The prevalence, genotypes, and vertical transmission characteristics of human papillomavirus (HPV) among pregnant women from Nanjing, China was investigated.Cervical cells were collected from healthy pregnant women  for cytological evaluation and determination of HPV infection status. Exfoliated oral and genital cells were collected from neonates  whose mothers were positive for HPV DNA. We used HPV Gene Chip technology with 23 HPV genotype probes to conduct our analysis.vs. 11.6%).Overall prevalence of HPV DNA among pregnant women was 13.4% (422/3139). The most frequently detected HPV genotypes were HPV-16 , -18 , and -58 . The rate of concordance for HPV DNA in maternal-neonatal pairs was 23.6% (55/233), with HPV type-specific concordance occurring in 26 cases. A higher prevalence of HPV DNA was apparent in female neonates compared with males (17.7 The prevalence of cervical HPV DNA in pregnant women from Nanjing was low, with vertical transmission rates slightly higher. From our findings, we concluded that there was efficient vertical transmission of three HPV genotypes, with HPV-16 the most prevalent type in pregnant women and newborn babies. Globally, cervical cancer is the second-most commonly occurring cancer in women. In recent years, the occurrence of sexually transmitted infections (STIs) involving human papillomavirus (HPV) has been increasing in China, and are now second only to the incidence of STIs for gonorrhea . HPV hasIn the early 1950s, a study revealed that pregnant women infected with HPV were able to vertically transmit the virus to neonates, resulting in infantile anal and genital condyloma acuminatum, congenital conjunctival papilloma, and juvenile laryngeal papillomatosis . A recenThe five most prevalent HPV genotypes associated with genital and oral cancers in females are HPV-16, -18, -31, -58, and -52 . Previouet al.  was then conducted to visualize results.HPV genotyping was conducted using PCR, DNA hybridization, and an HPV genotyping DNA chip (Decipher Bioscience). An HPV typing kit (Guangdong Hybribio Biotech) was used for quality control. An HPV GenoArray Test Kit (HybrMax), based on “Flow-through Hybridization” and certified for use by the State Food and Drug Administration, was also used for the rapid detection of 21 HPV genotypes. DNA was extracted from samples and centrifuged . PCR assays were performed in reaction tubes containing 5 μL of DNA and 20 μL of reaction buffer containing specific biotin-tagged oligonucleotide primers. Thermal cycling conditions involved preheating at 50°C for 15 min, then an initial denaturation step at 95°C for 10 min, followed by 40 cycles of 30 s at 94°C, 90 s at 42°C, and 30 s at 72°C, and then a final extension step at 72°C for 5 min. Reverse hybridization was performed using a line-probe assay to enable the PCR products hybridized with specific probes to fix to membranes. Chemical colorization [0.1 M sodium citrate, tetramethylbenzidine (TMB) substrate, 30% H2 or Fisher’s exact test. A P-value less than 0.005 was considered statistically significant.Statistical analyses were performed using the SPSS version 17.0 for Windows . Logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) to determine factors associated with HPV infection. The influence of delivery type and neonate gender on neonatal HPV infection was analyzed using the χ2 = 12.07, P = 0.001). Prevalence of HPV in women experiencing their first pregnancy was 13.8% . Parity did not appear to be associated with HPV prevalence . Most women in this study (72.4%) had a level of education that went past secondary school. A significant difference was seen in HPV prevalence among women with different education levels . Abnormal cervical cytological results were found in 42 (1.3%) women, with an HPV prevalence of 76.2% (32/42).The risk factors for HPV infection, and the cervical prevalence of one or more HPV genotypes in the 3139 participants is outlined in Table Figure 2 = 1.64, P = 0.268), or between the type of delivery . The HPV-16 genotype accounted for the majority  of infections in infants. In 233 mother-neonate pairs, the HPV DNA concordance rate between mothers and newborns was 23.6% (55/233). HPV type-specific concordance occurred in 26 cases, with HPV-16 the most frequently detected genotype (18/26), followed by HPV-11 (2/26) and -31 (2/26) (Table In 23.6% (55/233) of neonates, the oral and/or genital mucosa were positive for HPV DNA. No significant difference was seen between male and female infants . The HPV DNA concordance rate between these 233 mother-neonate pairs was 23.6% (55/233). HPV type-specific concordance occurred in 26 cases (11.2%) and HPV-16 was the most frequently detected genotype  of the tested neonates were delivered vaginally and 41.6% (97/233) were delivered by cesarean sections  was much higher than that of mothers with normal cytology, none of the 19 neonates from mothers with abnormal cytology were HPV-positive. There was no significant influence of delivery type on the vertical transmission of HPV, which is consistent with reports of congenital condyloma after cesarean section without premature rupture of membranes . Deliverrd blood -28. Dispet al. [Ping et al.  previousth week of gestation; 81.5% of the women in our study were at weeks 22–26 of gestation. Given this small interval of gestational age, it was not possible to examine the influence of this variable on HPV infection in pregnant women. It was previously found that HPV infection in pregnant women was primarily associated with maternal age and education. The influence of education level on HPV infection is most likely explained by the early age of first sexual intercourse and first pregnancy [Pregnant women in Jiangsu Province usually begin routine obstetric care around the 24regnancy .et al. [et al. [The microarray used in this study was developed by Decipher Bioscience to detect 23 HPV genotypes. As a diagnostic tool, the application of microarray technology has the advantage of discriminating HPV genotypes and detecting infection of multiple HPV subtypes . In a poet al.  confirme [et al.  found a  [et al. ,33.et al. [Immunological or hormonal changes may alter the prevalence of HPV and its clearance during pregnancy . Some reet al.  found noet al. [The prophylactic bivalent HPV 16/18 vaccine manufactured by GlaxoSmithKline is currently in phase-III clinical trials in Jiangsu Province. Few studies have evaluated the safety of this vaccine for pregnant women in China. Given that primary target population of the HPV vaccine is women of a reproductive age, the risks associated with its administration during pregnancy are important factors affecting personal decisions and public health policy. In a study of 3599 pregnancies, Wacholder et al.  detectedThe present study found a high prevalence of HPV among pregnant women in Nanjing, the urban center of a highly developed province in China. This prevalence did not differ significantly from that found among the general female population of China. Although some vertical transmission was documented, the high rate of discordance in the HPV genotypes of mothers and neonates indicates the need for efforts to prevent horizontal transmission. Subsequent investigations should examine the role of viral load in vertical transmission.This large-scale investigation evaluated the prevalence of HPV infection in pregnant women and the rate of vertical transmission. The most frequently detected HPV genotypes in mothers and neonates were HPV-16 and -18, consistent with the target genotypes of HPV vaccines. Currently, no vaccine recommendations for pregnant women have been provided and it is hoped that the current study provides preliminary information that can guide appropriate vaccination strategies for mothers and newborns.The most frequently detected HPV genotype in pregnant women and newborns was HPV-16.This study was approved by the Affiliated Drum Tower Hospital, and Nanjing University Medical School Ethics Committees.HPV: Human papillomavirusThe authors declare that they have no competing interests.YH conceived and designed the project, and analyzed data. S-QL participated in data collection. Y-LH provided guidance on this project. Z-QW participated in part of the data collection. All authors have read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2334/13/109/prepub


Cutaneous human papillomavirus (HPV) infections seem to be associated with the onset of actinic keratosis (AK). This study compares the presence of cutaneous HPV types in eyebrow hairs to those in tissues of normal skin and skin lesions of 75 immunocompetent AK patients.Biopsies from AK lesions, normal skin and plucked eyebrow hairs were collected from each patient. DNA from these specimens was tested for the presence of 28 cutaneous HPV (betaPV and gammaPV) by a PCR based method.The highest number of HPV prevalence was detected in 84% of the eyebrow hairs  compared to 47% of AK lesions  (p< 0.001) and 37% of normal skin  (p< 0.001), respectively. A total of 228 HPV infections were found in eyebrow hairs compared to only 92 HPV infections in AK and 69 in normal skin. In all three specimens HPV20, HPV23 and/or HPV37 were the most prevalent types. The highest number of multiple types of HPV positive specimens was found in 76% of the eyebrow hairs compared to 60% in AK and 57% in normal skin. The concordance of at least one HPV type in virus positive specimens was 81% (three specimens) and 88-93% of all three combinations with two specimens.Thus, eyebrow hairs revealed the highest number of cutaneous HPV infections, are easy to collect and are an appropriate screening tool in order to identify a possible association of HPV and AK. Presently, 151 HPV types are completely characterized  -15. The animals) ,10,15. AThe first evidence for the association of HPV in the development of actinic keratosis (AK) and cutaneous SCC was shown in patients with the disease Epidermodysplasia verruciformis (EV) ,17. EV pIn SCC of non-EV patients both beta1PV and beta2PV were detected ,21. In lSo far, only little is known about the natural history of cutaneous HPV types and in previous epidemiological studies mostly eyebrow hairs, skin swabs and rarely normal skin samples have been used to determine the cutaneous HPV profile of patients or volunteers -29. CutaINK4a and Ha-Ras in immunocompetent AK patients [This study was designed according to a previously reported study analyzing the tumor-specific mutations of p53, p16patients . BrieflyDNA isolation of both cryo-biopsies and eyebrow hairs was performed using QIA-amp DNA Mini Kit  according to the manufacturer’s protocol. The samples were eluted in 100 μl of AE buffer and stored at −20°C until processing. HPV detection and typing was performed as previously described ,33. WithThe prevalence of cutaneous HPV in each specimen  was calculated. A specimen was rendered positive if at least one HPV type was detected and statistical analysis was performed using chi-square testing or fisher-exact testing, when frequencies were smaller than five. A p-value of < 0.05 was considered significant either for alpha, or for alpha multiple with p-adjustment. HPV concordance between any two sample types of the three different specimens  was calculated with the U-test by Wilcoxon, Mann, and Whitney Figure . Kappa-vA significant higher number of cutaneous HPV infections (betaPV and gammaPV) were detected in eyebrow hairs 63/75; 84%) compared to AK lesions  and normal skin 28/75; 37%) p<0.001), respectively. All 28 HPV types examined were detected in the present cohort  from six different countries and cutaneous HPV infections were detected in 84-91% . AnotherOnly few studies examined cutaneous HPV types in normal skin biopsies, because routinely only perilesional skin is removed during surgery of skin cancer. A low number of cutaneous HPV was found in 16% of normal skin (57 skin biopsies) . In a fuIn a recent comparative study cutaneous HPV infections of 21 SCC patients were examined with four different specimens; eyebrow hairs, perilesional skin, normal skin and SCC . A high Cutaneous HPV infections were found in 41% of AK (27 skin biopsies) by PCR based methods able to detect approximately 100 HPV types . We deteIn our study, not a specific type or particular combinations of HPV types were detected in AK lesions compared to normal skin and eyebrow hairs. The concordance of all three different specimens of HPV positive samples was high. Most importantly, we identified a significant higher number of cutaneous HPV types in eyebrow hairs compared to normal skin and skin lesions of AK patients. Thus, eyebrow hairs seem to be an appropriate marker to examine the role of cutaneous HPV and AK.The authors declare that they have no competing interest.IS analysed the data, created the figures and revised the manuscript. MGL performed all experiments. VK interpreted the results and revised the manuscript. ES collected all clinical specimens, interpreted the results and revised the manuscript. IN designed the study, monitored the project activities and coordinated the activities of the laboratory, interpreted the results, drafted and edited the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2334/13/186/prepubCutaneous HPV types detected in 3 different specimens of 75 immunocompetent AK patients.Click here for file


