Prophylactic HPV vaccination: past, present, and future

Racial and Ethnic Disparities in Human Papillomavirus Vaccination Among US-Born and Foreign-Born Adults Aged 18 to 26 Years in the United States

BACKGROUND/OBJECTIVES

Human papillomavirus (HPV) is linked to multiple cancers that can be prevented through vaccination. While the optimal age for vaccination is in childhood and adolescence, vaccination recommendations include adults through age 26 who missed childhood/adolescent vaccination. There are limited data about disparities among adults eligible for catch-up HPV vaccination. We conducted a comprehensive examination of HPV vaccination among US young adults, disaggregating the group by race/ethnicity and nativity status to identify subgroups that may require additional interventions.

METHODS

We analyzed 2019 and 2022 data of individuals aged 18-26 years from the National Health Interview Survey. Generalized linear models using Poisson regression with log link were used to examine the receipt of 1+ dose of HPV vaccine, race/ethnicity, and nativity (i.e., US- versus foreign-born) status.

RESULTS

The overall receipt of 1+ doses of HPV vaccine was 47.5%. The vaccination rate among the US-born group was 49.7% versus 31.9% among the foreign-born group with an adjusted prevalence ratio (APR) of 0.72; (95% CI, 0.62-0.82). Foreign-born non-Hispanic (NH) Black individuals (APR 0.31; 95% CI, 0.13-0.70) were less likely to be vaccinated against HPV than foreign-born NH White individuals, while US-born NH Asians (APR 1.27; 95% CI, 1.09-1.48) had a higher prevalence of the vaccination than the US-born NH White group. Additionally, foreign-born NH Asian (APR 0.60; 95% CI, 0.46-0.77), NH Black (APR 0.27; 95% CI, 0.12-0.61), and Hispanic (APR 0.76; 95% CI, 0.60-0.97) populations were less likely to be vaccinated than their respective US-born counterparts. Conclusion: Profound HPV vaccination inequalities exist among US young adults with particularly low vaccine coverage among racially and ethnically minoritized immigrant populations.

The Impact of HPV Vaccination on Cervical Cancer in adolescent females: A narrative review

To effectively prevent cervical cancer, a leading cause of global morbidity and mortality among women, widespread adoption of the HPV vaccine has a well-established link to human papillomavirus (HPV) infection. HPV vaccine must be the vaccine's effectiveness in reducing HPV infections, and subsequent cervical lesions have been extensively demonstrated, marking a pivotal milestone in public health. Important research highlights the vaccine's safety profile, allaying worries and promoting trust in its application. By targeting HPV strains responsible for a majority of cervical cancer cases, vaccination emerges as a strategic intervention to curb the burden of this malignancy. The strategy is used to search PubMed and Google Scholar, with only free full-text and English language study included. However, addressing existing misconceptions and ensuring equitable vaccine access remains imperative. Informed decision making is pivotal, necessitating comprehensive public health initiatives that educate communities about the vaccine's benefits. Encouragingly, successful vaccination programs in various regions have demonstrated tangible reductions in HPV prevalence and cervical cancer incidence. This review concludes by emphasizing the urgent need for global collaboration to integrate HPV vaccination into routine immunization schedules, thereby fortifying the collective effort to mitigate cervical cancer's impact. As a cost-effective, evidence-based strategy, widespread HPV vaccination stands as a linchpin in the ongoing battle against cervical cancer, promising a healthier future for women worldwide.

Analysis of factors affecting the accuracy of colposcopic diagnosis of cervical lesions: a retrospective cohort study

Background

Cervical cancer is a leading cause of cancer-related deaths among women. However, in developing countries, the primary focus for cervical cancer prevention and control remains on the timely detection and treatment of precancerous lesions. This study aims to evaluate the accuracy of colposcopic diagnosis of cervical intraepithelial lesions and analyze the factors influencing its accuracy.

Methods

This study collected data from 512 eligible patients who visited the gynecology outpatient clinic of the Second Hospital of Jilin University from January 2022 to August 2023. The final diagnosis was based on the highest grade observed in both biopsy pathology and postoperative pathology. A self-controlled, retrospective analysis was conducted to evaluate the accuracy of colposcopic diagnosis. Univariate analysis was used to assess the impact of factors such as menopausal status, duration of menopause, high-risk human papillomavirus (HR-HPV) genotypes, and transformation zone (TZ) types on the accuracy of colposcopic diagnosis of cervical lesions.

Result

The overall colposcopy diagnostic concordance rate was 78.71%. The concordance rates between the premenopausal and postmenopausal groups differed significantly (χ 2 = 75.450, p < 0.05). The HPV16/18 positive group and the non 16/18 HR-HPV positive group also showed a significant difference in concordance rates (χ 2 = 5.890, p < 0.05). There were significant differences in concordance rates between TZ2 and TZ3 (χ 2 = 10.585, p < 0.05), as well as between TZ1 and TZ3 (χ 2 = 14.607, p < 0.05).

Conclusion

Factors such as menopausal status, duration of menopause, HR-HPV genotypes, and TZ types influence the accuracy of colposcopic diagnosis. Therefore, a comprehensive evaluation incorporating these factors should be performed in clinical practice to enhance diagnostic accuracy.

Early Cervical Cancer Diagnosis with SWIN-Transformer and Convolutional Neural Networks

Introduction: Early diagnosis of cervical cancer at the precancerous stage is critical for effective treatment and improved patient outcomes. Objective: This study aims to explore the use of SWIN Transformer and Convolutional Neural Network (CNN) hybrid models combined with transfer learning to classify precancerous colposcopy images. Methods: Out of 913 images from 200 cases obtained from the Colposcopy Image Bank of the International Agency for Research on Cancer, 898 met quality standards and were classified as normal, precancerous, or cancerous based on colposcopy and histopathological findings. The cases corresponding to the 360 precancerous images, along with an equal number of normal cases, were divided into a 70/30 train-test split. The SWIN Transformer and CNN hybrid model combines the advantages of local feature extraction by CNNs with the global context modeling by SWIN Transformers, resulting in superior classification performance and a more automated process. The hybrid model approach involves enhancing image quality through preprocessing, extracting local features with CNNs, capturing the global context with the SWIN Transformer, integrating these features for classification, and refining the training process by tuning hyperparameters. Results: The trained model achieved the following classification performances on fivefold cross-validation data: a 94% Area Under the Curve (AUC), an 88% F1 score, and 87% accuracy. On two completely independent test sets, which were never seen by the model during training, the model achieved an 80% AUC, a 75% F1 score, and 75% accuracy on the first test set (precancerous vs. normal) and an 82% AUC, a 78% F1 score, and 75% accuracy on the second test set (cancer vs. normal). Conclusions: These high-performance metrics demonstrate the models' effectiveness in distinguishing precancerous from normal colposcopy images, even with modest datasets, limited data augmentation, and the smaller effect size of precancerous images compared to malignant lesions. The findings suggest that these techniques can significantly aid in the early detection of cervical cancer at the precancerous stage.

Children's and parents' attitudes to and knowledge about HPV vaccination following a targeted information intervention

The aim of this study was to investigate Swedish children's and parents' attitudes and knowledge about human papillomavirus (HPV) vaccination a year after gender-neutral HPV vaccination was introduced in Sweden's national immunization program (NIP). Additional information about HPV and vaccine was provided in the extended immunazation program. In total, 276 parents and 206 children from 22 School Health Services responded to a web-based survey. Results showed that half of the children and about a third of the parents received additional Public Health Agency information about HPV vaccination, and a majority were satisfied. Parents considered HPV vaccination being important for their children's health, and both children and parents considered it important to vaccinate all genders against HPV. Both children and parents rated school nurses as most reliable source of HPV vaccination information. Teachers were also a common source of HPV and HPV vaccination information for children. Further research among teachers in Sweden is needed to explore their knowledge and abilities to inform students and parents about HPV and vaccination.

fRAP 2.0: a community engagement method applied to cervical cancer disparities among Hispanic women

focused Rapid Assessment Process (fRAP) 2.0 is a community engagement approach combining geospatial mapping with rapid qualitative assessment in cyclical fashion within communities to capture multifactorial and multilevel features impacting primary care problems. fRAP 2.0 offers primary care researchers a methodology framework for exploring complex community features that impact primary healthcare delivery and outcomes. The fRAP 2.0 study design expands the fRAP from a sequential design to a cyclical process of geospatial mapping and rapid qualitative assessment in search of modifiable contextual factors. Research participants are stakeholders from various socioecological levels whose perspectives inform study outcomes that they may use to then become the agents of change for the very problems they helped explore. Here, we present a proof-of-concept study for fRAP 2.0 examining disparities in cervical cancer mortality rates among Hispanic women in Texas. The primary outcomes of interest are features at the community level, medical health system level and regional government policy levels that offer opportunities for collaborative interventions to improve cervical cancer outcomes. In this study, geospatial mapping of county and ZIP code-level variables impacting postdiagnosis cervical cancer care at community, medical and policy levels were created using publicly available data and then overlaid with maps created with Texas Cancer Registry data for cervical cancer cases in three of the largest population counties. Geographically disparate areas were then qualitatively explored using participant observation and ethnographic field work, alongside 39 key informant interviews. Roundtable discussion groups and stakeholder engagement existed at every phase of the study. Applying the fRAP 2.0 method, we created an action-oriented roadmap of next steps to improve cervical cancer care disparities in the three Texas counties with emphasis on the high disparity county. We identified local change targets for advocacy and the results helped convene a stakeholder group that continues to actively create on-the-ground change in the high-disparity county to improve cervical cancer outcomes for Hispanic women.

