Progress in research of long-term protective efficacy of human papillomavirus vaccine / 中华流行病学杂志

The efficacy of HPV vaccine in preventing cervical cancer has been demonstrated in numerous clinical trials and clinical uses. The follow-up after clinical trials usually last for 5-6 years to evaluate the long-term efficacy, and a series of long-term follow-up studies have been conducted in some regions. The literature retrieval of HPV vaccine long term efficiency research both at home and abroad indicated that the protective efficacy of the vaccine against vaccine-type-related cervical intraepithelial neoplasia grade 2 and above is higher than 90%.

Infection of human papillomavirus and head and neck cancer / 中华肿瘤杂志

High-risk human papillomavirus (HPV)-related cancers consist of cervical cancer, anal cancer, penile cancer, vulvar cancer, vaginal cancer, and head and neck cancer (HNC). Of these, the disease burden of HNC is second only to cervical cancer. HNC mostly originates from malignant lesions of squamous epithelial cells and mainly includes oral cavity cancer, pharyngeal cancer (including nasopharyngeal cancer, oropharyngeal cancer, and hypopharyngeal cancer), and laryngeal cancer. Tobacco use, alcohol abuse, and HPV infection are three primary risk factors. Recently, there is an upward trend of HNC incidence globally, especially in high-income countries. In China, the disease burden and trends of HPV-related HNC are still not clear. A few small sample size and single-center studies suggest a high HPV prevalence and increasing trend in HNC. Methodological differences in HPV testing and regional variabilities still exist among these studies. Among the anatomic sites, oropharyngeal cancer has been shown to be caused by HPV infection, but the association of HPV with other sites is still under debate. In addition, there is a paucity of relevant studies. Here, this review narrates the association between HPV infection and HNC, compares the differences between global and Chinese studies, and then explores the importance of HPV infection in various anatomical sites. The main objective is to highlight the research on HPV-related HNC and promote relevant prevention and treatment programs.

Causes and countermeasures of the rapidly rising burden on cervical cancer in Chinese women / 中华流行病学杂志

The world is entering a new era of accelerated elimination of cervical cancer, while the age-standardized incidence, and mortality of cervical cancer in China are rising rapidly. This article summarizes and describes the current situation and trends of the burden of cervical cancer in China, reviews and analyzes the comprehensive prevention practice of cervical cancer, focusing on critical reasons for the increasing burden of cervical cancer, from the perspectives of sociology, behavior, and epidemiology in the population. Countermeasures are proposed to provide guidance and theoretical reference for the precise prevention of cervical cancer to eliminate cervical cancer.

Analysis on cancer incidence and mortality attributed to human papillomavirus infection in China, 2016 / 中华流行病学杂志

Objective: We aim to evaluate the morbidity and mortality of cancer attributable to human papillomavirus (HPV) infection in China in 2016. Methods: Based on the cancer incidence and mortality rates, national population data, and population attributable fraction (PAF) in China, we calculated the number of incidence and death cases attributed to HPV infection in different areas, age groups, and gender in China in 2016. The standardized incidence and mortality rates for cancer attributed to HPV infection were calculated by using Segi's population. Results: In 2016, a total of 124 772 new cancer cases (6.32 per 100 000) were attributed to HPV infection in China, including 117 118 cases in women and 7 654 cases in men. Of these cancers, cervical cancer was the most common one, followed by anal cancer, oropharyngeal cancer, penile cancer, vaginal cancer, laryngeal cancer, oral cancer, and vulvar cancer. A total of 41 282 (2.03 per 100 000) deaths were attributed to HPV infection, of which 37 417 occurred in women and 3 865 in men. Most deaths were caused by cervical cancer, followed by anal cancer, oropharyngeal cancer, penile cancer, laryngeal cancer, vaginal cancer, oral cancer, and vulvar cancer. The incidence and mortality rates of cervical cancer increased rapidly with age, peaked in age group 50-54 years, then decreased obviously. The morbidity and mortality rates of non-cervical cancer increased with age. The cancer case and death numbers in rural areas (57 089 cases and 19 485 deaths) were lower than those in urban areas (67 683 cases and 21 797 deaths). However, the age-standardized incidence rate (ASIR) and age-standardized mortality rate (ASMR) of cervical cancer were higher in rural areas than in urban areas. There were no significant differences in ASIR and ASMR of non-cervical cancers between urban areas and rural areas. Conclusions: The incidence of cancers attributed to HPV infection in China was lower than the global average, but the number of incidences accounted largely, furthermore there is an increasing trend of morbidity and mortality. The preventions and controls of cervical cancer and male anal cancer are essential to contain the increases in cancer cases and deaths attributed to HPV infection.

