Polyomaviridae, Papillomaviridae, and Herpesviridae oncoviruses on the vaginal Community State Types (CSTs) and host immune response in reproductive-age women. In our cohort, only Polyomaviridae and Papillomaviridae were detected and were associated with changes in the resident bacteria of CST I and IV (p < 0.05). Lactobacilluscrispatus increased in CST I while Prevotella timonensis and Sneathia sanguinegens increased in CST IV. Conversely, CST II and III showed an alteration of the immune response, with the decrease of Eotaxin, MCP-1, IL-7, IL-9, and IL-15 (p < 0.05), leading to reduced antiviral efficacy. An efficient viral clearance was observed only in women from CST I, dominated by Lactobacillus crispatus. Our in vivo study begins to address the knowledge gap with respect to the role of vaginal bacteria and immune response in susceptibility to oncoviral infections.The picture of dynamic interaction between oncogenic viruses and the vaginal bacteria-immune host milieu is incomplete. We evaluated the impact of  The mutualism between the vaginal mucosa and its bacterial microbiome is a key point of the physiologic condition of the female reproductive tract .Cumulative pieces of evidence have shown that, alongside bacteria, viruses are a constitutive part of the vaginal microbiome and that the virome is composed by both eukaryotic and prokaryotic viruses. As the virome study methodologies improve, eukaryotic viruses causing latent or asymptomatic infections are being recognized as the more prominent members of the vaginal microbiome, suggesting an intimate relationship with both resident bacteria and host susceptibility and immune response to viral infections .Though to date, metagenomic studies on this complex interaction are far from reaching a complete understanding, the most intriguing aspect is whether and how bacterial community may promote or inhibit viral pathogenesis . A portiThe vaginal dysbiosis of the mucosa-associated microbiota seems to represent a risk factor acting as an enhancer of the tumorigenic potential through mechanisms including mucosal barrier failure and inflammation . These eSince a persistent infection enables virus-induced tumorigenesis, we can develop new approaches for preventing and treating malignancies by characterizing the host environment by which tumor viruses achieve infection.Lactobacillus dominating the vaginal microbiota might reduce HPV-related disease burden or increase the viral clearance [Wojciech Kwasniewski et al. hypothesized that a disturbed heterogeneity of the vaginal microbiome is associated with Human Papilloma Virus (HPV)-induced carcinogenesis, identifying the vaginal dysbiosis as a putative and potentially modifiable factor for HPV . Moreovelearance .Polyomaviridae and Herpesviridae families. Despite this possible finding, current knowledge on dynamic interaction with vaginal microbiome and host immune response is scarce [The “omics” technologies allowed us to discover that several divergent oncogenic viruses promote tumorigenesis through shared host cell targets and pathways modulating the surrounding microenvironment . During s scarce ,11.Papillomavirus, Polyomavirus, and Herpesvirus oncogenic viruses with the vaginal community state types (CSTs) and local immune environments before any clinical evidence of the cellular transformation is obtained.In this study, we integrated metagenomics and immune quantitative approaches to provide, to our knowledge, the first in vivo view of the interaction of During the first two months of 2018, 90 vaginal swabs from Caucasian immunocompetent women of reproductive age (20–40) who visited the gynecological ambulatory of the IRCCS Burlo Garofolo, Trieste, Italy, for urogenital complaints, were retrospectively selected on the basis of the following exclusion criteria: pregnancy, menopause, 5–7 days after menstruation, antibiotic/probiotic therapy, oral contraceptive use or hormonal replacement therapy, smoking, endocrine diseases, history of cancer, current laboratory detection of STIs pathogens, HIV, and cervical-vaginal lesions.n = 29).After 8 months from the laboratory diagnosis, following the indications of the clinical protocol, an additional vaginal swab was collected only from women who tested positive for viral infection . The swab was suspended in 1.5 mL of TE buffer for microbiome assessment and immune factors dosage, and stored at −80 °C. ® easyMAG® system , following the manufacturer’s instructions, starting from 500 µL of sample and with an elution volume of 50 µL. All DNA samples were stored at −80 °C prior to further processing.DNA was extracted from the swabs using the NucliSENSFirstly, a 500 base pair region of the V1-V3 portion of the 16S rRNA gene was amplified and subsequently the 200 base pair region of the V3 portion was amplified as well, as described elsewhere . The V3 Quality filtering was performed using the software QIIME , version 1.9.1 . SequencPolyomaviruses , and 10 Herpesviruses  [The identification of infectious agents was performed using a highly sensitive species-specific multiplex genotyping assay, combined with multiplex polymerase chain reaction (PCR), and a bead-based Luminex technology . Multiplex type-specific PCR  used primers specific to detect the presence of 21 mucosal HPV types , 13 nd HHV8) ,16, respnd HHV8) ,18. SubsThe concentrations of 48 cytokines, chemokines, and growth factors were analyzed by a quantitative cytokine assay by means of the Bioplex Pro™ human cytokine standard 27-plex and 21-plex panels based on xMAP technology . Data were collected and analyzed using a Bio-Rad BioPlex 200 instrument equipped with Bio-Plex Manager software version 6.0 . The immunoassay data were expressed in terms of mg protein/mL estimated from Bradford protein concentration in respective samples using Bio-Rad microtiter microassay kit  and human serum albumin , as recently published .Using QIIME 1.9.1, Chao1, Observed OTUs, and Phylogenetic diversity (PD) whole tree metrics were calculated to assess the alpha diversity and compared by means of a nonparametric T-test.To highlight the differences in the microbial composition we applied a nonparametric T-test for the pairwise comparisons.p-value was observed (p < 0.05), a multiple comparison test was used to determine which groups were different.To test the differences in the immune soluble factors, GraphPad Prism  was used. Specifically, the Kruskal-Wallis one-way analysis of variance was used for comparisons between groups. When a significant The dataset supporting the conclusions of this article has been uploaded to the National Center for Biotechnology Information (NCBI) Sequence Read Archive (SRA) under the project number SRP152778.Lactobacillus species. Four samples provided an exception since the microbiome was characterized by a massive colonization of Bifidobacteria, classified as B group for two of them, and the remaining two, classified as Mixed CST, showed two dominant Lactobacilli at equal amounts (in one sample L. crispatus and L. gasseri and in two samples L. crispatus and L. iners).Bacterial microbiome composition was evaluated in 90 vaginal swabs through sequencing of the barcoded V3 region of the 16S rRNA gene, and the swabs were clustered into four community state types (CSTs) based on the predominant We obtained a total of 5,683,658 reads  and a total number of observed OTUs of 11,168. For the analyses, we rarefied the otu_table.biom to a depth of 5000 reads/sample, excluding four samples. The two negative controls did not produce an output after the quality filtering.Lactobacillus crispatus was 72%, while in CST II, the average relative abundance of Lactobacillus gasseri was 58%. In CST III, Lactobacillus iners was 94%, while in CST IV, G. vaginalis was 10%. L. iners (40%) and B. breve (58%) were the dominant species in Mixed and B groups, respectively.Streptococcus spp. (12%) and by Gram-negative species such as Atopobium vaginae (7%) and Escherichia fergusonii (5%), compatible with a status of dysbiosis and biofilm production. Conversely, the CST III was the most homogeneous group, showing only the 6% of bacterial species that were different from L. iners (94%), underscoring its ability to colonize the vaginal epithelium both in eubiotic and dysbiotic conditions. Indeed, the alpha diversity showed a significant decrease only for samples from CST III (p < 0.005), showing the most homogeneous bacterial composition. When viral infected CSTs were compared with the corresponding negative ones, no statistical variation was observed  dominated by observed .Ureaplasma parvum has been detected only in the CST I and CST II where, in this last group, U. parvum showed the highest rate of colonization. Moreover, Gardnerella vaginalis has been detected in all samples, but with a relative amount inversely proportional to that of Lactobacilli spp.  samples, DNA of oncogenic viruses was identified. MCPyV was the Polyomavirus most frequently detected, while the HPV genotypes identified mostly belongs to the High-Risk HPV genotypes. The highest rate of infection of this series was measured in CST III  and in CST I  than in CST IV  and CST II . HPV DNA was more frequently associated with CST IV (5/6) followed by CST III (8/28) while regarding Polyomaviruses, the highest rate of infection was recovered in CST III (3/3) and CST I (5/7).The virome analysis highlighted that a small cluster of oncogenic viruses, including iven CST . We did Polyomaviruses, specifically of JCPyV and MCPyV, as unique or co-infections in all CST groups. In detail, in CST I, 2/7 samples were infected with HPV, 1/7 with HPV/JCPyV, 1/7 with JCPyV/MCPyV and 3/7 with MCPyV. Among CST II samples, 1/3 showed HPV/MCPyV and 2/3 MCPyV. Within the CST III, 6/12 were infected with HPV, 1/12 with HPV/JCPyV, 1/12 with HPV/MCPyV, 2/12 with JCPyV and MCPyV. In CST IV, 3/6 samples were infected with HPV, 1/6 with HPV/JCPyV, 1/6 HPV/MCPyV and 1/6 with MCPyV. The overall distribution highlighted the strong presence of Bifidobacteria indicated a positive sign positive for MCPyV. No viral infections were detected in the samples defined as mixed CST.One of the two remaining samples showing a massive presence of The effect of the oncogenic viral infections on the vaginal microbial composition and/or immune environment perturbations was analyzed for each CST group and described in p < 0.05). Specifically, L. crispatus increased in infected samples from CST I, showing a high rate infection with Polyomavirus, while Prevotella timonensis and Sneathia sanguinegens increased in infected samples from CST IV, characterized by a high rate of HPV infection.Considering oncogenic viruses as a variable, we observed a significant modulation only for dominant bacteria characterizing CST I and IV samples (p < 0.05). Conversely, infected samples from CST I and CST IV did not show a significant variation of the immune basal pattern.As detailed in Samples from women who tested positive for oncogenic viruses were recovered after eight months from laboratory diagnosis for additional gynecological and microbiological evaluations, as indicated by clinical protocol. Clinical examinations showed no sign of cervical lesions.L. crispatus (5/7 samples). Conversely, persistent infections due to HPV and Polyomavirus-HPV co-infections were confirmed in CST III (9/12) and CST IV (5/6) groups, which are considered to indicate a transitional state into a dysbiotic and a dysbiotic-BV like composition, respectively.Microbiological analysis showed no residual viral DNA in 15/29 (51.7%) of the samples. To note, clearance of the virus was more frequently observed in CST I group dominated by One of the most interesting aspects of the virome world is its interaction with resident bacteria, probably influencing viral infectivity and thus the infection outcome. These events, playing a central role in shaping innate and adaptive immune defenses, are exerted during the early phase of viral entry, clinically corresponding to the asymptomatic phase of infection ,20.Despite increased attention has been focused on the complexity of vaginal microbiome and its