Terminal cleaning and disinfection of hospital patient rooms must be performed after discharge of a patient with a multidrug resistant micro-organism to eliminate pathogens from the environment. Terminal disinfection is often performed manually, which is prone to human errors and therefore poses an increased infection risk for the next patients. Automated whole room disinfection (WRD) replaces or adds on to the manual process of disinfection and can contribute to the quality of terminal disinfection. While the in vitro efficacy of WRD devices has been extensively investigated and reviewed, little is known about the in situ efficacy in a real-life hospital setting. In this review, we summarize available literature on the in situ efficacy of WRD devices in a hospital setting and compare findings to the in vitro efficacy of WRD devices. Moreover, we offer practical recommendations for the implementation of WRD devices.2O2 vapour, ultraviolet C and pulsed xenon ultraviolet. The in situ efficacy was based on environmental and clinical outcome measures. A systematic literature search was performed in PubMed in September 2021 to identify available literature. For each disinfection system, we summarized the available devices, practical information, in vitro efficacy and in situ efficacy.The in situ efficacy was summarized for four commonly used types of WRD devices: aerosolized hydrogen peroxide, HIn total, 54 articles were included. Articles reporting environmental outcomes of WRD devices had large variation in methodology, reported outcome measures, preparation of the patient room prior to environmental sampling, the location of sampling within the room and the moment of sampling. For the clinical outcome measures, all included articles reported the infection rate. Overall, these studies consistently showed that automated disinfection using any of the four types of WRD is effective in reducing environmental and clinical outcomes.Despite the large variation in the included studies, the four automated WRD systems are effective in reducing the amount of pathogens present in a hospital environment, which was also in line with conclusions from in vitro studies. Therefore, the assessment of what WRD device would be most suitable in a specific healthcare setting mostly depends on practical considerations.The online version contains supplementary material available at 10.1186/s13756-022-01183-y. Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE) and multidrug resistant Acinetobacter baumannii, have to be cared for in isolation. After discharge of a patient with an MDRO, the patient room needs terminal cleaning and disinfection to eliminate the MDRO from the environment.Hospitalized patients who have an infection with or are a carrier of a multidrug resistant micro-organism (MDRO), such as methicillin-resistant Terminal disinfection is often performed manually, which is labour intensive and prone to human errors. Errors can be made in the selection of the correct detergent, the formulation of the detergent in the correct concentration, the distribution of the product, and the adherence to the correct contact time –3. This Automated ‘whole room disinfection’ (WRD) is a technology that can contribute to the quality of the terminal disinfection of patient rooms. WRD devices replace or add to the manual disinfection process by an automated process with a constant result. WRD still needs to be preceded by manual cleaning of the patient room, which is also common practice for manual disinfection.2O2 vapour make use of gaseous hydrogen peroxide. Ultraviolet C (UV-C) and pulsed-xenon UV (PX-UV) make use of ultraviolet radiation.Currently, there are four types of WRD devices that are used most frequently in a hospital setting. Aerosolized hydrogen peroxide (aHP) and H2O2 vapour has the highest in vitro efficacy, followed by UV-C.The efficacy of WRD devices is primarily assessed by its in vitro outcomes, which considers the logarithmic reductions of in vitro presence of pathogens after treatment with a WRD device. In vitro studies are performed in a controlled environment, where the investigated pathogen is cultured in specific quantities and treated with a standardized disinfection process. Therefore, in vitro evaluations may present the efficacy under ideal circumstances. Amongst the most frequently used types of WRD devices, HIn contrast to the in vitro conditions, the real-life settings in which WRD devices will be implemented, such as hospitals, present less optimal environments. The exact location and quantity of the pathogen is unknown and disinfection may be limited due to soiled surfaces. Additionally, WRD devices may not reach all areas of the patient room and efficacy may differ for the various kinds of surfaces. Furthermore, materials and medical equipment present in the room may not be suitable for or suffer from disinfection with e.g. UV-C or hydrogen peroxide. Therefore, the in situ efficacy may differ from the in vitro efficacy of WRD devices.In this review we have summarized available scientific literature on the in situ efficacy of WRD devices in a hospital setting to get insight into the effect of WRD devices in real-life and less standardized settings. Therefore, we aim to describe the in situ efficacy of WRD devices in a hospital setting and how the in situ efficacy compares to the in vitro efficacy of such WRD devices. Moreover, we offer practical information concerning the WRD devices and provide recommendations for implementation.2O2 vapour, UV-C and PX-UV. The efficacy of these WRD devices has been investigated for common micro-organisms known to cause hospital-acquired infections or hospital outbreaks, being norovirus, Acinetobacter, carbapenemase-producing Enterobacteriaceae (CPE), extended spectrum beta-lactamase (ESBL) producers, MRSA, VRE, Clostridium difficile and Candida auris.This review is limited to the four types of WRD devices that are most frequently used in a hospital setting: aHP, HIn addition to a summary of the available literature concerning the efficacy of the four types of WRD devices, this review also describes and assesses the features and practicalities of each type. Data was collected via literature and through interviews with experts in hygiene and infection prevention, both within our unit as from other Dutch hospitals.For in situ efficacy, a distinction was made between environmental and clinical outcome measures. The environmental outcome measure was defined as the difference in the microbial contamination before and after disinfection with a WRD device, expressed in the number of positively tested sites or rooms, or the number of colony-forming units (CFUs) sampled in a patient room. This difference was converted to a percentage (increase or reduction in micro-organism). When both data regarding positive sites and rooms were reported in an article, data concerning positive sites were favoured as this information is more detailed. Only when no data concerning positive sites was available, data concerning the number of positive rooms was reported. The effect of disinfection as regarded in the studies performed for a certain micro-organism was summarized in a range of effect. In this range, data regarding the differences in the number of positive sites, rooms and CFUs were combined.The clinical outcome measures was defined as the difference between the pre- and post-implementation period patient infection rate. This difference was converted to a percentage of increase or reduction. Both the microbial colonization or acquisition infection rates and the clinical infection rates were included in the clinical outcome measure.The in vitro efficacy of the four WDR systems for the predefined micro-organisms was determined using a non-systematic literature search.A literature search was performed in the medical database PubMed in September 2021. After the initial search, it was discovered that the terms “patient” and “patient room” yielded relevant articles as well. A second literature search was carried out with an adjusted search string. The initial and second literature search are presented in Table 2O2 vapour, UV-C or PX-UV; (3) it was published between January 2000 and September 2021 in a medical scientific journal; (4) it was available in English language; (5) it reported at least one of the environmental or clinical outcome measures of interest; and (6) applied WRD devices as a solitary intervention. Articles describing infections with micro-organisms other than those previously predefined or articles that did not specify included micro-organisms and articles that studied the effect of a bundle of interventions instead of the solitary effect of WRD were excluded from this review. The preparation of a patient room by cleaning (and decontamination) prior to disinfection with WRD were not regarded as a bundle of interventions, as cleaning is a crucial preparational element of WRD.Articles were applicable for inclusion if (1) they focussed on the decontamination of a (patient) room after discharge of a patient with one of the predefined micro-organisms; (2) the automated room disinfection was performed using aHP, HData extracted from the included articles were: name of authors, year of publication, country in which the study was performed, setting (i.e. type of care institution in which the study was performed), study design, associated pathogen, type of WRD device and environmental or clinical outcome measure.For each of the four types of WRD devices, a detailed description of the features, practicalities, in vitro and in situ efficacy is provided.The initial search string yielded a total of 93 articles. After assessing these articles for eligibility, 73 articles were excluded. The main reasons for exclusion were having an incorrect outcome measure, an incorrect  setting or assessing in vitro instead of in situ efficacy. Through the assessment of references mentioned by the 20 eligible articles, another 20 relevant articles were included into the first literature search. A second search string yielded a total of 69 articles, of which 14 were eligible for inclusion. Based on the initial and second PubMed searches, a total of 54 articles regarding the in situ efficacy of WRD devices were included into the review. A flowchart of the article selection process is presented in Fig. There was a large variation between the included studies in methodology, reported outcome measures, preparation of the patient room prior to environmental sampling, the location of sampling within the room and the moment of sampling. This means that the findings were sometimes difficult to summarize. However, when the direction or magnitude of the effect was similar, outcomes have been combined when possible.In articles reporting environmental outcome measures, the sites that were sampled within a room also differed per study and varied from high-touch surfaces to other specific surfaces within a patient room such as medical equipment or furniture. Moreover, the preparation prior