Squamous Cell Carcinoma In Situ-The Importance of Early Diagnosis in Bowen Disease, Vulvar Intraepithelial Neoplasia, Penile Intraepithelial Neoplasia, and Erythroplasia of Queyrat

Cutaneous squamous cell carcinoma (cSCC) is the second-most-prevalent malignancy in humans. A delayed diagnosis of cSCC leads to heightened invasiveness and positive surgical margins. Bowen's disease (BD) represents an early form of cSCC and presents as a small erythematous, photo-distributed, psoriasiform plaque. Although certain dermoscopy features in BD are quite characteristic, histopathology remains the gold standard for diagnosis and provides a severity-scoring system that assists in guiding appropriate treatment strategies. The classification of precancerous lesions of the vulva and penis has undergone multifarious transformations due to variations in clinical and histopathological characteristics. Presently, erythroplasia of Queyrat is categorized as a clinical variant of penile intraepithelial neoplasia (PeIN). The diagnoses of vulvar intraepithelial neoplasia (VIN) and PeIN present significant challenges and typically necessitate one or more biopsies, potentially guided by dermoscopy. Aceto-white testing demonstrates a notably high negative predictive value for genital precancerous lesions. Histopathological examination represents the gold-standard diagnosis in VIN and PeIN, while p16 and p53 immunostainings alongside HPV testing provide crucial diagnostic clues. The histopathologic features, degree of differentiation, and associations with lichen planus, lichen sclerosus, and HPV guide the selection of conservative treatments or surgical excision.

Pharmacotherapy for cervical cancer: current standard of care and new perspectives

INTRODUCTION

Cervical cancer, while highly preventable, remains an international public health challenge especially in under resourced regions. Although early-stage cervix confined cancers are often amenable to surgical resection, larger tumors deemed locally advanced cervical cancer (LACC) necessitate systemic therapy as part of chemoradiation therapy. Moreover, systemic therapy is the standard therapeutic approach for those presenting with primary metastasis or recurrence.

AREAS COVERED

While several agents have been approved to treat recurrent cervical cancer including checkpoint inhibitors as well as both biomarker agnostic and specific antibody drug conjugates, the development of agents added to chemoradiation has been less fruitful. Until recently, the addition of novel therapies to chemoradiation has been negative in terms of improving outcomes; however, results of a recent Phase III clinical trial (NCT04221945) in LACC demonstrated that the addition of pembrolizumab to standard of care chemoradiation was associated with an improvement in progression-free survival and resulted in an FDA approval for this therapy. This observation led to the first change in treating LACC since the early 2000s.

EXPERT OPINION

Improvements in systemic therapy both alone and in combination with chemoradiation for cervical cancer have been realized. Ongoing research is needed for therapeutic options following immunotherapy.

Achieving cervical cancer elimination: The simulated impacts of HPV vaccination and transitioning from liquid-based cytology to HPV-based screening test

The Ministry of Health Malaysia aims to fully replace liquid-based cytology (LBC) with Human Papillomavirus (HPV) tests and increase the screening coverage from a baseline of 25% to 40% by 2023, followed by a 10% yearly increment until 70% coverage. This transition requires proper planning, including the number of tests needed and budget allocation. This study aims to simulate different transition strategies involving the shift from LBC to HPV testing with expanded screening coverage to predict their impact on cervical cancer elimination in Malaysia. A system dynamics model was developed to simulate the transition from LBC to HPV testing and HPV vaccination coverage in Malaysia. The dynamic model utilised local epidemiological data, published research, and expert opinion when data was unavailable. The simulation showed that a combination of high HPV vaccination coverage and transitioning fully to five-yearly HPV testing by 2030, coupled with a 70% screening uptake by 2040, would accelerate cancer elimination in Malaysia by 18 years with an estimated screening cost of MYR1.81 billion equivalent to USD 411 millions compared to the baseline of using LBC as the primary screening method (MYR1.39 billion, USD 315 millions). Sustained, it would lead to averting 6,000 new cancer cases by 2070. Alternatively, conducting HPV screenings twice before age 50 would advance cervical cancer elimination by 14 years and prevent approximately 1000 new cases by 2070, with an estimated cost of MYR1.13 billion equivalent to USD 257 millions. A delay in achieving the full transition prolonged the elimination more than a delay in increasing the screening coverage. In all scenarios, yearly vaccination of 90% of girls age 13 is crucial to achieving elimination. In the Malaysian context, where HPV vaccination coverage has reached considerable levels, the evidence advocates for a full transition from LBC to HPV testing, ideally by 2030. While expanding screening coverage remains a critical factor in this endeavour, the findings unequivocally endorse prioritising the transition process. Trial registration: Trial registration number: NMRR ID-22-00187-DJU.

Impact of mobile health technologies on human papillomavirus vaccination uptake among mothers of unvaccinated girls aged 9-14 years in Lagos, Nigeria (mHealth-HPVac): Study protocol of a randomised controlled trial

Background

Despite the availability of effective vaccines, human papillomavirus (HPV) vaccine uptake remains low in most resource-limited settings including Nigeria. Mobile health technology (mHealth) may empower patients to control their health, reduce inequalities, and improve the uptake of HPV vaccination.

Aim

The "mHealth-HPVac" study will assess the effects of mHealth using short text messages on the uptake of HPV vaccination among mothers of unvaccinated girls aged 9-14 years and also determine the factors influencing the uptake of HPV vaccination among these mothers.

Methods

This protocol highlights a randomised controlled trial involving women aged 25-65 years who will be enrolled on attendance for routine care at the General Outpatient clinics of Lagos University Teaching Hospital, Lagos, Nigeria between July and December 2024. At baseline, n=224 women will be randomised to either a short text message or usual care (control) arm. The primary outcome is vaccination of the participant's school-age girl(s) at any time during the 6 months of follow-up. The associations between any two groups of continuous variables will be tested using the independent sample t-test (normal distribution) or the Mann-Whitney U test (skewed data) and that of two groups of categorical variables with Chi-square (X2) or Fisher's exact test where appropriate. Using the multivariable binary logistic regression model, we will examine the effects of all relevant sociodemographic and clinical variables on HPV vaccination uptake among mothers of unvaccinated but vaccine-eligible school-age girls. Statistical significance will be defined as A P<0.05.

Discussion

The mHealth-Cervix study will evaluate the impact of mobile technologies on HPV vaccination uptake among mothers of unvaccinated but vaccine-eligible school-age girls in Lagos, Nigeria as a way of contributing to the reduction in the wide disparities in cervical cancer incidence through primary prevention facilitated using health promotion to improve HPV vaccination uptake.

Registration

PACTR202406727470443 (6th June 2024).

Impact of mobile health technologies on human papillomavirus vaccination uptake among mothers of unvaccinated girls aged 9-14 years in Lagos, Nigeria (mHealth-HPVac): study protocol of a randomised controlled trial

BACKGROUND

Despite the availability of effective vaccines, human papillomavirus (HPV) vaccine uptake remains low in most resource-limited settings including Nigeria. Mobile health technology (mHealth) has the potential to empower patients to manage their health, reduce health disparities, and enhance the uptake of HPV vaccination.

AIM

The "mHealth-HPVac" study will assess the effects of mHealth using short text messages on the uptake of HPV vaccination among mothers of unvaccinated girls aged 9-14 years and also determine the factors influencing the uptake of HPV vaccination among these mothers.

METHODS

This protocol highlights a randomised controlled trial involving women aged 25-65 years who will be enrolled on attendance for routine care at the General Outpatient clinics of Lagos University Teaching Hospital, Lagos, Nigeria between July and December 2024. At baseline, n = 123 women will be randomised to either a short text message or usual care (control) arm. The primary outcome is vaccination of the participant's school-age girl(s) at any time during the 6 months of follow-up. The associations between any two groups of continuous variables will be assessed using the independent sample t-test for normally distributed data, or the Mann-Whitney U test for skewed data. For two groups of categorical variables, the Chi-square (X2) test or Fisher's exact test will be used, as appropriate. Using the multivariable binary logistic regression model, we will examine the effects of all relevant sociodemographic and clinical variables on HPV vaccination uptake among mothers of unvaccinated but vaccine-eligible school-age girls. Statistical significance will be reported as P < 0.05.

