TRIM37 has been reported to be associated with the tumorigenesis of cancers. However, the role of TRIM37 in T-cell acute lymphoblastic leukemia (T-ALL) remains unclear. This study aimed to characterize the effect of TRIM37 on T-ALL.TRIM37 expression in T-ALL patients and T-ALL cell lines was determined by qRT-PCR and Western blot. Knockdown or overexpression of TRIM37 was conducted by transferring small-interfering TRIM37 or lentivirus-mediated transducing into T-ALL cells. CCK-8 assay and flow cytometry assay were conducted to analyze the proliferation and apoptosis of T-ALL cells. Co-immunoprecipitation experiments were conducted to investigate the relationship between TRIM37 and PTEN and the ubiquitination of PTEN.via TRIM37-mediated ubiquitination in T-ALL cells. Moreover, TRIM37 reduced the sensitivity of T-ALL cells to bortezomib treatment. Additionally, PI3K/AKT signaling pathway was involved in the function of TRIM37 in T-ALL. TRIM37 contributed to the proliferation of T-ALL cells and reduced the susceptibility of T-ALL cells to bortezomib treatment through ubiquitination of PTEN and activating PI3K/AKT signaling pathway.Our results suggested that TRIM37 expression was upregulated in the blood of T-ALL patients and T-ALL cell lines. Knockdown of TRIM37 noticeably inhibited the proliferation and promoted apoptosis of T-ALL cells. Ectopic expression of TRIM37 promoted the proliferation and suppressed the apoptosis rate of MOLT-4 cells and enhanced the phosphorylation of AKT. Moreover, TRIM37 interacted with PTEN and accelerated the degradation of PTEN Our study suggested that TRIM37 could be considered as a therapeutic target for T-ALL. T-cell acute lymphoblastic leukemia (T-ALL) was derived from the malignant transformation of progenitor T cell infiltrating the bone marrow and peripheral blood. Clinically, T-ALL patients have exhibited typical symptoms including increased white blood cells count, hematopoietic failure, neutropenia, anemia, and thrombocytopenia . The occTripartite motif (TRIM) protein family comprises more than 80 members in human and is found in all multicellular eukaryotes. Numerous evidences supported that TRIM family proteins participate in the occurrence and development of various diseases, namely, cancer, inflammation, pathogen infection, neuropsychiatric disorders, chromosomal abnormalities, and developmental diseases –3. Like The phosphatidylinositol-3-kinase (PI3K)/Akt signaling pathway exerts critical role in a variety of steps of tumorigenesis. Activation of PI3K/AKT signaling pathway is commonly accompanied by AKT phosphorylation, which further stimulate AKT downstream target factors . ConstitIn the present study, we found TRIM37 was upregulated in T-ALL patients and T-ALL cell lines. Knockdown or overexpression of TRIM37 revealed the oncogenic role and bortezomib resistance effect of TRIM37 in T-ALL. Moreover, immunoprecipitation experiments proved that TRIM37 mediated the ubiquitination of PTEN, which led to PI3K/AKT signaling pathway activation in T-ALL cells.n = 25) with T-ALL and normal individuals (n = 15) from The First Affiliated Hospital of Soochow University. All the participants signed the informed consent forms, and the project was approved by the Ethical and Scientific Committee of the Inner Mongolia Forestry General Hospital (20220816) and written informed consent was acquired from each participant.Human peripheral blood mononuclear cells were obtained from patients , 10 mM Hepes, and 100 U of penicillin/streptomycin. Human HEK 293T cells used for lentivirus package were maintained in Dulbecco’s Modified Eagle’s Medium (DMEM) supplemented with 10% FBS, 100 U of penicillin/streptomycin, 10 mM Hepes, and 2 mM L-glutamine  and were grown in humidified atmosphere with 5% CO2 atmosphere at 37°C.Human T-ALL cell lines, namely, Jurkat, MOLT-4, and RPMI8402 were brought from American Type Culture Collection  and cultured at 37°C in 5% COLipofectamine™ 2000 Transfection Reagent was used for plasmids transfection in HEK293T cells. Delivery of siRNA targeting TRIM37 and the negative control (si-NC) was conducted using Invitrogen™ DMRIE-C Transfection Reagent.The plasmids of pLVX-TRIM37-Puro  or empty vector control, together with psPAX2 and pMD2.G , were delivered into HKE293T cells by Lipofectamine™ 2000  to generate lentivirus. Supernatants containing virus were harvested at 48h post-transfection. MOLT-4 cells were incubated with viral supernatants for 24h and then refreshed the supernatants with fresh medium supplemented with 0.25 μg/ml of puromycin for TRIM37-positive cell selection.−ΔΔCt method. The sequence of primers used for detecting TRIM37 is synthesized as follows: F: 5’-TGGACTTACTCGCAAATG-3’, R: 5’-ATCTGGTGGTGACAAATC-3’.Total RNA was isolated by TRIzol , and the first strand of cDNA was synthesized with the PrimeScript RT reagent kit  in accordance with manufacturer’s instruction. qPCR SYBR green real-time PCR master mix  was applied for PCR reactions run on ABI 7900HT sequence detection system. The relative mRNA expression was normalized to inner control GAPDH and was calculated by 2g at 4°C for 10 min. The obtained supernatants was transferred into fresh tubes for immunoprecipitation with 1 μg of indicated antibodies overnight at 4°C, followed by reaction with 12 μl of protein A/G Plus-agarose  for 1h at 4°C. The immunocomplexes were then collected by centrifugation, washed by ice-cold RIPA buffer for five times and analyzed by Western blot experiments.MOLT-4 cells were lysed in RIPA buffer containing 50 mM pH 7.5 tris-HCl, 150 mM NaCl, 1% Nonidet P-40, 1 mM EDTA, 0.25% sodium deoxycholate, 1 mM Na3VO4, 1 mM NaF, 2% phenylmethylsulfonyl fluoride  and protease inhibitor . Cell debris was eliminated after centrifuging at 10,000Proteins from the immunoprecipitate or cell lysates were separated by SDS-PAGE and then transferred onto polyvinylidene difluoride membranes  to incubate with primary antibodies incubation overnight at 4°C. After washing by 1× TBST buffer, the membrane was reacted with horseradish peroxidase (HRP) labeled-secondary antibodies for 1h at room temperature and protein bands were visually recorded.3 cells/well. Cells were harvested at indicated time points, and the cell proliferation was quantified after 2h incubation and was determined by the reading of OD450 on a microplate reader .CCK-8 reagent  was adopted for detection following user’s manual. CCK-8 solution of 10 μl was added into cells seeded in 96-well plate at density of 6 × 10Apoptosis of human T-ALL cell lines was determined using Annexin V-FITC/propidium iodide (AV/PI) Apoptosis Detection Kit . The experimental Jurkat and RPMI8402 cells were incubated with medium containing Annexin V-FITC and PI staining solution for 10 min without light. After adding 500 μl of 1× binding buffer, all the samples were gently mixed and placed on ice until flow cytometry detection performed by a FACS Calibur .t-test was used to calculate significant differences. The gray value of protein was determined by ImageJ software . P value less than 0.05 indicated statistical difference.All the experiments were performed at least three times. Data in the current study were exhibited as mean ± standard deviation (SD), represented three independent experiments with similar results. One-way ANOVA or a two-tailed Student’s P < 0.001, P < 0.001, To investigate the function of TRIM37 in T-ALL, we firstly quantified the mRNA expression of TRIM37 in T-ALL patients and healthy individuals. Peripheral blood mononuclear cells from the patients with T-ALL and healthy donors were isolated, and qRT-PCR was conducted to analyze the mRNA level of TRIM37. Compared with control group, the expression of TRIM37 was significantly higher in patients with T-ALL (***P < 0.001). Cell proliferation assays revealed that knockdown of TRIM37 markedly repressed cell growth and promoted the apoptosis of Jurkat and RPMI8402 cells . CCK-8 assays revealed that overexpression of TRIM37 promoted cell growth of MOLT-4 cells (*P < 0.05). However, PI3K/AKT inhibitor LY294002 suppressed the cell growth of MOLT-4 cells at 24h post-treatment , prompting us to hypothesize that TRIM37 may reduce the sensitivity of cells to bortezomib treatment through inhibiting PTEN. To verify the speculation, we performed FACS assays to investigate the co-effect of bortezomib and TRIM37 on apoptosis of human T-ALL cells. As shown in The alteration of TRIM37 level contributed to the metastasis of several types of solid tumors and indicated the correlation between TRIM37 and poor prognosis of patients , 9, 11. Activation of PI3K leads to the production of phosphatidylinositol-3-phosphate (PIP3), which interacts with the PH domain of AKT to induce PDK1-mediated phosphorylation of AKT. The activated AKT further stimulates downstream target molecules to participate in regulation of various physiological processes . ExcessiPTEN has been identified to negatively regulate the P13K/AKT signaling pathway by phosphorylating PIP3 to PIP2 . As one in vitro. Both the survival analysis and the in vivo study of TRIM37 were required to further investigate the bio-function of TRIM37 in the malignization of T-ALL and the association between TRIM37 and the clinical prognosis of T-ALL patients.Ubiquitination plays an important role in cancer development and tumor metastasis through modulating the stability and functionality of oncoprotein and tumor suppressors . RecentlThe proposed study revealed that TRIM37 was upregulated in T-ALL. TRIM37 promoted the proliferation of T-ALL cells and reduced the sensitivity to bortezomib of T-ALL cells at least in part through the excessive activation of PI3K/Akt signaling pathway and by ubiquitination of PTEN, suggesting TRIM37 might be used as therapeutic targets for T-ALL treatment.The original contributions presented in the study are included in the article/In this study, the experiment involving human was permitted by the ethics committee of the Inner Mongolia Forestry General Hospital, Yakeshi city 022150, Inner Mongolia, China and written informed consent was acquired from each participates. The patients/participants provided their written informed consent to participate in this study.YD contributions to conception and design the project; HQ performed the experiment and wrote the draft; HG-w, YH, MR, JL, and BJ help to analyses the data and edit graph. All authors contributed to the article and approved the submitted version.


