Human papillomavirus (HPV) vaccines are efficacious against HPV infections and associated lesions in women HPV-naïve at vaccination. However, vaccine efficacy (VE) against oncogenic, high-risk HPV (HR-HPV) types in women infected with any other HR-HPV type at first vaccination (baseline) remains unclear. This post-hoc analysis of a phase II/III study (NCT00779766) evaluated AS04-adjuvanted HPV-16/18 (AS04-HPV-16/18) VE against HR-HPV type infection in 871 Chinese women aged 18–25 years over a 72-month follow-up period. Study participants were DNA-negative at baseline to HR-HPV type(s) considered for VE and DNA-positive to any other HR-HPV type. Initial serostatus was not considered. Baseline DNA prevalence was 14.6% for any HR-HPV type and 10.6% excluding HPV-16/18. In the total vaccinated cohort for efficacy, VE against 6-month and 12-month HPV-16/18 persistent infections (PIs) in women DNA-negative to HPV-16/18 but DNA-positive to any other HR-HPV type at baseline was 100.0%  and 100.0% (95%CI: 47.2–100.0), respectively. VE against HPV-16/18 incident infections in women DNA-positive to one vaccine type but DNA-negative to the other one at baseline was 66.8% (95%CI: −18.9–92.5). VE against HPV-31/33/45 incident infections, in women DNA-positive to HPV-16/18 and DNA-negative to the considered HPV type at baseline was 71.0% (95%CI: 27.3–89.8). No HPV-16/18 PIs were observed in vaccinated women with non-vaccine HPV A7/A9 species cervical infection at baseline. These findings indicated that women with existing HR-HPV infection at vaccination might still benefit from the AS04-HPV-16/18 vaccine. However, this potential benefit needs further demonstration in the future. All three vaccines induce strong and sustained protection against anogenital infections and precancerous lesions caused by the vaccine types in subjects HPV-naïve at the time of vaccination.9 targeting mainly adolescent girls. Independently, unvaccinated adult women may seek vaccination services on a user-pay basis. In China, for example, low awareness of HPV infections and related diseases and lack of availability of HPV vaccines in the NIP have led to HPV vaccines being mainly administered to adult women.11 Adult women are more likely to be sexually active and may thus already have been, or currently be, HPV-infected at the time of first HPV vaccination.As of June 2020, HPV vaccines were included in 107 countries worldwide as part of national immunization programs (NIP),12 In some countries where HPV DNA testing is used for cervical cancer screening and prevention efforts, women attending screening service may be aware of an eventual HPV infection before vaccination, although screening for presence of HPV prior to vaccination is not required.13 This raised the question about HPV vaccine benefit in this population, especially as the World Health Organization and a growing number of countries are proposing HPV testing as a primary screening tool for cervical cancer.14National screening programs for cervical cancer were in place in >144 countries worldwide by 2018.7 and some of them have demonstrated vaccine efficacy (VE) in women having cleared prior HPV vaccine type infection (seropositive but DNA-negative to vaccine type).16 It remains unclear whether, among women with cervical HPV infection (HPV DNA-positive) at the time of first vaccination, the residual benefit of preventing infection with other HPV types to which they have not yet been exposed would be sufficient to warrant vaccination. More VE evidence in the HR-HPV infected population is needed for informed decisions by public health authorities and healthcare professionals.Until now, most studies focused on subjects HPV-DNA-negative to vaccine types at baseline,Hence, we performed the current post-hoc analysis to determine VE against infections associated with HPV-16/18 and HPV-31/33/45 types  in Chinese women aged 18–25 years with cervical HPV infection (DNA-positive) with any other HR-HPV type at the time of first vaccination, irrespective of their serostatus.www.ClinicalTrials.gov; NCT00779766) design, methods, and results of event-driven analyses have been previously presented.18 This post-hoc analysis reports VE against HPV-16/18 and HPV-31/33/45 infections  in women with cervical infection (DNA-positive) with any HR-HPV type other than the one(s) considered for VE at the time of first vaccination (baseline). Subjects were followed up to 72 months with incident infection and persistent infection (PI) as endpoints.The primary study  and the International Conference on Harmonization Good Clinical Practice guidelines.Healthy women aged 18–25 years were enrolled at four sites  in Jiangsu Province, China. Women were included in the trial regardless of their HPV DNA status, HPV-16/18 serostatus, or cytology results at baseline. Virgins were not enrolled in the study due to cultural and ethical considerations. Written informed consent was obtained from each participant prior to the performance of any study-specific procedures.Cervarix, GSK) or aluminum hydroxide [Al(OH)3] at 0, 1, and 6 month intervals in a double-blind manner. AS04 is a proprietary GSK Adjuvant System containing monophosphoryl lipid A  adsorbed on aluminum salt (500 μg Al). Cervical cytology samples for HPV DNA testing were collected every six months at each study visit. Cervical cytology was tested using the ThinPrep PapTest  and reported according to the Bethesda 2001 classification system. Histopathological analysis was performed by a panel of gynecological pathologists at the Cancer Hospital, Chinese Academy of Medical Sciences (CICAMS), Beijing, China. Final case ascertainment of women assumed to meet the criteria for efficacy endpoints was reviewed in a blinded fashion by an independent review committee. A broad-spectrum PCR assay, SPF10-LiPA25  and type-specific PCR for HPV-16 and HPV-18 DNA were used to test cervical samples and biopsy material for HPV DNA from 14 HR-HPV types  and 11 non-HR-HPV types.Briefly, study participants were randomized in a 1:1 ratio to receive either the AS04-HPV-16/18 vaccine  at baseline in the TVC-E. Subjects were evaluated for subsequent development of HPV infection with the types they were DNA-negative to at baseline.Previously published reports of this research disclose the efficacy, immunogenicity, and safety analyses in women DNA-negative at baseline (or both at baseline and Month 6), and seronegative at baseline (or irrespective of serostatus for the considered HPV type) in the according to protocol cohort for efficacy (ATP-E) and the total vaccinated cohort for efficacy (TVC-E).Based on the analysis of VE against HPV-16/18 and HPV-31/33/45 infection in women DNA-negative to the considered HPV type and DNA-positive to any of the 14 HR-HPV types (i.e. HPV-16/18/31/33/45/39/45/51/52/56/58/59/66/68) at baseline, further analyses were performed in the following three subsets: (i) VE against HPV-16/18 infection in women DNA-negative to the considered HPV type and DNA-positive to any of the other 12 HR-HPV types  at baseline; (ii) VE against HPV-16/18 and HPV-31/33/45 infection in women DNA-positive to HPV-16/18 and DNA-negative to the considered HPV type at baseline; (iii) VE against HPV-16 infection in women DNA-positive to non-HPV-16 A9 species (i.e. HPV-31/33/35/52/58), and VE against HPV-18 infection in those DNA-positive to non-HPV-18 A7 species  at baseline. Besides meeting the above criteria for baseline status, women included in the relevant analyses must have samples available after vaccine dose 1 for the evaluation of the virological endpoints.The evaluated endpoints were incident infection, 6-month PI and 12-month PI associated with specific HPV type(s). Incident infection was defined as the first detection by PCR of an episode of infection by HPV type(s) in a subject previously negative for the considered HPV type(s) and may have been transient or become persistent. Six-month PI was defined as at least two positive HPV DNA PCR assays for the same HPV type(s) with no negative DNA sample between the two positive DNA samples, over an interval of approximately six months. Twelve-month PI was defined as the detection by PCR of the same HPV type(s) at all available timepoints over an interval of approximately 12 months. Due to the limited sample size and the insufficient number of cervical intraepithelial neoplasia of grade 2 or worse (CIN2+) cases, VE against histological endpoints is not presented.18 Case counting started on the day after the first dose and ended at the time of an endpoint event or until the end of the 72-month follow-up. Statistical analyses were carried out with SAS 9.4 on the SDD platform. A similar method was used for the analysis in the ATP-E cohort.Endpoint cases were calculated as number of subjects reporting at least one event in each group, and VE was calculated using a conditional exact method, as previously described.www.clinicalstudydatarequest.com.Anonymized individual participant data and study documents can be requested for further research from In total, 871 (14.6%) women [444 (14.9%) from the AS04-HPV-16/18 vaccine group and 427 (14.3%) from the control group] from the TVC-E were included in the analysis of ongoing infection with any HR-HPV types, based on the primary objective of this paper . At baseOverall, the vaccine had high efficacy against incident infection, 6-month and 12-month PIs associated with HPV-16 and/or HPV-18 in women infected with any of the 14 HR-HPV types at baseline: 74.7% , 100.0% (95% CI: 79.8 to 100.0) and 100.0% (95% CI: 47.2 to 100.0), respectively. Consistently, high VE was observed in women DNA-negative to HPV-16/18 but DNA-positive to any other 12 HR-HPV types .Table 2.We also analyzed the efficacy against infection related to HPV-16/18 in women with HPV-16 or HPV-18 infection at baseline. In 223 women DNA-negative at baseline to one vaccine type but DNA-positive to the other one, VE against incident infection endpoints associated with HPV-16/18 was 66.8% (95% CI: −18.9 to 92.5). There were not enough cases to evaluate 6- or 12-month PI-related endpoints in this subgroup .Two subsets were analyzed to investigate the impact of infection with non-vaccine A9 and A7 HPV species at baseline on VE against virological endpoints associated with HPV-16/18. VE against incident infection, 6- and 12-month PIs associated with HPV-16 in women DNA-positive to non-HPV-16 A9 species at baseline was 69.9% (95% CI: 0.6 to 92.9), 100% (95% CI: 0.8 to 100) and 100% (95% CI: −119.6 to 100), respectively. Similarly, VE against incident and 6-month PI associated with HPV-18 in women DNA-positive to non-HPV-18 A7 species at baseline was 100% (95% CI: 45.3 to 100) and 100% , respectively. VE against 12-month HPV-18 PI could not be