In Germany, the incidence of cervical cancer, a disease caused by human papillomaviruses (HPV), is higher than in neighboring European countries. HPV vaccination has been recommended for girls since 2007. However, it continues to be significantly less well received than other childhood vaccines, so its potential for cancer prevention is not fully realized. To find new starting points for improving vaccination rates, we analyzed pseudonymized routine billing data from statutory health insurers in the PRÄZIS study  in the federal state Saarland serving as a model region. We show that lowering the HPV vaccination age to 9 years led to more completed HPV vaccinations already in 2015. Since then, HPV vaccination rates and the proportion of 9- to 11-year-old girls among HPV-vaccinated females have steadily increased. However, HPV vaccination rates among 15-year-old girls in Saarland remained well below 50% in 2019. Pediatricians vaccinated the most girls overall, with a particularly high proportion at the recommended vaccination age of 9–14 years, while gynecologists provided more HPV catch-up vaccinations among 15-17-year-old girls, and general practitioners compensated for HPV vaccination in Saarland communities with fewer pediatricians or gynecologists. We also provide evidence for a significant association between attendance at the children´s medical check-ups “U11” or “J1” and HPV vaccination. In particular, participation in HPV vaccination is high on the day of U11. However, obstacles are that U11 is currently not financed by all statutory health insurers and there is a lack of invitation procedures for both U11 and J1, resulting in significantly lower participation rates than for the earlier U8 or U9 screenings, which are conducted exclusively with invitations and reminders. Based on our data, we propose to restructure U11 and J1 screening in Germany, with mandatory funding for U11 and organized invitations for HPV vaccination at U11 or J1 for both boys and girls. Invasive cervical cancer is a consequence of persistent human high-risk papillomavirus (HPV) infection , 2. CervHPV vaccination, with high immunogenicity particularly in preadolescents, high efficacy, and a good safety profile, is an effective measure for sustained reduction in the burden of HPV-associated cancers. Because HPV is sexually transmitted, vaccination is most efficacious when given prophylactically to HPV-naïve individuals, ideally before first sexual intercourse. Population studies from other countries with school-based vaccination such as Australia show high vaccination rates (>80%) providing herd immunity in the population beyond individual protection. This makes cervical cancer elimination a realistic goal . In AustIn Germany, the HPV vaccination for girls has been recommended by the Standing Committee on Vaccination (STIKO) in 2007 and has since been one of the mandatory benefits of statutory health insurance. Originally, the vaccination age was set at 12–17 years . In 2014The aim of the study PRÄZIS  was to analyze factors influencing HPV vaccination in Saarland on the basis of routine health insurance billing data for HPV vaccination and other health measures, such as preventive examinations for children, and thus to identify starting points for improving the uptake of HPV vaccination.We selected Saarland as a model region, a federal state in western Germany with relatively low migration  and relaOur study provided new findings, particularly on the age-specific implementation of HPV vaccination by specific medical specialist groups and on the uptake of HPV vaccination compared with other preventive measures among girls and young women. We found that pediatric medical check-up examinations at the HPV vaccination age of 9–14 years, the “U11” and “J1” examinations, can provide an excellent opportunity to deliver HPV vaccination in an age-appropriate manner. Specifically, our data indicate that there is a significant association between participation in U11 or J1 check-ups and HPV vaccination, and that the day of U11 has a high uptake for HPV vaccination in the year of the U11 preventive examination.In this study, we analyzed pseudonymized prospective and retrospective statutory health insurance billing data. The Ethics Committee of the Saarland Medical Association reviewed, approved all study procedures, and waived the requirement for informed consent . All procedures were performed in accordance with the recommendations of the data protection authorities .Pseudonymized routine data available from the KVS (2013–2019), IKK (2012–2019) and AOK (2009–2018) served as data sources. In addition to general information, service codes according to the uniform valuation standard (EBM) represented an essential component of the analyzed variables. Where necessary, the data from KVS and IKK were linked by automated record linkage in a study database and analyzed. The U11 check-up is not offered or not billed via the KVS by all statutory health insurance funds in Saarland. For our study, data on the U11 examination were only available from IKK. The procedure of pseudonymization is described in The KVS and IKK data sets contained data on females who had received services from physicians in Saarland . This inAn overview of the data sets used and the operationalization of the variables for the individual questions is provided in The data analysis was based on the pseudonymized files in the study database. Descriptive statistics and regression analyses including dependent and independent variables were prespecified. Because this was a full survey rather than a sample considering statutory health insurance billing data, i.e., pseudonymized routine data available from the KVS (2013–2019), IKK (2012–2019) and AOK (2009–2018), we focussed on exploratory statistical analyses.In the descriptive statistical analysis, absolute and relative frequencies were determined for qualitative data from the parameter list, such as HPV vaccination available, participation in child examinations U8, U9, U11, J1 and the mean was calculated for quantitative variables such as number of doctor visits. The data were additionally stratified by vaccination status: Once regarding vaccination present (yes/no) and the other according to vaccination status complete (yes/no). Logistic regression analyses were conducted, examining the following dependent and independent variables: dependent variable: HPV vaccination available (yes/no); independent variables: participation in U11 and J1 examinations.Vaccination rates of 15-year-old girls residing in Saarland from 2015 to 2019 were calculated based on the two EBM codes 89110A (first or subsequent vaccination) and 89110B . Considering the age at the start of the vaccination series and the recommended vaccination schedule , the completeness of the vaccination series was determined. The completeness of the vaccination series for 9–14-year-old girls at the start of the vaccination series was accordingly given, if a final dose was administered at the latest in the year of the 15th birthday or if two consecutive vaccination doses were administered at an interval of at least five months (two times 89110A). Completion of the vaccination series for 15-year-olds at the start of the vaccination series was given, if a final dose was administered no later than the year of the 15th birthday according to the billing code or if three consecutive vaccination doses were administered (three times 89110A) see also . AnalyseFirst, we determined the frequency of the first HPV vaccination in females in different age groups. For this purpose, we analyzed data from the KVS (years 2014 to 2019). Boys were not included in this analysis because there was no vaccination recommendation for boys at the beginning of the study.After lowering the vaccination age from 12 to 9 years, we observed a clear increase in HPV vaccinations in 2015. The first HPV vaccine dose was increasingly given to younger girls aged 9 to 11 years . The first HPV vaccination was more often given at the recommended age of vaccination (9–14 years) than catch-up vaccinations in 2015 to 15-17-year-old females .Data from the birth cohorts 2001 to 2004 living in Saarland were used to determine HPV vaccination rates for 2015 to 2019. The rates refer to girls who turned 15 in the corresponding year. For girls who received the first vaccine dose before their 15th birthday, a 2-dose schedule was sufficient for complete vaccination. For completeness, the required vaccine doses had to be administered no later than the end of the year, in which the girls turned 15 years. The interval between two vaccine doses must be at least five months apart, according to the guidelines. For girls who received the first vaccine dose after their 15th birthday, a 3-dose schedule was necessary see also . Our resSubsequently, it was analyzed whether the last HPV vaccination took place before or after a date indicating the start of sexual intercourse, e.g., consultation or smear test in the context of conception regulation, prescription of contraceptives or indication of pregnancy. We would like to emphasize that this evaluation can only refer to those vaccinees for whom the relevant data were available in the analyzed period, i.e., who had undergone the relevant measures or were pregnant. In particular, in the case of prescription for a contraceptive, where data were only available from one health insurance company, or pregnancy, this was only a smaller fraction of those vaccinated . Fig 1C We were also interested in the number of physician contacts at the vaccination age and whether there were differences between HPV-vaccinated and non-vaccinated females aged 9–17 years during the 2013–2019 data period. We found that HPV-vaccinated girls had more physician contacts on average than girls who were not vaccinated against HPV. The mean contacts among girls not vaccinated against HPV ranged from 11.67 (in 16-year-old girls) to 19.46 (in 9-year-old girls), whereas the mean contacts among girls vaccinated against HPV ranged from 20.68 (in 15-year-old girls) to 26.18 (in 10-year-old girls) .To further analyze access to HPV vaccination, we examined the regional distribution of medical specialist groups performing HPV vaccination. In