There is no consensus on screening strategy of high-grade intraepithelial neoplasia (HGAIN). Guidelines range from clinical examination with digital anorectal examination followed by standard anoscopy (SA), to anal cytology (Pap)+/− HPV genotyping. We compared screening strategy yields based on Pap, SA, and HPV-16 genotyping alone or in combination in HIV-MSM.Pap, SA, and HPV-16 genotyping were performed in all HIV-MSM attending a first anal cancer screening consultation in Paris, France. High-resolution anoscopy, the gold standard to detect HGAIN, was performed in the case of HPV-16 positivity or abnormal cytology. Yield was defined as the number of patients with HGAIN relative to the total number of patients screened.p < 0.001) and HPV-16 alone . Although none of the other strategies were significantly different from the complete strategy, Pap + HPV-16 and Pap + SA had closer yields (about 11%), with OR = 0.83  and 0.87 , respectively.On 212 patients, the complete strategy (SA + Pap + HPV genotyping) yield (12.7%) was significantly higher than that of SA (3.3%, Pap combined with HPV-16 genotyping or SA tended towards higher yields compared to Pap alone, and closer to that of the complete strategy. As for detection of cervical lesions, the Papanicolaou smear test (Pap) and HPV genotyping have been used in SCCA screening programs in HIV-MSM and have been suggested as effective to decrease SCCA incidence.6 However, there is no international consensus on SCCA screening. The most commonly accepted modality is anal Pap,8 which is recommended by Palefsky et al.9 Pap alone or combined with digital anorectal examination (DARE) is currently applied in several guidelines in the US12 and Europe.13 However, anal Pap is of suboptimal sensitivity, which leads to underdiagnosis of lesions. HPV genotyping using polymerase chain reaction (PCR) has also been proposed,14 but was not included in guidelines because of its low specificity for the diagnosis of HGAIN. Some authors have proposed restricting genotyping to HPV-16; other HR-HPV such as HPV-18 may be considered as less relevant due to their lower prevalence in HIV-MSM and lower involvement in HGAIN.16 Following a positive anal Pap or HPV genotyping, high-resolution anoscopy (HRA), which is the gold standard for diagnosis of AIN, is recommended. Finally, clinical examination, based on a DARE and perianal skin examination at least with or without anoscopy, could detect some lesions. Although DARE alone is recommended in few guidelines,17 it is well established that it may detect early cancer but not HGAIN.18 DARE combined with a standard anoscopy (SA) is recommended in French guidelines for HIV-MSM.19 Even if SA diagnoses HGAIN in some cases,20 it may underestimate this diagnosis and its performance as a screening tool has never been studied. All these recommendations are based on expert opinions, as few data are available on the performances of global strategies, including anal Pap, HPV-16 genotyping, and SA each alone or combined in HIV-MSM. Consequently, the US Centers for Disease Control and Prevention (CDC) consider that while screening seems to be useful, more evidence is needed to determine the best screening methods.21The natural history of SCCA shares analogies with that of cervical cancer: a persistent infection by a high-risk HPV (HR-HPV), mainly HPV-16,The aim of this study was to compare seven screening strategies to detect HGAIN in HIV-MSM, HGAIN definitely confirmed on a biopsy performed during HRA or SA: anal Pap, SA, and HPV-16 genotyping each alone, combination of two of them , or combination of the three (complete strategy: SA + Pap + HPV-16 genotyping).An annual anal cancer screening program including Pap, SA, and HPV-16 genotyping was implemented for HIV-MSM followed up in the Department of Clinical Immunology of the Georges Pompidou European Hospital  in 2012. Consecutive patients were enrolled prospectively and had the three procedures referred thereafter as “complete strategy” . HRA was performed in the case of HPV-16 positivity or abnormal cytology . During SA, if AIN was suspected, a biopsy was performed  were excluded from the study.Anal Pap, HPV-16 genotyping, and SA were performed during the same consultation. All patients included in the study got the three screening tests.Anal specimen was collected with polyester fiber swab prior to any examination and lubrification. The swab was then processed using a liquid cytology technique prior to Papanicolaou staining, and finally analysed by a pathologist.®, Gent) from January 2012 to September 2014 and using a multiplex real-time PCR assay AnyplexTM II HPV28  from September 2014 to August 2016.Anal specimens collected with a brush were removed on UTM medium. During the study, after DNA extraction, HPV-16 detection was performed using INNO-LiPA HPV Genotyping Extra  or only SA  or HPV-16 genotyping , or combination of screening tests  would have been performed, defining the yield of each strategy. In the main analysis, each strategy yield was compared with that of the complete strategy , and anal Pap alone. Altogether, seven strategies were tested: each exam alone, all combinations of two exams in comparison to the complete strategy including the three screening methods. The odds ratio and 95% confidence intervals were estimated.p-value < 0.05. All statistical analyses were performed using R software.All tests used were two-tailed and results were considered significantly different if n = 34). Patient characteristics are described in Table 3 in 73.8% of patients and HIV RNA was below 20 copies/mL in 84%. Baseline characteristics of excluded patients did not differ from those of the study population.Of 253 HIV-MSM who attended a first SCCA screening consultation between 2012 and 2016, 212 (83.8%) fulfilled the inclusion criteria and 41 were excluded, mostly because they did not attend the HRA within 6 months after the screening (None of the three screening tests was positive in 126 patients (59.4%). Pap was positive in 62 (29.2%) patients, HPV-16 genotyping in 40 (18.9%) patients, and SA in 19 (8.9%) patients. Overall, 86 (40.5%) patients had at least one positive test. Among them, 67 had no macroscopic suspicion of dysplasia and were referred for HRA. Finally, HGAIN was diagnosed by histology in 27 patients (12.7%), including seven with macroscopic lesions at SA . Conversely, although not significantly different from the complete strategy, anal Pap alone and SA + HPV-16 genotyping had slightly lower HGAIN detection yield .The HGAIN detection yields of SA (3.3%) and HPV-16 alone (6.6%) were significantly lower than that of the complete strategy 12.7%) . Although none of the yields of other strategies was significantly different from Pap alone, all bimodal strategies adding HPV-16 genotyping or SA to anal Pap, had a higher HGAIN detection yield than Pap alone, except for the combination of SA + HPV-16 genotyping. Finally, the yield with SA was significantly lower than the yields with all other strategies , except for HPV-16 genotyping  compared to SA alone (3.3%) or HPV-16 genotyping alone (6.6%). However, Pap combined with HPV-16 genotyping or with SA gave a trend towards higher yields (about 11%) in comparison to Pap alone or to SA + HPV-16 genotyping (9%).24 However, most authors agree that HRA cannot be used as a screening test25 because of its poor acceptability and accessibility. Thus, as in cervical pathology with colposcopy, HRA can only be used as a second-line diagnostic test for anal lesions after positive primary screening.HRA is the gold standard for diagnosis of HGAIN.27 reaching 89.2% for HGAIN detection in a recent study by Burgos et al.28 In our study, anal Pap alone detected only 19 of 27 (70%) cases of HGAIN, which is, however, more than SA or HPV16 genotyping alone .There is no international consensus on SCCA screening strategy. Pap is currently the most accepted screening test for HGAIN. The sensitivity of anal Pap ranges from 47 to 70% for the detection of AIN of any grade, but seems higher in HIV-MSM,29 Its use with anal specimens has been proposed.14 In recent prospective studies, anal HPV genotyping had a sensitivity of more than 90% in HIV-infected and HIV-uninfected MSM when all high-risk HPV were considered. However, specificity was very low (15–25%) because of the high prevalence of multiple HR-HPV infections in MSM.30 To increase HPV genotyping specificity, some authors have proposed restricting HRA referral to patients with positive HPV-16 only, based on the high involvement of HPV-16 in HGAIN and SCCA.32 In a multicentre study in HIV-infected men, the specificity of HPV-16 genotyping for the presence of HGAIN was 84%, but its sensitivity was only 35%31. In the present study, HPV-16 was found in 40/212 patients (18.9%); 14 of them had HGAIN. If HPV-16 alone was considered, 13/27 HGAIN cases would not have been detected. HPV-16 genotyping alone was significantly inferior to the complete strategy . Our data clearly indicate that HPV-16 genotyping should not be used as a screening method on its own. However, it would be interesting to consider each HR-HPV genotype alone or in combination as a way to improve the performance of HPV testing. Burgos et al. have shown that the sensitivity and specificity of detection of HPV-16 and/or 18 in predicting HGAIN were only 56% and 63%, respectively.26 Other HR-HPV seem more prevalent than HPV-18 in HIV-MSM16 and it has recently been confirmed that being infected with two or more HR-HPV genotypes was correlated with HGAIN recurrence.33 This reinforces the potential interest of focusing on combinations of selected HR-HPV genotypes. Therefore, further investigations are needed to consider the implementation of HR-HPV genotypes other than HPV-16 in anal cancer screening.For the detection of cervical cancers, the use of primary HPV-based screening rather than Pap is endorsed by several European guidelines, based on World Health Organization (WHO) recommendations.19 However, it is widely accepted that a clinical examination with SA including DARE, even performed by a specialist, may miss HGAIN because cases are mostly subclinical and detected only by HRA. In a study of 441 HIV-MSM, DARE failed to detect any of the 156 cases of HGAIN.18 In a prospective series of 121 HIV-infected patients, SA was normal in 75% of cases of HGAIN.8 In our study, SA detected only 7 of 27 HGAIN cases (26%).In France, national guidelines recommend annual SA for SCCA screening in HIV-MSM.Overall, considering our findings and the literature, anal Pap seems better than SA or HPV16 genotyping, but may be considered as suboptimal in detecting HGAIN if performed alone.28 In our study, compared to Pap alone, there was a trend towards a higher HGAIN detection rate when combining Pap with HPV-16 genotyping  and only 75/212 (35%) patients would have required HRA.We found that adding SA to anal Pap slightly increased the rate of HGAIN detection . Considering that SA is a simple tool, with a limited increase in costs, it may be implemented as part of the screening strategy. In a recent report by Burgos et al., HR-HPV genotyping was combined with anal cytology. This screening strategy identified almost all HGAIN lesions, but required HRA referral of almost 90% of patients, due to the lack of specificity of global HR-HPV testing.34 Therefore, it is likely that a screening strategy allows self-sampling would be more acceptable. Anal Pap self-sampling has been shown to be acceptable and efficient as a screening strategy,35 whereas HPV genotyping self-sampling is currently being studied.36Acceptability by the patient and the physician is a major concern for the success of a screening program. We and others have shown that more than 50% of HIV-MSM had never undergone any anal screening test, despite