DISCUSSION

The mHealth-Cervix study will evaluate the impact of mobile technologies on HPV vaccination uptake among mothers of unvaccinated but vaccine-eligible school-age girls in Lagos, Nigeria as a way of contributing to the reduction in the wide disparities in cervical cancer incidence through primary prevention facilitated using health promotion to improve HPV vaccination uptake.

REGISTRATION

PACTR202406727470443 (6th June 2024).

Cancer Screening in Low- and Middle-Income Countries

The worldwide cancer burden is growing, and populations residing in low- and middle-income countries (LMICs) are experiencing a disproportionate extent of this growth. Breast, colorectal, and cervical cancers are among the top 10 most frequently diagnosed malignancies, and they also account for a substantial degree of cancer mortality internationally. Effective screening strategies are available for all three of these cancers. Individuals from LMICs face substantial cost and access barriers to early detection programs, and late stage at diagnosis continues to be a major cause for cancer mortality in these communities. This chapter will review the epidemiology of breast, colorectal, and cervical cancers, and will explore prospects for improving global control through novel approaches to screening in cost-constrained environments.

Human papillomavirus infection: Epidemiology, biology, host interactions, cancer development, prevention, and therapeutics

Human papillomavirus (HPV) infection is one of the most common sexually transmitted infections worldwide. It is caused by the HPV, a DNA virus that infects epithelial cells in various mucous membranes and skin surfaces. HPV can be categorised into high-risk and low-risk types based on their association with the development of certain cancers. High-risk HPV types, such as HPV-16 and HPV-18, are known to be oncogenic and are strongly associated with the development of cervical, anal, vaginal, vulvar, penile, and oropharyngeal cancers. These types of HPV can persist in the body for an extended period and, in some cases, lead to the formation of precancerous lesions that may progress to cancer if left untreated. Low-risk HPV types, such as HPV-6 and HPV-11, are not typically associated with cancer but can cause benign conditions like genital warts. Genital warts are characterised by the growth of small, cauliflower-like bumps on the genital and anal areas. Although not life-threatening, they can cause discomfort and psychological distress. HPV is primarily transmitted through sexual contact, including vaginal, anal, and oral sex. It can also be transmitted through non-penetrative sexual activities that involve skin-to-skin contact. In addition to sexual transmission, vertical transmission from mother to child during childbirth is possible but relatively rare. Prevention of HPV infection includes vaccination and safe sexual practices. HPV vaccines, such as Gardasil and Cervarix, are highly effective in preventing infection with the most common high-risk HPV types. These vaccines are typically administered to adolescents and young adults before they become sexually active. Safe sexual practices, such as consistent and correct condom use and limiting the number of sexual partners, can also reduce the risk of HPV transmission. Diagnosis of HPV infection can be challenging because the infection is often asymptomatic, especially in men. In women, HPV testing can be done through cervical screening programs, which involve the collection of cervical cells for analysis. Abnormal results may lead to further diagnostic procedures, such as colposcopy or biopsy, to detect precancerous or cancerous changes. Overall, HPV infection is a prevalent sexually transmitted infection with significant implications for public health. Vaccination, regular screening, and early treatment of precancerous lesions are key strategies to reduce the burden of HPV-related diseases and their associated complications. Education and awareness about HPV and its prevention are crucial in promoting optimal sexual health. This study aimed to carry out a literature review considering several aspects involving HPV infection: Global distribution, prevalence, biology, host interactions, cancer development, prevention, therapeutics, coinfection with other viruses, coinfection with bacteria, association with head and neck squamous cell carcinomas, and association with anal cancer.

Evaluation of HPV infection and presence of licensed HPV vaccine genotypes among genital warts in Foshan, China

Objective

This study aimed to evaluate the prevalence of human papillomavirus (HPV) infection and presence of licensed HPV vaccine genotypes among patients with genital warts in Foshan, China from 2015 to 2022, to provide useful references for the detection, prevention and control of genital warts in Foshan.

Methods

The present study retrospectively analyzed the HPV detection rates in patients with genital warts. A total of 1,625 patients were seen at the Second People's Hospital of Foshan, Guangdong Province, China, from 2015 to 2022. Samples were collected from various lesions and genotyped for 21 genotypes of HPV by infusion hybridization. The classification principle of HPV genotypes in this study: (1) Based on the relationship between HPV and carcinogenicity; (2) Based on the number of HPV genotypes infected; (3) Based on the HPV genotypes of licensed HPV vaccines.

Results

The detection rate of any HPV in patients with genital warts was 80.37% (1,306/1,625). The detection rates of HPV for low-risk infection, co-infection and high-risk infection were 49.48% (804/1,625), 24.92% (405/1,625) and 5.97% (97/1,625), respectively. Single infection was the predominant type (51.94%, 844/1625). HPV-6 and HPV-11 were the predominant types of single infection; HPV-6 and HPV-52 were the predominant types of paired combinations of multiple infection. 82.22% (1,336/1,625) of the cases had an age distribution of ≤ 24, 25-34, and 35-44. The distribution of some HPV genotypes had age specificity, annual specificity and gender specificity. The genotype detection rates of 2v, 4v and 9v showed a decreasing trend with ages (all P < 0.05). The genotype detection rates of 4v and 9v showed a decreasing trend over the 8-year period (both P < 0.05). The genotype detection rates of 4v and 9v in the male group were higher than those in the female group (both P < 0.05). The genotype detection rate of 9v was significantly higher than that of 2v and 4v in the female group (both P < 0.05).

Conclusion

Our study demonstrated that low-risk infection and single infection were the main types of HPV infection in patients with genital warts, mainly among young patients. Our study provides epidemiological data for the detection, prevention and control of genital warts in China.

A comprehensive review of anal cancer-with a special focus on anal cytology

The diagnosis of anal cancer is relatively uncommon, but its incidence has been steadily increasing in high-risk populations. In the 2001 Bethesda System for Reporting Cervical Cytology, anal cytology was introduced as a component. Since then, it has been recognized as a potential tool for screening anal cancer, often in conjunction with high-resolution anoscopy. There are notable similarities between anal cancer and cervical cancer, including the causative role of human papillomavirus. However, there are also significant differences, particularly in terms of disease prevalence. Anal cytology may be used as a primary screening test, and in the event of abnormalities, patients are subsequently directed for high-resolution anoscopy. However, the best approach for anal cancer screening is yet to be determined and uniformly implemented. This comprehensive review article provides an in-depth analysis of the epidemiology and incidence of anal precursor and malignant lesions. It explores the various methods of sample procurement, preparation, interpretation (including sensitivity and specificity), and reporting terminology in anal cytology. The article also addresses the significance of concurrent high-risk human papillomavirus screening in anal cytology and its role in screening programs. Furthermore, it discusses the follow-up, prevention, and subsequent management strategies for anal cancers. By synthesizing current knowledge in these areas, this review aims to provide a comprehensive understanding of anal cytology and its implications in the early detection, prevention, and management of anal neoplasia and cancer.

Computational and AI-driven 3D structural analysis of human papillomavirus (HPV) oncoproteins E5, E6, and E7 reveal significant divergence of HPV E5 between low-risk and high-risk genotypes

There are over 220 identified genotypes of Human papillomavirus (HPV), and the HPV genome encodes 3 major oncogenes, E5, E6, and E7. Conservation and divergence in protein sequence and function between low-risk versus high-risk oncogenic HPV genotypes has not been fully characterized. Here, we used modern computational and structural folding algorithms to perform a comparative analysis of HPV E5, E6, and E7 between multiple low risk and high risk genotypes. We first identified significantly greater sequence divergence in E5 between low- and high-risk genotypes compared to E6 and E7. Next, we used AlphaFold to model the structure of papillomavirus proteins and complexes with high confidence, including some with no established consensus structure. We observed that HPV E5, but not E6 or E7, had a dramatically different 3D structure between low-risk and high-risk genotypes. To our knowledge, this is the first comparative analysis of HPV proteins using Alphafold artificial intelligence (AI) system. The marked differences in E5 sequence and structure in high-risk HPVs may contribute in important and underappreciated ways to the development of HPV-associated cancers.

The indirect costs of vaccine-preventable cancer mortality in the Middle East and North Africa (MENA)

BACKGROUND

Infections are responsible for ∼13% of cancer cases worldwide, with human papillomavirus (HPV) and hepatitis B (HBV) among the infections associated with cancer for which vaccines are available. The aim of this study was to estimate the indirect cost of premature mortality related to cancers caused by HPV and HBV in Middle East and North Africa (MENA) countries.

METHODS

The number of deaths and years of life lost (YLL) in 2019 from four HPV-related cancers: cervical cancer, oral cavity cancer, laryngeal cancer, and oropharynx cancer, as well as HBV-related liver cancer were sourced from the Institute for Health Metrics Evaluation (IHME) Global Burden of Disease database. HPV-attributable fractions were applied to deaths and YLL. The human capital approach was used to measure productivity loss, through value of YLL (VYLL), and estimated using gross domestic product per capita (World Bank; in USD). Seventeen countries in the MENA region were included. Four countries in the region were not included due to data availability.