particular, this included gynecologists, pediatricians, general practitioners, and internists, as well as the density of vaccinating doctors per municipality  in Saarland . There wWe then evaluated the spatial distribution of medical specialists with the respective administration of vaccine doses. The vaccination rates in the six districts showed little variation . HoweverTo obtain a more general picture of vaccine administration in Saarland, we compared the relative contribution of different medical specialties to HPV vaccination and to booster vaccinations against pathogens other than HPV. Between 2013 and 2019, 54% of HPV vaccine doses were administered by pediatricians, 32.5% by gynecologists, 11.5% by general practitioners, and 2% by internists. In contrast, 54.9% of booster vaccinations against diphtheria, pertussis, tetanus, and poliomyelitis were administered by general practitioners and only 23.2% by pediatricians . It shouAnalysis of HPV vaccination by discipline in terms of age of the vaccinees showed that 9- to 14-year-old girls were vaccinated mainly by pediatricians, whereas catch-up HPV-vaccinations of 15- to 17-year-old girls were performed mainly by gynecologists .The study also examined how HPV vaccination is delivered in comparison with other preventive measures, such as mandatory childhood check-up examinations U8 (age 46–48 months), U9 (age 60–64 months), U11 (age 9–10 years) or J1 (age 12–14 years). The U11 participation rates could only be evaluated for one health insurance company that provided the data.Our analysis showed that the numbers of U8 and U9 remained at a consistently high level between 2013 and 2019. In contrast, the number of J1 examinations at the HPV vaccination age of 12–14 years was significantly lower in 2013 and further declined steadily through 2019 . ParticiLogistic regression analysis was performed to examine the association between HPV vaccination and U11 and J1 participation during the HPV vaccination age of 9–14 years. Regression analyses for the birth cohorts 2004 and 2005 found that girls who participated in U11 check-up had 5.3 times (95% CI: 4.66–6.11) higher odds of receiving HPV vaccination than girls who did not attend the U11 (p <0.001). Girls who participated in J1 were 10.03 times (95% CI: 8.96–11.22) more likely to receive HPV vaccination than girls who did not attend J1 (p <0.001). In the year of the individual U11 examination, up to 63.9% of those vaccinated were vaccinated against HPV on the day of the U11 examination . In the Our study based on routine health insurance data not only provides data on HPV vaccination in a German model region in recent years but also provides new starting points for improving HPV vaccination rates.We show that HPV vaccination rates in Saarland among 15-year-old girls in 2019 are still well below 50%, far below vaccination rates in other countries such as Australia  or in otOur data show that overall, HPV vaccination rates have steadily increased since 2015 in Saarland. This was particularly due to an increase in the proportion of 9- to 11-year-old girls among HPV-vaccinated. Lowering of the HPV vaccination to age 9 with the 2-dose schedule  resultedProphylactic HPV vaccination should be completed ideally before first sexual intercourse  since HPInterestingly, there was no pronounced urban-rural difference in HPV vaccine doses administered in Saarland. In contrast, the specialty of the vaccinating physician played an important role. Pediatricians administered the most HPV vaccine doses and a particularly high proportion of vaccinations to girls of the recommended vaccination age between 9 and 14 years. These results underscored the importance of pediatricians in the successful delivery of HPV vaccination at the recommended age of 9–14 years. Gynecologists, on the other hand, administered more HPV catch-up vaccinations than pediatricians. In contrast, booster vaccinations against other diseases were more likely to be administered by general practitioners. Because the booster vaccinations evaluated in this study were not administered only to children, this may explain the significantly higher booster vaccination rates among general practitioners compared with pediatricians.In Saarland, in communities where there are fewer pediatricians, general practitioners and gynecologists increasingly administered HPV vaccinations. This suggests that, in addition to pediatricians and gynecologists, general practitioners should be involved in HPV vaccination campaigns, especially in regions with an undersupply of pediatricians, to increase vaccination rates in the future.In general, the adherence of vaccinated individuals to their physicians appears to play an important role. HPV-vaccinated individuals had significantly more physician contacts during the vaccination age than non-vaccinated individuals. This could indicate that more doctor visits may have increased the likelihood of vaccination. However, HPV-vaccinated individuals might also be more health conscious and therefore visit the doctor more often.Visiting the pediatrician is especially important to get vaccinated as early as possible. In Germany, children and adolescents who are not yet of vaccination age are invited and reminded to attend the preventive check-ups U3-U9. The pediatricians confirm the attendance and notify the facility issuing the invitation. If a child does not appear even after a reminder, a report is made to the youth welfare office. These early visits are therefore consistently well used. Child and adolescent health check-ups are also offered at the recommended immunization age of 9–14 years see also . In SaarOur data also show that the day of U11 has a high uptake for HPV vaccination in the year of the U11 examination. In our experience, parents at this age are more likely to accompany their children to the screening appointment than to J1, so parental consent for vaccination can be obtained on the spot and thus vaccination can take place on the same day. The prerequisite for this is that the HPV vaccine is stocked in the doctor’s office, which is the case in Saarland, and should be rolled out nationwide. Organized combined invitation to U11/J1 and HPV vaccination could address issues of different population subgroups and thus reach individuals of different geographical regions, ethnities, socioeconomic status and religions. In addition, HPV vaccination in younger individuals may be more considered as a "normal childhood vaccination" rather than an “STI  or cancer vaccine” and therefore more disconnected from the issue of sexual activity at a young age.There have been previous efforts in Germany to increase the HPV vaccination rate through organized programs. A pilot study of school-based HPV vaccination in Germany, which required broad alliances of many public health partners including district administrators, health and education authorities, ministries and associations of physicians, appeared to have reached higher participation rates . A recenOur data suggest that the integration of an organized HPV vaccination program into U11 and J1 health check-ups could be very well suited to increase vaccination rates in Germany. This could be an alternative to school-based vaccination, which is apparently difficult to enforce in Germany.The conclusion made in our study, that implementation of HPV vaccination in U11 and J1 child medical check-ups may increase vaccination rates, is in line with a strong recommendation of the S3 guideline “Vaccination prevention of HPV-associated neoplasms”  to improOur data are based on statutory health insurance billing data and are therefore more robust than data collected via questionnaires. However, our study also has limitations. (1) The analysis of HPV vaccination on the day of the U11 or J1 examination does not rule out the possibility that girls were vaccinated earlier. (2) U11 billing data were only available from one health insurance company, which might cause a bias in the results. Therefore, the numbers of girls eligible for U11 data were lower than the numbers of girls eligible for other child examinations and the Saarland-wide participation rate could not be determined. (3) 10–15% of people in Germany have private insurance and were therefore not included in our study. Their vaccination behavior may differ from that of those with statutory insurance. (4) We cannot rule out an influence of the socio-economic status or nationality of the children on HPV vaccination rate or attendance of medical check-ups, since such data could not be collected in this study. (5) When analyzing the association between U11 and J1 examinations and vaccination coverage, the "region" of Saarland could not be considered as a potential confounding factor, as the number of cases would have been too small for statistical analysis. (6) Our project started before 2018, when there was no vaccination recommendation for boys in Germany. However, vaccination of boys may provide more robust herd protection. Both aspects, privately insured children including boys, should therefore be considered in a future intervention study to test the effect of organized HPV vaccination.S1 Fighttp://sg.geodatenzentrum.de/web_public/nutzungsbedingungen.pdf.Billed by the KVS between 2013–2019, administered to females resident in Saarland and neighbouring regions. Administrative boundaries © GeoBasis-DE / BKG 2020; Data License Germany—Attribution—Version 2.0; Terms of use: (TIF)Click here for additional data file.S2 Fig(TIF)Click here for additional data file.S1 Table(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.S3 Table(DOCX)Click here for additional data file.S4 Table(DOCX)Click here for additional data file.S5 Table(DOCX)Click here for additional data file.S6 TableShown are the numbers of females with EBM code 89110B before or after the first date for counselling in the context of conception regulation , smear collection in the context of conception regulation , contraceptive prescription , or pregnancy detection .(DOCX)Click here for additional data file.S7 Table(DOCX)Click here for additional data file.S8 Table(DOCX)Click here for additional data file.S9 Table(DOCX)Click here for additional data file.S1 File(DOCX)Click here for additional data file.


