Changing dynamics of HR-HPV infection and associated cervical precancer in the population-based WOLVES cohort study 15 years after vaccination

Changing dynamics of HR-HPV infection and associated cervical precancer in the population-based WOLVES cohort study 15 years after vaccination | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Changing dynamics of HR-HPV infection and associated cervical precancer in the population-based WOLVES cohort study 15 years after vaccination Agnieszka Denecke, Jan Lennart Stalp, Jens Hachenberg, Dhanya Ramachandran, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8713719/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract We evaluated the distribution of HPV-genotypes in HSIL and LSIL a prospective cohort of young unscreened women. The relationship between hr-HPV status, HPV-genotyping cervical histology, and vaccination status were examined. Between 2009/10 and 2019/2020, three cohorts of young women between 21- and 26 years of age participated in a large epidemiological study with cytology-and HPV testing. Annual colposcopic examination of HPV positive participants and SPF10 LIPA for HPV genotyping was performed in this group. Our study showed changes of HPV-genotype distribution in the immunized- and non-immunized cohort of young women in Germany within 10 years after the introduction of vaccination against HPV. We confirm that immunization against HPV effectively protects against the development of dysplastic changes in our study population. We note that in our vaccinated populations, the HPV subtypes that were not part of the vaccine were more likely to be found in CIN cases. Additionally, only few LSIL (CIN 1) and hardly any HSIL (CIN2-3) cases were seen in the vaccinated population, indicating an increased protection against advanced cervical disease conferred by vaccination. Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Novelty and Impact This evaluation showed the distribution of HPV genotypes in HSIL lesions (CIN 2–3) in a population of young women after the introduction of HPV immunisation. Our analysis also showed a significant decline in lesions and the disappearance of individual genotypes in the vaccinated population. In our opinion, this is one of the first analyses of real-life data from a prospective longitudinal study of young women in Germany. Introduction Genital human papillomavirus (HPV) infection with high-risk HPV subtypes (hr-HPV) and their role in the development of cervical carcinoma and its precursors has been known for a long time ( 1 ). Currently over 450 HPV subtypes have been identified in skin and mucosa. Among these, 13 are known as hr-HPV and are responsible for almost all cervical cancer and dysplasia (cervical intraepithelial neoplasia, CIN) ( 2 ). HPV 16 and 18 alone are responsible for over 70% of all dysplastic changes and carcinomas in the cervix uteri ( 3 ). The fact that most infections are acquired at a very young age and that many of them are completely asymptomatic and heal is very well known ( 4 ). Overall, HPV prevalence shows two-age related peaks, one in the twenties and the second in the forties ( 5 ). More than 90% of infections are transient and unapparent and are eliminated within 6–18 months due to the host immune response. Reinfection with the same or different types of HPV as well as the reactivation of HPV infections are possible. The persistence of HPV infection is rare but very important and can lead to the development of precursor lesion in the cervix-, vagina-, vulva- and perianal area ( 6 ). The bivalent immunization against HPV types 16 and 18 for girls (at first from the age of 14, later at 9 years of age), which was introduced in Germany in 2007, and finally the HPV immunization of boys 11 years later (in 2018), were shown to be highly effective in preventing vaccine HPV subtype-related HPV infections and their associated diseases ( 7 , 8 ). Since 2015, a nonavalent vaccine is available that includes low-risk HPV subtypes 6 and 11 and hr-HPV subtypes 31, 33, 45, 52 and 58 and provides efficient protection against 90% of all cervical carcinomas (9, 10,11). Immunization rates in Germany remain about 50% lower than in countries with school vaccination programs such as England, Australia and Sweden ( 12 ). There is a lack of evidence on the persistence of individual HPV subtypes in the German population and the effects of immunization on HPV subtype distribution. The mechanisms of the replacement of individual genotypes and their significance for the development of the cancerous precursors in the future are also unclear ( 13 ). Especially, knowledge of type-specific hr-HPV prevalence in the population can help to develop risk-adapted and individualized screening strategies in the future ( 14 ). The Wol fsburg HP V E pidemiological S tudy (WOLVES) was a small-scale population-based cohort study on the prevalence- and incidence of HPV infections and associated diseases in women from two pre-defined strata (women aged 21 and 26 years). The primary aim of the study was to assess changes in the prevalence of HPV infections and related diseases after the introduction of vaccination between 2009 and 2020. The longitudinal design allowed a dynamic assessment of HPV infection in the pre-vaccination era and changes over a 10-year observation period. The secondary objective of this study was to establish the distribution of the most common HPV genotypes in different cervical lesions prior to the implementation of organized HPV based cervical cancer screening - and after the introduction of HPV immunization. The main purpose of our analysis was to determine the distribution of the individual HPV-types between LSIL and HSIL in the WOLVES study and to compare the distribution between the three cohorts upon further stratification based on vaccination status. The role of herd protection after the introduction of immunization and its effect on the possible distribution of HPV-types and decrease in HPV-related changes is also still unclear ( 15 , 16 ). Methods Patients: The original design of the WOLVES-study has been described several times ( 17 ). Participation in the study was voluntary and aimed at all women between the ages of 21 and 26, who resided in the German city of Wolfsburg between 2009 and 2020. Our final data analysis included data from 2,971 patients in three cohorts (Cohort 1,2 and 3). The first cohort, born in 1983/84, was studied for the first time in 2009/10 (when the participants were 26 years old). The second cohort (born 1988/89) and the third cohort (born 1993/94) were examined twice, in 2009 and 2014 as well as in 2014 and 2020 (when the participants were 21- and 26 years old, respectively). The first cohort was established to investigate the prevalence of HPV infection in the pre-vaccination era. The second cohort was set up to study changes in the incidence and prevalence of HPV shortly after vaccination was introduced. The third, and thus the most recent, cohort was intended to record HPV infections during the time when vaccination is established. The participants in the WOLVES study did not differ from the general population in terms of the total population regarding education, migration background or birth rate. The data of the registry office did not include medical data, so a recording of further risk factors is not possible. The exclusion criteria were previous incidences of cancer, transplantation- or immunosuppressive therapy or a permanent stay outside the Wolfsburg region. The study design was intended as a prototype of an HPV screening strategy for women aged 20 years and over and as a pilot study 10 years before HPV-based screening was introduced in Germany in 2020 ( 18 ). All participants completed a standardized medical questionnaire including questions on education, birth country, marital status, pregnancies, parity, contraception, smoking, number of sexual partners, age at sexual debut, and history of abnormal Pap smears, sexually transmitted infections and genital warts. Furthermore, the referring gynecologist collected information on HPV vaccination status by checking the certificate of vaccination. The cooperating gynaecologists collected information regarding immunization status from the vaccination certificate. Patients who received three doses at 0, 2, and 6 (5–13 months) were considered fully vaccinated. Participants were transferred for colposcopy if they had abnormal Pap smears conspicuous of high-grade lesions or had Pap smears classified as borderline/low-grade and tested positive for hrHPV. Colposcopists classified the type of transformation zones according to the Barcelona nomenclature of the International Federation for Cervical Pathology and Colposcopy (IFCPC) ( 19 ). No random punch biopsies were taken if colposcopy findings were