Association between Extremely Low-Frequency Electromagnetic Fields Occupations and Amyotrophic Lateral Sclerosis: A Meta-Analysis

Objectives

To estimate the relationship between exposure to extremely low-frequency electromagnetic fields (ELF-EMF) and the risk of amyotrophic lateral sclerosis (ALS) by a meta-analysis.

Methods

Through searching PubMed databases (or manual searching) up to April 2012 using the following keywords: “occupational exposure”, “electromagnetic fields” and “amyotrophic lateral sclerosis” or “motor neuron disease”, seventeen studies were identified as eligible for this meta-analysis. The associations between ELF-EMF exposure and the ALS risk were estimated based on study design (case-control or cohort study), and ELF-EMF exposure level assessment (job title or job-exposure matrix). The heterogeneity across the studies was tested, as was publication bias.

Results

Occupational exposure to ELF-EMF was significantly associated with increased risk of ALS in pooled studies (RR = 1.29, 95%CI = 1.02–1.62), and case-control studies (OR = 1.39, 95%CI = 1.05–1.84), but not cohort studies (RR = 1.16, 95% CI = 0.80–1.69). In sub-analyses, similar significant associations were found when the exposure level was defined by the job title, but not the job-exposure matrix. In addition, significant associations between occupational exposure to ELF-EMF and increased risk of ALS were found in studies of subjects who were clinically diagnosed but not those based on the death certificate. Moderate heterogeneity was observed in all analyses.

Conclusions

Our data suggest a slight but significant ALS risk increase among those with job titles related to relatively high levels of ELF-EMF exposure. Since the magnitude of estimated RR was relatively small, we cannot deny the possibility of potential biases at work. Electrical shocks or other unidentified variables associated with electrical occupations, rather than magnetic-field exposure, may be responsible for the observed associations with ALS.     

Characterization of Indoor Extremely Low Frequency and Low Frequency Electromagnetic Fields in the INMA-Granada Cohort

Objective

To characterize the exposure to electric fields and magnetic fields of non-ionizing radiation in the electromagnetic spectrum (15 Hz to 100 kHz) in the dwellings of children from the Spanish Environment and Childhood-“INMA” population-based birth cohort.

Methodology

The study sample was drawn from the INMA-Granada cohort. Out of 300 boys participating in the 9–10 year follow-up, 123 families agreed to the exposure assessment at home and completed a specific ad hoc questionnaire gathering information on sources of non-ionizing radiation electric and magnetic fields inside the homes and on patterns of use. Long-term indoor measurements were carried out in the living room and bedroom.

Results

Survey data showed a low exposure in the children''s homes according to reference levels of the International Commission on Non-Ionizing Radiation Protection but with large differences among homes in mean and maximum values. Daytime electrostatic and magnetic fields were below the quantification limit in 78.6% (92 dwellings) and 92.3% (108 dwellings) of houses, with an arithmetic mean value (± standard deviation) of 7.31±9.32 V/m and 162.30±91.16 nT, respectively. Mean magnetic field values were 1.6 lower during the night than the day. Nocturnal electrostatic values were not measured. Exposure levels were influenced by the area of residence (higher values in urban/semi-urban versus rural areas), type of dwelling, age of dwelling, floor of the dwelling, and season.

Conclusion

Given the greater sensitivity to extremely low-frequency electromagnetic fields of children and following the precautionary principle, preventive measures are warranted to reduce their exposure.     

COVID‐19 Disease Map,a computational knowledge repository of virus‐host interaction mechanisms

The authors requested to correct the spelling of Egon Willighagen and Andrea Senff‐Ribeiro''s names, as well as the following affiliations: Charles Auffray to: “European Institute for Systems Biology and Medicine (EISBM), Vourles, France”; Noriko Hiori to: “Graduate School of Media and Governance, Keio Research Institute at SFC, Keio University, Kanagawa, Japan”; and Leonard Schmeister to: “Center for Mathematics, Chair of Mathematical Modeling of Biological Systems, Technische Universität München, Garching, Germany and Helmholtz Zentrum München – German Research Center for Environmental Health, Institute of Computational Biology, Neuherberg, Germany”.     

Development of a Melanoma Risk Prediction Model Incorporating MC1R Genotype and Indoor Tanning Exposure: Impact of Mole Phenotype on Model Performance

Background

Identifying individuals at increased risk for melanoma could potentially improve public health through targeted surveillance and early detection. Studies have separately demonstrated significant associations between melanoma risk, melanocortin receptor (MC1R) polymorphisms, and indoor ultraviolet light (UV) exposure. Existing melanoma risk prediction models do not include these factors; therefore, we investigated their potential to improve the performance of a risk model.