The US Department of Housing and Urban Development-Department of Veterans Affairs (VA) Supportive Housing (HUD-VASH) program provides Veterans with a subsidy for rent and case management. In response to the Coronavirus 2019 pandemic, many states enacted stay-at-home orders that may have limited access to case managers. Therefore, we examined the association between statewide stay-at-home orders and utilization of HUD-VASH case management. We linked data on whether a state implemented a statewide stay-at-home order between March 1, 2020 and April 30, 2020 with VA medical records. Analysis time was centered on the date of a state’s stay-at-home order (exposed states). For Veterans in states without a stay-at home-order (unexposed states), we used the average date exposed states implemented an order . We used a difference-in-difference design and adjusted linear regression models to compare total, in-person, telephone, and video case management encounters per Veteran in the 60 days after a stay-at-home order relative to the prior year. There was no significant difference in utilization of case management between Veterans who lived in states that did and did not issue a stay-at-home order. Across all states and in the 60 days after the index date relative to the prior year, Veterans had more total, telephone and video, and fewer in-person encounters. Statewide stay-at-home orders did not differentially affect utilization of case management. Virtual case management in HUD-VASH can increase program reach; however, the effect of virtual case management on outcomes such as quality of life and Veteran satisfaction is unknown. The US Department of Housing and Urban Development-VA Supportive Housing (HUD-VASH) is one program to end Veteran homelessness. HUD-VASH provided nearly 80,000 Veterans with a subsidy for rent at the end of 20204. Veterans in HUD-VASH are responsible for only 30% of their rent5. As part of the HUD-VASH program, Department of Veterans Affairs (VA) staff provide Veterans with at least monthly or bi-monthly case management contacts that teach them life skills, link them with VA and community services and stabilize their mental health4. HUD-VASH case management is associated with increased access to VA healthcare services and increased use of primary care7. HUD-VASH is the largest supported housing program for Veterans in the country, and its expansion over the past 10 years has contributed to a major reduction in Veteran homelessness8.Veterans are one of the largest populations in the United States who are at risk of experiencing housing insecurity9. Concurrently, many VA medical centers transitioned HUD-VASH case management to virtual healthcare (telephone and video), but this method of care delivery may be inaccessible to Veterans experiencing housing insecurity10. The VA implemented several steps to help the most economically insecure Veterans continue to receive care during the transition to virtual healthcare11. First, Veteran facing staff received telehealth training. Second, HUD-VASH case managers increased outreach efforts and proactively contacted Veterans. Simultaneously, all frontline clinicians were tasked with identifying and contacting high risk populations in primary care and mental health. Third, the Homeless Program Office used CARES funding to distribute over 20,000 free smartphones to Veterans experiencing housing insecurity. Fourth, the VA Office of Rural Health funded various initiatives to help rural Veterans access virtual mental health services. Prior to the COVID-19 pandemic, HUD-VASH clinical teams typically delivered care in the community, at Veterans’ homes, or at VA medical centers. To inform HUD-VASH care delivery, it is important to understand how stay-at-home orders and change in care management delivery from in-person community care to virtual care may have affected the utilization of case management.In response to the COVID-19 pandemic, many states enacted stay-at-home orders, which may have limited access to transportation, healthcare services and HUD-VASH case managers10, we believe that HUD-VASH sites and case managers implemented virtual methods of contact independent of state stay-at-home policies. We expect that, on average, Veterans who lived in states that implemented a stay-at-home order did not differentially use case management services than Veterans who lived in states that did not implement a stay-at-home order.We evaluated the association between statewide stay-at-home orders and the frequency and modality  of HUD-VASH case management encounters. Following the VA’s COVID-19 Response Plan that encouraged medical centers to maintain care through telehealth9. We linked these data with data from the VA’s Corporate Data Warehouse and Homeless Operations Management and Evaluation System, which provide information on Veteran enrollment, demographics, and medical records. We assigned Veterans to a state of residence based on the location of the VA Medical Center that delivered their HUD-VASH case management.We used public data to determine which states and the District of Columbia implemented a statewide stay-at-home (includes shelter-in-place) order between March 1, 2020 and April 30, 2020n = 43). Unexposed states (n = 8) did not implement a stay-at-home order, so we assigned Veterans in these states an index date of March 27, 2020, which is the average date exposed states implemented an order.Analysis time was indexed on the date of a state’s stay-at-home order . We censored observations from Veterans during the months they were not enrolled in HUD-VASH and excluded Veterans with multiple enrollment dates without a separating disenrollment and who had missing data on covariates described below.We follow the STROBE Statement for observational studies study and our study was approved by the Providence VA Medical Center Institutional Review Board and Research and Development committees.We used the VA Managerial Cost Accounting Stop Codes to identify the total number of HUD-VASH encounters per Veteran in 60-day intervals before and after the index date. We also used Stop Codes to determine whether each case management encounter was in-person or via telephone or video. Finally, we calculated the proportion of Veterans with no HUD-VASH encounter within each 60-day period before and after the index date.12. We used VA Informatics and Computing Infrastructure definitions to determine whether a Veteran had a diagnosis of substance use disorder, post-traumatic stress disorder, and traumatic brain injury and the Chronic Conditions Warehouse definition to determine whether a Veteran had Alzheimer’s disease13.Veteran sociodemographic and clinical characteristics were obtained from the VA Corporate Data Warehouse. Specifically, we obtained each Veteran’s age, sex, race, whether they served in combat, whether they had a service-connected disability, and marital status on the month of enrollment in HUD-VASH. We used the Elixhauser algorithm to determine whether a Veteran had a diagnosis (yes/no) of rheumatic disease, renal disease, liver disease, depression, diabetes, hypertension, congestive heart failure, valvular disease, pulmonary disease, and HIVAnalyses were conducted at the Veteran level. We graphed unadjusted average total, in-person, telephone and video HUD-VASH encounters, and the proportion of Veterans with no HUD-VASH encounter within each 60-day period before and after the index date.We made all statistical comparisons of utilization between the 60 days after the index date relative to the same period in the prior year. We used a difference-in-differences design and adjusted linear regression models to compare encounters (separate models per outcome) among Veterans in 43 states with a stay-at-home order to Veterans in 8 states without a stay-at-home order. From the adjusted linear regressions, we also calculated the change in number of encounters per Veteran. We controlled for Veteran demographics  and individual chronic conditions which we believe may benefit from HUD-VASH case management or the ability to engage in virtual care. We obtained standard errors accounting for clustering within states.p < 0.001), less likely to live in a rural area , more likely to have a service connected disability , less likely to have alcohol ; p < 0.001) or drug  diagnoses and less likely to be diagnosed with depression .We observed 56,682 Veterans meeting the inclusion criteria. The mean (standard deviation) age of Veterans was 53.1 (12.8) years; 13% were women, 51% were white, 39% were black, 0.7% were Asian, and 9% were other races , a phone call or video encounter may not be as useful or stabilizing as an in-person visit. While there are no data on the effect of HUD-VASH encounter modality on housing or health outcomes, randomized trials of virtual healthcare (telephone and video) in other disease areas have found telehealth to be equivalent to in-person care19.Virtual healthcare was a powerful tool to increase outreach to Veterans in