During the COVID-19 pandemic many work tasks are being done remotely through digital meetings, including PPI in research. Yet, some PPI activities have been paused or cancelled altogether during the pandemic. In this commentary, we share our insights from observing digital meetings with researchers and public contributors, representing vulnerable groups. Additionally, we discuss how remote PPI activities can be understood and improved.As part of a PPI evaluation project, live observations were conducted by two trained observers, using a semi‐structured observation protocol developed to objectively assess aspects of group dynamics in PPI research meetings with public contributors with experience of seeking refuge and parents facing economic hardship. This project’s data collection is ongoing and the insights in this commentary is based on the observers’ discussion. We discuss these insights through the lens of the Media Richness Theory, stating that the choice of media we communicate through should be guided by what kind of information we want to communicate to each other. The more complex the information is, the richer the media tool needs to be. For example, information in a text message is more easily misinterpreted than information given in person. This is because meeting in person gives us more information, for example through body language and tone of voice. Based on our experiences from observing digital research meetings, we give suggestions on how to improve digital meetings with public contributors. A few key points are: actively choosing which media to use; being prepared to guide contributors to the chosen media in a way that is suitable for them; and the increased importance of the person chairing the meeting to actively include all participants.We reach the conclusion that digital meetings with public contributors is possible, but that researchers need to make a commitment and actively work to solve practical issues. Finally, the format and structure of digital meetings should be co-created together with public contributors. During the COVID-19 pandemic many work tasks are conducted remotely through digital meetings, including PPI in research. Yet, some PPI activities have been paused or cancelled during the pandemic. In this commentary, we share our insights from observing digital meetings with researchers and contributors with experience of seeking refuge and parents facing economic hardship, and discuss how remote collaborations can be improved. This is discussed through the lens of the Media Richness Theory, stating that the choice of media we communicate through should be guided by what kind of information we want to communicate to each other. The more complex the information is, the richer the media tool needs to be. For example, information in a text message is more easily misinterpreted than information given in person, since meeting in person gives us more information, for example through body language and tone of voice. Based on our experiences from observing digital research meetings, we give suggestions on how to improve digital meetings with public contributors. Some key points are: actively choosing which media to use; being prepared to guide contributors to the chosen media in a way that is suitable for them; and the increased importance of the person chairing the meeting to actively include all participants. We reach the conclusion that digital meetings with public contributors is possible, but that researchers need to make a commitment and actively work to solve practical issues. Finally, the format and structure of digital meetings should be co-created together with public contributors. This commentary sets out to discuss insights on remote Patient and Public Involvement (PPI), conducted through digital meetings, gained from observations in a PPI evaluation project. PPI in research, here defined as the active research partnership between patients and/or representatives of the public and researchers , has in During the ongoing pandemic, many workplaces have moved from in-person meetings to remote work through digital meetings in line with restrictions to minimize spread of the corona virus. Before the pandemic most work places, including research teams, did not have the practical experience of remote work to the extent they do now. Our experiences indicate that many research teams have discovered that research activities often can be done remotely. The fast development of digital tools, even before the pandemic, has most likely facilitated the transition to remote work.As with other work meetings, we can expect changes in PPI activities as consequences of the pandemic. Some activities might have been postponed or cancelled entirely, while other activities have been conducted remotely, i.e. not through in-person meetings but through video conferences or other digital communication tools. When attempting to find literature for this commentary only one example of digital PPI activities could be identified. In this report, researchers evaluated a digital collaboration forum which aimed to facilitate remote PPI. The forum was experienced as functional, feasible and acceptable, but users suggested it should be less researcher-focused and better meet the needs of public contributors . There aEven though there are clear benefits to remote work, like aspects on health and climate , we needsocial presence, i.e. if participants perceive others as psychologically present. In general, richer media formats enable higher social presence and are considered more personal [However, collaboration is not restricted to transmitting information, but factors such as social interaction and group dynamics are highly affecting collaboration . One spepersonal . One stupersonal . Anotherpersonal .The insights in this commentary stem from our experiences in an ongoing PPI evaluation project. In this project, we observe PPI research meetings in other research projects. Through the recruitment efforts in this study, it has become clear that researchers are postponing or even canceling PPI activities during the pandemic—especially when involving representatives from vulnerable populations, such as the refugee population. We would like to argue that this is unnecessary. Although exploring remote PPI conducted through digital meetings was not the focus of the mentioned PPI evaluation project, conducting these observations has led us to the conclusion that digital remote collaborations can be achieved with contributors from vulnerable groups—with adjustments. We think it is essential to try to maintain PPI activities throughout the projects, as important decisions are taken even during the pandemic. However, when conducting remote PPI through digital meetings, we need to be aware that digital communication, such as during video conferences, poses a different set of challenges than in-person communication. Additional efforts will be required from the researchers, to reach the same level of input, information sharing and collaboration.. In this project, we conducted behavioural observations of PPI research meetings conducted within other research projects, involving vulnerable groups. The observed research meetings were therefore held as part of three separate research projects; two refugee child mental health trials [This commentary is based on observations of PPI research meetings, conducted as part of the ongoing PPI evaluation projecth trials , 17, whiThese PPI research meetings were observed, using a semi‐structured observation protocol, developed to objectively assess aspects of group dynamics in PPI research meetings . The obsInitially, all observations within the PPI evaluation project were conducted in in-person meetings, but the pandemic forced meetings to rely on digital solutions. We then considered whether it was possible and meaningful to use the observation protocol in digital meetings with PPI representatives. Even though the group dynamics can be expected to change in a digital room, compared to in-person, we were uncertain whether there would be enough observable interactions between meeting participants to be able to assess the PPI activity. We decided to test the feasibility of the observation protocol in digital research meetings with PPI contributors, followed by a discussion between the observers on each item, whether it could be observed or how observations differed. From this, we reached the conclusion that the observation protocol can be used in digital meetings. In addition, the observers discussed and summarised the observed differences between in-person PPI meetings and digital PPI meetings, contributing to this paper.We observed a reduction in the number of spontaneous positive interactions in the digital meetings. This could be observed as an increased silence before the meetings had officially started, a time in in-person meetings that is often used for spontaneous interactions between individuals. We observed an increase in the amount of direction from the meeting chair, indicating that they had to work harder to facilitate positive interactions. Additionally, interactions were often interrupted by new meeting participants joining the digital meeting. Previously, less structured elements of the research meeting, such as coffee breaks, offered observable insights to the PPI dynamics, whereas the digital meetings that have been observed so far have not included this aspect. Instead, breaks were taken individually away from the screen. This removes the possibility to observe these moments and is likely to offer less opportunities for spontaneous interactions. In addition, we saw a difference between groups that had met in-person extensively prior to working remotely and those that were formed shortly before the transition. This suggests that it might be an increased problem if the group does not have an established in-person relationship before starting to work remotely.When observing digital meetings, non-verbal cues were more difficult to observe and interpret. This was both related to the limited view of other meeting participants in digital video meetings, which is limited to the face or upper body, with variations in video quality, and that meeting participants cannot turn towards each other as they would have in a room. In an in-person meeting, subtle gestures like making eye contact or turning in a person’s direction can signal an interest in their opinion and include them in the discussion. In a digital meeting, these discrete cues are more difficult to pick up on and we rely more on verbal communication. We observed less non-verbal invitations to including another meeting participant in the discussion, which we interpret as related to the digital format. Instead, more direct questions were asked and the meeting chair was more active in guiding the discussions, which was related to more structure and less dynamic discussions.Different forms of linguistic barriers to participation might increase in digital meetings. In the observed meetings, some contributors did not speak Swedish, the majority language of the context, thus interpreters were hired. Selecting suitable interpreters had required substantial considerations when organizing in-person meetings. When comparing observations of in-person meeting and digital meetings, the challenges with language interpretation seemed to be exacerbated in a digital meeting. Larger meetings, ten participants or more, in particular increased the obstacles for good language interpretation. This led one project team to opt for smaller meetings, in which one or two members of the research team met with PPI contributors. In another observed meeting, contributors were considered proficient enough in the majority language when meeting in person, but in the digital format we observed signs that communication was more challenging. For example, the contributors participated less in discussions and asked for questions to be repeated more often. In relation to this, in digital meetings it might be more difficult for the meeting chair to pick up if contributors miss out on information due to linguistic barriers or researchers’ jargon, and thus more difficult to solve potential linguistic issues.One important aspect for public contributors’ ability to contribute to a digital meeting is how comfortable they feel sharing their input in a meeting. We have observed that public contributors share less information in digital meetings, and this can be related to that it might be more difficult to claim your space in a digital room. When using video conferencing platforms, taking turns to speak is more pronounced, which means less spontaneity. Additionally, participants always need to speak to the entire group, which can be discouraging and might cause people to hesitate before speaking up. One project team opted for smaller meetings with the contributors and just a few researchers, which seemed to alleviate this issue.The role of the meeting chair is always important to guide the