, lower two-thirds and in more than two-thirds of epithelial layers, with parabasal positivity considered normal, while increased immunoreactivity was assessed for AIS. For CK7 and CK19, cytoplasmic positivity was assessed; for p40, nuclear immunoreaction was considered positive. A blue cytoplasmic reaction confirmed mucin presence by Alcian Blue staining.2 test was used. Differences in the distribution of HPV genotypes between SMILE and SMILE combined with SIL and/or AIS were calculated with Fisher’s exact test. Reported p values ≤ 0.05 were considered to be statistically significant.Statistical analyses were performed with Statistical Package for Social Sciences (SPSS). The Mann–Whitney U test was used to compare the staining percentage of different immunohistochemical biomarkers between groups and in the case of categorical variables, the χThe study was approved by the Slovenian National Medical Ethics Committee (consent No. 0120-526/2018/5).Twenty-six tissue samples with SMILE from 21 patients, with a median age of 33 years (range: 20–49 years), were used in this study. Sixteen out of twenty-six (61.5%) were small cervical biopsies and 10/26 (38.5%) were cone excision biopsies . In 13/26 (50%) tissues biopsies , SMILE was combined with other precancerous lesions . One SMIp = 0.0233).As shown in Diffuse strong nuclear and cytoplasmic block positivity to p16 was found in all cases of SMILE, LSIL, HSIL and AIS, although it was confined to the lower two-thirds of the epithelium in LSIL compared to the whole thickness in other lesions .Parabasal cell nuclear positivity to Ki-67 was observed in 16/17 (94.1%) cases in non-neoplastic squamous or squamous metaplastic epithelium, while rare single cells were positive in endocervical glandular  and reserve cells . SMILE exhibited increased nuclear positivity in all cases . HoweverCK7 was not detected in six (35.3%) cases in the areas of non-neoplastic squamous and squamous metaplastic epithelium and in LSIL, while in eight (47.1%) cases the areas of non-neoplastic squamous and squamous metaplastic epithelium exhibited less than 10% of positive cells, one (5.9%) case 10 to 50% and two (11.7%) cases more than 50% of positive cells . All casThe expected basal positivity for CK19 was observed within non-neoplastic squamous and squamous metaplastic epithelium in the majority of cases . In the remaining cases, CK19 was positive in 10–50% of cells in 4/17 (23.5%) cases and in 10% of cells in one case (5.9%). More than 50% of cells were positive in all cases, within endocervical glandular epithelium, reserve cells, SMILE, AIS, HSIL. CK19 was negative in LSIL and in one case of non-neoplastic squamous and squamous metaplastic epithelium .In 13/17 cases (76.5%) of non-neoplastic squamous and squamous metaplastic epithelium, as well as in 6/26 (24.1%) SMILE and LSIL, p40 immunopositivity was confined to the lower two-thirds of the epithelium, while it was found in the whole thickness of the majority  of SMILEs and in all HSIL . Focal pp = 0.21/NS)  . Scatter0.21/NS) .Glandular features with the presence of cytoplasmic mucin together with stratified architecture resembling SIL have been described for SMILE, which was included in the category of endocervical AIS for the first time in the 2014 edition, and again in the 2020 edition, of the WHO classification of female genital tumors ,4.Reliable data on the epidemiology of SMILE are lacking, although it has been reported to be a very rare cervical precancerous lesion. In our study, SMILE was diagnosed in the original histopathology reports and confirmed on the review (by MSF and HG) in 0.5% of cervical biopsies identified in our institutional computer files, a number similar to the previously reported 0.6% in a study in which all reports with endocervical AIS were reviewed to ascertain the presence of SMILE . In a stIn this study, SMILE coexisted with squamous and glandular high-grade intraepithelial lesions in 50% of cases, while previous studies have reported a majority of lesions associated with HSIL and/or AIS and/or carcinoma, namely, 92.3% to 100% ,7. SMILESimilar to previous studies, all SMILEs in this study exhibited strong block diffuse nuclear and cytoplasmic positive p16 immunostaining consistent with transforming HPV infection ,5,8,9,10In the majority of lesions , only one HPV genotype was identified, including cases in which SMILE was combined with HSIL and/or AIS 12/13, 92.3%). It is noteworthy that a single HPV genotype was detected in cervical tissue biopsies encompassing SMILE with SIL and/or AIS. It has previously been recognized by laser-capture microdissection studies of cervical tissue with multiple HPV genotypes detected that a single HPV genotype could be mapped to a specific tissue location and identified as responsible for the neoplastic process, whereas additional HPV genotypes were detected in uninvolved mucosal regions or in cellular debris, a phenomenon described as “one virus, one lesion” [, 92.3%. p = 0.0233) in HPV16 and HPV18 frequency between SMILE only vs. SMILE combined with other precancerous lesions. In this study, we also showed that HPV31 occurred in SMILE either alone or combined with other HPV genotypes, a finding similar to those of other HSIL lesions. Moreover, one SMILE was found to be associated with possibly carcinogenic HPV, namely, HPV70, which has not been reported previously.In one previous report, individual HPV16 and HPV18 were detected in four and seven SMILE cases, respectively, using the Roche COBAS 4800 HPV test, while four cases were positive with a pool of 12 other high-risk HPV genotypes  . CompareIn accordance with the transforming HPV infection indicated by diffuse p16 positivity in all SMILE cases, the proliferation activity of cells was also increased, as detected by Ki67 immunostaining, and the results are consistent with previous reports ,10. Ki67Expression of CK7 and CK19 by immunohistochemical staining was found in AIS and/or HSIL, as expected according to previous reports, and likewise in all SMILEs, which has not been previously demonstrated ,12,13,14This study showed positive immunohistochemical staining for p40 (ΔNp63) in SMILE; p40 is one of the many isoforms of p63 and is considered to also be a biomarker of the squamous lineage in other tumor sites, especially in diagnosing and triaging lung carcinoma for therapy-related molecular-genetic and immunotherapy studies ,16,17,24In relation to glandular differentiation as a hallmark of SMILE, and mucin presence shown by Alcian blue, the proportion of cells with mucinous vacuoles throughout all epithelial layers varied between lesions, not only in this study but also in the original and subsequent studies ,2. VariaIn conclusion, SMILE was found to be associated with different histological types and grades of precancerous lesions and carcinoma, similar to previous studies, although we found a lower proportion of lesions combined with HSIL and/or AIS and only one case of a small endocervical adenocarcinoma, possibly since the study was performed on women attending the organized population-based cervical cancer screening program resulting in low cervical cancer burden. We found a predominance of common high-risk HPV genotypes, namely, HPV16, 18 and 31, generally associated with high-grade cervical precancerous lesions. Our study also showed that a single HPV genotype can account for histomorphologically different lesions evolving from the cervical transformation zone, namely, SMILE in combination with HSIL and/or AIS, and that the lesions probably originate from the same SCJ cells. Moreover, we found ubiquitous p40 expression pointing to squamous along with glandular differentiation in SMILE and suggesting phenotypic diversity in cervical precancerous lesions.


