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HPV

Opportunities and challenges for human papillomavirus vaccination in China

Chao Zhaoa Gynaecology, Peking University People’s Hospital, Beijing, ChinaView further author information
,
Yun Zhaoa Gynaecology, Peking University People’s Hospital, Beijing, ChinaView further author information
,
Jingran Lia Gynaecology, Peking University People’s Hospital, Beijing, ChinaView further author information
,
Mingzhu Lia Gynaecology, Peking University People’s Hospital, Beijing, ChinaView further author information
,
Yujing Shib MRL Global Medical Affairs, MSD China, Shanghai, ChinaView further author information
&
Lihui Weic Department of Gynecology and Obstetrics, Peking University People’s HospitalCorrespondence[email protected]
ORCID Iconhttps://orcid.org/0000-0002-2478-8790View further author information
ORCID Icon
Article: 2329450 | Received 27 Nov 2023, Accepted 08 Mar 2024, Published online: 04 Apr 2024

ABSTRACT

Current estimates of the HPV infection rate in China vary by geographic region (9.6–23.6%), with two age peaks in prevalence in women ≤20–25 years of age and 50–60 years of age. HPV-16, 52 and 58 are the most commonly-detected HPV genotypes in the Chinese population. In China, five HPV vaccines are licensed and several others are undergoing clinical trials. Multiple RCTs have shown the efficacy and safety of the bvHPV (Cervarix), Escherichia coli-produced bvHPV (Cecolin), Pichia pastoris-produced bvHPV (Walrinvax), qvHPV (Gardasil) and 9vHPV (Gardasil-9) vaccines in Chinese populations, including two studies showing long-term efficacy (≥8 years) for the bvHPV and qvHPV vaccines. Real-world data from China are scarce. Although modeling studies in China show HPV vaccination is cost-effective, uptake and population coverage are relatively low. Various policies have been implemented to raise awareness and increase vaccine coverage, with the long-term aim of eliminating cervical cancer in China.

Introduction

Cervical cancer is the fourth most common cancer in women worldwide and nearly all cases are caused by chronic infection with the human papillomavirus (HPV).Citation1 In 2018, a global call to action toward the elimination of cervical cancer was announced by the World Health Organization (WHO).Citation2 This initiative aims to achieve the 90-70-70 targets by 2030, defined as 90% of girls fully vaccinated with the HPV vaccine by 15 years of age, 70% of women screened with a high-performance test two times per life by 35 and 45 years of age, and 90% of women identified with cervical disease receiving treatment and care. However, HPV vaccination population coverage in China is currently relatively low due to multiple factors including low public knowledge of HPV, limited supply, cost and because the vaccine is not currently included in the national immunization program. Therefore, reviewing and understanding the current situation for HPV vaccination in China is highly valuable.

More than 200 types of HPV have been identified to date and, of these, 15 have been associated with the development of cervical cancer [types 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68, 73 and 82].Citation1 Vaccination against HPV is a major preventative strategy for cervical cancerCitation1 and several vaccines are currently licensed for use based on efficacy and safety data from clinical trials.Citation3 Current HPV vaccines are described as bivalent (bvHPV – targeting HPV-16 and 18), quadrivalent [qHPV – targeting HPV-6, 11, 16 and 18] or 9-valent [9vHPV – targeting HPV-6, 11, 16, 18, 31, 33, 45, 52, and 58].Citation3

To date, the U.S. Food and Drug Administration (FDA) has licensed a bvHPV vaccine (AS04-HPV-16/18, Cervarix®, GSK), a qvHPV vaccine (Gardasil®, MSD), and a 9vHPV vaccine (Gardasil® 9, MSD).Citation4 These three vaccines plus an independently developed bvHPV vaccine (Cecolin, Xiamen Innovax Biotech Co, Ltd) are all included in the WHO List of Prequalified VaccinesCitation5 and have been approved by the China National Medical Products Administration (NMPA).Citation6 In addition, a second independently developed bvHPV vaccine (Walrinvax™, Shanghai Zerun Biotechnology Co., Ltd.) has been approved by the NMPA ().Citation6 Multiple additional HPV vaccines are currently under development in China, including a qvHPV vaccine, several 9vHPV vaccines, an 11vHPV vaccine, and a 14vHPV vaccine ().

