Journal of Epidemiology and Global Health

A Narrative Review of Human Papillomavirus (HPV) Vaccination in Ecuador: A Crisis of Inequity and an Evidence-Based Roadmap for Elimination

Human Papillomavirus (HPV) remains the leading cause of cervical cancer in Ecuador, which suffers from systemic programmatic failures that undermine the global elimination strategy. Ecuador's HPV vaccination coverage (35.6% first dose; 17.3% complete) is the lowest in Latin America, starkly contrasting with the WHO's 90% target for cervical cancer elimination (Pan American Health Organization 2025). Structural inequities, a profound genotypic mismatch with the circulating quadrivalent vaccine (HPV 58/31/52 prevalence), and fragmented implementation perpetuate this public health crisis (Jose Ortiz Segarra et al. Infectious Disease Reports, 15(3):267-278 2023). Our analysis reveals that the nation's health-center-based model fails to reach vulnerable populations, a problem exacerbated by critical cold chain deficiencies in 30% of facilities. In contrast, regional successes, such as Peru's school-based programs (94% coverage) and Colombia's strategic adoption of the nonavalent vaccine, offer a clear roadmap for reform (Pan American Health Organization 2025, María Ines Sarmiento-Medina et al. PLOS ONE, 19(2):e0297579 2024). We propose an evidence-based 5-point plan to overhaul Ecuador's strategy: a targeted nonavalent vaccine pilot, immediate adoption of a single-dose schedule, culturally adapted self-sampling programs, phased-in gender-neutral vaccination, and urgent investment in cold chain infrastructure.

Sociodemographic Determinants of Cervical Cancer Screening among Ever-Married Women in Jordan: Insights from the 2023 Jordan Population and Family Health Survey

Jordan faces significant challenges in cervical cancer prevention due to low screening participation and limited coverage. This study examined the sociodemographic factors associated with cervical cancer screening uptake among ever-married Jordanian women aged 20-49 years using data from the 2023 Jordan Population and Family Health Survey (JPFHS).  METHODS: We analyzed data from the 2023 JPFHS, which initially included 12,595 ever-married women. binary logistic regression analyses were conducted to identify sociodemographic predictors of cervical cancer screening uptake. A total of 12,405 ever-married women were included in the study. Among them, 2,038 (16.4%) reported having undergone cervical cancer screening through methods such as the Pap smear, human papillomavirus test, or visual inspection with acetic acid, while 10,367 (83.6%) had never been screened. Multivariable analysis revealed that older women, residents of Ajloun governorate, those with higher socioeconomic status, multiparous women, daily smokers, frequent internet users, and women with a history of HIV or sexually transmitted disease testing were more likely to undergo cervical cancer screening. Conversely, screening uptake was significantly lower among women residing in Irbid, Mafraq, Tafiela, and Aqaba governorates. To improve cervical cancer screening rates, policymakers should prioritize poor and underserved women, particularly younger women who have lower participation rates. Strengthening healthcare infrastructure, especially in the southern governorates, and integrating preventive health education into school curricula are crucial steps toward increasing awareness and early detection. Additionally, primary prevention programs should adopt a more inclusive approach, targeting all population groups including those with healthy lifestyles rather than focusing solely on women with high-risk behaviors.

Global Cervical Cancer Incidence by Histological Subtype and Implications for Screening Methods

Abstract Background Cervical cancer is a major global health concern, disproportionately affecting women in developing countries. Cervical cancer has two primary subtypes, squamous cell carcinoma (SCC) and adenocarcinoma (AC), each with distinct characteristics and screening effectiveness. In this study, we aimed to estimate the global incidence of cervical cancer according to histological subtype to inform prevention strategies. Methods Using data from population-based cancer registries, we computed the rates of SCC, AC, and other specified histology among all cervical cancer cases by country and by 5-year age group. Proportions were subsequently applied to the estimated number of cervical cancer cases from the Global Cancer Observatory 2020. Age-standardized incidence rates were calculated. Results SCC accounted for 82.72% of global cervical cancer cases, with AC contributing 12.18%. The highest SCC incidence was in Sub-Saharan Africa (29.79 per 100,000 population). The AC incidence was highest in South-Eastern Asia (3.67 per 100,000 population). Age-specific trends showed SCC peaking at approximately age 55 years and AC plateauing after age 45 years. Conclusions This study provided a comprehensive estimate of cervical cancer incidence by histological subtype. SCC remained the dominant subtype globally, whereas the incidence of AC varied across regions. These findings highlighted the need for tailored prevention strategies, especially testing for human papillomavirus to detect AC in high burden areas.