Men who have sex with men are a risk group for anal human papillomavirus (HPV) and anal cancer. Australia introduced a universal school-based HPV vaccination program in 2013. Self-reported HPV vaccination status has been widely used in clinical and research settings, but its accuracy is understudied.We aimed to examine the accuracy of self-reported HPV vaccination status among gay and bisexual adolescent males.We included 192 gay and bisexual males aged 16-20 years from the Human Papillomavirus in Young People Epidemiological Research 2 (HYPER2) study in Melbourne, Australia. All participants had been eligible for the universal school-based HPV vaccination program implemented in 2013 and were asked to self-report their HPV vaccination status. Written informed consent was obtained to verify their HPV vaccination status using records at the National HPV Vaccination Program Register and the Australian Immunisation Register. We calculated the sensitivity, specificity, positive predictive value, and negative predictive value of self-reported HPV vaccination status.The median age of the 192 males was 19 (IQR 18-20) years. There were 128 males (67%) who had HPV vaccination records documented on either registry. Self-reported HPV vaccination had a sensitivity of 47.7% , a specificity of 85.9% , a positive predictive value of 87.1% , and a negative predictive value of 45.1% .Self-reported HPV vaccination status among Australian gay and bisexual adolescent males underestimates actual vaccination and may be inaccurate for clinical and research purposes. Multiple countries have implemented national human papillomavirus (HPV) vaccination programs and demonstrated significant reductions in HPV infection, genital warts, and cervical cancer and its precursors -4. Self-Australia introduced a school-based HPV vaccination program for girls in 2007, with expansion to include 12- and 13-year-old boys in 2013. Additionally, Australia established robust population-based vaccination registries to document HPV vaccination coverage . SeveralMost previous studies verified self-reported HPV vaccination status from parents or electronic medical records instead of vaccination registries. One study examined the accuracy of self-reported HPV vaccination status in men, but the authors did not separate the data of heterosexual men and gay/bisexual men . AustralThe Human Papillomavirus in Young People Epidemiological Research 2 (HYPER2) study was a cross-sectional study aimed at examining HPV prevalence among young gay and bisexual males after the implementation of the school-based gender-neutral HPV vaccination program in Australia, with the main findings published elsewhere . A totalThe National HPV Vaccination Program Register (NHVPR) was established in 2008 to monitor HPV vaccination coverage in Australia. State Health Departments and local councils were mandated to report individuals who received the vaccine from the school-based program to the NHVPR . The NHVOnly men who received the vaccine via the school-based program were eligible for inclusion in this study. Self-reported HPV vaccination status was stratified into “vaccinated” and “not vaccinated or unsure” based on self-reported data on the survey. The sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, and negative likelihood ratio for self-reported HPV vaccination status were calculated using data from the registers as the reference standard. The positive likelihood ratio is the probability of individuals who self-reported being vaccinated in those who were vaccinated divided by the probability of individuals who self-reported being vaccinated in those who were not vaccinated . The negative likelihood ratio is the probability of individuals who self-reported being not vaccinated in those who were vaccinated divided by the probability of individuals who self-reported being not vaccinated in those who were not vaccinated . A positive likelihood ratio >10 is useful for ruling in being vaccinated, while a negative likelihood ratio <0.1 is useful for ruling out being vaccinated ,20. The Of the 200 men, 8 were excluded from the analysis because they were not vaccinated as part of the school-based vaccination program. Median age of the 192 men was 19 (IQR 18-20) years. Most men completed secondary school . The median number of lifetime male sex partners was 9 (IQR 5-25). There were 70 (36.5%) men who self-reported being vaccinated, 13 (6.8%) reported being unvaccinated, and 109 (56.8%) men were unsure about their vaccination status .At least one dose of HPV vaccination was recorded in the HPV vaccine registry for 66.7% (128/192) of men, 63.0% (121/192) completed 3 doses of vaccination, 6 men received 2 doses, and 1 man received 1 dose. Only 61 of the 128 men correctly reported they were vaccinated  and negative predictive value , but a decrease in the specificity . The positive likelihood ratio remained similar (2.3) but with a relatively low negative likelihood ratio (0.03).The agreement between self-reported vaccination status and registry record was minimal (κ=0.274) when including men with unsure vaccination status in the unvaccinated group. However, the level of agreement between self-reported vaccination status and registry record improved to moderate (κ=0.635) when excluding men with unsure vaccination status. This study examines the accuracy of self-reported HPV vaccination status among gay and bisexual adolescent males using national vaccine registry data as the reference standard. Our study showed that, of those vaccinated with at least one dose, only 48% of men correctly recalled their vaccination status, with over half of men unsure. However, the sensitivity improved to 98% after excluding men who were unsure about their vaccination status.The low sensitivity of self-reported vaccination status in our study is similar to a US study showing only 54% of 74 adolescent girls aged 14-17 years correctly reported their HPV vaccination status as verified via medical records . To our We found that the positive likelihood ratios were relatively small regardless of whether the unsure vaccination group was included or not. Given the positive likelihood ratios are <10 , this suThere are several limitations to this study. First, this study was conducted among adolescent gay and bisexual men; therefore, our findings may not be generalizable to other populations such as heterosexual men and adults. Second, adolescents also receive the meningococcal ACWY and whooping cough booster vaccines at school around the age they receive the HPV vaccine , and it In conclusion, the accuracy of self-reported HPV vaccination status among gay and bisexual adolescent males was low, and most men were unsure about their vaccination status. Underreporting HPV vaccination suggests that self-reported vaccination status may be inaccurate for clinical practice to guide vaccination and for research evaluating the effectiveness of vaccination programs. This highlights the benefit of using data on actual vaccination status from vaccination registries to verify vaccination status and dosage. The AIR is the national register that records vaccines that are given to individuals in Australia. Individuals can access their immunization history statement online. Additionally, general practitioners or other vaccination providers can also access the immunization history statement online.


In the Veterans’ Administration (VA), medical centers contract with community nursing homes to provide care to Veterans. As a purchaser, the VA could pursue a strategy of selecting a high-quality network; alternatively, it could focus resources on oversight by its nursing-home coordinators. The question of whether narrow networks are good for Veterans’ outcomes, conditional on quality, therefore, needs empirical investigation. We examined the effect of network concentration on hospital admissions, conditional on Veterans’ clinical acuity. We operationalized network concentration as the number of Veterans already in residence at the time of admission, and controlled for publicly reported quality measure (star rating). We identified 93,805 VA-paid admissions to nursing homes between 2013 to 2016. To address selectin bias, we estimated effects using a distance- based instrumental variable (IV) for each measure, with the log of distance to the nearest nursing home with a specified number of Veterans at the facility in the previous month . Going to a facility with 10-13 or 14+ Veterans had a higher hospitalization probability , than going to a facility with 1-4 Veterans. If quality rating improves outcomes, then broader networks are beneficial if consumers (Veterans) choose based on quality, given a broader choice set. Conditional on quality, concentrated networks do not seem to lead to fewer hospital admissions. Our results suggest that the VA could do more in its oversight role to work with these nursing homes to decrease hospital admissions.


