TERT promoter mutations were rarely observed and did not specifically distribute in a subset of SCCA and did not impact DCF efficacy. Among the 42 genes investigated, few gene alterations were observed, and were in majority amplifications (68.4%), but none were significantly correlated to PFS. As no biomarker is significantly associated with patients’ survival, it prompts us to include every patient failing CRT or with metastatic disease in DCF strategy.Squamous Cell Carcinoma of the Anal canal (SCCA) is a rare disease associated with a Human Papillomavirus (HPV) infection in most cases, predominantly the HPV16 genotype. About 15% of SCCA are diagnosed in metastatic stage and some will relapse after initial chemoradiotherapy (CRT). Treatment of patients by Docetaxel, Cisplatin and 5-fluorouracil (DCF) has been recently shown to improve their complete remission and progression-free survival. The aim of this retrospective study was to explore the impact of HPV infection, HPV DNA integration, TERT promoter mutational status and somatic mutations of oncogenes on both progression-free (PFS) and overall survivals (OS) of patients treated by DCF. Samples obtained from 49 patients included in the Epitopes-HPV02 clinical trial, diagnosed with metastatic or non-resectable local recurrent SCCA treated by DCF, were used for analyses. Median PFS and OS were not associated with HPV status. Patients with episomal HPV had an improved PFS compared with SCCA patients with integrated HPV genome (p=0.07).  Squamous cell carcinoma of the anal canal is a rare disease, representing less than 3% of all gastrointestinal malignancies in the world . Its inchttps://seer.cancer.gov/statfacts/html/anus.html, accessed July 25th 2022), and between 25% to 40% of patients treated initially by chemoradiotherapy will develop locally advanced recurrences or metastases in Western countries . Patients with diagnosis of metastatic or non-resectable local recurrent SCCA were included, and were treated by DCF. The study was described in detail elsewhere –17. AmonPrior to DNA extraction, separate hematoxylin-eosin-stained slides were reviewed by an experienced histopathologist and manually macro-dissected when appropriate to ensure tumor content greater than 20%. Depending on the size of the fixed tissue, between 3 and 8 formalin-fixed paraffin-embedded (FFPE) tissue sections of 10 µm thickness were processed for DNA extraction with the QIAamp DNA mini kit (QIAGEN) according to manufacturer’s instructions.® test (Fujirebio) allowing the identification of 28 different HPV genotypes as well as the HLA-DPB1 gene as internal control for sample quality for DNA detection. As recommended by the manufacturer, samples negative for the HLA-DPB1 gene and negative for HPV were excluded from the analysis.HPV genotyping was performed locally . Brieflin situ hybridization experiments were performed according to the manufacturer’s instructions. The INFORM HPV III Family 16 Probe  allowed the detection of 12 high-risk HPV genotypes.To confirm the HPV infection, E2 gene  was determined by assessing the disruption of the viral E2 gene Table 1.E2 gene , 21. ImpTERT (ENSR00001274355) was obtained from Ensembl database (www.ensembl.org). Specific primers were designed (www.ncbi.nlm.nih.gov/tools/primer-blast/)  . TargeteTERT promoter was analyzed for the presence of mutations at position C228 and C250 using two primers that contained an additional poly(dC) tail at their 5’ end, allowing for their simultaneous detection . Amplified etection Table 3.Libraries were prepared from 50 ng of DNA or by using KAPA Hyperplus Library Preparation (KAPA Biosystem) and Solid Tumor Solution capture kits and protocol by SOPHIA GENETICS. They were sequenced on MiSeq sequencer (Illumina). Criteria used to select mutations were depth (≥100) and allele frequency (≥10%). Allele frequency variants ≈100% or described as benign in ClinVar database, with intronic, frameshift, splicing or synonymous mutations were excluded. A list of the targeted 42 genes is shown in PIK3CA mutational status. PFS was determined at 12 months from the first DCF cycle. Fisher’s exact test was used for all other analysis.Log-rank (Mantel-Cox) test was used for the analysis of PFS and OS according to HPV integration status and + SCCA and 12.6 months (95% CI: 6.2-18.9) when HPV was not detected. Median OS was 36.3 months (95% CI: 24.2-NE) for HPV16+ SCCA and 26 months for HPV negative SCCA.Among patients included in the Epitopes-HPV02 study, there was a majority of female (83.7%) compared to male who represented only 16.3% Table 5.We next explored if the presence of HPV genome in an episomal or integrated form could influence clinical outcomes of SCCA patients treated with DCF . Three types of TERT promoter mutations investigated have been observed. One HPV16+ SCCA patient had a C250T mutation, and another HPV16+ had a C228A mutation. Three other patients (2 HPV16+ and one HPV- SCCA) had C228T mutations. Three of the SCCA patients displaying TERT promoter mutations showed partial responses after exposition to DCF. These results addressed the question of the overall distribution of TERT mutations in SCCA population. To validate the prevalence of TERT mutations in SCCA, sequencing analysis of the telomerase catalytic subunit TERT was performed in the EDITH V cohort. Among the 381 patients with available DNA, TERT promoter mutations were identified in 30 patients (7.8%). The C228T mutation was predominant , while the mutations C228A and C250T were observed in 1 and 7 patients respectively. Of note, one homozygote mutation of C228T was detected. Among the EDITH V cohort, there was a majority of patients with HPV positive SCCA  including 210 (81%) patients with HPV16 or 18 infections and 49 (19%) patients with other HPV genotypes; 10 (2.6%) patients represented HPV negative SCCA. HPV status was not available for 112 (29.4%) patients. TERT promoter mutations were not specifically correlated to HPV status in SCCA  and CDK4 (5 amplifications)  Table 7.Nineteen out of the 49 (38.8%) patients with SCCA tested presented no alterations among the 42 screened genes. Most of them were HPV positive, with 89% (n=17/19) of HPV16 and 11% (n=2/19) of other HR-HPV. Forty-seven percent (n=9/19) of SCCA harbored integrated or mixed forms of HPV DNA, whereas 32% (n=6/19) harbored only episomal forms of oncogenic HPV DNA. On the contrary, 61.2% (n=30/49) patients with SCCA presented one alteration or more. A majority of them had an HPV16 infection , one had an HPV16+33 infection and 2 were HPV negative. Almost 53% (n=16/30) had integrated or mixed forms, 26.6% (n=8/30) had an episomal HPV and 20% (n=6/30) were not identified. No difference was observed between the 2 groups concerning HPV status  nor integration status .PI3KCA amplification and mutations were the most frequent, we assessed the influence of these genomic alterations on SCCA patient overall survival. No difference of OS was observed between patients harboring PIK3CA alterations or WT PIK3CA  Table 8.Epitopes-HPV02 study was the first prospective clinical trial that included SCCA patients with advanced diseases and demonstrated the ability of Docetaxel-based polychemotherapy to induce long term remissions . An anciIn our study, a majority of SCCA was HPV positive, mostly HPV16 which is the most frequent high risk type in this disease –26. Althvia the inhibition of the binding between E2 and its binding sites (E2BS) at the viral promoter due to the methylation of said E2BS  in our study compared to episomal forms. Of note, the percentage of “pure” episomal HPV DNA is likely to be slightly overestimated in this study given that, in a minority of cases, HPV could be integrated in host genome without E2 disruption  cancers . Howeveraid E2BS . Severalaid E2BS  but, mosuencing) . Despiteuencing) . The betin fine cellular immortalization by preventing replicative senescence. TERT promoter mutations are correlated to increased TERT expression and a worse prognosis as confirmed by a recent meta-analysis in glioma patients (TERT promoter mutations have been previously identified in glioblastoma (84%), urothelial carcinoma (64.5%), oligodendroglioma (70.0%), medulloblastoma (33.3%) and hepatocellular carcinoma (31.4%) , which is mostly linked to an APOBEC  alteration . The fact that HPV integration is sometimes located in or near amplification regions has been shown for other genes, like MYC  and pembrolizumab (anti-PD1 antibody) were approved in progressive and metastatic cervical cancers , and werTERT promoter mutations, and mutational profiling are not significantly correlated to PFS and/or OS in this study, DCF chemotherapy should be proposed to all SCCA patients failing radio-chemotherapy (CRT) or with metastatic disease. Further investigations are required to identify SCCA-related predictive biomarkers.In conclusion, as HPV status, integration status, The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by The French ethic committee (NCT02402842). The patients/participants provided their written informed consent to participate in this study.CB, SK, J-LP and DG contributed to conception of the whole study or a part of it, and CB coordinated the clinical trial. AD, DG and PR performed the experiments and CB, AD, MH and AM performed data analysis and/or statistical analysis. AD wrote the first draft of the manuscript and CB, SK, AM and MH wrote sections of the manuscript. FM, LS, AV, AT, AL, ChlM and ChrM allowed data collection. All authors contributed to the article and approved the submitted version.Part of this work was funded by the Région Franche-Comté and the Belgian Fund for Scientific Research .The authors would like to thank Guadalupe Inés Tizón for English writing assistance. We also thank the biobank ‘Tumorothèque Régionale de Franche-Comté’ (registration number BB-0033-00024) for biobanking. CB has received a research grant from companies Bayer and Roche, and was an advisory board member of Bayer, MSD and Pierre Fabre companies. None of them had a role in the study design, analysis, or interpretation of the results.The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The HPV vaccination is a crucial line of defensing against cervical cancer. As a result of government support and positive publicity from the majority of media, a craze for HPV vaccination has occurred in China. Besides, the intentions to get the HPV vaccine among women of appropriate age is also influenced by families' and friends' attitudes and perceptions toward HPV vaccine. Therefore, the purpose of this study was to investigate how HPV related information exposure and injunctive norms affect young Chinese women's intentions to receive the HPV vaccine.A structural equation model was developed based on KAP theory, and 567 effective questionnaires were collected through an online survey. We used SPSS 26.0 for the reliability and validity analysis and the differential testing of demographic characteristics, and Amos 26.0 for the goodness-of-fit analysis and paths testing of the model.P = 0.046), educational background (P = 0.001), and occupation (P = 0.004). (2) Exposure to HPV related information positively affected knowledge about HPV  and intention to receive HPV vaccine . (3) Knowledge about HPV positively affected attitude toward HPV vaccine , but negatively affected intention to receive HPV vaccine , and attitude toward HPV vaccine positively affected intention to receive HPV vaccine . (4) Injunctive norms positively affected attitude toward HPV vaccine  and intention to receive HPV vaccine .Our findings showed that (1) intention to receive HPV vaccine differed significantly in age (Exposure to HPV related information influenced young Chinese women's intentions to receive the HPV vaccine and related knowledge, that is, the more