Self-collection of cervical samples to detect high-risk human papillomavirus (hr-HPV) is a trending topic in primary cervical cancer screening. This study evaluates the applicability of a self-sampling device to routine molecular procedures for hr-HPV detection.In a primary health care facility in Kinshasa, Congo, 187 self-collected samples  were gathered and sent to Ghent University Hospital (UZ Ghent) and Algemeen Medisch Labo (AML) in Belgium where routine tests for hr-HPV were applied , respectively). Sample type effect was evaluated by comparing the internal control (IC) between the self-collected samples and routine, clinician-taken samples randomly selected from the UZ Ghent archive.In UZ Ghent an error was encountered in 9.1% (17/187) of self-collected samples due to a lack of IC signal. The hr-HPV prevalence in the remaining 170 samples was 18,8%. Comparing IC results between the self-collected and clinician-collected groups, a significant difference  was found, with higher IC signals in the clinician-collected group. In AML, an error was encountered in 17.6% (33/187) of samples, including 16/17 of the UZ Ghent. The remaining sample with IC error gave a negative result in AML. Among the 154 samples without IC error at AML, a correlation of 90% was seen between both laboratories with a 77% negativity rate.Testing the self-collected specimens by 2 routine hr-HPV tests gave a high IC error rate (9.1–17.6%). A possible solution would be to differentiate cut-offs for IC values depending on sample type, as currently used cut-offs are set for clinician-taken samples.The online version contains supplementary material available at 10.1186/s12905-023-02691-8. Cervical cancer screening programs have already reduced the incidence and mortality rate of cervical cancer in industrialized countries . Many ofFor developing countries, where organized screening programs are lacking due to their high cost and the limited health infrastructure, self-collection and primary HPV testing offer a solution for the low screening rates .Currently, we have an abundance of HPV tests on the global market. The vast majority of them lack proper evaluation in line with consensus requirements, nor are they validated to be used on various clinical specimen types . Each diDespite a growing number of studies on self-collection and HPV testing, little attention has been directed towards the compatibility and alignment of the existing assays with these self-sampling devices. In terms of sensitivity, self-collection is comparable to current screening practices for detecting cervical carcinoma and high-grade lesions, but device and specimen processing effects exist . StudiesAnother critical point when shifting to self-collection is the sample adequacy. Unfortunately, not all HPV assays incorporate a sample adequacy control (SAC) or internal control (IC) . WithoutThe aim of the present study was to evaluate the applicability of the Evalyn self-sampling device to two routine molecular procedures for hr-HPV detection.In total, 187 self-samples were collected among women in a primary health care facility in Kinshasa, Congo. All women were between 29 and 73 years old .All women received an Evalyn brush  to perform self-sampling. When receiving this device, they were given oral information and a flyer about how to use it. The Evalyn brush is considered user-friendly . This deFor hr-HPV evaluation in UZ Ghent, the Abbott RealTime High Risk HPV test  was used to examine the samples. It is an automated, qualitative multiplex assay based on real-time polymerase chain reaction (PCR) for the detection of 14 hr-HPV genotypes  and genotyping for HPV 16 and 18. In the obtained results, the cycle numbers (CN) indicate the strength of the signal. The higher the CN, the weaker the signal, probably indicating a lower viral load. The Abbott test detects the endogenous human beta globin sequence as an internal control (IC) signal to evaluate cell adequacy, sample extraction and amplification efficiency. The CN cut-off for IC was set at 35 cycles, while for HPV detection, the CN cut-off was set at 32 cycles. When the CN is higher, the target (IC or HPV) is reported as undetected. In addition to the hr-HPV results, we collected the CN for every target in every sample.In the second laboratory, Algemeen Medisch Labo (AML) in Antwerp, qPCR (E6/E7) was used for hr-HPV evaluation. It is a qualitative assay based on real-time PCR for the detection and genotyping of 18 HPV genotypes, low- and high-risk . It also detects the endogenous human beta globin sequence as an internal control (IC) signal to evaluate cell adequacy. The CN cut-off for the IC is set at 35 cycles; when it is between 30 and 35, it is reported as “low DNA”.Considering we will compare the results of UZ Ghent with the results of AML, we exclude AML’s results of HPV 6/11/53/67 as these HPV genotypes are only detected by the AML-assay.All 239 clinician-taken samples were randomly selected from our routine archive at UZ Ghent. The samples were pap smears taken in routine care and stored in ThinPrep medium at room temperature.IBM SPSS Statistics version 28 was used for statistical evaluation and visualization. To evaluate whether data were normally distributed, the Shapiro-Wilk test was used in combination with a visual inspection using a histogram, boxplot and QQ-plot. If data were not normally distributed, it was retested for normality after log-transformation. Per HPV assay, HPV DNA-positive cases and cases of coinfection were determined. To evaluate the correlation between the two HPV assays, concordance in terms of HPV detection and IC signal among the two different HPV assays was assessed by a cross table comparison and by a Spearman correlation test . The two assays were negatively agreeing if they both demonstrated a negative result for all hr-HPV genotypes. To evaluate the sample type effect, the CN of IC (UZ Ghent) of self-collected samples and the CN of IC of clinician-collected samples were compared by using the Mann-Whitney U test. P-values of less than 0.05 were considered statistically significant.Of the 187 study samples, 17 samples  showed an error in the first test run. Of these, 12 reported the error “the internal control was nonreactive” and five samples reported the error “the cycle numbers of the internal control were out of range”. In these last samples, the CN for the IC was higher than 35 but still detectable . In none of these 17 samples was a signal for hr-HPV types detected . In the hr-HPV-positive group, 2/32  had an HPV 16 infection, 25/32  had an infection with at least one hr-HPV type other than HPV 16 and HPV 18, 3/32  had an infection with HPV 16 and at least one other hr-HPV and 2/32  had an infection with HPV 18 and at least one other hr-HPV .Four of the negative samples with an amplification curve suggestive of inhibition were diluted (1:3). However, two of these samples had a signal in the first test run but lost this signal after dilution probably because the viral load was diluted to such a level that the amplification signal was no longer detectable. The other two samples showed the same hr-HPV detection as before dilution, but the CN was higher. No interaction of inhibiting factors could be proven.The IC values generated with the qPCR E6/E7 were not normally distributed . In AML, an error was encountered in 17.6% (33/187) of samples, including 16/17 of the UZ Ghent IC errors. The remaining UZ Ghent IC error gave a negative result in AML . Comparing IC between the self-collected and clinician-collected groups, a significant difference was seen , with higher signals for IC (lower CN) in the clinician-collected group. The clinician-collected group had a mean of 21,61 CN, and the self-collected group had a mean of 26,69 CN  and the digene Hybrid Capture 2 (HC2) test . All samples contained enough biological material for testing. The overall agreement between the results of both tests was substantial but better for the Evalyn brush . JentschSnijders et al. concluded that the use of Qvintip resulted in a lower signal for cellular material than the use of Evalyn brushes. It did not, however, influence the clinical performance .Differences in test results can also be caused by differences in the method of hr-HPV detection. Jentschke et al. found better clinical performance for hr-HPV detection with Abbott RealTime PCR than with HC2 on self-collected lavage samples . In the In this study, 187 self-collected samples of Congolese women, using the Evalyn brush, were tested for 14 different types of hr-HPV with Abbott in UZ Ghent and qPCR (E6/E7) in AML. In UZ Ghent, an error was reported for 17 of these samples, indicating that there was no or a low signal for cellular material. Sixteen of these showed the same result in Antwerp, and the other one showed a negative hr-HPV result. The samples with a low signal for cellular material may contain cells, but fewer than when clinicians take the sample. The samples without a signal for the internal control probably did not contain any cells or hardly any cells. It is easy to believe that in these cases, the women were not able to or did not dare to take the self-sampling in a correct way, meaning they did not collect any cervico-vaginal cells on the brush, resulting in a false-negative result. When, for instance, women had difficulties understanding the instructions and were not aware they had to push the plunger before rotating it, they would take the self-sample without extending the brush out of the casing. The results of these samples regarding HPV presence are not reliable because HPV positivity could be underestimated. It is possible that the number of errors could be reduced by offering a better explanation to the women about how to use the self-sampling device and making them feel confident in their ability to take the sample themselves. When considering implementing a self-sampling option in cervical cancer screening programs, this issue needs particular attention.More studies are needed on what to do when the result is an error in IC and how to interpret IC values set for clinician-obtained cervical smears when applying them to self-samples. It can be suggested that women who provided a self-sample with a too low IC value will be requested to see a medical doctor to be taken a clinician-collected sample or given a second chance