to sampling differs between studies. In most studies the patient room was cleaned before disinfection, however some studies implemented WRD systems in an uncleaned room. The reported timing of sampling also varied from sampling before cleaning and after disinfection to sampling after cleaning and after disinfection to a combination of this.Studies regarding clinical outcomes also varied in the reported outcome measures. The majority of the included articles reported the microbial colonization (or acquired) infection rate (n = 14). Others reported the clinical infection rate (n = 4) or did not specify the infection rate (n = 1).Additional file Aerosolized hydrogen peroxide (aHP) is a type of WRD in which a solution of 5–6% hydrogen peroxide is fogged into a patient room. During this process of fogging, a so-called ‘dry mist’ is formed which spreads through patient room and disinfects the contact surfaces . FollowiAutomated room disinfection with aerosolized hydrogen peroxide has several benefits and limitations affecting the in situ efficacy. A benefit of aHP is that it is user friendly. The machine consists of only one unit and is therefore easy to transport within a hospital. Preparations of the patient room include cleaning and enlarging of the contact area. Although manufacturers state that the sealing of vents and doors with tape is not necessary, sealing is recommended by literature to prevent leakage of HP, which makes the preparations more labour intensive . FurtherA limitation of aerosolized hydrogen peroxide is the duration of disinfection. Hydrogen peroxide is toxic and therefore no people are allowed in the room during disinfection. A room that is disinfected with hydrogen peroxide may be re-entered only if the concentration of hydrogen peroxide has declined to 1 parts per million (ppm). The so-called aeration phase, the time between the injection of hydrogen peroxide in a room and the moment the room can be re-entered, is the main reason for the lengthy cycle time. For a single patient room, the cycle time is approximately 2–3 h –16. MoreAcinetobacter respectively, and higher reductions for MRSA (> 4-log) and ESBL (> 6-log) [C. difficile shows a reduction of ~ 5-log [C. auris.Ten articles have been included to assess the in vitro efficacy of aHP regarding the preselected micro-organisms Table  12, 14,–23. For > 6-log) , 17, 21. ~ 5-log , 23. No For the assessment of in situ efficacy of aHP, nine articles have been included , 24–30.Acinetobacter, MRSA, VRE and C. difficile  reduction in hospital MRSA infection rate was observed after implementation of aHP following manual cleaning [Clinical efficacy of aHP was assessed for one study only Table . Herein,cleaning . There w2O2 vapour evaporate a 30–35% hydrogen peroxide solution into a (patient) room. The hydrogen peroxide is broken down to water and oxygen after exposure. This decomposition is often facilitated by a aeration unit which reduces the disinfection cycle time [Systems using Hcle time .2O2 vapour is its ability to disinfect difficult-to-reach areas. Moreover, due to heat-generated evaporation of hydrogen peroxide and the presence of multiple nozzles on the devices, the H2O2 vapour is homogenously distributed amongst the patient room [Similar to aHP, a benefit of Hent room .2O2 vapour systems often consist of multiple units and are less straightforward in use than aHP systems. Moreover, the preparations before disinfection are time-consuming and labour intensive. To prevent leakage of hydrogen peroxide, vents and entry doors must be sealed off. Disinfection with H2O2 vapour is time consuming. No people may remain in the room during disinfection and the patient room may only be re-entered if the concentration of hydrogen peroxide has declined under the health and safety exposure limit of 1 ppm. Due to the active aeration unit, the cycle time (the disinfection cycle excluding preparations) is somewhat shorter than that of aHP and is estimated at 1.5–2 h for a single patient room [Hent room , 31–41. 2O2 vapour has been shown to effectively reduce norovirus in in vitro settings, in which log reductions of > 4-log have been observed  emit a radiation with a wavelength of 254 nm. This radiation is constantly emitted during the disinfection cycle. This radiation disrupts the stability of nucleic acids, which is fatal for a cell due to consequences on metabolism and cell division , 56.A broad range of UV-C systems are currently offered on the market. A distinction can be made between stationary systems and moving systems. Stationary systems have to be moved within the patient rooms by an operator in-between disinfection cycles to disinfect all areas. On the contrary, more advanced systems move autonomously through a patient room.Automated room disinfection with ultraviolet radiation has several benefits and limitation. A benefit of disinfection with UV-C is the short disinfection time. In contrast with hydrogen peroxide, a room is immediately accessible after disinfection is complete as no aeration is needed. Disinfection of a single patient room with a stationary device is estimated at 50 min, while a moving robot takes 10–20 min , 58. TheA limitation of UV-C is that the efficacy of disinfection is reduced in areas that are out of the direct line of sight. UV-C is most effective when a micro-organism is directly exposed to the radiation. If a micro-organism is shaded from direct UV radiation, e.g. due to an obstruction or its inaccessible location, efficacy is limited . MoreoveC. difficile, a reduction of 2.5-log is observed under optimal, and a < 2-log reduction under suboptimal circumstances [C. auris, the optimal log reduction is > 5 and the suboptimal 3.3-log [UV-C elicits log reductions of ≥ 4 for all predefined bacteria under optimal conditions Table  58, 60––60–72. Emstances , 66–72.  3.3-log . No studUnder suboptimal circumstances, the investigated micro-organism is diluted in organic soil, the sample does not receive direct UV-C light, received UV-C radiation for only a limited time or is placed at a further distance from the device. The in vitro efficacy is expressed in log reduction.A total of 13 articles was published regarding the in situ efficacy of UV-C, of which 8 focused on environmental outcomes , 76–80 acinetobacter, a total reduction of 35.8–98% in microbial load was observed [C. difficile ranged from a 23.9–100% reduction [C. auris [C. auris had already been removed after the initial cleaning step, rendering additional disinfection unnecessary. No studies regarding the environmental decontamination were performed for norovirus, CPE and ESBL.Two studies reported CFU as the outcome measure, one study reported the number of positive rooms and five studies reported the number of positive sites. All articles concerning the environmental outcomes reported a reduction in microbial contamination after disinfection Table . For Aciobserved , 77. Theobserved , 77–79. observed , 76–78 teduction , 76–80. Acinetobacter and VRE, the total ranges of effect were similar to the significant ones and described respectively a 53.1–71.8% and a 0.3–33.8% reduction in infection rates. For CPE, the range of effect of all studies ran from a 7.5% increase to a 100% decrease [C. difficile ran from a 26.1% increase to a 46.2% decrease [C. auris.Large discrepancies between micro-organisms were observed in the assessment of clinical outcomes related to disinfection with UV-C Table . The randecrease , 83. Onldecrease . One studecrease . Lastly,decrease , 83–85. Pulsed xenon ultraviolet (PX-UV) also make use of ultraviolet radiation. As opposed to UV-C, which only emits radiation at a constant wavelength, PX-UV emits radiation of a broad spectrum of wavelengths (200–320 nm). This spectrum includes both UV-C, UV-B and UV-A radiation. Moreover, the radiation is not emitted continuously, but with short pulses , 86, 87.The benefits and limitations of PX-UV are similar to those of UV-C devices. Disinfection of a single patient room with PX-UV, including the manual repositioning of the stationary device, only takes approximately 12–20 min –97. MoreSimilar to UV-C, the main limitation of PX-UV is the limitation of its efficacy due to shading , 69, 88.Acinetobacter and ESBL-producing bacteria are very susceptible to PX-UV, log reductions of > 5 have been observed under optimal circumstances [C. difficile shows a log reduction of 1.8 under optimal conditions, and 0.7 under suboptimal circumstances [C. auris is solely investigated under optimal circumstances, being 0.04–1.19-log [There is considerable variety in efficacy of PX-UV between the predefined micro-organisms Table . Acinetomstances . On the mstances , 69, 88.mstances , 69, 88.1.19-log , 69, 88.A total of 20 articles were published regarding the in situ efficacy of PX-UV, of which 10 focused on environmental outcomes and 10 on clinical outcomes.C. difficile  cleaning. The added value of automated WRD lies in the enhancement of the quality of the terminal cleaning and disinfection process. In general, methods making use of UV are faster than methods making use of HP. After disinfection using UV, rooms are directly accessible. On the contrary, when disinfecting with HP, the concentration of HP first has to lower to 1 ppm before a room can be entered safely. Moreover, HP systems also require more preparations prior to disinfection which is labour intensive and time consuming. To prevent leakage of hydrogen peroxide, the rooms need to be sealed off from the external environment by shutting the doors with tape and covering the ventilation system. For UV, the main preparation is to enlarge the contact are and to decrease the shading area as much as possible. As a consequence, HP-based WRD systems may be less suitable for the standard disinfection in healthcare settings that have a high patient turnover, due to the greater duration of disinfection and preparations.2O2 vapour systems are superior to aHP systems in this matter as they reach a more homogenous distribution of HP. The applicability of a system may therefore also be determined by the need or urgency to disinfect every inch of a patient room thoroughly. This may for example be dependent on the pathogenicity of micro-organisms or its transmission route.In contrast to UV systems, HP systems are able to disinfect difficult-to-reach areas whilst UV-C systems are limited to exposed surfaces that are reached by UV radiation. HRegarding costs, devices making use of HP are less expensive in purchase than devices making use of UV radiation. However, user or operation costs are more expensive for HP devices as hydrogen peroxide tanks have to be replaced periodically whilst UV lamps only need changing once every few years; although the frequency depends on the intensity of usage.To summarize, the choice for the most suitable WRD device cannot be summarized in a one-size-fits-all approach as the most suitable option relates to hospital-specific requirements.Automated room disinfection must always be preceded by a  cleaning process. Both