Given the change in policy recommendation to include males in routine HPV vaccination, our goals were to assess the HPV vaccination uptake in Canada, to understand We used an online survey methodology and collected data from a nationally representative sample of Canadian parents of boys aged 9–16 at baseline  and at 9 months’ follow-up (T2). Our analyses were guided by the Precaution Adoption Process Model (PAPM), a theoretical health behavior model that classifies parents in one of six stages: unaware, unengaged, undecided, decided not to vaccinate, decided to vaccinate and those who had already vaccinated their sons. Rigorous methods were used to filter out careless responders: response variance, bogus items, psychometric antonyms and psychometric synonyms.At T1 and T2, we received 3,784 and 1,608 respectively completed questionnaires; after data cleaning 3,117 (T1) and 1,427 (T2) were retained. Less than 3% of boys were vaccinated at both time points. At both T1 and T2, most parents (over 70%) belonged to the earlier vaccination adoption stages: 57% were unaware (T1) and 15.3% (T2); 20.9% were unengaged (T1) and 32.4% (T2); and 9.1% were undecided (T1) and 25.2% (T2). At follow-up, 37.7% of participants did not move from their initial PAPM decision-making stage. Most parents (55%) preferred to receive information from their healthcare provider (HCP) but only 6% (T1) and 12% (T2) had actually spoken with a HCP about the HPV vaccine for their son.HPV vaccination uptake in Canadian boys was very low in the absence of a publicly funded HPV vaccination programs for boys. Optimal HPV information preferences were identified and can be used in interventions to increase HPV knowledge and increase HPV vaccine uptake. Intentions to vaccinate or planning to speak to one’s HCP did not translate into action for most parents over the 9-month follow up; this finding is critical to consider to inform implementation strategies. Methodological challenges are described and suggestions for future research are offered.The online version of this article (doi:10.1186/s12889-016-3828-9) contains supplementary material, which is available to authorized users. The prevention of human papillomavirus (HPV)-associated diseases is an increasingly prominent public health issue. HPV is the most common sexually transmitted infection (STI) and accounts for 4.8% of the worldwide cancer burden , 2. HPV The quadrivalent vaccine, Gardasil® (Merck) protects against four strains of HPV: two oncogenic strains HPV 16, 18), and two that cause GW (HPV 6 and 11) . Epidemi, 18, andIn 2007, in Canada, the HPV vaccine (Gardasil®) was recommended for females and subsequently rolled out for females only in school-based immunization programs . As the Presently, all Canadian provinces and territories offer free, school-based HPV vaccination programs for females. Canada’s National Advisory Committee on Immunization  recommends HPV vaccine for females and males aged 9–26  Australiintentions to vaccinate rather than actual vaccination uptake [The examination of the attitudinal, behavioral, cognitive, social, cultural and logistical determinants  that influence the HPV-vaccine decision-making is a growing area of research –36. Becan uptake , 39.only to people who have been engaged (or are presumed to be engaged) sufficiently by the HPV vaccination to have formed such beliefs [few parents because HPV vaccination for males is relatively new and many parents may not yet have formed their beliefs—there are likely other stages in adopting HPV vaccination. The Precaution Adoption Process Model (PAPM) is a categorical stage theory, which aims to identify all the stages involved when people commence health-protective behaviors. The PAPM is therefore appropriate to apply to parental decision-making about HPV vaccination to determine the psychosocial determinates that lead parents to move from one stage to the next, and ultimately to vaccinate their child [Further, experts in HPV vaccine behavioral research recommend using theoretical health behavior frameworks to better understand the psychosocial determinants that influence an individual’s vaccine decision-making process , 40, 41. beliefs . As such beliefs , 37, 42.ir child .sixunaware of the health behavior); 2) unengaged in the decision; 3) undecided; 4) decided not to act; 5) decided to act (intending); and 6) acting (vaccinated). As opposed to linear models, the PAPM staged model acknowledges the fact that transition between stages can be explained by different psychosocial determinants, i.e. there are differences between determinants which influence the transition from stage 1 to 2 compared to the determinants which influence the transition from stage 5 to 6.The PAPM consists of where Canadian parents currently stand in the HPV vaccine decision-making process for their son and which psychosocial determinants influence their HPV vaccination decision-making process. Importantly, the present study was conducted just before several Canadian provinces began to include males in their school-based public vaccination program. This created a unique opportunity to provide baseline data about HPV vaccine uptake in the absence of publicly funded programs, and to evaluate the impact of recent recommendations of male HPV vaccination.Using a longitudinal design and online survey methodology guided by the PAPM, we surveyed a national sample of Canadian parents of boys to understand To provide an estimate of HPV vaccine uptake among males in Canada;where Canadian parents’ stand in the HPV vaccine decision-making process for their son (s) using the PAPM, at baseline  and at follow-up 9 months later ;To classify how Canadian parents’ changed in their HPV vaccine decision-making process from T1 to follow-up (T2); andTo describe which psychosocial determinants influence parents’ HPV vaccine decision-making process i.e., PAPM stageTo describe and analyze The study objectives were:This research article will present a comprehensive description of the study methodology, sample characteristics as well as the results for objectives 1–3. Descriptive result for objective four, specifically for the following psychosocial determinants: HPV and HPV vaccine Knowledge, HPV vaccination information sources, health behaviors , and childhood immunization practices) and implementation intentions will be presented. A more comprehensive statistical analysis of the psychosocial determinants of PAPM stages over time i.e., objective 4, is under way.The population of interest was Canadian parents and/or guardians (hereafter referred to as parents) of 9–16 year-old boys. We selected this population because it covers the current NACI HPV vaccine recommendation for males aged 9–26, and because after the age of 16, virtually all Canadian minors may make a vaccination choice without parental consent , 46. DatDan) was then replaced for my son in most items, making the questionnaire individualized for each participant. In this way, participants were asked about their beliefs and attitudes relative to one specific son. Participants were informed that their son’s name will not be used in any other way by the researchers. Participants were required to complete every item, obviating the problem of missing data. For 16 sensitive questions, “I prefer not to answer” was a response option provided. In order to further ensure recollection of answering the questionnaire at T1, participants were asked at T2 “Do you remember completing the survey related to the HPV vaccine about my son?” Participants who indicated no recollection were not invited to participate at T2. Respondents were compensated 3$ per completed questionnaire at both T1 and T2.Prior to beginning the questionnaire, participants were asked first if they prefer to answer the questionnaire in English or French and were provided the questionnaire in the language of preference. Participants were also asked to agree to answer the questions truthfully and thoughtfully or were excluded from completing the study. Participants were also asked at the beginning of the questionnaire to provide a name, nickname, initials or abbreviations for their son who is between the ages of 9 and 16 and who has had the nearest birthday. Using intelligent programming, the provided sons’ initials, name or nickname  working in the healthcare field. The questionnaires were virtually identical at T1 and T2 except for minor differences . The complete questionnaireThe English questionnaire was translated into French by a specialized translation firm and reviewed for accuracy by an independent bilingual group of professionals  residing in the 10 Canadian provinces in order to assure the generalizability of our results to the entire Canadian population. First, chi-square tests were performed to examine if there were any significant differences in socio-demographics between our T1 and T2 samples. Next, chi-square tests were performed to examine if there were any significant differences in socio-demographics between T1 and Statistics Canada’s sample (see Table p < 0.05) in proportions do not indicate the size of the difference, we further calculated Cohen’s h [The first 12 items were standard socio-demographic variables  selected from Statistics Canada 2011 Census questionnaire. We compared our sample to data the authors requested from Statistics Canada’s National Household Survey (2011) of participants who met our inclusion criteria i.e., parents of 9–16-year-old sons  they received from a HCP for their son concerning the HPV vaccine. Self-reported health behaviors were also assessed e.g., whether their son has attended a routine medical check-up in the past year, acceptance of all the recommended childhood vaccines. Parents were asked who the primary health decision-maker was for their son .Lastly, parents were also asked about behaviors they intended to complete at T1 , and at T2, using the computer-adaptive testing, we re-assessed if the specified behaviors they indicated at T1 were indeed carried out by T2.Other additional items include: if the participant have any daughters and/or any vaccinated daughters (2 items); parent's health behaviours (3 items) communication about sex/HPV vaccination (7 items); degree of parental/son involvement in HPV vaccine decision-making (3 items), willingness to vaccinate at different price points (4 items); vaccine conspiracy beliefs (9 items) ; right wOnce data collection was completed, we sought to ensure the highest level of data quality and integrity of our conclusions. We used four data cleaning methods to identify participants who might not have used appropriate care while completing the questionnaire i.e., careless or unmotivated responders . The fouall items would be removed by the variance method.For the validity criterion, we used three bogus items from Weinberger and colleagues : “I havez scores and correlated all items. We identified the 30 most positively and 30 most negatively correlated items. We recoded these items to create pairs of synonyms and then calculated the correlation between synonyms and antonyms for each participant, which established a synonym index and an antonym index for each participant. We then flagged all values less than -2 standard deviations (SD) on the synonyms index and greater than +2 SD on the antonyms index as these correlations could be seen as extreme outliers.Another method used was psychometric synonyms and antonyms , 63, whin = 575) and 5% of our sample (n = 202) at T2 belonged to a latent class that can be considered careless or unmotivated in their responses, a percentage nearly identical to findings by other research groups [These four methods identified that 15% of our sample at T1  vaccination as opposed to objective  