The goal was to evaluate how provider recommendations regarding Human Papillomavirus (HPV) vaccination impact uptake in a rural setting. The study used a cross-sectional, population-based design with cluster sampling to survey parents/guardians of children ages 9 to 18 in 2019 in Alabama. In addition to demographics/knowledge questions, participants were asked about type of healthcare provider recommendation and impressions they had from this interaction. The primary outcome variable was the result of the healthcare provider recommendation with options including: child got vaccinated day of recommendation, HPV vaccination was scheduled, or HPV vaccination was not scheduled. Bivariate analysis and multinomial logistic regression were performed. Of the 358 respondents, approximately 40% indicated receiving a recommendation from a provider to vaccinate their child. Age of the parent, race/ethnicity, educational attainment, and health insurance coverage were similar across groups. Female parents were more likely to report receiving HPV vaccination recommendation than males . The type of provider recommendation was not significantly associated with HPV vaccination uptake. The impression from the recommendation of HPV vaccination being “important” was significantly associated with the child being vaccinated that day  as well as scheduling HPV vaccination . Parents who got the impression that “there was no hurry” were less likely to vaccinate their child that day . Provider recommedation is well-established as a significant predictor of HPV vaccination, these findings indicate that how the recommendation is perceived may play a more important role in HPV vaccination uptake. Persistent HPV infection is responsible for approximately 90% of anal and cervical cancers, 70% of vaginal/vulvar cancers, 60% of penile cancers, and up to 70% of oropharyngeal cancers . In 2018The HPV vaccine protects against new HPV infection and consequently most HPV-associated cancers . The CenResearch exploring reasons for low HPV vaccination rates have identified numerous facilitators and barriers. These include parent-specific and provider-specific barriers. Studies have demonstrated that parental barriers to vaccination include lack of education/knowledge, safety concerns, absence of provider recommendation, and concerns about promoting sexual behavior . ProvideAlthough provider recommendation is the most significant predictor, previous work has determined that how the HPV vaccine recommendation is given is important and an influencing factor in itself. When providers give a high-quality recommendation, parents are more likely to vaccinate their child . High-qu2This was a cross-sectional, population-based study using cluster sampling in which interviewers were deployed to obtain a representative sample from all nine census tracts in a rural county in Alabama (Escambia County). Parents/guardians of children ages 9–18 years old were interviewed between 9/2019 and 12/2019 and analyzed in 2020. Interviews were anonymous and participation was voluntary. If participants had more than one child in this age range, they were asked to think about the child with the closest birthday month when asked specific questions about HPV vaccination. There was no evaluation based on sex of parent in combination with the sex of the child. Inclusion criteria were being a resident of Escambia County and being the parent or guardian of a child between the ages of 9 and 18.A 16-page questionnaire was developed based on questions from the Behavioral Risk Factor Surveillance System (BRFSS)  and othe3A total of 368 parents/guardians who had at least one child between the age of 9 and 18 were included in the final sample, for a response rate of 83.4% (number of surveys completed/ number of eligible parents approached). Of these, 149 (40.5%) indicated that a doctor or healthcare provider advised them to vaccinate their child against HPV, 209 (56.8%) indicated that they had not received such recommendation, and 10 (2.7%) reported that they did not know or they were unsure. There were no significant differences between parents/guardians who indicated receiving such recommendation compared with those who did not with regard to parent/guardian’s age, race/ethnicity, educational attainment, the child having a regular source of care, and having health insurance coverage . HoweverThere was no significant association between type of provider recommendation (i.e. “provider said that the HPV vaccine is very safe” or “provider stated he/she would vaccinate his/her own children”) and HPV vaccination uptake or scheduling in the bivariate analysis . However4The findings of this study emphasize the importance of how HPV vaccination recommendation is received by parents. In this sample of rural residents, recommendation style was not associated with the HPV vaccination uptake but how parents perceived these recommendations was. The average uptake for most routine vaccines in adolescents is 88–95% compared to the HPV vaccine at 51%  with draThis study further demonstrated that what providers say may be less important than how they actually say it. When the parent/guardian got the impression that the vaccine was important, the child was more likely to get vaccinated the day of the visit. Furthermore, when parents got the impression that “there was no hurry” to vaccinate their child, they were less likely vaccinate their child at all. This proposes the concept that if parents are presented with the HPV vaccine as a necessary requirement this will normalize it to be considered as part of routine care and vaccination rates should increase. This further endorses previous recommendations from the CDC to encourage parents that the HPV vaccine is important, emphasize the cancer prevention component, and recommending same-day vaccination .The topic of how a provider should approach HPV vaccination counseling is still widely discussed. We attempted to evaluate if the recommendation style, i.e. “the vaccine is safe” or “the provider would get their own child vaccinated,” made a significant impact on parents’ uptake of the vaccine. Research has demonstrated that placing an emphasis on the preventive measures of the vaccine, i.e. “decreasing the risk of cervical cancer,” has shown to motivate parents . Other mGiven the racial/ethnic disparities in cervical cancer incidence and mortality , there hLimitations of this study included it being performed in a single state and rural county which means findings may not be as generalizable to all of the United States. Given it is a self-reported survey, it also may include some recall bias and unintentional misrepresentation of vaccination status. Strengths of this study include a questionnaire based on previously proven surveys, a good response rate, and being a population-based survey. Most HPV vaccination data at the population level in the United States rely on telephone-based surveys  and limited representation of rural residents. Further, when rural residents are included most studies limit to the residents in the towns and are not inclusive of the entire county. This study included a balanced representative sample from all nine census tracts in a rural county.5The amount of strong evidence demonstrating that provider recommendations significantly improve HPV vaccination rates has created optimism and increased efforts in this area. The findings of this study emphasize the importance of the impression that the provider gives. Providers stressing the importance of the HPV vaccine increased same-day vaccination uptake while a “lack of hurry” impression led to decreased same-day vaccination. There was no indication that specific phrases altered vaccination rates. Instead, the sole difference was made with provider rhetoric emphasizing importance. This potentially allows providers to spend less time over-explaining the HPV vaccination and instead provide the parents with reassurance that it is an important part of routine healthcare. Ultimately, the goal is to continue to advance communication practices with parents, guardians, and patients in order to improve cancer prevention through the simple, yet effective, mechanism of vaccination.Teresa K.L. Boitano: Data curation, Writing – original draft, Writing – review & editing. Casey Daniel: Conceptualization, Methodology, Resources. Young-il Kim: . J. Michael Straughn: Writing – review & editing. Sylvia Peral: Data curation, Methodology, Writing – review & editing. Isabel Scarinci: Supervision, Conceptualization, Methodology, Resources, Writing – review & editing.The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.


The human papilloma virus (HPV) infection, caused by a ubiquitous virus typically transmitted through the direct contact of infected organs, either through the skin or mucosa, is the most common sexually transmitted infection, placing young women at a high risk of contracting it. Although the vast majority of cases spontaneously clear within 1–2 years, persistent HPV infection remains a serious concern, as it has repeatedly been linked to the development of multiple malignancies, including cervical, anogenital, and oropharyngeal cancers. Additionally, more recent data suggest a harmful effect of HPV infection on pregnancy. As the maternal hormonal environment and immune system undergo significant changes during pregnancy, the persistence of HPV is arguably favored. Various studies have reported an increased risk of adverse pregnancy outcomes among HPV-positive women, with the clinical impact encompassing a range of conditions, including preterm birth, miscarriage, pregnancy-induced hypertensive disorders (PIHD), intrauterine growth restriction (IUGR), low birth weight, the premature rupture of membranes (PROM), and fetal death. Therefore, understanding the mechanisms employed by HPV that negatively impact pregnancy and assessing potential approaches to counteract them would be of interest in the quest to optimize pregnancy outcomes and improve child survival and health. Papillomaviridae comprises over 200 HPV types, identified on the basis of genomic differences detected by DNA sequencing [Alphapapillomavirus [Human papilloma virus (HPV) encompasses a group of common viruses responsible for the most widespread sexually transmitted infection (STI), which is frequently asymptomatic and self-limiting  and alsoquencing . Phylogequencing . Based oquencing . The varquencing . While comavirus   . The capThe expression of the HR-HPV E7 oncoprotein has been demonstrated to mediate not only the deterioration of p105, but also those of p107 and p130, thus promoting cell cycle entry and re-entry in the basal and suprabasal epithelial layers ,56. AddiThe prevalence of HPV in pregnant women has been examined in several studies, with results collectively suggesting a higher risk of HPV infection among pregnant vs. non-pregnant women. In their systematic review gathering data from studies on HPV prevalence among pregnant patients, Liu et al. found an overall HPV prevalence of 16.82% in pregnant women vs. 12.25% in non-pregnant