recommendations. Among explanations, lack of information by physicians and lack of time/motivation were highlighted.37 Moreover, regression of HGAIN have been described either spontaneously or with immune restoration under ART.39Finally, the interest of screening HGAIN is still unresolved as it has never been shown that such screening could lead to a decrease in cancer incidence, morbidity, or mortality. The natural history of anal cancer is still an unresolved issue. Progression from HGAIN to cancer is not known, and probably lower than in cervical neoplasia. Based on a meta-analysis, Machalek et al. report a theoretical rate of progression of high grade anal dysplastic lesions (or HSIL) of 1/377 (0.27%) among HIV-MSM and 1/4 196 (0.024%) among HIV-uninfected MSM.40 Only one small randomised trial had tested Imiquimod versus placebo in 64 patients.41 However, the primary outcome in this study was the regression of HGAIN; progression to cancer was not assessed. Nevertheless, as for detection of cervical lesions, screening programs in HIV-MSM have been suggested as being effective to decrease SCCA incidence.6 The ongoing ANCHOR study (NCT02135419), currently recruiting more than 5000 HIV patients with HGAIN, randomised into two arms: experimental arm  or monitoring every 6 months, will provide a better understanding of the natural history of HGAIN and relevance of treatment.There is a need for prospective longitudinal and intervention studies to assess the interest of treating HGAIN in preventing the occurrence of cancer. Indeed, studies evaluating therapeutic intervention on HGAIN were mostly retrospective, not controlled, or too small.N = 41/253) were excluded from the study because they did not adhere to the complete screening strategy. Thirdly, we found a lower prevalence of HGAIN than the 30–42% reported.42 The prevalence may have been underestimated because of exclusion of patients with symptoms or with any history of previous screening and/or by the design of the study. And we cannot exclude that some patients with negative screening tests had HGAIN, as HRA was not performed in all patients. However, the low prevalence is consistent with the prevalence observed in other recent French cohorts43 and mirrors a trend in HGAIN epidemiology in France. This low prevalence and the relatively small study population may have underpowered the study. Finally, ours was a single-centre study and the reproducibility and external validity of our results should be confirmed.Our study had some limitations. Firstly, it was not designed to assess the sensitivity and specificity of each strategy, as HRA was only performed in patients with a positive screening test. Secondly, 16.2% of patients (In conclusion, among the single screening strategies, anal Pap alone had a higher HGAIN detection yield than SA and HPV-16 genotyping. Among the dual combination strategies, anal Pap + HPV-16 and SA + anal Pap had detection yields similar to that of the complete strategy. However, even though SA decreased the number of HRA performed, it is likely that it might also affect participation or acceptance. In the perspective of self-sampling, anal Pap + HPV-16 genotyping might be the best strategy to increase screening acceptance and to identify HGAIN in HIV-MSM, although it would increase the need for HRA. However, the added value of screening using detection of HPV-16 combined with other selected HR-HPV remains to be assessed in further studies. In addition, extending HRA accessibility is a remaining challenge that needs to be addressed. Finally, these strategies should be evaluated in further studies in the context of low HRA accessibility and health economics systems, with regard to acceptability by the patients.Supplementary Table 1


We recently described a method for unbiased detection of all known human papillomaviruses (HPV) types with the potential for the determination of their variant and integration from the resulting whole genome sequence data. Considering the complex workflow for target-enriched next generation sequencing (NGS), we focused on the reproducibility and limit of detection (LOD) of this new universal HPV typing assay in this study.2 = 1) and between experiments (R2 = 0.99). The number of mapped reads was positively correlated to copy number . The limit of blank (LOB) could be calculated based on mapped reads to HPV types not included in each sample. HPV genotyping was reproducible for all 9 types at 625 copies using multiple cut-off criteria but LOD was 25 copies based on number of reads above LOB even when multiple types were present. eWGS showed no bias for HPV genotyping under single or multiple infection (p = 0.16–0.99).We evaluated the reproducibility and LOD for HPV genotyping based on our recently published method that used RNA-baits targeting whole genomes of 191 HPV types, Agilent SureSelect protocol for target enrichment and Illumina HiSeq 2500 for sequencing . Two libraries, prepared from pooled plasmids representing 9 vaccine HPV types at varying input (1–625 copies/reaction), were sequenced twice giving four replicates for evaluating reproducibility and LOD. eWGS showed high correlation in the number of reads mapped to HPV reference genomes between the two flow-cell lanes within  contains supplementary material, which is available to authorized users. Papillomaviridae . Most assays focus on detection and typing of a subset of Alphapapillomavirus HPV types recognized to be clinically important. Conventional typing assays do not capture information on additional viral characteristics, such as integration and variant status within HPV type, therefore, systematic evaluation of the clinical importance of this information is lacking. While next generation sequencing (NGS) could address this limitation, current HPV NGS methods rely on sequencing PCR amplicons targeting a limited region of the genome for genotyping  as well as initial performance metrics for HPV type determination such as genome coverage and uniformity, but reproducibility and limit of detection (LOD) were not addressed. Given the complexity of the workflow for NGS methods, determination of these important characteristics is difficult. A few amplicon-based HPV NGS methods have reported reproducibility in terms of concordance at the level of final type determination; however, these studies did not give detailed measures of variability at the level of base quality, coverage, and mapped reads . MoreoveTwo cell lines known to include HPV 16 (SiHa: 1–2 copies/cell) and HPV 18 (HeLa: ~ 50 copies/cell) were obtained from American Type Culture Collection [ATCC] . Cells were cultured according to the recommendations of ATCC. DNA was extracted from the cell pellets collected from cultures in late log phase using DNA isolation kit for cells and tissues . Human placental DNA was obtained from Sigma-Aldrich Corporation . HPV 16 and HPV 18 whole genome plasmid DNA standards  were obtained from residual material in an HPV proficiency panel. Plasmids containing the full-length genomes of 9 vaccine HPV types  were received from various sources including ATCC, German Cancer Research Institute , Karolinska Institute , and Institute Pasteur . Each plasmid clone was expanded in bacterial culture and plasmid DNAs were extracted and purified using Zymo maxiprep kit  to form a working plasmid stock for each HPV type. The HPV type in each plasmid was verified by pattern of restriction enzyme digestion and/or genotype calling by Roche Linear Assay . DNA was quantified by Fluorescence-based Qubit dsDNA HS assay on a Qubit 3.0 Fluorometer . HPV genome equivalents (copy number) was calculated based on DNA content.human haemoglobin subunit beta (HBB). Individual libraries with indexing for sample identification were prepared for each sample. Following indexing, equal amounts of 16 libraries were pooled for enrichment by overnight hybridization to the RNA custom bait and the captured fragments were amplified using 14 PCR cycles. The quality and quantity of HPV-enriched, pooled libraries were assessed by Bioanalyzer 2100  and quantitative PCR using KAPA DNA library quantification kit  on a LightCycler 480 . Each pooled library was paired-end sequenced on an Illumina HiSeq 2500 using TruSeq Rapid SBS Kit HS (200 cycle) .The bait design, library preparation, HPV enrichment, and deep sequencing followed methods in original publication . BrieflyHBB or HPV reference genomes and cut-off criteria for HPV type determination were as described earlier [HBB reference sequences using CLC genomics workbench 7.5 . For this analysis, only reads with no mismatches in the index sequence were used and reference mapping was done by fixing the read length (L) and similarity score (S) at their most stringent level (L1S1).Procedures followed for read de-multiplexing, quality assessment, alignment to  earlier . BrieflyThe study was designed to evaluate the LOD, reproducibility of enriched library preparation as well as the reproducibility of sequencing and identification of HPV types. We used defined samples with known copies of HPV types to evaluate these parameters under controlled conditions. We focused on the 9 HPV types included in the HPV vaccine currently used in the US and prepared mixtures of types to simulate infection with multiple types. We prepared one pool with plasmids for 5 of these types  and the second with plasmids for the four remaining types . Within each pool, the individual types were present at the same copy number. Each pooled sample was used to make 5-fold serial dilutions (625 copies to 1 copy) in human placental DNA (100 ng/50 μL TE buffer). Serially diluting defined samples of known concentration has been used in previous reports of HPV detection using NGS or PCR or hybrid capture based assays , and in HBB . The reproducibility in the number of reads mapped to reference genomes between flow cell lanes and between experiments was evaluated using linear regression. Reproducibility of HPV type determination was done at L1S1 mapping stringency along with selected cut-off criteria , either individually or combined. Mean, standard deviation (SD), and coefficient of variation (CV) for number of mapped reads, depth of coverage and fraction of genome covered for each HPV type in each sample were used as additional measures of reproducibility.Sequencing results from the four replicates were evaluated for overall quality of sequencing reads and alignment parameters for both HPV and The LOD for each of the 9 HPV types was calculated based on the number of mapped reads using the equation: LOD = limit of blank (LOB) + 1.64 SD of the lowest concentration tested (1 copy/sample) , 22. Dat2 (CV = 5.71%) and 758 K ± 4.24 K/ mm2 (CV 0.56%) in experiments 1 and 2, respectively. Both experiments also generated reproducible cluster density . Sequence reads (in fastq format) from the 4 replicates had perfect match in the 8 bp index and passed the default filtering of the Illumina BCL2fastq V1.8.4 software. Prior to reference mapping, we evaluated the quality of the sequence data in terms of the mean number of reads, mean base quality score and percent of bases with quality score ≥ 30  and was highly reproducible among replicates within a sample  in both experiments  with decreasing copy numbers  individually or combined (Table p = 0.16 to 0.99) except for the marginal difference in the number of mapped reads for HPV type 58 (p = 0.042)  with the number of reads generated from libraries prepared with individual plasmids of the same HPV type (simulating single infection). This comparison of single and multiple infections was done with 625 copies of each HPV genome. eWGS showed no bias for detection of all 9 HPV types under single or multiple infection (2) Table .Table 3CThe mean number of non-specific HPV reads corresponding