The human papillomavirus (HPV) vaccination percentage among age-eligible girls in Japan is only in the single digits. This signals the need for effective vaccine communication tactics. This study aimed to examine the influence of statistical data and narrative HPV vaccination recommendation massages on recipients’ vaccination intentions.post hoc test, and analysis of covariance with Bonferroni correction.This randomized controlled study covered 1,432 mothers who had daughters aged 12–16 years. It compared message persuasiveness among four conditions: statistical messages only; narrative messages of a patient who experienced cervical cancer, in addition to statistical messages; narrative messages of a mother whose daughter experienced cervical cancer, in addition to statistical messages; and a control. Vaccination intentions to have one’s daughter(s) receive the HPV vaccine before and after reading intervention materials were assessed. Statistical analysis was conducted using analysis of variance with Tukey’s test or Games–Howell p < 0.001). A mother’s narrative messages in addition to statistical messages increased HPV vaccination intention the most of all tested intervention conditions. A significant difference in the estimated means of intention with the covariate adjustment for baseline value  was found between a mother’s narrative messages in addition to statistical messages and statistical messages only (p = 0.040).Vaccination intentions after intervention in the three intervention conditions were higher than the control condition (Mothers’ narrative messages may be persuasive when targeting mothers for promoting HPV vaccination. This may be because mothers can easily relate to and identify with communications from other mothers. However, for effective HPV vaccine communication, further studies are needed to understand more about persuasive differences in terms of statistics, narratives, and narrators. Directions for future research are also suggested. In communicating about risks and benefits of public health practices, it is essential to convey evidence-based information and to influence the audience to make better health decisions . This coIn Japan, unlike in many other developed countries, the primary care doctor system is underdeveloped, and school-administrated HPV vaccination has not been routinely performed. Most mothers and their daughters do not have health professionals whom they can consult with about HPV vaccines. They gather information independently and judge by themselves whether or not vaccination will be sought. Accordingly, when proactive recommendation of HPV vaccination resumes in the future, publicizing online and offline vaccination recommendation messages from the Ministry of Health, Labor, and Welfare and municipalities will be a means for recommending vaccination to mothers and their daughters. Therefore, examining persuasive messages that recommend HPV vaccination is an urgent issue in Japan.Since Aristotle, the use of evidence has been a primary means of enhancing message persuasiveness. Evidence is the set of factual statements that originate from a source other than the communicator and are offered to verify the communicator’s claims . Evidencwill a narrative message in addition to statistical messages result in higher intention to receive the HPV vaccine than statistical messages only?A primary question among scholars has focused on the relative persuasiveness of messages presenting statistical evidence compared with those presenting narrative evidence. At present, study results are somewhat contradictory, and no definitive difference has been demonstrated between narrative and statistical evidence –14. HoweSeveral models have been proposed to explain the persuasiveness of narratives, including the transportation-imagery model , extendeAlthough the relationship of the influence of identification and transportation on narrative persuasion is not entirely clear, identification may foster transportation and consequently enhance persuasiveness , 31. Idewill the narrative of a mother whose daughter experienced cervical cancer result in higher intention to have their daughters receive the HPV vaccine than the narrative of a patient who experienced cervical cancer among participants who are mothers with daughters?Japanese refer to the HPV vaccine as “sikyu keigan wakuchin” . Therefore, a narrative of a cervical cancer patient who recommends HPV vaccination may be persuasive for some audiences. However, healthy individuals may have difficulty identifying with a patient. When targeting mothers to promote HPV vaccination, the narrative of a mother who has a daughter may be easier to identify with and more persuasive than the narrative of a patient. Thus, our second research question emerges herein: This study aimed to examine the influence of HPV vaccination recommendation messages. It did so by using statistical data and narratives on vaccination intention of mothers with daughters aged 12–16 years, in Japan. This will help ensure that persuasive vaccine recommendation messages will be disseminated when proactive recommendation of the vaccination eventually resumes. A randomized controlled study was conducted to answer the above two research questions.Participants were recruited from persons registered in a survey company database in Japan. Eligibility criteria were mothers who have a daughter(s) aged 12–16 years who has never received HPV vaccination. An e-mail was sent to registered persons, which described that questionnaires  were created and intended for research purposes only. Recipients who were eligible and consented to participate in the study were invited to a web-based survey. After conducting a pretest among 120 participants in August 2017, a total of 1,432 mothers excluding pretest participants completed the survey in September 2017.When participants consented to participate in the study on the web screen, they were randomly assigned to a group that received statistical messages only, a group that received a patient’s narrative messages in addition to statistical messages, a group that received a mother’s narrative messages in addition to statistical messages, or a control group by algorithm included in the web-based survey computer program. Because required sample size in each intervention group was 394 participants (this will be discussed later), recruiting stopped when the number of participants of all of the intervention groups reached 394. All participants were asked about items such as sociodemographic information, history of cancer, and sexually transmitted disease, and whether they knew about the media coverage of adverse reactions to the HPV vaccine. Participants in the intervention groups were asked their intention to have their daughter(s) receive the HPV vaccine before and after reading the intervention material. They were also asked their attitude toward HPV vaccination after reading the material. Participants in the control group were asked their intention of vaccination without reading intervention materials. Token gifts were given to all participants upon completion of the study by the survey company. The protocol was approved by the ethical review committee at the Graduate School of Medicine, The University of Tokyo. All subjects gave written informed consent in accordance with the Declaration of Helsinki.Statistical content on the materials of the three intervention groups was taken from the websites of the Ministry of Health, Labor, and Welfare; National Cancer Center Japan; and a consensus statement from 17 relevant Japanese academic societies on the promotion of the HPV vaccine . The staNarrative contents of a patient and a mother were taken from a website of the United States Centers for Disease Control and Prevention  and modiThe primary outcome was intention to have one’s daughter(s) receive the HPV vaccine after intervention. Intention before intervention was assessed for covariate adjustment for baseline value and changes in intention before and after intervention. Participants responded to the following three questions on 1–6 scales ranged from “extremely unlikely,” “unlikely,” “a little unlikely,” “a little likely,” “likely,” to “extremely likely”: (1) “How likely would you have your daughter(s) receive the HPV vaccine sometime soon?”; (2) “If you were faced with the decision of whether to have your daughter(s) receive the HPV vaccine today, how likely is it that you would choose to have her receive the vaccine?”; and (3) “How likely would you have your daughter(s) receive the HPV vaccine in the future?” A summary score calculated by dividing the sum of scores of the three questions by three  was used in the analysis. Higher scores indicate greater intentions. This measure was adapted from a previous study . The secd = 0.2) (d) of 0.2 for comparing vaccination intention between “statistics only” and “a narrative in addition to statistics” conditions and between patient’s and mother’s narrative conditions at an alpha error rate of 0.05 (two-tailed) and a beta error rate of 0.20. We set the sample size at about 200 for the control group because the number of participants who matched the eligibility criteria was limited among persons registered with the survey company.A previous study of HPV vaccination communication showed that the effect sizes for comparing vaccination intention between “statistics only” and “a narrative in addition to statistics” conditions and between a peer’s and a third-person’s narrative conditions were small (Cohen’s d = 0.2) . Based od = 0.2) , 46 to dpost hoc test was performed when the assumption of homogeneity of variances was not satisfied. According to recommendations in the literature including the Consolidated Standards of Reporting Trials statement, significance testing of baseline differences and covariate adjustment for variables that differ at baseline are not recommended because such adjustment is likely to bias the estimated intervention effect. However, covariate adjustment for a baseline value of a quantitative outcome is recommended because a strong correlation between the baseline value and the outcome is expected .Descriptive statistics were used to describe participants’ sociodemographic information, history, and baseline intention to vaccinate, by summarizing in percentages for categorical variables and as mean ± SD for continuous variables. Analysis of variance (ANOVA) was conducted with the intention of vaccination or attitude toward vaccination as the dependent variable and the group assignment as the independent variable. Tukey’s test was conducted on significant main effects where appropriate. The Games–Howell expected –50. TherNumbers of participants were 394 in a group that received statistical messages only, 408 in a group that received a patient’s narrative messages in addition to statistical messages, 411 in a group that received a mother’s narrative messages in addition to statistical messages, and 219 in a control group. Table F = 17.198, MSE = 0.957, p < 0.001, η2 = 0.035]. Tukey’s test revealed a significant difference between the control and the statistics only , the control and the patient’s narrative in addition to statistics , and the control and the mother’s narrative in addition to statistics  groups. There was no significant difference in intention of vaccination between the three intervention groups. Regarding attitude toward vaccination, ANOVA revealed a main effect of the group assignment . The Games–Howell post hoc test revealed a significant difference between the control and the statistics only , the control and the patient’s narrative in addition to statistics , and the control and the mother’s narrative in addition to statistics  groups. There was no significant difference in attitude between the three intervention groups.Internal consistencies of questions about intention to have one’s daughter(s) receive the HPV vaccine and questions about attitude toward vaccination were excellent . Table F = 3.287, MSE = 0.255, p = 0.038, η2 = 0.0014]. The estimated means of intention after intervention with the covariate adjustment for baseline values are shown in Table post hoc analyses revealed a significant difference between the statistics only and the mother’s narrative in addition to statistics groups . There was no significant difference in the estimated means of intention between the statistics only and the patient’s narrative in addition to statistics groups.Analysis of covariance with the baseline intention set as the covariate revealed the main effect of the group assignment . Tukey’s test revealed a significant difference of change amount between the statistics only and the mother’s narrative in addition to statistics groups . There was no significant difference in change amount between the statistics only and the patient’s narrative in addition to statistics groups.The mean of intention to have one’s daughter(s) receive the HPV vaccine before and after intervention in the three intervention groups was 2.50 (SD = 0.94) and 2.81 (SD = 0.99), respectably. Figure We conducted a randomized controlled study to compare message persuasiveness between different conditions in terms of statistics, narratives, and narrators in the context of HPV vaccine communication. This study found that statistical only messages as well