Methods

Using 875 melanoma cases and 765 controls from the population-based Minnesota Skin Health Study we compared the predictive ability of a clinical melanoma risk model (Model A) to an enhanced model (Model F) using receiver operating characteristic (ROC) curves. Model A used self-reported conventional risk factors including mole phenotype categorized as “none”, “few”, “some” or “many” moles. Model F added MC1R genotype and measures of indoor and outdoor UV exposure to Model A. We also assessed the predictive ability of these models in subgroups stratified by mole phenotype (e.g. nevus-resistant (“none” and “few” moles) and nevus-prone (“some” and “many” moles)).

Results

Model A (the reference model) yielded an area under the ROC curve (AUC) of 0.72 (95% CI = 0.69, 0.74). Model F was improved with an AUC = 0.74 (95% CI = 0.71–0.76, p<0.01). We also observed substantial variations in the AUCs of Models A & F when examined in the nevus-prone and nevus-resistant subgroups.

Conclusions

These results demonstrate that adding genotypic information and environmental exposure data can increase the predictive ability of a clinical melanoma risk model, especially among nevus-prone individuals.     

Diversity of Basidiomycetes in Michigan Agricultural Soils

We analyzed the communities of soil basidiomycetes in agroecosystems that differ in tillage history at the Kellogg Biological Station Long-Term Ecological Research site near Battle Creek, Michigan. The approach combined soil DNA extraction through a bead-beating method modified to increase recovery of fungal DNA, PCR amplification with basidiomycete-specific primers, cloning and restriction fragment length polymorphism screening of mixed PCR products, and sequencing of unique clones. Much greater diversity was detected than was anticipated in this habitat on the basis of culture-based methods or surveys of fruiting bodies. With “species” defined as organisms yielding PCR products with ≥99% identity in the 5′ 650 bases of the nuclear large-subunit ribosomal DNA, 241 “species” were detected among 409 unique basidiomycete sequences recovered. Almost all major clades of basidiomycetes from basidiomycetous yeasts and other heterobasidiomycetes through polypores and euagarics (gilled mushrooms and relatives) were represented, with a majority from the latter clade. Only 24 of 241 “species” had 99% or greater sequence similarity to named reference sequences in GenBank, and several clades with multiple “species” could not be identified at the genus level by phylogenetic comparisons with named sequences. The total estimated “species” richness for this 11.2-ha site was 367 “species” of basidiomycetes. Since >99% of the study area has not been sampled, the accuracy of our diversity estimate is uncertain. Replication in time and space is required to detect additional diversity and the underlying community structure.     

Standardizing the Protocol for Hemispherical Photographs: Accuracy Assessment of Binarization Algorithms

Hemispherical photography is a well-established method to optically assess ecological parameters related to plant canopies; e.g. ground-level light regimes and the distribution of foliage within the crown space. Interpreting hemispherical photographs involves classifying pixels as either sky or vegetation. A wide range of automatic thresholding or binarization algorithms exists to classify the photographs. The variety in methodology hampers ability to compare results across studies. To identify an optimal threshold selection method, this study assessed the accuracy of seven binarization methods implemented in software currently available for the processing of hemispherical photographs. Therefore, binarizations obtained by the algorithms were compared to reference data generated through a manual binarization of a stratified random selection of pixels. This approach was adopted from the accuracy assessment of map classifications known from remote sensing studies. Percentage correct () and kappa-statistics () were calculated. The accuracy of the algorithms was assessed for photographs taken with automatic exposure settings (auto-exposure) and photographs taken with settings which avoid overexposure (histogram-exposure). In addition, gap fraction values derived from hemispherical photographs were compared with estimates derived from the manually classified reference pixels. All tested algorithms were shown to be sensitive to overexposure. Three of the algorithms showed an accuracy which was high enough to be recommended for the processing of histogram-exposed hemispherical photographs: “Minimum” ( 98.8%; 0.952), “Edge Detection” ( 98.1%; 0.950), and “Minimum Histogram” ( 98.1%; 0.947). The Minimum algorithm overestimated gap fraction least of all (11%). The overestimation by the algorithms Edge Detection (63%) and Minimum Histogram (67%) were considerably larger. For the remaining four evaluated algorithms (IsoData, Maximum Entropy, MinError, and Otsu) an incompatibility with photographs containing overexposed pixels was detected. When applied to histogram-exposed photographs, these algorithms overestimated the gap fraction by at least 180%.     

