Substantial increases in cervical cancer inequalities worldwide without enhanced

# Substantial increases in cervical cancer inequalities worldwide without enhanced human papillomavirus vaccination and screening efforts: a global modelling study *The Lancet 2026* Articles Substantial increases in cervical cancer inequalities worldwide without enhanced human papillomavirus vaccination and screening efforts: a global modelling study Marc Brisson, Mélanie Drolet*, Guillaume Gingras*, Jean-François Laprise, Éléonore Chamberland, Laia Bruni, Andrée-Anne Sabourin, Élodie Bénard, Cathy Ndiaye, Ruanne V Barnabas Summary Lancet 2026; 407: 1726–37 Background To reduce worldwide inequalities, WHO made a call for action to eliminate cervical cancer by vaccinating See Comment page 1662 90% of girls, screening 70% of women, and treating 90% of pre-cancers and cancers. Low-income countries and *Joint second authors lower-middle-income countries (LMICs) are far from reaching the WHO elimination targets compared with high- income countries (HICs). Using mathematical modelling, we aimed to examine the following questions: (1) Are we Centre de recherche du CHU de Québec - Université Laval, on the path to cervical cancer elimination in LMICs and HICs? (2) What is the potential evolution of inequalities in Québec, QC, Canada cervical cancer between LMICs and HICs under current screening and vaccination coverage? And (3) what would be (Prof M Brisson PhD, the potential impact of enhanced prevention strategies (ie, human papillomavirus [HPV] vaccination and screening) M Drolet PhD, G Gingras PhD, J-F Laprise PhD, on inequalities and cervical cancer elimination? É Chamberland MSc, A-A Sabourin MSc, Methods We used the HPV-ADVISE model to project the age-standardised cervical cancer incidence in 67 LMICs and É Bénard PhD); Département de 42 HICs for dierent HPV vaccination and screening scenarios. For the status quo scenario (of HPV vaccination and médecine sociale et préventive, Université Laval, Québec, QC, screening), we modelled the vaccine used, the start year of vaccination, vaccination coverage, and the target population Canada (Prof M Brisson, for each country, and current screening coverage in LMICs and HICs. We examined five enhanced prevention A-A Sabourin); Saw Swee Hock strategies for LMICs: (1) status quo for all countries using the nine-valent vaccine; (2) reaching 90% vaccination School of Public Health, coverage for girls-only routine vaccination; (3) reaching the WHO vaccination, screening, and treatment elimination National University Singapore, Singapore (Prof M Brisson); targets; (4) adding routine vaccination for boys with 90% coverage (ie, universal routine vaccination) and multi-age- Cancer Epidemiology Research cohort vaccination; and (5) reaching the WHO elimination targets combined with universal routine and multi-age- Program, Catalan Institute of cohort vaccination. Inequalities were measured as the age-standardised cervical cancer incidence (ASR) ratio between Oncology—IDIBELL, LMICs and HICs (RR =ASR /ASR ). L’Hospitalet de Llobregat, LMIC/HIC LMICs HICs Barcelona, Spain (L Bruni MD); Centro de Investigación Findings Under the status quo, the model projected that cervical cancer incidence in LMICs would decrease by only 23% Biomédica en Red: while HICs would reach elimination by 2048 (age-standardised cervical cancer incidence 50% by 2010). During 2023–24, the mean coverage (eg, Canada, USA, UK, Australia, and Sweden)6,35–38 vaccination coverage in HICs was 70%. In contrast, 60% of using projections for the USA and Canada only LMICs included in the study had an HPV vaccination (vaccination coverage of 85%), and the second analysis to programme. During 2023–24, the mean vaccination examine inequalities between LMICs and HICs assuming coverage in the 67 LMICs was 38% (appendix 2 pp 10–12). that all HICs included in the analysis reach 90% vaccination For the status quo of screening in LMICs, we used the coverage. Furthermore, we examined two less optimistic proportion of women never screened (91–95%) from our scenarios assuming that LMICs reach 80% vaccination four core LMIC models. These proportions are similar to coverage6 and that universal