Three meta-analyses and one systematic review have been conducted on the question of whether self-collected specimens are as accurate as clinician-collected specimens for STI screening. However, these reviews predate 2007 and did not analyze rectal or pharyngeal collection sites. Currently, there is no consensus on which sampling method is the most effective for the diagnosis of genital chlamydia (CT), gonorrhea (GC) or human papillomavirus (HPV) infection. Our meta-analysis aims to be comprehensive in that it will examine the evidence of whether self-collected vaginal, urine, pharyngeal and rectal specimens provide as accurate a clinical diagnosis as clinician-collected samples (reference standard).2 test. Sensitivity and specificity estimates with 95% confidence intervals as well as negative and positive likelihood ratios will be pooled and weighted using random effects meta-analysis, if appropriate. A hierarchical summary receiver operating characteristics curve for self-collected specimens will be generated.Inclusion and exclusion criteria: Eligible studies include both randomized and non-randomized controlled trials, pre- and post-test designs, and controlled observational studies. Search strategy: The databases that will be searched include the Cochrane Database of Systematic Reviews, Web of Science, Database of Abstracts of Reviews of Effects (DARE), EMBASE and PubMed/Medline. Data collection and analysis: Data will be abstracted independently by two reviewers using a standardized pre-tested data abstraction form. Heterogeneity will be assessed using the QThis synthesis involves a meta-analysis of self-collected samples  versus clinician-collected samples for the diagnosis of CT, GC and HPV, the most prevalent STIs. Our systematic review will allow patients, clinicians and researchers to determine the diagnostic accuracy of specimens collected by patients compared to those collected by clinicians in the detection of chlamydia, gonorrhea and HPV. Increasing rates of sexually transmitted infections (STIs) remain a growing concern worldwide -3. DespiSelf-collection of urine, vaginal, rectal and pharyngeal samples provides a different option for screening outside of the traditional clinical setting. Settings for self-collection of samples for STI testing can include community-based organizations, street outreach settings and the internet. However, more evidence is required to determine whether self-collected specimens are as accurate as clinician-collected specimens in terms of diagnostic accuracy for CT, GC and HPV, prior to recommending it as standard practice. The purpose of our systematic review and meta-analysis will be to examine whether a self-collected sample is as accurate as a clinical-collected sample for the diagnosis of CT, GC and HPV. Our specific research question is:Are self-collected vaginal, urine, pharyngeal and rectal samples as accurate as clinician-collected samples for the diagnosis of CT, GC and HPV?Eligible studies will include both randomized and non-randomized controlled trials, pre- and post-test designs, and controlled observational studies examining self-collected versus clinician-collected samples using the nucleic acid amplification test (NAAT) to detect GC, CT and HPV. All manuscripts must include a reference standard of a clinician-collected specimen. Manuscripts that only report a kappa statistic (measuring agreement between the self-collected sample and the clinician-collected sample) will also be reviewed. Table Neisseria gonorrhoeae assay), and the ligase chain reaction (discontinued as of 2002) [Our reference standard will be clinician-collected samples. Both self-collected and clinician-collected samples must have used a NAAT to be included. NAATs are highly sensitive and specific for the detection of CT and GC when using swabs from the genital tract or first-catch urine specimens . The difof 2002) -8.Dual assays that test for CT and GC, include AC2, Becton Dickinson ProbeTec™ CT/GC, AC and Abbott Realtime™ CT/NG assays -10. The Our search will include English and non-English databases. Our search will be limited to articles published since 1990 because of two factors: (a) the HC2 test is the most widely used HPV test worldwide and was first used in 1990  and (b) Sexually Transmitted Infections, Sexually Transmitted Diseases and Journal of Clinical Microbiology.MeSH headings, subject headings and keywords will be created using language that describes laboratory test performances for NAAT tests for GC, CT and HPV. The scope notes of the MeSH headings and subject headings and terms will be reviewed to identify additional terms, common usage and previous usage for terms being searched. Keywords in published journals will also be used. Search terms will include but will not be limited to: internet STI testing; sexually transmitted diseases; sexually transmitted infections; chlamydia; gonorrhea; human papillomavirus/HPV; screening; testing; reproductive health; adolescent health; non-clinic testing; urine testing; vaginal testing; pharyngeal testing; self-collected specimens; home sampling; test performance; test accuracy; PCR, polymerase chain reaction and nucleic acid amplification test sensitivity; specificity and diagnostic ratio. Boolean combinations will be created for more specific searches. Authors will also be asked to identify key articles that should be included in the review. The bibliographies of retrieved articles will also be manually searched as well as key journals such as Data will be abstracted independently by two reviewers using a standardized pre-tested form. Any disagreements between the reviewers will be resolved by a third reviewer. The following data elements will be extracted, and if appropriate, used for stratification if heterogeneity is found: true/false positive; true/false negative; sensitivity; specificity; reference (gold) standard used to compare test characteristics; NAAT platform used; specimen ; diagnostic odds ratio; positive likelihood ratio; negative likelihood ratio; kappa statistic; sex and age of participants; presence of symptoms ; HIV status; date of study initiation and publication status (published or unpublished); country of study and author affiliation; number of specimens analyzed; number of tests per patient; any elements of blinding; location of self-collection ; community type ; sex ; population type ; sexual orientation ; religion; clinician setting ; HPV type  and prevalence. If studies involve several self-sampling methods, the first method described will be used in the analysis. We consider any high-risk HPV positive test as standard; however, if the authors have not separated high- and low-risk HPV types, we used their combined data.The numbers of true positives, false negatives, false positives and true negatives will be extracted from each study, and test sensitivity and specificity as well as likelihood ratios will be calculated. Coupled forest plots for paired sensitivity and specificity for each study along with 95% confidence intervals will be created in RevMan 5.0 to detect publication bias, if present. A meta-analysis will be conducted according to the Cochrane Collaboration’s new recommended methodology for systematic reviews of Diagnostic Test Accuracy . HierarcValidity will be assessed using the Quadas-2  checklist . SensitiA search of the Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, EMBASE and PubMed/Medline using a review filter was conducted using the terms self-sampling and noninvasive sampling. One previous 2005 systematic review  evaluateIncreasing rates of STIs remain a growing concern in British Columbia, Canada, and worldwide. Rates of STIs continue to grow despite active and passive surveillance and multiple interventions aimed at increasing the number of cases found and treated. New interventions, such as self-collected sampling, are needed to identify STIs and stop the upward trend.Reported rates of genital chlamydia (CT) have steadily increased in British Columbia since 1998, from 122/100,000 (1998) to 255/100,000 (2011), with the majority of cases being in females between the ages of 15 and 24 .The prevalence of HPV among women aged 13 to 86 is estimated to be 16.8%  and gay, bisexual and other men who have sex with men (MSM) -37. StigGetCheckedOnline, aimed at decreasing barriers to STI and HIV testing with an emphasis on youth and MSM. Focus group discussions with youths, MSM and STI clinic clients revealed that they would use the internet-based testing service or recommend it to others [A number of models for internet-based testing have been developed, all typically including an online risk self-assessment, test recommendations and specimen collection without requiring presentation to a clinic . Self-coo others . The inco others ; howeverSelf-collected samples are also potentially more cost effective compared to clinician-collected samples. Organizing samples through the internet can reduce health service and delivery costs as interventions delivered over the internet are likely to cost less than treatments requiring frequent contact with health-care professionals . Huang aThe outcomes of this systematic review and meta-analysis are important in the detection of STI disease in hard-to-reach populations, in particular, those who may be unwilling to provide samples in traditional settings. The aim of exploring whether self-collected samples have comparable specificity and sensitively to samples collected in traditional settings has the potential to increase testing rates. Presumably, with higher testing levels, transmission could be reduced. Our systematic review will allow patients, clinicians and researchers to determine the diagnostic accuracy of specimens collected by patients compared to those collected by clinicians in the detection of chlamydia, gonorrhea, and HPV.CT: Genital chlamydia; GC: Gonorrhea; HPV: Human papillomavirus; HSROC: Hierarchical summary receiver operating characteristics; MSM: Men who have sex with men; NAAT: Nucleic acid amplification test; PCR: Polymerase chain reaction; SROC: Summary receiver operating characteristics; STI: Sexually transmitted infection.The authors declare that they have no competing interests.DT and NL drafted the manuscript. CL edited and finalized the manuscript. GO, RL and MG contributed to the research design. DT, CL, GO, MG, LH, MK and TW participated in writing the grant application and edited the manuscript. All authors read and approved the final manuscript.


