Although systematic reviews (SR) report that human papillomavirus (HPV) increases the risk of breast cancer, there are still disputes regarding this association. In particular, it has been argued that the risk level differs depending on nationality, type of tissue, subtype of HPV, and publication year. Considering that the searching year of publication for the previous SRs was June 2013, a renewal meta-analysis needs to be conducted.Using articles selected in the previous SRs, we compiled a list of references, cited articles, and related articles from the PubMed and Scopus databases. Of these, only publications with data from case-control studies on HPV DNA-positivity in tissues were chosen. Summary odds ratio (SOR) and 95 % confidence interval (CI) were calculated through meta-analysis. Meta-regression analysis was performed for nationality, types of tissue, subtype of HPV, and publication year.Twenty-two case-control studies were selected, and the total number of individuals in the case and control group was 1897 and 948, respectively. According to the meta-analysis about the 22 publications, HPV infection increased the risk of breast cancer . Statistical significance was not found in meta-regression performed on the four variables of nationality, type of tissue, subtype of HPV, and publication year which some researchers think sources of heterogeneity.The results of the present study supported the argument that HPV infection increases the risk of breast cancer. Age-matched case-control studies are in need in the future. Breast cancer is a primary cancer that has one of the highest incidences in women worldwide ,2. EpideIn particular, the HPV infection theory is significant in the prevention of cancer because HPV vaccines are currently in use . The assNevertheless, there are still disputes about the association between HPV infection and the risk of breast cancer . In partFigure Following the aforementioned exclusion process, 24 publications were selected for the meta-analysis , 20–41. p = 0.165)  for HPV DNA-positive individuals  Fig. .Fig. 2ThTable When we examined the results by HPV subtype, the risk of breast cancer was, in descending order, 5.67-fold higher for HPV 16 (95 % CI: 2.21-14.52), 3.64-fold higher for HPV 33 (95 % CI: 1.26-10.48), and 2.97-fold higher for HPV 18 (95 % CI: 1.64-5.38), and all risks were statistically significant. Again, the CIs of SORs were overlapping for 3 subtypes.The meta-regression analysis was performed on 26 datasets created around three subtypes, with nationality, types of tissue, subtype, and publication year as the variables. None of the variables showed statistical significance (not shown).In order to satisfy the criteria to prove that a specific virus causes cancer , case-coAccording to the meta-analysis for results from 22 case-control studies, the risk of breast cancer due to HPV infection was 4.02-fold higher. Even when the results were analyzed by categorizing into four regions, two types of DNA specimen and two publication periods, the risk of breast cancer due to HPV was statistically significant. The findings provide supporting evidence for the HPV infection as a risk factor of breast cancer. Additionally, the CIs of SOR calculated in the subgroup analysis were overlapping with one another, and the results from meta-regression analysis showed that none of the 4 variables caused heterogeneity. These findings support the validity of the SOR calculated in the meta-analysis.The estimated SOR in this study was similar to previous meta-analysis results Table . HoweverEarly study results were confusing, due to inappropriate experimental design, small sample sizes, and unstandardized HPV DNA detection methods ,14,15. HRegarding the link between the Epstein-Barr virus infection and breast cancer, it has been argued that different kinds of control tissue cause heterogeneity . Of the It has been proposed that not only HPV but also herpesvirus, polyomavirus, and beta retrovirus increase the risk of breast cancer . ProvingIn conclusion, this meta-analysis supports the hypothesis that HPV infection is a risk factor for breast cancer. In near future, it is anticipated that nested case-control studies will be actively performed, along with age-matched case-control studies.www.ncbi.nlm.nih.gov/pubmed) and Scopus (www.elsevier.com/solutions/scopus) databases for each article were also considered for inclusion. This searching strategy assumes that studies conducted with the ‘same research hypothesis’ have a high possibility of being cited in related articles and that they will have similar findings [Since we were using 3 previously published systematic reviews –13, we ufindings .The final selection criteria were case-control studies that detected HPV DNA in the tissue. Based on the titles and abstracts for the papers in the compiled list, the following 5 exclusion criteria were applied sequentially. (1) Articles with different hypothesis, (2) expert reviews or systematic reviews, (3) case only studies, (4) case-control studies without HPV DNA-positivity in both groups, and (5) articles published by using the same DNA samples as another study. The remaining case-control studies after applying the 5 aforementioned criteria were selected as publications for the final analysis.Two researchers applied the exclusion criteria for each publication and retrieved HPV-related data—the number of HPV DNA-positive and HPV DNA-negative individuals in the case and control group, nationality of study subjects, types of DNA specimen, types of HPV subtypes, and publication period. Using the obtained number of HPV DNA-positive and HPV DNA-negative individuals in the case and control group, OR and 95 % CI were calculated for each article. Based on the prevalence of HPV subtypes reported by the Zhou et al. , data onP-value of less than 5 % was considered statistically significant, and STATA version 14 (www.stata.com) statistics program was used.The presence of heterogeneity in meta-analysis was assessed using the I-squared value (%). The summary odds ratio (SOR) for a random effect model and its 95 % CI were calculated first because if the I-squared value is 0.0 %, using either a random effect model or a fixed effect model will result in the same value. To determine the publication bias, Egger’s test for small-study effects was conducted . Additio


Although screening for cervical cancer is recommended for women in most countries, the incidence of cervical cancer is greater in developing countries. Our goal was to determine the prevalence and factors associated with high-grade lesions/cervical cancer among women attending a reference clinic in Brazil and evaluate the correlation of histology with cytology, colposcopy and the high-risk HPV (HR-HPV) tests.Chlamydia trachomatis and HPV testing using the Hybrid Capture (HC) and PCR tests. Colposcopy was performed for all patients and biopsy for histology when cell abnormalities or cervical intraepithelial neoplasia (CIN) were present.A cross-sectional study of women attending a colposcopy clinic was carried out. The patients were interviewed to collect demographic, epidemiological and clinical data. Specimens were collected for cervical cytology, A total of 291 women participated in the study. The median age was 38 years (DIQ: 30–48 years). The prevalence of histologically confirmed high-grade lesions/cervical cancer was 18.2% , with 48 (16.5%) cases of CIN-2/CIN-3 and 5 (1.7%) cases of invasive carcinoma. In the final logistic regression model, for ages between 30 and 49 years old , practice of anal intercourse [OR = 2.4 ] and having positive HC test for HR-HPV [OR = 11.23 ] remained independently associated with high-grade lesions/cervical cancer. A total of 64.7% of the cases CIN-3\Ca in situ were related to HPV-16. Non-oncogenic HPV were only found in CIN-1 biopsy results. Compared to histology, the sensitivity of cytology was 31.8%, the specificity 95.5%; the sensitivity of colposcopy for high-grade lesions/cervical cancer was 51.0%, specificity was 91.4% and the concordance with HPV testing was high.The results confirm an association of HR-HPV with precursor lesions for cervical cancer. These data emphasize that cytological screening to detect precursor lesions is still important in some regions and that HR-HPV should be included for screening. Although screening for cervical cancer, with varying age ranges and periodicity of testing, is recommended for women in most countries, the incidence of cervical cancer and its related mortality is far greater in developing countries Persistent human papillomavirus (HPV) infection with specific high-risk (HR) HPV is an indicator of high-grade squamous intraepithelial lesions (HSIL) Invasive cervical cancer (ICC) is the second most common cancer in women of childbearing age in Brazil and about 14.1% of women in the general population are estimated to be infected by cervical HPV infection at any given time The best method for cervical cancer screening is still an uncertain decision in developing countries. Recommendations include several possibilities from those available, such as cytology, colposcopy, histology and HPV tests or even serial cytology Vitoria is the capital of the state of Espírito Santo, which covers an area of approximately 6,750 square miles on the southeastern coast between Rio de Janeiro and Bahia in Brazil. The economy is based on steel production, ports and harbors, agriculture, small industry, and tourism. The population of Espírito Santo is approximately 3.2 million, with the majority living in the metropolitan area of the capital. Among the total of estimated cases of ICC in Brazil, 340 cases are in Espiírito Santo State and 40 in Vitoria , resulting in an incidence of 17.0, 18.7 and 20.3/100,000 women, respectively The goal of this study was to determine the prevalence and associated factors of high-grade lesions/cervical cancer among women attending a colposcopy clinic in Vitoria, Brazil. This study also evaluated the different screening methods used for this diagnosis.Universidade Federal do Espírito Santo (#086/09). Written consent was given by the patients for their information to be stored in the hospital database and used for research. They received counseling and