routine vaccination is the 2021 estimates from a global systematic review for introduced without MAC vaccination. low-income countries (LICs) (89% [95% CI 87–90%]) and LMICs (91% [90–92]), showing a very small proportion of Outcomes women ever screened (using any screening test).5 For the The main population-level impact outcome was the status quo of screening in HICs, we used the proportion age-standardised cervical cancer incidence per of women not screened in the past 5 years in the USA and 100 000 women-years (2015 world standard population).39 Canada core models (12–30%), which is also similar to the We estimated the age-standardised cervical cancer 2021 estimates from a global systematic review for HICs incidence for all HICs and LMICs, and four LMIC (23% [12–34]).5 Second, we modelled the following regions (sub-Saharan Africa; Latin America and the enhanced prevention strategies in LMICs, starting Caribbean; South Asia and Europe and central Asia; and in 2025: (1) using the nine-valent vaccine for all countries east Asia and Pacific). Using age-standardised cervical under the status quo (no change in the population targeted cancer incidence over time, we estimated the timing of and vaccination coverage, no change in screening); cervical cancer elimination (defined as age-standardised (2) reaching 90% vaccination coverage for girls-only cervical cancer incidence less than four cases per routine vaccination (WHO vaccination target, no change 100 000 women-years). We used the absolute number of in screening); (3) reaching the WHO elimination targets4 cervical cancers over time (yearly and cumulated over (girls-only vaccination coverage of 90%, screening 100 years) as our secondary population-level impact coverage of 70%, and treatment of pre-cancers and cancers outcome. To estimate the number of cervical cancers, we at 90%); (4) adding routine vaccination for boys and a used population projections over time from the UN 1-year MAC vaccination strategy for girls and women up World Population Prospects (2022 revision; appendix 2 to the age of 25 years and boys, and men up to the age of p 6).40 Hence, the model projections include both herd 20 years with 90% vaccination coverage (universal routine eects and population change over time. and MAC vaccination, no change in screening);31 and We used the ratio of the age-standardised cervical cancer (5) reaching the WHO elimination targets combined with incidence (ASR) in LMICs and HICs as our main universal routine and MAC vaccination. inequality outcome (RR =ASR /ASR ). In LMIC/HIC LMICs HICs We made the following assumptions: 90% vaccination addition, we generated cartograms to illustrate the coverage is reached in 2025; the two-valent, four-valent, evolution of inequalities in the number of cervical cancers and nine-valent vaccines provide 98% ecacy and in LMICs and HICs. Cartograms were generated using lifelong duration of protection against vaccine types and the Dougenik method,41 which employs a rubber-sheet the two-valent and four-valent vaccines provide no cross- distortion technique to resize geographical areas protection against non-vaccine types; and the nine-valent proportionally to the number of cervical cancers. This vaccine is used for all enhanced strategies. We used 2025 approach visually amplifies countries with a higher as the year of introduction for the enhanced strategies. number of cervical cancers. In the sensitivity analyses, we Similarly to the study by Brisson and colleagues,4 we examined the impact of using alternative inequality used an optimistic scale-up scenario. If vaccination measures, which were the ratio of the age-standardised scale-up is slower than modelled, this would delay the cervical cancer incidence in LMICs and HICs unweighted projected timing of elimination and reductions in by the population size of each country (unweighted RR LMIC/ cervical cancer incidence, but it would not aect whether = mean ASR of the 67 LMICs/mean ASR of the HIC or not elimination can be achieved or long-term cervical 42 HICs), and the ratio of the crude cervical cancer cancer incidence. In a sensitivity analysis, we examined a incidence in LMICs and HICs, which considers less