determined as no cases were reported during the duration of the study .Similar results were obtained for the ATP-E cohort (Supplementary table 1).Cross-protective efficacies against incident infections with HPV-31 and HPV-31/33/45 (any or in combination) in women DNA-positive to any other HR-HPV type at baseline were 63.2% (95% CI: 28.0 to 82.3) and 55.5% (95% CI: 30.3 to 72.1), respectively. VEs against 6-month and 12-month PIs are presented in In women with HPV-16/18 infection at baseline, high cross-protective VE against incident infections associated with HPV-31/33/45 was observed: 71.0% (95% CI: 27.3 to 89.8). Cross-protective VE values for 6- and 12-month PIs were 37.3% (95% CI: −191.4 to 87.6) and −59.6% , respectively .Similar results were obtained for the ATP-E cohort (Supplementary table 2).In all 871 subjects DNA-positive to any 14 HR-HPV types at baseline, irrespective of serostatus, only five CIN2+ cases associated with HPV-16 and/or −18  were reported in subjects DNA-negative to the corresponding HPV type at baseline.As part of the debate on the added-value of prophylactic HPV vaccination in already sexually active women infected with HPV, this post-hoc analysis supplied data on Chinese 18–25-year-old women who, at the time of first vaccination, had cervical HR-HPV infection (regardless of their serostatus). It evidences that the AS04-HPV-16/18 vaccine may provide preventive benefit to this population.20 The FUTURE II study, using the quadrivalent HPV vaccine, provided results from women seropositive or DNA-positive to one to three HPV vaccine types before vaccination.19 The VIVIANE study, using the AS04-HPV-16/18 vaccine, had a subset analysis consisting of women with a history of previous HPV infection or disease.20 However, seropositivity is considered to be associated with prior HPV exposure even though the infection has been cleared, while DNA status informs more about ongoing HR-HPV infection, which significantly affects VE. Moreover, HPV antibody titers are not routinely tested. Thus, our study merely included subjects who were DNA-positive at the time of first vaccination (regardless of their serostatus). The findings provide real-world practical and instructive implications for both clinicians and infected women.The FUTURE II (NCT00092534), VIVIANE (NCT00294047) and PATRICIA (NCT00122681) studies have already demonstrated significant VE against vaccine type HPV infection or related neoplasia in subjects with previous or existing HPV infection but DNA-negative for the targeted HPV type at baseline.16 Considering DNA status might have more impact on efficacy compared with serostatus, the negative lower bound of the CI for the VE observed in our analysis could be explained by the limited sample size available. It is also possible that efficacy is higher against high-grade lesions than against infections.In women DNA-positive to one of the HPV-16/-18 types at baseline but DNA-negative to the other type, our results displayed a statistically non-significant VE against HPV-16/18 incident infections. The PATRICIA study group also analyzed VE against CIN2+ associated with HPV-16/18 in women who were HPV DNA-positive to one vaccine type at baseline but DNA-negative and seronegative to the other vaccine type. The VE was 90.0% (95% CI: 31.8 to 99.8) for HPV-16/18.21 This bias is stronger for 12-month PI than for 6-month PI and incident infection, and may explain the decreasing VEs observed in this study.21As demonstrated in our study, among women DNA-positive to the vaccine types (HPV-16/18), including those simultaneously infected with both types, cross-protection against HPV-31/33/45 incident infections is evident. We also observed decreasing VEs against HPV-31/33/35 infections that became persistence; VE for incident infection > VE for 6-month PI > VE for 12-month PI. These changes in VE estimates may be linked to the underestimation of non-vaccine HPV types in the control group due to the broad-spectrum HPV PCR methodology used. This method is known to potentially underestimate the prevalence of genotypes present at low relative concentrations in multiple infections, a scenario that is more likely to arise in the control group when considering vaccine and cross-protected HPV types.22 Based on the phylogenetic relatedness, it is interesting to explore the impact of the preexistence of non-vaccine A7/A9 species infections at first vaccination on VE against endpoints related to HPV-16/18. However, most published studies have focused on cross-protective efficacy and a possible cross-reactive immune response related to A7/A9 species.23 In contrast, our data indicate high VE against HPV-16 or HPV-18 infections in women DNA-positive to any other non-vaccine HR-HPV A9 or A7 species at vaccination, respectively.The L1 protein of non-vaccine A9 species (HPV-31/33/35/52/58) and non-vaccine A7 species (HPV-39/45/59/68) display amino acid homology with L1 proteins of HPV-16 and HPV-18 types, respectively.24 The second peak is thought to be associated with new HPV exposure and/or the reactivation of a latent infection, and coincides with the peak of cervical cancer incidence observed in women up to 50–55 years old in China.25 As evidenced by our study, vaccinating women with preexisting HR-HPV infection could reduce the risk of infection with and transmission of HPV type to which they have not yet been exposed. Moreover, even though HPV vaccines have no therapeutic impact on preexisting infection,19 vaccination could prevent eventual re-infection later in life. Vaccination of infected women on an individual basis would confer protection to women from the second attack peak, protect their partners from possible infection and may slow down the progression of the HPV infection26 at the scale of the Chinese population. Further evidence is required on this point.HPV prevalence studies among Chinese women have shown two peaks in HR-HPV infections: a first peak in those aged 15–24 years, soon after the onset of sexual debut, and a second in those aged >40 years.27–29 The results of our analysis lend support to this concept, suggesting vaccinating all women, irrespective of their HPV DNA status. Within the context of global investment and commitments toward the elimination of cervical cancer, this would allow to achieve maximum health benefit and equity to the entire population.The HPV-FASTER protocol proposed offering HPV vaccination to women in a broad age range (9–45 years) to contribute to faster and greater population impact, based on the results of high VE from phase III clinical trials among adult women. However, vaccination of HR-HPV infected women has been controversial.30The main strength of our analysis was the specific focus on HR-HPV DNA-positive women at baseline, ignoring confounding factor of serostatus that is moreover not examined routinely, apart from clinical trial testing. An unavoidable limitation is that the findings were generated from a post-hoc analysis of a randomized controlled trial, which was not designed to analyze efficacy in women HR-HPV positive at vaccination, and randomization was not controlled for HPV-infection at baseline. Besides, the small number of women with ongoing HR-HPV infection available for inclusion in the present analysis  limits its statistical power. Also, due to insufficient endpoint cases, we evaluated efficacy mainly on a virologic perspective in the form of incident infections, with some subsets based on 6-month and 12-month PIs. However, as demonstrated in previous clinical trials, efficacy against PI is an acceptable surrogate endpoint for efficacy in the prevention of cervical cancer.In conclusion, our analysis indicated that women with existing HR-HPV infection at the time of first vaccination might still benefit from the AS04-HPV-16/18 vaccine. However, this potential benefit needs further demonstration in the future.Click here for additional data file.


Previous studies have provided evidence suggesting a link between HCV and HPV-associated head and neck cancers. The epidemiological evidence of the relocated association between HPV and HCV-associated HCC is scarce. In the current study, from a secondary claim-based dataset, HPV infection is not associated with an increased risk of HCC in the CHC population. On the contrary, HPV infection seems to be associated with a lower risk of HCC development among patients with HCV infection. These findings suggest that the mechanism of association between procuring an HPV infection and reducing risk of HCC in the CHC population needs to be studied in detail in the future, with the opportunity to generate an intervention target that could delay the development of HCC.N = 1981) and age-, sex-, inception point-, comorbidity-, and medication-matched non-HPV (N = 7924) were followed up until HCC, death, or 2018. HCC patients were extracted from the Taiwan Registry for Catastrophic Illness Database. We adopted the propensity score match and inverse probability of treatment weighting (IPTW) to eliminate bias. Cox proportional hazard regression analyses were performed to calculate HCC risk. Results: After a full adjustment, HPV was not associated with HCC risk . Almost all subgroup analyses verified this finding (HRs < 1.0). Conclusions: Among CHC patients older than 18 years old, those with HPV infection were associated with a lower risk of subsequent HCC.Background: Hepatitis C virus (HCV) has been shown to be associated with human papillomavirus (HPV)-positive head and neck cancers. However, studies regarding HPV infection and the risk of new-onset hepatocellular carcinoma (HCC) among chronic hepatitis C (CHC) patients are limited. We examined the risk of HCC in CHC patients with or without HPV infection. Methods: In total, 9905 CHC patients from 2000 to 2016 constituted the whole cohort. HPV was defined as being diagnosed after HCV. The CHC cohort with HPV ( Hepatocellular carcinoma (HCC) is one of the most common cancers of the digestive system, with approximately 500,000 new cases diagnosed worldwide each year , and it Sta. aureus is negatively associated with Str. Pneumoniae [In ecosystems, there are simultaneous and rich heterogeneous interactions between microorganisms. Epidemiological and experimental analyses have provided quantitative evidence for the existence of subtle mutually beneficial or competitive interactions between respiratory viruses, especially cold and influenza viruses . There aeumoniae . Pathoge5B (NS5B) recruit HPV oncoproteins E6, leading to the proteasomal degradation of retinoblastoma tumor suppressor protein (Rb) [The association of carcinogenesis between HPV and HCV has been mentioned ,10. HCV ein (Rb) ,13. ThinAfter obtaining approval of institutional review board (IRB) from