RESULTS

In 2019, there were 11,645 potentially vaccine-preventable cancer-related deaths across the MENA region. This resulted in an indirect cost of $1,688,821,605, with 76.1% of this accrued in the Middle East ($1,284,923,633). The number of deaths in the Middle East (5,986) were similar to Northern Africa (5,659) but YLL were higher in Northern Africa (179,425) compared to the Middle East (169,207). The highest indirect cost per death occurred in Qatar ($1,378,991), compared to $14,962 in Sudan. Oral cavity cancer had the highest VYLL per death ($186,084).

CONCLUSIONS

There is a high burden of premature mortality and indirect costs of potentially vaccine-preventable cancer-related deaths in the MENA region. Improved vaccination program implementation, increased vaccine coverage of HPV and HBV vaccinations, and continued prioritization of public health measures, such as screening, could effectively reduce premature mortality and associated costs.

Epidemiology of human papillomavirus on condyloma acuminatum in Shandong Province，China

Condyloma acuminatum (CA) is a sexually transmitted disease (STD) caused by human papillomavirus (HPV) infection. It is important to study the prevalence and distribution of HPV genotypes before implementing the HPV vaccination program. Therefore, the aim of this study was to evaluate the epidemiological characteristics of CA cases and the distribution of HPV genotypes in Shandong Province, China. One-to-one questionnaire surveys were conducted on all patients diagnosed with CA in sentinel hospitals from Shandong Province, China. HPV genotypes were determined using the polymerase chain reaction (PCR)-reverse dot blot hybridization method. The study enrolled 1185 patients (870 males and 315 females) and found that CA patients are mainly males and sexually active people between the ages of 20 and 40. Recurrence occurred in 34.7% patients. Among the 880 CA patients who underwent HPV typing, the HPV test positivity rate was 91.4%. In these cases, low-risk (LR) HPV infection was predominant, with an infection rate of 91.3%, while high-risk (HR) HPV genotypes were found in 53.5% patients. The most frequent HPV genotypes encountered were HPV6 (57.8%), HPV11 (37.2%), HPV16 (13.7%), and HPV42 (10.3%). HPV6 and/or HPV11 are the main infections in all patients, and more than half of the patients are coinfected with HR-HPV. However, unlike other regions, HPV42 has a higher prevalence rate among CA patients in Shandong Province and is a nonvaccine HPV genotype. Therefore, regular HPV typing helps to understand the characteristics of specific genotypes and the choice of the best type for vaccine coverage.

Potential population-level effectiveness of one-dose HPV vaccination in low-income and middle-income countries: a mathematical modelling analysis

BACKGROUND

Given the accumulating evidence that one-dose vaccination could provide high and sustained protection against human papillomavirus (HPV) infection and related diseases, we examined the population-level effectiveness and efficiency of one-dose HPV vaccination of girls compared with two-dose vaccination, using mathematical modelling.

METHODS

In this mathematical modelling study, we used HPV-ADVISE LMIC, an individual-based transmission-dynamic model independently calibrated to four epidemiologically diverse low-income and middle-income countries (LMICs; India, Nigeria, Uganda, and Viet Nam). We parameterised and calibrated the model using sexual behaviour and epidemiological data identified from international population-based datasets and the literature. All base-case vaccination scenarios start in 2023 with the nonavalent vaccine and assumed 80% vaccination coverage with one or two doses. We assumed that two doses of vaccine provide 100% efficacy against vaccine-type infections and a lifelong duration of protection. We examined a non-inferior vaccination scenario for one dose compared with two doses, pessimistic scenarios of lower one-dose vaccine efficacy (85%) or a shorter duration of protection (ie, 20 or 30 years), and the effectiveness of a mitigation scenario in which schedules would switch from one dose to two doses. We also did sensitivity analyses by varying vaccination coverage. We used three outcomes: the relative reduction in cervical cancer incidence, the number of cervical cancers averted, and the number of vaccine doses needed to prevent one cervical cancer.

FINDINGS

Assuming non-inferior vaccine characteristics for one dose compared with two doses, the model projections show that two-dose or one-dose routine vaccination of girls aged 9 years (with a multi-age cohort vaccination of girls aged 10-14 years) would avert 12·0 million (80% UI 9·5-14·5) cervical cancers in India, 4·7 million (3·4-5·8) in Nigeria, 2·3 million (1·9-2·6) in Uganda, and 0·4 million (0·2-0·5) in Viet Nam over 100 years. Under pessimistic assumptions of lower one-dose efficacy (85%) or a shorter duration of protection (ie, 30 years), one-dose routine vaccination would avert 69% (61-80) to 94% (92-96) of the cervical cancers averted with two-dose routine vaccination. However, when assuming a duration of protection of 20 years, one-dose routine vaccination would avert substantially fewer cervical cancers (ie, 35% [26-44] to 69% [65-71] of the cervical cancers averted with two-dose routine vaccination). A switch from one-dose to two-dose routine vaccination of girls aged 9 years, with a one-dose catch-up of girls aged 10-14 years, 5 years after the start of the vaccination programme, could mitigate potential losses in cervical cancer prevention from a short one-dose duration of protection (averting 92% [83-98] to 99% [97-100]) of the cervical cancers averted with two-dose routine vaccination). One-dose routine vaccination would result in fewer doses needed to prevent one cervical cancer than two-dose routine vaccination, even if the duration of protection is as low as 20 years. Finally, for countries with two-dose routine vaccination, adding one-dose multi-age cohort vaccination in the first year would provide similar benefits as a two-dose multi-age cohort vaccination, and would be more efficient even under the pessimistic assumptions of lower one-dose vaccine efficacy or duration of protection.

INTERPRETATION

One-dose routine vaccination could avert most of the cervical cancers averted with two-dose vaccination while being more efficient, provided the duration of one-dose protection is greater than 20-30 years (depending on the LMIC). The doses saved by introducing one-dose routine vaccination could offer the opportunity to vaccinate girls before they age out of the vaccination window of 9-14 years and, potentially, to vaccinate boys or older age groups.

FUNDING

Fonds de recherche du Québec-Santé, Digital Research Alliance of Canada, Bill & Melinda Gates Foundation.

Unraveling Immunological Dynamics: HPV Infection in Women-Insights from Pregnancy

During pregnancy, hormonal and immune adaptations are vital for supporting the genetically distinct fetus during elevated infection risks. The global prevalence of HPV necessitates its consideration during pregnancy. Despite a seemingly mild immune response, historical gestational viral infections underscore its significance. Acknowledging the established HPV infection risks during pregnancy, our review explores the unfolding immunological changes in pregnant women with HPV. Our analysis aims to uncover strategies for safely modulating the immune system, mitigating adverse pregnancy consequences, and enhancing maternal and child health. This comprehensive narrative review delves into the existing knowledge and studies on this topic.

Ensuring equity with pre-clinical planning for chlamydia vaccines

Chlamydia trachomatis (Ct) remains the most common bacterial sexually transmitted pathogen worldwide, causing significant morbidity particularly among women, including pelvic inflammatory disease, ectopic pregnancy, and infertility. Several vaccines are advancing through pre-clinical and clinical development, and it is likely that one or more vaccines will progress into human efficacy trials soon. In this Perspective, we present a case for considering the challenges of Ct vaccine development through a lens of equity and justice. These challenges include the need to protect against multiple serovars, in both females and males, at multiple anatomic sites, and in resource poor areas of the world. We propose that early consideration of vaccine implementation by conducting community-engaged research will ensure that a scientifically sound chlamydia vaccine promotes equity, justice, and shared-gendered responsibility for STI prevention.

The efficacy of human papillomavirus prophylactic vaccination after conization in preventing cervical intraepithelial neoplasia recurrence: A prospective observational study in China

High-risk human papillomavirus (hrHPV) infection is the cause of most cervical cancers. Since therapeutic vaccines are not yet available for clinical practice, the administration of HPV prophylactic vaccines in patients with cervical intraepithelial neoplasia (CIN) arouses great interest and its value after excisional treatment of CIN remains unclear. We conducted this prospective cohort study to evaluate the impact of HPV prophylactic vaccination on preventing women from subsequent infection and cervical lesions after excision treatment. 148 patients after loop electrosurgical excision procedure (LEEP) for CIN2+ disease received HPV prophylactic vaccination (6/11/16/18 vaccine, Gardasil®, Merck) after surgery (V-group) and 273 didn't get vaccination (NV-group). The HPV infection rates at the first and second year after LEEP were significantly lower in the V-group than that in NV-group (P = 0.049 and P = 0.026). CIN2+ recurrence was observed in 29 cases (10.62 %) in the NV-group and 2 cases (2.03 %) in the V-group. Logistic regression analysis showed that the HPV16/18 infection, the CIN3 pathology after LEEP and no vaccination after LEEP were significant risk factors of recurrence. Patients without HPV vaccination had a higher CIN2+ recurrence rate (OR = 12.35, 95 % CI 1.919-79.492, P = 0.008). Our study showed the quadrivalent prophylactic HPV vaccination after LEEP had a significantly protective role in the prevention of high-grade squamous intraepithelial lesion recurrence. Further randomized, controlled trials are required in elucidating the efficacy of the prophylactic HPV vaccines using shortly after LEEP in patients with CIN disease.

