Vaccination against HPV is safe and effective in cancer prevention, yet vaccination uptake remains low. Strong recommendation of HPV vaccination by healthcare providers increases immunization rates, but gaps in knowledge persist surrounding HPV and HPV vaccination amongst health professional students (HPS). It is critical to educate HPS in all professions to maximize vaccination opportunities and increase vaccine uptake. The objective of this study is to evaluate evidence on HPV knowledge, vaccine uptake, and educational interventions in HPS to identify specific deficits to improve education.A systematic literature search for articles on HPV vaccine uptake, knowledge, and educational interventions in HPS was performed in PubMed, Embase, Web of Science, CINAHL, and Scopus from January 1, 2006 – July 21, 2021. Included studies assessed HPS for HPV vaccine uptake, knowledge, counseling comfort, or educational interventions to increase HPV vaccine knowledge. Studies were screened for inclusion by 2 independent reviewers and evaluated for risk of bias. PRISMA guidelines for reporting were followed.Twenty-one unique articles met inclusion criteria and were included in the analysis. Of the studies included, 20 included knowledge, 11 included vaccine uptake, 8 included interventions, and 12 included counseling comfort. The students in the studies included medical (n=14), dental (n=7), dental hygiene (n=6), nursing (n=3), physician assistant (n=2), public health (n=1), and pharmacy (n=1). Across studies, HPV vaccine series initiation ranged from 34.6-70.3%, with 28.3-58.3% up to date on vaccination. Most students knew that HPV causes cervical cancer (99%), but fewer knew that HPV causes head and neck cancer (40-47%) and oropharyngeal cancer (45%). Educational interventions included team-based approaches and lectures, and improved outcomes including vaccine knowledge, vaccination schedule, and cancer knowledge. Medical students with lower knowledge of HPV were more hesitant to recommend vaccination at baseline but were more likely to recommend vaccination after an education session.Across HPS, inadequacies persist in HPV vaccine uptake, knowledge, and counseling comfort. It is critical to target vaccine uptake in this population and improve existing educational efforts to reduce preventable cancers. Institutions must prioritize HPV vaccine education to impact HPV related death. In the US approximately 36,500 preventable cancers attributed to HPV are diagnosed yearly . WorldwiHPV vaccination, first approved by the FDA in 2006 , is a saUnfortunately, the nation fell well below the Healthy People 2020 goal to achieve a HPV vaccination rate of 80%, with only 53% of females and 46% of males between 13-17 years up to date on HPV vaccination . HPV vacTo increase HPV vaccination rates, education surrounding HPV vaccine must be improved for healthcare providers in all fields. HPV vaccines are the only cancer prevention vaccine currently available, and it is a responsibility of all healthcare providers to recommend the vaccine and utilize all opportunities to vaccinate patients. With an intensification in vaccine hesitancy, it is important to confidently ensure parents that HPV vaccination is safe . Strong HPS must receive comprehensive education on HPV and HPV vaccines while in the formal learning environment. While several single-institution studies have assessed HPV knowledge and performed associated educational interventions, the efficacy and merits of these interventions have not been weighed against one another. Previous systematic reviews have synthesized educational interventions surrounding HPV vaccines in practicing healthcare providers, but not in HPS . The objThe Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline was used as a framework to guide the design and reporting of our study . We perfFollowing the completion of searches, all articles identified were exported into EndNote and duplicates were removed. Articles were then imported into Covidence. First, titles and abstracts were reviewed independently by two reviewers . Next, full text articles were obtained and reviewed by two reviewers. Following this, articles were screened for risk of bias by two reviewers to assess methodologic quality. Disagreements between reviewers were resolved by the third reviewer. Finally, data extraction was performed in covidence by two reviewers. A third reviewer compared results of data extraction by both reviewers to compile the final data which was exported for analysis.For this review, HPS were defined as students in health professions that prescribe or promote HPV vaccination in their practice including medicine, nursing, pharmacy, public health, dentistry, and physician assistant. In studies that included practicing providers with students, >50% of the participants had to be students for inclusion. Inclusion criteria were as follows: 1) Original articles published in a peer-reviewed English language journals including quantitative, experimental, qualitative, quasi-experimental and observational studies. 2) Students attending school in the US due to the heterogeneity of health professional education worldwide. 3) Articles published in 2006 or later. 4) Studies with an objective to evaluate HPV vaccine uptake in HPS, knowledge of HPV vaccines in HPS, an educational intervention to improve knowledge of HPV vaccines in HPS, and/or HPS comfort counseling about HPV vaccination. Comfort counseling was defined as self-reported increase in confidence in counseling patients and/or their parents about HPV vaccination. The exclusion criteria were as follows: 1) Articles without full text, commentaries, editorials, perspective pieces, conference abstracts. 2) Studies of practicing healthcare providers including residents, fellows, nurses, dentists, pharmacists, physician assistants. Residents and fellows were excluded to focus on students in undergraduate medical education. 3) Studies of undergraduate students who were not in differentiated professional degree programs such as nursing.The risk of bias was assessed with the Joanna Briggs Institute Tool for Cross Sectional Studies . The resStudies selected for inclusion had data extracted by two independent reviewers. The Template for Intervention Description and Replication (TIDiEr) checklist was used to develop the data collection for HPV knowledge interventions .A full breakdown of the literature search appears in a PRISMA diagram Figure 1A total of 21 articles were included in the analysis Table 3 HPS also demonstrated knowledge gaps in the vaccine dosing schedule. Berenson et al. found that only 25.1% (44/175) of medical students knew whether a patient should restart the vaccine series if their last dose was more than a year ago . Cotter The majority of students in each study knew that the HPV vaccine is safe, though there was a wide range between 75% (751/1002) and 99% (198/200) of HPS with this knowledge , 39.Wiley et al. demonstrated that a team-based instructional module with video simulations and clinical vignettes improved HPV and vaccine knowledge among first year medical students . StudentIn Berenson et al. (2015), a brief lecture presentation discussing HPV and vaccination for healthcare workers significantly improved HPV knowledge . MedicalIn Evans et al. (2020), first- and second-year medical students attended a 1.5-hour HPV vaccine workshop covering HPV and strategies to address vaccine hesitancy . After tIn Cotter et al. (2020), an educational intervention for dental hygiene students consisted of a one-hour educational module covering the prevalence of HPV, HPV oropharyngeal cancers, HPV vaccination and information on counseling techniques . FollowiThese results demonstrate that a variety of effective educational strategies for improving knowledge about HPV and HPV vaccination. While elaborate interventions such as the team-based learning modules outlined in Wiley et al. (2018) and the three-part educational curriculum created in Schnaith et al. (2019) are effective, simpler models such as the one-hour educational module discussed in Cotter et al. (2019) and the 1.5 hour workshop in Evans et al. (2020) can be effective, and may be easier for institutions to implement , 46–48.p=.026) and general HPV knowledge assessment (p=.03) compared to students who were likely to recommend vaccination (p=.0003)  .Each study of medical students that included an educational intervention showed improvement in their ability to counsel others regarding HPV vaccination. Wiley et al. reported that 100% of students agreed that they would recommend the vaccine as a provider after a week-long team-based learning exercise . Schnaitp =.033).Studies among dental and dental hygiene students found that educational interventions improved comfort surrounding administering and discussing HPV vaccines. Guadiana et al. found that dental and dental hygiene students who were more confident in their ability to discuss HPV were more likely to be willing to administer the vaccine  . AdditioAn estimated 79 million people in the United States are infected with HPV, and in individuals not able to clear the virus, leads to cancer. Despite significant data demonstrating HPV vaccination efficacy, vaccination rates remain stagnant; and HPV related oropharyngeal and anal/rectal cancers are on the rise, particularly among men . Our stuThe rates of HPV vaccine series initiation across studies ranged from 34.6% to 70.3%, and the rate of those up to date on HPV vaccination ranged from 28.3% to 58.3% , 31, 46.While students consistently displayed awareness that HPV causes cervical cancer (99%), many lacked knowledge of the ability of HPV to cause other cancers including head and neck cancer 40-47%) and oropharyngeal cancer (45%) , 40. Mos-47% and Educational interventions varied in format but were consistently effective in increasing knowledge of HPV. One team-based instruction module significantly increased general HPV knowledge, HPV vaccine related knowledge, and likelihood of vaccine recommendation . A diffeAdditionally, comfort counseling patients about HPV vaccination was low – but increased following specific interventions targeting this objective. Students across studies cited similar barriers to HPV vaccine uptake to their patients including parental decline of the vaccine, not being recommended the vaccine by a healthcare provider , 38, 45.Limitations of this analysis include that most are single institutional studies and are thus subject to any bias resulting from the studies themselves. The risk of bias has been minimized through screening prior to inclusion. Additionally, it is of note that there are multiple studies from the same authors because there are investigators who have conducted multiple studies in this area.Future studies should focus on ways to target vaccine uptake in HPS and expand upon existing knowledge interventions to implement better education on a broader scale. This education should utilize an interprofessional approach is vital to expanding the number of knowledgeable professionals counseling and offering HPV vaccination