Taiwan Ministry of Health and Welfare, we identified medical records of all patients aged 20 years and older with hepatitis C infection collected in National Health Insurance Research Database (NHIRD). Taiwan’s National Health Insurance (NHI) program administered by the Taiwan government is single-payer and mandatory, and includes >99% of Taiwan’s population . NHIRD iThe study database contained two million people, which was sampled by Bureau of National Health Insurance (BNHI) from the original claim data of NHIRD. The Health and Welfare Data Science Center (HWDC) of the Ministry of Health and Welfare provided data on the medical records and causes of death of 2 million sampled people to use. The frequently used variables in the NHI data and the cause of death data were provided directly for each application. The distributions of sex, age, and health care cost between the 2 million files and the 23 million population was similar. The National Health Research Institutes (NHRI) assigned a random number for each person by using the Knuth1 and Park and Miller’s 2 method ,20.p = 0.613) [There was no significant difference in the sex (= 0.613)  and age = 0.613) . We iden= 0.613) . The dia= 0.613) .Patients infected with HPV were extracted from the database according to ICD-9-CM codes 079.4, 078.1, 078.10-078.12, 078.19, 795.05, 795.09, 795.15, 795.19, 796.75, and 796.79. To avoid selection bias, the inclusion criteria required at least three outpatient visits or one inpatient diagnosis in the same database. This definition was used in our previous epidemiological studies [Of these patients, the testing of HPV infection was conducted by using a clinical physician’s judgement, but not by screening. There was no exact false negative rate of HPV infection. However, it is believed that this happens rarely because HPV testing has a great relationship with NHI payment for subsequent treatment and follow-up.To increase the homogeneity, we excluded patients who had medical record of HBV infection , and viral hepatitis of others . Patients with malignancies (ICD-9-CM codes 140-208) were excluded prior to the index date to avoid potential liver metastases in our enrolled participants. Those that had HCC within 6 months after the inception day were excluded to avoid cases with under-diagnosed HCC. We excluded patients with missing information regarding age or sex.Patients’ age and sex were recorded at the inception point. We also collected information about individual monthly income , and urbanization level of residence area , a proxy for healthcare availability in Taiwan . BaselinWe set new-onset HCC as the primary outcome of the study . Patients with HCC were verified by linking to the Registry for Catastrophic Illness Patient Database (RCIPD). The positive predictive rate was 93% . The stuBaseline characteristics of participants were shown as event number and percentages for categorical variables and as means and standard. We used the propensity score method for analysis by referring to the following article by using the SAS program. This reference may help readers to more clearly understand the detailed statistical analysis procedures than log files of the statistical analyses from SAS .The propensity score was calculated using the probability of the disease status assignment by using a logistic regression model, including the following baseline variables: age, gender, urbanization, individual monthly income (TWD); comorbidities of hypertension, diabetes, hyperlipidemia, chronic kidney disease, peptic ulcer disease, helicobacter pylori infection, COPD, cirrhosis, liver decompensation, alcohol-related illness, and autoimmune disease; every single reported medications of aspirin, metformin, statin, NSAIDs, interferon; index year.CHC patients with HPV were matched (1:4 ratio) with those who did not have HPV according to their propensity score through nearest neighbor matching, initially to the eighth digit and then as required to the first digit. Therefore, matches were first determined within a caliper width of 0.0000001, and then the caliper width was increased for unmatched cases to 0.1. We reconsidered the matching criteria and performed a rematch . For each CHC patient with HPV, the corresponding comparisons were selected based on the nearest propensity score.t tests for continuous variables. All of the tests of significance were 2-tailed. p-value < 0.05 was considered statistically significant. The incidence of HCC during follow-up was calculated by dividing the number of events by the respective person years at risk and presented as the number of events per 1000 person years. Incidence rate ratio was assessed by Poisson regression. We plotted Kaplan–Meier curve to describe the cumulative incidence of HCC in the study and control group, and tested the difference between the groups by the log-rank test. We used multivariable Cox proportional hazards analysis to examine the HCC risk associated with HPV after adjustment for age, sex, hypertension, diabetes, hyperlipidemia, chronic kidney disease, peptic ulcer disease, Helicobacter pylori infection [Baseline characteristics of participants were shown as event number and percentages for categorical variables and as means and standard deviations for continuous variables. Chi-square test was adopted to examine the categorical variables, and Student’s nfection , COPD, cTo address over-fitting issue, we conducted sensitivity analysis (Model 2) by matching for age, sex, index date, low individual monthly income, living area, comorbidity, and medications. Given the insidious nature of cancer, we conducted sensitivity analysis (model 3) by minimizing indolent HCC around the inception point by exclusion of observation period. The first 12 months of observation after the diagnosis of HPV were excluded, eliminating all cases of HCC having occurred within the first 12 months during follow-up. We conducted further sensitivity analysis (model 4 and 5) by IPTW.We conducted subgroup analyses to examine the potential interaction of gender, age, alcohol-related illness, cirrhosis, and liver decompensation status among CHC patients. We determined significance of interaction by the likelihood ratio test.Statistical analysis was performed by using SAS, version 9.4 .The data source used in this study was the claims data of NHIRD published by Taiwan National Health Insurance. Participants were not involved in the retrospective secondary cohort study. For Taiwan legal restrictions according to “Personal Information Protection Act”, data in this study cannot be made publicly available. Requests for data can be sent as a formal proposal to the NHIRD.N = 1981) and non-HPV control group (N = 7924). We selected controls based on strict criteria of the same age (without age range), same sex, same inception point (HPV diagnosis date as the inception point for case and matched non-HPV), same comorbidities, and medications distribution.In total, 9905 adult CHC patients were enrolled between 2000 and 2016. Among them, we identified the HPV group (p = 0.02). In p < 0.05). The study group’s mean time from the inception point to the development of HCC was 6.75 years (standard deviation (SD) 4.15), while in the control group it was 5.88 years (SD 4.05).In the main model, CHC patients with HPV infection had a lower risk of developing HCC compared with those without HPV infection, 76 and 326 patients having developed HCC events, respectively. The study group had a lower incidence rate (IR) of HCC  than the controls . The current study using countrywide secondary claim data reported that a prior medically recorded HPV diagnosis was associated with a reduced risk of HCC in CHC participants. We extracted 10,800 CHC patients from an NHIRD sub-database of 200 million participants. In Taiwan, the prevalence of HCV infection among adults aged over 20 years old was about 4.4% . A potenFurthermore, in the CHC population with a baseline status of cirrhosis and liver decompensation, the HPV associated risk reduction in HCC remained. On the contrary, in the subgroup of alcohol-related disease, the negative association between HPV with HCC was obscured. The results of our epidemiological study may have potential implications for the prevention of HCC in the CHC population.The administration of interferon with ribavirin was the treatment of choice for HCV infection over the past 20 years, which was replaced by direct-acting antiviral (DAA) agents in the last decade. To date, several studies proved the usefulness of HCC prevention by interferon-based therapy in patients with HCV ,29. On eThe underlying mechanism to explain this inverse association remains unclear. Some studies have shown that HPV 16 DNA and HPV 18-related nucleotide sequences in HCC specimens  and HPV The interaction between HPV and HCV in oncogenesis has been mentioned; in a 2016 case–control study of head and neck cancers, HCV was found to be associated with HPV-positive head and neck cancers, and a possible synergistic oncogenic role of HPV E6 protein in the development of head and neck cancers has been postulated . HCV andSeveral rigorous statistical models were adopted in our study. By linking two databases (NHIRD and RCIPD) in Taiwan, the hard outcome of HCC was reliable. We found an inverse association between HPV infection and HCC. Whether there is a casual relationship between being free of HPV infection and HCC development needs further studies to clarify.First of all, although the numbers enrolled in this study were adequate, the HCC event rates were lower in this study. This was more obvious when we performed the subgroup analyses. However, this pilot study still offered a new point of view of the viral interaction and the association between virus and tumor occurrence. A larger-scale cohort study could be conducted in the future.Second, this was not a prospective study. Although we matched potential confounders between the two study groups, there was still a possibility of observation or selection bias. Fortunately, with a large number of well-validated coding for the exposure and outcome covariates, this study was able to overcome the possible bias and, thus, elucidate a clinically meaningful association.Third, some patients might have had a recurrent HPV infection during the study period. Our study mimicked an intention-to-treat analysis; therefore, patients with another HPV infection may have been included, and, therefore, the assessment of HPV and HCC risk should be conservative.Fourth, although both interferon and DAA reduce the risk of HCC , DAA wasIn this large-scale, retrospective CHC cohort study in Taiwan, people with a new medical record of HPV infection had a lower risk of HCC compared to CHC patients without HPV infection.


