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ABSTRACTIn the midst of the Covid‐19 pandemic, ethicists, researchers, and journalists have recommended studies that deliberately infect healthy volunteers with the coronavirus as a scientific means of expediting vaccine development. In this essay, we trace the history of infection challenge experiments and reflect on the Nuremberg Code of 1947, issued in response to brutal human experiments conducted by Nazi investigators in concentration camps. We argue that the Code continues to offer valuable guidance for assessing the ethics of this controversial form of research, with respect particularly to the acceptable limits to research risks and the social value of research necessary to justify exposing human participants to these risks.

Cover -- Half Title -- Title Page -- Copyright Page -- Preface -- Table of Contents -- Case 1: Anthrax -- Case 2: Aspergillosis -- Case 3: Burkholderia Cepacia Complex (BCC) in Cystic Fibrosis -- Case 4: Campylobacter Jejuni Infection -- Case 5: Clostridium Difficile Infection -- Case 6: An Outbreak of Cryptosporidium SP. Associated with a Public Swimming Pool -- Case 7: Giardia Outbreaks on Ship -- Case 8: HIV -- Case 9: Human Papillomavirus (HPV) -- Case 10: A Laboratory Incident Linked to Exposure to Botulinum Toxin -- Case 11: Legionella Pneumophila Infection -- Case 12: Multidrug-Resistant Tuberculosis (MDR-TB) -- Case 13: Measles: Achieving National Control of a Vaccine Preventable Infection -- Case 14: Four Cases of MERS-COV -- Case 15: A Case of Hospital- Acquired MRSA -- Case 16: Neisseria Gonorrhoeae with High-Level Resistance to Azithromycin -- Case 17: Increased Number of Infections with Plasmodium SPP During a Period of Sociopolitical Instability -- Case 18: A Clinical Incident Linked to Prion-Associated Disease -- Case 19: An Outbreak of Pseudomonas Aeruginosa in a Neonatal Intensive Care Unit -- Case 20: Rabies -- Case 21: An Outbreak of Nontyphoid Salmonellosis in the Workplace -- Case 22: A Case of Toxoplasmosis in Pregnancy -- Case 23: Viral Haemorrhagic Fever -- Case 24: A Case of Vero Cytotoxin-Producing Escherichia Coli (VTEC) -- Case 25: A Case of Varicella-Zoster Virus in a Maternity Unit.