as a narrative (of a patient or a mother) in addition to statistical messages significantly improved mothers’ attitude and intention to have their daughter(s) receive the HPV vaccine than a no message condition (control). This result is consistent with a number of studies that showed presenting statistical or narrative evidence enhances message persuasiveness –12.One of our research questions was: will the narrative of a mother whose daughter experienced cervical cancer result in higher intention to have their daughters receive the HPV vaccine than the narrative of a patient who experienced cervical cancer among participants who are mothers with daughters? This study found no significant difference in attitude and intention of vaccination between the statistics only, patient’s narrative in addition to statistics, and mother’s narrative in addition to statistics groups. One of the reasons may be that baseline intentions affected intentions after reading the material; the baseline intention was the highest in the statistics only group (M = 2.56) and the lowest in the mother’s narrative in addition to statistics group M = 2.41) (see Table  see Tab. SimilarHowever, even after adjusting for baseline intentions, we found no significant difference in vaccination intention between the patient’s narrative in addition to statistics and the mother’s narrative in addition to statistics groups. This may be because other factors such as increase in self-efficacy through modeling  and geneAnother of our research questions was: will a narrative message in addition to statistical messages result in higher intention to receive the HPV vaccine than statistical messages only under the circumstances of the HPV vaccination crisis in Japan? We found no significant difference in vaccination intention between the statistics only and the patient’s narrative in addition to statistics groups before as well as after adjusting for baseline intentions. The process of identification involves multiple dimensions such as sharing the character’s feelings and perspective, internalizing the character’s goals, and the loss of self-awareness by being absorbed in the story . ConsideThe findings of this study must be interpreted with several limitations. First, narrative persuasion is generally hindered when the persuasive intent is obvious, as in the intervention materials of the present study, because some audiences may react against being manipulated . This coStatistical messages of HPV vaccine efficacy and safety, the narrative of a patient who experienced cervical cancer in addition to statistical messages, and the narrative of a mother whose daughter experienced cervical cancer in addition to statistical messages increased vaccination intention among participants who were mothers with daughters. In the practice of HPV vaccine communication, exposure to messages of HPV vaccine efficacy and safety may increase a mother’s vaccination intention whether it includes only statistical messages or narratives of cervical cancer experience in addition to statistical messages. Our study results may indicate that active dissemination of messages about efficacy and safety of HPV vaccines by public health institutions including the Ministry of Health, Labor, and Welfare and mother’s exposure to those messages are the keys to improve their attitude toward and intention of HPV vaccination.A mother’s narrative in addition to statistical messages resulted in slightly higher vaccination intention than statistical messages only and a patient’s narrative message in addition to statistical messages. Mothers may feel similar to and easily identify with a mother’s narrative. Narrative of a mother with a daughter who experienced cervical cancer may be persuasive for audiences who are mothers. The public health institutions including the Ministry of Health, Labor, and Welfare may be able to increase persuasiveness of HPV vaccination recommendation messages by using the narrative of a mother’s daughter experienced cervical cancer in addition to statistical messages when they create materials such as leaflets and websites.However, further studies are needed to understand more about persuasive differences between statistical and narrative messages as well as factors influencing the persuasiveness of narratives. A deeper understanding of these factors will help health professionals to more effectively communicate with individuals and communities to encourage better decision making regarding HPV vaccination.This study was carried out in accordance with the recommendations of the ethical review committee at the Graduate School of Medicine, The University of Tokyo. The protocol was approved by the ethical review committee at the Graduate School of Medicine, The University of Tokyo. All subjects gave written informed consent in accordance with the Declaration of Helsinki.TO and HI conceived the concept and design of the study. TO conducted statistical analysis and wrote the manuscript. HI provided the first feedback for the manuscript. All authors discussed the manuscript critically and approved the final version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Although screening for pre-cancerous cervical lesions and human papilloma virus (HPV) vaccination are accepted and effective means to prevent cervical cancer, women in Mali have limited access to these interventions. In addition, cervical cancer prevention by HPV vaccination has been controversial in some settings. To reduce cervical cancer prevalence and increase HPV vaccine uptake, it is important to understand the level of knowledge about cervical cancer screening and practices related to vaccination in at-risk populations. In this study, the level of knowledge about HPV and cervical cancer and attitudes towards vaccination were assessed among 301 participants  in a house-to-house survey in two urban neighborhoods in Bamako, Mali. The survey was combined with a brief educational session on HPV. Prior to the education session, overall knowledge of HPV infection and cervical cancer was very low: only 8% knew that HPV is a sexually transmitted infection (STI). Less than 20% of women had ever consulted a gynecologist and less than 3% had ever had cervical cancer screening. After hearing a description of HPV vaccine, more than 80% would accept HPV vaccination; fathers and husbands were identified as primary decisions makers and local clinics or the home as preferred sites for vaccination. This study provides information on STI knowledge and vaccine acceptance in Bamako, Mali in 2012, prior to the introduction of HPV vaccination. Nearly 85% of worldwide cervical cancer (CC) cases diagnosed each year occur in low-resource countries. The main risk factor for CC is infection with high-risk types of human papillomavirus (HPV) . In highIn West Africa, CC is the second most common and lethal cancer among women. A total of 27,300 new cases are identified in West Africa every year, and 16,500 deaths per year are attributed to CC ,9. The pAs of 2015, HPV vaccines are only available through pilot programs in some regions of Bamako prior to countrywide HPV vaccine introduction. At the time this study was performed (2011–2013), HPV vaccine was not available, but plans were underway to bring the HPV vaccine to Mali. The GAVI alliance recently initiated a pilot program 2014–2016). This program targeted 12,500 10-years old girls in Fana and Commune V of Bamako. The vaccination includes three injections administered at school or in health centers and through community outreach. Scale up is planned for late 2016 or early 2017. In anticipation of the introduction of HPV vaccination and the expansion of current CC screening programs in Mali, it is important to assess the willingness of Malians to be vaccinated and the level of knowledge about the link between HPV and CC. Recent studies have shown that one of the barriers to the delivery of CC screening is the lack of awareness about the disease .Most of the participants reported that they were 15–18 years of age at sexual debut, indicating that the current targets for HPV vaccination (girls aged 9–12 years ) would bSexual coercion and sexual violence, which put women at risk of HPV infection and other STIs, appear to be common in this population. Overall, 14.7% of sexually active participants reported having had forced sex  at least once, including both females and males. Self-reporting (in the participants’ home) may underestimate the true prevalence. Studies in South Africa reported similar results, and surveys among young girls’ mothers revealed that the risk of forced sex or sexual violence is a factor that positively influences their willingness to vaccinate their child against HPV infection ,20.Our findings demonstrate that potential vaccination participants prefer to be contacted and to receive vaccinations by home visits or at their local CSCOM (community clinic). This is consistent with current practices in Mali, as vaccination campaigns are conducted at the community level, either in the CSCOM or in house-to-house campaigns for polio and measles . In thesAlthough high HPV vaccine coverage rates can be achieved through school-based delivery strategies in adolescent girls (age 9–14) in low and middle-income countries , this stIn this study, home visits were the preferred method of contact for participants. Phone calls were preferred over text messages by all participants suggesting that contacting study participants through text reminders for second and third doses in a three-dose regimen may not transfer to Mali at this time. This may be due to low literacy rates: only 31% of Malians over age 15 are literate (2010 data from the WHO), meaning that 69% of the target population would be unable to read a text message on a phone.Another factor to be considered when designing a prevention program will be the autonomy to make a health-related decision. This study is, to the best of our knowledge, is the first large-scale study to examine the differences in permission required to receive HPV vaccination in Mali. Female participants identified men (husbands and fathers) as the primary decision-makers regarding HPV vaccination. Men had significantly greater autonomy in the decision to vaccinate themselves than women and adolescents (p = 0.005). These findings were somewhat expected, as Mali has a patriarchal decision-making structure . Our resAlthough 52% of women need the approval of their husband to vaccinate their child, most men would ask their parents or could not answer. Engagement of husbands has been shown to be a critical factor for the delivery of CC screening in Malawi . TherefoCritical issues that remain to be addressed to improve the situation regarding CC prevalence and limited access to CC screening in Mali and West Africa include the following: (1) low levels of HPV and CC knowledge; (2) limited knowledge about the purpose and location of cervical cancer screening, and (3) lack of access to cervical cancer screening. We are currently evaluating methods for increasing participation in HPV/CC screening using community education sessions and a patterned cloth as a visual teaching tool.It is clear from this study that HPV vaccination campaigns should be carefully structured, taking into consideration local cultural norms. Autonomy regarding vaccination was low among women and girls, thus, future studies should examine whether HPV vaccination campaigns should be conducted in clinical settings or at home, and how decisions about HPV vaccination, that are made in consultation with fathers or husbands, could be facilitated.In conclusion, this study provides information to guide future interventions such as HPV vaccination, CC screening campaigns, and publicity campaigns designed to improve HPV knowledge and vaccine acceptability in West Africa. Our results may be useful to support the implementation of vaccines against HPV in Mali. Implementation of HPV vaccination in Mali (and West Africa) would avert tens of thousands of future deaths. Perhaps most important, HPV vaccination is desired and would be accepted by the vast majority of participants in this study.S1 FileQuestions asked before the education session are listed in S1 file. Every participant was asked questions 1–10, 21–31 and 41–50. Only female participants were asked questions 11–20 and 32–40. These questions are in bold within the questionnaire. Questions highlighted in green were asked again during the second interview after the education session.(DOC)Click here for additional data file.S2 FileQuestions asked after the education session are listed in S2 file. Every participant was asked questions 1–10 and 18–30. Only female participants were asked questions 11–17. Questions highlighted in green were also asked during the first interview before the education session.(DOC)Click here for additional data file.S3 FileAge-adapted informed consent forms were used in this study. Page 1–2 of S3 file shows the consent form used for adults > 18 years old. Pages 3–6 shows consent forms proposed to adolescents < 18 years old and their legal guardian.(DOC)Click here for additional data file.S4 FileA three- days training was provided for interviewers before initiation of the study. The training manual is displayed in S4 file, in French.(DOCX)Click here for additional data file.