Table 1. HPV vaccines currently approved in China.

Table 2. HPV vaccines under development in China.

In this article, we identify and review recent literature on HPV vaccination in China, with a focus on the epidemiology of HPV infection and the performance of HPV vaccines in Chinese populations. Furthermore, studies describing the barriers to HPV vaccination in China are reviewed and policies aimed at overcoming vaccine hesitancy are highlighted.

Literature search methodology

A narrative literature search was performed to identify recently published data on the epidemiology of HPV infection in China, the efficacy, effectiveness and safety of HPV vaccines in Chinese populations and the cost effectiveness of HPV vaccination in China. PubMed and Chinese-language databased were searched on 12 September 2023 and 3 January 2024, respectively, using the following search string: ((human papillomavirus[Title/Abstract] OR HPV[Title/Abstract]) AND (vaccine[Title/Abstract] OR vaccination[Title/Abstract])) AND (China[Title/Abstract] OR Chinese[Title/Abstract]). Articles published between January 2021 and December 2023 were reviewed for inclusion in this article. These dates were selected to avoid overlap with prior reviews of HPV vaccination and focus on the most recent data. The articles identified by literature searching were filtered manually by reviewing the titles and abstracts using the following inclusion criteria: (1) studies reporting data collected in China, (2) studies reporting epidemiology of HPV infection in China, (3) clinical studies reporting the efficacy, effectiveness and safety of HPV vaccines in Chinese populations, (4) real-world studies of HPV vaccination in China, (5) articles on HPV vaccination knowledge, attitudes and practices and (6) cost effectiveness studies. If multiple studies were identified for the same topic, the references were evaluated for scientific robustness and risk of bias and the highest quality evidence was selected (Supplemental Figure 1). Exclusion criteria included: (1) review articles, (2) clinical studies reporting low quality data (small patient numbers, single center studies, single region studies) (3) real-world studies not conducted in China. Additional relevant articles were identified from the bibliographies of the selected articles.

The prevalence of HPV infection and genotype distribution in Chinese women

In China, cervical cancer is the fourth most common cancer among women, with approximately 110,000 new cases and 60,000 associated deaths reported per year.Citation9 There has been year-on-year growth in the incidence and mortality of this disease, with the National Cancer Center of China reporting an 8.5% annual increase in incidence and a 5.4% increase in mortality between 2000 and 2016.Citation10 In addition, other cancers such as anal cancer, oropharyngeal cancer, penile cancer, vaginal cancer, laryngeal cancer, oral cancer, and vulvar cancer are also associated with HPV infection.Citation11

The HPV infection rate in Chinese women varies across different regions, with estimates ranging from 9.6% to 23.6%.Citation12–23 In general, these rates are high compared with the global rate of HPV infection.Citation24 In addition, studies in several regions of China have shown two age peaks in the prevalence of high-risk HPV infection; in younger women (around ≤20–25 years of age) and older women (around 50–60 years of age).Citation12,Citation17,Citation25

HPV-16 and −18 are the most commonly detected types of HPV infection in patients with cervical cancer in China, and are detected in as many as 69.1% of patients.Citation26,Citation27 However, non-HPV-16 or −18 infections are also commonly detected in patients with cervical cancer or cervical abnormalities.Citation28 Multiple recent studies conducted across China have demonstrated that HPV-16, −52 and −58 are the most prevalent HPV genotypes, both in women with cervical abnormalities and women undergoing routine cervical screening or physical examination.Citation12–14,Citation16,Citation21–23,Citation27,Citation29–36 Of note, the HPV-52/58 infection rate is higher in China compared with the global rate; for women with low-grade cervical lesions, the incidence of HPV-52/58 infection in China is 28.6% compared with 15.6% worldwide. Similarly, for women with high-grade cervical lesions, the incidence of HPV-52/58 infection is 33.3% versus 19.1% for China versus worldwide. For women with cervical cancer, HPV-52/58 infection is detected in 14.7% of cases in China compared with 7.4% worldwide.Citation27,Citation37