A comprehensive literature review was performed to determine the relationship between HPV infection and infertility and the eventual role of the 9-valent vaccine for infertility prevention. The search was extended from January 1997 through July 2021. Data collected from selected articles focused on three main topics: statistical associations between HPV prevalence and assisted reproductive technology (ART) outcome, association between HPV and characteristics of semen, and associations between HPV and miscarriage. Articles that identified HPV genotypes were selected for this review to study the possible role of the 9-valent vaccine in infertility prevention. To date, there is no agreement on the implication HPV female infection has on the fertility and miscarriage rate. Although it can be stated that HPV prevalence among couples with infertility undergoing ART treatment is consistent, it does not seem to affect the performance of oocytes. Otherwise, HPV infection affects sperm parameters, in particular spermatozoa motility. When an association can be found, most cases of HR-HPV involved are those included in the 9-valent vaccine. The correlation between HPV male infection both with asthenozoospermia and increased risk of pregnancy loss could recommend the extension of anti-HPV vaccination to adolescent males along with cancer prevention. Despite the fact that the relation between 9-valent HPV genotypes involved in female infection and miscarriage/infertility is not clear, the impact of this virus on health reproduction is evident. Considering this, the importance of HPV vaccination in adolescent females is confirmed. A vaccine efficacy study could be useful to confirm the importance of primary prevention for couple reproductive health. Infertility is a complex human health situation that particularly alters the quality of life in couples that face it. It represents a worldwide problem that affects about 10–30% of couples of reproductive ages . The AmeChlamydia trachomatis and Neisseria gonorrhoeae infection in salpingitis and infertility has been widely studied as well as the possible damage caused by Trichomonas vaginalis, Mycoplasma genitalium, and other microorganisms within the vaginal microbiome. While early diagnosis and treatment for C. trachomatis and N. gonorrhoeae have been developed for the prevention of pelvic inflammatory disease (PID) and subsequent tubal factor infertility (TFI), additional data are needed to determine whether early detection of other potential pathogens can reduce the incidence of TFI  , 5. The e of TFI .One of those is human papillomavirus (HPV). HPV infections are significantly associated with cancer of the male and female anogenital mucosa , 8 and sDespite genital HPV infection being the most common sexually transmitted viral infection worldwide, with an estimated overall prevalence of 10% in the general female population during reproductive age , 15, fewResearch over the last few years has been carried out to understand if HPV could be an etiological agent that determines infertility or miscarriage and if assisted reproductive technology (ART) requires specific management for HPV-positive patients .If this correlation were real, HPV prevention would play a dual role, not only for cancer but also for infertility. However, in order to perform efficacious prevention on infertility and adequate counseling in infertile couples, it is important to assess which HPV type could cause infertility or miscarriage. Identifying the prevalent genotypes could be important also to evaluate the possible role of the vaccine in preventing HPV-related infertility. In fact, it has not been studied yet if one of the three disposable HPV vaccines could significantly provide protection against infertility as well as neoplastic diseases.The purpose of this comprehensive review is to research the available knowledge regarding the implication of HPV genotypes included in the 9-valent vaccine HR-HPV 16, 18, 31, 33, 45, 52, and 58 and low-risk HPV (LR-HPV) 6 and 11 in couple infertility with the aim to hypothesize whether vaccination could have a protective role for reproductive health.in vitro fertilization (IVF), assisted reproductive technology (ART), sperm, and blastocyst in PubMed/Medline   and Scopus (Title/Abstract/Keywords)  databases. Relevant articles were selected for full-text reading and were restricted to those in the English language. Titles and abstracts were screened for relevance to determine which articles were to undergo full-text review. Articles identified as potentially relevant moved into a full-text review. The references of included studies were reviewed to identify additional publications not found through the database search.A comprehensive literature search was performed from January 1997 through July 2021 . The folThe PRISMA  guidelines were followed to systematically review the literature by searching the PubMed/Medline and Scopus database. The present study assessed the following PICOS  questions:Population: couples, men, or women affected by infertility with HPV infection;Intervention: observe data on IVF cycles, sperm analysis, ART, and pregnancy (miscarriage) outcomes;Comparison: no comparisons are expected;Outcomes: (1) prevalence of HPV genotype infection, with particular reference to those included in the 9-valent vaccine; (2) ART, semen parameters, and pregnancy outcomes.Review and meta-analysis, prospective and retrospective observational studies, population-based cohort study, prospective cohort study, case-control study, and cross-sectional clinical study.in vitro experimentations on mice embryos to explain the effect of HPV infection on reproductive health ; cases in a non-English language.in vitro fertilization—IVF OR assisted reproductive technology—ART OR sperm OR blastocyst) in PubMed , Medline  , and Scopus (Title/Abstract/Keywords)  databases. The only filter used was the English language. Relevant articles were obtained in full-text format and screened for additional references.We searched for (HPV) AND (infertility OR fertility OR miscarriage OR An independent reviewer (C. M.) selected the studies using a two-step screening method. At first, the screening of titles and abstracts was performed to assess eligibility and inclusion criteria and exclude non-relevant studies. Afterward, the reviewer evaluated full texts of included articles to assess study eligibility and the inclusion criteria and to avoid duplications of the included cases. Then, the same author performed a manual search of reference lists to search for additional relevant publications. J. D. G. and G. D. C. checked the data extracted.The objective of this review was to determine the relationship between HPV infection and infertility and the eventual role of the 9-valent vaccine for infertility prevention.Data collection was study-related (authors and year of study publication) and case-related .The data collected from selected articles focused on three main topics:statistical associations between HPV genotypes included in the 9-valent vaccine and ART outcome;associations between HPV genotypes included in the 9-valent vaccine and characteristics of semen, focusing also in HPV genotype; andassociations between HPV genotypes included in the 9-valent vaccine and miscarriage.No statistical analysis was performed.Many research teams were interested in the possible role of HPV infection in couple infertility. Articles were mainly focused on HPV infection and its relationship with infertility, semen parameters, and IVF outcomes. Only some authors discussed the relationship between HPV and fertility parameters specifying the HPV types or risks.The selected articles concerning HPV genotypes included in the 9-valent vaccine were as follows:in vitro fertilization outcomes;10 of 14 articles focused on the effect of HPV on 9 of 11 articles studied the effect of HPV on semen parameters; and13 of 15 articles studied the effect of HPV infection on the risk of miscarriage.Studies examining the impact of HPV genotypes on female fertility are limited. Most studies investigate the prevalence of HPV-positive women in ART programs or the connection between HPV infection and ART success. Some studies examine the association between HPV infection and infertility. Recently, it has been underlined by Rocha et al. that many high-risk HPV infections included in the 9-valent vaccine are associated with infertility and endometriosis . Cobas 4n = 294, age range 22–45) compared to the general population . Finally, Bugge et al. . Moreover, all pregnancies in HPV-positive couples resulted in miscarriage, whereas there was a 15.9% overall miscarriage rate in HPV-negative couples (p < 0.001). The most frequent genotypes in women were HPV 16 and HPV 66, whereas HPV 51 and HPV 52 were the most frequently identified in the male partner of infertile couples. HPV 16 and 52 are included in the 9-valent vaccine showing protection for women, male partners, and infertile couples.Perino et al.  stated tA study in 2013  stated tInfertility affects millions of people, about 10–30% of reproductive-age couples all over the world . At the It is interesting to note that many studies reported the involvement of genotypes not included in the 9-valent vaccine. These HPV genotypes may have a role in infertility though they are not yet part of the ones contained in the vaccine. Moreover, the list of known HR-HPVs could change in the next years as the genotypes contained in the vaccine. Arbyn et al. , 47 suggStudies that evaluated the impact of HPV on ART outcomes have shown conflicting results. Most studies did not find a higher incidence of high-risk HPV infections included in the 9-valent vaccine in the infertile population , 24–27. One of the most quoted articles on the subject is from Spandorfer et al. , findingAlso, Rocha et al.  reportedIn conclusion, the effect of HPV infection in women on ART outcome remains undefined also due to the methodological limitations of the studies performed. However, for years now, it has been known to clinicians studying reproductive medicine that the patient must always be the couple and not the individual. It is precisely in this consideration that we could attempt to explain the conflicting data. Most studies analyze the connection between HPV and infertility or ART outcome searching women HPV infection. However, taking the assumption that most couples suffering from infertility are stable couples, we should consider both partners positive for HPV regardless of whether the detection of the virus is done on a sperm or cervical swab. We should take into consideration HPV positivity not only in women but also in men. If we correlate infertility only with cervical positivity for HPV, we could not consider a large part of HPV-positive couples. On the other hand, any molecular techniques for the detection of HPV including PCR do not have a 100% sensibility. Not by chance, if we analyze the connection between ART and HPV by only studying sperm infections, the results will agree. Therefore, we should analyze the impact of HPV in infertility and ART outcomes by studying the presence of HPV not only in the female genital tract but also in the male counterpart.In the past years, some viral diseases such as hepatitis B and HIV were widely studied in men attempting ART to reduce the risk of transmission of STDs via the seminal fluid. Nevertheless, HPV infection was not considered as well.In the last years, there has been an increasing interest in the prevalence of HPV among men. Many studies have provided evidence of possible HPV-related subfertility in men, suggesting that HPV infection could be a risk factor . Indeed,However, not only HPV detection but also HPV genotyping could be of great value in infertility diagnosis at least in idiopathic infertility cases. As for the risk of carcinogenesis, another classification of HPV regarding the risk of fertility alteration may be considered after in-depth investigations . That isIt is interesting to note that many HR-HPV genotypes included in the 9-valent vaccine have a close relationship with semen alterations. Nevertheless, the role of HPV in determining couple infertility cannot be relegated to the mere damage to sperm production. Indeed, infected seminal liquid could be a carrier of HPV DNA in the reproductive tract, with the possibility of detrimental effects on oocytes during fertilization , 56. MenThe results of the study conducted by Perino et al.  showed, A recent study by Garolla et al.  investigWhile it is widely recognized that spontaneous abortion can be linked to fetal genetic abnormalities or viral infections involving cytomegalovirus , EpsteinThe association between HPV infection and failed placental invasion has already been widely demonstrated in studies that correlate HPV infection with spontaneous preterm delivery . The HPVConde-Ferráez et al.  did not Some studies , 23 did In 1997, Hermonat et al.  noticed A recent review of Isaguliants et al.  assumed The same authors underline that HPV infection could arrest the aquaporin AQP8 function involved in the cleaning of excessive reactive oxygen species, causing additional oxidative stress in sperm and oocyte, resulting in additional DNA damage and apoptosis , 66. MorIn vitro experiments  among men aged 18–40 years . It is ein vitro” studies have shown a possible relation, especially with high-risk viral strains. However, most recent clinical studies did not show a possible association. Considering the results of the experimental studies and the strong association between HPV infection and male infertility, we could hypothesize that infected spermatozoa may play a role as carriers of HPV DNA both in the reproductive tract and within the oocyte, with the possibility of detrimental effects during fertilization. This suggests to us the need for further studies concerning the association between HPV infection and miscarriage, testing contemporary HPV DNA in female and male counterparts.The literature on the association between HPV infection and abortion is still conflicting. Few older prospective or cross-sectional studies and “In conclusion, while numerous reviews analyzing the correlation between HPV and male infertility seem to find agreement –87, therThe relevance of the problem raised in this paper is undeniable, given how many HPV-infected couples, many of whom are also infertile as a couple, try to solve the problem of childbirth every day. In general, the value of vaccination against cervical cancer has been well-proven globally. Now, researchers should shed light on the issues of additional benefits that vaccination might be able or not able to provide.To date, there is no agreement in the literature on the implication that HPV infection has on the fertility and miscarriage rate. Although it can be stated that HPV prevalence among couples with infertility problems undergoing IVF treatment is consistent, it does not seem to affect the performance of oocytes. Otherwise, HPV infection affects sperm parameters, in particular spermatozoa motility.The proven correlation between HPV male infection both with infertility and abortion should implement new gynecological researches: it appears always clearer that it is necessary to consider contemporary female and male infection, particularly for infertile couples.The HPV DNA testing in male partners of infertile couples could be useful to follow up individuals with infected sperm. In these cases, despite the absence of treatment for HPV infection, the possibility of delaying IVF procedures until the viral infection has been cleared or eliminating HPV from sperm through a specific washing procedure of semen  could beThe correlation between HPV male infection both with asthenozoospermia and increased risk of pregnancy loss could recommend the extension of anti-HPV vaccination to adolescent males, along with anogenital and oral cancer prevention. In fact, when an association can be found, most HR-HPV involved are those included in the 9-valent vaccine.Despite the fact that the relation between 9-valent HPV genotypes involved in female infection and miscarriage/infertility is not clear, the impact of this virus on health reproduction is evident. Considering this, the importance of HPV vaccination in adolescent females is confirmed for not only preventing cancer but also couple infertility.A vaccine efficacy study could be useful to confirm the importance of primary prevention for the reproductive health of couples.Can HPV infection have a role in female infertility? To date, most studies did not find an association between female infertility and HPV infection.➢ Can HPV have a role in ART outcomes? To date, it is not in accordance with the literature. Most included studies did not find a possible association between HPV women infection and ART outcomes.➢ Can HPV infection have a role in male infertility? All included studies showed an association between asthenozoospermia and HPV male infection.➢ Can HPV infection modify the risk of miscarriage? To date, there is no agreement in the literature. Further prospective studies are necessary to confirm this association. We believe that it is necessary to search HPV infection in both females and males and to genotype HPV to discover the real impact of HPV infection on the risk of miscarriage.➢ Can immunological status modify the risk of infertility in couples affected by HPV? Immune system, pregnancy, and HPV infection appear to interact by modifying the host's immune response. The capacity of resolving the HPV infection in those women that contracted the infection from their partner makes it difficult to determine the real HPV prevalence and consequently the miscarriage correlation.➢ Can HPV the 9-valent vaccine have a role in preventing infertility? To date, we could hypothesize that the 9-valent vaccine could have an important role in preventing male infertility because current literature shows a correlation with HPV genotypes included in the 9-valent vaccine.➢ AC and JDG contributed to conception and design of the study. LG and GDC organized the database. CM, JDG, and FS wrote the first draft of the manuscript. All authors contributed to manuscript revision, read, and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.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.