Safer, more convenient methods for cervical sample collection and storage are necessary to facilitate human papillomavirus (HPV) DNA testing in low-resource settings. Our study aimed to evaluate the stability of cervical specimens collected with dry swabs and stored dry, compared to liquid-based cytology (LBC) samples, as detected by HPV DNA testing. Women with abnormal cytological findings or HPV-positive results at colposcopy were recruited from the West China Second University Hospital, Sichuan University, between October 2013 and March 2014. From each woman, physicians collected cervical specimens with a swab placed into a Sarstedt tube and a CytoBrush placed into LBC medium. Samples were randomly assigned to be stored at uncontrolled ambient temperature for 2, 7, 14, or 28 days and then were tested for 14 high-risk HPV (HR-HPV) types using the cobas HPV test. The rates of agreement between dry swab and LBC samples for any HR-HPV type, HPV16, HPV18, and the 12 pooled HR-HPV types were 93.8%, 97.8%, 99.4%, and 93.2%, respectively, with kappa values of 0.87 , 0.94 , 0.94 , and 0.86 . The performance of swab samples for detection of cervical precancerous lesions by means of cobas HPV testing was equal to that of LBC samples, even with stratification by storage time. Dry storage of swab-collected cervical samples can last for 1 month without loss of test performance by cobas HPV testing, compared to LBC samples, which may offer a simple inexpensive approach for cervical cancer screening in low-resource settings. Human papillomavirus (HPV) DNA testing has proven to be an effective primary screening approach for the secondary prevention of cervical cancer in developing countries , 2. The Specimens were collected from 743 women; 695 women were included for data analysis, however, because there were 48 ineligible cases. Two LBC samples and four swab samples were tested but yielded invalid results. There were 30 cases with no biopsy results among 689 women with valid cobas HPV results. A total of 689 cases were used for agreement analysis, and 659 cases were used to analyze the accuracy of swab and LBC samples for detection of cervical intraepithelial neoplasia grade 2 or worse (CIN2+) and CIN grade 3 or worse (CIN3+) with the cobas HPV test. Characteristics of the 695 eligible women are presented in P values of 0.61, 0.33, 0.73, and 0.91, respectively. There was also no significant difference in the distribution of invalid cases between LBC and swab samples (P = 0.41).The prevalence of high-risk HPVs (HR-HPVs) overall, 12 pooled HR-HPVs, HPV16, and HPV18, as detected by cobas HPV testing with LBC and swab samples, is shown in The kappa values for agreement between findings for LBC and swab samples detected by cobas HPV testing, stratified according to storage time, are presented in The performance in detecting HR-HPVs overall, 12 pooled HR-HPVs, HPV16, and HPV18 with dry-stored swab samples, which were stored at uncontrolled ambient temperatures for 1 month, was equal to that with LBC specimens using the cobas HPV test. The accuracy of detecting CIN2+ or CIN3+ with dry-stored swab samples with 1 month of storage was comparable to that with LBC specimens. Our study also showed a common limitation of the HPV test, i.e., low specificity for detecting cervical precancerous lesions, with both LBC and swab samples. In this respect, genotyping of HPV16 and HPV18 with the cobas HPV test can compensate for the loss of specificity . Of noteSeveral studies demonstrated that the testing performance of LBC samples did not decline over time –8. In th–9–The limitations of the current study are as follows. First, the accuracy of dry sample collection for detecting HPV and cervical precancerous lesions, compared to the liquid-based sampling strategy, was evaluated among patients at a colposcopic clinic rather than in the general female population. Second, the processing time for dry-collected and stored swab samples exceeded that of routine methods. The feasibility of shorter periods of vortex-mixing for preparation of dry swab samples should be further tested. In conclusion, swab-collected samples can last up to 1 month in dry storage without loss of test performance, compared to traditional LBC samples, which may offer a simple inexpensive approach of sampling in cervical cancer screening programs in low-resource settings.A parallel comparative experimental study was conducted in the Cancer Hospital, Chinese Academy of Medical Sciences, collaborating with the West China Second University Hospital, Sichuan University. Patients with abnormal cytological findings and/or HPV-positive results were recruited at the time of the colposcopy examination. All women supplied written informed consent. We excluded participants who were pregnant or had a history of total hysterectomy.Two cervical specimens from each woman were randomly collected by the physician prior to colposcopic evaluation. One sample was collected using a CytoBrush and placed into PreservCyt medium  (LBC sample), and one sample was collected using a polyethylene fiber swab and placed into a Sarstedt 15-ml tube (swab sample). The swab and Sarstedt 15-ml tube were provided by Roche Molecular Systems . The specimens were randomly assigned to be stored at uncontrolled ambient temperatures (0 to 30°C) for fixed times of 2, 7, 14, or 28 days. After storage at room temperature according to the protocol, the specimens were stored at −20°C until HPV DNA testing was performed. The specimens were stored at −20°C from 3 months to 6 months before HPV DNA testing was performed.Women classified as having a cervical abnormality by digital colposcopy underwent a biopsy. All pathology slides were read by the pathologists at the West China Second University Hospital, Sichuan University. Ten percent of the CIN1 and CIN3 cases (selected randomly) and all CIN2 cases were subjected to review by the pathologists at the Cancer Hospital, Chinese Academy of Medical Sciences, for quality control.The cobas HPV testing was performed in the laboratory of the West China Second University Hospital, Sichuan University, according to the manufacturer's instructions, except as noted below. The cobas HPV test provides specific genotyping results for HPV16 and HPV18 along with results for 12 pooled oncogenic types, i.e., HPV31, HPV33, HPV35, HPV39, HPV45, HPV51, HPV52, HPV56, HPV58, HPV59, HPV66, and HPV68. Specimen preparation for the cobas HPV test was accomplished using the cobas x 480 instrument, which simultaneously extracts, purifies, and prepares target HPV DNA and β-globin DNA for PCR amplification and detection. The processing of β-globin DNA functions as a control to differentiate HPV-negative specimens from samples that fail to exhibit positivity due to a lack of cells or the presence of PCR inhibitors in the specimens being tested. For the dry swab specimens, we added 1.2 ml PreservCyt medium into the tube with the dry swab specimen and then vortex-mixed the sample for 15 min. After vortex-mixing, the swab was removed from the tube. The tube with the sample eluted from the dry swab was then placed in the cobas 4800 instrument for DNA extraction and HPV detection.P values of <0.05 (two-sided) were considered statistically significant. The statistical analysis was conducted using SAS version 9.2 .From PASS software, a sample size of 168 pairs achieved 80% power to detect an odds ratio of 3.00 using a two-sided McNemar test, with a significance level of 0.05. We evaluated the agreement of results for HR-HPVs overall, HPV16, HPV18, and 12 pooled HR-HPV strains detected by cobas HPV testing with swab and LBC specimens for each storage time , by means of McNemar tests. We calculated the sensitivity and specificity for detecting CIN2+ and CIN3+ using cobas HPV testing with LBC and swab samples. All


Our study showed a high frequency of HR-HPV in both cervical and anal sites of women with negative cytology belonging to a risk group for the development of anogenital cancer.Human Immunodeficiency Virus (HIV)-seropositive women are more likely to have anogenital cancer, and high risk-HPV (HR-HPV) infection is the main associated factor. Between August 2013 and December 2015, we conducted a descriptive study to determine the HPV genotypes and HPV16 variants in cervical and anal samples of HIV-seropositive women with a normal Pap test. The viral DNA was amplified by PCR using the PGMY09/11 set of primers. Reverse line blot (RLB), restriction fragment length polymorphism (RFLP) and sequencing assays were used to determine the HPV genotypes. HPV16 variants were identified by gene sequencing. We found a high frequency of HR-HPV  at the anogenital site among HIV-seropositive women and without association with anal intercourse. HPV16 and European variant predominated among the HR-HPV. Mixed infections with at least three different HPV types were common, particularly at the anal site. CD4+ T-cell counts below 500 cells/mm Human papillomavirus (HPV) is the most common sexually transmitted infection (STI) worldwide, and it is associated with development of anogenital cancers . Over 20Cervical cancers, the fourth most common cancer in women, are a serious problem of public health worldwide, with approximately 500,000 new cases annually, 85% of them in developing countries . ExposurThe control procedure for cervical cancer is mainly based on the detection of precursor lesions by cervical cytology, a practice adopted by many countries, and the World Health Organization (WHO) recommends cervical cancer screening every three years after a normal Pap test in HIV-seropositive women –14. HoweIn this context, molecular tests have emerged as useful tools for HPV genotyping beyond detection, providing an early indication of cervical and anal potential lesions, especially in HIV-seropositive women, who are at particularly high risk for HPV-related malignancies . TherefoThis study is a case series study in HIV-seropositive sexually active women, aged 18 to 65 years old who attended a STI/AIDS Reference Clinic in Vitoria, southeastern Brazil, from August 2013 to December 2015. Cervical and anal samples collected using a cytobrush were stored in Tris-EDTA buffer and maintained in a freezer at -70°C. A 20-minute face-to-face interview was conducted with the use of a standardized questionnaire, which included demographic  and behavioural data . The CD4+ T-cell count and HIV viral load were measured in the