normal. Histological assessment was mandatory for any lesion where there was a suspicion of high-grade neoplasia (Figs. 1 and 2 ). This study was approved by the ethics committee of Lower Saxony in Hannover (Bo/07/2009). Written consent from all of the participants including an agreement that pseudonymized data may be used for research, was obtained. The handling and publication of patient data in this study were performed strictly in accordance with the Declaration of Helsinki DoH/Oct 2008 and included confidentiality and anonymity. HPV testing: All primary HPV testing was undertaken using the hybrid capture 2 assay (HC2/Qiagen Inc., Hilden Germany). All samples were analysed for the presence of at least 13 HR-HPV types (16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59 and 68) following the manufacturer’s instructions. A positive HR-HPV result in this study refers to a positive subject for the HR-HPV probe mix. All samples that tested positive for HR-HPV with HC2 underwent extended genotyping. HPV-genotyping was performed as described previously using SPF-10-PCR, followed by Reverse Line Probe Assay LiPA Extra (SPF-10-PCR) ( 14 ). Briefly, total DNA was isolated from the cervical samples with the use of a MagNAPure device (Roche, Indianapolis, IN) and analyzed with INNO-LiPA Extra HPV prototype assay (Innogenetics, Gent, Belgium) according to the manufacturer’s instructions. The INNO-LiPA Extra test identifies established high-risk HPV types (16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59 and 68) and five known or putative high-risk types (26, 53, 66, 73 and 82) ( 20 ). Statistical analysis All statistical analyses were undertaken by an independent statistician. The association between HPV infection and explanatory variables was analyzed in univariable and multivariable analyses. All statistical analyses were performed with the validated program R Version 4.1.2 by using descriptive statistical analysis. Continuous data are presented as means ± standard deviation. Categorial data are presented as counts and proportions. Results Study population Between October 2009 and March 2021, a total of 3,010 women were included in the study. The final analysis included complete data from 2,999 patients. We included 43% of all women living in the city of Wolfsburg from the 1983/84 cohort, 47% from the 1988/89 cohort in 2009/10 and 33% from the 1993/94 cohort (Statistical Office of the City of Wolfsburg Data, Fig. 1 ). HPV vaccination coverage rate: Among the 21-year-olds, the vaccination rate increased from 23.7% to 48.1% between 2009 and 2014 (Fig. 3 ). Among the 26-year-olds, the vaccination rate increased from 6.1% (2009/10) to 18.4% in 2014/15 and reached 59.2% in 2020. Cervical dysplasia and HPV-subtypes distribution The HPV prevalence amounts to 26.8% in the cohort 1983/84, 30.9% in the cohort 1988/89 in 2009 and 38.3% in 2014/15. In our youngest cohort (1993/94) the hr-HPV prevalence was 32.3% in 2014/15 and increased to 34.5% in 2019/2020 (Fig. 3 ). In the first cohort (born in 1983/84, 26 years old in 2009/2010), we observed the development of dysplastic precursors in 24 cases. CIN 3 (HSIL) was the most common with 11 cases. Whereas CIN 1 (LSIL) was present in 8 cases. Only three out of 24 findings occurred in vaccinated individuals, including one case of mild dysplasia and 2 cases of moderate cervical dysplasia (CIN 2). HSIL (CIN 3/Ca in situ) occurred 8 times (33%) and exclusively in unvaccinated patients (Fig. 5 ). As expected, HPV genotype 16 was the most common in patients with HSIL (4 cases in CIN 3 and 2 cases in CIN 2 lesions). Only HPV 51 was also found in the lesions with CIN 3 (2 cases) as well as a single case of a CIN 3 lesion containing HPV 6. HPV types 18, 31 and 53 are also represented with 1 lesion each. We also did not observe any difference in terms of single and multiple infections (Fig. 8a). In the cohort 1988/89 in 2009/10 (then 21-year-old women) we initially saw 20 dysplastic findings in the dysplasia consultation. The unvaccinated individuals had a four-fold higher risk of developing dysplastic changes than vaccinated individuals in the same cohort (16 vs. 4). LSIL (CIN 1) was the most common in the unvaccinated group with 11 cases (55%). HSIL was diagnosed in 5 cases among unvaccinated women (Figs. 5 and 6 ). Regarding HPV genotype distribution, only one CIN 2 lesion with subtype 52 in the vaccinated group was observed. In the unvaccinated group, HPV 16 was the most common with 3 cases, two of which had HSIL. Subtypes 51, 52 and 66 occurred only sporadically and were found in cases with mild dysplasia. 5 years later, in 2014/15, this cohort showed a much higher incidence of HSIL (a total of 29 CIN2 and 29 CIN3) in the unvaccinated population. Even with 12 LSILs, the mild lesion was 4 times more common compared to the vaccinated subgroup. HPV 16 again played the largest role in the development of HSIL with 14 cases and exclusively in the unvaccinated group, together with HPV 51 (5 cases), 52 (5 cases), HPV 58, 66 (2 cases) as well as 33 and 68. We did not have a relevant distribution of single and multiple infection in 21-year-old patients in this cohort (Fig. 6 + 8b). In 26-year-olds, with the increase in HSIL incidence, we also observed the increase in redistribution of single infections (17 vs.7 cases, Fig. 5 + 7a). Figure 7 Histology findings in the cohorts depends on vaccination status. a)1983/84 (26 years old) b)1988/89 (21 years old) c)1988/89 (26 years old) d)1993/94 (21 years old) e)1993/94 (26 years old) In the vaccinated population, we noted 3 HSIL cases and only one case of LSIL. 5 years later, in 2014/15, in the same population, 77 lesions were diagnosed (in 897 participants). No HSIL with CIN 3 was seen in this group. In contrast, we found 10-fold more lesions in the unvaccinated population (70). HSIL lesions predominated with 29 CIN 3 and 29 CIN 2 cases (Fig. 7c). From the 1993/94 cohort, among 405 21-year-old female patients, in 2014/15, only 2 patients had confirmed lesions, so no meaningful statistical evaluation was possible (Fig. 7d). In the same cohort in 2019/2020 (then 26-year-olds), only 15 lesions were found in this population. 8 lesions occurred in the non-vaccinated group and 6 in the vaccinated group. 4 HSIL cases were found exclusively in the unvaccinated group (Fig. 7e). In the group of 21-year-olds from the cohort 1993/94, we saw only single infections with HPV subtypes 16, 6, 18 in HSIL as well as 51, 52 and 66. In the analysis of 26-year-old female patients in the same cohort, we can confirm a significant increase of infections in the unvaccinated populations, especially with HPV 16. HPV types 51, 52 and subtypes 31, 66, 33 and 68 also played a role in the development of HSIL in this group. All HSIL lesions occurred exclusively in unvaccinated individuals (Fig. 4 + 8c). HPV-Subtyping distribution among the HPV positive participants without dysplasia In our oldest cohort from 1983/84, we only identified isolated infections among vaccinated people. Among the unvaccinated, we saw the dominance of HPV 16 with 55 infections as well as subtypes 51 (33 infections) – and subtype 31 (33 infections) (Fig. 8a). In the second cohort (1988/89) in the group aged 21 years, who were vaccinated, HPV type 51 played an important role (21 cases) as well as HPV 52 and HPV 66 with 14 and 13 cases, respectively. Among the unvaccinated women, HPV subtype 51 dominated (with 78 cases, almost three times as many infections as in the vaccinated group). HPV 16 was the second most common type in our analysis, with 68 cases. After 5 years, the ratio changed significantly in the unvaccinated population and HPV 16 was prevalent with 183 cases, followed by subtypes 51 with 98 cases and subtype 31 with 95 cases occurring most frequently (Fig. 8b). In our most recent cohort, among the vaccinated group at 21 years of age, we saw subtype 51 with 39 infections, followed by subtype 66 with 19 cases and subtypes 52 and 3 with 18 infections. Among the unvaccinated women, subtypes 52 and 51 dominated, with 22 and 20 infections, respectively. Among the vaccinated 26-year-olds, subtype 63 was predominant with 37 cases. Three other subtypes: 53, 51 and 39 were found with over 20 cases. Among the unvaccinated 26-year-olds, subtypes 52 and 16 (29 and 28 cases) and subtypes 53, 39 and 66 were common (Fig. 8c). Conclusions Our analysis provides information about the distribution of the most prevalent HPV-types among young German women in a longitudinal follow-up study. WOLVES was a small-scale study and played a crucial role prior to the introduction of the HPV vaccination program as a primary prevention program, followed by organized screening as a secondary prevention program In the present study we observed high prevalence of hr-HPV infection in women aged 