has been reported in the literature [Following T1 data collection, we inspected the data from our primary outcome variable, PAPM stage. The authors observed that some participants’ responses were implausible, nonsensical or inaccurate. We speculated that perhaps parents may have confused the HPV vaccine with other childhood vaccinations, and therefore some participants likely did not match the profile of a participant who had truly vaccinated his or her son against HPV. For example, some participants indicated that their son had been vaccinated in school, even though they lived in provinces where indeed no school-based programs for boys yet existed. This challenge of terature , 66.During data cleaning at T1, the authors therefore established a first method of examining a set of 10 criteria to increase the likelihood that parents who had indicated that they had vaccinated their son were not false positives. Furthermore, in order to improve upon the accuracy of parents’ self-reported vaccination status, at T2, we prompted those who selected PAPM stage 6  with a brief informative statement about the Canadian HPV vaccine policy  and then asked the PAPM stage item a second time to ensure that their PAPM stage was as accurate as possible.unaware, after having previously been aware that the HPV vaccine could be administered to males. The second issue was the impossibility of someone moving from reporting that their son had been vaccinated (Stage 6) at T1, to then reporting any other stage at T2 (i.e. implying that their son is no longer vaccinated). In total, using the aforementioned three methods, 92 participants were removed from the final sample due to likely inaccurate or implausible vaccination stage , was 66.0% at T1 and 80.4% at T2. The sample’s socio-demographic characteristics are presented in Table The final cohort consisted of 3,117 participants at T1 and 1,427 at T2, representing a 45% attrition rate , language , gender, education, marital status, employment status, income (except those earning between $40 000 and $59 999 and those earning between $60 000 and $79 999), nationality, ethnicity and religion (see Table p > 0.05). Two or three doses were reportedly received by 53% of sons at T1 and 44% at T2 .The number and percentage of parents across the six PAPM stages is presented in Table While there was a free school-based program in place for boys in Grade 6 in PEI, our results still show that 19 parents from PEI were unaware, unengaged or undecided. At T2, there was a program in place for boys in Grade 5 in Alberta, and our results indicate that 85 parents were unaware, unengaged or undecided from these two provinces. Moreover, at T1, only 1 parent from the 34 (2.9%) who reported their son was vaccinated were from provinces offering free HPV vaccination for boys (PEI) and at T2, 11 from the 39 (28.2%) were parents of vaccinated sons who were from provinces that were vaccinating boys against HPV as part of the provincial immunization schedule (PEI and Alberta).We validated and extended Waller et al.’s existing knowledge scales and create a 25-item HPV general knowledge scale and the 11-item HPV vaccine knowledge scale, which were found to be psychometrically robust .p < 0.01). The mean scores for HPV vaccination knowledge were 5.22 (from 11 possible points) at T1 and 6.3 at T2 .The mean scores for HPV knowledge were 11.67 (from 25 possible points) at T1 and 14.02 at T2  and the relationship between knowledge and PAPM stages are presented elsewhere .We developed and validated a comprehensive, psychometrically-sound HPV vaccination attitudes and belief scale (HABS), which contains 46 items and 9 factors: benefits, threat, influence, harms, risk, affordability, communication, accessibility and general attitudes .Most parents (94% at T1 and 88% at T2) never spoke with a doctor /HCP about the HPV vaccine for their son . At T1, 55.8% of those parents who vaccinated their son had spoken with a HCP about the HPV vaccine. More than half the sample (54%) at both T1 and T2 prefer to receive their information from an HCP, which was by far the most preferred source of information, followed by public health brochures, pamphlets, flyers or posters which was reported by 18% of parents at T1 and T2. Parents reported that the sources from which they actually received information about the HPV vaccine  did not correspond with their most preferred information source  who did speak to their doctors/HCP, 59% of them were recommended to get the HPV vaccine for their son at T1 and 69% at T2 , followed by mothers alone  and fathers alone .At both time points, parents indicated that their son’s healthcare decisions are typically a joint decision made by both parents . Most parents (93% at both T1 and T2) stated that their sons have received all childhood vaccines. Interestingly, at T1 and T2 respectively, 25.5% and 21.2% of parents who decided not to vaccinate their son against HPV stated their son did not receive all recommended childhood vaccines; the proportions were significantly higher than parents belonging to any of the other 5 PAPM stages at both time-points (p < 0.05).More than half of parents (61% at T1 and 59% at T2) mentioned that their son underwent a routine checkup with a healthcare provider in the previous year  at T2 (21%) compared to T1 (15%) see Fig. . Some pan = 106) moved towards decided to act or vaccination at T2. 130 participants (9.1%) moved from unaware, unengaged, undecided or decided to act at T1 to decided not to act at T2  participants who remained in the same stages of vaccination adoption  from T1 to T2; this includes 3 participants who indicated at T1 that their sons were vaccinated. A higher number, 705 49.4%) progressed from T1 to T2 towards advanced PAPM stages that are closer to action i.e., vaccination; 53 participants (3.7%) regressed ; only 36 parents (2.5%) advanced to having their sons vaccinated at T2. Of the 1238 participants who initially identified as being unaware, unengaged or undecided at T1 and who completed the T2 questionnaire, 27 progressed to vaccinated at T2. Of the 80 participants who had decided to act at T1 and who completed the T2 questionnaire, only 9 participants (11%) progressed to being vaccinated at T2. Not a single participant in stage 4 in T1  and T2 .To our knowledge, this is the first HPV vaccination specific survey in a pan-Canadian representative sample of parents of boys after the first HPV vaccine (Gardasil®) was licensed in Canada for males in September 2010 . Other vn = 34 and T1 and n = 39 at T2) who were vaccinated, and the majority was not even from provinces that offered free-school based HPV vaccination programs. Having two provinces that had introduced male HPV vaccination programs did not appear to skew our ‘snapshot’ of parental HPV vaccine decision. We were also able to establish a reliable estimate of HPV vaccine uptake in Canada. Currently (as of September 2016), there are six Canadian provinces with HPV vaccination programs for males. The six Canadian provinces join only a handful of other countries/regions e.g., Australia, Austria, Israel, Barbados, Lichtenstein, New Zealand that have implemented or are set to implement publicly funded HPV vaccination programs for boys [Similarly, the lack of programs for boys, and in turn the cost of vaccinations as well the lack of information  likely explains why at both time-points most parents (87% at T1 and 73% at T2) were in the first three stages of adoption . Furthermore, post-hoc, we examined the few sons  or simply by virtue of completing the questionnaire at T1. Furthermore, voluntary initiation of parents e.g. to acquire information via the internet or to speak to their HCP was not found at T2. Of those parents who had decided to vaccinate their son at T1 i.e., had intentions and who completed the T2 questionnaire, very few parents followed through in vaccinating their sons even when they were in the later stages of decision-making. This finding supports a growing body of research showing that there are important gaps between intending to act and carrying out intentions . Therefoall vaccines and not uniquely against the HPV vaccine, and perhaps more akin to what are known as “anti-vaxxers” [Of interest, the most immobile group were those who had decided not to vaccinate, with no parent in this stage (of 106) moving toward intentions or vaccination at T2. Our results complement previous research suggesting that a proportion of these parents may likely be hesitant towards vaxxers” , 72.For the entire sample, HPV knowledge and HPV vaccine knowledge remained poor at both time-points. The relationship between parent’s knowledge and vaccine acceptance/intentions is mixed and equivocal –77. Low n =36), 80% of parents who advanced towards actual vaccination from T1 to T2 received a recommendation from their HCP. An HCP recommendation has almost consistently been shown to be associated with increased parental HPV vaccine acceptability [Our results also indicated that the vast majority of Canadian parents have not received a recommendation from their HCP about the HPV vaccine for their sons despite their HCP being the primary source they prefer and want to receive information from. Moreover, while the sample size is small , data collection method (online survey to acquire a pan-Canadian sample) and data cleaning techniques. The online survey approach allowed us to: 1) use computer-adaptive testing, 2) avoid missing data, and 3) collect data in a time efficient way. Furthermore, by developing a strong data-cleaning algorithm, we increased the reliability of our final data. Moreover, the authors engaged in extensive psychometric testing , 68 to eself-report of vaccination as opposed to actual  has been reported in the vaccine literature [Our study is limited in several ways. Compared to data collected from Statistics Canada household survey sample of parents with 9-16-year-old, there were differences in the structure of our sample. The effect size was mostly small to medium with no effect size exceeding 0.6. In our opinion, the small to medium differences allow us to generalize our results to the Canadian context. Our suggestion for future studies would be to impose quotas based on the repartition of respondents consistently with national representative available data in order to further reduce sample differences. Additionally, our sample consisted of more mothers 65%) than fathers (35%). Importantly, our response rate of males is higher than in other studies reporting HPV vaccine related attitudes where the average proportion of mothers was 82.3% . Therefo% than faOur results illustrate the exceptionally low uptake of the HPV vaccine in Canadian boys in the absence of a funded immunization program. Parents are critical to a successful HPV vaccination program in children. Directing our attention to males as much as females is important because males play a role in transmission and are vulnerable to HPV-associated diseases. This data can help direct efforts towards helping Canadians become aware that males are recommended to get the HPV vaccine and be engaged in the decision to vaccinate their sons.Moreover, intentions to vaccinate one’s son or planning to speak to one’s HCP did not translate into action for most parents over the 9-month follow-up. These results have implications for implementation of strategies . Lastly, the use of staged-based health behavior model, i.e., the PAPM, allowed for more precision as to where parents stood along the HPV vaccine decision-making trajectory. Forthcoming analyses to better understand the psychosocial determinants that influence each specific stage will allow us to target the unique gaps and barriers of each PAPM stage.