Clinical studies of HPV vaccines in China

Pivotal, international, randomized controlled trials (RCTs) have demonstrated the efficacy and safety of the bvHPVCitation38–40 qvHPVCitation41,Citation42 and 9vHPVCitation43 vaccines, including in subgroup analyses of participants from Asia who received the 9vHPV vaccine.Citation44

Several RCTs of bvHPV vaccines have been performed in China. In a phase II/III RCT of the bvHPV vaccine (Cervarix) in Chinese participants, 87.3% vaccine efficacy against HPV-16/18-associated cervical intraepithelial neoplasia (CIN)2+ was demonstrated up to Month 72 in the according-to-protocol cohort.Citation45 Moreover, no fatal events or vaccine-related serious adverse events (SAEs) or congenital abnormalities were reported in the vaccine group. Similarly, in a phase III RCT conducted at five sites in China, the Escherichia coli-produced bvHPV vaccine (Cecolin) was shown to be 100% efficacious against HPV-16/18-associated high-grade genital lesions and 97.3% efficacious against persistent HPV infection after 66 months of follow-up. No SAEs related to vaccination were reported in this study.Citation46 The Pichia pastoris-produced bvHPV vaccine (Walrinvax) has also been investigated in clinical trials in Chinese participants. In a phase I RCT in Chinese women aged 9–45 years, immune responses were elicited in 100% of participants and no SAEs were reported.Citation47 In addition, in a Phase III RCT conducted in China in females aged 18–30 years, efficacy for HPV-16/18-related CIN2+ was 78.6% after 48 months of follow-up.Citation6,Citation48

The qvHPV vaccine (Gardasil) has also been studied in clinical trials in Chinese participants. In an RCT conducted in Chinese males (9–15 years) and females (9–45 years), high antibody levels were observed for each of the four HPV types and seroconversion was >96%. The vaccine was well-tolerated, with no vaccine-related SAEs reported.Citation49 Furthermore, in a phase III RCT that included 3006 Chinese women, the qvHPV vaccine was 100% efficacious against HPV-16/18-related CIN2 or 3 and cervical cancer and 100% efficacious against HPV-6/11/16/18-related CIN1 over a 78-month follow-up. Efficacy against 6-month and 12-month persistent cervical infection was 91.6% and 97.5% at Months 30 and 78, respectively.Citation50 No vaccine-related SAEs were reported and pregnancy outcomes were similar between the vaccine and placebo groups and within normal ranges.Citation51 In a prospective open-label study conducted in China, the qvHPV vaccine also reduced the risk of high-grade squamous intraepithelial lesion recurrence after loop electrosurgical excision of CIN2+ disease. In this study, CIN2+ recurrence rates were ~12-fold higher in unvaccinated versus vaccinated women (OR = 12.25, 95% CI 1.919–79.492, p = .008).Citation52

A phase III open-label study conducted in China demonstrated that antibody responses to the 9vHPV vaccine (Gardasil-9) were non-inferior in participants aged 9–19 years and 27–45 years compared to those aged 20–26 years.Citation53 In this study, the vaccine was well-tolerated and there were no vaccine-related SAEs, discontinuations due to AEs or deaths. A 9vHPV vaccine produced in E. coli is also under development in China (Xiamen Innovax Biotech Co., Ltd). In a phase I clinical trial, this vaccine was shown to be well-tolerated and immunogenic.Citation8

In a meta-analysis of 11 RCTs and 4 follow-up studies including Chinese patients, HPV vaccines were shown to reduce the incidence of CIN1+ and CIN2+. The risk of SAEs was comparable between the vaccinated and placebo arms.Citation54