21 and 26 years. The prevalence of HPV was the highest in our cohorts with 26–38% in 2019/2020. This prevalence is higher than described elsewhere, and there is no explanation for this. Our population is a real-world population. A comparison of HPV-HR genotypes in HPV-positive vaccinated and unvaccinated patients, separated by cohort, shows a significant decline in HPV 16 infections in vaccinated patients in all three cohorts. This result is consistent with the results of a large-scale study on HPV prevalence in the Netherlands showing HPV 16 as the most prevalent hr-HPV subtype. Similar results were shown by Arbyn et al . in Belgium with HPV 16 persistence in 32% of HSIL cases and HPV 31 in 22%. However, the percentage of HPV 31 with 8.2% in our study was considerably lower in comparison than this one ( 26 , 27 ). It is interesting to note that HPV 52 was the third most common HPV subtype found in our samples. Among women diagnosed with LSIL, HPV 16, 31 and 52 were the most frequently detected. Contrary to our expectation, HPV-18 and 45 were the less common hr-HPV subtypes in cervical samples with 4.2-and 2.2%, respectively ( 28 ). The most frequent HPV subtype in all cohorts were HPV 51 and HPV 16 detected with 14% and 13.4% of all samples, respectively. In the subgroup analysis by HSIL diagnosis, HPV 16 and 51 were the most relevant subtypes for HSIL in our study. Compared to the distribution of genotypes in unvaccinated women, HPV genotypes 51, 52 and 53 were detected in vaccinated women at nearly consistent levels. HPV 16 and 31, on the other hand, were rarely found in vaccinated women, while there was no significant difference between vaccinated and unvaccinated women for HPV 18 due to its low prevalence (around 2%) and an even lower number of vaccinated women. Similar findings were reported by other recent studies ( 23 ). A summary of 18 studies from 14 European countries confirmed HPV 16 as the most prevalent HPV subtype ( 24 ). The third most common subtype cumulative seen in our cumulative analysis was HPV 52 (13.2% of all samples), followed by HPV 31 (8.2%). A worldwide systematic analysis performed by Wei et al. suggests reclassifying the carcinogenic subtypes due to their findings ( 25 ). The age distribution of HPV infection was like to those reported in most studies. We observed an increased distribution of hr-HPV in young women from the age of 21 and 26 years ( 29 , 30 ). We confirm that, in our population, CIN among women after HPV vaccination ( 31 , 32 ). In the first cohort, CIN was typically associated with the HPV-types used in the vaccine ( 33 ). Those results are in line with data from Pimenoff et al. who showed the replacement of vaccine-targeted HPV-subtypes by non-targeted subtypes after community vaccination ( 34 ). What is very interesting is that we saw no reduction in the prevalence of HPV, but at the same time a disappearance of low-risk types such as HPV 6 and 11. This means that we also observed a possible replacement of HPV subtypes in our population and a resulting decline in dysplastic changes. This may have nothing to do with the acquisition of the infection and the resulting high prevalence. The disappearance of vaccine-associated hr-HPV and LR-HPV was substantial for vaccine types and occurred in our population shortly after the introduction of immunization. The current evaluation also possibly shows a very strong influence of the already immunized women on the non-immunized women in terms of herd immunity. There was a significant impact of HPV vaccination on HPV 16 infections and decline of all levels of dysplasia level in our youngest cohort while prevalence remained high. During the first round, we were able to observe the association with subtypes 16, 31 and 51 in the 26-year-old patients. Over time, this ratio shifted, and we observed more non-vaccine HPV subtypes in our histological findings (such as subtype 66 and 52). The constant number of mild dysplastic changes and decrease in moderate and severe changes during vaccination phase was also particularly significant (HSIL (CIN 3) p = 0.009, HSIL (CIN 2) p = 0.014). Strategies in cervical carcinoma screening should consider the changes in the prevalence of high-risk types 16 and 18. As recent findings by Grieger et al. show a first insight into the effective reduction of cervical carcinoma incidence due to HPV-vaccination, our national vaccination strategy should frequently adapt to new results to ensure the durability of this trend ( 35 , 36 ). Women with HPV16, and 51 and 52 infections have a high risk of clinically relevant lesions that seem to increase over time (as shown in the comparison between our three cohorts). In immunized individuals, however, non-progressive HPV subtypes will play a greater role. This may, in turn, slow down disease progression and cause a low number of dysplastic findings even in non-immunized patients. It is interesting to note the occurrence of severe dysplastic changes in young women who develop malignant disease, despite immunization. While it is important to clarify the causes of vaccine failure, a genetic disposition may underlie the development of invasive cervical disease. Unfortunately, this is not clear in our analysis due to the small number of dysplasia and lack of high-grade lesions in the vaccinated subpopulation with a follow-up period limited to only ten years. Knowledge of the prevalence level of type-specific hr-HPV in the population and in HSIL is very important to predict the burden of positive tests results and can lead to the development of a risk-adapted, individualized, and cost-effective screening strategy in the future, that includes HPV vaccination as the primary prevention and screening strategy. Strengths and weaknesses of our study: The current study is a small population-based study, limited to one geographical location within Germany. One of the weaknesses is representativeness, that we were able to requisite about 33–47% of the population from the region. In Germany, there are no health registers or country-wide biobanks and no data from organized screening as in other countries, such as Sweden, which does not allow us to extend our findings to the national level. Vaccination was carried out with the bivalent-and the tetravalent vaccine, but we cannot exclude with certainty that the data on extended immunization with the nonavalent vaccine (additional immunization against HPV 31, 33, 45, 52 and 58) has a possible effect on the distribution and replacement of HPV-types in the youngest cohort. Another possible drawback in our analysis is the young age of the patients. In many countries screening begins at the age of 23 or 26 (such as in Sweden or, - USA). Our patients younger in comparison, at 21–26 years of age. We know that at a very young age the incidence of HSIL is higher, but the risk of progression to cancer is very small. Many of them do not require treatment and heal spontaneously, as we saw this in our study. The large number of CIN was caused by non-progressive types such as 42, 51, 56 and 66. For this reason, the data is not transferable to other age groups and invites further longitudinal follow-up studies. Declarations Previous Presentation: The results from WOLVES was presented as poster presentation on ESGO in Rom (02/2025) Agnieszka Denecke, Jan Lennart Stalp, Jens Hachenberg, Matthias Jentschke, Peter Hillemanns: Effect Of HPV Vaccination In Cervical Cancer Screening Population – Results Of WOLVES, A Population-Based Cohort Study In Germany , ESGO Rom 02/2025 Authors’ contributions: WOLVES was one of the first cohort studies in Germany to establish HPV-based screening, 10 years before it was introduced into law. The idea of WOLVES study was created by the carcinoma screening pioneer in Germany, K.U.P. and A.D. worked on the WOLVES project for over 8 years and completed the study after the death of K.U.P as study leader. A.D. conceived the presented idea and drafted the manuscript. V.L. and P.S. verified the analytical methods and performed analysis. D.R. and J.L.S. edited the manuscript. P.H. is a member of the screening committee of the WOLVES study and involved in the study design. All authors discussed the results and contributed to the final manuscript. Ethics Statement: This study was approved by the ethics committee of Lower Saxony in Hannover (Bo/07/2009). Written consent from all of the participants including an agreement that pseudonymized data may be used for research, was obtained. The handling and publication of patient data in this study were performed strictly in accordance with the Declaration of Helsinki DoH/Oct 2008 and included confidentiality and anonymity. Availability of data: All data generated or analysed during this study are included in this published article [and its supplementary information files]. The database is in the Department of Gynaecology at Medical Hannover School and Klinikum Wolfsburg. All the data can be obtained from the authors on request. Competing interests: The authors declare no competing interests. Funding: WOLVES was an epidemiological study, and this work was supported by the Investigator Studies Program (MISP) from MSD Sharp & Dohme GmbH. The founder had no role in the study design, in the conducting of the study or data analysis. Hologic supported WOLVES with ThinPrep vials free of charge. Acknowledgements: Our study is dedicated to Prof. K.U.Petry, former leader of the Study Group of Colposcopy (SGK) in German, who passed away April 2020. The authors further would like to thank all participating gynaecologists and all WOLVES participants for their support. References Munoz N, Bosch FX, de Sanjosee S, Herrero R, Castellsague X, Shah KV, Meijer CJ. Epidemiologic classification of human papillomavirus types associated with cervical cancer. N Engl J Med 348:518–27. Licciardi PV, Frazer ICH, Garland SM. 