frequently they were exposed to HPV related information, the stronger their intentions to receive the vaccine and the higher their HPV knowledge. Also, the perception and support of HPV vaccination by people around them will further influence their attitudes and intentions to receive the HPV vaccine. HPV, known as human papilloma virus, is the most common sexually transmitted virus worldwide. HPV infection is usually unnoticed, and persistent infection with high-risk HPV types in particular is the leading cause of diseases such as penile cancer, anal cancer, precancerous cervical lesions and cervical cancer , 2. AccoHowever, awareness of HPV and the vaccine remains at a relatively low level. A meta-analysis showed that the pooled awareness and knowledge rates about HPV vaccination were 15.95 % and 17.55 % respectively . And theIn the era of social media, the vast amount of information sources related to HPV vaccine provides more and more channels for the public to know about HPV, which may implicitly influence the public's attitudes and beliefs, and then may influence their behaviors . And theGiven the above background, the aim of this study was to investigate how exposure to HPV related information and injunctive norms affect the intentions to receive HPV vaccine among the young women in China. The Knowledge-Attitude-Practice Theory, a classical theory in the field of health communication, was also adopted to construct a structural equation model in an attempt to verify the influence paths of information exposure and injunctive norms on HPV vaccination intention among the Chinese women of appropriate age.Previous studies into health information exposure mainly include three aspects: first, studies on the source types of health information exposure. In the Internet era, people's access to information is diversified and complicated, and information from different channels has different impacts on people's attitudes and behaviors –15. SecoExisting studies have explored the relationship between exposure to HPV information and intention to receive HPV vaccine in many countries. For example, in a study of parents' intention to vaccinate their children against HPV, McRee et al.  found thH1: Exposure to HPV related information positively affects the knowledge level about HPV among young women.H2: Exposure to HPV related information positively affects the intention to receive the HPV vaccine among young women.Knowledge-attitude-practice theory (KAP Theory) is used to explain the relationships between the three levels of health behavior change . And it On the topic of vaccination, Chen et al.  investigH3: Knowledge about HPV positively affects the intention to receive HPV vaccine among young women.H4: Knowledge about HPV positively affects the attitude toward HPV vaccine among young women.H5: Attitude toward HPV vaccine positively affects the intention to receive HPV vaccine among young women.Injunctive norms are one kind of social norms that refers to the perception of social approval for a certain behavior, which reflects the pressure of individuals to comply with it . If the Current studies have found that injunctive norms have a significant role in advising behaviors such as smoking cessation, alcohol cessation, and healthy eating –44. LikeH6: Injunctive norms positively affect the intention to receive the HPV vaccine among young women.H7: Injunctive norms positively affect the attitude toward HPV vaccine among young women.The research model is shown in The World Health Organization classifies young people as being aged 15–44 years , an age www.wjx.cn), an online questionnaire platform in China, to design the questionnaire and deliver it to the target population through social media such as WeChat and QQ. The privacy of questionnaire participants will be strictly protected. Data collection was carried out in two stages:This study adopted a random online questionnaire method, relying on Wenjuanxing . Amos was used for confirmatory factor analysis (CFA), goodness-of-fit testing and path testing of the structural equation model.P > 0.05, the result of ANOVA is taken as the final result; if the P < 0.05, the variance is not homogeneous (P < 0.05). Specifically, people aged 20–24, those with a master's degree or above, medical practitioners, civil servants and those working in public institutions were more likely to get HPV vaccine.To examine differences in intention to receive the HPV vaccine among demographic characteristics, we performed a one-way ANOVA using SPSS. The precondition of one-way ANOVA is to ensure the homogeneity of variance of each independent group, so the homogeneity of variance should be tested first. In the homogeneity of variance testing results, if the ogeneous . Accordiogeneous , Welch AIn order to measure the variables in the model, we referred to the maturity scale of previous studies, and adapted it to fit within the scope of this study. And its validity was tested by confirmatory factor analysis (CFA) method see . ConfirmIn this study, Cronbach's Alpha was used as the evaluation criterion of reliability. Fornell and Larcker  point ouThe validity testing includes content validity, convergent validity and discriminant validity. Firstly, this study was based on validated scales and adequate pre-research, so the content validity was well guaranteed. Secondly, according to the results in Through the above analysis, it can be seen that the questionnaire design of this study was reasonable and had good reliability and validity. To measure the valid and proper design of the structural equation model, further model fitting analysis can be conducted.2/df), should be between 1 and 5; (2) The root means square error of approximation (RMSEA), should be < 0.08; (3) The standardized root means square residual (SRMR), should be <0.08; (4) Tucker-Lewis index (TLI), should be >0.95; (5) The normed fit index (NFI), should be >0.9; (6) Comparative fit index (CFI), should be >0.9.In this study, the structural equation model was constructed and evaluated using Amos. And the following suggested criteria from Hooper et al.  were ado2/df = 3.504, RMSEA = 0.067, SRMR = 0.097, TFI = 0.933, NFI = 0.920, CFI = 0.941. Two indexes, SRMR and TFI, did not meet the suggested criteria, so the initial model was less than ideal and needed to be modified. According to the Modification index (MI) in the Amos output, covariant relationships were established to reduce the chi-square value and further fit the model. The results of the model fit after modification are shown in x2/df = 2.782, RMSEA = 0.056, SRMR = 0.039, TFI = 0.952, NFI = 0.937, and CFI = 0.958. All the indexes after modification met the fit criteria, and the model is good in fitting effect and well adapted to the sample data.The initial model fit was evaluated with the following results: xP < 0.05, indicating that the connectivity of the paths could be supported. Exposure HPV related information positively affected knowledge about HPV  and intention to receive the HPV vaccine , so H1 and H2 were supported. Knowledge about HPV positively affected attitude toward HPV vaccine , but negatively affected intention to receive the HPV vaccine . H4 was supported, but H3 was not. Attitude toward HPV vaccine positively affected intention to receive the HPV vaccine , and H5 was supported. Injunctive norms positively affected attitude toward HPV vaccine  and intention to receive the HPV vaccine , H6 and H7 were supported.There are seven paths in this study. Amos was used to analyze the paths, and then the research hypotheses were tested. The final path coefficient of proposed model and hypotheses testing results are presented in In recent years, the incidence and mortality rate of cervical cancer in China has been on the rise, posing a serious threat to the lives of Chinese women. And HPV vaccination, as a primary prevention measure, is the most crucial line of defense against cervical cancer. This study aimed to investigate how exposure to HPV related information and injunctive norms affect young Chinese women's intention to receive the HPV vaccine. Foremost, our results provided evidence to positive effect of HPV related information exposure on the knowledge about HPV, which is in line with previous studies . FurtherInformation exposure plays a prominent role in determining the HPV-related knowledge level and intention to vaccinate among the public. This study verified the applicability of the above two findings in mainland China and provided implications for how to improve HPV vaccination coverage among Chinese women of appropriate age, also highlighted the potential role of HPV information exposure in preventive medicine and public health strategies. Ortiz et al.  suggesteP). According to the theory, there is a positive and progressive relationship between knowledge, attitude and practice, that is, knowledge enhances attitude and attitude promotes practice. Our study results suggested that knowledge about HPV was positively related to attitude toward HPV vaccine, and that attitude toward HPV vaccine positively affected the intention to receive HPV vaccine. This result is in accordance with the basic logic of KAP theory and also ties well with other previous vaccine studies using this theory. For example, a KAP survey about pediatric vaccine among pregnant women in the city of Rome found that a good level of knowledge was the strongest predictor of positive attitude toward vaccination, which in turn influenced the majority of respondents' intentions to vaccinate , attitude formation (A), and behavior promotion (accinate .Surprisingly, a negative association between knowledge about HPV and intention to receive HPV vaccine was found in the results, which was contrary to prior studies . FirstlySecondly, we also speculated that this result might be explained by the perceived cost to the individual, with studies demonstrating that the high price of vaccines was a major cause of vaccine hesitancy, and that even if people were better informed about vaccines, the perceived high cost in terms of time, price, and availability would deter their vaccination . HoweverIt is notable that our study found that injunctive norms positively affected the attitude toward HPV vaccine and the intention to receive HPV vaccine. This finding is similar to previous studies from other countries, such as a cross-sectional study of HPV vaccination among US college students, which noted that US college students' perception of being expected by their parents and health care providers to get the HPV vaccine influenced their attitudes toward HPV vaccine and further influenced their intentions to get the vaccine . In pastHowever, behind the “vaccine fever,” we should see more clearly that some domestic women of the right age are blind and irrational about HPV vaccination, pursuing the quadrivalent and nine-valent vaccines, and in turn missing the best vaccination period as a result of waiting for quadrivalent and nine-valent vaccines that are currently in short supply. The WHO recommended that the best time for HPV vaccination was between the ages of 9 and 14 years, and therefore, HPV vaccination should be given as early as possible to achieve better effects. Accordingly, in the subsequent promotion of HPV vaccine, a four-level linkage of “government-healthcare sector-community-family” should be applied to health education. It is important to encourage women of the appropriate age to actively receive HPV vaccine under the role of social culture and social norms, as well as to improve HPV-related knowledge among them to reduce irrational vaccination.Additionally, peer education is one of the key tools to increase vaccine awareness and promote vaccination. Peer-led education programming is currently a prevailing strategy for adolescent