Human papillomavirus vaccination began using a 3-dose schedule. Compared with the 3-dose schedule in women, the 2-dose schedules are effective options in young girls as of 36 months after first dose. Two-dose schedules could improve compliance and vaccination coverage. We previously reported the noninferiority 1 month after the last dose of 2-dose human papillomavirus 16/18 AS04-adjuvanted (AS04-HPV-16/18) vaccine schedules at months 0 and 6  and months 0 and 12  in girls aged 9–14 years compared with a 3-dose schedule at months 0, 1, and 6  in women aged 15–25 years. Here, we report the results at study end (month 36 [M36]).Girls were randomized 1:1 and received 2 vaccine doses either 6 months  or 12 months apart ; women received 3 doses at months 0, 1, and 6 . Endpoints included noninferiority of HPV-16/18 antibodies for 2D_M0,6 versus 3D_M0,1,6; 2D_M0,12 versus 3D_M0,1,6; and 2D_M0,12 versus 2D_M0,6; and assessment of neutralizing antibodies, T cells, B cells, and safety.At M36, the 2D_M0,6 and 2D_M0,12 schedules remained noninferior to the 3D_M0,1,6 schedule in terms of seroconversion rates and 3D/2D geometric mean titers for anti-HPV-16 and anti-HPV-18. All schedules elicited sustained immune responses up to M36.Both 2-dose schedules in young girls remained noninferior to the 3-dose schedule in women up to study conclusion at M36. The AS04-HPV-16/18 vaccine administered as a 2-dose schedule was immunogenic and well tolerated in young girls. Cervical cancer is one of the most common cancers among women worldwide. Approximately 528000 new cervical cancer cases and 266000 deaths occurred in 2012 worldwide . UniversThe initially licensed schedule for the AS04-HPV-16/18 vaccine is comprised of 3 doses administered at months 0, 1, and 6 . However, high vaccine coverage and compliance rates can be difficult to achieve with the 3-dose regimen. The high immune response to the vaccine observed in the younger population led to the investigation of a 2-dose schedule .The current phase III confirmatory study evaluated the immunogenicity and safety of the AS04-HPV-16/18 vaccine administered as 2 alternative 2-dose schedules: a 2-dose schedule at months 0 and 6  or a 2-dose schedule at months 0 and 12  in girls aged 9–14 years compared with the standard 3D_M0,1,6 schedule in women aged 15–25 years. We previously reported that both 2-dose schedules were immunologically noninferior to the standard 3D_M0,1,6 schedule up to 13 months after the first dose.[This study was a phase IIIb, multicenter, open-label, randomized trial  conducted in 5 countries  between 2011 and 2014 . HealthyThe primary objective to demonstrate the noninferiority of the 2D_M0,6 schedule as compared with the 3D_M0,1,6 schedule at month 7 was met and described previously . Secondary objectives included evaluation of the noninferiority of the reduced schedules as compared with the 3D_M0,1,6 schedule until study conclusion at month 36 (M36), assessment of anti–HPV-16/18 neutralizing antibodies (nAbs), HPV-16/18–specific T-cell and memory B-cell responses, and safety.The study protocol, all amendments, and informed consent were reviewed and approved by an independent ethics committee or institutional review board. The study was designed and conducted according to the principles from the Declaration of Helsinki, Good Clinical Practice guidelines and all other applicable regulatory requirements. Written informed consent was obtained from every participant and/or the parent/legally authorized representative.50; serum dilution giving a 50% reduction of the signal compared with a control without serum). CD4+ and CD8+ T cells specific to HPV-16/18/31/45 were evaluated by intracellular cytokine staining. B-cell responses to HPV-16/18/31/45 were assessed by B-cell enzyme-linked immunosorbent spot assay.Anti–HPV-16/18 antibodies were assessed in all participants by enzyme-linked immunosorbent assay (ELISA), with the assay cutoff of 8 ELISA units (EU)/mL for anti–HPV-16 and 7 EU/mL for anti–HPV-18 up to month 12. The assay cutoff was revised from month 18 onward to increase precision ; hence 1The occurrence of serious adverse events (SAEs); the occurrence of SAEs related to the investigational product, to study participation, to GSK concomitant products or any fatal SAE; the occurrence of medically significant conditions; and the occurrence of pregnancy and pregnancy outcomes were recorded throughout the study period in all groups.The primary analyses of immunogenicity were based on the M36 according-to-protocol (ATP) cohort for immunogenicity (ATP-I); secondary immunogenicity analyses based on the M36 total vaccinated cohort (TVC) were performed to complement the ATP analyses. Safety analyses were based on the TVC.The ATP-I at M36 included all participants who met all of the eligibility criteria, complied with the study procedures, and for whom data concerning immunogenicity endpoint measures were available. The TVC at M36 included all participants who received at least 1 dose of the study vaccine and for whom data were available at the follow-up visit. Noninferiority and descriptive immunogenicity analyses were based on the initially seronegative participants in the ATP-I cohort.Seroconversion was defined as the appearance of antibodies  in the serum of subjects seronegative before vaccination. Seropositivity was defined as an antibody titer greater than or equal to the cutoff value. The geometric mean titer (GMT) calculations were performed by taking the antilog of the mean of the log titer transformations. Antibody titers below the cutoff of the assay were given an arbitrary value of half the cutoff for the purpose of GMT calculation. Seroconversion and seropositivity rates for each antigen and GMTs were calculated with exact 95% confidence intervals (CIs) before and after vaccination.+ T cells producing cytokines and memory B cells were summarized.The frequencies of HPV-16/18/31/45–specific CD4To assess the noninferiority, the following between-group comparisons were performed. For noninferiority in terms of seroconversion rates, for each HPV antigen, the upper limit (UL) of the 2-sided standardized asymptotic 95% confidence interval of the difference between the percentages of seroconverted subjects in the 3-dose schedule and the 2-dose schedule (or between the two 2-dose schedules) was computed. If noninferiority in terms of seroconversion rates was reached , the 2-sided 95% confidence intervals of GMT ratios were computed using an analysis of variance (ANOVA) model on the log10 transformation of the titers at each timepoint. Noninferiority in terms of GMTs was demonstrated if the UL of 95% confidence interval for the GMT ratio for both groups was <2. The ANOVA model included the vaccine group as fixed effect.Noninferiority was assessed sequentially first for the 2D_M0,6 versus 3D_M0,1,6, and then for 2D_M0,12 versus 3D_M0,1,6 and 2D_M0,12 versus 2D_M0,6. Noninferiority was tested at all timepoints, and if not reached, analysis at the subsequent timepoint was not performed.The sample size was calculated to provide sufficient power to compare the 2D_M0,6 group with the 3D_M0,1,6 group up to the study end (M36). A total of 1428 subjects allowed for the detection of a 5% difference between the 2D_M0,6 and the 3D_M0,1,6 groups for seroconversion rates and a 2-fold difference for GMTs with 91% power at study conclusion (M36).A total of 1447 participants were included in the study; 1362 of 1447 (94.1%) completed the M36 visit. A total of 1285 of 1362 (88.8%) participants were included in the ATP-I cohort at M36 . The firDue to the temporary unavailability of the allocated vaccine for the 2D_M0,12 group at some study sites, the randomization system allocated girls to the 2D_M0,6 group at a higher rate. Although this led to an imbalance in terms of the number of participants in both 2-dose groups, no impact on the validity of the study was noted because a sufficient number of girls were randomized to the 2D_M0,12 group to allow evaluation of study objectives . DemograThe primary objective of the study was to demonstrate the immunological noninferiority of the AS04-HPV-16/18 vaccine when administered according to the 2D_M0,6 schedule as compared with the 3D_M0,1,6 vaccination schedule at 1 month after last dose. This objective was previously reported .At M36, in the ATP-I, the 2D_M0,6 schedule remained noninferior to the 3D_M0,1,6 schedule in terms of seroconversion rates and GMT ratios for both antigens . NoninfeAt M36, noninferiority of the 2D_M0,12 compared with the 2D_M0,6 and the 3D_M0,1,6 schedules was demonstrated as well .At M36, in each group, all initially seronegative participants in the ATP-I were seropositive for HPV-16 antibodies, and all but 2  were seropositive for HPV-18 antibodies.After a peak response at month 7, GMTs for anti–HPV-16/18 antibodies gradually declined until month 18, and reached a plateau between month 18 and M36. In initially seronegative participants, at M36, GMTs for anti–HPV-16 and anti–HPV-18 antibodies were 1210.2 EU/mL (95% CI = 1124.8–1302.1) and 562.8 EU/mL (95% CI = 516.4–613.4) in the 2D_M0,6 group; 1559.3 EU/mL (95% CI = 1431.2–1699.0) and 804.0 EU/mL (95% CI = 731.8–883.4) in the 2D_M0,12 group; and 1326.4 EU/mL (95% CI = 1193.9–1473.5) and 552.6 EU/mL (95% CI = 494.1–618.0) in the 3D_M0,1,6 group, respectively .50 (95% CI = 6131.7–9569.7) for anti–HPV-16 nAbs and 2365.5 ED50 (95% CI = 1868.2–2995.2) for anti–HPV-18 nAbs; for the 2D_M0,12 group, GMTs were 9214.3 ED50 (95% CI = 7112.3–11937.5) for anti–HPV-16 nAbs and 4046.4 ED50 (95% CI = 3278.0–4994.8) for anti–HPV-18 nAbs; for the 3D_M0,1,6 group, GMTs were 5035.0 ED50 (95% CI = 3726.9–6802.0) for anti–HPV-16 nAbs and 1881.4 ED50 (95% CI = 1417.7–2496.7) for anti–HPV-18 nAbs.At M36, all of the initially seronegative subjects in all 3 groups had seroconverted for both anti–HPV-16 and anti–HPV-18 nAbs when measured by PBNA . For the+ T cells and memory B cells were within similar ranges for all groups , 101.0  and 27.0 , and median frequencies of HPV-45–specific Bcells were 59.0, 56.0, and 68.0 in these groups, respectively.At M36, the frequencies of HPV-16/18–specific CD4l groups  and 5. MSafety results included events that occurred since the study started, except reactogenicity following vaccination and potential immune-mediated diseases, which were previously published . Up to MUntil the last follow-up visit at M36, a total of 374 participants  reported at least 1 medically significant condition. A total of 36 pregnancies occurred during the entire study ; of those, 32 pregnancies resulted in live infants with no apparent congenital anomaly. One ectopic pregnancy, 2 elective terminations, and 1 stillbirth were recorded in the 3D_M0,1,6 group; none of these were considered by the investigator to be related to the vaccination.We previously demonstrated that the AS04-HPV-16/18 vaccine administered as a 2-dose schedule (either 6 months or 12 months apart) to girls aged 9–14 years elicited an immune response that was noninferior to the one elicited by 3 doses in women aged 15–25 years up to 6 months after the first dose., 19–23. Due to ethical and practical reasons, efficacy studies on HPV vaccination cannot be conducted in young girls; hence this study was not designed to assess efficacy endpoints such as high-grade cervical intraepithelial neoplasia (CIN) or persistent HPV infection. In this study, the AS04-HPV-16/18 vaccine immunogenicity profiles were noninferior for the 2-dose schedules in girls compared with the 3-dose schedule in women aged 15–25 years, the age group in which the vaccine was shown to be efficacious against HPV-16/18–associated infections and high-grade cervical intraepithelial neoplasia in previous efficacy trials . ProtectThe vaccine safety profile was similar between the 3 groups, SAEs were rarely reported (5.1%), and the overall safety profile was consistent with results of the previous pooled analyses of HPV-16/18 AS04–adjuvanted vaccine clinical trials , 33. OneA potential limitation of this study is the fact that no efficacy endpoints were assessed due to the age of participants (young girls). In addition, this study did not evaluate the 2-dose schedule in females aged >15 years.In conclusion, the immunogenicity of the HPV-16/18 AS04–adjuvanted vaccine administered according to the 2-dose schedules at 6- or 12-month intervals to girls aged 9–14 years remained noninferior to the standard 3-dose schedule administered to young women aged 15–25 years at 36 months after the first administered dose. These results support the use of the 2-dose schedules for HPV vaccination in adolescent girls. Availability of both of these 2-dose schedules makes it more convenient for the subject, the prescriber, and mass vaccination campaigns.The Journal of Infectious Diseases online. Consisting of data provided by the authors to benefit the reader, the posted materials are not copyedited and are the sole responsibility of the authors, so questions or comments should be addressed to the corresponding author.Supplementary materials are available at Huang_HPV2D-schedules_Supplemental-materialClick here for additional data file.