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Pre-vaccination prevalence of infections with 25 non high-rissk human papillomavirus types among 1,000 slovenian women in cervical cancer screening. J Med Virol. 2014;86:172–1779. Al-Shiibli KA, Mohammed HAL, Maurseth R, Fostervold M, Werner S, Serbyr SW. Impact of HPV mRNA types 16,18,45 detecton on the risk of CIN 3 + in young women with normal cervical cytology. PLoS ONE, November 22, 2022. Arbyn M, Benoy I, Simoens C, et al. Prevaccination distribution of human papillomavirus types in women attending of cervical carcinoma screening in Belgium. Cancer Epidemiol Biomark Prev. 2009;18:321–30. Gray P, Luostarinen T, Vanskaa S, Eriksson T, Lagheden C, Lehtinen M, et al. Occurence of human papillomavirus type replacement, sexual risk—taking behaviour group:post-hoc analysis of a community randomized clinical trial up to 9 years after vaccination (IV). Int J Cancer. 2019;145:785–96. Schmeink CE, Melcchers WJG, Siebers AG, Quint WGM, Massuger LFAG, Bekkers RLM. Human papillomavirus persistence in young unscreened women, a prospective cohort study. PLoS ONE, 6, Nov 2011, e27937. Giannella L, Rossi PG, Carpini GD, Giuseppe JD, Bogan G, Ciavattini A, et al. Age-related distribution of uncommon HPV genotypes in cervical intraepithelial dysplasia grade 3. Gynecol Oncol. 2021;161:741–7. Xiao M, Qiuxiang X, Hongyan L, Huiqiao G, Thang Z et al. Prevalence of human papillomavirus genotypes among women with high-grade cervical lesions in Beijing, China, Medicine, Vol.95, 2016, 10.1097/MD.00000000000002555 Tota JE, Struyf F, Marikukka M, Gonzales P, Kreimer AR, Lehttinen M, et al. Evaluation of type replacement following HPV 16/18 vaccination: pooled analysis oft wo randomized trials. JNCI J Nati Cancer Inst. 2017;109(7):djw300. Denecke A, Iftner T, Iftner A, Riedle S, Ocak M, Luyten A, Petry KU. Significant decline of HPV 6 infection and genital warts despite low HHPV vaccination coverage in young women in Germany: a long-term prosppective, cohort data analysis. BMC Infect Dis. 2021;21:634. Pimenoff V, Gray P, Louvanto K, Eriksson T, Lagheden C, Söderlund-Strand A, Dillner J, Lehtinen M. Ecological diversity profiles of non-vaccine-targeted HPVs after gender-based community vaccination efforts. Cell Host Microbe 31, 1921–9, November 8, 2023. https://doi.org/10.1016/j.chom.2023.10.001 Grieger P, Eisemann N, Hammersen F, Rudolph C, Katalinic A, Waldmann A. Initial Evidence of a Possible Effect of HPV Vaccination on Cancer Incidence in Germany. Dtsch Arztebl Int. 2024;121:415–21. Ye Y, Jones TE, Zhao C. Utility of extended HPV genotyping in cervical cancer screening and clinical management. Gynecol Obstet Clin Med. 2025;5:e000226. 10.1136/gocm-2025-000226 . Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8713719","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":587564501,"identity":"17690866-adbd-4703-8e2c-5cd68b1be164","order_by":0,"name":"Agnieszka Denecke","email":"data:image/png;base64,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","orcid":"","institution":"Hannover Medical School","correspondingAuthor":true,"prefix":"","firstName":"Agnieszka","middleName":"","lastName":"Denecke","suffix":""},{"id":587564502,"identity":"b84a9cc6-8112-461a-811c-1fcfc1074e7e","order_by":1,"name":"Jan Lennart Stalp","email":"","orcid":"","institution":"Hannover Medical School","correspondingAuthor":false,"prefix":"","firstName":"Jan","middleName":"Lennart","lastName":"Stalp","suffix":""},{"id":587564503,"identity":"13740066-8812-4c7d-91c8-c3e3633a0fed","order_by":2,"name":"Jens Hachenberg","email":"","orcid":"","institution":"Hannover Medical School","correspondingAuthor":false,"prefix":"","firstName":"Jens","middleName":"","lastName":"Hachenberg","suffix":""},{"id":587564507,"identity":"5a23a02b-3484-4d6b-8b78-1783fd913e5d","order_by":3,"name":"Dhanya Ramachandran","email":"","orcid":"","institution":"Hannover Medical School","correspondingAuthor":false,"prefix":"","firstName":"Dhanya","middleName":"","lastName":"Ramachandran","suffix":""},{"id":587564518,"identity":"2b22f9f9-c496-4800-9c08-379613c8f8b0","order_by":4,"name":"Philipp Sibbertsen","email":"","orcid":"","institution":"Leibniz University Hannover","correspondingAuthor":false,"prefix":"","firstName":"Philipp","middleName":"","lastName":"Sibbertsen","suffix":""},{"id":587564532,"identity":"812f912c-951a-4621-aee3-ebcc0e21538f","order_by":5,"name":"Vivien Less","email":"","orcid":"","institution":"Leibniz University Hannover","correspondingAuthor":false,"prefix":"","firstName":"Vivien","middleName":"","lastName":"Less","suffix":""},{"id":587564535,"identity":"bd1338d1-1bb8-4ca5-8d8a-591fadff10e7","order_by":6,"name":"Peter Hillemanns","email":"","orcid":"","institution":"Hannover Medical School","correspondingAuthor":false,"prefix":"","firstName":"Peter","middleName":"","lastName":"Hillemanns","suffix":""}],"badges":[],"createdAt":"2026-01-27 19:08:43","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8713719/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8713719/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102427301,"identity":"320939a4-9221-4d65-8f3b-31415b0488bb","added_by":"auto","created_at":"2026-02-11 14:50:44","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":70997,"visible":true,"origin":"","legend":"\u003cp\u003eFlow chart of the \u003cstrong\u003eWol\u003c/strong\u003efsburg HP\u003cstrong\u003eV\u003c/strong\u003e \u003cstrong\u003eE\u003c/strong\u003epidemiological \u003cstrong\u003eS\u003c/strong\u003etudy (WOLVES).\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8713719/v1/0b00f06b2fcacd63a068aa33.png"},{"id":102745709,"identity":"1031ea97-6b78-480c-827a-bb99b225dc10","added_by":"auto","created_at":"2026-02-16 08:53:30","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":49342,"visible":true,"origin":"","legend":"\u003cp\u003eTimeline for recruitment and analysis of participants in the study.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8713719/v1/289edcf32e86d4ab7b5eece6.png"},{"id":102427306,"identity":"9314f11d-3543-4e48-994e-dec2485c1941","added_by":"auto","created_at":"2026-02-11 14:50:45","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":29803,"visible":true,"origin":"","legend":"\u003cp\u003eHPV vaccination coverage rate among 21–26-year-old women in the WOLVES study\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-8713719/v1/358f49dc74f1e55acce10a89.png"},{"id":102746012,"identity":"757d76cc-7ef8-42ad-bd10-111c50f6c6f4","added_by":"auto","created_at":"2026-02-16 08:55:11","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":15122,"visible":true,"origin":"","legend":"\u003cp\u003eDecline of HPV 16, 31 and 18 among women aged 26 in WOLVES study (cumulative for vaccinated and unvaccinated women with- or without dysplasia findings)\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-8713719/v1/2d3314524a6091989c608dd0.png"},{"id":102427302,"identity":"6e36d71f-0fcc-4ba9-ace2-700e545c0a4c","added_by":"auto","created_at":"2026-02-11 14:50:44","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":15270,"visible":true,"origin":"","legend":"\u003cp\u003eThe Decline of high grade dysplasia findings and increase of low grade dysplasia in the study cohorts (cumulative for 26 years old women between 2009-2020)\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-8713719/v1/4166df32754969de8ce5415a.png"},{"id":102427309,"identity":"a7a2db60-76fc-4f36-b2d1-9008fad7e8a9","added_by":"auto","created_at":"2026-02-11 14:50:45","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":12612,"visible":true,"origin":"","legend":"\u003cp\u003eDecline of dysplasia findings in the study cohorts (cumulative for 21 years old women)\u003c/p\u003e","description":"","filename":"6.png","url":"https://assets-eu.researchsquare.com/files/rs-8713719/v1/bcf1a01b0ff9ee8c60d20445.png"},{"id":102745673,"identity":"479abb00-8fc7-4fad-9b81-15237b22302c","added_by":"auto","created_at":"2026-02-16 08:53:15","extension":"png","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":85621,"visible":true,"origin":"","legend":"\u003cp\u003eHistology findings in the cohorts depends on vaccination status.