in vitro and in situ findings report that the effectiveness of WRD systems is limited in the presence of organic soil, such as blood or faeces , 88, 98.The importance of an improved cleaning and disinfection process, of which the replacement of manual disinfection by automated disinfection is an example, is highlighted by the current problem with antimicrobial resistance. The world health organization (WHO) has declared that antimicrobial resistance is one of the ten most pressing public health threats. The WHO stated that one of the factors contributing to the spread of microbes, of which some resistant to antimicrobial treatment, is inadequate infection prevention . By imprA main strength of this review is its systematic approach in reviewing literature. Moreover, it is presumed that this review is the first to give a simultaneous overview of both in situ and in vitro efficacy, as well as practical considerations of the WRD systems. Moreover, besides reporting solely the environmental outcomes, this review also gave insight into the effect of WRD systems on both environmental and clinical outcomes.The main limitation of this review is the substantial variation in methodology and outcome measures of the included studies. Moreover, the availability of data was also limited to only a section of the preselected micro-organisms. As a consequence, no specific conclusions can be made regarding the in situ efficacy of the WRD devices. Nonetheless, a general conclusion that can be drawn is that all ARD systems are effective in reducing the pathogenic load in a hospital setting. Another limitation of this review is that no distinction was made in the clinical outcome measure between microbial colonization (acquisition) infection rates and clinical infection rates. Stratification could not be performed as this would lead to a too limited number of articles. A final limitation of this review is that most included studies are performed in a high-income or resource countries. As the infection rates greatly vary between high and middle-to-low income countries, the results of this review might not directly relatable to low or middle income counties.Due to the variability in research methodologies of the included articles, this review can only generally conclude that all WRD systems are effective in a healthcare setting. It is however not possible to conclude what system is most effective in situ. As such data could influence the choice for the best fitting WRD device in a specific healthcare setting, we recommend the initiation of a study that directly compares the four types of WRD devices regarding their in situ efficacy. If such a study uses a standardized protocol assessing preferably both environmental and clinical outcome measures for all WRD devices and for a range of pathogens, it would be possible to compare the in situ efficacy of the different types of WRD devices. Moreover, we recommend to base the choice for the best fitting automated WRD device in a healthcare setting as much on other practical considerations, such as disinfection time and preparation of a patient room, as on efficacy or even more. These practical considerations will eventually determine how well a devices performs with a healthcare setting.2O2 vapour, UV-C and PX-UV) are effective in reducing the amount of pathogens present in a hospital environment. Due to the comparable in situ effectiveness of the WRD systems, the assessment of what WRD device is most suitable in a specific healthcare setting may mostly depend on practical considerations.In conclusion, despite the large variation in the included studies, all automated WRD systems  as expressed in environmental outcomes. Table S2. The in situ efficacy of aerosolized hydrogen peroxide (aHP) as expressed in clinical outcomes. Table S3. The in situ efficacy of H2O2 vapour as expressed in environmental outcomes. Table S4. The in situ efficacy of H2O2 vapour as expressed in clinical outcomes. Table S5. The in situ efficacy of ultraviolet C (UV-C) as expressed in environmental outcomes. Table S6. The in situ efficacy of ultraviolet C (UV-C) as expressed in clinical outcomes. Table S7. The in situ efficacy of pulsed xenon ultraviolet (PX-UV) as expressed in environmental outcomes. Table S8. The in situ efficacy of pulsed xenon ultraviolet (PX-UV) as expressed in clinical outcomes.


The prevalence of human papillomavirus (HPV) in the oral cavity and oropharynx has not yet been as well studied as its infection of the vaginal tract. However, new study are emerge after the development of molecular biology techniques. The objective of this study is to show the prevalence of HPV in the oral cavity and the oropharynx. An ample bibliographic review was done showing a prevalence of HPV 6, 11 in a normal oral mucous membrane (latent infection). In oral benign lesions associated with HPV, a prevalence of HPV 6 and 11 was observed in squamous cell papilloma (SCP) and condylomas acuminatum, while HPV 2 and 57 were more prevalent in verruca vulgaris lesions. As for focal epithelial hyperplasia (FEH) and oral cancer, especially squamous cell carcinoma (SCC), the prevalence was of HPV 13 and 32, and HPV 16, respectively. The last findings are, nonetheless, controversial. The last findings are, nonetheless, controversial. Showed also discrepancy result the prevalence of human papillomavírus (HPV) in normal oral mucous (latent infection) and in oral cancer, however evidenced confirmatory result in oral benign lesions associated with virus. HPV is the acronym used to identify the human papillomavirus, responsible for the condiloma acuminata (from the Greek term kondilus = round tumor and the Latin term acuminare = make it pointed)Human papillomavirus belong to a large family of viruses, the papovaviridae. They are small (about 55nm in diameter) and epitheliotropic. Their genome is made up of 7,200 - 8,000 base pairs with molecular weights of 5.2 x 106 Daltons. They have a capsule with 72 capsomeres of icosahedral structures, without lipoprotein envelope, and in a single circular double DNA moleculeHuman papillomavirus infections and its spread occur all over the world. HPV infect the skin and mucosas and might induce the formation of both benign and malignant tumors6. The infection starts when the virus penetrates the new host, through micro-injuries. The development of this incubation phase into active expression depends on three factors: cell permeability, virus type and the host’s immune statusHPV prevalence in the normal oral mucosa (latent infection) and its relation to oral cancer have generated conflicting opinions. The discrepancy observed is mainly attributed to a variation in the sensitivity of the methods employed and epidemiologic factors related to the group of patients examinedThe goal of the present study is to carry out a bibliographic review on the prevalence of human papillomavirus in the oral cavity and oropharynx through HPV detection methods, immunohistochemistry, in situ hybridization, Southern blot hybridization and polymerase chain reaction, checking the HPV types prevalent in the normal oral mucosa (latent infection), in benign oral and oropharynx lesions , and in oral cancer.A.Major criteria: classic coilocytes, perinuclear cytoplasmic halos and nuclear dysplasia.B.Minor criteria: dysceratocytes, atypical immature metaplasia, macrocyte and binucleation. This method bears limited sensitivity and does not type the HPVThe diagnosis of human papillomavirus in the oral mucosa may be suspected when one inspects the lesion, and also through cytology and biopsy. The cytological aspect of the HPV infection is characterized by:The methods used to detect the HPV DNA in lesions vary broadly as far as their sensitivity and specificity are concernedLow Sensitivity: immunohistochemistry and in situ hybridization - because they only detect the virus when it is present in more than 10 copies of the viral DNA per cell.Moderate Sensitivity: Southern blot, dot blot and reverse dot hybridizations, because they only detect the virus when present in 1 to 10 copies of the viral DNA per cell; and the High Sensitivity: PCR, because it detects the virus in less than 1 copy of the viral DNA per cellImmunohistochemistry may detect the protein coat of HPV viral particles which are present in the lesions seen under light microscopy in paraffin bearing material or in cytological preparations, and in these cases, polyclonal antibodies are used against different types of HPV specific antigensHybridization tests are currently the methods of choice to detect HPV DNA or RNA in smears or tissue samples. They are made directly or after DNA and RNA amplification through PCR. The basic principle behind these hybridization techniques is the double formation between the DNA single strand, RNA molecules or cloned HPV types, denaturated DNA derivatives and viral nucleic acid molecules present in the cell, which represents the hybridization test targetThe Southern blot hybridization is used in order to detect the HPV DNA from biopsies and is considered the “gold standard” to detect HPV genome. It is a sensitive and highly specific test, thus proving to be a valuable research tool, however it has no application in clinical routine tests because it takes longer and it requires harder workAnother recently developed hybridization method is the hybrid capture (HCA), which does not distinguish among the specific HPV types; and their applicability as a research method is limited, however it may represent a good test for routine clinical usePolymerase Chain Reaction (PCR) is a technique that has revolutionized virology, because of its extremely high sensitivityPCR detection of HPV is usually carried out through one of the consensus primers, the MY09-MY11 or the GP5/GP6HPV prevalence in the oral cavity and oropharynx is uncertain. Studies have shown dubious results, assessing a small number of patients and identifying some of the many HPV types found in mucosal lesionsSo far, over 100 types of HPV have been identifiedIn order to explain the HPV infection relationship with many oral lesions, it is important to investigate HPV prevalence in the normal oral mucosa.Papillomavirus in normal oral mucosa must be investigated throughout studies on oral cavity HPV infection natural history. Its prevalence in the normal oral mucosa is controversialIn the normal oral mucosa we have seen a great variation in HPV rates detected, from 22% to 60%Human papillomavirus prevalence in benign lesions .Oral and oropharynx squamous cells papilloma are benign tumors that occur mainly between 30 and 50 years of age, although they may also occur below 10 years of ageThey usually involve the soft palate, tongue, frenulun linguae and the lower lip. In most of the cases, the papillomas are single and small (<1cm)Oral condiloma acuminata is usually considered a sexually transmitted disease, acquired by oral sexual contact. Currently, the trend is to consider that the oral condiloma may be acquired not only by oral Sex, but also by