Gulf War Illness (GWI) is a chronic, multisymptom  condition estimated to affect 25–32% of Gulf War (GW) veterans. Longitudinal studies suggest that few veterans with GWI have recovered over time and that deployed GW veterans may be at increased risks for age-related conditions.We performed a retrospective cohort study to examine the current health status of 703 GW veterans who participated in research studies at the San Francisco VA Health Care System (SFVAHCS) between 2002 and 2018. We used the Veterans Affairs Frailty Index (VA-FI) as a proxy measure of current health and compared the VA-FIs of GW veterans to a group of randomly selected age- and sex-matched, non-GW veterans. We also examined GW veterans’ VA-FIs as a function of different GWI case definitions and in relationship to deployment-related experiences and exposures.p < 0.01). However, the subset of GW veterans who met criteria for severe Chronic Multisymptom Illness (CMI) at the time of the SFVAHCS studies had the highest VA-FI . GW veterans who had Kansas GWI exclusionary conditions had higher VA-FI  than veterans who were Kansas GWI cases (0.08 ± 0.08) and controls  at the time of the SFVAHCS research studies. The VA-FI was positively correlated with several GW deployment-related exposures, including the frequency of wearing flea collars.Compared to matched, non-GW veterans, GW veterans had lower VA-FIs (0.10 ± 0.10 vs. 0.12 ± 0.11, Although GW veterans, as a group, were less frail than non-GW veterans, the subset of GW veterans who met criteria for severe CDC CMI and/or who had Kansas GWI exclusionary conditions at the time of the SFVAHCS research studies were frailest at index date. This suggests that many ongoing studies of GWI that use the Kansas GWI criteria may not be capturing the group of GW veterans who are most at risk for adverse chronic health outcomes. After the Gulf War (GW) ended, many soldiers returned home with a multitude of unexplained symptoms  . Gulf WaOver the years, the cross-sectional studies that have examined GW veterans’ post-deployment health status have reported higher rates of chronic multisymptom illnesses such as fibromyalgia , chronicThe first aim of this study was to examine the current health status of GW veterans who previously participated in research studies at the San Francisco VA Health Care System (SFVAHCS). We used the Veterans Affairs Frailty Index (VA-FI)  as a proIn the absence of diagnostic tests and validated case definitions for GWI, researchers have relied upon different criteria to study the chronic multisymptom condition. In 2013, the VA contracted with the Institute of Medicine (IOM), now the National Academy of Medicine (NAM), to develop a single case definition for GWI. However, the IOM/NAM panel was unable to do this due to limitations with the data that was available at the time . InsteadMany GW veterans were exposed to a myriad of chemicals during deployment . Some ofTo our knowledge, this is the first study to use the VA Frailty Index to examine GW veterans’ vulnerability to poor health outcomes. It has been suggested that deployed GW veterans may be aging more rapidly than their civilian counterparts . For thi2.All study procedures were approved by institutional review boards (IRB) at the University of California, San Francisco and the San Francisco VA Health Care System (SFVAHCS). Informed consent was obtained from all GW veterans who participated in the original research studies at the SFVAHCS. A waiver for consent was obtained for the retrospective cohort analysis because some of the study participants had died or were no longer receiving care through VHA when the analyses were performed.We performed a retrospective cohort analysis of 703 GW veterans who participated in research studies related to GWI and GW-related exposures at SFVAHCS between 2002 to 2018. Electronic health records (EHR) and VA health care encounter diagnostic codes were identified for 602 of the 703 past GW veteran study participants in the VA’s corporate data warehouse (CDW).International Classification of Diseases (ICD) diagnosis and procedure codes, Current Procedural Terminology (CPT), and Healthcare Common Procedure Coding System (HCPCS) codes for the GW veteran study participants from tables in CDW on an index date (04/05/2023). Smoking status was determined from the most recent clinical assessments of tobacco use prior to the index date.The VHA is an integrated health care system that captures and stores claims and health care data in a centralized national database . The VA-Structured data in CDW and from the Death Ascertainment File indicated that 44 of the former SFVAHCS GW veteran participants were deceased at the index date. We calculated the VA-FI for the 588 GW veteran participants who were alive at an index date. The VA-FI was calculated as the proportion out of 31 equally weighted deficits incurred by the patient . These dnot on the DMDC list. We extracted ICD-10, CPT, and HCPCS codes from the CDW for non-GW veterans on the same index date.To compare GW with non-GW veterans, we randomly selected 558 veterans from CDW who were matched in age and gender to the living GW veteran participants of SFVAHCS research studies. Because Congress never repealed the Authorization for Use of Military Force after the Gulf War ended in February 1991 , any mil2.1.Chronic Multisymptom Illness (CMI) by the Center for Disease Control (CDC) criteria  was dete2.2.The Kansas GWI case definition requires veterans to have moderately severe or multiple chronic symptoms in at least three of six categories: fatigue/sleep problems, pain, neurological/cognitive/mood symptoms, respiratory complaints, gastrointestinal problems or skin symptoms . The Kan2.3.In March of 1991, U.S. troops detonated a munitions storage pit at Khamisiyah, Iraq that was later found to contain stockpiles of sarin and cyclosarin . The plu2.4.We used the Kansas Gulf War and Health Questionnaire  to ascer2.5.ρ = 0.13 to 0.58), which suggests the potential for confounding error when evaluating exposure associations individually. Therefore, in post-hoc analyses, we examined the relationship between deployment-related exposures and VA-FI with a backward-step linear regression model. Potentially confounding variables  were also entered into the regression model with the deployment-related exposures that were significantly correlated with VA-FI. p values < 0.05 were considered significant. All analyses were performed using IBM SPSS Statistics (Version 29.0).Mean values of continuous variables were compared using Wilcoxon rank sum test or the Kruskal-Wallis test. Proportional comparisons between veteran subgroups were assessed using chi- square tests. Spearman’s rank order correlation was used to examine the associations between VA-FI and deployment-related experiences and exposures. Previous reports indicate that many of the GW deployment-related exposures are highly intercorrelated . We also3.3.1.Z = 2.34, p = 0.02) and had more years of formal education . There was marginally more veterans of “other” races among veterans in with EHR CDW than those not in CDW . More activity duty military personnel had EHR in CDW while more reservists did not have EHR in CDW .We located the EHR of 602 of the 703 former research study participants in CDW. Compared to veterans with EHR in CDW, veterans who were not in CDW were older at the index date . The average interval between the time of study participation and the index date was greater in living veterans compared to average interval between the time study participation and death among deceased GW veterans (Z = −3.71 p < 0.001). A larger proportion of veterans who were deceased at the index date had been in the Reserves during the GW . A larger proportion of veterans who were deceased at the index date had been excluded from the original SFVAHCS research studies . Forty-four of the 602 past study participants with EHR in CDW were deceased at the index date. Compared to veterans who were alive at the index date, the veterans who had passed away were older at the time of the SFVAHCS research studies (3.2.p = 0.001): Veterans who were excluded from research had higher VA-FIs (0.15 ± 0.11) than veterans who were included (0.09 ± 0.01) and veterans who withdrew from the research studies (0.09 ± 0.09). There was a significant effect of study participation on VA-FI category . Fewer veterans who had been excluded from research were non-frail (40%) compared to veterans who had been included (65%) and veterans who withdrew (66%) from the research studies. At the same time, more veterans who had been excluded from research were mildly frail (21%) compared to veterans who had been included (8%) and veterans who withdrew (7%) from the research studies.Although all veterans initially signed informed consent forms to participate in research activities at the SFVAHCS, not all veterans were included in the studies. Some veterans were excluded because they did not meet all of the parent research studies’ inclusion criteria. Other veterans withdrew from the research studies after signing consents. There was a significant effect of study participation on VA-FI . However, there were more current smokers among non-GW than GW veterans . When we re-ran the analysis and stratified by smoking status, the difference in VA-FI was only marginally significant in non-smokers  and insignificant in smokers . More GW than non-GW veterans had VA-FIs in the non-frail category (63% vs. 56%) and there was a trend for more non-GW than GW veterans to have VA-FIs in the severely frail category (3% vs. 1%). When we stratified the analysis by smoking status, there were no significant differences in VA-FI categories between GW and non-GW veterans among smokers and non-smokers.There was a marginal effect of group on VA-FI category , coronary artery disease , cerebrovascular disease , diabetes , hypertension , peripheral vascular disease , and weight loss . When we limited the analyses to current non-smokers, only differences in rates of diabetes  and hypertension  remained significantly different between GW and non-GW veterans.The prevalence of individual VA-FI deficits in GW and non-GW veterans is presented in 3.4.Z = −2.49, p = 0.01) despite there being a shorter time interval between study participation and index date among CMI cases than controls . Controls had more years of formal education compared to CMI cases .Z = 4.17, p < 0.001): Veterans who met CMI criteria at the time of the SFVAHCS studies had higher VA-FI (0.10 ± 0.01) than controls . Compared to controls, fewer CMI cases had VA-FIs in the non-frail category (59% vs. 76%) while more CMI cases had VA-FIs in the pre-frail (28% vs. 15%).There was a significant effect of CMI case status on VA-FI (p < 0.001): Controls had the lowest VA-FI (0.07 ± 0.9), mild–moderate CMI cases had intermediate VA-FI (0.10 ± 0.10), while severe CMI cases had the highest VA-FI (0.13 ± 0.10). See χ2 = 26.67, df = 12, p = 0.009). Fewer severe CMI cases had VA-FIs in the non-frail category (43%) compared to controls (76%) and mild–moderate CMI cases (62%). More severe CMI cases had VA-FIs in the pre-frail category (39%) compared to controls (15%) and mild–moderate CMI cases (26%).CMI can be categorized as “severe” if the veteran rates each defining symptom as severe or “mild moderate” for milder complaints. Of the 287 CMI cases, 49 met criteria for severe CMI cases while the remaining 248 were mild–moderate CMI cases. There was a significant effect of CMI category on VA-FI , chronic pain , dementia , depression , lung disease , and peripheral neuropathy . There were trends of higher rates of hypertension , liver disease , and thyroid disease  between CMI cases and controls , 106 veterans met Kansas GWI criteria (4 were deceased at the index date), while 60 were controls.p = 0.002) because GWI excludes were older than GWI cases. There was also a group effect on the interval between study participation and the index date . There was a group effect on race on  because more controls were White while more GWI excludes were Black and other races. Fewer controls met CDC CMI criteria  while no controls met severe CMI criteria .p < 0.001): Controls had the lowest VA-FI (0.04 ± 0.6), Kansas GWI cases had intermediate VA-FI (0.08 ± 0.08), while Kansas GWI excludes had the highest VA-FI . There was a significant effect of GWI case status on VA-FI category : More controls were non-frail, more GWI cases and GWI excludes were pre-frail, and more GWI excludes were moderately