Viruses have no gender, but virologists do. And, unfortunately, gender disparity in the STEM field continues, with, according to the UNESCO Institute for Statistics, only 30% of the world's researchers being women, and women being underrepresented at the highest levels of academia. As emphasized by UNESCO, science and gender equality are essential for a balanced future. To contribute to the laudable goal of creating a fairer world, and in celebration of International Women's Day 2022, Frontiers in Microbiology launched the Women in Virology 2022 Research Topic to highlight women's achievements in the field, and to act as a platform promoting the work of female scientists.Women in virology: 2022” was well received by the scientific community, with 13 manuscripts accepted for publication. In line with the broad call for submissions, the publications covered a variety of topics, describing both fundamental and clinical research on viruses infecting plants, oomycetes, and humans. An excellent overview by de la Higuera and Lázaro, is a valuable encounter with the world of viruses. The authors recap that viruses constitute the largest biomass on earth. With an estimated number of 1031 virus particles present, they greatly outnumber cellular organisms. Hundreds of millions of virions alone can be present in, for instance, a milliliter of seawater, and ≈20% of aquatic bacteria are lysed every day due to the actions of bacteriophages. Moreover, although it is impossible to draw a single phylogenetic tree of the Virosphere, the omnipresence of ancestral RNA-recognition motifs in viral replication proteins, which likely originate from the RNA world, viruses can be employed in studying the origin of life. The omnipresence and enormous diversity of viruses and their interaction with all organisms, further demonstrates their pronounced influence on the evolution of cellular life. For instance, viruses facilitate horizontal gene transfer in prokaryotes, while virus endogenization in eukaryotic genomes supports a role in evolutionary transitions. As viruses are found everywhere, are highly adaptable, easily dispersed by wind and water, and have a substantial influence on Earth's biochemical cycles and living organisms, the authors argue that, in the field of astrobiology, virus-like agents should be considered as potential carriers of life signatures, so-called “biosignatures,” when searching for extraterrestrial life.“Kaczorowska et al. report on mother-to-child transmission of the enigmatic anelloviruses (AVs), ubiquitous, persistent single-stranded DNA viruses with no known associated pathology. Sequencing the so-called anellome of five HIV-1 infected mother and child pairs suggested selected genotype transmission, as the majority of maternal lineages was not shared with the child. Some children harbored unique AV genotypes, likely acquired from other sources. In line with this finding, AV transmission of shared genotypes was not related to delivery or breastfeeding, as the HIV-positive mothers delivered by Caesarian section and did not breastfeed.Turning to viruses infecting humans, it is remarkable that nine out of ten contributors report on viruses that infect chronically or have the capacity to do so. Yang et al., Yang et al. studied the epidemiology and risk factors associated with HPV infection and associated malignancies in women from Liaoning province in north-eastern China during 2018–2021, as in recent years, cervical cancer rates have been increasing in China, especially in younger women, and routine screening or vaccination is not standard practice. From a total of 16,589 participants, ±12.5% of women were found to be HPV+, with ±10% presenting abnormal cytology. For primary cervical cancer screening and ASCUS  triage, Li et al. compared the performance of a HPV DNA Chip test (Sample-to-Answer HPV Genotyping System from Beijing Bohui Innovation Biotechnology Co.) and an HPV PCR test (5 + 9 High Risk HPV Detection kit from Tellgen) on cervical samples from 7,241 women from rural areas in Shanxi, China during 2017–2018. Both tests performed better than standard liquid biopsy screening, while the HPV DNA Chip test (14.9% HPV+) outcompeted the HPV PCR test (21.1% HPV+) in the study. As the HPV situation in many parts of the world is critical, and prophylactic vaccination is not universal, Ren et al. performed a meta-analysis on the efficacy of prophylactic HPV vaccines among Asian females, and confirmed that these vaccines significantly reduce the incidence of persistent HPV infection, cytological abnormalities and cervical neoplasia in Asian populations. Unsurprisingly, the authors advocate raising awareness amongst women, and accelerated implementation of HPV vaccination. In a next study, Dai et al. found that stable expression of the HPV oncoproteins E6 and E7 in cell culture induces the differential expression of genes encoding chemokines and cell adhesion proteins. The observation may stimulate novel research into targeting E6E7 for HPV-related cancer treatment.Five contributions investigated aspects of human papillomavirus (HPV) infection. In two papers, Belaiba et al. investigated the genomic variation of hepatitis B virus (HBV) in five ETV (entecavir) non-responders in Tunisia. Putative drug-resistance mutations were present in the genotype D genomes, often predating treatment, as were a plethora of other mutations, some associated with disease progression and increased replication. Hepatitis C virus (HCV) is another potentially chronic hepatitis infection able to induce liver malignancy. García-Crespo et al. report a decrease in the effectiveness of antivirals when added, later rather than earlier, to an ongoing infection in cell culture. These results are important, as most patients begin treatment only when the infection has been established for some time, something which is not assessed in preclinical trials.HBV is another example of a virus with an ability to persist and cause cancer in humans. Poole and Sinclair. They report that the cellular protein SERBP1 is upregulated during HCMV latency, is required for MIEP suppression and interacts with the transcriptional repressor CHD3 as well as with KAP1 to recruit SET1B, another repressor, to the viral genomic DNA, thus acting as a scaffold protein to maintain transcriptional silencing.Human cytomegalovirus (HCMV) is another persistent virus infection. Herpesviruses are capable of alternating between lytic and latent cycles, whereby the induction of latency is an active process, in which major immediate early gene (IE) expression from the major immediate early promoter (MIEP) is suppressed, a process studied by Liu et al. who evaluated the presence of viral RNA in vaginal and anal swabs in 63 women with no, or only mild disease symptoms. All vaginal swabs were qRT-PCR negative for SARS-CoV-2 RNA. Four anal swabs were positive, one from a case with gastro-intestinal symptoms, suggesting that the omicron variant does not readily invade the gut.A non-persistent virus, the omicron-variant of SARS-CoV-2, was studied by Dye et al. who investigated the viral variation in cassava mosaic disease, an infection caused by a complex of single-stranded DNA viruses of the family Geminiviridae, genus Begomovirus. In the Kenyan Lake Victoria region, virus mixtures were found to be distinct from those in coastal samples. Experiments suggested that transmission dynamics of the viruses also differed, with African cassava mosaic virus (ACMV) being transmitted through vegetative propagation, while East African cassava mosaic virus (EACMV) relied on a whitefly vector. These findings could explain the divergent virus mixtures observed.A different section of the Virosphere was studied by Raco et al. studied yet another realm of the virus world when searching for novel RNA viruses in the Vietnamese oomycete species, Phytophthora castaneae. Oomycetes are a group of fungus-like organisms with phylogenetic similarity to algae and diatoms, which include some of the most devastating plant pathogens. Five putative RNA virus genomes detected showed similarity to members of the order Bunyavirales and families Endornaviridae, Megabirnaviridae, Narnaviridae, Totiviridae, and the proposed family “Fusagraviridae”; a partial genome showed homology to the Endornaviridae. As initial virus identification was through small RNA sequencing, it was proposed that a RNAi antiviral defense mechanism had been targeting the viral RNA.Women in Virology” helps showcasing their contributions to the field.In conclusion, female virologists are as versatile as their subjects of study and work in all areas of the virosphere. Frontiers Research Topic “Women in Virology 2022”. All authors contributed to the article and approved the submitted version.AvdK drafted the manuscript. All three authors edited the Frontier's Research Topic “