Dilemma, causes and countermeasures of global health governance: taking COVID-19 Vaccines Global Access Facility as an example / 中华流行病学杂志

The pandemic of COVID-19 threatens the health and safety of the people all over the world. COVID-19 vaccine is the key public product to establish population immune barrier and achieve the global contain of the pandemic. The World Health Organization, the Global Alliance for Vaccines and Immunization and the Coalition for Epidemic Preparedness Innovations established COVID-19 Vaccines Global Access Facility (COVAX) in 2020, aiming to enable the fair access to COVID-19 vaccine by all countries in the world, especially the low- and middle-income countries. Although COVAX has facilitated the production and research of COVID-19 vaccine by coordinating the global supply chain, the implementation of COVAX is still facing many difficulties in financing, implementation and the awareness of public, revealing the problems of global health governance. Taking COVAX as an example, this paper analyzes the difficulties faced by global health governance and explore the underlying causes, so as to suggest feasible short and long-term paths for China's participation in global governance.

WHO global strategy on digital health and its implications to China / 中华预防医学杂志

The World Health Organization (WHO) released the global strategy report on digital health (2020-2025) in Geneva in 2019, which established the priority of the digital health strategy and formulated strategic objectives, guiding principles, action framework and implementation plans to promote the development of global digital health, and to achieve universal health coverage and the health-related sustainable development goals. Despite China's rapid development in the field of digital health, there is still a big gap between the realization of the goal of digital health. Therefore, it is urgent to grasp the major historical opportunity and step into a new era of digital health with the support of digital technology platform.

Mental Health Status and Its Influencing Factors among College Students during the Epidemic of Coronavirus Disease 2019:A Multi-center Cross-sectional Study / 中国医学科学院学报

Objective To measure the prevalence of mental health symptoms and identify the associated factors among college students at the beginning of coronavirus disease 2019(COVID-19)outbreak in China. Methods We carried out a multi-center cross-sectional study via snowball sampling and convenience sampling of the college students in different areas of China.The rates of self-reported depression,anxiety,and stress and post-traumatic stress disorder(PTSD)were assessed via the 21-item Depression-Anxiety-Stress Scale(DASS-21)and the 6-item Impact of Event Scale-Revised(IES-6),respectively.Covariates included sociodemographic characteristics,health-related data,and information of the social environment.Data pertaining to mental health service seeking were also collected.Multivariate Logistic regression analyses were performed to identify the risk factors. Results A total of 3641 valid questionnaires were collected from college students.At the beginning of the COVID-19 outbreak,535(14.69%)students had negative emotions,among which 402(11.04%),381(10.49%),and 171(4.90%)students had the symptoms of depression,anxiety,and stress,respectively.Meanwhile,1245(34.19%)college students had PTSD.Among the risk factors identified,male gender was associated with a lower likelihood of reporting depression symptoms(AOR=0.755,P=0.037],and medical students were at higher risk of depression and stress symptoms than liberal arts students(AOR=1.497,P=0.003;AOR=1.494,P=0.045).Family support was associated with lower risks of negative emotions and PTSD in college students(AOR=0.918,P<0.001;AOR=0.913,P<0.001;AOR=0.899,P<0.001;AOR=0.971,P=0.021). Conclusions College students were more sensitive to public health emergencies,and the incidence of negative emotions and PTSD was significantly higher than that before the outbreak of COVID-19.More attention should be paid to female college students who were more likely to develop negative emotions.We should strengthen positive and proper propaganda via mass media and help college students understand the situation and impact of COVID-19.Furthermore,we should enhance family support for college students.The government and relevant agencies need to provide appropriate mental health services to the students under similar circumstances to avoid the deterioration of their mental well-being.

