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[This corrects the article DOI: 10.1371/journal.pntd.0011390.].

Assay validation is an essential component of disease surveillance testing, but can be problematic in settings where access to positive control material is limited and a safety risk for handlers. Here we describe a single non-infectious synthetic control that can help develop and validate the PCR based detection of the viral causes of Crimean-Congo hemorrhagic fever, Ebola virus disease, Lassa fever, Marburg virus disease and Rift Valley fever. We designed non-infectious synthetic DNA oligonucleotide sequences incorporating primer binding sites suitable for five assays, and a T7 promotor site which was used to transcribe the sequence. Transcribed RNA was used as template in a dilution series, extracted and amplified with RT-PCR and RT-qPCR to demonstrate successful recovery and determine limits of detection in a range of laboratory settings. Our results show this approach is adaptable to any diagnostic assay requiring validation of nucleic acid extraction and/or amplification, particularly where sourcing reliable, safe material for positive controls is infeasible.

To investigate the barriers that prevent or delay people seeking a sexually transmitted infection (STI) test. Qualitative in‐depth interviews were conducted with 24 university students, who are a group prone to behaviours putting them at risk of STIs, to understand the factors that had prevented or delayed them from going for an STI test in the past. Resulting data were thematically analysed employing a qualitative content analysis method, and a final set of themes identified. There were three main types of barrier to STI testing. These were: personal (underestimating risk, perceiving STIs as not serious, fear of invasive procedure, self‐consciousness in genital examination and being too busy); structural (financial cost of test and clinician attributes and attitude); and social (concern of being stigmatised). These data will help health providers and policy‐makers provide services that minimise barriers and develop effective strategies for improving STI testing rates. The results of this study suggest a holistic approach to encouraging testing is required, which includes addressing personal beliefs, working with healthcare providers to minimise structural barriers and developing initiatives to change social views about STIs.

Human papillomavirus (HPV) is a common sexually transmitted infection that is implicated in 99.7% of cervical cancers and several other cancers that affect both men and women. Despite the role that HPV plays in an estimated 5% of all cancers and the evolving role of HPV vaccination and testing in protecting the public against these cancers, preliminary research in New Zealand health professionals suggest knowledge about HPV may not be sufficient. A total of 230 practice nurses, smear takers and other clinical and laboratory staff who attended a range of training events completed a cross-sectional survey between April 2016 and July 2017. The survey explored four broad areas: demographics and level of experience, HPV knowledge (general HPV knowledge, HPV triage and test of cure (TOC) knowledge and HPV vaccine knowledge), attitudes towards the HPV vaccine and self-perceived adequacy of HPV knowledge. The mean score on the general HPV knowledge questions was 13.2 out of 15, with only 25.2% of respondents scoring 100%. In response to an additional question, 12.7% thought (or were unsure) that HPV causes HIV/AIDS. The mean score on the HPV Triage and TOC knowledge questions was 7.4 out of 10, with only 9.1% scoring 100%. The mean score on the HPV vaccine knowledge questions was 6.0 out of 7 and 44.3% scored 100%. Only 63.7% of respondents agreed or strongly agreed that they were adequately informed about HPV, although 73.3% agreed or strongly agreed that they could confidently answer HPV-related questions asked by patients. Multivariate analyses revealed that knowledge in each domain predicted confidence in responding to patient questions. Furthermore, the number of years since training predicted both HPV knowledge and Triage and TOC knowledge. Although overall level of knowledge was adequate, there were significant gaps in knowledge, particularly about the role of HPV testing in the New Zealand National Cervical Screening Programme. More education is required to ensure that misinformation and stigma do not inadvertently result from interactions between health professionals and the public.