Long-term efficacy and safety of HPV vaccines

Multiple studies have shown long-term efficacy (after a follow up of ≥8 years) for HPV vaccines in preventing HPV-related disease, including two studies that were conducted in China (). For the bvHPV vaccine (Cervarix), two long-term follow-up studies (10–11 years) in patients in Costa Rica and Finland demonstrated high efficacy against HPV-16/18-associated diseaseCitation56,Citation57 and no vaccine-related SAEs were reported.Citation56 Four studies have evaluated the efficacy and safety of the qvHPV vaccine (Gardasil) in participants worldwide. These studies followed the participants for 10 to 14 years and reported 100% efficacy against HPV-associated disease.Citation57–59,Citation61 Two of these studies reported long-term safety data, with no vaccine-related SAEsCitation59 or new safety eventsCitation61 occurring. Finally, no new cases of HPV-16/18/31/33/45/52/58-related high-grade cervical dysplasia were observed in participants from Denmark, Norway and Sweden during an 8-year follow-up to the pivotal 9vHPV (Gardasil-9) efficacy study.Citation63

Table 3. Long-term safety and efficacy of HPV vaccines.

In China, long-term studies have been conducted for the bvHPV vaccine (Cervarix) and the qvHPV vaccine (Gardasil). In a 10-year follow-up study of Cervarix in 1791 Chinese women, vaccine efficacy was 97.2%, 94.8% and 90.5% against HPV-16/18-associated atypical squamous cells of undetermined significance, CIN1+ and CIN2+, respectively.Citation55 There were also no vaccine-related SAEs, immune-mediated diseases or adverse pregnancy outcomes reported. In an eight-year follow-up study of Gardasil in 368 Chinese female participants, vaccine efficacy against HPV-16/18-associated CIN, vulval intraepithelial neoplasia or vaginal intraepithelial neoplasia was 100%.Citation60

Real-world data for HPV vaccines

Real-world effectiveness

Multiple real-world studies have demonstrated the effectiveness of HPV vaccines. However, there is currently a lack of real-world data on the effectiveness of HPV vaccines in Chinese populations. A comprehensive global meta-analysis that included data from over 60 million people following vaccination with either bv or qvHPV vaccines demonstrated a substantial impact of vaccination on rates of HPV infections and HPV-associated disease. Notably, 51% and 31% reductions in the incidence of CIN2+ among females aged 15–19 years and 20–24 years, respectively, were observed 5–9 years after vaccination.Citation64 Similarly, a systematic review of global real-world data for qvHPV vaccination revealed a significant reduction in the prevalence of HPV type 6/11/16/18 infection in females aged 14–19 years and a reduction in genital infections and HPV-related disease outcomes following the introduction or expansion of HPV vaccination programs.Citation65

Several real-world studies have specifically shown that HPV vaccination programs offer protection against the development of CIN2+ or cervical cancer. For example, vaccination with the bvHPV (Cervarix) vaccine at age 14–17 years resulted in a reduction in the detection of CIN2+ from 6% to 3% during routine cervical screening at age 24–25 years in women in the UK (estimated vaccine effectiveness of 87%).Citation66 Similarly, in a systematic review of real-world studies conducted in Canada, vaccination with the qvHPV vaccine was associated with an up to 86% reduction in the incidence of CIN2+,Citation67 and in Denmark, a 73% reduction in the incidence of CIN2/3 was observed in females vaccinated with the qvHPV vaccine compared with non-vaccinated females (1993–1994 birth cohort).Citation68 In a real-world study conducted in the USA, there was a 72% decrease in the proportion of CIN2+ attributable to HPV16/18 in women who had received a HPV vaccine more than 48 months before their diagnosis of CIN2+.Citation69 In Sweden, the qvHPV vaccine was associated with an 88% and 53% reduction in the risk of cervical cancer among women who had been vaccinated before the age of 17 years or from 17–30 years, respectively.Citation70