frail.There was a significant effect of Kansas GWI case status on VA-FI , anxiety , arthritis , coronary artery disease , chronic pain , depression , diabetes , gait abnormality , hypertension , kidney disease , liver disease , peripheral neuropathy , and perivascular disease . There were marginal differences in rates of atrial fibrillation , use of durable medical equipment , and osteoporosis .Examination of VA-FI individual deficits revealed significant differences in anemia , using powdered pesticides on the skin, , wearing flea collars , and seeing living areas sprayed or fogged with pesticides  were significantly associated with VA-FI. Coming into contact with fresh chemical agent resistant coating (CARC) paint was marginally associated with VA-FI .R2 = 0.16, F6,158 = 5.07, p < 0.001). The final variables remaining in the model, that were significantly associated with VA-FI were Kansas GWI case status , wearing flea collar , and seeing living area sprayed or fogged with pesticides .Because there was high degree of correlation and interrelationships among deployment-related exposures (data not shown), in post-hoc analyses, we used a backward stepwise linear regression model to examine the relationship between deployment-related exposures and VA-FI. The regression model was significant  than age- and sex-matched non-GW veterans. This finding was somewhat unexpected given previous reports of higher rates of chronic multisymptom illness, neurological, and other disorders in GW veterans compared to other veteran control groups e.g., . HoweverBecause the two veteran groups were matched on age, it is likely a majority of the “non-GW” veterans are veterans of the U.S. wars in Afghanistan  and Iraq . However, we could not verify this in VA records because all military personnel who served on active duty from August 2, 1990 to present are considered Gulf War veterans. This is because Congress never repealed the Authorization for Use of Military Force after the Gulf War ended in February 1991 .If, in fact, most of the “non-GW” veterans were OEF/OIF/OND veterans, one reason why this group of veterans had higher VA-FI than GW veterans may be due to traumatic brain injuries (TBI), the “signature injury” of the U.S. wars in Iraq and Afghanistan . It is wAnother unexpected finding of this study is that rates of fatigue and chronic pain, two hallmark symptoms of GWI, were not higher in GW veterans compared to non-GW veterans at index date. However, not all of the GW veterans in the cohort had CMI/GWI at the time of the SFVHACS research studies. When we examined subgroups of GW veterans, we found differences in rates of chronic pain between controls and CDC CMI cases and between controls and Kansas GWI. Because the GW veterans were originally queried about their CMI/GWI symptoms 5–21 years prior to the index date, this suggests the veterans’ CMI/GWI symptoms of pain have not changed much over time. In contrast, rates of fatigue were not significantly different between controls and CMI cases or between controls and Kansas GWI cases. This suggests that, unlike pain, the veterans’ CMI/GWI symptoms of fatigue have likely changed or evolved over time.Not all of the GW veterans in the retrospective cohort actually participated in research studies at the SFVAHCS. Some veterans were excluded because they did not meet the original studies’ inclusion criteria. Other veterans changed their minds and withdrew from the studies. Results indicate that veterans who were excluded from the original research studies had higher VA-FIs than veterans who were included and veterans who withdrew. This is not unexpected considering that the original SFVAHCS research studies’ exclusionary criteria included contraindications for MRI , severe physical impairment, psychiatric disorders with psychotic features, history of neurologic or systemic illnesses that affect central nervous system function, and/or moderate to severe traumatic brain injury. In fact, significantly more veterans who had been excluded from the original SFVAHCS research study were deceased at the index date compared to veterans who were included or who withdrew from SFVAHCS research studies.There was a significant effect of CMI status on VA-FI: Veterans who met CDC CMI criteria at the time of the SFVAHCS studies had higher VA-FIs  at the index date than controls . Examination of individual VA-FI deficits revealed higher rates of anxiety, chronic pain, depression, lung disease, peripheral neuropathy, and dementia in CMI cases compared to controls. Considering that the mean age of the GW veteran cohort was 62 years at the index date, it is concerning that there was a higher rate of dementia (9.8% vs. 0.7%) among CMI cases compared to controls. We have previously reported a higher-than-expected rate of mild cognitive impairment , consideAs with CDC CMI, there was a significant effect of Kansas GWI case status on VA-FI. As one might expect, GWI cases had higher VA-FIs than controls. However, veterans who were excluded from being considered as GWI cases because of medical and/or psychiatric conditions  had even higher VA-FIs than GWI cases. When we examined individual VA-FI deficits, veterans who were excluded from being considered as GWI cases had higher rates of anemia, arthritis, coronary artery disease, depression, diabetes, hypertension, kidney disease, liver disease, peripheral neuropathy, and perivascular disease. This is not surprising because many of these conditions were likely what prevented these veterans from being considered as Kansas GWI cases at the time of the SFVAHCS studies. However, many of these conditions are also related to aging or may be accelerated by aging. Therefore, it is possible that not all of these medical conditions were pre-existing at the time of the SFVAHCS studies.Several deployment-related experiences and exposures were significantly and positively correlated with VA-FI. These include hearing chemical alarms sound , using powdered pesticides, wearing flea collars, seeing ones’ living area sprayed or fogged with pesticides, and coming into contact with chemical agent resistant coating paint. Notably, most of these deployment-related experiences and exposures contain neurotoxins, particularly organophosphates. Previous studies have reported that many of the exposures associated with GW deployment are highly intercorrelated . In lineIt is noteworthy that  previousThis study had some limitations that warrant discussion. First, the cohort included only GW veterans who enrolled in research studies at the SFVAHCS and whose EHR were located in the VA’s CDW. This may limit the generalizability of these findings to the larger population of GW veterans. Presumably, the veterans whose EHR we were unable to locate in CDW were not utilizers of VA healthcare services. This may further limit the generalizability of these findings because it has been reported that VA users are more likely to have multiple medical conditions, endorse a disability, and score lower on measures of functioning than non-VA users . Another5.We evaluated GW veterans’ vulnerability to poor health outcomes using the frailty index as a proxy measure conclusion. Our results suggest that GW veterans, as a group, are not frailer  than non-GW veterans who use VA healthcare. However, GW veterans who met criteria for severe CMI and who had Kansas GWI exclusionary conditions 5–21 years ago were significantly more frail than other GW veterans and non-GW veterans. We also found that GW veterans who met CDC CMI criteria had higher rates of dementia than control GW veterans. Thus, it may be prudent to counsel GW veterans with CMI to adopt lifestyle changes that have been associated with lowering dementia risk. The veteran subgroup with the highest VA-FI were GW veterans who had Kansas GWI exclusionary conditions. This suggests that research and treatment studies that employ the Kansas GWI case definition may be overlooking the subgroup of GW veterans who are most vulnerable to poor health outcomes.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving humans were approved by University of California, San Francisco Institutional Review Board. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.LC designed the experiment, analyzed the data, drafted the manuscript, contributed to the article, and approved the submitted version.This study was supported by grant from the U.S. Department of Veterans Affairs (No. CX000798-05 and IK6CX002522).The author declares that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Introduction: Cervical cancer remains the second leading cause of death among women in Cameroon despite the new strategies put in place. This study was conducted in order to determine the prevalence of precancerous cervical lesions and its associated factors in Douala (Cameroon).Methods: A cross-sectional study was conducted over a period of nine months in two hospitals of the city of Douala, Cameroon . Cervico-vaginal and endocervical samples were taken from women attending the above-mentioned hospitals in order to identify and characterize precancerous lesions by cytological examination and to genotype for human papillomavirus (HPV) using the Abbott RealTime High-Risk (HR) HPV kit. Data of sociodemographic characteristics, clinical history, and knowledge about cervical cancer were collected using a questionnaire.P=0.01), age, and school level. Moreover, the occurrence of precancerous lesions was positively associated with the participants' level of knowledge (P=0.01).Results: Of the 196 women included in this study, 17% had precancerous lesions, including 1.53% for atypical glandular cells (AGC), 4.53% for atypical squamous cells (ASC), 4.53% for low-grade squamous intraepithelial lesion (LSIL), 5.61% for high-grade squamous intraepithelial lesion (HSIL), 0.51% for atypical squamous cells of undetermined significance (ASC-US), and 0.51% for atypical squamous cells cannot exclude HSIL (ASC-H). In addition, the prevalence of HPV infection was 18%, of which 2% was for HPV 16, 2% for HPV 18, and 14% for undetermined HPV. A positive association was recorded between the occurrence of precancerous lesions and HPV infection (Discussion: Precancerous lesions were predominantly HSIL, and the factor most associated with these lesions was HPV infection.Conclusion: This study demonstrates that diagnosis is made at a relatively late stage due to a low level of knowledge about cervical cancer in the population. Cervical cancer is the result of the excessive and uncontrolled proliferation of the cervical cells of the cervix. It is secondary to a persistent infection by the human papillomavirus (HPV) , which iThe aim of this research was to determine the prevalence of precancerous cervical lesions and associated factors at the Laquintinie Hospital and Gyneco-Obstetric and Pediatric Hospital in the city of Douala, Cameroon. A large number of cases from all social groups and classes use the facilities of the hospitals mentioned above, making them suitable for the study.Participants and study procedureThe study was carried out at the Laquintinie Hospital and Douala Gyneco-Obstetric and Pediatric Hospital in Douala over a period of nine months. Our sample size was 329 women to be recruited using the non-probability exhaustive sampling method. Thus, any women presenting to the clinical biology and anatomopathology laboratories of these facilities was included in our study population. However, in terms of selection criteria, women aged 18 and over who were sexually active and consented to take part in the study were included. Women who had undergone partial or total hysterectomy were excluded.Cervical Specimen Collection and CytologyCervical samples were collected using standard gynecological procedures. Briefly, two exfoliated cervical cell specimens were collected for HPV DNA genotyping assays and liquid-based cytological diagnosis, with a cytobrush and an Ayres spatula. Sample slides were prepared using a liquid-based cytology , New Jersey, USA) method, and slides were read and interpreted according to the Bethesda 2001 classification: (i) normal cases may include reactive change due to inflammation, fungal infection, and atrophy; and (ii) cytological cases of squamous cell carcinoma (SCC), high-grade squamous intraepithelial lesion (H-SIL), atypical squamous cells (ASC) cannot exclude H-SIL (ASC-H), a low-grade squamous intraepithelial lesion (L-SIL), and typical squamous cells of undetermined significance (ASC-US).DNA Extraction and GenotypingGenotyping