optimistic scale-up scenario in which enhanced population projections over time.40 strategies are implemented in 2030. The upper age of For all outcomes, we used the mean of the 50 parameter MAC vaccination was based on the most ecient MAC sets. We used a 100-year time horizon to capture the strategy identified in the study by Bénard and colleagues.31 entire population-level impact of vaccination and Because approximately 30% of HICs included in the screening strategies.4,9,10 We reported our methods and analysis had vaccination coverage less than 60% results according to HPV-FRAME, which is a consensus- between 2023 and 2024, we performed two sensitivity based framework for HPV modelling analyses (appendix 2 analyses: the first to examine inequalities between LMICs pp 13, 14).42 Articles over time between HICs and LMICs would lead to a four-fold increase in inequalities (from RR =3 in 2022 LMIC/HIC to 12 in 2105). Switching to the nine-valent vaccine in all LMICs, keeping the status quo in terms of the targeted population and vaccination and screening coverage, is projected to have a minimal impact on cervical cancer incidence and inequalities between LMICs and HICs. 30 To have an impact on both cervical cancer incidence and inequalities, high routine vaccination coverage of 25 girls is required (figure 1; appendix 2 pp 15–17). Reaching 90% routine vaccination coverage of girls in LMICs would 20 substantially reduce age-standardised cervical cancer incidence by the end of the century (87% reduction, three cases per 100 000 women-years in 2105), leading to elimination and slightly reducing inequalities between LMICs and HICs (RR =2). However, cervical cancer LMIC/HIC elimination in LMICs would occur in 2094, approximately 5 45 years after HICs, and inequalities would increase to seven-fold by 2065 before decreasing again. Inequalities between LMICs and HICs are projected to increase up to 2065 because HICs started vaccination earlier with a higher coverage. It would take 20–40 years before the impact of increased vaccination coverage in LMICs could be observed in vaccinated cohorts. Adding universal routine and MAC vaccination would further reduce the long-term age-standardised cervical cancer incidence (93% reduction, two cases per 100 000 women-years in 2105; figure 1; appendix 2 pp 15–17). The strategy would also accelerate cervical cancer elimination (in 2080, approximately 30 years after HICs) and lead to near equality between HICs and LMICs by the end of the century (RR ≈1). However, LMIC/HIC there would still be a substantial rise in inequalities until 2055 given the later introduction of HPV vaccination in LMICs versus in HICs. Enhanced Figure 1: Projected population-level impact of different human papillomavirus (known as HPV) vaccination vaccination-only strategies are not expected to produce and screening strategies on cervical cancer incidence (A) and inequalities (B) between HICs and LMICs over substantial reductions in cervical cancer before more time than 20 years until the first vaccinated cohorts reach the The lines are the mean result of model projections using 50 parameter sets. The elimination threshold is less than age of cervical cancer diagnosis. four cervical cancers per 100 000 women-years. Inequality is measured as the ratio of the age-standardised cervical cancer incidence in LMICs and HICs. HIC=high-income country. LMIC=low-income and lower-middle-income It is projected that screening must be implemented in countries. *Includes five LMICs (Bhutan, Bolivia, Cameroon, Cape Verde, and Mongolia) with universal vaccination addition to vaccination to substantially accelerate declines in the status quo. in cervical cancer incidence in LMICs and limit the Role of the funding source temporary rise in inequalities between HICs and LMICs by The funders of the study had no role in study design, preventing cervical cancers among older women (eg, girls data collection, data analysis, data interpretation, or and women older than the target age of vaccination or who writing of the report. were infected before vaccination; figure 1; appendix 2 pp 15–17). In the long term, reaching the WHO elimination Results targets would lead to