Atypical squamous cells of undetermined significance: bethesda classification and association with human papillomavirus” which appears in this special issue, observers would agree in the diagnosis of ASCUS only in two out of three cases.Persistent infection from high-risk HPV types is necessary for the development of cervical cancer and constitutes a main cause for a significant proportion of cancers in other sites of the female anogenital tract such as the vulva, the vagina, and the anus . CervicaSecondary screening efforts focus on the detection and subsequent treatment of cervical intraepithelial neoplasia (CIN). However, the sensitivity of cytology in the detection of CIN has been questioned . ObviousHCII, however, does not allow HPV typing. Certain PCR-based tests allow the identification of the specific genotypes responsible for the infection, which could have future clinical applications. One of the first steps in PCR is DNA extraction. The study by Chranioti et al.  comparedClinicopathological comparison of adenocarcinoma of cervix and endometrium using cell cycle markers: P16ink4a, P21waf1, and p27Kip1 on 132 Cancers” the expression of two less studied proteins, p21WAF1 and p27Kip1 was significantly associated with lymph node invasion in cervical adenocarcinoma.Cell cycle biomarkers such as E6&7 mRNA testing and P16INK4a are further tools that could be used in the prevention of cervical cancer . HoweverPromoter methylation of p16INK4A, hMLH1, and MGMT in liquid-based cervical cytology samples compared with clinicopathological findings and HPV presence” examined the methylation-dependent inactivation of tumor suppressor genes connected with cell cycle regulation as p16INK4A and DNA repair mechanisms as human MutL Homolog 1 (hMLH1) and O6-methylguanine DNA methyl transferase (MGMT). Even though the accuracy of methylation was found lower than traditional tests, epigenetic effects are areas of promising future research.Most HPV infections are transient without clinical significance. However, in a minority of women HPV will persist and will initiate the neoplastic process. Epigenetic event such as gene methylation might play a role in the selection of the women who will progress to cancer. The study by A. Spathis et al. titled “Aspects of prophylactic vaccination against cervical cancer and other human papillomavirus-related cancers in developing countries” outlines certain issues that arise with respect to application of the vaccine in the developing countries where the need for cervical cancer prevention is the greatest. They suggest that given the low coverage rates, vaccination of the males might have to be considered in order to produce herd immunity. They also argue that strategies for vaccine implementation would have to be school based with community outreach activities in regions where school attendance is low. The deficiencies of secondary prevention, such as the need for sufficient infrastructure, which is absent in developing countries, the false negative results, the adverse effects of overtreatment on subsequent pregnancy outcome , 12, as Progress in the elucidation of the mechanisms of carcinogenesis has led to the development of exciting technologies that can be used for lower anogenital tract cancer prevention. The main challenge we face now is to find the proper way to use all these discoveries for the benefit of women's health. George KoliopoulosGeorge KoliopoulosPierre Martin-HirschPierre Martin-HirschMarc ArbynMarc Arbyn


RaSH approach identified differential expression of Annexin A1 (ANXA1), p16, RPL6, PBEF1 and KIAA1033 in high-risk HPV positive penile carcinoma; ANXA1 and p16 were overexpressed in penile squamous cells positive for high-risk HPVs compared to normal penile samples by qPCR. ANXA1 and p16 proteins were significantly more expressed in the cells from high-risk HPV-positive penile carcinoma as compared to HPV-negative tumors (p<0.0001) independently of the subtype of the carcinoma. Overexpression of ANXA1 might be mediated by HPV E6 in penile squamous cell carcinoma of patients with high-risk HPVs, suggesting that this gene plays an important role in penile cancer.The incidence of penile cancer varies between populations but is rare in developed nations. Penile cancer is associated with a number of established risk factors and associated diseases including phimosis with chronic inflammation, human papillomavirus (HPV) infection, poor hygiene and smoking. The objective of this study was to identify genes related to this type of cancer. The detection of HPV was analyzed in 47 penile squamous cell carcinoma samples. HPV DNA was detected in 48.9% of penile squamous cell carcinoma cases. High-risk HPV were present in 42.5% of cases and low-risk HPV were detected in 10.6% of penile squamous cell carcinomas. The  Penile cancer affects predominantly men aged between 50 and 70 years HPV contributes to tumorigenesis predominantly through the action of viral oncoproteins (E6 and E7) ANXA1 has been studied in various types of cancer, but there is no consensus concerning the role this protein plays during tumor initiation and/or progression. Some studies observed a correlation between the decrease of ANXA1 mRNA and protein with esophageal, prostate and breast cancers ANXA1 in head and neck and pancreatic cancers One gene that could be subject to regulation by the oncoprotein E6 is ANXA1 as previously suggested by Shimoji et al., 2009 Here, we aimed to identify novel genes differentially expressed in penile squamous cell carcinoma positive for high-risk HPVs and evaluate a possible correlation between HPV positivity, the expression of the genes and the subtypes of penile squamous cell carcinoma.Archival paraffin wax-embedded tissue sections from 47 penile squamous cell carcinoma were obtained and reviewed by a pathologist, with approval from the Research Ethics Committee of the College of Medicine of São José do Rio Preto, Research Ethics Committee of Hospital A. C. Camargo, São Paulo, and Research Ethics Committee of University Hospital João de Barros, Belem, all located in Brazil. Twelve penile squamous cell carcinoma samples and seven normal penile fresh-frozen tissue samples were obtained from the College of Medicine of São José do Rio Preto, and Hospital A. C. Camargo. The use of patient-derived material was approved by the institution's Committee Research Ethics Board and written consent was obtained from all patients. Tissues were obtained at surgery from patients undergoing tumor resection, and the diagnosis of penile squamous cell carcinoma was verified post-operatively using histopathology. All slides were histologically examined accordingly to the TNM classification system (American Joint Comittee on Cancer) β-globin gene served as an internal control to assess the sufficiency of DNA in each specimen.DNA was extracted from 6 slices of 10 micra of paraffin wax-embedded sections using the QIAamp DNA FFPE Tissue kit . The polymerase chain reaction (PCR) was performed on DNA extracted from penile squamous cell carcinoma samples. Purified DNA (1–10%) was subjected to PCR. The amplification of a fragment of the Globin positive specimens were analyzed by PCR for the presence of HPV DNA using the consensus primers GP5+/GP6+, which flank a fragment of approximately 140 bp of the L1 gene, a highly conserved sequence in HPV genomes, allowing several genital HPV types to be detected 2; 200 mM of each deoxyribonucleotide  and between 3.0 and 7.0 µl of DNA from the samples. The PCR conditions were an initial step of five min at 94°C, 40 cycles of one min at 94°C, one min at 45°C, and 90 s at 72°C; the last cycle was five min at 72°C. For each reaction, DNA from HeLa cells, a HPV-18 positive cervical cancer derived cell line, was used as a positive control and water and DNA from C33 cells were used as negative controls. The C33 and HeLa cell lines were a generous gift from Dr. Luisa Lina Villa from University of São Paulo Genotyping was performed with the INNO-LiPA HPV Genotyping Extra test  allowing the identification of 28 different HPV genotypes as well as the HLA-DPB1 gene as internal control for DNA quality. As recommended by the manufacturer, only samples positive for any HPV and/or for the HLA-DPB1 gene were included in the analysis.Total RNA was isolated from penile squamous cell carcinoma tissue and normal tissue using TRIzol reagent  according to the manufacturer’s instructions. RNA integrity post-purification was ensured using the Agilent 2100-Bioanalyser, giving a minimal RIN value of 5.5.RaSH cDNA libraries were performed as described previously Four fresh-frozen samples of penile squamous cell carcinoma were used to perform RaSH methodology. Tissues adjacent to tumor and tumor tissues from the same patient were reviewed by two pathologists and microdissected aiming to obtain most representative tumoral and morphologically normal tissues. HPV 16 was detected in tumoral cells while normal samples were HPV DNA negative. RaSH cDNA libraries were prepared, one using cDNA from the penile squamous cell carcinoma as a tester and normal tissue of penis as a driver, and the other using cDNA from normal tissue of penis as a tester with cDNA from the penile squamous cell carcinoma as a driver.The samples were diluted to 100 µl and 40 ul of the mixture was used for PCR amplification with the primer XDPN-18 (5′CTGATCACTCGAGAGATC 3′). Aliquots (10 µg) of the tester PCR products  were digested with 20 units of XhoI  and purified with phenol-chloroform extraction and ethanol precipitation. The fragments were inserted into XhoI-digested pZERO plasmid (1 µg/µl) at 16°C for three hours. The constructs were introduced into TOP10 competent cells. Two Bacterial colonies were analyzed using PCR and the M13 forward and M13 reverse primers to identify those with an insert. The sequences of these clones were determined using a DNA sequencer  and DYEnamic ET Dye Terminator Sequencing Kit . A total of 230 cDNA clones were sequenced, 27 clones obtained from the reverse library (downregulated genes) and 30 clones obtained from the upregulated genes library. The sequences were analyzed using an annotation pipeline with four steps: (1) quality checking, phred base-calling, cutoff 0.09, minmatch 