meeting, facilitate discussion and make sure meeting participants are included. However, in digital meetings we have observed that the meeting chair tends to take on a more active and directive role, and appears to have an increased responsibility for the active inclusion of all meeting participants. Not only has the meeting chair had more speaking time in the observed digital meetings, they have more actively guided the discussion and invited meeting participants into the discussion more often. More specifically, the meeting chair, and sometimes other researchers in the meeting, has invited the public contributors to share their views more often.In many video conferencing systems, it can be difficult to see all meeting participants at the same time, especially in larger meetings. When a person is quiet in a digital meeting, the other meeting participants do not necessarily notice their absence the same way they would have in a room. This leaves the meeting chair with larger responsibility to actively include all meetings participants in discussions.Opting for a video conference instead of a phone meeting provides more information sharing between meeting participants, as we can see each other’s faces. In the observed digital meetings, most meeting participants had their cameras turned on. When meeting participants instead had their camera turned off during a meeting, we observed that they were less likely to be asked for their opinion and actively included in the meeting.However, even with cameras turned on we could observe challenges with the limited view of each other’s faces in digital meetings. One issue is screen sharing. This is a useful feature allowing all participants to look at the same view on the screen. However, when someone in the meeting is screen sharing, only a limited number of meeting participant faces are visible. In many of the observed meetings, screen sharing was used for an extensive part of the meeting, which limited participants’ possibility to see each other. A second issue is that the number of visible participants varies depending on the tool. For tools that displays very few faces at a time, the meeting participants who are not the most active speakers tend to disappear from the screen. We observed that this might lead to them being less likely to be invited into the discussion. Finally, a third issue is that many video conferencing platforms display the participants’ own camera image and we are not used to seeing our own faces in this way during meetings, which seemed to be distracting for some meeting participants.In this article, we share our experiences from remote PPI conducted through digital meetings with contributors representing refugee parents and youth, and parents with experience of economic problems. Even though exploring remote PPI conducted through digital meetings was not an original aim of our research project, we believe that our insights during meeting observations can be of use for researchers working with involvement, including with vulnerable groups, and who are considering remote collaborations. We argue that digital PPI meetings are possible, when researchers commit to making adjustments in their preparations.The need for remote PPI has been highlighted even before the pandemic, as it can open up for involvement for contributors who experience barriers to on-site meetings such as those who are unwell or have caring responsibilities . Remote One important aspect to consider is how long the team has worked together and how well the meeting participants know each other. For a new team, the communicated information should be richer, as participants have an increased need to understand the social aspects as well as the actual meeting topic. Therefore, the choice of media must reflect this and a richer media with a good ability to convey social presence  is to prOur insights portrayed a few potential problems with digital meetings. These included increased linguistic barriers and difficulties to claim space in a digital room, which both risk leading to contributors becoming “invisible” to others in the meeting. We also observed that digital meetings seem to offer less spontaneous positive interactions, which we believe is important for getting to know each other and building a good team , 18. HowIn digital PPI meetings the meeting chair has an important role, possibly more important remotely than in in-person meetings. Our insights include that in digital meetings, the chair tends to, out of necessity, take a bigger and more directive role. This might be related to participants in video meetings feeling less comfortable with the format, as they are new to it, and therefore hesitate to speak up. It could indicate a need for more guidance on the expectation on and the structure of the meeting, both before and during the meeting. The meeting chair has an important role in setting ground rules that allow for all meeting participants to be included, both those that are comfortable with and those who are new with the media. One example of this is that it might be easier to use the “raise hand” function than taking the word spontaneously. The meeting chair can also advise meeting participants on how to use the screen effectively in digital meetings, for a richer interaction; keep their cameras on, minimise screen sharing, and turn off the self-view to avoid contributing to “Zoom fatigue” . AdditioRecently, we have experienced that researchers who planned involvement in their projects have cancelled or postponed PPI activities, especially when involving groups with perceived barriers to involvement, such as not speaking the majority language. In one of the observed projects with contributors in the same circumstances, which included an illiterate contributor, successful involvement was possible, but detailed preparations were essential. One example of these preparations was the information material, translated to the contributors’ preferred languages, was distributed by email and by ordinary mail several weeks before the first digital meeting. The information included detailed instructions on how to download the video conferencing tool, along with how to contact the researcher for technical support if required. For some contributors, reminders were sent with an offer of guidance over phone, in their preferred language. As the research team had established email contact with all contributors—in one case with the help of a family member of a contributor—an email with guidance to join the meeting was sent hours before the meeting started. In addition to this, the interpreter was available before the meeting started for assistance with practical issues. These preparations were successful and all contributors joined the meeting. Comments from contributors included that it was challenging to access the meeting, but they were proud that they had solved it. How familiar contributors are with digital meetings is likely to differ both in and between groups. This is not something we have explored in this study; however, it appears to be important that researchers are prepared to guide contributors to the first meeting.A recommendation for further research is to explore the experiences of both researchers and contributors involved in remote PPI activities. Additionally, involvement of contributors early in the process is preferable , 22 and Involving contributors from vulnerable groups should not be postponed due to the COVID-19 pandemic. With planning and adjustments, meaningful and inclusive remote involvement is feasible.Take an active decision on which digital media tool to use, depending on the needs, preferences and previous knowledge of the meeting participants, as well as on the meeting topic and the tools’ technical features.Prepare to guide your contributors to the chosen media in a way that is suitable for them. Plan for this ahead of time and be available for technical support.The meeting chair role is of increased importance in digital meetings, in order to facilitate an allowing atmosphere and social interactions, as well as an active inclusion of all meeting participants. The meeting chair needs to be aware of this and prepared for this responsibility.Seeing each other’s faces is important in digital meetings. The meeting chair should facilitate this through encouraging meeting participants to keep their cameras on and minimise screen sharing.Co-create the format and structure of meetings together with your meeting participants. The meeting participants are likely to have suggestions on how to make meetings more inclusive and meaningful. Be creative and open to new suggestions for collaborative work.Working remotely through digital PPI meetings are different to in-person meetings and involves a set of challenges. However, digital meetings with public contributors are possible, as long as researchers make a commitment and work together with contributors to solve practical issues. In this article, we share our insights from observations with the intention for them to be useful for other research teams. Our digital meeting observations are ongoing with the aim to explore how to conduct PPI in a meaningful way, which may include further insights on conducting PPI digitally; yet, given the shift to remote working that has been seen over the last few years and accelerated by the pandemic restrictions, further research directly addressing how to conduct PPI remotely is encouraged.


Human papillomavirus (HPV)-attributed cancers are preventable, yet HPV vaccination rates severely lag behind other adolescent vaccinations. HPVcancerFree (HPVCF) is a mobile health  intervention developed to influence parental HPV vaccination decision making by raising awareness of HPV, reducing HPV vaccination barriers, and enabling HPV vaccination scheduling and reminders through a smartphone app. Evaluating the user experience of mHealth interventions is a vital component in assessing their quality and success but tends to be underreported in mHealth intervention evaluation.We aimed to evaluate the user experience of HPVCF, an HPV cancer prevention app designed for a pediatric clinic network, using mixed methods data collected from log files, survey measures, and qualitative feedback.Study data were evaluated from parents in a large US pediatric clinic network using HPVCF in the treatment study condition of a group randomized controlled trial. Log data captured HPVCF retention and use. Postintervention rating scales and items assessed HPVCF utility, usefulness, understandability, appeal, credibility, and perceived impact. Overall quality was evaluated using the user version of the Mobile Application Rating Scale (uMars). Open-ended responses assessed parent recommendations for HPVCF enhancement.The 98 parents were mainly female , 41 (5.67) years of age, college educated , and White and non-Hispanic  and had private health insurance for their children . Parents used HPVCF 197 times, with the average visit duration approximating 3.5 minutes. The uMARS app quality score was positively skewed (4.2/5.0). Mean ratings were highest for information (4.46 [SD 0.53]) and lowest for engagement (3.74 [SD 0.69]). In addition, of 95 parents, 45 (47%) rated HPVCF as helpful in HPV vaccination decision making and 16 (17%) attributed HPV vaccine initiation to HPVCF. Parents reported that HPVCF increased their awareness , knowledge , and HPV vaccination intentions . Most of the 98 parents rated the 4 HPVCF components as useful (72-92 [73%-94%]). Parents also agreed that HPVCF is clear , accurate , and more helpful than other HPV vaccine information they had received  and that they would recommend it to others . In addition, parents suggested ways to increase awareness and engagement with the app, along with opportunities to enhance the content and functionality.HPVCF was well received by parents and performed well on indicators of quality, usefulness, utility, credibility, and perceived impact. This study contributes a multimethod and multimeasure evaluation to the growing body of literature focused on assessing the user experience of patient-focused technology-mediated applications for HPV education. Human papillomavirus (HPV) is a sexually transmitted infection that causes anogenital cancers and oropharyngeal cancers in men and women . HPV is National samples in the United States have found that 28% of parents have refused or decided not to get the HPV vaccine for their child and 8% of parents have delayed or put off getting the vaccine . RefusalFactors at the individual, provider, and clinic levels have been positively associated with HPV vaccination outcomes. Interventions that address parental psychosocial factors , provider behavior , patient-targeted systems , and provider-targeted systems  can positively influence HPV vaccination rates . MultimeThe use of parent- and patient-focused apps to promote HPV education and vaccination is on the rise -14. MobiHPVcancerFree (HPVCF) is an iOS- and Android-compatible smartphone app designed