ARF and p16INK4A. This lesion subsequently forms a warty- or basaloid-type SCC. The HPV vaccine is a promising new tool for prevention of this HPV related SCC of the vulva. The second pathway is HPV-independent. Keratinizing SCC develops within a background of lichen sclerosus (LS) through a differentiated VIN. It has a different set of genetic alterations than those in the first pathway, including p53 mutations, allelic imbalances (AI), and microsatellite instability (MSI). Further clinical and basic research is still required to understand and prevent vulvar SCC. Capsule. Two pathway for pathogenesis of squamous cell carcinoma of the value are reviewed.Squamous cell carcinoma (SCC) accounts for approximately 95% of the malignant tumors of the vaginal vulva and is mostly found in elderly women. The future numbers of patients with vulvar SCC is expected to rise, mainly because of the proportional increase in the average age of the general population. Two different pathways for vulvar SCC have been put forth. The first pathway is triggered by infection with a high-risk-type Human Papillomavirus (HPV). Integration of the HPV DNA into the host genome leads to the development of a typical vulvar intraepithelial neoplasia (VIN), accompanied with overexpression of p14 Squamous cell carcinoma (SCC) accounts for only 5% of the malignant tumors of the female genital tract, but it represents 95% of vaginal vulvar tumors . The incTwo different types of vulvar SCC have been delineated, each with their own precursors. The first type is associated with an infection with one of the high-risk types of Human Papillomaviruses (HPV), and it primarily affects younger women. The other type is associated with a lichen sclerosus (LS) condition, and it occurs predominantly in elderly patients independent of any HPV infection . AlthougWe herein give an overview, focusing on the molecular events of these two distinct HPV-associated and independent pathways for the development of vulvar SCC.Vulvar SCC accounts for 90% of vulvar cancers and 5% of gynecological cancers. Patients usually present with a vulvar mass, which may be pruritic or painful or be associated with bleeding, and, occasionally, with a groin mass. Clinical factors that have adverse prognostic significance include increased stage, older age, smoking, and fixed or ulcerated groin nodes .The three main histological subtypes of vulvar SCC are: warty, basaloid, and keratinizing . The preThe warty or basaloid types of SCC often accompany a normal-type VIN. The basaloid type typically grows in bands, sheets, or nests within a desmoplastic stroma, and focal cytoplasmic maturation and keratinization may be observed. The warty type exhibits invasion as bulbous or irregular jagged nests, often with prominent keratinization. The koilocytotic tumor cells have pleomorphic to bizarre, often multiple, nuclei with irregular contours that vary from hyperchromatic and shrunken to those with clumped or smudged chromatin . Other histological subtypes include verrucous carcinoma, giant cell carcinoma, and acantholytic squamous cell carcinoma. Verrucous carcinoma is highly differentiated squamous carcinoma that has a verrucous pattern and invades with a pushing border in the form of bulbous pegs of neoplastic cells. Squamous cell carcinoma with tumor giant cells is a variant of SCC characterized by multinucleated tumor giant cells, large nuclei with prominent nucleoli, and prominent eosinophilic cytoplasm. This variant is relatively rare and is associated with a poor prognosis. The acantholytic squamous cell carcinoma forms rounded spaces, or pseudoacini, lined with a single layer of squamous cells. Dyskeratotic and acantholytic cells are sometimes present in the central lumen .Various terms have been used to define the precursors of vulvar SCC. Bowen first reported on these squamous intraepithelial lesions in 1912, and they are now commonly referred to as Bowen's disease; since then, a myriad of clinical and histopathological terms have been employed to describe these vulvar precancerous lesions . The IntThe most recent classifications are shown in P = .005). Another study demonstrated that the mean time from the incidence of HPV infection to the development of VIN 1–3 was 18.5 months  [A systematic review of the progression rate from VIN 3 to invasive SCC, after various clinical treatments, was reported to be 3.3% . Nine pe.4–23.6) . The typical presentation of usual VIN is a pruritic, burning, or asymptomatic, white, red, or pigmented lesion. The incidence of this form of VIN has almost doubled over the past several decades, with a significant increase in younger women. The lesions of differentiated VIN usually range from 0.5 to 3.5 cm, appearing as single or multiple gray-white areas with a rough surface or ill-defined white plaques or nodules. The lesions usually occur in postmenopausal women [LS runs a relapsing and remitting course and presenting symptoms include pruritus, soreness, burning, and irritation. Typically, the lesions are white plaques and papules, often with areas of erythema hyperkeratosis, pallor, and ulcer .The histological features of lichen sclerosus (LS) include a thinned epidermis with loss of normal rete pegs, basal layer vacuolar changes and a paucity of melanocytes, and, moreover, a wide band of homogeneous collagen below the dermatoepidermal junction and a band-like lymphocytic infiltrate below the homogenized area are present . The derLS most commonly affects the anogenital area (85% to 98%), with extragenital lesions occurring in 15% to 20% of the patients . LS occuThe risk of development of vulvar SCC in women with LS was shown to be 4% to 5% . A previARF (a cell-cycle regulator which mediates p53 activation) and p16INK4A (a cyclin-dependent kinase inhibitor) [INK4A immunohistochemical staining, and that in all these cases a high MIB1 index was observed. No expression of p53 and p16INK4A was detected in normal epithelium of the vulva [ARF and p16INK4A in the carcinogenesis of vulvar SCC. Two distinct pathways, HPV related and HPV independent, were proposed for vulvar carcinogenesis . Warty/bhibitor) . Hoevenahe vulva . HoweverARF. E6 inhibits p53 function by binding with E6-AP ubiquitin ligase, and leads to p14ARF upregulation via p53 degradation by negative feedback mechanism [INK4A overexpression. Taken together, p14ARF and p16INK4A were over-expressed as a consequence of HPV E6 and E7 expression in cervical carcinomas. The HPV viral gene products E6 and E7 interact with host cell p53 and Rb proteins, resulting in p53 dysfunction and inactivation of Rb, respectively. In cervical carcinogenesis triggered by high-risk type HPV infection, E7 inhibits Rb, resulting in the release of active host E2F-1, which positively regulates host p14echanism , 23. FunARF and p16INK4A in VIN suggests that degradation and inactivation of p53 and Rb are early events in carcinogenesis of HPV-related SCC of the vulva.In carcinogenesis of HPV-related SCC, similar mechanisms to cervical carcinogenesis seem to play an important role. Degradation and inactivation of the tumor suppressor genes p53 and Rb leads to absence of cell-cycle arrest and hyperproliferation of tumor cells. Frequent detection of over-expression of p14In uterine cervical carcinogenesis, integration of the high-risk type HPV DNA into the host genome was demonstrated to be an initial step for monoclonal expansion of dysplastic cells . In the Similar mechanisms to those for cervical cancer seem to play an important role during the development of HPV-related vulvar SCC triggered by high-risk type HPV infection. Integration of HPV-16 DNA, with deletion of the E2 ORF in both the SCC portion and its adjacent VIN 3 lesions, which were all implied to be formed from a single cell of origin through monoclonal expansion, was first demonstrated in a case of vulvar SCC by Ueda et al. . MonocloThe HPV vaccine is a tremendously promising new tool for the prevention of HPV-related SCC of the vulva, as it has already been for the cervix. The FUTURE I study has demonstrated that a prophylactic quadrivalent HPV-(6/11/16/18) L1 VLP vaccine significantly reduced the incidence of HPV-associated anogenital diseases in young women . The proγ-associated proliferative CD4+ T-cell response and a broader response of CD8+ interferon-γ T-cells. A phase II clinical trial of the topical immune-modulator imiquimod, followed by therapeutic HPV-16 vaccine using a fusion protein of HPV-16 E6E7L2 on 19 cases with VIN 2/3, demonstrated that complete regression of VIN 2/3 lesions was observed in 63% of the cases (12 of 19) [Interestingly, a series of 3-4 vaccinations against a synthetic long-peptide of the HPV-16 oncoproteins E6 and E7 was shown to be therapeutically effective for HPV-16-positive VIN 3 patients . At 3 mo2 of 19) .The majority of vulvar SCC are considered to occur in elderly women through differentiated VIN in a background of LS . High-riWe have previously demonstrated that 2 of 6 LS lesions exhibited monoclonality, implying that certain important molecular alterations might occur in some LS lesions well before histologically apparent malignant transformation to differentiated VIN or keratinizing SCC occurs . Rolfe eA recent study demonstrated more frequent hypermethylation of RASSF2A, MGMT, and TSP-1 genes in SCC associated with LS than in SCC not associated with LS, suggesting a possible role of these genes in HPV-independent carcinogenesis . A fraction of squamous cell hyperplasia (SCH) lesions were shown to be monoclonal in composition  and p53 Two distinct pathways leading to vulvar SCC have been suggested. One is a pathway primarily linked to infection with high-risk types of HPV; the other is an HPV-independent scenario. Mechanisms similar to those that drive cervical carcinogenesis possibly play an important role in HPV-related carcinogenesis of vulvar SCC. HPV prophylactic and therapeutic vaccines are both promising to prevent HPV infection and prevent development of warty/basaloid type SCC from its precursor, the usual type VIN. On the other hand, keratinizing type vulvar SCC, which by far represents the majority of vulvar SCC, occurs independently from HPV infection in a background of LS. The mechanism of carcinogenic progression forward from LS in this second pathway has not fully delineated, and it is not yet clear whether medical treatments of LS prevent malignant transformation. Further clinical and basic research into these important areas is still required.