sexual and reproductive health education , and a sUnder the context of the HPV vaccination craze, this study was designed to investigate the effects of HPV related information exposure and injunctive norms on young Chinese women's intention to receive the HPV vaccine. On the basis of KAP theory, we proposed a structural equation model containing the influence paths of information exposure and injunctive norms. Through a questionnaire survey and the model testing, we found that exposure to HPV related information had an impact not only on young women's intention to receive HPV vaccine, but also on their knowledge level about HPV. The more frequently they were exposed to HPV related information, the stronger their intentions to get vaccinated and the higher their level of relevant knowledge. Also, the perception and approval of HPV vaccination by those around them further influenced their attitudes and intentions to receive the vaccine. Furthermore, this study confirmed the relationship between knowledge, attitudes, and practice regarding HPV vaccination, with results indicating that good possession of HPV knowledge led to more positive attitudes toward HPV vaccine, and in turn strengthened the intention to receive HPV vaccine. However, a negative association between knowledge level of HPV and intention to be vaccinated was also unexpectedly found, and we speculated that this result might be related to public concerns about vaccine safety issues and the high price of HPV vaccine in China. The findings of this study are of important practical implications for the public health departments and health information service providers to carry out HPV related health education and propel HPV vaccination policies.Despite the theoretical values and practical significance of this study, there are several limitations that need further improvement in the future research. First, this study was analyzed based on the cross-sectional data obtained from a questionnaire survey, and the study can be deepened in the future by combining qualitative interviews and other methods to explain the individual differences and enhance the dependability of causal inferences. Second, the items measuring information exposure contained both active and passive exposure, and different kinds of information exposure may have different effects on HPV vaccination. Therefore, future research should be undertaken to subdivide the variable of information exposure and explore the different effects of active and passive information exposure. Third, the positive association between HPV knowledge and intention to receive the vaccine was not supported in this study, and factors such as exposure to negative vaccine information and perceived cost could be considered for inclusion in future studies and explored for their moderating effects on the relationship between HPV knowledge and intention to receive the vaccine.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Academic Committee of School of Journalism and Communication, Huaqiao University. Written informed consent from the participants' legal guardian/next of kin was not required to participate in this study in accordance with the national legislation and the institutional requirements.YW and YC contributed to conception and design of the study. YC wrote the first draft of the manuscript, designed the model and questionnaires, and performed the data analysis. YW and SB collected the data and revised and edited the manuscript. All authors contributed to the article and approved the submitted version.


Young adults were receptive to watching narrative-based health information videos on social media. When promoting HPV vaccination, more engaging information leads to greater intentions to talk about the vaccine and get vaccinated.Rates of human papillomavirus (HPV) infection are highest in young adults, who can be vaccinated against HPV if they were not vaccinated as adolescents. Since young adults increasingly access health information on social media, we tested the impact of a social media campaign with narrative-based health information on intentions related to HPV vaccination. We also aimed to understand which ads resonated most with young adults and led to higher survey completion rates. We created social media posts featuring videos promoting HPV vaccination. We launched a sponsored ad campaign on Facebook to reach young women, ages 18–26, across the country. Participants were randomly assigned one of 6 videos and then completed a brief survey about video engagement and intentions to: talk with a health care professional, talk with friends or family, and vaccinate against HPV. A descriptive correlational design and a test for moderation were used to explore hypothesized relationships. Across all ads, 1332 link clicks led to 991 completed surveys that were reduced to 607 surveys . Higher video engagement was associated with stronger intentions to talk with a health care professional ( One in fThe HPV vaccine is recommended for adolescents between the ages of 11 and 12 years, when immunogenicity is highest and previous infection with HPV is rare.  While thThere is a small but growing body of evidence about HPV vaccine acceptability and uptake in young adults ages 18 through 26. The earliest studies focused on college students.  A more rUnderstanding effective messages is crucial to vaccine uptake. Numerous national organizations have campaigns to promote HPV vaccination, typically focusing on parents.  Messages1.2Narrative engagement theory  provides1.3RQ1: Do HPV videos with higher levels of narrative engagement have a stronger effect on intentions to talk about the HPV vaccine and be vaccinated against HPV than less engaging HPV videos?RQ2: Do perceptions of the COVID pandemic moderate the effects of video engagement on vaccine intention?RQ3: Which social media ad campaign, and corresponding ad features, was most likely to lead to survey completion?The purpose of this social media-based intervention study was to test whether variations in narrative engagement led to differences in HPV vaccine intentions. While there is a growing evidence base of the impact of interventions on social media,  this is 22.1Our goal was to engage an audience of young adult women to watch narrative-based videos addressing HPV vaccination and complete a survey about their engagement with the videos, their intentions to talk to others about HPV vaccination, and their own HPV vaccination intentions. We recruited via social media, where potential participants saw a sponsored ad that we created for the study. Contained within the ad was a link; clicking the link took participants to a randomly assigned, narrative-based video on HPV vaccination. After watching the video, participants completed a short survey. Participants were compensated $10 via an electronic gift card for completing the survey. This study was deemed exempt by the organization’s Institutional Review Board.2.2We used six narrative-based videos designed to increase HPV vaccination rates among adult women . These videos focused on vaccinating oneself rather than one’s child and stressed the sexually transmitted nature of the virus and its link to various cancers. The videos were evidence-based and part of the previously developed “HPV Wellness Suite: Women’s Stories” HPV intervention.  The vide2.3To recruit participants on social media to complete the survey, we created 15-second video ads that depicted mostly young women but could appeal to all women, given that the vaccine is approved for women up to age 45. The first video depicted general images of women in a slideshow format. The second video depicted 18–26-year-old male and female adults interacting with each other. The two video ads were paired with two different messages: a statement, “The HPV Vaccine Has Been Proven to Prevent Cancer in Women,” or a question, “Did you know the HPV Vaccine Prevents Cancer in Women?” We also created four static (single image) ads. The first two ads featured an image of a young Asian adult female, while the second two ads featured an image of a young African American adult female. The static ads were paired with the same messages that were used in the video ads. Facebook reviews all ads prior to distributing the ads across their platform. The third static add was rejected because it was labeled a social issue. The team decided not to pursue an advanced review and therefore it was not published. The full set of ads are in 2.4The study ran from August 12, 2020 through September 26, 2020 on Instagram platforms  using Facebook (FB) Ad Manager. We chose Instagram platforms because 18–26-year-olds are more likely to use Instagram rather than Facebook.  We used 2.52.5.1strongly disagree; 5 = strongly agree). Interest items included, “The video was interesting,” “I paid attention to the video,” “when watching the video, I did NOT think about other things,” “I had a hard time keeping my mind on the video” (reverse coded), “If this video was available on Instagram, I would share it,” and “The video was boring” (reverse coded). Realism items consisted of, “The video seemed realistic to me” and “the video was believable.” Identification items were, “The people in the video seemed like people I know” and “The people in the video seemed like me.” This scale obtained a reliable Cronbach alpha .The engagement variable measurement assessed interest, realism, and identification.  Items we2.5.2very unlikely, 5 = likely). Items included, “I intend to talk with my healthcare professional about the HPV vaccine” , “I intend to talk to my friends/family about the HPV vaccine” , and “I intend to get the HPV vaccine the next time I see my doctor” .Dependent variables identified participants’ intentions to talk with a healthcare provider or their friends or family about the vaccine or to receive the HPV vaccine the next time they visited their doctor. Each item was measured as a single item on a 5-point Likert-type scale  was measured on a Likert-type scale .To address Research Question 2, to understand if perceptions of the COVID-19 pandemic moderated the effects of video engagement on vaccine intention, the covariate regarding COVID-19 “COVID has impacted my decision to get the HPV vaccine” . Research Question 2, that perceptions of the COVID-19 pandemic (“COVID has impacted my decision to get the HPV vaccine”) would moderate the effect of video engagement on vaccine intentions, was answered using Model 1 from the PROCESS macro in SPSS.  Models u2.7Campaign ad performance was measured by using a number of metrics that were available through Facebook’s Ad Manager. ‘Reach’ was used to track the number of Instagram users who saw the ads at least once. ‘Impressions’ measured the number of times our ads were on screen, which included multiple views by the same user. ‘Link clicks’ and ‘unique link clicks’ were used as the main metric for measuring performance and included any Instagram user that clicked on the link in our ads. Cost per result indicated the cost per link click based on the total amount spent on the campaign. Research Question 3, which ad and ad features led to the greatest number of completed surveys, was determined by a frequency count of the number of surveys completed stemming from each ad.33.1The results of the four campaigns can be seen in 3.2n = 579, 95.4 %) were between the ages of 18–26, 23 (3.8 %) were 27–34, and 5 (0.8%) were between the ages of 35–45. The sample was diverse with 226 (37.2 %) who identified as white/Caucasian, 160 (26.4 %) Asian/Asian American, 88 (14.5 %) Hispanic/Latino/Latina, and 59 (9.7 %) Black/African American. The number of participants who were randomized to each narrative engagement video ranged from 93 (Video 5) to 107 (Video 2).Across all ad campaigns, 1332 link clicks led to 991 completed surveys and 607 usable surveys . A full 3.3Engagement scores for each of the six videos ranged from the lowest at 3.62 (SD = 0.65) for Video 2 to the highest at 3.89 (SD = 0.60) for Video 1 . EngagemM = 3.89, SD = 1.02) and lowest for “I intend to talk to my friends/family about the HPV vaccine” . The mean score for “I intend to get the HPV vaccine the next time I see my doctor” was 3.71 (SD = 1.08). . .r = 0.44, p =.01) and intentions to talk to friends/family about the HPV vaccine . Results of a two-tailed Pearson correlation indicated that there was also a positive relationship between engagement and intentions to vaccinate . Therefore, the hypothesis was supported  = 0.51, p =.77, (η2 = 0.004), “I intend to talk to my friends/family about the HPV vaccine” F = 0.98, p =.43, (η2 = 0.008), and “I intend to get the HPV vaccine the next time I see my doctor” F = 0.73, p =.60, (η2 = 0.00)  .Table 6C3.4F  = 60.32, p <.001, R2 = 0.23. However, the interaction effect between engagement and the impact that COVID-19 has on vaccine intentions was not significant B = -0.07, SE = 0.05, t = -1.49, p =.14, 95 % CI .   