HPV‐based instead of cytology‐based screening may be a more suitable strategy in China. Here, we assessed the effectiveness of HPV testing  and HPV‐based programs to detect high‐grade cervical intraepithelial neoplasia (CIN) or cancer compared with cytology  and cytology‐based programs through a cross‐sectional study in 11,064 Chinese women aged 21–65 years who were enrolled from Longyou County in Zhejiang Province, China. The rates of HPV positivity and cytology abnormality were 9.8% and 6.1%, respectively. The HPV positivity rate had two age peaks, 21–24 (15.4%) and 60–65 (14.4%) years. According to adjusted data, HPV testing demonstrated significantly higher sensitivity and negative predictive value (NPV) than cytology for detecting CIN2 or worse , and there was an acceptable specificity (91.3%) and positive predictive value . Furthermore, primary HPV testing with type 16/18 genotyping showed the highest sensitivity (78.6%) and NPV (99.7%) among four screening strategies, and there was similar specificity (96.8%) and PPV (23.9%) compared with co‐testing screening to detect CIN2+, while there were fewer colposcopies (4.2) and tests (106.3) performed than with co‐testing and primary cytology screening to detect a case of high‐grade CIN. The differences in effectiveness were approximately similar when CIN3+ was the identifying target. Our findings suggest that primary HPV testing with type 16/18 genotyping has a higher sensitivity and NPV, possesses optimal cost/effectiveness in the first round of screening and is a feasible strategy of cervical cancer screening for Chinese women.Cytology‐based cervical cancer screening is restricted because of a lack of cytologists. Thus,  Cytology‐based cervical cancer screening has greatly reduced the incidence and death of cervical cancer in developed countries. However, its suboptimal sensitivity and negative predictive value have not been overcome, despite the application of liquid‐based cytology techniques and the Bethesda diagnostic classification. The fact that high‐risk human papillomavirus (HPV) infection is a necessary event for cervical cancer development determines the value of HPV testing in cervical cancer screening. Compared with cytology, HPV DNA testing has a higher sensitivity and negative predictive value (NPV), providing more reassurance for women with a negative result. The American Society of Colposcopy and Cervical Pathology (ASCCP) initially recommended HPV testing as a triage for cytology diagnosed as atypical squamous cells of unknown significance (ASC‐US) in 2001 ® HPV testing using the real‐time fluorescent PCR technique can simultaneously detect HPV 16/18 and another 12 high‐risk HPV genotypes. With HPV 16/18 genotyping, the strategy of primary HPV screening with type 16/18 genotyping triage further reduces the necessary cytology tests and dependence on cytologists, which facilitates cervical cancer screening in developing countries. However, there are still no up‐to‐date data on the suitability of HPV testing with type 16/18 genotyping in Chinese women. Therefore, we assessed the effectiveness of HPV testing with type 16/18 genotyping and HPV‐based program to detect high‐grade cervical intraepithelial neoplasia (CIN) or cancer in 11,064 Chinese women through a population‐based cross‐sectional study. The aim of the study is to provide evidence of the suitability of an HPV‐based screening strategy in China.As the largest developing country, China possesses the most cervical cancer patients with 98,900 new cases and 30,500 death cases in 2015 This study is a prospective population‐based cancer screening trial. We chose Longyou County in Zhejiang Province, China as a candidate screening locale. A total of 332 administrative villages and communities were randomly selected, and large‐scale cervical cancer screening was not performed in the past three years in these communities. All women were recruited by local community staff and doctors in the Longyou County Maternal and Child Health‐Care Center according to household registry. Approximately 20% of women did not respond to the screening invitation because of outgoing for work or study, and other reasons. A total of 11,356 women aged 21–65 years participated in this cervical cancer screening program. All participants had a sexual history.Those women were excluded: pregnancy or within 6 weeks or less of the post‐partum period; previous total hysterectomy; a history of CIN or worse, vulvar intraepithelial neoplasia or worse, or vaginal intraepithelial neoplasia or worse; a history of other malignancies; a history of cervical cancer screening or physical cervical therapy in the past three years; serious autoimmune disease or uremia; and vaccinated or planned to vaccinate against HPV infection in the near future.The study was in line with the 2013 Declaration of Helsinki and was approved by the Ethics Committee of Women's Hospital, Zhejiang University School of Medicine.® 4800 Test, Roche Molecular Systems, Pleasanton, CA), respectively. All samples were collected during April to May of 2015.Each woman who met the inclusion criteria without meeting the exclusion criteria signed the informed consent form, provided a brief medical history, and underwent speculum examination by a gynecologist. According to instruction, samples of cervical exfoliate cells were collected using a cytology brush  and stored in the tubes with preservation solution for the Thinprep cytology test  and HPV DNA test , and HPV non‐16/18+ (result negative for genotype 16/18 and positive for 1 or more of 12 other high‐risk types). Cytology slides were read by two pathologists of our hospital, and 5674 cases were read with computer‐aided reading  prior to examination by cytologists. Cytology results were reported according to the Bethesda 2014 classification in situ), and carcinoma (squamous cell carcinoma or adenocarcinoma). Due to ethical considerations, most of the women with both negative HPV and cytology results were not referred to colposcopy and biopsy/ECC but were all regarded as LSIL or less. All women with pathologic abnormalities were processed according to the newest ASCCP guidelines All women with positive HPV testing or abnormal cytology (ASC‐US or worse) were referred to colposcopy; meanwhile, 4.5% of women with both negative tests were randomly selected and referred to colposcopy. Colposcopy was performed by colposcope specialists of our hospital. A woman underwent further cervical biopsy and/or endocervical curettage (ECC) if her colposcopy diagnosis was a high‐grade lesion or a non‐high‐grade lesion with one of the following conditions: cytology LSIL or worse; cytology ASC‐US and HPV+; HPV 16/18+; AGC; and unsatisfactory colposcopy. Tissues were paraffin embedded and slides were routinely HE stained. Two pathologists at our hospital separately made the diagnosis. If the diagnoses were concordant, they were reported as the pathologic diagnosis; otherwise, a panel of pathologists was consulted to reach a consensus diagnosis. The pathologic diagnosis standard was the 2014 WHO Classification of Tumors of the Female Genital Tract The study initially assessed the effectiveness of HPV testing, with cytology testing as a control, for identifying high‐grade CIN and then compared the effectiveness of four strategies that are currently used for cervical cancer screening. Strategy 1 (Co‐testing) primarily screens women with both cytology and HPV testing, and then refers those with cytology ASC‐US/HPV+ or LSIL or worse to colposcopy. Strategy 2 (Primary cytology with triage by HPV testing) primarily screens women with cytology alone and then refers those with cytology LSIL or worse to colposcopy, triages those with ASC‐US by reflex HPV testing, and refers HPV+ women to colposcopy. Strategy 3 (Primary HPV testing with triage by cytology) primarily screens women with HPV testing alone, triages HPV+ women with cytology, and refers those with cytology ASC‐US or worse to colposcopy. Strategy 4 (Primary HPV testing with type 16/18 genotyping) primarily screens women with HPV testing plus type 16/18 genotyping, refers HPV 16/18+ women to colposcopy, triages HPV non‐16/18+ women with cytology and refers those with cytology ASC‐US or worse to colposcopy. A detailed flow chart is shown in Figure P value less than 0.05 (two‐sided) was considered statistically significant.Abnormal rates of cytology and HPV testing were calculated based on all participants with cytology and HPV testing results. The effectiveness of detecting high‐grade CIN was assessed using the sensitivity, specificity, positive predictive value (PPV), NPV, positive likelihood ratio (PLR), and negative likelihood ratio (NLR). Both raw and adjusted data were analyzed. When adjusted data were analyzed, the numbers of participants with pathological examination diagnosed as CIN2 or worse were used as a positive base to calculate the likely number of high‐grade CIN cases that would have been found if all participants were referred to colposcopy for different cytology and HPV testing results. For screening strategies, the sensitivity, specificity, PPV, and NPV as well as the numbers of colposcopy cases and of screening tests needed to detect one case of high‐grade CIN were calculated. All data were analyzed by SPSS 19.0 and medcalc 15.6 software. A Of 11,356 participants, 247 women met the exclusion criteria and 45 had invalid HPV results/invalid or unsatisfactory cytology, and they were excluded. As a result, 11,064 women were included in the analysis.The total positivity rate of HPV testing was 9.8%. The positivity rates of HPV 16, HPV 18 and other high‐grade genotypes were 1.8%, 0.6% and 7.4%, respectively. The HPV positivity rate had two age peaks, 21–24 (15.4%) and 60–65 (14.4%) years, as shown in Figure P = 0.000) and NPV , while it had a significantly lower specificity , for detecting CIN2+. After verification of bias correction, the sensitivities of HPV testing and cytology were 90.0% and 66.7%, but the specificities