self inoculation or as a result of maternal transmissionClinical and histological similarities between squamous cells papilloma, condiloma acuminata and verruca in the oral cavity are clearIn the genital tract, the terms papilloma and condiloma were used separately, until the year 1970; since then, both lesions are called condiloma. This modification may also be applied to oral lesions, because both the papilloma and the condiloma have the same HPV types found in genital condilomasThe human papillomavirus was detected in condilomatous oral lesions, initially by immunohistochemistry, and later by hybridization techniques, with a positiveness varying between 75% to 85% for HPV 6 and 11In 1991, Zeuss et al.The common wart is one of the most common skin lesions, specially in childrenMany authors showed the presence of the virus in oral warts by immunohistochemistry and hybridization tests. They observed a variation in the HPV detection rates from 43% to 100% in oral wartsHPV prevalence in oral warts seems to be HPV 2, followed by the HPV 57, although more studies are necessary to identify the broad spectrum oral infectiosn caused by skin HPV typesThe term focal epithelial hyperplasia (FEH), or Heck’s disease, introduced by Archard et al.It is a benign lesion that may be located in the oral mucosa, lips and tongue, and most notably in the lower lipViral etiology has been initially shown by immunohistochemistry and later on by hybridization techniques identifying HPV 13 and 32, which were detected in 75-100% of the casesHPV 13 and 32 were considered specific in focal epithelial hyperplasia, however, HPV 32 was also found in other oral lesions, but never outside the oral cavityThe studies and their results are depicted on Unfortunately, oral cancer still bears high mortality rates. Its incidence rate varies from one region to another, being high in India, Sri Lanka, Vietnam, Filipinas, Hong Kong and Taiwan, where about 30% of all the cancers occur in the oropharynx. India has approximately 56,000 new cases per year, and is probably among the highest incidence rates in the worldIt is a disease that affects patients in their 50th decade of life, being more evident between 60 and 70 years of age. Oral cancer includes malignant neoplasms in the lips, oral cavity and oropharynxThe most common location for oropharynx cancers, is the palatine tonsils. Notwithstanding, lingual cancer corresponds to 30% of theseCigarette smoking and alcohol are the main causes of oral cancer. They act in synergy and are a dose-dependentThe simultaneous presence of chemical agents and HPV infection in the oral mucosa may favor the malignant transformationSyrjänen et al.Many studies have shown HPV 16 to be the most prevalent type in oral cancer, as it happens in anogenital cancerIn a 2001 metanalysis, Miller & JohnstoneAccording to many studies, the HPV prevalence rate in oral cancer varied from 0-100%One of the greatest difficulties in identifying HPV in oral cancer patients is the presence of this virus in only one subpopulation of cells and the reduced number of copies of these cells which are infected. That is why we need high sensitivity detection methodsThe verrucous carcinoma was first described as a variant of the squamous cells carcinoma, which originates in the oral cavity.Also known as Ackerman’s tumor, its growth is exophytic, slow and invasive -only superficially, with a low metastasis rate, and it may be treated with simple excision. Many authors have reported the HPV presence in the verrucous carcinomaEncompasses about 95% of all the oral cancers. Its clinical aspects vary from a nodule up to a chronic ulcer. Many researchers have shown HPV present in SCCStudies have shown the important role of HPV in head and neck cancers, and also suggest that HPV 16 may be involved in the development of some oral carcinomasWe searched the MEDLINE database and textbooks, English and Portuguese medical literature, from January 1990 to December 2003, and found reports of HPV prevalence by virus detection methods (immunohistochemistry and molecular biology exams) in the normal oral mucosa, in virus-related benign lesions  and in oral cancer.In the MEDLINE database, we used the following keywords: detection, human papillomavirus oral, Polymerase Chain Reaction, human papillomavirus, oral cavity, normal oral cavity, oral lesions, papillary lesions, oral condiloma acuminata, oral warts, oral focal epithelial hyperplasia, oral cancer, squamous cell carcinomas, among others, they were used alone or in combination in the search.After we selected these scientific papers we included some relevant papers about oral HPV, published before the period established in the search string.HPV prevalence in the oral cavity and oropharynx is considered uncertain, because many studies have shown different results with the estimate of a small number of patients, and a modest identification among the different types of HPV found in mucosal lesionsHPV diagnosis in the oral mucosa and the oropharynx may be suspected by the clinical exam of the lesion, cytology and biopsy; however the molecular biology exams are the ones able to detect the HPV DNA in the cell, stressing the polymerase chain reaction as the most sensitive method to detect HPV. Notwithstanding, the assessment of different methods used to detect HPV16 is important and fundamental in order to establish the etiological role of HPV in oral lesions.Still It is probably due to the small number of samples used in the research and the very difficulty in detecting HPV in swabs and biopsy samples.Among the factors that generate controversy about HPV prevalence in the normal oral mucosa seen on The human papillomavirus infection in oral cavity and oropharynx benign lesions  in 25 results from 14 authors was of HPV 6 and 11, in papillomas and in condilomas, through the following methods: IHQ, ISH and PCR; in oral warts, the prevalence was of 2 and 57, by the IHQ, ISH, HSB and PCR methods, with HPV 2 dominance. The presence of HPV is clear in all cases, varying from 13% to 100% in positiveness, with its prevalent types, according to the lesion, regardless of the methods used. It is very likely that this happens because these lesions bear a larger number of cells with HPV DNA. We could also see a dominance of low risk HPV, specially HPV 6 and 11 justified because they are the types most frequently associated with oral benign papillomatosis lesionsStill in HPV 16 presence in oral cancer in many studies depicted in Other factors that contribute to increase HPV prevalence in the oral cavity and oropharynx are: a reduction in the patient’s immune response for the virusHPV 16 prevalence found in the oral cancer results  and the 1.Among the techniques used to diagnose HPV, the most sensitive is PCR;2.HPV prevalence in the normal oral mucosa presents discrepant results;3.HPV prevalence in virus-related benign lesions is confirmed;4.Despite HPV prevalence in oral cancer there still are controversies as to the virus presence and oral carcinogenesis;5.Thus, more studies are necessary in order to enhance the methods used to detect HPV DNA and the sample collection techniques (swabs or biopsies), aiming at having less result interference and greater clarifications about HPV infection and its prevalence in both the oral cavity and the oropharynx, and we are motivated to continue the HPV research, especially in the normal oral mucosa and in oral cancer.The literature analysis on the HPV prevalence in the oral cavity and oropharynx leads us to the following conclusions:


Recommendation of the vaccine by a health professional and fear of HPV-related diseases were the main facilitators. Lack of knowledge about the vaccine, lack of recommendation by a health professional, and fear of vaccine side effects were the main barriers. Conclusions: HPV vaccination coverage remains insufficient among patients with autoimmune disease. Education and awareness of health professionals about HPV infections are crucial elements in vaccine acceptance.Objectives: To describe human papillomavirus (HPV) vaccination practices in adolescent girls with systemic lupus erythematosus (SLE) and juvenile idiopathic arthritis (JIA) and to identify barriers to and motivators for vaccination. Methods: Cross-sectional, multicenter study on girls aged 9 to 19 years and their accompanying adults. The measurement criteria were the proportion of girls who were vaccinated against HPV, compliance with the vaccination schedule, factors associated with vaccination, and reasons for vaccination and non-vaccination through a self-administered questionnaire. Results: Seventy-one patients (16 with SLE and 55 with JIA) were included with a mean age of 13 years old (rank 11–18). According to parental questioning, 39% of patients were vaccinated against HPV or in progress . This rate was 82% for the 22 patients ≥ 15 years of age. The vaccine was administered as often by a general practitioner (39%) as by a hospital pediatrician . Two factors were significantly associated with vaccination: Older age (OR 53.68, 95% CI 5.85–429.29,  Human papillomavirus (HPV) infection is one of the most widespread sexually transmitted infections. HPV is the main causative agent in the development of precancerous and cancerous lesions of the cervix, mainly related to HPV 16 and 18  and rheuWe conducted a multicentric, cross-sectional study among young girls and their accompanying adults between January 2020 and July 2021 in 2 French tertiary centers: Hôpital Femme-Mère Enfant, Lyon (Auvergne Rhône-Alpes) and Hôpital Necker-Enfants-Malades, Paris (Ile-de France).All patients with a confirmed diagnosis of SLE or JIA, aged 9–19 years old, who presented for a follow-up visit at one of the participating centers accompanied by an adult were eligible to participate. The exclusion criteria were refusal to answer the questionnaire by the patient or her parent.The patient and her accompanying adult completed a self-questionnaire. The first part was completed by the girl, and the second part was completed by the accompanying adult. The questionnaire included closed- and open-ended questions. The items completed by the girl included demographic information  and HPV vaccination status. For the accompanying adult, the following information was collected: Demographic data , vaccination status for themselves against hepatitis B, and vaccination status for their child against HPV, pneumococcus, flu, meningococcus C, hepatitis B. Information regarding current pathology (JIA or SLE) and date of diagnosis was collected. Treatments received during follow-up were also collected and included hydroxychloroquine, nonsteroidal anti-inflammatory agents, corticoids, anti-interleukin 1, anti-interleukin 6, methotrexate, sulfasalazine, leflunomide, azathioprine, anti-TNF-alpha, CTLA-4, cyclosporine, mycophenolate mofetil, cyclophosphamide, rituximab, thalidomide, belimumab, or other (open-ended answer).For vaccinated patients, additional information was collected: Prescriber , type of vaccine , and