to prevent HPV-related cancers. The papers reviewed in this analysis demonstrated that various educational modalities of different lengths effectively increase knowledge of HPV and HPV vaccination. Further studies should focus on educational methods to help determine optimal approaches by objective measures such as a significant increase in HPV vaccination. Ultimately, we must take active efforts to improve the quality of education provided. Taking these steps to enhance HPS education is critical to lowering the number of missed opportunities for HPV vaccination in a variety of healthcare settings.Across HPS, major gaps persist in HPV vaccine uptake, knowledge, and counseling comfort. It is critical to target vaccine uptake in this population, including ensuring availability of vaccination for students. Educational institutions must make education about the HPV vaccine a priority in both preclinical and clinical curriculums. This study highlights the need for interventions to improve HPV vaccination uptake and education on HPV in HPS to train healthcare professionals that strongly recommend HPV vaccination to prevent cancer.The original contributions presented in the study are included in the article/Supplementary Material. Further inquiries can be directed to the corresponding author.ML and MH had full access to all the data in the study and took responsibility for the integrity of the data and the accuracy of the data analysis. Concept and design, all authors. Acquisition, analysis, or interpretation of data, all authors. Drafting of the manuscript, ML, LF, and KL. Critical revision of the manuscript for important intellectual content, all authors. Statistical analysis, ML, LF, and KL. Administrative, technical, or material support, MH and PJ. Supervision, MH and PJ. All authors contributed to the article and approved the submitted version.The authors thank Dr. Barbara Sorondo and John Reynolds from Calder Library for consultation on study methodology.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


HPV (human papillomavirus) is an important cause of cervical cancer. Cervical-vaginal infection with pathogens, such as herpes simplex virus (HSV), bacterial vaginosis Trichomonas vaginalis and vaginal candidiasis could be a cofactor. This study aimed to assess the relationship between vaginal infection with HPV genotype and cytology test results and analyze the relationship between vaginal and HPV infections and cervical cancer.We performed a district-based study to elucidate the relationship among the vaginal and HPV infections and cervical cancer. We collected the cervical exfoliation data of 23,724 women admitted to the Shanghai Zhoupu Hospital and received ThinPrep cytology test (TCT) and HPV detection between 2014 and 2019.P < 0.01). The incidence rate of cervical intraepithelial neoplasia or cervical cancer with vaginal infection was higher than without vaginal infection (P < 0.001).Total vaginal infection rate was 5.3%, and the HPV-positive group had a slightly higher vaginal infection rate than the HPV-negative group (HPV/vaginal infection-positive women tended to have abnormal results of TCT. Women with vaginal infection were more likely to develop HPV infection. HSV combined with HPV infection was noted as a causal factor for HSIL.The online version contains supplementary material available at 10.1186/s12985-022-01850-x. Cervical cancer was reported as the fourth most common cancer among women worldwide, ranking after breast cancer, colorectal cancer, and lung cancer . ApproxiBacterial vaginosis (BV), trichomonas vaginalis (TV), vaginal candidiasis (VC), and herpes simplex virus (HSV) are the common vaginal infections. Recent researches has investigated the vaginal infection as a cofactor in cervical carcinogenesis , 8–11. IThe present study aimed to assess the relationship of vaginal infection with HPV genotype and results of cytology test in the Zhoupu District, explore the association between the vaginal infection and HPV genotype, and analyze the relationship between the vaginal and HPV infections and cervical cancer. We retrospectively analyzed the data from a tertiary hospital in Shanghai.We collected the cervical exfoliation data of 23,724 women admitted to Shanghai Zhoupu Hospital  and received both ThinPrep cytology test (TCT) and HPV detection between 2014 and 2019.The Ethics Committee approved the study of Shanghai Zhoupu Hospital. All patients have signed the written informed consent forms. For patients younger than 18 years old, their parents have signed the written informed consent forms. Confidentiality was ensured during data collection process, and data were analyzed anonymously.During the non-menstrual period, samples of exfoliated cervical cells were collected. Experienced cytologists conducted cytology tests based on cervical fluid. The diagnostic results of the TCT were classified according to the Bethesda system . Liquid-Besides, CIN1 and CIN2 + were corresponded to LSIL and HSIL, respectively. ASC-H, ASC-US, and AGC were associated with highly suspicious precancerous lesions. The ASC-US, LSIL, and HSIL were correlated to abnormal TCT results.According to the diagnostic criteria of the Bethesda system, there are four vaginal infections in liquid-based cytology: BV, TV, HSV, and VC.Using HPV typing test kits (PCR + membrane hybridization), HPV genotyping was performed on the collected samples (Certificate No. of China Food and Drug Administration (2014): 3,402,188).In addition, the PCR membrane hybridization could detect 21 HPV genotypes , through reverse dot hybridization and envelope specific probe membrane hybridization.www.r-project.org) (v3.2.0) and R packages.All HPV and TCT data collected from 2014 to 2019 were combined into an Excel spreadsheet and then analyzed and plotted using the R platform  of patients. In addition, 21 genotypes were identified, including HPV16, HPV18, HPV31, HPV33, HPV35, HPV39, HPV45, HPV51, HPV52, HPV56, HPV58, HPV59, HPV66, HPV68, HPV6, HPV11, HPV42, HPV43, HPV44, and HPV81  . The HPV-positive group had a slightly higher vaginal infection rate (6.4% > 5.1%) than the HPV-negative group (P < 0.001)  was higher than that in the vaginal infection-negative group (15.9%) (1) Table , demonstThe mean age of the HPV-positive women was 36.7 ± 11.3  years old, while the mean age of the HPV-negative women was 37.08 ± 12.03  years old (Table P < 0.001) (Table P < 0.001)  Table . MoreoveP < 0.001)  and cervical cancer with HPV and vaginal infections was higher than that of women without HPV/vaginal infections (1) Table , indicatP < 0.001) (Tables P < 0.001)  Table . Thus, wTable No vaginal infection was found in none of the cases with HPV43-positive infection. Although most women were single-type HPV-positive infections , there was almost the same percentage of vaginal-positive infection (6.15%) in double-type (7.12%) and triple-type (7.53%) HPV-positive infections. Moreover, more vaginal infections (17.65%) were found in the multiple-type HPV-positive infections.Figure No vaginal infections were detected in women with ASC and cervical cancer. Details of each distribution for four precancerous stages (LSIL/HSIL/ASC/NILM) will be shown in Additional file P = 0); the HPV infection rate in the vaginal infection-positive group (80.8%) was higher than that of the vaginal infection-negative group (15.9%) (P = 0). The results revealed that women with vaginal infection were more likely to develop HPV infection. The risk of CIN or cervical cancer with vaginal infection was higher than without vaginal infection (P < 0.001). The results suggested that women with both HPV and vaginal infections tended to have abnormal TCT results. When women were diagnosed with LSIL, HPV16 and HPV33 were prevalent in bacterial infections, HPV58 was prevalent in the TV, and HPV52 and HPV66 were prevalent in the VC. Women with HSIL were all infected, and they were infected by the HPV39, HPV51, HPV52, HPV81, and the HSV. Women with AGC were all infected by HPV58 and Candida. Overall, the data supported the role of HSV infection as a causal factor for HSIL, and the results also showed that interaction between HPV infection and vaginal infection might explain a substantial proportion of the high risk of infection found in the study.Although most HPV infections are cleared within two years , differeOnly a small proportion of women with HPV infection can persist and progress to cervical cancer , in whicTo our knowledge, BV is the most common type of vaginal infection in adult women. It is characterized by the overgrowth of anaerobic bacteria and elevated vaginal pH (> 4.5) . The bacTV and VC are common vaginal infections. Among women diagnosed with LSIL, women with TV were all infected by the HR-HPV58, those with Candida were all infected by HR-HPV52 and HR-HPV66, women with AGC were all infected by HPV58 and Candida, and there were no NILM women infected by TV and HPV43. Our study showed TV and 273 VC were associated with HR-HPV infection, consistent with other studies , 38. TriSince the use of many culture and staining techniques to improve the laboratory diagnosis reliability of BV, Candida spp., and TV. The highest percentage of positives in TV was found by examination of Papanicolaou-stained cervical smears, compared with microscopy of Giemsa (GS) applied in 1958 and acridine-orange (AO) stained smear in 1958 . PapanicHowever, there were some limitations in our study. First, this study was carried out in only a single center in the Zhoupu District, and additional multicenter data need to be collected. Second, although HPV genotypes, infection types, and cytological test results are biologically independent, their possible correlation should be further detected. Third, The detecting method of cervical-vaginal infection with HSV, BV, TV and VC has limitations. We plan to use the machine learning method to examine the relationship between HPV subtypes and pathological types, including cervicitis, cervical precancerous lesions, CIN2/3, and cervical cancer.The HPV/vaginal infection-positive women had abnormal TCT results. Women with vaginal infection were more likely to develop HPV infection. HSV infection was noted as one of the causal factors for HSIL. The observed associations among common vaginal and HPV infections and the cytology test results are worthy of further investigation. Elucidation of the role of these infectious agents in cervical carcinogenesis has important implications for the management of infected patients and the organization of preventive programs, highlighting the significance of the results of the current study. Further district-based research on cervical carcinogenesis is required to elucidate the etiology of such multifactorial diseases and to more reliably diagnose and treat cervical cancer that causes high morbidity and mortality among women globally.Additional file 1. Supplement 1: Distributions of four vaginal infections for 21 HPV subtypes at five precancerous stages.Additional file 2. Supplement 2: Distributions of five precancerous stages for 21 HPV subtypes at four vaginal infections.