for parents of patients aged 10-17 years who have not initiated HPV vaccination. HPVCF is part of a multilevel intervention aimed at increasing HPV vaccination initiation and completion rates in a large US pediatric clinic network . HPVCF wHPVCF was created using user-centered design principles and Intervention Mapping, an evidence- and theory-based systematic framework for developing behavior change interventions . The desHPVCF contains 4 self-tailored components: (1) HPV A-Z, a compendium of 9 content domains providing facts about HPV and the HPV vaccine; (2) Bust-a-Myth, 7 educational modules, including peer and health care provider testimonials addressing the most salient HPV vaccination barriers; (3) Notes 4 Doc, a medium to facilitate communication with health care providers about the HPV vaccine; and (4) Get the Vax, a feature to schedule HPV vaccination appointments and receive tailored reminders . There wThe purpose of this study is to evaluate the user experience of HPVCF, an HPV cancer prevention app designed for a pediatric clinic network, using mixed methods data collected from log files, survey measures, and qualitative feedback.Study data were drawn from parents who used HPVCF in a group RCT assessing HPVCF effectiveness within a large pediatric clinic network in Texas, USA, and completed a postintervention experience survey . The stuEligibility for the study included (1) having a 10-to-17-year-old child who was a patient in the clinic network, (2) having a child that had not initiated HPV vaccination, and (3) the ability to speak and write in English. Parents who had an eligible child were invited to participate in the study via patient health record portal invitations, flyers in the clinic waiting rooms, and posts on the clinic network Facebook page. Recruitment for the study took place on a rolling basis from September 2017 to September 2018. Each parent participated in the intervention for 5 months between September 2017 and March 2019, depending on when they were recruited and enrolled. Parent completed a presurvey before they were given access to the intervention and a postsurvey, which included an experience assessment, at the conclusion of their intervention time frame.HPVCF use data were gathered over the course of the 5-month intervention from log files, including total number of visits, number of visits per participant, actions (viewing an app page or link) per visit, and visit duration. A back-end data capture system (Matomo)  collecteHPVCF user experience was assessed with a postintervention survey using a quality rating scale, survey items, and an open-ended response item for recommended enhancements. The survey items included utility, perceived impact, component usefulness, clarity, credibility, and motivational appeal.App quality was assessed by the user version of the Mobile Application Rating Scale (uMARS) . uMARS iTwo utility items assessed whether HPVCF information helped parents decide to get the HPV vaccine for their child  and whether parents got their child the HPV vaccine as a result of using HPVCF . These items were adapted from prior surveys used with patient-focused digital behavior change interventions in clinic and school settings -43.Perceived impact was assessed with 5 items on user perceptions of HPVCF. These modified perceived impact uMARS items measured perceptions of change in awareness of HPV and the HPV vaccine, knowledge of HPV and the HPV vaccine, attitudes of HPV and the HPV vaccine, intentions to get their child the HPV vaccine, and communication with the child’s pediatrician about the HPV vaccine. These items were evaluated on a 4-point scale with response options “strongly disagree,” “somewhat disagree,” “somewhat agree,” and “strongly agree” . For anaUsefulness was assessed using ratings of 4 HPVCF components  with response options “did not use,” “not very useful,” “somewhat useful,” “very useful,” and “do not recall.” For analysis, “very useful” and “somewhat useful” were collapsed into an “agreement” category.Clarity was assessed with a single item on whether the goal of HPVCF was clear .Credibility was assessed using 1 rating of accuracy of HPVCF content  and 1 rating of trustworthiness of HPVCF information .Motivational appeal was assessed using 3 ratings: whether parents would use HPVCF again , a comparison of the helpfulness of HPVCF content against other HPV content received , and the extent to which parents would recommend HPVCF to others who might benefit from it . These items were adapted from prior surveys used with patient-focused digital behavior change interventions in clinic and school settings -43.Recommended enhancements were solicited from an open-ended question, “What would make the HPVCF app more appealing so that parents would want to use it?” adapted from prior surveys used with patient-focused digital behavior change interventions in clinic and school settings -43.Parent sociodemographic variables were gathered from preintervention survey items at the start of the 5-month intervention. The parent sociodemographic variables included age, number of adolescent children, sex, race, ethnicity, education, child’s health insurance status, and baseline HPV vaccination intention.In total, 168 parents completed the postintervention survey, of whom 98 (58.3%) were included in this experience analysis as they also downloaded and used the intervention , college graduates , and White and non-Hispanic  and had private health insurance for their children ; see Parents visited HPVCF 197 times during the study period . Most paThe uMARS app quality rating was 4.2/5.0 . The uMAOverall, 45 (47%) of 95 parents rated HPVCF as helping them decide to get their child the HPV vaccine, and 16 (17%) responded that they got their child the HPV vaccine as a result of HPVCF .Most parents  agreed that HPVCF increased their intentions to get their child the HPV vaccine. Parents reported that HPVCF positively impacted their awareness , knowledge , and attitudes  about HPV and the HPV vaccine and encouraged them to discuss the HPV vaccine with their child’s pediatrician ; see Most parents rated the 4 HPVCF components as useful . HPV A-ZThe majority of parents rated the purpose of HPVCF as clear  and that the information in HPVCF was accurate  and can be trusted . Parents also agreed that they would use HPVCF again , that it was more helpful than other information they had seen about HPV and the HPV vaccine , and that they would recommend HPVCF to others ; see Qualitative feedback gathered on how to improve HPVCF included themes of increasing awareness and engagement with the app and enhancing the content and functionality.Parents commented that they forgot to use the app after the initial download and needed a reminder from the app, pediatrician, or clinic to use HPVCF:It's been a long time since I used the app, so I don't remember if there was a function to remind the user in the future to make an appointment etc. That would prompt the user to reopen the app. I read all the information the first time I opened it and didn't open it again, so I've forgotten much of it now.Due to a lack of repeated engagement, some parents reported they had forgotten much of the information they had originally reviewed. Parents suggested improving engagement by having push notifications with HPV facts instead of having to open and use the app to obtain information. Further, to improve marketability, one parent recommended incorporating HPVCF content into a broader app that included topics outside of HPV.Parents also suggested making HPVCF more interactive and entertaining, especially by providing opportunities to engage and speak with adolescents about HPV and sexual health. To make HPVCF more adolescent friendly, parents suggested adding animations and games.To improve the content, parents suggested offering parent testimonials highlighting their struggle to decide to vaccinate and how they used HPVCF to make an informed decision:I think offering parent testimonials about their struggle to decide to vaccinate and how they used the info offered to help make an educated decision.Some parents were dissatisfied with the presentation of HPV’s long-term effects, expecting to see more in-depth information and studies about complications and side effects of the vaccine:This app, as a parent, did not give me the type of information I would want and need about HPV. I would prefer more information on the age of the vaccine. Credible studies completed. New research and side effects. More of that information would help. If the vaccine is less than 10 years old, I want more information on studies.Parents wanted a tailored reminder system that conveyed information regarding their child’s HPV vaccination status and recommendation:[I would suggest] some type of electronic reminder from the doctor to review the app. I downloaded the app for the survey, reviewed it, but then forgot about it. Maybe the doctor's office can send email to parents of 9-, 10-, and 11-year-old patients. Also, [a] reminder should have information on [the] child's status .Parents noted some issues with the available functionality, such as the app not storing their appointment information caused by usability issues with the design. For future iterations, parents suggested the ability to share information in the app with existing social media outlets:[It would be helpful if the app would] allow for flagging/sharing individual items to foster organic awareness through existing social outlets?This study evaluated the user experience of HPVCF, an HPV cancer prevention app designed for parents with children belonging to a large urban pediatric clinic network in the United States. Parents viewed HPVCF as having high quality, utility, and perceived impact. HPVCF quality ratings were robust (4.2) compared to quality scores of 2.4-4.6 for mHealth apps focused on prostate cancer risk , AlzheimInterestingly, 63 (66%) of 95 parents reported that they would use the app again, but log data indicated that 45 (46%) of 98 parents only used the app once. Triangulating these findings with information obtained in the qualitative feedback suggests possible reasons for this, including forgetting about the app after initial download, only using HPVCF on an as-needed basis, or no longer needing the app since it fulfilled its intended use after a single visit. Future iterations could be strengthened to help parents reengage by utilizing pediatricians and clinic staff to incorporate reminders as part of their standard communication. Exploring adjunct functionality that offers HPVCF information in more compact ways  may prove beneficial as most parents only looked at a few pages or links for a brief time (under 3.5 minutes).Parents perceived HPVCF as more impactful for increasing awareness and knowledge than in changing attitudes about HPV. Knowledge is necessary but not necessarily sufficient to elicit behavior change. Negative attitudes around HPV vaccine safety are particularly pervasive , and strImportantly, parent engagement with the intervention was low, with about 70 (41.7%) of 168 parents choosing not to use HPVCF, making it difficult to generalize results to the clinic network. The low engagement is partially a reflection of the real-world nature of the study and accompanying challenges of competing for attention in an open market. Future iterations might adopt a more assertive approach by having parents download HPVCF during clinic visits and having clinic staff be more involved in providing reminders for its use. Future studies can explore promotional strategies to motivate parents to use HPVCF.Additional limitations of this study should be considered. The intervention timeline did not include the back-to-school vaccination period  for many adolescent children, as the intervention took place on a 5-month rolling basis over the course of 1.5 years. This may have affected the parents’ decision to get their adolescents vaccinated. The 5-month intervention timeline also meant that some parents answered postintervention questions weeks after using HPVCF, possibly affecting their ability to accurately recall and report on some survey measures. A further limitation of the study was that the English-only content and the smartphone-based application may have excluded participation from parents with lower socioeconomic status or those who do not speak English. Although smartphone ownership among Americans is high , there are disparities between Americans who are college educated (93%) and those with a high school diploma or less (75%) , and heaAs digital technologies continue to evolve, they stand to provide a paradigmatic shift in how health education and health behavior research are conducted , but doiHPVCF was well received by parents and performed well on indicators of quality, usefulness, utility, credibility, and perceived impact. HPVCF contributes to a multimethod and multimeasure evaluation strategy for user experience, which remains underreported in mHealth apps.


