Each participant had a 30-second oral rinse and gargle sample tested for 37 types of HPV DNA, and a risk-factor survey. Factors associated with prevalent infection were explored using log binomial regression. Men had higher prevalence of any oral HPV  and vaccine-type oral HPV  infection than women. In multivariate analysis, male gender , number of recent oral sex partners (p-trend = 0.013) and having ever performed oral sex on a woman  were associated with increased oral HPV prevalence. Performing oral sex on a woman may confer higher risk of oral HPV acquisition than performing oral sex on a man.Oral HPV infection, the cause of most oropharyngeal cancer in the U.S., is not well studied among high-risk young adults. Men ( While HPV vaccination is now recommended for both girls and boys in the U.S., many young adults remain unvaccinated ,2. Oral Oral HPV infection is associated with sexual behavior ,9,10, anRecent studies have reported oral HPV incidence to be higher among heterosexual than homosexual men, consistent with a hypothesis of higher risk of oral HPV transmission for cunnilingus  than fellatio  ,17. Given = 95; 12.3%), decided to receive the free HPV vaccination when study staff explained benefits , age outside targeted range , or unwillingness to return for follow-up .A total of 775 individuals were screened for the study during the enrollment period. Of these, 165 declined or were ineligible due to the following: a history of HPV vaccination (n = 340) and women (n = 270) enrolled was 21 years (IQR = 19–23), 69.6% were Black and 82.9% were heterosexual. Current use of tobacco (42.2%), marijuana (38.7%) and alcohol (76.1%) was common. All but two participants were sexually active, and the median age of first intercourse was 14 years among men and 15 years among women. Most of these young adults had three or more sexual partners (84.4%) and had ever performed oral sex (93.9%). Forty percent had a history of a sexually transmitted disease (STD). Men reported similar numbers of lifetime oral sex partners, but a higher number of recent oral sexual partners, than women , STD treatment (16.0%) or STD symptoms  . Most ofDespite being within the recommended age range for HPV vaccination, many women (46.0%) and men (79.3%) reported never having discussed HPV vaccination with a healthcare provider. Additionally, only 29.9% of women and 39.0% of men reported intending to receive the HPV vaccine in the future . As thesn = 10, 1.6% prevalence), HPV16 , and HPV51 , and the most common non-oncogenic types were HPV6 , HPV84 , HPV89 and HPV66 . The baseline prevalence of oral HPV infection in the study population was 12.0% (95% CI = 9.5–14.7).Among the 610 participants in the study, 105 prevalent, type-specific oral HPV infections were detected. The most common oncogenic infections were HPV59 , as were multiple, concurrent infections , and detection of a vaccine-type oral HPV infection  . Indeed, oral HPV prevalence increased significantly with number of recent (p-trend = 0.008) or lifetime (p-trend = 0.05) oral sex partners and with number of recent (p-trend = 0.079) or lifetime (p-trend = 0.004) vaginal sex partners  . Oral HPpartners .on a woman . Although not significant, oral HPV infection was more common among heterosexual than homosexual men , but less common among heterosexual than homosexual women . Prevalence was also higher among those reporting a current boyfriend/girlfriend  and other factors  was associated with increased oral HPV prevalence , but ever performing fellatio  was not  and ever performing cunnilingus  attenuated but remained marginally significant.In multivariate analysis, male gender  remained elevated after controlling for number of recent oral sex partners  may be particularly effective in high-risk populations such as patients at STD clinics.Several barriers to receipt of the HPV vaccine observed in this study have been reported previously, including lack of information and awareness of the vaccine, concern about side effects, and lack of perceived risk for HPV infection ,24,25. SThis study had several strengths and weaknesses. Participants were recruited at sexually transmitted disease clinics, targeted as a group more likely to have oral HPV infection, and do not reflect the general population. Data on genital HPV infection, or HPV infections in partners of participants were not available. Strengths of this study included centralized testing of all samples, inclusion of both men and women, focus on a group at increased risk for acquisition and transmission of these infections, and collection of risk behavior information using a computer assisted self-interview (CASI).versus longer infection duration to this difference between men and women.This study demonstrated that, after adjusting for oral sexual behavior, men have a higher prevalence of oral HPV than women. This increased oral HPV prevalence among men is consistent with the higher incidence of HPV-positive oropharyngeal cancers in men than women in the U.S. . CurrentWe enrolled young adults from two Baltimore County Health Department STD clinics between April 2010 and November 2012 in a cohort study of oral HPV infection . Patients in the targeted age range were given a study brochure when they checked into the clinic and then approached by the study coordinator if they were interested in finding out more about the study. Men and women aged 18–25 attending an STD clinic as a patient or sexual partner of a patient were eligible if they were: able to give informed consent, willing to comply with follow-up visits, able to comprehend English to complete the risk factor survey, and had no history of HPV vaccination and declined vaccination when offered. This paper analyzes the baseline results from this study. At study screening, all participants received counseling regarding the benefits of HPV vaccination and were offered vaccination at the STD clinic. Only those declining vaccination were enrolled.Participants provided a 30-second oral rinse and gargle using 10 mL of Scope mouthwash to test for oral HPV DNA and completed a computer assisted self-interview (CASI) on an iPad with questions about demographics, health, lifetime and recent (past 3 months) tobacco, alcohol and drug use, and sexual behavior. Sexual behavior questions included questions on performing oral sex , open-mouth kissing (French kissing) and vaginal sex. Given the study design to enroll unvaccinated high-risk young adults, we felt it was important to collect data on reasons for declining HPV vaccination. These reasons were also collected in the survey with pre-specified categories for reason as well as an “other reason” free-text response option.etc.). The study was approved by the Institutional Review Board at the Johns Hopkins Bloomberg School of Public Health and Maryland Department of Health and Mental Hygiene.Participants were given a cash incentive ($10) and an incentive gift of $2–$5 value  and non-oncogenic  [Oral rinse samples were stored at 4 °C for up to one week until processed. DNA was purified from the oral rinse using a magnetic bead-based automated platform , as previously described . Purifie 84, 89) . The linAt the time of this analysis, study enrollment was complete. Oral HPV prevalence was described overall and when classified as oncogenic, non-oncogenic, or vaccine  types. Multivariate risk factors of oral HPV prevalence were modeled using a log binomial model clustered by person to account for multiple infections. All variables which were significant in univariate analysis, or known to be of importance in the literature, were included in a multivariate model and removed in a stepwise fashion. Because of the co-linearity of sexual behaviors, sexual variables were considered in separate models. When the number of oral sex, vaginal sex, and deep-kissing partners were included in the same model, the association of each variable attenuated due to the collinear nature of these sexual risk factors, but oral sex remained more strongly associated and was therefore retained as the only sexual variable in the final multivariable model. Statistical analyses were conducted using STATA version 12.0 .This study demonstrated a higher prevalence of oral HPV infection among men than women, even after controlling for sexual behavior. These results are consistent with the hypothesis that differences in the number of oral sexual partners do not completely explain the higher risk of oral HPV infection and HPV-related oropharyngeal cancer in men compared to women.


