Background: HPV tests differ for technology, targets, and information on genotyping of high risk (HR) HPV. In this study, we evaluated the performance of 6 HPV DNA tests and one mRNA test in the detection of cervical intraepithelial lesions (CIN) and as a test-of-cure in the follow-up after surgical conservative treatment. Methods: One hundred seventy-two women referred to the European Institute of Oncology, Milan, for surgical treatment of pre-neoplastic cervical lesions, were enrolled in this study (IEO S544) from January 2011 to June 2015. For all women, a cervical sample was taken before treatment (baseline) and at the first follow-up visit (range 3 to 9 months): on these samples Qiagen Hybrid Capture 2 (HC2), Roche Linear Array HPV Test (Linear Array), Roche Cobas 4800 HPV test (Cobas), Abbott RealTime High Risk HPV test (RT), BD Onclarity HPV assay (Onclarity), Seegene Anyplex II HPV HR Detection (Anyplex), and Hologic Aptima HPV Assay (Aptima) histology and cytology were performed at baseline, and the same tests and cytology were performed at follow-up. Results: At baseline 158/172 (92%), histologies were CIN2+, and 150/172 (87%) women were recruited at follow-up. Assuming HC2 as a comparator, the concordance of HPV tests ranges from 91% to 95% at baseline and from 76% to 100% at follow-up (PABAK ranging from 0.81 to 0.90 at baseline and PABAK ranging from 0.53 to 1 at follow-up). All HPV showed a very good sensitivity in CIN2+ detection at baseline, more than 92%, and a very good specificity at follow-up, more than 89%. Conclusions: HPV tests showed a good concordance with HC2 and a very good and comparable sensitivity in CIN2+ detection. Hence, an HPV test represents a valid option as test-of-cure in order to monitor patients treated for CIN2+ lesions during follow-up. High-risk (HR) human papillomavirus (HPV) persistent infection has been widely recognized as the main causal risk factor for the development of cervical intraepithelial neoplasia (CIN) and progression to cervical cancer ,2.Nowadays, an increasing number of HPV tests, which differ for technology, targets, and genotyping , is avaiThe threshold of validated HR-HPV tests is CIN2+ detection because this is the clinical target for screening. However, HPV tests have been employed not only for screening, but also as a triage test and test-of-cure for follow-up of women treated for precancerous lesions.If many studies are not present in previous literature regarding HPV tests in the screening setting, even less is known about their use in the follow-up after surgical treatment . The objThe aim of the present study is to evaluate and to compare the performance of six HPV DNA tests and one HPV mRNA test from liquid-based cervical cytology samples, for the detection of CIN2+ at baseline and as “test-of-cure” during post-treatment follow-up. The secondary objective of the study is to determine the sensitivity and the specificity of different HPV tests in the settings of screening and post-treatment follow-up.® 4800 HPV Test (Cobas), Abbott RealTime High Risk HPV (RT), BD Onclarity HPV Assay (Onclarity), and Seegene Anyplex II HPV HR (Anyplex) test were carried out on a left-over aliquot. Hologic APTIMA mRNA assay (Aptima) has been performed placing an aliquot of Thin Prep sample in the Aptima storage liquid upon arrival in the laboratory. The results of histology at baseline and at relapse, when occurred, were available for all patients. Principal characteristics of all HPV tests are detailed in All women aged between 25–61 years, scheduled to be conservatively treated for CIN2+ at the European Institute of Oncology (IEO), Milan, from January 2011 to June 2015, were enrolled. “Conservative treatment” included excisional procedures, such as Loop Electro-Excision Procedure (LEEP) and laser conization, and ablative procedures, such as laser vaporization, in cases of ectocervical lesion and no evidence of ICC at pre-treatment colposcopic-guided biopsies. The study was approved by the Institutional Ethical Committee (IEO S544 study), and informed consent was obtained from all women at enrollment. A ThinPrep PreservCyt  cervical sample was collected in all patients before treatment and at the first follow-up visit planned at 6 ± 3 months after surgical treatment, in order to perform cytology, Qiagen Hybrid Capture 2 (HC2) and Roche Linear Array HPV Test (Linear Array). Roche CobasQiagen HC2 test is a sandwich capture molecular hybridization assay: it is a signal amplification detection method based on chemiluminescence that detects 13 HR HPV types: HPV 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, and 68. The DNA:RNA hybrids are captured on a microplate, and the emitted light is measured in a luminometer as relative light units (RLU). Samples were considered as positive if the ratio RLU/cut-off was >1.0 . All samples with RLU between 1 and 2.5 should be retested, as requested in package insert instructions.The Roche Diagnostics Linear Array test uses biotinylated PGMY09/11 consensus primers to amplify a 450-bp region of the L1 gene. It is capable of detecting 37 HPV genotypes: HPV6, 11, 16, 18, 26, 31, 33, 35, 39, 40, 42, 45, 51, 52, 53, 54, 55, 56, 58, 59, 61, 62, 64, 66, 67, 68, 69, 70, 71, 72, 73 (MM9), 81, 82 (MM4), 83 (MM7), 84 (MM8), IS39 e CP6108. The denatured PCR products were then hybridized to an array strip containing immobilized oligonucleotide probes. The results were visually interpreted by using the provided reference guide according to manufacturer’s protocol by two independent operators, and the results were compared to reach the final one.Cobas is a real-time PCR-based test able to detect HR-HPV genotypes: HPV 16 and 18 are reported as single genotypes, as well as a group of 12 other HR-HPV types  are reported as HR positive readout. This fully automated test detects the same genotypes of HC2, which have been classified as HR by ), and in addition HPV66, and includes an internal control (B-globin) as the marker of sample adequacy.The Abbott RealTime HR HPV test  is a qualitative real-time PCR for the detection of DNA from 12 HR-HPV genotypes , and includes an internal control (B-globin) as the marker of sample adequacy. Even an RT test is able to provide the identified genotype: for HPV 16 and 18 as single and for other HR genotypes in the pool, respectively.The BD Onclarity HPV Assay detects 14 HR-HPV genotypes and co-amplifies a beta-globin internal control (IC) that acts as processing control. The primers for the 14 HPV genotypes are designed to target a region of 79–137 bases in the E6/E7 genome, whereas the IC primers amplify a 75 base region in the human beta-globin gene. The assay consists of three PCR assay tubes  and four optical channels for the detection of the 14 HR-HPV genotypes  as single infections and the remaining eight genotypes in three groups  and the IC.The Seegene Anyplex II HPV HR test simultaneously detects 14 HR-HPV genotypes , and co-amplifies a beta-globin internal control (IC), which acts as processing control in only one real-time PCR reaction based on TOCE (tagging oligonucleotide cleavage and extension) technology. In case of positivity, Anyplex also provides the information of semi-quantitative viral load level of amplification, which can be measured repeatedly at 30, 40, and 50 cycles during the PCR process.The APTIMA HPV Assay searches for E6/E7 HR-HPV mRNA by three main steps, which take place in a single tube: target capture, target amplification through amplification mediated by the transcription , and detection of amplification products (amplicons) by Hybridization Protection dosage Assay. The assay incorporates an internal control for the capture, amplification, and detection of nucleic acid, as well as any operator or instrumentation errors.The physician-collected ThinPrep PreservCyt cervical specimens were processed in the ThinPrep 2000 machine . All liquid-based cytology slides were stained according to the Pap method and all cytologic diagnosis were performed by trained specialist biotechnicians, following automated Focal Point evaluation of all slides. In case of abnormal cytology, a dedicated pathologist from the Cytology Unit of IEO reviewed cytology slides to confirm diagnosis. Results were reported according to the 2001 Bethesda Reporting System.All histological diagnoses were made on a colposcopic-guided biopsy of the transformation zone alone or with endocervical curettage or on excision surgical specimens, by dedicated gynecological pathologists working at the Division of Pathology of IEO.Stata Statistical Software: Release 17. College Station, TX, USA: StataCorp LLC).Patients’ characteristics were summarized by count and percent or mean and standard deviation (SD) for categorical and continuous variables, respectively. HPV test agreement, at both baseline and at follow-up, were estimated by the proportion of concordant cases. In order to take into account the low prevalence of negative and positive cases at baseline and at follow-up, respectively, concordance was estimated by the prevalence-adjusted and bias-adjusted kappa (PABAK)  statistiOne hundred and seventy-two women scheduled to be conservatively treated with LEEP or laser conization or laser vaporization for CIN2+ were enrolled. The main characteristics of the study population at baseline are listed in Not all HPV tests were performed at baseline and follow-up due to lack of supply of reagents. Histological diagnosis on surgical specimens at baseline confirmed a CIN2+ lesion in 158 (91.9%) patients. Only histology confirmed samples were included in the final analysis.Overall, 150 patients were recruited at post-treatment follow-up, but only 118 in a time range between 3 and 6 months. Twenty-two patients (12.8%) were lost to follow-up and 32 (21.3%) were excluded due to incorrect timing of test-of-cure. Assuming HC2 as comparator, all HPV tests employed showed a good degree of comparison at both baseline (PABAK ranging from 0.81 to 0.90) and follow-up (PABAK ranging from 0.53 to 1). The concordance between different HPV tests and HC2 ranges from 91% to 95% at baseline and from 76% to 100% at follow-up, respectively, as shown in Sensitivity and specificity of all employed tests for CIN2+ at baseline and at follow-up, compared to HC2, are summarized in The results of our study showed a very good concordance among different HPV tests performed in liquid-based cervical samples from a group of women with high prevalence