The primary outcome was incident-persistent vaccine type-specific cervical HPV infection. The primary evaluation was superiority analysis in the modified intention-to-treat (mITT) HPV 16/18 and HPV 16/18/31/33/45/52/58 cohorts. The trial met its prespecified end points of vaccine type-specific persistent HPV infection. A total of 75 incident-persistent infections were detected in the HPV 16/18 mITT cohort: 2 in the bivalent group, 1 in the nonavalent group and 72 in the control group. Nonavalent VE was 98.8%  and bivalent VE was 97.5% . Overall, 89 persistent infections were detected in the HPV 16/18/31/33/45/52/58 mITT cohort: 5 in the nonavalent group and 84 in the control group; nonavalent VE was 95.5% . There were no vaccine-related severe adverse events. Three years after vaccination, single-dose HPV vaccination was highly efficacious, safe and conferred durable protection. ClinicalTrials.gov no. NCT03675256.Cervical cancer burden is high where prophylactic vaccination and screening coverage are low. We demonstrated in a multicenter randomized, double-blind, controlled trial that single-dose human papillomavirus (HPV) vaccination had high vaccine efficacy (VE) against persistent infection at 18 months in Kenyan women. Here, we report findings of this trial through 3 years of follow-up. Overall, 2,275 healthy women aged 15–20 years were recruited and randomly assigned to receive bivalent ( In a prespecified 3-year analysis of the KEN SHE trial, single-dose HPV vaccination was shown to be well tolerated and provided durable protection against cervical HPV infection in Kenyan women aged 15–20 years. Further, there are notable disparities; cervical cancer incidence is three times higher and mortality is six times higher in countries with a United Nations Development Programme-defined low Human Development Index (HDI) than in countries with a very high HDI. Targeted strategies are needed to achieve the WHO goal of cervical cancer elimination and to reduce global cervical cancer disparities.Cervical cancer burden remains high globally, with more than 600 000 cases and 340 000 deaths in 2020 and incidence and mortality rates in most countries higher than the World Health Organization (WHO) threshold for cervical cancer elimination3. HPV vaccination is foundational in the WHO’s Global Cervical Cancer Elimination Strategy as a primary prevention of HPV infection4. The strategy aims to vaccinate 90% of girls globally. Four HPV vaccines are licensed to be given as 2–3 intramuscular injections over 2–6 months, all targeting high-risk (oncogenic) HPV types that cause 70–90% of cancers. The bivalent vaccines (Cervarix and Cecolin) prevent HPV 16/18 infection, the quadrivalent vaccine (Gardasil) prevents HPV 16/18/6/11, including the low-risk HPV types 6 and 11 to prevent genital warts, and the nonavalent vaccine (Gardasil-9) prevents HPV 16/18/31/33/45/52/58/6/11 infection, including five additional high-risk HPV types. Vaccinating the current global cohort of women aged 9–18 years would prevent HPV-associated precancerous lesions5 and 11.6 million cases of cervical cancer over their lifetimes6; however, current HPV vaccine coverage remains low. In 2019, only 15% of adolescent girls globally were vaccinated against HPV7.HPV vaccines prevent more than 90% of persistent oncogenic vaccine type-specific HPV infections, the primary cause of cervical cancer8. Single-dose HPV vaccine efficacy is comparable to the licensed two- or three-dose regimen in randomized trials and observational studies12. Thus, in April 2022, the WHO recommended one or two doses of HPV vaccines for children, adolescents and young adults aged 9–20 years; however, a desire for data about longer-term durability of single-dose HPV vaccination persists15 and national guidelines continue to recommend multi-dose strategies. Also, few low-HDI countries have catch-up vaccination programs for persons 15 years and older, although those programs accelerate the impact of vaccination5.Single-dose HPV vaccination would simplify the logistics and reduce costs of scaling up vaccine programs, lowering barriers to reaching high HPV vaccine coverage. The vaccine virus-like-particle (VLP) structure, which self-assembles to mimic the live virus without the replicating DNA, generates strong immunity with a single dose, analogous to highly immunogenic whole-virus vaccines rather than a subunit vaccine, supporting a biological mechanism for single-dose efficacy rather than the prime-boost multi-dose schedule that optimizes subunit vaccine efficacy (VE)1. Kenya’s two-dose HPV immunization program was launched in October 2019 to reach 10-year-old girls, in the context of vaccine supply constraints. In 2021, vaccine coverage for the first dose was 77% and 31% for the second dose16. With WHO guidance recommending vaccination for the multi-age cohort of 9–14 year olds, the easing of vaccine supply constraints, and the need to deliver immunization services to a larger number of adolescents, evaluating the efficacy of single-dose vaccination would provide evidence to policymakers for immunization scale-up, including multi-age cohorts and catch-up vaccination for those who may have missed vaccination during programmatic scale-up.In Kenya, the age-standardized incidence for cervical cancer is 31.3 per 100,000 person-years; annually, an estimated 5,236 new cases are diagnosed and 3,211 deaths attributable to cervical cancer occur18. As reported previously, at 18 months, bivalent and nonavalent vaccine efficacy was 97.5% for HPV 16/18 and nonavalent VE was 88.9% for HPV 16/18/31/33/45/52/5810. We hypothesized that single-dose HPV VE would be durable over 36 months. Here we report the final single-dose HPV VE 3 years after vaccine administration to evaluate the durability of single-dose HPV vaccination for zero versus single-dose HPV vaccination. As planned, all participants have received HPV vaccination and follow-up continues to evaluate the durability of single-dose efficacy.This study evaluated zero versus single-dose HPV vaccination and employed a superiority design to support efficacious, feasible, and timely evidence for catch-up vaccinationn = 419), 132 (32%) had a positive pregnancy test, 51 (12%) declined study procedures, 34 (8%) had a positive rapid HIV test and 202 (48%) met other exclusion criteria. Enrolled participants were randomized  were aged 15 to 17 years and 61%  had one sexual partner in their lifetime with comparable baseline characteristics between the groups  were enrolled. Of those ineligible  at enrollment, by self-collected vaginal swab at month 3, and HPV antibody negative at enrollment in the mITT cohort. For inclusion in the HPV 16/18 mITT cohort, participants were HPV 16/18 naive. Similarly, for the HPV 16/18/31/33/45/52/58 mITT cohort, participants were HPV 16/18/31/33/45/52/58 naive.n = 661) or had missing antibody results (n = 1) or a missing month 3 swab (n = 155) were excluded. Among the 1,458 participants meeting the criteria for the primary HPV 16/18 mITT analysis, 496 were in the nonavalent group, 489 were in the bivalent group and 473 were in the control group. For HPV 16/18/31/33/45/52/58, participants who tested HPV 16/18/31/33/45/52/58 antibody- or HPV 16/18/31/33/45/52/58 DNA-positive at enrollment or HPV DNA-positive at month 3 (n = 792) or had missing antibody results (n = 1) or a missing month 3 swab (n = 107) were excluded. Of the 615 participants eligible for the primary HPV 16/18/31/33/45/52/58 analysis, 325 were in the nonavalent group and 290 were in the control vaccine group. The median age was 17 years for the HPV 16/18 and HPV 16/18/31/33/45/52/58 mITT cohorts  participants did not contribute follow-up time after enrollment and 5 (0.2%) exited the study during follow-up. Overall, 2,256 of 2,275 (99%) participants contributed a median of 35 months of follow-up time between December 2018 and January 2023. A total of 34% of participants  provided a final analysis swab at month 30 and 62%  at month 36 as participants received cross-over vaccination at their next study visit after regulatory approvals were obtained to allow timely access to the effective intervention. Retention of four or more swabs collected at follow-up for the assessment of primary end points was 96%  and 91%  for five or more swabs (Extended Data Table The incidence of persistent non-vaccine HPV types (HPV 26/35/39/40/42/43/44/51/53/54/56/59/61/66/68/69/70/73/82) was comparable between the three study groups: 24.9 of 100 woman-years in the nonavalent group, 25.8 of 100 woman-years in the bivalent group and 22.0 of 100 woman-years in the control group (Extended Data Table P < 0.0001) and bivalent VE was 97.5%   Fig. .Table 2IP < 0.0001)  Fig. .P < 0.0001) and bivalent VE was 96.8%  and bivalent VE was 100% (P < 0.0001) (Table P < 0.0001)  Table . In the 1) Table .In the planned secondary analyses to assess VE in the prespecified subgroups, as defined at enrollment, for the presence of co-infections , self-reported condom use, number of self-reported lifetime sex partners (1 versus 2+) and contraceptive method use, there was no difference in VE in predefined subgroups (Extended Data Tables n = 7), including partner physical and verbal abuse and lack of social support from friends and family for trial participation.Serious adverse events (SAEs) were experienced by 201 participants, which included 122 participants with pregnancy-related SAEs, 71 with infections or inflammatory conditions , 7 injuries and 12 mental health illnesses. Overall, the SAE frequency was similar between groups   for the nonavalent vaccine and 97.3% (95% CI 89.0–99.3%) for the bivalent in the HPV 16/18 mITT cohort. Nonavalent VE was 95.3% (95% CI 88.4–98.1%) in the HPV 16/18/31/33/45/52/58 mITT cohort (Table The absolute reduction in the HPV 16/18 mITT cohort for cumulative incident-persistent HPV 16/18 infection was −16.0% (95% CI −19.5 to −12.5%) for the nonavalent group and −15.8% (95% CI −19.3 to −12.3%) for the bivalent group; an absolute incidence of 0.2% (95% CI 0–0.6%) in the nonavalent vaccine group and 0.4% (95% CI 0–1.0 %) in the bivalent group compared to 16.2% (95% CI 12.7–19.7%) in the control group. For the HPV 16/18/31/33/45/52/58 mITT cohort, the absolute reduction in persistent HPV 16/18/31/33/45/52/58 infection was −30.1% (95% CI −36.1 to −24.2%) for the nonavalent vaccine; an absolute incidence of 1.6% (95% CI 0.2–2.9%) in the nonavalent vaccine group compared to 31.7% (95% CI 25.9–37.4%) in the control group.1 is substantial. Saliently, there is high certainty of VE of at least 90% against HPV 16/18; the lower confidence interval limit for the bivalent and nonavalent VE.Three years after vaccine administration, the high efficacy of both single-dose bivalent or nonavalent HPV vaccine was sustained and durable against vaccine-specific oncogenic HPV infection. Protection against type-specific incident-persistent