Awareness and Attitude of Polish Gynecologists and General Practitioners towards Human Papillomavirus Vaccinations

Human papillomavirus (HPV) leads to diseases of the skin and mucous membranes of the anogenital and upper gastrointestinal tract, especially neoplasia. HPV vaccinations effectively protect against the development of HPV-related diseases. However, despite the wide availability of vaccination for patients, only a few percent of Polish children are vaccinated. The reasons for this are certainly complex. Therefore, the aim of the study was to evaluate gynecologists' and general practitioners' knowledge, awareness and attitudes towards HPV vaccination and analyze their opinions about the interest in HPV vaccinations among children and parents. An anonymous, voluntary, cross-sectional survey study was conducted among 300 Polish gynecologists and general practitioners. Participants were from a diverse group with a wide range of work experience and different workplaces. Most of the respondents (83%), especially the gynecologists (p = 0.03), declared informing and discussing with parents the HPV-related diseases and prevention methods. Only 8% of the participants reported a negative reaction from parents when talking about HPV vaccines. However, in practice, physicians very rarely recommend this vaccine. HPV vaccination was recommended more often by female physicians (p = 0.03), general practitioners (p < 0.001), physicians working over five years (p < 0.001), doctors who regularly vaccinated themselves against influenza (p = 0.01) and those who vaccinated their children against HPV (p =0.001). The availability of educational materials for parents and/or patients encouraged physicians to provide this information (p < 0.001). Polish gynecologists and general practitioners declared a positive attitude regarding HPV vaccines; however, they rarely recommended this vaccine. Physicians who vaccinate themselves against influenza and their own children against HPV are more likely to provide information and encourage HPV vaccination in others. Additionally, the availability of educational material for parents and adolescents plays an essential role in the popularization of this vaccination. Knowledge alone is not enough for physicians to recommend the vaccination to patients.

Proposal for a descriptive and differentiated presentation of the longitudinal impact of the new organized cancer screening guideline and HPV vaccination in Germany

INTRODUCTION

Since 01/01/2020, the cervical cancer screening in Germany has been carried out due to the organized early cancer diagnosis guideline (oKFE-RL). In 2007, HPV vaccination was initiated in Germany. The main goal of both initiatives is to further reduce the incidence of invasive cervical cancer. To assess the effect of the new screening strategy in a timely manner, monitoring of short-term changes need to be considered. Ideally, the effects of both prevention methods would be presented together in one model.

MATERIALS AND METHODS

Because no change in the incidence of invasive cervical cancer is initially expected, the incidence of CIN 3 is used as a surrogate parameter to assess the effects of the prevention efforts. Based on expected additional effects of vaccination and co-testing, a model-based estimation of the expected CIN 3 incidence during the evaluation of the screening program is performed using the CIN 3 incidence in the Saarland population.

MODELING RESULTS

The oKFE-RL provides for two groups: Primary cytodiagnosis continues until 35 years of age. Here, in the next few years, CIN 3 incidence will be reduced not by the oKFE-RL but by the increasing proportion of vaccinated women. In the group over 35 years, co-testing was introduced with a stringent algorithm. Due to the higher sensitivity of the HPV test, significantly more CIN 3 are detected in the first round of 3 years and thus, the CIN 3 incidence initially increases. As these CIN 3 are absent in the second round, significantly fewer CIN 3 cases will be detected then. These effects suggest a global decrease in CIN 3 incidence of 25.8% after 6 years.

CONCLUSION

Observation of the age distribution curve of CIN 3 allows both effects of prevention to be assessed in a timely manner and separately. In the future, data from epidemiologic cancer registries should be incorporated into the model to replace modeling with real data.

Reproductive and Obstetric Outcomes after Fertility-Sparing Treatments for Cervical Cancer: Current Approach and Future Directions

Cervical cancer is one of the leading causes of cancer-related death in women of reproductive age. The established fertility-sparing approaches for the management of early-stage cervical cancer for women who plan pregnancy are associated with a decline in fecundity and an increased risk of pregnancy complications. This article aims to offer an overview of fertility-sparing approaches and the management of potential subfertility and pregnancy complications after these treatments. An extensive search for the available data about infertility and cervical cancer, fertility-sparing techniques in patients with cervical cancer, fertility treatment, obstetrical complications, and pregnancy outcomes in cervical cancer patients was completed. Fertility-preserving procedures such as loop electrosurgical excision procedure (LEEP), cold-knife conization, and trachelectomy in women diagnosed with cervical cancer can be considered as safe and effective treatments that preserve reproductive potential. Current fertility-preserving procedures, based on the balance of the oncological characteristics of patients as well as their desire for reproduction, allow one to obtain acceptable reproductive and obstetric outcomes in women treated for cervical cancer. Nevertheless, careful monitoring of pregnancies obtained after fertility-preserving procedures is recommended, since this cohort of patients should be considered at higher risk compared with a healthy population.

Master mitotic kinases regulate viral genome delivery during papillomavirus cell entry

Mitosis induces cellular rearrangements like spindle formation, Golgi fragmentation, and nuclear envelope breakdown. Similar to certain retroviruses, nuclear delivery during entry of human papillomavirus (HPV) genomes is facilitated by mitosis, during which minor capsid protein L2 tethers viral DNA to mitotic chromosomes. However, the mechanism of viral genome delivery and tethering to condensed chromosomes is barely understood. It is unclear, which cellular proteins facilitate this process or how this process is regulated. This work identifies crucial phosphorylations on HPV minor capsid protein L2 occurring at mitosis onset. L2's chromosome binding region (CBR) is sequentially phosphorylated by the master mitotic kinases CDK1 and PLK1. L2 phosphorylation, thus, regulates timely delivery of HPV vDNA to mitotic chromatin during mitosis. In summary, our work demonstrates a crucial role of mitotic kinases for nuclear delivery of viral DNA and provides important insights into the molecular mechanism of pathogen import into the nucleus during mitosis.

Potential benefit of extended dose schedules of human papillomavirus vaccination in the context of scarce resources and COVID-19 disruptions in low-income and middle-income countries: a mathematical modelling analysis

BACKGROUND

The WHO Strategic Advisory Group of Experts recommended that an extended interval of 3-5 years between the two doses of the human papillomavirus (HPV) vaccine could be considered to alleviate vaccine supply shortages. However, three concerns have limited the introduction of extended schedules: girls could be infected between the two doses, the vaccination coverage for the second dose could be lower at ages 13-14 years than at ages 9-10 years, and identifying girls vaccinated with a first dose to give them the second dose could be difficult. Using mathematical modelling, we examined the potential effect of these concerns on the population-level impact and efficiency of extended dose HPV vaccination schedules.

METHODS

We used HPV-ADVISE, an individual-based, transmission-dynamic model of multitype HPV infection and disease, calibrated to country-specific data for four low-income and middle-income countries (India, Viet Nam, Uganda, and Nigeria). For the extended dose scenarios, we varied the vaccination coverage of the second dose among girls previously vaccinated, the one-dose vaccine efficacy, and the one-dose vaccine duration of protection. We also examined a strategy in which girls aged 14 years were vaccinated irrespective of their previous vaccination status. We used a scenario of girls-only two-dose vaccination at age 9 years (vaccine=9 valent, vaccine-type efficacy=100%, duration of protection=lifetime, and coverage=80%) as our comparator. We estimated two outcomes: the relative reduction in the age-standardised cervical cancer incidence (population-level impact) and the number of cervical cancers averted per 100 000 doses (efficiency).

FINDINGS

Our model projected substantial reductions in cervical cancer incidence over 100 years with the two-dose schedule (79-86% depending on the country), compared with no vaccination. Projections for the 5-year extended schedule, in which the second dose is given only to girls previously vaccinated at age 9 years, were similar to the current two-dose schedule, unless vaccination coverage of the second dose is very low (reductions in cervical cancer incidence of 71-78% assuming 30% coverage at age 14 years among girls vaccinated at age 9 years). However, when the dose at age 14 years is given to girls irrespective of vaccination status and assuming high vaccination coverage, the model projected a substantially greater reduction in cervical cancer incidence compared with the current two-dose schedule (reductions in cervical cancer incidence of 86-93% assuming 70% coverage at age 14 years, irrespective of vaccination status). Efficiency of the extended schedule was greater than the two-dose schedule, even with a drop in vaccination coverage.