Dynamic trajectory radiotherapy (DTRT) extends volumetric modulated arc therapy (VMAT) with dynamic table and collimator rotation during beam-on. The aim of the study is to establish DTRT path-finding strategies, demonstrate deliverability and dosimetric accuracy and compare DTRT to state-of-the-art VMAT for common head and neck (HN) cancer cases.A publicly available library of seven HN cases was created on an anthropomorphic phantom with all relevant organs-at-risk (OARs) delineated. DTRT plans were generated with beam incidences minimizing fractional target/OAR volume overlap and compared to VMAT. Deliverability and dosimetric validation was carried out on the phantom.0.03 cc to the ipsilateral optic nerve was above tolerance (54.0 Gy) for VMAT (54.8 Gy) but within tolerance for DTRT (53.3 Gy). For a laryngeal carcinoma, DTRT resulted in higher dose than VMAT to the pharynx and brachial plexus but lower dose to the upper oesophagus, thyroid gland and contralateral carotid artery. For a single vocal cord irradiation case, DTRT spared most OARs better than VMAT. All plans were delivered successfully on the phantom and dosimetric validation resulted in gamma passing rates of 93.9% and 95.8% .DTRT and VMAT had similar target coverage. For three locoregionally advanced oropharyngeal carcinomas and one adenoid cystic carcinoma, mean dose to the contralateral salivary glands, pharynx and oral cavity was reduced by 2.5, 1.7 and 3.1 Gy respectively on average with DTRT compared to VMAT. For a locally recurrent nasopharyngeal carcinoma, DThis study provides a proof of principle of DTRT for common HN cases with plans that were deliverable on a C-arm linac with high accuracy. The comparison with VMAT indicates substantial OAR sparing could be achieved.The online version contains supplementary material available at 10.1186/s13014-022-02092-5. Radiation therapy plays an important role in the management of head and neck (HN) cancer but is often challenging, especially for target volumes with complex shapes overlapping with organs-at-risk (OARs). The introduction of intensity-modulated radiotherapy (IMRT) has enabled clinically significant toxicity reduction through better dosimetric sparing of OARs  while voNon-coplanar radiotherapy can further improve OAR sparing  with, e.Despite encouraging dosimetric quality of DTRT plans and the promise of deliverability on standard C-arm linacs , 12, it A practical approach to determine dynamic table paths is the use of geometric criteria to minimize target/OAR overlap by combining gantry-table cost-maps of various OARs in one map where a path-finding algorithm returns the path of lowest cost , 9. HoweThe aim of this proof-of-principle study was to establish path-finding strategies for DTRT of HN cases, evaluate OAR sparing compared to state-of-the-art VMAT, and demonstrate DTRT deliverability and dosimetric accuracy. For this purpose, a publicly available library covering all common HN cases was created on an anthropomorphic phantom.The library of HN cancer cases was created on an axial computed tomography (CT) scan of the Alderson phantom . The phantom was immobilized in a 5-point thermoplastic mask  and scanned on a Philips Brilliance Big Bore CT-scanner  with 2 mm slices and 512 × 512 pixels in-plane resolution. All relevant OARs were delineated according to guidelines , 19. BotSeven typical HN cases were identified, six of whom had elective nodal volumes treated to 50.00 Gy in 2 Gy-fractions. Sequential boost volumes are prescribed a total of 66.00 Gy for any post-operative positive margin and nodal levels with extranodular extension and to 70.00 Gy for non-operated primary tumour and involved lymph nodes –28.The clinical target volumes (CTV) were delineated on the phantom based on commonly observed clinical cases and relevant guidelines –31. WateD95% = 100% of the prescribed dose. OAR clinical goals are summarized in Additional file 40% < 7.3 Gy [Corresponding planning target volumes (PTV) were obtained by applying a 3 mm isotropic margin around the CTV, trimmed 3 mm from body contour according to institutional practice. Plans for individual phases were normalized such that PTV< 7.3 Gy . All OARThe seventh case was an early stage glottic laryngeal carcinoma treated with single vocal cord irradiation (SVCI) to 58.08 Gy in 16 fractions . OAR delAll treatment plans were created for 6 MV-flattened beam on a TrueBeam linac  equipped with a 120-leaf Millennium multi-leaf collimator (MLC) and a PerfectPitch 6-degree-of-freedom table.DTRT plans were created based on Fix et al. . In shorAn A* path-finding algorithm is used to determine the GT-path of lowest cost for a given range of gantry rotation. For the chosen GT-path, a collimator-gantry (GC) map is created that quantifies field width in the x-direction. The A* is used to the determine the GC-path of lowest cost, thereby reducing the range of possible leaf-travel. The selected gantry-table-collimator (GTC)-paths are imported back into Eclipse via ESAPI for intensity modulation optimization.In this study, case-specific collision maps were determined based on a validated virtual linac model using Blender , 36. TheAll DTRT paths covered a full gantry rotation with control points every 2°. The A* algorithm was restricted to find GT and GC-paths with a maximum gradient of 3° table/collimator rotation per degree gantry rotation and paths were smoothed using a 10-points (20°) moving average to avoid abrupt table motion. Different paths per plan were created by selecting different OARs to generate each map. Individual OAR-maps were equally weighted. To increase the degrees-of-freedom at the intensity optimization stage, some paths were duplicated either by field-splitting in the x-direction using the secondary collimator jaws or by applying a constant 90° collimator offset to the A*-determined GC-path.For each DTRT plan, a VMAT plan was created with the same number of full arcs as GT-paths, the same field-splitting strategy, and collimator angle of 5 or 95°.Research version of the Eclipse photon optimizer (PO) and the Anisotropic Analytical Algorithm (AAA) version 15.6 were used for intensity modulation optimization and dose calculation with a 2.5 mm grid. Intermediate dose calculation was used, "convergence mode" was on, and "aperture shape controller" set to moderate .A set of manual planning rules was designed to minimize planner bias , and Paddick conformity index  for eacTo demonstrate deliverability of DTRT, all plans were delivered in developer mode using xml files and machine log-files were recorded to evaluate mechanical accuracy and the possible correlation between speed and mechanical deviations for each dynamic axis. Prior to delivery, the phantom was positioned on the TrueBeam PerfectPitch table with the thermoplastic mask. Orthogonal kV imaging was used to adjust patient positioning with 5 degrees-of-freedom. Rotation was not corrected because the dynamic table rotation is encoded for each control point in the xml files and any correction would be overridden during delivery.Dosimetric validation with film measurement was performed for one case as described in Additional file Recently, the Radiotherapy Treatment plannINg study Guidelines (RATING) were proposed to evaluate the quality of planning studies and there reporting. The guidelines were followed and the RATING score was calculated .https://dx.doi.org/10.48350/159243).The seven HN cases are presented in Table OAR selection strategies for each case were determined empirically to obtain DTRT paths covering the 4π-space while avoiding the most relevant OARs Table . ExamplePaddick were between 0.82 and 0.92 differing at most by 0.03 between DTRT and VMAT. HI95% were between 74.5% and 99.2% with a mean absolute difference of 3.2% between DTRT and VMAT .Each individual plan and dose distributions from all combined plans were considered clinically acceptable by a radiation oncologist. Target coverage were similar between DTRT and VMAT. For conventional fractionation (HN1-6) CITarget coverage in the dose distributions for the combined plans were similar for the high dose volume but differences were observed for lower dose volumes depending on the direction in which the elective volume extended the high dose volume . Dose volume histograms (DVHs) for HN4 are shown in Fig. For the oropharyngeal cases and the ACC HN1-4), challenging OARs were the salivary and swallowing structures. Mean dose to the contralateral salivary glands was on average 2.5 Gy lower for DTRT than for VMAT; it was on average 1.7 Gy and 3.1 Gy lower for the pharynx and oral cavity respectively , challenging OARs were the optic and visual structures. DVHs are shown in Fig. 50% to the contralateral carotid PRV was 14.0 Gy (DTRT) and 15.0 Gy (VMAT). For the SVCI case, HN7, the plan was normalized such that PTVD97% = 99% to fulfil the prescription for both plans. CIPaddick and HI95% were 0.71 and 96.0% for DTRT and 0.77 and 96.8% for VMAT. DTRT achieved better OAR sparing than VMAT for most OARs  are shown in Fig. All plans were successfully delivered on the Alderson phantom in developer mode  and one adenoid cystic carcinoma (HN4), the reduction in mean dose to the contralateral salivary glands , pharynx (1.7 Gy), and oral cavity (3.1 Gy) has the potential to reduce xerostomia and dysphagia, with a positive impact on quality of life .Few studies had previously investigated non-coplanar radiotherapy for HN cases with bilateral elective nodal irradiation volumes. Krayenbuehl et al.  reportedFor a nasopharyngeal case (HN5), DTRT resulted in lower dose to the optic structures compared to VMAT. In particular, near-max dose to the ipsilateral optic nerve was above tolerance for VMAT but within tolerance for DTRT, where the dose-volume effect for radiation-induced optic neuropathy risk is rapidly increasing . Near-maThe dosimetric benefit of DTRT for stage II laryngeal carcinoma (HN6) was unclear with DTRT resulting in higher doses than VMAT for the pharynx and brachial plexus but improved sparing for upper oesophagus, thyroid gland, and contralateral carotid artery. A recent analysis found no difference in survival for IMRT or 3D-conformal radiotherapy for early-stage laryngeal carcinoma but toxicity was not reported . For theOne possible limitation of this study is planner bias due to manual planning . All VMATo exploit the OAR sparing potential of DTRT, OAR grouping strategies to obtain different non-coplanar paths were developed through trial-and-error. This approach is a priori applicable to other geometry-based path-finding approaches , 9 but iAll DTRT paths were created using case-specific collision models automatically generated on a virtual linac and patient model  to optimDeliverability and dosimetric accuracy of dynamic trajectory delivery was previously demonstrated in cubic or cylindrical phantoms , 12, 55 There were several motivations to conduct this study on a phantom. First, patient CTs do not always extend to the vertex restricting possible beam incidences and preventing dose reporting in cut regions. Second, deliverability and dosimetric validation could be performed directly on the phantom, therefore enabling comprehensive end-to-end testing. Finally, the anthropomorphic phantom solution allowed to create a publicly available library of all common HN cases. The CT and contours can be directly used for in silico planning studies or users can register the contours to their own Alderson phantom (available in many clinics) for measurements. Given the anthropomorphism of the phantom, the proposed DTRT planning strategy is expected to be applicable to real patients presenting with similar target shapes and location to these available in the library. On the other hand, it may be possible to favour sparing specific OARs on a case-by-case basis.This study showed substantial improvement in OAR sparing for HN cancer radiotherapy using DTRT compared to VMAT with plans that are deliverable on standard linacs. Film measurements for one case showed good agreement with the calculated dose. A publicly available library of all common HN cancer cases was created and the treatment planning strategy applied on these cases can be applied to similar cases in future clinical studies, therefore bringing DTRT closer to clinical practice.Additional file 1: A.I. Manual planning rules; Table A.I Optimization objectives for target coverage and conformity; Table A.II. Clinical goals and starting optimization objectives for OARs. A.II. Film measurement protocol; A.III DVH endpoints; Table A.III DVH endpoints for HN1-6; Table A.IV DVH endpoints for HN7.Additional file 2: A.V. RATiNG.Additional file 3: A.VI. Video of DTRT delivery.