\u003c/p\u003e","description":"","filename":"7.png","url":"https://assets-eu.researchsquare.com/files/rs-8713719/v1/393517657999609b3a3a970f.png"},{"id":102745648,"identity":"cbf47a8d-6e2f-40db-a2a1-5822d5a8cc2e","added_by":"auto","created_at":"2026-02-16 08:53:06","extension":"png","order_by":8,"title":"Figure 8","display":"","copyAsset":false,"role":"figure","size":142463,"visible":true,"origin":"","legend":"\u003cp\u003eGenotyping distribution depends from HPV vaccination status\u003c/p\u003e","description":"","filename":"8.png","url":"https://assets-eu.researchsquare.com/files/rs-8713719/v1/c7e445bb33a4d07cdb0195ea.png"},{"id":109098015,"identity":"cfd18eab-351d-4915-8af7-054c5601b668","added_by":"auto","created_at":"2026-05-12 14:11:47","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":548718,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8713719/v1/8dae801e-75fc-4ff8-b00b-3214d38bd293.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eChanging dynamics of HR-HPV infection and associated cervical precancer in the population-based WOLVES cohort study 15 years after vaccination\u003c/p\u003e","fulltext":[{"header":"Novelty and Impact","content":"\u003cp\u003eThis evaluation showed the distribution of HPV genotypes in HSIL lesions (CIN 2\u0026ndash;3) in a population of young women after the introduction of HPV immunisation. Our analysis also showed a significant decline in lesions and the disappearance of individual genotypes in the vaccinated population. In our opinion, this is one of the first analyses of real-life data from a prospective longitudinal study of young women in Germany.\u003c/p\u003e"},{"header":"Introduction","content":"\u003cp\u003eGenital human papillomavirus (HPV) infection with high-risk HPV subtypes (hr-HPV) and their role in the development of cervical carcinoma and its precursors has been known for a long time (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eCurrently over 450 HPV subtypes have been identified in skin and mucosa. Among these, 13 are known as hr-HPV and are responsible for almost all cervical cancer and dysplasia (cervical intraepithelial neoplasia, CIN) (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). HPV 16 and 18 alone are responsible for over 70% of all dysplastic changes and carcinomas in the cervix uteri (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe fact that most infections are acquired at a very young age and that many of them are completely asymptomatic and heal is very well known (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Overall, HPV prevalence shows two-age related peaks, one in the twenties and the second in the forties (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). More than 90% of infections are transient and unapparent and are eliminated within 6\u0026ndash;18 months due to the host immune response. Reinfection with the same or different types of HPV as well as the reactivation of HPV infections are possible. The persistence of HPV infection is rare but very important and can lead to the development of precursor lesion in the cervix-, vagina-, vulva- and perianal area (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe bivalent immunization against HPV types 16 and 18 for girls (at first from the age of 14, later at 9 years of age), which was introduced in Germany in 2007, and finally the HPV immunization of boys 11 years later (in 2018), were shown to be highly effective in preventing vaccine HPV subtype-related HPV infections and their associated diseases (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Since 2015, a nonavalent vaccine is available that includes low-risk HPV subtypes 6 and 11 and hr-HPV subtypes 31, 33, 45, 52 and 58 and provides efficient protection against 90% of all cervical carcinomas (9, 10,11).\u003c/p\u003e \u003cp\u003eImmunization rates in Germany remain about 50% lower than in countries with school vaccination programs such as England, Australia and Sweden (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). There is a lack of evidence on the persistence of individual HPV subtypes in the German population and the effects of immunization on HPV subtype distribution. The mechanisms of the replacement of individual genotypes and their significance for the development of the cancerous precursors in the future are also unclear (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eEspecially, knowledge of type-specific hr-HPV prevalence in the population can help to develop risk-adapted and individualized screening strategies in the future (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe \u003cb\u003eWol\u003c/b\u003efsburg HP\u003cb\u003eV E\u003c/b\u003epidemiological \u003cb\u003eS\u003c/b\u003etudy (WOLVES) was a small-scale population-based cohort study on the prevalence- and incidence of HPV infections and associated diseases in women from two pre-defined strata (women aged 21 and 26 years).\u003c/p\u003e \u003cp\u003eThe primary aim of the study was to assess changes in the prevalence of HPV infections and related diseases after the introduction of vaccination between 2009 and 2020. The longitudinal design allowed a dynamic assessment of HPV infection in the pre-vaccination era and changes over a 10-year observation period. The secondary objective of this study was to establish the distribution of the most common HPV genotypes in different cervical lesions prior to the implementation of organized HPV based cervical cancer screening - and after the introduction of HPV immunization.\u003c/p\u003e \u003cp\u003eThe main purpose of our analysis was to determine the distribution of the individual HPV-types between LSIL and HSIL in the WOLVES study and to compare the distribution between the three cohorts upon further stratification based on vaccination status.\u003c/p\u003e \u003cp\u003eThe role of herd protection after the introduction of immunization and its effect on the possible distribution of HPV-types and decrease in HPV-related changes is also still unclear (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatients:\u003c/h2\u003e \u003cp\u003eThe original design of the WOLVES-study has been described several times (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eParticipation in the study was voluntary and aimed at all women between the ages of 21 and 26, who resided in the German city of Wolfsburg between 2009 and 2020.\u003c/p\u003e \u003cp\u003eOur final data analysis included data from 2,971 patients in three cohorts (Cohort 1,2 and 3).\u003c/p\u003e \u003cp\u003eThe first cohort, born in 1983/84, was studied for the first time in 2009/10 (when the participants were 26 years old). The second cohort (born 1988/89) and the third cohort (born 1993/94) were examined twice, in 2009 and 2014 as well as in 2014 and 2020 (when the participants were 21- and 26 years old, respectively).\u003c/p\u003e \u003cp\u003eThe first cohort was established to investigate the prevalence of HPV infection in the pre-vaccination era. The second cohort was set up to study changes in the incidence and prevalence of HPV shortly after vaccination was introduced. The third, and thus the most recent, cohort was intended to record HPV infections during the time when vaccination is established.\u003c/p\u003e \u003cp\u003eThe participants in the WOLVES study did not differ from the general population in terms of the total population regarding education, migration background or birth rate. The data of the registry office did not include medical data, so a recording of further risk factors is not possible. The exclusion criteria were previous incidences of cancer, transplantation- or immunosuppressive therapy or a permanent stay outside the Wolfsburg region.\u003c/p\u003e \u003cp\u003eThe study design was intended as a prototype of an HPV screening strategy for women aged 20 years and over and as a pilot study 10 years before HPV-based screening was introduced in Germany in 2020 (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAll participants completed a standardized medical questionnaire including questions on education, birth country, marital status, pregnancies, parity, contraception, smoking, number of sexual partners, age at sexual debut, and history of abnormal Pap smears, sexually transmitted infections and genital warts. Furthermore, the referring gynecologist collected information on HPV vaccination status by checking the certificate of vaccination. The cooperating gynaecologists collected information regarding immunization status from the vaccination certificate. Patients who received three doses at 0, 2, and 6 (5\u0026ndash;13 months) were considered fully vaccinated.