were 91.3% and 97.2%, respectively, and the difference was significant. The AUC of HPV testing was larger than that of cytology (0.91 vs. 0.82) for detecting CIN2+. With CIN3+ as the identifying target, HPV testing and cytology demonstrated similar results.The effectiveness of cytology and HPV testing to identify high‐grade CIN is shown in Table All subjects were divided into three age‐groups: 21–24 years, 25–49 years, and 50–65 years. We compared the effectiveness of HPV testing for detecting high‐grade CIN in different age‐groups. The 21‐ to 24‐year group was not included in the statistics because there were too few samples. With CIN2+ as the identifying target, after verification bias correction, the sensitivity of HPV testing in the 50‐ to 65‐year group was higher than that in the 25‐ to 49‐year group (97.6% vs. 87.2%), but the effect was not significant, and the NPV was similar (99.97% vs. 99.8%). However, the specificity in the 50‐ to 65‐year group was significantly lower than that in the 25‐ to 49‐year group (89.3% vs. 92.4%), and the PPV in the 50‐ to 65‐year group was significantly lower than that in the 25‐ to 49‐year group (9.0% vs. 15.1%). The differences in effectiveness between the 25‐ to 49‐ and 50‐ to 65‐year groups were similar when CIN3+ was the identifying target, as shown in Table As shown in Table This was the first large‐scale cross‐sectional study on the application of HPV testing with type 16/18 genotyping for cervical cancer screening in Chinese women. Using pathologic diagnosis of colposcopic biopsy as a standard, we assessed the effectiveness of HPV testing, with cytology as a control, to identify high‐grade CIN. Considering that cytological diagnosis significantly relies on cytologists, we employed at least two cytologists to blindly read the same slide to ensure the accuracy of cytological diagnosis. Our results revealed that Youden's index (YI) of HPV detecting CIN2+ and CIN3+ was higher than that of cytology after bias correction  with sensitivities of 90.0% and 91.3%, respectively, which were significantly higher than that of cytology (66.7% and 73.9%), and specificities of 91.3% and 90.9%, respectively, which were slightly lower, yet still acceptable, than cytology (97.2% and 97.0%). Our results are consistent with previous studies on HPV testing in areas other than China The HPV prevalence and its distribution in different ages may affect the aptness of HPV testing in cervical cancer screening. HPV testing is not yet recommended for young women less than 25 years old around the world due to the high HPV prevalence in this age period. In our study, the positivity rate of 14 genotypes of high‐risk HPVs was 9.8% in 11,064 women, which was consistent with 10.4% of the worldwide prevalence HPV or cytology testing alone has insufficient sensitivity or specificity, but the combination of two techniques can strengthen the detection advantage and overcome each test's individual weaknesses, elevating the accuracy of screening Since our study is cross‐sectional, our conclusions are preliminary, and there may be bias. For instance, Strategy 4 sends HPV 16/18 cases with NILM cytology directly to colposcopy, whereas these women in Strategy 3 will be sent to colposcopy one year later, and some of them will not need colposcopy in the second round of screening because of transient HPV16/18 infection. Therefore, the sensitivity of Strategy 3 will be considerably increased, while the PPV of Strategy 4 will be considerably decreased by follow‐up performed on HPV positive/NILM women. It has been observed that direct referral of HPV 16/18 positive women to colposcopy is possibly an excessive treatment.Considering our results together, HPV testing has optimal effectiveness for detecting high‐grade CIN and is suitable for cervical cancer screening in Chinese women who are older than 25 years of age. The strategy of primary HPV testing with type 16/18 genotyping shows the highest sensitivity and NPV with similar specificity and PPV among different screening strategies, and it requires fewer performed cytology tests and colposcopies to detect one case of high‐grade CIN, suggesting that this strategy possesses optimal cost/effectiveness in the first round of screening and is a feasible strategy of cervical cancer screening for Chinese women.None declared.


This commentary explores the distribution of human papilloma virus (HPV) and HPV-related diseases, and factors affecting attitudes towards HPV, HPV-related diseases, and HPV vaccination in the Latin American Andean region. Lack of knowledge of HPV, known negative attitudes or incorrect assumptions about HPV, HPV-related diseases, and HPV vaccination provide a basis upon which to develop targeted HPV awareness and preventive health media campaigns. For maximal effect, media campaigns should use the internet, radio, and television to address health care providers, parents, and students. Additional programming can be developed for clinics to use in-house with their clients. Ministries of Education, Finance, and Health all have roles to play to increase national HPV, HPV-related diseases, and HPV vaccination awareness. Bolivia, Chile, Colombia, Ecuador, and Peru form the Latin American Andean region. In the Andean region, as shown in HPV-16 82%) and -18 (18%) occur in 18.9% of squamous cell head and neck cancer (HNSCC) in Colombia . Overall2% and -1HPV-6 and -11 are causative of external genital warts (EGW) and recurrent respiratory papillomatosis (RRP) ,13. EGW CC mortality is correlated with human papilloma virus (HPV) prevalence and socioeconomic indicators . DespiteThe PubMed database was searched in January 2016 and June 2017, using the Andean nations Bolivia, Chile, Colombia South America, Ecuador, or Peru, followed by the terms “HPV”, “HPV vaccine”, “HPV vaccination”, “HPV attitudes”, HPV vaccine attitudes”, and “HPV vaccination attitudes”, selecting for human subjects, yielding 276 articles, as shown in The global background HPV-16 and -18 prevalence is 32% . CentralAlmost one-sixth of Bolivian women’s deaths are due to CC . La Paz,Mean age of CC occurrence in Colombia is 51.5 years . Irrespep < 0.001 [Coitarche is a known co-factor for HPV infection . In Peru < 0.001 . Further < 0.001 .Increased number of sexual partners is another known co-factor for HPV infection ,13,23,30Chilean adolescents are aware that multiple sexual partners are a CC risk factor (70.8%) and an HPV infection risk factor (78.3%). While 68.2% are aware that unprotected sex facilitates HPV transmission, only 31.1% used condoms ,18.Prior to school-based HPV vaccination in Colombia in 2012, only 44% of Colombian women aged 18- to 69-years-old were aware of HPV, and only 25% of these women were aware of HPV vaccination . Knowledp = 0.002) [p = 0.006) [Greater HPV and HPV vaccine awareness are found in Colombians who are university educated , married , or belong to a health maintenance organization (HMO)  . Middle = 0.002) . The eff= 0.006) . Colombi= 0.006) .Colombian women give illness (83%) and CC prevention (28.9%) as reasons why they received HPV vaccination . HPV vacp < 0.001; 90%, 62%, p < 0.01) [EGW more negatively affect sexuality and self-esteem of Colombian women than men  . Colombi < 0.01) . Colombi < 0.01) .Columbia has decentralized health care, such that local districts or municipalities independently decide which vaccinations to provide . There aWhile 58% of American Hispanic women are aware that CC is an HPV-attributable disease, only 38% of urban Peruvian women are so aware . Of notePeruvian mothers are the primary vaccination decision maker in Peruvian households, with fathers having input ,37. DespBefore an HPV educational intervention 50% of participating CerviCusco clients were unaware that CC is preventable, and only 7% thought that the HPV vaccine effectively prevents HPV infection . HoweverPeruvians have expressed concern about interactions between vaccinators and those receiving the vaccine, vaccinators’ training, needle reuse, post-expiration vaccine administration, and overall vaccine adverse events and safety . Adversep = 0.3) [As Peruvian FSW may be brothel-based and use a given health clinic, promoting an HPV vaccination program for new Peruvian FSW was suggested . Only 9.p = 0.3) . Most Pep = 0.3) ,19. In ap = 0.3) .p > 0.000, 95% CI 1.71–4.02), parity , and recognition that HPV is causative of CC; between having health insurance , being interviewed in a health center  and awareness that the HPV vaccine prevents CC [Among low-income urban-dwelling Peruvian women there are statistically significant associations between having at least a secondary education  is 77.1%, of which 47.3% are high risk HPV . PeruviaPeruvian policy-makers have contradictory opinions regarding the importance of CC to the public and in terms of health care system priorities . It is op = 0.04) [Increased knowledge of HPV, HPV-attributable diseases, and prophylaxis thereof requires education. While FSW in Peru can receive sexual health education through the special clinic from which health cards are received, MSM and TW do not access the public system in the same manner as FSW . This ma = 0.04) . Parents = 0.04) . Governm = 0.04) . Similar = 0.04) . Educati = 0.04) .Disease severity and prophylactic vaccine availability have been linked to increased vaccine acceptance . IncreasEducation should include safe sex practices and the need to reduce the lifetime number of sexual partners: Only 31.1% of sampled Chilean adolescents used condoms; 77% of HIV-negative Peruvian MSM and TW have condom-less anal or oral sex; In Colombia, age-specific HPV-16, -18, -31, and -58 prevalence is associated with more lifetime sexual partners; multiple sexual partners is a CC risk factor ,32,40. EQualitative research regarding attitudes to and knowledge of HPV, HPV-related diseases, and HPV vaccines appears to be lacking for Bolivia and Ecuador. Much more work and data are needed in the English language literature for Chile than for Colombia and Peru. New research studies will be most effective when planned in the context of the extant literature to allow a comparison with the literature. This research is needed to help formulate effective HPV vaccination programs in Bolivia and Ecuador, and to address any HPV vaccination issues that may be specific to the Andean region. Colombian data show that most knowledge of HPV and HPV vaccination derives from media campaigns, followed by educational establishments . Therefo