infection was ≥98% for bivalent and nonavalent vaccine protection against HPV 16/18 and >95% for nonavalent vaccine protection against HPV 16/18/31/33/45/52/58, which cause 70% and 90% of cervical cancer cases, respectively. This together with observed high reductions in the absolute cumulative incidence, the potential for public health impact in the context of disparities by HDI in cervical cancer incidence and mortality12 provided the first observational data for bivalent single-dose HPV vaccine effectiveness and recently demonstrated durability over 16 years19. The DoRIS study demonstrated that a single-dose nonavalent or bivalent HPV vaccine produced robust immune responses similar to two doses and three doses among 9–14-year-old girls20. The IARC-India study reported durability of single-dose quadrivalent HPV vaccine effectiveness over a decade11. Thus, consistent evidence on the efficacy and durability of single-dose HPV vaccination supports the WHO guidance for single-dose implementation to increase vaccine coverage. In mathematical modeling analyses of scale-up, implementation of routine single-dose immunization has the potential to avert most cervical cancer cases compared to two doses, with a durability of 20–30 years, in low-HDI settings21. Further, single-dose vaccination can increase coverage among girls in the 9–14-year-old group before they age out of vaccine eligibility and provide catch-up vaccination for those who may have missed the immunization due to the COVID-19 pandemic or other reasons.Taken in context, these data contribute to a suite of studies that provide evidence for single-dose HPV VE. The Costa Rica vaccine trial (CVT)5. Overall, the rate of incident persistent HPV infection in this population of African adolescent girls and young women was high; 13.8 per 100 woman-years in the control group, underscoring the need for effective, scalable vaccine programs that can achieve high coverage and reduce this high incidence of HPV infection and ultimately cervical cancer23. Catch-up vaccination programs for adolescents and young people aged 15–20 years, who do not qualify for current vaccination programs, have the potential to avert oncogenic persistent infections. Through this head-to-head comparison of bivalent and nonavalent HPV vaccines, sustained VE was demonstrated in the context of high HPV prevalence. Single-dose HPV vaccination could increase vaccine access and coverage and offer a cost-effective strategy for cervical cancer prevention.Of the 11.6 million cases of cervical cancer expected globally among girls born between 2005 and 2014, 75% of the burden will be concentrated in 25 countries largely in Africa and Asia, highlighting the need to focus prevention efforts among recently born girls8. This induces high levels of virIon-neutralizing serum antibodies and long-lasting plasma cells, supporting effective and durable VE. We did not see evidence of cross-protection with a single dose of the bivalent vaccine and it may be that two doses are required for cross-protection for the closely related HPV 31/33/45. The confidence interval did not include previous estimates of the multi-dose bivalent strategy of 50% cross-protection for HPV 31/33/45 (ref. 5).The vaccines’ underlying immunological mechanism of action could explain the observed VE. The vaccines contain monomers that self-assemble into capsomers and VLPs, a highly immunogenic structure mimicking the ordered, repetitive virus epitope structure and allowing for crosslinking of B cell receptors14.The study has several strengths, including its randomized, double-blind controlled design, high retention rate, use of cervical HPV DNA as the outcome measure, determination of incident persistent HPV DNA, head-to-head comparison of the licensed bivalent and nonavalent HPV vaccines in protection against persistent infection with oncogenic HPV types, and duration of follow-up. Moreover, the trial successfully enrolled individuals exposed to HPV infection and retained them in all randomized groups, facilitating a rapid evaluation of single-dose efficacy. Compared to the 18-month analysis, the final analysis VE estimates are stable through 36 months, with higher point-estimates and tighter confidence intervals, as additional follow-up time was accrued beyond the 6–12-month buffer period, during which infections that were prevalent at baseline but not detected at follow-up, and may contribute to a lower estimate of VE11. While participants in the control group have received single-dose HPV vaccination, we are collecting additional data in this cohort to 54 months post-vaccination24. The antibody plateau level for single-dose HPV vaccination is reached by 12 months9, suggesting that we have observed steady state efficacy. Second, 7% of primary end-point swabs were self-collected and 93% were provider-collected. All swabs would ideally be collected with one modality; however, the correlation between self-collected vaginal and provider-collected cervical swabs is high25 and there was no difference in the results when self-collected swabs were excluded. For the preplanned subgroup analyses by sexually transmitted infection (STI) status, the subgroups were defined at enrollment and may have changed over time; however, the incidence of persistent non-vaccine HPV types was comparable through the study in the three study groups. Finally, while the GST-ELISA multiplex assay used to exclude participants with HPV antibodies at enrollment demonstrated overall agreement of 89% with the gold standard secreted alkaline phosphatase pseudovirion-based neutralization assay26, misclassification of participants as antibody naive would not be different by study group. Further in sensitivity analysis including participants with HPV antibodies at baseline, overall VE was in keeping with the primary findings  cervical cancer cases and HPV 16/18/31/33/45/52/58 vaccination would avert 10.2 million (10.0–10.6) cases, with 70% of cases averted in low-to-middle HDI countries6. Cervical cancer is almost entirely preventable through HPV vaccination. Single-dose HPV vaccination could serve to close the gap between the WHO goal of 90% HPV vaccination coverage by 2030 and the 15% of girls globally currently vaccinated7, alleviate vaccine supply constraints27 and provide global policymakers with options to optimally allocate existing HPV vaccine supply. The most recent Cochrane review of the efficacy of single-dose HPV vaccination highlighted that there was moderate evidence on the durability of VE, which we have now provided with robust data over 3 years13. Single-dose HPV vaccination could facilitate rapid scale-up of vaccination worldwide.Globally cervical cancer is a leading cause of morbidity and mortality among women in mid-life; it is the second most common cancer and the greatest contributor to cancer-related mortality among women in southern and East Africa carrying a high cost to women, their families and communitiesOver 36 months, single-dose HPV vaccination offered high protection, >95% VE in preventing incident, persistent HPV 16/18/31/33/45/52/58 infection, with the lower bound of the confidence interval at almost 90% (89%) indicating a high minimum level of efficacy. Single-dose HPV vaccination was safe with no vaccine-related SAEs. These data add to the growing suite of evidence to support single-dose HPV vaccination implementation.17 and in the report of the primary results10. The study was conducted at three Kenya Medical Research Institute (KEMRI) clinical sites in Kisumu, Thika and Nairobi.This randomized, multicenter, double-blind, parallel, three-group controlled, superiority trial tested the efficacy of single-dose bivalent (HPV 16/18) and single-dose nonavalent (HPV 16/18/31/33/45/52/58/6/11) HPV vaccination, as described in the published protocol paper18.In GAVI-funded countries, including Kenya, multi-dose HPV vaccination is offered to 9–14-year-old girls through the national immunization program. Catch-up vaccination for adolescent girls and young women 15 years of age and older is not provided. Cervical cancer screening is offered to older women instead. We conducted a clinical trial to test the efficacy of single-dose HPV vaccination among young women aged 15-20 years within the context of cytological screening for dysplastic lesions. This was determined to be ethical, as vaccination for this age group in Kenya and many low-HDI countries is not currently supported through national programs or global immunization bodiesParticipants were eligible for the study if they were born female, aged 15–20 years old inclusive, were sexually active with one to five sexual partners reported in their lifetime, and planned to reside in the study area for 37 months. The exclusion criteria were people living with HIV for whom few data on single-dose HPV VE are available, history of previous HPV vaccination, allergies to vaccine components of latex, pregnancy, hysterectomy, history of autoimmune, degenerative or genetic diseases, and investigator discretion regarding participant safety. Sex assigned at birth was assessed through participant self-report at screening. Participants were recruited through community outreach. All participants, and their parents/guardians in the case of minors, provided written informed consent, which included counseling about randomization, risks and benefits of participation, study procedures and their rights as research participants.Meningococcal vaccination was chosen as the control because meningococcal antibodies offer potential clinical benefits and do not impact HPV outcomes. Participants were randomized to (1) nonavalent HPV vaccination (Gardasil-9), (2) bivalent HPV vaccination (Cervarix) or (3) meningococcal (control) vaccination. Following randomization, a single dose of each vaccine was administered.www.randomize.net. Study staff, participants, investigators, clinic