Ao-dake-humi is a traditional Japanese bamboo foot stimulator consisting of a half-pipe-shaped step made of bamboo used to stimulate the foot by stepping on it, and is commonly used to promote general health among the elderly in Japan. However, its efficacy has not been reported in the scientific literature. This study was performed to investigate the role of ao-dake-humi focusing on lower urinary tract symptoms (LUTS), constipation, and hypersensitivity to cold (HC).Ao-dake-humi was used twice a day for 28 days. Before and 28 days after starting ao-dake-humi use, international prostate symptom score (IPSS), quality-of-life (QoL) score, and overactive bladder symptom score (OABSS) were measured to evaluate the efficacy of ao-dake-humi on LUTS. To evaluate the objective efficacy of ao-dake-humi on LUTS, a frequency-volume chart (FVC) was plotted in LUTS patients for 3 days. A visual analogue scale (VAS) was used to evaluate the efficacy of ao-dake-humi on constipation (VAS-constipation) and HC (VAS-HC) in the participants with constipation or HC.Participants with LUTS, constipation, or HC were enrolled in this study. ao-dake-humi. The use of ao-dake-humi increased maximal bladder capacity, resulting in a significant decrease in urinary frequency as determined from the FVC. In accordance with the results of VAS-constipation and VAS-HC, both constipation and HC were significantly relieved after ao-dake-humi use.A total of 24 participants were enrolled in this study. Twenty-one participants had LUTS, 11 had constipation, and 17 participants had HC. IPSS, especially storage-subscore, QoL score and OABSS, decreased significantly after use of ao-dake-humi is safe and has therapeutic efficacy in cases of LUTS, constipation and HC. The possibility of using ao-dake-humi as physical neuromodulation therapy was shown in the management of LUTS, constipation and HC.The results of this prospective pilot study indicated that UMIN000019333  retrospectively registered. Therefore, we attempted to evaluate the safety and therapeutic efficacy of ao-dake-humi on LUTS, constipation and HC in this prospective pilot study.Lower urinary tract symptoms (LUTS) and constipation are common problems, especially among the elderly . On the This study was conducted between July 2013 and October 2015. The trial registration number is UMIN000019333 .Eligible participants were >20 y.o. with LUTS, constipation and/or HC. LUTS patients with IPSS >13 or dissatisfied with current LUTS treatments were enrolled. Constipation and HC were evaluated according to self-description. Exclusion criteria were as follows: patients who could not make the decision themselves, those with a custom of receiving foot massage, those incapable of walking by themselves, and those with a history of recurrent urinary tract infection or bladder stones. All of the LUTS patients had already received some medical care in a hospital or a private clinic. In the process of the previous management of LUTS before enrolling this trial, urinary tract infection and cancer including prostate cancer had already excluded. Subjects were also excluded if they received surgery, diagnosed malignant disease, and used other medical interventions, such as drugs, within the previous 3 months. Participants could continue to take medication for LUTS and constipation to maintain the same condition before and after the study. However, the participants were not permitted to start or stop any intervention for LUTS, constipation or HC during the study.Ao-dake-humi used in this study was made of bamboo, 40 cm in length, 8.5 cm in width, 4.5 cm in height, and almost 290 g in weight. The ao-dake-humi was brought to each participant’s home, and used twice a day, in the morning (after waking up) and evening (after taking a bath/shower or before going to bed) for 28 days. Holding something such as the wall, desk, or pillar, participants placed the arches of both feet on the ao-dake-humi, and then made repeated steps for 2 min in a set as shown in Fig. ao-dake-humi, steps were made 30–60 times/min, and participants could control the rate by themselves. If participants felt pain, they could reduce use to once a day. The rate of ao-dake-humi use was noted using a diary to evaluate the exact intervention and harmfulness of ao-dake-humi. All of the participants recorded ao-dake-humi use as “done” or “none” in the diary. Total practical rate (= number of sets performed/(2 sets  ×  28 days)) was calculated in all of the participants. Moreover, adverse events were also evaluated in all of the participants during this research.ao-dake-humi, international prostate symptom score (IPSS), quality-of-life (QoL) score, and overactive bladder symptom score (OABSS) were measured for evaluation of efficacy of ao-dake-humi on LUTS. IPSS storage, voiding, and postvoiding subscores were also assessed [ao-dake-humi on constipation (VAS-constipation) and HC (VAS-HC) in the enrolled participants with constipation or HC. VAS for constipation and HC were originally made, and were used to evaluate constipation and HC like pain scale. The line is 10 cm in length on the paper. The left edge of line is zero, and the right edge is maximal as 10 points. Zero means that patients have not any symptoms. And, 10 points means that patients have severe symptoms which patients can imagine maximally. Patients can place a vertical mark on the line to describe the severity of their symptoms intuitively. If the patients have severe symptoms, patients can put on the right part of the line. The length from zero to the point on which patients described the symptoms is treated as severity of symptoms, and the decrease or increase of length are considered as improvement or worsening of symptoms. IPSS, QoL score, OABSS, VAS-constipation, and VAS-HC was presented in Table Before and 28 days after assessed . Visual ao-dake-humi on LUTS, a frequency-volume chart (FVC) was used. The FVC on 3 continuous days was recorded in all of the enrolled LUTS participants before and 28 days after starting ao-dake-humi use. The average total voided volume, daytime voided volume, nighttime voided volume, total urinary frequency in a day, daytime urinary frequency, and nighttime urinary frequency were evaluated for each day. The average mean voided volume, maximal voided volume, and minimal voided volume were also evaluated. Nighttime micturition was defined as micturition between 10:00 pm and 6:00 am.To evaluate the objective efficacy of p < 0.05 was considered to indicate significance. The changes before and after ao-dake-humi were analysed using the paired t test.All data are presented as the means ± SEM. The data were analysed using Excel-based statistical program file, Excel TouKei , and ao-dake-humi use in the participants with LUTS. In analysis of IPSS subscores, storage and postvoiding symptom subscores were significantly improved after ao-dake-humi use. As the first step to show the efficacy of ao-dake-humi on constipation and HC, evaluation was performed in this study using only VAS-constipation and VAS-HC. In accordance with the results, of the 11 participants with constipation, subjective VAS-constipation score was improved in −31.8% after ao-dake-humi use with statistical significance. Of the 17 participants with HC, subjective score was significantly improved in −21.9% of VAS-HC after ao-dake-humi use. The results of objective evaluation are shown in Table ao-dake-humi use. Total and daytime urinary frequencies were decreased after ao-dake-humi use. These results may have been due to an increase in voided volume. Only the maximal voided volume increased significantly after ao-dake-humi use; mean and minimal voided volumes were also not significantly increased.A total of 24 participants were enrolled in this study, and their characteristics are shown in Table ao-dake-humi on HC was revealed subjectively. Moreover, constipation was also improved after ao-dake-humi use. Five of 11 participants with constipation had received drug treatment before starting this research. These results indicated that ao-dake-humi is a candidate therapeutic option to manage LUTS, constipation and HC. However, HC and constipation were evaluated on the basis of self-description using VAS. A further RCT with larger number of participants is needed.Previous reports indicated that a decrease in environmental temperature induces numerous physiological responses, including increased urinary frequency in both humans and animals , 11. PreAo-dake-humi is a Japanese traditional home health appliance based on the theory of reflexology, and can be used at home to promote general health in daily use. Ao-dake-humi consists of a half-pipe-shaped foot-step made of bamboo cut into pieces 30–40 cm in length, and is widely used in Japan. The mechanisms of ao-dake-humi promoting general health are not yet known. However, neuromodulation and acupuncture may have similar mechanisms of action on LUTS, constipation and HC. Therefore, the effect of ao-dake-humi is thought not to be due to exercise but to stimulation of afferent nerves in the foot to modulate visceral organs, such as the urinary bladder and colon. Indeed, some neuromodulation equipment has been reported for treatment of LUTS, constipation and faecal incontinence [ao-dake-humi, and our hypothesis about ao-dake-humi is described on Fig. ao-dake-humi stimulation , and is therefore easily portable, and ideal for daily use at home. Even in comparison with other similar treatments, including acupuncture and massage, ao-dake-humi has advantages. For example, the amount of stimulation can be controlled procedure-dependently in normal foot massage. In contrast, the amount of stimulation of ao-dake-humi is controlled according to bodyweight and of each patient. The average body mass index of the participants was 21.8 kg/m2, and obese participants were not included in this study. Although adequate methods should be proposed for participants with obesity in future studies, ao-dake-humi can standardise the amount of stimulation for patients. Adverse events associated with neuromodulation, such as infection, bleeding, pain, etc., have been reported [ao-dake-humi use, and 98.5% of participants achieved use of ao-dake-humi according to a review of their diaries. All of the participants wished to continue ao-dake-humi use after this study. Even the participants that complained of slight pain at commencement of this study eventually felt comfortable with ao-dake-humi stimulation. There were no severe adverse events, such as diarrhea or urinary retention, among the participants. Of course, on theoretical grounds, it is impossible for the participants to have any severe advised events associated with use of ao-dake-humi. Compared with other neuromodulators, this is the unquestionable advantage of ao-dake-humi in management of LUTS and constipation.reported , 32. In ao-dake-humi were done for 28 days. There have been no reports regarding adequate use of ao-dake-humi. Time, duration, and frequency should be evaluated in future studies. The most important limitation of this study is bias because of its single-arm nature. Subjective results, such as IPSS and OABSS, should be interpreted carefully. However, objective results from FVC indicated that ao-dake-humi has efficacy for LUTS. Of course, objective evaluation should be performed even for constipation and HC, and more objective evaluation for LUTS, including uroflowmetry, residual urine volume, and cystometry, should also be performed in future studies. Lack of objective evaluation of constipation and HC is also a limitation of this study. However, object evaluation for constipation without any intervention is difficult, and object measurement of HC has not been established yet. Further investigation is needed to evaluate the exact role of ao-dake-humi on constipation and HC. However, even with these limitations, ao-dake-humi showed statistically relevant subjective and objective results in this study, and there were no adverse events. Thus, ao-dake-humi is a candidate of therapeutic option for LUTS, constipation and HC.However, this study had some limitations. In this pilot study, 2 sets/day of 2 min of ao-dake-humi improved subjective symptoms of LUTS, constipation and HC. Ao-dake-humi also increased maximal voided volume leading to a reduction in urinary frequency without any severe adverse events.The results of this pilot study indicated that