and the , 0.02]. . Thus, C4The purpose of this study was threefold: to determine if videos with higher levels of engagement had higher levels of intention to talk with someone about the vaccine or to be vaccinated, to determine if certain videos resonated more strongly with young adults recruited through social media, and to determine if perceptions about the COVID-19 pandemic would impact intentions to vaccinate against HPV.First, we found that overall videos that scored higher on engagement evoked stronger intentions to vaccinate. This is consistent with, but an extension of, previous research conducted with the WS video intervention. For example, Rey et al. reported comparable levels of engagement and a strong association between engagement and video persuasiveness, but did not evaluate vaccination intentions.  Hecht etThe findings from this study also have implications for promoting research studies on social media. First, we found that static ads were more effective than video clips in attracting our audience to the study. This may be the nature of the social media environment, where people are rapidly viewing large quantities of content and do not intend to view any one post for a substantial amount of time. Being able to move quickly to the study rather than watching a short video was preferred for our audience of young adults. We also confirmed that recruiting through social media led to diverse representation of participants. In our sample, about two-thirds of participants identified with a racial or ethnic minority group. This is reflective of other studies that have had success in recruiting diverse participant samples through social media. .Our study also contributes to knowledge about perceptions of vaccination during COVID-19. Access to preventive care, like the HPV vaccine, was halted in many communities, resulting in steep declines in routine vaccination.  We wondeHPV Wellness Suite: Women’s Stories, can reverse this trend by providing high-quality, factually accurate information on social media. Moreover, the results of the study can inform future public health initiatives to increase HPV vaccination among an older age group, those over the age of 18, who are making vaccination decisions for themselves rather than relying on a parent.It is important to still be vigilant when promoting HPV vaccination. Currently, social media is a breeding ground for misinformation and disinformation, particularly as it relates to health information.  The publWhile there were numerous strengths to this study, such as using a theoretically grounded, evidence-based video intervention, there were limitations. Due to the nature of the study, we were unable to measure actual HPV vaccination behavior. While self-report of HPV vaccination status has been shown to be an acceptable measure of actual vaccination behavior,  and was Funding was supported by the Grant or Cooperative Agreement Number, 5 R44DP006291-03, by the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention or the Department of Health and Human Services.Amy E. Leader: Conceptualization, Methodology, Visualization, Writing – original draft, Writing – review & editing, Project administration. Michelle Miller-Day: Conceptualization, Methodology, Writing – original draft, Writing – review & editing. Rikishi T. Rey: Conceptualization, Methodology, Formal analysis, Data curation, Visualization, Writing – original draft, Writing – review & editing. Preethi Selvan: Conceptualization, Methodology, Software, Formal analysis, Data curation, Visualization, Writing – original draft, Writing – review & editing. Anne E. Pezalla: Conceptualization, Methodology, Writing – original draft, Writing – review & editing. Michael L. Hecht: Conceptualization, Methodology, Resources, Writing – original draft, Writing – review & editing, Funding acquisition.The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.


Live-streaming fitness is perceived by the Chinese government as an invaluable means to reduce the prevalence of physical inactivity amid the COVID-19 pandemic. This study aims to investigate the public altitudes of the Chinese people toward live-streaming fitness and provide future health communication strategies on the public promotion of live-streaming fitness accordingly.This study collected live-streaming fitness-related microblog posts from July 2021 to June 2022 in Weibo, the Chinese equivalent to Twitter. We used the BiLSTM-CNN model to carry out the sentiment analysis, and the structured topic modeling (STM) method to conduct content analysis.This study extracted 114,397 live-streaming fitness-related Weibo posts. Over 80% of the Weibo posts were positive during the period of the study, and over 85% were positive in half of the period. This study finds 8 topics through content analysis, which are fitness during quarantine; cost reduction; online community; celebrity effect; Industry; fitness injuries; live commerce and Zero Covid strategy.It is discovered that the public attitudes toward live-streaming fitness were largely positive. Topics related to celebrity effect (5–11%), fitness injuries (8–16%), live commerce (5–9%) and Zero Covid strategy (16–26%) showed upward trends in negative views of the Chinese people. Specific health communication strategy suggestions are given to target each of the negative topics. China has a burgeoning marketplace of live-streaming fitness. In 2021, TikTok, China's leading live-streaming site, reported that the number of fitness live-streamers rose 39% year-on-year, the followers of fitness live-streamers rose 208% year-on-year, and the revenue of fitness live-streamers increased 141% year-on-year  , 15. To Social media has been widely used as data source for public health studies in recent years . In compOur research objective is three-fold: (1) to examine the general sentiment of the Chinese people toward live-streaming fitness, (2) to analyze their (dis)satisfaction and (3) to come up with appropriate health communication strategy suggestions for the Chinese government to further promote live-streaming fitness in China. To achieve the above objective, the research questions are therefore framed as follows:RQ1: What was the overall Weibo activity on live-streaming fitness during the period of the study?RQ2: What was the general sentiment of Chinese people toward live-streaming fitness during the period of the study?RQ3: What health communication strategies can be drawn to further promote live-streaming fitness?This paper makes two major contributions to the present literature. First, this study focused on the (dis)satisfaction of the Chinese people in live-streaming fitness, which was somehow overlooked by the previous literature. In addition, this study has used natural language processing (NLP) techniques to conduct data collection and analysis while the previous literature mainly used conventional research methods such as questionnaires.The data collection and processing steps in this study are as follows. First, we used Weibo public streaming application programming interface (API) to extract Weibo posts. The API is provided in Weibo's open platform. Weibo continuously updates its API interface to the needs of users to help users collect data . HoweverIn order to mine and examine the public attitudes of the Chinese people toward live-streaming fitness, this study conducted both sentiment analysis and content analysis on the collected Weibo posts to monitor the public sentiment and trending opinions of the Chinese people on this fitness model. Sentiment analysis is a desirable method for opinion mining and subjectivity analysis , which aThis study adopted a BiLSTM-CNN model to carry out the sentiment analysis. Bidirectional Long-Short Term Memory model (BiLSTM) is an advanced type of Long Short-term Memory model (LSTM). It overcomes LSTM's shortcomings in only memorizing information located at the beginning of a text but not the later parts of the text . BiLSTM Sentiment analysis is a rather coarse-grained analysis as it cannot address the semantic dimension of public attitudes as expressed in the textual data . For thiSimilar to LDA, STM also assumes that a corpus is a bag of words, and the topics of a text can be measured by the frequency of occurrence of words. In the STM model, each document contains multiple topics, and each topic contains a series of high-frequency words that help define the nature of the topic. Compared to LDA, STM enables the possibility of considering metadata associated with the text using document-level covariates  so that The successful construction of a STM model requires the sample size corresponding to the covariates to be as consistent as possible . UnbalanFrom the dataset composed of 114,397 Weibo posts, the general picture of the evolution of the popularity of live-streaming fitness among Chinese netizens was drawn . In geneSentiment analysis was conducted on the collected Weibo posts. The sentiment data were reorganized to show the evolution of the public sentiment trend over the given period. The premise of conducting STM is to define the optimal number of topics. The topic number is one of the most essential parameters of the STM, which, in practical applications, is usually defined to obtain the most substantive interpretation of the outcomes rather than the maximization of the topics . In thisThe results of the topic clustering are shown in To better understand the meaning of the topics, we also examined the most representative Weibo posts of each clustered topic. From the topic modeling results, latent themes behind the Weibo discussions emerged, underlying a hidden structure that reflected the interests and concerns of the Chinese people toward live-streaming fitness. As previously mentioned, to further promote live-streaming fitness in China, we must understand the satisfaction and dissatisfaction that Chinese people have on live-streaming fitness. Only then can we come up with efficient strategies accordingly. To this end, this study added public sentiment as a covariate in the STM model. In other words, a topic will be identified as negative if the proportion of this topic in the negative Weibo posts is noticeably larger than it in the positive ones and vice versa . The resGiven that live-streaming fitness is an emerging fitness model in China, which is subject to change over time, the satisfaction and dissatisfaction of the Chinese public toward live-streaming fitness could change accordingly. Therefore, by tracking the most frequent topics overtime, we could able to offer a more detailed analysis on the evolution of the public sentiment toward live-streaming fitness. To achieve