women . More reHuman trophoblasts have been shown to not only possess HPV receptors, but also facilitate HPV DNA replication ,73. UsinThe clearance of HPV during pregnancy has been shown to be decreased, with high viral loads additionally favoring persistence, which is in line with the hypothesis that pregnancy is defined by an altered immune response . HoweverInfectious pathogens during pregnancy have repeatedly been indicated to be responsible for adverse pregnancy outcomes, as well as a number of severe neonatal sequelae . HoweverPreterm delivery refers to births occurring before 37 and after 20 weeks’ gestational age, and is typically linked to higher mortality rates, long-term morbidity, and hindered motor and cognitive development . WorldwiBoth term and preterm labors occur as a result of the complex interaction between the mechanical uterine stretch and cell signaling pathways mediated by steroid hormones owing to the enhanced activity of the fetal hypothalamic–pituitary–adrenal (HPA) axis. Preterm delivery either occurs spontaneously, with intact or ruptured membranes, or is medically induced . While tUreaplasma urealyticum, Mycoplasma hominis, Fusobacterium spp. and Streptococcus agalactiae has been studied and confirmed [Intrauterine infection oftentimes gives rise to preterm birth by activating the innate immune system, which uses pattern recognition receptors (PRRs) to identify pathogen-associated molecular patterns (PAMPs) on microorganisms, and then induce the release of proinflammatory and chemotactic cytokines. Prostaglandin synthesis is consequently stimulated, which, in turn, promotes uterine contractility . Infectionfirmed ,115, evionfirmed ,116. One potential mechanism for how HPV infection affects the outcome of pregnancy is through modifications in the vaginal microbiota that set off an immuno-inflammatory response initiating preterm labor . AdditioPregnancy loss describes the death of the fetus and may refer to miscarriage (spontaneous abortion) when it occurs before 28 weeks’ gestational age/with a birth weight less than 1000 g/with a crown-to-heel length less than 35 cm, or stillbirth when it arises after this age, or when the fetus weighs over 1000 g or measures over 35 cm in length . While tChlamydia pneumoniae [Helicobacter pylori [Preeclampsia or pregnancy-induced hypertension (PIH) is a potentially severe complication that may arise either in the second part of pregnancy or postpartum period, consisting of the onset of high blood pressure and end organ damage, that may be associated with increased proteinuria. While both maternal and fetal outcomes are generally favorable in mild cases, morbidity and mortality risks remain elevated in the more severe cases. Additionally, preeclampsia patients carry the risk of later succumbing to cardiovascular and/or renal disease . A systeeumoniae , and Helr pylori ,143, havSeveral studies have examined the potential involvement of HPV infection in preeclampsia, with opposing results. In 2008, Gomez et al. performed a case–control study of 108 subjects and found that HPV DNA prevalence in placental samples from preeclampsia cases was similar to the one in the control group . Later oIntrauterine growth restriction (IUGR) occurs when the fetus does not grow as expected according to its gestational age. IUGR encompasses fetal growth restriction (FGR) and small for gestational age (SGA) . While SToxoplasma gondii, rubella, cytomegalovirus, herpes simplex virus types 1 and 2, and other agents. Evidence regarding the negative impact on pregnancy, thus resulting in IUGR, has also been accumulating for varicella-zoster virus [Treponema pallidum [Plasmodium falciparum [Conclusively proved maternal infections that lead to FGR include the TORCH group, consisting of er virus , Treponepallidum , Plasmodlciparum , and parlciparum . The moslciparum . Additiolciparum . More relciparum . Furtherlciparum . On a silciparum . Followilciparum . Premature rupture of membranes (PROM) defines the breaking open of the amniotic sac before labor. Should this happen before 37 weeks’ GA, it is referred to as the preterm premature rupture of membranes (PPROM) . Term prp = 0.029), thus highlighting the increased risk of PROM that HPV entails [Concerning the link between HPV and PROM, several studies have analyzed its involvement in this condition. For instance, Cho et al. have specifically looked at the incidence rates of PROM in both HR-HPV-positive and HR-HPV-negative women. Their study found that 27.3% of HR-HPV-positive women experienced PROM, compared with 14.2% in the HR-HPV-negative group , quadrivalent , and nonavalent  ,173,174.p = 0.031), yet it did not take into account variables such as parity, race, or socioeconomic status, which could have greatly influenced the results [Since the vaccine may be delivered throughout a woman’s reproductive life for a variety of reasons, there is a danger of unintentional immunization either during or just before pregnancy in many situations . Thus, t results . Ectopic results . Overall results .As highlighted throughout this review, HPV infection during pregnancy might negatively impact both maternal and infant health, increasing the risk of severe pregnancy complications, such as spontaneous abortion, preterm birth, preeclampsia, intrauterine growth restriction, premature rupture of membranes, and even fetal death. While absolute conclusions are impeded by potential bias and the relatively small number of studies, it is our firm belief that further research fully addressing this matter would confirm the existence of a causal relationship between HPV and adverse pregnancy outcomes. Moreover, the widespread implementation of HPV immunization programs should be initiated and continued, since it is expected to reduce not only cervical cancer rates, but also the risk of cervical conization-related preterm birth, as well as negative pregnancy outcomes related to HPV infection.


Introduction: Cervical cancer, a major consequence of persistent HPV infection, is the third most common cancer in women worldwide and has claimed around 311,000 women lives in 2018. The majority of these deaths took place in low- and middle-income countries (LMICs). In LMICs, where cervical cancer screening coverage is low, the HPV vaccine is a promising tool for preventing HPV infections and, thus, averting cervical cancer cases. In Indonesia, cervical cancer is the second most common cancer and HPV vaccination demonstration programs are underway in several provinces, but the HPV vaccine has not yet been introduced nationally. Since students are an important source of information for the community, and medical and nursing students are the future healthcare professionals, this study explored the knowledge, attitude, and acceptability of the HPV vaccine among University students in Indonesia.Methodology: A self-administered online questionnaire was used to assess the knowledge, attitude, and willingness of University students toward HPV vaccination.Result: A total of 433 students from Medical, Nursing, Social Sciences, and other faculties participated in the survey. It was identified that over 90% of the students were aware of cervical cancer and HPV, but only 68% knew about the HPV vaccine before participating in the study. Despite an average knowledge on the HPV vaccine, the students showed a strong willingness to receive the vaccine (95.8% acceptance rate). They believed that the HPV vaccine is safe and effective and that it will protect against HPV infection. The high cost and the lack of adequate information flow on HPV-related topics have been identified as potential barriers to the adoption of the HPV vaccine in Indonesia.Conclusion: Despite a high willingness for HPV vaccine uptake among students, there is a need to provide education on HPV vaccine-related topics to Indonesian students through awareness and training programs and improving the academic curriculum on vaccination for the long-term sustainability of the HPV vaccination program. Cervical cancer, caused by high-risk genotypes of the Human Papillomavirus (HPV), is the third most common cancer among women worldwide with an estimated 569,847 new cases in 2018, contributing to 6.6% of all female cancers  of Indonesia. However, demonstration programs are underway in five provinces . Before Our study is the first to be conducted among University students in Indonesia to evaluate the knowledge, perception, and attitude toward HPV vaccine and vaccination. The study in this group is also important because students play a vital role in educating their community about HPV, cervical cancer, and the importance of vaccination. In addition, these students are future parents, and if they are aware of cervical cancer, they can play an important role in making positive decisions related to vaccination for their future children. Moreover, medical and nursing students are future healthcare professionals. Identifying the potential knowledge gaps and barriers to the acceptance of the HPV vaccine among University students can help develop effective educational messages, improve its content to increase the awareness of HPV and HPV vaccine, reduce negative beliefs, and promote HPV vaccine uptake.This study applied a cross-sectional study design with a self-administered online questionnaire to assess the knowledge, attitude, and willingness of University students toward the HPV vaccine and vaccination.The questionnaire was developed after an extensive literature review on the determinants of HPV vaccine decision-making, but was not limited to the knowledge, attitude, perception, acceptability, and behavior. The questionnaire was structured into a self-administered anonymous online survey and consisted of 40 items in total. The study was piloted with 12 students from the Nursing Faculty at Universitas Padjadjaran, Bandung, Indonesia to assess the clarity of the questionnaire, and no major modification of the questionnaire was required. The study was conducted in English since the participants in the pilot study highlighted that they were able to understand and interpret the questionnaire.The survey was conducted between February 24 and April 23, 2019 on University students enrolled in undergraduate or postgraduate courses at different faculties like Nursing, Medicine, Social science, Communication, Animal husbandry, Fisheries, and Marine sciences at Universitas Padjadjaran, Bandung, Indonesia. The questionnaire was entered into the SurveyMonkey Platform, and the link for the questionnaire was distributed through Gmail and WhatsApp by each Faculty Dean at Universitas Padjadjaran. Responses were recorded in the password protected SurveyMonkey platform. The minimum sample size was 380 based on the assumption that the acceptability rate was 50% with a 5% margin of error and 95% confidence interval. Participation in the study was voluntary and students could withdraw from the study at any time. Students were not paid for their participation. All participants provided their consent before answering the survey questionnaire.This study was conducted