Public Health Specialized Laboratory of Espírito Santo State, and the Pap test samples were probed in the Pathology Laboratory of Espírito Santo. Pap tests within the normal limits and benign cellular changes [β-globin [DNA was obtained using the QIAamp DNA Mini Kit  according to the manufacturer’s instructions. The HPV DNA was detected by amplification with the PGMY09/11 set of primers . PCR forβ-globin  gene wasβ-globin . A restrβ-globin  and sequThe HPV genotypes identified in this study were classified as high-risk , low-risk  and undetermined-risk  [LCR region [Samples identified as HPV16 were subjected to PCR with primers for the HPV16 R region , which aR region  and thenR region  using thR region . The conR region .The possible associations between the variables were tested using a chi-squared test with a Yates correction or Fisher's exact test, as appropriate. The HPV frequency of paired samples  was compared using the McNemar test. The Odds Ratio (OR) and confidence intervals were calculated using bivariate analysis to estimate the degree of association between infection and demographic variables. Variables were considered significant when the p value was < 0.05.In total, 126 HIV-seropositive women with a normal Pap test participated in this study. Demographic, behavioural and clinical data of the study population are shown in β-globin gene in all HPV negative samples. HR-HPV occurred in 60.3% (76/126) of the cervical and anal samples of the women, with a higher frequency at the anal site of 46.8% vs. 32.5% (p = 0.0284).HPV DNA was observed in 71.4% (90/126) of women, 38.9% (49/126) in the cervical site and 60.3% (76/126) in the anal site (p = 0.001); cervical and anal infection was concomitant in 38.9% (35/90) of the positive cases. The presence of amplifiable DNA was confirmed by PCR of the Overall, 34 distinct HPV genotypes were detected in both samples in the study population . HPV16 wAt least three distinct types of all HPV occurred concomitantly in 78.6% of anal samples and in 21.4% of cervical samples  . No moreLCR region) characterized: four from both cervical and anal sites, 12 from solely the anal site and four from solely the cervical site. The nucleotide sequences obtained were compared with the HPV16 prototype of each HPV16 variant lineage and sublineage, and each one was assigned to a specific lineage based on the phylogeny  of positive cases of cervical HPV also present at the anal site  .3 (p = 0.01) and a HIV viral load above 50 copies/mL (p = 0.001) , a CD4+ T-cell count below 500 cells/mm= 0.001) .The HPV test, a useful tool for monitoring women with equivocal or normal cytological results , 31, wasBetapapillomavirus genus) we observed in the genital samples suggests possible transmission during sexual contact. This finding is not exactly unexpected since Torres et al. (2015) [papillomavirus) at the anal site of HIV-positive MSM.The great diversity of HPV types was shown in our study using the RLB methodology complemented by the RFLP method and sequencing, which was also shown by Gonçalves et al. (2008)  and Koji. (2015)  found HPWe highlighted the high frequency of HR-HPV at both cervical and anal sites, which was significant in the latter site, similar to previous reports , 35. Thith to late 19th century and Asiatic immigration in the 20th century. Although all HPV16 variants are related to the development of precancerous lesions and cancer, the predominance of European variants in this study implies a lower risk for the development of HSIL [In a multicentric study, Cornet et al. (2013)  identifi of HSIL , 42.3) and detectable viral load (>50 copies/mL), were also statistically associated with the presence of HPV at the anal site. Indeed, previous studies have demonstrated that a lower CD4+ count is associated with anal HPV [Infection with multiple HPV types was greater at the anal site in relation to the cervical site. It is unclear whether this fact could increase the pathogenesis of intraepithelial lesions as previously suggested . Howeveranal HPV , 35 and anal HPV .Although a descriptive study is not the best model to determine risk factors, it was not our main objective, and its application may be justified to assess the prevalence of factors associated with HPV infection at the cervical and anal sites of HIV-seropositive women.The value of the implementation of molecular tests in cervical cancer screening for HIV-seropositive women has been emphasized , and the


Welding quality control is an important parameter for safe operation of oil and gas pipes, especially for high-strength steel pipes. Size control of welding defect is a bottleneck problem for current pipe construction. As a key part of construction procedure for butt-welding of pipes, pore defects in girth weld is difficult to ignore. A three-dimensional non-linear finite element numerical model is established to study applicability of size control indices based on groove shape and softening phenomenon of material in heat-affected zone of practical pipe girth weld. Taking design criteria of pipe as the basis, basic tensile, extremely tensile and extremely compressive loading conditions are determined for pipe stress analysis, and failure criteria based on flow stress is employed to perform stress analysis for pipe girth weld with pore defect. Results show that pipe girth welding stresses of pores at various radial locations are similar. Whereas, stress for pores of different sharpness varied significantly. Besides, tolerance capability of API 5L X90 grade pipe to pore defect of girth weld is lower than that of API 5L X80 grade pipe, and size control index of 3 mm related to pore defect in current standards is applicable to API 5L X80 and X90 grade girth welded pipes with radially non-sharp pore defects. Girth welding is a key procedure used in pipe construction, primarily influenced by welding technology and external environments . During Forming mechanism and control measures are major focus of current investigations of weld pore defects –13. In sQuality control for high strength girth welded pipe in enabling pipe safety is important. Additionally, research reported in literature rarely takes stress analysis of girth welded pipes with pore defects in account. As a result, it can be concluded that technological foundation for pore defect size control of girth weld in high strength pipe is currently lacking. The present work concentrates on groove shape and softening phenomenon of material in heat-affected zone of the pipe girth weld in practical engineering applications. Moreover, a numerical model for pipe girth weld with pore defect is established. Effects of pore defects based on stress distribution of pipe girth weld from simulation results for three loading conditions are analyzed. Effects of location and shape factor of pores on high-grade pipe are studied. Additionally, applicability of pore defect size control indices in current standards are evaluated. Based on results, some guidelines for reasonable control of welding quality of pipe girth weld s are discussed.Pipes simulated in the present work are modeled as in-service pipeline. The welding process is Flux-Cored Arc Welding (FACW) which has been successfully applied in API 5L X80 grade gas pipeline in China. The welding process combined with low-hydrogen electrode for root welding, self-shielded flux cored arc welding for semi-automatic filling and capping. The root welding material is AWS A5.1 E7016 low-hydrogen electrode, the filling and capping material is AWS A5.29 E81T8 self-shielded flux cored arc welding. Pipe dimensions are Φ 1219×16.3 mm for API 5L X90 grade pipe and Φ 1016×18.4 for API 5L X80 grade pipe, respectively. Here, a large-scale finite-element analysis (FEA) was carried out using commercial FEA software ABAQUS. Pore defect is approximated as a regular sphere located at the center of the pipe girth weld. Since, the pipe is symmetrical about the horizontal and vertical cross sections where the pore center is located, 1/4 of the pipe is used to carry out the modeling and simulation. Hexahedral elements with 20 nodes are used for model meshing. Fine meshing is adopted around the pore as stress gradients vary around the pore. Coarse mesh is used for the pipe, as the distance from the pore is increased. The finite element model is shown in During welding, the material is subjected to multiple thermal cycles, causing change in mechanical behavior of the materials in the weld or adjacent to the base material. In practice, matching factor of weld strength is used to characterize uneven change of material caused by welding, and this factor is typically obtained empirically. To understand strength matching for API 5L X80 and X90 grade pipes with girth weld, several pipe girth welded samples are tested and measured. This allows changes to material property of the weld, base material and heat-affected zone to be characterized. Test results show that yield limit of the weld is 10% to 12% higher than that of the base material, demonstrating overmatched welding. Welding with this factor can increase the stiffness of girth weld. However, microscopic structure is changed and a softened zone is formed in the heat-affected zone due to welding thermal cycles, causing decreased strength and toughness . Compareε is true strain, σ is true stress in MPa, E is Young’s modulus in MPa, σs is yield limit in MPa, α is offset of yield, n is hardening exponent, and εs is elastic strain corresponding to yielding, εs = σs/E.Based on matching relationship of weld strength obtained in the tensile tests on the static universal testing machine, calculations were carried out with overmatching factor of 1.1, i.e. strength of the weld zone material is 10% higher than the base material, and that of the heat-affected zone material is 10% lower. Material stress-strain relationship is described by Ramberg-Osgood (R-O) constitutive relation, as shown in Eq  can be reasonably ignored. Consequently, the pipe is subjected to biaxial stress, hoop stress (σh) and axial stress (σa), as shown in σs. Thus, extreme tensile and compressive loading conditions situations under basic loading can be determined when axial stress of pipe is compressive (σa<0), by:In fact, the thickness of pipe is much less than diameter, so the radial stress ,σs.When, axial stress of pipe is tensile Click here for additional data file.S2 File(DOCX)Click here for additional data file.