Framingham Risk Score with Cardiovascular Events in Chronic Kidney Disease

The Framingham Risk Score (FRS) was developed to predict coronary heart disease in various populations, and it tended to under-estimate the risk in chronic kidney disease (CKD) patients. Our objectives were to determine whether FRS was associated with cardiovascular events, and to evaluate the role of new risk markers and echocardiographic parameters when they were added to a FRS model. This study enrolled 439 CKD patients. The FRS is used to identify individuals categorically as “low” (<10% of 10-year risk), “intermediate” (10–20% risk) or “high” risk (≧ 20% risk). A significant improvement in model prediction was based on the −2 log likelihood ratio statistic and c-statistic. “High” risk (v.s. “low” risk) predicts cardiovascular events either without (hazard ratios [HR] 2.090, 95% confidence interval [CI] 1.144 to 3.818) or with adjustment for clinical, biochemical and echocardiographic parameters (HR 1.924, 95% CI 1.008 to 3.673). Besides, the addition of albumin, hemoglobin, estimated glomerular filtration rate, proteinuria, left atrial diameter >4.7 cm, left ventricular hypertrophy or left ventricular ejection fraction<50% to the FRS model significantly improves the predictive values for cardiovascular events. In CKD patients, “high” risk categorized by FRS predicts cardiovascular events. Novel biomarkers and echocardiographic parameters provide additional predictive values for cardiovascular events. Future study is needed to assess whether risk assessment enhanced by using these biomarkers and echocardiographic parameters might contribute to more effective prediction and better care for patients.     

PAROTID TUMOR OPERATIONS—The Case Against Enucleation

So-called mixed “encapsulated” parotid tumors are best managed by surgical procedures which avoid contact with the “capsule.” Enucleation is often a hazardous and incomplete procedure. Subtotal or total parotidectomy with exposure of the facial nerve to avert accidental damage to it is the treatment of choice.Microscopic study of the periphery of such tumors reveals that the “capsule” does not fully encapsulate; hence, enucleation and lesser procedures may leave neoplastic tissue behind.Surgical procedures to achieve complete excision without endangering the facial nerve were carried out in 123 cases. There was local recurrence in one case.     

Psychiatric Illness in General Practice: A Detailed Study Using a New Method of Case Identification

A self-administered questionary (the General Health Questionnaire) aimed at detecting current psychiatric disturbance was given to 553 consecutive attenders to a general practitioner''s surgery. A sample of 200 of these patients was given an independent assessment of their mental state by a psychiatrist using a standardized psychiatric interview. Over 90% of the patients were correctly classified as “well” or “ill” by the questionary, and the correlation between questionary score and the clinical assessment of severity of disturbance was found to be +0·80.The “conspicuous psychiatric morbidity” of a suburban general practice assessed by a general practitioner who was himself a psychiatrist and validated against independent psychiatric assessment was found to be 20%. “Hidden psychiatric morbidity” was found to account for one-third of all disturbed patients. These patients were similar to patients with “conspicuous illnesses” in terms both of degree of disturbance and the course of their illnesses at six-month follow-up, but were distinguished by their attitude to their illness and by usually presenting a physical symptom to the general practitioner.When 87 patients who had been assessed as psychiatric cases at the index consultation were called back for follow-up six months later, two-thirds of them were functioning in the normal range. Frequency of attendance at the surgery in the six months following index consultation was found to have only a modest relationship to severity of psychiatric disturbance.It is argued that minor affective illnesses and physical complaints often accompany each other and usually have a good prognosis.     

Medical Students’ Attitudes towards Overweight and Obesity

Objective

Studies from the USA have identified medical students as a major source of stigmatizing attitudes towards overweight and obese individuals. As data from Europe is scarce, medical students’ attitudes were investigated at the University of Leipzig in Leipzig, Germany.

Design

Cross-sectional survey containing an experimental manipulation consisting of a pair of vignettes depicting an obese and a normal weight 42-year-old woman, respectively. Vignettes were followed by the Fat Phobia Scale (FPS), a semantic differential assessing weight related attitudes. In case of the overweight vignette a panel of questions on causal attribution for the overweight preceded administration of the FPS.