There are no robust national prevalence of Human Papillomavirus (HPV) genotypes in Nigerian women despite the high burden of cervical cancer morbidity and mortality.This study aims to determine the pooled prevalence and risk factors of genital HPV infection in Nigeria through a systemic review protocol.Databases including PubMed, Scopus, Google Scholar and AJOL were searched between 10 April to 28 July 2020. HPV studies on Nigerian females and published from April 1999 to March 2019 were included. GRADE was used to assess the quality of evidence.p < 0.05). Irregular menstruation, post-coital bleeding and abdominal vaginal discharge were significantly associated with HPV infection (p < 0.05).The pooled prevalence of cervical HPV was 20.65% (95%CI: 19.7–21.7). Genotypes 31 (70.8%), 35 (69.9%) and 16 (52.9%) were the most predominant HPV in circulation. Of the six geopolitical zones in Nigeria, northeast had the highest pooled prevalence of HPV infection (48.1%), while the least was in the north-west (6.8%). After multivariate logistic regression, duration (years) of sexual exposure , history of other malignancies , history of sexually transmitted infection , coital frequency per week , the status of circumcision of the sexual partner , and marital status , were significant risk factors of HPV infection (HPV prevalence is high in Nigeria and was significantly associated with several associated risk factors. Rapid screening for high-risk HPV genotypes is recommended and multivalent HPV vaccines should be considered for women. Papillomaviridae family is recognized as a common and significant aetiology of sexually transmitted viral infection . Similarly, HPV type-specific prevalence by cervical cytology/histology was equally computed for participants who tested positive for a particular HPV genotype among all HPV-positive females who were investigated for that genotype. In HPV-specific type prevalence, just studies that investigated for a defined HPV type contributed to the analysis for that particular genotype, hence, sample sizes were dissimilar between specific HPV types that were analyzed. Medcalc software version 19.6.1  was used to perform every statistical analysis. A total of 3060 references were retrieved and 27 full articles were reviewed. Data were abstracted from 18 epidemiological types of research with individual-based data attaining the criteria. The flow diagram is illustrated in Data were collated from studies conducted between 2004  and 2019Out of 5390 women tested for any HPV infection, 2935 had normal cytology; 116 were classified as ASCUS, 2 were investigated for AGSUS, 157 were diagnosed with LSIL, 61 were positive for HSIL and 60 had ICC. Also, a total of 80 females were reported as either ASCUS or LSIL, and 61 were classified as undefined abnormal cytology. Based on the classification of geographic zones of Nigeria, the South-west had the highest number of females included in the study (3812), followed by North-central (1251), South-east (445), North-west (428), North-east (208), and South-south (80) . Ibadan p < 0.0001, χ2 =61.694), cervical cells collection method  and HPV severity .The crude overall HPV prevalence of each study ranged from 5.4% to 54.1%, while the prevalence of high-risk HPV of each study ranged from 5% to 46.12% . The HPV2 = 209.656, p < 0.0001) (As shown in  0.0001) .The analysis of the prevalence of HPV specific types based on the category of lesion according to the Bethesda classification of females with normal cytology and cervical neoplastic lesions  are presented in n = 2166), followed by North-western Nigeria (n = 398), North-central Nigeria (n = 245) and North-east (n = 126)  . HPV18, n = 126) .Overall, six studies stratified eligible females screened for HPV infection according to age ranges. Analysis of these studies revealed that the age range 60–69 years had the highest overall HPV prevalence at 73.2%, closely followed by the age group 30–39 years with 64.3%, ≥70 years with 63.6%, 50–59 years with 62.9%, 15–29 years with 53.1% and 40–49 years with 46.8% .n = 102), followed by North-central (n = 10) and North-west (n = 4)  .HPV 31, 51, 52, 35, 58, 16, 56, 18, 39 and 59 were the ten most common genotypes in females with ASCUS in descending order .Analysis of studies with ASCUS cases revealed that the age range 15–29 years had the highest overall HPV prevalence at 14.3%, closely followed by the age group 40–49 years with 12.5%, 30–39 years with 10.7%, ≥70 years with 9.1%, 60–69 years with 4.9% and 50–59 years with 3.7% .n = 133), followed by North-west (n = 19) and North-central (n = 5) regions of Nigeria . One participant each from North-central and South-west regions of Nigeria were enrolled in our study selection criteria .n = 52), followed co-equally by North-central, North-eastern and North-western regions of Nigeria with 3 participants each from of these regions , followed co-equally by the North-eastern and South-western regions of Nigeria with 3 participants each from of these regions  and circumcision status of sexual partner marital status were significant risk factors associated with HPV infection. Also, irregular menstruation, post-coital bleeding and abdominal vaginal discharge were significantly associated with HPV infection observed in our study. These findings agree with those of Soohoo et al. .The incrData on HPV infections, genotypes, diagnosis, geographical distribution and risk factors among women of childbearing age are important to determine the best HPV vaccines to be adopted in protection against cervical cancer and the identification of the ideal laboratory test for diagnosis of high-risk women.To the best of our knowledge, our study is the first systematic review in Nigeria to determine HPV genotype distribution, pooled prevalence and risk factors in women by geographical zones, lesion type, age group, publication year and PCR primers for genotyping. Eighteen studies matched the inclusion criteria for this systematic review.Each of the six geopolitical zones in Nigeria was fairly represented. Overall, the prevalence of cervical HPV infection in Nigeria was higher when compared with other regions in Africa; our study revealed the prevalence rates in women with normal cervical cytology (15.3%), ASCUS (23.3%), LSIL (27.4%), HSIL (50.8%) and ICC (10.0%). Furthermore, this study revealed that by pooling several studies examining HPV infection among women with normal cervical cytology, of the six geopolitical zones in Nigeria, North-east had the highest pooled prevalence of HPV infection (48.1%), followed by Northcentral (25.9%), Southwest (19.2%), Southeast (10.3%), South-south (10.0%), while the least was in the North-west (6.8%). However, the prevalence of any HPV infection among women with normal cytology was low (15.3%) compared to other regions which ranged between 27.8% and 57.3%. The observed variations in the HPV prevalence rates may be suggestive of the influence of geographical dissimilarities, a standardized and appropriate volume of body fluids, methods of DNA extraction and diagnostic performance of HPV detection protocols .Finding from this study showed that HPV-31, 35 and 16 were the most commonly identified genotypes among women in Nigeria. HPV-16 is considered as the most prominent type involved in the development of cervical cancer and other HPV-associated malignancies. HPV-35 is also an oncogenic HPV type, which is closely related phylogenetically to HPV-16. Some previous studies have shown that HPV-35 is the sixth most frequently detected HPV high-risk type in CIN3 and invasive cervical cancer ,34. FurtThe prevalence of HPV-31 (70.8%), 35 (69.9%) and 16 (52.9%) was high. This could be because most of the women screened for cervical cancers are adults over 18 years of age, the high prevalence of these HPV types in the study population suggests the need for a robust measure to prevent future re-occurrence. A previous review on the burden of HPV infections in the extended Middle East and Northern Africa reported a low prevalence of HPV infection in women with normal cervical cytology, which is not in agreement with previous findings .In regards to our findings, we observed variations in the prevalence of HPV infection among women across the studies which could be explained by the differences in the type of laboratory protocols used for HPV detection. This is because the detection rates were similar for HPV using PCR, hybridization, and PCR-hybridization, which were applied in 18 studies. Sample type may be one of the factors leading to differences in prevalence rates. Our analysis demonstrated that the detection rate of HPV using cytobrush/cervical brush for vaginal samples was significantly higher than the use of endocervical swab samples. Based on this, it could be inferred that among the various biological specimen, the vaginal sample provides the best performance for antigen, antibody, NAATs of HPV. This conforms with the report of Farahmand et al. .HPV vaccines have proven to be harmless and efficacious by offering long-term protection against HPV infections . Data frThe main barriers militating against the use of HPV vaccinations in Nigeria include the long duration it would take for the vaccine to be ready for mass distribution, cost of procurement and inadequate infrastructure needed to deliver the vaccine to women at risk of contracting HPV infection and cervical cancer.One of the major concerns in the use of HPV vaccines is that most polyvalent ones do not protect against HPV types other than 6, 11, 16, and 18. For instance, the majority of Female Sex Workers in the Netherlands were infected with HPV genotypes other than those was covered by the current vaccines . To overMoreover, as a measure for ensuring early cervical cancer diagnosis, the use of screening tools such as cost-effective cervical screening through visual inspection with acetic acid and/or Lugol’s iodine, or detection of high-risk HPV types  could rePrevious studies conducted in rural and semi-rural southwestern Nigeria revealed that HPV prevalence increased with decreased age in younger females . In the HPV prevalence is high in Nigeria and associated with several risk factors. Vaccination of women not infected with HPV 16/31/35 and rapid screening for high-risk HPV genotypes for the prevention of cervical cancer is recommended. The exceptionally high prevalence of HPV in the North-eastern part of Nigeria (an insurgency affect zone) requires urgent public health attention such as encouraging the use of cost-effective and acceptable tools to increase cervical cancer screenings and HPV DNA testing among the population to have an elaborate understanding of the prevalence of HPV genotypes and associated drivers. Moreover, the enrolment standard in some studies was biased as only women with possible illnesses (such as HIV/AIDS) underwent investigation which could have increased the HPV positivity rate. The limited sample size or absence of studies in some regions will not permit categorical inference on the association of HPV pooled prevalence and geographical regions of Nigeria.