Data of HPV genotype including 16 high-risk HPV (HR-HPV) and 4 low-risk HPV from 38,397 women with normal cytology, 1341 women with cervical cytology abnormalities, and 223 women with ISCC were retrospectively evaluated by a hospital-based study. The prevalence of high-risk HPV (HR-HPV) was 6.51%, 41.83%, and 96.86% in women with normal cytology, cervical cytology abnormalities, and ISCC, respectively. The three most common HPV types were HPV-52 (1.76%), HPV-16 (1.28%), and HPV-58 (0.97%) in women with normal cytology, whereas the most prevalent HPV type was HPV-16 (16.85%), followed by HPV-52 (9.55%) and HPV-58 (7.83%) in women with cervical cytology abnormalities. Specifically, HPV-16 had the highest frequency in ASC-H  and HSIL , while HPV-52 was the most common type in ASC-US  and LSIL . HPV-16 (75.78%), HPV18 (10.31%), and HPV58 (9.87%) were the most common types in women with ISCC. These data might contribute to increasing the knowledge of HPV epidemiology and providing the guide for vaccine selection for women in Shantou. Although liquid-based cytology screening for cervical cancer is recommended for women in most countries, however, cervical cancer accounts for 9% of the total new cancer cases and 8% of the total cancer deaths among females, with 85% especially in developing countries . The cruRecently, 9-valent virus-like particle vaccine against HPV, including HPV-6, HPV-11, HPV-16, and HPV-18 and five additional oncogenic types HPV-31, HPV-33, HPV-45, HPV-52, and HPV-58, has been developed . Using tThe purpose of this present study was to confirm the description of HPV prevalence and type-specific distribution in cervical cytological abnormalities in Shantou's population and to identify the most frequent multiple HPV types both in cervical cytological abnormalities and in invasive squamous cell carcinoma (ISCC).This is a cross-sectional and retrospective study, which was composed of three kinds of consecutive participants who proceeded to routine screening from the Healthcare Center, who were referred for opportunistic screening and for evaluation of HPV-associated lesions from the Outpatient and Inpatient Gynaecological Clinic of the Shantou Central Hospital between January 2011 and April 2014. Participants who met the following criteria were included: participants who were permanent residents of Chaoshan area, were not pregnant, had not undergone hysterectomy, had no history of cervical surgery, and had never had pelvic radiation therapy. All participants included in the study gave their written informed consent. This study was approved by Research Ethics Boards at Shantou Central Hospital.In this study, Pap test based cervical specimens were collected from exfoliated cell. Cervical exfoliated cell specimens were obtained by a gynecologist as part of routine investigative procedures. Two separated cervical exfoliated cell specimens were collected independently for liquid-based cytological diagnosis and HPV DNA genotyping assays, respectively. Cervical slides were prepared using a liquid-based cytology method. Cytological classifications of disease grade were performed according to the Bethesda 2001 criteria (TBS2001) , includiHPV genotyping was performed as described previously ; HPV DNAt-test was used to compare continuous variables among different groups. The data were analyzed by using SPSS 16 software .Categorical variables were summarized by absolute frequencies and percentages, and continuous variables were presented by means and Standard Deviation (SD). The Chi-square test and Fisher's exact test were used to compare proportions; the Combining cervical cytological and HPV-DNA testing including all of the 20 different HPV types was performed in a total of 39738 women. The mean age of those women was 38.16 ± 10.28 yrs. The prevalence of HPV infection and the distribution of the different HPV genotypes were shown in Tables P < 0.001). The most prevalent HPV type was HPV-16  in all of the cervical cytology abnormalities, followed by HPV-52  and HPV-58   women with cervical cytology abnormalities were classified, of whom 11.11% (149/1341) had ASC-H, 47.73% (640/1341) had ASC-US, 22.97% (308/1341) had HSIL, and 18.20% (244/1341) had LSIL . The mea05/1341) . HPV-16,A total of 223 ISCC were identified with mean age of 47.82 ± 6.79 yrs. The overall prevalence of HR-HPV for ISCC was 96.86%. As expected, HPV-16 was the most common genotype in the 223 ISCC, with the rate of 75.78% (169/223). The second most common genotype was HPV-18, which was detected in 23 (10.31%) ISCC. HPV-58 was the third most common genotype and was detected in 22 (9.87%) ISCC.The 39738 women were classified by their age into 6 groups, and the age-specific prevalence of HR-HPV types was shown in Accurate epidemiological information on HPV infections, including genotype-specific prevalence, is essential for achieving further progress in prevention, such as evaluation of potential impact of HPV vaccines, and type-specific monitoring. Therefore, validation set with large size of sample is desired to confirm HPV type in special region because of geographic diversity. To our knowledge, this is the first validation set to comprehensively describe prevalence of HPV infection and its subtypes from normal cytology and cervical cytological abnormalities to carcinoma in a large-scale population of Shantou, which is a high-incidence area of esophageal squamous cell carcinoma.In the HPV-positive population, HPV-52 genotype was the most common (24.52%), followed by HPV-16 (21.76%) and HPV-58 14.58%); this present result confirmed our previous findings, which demonstrated that HPV-52 (21.60%), HPV-16 (19.49%), and HPV-58 13.79%) were the three most prevalent types in overall population. Furthermore, the top three HPV types were consistent with those in Chaozhou's population, which was close to Shantou in terms of geographic location and population genetic background and also named Chaoshan area, with HPV-52 (21.60%), HPV-16 (20.95%), and HPV-58 15.93%) . Regardi.79% were.58%; thi.93% . ReP < 0.001). Although the change trend in this present study was similar to our previous study [Overall, the HPV infection occurred in 43.10% of women with cervical cytological abnormalities, of which HR-HPV was the highest in HSIL 56.17%), followed by LSIL (51.64%), ASC-H (48.32%), and ASCU-US (29.69%), and HR-HPV was greater in SIL  than in ASC (33.21%, 262/789, .17%, folus study . HoweverWe found 96.86% prevalence of HR-HPV in ISCC, which was consistent with 91.8–100% in China . The thrConsequently, our results could be baseline data and validation set, which provide the most robust available estimates of the prevalence of type-specific HPV, in normal cytological and cervical cytological abnormalities and cervical cancer, prior to HPV immunization in Shantou's population.


Currently, clinical data for primary HPV screening alone are lacking in China. Here, we evaluate cervical cancer screening with primary HPV genotyping, as well as possible future screening strategy. Overall, high-risk HPV (hrHPV) prevalence was 18.2% among hospital-based population in Taizhou area. For cervical intraepithelial neoplasia 2 or worse (CIN2+), the sensitivity of primary hrHPV genotyping strategy and current cervical cancer screening strategy were 93.5%, and 71.1%, respectively; whereas the specificity was 17.5%, and 62.4%, respectively. Current cervical screening strategy had slightly higher positive predictive values (28.4%) for CIN2+ than hrHPV genotyping strategy (21.9%), whereas primary hrHPV genotyping strategy demonstrated higher negative predictive values (94.7%) than current cervical screening strategy (91.1%). Compared to HPV35/39/45/51/56/59/66/68 genotypes, the odds ratios (OR) for CIN2+ in HPV16/18/31/33/52/58 infection women were 3.2 . Primary hrHPV genotyping strategy provides a better predictive value than HPV16/18 genotyping alone in guiding the clinical management of the current cervical cancer screening. HPV testing without adjunctive cytology may be sufficiently sensitive for primary cervical cancer screening. Worldwide, cervical cancer is the second most common female malignancy. Approximately 500,000 new cases of cervical cancer are diagnosed and 275,000 deaths from cervical cancer occur annually. Persistent infection of high-risk human papillomavirus (hrHPV) is necessary for the development of high-grade intraepithelial neoplasia (CIN2/3) and cervical cancer . More thPublic health screening programmes have successfully decreased cervical cancer incidence and mortality, including cervical cancer screenings and HPV vaccinations. Current guidelines for cervical cancer screening which cosponsored by the American Cancer Society (ACS), the American Society for Colposcopy and Cervical Pathology (ASCCP), and the American Society for Clinical Pathology (ASCP) in 2012, were recommendations address age-appropriate screening strategies, including the use of cytology and hrHPV testing (co-testing) , 4. ReceWith the aim to establish a foundation for primary HPV screening in a certain area, and to support the local vaccination program in Taizhou region. This population-based, prospective observational study was designed to analyze the distribution of individual hrHPV genotypes across the complete spectrum of cervical disease; we have performed the primary HPV screening in detecting precancerous high-grade cervical lesions and cervical cancer.The Taizhou Area HPV study is a population-based, prospective observational study. We used HPV genotyping for primary cervical screening strategy, women with screen results of hrHPV positive referred directly to colposcopy biopsy. Moreover, the current cervical screening strategy with cytology and hrHPV testing (co-testing), the management of screen results stratified follow by: 1) atypical squamous cells of undetermined significance (ASCUS) or worse, referred directly to colposcopy biopsy; 2) cytology normal and HPV16/18 positive, referred directly to colposcopy biopsy , 7.Between December 2012 and April 2015, a total of 19207 consecutive women  underwent cervical cancer screening in gynecological clinic at Taizhou Hospital of Zhejiang Province. The flowchart of study population was shown on Figure TM analyzer.HPV genotyping was performed using the GP5+/bioGP6+-PCR/MPG assay, which was approved by the China Food and Drug Administration (CFDA Certified NO. (2014): 3400847). DNA was extracted from 200μl of each sample and collected in 50μl elution buffer according to the manufacturer's instructions. 5μl of extracted DNA was amplified by the GP5+/bioGP6+ broad-spectrum primer set with a final volume of 20μl. Reactions were heated for 5min at 95°C, followed by 35 repeated cycles of 94°C for 30s, 55°C for 30s, 72°C for 30s, and a final extension step at 72°C for 10min. Following the PCR amplification, 3μl of biotin-labeled PCR products and 22μl of hybridization solution containing 27 types of coupled beads of each set were transferred to 96-well plates. Hybridization was performed at 95°C for 5min followed by 48°C for 30min. Subsequently, streptavidin-phycoerythrin was added to each well at 48°C for 15min. The biotin-labeled PCR products were captured by HPV type-specific probes attached to color-coded beads, streptavidin-phycoerythrin was used as the reporter bound to the target, and the HPV genotypes were analyzed using the Luminex200In short, it comprises the GP5+/bioGP6+-PCR, which using sets of biotinylated amplimers and a multiplex human papillomavirus genotyping (MPG) methods with bead-based Luminex suspension array technology , 9, whicin situ (AIS), and adenocarcinoma.Cytological results, which blinded to the outcomes of HPV testing, were reported according to the 2001 Bethesda system. Cytological results were grouped as negative for intraepithelial lesion or malignancy (NILM), ASCUS, atypical squamous cells and cannot exclude high-grade squamous intraepithelial lesions (ASC-H), low-grade squamous intraepithelial lesions (LSIL), high-grade squamous intraepithelial lesions (HSIL), squamous cell carcinoma, atypical glandular cells (AGC), endocervical adenocarcinoma Histopathologic diagnoses were adjudicated by pathologists and classified as normal, CIN grade 1, 2, 3 or invasive cervical cancer, according to international criteria. The suffix “+” means the indicated histology or more severe. Disease end points were histopathologically confirmed CIN2+ or CIN3+.in situ, and ICC) were determined using standard statistical tests. The chi-squared and Fisher's exact tests were used to evaluate relative CIN2+ risk associate with HPV genotypes, odds ratios (ORs) and relative 95% confidence interval (CI). All statistical analyses were performed using SPSS version 15.0 . P values were two-sided, and statistical significance was accepted if the P value was 0.05 or less.Performance