treatment for diagnosed cervical disorders.This study was submitted to and approved by the internal review board of the This is a cross-sectional study of women attending a reference clinic for colposcopy in a University Hospital in Vitoria, Brazil. This clinic is one of the main clinics for colposcopy care in the region.All women attending the clinic between March and December 2011, presenting incident cytological lesions, were invited to participate in the study. A 30-minutes face-to-face interview was conducted with the use of a standardized questionnaire. The trained staff from the local health department conducted the interviews. Enrolled patients answered the face-to-face interviews which included demographic ; behavioral , types of sexual activity, frequency of condom use in the last year and STI history) and clinical data .Chlamydia trachomatis (CT). A colposcopy examination was performed on all patients, independently if they presented cervical intraepithelial neoplasia (CIN) or not. Histological analyses were performed in face of any cytological or colposcopy abnormalities as defined by the Gynecology and Obstetrics Brazilian Society. Only one certified professional performed the colposcopy exams using Olympus equipment, model OCS-3. Women, who were pregnant, presented recurrent lesions, were HIV-infected or had been admitted with a previous diagnosis of invasive cervical cancer were excluded from the study.They also underwent a gynecological evaluation and cervical scrape samples were collected for cytological analysis and the hybrid capture (HC) test for HPV and Chlamydia trachomatis. The HC test for HPV includes probes for the following HR-HPV: 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68 and low-risk HPV (LR-HPV): 6, 11, 42, 43 and 44. HPV-DNA also was investigated by polymerase chain reaction (PCR), using the protocol previously established, which detects a fragment of 450 bp of the L1 gene region with consensus primers MY09/11 and was followed by the Restriction Fragment Length Polymorphism (RFLP).The HC tests were used for the detection of high-risk and low-risk genital HPV-DNA types and Sample size for this study was calculated to estimate the prevalence of high-grade lesions or cervical cancer diagnosed by the tripod diagnosis that is cytology plus colposcopy plus histology. The tripod method was considered the outcome (dependent variable). A 5% prevalence rate with confidence limits ±2.5% was taken as the basis for calculating the sample size chi-squared test for trend to compare cases diagnosed by the tripod diagnosis (dependent variable) and the other methods (independent variables), negative result, LSIL and HSIL. Multivariate analysis was performed to estimate effects of independent variables, through the use of logistic regression models. Variables with p value≤0.15 entered in the multivariate logistic regression model. Variables were considered as significant when p value was ≤0.05. In order to determine how useful the test is to detect cervical lesions in this population, we calculate the sensitivity and the specificity of tests. Histology was used as the gold standard.Data were analyzed using the SPSS - statistical software program for Windows, version 17.0. A preliminary analysis was performed using exploratory techniques on the data. Chi-square tests and Student’s-t tests and variance analysis were used. The odds ratio (OR) was used as a measure of association, estimated with a 95%CI. For assessing ordinary variables we used the A total of 291 women (90.7%) out of the 322 recruited were included in the study. Patients excluded were: 7 ; 5 (pregnancy); 10 (recurrent infections), 4 (HIV-infected), 4 (other immunosuppression conditions). The excluded patients presented similar characteristics than patients included in the study.The median age of women was 38 years (Interquartile range: 30–48). The prevalence of high-grade lesions/cervical cancer was 18.2% (CI95%: 13.8%–22.6%), 48 (16.5%) cases of high-grade lesions  and 5 (1.7%) subclinical cases of invasive cancer. The cancer cases came into the study as LSIL or HSIL and were diagnosed after histology in the colposcopy clinic.A total of 74 (25.4%) women had up to four years of schooling, 178 (61.2%) were married and 83 (28.5%) had monthly incomes of three Brazilian minimum salaries (US $822.00) or less. Behaviors are also described in Chlamydia trachomatis was positive in 4.9% (14/286). Having 4 or more children (p = 0.030), positive PCR for HPV (p = 0.001) and HR-HPV in HC (p = 0.001) were factors associated to high-grade lesions/cervical cancer.Clinical data are described in In the multivariate analyses, being 30–49 years old ; having anal sex [OR = 2.4 (CI95%: 1.10–5.03)] and being HR-HPV in HC [OR = 11.2 (CI95%: 4.79–26.36)] were factors associated to high-grade lesions/cervical cancer.There are some data not shown on Tables. On comparing isolated tests  to cases with histology, the sensitivity of cytology was found to be 31.8% and the specificity 95.5%. When analyzing the findings of colposcopy compared with histology results, abnormal colposcopy findings were found in 90.4% of the cases of histology abnormalities and 45% of the findings of the biopsies of women with normal histology. The sensitivity of colposcopy for high-grade lesions/cervical cancer compared to histology was 51.0% and specificity was 91.4%. Regarding the positivity of HPV, 55.9% of patients had a positive HPV test.Among the 154 cases of DNA-HPV identified by PCR, 120 (75%) were infected by high-risk genotypes. HPV-16 was identified in 35 (22.7%) from all HPV cases, followed by HPV-31 in 7 (4.5%), HPV 35, 52 and 58 in 6 (3.9%), HPV-18 and 62 in 4 (2.6%), HPV-6, 26, 33, 53, 82 and 89 in 3 (1.9%), HPV-51, 66, 67, 73 and 84 in 2 (1.3%) and finally HPV-11, 42, 45, 56, 59, 61, 69, 70, 72 and 92 in 1 (0.6%). Of the 160 genotypes detectable by HC, 120 (75%) are HR-HPV and 40 (25%) of LR-HPV.A total of 64.7% of the cases of CIN-3\Ca in situ were related to HPV-16. The non-oncogenic HPV-6 and 11 were only found in CIN-1 biopsy results. Five cases were of invasive carcinoma: two were positive for HPV-16, one for HPV-18, one for HPV-31 and one for HPV-73.This study reports a prevalence rate of high-grade lesions/cervical cancer of 18.2% among women attending a reference clinic for colposcopy in Vitoria, Brazil. This rate is higher than that reported in a Brazilian systematic review that included three large studies showing a prevalence of high-grade intraepithelial lesion of 6–12% Chlamydia trachomatisFactors associated with high-grade lesions in this study were age between 30–49 years old, tobacco users, anal sex practice and HR-HPV. HPV infection is described as a necessary cause for ICC There is evidence that HPV is the principal etiological agent in cervical neoplasia, and some other sexually transmitted agents may either contribute to cervical carcinogenesis, such as herpes simplex virus (HSV), CT and human immunodeficiency virus (HIV). Epidemiological studies suggested that HSV may have a role in cervical neoplasia, but there is no clear supportive experimental evidence. However, longitudinal epidemiological studies have provided evidence that CT is an independent risk factor for the development of cervical squamous carcinoma and this association is serotype specific. The increased risk of cervical neoplasia in patients infected with HIV also has been recognized for over a decade and HIV may interact with HPV either by alternating the HPV gene transcription or by immunosuppression In the present study, positive HPV tests were found in 76.9% of the patients with CIN-1, 82.75% with CIN-2, 94.44% with CIN-3 or Carcinoma in situ and 100% of patients with invasive carcinoma. Almost 70% of the cases with CIN-3\carcinoma in situ were related to HPV-16. HPV types 6 and 11 were only found in cases of CIN-1. A study performed in Rio de Janeiro reported a 50.1% prevalence of HPV, ranging from 25% among women with normal cytology to 100% in women with high-grade intraepithelial lesions The distribution of HPV types differs between cervical adenocarcinoma and SCC of the cervix, HPV-16 accounts for the majority of SCC, both HPV-16 and HPV18 are prominent in adenocarcinoma The association of cytology, colposcopy, and histology is called the “tripod diagnosis” and allows the diagnosis of neoplastic and pre-neoplastic lesions in 90% of cases Although a cross-sectional study is not the best study for determining risk factors, its application is justified for assessing the prevalence of and the associated factors for HR-HPV among women attending the colposcopy clinic. In this study, we cannot rule out of the possibility of response bias because there is always a general tendency to give socially acceptable answers regarding risk factors. Nevertheless, it is important to emphasize the importance of performing cervical cytological exams to monitor women’s health routinely and any degree of abnormality in this test should be referred for colposcopy assessment Cytology, colposcopy and histology are three important and complementary methods to study the cervix and its injuries. Different findings can show discrepancies among results, which can be explained by the experience of the pathologists and the resolution of the colposcopy. The strategies for diagnosing cervical lesions it is important theme to be discussed in Brazil because the cytology is recommended for screening. If our results are not satisfactory we need to start including other methodologies. The inclusion of HR-HPV test as a complementary test can assist in the diagnosis of cervical lesions identifying high-risk cases.Cancer prevention programs exist and have been shown to be successful at avoiding disease progression. Although this is encouraging, much work remains to identify additional innovative interventions that address the social, cultural, and environmental influences of HPV infection and cervical cancer. There is also a need to find better ways of disseminating evidence-based approaches to cervical cancer prevention, so that effective interventions are more widely used. Sexually active women need access to confidential, low-cost, and friendly services to teach them how to protect themselves.