10 and minscore 20; (2) vector trimming and removal of undesirable sequences such as bacterial, mitochondrial and rRNA sequences; (3) masking of repetitive elements and screening of low-complexity regions by Repeat Masker, using the default settings RaSH) in fresh samples of penile squamous cell carcinoma. For qPCR, 12 fresh samples of penile squamous cell carcinoma positive for high-risk HPVs and a pool of 7 fresh normal penile tissue samples were used; the normal tissues were defined as the normal reference. Gene-specific primers for qPCR were designed for optimal hybridization kinetics using the Primer 3.0 program .qPCR was used to assess the expression of genes identified by rapid subtraction hybridization (TUBA1A) for the endogenous control. The primer sequences are available on request.Quantitative Real-time PCR was performed using an ABI prism 7300 sequencer detector system and SybrGreen PCR Core Reagent , following the manufacturer’s protocol. In brief, the reaction mixture  contained 25 ng cDNA, gene-specific forward and reverse primers for each gene, and 10 µL of 2x Quantitative Sybr Green PCR Master Mix . Relative quantification was given by the CT values, determined for triplicate reactions of penile tumor samples and reference samples for each gene and tubulin (ΔCt target (control - sample)/(E endogenous)ΔCt endogenous (control - sample), as previously described Therefore, the relative expression of each specific gene was calculated by using the formula: R = (E target)For histopathological evaluation, two observers that were unaware of the clinical data, reviewed independently the slides, and discrepancies were resolved by joint review of the slides in question. The primary lesion was staged according to the TNM classification system (Americam Joint Committee on Cancer) ANXA1 and p16 protein expressions in 20 histologically normal tumor margins (10 margins from squamous cell carcinoma of penis high-risk HPV positive samples and 10 margins from squamous cell carcinoma of penis HPV negative samples - control group), 24 squamous cell carcinoma of penis samples without HPV (HPV-negative group), 3 samples of squamous cell carcinoma of penis samples with low-risk HPVs (HPV-low risk group) and 20 squamous cell carcinoma of penis samples positive for high-risk HPVs (HPV-high risk group)  .The detection of ANXA1 and p16 were conducted in 4 µm sections of each designated formalin-fixed, paraffin-embedded tissue blocks. After an antigen retrieval step using citrate buffer pH 6.0, the endogenous peroxide activity was blocked and the sections were incubated overnight at 4°C with the primary antibodies: monoclonal anti-p16 (1∶1000)  or rabbit polyclonal anti-ANXA1 (1∶2000)  diluted in 1% BSA. After washing, sections were incubated with a secondary biotinylated antibody . Positive staining was detected using a peroxidase conjugated streptavidin complex and colour developed using DAB substrate . The sections were counterstained with hematoxylin.The ANXA1 and p16 densitometric analyses were conducted with an Axioskop II microscope  using the Software Axiovision™ (Zeiss). For these analyses five different fields from each tumor fragments were used and 20 different points were analyzed for an average related to the intensity of immunoreactivity. The values were obtained as arbitrary units (a.u.).post hoc tests for multiple comparisons. The significance level was set at P<0.05 for all analyses.Statistical analysis was performed using GraphPad Prism 6 software  and data were expressed as means ± SEM. The Mann-Whitney U test was used to assess differences in age. The Wilcoxon Signed Ranks Test was applied to compare the gene expression levels in tumor tissue and normal penile tissue. Data from protein expression detected by immunohistochemistry were statistically examined by Kruskal-Wallis with Tukey’s The presence of penile squamous cell carcinoma was confirmed in all samples analyzed using a histopathological revision examination; these samples were subjected to DNA extraction for molecular analysis. All fresh samples were positive for the amplification of a human β-globin gene.p = 0.70). HPV DNA was present in 23 of 47 (48.9%) penile squamous cell carcinoma cases studied. Most commonly only 1 genotype was identified [21 of 23 (91.3%)]. High-risk HPVs were present in 42.5% (20/47) of the cases and low-risk HPVs were identified in 10.6% (5/47) of penile squamous cell carcinoma samples. High-risk type 16 was the most prevalent type, present in 19 of 23 (82.6%) of HPV positive tumours. HPV18 was not detected. In the majority of HPV-positive tumours [18 of 23 (78.2%)] HPV16 was the only HPV type detected. In tumors with multiple viral infections there was a simultaneous presence of low-risk and high-risk HPV (The patient age range was 31 to 95 years (mean 63 years), with no differences between patients with penile squamous cell carcinoma HPV positive and HPV negative , warty (4.2%), papillary (2.1%) and sarcomatoid (2.1%). For the usual type, HPV DNA was detected in 19 of 39 (48.7%) tumours, with high-risk HPV16 present in 15 of 39 (38.5%) samples. Verrucous and warty subtypes were positive for HPV DNA in 50% of the analyzed samples, with HPV16 present in the HPV positive samples. HPV type 16 was detected in 100% of the papillary tumours. In contrast, HPV was not detected in sarcomatoid tumours. No association of any of the HPV genotypes with subtypes of penile squamous cell carcinoma was found .RaSH approach was adopted to identify genes expressed differentially in penile with high-risk HPVs. After alignment with the RefSeq database, sequences that presented >90% of the target sequence length at alignment were selected. These included ANXA, p16, RPL6, PBEF1 and KIAA1033.The tubulin level. In the evaluation of the target genes, penile squamous cell tumor samples were used, and a pool of normal penile tissues was used as a reference (control group).For the detection of genes expressed differentially in penile tumors, a gene expression profile was performed using 12 fresh samples of primary penile squamous cell carcinoma positive for high-risk HPVs. The relative expression levels of five genes were compared using qPCR, using triple determination and normalization based on the PBEF1, KIAA1033 and RPL6 did not differ between penile squamous cell carcinoma and normal penile tissue, with fold-change values for gene expression raging from 1.6 to 3.3. ANXA1 and p16 were overexpressed in penile squamous cell carcinoma samples compared with the sample reference (P = 0.002 and 0.0001 respectively) and the fold-change values for gene expression were 7.9 and 8450, respectively      (Immunostaining of ANXA1 was mostly weak or negative in the cytoplasm of cells from tumor margins (control group)  comparedoc test)  and HPV-oc test)  groups. oc test) . Immunoroc test)  and incroc test)  comparedoc test)  relativeoc test) . ANXA1 aANXA1 mRNA and Annexin-I (ANXA1) protein were detected in squamous cell carcinoma of penis. ANXA1 was the first member characterized of the annexin superfamily, characterized by the calcium-dependent ability to bind phospholipids. ANXA1 inhibits the activity of cytosolic phospholipase A2 (cPLA2) and cyclooxygenase-2 (COX-2), thus exhibiting anti-inflammatory, anti-pyretic and anti-hyperalgesic activities Overexpression of in vivo and in vitro and overexpression of E6AP enhances proteasomal degradation of ANXA1 in vivoFurthermore, it is the first time in the literature that ANXA1 protein overexpression is associated with HPV related penile cancer. It is known that E6AP binds to ANXA1 INK4a (p16) is a protein belonging to the inhibitors of cyclin-dependent kinase (CDK) 4 family (INK4a family). The inactivation of pRb by E7 causes p16 overexpression as p16 is regulated by negative feedback of pRb HPV induces cervical cancer through uncontrolled G1-S transition. The E6 and E7 proteins of high-risk HPV inhibit p53 and pRb proteins, cell cycle regulatory proteins that control G1-S transition ANXA1 and p16, in penile squamous cell carcinoma positive for high-risk HPVs. To the best of our knowledge this report is the first to describe ANXA1 protein overexpression in penile carcinoma with high-risk HPV independently of the subtype. These genes are associated with various physiological processes including cellular differentiation, cell proliferation and signal transduction, suggesting that they have an important role in penile carcinogenesis. However, additional studies are required in order to elucidate their specific role in penile cancer with high-risk HPV.This study identified two overexpressed genes,


Betapapillomavirus.A novel human papillomavirus (HPV), now officially recognized as HPV-159, isolated from an anal swab, was fully cloned, sequenced, and genetically characterized. HPV-159 has a genomic organization that is typical of cutaneotrophic HPV types, and it belongs to the genus  Alphapapillomavirus, predominantly found in anogenital lesions, and Betapapillomavirus and Gammapapillomavirus, typically isolated from skin and hair follicle specimens and recently from other locations, such as the oral cavity (Human papillomaviruses (HPVs) are a diverse family of small double-stranded DNA viruses, etiologically linked with various skin and mucosal epithelial lesions. Based on their nucleotide similarities in the L1 gene, HPVs are classified into genera, species, and types , two putative TATA boxes (TATAAA) of E6 promoter, and the polyadenylation site (AATAAA) for L1 and L2 transcripts . In conclusion, the genetic characterization of HPV-159 adds to the present repertoire of betapapillomaviruses and indicates a broader spectrum of epithelial tropism than has been appreciated previously for HPV types from the genus Betapapillomavirus.The complete genome is 7,443 bp in length, with a G+C content of 40.6%, and it contains five early  and two late (L1 and L2) genes, but no E5 open reading frame (ORF). The long control region (LCR) of 411 bp is positioned between the L1 and E6 genes and contains two consensus palindromic E2-binding sites (ACC-Nnscripts . The put protein . The putHE963025.The complete genome sequence of HPV-159 is available in the EMBL, GenBank, and DDBJ databases under the accession no.