\u003c/p\u003e \u003cp\u003eParticipants were transferred for colposcopy if they had abnormal Pap smears conspicuous of high-grade lesions or had Pap smears classified as borderline/low-grade and tested positive for hrHPV. Colposcopists classified the type of transformation zones according to the Barcelona nomenclature of the International Federation for Cervical Pathology and Colposcopy (IFCPC) (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). No random punch biopsies were taken if colposcopy findings were normal. Histological assessment was mandatory for any lesion where there was a suspicion of high-grade neoplasia (Figs.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e This study was approved by the ethics committee of Lower Saxony in Hannover (Bo/07/2009). Written consent from all of the participants including an agreement that pseudonymized data may be used for research, was obtained. The handling and publication of patient data in this study were performed strictly in accordance with the Declaration of Helsinki DoH/Oct 2008 and included confidentiality and anonymity.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eHPV testing:\u003c/p\u003e \u003cp\u003eAll primary HPV testing was undertaken using the hybrid capture 2 assay (HC2/Qiagen Inc., Hilden Germany). All samples were analysed for the presence of at least 13 HR-HPV types (16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59 and 68) following the manufacturer\u0026rsquo;s instructions. A positive HR-HPV result in this study refers to a positive subject for the HR-HPV probe mix.\u003c/p\u003e \u003cp\u003eAll samples that tested positive for HR-HPV with HC2 underwent extended genotyping. HPV-genotyping was performed as described previously using SPF-10-PCR, followed by Reverse Line Probe Assay LiPA Extra (SPF-10-PCR) (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Briefly, total DNA was isolated from the cervical samples with the use of a MagNAPure device (Roche, Indianapolis, IN) and analyzed with INNO-LiPA Extra HPV prototype assay (Innogenetics, Gent, Belgium) according to the manufacturer\u0026rsquo;s instructions. The INNO-LiPA Extra test identifies established high-risk HPV types (16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59 and 68) and five known or putative high-risk types (26, 53, 66, 73 and 82) (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eAll statistical analyses were undertaken by an independent statistician.\u003c/p\u003e \u003cp\u003eThe association between HPV infection and explanatory variables was analyzed in univariable and multivariable analyses. All statistical analyses were performed with the validated program R Version 4.1.2 by using descriptive statistical analysis. Continuous data are presented as means\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation. Categorial data are presented as counts and proportions.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStudy population\u003c/h2\u003e \u003cp\u003eBetween October 2009 and March 2021, a total of 3,010 women were included in the study. The final analysis included complete data from 2,999 patients. We included 43% of all women living in the city of Wolfsburg from the 1983/84 cohort, 47% from the 1988/89 cohort in 2009/10 and 33% from the 1993/94 cohort (Statistical Office of the City of Wolfsburg Data, Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eHPV vaccination coverage rate:\u003c/h3\u003e\n\u003cp\u003eAmong the 21-year-olds, the vaccination rate increased from 23.7% to 48.1% between 2009 and 2014 (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAmong the 26-year-olds, the vaccination rate increased from 6.1% (2009/10) to 18.4% in 2014/15 and reached 59.2% in 2020.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eCervical dysplasia and HPV-subtypes distribution\u003c/h2\u003e \u003cp\u003eThe HPV prevalence amounts to 26.8% in the cohort 1983/84, 30.9% in the cohort 1988/89 in 2009 and 38.3% in 2014/15. In our youngest cohort (1993/94) the hr-HPV prevalence was 32.3% in 2014/15 and increased to 34.5% in 2019/2020 (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn the first cohort (born in 1983/84, 26 years old in 2009/2010), we observed the development of dysplastic precursors in 24 cases. CIN 3 (HSIL) was the most common with 11 cases. Whereas CIN 1 (LSIL) was present in 8 cases. Only three out of 24 findings occurred in vaccinated individuals, including one case of mild dysplasia and 2 cases of moderate cervical dysplasia (CIN 2). HSIL (CIN 3/Ca in situ) occurred 8 times (33%) and exclusively in unvaccinated patients (Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAs expected, HPV genotype 16 was the most common in patients with HSIL (4 cases in CIN 3 and 2 cases in CIN 2 lesions). Only HPV 51 was also found in the lesions with CIN 3 (2 cases) as well as a single case of a CIN 3 lesion containing HPV 6. HPV types 18, 31 and 53 are also represented with 1 lesion each. We also did not observe any difference in terms of single and multiple infections (Fig.\u0026nbsp;8a).\u003c/p\u003e \u003cp\u003eIn the cohort 1988/89 in 2009/10 (then 21-year-old women) we initially saw 20 dysplastic findings in the dysplasia consultation. The unvaccinated individuals had a four-fold higher risk of developing dysplastic changes than vaccinated individuals in the same cohort (16 vs. 4). LSIL (CIN 1) was the most common in the unvaccinated group with 11 cases (55%). HSIL was diagnosed in 5 cases among unvaccinated women (Figs.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e and \u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e). Regarding HPV genotype distribution, only one CIN 2 lesion with subtype 52 in the vaccinated group was observed. In the unvaccinated group, HPV 16 was the most common with 3 cases, two of which had HSIL. Subtypes 51, 52 and 66 occurred only sporadically and were found in cases with mild dysplasia. 5 years later, in 2014/15, this cohort showed a much higher incidence of HSIL (a total of 29 CIN2 and 29 CIN3) in the unvaccinated population. Even with 12 LSILs, the mild lesion was 4 times more common compared to the vaccinated subgroup. HPV 16 again played the largest role in the development of HSIL with 14 cases and exclusively in the unvaccinated group, together with HPV 51 (5 cases), 52 (5 cases), HPV 58, 66 (2 cases) as well as 33 and 68. We did not have a relevant distribution of single and multiple infection in 21-year-old patients in this cohort (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e\u0026thinsp;+\u0026thinsp;8b).\u003c/p\u003e \u003cp\u003eIn 26-year-olds, with the increase in HSIL incidence, we also observed the increase in redistribution of single infections (17 vs.7 cases, Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e\u0026thinsp;+\u0026thinsp;7a).\u003c/p\u003e \u003cp\u003eFigure\u0026nbsp;7\u003c/p\u003e \u003cp\u003eHistology findings in the cohorts depends on vaccination status.\u003c/p\u003e \u003cp\u003ea)1983/84 (26 years old)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eb)1988/89 (21 years old) c)1988/89 (26 years old)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003ed)1993/94 (21 years old) e)1993/94 (26 years old)\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIn the vaccinated population, we noted 3 HSIL cases and only one case of LSIL. 5 years later, in 2014/15, in the same population, 77 lesions were diagnosed (in 897 participants). No HSIL with CIN 3 was seen in this group. In contrast, we found 10-fold more lesions in the unvaccinated population (70). HSIL lesions predominated with 29 CIN 3 and 29 CIN 2 cases (Fig.\u0026nbsp;7c).\u003c/p\u003e \u003cp\u003eFrom the 1993/94 cohort, among 405 21-year-old female patients, in 2014/15, only 2 patients had confirmed lesions, so no meaningful statistical evaluation was possible (Fig.\u0026nbsp;7d).\u003c/p\u003e \u003cp\u003eIn the same cohort in 2019/2020 (then 26-year-olds), only 15 lesions were found in this population. 8 lesions occurred in the non-vaccinated group and 6 in the vaccinated group. 4 HSIL cases were found exclusively in the unvaccinated group (Fig.\u0026nbsp;7e).\u003c/p\u003e \u003cp\u003eIn the group of 21-year-olds from the cohort 1993/94, we saw only single infections with HPV subtypes 16, 6, 18 in HSIL as well as 51, 52 and 66. In the analysis of 26-year-old female patients in the same cohort, we can confirm a significant increase of infections in the unvaccinated populations, especially with HPV 16. HPV types 51, 52 and subtypes 31, 66, 33 and 68 also played a role in the development of HSIL in this group. All HSIL lesions occurred exclusively in unvaccinated individuals (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e\u0026thinsp;+\u0026thinsp;8c).