numbers and dates of injections. The reasons for vaccination were collected from the patients and their parents through closed-ended items : Fear of HPV-related diseases, health care provider (HCP) or relative guidance on HPV vaccination, sensitization following a relative’s disease, no specific opinion, or other (open-ended).For unvaccinated patients, reasons for non-vaccination were collected from the girl and her accompanying adult. The following reasons were proposed : Lack of knowledge about the HPV vaccine, vaccine not proposed by a prescriber, concerns about potential side effects, uncertain opinion because the vaccine had been introduced too recently, perceived uselessness, perceived inefficiency, not recommended by a relative, not recommended by a HCP, price/refund difficulty, past bad experience with a vaccine, fear of a disease flare, vaccination planned later, or other (open-ended).Educational level was assessed based on the International Standard Classification of Education (ISCED) . RespondIf the mother was the accompanying adult, she was asked about cervical cancer prevention practices, including participation in cervical cancer screening and previous abnormal Pap smear results.All of the answered questionnaires were returned to the coordinating center (Lyon) for data recording and processing.The main outcome measure was the proportion of girls who received or were receiving HPV vaccination in the whole included population and in each age category . In the event of discordance between the girl’s answer and that of the accompanying person, the accompanying person’s answer was considered in the analysis. Other outcome measures were as follows: The proportion of vaccinated girls who complied with the vaccination schedule according to the standard vaccination schedule in France at the time of the study  18], th, th18], The study was approved by the Comité de Protection des Personnes du Sud-Ouest et Outre-Mer (3 July 2019) and was registered at clinicaltrials.gov (NCT04180228).p values (two-tailed) less than 5% were considered significant. Variables significantly associated with HPV status in univariate analyses were considered for multivariate modeling.Medians and the 1st and 3rd quartiles were reported for quantitative variables. Nonparametric Wilcoxon rank sum tests were performed to compare distributions of quantitative covariates between groups. Frequencies were reported for categorical variables. The associations between HPV vaccination status and exploratory covariates were analyzed by fitting unconditional logistic regression models. Odds ratios were presented with corresponding 95% confidence intervals (95% CI). Nested logistic regression linear models were compared using likelihood ratio tests. Fisher’s exact test was performed in the case of small numbers. For all statistical tests, The questionnaire was offered to 82 girls consulting at participating centers between January 2020 and July 2021. A total of 71 patients (16 SLE and 55 JIA patients) were included in the analysis. Flowchart of the study participants is presented in The main characteristics of the patients with completed data and their accompanying adults are detailed in A total of 26 ) patients declared that they had received HPV vaccinations. Twenty-eight accompanying adults ) reported that their daughter had been or was being vaccinated. Among SLE patients, 7 of 16 received vaccination (44%), and 21 of 55 JIA patients (38%) were vaccinated. The mean age at vaccination (first injection) was 13.6 years (SD 1.6). The age at first injection was unknown in 11 of 28 patients. Of the 17 remaining vaccinated patients, 12 (71%) received the first injection between 11 and 14 years of age, and 5 patients (29%) received the first injection after 15 years of age. Eighteen of the 29 girls aged 15 years old or older (62%) and 10 of the 41 girls aged 11–14 years old (24%) had been vaccinated.Among the 43 nonvaccinated patients, 14 (33%) parents were planning to vaccinate their daughters later.The characteristics of the 28 vaccinated patients  are detailed in The main reasons given by accompanying adults and girls for vaccination are described in The main justifications declared by the accompanying parents and their daughters for non-vaccination are described in p < 0.001), whereas the age of accompanying adults did not influence vaccination (p = 0.453). Vaccination was less frequent among girls attending the Lyon center than among girls attending the Parisien center . Vaccinated girls were significantly more likely to be vaccinated for hepatitis B , as were their parents . There was no association with other usual vaccines proposed for patients suffering from autoimmune conditions, such as flu, pneumococcus, or meningococcus C (p > 0.05). We did not observe any difference in the proportion of HPV vaccinations among lupus or JIA patients (p = 0.698). Multivariate analysis (p = 0.040), or when adjusted on clinical center . We did not find any associations of parental educational level, maternal gynecological history , duration of disease evolution, or immunosuppression level.A comparison between vaccinated and nonvaccinated patients and their accompanying adults is detailed in analysis  confirmeThe proportion of girls undergoing or having been vaccinated against HPV was 39% (95%CI 28–52%). Almost half of the lupus patients and more than one-third of the JIA patients were vaccinated. Among girls aged 15 years old and older (assumed to have been previously vaccinated), this proportion was 62%. In addition, 14 parents planned to vaccinate their daughters later. Factors associated with vaccination were older age and vaccination of the child for hepatitis B. Vaccination coverage varied by health center. Insufficient knowledge about the HPV vaccine, concerns about potential side effects, concerns about the novelty of the vaccine, and lack of proposition from an HCP were the main barriers to vaccination.The prevalence of HPV vaccination in girls with autoimmune conditions is insufficient but remains higher than that described in the French general population . HoweverWe assessed factors independently associated with HPV vaccination. We found a positive association with hepatitis B vaccination, as found elsewhere ,28. ThisThe main motivating factor for vaccination in our study was the recommendation of an HCP. Strong provider recommendation is also a key determinant of HPV vaccine uptake in the general population ,32. ThisReasons for parents’ reticence to vaccinate were similar to those described in other cohorts of immunocompromised or chronically ill children: Lack of knowledge about the vaccine , concernAt the time of the study, the nonvalent vaccine had been available for two years, which might explain why only 36% of patients in our cohort received this vaccine.It might be interesting to conduct this study on young women older than 19 years of age to assess the vaccination rate after catch-up. Similarly, since the generalization of vaccination in boys, this study could be extended to young men with chronic inflammatory diseases.The findings of this study must be seen in light of some limitations. The cross-sectional design limits the interpretation of the observed statistical associations in terms of causal presumption, while the small size of the study sample leads to low power of the statistical tests performed, limiting the interpretation of the non-significant results. Second, the use of questionnaires is associated with a possible memory bias. We could also discuss the representativeness of our population since all of the patients were followed in expert centers. However, adolescents and young adults with SLE or JIA are intended to be followed in such structures. Finally, although the girls were asked to complete the first questionnaire on their own, the influence of an accompanying adult on their responses, particularly regarding reasons for vaccination or non-vaccination, cannot be excluded.Overall, the vaccination coverage in our study is encouraging. Nevertheless, considering the potential high risk for cervical dysplasia, particularly for SLE patients, the coverage remains insufficient. The involvement of health professionals is essential to improve immunization coverage, and strategies should be implemented to provide more accessible information to patients and their parents.


Cutaneous warts are common lesions in children caused by the Human Papilloma Virus (HPV) and for most lesions spontaneously resolve within months of the initial infection, regardless of treatment. The infection is most prevalent in the second decade of life affecting over 40% of children. Studies have demonstrated wart virus carriage on normal skin is higher in children with active lesions and family members. Subtypes HPV 2, HPV 27, HPV 57 and HPV 63 are particularly common in paediatric populations. Warts arising on the plantar surface of the foot (verrucae) can be particularly problematic owing to the location. They may interfere with daily activities causing pain and embarrassment. Plantar lesions have been shown to be more resistant to treatment than warts elsewhere on the skin. Systematic reviews and studies conducted over the last decade have demonstrated little evidence of innovation or effective improvements in treatment of recalcitrant lesions over the last 30 years. However, newer modalities such as immunotherapy (using injected vaccines) and hyperthermia using microwave treatment may hold promise in improving the treatment of these common and therapeutically frustrating lesions. Warts and verrucae are benign growths occurring in the skin and mucous membranes due to infection with various strains of the Human Papilloma Virus (HPV). Depending on their location and morphology they may be referred to as common, plane, flat, plantar or genital warts. This paper aims to review recent evidence from published reviews and other research regarding cutaneous  warts in children with a specific focus, where possible, on plantar lesions (verrucae).The cutaneous manifestations of HPV infection are cutaneous warts and verrucae, which have been shown to be unusual before the age of 4  but mostCutaneous warts are caused by small DNA viruses which have adapted to infect the skin and mucosal surfaces. Over 450 species have been identified amongst the five genera of the HPV viruses  , based oFew studies have investigated the most common HPV sub-types responsible for causing cutaneous warts. Researchers in the Netherlands selected 31 children aged 10–12 years) from three schools who were medically diagnosed with warts on the hands and feet. Skin swabs taken from their lesions and samples were analysed for the presence of HPV DNA using a polymerase chain reaction (PCR) test assay capable of being detected in 23 known HPV types. In total HPV was detected in 92% of warts. In 40 plantar lesions, the most common sub-types were HPV 2, HPV 27, HPV 57 and HPV 63 . A small number demonstrated multiple HPV strains within the same lesion –12 years. Tomson