of preneoplastic cervical disease. The confidence intervals of these concordances overlap, further demonstrating the similarities of these HPV tests in performance. These data are in agreement with previous studies summarized in the 2020 list of human papillomavirus assays suitable for primary cervical cancer screening, published by Arbyn et al. . All HPV tests employed at baseline and follow-up have been validated according to Meijer’s guidelines ,11,12,13Since validations have been usually performed in the screening setting, these data are only indicative for baseline. In the present analysis, we focused on comparing tests’ performance not only at baseline, but also at the post-treatment follow-up. Interestingly, our data showed comparable performance of the tests in terms of sensitivity and specificity at both baseline and test-of-cure.Due to the setting of samples, which show a high prevalence of positive at baseline and negative at follow-up, respectively, sensitivities were found to be higher at baseline and lower at follow-up. On the contrary, specificities are notably higher at follow-up than at baseline. Due to the low prevalence of HPV after treatment, we chose the prevalence and bias adjusted kappa, instead of either the simple or the weighted kappa, to estimate the HPV tests’ agreement.However, all tests perform similarly at baseline and follow-up. Although Cobas seems to show better performance than other tests, these data might suffer from a bias related to the smaller number of samples that have been tested with the Cobas method.A negative HPV result at follow-up provides a good negative predictive value. Indeed, we found only a case of disease recurrence in the cohort of patients with a post-treatment negative HPV test result, for any validated HPV test. In this patient, cytology was HSIL at follow-up and only LA revealed the presence of HPV18 and 73 at baseline, with the persistence of HPV 73 at relapse. Actually, LR HPV genotypes are not detected by validated HPV tests.Furthermore, HPV tests that provide partial or extended genotyping showed comparable results.The Aptima test, which detects HPV mRNA, showed no particular advantages in terms of sensitivity or specificity: the test performances are in line with other tests that detect HPV DNA.Strengths of the present study include the type of population (women with only confirmed CIN2 + histology) and the timing of test-of-cure that was performed at 6 ± 3 months, as also suggested by the most recent guidelines from the Italian Group for Cervical Cancer Screening (GISCi) . On the In conclusion, our results demonstrate that validated HPV tests produce comparable results, and this cannot be extended to non-validated tests without proven evidence. Thus, only the use of validated HPV DNA or RNA tests is strongly recommended in both screening and test-of-cure settings. Moreover, HPV genotyping could be helpful in post-treatment management, by identifying women at higher risk of CIN2+ recurrence, due to the persistence of the same HPV genotype, and reassuring women who may present new HPV genotype infection after surgical treatment.


Little is known about COVID-19 vaccine hesitancy and acceptance among individuals experiencing homelessness, despite their higher risk for morbidity and mortality from SARS-CoV-2. This study examines COVID-19 vaccination attitudes and uptake among U.S. military Veterans experiencing homelessness enrolled in transitional housing programs funded by the U.S. Department of Veterans Affairs (VA). Telephone interviews were conducted with 20 Veterans in California, Florida, Iowa, Kentucky, and Massachusetts, USA (January–April 2021). A rapid analysis approach was used to identify and enumerate commonly occurring themes. Although 60% of interviewed Veterans either received the COVID-19 vaccine or were willing to do so, one-third expressed hesitancy to get vaccinated. COVID-19 vaccination attitudes , military experience, beliefs about influenza and other vaccines, and sources of information emerged as influential factors for COVID-19 vaccination uptake or hesitancy. Veterans in VA-funded homeless transitional housing programs are generally willing to be vaccinated. However, a substantial minority is reluctant to take the vaccine due to concerns about the COVID-19 vaccine and distrust of authority. Recommendations for increasing uptake include utilizing Veteran peers, homeless service providers, and healthcare providers as trusted messengers to improve confidence in the vaccine. The COVID-19 pandemic has brought disruption and the risk of illness and death for individuals living in institutional settings throughout the United States. While vaccines offer hope for a return to safety and normalcy, COVID-19 vaccine hesitancy among socioeconomically disadvantaged individuals is poorly understood. Recent research has begun closely examining vaccine acceptance among vulnerable populations ,3. GlobaPromoting COVID-19 vaccine uptake among people experiencing homelessness is essential to reducing transmission, illness, and death. For these reasons, the U.S. Centers for Disease Control and Prevention (CDC) issued guidelines advising that state and local health departments consider prioritizing the vaccination of homeless populations residing in congregate facilities . HoweverPrevious studies examining COVID-19 vaccine hesitancy and uptake among individuals and Veterans experiencing homelessness in the U.S. ,16,17,18One subgroup of people experiencing homelessness, homeless Veterans, may differ from the general homeless population in vaccine attitudes and behaviors due to their unique experience of serving in the military. Prior to the U.S. military vaccine mandate ,25, actiEnsuring that Veterans experiencing homelessness receive the vaccine in significant numbers is important to the U.S. Department of Veterans Affairs’ (VA) effort to reduce the spread of COVID-19, as Veterans are disproportionately represented within the U.S. adult homeless population ,31. ThisQualitative interviews were conducted with Veterans from five GPD organizations in California, Florida, Iowa, Kentucky, and Massachusetts. The GPD organizations were all male-only facilities. The research team invited GPD grantee organizations to participate in the study through a monthly webinar call hosted by the National VA GPD Office, which is attended by GPD grantee organizations and VA homeless program staff. GPD grantee organizations interested in participating were invited to contact the research team. Seven organizations contacted the research team to participate in the study. These GPD organizations were then encouraged to invite their Veteran residents to participate in one of two ways: (1) Veterans received a recruitment flyer, which included a phone number they could use to contact the research team to set up a time for an interview, or (2) GPD organizations collected the names and phone numbers of Veteran residents who expressed interest in participating, and with the Veterans’ consent, shared that information with the research team, who contacted the Veterans directly. Five of the seven organizations successfully recruited Veterans to participate in interviews. The research team also interviewed staff at all seven GPD organizations to inquire about their experiences providing care during COVID-19 and what they were doing to facilitate Veterans’ vaccination. Staff perspectives are reported elsewhere ,36.The study team conducted qualitative, semi-structured telephone interviews lasting approximately 30 min from January to April 2021 until data saturation was reached , resultiThe interview guide was developed by the research team and consisted of 20 open-ended questions. The interview guide was derived from prior studies of vaccine attitudes and behavior among people experiencing homelessness ,23, whosAll interviews were audio recorded and transcribed. The study team utilized a rapid analysis approach (April to May 2021) to analyze the interview transcripts ,40 usingParticipating organizations varied in size and housing format, including two site-based programs with GPD beds located within larger organizations also serving the general homeless population, and three scattered-site programs with Veterans living in housing separate from the larger organization. Given the variation in timing, some Veterans were interviewed before the COVID-19 vaccine was first offered to them, whereas others were interviewed after they had access to vaccines.Respondents were between 29 to 65 years old, with most being in their 40s to late 50s. The majority identified were white, though five were people of color and four declined to state their race. Some GPDs made vaccines available onsite to Veterans through the local health department and the local VA, whereas Veterans at other sites had to go to the VA to receive the vaccine. Veterans mentioned factors that shape their vaccination decisions, including the rapid development of the vaccine and their views overall toward the COVID-19 pandemic. Major themes that emerged from the interviews included: (1) COVID-19 vaccination uptake attitudes; (2) Veterans’ military experiences; (3) influenza vaccination uptake; and (4) sources of information about the COVID-19 vaccine.Veterans stated various reasons for being either willing or hesitant to be vaccinated. “My first wife died from [COVID-19] and thousands of Americans are dying from it. I got the shot, I got PTSD, and it gave me some nightmares… I had flashbacks of being in the jungle again… I’m still going to get the second shot though, because… through time, I’ll be pretty much protected from it.” (Iowa2)Veterans who were eager or willing to uptake the vaccine had rationales that converged around the core theme of wanting to prevent illness, death, and transmission to loved ones and their community:Veterans who were more hesitant to get the vaccine had slightly more varied rationales. Perceptions that vaccines were either insufficiently tested or were “too new” were mentioned most frequently. Among vaccine-reluctant Veterans, all but one noted that the rapidness with which the COVID-19 vaccines were approved left too much uncertainty for their comfort. Half of the vaccine-reluctant Veterans also mentioned the related concern that long-term side effects of the COVID-19 vaccines were still unknown:“They rushed this in like seven, eight months, so they can’t tell you what it’s going to be like in two years, five years. You know, back when the smallpox [vaccine] first came out, they said—‘Oh, that was fine.’ Then they started having birth defects and you know, like different problems with that, you know what I mean?… You can’t tell me what it’s going to be like five years down the road, just to be safe today. I don’t want to get cancer five years down the road, so I didn’t get COVID today.” (Florida2)Mistrust of either government or vaccine manufacturers was also a factor in more than half of the vaccine-reluctant Veterans’ decision. The youngest Veteran was hesitant to get vaccinated because he does not like needles, while another did not see the need to get the vaccine since he already had COVID-19.All 20 Veterans unanimously reported that they did not experience or anticipate any barriers to accessing the COVID-19 vaccine. Two of the five organizations facilitated on-site vaccination. Two Veterans noted that while they were willing to be vaccinated, their motivation was low given the competing demands, such as finding permanent housing, that for a homeless person supersede the urgency of vaccination:“If someone wants to give it to me, I would absolutely, 100% take it. No issues, whatsoever. But… it’s such a low priority, I’m not generally going to seek it out.” (Iowa1)Three others noted that they would gladly get the vaccine if it were required for jobs or other benefits. Even among those who are very open to vaccination, Veterans experiencing homelessness may fail to uptake the vaccine unless it is available to them with little to no effort.Veterans’ military experiences and identity emerged as influential in shaping their views toward vaccines and had both a positive and negative effect on their vaccination uptake attitudes. Some Veterans mentioned their distrust of government or the military as their reason for refusing to get the vaccine; however, most Veterans who cited getting mandatory vaccines regularly as part of their military experience noted that they felt acclimated to getting recommended vaccines as a result:“They said you can get a vaccine today, and I said okay… When somebody offers me a vaccine, I’m like all right I’ll get it. I’m prepared… I’m used to being a guinea pig… I was in the Army active for three and a half years, and then I did nine and a half years total, the reserve and active. So, you know people sticking needles in me, telling me, ‘all right you need to take this’, and I’m like ‘okay’.” (Massachusetts4)The significance of military experience was especially notable given that despite not being asked about it, 11 of the 20 Veterans mentioned their military experience as influencing their views toward the vaccine. A quarter of Veterans noted that many immunizations were required in the military, such as the influenza or anthrax vaccines. Two recently discharged Veterans noted that there were adverse career consequences to not getting these vaccines during military service.For some Veterans, military experience engendered a sense of distrust toward government, the VA, and the military that extended to vaccine refusal. Exposure to environmental hazards during military service was cited as another factor behind distrust of government-endorsed science. One Veteran cited his exposure to water contamination at the Camp Lejeune Marine Base as a reason for distrust of the COVID-19 vaccine. Another Veteran cited mandatory vaccination while serving in the military and wanted to avoid putting more unnecessary things into his body now that he had a choice:“Going into the military, I had tons of vaccines, and putting one more in my body is something I try not to do if I don’t have to.” However, not all Veterans who expressed mistrust of the military and government were hesitant to receive the COVID-19 vaccine. One emphasized their desire to avoid spreading COVID-19 to loved ones helping to overcome feelings of military and government distrust.Most Veterans who refused to get the COVID-19 vaccine said their concerns about this specific vaccine made them hesitant. Only one expressed skepticism and hesitancy about vaccines in general; the remaining Veterans, including five of those who did not intend to get the COVID-19 vaccine, affirmed their beliefs that vaccines are effective tools to prevent disease. When asked whether they recently got the influenza vaccine, nine of the 20 Veterans received the flu shot in either 2019 or 2020. All but one of the Veterans who received the flu vaccine had either gotten the COVID-19 vaccine or intended to get it, suggesting among flu shot recipients a tendency to be more accepting of vaccines. A few Veterans had also received vaccines for hepatitis, and one reported having to delay COVID-19 vaccination because of recent hepatitis vaccination.Of the seven Veterans who reported that they routinely refuse flu shots, half accepted the COVID-19 vaccine, suggesting higher demand for the COVID-19 vaccine than the flu vaccine given the strong virulence and seriousness of COVID-19. Some Veterans cited distrust in both flu and COVID-19 vaccines.Veterans reported getting their information about COVID-19 and the vaccine from a wide variety of sources, with some citing more than one primary information source, see The “news” was the most popular, comprising the main source of information for 14 of the Veterans. Of these 14, nine were willing to get vaccinated, while four were unwilling, and one was undecided but leaning toward yes. “News” included sources ranging from television news and physical newspapers to podcasts, with television news comprising the vast majority (8 of 14). Eight Veterans, half of whom also had “news” as an information source, mentioned the internet as their primary way of seeking information. Internet sources included videos on YouTube and social media (Facebook or Instagram), but also, for younger Veterans, Reddit and stock market apps.Seven Veterans said they primarily receive their information on the COVID-19 vaccines from peers, including family, friends, colleagues, or strangers. Some Veterans said they trusted the word of close others in their lives more than “some news anchor’s opinion” (Iowa1) or social media:“The most reliable source of information about COVID is direct word of mouth from someone who has had it.” (Kentucky2)Of these seven, three were already vaccinated, three were unwilling, and one was undecided but leaning toward yes. Nine Veterans had spoken to other GPD Veterans about the vaccine: some were hesitant, while others were willing to be vaccinated. Two Veterans reported being convinced to take the vaccine or having convinced others to get it through these conversations.Eight Veterans cited information from professionals, including GPD staff, healthcare workers, or government organizations, as their primary information sources. Of these, five were already vaccinated, two were unwilling, and one was undecided and leaning toward yes. The Veterans did not receive any educational information about the COVID-19 vaccine from their own physician, with 17 of the 20 Veterans explicitly reporting that no such vaccine information was given, even though 11 Veterans said they trust their provider. Two Veterans in their 30 s said they did not trust their VA doctors because of bad experiences. The GPD was cited as a trustworthy source by seven Veterans who received information about the vaccine from their GPD staff. Several Veterans noted that they were not sure what sources to trust, given the prevalence of misinformation on television and the internet.Vaccine reluctance has previously been linked to confidence (distrust), complacency (lack of perception of seriousness), and convenience (perceived barriers to access) ,44,45, aNo access barriers were reported among Veterans. Two of the five GPD programs provided vaccines onsite in February 2021 when vaccine access was very limited. Some Veterans had assistance setting up appointments from VA and GPD staff, which helped facilitate uptake. Interventions to facilitate access have been previously recommended to reduce barriers and facilitate vaccination for people experiencing homelessness ,49,50. CSome support was found for Kuhn’s  finding GPD program-enrolled Veterans differ from the general homeless population in that most have access to a regular source of health care and a safe and secure living space , better Low vaccination rates among people experiencing homelessness pose a challenge for congregate residential programs due to concerns about COVID-19 transmission. Increasing homeless Veterans’ uptake of the COVID-19 vaccine would ameliorate safety concerns related to shared housing in VA-funded GPD facilities. VA Homeless Program documents  suggest People experiencing homelessness are, like most of the population, highly aware of the risks of COVID-19, and are likely willing, if not eager, to be vaccinated when opportunities are easily available. However, these findings underscore the vital role of trusted others as conduits for communicating the risks and benefits of vaccination to homeless individuals with vaccination doubts. Peer education and outreach by healthcare and homeless service providers, accompanied by easy access to vaccines, are likely to be highly influential in increasing vaccine acceptance and uptake. Understanding hesitancy toward vaccination uptake in vulnerable populations, such as Veterans experiencing homelessness, is vital to ultimately reducing the spread of COVID-19 and mitigating the pandemic’s worst impacts on unhoused individuals.


Success in delaying long term institutionalization (LTI) depends on creating means to adequately support each Veteran’s needs. To better understand the unmet needs of Veterans, we identified a random sample of 20,000 Veterans from five VA sites. Veterans were stratified into low-, moderate- or high-risk tiers using a measure of predicted 2-year probability of LTI. Veterans and their caregivers were asked to complete separate surveys to assess demographic, physical, psychological, and social domains, unmet needs, and experience with HCBS and caregiver support programs. Responses were received between July-Dec 2021 from 8056 Veterans  and 3579 caregivers  responded by mail (96%) or online (4%). Both Veterans and caregivers endorse complex Veteran unmet needs spanning medical, psychological, and social domains. Survey results will be used to inform HCBS policy to support aging Veterans and their caregivers.