to blank resulting from all samples of the 4 replicates was 26.4 ± 65.2, giving rise to a calculated LOB = 133.3 for each of the 9 specific HPV types in the plasmid pool. Based on this LOB, LODs were calculated in terms of number of mapped reads, and the corresponding LOD in terms of copy number was determined for each of the 9 HPV types. LOD for all 9 types in this study was determined to be 25 copies/reaction since each specific HPV type at 25 copies reproducibly generated specific mapped reads greater  than calculated LOD  in all 4 replicates of the data set  and the number of types in the samples provided additional insights into assay robustness and LOD.2 = 1) in both experiments and between the two experiments (R2 = 0.99). Importantly, eWGS results in terms of number of mapped reads  and fraction of reference covered  at copies/reaction ranging from 125 to 625 was consistent for all 9 HPV plasmids. Using all three cut-off criteria, HPV genotype calling was fully reproducible at 625 copies for all 9 HPV plasmids, while at 125 copies only 6 out of 9 types were called reproducibly among the 4 replicates. HPV 6, 16 and 31 did not meet the depth of coverage criteria ≥20 at 125 copies in all replicates. These results, taken together, suggest that despite the complex nature of its workflow eWGS is robust and highly reproducible for HPV genotyping on a whole genome level at 625 copies/reaction using all three cut-off criteria, with no significant type-specific differences.eWGS showed high reproducibility in cluster generation between flow cell lanes  and between experiments (CV: 13.4%). Consistency of cluster generation reflects consistency during the complex workflow of library preparation and DNA determination of recovered products added to the flow cell. The eWGS results from the 4 replicates demonstrates consistency in the number and quality of reads . The number of reads mapped to HPV genomes were highly correlated between the two flow-cell lanes (Rp < 0.0001), as well as the fraction of reference genome covered. Variability among replicates for both measures increased as HPV copy number/reaction decreased. The positive correlation of mapped reads and fraction of genome covered with target concentration as we observed with bait-based eWGS for HPV agrees with a recently reported study on whole genome sequencing of hepatitis C viral genomes following similar target enrichment [As expected, we observed a positive correlation between the number of mapped reads and copy number/reaction  on 8 of the 9 plasmids, suggesting eWGS has minimal bias for HPV typing. The data on reproducibility among the replicates  Mean number of reads passing the default filtering of Illumina BCL2fasq V1.8.4. (B) Mean base quality score. (C) Percentage of base with quality score ≥ 30. Y-axis indicates the mean of values of 4 replicates. Error bars represent standard deviation of 4 replicates. (PDF 107 kb)Additional file 2:Figure S2. Reproducibility for eWGS for internal control HBB. Data shown is mean ± SD of 4 replicates/sample for number of reads (A), average depth of coverage (B), and fraction of reference covered (C). Error bars represent standard deviations. (PDF 94 kb)


Glycemia is related to energy production during exercise. Coenzyme Q10 is an antioxidant that participates in adenosine triphosphate synthesis in mitochondria. The aim of this study was to investigate the level of coenzyme Q10, glucose parameters, and antioxidant capacity in athletes.n = 43) and age-gender matched healthy subjects (n = 25) were recruited from a college. The levels of glucose parameters, oxidative stress, antioxidant enzymes activity, Trolox equivalent antioxidant capacity (TAC), and coenzyme Q10 status were measured in the present study.This study was designed as a cross-sectional study. Well-trained college athletes (p < 0.01); however, no significant difference was detected in plasma coenzyme Q10 between the two groups. Regarding the glucose parameters, the athletes had significantly higher values for HbA1c  and quantitative insulin sensitivity check index , and lower homeostatic model assessment-insulin resistance  than the healthy subjects. A higher level of TAC was found in the athletes . In addition, WBC coenzyme Q10 status was significantly correlated with catalase activity , GPx activity , serum TAC , fasting glucose , HbA1c , HOMA-IR , and QUICK .The athletes had a significantly lower level of white blood cells (WBC) coenzyme Q10 than the healthy subjects (0.34 ± 0.24 vs. 0.65 ± 0.43 nmol/g, Athletes may suffer from a marginal coenzyme Q10 deficiency, and the level was related to glycemic control and antioxidant capacity. Further interventional studies are needed to clarify an adequate dose of coenzyme Q10 supplementation in athletes to optimize their coenzyme Q10 status and athletic performance or recovery during exercise. Adequate nutrients and energy intake are required for the health and exercise performance of athletes . CarbohyCoenzyme Q10 is a lipid-soluble nutrient that participates in the mitochondrial respiratory chain for adenosine triphosphate (ATP) synthesis , 10. AthThis study was designed as a cross-sectional study. Well-trained athletes and healthy college students were recruited from Fu Jen Catholic University in Taiwan. The inclusion criteria were as follows: athletes were required to train for more than 12 h every week, and healthy subjects were required to not train regularly (less than 12 h every week) and were age- and gender-matched with the athletes. The exclusion criteria were age younger than 18 years, the consumption of nutritional or coenzyme Q10 supplements, and the use of anti-hyperlipidemia or anti-thrombin agents. This study was approved by the Institutional Review Board of Fu Jen Catholic University, Taiwan (FJU-IRB C105132). Each subject participated in the study after providing written informed consent.A questionnaire was used to determine the characteristics, including gender, age, and lifestyle habits, of the subjects. The height, weight, and waist circumference of each subject were measured, and then, the body mass index and waist hip ratio were calculated. We used the International Physical Activity Questionnaires (IPAQ) to assess subjects’ activity. The unit used was metabolic equivalent of task (MET)-minutes/week. One MET was defined as the amount of oxygen consumed when sitting at rest and was equal to 3.5 ml oxygen/kg body weight/minutes .Fasting blood samples were collected in vacutainers containing K2-EDTA anticoagulant  or sodium fluoride ; serum was separated in the tube without anticoagulant. Plasma, buffy coat layer, erythrocytes, and serum samples were obtained after centrifugation at 4 °C and 3000 rpm for 15 min. White blood cells (WBC) were obtained from buffy coats layers using red blood cells (RBC) lysis buffer .Hematologic data, such as glucose, insulin, lipid profiles, albumin, blood urea nitrogen, creatinine, creatine phosphokinase, lactate dehydrogenase, alkaline phosphatase, glutamic oxaloacetic transaminase, glutamic pyruvic transaminase, and uric acid levels, were analyzed by an automated chemistry analyzer , glycated hemoglobin (HbA1c) was analyzed by an automated glycated hemoglobin analyzer , and total lymphocyte count was measured by a hematology analyzer . Then, we further calculated markers of insulin resistance, and the following formulas were used: homeostatic model assessment-insulin resistance (HOMA-IR) = glucose (mmol/L) × insulin (μU/mL)/22.5; homeostatic model assessment-β-cell function (HOMA-β) = 20 × insulin (μU/mL)/(glucose (mmol/L) – 3.5) ; and quaMalondialdehyde as an oxidative stress indicator, was determined in plasma and erythrocytes by the thiobarbituric acid reactive substance method . AntioxiCoenzyme Q10 status was measured by high-performance liquid chromatography (HPLC) with an ultraviolet detector. The plasma coenzyme Q10 analysis was performed according to Littarru et al. . The WBCp value ≤0.05.This was an exploratory study. Descriptive statistics are presented as the mean ± standard deviation (median) or percentages. The Shapiro-Wilk test was used to examine the normality of data distribution. Student’s t-test or Mann-Whitney rank sum test was used to examine the differences in coenzyme Q10, glucose parameters, oxidative stress, and antioxidant capacity between the two groups. A chi-square test or Fisher’s exact test was used to compare the differences in categorical variables. Spearman’s rank order correlation analyses and simple linear regression analyses were used to examine the correlations between coenzyme Q10 status and glucose parameters or antioxidant capacity in athletes. All statistical tests in the study were conducted using SigmaPlot software . The statistical significance level was set at a p < 0.01) and a significantly lower time spent sitting than healthy subjects (p < 0.01). For hematological values, the levels of blood urea nitrogen and HDL-C were significantly higher in athletes than in the healthy group (p < 0.05); in contrast, the levels of alkaline phosphatase and triglyceride were significantly lower in athletes than those in the healthy group (p < 0.05).The characteristics of the athletes and healthy subjects are shown in Table C (p = 0.01) and QUICKI (p < 0.01) than the healthy subjects, while significantly lower levels of insulin and HOMA-IR were found in the athletes (p < 0.01). Although there was no significant difference in oxidative stress and antioxidant enzymes activity between the two groups, the athletes had significantly higher levels of TAC in the serum and erythrocytes than the healthy subjects (p < 0.01).The levels of glucose parameters, oxidative stress, antioxidative enzymes activity, and total antioxidant capacity are shown in Table p < 0.01). However, there was no significant difference in plasma coenzyme Q10 .Figure r = 0.50, p < 0.01; WBC coenzyme Q10, r = 0.56, p < 0.01), GPx activity , and serum TAC .The correlations between coenzyme Q10 status and antioxidant capacity in athletes are shown in Table β = − 0.74, p = 0.04; WBC coenzyme Q10, β = − 1.10, p < 0.01), HbA1c , and HOMA-IR , and significantly positively correlated with QUICK .The correlations between coenzyme Q10 status and glucose parameters in athletes are shown in Fig. p = 0.09) up to 24 h after a 21.1 km marathon run, but the level of fasting glucose was significantly decreased after the run . It is recommended that athletes consume high glycemic index foods prior to, during and after exercise to elevate the blood glucose levels [Physical exercise may affect glucose dynamics  by improe levels . ConsumiPrevious studies have observed that athletes may suffer from coenzyme Q10 deficiency due to sustained heavy physical exertion , 28. Athp < 0.01), HbA1c (p < 0.01), and HOMA-IR  and positively correlated with QUICKI . As a result, an adequate coenzyme Q10 status could provide better antioxidant capacity and glycemic control in athletes.Coenzyme Q10 is a crucial lipid-soluble antioxidant that can regulate glycemia through its antioxidant capacity to inhibit nuclear factor-κB (NF-kB) expression, reduce inflammation, and improve insulin sensitivity , 11, 30.This study is the first to investigate the relationship between coenzyme Q10 status and blood glucose and antioxidative capacity in athletes. Although we could not determine a causal effect in this cross-sectional study, we found that athletes had a marginal coenzyme Q10 deficiency and that the level of WBC coenzyme Q10 may be associated with glycemic control and antioxidant capacity. Further interventional sport nutrition studies are needed to determine the adequate dose of coenzyme Q10 supplementation in athletes to optimize their coenzyme Q10 status to improve athletic performance and recovery during exercise.