This article reviews the existing realities in Uganda to identify opportunities and potential obstacles of providing universal routine HPV vaccination to young adolescent girls. Cervical cancer is a public health priority in Uganda where it contributes to about 50–60% of all female malignancies. It is associated with a dismal 5-year relative survival of approximately 20%. With adequate financial resources, primary prevention through vaccination is feasible using existing education and health infrastructure. Cost-effectiveness studies show that at a cost of US$2 per dose, the current vaccines would be cost effective. With optimal (≥70%) coverage of the target population, the lifetime risk of cervical cancer could be reduced by >50%. Uganda fulfils 4 out of the 5 criteria set by the WHO for the introduction of routine HPV vaccination to young adolescent girls. The existing political commitment, community support for immunization and the favorable laws and policy environment all provide an opportunity that should not be missed to introduce this much needed vaccine to the young adolescent girls. However, sustainable financing by the government without external assistances remains a major obstacle. Also, the existing health delivery systems would require strengthening to cope with the delivery of HPV vaccine to a population that is normally not targeted for routine vaccination. Given the high incidence of cervical cancer and in the absence of a national screening program, universal HPV vaccination of Ugandan adolescent girls is critical for cervical cancer prevention. Almost every case of cervical cancer is potentially preventable. Yet, women in low- as opposed to those in high-income settings have about a two fold cumulative risk of developing cervical cancer before the age of 65 years . EquallyPreventive HPV vaccines that protect against HPV 16 and 18 have been commercially available since 2006. Cervarix® made by GlaxoSmithKline (GSK) Biologicals, Rixensart, Belgium and Gardasil® made by Merck & Co. Inc.,Whitestation, NJ, USA. The antigens in these vaccines protect against oncogenic HPV types 16 and 18 responsible for 70% of cervical cancers, globally . The remThe introduction of these two vaccines presents an opportunity to prevent approximately 70% of cervical cancer cases, globally . Data frThere is an urgent need for preventive HPV vaccines in low-income settings particularly in Sub Saharan Africa (SSA) given the elevated age standardized incidence rates of cervical cancer . HoweverThe World Health Organization (WHO) recommends that routine HPV vaccination of young adolescent girls could be integrated in national immunization programs if 5 key criteria are fulfilled . These ind most frequent cancer among women aged 15–44 years. It contributes to about 40% of all malignancies reported by KCR, which represent 50-60% of all female malignancies. Current estimates show that annually, approximately 3500 women are newly diagnosed and 2400 die from cervical cancer. Projections show that by 2025, about 6400 new cervical cancer cases and 4300 deaths will occur annually [National data on cervical cancer burden in Uganda is not available. However, based on data from the population-based Kampala Cancer Registry (KCR), Uganda has one of the highest cervical cancer incidence rates in the world . The ageSince the 1960s, studies have shown an overall trend of elevated cervical cancer incidence among Ugandan women , which acareHPV™ test  presently under evaluation at the national referral hospital is accessed by very few women. Consequently, opportunistic cytology-based screening is offered upon request in a few selected hospitals.Access to new proven and appropriate low cost screening technologies such as visual inspection with acetic acid or Lugol’s Iodine (VIA/VILLI) that are based on “screen and treat” of positive cases in a single visit are limited to only a few referral health facilities. Similarly, the new HPV-based screening technologies such as the The majority (72%) of cervical cancer patients seen at the national referral hospital present with advanced disease . Most ofUgandan women are disproportionately affected by HIV/AIDS accounting for 57% percent of approximately 1.2 million adults living with HIV . Many stOther HPV-related cancers including anal, vulvar, vaginal and oro pharyngeal (excluding nasopharynx) are rare in Ugandan women .The Uganda National Drug Authority registered both HPV vaccines in 2007. Both were introduced in the public sector through donations to the Ministry of Health (MOH) ,31. GSK Merck & Co., Inc. through the Gardasil Access Program donated 1,600 doses of Gardasil to vaccinate 500 HIV positive girls aged 9–15 years . By the The main sources of funding for the health sector include the central government, donor projects, global initiatives and households through user fees levied in the private wings of hospitals. Uganda is one of the world’s poorest countries with approximately 38.0% of her population living below the international poverty line . CompareCost-effective analysis of HPV 16/18 vaccination in the 72 GAVI-eligible countries including Uganda has recently been published . CompareUganda has one of the youngest populations in the world with 50% of her population aged below 15 years . AlthougUganda has opportunities that could enhance the introduction of universal routine HPV vaccination of young adolescent girls including:The GOU is committed to protecting women of child bearing age from vaccine preventable diseases. In this regard, the budget line for vaccines and related supplies is protected in the MOH budget. Also, the ruling National Resistance Movement party in its manifesto 2011–2016 pledged to scale up HPV vaccination .The Public Health Act 1935 (Ch 281) and 2000 revision and the Local Government Act (Ch 243) ,48 mandaThe ultimate success of universal routine HPV vaccination will partly depend on acceptability of the HPV vaccine by the providers, parents and adolescents themselves. Although data on acceptability of the HPV vaccine is limited, health workers and teachers endorsed the HPV vaccine . AdditioFrom past experience, support from partners during the initial phases of new vaccine introduction is critical. GAVI has recently offered new support for HPV vaccine . Uganda There is an opportunity to build synergies between HPV vaccination and existing health programs such as the bi-annual CDP program, which is widely accepted by the community  and the HPV vaccination will bring together different stakeholders including teachers, and health workers in the departments of reproductive health, immunization, adolescent health and cancer who normally do not work together. This provides an opportunity to pool together available resources. With ample planning and appropriate packaging of messages to the community, it is feasible to deliver an HPV vaccine to young adolescent girls using existing health and educational infrastructure if adequate financial resources are available .The cost of the vaccine and its delivery is still a major potential obstacle. With Uganda’s high estimated population growth rate of 3.6% per annum , the groCultural barriers may arise for a vaccine targeting only girls. From past experience, roumours that oral polio and TT vaccines in Uganda were actually an anti-fertility vaccines became widespread and were difficult to manage for some years . AlreadyAlthough school attendance of girls who participated in the HPV demonstration project was high, attendance for girls in upper primary classes (P5-7) in general is unacceptably low as a result of high dropout rates and abseentism associated with menstruation ,57. In tHPV vaccination will have an impact on the cold chain, frequency of re-supply and transport at different levels. With the existing infrastructure, the capacity to store HPV vaccines seems inadequate as a result of broken down equipment and shortage of gas cylinders required to run the refrigerators during frequent power outages . Such chIntroduction of routine HPV vaccination will bring together staff from the traditional infant and childhood immunization, sexual and reproductive health and cancer control. These stakeholders will be involved in decision making on issues related to immunization. There are currently on-going discussions within the MOH to introduce pneumococcal, rotavirus and HPV vaccines before 2015. These vaccines are more expensive than the traditional infant and childhood vaccines . At a glNot all health policy makers are experts in the field of cervical cancer prevention and therefore may not be knowledgeable about HPV vaccines. Additionally, community members are generally uninformed about the need for vaccination of adolescents. An additional challenge would be how to provide culturally appropriate information to community members with limited or no reading skills, and who may not have access to regular mass media or may not even trust the government or health authorities . TherefoUganda fulfils 4 out of the 5 criteria set by the WHO for the introduction of routine HPV vaccination to young adolescent girls. Given the high incidence of cervical cancer and in the absence of a national screening program, universal HPV vaccination of Ugandan adolescent girls is critical for cervical cancer prevention.The authors declare that they have no competing interests.CB conceived the study, searched the literature, drafted the manuscript and produced the final table. FMM, ARK, PBN & EKM made substantial contributions to the manuscript and contributed to data interpretation. All authors read and approved the final manuscript.1Child Health and Development Centre, Makerere University College of Health Sciences, P. O. Box 6717, Kampala, Uganda. 2Department of Obstetrics and Gynaecology, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda. 3Uganda Virus Research Institute, P.O. Box 49, Entebbe, Uganda. 4National Institute for Health and Welfare, Oulu, Finland.