HUD-VASH during the COVID-19 pandemic while limiting the risk of virus transmission. In the period after the index date, Veterans primarily engaged with HUD-VASH providers via telephone (mean number of encounters [SD] 3.41 [3.59]) and Veterans had on average only 0.07 [0.49] video encounters. However, not all encounters may be equal. In-person community and potentially video encounters can provide important clinical insight . Prior evaluations of HUD-VASH have shown it to be effective across heterogeneous Veterans including both genders, those with criminal histories and those with substance use disorders11. However, the viability of enhanced case management outreach and providing Veterans with smartphones after the pandemic subsides is unknown. There are other challenges to sustaining telehealth in HUD-VASH. For example, a prior effort to integrate telehealth with chronic disease management in HUD-VASH was associated with enrollment, engagement and feasibility challenges20. In addition, Veterans’ preferences for in-person compared to telephone and video case management is unknown. Historically, Veterans in HUD-VASH or experiencing homelessness encountered barriers to engaging in virtual care which included limited access to a phone, computer, or stable internet. Cell phone ownership is common among homeless Americans, but smartphone ownership, which can facilitate video encounters, is less common22.There is enthusiasm that after the COVID-19 pandemic subsides, telephone and video care will continue to be a powerful tool to increase HUD-VASH program reach. During the COVID-19 pandemic, the VA and HUD-VASH took several steps to ensure Veterans could continue to engage in case management. This included case managers proactively contacting Veterans during the pandemic and providing smartphones to Veterans experiencing housing insecurityThis study had limitations. We did not examine housing or health outcomes, there is variation in statewide stay-at-home orders, and results are specific to Veterans enrolled in HUD-VASH. In addition, we only examined utilization up to 60 days after the index date, which captures short-term effects. Finally, there may be uncontrolled confounding such as staffing of individual VA medical centers, local operations of HUD-VASH programs, states’ funding of homeless supports, and the likelihood to enact a stay-at-home order.There was no significant difference in utilization of HUD-VASH case management between Veterans who lived in states that did and did not issue a statewide stay at-home order. Telephone and video case management in the HUD-VASH program is a viable method of care delivery that can increase program reach and access. Improving access to telephone and video-based care is a priority, but equally important is understanding which services can effectively be delivered virtually. For example, virtual care may not be the most effective modality for Veterans with housing insecurity who have challenging comorbidities. To improve telephone and video healthcare for all housing-insecure Americans, we must understand their preference for care modalities, and the effect of care modality on quality of care, housing and health outcomes.Supplementary Information


Background: In the Lombardy Region, Italy, HPV vaccination is recommended and offered free of charge to 12-years-old males since 2017. The expected vaccination thresholds are still far to be reached. Methods: A cross-sectional survey to investigate parents’ attitudes towards the HPV vaccine and knowledge about HPV was administered to parents of boys aged 6 to 18 years attending a large pediatric hospital for outpatient specialistic evaluations. Two parallel multiple logistic regression analyses were conducted to estimate the odds ratios (ORs) and the corresponding 95% confidence intervals (CIs) for attitude towards HPV vaccination and perceived need for more information about HPV vaccination. Results: A positive attitude towards HPV vaccination was found in 74% of interviewed parents. Knowledge of HPV, having a generally positive attitude toward vaccination, and mothers filling in the survey were positively associated with a positive attitude to the HPV vaccine. Parents’ perceived need for more information about HPV vaccination was positively associated with the child’s age, general positive attitude toward vaccination, Christian religion, and positive attitude toward HPV vaccination; knowing that HPV vaccination is free of charge significantly reduced the risk of asking for more information on HPV vaccination. Conclusions: The majority of parents of male children and adolescents in our study have a positive attitude toward HPV vaccination. Attitude toward HPV vaccination and perceived need for more information on HPV vaccination were directly related to a positive attitude toward vaccines in general. In addition, knowledge of HPV and related pathologies favors a positive attitude toward HPV vaccination. Future health programs should target an even wider diffusion of evidence-based information on vaccines in general and on the HPV vaccine in young males, to support a positive attitude toward vaccines in the general population. Human Papillomavirus (HPV) infection is the most common sexually transmitted infection worldwide, as up to 80% of sexually active men and women are expected to encounter it at least once in their lifetime ,2. CerviPrevention strategies for HPV-related diseases still comprise screening programs for women based on cytological smears; in addition to this, over the years, different HPV vaccines have been developed. Currently, there are three prophylactic HPV vaccines available . All of them target the high-risk HPV genotypes (HPV-16 and HPV-18) plus other low-risk genotypes , which are associated to anogenital warts and low-grade abnormalities. Previous studies have shown the vaccines’ efficacy in reducing the transmission and prevalence of HPV infection and cervical abnormalities ,11.In 2007, Italy began its campaign for immunization recommending the HPV vaccine to girls aged 11–12 years and offering it free of charge. With the latest National Vaccination Prevention Plan (PNPV), issued in 2017, the offer was extended to boys of the same age, starting from the 2006 cohort .Previous studies have investigated the knowledge of HPV and attitude toward HPV vaccination in adolescent or adult men ,16,17,18Considering the HPV-infection burden in men and women together with the increased availability of effective and safe vaccination strategies supported by the latest PNPV, we aimed to investigate the factors potentially predicting the unsatisfactory HPV vaccination coverage in Italian boys observed so far. In detail, we will examine either attitude toward HPV vaccination or the perceived need for more information on HPV, as well as their determinants, in parents of boys interviewed in a large hospital in the greater Milan area, in the Lombardy region, Italy. While shedding light on the gap between expected and actual coverage, we expect to inform future strategies in support of vaccination adherence.Upon approval from the Ethical Committee of the University of Milan, we conducted an anonymous survey regarding HPV vaccination in boys from November 2021 to February 2022. Eligible subjects were parents of boys aged 6–18 years who attended the large pediatric Buzzi hospital in Milan for outpatient specialistic visits in the study period. We excluded those subjects who were not able to read and understand the questionnaire in one of the proposed languages. After informed consent was signed, a questionnaire (details in the following) was delivered to one parent/caregiver and filled in in the waiting room. Trained medical personnel were available for any upcoming question. Upon completion, parents received a leaflet with information about HPV infection and vaccination.We specifically developed a 15-item self-administered questionnaire to evaluate parents’ knowledge and acceptability of the HPV vaccine in boys, based on an extensive literature search of factors related to vaccine acceptability, as well as questionnaires used in similar studies ,26,27,28After socio-demographic characteristics of parents and children were collected, the core focus of the questionnaire assessed parents’ knowledge about HPV infection and availability of free-of-charge vaccines for males and females, parents’ general attitude toward vaccines, and their attitude toward HPV vaccination for their son. Reasons for not vaccinating were also investigated. Finally, the last two questions addressed parents of boys >15 years who had not been included in the PNPV and were not offered the HPV vaccine for free. The administered questionnaires  are available in the The sample size was calculated considering a Chi-square test of independence between the three-level “attitude toward HPV vaccination” variable and any other possible three-level categorical variable of interest. Assuming an alpha value of 0.05 and a power of 