role in women’s health, the modality of interaction between oncogenic viruses and local microenvironment is still incomplete.A crucial point is the definition of the vaginal milieu that may influence the susceptibility and clearance of oncogenic viruses in women with an immune competent system, even if recent data suggest the vaginal dysbiosis as a risk factor for viral infections .Lactobacillus spp. in orchestrating the vaginal composition and immune defense has been exploited in our study [In order to optimize the complexity of the vaginal microbial profiles, the vaginal CSTs classification based on the central role of ur study . This stLactobacillus characterizing CSTs represent a key factor in influencing the modality of vaginal defense against viral infection through their direct involvement or by the modulation of the local immune response [L. crispatus, the increase of the relative abundance of this Lactobacillus, as the main controlling infection defense mechanism, did not modify the basal immune profile. The antiviral activity of L. crispatus has been very recently reported in mammalian cell lines to be preventing HSV entry to cells [L. crispatus as a first-line defense against HPV and MCPyV which share similar pathogenic mechanisms, even if MCPyV only very recently has been proposed as a sexually transmitted microorganism [We reinforced the concept that the species of response . In the to cells  and blocto cells . To corrorganism .L. gasseri and in CST III by L. iners, a different type of host response resulting in the modulation of immune profile leading to the simultaneous increase of pro-inflammatory cytokines and the decrease of anti-inflammatory and anti-tumoral factors has been observed. In the CST IV, depleted of Lactobacilli, the increase of Sneathia sanguinegens and Prevotella timonensis was observed in infected samples. Our in vivo study suggests the low antiviral efficacy of L. gasseri and L. iners, in contrast with recent in vitro data pointing to a protective anti-tumoral effect exerted by all Lactobacilli species colonizing the cervical epithelium [In contrast, in CST II dominated by ithelium .Sneathia spp. has been observed in HPV-positive women and associated with all stages of cervical carcinogenesis [S. sanguinegens to be more prevalent in women with high-grade dysplasia compared to women with a low-grade dysplasia [Prevotella spp. with symptomatic HPV infection [Previous studies have indicated the vaginal dysbiosis as a risk factor for HPV infection, although they cannot exclude reverse causation of HPV in altering the vaginal microbiome. A higher level of ogenesis . More reysplasia  while otnfection .We speculate that the composition of the vaginal microbiome “per se” is not a risk factor for the acquisition of viral infection but it seems to influence the viral clearance.Prevotella timonensis and Sneathia sanguinegens in women infected with HPV or Polyomavirus during the asymptomatic phase of infection, event probably facilitated by a steady state level of pro-inflammatory status characterizing the vaginal environment of these women. Thus, it seems that both HPV and Polyomaviruses may promote their active colonization of the mucosal microenvironment through immune evasion strategies, mainly directed towards down-regulating the pro-inflammatory response. Indeed, a decreased concentration of the pro-inflammatory IL-15, IL-7, and the anti-inflammatory IL-9 was observed. The down-regulation of these molecules, which are first-line immune components for fighting viruses, prevents basically the growth and the activity of monocytes and T cells and, most importantly, inhibits their immunostimulatory and immunomodulatory effects [In our cohort, we detected an increase of the relative abundance of  effects ,29,30. M effects . This fePolyomavirus as a sexually transmitted pathogen, although no significant association between MCPyV and cervical cancer has been already demonstrated. To note, HPV and MCPyV co-occurrence was detected mainly in samples with molecular signatures of mucosal inflammation, thereby indicating a similarity in the pathogenic pathway.Newly, the detection of MCPyV in the vaginal mucosa, as unique strain or in samples co-infected with HPV, reinforces a role for this oncogenic Lactobacilli load in the vagina is not an accurate parameter for asserting health status. Based on this observation, the introduction of CSTs has led to the comprehension that species of Lactobacilli differently exert a protective role in oncogenic viral infections. In addition, we highlighted that the microbiome heterogeneity is not predictive for HPV and Polyomavirus susceptibility, which, on the contrary, seems to benefit from the steady-state immune-bacterial crosstalk for establishing persistent infections. A main limitation of our study must be identified in the small study cohort. For this reason, we believe that further studies are needed to give more insights into the cross-talk between vaginal bacteriome and oncogenic virome.As already disclosed by several studies, the total


Background: Due to their higher rates of anal dysplasia/cancer, human immunodeficiency virus (HIV)-positive individuals are recommended to undergo anal dysplasia screening, which consists of anal cytology (AC) and high resolution anoscopy (HRA) with anal biopsy (AB) after abnormal AC result. However, AC variability limits its usefulness. Our objective was to evaluate human papillomavirus (HPV)-16 DNA quantitation as part of the screening algorithm. Methods: HPV-16 was detected in AC specimens from 75 HIV-positive participants using quantitative real-time polymerase chain reaction. AB results were available from 18/44 patients who had abnormal AC. Statistical tests included Mann-Whitney U, Kruskal-Wallis, receiver operating characteristic (ROC) analysis and Kappa coefficient tests. Results: HPV-16 copy numbers differed significantly across AC (p = 0.001) and AB grades (p = 0.009). HPV-16 ≥ 65 copies/cell predicted high-grade AB (p = 0.04). Using this cut-off in comparison to AB, it had better specificity (1.00) than AC (0.75) and specificity (0.77) than qualitative HPV-16 detection (0.38). Also, the Kappa coefficient of the cut-off (κ = 0.649) was higher than AC (κ = 0.557) and qualitative HPV-16 detection (κ = 0.258) to AB. Conclusion: Higher HPV-16 copy numbers corresponded to higher AC and AB grades, suggesting the importance of HPV burden on disease stage. Furthermore, HPV-16 ≥ 65 copies/cell distinguished high-grade disease and demonstrated better sensitivity, specificity, and agreement with AB than AC or qualitative HPV-16 detection. These results support the potential use of HPV quantitation in conjunction with AC in anal dysplasia screening. Human immunodeficiency virus (HIV)-infected individuals are at a higher risk for developing anal dysplasia and cancer, particularly men who have sex with men (MSM) ,2,3,4. HCurrently, treatment is recommended only for those with high-grade disease. Because low-grade disease is not typically treated, screening that identifies LSIL prior to HRA and AB could reduce the number of invasive procedures that appear unnecessary in retrospect. Another factor that influences AC results is its inherent sensitivity and specificity as a screening tool . AlthougSince HPV-16 is the most prevalent high-risk HPV genotype in anal dysplasia/cancer and is associated with high-grade lesions ,12, the For the Hawaii Center for AIDS RMATRIX Pilot Project RM004, 75 HIV-positive patients enrolled and provided consent under a protocol approved by the University of Hawaii Institutional Review Board (CHS #21953). AC specimens were collected in ThinPrep Collection vials during one study visit for routine healthcare maintenance and high-risk HPV (hr-HPV) assessment. Abnormal AC results were reported as ASCUS, ASC-H, LSIL, or HSIL. Participants were followed up after the AC results were available as part of routine medical care, and HRA was recommended to those with abnormal AC. If HRA was performed, and biopsies were obtained, biopsy results from participants who gave consent were available for the study. AB pathologies were reported as normal, LSIL, or HSIL.® HTB-35™), positive for HPV-16; and water. All qRT-PCR assays were performed in triplicate, using TaqMan™ Gene Expression Master Mix . Copy numbers of each target gene were calculated based on the standard curve, and HPV-16 copy numbers per cell were determined.DNA was extracted from AC specimens, using the Machery-Nagel NucleoSpin Tissue XS Kit, and quantitated on a NanoDrop 2000 instrument. Specimens were analyzed for HPV-16 genotype by quantitative real-time PCR (qRT-PCR), using primers and probes targeting the E6/E7 oncogenic region  and β-glt-test or Mann-Whitney U test was used for continuous variables, such as age and CD4 count.The data were summarized by mean and standard deviation (SD) for continuous variables such as age and HPV-16 copy numbers; number of participants and percentage for the categorical variables such as gender, smoking, and race. Two-sample p-value < 0.05 was considered to be statistically significant.Chi-square or Fisher’s exact test was used for the categorical variables, such as gender, smoking, and race. Mann-Whitney U test was used to determine whether qualitative HPV-16 detection differed between positive and negative AC or AB results. Kruskal-Wallis test was performed to assess statistical significance of HPV-16 copy numbers relative to AC or AB grade. ROC analysis was used to select the choice of a cut-off point for HPV-16 copy number to differentiate low-grade and high-grade AB. Sensitivity, specificity and Cohen’s Kappa coefficient were calculated to compare the following screening assays to the gold standard of HRA with AB: AC, qualitative HPV-16 detection, and HPV-16 copy number at a cut-off of 65 copies per cell. Negative and low-grade disease grades were combined since clinical recommendations for both would typically be medical follow-up without treatment. All analyses were performed using SAS 9.4 and GraphPad Prism, and a p = 0.005, p = 0.001) with the following medians (IQR): Negative 0 (0–0), ASCUS 0 (0–1.8), ASC-H 89 (0–178), LSIL 2 (0–417), and HSIL 51 (0.2–2991), p = 0.009) with the following medians (IQR): Negative 0 (0–117.5), LSIL 3 (0.54–114.5) and HSIL 530 (241–18018), A total of 75 HIV-positive participants were enrolled in the study. Overall, 67 (89%) were male with a mean age of 51 years. Forty-four (59%) had an abnormal AC, of which 25 (57%) had detectable HPV-16 DNA, a significantly higher rate than those with negative AC (19%), Since higher HPV-16 copy numbers exhibited an association with more advanced disease, ROC analysis was used to determine that HPV-16 copy number ≥65 copies per cell predicted HSIL with the area under the ROC curve (AUC) = 0.920, When comparing the screening assays against the current gold standard of HRA with AB, we found that AC had lower sensitivity (0.75) with a reasonable specificity (0.86), qualitative HPV-16 had a better sensitivity (1.00) with a low specificity (0.38), and HPV-16 copy number cut-off at 65 copies per cell also had the same sensitivity as qualitative HPV-16 (1.00) but with increased specificity (0.77), p = 0.005) than for those with negative AC results (19%). Among all participants, HPV-16 was detected at a rate (41%) consistent with other studies suggesting that HIV-infected individuals are more prone to HPV infections, which contribute to their risk for anal dysplasia/cancer [p = 0.001 and p = 0.009 respectively). The failure to reach statistical significance for qualitative HPV-16 detection may be due to the small sample sizes that resulted after stratification into the various grades. Although AC had reasonable specificity (0.86) when compared to the current gold standard AB, it had a decreased sensitivity (0.75) which would miss the detection of some high-grade lesions. Anal dysplasia/cancer screening guidelines have generally been adapted from cervical cancer screening because of many similarities, such as association with HPV infection. Current cervical cancer screening