In Brazil, the rate of cervical cancer remains high despite the availability of screening programs. With ongoing vaccine development and implementation, information on the prevalence of specific HPV types is needed, particularly among high-risk populations, such as HIV-infected women.We performed a study of HIV-infected women in Rio de Janeiro, Brazil, who underwent cervical HPV genotype testing between 2005-2013. We examined the prevalence of high-risk HPV types and the patterns of high-risk HPV type clustering. Using logarithmic binomial regression, we estimated the risk of abnormal cytology by HPV genotype result.p <0.001). No single high-risk HPV type was statistically associated with abnormal cytology after adjusting for the presence of more than one high-risk HPV type.Of the 562 women included, 498 (89 %) had at least one HPV type detected. 364 women (65 %) had at least one high-risk HPV type detected and 181 (32 %) had more than one high-risk type detected. HPV 58 was the most frequent HPV type detected overall , followed by HPV 53  and HPV 16 . Women infected with more than one high-risk HPV type were younger, had lower CD4+ lymphocyte counts, and were more likely to be infected with HPV 16 or 18. In adjusted analyses, presence of more than one high-risk HPV type was associated with a two-fold increased risk of abnormal cytology after adjusting for presence of individual high-risk type, age, and CD4+ lymphocyte count (adjusted prevalence ratios 1.88–2.07, all In the largest study of cervical HPV genotypes among HIV-infected women in Latin America, infection by high-risk HPV types other than 16 or 18 and infection by more than one high-risk HPV types were common. Infection by more than one high-risk type was more strongly associated with abnormal cervical cytology than any individual high-risk HPV type, highlighting the need for multi-valent HPV vaccines. Latin America has one of the highest incidence and mortality rates of cervical cancer in the world . As in oFor women with HIV infection, the risks and consequences of HPV infection are even greater. Women with HIV infection have higher prevalence of high-risk HPV types, are more likely to be infected with more than one HPV type, and are at increased risk of cervical dysplasia and cervical cancer –11. HIV-Given their increased risk, HIV-infected women are recommended to receive frequent screening for cervical dysplasia . VaccineTo address this need, we performed a prevalence study of cervical HPV infection among a cohort of HIV-infected women in Rio de Janeiro, Brazil. In this study, we describe the prevalence of HPV types, patterns of clustering, and patient clinical and demographic factors associated with high-risk HPV cervical infection and abnormal cytological outcomes.To examine the epidemiology of type-specific HPV infections, we performed an analysis of all HIV-infected women followed at the Women’s Cohort of the Instituto Nacional de Infectologia Evandro Chagas (INI), Fundção Oswaldo Cruz, who underwent HPV genotype testing by line assay at cohort entry. This study was approved by institutional ethics review boards of INI and Vanderbilt University.The Women’s HIV Cohort at INI is an observational study of the natural history of HIV infection in women that began in 1996. After recruitment from the general HIV clinic and signing informed consent, women complete surveys on sexual and gynecologic history and undergo routine cytology-based cervical cancer screening by Papanicolaou (Pap) tests and hybrid capture detection of oncogenic HPV DNA . Women with abnormal cytological results are referred for colposcopy and biopsies, as indicated according to the Brazilian Ministry of Health Guidelines. HIV history and pertinent laboratory results are obtained from the HIV clinical database .This study included women who enrolled in the Women’s HIV Cohort between 2005 and 2013. From 2005 through 2013, all women entering the cohort underwent cervical linear-array testing for HPV genotypes along with routine Pap smear testing at cohort entry. Cervical samples were collected using a cervical brush or swab and stored in conservative media . DNA was extracted by phenol-chloroform standard method. Five μL aliquots were used for HPV detection and genotyping using the Linear-Array HPV Genotyping Test  which targets low-risk HPV types  and high-risk (oncogenic) HPV types . Women with inadequate specimens or failed genotype testing were excluded from the study. HPV type designation of low-risk or high-risk (oncogenic) was performed in accordance to internationally-recognized classification . CervicaWe first described the distribution of low- and high-risk HPV types observed among all women. For descriptive purposes, overall prevalence rates and 95 % confidence intervals based upon normal distributions were calculated for the most frequently occurring types. We next examined the prevalence of each high-risk HPV type and of more than one high-risk type by cervical cytology outcome , defined as the proportion of women with the cytological outcome who were positive for the high-risk HPV type. To examine patterns of clustering of high-risk HPV types, we graphically examined the relative frequencies of each high-risk HPV pairing observed in women with abnormal cytology.We compared patient characteristics at the time of HPV testing associated with HPV genotype subsets: women uninfected with HPV, women infected with only low-risk HPV types, women infected with one high-risk HPV type, and women infected with more than one high-risk HPV type. Demographic and social factors included age, race, education, living situation, income, and tobacco use. We also examined sexual and health behavior, as well as HIV clinical variables including CD4+ lymphocyte nadir (defined as lowest recorded CD4+ lymphocyte prior to and up to 90 days after the HPV testing date), current CD4+ lymphocyte count , current HIV RNA value (up to one year prior), and total months since initiation of combination antiretroviral therapy (cART). Comparisons of HPV genotype group were performed using Wilcoxon rank sum and Fisher exact tests for continuous and categorical variables, respectively.p <0.01) were retained in adjusted models. Final models for each high-risk HPV type included the individual high-risk HPV type, age, CD4+ lymphocyte count, and presence of more than one high-risk HPV. In adjusted analyses, the detection of more than one high-risk HPV type reflects the relative risk of abnormal cytology associated with multiple high-risk HPV types, after accounting for the detection of the individual high-risk type included in the model, age, and CD4+ lymphocyte count. The individual high-risk type included in the model in the adjusted model reflects the risk of abnormal cytology adjusting for background risk associated with co-infections, age, and CD4+ lymphocyte count. To avoid co-linearity, for each model, presence of more than one high-risk type does not by definition include only those co-infections involving individual high-risk HPV of the model. P values were adjusted for multiple comparisons by Bonferroni correction in the final adjusted models .To study the association of each high-risk HPV type and presence of more than one high-risk type with abnormal cytology outcomes, we calculated prevalence ratios using logarithmic binomial regression. Prevalence ratios for abnormal cytology (defined as cytology results of ASC-US or higher) by demographic , social , and clinical  factors were first examined using unadjusted analyses (data not shown). Unadjusted prevalence ratios of each high-risk HPV type and presence of more than one high-risk HPV type for abnormal cytology were calculated. To develop the most parsimonious model possible, demographic and clinical variables highly statistically significantly associated with abnormal cytology . All p = 0.67). Excluded women had a higher proportion of failed hybrid capture tests ; however, among women with hybrid capture results, excluded and included women had similar rates of positive hybrid capture results . Lastly, excluded and included women had similar proportions of abnormal cervical cytology outcomes .From 2005 to 2013, 590 women enrolled in the women’s cohort and underwent HPV linear array genotyping at the time of cervical cancer screening. HPV genotype results for 28 women (4.7 %) failed or were incomplete, resulting in 562 women who were included in our study. Women with failed genotype testing who were excluded were statistically similar to those included with respect to age, race, education, and sexual history (data not shown). Excluded women had similar CD4+ lymphocyte counts at cohort entry compared to women included in the analyses . Women with infection by more than one high-risk type were younger than women with only one high-risk HPV type detected and were more likely to report a known HIV-infected sexual partner. They did not differ in reported condom use, tobacco, or hormonal contraception use. Women with more than one high-risk type had lower CD4+ lymphocyte count nadirs compared to women with no HPV types detected but did not differ from women with only one high-risk HPV type detected. However, women with more than one high-risk type had lower CD4+ lymphocyte counts at the time of HPV testing compared to both HPV negative women and those with only one high-risk type detected. Women with more than one high-risk type had a greater number of low-risk HPV types detected and were more often infected with HPV 16 or 18. Women with any high-risk type more frequently had abnormal cytology, with presence of more than one high-risk type associated with even higher frequency of abnormal cytology.Table The prevalence of high-risk HPV types and presence of more than one high-risk type by cytology result are shown in Fig. n = 166). Figure n = 10, prevalence = 6 %), 58 and 56 , and 16 and 56  were the most frequently observed high-risk HPV pairs. HPV 16 paired most often with HPV 58 (n = 7) and 68 (n = 7). Some high-risk HPV types occurred more frequently in paired infections than monoinfection, including HPV 39 and 68.We next examined the pairing frequencies of high-risk HPV types observed in women with abnormal cytology results  and analyses examined its epidemiology given its weakly carcinogenic risk. Of the 87 women infected with HPV 53, 67 (77 %) were also infected with a high-risk HPV type. Thirty-two (19 %) of all women with HPV 53 infection had abnormal cytology; however, 31 of these women were also infected with high-risk HPV types. One woman with HPV 53 infection without co-infection by a high-risk type was found to have ASC-US on cytology. In unadjusted analyses, infection by HPV 53 was associated with increased risk of abnormal cytology . In a model adjusted for age, CD4 lymphocyte count, and co-infection with high-risk types, the association was no longer observed .In this large study of HIV-infected women, we found that infection with high-risk HPV types and infection with multiple high-risk types, in particular, were highly prevalent and associated with abnormal cervical cytology. While HPV 16 infection was common, HPV 58 was the most common HPV type detected overall. Our study highlighted the role of infection by more than one high-risk type. Individual pairing frequencies of high-risk HPV types were relatively low overall; however, the presence of multiple high-risk HPV types was strongly associated with abnormal cytology outcomes, even when adjusting for detection of individual high-risk HPV types.In this cohort, infection by high-risk HPV types was common, occurring in more than half of all women. Infection with high-risk HPV types was associated with younger age and lower CD4+ lymphocyte counts. These findings are consistent with previous studies of this cohort and other studies of HIV-infected women in Brazil , 30–33. Additionally, infection with more than one high-risk HPV type was highly prevalent. Women with infections by more than one high-risk type were notably younger and had lower CD4 lymphocyte counts compared to women with high-risk HPV monoinfection. Increased risk of infection by multiple high-risk HPV types has been associated in HIV-infection and younger age –39. We aIn our study, presence of more than one high-risk type was consistently and independently associated with risk of abnormal cytology, after adjusting for presence of individual high-risk types (including HPV 16), age, and CD4+ lymphocyte count. Infection by more than one high-risk HPV type has been associated with increasing risk of cervical intraepithelial neoplasia , 41. A rIn this study, high-risk HPV 58 was the most common HPV type detected in all women, including those with multiple high-risk types detected and those associated with abnormal cytology. Worldwide, HPV 16 is the most frequently detected high-risk type, including in HIV-infected women . HoweverUnderstanding of epidemiology of specific HPV types, particularly in high-risk populations like HIV-infected women, is of critical importance for HPV vaccine development and implementation. While studies have suggested cost-effectiveness, general access to the HPV vaccines is not currently available in Brazil . ImportaOur study has important strengths and limitations. First, this study was designed as a cross-sectional analysis, which limits our ability to draw conclusions regarding causality. Additionally, without longitudinal genotype data available, we did not examine HPV infection clearance or long-term cytological and histological outcomes in this analysis. An important strength of our study is the large cohort of women included for which detailed health and behavioral information was available through questionnaires. This study reflects the largest epidemiologic study of HPV genotypes in HIV-infected women in Latin America. Nonetheless, women who chose to participate in the cohort may differ with those who declined and, given the single-center catchment, results from our study may not be generalizable to other settings. It is notable to highlight that all women who entered the cohort during the period of 2005-2013 underwent HPV genotype testing, thus minimizing the risk of selection bias of those tested. We used any abnormal cytology results as a composite outcome of interest rather than LSIL or HSIL. By including ASC-US outcomes, which are not as strongly associated with cervical intraepithelial neoplasia, we may have diminished the ability to detect risk conferred by specific high-risk HPV types and may have underestimated the effects of infection by more than one high-risk HPV.Finally, we included in our analyses those high-risk types most strongly considered oncogenic. Recently, a number of HPV types previously considered low-risk have been recognized to have some oncogenic potential, namely HPV 26, 53, 66, 67, 69, 70, 73, and 82 , 29, 53.In conclusion, in a large study of HPV epidemiology in a cohort of HIV-infected women in Brazil, we found that infection by high-risk HPV types and infection by more than one high-risk type were highly prevalent. Infection by more than one high-risk type was strongly associated with abnormal cytology, even after adjusting for age, CD4+ lymphocyte count, and specific high-risk HPV types. HPV type 58 was the most common HPV type detected overall and among abnormal cytological outcomes. Further studies on its risk for cervical intraepithelial neoplasia and longitudinal outcomes are needed. The diversity and frequency of infections by more than one high-risk HPV may have important implications on the effectiveness of second-generation HPV vaccines. However, the prevalence of high-risk HPV infections in this high-risk population underscores the importance of all methods of cervical cancer prevention, including regular screening and vaccine availability.