was based on the detection of the viral genome and the determination of the different HR-HPV types. This test was performed in the virology laboratory of the International Reference Centre Chantal Biya (CIRCB), and the method used was real-time polymerase chain reaction (PCR) using the Abbott RealTime HR HPV kit . At the time of testing, 600 µL of each sample was aliquoted and transferred to haemolysis tubes. The Abbott RealTime HR HPV kit uses the m2000sp instrument  for DNA extraction and the Abbott m2000rt instrument for HPV amplification and detection.A primer mix consisting of 3 sense and 2 anti-sense primers targeting a conserved L1 region was used to amplify HPV targets. The signal for 14 HR-HPV genotypes  was generated using fluorescently labelled probes. Internal control amplicons  were generated using a primer pair targeting an endogenous human β-globin sequence and were detected using the internal control specific probe. Probes for HPV 16, HPV 18, non-HPV 16/18 (other HR-HPV), and internal control genotypes were labelled with a different fluorochrome, allowing their signals to be recognized in a single reaction.Determination of Factors Associated With Precancerous LesionsA questionnaire was made available to the women included in the study to collect information on sociodemographic data, gynecological history, and knowledge of cervical cancer. The answers provided allowed us to determine the etiology of precancerous lesions.Data AnalysisThe survey forms were tabulated, analyzed, and processed. A chi-square test was used to compare frequencies, and P<0.05 was considered statistically significant. All statistical calculations were performed using SphinxPlus.V5.Tuite  and Microsoft Excel 2013 .Ethical approvalQualified women for the study were informed on the reason, detailed information, and procedures associated to the study. Only women willing to join the study and to sign the information consent form were included. All procedures were approved by the Institutional Ethics Committee of the University of Douala, Cameroon, through authorization N° 2501 CEI-Udo/07/2021/M and the Ethics Committee of Gyneco-Obstetric and Pediatric Hospital in the city of Douala through authorization N° 2021/0065/HGOPED/DG/CEI. All information was treated with strict confidentiality.Sociodemographic characteristicsOf the 340 women pre-selected for the study, 196 signed the inform consent. Seven were excluded due to unsuitable sample slides, and 189 women were included. As presented in Table Characterization of precancerous lesions and HPV genotypingThe distribution of precancerous lesions Table  in this The study on the HPV type distribution presented predominance of negative women (82%). Among the 18% women infected with HPV, 2% were infected with genotype 16, while 16.2% were infected with genotype 18, and the remaining 14% were infected with genotypes other than 16 and 18 , is alarming, considering the fact that this study has been carried on “healthy” women in two of the biggest hospitals in Douala. This prevalence could be a faithful representation of this city. The predominance of high-grade lesions (5.61%) can be explained by the lack of early diagnosis and treatment; indeed, most of the participants were undergoing this examination for the very first time, with low-grade lesions found to have already evolved into high-grade lesions. Comparable findings were also reported in previous studies in Cameroun, with incidence of precancerous lesions around 7.9% ,12. SurpHowever, 89% of the 189 women surveyed said that they had heard of cervical cancer, against the 23-39% in earlier studies performed in densely populated areas of other regions of the country, including in the Centre Region , South WLimitationsIt is worth mentioning that the current study has some limitations, including its limited sample size, which may not be adequate to represent the entirety of the region. Moreover, not all types of HPV encountered by the participants during the study were characterized and were classified under the heading "others."Overall, the results of this study, which aimed to determine the prevalence of precancerous lesions and associated factors, show that the population's lack of knowledge about cervical cancer is a major cause of delayed diagnosis, hence signifying the need to intensify awareness-raising efforts. Although most of the women were in the age range required for cervical cancer screening, they had never been tested in the past. This was mainly due to a lack of information about cervical cancer, leading to the development of HSIL. The main factor associated with these lesions in the women who were included in the study was HPV infection.


Atypical Squamous Cells for which a high-grade lesion cannot be excluded (ASC-H) were identified primarily in women with positive HC2 (6.1%). HR-HPV positivity was substantially more associated with low-grade ASC-US or low-grade squamous intraepithelial lesion (LSIL) and high-grade ASC-H cytology . Unmarried women  and women with multiple partners  were more likely to have an HPV infection when compared to married women and those with fewer sexual partners. Conclusions: Understanding the epidemiology of HPV genital infections is essential for developing preventive measures against this infection and CC. Identifying the most prevalent HPV types, and determining the incidence of HPV oncogenic infections, in conjunction with Pap test results and sexual behavior information, can constitute part of an algorithm for the efficient management of cervical intraepithelial lesions.Background: Human papillomavirus (HPV) infection is the major cause of cervical cancer (CC); hence, it is critical to understand the processes by which HPV infection causes squamous intraepithelial lesions, as well as the proper diagnostic tools. The objective of this study was to establish the correlations between Pap test results and Hybrid Capture 2 (HC2) tests findings. Materials and methods: This study included 169 women between the ages of 30 and 64, who presented for consultation in gynecological clinics in both the public and the private sectors. These women reported symptoms, such as abnormal vaginal discharge and genital irritation, as well as early onset of sexual activity, multiple sexual partners, history of other sexually transmitted infections or high-risk sexual partners, immunosuppression, or tobacco smoking. Pap tests and HPV testing, using the HC2 method, were performed for the women enrolled in the study, including data gathered after patients completed questionnaires concerning their sexual behavior. Results: The HC2 method revealed that 66 patients (39.1%) tested positive for high-risk HPV types. Of the patients with positive results, 14 (21.2%) presented Atypical Squamous Cells of Undetermined Significance (ASC-US) compared to 10 (9.7%) patients in the negative group ( Human papillomavirus (HPV) infection, the known cause of cervical cancer (CC), represents a subject of major interest in the medical literature. CC is the second-most-prevalent gynecological cancer worldwide. Almost all cervical precancerous lesions are caused by a chronic HPV high-risk oncogenic infection ,2,3.So far, more than 200 HPV types have been identified , 15 of tIt is estimated that nearly 80% of women will have an HPV infection throughout life, with an HPV oncogenic type causing 50–75% of those infections. Yet, more than 90% of cases are self-limited and will be gone in one or two years , with juEfficient identification of women with high-grade intraepithelial neoplasia (CIN3) during regular CC screening is a critical public health concern. Data available in the literature suggest that cervical cytology has a sensitivity that varies between 47% and 62%, with a specificity of 60% to 95% in detecting moderate and severe cervical dysplasia. In comparison to cytology, HPV genotyping by polymerase chain reaction (PCR) has a higher sensitivity but a significantly lower specificity, particularly in younger women [The association between CC and HPV infection led to the development of different methods of cervical screening, especially HPV genotyping (DNA testing), used for identifying high-risk strains . The disHybrid Capture 2 (HC2) HPV-DNA reaction determines the HPV strains, this being a triage test used to separate the cases of low-grade cervical dysplasia into two groups: high risk and low risk for developing CC . The HC2Although women in Romania have access to CC screening and HPV vaccination, this country has the highest burden of deaths caused by CC in Europe. When compared to the average mortality rate in Europe due to CC of 3.4/%000, the rate of 10.83/%000 in Romania is alarming and highlights the need for intervention ,18.The objective of this study is to identify a correlation between the results obtained after a Pap test and those after HC2, a method used to determine high-risk HPV types, less known and used in Romania, associating, at the same time, this information with data extracted from questionnaires, as well as data regarding sexual behavior and history.The selection of patients was carried out over a period of 18 months (2021–2022), and according to the inclusion and exclusion criteria, the selection was performed in three gynecological clinics (two from the public sector and one from the private sector), where the patients presented for gynecological consultation.Inclusion criteria: women between the ages of 30 and 64, currently or previously sexually active, asymptomatic or with symptoms, such as abnormal vaginal discharge and genital inflammation, or with risk factors, such as the early onset of sexual activity, high-risk sexual partners, multiple sexual partners, history of other sexually transmitted infections, immunosuppression, and cigarette smoking.Exclusion criteria: women under 30 years and over 64 years old, with a history of hysterectomy, with invasive surgical procedures in the genital sphere 12 months before, pregnant, or postpartum women.A group of 200 eligible women was formed based on the budget allocated for this study for individual Pap tests and HPV genotype detection using the HC2 reaction. After excluding those who did not fill out the medical questionnaire, in the end, the study was carried out on 169 patients.Patients included in this study gave their informed consent and were given information regarding the study protocol, which comprised cytological sample and biological collection, Pap test, and HPV genotype detection, using the HC2 reaction, results, etc.The women filled out a short medical questionnaire and received the results and details about their health status by telephone. The results and all data were confidential. After selecting the patients, the gynecologist took cervical samples with a cervical brush using a liquid medium, using one sample for the Pap test and one for the HPV test, using the HC2 method. Following collection, cervical samples were stored at a temperature ranging from 2 °C to 8 °C, before being transported and processed by a pathologist. Following the examination of the cytological specimen using the Babeș–Papanicolaou testing method, the pathologist provided two sets of information, one related to premalignant/dysplastic and malignant lesions, being the cytopathological examination, and the second one referring to the microorganisms that can be identified by the method. Thus, the gynecologist can decide on HPV testing and colposcopy with biopsy addressed to the first category of lesions, while also deciding on antibiotic/anti-inflammatory treatment for infections.Using the Bethesda system, the classification for cervicovaginal lesions was as follows: negative for intraepithelial lesions or malignancy (NILM), atypical squamous cells of undetermined significance (ASC-US), atypical squamous cells for which a high-grade lesion cannot be excluded (ASC-H), low-grade squamous intraepithelial lesion (LSIL), and high-grade squamous intraepithelial lesion (H-SIL). ASC-US describes an abnormal histological aspect of squamous cells, which usually indicates inflammation, reactive and reparatory alterations, or a precancerous lesion caused by persistent HPV infection. ASC-H describes the same abnormality, but the pathologist cannot exclude a high-grade lesion ,20.Candida, Trichomonas, Gardnerella, Chlamydia trachomatis, Mycoplasma, etc. The identification of microorganisms was carried out on the cytological specimens.Microbiological evaluation of vaginal discharge revealed possible infections