staff, laboratory technicians, the end points adjudication committee members and other study team members did not have access to the randomization codes, except for the unblinded statistical analysts and unblinded pharmacists at each site. At the conclusion of the enrollment visit, an unblinded pharmacist entered the participant identification number (PTID) on randomize.net, obtained the next sequential intervention assignment, recorded the PTID and randomization identifier on an eCRF, drew up the vaccine in a masked syringe and administered the vaccination via the intramuscular route. An independent observer, not on the study team, observed the masked vaccination to assess the success of masking.An unblinded statistical analyst generated the randomization sequence using SAS v.9.4. Randomization was stratified by site, using a fixed block size of 15 and a 1:1:1 allocation. Blinded study assignment was implemented via Potential participants completed eligibility screening with a provider, including a detailed medical history, collection of external genital , lateral vaginal, and cervical swabs for HPV DNA testing, and serum for HPV antibody testing. Participants received cytological screening for cervical cancer screening at enrollment. Sexual and reproductive health services  were offered at enrollment and every visit. Participants also received counseling including services for mental health. All questionnaires used electronic case report forms (eCRFs) .25, were available at subsequent follow-up visits by participant choice or to comply with COVID-19 research restrictions.Participants had study visits at months 3, 6 and then every 6 months for up to 36 months. Providers administered clinical questionnaires and collected a cervical swab at each 6-month visit. Participants self-collected vaginal swabs using validated instructions at month 3; self-collected swabs, which have similar accuracy compared to provider-collected cervical swabsFollowing dissemination and WHO review of the month 18 primary results, participants were offered vaccination at their next study visit, which was at either month 30 or 36, so as not to delay vaccine receipt. Participants provided a final analysis cervical swab before vaccination. Participants in the meningococcal group received the nonavalent HPV vaccine and those in the HPV vaccine groups received the meningococcal vaccine.29 at the University of Washington (UW) East Africa STI Laboratory, Mombasa, Kenya with standard proficiency testing30. For HPV-positive samples, a low (+), intermediate (++), or high (+++) positivity was indicated; + or greater was considered positive. The assay runs included negative and positive controls and the housekeeping human gene, β-globin, as an internal control. Runs were performed with CFX96 Real-time PCR System (Bio-Rad).HPV DNA genotyping was conducted using the Anyplex II HPV28 assay (Seegene), a multiplexed type-specific real-time PCR-based assay that detects 28 HPV types32. The mean pre-established fluorescent intensity seropositivity cutoffs for HPV 16/18/31/33/45/52/58 were used10.Serum specimens were shipped to the UW and tested at the Galloway Laboratory, Fred Hutchinson Cancer Research Center. HPV IgG antibodies were detected using a multiplex Luminex assayN. gonorrhoeae, C. trachomatis or T. vaginalis) were assessed by nucleic acid amplification testing  at the UW East Africa STI Laboratory; HSV-2 was evaluated by the Focus ELISA and BV was evaluated using the Nugent score at the National Quality Control Laboratory, Nairobi, Kenya.Sexually transmitted infections  detected at two consecutive visits after the month 3 visit, which were obtained no less than 4 months apart (with the same HPV type at both time points). Cervical swabs were tested for the primary end point; vaginal swabs were substituted if necessary. This analysis included follow-up through month 36 to evaluate the durability of VE.Secondary analyses assessed VE in the sensitivity cohorts and subgroup analyses. The prespecified subgroups were the presence of co-infections , self-reported condom use, number of self-reported lifetime sexual partners (1 versus 2+) and contraception method use.33. Participants were monitored for adverse events 30 min after vaccination, asked about adverse events at each study visit and reported adverse events outside of study visits. The study clinical monitor followed SAEs, including permission to access medical records. SAEs were recorded on a CRF. The study Principal Investigator and clinical monitor determined the relatedness of SAEs to vaccination. We followed the KEMRI Scientific Ethics Review Unit’s (SERU’s) guidance for reporting SAEs.Safety was assessed through adverse event reporting following Division of Allergy and Infectious Diseases Guidelines10. The sample size calculations assumed a combined persistent HPV 16/18/31/33/45/52/58 annual incidence of 5%, single-dose VE of 75%, and loss-to-follow-up of 10% with a fixed follow-up time of 12 months. Sample size calculations assumed that 52% of participants would meet the requirements for inclusion in the 18-month analysis based on the observed prevalence of HPV infection in similar settings34. Assuming a proportional hazards model (seqDesign in R) with 80% power to detect 75% efficacy, a sample size of 2,250 participants was planned.The study was powered for the 18-month analysis, which included follow-up through 18 months and has been previously publishedP value for each comparison (one degree of freedom). Cumulative incidence curves of time to infection were calculated by intervention group using Kaplan–Meier methods. Efficacy analyses were performed on the month 36 mITT cohorts. In post hoc analysis, we evaluated the absolute difference in cumulative incidence of HPV from the Kaplan–Meier survival estimates at month 36. We calculated the rates of chlamydia and gonorrhea during follow-up by assigned group.We used Cox proportional hazards models stratified by study site to estimate the hazard ratios (HRs) of the interventions versus control for the primary and sensitivity analyses. Models for the sensitivity analyses used crude incidence rate ratios instead of the Cox model when no events were observed in a group. Follow-up was calculated as days since the month 3 visit for the primary analysis and days since month 6 for the extended-sensitivity analysis until the first persistent infection. Participants who did not reach this outcome were censored at the last study visit with HPV testing where they did not meet the criteria for persistent infection. VE was expressed as 1 − HR (or relative risk). The log-rank test stratified by study site was used to calculate the Participants included in the primary analysis tested HPV DNA negative  at enrollment and at month 3, by self-collected vaginal swab and HPV antibody negative at enrollment in the mITT cohort. The ITT included all randomized participants. For inclusion in the HPV 16/18 mITT cohort, participants were HPV 16/18 naive. Similarly, for the HPV 16/18/31/33/45/52/58 mITT cohort, participants were HPV 16/18/31/33/45/52/58 naive. Participants without swabs after month 3 did not contribute follow-up time in the primary analysis. Participants in the bivalent vaccine group were excluded from the HPV 16/18/31/33/45/52/58 analysis as the study was not powered to detect cross-protection. Participants who seroconverted to HIV during follow-up are included in analyses.Sensitivity analyses were planned for the following subsets: participants who tested HPV DNA negative at enrollment and month 3, regardless of antibody status at enrollment (sensitivity cohort) and participants who tested HPV DNA negative at enrollment, month 3, and month 6 and antibody negative at enrollment (extended-sensitivity cohort); the sensitivity cohort was a less conservative definition of an HPV-naive cohort and the extended-sensitivity cohort more closely matched the analysis cohort for HPV vaccine licensure trials. The extended-sensitivity cohort excluded participants who might have had prevalent HPV infection at enrollment that was not detected. Safety was assessed among all participants; the three groups were compared using Fisher’s exact test. Exploratory analysis evaluated cross-protection of the bivalent vaccine against HPV 31/33/45. We performed all analyses using SAS software, v.9.4 (SAS Institute) and R (v.4.2.2).NCT03675256).An independent Data Safety and Monitoring Board was constituted to review study progress, participant safety and the primary outcome, and met annually. The trial is registered at ClinicalTrials.gov , including the senior author (N.R.M.) are from Kenya, a low-and-middle-income country and one other (R.V.B.) is South African and is now based in a high-income country. We fully endorse and are committed to the Nature Portfolio journals’ guidance on low-and-middle-income country authorship and inclusion.This research is locally relevant to Kenya and other countries that have not achieved the 90% HPV vaccine coverage goal.The KEMRI SERU (nos. 3745 and 3741) and the Massachusetts General Hospital Institutional Review Board (no. 2022P001178) approved the study. Study participation may have carried stigmatization associated with vaccination. The data collection and analysis techniques employed raised no risks pertaining to incrimination, discrimination, animal welfare, the environment, health, safety, security or other personal risks. All HPV and STI testing was conducted at local laboratories. Serum for specialized HPV antibody testing was shipped to Seattle for testing. No cultural artifacts or associated traditional knowledge has been transferred out of any country. In preparing the manuscript, the authors reviewed relevant studies from Kenya.Further information on research design is available in the Any methods, additional references, Nature Portfolio reporting summaries, source data, extended data, supplementary information, acknowledgements, peer review information; details of author contributions and competing interests; and statements of data and code availability are available at 10.1038/s41591-023-02658-0.Supplementary InformationSupplementary Tables 1 and 2Reporting Summary