Subjects

671 medical students were enrolled at the University of Leipzig from May to June 2011.

Results

The overweight vignette was rated significantly more negative than the normal weight vignette (mean FPS score 3.65±0.45 versus 2.54±0.38, p<0.001). A higher proportion of students had negative attitudes towards the overweight as compared to the normal weight individual (98.9% versus 53.7%, p<0.001). A “positive energy balance” was perceived as the most relevant cause for the overweight, followed by “negligent personality trait”, “societal and social environment” and “biomedical causes”. Attributing a “positive energy balance” or “negligent personality trait” as relevant cause for the overweight was positively associated with negative attitudes.

Conclusion

The results of this study confirm and complement findings from other countries, mainly the USA, and indicate that weight bias in the health care setting may be a global issue. Stigmatizing attitudes towards overweight and obesity are prevalent among a sample of medical students at the University of Leipzig. Negative attitudes arise on the basis of holding the individual accountable for the excess weight. They call for bringing the topic of overweight and obesity more into the focus of the medical curriculum and for enhancing medical students’ awareness of the complex aetiology of this health condition.     

Effects of Biogents Sentinel Trap Field Placement on Capture Rates of Adult Asian Tiger Mosquitoes,Aedes albopictus

The Biogents® Sentinel (BGS) trap is the standard tool to monitor adult Aedes (Stegomyia) albopictus (Skuse) (Diptera: Culicidae), the Asian tiger mosquito. BGS traps are commonly placed in residential properties during surveillance operations, but locations within properties may have significant differences in ambient light, temperature, and humidity (e.g. between a sunlit lawn and shady underbrush). We examined the effect of BGS trap placement on Ae. albopictus capture rates in three residential properties in Monmouth County, New Jersey, USA. In each property we visually selected locations as shade, partial shade, and sun. Traps in “partial shade” locations were under vegetation and were exposed to filtered sunlight during some parts of the day while “shaded” locations were never exposed to direct sunlight. Locations defined as “sun” were exposed to direct sunlight for large parts of the day. We placed a BGS trap in each of the three location types and used small data loggers to measure temperature, relative humidity, and light exposure at each trap during a 24-hour deployment. To address temporal variability, we made seven separate measurements from 31 August to 22 September 2010. We found that “partial shade” and “full shade” locations did not differ but that “full sun” locations had significantly higher light exposure, higher temperature, and lower humidity. Importantly, Ae. albopictus catches (males, females, or both) were consistently and significantly over 3 times higher in traps located in shaded locations. To further investigate the effects of local temperature and humidity on surveillance we examined Ae. albopictus collections from 37 BGS traps fitted with data loggers and deployed weekly from August through mid October, during the 2009 season, in three urban sites in Mercer County, NJ. We confirmed that local climate influences capture rates and that Ae. albopictus surveillance projects need to monitor trap placement carefully for maximum efficiency.     

Occupational Dermatoses in Ontario, 1955 to 1962

In Ontario in 1962, with a compensationeligible labour force of 1,814,000, 10 out of each 1000 workers received compensation for some occupational dermatosis, as defined here; 36 out of each 1000 workers received compensation for some cause. Contact dermatitides made up 5042 of 7448 cases of occupational disease for which compensation and/or medical aid was paid in 1955 and 1956. In eight years, 1955 to 1962 (inclusive), of a total of 534,557 “compensation only” cases, 7023 received payment for contact dermatitis. The average yearly cost of compensation of a worker with a contact dermatitis was estimated at $1113; the annual total cost, at $900,000. The average cost of an occupational dermatosis was $368; the annual total cost, $10 million. Occupational dermatoses account for almost one-third of all compensation costs. The cost of “medical aid only” is excluded from all of these estimates. In contact dermatitis, primary irritants (chemicals) are still the main causative agents. Skin sensitizers, the epoxy resins particularly, have become more prominent in recent years. There is no all-purpose barrier cream or protective clothing. Proper personal hygiene remains the most effective preventive agent in industry.     

A Clinical Study of Isoniazid Inactivation

The rate of inactivation of isoniazid (INH) in a host organism varies widely, probably because of genetic factors. A simple chemical test was used to determine INH levels in 24 tuberculous patients three and six hours after oral administration of the drug. Results are expressed in terms of half-life values of free INH in the body. Seven of the 24 patients inactivated INH rapidly (half-life average: 64 minutes); the remaining 17 metabolized INH at a slower rate (half-life average: 186 minutes). The range of individual half-life values was 30 to 305 minutes. A provisional half-life limit of 110 minutes was used to define “fast inactivators”; 110-160 minutes, “mo$\tilde{d}$erate inactivators”; and over 160 minutes, “slow inactivators”. Although INH inactivation may not be directly related to therapeutic failure, the security margin of the treatment may be diminished in those patients who inactivate INH rapidly.     