Cervical cancer incidence and mortality is high in Uyghur ethnics. Their life style and dietary habit were different from other ethnics living together. Study on the role of trace elements in HPV infection and cervical lesion of Uyghur minority is needed for future intervention and prevention work.In total, 833 Uyghur women were randomly selected from the screening site and hospital. The concentrations of the trace elements As, Fe, Cd, Ni, Cu, Zn, Mn, and Se were determined by atomic absorption spectrophotometry and inductively coupled plasma atomic emission spectroscopy. Univariate analysis was performed with chi-squared test between the HPV-positive and HPV-negative groups and between the case group and the control group. Multivariate analysis was performed with logistic regression.P < 0.05), and Ni concentration ≥ 0.1232 mg/kg and Se concentration ≥ 0.02 mg/kg were protective factors . Concentrations of Fe ≥ 6.9153 mmol/L and As ≥0.02 mg/kg were risk factors for CIN2+ , and concentrations of Ni ≥0.0965 mg/kg and Se ≥0.02 mg/kg were protective factors .An As concentration ≥ 0.02 mg/kg was a risk factor for HPV infection (OR > 1, Low serum concentrations of Se and Ni and a high serum concentration of As might be related to HPV infection and CIN2+ in Uyghur women in rural China. Cervical cancer is one of the most prevalent cancers worldwide, and the most recent compilation of data indicates that an estimated 470,000 new cervical cancer cases occur annually among women worldwide. An estimated 65,105 new cases developed, and 31,998 deaths occurred in Chinese women in 2015 [Trace elements are essential for the normal function of different metabolic processes in the body. Studies have shown that Se, Fe, As, Cu, Ni, Zn, Cd and Mn are essential trace elements that play an important role in malignant tumor incidence and progression , 5.A variety of studies have reported an increase in the levels of Cu in serum of patients with a malignancy. This increase has been found in carcinomas such as gastric, mammary, cervical, bladder and bronchial carcinoma –10; in sSe is a well-known essential trace element that plays an important role as a constituent of the enzyme glutathione peroxidase . This enUyghur women living in Xinjiang seem to suffer a higher disease burden of cervical cancer, in terms of both incidence and mortality, compared to women in other ethnic groups . The lowIn total, 5045 women were recruited for a cervical cancer screening survey in Maralbexi county, Xinjiang, between March 1, 2014 and June 15, 2014. careHPV, LBC (Liquid Based Cytology), VIA and VILI tests were adopted to screen for cervical cancer, and cervical biopsy by colposcopy was performed on women with any positive results. Some of the blood specimens were obtained from participants for trace element testing before the screening test began, while most were obtained with informed consent when the women went to the colposcopy visit. Blood specimens were collected from 646 women from the field survey, and 187 patients at the Affiliated Tumor Hospital of Xinjiang Medical University who were diagnosed with cervical lesions and came from Maralbexi county were also included in the survey. A total of 833 women were enrolled in the study. Inclusion criteria were age between 20 and 65 years, sexually active, no chemotherapy or radiotherapy, and no use of drugs or supplements containing trace elements. Written informed consent was obtained from each study participant before the study. The Ethical Committee of the Affiliated Tumor Hospital of Xinjiang Medical University approved the study.The new test, designated careHPV, is a signal-amplification assay that detects target HPV-DNA from 14 different carcinogenic HPV types . This is a qualitative test with the result of HPV positive or HPV negative.v/v) in a 50-mL collection bottle and then placed on an electrical hot board at 120 °C until white smoke was produced. The samples were adjusted with deionized water to a final volume of 50 mL. The concentration of the trace elements Arsenic (As) and Selenium (Se) was determined by atomic absorption spectrophotometry. The concentrations of Cadmium (Cd), Nickel (Ni), Cuprum (Cu), Zinc (Zn), Manganese (Mn), and Iron (Fe) were determined by inductively coupled plasma atomic emission spectroscopy. Μmol/L is refers to μmol of trace element in per Liter of blood, while mg/k refers to mg of trace element in per kg of blood. The test was analyzed at the Xinjiang Uyghur Autonomous Region Research Institute of Analysis. All standard substances were obtained from the National Standard Material Center, Peking, China.Blood samples were collecting with hemostix containing anticoagulant to avoid hemolyzis. The sample volume was 2–3 mL after centrifugation for all samples; serum was collected in disposable polypropylene tubes and kept frozen at − 70 °C until analyses were performed. Serum samples (0.5 mL) were digested by wet-washing using 5 mL of a nitric/perchloric acid mixture  while enumeration data are expressed as the rate. Univariate analysis was performed with Chi-squared test between the HPV-positive and HPV-negative groups and between the case group and the control group. Multivariate analysis was performed with logistic regression. The significance level was set at n = 551), and those without HPV infection formed the HPV-negative group (n = 282). Blood samples were obtained from most participants with HPV-positive results at the first screen when they went for the colposcopy visit, and women recruited from the hospital were also mostly infected with HPV. These reasons caused that in this study the HPV-positive rate was significantly higher compared to the total infection rate, which was as we mentioned above 10.9%. The participants with CIN ≥ 2  (n = 150) were regarded as the case group, since patients who are CIN2+ need treatment by clinical procedure, and those characterized as CIN < 2 formed the control group (n = 683). The age range of women was 20–65 years, with a median age of 39.62 ± 9.58 years.The HPV infection rate in a total of 5045 women was 10.9%. The participants with HPV infection were regarded as the HPV-positive group (0.1678 mg/kg), 105.9822 μmol/L (44.7862 μmol/L), 7.3485 mmol/L (3.7108 mmol/L), 19.8746 μmol/L (19.8724 μmol/L), 0.4879 μmol/L (0.8125 μmol/L), and 0.03618 μmol/L (0.0334 μmol/L), respectively, while those values were 0.1219 mg/kg (0.1854 mg/kg), 102.6875 μmol/L (45.9654 μmol/L), 6.5872 mmol/L (3.1275 mmol/L), 22.1089 μmol/L (21.2617 μmol/L), 0.5263 μmol/L (0.8174 μmol/L), and 0.0258 μmol/L (0.0289 μmol/L), respectively, in the HPV-positive group. To more accurately reflect the levels of the trace elements in serum and the relationship between HPV infection and Ni, Zn, Fe, Cu, Mn and Cd serum levels were classified according to the interquartile range of the HPV-negative group. The levels of serum Se and As were classified according to < 0.02 mg/kg and ≥ 0.02 mg/kg. Among women with an HPV infection, 42.47% had serum Se levels ≥0.02 mg/kg, and 60.44% had serum As levels ≥0.02 mg/kg. In the negative HPV group, 58.51% of women had Se levels ≥0.02 mg/kg, and 48.23% of women had As levels ≥0.02 mg/kg.The median and interquartile range were adopted to present the results of serum trace element  tests as the measurement data were abnormally distributed. In the HPV-negative group, the serum levels of Ni, Zn, Fe, Cu, Mn, and Cd were 0.1821 mg/kg . The serum levels of Zn, Fe, Mn and Cu in the samples with different HPV infection status were not significantly different  , while the concentrations of Ni ≥0.1232 mg/kg  and Se ≥0.02 mg/kg  were protective factors , Zn: 93.6937 μmol/L (48.9736 μmol/L), Fe: 7.2894 mmol/L (3.0267 mmol/L), Cu: 24.1875 μmol/L (22.1672 μmol/L), Mn: 0.4984 μmol/L (0.7098 μmol/L), and Cd: 0.0418 μmol/L , Zn: 105.5670 μmol/L (49.7065 μmol/L), Fe: 6.9153 mmol/L (3.8024 mmol/L), Cu: 21.8746 μmol/L (19.6439 μmol/L), Mn: 0.5493 μmol/L (0.7303 μmol/L), and Cd: 0.0359 μmol/L (0.0319 μmol/L). To more accurately reflect the levels of the trace elements in serum and the relationship with CIN2+, the serum levels of Ni, Zn, Fe, Cu, Mn and Cd were classified according to the interquartile range of the control group. The levels of serum As and Se were classified according to < 0.02 mg/kg and ≥ 0.02 mg/kg. In total, 81.33% of women in the case group had serum As levels ≥0.02 mg/kg, and 15.33% had serum Se levels ≥0.02 mg/kg. In the control group, 50.07% of women had As levels ≥0.02 mg/kg, and 55.78% had Se levels ≥0.02 mg/kg.P < 0.001), while the levels of Ni and Se had a downward trend (P < 0.001). The serum levels of Zn, Cd, Mn and Cu in samples from different groups were not significantly different  and Fe ≥6.9153 mmol/L  were risk factors for CIN2+ in Uyghur women, while concentrations of Ni ≥0.0965 mg/kg  and Se ≥0.02 mg/kg  were protective factors (Table Serum levels of Ni, Fe, As and Se, which were shown as statistically significant in the univariate analyses, were analyzed by the logistic regression model, and age and education level were adjusted. Concentrations of As ≥0.02 mg/kg (OR = 4.466, 95% CI: 2.218–8.996; Studies suggest that the content of trace elements has a great influence in the body on cellular structure stability, the stability of nucleic acids and immunity . Our datOur results were not consistent with the results reported by Ji et al. and Wu et al. , 44, whiZn plays an important role in cell division, growth, DNA synthesis, RNA transcription, and aspects of the immune system . Zn is aIn our data, the levels of Mn, Cu, Cd and Zn were slightly different in the two groups, but the difference was not statistically significant. The exact relationship between these elements and HPV infection and CIN2+ in Uyghur women needs to be verified in further studies. Although the findings from this epidemiological study cannot establish causality, they provide a solid base that low concentrations of Se and Ni and the high concentration of As might be related to HPV infection and CIN2+ in Uyghur women in rural China. Well-designed cohort studies or clinical trials may be warranted to confirm these associations.Based on our study, we conclude that low serum concentrations of Se and Ni and a high serum concentration of As might be related to HPV infection and CIN2+ in Uyghur women in rural China, while the serum levels of Cd, Zn, Fe, Mn and Cu were no obvious influence on HPV infection and cervical lesion of Uyghur women. The result will provide a theoretical basis for our future nutritional intervention in cervical cancer prevention project.