\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eHPV-Subtyping distribution among the HPV positive participants without dysplasia\u003c/h3\u003e\n\u003cp\u003eIn our oldest cohort from 1983/84, we only identified isolated infections among vaccinated people. Among the unvaccinated, we saw the dominance of HPV 16 with 55 infections as well as subtypes 51 (33 infections) \u0026ndash; and subtype 31 (33 infections) (Fig.\u0026nbsp;8a).\u003c/p\u003e \u003cp\u003eIn the second cohort (1988/89) in the group aged 21 years, who were vaccinated, HPV type 51 played an important role (21 cases) as well as HPV 52 and HPV 66 with 14 and 13 cases, respectively. Among the unvaccinated women, HPV subtype 51 dominated (with 78 cases, almost three times as many infections as in the vaccinated group). HPV 16 was the second most common type in our analysis, with 68 cases. After 5 years, the ratio changed significantly in the unvaccinated population and HPV 16 was prevalent with 183 cases, followed by subtypes 51 with 98 cases and subtype 31 with 95 cases occurring most frequently (Fig.\u0026nbsp;8b).\u003c/p\u003e \u003cp\u003eIn our most recent cohort, among the vaccinated group at 21 years of age, we saw subtype 51 with 39 infections, followed by subtype 66 with 19 cases and subtypes 52 and 3 with 18 infections. Among the unvaccinated women, subtypes 52 and 51 dominated, with 22 and 20 infections, respectively. Among the vaccinated 26-year-olds, subtype 63 was predominant with 37 cases. Three other subtypes: 53, 51 and 39 were found with over 20 cases. Among the unvaccinated 26-year-olds, subtypes 52 and 16 (29 and 28 cases) and subtypes 53, 39 and 66 were common (Fig.\u0026nbsp;8c).\u003c/p\u003e "},{"header":"Conclusions","content":"\u003cp\u003eOur analysis provides information about the distribution of the most prevalent HPV-types among young German women in a longitudinal follow-up study. WOLVES was a small-scale study and played a crucial role prior to the introduction of the HPV vaccination program as a primary prevention program, followed by organized screening as a secondary prevention program\u003c/p\u003e \u003cp\u003eIn the present study we observed high prevalence of hr-HPV infection in women aged 21 and 26 years. The prevalence of HPV was the highest in our cohorts with 26\u0026ndash;38% in 2019/2020. This prevalence is higher than described elsewhere, and there is no explanation for this. Our population is a real-world population.\u003c/p\u003e \u003cp\u003eA comparison of HPV-HR genotypes in HPV-positive vaccinated and unvaccinated patients, separated by cohort, shows a significant decline in HPV 16 infections in vaccinated patients in all three cohorts. This result is consistent with the results of a large-scale study on HPV prevalence in the Netherlands showing HPV 16 as the most prevalent hr-HPV subtype. Similar results were shown by \u003cem\u003eArbyn et al\u003c/em\u003e. in Belgium with HPV 16 persistence in 32% of HSIL cases and HPV 31 in 22%. However, the percentage of HPV 31 with 8.2% in our study was considerably lower in comparison than this one (\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e27\u003c/span\u003e). It is interesting to note that HPV 52 was the third most common HPV subtype found in our samples. Among women diagnosed with LSIL, HPV 16, 31 and 52 were the most frequently detected.\u003c/p\u003e \u003cp\u003eContrary to our expectation, HPV-18 and 45 were the less common hr-HPV subtypes in cervical samples with 4.2-and 2.2%, respectively (\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e28\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe most frequent HPV subtype in all cohorts were HPV 51 and HPV 16 detected with 14% and 13.4% of all samples, respectively. In the subgroup analysis by HSIL diagnosis, HPV 16 and 51 were the most relevant subtypes for HSIL in our study. Compared to the distribution of genotypes in unvaccinated women, HPV genotypes 51, 52 and 53 were detected in vaccinated women at nearly consistent levels. HPV 16 and 31, on the other hand, were rarely found in vaccinated women, while there was no significant difference between vaccinated and unvaccinated women for HPV 18 due to its low prevalence (around 2%) and an even lower number of vaccinated women. Similar findings were reported by other recent studies (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). A summary of 18 studies from 14 European countries confirmed HPV 16 as the most prevalent HPV subtype (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e). The third most common subtype cumulative seen in our cumulative analysis was HPV 52 (13.2% of all samples), followed by HPV 31 (8.2%). A worldwide systematic analysis performed by Wei et al. suggests reclassifying the carcinogenic subtypes due to their findings (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe age distribution of HPV infection was like to those reported in most studies. We observed an increased distribution of hr-HPV in young women from the age of 21 and 26 years (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWe confirm that, in our population, CIN among women after HPV vaccination (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e32\u003c/span\u003e). In the first cohort, CIN was typically associated with the HPV-types used in the vaccine (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e33\u003c/span\u003e). Those results are in line with data from Pimenoff et al. who showed the replacement of vaccine-targeted HPV-subtypes by non-targeted subtypes after community vaccination (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e34\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWhat is very interesting is that we saw no reduction in the prevalence of HPV, but at the same time a disappearance of low-risk types such as HPV 6 and 11. This means that we also observed a possible replacement of HPV subtypes in our population and a resulting decline in dysplastic changes. This may have nothing to do with the acquisition of the infection and the resulting high prevalence. The disappearance of vaccine-associated hr-HPV and LR-HPV was substantial for vaccine types and occurred in our population shortly after the introduction of immunization.\u003c/p\u003e \u003cp\u003eThe current evaluation also possibly shows a very strong influence of the already immunized women on the non-immunized women in terms of herd immunity. There was a significant impact of HPV vaccination on HPV 16 infections and decline of all levels of dysplasia level in our youngest cohort while prevalence remained high. During the first round, we were able to observe the association with subtypes 16, 31 and 51 in the 26-year-old patients. Over time, this ratio shifted, and we observed more non-vaccine HPV subtypes in our histological findings (such as subtype 66 and 52).\u003c/p\u003e \u003cp\u003eThe constant number of mild dysplastic changes and decrease in moderate and severe changes during vaccination phase was also particularly significant (HSIL (CIN 3) p\u0026thinsp;=\u0026thinsp;0.009, HSIL (CIN 2) p\u0026thinsp;=\u0026thinsp;0.014).\u003c/p\u003e \u003cp\u003eStrategies in cervical carcinoma screening should consider the changes in the prevalence of high-risk types 16 and 18. As recent findings by Grieger et al. show a first insight into the effective reduction of cervical carcinoma incidence due to HPV-vaccination, our national vaccination strategy should frequently adapt to new results to ensure the durability of this trend (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e36\u003c/span\u003e). Women with HPV16, and 51 and 52 infections have a high risk of clinically relevant lesions that seem to increase over time (as shown in the comparison between our three cohorts).\u003c/p\u003e \u003cp\u003eIn immunized individuals, however, non-progressive HPV subtypes will play a greater role. This may, in turn, slow down disease progression and cause a low number of dysplastic findings even in non-immunized patients.\u003c/p\u003e \u003cp\u003eIt is interesting to note the occurrence of severe dysplastic changes in young women who develop malignant disease, despite immunization. While it is important to clarify the causes of vaccine failure, a genetic disposition may underlie the development of invasive cervical disease. Unfortunately, this is not clear in our analysis due to the small number of dysplasia and lack of high-grade lesions in the vaccinated subpopulation with a follow-up period limited to only ten years.