similar age-standardised cervical Under the status quo of HPV vaccination and screening, cancer incidence (two cases per 100 000 women-years the model projected that the age-standardised cervical in 2105), inequalities ratio (RR ≈1), and timing of LMIC/HIC cancer incidence in LMICs would decrease only slightly elimination (in 2079, approximately 30 years after HICs) as within the next century, from 24 cases per 100 000 women- a universal routine and MAC vaccination strategy. However, years in 2022 to 18 cases per 100 000 women-years in 2105. reaching the WHO elimination targets would accelerate Conversely, HICs would reach elimination by 2048 (age- declines in cervical cancer incidence and inequalities and standardised cervical cancer incidence 10 000 for the second dose with universal routine findings and comparisons between regions. We examined vaccination in Canada).17,31 Our analysis also showed that alternative inequality measures, which produced similar the NNV of adding boys and men in LMICs was low (NNV results. To account for changes in demography, we also approximately 500) compared with other uses of HPV projected the absolute number of cervical cancers and the vaccines in HICs.17,52 The proposed enhanced HPV crude age-standardised cervical cancer incidence in HICs vaccination strategies have also consistently been shown to and LMICs over time. Fourth, conservatively, we used be highly cost-eective, and are thus considered an 42 HICs as our comparison group and assumed they excellent use of scarce resources.2–4,9,31 Although these would not have increases in vaccination coverage. strategies could seem optimistic, they are also feasible as However, we performed sensitivity analyses that restricted several LMICs have introduced enhanced vaccination HICs to those that have reached high vaccination coverage strategies (eg, five LMICs introduced universal vaccination (eg, USA, Canada, UK, Australia, and Sweden) or assumed in 2024) and many LMICs have reached very high routine that all HICs reach 90% vaccination coverage. These vaccination coverage (eg, Bhutan, Tanzania, Uganda, and sensitivity analyses show the extreme inequalities that Burkina Faso).6 would occur between LMICs and high-coverage HICs It is important to note that increasing screening and without enhanced preventon strategies (under the status treatment would substantially accelerate declines in quo, the age-standardised cervical cancer incidence would cervical cancers, deaths, and inequalities (vs vaccination be up to 45-fold higher in LMICs compared with HICs by alone). Finally, our findings illustrate the profound impact the end of the century). Finally, we conducted sensitivity universal vaccination combined with reaching WHO analyses on the timing of the enhanced prevention screening targets can have on cervical cancer elimination strategies. For most scenarios, we used 2025 as the year of and inequalities. Eliminating inequalities in cervical introduction to show, under the most optimistic cancer incidence would importantly eliminate the assumption possible, how cervical cancer incidence and accompanying high morbidity and mortality for middle inequalities can evolve under the enhanced prevention aged women with cervical cancer. The global strategy to strategies. In the sensitivity analyses, we have shown that a eliminate cervical cancer was adopted by the 194 member slower scale-up with an introduction of enhanced states during the 2020 World Health Assembly; hence, all prevention strategies in 2030 would delay the timing of nations have committed to eliminate cervical cancer as a cervical cancer elimination and reduction in inequalities in public health problem by achieving high vaccination and LMICs, but the long-term projections in cervical cancer screening coverage. This Article clearly highlights the incidence and inequalities would remain the same. The consequences of not introducing the enhanced strategies results clearly show that enhanced prevention strategies in terms of inequalities and preventable cervical cancers with high coverage must be implemented as soon as during the next century and, thus, can be used as a tool to possible in LMICs as, even under