INTERPRETATION

The three concerns are unlikely to have a substantial effect on the population-level impact of extended dose schedules. Hence, extended dose schedules will likely provide similar cervical cancer reductions as two-dose schedules, while reducing the number of doses required in the short-term, providing a more efficient use of scarce resources, and offering a 5-year time window to reassess the necessity of the second dose.

FUNDING

WHO, Canadian Institute of Health Research Foundation, Fonds de recherche du Québec-Santé, Digital Research Alliance of Canada, and Bill & Melinda Gates Foundation.

Prophylactic Human Papillomavirus Vaccination: From the Origin to the Current State

Immunization is the most successful method in preventing and controlling infectious diseases, which has helped saving millions of lives worldwide. The discovery of the human papillomavirus (HPV) infection being associated with a variety of benign conditions and cancers has driven the development of prophylactic HPV vaccines. Currently, four HPV vaccines are available on the pharmaceutical market: Cervarix, Gardasil, Gardasil-9, and the recently developed Cecolin. Multiple studies have proven the HPV vaccines' safety and efficacy in preventing HPV-related diseases. Since 2006, when the first HPV vaccine was approved, more than 100 World Health Organization member countries reported the implementation of HPV immunization. However, HPV vaccination dread, concerns about its safety, and associated adverse outcomes have a significant impact on the HPV vaccine implementation campaigns all over the world. Many developed countries have successfully implemented HPV immunization and achieved tremendous progress in preventing HPV-related conditions. However, there are still many countries worldwide which have not created, or have not yet implemented, HPV vaccination campaigns, or have failed due to deficient realization plans associated with establishing successful HPV vaccination programs. Lack of proper HPV information campaigns, negative media reflection, and numerous myths and fake information have led to HPV vaccine rejection in many states. Thus, context-specific health educational interventions on HPV vaccination safety, effectiveness, and benefits are important to increase the vaccines' acceptance for efficacious prevention of HPV-associated conditions.

Effectiveness of combination therapy with ISA101 vaccine for the treatment of human papillomavirus-induced cervical cancer

Cervical cancer is one of the women-associated tumors that affects numerous people yearly. It is the fourth most common malignancy in women worldwide. Following early diagnosis, this cancer can be cured mainly by traditional methods such as surgery, tumor resection, and chemotherapy; nonetheless, it becomes more challenging to treat in advanced and metastatic stages. With the advent of novel treatments such as angiogenesis inhibitors or immuno-checkpoint blockers in recent years, the survival rate of patients with advanced cervical cancer has significantly increased. However, it has not yet reached a satisfactory level. It has been revealed that human papillomavirus (HPV) infection is responsible for more than 90% of cervical cancer cases. However, evidence revealed that monotherapy with anti-HPV vaccines such as ISA101 could not affect tumor growth and progression in patients with HPV-induced cervical cancer. Therefore, combining ISA101 and immune checkpoint blockers or other immunotherapeutic approaches may be more robust and effective than monotherapy with ISA101 or immune checkpoint blockers for treating cervical cancer. This review summarizes the ISA101 properties, advantages and disadvantages. Furthermore, various conducted combination therapies with ISA101 and the effectiveness and challenges of this treatment have been discussed.

Governing HPV-related carcinoma using vaccines: Bottlenecks and breakthroughs

Human papillomavirus (HPV) contributes to sexually transmitted infection, which is primarily associated with pre-cancerous and cancerous lesions in both men and women and is among the neglected cancerous infections in the world. At global level, two-, four-, and nine-valent pure L1 protein encompassed vaccines in targeting high-risk HPV strains using recombinant DNA technology are available. Therapeutic vaccines are produced by early and late oncoproteins that impart superior cell immunity to preventive vaccines that are under investigation. In the current review, we have not only discussed the clinical significance and importance of both preventive and therapeutic vaccines but also highlighted their dosage and mode of administration. This review is novel in its way and will pave the way for researchers to address the challenges posed by HPV-based vaccines at the present time.

Papillomavirus Infection and Prevention: How Much Does the Sicilian Population Know? An Observational Study

Human papillomavirus is a sexually transmitted virus that is responsible not only for uterine cervical cancer, but also for the oral and oropharyngeal cancers. In this latter case, the virus indiscriminately affects both sexes at any age. Vaccination plays a key role in preventing infection and its possible consequences. Therefore, this study aimed to assess the degree of awareness of papillomavirus infection and its possible prevention in the Sicilian population. A prospective observational study was carried out on the Sicilian population through a self-administered questionnaire, consisting of 10 multiple-choice questions. The survey lasted from June 2021 to December 2021. A total of 844 respondents were included: 60.90% were female and 53.55% were aged between 21 and 30 years. Most of the surveyed population knew about the virus and the existence of the vaccine, however, many of them did not know about virus's effects on the oral and oropharyngeal sites (49.17%), or about the indication for vaccination for males (39.69%). Oral and oropharyngeal papillomavirus-related cancers are an increasingly frequent finding, especially in young adults. Therefore, it is necessary and quite mandatory to educate the population about the risks that certain voluptuous habits may cause, with the help of general practitioners, schools, social media, and social networks.

The Creation of the Suppressive Cancer Microenvironment in Patients with HPV-Positive Cervical Cancer

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.

Role of Immunity and Vaginal Microbiome in Clearance and Persistence of Human Papillomavirus Infection

Cervical cancer disproportionately affects women of reproductive age, with 80% of cases occurring in low- and middle-income countries. Persistent infection with high-risk human papillomavirus (HPV) genotypes has been described as the most common non-systemic biological risk factor for the development of cervical cancer. The mucosal immune system plays a significant role in controlling HPV infection by acting as the first line of host defense at the mucosal surface. However, the virus can evade host immunity using various mechanisms, including inhibition of the antiviral immune response necessary for HPV clearance. Pro-inflammatory cytokines and the vaginal microbiome coordinate cell-mediated immune responses and play a pivotal role in modulating immunity. Recently, diverse vaginal microbiome (associated with bacterial vaginosis) and genital inflammation have emerged as potential drivers of high-risk HPV positivity and disease severity in women. The potential role of these risk factors on HPV recurrence and persistence remains unclear. This article reviews the role of cellular or cytokine response and vaginal microbiome dysbiosis in the clearance, persistence, and recurrence of HPV infection.

HPV16 E6-Activated OCT4 Promotes Cervical Cancer Progression by Suppressing p53 Expression via Co-Repressor NCOR1

Human papillomaviruses (HPV), mainly HPV16 and HPV18, of high-risk classification are involved in cervical cancer carcinogenesis and progression. Octamer-binding transcription factor 4 (OCT4) is a key transcription factor that is increased in various cancer types. Cervical cancer patients with higher levels of OCT4 had worse survival rates. However, the definite mechanisms underlying its function in the development of cervical cancer still remain to be explicated. Here, our study demonstrated that OCT4 expression was slightly increased in cervical cancer tissues than in precancerous ones. However, OCT4 was significantly upregulated in HPV16-positive tissues, in contrast to the expression profiling for p53. Moreover, knockdown of HPV16 E6 in SiHa cells suppressed the expression of OCT4 with impaired activities of cell proliferation, migration, and invasion, while it recovered the expression of p53. Overexpression of OCT4 and p53 exerted opposite roles on cell proliferation, migration, invasion, and colony formation of cervical cancer cells. More importantly, the enforced expression of OCT4 augmented p53-inhibited cell migration, invasion, and colony formation in human cervical cancer by promoting EMT. Finally, we identified that OCT4 could bind to the p53 promoter region to repress p53 expression by recruiting co-repressor NCOR1 using luciferase, ChIP, and co-IP experiments. We further illustrated that OCT4 not only increased the lung metastasis of cervical cancer but also effectively reversed p53-inhibited lung metastasis. In conclusion, our results suggested that HPV16 E6 activated the expression of OCT4 and subsequently crippled the transcription of p53 via co-repressor NCOR1, which contributed to cervical cancer progression.

The Involvement of Human Papilloma Virus in Gastrointestinal Cancers

Human Papilloma Virus (HPV) is one of the most common sexually transmitted infections worldwide. HPV infection has a strong relationship with the onset of cervix uteri, vagina, penis, anus, and oropharynx, but also tonsils and tongue cancers. Some epidemiological data indicate that except for gynecologic cancers, HPV infection can be one of the risk factors associated with a greater risk of induction and progression of gastrointestinal cancers. Data, however, remain contradictory and definite conclusions cannot be drawn, so far. The following review aims to organize recent evidence and summarize the current state of knowledge regarding the association between HPV infection and gastrointestinal tumors primarily focusing on esophageal, liver, gastric, colorectal, and anal cancers.

Effects of Sex, Existing Antibodies, and HIV-1-Related and Other Baseline Factors on Antibody Responses to Quadrivalent HPV Vaccine in Persons With HIV

BACKGROUND

We compared antibody (Ab) responses to a quadrivalent (types 6, 11, 16, and 18) human papillomavirus (HPV) vaccine between men and women with HIV-1.