The number of members in the genus Gammapapillomavirus of Family Papillomaviridae has recently been expanding most rapidly. The aim of this study was to characterize a novel human gammapapillomavirus type identified in a vaginal swab from a 25-year-old pregnant woman suffering from vaginitis.Viral metagenomics method was used to detect the viral sequences in 88 vaginal swab samples collected from 88 pregnant women with vaginitis. A novel papillomavirus, named HPV-ZJ01 (GenBank no. KX082661), was detected in one sample and its complete genome sequence was amplified by PCR and sequenced by Sanger walking. Phylogenetic analyses based on the complete genome and the L1 protein of HPV-ZJ01 and other representative human papillomaviruses were done, respectively. Further PCR screening was performed in vaginal swabs (n = 135), cervical smears (n = 40) and cervical cancer tissues (n = 40) using nested-PCR primers designed based on HPV-ZJ01 sequence to investigate the prevalence of HPV-ZJ01.The genome of HPV-ZJ01 is 7,358 bp in length with a GC content of 37.8 %. HPV-ZJ01 was predicted to contain six open reading frames  and a non-coding long control region (LCR). The genome shared the highest overall similarity to HPV-166, with 70.6 % nucleotide sequence identity while its L1 gene shared the highest nucleotide similarity to HPV-162, with 71.1 % sequence identity. Phylogenetic analysis suggested that HPV-ZJ01 belongs to a novel HPV type in the Gamma-PV genus, species Gamma-19, already containing HPV161, HPV162 and HPV166. PCR screening results indicated that none of the other samples were positive for HPV-ZJ01 except the original HPV-ZJ01 positive vaginal swab specimen.The genome sequence of a novel type of species Gamma-19 HPV was characterized. The screening PCR results suggested that HPV-ZJ01 is not associated with any of the cervical cancer samples tested. In order to confirm the prevalence and disease association, if any, for HPV-ZJ01, a further study with different sample types and a larger sample size is needed. Human papillomaviruses (HPVs) belong to family Papillomaviridae, with small, circular, double-stranded DNA genomes . PapilloAs more HPV types are discovered, it is necessary to confirm the genomic characteristics and the clinical relevance of these new HPV types. Although a variety of laboratory techniques for detecting known HPVs are available, an efficient laboratory method for the identification of divergent HPVs from different biological samples is required.Viral metagenomics is a useful method that can non-specifically detect both already known and highly divergent viruses. Non capsid protected host-derived background DNA and RNA in biological samples can be digested by nuclease treatment and nucleotide sequence information from viral particles associated nucleic acids determined by sequence-independent amplification and deep sequencing to allows the identification of viruses recognizable through their nucleotide or translated protein sequence homologies to all known viruses. With the advent of viral metagenomics –12 and tIn the present study, a viral metagenomic method was applied to vaginal swab samples collected from pregnant women, and identified a novel gamma papillomavirus in a sample from a 25-year-old pregnant woman suffering from vaginitis. We describe here the genome and phylogenetic analysis of this novel Gamma-PV type. Type-specific PCR primers were also developed to test a representative collection of various clinical specimens.g). The supernatant was filtered through a 0.45-μm filter (Millipore) to remove eukaryotic and bacterial cell-sized particles. The filtrates enriched in viral particles were treated with DNase and RNase to digest unprotected nucleic acid at 37 °C for 60 min [From Jan. 2014 to Jan. 2015, 88 vaginal swab specimens were collected from 88 pregnant women with vaginitis in the affiliated Maternity and Infant Hospital of Jiangsu University, China. Swab specimens were re-suspended in 500ul of phosphate-buffered saline (PBS) and vigorously vortexed for five min. The suspension of each sample was subjected to centrifugation . Two sets of PCR screening primers were designed based on the genome sequence of HPV-ZJ01  model in MEGA6.0. Bootstrap values (based on 1000 replicates) for each node are given. Putative ORFs in the genome were predicted by NCBI ORF finder. Informed consents were provided by all participants included in the present study. Ethical Approval was given by Ethics Committee of Jiangsu University and the reference number is No. JSU2015045.The genome sequence of HPV-ZJ01 was deposited in GenBank under the accession number: KX082661.The complete circular genome of HPV-ZJ01 is 7,358 bp in length with a GC content of 37.8 %. The HPV-ZJ01 genome was predicted to contain six ORFs coding for four early proteins  and two late proteins (L1 and L2)  and acceptor (GUYACYAG/YU) RNA splicing sites , 24–26 aSequence analysis indicated that the L1 gene of the HPV-ZJ01 shares the highest nucleotide (nt) sequence identity (71.1 %) with HPV162, which was isolated from human healthy skin in China belonging to a member of the genus Gammapapillomavirus . AccordiTo characterize the phylogenetic relationship between HPV-ZJ01 and related HPVs, the entire L1 protein sequence of HPV-ZJ01 and the representative HPV types from other species and genera were aligned to generate a phylogenetic tree, as the L1 gene is well conserved and often used for classification. A phylogenetic tree based on the complete genome of HPV-ZJ01 and the related HPV strains was also constructed to confirm the phylogenetic analysis results based on the L1 protein. Both trees clustered the representative HPVs well in their respective genera, including Gamma-, Alpha-, Beta-, Mu- and Nupapillomavirus, where HPV-ZJ01 clustered within the genus Gammapapillomavirus, species 19 with a bootstrap value of 100 %, forming a monophyletic group with HPV161, HPV162 and HPV166 Fig.  and b.FiPCR screening results indicated that except the original HPV-ZJ01 positive vaginal swab specimen, none of the other vaginal swabs (n = 135), cervical smears (n = 40) and cervical cancer tissues (n = 40) samples were positive.The advent of metagenomics using high-throughput sequencing technology –12 facilAnalysis of genome organization of HPV-ZJ01, HPV161, HPV162 and HPV166 revealed that they share many similarities and some differences. Two conserved zinc-binding domains of CxxC(x)29CxxC separated by 36 amino acids are found at the same position away from the N-terminal end of E6 protein of these four HPVs, respectively. Additionally, the E7 proteins of them also contain a single zinc-binding domain of CxxC(x)29CxxC at the same position, respectively. The putative LXCXE motif found in the E7 protein of HPV-ZJ01, also identified in the three HPVs of Gamma genus, species 19 is a canonical pRB-binding motif and has been implicated in the transformation of host cells , 31, 32.HPV types have traditionally been classified as mucosal or cutaneous on the assumption that HPV tissue tropism is reflected in the location where the genome of the particular type was found , 34. AccHere we screened total 216 samples including vaginal swabs, cervical carcinoma tissues and cervical smears from cervical carcinoma patients using PCR methods. The negative PCR results suggested that HPV-ZJ01 may not be associated with cervical cancer. Further studies with different sample types and a larger sample size are needed to clarify the prevalence and disease association, if any, for HPV-ZJ01.A novel HPV type named HPV-ZJ01 was identified in a vaginal swab sample from a 25 years old pregnant woman with vaginitis and its genome was characterized. Comparative characterization of HPV-ZJ01 and its closest relatives and phylogenetic analysis demonstrated that it is a novel HPV type and clusters into the Gamma-PV genus, species Gamma-19. No evidence of disease association of the new HPV type was found.Alpha-PVs, Alphapapillomavirus; Beta-PVs, Betapapillomavirus; DNase, deoxyribonuclease; Gamma-PVs, Gammapapillomavirus; HPV, human papillomavirus; ICTV, International Committee on Taxonomy of Viruses; LCR, non-coding long control region; Mu-PVs, Mupapillomavirus; NCBI, National Center for Biotechnology Information; nt, nucleotide; Nu-PVs, Nupapillomavirus; ORF, open reading frame; PBS, phosphate-buffered saline; PCR, polymerase chain reaction; PV, papillomavirus; RCA, rolling circle amplification; RNase, Ribonuclease; URR, upstream regulatory region.


Human papillomavirus infection is common and causes different manifestations. This infection is a public health concern because it has been associated with genital tract malignant diseases among men and women. Currently two vaccines are available to prevent the human papillomavirus infection and its associated diseases. More than 100 types of HPV were identified to date, and of them at least 40 can infect the genital area.In general, one or more particular HPV types are associated with a clinical manifestation. For example, anogenital warts  are caused by types 6 and 11, which account for 90% of cases.Cervical cancer is more related with types 16 and 18, which correspond to 70% of cases, however, this condition could be caused by others HPV types e.g., children may acquire genital warts from hand contact with nongenital lesions.HPV genital infection is mainly transmitted by genital-to-genital contact often during sexual intercourse. However, other forms of transmissions are reported, .The majority of sexually active population will be in contact with HPV at some point in their lives. Condoms' use might reduce the risk for HPV and HPV-associated diseases, but condom protection against this virus is not infallible.Another form for HPV prevention is vaccination. Nowadays, there are two types of vaccines against HPV, the quadrivalent HPV (HPV 4) and the vaccine to prevent oncogenic HPV (HPV2). Both vaccines are based on virus-like particles (VLPs) using the recombinant DNA technique, which creates one of the proteins that compose the capsid of HPV, the L1 protein.VLPs can induce generation of high titers neutralizing antibodies that are enough to protect those who are vaccinated. This protection is independent of cell immune responseSaccharomyces cerevisiae (yeast) and is used with an aluminum adjuvant.The HPV4 vaccine contains VLPs that are similar to those found in HPV types 6, 11, 16 and 18. To produce this vaccine, the L1 gene of these genotypes is expressed in .Clinical studies have shown that HPV4 offer protection against persistent HPV infection, cervical lesions precursor of cancer, vaginal and vulvar lesions precursor of cancer and genital warts caused by HPV types 11, 16 or 18 in women aged 16 to 26 years old and who were not previously infected by these HPV types.A randomized multicenter, prospective, placebo-controlled, double-blind study with healthy boys and men 16 to 26 years of age reported that vaccine was effective to prevent infection of HPV types 6, 11, 16 e 18, besides preventing external genital warts associated with these HPV types in individuals who received HPV4 vaccineTM, Merck and Co., Inc., Whitehouse Station, New Jersey) is indicated for both sexes aged between 9 to 26 years, and it should be administrated in intervals of 0, 2 and 6 months.The HPV4 vaccine  is indicated for girls and women aged 10 to 25 years old, and it should be administrated in intervals of 0, 1 and 6 months.The HPV2 vaccine .HPV vaccines are contraindicated for persons with a history of allergic reaction to the vaccine or to any of its components. Pregnant women should be vaccinated after