Background: Anal infection with human papillomavirus (HPV) and associated anal squamous intraepithelial lesions (ASIL), are more prevalent among men who have sex with men (MSM) particularly among MSM and transgender women living with HIV The high prevalence of HIV among MSM and transgender women in Pakistan is a significant health concern and access to screening and health-seeking is often delayed due to stigmatization and discrimination. Anal Papanicolaou (Pap) screening may have utility in the identification of these lesions and is a cost-effective modality for anal cancer prevention among MSM, but no such data are available for Pakistan. Similarly, neither HPV vaccination nor anal-cytology screening is implemented in Pakistan. To design HPV associated health interventions, HPV knowledge and positive attitudes towards uptake of HPV prevention is crucial. This thesis aimed to assess the burden of HPV and HPV related precancerous lesions in Pakistan, to explore knowledge, attitudes and perceived self-risk for HPV and associated illnesses, and to understand the policy perspective and health systems' capacity and readiness to integrate an HPV preventive care model into existing HIV care and treatment program in Pakistan. Methods: Cross-sectional studies (paper I and II) were conducted between March 2016 to November 2017 at a sexual health centre run by a local community-based organization and the the center for HIV treatment in Karachi to estimate burden of anal type-specific HPV infection and anal intraepithelial lesions. We recruited 320 MSM and transgender women aged ≥ 18-years who reported anal sex in the preceding 6 months. Anal samples negative for β globin or with insufficient biological material for cytological analyses were excluded. We collected two anal samples for liquid-based cytology and HPV type testing by PCR. Socio-demographic and behavioural data were collected through face-to face interviews. The prevalence of HPV16 DNA infection, ASIL and associated risk factors were analysed through Cox regression for prevalence ratios (PR) and corresponding 95% confidence intervals (CIs). Study III was conducted between March to August 2019 and recruited 48 MSM and transgender women for focus group discussions from community-based organization. For study IV a total of 18 key informants, at different levels of seniority, were recruited from governmental and non-governmental organizations, high-level infectious disease healthcare managers, and United Nations Program representatives were recruited. Both qualitative studies employed content analysis to identify the manifest and latent themes, Results: In study I, we observed a 65.1% of overall HPV-DNA prevalence and was higher in participants living with HIV as compared to HIV negative (87%versus48%; 2p=<0.001). Likewise, in study II, almost 35% of the study participants had ASIL. ASIL was significantly more common among those living with HIV than in HIV negative ((50/118) 42.4%; vs. (43/153) 28.1%) (p = <0.001). HPV16 was the most common oncogenic HPV type found both in the anal canal (35.1%) and in anal lesions (35.5%), again individuals living with HIV had the highest burden. HIV-status (Prevalence ratio (PR) 2.81;95% confidence interval (CI) 2.16-3.82) and never-condom-use (PR:3.08;95%CI 1.69-5.60)) were independently associated with prevalence of "Anal-HPV16 infection" whereas, any HR-HPV type (PR 3.04; 95% CI 1.75-5.26), concurrent sexually transmitted infection (STI) (PR 2.13; CI (1.28–3.55)) and HIV+/HPV+ coinfection (PR 1.75; CI (1.07-2.88)) remained independently associated with ASIL in the multivariate model. Study III identified three themes in the focus group discussions. 1) Knowledge and risk perceptions about STIs and HPV, 2) Beliefs and attitudes towards HPV prevention, 3) Participant's recommendations for HPV vaccination and anal Pap screening. The overall knowledge of HPV was poor though, and none of the participants had heard about HPV prevention including vaccination and anal Pap screening for men but expressed a positive attitude towards prevention. In study IV, participants unanimously favoured integration of HPV preventive services into the existing HIV program, but also identified several service delivery barriers including shortage of trained workforce, limited capacity of information technology, lack of supplies needed for screening, lack of financing, and lack of services that could meet the needs of these key-populations. Conclusions: The findings of this thesis reaffirm the high burden of HPV and associated anal precancerous lesions in MSM and transgender women living with HIV. Current findings support anal Pap-smear HPV screening for this particular group and vaccination efforts for future generations. Educational interventions should be culturally tailored to address the knowledge gaps among key-populations. Moreover, integration of anal cancer screening is dependent on political will, financing, anti-stigma and discrimination interventions, and health system efficiency.

Taking into account the public health importance of the human papillomavirus (HPV) control in the future, it is mandatory to assess the effect of the vaccination campaigns on the control of HPV spread and the associated diseases using reliable mathematical models. We propose a computational random network model with the aim of studying the transmission dynamics of HPV infections. This model reflects the herd immunity effect in the heterosexual network more accurately than the classical models. We perform a sensitivity analysis of the sexual behavior changes consisting of increasing the number of men who have sex with men (MSM), increasing the frequency of the intercourses and increasing the number of sexual partners. We find that large changes in the sexual behavior, in some extent, only have minor effects on the decline of the HPV infections in women and men in the current vaccination campaign in Spain (vaccination of young girls with a coverage of 70%). Therefore, the current vaccination program in Spain is robust for the heterosexuals. However, we cannot say the same for MSM, where they do not benefit by the herd immunity effect of the vaccination of girls, and consequently, the circulation of the virus among them remains unchanged. A consequence of the present study is that the effect of other external factors that may affect the transmission dynamics of the HPV, for instance, the tourism or the immigration, does not influence the protection provided by the current Spanish vaccination program. ; This work has been supported by the Spanish Ministerio de Economía, Industria y Competitividad (MINECO), the Agencia Estatal de Investigación (AEI) and Fondo Europeo de Desarrollo Regional (FEDER UE) grant MTM2017-89664-P. This paper has been supported by the European Union through the Operational Program of the [European Regional Development Fund (ERDF) / European Social Fund (ESF)] of the Valencian Community 2014-2020. Files: GJIDI/2018/A/010 and GJIDI/2018/A/009.