L. iners enriched in HPV infection group compared with others significantly. BV  and HR-HPV infection  were risk factors for CIN. In conclusion, we consider BV as a risk factor for CIN. The enrichment of L. iners under HPV infection state may contribute to maintenance of vaginal dysbiosis, and BV infection could facilitate the disturb.Bacterial vaginosis (BV) is a genital infection that frequently presents in women infected with human papillomavirus (HPV), but the correlation between BV, HPV and cervical intraepithelial neoplasia (CIN) development is still elusive. We organized a cross-sectional analysis which enrolled 624 participants and obtained 423 samples of vaginal secretions from them, including 193 HPV-negative samples and 230 HR-HPV-positive samples. We used 16S rRNA sequencing to measure the vaginal microbiota diversity in women with different BV, HPV and CIN status, and then calculated risk factors for CIN by logistic regression. We found that the diversity of vaginal microbiota was significantly increased after BV, HPV and BV-infected CIN group. The Observed species and Chao1 index of H.C group showed little difference with normal group, while its Shannon index was considerable higher than normal group.  The prevalence of cervical cancer in China remains higher than in the Western World due to lower vaccine coverage among young women and less awareness of regular cervical cancer screening in adult. Persistent human papillomavirus (HPV) infection causes cervical intraepithelial neoplasia (CIN) that may develop into cervical cancer if not detected in its early stages during screening or treated well once detected. According to a systematic review by Yin et al.2 the rate of high-risk HPV (HR-HPV) infection caused by types 16, 52, 58, 53, and 18 is up to 19.0% in mainland Chinese women. Infection with HR-HPV is an independent risk factor for CIN and cervical cancer. HPV infection is the most common sexually transmitted infection (STI) especially in women with multiple sex partners3. Other factors like smoking, contraception and antibiotic use can disrupt the clearance of HPV leading to a high viral load that can trigger cervical lesions formation4.Cervical cancer affects millions of women worldwide, with an estimated incidence of 604,200 new cases and 310,000 deaths in 2020, with China having 109,700 (18.2%) new cases and 59,700 (17.6%) deaths3. There is no standard definition of BV, but it is widely recognized that its development is a process characterized by the dysregulation of vaginal microbiota with increased levels of Gardnerella vaginalis , Atopobium, Prevotella, Sneathia, Peptostreptococcus, Megasphera, BV-associated bacterium 1 (BVAB1) to BVAB3, and decreased levels of Lactobacilli spp.6. The classification of community state types (CSTs) summarizes five types of vaginal microbiota in healthy women based on different domination of bacterium. CST I, II, III, V are dominated by Lactobacillus crispatus (L. crispatus), L. gasseri, L. iners, and L. jensenii, respectively; whereas CST IV is defined as the depletion of Lactobacilli spp.9. Women with CST IV vaginal communities are more likely to experience BV, abortion, preterm labor, increased susceptibility to human immunodeficiency virus (HIV) and HPV infection, or delayed HPV infection clearance10. The percentage of women with CST IV cluster is significantly higher in Black and Hispanic women who also have a higher incidence of cervical cancer than that in Asian and White women11.Bacterial vaginosis (BV) occurs in the reproductive age group with 15–50% of women presenting with vaginal discharge, peculiar smell, itching, or increased vaginal pH levels15. Greater microbiota species diversity is observed in women infected with HPV. The abundances of bacteria associated with BV like Sneathia, Prevotella, and Megashaera are significantly higher in women who are positive for HPV6. Previous research focused on clarifying the association between the cervical cytological lesion and BV due to inadequate technological development18. With the popularity of colposcopy, recent studies have relied mainly on biopsy under colposcopy, which is more accurate than a thin prep cytology test (TCT), to determine the stage of cervical lesions.The association between BV and CIN was described 30 years ago, but the mechanism remains elusive. Some research revealed that BV is an independent risk factor for persistent HPV infectionThis study is focused on documenting the association of BV, CIN, and HR-HPV infection. We used 16S rRNA gene sequencing to display the vaginal microbiota in Chinese women and compared the composition of microbiota between women with different BV, HPV, or CIN statuses. We aimed to find a promising marker for vaginal dysbiosis.Samples were collected from November 2020 to April 17, 2021, from a total of 624 enrolled participants. 201 participants were excluded because of vulvovaginal candidiasis (VVC), trichomonas vaginitis (TV), other STIs infection (complete exclusion criteria seen in “P < 0.001). A total of 230 out of the 423 samples (54.37%) suffered HR-HPV and 86 out of the 230 samples (37.39%) had more than one type of HPV infection. Women with HR-HPV who progressed to CIN were 94 out of 230 (40.87%).According to the recommendations of the American Cancer Society (ACS), women with a cervix should undergo routine cervical cancer screening at least every five years starting at age 25 years until 65 years. We selected women between the age of 25 and 65 years as our participants, and divided them into 3 groups . There was no significant correlation between HPV infection and times of gestation or parturition, but there were significant correlations between age, contraception, and number of sexual partners. Of the 423 samples obtained, 160 out of 423 (37.83%) of the women had BV infections. The HPV-negative group had significantly lower rates of BV infection than the HPV-positive group (P < 0.05) was a protective factor for CIN, whereas BV  and HR-HPV infection  were risk factors for CIN.Next, we conducted logistic regression analysis on possible risk factors for CIN including age, times of gestation and parturition, methods of contraception, number of sexual partners, BV, HPV infection, and multitype HPV infection, which were collected in the questionnaire. As shown in Fig. To identify the difference in composition of vaginal microbiota between women with and without HPV infection, we sequenced the V3-V4 hypervariable region of the 16S rDNA gene utilizing 16S rRNA sequencing. We acquired 15,137 OTUs in our experiment, the sequence result was available in Supplementary Database Lactobacillus spp. predominant in both groups are displayed in Fig. Lactobacillus spp. in the HPV-negative group was much higher than that in the HPV-positive group. Meanwhile, microbiota composition in the HPV-positive group was more complicated. Bacteria such as Gardnerella vaginalis, Ralstonia pickettii, Streptococcus anginosus, Prevotella bivia, Prevotella timonensis, Bifidobacterium dentium, and Sneathia sanguinegens presented more frequently in the HPV-positive group. We analyzed the OTUs numbers in each group and displayed them in a Venn graph in Fig. In the HPV-negative group, 8 out of 193 samples and 1 out of 230 samples in the HPV-positive group were excluded because of low DNA copy numbers. The relative abundance of the top 19 prevalent vaginal microbiota in HPV-negative and HPV-positive women samples with Lactobacillus spp. had the highest percentage relative abundance of up to 82.6% in the normal group. Women with HPV infection only showed little change in the Lactobacillus spp. genera in their vaginal microbiota, but the percentage of L.crispatus, which presented most in a healthy vaginal environment was partly replaced by L.iners. Lactobacillus spp. lost its dominance (with less than 60% in composition) in the remaining three groups of women, who were all diagnosed with BV infection with a more complex bacterial composition.To further estimate the vaginal microbiota changes under different clinical condition, we divided all the samples into 6 groups according to the following BV, HPV or CIN statuses: Normal, BV (BV infection), HPV (HR-HPV infection), B.H (BV and HR-HPV co-infection), H.C (HR-HPV infection combined with CIN), and B.H.C (BV and HR-HPV co-infection combined with CIN). To better distinguish the differences between groups, we conducted random screening of the grouped data to balance the sample size of each group. A total of 342 samples were collected and the numbers of final samples of each group were 65, 52, 71, 60, 48, and 46, respectively  according to the dominant (> 60% of relative abundance in one sample) P < 0.001). Besides, the observed species and the Chao1 index of the H.C group were lower than those of the BV, HPV B.H, and B.H.C groups (P < 0.001). The Shannon indexes for the HPV and H.C groups were significantly lower than that of the B.H.C group (P < 0.001). Interestingly, the Observed species and Chao1 index of H.C group showed little difference with normal group, while its Shannon index was higher than normal group. In other words, for women with CIN, the total amount of vaginal microbiome changed slightly, but the complexity substantial rising, and when co-infection occurred, the richness and evenness of bacteria increased significantly (P < 0.001).The observed species count the number of visually observed species, Shannon’s diversity index and Chao1 index reflex the richness and evenness of species, respectively. These 3 indexes were used to measure the alpha diversity of microbiomes in 6 groups. High variability was observed among the samples; thus outliers were not shown in the boxplot Fig. a–c. ThreP < 0.001). P values were calculated by the ANOSIM test. Biodiversity was not dependent on BV, HPV, or CIN status  to analyze the bacterial diversity and find biomarkers. It combines statistical difference analysis and the impact score of the species on the grouping results while emphasizing statistical significance and biological relevance. Figure 21. Gene we detected were matched with the KEGG (Kyoto Encyclopedia of Genes and Genomes) database, predicted raw data was available in Supplementary Database S224. 