to self-sample. Unfortunately, the majority of HPV assays even lack an internal control or use controls that cannot challenge the cellularity of the specimen , 24. ThiOverall, when using the same cut-off levels as for the clinical setting for which Abbott is produced, the hr-HPV-positive prevalence is 18,8%. Sixteen of the 17 samples with an error as a result gave an error in the results of AML. The remaining Ghent error gave a negative result in AML. Another 17 samples resulted in an error in the AML analysis. In the remaining 154 samples, a correlation of 90% was seen between both laboratories with a 77% negativity rate.Considering that Abbott is produced for a clinical setting and clinician-collected cervical samples, we wondered if these cut-offs might need adjustment for the testing of self-collected samples of women in a screening setting. In a study by Bell et al., some cases were missed by the Abbott test using the manufacturer’s cut-offs. After adjustment of the cut-off for positivity to a less stringent one, the cases reported as negative nevertheless demonstrated the presence of hr-HPV but with associated Cq values above the manufacturer’s cut-off . In our Implementing self-sampling in existing screening programs can potentially improve screening coverage. With regard to the current data, we suggest that further research should be focused on the evaluation of cut-offs for internal controls as well as HPV high-risk genotypes, specifically on self-collected samples. Therefore, there is surely an increasing need to adjust or confirm the cut-offs of internal controls to the application on self-collected samples that can be different regarding the self-sampling device and subsequent molecular test used.Below is the link to the electronic supplementary material.Supplementary Material 1


Cutaneous and genital warts are common in both developed as well as developing countries. Human papillomavirus (HPV), which is a double-stranded DNA virus, is the causative agent of wart infection. Different types of HPV viruses are responsible for the different severity of diseases. Some types are associated with malignancy of the anal region and cervix. HPV is a common sexually transmitted disease in the United States. The incidence is most common in the younger age groups and the elderly population. Our main goal is to describe the different treatment modalities available for warts. Treatment modalities are divided into primary, secondary, and tertiary options. Topical medications, and physical excision of warts via cryotherapy, electrocautery, lasers, or photodynamic therapy are all common forms of treatment. Various clinical trials and randomized control trials have been seen as effective treatment against HPV infection. Higher remission rates are seen irrespective of different treatment options. Warts can be treated but the HPV virus cannot be completely removed. Older age, immunocompromised state, diabetes mellitus, and HIV are the predisposing factors for the disease. There is currently a large variety of medicines in use, all of which can differ significantly in terms of price, side-effect profiles, dosing regimens, length of therapy, and overall effectiveness. The best course of treatment has not yet been identified, and patients are often treated according to their unique needs. Infection with the human papillomavirus (HPV), which is thought to be the cause of one of the most prevalent sexually transmitted diseases (STDs) in the United States, results in cutaneous and genital warts, also called condylomata acuminata. There are at least 80 identified HPV strains, and about 30 of these are known to lead to genital infections . HoweverGenital warts are frequently noticed visually, negating the need for an additional biopsy. These exophytic lesions are characterized by hyperplastic squamous epithelium that displays koilocytes, which are squamous epithelial cells with an acentric, hyperchromatic nucleus displacement by a large perinuclear vacuole . They deThe success of the treatment depends on several clinical parameters, including the severity of the disease, the size, and the location of the warts. This review describes the many approaches to preventing and managing cutaneous and genital warts. The HPV types in condylomata acuminata are depicted in Table Search methodologyTo compile a comprehensive review of treatment approaches for cutaneous and genital warts, a systematic research methodology was adopted. Primary databases like PubMed, Google Scholar, and Web of Sciences were searched using keywords such as Cutaneous Warts, First Line Management, Second Line Management, Third Line Management, Genital Warts, Therapies, Vaccination, and Preventions, targeting publications in 2000-2023 in the English language. Emphasis was placed on peer-reviewed articles, clinical trials, and meta-analyses. Inclusion criteria focused on studies that focussed on the etiology and recent advances in cutaneous and genital warts. Exclusion comprised studies outside the set timeframe, non-peer-reviewed publications, and articles with a sole focus on recreational use. Once relevant articles were identified, data such as author names, publication year, study design, findings, and causes as well as modern treatment were meticulously extracted. Any overlapping or duplicate studies were filtered out to maintain the integrity of the review. To ensure organized citation and easy reference access, all sources were managed using the Zotero reference management software . The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was followed for conducting this systematic review Figure .Cutaneous wartsThe keratinocyte cell is damaged by the HPV, which has a stronger affinity for squamous epithelial tissue and causes papules or plaque on the skin and has a rough surface. Before beginning treatment, risk factors should be identified and treated accordingly. First-Line ManagementSalicylic acid:This is a simple and cost-beneficial treatment of choice for cutaneous warts. Salicylic acid is thought to trigger the local immune response even though its primary effects on HPV-induced hyperkeratosis are chemical ablation and irritation. Salicylic acid can be purchased without a prescription and comes in a variety of forms and dosages. Salicylic acid 17% is most frequently used; however, there isn't enough information to say that one preparation or concentration is better than another . The folCryotherapy: For the treatment of warts, cryotherapy is frequently used in hospitals and is also accessible over the counter. Primary care physicians typically utilize liquid nitrogen, which can freeze tissue to a temperature of 321°F 196°C), and over-the-counter cryotherapy devices can only freeze tissue to a temperature of 94°F (70°C). Liquid nitrogen can be applied using a piece of cotton swab or a cryogen. Cryotherapy and salicylic acid combination therapies had greater rates of elimination than monotherapies . There s6°C, and Second-Line Management 2 laser and electrocautery: Common wart or cutaneous wart removal is categorized under the category of ablative operations . For the treatment of warts, CO2 laser is commonly employed at medical offices and is also accessible over the counter. Doctors working in primary care typically utilize liquid nitrogen, which can freeze tissue to a temperature of 321°F (196°C) as over-the-counter CO2 laser devices can only freeze tissue to a temperature of 94°F (70°C). Using a cotton pad or a cryogen, liquid nitrogen can be applied [2 lasers and electrocautery techniques. Argon plasma coagulation may also be considered as an ablative technique if the necessary tools are available, particularly for condyloma acuminata [CO applied . When tr applied . Scarrincuminata .Photodynamic therapy: The cornerstone of photodynamic therapy is treatment with aminolevulinic acid (LEVULAN® KERASTICK®), which is followed by phototoxicity. A photosensitizer known as aminolevulinic acid works by causing the oxidation process in aberrant cells after exposure to visible light . The bumThird-Line ManagementCandida fungal antigen as an immunomodulator intravenously for persistent, non-genital warts are helpful. Mumps antigen may be tried for treatment. Fever and arthralgia are examples of side effects [Imiquimod cream:Imiquimod is the most commonly used chemotherapeutic agent. Adults with cutaneous warts can now be treated with imiquimod 5% cream. Interferon-alpha and other cytokines are released as a result, which prevents virus replication . Various effects . LevamisBleomycin, 5-fluorouracil (5-FU), and cidofovir injections: Chemotherapeutic bleomycin prevents cells and viruses from synthesizing DNA. It results in acute tissue necrosis, which could trigger an immunological reaction . IntraleGenital wartsOnce an individual has contacted HPV, the virus normally needs approximately 10-14 weeks of incubation time before showing any clinical symptoms. Physical symptoms typically start 8-10 weeks after the first contact with the virus . HoweverTopical AgentsPodophyllotoxin: An isolated podophyllum plant extract called podophyllotoxin adheres to intracellular tiny tubes. slows mitotic division, and causes wart necrosis that peaks three to five days after injection. As the lesions necrotize and recover in a short period, shallow erosions happen . This coImiquimod and diphenylcyclopropenone:Imiquimod is an immunity modulator that works by directly activating innate immune cells via the toll-like receptor 7 (TLR-7). After interacting with TLR7, imiquimod causes dendritic cells to produce a potent pro-inflammatory response in vitro. Additionally, imiquimod topical application causes the functional development of epithelial Langerhans cells in vivo, boosts these cells' migration to local lymph nodes, and supports a Th1-biased and specific antigen CD8+ T cell response . LocalizTrichloroacetic acid (TCA): The skin and mucosa are damaged chemically by TCA, which cauterizes, burns, and erodes them. TCA often requires a doctor to administer it because it is manufactured in 80-90% solutions. Warts can occasionally be successfully treated with just one dosage, but more often than not, many treatments are needed . TCA is Electronics-Based TherapyCryotherapy: The most common method of ablative treatment approach is cryotherapy, which is similar to the management of