Head and neck squamous cell carcinoma (HNSCC), especially oropharyngeal squamous cell carcinoma (OPSCC), has recently been found to be significantly associated with human papillomavirus (HPV) infection. The incidence of OPSCC has been increasing and surpassed the number of cervical cancer cases in the United States. Although HPV-associated OPSCC has a relatively better prognosis than HPV-negative cancer, approximately 20% of HPV-associated HNSCC patients show a poor prognosis or therapeutic response, and the molecular mechanism behind this outcome in the intermediate-risk group is yet to be elucidated. These biological differences between HPV-associated HNSCC and HPV-negative HNSCC are partly explained by the differences in mutation patterns. However, recent reports have revealed that epigenetic dysregulation, such as dysregulated DNA methylation, is a strikingly common pathological feature of human malignancy. Notably, viral infections can induce aberrant DNA methylation, leading to carcinogenesis, and HPV-associated HNSCC cases tend to harbor a higher amount of aberrantly methylated DNA than HPV-negative HNSCC cases. Furthermore, recent comprehensive genome-wide DNA-methylation analyses with large cohorts have revealed that a sub-group of HPV-associated HNSCC correlates with increased DNA methylation. Accordingly, in this review, we provide an overview of the relationship between DNA methylation and HPV-associated HNSCC. Head and neck cancer was the 7th most common cancer worldwide in 2018, with approximately 890,000 new cases and 450,000 deaths ,4. RemarHPV-associated OPSCC has different biological and clinical features from HPV-negative HNSCC ,11. A meTP53, CDKN2A, and PIK3CA, as well as in members of the NOTCH pathway, have been reported in HPV-negative HNSCC via genomic and transcriptomic approaches [TP53 and CDKN2A are very rare. However, somatic mutations in PIK3CA, E2F1, and TRAF3 have been reported [KMT2C), KMT2D, CREB-binding protein (CREBBP), and E1A-associated protein p300 (EP300), are also mutated in HPV-associated OPSCC [PIK3CA mutation and HPV genome mutation, has been reported in HPV-associated HNSCC [These biological differences between HPV-associated HNSCC and HPV-negative HNSCC are partly explained by the differences in mutation patterns. Frequent mutations in several genes, such as proaches ,17,18,19proaches ,21,22; treported , and chred OPSCC . In addied HNSCC ,26,27. Ted HNSCC ,26,27. OApart from mutations, epigenetic dysregulation is also a common pathological feature in human malignancy ,29,30,31Epigenetics was first defined in 1942 by Conrad Waddington  and is aDNA methyltransferases (DNMTs) can induce DNA methylation . They trDNMT1 [DNMT genes directly and recruits DNMTs to target genes, such as IL-4R and MT1F [Aberrant DNA methylation in cancers is associated with prior viral infections. As a result of host defense against the virus invasion, DNA methylation of the viral genome might be induced . HoweverDNMT1 ,53. In hand MT1F ,55.HPV is a small, circular, double-stranded virus that targets the basal layer of the epithelial cells ,56. In tHPV16 is approximately 7900 bp in size. It exists in the nucleus of infected cells as a circular episome. The HPV16 genome contains several genes that encode proteins that are transcribed following the differentiation of the infected cells ,62. The c-Myc (MYC) is also reported to recruit DNA methyltransferase 3 alpha (DNMT3A) [For example, wild-type p53 negatively regulates DNA methyltransferase 1 (DNMT1) expression by forming a complex with specificity protein 1 (Sp.1) and chromatin modifiers on the DNMT1 promoter in lung cancer . In HPV-(DNMT3A) , and the(DNMT3A) ,75,76 , ,78, CCNA [RASSF1 ), cellulnd CDH23 ,81,82,833 [ITGA4 ,84), celnd GATA4 ,85), andnd PTGIR ,86,87)  cases [BARX2 and IRX4 are hypermethylated and repressed in integration-negative tumors [RXRG, GHSR, CTNNA2, and ITGA4 are significantly correlated with HPV (+) status [RXRG methylation showed a significant correlation with a favorable prognosis. Kostareli et al. performed DNA methylation analysis using a human CpG-island tiling array for five HPV (+) and 10 HPV (−) HNSCC cases and reported that ALDH1A2, OSR2, GATA4, GRIA4, and IRX4 were significantly hypermethylated in the HPV (+) HNSCC samples [ALDH1A2 and OSR2, and high methylation of GATA4, GRIA4, and IRX4 were correlated with favorable prognosis.DNA methylation analysis of a small-sample cohort on a genome-wide scale has also been reported . Lechner+) cases . Parfenoe tumors . Nakagaw) status . The met samples . There wIn these reports, although some of the markers were shared among several cohorts, there were many cohort-specific DNA methylation markers. This observation is partly because of the small sample size and the difference in the methods used for the analyses, such as probe position or the selection of differentially methylated regions.NSD1 mutation. The other three groups were not precisely described. Taken together, these data suggested that at least HPV-associated HNSCC had a distinct DNA methylation pattern compared to HPV-negative HNSCC. However, the HPV (+) cases could not be further stratified because of the analysis of many HPV (−) cases in these reports.Recently, several comprehensive large cohort analyses have been reported . The CanCREBBP was significantly mutated in the group with increased DNA methylation.Ren et al. performed MBD-seq on 50 HPV+ OPSCC samples and 25 healthy mucosal tissues and identified 20 highly specific differentially methylated regions in HPV (+) OPSCC compare with normal mucosa . Ando etCREBBP and DNA-methylation subgroups in both of their cohorts and the TCGA dataset. Given these data, an HPV-associated OPSCC subtype with increased DNA methylation has only recently been discovered by two different research groups, although further analysis of the characteristics of this subgroup is needed  HNSCC cases from TCGA, Parfenov et al. reported that HPV-integration (−) HNSCC showed relatively higher methylation than HPV-integration (+) HNSCC. In addition, the DNA methylation status of HPV-integration (+) HNSCC is similar to that of HPV-negative HNSCC . This obIn HPV-associated cervical cancer, the TCGA performed DNA methylation analysis of 178 primary cervical cancers including 169 HPV (+) cases at a genome-wide scale using the Infinium 450 k bead array . HoweverThese data are consistent with the fact that HPV16-induced cancers, such as HPV-associated HNSCC, have two different types of HPV infection patterns—HPV integration (+) or HPV integration , as described previously herein. In this analysis, although the authors did not study the difference in DNA methylation pattern between the two infection patterns in HPV16-associated cancer, there is a possibility that the integration status changes the DNA methylation pattern in both HPV16-related cervical cancer and HNSCC.In HPV-associated HNSCC, Ren et al. reported that different expression patterns of HPV genes are correlated with the integration status of the virus . In 69 HTP53 or NOTCH1, which harbor mutations also in multiple exons [CALML5, DNAJC5G, and LY6D for ctDNA samples from eight HPV-associated OPSCC [DNA methylation analysis is also available from blood samples, based on around 200 base pairs of circulating tumor DNA (ctDNA) . Liquid le exons . In addile exons ,102. ctDed OPSCC . Pre-treed OPSCC , suggested OPSCC . Hence, Epigenetic-targeted therapy, especially targeting DNMTs, has the potential for tackling HPV-associated HNSCC. 5-azacytidine and 5-aza-2′-deoxycytidine are the most used, U.S. Food and Drug Administration-approved drugs  ,106,107.HPV induces DNA methylation in a complex manner during carcinogenesis. In this review, we provided an overview of DNA methylation, the relationship between DNA methylation and HPV-associated HNSCC, and how these mechanisms are related to the carcinogenesis of HPV-associated HNSCC. Recent comprehensive large-cohort DNA methylation analyses at a genome-wide scale have revealed that there is an HPV-associated HNSCC subtype with increased DNA methylation. However, there is still room for elucidation of the mechanism of HPV and DNA methylation. A more detailed understanding of the molecular basis of this subtype might lead to the development of new therapeutic strategies, such as therapeutic de-escalation in this subtype.


The natural history of human papillomavirus (HPV) is influenced by vaginal microenvironment disorders, such as bacterial vaginosis (BV). The objective of this study was to assess the epidemiology of HPV combined with BV prevalence among Chinese women aged 20–35 years.A total of 2000 sexually active women aged 20–35 years voluntarily enrolled in this study and underwent a ThinPrep cytologic test and PCR-reverse dot blot human papillomavirus genotyping (PCR-RDB HPV test). BV was diagnosed if clue cells were observed .P < 0.001). BV and HPV-51, -52 infection were more commonly associated with each other. In patients with cervical lesions (≥ CIN 1), the BV prevalence rate was higher than in patients with negative for intraepithelial lesion or malignancy (NILM) .The overall HPV infection rate in this population was 16.2% (324/2000). Compared with HPV-negative individuals, BV prevalence was higher in the High-risk human papillomavirus (HR-HPV) (5.9% vs. 3.1%, BV was found to be related to HPV-51, -52 infections and cervical lesions. To better manage HPV infected population, more attention should be paid to the prevention and proper treatment of BV. Cervical cancer is the fourth most frequently occurring cancer among women worldwide and is particularly common in resource-limited countries. Approximately, 311,365 cervical cancer-related deaths occurred in 2018 [There is a high prevalence rate for both BV and HPV among sexually active women, with a low cervical lesion rate . AlthougOur purpose was to assess the epidemiology of HPV and BV prevalence, analyze cytological and histological statuses and evaluate their association, thus providing a suitable protection program reference for the young Chinese population.The population eligible for this study were healthy volunteers aged 20–35 years from 8 cities in Fujian . The volunteers were recruited through targeted advertisements posted on communities and streets in various regions or on the local social media website. All participants provided informed consent. There was not money or other types of compensation. All women received HPV testing and cytology screening by gynecological practitioners between November 2016 and June 2017. The participants were required to fulfill the following criteria: (1) living in the selected regions, (2) volunteered to join the study and comply with follow-up visits, (3) aged between 20 and 35 years with an active sexual life, (4) no history of cervical treatment or surgery, (5) no immune system diseases, sexually transmitted diseases. The exclusion criteria included the following: washed vulva within 48 h, had sexual intercourse or used drug in vagina within the last 3 days, used antibiotics within one month. There were 2000 women aged 20–35 years who volunteered to participate in the study. The average period was 40.6 ± 10.21 days from study enrollment until the biopsy. A flowchart of the study protocol is shown in Fig. Cervical cells collection, storage method and the PCR-RDB HPV test (Yaneng Biotech) were illustrated in our prior study  and are All specimens were collected by clinical Physicians who are licensed as professional physicians, Physicians are trained in specimen collection skills. The cytological specimens were blinded and evaluated independently from the results of the other assays by two experienced cytopathologists. If the diagnosis was different, the cervical samples were reviewed again and a consensus diagnosis was