HPV infection causes cervical cancer, yet information on prevalence and risk factors for HPV in Africa remain sparse. This study describes the prevalence of HPV genotypes and risk factors associated with HPV among young women ≤ 30 years of age in KwaZulu-Natal (KZN), South Africa.Cervicovaginal lavage samples were tested for HPV genotypes in 224 women enrolled in a prospective cohort study. Clinical, behavioural and demographic data were collected. We measured prevalence of HPV genotypes and using logistic regression, examined for factors associated with HPV.Median age of participants was 21 years [interquartile range (IQR):18–23]. The overall prevalence of HPV was 76.3% (171/224) with multiple and single genotypes prevalent in 56.3% and 20.1% of women respectively. Proportion of women with high-risk genotypes  was 54.5%. Women not living with their partner [adjusted odds ratio (aOR)] = 3.42 95% CI1.22–9.60; p = 0.019), was significantly associated with HPV infection and high-risk HPV genotype infection.The high burden of HPV and associated risk behaviours highlight the need to intensify behavioural interventions to prevent HPV acquisition in young women. The large scale delivery of HPV vaccine should be prioritised to prevent HPV acquisition and reduce HPV-related morbidity. Human papillomavirus (HPV) is one of the most prevalent sexually transmitted viruses , 2. MoreGlobally, the prevalence of HPV among women with normal cytology is around 12%, whilst in Sub-Saharan Africa the rates are much higher at around 24%, ranging from 17.4% to 33.6% . Young wThe recently developed HPV vaccines offer hope in reducing HPV acquisition, a necessary cause in the pathogenesis of cervical cancer. Two types of vaccines are currently available in South Africa: a bivalent vaccine targeting genotypes 16 and 18 and a quadrivalent vaccine targeting genotypes 6/11/16/18 . The ranIn this study we determined the prevalence of HPV genotypes and explored the socio-demographic and behavioural factors associated with prevalent HPV among young women in KZN, South Africa.This study was an ancillary study nested within a larger HIV seroincidence study conducted by the Centre for the AIDS Programme of Research in South Africa (CAPRISA) in rural and urban KZN from March 2004 to May 2007 . BrieflyThe Roche Linear Array HPV Genotyping Test  was used for the detection of 37 high- and low-risk HPV genotypes in specimens. DNA from cervico-vaginal lavage (CVL) cell pellet was extracted for HPV typing using the Magna Pure Compact Nucleic Acid Isolation Kit I . This kit was used in conjunction with the MagNA Pure Compact Instrument  employing an automated extraction procedure performed according to the manufacturer’s instruction. Samples were tested blinded of other demographic, behavioural and HIV infection status data.Baseline variables were summarized as percentages for categorical variables, and mean or median for continuous variables . AlthougAll 224 enrolled women were Black African with a median age of 21 years (interquartile range [IQR]: 18–23 years). Just over half  of the women were from the rural area. Majority  of the women were in a relationship and reported having had one sex partner . Whilst a third  reported use of an injectable HC, about a quarter  reported using depot medroxyprogesterone acetate (DMPA) or norethisterone enantate (Nuristerate) . Less than half of the women  reported condom use .HPV prevalence was 76.3% (171/224) [95% confidence interval (CI) 70.8%-81.9%]. The distribution of the genotypes is shown in HPV was significantly associated in women who were not living with their partner (adjusted odds ratio (aOR) = 3.42; 95% CI 1.22–9.60; p = 0.019) . ResultsAmong women not living with their partner, 56% (112/200) had high-risk HPV infection. These women also had higher odds of having high-risk HPV infection compared to being HPV negative . Similarly, women who practiced intra-vaginal substance use had 2-fold higher odds of high-risk HPV infection . The distribution of high-risk HPV infection in these women was 66.7% (48/72). There were no observed associations between baseline risk factors and particular genotypes.The overall HPV prevalence of 76.3% in our study is almost 3–4 fold higher than reported estimates , demonstThe prevalence of high-risk genotypes in this study was 54.5%. In a recent study of 1,472 women from the Gauteng province, the prevalence of HPV DNA was 74.6% with high- risk HPV DNA in 54.3% ; similarWomen 18 years and older had a higher likelihood of multiple HPV genotype infection in this study. This may be due to a biological mechanism by which the acquisition of one genotype of HPV does, in some way, facilitate acquisition of another genotype . Also, sEpidemiological data on HPV prevalence and type distribution is crucial to evaluate the future impact of HPV vaccines. In this study, the number of women infected with vaccine high-risk genotypes was modest at 21% and is in keeping with findings from a cohort of sexually active HIV-uninfected South African adolescents 15.4%) [.4% [15].In our study we found that HPV prevalence was high both among women <18 years 70.3%) and ≥18 years 77.5%) old. These results are higher compared to global and local trends % old. Th and expl0.3% and Women reported to be with a partner yet not living with their partners, were at a 3.5 times greater risk of HPV infection, and had a similar risk of having high-risk HPV infection; suggesting that unmeasured sexual behaviour and sex partner characteristics  were important risk factors . Thus laet al [Regarding the role of HC use, HPV acquisition and subsequent development of cervical cancer; findings have been inconsistent as reported in the review by Morrison et al  where anet al , whilst et al . Anotheret al . In thiset al . FurtherIntravaginal practices may be associated with risk of HPV infection due to alterations in the vaginal pH, microflora, or cervical mucous . In thisThere are several limitations in our study. It is a small sample with limited power. We did not find an association with behavioural measures and condom use and prevalent HPV; reliable measurement of behaviours including consistent condom use remains problematic since face-to-face interviews were conducted leading to reporting bias due to social desirability (perhaps an over reporting of condom use) that could attenuate any true analysis of the effect of condoms . The effOur small sample size and the target population of Black African women aged 14–30 years limits generalizability to all women in South Africa, including women outside sub-Saharan Africa. Nevertheless, our population represented young sexually active women at risk of acquiring infections that are sexually transmitted. Whilst we used a molecular method for genotype identification, testing was carried out on stored samples and it is possible that there could be over time, some deterioration of sample quality with HPV positive samples misclassified as false-negative. Despite this misclassification HPV prevalence was as high and similar to reports from this region.The prevalence of HPV among women <18 years of age was extraordinarily high and it is therefore imperative that there should be determined efforts to rapidly roll-out, scale up and maximize on coverage of the recently developed highly effective HPV vaccines in preventing HPV acquisition, crucial to decreasing morbidity and mortality .S1 Dataset(XLSX)Click here for additional data file.S2 Dataset(PDF)Click here for additional data file.S1 Fig(A) % of women infected. (B) HPV genotype.(TIF)Click here for additional data file.S2 Fig(A) % of women infected. (B) Number of HPV types.(TIF)Click here for additional data file.