includes qualitative HPV detection of oncogenic types in conjunction with cytology. We found that when compared to AB, the use of qualitative HPV-16 detection had high sensitivity (1.00) but a low specificity (0.38). The use of a HPV-16 cut-off value of 65 increased the specificity (0.77) to better differentiate grade of lesions, demonstrating that quantitative HPV-16 detection using the cut-off value of 65 copies per cell may predict high-grade disease and is in better agreement with AB (0.649) than AC (0.557) or qualitative HPV-16 HPV detection (0.258). Genotyping studies have shown that HPV-16 DNA is frequently detected in anal specimens and is associated with anal dysplasia/cancer; however, there is limited data about variation in HPV copy numbers across AC and AB grades [In our study cohort, more than half (59%) of the participants had abnormal AC, which is consistent with other studies  that suga/cancer ,18,19. WB grades ,21. Our Limitations of this study include the small number of patients who followed up with recommended HRA and AB after abnormal AC results. The small sample size may influence the HPV-16 cut-off value. In a planned follow-up study, patients will be encouraged to return for HRA with AB after abnormal AC results. The study also focused on only HPV-16 even though other high-risk HPV genotypes are associated with anal dysplasia/cancer. In addition, HRA was only performed on participants who had abnormal anal cytologies. Future research could include quantitation of other HPV genotypes such as HPV-18 as well as performing HRA on all participants regardless of anal cytology results.Since HIV-positive individuals have a high risk of developing anal dysplasia/cancer they are recommended to undergo regular screening that consists of AC followed by an HRA with AB for abnormal AC. However, consistency of anal dysplasia/cancer AC screening results depends upon several factors such as sampling, operator error, and interpretation error . The con


Cervical cancer is the second most prevalent cancer among women of child-bearing age in Ethiopia. The aim of this study was to determine human papilloma virus (HPV) genotype distribution among HIV-negative women with normal and abnormal cervical cytology results.We investigated a consecutive of 233 HIV-negative women between December 2008 and March 2009 presenting in a Tertiary Gynecology Referral Clinic in Ethiopia. Screening was done by Pap cytology and HPV detection and genotyping method was nested PCR  and sequencing of the nested products. Sequencing of the non-purified nested PCR products was performed following re-amplification with Big dye terminator, using the GP6 primer.p < 0.0001). The most frequent genotypes identified were HPV16 (44.1%), followed by HPV35 and HPV45 (each 6.2%), HPV31 (4.4%), HPV56 (3.7%), HPV18 and HPV59 (each 3.1%), HPV58 (2.5%) and HPV39 (1.9%). While the most common HR-HPV infections among women with normal cytology were HPV16 (20.3%), followed by HPV35 (8.7%), HPV56 and HPV58 (each 5.8%), HPV18, HPV31 and HPV39 (each 4.4%), HPV45 (2.9%) and HPV59 and HPV68 (each 1.5%), the most common HR-HPV infections in women with abnormal cytology included HPV16 (62%), followed by HPV45 (8.7%), HPV 31, HPV35 and HPV59 (each 4.4%), and HPV18, HPV52 and HPV56 (each 2.2%). We also noted low prevalence of multiple HPV infections in women with normal or abnormal cytology. Multivariable logistic analysis showed that residing in rural area , being multipara  and having abnormal cervical cytology results  were all independently associated with HPV16 genotype.Of the 233 study participants, 92 (39.5%) had abnormal cytology. All women with abnormal cervical cytology had positive HPV DNA compared to only 48.9% of those presenting with normal cytology. Of these women, the frequency of high-risk (HR)-HPV was 83.2% and its prevalence in women with abnormal cervical cytology was significantly higher than those with normal cytology  contains supplementary material, which is available to authorized users. Cervical cancer is the second most common cancer among women worldwide and the leading cause of mortality in developing countries . It is tStudy participants were recruited between December 2008 and March 2009 from the population of women attending the out-patient clinic of the Department of Gynecology and Obstetrics, Tikur-Anbessa Tertiary General Hospital, Health Sciences College, Addis Ababa University, Addis Ababa, Ethiopia. The hospital is a tertiary referral facility with primary responsibility in medical education. Thus, several patients are referred to this hospital, which is located in the capital city of Ethiopia, for advanced diagnosis, management and care. The out-patient clinic of the Department of Gynecology and Obstetrics has several units, of which this specific study was undertaken at the Oncology Unit of the department, which runs once per week. On average, about 1500 patients are seen annually in the Unit. At presentation, potential participants were informed about the study. The criteria for enrollment included: age above 18 years, willingness to participate in the study and willingness for HIV counseling and testing. Exclusion criteria were age less than 18 years, pregnancy, women on menstrual cycle, women who did not start sexual activity, presence of cervical cancer and unwillingness to participate in the study.All women who agreed to participate in the study provided written informed consent. At the enrolment visit, data on detailed socio-demographic information, as well as a clinical history and information on behavioral risk factors were collected using standardized questionnaire by senior nursing staff. Trainings on sensitive data management topics were provided to all staff involved in the research project, which included topics like data recording, data collection, data validation, double entry, correction of data, data export, data security and safety, harmonisation and merging datasets. Common data safety and quality assurance policy were applied. In addition, full clinical examination was done by senior gynecologist and two cervical specimens were collected: one was for smear onto glass slides to be used for routine cytology and a second cervical swab was taken for HPV detection. The latter was placed in 1 ml of RNA/DNA stabilization reagent and then immediately placed in ice before transfer where it was stored at -80 °C until further analysis for HPV DNA PCR and genotyping at the Virology Laboratory, Hadassah University Hospital in Jerusalem, Israel. In addition, whole blood specimen was collected for HIV-1 serology.The smears were stained with the Pap stain and routinely reported by a pathologist according to the criteria of the Bethesda classification system . DiagnosCervical swabs were put onto lysis buffer and were incubated at 37 °C for 2–3 h and then heated to 96 °C for 10 min. The samples were subjected to DNA extraction (Roche – Magnapure). Sample adequacy for DNA amplification was validated by examination of the cellular gene RNase P, which was assayed using the Taqman RNase P kit (Applied Biosystems) according to the manufacturer’s instructions. Five μL of the eluted DNA were subjected to nested PCR amplification using primers derived from HPV L1 region  and reactive samples were tested again by HIV 1/2 STAT-PAK assay . Discordant samples were subjected to a tie-breaker test using Unigold HIV .The protocol was reviewed and approved by Institutional Review Committees of Addis Ababa University Health Sciences College and Hadassah University Hospital as well as the National Ethical Review Committee of the National Science and Technology Ministry, Addis Ababa, Ethiopia.X2 test and student’s t-test. Logistic regression analysis was also used to identify the association between the presence of HPV infection and a range of demographic, behavioral and morbidity characteristics. Multiple logistic regression analysis was carried out in order to see the effects of confounding factors. P value of less than 0.05 was considered indicative of statistical significance. All statistical analyses were performed using the Stata  and SPSS  Statistical Software packages.Questionnaire responses, cervical cytology results, HPV results and other laboratory data were entered onto a database. Through-out the study, double-data entry was undertaken in order to assure quality of the data. Proportions were compared using pearson’s A total of 233 HIV-negative women were enrolled for the study. The mean (95% CI) age of the patients was 41.7 years (40.1–43.2). Furthermore, a significant proportion of these women had multiple sexual partners, were multipara with low income status and no formal education . Furthermore, of those women referred, only 21.3% (95%CI:14.4-28.1) had normal cytology results that was significantly lower compared to those with abnormal cytology .Of the total of 233 patients included and evaluated for cytology examination, the results revealed that 141 (60.5%) samples were normal while 92 (39.5%) were abnormal. Of those with abnormal cytology results, the prevalence of high grade squamous intraepithelial lesion (HSIL) at 68.5% (95% CI: 58.8–78.2) was significantly higher than low grade squamous intraepithelial lesion (LSIL) at 6.5% (95% CI: 1.4–11.7) and invasive cervical carcinoma (ICC) at 25% (95% CI: 16–34.1). The prevalence of abnormal cytology findings among women also presenting with STI appears to be significantly higher from those without STI . The overall prevalence for HR-HPV was 83.2%. The prevalence of HR-HPV among women with normal cervical cytology was significantly lower than those with abnormal cytology . HPV was identified in all specimens from patients with abnormal cytology results and the prevalence of HR-HPV was 83.3%, 95.2% and 87% among those with LSIL, HSIL and ICC, respectively.Table n = 134), the most frequent genotypes was HPV16 (44.1%), followed by HPV35 and HPV45 (each 6.2%), HPV31 (4.4%), HPV56 (3.7%), HPV18 and HPV59 (each 3.1%), HPV58 (2.5%), HPV39 (1.9%) and HPV52 (1.2%). While the most common HR-HPV infections among women with normal cytology were HPV16 (20.3%), followed by HPV35 (8.7%), HPV56 and HPV58 (each 5.8%), HPV18, HPV31 and HPV39 (each 4.4%), HPV45 (2.9%) and HPV59 and HPV68 (each 1.5%), the most common HR-HPV infections in women with abnormal cytology included HPV16 (62%), followed by HPV45 (8.7%), HPV 31, HPV35 and HPV59 (each 4.4%), and HPV18, HPV52 and HPV56 (each 2.2%).Of all HR-HPV infections (p < 0.0001). The most frequent HR-HPV types in LSIL lesions were HPV16 (66.7%) and HPV45 (16.7%); in HSIL lesions were HPV16 (63.5%), HPV31, HPV45 and HPV59 (each 6.4%), HPV35 (4.8%), HPV18 (3.2%) and HPV56 (1.6%), and in ICC lesions were HPV16 (56.5%), HPV45 (13%), HPV52 (8.7%) and HPV35 and HPV56 (each 4.4%).Overall, the prevalence of HPV16 is significantly higher among women with abnormal cytology compared to the prevalence among women with normal cytology . This is somewhat higher than a previous reported results done in Ethiopia showing a prevalence of precancerous lesions of 22.1% , but is Our study also revealed a significant risk of infection with HR-HPV. Moreover, the overall prevalence of HR-HPV and the most prevalent genotype, HPV16, were also significant among women with normal cervical cytology , which is in accordance with the 93% reported by Abate E et al. from Ethiopia –9. The dIn the current study, the most important independent risk factors associated with HR-HPV was related to residence in rural setting. Though underlying conditions have not been studied in detail in the current study, it might be related to lower socio-economic status, as noted in previous studies from Mexico , differeThis study, unlike previous studies done in Ethiopia, included evaluation of cytological status. Indeed, this is the first study to investigate HPV prevalence and genotype distribution among women with normal cytology. The data provided herewith provide some information about the background HPV genotype distribution and also the lower diagnostic sensitivity of Pap smear compared to HR-HPV DNA PCR methods in identifying risk factors for cervical cancer –19.The limitation of the study includes the inclusion of a significant proportion of women who were referred for advanced diagnosis and management and those from rural area resulting in increased prevalence rates of abnormal cytology results as well as HPV infections. The fact that the selected women are mostly referred because of gynecological problems might limit the use of the current data for epidemiological purposes. The HPV genotype distribution in the current study was performed almost 10 years ago, nonetheless data from Ethiopia are still hardly available  and we bTo our knowledge, this study is the first comprehensive assessment of the overall prevalence and distribution of HPV genotypes among Ethiopian women presenting with normal and abnormal cervical cytology findings. Data from the present study indicate that vaccines currently available could prevent nearly 67% of all cervical cancer cases in women in Ethiopia. Moreover, our data suggests that newly licensed 9-valent HPV vaccines would prevent almost 80% of cancer cases in Ethiopian women. Current WHO guidelines advocate “screen and treat” approach for resource constrained settings . Such prEthiopia has no comprehensive national cancer control program. Likewise, there is no national HPV vaccination program. A pilot feasibility study is underway in two sites of the country before scale-up for national HPV vaccination programme. A more comprehensive and representative molecular epidemiology studies are also warranted to understand the real situation in Ethiopia.Additional file 1:Table S1. Socio-demographic characteristics. (DOCX 15 kb)