This study was the first to use functional respiratory imaging (FRI), known for increased sensitivity to airway changes versus spirometry, to assess the effect of the inhaled corticosteroid (ICS) component (budesonide) on lung function in patients with moderate-to-severe COPD and a blood eosinophil count > 150 cells/mmPatients in this Phase IIIb (NCT03836677), randomized, double-blind, crossover study received twice-daily budesonide/glycopyrrolate/formoterol fumarate (BGF) 320/18/9.6 μg fixed-dose triple therapy and glycopyrrolate/formoterol fumarate (GFF) 18/9.6 μg fixed-dose dual therapy over 4 weeks, each delivered via a single metered dose Aerosphere inhaler. Primary endpoints were the improvements from baseline for each treatment in specific (i.e. corrected for lobar volume) image-based airway volume (siVaw) and resistance (siRaw) measured via FRI taken at total lung capacity (Day 29). Secondary outcomes included spirometry and body plethysmography. Adverse events were monitored throughout the study.1] 63.6%). BGF and GFF both statistically significantly increased siVaw from baseline at Day 29 , with a greater increase observed for BGF versus GFF . Statistically significant reductions in siRaw were also observed with both BGF and GFF . Additionally, significant improvements from baseline in post-dose FEV1 were observed with BGF and GFF . Safety findings were consistent with the known profiles of BGF and GFF.A total of 23 patients were randomized and included in the intent-to-treat analysis  dual therapy with GFF, reflecting the ICS component’s contribution in patients with moderate-to-severe COPD.As observed using FRI, triple therapy with BGF resulted in greater increases in airway volume, and reductions in airway resistance versus long-acting muscarinic antagonist/long-acting βTrial registration: ClinicalTrials.gov, NCT03836677. Registered 11 February 2019, https://clinicaltrials.gov/ct2/show/NCT03836677The online version contains supplementary material available at 10.1186/s12931-021-01772-2. The cut-off of > 150 cells/mm3 was the same as that used as a level to stratify randomization in the KRONOS  and FVC, were also measured in accordance with previously set criteria ; 346 mL 18, 509; p p-value) from baseline was observed for FRC with BGF  and a statistically significant improvement with GFF ,   versus GFF (− 260 mL), respectively.p-value) in FVC were observed following treatment with BGF  and GFF   was observed and following treatment with GFF, a numerical mean [95% CI] increase from baseline in FEF25–75 of 83 mL/s  was observed  and six patients (26.1%) experienced any AE in the BGF and GFF treatment periods, respectively Table . One patIn this randomized, double-blind, Phase IIIb, crossover study, treatment with BGF and GFF demonstrated clinically meaningful and statistically significant improvements in airway volume and airway resistance in patients with moderate-to-severe COPD. The benefit of the addition of ICS to LAMA/LABA was demonstrated by the greater improvements observed in patients following treatment with BGF relative to GFF treatment.Prior studies have found that both open  and fixeThe spirometry and body plethysmography results were directionally consistent with FRI results; however, no statistically significant differences were shown between BGF and GFF in any spirometry or plethysmography endpoint, indicating the increased sensitivity of the FRI parameters to detect differences between treatments in a small number of patients.Prior results from scintigraphy studies showed BGF was homogeneously deposited throughout the airways of healthy subjects, with mass-deposition of 34.5% and 37.7% for 3- and 10-s breath-holds, respectively  for beclUse of the ICS/LAMA/LABA triple, fixed-dose combination BGF 320/18/9.6 µg delivered via single Aerosphere inhaler was associated with an improvement in untrimmed siVaw by approximately 72% (increase), and in untrimmed siRaw by approximately 50% (decrease), reflecting the presence of improved bronchodilation/constriction. The LAMA/LABA treatment, GFF, was associated with 53% and 48% improvement in untrimmed siVaw and siRaw, respectively. The significant increase in airway volume (9%) of BGF versus GFF further supports the benefit of budesonide in patients with moderate-to-severe COPD versus LAMA/LABA . The sma2-receptors in the lung [Budesonide is a glucocorticoid receptor agonist , which hthe lung , possiblthe lung . Thus, t3. The small number of patients in this study could also be considered a limitation in terms of assessing spirometry and body plethysmography endpoints. However, the number of patients within this study is consistent with that of prior FRI studies in similar populations [One limitation of the study is that it only recruited patients not currently being treated with an ICS, all of whom had eosinophil counts of > 150 cells/mmulations , 13. FinBGF and GFF were effective in increasing airway volume and decreasing airway resistance in patients with moderate-to-severe COPD. Importantly, the ICS component of BGF resulted in significantly greater increases in airway volume, as assessed using FRI, compared with GFF. The finding that BGF has effects on increasing airway volume and decreasing airway resistance throughout all lobes of the lung complements recent scintigraphy findings which show that BGF is also deposited throughout the large and small airways of the lung .Additional file 1.Table A1. Sensitivity analyses of co-primary endpoints based on trimmed data for siVaw and siRaw at TLC at Day 29 (ITT population).