In conclusion, the NeuMoDx HPV assay meets international guideline criteria for cross-sectional accuracy and reproducibility, and performs equally well on cervical screening specimens collected in two widely used collection media. The NeuMoDx HPV assay fulfils the requirements to be used for primary cervical screening.The NeuMoDx HPV assay is a novel fully automated, real-time PCR-based assay for the qualitative detection of high-risk human papillomavirus (HPV) DNA in cervical specimens. The assay specifically identifies HPV16 and HPV18 and concurrently detects 13 other high-risk HPV types at clinically relevant infection levels. Following the international guidelines, the clinical performance of the NeuMoDx HPV assay for cervical intraepithelial neoplasia grade 2 or worse (CIN2+) against the reference standard Hybrid Capture 2, as well as intra- and inter-laboratory reproducibility were assessed on PreservCyt samples. The clinical accuracy of the assay was additionally evaluated against the clinically validated Alinity m HR HPV and COBAS 4800 HPV Test on PreservCyt samples, and against the clinically validated HPV-Risk assay on SurePath samples. The NeuMoDx HPV assay performance for CIN2+ was non-inferior to the reference methods on both sample types (all  Worldwide, an increasing number of cervical cancer screening programs are converting from cytology to primary human papillomavirus (HPV)-based screening because of the better clinical performance for the detection of cervical cancer and its high-grade precursor lesions ,2. HPV aHere, the NeuMoDx HPV assay, i.e., NeuMoDx HPV Test Strip implemented on the NeuMoDx Molecular Systems, was evaluated according to the international guidelines for HPV DNA test requirements for cervical screening in women 30 years and older [The NeuMoDx HPV assay  combines automated DNA extraction and amplification/detection by real-time PCR. The assay is designed for the qualitative detection of 15 high-risk HPV types at clinically relevant viral load levels in cervical specimens. The detection of target region in the E7 gene is by hydrolysis probes with 3 different fluorescent dyes, each representing different (pools of) targets, in particular HPV16, HPV18, and 13 other high-risk HPV types combined. The human β-globin gene is detected in a fourth channel using a probe labeled with a different fluorescent dye and serves as a qualitative endogenous sample process control to monitor for poor sampling, presence of inhibitory substances and/or for system, process, or reagent failures. The primers and probes together with the other elements necessary for amplification of the HPV and β-globin targets  are dried using a proprietary process at the bottom of each well in a test strip and sealed from exposure to ambient light and atmosphere. All testing was performed according to the instructions of the manufacturer using the NeuMoDx 96 Molecular System (N96). Cervical specimens collected in PreservCyt collection medium) can be directly processed on the NeuMoDx system without sample pre-treatment utilising 0.25% of the original sample (0.05 mL). Specimens in SurePath collection medium require a pre-treatment to overcome the formaldehyde-induced crosslinking of the DNA. For this, the original SurePath sample is diluted 1:1 in NeuMoDx Viral Lysis buffer (NeuMoDx Molecular) and incubated at 90 °C for 20 min after which the sample is ready for loading on the system utilising 1% of the original sample (0.1 mL). The results processing algorithm is captured in an assay definition file (ADF) and scoring of a sample is based on second derivative Ct calling, endpoint fluorescence and endpoint fluorescence ratio. In samples where no HPV target(s) are scored, the sample is considered HPV negative only when β-globin amplification is detected. Samples where no β-globin nor HPV target(s) are scored are reported as Unresolved indicating invalid result.The study was performed using residual clinician-collected cervical specimens from women aged 30 years and older collected in PreservCyt collection medium (group 1) or in SurePath collection medium (group 2). All cervical specimens had been collected with the Cervex brush or the Combi-brush collection device . The work in this study with human-derived material was conducted under applicable international, EU and national rules and legislation/regulations, with approval by the local ethics committees where applicable .This series comprised 895 historical clinician-collected cervical screening samples including 68 samples from women with histologically confirmed CIN2+  and 827 from women attending a national screening programme with two consecutive normal cytology results , that were prospectively enrolled within a nationwide network of 16 outpatient gynaecology services in Slovenia between December 2009 and August 2016. The exclusion criteria for control group were attendance for a gynaecological examination after an atypical/abnormal cytology result, history of CIN of any grade or treatment for cervical disease in the preceding years, hysterectomy, and menstruation or pregnancy at presentation [For analysis of intra-laboratory reproducibility over time and inter-laboratory agreement, 512 archived clinician-collected cervical samples of which one third tested HPV positive were used. The NeuMoDx HPV assay was performed twice blinded on this sample series with an average 23 (range 12–78) days interval between testing using N96 System at the same laboratory . A third analysis was performed in a blinded manner using a second N96 System located at another laboratory .This series comprised 948 historical clinician-collected cervical screening samples including 106 samples from women with histologically confirmed CIN2+  and 842 samples from women who were without evidence of CIN2+ in up to 2 years of follow-up monitoring and twice tested cytology normal prior to inclusion  [p-values ≤0.05 were considered statistically significant.Testing of the NeuMoDx HPV assay was performed in a blind manner for any test result as well as cytological and histological outcomes, and data were correlated after-wards. The clinical sensitivity and specificity values for the NeuMoDx HPV assay were compared with those of the reference or comparator assay using a non-inferiority score test as described by Tang et al. , with a A series of 895 cervical screening samples collected in PreservCyt (68 from women with CIN2+ and 827 from control women without evidence of CIN2+) was tested, of which 97.0% (868/895) of samples gave valid test results with the NeuMoDx HPV assay. For samples with valid test results, the clinical sensitivity for CIN2+ of the NeuMoDx HPV assay was found to be 95.5%  and the clinical specificity for CIN2+ was determined to be 96.4% . For comparison, these figures were 97.0%  and 93.8% , respectively, for the reference assay HC2 .p = 0.018 and 0.0001, respectively).The relative sensitivity and specificity values of the NeuMoDx HPV assay compared to the reference assay HC2 were 0.98 (95% CI: 0.92–1.05) and 1.03 (95% CI: 1.01–1.05), respectively. Both the clinical sensitivity and clinical specificity for CIN2+ of the NeuMoDx HPV assay were non-inferior to that of the reference assay  and the clinical specificity for CIN3+ was determined to be 94.4% . For comparison, these figures were 95.9%  and 91.7% , respectively, for the reference assay HC2.n = 509), the intra-laboratory reproducibility over time was 95.7%  with a kappa value of 0.90  and 99.8% (511/512) of the samples tested in the two runs performed in laboratory 1, and for 99.8% (511/512) of the samples tested in laboratory 2. For samples with valid test results in all runs/laboratories .A series of 948 cervical screening samples collected in SurePath (106 from women with CIN2+ and 842 from women without evidence of CIN2+) was evaluated, of which 98.6% (935/948) of samples gave valid test results with the NeuMoDx HPV assay. For samples with valid test results, the clinical sensitivity for CIN2+ of the NeuMoDx HPV assay was determined to be 92.5%  and the clinical specificity for CIN2+ was calculated as 93.5% . For comparison, these figures were 92.5%  and 91.9% , respectively, using the HPV-Risk assay . The relp = 0.011 and p = 0.006, respectively) and non-inferior to those of Alinity m HR HPV assay . For detailed results see The performance of the NeuMoDx HPV assay in group 1 samples was further evaluated in relation to the COBAS 4800 HPV and Alinity m HR HPV assay. The clinical sensitivity and specificity of NeuMoDx HPV assay were non-inferior to those of COBAS 4800 HPV ; however, only a small number demonstrated full compliance with requirements of the 2009 international guidelines for HPV DNA tests , and an Clinical samples with discrepant test results between the NeuMoDx HPV assay and the reference assays were primarily found in controls. Discrepant results were not related to a specific HPV target, but mostly due to signals just above or below threshold settings of the assays (data not shown). This is a well-known cause of discrepancies for samples without underlying clinically meaningful disease harboring low viral load levels just around the clinical assay cut-off ,16.n = 169; 59.7% HPV-positive) were also subjected to testing on the N288 System, with similarly high inter-laboratory agreement results ; data not shown). The ability of the NeuMoDx Systems to run different assays in parallel, both combinations of other CE-IVD assays and homebrew or laboratory developed tests, with a true random access and continuous loading workflow, enhances their utility in molecular diagnostics laboratories.The NeuMoDx HPV assay has several advantages for cervical cancer screening purposes, including: (1) clinically relevant detection of all high-risk HPV genotypes (E7 region) with additional partial genotyping of HPV16 and HPV18; (2) being a fully automated “sample to result” system with a time to first result of approximately 60 min which is significantly shorter in comparison to the great majority of other HPV tests on the market, including the comparators used in this study; (3) utilising ambient-condition-stable reagents capable of being stored on the system, thereby eliminating the need for manual preparations, and (4) possessing high-throughput and high intra-/inter-system reproducibility. Herein, the reproducibility of testing on the N96 System was shown to be high, both intra- and inter-laboratory. Part of the samples (In conclusion, the NeuMoDx HPV assay has a high sensitivity and a high specificity for the detection of CIN2+, independent of cervical sample collection medium. The fully automated NeuMoDx HPV assay fulfils the requirements of the international guidelines for an HPV DNA test to be used for primary cervical screening.