0.80, the number of responders needed to reach an effect size of 0.20 with 4 degrees of freedom was 299. Accounting for a potential dropout of 20%, the final sample size to collect was set at 360.Subjects were included in the study until the expected sample size of 360 parents was reached. A total of 27 participants were excluded from the analysis due to incomplete questionnaires. A total sample size of 339 parents was considered in the final analysis.The study population was initially characterized through descriptive statistics, including absolute frequencies and percentages for categorical variables and mean and standard deviation for continuous variables because the corresponding distributions were symmetric.Two parallel multiple logistic regression analyses were further conducted to estimate the odds ratios (ORs) and the corresponding 95% confidence intervals (CIs) for each of the following outcome variables: attitude towards HPV vaccination  and perceived need of more information about HPV vaccination (yes vs. no). A confounding-factor-only model was initially fitted that included a selection of five confounding factors derived from a careful examination of the literature. The final regression model was obtained by taking the confounding-factor-only model for granted and adding the best set of all the remaining variables with a stepwise selection approach.We also examined pairwise interaction terms in the confounding-factor-only model and in the final model. In detail, we added one interaction term at a time to the main-effects model; evidence of a potential interaction effect was explored with the likelihood ratio test comparing main-effects models including versus excluding each interaction term.p < 0.05 for the main effects and when p < 0.1 for the interaction effects. The statistical analysis was performed using the R software, version 4.1.2 (1 November 2021).Significance was assumed when Socio-demographic characteristics of the sample are reported in Here, 90% of parents had a positive attitude toward vaccines in general vs. 74% had a positive attitude toward HPV vaccination. Among the latter, 20.6% of parents had their son already vaccinated and 53.4% of parents were willing to have him vaccinated. Almost half of those who did not want to vaccinate their sons indicated the lack of information as the main motivation.Among boys older than 15 years—to whom HPV vaccine was not offered for free when they were 12 years old—only 27.7% were vaccinated, whereas 61.7% of parents whose sons were not vaccinated would have done it if it had been free of charge.HPV infection is a cause of significant medical burden in both female and male populations, representing a public health priority. Therefore, vaccine-based preventive strategies have been increasingly available worldwide with target population extending toward young boys, as reported in the latest PNPV. Despite these measures, the goal of reaching >95% of HPV vaccination coverage in both girls and boys is far from being achieved.Factors underlying reduced parental compliance toward HPV vaccination have been investigated by previous studies, which, however, are often not concordant in their results. Most of the current evidence derives from studies carried out among parents of females, and the majority of them were not Italian studies. Our study is the first to be conducted in Italy, specifically addressing parents of boys, after the introduction of free of charge HPV vaccination in males.Our study reports that, overall, 74% of interviewed parents reported having a positive attitude toward HPV vaccination: 53.4% reported being willing to have their sons vaccinated and 20.6% reported having already vaccinated them. Previously published papers, though conducted in northern America and Asia, found a similar percentage of boys’ parents willing to vaccinate, ranging from 45% to 67% ,25,29,30Considering parents’ attitudes toward HPV vaccination, the major influencing factors were a positive attitude toward vaccines in general and a reported knowledge of HPV and related pathologies. These findings are consistent with previous evidence, both in males’ and females’ parents ,31,32,33In accordance with Nguyen’s recent findings , in our = 2.05, 95% CI: 1.00–4.20). In the absence of significant interactions involving knowledge of free HPV vaccination, this suggests that free of charge vaccination is not as important for parents in their decision-making as are other factors.A systematic review published in 2014 identified vaccine cost as a barrier to against HPV vaccination in children . In a ChParental education did not influence vaccination acceptability in our study. However, results from the literature are mixed, with some older studies reporting an inverse association ,39,40,41As in previous studies, we did not find strong associations between demographic characteristics and vaccination uptake in males . ParentaAs knowledge about HPV strongly influences parents’ willingness to vaccinate their sons, we further focused on the perceived need for information about the HPV vaccine and its determinants, a less investigated topic in all the previously cited papers. A child’s age was significantly and inversely related to parents’ perceived need for information. This suggests awareness-raising campaigns and informative conversations with pediatricians may be targeted at parents of younger children, thus encouraging earlier and better parents’ acceptability toward HPV vaccination.Unsurprisingly, parents reporting a positive attitude toward vaccines in general and parents reporting the intention to have their sons vaccinated were also more interested in receiving information about the HPV vaccine. In our study, parents reporting already know that vaccine is free of charge were less prone to be informed, because they have been likely in contact with someone who provided some information on HPV vaccination.On the contrary, the parental perceived need for information was not influenced by their age, nationality, and education level, suggesting a limited impact of demographic factors. Religion was, however, an exception: contrary to its null effect on parents’ willingness to vaccinate, being Christian was positively and significantly associated with a perceived need for more information about the HPV vaccine.Our study has some limitations. First, as an intrinsic limitation of survey-based research, our results may have been affected by response bias. The questionnaire was completed by parents while waiting for an outpatient specialistic evaluation for their sons in the hospital waiting room, thus, their participation in the study may have been influenced both by the setting and by a possible pre-existing greater attention to health care-related behaviors. Secondly, different attitudes related to religious beliefs may have been underestimated, since the catholic religion is still the most largely professed one in our sample. Third, our survey has been conducted during the third wave of the COVID-19 pandemic and while starting the COVID-19 immunization campaign for 5–11-year-old children in Italy. Thus, we cannot exclude that a generally better attitude toward vaccinations during the pandemic time may have influenced either survey participation or our findings on HPV vaccination attitude.Our study has also some strengths. The expected sample size was reached, and this is especially worthy note if compared to the relatively short recruitment window. This is due in part to the availability of several outpatient ambulatories within V. Buzzi Children’s Hospital. In addition, this hospital is one of the two large pediatric reference centers available in Milan. Its catchment area includes also patients belonging to the greater Milan area, as it represents a point of reference for several pediatric specialties. Our sample is multiethnic, as nearly 15% of interviewed parents were foreigners, a higher percentage than the one registered in Italy and Lombardy Region  . TherefoOur results show that the majority of parents of male children and adolescents have a positive attitude toward HPV vaccination. It represents a limited but positive signal, even if HPV vaccine coverage is still far from meeting the 2017 PNPV goals. Attitude toward HPV vaccination and perceived need for more information on HPV vaccination were directly related to a positive attitude towards vaccines in general. In addition, knowledge of HPV and related pathologies favor a positive attitude toward HPV vaccination. Similarly, lack of information was indicated, in our study, to be the most common reason for parents to refuse vaccination. Future health programs should target an even wider diffusion of evidence-based information on vaccines in general and, specifically, on primary prevention of cancer and other HPV-related diseases through vaccination in both girls and boys. This effort will itself provide support to a stronger positive attitude toward vaccines in the general population.