pregnancy. The HPV4 is also contraindicated for persons with history of immediate hypersensitivity to .Previous infection with HPV does not constitute a contraindication for vaccination, and there are no evidences on protection against diseases caused by HPV types that had already been infected the individual at the time of vaccination, but the vaccine could protect against diseases caused by other HPV types covered by the vaccine.Because this is an inactive, non-infectious vaccine, there is no contraindication for immunosuppressed individuals, although immunogenicity in this group of patients is not guaranteed.Both HPV vaccines have good tolerability profiles and present few adverse effects, the most commonly reported are injection-site pain and swelling.Syncope (faintness) can occur after vaccination and has been observed particularly among adolescents and young adults. To avoid serious injury related to a syncopal episode, vaccine providers should consider observing patients for 15 minutes after vaccination.HPV vaccines can be administered to individuals with mild acute illnesses. Vaccination of persons with moderate or severe acute illnesses should be deferred until after improvement of clinical picture.If the vaccine series is interrupted it could be restarted anytime since the minimal interval between missing doses is followed. Coadministration of different vaccines either simultaneously or at any time before or after HPV vaccine is permitted if different injection-sites are used.The vaccine against HPV is an important tool to prevent infection with HPV and its associated diseases. However, vaccination does not exclude the need of performing the screening for cervical cancer prevention (Papanicolaou's test), because cervical cancer could be related to other HPV types not covered by the vaccine


Extra Assay) and microarray-based comparative genomic hybridization using a 32K Bacterial Artificial Chromosome array platform. Sixty-four samples yielded interpretable results. Recurrent gains were observed in chromosomes 1p13.3-q44 (88%), 3p12.3-q29 (86%), 5p15.33-p11 (67%) and 8p12-q24.3 (84%). Amplifications of 5p15.33-p11 and 11p14.1-p12 were found in seven (11%) and four (6%) cases, respectively. Losses were observed in chromosomes 2q33-q37.3 (86%), 3p26.3-q11.1 (83%) and 11q12.2-q25 (81%). Although many losses and gains were similar throughout the cohort, there were small significant differences observed at specific loci, between human papillomavirus positive and negative tumors, between tumor types, and tumor grade and nodal status. These results demonstrate that despite the diversity of genetic aberrations in penile squamous cell carcinomas, there are significant correlations between the clinico-pathological data and the genetic changes that may play a role in disease natural history and progression and highlight potential driver genes, which may feature in molecular pathways for existing therapeutic agents.Penile squamous cell carcinoma is a rare disease, in which somatic genetic aberrations have yet to be characterized. We hypothesized that gene copy aberrations might correlate with human papillomavirus status and clinico-pathological features. We sought to determine the spectrum of gene copy number aberrations in a large series of PSCCs and to define their correlations with human papillomavirus, histopathological subtype, and tumor grade, stage and lymph node status. Seventy formalin-fixed, paraffin embedded penile squamous cell carcinomas were centrally reviewed by expert uropathologists. DNA was extracted from micro-dissected samples, subjected to PCR-based human papillomavirus assessment and genotyping (INNO-LiPA human papillomavirus Genotyping  Penile squamous cell carcinoma (PSCC) is a rare disease, but can have a profound physical and psychological effect on those afflicted. It mainly affects men aged 50–70 years old  and, altHistologically, PSSCs comprise a spectrum of lesions that differ in clinical behavior. The most common morphological subtypes of PSCC are usual type 48–65%), basaloid (4–10%), warty (7–10%) and verrucous (3–8%) [%, basaloIn comparison to other squamous cell carcinomas, relatively little is known about the molecular features of PSCC –11. SimiThere is a paucity of data on the somatic genetic characteristics of PSSCs, possibly due to the relative rarity of the disease. In England, PSCC services have been managed in supra-specialized centers in the UK. This has given us the opportunity to accrue a sufficiently sized cohort to analyze the molecular characteristics of PSCCs. Therefore, we sought to investigate the repertoire of somatic DNA copy number aberrations in PSSCs, and to determine whether patterns and types of gene copy number aberrations would correlate with HPV status and clinico-pathological features, including type, grade, stage and HPV status.We retrieved 70 formalin fixed paraffin embedded PSCCs from the Cellular Pathology Department of St George’s Hospital. Cases were reviewed by a panel of expert uropathologists  for grade, stage (including lymph node status) and subtype using established methods , 20. PatFor all cases, regions of PSCC and normal tissue were marked on the representative sections by a consultant genitourinary pathologist (DB). Ten to fifteen tissue representative sections were cut at 10μm thickness from each case and subjected to microdissection under a stereomicroscope as previously described .® assay as per the manufacturer’s instructions .DNA was extracted from microdissected sections using standard phenol-chloroform methods and its concentration was measured using PicoGreenExtra Assay  as previously described [The presence of HPV DNA was detected by PCR method using SPF10 primers, which amplify a 65-bp fragment of the conserved L1 open reading frame and HPV genotypes identified by the INNO-LiPA HPV Genotyping escribed .et al., 2012) which has been shown to be as robust as, and to have comparable resolution with, high-density oligonucleotide arrays [DNA extracted from microdissected sections was subjected to microarray-based comparative genomic hybridization using a 32K bacterial artificial chromosome (BAC) array platform (Hernandez e arrays –24. DNA e arrays .http://www.ensemble.org).After filtering polymorphic BACs, a final dataset was produced with unambiguous mapping information according to build hg19 (NCBI build 37) of the human genome  was used to pre-process and analyze the aCGH data as previously described , 26.http://www.ensembl.org) was smoothed using the circular binary segmentation (cbs) algorithm. A categorical analysis was applied to the BACs after classifying them as representing amplification (>0.4), gain (>0.08 and ≤0.45), loss (<-0.08), or no change according to their cbs-smoothed Log2 ratio values [After filtering polymorphic BACs, a final dataset of 31,367 clones with unambiguous mapping information according to build hg19 of the human genome  in amplifications and gains/ losses between the different subtypes, grades, stages, HPV associations and nodal status. Adjustment for multiple testing was performed with a step-down permutation procedure (maxT), which provides a robust control of the family-wise type I error rate (FWER) . UnsuperSubsequent assessment of the robustness of the cluster analysis was done by assessing the uncertainty with multiscale bootstrap resampling with the pvclust package in R 3.0.1.Of the 70 PSCC cases, 64 had adequate DNA quality and purity for successful array CGH analysis.Demographics including HPV status, stage, grade, lymph node status and histological classification can be found in PSCCs were shown to harbor many highly recurrent gains, the highest frequencies occurring on chromosomes 1p13.3-q44 (88%), 3p12.3-q29 (86%), 7p22.3-q36.3 (88%), 8p12-q24.3 (84%), 9p24.3-q34.3 (88%) and 20p13-q13.33 (84%) . PSCCs aThese loci enclose several genes identified in areas of gain, amplification and loss. Gain of 3p12.3-q29 harbor, amongst many other genes, PRKCI, PIK3CA, DCUN1D1, LAMP3 and RPL35A. The F-box protein, SKP2 (S-phase kinase-associated protein 2) was included in gain of 5p15.33-p11 and amplification of 5p15.33-p11 and the oncogene MYC is also highlighted in the gained region 8p12-q24.3. Amplification of 3q27.2-q29 encompasses the genes PIK3CA, SENP5 (SUMO1/Sentrin Specific Peptidase 5), CLDN1, TNK2  and FBXO45 (F-box protein 45). Genes of interest in the amplified region 3q26.1-q27.2 include FNDC3B and ACTL6A/BAF53 (actin-like 6A/BRG1 associated factor 53A). CPT1A, FGF3/4 and CCND1 are revealed in the amplified region 11p12.-p14.1.Potential tumor suppressor genes, also found in other squamous cell carcinomas, have been discovered in the lost regions 2q33-q37.3 (PLCD4), 3p26.3-q11.1  and 11q12.2-q25 .Firstly, we sought to define whether HPV DNA positive and HPV DNA negative PSSCs would be underpinned by distinct patterns of gene copy number aberrations. Multi-Fisher's exact test adjusted for multiple comparisons revealed that HPV-positive and HPV-negative PSCCs have similar patterns of copy gains and that higher frequencies were demonstrated in 1q, 3q, 5p, 7p and 8q and amplifications in 3q, 5p and 8q for both HPV-negative and HPV-positive tumors.Regions of differential gain included 1q, 2p, 7p and 10q, and regions of differential loss on 6p, 11p and q and 17p and q. When an unadjusted p value was used, 17p loss was exhibited with an increased frequency in the HPV negative group (p<0.05), but other areas of differential gain and loss showed no pattern of association with either the HPV positive or negative group. When p values were adjusted, regions with a statistically significant higher frequency of cases in HPV positive cohort exhibited gain on 1q . When p values were adjusted, regions with a statistically significant higher frequency of cases in HPV negative cohort exhibited gain of 2p , 7p , 10q  and loss of 11p . No significant differences in the prevalence of specific amplified loci were identified. Hierarchical cluster analysis failed to demonstrate a clear difference in clustering of genetic change between HPV-positive and HPV-negative tumors Figs  and 3.In addition, we conducted further analysis based on other defined clinic-pathological variables  than in high-grade lesions (i.e. 3), but this was not statistically significant when adjusted p values were calculated. Loss of 2p and 5p and q were significantly more frequently found in low-grade lesions (p<0.05). Loss of 8q and 11p were significantly more frequently found in high-grade tumors (p<0.05). No significant differences in the prevalence of specific amplified loci were identified .PSSCs of different stages displayed distinct patterns of differential loss on 5q (p = 0.03), 6p (p<0.01) and 18p, as well as amplification of 8q . These aAnalysis of aCGH data according to nodal status  yielded more frequent gain of 7q and loss of 2pq (p<0.05), 4q (p = 0.03), 9q (p<0.05), 10q (p<0.05), 11q (p<0.05), 15q (p<0.05) and 20p (p<0.05) in node negative cases compared to node positive cases . For 7q Given the diversity of gene copy number aberrations of PSSCs, we performed class discovery analysis using hierarchical clustering. There were stable clusters, but none showed enrichment for a particular clinico-pathological feature .We have provided a detailed characterization of the genetic landscape of prostate cancer by DNA copy number aberrations found in HPV-positive and HPV-negative PSCCs, and demonstrated that these tumors display similar patterns of genetic aberrations despite the distinct pathogenetic mechanisms, with statistically significant changes in only a few small loci. It has been documented that HPV