The cost-effectiveness of human papillomavirus (HPV) vaccination in women pre-sexual debut has been demonstrated in many countries. This study aimed to estimate the cost-effectiveness of a 3-dose bivalent HPV vaccination at ages 12 to 55 year in both rural and urban settings in China.The Markov cohort model simulated the natural history of HPV infection and included the effect of screening and HPV vaccination over the lifetime of a 100,000 female cohort. Transition probabilities and utilities were obtained from published literature. Cost data were estimated by Delphi panel using healthcare payers’ perspective. Vaccine cost was assumed Hong Kong listed price. Vaccine efficacy (VE) was based on the PATRICIA trial data assuming VE irrespective of HPV type at all ages on incident HPV. Costs and outcomes were discounted at 3 %. Cervical cancer cases and incremental cost-effectiveness ratio (ICER) for vaccination and screening compared with screening alone were estimated for each vaccination age. Reduced VE in women post-sexual debut were investigated in scenario analyses.With 70 % vaccination coverage, a reduction of cancer cases varying from 585 to 33 in rural and 691 to 32 in urban were estimated at ages 12 to 55, respectively. The discounted ICERs of vaccination at any age under 23 years in rural and any age under 25 years in urban were lower than the current threshold. Scenario analyses with lower VE post-sexual debut confirmed the results with age 20 in rural and 21 in urban had consistent lower ICERs. The more ‘catch-up’ cohorts vaccinated at the start of a program, the more cancer lesions are avoided in the long-term.Vaccination at any age under 23 years old in rural and any age under 25 years old in urban were cost-effective. Catch-up to the age of 25 years in rural and urban could still be cost-effective.The online version of this article (doi:10.1186/s12885-016-2207-3) contains supplementary material, which is available to authorized users. Cervical cancer (CC) is an important cause of morbidity and mortality among Chinese women. It is estimated the age-standardized incidence and mortality rates were 7.5 and 3.4 per 100,000 women in China in 2012, lower than corresponding world statistics, 14.0 and 6.8 per 100,000 [A new opportunity to reduce preventable deaths from cervical cancer is the use of HPV vaccination. Two prophylactic HPV vaccines are available since 2007 and have high efficacy (>90 %) for preventing high-grade cervical lesions associated with HPV-16 and HPV-18 . So far,The constant growth of healthcare demand, in an economic context characterized by limited resources, requires that the decision-making process is based on the comparison of alternative choices . The WorOur previous research have already estimated the incremental clinical and economic impact of HPV vaccination in addition to screening compared with screening intervention in rural and urban settings in China. However, important questions remain about how HPV vaccine should be used at population level. For example, what is the optimal age range for vaccination, and whether a catch-up vaccination campaign should accompany the introduction of routine vaccination?This economic study assumed a large age range from 12 to 55 years to evaluate the impact on the number of cervical cancer and incremental cost-effectiveness ratio (ICER) when adding vaccination to the current screening strategies in China. This wide age range allowed us to identify the age after which vaccination was no longer cost-effective. Since there is wide disparity in cervical cancer incidence and mortality, and unequal availability of health care services between rural and urban areas in China, our assessment will be based on a Markov cohort model adapted to each setting to evaluate lifetime costs and effectiveness of vaccinating girls aged 12 to 55. In such context, we propose to estimate the cost-effectiveness of a 3-dose bivalent HPV vaccination (3DBV) versus current screening practices at ages 12 to 55 years in both rural and urban settings in China.The model is a lifetime Markov cohort model  of Cancer Institute and Hospital of Chinese Academy of Medical Sciences (CICAMS) . The study population was a hypothetical cohort of 12–55 year old girls. The parameters in this modelling study were collected by expert consultation, literature review and data extraction from previous studies conducted by CICAMS in summary forms, so no individual patient information were involved, and informed consent was exempted by CICAMS’ IRB. We incorporated epidemiologic, clinical and economic data in the model to replicate the development of cervical cancer, and interventions such as vaccination, screening and treatment. Major data inputs are showed in Table A cost study from a societal perspective with a micro-costing approach had been conducted previously by our team to estimate aggregated costs associated with CC –21. We uThe two round Delphi panel, selecting 6 rural and 12 urban clinical gynecologists and epidemiologists from 8 provinces of China, was conducted to assess the costs of screening and treatment, the proportion of patients undergoing the treatment procedure for cervical intraepithelial neoplasia (CIN) and CC. The 8 provinces were chosen from Northern , Central , Western (Xinjiang) and Southwestern (Chengdu) of China. The two round panels lasted from August 2013 to December 2013 via written questionnaires.Since HPV vaccine has not been marketed in China, Hong Kong listed price (1900 CNY/3 doses) was used. In addition, we assumed the HPV vaccine could be added into current existing vaccine systems. Introducing a new type of vaccine into national immunization program can make use of existing personnel, equipment, cold chain management, and other management system and don’t need to build new systems. So we just need to consider the increased cost . The cost of HPV vaccine administration was calculated based on the marginal cost of introducing hepatitis B vaccine into China’s expanded programme on immunization, including the employee compensation, surveillance, propaganda, training, supervision, transportation, cold chain and other equipment that were related to the vaccine injection. The incremental vaccine administration cost for an additional dose of hepatitis B vaccine was 17.93 CNY/per child . FinallyData related to the natural history of the disease were derived from literature review –29 or caCurrently, Chinese cervical cancer screening program in rural areas sponsored by the government uses VIA/VILI or Pap smear as the primary screening method. In urban areas, most screenings are based on opportunistic exam or through employment-based physical exam using Pap smear. Therefore, we estimated 2/3 of screened women undergoing the Pap smear and the 1/3 undergoing the VIA/VILI in rural areas. In urban areas, we assumed all screened women undergoing Pap smear by the Delphi expert review panel . SensitiA 21.5 % screening coverage in urban areas was assumed as reported in the Human Papillomavirus and Related Cancers, Summary Report Update . From 20In the base case analysis, based on the results of the 4-year end of study analysis of the randomised, double-blind PATRICIA trial among HPV naïve girls, a 93.2 %, 64.9 %, 50.3 % overall efficacy against CC, cervical intraepithelial neoplasia 2 or worse (CIN2+), CIN1+ irrespective of types was assumed in the model as a proxy for vaccine effectiveness .The vaccination coverage was assumed as 70 % according to the hepatitis B vaccination uptake at three years after the availability of hepatitis B vaccination in China .A 3 % discount rate was used according to the WHO guidelines . We usedThe model essentially considered the perspective of the health care payer and included only direct medical costs.The main outcome measure used in the model was CC cases and the incremental cost/ quality-adjusted life-years (QALY). According to the recommendation of WHO, a strategy is ‘cost-effective’ when the ICER falls between 1 and 3 times per capita national gross domestic product (GDP) of the country . As therThe model was validated by comparing the age-specific incidence and mortality of CC in rural and urban China from the model with the ones reported by the National Office for Cancer Prevention and Control . CalibraThe base case analysis was performed on the two modelled cohorts of 12 to 55 years old girls, one cohort assuming to receive an HPV vaccination program with a 70 % coverage and screening, the other cohort assuming to receive only screening. In the regular base case analysis, only girls at one certain age would be vaccinated. For instance, vaccination at age 12 means that only the cohort of 12-year-old girls could be vaccinated; and vaccination at age 54 means that only the cohort of women aged 54 could be vaccinated. The vaccine efficacy was assumed constant across ages in base case analysis. The main outcome considered was CC cases prevented and the incremental cost per QALY gained for the vaccinated cohort compared with the non-vaccination cohort at ages 12 to 55 year in both rural and urban in China.The HPV-16/18 vaccine had efficacy against infection with HPV-16/18, with higher point estimates in the HPV naïve than in the women with HPV infection . So, theThe other was a catch-up program with additional vaccination cohorts up to age 25. An incremental approach was used to estimate the effect of catch-up scenario, that is, the vaccination of a 12-year-old cohort was compared with a supplementary annual vaccinated cohort in a stepwise manner to the final added vaccination cohort was 25 year old. In other words, regular vaccination would be conducted in the cohort of girls at age 12, and catch-up would be given to the cohorts of females older than age 12. The vaccination coverage rate for each supplementary cohort was fixed at 70 % .r = 0.985, 0.973, 0.954 and 0.952 for rural incidence, urban incidence, rural mortality and urban mortality respectively) . It could not analyse the benefits of herd immunity caused by the reduction of circulation of the infective agent. As a result, the benefits of the vaccination could be underestimated. Secondly, one of the uncertainties we had was whether HPV type replacement took place once vaccination against HPV-16/18 was widespread. The prevalence of HPV-16/18 may fall to very low levels with vaccination. Other oncogenic HPV subtypes currently responsible for relatively few CC case, might fill the niche left by HPV-16/18. To date, most vaccine trials have not seen significant increases in prevalence of non-vaccine types , and typWe conclude that 14 years old maybe the most favourable vaccination age in rural and urban, and a bivalent HPV vaccination program in girls before age 23 in rural and 25 in urban setting was shown to be cost-effective strategies for the prevention of CC in China. Catch-up programmes that extend to age 25 years in rural and urban could still be cost-effectiveness.