after the review and approval by the Institutional Review Board of Universitas Padjadjaran, Bandung, Indonesia. (Reference number_ 0719101405).The questionnaire included questions on the sociodemographic characteristics, knowledge of HPV, cervical cancer, and HPV vaccine, personal experience of HPV vaccination, perceived facilitators, and barriers to vaccination in general and specific to the HPV vaccine and willingness to accept the HPV vaccine.Awareness about HPV, cervical cancer, and HPV vaccine was assessed with seven items and the responses were recorded on a two-  or three-point scale . In order to find out the willingness to accept the HPV vaccine, four items were used and responses were also recorded on a three-point scale. Questions to assess students' belief and attitudes toward the HPV vaccine and vaccination were grouped into three constructs: opinion on vaccine and vaccination in general (six items), perceived facilitators (six items), and perceived barriers (eight items). Responses to all items were coded on a five-point Likert scale .p < 0.05 (two-tailed test) was considered statistically significant. Phi and Cramer's value was used to assess the degree of association. Fisher's exact test was used in the analysis of small samples. Multiple logistic regressions were used to assess the factors associated with HPV vaccine acceptance and barriers to HPV vaccination. Univariate logistic regression analysis was performed to evaluate the predictors of willingness to accept HPV vaccination. Variables with a p < 0.10 in the univariate analysis were further entered into the multivariate logistic regression model where adjusted odds ratios (AOR) and their corresponding 95% confidence intervals were calculated if possible.The data was analyzed using the Statistical Software SPSS 25.0. Frequencies and percentages were used to describe the sociodemographic characteristics of the participants, knowledge and views on cervical cancer, HPV, and HPV vaccine, and belief and attitude of students toward HPV vaccination. Chi-square test was used to assess the difference between subgroups with analysis conducted separately by age, faculty, and gender. To test the association between the variables, In total, 433 students from different faculties of Universitas Padjadjaran participated in the study.The sociodemographic profile of the study population is summarized in p-value = 0.001, Out of 430 respondents, 418 (97.2%) stated that they knew about cervical cancer. However, that number decreased for knowledge about the HPV vaccine. Of 372 respondents, 256 (68.8%) were aware of HPV vaccines before participating in the survey, while 116 (31.2%) had no information about the HPV vaccine at the start of this survey. Computational analysis showed a significant association between the knowledge about cervical cancer and faculty  (data not shown).Among 329 female participants, 246 responded whether they had received the HPV vaccine or not. Of 246 female respondents, 216 (87.8%) answered that they had not received any dose of the HPV vaccine to date. Only 30 respondents had received one or more doses of the vaccine: 13 had received all three doses, 6 had received two doses, 5 had received a single dose, and 6 could not remember the vaccine doses administered to them. Chi-square analysis showed no significant difference in the knowledge about cervical cancer between vaccinated and unvaccinated participants  stated that there are no religious/cultural barriers in their society regarding vaccination, whereas 27% (67) highlighted that there are negative beliefs such as vaccines that contain haram substances (pig contents) and are not natural, while 23% (56) of the students were unaware of these types of barriers in their society.Participants were asked whether they would accept HPV vaccination if they were within the recommended age when the HPV vaccination program was instigated by the government. Of 238 female respondents, 228 (95.8%) stated that they would receive the HPV vaccination and 217 (96% of 226) participants reported that they would recommend and encourage their family members, relatives, and friends to get the HPV vaccine. More than half of the students (59.7% out of 226 respondents) indicated that they already had information about cervical cancer, HPV, and the HPV vaccine.p-value = 0.002, p-value = 0.98, p-value = 0.93, Willingness to be vaccinated against HPV and to recommend the vaccine to others were found to be significantly associated  pointed out that there is a risk of HPV infection even at an early age of 9–14 years old. Of 226 students, 204 (90.3%) stressed that HPV vaccination should be integrated into the NIP in the future.Potential facilitators and barriers to HPV vaccination in Indonesia were assessed using 14 statements with the Likert-scale. As previously reported, the participants had an overall positive attitude toward the HPV vaccine and believed the HPV vaccine to be safe and effective. Over 60% believed that their families can afford the vaccine and support and encourage them to get HPV vaccination.In contrast, around 67% of the respondents, out of 312, pointed out that there was not enough information available about cervical cancer, HPV, and HPV vaccine in Indonesia. A quarter of participants also claimed that the HPV vaccine in the private market is expensive and their families cannot afford it.Participants were asked where they would prefer to go for HPV vaccination . The majIn addition, sources of information about HPV, cervical cancer, and HPV vaccination were also assessed . Media wThe main aims of this study were to provide an insight on the level of knowledge about cervical cancer, HPV, and HPV vaccine among University students, as well as to understand their willingness to accept HPV vaccination if introduced into the NIP, and to identify the potential facilitators and barriers which may have an impact on the decision to accept the vaccine.In this study, 97.2% of the participants knew about cervical cancer, which infers that the majority of the University students are well-equipped with cervical cancer knowledge. Over 90% claimed that HPV is the leading cause of cervical cancer, indicating that the students are knowledgeable about HPV. In contrast, just over two-thirds of the participants had heard of the available HPV vaccines, thus, demonstrating a knowledge gap and communication deficit leading to a low awareness on the HPV vaccine. In a similar study in health sciences students in Malaysia, it was found that 88.2% 241) of students out of 273, believed cervical cancer to be a serious disease, 80.2% (219) pointed out that HPV is the main cause of cervical cancer, and 78.7% (215) conjectured that the HPV vaccine can prevent cervical cancer 1 of stud. This stA previous study among Indonesian parents showed that only 16.6% knew about HPV, <16% had heard of HPV vaccination, and about 40% had no knowledge about HPV, HPV vaccination, and cervical cancer . CollectMore than a third of the participants thought that 15–20 years old is the appropriate age for HPV vaccine administration and about 28% believed that 21–26 years old is the optimal age group for HPV vaccination, which assumes that in Indonesia, youngsters start sexual activity in the later parts of their life and probably after marriage and are also less aware of the recommended age for HPV vaccination. Only 26% indicated 9–14 years old as the appropriate age for HPV vaccination, as per the recommendation of the WHO .The HPV vaccine in Indonesia is only available in the private market, resulting in a high cost and, probably, beyond the affordability of most of the middle-income families. This was reflected in the data because only 30 (12.2%) of the total 246 respondents had received the HPV vaccine before the onset of the study. This was similar in a study in Lebanon on female college students, where 16.7% out of 215 participants had been vaccinated with the HPV vaccine before starting the survey . The vacDespite an average knowledge of the HPV vaccine, the vaccine acceptance rate among Indonesian University students is immensely high at 95.8%, which is much higher than the acceptance rate in Nigeria  and TurkIn addition, about 96% of the students tend to recommend the HPV vaccine to their family members and friends who are within the recommended age for vaccination. This is higher than in Lebanon  where 72Overall, students have a positive attitude toward HPV vaccination. More than 90% of the students emphasized that the HPV vaccine should be provided as part of the NIP, making it accessible to a large number of people. The inclusion of HPV vaccination in the NIP has become a huge success in countries like Australia where cervical cancer is expected to be eliminated by 2035 .The major potential facilitators highlighted by the students were that HPV vaccines are safe and effective and can protect against HPV infection. However, a study in Turkey showed that 55.6% of the students were unsure of the vaccine effectiveness and 28.9% were afraid of the side effects of the vaccine . Thus, tMoreover, a majority of the students pointed out that a lack of sufficient information about cervical cancer and HPV vaccine in Indonesia and the high price of the vaccine were major barriers to HPV vaccination. These findings correlate with the previous study in Indonesian parents, where it was also shown that insufficient information about HPV, cervical cancer, and HPV vaccines and high cost of the vaccine, are two major barriers to HPV vaccine uptake . Thus, aThe preferred choice to receive HPV vaccination was the hospital followed by Puskesmas, while the school was the least desired location. Since this study was conducted in Bandung city, which is the fourth biggest city in Indonesia, the participants find it more convenient to go to a hospital for vaccination. However, Puskesmas was chosen as the second option because many people in Indonesia belong to middle-income families and Puskesmas are cheaper than hospitals.Almost half of the students stated that media  were the main source of information on HPV vaccination in Indonesia, followed by healthcare professionals and teachers. Similar results were obtained in Nigeria  and TurkThe study had some limitations as it was limited to one University in Indonesia. Therefore, it is difficult to generalize the findings. In addition, the study was conducted online through WhatsApp and Gmail, which are expected to be commonly used in this population but a few students with a lower socioeconomic status may have missed out. The attempt to minimize non-random selection bias was made by sending survey reminders to faculties that had a minimal response. Despite these reminders, more responses were received from the medical faculties , which could have created a selection bias.To sum up, University students have a good knowledge of cervical cancer and HPV but are slightly behind in having up-to-date information regarding the HPV vaccine. Despite a slightly insufficient knowledge about this vaccine, the students showed a strong willingness to receive the HPV vaccine and encourage others to get vaccinated. Students, in general, have a positive attitude toward the HPV vaccine and vaccination, but highlighted insufficient circulation of information about cervical cancer, HPV, and HPV vaccine in their community. They also identified the high cost of the vaccine to be one of the main barriers to HPV vaccine uptake. Furthermore, the majority of participants believed that the HPV vaccine prevents lifelong HPV infection and that the vaccines are safe and effective. Based on our study, it is recommended that the media can be widely mobilized to raise awareness about HPV vaccination in Indonesia, along with the active engagement of healthcare professionals. It is also equally important to involve religious leaders, ministry of health representatives, health organization representatives, and healthcare professionals in the organization of vaccination awareness programs to ensure that the correct message will be perceived by the general public.