changes cell physiology inactivating RB and p53 pathways , 29 and Another mechanism of TP53 pathway inactivation includes amplification/overexpression of an ubiquitin ligase, MDM2 (murine double minute 2). TP53 is usually kept at low levels by MDM2 in normal cells. MDM2 and TP53 form an auto-regulatory negative-feedback loop, in which TP53 induces the expression of MDM2, which then facilitates the breakdown of TP53 in the nucleus and cytoplasm, inhibits its transcriptional activity and assists its nuclear export . Our datet al investigated the chromosomal changes found in 26 PSCCs using a spread of metaphase chromosomes on a microscope slide as a hybridization target, prepared as in fluorescence in situ hybridization. In three cases no DNA copy number alterations were detected, but contamination of the PSCC samples with normal tissue could not be excluded. Alves et al. observed the most common copy number gains on 8q24 (48%), 16p11–12(48%), and 20q11–13 (48%); 22q (43%); 19q13 (39%) and 5p15 (35%). In comparison, our data demonstrated copy number gains in similar overlapping regions on chromosomes 8p12-q24.3 (84%), 16p11.2-q24.3 (77%), 20p13-q13.3 (84%), 22q11.1–13.3 (73%), 19p13.11-q13.43 (64%) and 5p15.33-q11.2 (67%). Losses were found by the Alves group on 15q, 16q, 21q and 20p. PSCC cases exhibited loss on p and q arms of all other chromosomes, excluding chromosomes 22 and Y, which did not show loss. We showed amplifications of 1q32.2 (6%), 3q27.2-q29 (11%), 3q26.1-q27.2 (8%), 5p15.2-p14.3 (9%), 5p14.3-p11 (8%), 5p15.33-p15.2 (6%), 8q21.13-q24.3 (23%) and 11p14.1-p12 (6%), none of which corresponded to the single amplified case in the Alves data set (37%). Deletions were confirmed by Alves et al. at 13q21–22 (43%) and 4q21–32 (30%), but our study did not detect deletions in any cases. The number of gene copy number aberrations was reported to be numerically associated with ‘shorter survival’ in Alves et al., but it was not made clear whether this was disease-free, disease-specific or overall survival. Our study did not assess survival data for comparison with this. Given the relatively low resolution of the methods employed by Alves et al. and lack of information on the HPV status of the tumors analyzed in their study, it is difficult to grasp the overall clinical and biological significance of their data. However, a more recent study utilizing aCGH describes copy number alterations in PSCCs and supports the hypothesis that PSCCs manifest different aetiologies according to viral status.[One previous paper has been published on the pattern and repertoire of somatic genetic aberrations in PSSCs. Alves etl status.Our current data has highlighted patterns of copy number gains, losses and amplifications in a PSCC cohort that bear some similarities to those in other HPV related squamous cell carcinomas . For exaSKP2 ubiquitin ligase complex and has been involved in the ubiquitin driven breakdown of cyclin dependent kinase inhibitor p27 (a dosage dependent tumor suppressor protein), which is an important regulator of G1 progression. Increased levels of expression have been demonstrated in squamous and non squamous cell carcinomas and it has been linked with tumor progression and poor prognosis [Within other gained (5p15.33-p11) and amplified (5p15.33-p11) lies SKP2. It comprises the substrate recognition unit of the SCFrognosis –37. Aparrognosis . CLDN1 irognosis .FBXO45 binds to TP73, a pro-apoptotic gene, and initiates its proteosome dependent degradation . FNDC3B et al. found gain of 3q and 12q to be more common in HPV-positive VSCC cases and gain of 8q more common in HPV-negative [et al. also demonstrated a distinction between HPV-positive (DNA/RNA positive) and HPV-negative (DNA/RNA negative and DNA-positive/RNA-negative) tumors, with clustering of the HPV-positive group, which was not reflected in our PSCC data.Focusing on our HPV subgroup, we showed gain of 1q to be more frequent in HPV-positive cases and gain of 2p, 7p and 10q, as well as loss of 11p to be more frequent in HPV-negative cases. Only a subset of the data on other squamous cell carcinomas includes HPV DNA analysis, but not all findings are in concordance with those of PSCC. For example, Yangling negative . Differenegative , 44, whinegative . In contnegative  and CSCCnegative –48. Furtin vitro suggests that HPV infectivity was independent of inflammation and may play a less significant role than first thought [Although there is lack of gross correlation between genetic copy number change and HPV status, more detailed analysis of PSCCs may reveal more striking differences between the HPV groups, as disclosed by next-generation sequencing in patients with head and neck squamous cell carcinoma that showed more mutations in HPV-negative than HPV-positive tumors , as well thought .In addition, lymph node metastases were associated with chromosomal amplifications in OSCC at 2q12–14, 3q24–26, and 7q21–31, while distant metastasis correlated to amplification at 7p13–21 . This isThe differences in genomic profile between PSCCs and other HPV related squamous cell carcinomas may, in part, be attributed to intrinsic genetic differences, the different methods of CGH used or the number of cases analyzed.It has long been suggested that SCCs in different locations may develop through similar molecular pathways and that HPV and non-HPV pathways are responsible in the pathogenesis of PSCC. The correlations between the clinico-pathological data and copy number aberrations in our study supports this, but with the differences in genetic aberrations between PSCCs and other types of squamous cell carcinomas this remains unproven. Nonetheless, the correlations demonstrated here could play an important role in PSCC natural history and progression and highlight potential driver genes, which may feature in molecular pathways for existing therapeutic agents.Further analysis of PSCCs would need to be conducted to establish whether or not there is a final common pathway of HPV and non-HPV associated PSCCs and this would need to include next generation sequencing, cell culture studies, acquisition of paired genetic information from metastatic lymph node tissue and correlation with survival data.S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.


Esophageal cancer is a common and aggressive malignant tumor. This study aimed to investigate the association between human papillomavirus (HPV) Types 16 and 18 and esophageal carcinoma (EC) in the world population by conducting a meta-analysis.http://www.ncbi.nlm.nih.gov/pubmed/) and CNKI (http://www.cnki.net/) were the primary sources of case-control studies, and key words used include human papillomavirus, HPV, esophageal, esophagus, cancer, carcinoma, and tumor. All searches were performed by reviewing articles and abstracts cited in the published systematic reviews and case-control studies. Prospective studies that reported relative risk (RR) estimates with 95% CIs for the association between HPV and EC were included.Computerized bibliographic and manual searches were performed to identify all eligible literatures between 1982 and 2014. PUBMED . In China, the merger OR value was 1.62 (95% CI: 1.26–2.07); while in the Asian region, the merger OR value was 1.63 (95% CI: 1.29–2.04). There were statistical differences in HPV testing due to different detection methods such as PCR, IHC and ISH. In the PCR detection group, the merger OR value was 1.61 (95% CI: 1.33–1.95).These results indicate that HPV infection and the incidence of EC are closely associated. Esophageal carcinoma (EC) is the most aggressive malignant tumor of the gastrointestinal tract and the eighth most commonly occurring cancer in the world . It has Human papillomavirus (HPV) infections, especially high-risk types 16 and 18, have recently been reported as a possible risk factor for EC. However, direct evidence of this relationship has been lacking, and results of those studies were not consistent. This study aimed to conduct a meta-analysis, and systematic review of literature to determine whether an association exists between HPV type 16 and 18 infection and EC.A literature search was performed from 1982 to 2014 using PUBMED and CNKI databases without restrictions, and the following search terms were used:  and  and . Moreover, reference lists were reviewed to search for relevant studies. This systematic review was planned and reported in adherence to the standards of quality for reporting systematic reviews.All searches were performed by reviewing articles and abstracts cited in the published systematic reviews and case-control studies. Inclusion criteria were as follows: (1) prospective case-control studies, (2) EC diagnosed by pathology, (3) Control group obtained from esophageal epithelial tissues of normal individuals (screening) or normal marginal tissues of EC.Exclusion criteria included the following: reports of poor quality, duplicate reports, inadequate information, unclear data descriptions or samples were removed, sample size less than 20, and abstracts.The Jadad scoring method was used to evaluate several aspects of the quality of the study. Three independent researchers extracted data, blindly evaluated the quality of the literature, and analyzed the data including withdrawals and dropouts . If ther2 statistics were obtained, using a predefined significance threshold of 0.05.If P≥0.05, it was considered that there was no heterogeneity between studies; and a fixed effects model (FEM) was used for the analysis. If P<0.05, it was considered that heterogeneity existed between studies; and a random effects model (REM) was used after correction for analysis. If a null hypothesis, which represents that there was no heterogeneity among each study, was accepted, the Mantel-Haenszel fixed-effects model was used to calculate the combined odds ratio (OR) with 95% confidence intervals (CI) and the Forest Plot. If the null hypothesis was rejected, REM was used to calculate the combined OR with 95% CI and the Forest Plot. To detect publication bias, the asymmetry of standard error–based funnel plots was examined using the linear regression method, as suggested by Egger et al. [A heterogeneity test was used to select the method of data combination in the systematic review. The Cochrane’s Q-test was performed and IEC incidence in subgroups were stratified and analyzed according to various geographical areas, the control group selection method, and various HPV detection methods.A total of 297 articles were identified by using the search criteria, and these studies were carried out from 1982 to 2014. All studies were obtained from published literature . Nine coDetailed steps of the literature search are shown in i = 94.78, P<0.001) revealed that there was heterogeneity between studies and between subgroups. Therefore, overall and subgroup analyses were corrected using REM; and the method of DerSimonian-Laird as used to merge data, and calculate ORs and 95% CIs. Egger’s regression analysis was used to more objectively evaluate publication bias  with a P<0.05 for the Q-test. A REM analysis was applied. The combined effect of these test results revealed an association between HPV infection and EC. From the independent OR and synthetic OR of the 33 researches, HPV infection was found to be closely associated with EC. The merger OR value was 1.62; 95% CI of 1.33–1.981.57, P = 0.058). Therefore, there was no significant bias in the publications, there was no substantive effect on the synthetic OR, and the conclusion was reliable  was found, indicating that the results had good reliability. In other regions (outside China) such as Egypt, France, Greece, Iran and other countries, merger OR value was 1.80 (95% CI: 1.16–2.79); and there was also no publication bias . In Asian countries such as China, Japan and India, the merger OR value was 1.63 (95% CI: 1.29–2.04); and there was no publication bias . In non-Asian countries such as Egypt, France, Greece, Iran, Italy, Mexico and Sweden, merger OR value was 1.64 (95% CI: 1.01–2.67); and there was no publication bias . In addition, results were same in both high risk and low risk areas. In high risk areas, merger OR value was 1.29 (95% CI: 1.05–1.59); while in low risk areas, merger OR value was 2.06 (95% CI: 1.08–3.94).  