obtained.According to previous study reports , at highWomen who were HPV-positive and/or had an abnormal cytological result  were referred for colposcopy and punch biopsy. Cervical biopsy specimens were then histologically examined and classified according to the CIN system. For women with negative results for cytology and HPV tests at a primary round, as the disease status, it was assumed that no new disease would be observed until further histology was received.P values were two-sided, and statistical significance was accepted if the P value was less than 0.05.All confidence intervals (CIs) were exact binomial CIs. Chi-square test, Fisher's exact test, and logistic regression were performed. All data analyses were performed using SPSS 22.0 . For all analyses, This study cohort consisted of 2000 women who were subject to HPV testing and cytology screening. The average age of the participants in this study was 29.70 ± 3.266 years (range: 20–35 years). According to the results, the overall HPV infection rate in this population was 16.2% (324/2000). In addition, 13.7% (273/2000) of the population was positive for HR-HPV, and 3.8% (76/2000) was positive for LR-HPV. The rate of mixed infection (both HR-HPV and LR-HPV infections) was 1.3% (25/2000). In the HPV infected population, HPV-52 was the most prevalent genotype. The HPV prevalence in different cervical lesions was performed in Fig. P < 0.001) and mixed-infection groups (P = 0.044). However, there was no difference between the LR-HPV and HR-HPV groups regarding BV prevalence (P = 0.76). There was no statistically significant difference in BV prevalence between women with single-type HPV infection and multi-type HPV infection (P = 0.23). BV was and HPV were more commonly associated with each other. HPV prevalence risk assessment was as follows: HPV-51  and HPV-52  . HR-HPV prevalence was 55.6% (55/99) in participants diagnosed with ASC-US and ASC-H, 82.4% (13/17) in participants with LSIL, 100.0% (2/2) in participants with HSIL, and 25.0% (1/4) in participants with AGC. The prevalence rate in individuals with ASC (including ASC-US and ASC-H) and LSIL was higher than that in the NILM population . The LR-HPV positivity rate was 3.3% (62/1878) in women with NILM and 11.5% (14/122) in women with abnormal cytological results (P < 0.001). In participants with NILM, the BV prevalence was 4.2% (75/1803). Of women with ASC-US and ASC-H, 5.1% (5/99) were diagnosed as BV. No cases of BV were found in women with LSIL, HSIL or AGC. The BV prevalence rate was not statistically associated with specific cytology results (P = 0.61).The study group displayed the following distribution: 93.9% (1878/2000) with normal cytology, 5.0% (99/2000) with ASC-US and ASC-H , 0.9% (17/2000) with LSIL , 0.1% (2/2000) with HSIL , and 0.2% (4/2000) with AGC . The HR-HPV positivity rate was 10.7% (201/1878) in women with NILM and 58.2% (71/122) in women with abnormal cytological results (P < 0.001). Cervical lesions were associated with HR-HPV infection, no matter in normal and abnormal cytology results  of the participants, besides 64.2% (122/190) was HPV positive. CIN 1 was found in 59 cases, accounting for 23.1% (59/256) of the participants. Additionally, CIN 2 was detected in 8 cases, accounting for 3.1% (8/256) of the participants. No cases of CIN 3 or cancer were detected. The proportion of HR-HPV infection was 76.4% (110/1775) in participants with cervicitis or NILM, 93.2% (55/59) in participants with CIN 1, and 100.0% (8/8) in participants with CIN 2  in the bivalent HPV vaccine (HPV-16/-18) and 17.9% (58/324) in the quadrivalent vaccine (HPV-6/-11/-16/-18). Although the nonavalent vaccine (HPV-6/-11/-16/-18/-31/-33/-45/-52/-58) targeted 50.00% (162/324) of the HPV genotypes, this vaccine has not been approved in Fujian. Thus, in this population, the introduction of Gardasil-9 should be encouraged. In addition, because the current HPV vaccines are both prophylactic and not effective in women with HPV infection, cervical cancer screening programs are necessary for early detection of precancerous cervical lesions and to treat HPV infection to reduce the rate of cervical cancer. Our study may provide a basis for formulating cervical cancer prevention strategies in the Fujian region.Currently, the association between BV and cervical HPV infection identified in several studies remains controversial . When anUp until now, there are few studies focus on the correlation between BV and specific HPV genotypes. According to the results of this study, BV was found to be related to HPV-51, -52 infections. Previews study in Africa suggested that BV associate with HPV-58 . ObviousNeisseria gonorrhoeae, Trichomonas vaginosis or Mycoplasma genitalium were not included. Nowadays, there is growing research into the relationship between other sexually transmitted infections (STI) and HPV. 11.4% of the women had at least one STI pathogen, the most common being Chlamydia trachomatis (6.7%) [However, this study also has some limitations. First, BV can be diagnosed by the Amsel's criteria, Nugent scoring system, Hay-Ison score , and Emes (6.7%) . Chlamyds (6.7%) . The mecThis study observed a relatively high HPV infection rate in 20–35 years women in Fujian. The high prevalence of HPV genotypes targeted by nonavalent vaccines suggested that the introduction of nonavalent vaccine may benefit a large number of women at high risk for HPV infection. Meanwhile, BV was found to be related to HPV-51, -52 infections and cervical lesions, suggesting that attention should be paid to the prevention, discovery and proper management of BV.


Self-collection of samples for HPV testing may increase women’s access to cervical cancer screening in low- and middle-income settings. However, implementation remains poor in many regions. The purpose of this systematic review was to examine implementation data from randomized controlled trials evaluating human papillomavirus (HPV) self-collection testing among women in sub-Saharan Africa using the RE-AIM  framework.We searched four electronic databases  for pragmatic randomized controlled trials that promote HPV self-collection among women in sub-Saharan Africa. Study selection and data extraction were conducted according to the PRISMA  checklist. Two researchers independently extracted information from each article using a RE-AIM data extraction tool. The reporting of RE-AIM dimensions was summarized and synthesized across included interventions.We identified 2008 citations, and eight studies were included. These reported on five unique interventions. The five interventions were conducted in five countries: Cameroon, Ethiopia, Kenya, Nigeria, and Uganda. Intervention reach (80%) was the most commonly reported RE-AIM dimension, followed by adoption (56%), efficacy/effectiveness (52%), implementation (47%), and maintenance (0%). All the interventions described increased uptake of HPV testing among study participants (effectiveness). However, the majority of the studies focused on reporting internal validity indicators such as inclusion criteria (100%) and exclusion criteria (100%), and few reported on external validity indicators such as participation rate (40%), intervention cost (40%), staff selection (20%), and cost of maintenance (0%).Our review highlights the under-reporting of external validity indicators such as participation rate, intervention, and maintenance costs in studies of self-collection for HPV testing among women in SSA. Future research should focus on including factors that highlight internal validity factors and external validity factors to develop a greater understanding of ways to increase not only reach but also implementation and long-term maintenance of these interventions. Such data may advance the translation of HPV interventions into practice and reduce health disparities in SSA. Findings highlight the need for innovative tools such as participatory learning approaches or open challenges to expand knowledge and assessment of external validity indicators to ultimately increase the uptake of HPV testing among women in SSA.The online version contains supplementary material available at 10.1186/s43058-021-00243-5. Contributions to the literatureWith poor screening for cervical cancer among women in sub-Saharan Africa, HPV self-collection provides a convenient and innovative tool to promote testing for HPV, the major cause of cervical cancer among women. Implementation evidence to guide the translation and dissemination of effective approaches is needed.We examined the external and internal validity of HPV self-collection interventions using the RE-AIM framework, which are critical factors to inform intervention translation and implementation.Our review found limited reported data on external validity indicators, which are important to determine generalizability and bridge the research to practice gap.Future research should focus on balancing reporting of external and internal validity indications and should be designed to highlight the translatability of empirical evidence to real-world settings.Human papillomavirus (HPV) causes cervical cancer and can be prevented by screening . HoweverHPV testing and treatment have been shown to reduce cervical cancer incidence and mortality in low-resource settings . HPV tesWhile emerging evidence supports the effectiveness, feasibility, and acceptability of HPV self-collection among women in SSA , 26, lesHowever, a comprehensive review of the internal and external validity of self-collection for HPV testing interventions among women in SSA is currently lacking. This gap in the literature limits the ability to guide the dissemination and implementation of self-collection for HPV testing interventions into practice. Thus, the purpose of this review is to (1) evaluate the extent to which randomized controlled trials aimed at evaluating self-collection for HPB testing in SSA have reported on dimensions on internal and external validity dimensions using the RE-AIM framework and (2) offer guidance on the design and reporting of future self-collection for HPV testing interventions to improve women’s health in the region.We conducted this systematic review following the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) checklist . The PRIWe searched four electronic bibliographic databases , and EMBASE) for articles published through August 9, 2020, and updated on November 20, 2020. We searched for articles including all three key concepts: (1) HPV self-collection, (2) pragmatic randomized controlled trials focused on intervention implementation, and (3) studies conducted in Sub-Saharan Africa guided by the work by Yeh and colleagues . KeywordAll citations from the initial search were imported into a reference manager, where duplicates were deleted, and titles and abstracts were screened independently by two reviewers . The full text of relevant articles was further screened by two independent reviewers  using the review inclusion/exclusion criteria. All disagreements regarding article relevance and eligibility were discussed until consensus was reached.Participants: Women; (b) Intervention: HPV self-collection; Comparators: Comparison of alternative interventions that do not include self-collection for HPV testing  testing services, clinician-collected primary HPV testing); (c) Outcomes: Uptake of self-collection for HPV testing, acceptability of HPV, frequency of cervical cancer screening, linkage to treatment following positive self-test diagnosis; (d) Study designs: Pragmatic Randomised controlled trials (RCTs) - pragmatic RCTs seek to maximize external validity by providing information on the relative merits or real-world clinical alternatives in routine care .Additional file 4. Quality of Included Studies based on Cochran Collaboration risk of bias tool .