It is unclear whether L1-VLP-based human papillomavirus (HPV) vaccines are efficacious in reducing the likelihood of anogenital pre-cancer in women with evidence of prior vaccine-type HPV exposure. This study aims to determine whether the combined results of the vaccine trials published to date provide evidence of efficacy compared with control (hepatitis A vaccine/placebo).A systematic review and meta-analysis was conducted. Randomized-controlled trials (RCTs) were identified from MEDLINE, Embase, Web of Science, PubMed, Cochrane Central Register of Controlled Trials and references of identified studies. The bivalent vaccine containing HPV-16 and 18 VLPs from GlaxoSmithKline Biologicals , the quadrivalent vaccine containing HPV-6, 11, 16, and 18 VLPs from Merck & Co., Inc., , and the HPV-16 monovalent vaccine from Merck Research Laboratories  were evaluated.Cervarix, Gardasil and HPV-16 monovalent vaccine and HPV-associated cervical intraepithelial neoplasia grade 3 or worse was 0·90 . For the association between Gardasil and HPV-associated vulval/vaginal intraepithelial neoplasia grades 2–3, the overall OR and 95% CI was 2.25 . Sample size and follow-up were limited.Three RCT reports and two post-trial cohort studies were eligible, comprising data from 13,482 women who were included in the vaccine studies but had evidence of HPV infection at study entry. Data on efficacy was synthesized using the Mantel-Haenszel weighted fixed-effect approach, or where there was heterogeneity between studies, the DerSimonian and Laird weighted random-effect approach. The mean odds ratio (OR) and 95% confidence interval (CI) for the association between There was no evidence that HPV vaccines are effective in preventing vaccine-type HPV associated pre-cancer in women with evidence of prior HPV exposure. Small effects of vaccination however cannot be excluded and a longer-term benefit in preventing re-infection remains possible. Cervarix) and HPV-6/11/16/18 quadrivalent (Gardasil) vaccines are highly effective in preventing vaccine-type HPV-related genital pre-cancer in women who are HPV-negative at the time of vaccination.Cervical cancer is the second leading cause of cancer-related death in women.The lifetime risk of a woman acquiring any HPV infection is more than 80%. Half of women acquire cervical infection within 3 years of initiating sexual activity.The impact of vaccination on the prevalence of infection in previously exposed women may initially be small, as vaccination may not increase viral clearance.There is a need for evidence to inform policy on whether vaccination programmes in older women, who will have a higher proportion with prior exposure, are likely to be of value. The present study aims to determine whether the combined results of the L1-VLP-based HPV vaccine efficacy trials published to date provide evidence that anogenital pre-cancer incidence rates are also reduced in women with evidence of prior vaccine-type HPV exposure. In order to do so, we conducted a systematic review and performed a meta-analysis of published data relating to HPV-exposed women participants. This review was planned to look at vaccine efficacy specifically against HPV-16/18 associated anogenital pre-cancer in women with evidence of prior exposure to types 16 and/or 18. However, it was only possible to analyse vaccine efficacy against vaccine-type HPV-associated anogenital pre-cancer in women with evidence of prior exposure to vaccine and non-vaccine (high-risk) HPV types combined.A systematic search was undertaken of MEDLINE, Embase, Web of Science, PubMed, and the Cochrane Central Register of Controlled Trials to identify RCTs of prophylactic HPV vaccination published up to 30 August 2013.RCT reports and post-RCT follow-on cohort studies published in English that investigated L1-VLP-based vaccine efficacy against vaccine-type HPV-associated cervical intraepithelial neoplasia grade 3 or worse (CIN3+) or vulval/vaginal intraepithelial neoplasia grades 2-3 (VIN2-3/VaIN2-3) were reviewed. Studies providing data on the sub-group of women with evidence of prior vaccine-type HPV exposure, in the total vaccinated cohort (TVC) and the total vaccinated cohort-naïve (TVC-naïve), were eligible for inclusion. The TVC consists of all women who were randomized and received at least one vaccine dose irrespective of baseline HPV-DNA , cytological, and serological status. The TVC-naïve consists of all women who received at least one vaccine dose, and were seronegative and HPV-DNA-negative at baseline. Two post-trial cohort studies were included.in situ (AIS) are lesions with strong malignant potential. About 30% of large CIN3 lesions may progress to cervical cancer within 30 years.CIN3 and adenocarcinoma VIN3 and VaIN3 are precursors of HPV-related invasive cancers of the vulval and vaginal areas respectively. Due to the reporting in the RCTs of composite endpoints that combined moderate and severe vulval and vaginal lesions, the analysis was planned to use the composite endpoint of incident and persistent prevalence of VIN2-3 or VaIN2-3.Virological endpoints are prone to misclassification bias in women with evidence of prior HPV exposure. It is difficult to distinguish a re-infection in DNA-negative women, regardless of serostatus, from a ‘reactivation’ of previously undetectable, low-level viral persistence in basal cells. In addition, if seroconversion is detected in vaccinated women, who were DNA-positive but seronegative at baseline, the presence of antibodies could be due to a re-infection, delayed seroconversion to the original infection or response to vaccine. The analysis plan therefore excluded virological endpoints.Two independent reviewers (AM and HP) extracted data on trial design, inclusion criteria, participant characteristics, vaccines administered, endpoints, efficacy populations, and methodological quality.The HPV vaccine trials were not designed to determine efficacy in women with evidence of prior HPV exposure, those that were DNA and/or seropositive at baseline. However, such women were still included as it was not practical to test all potential participants at screening and prior to randomization. One published analysis that combined the results of RCTs that evaluated vaccine efficacy in a sub-group of exposed women (seropositive but HPV-DNA-negative) was eligible for inclusion.One post-RCT follow-on cohort study analysed a population of women defined as naïve to the relevant HPV type (NRT).Women from three trials, who were seropositive for one or more of HPV-6/11/16/18 but DNA-negative at baseline, contributed data twice to the CIN3+ and the VIN2-3/VaIN2-3 analysis. 2X homogeneity p-values and 2I statistics were used to formally assess heterogeneity across ORs using a Mantel-Haenszel weighted fixed-effect model.Effect sizes were summarized as odds ratios (ORs) with associated 95% confidence intervals (CIs). The event rates in the vaccine and control arms are displayed as a L'Abbé plot. Resulting heterogeneity between studies that presented data on CIN3+ was allowed for by incorporating a DerSimonian and Laird weighted random-effects model, since the true vaccine effects were likely to be different but qualitatively similar across studies. This systematic review was performed according to the methods recommended by the Cochrane Collaboration.The study search strategy is detailed in The methodological quality was high for the studies determined as eligible. Each demonstrated adequate reporting of allocation concealment, blinding and dropouts, and loss-to-follow-up. The longest follow-up period was 4 years. The event rates in the vaccine and control/placebo arms are displayed in In this review the women evaluated for vaccine efficacy were a sub-group of the women enrolled in the TVC.2I = 60%) between studies presenting data on CIN3+, and on inspection of the effect measures we interpret this to indicate that the effect of vaccination probably differed between the combined analyses and post-RCT follow-on cohort study. Exposure and disease status differed across the sub-groups of exposed women in these studies. In the FUTURE trials women with HPV-associated disease at baseline were included.There was significant heterogeneity  indicated no significant publication and related bias.CIN3+ The DerSimonian and Laird weighted mean OR for 10,127 women with evidence of prior HPV exposure was 0·90 .VIN2-3/VaIN2-3 The Mantel-Haenszel weighted overall OR for 3355 women with evidence of prior vaccine-type HPV exposure was 2.25 .There was no statistically significant reduction in CIN3+ or VIN2-3/VaIN2-3 incidence for vaccine recipients compared with control/placebo recipients.There was no evidence from this analysis that HPV vaccines given to women with evidence of prior HPV infection can prevent vaccine-type HPV-associated CIN3+ and VIN2-3 or VaIN2-3. However, there are several limitations to this review. The trials included were not designed or powered to evaluate the effect of vaccination in women with evidence of prior vaccine-type HPV exposure. There have been no RCTs to date that have been designed to investigate the effect of vaccination in previously exposed women. For example, the PATRICIA trial was designed to assess vaccine efficacy in women who were HPV-DNA-negative and seronegative at baseline.The endpoints investigated in this review were rare. The annual event rate is 0·19% for HPV-16 related and 0·038% for HPV-18 related cervical pre-cancer. VIN2-3/VaIN2-3 lesions were even less frequent.This meta-analysis was not able to look at the efficacy of vaccination on virological endpoints in previously exposed women. The efficacy of vaccine to prevent re-infection in seropositive and DNA-negative women, or following transient infection in DNA-positive women over 3–4 years is an important question. However, the absence of a reliable method to distinguish vaccine from natural antibody precluded us from investigating it in this meta-analysis.Due to the design of the studies included, it was also possible to analyse CIN grade 2 or worse (CIN2+) as the endpoint, which would increase the number of events over 3–4 years . HoweverAn analysis of women with HPV-associated anogenital disease in the TVC has suggested that vaccine provides protection against recurrent disease. Among all women who underwent definitive cervical therapy in the FUTURE I and II studies, quadrivalent vaccination was associated with a 64.9%  reduction in the rate of any subsequent CIN2+.Furthermore, pre-cancer typically takes 5–10 years to develop from incident infection,Finally, not all women in the VIN2-3/VaIN2-3 analysis were evaluated for vaccine efficacy against VIN2-3/VaIN2-3 associated with one or more of the types to which they were exposed (HPV-6/11/16/18). Women from one combined analysis who had evidence of HPV-6/11 exposure prior to vaccination would not have been at risk for HPV-16/18 associated VIN2-3/VaIN2-3.Therefore, this review was a refinement of the TVC in terms of exposed women, but it did not conclusively assess the effect of L1-VLP-based vaccination against vaccine-type HPV-associated anogenital pre-cancer in women who had been at risk for the endpoint prior to vaccination. Moreover, some patients (though proportionately not many) were double counted in the meta-analysis. Finally, the estimation of variance can be imprecise in a DerSimonian and Laird model with very small numbers of included publications. Findings should be interpreted with caution.There was no evidence from this analysis that HPV vaccines given to women with evidence of prior vaccine-type HPV exposure can prevent premalignant lesions related to these HPV types over a 3–4 year time frame. Given the number of events, a small effect of vaccination however cannot be excluded and this review could not address the issue of efficacy against recurrent infection. Further studies are warranted to investigate these issues.Table S1Distribution of odds in three eligible RCT reports and two post-RCT follow-on cohort studies. * Data for CIN3 and AIS was reported separately. The number of evaluable women and cases where combined to calculate ORs for CIN3+. **Number of evaluable women with evidence of prior exposure reporting at least one event. ‡Number of evaluable women with evidence of prior exposure not reporting an event.‡‡An OR less than 1 suggested vaccine protection. ¥Vaccine efficacy was estimated as 100x (1-OR) and expressed as the percentage reduction in odds of CIN3+ or VIN2-3/VaIN2-3 compared to the control/placebo.(DOC)Click here for additional data file.Table S2Distribution of odds in four studies. Results displayed in terms of vaccine efficacy against CIN2+. *Number of evaluable women with evidence of prior exposure reporting at least one event. ‡Number of evaluable women with evidence of prior exposure not reporting an event. ‡‡An OR less than 1 suggested vaccine protection. ¥Vaccine efficacy was estimated as 100x (1-OR) and expressed as the percentage reduction in odds of CIN2+ compared to the control/placebo.(DOC)Click here for additional data file.Checklist S1PRISMA 2009 checklist.(DOC)Click here for additional data file.