Chlamydia trachomatis (CT), and Human Papilloma Virus (HPV) into applications in public health, especially in diagnosis, treatment, and prevention of complications of these infectious diseases. There is a significant amount of knowledge about genetic variants having a positive or negative influence on the course and outcome of HIV infection. In the field of Chlamydia trachomatis, genomic advances hold the promise of a more accurate subfertility prediction test based on single nucleotide polymorphisms (SNPs). In HPV research, recent developments in early diagnosis of infection-induced cervical cancer are based on methylation tests. Indeed, triage based on methylation markers might be a step forward in a more effective stratification of women at risk for cervical cancer. Our review found an imbalance between the number of host genetic variants with a role in modulating the immune response and the number of practical genomic applications developed thanks to this knowledge.Individual variations in susceptibility to an infection as well as in the clinical course of the infection can be explained by pathogen related factors, environmental factors, and host genetic differences. In this paper we review the state-of-the-art basic host genomic and genetic findings' translational potential of human immunodeficiency virus (HIV),  Infectious diseases representa major health threat worldwide and a significant part of the burden of disease in developing countries . Public Scientific developments in basic research and the development of public health genomics have changed many paradigms regarding infectious diseases. Indeed, the recent evidence of genetic factors in the pathogenesis of infectious diseases transformed the view of such diseases from strictly pathogen-centric to the one incorporating host genetic determinants that modulate immune response. Though research in the field of genetic susceptibility to infectious diseases started in 1954, recent progress in genomics led to the characterization of molecular biomarkers and pathways as targets for diagnosis or intervention . FurtherA great amount of effort and resources have been directed to obtaining knowledge about host genetic components of infectious diseases and to confirm associations in order to develop genomic applications in everyday clinical practice and prevention. Nonetheless, although the amount of genetic data in relation to disease is increasing exponentially , 6, therChlamydia trachomatis (CT) genital tract infections.In this paper, priority was given to three sexually transmitted diseases of significant public health relevance: HIV, HPV, and The aim of this review is to provide a state-of-the-art overview on the translational potential of basic genomic and genetic findings related to HIV, CT, and HPV infections, into applications in public health focusing on their diagnostics and treatment.Chlamydia trachomatis (CT) and the 2 most prevalent viral STDs Human Papilloma Virus (HPV) and the Human Immunodeficiency Virus (HIV) knowing that from these infectious diseases human genetic and genomic markers are described.Based on our field of expertise in sexually transmitted diseases (STDs) we selected the most prevalent bacterial STD http://hugenavigator.net/)) . CT. CT46]. Therefore it is crucial to develop a companion diagnostic to improve the assessment of risk of TP in CT-positive and negative women. By doing so, one is able to prevent invasive procedures in patients without TP and reduce both the cost and the psychological burden associated with laparoscopy. This companion diagnostic should merge serology, taking into account serological positivity and titres and considering new serological responses   and add Roughly 20% of cancers are linked to various infectious agents . Human pHPV-induced cancers account for approximately one-third of all cancers caused by infectious agents , and HPVThe HPV virus infects skin or mucosal tissues in the anogenital area or the region of the head and neck. So far more than 100 types have been reported . It has The strong association between HPV infection and cervical carcinogenesis makes cervical cancer preventable, thus fulfilling an important criterion for public health relevancy. With the introduction of HPV vaccines, a major breakthrough in prevention has been made. Vaccines proved to be safe and efficacious  and vaccOf all the women who are infected with HPV, only a small percentage develops cervical cancer. This observation suggests a role of host genetic factors influencing persistent HPV infections and progression into cervical cancer. The Role of HLA. Alleles have been reported to be associated with the development of HPV-related cervical cancer. In their review of evaluating this association, Hildesheim and Wang [and Wang  found seand Wang . Associaand Wang , while rand Wang .β, tumor necrosis factor α, interleukin-12 A and B, interferon-γ, interleukin-10, cytotoxic t-Lymphocyte antigen-4, p53, BRCA1, and LAMB3 as genes associated with persistent HPV infection and progression to cervical cancer [In their recently published review of the genetic susceptibility to cervical cancer, Chen et al.  presentel cancer . In addil cancer . So far, no genetic or genomic applications have been developed based on these findings. When it comes to applying genetic knowledge and discoveries into the field of HPV infection and cervical findings diagnosis and prevention, the strategy known as methylation takes the lead.Methylation is a common mechanism through which the silencing of genes, and among these tumor-suppressor genes, can be achieved . It reprin vitro. The promoter that was most commonly methylated (in 92% of the examined carcinoma samples) was MGMT. In the study by Henken et al. , 29 tumoP < 0.0005) with CIN2  and higher grade stages of cervical dysplasia, as was determined in the study by Yang et al. [Methylation of the promoters CCNA1 and C13ORF18 in cervical scrapings is found to be strongly associated  are short noncoding RNA molecules, which act in regulating expression of protein-coding genes, by pairing with sequences within such genes. hsa-miR-124 is an miRNA known to be silenced by methylation in many cancers, and Wilting et al. (2010) proved that this mode of silencing frequently occurs in cervical lesions as well . No methTriage could serve as an additional step that would more aptly bridge screening and diagnosis in order for a better stratification of women at risk to be achieved . It woulThe effects of constructing this type of triage test based on methylation would be expected to land a formidable impact on policies that currently regulate screening intervals.To our knowledge, this is the first review on the translational potential of basic genomic and genetic findings for HIV, CT, and HPV into applications in public health and in diagnostics, treatment, and prevention of late complications of these infectious diseases. We found scarce examples of the current application of genomic/genetic findings, in pharmacogenomics, and we found examples of genomic information with a promise of translation in the near future.In our review, we did not focus on analytic validity, clinical validity, and clinical utility and other criteria generally considered to be the most important factors in evaluation of the genetic/genomic applications . Since tBased on the review of the relevant literature some examples can be considered promising.CCR5Δ32 genetic variant opened the door for the development of new anti-HIV drugs. Although undoubtedly a very important step forward, CCR5 targeted therapy and the research behind it are just one of the possible applications of immunogenetic information. Indeed, there is a significant amount of knowledge of certain genetic variants having a positive or negative influence on the course and outcome of HIV infection. Possible future use of the knowledge about the expected course of the infection would be advancing the standard of care and therapy after routine genetic testing.The genes responsible for susceptibility to HIV infection can be basically divided in two groups, chemokine receptors genes and HLA genes. So far, the discovery of the Chlamydia trachomatis caused subfertility there is a promise for a more accurate subfertility diagnosis based on SNPs. Research showed that SNPs in TLR4 possibly increase the risk of tubal pathology. Specific TLR2 haplotypes are associated with protection from tubal pathology and development of the late inflammatory complications. In the field of TLR9, TLR4, CD14, and CARD 15/NOD2) doubles the risk of tubal pathology in Chlamydia trachomatis IgG-positive women compared to IgG-positive women carrying less than two SNPs, offer a proof of concept for the development of a genomic application in diagnosis of subfertility. These findings, together with the one carrying multiple SNPs in multiple pattern recognition receptors' (PRRs) encoding genes (A genetic test as a part of routine subfertility diagnosis should be able to save time and money by decreasing the number of unnecessary laparoscopies and the time patients unsuccessfully spend trying to get pregnant. In the field of HPV, there are some promising advancements in the early diagnosis of cervical cancer based on methylation tests. The methylation markers CADM1 and MAL were found to be an optimal combination for the detection of CIN3 lesions . MoreoveThe knowledge about the gene-disease associations should lead to growing numbers of genetic tests, which will in the future have an increasingly important role, in tailored clinical and drug treatment. However, in order for this translation process to succeed, the wide consensus among scientists, clinicians, policy makers, and the industry on necessity of going in this direction needs to be achieved .Chlamydia infections. However, we found an imbalance between the number of host genetic variants with a role in modulating the immune response and the number of practical genomic applications. Thus, such new knowledge and technologies from basic research are not yet integrated in health in a timely, effective, and efficient manner [Based on what we have shown here, there are many host genetic variants found to have a role in modulating the immune response to HIV, HPV, and t manner . This imbalance, the lack of translation from bench to bedside, is in favor of basic research that seems to be somewhat hermetic in quality, revealing confirmed positive association with a certain genetic variant and not exploring the future implications of these findings, should not represent a norm in the field. The next step is needed in which gene-disease association leads to the development of the genetic/genomic application. Starting with interdisciplinary collaboration is very important in the process of evaluation of role of genetic variants in the etiology of human diseases .There are some clear and well-supported genetic associations with particular infectious diseases; these should be driving forces of the successful translation process.