this research goal, we have implemented an interaction term of time and public sentiment into the STM model. To locate the dissatisfaction of the Chinese people toward live-streaming fitness, this study focused more on the changes in negative sentiments. To answer the first research question is about the overall live-streaming fitness-related Weibo activity, the result suggests that public interest in live-streaming fitness was ignited twice over the last 12 months. The first one was in August 2021 when the Chinese government officially acknowledged the significance of live-streaming fitness. The corresponding surge in Weibo discussions could come from the vast amount of media spotlight on the acknowledgment at that time as mass media often rushes in to promote the communication and understanding of public policy . The othWith regards to the second research question on the public sentiment of Chinese people toward live-streaming fitness, our findings showed that the majority of the Chinese public held positive attitudes (86.2%) about live-streaming fitness, as compared to the negative (13.8%) opinion holders. In addition, the two incidents that sparked the nationwide interest in live-streaming fitness also affected the public attitudes according to the public sentiment proportions. The first incident increased the positive view of the Chinese people (79–89%), which again proved the significant impact mass media has exerted on promoting public policies. Meanwhile, the second incident caused a decrease on the proportions of the positive Weibo posts. The sudden success of Liu Genghong put live-streaming fitness in the national spotlight for scrutiny. Unlike the previous time when people focused solely on the positive information of live-streaming fitness fed by the government through mass media, various problems of this new fitness model were exposed in the media scrutiny and were noticed by the Chinese public, which subsequently lowered the proportions of the positive attitudes.To further examine this research question, this study also looked into the evolution of the negative sentiment toward the eight topics generated by the STM . In doinFrom the analysis of the data around the first and the second research questions, a clear answer to the third research question about drawing health communication strategies to further promote live-streaming fitness unfolds itself. We propose the following health communication strategy-related suggestions to address the major concerns the Chinese people have against live-streaming fitness. First, in response to the potential fitness injuries live-streaming fitness could inflict upon its participants, the government should enhance the promotion of sports health information in the media to prevent people from injuring themselves due to lack of knowledge in such field. Second, the government should encourage more celebrities to endorse live-streaming fitness. Celebrities can efficiently promote live-streaming fitness through participating and advocating on social media, just as Liu Genghong did in April 2022. Third, the government should underscore the importance of separating live fitness and live commerce and require fitness live streamers to leave live commerce at the end of fitness sessions, thus avoiding interference with the fitness experience. Last, the results reflected the public anguish over China's strict policies on quarantines and lockdowns. Since the government showed no sign of changing course in this matter, it should step up its efforts in public education and emphasize on the great potential physical activity for the prevention and treatment of anxiety and anxiety and depression .A couple of limitations of this study need to be mentioned. First, this study collected data from only one social media site. Many individuals may have also dis-cussed about live-streaming fitness within online forums, Wechat groups, and other social media platforms. Another limitation of using social media posts as research data is that posts with extreme sentiments were often removed by the social media plat-forms. This may have reduced the overall percentage of a particular emotion in our samples.Notwithstanding these limitations, this study provides a clear indication of the public attitudes toward live-streaming fitness in China. This study used Weibo, China's leading social media site, as the data source to examine the attitudes of Chinese people. Data were extracted via Weibo public streaming API and a web crawler we programmed in python. In doing so, we are able to build a huge dataset that is extremely hard to achieve through traditional research methods such as surveys. A BiLSTM-CNN based sentiment analysis was employed to broadly evaluate public attitudes by measuring the degrees of public sentiment polarity (positive and negative). For a profound understanding of the data, sample posts were further examined by using STM to extract the main topics of Weibo discussions and then analyze the public attitudes from a topic perspective. The results show that Chinese people, in general, hold a positive attitude toward live-streaming fitness. However, the dissatisfaction of the Chinese public over topics such as fitness injuries, celebrity effect, live commerce and COVID-19 policies were also identified. Suggestions on health communication strategy were given accordingly.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Conceptualization, methodology, software, validation, formal analysis, writing—original draft preparation, and visualization: RT and RY. Writing—review and editing: RT, RY, and FG. Supervision and project administration: FG. All authors have read and agreed to the published version of the manuscript.This research was supported by the National Social Science Foundation (21ZD11) and Jiangsu Provincial University Philosophy and Social Science Research Fund (2020SJZDA078).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Identifying factors associated with human papillomavirus (HPV) vaccine uptake is essential for designing successful vaccination programmes. We aimed to examine the association between vaccine hesitancy (VH) and HPV vaccine uptake among male and female youth in Switzerland.With a cross-sectional study, an interview-based questionnaire was used to collect information on sociodemographic factors, vaccination records and to measure the prevalence of VH using the Youth Attitudes about Vaccines scale (YAV-5), a modified version of the Parent Attitudes about Childhood Vaccinations survey instrument.Eligible male and female participants, 15–26 years of age, were recruited through physicians’ offices and military enlistment in all three language regions of Switzerland. Of 1001 participants, we included 674 participants with a vaccination record available  in this study.The outcome was uptake for HPV vaccine (having received ≥1 dose of HPV vaccine). Covariates were VH, sex, age and other sociodemographics.151 (58%) female and 64 (15%) male participants received ≥1 dose of HPV vaccine. 81 (31%) female and 92 (22%) male participants were VH (YAV-5-Score >50). The odds for being unvaccinated were higher for VH women than non-VH women, adjusted OR=4.90 (95% CI 2.53 to 9.50), but similar among VH and non-VH men, OR=1.90 (95% CI 0.84 to 4.31). The odds for being unvaccinated were lower for younger men (born on or after 1 July 2002) than older men (born before 1 July 2002), OR=0.34 (95% CI 0.14 to 0.81), but we found no association between age and vaccine uptake for female youth, OR=0.97 (95% CI 0.48 to 1.97).VH was associated with lower HPV vaccine uptake in female youth but not male youth in our study population in Switzerland. Our findings suggest that issues other than VH contribute to HPV underimmunisation in male youth in Switzerland. This study is the first using the Youth Attitudes about Vaccines scale-5 to measure vaccine hesitancy (VH) in youth and to associate VH with HPV vaccination uptake.We include women and a large number of male youth from all three language regions of Switzerland, which allowed us to gain important insight into men’s perspectives and vaccine uptake.The findings of this study are likely comparable to other high-income countries, in which human papillomavirus (HPV) vaccination programmes have recently been extended to young men and where HPV vaccine is covered by health insurance or state-funded programmes.The large age range of the participants might diminish effects of HPV vaccine recommendations and programmes since programmes have changed frequently in the past years.As our participant sampling is not representative, VH participants might be less likely than non-VH persons to participate in a study examining VH.Identifying factors contributing to underimmunisation is essential for designing successful human papillomavirus (HPV) vaccination programmes. Previous studies have shown various influences on HPV underimmunisation in female youth, including access barriers, lack of efficient school vaccination programmes and concerns about safety and side effects.Vaccine hesitancy (VH), which ‘refers to delay in acceptance or refusal of vaccination despite availability of vaccination services’Since the determinants of HPV vaccination are context specific, local studies are needed. Additionally, previous studies investigating VH towards HPV vaccine had a limited sample sizeThe Swiss Federal Office of Public Health (FOPH) and the Federal Vaccination Commission have recommended HPV vaccine since 2007 as a routine vaccine for girls 11–14 years of age and young women as catch-up vaccination 15–26 years of age.We use the Youth Attitudes about Vaccines Scale (YAV-5), a modified version of the Parent Attitudes about Childhood Vaccination (PACV) tool, originally developed by Opel and colleagues, in order to measure youth VH.We conducted this cross-sectional study in the context of our Swiss National Research Program NRP74 on the determinants of VH and underimmunisation with HPV and childhood vaccines in Switzerland.Participants were male and female youth 15–26 years of age. We recruited participants in the offices of physicians providing either conventional biomedicine alone  or biomedicine combined with complementary and alternative medicine . In order to supplement the low number of male participants, we also recruited study participants during their military enlistment in the Swiss Army. Military service is mandatory for all Swiss men, with enlistment taking place at around 19 years of age. Participants recruited in physicians’ offices were interviewed on the phone after the physician visit. Participants recruited through the military were interviewed face-to-face on site. Medical students trained by senior researchers in recruiting and obtaining informed consent conducted the interviews, which lasted 25–35 min. Data collectors entered all data into open data kit using tablets.We measured VH using the YAV-5, an adapted version of the PACV survey instrument, which was originally developed by Opel and colleagues.In addition to the YAV-5, the survey included items about participants’ sociodemographic characteristics such as language and birthdate. After finalising the survey in English, we translated it into German, French and Italian using the forward and backward method,We divided participants into two age groups based on the later introduction of the recommendation of the HPV vaccine for boys in Switzerland. HPV vaccine has been covered by health insurance for male adolescents 11–14 years of age and as a catch-up vaccination until the age of 26 years since 1 July 2016. We, therefore, refer to male participants who were 14 years of age or older when insurance coverage for HPV vaccination began (born before 1 July 2002) as ‘older’ and those who were under 14 at this time (born on or after 1 July 2002) as ‘younger’ participants, respectively. For comparison, we applied the same age cut-offs to female participants.This study did not include patient or public involvement in designing the study, commenting the outcomes, interpreting the results or reviewing this manuscript.We present descriptive statistics to summarise participants’ age, place of birth, language region, YAV-5 score and their HPV vaccination status. We calculated unadjusted ORs for being unvaccinated for all independent variables. We then conducted multilevel logistic regressions with random effects by recruitment setting  to calculate adjusted ORs. Due to the high prevalence of VH, calculated ORs are significantly higher than prevalence ratios would be, however, as these models are standard in the literature and allow easier adjustment for sampling frames, we use them here. Control variables included younger versus older age group, being Swiss born, language region and living in an area with local HPV vaccine school programmes (model 0). Next, we extended the model by adding the YAV-5-score as a new control variable for testing our hypotheses (model 1). We also stratified analyses by sex. Additionally, we also checked for an interaction between VH and age, but found none. Results of those analyses are available on request. We analysed all data using STATA .We completed interviews with 1001 youth. For our analysis, we exclude youth who did not match our age criteria (n=15), who did not provide a correct postcode (n=10) or who did not provide vaccination records for any reason other than not having one due to not vaccinating (n=302).