We examined p16 expression in tumors from a population-based sample of laryngeal cancer cases diagnosed in the U.S. Samples had been previously genotyped for HPV DNA.p value=0.55). Our findings support a limited role of HPV in laryngeal carcinogenesis. p16 is not a reliable surrogate for HPV status in laryngeal cancers and is not a predictor of laryngeal cancer survival.Overall, p16 expression was observed in laryngeal tissue from 8 of 101 (7.9%) cases. p16 expression was observed in 2 of 16 (12.5%) cases previously determined to be HPV DNA positive. The two cases dually positive for p16 and HPV DNA were non-keratinizing SCC and papillary SCC tumors that were positive for genotypes 18 and 35/89, respectively. Positivity for p16 and/or HPV DNA was not associated with 5-year survival (log-rank  All patients were diagnosed in 1993–2004 within the catchment area of three population-based cancer registries De-identified, clinically annotated formalin-fixed paraffin-embedded (FFPE) tissue specimens were obtained from Residual Tissue Repositories (RTR) affiliated with the National Cancer Institute׳s Surveillance, Epidemiology, and End Results (SEER) Program 2.1H&E slides of squamous cell carcinoma cases of unspecified subtype, i.e. SCC NOS, were reviewed by a study pathologist (M.R.) for subtype assignment. SCC cases were classified as keratinizing, non-keratinizing, basaloid, verrucous, papillary, and spindle cell.2.2p16 expression was evaluated via immunohistochemistry. Sections of tumor tissue were obtained from the same FFPE blocks previously used for HPV genotyping. A p16 mouse monoclonal antibody  (dilution 1:400) was used according to the manufacturer׳s specifications. Slides were read by a study pathologist (M.R.) who was blinded to the HPV status of cases. p16 staining was evaluated based level of staining intensity , intracellular localization , staining distribution , and the proportion of tumor cells stained. Specimens exhibiting strong, diffuse nuclear and cytoplasmic staining in ≥70% of tumor cells were considered to be definitively positive for p16 based on established criteria 2.3p value <0.05 was considered to be statistically significant.Statistical analyses were conducted using SAS version 9.2. Comparison of p16 expression used the Chi-square statistic. Survival was calculated based on the time period from date of diagnosis to date of death or date of last follow-up. Overall five-year survival by p16 and HPV DNA status was evaluated using the Kaplan–Meier method and the log-rank test. All tests were two-sided and a 3The laryngeal cancer study population has been previously detailed Eight of the 101 (7.9%) of laryngeal tumors were considered to be positive for p16 based on the criteria of strong, diffuse p16 staining of the nucleus and cytoplasm in ≥70% of tumor cells. Thirty-two cases which exhibited strong, diffuse nuclear and cytoplasmic staining in fewer than 70% of tumor cells and were not considered to be p16 positive. p value=0.84) or positivity for either p16 and/or HPV DNA   HPV DNA positive laryngeal cancer cases . One p16ue=0.55) .Fig. 1p14Our findings support a limited role of HPV in laryngeal carcinogenesis. Fewer than 10% of all laryngeal tumors expressed p16 and p16 expression did not strongly correlate with HPV DNA status. In total, only a fraction (2%) of laryngeal cancers were positive for both p16 and HPV DNA. We previously observed HPV DNA in over 1 in 5 invasive laryngeal cancers. However, detection of HPV DNA alone is not indicative of a clinically relevant infection. In HPV-induced carcinogenesis, the E7 oncoprotein binds and inactivates the retinoblastoma tumor suppressor gene product, pRb Although the sample size was limited, we observed some histologic differences by p16 and HPV status. p16 positivity was most frequently found in basaloid SCC tumors, while HPV DNA positivity was highest in non-keratinizing and papillary SCC tumors. Interestingly, non-keratinizing SCC and, to a lesser extent, basaloid and papillary SCC tumors, are the histologic variants that are most common in HPV-associated oral and oropharyngeal squamous cell carcinomas The etiologic and prognostic role of HPV in oropharyngeal cancers is well-established Our findings support the evidence to date which collectively suggests that, in contrast with the well-established etiologic and prognostic role of HPV in oropharyngeal malignancies, its role in laryngeal cancers is comparatively limited


The NHS Cervical Screening Programme is now using human papillomavirus (HPV) testing as the primary test in six sentinel sites in England, with the intention of rolling this out across the whole of England. Previous research evaluating HPV testing in the cervical screening context suggests that an HPV-positive result may increase anxiety beyond that associated with abnormal cytology, but this has not been explored in the context of primary HPV testing. The main aim of this study is to explore the impact of the HPV primary screening programme on anxiety and distress.A cross-sectional between-groups design  will be employed to assess the psychological impact of different HPV and cytology results at three time points: shortly after receiving the results, and 6 and 12 months later. Women will fall into one of six groups based on their screening results. The primary outcomes will be anxiety and general distress. Secondary outcomes will include understanding of screening results, perceived risk of cervical cancer, psychosexual functioning, intention to attend future screening and knowledge of HPV. General linear modelling will be used to test for differences between groups and changes over the three time points.Health Research Authority approval was received on 26 September 2016. Ethical approval was received from London- Surrey Borders NHS Research Ethics Committee on 30 August 2016. Section 251 approval was received from the Confidentiality Advisory Group on 24 August 2016. Results will be disseminated via peer-reviewed publication and presentation at national and international conferences. This will be the first study to evaluate the psychological aspects of human papillomavirus (HPV) primary testing in routine cervical screening in England.This psychological evaluation will complement epidemiological and cost-effectiveness evaluations of HPV primary testing within the National Health Service Cervical Screening Programme (NHSCSP).The findings will be very timely, given that the UK Department of Health has recently announced its intention to roll out HPV primary testing nationally. The results of this study will most likely directly inform NHSCSP patient invitation letters, results letters and information materials.A cross-sectional between-groups design will be employed, which limits inferences of causality between outcomes. However, this design will allow for an overview of women's responses to receiving different HPV/cytology test results in practice, and follows the same design as adopted in previous psychological evaluations within the NHSCSP.Self-selection bias and an anticipated low response rate is likely to generate a sample that is not wholly representative of NHSCSP participants.In England, the National Health Service Cervical Screening Programme (NHSCSP) aims to prevent cervical cancer by detecting and treating precancerous cervical abnormalities. In recent years, the programme, which has historically used cytology to identify abnormalities in exfoliated cells, has evolved to incorporate the use of human papillomavirus (HPV) DNA testing. In 2010, HPV DNA testing was adopted as a means of triaging borderline and low grade cytology results, and as a test of cure following treatment of cervical intraepithelial neoplasia (CIN).HPV is a highly prevalent sexually transmitted infection; high-risk types are now accepted to be the main aetiological factor in the development of cervical cancer.HPV testing has a high negative predictive value, which means that there is the possibility to reassure women who are concerned or anxious about developing cervical cancer and, potentially, to increase the interval between screening tests. Since 2013, the NHSCSP has been using primary HPV testing across six sites in England, and the Department of Health has recently announced its intention to roll this out nationally.10The evidence is mixed regarding whether HPV testing in the context of cervical screening is associated with adverse psychological effects. A cross-sectional evaluation of HPV triage in the NHSCSP found temporary adverse psychological effects, whereby increased anxiety, distress and concern were present shortly after women received HPV-positive results, but not at 6 months follow-up.4Thus, although previous research has suggested a trend towards increased anxiety and distress associated with HPV-positive results, the psychological impact is not clear in the context of HPV primary testing, where communication of HPV results to all women entering the programme will be routine and there will be far greater numbers of women receiving hrHPV-positive results compared with HPV triage for low-grade and borderline cytology. Previous research has indicated poor knowledge and understanding of the link between HPV and cervical cancer, and between HPV and sexual activity, among women in the UK.With changes to the protocol for screening and follow-up, it is important that psychological factors are evaluated to help determine the information needs and support required for women engaging in HPV primary testing. Information materials for HPV primary testing have already been developed by NHSCSP.In line with a previous psychological evaluation of HPV triage within the NHSCSP,Epidemiological and cost-effectiveness analyses of HPV primary testing are already under way. This study protocol is for an evaluation of the psychological aspects of introducing primary HPV testing into the NHSCSP.A cross-sectional between-groups design will be employed to assess women at baseline (shortly after receiving their screening result), 6 months postscreening result and 12 months postscreening result.Participants will include women aged 25–64 years who have taken part in the NHSCSP in one of five sites where HPV primary testing has been introduced: North London, Sheffield, Norfolk and Norwich, Liverpool and Manchester NHS Trusts.Eligible women will include those who have received test results within the recruitment period at each NHS site (∼12 weeks recruitment at each).We will recruit three groups of women following their first HPV test, including those who test negative for HPV, those who are HPV positive with normal cytology and those who are HPV positive with abnormal cytology (groups 1 to 3 in Eligible patients will be identified by members of staff in cytology departments in NHS laboratories at each of the participating sites. University College London (UCL) will communicate numbers needed in each group to each laboratory as the study progresses, proportionate to the numbers of results processed at each laboratory.NHS staff will allocate each potential participant a unique identity number, and link this to the patient's name and address. Section 251 approval has been granted to the NHS to