the most optimistic support further engagement and investment. Nonetheless, assumptions, there will be a delay before reductions in it is important to acknowledge the persistent challenges of inequalities between LMICs and HICs would be observed. budget constraints and competing health priorities when The following limitations should be considered when implementing large-scale strategies such as universal interpreting the projections of our study. First, we used routine and MAC vaccination and increasing screening the WHO elimination target of vaccination coverage uptake in LMICs. of 90%, mirroring the coverage of other vaccines. In 2023, Our modelling study has several strengths. First, we about 90% of infants worldwide received at least one dose used our HPV-ADVISE models, which have been of diphtheria-tetanus-pertussis (DTP3) vaccine and extensively peer-reviewed,4,9,10,16–21 and used to inform 80% at least one dose of measles-containing vaccine.54 country-specific and global HPV vaccination policy,8,24-29 Given that very few LMICs and HICs have been able to Articles reach 90% vaccination coverage, we did a sensitivity empirical data used for calibration and validation are available in analysis with 80% vaccination coverage. We have shown appendices 1 and 2. that 80% and 90% universal vaccination coverage are Acknowledgments projected to produce similar reductions in cervical cancer. This study was funded by the Canada Research Chairs Program Tier 1 and the Canadian Institute of Health Research (grant numbers: Second, we excluded from our analysis countries from FDN-143283, GLB-192242, and PJT-195981). This study was supported by North Africa and the Middle East. Nonetheless, the Fonds de recherche du Québec through the research centre grant for the countries included in our analysis represent the CHU de Québec-Université Laval Research Center (reference: approximately 89% and 94% of the total population living 30641). This study was enabled, in part, by support provided by Calcul Québec (https://www.calculquebec.ca) and the Digital Research Alliance in LMICs and HICs in 2025, respectively.33 We also of Canada (https://www.alliancecan. ca). excluded upper-middle-income countries from our References analysis because this group is very heterogeneous in 1 International Agency for Research on Cancer. Globocan 2022. terms of screening and vaccination, and their cervical Estimated number of new cases and deaths in 2022, cervix uteri, cancer incidence generally falls within the range of females, all ages. https://gco.iarc.fr/today/home (accessed April 8, 2024). LMICs and HICs. Third, we did not model all possible 2 Fesenfeld M, Hutubessy R, Jit M. Cost-eectiveness of human HPV vaccination strategies. For example, we did not papillomavirus vaccination in low and middle income countries: examine girls-only routine vaccination with MACs, a systematic review. Vaccine 2013; 31: 3786–804. although we have previously shown that such a strategy 3 Jit M, Brisson M, Portnoy A, Hutubessy R. Cost-eectiveness of female human papillomavirus vaccination in 179 countries: could be highly ecient.31 Adding MACs to girls-only a PRIME modelling study. Lancet Glob Health 2014; 2: e406–14. vaccination would have a similar impact as adding MACs 4 Brisson M, Kim JJ, Canfell K, et al. Impact of HPV vaccination and to universal vaccination as it would accelerate reductions cervical screening on cervical cancer elimination: a comparative modelling analysis in 78 low-income and lower-middle-income in age-standardised cervical cancer incidence and countries. Lancet 2020; 395: 575–90. inequalities, but would not have an eect on long-term 5 Bruni L, Serrano B, Roura E, et al. Cervical cancer screening cervical cancer incidence or inequalities (appendix 2 p 21). programmes and age-specific coverage estimates for 202 countries and territories worldwide: a review and synthetic analysis. In conclusion, worldwide inequalities between HICs Lancet Glob Health 2022; 10: e1115–27. and LMICs in cervical cancer are projected to increase 6 WHO. Human Papillomavirus (HPV) vaccination coverage. https:// dramatically without enhanced HPV vaccination and immunizationdata.who.int/pages/coverage/hpv.html (accessed Sept 7, 2025). screening eorts and the requisite investment in these 7 Bruni L. Updated estimates of global HPV vaccination coverage evidence-based strategies. Implementation research to and cervical screening. EUROGIN; March 16–19, 2025. adapt the available prevention tools to the specific 8 WHO. Global strategy to accelerate the elimination of cervical contexts of countries and political will are urgently cancer as a public health problem. World Health Organization, 2020. needed. There are highly eective and cost-eective tools 9 Drolet M, Laprise J-F, Martin D, et al. Optimal human available to eliminate cervical cancer as a public health papillomavirus vaccination strategies to prevent cervical cancer in problem in all countries, but the inequitable use and low-income and middle-income countries in the context of limited resources: a mathematical modelling analysis. Lancet Infect Dis distribution of these tools remain major barriers to 2021; 21: 1598–610. achieving this goal. Our modelling study clearly identified 10 Bénard É, Drolet M, Laprise J-F, et al. Potential population-level strategies to considerably decrease inequalities. Several eectiveness of one-dose HPV vaccination in low-income and middle-income countries: a mathematical modelling analysis. examples of global public health strategies have Lancet Public Health 2023; 8: e788–99. successfully turned the tide for infectious diseases 11 Malagón T, Joumier V, Boily M-C, Van de Velde N, Drolet M, including HIV and vaccine-preventable diseases of Brisson M. The impact of dierential uptake of HPV vaccine by sexual risks on health inequalities: a model-based analysis. Vaccine childhood, providing a roadmap for stakeholder 2013; 31: 1740–47. engagement and commitment to interventions at scale. 12 Malagón T, Drolet M, Boily M-C, Laprise J-F, Brisson M. Changing inequalities in cervical cancer: modeling the impact of vaccine Contributors uptake, vaccine herd eects, and cervical cancer screening in the MB designed the study and led the overall data interpretation. MD and post-vaccination era. Cancer Epidemiol Biomarkers Prev 2015; MB drafted the Article. GG did the analysis and produced the figures. 24: 276–85. J-FL, A-AS, and ÉB collected the data. J-FL, A-AS, and ÉC did the model 13 Spencer JC, Brewer NT, Coyne-Beasley T, Trogdon JG, projections. LB provided vaccination coverage data. GG, J-FL, and EC Weinberger M, Wheeler SB. Reducing poverty-related disparities in verified the underlying data reported in the manuscript. All authors cervical cancer: the role of HPV vaccination. interpreted the modelling results and critically revised the manuscript Cancer Epidemiol Biomarkers Prev 2021; 30: 1895–903. for scientific content. MD, GG, A-AS, J-FL, EB, EC, and MB had full 14 Johnson HC, Laerty EI, Eggo RM, et al. Eect of HPV vaccination access to all study data; RVB, LB, and CN had access to the analysed data and cervical cancer screening in England by ethnicity: a modelling but did not have access to the crude data generated by the model as they study. Lancet Public Health 2018; 3: e44–51. were stored on a secure server only accessible to members of the Centre 15 Abbas K, Yoo KJ, Prem K, Jit M. Equity impact of HPV vaccination de recherche du CHU de Québec-Université Laval. All authors had final on lifetime projections of cervical cancer burden among cohorts in responsibility to submit the manuscript for publication. 84 countries by global, regional, and income levels, 2010-22: a modelling study. EClinicalMedicine 2024; 70: 102524. Declaration of interests 16 Van de Velde N, Boily M-C, Drolet M, et al. Population-level impact We declare no competing interests. of the bivalent, quadrivalent, and nonavalent human papillomavirus Data sharing vaccines: a model-based analysis. J Natl Cancer Inst 2012; No individual participant level data were used in this study. Descriptions 104: 1712–23. of the model structure, the parameters included in the model, and the 1736 Articles 17 Drolet M, Laprise J-F, Chamberland É, et al. Switching from a 36 Ministère de la Santé et des Services Sociaux du Québec (MSSS). 