Despite proven efficacy, HPV vaccination coverage is still suboptimal. Factors influencing vaccination uptake are education attainment, socio-economic position, and knowledge about HPV. This study aimed to assess HPV vaccination uptake and its correlates among medical students and identify logistic-organizational barriers, knowledge, and attitudes with regard towards HPV vaccination to improve current public health vaccination strategies. Medical students, with their acquired biological knowledge, were selected as a low-risk groups for HPV vaccination uptake. This cross-sectional study was conducted using a validated questionnaire.Students in their the first 3 years of study students were preferentially invited. Eventually, the invitation was extended to every medical student. Logistic multivariable regression was used to assess determinants of HPV vaccination uptake. Additional analysis explored determinants of knowledge of and attitude toward HPV vaccination. Finally, a sensitive analysis was conducted to further assess the effect of knowledge and attitude on the HPV vaccination rate.A total of 882 medical students participated, with 74.5% enrolled in the first 3 years of their training. HPV vaccination uptake was 55.5%, ranging from 78.5% for females to 16.5% for males. Male sex and increasing age were consistently associated with a lower vaccination uptake , whereasilst progress in their academic career was associated with a to higher likelihood of being vaccinated . These associations were confirmed when considering the knowledge of and attitude towards HPV. Additionally also, an active outreach from healthcare institutions was associated with a higher likelihood of receiving HPV vaccination (OR 1.70, CI 1.09–2.65.HPV vaccination in medical students was higher than in the general population; however, it was still suboptimal. An active and up-to-date call strategy and extending the free-of-charge offer are essential measures for to improvinge vaccination uptake. The findings support the need to improve public health strategies and increase awareness and knowledge ofregarding HPV vaccination. Human papillomavirus (HPV) is responsible for the most prevalent sexually transmitted infection , with a HPV vaccination is an effective primary prevention strategy to reduce HPV cancer-related infections . VaccineBarriers to HPV vaccine promotion and uptake are low education, low income, fears of embarrassment or stigma, lack of knowledge about HPV, cultural acceptability of sexual behavior, distrust of healthcare, general lack of information regarding cancer risks and prevention, privacy concerns, and limited access to health care providers and preventive care . Other sAs education attainment, socio-economic position, and knowledge about HPV are among the main factors that can explain the HPV vaccination uptake, it is pivotal to assess whether the coverage effectively increases in groups that are considered at low risk to further improve the public health strategy. Specifically for this study, we selected medical students as a low-risk group for HPV vaccination uptake due to their previously acquired biological knowledge necessary to pass the admission test. This study aims to assess HPV vaccination uptake and its correlates among medical students at the University “Federico II” in Naples, the largest university in Southern Italy, and identify logistic-organizational barriers to, knowledge of, and attitude toward HPV vaccination to improve current public health vaccination strategies.This cross-sectional study was conducted between April and May 2023. Data were collected through the administration of a validated anonymous questionnaire. All Italian medical students at the University Hospital “Federico II” of Naples, the largest university hospital in Southern Italy, were invited to participate through multiple communication channels, including email, posters distributed across university premises, and info points. All prospective participants received comprehensive information concerning the research’s purpose and scope, the methodology employed, the voluntary nature of their involvement, the assurance of complete anonymity and confidentiality of their shared information, and the option to discontinue their participation at any time without the need to provide a rationale. Before completing the survey, written consent was secured from each participant. Consent was collected separately from the survey to protect the privacy of the participants. Sample calculation was based on the population size of students attending the first 3 years of medical school, as they were our primary target population . However, we also extended the possibility to participate in the study to the other medical students. The desired sample size was 843 subjects, considering a population of 3,999 medical students, a confidence level of 95%, and a margin of error of ±3%. Ethical approval was granted by the University Hospital Ethics Committee ; the study was conducted in accordance with good clinical practice and the Declaration of Helsinki.Study variables were retrieved from a questionnaire that was adapted from a previously validated questionnaire . Before p-value was <0.05. Statistical analyses were performed using Stata MP 15.0 statistical software.Study population characteristics were analyzed using descriptive statistics, as appropriate. Analyses were performed for the entire study population but were also restricted to female students and the sexually active population. Multivariable logistic regression models were employed to identify factors associated with HPV uptake, whereas factors associated with knowledge were explored through multivariable linear regression models and factors associated with attitude were analyzed using multinomial logistic regression models. Models were controlled for sex, age, year of enrollment, smoking habits, province of residence, receipt of an invitation to undergo vaccination (HPV invitation), number of sexual partners over the last year, an ob-gyn visit , and the use of condoms . To better assess the contribution of each variable, multiple models were used . Being a sixth-year student was associated with a 3.5-fold increase in the likelihood of HPV vaccination uptake compared with first-year students . Furthermore, receiving an invitation for vaccination was positively associated with vaccination uptake . These findings were consistent with models considering both sexually active individuals and females. In the latter, a positive association was also observed for fifth-year students  .When examining correlates with the percentage of knowledge, we observed significant negative associations with male sex and individuals with 2–5 sexual partners over the last year . On the other hand, the year of enrollment displayed a positive likelihood of having a higher score . The observed results, except for the number of sexual partners, were consistent for the female and sexually active populations .The likelihood of having a higher attitude score was reduced by 62% for males . Conversely, being in a higher year of enrollment had a positive correlation with the likelihood of having a higher score ; these results were consistent when considering the female population, including the fourth year, and sexually active population, except for the fifth year. Only when considering the entire population, did former smokers (OR: 1.76) or individuals residing in the provinces of Avellino and Benevento (OR: 1.80) show an increased likelihood of having a higher attitude score .p-value was 0.051. These results were confirmed in the different samples, except for former smokers in the female population and for the fifth year of enrollment and residing in the province of Caserta in the sexually active population. Instead, the positive association with HPV invitation was found only in the sexually active sample  . For former smokers, the reduction was 61%  compared with non-smokers, and for those resident in the province of Caserta, the reduction was 55%  compared with those resident in the province of Napoli. Furthermore, increasing age showed a negative association with HPV vaccination . The likelihood of being vaccinated was higher for those in the fifth or sixth year of enrollment  compared with first-year students. We found a negative association with the percentage of knowledge  and a positive association with attitude score  . However12–3.46) .This survey-based cross-sectional study evaluated socio-demographic characteristics, healthcare-related and organization factors and barriers, and sexuality associated with knowledge, attitude, and self-reported HPV vaccination uptake in 882 medical students at the largest university in Southern Italy, from March to June of 2023. More than 60% of our study population were females, 78.5% of whom were vaccinated against HPV, as compared with 16.5% of males. We consistently observed that male sex and increasing age were associated with a lower likelihood of being vaccinated against HPV, whereas we found an increase in the likelihood of being vaccinated as students progressed in their academic career. Overall, these associations were confirmed when considering knowledge and attitude towards HPV. Additionally, we found evidence that active outreach from healthcare institutions was associated with a higher likelihood of receiving HPV vaccination.Sex was a strong correlate across all analyses. This result has been described previously in literature, and official data , 23 whicIncreasing age was