upload this information to a secure printing and mailing company (CFH Docmail) for the purposes of contacting participants. Docmail is contractually bound to comply with the Data Protection Act (1998) and securely destroy these data within 30 days of receipt.Potential participants will be mailed invitation packs to their home address. Invitation packs will include an invitation letter, participant information sheet, consent form and a baseline questionnaire booklet. If participants have not returned the questionnaire after 3 weeks, Docmail will send a reminder pack containing the same documents. Those who opt to take part can do so by returning a completed consent form and questionnaire booklet to UCL.Participants will also be mailed postal questionnaire packs at 6 and 12 months follow-up. Again, they will be sent a reminder pack containing a reminder letter and another copy of the questionnaire 3 weeks later.Data from NHS clinical records:Patient age, index of multiple deprivation score (derived from postcode), date of most recent cervical screen, date of last (previous) cervical screen, number of previous cervical screens and test results will be transferred as population data to UCL from each NHS site for all potential participants approached, with the exception of patients who have opted out. These data will contain no identifiable information; data will be pseudonymised using unique identity numbers. These additional data sets will include survey non-responders to allow for examination of response biases in relation to demographic and screening factors.State anxiety, measured by the State Trait Anxiety Inventory (STAI-6),HPV and cytology screening results , education level, NHS site, previous screening history and HPV vaccine status will be collected for descriptive information and as potential control factors. See The study has been powered to detect a small-to-medium between-group difference (f=0.14) in anxiety (as measured by the STAI-6).Assuming an initial response rate of 35%, with 75% of initial responders returning a second questionnaire at 6-month follow-up, and 75% of responders at 6 months completing a third questionnaire at 12 months, we plan to approach 3415 participants to achieve the target sample size. Response rate will be monitored as the study progresses so that the number of women approached at baseline can be adjusted if the response rate is higher or lower than expected (within our funding constraints).Data will be coded and analysed using SPSS, R and Stata. An α level of p<0.05 will be used throughout.Preliminary analyses  and χ²) will be conducted to explore descriptive statistics and to identify significant group differences, as potential control measures, for age, index of multiple deprivation, pilot site, screening result, previous screening history, HPV vaccine status, marital status, ethnicity and educational attainment. Primary analyses will comprise between-groups ANOVAs to explore whether anxiety and general distress differ between screening result groups shortly after initial presentation of screening result (baseline).Mixed ANOVAs will be conducted to explore whether differences in anxiety and general distress are observed between screening result groups over time .General linear modelling will be conducted to consider whether understanding of screening results, knowledge of HPV, perceived risk of developing cervical cancer, concern about screening result, psychosexual functioning and intention to engage in future screening differ between screening result groups for secondary analyses.Health-related quality of life data will be analysed in the health economic cost-effectiveness evaluation .Post hoc comparisons will be conducted where appropriate and effect sizes will be calculated.This psychological evaluation of HPV primary testing within the NHSCSP will provide evidence about the psychological consequences of testing positive for HPV in this context and is expected to show that the negative consequences are minimal and short-lived, as has been found when HPV testing is used to triage women.In addition, we will be gathering certain population-level data from NHS databases on all women approached to take part in this study, including index of multiple deprivation score, age, test results and cervical screening history. From this information, along with questionnaire data collected from study participants, we will explore predictive relationships between outcomes. This may help identify certain groups of women likely to need additional support. For example, previous research has suggested that younger age and lower understanding of the meaning of test results predicts higher anxiety among women who are HPV positive.We will also be asking women to self-report their test results in addition to collecting the same information from NHS clinical databases. This will allow for direct comparison between women's understanding of their test results and objective clinical data. From these comparisons, we will be able to explore whether women accurately interpret the meaning of their HPV and cytology test results.We plan to publish the results of this study in two peer-reviewed journal articles. In the first paper, we will report between-group differences at baseline for all outcomes. In the second paper, we will report outcomes which are relevant to analyses over time (6 and 12 month follow-up) and explore predictive relationships. Results will also be disseminated through presentations at national and international conferences and will be communicated to the NHSCSP and relevant third sector organisations, such as Jo's Cervical Cancer Trust.


Sub-Saharan African countries are marked by a high incidence of cervical cancer. Madagascar ranks 11th among the countries with the highest cervical cancer incidence worldwide.The aim of the study was to evaluate the performances of digital smartphone-based visual inspection with acetic acid (D-VIA) and Lugol’s iodine (D-VILI) for diagnosing cervical precancer and cancer.Human papillomavirus (HPV)-positive women recruited through a cervical screening campaign had D-VIA and D-VILI examinations with endocervical curettage (ECC) and cervical biopsy. Three images were captured for each woman  using a smartphone camera. The images were randomly coded and distributed on 2 online databases (Google Forms). The D-VIA form included native and D-VIA images, and the D-VILI form included native and D-VILI images. Pathological cases were defined as cervical intraepithelial neoplasia grade 2 or worse (CIN2+). Physicians rated the images as non-pathological or pathological. Using the ECC and cervical biopsy results as references, the sensitivity and specificity of D-VIA and D-VILI examinations for each and all physicians were calculated.P=.009). In contrast, the specificity was higher for the D-VILI interpretations  than for the D-VIA interpretations .Altogether, 15 clinicians assessed 240 images. Sensitivity was higher for the D-VIA interpretations  than for the D-VILI interpretations (78.8%; 95% CI 54.1-92.1; Smartphone-based image for triage of HPV-positive women is more accurate for detecting CIN2+ lesions with D-VIA than D-VILI, although with a small loss of specificity. Sub-Saharan African countries are marked by a high incidence of cervical cancer . MadagasBecause of the long interval between the initial human papilloma virus (HPV) infection and the development of cervical cancer, screening has proven to be largely effective in reducing the incidence of cervical cancer in industrialized countries . In low-Given the concerns about the suboptimal sensitivity of VIA/VILI tests and the lack of a quality assurance system, the use of digital VIA (D-VIA) and D-VILI is a promising choice for LMICs. Smartphone cameras are easy to use, have excellent image quality, and by sending the images to other on-site and off-site experts, they offer the possibility to obtain real-time feedback.A previous study conducted in Madagascar has shown that off-site detection of cervical lesions based on the evaluation of smartphone photographs was more reliable than on-site diagnosis alone . The aimThe cervical cancer screening campaign took place in the Saint Damien Healthcare Centre in Ambanja, Madagascar and in five dispensaries in the surrounding rural areas between February and October 2015. As a means of primary screening, women were asked to collect a vaginal self-sample with a sterile swab . The samples were then analysed in Ambanja by a point-of-care HPV assay . Women who tested positive for high-risk HPV genotypes were invited to the Saint Damien Healthcare Centre to undergo a gynecological examination. Women were included in the study if they were aged between 30 to 69 years, HPV-positive for high-risk HPV genotypes, able to understand study procedures, and voluntarily participated by signing the informed consent form. Exclusion criteria included a previous hysterectomy, conditions that could interfere with visualization of the cervix, pregnancy over 20 weeks, or that they could not comply with study protocol. This cross-sectional analysis included data from HPV-positive women with a disease prevalence corresponding to that of real-life conditions .All HPV-positive patients underwent digital VIA/VILI examinations, which were carried out on the same day or a few weeks following self-HPV testing. Three images per examination were captured using a smartphone . The first image corresponded to the native cervix. The second was captured one minute after application of a 5% acetic acid solution and the third following application of Lugol’s iodine. Cervical (Papanicolaou) smears, endocervical curettage and an average of 2 biopsies were performed on all patients. If no lesion was identified, a random cervical biopsy was performed at the 6 o’clock site. Patients for whom a pathological cervical lesion (CIN2+) was suspected based on the immediate evaluation by the on-site expert were treated with cold coagulation or large electrosurgical excision procedure (LEEP) on the same day. A hysterectomy was scheduled for the following days when invasive cervical cancer was suspected, if operable. Women who were not promptly treated on site but who were later diagnosed histologically with cervical dysplasia were called again to the Saint Damien Healthcare Centre for further management.The GeneXpert device was used on site for HPV DNA detection. Using a polymerase chain reaction method, this test detects 14 types of high-risk HPV. The results are divided into three sections: HPV 16, HPV 18/45, and 11 other high-risk HPV types . Endocervical samples were collected using an endocervical brush. A cervical biopsy forceps was used for histological specimen collection. Both samples were fixed in liquid formalin. The reference standard for the disease was the histological evaluation, which was performed in Geneva, Switzerland. The results were interpreted according to the WHO 2014 classification as Low-grade squamous intraepithelial lesions (LSIL) and High-grade squamous intraepithelial lesions (HSIL) and sub-classified as grade 1, 2, or 3 CIN.Throughout the pelvic examination, photographs were obtained at a distance of 10-15 cm of the cervix, with 3.3-3.8× optical zoom and in flash mode. The two smartphones, Samsung Galaxy S4 and S5, were chosen for their high-quality cameras . These devices allow highly precise and detailed visualization of the cervix after zooming and focusing in on the target. To improve the stability and quality of the images, the smartphone was fixed to the ground with a tripod and a support.The images were uploaded onto two online databases (Google forms). One form included the native and D-VIA images. The second included the native and D-VILI images. The images were randomly coded and distributed on the two databases so that the D-VIA and D-VILI images of each patient could not be linked to one another. Overall, 15 physicians with different clinical backgrounds and experience, blind to the histological and HPV genotypes, were asked to determine (for each patient in each of the two Google forms) whether the images of the cervix were non-pathological <CIN2) or pathological (CIN2+) using IARC Reference Chart for Visual Inspection with acetic acid (VIA) and Lugol’s iodine (VILI).  