Background and Objectives: To investigate the effect of infection with human papillomavirus (HPV) or Chlamydia trachomatis (CT) and HPV + CT coinfection on sperm quality, inflammation, and the state of oxidative stress (OS) in asymptomatic infertile men. Materials and Methods: Semen samples from 84 asymptomatic military infertile men were studied. The polymerase chain reaction (PCR) was used for the molecular detection of HPV and CT. Semen parameters were analyzed according to the World Health Organization guidelines. Inflammation was evaluated by an IL-1β, IL-6, and IFN-γ enzyme-linked immunosorbent assay (ELISA) and OS by the quantification of lipid peroxidation (LPO), 8-hydroxydeoxyguanosine (8-OHdG), and total antioxidant capacity (TAC). Results: A total of 81 of the 84 (96.4%) samples were positives for the pathogens, with 55/81 (68%) being positive for HPV, 11/81 (13.5%) for CT, and 15/81 (18.5%) for HPV + CT coinfection. Seminal parameters were affected in the infected groups, including pH increases above the normal range in all groups. An abnormal sperm morphology was observed in the HPV and HPV + CT groups. Higher cytokine levels were detected in the HPV group and the highest IL-1β level was found in the HPV + CT group. No cytokines were detected in the CT group. High LPO and 8-OHdG levels were found in all groups with a lower TAC. Comparisons between groups showed the highest OS state was observed in the HPV group. Conclusions: High HPV infection or coinfection (HVP + CT) in these infertile men suggest compromising male fertility by inducing a proinflammatory state and OS. Infection with CT suggests an alteration of the state of OS by promoting an alkaline pH.

Objective: In this study, we developed a paradigmatic model focusing on human papillomavirus (HPV) diseases, in order to formulate a theory by investigating pathology in health culture using Grounded Theory, as an inductive and exploratory research method. Materials and methods: It was a qualitative study, and data were collected using in-depth interviews with 20 people (10 men and 10 women) with cultural and religious specialties (clergy). In total, twenty interviews were conducted (mean duration = 45 min) using a semi-structured guide consisting of open-ended questions. All recordings were transcribed verbatim in Persian. All items were extracted based on the participants' responses and related literature. After data collection, the basic theory analysis was performed in terms of the three steps as follows: free coding, axial encryption, the implementation, refinement, and writing the theories in line with selective coding theoretical models. Finally, the paradigm model was determined from the presented models. Results: The paradigm model emerged from professors, clergy, and authorized people, showed that religious taboos about sexually transmitted diseases; lack of wise management, comprehensive supervision, compliance with health standards in the country, proper legislation regarding sexually transmitted diseases as causal factors, awareness, health education in the country, public demand for health, individual dignity, punishment for health detractors, familiarity with individual rights as intervening factors, concern for human lives, health, and belief in fatalism; ethnic differences; irresponsibility; risk perception; high cost of HPV vaccine; immorality in health speech; disregard for people's lives; gender differences as contextual factors; and the consequences is increasing burden of diseases due to sexually transmitted disease such as (HPV). Conclusion: It seems the overall lack of a health-based approach could be a major concern due to the weakness of cultural management in society that requires the ...

Introduction. The administration of Isère decided to launch an immunization campaign against Human Papillomavirus (HPV) from 2018 to 2022. In France, in 2017, HPV uptake was about 21%. In Isère, it is even lower (18%). However, this vaccine can prevent more than 90% of the cancers and lesions associated with HPV (6,000 cancers/ year in France). We aim to build a program that doubles the vaccination coverage against HPV by 2022. Method. We performed a literature realist review on three points. We first identified candidate theories that explain changes in health behavior and developed a theoretical framework. Then, this framework guided our selection, appraisal of studies. Indeed, we reviewed interventions according to their potential effect on immunization change to ultimately increase HPV immunization coverage. Finally, through a review of documents, we deepened our knowledge on the context in Isère. Results. We identified three theories; their combinations include intention and planning of action as determinants of changes. Otherwise we selected 58 primary studies and 8 systematic reviews evaluating vaccination uptake. The most efficient strategies are environmental and school-based. They induce a change in norms and help get over the intention to the action. On these results and given the context in Isère, we suggest a promotional program in Isère. It is a multi-components program directed at girls, their parents as well as physicians, generalists and specialists. Conclusion. Base on theoretical insights, using evidence and reviewing local document, we developed a proposal for a HPV immunization campaign in Isère. This proposal will provide useful information for local program implementers and policy makers. It will also serve the conception of the program evaluation. ; Introduction. Le Conseil Départemental de l'Isère a décidé de soutenir la vaccination contre les Papillomavirus (HPV) en organisant une campagne de promotion de 2018 à 2022. En France la couverture vaccinale était en 2017 de 21%. En Isère, elle est plus basse encore (18%). Or, ce vaccin peut prévenir plus de 90% des cancers et lésions associés aux HPV (6 000 cancers/an en France). L'objectif est de construire un programme pour doubler la couverture vaccinale contre les HPV en Isère. Méthode. Notre revue de la littérature s'est construite en trois points. Premièrement nous avons identifié des théories de changement de comportement en santé pour élaborer notre cadre théorique. Sur cette base, nous avons ensuite étudié les interventions reconnues comme efficientes, favorisant l'adhésion à la vaccination. Nous nous sommes enfin documentés sur le contexte isérois. Résultats. Nous avons identifié trois théories en santé. Par ailleurs, nous avons sélectionné 58 études dont 8 revues systématiques de la littérature qui évaluait l'augmentation de la vaccination. Les stratégies environnementales et basées sur l'école étaient les plus efficaces. Elles modifiaient les normes et modifiaient l'intention et facilitaient le passage à l'action. A partir de ces résultats et en contexte isérois, nous avons proposé un programme multicomposé destiné aux filles, à leurs parents ainsi qu'aux médecins. Conclusion. Le programme de promotion de la vaccination contre les papillomavirus en Isère de 2018 à 2022 a été élaboré avec une méthodologie basée sur la littérature pour répondre à des problématiques de terrain. L'évaluation incluse dans le programme sera un atout pour les décideurs politiques.