The diagnosis of warts is predominantly clinical, visual analysis of the lesion being the most common method, particularly as the cost of genotyping using polymerase chain reaction (PCR) precludes its use in regular day-to-day practice in many countries. In children, there are few differential diagnoses that may mimic plantar warts. A study undertook development of a visual assessment tool to assist clinicians in the identification of cutaneous warts. The CWARTS tool  was deveIn recent years, the use of dermoscopy has increased in the assessment and recognition of skin lesions. Dermatoscopic evaluation of the visual features of warts has been undertaken. Observable reported features in warts include the presence of dots and globules—these can be red, brown or black in colour and probably represent dilated capillaries . These cIt is well established that cutaneous warts and verrucae may undergo spontaneous regression—the underlying mechanisms responsible for this are not fully understood however several observational studies of warts in children have reported spontaneous clearance. A follow up study of 364 children aged eleven with warts discovered only 7% had them by the age of sixteen—demonstrating a 93% regression rate . A DutchIn the last ten years there have been several systematic reviews undertaken investigating wart treatments and outcomes. Some have focused exclusively on plantar lesions ,21,22; oIn 2014, a published systematic review  examinedSystematic reviews of the treatment of warts in children specifically are lacking. Warts in children are known to regress more quickly than in adults, which may give different efficacy rates to adults. In addition, younger patients may be less tolerant of painful interventions limiting the available treatment options. In 2020, a review of topical treatments for cutaneous warts in children was published , reviewiA recent systematic review focused exclusively on studies reporting treatments for plantar warts. The authors only included studies which had 100 or more subjects . A totalA systematic review published in 2022  reviewedAnother study, published earlier in 2020, systematically reviewed topical treatments for plantar warts including patients of all ages . The autAs the above reviews have highlighted, intralesional treatment for paediatric warts may have a place as a third line treatment for more resistant lesions, particularly for the less responsive plantar warts. For natural clearance of warts, it is generally accepted that cell mediated immunity is required. Immunity is facilitated through both innate and adaptive pathways within the skin. Intralesional immunotherapies increase host cell ability to recognise and eradicate HPV infection by facilitating cell mediated immunity. One review qualitatively evaluated studies which included the use of Candida antigen, the Mumps-Measles-Rubella vaccine (MMR), Tuberculin or Bacillus Calmette-Guerin (BCG) as a an intralesional injection. A total of 20 studies were identified (which included adult data). Complete resolution rates ranged from 39–88% for candida, 26–92% for MMR, 23.3–94.4% PPD and 33.3–39.7% for BCG. One study did show higher clearance rates in its younger patients (MMR and PPD). Local side effects for these treatments include injection pain or burning sensation or blistering whilst use of these agents have caused oedema, fever and myalgia in some cases. ®) which is active against HPV strains 6, 11, 16 and 18 [The HPV vaccine has been available for several years to protect against oncogenic strains of the HPV responsible for the majority of genital and anal cancers. Case reports have been published reporting cutaneous wart clearance following vaccination with the quadrivalent vaccine (Gardasil6 and 18 ,28. Foll6 and 18 . They re6 and 18 .The HPV vaccine has been available for several years to protect against oncogenic strains of the HPV responsible for the majority of genital and anal cancers. Although previous authors have remarked on the scant progress in efficacy for wart treatments in the last few decades, with a lack of new treatments ,30, new Clinically, the use of hyperthermia by way of a microwave device has shown benefit in the treatment of plantar warts. In the laboratory a study of the effects of the microwave device on skin explants showed increased antigen presenting cell activity and presentation to CD8+ T cells and increased γ-interferon release . A cliniCutaneous warts affect a significant number of children with limited evidence of effective treatment in this patient group. The most recent systematic reviews report little change in the last 20 years in the evidence base, with topical treatments such as salicylic acid and cryotherapy being the most studied. These show moderate effectiveness in paediatric and adult populations. Newer treatment modalities such as injection or immunotherapies and microwave heating show promise but further robust research is required to ensure effectiveness in this population group.


The present study aimed to evaluate the association of genital and oral HPV infection among different sexual practices in both sexes. In total, 6388 unvaccinated men and women aged 16–25 years from all state capitals of Brazil were enrolled in through primary care services between September 2016 and November 2017. Genital and oral HPV genotyping was performed using the Roche Linear Array. Poisson regression analysis with robust variance was conducted to examine factors associated with overall HPV infection. A higher prevalence of genital HPV was found in women who practiced oral sex (57.85%) and in men who practiced all types of sex (65.87%). However, having more sexual partners and being younger were more important than the type of sex practiced. HPV 6 (7.1%) and 16 (10.5%) were significantly more prevalent in women who practiced oral sex, while HPV 6 (23.96%) and 11 (21.49%) were more prevalent in men who practiced anal sex. The type of sex was not associated with oral HPV prevalence. Genital and oral HPV infection were not associated by different sexual practices in the studied population. The probability of acquiring HPV during one’s life has been estimated to be 84.6% for women and 91.3% for men2. While 90% of these infections are cleared within two years, mainly as a result of cell-mediated immune responses directed against early HPV proteins3, some types of the genus Alphapapillomavirus  can cause anogenital cancers4.Human Papillomavirus (HPV) infection is considered a risk factor for cancer in different sites of the body, such as the cervix, penis, vulva, and oropharynx6. For this reason, horizontal transmission occurs mainly through the sexual act—sexual penetration or intimate genital contact7—although it may also occur through kissing8 or hand-to-genital contact 9. The probability of HPV transmission per sex act seems to be around 40% (range 5–100%)10. Multiple HPV genotype infections are common, and genotype-specific concordance of HPV 6, 11, 16, and 18 was 25.5% in a meta-analysis focusing on 30 studies and 2972 couples11.These alpha-HPV infect mainly the basal epithelial cells of the anogenital mucosa via microabrasions in the epithelial lining12. In addition, a higher transmission rate of genital HPV seems to occur from women-to-men than men-to-women contacts, as shown by a systematic review and meta-analysis that synthesized data of 752 heterosexual couples13. However, many gaps still exist in our understanding of HPV transmission between different sites of the body, such as whether mouth-genitalia transmission is different from genitalia-genitalia transmission or whether different virus types have preferences for specific sites14.Transmission of HPV to the oral cavity and the consequent risk of oropharyngeal cancer is increased in women with cervical infection and in their partners, suggesting possible transmission between the oral cavity and the genitals15. The authors concluded that autoinoculation is a possible mechanism15. Both the presence of the virus in these two anatomic sites and the lack of viral concordance in some people could be due to genetic predisposition, conditions of altered immune response, host defense, or local cellular factors15.There are also other possible non-sexual transmission routes. Men who have sex with women with prior genital HPV infections also had a higher risk of a subsequent type-specific anal infection independent of sexual intercourse with female partners7. However, understanding the transmission dynamics of HPV and identifying different behaviors associated with an increased risk of HPV infection in the young population is of pivotal importance to promote adequate planning of public policies. Such findings may help health care providers to better counsel patients on safe sex practices and promote sexual health.The determinants of exposure to HPV seem to be similar to those for most sexually transmitted infections19, few studies have assessed the role of different sexual practices in HPV infection, especially in both men and women from the same underlying population20. Therefore, the present study aimed to evaluate the association of genital and oral HPV infection based on different sexual practices in both sexes.Although the overall prevalence of both genital and oral sites are well described in the Brazilian populationWe analyzed data from unvaccinated participants in the POP-Brazil study, a cross-sectional study with sexually active women and men aged 16–25 years from 26 Brazilian state capitals and the Federal District. Exclusion criteria were pregnancy, history of hysterectomy or trachelectomy, and history of cervical intraepithelial neoplasia grade 2 or higher.The participants were recruited in primary care services using different approaches such as personal invitations during routine healthcare visits and home visits, as well as outreach using patient lists and local media, between September 2016 and November 2017.This study was approved by the Ethics Committee of Hospital Moinhos de Vento (no. 1607032) and the committees from the collaborator’s centers. All study participants provided written consent after being informed about the study procedures.All participants answered face-to-face interviews with questions about sociodemographic factors, alcohol and drug use, sexual behaviors, and lifetime history of STIs.21. For analysis, social classes were grouped into three categories: A-B, C, and D-E. This social class structure reflects a monthly household income of R$768 (US$ 202) for classes D-E, R$2165 (US$ 569) for class C, and R$11,664 (US$ 3069) for classes A-B21.The demographic and socioeconomic variables investigated were sex , age (< 22 and ≥ 22 years), self-reported skin color , educational level  and marital status . Socioeconomic class was analyzed using the Brazilian Criteria of Economic Classification, a system for the Brazilian public that divides the market exclusively in terms of economic class based on the ownership of assets and the education level of the