Alphapapillomaviruses, and is most closely related to HPV-3 and HPV-28. HPV-125 has a typical genomic organization of Alphapapillomaviruses and contains genes coding for five early proteins, E6, E7, E1, E2 and E4 and two late capsid proteins, L1 and L2. The genome contains two non-coding regions: the first located between the L1 and E6 genes  and the second between genes E2 and L2 . The E6 protein of HPV-125 contains two regular zinc-binding domains at amino acid positions 29 and 102, whereas the E7 protein exhibits one such domain at position 50. HPV-125 lacks the regular pRb-binding core sequence within its E7 protein. In order to assess the tissue predilection and clinical significance of HPV-125, a quantitative type-specific real-time PCR was developed. The 95% limit-of-detection of the assay was 2.5 copies per reaction (range 1.7–5.7) and the intra- and inter-assay coefficients of variation were 0.47 and 2.00 for 100 copies per reaction, and 1.15 and 2.15 for 10 copies per reaction, respectively. Testing of a representative collection of HPV-associated mucosal and cutaneous benign and malignant neoplasms and hair follicles  showed that HPV-125 is a relatively rare HPV genotype, with cutaneous tropism etiologically linked with sporadic cases of common warts.The DNA genome of a novel HPV genotype, HPV-125, isolated from a hand wart of an immuno-competent 19-year old male was fully cloned, sequenced and characterized. The full genome of HPV-125 is 7,809-bp in length with a GC content of 46.4%. By comparing the nucleotide sequence of the complete L1 gene, HPV-125 is phylogenetically placed within cutaneotrophic species 2 of  Alpha-, Beta-, Gamma-, Mu- and Nupapillomavirus) contain members that can infect humans and are referred to as human papillomaviruses (HPV) Papillomaviruses (PV) are small non-enveloped viruses with a double stranded circular DNA genome, approximately 8-kb in size. So far, 29 genera of papillomaviruses, designated by letters of the Greek alphabet, have been described, of which 5 genera (Alphapapillomavirus species 7 (type species HPV-18) and 9 (type species HPV-16) is strongly associated with the development of cervical carcinoma and other cancers in the anogenital region of both genders Alphapapillomavirus species 10 (type species HPV-6) is associated with the development of benign tumors such as genital warts and laryngeal papillomas verrucae vulgaris, or common warts, is caused by members of Alphapapillomavirus species 2 and 4, and several species of Gama-, Mu- and Nupapillomavirus genera Alphapapillomavirus species 2 were first found in patients with the hereditary disorder epidermodysplasia verruciformisTo date, more than 150 HPV genotypes have been fully characterized; roughly a third of them have been discovered since 2004, mostly by the use of molecular methods In this study, a novel HPV genotype, isolated originally from a hand wart (isolate SIBX9) and initially characterized by our group in 2004 5′-TCNMGNGGNCANCCNYTNGG-3′5′- AYNCCRTTRTTRTGNCCYTG -3′2, 1.25 U of FastStart Taq DNA Polymerase, and 25 pmol of each primer. The thermal cycler program was set to 4 min at 94°C, followed by 40 cycles consisting of 1 min at 95°C, 2 min at 52°C and 1 min at 72°C. The final extension step was performed at 72°C for 4 min and the reaction mixtures were then cooled to 4°C. Sequencing of the 474-bp PCR fragment was done by using the primers HVP2 and B5 on the ABI Prism® 310 Genetic Analyzer System (Applied Biosystems) and Big Dye® Terminator v 1.1 Cycle Sequencing Kit (Applied Biosystems).The total DNA from the original clinical sample of a hand wart containing HPV-125 was extracted using a High Pure PCR Template Preparation kit , according to the manufacturer's instructions 2, 500 µM (each) of dATP, dCTP, dGTP, and dTTP, 0.75 U of Expand Long Template Enzyme Mix, and 3 pmol of each primer. The thermal cycler program was set to 2 min at 94°C, followed by 40 cycles consisting of 10 s at 94°C, 30 s at 58°C and 9 min at 68°C. The final extension step was performed at 68°C for 10 min and the reaction mixtures were then cooled to 4°C. Sequencing of the 7,770-bp PCR fragment was done by primer walking with 38 primers  of dATP, dCTP, dGTP, and dTTP, 0.75 U of Expand Long Template Enzyme Mix, and 3 pmol of each primer. The thermal cycler program was set to 2 min at 94°C, followed by 40 cycles consisting of 10 s at 94°C, 30 s at 56°C and 6 min at 68°C. The final extension step was performed at 68°C for 10 min and the reaction mixtures were then cooled to 4°C.PCR fragments for the cloning of the full genome of HPV-125 were prepared with the Expand Long Template PCR System (Roche Applied Science) from the original clinical sample using sequencing primer pairs 125-fpw5 and 125-rpw6, and 125-fpw14 and 125-rpw 15 , giving E.coli strain JM107 with the plasmids, according to the manufacturer's instructions.Before cloning, PCR products were run on gel electrophoresis, excised and purified from 1% agarose gel using a GeneJET™ Gel Extraction Kit . Plasmid clones containing overlapping PCR products were prepared using a CloneJET™ PCR Cloning Kit (Fermentas) according to the manufacturer's instructions. TransformAid™ Bacterial Transformation Kit (Fermentas) was used to transform Plasmid clones isolated from the transformed overnight bacterial culture with the GeneJET™ Plasmid Miniprep Kit (Fermentas) were checked for correct inserts by size analysis and sequencing with the pJET1.2 sequencing primers, according to the manufacturer's instructions. Full sequencing by primer walking was carried out for two clones, confirming the previously determined full sequence of the HPV-125 genome. Both clones, together covering the full genome of HPV-125, were deposited in the Reference Centre for Papillomaviruses, Heidelberg, Germany in September 2009, where they were re-sequenced and the novel genotype was assigned its number in October 2009.The ORFs of HPV-125 were determined using the ORF finder function of Vector NTI Advance™ v 11.0  and pairwise comparison of genes of closely related HPV genotypes.In order to phylogenetically place HPV-125, a multiple sequence alignment of L1 ORF of HPV-125 and 116 previously characterized HPV types available All further phylogenetic analyses were also conducted by using MEGA4 The optimal tree with the sum of branch length = 14,14565449 was used for Alphapapillomavirus species 2.Additionally, Maximum Parsimony analysis of the same dataset was conducted (data not shown), using the Close-Neighbor-Interchange algorithm to search for the optimal tree, also by using the MEGA 4 software package, which also grouped HPV-125 within the Alphapapillomavirus species 2, pairwise sequence alignments (both nucleotide and amino acid) were carried out and percentage similarity was calculated for each of the viral genes  between HPV-125 and each of the genotypes for which full genomic sequences were available , by using the BioEdit v7.0.9.0. software package In order to compare HPV-125 more closely with other genotypes of the 5′- GGTTACCCGACCCAAATAAGT -3′, nucleotide positions 5,851–5,871) and 125-RT-L1-R , specific for HPV-125, were chosen within the L1 gene by using the on-line ProbeFinder software (Roche Applied Science). FAM-labeled Universal Probe nr. 14 (Roche Applied Science) was used to detect the specific products in the real-time reaction.The primers 125-RT-L1-F , as described previously The optimized RT-PCR reaction mixture contained 10 µl of LightCycler® Probes Master 2× conc. (Roche Applied Science), 0.2 µM of each primer, 0.05 µM of Universal Probe nr. 14 (Roche Applied Science), 1 U of LightCycler® Uracil-DNA Glycosylase (Roche Applied Science), sample DNA and water up to a final volume of 20 µl. The assay was performed on a LightCycler® 480 real-time PCR Instrument (Roche Applied Science) under the following conditions: Uracil-N-Glycosylase activation at 40°C and pre-incubation at 95°C for 10 min each, followed by 45 cycles at 95°C for 10 s (denaturation) and 60°C for 30 s . Acquisition of the fluorescence signal (FAM 465–510 nm) was performed during each annealing/extension step. The final cooling step consisted of a 10 s hold at 40°C.To evaluate the linearity of the RT-PCR assay, ten-fold serial dilutions of the reference plasmid were prepared in 1.5 ml DNA LoBind tubes  using a water solution with carrier RNA (1 µg/ml) and tested in triplicate. The limit of detection of the assay was determined by testing 15 replicates of the reference plasmid dilutions corresponding to an input of 25, 13, 6, 3, 1.5, 0.8 and 0.4 copies per reaction and calculated by Probit analysis using SPSS software v.15.0.0.0 . Intra- and inter-assay reproducibility of the RT-PCR were assessed by testing triplicates of plasmid dilutions corresponding to an input of 100 and 10 copies per reaction, in three independent runs.7 to 108 copies of reference clones or synthetic L1 sequences  of HPV-2, HPV-3, HPV-7, HPV-10, HPV-27, HPV-28, HPV-29, HPV-40, HPV-43, HPV-77, HPV-78, HPV-91  were tested.To ensure specificity and to check for cross-reactivity of RT-PCR, 10The tissue predilection and clinical significance of HPV-125 were assessed on a representative collection of HPV-associated benign and malignant neoplasms and hair follicles. The DNA was isolated from a total of 601 samples obtained from the same number of patients, including tissue samples of histologically confirmed cervical squamous cell carcinoma (104), laryngeal papilloma (85), genital warts (71), common warts (102), squamous cell carcinoma (SCC) of the skin (52) basal cell carcinoma (BCC) of the skin (49) and hair follicles (138), as described previously Betapapillomavirus HPV genotypes, and INNO-LiPA HPV Genotyping Extra , which allows identification of 28 different Alphapapillomavirus HPV genotypes, and additionally by three consensus in-house PCRs using Ma/Ha The presence of additional HPV genotypes in HPV-125 positive samples was determined using two commercial line-probe assays: RHA skin (beta) HPV , which allows identification of 26 different None of the 601 clinical samples were collected solely for the purpose of this study. All samples included in the study were collected in compliance with the Helsinki declaration. Samples of cervical cancer, hair follicles, genital warts and common warts were collected prospectively in our previous studies. These studies were approved by the Ethics Committee of the Ministry of Health of Republic of Slovenia  and written informed consent was obtained for each patient. Samples of laryngeal papillomas, squamous cell carcinoma and basal cell carcinoma of the skin were retrieved from the tissue collection of paraffin-embedded samples of the Institute of Pathology, Faculty of Medicine, University of Ljubljana. Approval from Institutional Review Board of the Institute of Pathology, Faculty of Medicine, University of Ljubljana was obtained prior to starting work on samples included in this study. In accordance with national legislation of the Republic of Slovenia no informed consent is needed for research on archival clinical samples. In order to protect the identity of the patient, all archival clinical samples used in the study were coded and tested anonymously. The only available data were patient gender, age and immune status .HPV-125 was detected in 2004 in the biopsy specimen of a hand wart obtained from a 19 year-old immuno-competent male patient at the Department of Dermatovenereology, University Medical Centre, Ljubljana, Slovenia. It was initially identified as a putative novel HPV genotype by the use of HVP2/B5 primers By using PCR amplification, the complete genome of HPV-125 was cloned and deposited in the Reference Centre for Papillomaviruses in Heidelberg, Germany, where the genomic sequence of HPV-125 was independently confirmed and the novel genotype was assigned its name in October 2009, according to the consecutive number of characterization.Alphapapillomavirus species 2, closest to HPV-3 and HPV-28 29CxxC) at amino acid positions 29 and 102, whereas the E7 protein of HPV-125 exhibits one such domain at position 50  as was determined for other better-characterized Alphapapillomavirus, which have a mucosal tropism, members of Alphapapillomavirus species 2  exhibit cutaneous tropism epidermodysplasia verruciformisAlphapapillomavirus species 2 seem to be associated predominantly with flat and common warts in immuno-competent individuals, while some genotypes belonging to this species also have the potential to cause malignant transformation in immuno-compromised hosts.Unlike most HPV genotypes from genus 2 = 1.00) between the Ct (threshold) and the log of starting viral copy number, across at least seven orders of magnitude. The 95% limit of detection of the assay was 2.5 copies per reaction (range 1.7–5.7) and the intra and inter-assay coefficient of variation (CV (%) = (st.dev/mean Ct)*100) was 0.47 and 2.00 for 100 copies per reaction, and 1.15 and 2.15 for 10 copies per reaction, respectively. The assay showed no cross-reactivity with any of the tested non-targeted cutaneous HPV genotypes, including HPV-2, HPV-3, HPV-7, HPV-10, HPV-27, HPV-28, HPV-29, HPV-40, HPV-43, HPV-77, HPV-78 