The association of human papillomavirus (HPV) types to neoplastic lesions increase as a function of their oncogenicity and the duration of the infection since lesion severity progresses from low-grade to high-grade and cancer. In an outbreak, the prevalence of the HPV type involved would increase and the proportion of the associated low-grade lesions would predominate over severe lesions. In this study, the prevalence of HPV types and their association to neoplastic lesions was determined in women subjected to colposcopy in San Luis Potosí, Mexico.DNA from high-risk (HR) and low-risk (LR) HPV types was identified by E6 nested multiplex PCR in cervical scrapes from 700 women with normal cytology, atypical squamous cells of undetermined significance (ASCUS), low-grade squamous intraepithelial lesions (LSIL), high-grade squamous intraepithelial lesions (HSIL) or invasive cervical cancer (CC).increasing (LSIL < HSIL < CC) for HPV16, HPV39, HPV18, HPV58, HPV31 and HPV35; asymptotic (LSIL < HSIL ≈ CC) for HPV51 and HPV68; U-shaped (LSIL < HSIL > CC) for HPV33.Overall HPV-DNA prevalence was 67.7 %, that of HR-HPV was 63.1 %, and that of LR-HPV was 21.3 %. The highest prevalence (78.2 %) occurred in the 15–24 year group, whereas that of single infections was 52 % and that of multiple infections  was 48 %. The most prevalent HR types were HPV33 (33.1 %), HPV16 (16.6 %), HPV18 and HPV51 (6.7 % each). HR-HPV prevalence was 29.6 % in normal cytology, 26.7 % in ASCUS, 63.3 % in LSIL, 68.2 % in HSIL, and 90.5 % in CC. Three prevalence trends for HR-HPV types were found in neoplastic lesions of increasing severity: U-shaped trend with progressing neoplastic lesions differs from the growing/asymptotic trends of other HR-HPV types. An ongoing or recent HPV33 outbreak is consistent with its high prevalence and anomalous association to LSIL.Two-thirds of the women subjected to colposcopy from 2007 to 2010 in San Luis Potosí have HPV infections which predominate in the 15–24 years group. Around half of the infections are by one viral type and the rest by 2–6 types. HPV33 is the most prevalent type, followed by HPV16. Overall HR-HPV prevalence increases with the severity of neoplastic lesions. HPV33 prevalence is highest in LSIL and its The online version of this article (doi:10.1186/s13027-016-0063-z) contains supplementary material, which is available to authorized users. Cervical cancer (CC) is the second cause of death by cancer among Mexican women . In MexiPersistent infection of the cervical epithelium by anogenital human papillomavirus (HPV) types induces neoplastic lesions that may progress to invasive cancer , 5. AmonThe prevalence of HPV types infecting the cervix serves to predict the efficacy of the vaccines that prevent both HPV infections and cervical neoplastic lesions . AlthougA previous study of our group on cervical infections by HR-HPV types in women from the capital city of San Luis Potosí demonstrated that HPV16 had the highest prevalence, 59 times that of HPV33 . The preThis cross-sectional study of women attending the five colposcopy clinics of the state of San Luis Potosí was approved by the Ethics and Research Committee of the State Health Services. Informed consent from each participant included her authorization for colposcopy, cervical scraping and biopsy sampling, HPV DNA detection and genotyping and the use of clinical and sociodemographic data. Personal data of the participants are strictly confidential. The official Mexican guidelines for cervical cancer prevention, diagnosis, treatment, control and surveillance are mandatory at all Mexican hospitals and authorize health personnel to take samples both for cervical cytology and HPV infection tests to any sexually active woman less than 18 years old who requests them. Women are referred to colposcopy if a cervical anomalous result is diagnosed through gynecological examination or cytology; HPV tests are offered to women subjected to colposcopy and may be performed through hybrid capture or PCR.Recruitment was based on the availability of sociodemographic and clinical data, and of the cervical cytological and histopathological diagnoses of the women attending the clinics located at the Health Center of the capital city, the general hospitals of Matehuala, Rioverde, and Ciudad Valles, and the Tamazunchale Community Hospital, between June 2007 and August 2010.Eight hundred and thirty-seven 15–85 years-old women were eligible for the study. Those with incomplete or missing clinical records, inadequate conditions for cervical scraping , or refusing to participate were excluded. Those with complete records, cytologic diagnosis before colposcopy, histopathologic diagnosis after colposcopy and informed consent were included.The variables analyzed were age at the time of the cervical scraping, prevalence of the HPV types identified and the cytologic and histopathologic diagnoses formulated with the 2001 Bethesda System : normal,n = 682 cases), calculated with the OpenEpi 2.3.1 software [The minimum size of a significant random sample . Fixed scrapes were short term stored, transported at room temperature and maintained in the laboratory at 4 °C until DNA was extracted .g) for 5 min in a Mikro 20 centrifuge . The supernatant was discarded and to the pellet were added 500 μL of TES , 50 μL of 10 % SDS and 20 μL of proteinase K (20 mg/mL). The mixtures were incubated 3 h at 56 °C in a thermoblock to digest proteins. After this incubation, 151 μL of 5 M NaCl were added and each mixture was centrifuged 15 min at 16,250 × g. The supernatant was carefully aspirated, transferred to a new tube to which 577 μL of isopropanol at −20 °C were added, and allowed to stand 10 min at 4 °C to precipitate the DNA. The tube was centrifuged at 16,250 × g for 10 min and the supernatant discarded by decantation [Each fixed sample was centrifuged at 13,000 rpm . The supernatant was carefully discarded by decantation and the pellet allowed to dry at room temperature for 15 min with the tube inverted on a paper towel. Pelleted DNA was dissolved with 50 or 100 μL of TE  and 2 μL were applied to the Epoch Micro-Volume Spectrophotometer System  to determine optical densities at 260 and 280 nm.The DNA pellet was washed twice with 1 mL of 70 % ethanol at room temperature and centrifuged 1 min at 10,000 rpm  and 1 unit of Taq DNA polymerase . Nested PCR mixtures contained PCR buffer, 152 μM dNTPs, 2 mM MgCl2, 0.3 μM HPV-type-specific oligonucleotides (each) and 1 unit of Taq DNA polymerase . PCR mixtures for β-globin contained 0.3 μM PC04/GH20 oligonucleotides and the same final concentrations of PCR buffer, dNTPs, and Taq DNA polymerase as in nested PCR. Amplification of the 260 bp segment of the human β-globin gene served to assess the quality of DNA in the HPV-negative cases [The initial mixtures contained PCR buffer , 200 μM dNTPs (each of the four), 1.5 mM MgClve cases .The four nested PCR mixtures contained a total of 18 oligonucleotide pairs specific for 13 HR-HPV types  and six BR-HPV types . Mixtures without DNA were used as negative controls, whereas mixtures with DNA of the SiHa cell line (transformed by HPV16), DNA of the HeLa cell line (transformed by HPV18) or the pHPV33 plasmid containing the complete HPV33 genome were used as positive controls.Incubations were performed in a 2720 thermocycler  under the following conditions. Starting PCR mixtures: initial denaturation at 94 °C for 4 min; 40 cycles at 94 °C for 1 min, 40 °C for 1 min and 72 °C for 2 min and a final extension at 72 °C for 10 min. Nested and β-globin PCR mixtures: initial denaturation at 94 °C for 4 min; 35 cycles at 94 °C for 30 s, 56 °C for 30 s, 72 °C for 45 s and a final extension at 72 °C for 4 min.Five-μL of nested or β-globin PCR mixtures were applied to SB-2 % agarose  5-mm thiWas performed with the Epi Info 7.1.1.14 software . Age wasn = 31) or DNA of insufficient quality (n = 36) , ASCUS , LSIL , HSIL  and CC   with the following diagnoses: normal cytology  and 48.0 % having multiple viral types (“multiple infection”). HR-HPV DNA prevalence was 63.1 %, and LR-HPV DNA prevalence was 21.3 % , HPV16 (16.6 %), HPV18 (6.7 %) and HPV51 (6.7 %). The most prevalent LR-HPV types were HPV6/11 (8.3 %), HPV43 (7.9 %) and HPV66 (5.3 %)  occurred in the 15–24 years group; decreased to 67.4 and 62.8 % in the 25–34 and 35–44 years groups, respectively; increased slightly to 65.8 %) in the 45–54 years group and to 69.1 % in the ≥55 years group  occurred in the 15–24 years group, decreased to 65.6 % in the 25–34 years group and was slightly lower and similar in the groups of 35–44, 45–54 and ≥55 years groups   corresponded to the 15–24 years group, decreased to 21.4 % in the 25–34 years group, was maintained in the 35–44 years group (21.6 %), reached its minimum value in the 45–54 years group (14.5 %) and increased slightly to 19.1 % in the ≥55 years group  and 25–34 years (35.3 %) groups, decreased in the 35–44 years group (28.6 %), was highest in the 45–54 years group (38.5 %), and decreased in the ≥ 55 years group (26.5 %). In contrast to HPV33 prevalence, the highest HPV16 prevalence (20.8 %) occurred in the 15–24 years group, was slightly lower but similar in the 25–34 and 35–44 years groups , decreased to 8.5 % in the 45–55 years group, and increased in the ≥55 years group (20.6 %) to a value similar to that of the 15–24 years group , 63.4 % in LSIL, 68.2 % in HSIL and 90.5 % in CC. In contrast, LR-HPV DNA prevalence was only 7.4 % in cases with normal cytology and increased to 26.7 and 28.6 % in ASCUS and CC , clearly lower in cases with normal cytology 14.8 %), and intermediate and similar in LSIL, HSIL and CC  , HPV16 and HPV51 (11.1 %); in ASCUS the only types detected were HPV33 (13.3 %), and HPV39 and HPV51 (6.7 % each)  and HPV16 (14.9 %). In HSIL the most prevalent type was HPV16 (20.3 %), followed