householderParticipants were asked about their use of contraceptive methods, lifetime condom use and condom use in the first and last sexual intercourse, as well as alcohol and drug use and smoking. They were also asked about sex after drug use, condom use after alcohol and drug use, presence of sexually transmitted infections throughout life , age at first intercourse, number of sexual partners in the last year, same-sex relationships  and types of sexual practices . For the sexual practices variable, we asked participants, “When you have sex, what happens?” and questioned them about different practices during sex.22), and positive for quadrivalent HPV vaccine types .Genital HPV infection was classified as multiple infection (more than one HPV type), high-risk HPV  using magnetic beads for isolation and purification on a robotic system , according to the manufacturer’s extraction instructions23. The DNA concentration in the extract was determined using the NanoDrop 2000 (Thermo Scientific™). HPV genotyping was performed using the Roche Linear Array® (LA) genotyping test, which amplifies a 450 bp fragment in the L1 gene23. Per reaction, 25 µl working master mix was combined with DNA extract (between 100 and 150 ng) diluted in 25 µl of ultrapure DNase/RNase-Free water23. Polymerase chain reaction cycling conditions and hybridization were performed as recommended by the manufacturer. Probes could detect 37 types of HPV simultaneously. The assay incorporates β-globin as an internal control for sample amplification23.Oral samples were obtained through mouthwash and gargle cycles, using 10 mL of a standardized commercial mouthwash. The samples were collected from 3 cycles of 5 s each into a Falcon tube identified with a five-digit number bar code and the date of collection19.The sample size was defined to detect an HPV prevalence of at least 30% with an 80% power. It was calculated according to sex and took into account the study design. Sample size was purposely equal in all regions to maximize diversity in less populated areasA descriptive analysis was performed using means and confidence intervals for continuous variables and absolute frequencies for categorical data. The differences between the means were assessed with the t-test, and the chi-squared test was used to evaluate the differences between categorical variables.The prevalence of oral and genital HPV infection; infection with more than one type of HPV; high-risk HPV; HPV from quadrivalent vaccine; and HPV 6, 11, 16, and 18 separately were assessed according to the type of sex practiced, stratified by biological sex , and described with their respective 95% confidence intervals (95% CI).24.Poisson regression with robust variance analysis was conducted to examine factors associated with HPV infection, adjusting for confounders. For the multivariate analyses, a theoretical framework was structured discriminating hierarchical blocks: type of sex practices (Model 1), gender and age (Model 2), number of sex partners in the last year (Model 3), and same-sex relationships (Model 4). The hierarchical model is an available alternative in epidemiological studies with a large number of covariatesp < 0.05.To adjust the distribution of the sample to the study population, we used a weight adjustment for population size for each capital and by sex. Therefore, all results are reported as weighted. Analyses were performed by using SAS software , version 9.4, and statistical significance was defined as All procedures performed in studies involving human participants were in accordance with the ethical standards of the Moinhos de Vento Hospital research board  and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.Overall, 6,388 individuals were included (63.6% women). About 27.1% reported having exclusively vaginal intercourse, 49.7% reported having vaginal and/or oral intercourse, 2.8% reported having vaginal and/or anal intercourse, and 20.4% reported having all types of sex. Most participants were brown/mixed color (56.9%), followed by white (23.2%). The mean age of first sexual intercourse was 15.3 years (95% CI 15.2–15.4) and most participants were dating (39.8%) or married/living with a partner (36.5%).p = 0.0032) than women (Table p < 0.0001) and all types of sex .Men reported practicing more of all types of sex  and high-risk HPV prevalence  (data not shown).In total, 27.41% of 4,761 unvaccinated women reported having anal sex. No significant differences between those who practiced or did not practice anal sex were found between genital HPV  or vaginal sex  but was not significantly different between types of sex among each biological sex (Table p = 0.0397). Among men, overall HPV (65.87%) and multiple infection (39.34%) prevalence were significantly higher in those who practiced all types of sex.The prevalence of any type of cervical HPV and 4vHPV types was significantly higher for women who practiced oral sex and all types of sex. HR-HPV was higher in women than men who practiced oral  and 16 (10.5%) than those who practiced vaginal (4.1% and 8.0%), anal (3.5% and 1.9%), or all types of sex. On the other hand, men who practiced anal sex had significantly higher prevalence of HPV 6 (23.96%) and 11 (21.49%) : 2.08% among those who practiced exclusively vaginal sex, 2.04% for those who practiced oral sex, 0.64% for those who practiced anal sex, and 2.28% all types of sex. Furthermore, 47 individuals  had both oral and genital HPV infection (data not shown).Among oral samples from 4313 participants, only 0.06% and 0.10% were positive for HPV 16 and HPV 18, respectively. There was no significant difference in the prevalence of oral HPV by type of sex  than men. This may be because the susceptibility to infection varies with the epithelium. HPV infections are believed to occur following wounding of epithelium or mucosa and subsequent access of virus to basal epithelial cells. Natural transmission of cutaneous infections likely involves physical contact, allowing virus to be shed into the wounded site, or occurs following mechanical wounding during sexual intercourse for vaginal and anal infections27, no association was found between oral HPV and any particular sexual practice. The low prevalence may be one of the reasons for the lack of association. Even so, it is noteworthy that the number of lifetime sexual partners may be more relevant than the type of sexual practice28. Gester et al. evaluated unprotected sex and passive oral sex, and the prevalence of oral HPV was no longer apparent after adjustments29.As in previous studies7, but instead due to pathogenic differences. The HITCH cohort study, which enrolled young women (18–24 years old) and their male partners of over 4 months, indicated that HPV16/18 did not have particularly high transmission rates relative to other HPV types30. In the present study, only genital HPV 11 was significantly more common in those who practiced anal sex, which is interesting since this HPV type can cause anogenital lesions, and the risk for anal HPV infection in individuals with previous genital HPV seems to be higher than in individuals without an infection31.Besides a significant difference in transmission between the sexes, some studies also suggest selective transmission of different HPV types. HPV 16 could be the most readily transmitted type, not because of its intrinsic transmissibility32, while oral sex was more common among those who had more partners in the last year and those who had a history of consuming alcohol and drugs. Contrarily, heterosexual couples who reported always using condoms had lower HPV transmission rates30. Additionally, condom use in the last intercourse was significantly more frequent in those who reported exclusively vaginal sex, which may explain the lower prevalence of HPV in this group.This study confirmed findings from previous studies’ that showed the practice of anal sex was associated with certain behaviors, such as current smoking and having sex with partners of the same sex33. On the other hand, receptive anal sex is strongly associated with HPV detection in the anal canal in men who have sex with men (MSM)34. Nyitray et al. (2016) showed that persistence of high-risk anal HPV is associated with the number of male anal sex partners and inversely associated with the number of female sex partners34. The impact of vaccination in men goes beyond protecting the female population and directly benefits men themselves, as they showed a high prevalence of HPV vaccine types in the present study35. Since nearly 90% of anal cancers have been estimated to be caused by HPV36 and HPV 16 is the most carcinogenic type in the anus, vaccination could help prevent anal cancer in this population37. A systematic review and meta-analysis found that overall prevalence of anal, penile, and oral HPV infection among men who have sex with men were 78.4%, 36.2%, and 15.4%, respectively, with higher rates in HIV-positive than HIV-negative MSM. The most frequent HPV high-risk type detected in the anus, penis, and oral cavity was HPV 16 38.It is known that vaccination of sexually active women reduces transmission of different HPV types in heterosexual couples39, the awareness of HPV-associated cancers has increased. Nevertheless, many people might have doubts and anxieties regarding HPV transmission40. Clinicians and public health workers should be able to inform the public on the modes of transmission and prevention strategies.Knowledge about the roles of different sexual practices in HPV infection as well as the most prevalent HPV types is important to inform policy not only in Brazil but globally. Since the HPV vaccine and HPV testing are becoming widely implemented in many countries for cervical cancer screeningDespite the importance of this study, some limitations should be noted. The types of sexual practices were always categorized including vaginal sex, because we did not have enough data evaluating exclusive oral and anal intercourse. The practice of oral sex may have been reported as either “doing” or “receiving.” It is worth mentioning that the prevalence of anal HPV was not analyzed. In addition, a cross-sectional study could reflect transmission in previous or concurrent relationships. Further studies with larger sample sizes and with both sexual partners are needed to investigate the transmission modes for specific HPV types.Given the high prevalence of HPV in Brazilian young adults, it is important to assess how the virus can be transmitted. Few studies have assessed the presence of HPV infection at different anatomic sites simultaneously. The present study tries to elucidate this topic by assessing HPV prevalence according to sexual practice. The type of sex practiced was not significantly associated with cervical or oral HPV infection. While this study offers new information on the prevalence of genital and oral HPV infection, other analyses should be developed assessing the relationship between HPV infection in different sites of body and sexual practices in the population.