Construction of an Information Platform for Cervical Cancer Prevention in the Digital Era / 中国医学科学院学报

The advent of the digital era brings new challenges and opportunities for cervical cancer prevention and research.With the development of digital techniques in China,the construction of an information platform for cervical cancer prevention based on the current achievements has become an important trend.This paper expounds the importance,existing problems,and challenges of the data integration of population-based cervical cancer screening and the information platform construction,and puts forwards effective measures to promote its construction.The establishment of an information platform for cervical cancer prevention in the digital era has far-reaching significance for the global elimination of cervical cancer.

Multidisciplinary Prevention and Control of Cervical Cancer:Application and Prospects / 中国医学科学院学报

Cervical cancer is the second most common malignant tumor in women worldwide.The burden of cervical cancer is particularly heavy in less developed countries as the malignancy brings huge pain to the patients and their family members and causes huge losses to social development and global health.However,cervical cancer is a preventable and curable disease.While screening and human papillomavirus vaccination in developed countries have remarkably lowered the incidence and mortality of cervical cancer,there is still a far way to go to achieve the prevention and treatment of this disease.The multidisciplinary prevention and control programs slightly differ in different countries due to diverse economic and health conditions.The general principle is to vaccinate the young females and to implement a comprehensive strategy including human papillomavirus vaccine vaccination,screening,early diagnosis,and early treatment in adults.

Ethical Issues of Medical Artificial Intelligence / 中国医学科学院学报

As an important branch of artificial intelligence,the emerging medical artificial intelligence(MAI)is facing many ethical issues.MAI may offer the optimal diagnosis and treatment for patients but may also bring adverse effects on society and human beings.This article discusses the ethical problems caused by MAI and elucidates its development in a direction that meets ethical principles and requirements.

Prospective comparison of hybrid capture 2 and SPF₁₀-LiPA for carcinogenic human papillomavirus detection and risk prediction of cervical cancer: a population-based cohort study in China / 부인종양

OBJECTIVE: To investigate the extent of the cross-reactivity of hybrid capture 2 (HC2) assay and evaluate the potential effect of cross-reactivity on the long-term risk for cervical cancer and precancers. METHODS: Based on the Shanxi Province Cervical Cancer Screening Study-I (SPOCCS-I) cohort from 2005 to 2014 in Shanxi, China, SPF₁₀-line probe assay (LiPA) was performed in all 598 HC2 positive and 300 random-selected HC2 negative cervical specimens. Ten-year cumulative incidence rate (CIR) of cervical intraepithelial neoplasia grade 2 or worse (CIN2+) of these two tests was evaluated using Kaplan-Meier methods. Possible human papillomavirus (HPV) types to be cross-reacted by HC2 were also analyzed. RESULTS: The overall agreement between HC2 and SPF₁₀-LiPA for detecting carcinogenic HPV was 73.27%. The highest 10-year cumulative risk of CIN2+ was observed in both HC2 positive and LiPA-carcinogenic HPV positive women (25.70%; 95% confidence interval [CI]=23.55%–27.91%), followed by HC2 positive but LiPA-non-carcinogenic HPV positive women (9.97%; 95% CI=8.57%–11.50%), HC2 negative but LiPA-carcinogenic HPV positive (2.56%; 95% CI=2.44%–2.70%) and HC2 positive but LiPA-HPV negative (1.85%; 95% CI=1.78%–1.92%) women. The proportion of cross-reactivity of HC2 with untargeted carcinogenic types was 8.9%, most of which were attributable to HPV26, 73, 82, 69, 71, 53, 11, 43, and 54. CONCLUSION: The noticeable high risk of CIN2+ in women infected with cross-reacted non-carcinogenic HPV and low risk in those with miss-to-detective carcinogenic HPV supported an overall good clinical performance of HC2 for a general cervical cancer screening.

Role of active and passive smoking in high-risk human papillomavirus infection and cervical intraepithelial neoplasia grade 2 or worse / 부인종양