and HPV-91 in concentrations of 107–108 viral copies per reaction.In order to assess the biological and clinical importance of HPV-125, a quantitative HPV-125 type-specific RT-PCR assay was developed, based on amplification of a 61-bp region of the HPV-125 L1 gene . The staBecause phylogenetic relationships between HPV genotypes do not necessarily always reflect their tissue tropism, and to assess the clinical significance of HPV-125, a representative collection of HPV-associated benign and malignant neoplasms and hair follicles were tested for the presence of HPV-125 using type-specific RT-PCR. The sample collection was chosen to represent various sites of HPV infection  and possible outcomes of HPV infection . The panAlphapapillomavirus species 2, does not exhibit mucosal tropism.As shown in Betapapillomavirus genotypes HPV-8 and HPV-22, both known to be cutaneous HPV genotypes, the development of this common wart could not conclusively be attributed to HPV-125. In contrast, in the second sample, HPV-125 was the only HPV genotype detected, despite the use of several HPV genotyping assays, targeting a range of Alphapapillomavirus and Betapapillomavirus genotypes, which supports the causative role of HPV-125 in the development of this common wart  contained HPV-125, indicating the cutaneous tropism of this genotype . In the mon wart . In addiHPV-125 was not detected in any of the 101 samples of malignant tumors of the skin tested. This finding may be due either to the lack of HPV-125 potential for malignant transformation, or to the rarity of this genotype in immuno-competent individuals. The results obtained indicate that HPV-125 does not seem to be an important non-melanoma skin cancer causing genotype, although the possibility of HPV-125 contributing to the development of malignant skin lesions in immuno-compromised individuals cannot be finally excluded, due to the rarity of the genotype and the number of samples tested so far.Alphapapillomavirus species 2, it is possible that HPV-125 is significantly more frequent in immuno-compromised individuals Of the 138 hair follicle samples tested, a single hair follicle sample contained HPV-125. This sample also contained two additional HPV genotypes, HPV-10 and HPV-36, consistent with the current knowledge that HPVs are ubiquitous in hair follicles and that hair follicles represent a viral reservoir in immuno-competent individuals. Similarly to other members of Alphapapillomavirus species 2, which is phylogenetically nested deep within the predominantly mucosotrophic Alphapapillomaviruses. HPV-125 is a relatively rare HPV genotype with cutaneous tropism, ethiologically linked with sporadic cases of common warts.In conclusion, the characterization of the novel HPV genotype HPV-125 improves our knowledge about the cutaneotrophic Table S1Nt: nucleotide position, Cw: clockwise orientation, Ccw: counter-clockwise orientation.(DOC)Click here for additional data file.


Cervical cancer, caused by persistent infection with carcinogenic human papillomavirus (HR-HPV), is particularly prevalent in Sub-Saharan Africa and is associated with a high mortality rate. Some studies in West Africa, including our own, have found unusually high HR-HPV across all ages with a slight peak in older women. This increased prevalence at older ages may complicate screen-and-treat programs, which are implemented in regions where HPV prevalence declines with age and typically target women between 30-49 years. A better understanding of the determinants of high HR-HPV prevalence at older ages is needed. The goal of this study is to explore risk factors for HR-HPV prevalence by age among women in our population-based study in Irun, a rural town in southwestern Nigeria.1,420 women were administered a clinic-based questionnaire regarding sexual and reproductive behavior, marital status (including co-wives), and malaria exposure. Logistic regression compared questionnaire responses and PCR positivity for a set of 13 carcinogenic HR-HPV types. Results were stratified by age .p-value = 0.03 and 0.05, respectively). Early age at sexual debut and multiple sex partners were risks for HR-HPV, but did not reach significance . Neither self-reported malaria nor presence of co-wives in the household was associated with HR-HPV . In age sub-categories, early age at sexual debut was a significant risk factor for HR-HPV among women 35-45 years . Early age at first pregnancy remained a significant risk factor for women aged 56+ years . Greater than 2 sex partners and use of birth control were associated (though not significantly) with HR-HPV in women aged 30-45 .Birth control use and age at first pregnancy were associated with HR-HPV (In this high-risk region with elevated HR-HPV prevalence at older ages, we confirmed previously described, behavioral determinants of HR-HPV. There was no association with self-reported malaria or co-wives, which we had hypothesized might correlate with HR-HPV at older ages. Cervical cancer, caused by persistent infection with carcinogenic human papillomavirus (HR-HPV), is the second most common cancer in women worldwide and the leading cause of cancer deaths among women in developing countries . CervicaThe age-specific pattern of HR-HPV prevalence can differ somewhat by geographic location. In most populations, incidence and prevalence of HR-HPV infection peak at young ages soon after sexual debut, followed by a decline as nearly all infections clear and new sexual encounters decrease ,8. This However, high HR-HPV prevalence at all ages has been reported in some, but not all, population-based studies conducted in sub-Saharan Africa, including areas of West Africa -11. ReceHere we present a study examining clinic-based questionnaire data from approximately 1,400 women in our population-based cohort in Irun, Nigeria. The goal of this study was to evaluate the association between known and possible, novel risk factors for HR-HPV infection such as sexual and reproductive behaviors, living in a household with co-wives, and self-reported malaria exposure. Since we are particularly interested in understanding the elevated HR-HPV prevalence among older women in this region, we extended our analyses to look at these risk factors among women of different age groups.The protocol was reviewed and approved by both Nigerian and NCI institutional review boards. Detailed methodologic aspects of this study are described elsewhere . BrieflyAt the clinic visit, women completed a second informed consent and were given more detailed information of clinic procedures. Following consent, 1,420 women were administered a questionnaire that addressed potential risk factors associated with HR-HPV and cervical pre-cancer such as tar and tobacco exposure, number of malaria diagnoses within the past two years, menstrual history, sexual behavior, marital status, and birth control use. Nurses conducted a cervical exam involving the collection of cervical cells using a broom device and endocervical brush, and placed into PreservCyt buffer. On the day of collection, 1 ml was removed, frozen, and subsequently used for the HR-HPV DNA testing discussed here.The presence of HR-HPV DNA was determined from the 1 ml of residual cytology specimens using MY09-MY11 PCR-based method as described . We consBased upon previous age analysis of HR-HPV in this population of women and taking menopausal status into account , age catThe interviewers reported that the overall quality of the interview was either generally reliable (75.8%) or of high quality (22.2%). However, as shown in Figure Table In terms of marital status and related variables, the majority of women were in union (either married or living with a man) and about 60% of these women reported that they resided in a household with co-wives, reflecting the over-sampling in our field effort. A relatively equal percentage reported having 1, 2, or 3+ co-wives and 45% stated that they were ranked first among other wives. This reflects that our recruitment efforts were particularly successful among older women. The average age of the youngest wife was 39.4 ± 10.7 years.Most women reported that neither they nor their husbands used tobacco, thus the overall exposure to tobacco was relatively low (15.2%). A majority of women reported having at least one case of malaria in the past two years (average number of diagnoses 2.2 ± 1.5).p-value = 0.07 and OR 1.6; p-value = 0.03).Overall, age was observed to be a risk factor, although a non-linear one, for presence of HR-HPV, as we observed an increased prevalence in women 15-29 (18.9%) and 56+ years (15.1%). An age of 10-14 years at sexual debut was associated with a nearly two and a half-fold risk for HR-HPV infection  compared to late age. Early rather than late age of first pregnancy was also associated with increased HR-HPV prevalence with a 40% increased risk for ages 12-19  and a 50% increased risk for ages 20-24 years  compared to late age. Having more than two sexual partners and use of birth control were also positively related to HR-HPV risk  although this relationship was not significant. The number of self-reported malaria diagnoses in the past two years was not associated with increased risk of HR-HPV prevalence .With regard to our more novel hypothesized risk factors, we did not find associations of interest. Living in a household with co-wives was associated with a slightly decreased risk of HR-HPV positivity  in women aged 30-45 years. Early age at first pregnancy was associated with a greater than two-fold risk for HR-HPV in women aged 56+ years . Early age at sexual debut was also a risk factor among women in this age group, although the association was not quite as strong . Multiple sex partners and birth control use were risk factors for women aged 30-45 . Living in a household with co-wives was not associated with HR-HPV in this age stratified analysis. We did observe somewhat of a dose response relationship with the number of recent self-reported malaria diagnoses and HR-HPV prevalence in women aged 15-29 years, although this relationship was not significant (p-trend = 0.31).Table The main goal of this study was to identify risk factors for HR-HPV; particularly those associated with age that would help to explain the increased prevalence of HR-HPV infection among older women in this cohort. Instead, among all women, we found expected behavioral determinants of viral positivity, including early age at sexual debut and multiple sex partners. Although we did find that early age at sexual debut and first pregnancy were somewhat stronger risk factors among women aged 30-45 and 56+ years, respectively, the effects were not sufficiently different between the age groups to explain the high HR-HPV prevalence older women.We hypothesized that being a co-wife might correlate with HR-HPV appearance at older ages since a woman in a polygamous marriage is theoretically engaged in sexual relations with more than one partner; however we did not observe this finding. We also hypothesized that women with HR-HPV at older ages might be at increased risk due to partial immunosuppression from to chronics parasitosis, however there was no association with recent self-reported malaria. Although self-reported malaria exposure was not associated with risk for HR-HPV infection, we did find an increase in recent reported malaria cases among women aged 56+ years compared to women in younger age groups. Even though it was not related to HR-HPV, this is an interesting finding given that prevailing research in endemic areas indicates the highest malaria burden to be among younger age groups ,19. It iOne important limitation of this study was the potential for selective response bias on our clinic questionnaire, particularly regarding questions related to sexual and reproductive behavior as discussions of sexuality are considered taboo among some Yoruba women ,22. The The explanation for high HR-HPV prevalence at older ages in rural Nigeria and other regions of Sub-Saharan Africa remain elusive. Whether increased prevalence at older ages is due to acquisition of new infections or to attenuation in the immune response leading to a reemergence of a latent infection remains unclear . Data frThe authors declare that they have no competing interests.MC: Analyzed data, drafted manuscript. JG: Involved with the design of the study, acquisition and interpretation of data, and provided critical revisions of manuscript. KA: Local investigator, contributed substantially to the acquisition of data and design of the project. NW: Involved with the conception and design of the study and provided critical revisions of the manuscript. AA: Local investigator, contributed substantially to the acquisition of data and design of the project. SW: Biostatistician, involved in the design of the study and provided critical revisions of manuscript. RB: Laboratory collaborator, performed HPV typing, and provided critical revisions of manuscript. MS: Principal Investigator, involved in the conception and design of the study, and provided critical revisions of manuscript.All authors read and approved the final manuscript.