by HPV33 (16.3 %) and HPV39 (11.5 %)  for HPV16, HPV39, HPV18, HPV58, HPV31, and HPV35; 2) asymptotic  for HPV51 and HPV68; and 3) U-shaped  only for HPV33. Such prevalence trends for HPV16, HPV68 and HPV33 are illustrated in Fig. Three prevalence trends as a function of neoplastic progression were identified among HR-HPV types Fig. : 1) incrThe most prevalent LR-HPV types in LSIL were HPV43 (7.8 %), HPV6/11 (7.2 %) and HPV66 (4.9 %); in HSIL they were HPV6/11 (13.5 %) and HPV43 = HPV66 (7.4 %); and in CC they were HPV6/11 (14.3 %) and HPV43 = HPV44 (9.5 %)  of the women included in the study were infected by HPV, a prevalence five to six times higher than that reported for women in the general population of Mexico  and otheNearly half of the HPV-positive women (47.9 %) had multiple infections, with a prevalence value in the upper end of the range of international studies .In the state of San Luis Potosí circulate all 19 HPV types identifiable by the nested multiplex PCR method  used in The most prevalent LR-HPV types were HPV6/11 > HPV43 > HPV66. Although the typing method used does not distinguish HPV6 from HPV11, international and Mexican studies suggest that HPV6 may be the most prevalent . The ordThe overall HPV prevalence found by us is higher than that reported for women of the general population or with normal cytology, and the age-specific prevalence curve is U-shaped, as expected, although less pronounced than the curves found in international studies of the general population –30. BothThe overall HPV infection determined correlates with the severity of neoplastic lesions as has been observed in international studies , 31 and The discordance between the diagnosis of neoplastic lesion and HPV infection probably derives both from the cytological overdiagnosis in cases of apparent lesions without infection 32.4 %) and the lower sensitivity of cytology and colposcopy in cases of infection without apparent lesion (29.6 %). These results reinforce the notion that HPV DNA detection is preferable to cytology as the primary screening test for CC .4 % and .In this study HPV33 was the most prevalent type in LSIL, whereas HPV16 is the most prevalent type in several multicentric international studies . Moreoveincreasing  for the more oncogenic types and asymptotic for the less oncogenic ones . In the present study both trends were found for all the HR-HPV types identified except for HPV33, whose highest prevalence was in LSIL, the most recent lesions. Besides its predominance, HPV33 was also the only viral type whose prevalence as a function of the severity of neoplastic lesions was not increasing or asymptotic but U-shaped . Both of these anomalies suggest that an HPV33 outbreak was taking place during the sampling for the present study.A previous study of cervical samples taken between 2004 and 2005 from women of the city of San Luis Potosí with similar sociodemographic and clinical characteristics to those of the present study found that HPV16, HPV31 and HPV18 were the predominant high-risk types . HPV33 pA recent study performed by Chen et al.  in 30 coCurrent prophylactic vaccines prevent both the infection and development of neoplastic lesions caused by the HPV types to which they are directed . They alThis work is being complemented by the identification of the HPV types present in paraffin blocks of CC specimens to estimate the prevalence and relative oncogenicity of the HPV types as well as which prophylactic multivalent vaccines would be most effective in this region.Two-thirds of the women referred to colposcopy in San Luis Potosí, Mexico, were infected by all 19 HPV types identifiable with the method used. Overall HPV prevalence was higher than that expected in the general population because the women included in the study had been shown to have abnormal cytology results. The unexpected order of prevalence of the major HR-HPV types was HPV33 > HPV16 > HPV18 = HPV58. HPV33 appeared to be causing an outbreak at the time of the study because it was the most prevalent and the only HR-HPV type whose association to LSIL predominated. The prevalence of the circulating HPV types and their association to neoplastic lesions suggest that the divalent and quadrivalent prophylactic anti-HPV vaccines could have prevented 23 % of the infections as well as 25 % of the HSIL and 62 % of the CC associated to HPV16 and HPV18.


Many, if not all, environmental pollutants/chemicals and infectious agents increase intracellular levels of reactive oxygen species (ROS) at the site of exposure. ROS not only function as intracellular signaling entities, but also induce damage to cellular molecules including DNA. Among the several dozen ROS-induced DNA base lesions generated in the genome, 8-oxo-7,8-dihydroguanine (8-oxoG) is one of the most abundant because of guanine’s lowest redox potential among DNA bases. In mammalian cells, 8-oxoG is repaired by the 8-oxoguanine DNA glycosylase-1 (OGG1)-initiated DNA base excision repair pathway (OGG1–BER). Accumulation of 8-oxoG in DNA has traditionally been associated with mutagenesis, as well as various human diseases and aging processes, while the free 8-oxoG base in body fluids is one of the best biomarkers of ongoing pathophysiological processes. In this review, we discuss the biological significance of the 8-oxoG base and particularly the role of OGG1–BER in the activation of small GTPases and changes in gene expression, including those that regulate pro-inflammatory chemokines/cytokines and cause inflammation. The etiology of inflammatory lung diseases is diverse, and often linked to environmental pollutants  and exposure to biological agents . When inhaled, such pollutants primarily impact the surface of the airway (airway lining fluid and epithelia), and when in excess, their interactions with the airway epithelium and resident immune cells usually result in the release of pre-synthesized inflammatory mediators, or gene expression, including that of pro-inflammatory genes, and cause acute inflammation and/or lead to both flare-up and worsening of established diseases .Most, if not all, environmental agents elicit the generation of reactive oxygen species (ROS), either directly, indirectly or both, which is among the first cellular responses. ROS operate as intracellular signaling molecules, a function that is commonly documented but whose mechanism is not fully understood . Due to In this review, we discuss the significance/role of genomic 8-oxoG and the 8-oxoguanine DNA glycosylase-1 (OGG1)-generated 8-oxoG base in lung inflammatory processes and inflammation-associated pathologies. We also provide data to support the novel concept of a role for OGG1-generated DNA repair intermediate(s) and repair products in the activation of cellular signaling controlling pro-inflammatory gene expression, and its possible link to acute and chronic inflammation that may be important in lung diseases.2−) and the non-radical oxidant hydrogen peroxide (H2O2). These reactive species are promptly detoxified, but when in excess, are converted into a hydroxyl radical (·OH), the most reactive oxygen-centered radical [2) and, via electron transfer, forms 8-oxoG [The primary ROS generated by biological processes are the superoxide anion , Nei (endonuclease VIII-like DNA glycosylase), and MutT  [To prevent 8-oxoG accumulation and its mutagenic effects, mammalian cells express DNA repair proteins that are analogous to the  GTPase) . OGG1 is GTPase) . OGG1 ha GTPase) . OGG1 is GTPase) ,20).N-glycosidic bond, and 8-oxoG is released from DNA as a free base [OGG1-initiated DNA base excision repair pathway (OGG1–BER) is a multistep process, which includes lesion recognition, changes in DNA structure, insertion of the 8-oxoG-containing DNA double helix into the base-binding pocket (active site) of OGG1, and base excision and strand cleavage ,20,21. Tree base ./apyrimidinic endonuclease 1 (APE1), generating a 1-nucleotide gap [After 8-oxoG base removal, OGG1, via its AP-lyase activity, cleaves the DNA phosphate backbone at the abasic site by formation of 3'-phospho-α,β-unsaturated aldehyde (3'dRP) and 5'-phosphate termini -site). The 3'-dRP terminus produced by the β-elimination reaction cannot serve as a primer for repair synthesis by DNA polymerases, so it must be removed by a 3'-phosphodiesterase activity of the apurinictide gap ,20,22. D2), metals , smoke of various origins, particulate matter , chemicals , radiation and others) [Compelling evidence has established that guanine is the main target for ROS in DNA, with 8-oxoG being the most frequent base lesion ,14,15. T others) ,33,34,35 others) ,33,34,35Inflammation is widely documented in common lung diseases, including asthma, chronic obstructive pulmonary disease (COPD) and other infiltrative pulmonary diseases ,39,40,41Ogg1 knockout (Ogg1−/−) mice were developed in independent laboratories [Ogg1−/− mice without severe consequences, e.g., the liver regenerated to the same extent as it did in untreated Ogg1−/− or Ogg1+/+ mice, and there was no incidence of precancerous lesions or tumors in various organs during a 16-month observation period [vs. wild-type), the mitochondria were functionally normal, and there were no detectable changes in maximal respiration rates or in mitochondrial ROS generation [Ogg1−/− mice have shown a decreased inflammation upon bacterial infection [To study the consequences of 8-oxoG accumulation in DNA and the role of OGG1 in patho-physiological processes, ratories ,53. Intrn period ,55. Simineration . Unexpecnfection  or challnfection , which mOgg1−/− mice are more resistant to lipopolysaccharide (LPS)-induced inflammation and organ dysfunction [Ogg1−/− mice are markedly protected from type I diabetes induced by streptozotocin. This protection was obvious from decreased hyperglycemia and a low incidence of diabetes, and