including high incidence areas for EC such as the Taihang, Qinling and Dabie mountain ranges, as well as the northeast of Sichuan, east of Xinjiang, east of Fujian and east of Guangdong provinces. No publication bias . In the control patient group , merger OR value was 1.41 (95% CI: 1.06–1.89); while in the control tissue group , merger OR value was 1.82 ; in the ISH group, merger OR value was 1.21 (95% CI: 0.62–2.36); and in the IHC group, merger OR value was 1.69 (95% CI: 0.96–2.96). An opposite result was acquired in the ELISA group, where the merger OR value was 1.28  virus , family Currently, the role of HPV infection in esophageal cancer is unclear. Many studies from Africa and China have shown that HPV infections were associated with esophageal cancer. However, in areas with lower prevalence of HPV, there was no decrease in risk of EC –49. The In order to explain the association between HPV and EC, we reviewed many articles and selected only case-control studies for analysis. To our knowledge, this is the first study that conducted a systematic review of the relationship between HPV infection (types 16 and 18) and EC worldwide. Results of the comprehensive evaluation of this final systematic review revealed that there was a significant association between HPV infection and EC risk with an integrated OR = 1.62 (95% CI: 1.33–1.98). In META analysis, the presence or absence of heterogeneity directly affected the results of the statistics. Therefore, this study was conducted to strictly evaluate heterogeneity.HPV infection rates may be related to geographical location. Therefore, we preformed a subgroup analysis according to geographical location worldwide. The stratification study revealed that regardless of whether the studies were in China, Asia, outside of China, or outside of Asia, or in high or low risk areas, HPV infection was associated with EC. In the current research, most studies from low-risk areas also had an association between HPV and EC, and these correlations were stronger than high-risk areas; which was different from other reports. A possible reason was that in high-risk areas, EC occurred due to other reasons such as eating habits, tobacco, alcohol, pollution, genetic factors and HPV infection; thus, the influence of HPV decreased . In low-Although most of the esophageal cancer risk factors have been determined, there may still be unknown confounders that may interfere with the results. The literature included case-control studies that were inevitably affected by a variety of bias.However, due to the current study design, many kinds of bias were possible. (1) Most studies detected HPV from tumor tissues and tissues around tumors that could have been infected with HPV. (2) This systematic review included many studies from all over the world. The variable HPV prevalence could have been related to the various geographic regions studied.The choice of the control group may have also affected the results, because the healthy controls group revealed that HPV was associated more closely with EC. Cancer adjacent tissues as controls also confirmed a link between HPV and EC, but with a weaker correlation than the cancer tissue itself. This may be related to the HPV infection of the cancer tissue in the body or contamination of samples. There are many methods for detecting HPV, and there was no uniform detection method used in these studies. The researchers did not make use the same HPV detection methods used such as PCR, ELISA, ISH and IHC; although some of the early HPV detection techniques have since been abandoned. Therefore, these results are likely to have some bias, and PCR seems to be the most accurate monitoring method .The current result was the same as that reported by Zhang et al. ,52 excepThese results indicate that HPV is closely associated with EC in China, Asia, and all over the world. In investigating the association between HPV and EC, the selection of the control group is important in order to avoid interfering factors. This systematic review provides epidemiologic evidence to support the association between HPV infection and EC. Multi-center studies on regional incidences with strict control of false positives and false negatives would be needed to confirm the association of HPV and EC. If confirmed, HPV testing may be useful in groups at high risk for EC; while HPV vaccine might be useful as a primary prevention measure.Guarantor of the article: Bangwei Cao, PhD and Bing LiuS1 PRISMA Checklist(DOC)Click here for additional data file.


Statistics regarding HPV prevalence and cervical cancer rates in rural China are high, however, low levels of HPV awareness and HPV-related knowledge pose a great challenge for cervical cancer control.t-test was used when comparing quantitative variables. Chi-squared test or Fisher’s exact tests was used when comparing qualitative variables.The authors conducted an educational intervention study, which was embedded in a cervical cancer screening project in Yangcheng county, Shanxi Province, China from October to December, 2011 and was designed to assess the short-term effectiveness of a hospital-based, brief, HPV-focused session on rural Chinese women’s knowledge and attitudes. Student’s p < 0.001) and cervical cancer . Changes were also observed regarding women’s intention to vaccinate themselves  and their daughters , although the impact was more modest compared with the impact on change of awareness. Among women who were aware of HPV, 60.3 % knew that cervical cancer is related to HPV, while only 5.0 % knew the relationship between HPV and genital warts after the educational intervention.We found that following the intervention, significant increases were detected in awareness regarding HPV (5.9 % vs. 59 %, Educational campaigns, particularly those targeting women with limited education and poor access to public media or other educational channels are needed to improve knowledge regarding HPV in the general population. By the end of 2012, the registered permanent resident population of Shanxi province had reached 36.1 million. Yangcheng county locates at the southeast of Shanxi province, with approximately 0.4 million population, of which nearly 60 % live in the rural areas [Studies have clearly illustrated that lack of knowledge about HPV and low levels of understanding of HPV vaccination have direct implications for women’s participation in cervical screening , 8. DespA previous multi-center cross-sectional study reported that only 15.5 % of women interviewed reported to have ever heard of HPV in China. And the proportion among rural women was only 9.3 % . The stuAs no previous study has been conducted to evaluate a way of changing the ‘low HPV awareness’ in China, our study sought to assess the short-term effectiveness of a hospital-based, local health provider oriented educational intervention on rural women’s knowledge and attitudes towards the prevention of cervical cancer and HPV infection immediately following the group education as an intervention.If this intervention approves to be effective in raising the awareness of HPV and cervical cancer prevention among women, an increased attendance to cervical cancer screening might be achieved when such education is widely disseminated especially through the existed educational system led by China CDC. Also, it might help enhance the HPV vaccination uptake among Chinese women in the future when HPV vaccines become available.This study was a questionnaire-based, cross-sectional study conducted from October to December, 2011, and it was embedded in a project called “the Low-Cost Molecular Cervical Cancer Screening Study (LCMCCSS)” and was funded by the Bill & Melinda Gates Foundation. It was conducted collaboratively by Program for Appropriate Technology in Health (PATH) and the Cancer Institute of the Chinese Academy of Medical Sciences (CICAMS) after approval by the Institutional Review Boards of both organizations.Stratified randomized cluster sampling was used in one of the cervical cancer high-risk provinces of China, Shanxi province. Initially, a cervical cancer high-risk county from Shanxi, the Yangcheng county, was selected. Two high risk communities (Baisang Xiang and Dingdian Town) from Yangcheng county were then targeted based on the estimated numbers of women registered on the Shanxi permanent residency registry. Twenty-two villages as clusters were then randomly selected from a total of 38 villages to achieve a target population of 3,000. All non-pregnant women aged 25–65 years without a history of Cervical Intraepithelial Neoplasia (CIN), cervical cancer, or hysterectomy and who were mentally and physically competent to provide written informed consent were eligible for the ‘LCMCCSS’ screening study regardless of their marital status.Among the 22 villages that were targeted for cervical cancer screening, 8 as clusters were randomly selected for an extra educational intervention. Among women from the 8 villages, those who had an even last digit in their randomly allocated study ID were invited to attend our educational intervention study Fig. .Fig. 1StFor the cervical cancer screening study: All recruitment was done by village doctors. They were trained by investigators from CICAMS prior to the initiation of the study. After the training, a list of targeted women and their basic information  was provided by the local permanent resident registration system. The trained village doctors then dropped house-to-house visits to women according to the list. During the house visits, the inclusion and exclusion criteria as well as the potential benefits and risks were clearly explained to women. For those who verbally agreed to participate, village doctors made a screening appointment for them.For the educational intervention study: Recruitment was done on the same day when women attending cervical cancer screening at the screening site  by investigators from CICAMS. Free transportation and cervical cancer screening were offered to women who were willing to participate in the educational intervention study.Women who were willing to attend the educational intervention study provided informed consents on a voluntary basis. During the process, the words ‘HPV’ and ‘cervical cancer’ were not mentioned in order to avoid possible contaminations to the educational intervention. Instead, women were carefully explained by the investigators that they would be asked about some facts of an organ-specific female cancer, its etiology and methods to prevention. Questions would be asked both before and after a PowerPoint (PPT) oriented health education by trained interviewers.Immediately after providing the informed consent participants were administered a ‘Pre-intervention HPV questionnaire’ in independent rooms by trained female nurses aged 26–40 years. Questions on ①: Have you ever heard of HPV? ②: Have you ever heard of cervical cancer? ③: Do you have daughter (s)? ④: If prophylactic HPV vaccines were available, would you be willing