Many cervical cancers occurs among women over 65 and prevalence of HPV genotypes in this age cohort is sparingly studied. One aim of this study was to study the prevalence and distribution of HPV genotypes in women 55–59 years, with normal cytology when exiting the screening program. Secondly, HPV clearance as well as the value of HPV genotyping and/or liquid based cytology as triage tests for identifying histological dysplasia among women with persistent HPV was studied.Women that exited the screening program with normal cytology, between the years 2012–2014, in Örebro County, Sweden, were invited to this study. A total of 2946 samples were analyzed with a broad-spectrum assay to detect both hrHPV and lrHPV in order to investigate the distribution of genotypes. In the consent group, women with a positive hrHPV test were offered a follow-up test and a cone biopsy for histological confirmation, and a follow up sample 6 months post cone.The overall prevalence of hrHPV was 7.4% and 59% of them remained hrHPV positive in a follow-up test after 12 months. A total of 99 women had a cone biopsy done, where 19% showed histological dysplasia. HPV 53 was the most common genotype, and among women with histology confirmed LSIL or HSIL, HPV 31 was most common. A positive hrHPV result showed a PPV of 25% for LSIL+ and 12.5%for HSIL+. Using detection of HPV 16/18 genotypes as a triage test for hrHPV positive tests, indicated FNR for histological LSIL+ and HSIL+ of 94% and 87.5% respectively, whilst triage based on cervical cytology had a FNR of 69% for LSIL+ and 37.5% for HSIL+.The most common hrHPV genotypes among women 55–59 years of age were non HPV16/18 genotypes, and in this population, these genotypes represented most of the histological verified HSIL lesions. This result does not support the proposition of a HPV 16/18 triaging test after a positive hrHPV test as a marker of histological HSIL+ cervical lesions in women over 55 years of age. Similarly, cytological triage after a positive hrHPV showed no additional benefit in this population. Specific triaging tests should be validated to follow post-menopausal women with a positive hrHPV test. A national screening program for cervical cancer was introduced in Sweden around 1965 and since then the incidence of cervical cancer has been markedly reduced till around one third . ObviousUntil recently, cytology based screening was the standard both nationally and internationally but in Sweden and other countries, screening programs are transferring from primary cytology to detection of human papilloma virus (HPV) at least for parts of the population . The SweThe prevalence of HPV in women exiting the screening program is sparingly studied. Data indicate that there are variations of HPV genotypes and prevalence of HPV in different age cohorts among precancerous lesions –15. OtheOther data suggest that postmenopausal women are less likely to acquire new infections since the transformation zone and the squamocolumnar junction is retracted when reaching menopause , 24. AlsPopulation based prevalence data with a broad-spectrum assay of high-risk HPV and possibly and probably hrHPV among peri-/postmenopausal women were missing until recently. Different studies show a prevalence that differ greatly worldwide, and among European studies HPV prevalence among women between 55–60 differ from just below 5% to just over 10% , 26–28.Therefore, the aim of this research was to study the prevalence of HPV and the distribution of genotypes in an age specific cohort, women 55–59 years, with normal cytology when exiting the screening program. hrHPV positive women were followed-up in order to investigate if certain HPV genotypes and/or cytology could predict cervical histological changes in this particular age group, in order to modulate screening and follow-up strategies among postmenopausal women.A total of 2973 women in Örebro County, Sweden, that had their exit samples from the screening program during 2012–2014 in the biobank, were invited to participate in this study. Of those, 2031 women signed the consent and had sufficient cell material to analyze. Additionally, 915 women did not respond to the invitation (non-consent group) but had samples in the biobank [® HPV2  was used for genotype determination. This test detects HPV genotypes in International Agency for Research of Cancer (IARC) classification high risk group 1§2A§§ (probably high risk) and 2B§§§, (possibly high risk) and several lrHPV. The assay targets the L1-region of the virus and 35 different genotypes  as well as the human gene CTFR.For DNA extraction, 200 μl biobanked sample (concentrated LBC) or 1000 μl LBC sample was used for extraction with QiaAmp DNA mini kit  . CLART® ®  was used for detection of PCR-product and results were analyzed automatically in software CLART® Human Papillomavirus 2 specific software (Genomica). Prevalence of HPV was analyzed in both the consent group and anonymously in the non-consent group. Here after, in the following text when referring to “hrHPV”, genotypes according to IARC class 1, 2A and B are meant [PCR-reactions were run in 50 μl reactions containing 45 μl CLART HPV2 Amplification kit (Genomica) together with 5 μl of DNA. The low-density microarray platform, CLARTre meant . “hrHPV re meant . “lrHPV+In the consent group, women positive for hrHPV in their exit sample were invited for a follow-up visit with new professional sampling. Time between the exit samples and follow-up samples varied between 7 to 39 months, mean 24 months. Additionally to the follow-up sampling, they were offered an appointment to a gynecologist for loop electrical excision procedure for a cone biopsy. The last follow-up sample in the study was 6 months after the cone biopsy . None ofExcel 2010  and SPSS version 22  were used for data collection and evaluation. Chi Square test was used for calculations of significance, P<0.05 was considered statistically significant. Positive predictive value (PPV) and negative predictive value (NPV) were also calculated, as well as false negative rate (FNR), for calculations comparing test results between methods improperly indicating no presence of dysplasia, when the histological exam identifies dysplasia.ThinPrep cytology slides were assessed by experienced and IAC certified cytotechnicians and classified according to present guidelines . ConcernThis study was approved by the regional ethics committee board in Uppsala (Dnr 2014/122). All women included in the study have signed an informed consent before the exit sample was analysed and the invitations for further follow-up were sent out. The ethical approval also contained an agreement to analyse exit samples anonymized in the non-consent group.Among the 2973 women who exited the screening program, 2946 HPV tests were performed including 2031 women who accepted to participate in the follow-up study and 915 women who did not and whose HPV tests were analyzed anonymously. Median age  and HPV genotypes did not differ statistically between the two groups . The preThe most common hrHPV genotypes among the positive results were HPV53 (11.5%), followed by HPV51 (7.5%) and HPV16 (7.5%). Among the lrHPV genotypes HPV61 (15.2%) was most prevalent .Multi infections with lrHPV and hrHPV were seen in 25.9% of the positive samples. When analyzing only hrHPV according to IARC group 1, 2A and B, 11.7% were multi infections, and when hrHPV of clinical significance were analyzed the occurrence of more than one HPV infection was seen in 8.3%.Among the 143 women with positive hrHPV  test at exit, 126 (88%) continued with a follow-up test with a median interval between the first HPV test and the follow-up test of 24 months (range 7–39 months). If applying 12 months as the time range for clearance, 113 individuals had a follow-up of 12 months or more, 67 out of them had still a HPV infection at follow-up, thus the clearance rate at 12 months or more was 59%. Including all 126 even if tested before 12 months the clearance rate was the same, 75/126 (59.5%). If only focusing on the 14 hrHPV genotypes of clinical significance 48/84 (57%) were still hrHPV positive after 12 months or more.2 0, 93, p = 0,335).Concerning single and multi-infections of the 126 women continuing the study, 101 had HPV infection with a single HPV genotype. In this group, HPV clearance was observed for 43 women (42.6%) with a median time interval between exit test and follow-up of 26 months. At the exit test (HPV test 1), 25 out of 126 women were testing positive for multiple hrHPV genotypes. Among these, 8/25 (32%) had a negative HPV test at follow-up, with a median time interval of 19 months, thus there was no difference in clearance rate between single and multiple infections  were multi infections. The majority, 71/75 had the same or partly the same genotype, for example, one of the genotypes in a multi infection was not detected in the second test .Out of the 64 hrHPV positive women continuing in the study to the cone biopsy procedure, 13 cytology samples showed pathological cytology; 6 atypical squamous cells of undetermined significance (ASCUS), 3 low-grade squamous intraepithelial lesions (LSIL), 3 HSIL and one sample atypical glandular cells (AGC), when analyzing cytology on repeated test. Both cytology positive samples and histology abnormality was seen in five samples . Out of Of the 126 women that were hrHPV positive in their exit sample, 99 went through with a cone biopsy. Of the women hrHPV positive at follow-up test, 64/75 had a cone biopsy done, and 35/51 among the hrHPV negative women . HistoloOut of all 99 women with cone biopsies done, 33 (33%) post cone tests were still positive for hrHPV, 6 months after the procedure, 21/33 (64%) of these with the same genotypes in all samples. Interestingly, five individuals were positive with the same hrHPV genotype in the exit sample (HPV test 1) and post cone sample (HPV test 3), but the follow-up samples (HPV test 2) were negative. None of these five cone biopsies with hrHPV of the same genotype in test 1 and 3 had histological changes and the genotypes in those samples were HPV 16, 53 (n = 2), 66 and 70.Of the 19 cone biopsies with ≥LSIL, 10 were still hrHPV positive in the post cone sample (HPV test 3) and eight of these with the same genotype. None of these had cytological abnormalities.HPV-based screening has the potential to prevent additional cases of cervical cancer in women over 60 years of age. However, the clinical