Our aim was to review the major contributions of studies conducted in different Latin American (LA) countries to the field of human papillomavirus (HPV) epidemiology, natural history, risk of disease, and prevention strategies, mainly in the uterine cervix. Although cytological screening is established in several countries in LA, incidence and mortality rates from cervical cancer (CC) are still extremely high. Finally, data from large cohort studies conducted in LA countries provided seminal data to propose primary and secondary prevention modalities: the HPV vaccine has been introduced in the national immunization programs of several LA countries and multiple screening experiences using HPV testing are under evaluation in the region. Human papillomaviruses (HPVs) are a diverse group of epitheliotropic viruses that may cause warty and neoplastic changes in the epithelia at different anatomical sites. HPVs consist of a non-enveloped virus with a 50-nm diameter capsid that encloses a single circular double stranded DNA molecule of approximately 8,000 bp associated to cellular histones. The viral genome encodes six early  and two late proteins (L1 and L2). While both late proteins associate for capsid formation, early proteins control viral transcription and replication, and are involved in cellular transformation  cancers in both genders. Additionally, genital warts and the rare but very serious recurrent respiratory papillomatosis are etiologically associated with HPV infection  bears one of the highest incidence rates of CC with age-adjusted incidence rates ranging from 10 to 80 per 100,000 women/year . NeverthDecades of Papanicolaou-based screening to detect pre-cancerous cervical lesions in a few countries of the region have not had a major impact in reducing CC incidence and mortality rates, which are still high across LA. Moreover, estimates indicate an overall 72% increase in the incidence of CC and a 78% rise in mortality by this disease between 2012 and 2030 . Each yeThe global burden of HPV infections and associated diseases is significant. Particularly within LA, HPV was associated to 83,195 new cases of CC and 35,673 associated CC deaths in 2012  is also associated with higher risk of acquiring another HPV type in addition to multiparity, long term use of oral contraceptives, and tobacco smoking. The role of chronic inflammation, especially from coinfection with reported . Virus-rreported ,66. FurtThe analysis of HPV type prevalence and distribution in normal cytology and low grade squamous intra-epithelial lesion (LSIL) cervical samples reveals a wide spectrum of HPV types, both lr- and hr-HPVs, and as the severity of cervical lesions increases, hr-HPVs predominance increases, being the unique types detected in CC. Globally, hr-HPV-16 DNA is detected in 30% of cytologically normal HPV positive cervical samples and in 50–90% of HPV-positive CC. Additionally, hr-HPV-18 accounts for 10 to 20% of all CC cases. A wide variation in the prevalence of the lesser prevalent HPV types throughout the world is observed .Regarding countries from LA, the prevalence of any HPV type observed was 16.1% in an extensive meta-analysis including 48,171 women with normal cytology from studies conducted in Trinidad & Tobago, Costa Rica, Honduras, Guatemala, Belize, Mexico, Argentina, Brazil, Chile, Colombia, Paraguay, and Peru. Specifically, the vaccine-targeted hr-HPV-16 and -18 were identified in 4.3% of normal samples. In LSIL samples from LA, the most common viral types identified were hr-HPV-16 (26%), hr-HPV-33 (13%), lr-HPV-6 (11%), hr-HPV-58 (8%), and hr-HPV-31 (7%). Finally, among 2,446 HSIL cases, 46.5 and 8.9% were shown to be hr-HPV-16 and -18 positive, respectively, while in 5,540 CC cases, 53.2% of cases harbored hr-HPV-16 and 13.2% hr-HPV-18. The following five most prevalent types, in decreasing frequency, were hr-HPV-31, -58, -33, -45, and -52 .More recently, the worldwide meta-analysis regarding the cross-sectional viral type prevalence and distribution in HPV-positive women of all clinical status  accessed by PCR-based methods included 35,895 samples from South and Central America studies . OverallThe prevalence of hr-HPV variants and their association with CC has been reported in three case-control studies ,69,70, ain vitro functional assays have also shown that different hr-HPV-16 variants exhibit differences in their biological and biochemical properties, and further attributed to AA variants an increased oncogenic potential compared to E variants  composed of L1 protein, the main viral capsid constituent. Since 2006, three vaccines have been approved in LA for HPV prophylaxis: a bivalent vaccine composed of VLPs of hr-HPV-16 and -18 , a quadrivalent vaccine containing VLPs of hr-HPV-16 and -18 and lr-HPV-6 and -11 , and more recently a nine-valent vaccine containing VLPs for HPV types -6, -11, -16, -18, -31, -33, -45, -52, and -58. Large phase II and III clinical trials to evaluate prophylactic efficacy have been conducted in which both HPV infection and cervical disease endpoints were evaluated, particularly HSIL (CIN2 or CIN3) in addition to vulvar and vaginal intraepithelial neoplasias , anal infection and dysplasia, and genital warts . Within In most LA countries, a well-developed public immunization infrastructure is available, which has facilitated the introduction of national immunization programs in these regions. Furthermore, the organizations United Nations Children's Emergency Fund (UNICEF), Global Alliance for Vaccines and Immunization (GAVI), and Pan American Health Organization (PAHO) Revolving Fund had a crucial role in enhancing HPV vaccine introduction in LA. Currently, 80% of girls aged 9–14 years in the LA have access to HPV vaccination through national immunization programs due to political will and the negotiated purchase of the vaccines. Moreover, in several countries in LA, the HPV vaccine is also accessible to HIV-positive women up to 26 years of age. In the last few years, HPV prophylactic immunization has been extended to boys and men living with HIV in several LA countries. The countries have adopted 2 doses (0–6 or 12 months) for children up to 14 years of age, and 3 doses (0–2–6 or 12 months) for all above that age. Nevertheless, significant challenges remain including the cost of the program, the variable coverage rates, and the monitoring of this intervention that requires tools and strategies unavailable in many countries of the region.Since the introduction of HPV vaccination in national immunization programs, numerous articles on its impact in the real world have been published, supporting the effectiveness of an inclusive immunization program, preventing infection from spreading, and demonstrating potential for reducing cancer incidence in both genders . The impRecently, a broad evaluation of health programs is driving a revision of the entire CC control strategies adopted by each country, which comprises not only HPV vaccination of female adolescents but also cytology/HPV testing for adult women. Implementation with good coverage rates of cost-effective actions such as HPV vaccination alone or vaccination accompanied by screening will reduce HPV-related tumors in LA, as occurred in several countries of the world. For instance, in Argentina, a strong reduction in the prevalence of HPV 16/18 and closely related HPV types in sexually active adolescent women following the introduction of HPV vaccination was observed (unpublished data). Similar initiatives for the monitoring of HPV vaccine effectiveness are underway in Brazil. A nationwide HPV prevalence study of women and men from 16 to 25 years of age was recently finalized  to set tCytology-based mass screening programs, which have been adopted as the standard care for CC screening for over 50 years, have been successful in reducing incidence and mortality in diverse developed countries. Unfortunately, most LA countries tried unsuccessfully to reproduce these results, evidencing however very high incidence and mortality rates, with no significant impact on the disease burden after decades of efforts . InherenOver the last decade, diverse experiences with HPV testing have been conducted in LA countries; some as part of research studies, others to pilot the implementation of HPV testing in the public health system, and more recently, the implementation of HPV tests as part of the public programs provided by the ministries of health . Pilot sWorldwide, hr-HPVs, primarily HPV-16, are the main etiological agents of almost all CCs and of an important fraction of tumors in the anogenital region and oropharynx of both women and men. Increasing knowledge concerning the activity of E6 and E7 viral oncoproteins revealed crucial molecular mechanisms that lead to cellular transformation. The prevalence of HPV infection at diverse anatomical sites and the HPV-related disease burden in different LA countries highlight the need of supporting CC prevention strategies in this region. CC is one of the leading causes of women deaths in LA and thus, requirement for CC prevention and control are inestimable.The introduction of highly efficacious vaccines that prevent hr-HPV-16 and -18 infections (and other HPV types) revealed high potential of contributing to the reduction of a substantial proportion of tumors that without intervention would continue to increase in number. Although regional data point towards a favorable trend in prevention, important challenges remain, including the cost of vaccination programs, coverage of 2 vaccine doses, and the need to vaccinate susceptible populations like those living with HIV and other individuals with immunodeficiency. Equally important are the tools and strategies required to measure the impact of this intervention that are still unavailable in many countries of the region.Considering secondary prevention strategies, most countries throughout LA attained no success in implementing cytology-based screening programs at the population level. However, after the introduction of prophylactic HPV vaccines, CC screening with HPV testing has proven to be more sensitive than Pap testing while allowing for an accurate monitoring of HPV-associated diseases. It is noteworthy that while screening is essential, it is only one component of many other aspects of population-based programs, which should be employed to effectively impact a reduction in CC cancer incidence and mortality. Challenges include the need to update screening guidelines, strengthen treatment capacity, and develop a comprehensive quality assurance plan for HPV testing.Finally, several gaps still exist in the knowledge and the future lines of research, policy, and advocacy for non-cervical HPV cancer prevention, mainly regarding anal canal and oropharyngeal cancers and precursor lesions. Additional studies are necessary to better understand the natural history of viral infections, their pathogenesis and the impact on cancer patient management at these anatomical regions. Public health commitment and research to implement HPV-based preventive strategies, together with strong and common advocacy to overcome the barriers affecting the adoption of these strategies are likely to yield major benefits in reducing the burden of HPV-associated diseases in LA.pdf].Click here to view [