Endocavitary ultrasound probes are part of a commonly used procedure in the clinical arena. The cavities examined, vaginal canal and cervix, anal canal, and oral cavity are all areas commonly infected with the human papillomavirus (HPV), thus making them susceptible to contamination by HPV. It has been demonstrated that these probes can remain contaminated with high-risk HPV even when approved disinfection protocols have been performed. we have previously shown that HPV is resistant to some high-level disinfectant (HLD). In our present study we analyzed efficacy of using high-level ultra-violet C (UVC) radiation against HPV16 and HPV18 using a hard-surface carrier test. Stocks of infectious authentic HPV16 and HPV18 virions were dried onto carriers with a 5% (v/v) protein soil or 4ppm hard water. Efficacy testing were performed with the automated device, Antigermix S1 device (UVC radiation at 253.7nm) and 0.55% OPA in quadruplicate with matched input, neutralization, and cytotoxicity controls. Hypochlorite was included as a positive control for viral deactivation. Infectivity was determined by the abundance (qRT-PCR) of the spliced E1^E4 transcript in infected recipient cells. The automated Antigermix S1 device showed excellent efficacy against HPV16 and HPV18 whereas OPA showed minimal efficacy. While HPV is highly resistant to OPA, high-level UVC radiation offers an effective disinfection practice for ultrasound probes. Our results suggest that healthcare facilities using endocavitary ultrasound probes need to strongly consider disinfection methods that are effective against HPV. Human papillomaviruses (HPV) are responsible for over 5% of human cancers worldwide. Nearly all cases of cervical cancer are the result of HPV infection, as well as a significant number of anogenital and oropharyngeal cancers. While HPV is commonly known to be transmitted by sexual contact, the public is unaware of the risk of HPV infection through non-sexual transmission . Often tThe two pathways, direct host-to-host and non-direct fomite infection pathways, require the ability to survive great environmental pressures, the characteristics of these pressures are often different. The HPV life cycle including the assembly of infectious particles has a strict requirement for differentiating epithelium. HPV particle assembly is an intricate process, which includes the formation of stabilizing disulfide bonds –20. The Hospital-acquired, nosocomial or iatrogenic, infections are well-established routes for many infectious agents including viruses. It has been reported that transvaginal ultrasound probes can remain contaminated with HPV even when proper hospital disinfectant reprocessing procedures are followed –28. Use In this study we used the hard surface carrier test method based on the ASTM E1053-11 standard test method suitable for assessing virucidal activity on non-porous surfaces . This stThe HaCaT cell line was maintained in DMEM supplemented with 10% FBS, 0.025 mg/ml Gentamicin, and 0.11 mg/ml sodium pyruvate. Primary human keratinocytes were isolated from newborn foreskin circumcision as previously described . PrimaryThe use of human foreskin keratinocyte tissues to develop cell lines for these studies was approved by the Institutional Review Board at the Pennsylvania State University College of Medicine and by the Institutional Review Board at Pinnacle Health Hospitals. Discarded tissues were exempt from needing informed patient consent. Informed consent was waived by both Institutional Review Boards. No identifiers were attached to any tissue samples.8 to 104 copies per ml [Viral genomes were released using 10ml of a virus preparation resuspended in a 200ml HIRT DNA extraction buffer , with 2ml 20mg/ml Proteinase K, and 10ml 10% SDS for 2 hr at 37°C. Phenol-chloroform extraction followed by ethanol precipitation and re-suspended in 20ml TE purified the DNA. Viral titers were then determined using a qPCR-based DNA encapsidation assay utilizing a Qiagen Quantitect SYBR Green PCR Kit. Amplification of the viral genome target was performed using previously described HPV E2 open reading frame primers against a standard curve of 10-fold serial dilutions from 10HaCaT cells were seeded at 50,000 cells per well in 24-well plates, 2 days prior to infection. Virus and media were in a total volume of 500ml prior to addition to the cells. A multiplicity of infection (MOI) of 10 was used unless otherwise noted. Virus was incubated with the cells for 48 hr at 37°C and mRNA were harvested using a Qiagen RNAeasy Kit.3 (hard water) was added to the virus suspension and 200ml of this was spread onto a single carrier side with a sterile pipette tip. The inoculated carriers were allowed to dry in a laminar flow cabinet for 30 min or until dry.Carriers were 50-3mm circular discs made of acrylonitrile butadiene styrene, a plastic used in ultrasound transducer construction. Carriers were prepared by soaking in 10% hydrogen peroxide for 15min, neutralization in sterile water containing 200U/ml of catalase for 10min and rinsing in sterile water for 10min before being dried in a sterile petri dish. An organic load (soil) of 5% BSA or 4ppm CaCOThe Antigermix automated disinfection unit was used to test its efficacy to inactivate authentic HPV16 and HPV18. The carriers containing HPV were hung in the Antigermix device. The devise uses a strong exposure to ultra-violet radiation in a 90 sec preprogrammed cycle according to the manufacturer’s instructions. As a negative control for disinfection we included liquid OPA at the manufacturers recommended concentration of 0.55% . As a positive control for disinfection we used hypochlorite at the manufacturers recommended concentration of 0.87% . The use of both controls was based on their previous demonstrated efficacy against HPV16 and HPV18 in suspension and carrier tests , 34. AllCarriers were either disinfected by adding liquid disinfectant or utilizing the automated device. For device disinfection, carriers were transferred onto a rack, which suspended the carriers within the disinfection chamber. A standard cycle using the Antigermix S1 (AS1) device was run in accordance with the manufacturer’s instructions for use. AS1 device disinfects by using Ultraviolet C (UVC) radiation at 253.7nm. The system exposes the target to UVC terminating after the required dose has been delivered on all the surfaces of the probe. A control system adjusts the length of each cycle based on sensor feedback until the required dose is measured. In this way all the surfaces of ultrasound probe receive, at a minimum, the intended germicidal UVC dose during each HLD cycle. For the liquid disinfectants, 2ml of 0.55% OPA or 0.87% hypochlorite was added to the upward facing surface of the carrier so that the liquid formed a droplet covering the entire carrier surface. Carriers were then incubated at room temperature for 12 min (OPA) and 5 min (hypochlorite). Treated viral films were resuspended in 2 ml of cell medium and were collected in a 15ml 100K Amicon filter tube. Two ml of the appropriate neutralizer was added . The sample was filtered and assayed for infectivity as previously described , 34. AllInfection was analyzed using a previously described RT-qPCR-based infectivity assay for E1^E4 transcript levels . The E1^The use of reusable ultrasound probes is a common protocol in medical practice. Ultrasound probes are used routinely for transvaginal, transrectal, and transesophogeal endocavitary examinations. Coincidentally, these three sites are those that are common sites of HPV infection and cancer. In order to reduce the risk potential for transmission of HPV and other infectious agents healthcare facilities strive to use proper high-level disinfection procedures. Recently, studies have shown that conventional protocols and procedures used to clean and disinfect ultrasound probes have been insufficient in removing residual HPV DNA –27. StudCurrent guidelines from Centers for Disease Control (CDC) have established ultrasound probes as devices used for semi-critical applications (contact with mucous membranes or broken skin) necessitating protocols that use high-level disinfection (HLD) procedures . Therefo3) onto carriers made of plastic used in ultrasound transducer construction. We then tested UVC radiation for its efficacy as a disinfectant for HPV16 and HPV18.In this study, we used the stringent hard surface carrier test method in line with Federal Drug Administration (FDA) guidelines for assessing virucidal efficacy of high-level disinfectants , 36. To 10 reduction in infectivity and achieve complete viral inactivation. In addition, controls for cytotoxicity and neutralization are required to show less than a 0.5 log10 reduction, which is clearly demonstrated in our study. In FDA, EPA, and ASTM E1053-11 guidelines state that a hard surface carrier test must be used and show at least a 4 log10 reduction in infectivity  and hard water (4ppm CaCO3) included in the assay. The reduction is comparable to that achieved by hypochlorite (10 (3). The differences seen in these values with the same virus type and between virus types reflect different starting titers. These results indicate that the automated high-level disinfection AS1 UVC device was HPV virucidal according to the standard test method efficacy criteria. No cytotoxicity was observed with any of the assays.The AS1 UVC system managed to achieve complete inactivation of HPV16 with a >4 logchlorite . The comrite Click here for additional data file.