to vaccinate your daughter? ⑤: If prophylactic HPV vaccines are available, would you be willing to vaccinate yourself? (only for women aged ≤ 45 years) were asked in this section.When asked, women only need to answer ‘Yes’ or ‘No’. The word ‘prophylactic’ was also explained to women by the trained nurses in a very common sense way. For example, it was explained as : if you get vaccinated, you will not been infected by some types of the virus (HPV) that cause cervical cancer, like how HBV vaccines work to prevent hepatitis B infection.After administration of the ‘Pre-intervention HPV questionnaire’, women were convened in a meeting room in the hospital and an educational lecture was provided by a trained local doctor in local dialect by using a standardized PPT. During the lecture, women were taught basic concepts regarding ① What is cervical cancer, how does it threaten women’s health and lives;② What is HPV and its relation to cervical cancer;③ What kind of screening tests are available for the secondary prevention of cervical cancer;④ The current status of prophylactic vaccines for the primary prevention from cervical cancer. The lecture was given to 25–30 women per time by the same trained doctor, and lasted for about 40 min. Two group educations were given each day, one was in the morning and the other was in the afternoon.After the group education, it takes a short term (about 5 min) to re-allocate women to the same interview room and they were interviewed again by the same trained nurses in a confidential setting about cervical cancer, HPV and the related preventions. In addition to questions asked in the pre-intervention questionnaire, more specific information was collected using the pre-tested questionnaire administered in the earlier study .Prior to the screening and after informed consent for the screening study, the participants were administered a risk factor questionnaire, which contained not only the socio-demographics but also some risk factors related to HPV infection and cervical cancer  etc.). Women then received gynecological examinations in the study clinic situated in their residential district. Cervical and vaginal specimens were collected by doctors from women undergoing routine examinations.Two data input clerks in each site were recruited to double-enter data from the paper to computer-based database (FoxPro) independently after training. All finished double-entry databases were sent to CICAMS for validation by running EpiData. Any inconsistency found by CICAMS between the two databases was reported to the local clerks for adjudication until the databases agreed. As final check, one database was chosen and underwent a final consistency check. Logic errors  were again reported back to the local sites, and the local collaborators contacted the participants using the contact information provided in the risk factor questionnaires. After checking with the participants, the local staffs sent the revised database back to CICAMS for final analysis. This procedure was strictly followed as previously described .t-test was used when comparing quantitative variables. Chi-squared test or Fisher’s exact tests was used when comparing qualitative variables. SAS statistical software version 9.1  was used to analyze the data. Statistical significance was assessed by two-tailed tests with α level of 0.05.Basic descriptive statistics and frequency calculations were performed on all demographic variables. Student’s Of the 4,230 women that were recruited to attend the cervical cancer screening, 3,241 women came with a compliance of 80.9 %. Among them, 1,829 were from the 8 villages selected for educational intervention. Among the 1,829 women, 913 women with randomly allocated even ID numbers were recruited to attend the educational intervention study and all agreed.The mean age of participants was 42.3 years (s.d. =8.7 years), with the youngest of 25 years and the oldest of 64 years. All participants were ethnic Han. Table n = 396) of participants was 22 years or older. Most women reported only having one sexual partner in their lifetime (80.9 %). Most women (69.0 %) had two or more live births. Compared with the non-intervention group, the intervention group had more women from younger age group (25–34 years) and had a higher proportion of receiving middle school education (Table Most women (97.6 %) from the intervention group were married and the majority (82.0 %) had only primary school or middle school education. Few women smoked 0.1 %) or drank alcohol (7.3 %). Trichomonas (11.2 %), fungal infection (9.8%), and urinary tract infection (6.1 %) were the most common self-reported previous genital infections. The average age of sexual debut was 21.1 years (s.d. =1.8 years) and the age of sexual debut for 43.4 % ( % or draP <0.001). Age did not influence women’s awareness of HPV  women reported having ever heard of HPV. Women with >9 years of education were significantly more likely 22.4 %) to have heard of HPV than those with ≤9 years of education (2.9 %) (2.4 % to n = 539), 60.3 % (365/539) knew that HPV is related to cervical cancer with a higher proportion (69.7 %) among more educated women compared with less educated women (58.0 %). Younger women (≤45 years) were more likely (65.7 %) to know the relationship between HPV and cervical cancer than women >45 years (47.2 %). Only 5.0 % (30/539) of women knew that HPV is associated with genital warts, with a higher proportion (8.2 %) among more educated women compared with less educated women (4.1 %), and no significant difference was observed between the two age groups . Specific knowledge about the risk of HPV, its link between cervical cancer etc. is presented in Table 9/913. Spn = 814), 79.4 % (646/814) knew that cervical cancer is early detectable and treatable. Knowledge rates were higher among those with higher education level and younger age (P <0.05)  Table .Table Six hundred and thirty six (69.7 %) women reported that they had daughters. Among them, 88.1%(560/636) were willing to vaccinate their daughters, 11.9 % (76/636) were unwilling, mainly because they do not think their daughters are at risk , followed by doubt regarding the vaccine’s efficacy 28.2 %; 24/76). Education level did not influence the reasons for willingness or unwillingness to vaccinate their daughters (Table /76. EducP < 0.001) in women’s awareness was observed following the educational intervention. When asked about their awareness of cervical cancer, the proportion of ‘yes’ answers also increased significantly . When questioned about their intention of being vaccinated or vaccinating their daughters, the proportion of women with positive responses increased substantially.Table This study investigated rural Chinese women’s baseline HPV knowledge and their attitudes toward HPV vaccines. It is the first study in China to evaluate the short-term effectiveness of a hospital based group education to change local women’s knowledge, beliefs and attitudes towards the prevention of HPV infection and cervical cancer.Based on the most recent WHO position paper on HPV vaccines, the recommended primary target population are young females of 9–13 years, and the secondary target population are older adolescent females or young women. There is no defined up limit of age been vaccinated . In addiResults confirm that women living in rural China have very limited awareness of HPV and its related diseases , 13–16, Based on previous findings that hospital based lectures and suggestions from doctors and nurses were important in influencing decisions about being vaccinated in both rural and metropolitan areas , we evalImmediately after the educational intervention, women’s awareness of ever heard of HPV increased from 5.9 % to 59 %, however, 41 % of them still reported that they had never heard of HPV. The reason was possibly because that 86.6 % of women in this population received middle school or less education, suggesting that they did not have a chance to learn English. In our intervention, HPV was expressed in both English as ‘HPV’ and in Chinese as ‘Ren Ru Tou Liu Bing Du’, however, in our questionnaire, it was written only in English and asked by using the English term. This may result in the situation that women were unaware of the English term ‘HPV’ even immediately after the intervention. This should also be considered in the future studies and the question should be asked by using both the English term as well as the Chinese term.Another possibility might be that women at this education level were not very interested in a PPT oriented education, and some of them were absent minded during the intervention, a more easy and interesting way to conduct such intervention should be considered among women that were less educated.Compared with the very low baseline awareness of HPV, the acceptability of vaccination seemed to be high at baseline. Although increases were also observed in women’s attitudes toward HPV vaccination after education, the net change was not as significant as the degree of change in women’s awareness of HPV. The high acceptability of HPV vaccines have been reported both in developing , 16 and In order to guarantee the flow of the cervical cancer screening process, the baseline specific knowledge of HPV  and its related diseases were not examined, however, the previous study indicated poor specific knowledge about HPV especially among rural Chinese women . A studyStudies illustrated that greater knowledge about HPV may be associated with greater vaccine acceptability –39 and tThere are several limitations of the study that need to be considered. The study was undertaken in one cervical cancer high risk rural county and may not represent the general Chinese population. The lack of a matched control group weakens the ability to assess the effectiveness of the reported intervention. In addition, the short term effectiveness does not necessarily guarantee a long term impact, and a follow up study with monthly intervals was not conducted to evaluate the duration of effect as well as to help decide the interval for a ‘booster’ session in future education campaigns. Finally, the strongest measure of the effectiveness of such an intervention would be associations with long-term outcomes such as decrease in cervical cancer incidence and mortality , howeverOne of the major strengths of the present study is that this is the first study to evaluate a simple method to a conduct hospital based group education to change women’s knowledge and attitudes toward HPV and its vaccines in China. Additionally, the relatively large sample size renders the results valid for assessing the short-term effectiveness of the reported program and useful for developing further educational interventions.In conclusion, this is the first intervention study on changing rural Chinese women’s knowledge and attitudes toward HPV and its vaccines. Our results confirm that a brief, hospital-based educational intervention is feasible to conduct in low resource settings and is appropriate in increasing awareness and acceptability, although the observed impact on attitudes towards prevention was less compared with the impact in HPV awareness. On the basis of our results, education campaigns, particularly targeting women with limited education and less access to public media or other educational channels are needed in the near future, to improve knowledge regarding HPV in the general population. A multi-center nation-wide randomized trial to test the intervention in both rural and urban Chinese women with follow-up evaluation would build upon and broaden the impact of this study.