31 kinds of pathways changed in B.H compared with BV (P < 0.05). Pathways related to transporters, transcriptional factors, phosphotransferase system (PTS), carbohydrate metabolism , pentose phosphate pathway, replication, recombination and repair proteins, glycerophospholipid metabolism, lysine biosynthesis, lipid metabolism, , taurine and hypotaurine metabolism, RNA transport, dioxin degradation, Staphylococcus aureus infection and sphingolipid metabolism were enriched in the BV and HPV co-infected women, whereas oxidative phosphorylation, carbon fixation pathways in prokaryotes, protein folding and associated processing, pantothenate and CoA biosynthesis, protein biosynthesis , selenocompound metabolism, folate biosynthesis, porphyrin and chlorophyll metabolism, histidine metabolism, sulfur metabolism, peroxisome, PPAR signaling pathway and C5-Branched dibasic acid metabolism were depleted after HPV infection ion Fig. .Figure 6Lactobacillus spp. and increased microbiota diversity are a well-accepted finding in women infected with HPV25. We found that the vaginal microbiota in women with BV or HPV infection was more complex and had a reduction of Lactobacillus spp.  was a protective factor, whereas BV  and HR-HPV infection  were risk factors for CIN in our survey -binding adhesins41. The percentage of samples dominated with L. iners was higher in the B.H.C group than in the B.H group , hepatitis B virus (HBV) or Treponema pallidum; (f.) accompanied by hypertension, diabetes, immune system disease or other diseases; and (g.) antibiotics use in the past 30 days.This study was approved by the Ethics Committee of the Aviation General Hospital, Beijing, China . Written informed consent was obtained from all participants and all methods were performed in accordance with the guidelines and regulations. Women attending the Aviation General hospital, located in Beijing, China were recruited in our study. The close-ended questionnaire was drafted by two of the authors and conducted face-to-face. Prior to actual distribution, a pilot was conducted with 20 participants, and the results of pilot questionnaire were not included in subsequent analysis. The inclusion criteria included: (a.) age range from 25 to 65 years; (b.) untreated BV; (c.) voluntary signing of informed consent form and questionnaire; (d.) had sexual experience. The exclusion criteria included: (a.) current pregnancy; (b.) undergoing menstrual period; (c.) vaccinated against HPV; (d.) sexual activity, vaginal irrigation or drug application performed 48 h before sampling; (e.) diagnosed with vulvovaginal candidiasis (VVC), trichomonas vaginitis, or other STIs like Participants were put in the lithotomy position on the gynecological examination bed after signing the informed consent form and finishing the questionnaire. A well-trained clinical doctor swabbed the vagina using two disposable sterile swabs to collect cervical and vaginal secretions that were then stored in 2 ml saline and 2 ml phosphate buffer saline  tubes, respectively. Samples were kept on ice and transferred to the laboratory for subsequent testing.An experienced doctor made a diagnosis of BV if a patient met three out of the following four Amsel’s criteria: (a.) increased, thin, and homogeneous vaginal discharge; (b.) vaginal pH greater than 4.5; (c.) presence of clue cells; and (d.) amine odor when potassium hydroxide (KOH) was added to the vaginal secretions. The Hybrid Capture 2 assay (HC2) was used to detect seventeen HR-HPV types  and six low-risk types . Women who were positive for HR-HPV also accepted TCT to define the cytological lesion. If the results were atypical squamous cells of undetermined significance (ASC-US) or more severe lesions such as low-grade squamous intraepithelial lesions (LSIL) or high-grade squamous intraepithelial lesions (HSIL), they were recommended for colposcopy to define the grade of CIN.FastDNA Spin Kit  was used for DNA isolation from vaginal secretions. We added 200 μl of the samples suspended in saline and 1 ml cell lysis solution (CLS-TC) to Lysing Matrix A (FastPrep) and then followed the protocol. DNA concentration and purity was monitored on 1% agarose gel. According to the concentration, DNA was diluted to 1 ug/ μl using sterile water.V3-V4 hypervariable fragments of the 16S rRNA gene were amplified using primers 338F (338F: 5’- ACTCCTACGGGAGGCAGCA -3’) and 806R (806R: 5’- GGACTACHVGGGTWTCTAAT -3’) by PCR with the barcode. Mixture PCR products was purified with Qiagen Gel Extraction Kit . TruSeq DNA PCR-Free sample preparation kits  were used for library construction. The library quality was assessed on the Qubit@2.0 Fluorometer (Thermo Scientific) and Agilent Bioanalyzer 2100 system. At last, the library was sequenced on an Illumina NovaSeq platform  and 250 bp paired-end reads were generated.http://ccb.jhu.edu/sofeware/FLASH)42. Quality filtering on the raw tags were performed under specific filtering conditions to obtain the high-quality clean tag according to the QIIME  quality controlled process44. The tags were compared with the reference database  using UCHIME algorithm  to detect chimera sequences, and then the chimera sequences were removed46. Then the Effective Tags finally obtained. Sequences analyses were performed by Uparse software 47. Sequences with ≥ 97% similarity were assigned to the same OTUs. For each representative sequence, the Silva Database (http://www.arb-silva.de/) was used based on Mothur algorithm to annotate taxonomic information48. To study phylogenetic relationship of different OTUs and the difference of the dominant species in different samples, multiple sequence alignment were conducted using the MUSCLE software 49.Paired-end reads was assigned to samples based on their unique barcode and truncated by cutting off the barcode and primer sequence. Paired-end reads were merged using FLASH , and the images were drawn by R50.Alpha diversity indices Observed-species, Chao1 and Shannon were calculated with QIIME (V1.7.0) and displayed with R software (V3.6.3). Beta diversity was calculated by QIIME software (V1.9.1). Principal Coordinate Analysis (PCoA) analysis was displayed by WGCNA package, stat packages and ggplot2 package in R software. Linear Discriminant Analysis Effect Size (LEfSe) analysis and Phylogenetic Investigation of Communities by Reconstruction of Unobserved States (PICRUSt) were performed using the Novomagic, a free online platform for data analysis . P values of PCoA based on the Bray–Curtis dissimilarity were calculated by the ANOSIM test. LEfSe analysis was used to discover the metagenomic biomarker. Kruskal–Wallis rank-sum test and pairwise Wilcoxon test was calculate by LEfSe software (version 1.0). Alpha value less than 0.05 was considered statistically significant50. In PICRUSt part, two-tailed T-test was used to calculate the P-value. P value less than 0.05 was considered statistically significant.All statistical analyses were calculated using SPSS version 23  and R software (V3.6.3). The categorical variables collected in the questionnaire were displayed by frequencies and proportions. Statistical analyses were performed with Pearson’s Chi-squared Supplementary Information 1.Supplementary Information 2.Supplementary Information 3.Supplementary Information 4.


P < 0.001). No women vaccinated before sexual debut had HPV 16/18‐related cytological abnormalities. VE for HPV 16/18 infection and high‐grade cytological abnormalities in women vaccinated prior to sexual debut were 95.8%  and 78.3% , respectively, in multivariate analyses adjusted for age and number of sexual partners. However, analyses of all vaccinated women did not show significant effectiveness against cytological abnormalities. Our results showed the effectiveness of HPV vaccine against high‐grade cervical cytological abnormalities and the importance of the vaccination before sexual debut.Japanese girls aged 12–16 years are offered free human papillomavirus (HPV) vaccination and cervical cancer screening is conducted with cytology and not HPV testing from the age of 20 years. So far, no study has analyzed the effect of HPV vaccination against cervical precancers considering HPV infection status and sexual activity. We aimed to analyze the vaccine effectiveness (VE) against HPV infection and cytological abnormalities, adjusted for sexual activity. This study comprised women aged 20–26 years who underwent cervical screening in Niigata. We obtained HPV vaccination status from municipal records and a questionnaire along with information concerning sexual activity. Of 5194 women registered for this study, final analyses included 3167 women in the vaccinated group  and 1386 women in the unvaccinated group. HPV 16/18 (0.2% vs 3.5%), 31/45/52 (3.4% vs 6.6%), and 31/33/45/52/58 (5.0% vs 9.3%) positive rates were significantly lower in the vaccinated group  of >90% was observed concerning HPV 16/18 infection and that VE was nearly 80% for HSIL+ cytological abnormalities in the group vaccinated prior to sexual debut using real‐world data. In the Niigata study, official municipal vaccination records are checked, HPV testing is performed on registrants during cervical screening, and a questionnaire is used to obtain information on sexual activity. In an interim report of women aged 20–22 years, we reported bivalent vaccine effectiveness to be >90% in preventing HPV 16/18 infection.22.1This population‐based cross‐sectional study (the Niigata study) comprised women aged 20–26 years  who have undergone cervical screening in six cities in Niigata Prefecture  since April 2014.2.2Japan does not have a national vaccination database, and vaccination records are managed by individual municipalities. Therefore, we obtained information on the date of vaccination, the number of doses administered, and the type of vaccine from the official vaccination records kept by the aforementioned six cities. Some registrants may have been vaccinated in a different municipality from their place of residence. Therefore, we also used a questionnaire to obtain their HPV