In Canada, a group of trainees have created a trainee-initiated and trainee-led national collaborative to provide a vehicle for trainees to examine the diversity of knowledge translation research and practice, and to link trainees from diverse geographical areas and disciplines. The aim of this paper is to describe our experience and lessons learned in creating the Knowledge Translation Trainee Collaborative. In this meeting report, we outline the process, challenges, and opportunities in planning and experiencing the collaborative's inaugural meeting as participant organizers, and present outcomes and learnings to date.Trainees ( The most efficient way to advance the science of KT while developing new scholars will be to encourage new research collaborations and partnerships  were awarded a grant , along wThe aim of this paper is to describe our experience and lessons learned in creating the KT Trainee Collaborative (KTTC). We outline the process, challenges, and opportunities in planning and experiencing the KTTC inaugural meeting as participant organizers, and present outcomes and learnings to date.The inaugural meeting followed six months of planning via teleconference and email. The planning committee established three meeting objectives: forming our network; identifying areas for collaboration; and, with KT experts, reviewing potential gaps and training areas in KT research. We developed an agenda toward these goals and distributed a call for applicants.Sixty-six applications were received from 14 Canadian universities. The applications were peer-reviewed by a group of planning committee members and KT experts. Review criteria included training, research interests, expectations, and anticipated contribution to the meeting. The aim of the review process was to assemble a group of trainees that could both contribute to and gain from capacity building in the field of KT. Thirty trainees attended the meeting: 11 from the planning committee and 19 accepted through the application process. Table The meeting involved four activities, interspersed by networking opportunities: setting the stage for future interaction/collaborations; goal-setting; KT expert-led discussion on potential gaps/training areas in KT research; and post-meeting planning. Dr. Ian Graham, Canadian Institutes of Health Research (CIHR) Vice President of KT, participated as the overall meeting facilitator.To begin the meeting, each attendee introduced her/himself in a two-minute prepared talk describing her/his research, career stage, KT interests, and something about her/himself. These introductions oriented us to each other's work, provided opportunity to practice a fundamental skill in scholarship (concisely describing one's work to an interdisciplinary audience), and ensured that all attendees participated early on.Two planning committee members  then facilitated a 'creating space' exercise to establish principles for interaction and a sense of 'safety.' We acknowledged that over time our 'space' would likely take different forms because it was expected that, going forward, the KTTC would meet both in-person and virtually. However, the focus of this exercise was to co-construct shared principles for relating to and with one another in the context of this meeting. We also acknowledged that all shared spaces are inherently characterized by competing interests, agendas, needs, and experiences. Our aim was to encourage these interests and to conceive of new ways of working together wherein we each feel included and valued. The facilitators invited small groups to consider questions about creating an inclusive and engaging workspace, then collated responses to form a foundation of shared understandings upon which we continued our meeting.To make sense of our group's goals and expectations, first, each attendee identified his/her individual goals. Then, we iteratively and thematically categorized individual goals into four collective goals: networking, collaborative learning, collaborative work, and professional development. Although it was evident that attendees held diverse research interests in a broad range of health areas, the four collective goals reflected our common perspectives and desires.KT experts presented their perspectives and experiences in three different areas identified as representing fruitful areas for further research and training: behavioural theory in policy/decision support (Dr. Jamie Brehaut ), uninteWe ended the meeting by developing a post-meeting plan. We brainstormed activities to help us meet our collective goals, and elected a Steering Committee to oversee activities and establish a governance structure. We also reached agreement on preferred technological mechanisms to support ongoing collaboration with limited resources.Using a 'two stars and a wish' exercise to garner feedback, wherein attendees were asked to list two things about the meeting they enjoyed and one thing they would like to see changed or improved, attendees indicated they felt: encouraged to be engaged in the process ; accomplished ('amazing how much we accomplished in 1.5 days'); and well-facilitated . Members wished for: a clearer vision ('more concrete sense of how to collaborate immediately') and more opportunities to network .From this meeting, the KTTC emerged as a uniquely trainee-initiated and trainee-led national collaborative to provide a vehicle for trainees to examine the diversity of KT research and practice, and to link trainees from diverse geographical areas and disciplines. We identify as a type of community of practice (CoP)  for KT tTo date, we have created a formal collaborative, and opened to new membership in February 2011. We have identity, mission, and vision statements  at all career stages. Eventually, the group adopted the latter interpretation and clarified it in our Mission and Vision statements.Second, as with any large group aiming for inclusivity of all members, we encountered tension between the desire for a 'flat' structure--with its potential for time-consuming and stagnating discussions--and the inevitable hierarchy of a formal collaborative. Further, at the meeting, open-ended questions to attendees such as, 'How would you like to do this?' were sometimes more off-putting than welcomed. Ultimately, the planning committee reconciled these issues by being transparent about the 'tyranny of structurelessness'  and by iet al. [i.e., either task-oriented, doing for others, or holistic/enabling others), our experience was one of and/both. As facilitators, we needed to provide some structure to the meeting, but also needed to ensure that each activity unfolded in a way that left all attendees feeling their contributions were authentically valued. In other words, and as Harvey et al. [Third, in the same way that facilitation is important in KT initiatives ,21, we fy et al.  by focusy et al. . In thisAdvances in KT will necessitate multiple perspectives, research approaches , and opehttp://www.ktclearinghouse.ca/kttc/.To learn more about membership in the KTTC, go to The authors declare that they have no competing interests.EC developed the outline of the paper, coordinated the content from all authors, and prepared the first draft with assistance from RU and HW. All authors contributed to the final content. EC, RU, VC, and HW edited the final draft. EC, RD, HW, RU, and HC revised the manuscript according to reviewers' comments. All authors have read and approved the final manuscript.


The quadrivalent human papillomavirus vaccine has been provided in Australia through the National Human Papillomavirus Vaccination Program since April 2007. National registry data demonstrates good coverage of the vaccine, with 73% of school-aged girls having received all three doses. To evaluate the effectiveness of the program, we propose a two-pronged approach. In one (sub study A), the prevalence of the vaccine-targeted human papillomavirus genotypes in a population cohort is being estimated, and will be analysed in relation to vaccination status, cervical cytology screening status, demographic, social, behavioural, medical and clinical factors. In sub study B, the distribution of human papillomavirus genotypes detected in high grade cervical intraepithelial neoplastic lesions from vaccine eligible women is being assessed.Sub Study A involves the recruitment of 1569 women aged 18–25, residing in Victoria, Australia, through Facebook advertising. Women who are sexually active are being asked to provide a self-collected vaginal swab, collected at home and posted into the study centre, where human papillomavirus DNA detection and genotyping is performed. Participants also complete an online questionnaire regarding sexual history, experience with, knowledge of, and attitudes towards human papillomavirus, the human papillomavirus vaccine, and cervical screening.Sub Study B will involve the collection of 500 cervical biopsies, positively identified as containing high grade cervical intraepithelial neoplastic lesions and/or adenocarcinoma in situ. Five serial sections are being taken from each case: sections 1 and 5 are being assessed to confirm the presence of the high grade cervical intraepithelial neoplastic lesions or adenocarcinoma in situ; human papillomavirus genotyping is performed on sections 2 and 3; single lesions are excised from section 4 using laser capture microdissection to specifically define causality of a human papillomavirus genotyping of each specific lesion.Australia is well placed to gain a clear and early insight into the effectiveness of the human papillomavirus vaccine in reducing the prevalence of human papillomavirus infection in young women, and any subsequent reduction in the prevalence of pre-cancerous cervical lesions, specifically high grade cervical intraepithelial neoplasia lesions, particularly of vaccine related types. The findings of a successful population based human papillomavirus program will have wide-reaching translational benefits across the globe. In addition, vaccination status along with demographic, social, behavioural, medical and clinical factors, including HPV related knowledge, will be assessed to identify predictors of genital HPV DNA in the cohort, HPV vaccination , and participation in cervical cytology screening (Pap testing).st June 1981) in Victoria. CIN3 has now been demonstrated to be the true precursor lesion to cancer, unlike CIN2 which is a poorly reproducible category of lesions which contains a mixture of acute HPV infection and true CIN3 [In sub-study B, the objective is to assess HPV genotypes in prospectively and systematically collected CIN3 biopsies, in combination with vaccination status where available, to assess the distribution of HPV genotypes detected in CIN3 biopsies from HPV vaccine eligible women  produced by the National Health and Medical Research Council of Australia.A sample of women aged 18–25 years are being recruited via a Facebook advertising campaign. This recruitment and data collection strategy was piloted, and established to achieve a broadly demographically-representative sample in this age bracket, by comparison with census data obtained from the Australian Bureau of Statistics . ParticiHPV detection and genotyping is being performed at the Western Pacific Regional HPV Labnet Laboratory located at the Royal Women’s Hospital, Melbourne, Australia. Each self-collected Flocked swab is rotated in 400μL of phosphate buffered saline (PBS) and 200μL utilized for DNA extraction using the automated MagNA Pure LC isolation and purification system  with the DNA-I isolation kit. Following nucleic acid isolation, all samples are being tested for the presence of mucosal HPV DNA using L1 consensus primer set PGMY09-PGMY11 . PCR proParticipants identified as positive for HPV-16 or HPV-18 are contacted and advised by a senior researcher regarding appropriate follow-up according to an ethics approved protocol used in a previous Australia-wide HPV genotyping study , with coA number of factors were considered in the calculation of the sample size required for the population cohort study, including age at vaccination, vaccination coverage, HPV-16/18 prevalence in the non-vaccinated population, and vaccine efficacy against persistent HPV infection, which were used to estimate the likely vaccine effectiveness that would be observed. In regards to age, there were two populations to consider, being the school-vaccinated population  and the GP/community-vaccinated women . In