\u003c/p\u003e \u003cp\u003eKnowledge of the prevalence level of type-specific hr-HPV in the population and in HSIL is very important to predict the burden of positive tests results and can lead to the development of a risk-adapted, individualized, and cost-effective screening strategy in the future, that includes HPV vaccination as the primary prevention and screening strategy.\u003c/p\u003e \u003cp\u003eStrengths and weaknesses of our study:\u003c/p\u003e \u003cp\u003eThe current study is a small population-based study, limited to one geographical location within Germany. One of the weaknesses is representativeness, that we were able to requisite about 33\u0026ndash;47% of the population from the region. In Germany, there are no health registers or country-wide biobanks and no data from organized screening as in other countries, such as Sweden, which does not allow us to extend our findings to the national level.\u003c/p\u003e \u003cp\u003eVaccination was carried out with the bivalent-and the tetravalent vaccine, but we cannot exclude with certainty that the data on extended immunization with the nonavalent vaccine (additional immunization against HPV 31, 33, 45, 52 and 58) has a possible effect on the distribution and replacement of HPV-types in the youngest cohort.\u003c/p\u003e \u003cp\u003eAnother possible drawback in our analysis is the young age of the patients. In many countries screening begins at the age of 23 or 26 (such as in Sweden or, - USA). Our patients younger in comparison, at 21\u0026ndash;26 years of age. We know that at a very young age the incidence of HSIL is higher, but the risk of progression to cancer is very small. Many of them do not require treatment and heal spontaneously, as we saw this in our study. The large number of CIN was caused by non-progressive types such as 42, 51, 56 and 66. For this reason, the data is not transferable to other age groups and invites further longitudinal follow-up studies.\u003c/p\u003e "},{"header":"Declarations","content":"\u003cp\u003ePrevious Presentation:\u003c/p\u003e\n\u003cp\u003eThe results from WOLVES was presented as poster presentation on ESGO in Rom (02/2025)\u003c/p\u003e\n\u003cp\u003eAgnieszka Denecke, Jan Lennart Stalp, Jens Hachenberg, Matthias Jentschke, Peter Hillemanns:\u0026nbsp;\u003cstrong\u003eEffect Of HPV Vaccination In Cervical Cancer Screening Population – Results Of WOLVES, A Population-Based Cohort Study In Germany\u003c/strong\u003e, ESGO Rom 02/2025\u003c/p\u003e\n\u003cp\u003eAuthors’ contributions:\u003c/p\u003e\n\u003cp\u003eWOLVES was one of the first cohort studies in Germany to establish HPV-based screening, 10 years before it was introduced into law. The idea of WOLVES study was created by the carcinoma screening pioneer in Germany, K.U.P. and\u0026nbsp;A.D. worked on the WOLVES project for over 8 years and completed the study after the death of K.U.P as study leader. A.D. conceived the presented idea and drafted the manuscript. V.L. and P.S. verified the analytical methods and performed analysis. D.R. and J.L.S. edited the manuscript. P.H. is a member of the screening committee of the WOLVES study and involved in the study design. All authors discussed the results and contributed to the final manuscript.\u003c/p\u003e\n\u003cp\u003eEthics Statement:\u003c/p\u003e\n\u003cp\u003eThis study was approved by the ethics committee of Lower Saxony in Hannover (Bo/07/2009). Written consent from all of the participants including an agreement that pseudonymized data may be used for research, was obtained. The handling and publication of patient data in this study were performed strictly in accordance with the Declaration of Helsinki DoH/Oct 2008 and included confidentiality and anonymity.\u003c/p\u003e\n\u003cp\u003eAvailability of data:\u003c/p\u003e\n\u003cp\u003eAll data generated or analysed during this study are included in this published article [and its supplementary information files]. The database is in the Department of Gynaecology at Medical Hannover School and Klinikum Wolfsburg. All the data can be obtained from the authors on request.\u003c/p\u003e\n\u003cp\u003eCompeting interests:\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003eFunding:\u003c/p\u003e\n\u003cp\u003eWOLVES was an epidemiological study, and this work was supported by the Investigator Studies Program (MISP) from MSD Sharp \u0026amp; Dohme GmbH. The founder had no role in the study design, in the conducting of the study or data analysis. Hologic supported WOLVES with ThinPrep vials free of charge.\u003c/p\u003e\n\u003cp\u003eAcknowledgements:\u003c/p\u003e\n\u003cp\u003eOur study is dedicated to Prof. K.U.Petry, former leader of the Study Group of Colposcopy (SGK) in German, who passed away April 2020.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors further would like to thank all participating gynaecologists and all WOLVES participants for their support.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMunoz N, Bosch FX, de Sanjosee S, Herrero R, Castellsague X, Shah KV, Meijer CJ. Epidemiologic classification of human papillomavirus types associated with cervical cancer. N Engl J Med 348:518\u0026ndash;27.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLicciardi PV, Frazer ICH, Garland SM. Mullholland k: Editorial: Immunology of HPV Infection and Vaccination: Progress and Challenges. Front Imunology, 12:665463.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDe Vuyst H, Clifford G, Ni L, Franceschi S. HPV infection in Europe. Eur J Cancer. 2009;45:2632\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReich O, Reegauer S, Kashofer K. Possibly carcinogenic HPV subtypes are a cause of HSIL and negative clinical HPV tests- a european prospective single center study. Gynecol Oncol. 2020;158:112\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArbyn M, Benoy I, Simoens C, Bogers J, Beutels P, Depuydt C. Prevaccination distribution of human papilomavirus types in women aattendding at cervical cancer screening in Belgium, Cancer Epidemiol Biomarkers Prev 2009, 18(1), Jan 2009.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eViliers E-M, Fauquet C, Broker TR, Bernard H-U, zur Hausen H. Classification of papillomaviruses. 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Utility of extended HPV genotyping in cervical cancer screening and clinical management. Gynecol Obstet Clin Med. 2025;5:e000226. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1136/gocm-2025-000226\u003c/span\u003e\u003cspan address=\"10.1136/gocm-2025-000226\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-8713719/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8713719/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eWe evaluated the distribution of HPV-genotypes in HSIL and LSIL a prospective cohort of young unscreened women. The relationship between hr-HPV status, HPV-genotyping cervical histology, and vaccination status were examined.\u003c/p\u003e \u003cp\u003eBetween 2009/10 and 2019/2020, three cohorts of young women between 21- and 26 years of age participated in a large epidemiological study with cytology-and HPV testing. Annual colposcopic examination of HPV positive participants and SPF10 LIPA for HPV genotyping was performed in this group.\u003c/p\u003e \u003cp\u003eOur study showed changes of HPV-genotype distribution in the immunized- and non-immunized cohort of young women in Germany within 10 years after the introduction of vaccination against HPV.\u003c/p\u003e \u003cp\u003eWe confirm that immunization against HPV effectively protects against the development of dysplastic changes in our study population.\u003c/p\u003e \u003cp\u003eWe note that in our vaccinated populations, the HPV subtypes that were not part of the vaccine were more likely to be found in CIN cases. Additionally, only few LSIL (CIN 1) and hardly any HSIL (CIN2-3) cases were seen in the vaccinated population, indicating an increased protection against advanced cervical disease conferred by vaccination.\u003c/p\u003e","manuscriptTitle":"Changing dynamics of HR-HPV infection and associated cervical precancer in the population-based WOLVES cohort study 15 years after vaccination","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-11 14:50:40","doi":"10.21203/rs.3.rs-8713719/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c2b5fc0e-c8ed-4b14-b59e-a68c710c599a","owner":[],"postedDate":"February 11th, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Rejected","date":"2026-05-12T13:36:52+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-05T13:21:02+00:00","index":83,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-05-12T14:04:05+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-11 14:50:40","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8713719","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8713719","identity":"rs-8713719","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}