Cervical cancer is, globally known to be, one of the most common cancers among women especially in developing countries. More than 90% of cervical cancers are associated with high-risk human papillomaviruses (HPVs) particularly HPV types 16 and 18. Two major strategies have been developed for prevention and treatment of cervical cancer and other HPV-associated malignancies; the first one is based on HPV virus-like particles (VLPs) containing HPV structural proteins. VLP based vaccines can induce genotype specific virus neutralizing antibodies for preventing HPV infections. The other strategy is based on HPV early genes especially E6 and E7 for eliminating the established HPV infections; therefore they are classified as HPV therapeutic vaccines. This article reviews the preventive and therapeutic vaccines against HPV infections and cervical cancer. Cervical cancer ranks second in the list of the most common cancers and the third in the list of cancer death in women worldwide , 2. GlobCervical cancer is the principle cause of women cancer deaths in developing countries , 11. In Papillomaviruses (PVs) are small, non-enveloped, epitheliotropic DNA viruses that are 52-55 nanometers in diameter and consist of a circular double-stranded DNA approximately 8000 base pairs (bp) in size , 31, 32.Chlamydia trachomatis infections . Natural HPV infections induce low antibody concentrations and women with an acquired HPV infection remain at risk for a new infection with the same type of HPV . The exp. Natural In the first clinical trial for HPV vaccine, a monovalent HPV-16 L1 VLPs vaccine was used in humans and the results showed 100% vaccine efficacy against all grades of CIN , 34, 52.® is a quadrivalent vaccine containing non-infectious recombinant L1 VLPs of low-risk HPV types 6 and 11, and high-risk HPV types 16 and 18 mixed with an aluminum-containing adjuvant (Saccharomyces cerevisiae) and the proteins self-assemble into non-infectious VLPs  than in the placebo group (77%). Also, systemic adverse events were reported by a similar proportion of both groups. No deaths secondary to vaccine were reported in the trial  or a competitive radioimmuno assay (CRIA) were used to detect defined type- and epitope-specific antibodies against HPV types 6, 11, 16 and 18 in quadrivalent vaccinated subjects and enzyme-linked immunosobent assay (ELISA) technique utilizing VLPs as substrate was used to evaluate total serum anti-VLP IgG antibodies in bivalent vaccinated subjects  type of immune responses while ASO4 adjuvant containing monophosphospharyl lipid A and aluminum hydroxide is used for Cervarix™ that can induce innate immune responses via toll-like receptor molecules and induce a mix of Th1/Th2 differentiation  efficient in preventing the cervical cancer . A phase II trial of a recombinant vaccinia virus-based vaccine, Modified Virus Ankara (MVA), encoding E2 gene was performed in women with CIN2/3. The vaccine was administered via direct injection into the uterine cervix. The data showed that 59% of patients had complete regression and high antibody titers to E2 were detected in all vaccinated patients . Previous studies showed administration of an oral or intraperitoneal recombinant vaccine of L.monocytogeneses secreting HPV-16 E7 protein resulting in regression of E7-expressing murine tumors , γ-tubulin, HSV-1 VP22 enhanced the immune responses against desired gene in administered-DNA vaccine (96-100). Our previous study proved that administration of a DNA vaccine containing immunogenic region of human papillomavirus type 16 E7 gene linked to human HSP70 gene was able to induce the CMI responses in mice . Chimeric HPV VLP vaccines are another method for HPV vaccine development. HPV VLPs of L1 or L1/L2 can be fused to a foreign epitope or polypeptides. Several studies showed chimeric VLPs encoding E2 and/or E7 antigen induces both neutralizing antibodies and T-cell mediated immune responses , 112. Su Prime-boost regimen is another strategy in HPV vaccination. In a study, various combinations of viral vectors and nucleic acids were tested in a prime-boost regimen and suggested that priming with a DNA vaccine followed by a recombinant vaccinia viral vector booster might provide the most anti-tumor effects . In anotVLP-based preventive vaccines opened a prospective path for prevention of benign and malignant anogenital diseases caused by more prevalent genital HPV types. Two prophylactic vaccines against HPVs have been developed. Gardasil® is a quadrivalent vaccine consisting L1 proteins of HPV types 6, 11, 16 and 18. Another vaccine is Cervarix™ that is a bivalent vaccine containing L1 proteins of HPV types 16 and 18. Both preventive vaccines, Gardasil® and Cervarix™, are in the last stages of their clinical trials and their previous results demonstrated that they are safe, well tolerated and are able to generate high titers of neutralizing antibodies against vaccines' HPV types; however, they do not cover all high-risk papillomaviruses that cause cervical cancer. They can protect the body against only 70% of the HPV associated cervical cancers. Designing the other HPV VLP-based vaccines will be required for protection against a broad range of HPV high-risk types that cause cervical cancer. Therefore, current preventive vaccines will be able to reduce but not eliminate the risk of cervical cancers and other premalignant diseases related to HPVs. Although the prophylactic vaccine protection persists for at least 5 years, there is also a need to define duration of the vaccine protection. Furthermore, their safety in pregnant women is an issue for future studies. Another limitation for HPV preventive vaccines is their efficacy in different countries. In some countries with high rate of HPV associated diseases, the predominant high-risk HPV types may be different. Furthermore, it is possible that the elimination of common HPV types by prophylactic vaccination leads to an increase in the risk of infection with other high-risk types of HPV that are not included in the vaccines, resulting the increase in HPV related diseases and cancers in long time.  In addition to prophylactic vaccines, developments of therapeutic HPV vaccines are required for treatment of women who are currently infected with HPVs and require the treatment. Several strategies including vector-base vaccines, protein-based vaccines, peptide-based vaccines, nucleic acid-based vaccines, cell-based vaccines and chimeric vaccines enhance the virus-specific cell-mediated immunity activation and anti-tumor effects in mice tumor systems. Most of the HPV therapeutic vaccines are developed for targeting HPV E6 and/or E7; however, they have not shown the same success as the prophylactic vaccines in their clinical trials. The comparison of these methods will single out the most potent therapeutic vaccines with the minimum level of negative side effects against HPV established infections and cervical cancer.