Real-world safety

The safety profile of HPV vaccinations observed in the pivotal clinical trials has been confirmed in several real-world studies.Citation71,Citation72 The HPV vaccines are mainly associated with non-serious AEs, with observational data from the USA showing dizziness and syncope being among the most commonly reported events.Citation73 In China, the safety of the HPV vaccines was confirmed in a surveillance study, where the rates of vaccine-related reactions were only 4.00 and 3.46 per 100,000 doses following administration of the qvHPV and 9vHPV vaccines, respectively.Citation74 Similarly, in a post-marketing surveillance study of the 9vHPV vaccine in China, no safety signals were observed and no stillbirths were reported among 41,609 women who received the vaccine between 2019 and 2021.Citation75

Current status of HPV vaccine use in China

In China, HPV vaccination is voluntary and self-paidCitation76 and is administered by the Chinese Center for Disease Control and Prevention. However, HPV vaccination is not included in the national immunization program and supply remains limited and costly.Citation77 In addition, HPV vaccines are only approved for females, with RCTs in males ongoing. The vaccine is also only approved for the prevention of cervical cancer, precancerous lesions and HPV persistent infection, and not for other HPV-related diseases. As a result of these limitations, population coverage is currently low, with only 3% of females vaccinated three years after HPV vaccine licensure in China.Citation78 In addition, as of 2022 there was no HPV vaccination program for males, which limits the ability to achieve herd immunity.Citation79

Several policies have been implemented in order to increase vaccination rates. These include the China Action Plan for Accelerated Elimination of Cervical Cancer (2023–2030),Citation80 and free HPV vaccination pilot studies in some provinces.Citation76,Citation81 For example, driven by the Healthy City innovation pilot policy, multiple cities in China are carrying out government-led HPV vaccination programs based on local requirements and conditions. Cities participating include Ordos City in Inner Mongolia, Xiamen City in Fujian Province, Jinan City in Shandong Province, Wuxi City in Jiangsu Province, and Chengdu City in Sichuan Province.Citation82–87 The majority of these cities are utilizing a two-dose vaccination schedule for girls in middle school (aged 13–14 years). In addition, it has been reported that six Chinese provinces have decided to provide free vaccinations for eligible women. Recent years have also seen the publication of several technical papers, including “Expert consensus on immunological prevention of human papillomavirus‐related diseases,”Citation88 “Chinese experts consensus on the clinical application of HPV vaccine”Citation89 and “China Tertiary Prevention for Cervical Cancer (Blue Book).” Multiple Chinese-language treatment guidelines and consensus statements have also been published, all of which emphasize the effectiveness and safety of the HPV vaccine.Citation90–94 Multiple HPV vaccines are also currently under development in China ().

HPV vaccination knowledge, attitudes and practices

Since the introduction of the HPV vaccine programs in China, knowledge, attitudes and practices toward HPV vaccination have been studied extensively. Multiple recent studies have indicated that low levels of knowledge of cervical cancer and the HPV vaccine persist among young adults and also among the mothers of daughters who are eligible for the vaccine.Citation95–100 One Chinese-language systematic review article published in 2022 estimated that the total awareness rate of HPV among the Chinese population is 65.9%, with high variability by geographic region.Citation101 Another study of 13,914 child-bearing women in China conducted between 2009 and 2016 revealed that only 24.1% had heard of the HPV vaccine and of these 76.1% reported willingness to receive the vaccine; reasons for lack of intention to vaccinate included low knowledge of the risks of HPV infection (52.7%) and concerns around safety (30.3%) and efficacy (31.7%).Citation102 Levels of knowledge can also vary among healthcare professionals (HCPs), with a study conducted in Shenzhen revealing that HPV and HPV vaccine knowledge varied between different types of medical institutions, with the lowest scores achieved by private hospitals.Citation103 The authors concluded that private clinics, non-physician HCPs and HCPs with a low annual income were most in need of further education and training. A cross-sectional study in Shanghai, Guangzhou and Shenzhen also reported that only 30% of HCPs were frequently recommending HPV vaccination to patients.Citation104