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.This study was conducted after review and approval by the Institutional Review Board of Universitas Padjadjaran, Bandung Indonesia. (Reference number_ 0719101405).CDo and CK developed the original idea and are the supervisors of the study. Co-supervisors of the study are HM, CDe, and GV. MK conducted the study as part of his master studies developing the protocol and questionnaire, analyzing data and report writing, under supervision of all co-authors. CK and HM assisted with the ethical clearance and data collection. All authors reviewed the data analysis, report writing, gave input into the manuscript, and are equally responsible for the content of the manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Multicentric intraepithelial lesions of the lower genital tract (multicentric lesions) were defined as intraepithelial lesions of two or three sites within cervix, vagina, and vulva occurring synchronously or sequentially. The characteristics of multicentric lesions has been poorly understood. This study aimed to evaluate the risk factors for multicentric lesions, including specific HPV genotypes.A retrospective case-control study was performed involving patients histologically diagnosed with multicentric lesions between January 2018 and October 2019. Controls were patients histologically diagnosed with single cervical intraepithelial neoplasia (CIN) and admitted during the same period. Univariable and multivariable analyses were used to assess the risk factors for multicentric lesions.Of 307 patients with multicentric lesions, the median age was 50 years (interquartile range: 43–55.5), and they were older than patients with single CIN . In the multicentric lesion group, the proportions of cytologic abnormalities, HPV positivity, and multiple HPV infections were 68.9, 97.0, and 36.5%, respectively. In the multivariable analysis, menopause, a history of malignant tumors beyond the lower genital tract and multiple HPV infections were associated with the incidence of multicentric lesions (Odd ratio (OR) = 3.14, 95% confidence interval (CI) 2.24–4.41; OR = 9.58, 95% CI 1.02–89.84; OR = 1.47, 95% CI 1.03–2.10). The common HPV genotypes were HPV16, HPV53, HPV58, HPV52, HPV51, HPV56 and HPV18 in patients with multicentric lesions. The proportion of HPV16 infection was higher in high-grade lesions group than that in low-grade lesions group . The OR for multicentric lesions, adjusted for menopause, smoking, gravidity, parity, a history of malignant tumor beyond the lower genital tract and multiple HPV infection, was 1.97 (95% CI 1.04–3.75) in patients with HPV51 infection.Multicentric lesions were associated with menopause, a history of malignant tumors and multiple HPV infections. HPV16 was the most common genotype, especially in high grade multicentric lesions and HPV51 infection was found to be a risk factor for detecting multicentric lesions. Persistent human papillomavirus (HPV) infections play a critical role in the development of lower genital tract precancerous and cancerous diseases. Cervical intraepithelial neoplasia (CIN) is common with an incidence that is ten times higher than that of vaginal intraepithelial neoplasia (VAIN) or vulvar intraepithelial neoplasia (VIN). However, the incidence of VAIN or VIN has increased recently . In 1960A comprehensive diagnosis of multicentric lesions can be challenging, as vaginal or vulvar lesions are easily missed on clinical exam; these missed diagnoses lead to a poor prognosis. Previous studies have found that multicentric lesions are a risk factor for residual lesion and disease recurrence , 6, 7. ATherefore, in this study, we aimed to describe the clinical characteristics of a large number of patients with multicentric intraepithelial lesions of the lower genital tract which were detected synchronously. We also examined the prevalence of different HPV genotypes. Correlations between several risk factors and the incidence of multicentric lesions were also assessed.A retrospective case-control study was conducted with patients undergoing colposcopy-guided biopsy at the Cervical Disease Clinic of Liaoning Cancer Hospital and Institute, which serves as a referral center in northeastern China. Patients with a histologically confirmed diagnosis of multicentric lesions detected synchronously , between January 1st, 2018, and October 31st, 2019, were included in the study and were placed into the multicentric lesions group. Moreover, we enrolled patients with histologically confirmed diagnoses of single CIN, who were admitted during the same period to be in the single CIN control group. Exclusion criteria were the presence of concurrent invasive cancer in the lower genital tract, a history of invasive cancer in the lower genital tract, multicentric lesions detected sequentially or pregnancy. In the multicentric group, two subgroups were divided according to the grade of CIN, including high-grade lesions group (CIN2+ with VAIN and/or VIN) and low-grade lesions group (CIN1 with VAIN and/or VIN).Clinical data were retrieved retrospectively from electronic medical records and picture archiving and communication systems (PACS) in the hospital by trained gynecological staff using standardized data collection and quality control procedures, including demographic details, menopause status, symptoms, a history of other diseases, cytology results , HPV infection and genotypes, high-risk HPV (HR-HPV) viral loads and histopathologic results.HR-HPV DNA viral loads were detected using the Digene Hybrid Capture 2 (HC2) test . HPV DNA was detected and genotyped with the HPV GenoArray test kit  using both DNA amplification and a flow-through hybridization technique . A totalColposcopy was performed in the Cervical Disease Clinic of our hospital. Women were referred to colposcopy if cytologic result was low-grade squamous intraepithelial lesion (LSIL) or worse, or cytologic result was atypical squamous cell of unknown significance (ASCUS) companied with HPV infection, or HPV16/18 were positive with normal cytology, or other HR-HPV genotype infection persists 6 months with normal cytology. Comprehensive assessments of the cervix, vagina, and vulva were carried out. Colposcopy-guided biopsies were performed if suspicious lesions were found. Biopsy tissue sections were independently assessed by two expert pathologists.t-test was used to compare differences. When data were abnormally distributed, quantitative variables were presented as the Median and Interquartile range (IQR), and the Mann-Whitney U test was used to compare differences. Univariable analyses were performed to quantify the association between independent variables and binary outcomes using logistic regression analyses for categorical variables. The multiple logistic regression model was used to quantify independent factors associated with multicentric lesions. The prevalence of HPV was expressed as the proportion of HPV-positive cases compared with the total number of HPV cases. Logistic regression analyses, which were adjusted for menopause, a history of malignant tumors, and multiple HPV infections, were used to estimate correlations between specific HR-HPV genotypes and the number of multicentric lesions detected, and the Odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. Data were analyzed using the SPSS version 22.0 software .Normality of continuous variables was determined using the Kolmogorov-Smirnov test. When data were continuously and normally distributed, quantitative variables were presented as the mean ± standard deviation (SD), and the Student’s This study was approved by the ethical committee of Liaoning Cancer Hospital and Institute (reference number 2020–0610); this approval allowed access to the data used for this research.A total of 1950 patients were enrolled, including 307 patients in the multicentric lesions group and 1643 patients in the single CIN group  patients in the multicentric lesions group and 833 (62.5%) patients in the single CIN group had abnormal cytologic results, such as atypical squamous cell with unknown sense or worse . HR-HPV viral loads were available for 102 patients in the multicentric lesions group. The median relative light units over a positive control-derived cutoff value (RLU/CO) was 272.165 with an interquartile range (IQR) of 1118.17, which was higher than that in the single CIN group   . If the cervical intraepithelial lesions were high grade, combined vaginal or vulvar intraepithelial lesions was more likely to be high grade . Compared to low-grade lesions group, HPV16 infection was more popular in high-grade lesions group . However, the proportions of HPV18 infection in both subgroups was similar . In the low-grade lesions group, non HPV16/18 infections were more popular than that in high-grade lesions group  .Correlations among the top seven common HR-HPV genotypes and multicentric lesions detection are shown in Table In this retrospective case-control study, it was indicated that the risk factors for multicentric lesions included menopause, a history of malignant tumors beyond the lower genital tract and multiple HPV infections using the multivariable analyses. In the multicentric lesions group, the top seven common HPV genotypes were HPV16, HPV53, HPV58, HPV52, HPV51, HPV56 and HPV18. The risk of detecting multicentric lesions in patients with HPV51 infection was 1.97 times of that in patients with non-HPV51 infection adjusted for menopause, smoking, gravidity, parity, a history of malignant tumor beyond the lower genital tract and multiple HPV infection.With the advancement of cervical cancer screening, and the standardization of the colposcopy procedure, the detection rate of vaginal or vulva intraepithelial neoplasia has gradually increased –11. The The average age of patients with multicentric lesions has not been consistent in previous studies, ranged from 36.3 to 43 years , 13. In Most patients with multicentric lesions had no clinical symptoms. VAIN mostly involved the fornix and the upper third of vagina, high-grade lesions even involved the