Background: The burden of head and neck cancer in China is heavier, and studies have shown that it may be associated with HPV infection, especially high-risk HPV.Objectives: We aimed to conduct a meta-analysis to estimate the high-risk HPV-16 prevalence of head and neck cancer in the Chinese population.Methods: The reports on HPV and head and neck cancer in a Chinese population published between Jan 1, 2006 and Oct 23, 2018 were retrieved via WANFANG/CNKI/MEDLINE/EMBASE databases. The pooled prevalence and corresponding 95% confidence intervals was calculated by a random-effect model.Results: The meta-analysis included a total of 2,896 head and neck cancer cases from 28 studies. Overall, the pooled HPV-16 prevalence among head and neck cancer cases was 24.7% (20.2–29.3%) in China, 31.6% (21.7–41.5%) in oropharyngeal cancer, 28.5% (18.2–38.7%) in laryngeal cancer and 14.9% (10.1–19.7%) in oral cancer, 25.3% (14.8–35.8%) in fresh or frozen biopsies and 25.0% (19.5–30.5%) in paraffin-embedded fixed biopsies, 36.5% (17.9–55.1%) by E6/E7 region and 14.3% (6.4–22.1%) by L1 region of HPV gene. The highest HPV-16 prevalence was found in Central China.Conclusions: High prevalence of HPV-16 was found in the samples of Chinese head and neck cancers. Preventive HPV-vaccination may reduce the burden of HPV-related head and neck cancer in China. As a member of the papillomavirus family of viruses, human papillomavirus (HPV) can infect humans by attacking the squamous cell of skin and mucous membranes, including those of the cervix, anogenital region and head and neck –3. As weEven in the same country, the HPV prevalence in head and neck cancers range widely . DemograThe aim of the meta-analysis is to estimate the prevalence of HPV-16 detected in head and neck cancer cases and the different cancer sites, influence of regions, specimen types, and detection methods in China from all published studies of English and Chinese language literature.This meta-analysis was reported following the guideline of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) . The keyin situ hybridization (ISH) to amplify HPV DNA, (c) to report the prevalence of HPV-16 in head and neck cancer tissue samples with clear anatomical subsite.According to the PRISMA statement, the literatures contained in this study must meets the following criteria: (a) to inform at least 10 cases of head and neck cancer confirmed by biopsy or histopathology, (b) to use polymerase chain reaction (PCR)-based methods  or The literatures excluded in this study were mainly due to the following reasons: were cellular or animal studies; were not conducted in Chinese; unable to extract or calculate the necessary data directly from the original article; without clear definition of anatomical subsite; reviews.All studies included in the final meta-analysis extracted the following data: first author's name, publication year, geographical areas, cancer site, clinical stage, numbers of cases and HPV positive cases, HPV test method, specimen types .CI) for HPV-16 prevalence were calculated through the method of DerSimonian and Laird  and I2  was used to assess the heterogeneity between eligible studies  for Windows. HRs or CIs, 11 were cytological study, 7 were abstract, 4 had not clear anatomical subsite, 2 were not in Chinese population and 1 was case report. So, 28 studies (11 in English and 17 in Chinese) were eligible and included in this meta-analysis , and the remaining studies distributed in three other regions of China as follows: 6 (21.43%) studies in Central China, 5 (17.86%) studies in Western China and 1 (3.57%) study in Northeastern China. 14 (50.00%) studies conducted in laryngeal cancer cases, 11 (39.29) conducted in oral cancer cases, and 8 (28.57%) conducted in oropharyngeal cancer cases. For HPV detection methods, 26 (92.86%) studies used PCR, and 2 (3.57%) studies used ISH. 21 (75.00%) studies used formalin-fixed paraffin-embedded biopsies (FFPE), and 7 (25.00%) studies used fresh or frozen biopsies. Besides, 7 (25.00%) studies used the gene detected from HPV E6/E7 region, and 5 (17.86%) used the gene detected from HPV L1 region.Figure analysis –40. IndiCI, 20.2–29.3%) in head and neck cancer cases in the Chinese population. Overall, high heterogeneity was observed in the studies included .Figure CI, 21.0–52.9%), followed by that in Western China , and in Eastern China . Oropharyngeal cancer had the highest infection rate of HPV-16 , followed by laryngeal cancer  and oral cancer . Stratified analysis by published year showed that head and neck cancer before the year 2011 had the highest HPV-16 prevalence  as compared with the period from 2011 to 2015  and the period from 2016 to 2017 . Stratified analysis by number of patients showed that head and neck cancer patients < 100 has the higher HPV-16 prevalence  as compared with those more than 100 . HPV-16 prevalence with PCR method  was lower than with ISH method . Hierarchical analysis by specimen types showed that head and neck cancer in FF tissue  had almost the same prevalence of HPV-16 compared with the FFPE tissue . Regarding the HPV-16 test methods, the prevalence of head and neck cancer in the E6/E7 region of HPV gene  was significantly higher than that in the L1 region . In short, the estimated heterogeneity for studies included decreased to some extent but not disappeared. Meta-regression analyses found significant association of HPV-16 prevalence with HPV detection method .Table CI, 18.7–27.3%) to 26.4% . Point estimates for all results of influence analysis were within 95% CIs of the pooled prevalence. The meta-analysis of pooled HPV-16 prevalence in head and neck cancer cases was not significantly affected by any of the 33 individual studies that was not analyzed, indicating that each study did not affect the stability of overall HPV-16 prevalence estimate.To address the potential bias due to the quality of the included studies, we performed the sensitivity analysis by calculating pooled HPV-16 prevalence again when omitting one study at a time. Figure P-values of Begg's test (0.09), Eegg's test (0.07), and the near-symmetric funnel plot  in China for the highly lethal cancer. As we know, this is the first meta-analysis to exploring the prevalence of HPV-16 in Chinese head and neck cancer tissues. The results of the meta-analysis showed that about 25% cases of head and neck cancer harbored HPV-16, indicating a high level of HPV 16 infection in head and neck cancer cases of China. Our results were little higher than the global prevalence .Characterizing the HPV-16 prevalence in head and neck cancer is an important preliminary step in assessing the relationship between HPV-16 and head and neck cancer. Estimates of the HPV prevalence in various cancer sites of head and neck cancer vary considerably. Our meta-analysis showed that oropharyngeal cancer had the highest HPV-16 prevalence (31.6%), followed by that in laryngeal cancer (28.5%), and in oral cancer (14.9%). Interesting, the prevalence of HPV-16 in oropharyngeal cancer and oral cancer were much lower than Asian average, but much higher in laryngeal cancer . More caThe detection rate of HPV-16 DNA in FF tissue was found somewhat higher than that in FFPE tissue, given significant DNA degradation could be observed in FFPE tissue . The HPVSome possible reasons for variation in HPV prevalence among studies include small study sizes, different HPV testing, inter-laboratory variability, and manipulation of specimens leading to contamination –45. In oThe highlights of this meta-analysis includes a large sample size, both English and Chinese published studies are included with a strict inclusion criteria. By including English and Chinese studies, the selection bias caused by the publication language was avoided. Finally, by astricting studied published after 2006, limiting PCR and ISH detection methods and excluding studies without specific subsites, we tried to minimize the HPV prevalence variation as much as possible.However, the meta-analysis has several limitations. First, the studies included in the meta-analysis are heterogeneous, which could be explained by changes in the population, the cancer site, the year of publication, the number of patients, the HPV detection method, the sample collection method, and the sensitivity of HPV primer PCR different protocols. To solve this issue, the random-effects model was used in the meta-analysis to combine data if significant heterogeneity was found. We directly tested heterogeneity by describing the HPV-16 prevalence in head and neck cancer cases by study area, cancer site, year of publication, number of patients, method of HPV detection and sample types. Of course, we have not been fully able to explain the heterogeneity. Even in stratified outcomes , the prevalence estimates are still uneven. Second, the study estimates may be biased because the accuracy of these estimates depends on the test method used and the type of HPV evaluated. That is, some studies use multiple probes or wide primers to detect multiple types of HPV, while other studies only detect HPV-16 type. Finally, the possibility of confounder cannot be ruled out. Limited studies have implicated the effect of age and smoking on the prevalence of HPV. We could not determine whether the variation of HPV prevalence was due to differences in environmental factors: age, sexual habits, smoking, alcohol consumption and other ethnic and cultural differences, as little or no information on these potential confounders in the studies involved. Therefore, studies with good designs to explore HPV infection by major confounding factors are likely to be required in future studies.In short, the current meta-analysis provides a quantitative estimate of HPV-16 prevalence in head and neck cancer lesions in China. Although this review is a preliminary step in assessing the relationship between HPV-16 and head and neck cancer in China, it may be useful to evaluate the effect of HPV-16/18 prophylactic vaccines against carcinogenesis in the future. Considering that HPV infection plays an important role in the tumorigenesis of head and neck, other scientific studies deserve to be done in the future.All authors have made substantial contributions to the conception and design of the study. LG and FY led protocol design, search, data extraction, statistical analysis, and manuscript drafting. YY and SL contributed to search, data extraction, and manuscript modifications. PL, XZ, DC, YL, JW, KW, YZ, QL, and XW contributed to quality assessment and revision of the manuscript. XS contributed to data interpretation and revision of the manuscript. All authors have reviewed 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.


Human papillomavirus (HPV) is a viral infection with skin-to-skin based transmission mode. HPV annually caused over 500,000 cancer cases including cervical, anogenital and oropharyngeal cancer among others. HPV vaccination has become a public-health concern, worldwide, to prevent the cases of HPV infections including precancerous lesions, cervical cancers, and genital warts especially in adolescent female and male population by launching national programs with international alliances. Currently, available prophylactic and therapeutic vaccines are expensive to be used in developing countries for vaccination programs. The recent progress in immunotherapy, biotechnology, recombinant DNA technology and molecular biology along with alternative and complementary medicinal systems have paved novel ways and valuable opportunities to design and develop effective prophylactic and therapeutic vaccines, drugs and treatment approach to counter HPV effectively. Exploration and more researches on such advances could result in the gradual reduction in the incidences of HPV cases across the world. The present review presents a current global scenario and futuristic prospects of the advanced prophylactic and therapeutic approaches against HPV along with recent patents coverage of the progress and advances in drugs, vaccines and therapeutic regimens to effectively combat HPV infections and its cancerous conditions. Papillomaviridae family comprises more than 130 HPV genotypes that have been isolated from various human neoplasias such as warts, cancers, and cases of recurrent respiratory papillomatosis (RRP) (Human papilloma virus (HPV) infection is usually a commonly encountered infection (transient) which has attracted the attention of media in recent years due to the advancement in the field of vaccine development and changes in recommendations for screening of cancer , 2. HPV is (RRP) . The preis (RRP) . This viis (RRP) . Globallis (RRP) , 9. Throis (RRP) , 11. It is (RRP) , 13.To control HPV infection, HPV vaccines have been introduced into national immunization programs . Since 2Among effective prophylactic HPV vaccines, Cervarix  is protective against adenocarcinoma-causing types including HPV-16, 18, 31, 33 and 45 for a documented period of 6.4 years. Whereas, Gardasil  has been confirmed to protect against genital warts, respiratory papillomatosis, and certain types that cause squamous cell cancer, including HPV-6, 11, 16, 18, and 31, for 5 years . DespiteChimeric vaccines, multivalent vaccines to address HPV types (broader spectrum) or to combine HPV with other pathogens, edible vaccines, biodegradable and mucoadhesive polymer-based vaccines, and various viral vectors harboring recombinant HPV DNA vaccines are being developed for greater immunogenicity than that of current vaccines. Similarly, for a more recipient-friendly vaccine, needleless immunization technologies, including the use of a jet gun, gene gun, and microneedles are being evaluated for HPV cancer prevention . LyophilThe present review presents a current global scenario and futuristic prospects of the advanced prophylactic and therapeutic approaches against HPV along with recent patents coverage of the progress and advances in drugs, vaccines and therapeutic regimens to effectively