OBJECTIVE: We performed a pooled analysis to examine cigarette smoking and household passive smoke exposure in relation to the risk of human papillomavirus (HPV) infection and cervical intraepithelial neoplasia grade 2+ (CIN2+). METHODS: Data were pooled from 12 cross-sectional studies for cervical cancer screenings from 10 provinces of China in 1999–2007. A total of 16,422 women were analyzed, along with 2,392 high-risk-HPV (hr-HPV) positive women and 381 CIN2+ cases. Pooled odds ratios (ORs) and 95% confidence intervals (CIs) were estimated using logistic regression models controlling for sexual and non-sexual confounding factors. RESULTS: There was an excess risk between active smoking and hr-HPV infection and CIN2+. Adjusted OR for ever smokers vs. never smokers was 1.45 (95% CI=1.10–1.91), for hr-HPV infection and 1.89 (95% CI=1.03–3.44), for CIN2+. Passive smoking had a slightly increased risk on the hr-HPV infection with adjusted OR 1.11 (1.00–1.24), but no statistical association was observed between passive smoke exposure and CIN2+. Compared with the neither active nor passive smokers, both active and passive smokers had a 1.57-fold (95% CI=1.14–2.15) increased risk of HPV infection and a 1.99-fold (95% CI=1.02–3.88) risk of CIN2+. CONCLUSION: Our large multi-center cross-sectional study found active smoking could increase the risk of overall hr-HPV infection and CIN2+ adjusted by passive smoking and other factors. Passive smoking mildly increased the risk of HPV infection but not the CIN2+. An interaction existed between passive tobacco exposure and active smoking for hr-HPV infection and the CIN2+.

The Natural Progression of Parkinson's Disease in a Small Cohort with 15 Drug-naïve Patients / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>The studies of the natural progression of Parkinson's disease (PD) in Chinese populations have been lacking. To address this issue and obtain a preliminary data, we conducted a PD progression assessment in 15 adults with de novo PD from a nutritional intervention trial (NIT) cohort in Lin County China.</p><p><b>METHODS</b>Using the Copiah County screening questionnaire and United Kingdom Parkinson's Disease Society Brain Bank diagnostic criteria, we surveyed the available NIT cohort members in 2000 and diagnosed 86 patients as PD. In 2010, we resurveyed all PD patients and confirmed definite PD diagnosis in 15 cases with the rest of them being dead (54); having probable (10) PD or vascular Parkinsonism (3); refusing to participate (2); or being away (2). In both surveys, we used Hoehn and Yahr (HY) scale and assessed the disease progression. Unified Parkinson's Disease Rating Scale (UPDRS) was added to the second survey.</p><p><b>RESULTS</b>In 2010, the average disease duration for 15 definite PD patients was 13.6 ± 7.3 years. Over a 10-year time span, 9 out of 15 patients remained at the same HY stage while the remaining 6 progressed. Rigidity (47% vs. 100%; P = 0.002) and postural instability (7% vs. 47%; P = 0.005) worsened significantly. The mean UPDRS motor scores in 2010 were 39.4 ± 23.7.</p><p><b>CONCLUSIONS</b>Overall worsening of motor function in PD seems to be the rule in this untreated cohort, and their rate of progression seemed to be slower than those reported in the western populations.</p>

Trend analysis of cervical cancer incidence and mortality rates in Chinese women during 1989-2008 / 中国医学科学院学报

<p><b>OBJECTIVE</b>To evaluate the trend of cervical cancer incidence and mortality rates during 1989-2008 in Chinese women, so as to inform the development of relevant policies and strategies in China.</p><p><b>METHODS</b>The incidence and mortality rates of cervical cancer during 1989-2008 in urban and rural areas were calculated based on the data from the National Cancer Registry Database. Age-standardized rates were calculated using the Chinese population of 1982 and World Segi's population of 1985. Joinpoint regression analysis was performed to obtain annual percentage changes (APC) so as to assess the trend of incidence and mortality rates over the period from 1989 to 2008.</p><p><b>RESULTS</b>The crude incidence rate of cervical cancer in Chinese women increased from 3.06/10(5) in 1989-1990 to 11.87/10(5) in 2007-2008 (from 4.96/10(5) to 11.98/10(5) in urban registration areas and from 2.39/10(5) to 11.77/10(5) in rural registration areas).The crude mortality rate slightly increased from 2.19/10(5) in 1989-1990 to 3.20/10(5) in 2007-2008 (from 3.21/10(5) to 2.56/10(5) in urban registration areas and from 1.82/10(5) to 3.75/10(5) in rural registration areas). Generally, the upward trends of crude incidence rates were shown over the year 1989-2008, with an APC of 14.4% after 1997 in urban areas and 22.5% after 1999 in rural areas.After age standardization of world population, the APC of incidence rates in recent decade in urban areas remained stable, and the one in rural areas slightly decreased.Although the overall crude and world age-standardized mortality rates had no significant changes during 1989-2008, the crude mortality rates increased by 8.1% annually after 1999.The upward trends were also shown for crude and world age-standardized mortality rates in urban areas after 2001 with an APC of 7.3%.The crude mortality rates in rural areas increased by 3.9% annually during 1989-2008, but no significant change was found after age standardization.</p><p><b>CONCLUSIONS</b>Over the last decade, the cervical cancer incidence and mortality rates ascended by year in China. It is particularly urgent to establish a comprehensive prevention and control system that combines cervical cancer screening and human papillomavirus vaccination, so as to reduce the burden of cervical cancer in Chinese women.</p>