whole vagina. The images of VAIN under colposcopy were mainly micropapillary hyperplasia, acetic acid white epithelium, punctate blood vessels and Lugol’s iodine non-coloring . Frega e. In addition, in high-grade lesions subgroup, more than half (53.3%) of the patients were HPV16 infection. Consistent with the second pathogenesis theory and previous study [Multicentric lesions development is closely related to HR-HPV infection in the lower genital tract; however, the pathogenesis is not completely clear. So far, there are three theories to the pathogenesis. First, one persistent infection with a certain HPV genotype could induce the development of several independent lesions, representing synchronous multicentric lesion development, where there are either high viral loads or a high-risk for transformation. Second, repeated independent infections with various HPV genotypes can induce independent lesions , 4. Thirhan half 3.3% of tus study . In thisThe prevalence of HPV genotypes would be useful for the development of screening and management guidelines for multicentric lesions. In this study, HPV16 was also the most common genotype, especially in high-grade lesions subgroup; HPV53, HPV58, HPV52, HPV51 and HPV56 were all more common than HPV18. Similar findings have previously been reported. HPV18 was rare in Asian patients with VAIN . A JapanThis study was done in relatively higher sample size with appropriate analysis technique that provides important information regarding HPV genotypes prevalence and risk factors associated with multicentric lesions in northeastern China. However, this study had some limitations. First, the retrospective design of this study could miss some variables in the analysis such as data related to oral contraceptives and number of sexual partners. Second, the number of patients that had HPV genotyping performed was relatively limited. Hence, more studies, specifically large prospective studies, are required.Currently, the incidence of multicentric lesions is increasing. Multicentric lesions were closely related to menopause, a history of malignant tumors beyond the lower genital tract and multiple HPV infections. The common HPV genotypes were HPV16, HPV53, HPV58, HPV52, HPV51, HPV56 and HPV18. HPV51 infection was a risk factor for multicentric lesions detection. To avoid missing a diagnosis of multicentric lesions, comprehensive colposcopical evaluations of the cervix, vagina, and vulva is warranted especially in women with risk factors.


The epidemiological studies in Iran on HPV18 nucleotide changes are rare. This type of virus is prevalent in the Iranian population. Therefore, in the present study, we aimed to identify the genetic variability in HPV18 in the E6 region to evaluate the prevalence of lineage distribution and sublineages in a sample population in Iran. Overall, 60 HPV18 confirmed cases were investigated between 2019 and 2021. The specimens were collected, and molecular genotyping was done using the Linear Array HPV Genotyping Test. DNA extraction was performed by a viral DNA/RNA kit. The HPV E6 gene was amplified by using type-specific primers designed according to the HPV18 genome prototype sequence. The sequencing of the E6 region was successfully done on 43 samples which were then compared to the reference sequence. The most frequent sublineage of HPV18 in this study was A4 (69.7%), followed by A1 (18.6%) and A3 (11.6%). Neither A2 nor A5 sublineage was not detected in this study. The related nucleotide acid changes according to the main references were as follows: A3: T104C/T232G/T485C/C549A, A4: T104C/T485C/C549A. The predominance of A lineage with the high frequency of A4 sublineage was found in the present research. The importance of sublineages in susceptibility to a progressive form of infection requires to be more investigated among the different population. Human papillomavirus (HPV) is a well-known cause of cervical intraepithelial neoplasia (CIN) and invasive cervical cancer (CC) as the third most prevalent cancer among females , 2. GeneThere have been more than 200 identified HPV types from which 13-15 kinds are carcinogenic. Among the high-risk genotypes, HPV16 and HPV18 are considered the most common oncogenic HPV genotypes causing approximately 70% of all cervical cancers , 5.The contribution of HPV genotypes to cervical cancer differs across the world which may stem from geographic variations in HPV type-specific prevalence among the populations. Cervix HPV infections are mostly asymptomatic, and about 90% of detected infections are cleared in two years although the protection and duration of immunity after a natural infection has remained unknown –8.According to the published data, the highest HPV prevalence was found in Oceania, Africa, Europe, America, and Asia, respectively . The fouIn the other study which included 1218 Iranian samples with normal cervical cytology, HPV was found in 7.2% which varied according to the geographical regions. The data showed HPV was most common in the North (11.7%) whereas the lowest in the Center (4.5%) of Iran .HPV variants have different phenotypic characteristics in terms of carcinogenicity and cancer progression. In addition to the virus type, there have been some reported substitutions in oncogenes which might affect the related protein function and thus the infection progress as well .HPV18 has been classified into three main variants such as European, African, and Asian-Amerindian variants . HPV varGenetic variation has been shown to be associated with different manifestations of infectious diseases even in the host or the pathogen –17. TherInvestigation on HPV variants and also probable nucleotide variability is essential to assess the nucleotide variations which may contribute to the viral oncogenic potential. Moreover, the host cellular immune response might be affected by amino acid substitutions on the viral capsid. Finally, HPV infection of a particular variant may not raise immunological protection against another subsequent incidence of the other variant with the same genotype .The epidemiological studies in Iran, which refer to HPV18 nucleotide variability as a frequent type in the region, are rare. Therefore, in the present study, we aimed to characterize the genetic variability of HPV18 regarding the E6 genomic region to assess the prevalence of HPV18 lineage and sublineages in a sample population of our country.60 cervical samples were collected from cases referred to medical centers from 2019 to 2021 for routine screening. Molecular genotyping was achieved using the “Linear Array HPV Genotyping Test” kit (Roche Molecular Diagnostics). Then, HPV18-diagnosed samples were excluded and applied for further steps. All the procedures were approved by National Institute for Medical Research Development (IR.NIMAD.REC.1398.331) and complied with the guidelines and ethical standards for experimental investigation with human subjects of the Helsinki Declaration.μl AE buffer and stored at -20°C until amplification.DNA extraction was performed by the viral DNA/RNA kit  according to the manufacturer's instructions. Extracted DNA was eluted with 50 μl of reaction mixture containing 10X PCR buffer, 25 mmol/l MgCl2, 25 mmol/l of each dNTP, 100 pmol/l of sense and anti-sense primer, 5 μl of template DNA, and 2.5 U of Taq DNA polymerase . The initial denaturation started at 95°C for 5 min, followed by 42 cycles of 53°C annealing temperature, and finished with a final extension at 72°C for 5 min (Amplification of HPV E6 was performed using type-specific primers designed according to the HPV18 genome prototype sequence (GenBank accession number NC001357). PCR was performed in 25 or 5 min . PCR proThe same forward-specific primers applied in amplification were then used as the sequencing primers. HPV obtained sequences were aligned in NCBI and compared to the reference HPV18-type sequence which belongs to the Asian-Amerindian lineage (accession number NC001357) by the MEGA 6.0 tool.p value less than 0.05 was considered significant.The SPSS 26 program for statistical analysis was applied, and a p < 0.05).In this study, 60 women aged 21-49 (mean: 34.26) who were referred to the medical centers for routine screening were enrolled. Overall, 43 collected cervical samples were of proper quality for further steps. E6 fragment was amplified and subjected to sequencing. The sequencing analysis by the MEGA 6.0 tool showed that all the samples belonged to lineage A of HPV18 which is common in Iran . The relHPV18 variants require to be more investigated in Iran regardless of the fact that HPV18 prevalence is common in the population. This genotype besides genotype 16 causes 70% of cervical cancer cases which highlights the importance of the epidemiologic studies and determination of the virus variations.The distribution of HPV variants has been found to be associated with race or geographic region , 25. ThiThe predominance of A variant (including Asian-Amerindian and European) is supposed for the Persian population which is in accordance with the result of this study. Non-European HPV18 variants have been found to be associated with preinvasive lesions and are also more persistent . In a stIn the previous study in Iran, lineage A was detected in all collected samples, and similar to our finding, sublineage A4 was the most frequent type . LineageIn the other investigation on 25 Taiwanese with HPV18 cases, 7 of them were coinfected with HPV16. C183G of the E6 as a silence mutation was the most dominant mutation among all the subjects .In the other study in Spain, Basaras et al. found that specific African substitutions were related to the high-grade squamous intraepithelial lesion samples. They concluded that non-European HPV variant prevalence is a risk factor for persistence and progression .It was determined that mutations in the last nucleotide of the LCR, at position 104, modified Sp1 and YY1 activity, and this variation is related to the higher activity of the E6/E7 promoter. We determined T104C mutation in most of our cases (71.5%). Interestingly, cancer recurrence is less likely to occur in women with T104C mutations in contrast to those infected with wild-type .Shin et al. determined that all the investigated samples from Korean HPV18-positive patients belonged to linage A. Moreover, sublineage A1 comprised 91.7%. Fifteen new nucleotide substitutions were identified among 44 nucleotide substitutions from which six substitutions at positions 317, 443, 5467, 5560, 6462, and 6823 resulted in amino acid changes in E6 including F71L, N113K; L1: H13R, H44P, A345T, and N465S . Among tIn the present study, lineage A was identified in Iranian females with HPV18. So far, the A4 sublineage of HPV18 is the most prominent variant of HPV18 in Iran whereas neither A2 nor A5 was not detectable. The gathering data of HPV18 distribution and geographic diversity provides us with critical information to expand diagnostic tools and epidemiologic association with cervical cancer risk and also to come up with a proper HPV vaccine type for targeted populations worldwide.