Despite low levels of knowledge around HPV vaccines, a high willingness toward vaccination has been reported among Chinese females, both of themselves (92.8–93.6%) and their daughters (83.3%).Citation98,Citation99,Citation105 Although, it should be noted that in several online surveys discrepancies between high HPV vaccine intent and low uptake have been observed.Citation106,Citation107 Lower maternal education, rural residence, inadequate knowledge of HPV or the HPV vaccine, costs of the vaccine, and household income have frequently been identified as barriers to HPV vaccination.Citation108–111 In contrast, facilitators of vaccination included vaccine information from reliable sources, a vaccination program arranged by schools and the government, and recommendations from HCPs.Citation109

The introduction of the 9vHPV vaccine may have increased interest in HPV vaccination amongst the Chinese population. For example, in an online cross-sectional survey of mothers of primary school-aged children in China, over one third (41.4%) expressed a preference for their daughter to be vaccinated with the 9vHPV vaccine.Citation105 Similarly, in a nationwide, cross-sectional study of 15,967 female healthcare workers, 58.6% preferred to receive the 9vHPV vaccine.Citation112 Moreover, after the expansion of the indication for the 9vHPV vaccine in China to women aged 9–45 years, vaccine non-coverage decreased from 83.3% to 57.6% in a study conducted in Wuhan.Citation12 There is also a high willingness to pay for the 9vHPV vaccine in China, as evidenced by a nationwide online survey among 15,969 female healthcare workers in which 66.2% of respondents indicated willingness to pay 800–1200 RMB for HPV vaccination.Citation113 However, when China’s provinces (including autonomous regions and municipalities) provide free HPV vaccination for adolescent girls, they usually include only the bvHPV or qvHPV vaccines, as they have a lower cost compared to the 9vHPV vaccine. In addition, the increased demand and preference for the 9vHPV vaccine among Chinese women is coupled with supply issues. These factors can cause a barrier to vaccination and lead to vaccination delays. However, efforts are being made to improve the supply of the 9vHPV vaccine in China.

Cost-benefit of HPV vaccination

Several studies have indicated that HPV vaccination is likely to be cost-effective in China. However, it should be noted that there is no established cost-effectiveness threshold used in China, and various thresholds are utilized. For example, the cost-effectiveness of HPV vaccination was assessed nationally and in 31 provinces in China in 2019 using the Papillomavirus Rapid Interface for Modeling and Economics (PRIME) model.Citation114 The results showed that a total of 12,545 cervical cancer cases and 5109 deaths could be averted by use of the bvHPV and qvHPV vaccines. This increased to 28,140 cases and 11,459 deaths averted after use of the 9vHPV vaccine. Overall, inclusion of HPV vaccination in the immunization program was considered to be cost-effective at a national level and in most provinces, with a maximum cost of $18,165 USD per disability-adjusted life-year (DALY) gained which was below the threshold for cost effectiveness of three times GDP per capita ($30,837 US).Citation114 Furthermore, a systematic review of modeling studies indicated that the HPV vaccine was generally cost-effective in China, across 14 studies using various methodologies and thresholds for cost-effectiveness.Citation115 When specifically considering women who have previously been treated for HPV-related cervical precancerous lesions, a three-dose qvHPV vaccine was predicted to be highly cost-effective in China, with an Incremental Cost-Effectiveness Ratio (ICER) of $27,785USD per quality-adjusted life year (QALY) gained.Citation116 In a model-based economic evaluation, the use of an optimal pathway that integrates tailored optimal strategies for different birth cohorts is predicted to eliminate cervical cancer in China by the late 2040s and would result in savings in net economic costs, with a discounted ICER of $-339 (95% CI −687 to −79) per QALY.Citation117 A Chinese-language systematic review of 15 pharmacoeconomic studies concluded that HPV vaccination plus cervical cancer screening is more cost effective than screening alone, although the study found variability in cost-benefit between the different types of HPV vaccination.Citation118

Expert commentary

Cervical cancer is the fourth most common cancer in women. Cervical cancer in China accounts for 18% of new cases and 17% of cervical cancer related deaths globally. In this article we reviewed the epidemiological characteristics of HPV infection in China, summarized the results of randomized controlled trials of HPV vaccines conducted in China, and evaluated available data from real-world research and cost-effectiveness studies. Overall, our review confirms that vaccination with HPV vaccine is the most effective way to prevent cervical cancer in China.