management of HPV positivity in this age group is not well established due to a number of reasons.This is an age group where HPV prevalence and distribution of genotypes are mainly unknown. In this study, HPV status was assessed in biobanked samples from women exiting the screening program with normal liquid based cytology at 55–59 years, in a population based cohort. The HPV prevalence was 12.7% when including 35 both lr- and hrHPV genotypes, 7.7% when including hrHPV according to IARC class 1, 2A and 2B and 5.5% when including the 14 genotypes that are most clinically used for screening purposes. The latter in concordance with two other recent Swedish studies that showed incidence rates of 5.6 and 5.5% respectively , 34, as 2 0.004, p = 0.95). Age is shown to be a risk factor for persistence and among younger women, most infections clear [Persistence of HPV infection is often referred to as a positive test after 12 months internationally, even though there is still no consensus concerning the definition of persistency of HPV infections. In this study 67/113 (59%) remained hrHPV positive after 12 months. Looking at our data of type-specific clearance rates between exit test and follow-up test, with the obvious limitation of low case numbers, the clearance rate for HPV16/18 and non-HPV16/18 were similar, 41% (7/17) vs 40% (44/109), with no statistical difference  as compared to single infections (43% clearance). To the best of our knowledge, there is no understanding of the clinical meaning of multiple infection in the genital tract and consensus is pending on whether a multiple infection leads to higher risk for cervical neoplasia –39. Due It is well known that HPV as primary screening is the superior test in women, at least over 30, and is recommended by WHO, EU and the Swedish National Board of Health and Welfare. Initially screening was performed with cytology PAP smear, but cytological screening of women aged 60–69 ceased in Sweden during the 1990’s due to the limited sensitivity and specificity of PAP smears in this age group . HoweverHPV genotyping of HPV16/18 as an augmented screening tool among women with hrHPV and normal cytology/LSIL have been proposed , 43 and Usually HSIL is the endpoint in studies but maybe a LSIL in this age cohort with a persistent hrHPV infection is as accurate to identify? Another interesting finding is the hrHPV positive LSIL group among the cytological normal women. None of these cases were identified by cytology or would have been detected by HPV16/18 as a supplementary tool. Furthermore, the progression from LSIL to HSIL varies in time  and the Post cone tests, 6 months after the procedure were still positive for hrHPV in 33%, even though an adequate cone biopsy including the transformation zone had been conducted. A number of different mechanisms can be in place, persistence, reinfection and reactivation of latent infections among them, or the possibility that the test is taken to close in time to the cone biopsy. In this study we have followed the Swedish national guidelines where a “test of cure” (post cone test) is recommended 6 months after the biopsy.Thus, our data addressing the question of how a hrHPV woman in the postmenopausal age group should undergo follow-up indicates that there is a need for different strategies in different age groups. A non-interventional approach on the initial hrHPV finding still seems to be valid since no HSIL occurred in the HPV negative group at follow-up, but what is the best time-interval for the follow-up of women over 55 years with a normal cervical smear and a positive hrHPV test? Furthermore, neither cytology nor HPV 16/18 complementary analysis of the HPV persistent group could be used in order to limit the number of surgical procedures since major pathological findings occurred among women with normal cytology and/or nonHPV16/18 at follow-up. Maybe the most interesting finding is the prevalence and significance concerning HSIL lesions of IARC group 2A/B genotypes, especially HPV 53 in our study of elderly women. Thus, HPV test with broad genotype coverage and liberally use of cone biopsies would be key components in such a follow-up schedule.Altogether, our data highlights the need for a solid evidence based guideline for the clinical management of hrHPV positive women intended to exit the screening program where the concomitant cytological evaluation is normal. Further studies to identify biomarkers such as for example methylation, in the context for pretreatment persistence and/or clearance as well as further information of sexual habits and partner HPV testing must be taken into consideration but are presently out of scope of our present study.


Overall, our research sheds light on why and under what conditions the dark side of humble leader behaviors is going to emerge and take its toll on the leaders themselves. Theoretical and practical implications are discussed.Although existing studies to date predominately focus on the beneficial effects of leader expressed humility on followers, knowledge about how those behaviors impact the leaders themselves is scarce. Drawing on the conservation of resources theory, we develop and test a model that specifies for whom and how expressing humility has detrimental effects on leaders’ emotional exhaustion and the downstream implications of this effect for leaders’ turnover intentions and work-to-family conflict. Data from a multisource, time-lagged survey of 55 team leaders and 281 followers showed that expressed humility was positively associated with leaders’ emotional exhaustion when Honesty–Humility was low, after controlling for Emotionality, sleep quality, overall job satisfaction, and hindrance stressors. In addition, we found that expressed humility was positively and indirectly related to leaders’ turnover intentions and work-to-family conflict  With the increasingly turbulent and unpredictable environment, organizations have to move beyond the “great man” or the hero myth perspectives of leaders who could figure it all out at the top . To attaHowever, while prior studies have documented how leader expressed humility could exert benefits on followers’ affective and behavioral outcomes, it is unclear whether and in what ways engaging in humble behaviors impacts the leaders themselves, and further on, for whom and how expressed humility may take its toll on leaders. Failing to address the potential detriments of humble leader behavior is problematic because emerging research reveals that engaging in what are generally thought to be “good” leader behaviors also have depleting effects on leaders . AddressTo answer these questions, we draw on the conservation of resources (COR) theory and the counterdispositional framework from an actor-centric perspective to examine the possible detrimental impacts of engaging in humble leader behaviors for non-humble leaders. We argue that non-humble leaders  could counterdispositionally express humility at work since they are dishonest and they have the purpose of influencing followers to reach desired goals , 2016. HBy examining the hypothesized model in a time-lagged, multisource study, our paper makes several contributions. First, we shift the literature’s dominating focus on the effects of expressed humility from followers to leaders. While relevant literature constantly suggests a positive relationship between leader expressed humility and follower affective and behavioral outcomes , it remar = 0.20, p > 0.05) between self-reported humility and expressed humility has been found in an empirical study  and 356 follower surveys (73.25%) were returned. Finally, a total of 55 leaders completed all three phases, for a final leader response rate of 60.44% and a total of 281 matched leader–follower dyads. The mean team size was 5.11.In the final sample, 49.10% of the leaders were male and an average of 43.31 years old. Leaders also averaged 21.39 years of tenure at their company. In total, 38.8% of subordinates were female. Subordinates were 37.13 years old on average, with an average of 16.28 years with the organization.All survey items were translated into Chinese following the standard translation and back-translation procedures .viaRwg), Intra-Class Correlation 1 (ICC1), and Intra-Class Correlation 2 (ICC2) were examined to justify the appropriateness of aggregating leader expressed humility to the team level  was highly significant in terms of between-team variances , which provided support for aggregating this construct to the team level.Humble leader behaviors were measured by aggregating subordinates’ ratings of their leaders am level . The resLeader Honesty–Humility was measured with the 10-item measure of Honesty–Humility included in the HEXACO-60, a brief personality inventory that measures the HEXACO model of personality structure . Sample Emotional exhaustion was measured with the five-item subscale from the Maslach Burnout Inventory . Leadersvia three items from Turnover intentions were measured via five items from Work-to-family conflict was measured Since our research is non-experimental, extraneous  variables may increase the concerns of contaminating the assessment and producing confounded relationships among study variables. In addition, controlling for third variables could help build the incremental validity between a predictor and a criterion . Therefovia a single item validated by viaEmotionality was measured with the 10-item measure of Emotionality included in the HEXACO-60 . Sample 2 (281) = 499.61, p < 0.01, χ2/df = 1.78, Tucker-Lewis index (TLI) = 0.90, Comparative fit index (CFI) = 0.90, Root mean square error of approximation (RMSEA) = 0.05, Standardized root mean square residual (SRMR) (between) = 0.07], and all loadings were significant (p < 0.05). This model fits the data significantly better than other alternative models, including a seven-factor model in which work-to-family conflict and turnover intentions were set to load on a single factor (Δχ2(6) = 41.45, p < 0.01), a six-factor model in which Honesty–Humility, job satisfaction, and hindrance stressors were set to load on a single factor (Δχ2(11) = 156.72, p < 0.01), and a three-factor model in which Honesty–Humility, emotional exhaustion, turnover intentions, work-to-family conflict, job satisfaction, and hindrance stressors were set to load on a single factor (Δχ2(20) = 428.58, p < 0.01). Those results demonstrated the discriminant validity of our measures.Due to the hierarchical data structure of our research (multiple subordinates belong to one leader), it is necessary to account for multilevel variability when conducting factor analysis . Therefop = 0.03) after controlling for all control variables. And results remain similar when omitting all control variables , unrelated to emotional exhaustion when Honesty–Humility was at the mean level  or high . Thus, Hypothesis 1 was supported.Before testing the specific hypotheses, we standardized leader expressed humility and Honesty–Humility and created the interaction term (expressed humility X Honesty–Humility) using the standardized variables. First, we tested Hypothesis 1 by examining the interactive effect of expressed humility and Honesty–Humility on emotional exhaustion. As presented in Model 2 of via emotional exhaustion, moderated by Honesty–Humility. We followed the methods suggested by via emotional exhaustion. In addition, we reported the index of moderated mediation, which directly provides an inferential examination of the conditional indirect effect  after controlling for all first-stage effects and control variables. In addition, the results remain similar when omitting all control variables  ) and not significant when leader Honesty–Humility was at the mean level  or high . The index of moderated mediation was significant as well, again demonstrating a meaningful role of Honesty–Humility in the effects of leader expressed humility on work-to-family conflict via emotional exhaustion . Thus, Hypothesis 2a was supported.As presented in Model 5 of p < 0.01) after controlling for all first-stage effects and control variables. In