vaccination status, along with information concerning sexual activity . The number of sexual partners was separated into the following five categories: 0, 1, 2–5, 6–9, and ≥ 10. We extracted “the vaccinated prior to sexual debut group” from the overall vaccinated group according to information on the date of vaccination and age at sexual debut.2.3Cervical cytology was performed using liquid‐based samples  at the facilities where the registrants underwent screening. Data used in the analysis comprised the screening results recorded by each municipality. HPV testing was performed using residual fluid from the sample used for cervical screening. The HPV screening test was performed using HC2  or a BD Onclarity HPV kit , and positive screened samples were tested for genotype using the MEBGEN HPV kit . Genotype testing can detect 13 types of high‐risk HPV: 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, and 68.2.4U, Pearson’s χ2, and Fisher’s exact tests were used to compare baseline characteristics, HPV infection rates, and abnormal cytology rates in vaccinated and unvaccinated women. Univariate and multivariate logistic regression analyses were performed to evaluate vaccine effectiveness (VE) for HPV 16/18 infection and HSIL+. In the multivariate logistic regression analysis, Model 1 was adjusted for age and Model 2 was adjusted for age and total number of previous sexual partners. We set the “previous sexual partner = 0” group as the reference in Model 2. VE was calculated as 100 × [1 − odds ratio] along with the corresponding 95% confidence interval (CI). A P‐value <0.05 was considered statistically significant.Data were analyzed using EZR , a graphical user interface of R .2.5All registrants provided written informed consent. HPV testing, which is not part of Japan’s cervical screening program, was provided free of charge. This study was approved by the Ethical Review Board of the Niigata University Graduate School of Medical and Dental Sciences (2015–2268) and registered with the University Hospital Medical Information Network Clinical Trials Registry (UMIN) (UMIN000026769).33.1Figure 3.2P < 0.001). In the vaccinated group (n = 3167), mean age (±standard deviation [SD]) at first vaccination was 14.2 (±1.5) years. Of these registrants, 2821 (89.0%) women had been vaccinated prior to sexual debut, and 347 (11.0%) had their sexual debut prior to their first vaccination or at the same age. In total, 3026 (95.5%) women had completed all three vaccinations, and 2822 (89.1%) had received the bivalent vaccine. Number of sexual partners was found to be significantly higher in the unvaccinated group (P < 0.001). The percentage of women who responded that they had ≥10 sexual partners was 7.4% (235 of 3168) in the vaccinated group and 14.3% (198 of 1386) in the unvaccinated group. Further, the median age (range) at sexual debut was 18 (12–24) years in the vaccinated group and 18 (11–26) years in the unvaccinated group. Although the median age at sexual debut was 18 years for both groups, there were statistically significant differences in the age distribution (P = 0.022).Table 3.3n = 7) and 3.5% (n = 48), respectively. Both positive rates were significantly lower in the vaccinated group (P < 0.001). Atypical squamous cells of undetermined significance (ASC‐US) or worse (ASC‐US+) were observed in 148 (4.7%) women in the vaccinated group and in 101 (7.3%) women in the unvaccinated group, respectively. A high‐grade squamous intraepithelial lesion (HSIL) or worse (HSIL+) was observed in 11 (0.3%) women in the vaccinated group and in 13 (0.9%) women in the unvaccinated group. Both findings indicated a significant reduction in the vaccinated group . The HPV 31/45/52 and HPV 31/33/45/52/58 positive rates were 3.4% (n = 107) and 5.0% (n = 157) in the vaccinated group, and 6.6% (n = 91) and 9.3% (n = 129) in the unvaccinated group, respectively. Both positive rates were significantly lower in the vaccinated group (P < 0.001). HPV 31/45/52 are cross‐protective types of the bivalent vaccine for Japanese womenTable Figure 3.4P < 0.001) in the univariate analysis, 91.4%  in Model 1 (adjusted for age), and 88.8%  in Model 2 , showing significant effectiveness in all analyses. In terms of effectiveness against HSIL+, VE was 64.0%  in the univariate analysis, 54.1%  in Model 1, and 41.1%  in Model 2, with the multivariate analyses adjusted for age and number of sexual partners not showing significance.Table 3.5P < 0.001) in the univariate analysis, 97.4%  in Model 1 and 95.8%  in Model 2. VE for HSIL+ was 89.1%  in the univariate analysis, 86.2%  in Model 1, and 78.3%  in Model 2, showing significant effectiveness in all analyses, especially multivariate analyses adjusted for age and the number of sexual partners.It is recommended that the HPV vaccine be administered prior to sexual debut to maximize its effectiveness. Therefore, we have added an additional analysis of the vaccine effectiveness against cytological abnormalities in vaccinated women prior to sexual debut, in addition to a comparison with all vaccinated women. Table Because vaccinated women prior to sexual debut include women who have not had sexual intercourse, we excluded the “previous sexual partner = 0” group from the “after vaccination” group for our statistical analysis. The corrected results, which were almost identical to the previous results, are added as Tables 4This study is the first in Japan to evaluate the effectiveness of HPV vaccination against cervical cytological abnormalities using accurate municipal vaccination data and taking HPV infection status and sexual activity into account. Using multivariate analyses adjusted for age and the number of sexual partners, we found a significant preventive effect against high‐grade cytological abnormalities (HSIL+) for women who had received the HPV vaccine prior to sexual debut.This study had the following three strengths. First, the analysis used accurate vaccination information obtained from municipalities . Second, the questionnaire survey of sexual activity allowed us to adjust for the number of sexual partners in the multivariate analysis and restrict some analyses to women who had been vaccinated prior to sexual debut. Adjusting for sexual activity, which is a confounding factor that has a considerable effect on HPV infection, has not been performed in most previous analyses from Japan and is likely to enhance the accuracy of the present study’s findings on the effectiveness of the HPV vaccine. Third, HPV testing was performed at the same time as cytology examinations. Understanding HPV infection status made it possible to analyze cytological abnormalities associated with the HPV types targeted using the vaccines.In an interim analysis as part of the Niigata study, we examined the effectiveness of the bivalent vaccine for preventing HPV 16/18 infection in 1814 women aged 20–22 years in Niigata Prefecture between fiscal years 2014 and 2016. We found that VE was 91.9% in the HPV vaccinated group overall and 93.9% in the group vaccinated prior to sexual debut.P < 0.0001).P = 0.01); however, the difference in HSIL+ was not significant (P = 0.596).Using Miyagi Prefecture cervical cancer screening data, Karube et al. reported that the rate of HSIL+ was 0.20% (2 of 1002) in vaccinated women and 1.14% (56 of 4922) in unvaccinated women, indicating a significant reduction of 82.5% due to vaccination (P < 0.01).Using municipal vaccination records, Ueda et al. conducted a survey concerning the low‐grade squamous intraepithelial lesion cytological abnormality (LSIL+) rate in 20‐year‐old women who had undergone cervical cancer screening. The LSIL+ rate was significantly lower among women young, enough to be eligible for vaccination at 0.58% (6 of 1032) compared with women from the generations before vaccination was introduced  has recommended that girls become vaccinated for HPV before they are sexually active,This study had some limitations. First, the data are only derived from a single region of Japan (Niigata Prefecture). Niigata is located on the northwest coast of Honshu, Japan’s largest island, and its current population is approximately 2,200,000. The six cities that participated in the study account for approximately 70% of the population of Niigata and are representative of the prefecture’s municipalities. The mean annual income in Niigata is 5,331,000 yen , which is similar to the mean annual income of Japan overall . Thus, it can be considered a socially average prefecture in Japan.Recently, we reported that the HPV 16/18 infection rates were increasing again due to discontinuation of active recommendations for the HPV vaccineWe found that among Japanese women aged 20–26 years, a high VE of >90% was observed concerning HPV 16/18 infection and that VE was nearly 80% for HSIL+ cytological abnormalities in the group vaccinated prior to sexual debut using real‐world data. Japanese girls aged 12–16 years are offered free HPV vaccination; however, the WHO recommends vaccinating girls aged 9–14 years. After proactive recommendation for HPV vaccine resumes, it will be necessary to discuss the recommended age for routine HPV vaccination in Japan based on our results. As part of the Niigata study, we plan to further verify the effectiveness of the vaccines against histological abnormalities and analyze their long‐term prevention effectiveness.M. Y., Y. U., and T. E. have received lecture fees from Merck Sharp and Dohme. E. M. received honoraria and lecture fees from Roche Diagnostics, Hologic Japan, and Merck Sharp and Dohme. All other authors report no potential conflicts.Animal Studies: N/A.Approval of the research protocol by an Institutional Reviewer Board: This study was approved by the Ethical Review Board of the Niigata University Graduate School of Medical and Dental Sciences (2015–2268). Informed Consent: All registrants provided written, informed consent. Registry and the Registration No. of the study/trial: This study was registered with the University Hospital Medical Information Network Clinical Trials Registry (UMIN) (UMIN000026769). Table S1Table S2Table S3Click here for additional data file.