extragenital warts. The largest possibility of clearance rate is induced by cryotherapy, which is suitable for the treatment of multiple wart lesions . Through2 laser therapy: A focused beam of infrared light energy is used in CO2 laser therapy to heat and eventually vaporize the areas that are being treated. The additional advantage of the high light intensity is that it immediately cauterizes any ligated vessels, guaranteeing a nearly bloodless treatment. The laser beam's spatial confinement enables precise tissue ablation, resulting in quick recovery with minimal to no scarring. Sadly, laser therapy is a treatment option that is both expensive and challenging. Physicians themselves must need further training to efficiently use the specialized laser equipment, which must be acquired and maintained continuously. Additionally, the vaporization of viral lesions may cause the release of HPV DNA into the environment [COironment . It is nNewer TherapyInterferon therapy, podophyllotoxin, and 5-FU are not advised for routine usage in the primary care context due to their limited efficacy and toxicity. The first local therapy for genital warts was podophyllotoxin, although samples of the medicine differed widely in terms of its active ingredient due to a lack of standardized drug manufacturing. Negative skin effects like burning, redness, discomfort, itching, or swelling became more likely as a result. Extremely rare, enteritis, bone marrow suppression, gastrointestinal pain, and neurological deterioration have all been connected to overusing podophyllotoxin and high systemic absorption . When adVaccination and PreventionThe HPV vaccine is recommended to be administered in the early adolescent years since it is most efficient before sexual activity-related HPV exposure. Obstetricians-gynecologists and other physicians could participate in shared clinical decision-making regarding HPV vaccination for some women aged 27-45 who had never received the vaccine, taking into account the patient's risk of contracting a new virus associated with HPV and the possible benefits of the HPV vaccine. Women aged 27-45 who are more likely to be exposed to or acquire HPV, including younger women, those who are not in established committed partnerships, and those who have recently been diagnosed with STDs would get the most advantages from vaccination. It is not typically advised for women in long-term monogamous relationships .GardasilIt is the first HPV vaccine that the FDA has approved. The recombinant, quadrivalent vaccine was created to prevent the diseases caused by HPV types 6, 11, 16, and 18: cervical, vulvar, and vaginal cancer, as well as condyloma acuminata in girls and young women aged 9-26 . AdditioCervarixIt protects against HPV 16 and 18 and is a recombinant bivalent vaccination. HPV 16 and 18 are two carcinogenic kinds that are targeted by Cervarix and are linked to cancer of the cervical region, cervical intraepithelial neoplasia grade 1 or even worse, and in situ malignancy. Similar to the HPV 4 safety information, there were significantly greater reports of discomfort, redness, and swelling at the injection site in the HPV 2 group than in the placebo group. The most prevalent general complaints were fatigue, headaches, and myalgia . ModificAmong the most prevalent STDs infecting people of all ages are external genital warts and the HPV infections associated with them. To combat the underlying viral infection, current treatment approaches only target exterior warts and have thus shown to be ineffective in producing lasting effects. Topical, surgical, and immunomodulatory treatments fall into several categories and have varying costs, lengths of treatment, dose regimens, and side effects. One particular technique has not yet proven itself as the gold standard for treatment, and there is currently little data to support the idea that a particular class of therapy is not more successful than others. The demands and preferences of each patient are normally taken into account while choosing a therapy approach. Considering people's startlingly high genital wart incidence and a shortage of effective treatments, HPV vaccinations like Gardasil and Cervarix may significantly lower the impact of infectious diseases by avoiding viral spread and infection.


Homelessness is a major public health problem among U.S. military veterans. However, contemporary, population-based data on the prevalence, correlates, and mental health burden of homelessness among veterans are lacking.n = 4069). Analyses examined the prevalence and correlates of homelessness, as well as the independent associations between homelessness and current probable psychiatric conditions, suicidality, and functioning.Data were analyzed from the 2019–2020 National Health and Resilience in Veterans Study, a nationally representative survey of veterans (s.d. = 12.6). Adverse childhood experiences (ACEs), cumulative trauma burden, current household income, younger age, and drug use disorder emerged as the strongest correlates of homelessness . Veterans with a history of homelessness had elevated odds of lifetime suicide attempt, attempting suicide two or more times, and past-year suicide ideation [odd ratios (ORs) 1.3–3.1]. They also had higher rates of current probable posttraumatic stress disorder, major depressive, generalized anxiety, and drug use disorders (ORs 1.7–2.4); and scored lower on measures of mental, physical, cognitive, psychosocial functioning (d = 0.11–0.15).The lifetime prevalence of homelessness was 10.2% . More than 8-of-10 veterans reported experiencing their first episode of homelessness following military service, with a mean of 10.6 years post-discharge until onset (One in ten U.S. veterans has experienced homelessness, and these veterans represent a subpopulation at substantially heightened risk for poor mental health and suicide. ACEs were the strongest factor associated with homelessness, thus underscoring the importance of targeting early childhood adversities and their mental health consequences in prevention efforts for homelessness in this population. Homelessness is a major public health problem in the United States. In 2020, the number of people experiencing homelessness in the U.S. was estimated to be approximately 600 000, although the true figure is likely much higher . Among veterans endorsing a history of homelessness, 82.4% (n = 259) reported that their first episode of being homeless occurred following military service. The mean number of years after service that veterans experienced homelessness was 10.6 (s.d. = 12.6); median = 4.0 years (interquartile range = 19.0). The mean number of months homeless among veterans reporting a history of homelessness was 15.8 (s.d. = 29.7); median = 6 months (interquartile range = 9.4). Approximately one-fourth  of veterans reported using VA healthcare or homelessness services while homeless.The weighted lifetime prevalence of homelessness in the sample was 10.2% [Results of relative importance analysis  revealeds.d. = 12.6). These results accord with prior literature demonstrating a sleeper effect (e.g. delayed homelessness) following military discharge , which is broadly consistent with prior national population-based studies of veterans  relative to veterans who had never been experienced homelessness . These findings parallel results from a recent meta-analysis by Liu et al.  which we found to be at heightened risk for experiencing homelessness. Further research is needed to evaluate the prevalence, correlates, and burden of homelessness in these more vulnerable segments of the veteran population  should consider incorporating screening measures for ACEs and cumulative trauma exposure into pre-discharge procedures  as a means to identify service members who may be at heightened risk for poor mental health outcomes and homelessness following discharge from the military (Nichter, Hill, Norman, Haller, & Pietrzak, Second, on a broader level, results suggest that leveraging interventions to reduce early childhood adversity may be a critical component to end the cycle of homelessness among veterans and other at-risk populations. Indeed, prior research has found that approximately 20% of male and 50% of female veterans with current housing instability have children in their custody, a statistic that is concerning given that unstably housed veterans are more likely to have psychiatric disorders and chronic medical conditions (Tsai et al.,


Restricted cubic spline regression showed a linear relationship between vitamin E consumption and overall high-risk HPV infection. This linear relationship also existed for vitamin E consumption and overall low-risk HPV infection. After being stratified by gender and site, vitamin E consumption was inversely related to vaginal low- and high-risk HPV infection, penile high-risk HPV infection, and male oral low-risk HPV infection. In conclusion, we identified inverse linear relationships between dietary vitamin E intake and overall high- and low-risk HPV infection. Future well-designed longitudinal studies are still required to validate the impact of vitamin E on HPV carcinogenesis.Persistent high-risk human papillomavirus (HPV) infection is responsible for most genital, anal, and oropharyngeal cancers, in which men contribute significantly to infection and subsequent tumorigenesis in women. Vitamin E has been shown to be associated with vaginal HPV infection and cervical cancer. However, the association of vitamin E consumption with HPV infection among the overall population remains unclear. We investigate the association between vitamin E consumption and genital and oral HPV infection in both men and women. We used cross-sectional data from the National Health and Nutrition Examination Survey between 2013 and 2016 to collect details on their dietary vitamin E intake, genital and oral HPV infection status, and other essential variables. In total, 5809 participants aged 18–59 years were identified, with overall prevalence of high-risk and low-risk HPV infection of 23.7% and 21.1%, respectively. Compared with the lowest vitamin E group Q1 (<5.18 mg/day), the adjusted OR for vitamin E consumption and overall high-risk HPV infection in Q2 (5.18–7.54 mg/day), Q3 (7.55–10.82 mg/day), and Q4 (>10.82 mg/day) were 0.91 (95% CI: 0.81–1.03,  Human papillomavirus (HPV) is one of