addition, the results remain similar when omitting all control variables  and not significant when leader Honesty–Humility was at the mean level  or high . The index of moderated mediation was significant as well, again demonstrating a meaningful role of Honesty–Humility in the effects of leader expressed humility on turnover intentions via emotional exhaustion . Thus, Hypothesis 2b was supported.As presented in Model 8 of Based on the COR theory, we developed and examined a model explaining for whom and how expressing humility affects leaders’ resource loss and work- and family-related consequences. Findings from a time-lagged, multisource field study revealed that emotional exhaustion mediated the interactive effect of leaders’ expressed humility and Honesty–Humility on their turnover intentions and work-to-family conflict, such that expressed humility was associated with an increase in emotional exhaustion when combined with low Honesty–Humility, which in turn leads to increased turnover intentions and work-to-family conflict.However, we found that when leaders high on Honesty–Humility behave less humbly than normal, they do not experience an increase in emotional exhaustion. This asymmetrical finding is consistent with previous research in that they all found that not all counterdispositional behaviors have a detrimental effect on the actors . One posOur study has several key theoretical and practical contributions. First, we contribute to the leader expressed humility literature by broadening scholars’ understanding of the consequences of expressed humility. While previous studies have confirmed the beneficial effect of leader expressed humility on followers , the impSecond, we contribute to the COR theory by identifying that acting counterdispositionally is an important process involving resource loss. While previous studies have established that behaving in ways that contradict dispositions was related to a negative affect and ego depletion , the resFrom a practical standpoint, our finding that behaving humbly can lead to resource depletion when leaders are actually non-humble is noteworthy. With previous studies consistently revealing that leader expressed humility is associated with team performance and team innovation  and thatN = 55). It is well established that an inadequate sample size may lead to biased parameters (Although our study adopted a time-lagged and multisource study design, it still has several limitations worth noting. First, although our research design reduced concerns of common method bias, the nature of our study precludes us drawing any causal inferences. There might exist other endogenous variables, beyond our control, explaining the relationships of our focal measurements. Thus, experimental research designs are needed. Alternatively, more robust statistical frameworks, particularly the instrumental variable estimations, would help address the endogeneity concerns . Second,rameters . We encoAlthough leader expressed humility brings benefits to followers, teams, and firms, our study demonstrates for whom and how it may be detrimental to the leaders themselves. Drawing on the COR theory, the results showed that leader expressed humility did have a dark side, and the extent to which this dark side shows up rests with whether they are acting counterdispositionally. We hope that our work not only shifts the focus of expressed humility research toward the outcomes for the leaders themselves but also fuels scholars’ interest to further explore the pros and cons of leader expressed humility.The datasets generated for this study are available on request to the corresponding author.An ethics approval was not required as per institutional guidelines and national laws and regulations, because no unethical behaviors existed in this study. We just conducted a paper-pencil test and were exempt from further ethics board approval since our study did not involve human clinical trials or animal experiments. In the survey process, all participants were informed that participation was voluntary and assured that their responses would be used only for our research and kept strictly confidential. Therefore, only those who were willing to participate were recruited. The informed consent of the participants was implied through survey completion. To ensure confidentiality, the questionnaires completed during their working hours were directly returned to the research assistants in sealed envelopes.ZL and ZW made substantial contributions to the conception and design of the studies. KY and LZ were responsible for collecting and analyzing the data. KY drafted the manuscript. All authors critically revised the manuscript for important intellectual content.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.


FDC males were at increased risk for reporting seven chronic medical conditions compared with NHANES males. FDC females were at decreased risk for high blood pressure and increased risk for diabetes when compared with NHANES females. FDC veterans reporting war-related chemical weapons exposure showed higher risk of high blood pressure; diabetes; arthritis and chronic bronchitis while those reporting taking anti-nerve gas pills had increased risk of heart attack and diabetes. GW veterans are at higher risk of chronic conditions than the general population and these risks are associated with self-reported toxicant exposures.Prevalence of nine chronic medical conditions in the population-based Ft. Devens Cohort (FDC) of GW veterans were compared with the population-based 2013–2014 National Health and Nutrition Examination Survey (NHANES) cohort. Excess prevalence was calculated as the difference in prevalence estimates from the Ft. Devens and NHANES cohorts; and confidence intervals and  From August 1990 to June 1991, nearly 700,000 U.S. troops were deployed to the Persian Gulf to serve in Operations Desert Shield and Desert Storm. Shortly after returning, many Gulf War (GW) veterans began reporting a variety of symptoms in multiple body systems that medical professionals could not diagnose. This array of symptoms was termed “Gulf War Illness” (GWI) or “Chronic Multisymptom Illness” (CMI) . ResearcWhile the exact etiology and pathobiology of these symptoms remains undetermined, research clearly suggests that neurotoxicant exposures in theater contributed to the disorder ,6,7,8. GCorrespondingly, GW veterans have shown increased prevalence of chronic multisymptom illnesses, including GWI, fibromyalgia ,3,9,10, For non-neurological disorders, there have been reports of higher rates of arthritis ,13,14,22One of the earliest and the longest-running studies of GW veterans’ health symptoms was conducted with the Ft. Devens, MA Cohort (FDC). This cohort was surveyed in regard to their health symptom reporting and provided important information regarding the rates and types of current health patterns ,27. ResuEpidemiologic studies of health symptoms have compared rates of cohort samples to the National Health and Nutrition Examination Survey (NHANES) data set. This is a program of studies created by the Centers of Disease Control and Prevention (CDC) to assess the health and nutritional status of adults in the United States. The NHANES surveys began in the early 1960s and continue to this day.In the current study, we build upon, extend and update prior work by comparing the rates of chronic conditions in GW veterans to that of the general population. Specifically, we compared the FDC survey data to the general population (2013–2014 NHANES), to compare rates of self-reported doctor diagnosed chronic medical conditions between cohorts. We also investigated the health status of GW veterans from the FDC survey of 2013–2014 as it relates to self-reported neurotoxicant exposures. We hypothesized that GW veterans would have higher rates of chronic conditions than the general population. We also hypothesized that GW veterans who reported neurotoxicant exposures would have higher rates of chronic conditions than GW veterans who did not report neurotoxicant exposures, similar to other deployment-related toxicant exposed veteran groups.n = 2949) was obtained from the NHANES survey for the year 2013–2014, restricted to the age range of the FDC respondents. For the current analyses, veterans were excluded from the NHANES sample.Comparison data for this study came from two different population-based cohorts. The first cohort included the Ft. Devens, MA Cohort of GW veterans (FDC), and the second cohort was the NHANES dataset. The FDC is one of the few longitudinal cohorts of GW veterans and is the longest running cohort of GW veterans. The most recent Time 5 resurvey began in 2013 and 448 participants who had data for at least one medical condition responded to the FDC Reunion Survey (47 women). Data for the comparison group , high cholesterol, heart attack, diabetes, stroke, cancer, asthma, arthritis, and chronic bronchitis. Responses were recorded dichotomously (yes/no). NHANES participants also self-reported whether or not a doctor had ever diagnosed them with these conditions (yes/no) and these data were compared with the FDC survey data.FDC veterans were asked during this resurvey to self-report if they were ever exposed to chemical or biological warfare (CBW) agents or pyridostigmine bromide (PB) anti-nerve agent pills. CBW was used as a proxy for chemical weapons (sarin/cyclosarin) exposure.p-values are based on the standard errors for the two prevalence estimates. Odds ratios and test-based confidence intervals were calculated from the prevalence estimates and standard errors from the two cohorts, similar to what was done in Yun et al. 2006 [Since the FDC and NHANES used different sampling strategies, prevalence estimates and their standard errors were calculated separately for each cohort. NHANES employed a complex survey design and prevalence was estimated using SAS survey procedures to account for weighting and clustering in estimating both parameters estimates and standard errors. The FDC was analyzed as a random sample from the Ft. Devens population. Excess prevalence was calculated as the difference in prevalence estimates from the Ft. Devens and NHANES cohorts, and confidence intervals and al. 2006 .Comparisons were made separately for men and women to assess for gender- and age-specific associations. For the age-specific associations, we compared three different age groupings: 40s, 50s, and 60s+ by cohort. Reflecting the Ft. Devens population, the FDC sample was largely white (94%), with high school education or higher (99%). To account for demographic differences between cohorts, we restricted both cohorts to White/Caucasian individuals with a high school or above education. After restriction, there were some demographic differences between cohorts on age (Ft. Devens women were younger) and education (Ft. Devens men were more likely to have other training or some college), and analyses adjusted for these demographic differences by modifying the NHANES weights to match the age and education distribution, for men and women separately, of the Ft. Devens cohort. After restriction and weighting , there were no significant differences in current smoking between the two cohorts.p < 0.05 was considered significant, and no adjustments were made for multiple comparisons.Chi-square tests of independence were used to examine the association between gender and medical conditions, as well as the association between exposures and medical conditions, and to calculate odds ratios in the FDC. Multinomial logistic regressions were run to obtain the adjusted ORs, when applicable. For all analyses, two-sided Data Availability Statement: Analyses were performed using raw data that are only available within the US Department of Veterans Affairs firewall in a secure research environment. VA privacy and data security policies and regulatory constraints provide that only aggregate summary data may be removed from the VA for publication. The authors have provided detailed results of these analyses in the paper. These restrictions are in place in order to maintain