Gammapapillomavirus. It has the classical genomic organization of Gammapapillomaviruses. Epidemiological investigation showed that one out of the 413 AGW tissue samples was positive for HPV-JDFY01. Further research with large size and different type of samples should be performed to elucidate the epidemiologic status of HPV-JDFY01.Viral metagenomics is widely employed to identify novel viruses in biological samples. Recently, although numerous novel human papillomavirus (HPV) types have been identified in clinical samples including anogenital warts (AGWs), many novel HPV sequences remain to be discovered. In this study, a putative novel HPV type designated as HPV-JDFY01 was discovered from library GW05 with 63 sequence reads by the viral metagenomic technique. Its complete genomic sequence was determined by PCR to bridge the gaps between contigs combining Sanger sequencing. The complete genome of HPV-JDFY01 is a 7186 bp encoding 7 open reading frames (ORFs)  and contains a 487 bp long control region (LCR) between L1 and E6. Sequence and phylogeny analysis indicated that HPV-JDFY01 shared the highest sequence identity of 74.2% with HPV-mSK_244 (MH777383) and well clustered into the genus  HPVs are present as small, nonenveloped and circular double-stranded DNA viruses with an icosahedral capsid, and they consist of an average genome length of 8000 bp ,2. The whttps://www.hpvcenter.se/>. These HPVs are only distributed over five evolutionary genera, including Alphapapillomavirus, Betapapillomavirus, Gammapapillomavirus, Mupapillomavirus and Nupapillomavirus.The International Human Papillomaviruses Reference Center has confirmed 223 HPV types with complete genome as of 5/April/2022 <Gammapapillomavirus accounts for over 50% of total HPVs and owns 83.3% of the novel types from 2014, which demands significant attention [Gammapapillomavirus [ttention . In addiomavirus .https://www.hpvcenter.se/), three of which belonged to Gammapapillomavirus. Latsuzbaia et al. [In the past four years, only four novel HPV types had been identified, including HPV226 (Gamma-6), HPV227 (Beta-2), HPV228 (Gamma-27) and HPV229 (Gamma-7)  was discovered from AGWs tissue samples and the complete genome was acquired by combining PCR and Sanger sequencing. Sequence and phylogeny analysis were further performed to fully characterized this putative novel type of HPV.g under the conditions of 4 °C.A total of 110 tissue samples of wart from AGW patients, including 34 females and 76 males, were collected from September 2016 to August 2017 from the Department of Dermatology and Venerology at the Affiliated Hospital of Jiangsu University. The mean age of AGW patients was 42.5 years and the mean disease duration was 3.26 months. Each sample was transferred into 1.5 mL test tube with 1 mL dulbecco’s phosphate-buffered saline (DPBS) and then added into several 5 mm sterile stainless-steel beads to fully grind tissue for 5 min. After freeze and thaw 3 times on dry ice for 3 min each time, the tissue supernatants were obtained after centrifuging for 10 min at 12,000× −5, where the viral proteome databased included NCBI virus reference proteome together with viral proteins sequences from NCBI nr fasta file.The 110 supernatants of wart tissues were randomly pooled into 11 sample pools, each containing 10 samples. These sample pools were filtered through a 0.45 μm filter  to remove cellular particles in the sample ,14. The Finding six contigs ranging from 123 bp to 645 bp in length in GW05 pool, which showed low sequence similarity to known HPVs, 2 sets of specific PCR primers derived from a contig belonging to L1 gene of HPV were, respectively designed to confirm the existence of the putative novel HPV sequence in samples from GW05 pool. PCR primer sequences are displayed in Alphapapillomavirus, Betapapillomavirus and Gammapapillomavirus. Multiple alignments were conducted using ClustalW in MEGA7 with the default settings [Phylogenetic analysis was performed based on amino acid sequences of predicted ORFs to analyze the genetic relationships between HPV-JDFY01 and the other related HPV types which included the representative types of settings . The alisettings . The measettings .The NGS results indicated that the 11 libraries generated a total of 6,509,970 reads, 726,777 (11.16%) of which showed significant sequence similarity to HPV. The library GW02 generated the largest number of total reads  while the library GW09 contained the most abundant HPV-related sequence reads 227,374). Among the HPV sequence reads in these libraries, Alpha-10  ranking first was followed by Alpha-8 , Alpha-14 (1622) and Alpha-9 (1066). HPV11 occupied the dominant part in Alpha-10 (95.41%) and HPV of the GW05 library (33.87%), respectively, in accordance with that of the literature reported previously [,374. AmoA putative novel HPV type HPV-JDFY01) was discovered from AGW, of which the complete circular genome is 7186 bp in length with a GC content of 36.6%. The details of the seven predicted ORFs are described as follows: Early proteins: E6 (nucleotide (nt) 1–420, 420 bp), E7 , E1 , E2  and E4 ; Late proteins: L2  and L1 ; and a 487 bp long control region (LCR) is located at 6700 to 7186 of the genome between L1 and E6 . The put was discAlphapapillomavirus, 9 from Betapapillomavirus, 15 from Gammapapillomavirus and 13 from unclassified papillomavirus so as to generate the phylogenetic tree that clearly reflected the evolutionary relationships of these representative HPV types. From the results of the phylogenetic analysis, the HPV-JDFY01, together with HPV-mSK_244  of HPV have been designed and developed for the purpose of prophylactic HPV vaccines . FurtherGammapapillomavirus named HPV-JDFY01 was detected by a viral metagenomics method from AGWs, whose complete genome was determined and genomic structure and phylogeny were fully characterized. The functional, biophysical and carcinogenic properties of HPV-JDFY01 need to be elucidated in the future research.In this study, a putative novel


Recurrent respiratory papillomatosis (RRP) is a rare manifestation of human papillomavirus (HPV) infection. It is characterized by relapsing bulky papillomas in the respiratory tract, which are usually benign in nature. We describe a challenging case of RRP in an HIV-infected patient with extensive pulmonary disease, presenting with worsening dyspnea. The interaction between HPV with HIV as a coinfection is still not completely understood, particularly the role of HIV-associated immunosuppression in RRP.Our main goal is to raise awareness of this clinical entity and to promote further studies on its management, particularly in specific populations such as HIV-infected individuals. A brief review of the theme is also presented. Papillomaviridae family with a propensity to infect epithelial cells, especially in the junction between stratified squamous and respiratory columnar epithelium [Human Papillomavirus (HPV) is a DNA virus of the ithelium ,2. Recurithelium .RRP shows a characteristic bimodal age distribution divided into juvenile-onset RRP and adult-onset RRP. Juvenile-onset RRP, occurring in children before the age of 12 years, is usually more aggressive and more likely to recur . The aduRRP is difficult to treat given its tendency to recur and spread through the adjacent aerodigestive tract. There is no cure for RRP, and treatment is primarily focused on maintaining airway patency, often requiring multiple endobronchial procedures ,6. 3, without sustained viral suppression due to frequent interruptions of her highly active antiretroviral therapy (HAART) regimen. She also had severe chronic obstructive pulmonary disease (COPD), with bronchiectasis and emphysema, due to lifelong smoking and inhaled drug, as well as a previous episode of tuberculosis. These sequelae resulted in chronic respiratory insufficiency requiring continuous domiciliary oxygen flow at 2L/min, despite optimized long-acting bronchodilator therapy. The patient had not been vaccinated for HPV and previous cervical cytology screening was negative for dysplasia.We describe the case of a 46-year-old female patient with a past medical history of HIV infection with 253 CD4+/mmShe was admitted to the emergency department due to worsening dyspnea requiring increased oxygen flow and productive cough with mucopurulent sputum for over a week, without fever or other accompanying signs or symptoms. An infectious exacerbation of her COPD was assumed. Since there was no improvement after three days of antibiotics (intravenous ceftriaxone 1g/12h and azithromycin 500mg/24h), with negative results in sputum cultures and respiratory virus panel, a pulmonary computed tomography scan was performed that revealed a polypoid lesion on the tracheal lumen Figure  without The patient was re-admitted to our center two years after the first admission with a new episode of worsening dyspnea and stridor. Recurrence of tracheal papillomatosis lesions was documented on a new bronchofibroscopy which revealed obstruction in the lower third of the trachea with a lesion occupying about half of its lumen near the location of the previous papilloma, with no other lesions Figure . MechaniRRP is a disease of the aerodigestive tract that typically affects the larynx but can occasionally become aggressive, resulting in persistent or recurrent involvement of the nasopharynx, tracheobronchial tree, and, more rarely, the pulmonary parenchyma . The solEven though several distinct genotypes of HPV may cause RRP, current evidence shows that more than 90% of RRP cases are caused by the low-risk HPV genotypes (HPV 6 and 11) with transformation to malignant forms being rare and usually associated with infection by HPV genotype 16 ,9.There is no curative treatment for RRP. The mainstay of treatment is endobronchial and surgical debulking, predominantly through laser therapy or the use of microdebriders . Due to Death secondary to respiratory papillomatosis is rare and most frequently due to pulmonary compromise. Even though dysplasia can be identified in up to 50% of cases with RRP, malignant transformation occurs only in about 1-2% of cases [A preventive strategy through the administration of HPV recombinant vaccines was shown to be effective in reducing the incidence of RRP, particularly juvenile-onset RRP, in a large prospective study developed in Australia following the implementation of a national HPV vaccination program with the quadrivalent HPV vaccine Gardasil  which protects against infection caused by HPV types 6, 11, 16, and 18 ,13. The Patients with HIV have an increased risk of cervical and anogenital cancers, which is related to the degree of immunosuppression ,15. In cThe presented case intends to show a case of RRP in a patient with a particularly challenging clinical setting due to poorly controlled HIV infection and extensive pulmonary disease. In this case presentation, the symptoms presented by the patient were attributed to an exacerbation of her COPD rendering a delay in diagnosis and appropriate treatment of RRP. This case also shows the recurrent pattern of RRP even after complete excision of the papillomatous lesions. The patient had inconsistent adherence to the health care system, mainly due to her social-economic status and substance abuse; it is unknown if RRP and/or its complications may have been implicated in the cause of death.RRP is a chronic and difficult-to-treat disease due to its frequent recurrence rate and unpredictable aggressiveness. The association between HIV and HPV, particularly for RRP, is not fully understood but there seems to be an association between HIV-associated immunosuppression and more frequent and severe manifestations of HPV infections, namely RRP. Therefore, it seems reasonable to think that HPV vaccination should be recommended for all unvaccinated patients who present with RRP, particularly for HIV-infected patients, regardless of age at presentation, and that it should be included in national vaccination programs for this population. The presented case intends to show the difficulties in the management of RRP and the need for frequent revaluations and endobronchial/surgical procedures.