Cervical Cancer Care Continuum in South India: Evidence from a Community-based Screening Program

In India, cervical cancer screening is conducted at various levels; however, after screening, the adherence to the cancer care continuum is barely understood. This study evaluated a community-based cancer screening program conducted in a rural setting (Tirunelveli and Tuticorin districts) in South India and reviewed the completion of care continuum. In this longitudinal descriptive study involving secondary data collection, data from the case records of 2192 women who were consecutively screened between March 2015 and May 2016 were included. All women underwent conventional cytology-based screening (Pap smear) and Visual Inspection with Acetic Acid (VIA). Those for whom either test was positive were referred for histopathological confirmation. Patients with confirmed precancerous conditions and unsatisfactory Pap smears were referred for further management. In total, 2192 women were screened [age range, 17-69 years; mean (standard deviation), 39.2 (8.5)]. Common symptom and sign were white discharge per vaginum (34.9%) and cervical erosion (34.4%), respectively. The VIA was positive for 24% (523/2178; 14 women did not cooperate for VIA) and 113 (5.1%) had epithelial cell abnormality in the Pap smear test. Per histopathology findings, one woman had non-keratinizing squamous cell carcinoma. Seven, three, and four had cervical intraepithelial neoplasia I, II and III, respectively. Of 2192, 807 were eligible for referral (597 had positive results on either Pap or VIA). Among the 807 women referred, only 74 (9.2%) women visited the referral center. The follow-up rate was very poor accounting to fragmentation of care continuum. The success of the screening program depends on the completion of the care continuum.

False-Positive Screening, Over-Referral, and Length of time between Cervical Cancer Early Detection and Confirmed Diagnosis Over Nine Years in Lusaka, Zambia

While Zambia has an efficient program for early detection of cervical cancer, most cases are diagnosed at advanced stages. This study examined the time between suspecting cancers at screening clinics and histopathologic confirmation of cervical cancer in the Lusaka Province of Zambia. This study included the records of 3,483 women with suspected cancerous lesions identified by visual inspection of the cervix (VIA) who were referred from Lusaka Province screening facilities from 2014 to 2022. The study linked screening records with corresponding histopathologic results of the lesions after examination at the University Teaching Hospital. Variables abstracted from the medical records included age, human immunodeficiency virus (HIV) status, district of residence and referral clinic, and dates of referral and confirmed diagnosis. False-positive VIA results constituted about 90% of all referrals. Women living with HIV (WLWH) had longer wait times between screening referrals and receipt of histopathologic results, most notably women coming from rural settings (median of 146 days) compared to urban settings (median of 69 days) (p < 0.05). Among women diagnosed with low-grade intraepithelial lesions, WLWH had a 63% higher risk of confirmed cancer diagnosis (CI: 1.16, 2.29) than women not living with HIV. For high-grade intraepithelial lesions, the adjusted HR showed WLWH having a 17% (CI: 0.89, 1.53) higher risk of confirmed cancer diagnosis compared to women not living with HIV. The high rate of false-positives and long wait times call for expanded service infrastructure, particularly in rural settings, and continuing provider education/training to optimize screening sensitivity and shorten wait times in the Lusaka Province. Such measures may reduce the overload on the existing histopathology infrastructure and may provide lessons for other limited-resource countries facing similar cancer control and prevention challenges.