patient privacy and confidentiality. Access to these data can be granted to persons who are not an employee of the VA; however, there is an official protocol that must be followed for doing so. The authors invite those wishing to access the raw data that were used for this analysis to contact Maxine Krengel (Maxine.Krengel@va.gov) to discuss the details of the VA data access approval process.The mean age of the FDC was 53.93 years. The mean age of the NHANES cohort was 55.86 years. The two cohorts differed significantly in age, sex, race, education, and current smoking status. For the FDC exposure analyses, veterans who were exposed and unexposed did not differ on any of the demographic variables. However, adjusted analyses for exposure were performed to control for gender and current smoking, potential risk factors for these chronic conditions. Demographics are reported in p < 0.05). The FDC excess prevalence ranged from 2.7 to 12.2% higher for these conditions . The FDC women had a 16.4% lower prevalence of HBP and a 19.5% higher prevalence of diabetes compared to the NHANES general population. There was no significant association between cohort and high cholesterol, heart attack, stroke, cancer, asthma, arthritis, and chronic bronchitis (p > 0.05). FDC and NHANES cohort comparison results are shown in Non-restricted and restricted analyses revealed that the FDC females reported a significantly lower rate of HBP and a significantly higher rate of diabetes compared with the NHANES females (p < 0.05), with the FDC reporting higher prevalence (p < 0.05), with the FDC reporting a higher prevalence than the NHANES cohort. The excess prevalence for heart attack was 4.4% , with the FDC reporting more chronic conditions. In the restricted analyses, there was a significant association between cohort and arthritis and chronic bronchitis (p < 0.05) with the FDC reporting more chronic conditions than NHANES men. The FDC excess prevalence for these conditions ranged from 9.0 to 17.9% (p > 0.05).For males in their 50s, the non-restricted analyses indicated significant associations between cohort and HBP, high cholesterol, cancer, arthritis and chronic bronchitis (to 17.9% . The oddp < 0.05), with the FDC reporting higher prevalence. In the restricted analyses, there was a significant association between cohort and two chronic conditions including stroke and chronic bronchitis (p < 0.05) with FDC reporting higher rates than NHANES men. The excess prevalence was 12.1 and 10.5% respectively , with CBW-exposed veterans reporting higher prevalence rates of HBP, diabetes, arthritis and chronic bronchitis  exposure and 4 chronic conditions (onchitis . The excp < 0.05) with PB exposed veterans reporting higher prevalence rates of heart attack and diabetes (p < 0.05). The excess prevalence for these two conditions were 10% and 12.5% respectively. PB-exposed veterans had 11 times the odds of reporting a heart attack in unadjusted analyses and 12 times the odds in adjusted analyses than the non-PB-exposed FDC veterans ; high cholesterol, for which FDC men had more than 2 times the odds of reporting compared to FDC women (OR = 2.25); and diabetes, for which FDC men had decreased odds of reporting compared to FDC women (OR = 0.38). Gender was not associated with any of the other chronic conditions .More than 25 years post-deployment, GW veterans continue to report more chronic health symptoms and chronic medical conditions than non-deployed veterans ,22,23,30Results showed that male GW veterans have significantly greater odds of developing chronic conditions including HBP, high cholesterol, heart attack, diabetes, stroke, arthritis, and chronic bronchitis. Specifically, FDC men in their 40s have 27 times higher odds of reporting a heart attack compared to the NHANES cohort of the same age. Rates of chronic conditions such as arthritis and chronic bronchitis also appear to be significantly higher in FDC males in their 50s and stroke risk is five times higher in the 60s age range compared to the NHANES cohort. These results correspond with prior accelerated aging cognitive patterns previously noted in the FDC veterans . SignifiImportant gender differences were also observed in this study. Male GW veterans had significantly higher odds of developing seven out of the nine chronic conditions assessed when compared with age-matched NHANES males. Conversely, female GW veterans had lower odds of developing HBP and higher odds of developing diabetes when compared with age-matched NHANES females. The FDC was one of the first studies to report a 1.8 times higher risk of GWI in women veterans . AlthougGW veterans’ chronic medical conditions were also compared by exposure status. Results indicated that neurotoxicant exposures during deployment were associated with higher rates of chronic conditions, compared to unexposed FDC veterans. In several prior studies, CBWs including sarin and cyclosarin were associated with GWI, as well as with altered brain imaging outcomes and other chronic illnesses including brain cancer ,36,37,38Collectively, these results indicate that toxic wounds from GW deployment related exposures appear to be associated with more than the chronic health symptoms of GWI but also with chronic conditions of aging. These results are similar to those observed in aging Vietnam veterans who were also shown to have increased risk of developing HBP, diabetes and multiple types of cancer if they were exposed to Agent Orange, the signature toxic wound during the Vietnam era ,41. FurtThe strengths of the current study are that it includes comparisons of chronic conditions in two population-based cohorts including a cohort of deployed GW veterans who were followed within a week after their return from the Gulf War and the well-designed general population cohort called the National Health and Nutrition Examination Surveys (NHANES). Both cohorts were designed as population-based survey study cohorts. The limitations of the current study are the relatively low response rate of the current FDC survey (35%), which could have introduced some response bias, where sicker veterans responded to the survey. However, recent other longitudinal cohorts of GW veterans including the National Survey of Gulf War veterans have reported almost identical response rates on recent surveys with no response bias when prior participant rates were compared suggesting this may be less of an issue with population-based GW veteran cohorts . In addiLastly, in splitting the samples by age, the sample was smaller for each age group, which may have introduced statistical power issues. Future work is needed to replicate these findings with larger cohorts.In summary, GW veterans in the FDC cohort had significantly increased odds for reporting chronic conditions including high blood pressure, high cholesterol, heart attack, diabetes, stroke, arthritis and chronic bronchitis compared with the NHANES general population cohort. This was true for comparison of males in the two cohorts with heart attack being higher in the FDC 4th decade and chronic bronchitis and arthritis being higher in the FDC 5th decade and the addition of stroke risk being higher is the 6th decade. Female comparisons showed a different pattern with FDC women veterans having significantly lower odds of high blood pressure and significantly higher odds of diabetes when compared with NHANES women. Direct comparisons of male and female FDC showed male veterans had higher odds for reporting HBP and high cholesterol and lower odds of reporting diabetes than FDC women veterans. Gulf War-related exposures, including self-report of chemical weapons, was associated with significantly higher odds of HBP, diabetes, arthritis and chronic bronchitis and self-report of PB exposure was associated with higher risk of heart attack and diabetes. Results indicate that GW veterans are at higher risk of chronic conditions than the general population and these risks are associated with self-reported toxicant exposures. These results should be considered when assessing the functionality of exclusionary criteria for currently used GWI case definitions.


E6™ Cervical Test) in remote areas in Brazil.To evaluate both the performance and acceptability of a method coupling self-sampling with detection of cervical malignancy via elevated HPV 16 and 18 E6 oncoproteins , followed by typing by the Papillocheck™ if positive. Subjects who were found to be positive for OncoE6 or HPV-DNA were referred for colposcopy.For 110 subjects (27%) this was the first cervical cancer exam. Overall the HPV-DNA prevalence was 19.1% (n = 79); 1.4% (n = 6) were positive by the OncoE6 Test. Fifty-six women attended the invitation for colposcopy where nine had an abnormal cervix and were subsequently biopsied. Histopathological analysis revealed 2 CIN3, 2 carcinomas and 5 CIN1. OncoE6 called two out of the three HPV 16 or 18 associated CIN3+ lesions.The findings suggest that self-administered sample collection in combination with OncoE6 Test is feasible in this population. This could enable expanded screening coverage while ensuring a high specificity which is imperative given the remote geographic location, since women bearing abnormal test results would necessitate travel and logistical burden to access colposcopy and treatment. In the last decade, large randomized controlled trials conducted in developed nations have demonstrated the superiority of HPV nucleic acids detection over cytology for primary screening for cervical cancer (CC) . In contUnfortunately, this may not be the case in low-income countries where access to cervical screening is not widely available. These neglected and unscreened/underscreened populations are at highest risk for CC , IndepenThere are several reasons as to why women may not adhere to a CC screening program. Low level of education, with relative lack of awareness of the disease risk and prevention, coupled with limited access to any existing screening offers are two major contributing factors.An innovative, active approach has been proposed: rather than adopting a passive approach whereby women come for screening, rather one should deliver screening to the women. One such approach is self-administered sampling (SS). SS has been shown to be as effective as collections by health-care workers for downstream HPV testing . SS can Several devices have been validated for the collection of cervicovaginal material for HPV nucleic acid testing (NAT). These devices are sent by mail to patients who -in general- respond favorably to the SS approach ,8. Self-Brazil has an estimated incidence of 17 CC cases/100,000 women per year with important regional differences . In the The estimative for CC incidence for the Amazonas state and Manaus are 47 and 61 /100,000 women respectively , which iPrevention is both at a lower cost and more effective than treatment. Such is the case for CC whereby the current 5-year mortality rate from diagnosis is 50% in Amazonas state . In receOver the last decade, economic initiatives by the Brazilian government have been implemented to assist impoverished families; this has contributed to the improvement of social conditions. A stipend is paid preferentially to eligible women. Eligibility contingent upon their children attending school and adherence to a vaccine schedule. In addition, women must attend the CC screening program. Despite this initiative, the regional incidence of CC has not decreased, in part due to limitations of the screening approach i.e. cytology . Access We aimed to evaluate an approach that would: increase populational coverage, detect CC and precursor lesions at a high sensitivity and, be as specific as possible, only referring women at high risk for CC. Providing a rapid feedback to the women was also seen as an extra but extremely valued asset.2, equivalent to that of Germany, France, UK and Spain altogether. The population of Amazonas is 4 million people, half of whom reside in Manaus, the state capital.We sought to investigate alternatives to the current, regional CC screening program, which uses cytological screening as