combat HPV infections and its induced- pathological sequels.HPVs belong to a large family of non-enveloped, small, approximately 7.9–8 kbp circular dsDNA viruses that are surrounded by an icosahedral protein capsid composed primarily of a highly immunogenic L1 protein, with a minor contribution from the L2 protein , 31. TheHPVs with different oncogenic potential have been assigned to three main groups: high-risk types, intermediate-risk types, and low-risk types. High-risk types include HPV-16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68, 73, and 82; intermediate-risk types include HPV-26, 53, and 66; and low risk-types include HPV-6, 11, 40, 42, 43, 44, 54, 61, 70, 72, and 81. Among these types, 70% of cervical cancers result from type 16 and 18 infections, and if multiple HPV types infect women, persistent HPV infections can be established, and cervical cancer exacerbated . It is tHPV is held responsible for the trends in the increase in the rate of oropharyngeal carcinoma as is revealed by molecular detection methods. The viral nucleic acid is detectable in a clinical specimen by polymerase chain reaction at a much greater frequency after the year 2000 as compared to before 1990 in the United States alone. The involvement of HPV in oropharyngeal carcinoma has greatly increased during a span of 20 years in the Netherlands from 1990 to 2010. Similar is the situation in another European country like Spain , 38.Despite this, most HPV infections induce no or only mild cytological abnormalities; and few HPV infections lead to cervical cancer. HPV can also cause cervical and other cancers such as cancer of the vulva, vagina, penis, or anus. It can also cause cancer in the back of the throat, including the base of the tongue and tonsils . UsuallyAmong oncogenic HPVs, genotypes 6 and 11 cause laryngeal papillomas and most of the genital warts, whereas types 16 and 18 are responsible for 70% of cervical cancers. To prevent infection with highly transmissible HPV, a quadrivalent  HPV vaccine has been evaluated and shown good results in clinical trials. Similarly, a bivalent vaccine (types 16 and 18) has shown greater than 90% protection against persistent HPV infections, even 5 years post-vaccination. In both, the vaccines were non-infectious, DNA-free VLPs, developed using recombinant technology, administered in conjunction with appropriate adjuvants, and three doses at 6-month intervals have been shown to elicit high-titer serum antibodies .A study performed in young women 15–25 years of age to assess the immunogenicity and efficacy of a human papillomavirus 16 and 18 (HPV-16/18) AS04-adjuvanted vaccine against cervical intraepithelial neoplasia (CIN) grade 1 or greater  showed that vaccination of adolescent girls before their first sexual encounter resulted in better protection and prevention of HPV-associated cervical cancers and persistent infections . The HPVThe clinical efficacy of bivalent (HPV-16 and 18), quadrivalent , and nonavalent  vaccines against cervical cancer was tested. The bivalent and quadrivalent vaccines reduction in the rate of HPV-16 and 18 prevalences significantly compared to that of the 9vHPV vaccine and all three vaccines decreased the morbidity and mortality from cervical cancers resulting from oncogenic HPVs . The HPVChronic local inflammation, alone or as a result of oral HPV infection, may play an important role in the etiology of head and neck squamous cell carcinomas . A studyBecause the cultivation and propagation of HPV in cell/tissue culture are difficult, developing inactivated or live attenuated HPV vaccines is not a common practice. Therapeutic vaccines against HPV can be categorized into nanoparticle-, bacterial-, live vector- , nucleic acid- (DNA and RNA), protein-, peptide-, cell- (cytokine-transduced autologous tumor cells and dendritic cells [DCs]) based vaccines [reviewed in  and 54)54)]. CytVarious new approaches are presented as below:Haemophilus influenzae protein D (PD), adjuvanted with AS02B. Vaccinated patients with oncogenic HPV-positive CINs mount significant E7- and PD-specific IgG responses  peptides. In mammalian models, the cell-mediated immune response is generated by immunizing with a peptide that carries E6 or E7 origin epitopes . VariousVaccines designed using a traditional approach involve attenuation of a pathogen by sub-culturing, which is a long and tedious process that can take up to 15 years, and the safety of these vaccines is a matter of concern , 77. BioIn silico tools, paired with improvements in recombinant DNA (rDNA) technology and knowledge of the host immune response and genetic background of the pathogen, will contribute to the future development of new vaccines (in silico vaccine design tools (vaccines . The firvaccines . Predictvaccines . With thgn tools .p < 0.002) increase and ~0.4-fold (p < 0.328) decrease in antibody titer, respectively, after the final injection. This study offered a roadmap for the use of both in silico tools and experimental methods to develop DNA-based vaccines. The authors also suggested that multi-epitope DNA vaccines might induce more effective immune response against HPVs with different epitope variants than those constructed without a consideration of this variation (A prediction for the 16 major epitope variants (V1–V16) in the full-length L1 protein of HPV-16 and evaluation of the immunogenicity of these variants and reference DNA vaccine constructs was recently reported by Kumar et al. . The resariation .in silico tools (B-cell and T-cell epitope prediction methods) were used to design a subunit vaccine against HPV  and E7 (n = 22) were predicted using Immune Epitope Database Analysis Resource. Among the 20 clusters of epitopes in HPV-16 E6 generated, cluster 3 contained the most epitopes (10 epitopes), representing HLA-A*31:01 and -A*33:03. Of the 10 clusters of HPV-16 E7, cluster 3 contained the most epitopes (5 epitopes), representing HLA-A*01:01 and -A*26:01. Based on their observations, the authors suggested that a cocktail of E6 and E7 epitopes such as 52FAFRDLCIVYR62 of E6 , 66PYAVCDKCLKF76 of E6 (HLA-A*11:01 and HLA-A*24:02), 2HGDTPTLHEY11 of E7 (HLA-A*01:01 and HLA-A*26:01), and 11YMLDLQPETT20 of E7 (HLA-A*02:01) could be used to vaccinate more than 50% of all individuals worldwide  was detected by MS3 analysis of the HLA-A*02 immunoprecipitate from seven of them. However, of the 13 epitopes predicted using the in silico approach, only one was observed through an exquisitely sensitive physical detection method, suggesting that bioinformatic prediction should be used to identify probable epitopes for confirmation by physical detection. Because the conserved E711−19 peptide is the dominant HLA-A*02 binding tumor antigen in HPV-16 transformed cervical squamous cells cancers and adenocarcinomas, it has the potential to be used for the development of therapeutic cancer vaccines  in patients with HLA-Avaccines .In silico approaches to predict the epitopes are highly valuable compared to conventional procedures that are costly and time-consuming. The predicted peptides can then be tested both in vitro and in vivo to verify their effectiveness in triggering an immune response. Assays with short peptides (overlapping) covering the entire sequence of the targeted protein/antigen are used to define CTL epitopes (MHC Class I restricted). Determination of the epitopes of HPV-16 is also done in the same way . It can, therefore, be mentioned without a doubt that as far as designing vaccine is concerned a better target is L1 protein compared to L2 . In silisame way .in vivo  type 5 encoding the major capsid protein L1 of HPV-16 showed that a single-dose of this vaccine without an adjuvant was sufficient to elicit high titers of mucosal antibodies in vaginal washes and L1-specific serum antibodies . Immunizin vivo .Pichia pastoris expressing HPV protein. A patent has been granted to Mendiretta et al.  expressing HPV E2 (MVA-E2). This vaccine showed potential to be used as a therapeutic vaccine . The virListeria monocytogenes (Lm) were engineered by Gunn et al.  assay has been employed for evaluation of the E7 specific-cellular immunity. When treatment with four-six capsules/day is done, there is exhibition of HPV E7 specific-cellular immunity in lymphocytes of the cervix  produced edible HPV vaccines that were administered to female BALB/c mice  and include conformational epitopes which help in induction of neutralizing antibodies . VaccineSalmonella enterica serovar Typhi, i.e., Ty21a engineered to produce VLPs with HPV-16 L1 was administered as a potent live HPV vaccine to simultaneously induce protective immunity against cervical cancer and typhoid fever  insect cells and suggested administration of recombinant baculovirus containing the HPV-16 L1 gene as a prophylactic vaccine and for diagnostic tests  in both mouse and rabbit challenge models . Also, tE. coli represent an economical alternative to (VLP)-based prophylactic vaccines against HPV-16 and 18 (Purified L1 capsomeres expressed in 6 and 18 . Schädli6 and 18 . Licensi6 and 18 . A novel6 and 18 . It is i6 and 18 .The safety of DNA (naked) is relatively higher. They are stable and lucrative due to ease of production and they have got application in sustaining expression of antigen in the cells at greater level –152. AddMycobacterium tuberculosis Hsp70 fusion DNA vaccine and introduce as candidate therapeutic tumor vaccine  as an adjuvant elicited IFN-γ responses and cytolytic effector CD8 T-cell responses . Recentl vaccine . Another vaccine . VGX-310 vaccine , 163. Fi vaccine .in vivo) in the surrounding. Nevertheless, there may be enhancement of potency of DNA vaccines  by making DNA or the encoded antigen as the target to antigen presenting cells (APCs) and along with this, modification of the feature of APCs (antigen expressing) can boost immune response induced by the vaccine  DNA vaccines show low immunogenicity. The DNA further lacks the capability (intrinsic) of amplification or nature of spreading to the cells  of Clostridium thermocellum elicited a protective response with a yield of 100 mg/kg biomass with 99% purity after metal ion chelation and gel filtration purification (Expression of an HPV-16 L2 epitope fused to the N- and C-terminus of the coat protein of potato virus X (PVX CP) in transgenic a et al.  and repoa et al. . Anothera et al. . A circu vaccine . A N. befication . Transplfication , 180.in vivo , grades 2 and 3 vulvar intraepithelial neoplasias (VINs), grades 2 and 3 vaginal intraepithelial neoplasia (VaINs), and grades 1, 2, and 3 anal intraepithelial neoplasia (AINs). Gardasil is also administered to boys and men 9 to 26 years of age for the control of anal cancers induced by HPV-16 and 18, genital warts (condyloma acuminata) induced by HPV-6 and 11, dysplastic lesions induced by HPV-6, 11, 16, and 18, and grades 1, 2, and 3 AINs.A tetravalent vaccine targeting HPV known as Gardasil or Silgard  was licensed in 2006 and is composed of 120 μg of antigen per dose , adjuvanted with 225 μg of aluminum hydroxyphosphate sulfate , 193. ThAccording to a FUTURE I and FUTURE II analysis, the efficacy of cervical and vulvar neoplasias and grade I VINs are 30, 75, and 48% respectively, and 83% for condyloma acuminate . CurrentTrichoplusia ni [Hi 5]) infected with recombinant baculovirus HPV-16 and 18 L1 and adjuvanted with 500 μg of AS04, which consists of 50 μg of 3-O-deacetylated-4-monophosphoryl lipid A adsorbed into 500 μg of aluminum hydroxide  was licensed by the U.S. Food and Drug Administration (FDA) for administration to females 10–25 years of age  and has ydroxide . It consydroxide , 200. Thydroxide . The vacydroxide , 197. Thydroxide , 203. A ydroxide . Currentydroxide , 206. Onydroxide .Gardasil 9 , a 9vHPV (6/11/16/18/31/33/45/52/58) VLP-based vaccine provides protection against five additional oncogenic types  and was approved by the FDA on December 10, 2014, for administration to females aged 9–26 years and males aged 9–15 years . GardasiBordetella pertussis binding to specific CD11b+ antigen presenting cells (APC)  known as GTL001 is available. It is a fusion of HPV-16 E7 as well as HPV-18 E7 and detoxified adenylate cyclase (CyaA) of ls (APC) . The intls (APC) , 219. Thls (APC) .The safety as well as efficacy of the 9-valent vaccine providing protection against HPV types 6, 11, 16, 18, 31, 33, 45, 52, and 58 has been proven recently. This will help further in reducing the incidences of infection due to HPV along with the cancer related to the virus. Moreover, a herd immunity is generated for providing indirect protection to individuals that are unvaccinated . In boysversus 