the school-vaccinated population we expect ~80% coverage (at least one dose ); whilstth June 1981.All cervical biopsies reported either at the Royal Women’s Hospital (RWH) Department of Pathology or Victorian Cytology Service (VCS) Pathology are being screened for eligibility for study. Biopsies are considered eligible for inclusion if CIN3 or ACIS is identified in the biopsy and subjects were born after 30Participant’s HPV vaccination histories are obtained from the NHVPR, where participants have provided consent to access their records as part of their clinical care. Self-reported vaccine status including number of doses and time of vaccination are requested for RWH participants at the time of their dysplasia assessment.Serial sections are taken from each case, 5 sections per block. Cross-contamination is minimised by ensuring that the microtome stage and forceps were cleaned with Para Kleaner  followed by ethanol between blocks, a fresh blade, and a new water container for floating of sections are used for each case. For each biopsy, the first and last sections are cut at 3μM thickness onto standard glass slides, H&E stained and cover-slipped. The first intervening section is cut at 8μM and placed onto a PEN membrane slide . This slide remains unstained and not cover-slipped until ready for Laser Capture Microdissection (LCM). The stained H&E slides are scanned using an Aperio ScanScope  slide scanner at 10x resolution, and reviewed by a pathologist who annotates CIN3 regions to be excised by LCM, using the Aperio ImageScope software (Aperio).The second and third intervening sections are cut at 8μM and placed inside a sterile 1.5ml Eppendorf tube for DNA extraction and subsequent HPV detection. These sections are firstly de-waxed by adding 800 μl Histolene reagent and 400μl 100% ethanol directly to the sterile 1.5ml Eppendorf tube. The supernatant is removed, the section washed in 100% ethanol and dried briefly at room temperature before digestion in Tissue Lysis Buffer (Roche) and Proteinase K and incubated at 55°C for 1 h and overnight at 37°C. The entire reaction is then loaded onto the MagNA Pure instrument (Roche) for automated DNA extraction. Subsequent HPV detection is performed using the RHA kit HPV SPF10-LiPA25, version 1 .Each unstained PEN Membrane slide is individually and manually de-waxed to minimise cross-contamination of tissue. The slide is de-waxed in two washes of 100% xylene (5 min each) and stored in 100% ethanol for LCM analysis. This is performed on the day of LCM analysis to minimise over-fixing the tissue to the slides. LCM is performed using an Arcturus Veritas Microdissection Instrument , using CapSure Macro LCM Caps (Life Technologies).DNA extraction from LCM captured tissue is performed using the PicoPure DNA Extraction Kit (Life Technologies). Briefly, 50μl of PicoPure Reagent is added to each CapSure Macro LCM Cap and incubated at 65°C for 13 hours, followed by 95°C for 15 min to inactivate the Reagent. Following incubation, HPV detection is conducted using the RHA kit HPV SPF10-LiPA25, version 1 .Baseline data for this study comes from a pre-vaccine era study of women treated for CIN3, with HPV typing performed by our laboratory on a concurrently collected cervical smear. The prevalence of HPV-16 or 18 for 78 women aged ≤24 was 66.7% and 9.0% respectively, and 69.2% overall. For the 102 women aged 25–29 it was 60.8% or 6.9% respectively and 63.7% overall. For women aged <25 years, a sample 217 of women will have 80% power to detect a fall from 67% to 50%. For women aged 25–29 years a sample of 276 women will have 80% power to detect a fall from 61% to 46%. Therefore, the total sample size was calculated to be 500 (220 women aged <25 and 280 women aged 25–30). If funding allows we will retrospectively analyse a separate random sample of pre-vaccine CIN3 specimens from young women using the current LCM methodology to provide an even more robust comparative baseline.Australia is a world leader in the early implementation of HPV vaccine programs, with approximately 83% of eligible females in the target population of 12–13 year olds having had at least one dose of the vaccine, and 73% having completed the 3 dose program . With thEarly understanding of the prevalence of HPV genotypes after vaccine implementation in the real world, rather than in the restricted population of phase 3 vaccine trials, will help refine estimates of the eventual impact and cost-effectiveness of universal HPV vaccination as a strategy to prevent cervical cancer. This data will be important for refining models of HPV infection and cervical disease to inform the renewal of Australia’s national cervical screening program .In addition, this study will provide key insights into the motivation for cervical screening behaviours in young women post-vaccination. A lack of awareness of young women that 30% of cervical cancers and 50% of high grade abnormalities will not be prevented by the vaccine could result in a decline in participation in cervical screening, and some loss of trust in the HPV vaccination program within the general community when cervical abnormalities are diagnosed among vaccinated women . For theWhilst natural induced immunity is type-specific, it is noteworthy that vaccine-induced cross-protection against non-vaccine HPV types that are phylogenetically-related, has been seen in recent phase III trials. The PATRICIA trial showed cross-protective efficacy against HPV-33, HPV-31, HPV-45 and HPV-51 following vaccination with Cervarix® . AnotherAn unresolved issue in relation to widespread HPV vaccination is whether a potential exists for the replacement of HPV-16 and 18 as the most prevalent oncogenic HPV types by other currently less common, but also strongly oncogenic, types. Current genetic and evolutionary understanding of HPV  suggests such a development is unlikely, with the weight of evidence suggesting only a slight interaction, at most, between infecting HPV types -45. HoweIn summary, the VACCINE study will add significant data to the information already emerging from population based programs regarding the impact of HPV vaccination in early adopter populations.ACIS: Adenocarcinoma in situ; CIN: Cervical Intraepithelial Neoplasia; HPV: Human Papillomavirus; LCM: Laser Capture Microdissection; NHVPR: National HPV Vaccination Program Register; PBS: Phosphate buffered saline; RWH: Royal Women’s Hospital; VACCINE: Vaccine Against Cervical Cancer Impact and Effectiveness; VAIN: Vaginal Intraepithelial Neoplasia; VCS: Victorian Cytology Service; VIN: Vulvar Intraepithelial Neoplasia; WHINURS: Women’s HPV Indigenous Non-Indigenous Urban Rural Study; WHO: World Health Organization.JMLB, DMG, MS, and SMG were partner investigators on an Australian Research Council Linkage Grant 2008–2011 on which CSL Biotherapies was a partner organisation. SMG has received funding through her institution to conduct HPV vaccine studies for MSD and GSK, advisory board and lecture fees and grant support from CSL and GlaxoSmithKline, and Sanofi Pasteur and is a member of the Merck Global Advisory Board plus the Merck Scientific Advisory Committee for HPV.EJY is the project manager and data manager for the study, and is the primary author of this manuscript. SMG, chief investigator of the study, conceived the study and was involved in study design, study coordination and helped to draft this manuscript. SNT has overseen all laboratory aspects of the study, including study design and data collection, and drafted the methodology section of this manuscript. JMLB was involved in study design, data analysis and helped to draft this manuscript. MP, DG, JDW, YJ were involved in study design. MS, JP were involved in study design, planning and co-ordination of histology processing and pathologic review of all study cases for sub study B. JT was involved in the study design for sub study B. CDW is involved in the coordination of sub study B. All authors read and approved this manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2407/13/296/prepub


Limited data suggested that the prevalence of Human Papillomavirus (HPV) among female sex workers (FSW) is much higher than in the general female population. The current study aimed to examine the HPV and cervical cancer related awareness, knowledge, and behaviors among FSW in China.A total of 360 FSW recruited from entertainment establishments in Beijing completed a self-administered survey including demographics, HPV related knowledge, and health-seeking and cervical cancer preventive behaviors.Approximately 70.8% of the participants ever heard of cervical cancer, and as few as 22.1% and 13.3% ever heard of HPV and HPV vaccine, respectively. The mean score on a 7-item knowledge scale was 2.2 (SD = 2.4). Less than 10% of FSW perceived any risk of cervical cancer, and only 15.3% ever had a Pap smear. About 40.8% of FSW would accept HPV vaccine if it is free, and 21.8% would accept it even with a charge. Multivariate regression suggested that women with better knowledge of cervical cancer were more likely to have a Pap smear (aOR = 1.35); women who had tested for HIV were 11 times more likely to have a Pap smear, and women who had worked longer in commercial sex (aOR = 1.01) and had regular health check-ups (aOR = 1.95) were more likely to accept HPV vaccine.Our study underscores the needs for effective cervical cancer prevention programs for FSW in China and other resource-limited countries. We specifically call for cervical cancer and HPV knowledge and awareness programs and regular screening as well as HPV risk-reduction programs for these vulnerable women. Cervical cancer, the second most common female cancer, kills more than 275,000 women annually. More than 80% of cervical cancer occurs in women in developing countries. As the most populous country, China has observed an increase in the cervical cancer incidence rate in younger females (25–44 years of age) within a context of a growing cancer burden ,2. For iAlmost all cervical cancers are caused by human papillomavirus (HPV) infection, one of the most common sexually transmitted infections -6. The pIn addition to an increasing cancer burden, the past three decades have also witnessed the resurgence of commercial sex in China because of widening income disparities and changing sexuality . An estiData in the current study were collected in 2011 from Chaoyang District in Beijing, China. Chaoyang District is the most populous district in Beijing with a population of about 3.64 million, including about 840,000 migrants. The study participants were recruited from local entertainment establishments  that were known to the local public health agency for providing commercial sex services. Our research staff approached owners or managers or other gatekeepers of these venues to obtain their permission to conduct research on their premises. Owners or managers of a total of 15 establishments were approached, and 11 of them agreed to participate. Once we received permission, we then invited eligible women working in these establishments to participate. Participation was completely voluntary. Eligibility criteria included the following: 1) 18 years of age or older; 2) acknowledged practice of commercial sex. A small number (3% to 8% with a mean of 4%) of women we approached in each of the 11 participating establishments refused to participate. A final sample of 360 women provided written informed consent and completed a self-administered confidential survey.The survey was conducted in separate rooms or private spaces at the establishments where women were recruited. No one was allowed to stay with participants during the survey except the interviewer, who provided assistance when necessary. All the interviewers had a prior experience working with FSW. For some FSW who never heard of cervical cancer, HPV, the HPV vaccine, or the Pap smear, the interviewer explained the terms to them before the FSW proceeded to the next question. For FSW who had reading difficulty, the interviewer read questions to them and recorded their oral responses in the survey. The survey typically took about 45 minutes to complete. Each participant received a research incentive of 20 Chinese yuan (approximately US$3.00) and reimbursement for their transportation expenses (up to US $5) upon the completion of the survey. The study protocol, including the consent process, was approved by the Institutional Review Board at Wayne State University School of Medicine in the US and