The HPV-status was confirmed by HPV16/18 polymerase chain reaction and IHC for p16INK4a. IHC for p16 or EpCAM were utilized for defining tumor region. Infiltration of T cell populations including CD45+CD3+CD8+ T cells (P < 0.01), CD45+CD3+CD8−Foxp3+ regulatory T cells (P < 0.05) and CD45+CD3+CD8−Foxp3+T-bet+ Th1 cells (P < 0.01), CD45+CD20+CD3−B cells (P < 0.05), CD45+CD68+CD163− macrophages (P < 0.001), and CD45+Tryptase+ mast cells (P < 0.01) was significantly higher in the HPV-positive group than in the HPV-negative group. CD8/CD68 ratio of HPV-positive tumor was higher than that of HPV-negative tumor (P < 0.05), and the highest CD163−CD68+/CD163+CD68+ ratio was observed in the intra-tumor region of HPV-positive tumors. High PD-L1 expression on CD68+CD163+ macrophages and MHC class II+CD83+ dendritic cells was intensively observed in the intra-tumor region of the HPV-positive group while maturation of dendritic cells assessed by CD83/DC-SIGN ratio was significantly higher in the peritumoral stroma than intra-tumor regions (P < 0.05), indicating distinct immune regulatory mechanisms between intra and peritumoral regions. These signatures provide further evidence of anti-tumor immunity against HPV-positive head and neck cancer, and potentially lead to personalized treatment including immunomodulatory therapeutic targets specialized for the HPV/immune status.Human Papilloma Virus (HPV)-positive head and neck squamous cell carcinoma (HNSCC) is clinically distinct from HPV-negative HNSCC, and as such requires differential therapeutic approaches. Accumulating evidence indicates a significant linkage between the immune response within the tissue and pathogenesis of HPV-associated HNSCC. To further elucidate immune-related signatures in HPV-associated HNSCC, we performed multiplex histological analysis in de-identified tissue microarray sections including HPV-positive (n = 21), HPV-negative (n = 17), and normal oropharynx (n = 8). Following immunohistochemistry (IHC) for CD45, CD3, CD8, Foxp3, T-bet, GATA-3, RORgT, CD20, CD56, CD68, MHC class II, CSF1R, CD66b, tryptase, CD83, DC-SIGN, PD-1, and PD-L1, the cell intensity per mm


In the Netherlands, human papillomavirus (HPV) vaccination is part of a national program equally accessible for all girls invited for vaccination. To assess possible inequalities in vaccine uptake, we investigated differences between vaccinated and unvaccinated girls with regard to various characteristics, including education and ethnicity, , sexual behaviour and knowledge of HPV.In 2010, 19,939 nationwide randomly-selected 16–17 year-old girls (2009 vaccination campaign) were invited to fill out an online questionnaire. A knowledge scale score and multivariable analyses identified variables associated with vaccination status.2989 (15%) of the selected girls participated . The participants were comparable with regard to education, ethnicity, most sexual risk behaviour and had similar knowledge scores on HPV transmission and vaccination. However, unvaccinated girls lived in more urbanised areas and were more likely to have a religious background. Irrespective of vaccination status, 81% of the girls were aware of the causal relationship between HPV and cervical cancer, but the awareness of the necessity of cervical screening despite being vaccinated was limited.HPV vaccine uptake was not associated with knowledge of HPV and with factors that are known to be associated with non-attendance to the cervical cancer screening program in the Netherlands. Furthermore, most sexual behaviour was not related to vaccination status meaning that teenage unvaccinated girls were not at a disproportionally higher risk of being exposed to HPV. Routine HPV vaccination may reduce the social inequity of prevention of cervical cancer. Human papillomavirus (HPV) infection is one of the most common sexually transmitted infections (STI) worldwide. By the age of 50, about 80% of sexually active women will acquire HPV -3. Most Since 2006, a quadrivalent vaccine that induces protection against HPV types 6, 11, 16 and 18 (Gardasil®), and in 2007 a bivalent vaccine against HPV type 16 and 18 (Cervarix®) are available. Both have shown an efficacy of >90% in preventing CIN2/3 [In the Netherlands, the bivalent HPV vaccine (Cervarix®) targeting 12-year-old girls became part of the National Immunisation Program in 2010. In 2009, girls aged 13 to 16 years were offered this vaccine during a “catch-up” vaccination program where the uptake amounted to 52% . In the Prior to introduction of vaccination, some studies have reported on girls’ intention to be vaccinated -19. HoweA nationwide self-reported cross-sectional study of 16-17-year-old girls was performed in the Netherlands in December 2010. A random sample of 19,939 girls born in 1993, invited for the HPV catch-up vaccination campaign in 2009 (9992 vaccinated and 9947 unvaccinated), was selected from the national vaccination database (Praeventis) held at the National Institute for Public Health and the Environment (RIVM) .Socio-demographic: education level (girl and parents), ethnicity , religion, alcohol and smoking behaviour. Sexual behaviour: e.g. ever have had sexual contact , age of sexual debut, use of contraceptives , number of sexual partners, type of current partner  and history of STI. HPV knowledge and HPV vaccination: e.g. modes of transmission, protection level of HPV vaccination, risk of infection and participation in the cervical cancer screening program. Each girl selected for the study received an invitation by post with an information letter for the girl and one for her parents/caretakers, and a link and a unique code to access the online questionnaire. The questionnaire took approximately ten minutes to fill out and the information was processed anonymously.A semi-structured questionnaire was developed, pre-tested and applied to the study population via online research survey software ). The questionnaire contained pre-coded questions on the following topics: This research was performed according to the principles contained in the Declaration of Helsinki . The Dut2 test. Socio-economic status was also assessed using the ‘status score’ computed by the Dutch Institute for Social Research , as a proxy for socioeconomic status (SES). This score takes into account the average income per household in a given postcode area as well as the percentage of households with low income, without a paid job and with low education level. The lower the score is, the higher the socioeconomic status [Differences in socio-demographic characteristics, sexual behaviour and knowledge of HPV between vaccinated and unvaccinated women were compared in contingency tables using χc status . KnowledVariables associated with vaccination status found to approach significance  were fitted in a multivariable logistic regression model. The strength of the associations was expressed as crude odds ratios (OR) in univariable analysis and as adjusted OR (aOR) in multivariable analysis, comparing vaccinated vs. unvaccinated girls. Two models were carried out: one including the total sample of girls and the second comprising only sexually active girls. The final models included those factors that remained significant  after backward selection and those found to change the OR of other variables by at least 10%. Analyses were conducted using software packages from SAS 9.2 .A total of 2989 females (15% of invited participants) aged 16–17 (median 17) participated in this study. Among them, 65% received at least 1 HPV vaccination and 35% received none. The distribution of most characteristics was similar between vaccinated and unvaccinated girls (Tables The majority of both vaccinated and unvaccinated girls (97.3% vs. 98.2%) thought that HPV vaccination had not changed their sexual behaviour, 0.8% of the girls answered that use of condoms would not be needed to protect against STIs after HPV vaccination. However, 17% of the vaccinated and 26% of the unvaccinated replied that other girls would be inclined to use less condoms after vaccination. In addition, a higher proportion of vaccinated girls thought HPV could not be transmitted when using condoms.. The general knowledge score (one point for every right answer) was similar between vaccinated and unvaccinated girls.Vaccinated girls were less aware that HPV vaccination does not protect against all HPV types, but were more aware that HPV vaccination does not protect against all STIs Table . In geneVaccinated girls reported more often that their mother participated in the cervical cancer screening program, and that it would still be necessary to participate in such a program after being vaccinated. However, they were less aware of the existence of this program Table .Most girls were familiar with the association between unsafe vaginal sex and transmission of HPV. This knowledge was lower for other forms of sex, such as unsafe anal or oral sex. A low proportion knew that HPV could be transmitted via skin-to-skin contact or by stroking their partner’s genitals Table . The HPVVariables whose association with vaccination status approached significance  were fitted in a multivariable logistic regression model Table . The facFurthermore, considering perceptions of HPV, vaccinated girls thought more often that HPV vaccination protects against all HPV types and were less likely to think that girls would use condoms less frequently once vaccinated. Interestingly, more unvaccinated girls did not know that condoms were still needed after vaccination.This population-based study is one of the first that examined actual determinants for individual vaccine uptake instead of willingness to be vaccinated. Vaccinated and unvaccinated girls were comparable with regard to education, education of parents, ethnicity, most sexual risk behaviour and had similar scores on knowledge of HPV infection and HPV transmission. They differed with respect to characteristics such as urbanisation degree, religion, contraceptive use, number of lifetime sexual partners and importantly, their opinions on the use of condoms after HPV vaccination and the protection of vaccination against all HPV types.Studies in the Netherlands have shown that women who are non-Dutch nationals and have a lower socio-economic status are less likely to participate in the cervical cancer screening program ,15. ThesReligion has influenced vaccination decision-making process since the beginning of vaccination efforts . Anti-vaContradicting results regarding the influence of HPV knowledge and perceptions on vaccination uptake have been reported . ConsistIn general, only 50% of the young girls in our study recognised that after an HPV vaccination it is still indicated to participate in the cervical cancer screening program (which takes place from age 30 onwards in the Netherlands). This fact has also been reported by Bowyer HL et al.  amongst In our study, only 2-3% reported that HPV vaccination had changed their sexual behaviour in the first year after vaccination. However, Marlow LA et al.  found thThere were no significant differences amongst vaccinated and unvaccinated girls for reported condom use with a casual or steady partner. However, sexually active vaccinated girls were more aware of the risk of HPV infection when engaging in unprotected sex. Irrespective of vaccination status, only a quarter of the girls reported to always use condoms with a casual partner and 18% with a steady partner. In line with Mather T et al.  inconsisWith regard to other sexual risk factors we found that among the vaccinated sexually active girls, a somewhat lower mean number of lifetime sexual partners was reported. However, no differences were found for other sexual behavioural characteristics such as age of sexual debut and history of STIs. These results imply that girls who decided not to get vaccinated were not the ones with increased  risk behaviour. Thus in contrast to screening, where it has been found that more than half of the cervical cancer cases were found in women who did not attend screening, it seems that although these girls are not benefiting from vaccination, they have no disproportional disadvantage compared to vaccinated girls.This study has several strengths. Firstly, it was a randomly selected, large, nationwide population-based study. Secondly, vaccination status was derived from a national vaccination database instead of being self-reported. Thirdly, we obtained information on the actual vaccination uptake instead of the intention to vaccinate.Although a limitation of this study was a relatively low response rate (15%), online surveys/questionnaires, while advantageous, are known for their average lower response rate compared to mail or telephone surveys ,37. SimiRoutine HPV vaccination in the Netherlands has the potential to reduce the inequity of prevention of cervical cancer. In particular, vaccination uptake was not associated with factors that are known to be associated with non-attendance in the cervical cancer screening program, such as education and ethnicity. Furthermore, most sexual characteristics were comparable amongst both groups indicating that unvaccinated girls are probably not at higher risk of exposure to HPV compared to vaccinated girls. Although in general knowledge could be improved, the large majority of participants knew HPV caused cervical cancer suggesting an informed vaccination choice was made.Tjalke Westra (TAW) was involved in this study during his PhD at the University Medical Center Groningen, on an unrestricted educational grant from GlaxoSmithKline (GSK). Currently, TAW is employee of GSK. The other authors declare that they have no conflict of interest.KL, MM, AT, HEDM were involved in the data collection, made substantial intellectual contributions to the conceptualization and design of this study and contributed to the content and preparation of this manuscript. MABVDS, SKS, TD, WCMWS, HWN, TAW made substantial intellectual contributions to the conceptualization of this study, the critical reading of the manuscript and final approval of the version to be published. All authors read and approved the final manuscript.Madelief Mollers and Karin Lubbers shared first authorship.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/14/288/prepub