We determined baseline oral and cervicogenital human papillomavirus (HPV) prevalence and determinants of infection in the Michigan HPV and Oropharyngeal Cancer (MHOC) study. We enrolled 394 college-age and older participants of both sexes in Ann Arbor, Michigan and the surrounding area. All participants provided an oral sample at baseline, and 130 females provided a cervicogenital sample. Samples were tested for 18 HPV genotypes using polymerase chain reaction (PCR) MassArray. Participants filled out sociodemographic and behavioral questionnaires. Prevalence ratios for HPV oral or cervicogenital prevalence by predictor variables were estimated in univariable log-binomial models. Analysis was conducted 2018–20. In the full cohort, baseline oral HPV prevalence was 10.0% for any detected genotype  and 6.5% for high-risk types, and cervicogenital prevalence was 20.0% and 10.8%, respectively . Oral HPV prevalence did not vary by sex, with 10.5% of women and 9.0% of men having an infection. We found a high prevalence of oral and cervicogenital HPV infection in college-age participants reporting no lifetime sexual partners. Reporting a single recent partner was associated with a lower oral HPV prevalence  than reporting no recent (but at least one ever) partner. No similar protective effect was seen for cervicogenital HPV. Both oral and cervicogenital prevalence increased with the number of recent partners for most sexual behaviors. We observed an ecological fallacy masking the direction of impact of vaccination on HPV prevalence in the full cohort compared to the college-aged and the age 23+ populations considered separately. Substance use was not significantly associated with oral or cervicogenital HPV infection. Many studies report substantially higher oral HPV infection prevalence in men than in women. That difference may not be uniform across populations in the US. While the human papillomavirus (HPV) is well known as the primary cause of cervical cancer, incidence of HPV-related oropharyngeal squamous cell carcinoma (OPSCC) in the U.S. is now greater than that of cervical cancer –4. IndeeOPSCC is more than three times more common in men than in women in the U.S. , 4, whicThe Michigan HPV and Oropharyngeal Cancer (MHOC) Study aims to evaluate patterns of oral HPV infection, prevalence, incidence and clearance and their relationship to sexual history and sexual behaviors. MHOC includes an epidemiological arm that tests a longitudinal cohort for oral  HPV . The lonWe previously published the full study protocol , includiStudy participants were recruited in Ann Arbor, Michigan and the immediate surrounding areas. Participants were recruited at University of Michigan campus residence halls, through community fliers, and through the University of Michigan Health Research website. Volunteers over the age of 18 without a history of head and neck cancer who were willing to participate in both the baseline and longitudinal (3–4 visits per year for 3 years) portions of the study were invited to enroll. We enrolled participants between April 2015 and December 2017. A substudy focusing on cervicogenital HPV enrolled participants that had a vagina and were not pregnant to enroll; these participants could not collect cervicogenital specimens on days that they were menstruating. Documented informed consent was obtained from all participants. The University of Michigan Institutional Review Board approved consent documents and study protocol (HUM00090236).A baseline questionnaire was administered to each participant at their initial visit. Participant ID numbers were assigned to ensure participant confidentiality. The surveys were designed to individually assess a variety of topics including demographics, vaccination and screening history, sexual health and behavior, and alcohol and drug use. Sexual behavior questions assessed current and past experiences of vaginal, oral, and anal sex, including the number of ever and recent (past 6 months) sexual partners with whom they engaged with each of these types of sex. Vaginal and anal sex were defined to participants as vaginal and anal penetration of any kind, respectively, and oral sex was defined as stimulation of genitals by the mouth.® HPV test  used in clinical settings, those designated by the International Agency for Research on Cancer (IARC) as group 1  or group 2A (probably carcinogenic: 68) carcinogens [All participants self-collected a saliva sample with Scope mouthwash  as in NHANES  or an Orcinogens , those iStudy data were collected and managed using REDCap electronic data capture tools hosted at the University of Michigan , 26. Datα = 0.05.We consider two main outcome variables: 1) presence of HPV in a participant’s oral sample at the baseline study visit and 2) presence of HPV in a participant’s first valid cervicogenital sample. We use baseline oral and first valid cervicogenital test because the cervicogenital substudy was rolled out after the main study began. We assessed sample prevalence of these two outcomes in their respective populations based on demographic and behavior variables derived from participant answers to the surveys. We also stratified the cohort into ages 18–22 years (college-age cohort) and ages 23+ (older cohort) for oral HPV prevalence. To estimate prevalence ratios, we ran univariable, log-binomial regression models for oral HPV prevalence predicted by the variables in We recruited 394 participants, 241 in the college-age cohort (ages 18–22 years) and 153 in the older cohort (ages 23+); 130 participants from the full cohort were recruited to also participate in the cervicogenital substudy . ApproxiParticipants also reported the number of partners in the last 6 months for a variety of intimate and sexual activities . Approxi® HPV test, currently the only test FDA-approved for clinical use , the prevalence of oral HPV was only 6.5%, while the prevalence of cervicogenital HPV was 10.8%. The distribution of genotypes in the oral and cervicogenital samples is given in the vaccination status and age-group  and older ages (50+), with lower prevalence in between. Oral but not cervicogenital HPV was higher in Asian participants, although this result is likely due to the fact that most Asian participants were in the younger cohort. Oral HPV prevalence was not statistically significantly higher in men who were uncircumcised (10.0% vs. 7.6%) and among those who reported ever being diagnosed with an STI (15.8% vs. 9.7%). There were no cervicogenital infections among women ever reporting an STI, but the sample size was small (n = 9).We found oral and cervicogenital HPV prevalence varied by demographic and behavioral variables, though almost no variable achieved significance in univariable log-binomial regression models . Oral HPThere was little difference in oral or cervicogenital prevalence among those who reported being vaccinated and those who reported being unvaccinated, even when considering only genotypes 6, 11, 16, and 18  and unvaccinated (6.3%); cervicogenital prevalence among vaccinated (1.5%) and unvaccinated (1.7%)) although the absolute numbers of positives are small. The apparent lack of protection from vaccination appears to be the result of an ecological fallacy, however. When considering the college-age and older adult cohort separately, the point estimates of oral HPV prevalence were lower in vaccinated individuals of both groups.Those reporting ever engaging in deep kissing  or any sexual behavior  had lower oral and cervicogenital HPV prevalence than those that did not . This reThis analysis presents a first look at the Michigan HPV and Oropharyngeal Cancer (MHOC) Study’s epidemiological cohort. In this baseline analysis, we investigated associations of HPV prevalence with demographic and behavioral risk factors. Compared to the nationally representative National Health and Nutrition Examination Survey , 11, we However, while the prevalence magnitudes differ between NHANES and MHOC, the age-specific patterns are very similar, both exhibiting the classic bimodal distribution : high prWe found high oral and cervicogenital prevalence among college-age participants who reported no sexual partners in their lifetime. It may that these participants were not reporting their experiences accurately, possibly to avoid consequences if their answers were ever