The Study on Cervical Cancer Burden in 127 Countries and Its Socioeconomic Influence Factors

Abstract Objectives To explore the relationship between cervical cancer burden and HDI and other socioeconomic influence factors in 127 countries. Methods Dividing 127 countries into low-, medium-, high-, ultrahigh-HDI groups, and using statistical method to compare the prevalence trend of cervical cancer in different HDI country groups. Then selecting mortality-to-incidence ratio (MIR) to measure the cancer burden as the dependent variable, HDI and other socioeconomic factors selected from 2020 Human Development Report as independent variables, and using multi-regression model to analyze the correlation between variables. Results Countries with higher HDI were found to have lower prevalence and mortality of cervical cancer, and vice versa. Besides that, air and water pollution, government-coordinated spending, and the intimate partner of 15–49-year-old women and girls have positive correlation impact on cervical cancer burden. Discussion The cancer prevention and control policies in countries with high HDI have achieved relatively ideal implementation effects. Countries with relatively backward social and economic development level, cancer prevention and control policies had little effect, such as lower HPV vaccination coverage, poor regional health resource allocation, and week public education awareness. Therefore, cervical cancer control plan must be integrated into national strategies and implemented in people-oriented comprehensive health services.

The Vaginal Microbiota, Human Papillomavirus Infection, and Cervical Carcinogenesis: A Systematic Review in the Latina Population

Abstract Background Latina women experience disproportionately higher rates of HPV infection, persistence, and progression to cervical dysplasia and cancer compared to other racial–ethnic groups. This systematic review explores the relationship between the cervicovaginal microbiome and human papillomavirus infection, cervical dysplasia, and cervical cancer in Latinas. Methods The review abides by the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. PubMed, EMBASE, and Scopus databases were searched from January 2000 through November 11, 2022. The review included observational studies reporting on the cervicovaginal microbiota in premenopausal Latina women with human papillomavirus infection, cervical dysplasia, and cervical cancer. Results Twenty-five articles were eligible for final inclusion (N = 131,183). Forty-two unique bacteria were reported in the cervicovaginal microbiome of Latinas. Seven bacteria: Lactobacillus crispatus, Lactobacillus iners, Chlamydia trachomatis, Prevotella spp., Prevotella amnii, Fusobacterium spp. and Sneathia spp. were enriched across multiple stages of cervical carcinogenesis in Latinas. Therefore, the total number of reported bacteria includes four bacteria associated with the healthy state, 16 bacteria enriched in human papillomavirus outcomes, 24 unique bacteria associated with abnormal cytology/dysplasia, and five bacteria associated with cervical cancer. Furthermore, three studies reported significantly higher alpha and beta diversity in Latinas with cervical dysplasia and cancer compared to controls. Lactobacillus depletion and an increased abundance of L. iners in Latinas compared to non-Latinas, regardless of human papillomavirus status or lesions, were observed. Conclusions The identification of 42 unique bacteria and their enrichment in cervical carcinogenesis can guide future cervicovaginal microbiome research to better inform cervical cancer prevention strategies in Latinas.

Study of the Prevalence of Human Papillomavirus Genotypes in Jeddah, Saudi Arabia

Human papillomavirus (HPV), a common sexually transmitted infection, includes over 200 types, some linked to genital warts and various cancers, including cervical, anal, penile, and oropharyngeal cancers. In Saudi Arabia, an estimated 10.7 million women aged 15 years and older are at risk of HPV-related cervical cancer. This study assessed HPV prevalence, genotype distribution, awareness, and health behaviors among females in Jeddah, Saudi Arabia. Pap smear samples were collected from 106 women attending gynecology clinics at King Abdulaziz University Hospital and were analyzed using nested PCR and Sanger sequencing. Results showed a 15.1% HPV positivity rate, with genotypes of HPV 16, 6, and 58 identified. HPV 16 was the most prevalent (43.75%), particularly among women aged 35-44. In addition, over 60% of the participants were unaware of the link between HPV and cervical cancer, or the availability of vaccines, indicating significant knowledge gaps in the population. These findings underscore the urgent need for comprehensive HPV surveillance and targeted public health interventions in Saudi Arabia. This study emphasizes the importance of HPV vaccination programs, increased screening, and educational campaigns to address the high prevalence of high-risk genotypes, particularly HPV 16. Tailored strategies are crucial to reducing HPV-related health risks, especially for high-risk age groups and under-informed populations. The data provide a foundation for improving HPV prevention and reducing the burden of related diseases in the Saudi population.