Background Titanium dioxide (TiO 2 ) is a compound that is often used as a white pigment. Commercial TiO 2 , such as the food additive E171, contains a mix of particle sizes, including a fraction in the nanoscale range (< 100 nm). It is an ingredient in everyday products such as toothpaste, dietary supplements, and pharmaceuticals. Although the oral and gastrointestinal (GIT) tracts are the initial sites of exposure, in vivo studies have shown that TiO 2 can cross the intestinal epithelium, enter systemic circulation, and accumulate in vital organs, where elimination is slow. This accumulation has been associated with oxidative stress, inflammation, cytotoxicity, and altered cellular function. Main body This systematic review assesses titanium (Ti) accumulation in vital organs of rats and mice following oral TiO 2 exposure, focusing on dose- and time-dependent patterns across acute, subacute, subchronic, and chronic durations. Following PRISMA guidelines, 3,012 records were identified and screened by title and abstract, with 54 studies meeting predefined inclusion criteria. The findings reveal that acute oral exposure to TiO 2 consistently results in minimal titanium accumulation across all major organs, indicating limited gastrointestinal absorption and rapid excretion. In contrast, subacute and subchronic exposures lead to significant, dose-dependent titanium accumulation, especially in the liver, spleen, kidneys, gastrointestinal tract, and brain. Chronic exposure studies, though fewer, indicate persistent Ti presence, especially in the liver, kidneys, and colon. Ti was also found in the brain, pancreas, and reproductive tissues, with histopathological changes indicating broader systemic effects. A few studies reported negligible accumulation even at high doses. Conclusion This review highlights the organ-specific and exposure-dependent biodistribution of titanium following oral TiO 2 intake in rodents. The evidence emphasizes the need for standardized reporting and experimental methodologies to improve data comparability across studies. Importantly, it underscores significant gaps in our understanding of chronic and low-dose exposures, conditions more reflective of real-world human scenarios, warranting further investigation to better assess long-term health risks.

Introduction In Aotearoa New Zealand, human papillomavirus (HPV) self-testing was introduced simultaneously with HPV primary screening in September 2023 to improve access and reduce inequities for priority populations, including Indigenous Māori, Pacific and under-screened people. To contribute policy-relevant information, we implemented non-standard engagement and screening strategies, including text message invitation, mailed test kits, at-home self-testing, telehealth support and follow-up by a central nurse-led co-ordination team. Methods We partnered with an Auckland primary health organisation (PHO) with high enrolment of priority populations. We invited people eligible for cervical screening aged 30—69 years by text message to receive mailed test kits (April–October 2023); people who did not respond were re-invited (October–November 2023). Offering a financial incentive to return a sample (intervention group) was compared with no offer (control group) in a sub-group of eligible Māori and Pacific who received a repeat mailed test kit in a nested randomised controlled trial (April–May 2024). Self-tested participants were invited by text message to an online survey. Results We invited 25,315 people and 24.0% opted in. Lower initial consent rates were increased after additional re-invitation reminders for Māori (20.0% to 30.4%) and Pacific (13.7% to 24.9%), with the final consent rate in Māori equal to European/Other (29.2%; p  = 0.284). Almost half (48.2%) of consenting participants returned a sample, giving a self-test uptake of 11.6% ( n  = 2,925). Uptake was significantly lower (all p  < 0.001) for Māori (12.7%) and Pacific (8.4%) vs. European/Other (19.0%), and for those under-screened (10.5%) vs. those overdue by < 6 months (19.4%). In the RCT, sample return rate did not differ significantly ( p  = 0.704) between the intervention (7.9%) and control (8.5%) groups. HPV was detected in 7.7% of 3,018 valid results. Follow-up test rates were high (96.8% for cytology, 90.5% for colposcopy). Almost all survey respondents preferred a mailed at-home self-test for their next screen (91.9%; n  = 193 of 210). Discussion Invitation by text message to mailed at-home HPV self-testing engaged priority populations in cervical screening. Central co-ordination support achieved high rates of sample return and follow-up testing where required. A mailed at-home testing option, strongly preferred by survey respondents, warrants consideration in a broader programme to improve access to cervical screening, with additional targeted strategies to improve sample return rates for priority populations. Clinical trial registration While the overall study did not reach the ICJME or WHO criteria for clinical trial registration, the nested RCT was retrospectively registered with the Australian New Zealand Clinical Trials Registry (ACTRN12625000798460) and World Health Organization (WHO UTN U1111—1324—8454).