Human papillomavirus (HPV) can cause condyloma acuminatum and cervical cancer. Some mutations of these viruses are closely related to the persistent infection of cervical cancer and are ideal cancer vaccine targets. Several databases have been developed to collect HPV sequences, but no HPV mutation database has been published. This paper reports a Chinese HPV mutation database (HPVMD-C), which contains 149 HPV genotypes, 468 HPV mutations, 3409 protein sequences, 4727 domains and 236 epitopes. We analyzed the mutation distribution among HPV genotypes, domains and epitopes. We designed a visualization tool to display these mutations, domains and epitopes and provided more detailed information about the disease, region and related literature. We also proposed an HPV genotype prediction tool, which can predict HPV carcinogenic or non-carcinogenic risk genotypes. We expect that HPVMD-C will complement the existing database and provide valuable resources for HPV vaccine research and cervical cancer treatment. HPVMD-C is freely available atDatabase URL: http://bioinfo.zstu.edu.cn/hpv. Cervical cancer is one of the main causes to result in cancer incidence rate and mortality worldwide. More than 500 000 people are diagnosed with cervical cancer every year, and nearly 280 000 die from it , 2. SomeHPV is an icosahedral non-circular particle with small double-stranded circular DNA containing about 8000 nucleoside base pairs . It beloet al. confirmed that HPV16 E6 variant is related to human leukocyte antigen (HLA)-DRB1 and DQB1 alleles in Chinese young cervical cancer population , China National Knowledge Infrastructure (CNKI) (https://www.cnki.net) and other public databases. There are 468 mutations covering 10 HPV genotypes   which consists of a collection of well annotated multiple sequence alignment models for ancient domains and full length proteins and many domain models imported from external source databases, such as Pfam (http://ftp.ebi.ac.uk/pub/databases/Pfam), simple modular architecture research tool , clusters of orthologous genes  and so on. For CDD, we set the parameter expect value as 0.01 and the default maximum number of hits is 500 to obtain the identification result. We used RADAR  68 HPV genotypes, genome sequences and protein sequences are collected from NCBI, and eight data sets are constructed according to eight HPV proteins. (ii) Five hundred and twenty-two amino acid indexes were extracted and sorted from AAindex database . These ihttps://ftp.ncbi.nlm.nih.gov/blast/executables/blast+/2.6.0/) analysis tool to create a comparison library  for sequence similarity search is introduced into HPVMD-C . We down library . Users c library .http://www.apache.org) on Windows 7 operating system. All data in the database are managed using MySQL (http://www.mysql.com). The web page of the client is generated using PHP (V5.6) scripting language (http://www.php.net). HPVMD-C has been successfully tested on Microsoft Internet Explorer 8, Firefox 60 and Google Chrome 66.HPVMD-C system consists of three parts: client, server and database. The database is hosted on a web server running Apache   , a multiet al.  on the BLAST result page to enter the ‘Detail’ page, as shown in Some databases have been developed specifically for HPV. For example, HPVdb  databaseAlthough the above two databases provide researchers with important sequence information and related immune information, they do not include HPV mutation data, which is an ideal target for cancer vaccine. HPVMD-C contains 149 HPV types, 468 HPV mutations, 3409 protein sequences, 4727 domains and 236 epitopes. It has visualization technology to display these mutations, domains and epitopes and provide more detailed information about disease, region, race and related literature. It also provides a BLAST to facilitate user search and an HPV genotype prediction tool, which can predict the carcinogenic risk or non-carcinogenic risk genotype of unknown HPV.HPV mutation and epidemiological data of cervical cancer in China will play an important role in the development of cervical cancer vaccine. HPVMD-C not only provides convenient browsing and search functions, mutation and domain or epitope combination analysis but also includes a tool to predict HPV genotypes. In order to make the database as comprehensive as possible, we collected a large number of identified HPV sequences, mutations and epitopes in China and used various online tools to identify sequence domains. We first combined domains, secondary structures and epitopes with mutations to find some regions that may lead to functional changes and may affect immunogenicity. We introduced some visualization techniques to display these mutations, domains and epitopes and provided more detailed information about disease, region, race and related literature. We also provided a BLAST to facilitate user search and an HPV genotype prediction tool to predict HPV carcinogenic risk or non-carcinogenic risk genotypes. In the future, since more data sets are available, we will regularly update HPVMD-C and add HPV mutations and related domains in other HPV genotypes to expand the database. We expect that HPVMD-C will supplement the existing database and provide valuable resources for HPV vaccine research and cervical cancer treatment.baac018_SuppClick here for additional data file.


This cohort study of US veterans reports changes in rates of anxiety and depressive disorders following the COVID-19 pandemic. It is not clear whether these increases portend exacerbated or persistent courses of distress, and what risk or protective factors are associated with these courses.A considerable minority of US adults (approximately 13%)2 which characterized the prevalence of distress  before and 1 year into the COVID-19 pandemic by analyzing 2 additional years of longitudinal data, and identifying factors associated with exacerbated and persistent courses of distress.In this study, we build upon our previous study of US military veterans,STROBE) reporting guidelines, and participants provided written informed consent. The ethics committee of VA Connecticut Healthcare System approved the study.A total of 2289 US veterans participated in a 3-year longitudinal study as part of the National Health and Resilience in Veterans Study (NHRVS). The study period was divided into 3 phases of the pandemic: prepandemic , peripandemic , and 2-year postonset . Poststratification weights were employed to yield inferential results representative of the US veteran population. The NHRVS followed the Strengthening the Reporting of Observational Studies in Epidemiology  , most veterans were classified as resistant (1962 participants [83.7%]). The remainder exhibited resilient (105 participants [5.3%]), persistent (96 participants [5.0%]), remitted (78 participants [3.5%]), or exacerbated (48 participants [2.5%]) courses of distress.In the full sample and all sex and age subgroups except veterans aged 65 years or older, distress significantly increased from the prepandemic to peripandemic period  but returned to prepandemic levels 2 years later  . Veteran3 Nevertheless, 2 years later, distress prevalence returned to prepandemic levels, which aligns with prior work suggesting resilience is the modal response to stressful events.4This nationally representative longitudinal study of US veterans revealed that, 1 year into the COVID-19 pandemic, the prevalence of positive screens for distress increased by 51%, with younger and female veterans demonstrating the highest increases, possibly due to unique pandemic-related stressors .5 and higher levels of stress sensitization.6Despite this overall pattern of resilience, a significant minority of veterans had exacerbated  or persistent  courses of distress. Veterans with exacerbated distress 2 years into the pandemic reported greater prepandemic alcohol use problems, greater likelihood of lifetime MDD or PTSD, and lower emotional stability. Possible mechanisms underlying these findings include alcohol-related neuroinflammatory or metabolic changesPandemic-related socioeconomic concerns were significantly associated with persistent distress. Younger age, lower community integration, and higher pandemic-related social restriction stress were also associated with this outcome. These findings underscore the importance of assessment, treatment, and policy strategies that target the economic and social needs of veterans with these risk factors.Limitations of the current study included reliance on self-report and screening measures. Further research is needed to replicate these findings in other samples, identify factors associated with continued distress over time, and evaluate interventions and policies to mitigate distress in veterans at risk for persistent pandemic-related distress.