associated with a lower likelihood of being vaccinated against HPV, as with each additional year, there was a 23% drop in the probability of being vaccinated. This evidence is supported by previous studies carried out in similar settings . A possiSenior year students were associated with HPV vaccination uptake in both the entire and female populations, whereas no differences were observed in those who were sexually active. When restricting analyses to female students only, this association was further strengthened, and there was also a trend in fifth-year students. This finding has been reported in previous studies conducted in similar settings , 29. AltReceiving an invitation increased the probability of being vaccinated against HPV. This evidence enlightens the role of an active call-in determining HPV vaccination uptake, and although it has been suggested by previous documents , 33, itsWe conducted our analysis in the largest university in Southern Italy, which accounts for over 4,000 medical students  . Hence, Medical students are an ideal population for identifying determinants of HPV vaccination uptake. A decrease in the rate of vaccination, exacerbated by the pandemic , may draIn this study, we found that HPV vaccination in medical students at University “Federico II” of Naples is higher than in the general population but still suboptimal. Sex and increasing age are strong drivers of vaccination uptake. We confirmed that an active call strategy, an important organizational factor, is essential for improving vaccination uptake. Further studies addressing the impact of other organizational factors that might influence HPV vaccination uptake should be conducted to better tailor interventions.Our findings support the need to improve public health strategies to strengthen communication strategies and increase awareness and knowledge regarding HPV vaccination, even in hard-to-reach groups. A comprehensive strategy, which might also include extending the free-of-charge offer, may increase HPV vaccination uptake as well as improve the knowledge of and attitude toward vaccination in general.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving humans were approved by Ethical approval was granted by the University Hospital Ethics Committee . The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.MS: Data curation, Formal analysis, Methodology, Writing – original draft. MM: Writing – original draft. FE: Writing – original draft. AL: Writing – original draft. GB: Writing – original draft. CR: Writing – original draft. MT: Writing – original draft, Writing – review & editing. RP: Writing – original draft, Writing – review & editing.


The World Health Organization (WHO) has called for the elimination of cervical cancer as a public health problem. Cervical cancer screening through human papillomavirus (HPV) testing is a core component of the strategy for elimination, with a set target of screening 70% of women twice in their lifetimes. In this review, we discuss technical barriers and opportunities to increase HPV screening globally. Cervical cancer remains a major cause of female morbidity and mortality globally, with an estimated 604,000 new cases and 342,000 deaths in 2020 . Almost Cervical cancer is preventable through prophylactic HPV vaccination of young women, most effectively in those who have not yet acquired HPV, and screening with treatment of screen positives with pre-cancers in mid-adult women. In 2018, the World Health Organization (WHO) announced a global call for action to eliminate cervical cancer with the target of having 90% of girls fully vaccinated by age 15, 70% of women screened, and 90% of women with pre-cancer or invasive cancer managed. Currently, many LMICs are not poised to achieve the WHO screening target. For example, no country in sub-Saharan Africa (SSA) has achieved the screening target , the aveTesting for carcinogenic HPV (“HPV testing”), the etiologic agent that causes virtually all cervical cancer, is the more sensitive, reliable screening method compared to cytology  or visual inspection with acetic acid (VIA)  2]. HPV. HPV2]. Although the evidence indicates that HPV detection is the most effective method of cervical cancer screening, HPV testing remains largely inaccessible in LMICs, where most of the global burden of cervical cancer resides. Of the 47 countries in SSA, national screening policies exist for 15 countries; but only two countries, Botswana, and Rwanda, have national screening policies that include HPV DNA testing . HoweverThus, to overcome this global health disparity in cervical cancer, measures need to be taken to increase the access and availability of validated HPV tests and testing protocols for cervical cancer screening. Here, we provide background on pre-analytic and analytical aspects of HPV testing, and we then consider technical barriers and opportunities related to universal access HPV testing for cervical cancer screening aligned with the framework shown in HPV testing requires sample collection, stable sample storage and transport, and molecular testing by trained laboratorians. Technical considerations related to pre-analytic and analytic phases of testing are discussed below.HPV testing may use a provider-collected specimen with or without pelvic exam or a self-collected cervicovaginal specimen. With self-collection, the sample is collected with a swab and is stored in a tube either with liquid sample collection media or without  until analysis. Samples must be transported to a lab for HPV testing and subsequent triage testing of HPV-positive specimens, which requires transport infrastructure, trained laboratory personnel, equipment, and reagents.As of January 2020, there were 254 distinct HPV tests on the global market and 425 HPV test variants  . Even th1.2.1 HPV molecular targets. Commercial, validated HPV tests detect the DNA or RNA of HPV16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, and/or 68, which are considered carcinogenic or probably carcinogenic [Most HPV tests on the market detect HPV DNA. Persistence of an HPV infection and progression toward high-grade disease will lead to the overexpression of HPV early viral proteins, e.g., oncoproteins E6 and E7 . Therefo1.2.2 HPV Genotyping. Pooled HPV DNA testing reports a positive or negative readout for the presence of any carcinogenic HPV genotype, which is appropriate for screening per WHO guidelines [idelines . At the idelines .Most HPV tests on the market identify some HPV genotypes individually. Recent evidence indicates genotyping is clinically useful for risk determination, either by categorizing genotypes into risk strata or through tracking single-genotype persistence . AdditioCountry-level data on HPV genotype carriage to inform screening algorithms, policy, and research are lacking . There mEstablishing a new cervical cancer screening program or sustaining an existing program requires navigating technical differences to choose an appropriate collection device, transport media, and test. Many of the collection devices and transport media options on the market are proprietary and specific to a single test or have been validated and approved for use in a subset of available tests . Moreove2.1.1 Self-collection for HPV testing. One of the important advantages of HPV testing is that women can self-collect a cervicovaginal specimen [specimen ,19. Selfspecimen . Moreovespecimen ,22.Importantly, a 2018 meta-analysis of well-controlled, research studies found the clinical performance of HPV testing using self-collected cervicovaginal specimens was comparable to provider-collected cervical specimens when a PCR-based DNA test is used and slightly less sensitive when a signal-amplification DNA test is used . RNA tesHowever, clinical performance of HPV testing of self-collected specimens in real-world settings may have reduced performance  and may 2.1.2 Self-collection implementation considerations. A major challenge associated with HPV test implementation is a lack of standardization of sample collection brushes and media [nd media . The shend media . A summand media . Yet, thThe choice of collection device has implications for downstream laboratory testing, as the amount of genetic material and inhibitors varies based on geometry and material of the collection device. Moreover, commonly available materials used for sample collection, like cotton swabs and tampons, may introduce additional inhibitors and require more complex laboratory procedures to recover HPV DNA for testing .Aside from the sampling product, samples can be collected into liquid cytology buffers, liquid molecular buffers, or stored without a buffer (“dry”) . BenefitCurrently, there is not a single universal molecular testing buffer. An ideal universal molecular buffer for testing for HPV and other analytes should be intended for molecular testing for any HPV target, including DNA, mRNA, and perhaps even proteins. It should be inexpensive and non-toxic, stabilize the molecular targets under a wide range of environmental conditions, and require minimal laboratory processing. Several technical challenges persist even when a buffer is designed for molecular testing. Many molecular testing buffers include lysis agents, including salts or detergents, that preserve DNA in a range of storage conditions, but that also interfere with enzymatic activity in downstream DNA detection. Different testing platforms may use different methods to purify DNA from the buffers’ inhibitory components, thereby limiting the universality of molecular lysis buffers in use today. There is a technical knowledge gap on protecting DNA from degradation through time and temperature fluctuations without requiring DNA extraction and/or purification during sample processing.There is also limited validation among the many products that already exist for sample collection, which provides