the most ubiquitous sexually transmitted viruses around the world, which is usually asymptomatic, temporary, and eliminated by their hosts’ immune system within 1–2 years . Nearly There is growing evidence that consuming “healthy” foods such as fruits and vegetables and taking in specific nutrients such as antioxidants and minerals can reduce the risk of contracting HPV, developing preneoplastic lesions, and subsequent cervical cancer among women ,16,17,18To fill these research gaps, we investigated the association of dietary vitamin E intake with genital and oral HPV infection in both men and women, especially high-risk HPV infection among US adults, with data from the NHANES. As a substitute for cervical HPV infection in this investigation, we collected data on vaginal HPV infection. Prior research revealed an excellent consistency of the detection of HPV between cervical swabs obtained from clinicians and vaginal swabs obtained from their own ,27. AccoData from the NHANES, a US nationally representative survey conducted by the National Center for Health Statistics (NCHS), using stratified, multistage probability cluster sampling to track the nutritional status of the US population who are not institutionalized, were used in this cross-sectional study. The details of NHANES are available on the official website . The NHAA total of 37 HPV genotypes  were detected in NHANES with the Linear Array HPV Genotyping Assay (Roche Diagnostic) on samples from self-collected vaginal or penile swabs and oral rinse. This assay uses biotinylated PGMY09/11 primer sets in HPV L1 consensus polymerase chain reaction (PCR). More details of the testing procedures are available on the Laboratory Data section of the NHANES website . The outParticipants in the NHANES were asked to calculate their dietary consumption in detail, including the calorie intake, nutrients, and other components of food they consumed in the 24 h before the interview. Everyone who took part in the NHANES was qualified for two 24 h dietary recall interviews. In the Mobile Examination Center (MEC), the initial dietary recall interview was conducted in person, and the second interview was conducted over the phone three to ten days later. The NHANES dietary interviewer procedures manuals comprehensively document the examination protocol and data-gathering techniques . In our According to previous literature ,15,16,18Participants’ baseline characteristics were expressed as means with standard deviations (SD)  or medians with interquartile ranges (IQR) (skewed distribution) for continuous variables and as frequencies with percentages (%) for categorical variables. The participants were split into four groups  based on the dietary vitamin E intake quartile. For continuous variables, the differences in baseline characteristics between four groups were examined using one-way ANOVA  or the Kruskal-Wallis test (skewed distribution), and for categorical variables, the chi-square test.p for trend.To replace missing covariate data with statistical estimates, we used dummy variables to indicate missing continuous covariate values and 9 was used as a level for missing categorical covariates. We also performed sensitivity analyses using a complete data analysis. The correlation between covariates and HPV infection status was investigated using univariate multinomial logistic regression. To evaluate the relationship between dietary vitamin E intake and HPV infection status, we used multivariate multinomial logistic regression models. The odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. We conducted three models: the crude model did not adjust any confounders; Model 1 was modified to account for sociodemographic factors such as age, sex, race, education, marital status, number of persons in the household, and family income; Model 2 was the fully adjusted model, which included adjustments for all of the factors shown in To further explore nonlinearity, restricted cubic spline (RCS) regression was conducted with four knots located at the 5th, 35th, 65th, and 95th percentiles of dietary vitamin E intake to look at the dose-response relationship between vitamin E consumption and HPV infection status.In order to examine the differences in gender and site of the relationship between vitamin E consumption and HPV infection status, stratified analysis was performed, including samples from female vaginal swabs, female oral rinses, male penile swabs, and male oral rinses.Additionally, we conducted sensitivity analysis by removing those with extreme calorie consumption  and missing covariate values in multivariate multinomial logistic regression models to evaluate the robustness of the results.http://www.R-project.org, The R Foundation, Shanghai, China) (accessed on 1 March 2023) and Free Statistics, version 1.7.1. p-value < 0.05 (two-sided) was declared statistically significant.All statistical analyses were performed with R, version 4.3.1  and 21.2% (1234/5809), respectively. The sociodemographic and behavioral characteristics of vitamin E intake quartiles are shown in As presented in p < 0.05). This inverse relationship between vitamin E consumption and overall high-risk HPV infection was even more pronounced in the fully adjusted model . The inverse relationship was also found in vitamin E consumption and overall low-risk HPV infection, with an estimated OR value of 0.99 (p < 0.05) in the unadjusted model and sociodemographic adjusted model and an estimated OR value of 0.98  in the fully adjusted model , 0.77 , and 0.72 , respectively. The result of the trend test suggested a linear relationship between dietary vitamin E intake and overall high-risk HPV infection (p for trend = 0.002). Compared with the lowest vitamin E group Q1, the fully adjusted OR values for vitamin E consumption and overall low-risk HPV infection in Q2, Q3, and Q4 were 0.96 , 0.89 , and 0.75 , respectively. The trend test also suggested a linear relationship between dietary vitamin E intake and overall low-risk HPV infection (p for trend = 0.018) (p for nonlinearity > 0.05) , the fully adjusted OR values for vitamin E consumption and overall high-risk HPV infection in Q2 (5.18–7.54 mg/day), Q3 (7.55–10.82 mg/day), and Q4 (>10.82 mg/day) were 0.91  . Further > 0.05) .p for trend < 0.05) remained stable. In the male population, dietary vitamin E intake was inversely but nonlinearly correlated with penile high-risk HPV infection (p for trend = 0.292) and was not significantly correlated with penile low-risk HPV infection. As for the risk of oral HPV infection, dietary vitamin E intake was only inversely correlated with male oral low-risk HPV infection and was not significantly correlated with male oral high-risk HPV infection and female oral HPV infection.A stratified analysis was conducted to investigate the relationship between dietary vitamin E intake and HPV infection in participants with different genders and infection sites. As shown in p = 0.270), 0.80 , and 0.74 , respectively, and the fully adjusted OR values for overall low-risk HPV infection in Q2, Q3, and Q4 were 0.94 , 0.86 , and 0.73 , respectively. After excluding 2253 participants with incomplete covariate data, the inverse linear association between dietary vitamin E intake and overall high-risk HPV infection remained stable (After excluding 86 participants with extreme calorie consumption, the inverse linear relationship between dietary vitamin E intake and overall HPV infection remained stable . Compared stable .Persistent high-risk HPV infection is a prerequisite for developing cervical, anal, penile, and oropharyngeal cancers ,4,5,6,7.It is well-known that host factors play a crucial role in acquiring and preventing HPV infection. These host factors can be divided into behavioral and biological . BehavioAlthough the exact mechanism causing the inverse correlation between vitamin E consumption and HPV infection remains to be researched, our findings seem biologically tenable considering the current evidence on the immunomodulatory effects of vitamin E. First, as previously demonstrated, immune cells have an exceptionally high vitamin E content, which may help to preserve the high PUFAs content of their membranes from oxidative damage caused by their high metabolic activities and normal defense function ,35. ImmuOur research broadens the comprehension of the relationship between dietary vitamin E intake and HPV infection risk in the overall population at genital and oral sites. Our findings suggest that vitamin E deficiency, which is thought to be related to immune dysregulation, might have a more significant impact on genital HPV infection than oral HPV infection in both men and women and might indicate that HPV has a different tendency for clearance and persistence in different sites. Our results imply that human reproductive mucosa might be more vulnerable to vitamin E’s immunomodulatory effects. These findings, if supported by prospective studies of the association between diet vitamin E intake and HPV persistence, might inform novel dietary-based preventive strategies against genital high-risk HPV infection, particularly in areas where male vaccination programs have not yet been implemented, or vaccination coverage levels are inadequate. Given that it takes decades for persistent high-risk HPV infection to progress to cancers, this lengthy window offers a perfect chance for clinical intervention.Several limitations should be considered when interpreting these results. First, the NHANES only collected information on male penile HPV from 2013 to 2016, which stopped us from further validating these findings using NHANES data from other periods. Second, the 24 h recall was used to determine vitamin E consumption, which could introduce recall bias. However, compared to the 24 h recall, the food frequency survey offers less accurate data on food types and quantities ,42. ThirIn conclusion, our study demonstrated inverse linear relationships between dietary vitamin E intake and overall high- and low-risk HPV infection. For both men and women, vitamin E may have a preventive effect on genital high-risk HPV infection. The findings of this study highlight the link between diet-related vitamin E consumption and HPV infection. Future well-designed longitudinal studies are still required to validate the impact of vitamin E on HPV carcinogenesis.