caused by different microorganisms, such as For the detection of high-risk HPV, we used the HC2 assay (Qiagen). The HC2 analysis was performed according to the manufacturer’s recommendations, with results being positive or negative using 1.0 relative light units/cut-off (RLU/CO) as the cut-off value ,14. We cThe HC2 technique of DNA-based testing for high-risk HPV is a nucleic acid hybridization test with signal amplification, employing chemiluminescence of microplates for quality detection of 13 high-risk types of HPV: 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, and 68. The samples were collected and transported using the test kit’s medium. We were able to retain the samples at room temperature for two weeks, before storing them at 2 °C to 8 °C, for one week. If testing was performed after more than three weeks, samples were stored at −20 °C. The DNA was neither altered nor contaminated as a result of this technique during transit and storage. HPV testing services were performed at Oncological Institute “PROF. Dr. I. CHIRICUŢĂ” Cluj-Napoca, based on a collaboration protocol.Using a medical questionnaire, selected patients were evaluated based on age, economic–social status, education level, marital status, tobacco smoking, alcohol consumption, sexual behavior, and characteristics , personal physiological antecedents , and history of illnesses.This questionnaire-based study was approved by The Ethics Committee of George Emil Palade University of Medicine, Pharmacy, Science, and Technology of Targu Mures (no. 530/21/11/2019).Data were collected in Excel spreadsheets and statistically analyzed using the Statistical Package for Social Science .p < 0.05. All p values reported are two-tailed.Absolute and relative frequencies (%) were used to represent nominal variables, and the association between these variables was analyzed using Pearson’s Chi-square test or Fisher’s exact test. The size effect was reported as an odds ratio (OR) with a 95% confidence interval for the statistically significant associations, and with p = 0.042). ASC-H was identified primarily in women with positive HC2 (6.1%), while NILM was found mostly in women with negative HC2 (33.3%). The cytopathological type H-SIL was not identified in those patients. The colposcopy/biopsy recommendation was noted on the cytology exam bulletins in 18.2% of the patients with positive HC2 tests (p = 0.0001). Among the microorganisms, Candida albicans and Gardnerella vaginalis were identified  tested positive for high-risk HPV types, whereas 103 patients (60.9%) tested negative. Of the patients with positive results, 14 presented ASC-US (21.2%), compared to 10 patients in the negative group (9.7%) (entified . HR-HPV p = 0.004). More than 60% of patients, regardless of their findings, believe that the first sexual encounter or first time living with a partner should occur after the age of 18. More than 90% of patients had a consistent sexual partner, and 10.6% of the women with positive results had at least four sexual partners up to the day of inclusion in the study (p = 0.03). The distribution of the two groups was similar in response to the following questions: “Have you had sexual contact outside your couple?”, “Duration of sexual activity”; “Frequency of sexual acts per week or at what age does sex should usually start?” A difference was observed between the groups in terms of extramarital sexual intercourse, with 13.6% of the positive patients requesting a consultation with a specialist doctor after 4 to 6 months (p = 0.04). Bleeding accounted for 50% of the positive patients, indicating that they should visit a doctor for a specialist consultation (p = 0.038). For both subgroups of patients, doctors/health workers and the internet are the two primary sources of information about sexually transmitted illnesses (llnesses .p = 0.02). Women in both groups responded similarly to the method of prevention/reduction in HPV infection and awareness about HPV, as well as the number they received from a Pap test. When evaluating the causes for the patients not undergoing a Pap test, the lack of time and fear of a positive result were the primary reasons, but a significant number of women considered that this test is unnecessary. The two main sources of information regarding HPV infection are medical doctors and the internet, and patients consider that school and medical doctors should offer more information regarding HPV infection . Further, 81.8% of the women with positive results considered that HPV infection is a high risk for their health status , and significant false-positive rates (between 15% and 50%) . Using HEstablishing the diagnosis algorithm is not complete without the detection of HPV types. Using manufacturer’s recommended cut-off (RLU/CO = 1.0), sensitivity was 93.8% (95% CI: 90.1–97.5) and specificity was 63.2% (IC 95%: 58.6–67.6%) .In our study, the percentage testing positive for high-risk HPV types at HC2 was 39.1 (95% CI: 30.2–49.7%), with most of the women presenting symptoms, such as abnormal vaginal discharge, genital inflammation, or one of the risk factors known to be associated with a higher risk for developing CC. In the group of women with positive HPV test via HC2, when evaluating low-grade lesions (ASC-US + LSIL), we identified a percentage of 22.7%, compared to 12.6% in the group with a negative test. When evaluating women with a positive HPV test by HC2, 6.1% had a high-grade lesion (ASC-H), compared to 0.0% amongst women with a negative HPV test. After calculating the causal relationship between cytology and positive HR-HPV using HC2, we obtained an OR = 2.53; 95%CI: 1.10–5.80 for positive HPV and low-grade cytology (ASC-US or LSIL), and an OR = 14.9; 95%CI: 1.006–34.59 for positive HPV and high-grade cytology (ASC-H). We, thus, mention that there is a correlation between HC2 positivity and high-grade cytological lesions.According to Oliviera et al. , HR-HPV Romania has a high incidence and mortality rate caused by CC ,26, withIn a study conducted by Agorastos et al. , a prevap = 0.0001). Additionally, the correlation between HC2 results and sexual behavior/characteristics was evaluated. Among patients with a positive result, it was shown that unmarried women  and those with multiple sexual partners  have a higher risk of HPV infection when compared to those married or with fewer sexual partners. The study highlighted that 13.6% of positive women came for a gynecological consultation 4–6 months after having extramarital sexual intercourse (p = 0.04), knowing better than patients with negative results that bleeding is a symptom that would determine them to ask for a consultation (p = 0.038).In our study, women with abnormal cytology and positive HPV test were advised to follow up and to repeat the test in 6 months and/or colposcopy and biopsy  had heard about HPV but did not know what diseases are associated with this infection; a high proportion of these patients highlighted incorrect ways of contracting the infection, such as unsterilized needles (28%) or blood transfusion/organ transplant (27%). Among women with positive results, 81.8% consider HPV infection to have a high risk for health status, compared to 64.1% in the group with a negative result. When asked about methods of prevention/reductions in HPV infection or knowledge about HPV and how many times they undertake a Pap test, it was shown that lack of time and fear of a positive result are the main reasons, but 56.1% of the positive group and 61.2% from the negative group consider a Pap test as not being necessary.According to GFK research ,35, condAccording to our findings, the two main sources of sexually transmitted disease information are medical workers (59.1% vs. 57.3%: positive group vs. negative group), and the internet (43.9% vs. 39.8%: positive group vs. negative group). The same applies to information regarding HPV infection, doctors (71.2% vs. 74.8% positive group vs. negative group), and the internet (51.5% vs. 43.7% positive vs. negative). In the opinion of patients, doctors (95.5% vs. 75.7% positive group vs. negative group) and schools (42.4% vs. 44.7% positive group vs. negative group) should make information about HPV infection available. Further, in a previous study, by Voidăzan et al. [Women’s adherence to screening programs and medical dissemination of relevant information are important factors in reducing the risk of HPV-associated cancer, and campaigns to inform the population about screening and vaccination programs represent effective ways to reduce incidence, mortality, and morbidity. In Romania, vaccination against HPV is not included in the National Vaccination Plan; instead, it is free and is carried out in family doctors’ offices, for females aged 11 to 18, based on parental request.In Romania, the first regional screening program for CC was implemented in 2002, in the northeastern region of the country, with a coverage area of 21% . In JuneNowadays, programs for the early detection of CC using the Pap test are in place in Romania. The goal of this screening program is to reduce the burden of CC by detecting it in its early stages, guiding patients with precancerous lesions toward specialized diagnostic and treatment centers, educating the population regarding screening as a method for early detection of CC in asymptomatic women.The follow-up process for women with squamous intraepithelial lesions is rather laborious and with extra costs that are covered by the national screening program. For ex-ample, HPV-DNA testing is included in the programs for prevention, early detection, diagnosis, and prompt management of CC.This type of program has the benefit of reducing poverty and any kind of social exclusion, allowing access to a high-quality healthcare system and sustainable social services. At least 50% of women are part of vulnerable groups. A screening program consists of interventions and complex measures that require a vast mobilization of financial, human, and material resources in order to attain high performance rates in accordance with European standards.In order to enhance the degree of acceptance for our screening methods among women in Romania, efforts must be made to: (1) encourage eligible women to take the test as part of our national screening program, hoping that after, they will start taking their routine medical appointments and learning basic rules of hygiene and healthy lifestyle; (2) let people know that screening for CC is free; (3) create an active role of healthcare professionals in promoting information about sexual health, discussing with younger women who have a higher risk of acquiring HR-HPV infection, facilitating access to screening in isolated communities from rural areas .The limitation of this study is the absence of probability sampling when enrolling the patients, given that patients were enrolled from public and private clinics where they attended routine check-ups. However, the research population’s diverse socio-demographic characteristics, the pre-established inclusion criteria, and the high rates of response to our surveys alleviate this susceptibility. Another limitation is from the method of completion; given that the questionnaire was self-managed, perhaps some of the items were not comprehended, which draws into doubt the reliability of their answers. To alleviate this constraint, all incomplete questionnaires were excluded after conducting an in-depth review of the study’s internal validity.Understanding the epidemiology of genital HPV infection is essential for developing preventive measures against this infection and HPV-related neoplasia. By identifying the most frequent HPV types and calculating the incidence of HR-HPV infections, based on Pap test results and the patient’s sexual activity, an algorithm can be established for better management of women with cervical intraepithelial lesions. Doctors can assist with reliable information regarding the diagnosis method, facilitating access to effective and prompt cervical dysplasia therapy.Any screening program’s primary goal is to minimize morbidity and mortality. Long term, in order to reduce the mortality caused by CC, changes in the behavior of the population must be undertaken, promoting health actions and reducing the increased risk of the disease, prolonging an active life, and reducing the incidence of CC and the associated complications. By enhancing the interest in preventive services, we can teach the population that they need to prevent, not just treat, diseases.