Since 2007, HPV vaccination programs have been implemented in Europe. Significant real-life impact has already been reported in countries where the programs have been successfully implemented. In France, HPV vaccination coverage rate (VCR) is currently one of the lowest in Europe. This represents a missed opportunity for individuals who will not be protected. The study aimed to estimate the consequences of the sub-optimal VCR.A dynamic transmission model was calibrated to the French setting. Outcomes resulting from the vaccination of girls with quadrivalent HPV vaccine according to two theoretical VCR: 17% and 70%, reflecting the range of VCRs in Western Europe, were evaluated.Over 100 years, with the current low VCR, an additional 85,000 cancers, 28,000 deaths and more than 5 million avertable disease events overall would occur compared with a 70% VCR. At steady state, the 17% VCR was estimated to be associated with an additional 1700 cancers, 600 deaths and 66,000 avertable disease events each year, compared with a ‘standard’ EU VCR.The loss of chance associated with sub-optimal VCR is substantial for the French population and could amount to the occurrence of hundreds of avoidable deaths and thousands of disease events annually. •HPV vaccination coverage rate in France is suboptimal.•Loss of chance associated with the sub-optimal VCR is tremendous for the French population.•Communicating on the magnitude of the loss of opportunity of not vaccinating the population is important. In France, screening is mostly opportunistic, with women aged between 25 and 65 years undergoing a Pap test every 3 years  Since 2007, HPV vaccination programs have been implemented in most European countries for the prevention of cervical cancer, targeting girls aged between 9 and 14 years, depending on the local recommendations. Some countries, like France, have also implemented catch-up vaccination for girls aged between 15 and 19. Early and significant real-world impact of HPV vaccination has been reported in countries were the vaccination programs have been successfully implemented Although vaccination coverage rates are >80% in the United Kingdom and Portugal, coverage rates remain sub-optimal in many European countries, including France Many publications have analyzed the determinants of vaccination uptake 22.1A previously published US model, simulating the natural history of HPV-infections and related diseases, caused by genotypes 6, 11, 16, 18, was adapted to France to estimate the public health impact of the quadrivalent HPV vaccine (1)a demographic model that defines the demographic characteristics of the population and describes how persons enter, transition and exit the model;(2)an epidemiologic module that simulates HPV transmission and the occurrence of HPV-related diseases;(3)an economic model that estimates the costs and quality of life associated with the screening, vaccination and management of the diseaseThe model has three connected modules:The epidemiologic module consists of 14 separate and independent models to take into account the different HPV genotypes and diseases. The model accounts for the transmission dynamics of four HPV genotypes: 16, 18, 6, 11, and simulates the occurrence of genital warts; recurrent respiratory papillomatosis; pre-cancerous lesions such as cervical intraepithelial neoplasia (CIN); cervical, vulvar, vaginal, penile, anal, and head/neck cancers related to these HPV genotypes. In the analyses presented here we focused only on the diseases included in the indication of the HPV quadrivalent vaccines, and therefore penile cancers, head and neck cancers and recurrent respiratory papillomatosis were excluded.2.22.2.1Institut National de la statistique et des études économiques, INSEE) The population of France and the annual all-cause mortality rates for the general population were retrieved from the French National Institute of Statistics and Economic Studies  were used to estimate HPV-related cancer mortality. It was necessary to make the following assumptions: vaginal cancer mortality was assumed to be the same as that for vulvar cancer and mortality for anal cancer was assumed to be the same as that for both colon and rectum cancer. The five-year mortality rates were then converted to one-year death probabilities to provide the percentage of individuals with cancer expected to die in one year.Since survival data were only available by age, we estimated the stage-stratified data using UK data from Cancer Research UK 2.2.4The annual cancer screening rates and percentage of females undergoing cervical cancer screening at least every three years was extracted from a report from the French National Authority for Health  2.2.5Two HPV vaccines  are recommended in France. The quadrivalent vaccine occupies the majority of the French HPV vaccine market (around 85%) and as the model is unable to simulate mixed vaccination strategies, it was assumed that all vaccinees had received the quadrivalent vaccine.The assumptions for the prophylactic efficacy of the vaccine were based on clinical trial data 2.2.6According to the model structure, the health outcomes were evaluated on a yearly basis. The assessment was conducted over a 100-year horizon because this was consistent with the time frame under which the system approached a steady state and the majority of the benefits of vaccination would be obtained 2.3The model was calibrated on incidence and mortality rates of HPV-related diseases observed in France. The calibration process involved many iterations to move the model outcomes closer to the targets. The following model outcomes were compared against the calibration target in each iteration: cervical cancer incidence, genital warts incidence, vaginal/vulvar/anal cancer incidence, and mortality rates for cervical/vaginal/vulvar cancer.Most of the incidence data were found in a report developed by the World Health Organisation (WHO) and the Institut Català d'Oncologia (ICO) Information Centre on HPV and Cancer; the mortality data were collected from the French CépiDc  database The target incidences were calculated by multiplying the overall incidence and mortality rates by the proportions of diseases attributable to HPV infection found in the literature  [3], [472.4–Institut de Veille Sanitaire in France in 2015.a cumulative coverage rate of 17% at 16 years old corresponding to the vaccination coverage rate reported by the –a cumulative coverage rate of 70% at 16 years old reflecting a level of protection frequently observed in the rest of Western Europe  [14], [1To quantify the impact of a low vaccination coverage rate (VCR), the health outcomes resulting from the vaccination of girls with quadrivalent HPV vaccine were assessed according to two theoretical vaccination coverage rates:in addition, the two scenarios considered an increasing coverage rate, reaching the target vaccination coverage rate after 15 years.As stated above, it is assumed in the analyses that all vaccinees receive the quadrivalent vaccine.Scenarios with an alternative time horizon (70 years), vaccination coverage rate (60%), and vaccine duration of protection (20 years) were run in sensitivity analyses.33.1The summary of the incidence targets collected from the literature and the model outputs are summarized in 3.2Over 100 years, it was estimated that the 17% VCR observed in France would be associated with around more than 85,000 additional cancers, almost 28,000 additional deaths and more than 5 million diseases events overall compared with a 70% VCR .Table 3IIt was estimated that in the first ten years of the vaccination program, 73,837 additional diseases events including 73,067 genital warts, 346 CIN1, 421 CIN2+ and 3 cervical cancers would be averted with a 70% VCR scenario compared with 17% VCR.The model results showed that both strategies would have a significant impact on the epidemiology of cervical cancer, in particular, and HPV diseases, in general ; Table 43.3According to the scenario, with a duration of vaccine protection of 20 years, the incremental number of events averted over 100 years ranged from more than 2,6 million cases to 5,3 million cases (base case) and the number of deaths averted ranged from more than 17,000 to almost 28,000 (base case) .Table 6I4HPV vaccination is an essential component of HPV-related cancer prevention and control There are several examples of unsuccessful vaccination programs. For example, the polio outbreak in Nigeria after suspicion that the polio vaccine was contaminated with antifertility drugs intended to sterilize young Muslim girls In the present modeling study, we estimated the consequences of sub-optimal HPV vaccination coverage, using the French context as an example. The results showed that if the vaccination coverage rate does not increase in France there could be a dramatic public health impact. Compared with the public health impact of a’standard’ vaccine coverage of 70%, the 17% coverage currently observed in France would be associated with a substantial loss of opportunity if this coverage rated were to remain constant. Over 100 years, this would correspond to more than 85,000 additional cancers, almost 28,000 additional deaths and more than 5 million avertable diseases events overall in the French population. Sensitivity analyses showed that the estimation of the number of events averted is sensitive to the assumptions for parameters whereas the estimation of the number of deaths averted is less sensitive. For example, under the assumption of a duration of vaccine protection of 20-year, the total number of case averted is halved while the total number of deaths averted is decreased by less than 40%. This is mainly explained by the impact on genital warts that have a high incidence and fast evolution compared with cancers.The burden of HPV disease not averted will translate into an important economic burden through treatment and hospitalization costs, and sick leave or work days lost by a caregiver. Once the majority of the benefits of the vaccination program are obtained, i.e. when an epidemiologic equilibrium is reached, the annual burden would be strikingly different between the two coverage scenarios, since, at steady state, the current low vaccination coverage rate in France would be associated with an additional 1700 cancers, 600 deaths and 66,000 overall disease events each year as compared to the’standard’ EU vaccination coverage rate. If the HPV vaccine coverage rate of 60%, as targeted in the French Cancer Plan, were to be reached, most of this burden would be avoided Face validity of the model was demonstrated by several publications in peer-reviewed journals One of the potential limitations of the present study is that not all of the various model parameters were found in French-specific studies, which may have an impact on the validity of the results. Also, the CIN2+ incidence estimated by the model is 4.57 times lower than the observed CIN2+ incidence due to an imperfect calibration for this outcome. Hence, the “true” burden of CIN2+ associated with the low VCR is probably closer to 1,445,230 over 100 years than to the 316,243 cases estimated by the model. As a consequence, the burden associated with the low VCR was underestimated. Another potential limitation involves the assumptions of vaccination coverage rates that were based on 2014 French data. The VCR in the previous year and the distribution of the vaccinees among cohorts and by year were not taken into consideration, consequently, the estimations may not be fully representative of the French situation. This choice was made because of the lack of detailed data on the VCR. However, it is likely that the results and the conclusions would remain similar if the actual figures were used. French-specific sexual behavioral data were privileged whenever available The importance of the missed opportunity is acknowledge by the French government which formally defined increasing HPV vaccination uptake as a public health priority in its Cancer Plan for 2014–2019 A recent French survey showed that low educational and socioeconomic levels were associated with lower cervical cancer screening uptake in women and lower HPV vaccination rates in their daughters Vaccination of boys was not identified as a priority in France but this would constitute the most effective strategy to reduce the incidence of HPV-related cancers and diseases 5The low HPV vaccination coverage rate observed in France in 2014 highlights the difficulties this prevention program is facing. Timely, pertinent information on the burden of HPV and reassurance about the favorable benefit-risk ration are needed. Public health authorities and health care professionals have a key role to play in providing such information and strong recommendations to vaccinate to the public. Increasing the public trust in vaccination programs is essential if we are to achieve higher coverage with HPV vaccines. All stakeholders should work together and increase their efforts to achieve broader implementation of HPV vaccination and to enable HPV vaccination to deliver its full public health potential since partnerships could have positive outcomes on vaccination programs M Adam, X Bresse, A Dahlab and M Uhart are employees of Sanofi Pasteur MSD, a pharmaceutical company that commercializes the HPV vaccines Gardasil and Gardasil9.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.