To examine the association between YouTube usage and HPV-related cancer knowledge .N = 16,092). Logistic regression was used to analyze the independent effect of YouTube use on cancer knowledge, controlling for sociodemographic characteristics.Cross-sectional study using data from the Health Information National Trends survey conducted between 2017 and 2020  in models adjusted for all covariates. Other independent predictors of HPV-related cancer knowledge included female gender, younger age, a higher income, and higher education.YouTube could play an important role in educating people about HPV-related cancers and should also target other populations, such as males and those with less formal education.The study provides novel insights into the potential of YouTube as an educational tool for promoting cancer knowledge with the goal of cancer prevention. •Novel investigation of YouTube use as an important resource for patient education.•Cross sectional study utilizing large sample data set from HINTS 5 (2017–2020).•YouTube use is an independent predictor of HPV-related cancer knowledge.•Gender, income, education as independent predictors of HPV-related cancer knowledge.•Targeting other high-risk groups and non-Internet-based platforms remains crucial. One posOur objective was to examine the association between Internet and YouTube usage on knowledge of HPV-related cancers and to explore the role of underlying sociodemographic characteristics on this association. Understanding these characteristics will allow for the creation of interventions geared towards specific sociodemographic groups to improve HPV vaccine uptake.22.1N = 66,723), a cross-sectional study of civilian, non-institutionalized adults 18 years or older living in the United States. HINTS examines trends in health information usage over time and provides data for conducting fundamental research on associations among cancer-related communication, knowledge, attitudes, and behavior at the population level. Data were obtained from HINTS and prepared for the National Cancer Institute by Westat. Cycle 1 data  were collected from January 2017 until May 2017; Cycle 2 data (n = 3504), from January 2018 until May 2018; Cycle 3 data (n = 5438) from January 2019 until May 2019; and Cycle 4 data (n = 3865) from January 2020 until June 2020. All households received a mailing of the survey either in English or in Spanish, and one adult in the household completed the survey. Details about the HINTS data source and methodology are available on the HINTS website [We used data obtained from HINTS 5  non-Internet users/non-YouTube users; 2) Internet users/non-YouTube users; 3) Internet users/YouTube users. For simplicity, we use the term “YouTube user” to describe this last group henceforth.Sociodemographic characteristics (covariates) assessed were gender ; race and ethnicity ; age, marital status, education level, income level, insurance, whether they had regular health provider, general health, and number of children under 18 in the household. 2.3The primary outcome was knowledge of HPV-related cancers, assessed by a “yes” response to each of the following questions: 1) Do you think that HPV can cause cervical cancer? 2) Do you think that HPV can cause anal cancer? 3) Do you think that HPV can cause oral cancer? 4) Do you think that HPV can cause penile cancer? Answering either “no” or “not sure” on any question equated to not being knowledgeable about the respective HPV-related cancer; answering “yes” equated to being knowledgeable to HPV-related cancers. We restricted our analysis to respondents who answered “yes” to the preceding question “Have you heard of HPV?”; respondents who answered “no” were not asked any of the four HPV-related questions and were categorized as “Have not heard of HPV” , Fig. 2.2.4p < 0.05 with no formal adjustment for multiple comparisons.All analyses were performed using STATA version 17.1. Unweighted and population-weighted estimates  were calculated for all participant characteristics and outcome prevalence. A weighted multivariate logistic regression model was performed to assess the independent association of HPV knowledge among YouTube users compared with non-Internet users/non-YouTube users and to assess whether sociodemographic characteristics independently predicted HPV knowledge regarding HPV-related cancers. We included all aforementioned covariates in this analysis. All weighted analyses accounted for the complex survey design using jackknife replication as documented in the HINTS technical manuals. Statistical significance was a two-sided 3Independent predictors for HPV-related anal and oral cancer knowledge were similar with a few exceptions. For anal cancer, those with one or more children under age 18 in the household  had increased knowledge compared to those without children, but no effect was seen with race and ethnicity. For oral cancer, both an effect of having children in the household  and NHW race and ethnicity  were noted; no knowledge association was apparent for age. For HPV-related penile cancer, no significant associations were noted between knowledge and age, race/ethnicity, income or having a regular provider. However, having one or more child in the household was associated with increased odds of knowledge . Similar to HPV-related cervical cancer, YouTube use was associated with the highest increased odds of knowledge regarding HPV-related cancers .44.14.1.1We found that most respondents who have heard of HPV knew that HPV causes cervical cancer but relatively few knew of its relationship to anal, oral, and penile cancers. Though our analysis showed statistically significant knowledge gaps across various sociodemographic characteristics, this overall knowledge is consistent with previously published studies .  Our st4.1.2The emphasis on YouTube to distinguish levels of knowledge regarding HPV-related cancers stems from previous studies showing that YouTube is the most used social media platform and approximately 41% of the US adult population watch health-related videos on YouTube .  A syst1 and from other studies [Furthermore, we also highlight gender and racial differences in HPV-related cancer knowledge due to the persistent knowledge gap that exists in these subgroups .    Unli studies .  This a studies , and the studies .  Highli studies .  As sucOur study also showed racial and ethnic disparities in knowledge regarding HPV-related cancers, a novel finding that was not shown in a previous study ,  perhap4.1.3n = 324 respondents  identified themselves as non-Internet/YouTube-users. Rather than reclassifying these individuals as Internet users, since, by definition, one must use the Internet to access YouTube, we categorized them as data entered in error and excluded them. Our study was also limited in the depth of knowledge associated with the HPV-related cancers. Specifically, we could only assess whether knowledge was present or absent, but not the quality of that knowledge (whether informative or non-informative). As such, we cannot draw any conclusions regarding whether increased knowledge will lead to increased HPV vaccine uptake. Despite these limitations, our study had significant strengths. Primarily, it is a national, publicly available database designed to represent the United States population which allowed us to extrapolate data at a larger population level. Secondarily, it had a relatively large sample size to explore the association of sociodemographic characteristics with our outcome of interest.This study has several limitations. First, we had to create a trichotomous variable that combined Internet use and YouTube use because these questions were not mutually exclusive in the dataset. As such, across all 4 survey years, 4.24.2.1The novelty in our study lies in our detailed investigation of YouTube use as an important resource for patient education. This methodological approach innovatively utilized the most recently available HINTS data spanning four years, allowing for an increase in power and statistical significance of our analysis not seen in previous studies. By using such a large sample size, not only did we capture a representation of the population that can vary seasonally or cyclically for any number of reasons, but it also helped mitigate any potential confounding variables that can vary from year to year, such as changes in health policies or demographic shifts. In addition, to gain a more comprehensive understanding of the factors that affect knowledge about HPV-related cancers, we focused our attention to those with prior knowledge regarding the cancerous effects of HPV. Using this methodology enabled us to pinpoint particular factors linked with enhanced comprehension of these types of cancers, especially among those with prior knowledge. This information can be valuable in formulating specialized educational strategies aimed at strengthening cancer prevention efforts. In fact, our results show various independent predictors of HPV-related cancer knowledge other than YouTube / Internet use as a reflection of individuals also seeking their health information outside of the Internet. For instance, having a regular health care provider was an important independent predictor of HPV-related cancer knowledge. This finding emphasizes that the onus remains with the healthcare provider to ensure discussing these important health care topics with their patients, especially for those individuals without access to YouTube and/or the Internet. In addition, despite the misinformation that can plague YouTube and the anti-vaccine rhetoric even in the pre-Covid 19 era, there is evidence that knowledge regarding HPV-related cancers is retained and could impact HPV vaccine uptake in the future.4.2.2Future directions in research include the use of implementation sciences to evaluate which content on platforms such as YouTube is most beneficial in increasing knowledge regarding HPV-related cancers and how that information might best be disseminated. It is a call to researchers to investigate the quality of HPV-related content online, improve the quality of health information disseminated offline since many individuals still seek their health information from other sources , and to ensure these messages are culturally appropriate. Additionally, with the introduction of new social media applications, such as Tiktok and Snapchat, it would be innovative for future studies to investigate knowledge and awareness of HPV and HPV vaccine across these platforms as these viewers compromise the predominant HPV-vaccine eligibility age group. Finally, it would be novel to see the association of HPV-related cancer knowledge, YouTube use and HPV vaccine uptake in the time of the Covid-pandemic where the anti-vaccine rhetoric was at an all-time high across social media.4.3Efforts to educate the public about human papillomavirus-related cancers should include both Internet and non-Internet platforms to target populations such as older individuals, males, and those with low incomes and less formal education. The innovative nature of this research lies in its ability to provide broader insights into the relationship between HPV-related cancers and knowledge while also suggesting that internet-based platforms such as YouTube could play an important role in educating people about HPV-related cancers.No funding source was provided.None.