or pathoThe sensitivity and specificity for the detection of CIN2+ were calculated for the D-VIA and D-VILI interpretations of each rater. The correlation coefficients between screener-specific sensitivities and specificities were assessed for both D-VIA and D-VILI (Spearman coefficient of correlation). To assess the global sensitivity and specificity , we used logistic regression models with mixed effects to account for repeated measures: a random intercept was introduced into the model, and the random effects for patients and readers were crossed. Models were applied to patients with a positive biopsy to assess sensitivity and to patients with a negative biopsy to assess specificity. Additional logistic regression models with mixed effects were used to test a difference in sensitivity or specificity between expert screeners and novice screeners and to test a difference between D-VIA and D-VILI.All statistical tests were two-sided, with a type 1 error of 0.05. Statistical analyses were performed with R Core Team 2015 software  and Stata13 IC software .The study was approved by the Malagasy National Commission for the Ethics of Science and Technology and the Ethical Cantonal Board of Geneva, Switzerland (CER: 14–071). The trial has been registered on clinicaltrials.gov (NCT02693379).Among the 1041 participants screened for HPV, 231 were HPV-positive (22.2%) and 584 HPV-negative (77.8%). Among HPV-positive women, 187 underwent digital VIA/VILI testing in the Saint Damien Health Care Centre. A total of 561 images were captured during the examination. A total of 120 out of 187 (64.2%) sets of photographs of women who underwent digital VIA/VILI were considered of good quality and were included in the study. Images were excluded because of insufficient focus or inadequate magnification. The resulting disease prevalence in our study corresponds to that of an unscreened asymptomatic population (10-15%) [The overall distribution of cervical disease among the 120 patients was 14 (11.6%) pathological cases (CIN2+) that included 4 (3.3%) cases of invasive cancer. There were 7 (5.8%) cases of CIN3, 3 (2.5%) cases of CIN2, and 4 (3.3%) cases of CIN1. In all, 102 (85.0%) cases were negative for any cervical lesion. CIN1 lesions were considered and managed as negative cases. Overall, 14 out of 65 (21.5%) CIN2+ cases were promptly treated with thermocoagulation or conisation, whereas 51 out of 64 (79.7%) cases were overtreated.The raters’ mean age was 39.7 years (SD 8.3). Their mean number of years of experience in clinical practice was 11.0 years (SD 6.5). P=.009). The overall specificity was 50.4% (95% CI 35.9-64.8) for D-VIA and 56.4% (95% CI 38.3-72.9) for D-VILI (P=.005).The diagnostic performance of D-VIA and D-VILI varied broadly among raters: the overall sensitivity was 81.6-98.3% for D-VIA and 54.1-92.1% for D-VILI. The specificity was 35.9-64.8% for D-VIA and 38.3-72.9% for D-VILI. For both techniques, the specificity decreased as the sensitivity increased (ρ=−0.59 for D-VIA and ρ=−0.80 for D-VILI). The overall sensitivity was 94.1% (95% CI 81.6-98.3) for D-VIA and 78.8% (95% CI 54.1-92.1) for D-VILI (P=.04). No statistically significant differences between experts and novices were found concerning sensitivity. Among the expert raters, D-VIA had higher sensitivity than D-VILI (P=.01) and lower specificity (P=.02). In novice raters, the trend of the findings was the same, but the difference in specificities and sensitivities were not statistically significant . P values for D-VIA and D-VILI among all raters, experts, and novices.The specificity was higher for experts than novices, but the difference was statistically significant only for D-VIA  [In a low-income setting, such as that of Madagascar, cervical cancer screening tools that are commonly used in industrialized countries such as Pap smear and colposcopy, coupled with the continuous training of health care providers, are unlikely to be systematically available. The introduction of a smartphone-based approach for cervical cancer screening in such settings would allow to overcome some of the barriers to the implementation of screening programs in developing countries. The capture of cervical images with the smartphone camera allows the user to look back at either the native, post-VIA, or post-VILI cervix and to magnify the pictures in order to see them more closely before deciding whether or not to treat. In addition, the automatic saving of digital images on the smartphone allows the on-site, often less experienced and less qualified healthcare worker, to seek advice from long-distance off-site specialists .Moreover, the use of automated phone applications is on the rise and might improve and facilitate CC screening in LMICs by providing a system to classify the images and to guide health workers through their decision-making algorithm . Such moThe strengths of our study were the large number of consecutive cases included in a “triage context” and the fact that all of them underwent ECC and cervical biopsy, which served as the gold standard. In addition, patient recruitment and data collection took place in a real-world setting, which entails several consecutive, unselected cases.Limitations that need to be addressed are the fact that D-VIA and D-VILI images of each patient were assessed separately rather than consecutively. Another limitation is the fact that most of our raters were medical doctors, which does not allow us to validate our results for all healthcare workers, such as nurses and midwives. The technical difficulties encountered in obtaining high quality images also did not allow us to include pictures of all the patients in the analysis. Additional practice is necessary in order to improve the quality of the images before transferring the smartphone use on to a real-life setting.In conclusion, our study emphasizes the higher sensitivity of D-VIA when compared to D-VILI for detecting precancerous lesions, although at the cost of slightly lower specificity. Further research should focus on comparing the performance of these two digital screening techniques with naked-eye methods and on assessing their feasibility in a low-resource context.


Offering human papillomavirus (HPV) vaccination to men who have sex with men up to age 40 years via genitourinary clinics will have a large impact on HPV-related diseases and is likely to be cost-effective. Men who have sex with men (MSM) have a high lifetime risk of anogenital warts and cancers related to infection with human papillomavirus (HPV). They also benefit less from herd protection than heterosexual males in settings with female-only HPV vaccination.We evaluated the potential health impact and cost-effectiveness of offering vaccination to MSM who visit genitourinary medicine (GUM) clinics. We used a mathematical model of HPV 6/11/16/18 sexual transmission within an MSM population in England, parameterized with sexual behaviour, GUM attendance, HPV prevalence, HIV prevalence, warts, and cancer incidence data. Interventions considered were offering HPV vaccination to either HIV-positive MSM or MSM regardless of HIV status, for age bands 16–25, 16–30, 16–35, and 16–40 years.Substantial declines in anogenital warts and male HPV-related cancer incidence are projected to occur following an offer of vaccination to MSM. MSM not attending GUM clinics will partially benefit from herd protection. Offering vaccination to HIV-positive MSM up to age 40 is likely to be cost-effective if vaccine procurement and administration costs are below £96.50 a dose. At £48 a dose, offering vaccination to all MSM up to age 40 is likely to be cost-effective.Quadrivalent HPV vaccination of MSM via GUM clinics is likely to be an effective and cost-effective way of reducing the burden of HPV-related disease in MSM. Human papillomavirus (HPV) infection causes cervical, anal, penile, oropharyngeal, and oral cavity cancers as well as anogenital warts . Most hiAlthough most economic evaluations of gender-neutral vaccination have only considered heterosexual men, more recent evaluations have incorporated consideration of their impact on MSM . Even thIn England, HPV vaccination has been offered to girls aged 12–13 since September 2008, with uptake exceeding 80%. At these coverage levels, adding boys to a girls-only HPV vaccination program is unlikely to be cost-effective [To address this gap, we have evaluated the potential health impact and cost-effectiveness of offering vaccination to MSM via GUM clinics, beginning in year 2016, using a model of HPV 6/11/16/18 sexual transmission within an MSM population, and data from these clinics in England.Our analysis consisted of interlinked models of: (i) same-sex HPV 6/11/16/18 transmission within an MSM population as well as the impact of vaccination, (ii) natural history of HPV infection and disease , and (iii) costs and quality-adjusted life year (QALY) implications of disease outcomes see . A briefThe third National Survey of Sexual Attitudes and Lifestyles   suggestsSimilar to our previous model of heterosexual HPV 6/11/16/18 transmission , we use Disease outcomes modeled were anogenital warts (for HPV 6/11) and all male cancers (for HPV 16/18) classified by the International Agency for Research on Cancer (IARC) as having evidence of causation by HPV 16, that is, cancers of the anus, penis, oropharynx, and oral cavity [For warts, we adapted a previous model , in whicWe considered a strategy of offering quadrivalent HPV vaccination to either HIV-positive MSM or MSM regardless of HIV status, and to either 16–25, 16–30, 16–35, or 16–40 year olds. Offering vaccination outside this age range was not modelled because of limited GUM clinic attendance data, and in the case of under 16s, confidentiality constraints.When vaccination is initiated, all MSM of the eligible age range and HIV status attending GUM clinics are offered vaccination. At subsequent time steps, vaccination is offered only to MSM attending GUM clinics for the first time since the selective vaccination program was initiated. GUM attendance rates were based on 2009–2012 clinic returns , stratifQuadrivalent vaccine efficacy against persistent infection from the naive-to-relevant type cohort in trials in males was used . We assuWe estimated changes in costs  and quality adjusted life years (QALYs) following vaccination. The economic evaluation followed the reference case of the National Institute for Health and Care Excellence , as inteWe constructed 5000 meta-scenarios by altering assumptions governing sexual partnership formation, HPV epidemiology and disease natural history for each HPV type. Each meta-scenario was fitted by varying transmission probability per partnership to minimize the sum of squared residuals between data and model outcomes by age and HIV status . The 1000 best-fitting meta-scenarios were paired with 1000 sets of parameters drawn using Latin hypercube sampling from the distribution of cost and QALY consequences of HPV-related disease.In addition to probabilistic sensitivity analyses, we also considered the following alternative scenarios: (i) Low/high vaccine efficacy, based on the lower/upper limits of the confidence interval around efficacy , (ii) VaResults show rapid declines in warts incidence by 35% (interquartile range 32%–39%) within 5 years of initiating vaccination for 