This survey study assesses the status and timing of HPV vaccination as self-reported by female participants in the National Health and Nutrition Examination Survey from 2011 to 2018. Although the importance of vaccination uptake is well known, vaccination often occurs later than recommended.2 Recent studies have documented the effectiveness of early-age vaccination for reducing cervical precancer and cancer incidence.4 We used data from the National Health and Nutrition Examination Survey (NHANES)5 to estimate the proportion of female individuals who were vaccinated before sexual debut, assess the association of delayed vaccination with HPV-16/18 prevalence, and quantify potential racial and ethnic disparities in timely vaccination.The Centers for Disease Control and Prevention Advisory Committee on Immunization Practices (ACIP) recommends routine human papillomavirus (HPV) vaccination at ages 9 to 12 years5 All NHANES participants or their guardians provided written informed consent. This study was deemed exempt from review by the National Cancer Institute Institutional Review Board because it used deidentified data sets. We followed the AAPOR reporting guideline. NHANES variables and the analytic approach are described in the eMethods in the NHANES is a biennial cross-sectional multistage probability sample representing the noninstitutionalized civilian US population.1 We compared HPV-16/18 prevalence among unvaccinated participants, those vaccinated before sexual debut (predebut group), and those vaccinated after (postdebut group) sexual debut. In participants eligible for routine vaccination (RV), we estimated vaccine uptake and proportion vaccinated by racial and ethnic subgroups.Participants self-reported race and ethnicity, HPV vaccination, and sexual history and underwent vaginal HPV testing. Using responses to NHANES cycles 2011 to 2018, we identified female individuals who were 26 years or younger in 2006 (when HPV vaccination was introduced) and eligible for either routine (aged 9-12 years) or catch-up (aged 13-26 years) vaccination per ACIP recommendations.P = .05 indicated significance.Data were analyzed from September 2021 to March 2022 using R, version 3.6.0, “survey” package. A 2-sided P < .001) lower in the predebut group but only 41% (P = .29) lower in the postdebut group compared with the unvaccinated group. Compared with postdebut vaccination, predebut vaccination was associated with an 82% (P = .08) reduction in HPV-16/18 prevalence.Among the 4727 female individuals  ever eligible for vaccination, cervical HPV-16/18 prevalence decreased from 6%  in the unvaccinated group to 3%  in the postdebut group and less than 1%  in the predebut group . HPV-16/Only 38% of ever-eligible participants were vaccinated, increasing to 56% when restricted to those eligible for RV. However, only 21%  of vaccinated, RV-eligible female adults reported receiving their first dose by age 12 years per ACIP recommendations . Among these adults, 33% were vaccinated before and 23% after sexual debut. Thus, 41% of vaccinated participants received postdebut vaccination.P = .22). Similar proportions of participants were vaccinated before sexual debut (32%-35%).Differences by race and ethnicity were negligible . Proportions of vaccinated Asian and White participants were slightly higher than those of Black and Hispanic participants (57% and 58% vs 54% and 52%; 2 Vaccination by age 12 years is estimated to prevent most lifetime cervical cancers caused by HPV-16/18, but this benefit decreases by one-fourth as vaccination age increases to 16 years.6This study highlights the importance of timely vaccination against HPV, particularly before sexual debut. The findings confirm previous reports that many female individuals receive HPV vaccination after the ACIP-recommended ages.A study limitation is that NHANES 2011 to 2018 data may be subject to recall bias. Further studies are needed to check whether these patterns persist in the 2020s, particularly as the COVID-19 pandemic may have impeded vaccine uptake. To ensure maximum effectiveness from vaccination, pediatricians may stress the importance of timely HPV vaccination.


Accelerated cervical cancer control will require widespread human papillomavirus (HPV) vaccination and screening. For screening, sensitive HPV testing with an option of self‐collection is increasingly desirable. HPV typing predicts risk of precancer/cancer, which could be useful in management, but most current typing assays are expensive and/or complicated. An existing 15‐type isothermal amplification assay  was redesigned as a 13‐type assay (ScreenFire) for public health use. The redesigned assay groups HPV types into four channels with differential cervical cancer risk: (a) HPV16, (b) HPV18/45, (c) HPV31/33/35/52/58 and (d) HPV39/51/56/59/68. Since the assay will be most useful in resource‐limited settings, we chose a stratified random sample of 453 provider‐collected samples from a population‐based screening study in rural Nigeria that had been initially tested with MY09‐MY11‐based PCR with oligonucleotide hybridization genotyping. Frozen residual specimens were masked and retested at Atila Biosystems. Agreement on positivity between ScreenFire and prior PCR testing was very high for each of the channels. When we simulated intended use, that is, a hierarchical result in order of clinical importance of the type groups (HPV16 > 18/45 > 31/33/35/52/58 > 39/51/56/59/68), the weighted kappa for ScreenFire vs PCR was 0.90 (95% CI: 0.86‐0.93). The ScreenFire assay is mobile, relatively simple, rapid (results within 20‐60 minutes) and agrees well with reference testing particularly for the HPV types of greatest carcinogenic risk. If confirmed, ScreenFire or similar isothermal amplification assays could be useful as part of risk‐based screening and management. What's new?Due to cost and perceived complexity, most existing human papillomavirus (HPV) assays for cervical cancer screening are designed to yield a pooled result for the carcinogenic HPV types. Here, to promote rapid, affordable and risk‐based cervical screening, an existing isothermal DNA amplification test was redesigned to group the carcinogenic HPV types into four channels based on clinical importance . In masked retesting of 453 Nigerian specimens, the new ScreenFire assay showed good‐to‐excellent type group agreement with prior PCR testing. When validated, the redesigned test could support risk‐based screening in resource‐limited settings. ANOVAanalysis of varianceCEConformité EuropéenneCIconfidence intervalCIN2+cervical intraepithelial neoplasia grade 2+COVID‐19Coronavirus Disease of 2019ctcycle thresholdHPVhuman papillomavirusHRHigh‐riskIARCInternational Agency for Research on CancerIQRinterquartile rangeIRBInstitutional Review BoardsLBCliquid‐based cytologyNCINational Cancer InstitutePCRpolymerase chain reactionSPSSStatistical Package for Social SciencesWHOWorld Health Organization1Cervical cancer incidence and mortality are highest in lower‐resource regions of the world.,Nevertheless, HPV infections are too common and benign in many high‐risk regions to treat all infected women.Due to cost and perceived complexity, most existing HPV assays are designed to yield a pooled result for the carcinogenic HPV types with no or only limited genotyping (mainly of HPV16 and HPV18), obscuring the finer risk‐stratifications within the other HR HPV types . Moreover, many existing assays also include HPV66 and a few include HPV53 . The latest version of the IARC monograph, rectifying the mistake of the previous versions, reclassifies HPV66 along with HPV53 as only possibly and rarely carcinogenic to humans .Additionally, HPV assays need to be rapid, low‐cost and practical for scale‐up in cervical cancer screening programs in resource‐limited settings. An isothermal amplification technology‐based AmpFire HPV assay  shows promise in this regard.We collaborated with the scientists at Atila Biosystems to redesign the AmpFire HPV assay into a single‐step 13‐type assay providing risk‐based, extended HPV genotyping in four channels in a single tube as follows: (a) HPV16, (b) HPV18/45, (c) HPV31/33/35/52/58 and (d) HPV39/51/56/59/68. These efforts were undertaken for public health benefit. The current article aims to independently validate the redesigned AmpFire HPV assay (ScreenFire HPV RS hereafter referred to as ScreenFire) compared against a well‐validated MY09‐MY11‐based polymerase chain reaction (PCR) assay with genotyping.22.1Our study utilized 1339 residual provider‐collected cervical samples from a population‐based screening study of 16 to 88 year‐old (mean [SD] = 44.0 [15.8]) women in rural Nigeria. Project Itoju was conducted during 2009 to 2010; residual specimens were stored frozen in Preservcyt solution . The study methodology has been described in detail previously.One milliliter aliquots of the frozen residual cytology samples were tested in the United States (Albert Einstein Cancer Center) for HPV using a AmpliTaq Gold MY09‐MY11 PCR‐based test that included additional type‐specific primers, and primers to amplify a cellular beta‐globin fragment as an internal control (IC) for amplification as previously described.Of the 1339 such residual samples, valid PCR results were available for 1305 samples. A small set (n = 8) of typed samples positive for only low‐risk HPV types was unblinded and provided to the Atila Biosystems laboratory for the modification of the AmpFire assay chemistry. Of the remaining 