The impact of human papillomavirus (HPV) status on cervical glandular lesions is a debated topic. In general, non-HPV-related adenocarcinomas would appear to have a worse prognosis. Assessing this question in early stage or in situ adenocarcinomas may be interesting, as conservative surgery is feasible in these cases. Moreover, this population group accounts for 80% of the cases of high-grade glandular lesions in clinical practice. This research aims to evaluate the outcomes of long-term follow-up in HPV-positive and -negative women. Evaluating these findings may be of interest to know whether HPV status may impact management planning in the early and in situ stages of adenocarcinomas. Our results showed that the recurrence rate was not significantly different between the two groups. However, an analysis limited to only a portion of our sample showed a type-specific association with disease relapse.p = 0.148). HPV genotyping, available for 76 women and including 9/11 recurrences, showed a higher relapse rate for HPV-18 than HPV-45 and HPV-16 . In addition, 60% and 75% of in situ and invasive recurrences, respectively, were HPV-18 related. The present study showed that most ACs were positive for high-risk HPV, and the recurrence rate was unaffected by HPV status. More extensive studies could help evaluate whether HPV genotyping may be considered for recurrence risk stratification in HPV-positive cases.It is unknown whether human papillomavirus (HPV) status impacts the prognosis of early stage cervical glandular lesions. This study assessed the recurrence and survival rates of in situ/microinvasive adenocarcinomas (AC) according to HPV status during a 5-year follow-up. The data were retrospectively analyzed in women with available HPV testing before treatment. One hundred and forty-eight consecutive women were analyzed. The number of HPV-negative cases was 24 (16.2%). The survival rate was 100% in all participants. The recurrence rate was 7.4% ). Cox proportional hazards regression showed no difference in recurrence rate between HPV-positive and HPV-negative cases ( The rates of cervical cancer in industrialized countries have decreased in the last twenty years, though it represents one of the leading causes of cancer death in developing countries . This shAnother difference between cervical adenocarcinoma (CA) and squamous cell cancer is the relationship with HPV infection. While squamous lesions are predominantly related to HPV infection, AC has a frequency of HPV-negative lesions ranging from 10 to 20% ,8. GlandIn a recent study including 341 surgical specimens of AC, 100% of non-HPV-related lesions  were classified as Silva Pattern C (the worst prognostic pattern) . Based oGiven that for in situ/microinvasive glandular lesions, conservative surgery is feasible as an alternative to standard treatment, it may be of interest also to assess the HPV status impact in these early stages. The evaluation of long follow-up outcomes in in situ and microinvasive stages of the cervical glandular lesions according to HPV status (positive vs. negative) is lacking.The present study aimed to assess the recurrence and survival rates in women with in situ/microinvasive AC according to HPV status. Secondly, it assessed the type-specific HPV recurrence and survival rates.This retrospective multi-institutional study included women with a histological diagnosis of AIS or micro-invasive AC (stage 1A) on cone or hysterectomy specimens. All participants were treated at 13 oncology referral Centers between January 2012 and December 2016 with a complete follow-up of 5 years. All women had a screening HPV testing dated no more than two months before conization. Further definitive treatments were to be at most two months after the first conization. All patients with previous conizations, immunological disease, and unavailable HPV testing before surgery were excluded. The participating departments are research centers managing women included in both opportunistic and organized cervical cancer screening programs.Based on the Italian law on non-interventional observational studies, the Ethics Committee  took note of the study (Prot. 2022/146) . FurtherBased on pre-treatment HPV testing results via Hybrid Capture 2 (including genotypes 16/18/31/33/35/39/45/51/52/56/58/59/68), women were divided into HPV-positive vs. HPV-negative. The following variables were collected: age, menopausal status, parity, smoking habit, HPV vaccination status, conization type , cone length (mm), pre-treatment cytology results, definitive treatment (fertility-sparing vs. standard treatment), adnexa treatment, lymphovascular space status, stage , histology , HPV status and cytology during follow-up, recurrence rate , survival rate, and time to recurrence (months). We included pre-treatment HPV genotyping in the analysis performed in eight of the thirteen centers participating in the study. Since most cervical glandular lesions are due to HPV-16/18/45, the genotypes have been divided into HPV 16, HPV-18, HPV-45, other HPVs, and multiple HPV infections . According to the study period, the histopathological diagnosis of stage 1A refers to the 2014 FIGO staging . Similar® Genotyping Test , INNO-LiPA® HPV Genotyping Extra assay , or CLART® HPV2 PCR .All data were retrieved from the electronic database used in our clinics and anonymized before analysis. HPV genotyping was performed using the HPV SignFertility-sparing treatment for women with stage AIS or 1A1 without LVSI included conization with negative margins; stage 1A1 with LVSI or 1A2 included conization with negative margins + pelvic lymph node dissection . StandarFollow-up was standardized for all women: co-testing + colposcopy every six months for three years, then co-testing + colposcopy annually for two years . t-test or Mann–Whitney test. The univariate analysis compared independent variables according to HPV status. Based on the results of univariate analysis, follow-up outcomes based on HPV status were measured using Cox proportional hazards regression. The Cox proportional hazards regression model included significant explanatory variables in univariate analysis, in addition to HPV status and treatment type. The Kaplan–Meier survival analysis with the Log-rank test assessed the recurrence rate according to HPV genotypes.Categorical variables were expressed as numbers and percentages. The chi-squared test was used to compare categorical variables. Continuous variables were tested for normal distribution using the Kolmogorov–Smirnov test. The variables were expressed as median and interquartile range or media and standard deviation according to distribution. As appropriate, continuous variables were assessed using Student’s Given that we included women with no follow-up losses, sample size calculation was performed using the estimation of a confidence interval with a required width for a single proportion based on the primary outcome: recurrence rate in in situ/microinvasive ACs. The literature reports a range of disease relapses between 2 and 14% ,21,22,23® Statistical Software version 20.218 . A value of p < 0.05 was considered statistically significant.MedCalc Statistical Software was used to perform statistical analyses . Menopausal status was present in 14.5% vs. 33.5% of HPV-positive vs. HPV-negative women, respectively (p = 0.027). HPV-positive women had a rate of LVSI of 7.3% vs. 29.2% of HPV-negative women, respectively (p = 0.001). Histopathology showed a “usual type” histology in 83.9% of HPV-positive women vs. 66.7% of HPV-negative patients, respectively (p = 0.049). Finally, HPV positivity during follow-up was 22.6% in HPV-positive women vs. 4.2% in HPV-negative women, respectively (p = 0.038). No significant differences were found in parity, smoking habit, HPV vaccination status, conization type, cone length, pre-treatment cytology, definitive treatment, salpingectomy or salpingo-oophorectomy, stage, positive pap test in follow-up, recurrence rate including pre-invasive and invasive disease, and time to recurrence. HPV positivity during follow-up occurred at 19.5 ± 16.2 vs. 29.1 ± 19.5 months in women with and without recurrence (p = 0.22), respectively.The univariate analysis results comparing HPV-positive vs. HPV-negative women are reported in p = 0.002).According to the results of univariate analysis and criteria reported in the method section, the Cox proportional hazards regression analysis is reported in p = 0.148 and (b) p = 0.294, respectively)  .HPV genotyping was available for 76 of 124 HPV-positive cases, including all recurrences in HPV-positive women (9 cases). Pre-invasive and invasive recurrences were related to HPV-18 in 3/5 cases (60%) and 3/4 cases (75%), respectively .p = 0.046)  .The main findings of the present study showed that most ACs were HPV related, and the recurrence rate in in situ/microinvasive AC was unaffected by HPV status. Secondly, and limited to a fraction of our sample, HPV genotyping found that most preinvasive and invasive recurrences were HPV-18 related.Cervical glandular lesions, unlike their squamous counterparts, are characterized by a higher rate of skip-lesions, and more aggressive behavior, resulting in a higher recurrence rate . A