16–40 year old MSM GUM attendees and 15% (12%-18%) if only HIV-positive 16–40 year old MSM are vaccinated . Herd prWith the quadrivalent vaccine costing £96.50/dose, the best option with an incremental cost-effectiveness ratio (ICER) below £20 000/QALY gained would be to vaccinate all HIV-positive MSM 16–40 years . If the Multivariate uncertainty analysis suggests this conclusion is robust . JCVI considers vaccination cost-effective if the most plausible ICER falls below £20 000/QALY gained, and there is no more than a 10% probability that the ICER exceeds £30 000/QALY gained . At a vaUsing the bivalent vaccine instead of the quadrivalent vaccine is only likely to be the most cost-effective option if the bivalent vaccine is £41 or cheaper per dose than the quadrivalent vaccine.Quadrivalent HPV vaccination of 16–40 year old MSM attending GUM clinics is cost-effective if the vaccine can be procured and delivered at no more than £63/dose in the base case . Although HPV vaccine tender prices in England are unknown, equivalent prices in high-income countries submitting data to the World Health Organization range from £20.90 to £48.00 , while dBesides vaccine costs, results are sensitive to uncertainty in the disutility caused by warts or anal cancer, and the cost of treating anal cancer. Warts’ disutility is especially influential and is driven particularly by variability not just in the measured quality of life of someone with warts but also the duration of time spent with warts .The cost-effectiveness of MSM vaccination may be even better than reported due to additional benefits of vaccination not fully captured. First, although we assumed that HIV increases the rate of HPV-related disease progression, we assumed for computational simplicity that HPV has no effect on HIV acquisition, despite some evidence to the contrary . Second,Our modelling has limitations because we model compartments of the MSM population rather than discrete individuals. In particular, we divide the population into 3 sexual activity tiers, within which individuals have the same number of partners. Thus, we do not separately model those rare individuals with many partners, even compared to the 5% most same-sex active individuals. In addition, we do not vary all parameters in the model, such as those obtained from Natsal-3 or GUMCAD. However, by widely varying other correlated epidemiological and vaccination uptake parameters, we likely capture the uncertainty in outcomes. Furthermore, the data requirements of an individual-based model may not be justified given the sparsity of data on MSM. Lastly, we do not model separate disease risks for diagnosed and undiagnosed HIV-positive MSM.Only 2 cost-effectiveness analyses of selective MSM HPV vaccination programs have been previously conducted, both in the United States , 37. BotOur work suggests that MSM HPV vaccination can be delivered in a feasible and cost-effective way in settings where MSM regularly attend specialist sexual health services. Although our analysis considered GUM clinics only, the results likely apply to other sexual health service providers able to deliver vaccines attended by MSM with a similar HPV infection risk profile. Although we only considered vaccination between the ages of 16 and 40 due to data limitations, vaccinating younger MSM is highly likely to also be cost-effective, and our analysis does not preclude that vaccinating beyond age 40 could also be cost-effective.Although GUM clinic-based HPV vaccination for MSM was found to be cost-effective with large impact on disease incidence, the largest reductions in HPV-related disease will only occur through universal vaccination of 12–13 year-old boys, because many MSM initiate same-sex activity and hence are at risk of HPV infection before attending such clinics. However, introducing gender-neutral vaccination does not preclude offering vaccination to MSM up to a higher age, particularly because many MSM were not born in England and may be missed by an adolescent program.Supplementary DataClick here for additional data file.


In retrospective observational study, six RRP patients who received the quadrivalent HPV vaccine and whose HPV seroreactivity was measured were included. Multiplex HPV Serology was used to determine HPV-specific antibodies pre- and post-vaccination. Surgical interventions and patient records were analyzed. Five HPV6 and 1 HPV11 infected patient were included. Mean antibody reactivity against the associated HPV type rose from 1125 median fluorescence intensity (MFI) pre-vaccination to 4690 MFI post-vaccination (p < 0.001). Median post-vaccination follow-up was 4 years. Poisson regression analysis showed that the quadrivalent HPV vaccine decreased the incidence rate of surgeries. The immune system of RRP patients is able to increase antibody reactivity against the associated HPV type. A double blind randomized controlled trial is needed to determine whether this immunological increase can cause decrease in number of surgeries.Aim of this study was to explore influence of the quadrivalent HPV vaccine (Gardasil Papillomavirus vaccines are generally safe and highly effective  represents 95 % confidence interval. p value of <0.05 was considered statistically significant.Categorical variables are presented as number (percentage). Normally distributed variables are presented as mean ± standard deviation. Data presented as . This meant that the mean number of surgical interventions in a specific time frame after vaccination decreased with approximately a factor of 3.3 , the sample size for detecting reduction in the mean number of surgical interventions after vaccination with a factor of 2 was calculated. If a theoretical trial period would be 1 year, the total number of patients in each group should be 57. If a trial would be extended to 1.5 years, the number of patients in each group should be 38, while for a trial of 2 years the number of patients should be 29 in each group.Many therapies have been tried to diminish disease burden of RRP. Nonetheless there is still no curative therapy for RRP patients. The primary goal of this exploratory study was to monitor effectiveness of the quadrivalent HPV vaccine during treatment of RRP as determined by increased seroreactivity. This is the first study that shows that vaccination of a group of RRP patients with the quadrivalent HPV vaccine results in increased seroreactivity against associated viruses.Five of six patients were infected with low-risk HPV6, one was infected with low-risk HPV11. The ratio between HPV6 and HPV11 differs per cohort , probablThe presented data show that RRP patients with HPV6 and HPV11 have low levels of seroreactivity against these viruses despite many years of disease. After administration of the quadrivalent HPV vaccine HPV seroreactivity against the causal HPV type rose in every patient. The vaccination induced higher seroreactivity than the natural infection in the same patients. Theoretically this induced increase in seroreactivity might influence the clinical course of RRP by intensifying immune response and preventing re-infection.This study is the first study to measure seroreactivity in a group of RRP patients. Results could be biased due to the small sample size and short follow-up. An effect of other adjuvant therapy on immunological response was not expected as patients did not receive any adjuvant therapy 1 month before, neither during or after vaccination. More research is needed to analyze the duration of the immunological response.Chirila et al. concluded that the quadrivalent HPV vaccine was effective to diminish the recurrence rate of RRP in 85 % of patients, although that study was retrospective and lacked a control group . FurtherRRP patients increase seroreactivity against the quadrivalent HPV vaccine, regardless of their age, age of onset, HPV type and severity of disease. Antibody reactivities to the associated viruses of all patients rose significantly. A double-blinded randomized controlled trial is needed to evaluate the effect of this vaccination on the clinical course. The quadrivalent HPV vaccine could be of future help in the treatment of RRP, as this research showed that vaccination causes a robust immunological response.


In addition to being useful for classification, sequence variations of human Papillomavirus (HPV) genotypes have been implicated in differential oncogenic potential and a differential association with the different histological forms of invasive cervical cancer. These associations have also been indicated for HPV genotype lineages and sub-lineages. In order to better understand the potential implications of lineage variation in the occurrence of cervical cancers in Ghana, we studied the lineages of the three most prevalent HPV genotypes among women with normal cytology as baseline to further studies.Of previously collected self- and health personnel-collected cervical specimen, 54, which were positive for HPV16, 18 and 45, were selected and the long control region (LCR) of each HPV genotype was separately amplified by a nested PCR. DNA sequences of 41 isolates obtained with the forward and reverse primers by Sanger sequencing were analysed.Nucleotide sequence variations of the HPV16 genotypes were observed at 30 positions within the LCR (7460 – 7840). Of these, 19 were the known variations for the lineages B and C (African lineages), while the other 11 positions had variations unique to the HPV16 isolates of this study. For the HPV18 isolates, the variations were at 35 positions, 22 of which were known variations of Africa lineages and the other 13 were unique variations observed for the isolates obtained in this study (at positions 7799 and 7813). HPV45 isolates had variations at 35 positions and 2 (positions 7114 and 97) were unique to the isolates of this study.This study provides the first data on the lineages of HPV 16, 18 and 45 isolates from Ghana. Although the study did not obtain full genome sequence data for a comprehensive comparison with known lineages, these genotypes were predominately of the Africa lineages and had some unique sequence variations at positions that suggest potential oncogenic implications. These data will be useful for comparison with lineages of these genotypes from women with cervical lesion and all the forms of invasive cervical cancers.The online version of this article (doi:10.1186/s12985-017-0755-z) contains supplementary material, which is available to authorized users. With an estimated 3052 new cases of cervical cancer in Ghana in the year 2012, cervical cancer is one of the two leading cause of cancer incidence and mortality in Ghana and in most sub-Saharan African countries. Cervical cancer is a significant health concern in Ghana in light of the facts that in spite of its high burden, cervical cancer screening programmes are still lacking. In the absence of empirical cancer registry based data, the estimated age-standardized cervical cancer incidence rate for Ghana  indicates a possible difference in the cervical cancer burden among close neighbours; Benin , Togo , Burkina Faso  and Cote d’Ivoire  [These geographical variations in the incidence of cervical cancer are also seen in the prevalence of its etiological agent, which is the human Papillomavirus (HPV). In spite of these variations, HPV genotypes 16, 18 and 45 together are responsible for more than 80% of cervical cancer globally –4. MolecSpecifically, variants of HPV16 have been classified most recently, as 4 phylogenetic lineages based on LCR and E6 open reading frames of its genome. These are, a) lineage A , consisting of at least the sub-lineages A1, A2, A3,  and A4 ; b) Lineage B (known previously as African-1 (Afr-1) lineage), consisting of at least two sub-lineages B1 (Afr-1a) and B2 (Afr-1b); c) Lineage C (known