While boundary-driven acoustic streaming resulting from the interaction of sound, fluids and walls in symmetric acoustic resonances have been intensively studied in the literature, the acoustic streaming fields driven by asymmetric acoustic resonances remain largely unexplored. Here, we present a theoretical and numerical analysis of outer acoustic streaming flows generated over a fluid–solid interface above which a symmetric or asymmetric acoustic standing wave is established. The asymmetric standing wave is defined by a shift of acoustic pressure in its magnitude, i.e.,  Acoustic streaming is the steady flow driven by acoustic energy dissipation in a viscous fluid. The acoustic energy dissipation in a fluid could occur from two different mechanisms, dissipation in the boundary layers and attenuation in the bulk of the fluid . The resIn most micro-acoustofluidic systems of interest where standing waves are typically generated, the acoustic streaming fields are generally dominated by boundary-driven acoustic streaming. As early as 1787, the German physicist Chladni  observedIn this work, we investigate the outer acoustic streaming fields near a fluid–solid interface (FSI) by combining the basic theory of acoustofluidics and the limiting velocity method. A generalized standing wave field either symmetric or asymmetric to the acoustic pressure node is considered. We verify numerically the outer acoustic streaming in the symmetric case with the classical theory of Rayleigh streaming, and discuss the outer acoustic streaming patterns in various asymmetric acoustic resonances. Our analysis of outer acoustic streaming in asymmetric acoustic resonances elucidates fundamental physical aspects and further has potential applications in micro- and nanoparticle manipulation.In micro-acoustofluidics systems of particular interest where standing waves are typically excited, the acoustic streaming field that has received more attention than any other is that which arises from acoustic dissipation near FSIs, which, in most cases, could disturb the movements of particles  induced by the acoustic radiation force. Here, we aim to analyze and compare this type of acoustic streaming driven by symmetric and asymmetric acoustic resonances. The basic acoustic streaming equations have been presented in the We assume that the time variation of each of the first-order acoustic quantities is sinusoidal with Here, outside the boundary layer, the first-order acoustic velocity is irrotational and has only an Here, for a 1D standing wave in the Hence, by substituting Equation (2) into (3), the limiting velocity that drives the outer acoustic streaming field for the generalized 1D standing wave case presented in Equation (1) is obtained, which followsIt is interesting to notice that the limiting velocity that drives the outer acoustic streaming field is independent of the pressure shift We now take up the outer acoustic streaming flows associated with a 1D standing wave over a FSI, assuming a slip-velocity condition at the boundary. As shown in The special case However, for the asymmetric cases, i.e., For the acoustic pressure and velocity distributions presented in We have demonstrated here that outer acoustic streaming flows driven by 1D symmetric and asymmetric standing wave fields near a FSI could behave very differently. The results for symmetric acoustic resonances replicate the characteristics of Rayleigh streaming: Nodes of acoustic pressure and limiting velocity (or outer acoustic streaming) share same locations; that is, on a slip-velocity boundary which drives circulations of outer acoustic streaming the direction of limiting velocity always goes from acoustic pressure nodes to adjacent antinodes. For asymmetric acoustic resonances, it is interesting to notice that acoustic streaming nodes on a slip-velocity boundary always locate at the channel center wherever the acoustic pressure nodes are, enabling spatial separation of acoustic pressure nodes and acoustic streaming flows. Asymmetric acoustic resonances could potentially be generated in fluid channels where neighbor FSIs are not orthogonal . In a fluid channel of irregular cross-section, the acoustic pressure field may slightly vary in other directions  of the channel, which, however, will not greatly affect the resulting acoustic streaming field. This is based on the fact that it is the gradient of the acoustic velocity in the main standing wave direction that determines the distribution of limiting velocities (and thus the location of acoustic streaming vortices and the streaming velocity magnitudes), as described in Equations (A12) and (A13). Therefore, although it is assumed here a 1D standing wave in the


Cardiovascular and renal adaptation in neonates with Respiratory Distress Syndrome (RDS) and Transient Tachypnea of the Newborn (TTN) may be different.Neonates ≥32 weeks were diagnosed with RDS or TTN based on clinical, radiologic and lung sonographic criteria. Weight loss, feeding, urine output, and sodium levels were recorded for the first 3 days, and serial ultrasounds assessed central and organ Doppler blood flow. A linear mixed model was used to compare the two groups.p = 0.03), Superior Mesenteric Artery Resistance Index was higher in RDS, compared to TTN (p = 0.02).Twenty-one neonates were included, 11 with TTN and 10 with RDS. Those with RDS showed less weight loss (− 2.8 +/− 2.7% versus − 5.6 +/− 3.4%), and less enteral feeds (79.2 vs 116 ml/kg/day) than those with TTN, despite similar fluid prescription. We found no difference in urine output, or serum sodium levels. Doppler parameters for any renal or central parameters were similar. However, Anterior Cerebral Artery maximum velocity was lower (In cohort of moderately preterm to term neonates, those with RDS retained more fluid and were fed less on day 3 than those with TTN. While there were no renal or central blood flow differences, there were some cerebral and mesenteric perfusion differences which may account for different pathophysiology and management. Neonatal respiratory distress is one of the most common clinical conditions dealt with in the Neonatal Intensive Care Unit (NICU). Within the moderate to late preterm group (32 0/7–36 + 6/7 weeks of gestation), Respiratory Distress Syndrome (RDS) was diagnosed in 7.2% of NICU admissions within the Canadian Neonatal Network (CNN) in 2016 [While patho-physiologically, RDS and TTN represent two distinct entities, clinical overlap, especially early in the neonatal course, makes diagnosis challenging. RDS is characterized by surfactant deficiency with worsening pulmonary insufficiency over 2–3 days. TTN, in contrast, is believed to result from incomplete resorption of fluid from the newborn lung with immediate-onset tachypnea and mild work of breathing confined generally to the first 24 h of life. Radiographic imaging is employed to differentiate with a typical diffuse reticulo-granular honey-comb pattern for surfactant deficiency , 6.In infants without RDS, independent of GA, postnatal diuresis and physiological weight loss of about 7% occur during the transitional period in the first 3 days of life , 9. InulThe aim of our study is to compare fluid handling in the first 3 days in a group of moderately preterm to term infants with RDS versus TTN by comparing weight loss as primary outcome. Enteral feeding, fluid prescription, serum sodium and urinary output were compared. We assessed ultrasound-derived central and organ Doppler parameters of blood flow between the 2 groups to delineate any potential physiologic difference.Single-center prospective exploratory observational pilot cohort studyWeight loss as a percentage of birth weight (BW) on day of life (DOL) 3 (hours 73–96).Max  and flow of cerebral, mesenteric and renal arteries with 3 evaluations in the first 3 days of life: within the first 24 h (Time Point 1), 25–48 h (Time Point 2) and 73–96 h of life (Time Point 3).Secondary outcomes: Amount of enteral feeding, total fluid prescription, average urinary output, and minimal serum sodium concentration within the first 3 days of life. Comparison of central and peripheral Doppler parameters such as LVO (Left ventricular Output), RVO (Right Ventricular Output), Pulsatility Index (PI), Resistance Index (RI), VPerinatal characteristics were collected and compared: GA, BW, gender, single or multiple pregnancy, mode of delivery, delayed cord clamping defined as >60s. As diagnosed by obstetrician: pregnancy-induced hypertension (PIH), gestational diabetes mellitus (GDM), clinical chorioamnionitis, presence of any abnormal antenatal Doppler findings such as absent or reverse end-diastolic uterine artery flow.Moderately preterm to term infants (≥32 weeks of gestation) admitted to Foothills Medical Center (FMC) tertiary care NICU in Calgary, Alberta, Canada, and on any respiratory support  at age 4 h of life. Parental written consents were obtained.Any known congenital organ malformation or condition. Known or suspected meconium aspiration, congenital pneumonia, or pulmonary hemorrhage.Classification was defined a priori, and the designation was consensus-based and derived from clinical, sonographic, and radiological investigations according to CNN definitions :.2 > 25% for a minimum of 24 h. CXR at day 1–2 reports RDS or hyaline membrane disease (HMD). Lung ultrasound was consistent with RDS.RDS: Babies requiring respiratory support > 24 h, intubation, surfactant administration , or FiOTTN: Requiring any kind of respiratory support  for a minimum of 4 and a maximum of 24 h, and no surfactant or intubation. Lung ultrasound was consistent with TTN.serum sodium levels obtained for clinical reasons during the first 3 DOL, minimum value; Total Fluid Intake (TFI) as prescribed as ml per kilogram per day; urinary output observed over at least 4, maximum 12 h, before time point 3. Heart rate, SpO2, blood pressure by non-invasive oscillatory appropriate-sized cuff measurement, and kind of respiratory support at each time point. All patients were either cared for in an incubator or open cot with body temperature monitored, ambient temperature was adjusted to maintain normothermia according to unit’s policy.Clinical information obtained from infant and maternal charts. Weight change calculated in percentage from BW at time points 2 and 3; Any Max, and perfusion) at each time point as previously described [2, then a calculation of stroke volume as SV = TVI x CSA, where TVI is time velocity integral. Indexed CO will be derived as SV x HR/ weight [Ultrasound of the lung was completed with lung ultrasound scores calculated with a range from 0 to 18, as previously described . Dopplerescribed . Calcula/ weight . Pulsati/ weight .Institutional Research Ethics Board approval was obtained (REB17–2344). Written informed voluntary consent was provided by all participants’ caregivers before enrolment.p-value of less than 0.05 was deemed significant.Based on a test for difference in means between RDS and TTN groups, assuming a standard deviation of 1.25 for the variability of the weight loss, with a population sample size of 10 in each group, and at a significance level alpha of 0.05, considering the clinically important difference of 2% in weight loss between the two groups, we would have 80% power to detect such a difference. Descriptive analyses regarding the demographic characteristics of the study were performed on two groups. Mean ± standard deviation (SD) was provided for normally distributed continuous variables while the median  for non-normally distributed. Absolute and relative frequencies (percent) were reported for categorical variables. The distributions of continuous variables were examined for skewness and normality using Kolmogorov-Smirnov tests. Linear mixed-effects model and generalized estimating equations model were used to assess differences of vital signs, central and peripheral hemodynamic between two groups. The statistical analyses were performed by using SAS Enterprise 7.15 , and a two-tailed p = 0.03, Table P = 0.003, Table There were 21 babies included in this study, with 10 babies diagnosed as RDS, and 11 as TTN. GA was similar in both groups, with 33.2 +/− 1 weeks for RDS, and 34.7 +/− 3 weeks for TTN ; there was no difference of TFI, nor minimal serum sodium concentration between the two groups , but no difference in ACA PI or RI. SMA RI was higher in RDS compared to TTN , but no difference in SMA VMax or flow between the groups.Vital signs and central Dopplers are summarized in Table rs Table . ACA VMap = 0.23, Table In our comparative cohort study of a group of neonates with RDS versus TTN, infants in the RDS group had less weight loss on all three time points than the TTN group, despite having been prescribed similar TFI Table . This ocWe could not show a different urinary output or different minimal serum sodium concentration between the two groups. This may be due to the small random time frame we used to calculate urinary output. Furthermore, weight loss is a more inclusive marker of fluid loss than just urinary output as it includes insensible losses. Serum sodium concentration is dependent on care providers’ supplementation, usually with intravenous fluid in the first days of life, and any potential dilution hyponatremia would have been counteracted by parenteral nutrition electrolyte prescription. All values reported in our cohort were within normal limits for newborn infants, with 136.7 ± 4.1 mmol/l for RDS and 137.1 ± 3.4 mmol/l for TTN .Max was significantly lower in the RDS compared to the TTN group (Table Max, or intestinal blood flow. We speculate that the lower SMA resistance to flow in those with TTN may be in response to the higher enteral feeding volume in this group, compared to RDS (Table We found no difference in vital signs nor in central Doppler parameters between the RDS and TTN groups Table . Expecteup Table . Howeverup Table . With moDS Table . It is kSmall sample size. There may have been some overlap between RDS and TTN in those who did not receive surfactant. Limitations of Doppler assessment apply. Timing of ultrasound to feeds could not be made standard for practical reasons.Max was lower in RDS and mesenteric artery resistance index was higher, compared to TTN, suggesting different blood flow patterns according to disease and may imply grounds for differential management.In our cohort of ≥32 weeks moderately preterm to term neonates during the first 3 days of life, those with RDS had less weight loss and were prescribed less enteral feeds than those with TTN despite similar total fluid intake. There was no difference in renal or central Doppler parameters between the RDS and TTN groups. Cerebral artery V