Generation of Murine Cardiac Pacemaker Cell Aggregates Based on ES-Cell-Programming in Combination with Myh6-Promoter-Selection

Treatment of the “sick sinus syndrome” is based on artificial pacemakers. These bear hazards such as battery failure and infections. Moreover, they lack hormone responsiveness and the overall procedure is cost-intensive. “Biological pacemakers” generated from PSCs may become an alternative, yet the typical content of pacemaker cells in Embryoid Bodies (EBs) is extremely low. The described protocol combines “forward programming” of murine PSCs via the sinus node inducer TBX3 with Myh6-promoter based antibiotic selection. This yields cardiomyocyte aggregates consistent of >80% physiologically functional pacemaker cells. These “induced-sinoatrial-bodies” (“iSABs”) are spontaneously contracting at yet unreached frequencies (400-500 bpm) corresponding to nodal cells isolated from mouse hearts and are able to pace murine myocardium ex vivo. Using the described protocol highly pure sinus nodal single cells can be generated which e.g. can be used for in vitro drug testing. Furthermore, the iSABs generated according to this protocol may become a crucial step towards heart tissue engineering.     

Static and Dynamic Factors Limit Chromosomal Replication Complexity in Escherichia coli,Avoiding Dangers of Runaway Overreplication

We define chromosomal replication complexity (CRC) as the ratio of the copy number of the most replicated regions to that of unreplicated regions on the same chromosome. Although a typical CRC of eukaryotic or bacterial chromosomes is 2, rapidly growing Escherichia coli cells induce an extra round of replication in their chromosomes (CRC = 4). There are also E. coli mutants with stable CRC∼6. We have investigated the limits and consequences of elevated CRC in E. coli and found three limits: the “natural” CRC limit of ∼8 (cells divide more slowly); the “functional” CRC limit of ∼22 (cells divide extremely slowly); and the “tolerance” CRC limit of ∼64 (cells stop dividing). While the natural limit is likely maintained by the eclipse system spacing replication initiations, the functional limit might reflect the capacity of the chromosome segregation system, rather than dedicated mechanisms, and the tolerance limit may result from titration of limiting replication factors. Whereas recombinational repair is beneficial for cells at the natural and functional CRC limits, we show that it becomes detrimental at the tolerance CRC limit, suggesting recombinational misrepair during the runaway overreplication and giving a rationale for avoidance of the latter.     

“Bicycles May Use Full Lane” Signage Communicates U.S. Roadway Rules and Increases Perception of Safety

Many global challenges, including obesity, health care costs, and climate change, could be addressed in part by increasing the use of bicycles for transportation. Concern about the safety of bicycling on roadways is frequently cited as a deterrent to increasing bicycle use in the USA. The use of effective signage along roadways might help alleviate these concerns by increasing knowledge about the rights and duties of bicyclists and motorists, ideally reducing crashes. We administered a web-based survey, using Twitter for recruitment, to examine how well three US traffic control devices communicated the message that bicyclists are permitted in the center of the travel lane and do not have to “get out of the way” to allow motorists to pass without changing lanes: “Bicycles May Use Full Lane” and “Share the Road” signage, and Shared Lane Markings on the pavement. Each was compared to an unsigned roadway. We also asked respondents whether it was safe for a bicyclist to occupy the center of the travel lane. “Bicycles May Use Full Lane” signage was the most consistently comprehended device for communicating the message that bicyclists may occupy the travel lane and also increased perceptions of safety. “Share the Road” signage did not increase comprehension or perceptions of safety. Shared Lane Markings fell somewhere between. “Bicycles May Use Full Lane” signage showed notable increases in comprehension among novice bicyclists and private motor vehicle commuters, critical target audiences for efforts to promote bicycling in the USA. Although limited in scope, our survey results are indicative and suggest that Departments of Transportation consider replacing “Share the Road” with “Bicycles May Use Full Lane” signage, possibly combined with Shared Lane Markings, if the intent is to increase awareness of roadway rights and responsibilities. Further evaluation through virtual reality simulations and on-road experiments is merited.     