characteristics of hrHPV test  for identification of CIN2+ . According our recommended hrHPV genotyping for primary cervical screening strategy, 1399 women underwent colposcopy biopsy. According the current cervical screening strategy, 567 women underwent colposcopy biopsy.As shown in Table The overall prevalence of HPV was 22.2% (95% CI 21.6-22.8%), hrHPV and lrHPV infection rates were 18.2% (95% CI 17.6-18.7%) and 4.0% (95% CI 3.7-4.3%), respectively. Overall, HPV52 was the most prevalent genotype (4.9%), either alone or in combination with other types, followed by 16 (3.1%), 58 (2.7%), 39 (1.6%), 18 (1.5%), 56 (1.5%) .To assess the clinical predictive value for different hrHPV types, we further evaluated our data on the prevalence of individual hrHPV infection rates for cervical pathology status Table . For theIn this study, we recommended hrHPV genotyping for primary cervical screening strategy, when women with screen results of hrHPV positive referred directly to biopsy. According to this guideline, 3210 women need biopsy, irrespective of women age. In fact, 1399 (43.6%) women with hrHPV infection accepted biopsy, including 885 women with cervicitis, 195 with CIN1, 117 with CIN2, 169 with CIN3, and 33 with ICC, respectively. According this screening strategy, the sensitivity and specificity for detecting CIN2+ were 93.5 % and 17.5%, respectively. The positive predictive value and negative predictive value were 22.8% and 91.2%, respectively.According to the current cervical screening strategy, 1217 women need biopsy, irrespective of women age. In fact, 567 (46.6%) women with ASCUS+ or HPV16/18 positive accepted biopsy, including 309 women with cervicitis, 95 with CIN1, 60 with CIN2, 81 with CIN3, and 22 with ICC, respectively. The sensitivity and specificity for detecting CIN2+ were 71.1% and 62.4%, respectively. The positive predictive value and negative predictive value were 28.4% and 91.1%, respectively. Compared to the current cervical screening, primary hrHPV genotyping test had higher sensitivity and lower specificity (Table We further examined whether hrHPV positive women for HPV16/18 (2 types), or HPV16/18/31/33/52/58 (the 6 major carcinogenic types) can serve as a triage tool to discriminate women who need biopsy immediately. Compared to 12 other hrHPV infection women, the ORs for CIN2+ in HPV16/18 (2 types) infection women was 2.7 (95%CI 2.1-3.4). Notably, the relative CIN2+ risk (ORs) was 3.2(95%CI 2.3-4.1) for women with HPV16/18/31/33/52/58 (6 types) infection compared to women with HPV35/39/45/51/56/59/66/68 infection. For detecting CIN2+, the sensitivity and specificity were 86.5% and 43.5%, respectively. The positive predictive value and negative predictive value were 28.5% and 92.5%, respectively. Therefore, when women with HPV16/18/31/33/52/58 infection can be recommended colposcopy biopsy immediately.Women who are HPV35/39/45/51/56/59/66/68 positive should be detected with cervical cytological testing. Among women with ASCUS cytology, HPV35/39/45/51/56/59/66/68 infection rate was 32.4%. Women with ASCUS+ can be recommended colposcopy biopsy immediately. The accuracy values of different triage strategies for the detection of CIN2+/CIN3+ were shown in In recent years, hrHPV testing for triaging ASCUS and co-testing with cervical cytology have been implemented in clinical practice , 10. HowThe prevalence of hrHPV (18.2%) obtained in this present study were similar to that in Hangzhou 19.9%) and Nanchang (18.4%) which also region in southeast of China . Consist.9% and NIn our population, we found that HPV16, 31, 33, and 58 increased the risk for CIN1 lesions progress to CIN2 or worse  10-18 years after enrollment compared with hrHPV-negative women. The 18-year cumulative incidence rates (CIRs) of CIN2+ among hrHPV-positive and hrHPV-negative women were 23.2% and 1.5%, respectively. [Compared with current cervical cancer screening strategy, we recommended screening strategy had higher sensitivity (93.5%) and higher negative predictive values 91.2%). In the present study, the current cervical screening strategy had been missing the majority of women  with hrHPV infections who progress to high-grade cervical lesions (CIN2+)  and poor positive predictive value (22.8%) for the determination of CIN2+ in the current study would be limits the use of our recommended screening strategy. In our study, women with HPV16/18/31/33/52/58 (the 6 major carcinogenic types) infections rate were 71.1% (2282/3210) of overall hrHPV-positive women. In order to reduce the number of biopsy, we suggested when women with HPV16/18/31/33/52/58 infection can be recommended colposcopy biopsy immediately. For detecting CIN2+, the specificity and positive predictive value were 43.5% and 28.5%, respectively. In order to improve the CIN2+ detection rate, our data suggested that reflex cytology for women with HPV35/39/45/51/56/59/66/68 infection will be clinically useful as a triage test tool for immediate biopsy for women with ASCUS or worse.In summary, hrHPV genotyping provide a better predictive value than HPV16/18 genotyping alone in guiding the clinical management of the current cervical cancer screening. HPV testing without adjunctive cytology may be sufficiently sensitive for primary cervical cancer screening.


Specific research foci: (1) Mouse models of gamma-herpes virus-68 (γHV-68) and polyomavirus (PyV) infections during neonatal versus adult life. (2) For human papilloma virus (HPV)-positive oropharyngeal carcinoma (OPC)—(a) Asking the question: Is oral sex a powerful carcinogen? (b) Examining the evidence for the vertical transmission of HPV infection. (c) Examining the relationship between HPV and Epstein–Barr virus (EBV) infections and nasopharyngeal cancer (NPC) in West European, East European, and East Asian countries. (d) Examining the association between HPV-positive OPC and human leukocyte antigen (HLA). (3) For non-smoking East Asian female lung adenocarcinoma—(a) Examining the incidence trends of HPV-positive OPC and female lung adenocarcinoma according to birth cohorts. (b) Examining the association between female lung adenocarcinoma and HPV. (c) Examining the associations of lung adenocarcinoma with immune modulating factors. (4) For triple-negative breast carcinoma (TNBC) in East Asians—(a) Examining the association between TNBC and HPV. (b) Examining the unique epidemiological characteristics of patients with TNBC. A summary “epidemiological” model tying some of these findings together. Mice infected with different viruses during neonatal or adult life display different outcomes.For PyV infection, Rowe et al.  first reFor γHV-68 infection, Ptaschinski and Rochford  observed+ T-cell response.Ptaschinski and Rochford  also notPtaschinski and Rochford  further Toll-like receptor 8 (TLR8) is involved in the innate immune response to different pathogens. In mice, TLR8 lacks five amino acids and is non-functional and perhaps redundant, but it plays a critical role in humans as it is the only TLR that is active in the neonatal period as described by Levy and Zarember . Cheng eGenden et al.  wrote thIn a provocative article, Rosenquist  summarizIn a longitudinal prospective Finnish family HPV infection study  highlighn = 12,571) done in 2002 by the United States Centers for Disease Control and Prevention, showing that cunnilingus was practiced by 90% of male respondents and fellatio by 88% of female respondents. “Similarly, research from other cultures shows oral sexual contact to be very common, and oral genital contact is more common than anal intercourse among gay and bisexual men.” Thus, the “link between oral sex, HPV and cancer is not a simple cause and effect relationship,” especially as oral sex behaviors appear to be common and widespread, thus making any perceived relationship not significant. This led Rosenquist to conclude that many factors are involved in making an HPV infection to become persistent, and subsequently, to become carcinogenic; some are unknown, and others are likely involved in compromises to the immune system.A literature review on the sexual transmission of virus infections by Edwards and Carne  in 1998 In a meta-analysis, Li et al.  demonstrOne might be tempted to hypothesize that having multiple sexual partners might be an indicator for chronic infection and inflammation associated with sexual transmission of HPV and other virus infections, which might have the same effect as chronic periodontitis perhaps through the systemic bystander effects of the immune system reacting to chronic infection and inflammation.In a review article, Mammas et al.  stated tSeveral studies suggest that EBV and HPV infections do not co-exist in NPC patients in West and East European countries , 20.Early EBV infection appears to be related to socio-economic status and demonstrates a decreasing trend from East Asia through East to West Europe. On the other hand, the incidence trend of adolescent EBV infection in the form of infectious mononucleosis is reversed, and this effect is also reflected by the incidence of multiple sclerosis. Of interest, the male-to-female ratio for multiple sclerosis is the highest in East Asia and gradually decreases as one moves west, which supports the hypothesis that early EBV infection predisposing East Asians to NPC could be related to a sex-linked recessive form of transmission .HPV-positive OPC follows a reverse trend, with male Westerners exhibiting the highest incidences. The incidences gradually decrease as one moves east. This result is a “perfect” mirror image of EBV-related NPC. On the other hand, although HPV-positive OPC is rare in East Asian females, 60% of these females who develop OPC are HPV-positive  Table 11.Table 1One potential explanation of why EBV and HPV are “complementary” but do not usually co-exist is that both EBV and HPV infections could conceivably persist in salivary gland tissues. Vestigial ectopic salivary gland tissues can be found in human tonsils and tongue base , and thiFinally, the sexual revolution, which started just after the Second World War, puts the 1950s birth cohort at risk. If these individuals were to develop cancers 40 years later , HPV-positive OPC would be expected to become evident only after the 1990s, which would fit into the epidemiological picture of this cancer.A recent genome-wide association study (GWAS)  showed tInterestingly, it was the 1950s birth cohort that exhibited a spike in female lung adenocarcinoma in Japan  and HongAnatharaman et al.  observedOn the other hand, an East Asian study showed a significant increase in lung cancer risk amongst Taiwanese women with HPV infection . An “adaP trend = 0.027]” ” . Two stu 0.027]”  and that 0.027]” .In sheep, the Jaagsiekte sheep retrovirus (JSRV), which can induce neoplastic transformation of the alveolar and bronchiolar secretory epithelial cells, is the cause of ovine pulmonary adenocarcinoma .−/p16+ phenotype. A study from Singapore showed a high prevalence of infection with high-risk HPV in breast cancer patients  . In anotRecent studies also showed that “there were more cases with high expressions of HLA-G in non-luminal than in luminal subtypes (of breast cancer)”  and thatLgr6, which labels progenitor cells, was associated with the luminal type of breast tumors [Lgr6 single nucleotide polymorphism was associated with estrogen receptor (ER)-negative breast cancer [Another study identified that the gene t tumors . One migt cancer , and thet cancer . It is at cancer .Younger women, who are diagnosed with breast cancer, appear to have more aggressive tumors and a higher incidence of poorly differentiated (grade III) and ER/progesterone receptor (PR)-negative cancers compared with older women. Interestingly, a study from Malaysia showed that TNBC appears to be associated with a lower socio-economic status and that TNBC was most common in the native population of Sarawak (37%) and less frequent in Chinese (23%) and Malays (33%) . SimilarA recent study assessing breast cancer incidence trends in Japan  exhibiteA study from Sweden reported an increased incidence of breast cancer within 15 years, amongst the women who were diagnosed with periodontal disease at an initial examination . The aveAlthough no definite cause and association can be concluded from the above, the circumstantial evidence suggests the plausibility of the vertical transmission of HPV infection giving rise to HPV-positive OPC, non-smoking East Asian female lung adenocarcinoma, and East Asian TNBC Table .Prevention—using a HPV vaccination strategy applied during the perinatal period similar to that in the hepatitis B programme.Targeted screening—for example, using HPV serology measured during the first month of life together with a susceptibility marker, such as “susceptible” HLA alleles.If HPV infection is a causative factor and is transmitted vertically in the three types of cancers, there are potential applications in terms ofA favorable response to the new checkpoint inhibitors.Some chronic infections/inflammation such as chronic periodontitis or chronic rhinosinusitis.The second observation is that the three types of cancers appear to be associated withThe following two potential clinical implications can arise:These findings might imply that the immune reaction associated with chronic infection might have a systemic bystander effect, namely affecting the body’s immune surveillance toward the pre-cancer, perhaps removing the immune suppressive effect, and thus allowing the cancer to grow . It is c