Climate change and other global change drivers threaten plant diversity in mountains worldwide. A widely documented response to such environmental modifications is for plant species to change their elevational ranges. Range shifts are often idiosyncratic and difficult to generalize, partly due to variation in sampling methods. There is thus a need for a standardized monitoring strategy that can be applied across mountain regions to assess distribution changes and community turnover of native and non‐native plant species over space and time. Here, we present a conceptually intuitive and standardized protocol developed by the Mountain Invasion Research Network (MIREN) to systematically quantify global patterns of native and non‐native species distributions along elevation gradients and shifts arising from interactive effects of climate change and human disturbance. Usually repeated every five years, surveys consist of 20 sample sites located at equal elevation increments along three replicate roads per sampling region. At each site, three plots extend from the side of a mountain road into surrounding natural vegetation. The protocol has been successfully used in 18 regions worldwide from 2007 to present. Analyses of one point in time already generated some salient results, and revealed region‐specific elevational patterns of native plant species richness, but a globally consistent elevational decline in non‐native species richness. Non‐native plants were also more abundant directly adjacent to road edges, suggesting that disturbed roadsides serve as a vector for invasions into mountains. From the upcoming analyses of time series, even more exciting results can be expected, especially about range shifts. Implementing the protocol in more mountain regions globally would help to generate a more complete picture of how global change alters species distributions. This would inform conservation policy in mountain ecosystems, where some conservation policies remain poorly implemented. We summarize the findings achieved with the standardized sampling protocol developed by the Mountain Invasion Research Network (MIREN) for monitoring the impact of global change on elevational plant species distributions. We intend to promote the use of the protocol to generate global insights into native and non‐native species responses to rapid global change in mountains. At the global scale, the Global Observation Research Initiative in Alpine Environments  , allowing vegetation change to be monitored across a broad range of climates and plant community types. It explicitly contrasts anthropogenically disturbed and (semi‐)natural vegetation within sampling sites, thus increasing detection of rapid community changes and providing greater insight into the drivers of change. The protocol has been developed by the Mountain Invasion Research Network  was founded in 2005 as a first global effort to apply the known principles from plant invasion ecology in mountainous environments . Taxa should be identified to species level using up‐to‐date local floras. Before being included in the global database, submitted regional species lists undergo taxonomic harmonization to detect synonyms for the same species in different regions, and to correct spelling problems. This procedure is done by the MIREN data managers, using the R‐packages “taxize” , and if not found there, they are searched via the additional databases included in the Taxonomic Names Resolution Service  and visually estimate vegetation cover  and record abundance , 2 = 11–100 individuals, 3 = >100 individuals) of each species. The detailed sampling protocol is provided in Supporting Information Each taxon should be classified as native or non‐native to that region by the participant using local floras and databases. As a general rule, plant species introduced into the country or mountain range after AD 1500 are considered as non‐native, although regional deviations are welcome if properly justified. For noteworthy records , specimens should be collected outside of the plots (when possible) and placed in a herbarium to facilitate identification and to inform local floras . To facilitate monitoring, all plots should be permanently marked in the field, for instance with magnets or metal tags that can be relocated with a metal detector or colored sticks or plastic seal security tags in remote areas where their removal is unlikely. In addition, precise sub‐meter GPS coordinates should be taken at least once. Photographs should also be taken of each transect to visualize changes over time, document data collection, and facilitate relocation of plots. Surveys and resurveys should always be done at peak biomass or flowering to minimize the risk of missing species with early or late phenology. For repeated surveys, this means that timing should be kept constant relative to the onset of spring, rather than to a fixed date, while sampling within season is recommended from valley bottom to top.2.5Phytophthora species) in Australia  that test more detailed or region‐specific questions about the drivers of plant species redistributions. For example, soil temperatures have been recorded with a high temporal resolution for a year or longer in several MIREN regions to document how disturbance along roadsides affects microclimate, including consequences for species redistributions . Any researcher can also request the full MIREN database from MIREN data managers for global analyses. The structure of the database, with its plot‐level table with accurate coordinates, and easy linkable species information, allows smooth integration into larger global integrative projects .All data will be made public in a data repository in the context of paper publications, or at the very latest five years after the survey is undertaken Figure . To date3The standardized protocol for recording plant species communities along mountain roads has been thoroughly tested in the field on all continents except Antarctica Figure . The firOne of the most striking findings of the global MIREN surveys to date has been to document the importance of roads in facilitating mountain invasions. Specifically, we found that non‐native species richness in roadsides decreases with increasing elevation, but generally peaks in the lower third of the elevation gradient  natural habitat along elevation gradients, suggesting the existence of additional region‐specific mechanisms, driven by differences in biome, vegetation type, and human activity. These mechanisms are now the subject of further study. In contrast, a clearer elevation signal is present on roadside plots, with total species richness peaking at mid‐elevations in most regions  and sometimes large distances between elevational increments  can limit understanding of local processes, while also biasing sampling against rarer plant species or habitats. Furthermore, while repeated surveys facilitate investigation of species range dynamics under global change, the complete design does not explicitly consider dispersal dynamics , instead assessing such dynamics indirectly through repeated snapshots of plant community composition. Additionally, with only one observational moment in a year, the phenological window of observation is small, with the risk of (1) excluding species flowering early or late in the season . Finally, the protocol has already shown to have great potential for teaching, for instance by training undergraduate and graduate students in vegetation sampling, while also having relevance for local policy and management, for example as demonstration sites ; Data curation (lead); Methodology ; Writing – original draft (lead); Writing – review & editing (lead). Jonas J. Lembrechts: Conceptualization (lead); Methodology ; Writing – original draft (lead); Writing – review & editing (lead). Keith McDougall: Methodology ; Writing – original draft ; Writing – review & editing . Aníbal Pauchard: Methodology ; Writing – original draft ; Writing – review & editing . Jake M. Alexander: Methodology ; Writing – original draft ; Writing – review & editing . Agustina Barros: Methodology ; Writing – original draft ; Writing – review & editing . Lohengrin A. Cavieres: Methodology ; Writing – original draft ; Writing – review & editing . Irfan Rashid: Methodology ; Writing – original draft ; Writing – review & editing . Lisa J. Rew: Methodology ; Writing – original draft ; Writing – review & editing . Alla Aleksanyan: Methodology ; Writing – review & editing . José R. Arévalo: Methodology ; Writing – review & editing . Valeria Aschero: Methodology ; Writing – review & editing . Chelsea Chisholm: Methodology ; Writing – review & editing . Vincent Ralph Clark: Methodology ; Writing – review & editing . Jan Clavel: Methodology ; Writing – review & editing . Curtis Daehler: Methodology ; Writing – review & editing . Pervaiz A. Dar: Methodology ; Writing – review & editing . Hansjörg Dietz: Methodology ; Writing – review & editing . Romina D. Dimarco: Methodology ; Writing – review & editing . Peter Edwards: Methodology ; Writing – review & editing . Franz Essl: Methodology ; Writing – review & editing . Eduardo Fuentes‐Lillo: Methodology ; Writing – review & editing . Antoine Guisan: Methodology ; Writing – review & editing . Onalenna Gwate: Methodology ; Writing – review & editing . Anna Hargreaves: Methodology ; Writing – review & editing . Gabi Jakobs: Methodology ; Writing – review & editing . Alejandra Jiménez: Methodology ; Writing – review & editing . Paul Kardol: Methodology ; Writing – review & editing . Christoph Kueffer: Methodology ; Writing – review & editing . Christian Larson: Methodology ; Writing – review & editing . Jonathan Lenoir: Methodology ; Writing – review & editing . Bernd Lenzner: Methodology ; Writing – review & editing . Miguel A. Padrón Mederos: Methodology ; Writing – review & editing . Maritza Mihoc: Methodology ; Writing – review & editing . Ann Milbau: Methodology ; Writing – review & editing . John W. Morgan: Methodology ; Writing – review & editing . Jana Müllerová: Methodology ; Writing – review & editing . Bridgett Naylor: Methodology ; Writing – review & editing . Ivan Nijs: Methodology ; Writing – review & editing . Martin A. Nuñez: Methodology ; Writing – review & editing . Rüdiger Otto: Methodology ; Writing – review & editing . Niels Preuk: Methodology ; Writing – review & editing . Amanda Ratier Backes: Methodology ; Writing – review & editing . Zafar A. Reshi: Methodology ; Writing – review & editing . Sabine B. Rumpf: Methodology ; Writing – review & editing . Verónica Sandoya: Methodology ; Writing – review & editing . Mellesa Schroder: Methodology ; Writing – review & editing . Karina Lilian Speziale: Methodology ; Writing – review & editing . Davnah Urbach: Methodology ; Writing – review & editing . Graciela Valencia: Methodology ; Writing – review & editing . Vigdis Vandvik: Methodology ; Writing – review & editing . Michaela Vítková: Methodology ; Writing – review & editing . Tom Vorstenbosch: Methodology ; Writing – review & editing . Tom W. N. Walker: Methodology ; Writing – review & editing . Neville Walsh: Methodology ; Writing – review & editing . Genevieve Wright: Methodology ; Writing – review & editing . Shengwei Zong: Methodology ; Writing – review & editing . Tim Seipel: Conceptualization (supporting); Data curation (lead); Methodology ; Writing – original draft ; Writing – review & editing (lead).Supplementary Material S1: MIREN road survey protocolClick here for additional data file.Supplementary Material S2: Structure of the global MIREN road survey databaseClick here for additional data file.Supplementary Material S3: MIREN Data‐sharing agreementClick here for additional data file.