0.4 per 100,000 non-vaccinated subjects , photodynamic therapy (PDT) is an option already approved by Food and Drug Administration (FDA) –258. PDTHexaminolevulinate-mediated PDT has been found to be safe for treating cervical intraepithelial neoplasia (CIN) , 263. ImFor treating cervical intraepithelial neoplasia, the efficacy along with safety and acceptability of cryotherapy is well documented. The cure rate with cryotherapy is very high . In low 2O3) and carboplatin target transcription factors AP-1 and NF-κB, play important roles in the expression of HPV oncoproteins E6 and E7  . At presex.html, ]. Xinfunex.html, .in vitro as well as in vivo, the activity of interferons (IFNs) against HPV is well proven. Due to the anti-viral activity, anti-proliferative nature and capability to generate host immune response, interferons are quiet noteworthy for treatment of HPV  on infection due to HPV is well known. This particular medicine has been found to interfere with DNA expression of HPV in genital warts. Youdujing is another medicine that is responsible for reversion of the cervical lesion function in patients having a greater risk of infection due to HPV  which are used for preventing as well as treating cancer in relation to HPV. The inhibitory effect of Chai Hu . It can eradicate HPV from cultured cells. This drug has been used to treat several malignancies with few side effects, even with a transiently increased serum creatinine level. Three different formulations containing 1 mg/mL ranpirnase were applied topically to genital or anal warts of male volunteers, and it was moderately tolerated in these patients with a mean healing time 30 days . HPV-11 in vitro and in vivo experiments  only on tumor cells . As far eriments . Howevereriments . It is feriments .For clearance or suppression of infection due to HPV immunologically in a normal manner, the usefulness of localized immunomodulation has already been proven. The Aldara cream contains an active agent called imiquimod (a Toll like receptor-7 agonist) and this cream can be used topically. There is release of interferons (type I) along with proinflammatory cytokines due to activation of macrophages, dendritic cells along with keratinocytes by imiquimod , 316. Imvia catheter into bladder with tumor mass in several cycles over several months reduces the otherwise high recurence and progression rates of bladder cancer by causing stimulation of effective immune response against cancer cells (American Cancer Society). Cytokines (such as interferons) enhance immune system aganst cancers. Therapeutic antibodies, nakedly or conjugated (loaded) with radioisotope, toxin, or drug, kill directly the cancer cells. Some antibodies recognizes molecule which is highly expressed on cancer cells such that the cells are better seen by the effector immune system for antibody-dependent cell-mediated cytotoxicity (ADCC) or complement-mediated cell lysis. Anitbody binding to cell surface receptor can also cause inhibition of downstream cell signaling and prevent cancer cell shading of decoy to increase effectiveness of the host immune system. Monoclonal antibodies in the form of bispecific T cell engager (BITE) bind to cancer cell and effector T cell simultaneously and bring them into vinicity for increasing the effector cell effectiveness. Antibodies to immune checkpoint molecules on effector T cells such as programmed cell death-1 (PD1) and cytotoxic lymphocyte antigen-4 (CTLA-4) restores the effector T cell activity which is suppressed by ligands highly expressed on the cancer cells leading consequently to not only cancer cell death, but also death of regulatory T cells in the tumor environment. Anti-PD-1/OX40 monoclonal antibody treatment increased CD4+ and CD8+ cells and decreased immunosuppressive CD4+FoxP3+ regulatory T (Treg) cells . Substances used in the cancer immunotherapy include non-specific immune stimulators, cytokines, monoclonal antibodies and adoptive or engineered autologous immune cells, mainly T cells. The same strategies canbe applied for treatment of HPV-induced cancers. Bacillus Calmette-Guerin (BCG) given g) cells . Chimerig) cells  and cytog) cells  are effeg) cells . Anti-HPg) cells .Cimetidine has been found to be useful for papillomas of conjunctiva (in case of ocular surface infection due to HPV). It augments the immune system by inhibition of T suppressor cell function and enhances delayed-type hypersensitivity (DTH) . One intvarious therapies available to treat HPV are summarized in Table An overview on various therapeutic approaches available for treatment of HPV is depicted in Figure Last but not the least this review is a unique/comprehensive review which highlights the various advances in developing vaccines (both prophylactic and therapeutic) and therapeutic regimens along with recent patents coverage on drugs, vaccines and therapeutics against HPV that will help the scientists and medical practitioners to prevent, treat and facilitate the eradication of the malignancies in relation to HPV in an effective and more promising manner. Moreover, the mind of researchers will be more innovative to combine therapeutic vaccines against HPV with radiation and chemotherapy for designing better control measures along with adopting advanced therapeutic approaches to counter HPV infections and the associated cancerous conditions. The advanced information on HPV vaccines and therapeutics presented in this review compilation along with carrying out more researches in futuristic prospects in the right directions would pave way to design and develop suitable prophylactic and therapeutic vaccines, drugs and treatment modalities delivering clinical outcomes in an improved manner and to combat HPV and its cancerous conditions effectively at global level.Aloe vera, turmeric, Citrullus colocynthis, hard sea salt, myrrh, and garlic to treat HPV. More clinical trials are needed to be conducted to explore the utility of topical microbicides. Studies through mathematical modeling have predicted that vaccination can maintain the antibody levels  at a much higher level than the level reached due to natural infection for a period of minimum two decades after vaccination. So it can eliminate the requirement of booster dose for a long period. Derivation of the consensus sequence for E6 and E7 genes, followed by codon optimization of these genes and their use as immunogen will pave the way for effective prophylactics. Three commercially available prophylactic vaccines show sufficient efficacy; however, attempts to develop next-generation vaccines that are inexpensive, effective, stable, and that show broad cross-neutralizing immunity are in progress. Recombinant vaccine immunogens based on transgenic plants are an attractive and potentially affordable alternative to vaccines by injection. For example, edible plants can be grown locally and distributed easily without special training or equipment. Approved HPV vaccines based on recombinant VLPs of important high-risk HPV L1 major capsid antigen are effective in controlling HPV infections, but do not have therapeutic applications or protect against cutaneous infections. There are studies to evaluate alternative approaches to deliver current vaccine in a safer and affordable way. For example, microneedle deliveries of lyophilized HPV pseudovirions are thermostable and have been tested in a murine model. Also, acceptance of HPV vaccines has been hindered by many factors associated with place of residence, culture, and economics. Administration of these vaccines has been virtually non-existent in developing countries, mainly because of their extremely high costs and the technical challenges of vaccination, which require multiple doses over a 6-month period (This review highlights the advances in designing prophylactic and therapeutic vaccines as well as treatment regimens against human papilloma virus (HPV) to encourage the development of effective vaccines and therapies against this important disease. For prevention of HPV infection, the use of topical microbicides has been explored widely. For instance, like the use of carrageenan to prevent genital infection due to HPV, several patent applications for formulations are pending which comprise several natural components, such as h period . Also, rE. coli represent one important approach to reducing manufacturing costs. Studies in animal models have reported that HPV capsomeres alone induce lower antibody titers than VLPs. Therefore, this approach will require further optimization for increased antibody titers. However, the pentamers can be lyophilized for greater thermostability, suggesting the potential for formulations that can be shipped and stored without refrigeration  has been observed, without affecting the cervical tissue morphology. Topical application of few cytotoxic compounds including podophyllin, arsenic trioxide, carboplatin or trichloroacetic acid also has been suggested to remove genital warts. Interferons and immunomodulators like imiquimod also have been tested for their efficacy in removing genital warts and found useful. Antivirals like cidofovir, ribavirin, and acyclovir have been tested against HPV, but cidofovir has been used widely, and since it can be administered through inhalation, additional benefits are present for using it in clinical applications. Ranpirnase RNase enzyme cleaves dsRNAs, and in the form of a topically applicable ointment, it has proved effective in treating anal warts. The treatment modules encompassing the use of antisense RNA are still in infancy but have shown some promise in therapeutic efficacy.For HPV vaccines, pre-adolescent girls are the primary target but evaluation of the cost effectiveness of vaccination of other groups needs to be done. For certain candidate vaccines entering phase III trial, a viable vaccine (prophylactic) against a few types of HPV may become available in a less period of five years. For complementing conventional therapy designing of the therapeutic vaccines (under investigation) are done mostly. However, the extent of benefit or the cost at which such benefits can be offered to the women are not yet clear. Clearing of the earliest stage of infection due to HPV by therapeutic vaccines is possible but is less developed. Certainly such vaccines hold promises to reduce the suffering as well as cost of treatment associated with disease of the cervix. For precancerous lesions, it is, however, crucial to continue the process of development of accurate screening as well as treatment plans and programs as there is forward movement of the process of vaccine development.No one can deny the fact that vaccination against HPV has proven to be a landmark in the history of prevention of cancer. The incidence of HPV-induced cervical cancer will reduce drastically if adolescent girls are immunized, and this must be the priority not only in the industrialized world, but also in developing nations where it is sometimes impossible to detect the precancerous lesions at an early stage. It is however unfortunate that even in the developed nations of the Western world, the screening to detect cervical HPV-induced cancer is not performed on a regular basis. In this context, implementation of immunization of girls in every nation universally is of immense benefit. To succeed in such aspect of prevention of HPV infection especially in women, convincing the parents as well as their daughters is a top priority. Similarly, vaccination in homosexual males is of utmost relevance concerning prevention of HPV in the community. But to assess the sexual orientation in every male is somewhat difficult for which universal male vaccination is essential. With the usage of efficient vaccination and application of potent therapeutics, the effective elimination of the disease is expected and in fact combinations of several therapies have helped people in getting rid of this ailment. For all these reasons, it is necessary for the public health authorities to remain proactive and at the same time innovative methods will also be required for financing introduction of HPV vaccine and advancing the development of potent therapeutics.All the authors substantially contributed to the conception, design, analysis, and interpretation of data, checking and approving the final version of the manuscript, and agree to be accountable for its contents. MD, KD, SH, and RT initiated this review compilation. SC, RK, AM, MP, and DK updated different vaccines and therapies. RK designed table. KK designed the figures. KD, HI, MD and WC reviewed, analyzed and edited.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.