In order to protect and promote women’s health, China has responded to the WHO’s call to accelerate the elimination of cervical cancer and has taken numerous measures to promote HPV vaccination, including releasing specific plans to eliminate cervical cancer, promulgating relevant guidelines and consensus statement, and waiving or subsidizing the cost of HPV vaccination for teenagers in pilot areas. The WHO’s current position paper on HPV vaccination schedule states that a single-dose schedule, referred to as an alternative, off-label single-dose schedule, can provide comparable efficacy and durability of protection to a two-dose regimen.Citation119 Once the China NMPA approves a single-dose indication for the HPV vaccine, we predict it will promote increased vaccination uptake and increase the vaccination rate. However, more Chinese research data are still required to confirm the long-term effectiveness of single-dose HPV vaccines. At the same time, in addition to the five HPV vaccines already on the market, China is developing multiple novel HPV vaccines, with several candidate vaccines currently entering phase 3 trials. The successful launch of locally developed HPV vaccines may help to solve supply problems and increase the vaccination rate. These measures will bring great opportunities for HPV vaccination in China.

However, despite current efforts and initiatives, HPV vaccination in China still faces many challenges. For example, the HPV vaccination rate in China is still very low, and there is also a problem of insufficient vaccine supply. In addition, HPV vaccines have not yet been included in the national immunization program and are paid for out-of-pocket, representing a significant expense for most Chinese people. Public awareness of HPV-related diseases and HPV vaccines is also insufficient. These specific challenges are superimposed against a large national population with an uneven distribution of economic development. In areas of China with limited health resources, strong government support is required to promote HPV vaccination. In summary, there is a need to continue to vigorously strengthen health education for the Chinese population, expand the production of HPV vaccines, and promote the application of HPV vaccines in China.

In conclusion, in China, a lot of work remains to meet the goal of eliminating cervical cancer. In developing strategic plans to eliminate cervical cancer, the prevalence of HPV infection and cervical cancer should be continuously monitored to assess the effectiveness of preventive measures, including HPV vaccination. Since China has a large population and the cost of the HPV vaccine is relatively high for most Chinese citizens, the government should also consider economic cost-effectiveness when funding HPV vaccination programs and consider the accessibility and equity of HPV vaccination for women of an appropriate age across different geographic regions.

Author contributions statement

Chao Zhao conducted the literature search and interpreted the findings, wrote sections of the initial draft and provided substantial intellectual contributions to the subsequent drafts. Yun Zhao conducted the literature search, interpreted the findings and provided substantial intellectual contributions during revision of manuscript drafts. Jingran Li, and Mingzhu Li interpreted the findings and provided substantial intellectual contributions during the revision of manuscript drafts. Yujing Shi conceived and planned the review, conducted the literature search, wrote sections of the initial draft and provided substantial intellectual contributions during revision of manuscript drafts. Lihui Wei conceived and planned the review, interpreted the findings and provided substantial intellectual contributions during revision of manuscript drafts. All authors reviewed and approved the final submitted version and agree to be accountable for all aspects of the work after publication.

Acknowledgments

Medical writing support was provided by Stephanie Carter on behalf of Rude Health Consulting Limited and funded by MSD China.

Disclosure statement

Yujing Shi is employee of MSD China. All the other authors have no conflict of interest to declare.

Correction Statement

This article has been corrected with minor changes. These changes do not impact the academic content of the article.

Additional information

Funding

Medical writing support was funded by MSD China.

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