disclosed or simply to minimize the survey burden. In any case, we believe that our analysis of the associations of sexual behavior and HPV prevalence are subject to some level of misclassification bias. We also found that oral HPV prevalence was generally higher among those reporting at least one lifetime but no recent partners compared to those reporting one recent partner, and this result was consistent for both age groups. However, we did not find an analogous result for cervicogenital HPV; those reporting no recent sexual partners had lower than those reporting at least one. When considering only those who report at least one recent sexual partner, prevalence increased with the number of recent sex partners, as expected. While sexual acts are strongly correlated, previous studies have differed in the reported strength of association between oral vs. vaginal sex and oral HPV prevalence –15; hereNationally representative data demonstrate that oral and genital prevalence of HPV vaccine genotypes is reduced among vaccinated people , 18. In The limitations of this baseline analysis include the relatively small sample size compared to NHANES and other HPV prevalence studies. However, because this cohort is designed to be studied longitudinally, we will have substantially more power in the analysis of HPV prevalence over time. Analysis of the longitudinal data will later provide a detailed consideration of the short-term dynamics of the detection of oral and cervicogenital HPV . This inThis hypothesis-generating work contributes to our understanding of the prevalence and determinants of oral HPV by suggesting that prevalence of HPV in women is not uniformly lower than in men. More work is needed to understand regional variation in oral HPV prevalence overall and by genotype. Too, more work is needed to better understand the specific transmission pathways that lead to oral HPV infection, particularly the relative contribution of oral sex vs autoinoculation from genital infection and the role of latent infections.S1 TableData collected in Ann Arbor, MI, 2015–17, analyzed 2018–2020. Note: percentages may not add up to 100% as participants could refuse to answer questions. *Other than HPV.(DOCX)Click here for additional data file.S2 Table(DOCX)Click here for additional data file.S1 FileThis minimal, deidentified data set contains the baseline demographic, behavioral, and HPV data on each MHOC Study participant.(CSV)Click here for additional data file.


Aim: The aim of this study was to verify the prevalence of some peculiar characteristics of HPV - koilocytosis - in oral and oropharyngeal SCC. Study design: transversal cohort. Material and method: Twenty slides with oral and/or oropharyngeal SCC were examined under microscopy. Results: in 15 of them, koilocytosis was found, amounting to 75%. Although we know that polymerase chain reaction (PCR) is the method with the best sensitivity for HPV detection, we began this research looking for koilocytosis, which is highly suggestive of HPV infection. Conclusion: This study is a trial project and we will continue this research with PCR measures to confirm this high prevalence of HPV infection in oral and oropharyngeal SCC.Human papillomavirus (HPV) is considered to be an etiologic agent of cervical cancer and, recently its relation to oral and oropharyngeal cancer has also been investigated. Oral squamous cell carcinoma (SCC) represents 90% of all malignant tumors that affect the oral cavity. The prevalence of HPV in patients with SCC ranges from 0 to 100%. The most known viral cytopathic effect is koilocytosis, considered to be a major characteristic of HPV infection.  The Human papillomavirus virus (HPV) is a small sized virus of intranuclear replication with diameter of approximately 50 nm Comprehensive research studies related some subtypes of HPV to malignant and pre-malignant lesions of cervix, vulva, penis, conjunctive and upper digestive tract and airwaysToday, there are molecular biology methods to study HPV such as in situ hybridization (ISH), hybrid capture and PCR that provide not only increased sensitivity in diagnosis, but also the typing of HPV, but costs of such exams are higher if compared against the detection of koilocytosis hematoxylin-eosin stained slides.Oral squamous cell carcinoma is also known as epidermoid or oral spinocellular carcinoma (OSC) and accounts for 90% of all malignant tumors that affect the oral cavityTobacco and alcohol abuse are well established risk factors for oral cancer, but a small rate (15-20%) of the patients do not have any past history of smoking or alcohol addiction suggesting the presence of other risk factors HPV 16 is the most common type of virus associated with oral and cervical cancer in vitroThe importance of HPV infection in oral carcinogenesis is supported by the ability of high risk HPV to immortalize oral keratinocytesThe objective of this study is to determine the prevalence of suggestive findings of HPV, koilocytosis in OSC of the oral cavity and oropharynx through histological analysis of such lesions.Twenty patients diagnosed with OSC of the oral cavity and oropharynx were examined with optical microscopy to investigate suggestive signs of HPV infection in hematoxylin-eosin stained slides.Concomitantly, the records of the 20 cases were investigated as shown in Seventy-five percent of the cases (15/20) presented koilocytosis, and were identified as positive cases of koilocytosis (C+).The survey in patients’ records showed that 19 patients were male and 1 patient was female, ages ranging from 42 to 86 years (mean age= 58.9). Fifteen patients were White, three were Brown and two were Black. The group of C+ patients had ages that ranged from 47 to 80 years (mean age= 57.9). The group of C-patients had ages that ranged from 42 to 86 years (mean age= 61.8).Eleven patients were smokers (55%) and six were alcohol abusers (30%), with 6 patients (30%) - 5 C+ and 1 patient C- that did not have any smoking or alcohol history in their records. The group of C+ patients had 60 % of smokers and 40% of alcoholics, whereas the group C- had 40% smokers and did not have any alcoholic patient as shown in The tumor location varied. Most occurred in the palate (35%) - 20% in the soft palate and 15% in the hard palate – followed by the oral cavity floor (25%), oropharynx (20%), tongue (10%), gums (5%) and jugal mucosa (5%). In the C+ group, the most common sites were palate and oral cavity floor, both with 27% rate, whereas in the group C- the most common site involved was the palate region (60%).In regards to the clinical aspect upon diagnosis, most of the patients had ulcerated infiltrating lesion (60%) and in advanced staging - T4 (50%), in 7 patients (35%) - 5 C+ and5122 C- - did not have any report of clinical staging in their records. In the C+ group, 66% of the patients had ulcerated infiltrating lesion and 54% were in advanced staging, whereas in the C- group, 40% of the patients had ulcerated infiltrating lesions and 40% were in advanced staging.In this study, koilocytosis was found in 15 out of the 20 slides investigated, accounting for 75% of the cases.Koilocytosis first described by Leopoldo Koss et al. in 1956According to some authors Some papers in the literature report that HPV frequency in oral carcinoma ranges from 0 to 100%Herrero et al. Niv et al. Positive HPV carcinoma seem to be a distinctive entity , with distinct biology (less p 53 mutation), distinct risk factors  Cruz et al. Klussmann ET al. Some authors Miller and JohnstoneBrandwein et al. Although we know that PCR is the best current method to detect HPV this study began by investigating koilocytosis in hematoxylin-eosin stained slides, which is highly suggestive of HPV infection. This study is part of a pilot project that will be followed up by PCR tests to be performed in all slides previously examined to confirm the high prevalence of HPV infection in oral OSC. The histological analysis by itself may suggest the presence of HPV and is a screening method of HPV-related lesions. It is quite a useful method in centers in which sophisticated molecular biology survey methods are unavailable.Careful anatomic pathological survey of OSC of oral cavity and oropharynx showed high prevalence of koilocytosis - 75% -, indicating a likely high HPV prevalence in this type of tumors.