In France, human papillomavirus (HPV) vaccination coverage varies across socioeconomic levels.We aimed at assessing HPV vaccine awareness, uptake and vaccination intention among adolescents in France.In a cluster-randomised study, 13–15-year-old students in 61 French middle schools completed a web-based questionnaire. We used multivariable logistic regression to evaluate determinants of HPV vaccine awareness, self-reported uptake and vaccination intention among unvaccinated students and interaction terms to explore effects of visits to family physician and remembering school lessons on vaccination. The French deprivation index of school municipalities served as proxy for socioeconomic levels.Among 6,992 participants, awareness was significantly associated with parental education (odds ratio (OR) = 0.82; 95% confidence interval (CI): 0.71–0.95), language spoken at home  and deprivation level , regardless of physician visit or school lessons. Vaccine uptake was associated with parental education without a recent physician visit . Vaccination intention among unvaccinated was associated with deprivation level (moderate-low vs low) among students not remembering school lessons on vaccination . Parental education was associated with vaccination intention among students reporting a physician visit .Our results suggest that healthcare and school could promote vaccination and mitigate social inequalities in HPV vaccination coverage. What did you want to address in this study?Human papillomavirus (HPV) can cause genital cancer. Vaccination against HPV protects against virus types causing most cases of cervical cancer, as well as some other cancers. Vaccine uptake among adolescents varies in France and other European countries. We wanted to investigate awareness, uptake and intention of HPV vaccination among French adolescents and factors affecting vaccination.What have we learnt from this study?Adolescents were less aware of vaccination and less often vaccinated or planning to vaccinate if their parents had a lower education, other languages than French were spoken at home and the family lived in a poorer area. Importantly, if the adolescents had recently visited a family physician or were taught about vaccinations at school, vaccination or planning to vaccinate were independent of parental education, language or neighbourhood.What are the implications of your findings for public health?Family physicians and school lessons on vaccination are important in promoting systematic vaccination of all adolescents against HPV, irrespective of their social context. How to use such communication ways to enhance vaccination in France needs further investigation.Human papillomavirus (HPV) vaccines are highly effective against cervical and other HPV-related cancers, while being safe and generating population immunity . In FranPrevious studies suggest that the main barriers to HPV vaccination in France are lack of parental awareness and low perceived accessibility, combined with widespread doubts on the need and safety of the vaccine . In partAs in other countries , HPV vacA systematic review suggested that young adolescents, the target group for HPV vaccination in most countries, have relatively favourable attitudes towards HPV vaccination, but lack awareness . To dateIn this context, we aimed to delineate socio-educational inequalities of HPV vaccine awareness, self-reported uptake and vaccination intention among French adolescents aged 13–15 years, and to investigate whether visits to the family GP and school lessons on vaccination could mitigate these inequalities.https://www.project-redcap.org/). Middle schools in nine regions throughout the French mainland were randomised as previously described [The national research programme to improve HPV vaccine coverage among French adolescents, PrevHPV, is a cluster-randomised study in mainland France evaluating the effect of a multicomponent intervention on HPV vaccine uptake among adolescents irrespective of their sex . Betweenescribed . Ninety-Supplementary Table 2.The questionnaire included questions on socio-educational characteristics of the adolescents’ family, awareness, knowledge, perceptions and behaviour around HPV-related disease and vaccination, their self-declared HPV vaccination status and intention to get vaccinated. We assessed intention to get vaccinated among unvaccinated adolescents aware of HPV vaccine as follows: refusal (‘HPV vaccination is not relevant for me’), indecision  or intention (‘I have the intention to soon get vaccinated’). More details can be seen in To assess the socio-educational characteristics, we collected individual and ecological variables. Educational level of the mother and the father was grouped as ’below or equal to high school’, ‘above high school’ and ‘do not know’. We assessed language by the question ‘Do you commonly speak another language than French at home’ (French or other languages). For specific analyses, we collated parental education (the highest achieved level among parents) and language. We assumed that the relevance of a multilingual family environment for vaccine uptake depends on the level of parental education.As an ecological study, we used the 2015 French deprivation index (Fdep) , a proxySupplementary Table SM1.Knowledge on health-related subjects covered at school was assessed as remembering specific topics taught during school lessons . In France, these topics can be addressed in biology classes in middle schools, but the content or the format is not harmonised. We assessed whether the students had seen their GP during the past 12 months and whether the GP had offered HPV vaccination. In the French context, the gatekeeper function of family physicians comprises mostly GPs. Although other medical specialities (e.g. paediatricians) can take this role, for simplicity, we refer here to GPs. Adolescents commonly visit GPs for acute or chronic health issues and for medical certificates of fitness to participate in sports. Three GP visits dedicated to health promotion, including vaccination, are fully reimbursed for children between the ages of 8 and 16 years. For specific analyses, we collated these variables into one variable (no visit/visit with a vaccine offer/visit without a vaccine offer). Most questions included a ‘do not know’ modality, which was included into ‘no’. More information can be seen in Additionally, we collected variables not part of the main hypothesis but known to impact health behaviour . These iWe performed descriptive analyses on socio-educational characteristics by sex and on HPV vaccine knowledge and attitude items between subgroups according to socio-educational and mitigation variables. We used chi squared tests for differences between subgroups.For the first analysis on determinants of HPV vaccine awareness (binary), vaccine status (binary) and vaccination intention , we built multivariable logistic and multinomial regression models including all socio-educational variables and variables related to contact with GP, health-related knowledge, behaviour and aptitudes and social influence. For each outcome, we included in the final multivariable model only variables associated in bivariable models at p value < 0.2.For the main objective of exploring social inequalities, we analysed, for each outcome, a model including only socio-educational variables . We then explored mitigation including interaction terms between socio-educational determinants  and hypothetical mitigation variables . Interaction terms with p < 0.05 were interpreted as mitigation, and in this case, the effects of determinants were represented stratifying for the mitigation factor.Statistical significance was defined as p value < 0.05. Data analyses were performed on Stata Version 17 .Supplementary Figure SM2.Given constraints during the COVID-19 pandemic, only 61 middle schools with 12,833 students in third and fourth grades participated in the survey. While no information on the number of school classes was collected, we estimated that baseline questionnaires were administered in 70% of classes. More details can be seen in Supplementary Table SM3. Almost half of the participants were unaware of at least one parent’s educational level, while 32.3% and 25.4%, respectively, reported higher education for their mothers and fathers. Other languages than French were spoken at home of 1,480 (21.2%) respondents. Of these, 335 (4.8%) had parents with lower education and 541 (7.7%) had higher education. A total of 611 (8.7%) participants attended school in a low and 1,310 (18.7%) in a high deprivation area. Overall, 1,233 (17.6%) 24.1% participants reported no recent GP visit  and 35.7% reported a visit without an offer to vaccinate against HPV . More information can be seen in Supplementary Table SM4. Similarly, 70.3% remembered school lessons on vaccination.In total, 7,632 persons opened the questionnaire, with 7,580 accepting participation and 6,992 leaving valid responses, or 54.5%  of the eligible students. There were 3,564 females and 3,428 males responding, approximately equally distributed over the two school grade levels and with similar socio-educational characteristics. More information can be seen in Supplementary Figures SM5 and SM6. Among the participants aware of HPV vaccine or not sure but reporting their vaccination status , 1,568 (35.8%) knew they were vaccinated , while 2,344 (53.5%) were not and 473 (10.8%) were not sure, seen in Supplementary Figures SM5 and SM7. Among the 2,815 participants aware of the HPV vaccine but not vaccinated or not sure of vaccination, 939 (33.4%) intended to get vaccinated  and 311 (11.1%) did not, while 1,565 (55.6%) were not sure, seen in Supplementary Figures SM5 and SM8. In summary, among the 4,385 participants aware of the HPV vaccine, 2,507  were either vaccinated or intended to get vaccinated.Overall, 4,051 (57.9%) participants had heard about the HPV vaccine  and 421 (6.0%) were not sure. More information can be seen in Supplementary Table 6. When only variables grade level, sex, parental education, language and deprivation level were included in the model, the respondents were less aware of the HPV vaccine if they lived in an area with high local deprivation , spoke other languages than French at home  and had parents with a lower level of education   = 0.32; 95% confidence interval (CI): 0.29–0.36), language spoken at home , high local deprivation , high self-efficacy  and knowledge on vaccination  or on sexually transmitted infections  . More de71–0.95) . Visits Supplementary Table SM7. In the model focusing on socio-educational determinants, vaccine uptake was decreased when the parents had a lower level of education  and other languages than French were spoken at home   and without  a vaccine offer, a social environment favourable to HPV vaccination , friends being vaccinated against HPV , male sex  and fourth grade at school (instead or third)  (50–0.72) . Low levThe participants had significantly higher intention to get vaccinated if the attitudes towards HPV vaccination were more favourable in their social environment  or in the family , they had visited the GP and received a vaccine offer , their friends were vaccinated  or they considered finding of HPV-vaccine-related information easy  . NotablyParticipants who had visited a GP and been offered a vaccine had better knowledge on HPV and HPV vaccine than those with no GP visit . For exaIn this cross-sectional study among adolescents aged 13–15 years in France, we identified several socio-educational inequalities in HPV vaccine awareness, uptake and vaccination intention, relating to lower parental education, languages spoken at home and higher local deprivation levels. Recent GP visits mitigated inequalities in vaccine uptake and school lessons on vaccination mitigated inequalities in vaccination intention among unvaccinated adolescents. Surprisingly, for unvaccinated adolescents, we found disparities in vaccination intention by parental education specifically among those who reported a recent GP visit.The use of other languages than French at home was associated with lower HPV vaccine awareness, uptake and vaccination intention, irrespective of parental education level. Following French research regulations on good ethical practice, we did not collect information on family origin, ethnicity or religious background, and consequently, we cannot fully interpret this disparity. However, given the independence from parental education level, the most relevant explanation may be language or cultural barriers leading to lower understanding of and lower feeling of being targeted by health promotion messages. This would be consistent with studies from the United States that have demonstrated the challenges faced by diverse communities regarding access to culturally and linguistically adapted HPV information ,16. ThesThe fact that inequalities In HPV vaccine awareness were not mitigated by school lessons