Ancylostoma duodenale) and high carcinogenic risk HPV types, via Kato Katz and PCR, respectively. Cytokine, chemokine and immunoglobulin levels were analysed in cervicovaginal lavages and plasma samples. A pronounced mixed Type 1/Type 2 immune response was detected in the vaginal fluids of women with hookworm infection and this immune signature was a notable feature in hookworm-HPV co-infected women. Moreover, hookworm infection is positively associated with increased risk and load of HPV infection. These findings highlight helminth infection as a significant risk factor for acquiring a sexually transmitted viral infection and potentially raising the risk of subsequent pathology.Helminth infection-driven changes to immunity in the female reproductive tract (FRT) is an immune axis that is currently understudied but can have major implications for the control of FRT infections. Here we address how human hookworm infection associates with vaginal immune profile and risk of Human papillomavirus (HPV) infection. Stool, blood, cervical swabs and vaginal flushes were collected from women from the Central region of Togo to screen for hookworms ( Soil-transmitted helminth (STH) infections in low- and middle-income countries (LMIC) are common . Disprop+ T cell responses against murine norovirus are reduced in mice infected with Trichinella spiralis , which is suggested as a co-factor in the HPV-driven etiology of invasive cervical cancer -funded GSAT study within the German-African Cooperation Projects in Infectiology. All participants were over 18 years of age at the time of recruitment and gave written informed consent prior to sample collection. Ethical approval was received from the Comité Bioéthique pour la Recherche en Santé (CBRS) of the Ministry of Health of Togo (N°26/2017/CBRS) and the Ethics Committee at the University Hospital Bonn, Bonn, Germany (Lfd. Nr. 273/16).Samples were collected from study participants from six villages  in the Central region of Togo in October 2019. To obtain a more comprehensive overview of the patient cohort, an epidemiological-based survey was conducted at the beginning of the study to assess sociodemographic variables, sexual behavior and vaginal hygiene practices . A totalAncylostoma duodenale, Hymenolepis nana, and Schistosoma mansoni) performed in stool samples using the Kato-Katz technique as previously described (Schistosoma haematobium eggs in urine samples was established by centrifuging urine (10 ml) at 1500 rpm for 5 minutes and examining the resulting pellet microscopically, but no S. haematobium eggs could be detected. To determine the presence of Onchocerca volvulus microfilariae, two skin snips of 1-2 mm in diameter were taken from left and right iliac crests using biopsy forceps. Skin snips were then incubated in 100 µl of NaCl (0.9%) in 96-well microtiter plates for 18-24 hours at room temperature. Then, the presence of microfilariae was examined microscopically at 40x magnification. However, no O. volvulus microfilariae were detected. Moreover, blood smears were either incubated in water for 15 minutes, fixed with methanol and stained with 10% Giemsa for 45 minutes or fixed with May-Grunwald solution for 2 min and then stained with a 1:10 diluted Giemsa staining solution for 15 min to microscopically assess blood-dwelling microfilariae and Plasmodium spp., respectively. Staining reagents were obtained from Química Clínica Aplicada  and microscopic assessment of parasites was performed using the Olympus CX23 light microscope . All parasitological analyses were directly performed in the field or in the laboratory of the UR2IM in Lomé, Togo.Examination for parasitic eggs  and shipped to the IMMIP, Bonn, Germany. Then, DNA was extracted from cervical swabs using the Seegene Microlab Nimbus IVD automaton kit  according to the manufacturer’s instructions to screen for HPV using the CFX96 IVD Real-time PCR System . The Anyplex™ 2 HPV HR Detection (CE/VD) kit was used to detect HPV 16, HPV 18, HPV 31, HPV 33, HPV 35, HPV 39, HPV 45, HPV 51, HPV 52, HPV 56, HPV 58, HPV 59, HPV 66 and HPV 68. The test was performed in a diagnostic reference laboratory for microbiology. This diagnostic assay was chosen because of its extensive clinical and analytical evaluation through VALGENT-3 Framework (th (intensity grade 3), 40th (intensity grade 2) and the end-cycle  is based on the proprietary diagnostic (CE/IVD) algorithm. In addition, this assay uses internal control to assure that just the samples of certain cellularity are diagnostically valid and the same target gene is used as the inhibition control.To assess if hookworm infection influences HPV viral load, we applied a semi-quantitative analysis using three categories (“intensity grade 1-3”). This type of semi-quantification is part of IVD/CE-approved diagnostic based on the proprietary chemistry of the SeeGene. In detail, extracted DNA is added to the mastermix and instead of the endpoint thermal cycler programme, a cyclic programme was chosen. The mastermix chemistry for HPV typing is based on high-resolution-melt profiling, the semi-quantification is based on the high-resolution melt (HRM) detection and the intensity of the obtained peaks after 30Blood was collected in 5 ml EDTA tubes and centrifuged at 4000 rpm for 5 minutes. Then, plasma was collected and stored at -20°C. In addition, vaginal flushes were collected by flushing the vagina of the enrolled women with 1 ml sterile PBS. To remove the cells, VF were centrifuged at 1200 rpm for 5 minutes and supernatants were stored at -20°C. Then, plasma and VF samples were shipped to Bonn, Germany for analyses of soluble cytokines, chemokines and antibodies.Levels of Type 1 cytokines , proinflammatory cytokines (IL-6 and IL-1β), Type 2 cytokines , cell survival and growth factors (IL-2 and GMCSF), as well as chemokines  in the plasma and vaginal flush samples were measured using the ProcartaPlex Human Th1/Th2 & Chemokine Panel 1 Luminex assay . In addition, IL-17A, IL-21, IL-22, eotaxin-2 and eotaxin-3 were also analysed using a Human ProcartaPlex Mix&Match kit (Thermo Fisher Scientific). Moreover, levels of IgA, IgE, IgM, IgG1, IgG2, IgG3 and IgG4 were measured using the human antibody isotyping 7-Plex ProcartaPlex Panel (Thermo Fisher Scientific). All Luminex assays were analysed on the Luminex™ MAGPIX system . In addition, IL-10 was measured by high sensitivity enzyme-linked immunosorbent assay (ELISA) using the High Sensitivity IL-10 Human ELISA Kit (Thermo Fisher Scientific) according to the manufacturer’s instructions. To normalise cytokine, chemokine and immunoglobulins levels relative to the protein concentration in the VF, protein levels were measured using the Bio-Rad Protein Assay Dye reagent concentrate . Individual analyte concentration was then expressed as ratio of the measured parameter and the total protein concentration of the sample.Plasmodium infection was associated with hookworm or HPV infection status, a Chi-square test was applied. To test the relationship between HPV intensity and immune parameters, a Spearman’s correlation test was performed and in order to determine whether hookworm infection was a risk factor for the severity of HPV infection, we performed a univariate logistic regression analysis with HPV intensity as a dependent factor. All associations, correlations and regression analysis were performed using the SPSS software Version 27.0  and odds ratio (OR) was calculated with a 95% confidence interval and a p-value < 0.05 was considered as significant.Statistical analyses were performed using the PRISM 8 program . Before testing for statistical significances between the groups, we performed a D’Agostino-Person omnibus normality test to test the distribution of the values. Since variables were non-parametric, a Mann Whitney U test was used to compare two groups, whereas a Kruskal-Wallis-test was performed to compare more than two groups. If a Kruskal-Wallis test was significant, a Dunn’s multiple comparison test was performed for a further comparison of the groups. To assess whether 367 women were enrolled in this study of which 205 women consented to provide paired stool samples and cervical swabs. Two women tested positive for HIV and were excluded from the study, while 8 participants had missing HPV data. Hookworm prevalence was assessed in 203 women and HPV infection prevalence could be investigated in 195 women. However, sufficient amounts of plasma and vaginal flush (VF) samples could be obtained only from a study cohort of 113 women to perform the immunological analyses Figure 1Ancylostoma duodenale infection was 20.2% (n=41), followed by Plasmodium falciparum  and Hymenolepis nana and Schistosoma mansoni infections, which were each detected at prevalence of 0.5% (n=1)  , 18.However, immune responses in plasma did not correspond to those detected in vaginal samples. In detail, Type 2 and regulatory immune responses did not differ between hookworm+ and hookworm- women and IL-5, IL-13 and IL-4 levels were undetectable in most plasma samples  in comparison to HPV+ hookworm– women who had no HPV16 infections and only 3% HPV18 infections  directly d tissue  followind tissue . MucosalChlamydia trachomatis and HIV . Importantly, HPV 35 that is implicated in cervical cancer progression in SSA , 34, andThe raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Comité de Bioéthique pour la Recherche en Santé (CBRS) of the Ministry of Health of Togo (N°26/2017/CBRS) and the Ethics Committee at the University Hospital Bonn, Bonn, Germany (Lfd. Nr. 273/16). The patients/participants provided their written informed consent to participate in this study.GK, LEL, WGCH and MR conceived and designed the study. GK, EHK, CNT, CV, EPT, OMA, KA, SDK, YA and MK performed the field research. MAO, GK, CNT, CV, EPT, OMA, KA, WGCH and MR analyzed the results. MAO, WGCH and MR drafted the manuscript while GK, CNT, KA, MP, LEL and AH critically revised the article and controlled the intellectual content. All authors contributed to the article and approved the submitted version.This work was supported by the German Research Foundation (DFG) within the German-African Projects in Infectiology . Moreover, MR is financially supported by the German Federal Ministry of Education and Research (BMBF) and the Ministry of Culture and Science of the State of North Rhine-Westphalia (MKW) within the framework of the Excellence Strategy of the Federal and State Governments. AH is supported by the BMBF [01KA1611 and 01KA2027] and additionally funded by the DFG under Germany’s Excellence Strategy – EXC2151 – 390873048. MAO was supported by the Poliomyelitis Research Foundation Bursary . The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.We thank all participants, community health workers as well as local and national health officials for their support. In addition, we thank Mrs. Özlem Mutluer for excellent technical assistance. The Wellcome Centre for Infectious Disease Research in Africa is supported by core funding from the WellcomeTrust (grant 203135/Z/16/Z).