previously as African-2 (Afr-2) lineage), previously consisting of the sub-lineages Afr-2a and Afr-2b, and d) lineage D , consisting of at least the sub-lineages, D1 (known previously as North-American (NA) lineage), D2 (known previously as Asian-American-1 (AA1) lineage), and D3 (Asian-American-2 (AA2) lineage). These groups of lineages have more than 95% sequence homology in the long control region (LCR) , 12–14.For HPV18 variants, two phylogenetic lineages (previously known as non-African and African) were identified based on full genome sequence analysis in an older classification. The non-African lineages had two sub-lineages namely, European (E) and Asian-American (AA) while the African lineage also had two sub-lineages, namely African 1 (Afr-1) and African-2 (Afr-2) . HoweverThe long control region (LCR) of the HPV genome is a 850 bp regulatory region that includes a section for regulating the transcription of HPV genes through interactions with many cellular and viral factors . TherefoIt is therefore important for our population and in order to enhance cervical cancer screening, to study the variants of the reported most prevalent HPV genotypes in Ghana, to better understand the potential of developing cervical cancers. Although there are limited empirical data on the prevalence of human Papillomavirus (HPV) in the general population, the most prevalent HPV genotypes in Ghana are HPV 16, 18 59, and 45. Few hospital based studies on HPV and its distribution in cancers have reported, for instance, a 10% HPV prevalence among 75 women screened for cervical cancer in a tertiary hospital . Three oPreviously collected cervical specimen of women with normal cytology results, during a community based cervical cancer screening programme, were used for this study. The specimen positive for HPV16, 18 and 45 (either as a single infection or in a multiple infection) were selected and the long control region (LCR) of each HPV was separately amplified by a nested PCR to confirm the genotype present in the specimen. A total of 20 HPV16 positive specimens, 15 HPV18 positive specimens and 18 HPV45 positive specimens were used.DNA was extracted from these specimen on a MagNA Pure LC automated system  using 200 μL of the cell suspension and the MagNA Pure DNA Extraction Kit  according to the manufactures specification with a modification of an addition of 15 μL of RNase to the lysis buffer for each specimen. The negative controls included for each set of extraction were PBS, DNase/RNase free water, and DNAGard, while the positive control was a suspension of SiHa and HeLa cells with an integrated HPV16 and HPV18 genome respectively. The specimen/DNA quality was assessed by the amplification of the human RNase H gene in 10 μL of DNA extract and analysed with Light Cycler 480 and related software .2, 1.25 μM of each of the two primers, and 5U of AmpliTaq DNA polymerase. The amplifications were achieved with the following conditions; an initial denaturation step at 95 °C for 5 min (10 min for HPV45) was followed by 60 cycles (40 cycles for HPV45) of denaturation at 95 °C for 30 s, primer annealing at 65 °C (55 °C for HPV45) for 30 s and an elongation at 72 °C for 30 s followed with a 7 min final extension at 72 °C and holding the temperature at 4 °C. Extracted DNA form Hela cells, SiHa cells with integrated HPV18, HPV16 genome respectively and confirmed clinical isolate of HPV45 were used as positive control and additional PCR water negative controls were used in each set of amplification.Using 5 μL of DNA extracted from each of the selected specimen, first round PCRs were performed with the primer sets as indicated in Table 2, 1.25 μM of each of the two primers, and 6.3 U of Taq DNA polymerase. The amplifications were achieved with the same cycling conditions as that of the first round PCR.The second round PCR used 5 μL of the first round product with the second round primer sets indicated in Table For all the second round PCR products of HPV16, 18 and 45, 20 μL were resolved on a 1.5% agarose gel in 1X TBE buffer with 1 μg/mL ethidium bromide at 120 V for an hour. The gels were documented with GelDoc™ XR+ System .The second round PCR products were purified with the Amicon Ultra centrifuge filers  with slight modification made to the manufactures instruction. Specifically, a filter column was place upright, into a micro-centrifuge tube for each sample, after which 200 μL of PCR water and 80 μL of a PCR product were added. The assembly was spun at 14000xg for 12 min. Additional 100 μL of PCR water were added to each filter column. The filter columns were thereafter transferred, inverted, to a new set of micro-centrifuge tubes and spun for 2 min at 1000xg. The columns were discarded and the eluted DNA in each tube was quantified at 230 nm using NanoDrop ND-100 spectrophotmeter . The eluted DNA was diluted to 50 ng/μL and sequenced with ABI Applied Biosystems 3730xl DNA Analyzer BigDye® Terminator v 3.0 . DNA Sequences obtained with the forward and reverse primers by Sanger sequencing were assembled with SeqMan Pro software (DNAStar). The sequences obtained for HPV16, HPV18 and HPV45 PCR products  and worked within the guidelines of the Ethical Review Committee and conducted the study in accordance to the ethical standards as declared in Declaration of Helsinki and the Belmont Report. Assurances were given and efforts were made to protect the privacy and confidentiality of the participants enrolled and their collected data. As such personal/demographic data as well as data that will be useful for identifying the participants were not included in this study.The obtained partial LCR nucleotide sequences for each of the HPV genotypes were of an average size of 375 bp. These have been deposited in NCBI GenBank and the accession number shown in the Additional file Of the 15 specimen positive for HPV18 isolates, 13 were confirmed as positive by the LCR HPV18 type specific PCR, one of which gave poor sequence data. Nucleotide variations were determined in 35 positions, 22 of which were known variations of the lineages B and C (Africa variants) of HPV 18. The other 13 variations were unique to the isolates of this study Table . CompareThis long control region of the HPV genome has been shown to be very informative and therefore very useful in the study of HPV variants , 12–14, A more detail investigation of the variations in the sequences Table  showed hThe phylogenetic tree presented as Fig. All the 9 HPV45 genotypes sequenced were identified without difficulty and were determined to belong to the HPV45 lineage A1 (Table This study provides the first DNA sequence data on the variants/lineages of HPV 16, 18 and 45 isolates from Ghana and has shown that predominately, these genotypes are of the Africa lineages. The observance of specific sequence variation within region associated with transcription binding, indicates a potential for differential oncogenicity of the isolate. The fact that these were obtained from the specimen of women with normal cytology, these data will be useful for comparison with variants of these genotypes from women with the different form of ICC and different grades of cervical lesions to improve our understanding of relationship between lineage and oncogenicity. However, there is need for additional gene or a full genome sequencing to better clarify the classification of a few of the isolates that did not cluster with most of the isolates within a clear lineage.


Cervical cancer is one of the most widespread gynaecological cancers worldwide and remains the second leading cause of gynaecological-related mortality. More than 85% of cases occur in developing countries, resulting in an estimated 275,000 deaths annually . In mainFurther, as recommended by the World Health Organization (WHO), screening is a common preventative strategy targeting women of reproductive age for the early detection and treatment of HPV infection, cervical cancer, and cervical intraepithelial neoplasia (CIN). In developing countries, routine screening programs reportedly reduced the incidence of cervical cancer by up to 60% . In 2005Although the cost-effectiveness of the HPV vaccine in China has been analysed –20, a thA Markov model was used to simulate the natural history of HPV infection and to estimate the economic consequences of HPV-related diseases from a societal perspective view Fig. . The ratWe assumed that girls under 12 years old were virgins. In our analysis, we simulated a cohort of 100,000 HPV-free girls (from 12 years old and followed up until death). In the strategies using vaccination, individuals were given the respective vaccines at the beginning of the simulation. HPV genotypes were divided into high risk  and low risk (HPV 6/11 and etc.) groups in the analysis. Health states were defined based on the natural history of HPV infection in the following manner: healthy, low risk HPV infection, high risk HPV infection, mild cervical intraepithelial neoplasia (CIN 1) caused by high risk HPV infection, moderate cervical intraepithelial neoplasia (CIN 2) caused by high risk HPV infection, severe cervical intraepithelial neoplasia or carcinoma in situ (CIN 3) caused by high risk HPV infection, CIN1/2 caused by low risk HPV infection, genital warts, invasive cervical cancer (ICC) , cervical cancer survival, death from cervical cancer, and death from other causes . Orophar2005 Guidelines for Screening, Early Detection and Treatment of Cervical Cancer [The Markov model developed for this study comprehensively assessed relevant and currently in-use preventative strategies including both vaccination and screening in China. The screening strategies included the three protocols recommended in the l Cancer : 1) liquThe target population for screening was women older than 21 years. Screening every three years was recommended. Based on the cervical cancer prevention guidelines of mainland China and several Chinese reports, we assumed that a liquid-based cytology test would have a sensitivity of 0.85 and a specificity of 0.90 . The HPVA screening coverage rate of 20% was assumed due to the large geographical diversity in socioeconomic development, and 10%–100% was set for the sensitivity analysis .As vaccine efficacy data specific to the Chinese population were unavailable, the data used here were obtained by multiplying the direct efficacy targeting specific HPV types by serotype coverage on mainland China. In the clinical trials, HPV2 (CERVARIX),HPV4 (GARDASIL®), and HPV9 (GARDASIL®9) all showed excellent efficacy against the relevant CIN and AIS (Adenocarcinoma in situ) in women with HPV DNA negative for oncogenic HPV types at baseline: HPV2: 96.5% (95% CI: 91.6%–98.9%) ; HPV4: 9After calculation, the overall efficacy of HPV2, HPV4, and HPV9 against cervical cancer was 80.72% (57.47%–98.9%), 81.51% (58.78%–98.2%), and 90.78% (66.54%–100%), respectively, and that against genital warts was 10.36% (7.56%–13.07%), 86.06% (62.72%–99.99%) and 86.06% (62.72%–99.99%), respectively.Moreover, considering the reported efficacy data and demonstration of immunological memory , we assuA vaccine coverage rate was assumed as 20%, and 10%–100% was set for the sensitivity analysis.Each strategy (screening plus vaccination or screening only) modelled probabilities for mutually exclusive health states within a one-year cycle. At each transition, the model produced figures for the costs incurred and the QALYs according to the individual’s health condition. Each year, the target population was exposed to an age-specific risk of HPV infection that could persist, progress  or resolve. In those who developed CIN 3, their disease might persist, remit, or progress to localized (FIGO stage I and IIA), regional (FIGO IIB to IVA) or metastatic invasive cancer (FIGO IVB). Given the course of cervical