The development of malignancy is closely connected with the process of cancer microenvironment remodeling. As a malignancy develops, it stimulates the creation of the suppressive microenvironment of the tumor through the presence of cells that express membrane proteins. These proteins are secreted into the cancer microenvironment, where they enable tumor growth. In patients with cancer of the cervix, the development of the disease is also linked to high-risk HPV (hr-HPV) infection. Such infections are common, and most clear spontaneously; however, a small percentage of these infections can persist and progress into precancerous cervical intraepithelial neoplasia and invasive cervical carcinoma. Consequently, it is assumed that the presence of hr-HPV infection alone is not sufficient for the development of cancer. However, chronic HPV infection is associated with the induction of the remodeling of the microenvironment of the epithelium. Furthermore, the local microenvironment is recognized as a cofactor that participates in the persistence of the HPV infection and disease progression. This review presents the selected immune evasion mechanisms responsible for the persistence of HPV infection, beginning with the delay in the virus replication process prior to the maturation of keratinocytes, the shift to the suppressive microenvironment by a change in keratinocyte immunomodulating properties, the alteration of the Th1/Th2 polarization of the immune response in the microenvironment, and, finally, the role of HLA-G antigen expression. The development of malignancy is closely connected with the process of cancer microenvironment remodeling. As a malignancy develops, it stimulates the creation of the suppressive microenvironment of the tumor through the presence of cells that express membrane proteins. These proteins are secreted into the cancer microenvironment, where they enable tumor growth ,2,3. In Human papillomaviruses (HPVs) belong to the Papillomaviridae family that comprises epitheliotropic DNA viruses with an affinity for squamous epithelia. These viruses infect the skin and mucosae, inducing benign hyperproliferative lesions, such as warts and asymptomatic precursor lesions, that can progress to high-grade neoplasia and malignancy. Certain types of papillomaviruses are also known to show a preference for distinct anatomical sites ,9,10,11.The transforming potential of the HPV virus is determined by HPV E6 and E7 oncoproteins. These oncoproteins are responsible for the inactivation and degradation of both the tumor suppressor protein p53 (E6) and the retinonblastoma protein (Rb). E6 proteins that bind p53 stimulate its degradation . The P53Human papillomavirus is a tissue-specific intraepithelial pathogen that can infect and replicate only within a fully differentiated squamous epithelium. The HPV replication cycle involves the infection of basal keratinocytes in an abrased epithelium ,30. In tAccording to many studies, HPV infection contribution in the development and progression of invasive cervical cancer is quite common; however, 10–15% of invasive cervical cancer tissue samples test HPV-negative ,35,36. THPV infects mucosal epithelia, targeting the dividing cells in the basal epithelial layer. In epithelial tissue stem cells, the HPV genome is deposited in the nucleus and begins to express early viral proteins. When infected basal epithelial cells divide, the viral genome copies are replicated into daughter cells. The continued presence of the viral genome over a period of several years in actively dividing epithelial cells results in persistent infection . The kerInterleukin-6 (IL-6) is a proinflammatory cytokine that inhibits the apoptosis of cells during inflammation through the activation of JAK-STAT signaling pathways after binding to the IL-6 receptor (IL-6R) ,48. IL-6The cervical cancer tumor is infiltrated by tumor-infiltrating lymphocytes (TIL), meaning CD3+, CD4+, and CD8+T cells, and CD3+CD4+ (double positive) T cells are predominant in the tumor center . An incrWithin the tumor microenvironment at virus-infected sites, a suppressive profile is created through hypoxia and oxidative stress. This process is regulated by various cells and mediators. It has been found that HPV may interfere with the Th1/Th2 polarization of the immune response. In early lesions induced by HPV-infection, a Th2-like immune response with dominating cytokines, such as IL-6 and IL-10, has been observed. In high-grade epithelial lesions, TNF-alpha levels are upregulated, and both Th1- and Th2-response cytokines are increased. The change in the profile of the immune response from Th1 to Th2 during the disease’s early stages may influence its persistence and progression ,56,57,58Regulatory and suppressive immune cells can be recruited to the virus-infected sites and cancer microenvironments through various factors, including cytokines IL-6 and IL-10, as well as growth factors like VEGF and PGE2. Tumor-associated macrophages present in the tumor microenvironment are strongly associated with viral infection . IncreasThe progression of cervical cancer is determined by a complex interaction between the host’s immune system and the HPV infection. Only a small percentage of HPV infections develop into high-grade squamous intraepithelial lesions (HSIL)- CIN3 (10% of HPV infections) and cervical cancer (less than 1% of HPV infections). Many studies have analyzed HLA-G expression in cervical cancer patients. Human leukocyte antigen-G (HLA-G) is one of the nonclassical HLA-class Ib molecules associated with various mechanisms of immune suppression. For the first time, HLA-G has been identified in trophoblast cells as a ligand for suppressive receptors present on uterine NK cells and participating in the process of immune tolerance during pregnancy . MalignaFinally, HLA-G polymorphism was studied, revealing that in women in Brazil, CIN3 polymorphism of HLA-G was linked to HPV infection and CIN3. The studies concluded that the presence of HLA-G polymorphism created a profile compatible with a predisposition to cervical cancer development . ResearcIn summary, an infection of HPV is an unquestionable causative factor for cervical cancer, however, it is not well understood how the virus persists for decades before the development of cancer; it seems that the virus needs mechanisms to escape host immunity. The HLA-G protein expression was upregulated in tissues from the HPV-positive cervical carcinoma, as compared to the HPV negative normal cervix ,72,73,79The local, post-infection, immunosuppressive, virus-supporting microenvironment seems to have become a novel yet important diagnostic and therapeutic target. This diagnostic and therapeutic strategy focuses on the identification of post-infection microenvironment biomarkers and the on inhibition of post-infection microenvironment formation. At present, the research is performed to identify biomarkers reflecting the formation of the local post-infection microenvironment. This includes the identification of the immune cells and their activity and the presence of the cytokines, and chemokines, participating in suppressing the immune responses  ,48,49,50The targeting of the local immunosuppression encompasses the reactivation of antiviral immune response and the reversal of the local immunosuppression. Immune checkpoint inhibitors (ICIs) are one of the therapeutic targets, having been used in the treatment of melanoma, Hodgkin’s lymphoma, and bladder cancer. PD-1 (programmed cell death protein 1) and PD-L1 (programmed death-ligand 1) inhibitors have been approved by the U.S. Food and Drug Administration for clinical use . PD-1 anIFNγ and TNFα suppress the proliferation of keratinocytes; IFNγ induces growth arrest and differentiation, and subsequently induces caspase-mediated apoptosis ,86. Ma eIn conclusion, the development of novel biomarkers and therapies in cervical cancer has to consider the deep influence on the microenvironment remodeling related to HPV infection.