recommended by the Brazilian Ministry of Health. Our focus is the interior of the Amazon State, which is the largest state in Brazil, covering a geographical area of 1,559,159,148 kmMost inhabitants are subsistence farmers, living off from what they harvest and/or extract from the river. They are referred to as “ribeirinhas”. The local economy is based on fishing but in recent years there has been investment in Coari through natural gas exploitation. This has led to mass migration (e.g. workers) of predominantly men, to the area, increasing the incidence of sexually transmitted diseases.E6™ Cervical Test, Arbor Vita Corporation, Fremont, CA, USA); OncoE6 detects the cancer causing virally encoded E6 oncoprotein of HPV types 16 and 18, which correlates to the presence of high-grade cervical lesions, as previously demonstrated in a triage study in Barretos [Our strategy consisted of self-sampling followed by an immunochromatographic test that is simple to perform , researchers from FCECON and Instituto de Medicina Tropical da Universidade de São Paulo. This study was approved by the Ethical Committee from FCECON prior to initiation; subject enrollment was conducted under full informed consent.From August 2014 to March 2015, 30 villages were visited by the research team: Itapéua, Isidório, Vila Lira, Saubinha, Esperança I, Ananidé, Nossa Senhora de Fátima, Nossa Senhora de Aparecida, Menino Jesus, Santa Maria, Nossa Senhora do Livramento, Laranjal, São José da Boa Vista, São Tomé do Patoá, Andirá, Lauro Sodré, São José do Estirão Sto Antonio, Nossa Sra Perpétuo Socorro Boa Fé, Santa Maria do Poção, Vila Fernandes, Santa Terezinha, Santo Expedito, Vila Trocaris, Amazonino Mendes, São Rdo da Costa do Trocaris, Nova República, São Pedro, Santa Rosa and Canaã. The participating villages are situated in rural locations and reachable by boat; the most remote village is located 60 km from Coari.Enrollment was spontaneous. All women that presented to the research team at the day of the visit to a locality, and manifested their will to participate in the study were enrolled, upon signature of the informed consent form.Women were offered self-sampling with Evalyn™ brush . Detailed, illustrated instructions, previously explained by a health agent, was provided to the candidates with the device. Samples were collected at home or in the local schools and health centers. Brushes were transported to Laboratório de Genética do Instituto de Saúde e Biotecnologia de Coari da Universidade Federal do Amazonas in Coari, where the OncoE6 test , DNA extraction and HPV generic PCR were performed. Maximum time in between sample collection and processing was 96 hours, during which samples were stored at 4°C.Caps were removed from brushes and bristles were cut with a disposable scalpel and placed in a microtube. Samples were lysed with a reagent contained in the kit and centrifuged at 10,000xg for 10 minutes. An aliquot of 200μL from the supernatant was incubated again with the lysis and conditioning solutions, containing high-affinity monoclonal antibodies against the protein E6 from HPV 16 and 18 conjugated with alkaline phosphatase(AP). Following a 10-minute incubation the solution was pipetted into individual cartridges containing the same monoclonal antibodies anti-E6 from HPV 16 and 18 spotted into a nitrocellulose membrane in separate bands. The lysate was allowed to migrate over the strip for 55 minutes and further processed for color development employing AP substrate for another 10 minutes.All excess supernatant and bristles were removed and the cellular pellet was re-suspended in 200 μL of DNAase free ultrapure water . The suspension was submitted for DNA extraction using the Qiagen DNA Mini kit  in accordance with the manufacturer instructions.2, dNTPs 200ηM, glycerol 5.7% and Cresol Red 250 ηg/μL. PCR products were run on a 2% agarose gel, stained with ethidium bromide and visualized under UV light irradiation.50–250 ηg of extracted DNA was added to a PCR mixture containing PGMY09/11 primers  spanningAn aliquot of the DNA obtained from all samples demonstrating a band of 450bp in the generic PCR, as above, was subjected to microarray HPV genotyping at the Virology lab from the Instituto de Medicina Tropical da Universidade de São Paulo ; the latter is based on PCR amplification of a fragment of approximately 350bp from the E1 region of HPV genomes using broad-spectrum consensus primers. Amplicons are hybridized to type-specific probes immobilized on plastic slides, allowing simultaneous detection and genotyping of 24 different HPV types , including 6 low-risk HPVs .Women who were found to be reactive either by OncoE6 or generic L1 HPV PCR were offered colposcopy. A trained colpolscopist from Manaus (MBM) performed the colposcopy in Coari.A total of 412 women agreed to participate; the age distribution and socio-demographic characteristics are presented in In general, self-administered sampling had high level of acceptance, with only 2% (N = 9) disapproving of the procedure; 95% considered it simple to perform and 80% preferred this mode of collection than by a health professional.Over the course of the study, seven visits to the villages were conducted, each taking from 1–2 days; samples were maintained dry, and refrigerated (2–8°C) in the boat for a maximum of 4 days, prior to delivery at the laboratory in Coari. Upon arrival, samples were always processed on the same day.All samples showed proper amplification of the human β-globin fragment, attesting the adequacy of the collection procedure. DNA from seventy-nine samples (18.6%) amplified the 450 bp band and were considered HPV-DNA positive, including the six OncoE6+ (see below).The 79 HPV+ DNAs were subjected to the Papillocheck™ assay; 46 were positive of which HPV 51 was the most prevalent (n = 8), followed by HPV 16 (n = 7), HPV 53 (n = 5), HPV 18, 31 and 70 , HPV 52, 56, 66 and 82 , HPV 43, 58 and 68  and HPV 11, 40, 45 and 59 . The sum surpasses 46 due to co-infections which were observed in 14 patients out of the 46 with detectable HPV DNA. Fourteen samples were negative, despite being HPV L1 positive, and 19 were found invalid following failure to amplify the endogenous gene (ADA) included in the Papillocheck method.Seventy-nine HPV-DNA positive patients were invited to undergo colposcopy, when a liquid-based cytology specimen was collected .Fifty-six completed the procedure while one patient didn`t collect a liquid-based cytology sample. Macroscopic cervical abnormalities were detected in 9 who were biopsied .Forty-one smears were classified as Negative for Intraepithelial Lesion or Malignancy (NILM), 7 as Atypical Squamous Cells of Undetermined Significance (ASCUS), 5 were low-grade squamous intraepithelial lesions (LSILs) and 2 high-grade squamous intraepithelial lesions (HSILs). Of the nine biopsies, five had evidence of cervical intraepithelial neoplasia grade 1 (CIN1), two CIN 3 and two had invasive carcinomas (one squamous and the other adenosquamous) Tables  and 5.Six samples (1.4%) were found positive for this assay, 3 for HPV 16 E6 and 3 for HPV 18 E6 . The oveCIN 1 cases were followed-up at the health unit in Coari, where they were counselled to repeat the examination in one year. The two CIN 3 and two ICCs were referred to FCECON in Manaus for definitive management. DNA was extracted from the the adenosquamous carcinoma after conization surgery and submitted for real-time PCR assay specific for HPV 18; this confirmed positivity and also revealed a single HPV 18 infection when genotyped by the Papillocheck.Over the course of the last two decades, Brazil has transitioned from a low to an upper middle-income country . This isThere are several reasons for the deficiencies of the current screening program. Foremost, low screening coverage of the target population is a major factor that underlies the failures of the CC screening program. In contrast, some women are over-screened, undergoing annual Papanicolaou testing, contrary to the Brazilian guidelines that recommends a three-years interval. This serves to deplete, limited resources that could otherwise be directed toward expanding access to those in greater need . Second,Our results showed the incidence of CC to be even higher than the estimates; 2 cases were observed in 412 women, making a raw, non age-adjusted incidence of 485/100,000! Two high-grade precursor lesions (CIN3) were detected and treated, potentially avoiding another two ICC cases. Since laboratory processing is quite simple for the OncoE6 assay, samples were able to be processed and tested at a low-technology local laboratory with reporting of results within a few days of collection. By contrast, these women reported Pap smear waits of up to a year prior to resulting.HPV NAT have been transformative given their high sensitivity to detect high-grade cervical abnormalities, yet low clinical specificity given that the majority of HPV+ women have normal cervices. In the remote geographic setting such as in our study, specificity is a high priority, given the logistic challenges of follow-up. Low specificity in CC screening can also lead to overtreatment, which may impair reproductive capacity of those submitted to surgical interventions . To thisSensitivity is central to any cancer screening test. OncoE6 missed 2 out of the 4 CIN3+ cases. One case had a NILM cytology and harbored HPV 45, a genotype not included in the version of the OncoE6 assay employed. Consequently, if we restrict the analysis to CIN3+ cases driven by HPV 16 or 18, sensitivity would increase to 66% (2/3), since an HPV 18+ adenosquamous carcinoma was negative by OncoE6. It is difficult to account for the OncoE6 failure to detect one carcinoma containing HPV 18. Histological assessment showed this to be an undifferentiated adenosquamous tumor, which may have been less likely to be driven by HPV 18 E6 synthesis.In the study of Zhao and co-workers , HPV 45 Performance of HPV NAT on the same self-collected sample and referral of all HPV-DNA+ to colposcopy, afforded insight into the incidence of CC and precursor lesions in the population investigated. PCR screening would certainly provide optimal sensitivity, but -in addition- to the aforementioned challenges, would also be technically complex under local conditions. Nonetheless, it does provide a reliable gold-standard to estimate OncoE6 clinical sensitivity.ribeirinhas, with a view toward detection of the majority of the CIN3+ cases. This could further move to self-collection+DNA screening/OncoE6 strategy by capacitating regional labs to implement automated NATs. As a model to be replicated, for several years, HIV viral load has been performed locally in all Brazilian states [A recent study  also empn states , drawingn states ,20. BothThe strategy here presented has not been evaluated for its cost-effectiveness. However, the costs were evaluated and compared to those incurred for transportation and treatment of women with ICC. Of note, most are diagnosed at FIGO grade II or higher (FCECON unpublished data). When combined with the social and economic costs of the loss of women in economic productive age, it will most likely prove to be cost-effective.Despite boasting the highest burden of ICC in Latin America, there seems to be reluctance to adopt new strategies for CC screening in Brazil with continued advocacy for the use of the Pap test. In contrast in Argentina  and severibeirinhas, while establishing permanent centers, locally, for colposcopy and treatment of precursor lesions. We believe that, by continuously promoting and improving this program, CC incidence in the Amazonas state may decline within a few years. In conjunction to HPV vaccination, which is routine for girls since 2013 in the state and was extended to boys, in the whole country, from 2017 on, eradication of CC seems an achievable goal in the next two decades.Our study mobilized many key stakeholders in CC prevention and treatment in the Amazonas state. Many are convinced by the results and the feasibility of this strategy. There are plans to expand the current approach to approximately 10,000