technical barriers for implementers. Several combinations of collection buffers and devices have been evaluated across HPV testing platforms , but theReducing the complexity of the testing landscape could include (1) standardizing a common buffer or sample type across platforms and (2) expanding validation studies of a wide range of buffers or sample types across platforms. Validation studies investigating dry swab stability and resulting clinical sensitivity for high-grade disease across platforms could be useful in expanding the use of dry swabs.2.1.3 Increasing access with self-collection. Self-collection is a safe, easy, and acceptable method of sample collection that allows for decentralized cervical cancer screening participation for women who otherwise may not participate. However, there are several challenges specific to self-collection. Logistically, samples need to be transported from the screening site to the laboratory, and the result of the test needs to be communicated back to the screening participant with appropriate linkages to follow-up care [-up care . One exa-up care . Moreove-up care . If self-up care . Finally-up care .Additional efforts to optimize dry swab stability for transport, protocols for vaginal sample processing, and test characteristics for compatibility with dry swabs could improve performance of self-collection with dry swabs. Characterization of sample stability in diverse modes of transport  over different time spans is needed to inform future self-collection schemes. Moreover, quality control indicators should be designed at the sample and/or test level to identify sample degradation in dry swabs.2.1.4 Emerging evidence on urine. In addition to swab-based testing, there is growing body of evidence of good analytic performance of HPV testing using urine. A recent meta-analysis found that, like using self-collected cervicovaginal specimens, using a PCR-based HPV test achieved better performance than other technologies for HPV detection and approached that of a provider-collected cervical specimen [specimen . The metspecimen . There iCurrently, HPV tests on the market remain too complex or too expensive for true point-of-care use, which would enable rapid screening testing, diagnose, and treat patients within a single appoinent, thereby reducing loss to follow-up . Expandiin vitro diagnostics globally, especially in SSA [Perhaps an underappreciated challenge to expanding the use HPV testing and other y in SSA , is the y in SSA ,34.Despite the high number of HPV tests on the market, very few of them have been properly validated. Intensive resources and effort are required for implementing new validation studies. Existing sample banks limit test developers to samples that are stored in specific buffers or are stored dry. Both new studies and existing sample banks may not include appropriate correlated data on HPV status and clinical endpoints. Test developers could benefit from a standardized and well-validated set of reference samples. Even though the creation of validated banks of samples also demands significant invesent of time, resources, and effort, having such bank could facilitate the validation of novel HPV tests from small companies with innovative and promising technologies.Even with new innovations and further validation of existing tests, access to HPV testing in LMICs will require a global procurement strategy ,36. SuchFor example, as of July 2021, the Clinton Health Access Initiative (CHAI) reports that per-test pricing for nine selected HPV tests ranged from US$4.95 through US$14.90   and low positive predictive value (est. <20%) . In highp16ink4a) [Potential strategies to triage HPV DNA screen-positive women are being investigated, including detecting HPV biomarkers more specific to disease progression such as HPV mRNA ,45, HPV 16ink4a) , host or16ink4a) ; and HPV16ink4a) . It may The WHO already recommends partial genotyping of HPV16 and HPV18, and in some cases HPV45, for the management—not screening, per se—of HPV-positive women. HPV16- or HPV18-positive women are at sufficiently high risk that they recommended further evaluation and treatment if needed regardless of the cytology result . IncreasRecent cervical imaging innovations may provide technological solutions for enabling high-performance diagnosis for screen-positive women. Automated visual examination (AVE), a machine-learning algorithm that analyzes images to improve accuracy of visual cervical inspection, may increase access to high-performance diagnosis; even though AVE showed very promising initial results, it still requires further development and validation before its implementation in clinical practice .Additionally, the high-resolution microendoscope (HRME) is an emerging technology that provides subcellular resolution for real-time cervical imaging ,32. The Once rigorously evaluated, automated imaging modalities with HPV genotyping may provide the highest quality determination of who should be preventively treated . ProcureAccess to more affordable and suitable testing platforms is needed. The massive disruptions to global and national health systems brought by the COVID-19 pandemic showed the need for new tests suitable for all resource-settings. Importantly, diagnostic technology development and access have exacerbated global health inequities, with manufacturing and testing capacity lacking where it has been needed most .https://www.nih.gov/research-training/medical-research-initiatives/radx/radx-programs) initiative to speed test development, commercialization, and implementation of SARS-CoV-2 testing. RADx focuses on multiple areas, including point-of-care and home-based tests, and testing strategies to reduce health disparities, and increased testing capacity with high-throughput platforms. Emergency measures were taken in most countries to expedite the approval process to get vaccines or drugs into their countries. Building from these measures, regional approval approaches could facilitate access to new technologies.In response to SARS-CoV-2 testing demand that outpaced supply, several initiatives were launched . Similarhttps://www.finddx.org/test-directory/) has tracked 2,099 commercialized molecular tests, 196 of which are categorized as near point-of-care, and 1,043 are categorized as true point-of-care. The tests included in the directory have different regulatory statuses, which are detailed in FIND’s directory, with 1,465 tests approved under European CE marking for in vitro diagnostics (CE-IVD) and WHO Emergency Use Listing (EUL) guidelines. These new technology platforms that enable molecular testing at home, at the point-of-care in decentralized clinics, or in centralized labs with samples collected at home all create major opportunities for expanded HPV testing. One clear opportunity is to develop HPV assays into the platforms that were developed, manufactured, and commercialized for SARS-CoV-2 detection. Another is to apply the same design principles to develop new molecular tests specific to HPV DNA, a simpler target to detect compared to SARS-CoV-2 RNA, and therefore potentially at a lower cost.As a result of the pandemic, an unprecedented number of molecular tests came onto the commercial market, ranging from home-use molecular tests through ultra-high-throughput platforms. As of November 2022, FIND Click here for additional data file.


Members of the human papillomavirus (HPV) family have been known for causing cancers and condylomas in the anogenital tract for some time, as reflected by the Nobel Prize in Medicine given to Professor Harald zur Hausen 2008. In the past decades, however, much attention has also been directed to the importance of HPV and diseases in the head and neck region. This is because the cases of HPV-associated head and neck carcinomas are increasing globally. Recently, we presented a Special Issue on “HPV in the head and neck region” which included several contributions to the overall knowledge of HPV in the head and neck region. In this second “Special Issue on HPV in the head and neck region 2.0”, eight original articles, one review, and one systematic review are presented ,7,8,9,10One of the original articles investigated whether HPV or human polyomaviruses (HPyV) had an aetiological role in the development of adenoid cystic carcinoma (AdCC) in a cohort of 68 diagnosed with AdCC between 2000–2014; no cases with HPyV were detected, while three cases were HPV positive [Another of the original papers examined the presence and role of HPV in 48 mucoepidermoid carcinomas (MEC) . HPV wasThree of the original articles describe the prevalence of HPV in locations and various consequences ,4,5. OneA sixth original article investigated the presence of the neutrophile-to-lymphocyte ratio (NLR) as a prognostic marker in HPV+ and HPV− OPSCC . The autA seventh original article investigated the value of post-treatment neck dissection (ND) after tonsillar and base tongue cancer in the Era of PET-CT, HPV, and p16 . The preAn eighth original article described attempts to experimentally use various targeted therapies for HPV+ and HPV− tonsillar and base tongue cancer . The autThe review included in this Special Issue focuses on high-risk HPV-E6 or -E7-based vaccines, based on plasmid, messenger RNA, or peptide, and their present stage of development and testing . In addiFinally, the systematic review investigated the presence of HPV in oral cavity squamous cell carcinoma (OCSCC) and included 31 studies comprising 5007 from 24 countries . The oveWith this summary, we would like to thank all authors for their very informative contributions to this Special Issue. It has been of great interest to follow the most recent events in this relatively new cancer field and hopefully, many of these contributions will also be helpful to both better prevent disease as well as improve tailored treatment.