>50.All analyses are, therefore, based on 674 participants, of which 415 (62%) are men and 259 (38%) are women. Their characteristics are shown in In univariable analysis, the odds of being unvaccinated with HPV were higher for men than for women  and higher among participants recruited during military enlistment, most of whom were male, and in CAM offices . VH youtThe univariable odds for being unvaccinated were lower for younger men compared with older men, but we found no significant difference in the odds among younger and older women . The uniHere we show that male youth have higher odds of being unvaccinated against HPV than women, despite fewer men being VH in our study. We found a significant association between VH and HPV underimmunisation only for women. The main finding of the present study shows that VH is a major determinant of HPV underimmunisation for female youth but not for male youth.HPV vaccine uptake in our study was far lower in men than in women, despite the HPV vaccine recommendation having been officially made >4 years prior to the interviews. Our finding of higher HPV vaccine uptake in younger male participants than older ones suggests that the Swiss HPV vaccine recommendation for boys in 2015 led to a higher HPV vaccine uptake among younger eligible men. The finding of lower HPV vaccine uptake among older male youth point suggests a need for public health campaigns designed to increase awareness of catch-up vaccinations for male youth.The VH prevalence in our study was almost 10 percentage points lower in men than in women, but this difference might be influenced by the fact that female participants were selected in a less random sample compared with men, who mostly were recruited through military enlistment. Still, this finding is consistent with previous reports suggesting that, in general, women tend to be more VH than men.The finding that VH is not significantly associated with HPV underimmunisation in men suggests that male youth face additional barriers to HPV vaccination, which may include limited HPV vaccine awareness and knowledge, access barriers and a lack of priority given to male HPV vaccination by public health authorities and providers. An explanation for higher access to the HPV vaccine among female youth is that catch-up HPV vaccination in young Swiss women is partially done by gynaecologists.To our knowledge, this is the first study that measures VH in youth using the YAV-5 instrument, an adapted version of the PACV survey, in order to examine associations between VH and HPV vaccine uptake. Similarly, we here show a significant association of youth VH and HPV underimmunisation in female youth using the YAV-5-score. Our results echo the findings of Preston and colleagues who identified an association between negative attitudes towards HPV vaccine and HPV underimmunisation among women, but not among male college students in Florida, USA.Strengths of our research include this being the first study using the YAV-5 to measure VH in youth and to associate VH with HPV vaccination uptake. Additional strengths of our study include integration of a large number of male youth from all three language regions of Switzerland, which allowed us to gain important insight into males’ perspectives and vaccine uptake. Little research has been done on males’ HPV vaccine attitudes and uptake, particularly in the Swiss setting.Our findings are likely comparable to other high-income countries in which HPV vaccination programmes have recently been extended to young men and where HPV vaccine is covered by health insurance. Since the YAV-5 survey instrument has been previously validated to measure VH in youth,Our study also has limitations. There was no evidence in our study that the availability of an HPV school vaccination programme was associated with increased HPV vaccination uptake. This stands in contrast to a 2018 Swiss study on the association between school vaccination programmes and HPV vaccine uptake in young women.Our sample is not representative for Switzerland. Additional potential sources of bias result from us not being able to include participants who do not go to a physicians’ office. This bias applies more to women in our study and less to men because the majority of men were recruited during military enlistment. Finally, VH persons might be less likely than non-VH persons to participate in a study examining VH. Future research could address these gaps by using a random sampling approach throughout the population with the aims of gathering representative data.By administering the YAV-5, a validated instrument for measuring VH in youth,


The human papillomavirus (HPV) is a non-enveloped double-stranded DNA virus capable of infecting skin and mucosa epithelial cells. Commonly, HPV infection is associated with sexually transmitted diseases and is considered the leading cause of cervical cancer and other carcinomas of the anogenital tract. However, several studies reported their involvement in cancers of non-sexual regions, including colorectal, head and neck, and breast cancers. There are several studies from the Middle East and North Africa (MENA) regions on the potential association between high-risk HPVs and cancer; nevertheless, there are limited studies that address the significance of HPV vaccination as a potential guard against these cancers. In the current review, we present a comprehensive description of the current HPV-associated cancers prevalence rates in the MENA region, demonstrating their steady increase with time, especially in African regions. Moreover, we discuss the potential impact of vaccination against HPV infections and its outcome on human health in this region. Cancer is one of the leading causes of mortality, with approximately 20 million new cancer cases worldwide and 10 million cancer deaths . Some ofPapillomaviridae family and are the etiological agent of dermatological and sexually transmitted diseases . B. B192]. Interestingly, to date, there are no studies about the prevalence of HPVs in CRC in Maghreb countries within the MENA region.Compared to studies in the GCC, Levant, and Maghreb countries, there are several reports from Egypt, Iran, Israel, and Turkey analyzing the prevalence of HPV in CRC.There is only one study from Egypt regarding HPV’s association with CRC . The stuThe bulk of the reports on HPV association with the pathogenesis of colorectal cancer in the MENA region come from Iran. Only a few of these studies report a high prevalence of HR-HPVs in colorectal cancer. In this context, a recent study by Tavakolian et al. (2020) reported that 12% of CRC samples were positive for HPV DNA . AnotherOn the other hand, data depicting the prevalence of HPV-association with CRC in an Israeli population are part of a large international study on populations from three different countries that included 106 patients from Israel . As statConversely, there are numerous studies regarding HPV association with CRC from Turkey. Five studies attempted to evaluate the presence of HPVs in the pathogenesis of CRC. Interestingly, two out of these studies reported the highest frequency of HR-HPV in CRC in the MENA region (81% and 82%) ,188; genEvidently, HPV-16 and HPV-18 are the most commonly associated with CRC among the countries in the MENA region. However, it is of interest to note the high prevalence of certain regional strains of HPV, such as HPV-18 and HPV-33, which were largely identified by three out of five studies from Turkey. Another interesting finding pertains to co-infection cases with more than one HR-HPV type, as was noted by a few groups within the MENA region ,178,189.GLOBOCAN 2020 estimates breast cancer (BC) to be the most commonly diagnosed cancer, accounting for about 2.3 million new cases 11.7%) with a mortality rate of 6.9% globally 1.7% with, the assIn the State of Qatar, Sher et al., 2020  examinedAs compared to studies in the GCC, there are comparatively more studies in the Levant region analyzing the prevalence of HPV in breast cancer.In Iraq, the frequency of HPV in breast cancer was evaluated by detecting the presence of HPV16 E7 protein; they reported an incidence rate of 30.67% in breast cancer patients .Moreover, in Jordan, a recent study by Al Hamad et al., 2020  examinedOn the other hand, in Lebanon, our group conducted a study to determine the presence of high-risk HPVs in breast cancer and normal breast samples . The stuSimilar to the Lebanese population, our group explored, for the first time, the genotype distribution of HPVs in BC samples from Syria. In this study, the authors analyzed the expression of high-risk HPVs, as well as correlated E6 oncoprotein and Id-1 gene expression in 113 Syrian breast cancer samples. Using PCR, we were able to establish a high HPV positivity (61%) with HPV33 as the most predominant subtype in this population (56%) . MoreoveStudies reporting the presence of HPV in breast cancer in Maghreb countries are scarce. In Algeria, HPV DNA was detected in 12% of breast tumor cases, with HPV16 as the most prevalent type accounting for 53.3% of HPV+ tumors .Similarly, in Morocco, ElAmrani et al. examined the prevalence of mucosal and cutaneous HPV in tumors obtained from both controls and breast cancer patients . The stuOn the contrary, in Tunisian samples, Hachana et al. did not detect any HPV DNA in breast cancer samples .Contrary to the scarce data obtained from the GCC, Levant, and Maghreb regions, there are numerous studies in other MENA countries and Turkey analyzing the prevalence of HPV in breast cancer.In Egypt, a very recent study reported differential expression of HPV in FFPE tissue (17%), fresh breast cancer tissue (50%), as well as white blood cells of breast cancer patients (40%) . AnotherMultiple studies were conducted to measure the prevalence of HPV in breast cancer patients in Iran; older studies reported a prevalence of more than 20% ,225, whiIn the Turkish population, the first study by Gumus et al.  revealedIn conclusion, most of the recent studies in the MENA region confirm the presence of HPV in human breast cancer and the effect of geographic locations on it. Therefore, we