Description of a perpetrator’s eye colour can be an important investigative lead in a forensic case with no apparent suspects. Herein, we present 11 SNPs (Eye Colour 11-EC11) that are important for eye colour prediction and eye colour prediction models for a two-category reporting system (blue and brown) and a three-category system . The EC11 SNPs were carefully selected from 44 pigmentary variants in seven genes previously found to be associated with eye colours in 757 Europeans . Mathematical models using three different reporting systems: a quantitative system (PIE-score), a two-category system (blue and brown), and a three-category system  were used to rank the variants. SNPs with a sufficient mean variable importance (above 0.3%) were selected for EC11. Eye colour prediction models using the EC11 SNPs were developed using leave-one-out cross-validation (LOOCV) in an independent data set of 523 Norwegian individuals. Performance of the EC11 models for the two- and three-category system was compared with models based on the IrisPlex SNPs and the most important eye colour locus, rs12913832. We also compared model performances with the IrisPlex online tool (IrisPlex Web). The EC11 eye colour prediction models performed slightly better than the IrisPlex and rs12913832 models in all reporting systems and better than the IrisPlex Web in the three-category system. Three important points to consider prior to the implementation of eye colour prediction in a forensic genetic setting are discussed: (1) the reference population, (2) the SNP set, and (3) the reporting strategy. HERC2, OCA2, SLC24A4, SLC45A2, TYR, and IRF4) that are associated with eye colour variation. The IrisPlex predicts eye colour in three categories: blue, intermediate, and brown [HERC2, rs12913832, is almost perfectly associated with blue and brown eye colour [OCA2 and strongly associated with OCA2 expression [OCA2 expression was increased in melanocytes carrying the rs12913832: A allele and decreased in melanocytes carrying the rs12913832: G allele. Hence, individuals carrying a rs12913832: A allele (genotypes rs12913832: AA and rs12913832:AG) are expected to have brown eye colour, and individuals carrying the genotype rs12913832:GG are expected to have blue eye colour. Eye colour prediction using the IrisPlex relies heavily on rs12913832 [OCA2, TYRP1, TYR, and SLC24A4 that may explain the incorrectly predicted eye colours [Prediction of physical traits  from DNA can be important in criminal cases with no apparent suspects. Multiple assays for forensic prediction of eye colour, hair colour, skin colour, and biogeographic ancestry have been developed with varying accuracies ,2,3,4,5.nd brown . It is we colour ,8. The S12913832 . Thus, t12913832 ,11. We pA total of 757 healthy individuals residing in Denmark, Sweden, or Italy comprised the variant discovery data set. The model data set included 523 healthy individuals living in Tromsø and Bodø (Norway). Blood samples were collected from employees and students at universities, residents and employees at health care centres, employees at hospitals, and through the Danish Blood Donor Study as described elsewhere ,13,14. DA digital photograph of one of the eyes of each participant was taken as described previously . The pixOCA2 found to be associated with blue eye colour in individuals with the rs12913832:GA genotype [IRF4, TYRP1, SLC24A4, and TYR, associated with brown eye colour in individuals with the rs12913832: GG genotype [TYRP1  to tag one large haploblock associated with eye colour [TYR were also in strong LD . rs1393350 was part of the IrisPlex [OCA2 variants [IRF4, TYRP1, SLC24A4, and TYR were typed using two multiplexes, a 24 plex and an 11 plex, respectively . The 11 plex comprised rs1393350 from the IrisPlex and 10 variants in IRF4 and TYR . Samples were typed with the iPLEX™ Assay  and analysed with matrix-assisted laser desorption-ionization time of flight mass spectrometry (MALDI-TOF MS) using the MassARRAY Analyzer 4 System . The PCRs contained 0.5 µL 10X PCR buffer, 0.4 µL MgCl2 (25 mM), 0.1 µL dNTP mix (25 mM), 0.2 μL PCR Enzyme, 1 μL primer mix (1 µM of each primer), and 1 µL DNA (≥1 ng). Thermal cycling comprised initial denaturation for 2 min at 94 °C followed by 45 cycles of denaturation at 94 °C for 20 s, annealing at 56–58 °C for 30 s (56 °C for the 11 plex and 58 °C for the 24 plex), and extension at 72 °C for 1 min. A final extension step at 72 °C for 3 min was included. Shrimp alkaline phosphate (SAP) treatment, single-base extension (SBE) reactions, and preparation for mass analysis was carried out following the manufacturer’s recommendations. In the MassARRAY Nanodispenser RS1000, 5–15 nl sample was robotically spotted onto a SpectroCHIP® II . Mass analysis was carried out using the MassARRAY Analyzer 4, and the mass spectra were analysed with the Typer 4.0 software . The Hardy–Weinberg equilibrium (HWE) and pairwise r2 values for linkage disequilibrium (LD) were calculated with HaploView version 4.2 [A total of 44 pigmentary variants were investigated. The variants included all six IrisPlex SNPs , five vagenotype , as wellvariants ,11. The ectively . The 24 sion 4.2 .Eye colour was considered in three different reporting systems, the quantitative system (PIE-score), the two-category system, and the three-category system. For numerical reasons , the PIE-score  in the quantitative system was transformed to resemble unbounded values. The transformation had an inverse, such that any real number could be transformed into a PIE-score. The PIE-score, r, was transformed by:rpart version 4.1–15 were used [Genotypes were coded as 0, 1, or 2 according to the number of minor alleles, where the minor alleles were determined based on the allele frequencies in all samples. Due to low allele frequency, the two variants rs121918166 and rs74653330 were combined . rs12913® Size Standard (200:1). The results were analysed with GeneMapper® ID-X v.1.5 . One of the selected variants, rs7120151, could not be typed and was excluded. Hence, we used 11 selected variants for the eye colour prediction model (EC11).The 12 selected variants and two non-selected SNPs from the IrisPlex  were typi, all observations except number i were used to train the model. The model was used to predict the eye colour of observation i, and the predicted and observed values were compared. Three different reporting systems were used , and thereby three different ways of measuring the prediction error were employed. For the quantitative system, a linear regression model was used where the prediction error was the mean squared error. For the two-category system, a logistic regression model was used where blue was chosen as 1 and brown as 0 . The prediction error for a predicted probability (p) was log(p) if the true eye colour was blue, and log(1-p) if the true eye colour was brown. For the three-category system, a multinomial logistic regression model was used [https://hirisplex.erasmusmc.nl/, accessed 1 July 2020) to predict eye colour in three categories.Eye colour prediction models were modelled with leave-one-out cross-validation (LOOCV) using the model data set  and the selected variants. For observation number was used . The prep-value < 0.001) in the discovery data set. This could be explained by positive selection in the European population or a lack of random mating between the Scandinavian (Danish and Swedish) and the Italian populations.We investigated 44 pigmentary variants in our discovery data set of 757 individuals. In this work, we typed 33 variants  in two mTYR variant rs1393350 (ranked 18) and the IRF4 variant rs12203592 (not in top 20) from the IrisPlex were not selected.The discovery data set with information on eye colour and the 44 pigmentary variants was analysed with seven different mathematical models. Variants were ranked according to the mean variable importance across the mathematical models . rs12913The 12 selected variants (SNPs) were typed with single-base extension in an independent data set, the model data set of 523 Norwegians bold in . To enabWe constructed nine different eye colour prediction models based on the model data set with 523 Norwegians by using three different reporting systems and three different SNP sets . We alsoThe sensitivity and specificity of eye colour prediction models in the two-category and the three-category reporting systems were determined without applying a probability threshold (pmax) . Hence, In the three-category system, the sensitivity was highest for blue and brown eye colours and lowest for intermediate eye colour with all three SNP sets and the IrisPlex Web . The rs1In the three-category reporting system, we tested the prediction with pmax, a probability threshold of 0.5, and a probability threshold of 0.7 . With noTYR SNP, rs1393350 (ranked 18), was replaced by another TYR SNP, rs1126809 (ranked 8), and the IRF4 gene represented by the SNP rs12203592 (not in top 20) from the IrisPlex, was not included in EC11. For the selection of SNPs, we combined individuals of Scandinavian (Danish and Swedish) and Italian descent and treated these as one population. We are aware that we may had selected different SNPs if the selection was performed solely on either the Scandinavian or the South European population. We typed the EC11 SNPs and the two additional IrisPlex SNPs in an independent data set of 523 Norwegians whose eye colours were determined with the same quantitative method as the 757 individuals in the discovery data set. We modelled nine different eye colour prediction models on the Norwegian population using the LOOCV method. Each eye colour prediction model consisted of a combination of one of three reporting systems: the quantitative system (prediction of PIE score), the two-category system (blue and brown), and the three-category system , and one of three SNP sets: EC11, IrisPlex SNPs, and rs12913832. We also evaluated the IrisPlex Web model for prediction of eye colour in three categories. Based on the analysis of error rates, sensitivity, and specificity of the different eye colour prediction models, there are three main points to consider prior to implementation of eye colour prediction in a forensic genetic setting: (1) the reference population, (2) the SNP set, and (3) the reporting strategy.In this study, we selected 11 SNPs (EC11) for eye colour prediction and developed new eye colour prediction models for a two-category and a three-category system that performed better than the corresponding IrisPlex and rs12913832 prediction models. The 11 SNPs in EC11 were selected from a group of 44 pigmentary variants that were originally identified in eye colour association studies  and fromThe rs12913832, IrisPlex Norway, and IrisPlex Web models showed almost identical results in the three-category system , Table 6The eye colour prediction models based on EC11 had the lowest prediction error rates in all three reporting systems and consistently performed better than the rs12913832, IrisPlex Norway, and IrisPlex Web models in the Norwegian population . In the 1: The person has brown eyes and H2: The person has blue eyes). Hence, it is possible to report the weight of the evidence with a single likelihood ratio, which resembles standard STR-profiling reports. The likelihood ratio could be supplemented with picture examples of eye colours represented by each category. This may overcome any misunderstandings or subjective opinions of eye colour interpretation, especially for eye colours that may appear non-blue and non-brown.In this work, we tested three different eye colour categorisation systems: the quantitative system (prediction of PIE score), the two-category system (blue and brown), and the three-category system . Although it is possible to report the predicted eye colour in the form of a PIE-score, this likely requires that the end-user or the reporting laboratory translate the PIE-score into an eye colour category. Therefore, the use of a quantitative system for reporting is not relevant in a forensic genetic setting. The difference between the two- and three-category system