The HPV prevalence observed shows an increased transmission of the virus in Lagos, Nigeria. Therefore, there is a need for intense public awareness and the implementation of early detection tests, treatment, and vaccination to prevent an increase in cervical cancer cases in Lagos, Nigeria.Regional variations exist in HPV prevalence worldwide despite reports of high prevalence rates among African women. Limited data on genital HPV prevalence necessitated this study with the aim of determining the prevalence of genital HPV and associated risk factors among women in Lagos, Nigeria. Exfoliated cervical cells were collected with consent from 165 women using a cervical brush. Viral DNA was extracted and amplified by nested PCR using two sets of consensus primers (MY09/11 and GP5+/6+). An unconditional logistic regression model was used to identify predictors of HPV positivity. The HPV prevalence was 81.82% in all women and 87.59% in women with normal cytology. The risk of HPV infection was significantly increased among women who had a history of STI (odds ratio (OR) 3.94; 95% confidence interval (CI): 1.51–10.25,  Genital human papillomavirus (HPV) infections with a global prevalence of about 11–12% have been ranked as one of the most common viral agents of sexually transmitted infections worldwide [The estimated prevalence of HPV in different regions of the world differs. Compared to other regions of the world, the highest prevalence of 22.1% is reported in Africa . There aIn Nigeria, HPV prevalence has been reported to vary in different parts of the country. It ranges from 10.0% in Irun, Ondo State to 21.6% in Ile-Ife, Osun State and 26.3% in Ibadan, Oyo State ,15,16. PSome risk factors that have been linked to the increased prevalence of HPV infection include early onset of sexual activity, sexual promiscuity, an increasing number of lifetime sexual partners, and poor hygienic conditions ,20. ReseThis is a hospital-based cross-sectional study carried out among women who visited the gynecology clinic of the Lagos University Teaching Hospital (LUTH), Idi-araba, Lagos between July 2017 and June 2018. LUTH is a foremost federal-government-owned tertiary health institution in Lagos that offers specialty and subspecialty care including gynecological oncology services such as Papanicolaou (Pap) tests, human papillomavirus (HPV) testing, and colposcopy for cervical cancer screenings. The hospital acts mainly as a referral center for other government-owned and private hospitals in Lagos State. Lagos State is the commercial hub of Nigeria which has a population of almost 20 million inhabitants.A total of 180 participants were recruited into the study out of which only 15 participants did not give their written informed consent. A total of 165 consecutively consenting, sexually active women aged 18 years and above with or without cervical cytological abnormalities were enrolled in the study during their routine cervical cancer screening (Pap smear) at the gynecology and cytology clinics of the hospital. Women with ongoing pregnancy or within 6 months of childbirth, those who had undergone treatment for benign or malignant lesions of the cervix, those who were physically or mentally unable to give consent or undergo an interview, and those with a current cervical cancer diagnosis or on anticancer therapy were excluded from participation in the study. Interviewers used questionnaires to collect data on sociodemographic, sexual, and clinical data with confirmation of details from participants’ clinic records. All participants’ data were anonymized throughout the study.A cervical brush was used to collect samples of exfoliated cervical cells from the cervical os of all the study participants after inserting a Cusco’s speculum into the vagina to expose the cervix. The cervical brush was then inserted into a liquid-based cytology medium  and vortexed to dislodge the cells into the medium. Exfoliated cervical cells were prepared from the liquid-based medium according to the kit manufacturer’s guide for the Papanicolaou test . The smears were made at two points on prelabelled glass slides and allowed to dry. The slides were delivered to the cytopathology laboratory in the Department of Morbid Anatomy and Histopathology, Lagos University Teaching Hospital for staining and microscopic examination. A 2 mL aliquot of the cervical cells in the liquid-based medium was transported on ice to the virology laboratory of the Central Research Laboratories, University of Ilorin and stored at −20 °C until DNA extraction and HPV studies were carried out.Genomic DNA was extracted from each of the samples collected using a commercially available DNA extraction kit  according to the manufacturer’s instructions. The consensus region of HPV DNA was amplified by nested PCR using primers targeting the L1 gene region (one forward primer (MY09) and reverse primer (MY11) for the first amplification and one forward primer (GP5+) and reverse primer (GP6+) for the nested amplification). The cycling conditions for nPCR were preceded by an initial denaturation of 95 °C for 9 min, followed by 40 amplification cycles of 95 °C for 30 s, while annealing was for 2 min each at 50 °C and 45 °C, respectively, for the first and nested round of amplifications with an extension at 72 °C for 1 min 30 s and a final extension at 72 °C for 4 min. The size of the PCR products that were generated with MY09/11 and GP5+/6+ were 450bp and 150bp, respectively, as described by Hammou et al. . The ampp values of <0.05 considered as statistically significant. Multivariate logistic regression analysis was not used because there were not enough variables that were significant in the bivariate analysis.Data were double entered into Microsoft Excel 2016  for cleaning and imported into IBM SPSS statistic version 21 software  for analysis. Data analyses were performed using IBM SPSS statistic version 21 software for Windows. The chi-square test was used to determine differences between young (≤30 years) and middle-aged women (>30 years), and a one-sided probability of <0.05 was considered statistically significant. Bivariate logistic regression was used to identify factors associated with HPV positivity, with The approval to conduct this study was obtained from the Health Research Ethics Committee of the Lagos University Teaching Hospital (ADM/DCST/HREC/APP/1603). Informed consent was obtained from each potential participant before inclusion in this study. The ethical principles of the Declaration of Helsinki were observed throughout the study.The age of study participants ranged from 18 to 65 years with a mean age of 41.38 ± 8.1 years. The median age of participants was 40  years. The majority of participants were within the age group of 25–54 years (83.0%), which consists more of married women (76.4%) and in a monogamous marriage (94.4%). There was greater representation among those who had tertiary education (77%) while only 2.4% had no formal education. Alcohol use was recorded among 19.4% of the participants.The age of participants at first sexual experience ranged from 11 to 49 years with a mean age of 20.4 ± 3.3 years. It was observed that the majority of the women had their sexual debut at or below 16 years of age (38.8%) compared to those who had sexual initiation at ≥21 years (30.9%). There were more participants who had between two and four sexual contacts than those who had five or more sexual contacts.2 = 1.213; p-value = 0.271). Forty samples were HPV DNA positive (24.2%) using the MY09/11 primers, while one hundred and twenty-six samples (76.4%) were positive for HPV DNA when GP5+/6+ primers were used in a nested PCR (nPCR). A total of thirty-two samples (19.4%) were positive for both MY09/11 and GP5+/6+ consensus primers with an amplicon size of 450bp and 150bp, respectively.Of the 165 cervical samples of participants screened for HPV in the study population, the prevalence of HPV was 81.82% (135/165) in all women and 87.59% (113/129) in women with normal cytology. The prevalence of HPV among women ≤ 30 years was 90.47% (19/21), while the prevalence among women > 30 years was 80.56% (116/144)  results is depicted in The relationship between HPV positivity and clinical characteristics variables is shown in 2 =1.213; p-value = 0.271). Reports exist on the prevalence of HPV in Nigeria among different populations. In Lagos, HPV prevalence rates of 30.4%, 36.5%, and 37.5% have been reported, which is lower than the prevalence obtained in this study [This study reported the prevalence of HPV in Lagos to be 81.82% among all participants in the study population and 87.59% among women without abnormal lesions in their cervix. This study has one of the highest prevalence rates reported from any part of Nigeria. This implies that less than 20% of sexually active women in Lagos, Nigeria have not been exposed to the virus already; therefore, the implementation of control measures and vaccination to mitigate the continuous spread of HPV among the younger women should be prioritized. The prevalence of HPV among young women (≤30 years) was higher when compared with middle-aged women (>30 years) in this study, although the difference was not statistically significant (χis study ,18,25. Ois study ; 26.3% iis study ; 37% in is study .Reports from a meta-analysis of HPV among Nigerian women that reviewed 17 studies in six geopolitical zones of the country reported a prevalence of 29% among studies that detected HPV [The prevalence obtained in this study was higher than in other communities in sub-Saharan Africa where similar population groups were considered. In rural Ethiopia, Leyh-Bannurah et al.  reportedThe disparity in this study when compared with other studies may be because this study was conducted among women who were present for cervical cancer screening at a tertiary health facility in Lagos, and it is presumed that many of the patients were referred by healthcare workers following complaints of symptoms suggestive of either genital tract infection or cervical cancer. Moreover, the result obtained in other studies may be due to the sensitivity of the HPV assay used; existing variations in the different study populations due to varying risk exposures based on diverse sociocultural and geographical differences; and coinfection with HIV.The HPV prevalence figure of 97.2% among HIV-infected individuals reported by Sahasrabuddhe, Mwanahamuntu, Vermund, Huh, Lyon, Stringer, and Parham  in ZambiThis study found the highest prevalence rate in the age group of 18–44 years, though there was a similarity in HPV prevalence across all age groups. There was a decline in the likelihood of HPV infection in the age group of 25–34 years when compared to women aged 35–44 years in this study. This may be related to the sexual transmission and initiation of sexual activity of women in this age group. However, a high prevalence of HPV was found among women above 55 years old. This may reflect cumulative lifetime exposure and immune system vulnerability to the persistence or reactivation of latent infection [There was a relationship between marital status and HPV infection in this study. Women who were either separated or unmarried were more prone to HPV infection in this study. This is understandable because it has been postulated that these groups tend to date new partners which puts them at an increased risk of HPV infection. The study by Nejo et al.  reportedIn the current study, there was a higher risk of exposure to HPV among women who had their first sexual experience around the age of 21 years, which is an indication that the late onset of sexual activity does not limit the risk of HPV infection later in life. It is believed that most young women have their first sexual experience during adolescence, although that was not observed in this study. Moreover, based on findings in this study, there was an increased likelihood of HPV infection among those who had their first pregnancy between the ages of 17 and 24 years. Other studies have also reported that early sexual debut and childbirth at an early age could increase the likelihood of HPV infection. This present study found that only childbirth at an early age could be relied on as a representation of the onset of sexual activity among women in our study environment because it is conceivable that some women may have underreported the age of sexual debut ,35.There was an increased risk of HPV infection when there were more than four lifetime sexual partners. On the other hand, a significant reduction in HPV infection risk was observed when condoms were used by women in this study. This further emphasizes the importance of the use of condoms as a means of protection during sexual intercourse to prevent sexually transmitted infections such as HPV. This is similar to the findings of Veldhuijzen et al.  who repoOn consideration of some past clinical history, it was observed that those who had a history of STI or genital warts and those who had used hormonal contraceptives had a greater likelihood of infection with HPV. This result agrees with the findings of Clarke et al.  who repoThe high prevalence of HPV reported in this study is a pointer to the fact that there is an increased transmission of HPV among sexually active women in Lagos, Nigeria. There were associations with risk factors, such as young age, marital status, alcohol use, a higher number of lifetime sexual partners, and a history of genital warts, identified in this study. Significant associations were observed in this study among women who had a history of STI, those who had their first pregnancy around the age of 25 years, and those who used condoms. Therefore, there is a need for educating the public about HPV testing, vaccination, and early detection tests for cancer prevention in Lagos, Nigeria.