High-risk human papillomaviruses (HR-HPV) infect basal keratinocytes, where in some individuals they evade host immune responses and persist. Persistent HR-HPV infection of the cervix causes precancerous neoplasia that can eventuate in cervical cancer. Dendritic cells (DCs) are efficient in priming/cross-priming antigen-specific T cells and generating antiviral and antitumor cytotoxic CD8+ T cells. However, HR-HPV have adopted various immunosuppressive strategies, with modulation of DC function crucial to escape from the host adaptive immune response. HPV E6 and E7 oncoproteins alter recruitment and localization of epidermal DCs, while soluble regulatory factors derived from HPV-induced hyperplastic epithelium change DC development and influence initiation of specific cellular immune responses. This review focuses on current evidence for HR-HPV manipulation of antigen presentation in dendritic cells and escape from host immunity. Cervical and other anogenital cancers account for ~5% of the global cancer burden The immune system plays a key role during HPV-associated carcinogenesis. About 90% of immunocompetent HPV-infected individuals resolve a cervical infection spontaneously within three years and less than 1% develop invasive cervical cancer 2In vitro transfection of primary KC with episomal HPV, or HPV gene expression vectors, has demonstrated that HR-HPV gene products can prevent proinflammatory KC innate immune responses and susceptibility of KC to immune mediated elimination. Expression of the E6 and E7 genes of HR-HPV downregulates transcription and function of the viral DNA sensor, TLR9 3To induce a cytotoxic T cell response against infected KCs, skin resident antigen presenting cells (APCs) must initiate and coordinate innate and adaptive immune responses. Skin resident professional APCs tissue-resident macrophages and dendritic cells (DCs). DCs are the only professional APCs that efficiently cross-present cell-associated Ags and transport processed Ag to the draining lymph nodes (LNs) to activate proliferation of naïve T cells 3.1in vitroEpidermodysplasia Verruciformis patient skin lesions Regulating DC differentiation and function is an essential mechanism for tumor escape from immune surveillance vβ6 and αvβ8 derived from KCs in vitro experiments revealed that the KC-to-LC interaction mediated by E-cadherin is required for LC differentiation in vitro promotes CCL20 secretion and LC migration into HPV-infected epithelium in vitro gene transfection studies in human primary KCs have demonstrated that CCL20 expression is inhibited by HPV viral proteins via downregulation of NF-κB signaling In vitro, inhibition of HPV16 E6 and E7 oncoproteins restored E-cadherin expression and LC adhesion to KCs One mechanism that could produce the altered number and distribution of LCs may be the observed downregulation in HR-HPV-infected KCs of the expression of the chemokines CCL20/MIP3α and E-cadherin 3.2DC functional maturation is instrumental in generating Ag-specific immune responses. DCs continuously sample the peripheral tissues and recognize pathogens or danger-signals from dying or infected cells and undergo immunogenic maturation, characterized by transport of endosomal MHC-II to the cell membrane, up-regulation of CD80 (B7-1) and CD86 (B7-2) co-stimulatory molecules and secretion of instructive proinflammatory cytokines, including IL-1α/β, IL-6, IL-12 and TNF-α, and chemokines, including CCL2, CCL3, and CCR4 in vitro model using self-assembled HPV viral-like particles (VLPs) was designed to study skin-resident APC-mediated anti-HPV immune responses. In vitro exposure of immature LCs isolated from CIN2/3 patients in vitro suppressive effect of VLPs is not limited to HPV16, but exposure to many HR-HPV and LR-HPV VLPs also inhibits activation of LCs In the context of chronic HPV infection, in addition to the low density of LCs, expression of MHC-ΙΙ and langerin on LCs in HR-HPV positive cervical low-grade CIN1 lesions was significantly reduced as compared to the normal cervical epithelium in vivo Ag-processing and T cell priming capacity of K14E7 skin DCs was impaired The effect of HPV-induced malignancy has been modelled in a murine skin grafting model where mice are engineered to express a HPV16 E7 transgene within basal KCs under the control of keratin 14 (K14) transcriptional promoter (K14E7). K14E7 skin displays epithelial hyperplasia that mimics HPV-related human CIN 44.1reg) cells, which instruct tolerogenic DC differentiation and promote lesion progression reg cells downregulated maturation of DCs by up-regulating the E3 ubiquitin ligase MARCH-I expression, which increased ubiquitination and degradation of MHC and costimulatory molecule reg cells, regulatory DCs and impaired CTL responses in cervical cancer epithelium compared to normal cervix in vitro examination of HPV-positive cervical cancer cell lines demonstrated that IL-10 and TGF-β derived from cancer cells suppress MHC-I expression in tumor cells in vitro. However, the migration of mature DCs was impaired by cervical cancer cell-derived IL-6, which led to suppression of CCR7 As indicated in reg cells modulate the maturation of DCs via cytotoxic T lymphocyte-antigen-4 (CTLA-4)-mediated down-regulation of CD80 and CD86 expression. CTLA-4 binds to CD80 and CD86 with higher affinity than CD28, and Treg cell interaction with DCs via CTLA-4 downregulates CD80 and CD86 expression, thus limiting the ability of DCs to stimulate CD8+ T cells reg cells provides an important strategy for different tumor cells to evade host immune surveillance. Accumulation of CTLA-4+ Treg cells in the HPV-positive HNSCC tumor microenvironment Antigen-experienced TListeria monocytogenes or bacterial endotoxin at the time of grafting of E7 transgenic skin promoted graft rejection HPV16 E7-expressing mouse premalignant skin has also shown suppressed immune responses. Unlike skin expressing mOVA from an epidermal keratin 5 (K5) promoter- 4.2reg cells or leading to cell cycle arrest Prolonged local IFN-γ-signaling contributes to E7-induced immunosuppression in K14E7 animals, as IFN-γ-deficient K14E7 skin grafts were spontaneously rejected by non-transgenic immunocompetent hosts in vitro tumor cell growth was not affected, inhibition of IDO activity promotes significant intratumoral accumulation of natural killer (NK) cells and regression of tumor growth In a cervical cancer patient biopsy analysis, IDO1 gene expression and kynurenine to tryptophan ratio was significantly elevated as compared to healthy controls 4.3In vitro studies involving human cell lines expressing HPV16 E7 Ags have shown that blockade of PD-1/PD-L1 signaling significantly enhanced CTL responses DCs exposed to the HR-HPV-induced tumor microenvironment may attenuate effector T cell functions through programmed death receptor 1 (PD-1)/programmed death ligand 1(PD-1/PD-L1) immune inhibitory signaling 5HPV utilizes multiple strategies to evade host immune responses. HR-HPV- infected KCs escape from CTL recognition through downregulation of MHC-I molecules and the associated Ag-processing machinery. Subverting the KC’s inflammatory response by HR-HPV E6 and E7 non-structural oncoproteins contributes to the ineffectiveness of the host immune response, thus promoting persistent HPV infection and KC transformation. HPV E6 and E7 affect epidermal recruitment and localization of LCs through disrupting KC-to-LC networks. The various cell types recruited to HR-HPV infected lesions appear to interact with resident (or recruited) APCs, setting up a feed-forward loop of immunoregulation to favour persistence of infected cells. In both pre-clinical animal models and cervical cancer patients, HPV-related epithelial dysplasia is associated with infiltration of immature DCs with reduced ability to present Ags and stimulate T cell proliferation. Most strikingly, within HR-HPV-infected or E6/E7-expressing hyperproliferative epithelia, DCs exhibit regulatory phenotypes associated with production of IL-10, IDO-1, and PD-L1. Persistent immunosuppressive signaling through chronic IFN-γ, IL-10, and TGF-β in the HR-HPV-infected hyperproliferative lesion is presumably responsible for recruiting and programming tolerogenic DCs. Multiple clinical trials targeting blockade of PD-1/PD-L1 and CTLA-4 immune checkpoints are being conducted and may provide crucial help in diminishing the burden of HPV- associated diseases. However, it is not yet clear whether HR-HPV-induced malignancies directly suppress the CTL response or DCs conditioned by the regulatory milieu actively divert T cell responses towards tolerance. Thus, further investigation of the interaction between APCs and tumor -derived soluble mediators within HPV-induced malignant epithelia may help with targeting DCs for therapeutic intervention.