is the definition of the intermediate eye colour, which is very difficult to perceive. When multiple individuals were asked to evaluate eye colours categorised as intermediate, they often disagreed, whereas they agreed much more frequently when eye colours were blue or brown . Interme1/rs12913832:GG|H2) = 0.1, LR = (rs12913832:AG|H1/rs12913832:AG|H2) = 19, and LR = (rs12913832:AA|H1/rs12913832:AA|H2) = 54 [1: The person has brown eyes and H2: The person has blue eyes. The EC11 model may be implemented at the Section of Forensic Genetics in Denmark in the future once the EC11 markers are included in a validated massively parallel sequencing (MPS) assay. The most important shortcoming of the rs12913832 two-category prediction model is the lack of information gained when including the two OCA2 variants, rs121918166 and rs74653330. These variants were previously shown to be of importance for blue eye colour in Scandinavians with the rs12913832:AG genotype [OCA2 variants and were correctly predicted to have blue eyes using the EC11 two-category model. By contrast, only one of the 30 individuals was correctly predicted with the IrisPlex Norway model, and none were correctly predicted with rs12913832. Moreover, two Norwegians with the rs12913832:AA genotype had blue eye colours according to the PIE-score. One of the two individuals was correctly predicted to have blue eye colour with the EC11 two-category model. This individual was homozygous for the rs74653330 variant. We hypothesise that the second individual has other variants in or around the OCA2 gene that could explain the formation of blue eye colour in the rs12913832:AA genotype background. Both individuals were incorrectly predicted to have brown eye colours with the IrisPlex Norway and rs12913832 models. Lastly, 10 Norwegians with the rs12913832:GG genotype had brown eyes according to the PIE-score. Only one of them was correctly predicted to have brown eyes with the two-category EC11 and IrisPlex Norway models. This shows that we do not fully understand the formation of brown eye colour in rs12913832:GG individuals and that the EC11 model may have to be expanded further.The Section of Forensic Genetics in Denmark recently began offering eye colour prediction to the police using the two-category system based on the genotype of rs12913832. Prediction of EVCs can cause ethical concerns as discussed in . This isH2) = 54 , where H


A randomised trial designed to compare three and two doses of quadrivalent human papillomavirus (HPV) vaccine in adolescent girls in India was converted to a cohort study after suspension of HPV vaccination in trials by the Indian Government. In this Article, the revised aim of the cohort study was to compare vaccine efficacy of single dose to that of three and two doses in protecting against persistent HPV 16 and 18 infection at 10 years post vaccination.ClinicalTrials.gov, NCT00923702.In the randomised trial, unmarried girls aged 10–18 years were recruited from nine centres across India and randomly assigned to either two doses or three doses of the quadrivalent HPV vaccine . After suspension of recruitment and vaccination, the study became a longitudinal, prospective cohort study by default, and participants were allocated to four cohorts on the basis of the number vaccine doses received per protocol: the two-dose cohort (received vaccine on days 1 and 180 or later), three-dose cohort , two-dose default cohort (days 1 and 60 or later), and the single-dose default cohort. Participants were followed up yearly. Cervical specimens were collected from participants 18 months after marriage or 6 months after first childbirth, whichever was earlier, to assess incident and persistent HPV infections. Married participants were screened for cervical cancer as they reached 25 years of age. Unvaccinated women age-matched to the married vaccinated participants were recruited to serve as controls. Vaccine efficacy against persistent HPV 16 and 18 infections (the primary endpoint) was analysed for single-dose recipients and compared with that in two-dose and three-dose recipients after adjusting for imbalance in the distribution of potential confounders between the unvaccinated and vaccinated cohorts. This trial is registered with ISRCTN, ISRCTN98283094, and Vaccinated participants were recruited between Sept 1, 2009, and April 8, 2010 (date of vaccination suspension), and followed up over a median duration of 9·0 years (IQR 8·2–9·6). 4348 participants had three doses, 4980 had two doses (0 and 6 months), and 4949 had a single dose. Vaccine efficacy against persistent HPV 16 and 18 infection among participants evaluable for the endpoint was 95·4% (95% CI 85·0–99·9) in the single-dose default cohort (2135 women assessed), 93·1% (77·3–99·8) in the two-dose cohort (1452 women assessed), and 93·3% (77·5–99·7) in three-dose recipients (1460 women assessed).A single dose of HPV vaccine provides similar protection against persistent infection from HPV 16 and 18, the genotypes responsible for nearly 70% of cervical cancers, to that provided by two or three doses.Bill & Melinda Gates Foundation. A combined strategy of high-coverage human papillomavirus (HPV) vaccination of girls aged 9–14 years, twice-lifetime screening of women at 35 years and 45 years of age, and effective treatment of those with cervical neoplasia can potentially eliminate cervical cancer as a public health problem.6Evidence before this studyWe searched PubMed between Feb 1 and March 31, 2021, for all types of publications  that reported on the efficacy of a single dose of human papillomavirus (HPV) vaccines, without date or language restrictions. We used the terms “HPV vaccine” AND “efficacy” AND “one-dose”. This search retrieved 21 results. The articles were related to several topics: efficacy, effectiveness, immunogenicity, and durability of vaccination schedules of fewer than three doses. The efficacy of a single dose was compared with no vaccination, or with efficacy of two or three doses. The vaccines were either the bivalent or the quadrivalent HPV vaccines. The outcomes included vaccine efficacy on cervical incident HPV infection, on prevalent infection, and on persistent infection. We identified a recent systematic review reporting on the efficacy and immunogenicity of a single dose of an HPV vaccine. The review included three major HPV vaccine trials: the Costa Rica Vaccine trial, the Papilloma Trial Against Cancer in Young Adults trial, and the International Agency for Research on Cancer India HPV vaccine trial. The results of this systematic review as well as other studies suggested that one dose could be as efficacious as two or three doses in healthy women. The authors of the systematic review highlighted the small sample size of the existing studies and their other weaknesses, and acknowledged the need for additional evidence to confirm the preliminary results of the three trials.Added value of this studyWe report similar vaccine efficacy of a single dose of quadrivalent vaccine in adolescent girls compared with that of two or three doses at 10 years post vaccination against persistent and incident HPV 16 and 18 infections as well as cervical neoplasia. The major strengths of the study are large number of single-dose recipients, presence of two-dose and three-dose recipients belonging to the same age group as the comparators, and systematic follow-up over many years. The evidence from our study demonstrating high efficacy of single dose of quadrivalent vaccine in prevention of persistent infection from HPV 16, 18, or both helps to address the existing evidence gap identified by the systematic review.Implications of all the available evidenceThe evidence generated by our study is consistent with the high efficacy of a single dose of HPV vaccine observed in other clinical trials and in ecological studies nested in national immunisation programmes. More than 90% efficacy of a single dose in preventing persistent HPV 16 and 18 infections indicate that the quadrivalent vaccine (with its limited cross-protection) could potentially prevent around 70% of the cervical cancers—a huge gain for low-income and middle-income countries considering the great benefits of a single dose in reducing programme costs and complexities.Adoption of a single-dose schedule for the HPV vaccine could potentially address many of the challenges by improving affordability, making the vaccination programmes logistically simpler and more resilient, and helping to tide over the supply crisis. We aimed to describe the efficacy of a single dose of the quadrivalent HPV vaccine compared with two or three doses to protect against incident and persistent cervical HPV infections 10 years post vaccination. We also report the early evidence of protection against cervical precancers among recipients of different vaccine dosing regimens.A multicentre, cluster-randomised trial designed to compare the efficacy of two versus three doses of quadrivalent HPV vaccine among unmarried girls aged 10–18 years in India initiated recruitment on Sept 1, 2009. The methods of the study are described elsewhere in detail and are summarised in After suspension of recruitment and vaccination, the trial was converted to a longitudinal, prospective, cohort study by default. For the cohort study, we recruited two cohorts of unvaccinated women at different time periods to serve as age-and-site-matched controls post hoc.The study was approved by the ethics committees at the International Agency for Research on Cancer  and all collaborating institutions. Every participant signed an informed consent or an assent (if aged <18 years). Either of the parents gave written consent for the girls aged younger than 18 years. The study was monitored by a data safety monitoring board.Each participant received 0·5 mL of the quadrivalent HPV vaccine  administered intramuscularly. After suspension of recruitment and vaccination, participants were distributed across four cohorts on the basis of the doses received per protocol: recipients of three doses on days 1, 60, and 180 or later (three-dose cohort), recipients of two doses on days 1 and 180 or later (two-dose cohort), recipients of two doses on days 1 and 60 or later (two-dose default cohort), and recipients of a single dose of the vaccine (single-dose default cohort).9, TX, USA).All participants are being followed up yearly, and the follow-up will continue for at least another 5 years to August, 2026. History of receiving an HPV vaccine outside the study was obtained at each visit along with routine medical history; any participants receiving HPV vaccine outside the study were excluded from further follow-ups. We collected information on clinically significant medical events at each visit. However, the data were not analysed for this study. Participants became eligible to provide cervical specimens for individual detection of any of the 21 HPV genotypes 18 months after marriage or 6 months after first childbirth, whichever was earlier. One cervical specimen was collected per year (within a window of minus 2 months and plus 6 months) from eligible participants for 4 consecutive years. Participants in whom a new HPV infection was detected in the fourth sample were advised to return to provide a fifth sample after 1 year. Genotyping was done with the Luminex assay  for the qualitative detection of high-risk HPV types 16, 18, and 45. The digene PS test detects the genotype associated with cervical neoplasia (if detected) as some of the screening-eligible women might have completed providing samples for Luminex genotyping years before screening. We recalled every HC-II-positive participant for colposcopy. A Swede score of five or more on colposcopy was an indication for obtaining punch biopsies from the areas of worst abnormalities.Participants were invited to cervical cancer screening once they reached 25 years of age and were married. A well validated HPV detection test  was used as the screening test, for which cervical specimens were collected by a trained provider. Positive specimens were further tested with the The first