Quality of life in women with cervical precursor lesions and cancer: a prospective, 6-month, hospital-based study in China / 癌症

The overall survival of patients with cervical cancer has improved due to detection at an early stage and availability of comprehensive treatments in China. As patients' lives prolonged, it is important to understand their health-related quality of life (QoL) during and after treatment. We used the EQ-5D questionnaire to assess QoL of 194 patients with cervical lesions at Sichuan University West China Second Hospital between May 2010 and January 2011. Patients were surveyed before primary treatment and at 1, 3, and 6 months after primary treatment. Results showed a consistent decline in EQ-5D scores in the spectrum of cervical lesions at each time point after treatment (all P < 0.05). For patients with precursor lesions, there was an increasing trend along the timeline of treatment (P < 0.01). For patients with early-stage cervical cancer, EQ-5D scores declined in the first month (P = 0.01) and gradually increased to higher levels at 6 months post-treatment than those before treatment (P < 0.01). EQ-5D scores followed a similar trend in patients with advanced cervical cancer (P = 0.04), though they did not statistically rebound after 6 months (0.84 ± 0.19 vs. 0.86 ± 0.11, P = 0.62). Regarding advanced cervical cancer, EQ-5D scores for women above 40 years of age appeared to recover more rapidly and reached higher levels than those for women below 40 years (P = 0.03). Caution and extra care are recommended in the early period of cervical cancer treatment given the slight deterioration in the QoL, and in particular, for younger cervical cancer patients. Our study implies that health care providers may need to improve the health-related QoL of cervical cancer patients.

Comprehensive cervical cancer prevention and control in the Asia Pacific region: the 6th Biennial Conference of the Asia Oceania Research Organization on Genital Infections & Neoplasia (AOGIN) / 부인종양

No abstract available.

Population-attributable risk estimates for breast cancer in Chinese females / 中华肿瘤杂志

<p><b>OBJECTIVE</b>To estimate the contribution of known identified risk factors to breast cancer incidence and mortality in China, and provide evidence to support the prevention and control of breast cancer for Chinese females.</p><p><b>METHODS</b>We calculated the proportion of breast cancer attributable to specific risk factors. Data on exposure prevalence were obtained from Meta-analyses and large-scale national surveys of representative samples of the Chinese population. Data on relative risks were obtained from Meta-analyses and large-scale prospective studies. Cancer mortality and incidence were taken from the Third National Death Survey and from cancer registries in China.</p><p><b>RESULTS</b>The first 5 risk factors of breast cancer in China were benign breast disease (RR = 2.62), family history of breast cancer (RR = 2.39), smoking (RR = 1.86), overweight (RR = 1.60) and age at menarche (RR = 1.54). The proportion of breast cancer deaths attributable to reproductive factors, lifestyle factors, benign breast disease, the use of external hormone and family history of breast cancer was 27.84%, 23.55%, 15.09%, 3.60% and 2.49%, respectively. The total population attributable fraction (PAF) was 55.95% for risk factors in our study. Overall, we estimated that 79 862 breast cancer cases and 22 456 deaths were attributed to the five risk factors in China in 2005.</p><p><b>CONCLUSIONS</b>The prevention and control of unhealthy lifestyle factors may significantly reduce the number and death of breast cancer in China.</p>