Beijing Normal University in China.Demographic characteristics measures include age (in years), ethnicity (Han or ethnic minority), residency , marital status , education , length of time working in the city (in months), length of time working as a FSW (in months), and monthly income (in Chinese currency yuan). For the purpose of data analysis in the current study, we categorized ethnicity into Han and non-Han, educational attainment into less than nine-year schooling verses at least nine-year schooling, marital status into currently not married (including divorced or widowed) verses currently married (including cohabited). In addition, we divided FSW into two groups based upon the distribution of their age: younger than 25 years old and 25 years of age and older.Health-seeking behaviors were measured using two questions regarding whether the FSW ever had regular health check-up or HIV testing .Awareness. The participants were asked whether they ever heard of cervical cancer, HPV, and the HPV vaccine (1 = ever vs. 0 = never); they were also asked to rate their perceived likelihood of getting cervical cancer . For the purpose of data analysis, we assigned respondents who answered “very likely” and “likely” into “high perceived risk of cervical cancer” group; otherwise, we assigned them into “low perceived risk of cervical cancer” group.Knowledge of cervical cancer prevention and HPV was measured using a 7-item scale. The scale was developed based upon existing literatures [eratures ,31 as weeratures . The knocervical cancer preventive behavior included whether they ever had a Pap smear  and whether they would have an HPV vaccination . Respondents who answered “yes if free” or “yes even with a charge” were categorized into “1 = willing to have an HPV vaccine” group; otherwise, they are assigned into “0 = unwilling to have an HPV vaccine”.Questions on First, we conducted an exploratory data analysis to examine the distribution of key demographic and background variables of interest in the current study. The variables of interest included FSW’s demographic information and health-seeking behaviors. Second, we employed Chi-square test and ANOVA to compare women’s awareness as well as knowledge and behaviors with regard to cervical cancer and HPV. For analysis with knowledge, we only included responses from FSW who were aware of cervical cancer or HPV. Third, univariate logistic models and multivariate logistic models were employed to examine the association of cervical cancer-related preventive behaviors with key demographic and awareness variables. The measures of preventive behaviors (willingness of having an HPV vaccine and had a Pap smear) were dichotomized to serve as dependent variables in the logistic regression models. Demographic and background variables that were significantly associated with the preventive behaviors (p < .05) in the univariate analyses were included in the multivariate models as independent variables. Unadjusted odds ratios (ORs) and adjusted odds ratios (aORs) from the logistic regression models and their 95% confidence intervals (95% CIs) were used to depict the relationship between cervical cancer-related preventive behaviors and independent variables. All statistical analyses were performed using SPSS 18.0.Table As shown in Table Table This is one of the first studies that measures cervical cancer and HPV- related knowledge, awareness, and behaviors among FSW in China. Our data revealed that FSW in China had low levels of knowledge of cervical cancer, HPV, and the HPV vaccine. Few FSW perceived themselves at risk for cervical cancer despite their high exposure to multiple sex partners and high rates of unprotected sex. Only a small portion of FSW ever had a Pap smear, but many were willing to take the HPV vaccine. The level of cervical cancer- and HPV-related knowledge among FSW was lower than that of FSW in other countries, such as Thailand and Peru ,26. as wOur data provide useful information for further research and policy making. As China’s cancer burden continues to grow, more attention has been directed toward effective prevention programs . OverallTo date, no national cancer prevention program is available in China despite several national and international efforts working towards this goal ,34. MostEmpirical studies, including the ones conducted in China, showed that early screening can efficiently reduce cervical cancer mortality ,24. SeveOur study has several limitations. First, our survey was based on a closed-ended questionnaire; open-ended questions might have gauged better cervical cancer-and HPV-related awareness and perceptions, especially when no prior data were available from this population. Second, our study was based on a cross-sectional survey, and the correlation observed in our data could not be interpreted as a causal relationship. Finally, our sample was a convenience community sample which may limit our ability to generalize the findings to FSW populations in other areas of China.Our study examines HPV and cervical cancer related knowledge, awareness and behaviors among FSW in China. Despite being at high risk for HPV infection, they have very low levels of knowledge and awareness of cervical cancer and HPV; very low rates of Pap smears and perceived risks have increased their actual risks. These findings underscore the necessity and urgency of targeted intervention. We call for culturally appropriate programs to promote awareness of HPV and cervical cancer and to provide access to low or no-cost cervical cancer screening for all FSW and low-cost HPV vaccine for young FSW.The authors declare that they have no competing interests.YH made substantial contribution to conception and design as well as manuscript development. CZ performed data analysis and manuscript development. XL supervised the project, and participated in its design and coordination and helped to draft the manuscript. DL and YL collected research data. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/13/696/prepub


The aim of this randomized controlled trial is to assess the impact of financial incentives on (a) the uptake and completion of an HPV vaccination programme and (b) the quality of the decisions to undertake the vaccination.HPV vaccination reduces the risk of cervical cancer. Uptake however, of the ‘catch-up’ campaign in England for 17-18 year old girls is below the 80% NHS targetst and 3rd vaccinations. The secondary outcome will be the quality of the decisions to undertake the vaccination, measured by assessing attitudes towards and knowledge of the HPV vaccination.One thousand (n = 1000) 16-18 year-old girls will be invited to participate in an HPV vaccination programme: Five-hundred (n = 500) will have received a previous invitation to get vaccinated but will have failed to do so (previous non-attenders) and 500 will not have previously received an invitation (first-time invitees). Girls will be randomly selected from eligible participants who are registered with a GP in areas covered by the Birmingham East and North (BEN) and Heart of Birmingham Primary Care Trusts. The two samples of girls will be randomised to receive either a standard vaccination invitation letter or an invitation letter including the offer of vouchers worth £45 for receiving three vaccinations. Girls will also complete a questionnaire to assess the quality of their decisions to be vaccinated. The primary outcome will be uptake of the 1st and 3rd vaccinations; b) the role of participants’ socio-economic status in the moderation of the impact of incentives on uptake; and c) the impact of incentives on the quality of decisions to undertake the HPV vaccinations.The key results will be: a) the effectiveness of financial incentives in increasing uptake of the 1 Completion of all three vaccinations is necessary to effectively reduce the risk of cervical cancer [Human Papillomavirus (HPV) is an ubiquitous sexually transmitted virus that could lead to cervical cancer ,2. HPV vl cancer . The degl cancer .Since September 2008 a national programme has started in England and Wales aiming to vaccinate girls aged 12-13 against HPV. A two-year ‘catch-up’ campaign that offers the HPV vaccine to 17-18 year old girls has also been initiated. The objective of these HPV vaccination programmes is to provide three doses of the HPV vaccine to females before they become sexually active, when the risk of HPV infection and subsequent cervical cancer development increases. It is estimated that if this objective is met and vaccination coverage is sufficiently high (80% of the target population), up to 400 deaths per year in England could be prevented [Offering girls financial incentives to undergo the HPV vaccination could increase these uptake rates. Incentive mechanisms are increasingly being considered and used in health care policy in the UK and elsewhere in an attempt to change health-related behaviour ,9. They Even if effective in improving uptake of the HPV national vaccination programme, the use of financial incentives raises concerns about the possible adverse effects they may have on the quality of people’s decisions to engage in incentivised behaviours. For example, it has been argued that the prospect of receiving a financial reward could result in the risks associated with a particular health behaviour being overlooked .To date,In summary, further research is needed to determine the impact of financial incentives upon first, uptake of the HPV vaccination, and second, the quality of recipients’ decisions to get vaccinated. Furthermore, research is needed to determine the role of social deprivation in the moderation of the impact of financial incentives on uptake of vaccinations.The primary objectives of the present study are:(a) To assess the impact of financial incentives on the initial uptake (uptake of the first vaccination) and completion rates (uptake of the third vaccination) of an HPV vaccination programme.(b) To assess the impact of financial incentives on the quality of the decision to be vaccinated as measured by attitudes towards and knowledge of the vaccination.The secondary objective is:(a) To assess whether the impact of financial incentives on the initial uptake and completion rates of an HPV vaccination programme is moderated by participants’ levels of social deprivation.Those offered financial incentives to get vaccinated against HPV are more likely to receive the first and third HPV vaccinations.The effect of incentives on uptake of the first and third vaccinations will be moderated by participants’ levels of social deprivation, with larger effects of the incentives being observed for the most socially deprived.Offering financial incentives reduces the quality of decisions to get vaccinated against HPV.This is a randomised controlled trial in which two independent samples of participants are separately randomised to the offer of financial incentives for getting vaccinated.Participants will compromise of 16-18 year old girls, living in Birmingham. To be included in the trial, girls must fulfill the following inclusion criteria:(a) Live in areas falling under the administration of the Birmingham East and North (BEN) and the Heart of Birmingham Primary Care Trusts(b) Be registered with a GP within one of the two PCTs(c) Be eligible to be vaccinated through the clinics (d) Not have been vaccinated against HPV before.Half of the sample will consist of girls who have previously received an invitation to get vaccinated, but have failed to attend the first appointment (previous non-attenders). The remaining half will consist of girls who have not yet received an invitation to attend the vaccination programme (first-time invitees).The components of the intervention used in the present HPV vaccination programme are:All participants will receive letters inviting them to attend their first HPV vaccination session. These will be sent on behalf of the Birmingham East and North and Heart of Birmingham Primary Care Trusts, and will include the date, time and location of the allocated appointments.