This analysis assessed the epidemiological and economic impact of quadrivalent human papillomavirus (HPV4: 6/11/16/18) vaccination in Estonia.A dynamic transmission model was used to assess the epidemiological and economic impact of the routine vaccination of 12-year-old girls with a HPV4 vaccine in preventing cervical cancer, cervical intraepithelial neoplasia (CIN) grades 1, 2 and 3 and genital warts.The model projected that at year 100, HPV4 vaccination would lead to a reduction of HPV 16/18 related cervical cancer incidence and deaths by over 97% and the incidence of HPV 6/11 related genital warts among Estonian women and men by over 94% and 81%, respectively. The incremental cost-effectiveness ratio of the HPV4 vaccination strategy was € 4,889 per QALY gained over a time horizon of 100 years.Routine vaccination of 12-year-old girls with HPV4 vaccine appears to be cost-effective in Estonia, in addition to providing both short term and long term health gains. Evaluations of the cost-effectiveness of high-risk human papillomavirus (HPV) vaccination as a cervical cancer prevention measure are mostly limited to countries in Western Europe and North America . Few stuIn Estonia the cervical cancer incidence  and mortality  are significantly higher than in many developed countries including neighboring Scandinavian countries . SystemaThis study investigated the clinical benefits and economic consequences of routine quadrivalent HPV vaccination of females by the age of 12 years in Estonia. Specifically, this study was designed to evaluate the potential impact in Estonia of prophylactic quadrivalent HPV vaccination on the incidence of cervical intraepithelial neoplasia (CIN), cervical cancer, genital warts, and cervical cancer mortality when added to the current cervical cancer screening and standard of care.We adapted a previously developed HPV dynamic mathematical model to Estonia  benefits of vaccination. Hence, the model required inputs on sexual activity risk groups in the population.In the model, it is assumed that vaccination occurs prior to sexual debut and would consist of the three recommended doses, and the vaccination would confer type-specific protection. Other parameters subjected to greater uncertainty such as vaccination coverage and duration of protection were further explored in the sensitivity analysis. The model incorporates vaccine efficacy from the most recent clinical trials. The prophylactic vaccine efficacy against transient HPV 6, 11, 16 and 18 infections was assumed to be 76.1%, 76.1%, 76.0%, and 96.3%, respectively . The vaccine efficacy against persistent HPV 16 and 18 infections was assumed to be 98.8% and 98.4%, respectively.In both the vaccinated and unvaccinated cohorts, screening was modelled according to the actual current/routine Estonian cervical cancer screening practice.The model requires input values for demographic, behavioural, epidemiological, screening, treatment, vaccine, and economic parameters  database was used as the source for health care utilization data, HPV disease occurrence and health care costs  Demographic data  was taken from Statistics Estonia  (Table 2) Sexual behaviour data was derived from the Estonian Health Interview Survey 2006 . Estimat3) The age and stage-specific cervical cancer mortality was assumed to be the same as in the US  (Table A4) Screening data  (Table A5);5) Treatment variables (Table A5):(i) proportion of women with cervical cancer who develop symptoms and seek care, by cancer stage – Estonian cancer registry;(i) proportion of CIN/carcinoma in situ (CIS) treated, by stage – expert opinion and literature . Based o(i) hysterectomy rates by age group, % per year – based on the data from HIF;6) Economic variables:(i) direct medical costs of interventions were estimated using the national tariffs of the HIF for 2011 were reported in euros. Euro is the national currency in Estonia.(i) costs of diagnosing and treating HPV disease  episode of care) – data from HIF ;(i) vaccine cost: A cost of €59.00 per dose for the HPV4 vaccine was used, based on assumptions made in an earlier published analysis for Estonia  (Table A7) Vaccine strategy variables are based on the following assumptions and data sources:(i) HPV4 coverage of 85% of females age 12. This was set slightly below the 91.2% reported in 2010 for coverage with two doses of measles, mumps, and rubella vaccine (MMR), the second dose of which is administered to 13- to 14-year-old adolescents within the state calendar vaccination programme and via the school health system ;(i) 100% adherence with the 3-dose regimen;(i) Vaccine will be delivered through the existing school-based delivery system, similar to the current MMR regimen;(i) Lifetime duration of protection was assumed in base scenarios. Effects of different lengths of duration were tested in a sensitivity analysis.To calculate the cost-effectiveness of the vaccination strategy in preventing disease with respect to costs, we used the total discounted costs and effects  accrued over a 100-year period with and without vaccination. In addition, the incremental costs incurred to achieve the incremental benefits by vaccination were calculated and the ratio of the incremental costs to incremental QALYs gained  are presented.QALYs were estimated based on health utilities from the U.S. (Table A7). In addition to utilities for HPV disease states, age and gender-specific utility weights were also incorporated for individuals without HPV disease to account for the impact of co-morbid conditions (Table A7).Both costs and medical outcomes were discounted at an annual rate of 3% ,18.As described above, the model was calibrated for Estonia using sexual activity and cancer detection rate parameters. We assessed the predictive validity of the model by comparing model predictions with observed data on the age specific incidence of cervical cancer and cervical cancer deaths in Estonia.The cost effectiveness analysis is based on a number of assumptions. Due to uncertainty in some of these assumptions, several one-way sensitivity analyses were carried out. The parameters included duration of vaccine protection (20 years), vaccine coverage rates , HPV disease diagnosis and treatment costs (+/−20%), vaccine cost per dose (+/−10%), discount rate (5%), and QALY weights. We also examined a scenario assuming no quality of life adjustments (cost per life years saved). Additionally, we examined the impact of HPV 6 and 11 protection in HPV4 on cost-effectiveness by running a scenario without the HPV 6 and 11 protection.We also examined the cost-effectiveness of HPV vaccination under a hypothetical improved screening program. This hypothetical program was assumed to have immediate coverage of 95% (compared with the current/routine coverage of 72%) and the same age-specific annual rate as the base case scenario. Hypothetical improved screening independently gradually reduced the HPV16/18-related cervical cancer incidence to ~6 per 100,000 per year (age-standardized) at the steady-state in the model, about 100 years after screening had been initiated in the population. This steady-state cervical cancer incidence corresponded to ~ 8 per 100,000 per year of any HPV type  treated was about 110 cases per 100,000 for females and 45 per 100,000 for males. The GW treatment incidence differed by gender. We incorporated this gender difference in the model by changing the proportion of those who received treatment among those who developed GW. This is consistent with overall GW treatment incidence of 123/50  per 100,000 , of which approximately 90%  is thought to be related to types 6/11 [Figures The effect of vaccination was to progressively reduce the incidence of cervical cancer cases and deaths until the system approached a steady state, about 100 years after vaccination has been initiated in the population. Compared with no vaccination, the vaccination reduced the incidence of 16/18-related cervical cancer cases and deaths by over 97% by year 100. At year 50, the vaccination strategies reduced the incidence of 16/18-related cervical cancer cases by 59% (no vaccination vs vaccination: 11.8 vs 4.85 per 100 000), and deaths by 50% (no vaccination vs vaccination: 3.42 vs 1.71 per 100 000). Numbers of HPV 16/18-related cervical cancer cases were halved in the vaccinated group by year 46.A similar dynamic was observed for the reductions in CIN 2/3, CIN 1, genital warts-female and genital warts-male cases as displayed in Figures At year 100, the model predicted that the vaccination strategy would provide over 98% relative reduction in the incidence of 6/11/16/18-related CIN 2/3 and CIN 1, and 94% and 81% reductions in HPV 6/11 related genital warts in females and males, respectively. The number of 6/11/16/18-related cases of CIN2/3, CIN1, genital warts-female, and genital warts-male were halved by year 29, 26, 16, and 19.Adding vaccination to the cervical cancer screening led to significant health benefits. The model showed reductions over 100 years in: HPV 16/18 related deaths (50%); cervical cancer incidence (52%); CIN 2/3 (68%); and genital wart incidence among women (79%) and men (67%) (over 100 years)  accrued over a 100-year period with and without vaccination strategy, incremental costs, and incremental QALYs, and the incremental cost effectiveness ratio are presented Table The ICER increased when we excluded protection against HPV 6/11 disease (€ 5771 per QALY) or limited the time of vaccine protection to 20 years (€ 8090 per QALY) Table . The ICEThis is one of the first studies to examine the potential impact of HPV2 and 4 vaccination in Estonia . The incThe analysis of HPV vaccination by Liiv et al.  derived However, both studies are in agreement with the recent systematic review  in conclOur results document significant health effects related to the combined use  of cervical cancer prevention methods. The model projected that at year 100, HPV4 vaccination would lead to a relative reduction of HPV 16/18 related deaths and cervical cancer incidence by over 97% and the incidence of HPV 6/11 related genital warts among Estonian women and men by over 94% and 81%, respectively. In addition, there are relevant immediate public health impacts of HPV4 vaccination on genital warts among both women and men. Every year, approximately 751 women and 276 men receive treatment for genital warts in Estonia . Our model projected a substantial reduction in the incidence of genital warts in the first 25 years.Based on the sensitivity analysis, the incremental costs per QALY are about 20% higher if vaccination is implemented against a background of improved cervical cancer screening. We found that the cost-effectiveness ratio was heavily impacted by the discount rate and health utility values used. Assuming a limited duration of vaccine protection and reducing the costs of the vaccine led to modest changes in ICER in opposite directions (i.e. limiting duration increased ICER and reducing costs decreased ICER).Our findings should be interpreted with due consideration for a number of limitations. First, we did not conduct an in-depth literature review to obtain data on the natural history of site- and type-specific HPV infection and disease or on health utility requirements of HPV disease states. Instead, we abstracted relevant data from published studies  and we aFinally, there are several unresolved issues for successful implementation of cervical cancer prevention, including delineating the optimum set of components  to reduce cervical cancer incidence and mortality. Mathematical modelling studies and statistical evidence synthesis are methods that are best suited to investigating the optimal combination of different cervical cancer prevention strategies and should be developed to guide policy decisions about cancer control.In general, routine vaccination of 12-year-old females appears to be cost-effective in Estonia and may provide both short-term and long-term health gains.AM is employed by MSD. MJ is a former employee of MSD. KK is a post-doctoral fellow funded by Merck & Co., Inc. MP is a consultant to Merck & Co., Inc.AU, AM, and MJ developed the concepts for and designed the country level data acquisition and analysis plans; MR organized and analysed the data; and KK and MP conducted the modeling analysis. AU wrote the first draft of the manuscript. All authors contributed to revising the manuscript critically for important intellectual content and have approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2334/13/304/prepubAppendix: Table A1. All-Cause Mortality, Estonia, 2009. Table A2. Age and stage-specific cancer mortality (% per year). Table A3. Mean number of sexual partners per year by age groups, Estonia. Table A4. Distribution of sexual activity risk groups and corresponding mean numbers of partners per year, Estonia. Table A5. Screening and Treatment Parameters, Estonia. Table A6. Costs of diagnosing and treating HPV disease in Estonia (in €). Table A7. Quality-of-Life Parameters*, Estonia. Table A8: Diagnosis and treatment costs of genital warts – male and female, Estonia.Table A9: Costs related to the conventional cytology screening exam, Estonia. Table A10: Costs related to colposcopy, Estonia. Table A11: Costs related to biopsy, Estonia. Table A12: Diagnosis and treatment costs assumed for CIN1, CIN 2/3, Estonia. Table A13: Assumed diagnosis and treatment costs of localized cervical cancer (LCC), regional cervical cancer (RCC) and distant cervical cancer (DCC), Estonia.Click here for file