In both SES measures, the proportion of HPV-unvaccinated teenagers was lowest at the highest SES level in analyses with parental reports. However, it was the opposite in analyses with provider records. Interestingly, regardless of the vaccination information source, the HPV unvaccinated rate was highest in the middle-SES teens . Conclusions: Significant social inequality in HPV vaccination among teenagers exists in the United States. The pattern of social inequality in HPV vaccination can be distorted when only parent-reported vaccination information is used.Background: Relatively little is known about social inequality in human papillomavirus (HPV) vaccination among teenagers in the United States. This study aims to investigate whether there is a social disparity in HPV vaccination among teenagers and if so, whether it can differ according to the source of teen vaccination information . Methods: We used the data from the 2019 National Immunization Survey-Teen  including parent-reported vaccination status. Among them, 18,877 teenagers had adequate provider-reported vaccination records. Two socioeconomic status (SES) measures were used: mother’s education and annual family income. Multivariate logistic analyses were conducted. Results: False negatives of parental reports against provider records were more than two times higher ( Human papillomavirus (HPV) infection, resulting in cervical and other cancers, is the most common sexually transmitted disease (STD) . While mIn the United States, HPV inactivated vaccines, such as Gardasil , Cervarix , and Gardasil 9 , have been developed for the prevention of HPV-associated cervical and other cancers, but since 2016, only Gardasil 9 has been distributed, targeting seven high-risk and two low-risk HPV types . As of nHowever, the HPV vaccination of teenagers and its promising future benefits may vary significantly between SES strata. Monitoring social inequality in HPV vaccination among teenagers while working towards the health equity of HPV vaccination is a primary national task for public health in the United States (US) .Several investigators ,13,14,15However, several studies ,17,18,19This study aimed to investigate (1) whether there is a significant difference in HPV vaccination according to SES among teens and if so, (2) whether it differs according to the source of teen vaccination information  in the recent 2019 NIS-Teen data of the US. The NIS-Teen was launched in 2006 and is sponsored by the National Center for Immunization and Respiratory Diseases of the Centers for Disease Control and Prevention (CDC). It has been used to monitor vaccination coverage among teens aged 13–17 years living in the US  ever received any human papillomavirus shots?”) with four response options . HPV-unvaccinated teens were defined as teens whose parents responded to the interview question with “No”. In addition, the HPV vaccination status of teens was assessed with the provider-reported vaccination information (Method 2) in Subsample A. The number of HPV shots, which was determined from the vaccination provider data, was available in the NIS-Teen data. HPV-unvaccinated teens were defined as teens whose vaccination providers reported no HPV vaccination. Teens’ SES was measured with two indicators: mother’s education and annual family income. Each indicator was measured with a single interview question. The following teen-related covariates were considered in the analyses of the current study: age, sex, geographical region, and race/ethnicity. Each of the covariates was measured with a single interview question. The distributions of sociodemographic characteristics and HPV vaccination status of teens were first examined in the whole sample. Then, the distributions were compared between the two subsamples using the Pearson chi-square test. In addition, we compared the parent-reported vaccination response against the provider-reported vaccination record (the reference) in Subsample A, which was also replicated by each level of SES due to potential SES-differential false negative percentages ,18,19. TIn the whole samples, 25,263 (59.2%) out of 42,668 parents responded to the any HPV shot question with “Yes”; 32.1% with “No”; 8.6% with “Don’t Know”; and 0.1% with “Refused” . The disThe parent responses to the HPV shot question were compared with the provider information on teen’s HPV vaccination in Subsample A. p < 0.001): for example, 20.5% vs. 11.8% with mother’s education; 20.2% vs. 11.4% with annual family income (p < 0.001)  B,C. As a< 0.001) B,C.The proportion of HPV-unvaccinated teens (Method 1: parent-reported) was lowest in the teens with the highest SES level with both mother’s education and annual family income in the whole sample . HoweverIn Subsample A, the distributions of HPV-unvaccinated teens (Method 1) according to mother’s education and annual family income were similar to in the whole sample . When MeNonetheless, regardless of Method 1 and Method 2, the odds of HPV-unvaccinated teens were highest in the teens with the middle level of SES levels : ORs (compared to the teens with the highest SES level), 1.27~1.33 and 1.10~1.12, respectively. Additionally, as expected, in the multivariate logistic models, a significantly lower number of younger teens, who were 13–14 years old (vs. teens aged 17 years), male, non-Hispanic white, and non-Northeastern were vaccinated against HPV. To the best of our knowledge, this was the first study demonstrating that the direction of social inequality in HPV vaccination along the SES strata of teens can be reversed, depending on the source of teen vaccination information in the NIS-Teen data. In both SES measures, the proportion of HPV-unvaccinated teens was lowest in the highest SES level in analyses with parent-reported vaccination status. In contrast, it was lowest in the lowest SES level in analyses of provider-reported vaccination status. The false negative propensity of provider-reported vaccination status against provider vaccination records was greatest in the lowest SES level, which was the reason for the contrasting pattern of social inequality in HPV vaccination between the lowest and highest SES levels in the NIS-Teen data. Nonetheless, regardless of the source of teen vaccination information, the proportion of HPV-unvaccinated teens was highest in the teens with the middle-SES level . Our finding on social inequality in HPV vaccination with parent-reported vaccination information is consistent with two previous studies with data from the NIS-Teen ,12. HoweThis study has several important implications for research and public health policies on social inequality in HPV vaccination among US teens. First, despite the increasing rates of HPV vaccination in recent years ,21, our Our study has some limitations. In our study, we utilized only a single year of data from the NIS-Teen due to our main focus on the methodological issues in the current study. Thus, the findings of our study remain to be confirmed in future studies with recent multi-year NIS-Teen data. In our study, about 44% of the whole sample (Subsample A) had adequate provider data. There were some significant differences in sociodemographic variables between Subsample A and Subsample B (56% of the whole sample). However, the results of our study were very similar in the whole sample and Subsample A with Method 1. The main difference in our findings was based on the method, not which subsample. We did not analyze the reasons for the observed nonlinear social inequality in HPV vaccination among US teens, which goes beyond the research question of the current study. Several researchers ,25,26,27