cancer, each individual might continue to suffer from the disease, die, or experience complete remission. Each year individuals faced age-specific risks of dying from other causes or of undergoing a hysterectomy for reasons unrelated to cervical neoplasia. Women who underwent a hysterectomy did not develop cervical cancer in our model. Table Utilities are a measure of the quality of life rated on a scale of 0 (death) to 1 , and are based on economic studies in China. CIN 2 was assigned a lower utility (0.88) , while CGardasil, a quadrivalent vaccine developed by Merck and Cervarix, a bivalent vaccine developed by GlaxoSmithKline, both costing about the same, were approved in Hong Kong. We estimated the costs of three doses according to the standard price in Hong Kong (2000 ~ 3000 CYN) [Cost estimates included the cost of vaccination, screening, and treatment of diseases related to HPV infection. Data were initially calculated in Chinese Yuan and then converted to US dollars in 2015 using the consumer price index (CPI) and the official exchange rate of the Chinese Yuan to US dollar . Although the three HPV vaccines mentioned above were not yet available on mainland China, 000 CYN) , and the000 CYN) . Conside000 CYN) . The tre000 CYN) . A half In terms of compliance, the baseline value for CIN 2/3 treatment extracted from Screening Technologies to Advance Rapid Testing for Cervical Cancer Prevention (START) was set at 90% . The selThe model was programmed using TreeAge Pro 2011. We expressed the results in terms of the number of cases of cervical cancer, genital warts, and deaths from cervical cancer prevented, as well as the lifetime cost and QALYs gained. The incremental cost-effectiveness ratio (ICER) was calculated as incremental cost divided by the QALYs gained per woman by adding vaccination to the status quo . According to the WHO, if the ICER is less than the per capita gross domestic product (GDP) a strategy can be considered as “very cost effective”, and if less than three times the per capita GDP, as “cost effective” . Three tOne-way sensitivity analysis was performed to explore the impact of the uncertainty of the parameters, taking into account simultaneous changes within the plausible ranges. The efficacy of each vaccine, the sensitivity and specificity of different tests, and the utilities associated with different health stages varied uniformly within the referred ranges. The cost parameters obtained varied uniformly in a range of +/− 50% of the deterministic estimate. The discount rate for cost and effectiveness varied uniformly between 0 to 6%. According to the results of tornado diagrams, threshold analyses were performed.Cervical cancer mortality in the trial (screening only without vaccination) was based on cancer statistics. The predicted cervical cancer mortality showed acceptable correspondence with data from the 2011 Chinese Cancer Registry Annual Report  , 1893 cases got cervical cancer and 348 cases died of it. HPV and genital wart infections occurred 895,739 times and 100,676 times, respectively. Among all 15 strategies, Screening 1 + HPV9 showed the best preventative effect against HPV-related disease by reducing cervical cancer incidence by 34.39%, cancer mortality cases by 35.95%, HPV-Hr infection rate by 25.82%, and genital wart incidence by 20.80% compared to no intervention. Among the three screening protocols, Screenings 1 and 2 showed no significant difference in their preventative effects against diseases related to HPV infection but were superior to Screening 3. Among the three vaccines, HPV9 showed the strongest preventative effect against HPV-related disease compared to the other two in both the single and combination strategies (Table Variables with a range ≥ 1% of base case ICER (comparing each HPV9 combination strategy to HPV4 combination strategy) were listed in descending order Fig. .1–3.3. TAs HPV2 is the only accessible vaccine on mainland China so far, we also did a one-way sensitivity analysis for HPV2, comparing HPV2 combination strategies to screening alone , and especially the strategy combining HPV9 with screening program showed best health impact on reducing the cervical cancer incidence and mortality rate, compared to that of the HPV2 vaccine combination strategy. These results were consistent with those of studies conducted in the United States , 49, whiOur results highlighted the validity of combining screening and vaccination. Combination strategies using HVP4/9 were cost-effective and able to confer greater health benefits than screening alone. Data from both developed and developing countries thus far have demonstrated that neither secondary prevention, such as screening alone, nor a conventional vaccination program can reduce the incidence of cervical cancers and warts or the disease burden . Our resVaccination is the primary preventative measure but effective only in those not yet infected by HPV . MoreoveThe different combination strategies examined in this study were flexible enough to be adapted to the wide geographical and socioeconomic diversity found in China according to the varying income levels and availability of medical resources. The Screening 3 or 2 protocols are recommended for low income settings, and if economic conditions permit, the screening plus vaccine strategy, which is likely to achieve have greater prevention impact, is also recommended even if HPV2 vaccine alone is available in mainland China so far.The sensitivity analysis of HPV9 showed the robustness of its cost-effectiveness. The sensitivity analysis of HPV2, on the other hand, demonstrated that screening coverage crucially influenced the cost-effectiveness of different strategies. This study found that only when screening coverage increased to 60% ~ 70% did the HPV2 and screening combination strategies become economically feasible. In practice, coverage tends to be affected by various factors at both the social and individual level, such as affordability, the socioeconomic status of different regions, the educational level, and adherence of the target population to vaccine protocol recommendations . RegardiThere were several limitations to this study. First, we did not model the transmission dynamics of HPV nor consider what protection might be conferred by HPV vaccinations against other HPV-related cancers like cervical adenocarcinoma, vulvar carcinoma, and laryngeal papillomatosis due to the lack of data. Consequently, the overall effectiveness of the vaccination program might have been underestimated, thus making the cost-effectiveness of the HPV vaccine appear even more favourable if herd immunity or protection against other diseases existed , 64 espeWe demonstrated that HPV4/9 vaccination for adolescent girls was highly cost-effective in China when integrated into the current screening strategies. Integrated vaccination and screening is recommended. HPV9 vaccination combined with Screening 1 (liquid-based cytology test + HPV DNA test) proved to be the best preventative strategy against cervical cancer and warts.


The use of thermocoagulation for the treatment of cervical precancerous lesions has recently generated a great deal of interest. Our aim was to determine the feasibility of this outpatient procedure in the context of a cervical cancer (CC) screen-and-treat campaign in sub-Saharan Africa.Between July and December 2015, women living in the area of Dschang (Cameroon) aged between 30 and 49 years, were enrolled in a CC screening study.HPV self-sampling was performed as a primary screening test and women who were either “HPV 16/18/45-positive” or “positive to other HPV types and to VIA” were considered screen-positive, thus requiring further management. The primary outcome was the percentage of screen-positive patients who met the criteria to undergo thermocoagulation. The secondary outcome was the assessment of the procedure’s side effects immediately after treatment and at the 1-month follow-up visit.versus 2.9 ± 1.5, respectively; p value = 0.016). A total of 109/110 (99.1%) patients came to the 1-month follow-up visit. Vaginal discharge was reported in 108/109 (99.1%) patients throughout the month following treatment. Three patients (2.8%) developed vaginal infection requiring local antibiotics. No hospitalizations were required.A total of 1012 women were recruited in the study period. Among 121 screen-positive women, 110 of them (90.9%) were eligible to be treated with thermocoagulation. No patients discontinued treatment because of pain or other side effects. The mean ± SD (Standard Deviation) score measured on the 10-point Visual Analogue Scale (VAS) was 3.0 ± 1.6. Women having less than 2 children were more likely to report a higher pain score than those with more than two (4.2 ± 2.0 The majority of screen-positive women met the criteria and could be treated by thermocoagulation. The procedure was associated to minor side effects and is overall feasible in the context of a CC screen-and-treat campaign in sub-Saharan Africa.ISRCTN99459678.The trial was retrospectively registered on November 11, 2015 with the identifier:  Thermocoagulation is a feasible approach for the treatment cervical precancerous lesions in the low-resource context of sub-Saharan Africa.Cervical cancer (CC) represents the fourth most common cancer among women worldwide . NeverthExcisional procedures such as Loop Electrosurgical Excision Procedure (LEEP) require trained personnel and expensive infrastructures, which makes them scarcely applicable in LMIC. Two low-cost and simple treatment methods are represented by cryotherapy and thermocoagulation. Cryotherapy is a highly effective intervention with a good cure rate, but the low availability of refrigerant gas makes its use challenging in LMIC . In the Thermocoagulation has been available for several decades in Western countries. A recent meta-analysis including studies conducted mainly in industrialized countries has shown that the use of thermocoagulation for the treatment of CIN is as effective as other methods, such as cryotherapy and LEEP, with the advantage of being rapid and associated to a low occurrence of side effects . This meAn issue of particular interest is to determine, in the context of a screening campaign conducted in a low-resource setting, the percentage of screen-positive patients who meet the criteria to undergo thermocoagulation, as well as the side effects that can disrupt the procedure. These data would enable us to plan the allocation of resources in order to embody the procedure in a resource-constrained setting.Our aim was to conduct a pragmatic analysis evaluating the feasibility of thermocoagulation in the context of a CC screen-and-treat campaign in sub-Saharan Africa.Centre de Recherche Clinique) of the Geneva University Hospitals.The Faculty of Medicine and Biomedical Sciences, Yaoundé, the National Committee for fight against cancer, Cameroon, the University of Dschang, Cameroon and the Geneva University Hospitals currently work together to evaluate innovative cervical cancer screening options in order to develop a screening approach adapted to the needs and means of people in Cameroon. This prospective study is part of this collaborative platform, which has been approved by the National Ethics Committee of Cameroon (2015/02/559/CE/CNERSH/SP) and by the Ethical Cantonal Board of Geneva, Switzerland (CCER 15–068). The study has been conducted at the District Hospital of Dschang, Cameroon. All participants were asked to sign a written informed consent form before taking part to the study. Assistance for data management was provided by the CRC  and the study’s procedure. Exclusion criteria were pregnancy and previous total hysterectomy. The health care providers instructed all enrolled women on how to perform HPV self-sampling using a dry