“(Name), don’t forget your HPV jab today at (time) at the (venue). Thank you”.Participants attending their first vaccination appointment will be asked to inform the researchers of their mobile phone numbers. These will be used to send text messages reminding them of their subsequent vaccination appointments. These will be sent during the intervals between the first and second vaccinations and the second and third vaccinations and two days prior to the next session. An example of the wording of these messages is: Participants from the two samples (i.e. previous-non attenders and first-time invitees) allocated to the incentivised groups will receive a modified version of the standard vaccination invitation letter, described above, which will include the offer of vouchers worth £45 for receiving the three vaccinations. Specifically, participants will be informed that they will receive:£20 for the first vaccination£5 for the second vaccination£20 for the third vaccinationhttp://www.healthyincentives.org.uk/, a social enterprise arising as a result of a partnership between the Young Foundation and the Birmingham East and North Primary Care Trust). The Birmingham East and North PCT has employed the Birmingham Primary Care Shared Services Agency (BPCSSA) to do the following: select participants to be included in the trial; randomise them to each group and post the invitation letters. Once the letters have been sent, the BPCSSA will provide the Healthy Incentives team with the details of all the participants who have been invited, including their names, addresses, scheduled vaccination dates, the participant group (previous non-attender or previously not invited) and randomisation group (incentive or not). The vaccinations for all individuals will take place at three community clinics. The BPCSSA will schedule a number of ‘incentivised only’ sessions at these clinics to avoid any tensions caused by not incentivising all groups. Vaccinations will be carried out by nurses working with Heart of Birmingham (HOB). When attending their first vaccination session and while waiting to get vaccinated, participants will be asked to sign a consent form and complete a measure assessing the quality of their decision to get vaccinated. They will also be requested to select a date for their next vaccination. Receipt of each vaccination will be contingent on completion of all the previous doses (i.e. in order to receive the 3rd vaccination participants will need to have first completed the 1st and 2nd vaccinations), with no skipping of doses being allowed. After receiving their vaccinations, participants in the incentivised groups will be provided with the appropriate shopping vouchers. Two days prior to their 2nd and 3rd vaccination sessions, the Healthy Incentives team will send participants text messages reminding them of their appointments.The trial will be run by the Birmingham East and North Primary Care Trust in collaboration with Healthy Incentives  A standard letter inviting them to attend their first vaccination session  A modified invitation letter, which will include the offer of vouchers worth £45 for receiving the three vaccinations  scores. This is a measure of multiple deprivation measured at the small area level, i.e. the Lower Layer Super Output Area (LSOA). It is made up of seven LSOA level domain indices, which relate to income deprivation, employment deprivation, health deprivation and disability, education skills and training deprivation, barriers to housing and services, living environment deprivation, and crime. IMD scores range from 0 to100, with higher scores indicating higher levels of deprivation.In order to assess whether the offer of financial incentives undermines the quality of decisions to undertake the HPV vaccinations, a short modified version of a validated measure of informed choice will be used . This wi1. Two items rated on a seven point scale, assessing attitudes towards the HPV vaccination: “For me, having the HPV vaccination is (a) 1: not at all good −7: extremely good and (b) 1: not at all harmful-7: extremely harmful.”; I am less likely to get other sexually transmitted diseases; I am less likely to get pregnant.”2. Three items assessing knowledge of the HPV vaccination by requesting participants to determine the validity  of three statements relating to the vaccination: “If I have the HPV vaccination: I am less likely to get cervical cancerrd vaccination) of the HPV vaccination programme by 8.5%, resulting in a completion rate of 40.9% by incentivised groups. To detect this difference between arms using a two-tailed χ2 test at the 5% significane level with 80% power, a sample of 1008 participants is required ; This figure has been rounded off to the nearest whole number, resulting in a required sample of 1000 participants , giving 500 in each intervention arm . Data relating to participants’ uptake of each of the three HPV vaccinations, along with their postcodes, age and answers to the measure of informed choice will be transferred by the Healthy Incentives team to CSI Health researchers. All information will be anonymised and kept securely. Data will be transferred via email in password protected files. CSI Health researchers will analyse the data with the aim of: i) determining the impact of financial incentives on uptake of the HPV vaccination and on the quality of girls’ decisions to get vaccinated; and ii) writing up and publishing the findings.The evaluation of the financial incentive scheme will be conducted by researchers at King’s College London, Centre for the Study of Incentives in Health  and completion of the HPV vaccination programme (i.e. the 3rd vaccination) logistic regressions will be performed separately for each of the two samples, i.e. for girls who have not received an invitation to get vaccinated before and those who have received a previous invitation but have failed to attend. To test the moderating effect of social deprivation on the impact of the intervention, the interaction between IMD scores and intervention will be added to the logistic regression models. To test whether there is a difference in the size of effect of the intervention in the two samples, datasets will be combined and another logistic regression conducted, in which whether participants have received an invitation to get vaccinated before or or not will be added as a predictor to the model, along with the intervention. To test for differences in the attrition rates between the 1The results of the study will produce valuable information regarding the potential effectiveness of financial incentives in increasing uptake and completion of the HPV vaccinations by teenage girls. The results will also provide valuable information regarding the validity of concerns about the potentially adverse effects of financial incentives on the quality of people’s decisions to engage in incentivised behaviours. If evidence from this trial supports such concerns, further research will be needed to assess how incentives might undermine informed choice, e.g. whether they alter who attends or whether they alter the attitudes towards and/or knowledge of the target behaviour in all who are offered incentives and therefore in those who attend. The design of the present trial does not allow for such assessments to be made.Knowledge regarding the impact of financial incentives both on uptake of the HPV vaccination and on the quality of decisions to engage in incentivised behaviours is lacking in the literature. Findings therefore, are expected to clarify these issues and have the potential to inform discussions concerning the increasing use of financial incentives for health promotion.th April 2011). NHS Permission for Research was granted by the Birmingham and the Black Country Comprehensive Local Research Network (BBC CLRN) Research Management & Governance (RM&G) Consortium Office on behalf of the BBC CLRN RM&G Consortium Trusts .The trial is run by the Birmingham East and North Primary Care Trust, in partnership with the Young Foundation, as part of the former’s service development. In consultation with the Trust, it was deemed that ethical approval was not required for its implementation. Ethical Approval was sought for researchers at King’s College London, Centre for the Study of Incentives in Health, to access data from the Birmingham East and North Primary Care Trust in order to evaluate the financial incentives scheme. This was granted by the Birmingham East and North Research Ethics Committee (reference 11/WM/0073, 8Current Controlled Trials, ISRCTN52339409.The trial is funded by the Birmingham East and North Primary Care Trust. The evaluation is funded by the Wellcome Trust, as part of a Strategic Award in Biomedical Ethics; programme title: “The Centre for the Study of Incentives in Health”; grant number: 086031/Z/08/Z.The authors declare that they have no competing interests.TMM advised on the research design. EM drafted the protocol. All authors provided input on the protocol and read and approved the manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6963/12/301/prepub HPV Vaccination Invitation Letters.Click here for file HPV Vaccination Survey Form.Click here for file


Since October 2001, more than 2 million Americans have served in the US wars in Afghanistan and Iraq, and nearly half of these veterans have been deployed more than once   . Data on2) . In a la2) . Further2) . Compare2) .Although it is easy to focus on risk behaviors, there are also potentially strong protective factors relating to tobacco use and weight gain that may be leveraged to reduce chronic disease risk. For instance, military culture highly values physical fitness. Evidence exists that the veterans of the Iraq and Afghanistan wars are more likely to engage in strength training compared with their nonveteran peers . AdditioBoth tobacco use and weight-related behavior patterns appear to be established during young adulthood and persist throughout life. Although most smokers had their first cigarette while they were adolescents, most young smokers have not established their smoking pattern before they reach age 18. Young adulthood appears to be the period when smoking patterns "lock in," as few people initiate or quit smoking in the decade following young adulthood  . Weight-Another reason to intervene during young adulthood is that the process of developing chronic disease begins often decades before symptoms emerge. For instance, most of the deaths associated with smoking can be avoided by quitting smoking by age 35 . ConsequWhat is needed to develop interventions, opportunities, policies, and systems that promote healthful lifestyles for returning veterans? First, we need more data that can describe the magnitude and correlates of the problem of risk behaviors in the population of young veterans. Our data-gathering processes must be updated to be consistent with 21st-century young adult culture. For instance, researchers and research institutions should be open to recruiting participants for studies by using social networking websites, surveying online, and formulating questions that are relevant to young adults. The data should tell us both who is at risk and how personal, cognitive, and environmental factors contribute to the establishment of behaviors and enable or impede behavior change. In the absence of knowledge about these issues in this new cohort of veterans, promoting more healthful lifestyles and providing preventive health services aimed at reducing health risk behaviors among Iraq and Afghanistan war veterans is an insurmountable challenge.The next step is to develop innovative interventions and craft policies that steer young veterans toward healthful behaviors long before signs and symptoms of chronic disease appear. Policies such as improving the nutrition of food served at National Guard drill weekends may contribute to positive dietary change. Other interventions could include developing opportunities for physical activity for veterans, such as fitness classes held at VA clinics. Ensuring that all Iraq and Afghanistan war veterans have access to free evidence-based tobacco use cessation aids could also reduce barriers to cessation.To reach young veterans, we need to establish partnerships that cut across traditional institutional domains, for example. Although the VA is the largest health care provider to veterans, many returning veterans are reluctant to use VA services. Since the wars began, only 51% of eligible Iraq and Afghanistan war veterans have sought care through the VA -19. SomeAdoption of healthful lifestyles has the benefits of improved health, reduced disease, and an enhanced quality of life for years to come. As young Iraq and Afghanistan war veterans return, many will interact with organizations that have a stake in their well-being, which represents an opportunity to emphasize ways to prevent chronic illness in this population.