METHODS

A retrospective analysis of participant-level data from published clinical trials of HPV vaccine administered at study entry and at weeks 8 and 24 was conducted separately for baseline Ab undetectable and baseline Ab detectable using Ab titers and titer changes from baseline, respectively, at week 28 and year 1.5. Generalized estimating equations accounted for multiple HPV types and were adjusted for multiple baseline factors, including existing HPV antibodies before vaccination from natural exposure.

RESULTS

We evaluated 575 participants with CD4+ count >200 cells/mm3, 323 men and 252 women: median ages 46 and 38 years, respectively. Week 28 and year 1.5 Ab titers were similar between men and women regardless of the baseline Ab detection in multivariate models. HIV-1 RNA ≥400 copies/mm3 was associated with a lower week 28 Ab response; in baseline Ab detectable, the baseline HPV Ab titer level, HPV DNA detection, and lower CD4+/CD8+ ratio were also associated with a lower response. CD4+/CD8+ ratio was a stronger predictor in the year 1.5 Ab analysis than in the week 28 analysis. Ab responses among baseline Ab detectable were only somewhat higher than those among baseline Ab undetectable (eg, type 16 week 28 median 3.46 vs 3.20 log10 mMU/mL) despite the existing baseline titer (median 1.74).

CONCLUSIONS

We did not find any sex differences of serologic response to HPV vaccine. Ab titer gain was lower in those with preexisting antibodies due to previous natural infection.

Cancer Immunotherapies: What the Perioperative Physician Needs to Know

Purpose of Review

For patients with cancer, treatment may include combination therapy, including surgery and immunotherapy. Here, we review perioperative considerations for the patient prescribed immunotherapeutic agents.

Recent Findings

The perioperative period is a poignant moment in the journey of a patient with cancer, potentially deemed most influential compared to other moments in the care continuum. Several immunotherapeutic medications have been employed near the time of surgery to potentially increase effectiveness. Of the various drug classes, including immune checkpoint inhibitors, cytokines, toll-like receptor agonists, and oncolytic viruses, among others, several notable immune-related adverse effects were noted. They range from minor effects to more serious ones, such as renal failure, myocarditis, and tumor growth.

Summary

Surgery and immunotherapy are often employed in combination for primary treatment and prevention of cancer recurrence. Careful review and consideration of the pharmacokinetics, pharmacodynamics, and toxicities of immunotherapy benefit the perioperative physician and their patients.

Peptide-Based Nanovaccines in the Treatment of Cervical Cancer: A Review of Recent Advances

Persistent infection with high-risk human papillomaviruses (HPVs), such as HPV-16 and HPV-18, can induce cervical cancer in humans. The disease carries high morbidity and mortality among females worldwide. Inoculation with prophylactic HPV vaccines, such as Gardasil^® or Cervarix^®, is the predominant method of preventing cervical cancer in females 6 to 26 years of age. However, despite the availability of commercial prophylactic HPV vaccines, no therapeutic HPV vaccines to eliminate existing HPV infections have been approved. Peptide-based vaccines, which form one of the most potent vaccine platforms, have been broadly investigated to overcome this shortcoming. Peptide-based vaccines are especially effective in inducing cellular immune responses and eradicating tumor cells when combined with nanoscale adjuvant particles and delivery systems. This review summarizes progress in the development of peptide-based nanovaccines against HPV infection.

Vaccine Strategies for Human Papillomavirus-Associated Head and Neck Cancers

Simple Summary

Human papillomavirus (HPV) is recognized as a significant risk factor for head and neck cancers worldwide, and it is the most common cause of oropharyngeal cancers in the United States. Here, we review the incidence and pathogenesis of HPV-related cancers, the development and approval of HPV prophylactic vaccines, and the use and effectiveness of HPV vaccines around the world. Furthermore, we discuss advances in the development of HPV therapeutic vaccines as well as its associated challenges.

Abstract

The rising incidence of oropharyngeal squamous cell cancers (OPSCC) in the United States is largely attributed to HPV. Prophylactic HPV vaccines have demonstrated effectiveness against oral infection of HPV 16 and HPV 18. We review the global epidemiology and biology of HPV-related cancers as well as the development of HPV vaccines and their use worldwide. We also review the various strategies and challenges in development of therapeutic HPV vaccines.

Analysis of HPV Vaccination Willingness amongst HIV-Negative Men Who Have Sex with Men in China

Objective: Men who have sex with men (MSM) are high-risk groups of human papillomavirus (HPV) infection, the best measure to prevent this is the HPV vaccine. However, few studies have investigated HPV vaccination willingness in the MSM population in China. We aimed to explore the willingness of human immunodeficiency virus (HIV)-negative MSM for HPV vaccination and the factors affecting their willingness to vaccinate. Methods: We adopted a non-probability sampling method to recruit HIV-negative MSM volunteers. Participants completed a questionnaire, including sociodemographic characteristics, sexual behavior characteristics, HPV infection and vaccine-related knowledge, risk perception, and HPV vaccination willingness and promotion attitudes. Results: Of the 406 HIV-negative MSM surveyed, 86.21% were willing to receive HPV vaccine. HPV infection and vaccine-related knowledge (odds ratio [OR] = 2.167, 95% confidence interval [CI] = 1.049–4.474), HPV infection risk perception (OR = 5.905, 95% CI = 1.312–26.580), and HPV vaccine promotion attitude (OR = 6.784, 95% CI = 3.164–14.546) were all related to HPV vaccination willingness. Conclusion: MSM have a high willingness for HPV vaccination. Strengthening health education for MSM, raising their awareness of HPV infection and vaccines, and promoting their risk perception of HPV infection will help increase their willingness for HPV vaccination.

Biomaterials, biological molecules, and polymers in developing vaccines

Vaccines have been used to train the immune system to recognize pathogens, and prevent and treat diseases, such as cancer, for decades. However, there are continuing challenges in their manufacturing, large-scale production, and storage. Some of them also show suboptimal immunogenicity, requiring additional adjuvants and booster doses. As an alternate vaccination strategy, a new class of biomimetic materials with unique functionalities has emerged in recent years. Here, we explore the current bioengineering techniques that make use of hydrogels, modified polymers, cell membranes, self-assembled proteins, virus-like particles (VLPs), and nucleic acids to deliver and develop biomaterial-based vaccines. We also review design principles and key regulatory issues associated with their development. Finally, we critically assess their limitations, explore approaches to overcome these limitations, and discuss potential future applications for clinical translation.

A Framework for Cervical Cancer Elimination in Low-and-Middle-Income Countries: A Scoping Review and Roadmap for Interventions and Research Priorities

The World Health Organization announced an ambitious call for cervical cancer elimination worldwide. With existing prevention and treatment modalities, cervical cancer elimination is now within reach for high-income countries. Despite limited financing and capacity constraints in low-and-middle-income countries (LMICs), prevention and control efforts can be supported through integrated services and new technologies. We conducted this scoping review to outline a roadmap toward cervical cancer elimination in LMICs and highlight evidence-based interventions and research priorities to accelerate cervical cancer elimination. We reviewed and synthesized literature from 2010 to 2020 on primary and secondary cervical cancer prevention strategies. In addition, we conducted expert interviews with gynecologic and infectious disease providers, researchers, and LMIC health officials. Using these data, we developed a logic model to summarize the current state of science and identified evidence gaps and priority research questions for each prevention strategy. The logic model for cervical cancer elimination maps the needs for improved collaboration between policy makers, production and supply, healthcare systems, providers, health workers, and communities. The model articulates responsibilities for stakeholders and visualizes processes to increase access to and coverage of prevention methods. We discuss the challenges of contextual factors and highlight innovation needs. Effective prevention methods include HPV vaccination, screening using visual inspection and HPV testing, and thermocoagulation. However, vaccine coverage remains low in LMICs. New strategies, including single-dose vaccination could enhance impact. Loss to follow-up and treatment delays could be addressed by improved same-day screen-and-treat technologies. We provide a practical framework to guide cervical cancer elimination in LMICs. The scoping review highlights existing and innovative strategies, unmet needs, and collaborations required to achieve elimination across implementation contexts.

Vaccine Development Throughout History

The emergence of the coronavirus disease 2019 (COVID-19) pandemic has made us appreciate how important it is to quickly develop treatments and save lives. The race to develop a vaccine for this novel coronavirus began as soon as the pandemic emerged. Time was the only limiting factor. From the first vaccine developed in 1796 against smallpox to the latest COVID-19 vaccine, there have been several vaccines that have reduced the burden of disease, with the associated mortality and morbidity. Over the years we have seen many new advancements in organism isolation, cell culture, whole-genome sequencing, and recombinant nuclear techniques. These techniques have greatly facilitated the development of vaccines. Each vaccine has its own development story and there is much wisdom to be gained from learning about breakthroughs in vaccine development.