Screening for Parkinson syndrome in a Chinese rural population: re-examination of a historic questionnaire / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Standardized screening tools for Parkinson syndrome have not been developed for non-western populations. This study aimed to validate the Copiah County questionnaire (CCQ) as a screening instrument in a Chinese rural population.</p><p><b>METHODS</b>All participants of a previously reported prevalent study were interviewed using CCQ. The participants who answered yes to at least one item on CCQ were defined as positive. The Parkinson's disease (PD) diagnosis was established using United Kingdom Parkinson's disease Brain Bank Clinical diagnosis criteria (UKPDBBC) and served as a gold standard to determine the sensitivity, specificity, and positive and negative predictive values (PPV, NPV) for the questionnaire.</p><p><b>RESULTS</b>Among 16 130 participants, 2872 (17.8%) were screened positive for CCQ and 13 258 negative (82.2%). Among the 697 participants diagnosed as having Parkinson syndrome, 605 were positive for CCQ, and 92 were negative, leading to a sensitivity of 86.8%. Out of the 15 433 non-Parkinson syndrome participants, 13 166 were negative to CCQ, giving a specificity of 85.3%. Among the 2872 participants screened positive, 605 were diagnosed with Parkinson syndrome, and their PPV was 21.1%. For the 13 258 participants screened negative on CCQ, 92 were diagnosed with Parkinson syndrome and 13 166 did not have Parkinson syndrome, leading to a NPV of 99.3%.</p><p><b>CONCLUSIONS</b>CCQ appeared to have satisfactory statistical parameters to serve as a screening instrument for Parkinson syndrome in this rural Chinese population. Further studies may prove the utility of this short questionnaire in Parkinson syndrome screening among Chinese populations including those residing in rural areas.</p>

Incidence and mortality of oral and pharyngeal cancers in China, 2003 to 2007 / 中华流行病学杂志

Objective To analyze the incidence and mortality of oral and pharyngeal cancers from 32 cancer registration centers,2003 to 2007.Methods Data from 32 eligible cancer registries were included in this study.Both crude and age-standardized incidence and mortality of oral and pharyngeal cancers from 2003 to 2007 were calculated and stratified by area and gender.Age-stratified incidence and mortality,as well as the proportions of new and death cases of oral and pharyngeal cancer were also calculated at each site.Results Mouth,tongue and salivary gland were the most predilcction sitcs of oral and pharyngeal cancers.The crude incidence for both oral and pharyngeal cancers was 3.15/105 from 2003 to 2007.The age-standardized incidence rates using the Chinese population (1982) and the World Segi' s population were 1.75/105 and 2.26/105.The crude mortality of oral and pharyngeal cancer was 1.37/105 from 2003 to 2007; with age-standardized mortality rates,using the Chinese population (1982) and the World Segi' s population were 0.69/105 and 0.94/105.Both incidence and mortality were higher in males than in females,higher in urban than in rural areas,and ascended with age.Age-standardized incidence and mortality in Zhongshan city ranked first among all the cancer registration areas.Age-standardized incidences by gender and area increased slightly from 2003 to 2007,while age-standardized mortalities were stable.Conclusion Although the incidence and mortality of oral and pharyngeal cancer were low in China from 2003 to 2007,attention should also be paid since the exposure of relative risk factors did not seem to have reduced and the incidence increased slightly.

Comparison on the predictive values of four screening methods regarding cervical cancer / 中华流行病学杂志

To compare the predictive values of 5% acetic acid stain and visual inspection, human papillomavirus (HPV) Self test, ThinPrep Pap and HPV direct test in screening for cervical cancer with biopsy as gold standard. Positive predictive values and negative predictive values were compared simultaneously by joint hypothesis tests and then either positive predictive values or negative predictive values of the any two screening tests were compared by marginal regression based on both GEE and weighted least square methods. Hochberg method was used for multiplicity adjustment. It was showed that HPV direct test had the highest negative predictive value and ThinPrep Pap the highest positive predictive value. 5% acetic acid stain and visual inspection had both the lowest positive predictive value and negative predictive value. Both HPV direct test and ThinPrep Pap were efficient, but the latter required compatible infrastructure and skilled caregivers to go with. Both 5% acetic acid stain and visual inspection were inexpensive, and their positive predictive value and negative predictive value were lower than HPV self-test. They also had similar positive predictive value with HPV direct test and similar negative predictive value with ThinPrep Pap. HPV self-test appeared to be efficient, suggesting that it had significant potential for screening program to be implemented in the rural areas of China since the test could be performed without speculum examination in low-resource regions.