on vaccination or recent physician visit appears surprising. Further investigation is needed to explore the reasons behind such inequalities, including lower health literacy (capacity to understand the vaccine information) and selective information (to not mention HPV vaccines towards specific groups). To overcome inequalities in HPV vaccine awareness among adolescents, specific targeted interventions on HPV vaccine may be needed.The prominent role of GPs in our study echoes previous research highlighting that limited access to GPs, GPs not offering the vaccine and challenges faced by GPs in promoting the HPV vaccine act as major barriers to HPV vaccination in France  and otheKnowledge and perceptions on HPV vaccine among teenagers have been well researched across Europe and the world ,20, howeAdolescents’ HPV knowledge remains sub-optimal, with only 51.8% across 16 European countries . Many yoIn the analysis of wider determinants, the opinion of the social environment on HPV vaccination was the dominant determinant of vaccine intention among unvaccinated adolescents, concordant with the existing literature . HoweverThe mitigation of inequality by socioeconomic level in case of school lessons on vaccination was largely carried by an increase in intention in municipalities with higher deprivation levels, with little change in low-deprivation areas. Studies on free school-based HPV vaccine access in Belgium and in Canada have described a similar pattern, with such interventions benefiting higher-deprivation areas ,28. ThusOur study has several limitations. Firstly, a self-administered questionnaire among adolescents is at risk of low-quality answers given haphazardly or too quickly, particularly if respondents lacked interest or did not understand the question. We tried to minimise these effects by offering a ‘do not know’ answer modality. We did not analyse durations of questionnaire administrations, but teachers or school nurses were present and surveyed questionnaire administration, which should guarantee a minimal level of information quality. Additionally, the use of anonymous self-administration should have limited the risk of social desirability bias.Secondly, our participants were not a representative sample of middle school students in France, given the fact that participation depended on the school directors’ agreement and on parental non-opposition, which may have excluded students with parents with strongly negative attitudes towards vaccination. Prevalence estimates should therefore be interpreted with caution. Nevertheless, the HPV vaccine prevalence of 36% among girls and 9% among boys is close to the national estimates for 2021 (37% and 6%). Across all study participants, 21% reported a multilingual background, which corresponds to national survey data from the French Ministry of Culture . FurtherFinally, the requirement of parental consent to vaccination in France could have impacted in a differential way the vaccine intention expressed by adolescents in different socio-educational subgroups.Coverage of HPV vaccination in France has been steadily increasing over the last decade, but larger efforts are required to meet programmatic objectives. Of particular importance will be addressing the social inequalities in vaccine awareness, intention to get vaccinated and uptake, demonstrated throughout this study, that could lead to substantial inequalities in HPV-related cancer risk. The adolescents contribute to making decisions on vaccine uptake and our data suggest that policies facilitating and harmonising HPV vaccine promotion by healthcare professionals and adapted school lessons on HPV vaccination could mitigate inequalities in vaccine coverage. A first nation-wide vaccination campaign for 12–13-year-olds is scheduled in France during the current school year 2023-2024, and there is hope that this will not only increase coverage rates, but also reduce related social inequalities.


Choerospondias axillaris) fruit juice. The intent of the present investigation was to process lapsi fruit juice using both thermosonication and thermal pasteurisation and to compare the effects of these treatments on the juice’s physicochemical, nutritional, and microbiological qualities. In order to maximise the retention of nutritional properties, enhance juice quality, and boost efficiency, an artificial neural network (ANN) model was also developed to forecast the optimisation of process parameters for the quality of lapsi fruit juice. This study establishes a novel experimental planning method using an ANN to multi-objectively optimise the extraction process and identify the ideal extraction conditions for thermosonication  to augment lapsi juice’s nutritional and microbiological properties by improving certain attributes such as ascorbic acid (AA), antioxidant activity (AOA), total phenolic content (TPC), total flavonoid content (TFC), total plate count, and yeast and mould count (YMC). The maximum values for AA (71.80 ± 0.05 mg/100 mL), AOA (74.60 ± 0.28%), TPC , TFC , total plate count (not detected), and YMC were achieved in thermosonicated lapsi juice (TSLJ) under optimal conditions. For AA and TFC, the optimal conditions were 100% amplitude, 40 °C, and 45 min. For AOA and TPC, the optimal conditions were 100% amplitude, 40 °C, and 60 min, and for YMC, the optimal conditions were 100% amplitude, 50 °C, and 60 min. According to the findings, thermosonicated juices have improved nutritional properties, making them an excellent source of bioactive elements for use in both the food and pharmaceutical sectors. According to this study, ANN has been identified as a valuable tool for predicting the effectiveness of lapsi fruit juice extraction, and the application of thermosonication as an approach for lapsi juice preservation could be a potential successor to thermal pasteurisation. This approach can help to minimise or hinder quality degradation while improving the juice’s functionality.This study explored the effect of thermosonication on the nutritional properties of lapsi ( Fruits and vegetables are vital parts of a nutritious diet. They contain essential minerals, vitamins, and fibre to promote overall wellness and good health. Consuming a variety of fruits and vegetables has been linked to a lower risk of chronic diseases such as stroke, heart disease, and certain cancers . AdditioChoerospondias axillaris) is a lesser-known fruit native to Bhutan, Nepal, and parts of Northeast India  [Lapsi (d Assam) . At the d Assam) . The fruAs lapsi fruits are perishable in nature, it is essential to prevent their loss and promote their use by processing them into value-added products such as fruit juices . The proThermal treatment, such as pasteurisation (PS), is required to ensure the safety and quality of fruit juices . PasteurA promising non-thermal technology known as ultrasound (US) treatment can successfully remove microorganisms from fruit juices with little to no effect on nutritional and sensory qualities. Due to its various benefits over conventional thermal processing techniques, this novel method can greatly benefit the fruit juice industry. Thermosonication (TS), a type of ultrasonication method, uses heat and high-frequency sound waves (ultrasound) for food preservation. It involves heating food to a specific temperature  and then exposing it to high-frequency sound waves  [Several researchers have shown the preservative effect of ultrasound on fruit juices, including  pomelo jAn artificial neural network (ANN) is a machine-learning algorithm that draws inspiration from the structure and operations of the human cerebral cortex. ANNs consist of interconnected nodes, often referred to as “neurons,” which play the crucial roles of processing and transmitting data . The steTo date, there have been no reports on the use of thermosonication for the processing lapsi fruit juice. Thus, the objective of this study was to utilise both thermosonication and thermal pasteurisation to process lapsi fruit juice and to assess the resulting influence on the physicochemical, nutritional, and microbiological properties of the juice. Additionally, an ANN model was created to forecast the optimisation of process parameters for the quality of lapsi fruit juice for maximum retention of nutritional properties, improvement of juice quality, and increased efficiency.Mature and flawless lapsi fruits, freshly harvested from a garden in the vicinity of Ranipool, Sikkim, were carefully collected and transferred using an insulated container (sterile ice box maintaining 4 °C) to the laboratory of the Department of Food Engineering and Technology, CITK, Kokrajhar. The fruits were removed from their stalks, washed in water, allowed to air dry, and sliced into small pieces before the juice was extracted.The chemicals utilised in this study were obtained from two different sources, namely Bengaluru-based Sigma Aldrich and Mumbai-based HiMedia Chemicals, nestled in India. Additionally, the chemicals utilised to determine microbiological properties, including potato dextrose agar, total plate count agar, and peptone water, were acquired from MERCK Group.Slices of lapsi fruit (approximately 2–3 cm in size) were crushed using a domestic grinding device (mixer). After that, Whatman number one filter paper was used to eliminate any remaining impurities and clarify the juice. Three separate treatment groups of the juice were established as follows: the raw juice (control), the pasteurised lapsi juice (PSLJ), and the thermosonicated lapsi juice (TSLJ). All juice samples were processed immediately after their separation on the same day.Lapsi fruit juices were thermally treated in an experimental establishment employing a vertical pasteuriser at a temperature of 90 °C for a duration of 60 s . After pThermosonication treatments on juice samples were conducted using an ultrasonicator probe  at various temperatures  with 750 W full power . Juice sThe pH levels of both control and treated lapsi juice samples were measured at 25 ± 1 °C applying a digital pH meter . The conCentrifugation was carried out using 5 mL samples of both treated and untreated LJ at room temperature for estimating the cloudiness (CI) and browning index (BI). The centrifugation was performed using a centrifuge  spinning at 6000 rpm for a duration of 10 min. After the centrifugation process, the supernatant was utilised to determine CI and BI. To assess the degree of cloudiness, the absorbance was measured at 660 nm using a UV-Vis spectrophotometer  . In ordeThe level of ascorbic acid content (AA) in LJ samples was measured by employing the iodine titration method . Solubleo = absorbance of the control, and A1 = absorbance of the juice.The antioxidant activity (AOA) of samples (lapsi juice) was evaluated using the DPPH  scavenging method . A measuThe determination of the total phenolic compounds present in both treated and untreated fruit juices was conducted using the method suggested by Nayak et al. . LJ was w/v aluminium chloride and 5% sodium potassium tartrate solution. After adding 5.6 mL of distilled water, the solution was incubated in the dark for 30 min. Absorbance at 415 nm was measured using a spectrophotometer, and a calibration curve was generated using catechin as the standard. The concentration of flavonoids in the lapsi juices was denoted as milligrams of catechin equivalent (CE) per mL of juice.The total flavonoid content (TFC) of lapsi juice samples was determined using the approach laid out by Nayak et al. . A 6 mL Microbiological determination was performed to determine the total plate counts as well as total yeast and mould counts (YMC) of lapsi juices by the method followed in the work of Tomadoni et al. . For tot2), mean absolute error (MAE), and mean square error (MSE) values, which were determined using Equations (1)–(3) [Using MATLAB R2020a software, artificial neural networks were created to generate predictive analytics for examining the physicochemical, functional, and microbial characteristics of LJ samples that underwent thermosonication. Preliminary studies were used to designate the input parameters and their ranges. The independent variables included thermosonication amplitude X1 , thermosonication temperature X2 , and treatment time X3 . The output parameters considered in this study were pH, TSS, TA, cloudiness, browning index, ascorbic acid, antioxidant activity, TPC, TFC, and YMC. The 36 experimental data points were randomly divided into three sets for training (75% of the data), validation (15% of the data), and testing (15% of the data) purposes. The structure of the well-trained ANN model with the optimal topology was (3:10:10), where the weights of connections between neurons in different layers and the bias or threshold values of hidden- and output-layer neurons were organised in matrix form with a network-type feed-forward backprop along with a training function (TRAINLM). Specifically, the matrix size of