believe that high-risk HPVs are present and take part in the initiation and/or progression of breast cancers through the interactions of E5, E6, and E7 oncoproteins of HPV viruses, similar to those of cervical and head and neck cancers. However, it is clear that more comprehensive studies with large cohorts of samples are needed to clarify much of the controversy pertaining to HPV association with BC cases. Molecular studies elucidating the specific mechanism of the action of HPV infection in BC carcinogenesis are still nascent.Since HPV is largely transmitted via sexual activity, appropriate precautionary methods are the mainstay in preventing the spread of the disease. However, a number of prophylactic vaccines were also developed in recent times to prevent infections against both low and high-risk HPV types.Under normal circumstances, the virus remains generally protected from the functional immune system, specifically antigen-presenting cells (APCs) and patrolling macrophages . HoweverTM is a bivalent HPV vaccine protecting against two HPV types: -16 and -18 [TM is administered through an intra-muscular injection and is usually followed up with repeat doses at 1 and 6 months after the initial dose [Cervarix and -18 . The vac and -18 . Cervariial dose .TM maintains an effect over a five years period [TM were identified in the pre-teen/adolescent group in comparison with the 15 to 25 years age group [Results from the clinical trials of the vaccine indicate that it was highly immunogenic and capable of generating high titers of HPV 16/18 neutralizing antibodies and is well tolerated; thus proving to enhance activity against cervical intraepithelial neoplasia grade 2 (CIN2+) lesions expressing HPVs 16 and 18 . Accordis period . On the ge group . This clge group .®, a quadrivalent vaccine, is formulated through the generation of virus-like particles (VLPs) for each HPV type through the use of a recombinant Saccharomyces pombe vector and offers protection against infection with four HPV types, namely, HPVs -6, -11, -16, and -18 [Gardasil and -18 . The pur and -18 . Since t and -18 . The vac and -18 .®9. This vaccine is nonavalent and protects against nine HPV types, namely HPVs -6, -11, -18, -31, -33, -45, -52, and -58 [®, Gardasil®9 is formulated on a similar VLP platform and is approved for use in both genders within the age group of 9 to 45 years [®9 also offers a 30% increased prevention of pre-cancer cervical lesions or CIN 2/3, relative to first-generation vaccines [Another FDA-approved HPV-targeted vaccine is Gardasil and -58 , making 45 years . The vac45 years . In addivaccines ,237. Morvaccines .Although the MENA region is not similar to western civilizations in terms of culture or religion, particularly when it comes to sexual behavior, there are a few social, cultural, and religious factors contributing to vaccine hesitancy . Since tEvidently, HPV vaccines are well established in terms of their safety and efficacy. However, the applicability of these vaccines is often limited due to a huge gap in awareness . Since HIn summary, there is sufficient HPV infection burden in MENA countries to warrant public health interventions and to emphasize the need for introducing HPV-based screening strategies and HPV vaccination programs; since it is clear that HPVs are associated with several types of human cancers, including cervical, head and neck, colorectal, and breast. The data presented herein on HPV genotype-specific distribution can provide a reference point to evaluate the efficacy of currently available HPV vaccines and may help healthcare authorities assess the impact of introducing HPV vaccination programs on cancer prevention. Additionally, sexual health education could also protect the MENA population from HPV and other sexually transmitted diseases.


Human papillomavirus (HPV) integration within the host genome may contribute to carcinogenesis through various disruptive mechanisms. With next-generation sequencing (NGS), identification of viral and host genomic breakpoints and chimeric sequences are now possible. However, a simple, streamlined bioinformatics workflow has been non-existent until recently. Here, we tested two new, automated workflows in CLC Microbial Genomics, i.e., Viral Hybrid Capture (VHC) Data Analysis and Viral Integration Site (VIS) Identification for software performance and efficiency. The workflows embedded with HPV and human reference genomes were used to analyze a publicly available NGS dataset derived from pre- and cancerous HPV+ cervical cytology of 21 Gabonese women. The VHC and VIS workflow median runtimes were 19 and 7 min per sample, respectively. The VIS dynamic graphical outputs included read mappings, virus-host genomic breakpoints, and virus-host integration circular plots. Key findings, including disrupted and nearby genes, were summarized in an auto-generated report. Overall, the VHC and VIS workflows proved to be a rapid and accurate means of localizing viral-host integration site(s) and identifying disrupted and neighboring human genes. Applying HPV VIS-mapping to pre- or invasive tumors will advance our understanding of viral oncogenesis and facilitate the discovery of prognostic biomarkers and therapeutic targets. Human papillomavirus (HPV) is the most common viral cause of cancer worldwide ,2. In 20E1, E2, E4, E5, E6, and E7) and 2 late genes (L1 and L2) [The HPV genome is an ~8000 base pair (bp), double-stranded, circular DNA encoding 6 early genes ( and L2) . “Accide and L2) . During  and L2) ,11. Spec and L2) ,10,11,12E2 gene (often with E1) is frequently disrupted and functionally incapacitated for E6/E7 repression. One study identified the E2 hinge region (3172 to 3659 bp) as the most frequently disrupted site; the most prevalent site for E1 was located between 1059 and 1323 bp [E1/E2 gene loss may also occur. The rates of HPV-16 E1 and E2 disruption between benign and malignant cervical tumors are also significantly different (9% vs. 46%) and (18% vs. 63%), respectively [E6 and E7 oncogenes, is consequently unleashed to drive tumorigenesis [HPV integrates fortuitously but preferentially at vulnerable regions of the host genome. Chromosomal fragile sites (loci sensitive to replication stress and breakage) and transcriptionally active regions of open chromatin are reportedly more common ,9. Post ectively . Yet theectively . The HPVigenesis .The era of next generation sequencing (NGS) has transformed viral discovery and metagenomic research. Viral enrichment strategies have also been developed and employed to obtain greater depth of coverage for regions of interest and comprehensive variant profiling. The two most common approaches for target enrichment are amplicon sequencing and hybrid-capture NGS ,17. For Here, we tested the performance of the pre-built VHC and VIS workflows used in tandem for HPV integration analytics. We leveraged curated HPV and human reference genomes (easily accessible within CLC) by embedding them within the workflows to reduce computation time and ambiguous results. Our findings demonstrate that VHC/VIS workflows offer a rapid and accurate means of localizing viral-host integration site(s) for identifying disrupted and neighboring host genes of clinical significance.The entire dataset comprised of 21 FASTQ files and 2.9 GB of digital information was downloaded in 08:31 min. The cytological categories are provided in The HPV taxonomic profiling workflow produced individual abundance tables that displays the names of the identified taxa, 7-level taxonomic nomenclature, coverage estimate, and abundance value (raw or relative number of reads found in the sample associated with the taxon). Low abundance genotypes were cut-off at a threshold of <1% of total composition. The merged abundance table  lists alTo determine the HPV sub-lineage of the dominant genotype within each sample, the “HPV consensus sequence” generated from the VHC workflow was aligned against the “HPV VAR” BLAST database using the CLC BLAST tool. The BLAST output table is provided in To construct the phylogenetic tree based on HPV genotype and sub-lineages, the “HPV consensus sequence” output from the VHC workflow of the 21 samples were aligned collectively and analyzed phylogenetically using the “Create Alignment” and “Create Tree” tools sequentially. The resulting neighbor-joining (NJ) tree was labeled according to sample ID, sample number, HPV genotype, sub-lineage, and cytological grade as shown in n = 2), B1–2 (n = 3), and C1 (n = 7) : A3 ( (n = 7) B. IdentiThe VHC workflow generated a “Track List” containing: (1) read mapping track, (2) annotated variant track, (3) amino acid track, and (4) low coverage areas track. A representative track list (S01) shows paired-reads mapped onto the linearized HPV-16 reference genome . The larE2 and L2 genes was easily discernable, and viral-host integration within chromosome 11 was detected. The 1,000,000× gene-level view exposes the host integration site(s), disrupted gene, and nearby genes. The dynamic functions of the VIS circular plot and read mapping tracks are presented in a brief video (The VIS workflow median runtime per sample was 6.6 min (range 3.0 to 30 min). The workflow generated the following output files: (1) viral mapping and breakpoints annotation track, (2) host mapping and breakpoints annotation track, (3) zoomable and rotatable VIS circular plot, and (4) VIS summary report. A representative VIS circular plot (S01) presents the entire HPV and human genome in a circular layout with inner circles of different read tracks A. Virus-ef video . In the ef video B. A collHPV integration was detected in 15 of the 21 samples . For eac2–log10 transformation , LSIL 60% (3/5), ASCH 66.7% (2/3), HSIL 71.4% (5/7), and Carcinoma 85.7% (6/7) . Normal Beyond cervical cancer, Harle et al. reported the use of hybrid-capture NGS for confirming a tongue metastasis from a primary HPV16+, stage T3NxM0 anal cancer by matching HPV insertional signatures . McEllinWe acknowledge that our study has limitations that is, only one clinical dataset derived from custom SeqCap EZ probes was used for performance testing. Commercial kits produced by different manufacturers should be tested comparatively in the current “sequencing/computing” paradigm of viral research. To bridge this gap, we intend to start with a new, standardized hybrid-capture NGS kit  dedicated to detecting and genotyping 19 high-risk HPV genotypes, HBV, and HIV-1 . Detectin = 6), HSIL (n = 6), ASCH (n = 2), LSIL (n = 3), and ASCUS (n = 4). After cellular DNA extraction, the DNA genomic library of this cohort were constructed using a double-capture, probe-based technique (SeqCap EZ probes) to enrich for HPV fragments prior to sequencing on the Miseq instrument [https://www.ebi.ac.uk/ena) (accessed on 20 August 2021) under Accession Number: SUB4880803 [We used a publicly available dataset of 21 HPV-positive, liquid-based cytology specimens from a Gabonese population generously deposited by Nkili-Meyong et al. . The cerstrument . The GabB4880803 . For thin = 219) and variant (n = 139) genomes were downloaded using the “Download Curated Microbial Reference Database” tool built within the CLC Microbial Genomics Module [Customized HPV reference  21.0  were installed on an HP notebook computer  for all analyses. The CLC system requirements are provided online . The “AnThe “Identify Viral Integration Sites (VIS)” ready-to-use workflow of CLC MGM was used for automated data analysis A,C. The The CLC VHC and VIS workflows embedded with HPV and human reference genomes proved to be a rapid and efficient method of HPV taxonomic profiling, read mapping, and integration site analysis. The streamlined workflows will undoubtedly accelerate genomic exploration and advance our understanding of viral carcinogenesis.