an increase in β-cell mass. Pancreatic levels of macrophage inflammatory protein 1 α (MIP-1α), tumor necrosis factor alpha (TNF-α) and interleukin (IL)-12 were significantly lower, while basal pancreatic levels of IL-10 were increased in Ogg1−/− mice compared to the wild type (Ogg1+/+) ones [Szabo and colleagues documented for the first time that when compared to the wild type, function . The dec/+) ones . Althoug/+) ones ,60,61, aOgg1+/+, ovalbumine (OVA) challenge of Ogg1−/− mice causes significantly less inflammatory cell infiltration. A decreased inflammatory response was associated with lower levels of T helper (Th) 1 , and Th2 cytokines  and IL-17 levels in BALF and lung tissues. This was, in turn, due to decreased signal transducers and activators of transcription-1 (STAT1), STAT3, and STAT6 expression/signaling, and thereby to decreased NF-κB phosphorylation, after OVA challenge. These results are supported by data showing that downregulation of Ogg1 by siRNA led to lower ROS release and IL-4, IL-2, and IL-17 production, but higher IFN-γ production in lung epithelial cells [Li and colleagues  documental cells . The autD mice) before inducing allergic lung inflammation by RWPE challenge. Mice treated with scrambled RNAi were used as controls (OGG1 proficient: OGG1P mice). In these studies, Ogg1−/− mice were avoided, as they lack OGG1 activity globally . The results showed that the RWPE challenge-induced allergic inflammatory response was significantly lower in sensitized OGG1D mice, as determined by the expression of Th2 cytokines, number of eosinophils recruited to airways, epithelial metaplasia, and airway hyperresponsiveness (AHR). In contrast, OGG1–BER proficiency in the airway epithelium was coupled to robust innate (from 6–24 h) and late allergic (from 48–144 h) inflammation. The role of OGG1–BER in these processes was specific, as RNAi depletion of the Nei-like glycosylases NEIL1 and NEIL2 that preferentially excise ring-opened purines and 5-hydroxyuracil, respectively, had no significant inhibitory effect. In fact, NEIL2 somewhat increased innate and allergic immune responses. The mechanism of this is being presently investigated.Substantial amounts of data support the idea that the airway epithelium is the primary cell type in orchestrating an inflammatory response in the lungs ,63,64. Tet al. [Studies by Bacsi et al.  have proet al. , and, viet al. ,70,71. Uet al. ,72. In ret al. ,70,73, let al. ,78,79,80Kd) of 0.56 nM indicates tight binding of OGG1 with free 8-oxoG base [An implication of OGG1–BER in cell signaling was not evident until recent studies, showing that OGG1 binds free 8-oxoG base with high affinity, and the formed OGG1·8-oxoG complex has guanine nucleotide exchange factor (GEF) activity . The binxoG base . These rxoG base , which mxoG base ,22. The xoG base . In contxoG base  was not xoG base .in vitro studies was underlined by those showing that increasing the cellular 8-oxoG level by adding it to cells or activating OGG1–BER rapidly increased RAS–GTP levels in a cell type-specific manner. Activation of RAS led to phosphorylation of the mitogen-activated protein kinase (MAPK) kinase (MEK1/2), and extracellular signal-regulated kinase (ERK1/2), and the latter’s nuclear translocation [These intriguing observations gained high significance because the 8-oxoG-induced conformational change in the OGG1 molecule allowed its interaction with and activation of small guanosine triphosphatases (GTPases). Specifically, in the presence of 8-oxoG, OGG1 caused replacement of GDP for GTP bound to Kirsten rat sarcoma viral oncogene homolog , neuroblastoma RAS viral oncogene homolog (N-RAS) and Harvey (H)-RAS. Thus, the OGG1·8-oxoG complex functions as a GEF in a manner similar to that of other Ras-activating factors ,84. The location ,85.et al. (2014) provided further insights into the biological consequences of OGG1-initiated release of 8-oxoG from DNA [There is high sequence homology among the RAS and Ras homology (Rho) family of small GTPases (RHO) family of GTPases (Ras-related C3 botulinum toxin substrate 1 GTPase (RAC1), RAC2 and RAC3), and cell division control protein 42 homolog , which lfrom DNA . These afrom DNA . Taken tfrom DNA ,87,88,89To test for the link between OGG1·8-oxoG and RAS activation, as well as increased pro-inflammatory chemokine/cytokine expression and inflammation, mouse lungs were challenged intranasally with 8-oxoG base . At various times thereafter, lung extracts were prepared and activated levels of RAS–GTPase examined by an active RAS pull-down assay. Challenging the lungs with 8-oxoG base resulted in activation of RAS–GTPase as shown in Utilizing cultured cells, previous studies showed that activation of RAS by OGG1·8-oxoG induces downstream signaling, e.g., MEK1/2, and ERK1/2 ,85. To fRas antagonist, farnesylthiosalicylic acid (FTS), was found to be beneficial in lowering autoimmune, acute and chronic inflammatory processes [in vivo [The relevance of RAS–GTPase and downstream signaling in lung inflammation is underlined by studies using pharmacological inhibitors of RAS and RAS-induced pathways. For example, the rocesses . Similarrocesses . The Rafrocesses . PD09805rocesses . The PI3rocesses , and als[in vivo .In vivo, the 8-oxoG base can be generated specifically by OGG1-initiated BER [in vitro [in cellulo before being excreted from the cells into the extracellular milieu. This hypothesis is supported by data showing that in OGG1 activity-deficient mice, which do not generate the 8-oxoG base, innate and allergic inflammation are decreased after challenge with LPS, OVA, or RWPE [Increased 8-oxoG levels in the serum, urine, and sputum of individuals exposed to environmental pollutants or of asthmatic and COPD patients are considered biomarkers of ongoing inflammatory processes (see above). ated BER . Althougin vitro , we prop or RWPE ,62,65.Tnf) and chemokine(C–C motif) ligand 3 (Ccl3) were examined using appropriate primers with qRT-PCR. As shown in Ccl3 , and Tnf mRNA levels were increased from 30 min on, reaching their maximum after 60–120 min of challenge. We also examined their expression at the protein level after 120 min of 8-oxoG exposure. We found that protein levels of TNF-α and CCL3 were increased 10,600 and 9200-fold, respectively, compared to the mock-treated control. These mediators individually or in combination are potent inducers of pro-inflammatory gene expression [To test the role of OGG1–BER in an immune response, mouse lungs were challenged with the repair product, 8-oxoG base, as described in the legend to pression . TherefoCcl1, Ccl19, Ccl2, Il6st, Il4, Il13, Il3 and Igam only at 60 min (1.8–2.1-fold) and unaltered, or downregulated  at all time points. Cluster B contains 37 genes out of which 19 genes were upregulated , and C–X–C motif chemokines  and Tnf. In addition to chemokines/cytokines, 8-oxoG challenge of lungs increased the expression of chemokine receptors, including Ccr1, Ccr7 and Ccr8. As shown in Cxcl1 expression is the highest (>65-fold) among the genes included in the array, followed by Ccl3 (>10-fold), Ccl20 (>7-fold), Tnf (<9-fold), IL1a (>5-fold) and IL1b (>4-fold). We note that mRNA levels for these chemokines and cytokines could actually be higher at the site of exposure in the airway epithelia, as RNAs were isolated from the whole lungs.Next, mice were challenged with 8-oxoG base (50 ng per kg), lungs were harvested, and RNAs were isolated after 0, 60 min and 120 of challenge. Purified RNAs from five mice per time point were pooled and reverse transcribed, and the cDNAs subjected to analysis. RNA levels of pro-inflammatory mediators were determined by using an RT² Profiler PCR Array containing 84 key genes . The results are summarized in For further evaluation, genes altered significantly at 60 min post-exposure were subjected to PANTHER analysis to identify and rank the signaling pathways . The resImportantly, chemokine/cytokine and interleukin signaling pathways account for more than 60% (63.9%) of the total genes activated by OGG1–BER product 8-oxoG, which may mean that 8-oxoG challenge induced primarily an inflammatory response.To test whether increased expression of chemokines/cytokines/interleukins translated into actual lung inflammation, mice were challenged i.n. with 8-oxoG base (50 ng per kg) . In contThese results suggested to us that the 8-oxoG base was taken up by the epithelium. When internalized, 8-oxoG possibly formed a complex with OGG1 as proposed previously . The OGGEnvironmental exposures and an increase in the genomic 8-oxoG level have been associated with inflammatory lung diseases. Intriguing recent studies have shown that a decrease in OGG1 activity markedly prevented chemokine/cytokine expression and a cellular inflammatory response. Based on previous studies and the data shown in this paper, it is evident that OGG1-initiated DNA BER led to the generation of an OGG1•8-oxoG complex that functions as a guanine nucleotide exchange factor “fueling” the activation of small GTPases, which generate cell activation signals for increased expression of pro-inflammatory chemokines/cytokines leading a full-blown inflammatory response. OGG1–BER-mediated inflammation could be an important physiological  response aimed at host protection upon environmental challenge. However, it is also possible that when the challenge of the host occurs in association with pre-existing conditions  where inflammation is not properly controlled, OGG1–BER-driven innate signaling may exacerbate ongoing diseases and aging processes. In addition, the data provided in this review point to a novel mechanism—the potential role of OGG1–BER in the maintenance of chronic inflammation, not only in the lungs, but also in other systemic diseases—such as cardiovascular, arthritis, cancer, dementia, obesity, and diabetes.