Introduction. The administration of Isère decided to launch an immunization campaign against Human Papillomavirus (HPV) from 2018 to 2022. In France, in 2017, HPV uptake was about 21%. In Isère, it is even lower (18%). However, this vaccine can prevent more than 90% of the cancers and lesions associated with HPV (6,000 cancers/ year in France). We aim to build a program that doubles the vaccination coverage against HPV by 2022. Method. We performed a literature realist review on three points. We first identified candidate theories that explain changes in health behavior and developed a theoretical framework. Then, this framework guided our selection, appraisal of studies. Indeed, we reviewed interventions according to their potential effect on immunization change to ultimately increase HPV immunization coverage. Finally, through a review of documents, we deepened our knowledge on the context in Isère. Results. We identified three theories; their combinations include intention and planning of action as determinants of changes. Otherwise we selected 58 primary studies and 8 systematic reviews evaluating vaccination uptake. The most efficient strategies are environmental and school-based. They induce a change in norms and help get over the intention to the action. On these results and given the context in Isère, we suggest a promotional program in Isère. It is a multi-components program directed at girls, their parents as well as physicians, generalists and specialists. Conclusion. Base on theoretical insights, using evidence and reviewing local document, we developed a proposal for a HPV immunization campaign in Isère. This proposal will provide useful information for local program implementers and policy makers. It will also serve the conception of the program evaluation. ; Introduction. Le Conseil Départemental de l'Isère a décidé de soutenir la vaccination contre les Papillomavirus (HPV) en organisant une campagne de promotion de 2018 à 2022. En France la couverture vaccinale était en 2017 de 21%. En Isère, elle est plus basse encore (18%). Or, ce vaccin peut prévenir plus de 90% des cancers et lésions associés aux HPV (6 000 cancers/an en France). L'objectif est de construire un programme pour doubler la couverture vaccinale contre les HPV en Isère. Méthode. Notre revue de la littérature s'est construite en trois points. Premièrement nous avons identifié des théories de changement de comportement en santé pour élaborer notre cadre théorique. Sur cette base, nous avons ensuite étudié les interventions reconnues comme efficientes, favorisant l'adhésion à la vaccination. Nous nous sommes enfin documentés sur le contexte isérois. Résultats. Nous avons identifié trois théories en santé. Par ailleurs, nous avons sélectionné 58 études dont 8 revues systématiques de la littérature qui évaluait l'augmentation de la vaccination. Les stratégies environnementales et basées sur l'école étaient les plus efficaces. Elles modifiaient les normes et modifiaient l'intention et facilitaient le passage à l'action. A partir de ces résultats et en contexte isérois, nous avons proposé un programme multicomposé destiné aux filles, à leurs parents ainsi qu'aux médecins. Conclusion. Le programme de promotion de la vaccination contre les papillomavirus en Isère de 2018 à 2022 a été élaboré avec une méthodologie basée sur la littérature pour répondre à des problématiques de terrain. L'évaluation incluse dans le programme sera un atout pour les décideurs politiques.

The study set out to investigate what influences the intentions of college students to get vaccinated against genital human papillomavirus (HPV). College men and women were surveyed to understand their intentions. Regression was used and supported that the constructs of the health belief model (HBM) as well as gender, norms, and information seeking contributed to predicting intent to receive the HPV vaccine, R2 = .61, F(6, 159) = 39.41, p < .001. Benefits and barriers were the most influential variable, and men were more likely to intend to receive the vaccine. The findings should be applied to future campaigns aimed at increasing preventive health behaviors, especially vaccinations among college students.