wide Time to recurrence is another critical aspect of cervical glandular lesions. HPV clearance in adenocarcinoma has been reported to take longer than in squamous lesions; therefore, more extended surveillance is recommended ,18. Our A further distinctive aspect of ACs is the link with HPV-negative cases . ConsistThere is scant literature on the impact of HPV status during long-term follow-up in in situ or microinvasive ACs. This population group is interesting as they account for more than 80% of high-grade cervical glandular lesions in clinical practice. Furthermore, they can be managed both conservatively and with standard treatment. Although previous studies have demonstrated comparable follow-up outcomes in women treated conservatively versus standard treatment in early stages of ACs, it is unknown whether this is also true for HPV-positive or -negative women with AIS or microinvasive adenocarcinoma.Our results indicate that HPV status should not impact management planning, as there is no difference in follow-up outcomes. Although HPV-negative cases appear to have a higher recurrence rate after treatment, these results did not reach statistical significance , Table 3HPV genotyping included 9/11 recurrences and showed that HPV-18 was present in most preinvasive and invasive relapses. Previous studies have found HPV-18 as an adverse prognostic factor in cervical cancer. In 1067 early stage cervical cancers, HPV-18 positivity was an independent prognostic factor for disease relapse . FurtherInterestingly, our study found only three cases of histopathologically non-HPV-related ACs. Consequently, the data on this type of ACs can be considered inconclusive. Furthermore, this underlines the rarity of these cases. On the other hand, this means that some of our HPV-negative cases had HPV-related histopathology. The explanation for this event may be due to false negative cases, or, as previously reported, they may be true negative HPV usual-type adenocarcinomas where HPV drives the initial transformation process; subsequently, it is lost in more advanced stages of transformation, and progressive somatic mutations play a crucial role ,33.The limitation of our study lies in its retrospective design. Additionally, there was no review of histopathology and HPV data using more sensitive methods. Genotyping was available for some women; therefore, these data should be taken cautiously. On the other hand, we have collected a fair number of women with rare conditions. The homogeneity of the sample, including well-standardized treatment options and long-term follow-up planning, should also be highlighted. Finally, being a multi-institutional study including numerous referral centers, the results are more generalizable.The recurrence rate in in situ/microinvasive ACs was unaffected by HPV status. Therefore, decision making regarding the management of these women should not be based on this finding. During follow-up, HPV-18 was a recurrent factor for relapse. Given that the latter result is based on only a portion of the sample, more extensive studies could help evaluate whether HPV genotyping may be considered in HPV-positive cases for recurrence risk stratification in this population group.


We assessed the safety, immunogenicity and antibody persistence of two- and three-dose schedules of the novel bivalent HPV16/18 vaccine  in the per-protocol target population of initially seronegative 9–14 year-old girls, including a non-inferiority comparison with the three-dose schedule in 18–26 year-old women.This randomized phase 3b trial in Guangxi Zhuang Autonomous Region, China, involved healthy Chinese females in two age cohorts; 600 girls aged 9–14 years and 300 women aged 18–26 years. Girls were randomly assigned (1:1) to receive either two  or three  intramuscular doses of HPV-2. All participants were monitored for immunogenicity as neutralizing antibodies up to 36 months. Primary objectives were non-inferiority analyses of immunogenicity between two- and three-dose girl groups and adult women at Month 7; safety assessments were based on participant-completed diary cards.All groups demonstrated marked increases in neutralizing antibodies against HPV 16 and 18 that persisted above baseline to 36 months. Month 7 responses in both girl groups were non-inferior to those in the women and were statistically higher after two-doses than girls or women who received three doses. GMTs waned after month 7, but then maintained a plateau level until month 36. Vaccination was well tolerated in all groups with no serious adverse events reported.Immune responses to two doses of HPV-2 vaccine in adolescent girls were non-inferior to those after three doses in young women, an age cohort in which clinical efficacy of HPV-2 against cervical cancer has been demonstrated. This vaccine targets HPV strains 16 and 18, which are responsible for over 70% of HPV-related diseases. The vaccine has demonstrated safety and immunogenicity in females from 9 to 45 years in phase 1 and 2 studies The target population for HPV immunization is girls under 15 years of age before they become sexually active and are exposed to HPV The present study was performed to demonstrate non-inferiority of the neutralizing antibody responses against HPV 16 and 18 following two doses  or three doses  of Walrinvax vaccine compared with the responses to the three-dose regimen in adult women (18–26 years old). We also assessed the safety and reactogenicity of the vaccine, and the persistence of these immune responses up to three years after receipt of the first dose.2ClinicalTrials.gov, identifier NCT02740777. The study was performed in compliance with International Council for Harmonisation (ICH) and Good Clinical Practice (GCP) guidelines. Written informed consent was obtained from all participants and the parents/guardians of the adolescent girl cohort before enrollment. The primary objective was to demonstrate non-inferiority of the immune response to two doses of HPV-2 in adolescent girls compared with the response to three doses in young women. Secondary objectives included a non-inferiority comparison of immune responses to three doses in adolescent girls vs. young women, and safety and reactogenicity of HPV-2. The study was extended to assess the persistence of the immune responses to 3 years following the first vaccination, 30 months after the last vaccination.This Phase 3b study was conducted at two clinical study sites in Hezhou City and Zhongshan County of the Guangxi Zhuang Autonomous Region from February 2016 to July 2019. The protocol was approved by the independent ethics committee Guangxi Provincial Centre for Disease Control and Prevention and registered on Eligible adolescent girl participants were aged between 9 and 14 years at the time of enrollment and healthy as established by their medical history and clinical examination. Eligible women participants were aged between 18 and 26 years, free of obvious health problems as established by their medical history and clinical examination, were not pregnant (confirmed by urine pregnancy test) nor planning to become pregnant until at least Month 7 of the study, and those who were sexually active agreed to use effective contraception until then. Main exclusion criteria for both cohorts included previous HPV vaccinations, known allergy to any vaccine component, prior or ongoing immunosuppression, and any acute illness within the seven days preceding enrollment or any fever (axillary temperature >37.0 °C) at the time of vaccination.2.1Pichia pastoris. Proteins are purified and self-assemble into virus-like particles (VLP) which can be absorbed on aluminum phosphate for vaccine formulation. The vaccine contained 40 μg of HPV16 and 20 μg of HPV18 L1 VLPs protein adsorbed to 225 μg of aluminum phosphate suspended in 0.5 ml of buffered saline . The vaccine batch used (Lot A201501202) was prepared in a Good Manufacturing Practices compliant facility and verified by the National Institutes for Food and Drug Control before use. Vaccine was administered by intramuscular injection in the lateral deltoid muscle of upper arm.The study vaccine, Walrinvax (HPV-2), is a recombinant bivalent HPV (types 16 and 18) vaccine developed by Shanghai Zerun Biotech Co., Ltd, China, and produced using recombinant DNA technology to produce HPV 16 and 18 L1 proteins using the yeast 2.2Adolescent girl participants were randomly allocated 1:1 to two groups to receive either two doses (at Months 0 and 6) or three doses  of Walrinvax, while young women all received three doses at Months 0, 2 and 6. On Day 0, following enrollment and after a baseline blood draw (and a negative urine pregnancy test in young women) the first dose was administered. In the three-dose groups a second dose was administered at Month 2 and all participants received their second or third dose at Month 6. Participants were monitored for 30 min after each vaccination for any immediate reactions. They were supplied with study diary cards on which to record solicited local reactions  and systemic adverse events  for 7 days which were returned on Day 8. Any unsolicited adverse events were recorded from enrollment to Month 7, and any serious adverse events (SAE) were