The oncogenic human papillomaviruses (HPV) types 16 and 18 contribute to more than 73% cases of all HPV-related cancers and commonly affect the anogenital and head and neck region, with rapidly rising incidence rates of HPV-related oropharyngeal squamous cell carcinomas (OPSCC). HPV vaccination has the potential to decrease the burden of HPV-related disease, but vaccination rates remain low in many countries. We investigated the level of awareness of HPV, and HPV-OPSCC in particular, in a representative sample of the German population.As part of an online, population-based survey, an electronic questionnaire was administered to a representative sample of 1,095 adult individuals with a specific emphasis on awareness of HPV, transmission, and indicator symptoms of oropharyngeal cancer. Statistical analysis of levels of awareness and relation of these to age, gender, and socioeconomic background were conducted using the IBM SPSS Statistics Version 25.0.p = 0.357), educational status (p = 0.581), or family status (p = 0.719). 416 subjects knew that a preventive vaccine against HPV existed (44.9%). Women were significantly more aware of HPV  and the vaccination  as were men. Younger individuals (age group 25–34) were significantly more aware of HPV (p < 0.001), likely as they were offered and/or had received the HPV vaccination. There was no regional variation of HPV awareness within the German state (p = 0.051).699/1,095 (63.8%) subjects had never heard of HPV. Of the subjects with awareness for HPV, 210 knew that HPV could be transmitted during sex (58.3%) and 138 recognized HPV as a risk factor for OPSCC (14.2%), unrelated to gender (Here we demonstrate a significant lack of awareness of HPV and HPV vaccination in a representative sample of the German population. Levels of awareness of the link of HPV and oropharyngeal cancer are particularly low, bearing in mind that this cancer is commonly affecting men and incidence rates are rapidly rising in many European countries and the USA. Awareness programs and further education are required to tackle the low awareness rates and increase the uptake of the vaccination program not only in Germany, but also worldwide. Helicobacter pylori  vs. 22.4% [n = 39/174]), but these results were not significant (p = 0.051).There was no significant regional variation in HPV awareness observable. Inhabitants of the western federal states of Germany generally knew more often about HPV than the ones living in the eastern states  and subjects who did not have children  (p = 0.067).There was no significant difference in HPV awareness between subjects who had children  subjects stated that they have heard of an HPV vaccination. 506/919 (55.1%) have never heard of an HPV vaccination .n = 145/444) (p < 0.001).Women have heard of an HPV vaccination significantly more frequent than men: 268/475 (56.4%) women have heard of an HPV vaccination in comparison to men with 32.7%  in comparison to the other age groups  (p = 0.019).The awareness for HPV vaccination is again age dependent. Subjects in the age group 25–34 have heard of an HPV vaccination significantly more frequent  and subjects who did not have children  (p = 0.188).There was no significant difference in HPV vaccination awareness between subjects who had children  subjects stated that excessive alcohol consumption can be a causative factor for OPSCC, 765/1,095 (69.9%) subjects stated that smoking and 280/1,095 (25.6%) subjects stated that poor oral hygiene is a causative agent. Only 181/1,095 (16.5%) subjects declared that HPV is a causative agent. At the same time, 188/1,095 (17.2%) stated that the herpes simplex virus is a causative agent.n = 836/974, 85.8%) and only 14.2% (n = 138/974) are aware. Yet, the awareness for HPV as a causative agent for OPSCC was significantly higher in the age group 25–34 with 26.7% (n = 47/176) and lowest in the age group 65–74 with 4% (n = 7/175) (p < 0.001). The awareness was not related to gender (p = 0.357), educational status (p = 0.581), or family status (p = 0.719).The majority of subjects stated that they are not aware of the fact that HPV could cause OPSCC as well as cervical cancer (n = 210/360) or by oral sex . Almost 1/5 of the subjects who have heard of HPV stated that HPV can be the cause for HIV/AIDS (19.4% [n = 54/278]).Overall, only a slight positive tendency of correlation can be seen between subjects, who have heard of HPV and the awareness of possible symptoms for OPSCC  [Furthermore, the awareness for HPV and HPV as a causative agent for cancer was significantly age dependent and younger subjects had a higher awareness, but still, only 43.6% of the 25- to 34-year olds have heard of HPV and only 26.7% of the same age group have heard of HPV as a causative agent for cancer. Comparatively, only 12.8% of the 65- to 74-year olds had an awareness for HPV and only 4% knew about the fact that HPV could cause OPSCC. This is in line with the finding of another study, in which people older than 65 years had heard of HPV significantly less than the younger generations (= 0.001) . Still, = 0.001) , 20. In = 0.001) .We were also able to show significantly higher awareness in German women on both, HPV and HPV vaccination (34.2% and 56.4%) (age dependent), and it does not come surprising that there is a disparity in knowledge and awareness of HPV vaccines between men and women , 22. SevNonetheless, there are clear limitations of this study, and even though the number of subjects is quite high, the study cohort was too small to stratify for more than age and gender. Stratification by educational status and region was not possible. Furthermore, we did not include questions on how the subjects were informed about HPV making it difficult to understand, which would be the best way to address the lack of HPV knowledge.Apart from the extreme health burden that HPV can cause in the different fields of medicine with a massive impact on overall survival, there is a huge economic burden, also of HPV-related OPSCC worldwide and in Germany , 28, 29.Our data demonstrate a significant lack of HPV awareness in a representative cohort of German adult citizens. Particularly, HPV as a causative agent for OPSCC is commonly unknown. Sociodemographic and behavioural factors are less likely to be the reason for this awareness. Instead, a lack of health education has most likely contributed to the alarming data, indicating the need for further education.Ethics approval was not required as it was an anonymous survey and did not include patients (Ethics Committee of the University Witten-Herdecke). Informed consent to participate was not directly obtained but inferred by completion of the questionnaire.The authors have no conflicts of interest to declare.No funding was obtained.Shachi Jenny Sharma and Matt Lechner: study design, acquisition, analysis, interpretation, drafting, accountability, and final approval. Volker H. Schartinger, Lisa Collin, Liam Sutton, and David Riedl: study design, acquisition, drafting, accountability, and final approval. Nora Wuerdemann and Christine Langer: interpretation, drafting, accountability, and final approval. Kathrin Moellenhoff: analysis, interpretation, drafting, accountability, and final approval. Alexander Kreuter: interpretation, drafting, accountability, and final approval. Ulrike Wieland: analysis, interpretation, drafting, accountability, and final approval. Jens Peter Klussmann: study design, acquisition, analysis, interpretation, accountability, and final approval.All data generated or analysed during this study are included in this article. Further enquiries can be directed to the corresponding author.Supplementary dataClick here for additional data file.