Occupational Skin Diseases in the San Francisco Bay Area

From answers by one-third of the practicing dermatologists in the San Francisco Bay Area to a questionnaire on occupational skin diseases, contact dermatitis due to irritants and sensitizers was found to rank first. Poison oak, which is the leading reported cause on “Doctor''s First Report of Work Injury” received by the California Department of Industrial Relations, was sixth on the list of the survey, trailing solvents, cleansing agents, petroleum products and epoxy resins. A history of atopic dermatitis was often noted in current cases of occupational diseases of the skin.Avoidance of exposure or limiting the contact with pathogenic substances—through engineering changes, observation of working conditions by physicians, education of workers—appeared to be the best preventive measures.     

Why Has the Continuous Decline in German Suicide Rates Stopped in 2007?

Background

Whereas German suicide rates had a clear decreasing tendency between 1991 and 2006, they increased from 2007 to 2010. Deeper analyses of suicide data might help to understand better this change. The aim of this study was to analyze 1) whether recent trends can be related to changes in specific suicide methods and diverge by gender and age; 2) whether the decrease of suicide rates before 2007 as well as the increase from 2007 to 2010 are driven by the same suicide method.

Methods

Analyses were based on suicide data from the Federal Statistical Office of Germany. For 1998–2010, 136.583 suicide cases of men and women with known age and suicide method could be identified. These data were analyzed by joinpoint regression analysis, allowing identification of the best fitting point in time (“joinpoint”) at which the suicide rate significantly changes in magnitude or direction.

Results

The national downward trend between 1998 and 2007 was mainly due to corresponding changes in self-poisoning by other means than drugs (e.g., pesticides) (annual percentage change (APC) ≤ −4.33), drowning (APC ≤ −2.73), hanging (APC ≤ −2.69) and suicides by firearms (APC ≤ −1.46) in both genders. Regarding the overall increase of age-adjusted suicide rates in Germany 2007–2010, mainly the increase of self-poisoning (e.g., by drugs) and “being overrun” (APC ≥ 1.50) contributed to this trend.

Limitations

The true suicide rates might have been underestimated because of errors in the official death certificates.

Conclusions

Increase in suicide rates in Germany since 2007 went along with corresponding changes for “being overrun” and “self-poisoning”. Copycat suicides following the railway suicide of the goalkeeper Robert Enke partly contributed to the results. Thus, prevention of Werther effects and limitation of the availability of high pack sizes for drugs are of special relevance for the reversal of this trend.     

Incremental Benefits of Male HPV Vaccination: Accounting for Inequality in Population Uptake

Background

Vaccines against HPV16/18 are approved for use in females and males but most countries currently have female-only programs. Cultural and geographic factors associated with HPV vaccine uptake might also influence sexual partner choice; this might impact post-vaccination outcomes. Our aims were to examine the population-level impact of adding males to HPV vaccination programs if factors influencing vaccine uptake also influence partner choice, and additionally to quantify how this changes the post-vaccination distribution of disease between subgroups, using incident infections as the outcome measure.

Methods

A dynamic model simulated vaccination of pre-adolescents in two scenarios: 1) vaccine uptake was correlated with factors which also affect sexual partner choice (“correlated”); 2) vaccine uptake was unrelated to these factors (“unrelated”). Coverage and degree of heterogeneity in uptake were informed by observed data from Australia and the USA. Population impact was examined via the effect on incident HPV16 infections. The rate ratio for post-vaccination incident HPV16 in the lowest compared to the highest coverage subgroup (RR_L) was calculated to quantify between-group differences in outcomes.

Results

The population-level incremental impact of adding males was lower if vaccine uptake was “correlated”, however the difference in population-level impact was extremely small (<1%) in the Australia and USA scenarios, even under the conservative and extreme assumption that subgroups according to coverage did not mix at all sexually. At the subgroup level, “correlated” female-only vaccination resulted in RR_L = 1.9 (Australia) and 1.5 (USA) in females, and RR_L = 1.5 and 1.3 in males. “Correlated” both-sex vaccination increased RR_L to 4.2 and 2.1 in females and 3.9 and 2.0 in males in the Australia and USA scenarios respectively.

Conclusions

The population-level incremental impact of male vaccination is unlikely to be substantially impacted by feasible levels of heterogeneity in uptake. However, these findings emphasize the continuing importance of prioritizing high coverage across all groups in HPV vaccination programs in terms of achieving equality of outcomes.