Introduction Māori, Pasifika and Asian women are less likely to attend cervical screening and Māori and Pasifika women are more likely to be diagnosed with later‐stage cervical cancer than other women in Aotearoa New Zealand. This study—with under‐screened women taking part in a randomized‐controlled trial comparing self‐testing and standard screening—explored the acceptability of a human papillomavirus (HPV) self‐test kit and the preferred method for receiving it. Methods Māori, Pasifika and Asian women (N= 376) completed a cross‐sectional postal questionnaire. Twenty‐six women who had not accepted the trial invitation were interviewed to understand their reasons for nonparticipation. Results Most women found the self‐test kit easy and convenient to use and reported that they did not find it painful, uncomfortable or embarrassing. This was reflected in the preference for a self‐test over a future smear test on the same grounds. Most women preferred to receive the kit by mail and take the test themselves, rather than having it done by a doctor or nurse. There was a range of preferences relating to how to return the kit. Phone calls with nonresponders revealed that, although most had received the test kit, the reasons for not choosing to be involved included not wanting to, being too busy or forgetting. Conclusion HPV self‐testing was acceptable for Māori, Pasifika and Asian women in Aotearoa New Zealand. HPV self‐testing has considerable potential to reduce the inequities in the current screening programme and should be made available with appropriate delivery options as soon as possible. Patient or Public Contribution This study explored the acceptability of HPV self‐testing and their preferences for engaging with it among Māori, Pasifika and Asian women. Thus, women from these underserved communities were the participants and focus of this study.

Background Human papillomavirus (HPV) self-testing was introduced in Aotearoa New Zealand in September 2023, with the potential to improve screening access and reduce inequities for priority populations: Māori, Pacific, and those overdue for screening by ≥ 2 years (underscreened). To contribute towards informing this change, we tested the implementation of offering the self-test opportunistically in primary care (with a take-home option) with follow-up by a central nursing team. Methods Trained general practice clinicians offered HPV self-tests to eligible people aged 30–69 years who attended for any reason between November 2021 and September 2023. Six clinics were selected for high proportions of priority populations. The central team reminded participants to return samples (if tested at home), and notified and managed HPV results via telehealth. Results Of 9,292 potentially eligible people, 37.9% ( n  = 3,524) were self-tested. A lower rate of self-testing was seen in all priority populations: 34.7% in Māori and 36.3% in Pacific vs. 40.4% in European/Other ( p  < 0.01, p  < 0.05, respectively), and 32.2% in underscreened vs. 52.3% in those < 6 months overdue (due) ( p  < 0.001). In the 16.8% of participants who took self-test kits home ( n  = 635), 61.1% ( n  = 388) returned a sample. Priority populations were more likely to take a test kit home: 22.2% of Māori and 20.0% of Pacific vs. 12.1% of European/Other, and 21.5% of underscreened vs. 11.7% of due (all p  < 0.001). Although a similar return rate was seen in Māori (64.3%) vs. European/Other (70.3%), fewer Pacific (51.1% vs. 70.3% in European/Other; p  < 0.05) and underscreened (48.7% vs. 89.4% in due; p  < 0.001) returned their sample. HPV was detected in 9.5% of 3,524 returned results. Follow-up testing rates were high (96.4% for cytology; 92.8% for colposcopy). Conclusions Opportunistically offering HPV self-tests in primary care engaged priority populations in cervical screening. Intensive support is required to achieve high rates of sample return (if tested at home) and follow-up where HPV was detected. Opportunistic offer of HPV self-testing in primary care should be considered as an important component of a broader strategy to increase equitable participation in cervical screening, with more focus needed for Māori, Pacific and those who are underscreened. Trial registration This study did not reach the ICJME or WHO criteria for clinical trial registration.