the weights of synaptic connections between input- and hidden-layer neurons was 10 × 3, and the matrix size of the weights of connections between hidden- and output-layer neurons was 10 × 10. Finally, the matrix size of the bias or threshold values of hidden- and output-layer neurons was 10 × 1 and 10 × 1, respectively. The adaption function was set at LEARNGDM with transfer function PURELIN. Preliminary experiments were conducted with treatment temperatures ranging from 30 °C to 50 °C, which were determined by referring to previous studies that reported the extraction of different fruit juices using ultrasonication ,29. The x representing the mean value of experimental data, y representing the mean value of predicted data, and n representing the total number of observations.The variables used in this context are R2) is a statistical measure that represents the proportion of the variance in the dependent variable (the variables to predict) that is explained by the independent variables (the inputs to model). In the context of evaluating ANN models, R2 is often used to assess how well the model captures the variation in the target variable. It ranges from 0 to 1, with higher values indicating a better fit. An R2 value of 1 means the model perfectly predicts the target variable, while an R2 of 0 means the model provides no improvement over a simple mean prediction. MAE is a common metric used to measure the average absolute difference between the actual values and the predicted values. It quantifies the average magnitude of errors in the predictions made by the model. Smaller MAE values indicate better accuracy, as they imply that the model’s predictions are closer to the actual values on average. MSE is another common metric used to measure the average squared difference between the actual values and the predicted values. It squares the errors, giving more weight to larger errors. Like MAE, a lower MSE indicates better accuracy, with values closer to zero implying better model performance.R-squared  using SPSS version 16.0, with a predetermined significance level of The study aimed to improve the shelf life of lapsi juice by conducting thermosonication treatments under appropriate experimental conditions. In this study, the quality parameters of freshly extracted lapsi juice were compared with those of thermally and non-thermally processed juice using thermosonication. The experimental data for the pH, TSS, and TA of raw, pasteurised, and thermosonically processed lapsi juices are shown in The pH of the control sample differed significantly from that of the PSLJ and TSLJ samples. The pH values of the control and PSLJ were determined to be 3.77 ± 0.00 and 3.64 ± 0.01, respectively. Minor variations in pH were observed in the TSLJ, with values ranging from 3.32 ± 0.01 to 3.57 ± 0.01 at 50% amplitude, 3.29 ± 0.00 to 3.55 ± 0.01 at 75% amplitude, and 3.21 ± 0.02 to 3.51 ± 0.01 at 100% amplitude. The pH decrease observed in the TSLJ could be due to the generation of new chemical compounds, such as limonoids, flavonoids, carotenoids, and coumarins, resulting from the high-amplitude energy produced during ultrasonication. Nadeem et al.  suggesteThe total soluble solid (TSS) content of both treated and fresh lapsi juice samples did not exhibit major significant variations, with all the samples having a TSS of 11.00 ± 0.10 °Brix . These fUntreated and thermally treated lapsi juices both had titratable acidities (TA) of 3.30 ± 0.01% and 3.27 ± 0.01%, respectively . Accordip < 0.05) in cloudiness values were observed between the fresh and thermally treated juice samples, as indicated in p < 0.05) higher than that of the fresh and PSLJ samples, ranging from 0.897 ± 0.005 to 1.757 ± 0.001 after the thermosonication treatments. The CI values of lapsi juices subjected to thermosonication at 50% amplitude ranged from 0.897 ± 0.005 to 1.583 ± 0.002, while the juices treated at 75% amplitude showed cloudiness values ranging from 1.157 ± 0.001 to 1.696 ± 0.002. Additionally, lapsi juices treated at 100% amplitude showed cloudiness values ranging from 1.196 ± 0.002 to 1.757 ± 0.001. The study by Oladunjoye et al. [The cloudiness of fruit juices is influenced by various compounds such as cellulose, hemicellulose, pectin, and protein, and can affect their flavour and colour . No signe et al.  found the et al. . Additioe et al. ,26.p < 0.05) from those of the raw lapsi juice. The control and TSLJ samples had BI values of 0.118 ± 0.001 and 0.192 ± 0.001, respectively, while the TSLJ samples displayed BI values in the range of 0.184 ± 0.001 to 0.301 ± 0.002. The BI values of TSLJ showed a range from 0.897 ± 0.005 to 1.583 ± 0.002 at 50% amplitude, while the BI values for lapsi juices treated at 75% amplitude ranged from 0.198 ± 0.001 to 0.289 ± 0.002, and from 0.216 ± 0.001 to 0.301 ± 0.002 for 100% amplitude. Ultrasonication causes cell-wall breakdown in fruit juices, releasing enzymes such as polyphenol oxidase and peroxidase. These enzymes react with the phenolic compounds in juice to produce brown pigments. According to previous findings by Kesavan et al. [n et al.  and Nayan et al. , the incAscorbic acid (AA) is a vitamin that is essential to produce carnitine, neurotransmitters, and collagen. It is primarily found in fruits and vegetables. It has several beneficial health effects due to its antiatherogenic, antioxidant, anti-carcinogenic, and immunomodulatory properties.2 that is dissolved during cavitation could be correlated to a rise in AA levels, and studies have shown an improved retention of AA in fruit juice samples during TS [The AA content of untreated juice and PSLJ was measured as 61.73 ± 0.02 mg/100 mL and 41.96 ± 1.31 mg/100 mL, respectively. uring TS ,38.The effects of TS and PS on the antioxidant activity (AOA) of lapsi juice samples, both fresh and treated, are represented in On the other hand, the AOA of TSLJ was observed to have higher retention than that of fresh and PSLJ samples, as observed in p < 0.05) at all three amplitudes . The maximum retention of phenolic content obtained was 187.33 ± 0.03 mg GAE/mL (TSLJ) at 100% amplitude and 40 °C temperature for 60 min of treatment.The findings of the experimental results from the TPC determination of TSLJ, PSLJ and fresh lapsi juices are represented in 2 from the lapsi juice samples. In addition, treatment temperature possessed a significant (p < 0.05) impact on the total amount of phenols (at each amplitude), and the TPC of lapsi juices increased with amplitude and temperature.The study shows that the TPC of TSLJ increased compared to that of raw and PSLJ samples, as observed in The rise in the TPC of TLJ may be credited to several factors. Initially, cavitation may necessitate phenolic compounds to change from restricted to free-form states . AdditioThe influence of PS and TS on the TFC of lapsi juices was investigated in this study, and the results of the experiments were presented in Phenolic and flavonoid substances are typically present in plant cells in bound or soluble forms. Ultrasonication can induce the release of phenolic compounds because of the cavitation generated around the particles. The overall extraction efficiency rises as a result of the high amplitude of ultrasonic waves, which improves the diffusion of flavonoids from the plant material into the juice. The flavonoid compounds’ stability and preservation are probably enhanced by the process’s precise temperature and time parameters, which stop them from degrading or denaturing. Moreover, the increase in TPC and TFC levels may be attributed to the incorporation of a hydroxyl group into the aromatic phenolic ring structure as a result of thermosonication . SeveralThe effect of TS on microbial counts is presented in The high temperature of pasteurisation causes damage to the cell membrane, nucleic acids, and protein structure of the microorganisms present in the juice. This damage to the microorganisms can cause cytolytic reactions, which eventually kill them. The heat causes the microorganisms’ cell membranes to become unstable and rupture, resulting in the leakage of the contents from cells . Figure The YMC of the TS-treated juice was lower than the YMC of the fresh juice samples (2.94 ± 0.04 log cfu/mL), ranging from 2.02 ± 0.02 to 2.82 ± 0.01 log cfu/mL. However, unlike the TPC, the YMC was not completely eliminated, which could be attributed to yeast and mould’s higher resistance to sonication compared to that of bacterial populations, as previously reported . A decreThe optimal parameters for the artificial neural network (ANN) were determined using various criteria such as a correlation plot, mean absolute error, correlation coefficient, and performance plot, as described in previous studies . After t2), MSE, and mean absolute error (MAE) were calculated to verify the developed ANN model [2, MSE, and MAE values for all responses obtained from the ANN modelling of lapsi juice processing by thermosonication [2 for pH, TSS, TA, CI, BI, AA, AOA, TPC, TFC, and YM values were 0.97, 0.91, 0.99, 0.99, 0.99, 0.99, 0.97, 0.99, 0.99, and 0.99, respectively. All values are satisfactory and acceptable according to the literature [2 is considered a criterion for the best-fit model [2 values exceeded 0.80 for all responses, demonstrating the model’s viability [The performance of the generated ANN model was assessed using the correlation coefficient (R), which was found to be 1.0 for the training set and 0.99989 for the test data set. R was 0.99904, as observed in NN model . Table 3nication . The R2 terature . A minimit model . The deviability . Table 4Three sets of the 36 experimental observations were selected at random for training , validation , and testing  purposes, respectively. The network parameters were established using the training process, validated to evaluate the network parameters’ stability, and tested for the management of network parameter error . In thisANN is a widely used approach that employs various functions such as crossover, choices, and alteration of entities in the populace in order to optimise non-linear and near-linear issues ,16. The The current investigation used a multi-layer ANN to model and optimise the ultrasound-assisted extraction of lapsi juice. The influence of thermosonication at various levels of amplitude, temperature, and time on various responses such as physicochemical , nutritional , and microbiological  properties was also ascertained. The maximum levels of AA (71.80 ± 0.05 mg/100 mL), AOA (74.60 ± 0.28%), TPC (187.33 ± 0.03 mg GAE/mL), and TFC (127.27 ± 0.05 mg QE/mL) were obtained. The microbial populations in TS samples were recorded as lower than those in fresh samples and were attained by total plate count (not detected) and YMC (2.02 ± 0.02 log cfu/mL) in TSLJ under optimal TS conditions. For AA and TFC, the optimal conditions were 100% amplitude, 40 °C, and 45 min. For AOA and TPC, the optimal conditions were 100% amplitude, 40 °C, and 60 min, and for YMC, the optimal conditions were 100% amplitude, 50 °C, and 60 min. The high R values indicated a high degree of concurrence among the actual and predicted values. The optimal extraction variables have been identified using an established ANN as follows: The ideal conditions for processing lapsi juice with thermosonication have been identified through ANN and are listed following 20 iterations. The actual responses at the optimised process parameters closely matched the predicted values acquired from the established ANN model. In accordance with the outcomes, thermosonication might serve as an intriguing alternative to thermal pasteurisation for preserving lapsi juice while minimising or avoiding quality deterioration and augmenting functional attributes.Ultrasound-assisted extraction (UAE) is an innovative method that is gaining popularity in a variety of industries, including the food and beverage industry. When it comes to the extraction of lapsi fruit juice, UAE provides several benefits and has significant industrial significance. UAE not only improves extraction efficiency and speed, but it also improves the quality of lapsi fruit juice. The moderate and non-thermal nature of ultrasonic waves reduces the breakdown of heat-sensitive components found in fruit, such as vitamins, enzymes, and antioxidants. As a result, the extracted juice maintains its nutritious value, brilliant colour, and flavour profile. This element of UAE quality preservation is very important for the food and beverage industry, as customers are increasingly looking for natural and less processed products. It is the best option for the food and beverage industry because of its adaptability in terms of process parameters and its ability to improve extraction efficiency, speed, and quality. UAE represents a viable technique for industrial-scale lapsi fruit juice extraction, providing firms with a competitive edge in the market with the added advantages of sustainability and environmental concern.