Researchers at the U.S. Department of Veterans Affairs (VA) have used administrative criteria to identify homelessness among U.S. Veterans. Our objective was to explore the use of these codes in VA health care facilities. We examined VA health records (2002-2012) of Veterans recently separated from the military and identified as homeless using VA conventional identification criteria , plus closely allied V60 codes indicating housing instability. Logistic regression analyses examined differences between Veterans who received these codes. Health care services and co-morbidities were analyzed in the 90 days post-identification of homelessness. VA conventional criteria identified 21,021 homeless Veterans from Operations Enduring Freedom, Iraqi Freedom, and New Dawn (rate 2.5%). Adding allied V60 codes increased that to 31,260 (rate 3.3%). While certain demographic differences were noted, Veterans identified as homeless using conventional or allied codes were similar with regards to utilization of homeless, mental health, and substance abuse services, as well as co-morbidities. Differences were noted in the pattern of usage of homelessness-related diagnostic codes in VA facilities nation-wide. Creating an official VA case definition for homelessness, which would include additional ICD-9-CM and other administrative codes for VA homeless services, would likely allow improved identification of homeless and at-risk Veterans. This also presents an opportunity for encouraging uniformity in applying these codes in VA facilities nationwide as well as in other large health care organizations. U.S. Veterans are at higher risk for homelessness compared to the general population and are over-represented within the homeless population . AccordiBy convention, VA researchers have used administrative criteria to identify homelessness among Veterans, such as ICD-9-CM coding by providers and VA specific administrative codes for outpatient clinics and inpatient treatment specialties indicating receipt of homelessness services –7. The kThere have been no systematic investigations of the administrative use and consequences of applying V60.0 as compared to one of the V60.x codes or the clinic and treatment codes to identify Veterans experiencing homelessness. Additionally, it is possible that non-uniform or non-standardized assignment of V60.0 to Veterans who are indeed homeless  and, conversely, the non-recognition of homeless Veterans who might receive a V60.x code instead of V60.0, could result in needy and eligible Veterans not being offered appropriate services in a timely manner. This in turn could lead to barriers to access to care and disparities among an already vulnerable population of Veterans. A related issue is that if V60 codes are not being used in a systematic or standardized way in the VA, this would have implications for arriving at accurate estimates of the prevalence of homelessness among Veterans. Finally, as stated by Brown, et al. , “…even Collectively, these issues underscore the need to better understand and standardize the use of all V60 codes. With anticipated transitions to the ICD-10 classification system .The purposes of this study are to 1) explore the use of V60 codes in the VA health care system for identifying homelessness among Veterans and 2) contribute to the accuracy of determining homelessness among Veterans in order to enhance prevention and early intervention efforts in the VA for Veterans experiencing or at-risk for homelessness. As a first step, we address the hypothesis that V60.x codes are used to designate homelessness among Veterans in a similar way that the V60.0 code is used . Second, we examine the temporal course of the application of V60.0 and V60.x codes in order to understand administrative changes in homelessness . Third, we assess the differences among Veterans receiving an ICD-9-CM V60 code and those who receive a non-ICD designation  as their first indicator of homelessness . Fourth, we explore rates of V60.0 and V60.x codes across VA facilities to determine whether these codes are used systematically .VA records were examined for all individuals listed on an official roster indicating they had served in the U.S. military as part of the recent conflicts in Iraq or Afghanistan. Specifically, these include those who were deployed as part of Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND). This roster consisted of 941,970 Veterans who separated from the military after deployment as part of OEF/OIF/OND and who were eligible for and enrolled in VA health care services as of July 2011. Of these, 845,593 (89.8%) had at least one documented encounter within the VA system as of April 2012. Records from this latter group were taken from a nationwide VA research database of administrative and clinical data managed by Veterans Informatics and Computing Infrastructure (VINCI) );528 ;529 ;530 (Telephone/HUD-VASH); and590 (Community outreach to homeless Veterans by staff)Veterans were selected for analysis if they belonged to one of three mutually exclusive homeless groups, based on the ces) see . The fin37 Domiciliary care for homeless Veterans (DCHV); and28 Mental Health Residential and Rehab Treatment Program for Compensated Work Therapy/Treatment Resident (MH RRTP CWT/TR).as well as the inpatient treatment specialty codes :Only Veterans who had at least one additional VA visit in the 90 days immediately following the identification of homelessness were retained in the sample to allow for an examination of receipt of at least one service (and associated ICD-9-CM codes) after the initial homeless designation. Outpatient clinic visits in the 90 days immediately after the first indicator of homelessness were categorized as either homeless, mental health, or substance abuse/addiction services. Additionally, comorbidities among VA homeless groups were also explored by summarizing their ICD-9-CM diagnoses. VA medical center region and station identification was also obtained from the administrative data.after separation from the military; 2) a V60.x code first and a subsequent V60.0 code within the following 90 days and 3) a V60.0 code first and a subsequent V60.x code within the following 90 days. We then analyzed the type of clinical service assigning either V60.0 or V60.x (using chi-square statistics). We next explored various outpatient homeless, mental health, and substance abuse services the Veterans utilized in the immediate 90 days after receiving a homeless designation, stratified by first indicator of homelessness group .Descriptive statistics for study variables were computed and stratified by VA homeless group . We computed the percentage of Veterans receiving 1) V60.0, V60.x or a non-ICD indicator of homelessness in a VA medical facility first indicator of homelessness, we conducted a series of three binary logistic regression analyses with the following dependent variables: 1) V60.x compared to V60.0; 2) V60.x compared to the non-ICD indicator; and 3) V60.0 or V60.x (any V60) compared to the non-ICD indicator. The following covariates were included in all logistic regression models: sex, race , marital status , level of education , rank , and VA evidence of mental health visits  or receipt of substance abuse/addiction services  in the 90 days following the first indicator of homelessness.To investigate differences among Veterans receiving a V60.0, V60.x, or non-ICD designation as their To explore the possibility of geographic variations in the use of specific V60 codes, we performed both cartographic and statistical modeling. Nationally, the VA healthcare system is administratively divided into four regions, which are further subdivided into 21 Veterans Integrated Service Network (VISN) areas that contain 152 separate medical facilities (stations). First, maps were generated for the 1) 21 VISNs and 2) 152 VA station areas for each fiscal year (2002–2012). These maps depicted the proportion of Veterans receiving each V60 code  of the total number of Veterans identified as homeless in each area. We then conducted statistical analyses to determine whether V60.0 and V60.x codes varied at the region, VISN, or medical facility level nationally. These analyses consisted of a set of multinomial models with three sets of predictor variables  with the outcome being the proportion of Veterans with either V60.0 or V60.x.multinom function from the nnet package [Descriptive statistics and logistic regression analyses were conducted using SPSS Version 21 . The geo package . Maps we package .The work described was approved by the University of Utah and Utah State University Institutional Review Boards as well as by the Research and Development committee at VA Salt Lake City Health Care System. A waiver of authorization was approved for retrospective review of existing medical record data. All data was de-identified prior to analysis.Of the 845,593 OEF/OIF/OND Veterans who had at least one documented encounter within the VA system as of April 2012, the current VA case definition of homelessness  was the basis for identifying 21,021 homeless Veterans (2.5%). Expanding the criteria to include the three V60.x codes increased that number to 31,260 Veterans . Of these, 30,886 Veterans (98.8%) had at least one VA visit in the 90 days following the first identification of homelessness (using any of the aforementioned indicators) and were retained for further analysis.st homelessness classification groups due to the large sample sizes .A summary of the demographic characteristics of each “first indication of homelessness” group is presented in The frequency with which each specific type of service provider assigned V60.0 or V60.x for the first time for a given Veteran is presented in In the 90 days immediately after the first indicator of homelessness, Veterans receiving V60.0 logged an average of 14 visits  to VA medical facilities, similar to those with V60.x  . VeteranAs shown on the map in These findings suggest that identifying homelessness based upon VA administrative records alone may lead to challenges in determining the extent of this problem among Veterans seeking care in VA medical facilities. Inferring homelessness based on a combination of V60 codes (from the ICD-9-CM) and evidence of receipt of homeless-related VA services is sensitive to the criteria used. The conventional criteria (V60.0 code or a non-ICD-9-CM administrative code for receipt of VA homeless services) identified 2.5% of Veterans who served in Iraq or Afghanistan as experiencing homelessness. When adding an additional set of V60 codes (denoted as V60.x in this study), which expands these criteria to include conditions indicating unstable housing, this proportion increased to 3.3%. Many of these added by a V60.x code subsequently also received a V60.0 code or a non-ICD-9-CM administrative code.It is likely that, in many instances, V60.x codes are either being used interchangeably with V60.0 by VA staff for indicating homelessness or that Veterans so designated have an unstable housing situation and subsequently become homeless. Determining which explanation is more prevalent goes beyond the parameters of these data, but the data do indicate fluidity among the expanded set of V60 codes and the conventional criteria for determining homelessness. It is likely that this fluidity is, in part, due to Veterans moving interchangeably from housing instability (V60.x) to literal homelessness (V60.0) as they negotiate a series of makeshift housing arrangements. This situation of assigning administrative codes for homelessness creates a degree of ambiguity that will likely persist after billing and coding systems are converted to ICD-10 in the U.S. (now scheduled for October 2015), as the equivalent ICD-10 codes for homelessness  may have changed over time from 2001 to 2012 and may represent a surveillance artifact. Other than the administrative indicators of homelessness and subsequent homeless/allied service use, for this study, we have not independently verified the homeless status of Veterans by interviewing Veterans or by a manual review of medical notes. There is a need for further studies to validate the use of V60 codes for homelessness in the VA with detailed follow-up and review of electronic medical records. Our analyses are restricted to those Veterans seeking care in the VA; we have no data on those Veterans who may be homeless and have never sought care in the VA .In conclusion, these results support the creation of a standard administrative definition and method for identification of homeless Veterans. The expanded V60.x criteria proposed here would be consistent with changes in the 2009 HEARTH Act , in whicWith the VA being the largest healthcare provider for individuals experiencing homelessness , our finOur work in the VA likely has application to large health care organizations  that provide care to individuals experiencing homelessness. Providers in VA medical facilities across the country, especially those in primary care, would likely benefit from an increased awareness of homelessness among Veterans and the importance of appropriate ‘coding’ to trigger the initiation of appropriate services.S1 FileThere tended to be a greater than average use of V60.x codes in VA medical facilities in the coastal areas of the country; whereas in VA facilities in the central parts of the U.S., there was less-than-average use of the V60.0 code.(GIF)Click here for additional data file.