2-dose to a 1-dose program of gender-neutral routine vaccination Flash Vigie. Bulletin québécois de vigie, de surveillance et against human papillomavirus in Canada: a mathematical d’intervention en protection de la santé publique. 2019. https:// modelling analysis. CMAJ 2024; 196: E1136–43. publications.msss.gouv.qc.ca/msss/fichiers/flashvigie/FlashVigie_ 18 Laprise J-F, Chesson HW, Markowitz LE, et al. Eectiveness and vol14_no7.pdf (accessed Jan 20, 2020). cost-eectiveness of human papillomavirus vaccination through age 37 UK Health Security Agency. Human papillomavirus (HPV) 45 years in the United States. Ann Intern Med 2020; 172: 22–29. vaccination coverage in adolescents in England: 2021 to 2022. 19 Laprise J-F, Drolet M, Boily M-C, et al. Comparing the cost- https://assets.publishing.service.gov.uk/media/63a5b83be eectiveness of two- and three-dose schedules of human 90e07048f4d598f/hpr1322-HPV2.pdf (accessed March 27, 2024). papillomavirus vaccination: a transmission-dynamic modelling 38 Australian Government. Historical human papillomavirus (HPV) study. Vaccine 2014; 32: 5845–53. immunisation coverage rates. https://www.health.gov.au/resources/ 20 Brisson M, Laprise J-F, Drolet M, et al. Population-level impact of publications/historical-human-papillomavirus-hpv-immunisation- switching to 1-dose human papillomavirus vaccination in high- coverage-rates (accessed March 27, 2024). income countries: examining uncertainties using mathematical 39 UN. Department of Economic and Social Aairs. World Population modeling. J Natl Cancer Inst Monogr 2024; 2024: 387–99. Prospects: The 2017 Revision. https://www.un.org/en/desa/world- 21 Bénard É, Drolet M, Laprise J-F, et al. Potential benefit of extended population-prospects-2017-revision (accessed April 1, 2026). dose schedules of human papillomavirus vaccination in the context 40 UN. World population prospects. 2022. https://population.un.org/ of scarce resources and COVID-19 disruptions in low-income and wpp/Download/Standard/Population (accessed March 22, 2022). middle-income countries: a mathematical modelling analysis. 41 Dougenik J, Chrisman N, Niemeyer D. An algorithm to construct Lancet Glob Health 2023; 11: e48–58. continuous area cartograms. Prof Geogr 1985; 37: 75–81. 22 Drolet M, Laprise J-F, Brotherton JML, et al. The impact of human 42 Canfell K, Kim JJ, Kulasingam S, et al. HPV-FRAME: a consensus papillomavirus catch-up vaccination in Australia: implications for statement and quality framework for modelled evaluations of HPV- introduction of multiple age cohort vaccination and postvaccination related cancer control. Papillomavirus Res 2019; 8: 100184. data interpretation. J Infect Dis 2017; 216: 1205–09. 43 Drolet M, Bénard É, Pérez N, et al, and the HPV Vaccination Impact 23 Brisson M, Bénard É, Drolet M, et al. Population-level impact, Study Group. Population-level impact and herd eects following the herd immunity, and elimination after human papillomavirus introduction of human papillomavirus vaccination programmes: vaccination: a systematic review and meta-analysis of predictions updated systematic review and meta-analysis. Lancet 2019; from transmission-dynamic models. Lancet Public Health 2016; 394: 497–509. 1: e8–17. 44 Kjaer SK, Dehlendor C, Belmonte F, Baandrup L. Real-world 24 Comité sur l’immunisation du Québec (CIQ). Avis sur la eectiveness of human papillomavirus vaccination against cervical vaccination contre les virus du papillome humain (VPH) des cancer. J Natl Cancer Inst 2021; 113: 1329–35. hommes ayant des relations sexuelles avec d’autres hommes 45 Falcaro M, Castañon A, Ndlela B, et al. The eects of the national (HARSAH). 2015. https://www.inspq.qc.ca/publications/2009 HPV vaccination programme in England, UK, on cervical cancer (accessed Aug 30, 2023). and grade 3 cervical intraepithelial neoplasia incidence: a register- 25 Comité sur l’immunisation du Québec (CIQ). HPV immunization based observational study. Lancet 2021; 398: 2084–92. of Quebec pre-adolescents: two or three doses? 2013. https://www. 46 Goldie SJ, Gakin L, Goldhaber-Fiebert JD, et al, and the Alliance inspq.qc.ca/en/publications/1837 (accessed Aug 30, 2023). for Cervical Cancer Prevention Cost Working Group. Cost- 26 Meites E, Kempe A, Markowitz LE. Use of a 2-dose schedule for eectiveness of cervical-cancer screening in five developing human papillomavirus vaccination - updated recommendations of countries. N Engl J Med 2005; 353: 2158–68. the advisory committee on immunization practices. 