Background To support the introduction of human papillomavirus (HPV) self-testing in the New Zealand National Cervical Screening Programme, we conducted an implementation study aimed to explore the acceptability and feasibility of opportunistically offering HPV self-testing in general practice from both clinician and participant perspectives with a home testing option and centralised follow-up. Methods Primary care clinicians trained to offer the HPV self-test were invited to semi-structured interviews exploring their perception of receptivity to the opportunistic offer and challenges and enablers to implementation. Reflexive thematic analysis was undertaken on transcripts. Participants (aged 30–69 years) were sent a link to an online survey after HPV result notification. Survey results were analysed using descriptive statistics with an inductive approach to analysis of free text responses. Participant recruitment and data collection occurred between November 2021 and January 2024. Results Of the 40 clinicians trained to offer HPV self-testing, 12 primary care clinicians from six ethnically diverse primary care sites in Auckland completed an interview. ‘Positive reception’ was the strongest theme with clinicians reporting that overwhelmingly, participants were receptive to the HPV self-test offer. The four enabler themes were: ‘supportive practice systems’, ‘importance of the discussion’, ‘options for testing' and ‘specialised support and consistency’. Key challenge themes in implementing opportunistic self-testing were ‘competing demands’ and ‘communicating what it’s all about’. Of the 3,524 self-tested participants, 394 responded to the survey. Most (93%) found the amount of information they received about HPV self-testing ‘about right’ and 86% were comfortable in their decision to self-test. Considering their next cervical screening, more respondents preferred home-based self-testing options than self-testing at a clinic (46% versus 37%). Conclusion Offering the HPV self-test opportunistically to people due for screening when they visited their primary care provider for any reason was generally well received and feasible for clinic staff. The option to take kits home for sampling was an enabler of participation. Supportive systems and resources for clinicians will be important if opportunistic HPV self-testing is offered more widely in primary care, including further consideration of a central specialist team to follow-up and support home testing and participants with HPV detected results. Trial registration This study did not reach the ICJME or WHO criteria for clinical trial registration.

Background Māori, Pacific and Asian women in New Zealand have lower cervical-cancer screening rates than European women, and there are persistent inequities in cervical cancer outcomes for Māori and Pacific women. Innovative ways to address access barriers are required. New Zealand is transitioning to screening with human papillomavirus (HPV) DNA testing, which could allow women themselves, rather than a clinician, to take the sample. Internationally, self-sampling has been found to increase screening participation rates. The aim of this open-label community-based randomised controlled trial is to investigate whether self-sampling increases screening participation among un- and under-screened Māori, Pacific and Asian women in New Zealand. Methods/design We aim to invite at least 3550 un- or under-screened (≥5 years overdue) Māori, Pacific and Asian women (1050, 1250, 1250 respectively), aged 30–69 years, for screening. The three study arms are: usual care in which women are invited to attend a clinic for a standard clinician-collected cytology test; clinic-based self-sampling in which women are invited to take a self-sample at their usual general practice; and mail-out self-sampling in which women are mailed a kit and invited to take a self-sample at home. Women will be randomised 3:3:1 to the clinic and mail-out self-sampling groups, and usual care. There is also a nested sub-study in which non-responding women in all allocation groups, when they subsequently present to the clinic for other reasons, are offered clinic or home-kit self-sampling. The primary outcome will be the proportion of women who participate (by taking a self-sample or cytology test). Discussion This trial is the first to evaluate the effectiveness of mailed self-sampling in New Zealand and will be one of the first internationally to evaluate the effectiveness of opportunistic in-clinic invitations for self-sampling. The trial will provide robust evidence on the impact on participation proportions from different invitation approaches for HPV self-sampling in New Zealand un- and under-screened Māori, Pacific and Asian women. Trial registration ANZCTR Identifier: ACTRN12618000367246 (date registered 12/3/2018) https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=371741&isReview=true; UTN: U1111–1189-0531.