cotton swab . The participants were told to gently unscrew the cap of the plastic tube in order to remove the dry swab. They then had to insert the soft-tip end of the swab into the vagina while being careful to avoid contact with external genitalia. When resistance was met (at about 5–6 cm), they had to gently turn the swab from three to five times clockwise and counterclockwise. Subsequently, the swab had to be placed back into the plastic tube. The procedure was performed by the women themselves.The cervico-vaginal samples collected by the women were promptly analyzed with the HPV GeneXpert machine . To do this, the swabs were first introduced in a NaCl 0,9% solution and vortexed for 3x15 s. Then, 1 mL of each sample was transferred to the cartridge and ran on the four-module GeneXpert machine. The GeneXpert HPV analysis consists of a real-time polymerase-chain-reaction (PCR) which uses, as an internal assay control for specimen adequacy, the detection of a Human reference gene (HMBS [hydroxymethylbilane synthase]) and an internal Probe Check Control (PCC). The PCC verifies reagent rehydration, PCR tube filling in the cartridge, probe integrity, and dye stability. This test includes reagents that allow the simultaneous detection of 14 hrHPV types . The assay uses multiple fluorescent channels in order to detect individual types of HPV, groups of HPV, and the human reference gene. When sufficient signal is detected by the human reference gene, the assay results are reported as overall “positive”. In addition, if HPV16 and pooled HPV 18/45, together with other high-risk types are detected by the assay, the result will be labeled as either “positive” or “negative”. The HPV test results were available in less than an hour and the test was done on site, enabling us to screen, triage and treat women on the same day. The use of GeneXpert as a front-line cervical cancer screening test has been validated in a recently published study, which concluded that its performance and reproducibility are comparable to those of well-established HPV assays [After obtaining the results of the sample analysis, HPV-negative women were advised to repeat screening after 5 years. HPV-positive women were invited to undergo visual inspection with acetic acid (VIA) as a triage test. Visual Inspection with Lugol’s Iodine (VILI) was also performed in order to aid delineate the pathological areas. VIA and VILI were performed by three trained local gynecologists. VIA consists in the application of a 4% acetic acid solution on the cervix, which may cause a slight burning sensation for a few minutes. The appearance of aceto-white areas touching the squamo-columnar junction (SCJ) helps define the pathological areas of the cervix. VILI consists in the application of Lugol’s iodine on the cervix, which does not cause any discomfort. The appearance of a well-defined, bright yellow area touching the SCJ defines the presence of a suspicious lesion. The application and interpretation of VIA and VILI were conducted according to the World Health Organization’s recommendations.Women who were either “HPV-16/18/45-positive” or “positive to HPV-other high-risk types (HR-HPV) and to VIA” were considered as screen-positive, thus requiring treatment. Screen-positive women were considered eligible for thermocoagulation if (i) the lesion extended itself less than 2 mm in the endocervical canal, (ii) the anatomy of the cervix allowed to treat the entire lesion (multiple applications were possible), (iii) the lesion did not extend onto the vaginal wall, and (iv) if there was no suspicion of invasive cancer. No anesthetic prior to the procedure was administered. Treatment was performed using the thermocoagulator  after delineation of the lesion using Lugol’s iodine. Treatment was performed with a probe heated to 100 °C, which was applied on the cervix for a period of 60 s. If necessary, the application was repeated in order to treat the entire abnormal area. After usage, the probe was washed with cold water, dried and heated for about 45 s at 120 °C to sterilize it. A cervicography of the cervix was undertaken before and after treatment for quality control.The primary outcome was the proportion of screen-positive women who were eligible for thermocoagulation. At the end of the procedure, the physician had to report whether any complications had taken place, as well as whether treatment had been completed specifying, if not, the reason why it had to be interrupted.The secondary outcomes were the procedure’s side effects. The discomfort felt throughout thermocoagulation was assessed immediately after treatment by asking participants to report if they had felt pain, and to specify its intensity through the visual analogue scale (VAS). They had to indicate a point on a 10-cm line, with 0 meaning the procedure was not painful at all and 10 meaning it was the most painful experience one could imagine.All treated women were invited for a follow-up visit at 1 month. The women’s subjective assessment of symptoms and side effects, as well as their duration in time, were registered. A vaginal examination was performed on all participants in order to exclude any infection and/or wound healing problem. Cervicography was also undertaken throughout this visit. Figure Data were analyzed with a statistical analysis software package StataCorp. 2013 .U-test or the Kruskal-Wallis test, when appropriate. All hypotheses were two-sided and p-values <0.05 were considered as statistically significant.Quantitative variables were expressed as means and standard deviations, and qualitative variables were expressed as percentages, unless otherwise stated. Descriptive analyses were carried out in order to compare women by their socio-demographic characteristics, reproductive and sexual history, disease status and other aspects. Categorical variables were analyzed by Pearson’s chi-square or Fisher’s test and continuous and ordinal variables with the Mann-Whitney A total of 1012 women underwent primary screening through HPV self-sampling. Sixty-one  participants among those who underwent screening were positive for HPV-16/18/45, and were thus referred directly for treatment, while 126  women were positive for other HR-HPV types. Two of these women did not follow through with triage by VIA and VILI, corresponding to a dropout of 1.6% (95%CI:0.1–6.0). Among the 124 women who underwent triage with VIA, 60  of them were positive to these tests and were thus referred for treatment. Overall, 121 out of 187 HPV-positive women  had a positive screen and were referred to further management. The characteristics of all screened women are reported in Table n = 5), and having a lesion suspicion of cancer (n = 3). Three (2.7%) patients were excluded from the study. These include 2 women not identified as pregnant at the time of enrolment due to an inclusion error and one who could not be treated because of a technical issue due to impossibility of heating the probe. Patients with large pathological areas or having a lesion suspicious for cancer were referred to LEEP or hysterectomy. Pregnant patients were invited for a follow-up visit after childbirth.Overall, 110 out of 121  screen-positive women were considered eligible for thermocoagulation and treated. No patients discontinued treatment because of pain or other adverse effects. A total of 8  patients were ineligible for thermocoagulation. Ineligibility reasons included inability to identify the cervix, no visualization of the SCJ or the presence of a lesion going more than 2 mm inside the cervix (The participants were asked to quantify the discomfort felt throughout thermocoagulation using the VAS. A mean ± standard deviation (SD) pain score of 3.0 ± 1.6 was reported. Thermocoagulation never had to be interrupted because of pain. Table No serious adverse events occurred during the procedure or in the 30 days following treatment. Three patients (2.8%) consulted prior to the 1-month control visit because of important vaginal discharge, and a vaginal antibiotic therapy was prescribed to them.p = 0.016).Table The 1-month follow-up was achieved for 109 out of 110 treated patients, corresponding to a drop out of 0.9% (95%CI:<0.0001–5.5). Overall, 34  patients reported having felt some degree of pain, mainly during the first few days following treatment, while 75  women did not experience any. The mean ± SD pain intensity was 0.8 ± 1.4, with a mean ± SD duration of 2.0 ± 4.2 days. Vaginal discharge, sometimes with little blood, was reported in 108 out of 109  patients, with a mean ± SD duration of 16.2 ± 8.4 days. Adequate wound healing was reported in 100 out of 109  women; the remaining ones showed delayed cervical healing and were prescribed a local antibiotic. These results are also reported in Table Figures In a sample of more than 1000 women participating in an HPV-based cervical cancer screening campaign, most screen-positive participants met the criteria to undergo thermocoagulation in the context of a screen-and-treat approach, with less than 10% of them not fulfilling the eligibility criteria and needing to be referred for LEEP or a more radical type of CC treatment. These results are comparable to those obtained in a VIA-based cervical cancer screening campaign involving 6 African countries and almost 20,000 screened women, where 87.7% of VIA-positive women were considered eligible for cryotherapy . AnotherAccording to our experience, thermocoagulation is a quick and easy procedure to learn and perform in the African context. The thermocoagulator costs approximately the same as a small cryosurgical unit . When coOur triage algorithm allowed all HPV-16/18/45-positive women, who have a higher risk of CIN2+ when compared to women positive for other HR-HPV genotypes to be promptly treated, whereas women positive for other HR-HPV types were only treated in presence of pathological VIA/VILI . This tyNo patients in our study discontinued treatment because of pain or other adverse effects, thus demonstrating that thermocoagulation is a low-pain procedure that can be successfully carried out until the end if patients are correctly informed and sufficiently cooperative . Women gStrengths of this study are represented by the fact that it describes the main key points associated with this quite unexplored technique in the context of sub-Saharan Africa. In addition, we have assessed the eligibility or participants for thermocoagulation and the overall feasibility of this technique in the context of a CC screen-and-treat program. Finally, we have a minimal loss to follow-up at 1-month, which allows us to validate the low complication rate in the 30 days that follow treatment. Limitations that need to be addressed are the short follow-up period and the absence of results regarding the cure rate.This is one of the largest studies conducted in LMIC on the use of thermocoagulation for the treatment of cervical precancerous lesions. The aim of this pragmatic and descriptive analysis is to improve knowledge about a procedure that is potentially widely applicable in LMIC for the management of screen-positive women. Further prospective studies should focus on evaluating the long-term efficacy of thermocoagulation in preventing the development of CIN and CC, as well as its impact on fertility in LMIC. In our series, about half of the women still wished to become pregnant in the future, and the health care provider has to take this aspect into consideration. To date, there aren’t any known adverse effects of thermocoagulation on fertility, but this issue still needs to be investigated with long-term follow-up studies .The high availability of thermocoagulation, together with its efficacy, renders it a valuable option for the treatment of screen-positive women in LMIC, such as those in sub-Saharan Africa , 18, 19.