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Studies comparing self-collected vaginal samples with clinician-collected cervical samples with respect to high-risk human papillomavirus (HPV) detection and genotype agreement based on clinically validated full HPV genotype assays (e.g. the CLART HPV4S) are limited. This study compared the two types of samples using the CLART assay with respect to HPV detection and genotype agreement in a referral population.A total of 212 women aged 30–59 years and diagnosed with atypical squamous cells of undetermined significance (ASC-US) within the Danish cervical cancer screening programme had a cervical sample taken at their general practitioner. Afterwards, the women took a vaginal sample with the Evalyn Brush device at home. The paired samples were HPV-tested with the full genotyping CLART HPV4S assay. Histological results, i.e. cervical intraepithelial neoplasia of grade 2 or worse (CIN2+) were available for 14 women with HPV-positive clinician-collected samples.The study found the same HPV prevalence in self-collected vaginal samples compared to clinician-collected cervical samples . The CLART HPV4S assay detected approximately the same number of CIN2+ cases in the self-collected vaginal samples compared to the clinician-collected cervical samples (13 vs 11 cases). Exactly the same genotypes were detected in 75% (21/28) of the HPV-positive paired samples, while at least one identical genotype was found in the remaining 25% (7/28) of the paired samples.The CLART HPV4S assay performed similarly well in self-collected vaginal samples as in clinician-collected cervical samples with respect to both HPV detection and genotype agreement when using the Evalyn Brush and the CLART HPV4S assay in a referral population. Although further evaluation is needed, the findings suggest that full HPV genotyping based on the CLART assay can be useful when establishing HPV genotype-specific referral strategies for women tested HPV-positive by self-sampling. High-risk human papillomavirus (HPV) testing on self-collected vaginal samples (self-samples) has proven an effective screening method for reaching under-screened women who are reluctant to attend routine clinician-based cervical cancer screening , 2. AcroAmong commercially available full genotype assays, the CLART HPV4S assay (GENOMICA) is a clinically validated PCR-based HPV DNA test. It detects 14 individual oncogenic HPV genotypes . Yet, toThis study investigated whether the CLART HPV4S assay performed similarly well with respect to HPV detection and genotype agreement in paired self-samples collected at home and clinician-collected cervical samples in a referral population.In Denmark, cervical cancer screening is a nationwide free-of-charge population-based programme that invites women aged 23–64 years for liquid-based cervical cytology sampling at their general practitioner (GP) , 13. CurThis cross-sectional study was conducted between June 2015 and December 2016. Paired clinician-collected cervical samples and self-samples, taken at home, were obtained from women aged 30–59 years diagnosed with ASC-US within the screening programme. Exclusion criteria were pregnancy, childbirth less than three months before inclusion, and obtainment of the vaginal self-sample after colposcopy. The inclusion procedure has been described in detail in previous publications . In brieAt screening, the women had a cervical cytology sample collected using the Cervex-Combi Brush®  at their GP. This brush head was rinsed in 10 mL SurePath medium  and mailed to the Department of Pathology, Randers Regional Hospital, for routine processing and testing as previously described , 17. FroA sample was defined as HPV positive if at least one of these 14 genotypes was detected: HPV16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, and 68. If the sample only detected HPV6 and/or HPV11, it was considered HPV negative.To account for the low number of HPV positives, the genotypes were hierarchically subdivided into five groups based on the oncogenicity for cervical (pre-)cancer : (1) HPVHistological results were grouped using the most severe diagnosis as either ≤ CIN1  or CIN2+  . HistoloFor analysis, only women with valid HPV results from paired cervical clinician-collected samples and self-samples (paired samples) were included. HPV concordance (any type) between the paired samples was assessed using Cohen’s kappa statistics (κ) and defined as: “Poor” (κ ≤ 0.20), “Fair” (0.21 ≤ κ ≤ 0.40), “Moderate” (0.41 ≤ κ ≤ 0.60), “Good” (0.61 ≤ κ ≤ 0.80), or “Very good” (κ ≥ 0.81) . All datThis project was approved by The Danish Data Protection Agency  and due to the use of human biological material, also by the local Ethical Committee of the CDR . All participants gave written informed consent to participate in the study. All methods were carried out in accordance with relevant guidelines and regulations.A total of 1,110 eligible women were invited of whom 216 (19.5%) returned a self-sample  detected in the self-samples was similar to the prevalence in the clinician-collected samples  . The corresponding percentage was 32% of all HPV-positive self-samples (13/41). Exactly the same genotypes were detected in 75% (21/28) of the paired samples that were HPV positive in both the clinician-collected sample and the self-sample, while at least one identical genotype was found in the remaining 25% (7/28) of the paired samples (data not shown).HPV35/39/68 was the genotype group most frequently observed both in the clinician-collected samples and self-samples constituting 33% and 29% of the HPV genotypes  of the HPV-positive paired samples, while at least one identical genotype was found in the remaining 25% (7/28) of the paired samples.Overall, we found that self-samples performed at least as good as clinician-collected samples with respect to HPV detection and genotype agreement.The main strength of this study was the paired design in which the women acted as their own control and lowered the risk of confounding factors. In addition, we used a combination of a clinically validated self-sampling brush device  and a fuThe main limitation was the time span between the sample sets. The time interval could have increased inequality between results from self-samples and clinician-collected samples as the 24 conflicting cases to some extent can be explained by women who cleared an existing HPV infection or acquired a new infection, or reactivation of a previous latent HPV infection [Only 19.5% of the eligible participants accepted the study invitation, which may lead to selection bias if participants and non-participants (80.5%) differed in their capacity to collect the vaginal self-sample correctly, i.e. collect a sufficient number of cervico-vaginal cells. However, as none of the self-samples was invalid for HPV testing, this scenario was considered less likely.Ideally, histological results should have been available for all women with an HPV-positive self-sample and not only from women with an HPV-positive clinician-collected sample but this was not possible within this study population. This methodological issue was also the reason why we avoided to present the clinical accuracy of self-samples using histology as reference.Moreover, if histological results from all samples had been gathered, we would also have been able to predict whether the false-negative and false-positive samples depended on the women clearing or acquiring infections or if the samples were inaccurate or insufficient.While many studies have reported the dominance of HPV16 and HPV18-associated cervical cancer, there is to the best of our knowledge no clear consensus on the ranking of the next most oncogenic genotypes. For instance, HPV45 was ranked as the third most common oncogenic genotype globally by Sanjose et al.  and TjalSince the study was conducted in a referral population among women already diagnosed with ASC-US, the results cannot be directly generalised to a screening population and should therefore be interpreted with caution. In addition, the results should be interpreted with caution due to the limited number of HPV positive cases.Our study showed good concordance between vaginal self-samples and clinician-collected samples (κ: 0.63) for HPV detection (any type). Our result corresponds to the good concordance (κ: 0.70) observed in a previous study by Tranberg et al. within the same study population using the COBAS 4800 assay . Our conIn our study, HPV infections were detected in 19.3% of the self-samples. This prevalence was higher than, but not significantly different from, the 14.8% reported by Enerly et al. and the 11.3% reported by Lam et al. which used the CLART HPV2 assay in combination with the Evalyn brush to investigate the HPV prevalence among self-samplers , 30. TheConsistent with other studies , 15, 23 The CLART HPV4S assay performed at least as good in vaginal self-samples as in clinician-collected cervical samples with respect to both HPV detection and genotype agreement. Although further evaluation is needed, the findings suggest that full HPV genotyping based on the CLART assay can be useful when establishing HPV genotype-specific referral strategies for women tested HPV-positive by self-sampling.


Malignancies are found between the first three reasons of mortality in pediatric and adult kidney transplant recipients, who overall have disproportionately higher rates of cancer compared to the general population, including human papillomavirus (HPV)-related genital, anal and oropharynx region cancers. Therefore, preventing HPV in this patient population is extremely important. HPV-vaccine was demonstrated to prevent HPV infection in individuals with intact immune systems. In addition, recent data reported less precancerous HPV lesions and cervical cancers with use of HPV vaccine. Since HPV is a sexually transmitted virus that is typically acquired shortly after the onset of sexual activity, it is best to administer the HPV vaccine immunization prior to the onset of sexual activity. This article reviews the epidemiology and pathophysiology of the HPV infection, as well as its role in the development of HPV-related pre-cancerous lesions and cancers in both general population and kidney transplant recipients. The focus is on the most effective primary prophylactic strategy, which is the HPV vaccination. The particularities of HPV vaccination strategies in kidney transplant recipients are compared to the general population. In addition, the article analyzes the various causes of suboptimal HPV immunization rates in kidney transplant candidates and recipients and discusses vaccination optimization strategies that can be applied during childhood and adolescence to reduce the burden of HPV-related disease states and cancer among adult kidney transplant recipients. Cancers in general are between the first three reasons of death in adult solid organ transplant (SOT) recipients, including kidney transplant (KT) recipients . It is d, medical professionals need to get an early start with the most efficacious preventive strategies during childhood and adolescence  patients and SOT recipients, continue to be limited, but emerging. For example, the quadrivalent HPV vaccine has been recently shown to reduce HPV infections and genital warts in HIV women , 56. TheThe dosing for KT recipients, which actually applies to all SOT recipients, is slightly different than for the general population. In essence, while healthy individuals less than 15 need only two doses of the vaccine, KT recipients should always receive three doses, regardless of their age . FurtherTiming of the HPV vaccine for KT recipients should be as recommended for the general population. It is optimal to vaccinate whenever possible prior to transplantation, during the last stages of chronic kidney disease (CKD) or while on dialysis, as it has been shown that after transplantation the vaccine responses are reduced , 60.The HPV vaccines are efficacious in SOT recipients, including KT, but nevertheless the immune response appears to be reduced compared to the general population . The verFive years post-HPV vaccination in SOT recipients, seropositivity rates dropped from 100% immediately post-vaccination to 94.6% for HPV-16 and from 91.2% to 78.4% for HPV-18 in a recent Australian study . This stIn a study of pediatric KT recipients from University of Minnesota followed long-term it was noted that at 20 years post-KT, 13% of the patients were suffering from a form of malignancy, while by 30 years post-KT, 26% . It is kKT recipients appear to be vaccinated later than the recommended time . This isIn addition, vaccine hesitancy has been an even greater issue in successfully vaccinating children and adolescents, therefore general pediatricians and pediatric transplant nephrologists can help to overcome reluctance by educating their patients regarding to the safety profile and the benefits of the HPV vaccine . In ordeIn conclusion, in order to optimally protect KT patients from acquiring HPV-associated cancers, pediatric transplant professionals should advocate that their patients get the HPV vaccine before transplantation, provided that they have reached age nine. If the KT occurs during the series, vaccination should be completed afterwards, resuming the series at least 3–6 months after transplant. If still unvaccinated post-transplant, medical professionals should recommend the HPV vaccine even after age 26. Further research will be needed to assess the effectiveness of the HPV vaccine when given before transplantation in preventing actual HPV-related pathology. Consideration is being given to administering the vaccine at an earlier than currently recommended age. If proven effective enough and safe, this could change the life of many patients, who otherwise would become transplanted without the HPV vaccine and therefore would miss the opportunity to mount a strong serologic response pre-transplant.