1297 masked samples with valid results, we chose all 356 samples that had tested positive for any HPV types, including low‐risk types, by either PCR or HPV16/18 Luminex, and 100 randomly selected specimens testing HPV negative for all HPV types including low‐risk, by both PCR and Luminex. These specimens were provided to Atila BioSystems with masked labeling and retested there with the ScreenFire HPV assay.The first masked comparison generated fair to good agreement (data not shown). There was evidence of competition for reagents in the presence of multiple HPV infections, and slightly diminished sensitivity for some types. We provided the summary results to the Atila Biosystems team and re‐randomized the specimens under NCI direct supervision to permit another valid masked testing round. After primer redesign and reagent optimization were completed, the Atila Biosystems team “locked” their new format, which emphasized more sensitive detection particularly of HPV16 and HPV18/45. The masked testing of the specimen set was then completely repeated. This article reports the independent analysis of results from the second round of testing.2.2The assay is intended to be performed on “dry swabs”; thus, centrifugation was needed to process the 0.5 mL of cervical cell suspension in Preservcyt. Specifically, the suspension was transferred to a 1.5 mL tube for centrifugation at maximum speed for 20 minutes and the supernatant was discarded, followed by the addition of 50 μL of ×1 lysis buffer and vortexing thoroughly to resuspend the cell pellet. The resuspended cell pellets were then transferred to 96‐well PCR plates for incubation at 95°C for 15 minutes, cooled at room temperature and briefly spun. After this initial sample preparation, 5 μL of this prepared specimen was mixed with 20 μL of freshly prepared master mix (including reaction mix and primer mix) into a 96‐well PCR plate using hand pipetting. Additionally, positive and negative template controls were included in each 96‐well plate as well. Next, the plates were sealed with an optical compatible film, vortexed gently for mixing the reagents and centrifuged to bring down all liquid to the bottom of the wells. The plates were then loaded into the Bio‐Rad CFX96 real‐time PCR machine on the isothermal program mode run at 1 minute per cycle at 60°C for 60 cycles with fluorescence obtained from CY5 (for HPV16), ROX (for HPV18/45), CY5.5 (for HPV31/33/35/52/58), FAM (for HPV39/51/56/59/68) and HEX . A sample was considered positive for an HPV channel if the signal was detected within 60 minutes in the channel, regardless of the signal in the HEX channel. If no signal was detected for any of the four HPV channels within 60 minutes, then a signal was required in the HEX channel for the batch run to be called a valid negative.2.3Valid ScreenFire HPV results were available for 453 of the 456 samples and were included in the analysis. HPV results from PCR were categorized a posteriori into the same four risk groups .First, HPV group results were considered nonhierarchically, recognizing that a given specimen could test positive for more than one channel. Agreement statistics and McNemar's test for asymmetry were calculated for each of the channels. The analysis accounted for sampling of HPV‐negatives by reweighting to the original sample size for point estimates, but maintained standard errors derived from the subset tested. Box and whisker plots were examined for time to detection  of the positive samples for each channel by the ScreenFire HPV assay. Outlier positive samples were identified as the ones with “time to detect positive” of greater than Q3 (third quartile of detection times) + 1.5 times interquartile range (IQR) in minutes. For the samples that tested positive by both the ScreenFire and PCR assay, an association between the time to detect positive in minutes by the ScreenFire assay and the signal strength by PCR assay was examined by Analysis of Variance (ANOVA) and nonparametric ranked test for trend in a pooled analysis combining the channels, including only samples positive by PCR for a single HR13 HPV type and positive by ScreenFire for a single HPV channel (n = 127). The PCR signal strength variableSecond, the two tests were also compared using risk‐based hierarchical HPV group types, considering that varying risks of cervical cancer associated with different risk groups are usefully interpreted according to the highest‐risk result obtained to permit risk‐based management. Thus, the hierarchical risk‐groups were considered as HPV16 positive, else positive for HPV18 or HPV45 (if HPV16 was not present), else positive for HPV31, HPV33, HPV35, HPV52 or HPV58 , else positive for HPV39, HPV51, HPV56, HPV59 or HPV68, else negative. Agreement on positive results and kappa values were calculated for the hierarchical analysis.As a supplementary analysis, the investigational Luminex testing for HPV16 and HPV18 was examined to look for clues as to the meaning of interassay disagreement. Results from this assay are presented because they revealed interesting patterns but are outside the a priori comparison.All analyses were conducted using Microsoft Excel, SPSS  (Build 1.0.0.1089) and R (version 3.6.2).33.1There was good to excellent agreement between the ScreenFire assay and the PCR assay for all the channels on nonhierarchical analyses Table . No majoWhenever there was an agreement between PCR and the investigational Luminex assay for HPV16, ScreenFire always agreed with them. When there was discrepancy between PCR and Luminex assay (n = 19), ScreenFire agreed with Luminex for 57.9% (11 of 19) times and with PCR for 42.1% (8 of 19) times. Whenever there was an agreement between PCR for HPV18/45 and investigational Luminex assay for HPV18, ScreenFire for HPV 18/45 agreed with them for all but one time. When there was discrepancy between PCR and Luminex assay (n = 14), ScreenFire agreed with Luminex for 21.4% (3 of 14) times and with PCR for 78.6% (11 of 14) times. This is likely due to lack of HPV45 in Luminex assay   (data not shown). However, a significant negative correlation was found between the time to detect positive HPV signals and the time to detect positive internal control (HEX) signal on the ScreenFire HPV assay (Pearson's correlation coefficient = (−0.25), P‐value =.001; Spearman's correlation coefficient = (−0.38), P‐value <.001), suggesting some reagent competition.A significant association was found between the time to detect positive samples on the ScreenFire HPV assay and the signal strength by PCR  Figure . No sign3.2On the hierarchical analysis, which would be useful for risk‐based clinical management of the women, there was an overall 96.8%  agreement between the ScreenFire and PCR assay  Table . OverallData on valid liquid‐based cytology and histopathology were available for only 420 and 172 samples, respectively. Of these, for the 12 histopathologic high‐grade Cervical intraepithelial neoplasia grade 2+ (CIN2+) cases, 10 were detected by both the ScreenFire and PCR assay, both assays missed one case and the ScreenFire assay picked up one additional CIN2 on the HPV39/51/56/59/68 channel. Nevertheless, both assays were positive for all five CIN3 cases. In fact, out of 36 cytologic or histopathologic high‐grade samples, there was only one discordant result , simple  and less expensive than most other HPV typing tests .The assay could help to address an identified public health need. In resource‐limited settings, which account for 90% of cervical cancer deaths, vaccine coverage and particularly organized screening are minimal.As a result of this satisfactory pilot evaluation, the ScreenFire HPV assay is being evaluated in two independent US laboratories, for clinical accuracy against both prior HPV reference testing and histopathologic outcome, based on an extensively‐validated set of >2000 provider‐collected cervical samples.5In conclusion, the redesigned ScreenFire HPV assay was shown to provide accurate risk‐based genotype grouping. If the ongoing large validation study in two independent laboratories yields similar results, the assay using self‐collected dry swabs will be deployed for field evaluation in multiple international cervical cancer screening sites. The longer‐range public health goal is implementation in resource‐limited settings.The work reported in the article has been performed by the authors, unless clearly specified in the text. Conceptualization, Mark Schiffman, Silvia de Sanjose, Kanan T. Desai; methodology, Mark Schiffman, Kanan T. Desai, Silvia de Sanjose, Didem Egemen; formal analysis, Kanan T. Desai, Mark Schiffman, Didem Egemen; Itoju field investigation, Mark Schiffman, Kayode O. Ajenifuja, Clement A. Adepiti, Julia C. Gage, Nicolas Wentzensen, Robert D. Burk; original PCR and Luminex testing, Robert D. Burk; resources, Mark Schiffman, Kayode O. Ajenifuja, Clement A. Adepiti, Nicolas Wentzensen; data curation, Kayode O. Ajenifuja, Julia C. Gage, Clement A. Adepiti, Kanan T. Desai; writing—original draft preparation, Kanan T. Desai; writing—review and editing, all. All authors have read and agreed to the published version of the article.The authors declare no conflict of interest. Atila BioSystems had no role in the design, analysis, interpretation or drafting of this article.Both Nigerian and National Cancer Institute  institutional review boards (IRBs) (NCT 00804466) approved the original study protocol that included consent for specimen storage for future research.