Of the ~60 human papillomavirus (HPV) genotypes that infect the cervicovaginal epithelium, only 12–13 “high-risk” types are well-established as causing cervical cancer, with HPV16 accounting for over half of all cases worldwide. While HPV16 is the most important carcinogenic type, variants of HPV16 can differ in their carcinogenicity by 10-fold or more in epidemiologic studies. Strong genotype-phenotype associations embedded in the small 8-kb HPV16 genome motivate molecular studies to understand the underlying molecular mechanisms. Understanding the mechanisms of HPV genomic findings is complicated by the linkage of HPV genome variants. A panel of experts in various disciplines gathered on 21 November 2016 to discuss the interdisciplinary science of HPV oncogenesis. Here, we summarize the discussion of the complexity of the viral–host interaction and highlight important next steps for selected applied basic laboratory studies guided by epidemiological genomic findings. Alphapapillomavirus [High-risk human papillomaviruses (HR-HPVs) cause a heavy burden of cancer with more than 600,000 cancers attributed to HR-HPVs worldwide in 2008 ,2,3. Of omavirus , has notPapillomaviruses (PVs) are circular, double-stranded DNA viruses that are believed to have co-diverged with animal and human host populations for millions of years, and are ubiquitous throughout the world ,7,8,9. HL1 gene, and distinct types  are defined by differences of at least 10% at the nucleotide level [Alphapapillomaviruses-9) comprises HPV types sharing ≥70% of their L1 sequences [Alphapapillomaviruses-9 species group); HPV18, HPV39, HPV45, HPV59, and HPV68 (Alphapapillomaviruses-7 species group); HPV51 (Alphapapillomaviruses-5 species group); and HPV56 (Alphapapillomaviruses-6 species group) [HPV types are classified based on pairwise nucleotide sequence identity within the highly conserved de level . An HPV equences . To dateequences . Some HPs group) . On a fis group) . HPV16 is by far the most carcinogenic HPV type, associated with approximately 50% of all cervical cancers, the majority of other HPV-related anogenital cancers, and more than 80% of HPV-positive head and neck cancers ,18,19,20Recent advances in high-throughput next-generation sequencing  have enaThrough an international collaborative effort, the NCI HPV Genomics Project has sequenced many thousands of HPV genomes from well-characterized populations. With an initial focus on HPV16, recent data have confirmed and expanded earlier reports relating precancer/cancer risk to particular HPV16 lineages and uncovered several remarkably strong associations between HPV16 genetic variation and cervical carcinogenicity, as well as providing new insights into HPV diversity in the population. We have applied lineage-based and agnostic, gene and single nucleotide polymorphism (SNP)-based approaches to studying HPV genetic variation ,38. At tNext-generation sequencing (NGS) HPV genome data with deep sequence coverage allows the sensitive identification of within HPV16 variant lineage co-infections. Using these data, within type co-infections are suspected in women with multiple “heterozygous” allele calls (HPV is a monoploid genome). The co-infections can be confirmed by the identification and visualization of multiple lineage-specific sequence variants occurring in shared sequence reads, representing two separate HPV16 variant lineage isolates. In the case of multiple lineages present in a specimen, a predominant lineage can usually be assigned based on presence in at least 60% of the sequence reads, and nucleotide variants only included from the predominant lineage; and, if a predominant lineage cannot be assigned (~50/50 of each lineage), that sample excluded . E7 was more variable in the controls compared to the cases, and we confirmed that E7 showed extremely low variability in ~1700 cervical cancers from around the world. The E7 gene was significantly less variable than all other gene regions in the cancers, including E6. This highlights that genetic conservation of E7 (but not E6) is critical for HPV16 carcinogenesis. These rare nucleotide variants in E7 frequently occurred in DNA motifs that are associated with the antiviral activity of human APOBEC3  family of cytidine deaminases. Interestingly, the majority of cervical cancer cases have been shown to be enriched for somatic APOBEC mutation signatures, suggesting that APOBEC antiviral activity is also a major source of somatic mutations in cervical cancers [To address whether even finer genetic variation  is associated with HPV16 carcinogenicity, we evaluated non-lineage-specific SNPs and the distribution of rare variants occurring within HPV16 lineages in a collection of 5,570 HPV16-infected case-control samples . Thousan cancers ,46. As discussed by the panel, these findings suggest that genetic variation within specific regions of the genome may differentially allow the virus to be cleared by the host; alternatively, the phenotype of cancer may require a fixed set of nucleotide variants at the viral genome level. The Workshop agenda outlined many key questions related to three broad topic areas for discussion . The firThe HPV life cycle is tightly linked to the differentiation state of infected epithelial cells. HPV infects basal keratinocytes that are exposed as the result of micro-abrasions in the epithelial surface ,48. ViraHPV infections can occur within specific sites of transitional epithelial cells  with complex patterns of regulation that may render them more prone to viral transformation ,53,54. AAlphapapillomaviruses-9 and Alphapapillomaviruses-7 genomes and probably relates to their genetic differences. Efficiency of splicing may also differ [High-risk HPV types have evolved regulatory strategies to tightly control viral gene expression during productive and quiescent infections. Because of its critical role in regulating gene expression at different stages of the HPV life cycle, mRNA splicing efficiency may contribute to carcinogenic potential . Recent o differ ,58, sinco differ  and theiE1 and E2 ORFs (termed E8^E2), which limits viral transcription and replication through the virus life cycle in undifferentiated keratinocytes [In vitro studies have recently shown that HPV16 and related types express a fusion protein encoded by subregions of the inocytes . This maMYC oncogene compared with HPV16-associated cancers [Integration of HPV DNA into the host genome occurs in the majority of cervical cancers, but not all ,62. Mech cancers ,70. At t cancers . More stE5, E6, and E7 residues; 65–83% of E2, E4, and L1 residues; and only 7% of E1 residues (Immune Epitope Database). E6 and E2 epitopes appear to be the most important for a CTL response [In response to infection with HPV, humans can mount an adaptive immune response including the development of specific antibodies to the virion L1 coat protein. Antibody and/or human cytotoxic T-lymphocyte (CTL) epitopes have been predicted within the peptides encoded by all HPV16 ORFs: 100% of response . E5, E6, L1, and L2 ORFs [Alternative approaches for identifying potentially important HPV epitopes are based on evolutionary methods to identify positive selection that might indicate a pressure for immune escape, and these have mainly detected codons in the  L2 ORFs ,73. FutuBoth genetic and environmental host factors play key roles in determining viral oncogenicity. Epidemiologically defined co-factors, such as smoking and use of hormonal contraceptives, also play a role—for example, smoking has been associated with an approximate two-fold increased risk of precancer and cancer . One goaThe final session covered a range of topics related to characterizing and defining HPV fitness, annotation of HPV genomes, and host-viral interactions. These topics have important implications for HPV genomics research and could serve as a model for other genetic systems. Evolutionary fitness in biology is usually defined as reproductive success. The definition of how to define viral fitness in general, and HPV fitness in particular, remains unresolved and was not agreed upon by the workshop panel. An increase in viral replicative success may have conflicting proximal and ultimate outcomes for the host. For example, a particular viral genotype may replicate to high viral load in a particular cell, but the outcome may be to increase the likelihood of an immune response, thereby drastically decreasing the actual fitness of the virus. Surprisingly, much of the feedback from the panel was that a consensus definition for fitness might not be useful for describing carcinogenic features of different HPV types and variants. The intellectual divide resided in whether viral evolution, niche adaptation, and fitness represent the key drivers of carcinogenesis, although carcinogenesis does not support viral replication. Some attendees suggested a more direct paradigm using viral outcomes, such as causing cancer or not, as the “viral” phenotype . Others Given that the most prevalent anogenital HPV type (HPV16) is also the most carcinogenic, future research should consider the relationship between viral prevalence and oncogenicity. It appears that viral traits that improve reproductive success also tend to initiate processes that predispose host cells to cancer. In either case, the ability to induce cancer is neither necessarily, nor inextricably, linked to HPV’s ability to successfully propagate in populations, such that oncogenicity may be considered an unfortunate byproduct that is not itself under selection. Adaptation to a specific cellular environment may define features of the HPV genome that induce cancer as “collateral damage” rather than a selective trait, since cancer does not support the production of infectious virus.The importance of genome annotation is critical for evaluating the impact of sequence variations across viral variants and between viral types. In fact, since the variation between viral types is so large (approximately 30%), unequivocal alignment and position assignments are not currently feasible. Therefore, annotation of functions could serve as a common database to connect different features of disparate genomes. The way forward was not defined, but a bioinformatic approach is a promising area that could build upon work done on the annotation of various mammalian genomes that face similar challenges.The field of HPV genomics is undergoing a major paradigm shift from thinking of an HPV type infection as an evolutionarily static entity to thinking of thousands of unique viral genomes with differences in carcinogenic potential. Findings from recent large epidemiologic studies defining the association of HPV variant lineages/sublineages/SNPs with cervical cancer risk have led to new discoveries that call for HPV natural history and carcinogenesis to be re-visited. These findings also merit additional experimental studies using tools developed in the “omics” era. These novel discoveries underscore the importance of designing relevant comparisons to help sort out the differences in viral genetic features of carcinogenesis at the biochemical and mechanistic level. For example, across HPV genotypes, a large number of nucleotide differences may reveal more broad associations between HPV type and processes such as viral–host interactions, tissue tropism at the cellular level, splicing, and protein translation. In contrast, variant lineage/sublineage studies within a particular HPV type will allow for the identification of individual variants, or small groups of variant sites (haplotypes), related to differences in carcinogenicity. Integrating epidemiologic findings with functional studies may transform our basic understanding of HPV-associated carcinogenesis and may eventually elucidate the genetic basis defining what makes some HPVs, especially HPV16, such powerful carcinogens. HPV carcinogenesis is a multifactorial complex process that involves a confluence of viral and host factors. However, compared with the complexities associated with studying the human genome, the genetic basis of HPV carcinogenicity in an 8000 bp genome is a more tractable problem that deserves immediate attention.