Potent Neutralizing Humanized Antibody With Topical Therapeutic Potential Against HPV18-Related Cervical Cancer

Cervical cancer caused by human papillomavirus (HPV) infections is the fourth most common cancer in women worldwide. Current prophylactic HPV vaccines have achieved promising success in preventing HPV infection. However, still 570,000 new cases were reported in 2018. The current primary treatment for the patient with cervical cancer is either surgery or chemoradiotherapy. Cervical cancer still lacks standard medical therapy. HPV18 induced cervical cancer has the worst prognosis and high mortality compared to other HPV infections. The development of HPV18 related with cervical malignancy requires the persistent infection of cervical-vaginal epithelium by HPV18 subtype, which can take years to transform the epithelium. This period of repeated infection provides a window for therapeutic intervention. Neutralizing antibodies formulated as topical agents that inhibit HPV18 infection should reduce the chance of cervical malignancy. We previously demonstrated that potent neutralizing anti-sera against HPV18 infection were induced by HPV18 viral like particle (VLP) generated in mammalian cells. We, therefore, isolated two potent neutralizing antibodies, 2A12 and 8H4, from over 3,810 hybridomas prepared from mice immunized with HPV18 VLP. 2A12 and 8H4 exhibited excellent potency, with 50% virus-inhibitory concentrations (IC₅₀) of 0.4 and 0.9 ng/ml, respectively. Furthermore, 2A12 and 8H4 recognized distinct and non-overlapping quaternary epitopes and bound specifically with HPV18. Humanized 2A12 (Hu2A12) retained comparable neutralizing activity against HPV18 infection in various acidic pH settings and in hydrogel formulation with IC₅₀ values of 0.04 to 0.77 ng/ml, indicating that Hu2A12 will be a promising candidate for clinical development as a topical vaginal biopharmaceutical agent against HPV18 infection.

The confounding effect of multi-type human papillomavirus infections on type-specific natural history parameter identification

The natural history of human papillomavirus (HPV) from infection to cervical cancer differs between HPV types. Accordingly, type-specific natural history parameters are crucial for the mathematical models used to optimize the nearly life-long series of disease prevention measures. These parameters are estimated from genotyped data from trials and population level screening programs, typically one type at a time, which requires projecting the multiple-type data to the single type. To analyze impacts of such projection methods on the estimates, we compared estimating one type at a time using different projection methods with estimating all types together. We simulated genotyped data with chosen parameter values for two HPV types and analyzed the identifiability of the chosen values using the different estimation methods. We found the success of estimating one type at a time to be excessively sensitive to the data projection method, with potential to falsely identify the parameters at wrong values. Estimating all types together identified the parameters well. Our results were consistent both when trial and population level data were used. In conclusion, the potential confounding by multi-type infections has to be considered when choosing an estimation method for type-specific natural history parameters.

Cancer Vaccines: Promising Therapeutics or an Unattainable Dream

The advent of cancer immunotherapy has revolutionized the field of cancer treatment and offers cancer patients new hope. Although this therapy has proved highly successful for some patients, its efficacy is not all encompassing and several cancer types do not respond. Cancer vaccines offer an alternate approach to promote anti-tumor immunity that differ in their mode of action from antibody-based therapies. Cancer vaccines serve to balance the equilibrium of the crosstalk between the tumor cells and the host immune system. Recent advances in understanding the nature of tumor-mediated tolerogenicity and antigen presentation has aided in the identification of tumor antigens that have the potential to enhance anti-tumor immunity. Cancer vaccines can either be prophylactic (preventative) or therapeutic (curative). An exciting option for therapeutic vaccines is the emergence of personalized vaccines, which are tailor-made and specific for tumor type and individual patient. This review summarizes the current standing of the most promising vaccine strategies with respect to their development and clinical efficacy. We also discuss prospects for future development of stem cell-based prophylactic vaccines.

Wide Spectrum Analysis of Human Papillomavirus Genotypes in External Anogenital Warts

External anogenital warts (EGW) are primarily associated with the low-risk human papillomavirus (HPV) genotypes 6 and 11, though coinfection with other low-risk and oncogenic high-risk HPV genotypes also occurs. Although there have been many studies on HPV-associated disease, the prevalence of HPV genotypes associated with EGW is not well characterized. The objective of our retrospective study was to determine the prevalence of HPV genotypes among patients diagnosed with EGW in the south-west of Hungary. Archived formalin-fixed paraffin-embedded tissues from 94 patients were processed in our study. HPV genotypes were determined, applying HPV Direct Flow CHIP test. The overall prevalence of HPV DNA in the EGW samples was 100%, yielding 131 infections among the 94 samples. Of these cases, 72.3% were mono while 27.6% were multi-infections. Out of the 131 infections, the cumulative prevalence of HPV 6 and 11 was 71%. A total of 98.9% of the samples were carrying at least one of these genotypes, while 19.1% of the cases occurred with at least one high-risk genotype. Data from our study could provide invaluable information concerning the prevalence of HPV types among patients with EGW, enabling improved assessment of the actual and future efficacy of vaccination programs, vaccine development, and forecast changes in infection patterns.

Non-invasive saliva-based screening of high-risk Human Papilloma Virus 16 and 18 in healthy young adults and creating awareness about its vaccination

Context:

Human Papilloma Virus (HPV) has not only been linked with cervical cancer but also a key player in other types including oral cancer. Vaccine against HPV has shown promising outcomes in protection against cervical cancer. It is suggested that the same vaccine may be a safeguard against oral cancer as well. Since prevalence of oral cancer is on rise because of various reasons besides high-risk sexual behavior, its prevention becomes equally important.

Aim:

Study aimed at screening saliva samples of healthy young adults to detect the presence of HPV with an intention to increase awareness regarding HPV and its vaccination.

Settings and Design:

The study was executed in the department of Biochemistry, AIIMS, Patna. This cross-sectional study included 100 consented healthy undergraduate medical and nursing students.

Methods and Material:

We isolated DNA from all saliva samples, amplified using multiplex PCR and gel electrophoresed to screen HPV 16 and 18. Feedback about the study in creating awareness regarding HPV and its vaccine was conducted using three-point Likert scale.

Statistical analysis:

The collected responses were entered in Microsoft excel. The results were expressed in frequency and percentages.

Results:

All saliva samples screened were found negative for HPV 16 and 18 DNA. Responses from feedback showed improved knowledge and awareness about the HPV and its vaccine among the participants.

Conclusion:

Even all the saliva samples tested were found negative for HPV DNA, the screening of high-risk HPV in saliva of young medical and nursing students generated curiosity among them to know more about HPV and its vaccine. This exercise may have helped in increasing the acceptance of HPV vaccine and the awareness of getting it at their ideal age to be benefited with dual protection, from oral and cervical (in case of females) cancers lifelong.

Extracellular vesicles as drug vectors for precise cancer treatment

Extracellular vesicles (EVs) are nano-sized vesicle structures secreted from a variety of cells, which carry numerous biological macromolecules, participate in cell signal transduction and avoid immune system clearance. EVs have a plethora of specific signal recognition factors, and many studies have shown that they can play an important role in the precise treatment of tumors. This review aims to compile the applications of EVs as nanocarriers for antitumor drugs, gene drugs and other nanomaterials with anticancer capability. Additionally, we systematically summarize the preparation methodology and expound upon how to improve the drug loading and cancer-targeting capacity of EVs. We highlight that EV-based drug delivery has the potential to become the future of precise cancer treatment.

Human papillomavirus vaccination uptake in low-and middle-income countries: a meta-analysis

BACKGROUND

The proportion of incident cases of HPV-attributable cancers is highest in the low- and middle-income countries (LMICs) but many are yet to initiate HPV vaccination programs. This meta-analysis was performed to assess the uptake of HPV vaccination in LMICs at the beginning of the global strategy to eliminate cervical cancer and describes the gaps and challenges.

METHODS

A systematic search was conducted in PubMed, EMBASE, Scopus, Web of Science, and CENTRAL databases for observational studies that reported the uptake of HPV vaccination until October 2020. The meta-analysis was done using a random-effects model to assess the pooled estimate of HPV uptake. CRD42021218429.

FINDINGS

During 2008-2020, an estimated 3.3 million females received at least one dose of HPV vaccine with 61.69% of the target population vaccinated. In countries with high uptake, the pooled estimate of uptake was higher in females than males (45.48% vs 8.45%) and showed significant decline in 2015-2020 compared to 2006-2014 (89.03% vs 41.48%). In countries with low uptake, the estimate of uptake was low in both males and females (5.31% vs 2.93%) and showed increase in uptake in 2015-2020 compared to 2006-2014 (0.76% vs 5.22%). In countries with high uptake, compared to routine programs, the estimate was higher when delivered through demonstration programs (89.94% vs 59.74%).

INTERPRETATION

The major concern was a significant drop in the uptake in countries that started with high uptake, challenges in the maintenance of vaccine uptake, sustainability of funding and the lack of standard monitoring and reporting.