recorded from enrollment to Month 12, regardless of cause, and participants or parents/legal guardians were asked to contact the investigator immediately in the event of an SAE. An SAE was defined as any untoward medical occurrence that resulted in death, was life-threatening, resulted in persistent or significant disability/incapacity, necessitated hospitalization or prolongation of existing hospitalization, or was a congenital anomaly/birth defect in the offspring of a study participant.2.350/mL, and 60 μL of diluted pseudovirions were mixed with 60 μL of serially diluted sera. The mixtures were incubated at 25 °C for 1 h and then transferred into plates pre-seeded with 293 FT cells at 100 μL/well and incubated for 68–76 h following which expression of green fluorescent protein (GFP) was observed by fluorescence microscopy. Neutralization titers are expressed as the reciprocal of the dilution causing a 50% reduction in GFP expression compared with a negative control and a titer ≥40 was considered to indicate seropositivity for HPV16 and 18, respectively.Sera prepared immediately from blood samples obtained from all participants before administration of vaccine at baseline and then at follow-up visits at Months 7, 12, 24 and 36 were used to test for neutralizing antibodies against HPV16 and HPV 18 in the three study groups. Sera were also obtained from a subset of 100 participants in each group at Month 6 for an exploratory assessment of the response after one and two doses. Immunogenicity testing was performed at the China National Institute for Food and Drug Control using a highly sensitive, automated, high-throughput, pseudovirion-based neutralization assay (PNBA) specific for neutralizing epitopes in the HPV-L1 proteins of HPV16 and 18 as previously described 2.4Non-inferiority was assessed based on neutralizing antibodies against HPV 16 and 18. The endpoints to determine the primary objective were the neutralizing antibody responses against HPV 16 and 18 measured at Month 7, one month after the last of two or three doses of HPV-2. Non-inferiority comparisons for each HPV type were calculated between the geometric mean titers (GMTs) in the two groups of 9–14-year-old girls who received either two or three doses of HPV-2 compared with the GMT in 18–26-year-old women one month after a third vaccination. Non-inferiority between two groups was demonstrated if the lower limit of the 95% confidence interval (CI) of the GMT ratio of the two groups was greater than 0.5 (the 95% CI lower limit of the inter-group difference after 10-based logarithmic conversion should be greater than −0.3). The primary objective was calculated in the per protocol set (PPS) consisting of those who were seronegative to the appropriate HPV type at Day 0, had received all their assigned vaccinations punctually according to schedule, provided paired sera samples with valid serology results from Months 0 and 7, and did not have any protocol violations that could interfere with the participant’s immune response. With at least 235 participants in each group, the study had greater than 90% power to establish both immunogenicity hypotheses at a 1-sided significance level of 0.025. Assuming a 15% withdrawal rate and some participants being seropositive at baseline, we determined that a sample size of 300 participants per group, a total of 900 participants, was required. Statistical analyses were performed using PASS11 software.3A total of 997 female volunteers were screened for inclusion in the study and 97 were excluded before 900 eligible participants were enrolled during February and March 2016; 600 girls aged 9 to 14 years randomly allocated to two equal groups and 300 women aged 18 to 26 years . A total3.1Then immune responses against HPV 16 and 18 at each study timepoint are illustrated in There were no differences in seropositivity rates  at Month3.2Antibody GMTs against HPV 16 were consistently comparable or significantly higher in the two- and three-dose adolescent girl groups than the three-dose women group up to Month 36 . ThroughWaning antibody titers had little effect on the seropositivity rates . By Mont3.3Vaccination with HPV-2 was generally well tolerated with no safety signals. There were no deaths during the study and of the five serious adverse events (SAE) reported, one case of appendicitis in a young woman and cases of bronchitis, skin infection, tonsillitis and a burn in three girls in the three-dose group), none was considered to be related to vaccination. Unsurprisingly, more girls in the three-dose group reported having an adverse event than girls in the two-dose group, presumably due to the greater number of injections, and adolescent girls reported more AEs than young women . Most soThe most frequently reported solicited systemic adverse event was fever, an axillary temperature >37 °C, but there were only six reports of fever >39 °C which occurred in 2 and four girls in the two- and three-dose groups, respectively. Headache was the only other systemic AE reported by more than 5% of any the study groups. All systemic AEs resolved without sequelae. Unsolicited AEs, reported by 21.7% of young women and 24.7% and 33.7% of the two- and three-dose adolescent girl groups, mainly consisted of upper respiratory tract viral infections, upper respiratory tract infections, cough, fever, pharyngitis and abdominal pain. A total of 13 unsolicited AEs were graded as severe, but none of these severe cases were considered to be related to vaccination by the investigators.Despite the contraception requirement there were six pregnancies in the cohort of young women  which re4The primary objectives of this study were successfully met as we demonstrated that in girls aged 9 to 14 years immune responses to HPV 16 and HPV 18 after two or three doses of the novel HPV-2 vaccine, Walrinvax, were non-inferior to those observed in young women aged 18 to 26 years after three doses. Neutralizing antibody responses against both HPV 16 and HPV 18 in adolescent girl groups who received either a two- or three-dose HPV-2 regimen were not only non-inferior but were actually higher than those observed in the young women one month after the last vaccination of their three-dose regimen. The robust immune response in the young girls was maintained for at least 30 months post-vaccination after either two or three doses with non-inferiority of the response in girls compared with young women persisting for the 30 months of follow-up. Furthermore, all vaccinations in either two- or three-dose schedules, were well tolerated by the girls with no vaccine-related serious adverse events reported, and generally mild to moderate reactogenicity mainly consisting of injection site pain and low-grade fever.Our immunogenicity observations are important for several reasons. Firstly, they bridge the immune response to HPV-2 in the target population of adolescent girls to the response in an older cohort of young women in which 78.6% efficacy of HPV-2 vaccine against cervical precancer associated with HPV 16 or 18 has been demonstrated E. coli in 9–14-year-old girls versus 18–26-year-old women Our results are consistent with previous reports. A multi-center study in Canada, Germany, Italy, Taiwan, and Thailand found non-inferiority of a two-dose regimen of the ASO4-adjuvanted bivalent HPV vaccine in 9–14-year-old girls compared with three doses in 15–25-year-olds More recent investigations have focused on the potential of a one-dose HPV vaccination regimen including a large study in 15–20 year-old African women which has demonstrated similar effectiveness of one or two dose HPV regimens with either the bivalent Cervarix or nonavalent Gardasil-9 vaccines There are limitations in our trial which must be acknowledged. Firstly, this study bridges immunogenicity data between cohorts of adolescent girls and young women, and the immunogenicity follow-up in the present was stopped at 36 months, 30 months after the vaccination. Clinical efficacy of a three-dose regimen of Walrinvax has been studied in a cohort of women aged 18–30 years with only 48 months follow-up Our present data from this bridging study indicate that Walrinvax meets the necessary criteria for licensure according to the WHO guidelines as it shows at least equivalent immunogenicity in the target population of 9–14-year-old girls to an adult cohort in which clinical efficacy has been demonstrated. Availability of another HPV vaccine will help overcome supply and cost issues which are currently preventing China achieving the goals of HPV immunization.5In conclusion, this study provides important evidence supporting the use of a two-dose regimen of Walrinvax in 9–14-year-old girls. The findings contribute to the growing body of evidence on the effectiveness and safety of two-dose HPV vaccine regimens and highlight the potential of implementation of a two-dose Walrinvax vaccination schedule to realize the economic and health benefits this bivalent vaccine could provide in the global effort to prevent HPV-related diseases.The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: B-W Yu, K Li, M Ji, Q Yang and L-Y Zhou are full-time employees of the manufacturer. Other authors declare no conflicts of interest.