cohort of unvaccinated married women matched by age and study site to the vaccinated women eligible to provide specimens for genotyping was recruited in 2013–15. The participants belonging to the first unvaccinated cohort provided specimens for Luminex genotyping and were also screened for cervical cancer following the same protocol applicable for vaccinated participants. A second unvaccinated cohort of married women, age and site matched to the screening-eligible vaccinated women, was recruited in 2017–19. Women recruited to the second cohort were only screened for cervical cancer (screening-only cohort) following the protocol described earlier. No specimens were collected from them for the Luminex assay.Luminex is a type-specific E7 PCR multiplex assay to detect 19 high-risk or probable high-risk types , and two low-risk types (HPV 6 and 11). A centralised facility has been set up for the assay at Rajiv Gandhi Centre for Biotechnology in Thiruvananthapuram . The laboratory was certified as proficient by the International HPV Reference Centre at the Karolinska Institute in Stockholm (Sweden) following a quality control exercise based on the global HPV DNA proficiency panel 2017.HC-II is a semi-quantitative chemiluminescence assay to detect any of the 13 most oncogenic HPV types in the specimen. The specimen should have at least 5000 copy numbers of viral DNA of the targeted HPV types to test positive. The HC-II test is centralised at one of the study sites . All laboratory staff and colposcopists were masked to the vaccination status of participants.The formalin-fixed cervical biopsy specimens were processed for histopathology at respective study sites and examined by the site pathologists. A trained and experienced gynaecological pathologist examined all the slides centrally at Regional Cancer Center in Thiruvananthapuram. She was masked to the group allocation, colposcopy interpretation, and site histopathology result. Diagnosis made by the expert pathologist was considered as final.The primary endpoint of the original randomised, controlled trial aiming to compare two versus three doses of the vaccine was detection of cervical intraepithelial neoplasia grade 2 or worse (CIN2+) lesions, which was the standard endpoint being used by all other vaccine trials at that time. Subsequently, prevention of persistent oncogenic HPV infection was well accepted as a valid surrogate to demonstrate protection against CIN2+ lesions. In this study, we assessed persistent infection from HPV 16, 18, or both (hereafter referred to as HPV 16/18) as the primary outcome. The secondary outcomes were incident HPV 16/18 infections, and HPV 16/18-related CIN2+ lesions. Other exploratory outcomes were persistence and incidence of any one or more of HPV 6 and 11; any one or more of HPV 31, 33, and 45; and any HPV type.For any participant, incident infection was defined as detection of an HPV type in any one sample, and persistent infection was defined as detection of the same HPV type in two consecutive samples taken at least 10 months apart. Only Luminex assay outcomes were used to assess incidence and persistence. Each enrolled participant contributed once to persistent infections, once to incident infections, or both.Participants' baseline characteristics were stratified by the vaccine dose received and are presented as proportions. For the incident HPV infection outcomes, the analyses included participants who provided at least one cervical cell sample, and persistent HPV infection analyses included participants with at least two cervical cell sample collections. HPV incidence and persistence outcomes were also stratified by the vaccine dose received and are presented as proportions with their 95% CIs.Vaccine efficacy was analysed against incident and persistent infections. Vaccine efficacy was calculated as one minus HPV infection rate in the vaccinated group divided by HPV infections rate in the unvaccinated group. The 95% CI for vaccine efficacy was obtained using a two-step approach: first, estimating the proportion of cases in the vaccinated cohort conditioned on the total number of cases in both the vaccinated and unvaccinated cohorts computed using an exact conditional procedure; and, second, using the lower and upper limits of the proportion 95% CI to calculate the 95% CI for vaccine efficacy.Because of the ad-hoc nature in which the first unvaccinated cohort (the second unvaccinated cohort was not tested for incident and persistent infections) was recruited, several descriptive analyses were done to arrive at an appropriate modification needed to minimise the imbalance in the distribution of potential confounders between the unvaccinated and vaccinated cohorts. To minimise the imbalance, we created strata that would effectively have similar distribution of characteristics, and that, in the absence of vaccination, would have had extremely similar frequencies of HPV infection . Such stFirst, we used the non-vaccine targeted HPV types, excluding 31, 33, and 45, as the outcome for HPV types that are unlikely to be influenced by vaccination. We then performed logistic regression models to obtain odds ratios together with their 95% CI and to show that those non-vaccine-targeted HPV types significantly predicted the vaccine-targeted (HPV 16/18) and cross-protective  outcomes .Second, using only data for the unvaccinated cohort, we ran a multivariate logistic regression model to determine the potential confounders (characteristics) that significantly predict these non-vaccine-targeted HPV types. The potential confounders included were study site groups created based on background site-specific HPV infection profile .As the final step, we created five strata from the fitted scores using the lowest level as the first stratum of individuals with minimal or no risk and the remaining four from quantiles of the scores. As such, we avoided assuming that the risk score and the outcome were related through a particular function. More details are in the Five strata with similar risk profiles were used in the direct standardisation method, with the total vaccinated cohort as the standard population, to obtain the effective number of events and effective population sizes for each dose group. These values in turn were used as the true values in the exact conditional model to obtain adjusted vaccine efficacy estimates.The analyses for the CIN2+ outcome were based on individuals with HC-II testing results, presented as proportions and compared between the unvaccinated and vaccinated cohorts. Significance was inferred when the p value was less than 0·05. The statistical analyses were carried out in Stata (version 15.1) and Just Another Gibbs Sampler software.ClinicalTrials.gov, NCT00923702.This study is registered with ISRCTN, ISRCTN98283094, and The funder of the study had no role in study design, data collection, data analysis, data interpretation, or writing of the report.Vaccinated participants were recruited between Sept 1, 2009, and April 8, 2010. The first unvaccinated cohort was recruited between April 29, 2013, and June 16, 2015, and the second between Oct 6, 2017, and June 27, 2019. 4348 participants were included in the three-dose cohort, 4980 in the two-dose cohort, 3452 in the two-dose default cohort, 4949 in the single-dose default cohort, 1541 in the first unvaccinated cohort, and 3631 in the second unvaccinated cohort. No participant reported receiving a HPV vaccine outside our study. The median duration of follow-up was 9·0 years (IQR 8·2–9·6) for the vaccinated participants. The distribution of participants by cohorts varied across the study sites . Sites iOf the total 17 729 vaccinated women, 10 915 (61·6%) were eligible for HPV genotyping. Among these women, frequency of incident HPV infection was assessed in the 9183 (84·1%) women who provided at least one cervical cell sample . IncidenAmong the 10 915 vaccinated women eligible to provide cervical specimens, persistent infection was assessed in 6673 (72·7%) women who provided at least two cervical cell samples . PersistSince there were very few records with missing data (five missing dates of marriage for the unvaccinated group), they were excluded from the vaccine efficacy analysis. Adjusted vaccine efficacy against incident HPV 16/18 infection in the single-dose recipients was 63·5% (95% CI 51·2–73·1), which was similar to the vaccine efficacies observed in the two-dose cohort  and three-dose cohort , which was not significantly different from that observed with two doses  and three doses  was detected in one (0·1%) of 1037 three-dose recipients, four (0·3%) of 1143 the two-dose recipients, two (0·1%) of 1511 single-dose recipients, and 63 (1·4%) of 4626 the unvaccinated women. The single case of CIN3 detected in the vaccinated women was a single-dose recipient. She was negative for HPV 16/18, both on the Luminex assay and digene PS test. No CIN2 or invasive cancer was detected in the vaccinated cohorts. Five cases of CIN2 or CIN3 were detected among the unvaccinated women, three of which were associated with HPV 16/18. One case of invasive cancer, not associated with HPV 16/18, was detected in the unvaccinated women cohort.The HPV screening test was positive in 197 (4·1%) of the 4819 vaccinated and 277 (6·0%) of the 4626 unvaccinated women . HPV 16/Based on systematic follow-up of more than 4000 adolescent girls receiving a single dose, our study has demonstrated very high efficacy of one dose of the quadrivalent vaccine against persistent infection from HPV 16/18, which is sustained until 10 years post vaccination. Vaccine efficacy of one dose was no different from that observed for two or three doses of the same vaccine.An expert group convened by the IARC in 2013 unanimously decided that demonstration of protection against persistent cervical infection would be considered adequate proof of efficacy of a single dose of HPV vaccine to prevent advanced cervical precancers or cancer.High efficacy of single dose of a HPV vaccine against persistent HPV 16/18 infection was previously reported by a combined post-hoc analysis of the Costa Rica Vaccine trial and PATRICIA trial in a smaller number of single-dose recipients (n=292).26The non-randomised design of our study could be considered as a limitation. However, the fact that allocation of the participants to different dose groups happened by default and was not controlled by the investigators or decided on by the participants reduces any selection bias. A recent systematic review of single-dose efficacy trials accepted that our study had low risk of exposure or outcome misclassification, since the dose cohorts were well matched for age and sociodemographic characteristics and were followed up in the same manner.Nearly half of LMICs have not been able to introduce HPV vaccination because most of them have phased out of support from Gavi, the Vaccine Alliance, and many countries cannot afford the price of US$4·50 per dose negotiated by Gavi.External researchers can make written requests to the IARC for sharing of data after publication. Requests will be assessed on a case-by-case basis in consultation with lead and co-investigators. A brief analysis plan and data request will be required and reviewed by the investigators for approval of data sharing. When requests are approved, anonymised data will be sent electronically in password protected files. All data sharing will abide by rules and policies defined by the sponsor; relevant institutional review boards; local, state, and federal laws and regulations. Data sharing mechanisms will ensure that the rights and privacy of individuals participating in research will be protected at all times.PB has received research funding from GlaxoSmithKline through the Chittaranjan National Cancer Institute  during his previous position at the institute. NB has received research funding through her institute from GlaxoSmithKline and Merck. SJ has received funds from GlaxoSmithKline through the Jehangir Clinical Development Center  for a human papillomavirus vaccine study. All other authors declare no competing interests.