47 Roden R. New prophylactic HPV vaccines. 35th International MMWR Morb Mortal Wkly Rep 2016; 65: 1405–08. Papillomavirus Conference (IPVC); April 19, 2023. 27 WHO. Evidence based recommendations on human papilloma 48 Zhao F-H, Wu T, Hu Y-M, et al. Ecacy, safety, and virus (HPV) vaccines schedules. Background paper for SAGE immunogenicity of an Escherichia coli-produced human discussions. 2014. https://terrance.who.int/mediacentre/data/sage/ papillomavirus (16 and 18) L1 virus-like-particle vaccine: end-of- SAGE_Docs_Ppt_Apr2014/7_session_hpv/Apr2014_session7_HPV_ study analysis of a phase 3, double-blind, randomised, controlled schedules.pdf (accessed Aug 4, 2023). trial. Lancet Infect Dis 2022; 22: 1756–68. 28 WHO. Strategic Advisory Group of Experts (SAGE) on 49 Shi L-W, Li J, Yu B-W, et al. Safety and immunogenicity of a bivalent immunization. Meeting of the strategic advisory group of experts HPV16/18 vaccine in Chinese females. Hum Vaccin Immunother on immunization, October 2019: conclusions and 2023; 19: 2209001. recommendations. Wkly Epidemiol Rec 2019; 94: 541–60. 50 Sharma H, Parekh S, Pujari P, et al. Immunogenicity and safety of 29 WHO. Meeting of the strategic advisory group of experts on a new quadrivalent HPV vaccine in girls and boys aged 9–14 years immunization, April 2022: conclusions and recommendations. versus an established quadrivalent HPV vaccine in women aged Wkly Epidemiol Rec 2022; 97: 261–76. 15–26 years in India: a randomised, active-controlled, multicentre, 30 de Sanjosé S, Diaz M, Castellsagué X, et al. Worldwide prevalence phase 2/3 trial. Lancet Oncol 2023; 24: 1321–33. and genotype distribution of cervical human papillomavirus DNA 51 Hu Y-M, Bi Z-F, Zheng Y, et al. Immunogenicity and safety of an in women with normal cytology: a meta-analysis. Lancet Infect Dis Escherichia coli-produced human papillomavirus (types 2007; 7: 453–59. 6/11/16/18/31/33/45/52/58) L1 virus-like-particle vaccine: a phase 2 31 Bénard É, Drolet M, Gingras G, et al. Ranking the most ecient double-blind, randomized, controlled trial. Sci Bull 2023; human papillomavirus vaccination strategies in low-income and 68: 2448–55. lower-middle income countries: a mathematical modelling analysis. 52 Laprise J-F, Chesson HW, Markowitz LE, Drolet M, Brisson M. Lancet Glob Health 2025; 13: e2153–64. Cost-eectiveness of extending human papillomavirus vaccination 32 UN. Member states. https://www.un.org/en/about-us/member- to population subgroups older than 26 years who are at higher risk states (accessed May 24, 2024). for human papillomavirus infection in the United States. 33 The World Bank. World Bank country and lending groups. https:// Ann Intern Med 2025; 178: 50–58. datahelpdesk.worldbank.org/knowledgebase/articles/906519-world- 53 Harper S, Lynch J, Meersman SC, Breen N, Davis WW, bank-country-and-lending-groups (accessed Nov 11, 2025). Reichman ME. An overview of methods for monitoring social 34 Obeid DA, Almatrrouk SA, Alfageeh MB, Al-Ahdal MNA, disparities in cancer with an example using trends in lung cancer Alhamlan FS. Human papillomavirus epidemiology in populations incidence by area-socioeconomic position and race-ethnicity, with normal or abnormal cervical cytology or cervical cancer in the 1992–2004. Am J Epidemiol 2008; 167: 889–99. Middle East and North Africa: a systematic review and meta- 54 WHO. Immunization coverage. https://www.who.int/news-room/ analysis. J Infect Public Health 2020; 13: 1304–13. fact-sheets/detail/immunization-coverage (accessed April 3, 2025). 35 Pingali C, Yankey D, Elam-Evans LD, et al. Vaccination coverage among adolescents aged 13–17 years— National Immunization Survey-Teen, United States, 2022. MMWR Morb Mortal Wkly Rep 2023; 72: 912–19. --- [PDF原文](https://sci-net.xyz/storage/7932541/e7378ebae54a96d8367ea13be6c4ebdfa63be349d49470b3b6ec1df659ac4e23/Substantial-increases-in-cervical-cancer-inequalities-worldwide-without-enhanced-human-papillomavirus.pdf) DOI: 10.1016/S0140-6736(26)00410-1