EXOC1 rs13117307 polymorphism, which has been linked to cervical cancer in a large study in a Chinese population. We confirmed the association between CC and the rs2844511 polymorphism previously identified in a GWAS study in a Swedish population. The major histocompatibility region of chromosome 6, or perhaps other SNPs in linkage disequilibrium, may be involved in CC onset.A small proportion of women who are exposed to infection with human-papillomavirus (HPV) develop cervical cancer (CC). Genetic factors may affect the risk of progression from HPV infection to cervical precancer and cancer. We used samples from the International Agency for Research on Cancer (IARC) multicentric case-control study to evaluate the association of selected genetic variants with CC. Overall, 790 CC cases and 717 controls from Algeria, Morocco, India and Thailand were included. Cervical exfoliated cells were obtained from control women and cervical exfoliated cells or biopsy specimens from cases. HPV-positivity was determined using a general primer GP5+/6+ mediated PCR. Unconditional logistic regression was used to estimate odds ratios (OR) and corresponding 95% confidence intervals (CI) of host genotypes with CC risk, using the homozygous wild type genotype as the referent category and adjusting by age and study centre. The association of polymorphisms with the risk of high-risk HPV-positivity among controls was also evaluated. A statistically significant association was observed between single nucleotide polymorphism (SNP) CHR6 rs2844511 and CC risk: the OR for carriers of the GA or GG genotypes was 0.70 (95% CI: 0.43–1.14) and 0.61 (95% CI: 0.38–0.98), respectively, relative to carriers of AA genotype . We also observed associations of borderline significance with the TIPARP rs2665390 polymorphism, which was previously found to be associated with ovarian and breast cancer, and with the  Although the burden of cervical cancer (CC) has decreased considerably over recent decades in countries that have implemented high-quality cytology screening programmes , 2, it rThe host immune response is involved in the persistence of HPV infection in certain individuals. For instance, Toll-like receptor 9 (TLR-9) is an essential component of innate immunity able to recognize double-stranded DNA molecules of viral origin and to elicit the production of immunostimulatory and pro-inflammatory cytokines including Type I interferon (IFN). Studies demonstrated that HPV16, the most oncogenic HPV type , interfeThe main objective of the present study is to replicate the associations of genetic variants identified by a genome-wide association study (GWAS) –12 in prIn the present analysis, we included four (of the nine) countries included in the IMCC: Algeria , MoroccoInformed written consent was obtained from all participants. The studies were approved by the IARC Ethical Review Committee and by local ethical committees in each of the participating countries .Study samples for DNA extraction included buffy coats, paraffin-embedded tumour biopsies, cervical cells in liquid-based cytology media or cervical cells in phosphate-buffered saline and were available for 912 cases and 822 controls. Specific DNA extraction protocols were envisaged for different types of samples.In Algeria and India, DNA was extracted from buffy coats using the EZ1 DNA blood 350 μl Kit  according to the manufacturer’s protocol. A total of 195 cases and 187 controls in Algeria, and 132 cases and 174 controls in India had good quality DNA and were included in the present analysis.In Morocco and Thailand, DNA was extracted from cervical cells using the QIAamp DNA mini kit . For paraffin-embedded tumour biopsies, the DNA was extracted as previously described . Overallhttp://hapmap.ncbi.nlm.nih.gov/cgi-perl/gbrowse/hapmap24_B36/). Robust separation of genotype clusters was impossible only for rs9272105 and hence this variant was not included in the present report. The genotype distributions (in controls and by country of origin) were in line with that expected assuming Hardy Weinberg Equilibrium.Genotyping of genetic variants was performed using the TaqMan genotyping platform (Lifetechnologies), as described previously . Taqman HPV testing was performed in the Department of Pathology at the Vrije University Medical Center, Amsterdam, the Netherlands, as described in the individual study publications , 28. TheUnconditional logistic regression was used to estimate odds ratios (OR) and corresponding 95% confidence intervals (95% CI) for the association of each genotype with CC risk, using the homozygous wild type (WT) genotype as the referent group. The analyses were adjusted for age  and study centre. The association between each genetic variant and CC risk was also estimated assuming a log additive genetic model. Tests for trend were computed using the three-level variables  of homozygote wildtype, heterozygote, and homozygote variant as continuous variables. When small cell sizes were found (less than 5%), the combined effect of homozygote and heterozygote variants versus wildtype was assessed. Heterogeneity of ORs between countries was tested by fitting separate models to each area and then comparing the observed with the expected dispersion of estimates around the pooled mean using a chi-squared statistic. We also evaluated the association between SNPs and HR-HPV positivity among controls. In this case, the focus is not on cancer risk, but rather on the risk for healthy women to be infected with HR-HPV types. We therefore considered HR-HPV-positivity among controls as the outcome (dependent variable) and evaluated the excess (or deficit) in the risk of being HR-HPV-positive, as compared to being HR-HPV-negative, in relation to carrying a particular allele of the SNP. The association between SNPs and positivity for any HPV type among controls was used to assess sensitivity. Analyses were conducted using R and SAS version 9.4.EXOC1 rs13117307, we found associations of borderline statistical significance , with TC carriers of TIPARP rs2665390 showing an increased risk of CC  as compared to TT carriers, and with CT and TT carriers in EXOC1 rs13117307 showing a reduced risk .A total of 790 women diagnosed with CC and 717 controls were retained for the present analysis . Mean agEXOC1, with individuals with a genotype of TT for the SNP EXOC1 rs13117307 having a 3-fold increase (95% CI: 1.09–10.6) in risk of being HR-HPV-positive as compared to individuals with a genotype CC, p-value for trend 0.04. AA carriers of TERT rs2736100 had a significantly reduced risk  of HR-HPV-positivity as compared to CC carriers, although the p-value for the trend was of a borderline statistical significance (0.05).In this international multicentric case-control study of CC that included women from Morocco, Algeria, India and Thailand, we confirmed the association of the rs2844511 polymorphism previously identified in a GWAS study in a Sweden population  with CC.We showed that the distribution of alleles was significantly different between cases and controls for the rs2844511 polymorphism. This observation is consistent with and of similar magnitude to the reduction in risk for rs2844511 GG as compared to AA carriers previously observed by a GWAS study in a Swedish population , (OR in MICA gene within the major histocompatibility complex (MHC) region at 6p21.3. The MICA protein is a stress-induced highly polymorphic, epithelia-specific membrane-bound glycoprotein interacting with the activating NK cell receptor NKG2D [MICA, including the A5.1 allele, correlated with rs2516448, characterized by an additional insertion of guanine after the second triplet, which creates a frame shift mutation resulting in a MICA truncated protein lacking part of the transmembrane domain. Rs2516448 is in perfect LD (r2 = 1.0) with A5.1 in Europeans, a frameshift mutation of MICA [MICA–A5.1 variant has been implicated in many immune-related diseases, including CC [MICA-A5.1 homozygote carriers, whereas MICA-A5 homozygotes had nearly threefold protection against CC [The rs2844511 SNP is a proxy for SNP rs2516448, which was also previously linked to CC  with theor NKG2D . Importaor NKG2D . Furtheror NKG2D . Six dis of MICA . MICA–A5uding CC , thus suainst CC .In the present analysis, we decided to report the original p-values, without correction for multiple testing. However, the success in replicating the results of Chen et al, 2013  in diffeTIPARP with CC, which has been previously associated with ovarian and breast cancer [Shi et al  reportedt cancer , did nott cancer  CC carriWe were also able to assess the association between SNPs and HPV-positivity among control women. None of the SNPs that were significantly associated with CC were also associated with HR-HPV positivity among controls, with the possible exception of rs13117307 in the EXOC1 region for which, however, the direction of the association with HPV positivity among TT carriers was opposite to that with CC. This discrepancy is not, however, implausible as the genetic determinants of susceptibility and persistence of HPV infection may well differ from those of malignant transformation. Indirect support for the distinction between the potential for persistence and neoplastic transformation comes from studies of the viral genome which showed that evolutionary distinct HPV types, that differ from each other by at least 10% in the DNA sequence of the L1 ORF, have varying probabilities of persistence and, given persistence, different probabilities of neoplastic progression . Conversa priori interesting SNPs, the relatively low statistical power for the study of polymorphisms that vary in both frequency and LD structure across populations, and the impossibility to asses jointly the influence of genetic characteristics of the host and of the virus, e.g., types and variants.The present study has strengths and weaknesses. The joint assessment of the genetic determinants of HPV persistence and malignant transformation is a major asset as is the application of the same epidemiological and testing protocols (for both HPV and SNPs) to different populations. Weaknesses of the present study include, however, the restriction to a selection of In summary, this study confirms the association with the rs2516448 variant suggesting that the MHC region is involved in the CC process. The underlying mechanisms that mediate changes in CC disease remain however to be elucidated and further GWAS-based investigations are required, in particular to demonstrate the stage of the carcinogenic progress at which these genes may be involved.