Recent advances have uncovered the non-random distribution of 7, 8-dihydro-8-oxoguanine (8-oxoGua) induced by reactive oxygen species, which is believed to have epigenetic effects. Its cognate repair protein, 8-oxoguanine DNA glycosylase 1 (OGG1), reads oxidative substrates and participates in transcriptional initiation. When redox signaling is activated in small airway epithelial cells, the DNA repair function of OGG1 is repurposed to transmit acute inflammatory signals accompanied by cell state transitions and modification of the extracellular matrix. Epithelial-mesenchymal and epithelial-immune interactions act cooperatively to establish a local niche that instructs the mucosal immune landscape. If the transitional cell state governed by OGG1 remains responsive to inflammatory mediators instead of differentiation, the collateral damage provides positive feedback to inflammation, ascribing inflammatory remodeling to one of the drivers in chronic pathologies. In this review, we discuss the substrate-specific read through OGG1 has evolved in regulating the innate immune response, controlling adaptations of the airway to environmental and inflammatory injury, with a focus on the reader function of OGG1 in initiation and progression of epithelial to mesenchymal transitions in chronic pulmonary disease. The reoccurring injury and repair produce structural changes in tissue leading to non-physiological airway configuration, airway narrowing and ultimately permanent airflow impediment. Loss of airway function has been characterized by an excessive deposition of extracellular matrix (ECM) and tissue scar formation. Cell types primarily responsible for ECM accumulation are the myofibroblasts . After i2syn conformation is thermodynamically preferred for 8-oxoGua, it is able to form a stable Hoogsteen base-pair with adenine rather than cytosine, leading to transversion mutations after replication  considered the most easily oxidized nucleobase. Oxidation of Gua in DNA at C8 produces 7,8-dihydro-8-oxoguanine , whereas both 5’ Gua and 3’ Gua are more reactive , 5. 8-oxlication . OGG1 diAlthough 8-oxoGua differs from normal guanine by only two atoms, OGG1 can recognize and remove it very efficiently. The specificity of OGG1 not only depends on recognizing 8-oxoGua itself, but also complementary bases, which are checked before the catalytic reaction. A major question for base excision repair (BER) glycosylases is how they locate damaged bases in nucleosomes. It is presently believed that OGG1 does not require cofactors or energy for such activity, because it scans DNA by thermal diffusion . Moreove3Unlike enzymatic DNA methylation, it is challenging to envision selective Gua oxidation by reactive oxygen species (ROS). Lysine-specific demethylase 1 (LSD1) is a nuclear flavoenzyme that generates ROS during demethylation of H3 lysine . The stutrans-regulatory function were catalyzed by the advancement in technologies that mapped 8-oxoGua in the genome. A series of studies associated 8-oxoGua with regulation of transcription, especially from enhancers and promoters  term was inflammation and immune response (IIR) processes. The most significantly modulated processes were the positive regulation of cytokine production, including TNFα, IL6, IFNs, C-X-C motif chemokine ligands and IL1, the heterodimeric IL23 and IL17. In independent studies  mice in inflammatory models. Compared with wild-type counterparts, Ogg1 KO mice are resistant to LPS-induced tissue damage and organ dysfunction, with decreased cytokine and chemokine levels in body fluids . The significantly overrepresented protein classes included ECM proteins, cell adhesion molecules, structural proteins, actin family cytoskeletal proteins, ECM structural proteins, cadherins, protease inhibitors, metalloproteinases, serine protease inhibitors, cell junction proteins, cell adhesion, in line with tissue histology, cell morphology and remodeling. Although these experiments utilized the rodent model, hierarchical clustering using gene-by-environment (GEN-E) showed that protein expression profiles and pathways are similar to those involved remodeling in humans , epidermal growth factor (EGF), the TGFβ superfamily protein, the growth differentiation factor 2, myosin heavy polypeptide 1 to 13 and Wingless-type MMTV integration site family (Wnt), collagen type I to XVII)  Figure 22O2 that is required for myofibroblast differentiation, ECM production and contractility   , where tAGAC-3′) . The 5’-AGAC-3′) , yet aloAGAC-3′) , which aAGAC-3′) . We and AGAC-3′) , 57. TGFCol1a2, Fn1 and Vim, Keratin 14  lungs)  lungs) , Nodal g) lungs) Figure 3) lungs) . OGG1-dr5.2In TGFβ- or bleomycin-induced fibrosis, significant increases in OGG1 protein levels were documented in lung lysates , 94. In OGG1 promoter revealed the lack of TATA or CAAT boxes, implying a promoter type similar to constitutively expressed housekeeping genes. However, signal transduction, such as ROS signaling, can modulate the activity of promoters of housekeeping genes (OGG1 promoter region contains an antioxidant response element with a binding site for NF-E2-related factor 2 (Nrf2), suggesting that redox signaling upregulates OGG1 expression.An important question is how OGG1 expression is regulated upon TGFβ exposure, particularly under pro-fibrotic/fibrotic conditions. Analysis of the ng genes . Both blng genes –100. Imp5.3Ogg1 KO or inhibition of its reader function with TH5487 can be utilized in ameliorating oxidation-induced inflammation (OGG1-targeting siRNA and inhibition (TH5487) of OGG1 significantly inhibit pro-migratory effects of TGFβ. Bioanalytical liquid chromatography tandem mass spectrometry data-independent acquisition (LC-MS/MS DIA) analysis showed significant down-regulation of OGG1-dependent GO terms, including collagen biosynthesis processes, wound healing involved in inflammatory response, endothelial cell proliferation, collagen metabolic processes, response to fibroblast growth factor, regulation of cytokine production, wound healing, and response to wounding in fibrotic tissue  targets tyrosine kinases by binding to the ATP-binding pocket, thereby blocking signaling cascades that result in the proliferation and migration of lung fibroblasts (®) decreases TGFβ expression and inactivates downstream signaling, including phosphorylation of SMAD3   –116. In 68-oxoGua as an epigenetic mark read by OGG1 is captured as the underlying principle for the genomic response to oxidative stress. This epigenetic reprogramming induced by OGG1 modulates cell fate in response to environmental changes, including whether to undergo death or to survive through transition, and may ultimately result in complex phenotypes or disease conditions. The aforementioned correlations between the temporal and repurposed nuances in OGG1 behavior and transcription profiles in small airway epithelial cells likely influence the nature and magnitude of mucosal immune response. There is a transitioned cellular landscape maintained by OGG1 that is critical for amplifying the stress signal into mucosal responses. A better understanding of the molecular checkpoints that control these transitions might provide new insights for modulating immunity in pulmonary disorders. OGG1-targeted small molecules such as TH5487 have the potential to mitigate aberrant inflammatory responses and epithelium reepithelization through inhibition of NFκB activation and of the SMADs signaling pathway. Recent advances in single cell sequencing enabled us to identify cell phenotypes and to examine their proteomes and metabolomes in addition to surveying their epigenetic modifications. Mapping cell location in spatial transcriptomic techniques will undoubtedly enhance our understanding of cell molecular phenotype and function of transitional cell states driven by OGG1. Treating airways with small molecule OGG1 inhibitors will allow us to link molecular changes with disease phenotypes and could provide clinical relevance to decrease fibrotic processes in lung injury.LP and IB conceived, designed, and wrote the manuscript. SV, LT contributed to the writing and editing of the manuscript. AB, ZR, JB, AE, XB and ARB contributed to scientific advice, discussions about the generated network. All authors contributed to the article and approved the submitted version.